Every finding on record at Clarkston Health and Rehab of Cascadia

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, food was not labeled, dated or discarded when expired for 5 of 5 refrigerators, and 1 of 1 dry storage areas. The facility failed to perform hand hygiene when indicated during the meal service and to maintain a clean cooking environment. These failures placed residents at risk for foodborne illnesses.Findings included . <Expired/undated food>During an initial tour of the kitchen on 08/11/2025 at 5:38 AM, the dry storage area revealed a container of Frank's red-hot sauce that expired on 10/26/2023. An observation of the large walk in refrigerator on 08/11/2025 at 5:50 AM revealed 11 boxes of Thick and Easy (a powdered substance used to thicken liquids) that expired on 05/30/2025, a box of apples that contained two brown moldy apples, three bags of wilted spinach that was wet and soggy, two bags of brown wilted lettuce, and two bags of brown wilted salad mix. On 08/11/2025 at 6:20 AM, the refrigerator near the middle of the kitchen contained a lemon cream pie and three apple pies with no dates. The refrigerator near the back of the kitchen contained a bag of salad mix that said it was to be used by 08/07/2025. In an interview on 08/11/2025 at 6:31 AM, Staff Y, Cook, stated the dietary manager monitored the dates on the food. Staff Y stated when freight was delivered, the night shift staff dated it, and every food item should have had a received by date. Staff Y stated it was important to date food, so you knew how long you had it and when it expired. The main refrigerator had waffles and two packages of French toast with no dates. Staff Y was unable to find any dates on the packages. On 08/11/2025 at 7:52 AM, the refrigerator in the Cabin Cove dining room contained a sandwich and three fruit cups that had no date on them. There was a bag of huckleberries for Resident 75 that had no date and a chef salad for Resident 18 that had no date. On 08/18/2025 at 12:03 PM, the refrigerator in the [NAME] dining room contained a container of Med Plus 2.0 vanilla nutritional drink that was opened on 08/02/2025. Staff Y, Cook, stated the nutritional drink had to be discarded within seven days of opening it. There was a frozen chocolate milkshake in the freezer with no date or name. Staff Y stated the refrigerator was for the residents. <Food Temperatures>During an observation of the lunch meal service on 08/15/2025 at 11:18 AM, Staff Y, Cook, had checked the temperatures of the cold items. The milk was 42.8 degrees Fahrenheit (F), and the cookie dessert was 44.9 degrees F, all above the recommended food temperature of 40 degrees. At 11:27 AM, Staff Y put on gloves and plated the food, while Staff EE placed the cold items on the trays. On 08/15/2025 at 11:41 AM, Staff Y checked the temperatures of the pureed food (altered food texture that resembled the consistency of applesauce). The pureed corn chowder soup was 111 degrees F, below the recommended food temperature of 140 degrees F. On 08/15/2025 at 11:58 AM, Staff Y checked the temperature of the cheese sandwiches which was 57.3 degrees F and the chef salad was 47.4 degrees F, above the recommended temperature of 40 degrees F. On 08/15/2025 at 12:07 PM, Staff EE placed the milk on the meal tray to be served. When asked what temperature of cold items needed to be, Staff Y stated below 42 degrees, explained the temperature had to be 40 degrees F or below and they removed the milk from the meal tray. At 12:08 PM, Staff EE placed the cookie dessert on the meal tray and was going to serve it until they were asked what the temperature had to be. At 12:12 PM, Staff Y placed the cheese sandwich on the meal tray to be served. Staff Y was asked what the temperature had to be and they removed the sandwich. In an observation on 08/15/2025 at 12:21 PM, Staff Y stated they had to give a resident their chef salad because they would not eat fish. Staff Y re-temped the salad and it was 53 degrees F. Staff Y took the salad back to the kitchen. At 12:28 PM, Staff Y entered the dining room with a new chef salad and the temperature was 51 degrees F. At 12:21 PM, Staff Y rechecked the temperature of the salad and it was 50 degrees F. Staff Y served the salad to the resident despite the temperature being above the recommended temperature for cold foods. On 08/15/2025 at 12:44 PM, Staff Y entered the Cabin Cove dining room, which was the last dining room to be served. The temperature of the cheese sandwiches that were just made was 41 degrees which contained mayonnaise. The temperature of the soft and bite sized fish was 131 degrees F. At 12:58 PM Staff Y plated the fish and was going to serve it. When asked about the temperature of the food, Staff Y removed the fish and gave the resident soup. At 12:59 PM, Staff Y served the cheese sandwiches despite them not meeting the recommended temperature for cold food. On 08/15/2025 at 1:10 PM, during a sampling of the lunch meal, the temperature of the mashed potatoes was 118 degrees F and the carrots were 126 degrees F, all below the recommended temperature of 140 degrees F for hot food. <Hygiene>In an observation on 08/15/2025 at 11:28 AM, Staff EE took their arm and wiped their mouth while standing over the food. In an observation on 08/15/2025 at 11:29 AM, Staff Y touched a book with their gloves and then grabbed drinks for a resident and placed them on their tray. On 08/15/2025 at 11:29 AM, Staff EE left the kitchen wearing a pair of gloves. Staff EE re-entered the kitchen at 11:30 AM wearing a pair of gloves and continued to place cold items on food trays after touching the door with their gloves. At 11:31 AM, Staff EE scratched the back of their head with their gloves while they placed cold items on meal trays. On 08/15/2025 at 11:33 AM, Staff Y touched the potatoes with their gloved hands that they touched the binder with and cut the potatoes in half. At 11:36 AM, Staff Y picked up the potato they had cut in half and touched the inside of the potato the resident was going to consume. On 08/15/2025 at 11:36 AM, Staff EE removed their gloves and touched their face and rested their arms on the meal cart that contained the cold food items. On 08/15/2025 at 11:37 AM, Staff Y dropped a piece of tin foil on the ground and picked it up and did not perform hand hygiene. Staff Y wearing the same gloves loaded the leftover food and condiments into the cart. At 11:39 AM, Staff Y took the small food cart back to the kitchen and without performing hand hygiene, emptied the leftovers into the steam table (a cart to keep the food hot). On 08/15/2025 at 11:54 AM, Staff EE wiped the tip of their nose with their finger and put trays on top of the steam cart and grabbed meal cards without hand hygiene being performed. At 11:55 AM, Staff EE adjusted their hair net and put on gloves without hand hygiene being performed. At 12:05 PM, Staff EE pulled their cell phone out of their pocket with their gloved hands and without hand hygiene being performed, they continued putting cold food items on meal trays. On 08/15/2025 at 12:11 PM, Staff Y dropped some sour cream packets on the floor, picked them up with their gloved hands and put them back in the container to be served to the residents. Staff Y kept the same gloves on and then adjusted their pants and continued to serve food. On 08/15/2025 at 12:13 PM, Staff EE while wearing gloves, opened the lid to the garbage and threw away some cheese sandwiches. Staff EE wearing the same gloves continued to place cold food items on meal trays. At 12:15 PM, Staff EE wiped their forehead with their arm while putting cold food items on the trays next to Staff Y who was plating food. On 08/15/2025 at 12:17 PM, Staff Y continued cutting potatoes in half and touching the fish with the same gloved hands they used to pick up the sour cream packets from the floor. On 08/12/2025 at 12:25 PM, Staff EE rested their hands on the steam table that contained food and rubbed their nose with their gloves. On 08/15/2025 at 12:36 PM, Staff Y picked up a container of crackers that were placed on the floor in the dining room and put them at the bottom of the steam cart. On 08/15/2025 at 1:02 PM, Staff Y wiped the side of their face on their shirt while standing over the food and plating it. <Sanitary Environment>In an observation of the kitchen on 08/11/2025 at 6:18 AM, the floor under the steamer and stove were covered with food debris and dirt and the oven had thick burned food debris on the bottom. In an observation on 08/11/2025 at 6:23 AM, the outside of the ice machine had white splatter and dust on it. There was a floor mat in front of the ice machine that had dirt and debris under it and the floor around the ice machine had dirt and debris. In an observation on 08/11/2025 at 6:40 AM, the floors in the dry storage room had liquid spills, garbage, and spilled cereal on the floor. The floors in the walk-in refrigerator were dirty with spills and food debris. In an observation on 08/11/2025 at 7:52 AM, the Cabin Cove refrigerator was unclean with juice spilled on the bottom shelf. In an interview on 08/18/2025 at 12:27 PM, Staff Z, Dietary Manager, stated staff were to check for dates and expired food every time they walked into the refrigerator. Staff Z stated they tried to put the old freight up front and the new freight in the back. Staff Z stated it was important to date and discard expired food to prevent foodborne illness. Staff Z stated it was important to serve food at the appropriate temperatures to prevent illness, and the food should be heated and held at the appropriate temperatures. Staff Z stated it was important to maintain the temperature of the cold food, so it did not spoil. Staff Z stated hand hygiene and gloves were to be changed when their gloves became soiled and staff should not have picked up food items off the floor and put them back in the container to be served. Staff Z stated staff were not to touch their hair, face, or anything and if they did, they needed to discard their gloves, perform hand hygiene and put a new pair on. Staff Z stated it was important to maintain hygiene to prevent food contamination and illness. Staff Z stated whoever accepted food items that needed refrigeration were responsible to label and date them and housekeeping was to keep the refrigerators clean. Staff Z stated the refrigerators and floors in the kitchen needed to be kept clean for sanitization. Reference: WAC 388-97-1100 (3), 2980

Based on observation, interview and record review, the facility failed to ensure meals were served at palatable temperatures for 2 of 6 sampled residents (Residents 17 and 42) reviewed and 1 of 1 meal test trays sampled. This failure put residents at risk of decreased enjoyment of their meals, and possible reduced dietary intake. Findings included . According to the Washington State Food Handlers Guide Website, the Washington State Department of Health Safety and Licensing Division recommended that all potentially hazardous foods be held at a temperature of 41 degrees Fahrenheit (F) or below in commercial refrigerators and freezers. This included meats, fish, poultry, eggs, dairy products, cooked vegetables, cooked rice and pasta, cut melons, and other perishable items. All frozen foods were to be stored at 0 degrees F or below. Hot food items were to be held at a temperature of 140 degrees F or above. <Resident 17> The 08/06/2025 quarterly assessment documented Resident 17 had diagnoses which included a stroke, malnutrition and depression. The assessment further documented the resident was cognitively intact and was able to make their needs known. In an observation and interview on 08/11/2025 at 12:02 PM, Resident 17 was sitting on the side of their bed in their room. Resident 17 stated their food was always cold. In an observation and interview on 08/13/2025 at 8:19 AM, Resident 17 was lying in bed. The resident stated it was a wonder they got hot food, and it was better this morning. In an interview on 08/14/2025 at 10:02 AM, Resident 17 stated the eggs [NAME] they had for breakfast were cold. In an observation and interview on 08/15/2025 at 8:36 AM, Resident 17 was sitting up in bed eating biscuits and gravy. The resident stated it was cold, and they had to send it back. <Resident 42> The 07/09/2025 quarterly assessment documented Resident 42 had diagnoses which included heart failure, high blood pressure and diabetes. The assessment further documented the resident was cognitively intact and was able to make their needs known. In an observation and interview on 08/11/2025 at 7:02 AM, Resident 42 was sitting in their wheelchair in the hallway. The resident stated the food was usually good but it was cold. In an observation and interview on 08/13/2025 at 8:13 AM, Resident 42 was sitting in their wheelchair in the dining room eating breakfast. The resident stated the eggs were cold. In an interview on 08/18/2025 at 8:47 AM, Resident 42 stated the waffle for breakfast was cold. During an observation and sampling of the lunch meal served on 08/15/2025, the temperatures of the food items were outside of the acceptable parameters and were as follows: mashed potatoes 118 degrees F and the carrots were 126 degrees F. <Resident Council> Review of May 2025 through July 2025 resident council minutes showed the council voiced concern of cold food during meals, all three months. During an interview on 08/13/2025 at 9:54 AM, the resident council stated cold food was still an ongoing issue. The council stated, today was the first day the eggs were hot and explained the food was typically lukewarm. In an interview on 08/18/2025 at 12:27 PM, Staff Z, Dietary Manager, stated it was important to serve food at appropriate temperatures to prevent foodborne illnesses. Reference: WAC 388-97-1100 (1)(2)

Based on observation and interview, the facility failed to post survey results in a place readily accessible and frequented by most residents, as required. This failure placed residents at risk of being unable to exercise their resident rights.Findings included .During observation on 08/11/2025 at 4:45 AM, the facility's main lobby was entered. The lobby was a small foyer and contained a reception desk to the right with a few chairs. Within of few feet of walking into the building an elevator was observed straight ahead, to the left of the elevator was a set of stairs that led downstairs to the first floor that contained resident rooms, to the left of that was a set of stairs that led upstairs to the second floor that contained resident rooms, and a binder that contained survey results was posted on the wall at the base of the stairs that led to the second floor. In an interview on 08/13/2025 at 10:06 AM, the Resident Council was asked without having to ask, are the results of our inspections available for you to read? Only one of 16 residents in attendance voiced knowing the survey results were posted in the main lobby. The Council then stated the lobby was locked because of the elevator and explained staff needed to enter an elevator code to access the lobby so residents would have to ask staff for assistance to access the lobby. The Council unanimously agreed. During an interview on 08/14/2025 at 7:20 AM Staff S, Nursing Assistant, stated the elevator only required a code to access the lobby not the floors that contained resident rooms. Staff S explained only residents who were safe enough could independently access the lobby. During observation on 08/14/2025 at 8:13 AM, the facility elevator contained a number keypad at eye level, when standing. Above the keypad was a small white label with a spelled-out number code that needed to be entered in order to access the facility's main lobby. Below the written code was a white sign that read please do not enter lobby code for residents without staff knowledge or supervision. In an interview on 08/14/2025 at 11:36 AM, Staff T, Registered Nurse, stated a code needed to be entered into the elevator to access the lobby, this was a safety measure to prevent confused residents from accidently exiting the front door. Staff T acknowledged residents typically did not frequent the lobby unless they had an appointment. Staff T further stated residents and visitors did not really see the elevator code sticker and often pressed the lobby button but did not go anywhere, they just sat there waiting for the elevator to move. Staff T stated residents had the right to see the results of the survey inspections. In an interview on 08/14/2025 at 11:52 AM, Staff E, Resident Care Manager, explained the elevator had a code for safety, to ensure residents that wandered did not get to the lobby. Staff E explained residents could move freely between the first floor and second floor, but a code was needed to access the lobby. Staff E further stated, not all residents can or should access the lobby. Staff E acknowledged residents should be able to access survey results without having to ask staff. In an interview on 08/14/2025 at 1:02 PM, Staff B, Director of Nursing, explained the purpose of the elevator code was to prevent confused residents from wandering outside because they should not be able to enter the elevator code to access the lobby. Staff B stated the survey results were posted in the lobby. Staff B further explained that the residents who could not access the lobby by themselves were also the residents that were unable to read the survey results, but they could have access to the lobby if they were accompanied by staff. In an interview on 08/18/2025 at 11:12 AM, Staff A, Administrator, stated the survey result binder was absolutely posted in a place that was readily accessible and frequented by residents. Reference WAC 388-97-0480

Based on observation, interview and record review, the facility failed to ensure it implemented its protocol for the management of constipation for 2 of 5 residents (Residents 70 and 83) whose records were reviewed for constipation and to ensure physician orders were in place for specific medication dose administration (Resident 22) and wound dressings (Resident 81). These failures placed the residents at risk for medication errors, deterioration of non-pressure skin conditions, and constipation-associated complications, like fecal impaction (where hardened, dry stool accumulates in the colon or rectum, blocking the passage of waste). Findings included . <Resident 81> Review of a 07/16/2025 quarterly assessment showed Resident 81 was admitted to the facility on [DATE], the primary reason for admission was a stroke, and had moderate cognitive impairment. The assessment also showed the resident had no ulcers, wounds or skin problems, to include skin tears (a wound that occurred when the top layers of the skin ripped or pulled away from the layers underneath). An interview and observation on 08/11/2025 at 7:54 AM showed Resident 81 in bed with a breakfast tray in front of them. Two dressings were observed to the side of the right upper arm and above the elbow with no date. Resident 81 said the staff changed their dressings, Yesterday. The dressings were blood stained and dry. On 08/12/2025 at 2:53 PM, the resident was sitting in their wheelchair in front of the Nurses Station, dressed in a tie-dye tank top and shorts. The right upper arm was observed with a white bandage dated 08/11/2025 and directly below it an undated medium brown band-aid. Additionally, an undated regular sized band aid was observed to the left outer arm at the base of a large purple bruise that covered almost the entire left side of the upper arm. On 08/15/2025 at 11:17 AM, two dressings were observed to Resident 81's right arm, by the elbow and one directly above it, and showed 8-15. A dressing above the left arm elbow was partially detached and also showed 8-15. Review of the medical record showed no physician orders to instruct the staff to apply dressings to Resident 81's arms. Additionally, review of the medical record from 07/01/2025 to 08/15/2025 showed no documentation of when or why the multiple dressings were initiated or subsequently monitored by the staff. Review of Skin Inspection progress notes of 07/02/2025, 07/09/2025, 07/30/2025 and 08/14/2025 showed, No new skin issues. Review of Resident 81's care plan showed no acknowledgment of actual or current impaired skin integrity to the arms. In an interview on 08/15/2025 at 11:27 AM, Staff H, Nursing Assistant (NA), stated that, It's skin tears, under Resident 81's multiple dressings to their arms. In an interview on 08/15/2025 at 11:20 AM, Staff J, Licensed Practical Nurse, stated they became aware a resident required a change in wound dressing by completing weekly skin inspections, and being informed by the NA or the resident. Staff DD, Registered Nurse (RN), interjected and said the Treatment Administration Record (TAR) alerted the nurse of the required wound treatment and Staff J concurred. Staff J said Resident 81 required dressing changes to their arms and shins and stated they changed the dressings to the arms dated 08-15. Staff J stated Resident 81 had like a skin tear and said if there was no instruction to identify, monitor and direct the nurse to the appropriate wound care, It can get infected. <Resident 22> Review of a 07/16/2025 quarterly assessment showed Resident 22 admitted to the facility on [DATE] with a diagnosis of seizure disorder. The assessment showed the resident's cognition was severely impaired. Review of the May 2025 Medication Administration Record (MAR) showed the staff administered Fycompa [a seizure medication] at the dose of 12 milligrams (mg, a measurement) nightly at 9:00 PM from 11/26/2023 until 05/06/2025. Review of a 05/06/2025 progress note showed the staff, Received a call from [neurologist, doctor who specialized on the diagnosis, treatment, and study of disorders and diseases affecting the nervous system] office stating that resident's fycompa level was too high and they would like to decrease the fycompa from 12mg to 8mg PO [orally] QHS [at bedtime]. Review of the May 2025 MAR showed the Fycompa dose was lowered to 8mg and the staff administered it nightly at bedtime from 05/07/2025 through 05/31/2025. Although the nurses signed in the May 2025 MAR that they administered 8mg of Fycompa nightly, review of the progress notes showed they gave Resident 22 the dose of 12 mg on 05/07/2025, 05/08/2025, 05/09/2025, 05/10/2025, 05/11/2025, and 05/12/2025 until the 8mg dose arrived from the pharmacy. In an interview on 08/14/2025 at 11:31 AM, Staff DD stated the MAR should accurately reflect the dose of medication the nurse stated they gave and when the MAR did not reflect that information, the resident ran the risk of getting the wrong dose. Staff DD stated it was important to have an order with the correct dose because if a resident transferred to the hospital, it could confuse the hospital staff, and they too might give the wrong dose. Staff DD said they did not usually send progress notes to the hospital. In an interview on 08/14/2025 at 11:33 AM, Staff J stated a nurse should notify the doctor, find out what the correct dose was and write the order accordingly in the MAR. Staff J said that failure to reconcile a medication dose in the physician order could possibly result in a medication error. The above findings were shared with Staff B, Director of Nursing (DNS), on 08/14/2025 at 11:51 AM. When asked if the MAR reflected the neurologist's intent to continue with the 12 mg of the Fycompa as the nurses documented in the progress notes until arrival of the 8mg dose, Staff B said the 12 mg Fycompa dose order should have been re-instated, and The risk of missing that medication would have been worse according to [the neurologist]. <Resident 70> The 07/09/2025 quarterly assessment documented Resident 70 had diagnoses which included diabetes, high blood pressure and dementia. The resident was unable to make decisions regarding cares and needed moderate assistance from staff for activities of daily living, such as toileting. The 04/06/2023 alteration in bowel function related to use of narcotic medication care plan instructed nursing staff to administer medications per the physician's orders. Review of the physician's order summary documented the following orders: -04/06/2023 Miralax 17 grams as needed for bowel management -03/01/2024 Dulcolax 10 milligrams (mg) as needed for no bowel movement (BM) times three days -03/01/2024 Milk of Magnesia (MOM) 30 milliliters as needed for no BM times four days -03/01/2024 Dulcolax suppository 10mg as needed for no BM times five days -03/01/2024 Fleet enema as needed for no BM times six days and to notify the provider Review of the bowel records from 07/14/2025 through 08/11/2025, documented Resident 70 had no BMs from 07/25/2025 through 07/27/2025 (three days), 07/31/2025 through 08/05/2025 (six days), and 08/08/2025 through 08/10/2025 (three days). Additional review of the MARS for July 2025 and August 2025, documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 70's record that stated the reason for the omissions. <Resident 83> The 07/09/2025 quarterly assessment documented Resident 83 had diagnoses which included quadriplegia (partial or total loss of function of all limbs and trunk of the human body), multiple sclerosis (a disease that causes nerve damage) and opioid dependence. The resident was able to make decisions regarding cares and needed total assistance from staff for activities of daily living, such as toileting. In an interview on 08/11/2025 at 11:41 AM, Resident 83 stated they were not having regular BM's and their surgeon wanted them to have an enema daily and at least two suppositories throughout the day. The resident stated they had blockages in the past and had to have surgery. The 01/07/2025 alteration in bowel function related to use of medications and decreased mobility care plan instructed nursing staff to administer medications per the physician's orders. Review of the physician's order summary documented the following orders: -04/09/2025 Bisacodyl 5mg, give two tablets as needed for no BM times three days -04/09/2025 MOM 30 milliliters as needed for no BM times four days -04/09/2025 Dulcolax suppository 10mg as needed for no BM times five days -04/09/2025 Fleet enema as needed for no BM times six days and to notify the provider -07/31/2025 Miralax 17 grams every 24 hours as needed for bowel management Review of the bowel records from 07/01/2025 through 08/13/2025, documented Resident 83 had no BMs from 07/08/2025 through 07/10/2025 (three days), 07/19/2025 through 07/21/2025 (three days), 08/02/2025 through 08/04/2025 (three days) and 08/08/2025 through 08/10/2025 (three days). Additional review of the MARS for July 2025 and August 2025, documented the resident had not received the bowel medication as ordered during the above time frames, and no documentation was found in Resident 70's record that stated the reason for the omissions. In an interview on 08/14/2025 at 2:14 PM, Staff U, Nursing Assistant, stated BM's were monitored every shift and documented in the plan of care. Staff U stated they notified the nurse for signs of constipation. In an interview on 08/14/2025 at 2:16 PM, Staff T, RN, stated the bowel protocol started on two days of no BM. Staff T stated they gave the residents Bisacodyl, followed by MOM, a suppository and lastly an enema and if that was ineffective the provider was notified. In an interview on 08/14/2025 at 2:18 PM, Staff B, DNS, stated they had standing bowel protocol orders and on day three the protocol was started. Staff B stated it was important to give the bowel medications as ordered to prevent bowel obstruction and to ensure the residents had good health. Reference: WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to ensure complete and accurate medical records for 6 of 25 sampled residents (Residents 1, 5, 8, 9, 22 and 86) whose medical records were reviewed. Specifically, the facility failed to ensure Resident 8 and 5's care conference documents (to include a complete resident identifier for Resident 5), Resident 5's visit summaries from a dental appointment, Resident 9's Psychosocial History Document (to include a complete resident identifier), Resident 22's clinic and lab results from a community provider appointment, Resident 1's smoking assessment, and Resident 86's bed hold notice were present and easily accessible in their medical records. These failures placed the residents at risk for a delay in care or services. Findings included. <Resident 5> In an interview on 08/11/2025 at 8:38 AM, Resident 5 stated they did not get invited to care planning conferences, That stopped. Review of Resident 5's electronic medical record from 01/2025 to 08/2025 showed no documentation the resident participated in care planning conferences. The above findings were shared with Staff C, Social Services Director, on 08/15/2025 at 9:26 AM. Staff C checked the folders on their desk, then went to an area inside their office closet but could not find Resident 5's care conference records. Afterwards, Staff C produced three copies of care conferences dated 08/15/2024, 02/20/2025, and 05/15/2025. None of the copies had Resident 5's last name on the forms. Review of Resident 5's medical record showed they went to dental appointments on 11/02/2024 (fitted for dentures), 11/15/2024 (returned with new dentures), and 12/06/2024. Review of the medical record showed no documentation of the visit summaries. <Resident 9> A similar finding was identified upon review of an 11/08/2022 Psychosocial History form produced by Staff C on 08/13/2025 at 12:44 PM to show the facility reviewed advance directives information with Resident 9's representative. The form had no resident identifier on it. <Resident 22> Review of Resident 22's medical record showed a 05/06/2025 progress note that showed the staff received a call from the community provider stating the blood level of a seizure medication was too high and they would like to decrease the medication dose. Record review showed no documentation what the too high results were or facility efforts to procure lab results that resulted in a seizure medication dose adjustment. In an interview on 08/14/2025 at 11:54 AM, Staff B, Director of Nursing (DNS), was asked what the process was to show continuity of care between community providers and the facility reflected in the medical record. Staff B stated visit summaries and lab results from community providers, should be uploaded [in the medical record] sooner than later. On 08/15/2025 at 10:56 AM, Staff B acknowledged Resident 5's medical record was not complete and accurate and also should have but did not include summaries of dental visits from 9 months ago. Staff B acknowledged the wait time to procure community appointment notes and blood work results was not timely. No further information was provided. <Resident 1> According to the 06/21/2025 admission assessment, Resident 1 admitted to the facility on [DATE] with diagnoses including respiratory failure (inability to effectively exchange oxygen and carbon dioxide). Resident 1 was cognitively intact and able to clearly verbalize their needs. Review of the residents that smoke list provided to the survey team on 08/11/2025, identified Resident 1 as choosing to smoke. During observation on 08/11/2025 at 7:07 AM, Resident 1 was observed outside the facility in the designated smoking area, smoking a cigarette. A similar observation was made on 08/13/2025 at 1:39 PM. Additional review of Resident 1's medical record showed no documentation a smoking assessment or evaluation was completed. In an interview on 08/13/2025 at 1:59 PM, Staff B, DNS, stated if a resident chose to smoke, they would be assessed for safety and care planned accordingly to include any potential interventions. Staff B reviewed Resident 1's medical record. Staff B acknowledged they were unable to find documentation a smoking assessment had been completed and would check to see if they could find any additional paperwork. In a follow-up interview and record review on 08/13/2025 at 2:15 PM, Staff B, produced a 06/17/2025 smoking assessment that had been completed on a paper form. Review of the assessment provided showed Resident 1 was able to smoke independently. Staff B stated they expected staff to scan or transcribe assessments into a resident's electronic medical record to ensure a complete and accurate medical record. <Resident 8> According to the 07/02/2025 quarterly assessment, Resident 8 re-admitted to the facility on [DATE] from a visit to the hospital. The assessment further showed Resident 8 had diagnoses including ground level fall and cervical disc displacement (soft rubbery cushion between spine bones moved out of its proper place), was cognitively intact and able to clearly verbalize their needs. Review of the 04/02/2025 falls care plan showed Resident 8 was at risk for falls and instructed staff to apply Dycem (grippy, non-stick material that prevented objects from slipping and/or sliding) to the recliner and wheelchair (WC), utilize anti-roll back WC brakes, treat infections per provider orders, and ensure glasses were worn. Review of a 04/18/2025 unwitnessed fall report showed Resident 8 was found on the floor in their room covered in blood with a large gash to the top of their head, and cuts to the right side of their face near the eye. A 04/23/2025 incident summary showed Resident 8 was transported to the hospital for further evaluation. Attached to the incident report was a face sheet, post fall investigation evaluation that documented nursing interventions implemented as sent to [Emergency Department, ED], fall risk assessment, falls care plan, and a five whys root cause tool. Additional review of the care plan showed the only intervention implemented after Resident 8 sustained a fall with head injury on 04/18/2025 was Resident sent to ED for evaluation. In an interview on 08/18/2025 at 11:17 AM, Staff B, DNS, explained the facility fall process and stated new fall interventions that attempted to address the root cause should be implemented every single time there was a new fall to prevent fall recurrence. Staff B was informed that the only documentation found for the fall intervention for the fall Resident 8 sustained on 04/18/2025 was to transport them to the ED for further evaluation. Staff B stated they would look for additional documentation. In a follow-up interview and record review on 08/18/2025 at 1:05 PM, Staff B, produced a 04/21/2025 care conference summary that had been completed on a paper form. Staff B explained that a care conference was held after Resident 8 returned from the hospital. During the care conference every care planned fall intervention implemented was reviewed with Resident 8's child in an attempt to find further potential creative fall interventions that had not been attempted or implemented yet. Review of the paper care conference form provided showed Resident 8's child stated Resident 8 had a history of falling and would continue to fall because previous fall interventions were unsuccessful, no documentation was found to show every fall intervention had been reviewed as described by Staff B. Additional review of Resident 8's medical record showed no documentation of the care conference held on 04/21/2025. <Resident 86> According to the 07/19/2025 Medicare five-day assessment, Resident 86 admitted to the facility on [DATE] with diagnoses including anemia (not enough blood cells) and gastritis (inflammation of the stomach lining) with bleeding. Resident 86 was cognitively intact and able to clearly verbalize their needs. Review of July 2025 nursing progress notes showed on 07/20/2025 Resident 86 complained of abdominal pain and informed staff that was a symptom they previously experienced when they had a gastrointestinal (GI, digestive system) bleed. The provider was notified, and Resident 86 was transported to the hospital via a facility van. No documentation was found to show a bed hold was offered at time of transfer. In an interview on 08/15/2025 at 9:49 AM, Staff E, Resident Care Manager, stated when a resident was transferred to the hospital, social services typically offered a bed hold the day of or the day following a hospital transfer. In an interview and record review on 08/15/2025 at 10:25 AM, Staff C, Social Service Director, explained when a resident was transported to the hospital, they spoke to the resident or their representative the day of or day after hospital transfer, to discuss a bed hold. Staff C reviewed Resident 8's medical record and was unable to located documentation a bed hold was offered, as required. Staff C then produced a 07/21/2025 bed hold agreement that had been completed on a paper form. Staff C acknowledged bed hold forms should be uploaded into the resident's medical record to ensure a complete and accurate record, as required. In an interview on 08/15/2025 at 10:31 AM, Staff B, stated they expected bed hold information to be uploaded into a resident's medical record to ensure a complete and accurate medical record, as required. In an interview on 08/18/2025 at 11:12 AM, Staff A, Administrator, stated they expected staff to ensure resident records were complete, accurate, and readily available, as required. Reference WAC 388-97-1720 (2)(a-m), -1720 (1)(a)(i-iv)(b)

Based on interview and record review the facility failed to repeatedly ensure registered nursing assistants (NAR) obtained their nursing assistant certification (NAC) within 120 days of hire and had the required paperwork on file to include a certification of completion of NAC program or Department of Health (DOH) authorization to test, passed skills test score sheet e-mail from Washington State Board of Nursing (WABON), passed online written test sheet from Credentia (a company that provided oversight and scheduling services for nurse aide certification exams), and the completed NAR certification application attestation form to continue to work beyond the 120-day deadline, as required for 6 of 6 sampled staff (Staff K, L, M, N, O, and P), reviewed for staffing. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life.Findings included.<Staff K>Review of the facility employee list provided by the facility on 08/11/2025 showed Staff K, NAR, was hired on 09/20/2024. Review of Staff K's credentials showed they were credentialed as a Washington State NAR on 01/14/2025. No documentation was found to show Staff K received a certification of completion from an NAC training program, passed the NAC examination, or completed the NAR certification application attestation form, as required to continue to work beyond the 120-day deadline. Review of payroll/time clock data from 01/18/2025 (120 days from 09/20/2024 hire date) through 08/15/2025 showed Staff K worked on the following dates:January- 01/18/2025, 01/24/2025, 01/25/2025, 01/26/2025, 01/28/2025, and 01/31/2025February- 02/01/2025, 02/02/2025, 02/03/2025, 02/07/2025, 02/08/2025, 02/10/2025, 02/13/2025, 02/21/2025, 02/22/2025, 02/25/2025, and 02/28/2025March- 03/01/2025, 03/02/2025, 03/03/2025, 03/06/2025, 03/07/2025, 03/08/2025, 03/11/2025, 03/14/2025, 03/15/2025, 03/21/2025, 03/22/2025, 03/25/2025, 03/26/2025, 03/28/2025, and 03/29/2025April- 04/04/2025, 04/05/2025, 04/11/20258, 04/12/2025, 04/13/2025, 04/17/2025, 04/18/2025, 04/19/2025, 04/25/2025, and 04/26/2025May- 05/01/2025, 05/02/2025, 05/03/2025, 05/04/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/17/2025, 05/18/2025, 05/23/2025, 05/24/2025, and 05/31/2025June- 06/06/2025, 06/07/2025, 06/13/2025, 06/14/2025, 06/20/2025, 06/21/2025, 06/27/2025, and 06/28/2025July- 07/04/2025, 07/05/2025, 07/10/2025, 07/11/2025, 07/12/2025, 07/18/2025, 07/25/2025, and 07/26/2025August- 08/02/2025, 08/03/2025, 08/08/2025, and 08/09/2025 Review of 08/13/2025 text message correspondence between Staff K and management showed Staff K had one last chance to test for their NAC but had not scheduled the test yet, 327 days after their date of hire. <Staff L>Review of the facility employee list showed Staff L, NAR, was hired on 11/11/2024. Review of Staff L's credentials showed they were credentialed as a Washington State NAR on 12/12/2024. Review of Staff L's records showed a certification of completion of a NAC training program on 04/16/2025 and passed an out-of-state Idaho NAC examination on 05/14/2025, 184 days after their date of hire. No documentation was found to show Staff L completed the NAR certification application attestation form, as required to continue to work beyond the 120-day deadline. Review of payroll/time clock data from 03/11/2025 (120 days from 11/11/2024 hire date) through 08/15/2025 showed Staff L worked on the following dates:March- 03/11/2025, 03/12/2025, 03/15/2025, 03/17/2025, 03/18/2025, 03/19/2025, and 03/31/2025April- 04/01/2025, 04/10/2025, 04/15/2025, 04/17/2025, 04/22/2025, 04/28/2025, and 04/29/2025May- 05/01/2025, 05/08/2025, 05/12/2025, 05/13/2025, 05/15/2025, 05/18/2025, 05/19/2025, 05/20/2025, 05/21/2025, 05/28/2025, 05/29/2025, and 05/30/2025June- 06/01/2025, 06/02/2025, 06/03/2025, 06/04/2025, 06/10/2025, 06/11/2025, 06/12/2025, 06/16/2025, 06/17/2025, 06/18/2025, 06/23/2025, 06/24/2025, 06/25/2025, and 06/30/2025July- 07/03/2025, 07/06/2025, 07/07/2025, 07/08/2025, 07/09/2025, 07/16/2025, 07/17/2025, 07/20/2025, 07/21/2025, 07/22/2025, 07/23/2025, 07/24/2025, 07/29/2025, and 07/30/2025August- 08/03/2025, 08/04/2025, 08/05/2025, 08/06/2025, 08/10/2025, 08/11/2025, 08/12/2025, and 08/13/2025 <Staff M>Review of the facility employee list showed Staff M, NAR, was hired on 11/27/2024. Review of Staff M's credentials showed they were first credentialed as a Washington State NAR on 12/11/2024. Review of Staff M's records showed a certification of completion of a NAC training program on 06/09/2025 and passed an out-of-state Idaho NAC examination on 07/02/2025, 217 days after their date of hire. No documentation was found to show Staff M completed the NAR certification application attestation form, as required to continue to work beyond the 120-day deadline. Review of payroll/time clock data from 03/27/2025 (120 days from 11/27/2024 hire date) through 08/15/2025 showed Staff M worked on the following dates:March- 03/29/2025, and 03/30/2025April- 04/04/2025, 04/06/2025, 04/11/2025, 04/13/2025, 04/18/2025, 04/19/2025, 04/20/2025, 04/25/2025, and 04/27/2025May- 05/02/2025, 05/04/2025, 05/09/2025, 05/11/2025, 05/16/2025, 05/18/2025, 05/20/2025, 05/23/2025, 05/25/2025, and 05/30/2025June- 06/01/2025, 06/06/2025, 06/08/2025, 06/13/2025, 06/15/2025, 06/16/2025, 06/20/2025, 06/22/2025, 06/27/2025, 06/29/2025, and 06/30/2025July- 07/04/2025, 07/06/2025, 07/07/2025, 07/11/2025, 07/13/2025, 07/14/2025, 07/15/2025, and 07/18/2025August- 08/08/2025, 08/10/2025, and 08/11/2025 <Staff N>Review of the facility employee list showed Staff N, NAR, was hired on 04/01/2025. Review of Staff N's records showed they passed an out-of-state Idaho NAC examination on 10/25/2024. No documentation was found of a certification of completion of a NAC training program or to show Staff N completed the NAR certification application attestation form, as required to continue to work beyond the 120-day deadline. Review of Staff N's credentials showed they were credentialed as a Washington State NAR on 05/02/2025. Review of payroll/time clock data from 07/30/2025 (120 days from 04/01/2025 hire date) through 08/15/2025 showed Staff N worked on the following dates:July- 07/31/2025August- 08/01/2025, 08/04/2025, 08/06/2025, 08/08/2025, 08/11/2025, and 08/14/2025 <Staff O>Review of the facility employee list showed Staff O, NAR, was hired on 04/09/2025. Review of Staff O's credentials showed they were credentialed as a Washington State NAR on 04/06/2012 with an expiration date of 01/30/2013. No further credential documentation was provided. Review of Staff O's records showed they passed an out-of-state Idaho NAC examination on 10/16/2024. No documentation was found of the certification of completion of a NAC training program or to show Staff O completed the NAR certification application attestation form, as required to continue to work beyond the 120-day deadline. Review of payroll/time clock data from 08/07/2025 (120 days from 04/09/2025 hire date) through 08/15/2025 showed Staff O worked on the following dates:August- 08/07/2025 and 08/15/2025 <Staff P>Review of the facility employee list showed Staff P, NAR, was hired on 04/09/2025. Review of Staff P's records showed they passed an out-of-state Idaho NAC examination on 01/12/2018. No documentation was found of the certification of completion of a NAC training program or to show Staff P completed the NAR certification application attestation form, as required to continue to work beyond the 120-day deadline. Review of Staff P's credentials showed they were credentialed as a Washington State NAR on 06/16/2025. Review of payroll/time clock data from 08/07/2025 (120 days from 04/09/2025 hire date) through 08/15/2025 showed Staff P worked on the following dates:August- 08/08/2025, 08/11/2025, and 08/12/2025 On 08/15/2025 at 8:00 AM, a certification of completion of NAC program or DOH authorization to test, passed skills test score sheet e-mail from WABON, passed online written test sheet from Credentia, and the completed certification application attestation forms for Staff K, L, M, N, O, and P were requested from Staff A, Administrator. In an interview on 08/15/2025 at 8:37 AM, Staff D, Human Resources, explained Staff N, O, and P had their NAC in Idaho but only had their Washington State NAR and worked as NARs while they waited for their Washington State NAC. Staff D acknowledged Staff K's date of hire was 09/20/2024, Staff K failed the NAC test twice and had one more chance to test but had not scheduled the test yet. Staff D stated they were unsure if Staff K, L, M, N, O, or P had a completed NAR certification application attestation form on file. In a follow-up interview on 08/15/2025 at 10:52 AM, Staff D, provided NAR certification application attestation forms for Staff L, M, N, O, and P. No documentation was provided for Staff K. Staff D acknowledged the forms provided were completed on 08/15/2025 because they were unaware the form had to be completed for an NAR to continue to work beyond the 120-day deadline until today. In an interview on 08/18/2025 at 11:12 AM, Staff A, Administrator, stated the facility was in compliance with NARs obtaining their NAC within 120 days of hire. Reference WAC 388-97-1660 (3)(a)(i)

Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR, an assessment completed prior to admission into a skilled nursing facility to determine whether a resident with a diagnosis of a serious mental illness needed specialized mental health services) was accurately completed prior to admission, and if indicated, a referral for a PASARR Level II (a more in-depth screening assessment) was made for 3 of 7 sampled residents (Residents 1, 24, and 70), reviewed for PASARR. Specifically, Resident 1 and 24's PASSAR Level I was inaccurately completed prior to admission. In addition, Resident 1 admitted to the facility with an exempted hospital stay and should have been referred for a Level II evaluation after they remained in the facility for more than 30 days. This failure placed the residents at risk for unidentified care needs related to their mental health and a diminished quality of life.Findings included. Review of the facility policy titled, Pre-admission Screening and Resident Review (PASARR) revised November 2024, showed a PASARR screening sheet was completed prior to admission, a negative Level 1 screen permitted admission to proceed and ended the pre-screening process unless possible serious mental disorder or intellectual disability arose later. A positive Level 1 screen required a PASARR Level II screen be conducted prior to facility admission. Individuals who had or were suspected to have a mental disorder or related conditions were not permitted for admission unless approved based on the Level II evaluation and determination. For residents admitted to the facility as an exception (an exempted hospital discharge) and was later found to require more than 30 days of nursing facility care, the State mental health or intellectual disability authority must conduct a Level II resident review within 40 calendar days of admission. <Resident 24> According to the 05/24/2025 admission assessment, Resident 24 admitted to the facility on [DATE] with diagnoses including anxiety, depression, nightmare disorder, and Post Traumatic Stress Disorder (PTSD, a condition that may develop after experiencing or witnessing a terrifying event where life was threatened or severe injury occurred). The assessment further showed Resident 24 had severe cognitive impairment. Review of the 05/20/2025 PASARR showed Resident 24 showed indicators of a serious mental illness. The PASARR identified Resident 24 as No Level II evaluation indicated related to not showing indicators of serious mental illness or related conditions. Review of May 2025 through August 2025 social service progress notes showed no documentation Resident 24's PASARR Level I was redone or referred for Level II evaluation as required. In an interview on 08/14/2025 at 9:47 AM, Staff C, Social Service Director (SSD), explained a PASARR was received with preadmission paperwork, reviewed for accuracy, fixed if inaccurate, and sent off for Level II evaluations when indicated. Staff C reviewed Resident 24's PASARR. Staff C stated they were unaware the PASARR guidance changed in July 2024. <Resident 1> According to the 06/21/2025 admission assessment, Resident 1 admitted to the facility on [DATE] with diagnoses including anxiety, depression, bipolar disorder (mental health condition that caused extreme shifts in mood, energy, and ability to function, swinging between periods of elevated mood and periods of depression), suicidal ideations (thoughts or rumination of dying by suicide), and PTSD. Resident 1 was cognitively intact and able to clearly verbalize their needs. Review of the 06/17/2025 PASARR showed Resident 1 showed indicators of a serious mental illness. The PASARR identified Resident 1 as an exempted hospital stay and would likely require fewer than 30 days of nursing facility services. A Level II must be completed if scheduled discharge does not occur. Review of June 2025 through August 2025 social service progress notes showed no documentation Resident 1's PASARR Level I was redone or referred for Level II evaluation as required when they did not discharge the facility within 30 days as anticipated. In an interview on 08/14/2025 at 9:55 AM, Staff C reviewed Resident 1's medical record. Staff C stated Resident 1 admitted with an exempted hospital discharge PASARR and their planned discharge had not occurred yet. Staff C explained when a resident admitted with a hospital exempted stay, a new PASARR was not redone or referred for a Level II evaluation within the 30 days because they thought the PASARR had to be redone or referred if their normal scheduled discharge did not occur whenever that may be, even if it was beyond the 30-day hospital exemption. Staff C acknowledged Resident 1's PASARR was not redone or referred for a Level II evaluation, as required. <Resident 70> The 07/09/2025 quarterly assessment documented Resident 70 admitted to the facility on [DATE] with diagnoses which included depression and dementia. The assessment further showed Resident 70 had severe cognitive impairment. Review of the 08/22/2024 PASARR showed Resident 70 had indicators of a serious mental illness. The PASARR identified Resident 70 as No Level II evaluation indicated related to not showing indicators of serious mental illness or related conditions. Review of May 2025 through August 2025 social service progress notes showed no documentation Resident 70's PASARR Level I was redone or referred for Level II evaluation as required. In an interview on 08/14/2025 at 1:15 PM, Staff C stated Level II PASARR's were completed based on the resident's mental health, medications and diagnoses. Staff C stated Resident 70 should have had a Level II PASARR completed but was unaware the guidelines had changed. Staff C stated it was important to complete Level II PASARR's, so the residents were appropriately assessed for their mental health needs. In an interview on 08/14/2025 at 1:27 PM, Staff B, Director of Nursing, stated their expectation was for residents to be referred for Level II PASARR's when indicated and it was important so that all their mental health needs were addressed. In an interview on 08/18/2025 at 11:12 AM, Staff A, Administrator, stated they expected staff to ensure PASSAR Level I was completed accurately, exempted hospital stay PASARRS were re-done when indicated, and PASARRs referred for Level II evaluations as indicated. Refer to WAC 388-97-1915 (1)(2)(a-c)

Based on observation, interview and record review, the facility failed to revise comprehensive care plans for 4 of 5 sampled residents (Residents 81, 5, 22 and 9) whose care plans were reviewed for pressure ulcers, restorative nursing programs, dental care, and advanced directives. Additionally, the facility failed to ensure Resident 42 and/or their representative were offered the opportunity to participate in care planning. These failures placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <Advanced Directives> <Resident 81> Review of a 07/16/2025 quarterly assessment showed Resident 81 admitted to the facility on [DATE] with diagnoses including stroke with right-sided hemiplegia (total or partial paralysis on one side of the body). The assessment showed the resident had moderately impaired cognition. Review of a 08/03/2022 POLST (Physician Orders for Life Sustaining Treatment, a written medical order from a provider that helps give people more control over their own care by specifying the types of medical treatment they want to receive during a serious illness) showed the choice of Do Not Attempt Resuscitation [DNR] or Allow Natural Death if the staff found Resident 81 with no pulse and not breathing. Review of an 08/05/2022 care plan showed, Honor resident's code status: FULL CODE, contrary to the choice of DNR in the POLST. The above findings were shared with Staff B, Director of Nursing, on 08/13/2025 at 12:44 PM. Staff B acknowledged the care plan should have been but was not updated to show Resident 81's choice in the POLST. <Restorative Nursing Program> <Resident 22> Review of a 07/16/2025 quarterly assessment showed Resident 22 admitted to the facility on [DATE] with medically complex conditions, was cognitively impaired and had limitation in range of motion (ROM, the extent to which a joint can move) to one side of their body. An observation on 08/11/2025 at 7:13 AM showed Resident 22 sitting in a wheelchair across the nurses' station, glasses on and an orthotic brace (a custom or prefabricated device that provides support, stability, and protection to the forearm, wrist, and hand to improve function, reduce pain, and promote healing for various musculoskeletal conditions) to the right forearm. Review of the Restorative Nurse Notes of 01/15/2025, 04/16/2025 and 07/16/2025 showed Resident 22 was, not currently working with restorative. Resident was currently working with the therapy department. Will eval [evaluate] quarterly and PRN [as needed]. Review of a 03/22/2022 care plan showed Resident 22 required a ROM program r/t [related to] physical weakness, risk for contractures and Review restorative program routinely to validate effectiveness. Adjust program as indicated. In an interview on 08/15/2025 at 8:45 AM, Staff R, Restorative Nurse, stated Resident 22 was not on a Restorative Nursing Program (RNP) for the ROM and the RNP was resolved on 01/06/2025. Staff R acknowledged the care plan should have been but was not updated. <Denture Care> <Resident 5> A review of a 06/09/2025 Medicare 5-day assessment showed Resident 5 admitted to the facility on [DATE] with medically complex conditions and was cognitively intact. This assessment showed the resident was dependent on the staff to use use suitable items to clean teeth, to include dentures and their related care (like ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with use of equipment). The assessment also showed Resident 5 was at risk for developing pressure ulcers (bed sores) and used a pressure reducing device for the bed. In an interview and observation on 08/11/2025 at 8:45 AM, a denture cup was observed sitting on Resident 5's bedside table. Inside the denture cup was a full set of dentures in water. A somewhat transparent film was observed on the water. Resident 5 was in bed sitting up and said the dentures, been sitting in that water for a long period of time. [The staff] just soak them in water. Review of Resident 5's care plan showed no recognition of the presence of dentures or their related care. In an interview on 08/18/2025 at 9:23 AM, Staff H stated they became aware of what kind of dental care a resident required by reviewing their Kardex (an abbreviated care plan for the nursing assistants). Staff H said dentures required brushing them with a denture brush and then soaking overnight. Staff H said Resident 5 owned dentures. In an interview on 08/18/2025 at 8:57 AM, Staff I, Registered Nurse, said they expected denture care to be in the care plan or in the Tasks section of the electronic record and that dentures should be cleaned on day shift and night shift, and at night placed in a denture cup soaked in water with a denture cleanser tablet. The use of denture adhesive was a resident preference. Staff I confirmed Resident 5 owned a full set of dentures and the care plan showed no indication of the existence of dentures and their required care. <Specialty Mattress Settings> In an interview and observation on 08/11/2025 at 8:54 AM, Resident 5 said, There's potholes everywhere in this mattress. Observed was a motor pump to the foot board of the bed which showed the mattress setting was set to Firm as opposed to normal pressure. Resident 5 added, I feel like I'm sitting on two cinder blocks, and I cry. This is like medieval times and I'm gonna' get one [a pressure ulcer]. Resident 5 stated their left butt bone was sore but not open. Review of Resident 5's care plan showed, Air mattress to bed but showed no direction to the setting required to provide prevention of pressure ulcers and comfort for the resident. Review of the rest of the medical record showed no instruction on the pump setting required to prevent pressure ulcers and maintain comfort. <Resident 9> Review of an 08/06/2025 quarterly assessment showed Resident 9 admitted to the facility on [DATE] with weakness and heart and lung conditions, dementia, and seizures. This assessment showed the resident was at risk for developing pressure ulcers and was dependent on the staff for turning and repositioning. Review of Resident 9's medical record showed a 05/04/2023 Order Summary for a bariatric bed (a specialized bed designed to safely accommodate and support individuals with a higher body weight, often exceeding 350 pounds) with an air mattress to allow for more room for bed mobility and prevent skin impairments. Additionally, the care plan reiterated the use of a bariatric bed with an air mattress since 05/04/2023. No settings to ensure comfort and prevent pressure ulcer development were identified either in the order summary or the care plan. In an interview on 08/18/2025 at 9:12 AM Staff I, Registered Nurse, said information related to specialty mattress settings was found either in the care plan or the Treatment Administration Record (TAR). Staff I confirmed Resident 5's and 9's medical record showed no indication of the settings required to prevent pressure ulcers and provide comfort and that it should because, If it's at the wrong setting it could cause a sore. The above findings were shared with Staff B, Director of Nursing, on 08/18/2025 at 10:46 AM. Staff B said the care plan should show instructions for denture care. Staff B acknowledged Resident 5's and 9's medical records or care plans showed no information related to denture care or mattress settings. <Resident 42> The 07/09/2025 quarterly assessment documented Resident 42 had diagnoses which included heart failure, high blood pressure and diabetes. The resident was cognitively intact and able to make their needs known. In an interview on 08/12/2025 at 9:17 AM, Resident 42 stated they had not been invited to a care conference. A review of Resident 42's medical record showed no care conference notes from 01/01/2025 through 08/13/2025. The record showed the resident had quarterly assessments completed on 04/09/2025 and 07/09/2025. In an interview on 08/13/2025 at 2:28 PM, Staff E, Resident Care Manager, stated care conferences were held within 24 to 72 hours of admission and quarterly thereafter. Staff E stated the residents and family members were invited to attend. Staff E added the care conferences were documented under evaluations and it was important to have care conferences, so the residents and family had a say in their care and knew what was going on while in the facility. In an interview on 08/13/2025 at 2:35 PM, Staff C, Social Service Director, stated care conferences were documented under evaluations or in the progress notes. Staff C showed a psychological evaluation form dated 01/10/2025 and stated it was Resident 42's initial care conference. Staff C stated Resident 42 should have had a care conference in April, but they completed it in May. Staff C stated they discussed the resident's condition with their family member. The progress note did not address the required elements of a care plan conference. There was no mention of Resident 42's care plan, medications, or how they were doing with activities of daily living. Staff C stated Resident 42 was ill at the time. Staff C stated the resident was due for a care conference in July and they were unsure why this did not occur. Staff C checked their calendar for August and Resident 42 was not scheduled for a care conference. In an interview on 08/13/2025 at 3:13 PM, Staff B, Director of Nursing, stated care conferences needed to have the interdisciplinary team present. Staff B stated the resident's medications, code status, immunizations, therapy, and activity preferences were discussed at the care conference. Staff B stated it was important to have care conferences because it was the main source of communication with the residents and their families and to ensure the code status and goals of care had not changed. Staff B stated Resident 42 should have had care conferences in April and July. Reference: WAC 388-97-1020(5)(b)

Based on observation, interview, and record review, the facility failed to ensure it coordinated follow-up appointments with the denturist (a person who made dentures) for 1 of 1 sampled resident (Resident 5) reviewed for dental needs. This failure placed Resident 5 at risk of discomfort or pain from ill-fitting dentures, weight loss and decreased self-esteem. Findings included. Review of an 08/13/2025 annual assessment showed Resident 5 admitted to the facility on [DATE] with medically complex conditions and was cognitively intact. This assessment showed the resident had no natural teeth or tooth fragments or abnormal mouth tissue. A care area assessment worksheet associated with the 08/13/2025 annual assessment showed Resident 5 was, having a sore on gum line that is being treated/monitored. Resident is at risk for weight changes and chewing problems. The note also showed, dental appointments as ordered or requested PRN [as needed]. In an interview and observation on 08/11/2025 at 8:45 AM, Resident 5 said the staff should have but did not set up a dental appointment in January 2025. Resident 5 explained they were fitted and received new upper and lower dentures that did not fit well and felt, the teeth need to be brought down more. Resident 5 said, I can't eat with them in my mouth. It feels really wrong, the fit is not correct, the bite. The teeth are too large on the dentures. Observed on the bedside stand was a denture cup to which Resident 5 said dentures were inside and, been sitting in that water for a long period of time. They just soak them in water. Inside the denture cup was a full set of dentures with a somewhat transparent film observed on the water.On 08/13/2025 at 12:07 PM, a peanut butter and jelly sandwich on wheat bread, a vanilla ice cream cup and a small bag of Doritos chips were served to Resident 5 for lunch. The resident said, I asked for potato chips [not Doritos] coz I can't chew!Review of a 10/18/2019 oral/dental health problems care plan showed the goal of the resident, will be free of infection, pain or bleeding in the oral cavity. An intervention instructed the staff to, Coordinate arrangements for dental care, transportation as needed/as ordered. The care plan showed Resident 5 had no teeth and no recognition of the presence of dentures.Review of the progress notes showed that on 11/02/2024, Resident 5 went to a dental clinic and was fitted for dentures, with a follow up appointment on 11/15/2024. An 11/15/2024 progress note showed the resident returned from the dental office, with [their] new dentures and had a follow-up fitting appointment on 12/06/2025. Between 11/15/2024 and 12/06/2024, the progress notes showed Resident 5 chose not to wear their dentures because they described them as too thick, wants them filed down, and was not going to wear them until their follow-up appointment on 12/06/2024. Review of the progress notes showed the resident went to their follow-up appointment of 12/06/2024 but the medical record showed no documentation of the appointment's summary. Review of progress notes of 12/07/2024 showed Resident 5 did not tolerate and was not wearing their new dentures, states they feel foreign and don't seem to fit right, upper gums are slightly inflamed and has a follow-up dentist appointment and will re-evaluate at that time. A 12/09/2024 progress note showed the resident continued to refuse to wear the dentures, as they are still uncomfortable to wear, until seen by the denturist in January 2025. The medical record showed no documentation of what efforts the facility made to notify and secure an earlier appointment with the denturist prior to the January 2025 appointment. Additionally, the medical record showed no documentation that the facility coordinated Resident 5's January 2025 follow-up appointment with the denturist. Review of the progress notes through 08/03/2025 showed Resident 5 continued to not wear the dentures (06/12/2025) or refused to wear them (08/01/2025). An 08/01/2025 progress note showed the resident reported to the nurse an open sore to bottom right inner gums from the resident picking at it and from biting down on it - has been refusing to wear dentures since [they] obtained them. Appears similar to canker sore [a small, painful sore inside the mouth on the tongue, gums, or inner cheeks]. On 08/04/2025, the progress note showed the resident reported to the staff they had pain at the site of the sore and was grinding their gums at times. On 08/05/2025, an order was obtained for chlorhexidine, a prescription-strength mouth rinse used to treat gum disease. Review of the medical record showed no documentation that the facility coordinated a follow -up appointment with the denturist for Resident 5 from January 2025 to August 2025 even though they knew the resident continued to refuse to wear the dentures secondary to fit issues. In an interview on 08/18/2025 at 9:23 AM, Staff H, Nursing Assistant, stated that they were aware Resident 5 mentioned it a few times they did not like how their dentures fit them. In an interview on 08/18/2025 at 8:57 AM, Staff I, Registered Nurse, stated that if dentures did not fit correctly, the facility would get a resident to see a denturist. Staff I stated Resident 5 refused to wear their dentures because they don't fit properly and did not know what the plan was at the moment to address the ill-fitting dentures. In an interview on 08/18/2025 at 10:03 AM, Staff CC, Receptionist, confirmed they coordinated appointments and transportation for the residents in the facility. Staff CC stated Resident 5 refused to go to their January 2025 appointment because it was during the winter months and the resident, wanted to wait until the weather got better. When asked when the appointment would be coordinated in better weather, Staff CC stated, Probably March. When asked if they had any documentation to show efforts were made to reschedule or coordinate Resident 5's follow-up appointments with the denturist, Staff CC stated, Probably not. I haven't talked to [Resident 5] in a while.The above information was shared with Staff B, Director of Nursing, on 08/18/2025 at 10:46 AM. Staff B acknowledged there was no documentation to show coordination of follow-up denturist appointments for Resident 5 as planned or when they continued to refuse to wear their dentures due to poor fitting. Staff B said the January 2025 appointment with the denturist, should have stayed on our clinical follow-up tool until we obtained those [visit] documents. Reference WAC 388-97-1060 (1), (3)(j)(vii)

Based on observation, interview, and record review, the facility failed to ensure an allegation of staff- to-resident rough handling was reported to the Administrator or designee and to the State Agency (SA) within the required timeframe for 1 of 1 sampled residents (Resident 81) reviewed for abuse. This failure placed the resident and other residents at risk for potential physical abuse and precluded the SA from being aware of and investigating the circumstances surrounding the resident's allegation.Findings included. Review of a revised 08/01/2023 facility policy titled Identification and Investigation of Abuse, Neglect, Misappropriation, and Injuries of Unknown Origin showed the facility identified incidents and occurrences that could constitute or contribute to abuse and neglect by reviewing grievances and complaints, and reports of allegations of abuse or neglect, injuries of unknown origin, or other evidence of physical, verbal, sexual or psychological abuse. The policy showed the staff notified the Administrator, the Director of Nursing, and Social Services personnel immediately upon knowledge of an allegation of abuse or neglect, managed the incident for any immediate medical needs, evaluated the resident for signs of negative psychosocial impact, protected the residents during and after the investigation by increasing supervision of the alleged resident, making room or staffing changes if necessary to protect the residents from the alleged staff, and protecting the resident from retaliation. The policy showed that if a staff member was implicated in the allegation, the facility would protect the resident by suspending the staff pending investigation. The administrator or designee notified the SA immediately but no later than two hours after an allegation of abuse or serious bodily injury was identified. All other allegations were reported to the SA immediately but no later than 24 hours from the time the allegation was known to the staff member. Review of a 07/16/2025 quarterly assessment showed Resident 81 admitted to the facility on [DATE] with a stroke and right-sided hemiplegia (total or partial paralysis on one side of the body). The assessment showed the resident had moderately impaired cognition and required assistance from the staff for Activities of Daily Living. An observation on 08/12/2025 at 2:53 PM showed Resident 81 sitting in a wheelchair across the Nurses Station with a transfer sling underneath them. Their right upper arm showed scattered purple bruises, a white dressing dated 08/11/2025 and directly below it a brown undated dressing. Observation of the left arm showed a large purple bruise that extended from the bicep (large muscle that lies on the front of the upper arm) to the elbow, with faded yellow green discoloration to the upper edges, and a dressing above the left elbow area. In an observation and interview on 08/13/2025 at 8:19 AM, Resident 81 was in bed with their breakfast in front of them. When asked about the large bruise to the left upper arm, the resident said, Some aides got rough with me this past weekend. I was abused by a couple aides this weekend on Night Shift. Resident 81 said that when the staff provided incontinence care, How they changed me, how they cleaned me up, they pulled on my arm. Review of an 08/14/2025 Skin Inspection Evaluation completed by Staff I, Registered Nurse, showed No new concerns, no actual skin impairments and continue with current POC [plan of care]. In an interview on 08/15/2025 at 11:27 AM, Staff H, Nursing Assistant, stated they noticed the large bruise to Resident 81's left arm on 08/11/2025 when they worked on Day Shift and, I wouldn't even know how to explain that. I don't know what could have happened. Staff H said the resident told them they, already talked to management on Monday. In a follow up interview on 08/18/2025 at 9:28 AM, Staff H said there were skin tears under the dressings to Resident 81's arms. When asked what Resident 81 told them about the bruise to the left arm, Staff H said, I don't know how to even word that. [The resident] started saying something about the night shift girls being rough with [them]. But I reported it. I did mention it to [Staff I]. Staff H said they and Staff I, sat and talked about that last week and I'm sure someone must have reported it before because this happened over the weekend. Staff H said Resident 81 said two girls were the alleged staff but was not specific if it happened in the evening hours or night shift. Staff H recognized the resident description of the incident as an allegation of physical abuse. Staff H said everyone was a mandated reporter whose responsibility was to go ahead and report it, file a report, take it further up because it's an allegation that can't be side swiped. I know I report it to the nurse. Staff H made no mention of reporting the allegation to the Administrator or their designee or the SA as a mandated reporter. In an interview on 08/18/2025 at 9:08 AM, Staff I said they were unaware of the allegation of staff-to-resident rough handling, not until this morning when the resident showed them their left arm and stated Staff H, did not report anything that happened to [Resident 81] with the night aides. There was nothing ever said to me about the bruise to the left arm. Staff I said everyone was a mandated reporter and must report to the Director of Nursing, the Administrator and the State Hotline (or SA). Review of the facility incident log and medical record showed no documentation the facility recognized and questioned the presence of a large substantial bruise to the left arm or reported the allegation of staff-to-resident rough handling to the SA within the required timeframe of two hours. The above findings were shared with Staff B, Director of Nursing, on 08/18/2025 at 11:16 AM. Staff B acknowledged the staff should have reported the allegation of staff-to-resident rough handling to the SA and the Administrator or designee on 08/11/2025 and did not. Staff B said residents were placed in similar occurrences when the staff fail to report to the Administration or the SA allegations of abuse or neglect. Reference WAC 388-97- 0640(5)(a).

Based on interview and record review the facility failed to ensure the appropriate minimum information to include contact information of the practitioner responsible for the care of the resident, resident representative contact information, advanced directive information, comprehensive care plan goals, any special instructions and/or precautions for ongoing care, and all other necessary information was communicated to hospital at time of transfer, as required for 1 of 3 sampled residents (Resident 86) whose closed records were reviewed. This failure placed residents at risk of potential delays in emergent hospital treatment, potential medical complications, and diminished quality of life. Findings included.According to the 07/19/2025 Medicare five-day assessment, Resident 86 admitted to the facility on [DATE] with diagnoses including anemia (not enough blood cells) and gastritis (inflammation of the stomach lining) with bleeding. Resident 86 was cognitively intact and able to clearly verbalize their needs.Review of July 2025 nursing progress notes showed on 07/20/2025 Resident 86 complained of abdominal pain and informed staff that was a symptom they previously experienced when they had a gastrointestinal (GI, digestive system) bleed. The provider was notified, and Resident 86 was transported to the hospital via a facility van. No documentation was found to show what information was conveyed to the hospital at time of transfer, as required. In an interview on 08/15/2025 at 8:33 AM, Staff G, Registered Nurse, stated if/when a resident required hospital transport, they would assess the resident and notify the provider. Staff G explained they would then print out a face sheet (quick summary of essential medical history details for healthcare providers at a glance), most recent labs, medication list, and send a POLST (Physician Orders for Life Sustaining Treatment- a form that informed healthcare professionals of a person's wishes related to cardiopulmonary resuscitation in case of a medical emergency). Staff G further stated a report was then called to the hospital and the process documented in a progress note. In an interview on 08/15/2025 at 9:49 AM, Staff E, Resident Care Manager, stated if/when a resident required hospital transport, the nurse would assess the resident and call the provider. Staff E explained a face sheet, POLST, medication list, most recent vital signs, and progress notes were sent to the hospital upon transfer. Staff E further stated staff typically did not document what information was sent to the hospital at time of transfer but if staff called the hospital and gave a verbal report on the resident's condition, it would be documented in a progress note. Staff E reviewed Resident 86's medical record. Staff E acknowledged they were unable to find documentation of what information was conveyed to the hospital at time of transfer. In an interview on 08/15/2025 at 10:31 AM, Staff B, Director of Nursing, stated when a resident required hospital transfer, a face sheet, medication list, POLST, and any pertinent information would be printed out and physically sent with the resident to the hospital. The nurse would then call the hospital to report the resident's condition and document a summary in a progress note. Staff B further stated the facility was not electronically integrated with the hospital and did not utilize electronic forms of communication with the hospital. Staff B stated staff should document information conveyed to the hospital in a progress note. In an interview on 08/18/2025 at 11:12 AM, Staff A, Administrator, stated they expected staff to document what information was conveyed to the hospital at time of transfer, as required. No associated WAC

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 sampled residents (Resident 1), reviewed for smoking. This failure placed residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included.Review of the facility policy titled, Care Plans revised October 2024, showed a comprehensive person-centered care plan was developed and implemented consistent with the resident's specific conditions, risks, needs, behaviors, and preferences within seven days after the completion of the comprehensive assessment. According to the 06/21/2025 admission assessment, Resident 1 admitted to the facility on [DATE] with diagnoses including respiratory failure (inability to effectively exchange oxygen and carbon dioxide). Resident 1 was cognitively intact and able to clearly verbalize their needs. Review of the residents that smoke list provided to the survey team on 08/11/2025, identified Resident 1 as choosing to smoke. Review of the 07/15/2025 substance use disorder care plan showed Resident 1 was alcohol and nicotine dependent, interventions instructed staff to encourage the resident to discuss their feelings, assist the resident in learning and use of relaxation skills, encourage fluids, exercise, and deep breathing to minimize withdrawals symptoms. No documentation was found to show goals and interventions were developed related to Resident 1 currently smoking. During observation on 08/11/2025 at 7:07 AM, Resident 1 was observed outside the facility in the designated smoking area, smoking a cigarette. A similar observation was made on 08/13/2025 at 1:39 PM. In an interview on 08/13/2025 at 1:53 PM, Staff U, Nursing Assistant, stated if a resident was safe and allowed to smoke, it would be documented on their care plan. Staff U acknowledged Resident 1 smoked. In an interview on 08/13/2025 at 1:55 PM, Staff V, Licensed Practical Nurse, stated if a resident was cleared to smoke, it would be documented on their care plan. Staff V stated Resident 1 was ok to smoke. In an interview on 08/13/2025 at 1:59 PM, Staff B, Director of Nursing, explained if a resident was assessed as safe to smoke, it would be documented on their care plan. Staff B reviewed Resident 1's medical record. Staff B acknowledged there was no smoking care plan in place and there should be. In an interview on 08/18/2025 at 11:12 AM, Staff A, Administrator, stated they expected staff to ensure the care plan accurately reflected the residents care needs. Refer to WAC 388-97-1020 (1), (2)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure the periodic review and monitoring of splint and/or brace wear and effectively address refusals of the Restorative Nursing Program (RNP) for 2 of 2 sampled residents (Residents 22 and 81) reviewed for limited range of motion (ROM, the full movement potential of a joint or series of joints). These failures placed the resident at risk of worsening contractures (a medical condition where muscle, tendon, or other soft tissue becomes abnormally tight and shortened, limiting the ROM at a joint) and diminished quality of life.Findings included.Review of a revised 01/20/2025 facility policy titled Restorative Nursing showed that RNPs, to include splint or brace (a custom or prefabricated device that provided support, immobilized or assisted movement in the hand, wrist, or fingers to heal injuries, correct deformities, prevent stiffness, or manage contractures) assistance programs, required measurable objectives and interventions that were documented in the care plan. Implementation of the interventions were recorded in the medical record. Resident tolerance and compliance were monitored to evaluate progress toward resident goals. The policy showed that while therapists might participate in the RNP, a nurse was still responsible for the overall coordination and supervision of the RNP. <Resident 81>Review of a 07/16/2025 quarterly assessment showed Resident 81 admitted to the facility on [DATE] with a stroke and associated right-sided hemiplegia (complete or partial paralysis to one side of the body). The assessment showed the resident had moderately impaired cognition, functional limitation in ROM to both upper and lower extremities to one side of the body and received no RNP or therapy services. Both the resident and the legal guardian participated in the assessment and goal setting.An observation and interview on 08/11/2025 at 7:54 AM showed Resident 81 in bed with breakfast in front of them. Resident 81 brought food to their mouth with their left hand although cutlery was present. The resident said, It sucks, as they were unable to move or use their right arm or hand. Some of the right hand fingers were observed curled inwards. In an interview on 08/15/2025 at 10:02 AM, Staff AA, Physical Therapist (PT), said that Resident 81 was released from therapy caseload to a RNP on 04/03/2024. Staff AA said the resident was to wear a right hand and knee orthotic (supportive device, like a brace or splint) every day on Saturdays, start one hour a day for two weeks and then one hour every two weeks, progress until [the resident] reached the ability to wear hand orthotics eight hours, six days a week. Review of a 10/18/2023 care plan showed Resident 81, has risk for contractures/impaired functional range of motion related to hemiplegia and that the resident would not experience any complications related to wearing a splint. The care plan instructed the staff to monitor skin condition under splint upon splint removal and report any areas of concern, provide hand hygiene prior to application and upon removal of the hand splint, refer to therapy as needed, and see restorative programs. The care plan showed no rejection or refusals to participate in the RNP. Review of Resident 81's medical record showed no splint application or other restorative programs. Review of Resident 81's medical record showed the most recent Restorative Nursing Evaluation was last completed on 02/15/2024. This evaluation showed the resident was currently on restorative and had splint/brace assistance 15 minutes a day, six days a week. The evaluation showed the resident participated in the program but chose not to wear the leg brace, only wearing a wrist/hand brace at this time and would evaluate quarterly and as needed. Review of the Restorative Progress Notes showed:- 04/03/2024 Resident continues to choose not to participate in restorative brace program. Will discontinue at this time and re-evaluate PRN (as needed).- 07/17/2024 Resident not currently on restorative. Was on programs in past that were discontinued due to non-participation. Resident offered programs again this quarter and chooses not to participate.- 10/16/2024 Resident is not currently working with restorative. Resident has had programs in the past but continues to choose not to participate. Will eval [evaluate] quarterly and PRN.Review of a 01/02/2025 facility multidisciplinary evaluation report showed Resident 81 was assessed to have severely limited upper extremity (UE) ROM limitations including the right shoulder, elbow, wrist, knee, and foot, and hemiparesis (weakness on one side of the body).Continued review of the Restorative Progress Notes showed:- 01/15/2025 Resident not currently working with restorative. Has had programs in the past but continues to choose not to participate.- 04/16/2025 Resident not currently working with restorative. Has had programs in past but chooses not to participate. Will eval quarterly and PRN.- 07/16/2025 Resident not currently working with restorative. Resident has had programs in the past but continues to choose not to participate. Will eval quarterly and PRN.Review of the medical record showed no associated documentation to the quarterly Restorative Progress Notes where the facility re-assessed Resident 81 and established why the resident continued to choose not to participate in the RNP. The medical record showed no documentation that the facility involved the resident and their representative to review the potential positive and negative outcomes (risks and benefits) of Resident 81's choice not to participate in the RNP, potential alternatives or mitigation plans for risks. In an interview on 08/15/2025 at 9:15 AM, Staff BB, Restorative Aide, said Resident 81 was formerly in a RNP that included a Nustep [a cross-trainer equipment], a ROM program for the legs, and a splint to the right hand, a long time ago but not in use currently. In an interview on 08/15/2025 at 10:02 AM, Staff AA stated they expected of the staff to notify the therapy department of RNP refusals. No information was provided to show the staff notified therapy services of Resident 81's RNP refusals for re-evaluation.In an interview on 08/15/2025 at 9:01 AM, Staff R, Restorative Nurse, confirmed Resident 81 had weakness and impaired ROM to the right side of their body. Staff R said that Resident 81's RNP was discontinued and not restarted because of their refusal to participate. No information was provided to show how the facility managed Resident 81's RNP refusals, to include a review of the risks and benefits of the resident's choice with the resident and their representative and offering and trial of alternatives.In an interview on 08/18/2025 at 10:47 AM, Staff B, Director of Nursing, stated that the provider should be notified of refusals, hold a care conference to review the possible negative impacts to the resident or discuss the risks and benefits with the resident or their advocates, and address the refusals in the care plan. <Resident 22>Review of a quarterly assessment of 07/16/2025 showed Resident 22 admitted to the facility on [DATE] with seizures and hemiplegia or hemiparesis (weakness to one side of the body). The assessment showed the resident had severely impaired cognition, functional limitation in ROM to both upper and lower extremities to one side of the body, last received therapy services on 03/10/2025 by PT, and received no RNP.An observation on 08/11/2025 at 6:49 AM showed Resident 22 in bed with a brace to the right forearm. On 08/13/2025 at 11:55 AM, Resident 22 was sitting in their wheelchair in the dining room, and no brace was observed to the right forearm. On 08/13/2025 at 3:37 PM, no orthotic was observed on or to Resident 22's right arm or hand. On 08/14/2025 at 8:00 AM, the resident was in the dining room eating breakfast and a brace to the forearm was observed. Review of a 03/04/2025 PT Therapy Discharge note showed, RA staff have been trained on donning and doffing R [right] hand brace. A 04/09/2025 PT note showed continuing to wear right hand brace.Review of the August 2025 Treatment Administration Record (TAR) showed a 09/29/2024 order that instructed the staff to, Apply R [right] arm brace. place on in AM [morning at 7:00 AM and remove at 1:00 PM] Wear during the day for 6-8 hours, an opportunity of six hours. Review of the TAR showed no documentation how long Resident 22 tolerated the brace on. Review of the August 2025 TAR also showed a 02/19/2025 order that instructed the staff to apply a carrot [a device that painlessly positions the fingers away from the palm] twice a day at 3:00 PM and 7:00 PM, for a period of 60 to 90 minutes at a time. Review of the TAR showed no documentation how long Resident 22 tolerated the carrot in place. Review of the Restorative Nurse notes showed on 01/15/2025, 04/16/2025 and 07/16/2025, Resident not currently working with restorative. Resident is currently working with the therapy department. Will eval quarterly and PRN. There was no documentation to show the facility evaluated the effectiveness of the brace or carrot and if the resident met the order goals for tolerance.Review of Resident 22's care plan showed, Review restorative program routinely to validate effectiveness. Adjust program as indicated. The care plan showed no indication what the RNP was nor acknowledgment and purpose of the right-hand carrot or arm brace. The above findings were shared with Staff R on 08/15/2025 at 8:37 AM. Staff R acknowledged the medical record showed no periodic evaluation of the right-arm brace or right-hand carrot effectiveness for Resident 22's contracture management. Reference WAC 388-97-1060 (3)(d), (j)(ix)

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate care and services to minimize the risk of associated urinary tract infections for 1 of 1 sampled residents (Resident 8), reviewed for catheter (a flexible tube inserted into the bladder to drain urine) care. This failure placed the resident at risk for urinary tract infections. Findings included. Per the Lippincott Manual of Nursing Practice 10th Ed. ([NAME], 2014), infectious organisms can move into the bladder along the outside of any urinary catheter, and the catheter bag (a urine collection bag attached to the catheter) should be kept off the floor (and other unclean surfaces), to prevent bacteria from entering the bladder (pg. 781-782). The 07/02/2025 quarterly assessment documented Resident 8 had diagnoses which included benign prostatic hyperplasia (BPH, prostate gland enlargement that blocks the flow of urine out of the bladder), obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed) and a urinary tract infection (UTI). The assessment showed Resident 8 required a urinary catheter. In an observation on 08/12/2025 at 12:44 PM, Resident 8 was sitting in their wheelchair in their room eating lunch. Resident 8's catheter bag was resting on the floor. Similar observations of Resident 8's catheter bag and tubing resting on the floor were made on 08/13/2025 at 2:27 PM, 08/14/2025 at 7:15 AM, 8:35 AM, 9:30 AM and 12:33 PM. A review of Resident 8's medical record showed the resident was treated for UTI's on 06/08/2025 and 07/17/2025. The 05/19/2025 urinary catheter care plan did not instruct staff to keep the catheter bag and tubing off the floor. In an interview on 08/14/2025 at 12:46 AM, Staff W, Nursing Assistant, stated catheters were hung underneath the resident's wheelchairs and it was important to keep the collection bag and tubing off the floor to prevent contamination. In an interview on 08/14/2025 at 12:49 PM, Staff G, Registered Nurse, stated catheter bags were hooked underneath the wheelchairs, and it was important to keep the collection bags and tubing off the floor to prevent infection. When asked if Resident 8 had been treated for UTI's in the past, Staff G stated yes, they get them often. In an interview on 08/14/2025 at 12:51 PM, Staff B, Director of Nursing, stated catheters were hung underneath or on the side of the wheelchair below the level of the bladder. Staff B stated it was important to keep the tubing and collection bag off the floor to prevent infection. Staff B also stated Resident 8 has had UTI's. Reference: WAC 388-97-1060 (3)(c)

Based on observation, interview and record review, the facility failed to ensure residents were given their medications as ordered for 1 of 5 sampled residents (Resident 70) reviewed for medication management. This failure placed residents at risk of exacerbations of their chronic health conditions, and unintended consequences when doses of their medications were omitted. Findings included . The 07/09/2025 quarterly assessment documented Resident 70 had diagnoses which included arthritis, migraines and a neck fracture, and had severe cognitive impairments. The 04/06/2023 care plan documented Resident 70 was at risk for pain. Staff were instructed to give medications as ordered. A review of the August 2025 Medication Administration Record (MAR) documented medication orders and omissions:-Pregabalin 150 milligrams (mg) three times a day for neuropathy (weakness, numbness, and pain from nerve damage). The entry on 08/10/2025 and 08/11/2025 said the medication was not available. There was a progress note on 03/11/2025 that stated the medication was reordered. -Humalog insulin inject subcutaneously (under the skin) per sliding scale (a scale that determines how much insulin is needed) before meals for diabetes. The entry on 07/16/2025 and 07/29/2025 for evening shift was blank. -Humalog insulin inject 20 units before meals for diabetes, give 15 units in addition to sliding scale at meals. The entry on 07/16/2025 was blank and the entry on 07/29/2025 had a blood sugar of 135 but no insulin was administered. In an interview on 08/14/2025 at 11:15 AM, Staff G, Registered Nurse, stated medications were reordered when they had a week supply left. Staff G stated if a medication was not available, they would check their Cubex (a locked container that contained an emergency supply of medications) and if the medication was not in the Cubex they would call the pharmacy and have it delivered. Staff G stated to get the medication out of the Cubex they would phone the provider, have them send a new script to the pharmacy and they would obtain a code to pull the medication from the Cubex. They stated the process normally took a couple of hours. Staff G stated the provider should have been notified that the medication was not available. Staff G stated the outcome to the resident regarding not receiving their Gabapentin could have resulted in increased pain, numbness and tingling. In an interview on 08/14/2025 at 11:21 AM, Staff E, Resident Care Manager, stated the nurses were to order medications when they saw they were getting low and if medication was not available they needed to call the pharmacy to ensure the medication was on its way to the facility. Staff F stated they checked the Cubex to see if the medication was available. Staff F looked at the July and August 2025 MAR's and stated the Gabapentin should have been addressed immediately on 08/10/2025 when the first dose was unavailable. Staff F did not find blood sugars for 07/16/2025 and 07/29/2025 and stated that the blood sugars should have been documented and whether the insulin was given or held. Staff F added it was important to check the blood sugars related to hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). In an interview on 08/14/2025 at 11:33 AM, Staff B, Director of Nursing, stated medications needed to be reordered, the nursing staff needed to check the Cubex for the medications, the provider needed to be notified, and the pharmacy was to be notified for a pull code to obtain medications from the Cubex. Staff B stated Resident 70 could have had increased pain related to not receiving their Gabapentin. Staff B stated their expectation was nursing staff should have documented the residents' blood sugar or that the resident refused to have their blood sugar taken. A review of the Cubex medications showed the Gabapentin and Humalog insulin was available. Reference: WAC 388-97-1060(3)(k)(iii)

Based on observation, interview, and record review, the facility failed to perform hand hygiene when indicated during 2 of 3 medication administration observations. Additionally, the facility failed to ensure enhanced barrier precautions (EBP, use of personal protective equipment such as disposable gowns and gloves when providing high contact types of care for residents with drains, tubes, or colonized with antibiotic resistant bacteria) were implemented and followed when indicated or ensure PPE was readily available for 2 of 3 sampled residents (Residents 1 and 6), reviewed for infection control. This failure placed residents at risk for potential unintended health consequences, the potential spread of infectious diseases or organisms resistant to antibiotics, and diminished quality of life.Findings included.According to The Centers for Disease Control (CDC) Implementation of Personal Protective Equipment (PPE- gloves, disposable gowns, eye protection or masks) Use in Nursing Homes to prevent Spread of Multidrug-Resistant Organisms updated July 12, 2002, retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html recommended use of EBP as an infection control intervention that employed targeted gown and glove use during high contact resident care activities when Contact Precautions do not apply for residents with wounds or indwelling medical devices such as feeding tubes (inserted tube that provides liquid nutrition) or catheters (flexible tube inserted into bladder to drain urine). EBP directs staff to put on gowns and gloves when dressing, bathing/showering, transferring, changing linens, providing hygiene, wound care and assisting with toileting.Review of the facility policy titled, Transmission-Based Precautions Conventional Plan revised June 2025, showed EBP were infection control interventions designed to reduce transmission of multi-drug-resistant organisms that employed targeted gown and glove use during high contact resident care activities. EBP were recommended for use in resident rooms when residents had open chronic wounds, indwelling medical devices such as a peripherally inserted central catheter [PICC, long term intravenous (IV) access] or colonized with a multi-drug-resistant organism. Staff was to implement precautions upon identification of high-risk residents that require EBP. High-contact care activities included dressing, bathing, transferring, providing hygiene, changing linens, device care or use, and wound care. EBP was intended for the resident's entire length of stay unless a device was removed or a wound healed. ENHANCED BARRIER PRECAUTIONS <Resident 6> According to the 07/20/2025 admission assessment, Resident 6 admitted to the facility on [DATE] with diagnoses including a non-pressure chronic right foot ulcer. The assessment further showed Resident 6 received IV medications while a resident, was cognitively intact and able to clearly verbalize their needs. Review of the 07/17/2025 hospital discharge report showed Resident 6 discharged from the hospital with a diabetic foot ulcer that required a wound vac (medical device that used gentle suction to help large or difficult wounds heal faster) application and continued IV antibiotics to treat a foot infection. Review of the 07/17/2025 care plan showed Resident 6 required EBP related to wounds and IV antibiotics. Interventions instructed staff to use a gown and gloves for high-contact resident care such as device or wound care. Review of provider orders showed active 07/17/2025 order for EBP because Resident 6 had a PICC. During observation and interview on 08/11/2025 at 6:34 AM, Resident 6 sat in their wheelchair in their room with an IV pump. Resident 6 stated they had a wound vac dressing to their right foot that was changed three times a week and also had a PICC to their right arm. No EBP signage or other unique signage/symbol was posted on the room door or door frame, no PPE was observed to be readily available. In a follow-up interview 08/11/2025 at 9:35 AM, Resident 6 stated staff only wore gloves, no gowns, when they changed their wound vac. No EBP signage or other unique signage/symbol was posted on the room door or door frame, no PPE was observed to be readily available. During observation on 08/11/2025 at 9:57 AM, Resident 6 had their PICC connected to IV tubing and IV medication infusing when the IV pump began to beep because the infusion was complete. Staff X, Registered Nurse (RN), entered Resident 6's room, washed their hands, put on gloves but no gown and proceeded to disconnect Resident 6 from the completed IV. Staff X proceeded to flush the PICC. During observation on 08/11/2025 at 12:22 PM, Resident 6's door frame now had a dark colored flower to the top left corner, 25 days after they admitted to the facility with a chronic wound and a PICC. No PPE was observed to be readily available. During observation on 08/12/2025 at 11:19 AM, Staff X, RN, entered Resident 6's room with IV tubing, an IV medication, IV flushes, and placed them on the table. Staff X washed their hands, put on gloves but again no gown was worn. Staff X then flushed the PICC, connected the IV medication to the resident, and began infusing the medication. <Resident 1> According to the 06/21/2025 admission assessment, Resident 1 admitted to the facility on [DATE] with diagnoses including pneumonia (lung infection). Resident 1 was cognitively intact and able to clearly verbalize their needs. Review of the 07/02/2025 care plan showed Resident 1 received antibiotics for a bladder infection, interventions instructed staff to administer medications as ordered and monitor for adverse reaction. No documentation was found for staff to implement or follow EBP related to Resident 1 having a PICC. Review of 07/09/2025 urine culture results showed handwritten provider orders on the bottom of the page that instructed Resident 1 get a PICC placed as soon as possible and start IV antibiotics for a bladder infection. Review of July 2025 medication administration record showed Resident 1 had IV access and IV antibiotics started on 07/09/2025. Review of provider orders showed active 07/15/2025 orders for Resident 1 to have their PICC dressing changed weekly and as needed when dirty or soiled. No provider orders were found for staff to implement or follow EBP related to Resident 1 having a PICC. Review of a 08/08/2025 provider order showed Resident 1's IV antibiotics ended on 08/09/2025 but the provider ordered staff to leave PICC in place for now due to recurrent bladder infections. During observation on 08/11/2025 at 6:08 AM, Resident 1 laid in bed with an IV pump to the right side of their bed, the trashcan contained used IV flushes and discarded IV bags. No EBP signage or other unique signage/symbol was posted on the room door or door frame, no PPE was observed to be readily available. During a follow-up observation and interview on 08/11/2025 at 7:07 AM, Resident 1 stated they received the last dose of IV antibiotics yesterday but still had the PICC in place in case they required further IV antibiotics to be administered. Resident 1 pulled down a light compression wrap on their right upper arm to expose their PICC. In a follow-up interview on 08/11/2025 at 10:19 AM, Resident 1 stated staff wore gloves and a mask when they changed the PICC dressing but staff did not wear gowns. No EBP signage or other unique signage/symbol was posted on Resident 1's room door or door frame, no PPE was observed to be readily available. During observation on 08/11/2025 at 12:21 PM, Resident 1's door frame now had a dark colored flower to the top right corner, 33 days after they had their PICC inserted. No PPE was observed to be readily available. In an interview on 08/14/2025 at 9:08 AM, Staff U, Nursing Assistant, stated EBP required the use of gloves and a gown when providing high touch resident care. Staff U explained the facility placed succulents, a flower, above the resident doors who required EBP. Staff U pointed a flower to the door frame of room [ROOM NUMBER]. Staff U explained PPE should be in the bottom nightstand drawer. Staff U did not find any gowns in any nightstand drawers but found one gown in the bathroom cabinet. Staff U acknowledged staff should implement and follow EBP when indicated to reduce the spread of infection; Resident 1 required EBP related to having a PICC and Resident 6 should be on EBP related to having a PICC and wound vac in place. In an interview on 08/14/2025 at 10:38 AM, Staff T, RN, stated EBP required the use of gloves and a gown when care was provided such as PICC management to prevent the spread of infection. Staff T explained the facility placed a flower on a resident's room door when they required EBP. Staff T acknowledged staff should implement and follow EBP when indicated. In an interview on 08/14/2025 at 11:58 AM, Staff E, Resident Care Manager, explained the facility placed succulents on the door frames to resident rooms that required EBP. Staff E stated EBP required the use of gloves and gown during high contact care activities such as accessing lines. Staff E further stated they expected staff to implement and follow EBP when indicated to prevent the spread of infection. In an interview on 08/14/2025 at 12:16 PM, Staff F, Infection Preventionist, stated EBP required the use of gloves and gowns with any high contact care activities such as changing linens or accessing a PICC. Staff F explained the facility placed succulents on resident room door frames to inform staff EBP was required in a room; gowns were stocked and stored in varying room locations depending on which staff stocked the gowns. Staff F further staff also obtained a provider order and care planned EBP. Staff F stated they expected staff to implement and follow EBP when indicated to reduce the risk of infection transmission. In an interview on 08/14/2025 at 12:57 PM, Staff B, Director of Nursing, explained the facility placed succulents on resident room door frames to indicate when EBP was required, in an attempt to create a homelike environment. Staff B stated EBP required gloves and gowns be worn during high touch resident care for residents with chronic wounds or implanted devices. Staff B further stated they expected staff to implement and follow EBP when indicated. In an interview on 08/18/2025 at 11:12 AM, Staff A, Administrator, stated they expected staff to implement and follow EBP when indicated. HAND HYGIENE During observation on 08/14/2025 at 7:16 AM, Staff T, RN, put a pair of gloves on without performing hand hygiene, drew insulin up in a syringe, walked down the hall with their gloves on, and administered insulin to Resident 26. Staff T removed their gloves, did not perform hand hygiene and began dispensing medications for Resident 25, grabbing some over-the-counter vitamins with their bare hands to place them in the medication cup. Staff T performed hand hygiene twice, then administered the dispensed medications to Resident 25. In an interview on 08/14/2025 at 10:37 AM, Staff T, acknowledged they did not perform hand hygiene and should have prior to dispensing medications and between residents. In an interview on 08/14/2025 at 12:12 PM, Staff F, Infection Preventionist, stated hand hygiene should be preformed before glove application, after removal, before dispensing medication, after medication administration, and between residents. Staff F stated they expected staff to perform hand hygiene when indicated. During a medication administration observation on 08/14/2025 at 7:56 AM, Staff G, RN, sanitized their hands and put on gloves. Staff G then opened Resident 83's blinds, adjusted their bed, turned on their light, removed the old IV bags from the pole, and with the same gloves hung the new IV medication. Staff G wearing the same gloves then wiped the resident's IV canula with alcohol, flushed their IV line and connected the new IV bag. Staff G, wearing the same gloves adjusted Resident 83's pillow, got the resident a second pillow and administered some of the resident's medications. A cup fell on the floor and Staff G picked it up with the same pair of gloves they had been wearing and administered the rest of Resident 83's medications. In an interview on 08/14/2025 at 8:12 AM, Staff G stated they should have performed hand hygiene and put on new gloves after they had touched the things in the room prior to giving the resident the resident's medications. In an interview on 08/14/2025 at 9:51 AM, Staff F, Infection Preventionist, stated hand hygiene should have been performed after things in the room were touched and prior to administering medications and it was important to prevent infection. In an interview on 08/14/2025 at 12:55 PM, Staff B stated they expected staff to perform hand hygiene when indicated to prevent the spread of infection. In an interview on 08/18/2025 at 11:12 AM, Staff A stated they expected staff to perform hand hygiene when indicated. Reference: WAC 388-97-1320 (1)(c)(2)(b)

Based on observation, interview, and record review, the facility failed to ensure the use of an indwelling urinary catheter (a tube which drains urine from the bladder into a collection bag) was properly monitored to ensure it was functioning for 2 of 2 sampled residents (Residents 1 & 3), reviewed for urinary catheters. This failure placed the residents at risk for complications, prolonged therapy, and unmet care needs. Findings included . Review of a facility's policy titled, Indwelling Catheters, revised 04/12/2022, showed if an indwelling catheter was in use, the facility provided appropriate care for the catheter in accordance with current professional standards of practice and staff were to monitor for changes in condition related to potential catheter-associated urinary tract infections. <Resident 1> Review of the admission assessment dated [DATE] showed Resident 1 was admitted to the facility with multiple diagnoses to include neurogenic bladder (a lack of bladder control due to a brain, spinal cord, or nerve problem) and urinary tract infection (UTI). In addition, the resident was able to make their needs known, was dependent on staff assistance with activities of daily living, and had an indwelling urinary catheter. Review of Resident 1's care plan initiated 01/07/2025 showed the resident had an indwelling urinary catheter related to neuromuscular dysfunction (lack of control of muscles). Interventions included for nursing staff to empty the catheter bag every shift. Additional interventions were for LNs to monitor and document for signs and symptoms of pain, blood-tinged urine, cloudiness, no output deepening of urine, foul smelling urine, and change in behavior. Review of Resident 1's treatment administration record (TAR) for March 2025 showed staff were to measure and record urinary output every shift (twice daily). Further review showed in March 2025 staff did not document urinary output on 21 of 62 opportunities. Additionally, on 03/05/2025, 03/06/2025, 03/12/2025, and 03/21/2025 the resident's urinary output was documented at less than 30ml (milliliter; unit of measurement) per hour. Review of the March 2025 progress notes showed no corresponding note on 03/21/2025 showing assessment of the low output and/or notification to the medial provider of a change in the resident's condition. A progress note the following day, 03/22/2025, showed the resident's bedsheets were soiled with urine, the urinary catheter was leaking, the resident's abdomen was firm and distended, and the resident reported they had pressure in their abdomen and perineal area (the area between the anus and genitals) since the previous day. The urinary catheter was replaced and the new catheter drained 1700ml within 25 min, after which the resident reported relief of the pressure sensation, and the abdomen was no longer hard and distended. Review of the April 2025 TAR for Resident 1 showed staff did not document urinary output on 2 of 14 opportunities. Additionally, on 04/01/2025 the resident's urinary output was documented at less than 30ml per hour. Review of the April 2025 progress notes showed no corresponding note on 04/01/2025 showing assessment of the low output and/or notification to the medial provider of a change in the resident's condition. A progress note the following day, 04/02/2025, showed the resident had a change in condition and was sent to the hospital. Observation on 04/15/2025 at 11:40 AM showed Resident 1 was sitting up in their wheelchair in their room with their urinary catheter attached to the lower portion of their wheelchair. The resident stated they had experienced multiple urinary tract infections while at the facility and that they did not feel staff responded timely when they reported concerns with their urinary catheter. Resident 1 stated before they were hospitalized on [DATE] they had reported concerns with their urinary catheter but staff did not respond until the day they were sent out. The resident stated they were diagnosed with a UTI when they arrived at the hospital. In an interview on 04/15/2025 at 1:53 PM Staff E, Licensed Practical Nurse, stated nursing assistants (NA) were responsible for routine urinary catheter care and nurses would assess the catheter if the NA or resident reported changes or concerns. Staff E stated on 04/01/2025 Resident 1 reported they were feeling unwell and the resident appeared flushed (red and hot skin as the result of illness or strong emotion) and they requested the next shift to monitor the resident. Per Staff E, the resident's condition worsened and the resident was sent to the hospital the following day where they were diagnosed with a urinary tract infection. Staff E stated the resident had frequent UTIs and were at risk for UTIs but their urine appeared clear on 04/01/2025 so no diagnostic testing of the urine was done prior to their hospitalization . In an interview at 4:36 PM the same day, Staff D, Resident Care Manager, stated urinary output was not measured on all residents, but if it was, the interdisciplinary team (IDT; group of medical professionals of various disciplines) monitored to ensure staff completed the required documentation. Staff D reviewed Resident 1's physician orders and TAR and confirmed there were many missing entries of the resident's urinary output. Staff D stated many of the staff in the facility were from an outside agency and did not always complete required documentation. During an interview on 04/15/2025 at 5:00 PM, Staff B, Director of Nursing, stated urinary output was only measured on residents with a physician's order for monitoring as most of the residents in the facility had stable urinary statuses. Staff D confirmed Resident 1 had orders for measuring urinary output as their urinary status was complicated and further stated the facility was working on a referral to a urologist (doctor who specializes in kidney/urinary care) prior to their hospitalization . Staff D stated they were aware of concerns with tracking urinary output due to both the use of agency staff and confusion amongst staff of which residents were or were not to have their urinary output measured. <Resident 3> Review of the admission assessment dated [DATE] showed Resident 3 was admitted to the facility with multiple diagnoses to include obstructive uropathy (bloackage that prevents urine from flowing normally through the urinary system. In addition, the resident was able to make their needs known, required substantial staff assistance with activities of daily living, and had an indwelling urinary catheter. Review of Resident 3's treatment administration record (TAR) for March 2025 showed staff were to measure and record urinary output every shift (twice daily). Further review showed in March 2025 staff did not document urinary output on 21 of 62 opportunities. Additionally, on 03/01/2025, 03/03/2025, 03/18/2025, and 03/27/2025 the resident's urinary output was documented at less than 30ml (milliliter; unit of measurement) per hour. Review of the March 2025 nursing progress notes for Resident 3 showed no corresponding note on 03/18/2025 showing assessment of the low output and/or notification to the medial provider of a change in the resident's condition. A progress note dated 03/27/2025 showed the resident's urinary catheter was in place and draining yellow urine with sediment, but no assessment of the low output and/or notification to the medical provider was found. Review of the April 2025 TAR for Resident 3 showed staff did not document urinary output on 6 of 28 opportunities. Additionally, on 04/05/2025 the resident's urinary output was documented at less than 30ml per hour. Review of the April 2025 nursing progress notes for Resident 3 showed no corresponding note on 04/05/2025 showing assessment of the low urinary output and/or notification to the medial provider of a change in the resident's condition. In an interview on 04/151/2025 at 4:36 PM, Staff D reviewed Resident 3's physician orders and TAR and confirmed there were missing entries of the resident's urinary output. At 5:00 PM the same day Staff B stated the facility was aware of concerns related to staff measuring and recording urinary outputs on residents with orders that specified to monitor output amounts. Reference WAC 388-97-1060(3)(c)

Based on interview and record review, the facility failed to ensure 1 of 3 sample residents (Resident 1), reviewed for medication administration, received medications appropriately, in accordance with the physician's order. This failure resulted in a pattern of significant medication errors which placed the resident at risk for medical decline, discomfort, and a diminished quality of life. Findings included . Review of the facility's policy titled, Medication Errors, revised 08/01/2024, showed a medication error occurred when a medication was not administered in accordance with the prescriber's orders. Review of the September 2024 Medication Administration Record (MAR) showed Resident 1 had an order for a narcotic pain medication, hydrocodone-acetaminophen, to be given every 6 hours as needed. The resident could take 1 tablet for mild to moderate pain and 2 tablets for moderate to severe pain. The order included instructions not to administer more than four tablets every 24 hours. Further review showed the resident was administered more than 4 tablets on 15 occasions: 09/07/2024, 09/09/2024, 09/11/2024, 09/14/2024, 09/15/2024, 09/16/2024, 09/17/2024, 09/18/2024, 09/19/2024, 09/20/2024, 09/22/2024, 09/23/2024, 09/24/2024, 09/25/2024, and 09/27/2024. Review of the October 2024 MAR showed the resident received more than four tablets of their hydrocodone-acetaminophen in a 24-hour period on an additional four occasions: 10/07/2024, 10/17/2024, 10/18/2024, and 10/21/2024. In an interview on 11/01/2024 at 1:11 PM Staff F, Licensed Practical Nurse, stated Resident 1 would intermittently request medication for pain in their legs, hydrocodone-acetaminophen one or two tablets as needed. Staff F did not include the listed medication parameters of only four tablets in a 24-hour period. Staff F stated the resident's pain medication needed to be changed to something that did not affect the liver due to elevated liver enzymes identified on a recent laboratory report. In an interview at 4:51 PM the same day, Staff A, Director of Nursing, stated the entire nursing team was responsible for double checking that medications with parameters/restrictions on administration were administered correctly. Staff A stated Staff C, Resident Care Manager, reviewed a medication administration report daily. In an interview at 5:12 PM the same day, Staff C stated they were the nurse manager responsible for overseeing Resident 1's care. Staff C stated they were not aware of the special instructions not to exceed four tablets in 24 hours on Resident 1's pain medication because they did not administer the medications. Staff C stated the pharmacy also reviewed resident's medication regimens and made reports to Staff A. At 5:27 PM pharmacy audits for Resident 1 were requested; none were provided. Reference: (WAC) 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures to include, not reporting allegations of abuse to the State Agency (SA) within the required timeframe and completing thorough investigations for 1 of 3 sampled residents (Resident 1), reviewed for abuse/misappropriation. This failure placed the resident and other residents at risk for abuse/misappropriation. Findings included . Review of the facility's policy titled Identification and Investigation of Abuse, Neglect, Misappropriation, and Injuries of Unknown Origin, revised 08/01/2023, showed staff were to report any form of alleged abuse to the SA immediately, but not later than two hours after the allegation is made if abuse was alleged and there was serious bodily injury. All other allegations were to be reported within 24 hours. Additionally, the facility would investigate the allegation and document evidence of the investigation. Review of the September and October 2024 facility incident logs showed no reported incidents for Resident 1. Review of the October 2024 Medication Administration Record showed Resident 1 had an order for a narcotic pain medication, hydrocodone-acetaminophen, to be given every 6 hours as needed. The resident could take 1 tablet for mild to moderate pain and 2 tablets for moderate to severe pain. In an interview on 11/01/2024 at 12:28 PM Resident 1 stated they took narcotic pain medications to treat their pain and on several occasions when Staff E, Licensed Practical Nurse, administered their medications they tasted differently and did not treat their pain effectively. Resident 1 stated on 10/08/2024 when Staff E administered their narcotic pain medications, they did not swallow the medications and instead spit them out after the staff member left the room. The resident stated they showed the nurse on the next shift, Staff D, Registered Nurse, the two pills they spit out and reported that one of the pills was not their prescribed medication. In an interview at 3:34 PM the same day Staff D confirmed Resident 1 reported to them that Staff E was giving them a medication they were not prescribed when they were documenting that they were administering the resident's narcotic pain medication. Staff D stated they asked the resident to keep monitoring the situation and then on 10/08/2024 the resident showed them two pills that were not the same at the beginning of their shift following Staff E. Staff D stated they reported the incident to Staff B, Assistant Director of Nursing, on 10/08/2024 and believed the facility administration had investigated and reported to the SA as required. At 4:40 PM the same day Staff B, Assistant Director of Nursing, confirmed Staff D reported the incident on 10/08/2024 to them and they immediately went to interview the resident. Staff B stated Resident 1 alleged Staff E was giving them an over-the-counter medication they were not prescribed instead of their prescribed narcotic pain medication. Staff B confirmed the resident reported misappropriation of their narcotic pain medication and stated they reported the concern to Staff A, Director of Nursing, who was responsible for investigating and reporting allegations of abuse/misappropriation. In an interview on 11/01/2024 at 4:51 PM Staff A stated they were aware of the report from 10/08/2024, though they were not aware the resident had reported it was a repeatedly ongoing issue. Staff A stated they did investigate the incident and did not substantiate abuse, but the investigation was undocumented, and they were unable to provide evidence of a completed investigation. Staff A stated because the investigation showed the allegation was not substantiated, the resident's allegation was not reported. Reference WAC 388-97-0640(2)

Based on interview and record review, the facility failed to inform the Resident Representative (RR) of changes to the resident's weight, treatments, wound status, medication changes, refusals of treatments, and changes in condition for one (1) of 4 residents reviewed for the right to be informed of care for a span of five months. This failure precluded the RR from the opportunity to contribute to help Resident 1 make an informed decision related to medication and treatment changes and move forward with the treatment options being proposed. Findings included . Review of an 11/28/2017 facility policy titled Resident Change in Condition, described a change in condition as a change from the resident's normal status or whenever there was a change in the resident's medical condition. Some of the examples of a change in condition included, new or increasing confusion, newly identified incontinence, weight loss of more than 5 % (percent) of body weight, behavior changes, and potentially life-threatening conditions due to a change in the resident's chronic disease and medical condition. The policy instructed the staff to notify the resident representative (consistent with their authority), family member, or responsible party, when there was a significant change or a deterioration in the resident's physical, mental or psychosocial status in health, life-threatening conditions or clinical complications, a need to change treatment significantly, the decision to transfer the resident from the facility, and/or when there is a change in room or roommate assignment. Additionally, the policy instructed the staff to document in the resident's medical record all attempts to notify the resident's family member or responsible party of the change in condition. <Resident 1> Review of a 09/17/2024 assessment showed Resident 1 readmitted to the facility on [DATE] with medically complex conditions. This assessment showed the staff identified Resident 1 had moderate cognitive impairment and the family participated in the assessment and goal setting. Record review showed the resident admitted to the facility with a chronic wound and a history of falls. Review of the medical record showed Resident 1 had two designated Power-of-Attorneys (POA) for health care decision-making. A POA has the privilege, in the event of an unfortunate medical condition, to make health-related decisions for the resident. The medical record also showed designated Emergency Contacts and in what order staff should contact them, like Emergency Contact # [number] 1. Review of the medical record also showed physician orders that read, Patient is aware of patient's medical condition(s), Resident is capable of making his/her own health decisions, and Resident is incapable of making his/her own health decisions. Record review showed supporting POA documents were available to the staff in the electronic medical record since on 04/02/2024. A 04/02/2024 progress note showed the resident, has family for support and that their son is POA and a source of support to [the resident]. Review of the progress notes showed Resident 1 experienced events that met the definition of a change in condition, but no documentation to show the staff notified the RR as instructed: 04/12/2024 - Resident lethargic and very confused. awaiting lab results. will place note in Provider's box for review and Received signed lab results from [provider]. Received orders for referral to nephrology [kidney specialist]. 04/25/2024 - Rec'd [Received] call from infectious disease stating resident's WBC's [white blood cell count] are low and gave the following new orders to discontinue one antibiotic and start another. 04/26/2024 - Resident came out of room with visible 2cm [centimeter - a unit of measurement] x 2cm bump to his right eye brown [sic]. Purple bruising already present and Lung have rhonchi [wheezing breaths] throughout . Due to change in respiratory assessment and new injury to eyebrow, Dr. [NAME] was notified. RN [Registered Nurse] advised to start neuro [neurological] checks to monitor patient and put an order in for the AM [morning] for a 2-view chest xray. 5/17/2024 - RT [Resident] tested positive for COVID at this time 06/06/2024 - Provider reviewed pharmacy recommendation to discontinue sliding scale (insulin dose based on your blood sugar level just before your meal), order signed and discontinued by provider. 06/06/2024 - Review of a 06/07/2024 Notice of Room-to- Room Transfer showed no documentation the facility adequately informed Resident 1 or their representative. There were no resident or RR signatures, and page 2 of the notice was entirely blank. Page 2 required the date the notice was issued, the room Resident 1 was being transferred to, that they were informed of their rights to transfer, to include the rationale for the transfer. 06/17/2024 - The resident complained to the staff of left ring finger pain and that it had been hurting for two weeks. the resident requested an xray. On 06/19/2924, the staff, Received new orders from provider for X-ray to L hand r/t [related to] pain. X-ray tech [technician] here now to do exam. X-ray results back, conclusion possible avulsion [a bone fragment is pulled away from its main body by soft tissue that is attached to it] fx [fracture] of base of the L 4th proximal [finger]. Placed in provider box for review. Resident stated to this LN [Licensed Nurse] finger has been this way for over a month and a half. 06/24/2024 - Resident 1 told the staff they felt like, an abscess on [their] upper gum area where one of [their] teeth were removed. Upon inspection, the area is slightly red and swollen. [Resident] said it is painful and would like to have an order for a dental appt [appointment] as well as something for the pain besides prn [as needed] Tylenol. 06/26/2024 - Provider in and assessed Resident 1's mouth due to redness, swelling along with c/o [complaints of] pain. New order received for [antibiotic twice a day for 10 days] r/t peridontal [sic] abscess [a pocket of infection that starts in your gums]. 07/12/2024 - The progress note showed the Resident 1 returned from the dental clinic who referred the resident to an oral surgeon for impacted wisdom teeth and extraction was recommended. The resident was prescribed antibiotics and a prescription mouthwash. 07/22/2024 - Orders received by the staff for stronger analgesics and another dentist referral secondary to Resident 1's complaints of pain. 07/26/2024 - Resident gum swelling increased, seen by Dr. [NAME] this [morning] who gives the following new order: [antibiotic twice a day for 10 days]. 07/27/2024 - The staff identified Resident 1 had a 1cm x 1cm palpable mass to upper right jaw. 08/14/2024 - Resident continues to have increased pain and swelling to left side of face. Area is also noted to be very firm and orders for antibiotics for 30 days and a narcotic analgesic were received. 09/01/2024 - Tooth abscess has grown. Last week this RN could palpate mass to upper left jaw, measuring about 1 cm x 1 cm. It now is felt on his face measuring 2cm x 2cm and is visible and, Left cheek is notably swollen and warm to touch. The affected area on gums is creamy/yellow. Surrounding gum tissue is swollen and red. 09/04/2024 - Resident with new orders to continue antibiotic and an additional antibiotic was added by the Infectious Disease clinic. Review of the progress notes showed that on 09/06/2024, the facility received a call from Resident 1's RR who expressed concern that he was not being kept up and informed on resident's condition, new orders, especially related to resident's left foot lesion and the plan to resolve the infection in it. This author apologized to [them] for the lack of communication and stated would inform nursing staff to remember to contact [the POA] for any changes, new orders, etc.[etcetera]. Short discussion regarding resident's new antibiotic orders, upcoming repeat [lab work], and the consideration for IV [intravenous - by vein] antibiotics. Record review showed no documentation the facility informed or updated the RR of the oral/dental status/concerns. 09/08/2024 - The progress notes showed the resident continued to complain about the abscess to the upper left jaw and staff described a palpable area measured the previous week to be at 4cm diameter, now increased in size to 4cm x 8cm, extending clear back to [the resident's] left ear and red, scabbed rash to both arms and legs. The notes also showed they assessed Resident 1's left foot wound with increased drainage that required additional dressing changes and with redness that spread to the top of the foot. The drainage was described as copious. While the staff notified the provider, who in turn gave treatment orders, it showed no documentation the staff informed the RR. 09/9/2024 - The progress note showed a chronology of events about the abscess to the resident's upper left jaw, completed/pending/incomplete dental appointments and referral to an oral surgeon. It showed no documentation the facility shared this information with the RR. Review of 09/10/2024 and 09/18/2024 provider notes showed the staff acknowledged Resident 1 was chronically refusing their dressing changes to the left foot wound to include becoming combative with staff at times and not allowing the staff to change the dressings. It showed no documentation the facility shared this information with the RR. 09/20/2024 - The nurses reported to the provider that Resident 1 stated that they experienced shooting pains in their mouth and also has four new sores. 09/21/2024 - The progress note showed the staff assessed Resident 1 had, Foul smelling, copious amount of drainage to the foot wound. The staff described the entire foot is macerated and raw with thick layers of dead skin. Open area is measuring 5 x 5 cm, center is dark purple. Patient has redness and warmth extending 6 inches up calf. 09/22/2024 - Staff reported, episodes of confusion over the last 2-3 days. Patient frequently taking [their] pants off and urinating on the floor and that Resident 1 acted like they didn't know how to put [their] pants back on. Review of the medical record showed Resident 1 weighed 283 # (pounds) on 03/29/2024. The record showed that on 04/28/2024, the resident experienced a loss of 14 pounds (268.2), a significant weight loss of 5.23% in a 30-day period. On 07/01/2024, the resident weighed 259.2, or a significant weight loss in 90 days of 8.41%. On 9/30/2024, Resident 1 weighed 235 pounds, or a 16.96% significant weight loss at 180 days. Resident 1 lost 48 pounds in six months. Record review showed no documentation the staff informed Resident 1's representative of the continued and significant weight loss or plans to address it. In an interview on 10/03/2024 at 12:35 PM, the POA stated that when Resident 1 was in room [ROOM NUMBER], one of the staff told them, They did not know the resident had a POA or a medical proxy. The POA stated that the staff did not inform them of Resident 1's changes in mentation, referral to specialists, refusal of cares, medication changes, bruise and bump to the right eyebrow, a possible fracture to the left fourth finger, or status of the wound throughout the resident's stay, until they called to complain to the facility about the lack of communication early September. I had no knowledge of the dental issues until the Spokane appointment in September. I never heard of an oral surgeon. The POA stated that they never heard someone talking specifically about a significant weight loss. I've never had a conversation like that. The POA stated that when they brought up the lack of care concerns to the facility, the staff told them Resident 1 was refusing care and being disgruntled. They never contacted me about [the refusals]. They haven't been telling me [Resident 1] was argumentative or refusing. I am the POA, maybe they should have called me at least to let me know of any issues [Resident 1] has been giving them. The above information was shared with Staff A, Director of Nursing, on 10/4/2024 at 10:40 AM. Staff A stated, I agree to the communication [with the POA] was lacking and managed poorly and that the staff, Yes, should have called POA. Reference WAC 388-97-0300(3)(a), -0260, -1020(4)(a-b).

Based on observation, interview, and record review, the facility failed to prevent development of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure) for 1 of 3 sampled residents (16), reviewed for pressure ulcers. Failure to implement pressure relieving interventions resulted in actual harm to Resident 16, who required surgical treatment after developing a pressure ulcer to the left heel which after being admitted to the facility. These failures placed other residents at risk for pressure ulcer development and a decreased quality of life. Findings included . The 07/03/2023 Admission assessment showed, Resident 16 was able to direct their own care and had medical complex conditions which included right and left hip fractures, and diabetes (a chronic condition where the pancreas produces little or no insulin.) In addition, the assessment showed the resident required extensive assistance of two staff for repositioning in bed. Review of the 07/03/2023 admission skin assessment showed, Resident 16 had no skin conditions or wounds. The Braden scale, an assessment tool used to evaluate a resident's risk of developing skin breakdown, showed Resident 16 was at risk. The care plan dated 07/03/2023 showed pressure relief interventions instructed the nursing staff to off load heels when in bed, inspect the skin when care was provided and report issues to the nurse, utilize a pressure relieving mattress, and complete weekly skin assessments, inspect and check footwear, and report any alterations in skin. Review of Resident 16's record from 07/03/2023 through 07/18/2023, which included progress notes and providers notes, found no documentation that the pressure relieving interventions had been implemented, nor was there documentation that stated the resident had refused care. In addition, no documentation was found that the resident had any wounds or skin alterations. A progress note dated 07/18/2023 documented a large black/dark purple deep tissue injury (DTI) was found on Resident 16's heel. A DTI is an injury when the skin is intact, but the underlying subcutaneous tissues are damaged due to prolonged pressure to the area. Review of the July 2023 Treatment Administration Record (TAR), showed on 07/19/2023, the physician ordered a treatment to the resident's left heel DTI. During observations on 01/18/2024 at 9:59 AM, 01/21/2024 at 9:06 AM, 01/22/2024 at 9:11 AM and 11:34 AM, 01/23/2024 at 6:30 PM, and 01/24/2024 at 3:20 PM, Resident 16 was observed lying in bed without their heels being floated/off loaded. In an interview and observation on 01/20/2024 at 9:18 AM, Resident 16 stated they broke both thighs and had to come to the facility to work with therapy. When asked if they had any skin issues, Resident 16 stated they have a sore on their heel. Additional review of Resident 16's record from 07/18/2023 through 01/26/2024 showed after the resident developed the left heel DTI, the nursing staff began documenting that the heels were being floated/offloaded. On 01/29/2024, three days after the survey had been completed, the facility provided additional documentation that had not been present in Resident 16's record at the time of survey. Review of the documentation showed the following: - On 09/12/2023 the physician wrote a referral to the wound clinic for the treatment of Resident's left heel DTI, and the resident began treatment at the wound clinic on 09/25/2023. - A wound clinic progress note dated 11/28/2023 documented Resident 16 was started on an intravenous antibiotic (a medication used to treat or prevent bacterial infection, administered directly into a vein) for suspected osteomyelitis, a serious infection of the bone, of the left heel. - A wound clinic progress note showed on 12/19/2023 a tissue graft, a surgical procedure to transplant tissue from one area of the body to another area on the body, was performed on the left heel wound, and on 01/11/2024 a second skin graft was performed. In an interview on 01/26/2024 at 11:32 AM Staff H, Nursing Assistant, stated they were assigned to the unit where Resident 16 resided when they admitted to the facility. Staff H stated Resident 16 did not have a heel wound upon admission to the facility and Resident 16's heels were not floated, or any other pressure relief interventions provided prior to the heel wound being found on 07/18/2023. In an interview on 01/26/2024 at 3:49 PM Staff I, Assistant Director of Nursing (ADON) stated they performed the 07/03/2023 admission skin assessment for Resident 16 and there was no heel wound present at that time. When asked when Resident 16's heels started being floated, Staff I stated with having two broken hips, impaired mobility, and being at risk for breakdown, it should have been done upon admission. In addition, Staff I stated it was reasonable to expect the heel wound could have been prevented if pressure relieving interventions had been implemented at that time. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to ensure anticoagulant (AC) medication (medication that stops blood from clotting) side effects were consistently monitored for 3 of 4 sampled residents (Residents 1, 5 and 6), reviewed for unnecessary medications. This failure caused Resident 1 re-hospitalization and treatment to reverse blood thinning and placed additional residents at risk of experiencing medication side-effects and a diminished quality of life. Findings included . <Resident 1> Review of the 07/31/2023 admission assessment showed Resident 1 was severely cognitively impaired and had a diagnosis of irregular heart rhythm for which they took an AC medication. Review of the July 2023 and August 2023 Medication Administration Records (MARs) showed Resident 1 took Apixaban (an AC medication) twice daily from 07/26/2023 to 08/16/2023. The MARs and associated monitors did not show any documentation of monitoring for complications of AC use. In an interview on 08/31/2023 at 2:09 PM, Collacteral Contact 1 (CC1) stated the resident had signs of bleeding while in the facility including bruises, lacerations that would not stop bleeding, and bleeding in the urine. CC1 stated the resident was discharged from the facility on 08/16/2023 to the family's care, and was re-hospitalized within five hours after due to excessive bleeding. CC1 stated they had reported bloody discharge in the resident's brief twice while they were still in the facility, including in the days immediately prior to discharge. Review of a provider note dated 08/08/2023 showed laboratory (lab) work for Resident 1, per the resident's family reporting urinary symptoms, and no signs of infection were found. The note did not specify which urinary symptoms the family was referring to and the lab work did not include tests specific to blood clotting. Review of the nursing progress notes for August 2023 showed Resident 1 fell out of bed on 08/10/2023 around 4:30 AM and had [NAME] blood (visible bright red blood) present under a scab to their right forearm and under a scab to their left knee, as well as blood present on the bed sheets. At 7:00 PM the same day the resident's knee was still bleeding, and the resident was sent to the hospital where a pressure bandage was applied. The resident returned to the facility at 11:00PM the same day. The bandage was removed on 08/12/2023 with no further bleeding from the left knee. Review of the nursing progress notes and provider notes for August 2023 showed no further monitoring and/or lab tests related to blood clotting/AC medication side effects. Review of the 08/16/2023 hospital records showed Resident 1 was admitted to the hospital the same day as they discharged from the facility with bright red blood in their urine, vaginal bleeding, and a significantly elevated PT/INR (Prothrombin Time Test and International Normalized Ratio, lab tests related to blood clotting) for which they received intravenous (IV) vitamin K. In an interview on 08/31/2023 at 3:00 PM, Staff H, Nursing Assistant, confirmed that Resident 1 had blood in their brief in the days prior to their discharge from the facility and they had not reported it to the nurse because it had already been reported by other staff members. Staff H stated if they were the first person to note bleeding of any source, they would report it to the nurse. At the same time, Staff G, Licensed Practical Nurse, was standing at the nurse's station and listening to Staff H's interview. They stated they were not aware of any concerns related to Resident 1 bleeding (after 08/10/2023). Staff G stated it should have been reported so the nurse could visually assess the resident to find the source of the bleeding, which could be urinary, rectal or from a cut to the skin. On 09/06/2023 at 9:40 AM, Staff E, Advance Registered Nurse Practitioner (ARNP), stated all residents who were on AC medications should be monitored (for adverse side effects), and since Resident 1 was on an AC medication they would have related documentation in the MAR. Staff E confirmed Resident 1 went to the hospital on 08/10/2023 for uncontrolled bleeding after a fall and stated no lab work was performed at the hospital, or at the facility after their return, because the bleeding came under control with bandaging. Additionally, Staff E stated they did not speak directly with CC1 about their urinary concerns and were not aware of concerns for [NAME] blood in the resident's brief. <Resident 5> Review of the July 2023 and August 2023 MARs showed Resident 5 took daily AC medication (Eliquis, Pradaxa, Lovenox) starting 07/14/2023. The MARs and associated monitors did not show any documentation of monitoring for complications of AC use. Review of the July 2023 and August 2023 nursing progress notes showed Resident 5 was monitored for AC use and had no adverse side effects from 07/14/2023 to 07/18/2023, with an additional monitor on 07/21/2023 and 07/23/2023. No further notes related to AC monitors were found after 07/23/2023. In an interview on 09/06/2023 at 9:40 AM, Staff E stated Resident 5 was started on a short-term AC medication during a hospital visit for a blood clot in their lower extremity, and was transferred to a long-term AC medication after the short-term medications were completed. Per Staff E, residents who took AC medications should have monitors in place for bruising and bleeding as AC medications increased the risk of bleeding. On 09/25/2023 at 12:55, Staff I, Registered Nurse, stated Resident 5 continued on a daily AC medication and had an order for daily monitoring initiated on 09/08/2023. An observation at 4:04 PM the same day showed Resident 5 had no signs of bleeding or bruising. <Resident 6> Review of the August 2023 MAR showed Resident 6 took a daily AC medication (Xarelto) for an irregular heart rhythm. The MAR and associated monitors did not show any documentation of monitoring for complications of AC use. Review of the August 2023 nursing progress notes showed no monitoring for AC use. In an interview on 09/25/2023 at 2:56 PM, Staff C, Resident Care Manager, stated when a resident admitted to the facility with an order for AC medications medical records staff would enter orders for nursing staff to monitor for adverse side effects. Per Staff C, if medical records did not identify the AC medication and enter orders for monitoring, it would be caught by the interdisciplinary team during a care plan review. Staff C reviewed Resident 6's record and confirmed no AC monitors were present. In an interview at 4:38 the same day, Staff A, Chief Nursing Officer, stated the facility identified concerns related to AC medication monitors on 09/08/2023 (after the surveyor interview with Staff E). Reference WAC 388-97-1060 (3)(k)(i)

Based on observation, interview, and record review, the facility failed to accurately assess and document pain levels and administer pain medication timely as ordered/needed for 1 of 3 sampled residents (267), reviewed for pain. These failures caused actual harm to the resident, who experienced inadequate pain control and a diminished quality of life. Findings included . An admission assessment dated [DATE] showed Resident 267 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A pain assessment completed by a registered nurse on 10/18/2022 showed the resident had verbally reported frequent significant pain at a level of 7 on a scale of 0 to 10 (0 meaning no pain, and 10 the worst pain a person could experience), which was rated on a pain severity scale. The assessment also showed the resident's acceptable level of pain was 5. The same assessment showed the pain the resident was experiencing interfered with their ability to rest, sleep, dress themselves, and perform personal hygiene. The direction listed on the pain assessment was to notify the physician if the resident scored 3 to 4 out of 10 on the pain severity scale. No documentation of any medical provider being notified of the pain level of 7 was found. Resident 267's initial care plan had a goal for the resident to express their pain as controlled, and included interventions to manage pain such as anticipating the need for pain relief and responding immediately to any report of pain. During an observation on 10/24/2022 at 4:48 PM, the resident reported a pain level of 8 out of 10 to Staff U, Nursing Assistant, and asked Staff U to tell the nurse that they needed pain medication. Staff U was observed to report the pain indicator of 8 to Staff V, Registered Nurse. Staff V entered Resident 267's room at 4:55 PM with medication. During an interview on 10/25/2022 at 9:10 AM, Resident 267 stated that the nursing staff usually asked about their pain level, but then waited too long to bring the medication, and their pain was out of control. The resident went on to say they had asked for pain medication from a nursing assistant during the previous night shift (evening of 10/24/2022 into early morning of 10/25/2022), and then waited outside their room in their wheelchair. When the nurse did not come, the resident used their wheelchair to go up to the nurses' station and ask for pain medication again. The resident reported they received the pain medication about 6:00 AM, but the nurse did not ask about their pain level, and the resident stated they were upset because the nurse just gave them the medication and walked away. The resident stated it had been about seven hours since they had pain medication, and that the pain was really bad, and had woken them from sleep. On 10/26/2022 at 11:26 AM, Resident 267 was observed in their wheelchair with Staff W, Physical Therapy Aide, at the nurses' station telling Staff S, Registered Nurse, that their pain was a 7 out of 10 and they needed a pain pill. Staff S stated that they were aware that the resident needed pain medication, but the resident's supply of pain medication was gone. The resident stated the night nurse had given them one tablet that morning instead of two and told them it was because their pain medication was gone, and they thought the staff would have gotten the medication by that time. Resident 267 then stated that they had called the hospital where they had surgery to get more pain medication, but they were told they would have to go to the hospital to pick it up, and that they were in pain and needed the medication. Staff S then stated, that is not how it works, and stated that they would try and go find another nurse to figure out how to get a narcotic pain medication from the building supply. Resident 267 was visibly upset during the conversation and spoke with an elevated tone and facial grimace. During an interview with Staff S, Registered Nurse, just after the conversation above, they stated that they were an agency nurse and were not sure how to get narcotic pain medication from the building supply. They said they were aware the resident was out of pain medication but had not had time to figure out how to get the medication. Review of Resident 267's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Another physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No further direction for how to determine when to give one or two tablets was written in the order. Resident 267's October 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Another section of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This section had recorded pain levels of 0 to 8 without a time associated with the pain assessment, and no indication the medical provider had been notified of pain levels greater than 5 (the resident's acceptable level of pain), which had occurred 7 times. The section listing non-medication interventions to attempt prior to administering pain medication was blank. Further review of Resident 267's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The next pain medication was not administered until 6:15 AM the morning of 10/25/2022 (greater than 13 hours later), where a pain level of 4 was recorded (when the resident stated when interviewed [see above] that the nurse had not asked about their pain level). On 10/26/2022, when the resident was overheard to have run out of pain medication, one pain medication tablet was recorded administered at 5:27 AM, with a pain level of 7 recorded. The next administration of pain medication was recorded at 12:21 PM (almost 7 hours later), and 45 minutes after the resident was observed to report a pain level of seven, with a pain level of 8 recorded. No indication of a medical provider being notified of the resident's pain level above 5 was found, as per order. During an interview on 10/27/2022 at 9:32 AM, Staff G, Resident Care Manager, stated that a pain assessment which indicated frequent significant pain, and a level of 4 to 8 during pain assessments, prior to pain medication administration, did not seem like an acceptable level of pain control, especially if it was waking the resident up at night. They went on to say that usually the floor nurses would notify the physician or nurse practitioner if a resident did not have good pain control, but they were not aware of either medical provider having been notified of Resident 267 having inadequate pain control. During an interview on 10/27/2022 at 10:40 AM, with Staff W, Physical Therapy Assistant, they stated that they had been working with Resident 267 for a couple of days and the resident had been having some issues with pain. They continued to state that the day before, the resident had run out of pain medication, was in significant pain, and declined therapy sessions a couple times because of pain. Staff W stated it seemed like Resident 267's pain level was on the high side. During an interview on 10/27/2022 at 10:10 AM, Staff E, Nurse Practitioner, stated that they had been made aware by Staff G that Resident 267 was reporting unresolved pain, and they would start another medication. Staff E further stated that Resident 267 had told them that they had been shot five times in their past, and the pain they were experiencing was different and worse. Reference: WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to contact the resident's physician in a timely manner for one of three sample residents (#1), reviewed for a change in condition. Failure to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included . Review of Resident #1's 12/30/2020 comprehensive assessment showed the resident had significant cognitive impairment, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Medication Administration Records for January and February 2021 showed the resident required Insulin (an injectable medication for diabetics), to control her blood glucose levels. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Weights and Vitals Summary showed on 02/06/2021 at 11:47 AM, the resident's blood glucose reading was 442 . Review of the resident's progress notes showed the physician was not notified on 02/06/2021 of the high blood glucose reading. Additional review of the record showed on 02/07/2021, the resident's blood glucose remained at elevated levels, with readings as follows: 321 (2:46 AM), 365 (6:53 AM), 306 (9:59 AM), and 389 (11:29 AM). The progress notes showed no notification/consultation with the physician. Per review of the progress notes dated 02/07/2021 at 9:15 AM, the resident developed a low grade fever the evening of 02/06/2021, had a rapid pulse, refused food/nutrition, and was not acting herself, meaning she is not verbally responding to stimuli like she normally would. The resident was placed on alert charting, but the physician was not notified. On 02/07/2021, per the progress notes, the physician was contacted at 1:30 PM (over 24 hours since the initial high blood glucose reading of 442), when the resident continued to be symptomatic. The physician ordered the resident be sent to the hospital for evaluation. The resident's blood sugar at that time was 389. Hospital records dated 02/07/2021 showed the resident was admitted to the Intensive Care Unit for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The records further showed the resident remained at the hospital for two days for additional treatment. In an interview on 03/12/21 at 12:09 PM, Staff C, Resident Care Manager, confirmed the physician had not been notified on 02/06/2021, when the resident's blood glucose level was initially above 400, as per order, or when the blood glucose readings remained elevated. Reference (WAC) 388-97-0320(1)(b)

Based on interview and record review, the facility failed to ensure one of four sample residents (#1), received adequate supervision to prevent accidents, related to smoking. Failure to implement adequate supervision resulted in a fire, and constitued a Past Non-Compliance Immediate Jeopardy; the facility was notified on 01/26/18. Findings included: Resident #1 was admitted with [DIAGNOSES REDACTED]. According to a smoking evaluation dated 01/09/18, the resident required supervision when smoking. According to the facility smoking policy dated 06/17, ALL smoking materials, including cigarettes, electronic cigarettes, and lighters will be kept at the nurses station. Per review of facility progress notes dated 01/18/18, Resident #1 was disruptive with staff, and had been having hallucinations(hearing voices when nobody speaks, or seeing objects no one else sees). He was taken out to smoke at 7:15 p.m., with staff supervision. According to a written statement by Staff C, Nursing Assistant, after supervising the resident to light and smoke two cigarettes, he returned the resident to his room. Resident #1 refused to give Staff C his lighter. Staff C reported to Staff B, Licensed Practical Nurse, that the resident still had the lighter. According to Staff B, during an interview on 01/25/18 at 3:05 p.m., she was alerted on 01/18/18 that Resident #1 had a lighter in his room, and immediately went to his room. Per Staff B, Resident #1 remained extremely agitated and attempted to punch her, when she tried to obtain the lighter. She was unable to calm him down, or get the lighter from him. Staff B said she attempted to reproached him two more times, but was still unable to get the lighter. She stated during this time, Resident #1 was receiving oxygen through a nasal cannula (a small flexible tube, inserted into the nose). Staff B stated Resident #1 was left alone in his room for 10 minutes. At approximately 8:40 p.m., Resident #1 was found in his room; he had used the lighter to set his mattress was on fire. Per review of written statements related to the incident, staff immediately removed the resident, pulled the fire alarm, and extinguished the fire. The local fire department responded. No residents were injured. Resident #1 continued to have increased agitation, was taken to the hospital for a psychological evaluation, and did not return to the facility. Immediately after the incident, the facility revised the dependent smoking resident care plans to include: residents would no longer carry or handle lighters, staff would light cigarettes for residents. In addition, staff were provided education and additional information, related to safe smoking, and care plan updates. Resident #1 was no longer residing in the facility. This was a Past Non-Compliance Immediate Jeopardy situation and is no longer outstanding. WAC reference: 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to implement written policies and procedures for protecting residents from sexual abuse. The facility did not implement interventions that were already in place to protect Resident #1 from harm related to sexual abuse by a staff member. In addition, the facility failed to thoroughly screen 1 of 2 employees reviewed (staff B) for a history of abuse, neglect, or mistreating residents. Findings include: The January 2016 facility Abuse Policy and Procedure indicated it was the policy of the facility to protect residents from abuse. The policy further indicated facility staff, including nurses and administration, were responsible for following the care plan, and administrative staff were responsible for supervision of facility staff (to ensure this was being done). Resident #1 was admitted to the facility 05/09/16, with [DIAGNOSES REDACTED]. These were changes from previous assessments. Review of a facility investigation, dated 11/09/16, revealed the resident said on 11/09/16, an individual not employed by the facility was her boyfriend. She stated they met while he visited the facility as an employee of an outside agency. She further stated while out on passes with the individual, they kissed. The individual asked if they could have a sexual relationship, she told him no, and he respected her decision. The investigation ruled out sexual abuse. As a result of this incident, staff were provided inservice education, specific to Resident #1. This included: having all visitors and/or phone calls to the resident authorized by the licensed nurse on-duty at the time, and prohibiting the individual involved from coming to the facility. Review of the resident's current care plan revealed on 11/11/16, the facility added an intervention, which directed staff to have 2- person supervision for all care. In addition to the care plan modifications, on 11/18/16, the resident was evaluated by a psychologist, related to her capacity and judgment to consent to any form of intimacy. The results of the psychologist's evaluation were received by the facility on 11/22/16. The psychologist determined the resident had severe cognitive impairment, and impaired judgment, related to dementia. Review of a facility investigation dated 11/20/16 revealed at 2:20 p.m. the same day, Staff D witnessed Resident #1 and Staff B (a nurse) in the resident's bathroom, with the door open. Staff B's pants were lowered, and the resident's face was leaning into his groin, which was exposed. Staff B then saw Staff D, and left the resident's room. Staff D reported the incident to another licensed nurse, and the facility Administrator. Staff B was removed from the building, and did not return. The facility thoroughly investigated, and reported the incident, as an allegation of abuse. The investigation confirmed sexual abuse occurred. According to the police report dated 11/20/16, the resident stated she and Staff B had intimate conversations and contact. The resident was unable to describe the duration of their relationship, but stated she had kissed and touched his groin. Additional review of the facility investigation revealed multiple staff reported observing Staff B in the room alone with the resident, without a second staff member present (as directed in the care plan). During observation of the resident, and interview, on 12/01/16 at 2:20 p.m. (with staff present at the doorway to the room), she said she was confused about whether she was living at the facility, or working there, and going home later. She had bruises on the left side of her forehead and right upper lip (from a fall). During interview on 12/01/16 at 3:40 p.m., Staff E stated she worked the evening shift, with Staff B and Staff D, on 11/20/16. When asked, she stated 2 staff were supposed to be present, whenever the resident needed care. She said that applied to Staff B, but said he was in her room alone at times, without a second person, and she didn't report it. During interview on 12/01/16 at 3:50 p.m., Staff F stated she worked evening shift with Staff B, and found him alone with the resident in the bathroom, on more than one occasion. Staff F stated if this happened, she would then stay in the room, and provide care. When asked if requiring 2 staff present for all care included the licensed nurse, she stated yes. Staff F said that Staff B had told her the nursing assistants were all busy, so he was just helping out. In an interview on 12/02/16 at 10:45 a.m., Staff D stated she had previously observed Staff B alone in the room with the resident, but since he was the licensed nurse, she did not say anything. On 12/02/16 at 10:30 a.m., Staff AK, social services staff, was interviewed. When asked, she stated the resident had been interviewed several times about the incident. As a result, the resident was more confused, and it was hard for her to understand what was happening. During interview on 12/02/16 at 12:30 p.m., Staff A confirmed that staff who witnessed Staff B in the room alone with the resident did not report it, until the facility investigation on 11/20/16. She confirmed all staff, including licensed nurses, should have had a second staff person present, when providing care to the resident. Screening: The January 2016 facility Abuse Policy and Procedure indicated it was the policy of the facility to screen potential employees for history of abuse, neglect, or mistreating residents. The policy further indicated: Contact previous employers requesting employment history to include but not limited to; dates of service, position held, performance history, history of abuse, neglect, or mistreating residents. Review of Staff B's employee file included letters of references from a former employer in 2001, and personal references from 1999 and 2007. There was no documentation of reference checks from more recent employers. In an interview on 12/02/16 at 12:30 p.m., Staff L stated she contacted, but did not document, reference checks from more recent employers.

Based on interviews and record review, the facility failed to provide necessary supervision during meals, to ensure resident care was provided based on the plan of care and known behaviors, for 1 of 6 residents (#1), who required staff assistance with meals. This failed practice resulted in actual harm to Resident #1, who sustained a second degree burn, which later became infected, requiring antibiotic therapy . Findings include: Resident #1. Review of the medical record revealed [DIAGNOSES REDACTED]. Review of a physician assessment, dated 05/06/16, noted the resident had memory impairment and poor judgment. Review of the resident's plan of care, dated 07/31/15, revealed the resident required extensive assistance by staff with her meals, and her soups and drinks were to be served in mugs. A physician's orders [REDACTED]. Review of the resident's tray card (used in the kitchen to prepare meals) also documented soups/drinks were to be served in mugs with lids. Review of a facility investigation report revealed on 08/31/16 at 5:45 p.m., the resident, while seated at the assisted dining room table, pulled her hot soup onto her lap. Staff B, a nursing assistant (NA), immediately attempted to clean the soup from her lap. However, the resident became combative, and was then given a hand towel to clean herself up, with cueing. The resident sustained [REDACTED].), with a blister in the center measuring 3.5 by 2.0 cm. In an interview with Staff B on 09/15/16 at 2:50 p.m., she said she was serving meal trays, when Staff C, a nurse, told her Resident #1 had spilled soup onto her lap. She found a soup bowl upside down on the resident's lap, with the entire contents spilled. Per Staff B, a bowl had been utilized without a lid for the soup, rather than the ordered mug with a lid. Staff D, an agency NA, was also in the dining room at that time, passing meal trays. Staff B said Staff D must have placed the soup bowl within the resident's reach, as he was new to the facility; everyone else knew not to do that, due to her behaviors. Staff B said the resident at times could get kinda grabby with her food, and in the past she had seen her pull on the tablecloth, causing food items to spill on the table. She stated the resident continued to sit in the dining room for 45 minutes following the incident, before she was taken to her room, and her wet pants removed, which was when the reddened area (burn) to her thigh was discovered. Telephone interviews on 09/15/16 at 6:54 p.m., and 09/16/16 at 8:35 a.m., with Staff C, revealed she was in the dining room administering medications, when she noticed the resident had pulled food onto her lap. She then alerted Staff B to assist in cleaning up the resident. She stated she did not realize the food that spilled was hot soup, so she continued to administer medications to residents. She was summoned to the resident's room by NA staff, approximately 45 minutes following the incident, at which time she observed the burn area to her right thigh. When interviewed on 09/15/16 at 12:46 p.m., Staff E, NA, said the resident could sometimes be combative, and start grabbing. Staff E said typically, as soon as Resident #1 received her food, staff needed to sit down and feed her, or she would start grabbing food items. The NA said approximately one week prior to the incident, the resident almost pulled the tablecloth off the table, and had done so previously.

Based on record review and interviews, the facility failed to provide the necessary care and services to manage the respiratory status for 1 of 3 residents (#1), reviewed for significant changes in condition. This deficient practice resulted in actual harm to Resident #1, who experienced increased respiratory distress, anxiety, and discomfort. Findings include: Resident #1: admitted to the facility on [DATE], following orthopedic surgery at the hospital on [DATE]. Other significant [DIAGNOSES REDACTED]. Review of hospital records dated [DATE] documented the resident had developed shortness of breath (SOB), two days following his surgery. On [DATE], the resident was being ambulated with assistance by the Physical Therapist, when he lost consciousness for ,[DATE] seconds. Due to this incident, and his SOB, a lung CT scan was done on [DATE], which revealed [MEDICAL CONDITION] (lungs restricted from fully expanding). Review of nursing assessments at the hospital noted the resident was on oxygen therapy per mask at ,[DATE] liters, depending on his activity level, to keep his oxygen saturation levels above 90. Review of physician's orders on admission to the facility noted [MEDICATION NAME] (a medication used to relax muscles in the airways, and increase air flow to the lungs) was ordered to be administered, every ,[DATE] hours as needed, for shortness of breath (SOB). Review of admission Progress Notes, dated [DATE] at 6:03 p.m., documented the resident was on oxygen therapy at two liters per nasal cannula, which was changed to a mask for resident comfort. However, there were no physician orders for oxygen therapy, or to monitor oxygen saturation levels. There was no evidence facility staff contacted the physician related to the use of oxygen, and/or the monitoring of the resident's response to using oxygen (i.e., checking saturation levels). The following Progress Notes evidenced respiratory distress with resultant anxiety exhibited by the resident, from the time he was admitted to the facility, until an acute medical event on [DATE]: -,[DATE] at 6:03 p.m. - frequently had to be reminded to slow down his breathing, very anxious. -,[DATE] at 1:14 p.m. - complained of SOB this shift. -,[DATE] at 11:09 p.m. - very anxious and frequently had to be reminded to slow down his breathing. -,[DATE] at 3:54 a.m. - hyperventilating causing SOB, relaxation techniques to calm resident but he continued to hyperventilate. -,[DATE] at 2:00 p.m. - complained of SOB this shift. -,[DATE] at 11:15 p.m. - frequently had to be reminded to slow down his breathing, very anxious with all activity. -,[DATE] at 2:40 a.m. - hyperventilating causing SOB, relaxation techniques to calm resident, but he continued to hyperventilate. -,[DATE] at 2:56 p.m. - multiple episodes of increased SOB, occasional episodes of increased anxiety. -,[DATE] - evening shift (no reference of time) - continued to breathe rapidly, despite being reminded to breathe slow through his nose and out through pursed lips. The Medication Administration (MAR) for [DATE] was reviewed. Despite the resident's frequent episodes of shortness of breath and anxiety, licensed nursing staff did not administer the as needed medication ([MEDICATION NAME]), to assist in relief of his respiratory distress. On [DATE] at 2:30 a.m., the physician was sent a faxed message which stated the resident had panic breathing .nothing is helping resident calm down so that he can rest and not hyperventilate. The resident had been on the call light at least every ,[DATE] minutes since the start of the night shift at 10:00 p.m. The faxed message was requesting an order for [REDACTED]. In addition, review of Progress Notes between ,[DATE]-,[DATE] revealed the amount of oxygen provided to the resident varied, from ,[DATE] liters per minute, despite an absence of a physician's orders for oxygen therapy, or oxygen saturation level monitoring and parameters. A telephone interview with the resident's spouse on [DATE] at 5:15 p.m. revealed the resident had exhibited respiratory problems at the hospital, but it had gotten worse during his stay at the facility. She stated when she saw the resident the morning of [DATE] he did not feel good at all and had labored breathing. She stated his eyes seemed dilated, and he would get excited and try and get air. A telephone interview on [DATE] at 5:35 p.m. with Staff A (Nursing Assistant caring for the resident on the evening shift of [DATE]) revealed at the beginning of her shift the resident had severe anxiety, restless, and his oxygen mask was out of place. Between 3:,[DATE]:00 p.m. he had asked Staff A to turn off his lights as he wanted to sleep. At 5:00 p.m. Staff A checked on him as it was time for his dinner, however he was noted to be sleeping. She rubbed his arm in an attempt to wake him but he only shifted slightly and grunted. She then notified the Licensed Nurse of her observations. Review of the facility investigation report revealed that at approximately 5:45 p.m. on [DATE] the resident was found in respiratory arrest and CPR was initiated by staff until emergency personnel arrived. Despite CPR measures the resident expired at the factility at 6:10 p.m. Despite the resident's unstable condition in the hospital relative to his respiratory status, which worsened during his stay in the facility as evidenced by SOB with anxiety, staff did not provide the necessary care and services to help alleviate his symptoms.

Based on observation, interview, and record review, the facility failed to accurately identify, prevent, and/or implement interventions to promote healing, for 2 of 3 residents (#44, 163), reviewed for pressure sores, in a sample of 39. This failure placed residents at risk for complications, and resulted in harm to Resident #44, who developed a wound infection and a second avoidable pressure sore. Findings included: 1. Resident #44 admitted to the facility in 2009. According to the 03/27/15 quarterly Minimum Data Set (MDS) assessment, she had [DIAGNOSES REDACTED]. Resident #44 was totally dependent on 2 persons for bed mobility and transfers. In an interview on 06/22/15 at 3:57 p.m. Staff F, the Resident Care Manager, stated Resident #44 had an unstageable pressure sore on the left ankle. Per Resident #44's record, a skin issue was first identified on 08/21/14, and labeled a bruise. Rather than monitoring the wound as a pressure related injury, it was tracked on a skin grid for all other skin problems. An incident investigation, completed on 10/09/14, after the area opened into a wound, documented - It is likely that the existing wound started to deteriorate opening up and then healing over with a scab. Area is now open draining scant amount of purulent drainage. Area is red and warm to touch, pink spreading up the leg, rsdt (resident) running a fever. Wound was first found on 8/21/14 and called a bruise. after speaking with staff the wound was described as an abrasion with a blood blister. Wound was mis identified in the beginning. Progress note review revealed Resident #44 had an elevated temperature of 101.4 on 10/14/14, and required antibiotic injections related to a probable infection to the left ankle, beginning on that date. A notification fax to the doctor, dated 01/09/15 indicated, Rsdt's wound on left ankle is not improving at this time, has increase odor and looks infected. The facility then initiated wound clinic management, approximately three months after the wound opened. Record review revealed an order dated 2/17/15, for Physical Therapy (PT) and Occupational Therapy (OT) evaluations, for positioning related to the left ankle wound. PT or OT notes, for services provided, were requested on 06/25/2015 at 4:19 p.m. On 06/26/15, both Staff I, Acting Rehabilitation Director, and the medical records department confirmed no record of PT/OT services since 2013. In addition, a wound management order, dated 02/24/15 documented the resident needed a specific type of boot (for pressure sore prevention/treatment). The boot contained a bar, which when placed properly, kept the ankle with the wound from turning out to the left. Staff were directed to keep the boot in place at all times, ensure proper placement, and check for additional pressure areas. Record review of a 06/18/15 progress note revealed: Was noted that rsdt. (resident) had blood on her drsg (dressing). Upon assessment, the boot was placed wrong and caused increased pressure to the wound. Staff identified a second pressure ulcer, to Resident #44's left outer ankle, on 06/22/15. A progress note, dated 06/23/15 documented, Her left ankle has increased in size r/t (related to) pressure on site from boot not being placed properly. new wound site in place below old wound site. In an interview on 06/25/15 at 10:49 a.m., when asked what was incorrect about the way the boot was applied previously, Staff F replied, The kickstand was on the wrong side, pointing to the inside of the boot, rather than the outside, where it would have lessened the pressure on the wound. Observation of the wounds to Resident #44's left outer ankle, on 06/25/15 at 10:42 a.m., revealed 2 open areas with dark wound beds. They were described by Staff F as having some new tissue in the middle, with darker edges, and some redness to the skin around them. Failure of the facility to properly identify a wound over a pressure area, implement timely and effective interventions, as well as ordered therapy evaluations and treatment, resulted in complications to a pressure sore, and the development of a second pressure sore for Resident #44. 2. Resident #163 had [DIAGNOSES REDACTED]. According to her 05/22/15 comprehensive assessment, she required 2-person assistance with repositioning and transfers. She was identified at slight risk for the development of a pressure sore. Per facility report dated 06/19/15, Resident #163 developed a pressure-related sore on the heel of her right foot. The 06/24/15 care plan interventions included: skin assessments, pain relief, monitoring nutrition, pressure reduction on the bed/chair, frequent repositioning, and encouraging her to float her heels (keep pressure off) while in bed. On 06/24/15 at 1:54 p.m., Resident #163 was observed in her room. She was sitting in a wheelchair, and had her feet propped up on the bed - both heels were directly on the bed. On 06/25/15 at 3:28 p.m., Resident #163 was in the same position, with both heels directly on the bed. On 06/26/15 at 11:19 a.m., the resident was sitting in her wheelchair, with both legs elevated, and the right heel (the area with a pressure sore) was directly against the end of the bed. Per interview with Staff T on 06/26/15 at 11:25 a.m., she reported Resident #163 puts her legs up at least three times on day shift. Staff T confirmed Resident #163 generally puts her legs up by resting them on the bed or a chair. She said the resident should have her heels elevated. The facility failed to ensure the resident had pressure relief to her heels, placing her at risk for a worsening pressure sore, and/or the devlopement of additional skin breakdown.

Based on record review and interviews, the facility failed to ensure the necessary care and services were provided to 2 of 4 sample residents (#1, 2), related to ensuring lab work was completed when ordered, and a change in condition was assessed in a timely manner. This failure resulted in actual harm to Resident #1, who required hospitalization for a serious [MEDICAL CONDITION]. Findings included: 1. Resident #1: admitted to the facility on [DATE] from the hospital, following surgery for [REDACTED]. Review of hospital discharge physician's orders [REDACTED]. The effectiveness of [MEDICATION NAME] is monitored through a blood test (PT/INR). Per review of the hospital admission records, there were 3 separate orders for the PT/INR to be checked - weekly for 3 weeks, 3 days after admission (excluding the weekend), and 2 days after admission. The 2 day order also directed a complete blood count be checked - to ensure there was no evidence of blood loss. Review of the lab test results prior to discharge from the hospital were: 05/27/15 - PT was 17.3 seconds, INR was 1.4 seconds (normal range is 2-3 when on blood thinners). Complete blood count - hemoglobin was 10.3 (normal range is 13.5-16.5), and hematocrit was 30.1 (normal range is 41-55). Review of the resident's Medication Administration Record [REDACTED]. One order documented a PT/INR, and complete blood count, were scheduled to be done on 06/01/15 (lab work was not done on weekends). The other order was for a PT/INR to be done in 3 days, then weekly for 3 weeks, while the resident was on [MEDICATION NAME] (with no scheduled date for the first labs to be done). There was no evidence in the record any lab testing had been done. An interview on 06/17/15 at 4:15 p.m. with Staff A (Director of Nursing), confirmed staff had not obtained physician clarification relative to three different discharge orders for labs, nor had any lab testing been done on the resident, since his admission to the facility on [DATE]. Review of the resident's medical record evidenced a change of condition on 06/02/15 at 10:45 a.m., noting significant right-sided facial drooping and slurred speech. The physician was notified, and orders were received to transport to the emergency room (ER). Review of hospital records dated 06/02/15 noted the resident's stool tested positive for blood, and he stated he had dark stools over the past couple of days. Lab testing done in the ER at that time noted significant abnormal labs results: PT time of 56.1 seconds, INR of 6-7, hemoglobin of 4.6, and hematocrit of 14.2. The resident was diagnosed with [REDACTED]. Despite the resident's recent surgical procedure, [MEDICATION NAME] therapy being initiated on 05/26/15, multiple physician orders [REDACTED]. 2. Resident #2: Review of hospital records dated 06/11/15 noted the resident [MEDICAL CONDITION] (severe blood infection that can lead to organ failure and death) in February 2015, after which she developed a bowel infection. The resident [MEDICAL CONDITION] a second time in May 2015. She was readmitted to the facility on [DATE] from the hospital, with [DIAGNOSES REDACTED]. A note on 06/10/15 indicated the resident was alert, and made her needs known. She was working with therapy, required assistance with transfers, and had a fair appetite. On 06/11/15, the resident's body temperature was 98.1 degrees in the morning, and elevated to 101.4 degrees by 1:00 p.m., for which Tylenol was given. She was complaining of not feeling well that afternoon. She had refused both meals during the day shift. The next documented entry was on 06/11/15 at 11:33 p.m. - after the resident was sent to the emergency room . The note indicated the resident's spouse said she was hard to wake up, and asked how long she had been that way - the note did not indicate what time this interaction occurred. It was after the resident's spouse initiated contact with staff that an assessment was done, noted her body temperature continued to be elevated (100.5 degrees), the physician was contacted, and orders were received to transfer her to the ER. Review of hospital records dated 06/11/15 revealed the resident's first set of vital signs in the ER were obtained at 6:07 p.m., and noted a temperature of 100.5 degrees. She was diagnosed with [REDACTED]. An interview on 06/18/15 at 9:50 a.m., with Staff B (Licensed Nurse on the day shift of 06/11/15), revealed that after Tylenol was administered to the resident at 1:00 p.m., her temperature after 30 minutes later was 101.4, and at 2:00 p.m., 101.0 degrees. Staff B said she instructed the evening shift Licensed Nurse (LN) at 2:00 p.m. to call the physician. A telephone interview on 06/18/15 at 10:20 a.m., with Staff C (Nursing Assistant caring for the resident on the evening shift of 6/11/15), revealed the resident was obviously very sick and lethargic when she arrived on shift. She stated the resident stayed in bed, and did not eat any supper. She reported an elevated body temperature of 100.5 degrees to the LN at 3:30 p.m. During a telephone interview on 06/18/15 at 11:38 a.m. with the resident's spouse, he stated he arrived at the facility on 06/11/15, at approximately 3:00 p.m. A Nursing Assistant met him at the door, and asked if anyone from the facility had contacted him yet regarding the resident as she was not feeling well. When he arrived at the resident's bedside she could hardly lift her head off the pillow and could hardly utter any words. He stated he sat with her approximately 30 minutes, and her condition did not improve. He then went to the nurse's station and said to the LN in charge, there is really something wrong with the resident. He returned to the resident's room, to wait for staff to evaluate her. When staff did not arrive, he again went up to the nursing station. He stated he thought staff should have taken care of the resident's change of condition sooner than they did. Despite the resident's signficant history [MEDICAL CONDITION] with recent hospitalization , elevated temperature beginning at 1:00 p.m. on 06/11/15, which remained elevated despite Tylenol, increased lethargy, refusals of meals, complaints of not feeling well, and concerns voiced by the spouse, staff failed to perform assessments and physician notification in a timely manner, which resulted in a delay in treatment.

Based on record review and interviews the facility failed to identify and provide adequate supervision to prevent falls for 1 of 3 residents (#1) reviewed for falls. This deficient practice resulted in actual harm to Resident #1 who exhibited increased pain to his right shoulder/arm following the fall. Findings include: Resident #1: admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the resident's plan of care revealed he was extensive assistance with transfers and toileting, high risk for falls, tab alarm to his wheelchair, and had impaired cognition. Review of facility investigation reports revealed the resident had two falls (10/15,16/14) when he rolled out of bed. Due to increased complaints of pain to his right shoulder following the fall on 10/15/14 an x-ray was obtained which noted the initial fracture (prior to admission) of his right shoulder. Following the fall on 10/16/14 an alarm was placed on the resident's wheelchair to be utilized when he was up. Review of Progress Notes dated 10/23-24/14 documented the resident displayed increased swelling to his legs, and was encouraged by staff to elevate his feet. Review of Progress Notes and a facility investigation report noted on 10/25/14 at 1:30 p.m. the resident was assisted to the toilet by Staff C (Nursing Assistant). Staff C left the resident on the toilet when another resident's alarm went off. When she returned to check on the resident he was on his hands and knees on the floor. He stated he hit his right elbow and head. A red mark was noted to his right elbow and lower arm, and the top of his head. The investigation concluded the resident's unsteady gait, intermittent confusion, and forgetfulness contributed to his fall. Review of Progress Notes dated 10/25/14 and 10/26/14 following the resident's fall noted he complained of increased pain to his right shoulder. On 10/27/14 documentation stated the therapist had informed nursing staff the resident's right bicep (muscle on the front of the arm) was hurting and it appeared that it was torn. The physician was notified on 10/27/14 and orders noted staff was to monitor the area. On 10/28/14 the resident's right arm bicep continued to bother him. There was a fading bruise to the area. A fax was sent to the physician on 10/29/14 which stated the resident continued to complain of increased pain to area and had not been able to fully participate with therapy due to the pain. The physician responded to the fax on 10/31/14 and ordered a MRI (magnetic resonance imaging - diagnostic test that can detect soft tissue and nerve damage), which was scheduled for 11/6/14. Review of the resident's Medication Administration Record revealed that prior to the resident's fall on 10/25/14 he requested narcotic medication once daily on 10/20, 21, and 22/14. He did not request any narcotic medication on 10/23, 24/14. On 10/25, 26/14 he received it twice daily, and once daily on 10/27, 28/14. An interview on 11/4/14 at 10:05 p.m. with Staff D (Physical Therapist) noted the resident's ability to bear weight on his right arm had not yet been determined by the physician. He stated therapy staff always made sure the resident was visible to them, and if he used the bathroom they would either stay with him or watch him through a crack in the bathroom door. He stated the resident was very "impulsive" with confusion at times. He stated that following the fall on 10/25/14 he felt the resident had a "torn bicep", due to his complaints of pain and the appearance of his right arm. Staff C stated on 11/4/14 at 2:35 p.m. that she had placed the resident on the toilet on 10/25/14 and had to leave him to answer an alarm that had gone off on another resident. The resident had promised her he would not get up on his own. She stated the resident was "iimpulsive, head strong and wants to do everything on his own." Despite the resident's multiple [DIAGNOSES REDACTED].

Based on interview and record review, it was determined the facility failed to consistently implement planned interventions to promote safety, and to prevent injury for 1 of 3 residents ( #1). This failure resulted in actual harm to Resident #1, who received an injury to the leg requiring stitches. Findings include: Resident #1 was admitted the facility in December 2012, with [DIAGNOSES REDACTED]. According to the facility's most recent assessment, Resident #1 was alert only to self, unable to make her needs known, and required extensive assistance with all activities of daily living. Per review of the in-room care plan dated 4/28/14 for Resident #1, she required 2-person extensive assistance for all transfers. On 9/24/14, Resident #1 was transferred from her bed to her wheelchair by one staff person. Resident #1 sustained a laceration, which required her to be transported to the hospital, where she received stitches on her right lower leg. Per review of the facility investigation, Staff #A did not follow the care plan for Resident #1 during a transfer, resulting in a substantial injury. Per interview with Staff #B on 10/16/14 at 1:30 p.m. the investigation resulted in termination of Staff#A. The facility failed to implement planned interventions to prevent injury for Resident #1, which resulted in a substantial injury requiring transport to, and treatment from, a local hospital.

Based on observation, interview, and record review, it was determined the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care related to bowel management and skin conditions for 2 of 2 residents ( #54, 59) in a sample of 39. The facility's failure to consistently monitor Resident #59's bowel pattern and implement timely interventions resulted in the resident suffering harm from fecal impaction, increased anxiety, restless behavior, and localized rectal bleeding. Findings include: Bowel Management The facility Bowel Protocol included the following interventions: - Bowel records are monitored on a daily basis. -Residents who have not had a bowel movement (BM) in 3 days (9 shifts) will be given Milk of Magnesia (MOM) at bedtime. -If no bowel movement by the following morning (10 shifts) a [MEDICATION NAME] suppository is given. -If resident continues without BM a Fleets enema will be given the afternoon of the 4th day (12 shifts). -If resident exceeds 4 days without a BM the physician will be notified for further orders. 1. Per record review, Resident #59 was receiving end of life care. The resident had memory problems and required total assistance of 1-2 staff for all activities of daily living. The resident was refusing solid food and was drinking small amounts of health shakes, supplements, and water. Review of the resident's medications noted physician orders [REDACTED]. Constipation was a common side-effect of both medications. Review of the April 2013 bowel records noted the resident had no BM from 4/6 until 4/14/13 (7 days) when a licensed nurse administered MOM. Nurse's notes dated 4/12/13 and 4/13/13 noted the resident did not have a distended abdomen with no additional evaluation regarding why the resident did not receive medication or why the physician was not notified (per the Bowel Protocol). Additional review of the April 2013 bowel record noted the resident had no BM and no bowel medications per the Bowel Protocol from 4/16/13 through 4/22/13 (6 days). A nurse's note dated 4/23/13 on the night shift noted the presence of hard BM present in the rectum. The resident received a [MEDICATION NAME] suppository at that time. There was no results/effectiveness of the suppository documented until the night shift of 4/24/13 when the licensed nurse administered a Fleets enema due to no results from the suppository for 24 hours. Per the nurse's note, the resident was "seeping"stool. There was no results/effectiveness of the Fleets enema documented until the night shift of 4/25/13 when the licensed nurse noted she asked the resident if he needed to have a BM and he replied "no." The night shift licensed nurse noted she left a communication for the day shift staff to ask the family if they wanted further bowel program interventions. There was no communication to the physician. Per record review, the resident had a small and medium BM on 4/25 and 4/26/13. Per record review, during the night shift on 4/28/13, the resident was "anxious and restless" and had a large amount of BM he could not expel. He "appeared uncomfortable and was groaning." The licensed nurse manually removed an extra large BM and gave a fleets enema, MOM, and 2 doses of as needed [MEDICATION NAME] during the shift. The resident had a small bleeding skin tear from the amount of impacted BM. The licensed nurse sent a Fax to the physician notifying him of the resident's impaction and requesting routine bowel medications. On 5/2/13, Staff #D was informed of the lack of monitoring and intervention to prevent bowel impaction. After record review, Staff #D confirmed facility staff did not consistently implement the Bowel Protocol and had no additional information to offer. The facility's failure to consistently monitor and implement Bowel Protocol interventions for the resident who could not make his needs known resulted in harm. 2. Resident #54 had [DIAGNOSES REDACTED]. Per record review, the resident had no memory problems and was able to make her needs known. She required extensive assist with activities of daily living (ADL's). Review of the April 2013 bowel records noted the resident had no bowel movement (BM) from 4/10/13 night shift until 4/15/13 evening shift (5 1/2 days). No medication was administered to the resident and the physician was not notified per the Bowel Protocol. Additional review of the April 2013 bowel record noted the resident had no BM from 4/16/13 night shift through 4/20/13 day shift (4 1/2 days). It was documented the resident had a small BM on 4/20/13, received a [MEDICATION NAME] suppository on 4/21/13 and then had a large BM on 4/21/13 day shift. A nurse's note on 4/22/13 noted that the resident had problems with constipation and the physician was faxed for an order for [REDACTED]. Further review of the April 2013 bowel record, the resident had no BM from 4/24/13 evening shift until 4/29/13 day shift (over 4 days). On the 4th day she was offered and refused some Milk of Magnesia (MOM). She was then given a [MEDICATION NAME] 4/29/13 on night shift of the 5th day and had a large BM on 4/29/13 day shift. On 5/3/13, Staff #D confirmed facility staff did not consistently implement the Bowel Protocol and had no additional information to offer. The facility failed to consistently monitor and implement the Bowel Protocol which placed the resident at risk for an impaction. Skin Condition Per record review, Resident #59 was receiving end of life care. The resident had memory problems and required total assistance of 1-2 staff for all activities of daily living. The resident had a left heel pressure ulcer and left hip surgical incision. Per record review, on 4/21/13 the resident was scratching at his skin, the physician was notified, and ordered an as needed medication which had helped before. On 4/22/13, the resident developed a small open area at the hip incision with a 7x5 centimeter (cm) red area around the open area, possibly related to scratching the area. Per record review, the resident received the medication for itching on 5 of 8 days between 4/22/13 through 4/30/13. A night shift nurse's note dated 5/2/13 noted the resident removed his hip dressing, and was scratching the open area which had increased in size and was inflamed. On 5/2/13 at 1055 a.m., the resident was uncovered and laying on his back. He had removed the dressing to the left hip exposing a superficial open area with dark brown drainage in front of an intact surgical incision. The resident had red scratch marks of the left knee and thigh and periodically scratched the left knee. Staff was informed. Staff #M was interviewed after providing wound care. Staff #M stated the resident had intermittent problems with itching since admission several months earlier. Later the same day, Staff #E confirmed the left hip skin condition was worse due to scratching and the physician had not previously been notified that despite the current ordered medication, the resident continued itching. The facility's failure to consistently monitor and take action to control the resident's itching. This contributed to continued discomfort and worsening of the left hip skin condition.

Based on record review and interviews the facility failed to provide sufficient staff supervision based on the assessed needs of the resident and to ensure the plan of care was followed for 1 of 3 sampled residents (Resident #1) who sustained injuries from a fall. Resident #1 sustained a fractured hip due to a lack of staff supervision. Findings include: Resident #1: admitted to the facility on [DATE] from the hospital following surgery for [REDACTED]. Other [DIAGNOSES REDACTED]. Review of the Falls Risk Assessment form dated 1/11/11 noted a personal alarm was to be placed on the resident to alert staff when she attempted to transfer on her own. Review of the resident's plan of care dated 1/11/11 noted a problem addressing the resident's dementia with confusion, poor safety awareness, and impaired mobility due to the recent fractured right hip. Nursing approaches were to use an alarm system on the resident when seated in her wheelchair or when in bed. Review of a comprehensive assessment dated [DATE] relative to the resident's risk for falls noted her risk might increase due to improved pain control and less fear in moving her right leg. Review of a facility investigation report noted on 1/25/11 at 10:35 a.m. the resident had completed her therapy session and was seated in her wheelchair in the therapy room awaiting transport by staff to her room. Therapy staff (with the exception of a Physical Therapist) was in the office area of the therapy room doing paperwork and were not able to visualize the resident. The Physical Therapist was approximately 15 feet away with her back to the resident working with another resident when the resident attempted to stand up and fell on the floor on her left side. She was transferred to the emergency room and diagnosed with [REDACTED]. Further review of the above facility investigation report noted the resident was impulsive per reports from caregivers. The resident did not have an alarm system in place at the time of the fall despite the plan of care noting the need for it as a preventative measure for falls. During an interview on 2/9/11 at 3:40 p.m. with Licensed Nurse (LN) #1, she stated prior to the fall on 1/25/11 the resident would occasionally attempt to stand up. Her alarm would then go off alerting staff and they would intervene and prevent her from falling. An interview on 2/10/11 at 9:30 a.m. with a family member revealed that prior to the fall on 1/25/11 she would scoot to the front of her wheelchair and put both hands on the armrests in preparation to stand. Family members would tell her to sit back and they would locate staff to assist her. An interview conducted on 2/10/11 at 10:00 a.m. with the Administrator revealed that when the resident is in skilled therapy, a therapy staff member should be with the resident during the entire time she was in the therapy room. Therapy staff should never have left her "unattended" in the therapy room. The facility failed to implement the fall alarm as per the plan of care to prevent falls, and the facility also failed to institute other measures to supervise the resident more closely despite a history of falls at home resulting in a recent fractured right hip; impulsive type behaviors; dementia with poor safety awareness; previous attempts to get up unassisted; and need for 1:1 staff supervision in the therapy room.

Based on record review and interviews the facility failed to ensure its policies and procedures regarding reporting and investigating of abuse were implemented. At least 3 Nursing Assistants (#'s 2, 3, and 4), 2 Licensed Nurses (#'s 1 and 2), and the Administrator had direct observation or knowledge of possible abusive acts to 3 of 4 sampled residents (#'s 1, 2, and 3) by Nursing Assistant #1. These same above staff members failed to immediately report different observations or knowledge of NA #1's possible abusive acts to their immediate supervisor and/or facility Administrator or the Director of Nursing, the state Complaint Resolution Unit (CRU), and local law enforcement per facility policy and procedure for abuse prevention. This failure by multiple staff to report abusive acts and conduct immediate investigations as required demonstrated the facility's Abuse Prevention Program was ineffective. The failure to ensure a thorough Abuse Prevention Program was developed and implemented placed all residents in the facility at potential risk of abuse. The findings constituted an immediate jeopardy situation. Findings include: The facility's policy and procedure for abuse prohibition included a clear description of who the staff should report abusive incidents to and to conduct immediate investigations. However, their Abuse Prevention Program did not evidence what management was doing to ensure staff were implementing correctly the information on which they were trained. There was no evidence the facility's prevention program focused on management responsibility to prevent abuse to include such factors as ensuring supervision of staff providing care and providing a safe environment for residents. On 9/30/10 the facility Administrator was informed by a state agency staff member that Resident #1 had stated she had sexual relations with Nursing Assistant (NA) #1 in the facility. On 10/7/10 the Administrator was informed by the local police department that the sexual encounters between Resident #1 and NA #1 had taken place sometime in November 2009. Resident #1: An interview with NA #2 on 10/15/10 at 1:25 p.m. revealed that sometime last fall-winter 2009 the resident had stated to her 2-3 times that NA #1 would just keep looking at her breasts during therapy sessions and she did not like it. Following these statements by the resident NA #2 observed NA #1 standing at the resident's bedside just looking at her. The resident was naked from the waist up. When NA #1 was questioned by NA #2 as to why he was in the room he stated he came to say "hi" to the resident. Nursing Assistant #2 immediately reported her observations to LN #1. Licensed Nurse #1 stated NA #1 "should not be up here (referring to the resident's room)". Nursing Assistant #3 was also present when the observations were reported to the LN. During a later interview with NA #2 on 10/15/10 at 3:30 p.m. she stated she had provided the Administrator in early October 2010 with a written statement relative to the above incident but had never been further questioned as to contents of the statement. Review of the facility investigation report provided by the Administrator on 10/14/10 to the state investigator contained no written statement by NA #2 regarding the above incident. Despite the written statement noting possible sexual abuse by NA #1 the facility investigation concluded staff had not observed any wrong doings by NA #1. The Administrator stated on 10/15/10 at 4:00 p.m. she had "shredded" the written statement as NA #2 had completed the facility questionaire, which then replaced the written statement. Review of the facility questionaire dated 10/1/10 noted there were 6 questions asked with responses of yes/no. Nursing Assistant #2 had answered "yes" to the question of "Did you ever observe any men alone with (Resident #1) in her room. There was no further information given. The Administrator had not reported the above findings (written statement by NA #2) to the state CRU or the local police department, nor was an investigation relative to the statement conducted by staff. A telephone interview with LN #1 on 10/17/10 at 8:45 p.m. revealed she was unable to recall being informed by NA #2 of the above incident involving NA #1 but that did not mean it did not occur. She stated "never would I think a staff member would be inappropriate with a resident". Despite an observation of possible sexual abuse the incident was never investigated or reported to the state CRU or local police department. In addition, staff did not report the incident to facilty administration in a timely manner (not reported until early October 2010). Resident #2: A telephone interview on 10/17/10 at 8:31 p.m. with NA #3 revealed two different observations involving the resident and NA #1. The first incident occurred during the summer of 2009. Nursing Assistants #'s 2 and 3 noted the door to the resident's bathroom was locked thus they went around to an adjoining door and entered the bathroom. Upon entering NA #1, who had been on his knees in front of the resident, immediately got up from the floor. The resident was seated on the toilet (lid was down) and was dressed only in her bra and underwear. The resident stated NA #1 was doing her exercises. The second incident occurred approximately late summer of 2009. Nursing Assistant #3 went to get the resident for lunch. Upon knocking she found the door to the resident's room was locked. Upon the door being opened she found NA #1 in the resident's room. The resident was lying on her bed and upon seeing NA #3 she immediately started "straighening her dress". Later that day the resident stated to NA #3, "I don't want you to think anything is going on". Nursing Assistant #3 shared the above observation with NA #2. She stated she did not know who to report the incident to and did not want to get anyone in trouble... "I was giving him (NA #1) the benefit of the doubt". The above two incidents were never reported by Nursing Assistants #'s 2 and 3 to administration and the CRU. Observation on 10/19/10 at 2:00 p.m. of Resident #2's room (#27) noted the door could be locked from the inside of her room. On 10/20/10 at 11:30 a.m. the Director of Nursing stated there were three additional rooms (#'s 16, 26, and 29) that had doors which could be locked from the inside and only the maintenance supervisor had keys for the locks. The locks demonstrated additional risks to residents for potential abuse to occur. Resident #3: During an interview on 10/14/10 at 4:30 p.m. with NA #4, she stated she was informed a few months ago by the resident that NA #1 would go to her room to perform therapy exercises and would kiss her before and after therapy sessions. She stated the resident did not like to be kissed as it made her uncomfortable. She stated she informed LN #2 of the resident's concerns the day she was informed by the resident. An interview with LN #2 on 10/15/10 at 12:30 p.m. noted she had been informed by NA #4 of the above incident approximately 6 months ago. She stated she had visited the resident that same night (as she usually did on her shift) and the resident never said anything to her regarding NA #1. She stated that despite her knowledge of the incident she never asked the resident any questions about it. During an interview on 10/15/10 at 9:30 a.m. with the resident she stated, "I didn't like him (referring to NA #1), he was hugging me too much". She stated he would embrace her each time he came in to do exercises with her and would bring his hand under her breast area which made her very uncomfortable. In addition he would kiss her on the forehead and cheek each time. She stated one time NA #1 had tried to kiss her on the lips but she turned her head, and told her he loved her which made her "very uncomfortable". review of the resident's medical record revealed [REDACTED]. Review of the Restorative Flowsheets for August-September 2010 noted NA #1 attempted and/or provided restorative services 32 times. Despite the above resident's statement relative to the inappropriate actions of NA #1 it was not reported to administrative staff or the state CRU, nor was an investigation conducted. Review of inservicing records relative to the facility Abuse Prevention Program revealed the last inservice conducted for staff was on 2/10/10. Despite the intent of the inservice to be for all staff there were only 27 that attended of the approximate 120 (22.5%) staff members. During 2009 the inservice was held on 5/29/09 and only 20 staff members attended. Interviews with administrative staff on 10/19/10 at 3:00 p.m. relative to the above inservices noted their awareness of the inservices being poorly attended by staff, however no attempt was made to provide additional thorough education or methods to increase participation. Administrative staff stated the inservices for their Abuse Prevention Program were conducted on an annual basis with new employees receiving training on date of hire. The number of staff members who were witnesses to or had knowledge of potential abusive acts and failed to intervene or immediately report their knowledge, demonstrated the facility failed to have an effective abuse prevention program, placing all residents at potential risk for continued abuse.

Based on record review and staff interviews the facility failed to thoroughly investigate and/or report to the appropriate entities four of five occurrences of witnessed and/or alleged abuse for 3 of 4 sampled residents (#'s 1, 2, and 3) in accordance with CFR 483.13(c)(2)-(4). In addition, the facility failed to protect residents as required by CFR 483.13(c)(1)(3). The failure to thoroughly investigate and protect residents after each occurrence resulted in harm to two residents (#'s 1 and 3) and placed all residents at risk for harm. Finding include: Five staff members (3 Nursing Assistants and 2 Licensed Nurses) had direct observation or knowledge of possible abusive acts to three residents by Nursing Assistant #1. Staff members failed to immediately report possible abusive acts to their immediate supervisor and/or facility administration, the state Complaint Resolution Unit, and local law enforcement. In addition, the incidents were not investigated to determine if abuse had occurred, and residents were not protected from possible further abuse. The findings constituted an immediate jeopardy situation. Cross-refer to F226. The facility failed to ensure its policies and procedures regarding and investigation of abuse incidents were implemented.

Based on record review and staff interviews the facility's administration failed to effectively and/or efficiently use its resources to attain or maintain the highest practicable well being of each resident. Failure of the Administrator to ensure a thorough and effective abuse prevention program was implemented resulted in harm for Resident #'s 1 and 3 and placed all other residents at imminent risk for experiencing unrecognized abuse. In addition the Administrator failed to ensure staff received educational training relative to the facility Abuse Prevention Program and to ensure a safe environment for all residents relative to potential abuse. Failure by multiple staff to report potentially abusive acts and conduct immediate investigations as required demonstrated the facility's Abuse Prevention Program was ineffective which resulted in an immediate jeopardy situation. Findings include: 1) The Administrator failed to ensure Resident #'s 1 and 3 right to be free of abuse. Cross-refer to F223. 2) The Administrator failed to ensure staff thoroughly investigated and/or reported occurrences of witnessed and/or alleged abuse, and failed to protect residents after each occurrence. Cross-refer to F225. 3) The Administrator failed to ensure its policies and procedures regarding reporting and investigating of abuse were implemented. Cross-refer to F226.

Based on interviews the facility failed to ensure residents' right to be free of abuse for 2 of 2 residents (#'s 1 and 3) who were sexually abused by Nursing Assistant #1. Findings include: Resident #1: An interview on 10/15/10 at 1:25 p.m. with Nursing Assistant (NA) #2 revealed that sometime last fall-winter 2009 the resident had informed her she was uncomfortable with how NA #1 was looking at her breasts. Later NA #2 observed NA #1 standing over the resident's bedside just looking at her. The resident at that time was naked from the waist up. Nursing Assistant #1 stated she had informed LN #1 that day of her observations. Despite staff knowledge of the above incident relative to Resident #1 there was no attempt to prevent further potential abuse. On 9/30/10 the facility Administrator was informed by a state agency staff member that Resident #1 had stated she had sexual relations with NA #1 in the facility. On 10/7/10 the Administrator was informed by the local police department that the sexual encounters between Resident #1 and NA #1 had taken place on two different occasions in the therapy department of the facility sometime in November 2009. Resident #3: During an interview with the resident on 10/15/10 at 9:30 a.m. she stated that each time Nursing Assistant (NA) #1 would come into her room to do therapy exercises with her he would embrace her and bring his hand under her breast area which made her very uncomfortable. In addition he would kiss her on the forehead and cheek. She stated one time he tried to kiss her on the lips but she turned her head. She stated she had told him she did not like to be kissed. She stated "I didn't like him - he was hugging me too much." She stated she had informed NA #4 of what NA #1 was doing to her. Interviews with NA #4 and Licensed Nurse #2 on 10/15/10 at 12:30 p.m. revealed they had received knowledge of the resident's concerns several months ago. review of the resident's medical record revealed [REDACTED]. Review of Restorative Flowsheets for August-September 2010 noted NA #1 attempted and/or provided restorative services to the resident 32 times. Despite the incidents of sexual abuse over several months to the resident by NA #1 and staff knowledge of the incidents there was no attempt to prevent further abuse to the resident. Cross-refer to F226. The facility failed to ensure its policies and procedures regarding reporting and investigating of abuse were implemented.