Every finding on record at Columbia Basin Hospital

Based on observation, interview and record review, the facility failed to ensure refrigerated medications were stored at proper temperatures in 1 of 1 medication refrigerator. The failure placed residents at risk of medications that could cause unintended outcomes due to improper storage. Findings Include. Review of the TUBERSOL(R) Tuberculin Purified Protein Derivative ([PPD], a serum used in a skin test to help diagnose tuberculosis infection) manufacturer's package insert showed the medication should be stored as follows: Refrigeration: Store at 2 degrees to 8 degrees Celsius (C) (35degrees to 46 degrees Fahrenheit [F]). No Freezing: Do not freeze; discard if the product has been exposed to freezing temperatures. Light Protection: Always protect from light (e.g., store in a brown paper bag). Opened Vial Stability: Once opened, the vial should be discarded after 30 days. Do not use after expiration date. During an observation and concurrent interview on 04/21/2026 at 12:43 PM, in the medication room a medication refrigerator showed two boxes of Tubersol on the inside the door of the refrigerator. Above the refrigerator was a medication refrigerator temperature monitor log with missing medication monitoring checks. Staff F, Licensed Practical Nurse (LPN), stated the temperatures were to be checked twice a day to keep the efficacy of the medications. Review of the medication refrigerator temperature monitor log dated April 2026 showed staff were to monitor medication temperatures daily in the AM and in the PM. Further review showed eleven shifts without temperature monitoring. During an interview and concurrent observation on 04/21/2026 at 3:07 PM, Staff B, Director of Nursing Services, acknowledged the missing shifts and stated the medication refrigerator temperature monitoring log should be checked twice a day. Staff B explained the temperature checks should be completed once with the dayshift nurse and once with the nightshift nurse. Reference: WAC 388-97-1300 (2)

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for 3 of 3 residents (Resident 2. 10, and 12) reviewed for Beneficiary Notices. This failure placed residents and/or their representatives at risk of not having adequate information to make financial decisions related to the residents' stay within the facility. Findings included . Resident 2 Review of the medical record showed Resident 2 had been discharged to hospital on [DATE] and returned to the facility on [DATE]. There was no documentation in the record to show that Resident 2 had been provided with a SNF ABN. Resident 10 Review of the medical record showed Resident 10 had been discharged to a lesser care setting on 02/17/2026. There was no documentation in the record to show that Resident 10 had been provided with a SNF ABN. Resident 12 Review of the medical record showed Resident 12 had been discharged to a lesser care setting on 03/03/2026. There was no documentation in the record to show that Resident 12 had been provided with a SNF ABN. In an interview on 04/21/2026 at 3:23 PM, Staff B, Director of Nursing Services, stated the facility had not completed the beneficiary notice process. Staff B stated Residents 2, 10, and 12 had not been provided with the SNF ABN. Reference (WAC) 388-97-0300 (4) (a-c)

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment was maintained for 3 of 11 resident rooms (rooms [ROOM NUMBER]) reviewed for environment. This failure placed residents at risk for potential injury, diminished quality of life, and a lack of security within their environment. Findings included.room [ROOM NUMBER]An observation on 04/20/2026 at 10:20 AM showed: Bed Area (Window Side): Multiple wall gouges (deep grooves) to the left of the head of the bed measured at 12 inches (in-a unit of measure), 6 in, and 4 in. The wall behind the bed showed multiple deep scratches with exposed drywall and chipped paint. Sink Cabinet: Missing laminate with wood showing on the bottom left drawer (5 in by 1 in) and the bottom right drawer (2 in by 1 in). Wall (Adjacent to Bathroom Door): Multiple scratches with exposed drywall and missing paint in an area of 5 in by 1 in and an area of 1 in by1 in. Bathroom Door Trim: Multiple scratches with paint loss and exposed metal. Entrance Wall: A black scratch measuring 5 feet (ft-a unit of measure) was observed on the wall to the left of the entrance door. During an interview on 04/22/2026 at 1:35 PM, Resident 2 (resided in room [ROOM NUMBER]) stated they would like the items in their room to be repaired so that the environment feels more like home. room [ROOM NUMBER]An observation on 04/20/2026 at 3:00 PM showed: Closet Area: An 8 in by 5 in section of exposed drywall next to the door. Window Area: A 2 ft gouge under the window exposing drywall. Bed Area (Door Side): Three 1 ft gouges behind the bed exposing drywall. Bathroom Entry: Missing multiple dime sized areas of drywall to the left of the door; trim showed paint chips and exposed metal. Doors: The bathroom door had a 1 in by 2 in- gouge; the room entry door had a 4 in gouge under the knob. room [ROOM NUMBER]An observation on 04/21/2026 at 1:30 PM showed: Bathroom Entry: Missing multiple dime sized areas of drywall to the left of the door; trim showed paint chips and exposed metal. Entrance Wall: The wall to the right of the entry showed a 3-ft area with bubbling paint and exposed drywall. During an interview on 04/22/2026 at 3:26 PM, Staff B, Director of Nursing Services, stated the facility utilized an electronic ticket system called the Works Hub that was directly sent to maintenance. Staff B stated they were not aware of the environmental issues identified in rooms [ROOM NUMBER]. Staff B stated, I would expect staff to put in those tickets for those room issues; they all know how to do it. During an interview on 04/22/2026 at 3:50 PM, Staff C, Maintenance Manager, stated the Works Hub portal allowed every employee to submit maintenance tickets. Staff C performed a system search and confirmed that no work orders had been submitted for rooms [ROOM NUMBER]. Staff C stated their team conducted general facility rounds, but they did not typically enter occupied resident rooms and relied on staff to report issues. Staff C stated that staff failed to communicate environmental needs. Staff C stated they were unaware that repairs were needed in the referenced rooms. Reference WAC: 388-97-0880 (1)(2)

Based on interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic (drugs that change brain chemistry to alter a person's mood, thoughts, behavior, or perceptions) medications by failing to provide a clinically valid and accurate diagnosis to justify medication use for 3 of 5 residents (Residents 1, 3, and 6 ) Reviewed for unnecessary medications. This failure placed residents at an increased risk for falls, medication-related adverse side effects, and unmet care needs. Findings included. Review of the policy titled, Monitoring of Psychotropic Medications, dated 04/04/2025, showed, psychotropic medications will only be given to treat a specific diagnosis and documented conditions. Resident 1 Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life, unlike temporary, situational stress). The comprehensive assessment date 04/02/2026 showed the resident required assistance of one staff member with transfers and their cognition was intact. Review of a physician's order dated 12/22/2025 showed an order for an anti-depressant medication to be administered daily for a diagnosis of transition from acute care to long term care. Resident 3 Review of the medical record showed Resident 3 admitted to the facility on admitted on [DATE] with diagnoses including anxiety disorder and depression (a serious, common medical illness causing persistent sadness, loss of interest in activities, and functional impairment). The comprehensive assessment dated [DATE] showed Resident 3 required assistance of one staff member with Activities of Daily Living (ADLs) and their cognition was intact. Review of a physician's order dated 12/24/2025 showed an order for an anti-depressant medication to be administered daily for a diagnosis of Lives in long-term care facility. In an interview on 04/21/2026 at 8:45 AM, Staff K, Licensed Practical Nurse, stated there were medications without an appropriate indication of use/diagnosis. Resident 6 Review of the medical record showed the resident was admitted to the facility with diagnoses including Lewy body dementia (a progressive brain disease) with agitation and psychosis (a mental health symptom where a person loses contact with reality, making it difficult to distinguish what is real form what is not). The 03/18/2026 comprehensive assessment showed Resident 6's cognition was moderately impaired and required the assistance of one to two staff members for Activities of Daily Living (ADLs). Further review showed Resident 6 received antianxiety (a class of drugs used to treat symptoms of anxiety, such as feelings of fear, dread and uneasiness) and antipsychotic (a class of drugs used to treat symptoms of psychosis, such has hallucinations [seeing or hearing things that are not there], delusions [strong beliefs that are not true] and severely disorganized thinking) medications. Review of a physician's order dated 12/22/2025 showed an order for an anti-anxiety medication to be administered twice daily for a diagnosis of pain aggravated by activities of daily living. Review of a physician's order dated 12/22/205 showed an order for an anti-psychotic medication to be administered twice daily for a diagnosis of hospice care patient. During an interview on 04/21/2026 at 3:11 PM, Staff B, Director of Nursing Services, stated that Resident 6 was not currently receiving hospice services and has not been on hospice for approximately one year. Staff B stated the diagnoses listed for the antianxiety and antipsychotic medications were incorrect and did not clinically support the use of those specific drugs. Staff B stated the facility lacked a formal process to ensure that resident diagnoses were accurate or appropriately linked to medications. Staff B further stated the facility's pharmacist did not have a consistent process for reviewing diagnoses during monthly psychotropic medication reviews. Reference: WAC 388-97-1060 (3)(k)(i)

Based on observation, interview, and record review, the facility failed to ensure restorative nursing services programs were implemented for 1 of 4 residents (Resident 12), reviewed for restorative nursing and limited range of motion [(ROM) the extent the joint can move within the expected (normal) range of values]. This failure placed the residents at risk for loss of ROM, deconditioning, pain, and worsening contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Findings included . Resident 12Review of the medical record showed the resident admitted with diagnoses including stroke. (when blood supply to part of your brain is suddenly cut off) and contractures. The 03/18/2026 comprehensive assessment showed Resident 12's cognition was moderately impaired and required the assistance of one to two staff members with activities of daily living and had impairment to both their upper and lower extremities. The assessment further showed Resident 12 had no restorative nursing programs in place. An observation and concurrent interview on 04/20/2026 at 2:52 PM showed Resident 12 lying in bed with a notable contracture of the right ring finger. Resident 12 stated no one works with my fingers, and indicated that movement causes pain. An observation and concurrent interview on 04/22/2026 at 11:28 AM showed Resident 12 in their wheelchair with the right arm at their side. During the observation of the resident's right hand, it was noted to be held in a fixed, contracted position resembling a clenched fist. The thumb was pulled inward toward the center of the hand and tucked tightly inside the palm. Resident 12 was able to extend the index, middle, and pinky fingers; however, the thumb and ring finger remained in a rigid, flexed position that could not be straightened. Record review of Resident 12's care plan, dated 01/01/2026, showed no restorative nursing programs or interventions were in place to address Resident 12's right hand contractures. Review of the restorative nursing programs binder on 04/23/2026 showed no active restorative program or individualized interventions for Resident 12's upper extremities. Review of the Occupational Therapy (OT) assessment dated [DATE] showed Resident 12 was evaluated for contracture management of right hand, wrist and elbow. The OT documented Resident 12 would benefit from skilled OT intervention to prevent further decline and worsening of existing contractures. During an interview on 04/22/2026 at 12:36 PM Staff H, Director of Rehab, stated although an initial OT assessment was completed on 04/01/2022, there was no documented evidence that any therapy was subsequently provided or that the resident was evaluated for a restorative nursing program. Staff H stated they would expect a resident with identified contractures to be enrolled in a restorative or maintenance program. Staff H stated there was no documentation to support ongoing monitoring or preventive care for Resident 12's contractures since the 2022 evaluation. During an interview on 04/23/2026 at 9:33 AM Staff G, Nursing Assistant, stated they only performed a walking program with Resident 12 and did not provide any other restorative programs. Staff G stated they had never performed a restorative program for the resident's right hand or arm, nor have they seen any restorative programs in place for those areas. Staff G stated, (Their) arm hurts her, so you have to be really gentle with her, and when dressing the resident, they hold their hand in a contracted position. Staff G stated they informed the nurse of these issues, but they were unaware of any follow-up or interventions from therapy. During an interview on 04/24/2026 at 10:07 AM Staff B, Director of Nursing Services, stated they would expect any resident with contractures to be evaluated and treated by therapy and be placed on a restorative maintenance program. Staff B stated they were aware the restorative program needed attention and they needed to formalize the program to incorporate the care of the resident's needs. Reference: WAC 338-97-1060 (3)

Based on interview, and record review, the facility failed to ensure a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice by not identifying triggers (a stimulus that causes a reaction, often an emotional or physical response) regarding a resident history of Post-Traumatic Stress Disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening or traumatic event) for 1 of 5 residents (Resident 2) reviewed for trauma-informed care . This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included.Review of the resident's medical record showed they were admitted to the facility with diagnoses including PTSD. The 02/04/2026 comprehensive assessment showed Resident 2 required the assistance of one staff member for activities of daily living and had intact cognition. During an interview on 04/21/2026 at 8:38 AM, Resident 2 stated they were a survivor of sexual assault. The resident stated that certain men made them feel very uneasy and uncomfortable, creating a significant trigger of anxiety. Resident 2 stated that receiving care from male caregivers, such as during bathing or dressing, was extremely uncomfortable for them. Resident 2 stated they had a past traumatic experience involving a family member, which caused them to panic at the sound of sirens, an event that occurred as recently as last week. Resident 2 further stated staff had never asked them about their trauma history or identified their specific triggers. Record review of Resident 2's care plan, dated 06/26/2025, showed no trauma-informed care plan was in place that included Resident 2's triggers, behaviors, or person-centered interventions. Record review of Resident 2's Social Work initial assessment, dated 08/27/2024, showed no documentation addressing the resident's diagnosis of PTSD. Further review showed the assessment contained no mention of specific trauma-informed care needs or potential triggers. During an interview on 04/21/2026 at 2:30 PM, Staff B, Director of Nursing Services, stated that they were responsible for formulating the care plans for trauma-informed care. Staff B stated they did not address the PTSD or the specific triggers for Resident 2 within the current care plan. Staff B stated they would expect a resident's triggers to be clearly documented to facilitate trigger avoidance and to ensure staff have the necessary information to provide competent care. Staff B further stated neither the triggers nor the trauma history were present in Resident 2's medical record and the process was not followed for this resident. During an interview on 04/21/2026 at 2:36 PM, Staff E, Social Services Director, stated they completed the Social Work Initial Assessment which was to include the trauma assessment for each resident upon admission to the nursing home. Staff E stated the Social Worker Assessment completed on 08/27/2024 contained no mention of PTSD or specific triggers. Staff E stated all PTSD screening results, including history and triggers, should have been added to the care plan to ensure staff knew how to properly care for the residents. Staff E stated the correct information was currently missing from Resident 2's care plan. Staff E further stated the facility's process was not correctly followed regarding the resident's assessment and care plan. WAC Reference: 388-97-1060 (3)(e)

Based on observation, interview, and record review, the facility failed to ensure the nursing staff posting was posted daily and/or reflected the actual nursing staff hours worked during 3 of 5 days (04/20/2026, 04/21/2026, and 04/22/2026) of the survey period. This failed practice prevented residents, family members and visitors from knowing the facility's actual number of available nursing staff. Findings included . During an observation on 04/20/2026 at 10:30 AM, and 04/21/2026 at 1:36 PM there were no nursing staff postings within the facility available to view for the residents/ resident representatives, or for visitors to view the actual staff available to provide resident care. During an observation on 04/22/2026 at 9:26 AM, the facility had no nursing staff posting viewable for residents or the public to show the actual staffing availability for resident care. During an interview on 04/22/2026 at 2:42 PM, Staff F, Licensed Practical Nurse, (LPN), stated their white board was not used for the nursing staff postings. Staff F stated they were told by Director of Nursing Services (DNS) that they no longer had to post actual nurse staffing, because the information was available online. During an interview on 04/23/2026 at 3:54 PM, Staff B, Director of Nursing Services, stated it was their understanding that the postings were online and did not have to have it posted after switching to the computer system. Staff B stated, It was an oversight on my part. Reference: WAC 388-97-1620(2)(b)(i)

Based on interview and record review, the facility failed to timely investigate and report, as required, an allegation of neglect for 1 of 3 residents (Resident 1) reviewed for abuse and neglect. This deficient practice disallowed the facility from identifying the extent of the allegation and placed residents at risk for unidentified and ongoing abuse/neglect.Findings included.Review of the Washington State Department of Social and Health Services (DSHS) Nursing Home Guidelines 'The Purple Book', dated October 2015, showed Appendix H, titled Responsibility Table, listed nursing home responsibilities included reporting all suspected incidents of abuse, neglect, financial exploitation, or misappropriated property immediately or as soon as resident is protected to the State Hotline.Review of the facility policy, titled Guidelines for Staff Reporting Resident Abuse or Neglect-Long Term Care, Assisted Living and Hospital, revised 02/19/2024, showed the facility would follow the guidelines in The Purple Book regarding investigating, determining, and reporting incidents of resident abuse and neglect.Resident 1Review of the medical record showed Resident 1 was admitted to the facility, on 06/24/2025, with diagnoses of dementia (a disease causing a progressive decline in cognitive skills beyond normal aging), aphasia (a disorder that affects how you communicate), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the comprehensive assessment and care plan, dated 09/07/2025, showed Resident 1 had severe cognitive impairment and required the assistance of one to two people for dressing, personal hygiene, eating, transfers, toileting, and incontinent care.Review of the nursing Progress Notes (PNs), dated 11/20/2025 at 11:03 AM, showed Resident 1 had a fever of 101.4 degrees Fahrenheit (a unit of measure of temperature) at 6:30 AM and was administered acetaminophen (a medication that lowers fever in the body). At 7:30 AM, Resident 1's Representatives (RRs) were notified of the fever and interventions taken. At 8:40 AM, Resident 1's temperature was 98.5 degrees Fahrenheit and the RRs requested for Resident 1 to be sent to the emergency room for evaluation and treatment. At 11:05 AM, RRs were notified that an order was received from the medical provider to transfer Resident 1 to the emergency room for evaluation. At 11:30 AM, Resident 1 was transported to the emergency room and care was transferred to the emergency room staff.During an interview, on 12/01/2025 at 11:00 AM, a RR stated they were concerned Resident 1 experienced a delay in treatment when five hours passed between the initial assessment of fever and Resident 1's transfer to the emergency room for evaluation. The RR stated the concern was reported to the facility's nurse management staff.Review of the facility investigation reporting log, on 12/01/2025 at 1:15 PM, showed no logged investigation involving Resident 1 or an investigation regarding an allegation of neglect.During an interview, on 12/01/2025 at 1:40 PM, Staff A, Chief Nursing Officer (CNO), stated they were made aware of the delay in treatment concern expressed by Resident 1's Representative on 11/21/2025. Staff A stated Resident 1 passed away on 11/25/2025 and due to the nature of the RR's concerns, Staff A initiated a Root Cause Analysis. Staff A stated the preliminary conclusion was that facility staff followed protocol. Staff A stated they did not report this incident to the State Hotline and they did not perceive the concerns expressed by Resident 1's Representatives as an allegation of neglect.During an interview, on 12/03/2025 at 3:10PM, Staff B, Director of Nursing (DON), stated they were aware of the concerns expressed by Resident 1's Representatives and Staff A completed an investigation. Staff B stated they did not report the investigation to the State Hotline because the concerns regarding Resident 1's death were not proven. Staff B stated they would report an incident to the State Hotline when the facility's investigation showed the facility was at fault.Reference: WAC 388-97-0640 (5)(a)

Based on interview and record review the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that met at least quarterly and included the Infection Preventionist who was a required member of the QAA committee. This failure minimized the effectiveness of the interdisciplinary QAA team ' s ability to identify processes and outcomes related to infection control practices and disease management. Findings included . Record review of the QAA quarterly committee team minutes dated 05/01/2024 to 03/06/2025 showed no input from the Infection Preventionist related to infection prevention and control data. Additional review of the minutes showed the third quarter QAA committee meeting was missed, and the data was included in the fourth quarter meeting (three months late). During an interview on 03/13/2025 at 10:17 AM, Staff Q, Infection Preventionist (IP), stated they had never participated or prepared a report for the QAA committee on infection control data and stated, I was not aware that I was required to be at the QAA committee or present any data. During an interview on 03/14/2025 at 9:24 AM, Staff G, Nursing Services Manager, stated the IP had not been included in the QAA committee meetings over the past year and infection control data had not been presented. Staff G stated they agreed that the IP needed to be at all the quarterly QAA meetings so infection control data could be reviewed and analyzed as a part of the meeting. Additionally, Staff G stated the third quarter QAA committee meeting had been missed therefore they had combined the two quarters and presented the data for both quarters together. Reference: WAC 97-388-1760(1)(2)

Based on observation and interview the facility failed to provide a sanitary environment by not providing scheduled maintenance services for cleaning for 1 of 1 kitchen. This failed practice placed the residents at risk for cross contamination, food borne illness, and negative health outcomes. Findings included . During an observation on 03/10/2025 at 11:24 AM, the air vent in the kitchen located on the overhead in the middle ceiling over the food preparation areas had fuzzy brown substances that were unclean around the air filter vent grills. The air vent ' s grill, located on the ceiling over the cook's area, had multiple areas of a dark brown fuzzy substances. The air vents grill, over the first entry door to the kitchen and towards the dry goods storage area had accumulated brown fuzzy dust. The ceiling air vent ' s grill, located inside of the second entryway had brown fuzzy substances. Additionally, the overhead light fixture and plastic covering located over the cook's area and food serve out area was dirty with yellow brown substances. During an interview on 03/10/2025 at 2:20 PM, Staff M, Environmental Services-Lead, visualized the vents in the kitchen and stated they were dirty and were not cleaned for a while. Staff M stated they had an assigned custodian for the kitchen and one of their responsibilities was to clean the kitchen vents but was not sure when the vents were scheduled to be cleaned. During an interview on 03/13/2025 at 12:46 PM, Staff L, Environmental Services Director, stated it had been two months of not cleaning the accumulation of dust and grime on the vents. Staff L stated they would replace the lighting fixtures over the stove which were discolored and unable to be cleaned. Staff L stated the cleaning of the kitchen vents and ceiling had not been on a scheduled cleaning and needed to be on a schedule. Reference: WAC 388-97-3220(1)

Based on interview and record review the facility failed to implement an effective and individualized Infection Prevention and Control Program (IPC) for long-term care (LTC) residents that met the Center for Medicaid and Medicare Services federal regulatory requirements included monthly surveillance, monitoring/tracking of infectious diseases. This failure disallowed the designated Infection Preventionist (IP) the ability to identify trends and implement interventions. The failure placed residents at risk for infectious diseases and deterioration in their health status. Findings included . Record review of the October 2024 through March 2025 infection control process and reports which included all infections the hospital showed the LTC unit infectious diseases had not been tracked or reviewed for trends and infection rates. During an interview on 03/13/2025 at 10:11 AM, Staff Q, IP, stated they were the IP for the long-term care unit and the hospital. Staff Q stated they did not identify infection trends or rates specific to the LTC unit and had no surveillance reports or identifying data to include the infection rates. Staff Q further stated they looked at infections for the whole hospital including the Assisted Living unit, however had been unaware of the additional requirements for LTC and did not have a process in place. During an interview on 03/14/2025 at 9:50 M, Staff G, Nursing Operations Manager, stated Staff Q was new in the IP role and had not received the training they needed after the other IP left the position. Staff G stated the LTC Infection Control Program should have specific reports and data for the unit. Reference: WAC 388-97-1320(1)(a)

Based on interview and record review the facility failed to ensure a system was in place to provide a written notice of a bed-hold at the time of discharge to the hospital prior to a hospital transfer for 1 of 1 resident (Resident 5) reviewed for hospitalization. This failure placed the resident at risk for lack of knowledge regarding their right to hold their bed on the long-term care unit while in the hospital. Findings included . <Resident 5> Review of the resident's medical record showed they were admitted to the facility with diagnoses that included congestive heart failure (the heart is unable to keep up with the demands of the body), history of a cerebral vascular accident (when oxygen is cut-off from a part of the brain) and chronic urinary retention. Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required substantial assistance with their activities of daily living (basic skills required to care for oneself). Review of Resident 5's progress notes showed the resident was discharged to the hospital on [DATE] for a urinary tract infection with sepsis (a life-threatening complication of an infection which occurs when chemicals released to fight infection in the blood stream trigger inflammation throughout the body). Resident 5 remained in the hospital from [DATE] to 02/05/2025. Further review of the resident's record showed no written bed-hold notification had been given to the resident to inform them of their right to return to their bed on the long-term unit. During an interview on 03/11/2025 at 9:36 AM, Staff H, Registered Nurse, stated they did not send a written notice or information on bed-hold with residents when they discharge to the hospital. Staff H stated they had no bed-hold form available to them nor had they even heard of one. During an interview on 03/11/2025 at 2:35 PM, Staff B, Resident Supervisor, stated they were aware of the requirement to provide a written notice of bed-hold prior to a resident ' s discharge from the long-term care unit and they were working on a policy to start the process. Staff B stated the policy had not been initiated yet, therefore, the discharged residents had not been receiving bed-hold notices as required. Reference: WAC 388-97-0120(4)

Based on interview and record review the facility failed to notify the Office of the State Long-Term Care Ombudsman of the discharge of 1 of 1 resident (Resident 5) reviewed for transfer/discharge notifications. This failure placed the residents at risk for decreased protection from being inappropriately discharged and lack of access to an advocacy group whom could inform them of their rights and options. Findings included . <Resident 5> Review of the resident's medical record showed they were admitted with diagnoses that included congestive heart failure (the heart is unable to keep up with the demands of the body), and history of a cerebral vascular accident (also known as a stroke when oxygen is cut-off from a part of the brain). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required substantial assistance with their activities of daily living (basic skills required to care for oneself). Review of Resident 5's progress notes showed the resident was discharged to the hospital on [DATE] for a urinary tract infection with sepsis (a life-threatening complication of an infection occurs when chemicals released to fight infection in the blood stream trigger inflammation throughout the body). Further review showed they remained in the hospital from [DATE] to 02/04/2025. During an interview on 03/11/2025 at 2:24 PM, Staff Social Services Director stated they did not notify the State Long-Term Care Ombudsman Office for Resident 5 related to their discharge to the hospital. Additionally, Staff K stated they did not have a process currently in place for notifying the Ombudsman office when residents transfer or discharged out of the facility. Reference: WAC [PHONE NUMBER](2)(a-d)

Based on observation, interview and record review the facility failed to obtain informed consent regarding the potential risks and benefits associated with the use of a psychotropic medication (medications that affects behavior and alter mental thought processes) for 3 of 5 residents (Residents 2, 7, and 11) reviewed for psychotropic medications. This failure placed residents and/or the legal representative at risk of not being fully informed about the medication prior to administration or discontinuation. Findings included . <Resident 2> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of anxiety, depression, and Post Traumatic Stress Disorder (PTSD-symptoms lasting for an extended time over a traumatic event). The 02/06/2025 comprehensive assessment showed Resident 2 was alert and oriented, made their needs known, had signs/symptoms of depression (sad affect) and anxiety (feelings of negative outcomes of events), was on an antidepressant (a type of psychotropic medication) and two antianxiety (a type of psychotropic medication) medications during the assessment period. Review of Resident 2 ' s physicians' order showed that an antidepressant and two antianxiety medications were ordered on 08/27/2024 and consents were signed at that time. During an interview on 03/11/2025 at 1:43 PM, Resident 2 stated they were concerned about their antianxiety medications being discontinued without them being informed and there was no discussion with their provider prior to the medications being discontinued. Resident 2 stated their pain had increased a bit and their anxiety was okay, but they were not happy with their current provider and asked them to be removed. Resident 2 stated they had chosen another provider to handle their medications and care. During an observation on 03/11/2025 at 2:00 PM, Resident 2 had a flat affect (lack of facial expressions) when talking to other staff. Resident 2 was able to express their feelings and communicate to staff and family who visited daily. Review of a 02/11/2025 pharmacist recommendation showed to discontinue all psychotropic medications, which included the combination of three or more Central Nervous System (CNS) active medications which could cause an increase in falls and fractures. The consultation report recommended the prescriber assess the risk/benefits if they continued the medications and the provider declined the recommendation. On 02/17/2025 the attending provider discontinued Resident 2's routine Buspar (a specific antianxiety medication) medication, and their routine clonazepam (a specific antianxiety medication) medication. The provider did not communicate with Resident 2 about the change or if Resident 2 consented to the proposed change in their antianxiety medications. Review of Resident 2 ' s psychotropic/behavior meeting, dated 02/06/2025, showed the residents psychotropic medications and/or behavior changes were not addressed. The psychotropic/behavior committee meeting consisted of the pharmacist, Social Services Director (SSD), Director of Nursing Services (DNS), and the physician. During an interview on 03/11/2025 at 2:30 PM, Staff K, SSD, stated the provider did not speak with them, the nursing staff, or Resident 2 about their medication changes. The order was received by the charge nurse on 02/17/2025. On 03/12/2025 at 10:00 AM, Staff B, Resident Manager, stated their process was to ensure Resident 2 was notified of changes in their medications but had not been notified of the medication changes on 02/17/2025. Also, as of 03/11/2025 Resident 2 had not had a discussion regarding the risks and benefits of continuing with these medications. <Resident 7> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of heart failure, depression, and anxiety. Review of the 12/23/2024 comprehensive assessment showed the resident was alert and able to make their needs known and required minimal assistance with activities of daily living (ADLs). The assessment showed Resident 7 used a wheelchair for mobility. Review of the 03/21/2024 Medication Administration Record (MAR) showed Resident 7 was started on Lexapro (a specific antidepressant) and Trazadone (a specific antidepressant) on 03/23/2024. During an interview on 03/10/2025 at 10:00 AM, Resident 7 stated they had not been educated or given information by the facility staff concerning their antidepressant or antianxiety medications and had not signed any consents for the medications. During an interview on 03/10/2025 at 10:40 AM, Staff K stated they did not review informed consents on Resident 7 for ordered antianxiety and antidepressant medications. Staff K stated it was the facility's process to review psychotropic medications with the resident/or Resident's Representative (RR) before administration of the medications to a resident. <Resident 11> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses to included dementia (cognitive impairment) with behavioral disturbances, falls, and heart disease. Review of the 01/20/2025 comprehensive assessment showed the resident had impaired memory/cognition and required assistance in their ADLs. Resident 11 used a front wheeled walker for mobility. Review of the physicians ' orders for 01/15/2024 and 12/03/2024 showed that Duloxetine (a specific antidepressant medication) was started on 01/15/2024 for pain, and Risperidone (a specific type of psychotropic) was started on 12/03/2024 for increased verbal behaviors. During an interview on 03/11/2025 at 12:45 PM, Staff K stated they did not obtain consents or review risk and benefits of the psychotropic medications with Resident 11's RR. Staff K stated it was the policy of the facility to review these medications before administering them. During an interview on 03/13/2025 at 2:15 PM, Staff B stated the facility was to ensure the resident and/or the RR were informed of psychoactive medications benefits and side effects before administration of the medications. Staff B stated the facility failed to follow through on informed consent recommendation for new medications and when changes were made to resident psychotropic medications. Reference: WAC 388-97-0260(1)(a)(b)(2)(d)

Based on observation, interview, and record review the facility failed to comprehensively assess and identify side rails attached to resident beds as a physical restraint for 2 of 2 residents (Residents 8 and 7) reviewed for physical restraints. This failure placed the residents at risk for injury and poor quality of life. Findings included . Record review of a facility policy titled, Long-Term Care Residents Physical Restraints, revised 12/31/2024 showed, . Physical restraints are identified as .side rails that keep the resident from voluntarily getting out of bed. Procedure: A. A Safety Device Assessment will be completed by the licensed staff for the need of the restraint related to a medical symptom. B. The resident's consent will be obtained .and documented on the assessment form. C. A physician's order will be obtained prior to the use of the restraint. D. Family will be consulted by nursing or social services in the event the resident is unable to give consent. E. Multidisciplinary care planning [NAME] be done quarterly to reassess usage and identify least restrictive alternatives. <Resident 8> Review of the resident's medical record showed they were admitted with diagnoses that included dementia, atrial fibrillation (an irregular heartbeat), and dysphagia (difficulty swallowing foods or liquids). Review of the comprehensive assessment dated [DATE] showed the resident was severely cognitively impaired and required substantial assistance with their activities of daily living (basic skills required to care for oneself). An observation and interview on 03/10/2025 at 2:23 PM, showed Resident 8 lying in their bed with half side rails attached to both sides of their bed and in the up position. The resident had their arms crossed over their chest and was lying in the center of the bed. When asked if they used the side rails to move around in bed, Resident 8 stated, I don't know they just keep me in. Record review of Resident 8's care plan dated 12/11/2024 showed no information on the side rail use including directions for use. Review of the February 2025 and March 2025 physician orders showed no orders or medical symptom to justify the use of side rails. Additionally, there was no Safety Device Assessment or consent to use the side rails. During an observation on 03/11/2025 at 1:45 PM showed Resident 8 in bed with the side rails in the down position. During an interview on 03/11/2025 at 1:46 PM, Staff H, Registered Nurse, stated Resident 8 had side rails to assist them to move around in bed and they should be placed in the down position after cares and while in bed. Staff H stated there were no specific written care plan guidance on how to use Resident 8's side rails to include when the rails should be in the up or down position. During an observation on 03/12/2025 at 7:50 AM, showed Resident 8 lying in bed with both half rails in the up position. During an observation on 03/12/3025 at 11:15 AM, Resident 8 was in their room resting in bed with their side rails in the down position. During an interview on 03/12/2025 at 2:03 PM, Staff I, Nursing Assistant (NA), stated they were routinely assigned to work with Resident 8 and were very familiar with their care needs. Staff I stated they put up Resident 8's side rails because it made them feel safe and secure in bed as well as they prevented them from falling out of bed. Additionally, Staff I stated they also placed the side rails in the down position after cares as well. Staff I stated there were no specific directions on how to use Resident 8's side rails they just knew what to do. <Resident 7> Review of the resident's medical record showed the resident was admitted to the facility with diagnoses of depression, anxiety, heart failure, and respiratory issues. The comprehensive assessment dated [DATE] showed the resident was alert, oriented, and able to make their needs known. Additionally, Resident 7 required oversight assistance to transfer. On 03/10/2025 at 3:32 PM, observations of side rails for Resident 7 showed the residents bed on the left side was against the wall and half rails on both sides of the bed, in the up position. The half side rails when in the up position extended from the top of the bed to the middle of the bed. On 03/11/2025 at 8:40 AM, Resident 7's right half side rail was observed in the down position and the left side rail was in the up position. On 03/12/2025 at 1:30 PM, both half rails were in the up position while Resident 7 was napping in bed. On 03/13/2025 at 3:00 PM, an observation showed Resident 7's half rails were both in the up position. During an interview on 03/13/2025 at 3:39 PM, Resident 7 stated they had not been informed of the use of the side rails by staff, and they used the half rails in bed so they would not roll out of bed. During an interview on 03/13/2025 at 2:30 PM, Staff B, Resident Manager, stated there were no assessments, physician's orders, consents, or care plans for the use of any resident side rails. Staff B further stated they understood the need for an assessment for the side rails as some of the residents could be potentially restrained or injured using side rails. Reference: WAC 388-97-0620(1) 31168

Based on interview and record review the facility failed to ensure the designated Infection Preventionist (IP) responsible for the facility's Infection Control Program met the education qualifications for certification prior to accepting the role as the IP in a long-term care facility. This failure placed residents at risk for not having an adequate oversight of infection control issues specific to long-term care. Findings included . During an interview on 03/13/2025 at 10:17 AM, Staff Q, IP, stated they had been hired as the IP for the hospital and the long-term care unit. Staff Q stated they had not completed the required infection control training for certification as an IP. No one told me I needed to be certified so I have not taken any of the trainings for long-term care. During an interview on 03/13/2025 at 2:36 PM, Staff B, Resident Manager, stated they were not aware that there were specific training requirements for the IP to be certified and stated they understood why it was important for the IP to have the training. Reference: WAC-388-97-1320(1)(a)

Based on observation, interview, and record review, the facility failed to ensure infection control interventions intended to mitigate the risk of exposure and transmission of COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing, that could result in severe impairment or death) were consistently implemented during a COVID-19 outbreak [two or more facility-acquired cases with epi-linkage (an overlap on the same unit or other patient location, or having the potential to have been cared for by common healthcare professionals (HCP) within a seven day time period of each other)]. The facility failed to implement infection control interventions for: personal protective equipment (PPE - protective clothing, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) use for 8 of 9 staff (Staff K, B, Q, L, O, I, R, and P) reviewed for PPE use; COVID-19 testing for 2 of 2 residents (Residents 8 and 112) reviewed for COVID-19 testing; implementation of transmission-based precautions (TBPs) for 1 of 1 resident (Resident 7) reviewed for implementation of precautions; hand hygiene for 3 of 3 staff (Staff L, O, and I) reviewed for hand hygiene while providing personal cares for 1 of 1 resident (Resident 3) and passing medications for 3 of 3 residents (Resident 4, 6, and 3); annual review of the infection control policies and procedures. These failures in infection control practices placed all residents at risk for exposure to COVID-19 and serious medical complications. Findings included . Review of the Centers for Disease Control and Prevention (CDC) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 05/08/2023, showed HCP that enter the room of a resident with suspected or confirmed COVID-19 infection should adhere to Standard Precautions (minimum infection prevention practices that apply to all patient care) and use of a National Institute of Occupational Safety and Health (NIOSH) approved N95 respirator (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles), gown, gloves, and eye protection (goggles or a face shield that covers the front and sides of the face). Additionally, a resident identified as suspected or confirmed COVID-19 infection, should be placed in a single-person room. The door should be kept closed. Information regarding residents with suspected or confirmed COVID-19 infections should be communicated to appropriate personnel before transferring them to other departments in the facility (e.g., radiology). HCP that entered the room of a patient with suspected or confirmed COVID-19 infection should use Standard Precautions and use an N95 respirator, gown, gloves, and eye protection. Review of the CDC's guidance titled How to Use Your N95 Respirator, dated 05/16/2023, showed an N95 respirator must form a seal to the face to work properly. Gaps could occur if the N95 respirator was too big, too small, or not put on correctly. The N95 respirator should be placed under the chin with the nose piece bar at the top. The top strap should be pulled over the head and placed near the crown of the head. The bottom strap should be pulled over the head and placed at the back of the neck, below the ears. The straps should not be crisscrossed or twisted. Review of the facility policy titled, Hand Hygiene - CDC Guidelines), dated 03/21/2021, showed effective hand hygiene was required to prevent the transmission of bacteria, germs, and infections. The policy showed staff were required to perform hand hygiene (HH): Before starting their shift; When hands were soiled; Before each patient encounter; After coming in contact with the resident's skin; After working on a contaminated body site and then moving to a clean body site on the same resident; After coming in contact with bodily fluids, dressings, mucous membranes; Always after removing gloves or facemasks; Leaving an isolation area. <Resident 8> Review of the medical record showed Resident 8 was admitted to the facility on [DATE] with diagnoses including age-related memory disorder and type 2 diabetes (a group of diseases that result in too much sugar in the blood). The 11/07/2023 comprehensive assessment showed Resident 8 required partial to maximum assistance of one staff member for ADLs. The assessment also showed the resident had a severely impaired cognition. <Resident 112> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including dementia with behavioral disturbances (an impairment of brain function, which causes memory loss, forgetfulness, impaired thinking abilities and can be accompanied with mood/behavior change) and chronic (long term) right hip pain. The 01/26/2024 comprehensive assessment showed the resident was cognitively impaired but was able to communicate and make their needs known to staff. Additionally, the comprehensive assessment showed the resident was taking a high-risk medication for their dementia. <Resident 7> Review of the medical record showed Resident 7 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and trigeminal neuralgia (a type of chronic pain disorder that involves sudden, severe facial pain). The 12/18/2023 comprehensive assessment showed the resident required partial to maximum assistance of one staff member for ADLs. The assessment also showed Resident 7 had a moderately impaired cognition. <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses including a stroke with right sided weakness, atrial fibrillation (an irregular heart rate that causes poor blood flow), obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), neurogenic bladder (a number of urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem) and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland). The 11/21/2023 comprehensive assessment showed the resident was dependent on assistance of two staff members for activities of daily living (ADLs - activities related to personal care such as bathing, dressing, using the toilet, and getting in and out of a chair or bed). The assessment also showed the resident was cognitively intact. <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility on [DATE]. The 11/27/2023 comprehensive assessment showed the resident required substantial/maximal assistance of one staff member for ADLs. The assessment also showed the resident had a severely impaired cognition. <Resident 6> Review of the medical record showed Resident 6 was admitted to the facility on [DATE] with diagnoses including arthritis and muscle weakness. The 11/07/2023 comprehensive assessment showed Resident 6 required maximum assistance/dependent on one staff member for ADLs. The assessment also showed the resident had an intact cognition. <PPE> An observation on 01/29/2024 at 8:47 AM, showed signage on the door to a resident's room that showed airborne contact precautions were required when entering the room. There was a PPE cart outside of the room that contained N95 masks, surgical masks, gowns, hair covers, briefs, and wipes. There were four paper bags on the floor outside of the door. The paper bags were labeled with staff names and contained eye protection and used N95s. There was a trash can with a lid next to the left of the door, along with a food cart that contained a breakfast meal tray. Staff K, Nursing Assistant (NA), put on a gown, gloves, and hair cover. Their N95 mask had both straps around their neck. Staff K removed eye protection from a bag labeled JG (belonged to another staff member) and put them on. Staff K entered the COVID-19 isolation room. At 9:07 AM, Staff K exited the room holding their gown and gloves. They placed them in the trash can in the hallway. Staff K then placed the eye protection back into the paper bag and performed HH. They did not remove their N95 and proceeded to the nurse's station. A second observation that same day at 10:16 AM, showed Staff K putting on PPE to enter the COVID-19 isolation room. Staff K donned a clean N95 and placed both straps around their neck. Staff K stated they were trained on how to properly don PPE and were fit tested for their N95. Staff K then entered the COVID-19 room while wearing the improperly donned N95 mask. During an observation on 01/29/2024 at 11:56 AM, Staff B, Acting Director of Nursing Services, and Staff Q, Licensed Practical Nurse (LPN) were at the nurse's station. Staff B was wearing an N95 mask with the straps crossed at their ears, and Staff Q had an N95 mask dangling around their neck, leaving their nose and mouth exposed. During an interview on 01/29/2024 at 12:25 PM, Staff Q stated they were told that on the unit, they were required to wear an N95 and when at the nurse's station, they were able to wear a surgical mask. They stated that the paper bags outside of the COVID-19 isolation room contained eye protection and N95s that were reused when going into that room. They stated they were not aware of any shortage of PPE and staff were just being conservative. An observation on 01/31/2024 at 7:14 AM showed Staff L, NA, and Staff O, NA, entering a resident room wearing N95's with both straps around their neck. During an observation on 01/31/2024 at 8:11 AM, showed Staff L, NA, wearing an N95 mask with straps around their neck, don gown, gloves, and eye protection and entered the COVID-19 isolation room. At 8:23 AM, Staff L exited the room, removed their PPE in the hallway with exception of the N95 mask, cleaned their eye protection and placed them into a paper bag, performed HH, and proceeded to the nurse's station, still wearing the same N95 mask. During an interview on 01/31/2024 at 9:47 AM, both Staff L and Staff O stated they were trained to wear their N95s with one strap over the top of their head and one around the neck. Staff L stated they did not remove their N95 when exiting the COVID-19 isolation room because there were no N95 masks on the PPE cart and no trash can outside the room (that day). They stated they should report concerns such as no PPE or needing a trash can on both the inside and outside the COVID-19 isolation room to management but had not done that. An observation on 01/31/2024 at 7:14 AM, showed Staff I, Registered Nurse (RN), at the medication cart with their N95 respirator straps around the back of their neck. An observation on 02/01/2024 at 8:10 AM, showed Staff R, Licensed Practical Nurse (LPN), standing at the medication cart wearing an N95 respirator. Both straps of the respirator wear at the crown of their head. An observation on 02/02/2024 at 9:12 AM, showed Staff P, NA, sitting at the nurse's station with their N95 respirator pulled down to their chin, leaving their nose and mouth exposed. During an interview on 01/30/2024 at 1:18 PM, Staff C, Infection Preventionist (IP), stated staff were to wear their N95 respirator with all patient care, not just the COVID-19 isolation resident. They stated they were permitted to wear a surgical mask at the nurse's station if there were no residents in the area. They stated staff were required to wear full PPE (N95 respirator, gown, gloves, and eye protection) when going into the COVID-19 isolation room. Staff were not to store soiled PPE in paper bags. N95 respirators needed to be replaced after leaving the COVID-19 isolation room and eye protection needed to be cleaned at that time. Staff C stated there was no shortage of PPE for staff use, the practice of reusing N95 respirators was a left over practice from when there were PPE shortages. <COVID-19 Testing> An observation on 01/31/2024 at 9:33 AM, showed Staff I at a COVID-19 testing cart outside of Resident 8's room. The cart had three shelves, the top contained a box of gloves, plastic bags that contained a test tube and swab for the specimen, resident labels, lab slips, a black pen, and hand sanitizer. The middle shelf contained a bin for the completed tests. Staff I was wearing an N95 mask with both straps around the back of their neck and eye protection. Staff I picked up a bag containing a test tube, placed a resident label on the tube and opened a swab for testing. Staff I donned clean gloves, and without wearing a gown, entered Resident 8's room. Staff I performed the nasal swab and placed the swab into the test tube, then placed the specimen into the bag. Staff I removed their gloves and exited the room with the bag and placed it into the bin on the cart. Staff I performed HH and moved the cart to Resident 112's room. Staff I, still wearing the same N95 respirator and eye protection, proceeded to complete the lab slip, remove the test tube and swab from a bag, and placed a label on the test tube. Staff I entered Resident 112's room wearing gloves, the same soiled N95 and soiled eye protection, and without putting on a gown, entered Resident 112's room and performed the nasal swab test. Staff I removed their gloves, placed the specimen into the test tube, placed the test tube into the bag, exited the resident's room and placed the bag into the bin on the cart. Staff I, wearing the same N95 and eye protection, moved to the next resident room. During a concurrent observation and interview on 01/31/2024 at 10:44 AM, Staff I stated they were trained to test for COVID-19. They stated they wore their N95 with both straps around the back of their neck because it was more comfortable that way. Staff I then placed the top strap in the correct position, at the crown of their head. Staff I stated they did not change their N95 in between resident testing because the residents were not symptomatic. They stated if a resident had coughed on them, they would have changed it. They stated they were not trained to wear a gown during testing, only if going into a COVID-19 isolation room. They stated they cleaned their eye protection after all the testing was completed because the cleaner left streaks on their glasses. During an interview on 02/01/2024 at 9:19 AM, Staff C, Infection Preventionist, stated during COVID-19 testing, they expected staff to wear full PPE, that included N95 respirator, gown, gloves, and face shield or eye protection. Staff C stated the process for testing was a failed process . <Transmission Based Precautions> During a concurrent observation and interview on 02/01/2024 at 8:10 AM, Staff R, LPN, wearing an N95 with both straps at the crown of their head, stated Resident 7 was congested that morning. They stated Resident 7 was seen by the provider that morning and had ordered a COVID-19 test to rule out infection because they were symptomatic. Observation of Resident 7's room showed the door was open and there was no signage or PPE cart that indicated isolation precautions were needed. Resident 7 was seated in their room in their wheelchair, coughing that was audible and visible from the hallway. Staff R stated a chest x-ray was also ordered. Staff R stated Resident 7 was currently not on precautions because they were keeping them isolated to their room. Staff R stated they had not done the COVID-19 rapid test yet because they did not know how to order it in the computer system. During a concurrent observation and interview on 02/01/2024 at 8:24 AM, Resident 7 stated they did not feel very well that day. They stated their nose was runny and they had a cough. Resident 7 was sitting in their wheelchair coughing and had a runny nose with watering eyes. During an interview on 02/01/2024 at 9:42 AM, Staff C, IP, stated if there were residents that were suspect for COVID-19 infection, they should be isolated to their room with the door closed until lab results proved negative. They stated the suspect resident should be placed under isolation precautions with appropriate signage on the door. Staff C stated the process for testing was a failed process . <Hand Hygiene> During an observation on 01/31/2024 at 7:14 AM, Staff L and Staff O entered the room of Resident 3, both wearing N95 respirators with the straps around the back of their necks. Both Staff L and Staff O put on clean gloves and proceeded to assist Resident 3 with their morning cares. Staff O performed personal care around the residents' genitals, then rolled Resident 3 towards Staff L. Staff O removed the residents brief that was soiled with fecal matter, while Staff L held the resident in place. Staff O placed a clean brief under the resident and Staff L rolled Resident 3 to their back. Both Staff L and Staff O positioned the resident on the brief and secured the tabs on the brief. Staff L proceeded to apply lotion Resident 3's legs and arms, still wearing the same gloves. Staff O placed the Resident 3's shirt over their head, and while still wearing the same gloves, both Staff L and Staff O assisted the resident in pulling their shirt down. Staff L and Staff O then assisted the resident by placing their legs into their pants. Staff O threaded the urinary catheter (a hollow tube placed into the bladder to drain urine) bag through the pant leg. Wearing the same gloves, Staff L and Staff O positioned the resident onto the mechanical lift sling and transferred Resident 3 to their wheelchair. Staff O, still wearing the same gloves, proceeded to make the resident's bed, while Staff L, still wearing the same gloves, obtained an electric razor from the resident's sink area, and proceeded to shave the resident. Wearing the same gloves, Staff L obtained the residents dentures from their denture cup, applied denture adhesive, and handed them to Resident 3 to place in their mouth. Staff O, wearing the same gloves, used a sanitizing wipe to clean the mechanical lift. Staff L then removed their gloves and washed their hands with soap for 11 seconds. Staff O removed their gloves and left the room without performing HH. During an interview on 01/31/2024 at 9:40 AM, Staff O stated they sanitized their hands before putting gloves on. They stated they like to change their gloves between personal cares and clean things. During an interview on 01/31/2024 at 9:45 AM, Staff L stated when doing personal cares, they should change gloves between the dirty and clean cares. They stated their process was to change their gloves before handling dentures but had not done it that day. During an observation on 01/31/2024 at 7:14 AM, Staff I prepared Resident 4's medications at the medication cart by placing them in a cup of applesauce. Staff I carried the medications into the resident's room, did not perform HH, and administered the medications to the resident using a spoon. Without performing HH, Staff I then removed gloves from their pocket, donned gloves, swabbed Resident 4's abdomen with an alcohol pad and administered their insulin (a medication delivered by a needle and syringe that helps the body turn food into energy and manages blood sugar levels). Staff I disposed of the needle into the sharp's container, removed their gloves, and performed HH upon exiting the room. A second observation the same day at 7:28 AM showed Staff I prepared Resident 6's medications at the medication cart by putting them into a cup of applesauce. Staff I carried the medications to the Resident 6's TBP room. Without performing HH, Staff I, wearing an N95 respirator, put on a gown and gloves. They removed eye protection from a paper bag located on the cart outside the room. Staff I then entered the resident's room and administered their medications. Staff I disposed of their gown and glove in the trash bin in the resident's room, left the room, shut the door, and performed HH. A third observation at 9:54 AM showed Staff I entered Resident 3's room, did not perform HH, administered an inhaled medication to the resident along with a cup of medications (pills), and orange juice. <Annual Policy and Procedure Review> Review of the facility's infection control standards, policies, and procedures showed they were last reviewed in their entirety on 09/30/2019. During an interview on 02/01/2024 at 9:19 AM, Staff C stated the facility infection control policies and procedures were not up to date and were not updated annually. Staff C stated they try to do them every two years and was not aware of the requirement to review them at least annually. During an interview on 02/01/2024 at 11:23 AM, Staff B, Acting Director of Nursing Services, stated they expected all staff to gel in, gel out, between the dirty and clean tasks during personal cares, and remove gloves and perform HH before moving on. Staff B stated PPE and TBP use had been communicated to staff. They were instructed to wear an N95 respirator for any patient care and should not wear their N95 from room to room. Staff B stated they should be using a paper bag for storing their N95 and could wear a surgical mask at the nurse's station. Staff B stated PPE use for the COVID-19 isolation room consisted of putting on gloves, a gown, an N95 respirator, and eye protection. They stated the N95 respirator could be reused for the isolated resident and staff should be putting in a paper bag. They needed to clean their eye protection after leaving the isolation room. Staff B then stated the use of paper bags was not a current need as there was plenty of PPE available. Staff B stated staff should be throwing away their N95 after each use. Staff B stated they did not have a lot of experience in infection control and was not aware of the requirement for policy review. During an interview on 02/02/2024 at 1:10 PM, Staff A, Administrator, stated what we are dealing with right now (continued COVID-19 outbreak), there is absolutely something wrong with our process that we need to look at with the PPE failures and continued cases of COVID-19. Reference: WAC 388-97-1320(1)(a)(c)(2)(a)(b)(5)(b) 43280 46722

Based on interview and record review the facility failed to; 1) maintain a Quality Assessment and Assurance (QAA) committee that included the medical director, or their designee, to participate in the committee's effort for 3 of 3 quarterly (Q, every three months) meetings (Q1, Q2, Q3 2023) reviewed for the QAA process, and 2) ensure that a thorough analysis of the high risk/adverse events were acted upon, and, a good faith attempt was made (once the facility had become aware of the adverse event) to correct quality deficiency and care concerns identified by the facility's infection control committee (which information was submitted to the facility's QAPI committee) for 2 of 3 quarterly meetings (Q2 and Q3 2023), reviewed for QAPI and infection control concerns identified on survey. This failure placed all residents at risk for unidentified complications and prompt corrective action in resident care/services areas. Findings included . Review of the facility's policy titled, Performance Improvement Plan, dated 08/09/2022, showed that the administrator, a representative of the governing body, medical staff and departmental managers would be involved in the performance improvement committee for managing of the Quality Assurance Performance Improvement (QAPI) program. The Policy showed the committee's responsibilities were to have a planned, continuous, systematic and organization wide approach to designing, measuring, assessing, and improving performance. Oversight of staff education and training for performance improvement .Identify organizational trends or opportunities for improvement projects from reports received throughout the organization. Sources of data and information include report from infection control studies .integrating PI (Performance Improvement) efforts with daily work activities. Additionally, each department was to submits quality assessments studies that were being conducted on an ongoing basis and could lead to a performance improvement studies or a quick fix process which was to be used for identified problems, which do not require a comprehensive approach to problem solving and solutions implementation. Review of the facility's 2023 QAPI meeting minutes (Q1, Q2 and Q3) showed the medical director, or their designee were not in attendance during the meetings. The Q2 infection control section showed that the facility had an outbreak of COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death). Additionally, the Q3 infection control section showed that a COVID-19 outbreak had occurred in the assisted living section of the facility (the nursing home and assisted living were connected by a double door) isolation precautions were initiated but 7 other residents were affected. Review of the facility's 2023 infection control /QAPI meeting minutes showed that in Q2 2 long-term patients contracted COVID, the source of the infection was not determined . and that all staff were to wear an N95 (a mask used to filter out and protect against harmful viruses like COVID-19) mask while preforming care with resident on the assisted living side and on the hospital side for the duration of the outbreak. The Q3 meeting noted that a COVID-19 outbreak had taken place in the assisted living side of the facility and that staff were wearing a surgical mask (a mask that does not filter out viruses like COVID-19) unless staff had become positive and then would wear and N95 mask. The Q3 meeting also noted that 14 staff were COVID-19 positive in September. During an interview on 02/02/2024 at 12:32 PM, Staff A, Administrator, stated the medical director, or their designee, did not always attend the QAPI meeting. Staff A explained if the medical director or designee had attended QAPI meeting, it would have been documented on the QAPI meeting minutes. Staff A stated that a COVID-19 outbreak would have been a high-risk/adverse event and they implemented the same outbreak measures and monitored the same quality indicators as they had been doing in previous quarters regarding infection control. Staff A stated that they were aware of the COVID-19 outbreaks and were monitoring the COVID rates in the facility but that no additional monitoring or revisions of corrective action had taken place. Refer to F880 for additional information. Reference: WAC 388-97-1760(1)(2)

Based on interview and record review, the facility failed to perform an annual review of the Facility Assessment (FA, an evaluation that determine what resources are required to meet each resident's care/service needs with the facility's resident population) and did not include a representative of the governing body or medical director in the development of the FA. Additionally, the FA failed to address the staffing competencies necessary to provide the level and types of care needed for the resident population. These failures placed all residents at risk of unidentified and/or unmet care and service needs. Findings included . Review of the 02/03/2023 Centers for Medicare and Medicaid Services (CMS) State Operations Manual - Appendix PP, showed, CFR 483.70(e) Facility assessment. The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update the assessment, as necessary, and at least annually . Additionally, The facility assessment must address or include .the staff competencies that are necessary to provide the level and types of care needed for the resident population . Review of the facility's document titled, Facility Assessment Tool, dated 01/17/2021, showed the FA had not been completed for the 2023 to [AGE] year and did not involve the medical director nor a representative of the governing body in the FA. Additionally, the document did not include the staffing competencies that would be needed to provide the level of care need for the current resident population. During an interview on 02/01/2024 at 5:01 PM, Staff A, Administrator, stated they were aware that the FA was required to be completed annually and that a current FA had not been completed. Additionally, Staff A stated that the FA should have addressed the staffing competencies needed to care for the resident population. Reference: WAC 388-97-1620(2)(b)(i)(ii)

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan that addressed the resident's medical, physical, mental, and psychosocial needs for 5 of 7 residents (Resident 3, 2, 112, 6, and 7) reviewed for urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) use, medication use, and transfers. These failures placed the residents at risk for not receiving care and services to meet their individualized needs. Findings included . <Urinary Catheter Use> <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses including a stroke with right sided weakness, atrial fibrillation (an irregular heart rate that causes poor blood flow), obstructive uropathy (a disorder of the urinary tract that occurs due to obstruction in urinary flow), neurogenic bladder (a number of urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem) and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland). The 11/21/2023 comprehensive assessment showed the resident was dependent on assistance of two staff members for activities of daily living (ADLs - activities related to personal care such as bathing, dressing, using the toilet, and getting in and out of a chair or bed). The assessment also showed the resident was cognitively intact. An observation on 01/29/2024 at 9:46 AM, showed Resident 3 lying in bed, a urinary catheter tube exiting their left pant leg, connected to a drainage bag that was hanging on the side of the bed. Resident 3 stated the urinary catheter had been in place for about five to six years. Review of the Resident 3's comprehensive care plan, last updated 11/07/2023, showed there was no problem area, goal, or interventions related to the use of Resident 3's urinary catheter. <Medication Use> An observation on 01/30/2024 at 10:08 AM, showed Resident 3 lying in bed. They had dark purple bruising to their right elbow area and left forearm. Record review of Resident 3's physician orders, dated 11/07/2023, showed the resident received a blood thinning medication used to treat and prevent blood clots and lower the risk of stroke, that can cause excessive, unwanted bruising or bleeding. Review of the Resident 3's comprehensive care plan, last updated 11/10/2023, showed it did not reflect the resident's current use of, or interventions related to the use of the blood thinner. <Resident 2> Review of the medical record showed Resident 2 was admitted on [DATE] with diagnoses including respiratory failure with a lung infection, seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements), a heart condition that required a blood thinning medication, depression, and anxiety. The 01/13/2024 comprehensive assessment showed the resident was cognitively intact, able to make their needs known. Review of Resident 2's physician medication orders, dated 01/05/2024, showed the resident was being administered apixaban (a blood thinning medication used to treat and prevent blood clots and strokes), paroxetine (a medication used to treat depression and anxiety disorders), lamotrigine [a medication used to treat seizures and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and remeron (a medication used to treat depression). Review of Resident 2's care plan, last updated 01/12/2024, showed there was no problem area related to the resident's use of the apixaban, paroxetine, lamotrigine, and remeron medications or diagnoses connected to them. During an interview on 02/02/2024 at 11:17 AM, Staff B, Acting Director of Nursing Services, stated that Resident 2 should have been care planned with goals and interventions for their seizures, heart condition, depression, anxiety, and the high-risk medications being administered with the diagnoses. <Resident 112> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including dementia with behavioral disturbances (an impairment of brain function, which causes memory loss, forgetfulness, impaired thinking abilities and can be accompanied with mood/behavior change) and chronic (long term) right hip pain. The 01/26/2024 comprehensive assessment showed the resident was cognitively impaired but was able to communicate and make their needs known to staff. Additionally, the comprehensive assessment showed the resident was taking Cymbalta (high-risk psychotropic medication used to treat certain mental/mood disorders) medication for their dementia. Review of Resident 112's physician medication orders, dated 01/15/2024, showed the resident was being administered Cymbalta for their dementia with behavioral disturbances and an analgesic (a medication used for pain management) medication for their chronic right hip pain. Review of Resident 112's care plan, last updated 01/22/2024, showed there was no problem area, goals, or interventions related to the resident's high risk psychotropic medication or chronic right hip pain. During an interview on 02/02/2024 at 11:26 AM, Staff B, stated that Resident 112 should have been care planned with goals/interventions for their dementia with behavioral disturbances, with high-risk medication, and chronic right hip pain. <Transfers> <Resident 6> Review of the medical record showed Resident 6 was admitted to the facility on [DATE] with diagnoses including arthritis and muscle weakness. The 11/07/2023 comprehensive assessment showed Resident 6 required maximum assistance/dependent on one staff member for ADLs. The assessment also showed the resident had an intact cognition. An observation on 01/29/2024 at 1:17 PM, showed Staff K, Nursing Assistant, transferring Resident 6 from their wheelchair to their recliner using a sit-to-stand (a mechanical lift that assists individuals with limited mobility to a standing position from a seated position) mechanical lift. Review of Resident 6's comprehensive care plan, last updated 1/22/2024, showed no interventions related to transfers or the use of the sit-to-stand lift. <Resident 7> Review of the medical record showed Resident 7 was admitted to the facility with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and trigeminal neuralgia (a type of chronic pain disorder that involves sudden, severe facial pain). The 12/18/2023 comprehensive assessment showed the resident required partial to maximum assistance of one staff member for ADLs. The assessment also showed Resident 7 had a moderately impaired cognition. During an interview on 01/31/2024 at 2:52 PM, Staff I, Registered Nurse stated the resident used a front wheeled walker and assistance of one staff member for transfers, unless their condition (trigeminal neuralgia) flared up (a worsening of the disease process) then they would need to transfer with staff assistance and the use of the sit-to-stand. Review of Resident 6's comprehensive care plan, last updated 12/11/2023, showed no interventions related to the use of the sit-to-stand lift, including when staff were to use it for safe transfer of the resident. During a follow up interview on 02/02/2024 at 12:23 PM, Staff I stated the care plans were created based on the comprehensive assessments and were individualized from there. Staff I stated they adjusted the care plans quarterly to ensure accuracy. They stated the comprehensive care plan should contain information such as their ADLs, mobility, toileting requirements, and medication use. Staff I stated they were able to individualize the care plan for each resident's needs. Staff I stated all current resident care plans were comprehensive and up to date, with exception of the resident who was recently admitted (01/15/2024). During an interview on 02/01/2024 at 3:40 PM, with Staff B and Staff A, Administrator, Staff B, stated the resident's care plans needed to be comprehensive, up to date, and reflect the current needs of the resident. Staff A, stated they agreed with Staff B. Reference: WAC 388-97-1020(1)(2)(a)(b) 43280 46722

Based on observation, interview, and record review, the facility failed to prevent an avoidable accident for one of three residents (#1) reviewed for falls. This failed practice resulted in actual harm to Resident #1 who fell out of a mechanical lift during a transfer when the straps were not properly secured. The resident sustained [REDACTED]. Findings included . Resident #1: Review of the medical record revealed the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's plan of care, dated 05/01/19 showed the resident required two-person assistance using a mechanical lift for all transfers. Review of a facility investigation report showed on 05/22/19, the resident was in the mechanical lift, being set up for a shower by Staff B, Nursing Assistant (NA). When moving the lift into the shower the safety strap fell off and the resident fell from the lift onto her right side hitting her head on the shower floor. The resident sustained [REDACTED]. Review of hospital records, dated 05/22/19, showed the resident was diagnosed with [REDACTED]. According to the investigation, Staff B, NA, explained the lift sling strap was not hooked completely on the right shoulder side and that she should have made sure it was. In a statement, dated 05/22/19, Staff C, NA, stated she was assisting Staff B to get Resident #1 ready for her bath, but was not present at the time of the fall. In an interview with Staff A, Director of Nursing, on 06/04/19 at 12:40 PM, she confirmed the incident occurred due to the strap not being properly secured. Observation and interview with the resident on 06/04/19 at 1:00 PM showed she was lying in bed with a small incision scar on the right side of her forehead. The stitches had been removed. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure 1 of 3 sample residents (#1) was free from mental abuse while being cared for by a caregiver (Staff Member D). This failure resulted in harm to the resident as she was experiencing mental anguish after being mistreated by a staff member during routine care. Findings include: Review of the facility policy regarding reporting abuse, dated 11/28/16, defined mental abuse as a willful verbal or nonverbal action that threatens, humiliates, harasses, coerces, intimidates, isolates, unreasonably confines or punishes a vulnerable adult. Resident #1. Review the most recent quarterly assessment, dated 05/15/17, revealed the resident had [DIAGNOSES REDACTED]. A facility investigation dated 06/21/17 revealed an allegation of mistreatment/abuse on 06/17/17 involving Resident #1. A summary included in the investigation documented on the morning of 06/17/17 Staff Member D, a nursing assistant, had taken the resident from the dining room to the resident's room to use the bathroom. After returning to the dining room the resident complained to her tablemates she had been treated roughly by Staff Member D. The resident then became tearful, and when questioned by staff, stated she no longer wanted breakfast and began to cry. The resident was taken to her room and assisted to bed per her request. When again questioned by staff, the resident stated Staff Member D had been very rough with her when taking her to the bathroom, and added while sobbing, What did I ever do to her to make her treat me so bad? The resident responded yes when asked if Staff Member D hurt her, but would not elaborate. No marks or injuries were observed. Staff Member D was removed from the floor and interviewed. Staff Member D denied anything had happened while toileting the resident. Staff Member D was sent home and placed on suspension. In a witness statement Staff Member E, a nursing assistant, reported Resident #1 seemed upset and tearful after returning from being toileted, and Staff Member D seemed upset, mad. Staff Member E added the resident became tearful and stated Staff Member D had handled her roughly, hurt her, and treated her like dirt. The resident was very upset and refused to eat breakfast. The resident's tablemates were interviewed as part of the investigation. Resident #3 reported Resident #1 was emotionally upset after returning from being toileted and stated What did I ever do to her (Staff Member D) to be treated like a dog? The investigation summary conclusion documented the allegation of abuse has been substantiated as psychological harm, and Staff Member D was terminated. Review of nursing progress notes revealed Resident #1 was put on alert charting and monitored for psychosocial harm 06/17/17 - 06/22/17 with none observed. Social Services followed up with the resident on 06/20/17 and 06/22/17, and the resident denied any complaints with her care. On 07/17/17 at 12:32 p.m., Resident #1 was observed seated in her wheelchair in the hallway. Staff was asking the resident if she wanted to attend BINGO that afternoon. The resident appeared relaxed. In an interview on 07/17/17 at 12:44 p.m. Resident #1 denied any concerns with her care, or treatment from staff since the incident on 6/17/17. In an interview on 07/17/17 at 2:34 p.m. Staff Member A, the Director of Nursing, confirmed that emotional abuse had been substantiated regarding the allegation on 06/17/17. Staff Member A added the resident was obviously distraught when she returned to the dining room after being toileted by Staff D, which was not typical behavior for the resident. Reference: (WAC) 388-97-0640(1)

Based on observation, record review, and interview, the facility failed to ensure each resident's environment was free of accident hazards for 3 of 3 sampled residents (#1, #2, & #3). Despite knowledge of the prohibition of the use of portable heaters in residents' rooms, the heaters were placed during a period of cold weather to warm the rooms. Resident #1 sustained burns to his hands when he attempted to move the heater. Findings include but were not limited to: Resident #1: Review of the medical record revealed the resident had multiple medical [DIAGNOSES REDACTED]. The resident's plan of care documented he experienced mild cognitive loss, refused ambulation, used a wheelchair for mobility, and experienced tremors. In addition, the resident had a history of [REDACTED]. The resident received anti-psychotic medications. The resident was identified as at risk for falls and/or injuries related to his medications, tremors, and decreased mobility. "Handle skin carefully as it is very fragile." According to a nursing entry, dated 2/07/14, Resident #1 had come to the nurses' station at 9:30 a.m. and reported to the nurse that he had burned himself. He stated he was trying to move the portable heater in his room and felt a burn once he grabbed onto the heater with both hands. The heater was not in the way but he just wanted to move it a little. The Licensed Nurse (LN) assessed the resident's hands and noted redness covering both palms but no blisters. A cold pack was applied immediately and the pain decreased once his hands cooled. Ice was applied later in the shift when the resident complained of discomfort. Good relief was reported from the application of the ice. The heater was removed from the room right away. The resident was instructed not to wash his hands with very warm or hot water to decrease the risk of further injury to the skin. The physician was notified. There were no further orders. The burn areas were to be monitored until the areas were healed. A nursing entry for the evening shift of 2/07/14 documented the resident had requested his hands be wrapped because it felt better. The resident was receiving an antibiotic for a throat infection at the time. A nursing entry on 2/08/13 documented the resident's bilateral palms remained reddened and without blistering. The resident denied pain when asked. The next day, on 2/09/14, the nursing entry noted the resident had a blister on his right hand (no size or exact location was noted) from the 2/07/14 burn. The resident stated, "it hurts just a little". (sic) A 2/10/14 nursing entry noted the blister on the resident's hand was intact and the redness on his hands was improving. The February 2014 medication administration record documented the resident had received Extra Strength Tylenol 1000 milligrams twice daily per his routine orders (for pain). The 2/07/14 facility investigative documents revealed the resident had an oil radiator heater in his room and he attempted to move the heater to release some of the tension on the cord. The resident's burn incident was immediately discussed with maintenance staff and the portable heaters were removed from the residents' rooms. An alternate heating source was installed. Resident #1 was observed/interviewed on 2/11/14 at approximately 12:25 p.m. The resident was self-propelling his wheelchair in his room. The resident spoke of the burn incident. He recalled he had grabbed the heater on both sides to make the cord less taunt (tight). The burn was "painful." The resident had bilateral hand tremors as he held his hands out for viewing. There was a dark pink area approximately 2.5 centimeters (about one inch) over the web between his right thumb and index finger. There were no open areas. The resident's left palm was pink in appearance. The resident stated his right thumb and left palm "still hurts." On 2/11/14 at approximately 11:15 a.m. and 1:55 p.m., Staff Member A, the Plant Manager, stated they had been experiencing very cold outside temperatures, in the single digit range. The indirect heater on the roof was insufficient to maintain adequate temperatures in the residents' rooms. The residents' rooms were in the 60 degree temperature range. Although he was aware that portable heaters were not to be used, he placed six portable oil radiant heaters in residents' rooms, either between the residents' beds or by the sink per availability of the wall outlet. The heaters were placed on 2/05/14 and removed from all the residents' rooms directly following Resident #1's burns on 2/07/14. An alternate heating source was provided thereafter. Observations of the portable heaters on 2/11/14 at approximately 12:25 p.m. revealed they were constructed with six exposed surface/coils on the unit that provided heat and were 1500 watt units. Resident #2: Review of the 11/18/13 quarterly assessment documented the resident scored 15 of 15 on a cognitive test, indicating the resident was cognitively intact. She required staff assistance for her activities of daily living. When interviewed on 2/11/14 at approximately 1:30 p.m., Resident#2 stated it got pretty cold at night. A portable heater was provided in her room for little while. Resident #3: Review of the 12/30/13 quarterly assessment revealed the resident had adequate hearing and vision, scored 13 of 15 on the cognitive test, and required staff assistance for her activities of daily living. On 2/11/14 at approximately 1:35 p.m. Resident #3 (Resident #2's roommate) stated she recalled being cold in her bed but staff had provided extra blankets. The resident did not mention having a heater. However, Staff Member A stated he had placed a heater in the room where Residents #2 and #3 resided during the previously noted interview. In order to provide environmental heat, the facility placed portable heaters in the residents' rooms. The presence of the heaters in the residents' room constituted a safety hazard. Resident #1 was harmed after contact with the hot surfaces of the portable heater.

Based on observation, interview and record review the facility failed to provide the necessary care and services to prevent pressure ulcer devlopment for 1 of 3 residents (#9). This resulted in harm to Resident #9. Findings include: Resident #9, per record review, had [DIAGNOSES REDACTED]. The resident had no memory problems or difficulty with making daily decisions. The resident required extensive assistance with activities of daily living (ADL's), including toileting and repositioning. The admission pressure ulcer summary dated 7/30/10 noted that the resident did not have any pressure ulcers, but had multiple skin tears. The facility documented that they would address areas as they appeared. The assessment noted that the resident's skin was to be checked weekly and as needed. Per record review, there was no documentation that the resident's skin was checked weekly as directed by the care plan from 10/10/10 to 11/18/10 (over 30 days) prior to the pressure ulcers developing. Per record review, on 11/18/10 the resident developed 3 pressure ulcers to her coccyx. The first area was a Stage I (an area that stays red even after pressure is relieved) that measured 3.5 centimeters (cc) x 3.7 cm to her coccyx (#1), and 2 (# 2, 3) Stage II (superficial break in the skin) areas on the coccyx that measured 0.5 cm x 0.5 cm. The physician was notified and orders were obtained to turn/reposition the resident every two hours, obtain an air mattress, and a treatment for [REDACTED]. Per record review the following was noted: On 11/30/10 pressure sore # 2 and 3 combined to make one larger pressure ulcer which had developed into a Stage III (full thickness of the skin). The pressure ulcer had moderate serosanguinous drainage. Area 1 was healed. On 12/8/10 the resident was evaluated by an occupational therapist for a pressure reduction cushion for her wheel chair. This was over 3 weeks after the resident's skin deteriorated. On 12/10/10 the resident's pressure sore required antibiotics for an infection. On 12/21/10, the pressure ulcer increased in size and meaured 2 cm x 1.5 cm and was .02 cm deep. The physician was notified and new treatments were obtained. On 12/22/10 the facilty placed the air mattress on the resident's bed (over 30 days after the doctor ordered the air mattress). On 12/28/10 the pressure ulcer measured 2 cm x 3 cm and was 1 cm deep. On 1/11/11 the pressure ulcer measured 1.5 cm x 2 cm and was 1.5 cm deep. The pressure ulcer continued to have moderate drainage. The area was measured weekly. It continued to increase in size and had drainage present. By 2/15/11 the pressure ulcer measured 2.2 cm x 2.2 cm and 2.2 cm depth. The nurse practitioner evaluated the resident's pressure ulcer, and ordered a wound culture and antibiotics. On 2/22/11 the pressure sore had eschar (black dead tissue) on the right side of the wound. On all days of the survey, (2/23/11, 2/24/11, 2/25/11, 2/28/11, 3/1/11, and 3/2/11) the resident got up around 10:30 a.m. and stayed up in the chair all day. She was able to lean forward to off load the pressure from her coccyx. On 3/1/11 at 1:00 p.m., the resident was up in her wheel chair. She reported that she thought that the pressure ulcer started when staff pulled her up in the bed fast and caused a friction area. She reported that the facility did not get her a special mattress or cushion until she received the pressure ulcer. On 3/1/11 at 5:33 p.m., Staff #K reported that the facility put the resident on a turning schedule after the resident developed the pressure ulcer. She reported the resident spent most of her time up in her chair and that was why they had her evaluated for a different cushion. On 3/2/11 at 11:12 p.m., Staff #A and B reported they just started completing pressure ulcer risk assessment tools. They reported that they were not done in the past. They reported this resident had complex issues going on. The facility failed to obtain treatments, turn/reposition, obtain an air matterss, and wheelchair cushion in a timely manner for a resident who was at risk of developing pressure sores. This failure resulted in harm for Resident # 1.

Based on observation, interview and record review, the facility failed to implement their plan of correction to prevent accidents for 12 of 12 (# 30, 2-12) residents in a sample of 13 related to side rails. Findings include: Resident #30 had [DIAGNOSES REDACTED]. He had short term memory problems and poor decision making regarding safety with transfers. The resident required limited assistance with bed mobility and transfers. Per record review, on 1/24/11 the resident was noted to have a 3 centimeter (cm) x 1 cm dark purple bruise on the left side of his neck. The resident stated he got the bruise from falling on his side rail. The investigation concluded that the resident bruised easily due to medications and no interventions were implemented to prevent further accidents. Facility POC Per the facility plan of correction dated 3/25/11 resident # 30's side rails were to be padded; If side rails were used for residents, risks of their use would be explained to the resident(s) or responsible parities and this would be done on admission and quarterly. The plan of correction was to be complete 3/25/11 During the onsite post survey on 4/12, 19, 20/11 resident # 30's side rails were not padded. The resident suffered no further harm at that time. During the post survey, resident's were reviewed for side rail use and assessments per the plan of correction. 12 residents had side rails in use at the time of the post survey. 6 of the residents had side rail assessments dated 2010 or earlier (over 1 year old), 3 residents had no side rail assessments done. And 4 residents had current side rail assessments. Per the residents' plans of care the side rails were to be used during cares, and/or to assist with bed mobility and transfers. During the onsite post on 4/19/11 between 8:30 PM and 11:30 PM, the 12 residents with side rails were in bed for the evening. Per interviews with the licensed staff, the side rails were "used to keep the resident's from falling out of bed". The residents "were like monkeys and tried to climb out of bed all the time". The side rails kept the residents in bed if "staff was busy in another room and could not get to them right away". Per interviews with administrative staff, the assessments had not been finished per the plan of correction(s).

Based on observation, interview, and record review the facility failed to provide the necessary care and services to maintain the highest practicable level for 2 of 3 (#9,13) residents in a sample of 20, related to pain. This resulted in harm for Resident #9 and 13. Findings include: 1. Resident #13, per record review, had [DIAGNOSES REDACTED]. She had problems with hearing/vision and also had pressure ulcers on her coccyx. The resident had memory problems and difficulty with making daily decisions. The resident required extensive assistance with activities of daily living (ADL's). The care plan directed staff to report any non-verbal indications of pain and assist the resident to a position of comfort. Per the latest facility assessment dated [DATE], the facility noted the resident experienced pain daily and showed non-verbal sounds of crying, whining, and moaning. She showed facial expressions of pain, grimaced, winced, and wrinkled her forehead. The latest pain summary dated 12/27/10, the resident was on a non-narcotic pain medication and would call out and complain of pain. She would also grimace and clench her teeth. The licensed nurse who evaluated the resident's pain documented that she did not feel the resident's pain was adequately managed and would notify the doctor and await for further direction. She also discussed that the resident's pain could be causing the resident increased anxiety and restlessness. There was no documentation that the doctor was notified of her assessment. Per record review, on 1/18/11 the doctor rounded and increased the resident's non-narotic pain medication. (3 weeks after first noted) Per review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident started on a low dose pain patch on 2/21/11, but continued to complain of pain. On 2/28/11 at 4:45 p.m., the resident was in the dining room. She looked upset and had a pained look on her face. At 4:52 p.m., the resident had a pained look on her face and moaned, "I can't eat this! I'm cold." A staff member tried to comfort her and fed her a bite of food. At 5:10 p.m., the resident had a facial grimace and moaned. At 5:17 p.m., another staff member gave the resident a drink of soup. At 5:21 p.m., the resident stated, "My neck hurts!" She again moaned, the staff went to her and tried to feed her some more food. At 5:24 p.m., the resident continued to yell out, "I can't stand it! I can't stand it! Staff #F continued to assist the resident with fluids. The resident continued to moan out. Staff tried to reassure her, but the resident continued to yell out. On 2/28/11 at 5:38 p.m., Staff #F reported that the resident was like this every meal during evening shift. She stated, "The resident doesn't see or hear well and it's more of a behavior." She went on to say that nothing really helped. Per review of the MAR, the resident last received narcotic pain medication on 2/28/11 at 10:00 a.m., this was over 6 hours previously. The staff did not report the signs and symptoms of pain and behaviors to the licensed nurse. On 3/1/11 11:40 a.m., the resident was in the dining room. She sat quietly and did not appear to be in pain. Review of the record showed the resident received as needed narcotic pain medication at 10:00 a.m. On 3/1/11 at 3:35 p.m., a family member was with the resident in her room. She reported that she visited every afternoon and stated, "Yesterday was a bad day for her and she was in a lot of pain!" On 3/1/11 at 5:08 p.m., Staff #K reported the resident had behaviors and pain. She reported that her daughter was there in the afternoons and would tell the licensed staff if she was in pain. Staff #K reported that she would sometimes give her a narcotic pain medication before dinner to help her with her pain and behaviors. On 3/1/11 at 10:45 a.m., Staff #A and B reported that the resident's pain was reviewed quarterly. They reported that the nurse monitored the alert residents and gave them medication when needed. They reported that the nursing assistants monitored the non-verbal residents for signs and symptoms of pain and would report to the licensed nurse. Staff #B reported that they notified the doctor by fax on 2/9/11 of the increase in the resident's pain. There was no response from the doctor and so she refaxed the doctor on 2/17/11. They received orders on 2/18/11 to increase the pain patch. (This was 9 days after increased pain was noted). The facility failed to ensure that a resident's pain was managed at her highest practicable level and resulted in harm. 2. Resident #9, per record review, had chronic medical conditions and a Stage III pressure ulcer. She had no memory problems or difficulty with making daily decisions. The resident required extensive assistance with activities of daily living (ADL's). The care plan directed the nursing assistants to observe for any complaints of pain and report to the licensed nurse. The goal was for the resident to get relief with medications and to express her pain daily. Per record review, the resident was on a narcotic topical pain patch, fast acting liquid narcotic that she could have every 3 hours as needed, and an oral narcotic that she could have 3 times daily as needed. Per the latest pain summary dated 1/24/11, the facility documented that the resident complained of pain daily, mostly with dressing changes to her pressure ulcer. The nurse evaluating the pain noted the resident would benefit from an increase in her scheduled pain medications. The plan was to follow up with the doctor. Per record review, the doctor was faxed on 1/27/11 with no response, and then refaxed on 2/1/11. The doctor contacted the facility on 2/8/11 and increased the dosages for the pain patch and narcotic. This was over 13 days after the facility initially contacted the physician. On 2/28/11 at 12:30 a.m., the resident was up in her wheel chair in her room. She had a pained looked on her face and when asked rated her pain "6-7" out of 10 to the surveyor. She was headed out of the facility for a doctor's appointment. On 2/28/11 at 3:25 p.m., the resident returned from her doctor's appointment and reported that her pain was still a "6-7" out of 10 to the surveyor. Per review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She did not take any as needed medications for the rest of that day. She is able to have the liquid narcotic every 4 hours and the oral narcotic pain medication 3 times per day. On 3/1/11 at 1:00 p.m., the resident was up in her wheel chair in her room. She rated her pain at "6" out of 10. She reported that the pain never completely went away. She discussed that the facility didn't like her to take the liquid narcotic pain medication during the day because it made her sleepy, and wanted her to take the oral narcotic pain medication. She reported that the facility didn't want her to take too much of the medication, because it was hard on her kidneys and liver. She stated, "I'm on comfort care, their already shot!" She reported that the nurses asked her about her pain when she got up in the morning and then again around 3:30 p.m. She thought that they asked her about her pain once per shift. Per review of the MAR, the resident received as needed medications, but the nurses did not evaluate the level she rated her pain. There was no subjective rating of whether or not the pain medication was effective. The facility failed to ensure that a resident's pain was managed at their highest practicable level and resulted in harm for this resident.

Based on observation, interview and record review, the facility failed to identify, evaluate, and implement interventions to prevent accidents for 5 of 5 (#7, 8,13, 20, 30) residents in a sample of 20 related to side rails and the use of portable heaters. Findings include: Resident #30 had [DIAGNOSES REDACTED]. He had short term memory problems and poor decision making regarding safety with transfers. The resident required limited assistance with bed mobility and transfers. Per record review, the resident admitted to the facility with a history of falls. The resident had an order for [REDACTED]. Per record review, on 1/24/11 the resident was noted to have a 3 centimeter (cm) x 1 cm dark purple bruise on the left side of his neck. The resident stated he got the bruise from falling on his side rail. The investigation concluded that the resident bruised easily due to medications and no interventions were implemented to prevent further accidents. On 1/27/11, per record review, the resident had a safety device assessment done for use of side rails (3 days after his accident with the side rails). The assessment stated the resident was able to turn and reposition himself independently while in bed with the use of the half side rails. There was no mention of the accident that occured on 1/24/11. Per interview on 2/28/11 at 3:15 p.m., a family member stated she saw him on another occassion pull himself up with the rail and fall back and hit his head on the side rail. She was not aware the bruise on his neck was caused by the side rail. On 3/2/11 at 8:50 a.m., the resident stated he used the side rails on occasion to sit on the side of the bed but it was much easier to call staff for assistance. The resident confirmed he had fallen back and hit the side rails on occasion. On 3/2/11 at 12:45 p.m., Staff #A confirmed there were no new interventions in place to prevent reocurrence. The facility failed to protect the resident from further injury related to the side rails. 2. Resident #7, per record review, had multiple chronic conditions that made long term care necessary. The resident had no memory problems or difficulty with making daily decisions. The resident required limited assistance with activities of daily living (ADL's). Per review of the care plan, there was no direction for staff on use of the portable heater. On 2/23/11 at 2:30 p.m., the resident had a portable heater in her room. The portable heater was on and was hot to touch. On 2/23/11 at 2:45 p.m., Staff #D reported that the resident complained of being cold all of the time. She reported the resident has used the portable heater for quite a while and they don't check the portable heaters unless they notice that there were problems. On 2/23/11 at 2:50 p.m., Staff #C confirmed that the portable heater was hot. He reported that if they tipped over they were the kind that would not catch fire. On 2/23/11 at 2:55 p.m., Staff #E reported that they do not adjust the heaters and if there are any problems they contact maintenance. On 2/23/11 at 3:00 p.m., Staff #F reported that maintenance took care of all the heaters. She reported that if she had any problems she would notify maintenance. The facility failed to ensure the resident's safety by allowing a portable heater to be used in a resident care area and placed the resident at risk for injury. 3. Resident #13, per record review, had a history of [REDACTED]. The resident required extensive assistance with activities of daily living (ADL's), including bed mobility and transfers. Per the side rail assessment dated [DATE], the facility noted the resident was to have one side rail up when in bed and the bed was placed against the wall. There was no indication that risks and benefits were discussed with the resident/representative. The goal was for her to maintain some ability to assist staff with transfers and bed mobility. The care plan directed staff to have one side rail up in bed, and an alarmed mat on the floor to alert staff when attempting to get out of bed without assistance. On 2/25/11 at 9:15 a.m., the resident was in bed and had three half rails that were in the up position. On 2/28/11 at 2:00 p.m., the resident was in bed and all four side rails were in the up position. On 2/28/11 at 3:15 p.m., Staff #G got the resident up to her recliner. She reported that the resident sometimes used the side rails to position herself in bed. She stated that sometimes she was calm and other times she was not. On 3/1/11 at 9:35 a.m., Staff #D reported that she had just got the resident up from bed and placed her in a recliner in her room. She stated that there were times when she took care of her and the resident had all four side rails in the up position when she was in bed. On 3/1/11 at 10:40 a.m., Staff #A and #B confirmed that all four side rails should not be in the up position. The facility failed to implement planned interventions for safety. This placed the resident at risk for injury. 4. Resident #8, per record review, had a [DIAGNOSES REDACTED]. She required extensive assistance with activities of daily living (ADL's), including transfers and bed mobility. The care plan directed staff to place the half side rails up while in bed to assist with positioning and transfers. On 2/24/11 at 4:22 p.m., Staff #B reported the resident used half side rails when she was in bed. She discussed that the resident did not move on her own and would not be able to get out of bed without assistance. Per the safety device assessment dated ,[DATE], the facility determined that the resident used side rails to with positioning and bed mobility, but did not discuss the potential adverse effects and benefits for side rail usage. On 3/1/11 at 11:30 a.m., Staff #A and B reported they thought the resident could go without the side rails. The facility failed to evaluate the appropriate use of side rails. 5. Resident #20, per record review, had [DIAGNOSES REDACTED]. She required extensive assistance with activities of daily living (ADL's), including transfers and bed mobility. The care plan directed staff to place the half side rails up while in bed to assist with positioning and transfers. Per the safety device assessment dated [DATE], discussed that the resident had a history of [REDACTED]. There was no documentation in the resident's record to indicate the facility assessed the safety factors associated with the use of the side rails. On 2/24/11 at 9:30 a.m., the resident was in bed with both half rails in the up position at the head of her bed. The resident did not move or attempt to get out of bed. On 2/25/11 at 9:00 a.m., the resident was in bed with both half rails in the up position at the head of her bed. The resident did not move or attempt to get out of bed. On 2/28/11 at 11:15 a.m., the resident was in bed with both half rails in the up position at the head of her bed. The resident did not move or attempt to get out of bed. On 3/1/11 at 11:30 a.m., Staff #A and B reported they thought the resident could go without the side rails. The facility failed to evaluate the appropriate use of side rails.