Every finding on record at Colville Health and Rehabilitation of Cascadia

Based on interview and record review, the facility failed to routinely provide pharmaceutical service that ensured accurate dispensing and administration of medications for 3 of 3 sampled residents (Resident 1, 2, and 3), reviewed for medication administration. This failure placed residents at risk for potential medication errors, misappropriation of opioid medications (also referred to as narcotic, powerful pain medication used to treat severe pain) and diminished quality of life.Findings included.Review of the facility policy titled, Medication Administration, revised September 2025, showed all staff authorized to administer medications must follow the 10 rights of medication administration to ensure resident safety, reduce medication errors, and maintain compliance with federal and state regulations. The policy listed the 10 rights of medication as 1) Right Medication- verify the medication against the provider's order and the Medication Administration Record (MAR), 2) Right Resident- use identifiers such as photo along with verbal confirmation, 3) Right Dose- confirm the dose with the MAR and provider's order, 4) Right Route- confirm the prescribed route of administration, 5) Right Time and Frequency- administer medications as scheduled, 6) Right Documentation- promptly document in the resident's medical record after administration, 7) Right Assessment- assess the resident's condition before administration as applicable, 8) Right to Refuse- respect the resident's right to refuse, 9) Right Evaluation- monitor response and follow-up on as needed medication use for effectiveness, and 10) Right Education- inform the resident about the medication's purpose, expected effects, and possible side effects.<Resident 1>According to the 06/12/2026 quarterly assessment, Resident 1 had diagnoses that included chronic pain. The assessment further showed Resident 1 was frequently in pain and received opioid pain medication.Review of provider orders showed an active order dated 06/09/2026 for Resident 1 to receive hydrocodone (opioid or narcotic pain medication) every six hours as needed for pain.Review of the June 2026 hydrocodone narcotic tracking log showed the pain medication was removed from Resident 1's supply for administration on 06/01/2026 at 7:30 AM, 06/04/2026 at 7:30 AM, 06/05/2026 at 7:15 AM, 06/10/2026 at 8:30 PM, 06/12/2026 at 7:30 AM, 06/13/2026 at 8:00 AM, 06/17/2026 at 7:00 AM, 06/18/2026 at 7:30 AM and 7:30 PM, 06/20/2026 at 9:30 PM, 06/23/2026 at 7:30 AM, 06/26/2026 at 7:30 PM, 06/29/2026 at 8:24 PM, and on 06/30/2026 at 8:35 AM and 6:57 PM.Review of the June 2026 MAR showed no documentation Resident 1 was administered hydrocodone on 06/01/2026 at 7:30 AM, 06/04/2026 at 7:30 AM, 06/05/2026 at 7:15 AM, 06/12/2026 at 7:30 AM, 06/13/2026 at 8:00 AM, 06/17/2026 at 7:00 AM, 06/23/2026 at 7:30 AM, 06/26/2026 at 7:30 PM, 06/29/2026 at 8:24 PM, or on 06/30/2026 at 8:35 AM or 6:57 PM. The MAR further showed Resident 1 was administered hydrocodone on 06/10/2026 at 7:10 PM (one hour and 20 minutes prior to the medication being removed from the resident supply), on 06/18/2026 at 6:56 AM (34 minutes prior to the medication being removed from the resident supply) and 7:05 PM (25 minutes prior to the medication being removed from the resident supply), and on 06/20/2026 at 7:15 PM (two hours and 15 minutes prior to the medication being removed from the resident supply).During observation and interview on 07/01/2026 at 11:44 AM, Resident 1 stated they had no concerns related to their pain management. Resident 1 showed no verbal or non-verbal signs of pain.<Resident 2>According to the 05/21/2026 quarterly assessment, Resident 2 had diagnoses that included toe pain. The assessment further showed Resident 2 was occasionally in pain and received opioid pain medication.Review of provider orders showed an active order dated 05/06/2026 for Resident 2 to receive hydrocodone every six hours as needed for pain.Review of the May 2026 and June 2026 hydrocodone narcotic tracking log showed the pain medication was removed from Resident 2's supply for administration on 05/11/2026 at 1:00 PM, 05/21/2026 at 8:30 AM, 05/27/2026 at 1:50 PM, 06/07/2026 at 8:00 PM, 06/08/2026 at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM, on 06/09/2026 at 6:00 AM, 7:30 AM, 10:15 AM, 1:30 PM, 5:40 PM, and 10:00 PM, on 06/15/2026 at 4:40 PM and 10:55 PM, and on 06/16/2026 at 6:15 AM and 12:30 PM.Review of the May 2026 and June 2026 MAR showed no documentation Resident 2 was administered hydrocodone on 05/11/2026 at 1:00 PM, 05/27/2026 at 1:50 PM, 06/07/2026 at 8:00 PM, 06/08/2026 at 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM, on 06/15/2026 at 4:40 PM and 10:55 PM, or on 06/16/2026 at 6:15 AM and 12:30 PM. The MARs further showed Resident 2 was administered hydrocodone on 05/21/2026 at 7:20 AM (one hour and 10 minutes prior to the medication being removed from the resident supply), and on 06/09/2026 at 7:00 AM, 1:00 PM, and 5:13 PM (six doses were removed from the resident supply this day but only three doses documented as administered).During observation and interview on 07/01/2026 at 9:16 AM, Resident 2 denied concerns with their pain management. Resident 2 showed no verbal or non-verbal signs of pain.<Resident 3>According to the 05/29/2026 discharge assessment, Resident 3 had diagnoses that included shoulder and back pain. The assessment further showed Resident 3 was occasionally in pain and received opioid pain medication.Review of provider orders showed an active order dated 05/01/2026 for Resident 3 to receive oxycodone (opioid pain medication) every eight hours as needed for pain.Review of the May 2026 oxycodone narcotic tracking log showed the pain medication was removed from Resident 3's supply for administration on 05/18/2026 at 3:30 PM, 05/20/2026 at 6:30 AM and 11:00 AM, on 05/22/2026 at 5:30 PM, and on 05/28/2026 at 5:40 PM.Review of the May 2026 MAR showed no documentation Resident 3 was administered oxycodone on 05/18/2026 at 3:30 PM, 05/20/2026 at 11:00 AM, 05/22/2026 at 5:30 PM, or on 05/28/2026 at 5:40 PM. The MAR showed Resident 3 was administered oxycodone on 05/20/2026 at 6:06 AM (24 minutes prior to the medication being removed from the resident supply).During an interview on 07/01/2026 at 12:59 PM, Staff E, Nursing Assistant, stated if a resident reported pain, they would notify the nurse on duty so they could follow up.During an interview on 07/01/2026 at 2:20 PM, Staff D, Registered Nurse, stated when a resident voiced pain, the nurse was to assess the source of the pain and provide nonpharmacological interventions. Staff D explained that if a narcotic pain medication was administered, the nurse should follow the rights of medication administration which included verifying the provider order and ensuring the right medication was administered to the right resident at the right dose. Staff D stated narcotic medication needed to be signed out of the narcotic tracking log as well as ensuring the correct date and time the medication was administered was documented in the MAR. Staff D acknowledged if medication administration was not documented accurately, it could result in potential medication errors.During interview and record review on 07/01/2026 at 2:30 PM, Staff C, Resident Care Manager, stated when a resident voiced pain, the nurse was to assess the pain. Staff C explained if a narcotic pain medication was to be administered, the nurse was to follow provider orders and verify the right medication was administered to the right resident at the right dose. Staff C further stated narcotic pain medication needed to be signed out of the narcotic tracking log as well as document the correct date and time the medication was administered in the MAR because it could cause potential medication errors if not documented accurately. Staff C reviewed Resident 1 and 2's medical records. Staff C acknowledged there were numerous discrepancies between the narcotic tracking log and the MAR.During interview and record review on 07/01/2026 at 3:00 PM, Staff B, Director of Nursing, stated nurses were expected to follow the facility medication administration policy when administering medications. Staff B further stated if a narcotic medication was administered, nurses were to sign the medication out of the narcotic tracking log and ensure the MAR documentation matched to prevent confusion and potential medication errors. Staff B reviewed Resident 1, Resident 2, and 3's medical records. Staff B acknowledged there were numerous discrepancies between the narcotic tracking logs and the MAR. Staff B stated they expected the narcotic tracking log and the MAR documentation to be accurate.In an interview on 07/01/2026 at 3:45 PM, Staff A, Administrator, stated they expected staff to administer medications per provider orders and ensure accurate documentation was in the resident's medical record. Reference WAC 388-97-1300 (1)(a)(4)(e)

Based on interview and record review, the facility failed to ensure an allegation of potential abuse was reported as required to the State Survey Agency within two hours after the allegation was made, for 1 of 3 sampled residents (Resident 1), reviewed for abuse and/or neglect. Failure to report an allegation of potential abuse placed Resident 1, and other residents in the facility, at risk for additional abuse. Findings included .The 02/27/2026 annual assessment showed Resident 1 had diagnoses to include kidney disease. The assessment showed Resident 1 had memory impairments and difficulty making their needs known and required substantial to maximum assistance with bed mobility. The facility policy titled Abuse - Reporting and Response dated 08/25/2025, documented allegations involving abuse, neglect .will be promptly reported, investigated, and addressed in accordance with applicable Federal and State regulations. Alleged or suspected incidents involving resident abuse, neglect . must be promptly reported to the Administrator and/or Director of Nursing. Facility staff are required to immediately report any suspicion of resident abuse to their direct supervisor or another designated facility representative. If it involves a facility employee, they will promptly be removed from resident care areas and placed on suspension. Allegations that involve abuse or results in serious bodily injury to a resident, the facility is required to report without delay. The report must be submitted no later than two hours from the time the allegation was made.A facility document titled Annual Acknowledgment of Abuse reporting obligations, dated 10/01/2017, showed all staff had the responsibility to report to the State Survey Agency. The document explained how to report, time frame to report, and retaliation was prohibited to staff who reported. The document was to be read and signed annually. A 03/15/2026 progress note written by Staff A, Licensed Practical Nurse (LPN), showed Staff A heard Resident 1 yell from their room. Staff A entered the room and Staff C, Certified Nursing Assistant (CNA), was in the room and appeared to have finished care for the resident. Resident 1 started to yell keep her away from me! Staff A asked the resident what happened and the resident replied, look at my arms. Staff A observed skin tears on the resident's left and right wrist and back of the right arm. Staff A then asked Staff C what happened to the resident's arms and Staff C replied, they were like that when I got here. After Staff C left the room, the resident stated they were scared to be alone and wanted to leave. A facility investigation dated 03/15/2026, showed Resident 1 reported Staff C had hurt them during care. Staff B, Director of Nursing Services (DNS), documented an investigation was started upon discovery of the incident and the State Requirement for reporting was followed. After the investigation was conducted, it was concluded the resident had an unexpected/unavoidable accident related to mishandling during care and a bed change. All staff were educated on safe handling and how to make an occupied bed. Staff C received the training individually as well as additional training. Review of the State Survey Agency Secure Tracking and Reporting System (STARS), showed Staff B had called in an allegation of injury of unknown source for Resident 1 on 03/15/2026 at 9:07 PM. The alleged abuse occurred at 5:00 AM on 03/15/2026.On 04/07/2026 at 1:55 PM, Staff A was interviewed and stated it was around 5:00 AM on 03/15/2026 when they heard Resident 1 scream. Staff A went into the resident room, and Staff C had just finished care. The resident yelled keep her away from me and was very upset. Staff A asked Staff C what happened and Staff C stated the skin tears were already there and left the room. After Staff C had left, Resident 1 said they were scared to be alone. Staff A stated the skin tears looked like they had just happened. Staff A was asked if they thought this was potential abuse, Staff A stated yes, and they had called Staff B to report it to them. Staff A went on to say the resident was very lucid (something is clear, easy to understand, or rational) at the time of the incident and was really scared. Staff A was asked if they called the allegation of abuse into the State Survey Agency as a mandatory reporter, Staff A said they hadn't. Staff A stated staff were to report allegations to management and management would call the State.On 04/07/2026 at 2:27 PM, Staff D, Registered Nurse (RN), was asked what they would do if a resident reported an allegation of abuse. Staff D stated they would make sure the resident was safe and remove the staff member away from the resident. Staff D would then let Staff E, Administrator, or Staff B know. When Staff D was asked if they would call the State Survey Agency as a mandatory reporter, Staff D stated they would confer with Staff B or Staff E before they would call the state. On 04/07/2026 at 2:34 PM, Staff F, CNA, was asked what they would do if a resident reported an incident of abuse. Staff F stated management would be told and then management called the state unless it was severe enough of an allegation then they would call. On 04/07/2026 at 2:38 PM, Staff G, CNA, was asked what they would do if a resident reported an incident of abuse. Staff G stated they would report it to their assigned nurse. When asked if they would call the state as a mandatory reporter, Staff G stated they would just report to their assigned nurse and then it would go up the chain of command from there. On 04/07/2026 at 2:40 PM, Staff H, Resident Care Manager (RCM) and Staff I, RCM, were asked what the process of reporting an allegation of abuse and/or neglect was. Staff H stated staff were to immediately report it to Staff E, the Abuse and Neglect Coordinator. When asked if staff were to report it to the State Survey Agency, both Staff H and Staff I stated Staff E was the one that called the state.On 04/07/2026 at 2:54 PM, Staff E and Staff B were interviewed. Staff E was asked what the process was when a staff member suspected potential abuse. Staff E stated staff would make sure the resident was safe, let their assigned nurse know, notify the provider, and an investigation would be started. Staff E would be notified since they were the Abuse and Neglect Coordinator and would call the state if abuse was suspected. Staff E stated Administrative staff were available all hours for staff to call if there was an allegation of abuse and/or neglect. When asked about other staff calling the State Survey Agency, Staff E stated all staff were mandatory reporters and could call the State hotline and that staff received training on mandatory reporting in their yearly training for abuse and neglect. Staff B stated they had received a call from Staff A on 03/15/2026, who reported Resident 1 had new skin tears and requested Staff B come to the facility to look at the resident. Staff B stated they immediately went to the facility and interviewed Staff A, Staff C, and Resident 1. Staff B stated Resident 1's skin tears appeared to be new since they were bright red and had no scabbing. Staff B stated they could not validate if Staff C was the source of the injury, so the skin tears were determined to be an injury of unknown origin, and it was called in within the 24 hours as required. Reference: WAC 388-97-0640(5)(a)

Based on observation, interview and record review, the facility failed to identify, report, protect, assess and prevent a pattern of resident-to-resident verbal and physical abuse. This included identifying a known pattern of aggressive behaviors by Residents 19. Abusive behaviors identified by staff included hitting, punching, kicking, ramming into other residents with a wheelchair (w/c), verbal abuse, threats and intimidation of other residents. The facility failed to recognize these instances as abuse, analyze the circumstances of these abusive behaviors, or implement plans for prevention or recurrence of abuse for 11 of 12 sampled residents (Resident 19, 31, 49, 21, 43, 27, 37, 33, 45, 3, and 41), reviewed for abuse. Failure to recognize, analyze, and act upon multiple incidents of resident-to-resident altercations as abuse and provide adequate supervision and care planning with effective interventions placed all 61 residents at risk of serious injury or harm and represented an immediate jeopardy (IJ). 13 residents experienced fear when they were subjected to repeated unpredictable outbursts of verbal abuse and actual physical injuries such as coffee thrown on them, grabbing, scratching, punching, kicking, and skin tears. On 05/20/2025 at 5:40 PM, the facility was notified of the identified IJ related to F600 CFR S483.12 (a)(1) Freedom from Abuse and Neglect. Onsite verification by surveyors on 05/23/2025 at 10:25 AM showed, the facility removed the immediacy by reviewing Resident 19's medications and placing Resident 19 on one to one (1:1) supervision until lower level of care was determined to be appropriate. The survey team verified the facility educated all staff to the abuse prevention policies and procedures. All residents were interviewed to determine feeling safe and secure in the facility. Findings included . Review of the facility policy titled, Preventing Abuse revised August 2023 showed, the facility would identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property was more likely to occur. Staff were to observe residents, visitors and staff to identify inappropriate behaviors and deploy sufficient staff on each shift to meet the needs of the residents. The policy instructed staff to assess, care plan and monitor residents who exhibited behaviors which might lead to conflict such as verbally aggressive behaviors such as screaming, cursing, intimidating, or demanding behaviors and physically aggressive behaviors such as hitting, kicking, grabbing, scratching, biting, pushing, wandering, rummaging, threatening gestures, or throwing objects. Review of the facility policy titled, Identification and Investigation of Abuse, Neglect, Misappropriation, and Injuries of Unknown Origin revised August 2023 showed, the facility reviewed reports of grievances, complaints, and allegations of abuse, neglect, injuries of unknown injury to identify a pattern or isolated incidents. The policy instructed staff to determine a root cause of any incident and evaluate the resident for signs of negative psychosocial impact of the incident to include fear of a person or place or extreme changes in behavior. The facility was to protect all residents from physical and psychosocial harm during and after the investigation by responding immediately to protect the alleged victim and provided increased supervision of the alleged victim and other residents as indicated. Staff were to immediately report all incidents and allegations of abuse to the CEO or designee, the State Survey Agency, and Law Enforcement if a crime was suspected. Once an incident was reported it was to be thoroughly investigated within five working days by conducting resident and staff interviews, determine root cause of the incident and implement corrective action to immediately address safety issues, updated care planned interventions based on the investigation findings, and complete staff training as indicated. According to the 04/10/2025 quarterly assessment, Resident 19 had severe cognitive impairment with inattention and disorganized thinking. The assessment further showed Resident 19 exhibited worsening verbal and physical behaviors directed towards others that significantly interfered with Resident 19's care, participation in activities or social events, placed others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or the living environment. Review of the facility October 2024 through May 2025 incident report tracking log showed Resident 19 was involved in 11 resident-to-resident altercations with 10 different peers (Resident 31, 49, 21, 43, 27, 37, 33, 45, 3, and 41) on the following dates: 10/16/2024, 11/07/2024, 01/11/2025, 01/13/2025, 02/10/2025, 02/27/2025, 03/08/2025, 04/04/2025, 04/11/2025, 04/25/2025, and 05/10/2025. Review of the facility resident-to-resident incident reports showed the following: - 10/16/2024- Resident 19 allegedly struck Resident 27 on the hand with a spoon while in the dining room - 11/07/2024- Resident 33 threw coffee on Resident 19 in the dining room - 01/11/2025- Resident 19 randomly grabbed, kicked, and shook Resident 3's walker as they walked down the hall - 01/13/2025- Resident 19 yelled, grabbed at, and stopped Resident 41 from entering the dining room. The incident included a 01/13/2025 staff statement that showed Resident 19 continued to escalate with anger trying to grab and hit anyone close to [them]. - 02/10/2025- Resident 19 grabbed at Resident 31. Resident 19 called Resident 31 a fucking asshole! and grabbed Resident 31's shirt neck collar. Resident 31 open handedly slapped Resident 19 in the face. - 02/27/2025- Resident 19 was self-propelling their WC and spontaneously grabbed, hit, scratched, and kicked at Resident 49. Resident 49 sustained a scratch that bled and required first aide. Resident 49 did not know why Resident 19 attacked them. Root cause of incident was identified as Resident 19 was agitated and within close proximity of another resident. - 03/08/2025- Resident 19 was yelling and hitting at Resident 43 and Resident 21. The incident included a 03/08/2025 statement where Resident 21 was asked if they felt safe in the facility. Resident 21 replied Yes, but if [Resident 19] comes back I will be scared to death. - 04/04/2025- Resident 19 yelled at Resident 37 to remove their hat when sitting at the dining room table. After the meal, at the nurses' station, Resident 19 continued to yell at Resident 37 and allegedly ran over Resident 37's toes with their WC. - 04/11/2025- Resident 19 unprovoked began to punch Resident 45 with a closed fist, in the hallways, as Resident 45 rolled past Resident 19. - 04/25/2025- Resident 19 had a second physical altercation with Resident 31, in the dining room, with staff present but who did not observe the altercation. Resident 19 and Resident 31 grabbed and hit at each other. Resident 31 sustained a skin tear to their arm. - 05/10/2025- Resident 19 had a third verbal and physical altercation with Resident 31. Resident 31 yelled I am going to kill you! Residents 19 and 31 were observed grabbing and hitting each other. Resident 31 sustained a scratch to the back of their hand and Resident 19 sustained a scratch to the tip of their nose. Review of the 09/10/2024 self-care deficit care plan showed Resident 19 was able to self-propel their wheelchair (WC) independently. The 10/17/2024 care plan showed Resident 19 had potential to yell and strike out at other residents related to dementia and poor impulse control. Interventions included to assess and anticipate Resident 19's needs, give positive feedback, frequent safety checks when out of bed, reapproached with different staff when agitated, and maintain a consistent routine. On 11/01/2024 Resident 19 was placed on 15-minute safety checks around the clock, on 03/27/2025 a basket of favorite things was placed at the nurses' station for Resident 19 to rummage through, and on 04/28/2025 Resident 19 was to be in staff's direct line of sight when in the dining room for meals. Review of the 03/25/2025 Staff Z, Medical Doctor, progress note showed Resident 19 was started on Zyprexa (antipsychotic, medication that affect the mind, emotions and behaviors) for dementia with agitation. Resident 19's became less aggressive without sedation, more interactive, and pleasant while on Zyprexa and was a danger to others without it. Review of 04/15/2025 Staff Z, provider progress note showed Resident 19's wheeled themselves around the facility, would be calm for extended periods then violently attack other residents who irritated [them]. Resident 19 was off of Zyprexa as state insists on GDRs [Gradual Dose Reductions, when antipsychotic medication was gradually, slowly and carefully reduced to find the lowest effective therapeutic dose to prevent unnecessary medication use]. Additional record review showed Resident 19's Zyprexa was decreased and discontinued on 04/01/2025. Review of October 2024 through May 2025 nursing progress notes the following: - 10/16/2024 Resident 19 was witnessed hitting another resident during dinner. Resident 19 was involved in two different resident-to-resident altercations with two different peers. - 10/24/2024 Resident 19 yelled at peer as they walked down the hall. - 10/27/2024 Resident 19 was started on 15-minute safety checks while awake related to yelling, arguing, and hitting other residents without combativeness. - 10/28/2024 Resident 19 wandered the into others' rooms rummaging through their belongings. - 11/08/2024 Resident 19 yelled out and banged on the wall for two and a half hours, from 2 PM until 4:30 PM. - 11/28/2024 Resident 19 loudly and persistently yelled at their roommate. Resident 19's roommate did not answer, to avoid aggravating Resident 19 further. - 12/06/2024 Resident 19 yelled and argued with the resident in room [ROOM NUMBER] B related to use of the shared bathroom. - 12/16/2024 Resident 19 exhibited yelling and aggressive behaviors towards staff and other residents. Resident 19 was independent with WC mobility, impulsive, and destructive to property. - 12/18/2024 Resident 19 yelled out through the night shift. Resident 19's roommate along with other facility residents complained about the disruptive behavior and interrupted sleep. - 01/01/2025 Resident 19 was extremely agitated and upset while they self-propelled their WC down the hall yelling at other residents and staff, confronting the resident in room [ROOM NUMBER] A. - 01/11/2025 Resident 19 attacked Resident 3 as they walked down the hall. - 01/13/2025 Resident 19 aggressively grabbed at a male peer, causing them to cry. - 01/14/2025 Resident 19 tore their room apart by throwing water, knocking furniture over, throwing clothing and blankets around, while a roommate remained in the room. - 01/26/2025 Resident 19 was approached and confronted by Resident B. Resident B yelled at Resident 19 I am tired of you yelling all the time. Resident 19 hit Resident B in the face. - 02/10/2025 Resident 19 and 31 were involved in a physical altercation. Resident 31 open handedly slapped Resident 19 face. - 02/11/2025 Resident 19 was in a foul mood as they repeatedly propelled up and down the hall. The resident in room [ROOM NUMBER] A reported experiencing a run in with Resident 19. The resident in 35 A reported Resident 19 yelled at them and called them stupid. - 02/15/2025 Resident 19 was angry much of the time and got into fights with other residents. - 02/19/2025 Resident 19 was visibly upset and grabbed Resident 4's arm and would not let go. - 02/25/2025 Resident 19 was agitated, aggressive, yelled, and screamed out as they self-propelled down the hall, calling peers names such as whores. Numerous residents on the unit were upset by Resident 19's behaviors and began cursing at Resident 19. - 02/27/2025 Resident 19 was involved in a resident-to-resident altercation with Resident 49. - 02/28/2025 Resident 19 threw water on a peer and attempted to go after them. - 04/04/2025 Resident 19 displayed violent behaviors towards another resident after the evening meal. - 04/11/2025 Resident 19 quickly became upset, yelled, and hit Resident 45 with a closed fist. - 04/15/2025 Resident 19 will be calm for extended periods then will violently attack other residents who have irritated [them]. - 04/22/2025 Resident 19 screamed and yelled for about 4 hours. - 04/25/2025 Resident 19 was involved in a second resident-to-resident altercation with Resident 31. - 04/29/2025 Resident 19 was self-propelling their WC up and down hallways throughout the facility and continues with random acts of boisterous yelling/calling out which mimics the call of Tarzan, often times startling other resident's and staff. - 05/10/2025 Resident 19 was involved in a third resident-to-resident altercation with Resident 31. Eight additional facility incident report investigations for resident-to-resident altercations involving Resident 19, not identified on the facility accident and incident log, on the following dates 10/28/2024, 11/28/2024, 12/06/2024, 01/01/2025, 01/26/2025, 02/11/2025, 02/19/2025, and 02/25/2025 were requested on 05/19/2025 at 5:22 AM, from Staff A, Administrator. Only one of the eight requested incident investigation was provided, 01/26/20205. Review of the facility census as of 05/12/2025 showed Resident 19, 31, 49, 21, 43, 27, 37, 33, 45, 3, and 41 continued to resided at the facility. During observation on 05/12/2025 at 11:12 AM, Resident 19 was sitting in their WC, with a scab to the tip of their nose approximately the size of a pencil eraser, yelling out . Resident 19 self-propelled their WC down the hall. Similar observations were made at 11:16 AM, 11:27 AM, 2:05 PM, and 3:40 PM. In an interview on 05/13/2025 at 10:44 AM, Resident 49 stated Resident 19 used to grab and hit me. Resident 49 explained Resident 19 wandered the halls all day and night looking for trouble, their behavior flipped easily, and Resident 19 goes around beating up people here. During observation on 05/13/2025 at 11:41 AM, Resident 19 self-propelled down the hall and yelled out. Another resident yelled back for Resident 19 to be quiet! In an interview with the resident council on 05/14/2025 at 10:25 AM, stated Resident 19 wandered, was disruptive, and aggressive towards others. The council explained Resident 19 was spontaneous, unpredictable, with quickly fluctuating behaviors and could be smiling and friendly one minute then flying off the handle at residents and staff then next minute. The council voiced feeling unsafe due to Resident 19's continued behaviors. During observation on 05/15/2025 at 2:18 PM, Resident 19 was heard yelling out, resembling Tarzan, from the conference room. Resident 19 was observed at the opposite end of the hall, approximately 10 resident rooms, two offices, a dining room, and nurses station down the hall. In an interview on 05/16/2025 at 11:18 AM, Resident 4's representative stated Resident 19 targeted and threatened Resident 4. The representative explained they observed Resident 19 wander up and down the halls yelling. Review of Resident 4's medical record showed Resident 19 followed and chased Resident 4. Resident 4 alleged Resident 19 bruised their arm on 02/28/2025. In an interview on 05/19/2025 at 4:06 AM, Staff I, Registered Nurse, stated it was difficult to manage resident behaviors on night shift. Staff I explained Resident 19 yelled out at times and the behavior bothered other residents. Staff I acknowledged Resident 19's behaviors placed them at risk for harm or abuse. Staff I further stated Resident 19 had been involved in numerous resident-to-resident altercations even while on 15-minute safety check monitoring. In an interview on 05/19/2025 at 8:00 AM, Staff E, Social Service Coordinator, stated resident behaviors were tracked by nursing staff via nursing progress notes, social services and the provider would be notified of odd or abnormal behaviors so additional follow up could be done. Staff E further stated allegations of potential abuse were investigated by conducting resident and staff interviews to get a broader picture of the incident. Staff E was asked if instances of resident-to-resident altercations were considered abuse. Staff E explained if there was physical contact then yes that was definitely an allegation of abuse but instances of yelling back and forth were not considered potential abuse unless the yelling involved threats. Staff E stated Resident 19's mood and behaviors could quickly randomly fluctuate and escalate to the point of being too ramped up to calm down. Staff E explained Resident 19 enjoyed to self-propel their WC up and down the hall but that could create resident-to-resident altercations because Resident 19 would get upset when peers were in the way and lashed out physically. Staff E was asked if any residents voiced concerns over Resident 19's behaviors. Staff E stated Resident 4 would often be irritated with Resident 19. Resident 4 would look out into the hall, if they saw Resident 19, they would ask staff to escort them to the therapy gym to avoid interacting with Resident 19. Staff E acknowledged Resident 19's behaviors placed them and others at risk for abuse and Resident 19 was involved in the most resident-to-resident altercations. Staff E explained Resident 19 had been involved in resident-to-resident altercations even while on 15-minute safety check monitoring because Resident 19 was mobile, and it was difficult to anticipate what would trigger them. Staff E acknowledged staff should protect residents from abuse. In an interview on 05/19/2025 at 8:55 AM, with Staff B, Director of Nursing, and Staff C, Clinical Resource Nurse. Staff B reviewed Resident 19's medical record. Staff B acknowledged Resident 19 enjoyed self-propelling their WC throughout the facility, had quickly fluctuating verbally and physically aggressive behaviors towards others that placed them at risk for abuse. Resident 19 was involved in numerous verbal and physical resident-to-resident altercations even while on 15-minute safety checks. Staff B explained if a resident exhibited physical behaviors towards others it was reported, investigated, and addressed as potential abuse but verbally aggressive behaviors were documented and monitored per the facility behavior monitoring policy as behaviors experienced. Staff B acknowledged the facility had not been addressing verbally aggressive altercations as potential verbal abuse and should have. Staff B further stated the facility had not protected residents from abuse. In an interview on 05/23/2025 at 9:36 AM, Staff A, Administrator, stated they expected staff to identify, monitor, investigate, report, and protect residents from abuse, as required. Reference WAC 388-97-0640 (1) Refer to F725 for additional information.

Based on observation, interview, and record review, the facility failed to consistently provide effective monitoring and supervision, implement interventions, develop adequate and effective interventions to prevent repeated falls with adverse and injurious sequelae related to those falls for 3 of 7 sampled residents (Residents 19, 50, and 60), reviewed for falls. Resident 19 experienced harm when they had repeated falls as evidenced by a dislocated hip on 09/12/2024, a right femur (leg bone) fracture on 01/14/2025, and a back fracture on 03/03/2025. Resident 50 experienced harm when they fell a total of 36 times between 04/04/2024 to 05/17/2025 and sustained a range of injuries, to include hospital transfers for their treatment. Resident 60 experienced harm when they fell and sustained a fracture to their eye socket and left lower leg and had a delay in discharge to the community. These failures placed the residents at risk for further repeat serious injuries such as fractures, disability, or death and represented an immediate jeopardy (IJ). In addition, the facility failed to assess, evaluate, and implement interventions for potential risks associated with substance use disorders (SUD) for 1 of 3 sampled residents (Resident 49), reviewed for SUD. On 05/20/2025 at 5:40 PM, the facility was notified of the identified IJ related to F689 CFR S483.25 Accidents and Supervision. Onsite verification by surveyors on 05/23/2025 at 10:25 AM showed, the facility removed the immediacy by placing both Resident 19 and 50 on one to one (1:1) supervision. The survey team verified the facility educated all staff to the policies and procedures for accident prevention and fall interventions, including notification to management of ineffective fall interventions. The facility reviewed accidents that occurred the past 30 days to ensure care planned interventions were resident specific. The facility reviewed Resident 19 and 50's care plans and ensured interventions were pertinent to the root-cause of the falls. Resident 60 discharged from the facility on 05/19/2025. Findings included . Review of the facility policy titled, Fall Response and Management revised May 2021 showed, nursing staff would assess a resident who had fallen for injuries, obtain vital signs, document the fall in the resident's medical record, notify the family and provider, and immediately implement interventions to prevent a repeat fall. For a fall with injury staff was to evaluate the resident's injury, assess for pain, provide first aide as needed for minor injuries, determine whether head trauma was experienced, monitor neurologic assessments (neuro and/or neuro checks, a series of tests that assess mental status, reflexes, movement, and pupil reaction to evaluate brain and nervous system function), notify the family and provider. The policy further showed staff were to determine causal factors of a fall, revise the residents care plan with interventions, and communicate the fall and intervention changes to staff. Review of the Neurological Evaluation Flow Sheet used by the facility to assess for any neurological changes instructed staff to complete a neuro evaluation with vital signs every 15 minutes for one hour then every hour for four hours then every four hours for 20 hours. The form included a graph to document the required information on. <Resident 19> According to the 04/10/2025 quarterly assessment, Resident 19 admitted to the facility on [DATE] with diagnoses including weakness, dementia, and hip fracture. The assessment further showed Resident 19 had severe cognitive impairment and required substantial staff assistance for transfers. Resident 19 sustained two or more non-injury falls since their admission. Review of the 09/10/2024 hospital discharge summary showed Resident 19 sustained a fall that resulted in a right hip fracture. Resident 19's right hip was surgically repaired, and they discharged to the facility. Review of the facility September 2024 through May 2025 incident report tracking log showed Resident 19 sustained 15 falls on the following dates: 09/12/2024, 10/10/2024, 10/16/2024, 10/25/2024, 10/30/2024, 11/20/2024, 12/10/2024, 12/19/2024, 12/23/2024, 01/14/2025, two falls 03/07/2025, 03/22/2025, 05/02/2025, and on 05/12/2025. Review of October 2024 through May 2025 nursing progress notes showed Resident 19 additionally sustained falls on 12/06/2024 and on 03/03/2025 in the dining room that resulted in a hospital transfer, not identified on the facility accident and incident log. The 12/06/2024 and 03/03/2025 facility fall incident reports were requested from Staff A, Administrator, on 05/19/2025 at 5:22 AM. No documentation was provided. Review of the facility fall incident reports showed the following: - 09/12/2024 Resident 19 fell near their bed when self-transferring to the bathroom and was transported to the hospital for evaluation related to right hip pain. Resident 19's recently surgically repaired hip was displaced and required sedation to reinsert the hip. - 10/10/2024 Resident 19 fell while self-toileting and reached down to pull up their pants. Omission in neuro check documentation. - 10/16/2024 Resident fell at the nurses' station reaching for an item out of reach. Resident 19 sustained a skin tear to their right hand. - 10/25/2024 Resident 19 fell when attempting to make their bed and their wheelchair (WC) rolled away. Anti-roll back WC brakes were to be implemented. - 10/30/2024 Resident 19 fell when they stood up in the dining room and their WC rolled away. Again, anti-roll back WC brakes were to be implemented. - 11/20/2024 Resident 19 fell when they attempted to self-transfer into bed. Staff was educated on putting Resident 19 to bed upon request. No documentation of staff education was provided. Omission in neuro check documentation. - 12/10/2024 Resident 19 slid off the toilet and hit their head on the wall. Resident 19 was educated on use of the call light. Staff was educated on toileting Resident 19 before and after meals. No documentation of staff education was provided. Omission in neuro check documentation. - 12/19/2024 Resident 19 fell next to their closet and sustained a left-hand skin tear. Therapy was to possibly increase ambulation in a restorative nursing program. Omission in neuro check documentation. - 12/23/2024 Resident 19 ambulated out of the bathroom using their roommate's walker. Staff educated to keep the roommate's walker out of Resident 19's sight. No documentation of staff education was provided. - 01/14/2025 Resident 19 again fell reaching for an item out of reach while at the nurses' station. Root cause identified as Resident 19 did not request or accept assistance from staff. Resident 19 sustained a right femur peri-prosthetic (around the artificially replaced hip) fracture that required surgical repair. - 03/07/2025 at 4 AM Resident 19 fell out of bed on the opposite side of the fall mat. All interventions in place continue current care plan, and frequent rounding. - 03/07/2025 at 5:45 PM Resident 19 again fell out of bed. A fall mat was added to both sides of the bed. Omission in neuro check documentation. - 03/22/2025 Resident 19 was found on the floor in their room again on the opposite side of fall mat. Fall mats were again added to both sides of the bed. Omission in neuro check documentation. - 05/02/2025 Resident 19 was on the floor. Root cause was determined to be recent illness involving nausea, vomiting, and diarrhea. Staff were to monitor and treat symptoms as able and provide frequent toileting. - 05/12/2025 Resident 19 was on the floor next to their bed. A perimeter mattress was added. Omission in neuro check documentation. Review of the 01/23/2025 falls care plan showed Resident 19 was at risk for falls related to confusion, history of falls, and poor safety awareness. Interventions instructed staff to keep the door to the room open, reinforce safety awareness, maintain the floor free of clutter, and monitor for injuries when falls were sustained. A 11/21/2024 intervention showed Resident 19 was to have a fall mat on the exit side of the bed, 12/23/2024 a call for assistance sign was placed in the room, 12/31/2024 encourage Resident 19 to use the bathroom before and after meals, 03/03/2025 Resident has the right to fall, and 05/13/2025 perimeter mattress was added to define the edges of the bed. Additional record review showed care plan interventions were not reviewed and/or revised each time Resident 19 sustained a fall. Review of the 09/12/2024 hospital after visit summary showed Resident 19 right hip was dislocated and was given sedation to reinsert the hip back into the socket. Review of the 01/21/2025 hospital discharge summary showed Resident 19 sustained a per-prosthetic right femur fracture which required surgical intervention for repair. Review of the 03/03/2025 Computed Tomography (CT, medical imaging that create detailed images of the inside of the body) imaging showed Resident 19 fell out of their WC which resulted in back and hip pain. The imaging results showed a significant back fracture likely acute [new onset] given the history of fall and tenderness. In an interview on 05/20/2025 at 9:50 AM, Staff K, Nursing Assistant, stated when a fall occurred, they notified the nurse so they could assess the resident for potential injuries and implement neuro checks when falls occurred, documenting them on the paper form. Staff K further stated new fall interventions needed to be implemented immediately to prevent recurrent falls and potential injuries. Staff K acknowledged Resident 19 sustained a few falls even while on 15-minute safety checks. In an interview on 05/20/2025 at 10:04 AM, Staff L, Registered Nurse, stated residents were assessed for fall risk upon admission, after falls, with changes of condition, and quarterly. A fall was a change in plane. Staff L explained when a fall occurred residents would be assessed for injuries, completed a fall report, notify the family, nurse management and provider. Neuro checks were to be initiated when a head injury was witnessed or if a fall was unwitnessed, documenting them on the paper form in the fall packet. Staff L acknowledged a new fall intervention needed to be implemented immediately because residents could fall again in the window of time it took to implement the intervention. Staff L acknowledged Resident 19 sustained repeat falls some with some requiring hospital transfer and fractures sustained even while they were on 15-minute safety check monitoring. In an interview on 05/20/2025 at 1:00 PM, Staff B, Director of Nursing, explained the facility fall process. Staff B stated a fall was a change in plane, a new fall intervention needed to be implemented immediately after a fall occurred to prevent recurrence, and neuro checks completed for unwitnessed fall or falls with head injury, documenting them on the paper form. Staff B reviewed Resident 19's medical record. Staff B acknowledged Resident 19 sustained a fall on 09/12/2024 that resulted in dislocation of the recently surgically repaired hip, a fall on 01/14/2025 that resulted in a right femur fracture, and on 03/03/2025 that resulted in a broken back. Staff B stated they expected staff to follow all the appropriate steps when a fall occurred. 40297 <Resident 50> Review of a 04/07/2025 quarterly assessment showed Resident 50 admitted to the facility on [DATE] with medically complex conditions, to include dementia, repeated falls, and impaired vision. This assessment showed the resident had moderately impaired cognition, required supervision or touching assistance from the staff for ADLs (Activities of Daily Living) and experienced falls since their admission to the facility or their prior assessment. The assessment showed Resident 50 was always continent of bowel and bladder and was not on a toileting program. In an observation on 05/15/25 at 8:36 AM, Resident 50 was seated in their wheelchair, eating their breakfast in front of a small table against the wall. The call light was approximately five feet away from the resident, clipped to its own cord attached to the wall above the bed. Signage on the opposite wall showed instructions that said, Play it safe. Use your call light for help. An interview and observation on 05/12/2025 at 10:55 AM showed Resident 50 in bed and stated, I fall quite frequently. I have progressive palsy (loss or reduction of movement in a part of the body, often accompanied by shaking or trembling) and they've gone over things that I do that cause the falls like how I turn and so forth. The resident said they had fallen five times since admission to the facility. Review of Resident 50's 11/04/2024 care plan showed the staff identified the resident fell because of dementia, an unsteady walk, leaning forward in their wheelchair to pick items up from the floor and transferring from bed or wheelchair unassisted. The care plan showed the 04/05/2024 goal of the resident will be free of fall related injuries. The care plan informed the staff Resident 50 required assistance for transfers. The care plan showed that on the day of admission, 04/05/2024, the staff added the following interventions, Provide direct supervision while resident is toileting, Reinforce safety awareness: use call light, lock brakes on chair before transferring. When rising from a lying position, sit/rest at edge of the bed at least 10 seconds before transferring, Respond to resident requests timely. Anticipate needs. Keep call light and bedside table items within reach. On 12/01/2024, the staff added, Pharmacist to review medications quarterly and prn when falls occur to address fall risk side effects. Develop plan with risks and benefits as indicated. On 01/06/2025, the staff added, will get ice cream if [the resident] does not have a fall in 30 days. On 02/05/2025, the staff added, Resident agreed to wear pull ups at night for urine urgency. On 04/21/2025, the staff added, make sure to help remind [resident] to position the wheelchair at a 45-degree angle facing the bed, so that [the resident] can still reach the arm rests and make small steps, and travel a shorter distance, to decrease risk of falls. On 05/08/2025, the staff added, Educate resident to call out for help and to wait for assistance as it is [their] preference not to use the call light. Review of a toileting care plan initiated on 04/05/2024 showed Resident 50 was continent of urine and required assistance to the bathroom. The care plan informed the staff on 04/05/2024 the resident, manages toileting and incontinent episodes and assist with maintaining supplies as needed and to toilet the resident with morning and afternoon cares, before meals, at bedtime and as needed. On 01/14/2024, the care plan instructed the staff to place a stack of washcloths on bedside table for resident use. On 01/28/2025, the care plan instructed the staff to help the resident use the urinal by lowering their pants to their knees, tuck folded washcloth under penis (Keep stack on bedside table), and Wait a minute before removing cloth until dribbling stops. A 04/05/2024 ADLs care plan showed on 05/13/2024, it instructed the staff to complete Frequent rounding with the 4P's to help anticipate resident needs. Help keep room free from clutter. The 4P's stand for: Pain, Position, Placement, and Personal Needs. This approach may be used by anyone who entered a resident room for any reason to help prevent falls and developed a culture that checked in with the resident and addressed their needs at different times of the day. Review of progress notes from 04/05/2024 to 05/17/2025 showed staff identified Resident 50 fell frequently, was impulsive, forgetful to use their call light, and self-transferred in and out of bed or wheelchair. Documentation showed the staff continued to ask the resident to use the call light or call for help even though it was identified Resident 50 was impulsive and does not call for help/assistance with transfers or mobility and transfers without use of call light. Sometimes will yell help when is about to fall or needs help. Requires frequent reminders. Review of the progress notes showed Resident 50 fell 36 times (4/30/2024, 05/03/2024, 05/06/2024, 05/09/2024, 05/11/2024, 05/17/2024, 05/22/2024, 06/04/2024, 06/14/2024, 07/18/2024, 08/01/2024, 08/26/2024, 09/20/2024, 10/27/2024, 11/04/2024, 11/11/2024, 12/16/2024, 01/12/2025, 01/19/2025, 01/25/2025, 02/02/2025, 02/14/2025, 02/16/2025, 03/04/2025, 03/07/2025, 03/25/2025, 03/26/2025, 03/26/2025, 04/03/2025, 04/19/2025, 04/24/2025, twice on 05/03/2025, 05/05/2025, 05/14/2025, and 05/17/2025) from 04/05/2024 to 05/17/2025. Review of the electronic medical record from 04/05/2024 to 05/17/2025 showed Resident 50 experienced injuries of varying severity related to 36 falls that included abrasions (05/09/2025, 05/11/2024, 06/14/2024, 07/18/2024, 08/01/2024, 11/11/2024), contusions (an injury to soft tissue that causes bleeding beneath the skin, usually without breaking the skin itself, 08/01/2024, 08/26/2024, 11/11/2024, 03/27/2025), lacerations (08/01/2024, 08/26/2024, 02/02/2025) closed head injuries (08/01/2024, 03/27/2025), swelling to right side of forehead (10/27/2024), skin tears (03/04/2027, 03/07/2025, 04/20/2025), and multiple transfers to the Emergency Department (08/01/2024, 02/02/2025, 05/07/2025). Review of progress notes and investigative review documents associated with the falls showed no documentation the facility evaluated why previous interventions were ineffective and revised or developed interventions accordingly or developed effective interventions to compensate for Resident 50's forgetfulness and impulsiveness, like increased supervision or monitoring of the resident to intercept self-transfers to complete their ADLs. Facility reviews of the falls showed the staff continued to ask of Resident 50 to request assistance by using the call light and ultimately to call out for help, both repeatedly failed interventions. The facility investigations of the falls failed to show the facility considered what actually prompted the resident to self-transfer and effectively address the root-cause of the falls which precluded the staff from anticipating the resident's needs differently. The investigative reviews repeated interventions already established on Resident 50's day of admission and shortly thereafter to address the continued falls and did not determine how the interventions failed to prevent falls and their associated injuries. The investigations and their conclusions did not define for the staff what frequent checks or rounding of the resident entailed or show how staff supervision of the resident changed. Record review showed 10 of the 36 falls were related to Resident 50's toileting needs. The care plan showed no revision of the toileting program to effectively anticipate this ADL which required staff assistance. No documentation was located to show the facility requested a review by the pharmacist as instructed in the care plan. Investigative reviews associated with the 09/20/2024, 10/27/2024, 11/04/2024, 11/11/2024 falls showed the facility concluded the resident desires to fall and maintain their independence even if that means [they are] going to fall. Resident 50 fell another 20 times after 11/11/2024. In an interview on 05/20/2025 at 9:58 AM, Staff R, Nursing Assistant - Registered, stated they were formally re-assigned to Resident 50 for the first time on 05/20/2025 after their shift had already started but had assisted another aide with the resident on a previous occasion during training. Staff R stated they obtained information on resident care by getting report from the nurse and shift to shift report from another aide. When asked if Resident 50 had any falls, Staff R stated, Not that I'm aware of. Staff R stated they thought Resident 50 transferred in or out of bed or wheelchair because they needed to, use the rest room and they transferred, Either before or after lunch. Staff R stated that a resident who was cognitively impaired, impulsive, and showed they were not receptive to reminders or signage would require supervision of, every 15 minutes checks. In an interview on 05/20/2025 at 8:10 AM, Staff M, Licensed Practical Nurse (LPN), stated Resident 50 experienced several falls, doesn't call for help, will self-transfer, eyesight is very poor. Staff M stated the resident, can't seem to get his feet situated, sometimes [they] will step on one foot with the other and loses balance and flops back, does not sit down, rarely calls for help. Staff M indicated the resident's poor balance, impaired vision, poor body mechanics, and no safety awareness placed them at risk for falls. Staff M stated Resident 50 had no pattern when they self-transferred out of bed or wheelchair but that the staff, try to get in there before breakfast, before meals, because [the resident] likes to sit up for [their] meals. Staff M said that even though they parked their medication cart by Resident 50's room so they could hear the resident when they moved around, and staff made frequent checks and placed the wheelchair by the bed to prevent the resident from falling, it did not help decrease or prevent Resident 50's falls. Staff M stated they felt there was not enough staff to monitor the resident to make sure they did not fall when trying to transfer out of bed or the wheelchair. Staff M stated they did not think an increase in supervision was attempted by the facility to prevent Resident 50 from falling and that even with frequent checks Resident 50 fell . Staff M stated, It's hard to be there when you don't have enough staff. In an interview on 05/20/2025 at 8:40 AM, Staff S, Occupational Therapist, stated they wanted to be notified immediately if fall interventions were not effective, If that's what we are working on. Staff S stated they were unaware Resident 50 fell 36 times but knew the resident fell , a lot of times because they did not listen, was forgetful and impulsive. Staff S stated that impulsivity and decreased safety awareness were the main reasons for Resident 50's fall occurrences. When asked if increased supervision was attempted to help decrease falls or prevent Resident 50 from falling, Staff S stated, I know the aides were checking on [the resident] regularly. We haven't done that before. Staff S stated that staff could try 10-minute interval checks on the resident and concluded the signage on the wall was ineffective in preventing Resident 50 from falling. In an interview on 05/20/2025 at 8:20 AM, Staff T, Therapy Director, stated that they wanted to be notified when a resident fell at the time of occurrence or anytime there is a problem. Staff T stated they identified when interventions were suitable for a resident at risk for falls, Through the assessment process. Sometimes it's trial and error. Staff T explained that because of Resident 50's progressing palsy, they were going to lose the ability to sequence events, experience vision loss, and become increasingly dizzy. Staff T said Resident 50 did not want to wait for help to go to the bathroom because they were afraid of experiencing incontinence. When asked at what point was a recommendation made to increase and define the type of supervision required to help prevent falls and associated injuries, Staff T stated, We have discussed that and talked about if a different room would help but right now [the resident] is close to the door and we all pass by. Staff T stated to prevent falls for a resident who was cognitively impaired, impulsive, and not receptive to reminders or signage, the resident required, more frequent checks, asking every two hours if they need to go to the bathroom. Staff T stated, With somebody like [Resident 50], I would almost like to go back to the sensor pad pressure alarm because it will sound off when the resident is moving, and staff can be there to help [the resident]. To have a 1:1 on [Resident 50] would be super costly. Staff T stated, I don't think there's a trend to Resident 50's falls. The above findings were shared in a joint interview on 05/20/2025 at 10:21 AM with Staff B Director of Nursing, and Staff C, Clinical Resource Nurse. Both staff acknowledged the ineffective fall prevention interventions in Resident 50's care plan. Staff C acknowledged the consistently inadequate reviews of the falls that failed to determine what truly prompted Resident 50 to self-transfer, along with staff misperception of the resident's ability to recall or process information. When asked if the facility effectively supervised Resident 50 to prevent falls and their associated injuries, Staff B answered, No. When asked if the facility attempted to increase supervision of the resident Staff C answered, No and that doing so could have possibly prevented Resident 50 from falling. On 05/22/25 at 12:23 PM, Staff M (the nurse assigned to Resident 50) was observed walking past the resident's room with another staff. Resident 50 was observed by the surveyor standing up from the wheelchair next to their bed and transfer to the bed holding on to the grab bar to the left side, placing themselves on the bed, with the call light underneath them. Resident 50 admitted they self-transferred and said, No, I don't want to fall, then pulled the bed linens over themselves. Observation directly outside of Resident 50's room showed a clipboard on the handrail with a form titled Resident Monitoring Tool. The form showed Resident 50 was on 15-minute checks but no documentation the staff checked on the resident on or around 11:30 AM, 11:45 AM, 12:00 PM, or 12:15 PM. Review of progress notes between 05/21/2025 and 05/22/2025 showed that despite the 15 minute checks, the staff continued to identify Resident 50 self-transferred to the bathroom both with assist and unattended, does not call for help nor has called out loud for help, found several times already up in [their] wheel chair, Nurse is alerted outside of room doorway, when the bathroom door bangs into the room door that this resident is on the move . able to sit up and get out of bed & into wheel chair very quietly without being heard . TV volume up relatively high that also hinders the sounds of [their] movement. Another 05/21/2025 note showed, Continues to self-transfer quietly without staff noticing despite being moved closer to nurses station. Attempt to redirect and instruct on use of call light without effect. Cart nurse unable to stand at doorway or next to doorway for long periods of time to monitor resident as other residents need meds [medications]/cares as well. Another 05/21/2025 note showed, Resident was up again at this time, while this nurse was documenting previous note, noises/crashes were heard from [their] room and resident again was found seated in [their] wheelchair not 7 minutes from prior use of bathroom and was assisted to bed at that time . Another 05/21/2025 note showed, Resident is impulsive and transfers without use of call light. Sometimes will yell help when [they are] about to fall or needs help. Requires frequent reminders and observation. Resident has limited safety awareness and poor vision. Stiff/rigid body mechanics makes transfers difficult as well as bending at the hips/low back to sit . often times flops backwards into wheelchair. In an interview on 05/22/2025 at 12:35 PM, Staff M stated Resident 50 self-transferred, Last night, even with the 15-minute checks. Staff M stated they felt the 15-minute checks were ineffective as the resident did not call for help, I could be standing right here and will not always hear [them]. Staff M stated they did not tell anybody about the failed 15-minute checks, that they should have reported the failed intervention, Right away. I'll do it right now. The above findings were shared with Staff A (Administrator), Staff B, Staff C, and Staff Q (Director of Clinical Services) on 05/22/2025 at 1:12 PM. Staff C said they ensured interventions were effective by making observations of the staff and resident and reviewing the progress notes. Staff B stated they expected the staff to alert them of failed fall prevention interventions, As soon as they know it's not working. <Resident 60> Review of a 05/01/2025 admission assessment showed Resident 60 admitted to the facility on [DATE] with a diagnosis of a stroke, orthostatic hypotension (when the blood pressure drops when you sit or stand up), and diabetes. This assessment showed the resident had intact cognition, was dependent on the staff for toileting hygiene, required partial to substantial assistance for transfers, and used a wheelchair for mobility. The staff assessed Resident 60 was frequently incontinent of urine and always continent of bowel and had no toileting program. The assessment showed Resident 60 had no falls prior to admission but fell since admission to the facility. Review of a 04/25/2025 progress note showed the staff identified Resident 60 required extensive assistance with transfers and ADLs, Left sided weakness secondary to CVA [cerebrovascular accident, a stroke]. A 04/26/2025 note showed the resident, Has left sided weakness. Requires 2 person assist for transfers, bed mobility and toileting. Review of Resident 60's care plan showed 04/25/2025 instructions to the staff to provide assistance of 1 or more person for toilet transfers going to the right side with the use of the grab bar, that Resident 60 required constant verbal cues for sequencing and left sided neglect. The interventions also asked the staff to, Stay with patient when on toilet to decrease risk of falls, and Respond to resident requests timely. Anticipate needs. Keep call light and bedside table items within reach. Review of a 04/27/2025 progress note showed when the nurses walked down the hallway to administer medication to another resident, they heard Resident 60 yelling for help. The resident was found lying on their left side with their upper body under the edge of the bed. No injuries were sustained from this fall. The progress notes showed, Interventions placed were to encourage resident to use call light for assistance, frequent bathroom checks and bed to remain in lowest position. Review of 04/28/2025 care plan intervention showed the resident was totally dependent on staff when transferred by two or more staff in a mechanical lift and used the bed pan for toileting. Review of 04/29/2025 care plan intervention showed the staff placed a Call don't fall sign in Resident 60's room and the staff was asked to Monitor resident position in bed or wheelchair for safety upon entry and exit from room and with rounding. Anticipate resident needs. Review of a 05/03/2025 progress note showed a staff member assisted Resident 60 to the toilet per resident request and that the resident asked the aide to step out for privacy. The aide stepped out and was standing outside the door when the resident reached for wipes on their wheelchair and because of left sided weakness fell on [their] left side hitting [their] left orbital [eye socket] area. The note showed the nurse applied an ice pack to Resident 60's face, educated staff not to leave the resident unattended, and called the provider who gave orders to transfer Resident 60 to the hospital. Review of a 05/03/2025 Incident Note showed the fall resulted in a left orbital fracture (a break in one or more of the bones surrounding the eye socket). Nursing interventions included, Educated staff not to leave [resident] unattended, an intervention which was in place on 04/25/2025 (Stay with patient when on toilet to decrease risk of falls), two days prior to the fall. Review of investigative documents associated with the fall of 05/03/2025 showed Resident 60 was sent to the hospital secondary to being on an anticoagulant (a blood thinner) and acknowledged the fall resulted in a fracture of the left orbital area. The investigation concluded Resident 60 did not use the call light to request assistance and attempted to use their affected side to reach for an item within the reach of their unaffected side, which caused the resid[TRUNCATED]

Based on observation, interview and record review, the facility failed to consistently ensure the facility had enough staff to provide adequate supervision and safe care according to the facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 3 of 7 sampled residents (Resident 19, 50, and 60), reviewed for falls. Resident 19 experienced harm from repeated falls as evidenced by a dislocated hip on 09/12/2024, a right femur (leg bone) fracture on 01/14/2025, and a back fracture on 03/03/2025. Resident 60 experienced harm when they fell three times and sustained a fracture to their eye socket and left lower leg. Resident 50 experienced harm when they fell a total of 36 times from 04/04/2024 to 05/17/2025 and experienced a range of injuries, to include hospital transfers for their treatment. Additionally, the facility failed to identify, report, protect, assess and d provide staff supervision to prevent a pattern of resident-to-resident verbal and physical abuse by Residents 19 towards 10 different peers (Resident 31, 49, 21, 43, 27, 37, 33, 45, 3, and 41). These failures placed residents at risk for further repeat serious injuries such as fractures, repeat abuse, potentially avoidable accidents and diminished quality of life. Findings included . Review of the facility assessment reviewed May 2025 showed, the facility provided care to residents who required assistance with activities of daily living such as toileting, transfers, ambulation and fall prevention. The assessment further showed facility staffing included nurse managers, licensed nurses, nursing assistants, and ancillary department staffing. Staffing levels were determined by acuity and regulatory requirements that met the minimum staffing requirements. Staffing was reviewed daily to ensure appropriate staffing ratios to meet requirements and acuity level of current resident population which consisted of residents that may require additional staff to help mitigate falls and manage behaviors. The facility utilized staffing agencies to meet the facility staffing goals and additional staffing efforts were coordinated under the facility Quality Assurance and Performance Program (QAPI) via a Performance Improvement Plan (PIP). <Resident 19> According to the 04/10/2025 quarterly assessment, Resident 19 had severe cognitive impairment with inattention and disorganized thinking. The assessment further showed Resident 19 exhibited worsening verbal and physical behaviors directed towards others that significantly interfered with Resident 19's care, participation in activities or social events, placed others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or the living environment. Resident 19 sustained two or more non-injury falls since their admission. RESIDENT-TO-RESIDENT ALTERCATIONS Review of the facility October 2024 through May 2025 incident report tracking log showed Resident 19 was involved in 11 resident-to-resident altercations with 10 different peers (Resident 31, 49, 21, 43, 27, 37, 33, 45, 3, and 41) on the following dates: 10/16/2024, 11/07/2024, 01/11/2025, 01/13/2025, 02/10/2025, 02/27/2025, 03/08/2025, 04/04/2025, 04/11/2025, 04/25/2025, and 05/10/2025. Review of the 09/10/2024 self-care deficit care plan showed Resident 19 was able to self-propel their wheelchair (WC) independently. The 10/17/2024 care plan showed Resident 19 had potential to yell and strike out at other residents related to dementia and poor impulse control. Interventions included to assess and anticipate Resident 19's needs, give positive feedback, frequent safety checks when out of bed, reapproached with different staff when agitated, and maintain a consistent routine. On 11/01/2024 Resident 19 was placed on 15-minute safety checks around the clock. Additional review showed Resident 19 was involved in repeat resident-to-resident altercations while on 15-minute safety check monitoring. Review of the facility resident-to-resident incident reports showed the following: - 10/16/2024- Resident 19 allegedly struck Resident 27 on the hand with a spoon while in the dining room - 11/07/2024- Resident 33 threw coffee on Resident 19 in the dining room - 01/11/2025- Resident 19 randomly grabbed, kicked, and shook Resident 3's walker as they walked down the hall - 01/13/2025- Resident 19 yelled, grabbed at, and stopped Resident 41 from entering the dining room. - 02/10/2025- Resident 19 grabbed at Resident 31. Resident 19 called Resident 31 a fucking asshole! and grabbed Resident 31's neck collar. Resident 31 open handedly slapped Resident 19 in the face. - 02/27/2025- Resident 19 was self-propelling their WC and spontaneously grabbed, hit, scratched, and kicked at Resident 49. Resident 49 sustained a scratch that bled and required first aide. Resident 49 did not know why Resident 19 attacked them. Root cause of incident was identified as Resident 19 was agitated and within close proximity of another resident. - 03/08/2025- Resident 19 was yelling and hitting at Resident 43 and Resident 21. - 04/04/2025- Resident 19 yelled at Resident 37 to remove their hat when sitting at the dining room table. After the meal, at the nurses' station, Resident 19 continued to yell at Resident 37 and allegedly ran over Resident 37's toes with their WC. - 04/11/2025- Resident 19 unprovoked began to punch Resident 45 with a closed fist, in the hallway, as Resident 45 rolled past Resident 19. - 04/25/2025- Resident 19 had a second physical altercation with Resident 31, in the dining room, with staff present but who did not observe the altercation. Resident 19 and Resident 31 grabbed and hit at each other. Resident 31 sustained a skin tear to their arm. - 05/10/2025- Resident 19 had a third verbal and physical altercation with Resident 31. Resident 31 yelled I am going to kill you! Residents 19 and 31 were observed grabbing and hitting each other. Resident 31 sustained a scratch to the back of their hand and Resident 19 sustained a scratch to the tip of their nose. FALLS Review of the 09/10/2025 hospital discharge summary showed Resident 19 sustained a fall that resulted in a right hip fracture. Resident 19's right hip was surgically repaired, and they discharged to the facility. Review of the facility September 2024 through May 2025 incident report tracking log showed Resident 19 sustained 15 falls on the following dates: 09/12/2024, 10/10/2024, 10/16/2024, 10/25/2024, 10/30/2024, 11/20/2024, 12/10/2024, 12/19/2024, 12/23/2024, 01/14/2025, two falls 03/07/2025, 03/22/2025, 05/02/2025, and on 05/12/2025. Review of the facility fall incident reports showed the following: - 09/12/2024 Resident 19 fell near their bed when self-transferring to the bathroom and was transported to the hospital for evaluation related to right hip pain. Resident 19's recently surgically repaired hip was displaced and required sedation to reinsert the hip. - 10/10/2024 Resident 19 fell while self-toileting and reached down to pull up their pants. - 10/16/2024 Resident 19 fell at the nurses' station reaching for an item out of reach. Resident 19 sustained a skin tear to their right hand. - 10/25/2024 Resident 19 fell when attempting to make their bed and their wheelchair (WC) rolled away. - 10/30/2024 Resident 19 fell when they stood up in the dining room and their WC rolled away. - 11/20/2024 Resident 19 fell when they attempted to self-transfer into bed. - 12/10/2024 Resident 19 slid off the toilet and hit their head on the wall. - 12/19/2024 Resident 19 fell next to their closet and sustained a left-hand skin tear. - 12/23/2024 Resident 19 ambulated out of the bathroom using their roommate's walker - 01/14/2025 Resident 19 again fell reaching for an item out of reach while at the nurses' station. Resident 19 sustained a right femur peri-prosthetic (around the artificially replaced hip) fracture that required surgical repair. - 03/07/2025 at 4 AM Resident 19 fell out of bed on the opposite side of the fall mat. All interventions in place continue current care plan, and frequent rounding. - 03/07/2025 at 5:45 PM Resident 19 again fell out of bed. - 03/22/2025 Resident 19 was found on the floor in their room again on the opposite side of fall mat. - 05/02/2025 Resident 19 was on the floor in their room. - 05/12/2025 Resident 19 was on the floor next to their bed. Review of the 01/23/2025 falls care plan showed Resident 19 was at risk for falls related to confusion, history of falls, and poor safety awareness. Interventions instructed staff to keep the door to the room open, reinforce safety awareness, maintain the floor free of clutter, and monitor for injuries when falls were sustained. A 11/21/2024 intervention showed Resident 19 was to have a fall mat on the exit side of the bed, 12/23/2024 a call for assistance sign was placed in the room, 12/31/2024 encourage Resident 19 to use the bathroom before and after meals, 03/03/2025 Resident has the right to fall, and 05/13/2025 perimeter mattress was added to define the edges of the bed. Additional record review showed care plan interventions were not reviewed and/or revised each time Resident 19 sustained a fall. Review of the 09/12/2024 hospital after visit summary showed Resident 19 right hip was dislocated and was given sedation to reinsert the hip back into the socket. Review of the 01/21/2025 hospital discharge summary showed Resident 19 sustained a per-prosthetic right femur fracture which required surgical intervention for repair. Review of the 03/03/2025 Computed Tomography (CT, medical imaging that create detailed images of the inside of the body) imaging showed Resident 19 fell out of their WC which resulted in back and hip pain. The imaging results showed a significant back fracture likely acute [new onset] given the history of fall and tenderness. <Resident 60> According to the 05/01/2025 admission assessment, Resident 60 admitted to the facility on [DATE] with a diagnosis of a stroke, orthostatic hypotension (when the blood pressure drops when you sit or stand up), and diabetes. This assessment further showed Resident 60 had intact cognition, was dependent on the staff for toileting hygiene, required partial to substantial assistance for transfers, and used a wheelchair for mobility. The assessment showed Resident 60 had no falls prior to admission but fell since admission to the facility. Review of Resident 60's 04/25/2025 care plan showed staff were to respond to requests timely, keep frequently used items within reach, provide assistance of one or more staff for toilet transfers related to Resident 60 required constant verbal cues for sequencing, and for staff to stay with Resident 60 when on toilet to decrease risk of falls. Review of May 2025 nursing progress note showed a staff member assisted Resident 60 to the toilet on 05/03/2025 per resident request and that the resident asked the nursing assistant (NA) to step out for privacy. The aide stepped out and was standing outside the door when the resident reached for wipes on their wheelchair and because of left sided weakness fell on [their] left side hitting [their] left orbital [eye socket] area. The note showed the nurse applied an ice pack to Resident 60's face, educated staff not to leave the resident unattended, and called the provider who gave orders to transfer Resident 60 to the hospital. On 05/14/2025 staff reported they had run over Resident 60's leg when transporting resident down the hallway. The incident was described as the resident's left foot came off the wheelchair footrest (for the user's foot to rest on), the aide did not notice and rolled the wheelchair over Resident 60's left foot. The nurse then completed an assessment and found Resident 60's left leg with visible swelling, complaints of pain to the knee, calf and thigh, and a bruised area to a swollen ankle. On 05/15/2025 Resident 60 was assessed to be in uncontrollable pain, swelling to left ankle, and a bruise with a superficial scratch to the back of resident's left calf. Resident 60 stated repeatedly, I want to go to the hospital. The staff transferred Resident 60 to the local emergency department. Review of the facility fall incident reports showed the following: -05/03/2025 Resident 60 fell while on the toilet which resulted in a left orbital fracture (a break in one or more of the bones surrounding the eye socket). Nursing interventions included, Educated staff not to leave [resident] unattended, an intervention which was in place on 04/25/2025 (Stay with patient when on toilet to decrease risk of falls), two days prior to the fall. -05/21/2025 Resident 60's left foot fell off the foot pedal during transport unbeknownst to the aide. The aide and resident were going through the resident room's doorway, the residents foot became lodged between the door and the wheelchair, the aide did not know the foot was caught, pushed three times due to the resistance, and ran over the left foot. The investigation concluded it was an accident that resulted in a new distal end of left fibula [calf bone] fracture. <Resident 50> According to the 04/07/2025 quarterly assessment, Resident 50 admitted to the facility on [DATE] with medically complex conditions, to include dementia, repeated falls, and impaired vision. This assessment showed the resident had moderately impaired cognition, required supervision or touching assistance from the staff for ADLs and experienced falls since their admission to the facility or their prior assessment. During observation and interview on 05/12/2025 at 10:55 AM Resident 50 was in bed and stated, I fall quite frequently. I have progressive palsy (loss or reduction of movement in a part of the body, often accompanied by shaking or trembling) and they've gone over things that I do that cause the falls like how I turn and so forth. Review of nursing progress notes from 04/05/2024 to 05/17/2025 showed the staff identified Resident 50 fell frequently, was impulsive and forgetful to use their call light, and self-transferred in and out of bed or wheelchair. documentation showed that staff continued to ask the resident to use the call light or call for help evenh it was identified that Resident 50 was impulsive and does not call for help/assistance with transfers or mobility and transfers without use of call light. Sometimes will yell help when is about to fall or needs help. Requires frequent reminders. The notes further showed Resident 50 fell 36 times (4/30/2024, 05/03/2024, 05/06/2024, 05/09/2024, 05/11/2024, 05/17/2024, 05/22/2024, 06/04/2024, 06/14/2024, 07/18/2024, 08/01/2024, 08/26/2024, 09/20/2024, 10/27/2024, 11/04/2024, 11/11/2024, 12/16/2024, 01/12/2025, 01/19/2025, 01/25/2025, 02/02/2025, 02/14/2025, 02/16/2025, 03/04/2025, 03/07/2025, 03/25/2025, 03/26/2025, 03/26/2025, 04/03/2025, 04/19/2025, 04/24/2025, twice on 05/3/2025, 05/05/2025, 05/14/2025, and 05/17/2025) from 04/05/2024 to 05/17/2025. Review of Resident 50's 11/04/2024 care plan showed the staff identified they had impaired mobility with actual falls due to dementia, unsteady walking, leaning forward in their wheelchair to pick items up from the floor and transferring self from bed or wheelchair. The care plan instructed staff on Resident 50 required assistance for transfers. The care plan showed that on the day of admission, 04/05/2024, the staff added the following interventions: provide direct supervision while resident is toileting, reinforce safety awareness: use call light, lock brakes on chair before transferring, utilize device. When rising from a lying position, sit/rest at edge of the bed at least 10 seconds before transferring, respond to resident requests timely, anticipate their needs, keep call light and bedside table items within reach. On 12/01/2024 pharmacist to review medications quarterly and prn when falls occur to address fall risk side effects. Develop plan with risks and benefits as indicated. On 01/06/2025 Resident 50 would get ice cream if they did fall in 30 days. On 02/05/2025 Resident 50 agreed to wear pull ups at night for urine urgency. On 04/21/2025 make sure to help remind [resident] to position the wheelchair at a 45-degree angle facing the bed, so that [the resident] can still reach the arm rests and make small steps, and travel a shorter distance, to decrease risk of falls. On 05/08/2025 Educate resident to call out for help and to wait for assistance as it is [their] preference not to use the call light. Additional record review showed care plan interventions were not reviewed and/or revised each time Resident 50 sustained a fall. Review of the medical record from 04/05/2024 to 05/17/2025 showed Resident 50 experienced injuries of varying severity related to the 36 falls that included abrasions (05/09/2025, 05/11/2024, 06/14/2024, 07/18/2024, 08/01/2024, 11/11/2024), contusions (an injury to soft tissue that causes bleeding beneath the skin, usually without breaking the skin itself; 08/01/2024, 08/26/2024, 11/11/2024, 03/27/2025), lacerations (08/01/2024, 08/26/2024, 02/02/2025) closed head injuries (08/01/2024, 03/27/2025), swelling to right side of forehead (10/27/2024), skin tears (03/04/2027, 03/07/2025, 04/20/2025), and transfers to the Emergency Department (08/01/2024, 02/02/2025, 05/07/2025). Review of November 2024 through April 2025 grievance log showed grievances related to excessively long call light wait times on 11/06/2024, 03/02/2025, 03/20/2025, and 04/01/2025. In an interview on 05/14/2025 at 10:26 AM, the Resident Council stated the facility did not have sufficient staff. The Council explained they experienced excessively long call light wait times, staff did not answer call lights during mealtimes, so residents had to wait until the meal was over or have an incontinent episode if they needed to toilet during mealtimes, waiting up to an hour to have their call light answered. A resident's spouse in attendance of the meeting, acknowledged they often toileted their spouse to help direct care staff because staff were too busy with other residents and there is not enough staff. The Council again stated, the facility is severely undermanned. In an interview on 05/19/2025 at 4:06 AM, Staff I, Registered Nurse, stated the facility did not have enough staff. Staff I explained they worked night shift and was lucky if they worked with two-three nursing assistants. Staff I further stated it was difficult to manager behaviors on night shift, if a resident needed one:one (1:1) monitoring, they would have to pull a nursing assistant off the floor to provide the needed increased monitoring which left the floor short so I take a section. In an interview on 05/20/2025 at 11:37 AM, Staff P, Licensed Practical Nurse (LPN), stated they were a full-time LPN. Staff P explained the facility was short staffed and routinely worked as a NA three out of five workdays. In an interview on 05/22/2025 at 3:01 PM, Staff D, Resident Care Manager, stated staffing levels were based on census. Staff D explained the facility cared for residents that required two staff assist, were dependent on staff assistance, used mechanical lifts to transfer which required two staff for use, were high fall risks, and exhibited behaviors. Staff D further stated the facility attempted to staff four NAs for both day and evening shifts and two NAs for night shift, but that was not enough staff. The facility utilized agency staffing daily but Staff D continued to hear residents and family's voice concerns over lack of staffing. Staff D acknowledged some falls and resident-to-resident altercations could have been prevented if the facility had more staff. During an interview and record review on 05/22/2025 at 3:12 PM, Staff X, Staffing Coordinator, stated the facility utilized a staffing level guide based on census and the minimum staffing requirements to staff the facility, as instructed. Staff X explained the form was reassessed quarterly by management, we count heads [residents] not acuity. Staff X provided a copy of the staffing guide. Review of the staffing guide provided showed a graph with columns for 1) census, 2) day shift nurses, NA, and restorative NA numbers, 3) evening shift nurse and NA staffing numbers, and 4) night shift nurse and NA staffing numbers. Staff X further stated they were also an NA, often worked the floor to help out due to short staffing, and had not had a full weekend off in a month. Staff X acknowledged staff had voiced staffing concerns, we are struggling, we are having a rough time with staffing. In an interview on 05/22/2025 at 3:43 PM, Staff B, Director of Nursing, stated the facility utilized a staffing guide based on the minimum staffing standards that was reassessed daily with census and acuity. Staff B stated they expected the facility to be staffed with sufficient staff to provide adequate care to the facility residents based on their plans of care. In an interview on 05/23/2025 at 9:36 AM, Staff A, Administrator, stated they expected the facility to have adequate staffing coverage to meet the needs of the facility resident population. Reference WAC 388-97-1080 (1), 1090 (1) Refer to F600, F689, F726, and F727 for additional information.

Based on observation, interview and record review, the facility failed to ensure medications were administered as prescribed for 2 of 6 sampled residents (Residents 34 and 61) reviewed for medication administration. Resident 34 received an injection of Lantus insulin (a type of insulin used to treat high blood sugar that provided a consistent level of insulin over a 24-hour period and mimicked the body's natural insulin production) that was 7.2 times their prescribed dose that was ordered for a different resident (Resident 42). Resident 34 experienced harm when they had an extended period of symptomatic hypoglycemia (extremely low blood sugar) that required administration of rescue medications on five different occasions to normalize their blood sugar level and symptoms. Additionally, Resident 61 did not receive their ordered doses of a blood thinner and an injectable medication that managed weight and blood sugar which placed the resident at risk for unintended health consequences. Findings included . The ISMP, or the Institute for Safe Medication Practices, is a recognized leading authority in medication safety information. It is dedicated to preventing medication errors and promoting safe medication practices. According to the ISMP, insulin and anticoagulants (blood thinners) are considered high alert medications. High alert medications are drugs that bear a heightened risk of causing significant harm to the resident when they are used in error. The consequences of an error can be devastating to residents. <Insulin> <Resident 34> The 04/08/2025 Admission assessment documented Resident 34 had diagnoses that included diabetes, and end-stage kidney disease dependent on dialysis (use of a machine to filter toxins from the body when the kidneys no longer functioned). Resident 34 was cognitively intact and received insulin injections (medications that lowered blood sugar levels) daily. During an initial interview on 05/13/2025 at 10:18 AM, Resident 34 was observed seated on the edge of their bed. Their half-eaten breakfast tray remained on their overbed table. The resident was alert, pointed to a container of orange juice and stated normally they were supposed to limit their fluids but were given orange juice because they were given too much insulin that morning. A review of the record documented the following: The 04/02/2025 care plan showed Resident 34 had diabetes. Staff were instructed to administer diabetes medications as ordered by the provider, monitor for effectiveness and side effects, monitor/record/report to the provider signs or symptoms of hypoglycemia (low blood sugar) to include sweating, tremors, fast heart rate, pale skin color, confusion, or slurred speech. If hypoglycemic, defined as a blood sugar level below 70 milligrams per deciliter (mg/dl), staff were to treat according to the hypoglycemic protocol, document the treatment, interventions, symptoms, and assessment in the progress notes. Resident 34 had the following provider orders: -04/02/2025 check finger stick blood sugar level before meals and at bedtime. If blood sugar is below 70 mg/dl, initiate hypoglycemic protocol and notify the provider. -04/02/2025 hypoglycemic protocol-if able to take oral, give 15 grams (gm) of fast acting carbohydrates, recheck blood sugar in 15 minutes. If still less than 70mg/dl, give another 15 gm fast acting carbohydrate. Recheck blood sugar in 15 minutes. If still less than 70 notify the provider. Once above 70mg/dl, give a protein snack or assist to next meal. Document intervention on the Medication Administration Record (MAR) as follows: J=4 ounces of fruit juice, S=4 ounces of soda, C=6 saltine crackers, G=tube of glucose gel. May repeat in 15 minutes. -04/02/2025 Glucagon (fast acting sugar solution) HypoPen injector, inject 1mg as needed for blood sugar less than 70mg/dl and unable to swallow. Recheck in 15 minutes. If no improvement, notify the MD immediately. -04/15/2025 Lantus (long acting, effect lasted 24 hours) insulin, inject 10 units at bedtime. -04/15/2025 Humalog (fast acting, short duration of effect) insulin, inject 3 units before meals. -05/13/2025 at 11:00 AM check fingerstick blood sugar every hour for 12 hours for diabetic monitoring. -05/14/2025 at 6:00 AM alert charting; Lantus 72 units given, monitor for signs/symptoms of hypoglycemia, document a health status note if side effects occur. 72 units was given instead of 10 units = 7.2 times the prescribed dose of lantus. Significant medication error. A review of nursing progress notes documented the following events: A late nursing entry progress note effective 05/13/2025 at 10:42 AM documented the Medical Director was notified of the occurrence at 10:32 AM. At 11:06 PM, Resident 34's blood sugar result was 80. The resident ate shrimp with cocktail sauce. On 05/14/2025 at 12:03 AM, Resident 34's blood sugar result was 109. There were no signs of hypoglycemia. At 1:02 AM, the blood sugar result was 103, with no signs of hypoglycemia. At 2:04 AM, the blood sugar result was 85. The resident was given half of a peanut butter and jelly sandwich and had no signs of hypoglycemia. At 2:41 AM, the resident had not eaten the sandwich and stated they felt stuffed. At 3:27 AM, the blood sugar result was 83 and there were no signs of hypoglycemia. At 4:24 AM, the on-call provider was notified that the blood sugar level was 70 and Resident 34 was having difficulty taking anything orally other than juice. Instructions were given to give the glucagon injection if the blood sugar dropped below 70. At 6:11 AM, Resident 34's blood sugar was 64, and the resident was given the rescue glucagon injection. On 05/14/2025 at 12:59 PM, a progress note documented alert charting regarding Lantus 72 units given. No adverse drug reaction from the Lantus administration, the resident awakened easily, ate breakfast, and went to dialysis at 9:30 AM. The note documented the blood sugar levels had been within normal limits even though rescue glucagon had been administered. On 05/14/2025 at 3:23 PM, a progress note documented the registered nurse (RN) from dialysis called and notified the facility that Resident 34's blood sugar was 50 earlier, the resident was given a dose of rescue glucagon gel, and the blood sugar came up to 91. The blood sugar then dropped to 38 (a critical level). More glucagon gel was administered, and the blood sugar came up to 89. On arrival back to the facility, Resident 34's blood sugar was 48 and the charge nurse attended to the resident. Resident 34 was pale and sweating and was given another injection of glucagon and two packets of sugar. At 3:39 PM, Resident 34 was given another packet of sugar for a blood sugar of 62. The resident reported they ate only yogurt from their sack lunch at dialysis. On 05/14/2025 at 9:34 PM, the progress note documented the resident had no adverse drug reaction from the 72 units of Lantus given the day prior. The blood sugars ranged from 48 to 299 and the resident ate well. Resident 34 was given their own scheduled bed time dose of Lantus 10 units for the blood sugar result of 299. Monitoring continued. The progress notes did not document any further review with the provider of blood sugars results or notification the resident had received rescue medications four times thus far. On 05/15/2025 at 4:40 AM, the progress notes documented the nursing assistant notified the nurse that Resident 34 had abnormal behavior and mumbled their words. The resident was sweating and lethargic and unable to swallow and had little response. Resident 34's blood sugar was 36, and glucagon was injected at this time. At 5:05 AM, the repeat blood sugar was 72. The resident reported they had not eaten dinner before bed, only Cheetos. The provider, Director of Nursing, and Resident Care Manager were notified. On 05/19/2025, Staff O, Nurse Practitioner (NP), documented Resident 34 was seen for a Federally Mandated Visit. When evaluated, the resident was in bed, sleepy but agreeable to the visit. The resident reported adequate appetite, denied pain, and had been started on an antibiotic for a urinary tract infection. There was no mention in the progress note that the resident had been symptomatic with low blood sugar levels the days prior. A review of the May 2025 MAR did not show documentation of the administration of glucose gel per the hypoglycemic protocol, or the rescue injections of glucagon. A 05/13/2025 at 8:00 AM incident report documented Resident 34 was given 72 units of Lantus intended for another resident. The provider had been notified, and staff were instructed to check blood sugar levels every hour for 12 hours and hold Resident 34's scheduled insulin. The incident report documented that on 05/14/2025, the post-incident review was completed. Findings noted that during the morning medication pass, Resident 34 was to receive 10 units of Lantus while a different resident was to receive 72 units of insulin. Staff P, Licensed Practical Nurse, recently licensed, was orienting and worked in tandem with Staff L, RN. They simultaneously checked blood sugars and prepared medications for multiple residents. Staff P was handed a pre-drawn insulin syringe, became confused and administered 72 units of Lantus to the wrong resident. It was recommended that both Staff P and Staff L be provided with education regarding the rights of medication administration. The investigation packet included a Cascadia Healthcare Medication Administration-Oral competency checklist. The form instructed one on the correct procedure for administering medications to include comparing the medication label with the MAR to ensure the right medication was given, preparing medications for one resident at a time, ensuring the right resident by checking the resident's name, photo, and asking the resident to identify themselves, and checking to ensure the right dose by checking the medication label and the order. Staff B, Director of Nursing initialed that Staff P had been satisfactorily reviewed regarding ensuring the right resident, right medication, right dose, right route, right time, in the appropriate form, with the right documentation, right rationale and right response. The form was signed and dated by Staff P on 05/19/2025. On 05/15/2025 at 8:39 AM, Resident 34 was observed in bed covered in blankets. The resident looked pale and appeared tired. Resident 34 stated they did not know how low their blood sugar had been during the night, but was aware they had been talking and did not make sense. Resident 34 stated that when their blood sugar dropped down so low, they felt like they were going to die. Resident 34 stated they currently had a headache, and they did not understand why their blood sugar levels were all over the place. On 05/16/2025 at 9:09 AM, Resident 34 was observed seated on the edge of their bed. They were dressed, groomed, had color in their cheeks, and were more animated than the prior observation. Resident 34 stated they felt much better and ate well. They stated they had been afraid to go to sleep the night prior because they thought if they did, they were going to die. They stated they caught themselves dozing off and snapped awake then felt anxious. During an interview on 05/19/2025 at 6:14 AM, Staff L, RN, stated in the beginning of their shift on 05/13/2025, they instructed Staff P that they would prepare medications for Resident 42 and Staff P was to stay right by their side. Staff L was to hand the medication to Staff P, then go with Staff P and observe Staff P give medications to Resident 42 because the facility residents did not wear identification bracelets. Staff L stated they prepared the medications for Resident 42, handed them to Staff P, and stated they would meet Staff P in the resident's room. Staff L stated they closed their laptop and looked at the narcotic sign out book, then went in Resident 42's room. Staff L did not see Staff P in the room and saw that Staff P had gone in the room next door. Staff L stated when they went in Resident 34's room, Staff P had already finished injecting Resident 42's insulin into Resident 34. Staff L stopped Staff P before any other pills were administered. Staff L stated they discussed resident identification, but Staff P was flustered so they focused on the management of Resident 34 for hypoglycemia and Staff P did not give any other medications after that. Staff L stated they should have gone in the room with Staff P to give the medications. They stated they had not been given a checklist to verify Staff P's competencies while they were oriented. Staff P was unsure what on-boarding Staff P had received when they began their employment. Staff P was not aware Resident 34 required the use of rescue medications five times and agreed the resident had been harmed. During an interview on 05/20/2025 at 11:34 AM, Staff P stated they had worked for the facility for about one month and they had just received their LPN license recently. Staff P stated their orientation to the facility included filling out paperwork, instructions on how to don and doff personal protective equipment and hand hygiene. Staff P stated there had been a recent skills fair, and staff read information from a poster board then signed that they had read it. Staff P stated they had not been given a medication competency checklist until after they had given Resident 34 the wrong insulin. Staff P stated they had been told that the best way to learn who the residents were was to work as a nursing assistant and so they mainly worked obtaining blood sugars and vital signs instead of learning the role as an LPN. Staff P stated on the morning of the medication error, they had checked the blood sugars for both Resident 42 and Resident 34. Staff P stated Staff L prepared the medications for Resident 42 and handed them to Staff P. They had taken Resident 34's blood sugar last, so took the medications to Resident 34 and gave Resident 34 the insulin intended for Resident 42. They became distraught after the medication error and intended to submit their letter of resignation after the surveyor interview was concluded. During an interview on 05/21/2025 at 2:38 PM with Staff D, Resident Care Manager (RCM), and Staff N, RCM, Staff D stated the RCMs each took a hall and watched staff nurses pass medications from start to finish. They stated each nurse completed the competency yearly and signed a form. Staff N and Staff D stated they had been made aware of the insulin error right away, right after Staff P and Staff L had notified the provider. When asked if they had considered sending Resident 34 to the emergency room or having a provider see the resident, Staff N stated they notified the provider, gave the glucagon and did closer monitoring and they were able to manage the resident. Staff N stated if they had given the glucagon and the resident did not improve or if the resident had become unconscious, they would have sent the resident to the hospital. Staff N stated they had just recently gone over a document, 10 Rights for Safe Medication Administration with the nursing staff and provided the staff a copy, which included ensuring the resident and the right dose. Staff D stated they expected staff to document all medications including rescue medications to be documented in the MAR. During an interview on 05/22/2025 at 2:24 PM, Staff O, NP, stated they had been notified through their on-call service that Resident 34 had been given someone else's insulin. Staff O stated they examined the resident on 05/19/2025 for staff reports of symptoms of a urinary tract infection but had not been notified that Resident 34 had required rescue medications 5 different times. They agreed the resident might need to be hospitalized to stabilize their blood sugar. Staff O stated they expected to be notified when a resident had blood sugars in the 30's and required rescue medications. They said waiting until a resident was unconscious before sending them to the emergency room was too late. 40297 <Anticoagulant> <Resident 61> Review of a 04/27/2025 admission assessment showed Resident 61 admitted to the facility on [DATE], was assessed as cognitively intact, and had the diagnosis of diabetes with long term use of insulin and atrial fibrillation (an irregular heart rhythm). This assessment showed Resident 61 received an anticoagulant (a blood thinner) and insulin. Review of an April 2025 MAR showed an order to administer Xarelto (an anticoagulant) every evening. The MAR showed NA or Medication Not Available on 04/24/2025. Review of a 04/24/2025 eMAR Note showed the reason the medication was not available was because the Medication [was] back ordered [,] spoke with [pharmacy]. Review of a pharmacy inventory list for the emergency medication stock in the facility showed the Xarelto was available. Review of the progress notes showed no documentation of what the staff did to procure the anticoagulant or notified the provider of the missed dose. The above findings were shared with Staff B on 05/16/2025 at 9:05 AM. Staff B stated that Xarelto was available in the emergency medication stock and that the nurse should have called the provider and let them know the medication was not given or missed. Staff B stated the facility monitored for missed medication doses by pulling a daily report from the electronic medical record and reviewed medication errors in the daily clinical meeting. When asked if the facility identified and addressed why the staff failed to administer the Xarelto to Resident 61, Staff B stated, they completed a risk management review if the drug could cause harm, to include a drug like Xarelto. When asked if the facility completed a review on the missed high alert drug dose, Staff B stated, For that one, nope. <Other> Review of a pharmaceutical package insert showed Ozempic was an injectable medication that when used along with diet and exercise helped improve glycemic (blood sugar) control and reduced the risk of major adverse cardiovascular (heart) events in individuals with diabetes. Following the dosing schedule was essential for the medication to work correctly. If a dose was missed, it should be administered as soon as possible within five days after the missed dose. If more than five days had passed, the missed dose should be skipped and the next dose administered on the regularly scheduled day. Review of Resident 61's April and May 2025 Medication Administration Record (MAR) showed an order for the staff to administer an injection of Ozempic every Friday. The scheduled doses for 04/25/2025, 05/02/2025, and 05/09/2025 were marked as NN or Other/See Nurse Notes. Review of the progress notes for 04/25/2025 showed no documentation why the staff did not administer the Ozempic. Review of a 04/29/2025 provider note showed, Ozempic daily and Continue Ozempic. Review of a 05/02/2025 electronic MAR (eMAR) Note showed the staff did not administer the Ozempic because the medication was still, On order, that Staff N, Resident Care Manager, was aware, and pharmacy needed permission from the facility to bill the facility for the medication before dispensing it. The note showed Staff B had the required paperwork to authorize billing to the facility. Review of a 05/06/2025 provider note showed, Ozempic daily. Review of a 05/09/2025 eMAR Note showed that on the scheduled third weekly dose, the staff administered the Ozempic for the first time since admission to the facility. In an interview on 05/16/2025 at 8:58 AM, Staff B, Director of Nursing, said, I know there was like a discussion about [the resident] bringing in [their] medication from [previous community living setting]. I think [the resident] told us not to order it or [they were] gonna' bring it and [they] didn't bring it in, and we didn't pay for it. Staff B acknowledged the staff did not administer Resident 61 the Ozempic as ordered on 04/29/2025 and 05/02/2025 and constituted medication errors. Reference WAC 388-97-1060 (3)(k)(iii). Refer to F684 for additional information.

Based on interview and record review, the facility failed to develop, implement and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that identified deficiencies, implemented good faith efforts for corrective actions, and evaluated implemented corrective actions or performance improvement activities for effectiveness. The facility's QAPI program failed to timely recognize already compromised care and services that resulted in a potential for a pattern of resident harm. Findings included . Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) revised April 2024 showed, the facility monitored quality deficiencies related to facility operations and practices causing negative outcomes through the QAPI process. The QAPI committee served as a preventative function by reviewing and improving facility systems and took actions toward enhancing quality of care and quality of life for facility residents. The QAPI framework was established through five elements: 1) design and scope, 2) governance and leadership, 3) feedback, data systems and monitoring, 4) Performance Improvement Projects (PIPs), and 5) systematic analysis and systemic action. The committee was to meet monthly to identify performance improvement opportunities through tracking and trending of data that necessitated quality assessment and assurance activities against state and national benchmarks. The QAPI committee was to prioritize action plans and evaluate effectiveness of the process improvement activities. The policy included a list of potentially preventable events the facility may monitor including various high-risk medication use to include blood thinners and diabetes medications, care events such as falls, elopements, instances of abuse, neglect or misappropriation and infection such as respiratory infections and infectious diarrhea. The facility QAPI committee reported routinely to the governing body. Review of the facility QAPI Plan dated May 2025 showed the governing body appointed the facility executive director/administrator responsible for management of the facility and reported to and was accountable to the governing body. The governing body was responsible for the development and implementation of the QAPI program by identifying and prioritizing problems based on performance indicator data, ensure corrective actions address gaps in systems, evaluate effectiveness of corrective actions, and set clear expectations for safety, quality, rights, choices, and respect. The facility utilized a web-based application that allowed the governing body and Quality Assessment and Assurance (QAA) committee to access and view virtually all of an organization's QAPI activity including quality assessments, facility QAPI self-assessment, care area investigations, PIPs, and detailed reporting. Review of the July 2024 through April 2025 QAPI Committee minutes showed the following: - 07/21/2024 the facility experienced 25 falls, six falls were repeat falls, no falls with major injury identified. The facility identified one medication error. Staffing challenges with the need for more nursing staff. No PIPS in place. - 10/29/2024 the facility again experienced 25 falls, six falls were repeat falls, no falls with major injury identified. The facility identified one medication error. Staffing challenges with the need for more nursing staff. No PIPS in place. - 01/21/2025 the facility experienced 39 falls, 18 were repeat falls, no falls with major injury identified. Summary of fall trends showed frequent fallers were identified and corrective action was documented as implement fall meetings. The facility identified six medication errors, no trend or corrective action documented. Staffing challenges with the need for more therapy staff to perform timely evaluations. No PIPS in place. - 04/30/2025 the facility experienced 24 falls in April, with two residents sustaining repeat falls, and 1 fall with fracture. Summary of fall trends showed no tracking or trending. No documentation of tracking or trending for medication errors or staffing was found. No PIPs in place. Review of the September 2025 through May 2025 facility accident and incident tracking log showed the documentation did not meet the minimum required information to include date and time of the incident, nature of occurrence, incident location, incident findings, actions taken, if the State abuse reporting hotline was notified of the incident and by whom to easily track and trend facility incidents. Additional review showed some residents were involved in recurrent verbal and physical resident-to-resident altercations and sustained repeat falls that resulted in hospitalization and numerous fractures. In an interview on 05/23/2025 at 11:34 AM, with Staff A, Administrator, Staff B, Director of Nursing, and Staff C, Clinical Resource Nurse. Staff C stated QAPI collected data through the facility clinical stand-up meeting where falls, infections, and grievances were reviewed. Staff A explained QAPI prioritized identified concerns based on trends and negative trends, implementing PIPs when needed. Staff B stated the facility had two current PIPs in place, one for care planning and the second related to falls which was implemented approximately November 2024 and consisted of implementation of a fall meeting. When Staff B was asked about the effectiveness of the falls PIP, Staff B replied, the PIP is going to be drastically revised. Reference WAC 388-97-1760 (1)(2) Refer to F600, F689, F725, F760, F867, F868, F835, and F837 for additional information.

Based on interview and record review, the facility failed to ensure direct care staff were provided the mandatory effective communication training for 10 of 10 sampled staff (Staff P, L, AA, R, BB, K, CC, DD, EE, and FF) reviewed for communication training. This failure placed all residents at risk of unmet care needs and diminished quality of life. Findings included . Review of the following employee files found no documentation that showed effective communication training had been provided as required: - Staff P, Licensed Practical Nurse - Staff L, Registered Nurse - Staff AA, Licensed Practical Nurse - Staff R, Nursing Assistant, registered - Staff BB, Licensed Practical Nurse - Staff K, Nursing Assistant - Staff CC, Nursing Assistant - Staff DD, Nursing Assistant - Staff EE, Nursing Assistant - Staff FF, Nursing Assistant In an interview on 05/22/2025 at 4:12 PM, Staff C, Clinical Resource Nurse, stated the previous Administrator did a lunch and learn meeting with the staff for effective communication training, but there was no signature sheet, and they were unable to find any documentation that showed the trainings had been completed. In an interview on 05/23/2025 at 9:36 AM, Staff A, stated they expected staff to receive adequate training in order to have adequate skills and competencies to meet the needs of the facility resident population. Reference WAC: 388-97-1680

Based on observation and interview the facility failed to maintain a resident call light system that was functionable and audible, as required. This failure placed all facility residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included . During observation on 05/12/2025 at 12:16 PM, a call light was visibly lit up above a resident room but not audible in the hallway. Similar observations were made at 12:36 PM, on 05/13/2025 at 8:23 AM, 8:38 AM, 10:13 AM, and 12:47 PM, and on 05/19/2025 at 4:09 AM. During an observation on 05/12/2025 at 12:46 PM, the call light indicator board at the nurses' station showed one or more resident room call lights were lit up as activated but not audible in the hallway. Similar observations were made at 3:30 PM, on 05/13/2025 at 8:40 AM, 10:14 AM, 10:41 AM, 11:41 AM, 1:27 PM, on 05/14/2025 at 8:37 AM, on 05/15/2025 at 8:42 AM and 2:22 PM, on 05/16/2025 at 8:35 AM, on 05/19/2025 at 4:30 AM and 4:49 AM. In an interview on 05/14/2025 at 10:26 AM, the Resident Council stated they experienced excessively long call light wait times, sometimes waiting up to an hour. The Council acknowledged the call lights do not make a sound at all. During an observation and interview on 05/20/2025 at 9:57 AM, Staff K, Nursing Assistant, stated the facility had been having issues with call light audibility. Staff K walked to room [ROOM NUMBER] and activated the call light, the light lit up outside the room, but no sound was audible from the hallway. When the surveyor and Staff K looked down the hall attempting to visualize activated call lights outside of the resident rooms, brown speaker appearing boxes were observed intermittently placed throughout the hallway, adjacent to the call light placement, obscuring visibility of some call lights. Staff K acknowledged some call lights were blocked from view when in the hall or at the nurses' station related to speaker box placement. Staff K further acknowledged the call lights were not audible when activated. During an observation and interview on 05/20/2025 at 10:14 AM, the call lights were observed down the hall with Staff L, Registered Nurse, who explained the brown boxes that obscured visibility of some call lights was an overhead paging system. Staff L acknowledged the call lights had not been audible in over a year. During an observation and interview on 05/20/2025 at 10:19 AM, Staff W, Maintenance Director, stated our call light system is horrible. Staff W explained the annunciator, portion of the system that made call lights audible, constantly shorts out and goes out. The surveyor and Staff W walked down to the call light indicator board at the nurses' station, the call lights for room [ROOM NUMBER] and 32 were lit up on the board as activated but no sound was heard. Staff W pointed out a low click emitted from the indicator board. Staff W explained the click was the annunciator, when a call light was activated, the annunciator would typically click and trigger the call light audible beeping but it froze again and was not allowing the call lights to be audible when activated. During a follow-up interview on 05/20/2025 at 10:44 AM, Staff W explained they did monthly facility rounds to check for needed repairs, but staff would typically enter a maintenance work order if items or equipment were in disrepair. Staff W acknowledged they had not received a work order for the non-audible call light system and had not implemented more frequent rounding to ensure the call light system was functioning appropriately, as required. During a follow-up observation and interview on 05/20/2025 at 10:51 AM, Staff W stated they fixed the annunciator and the call lights were audible again. Staff W pointed out a single intermittent beep heard in the hallway; no call light was observed visibly on above a room door. The Surveyor and Staff W again walked down to the call light indicator board at the nurses' station, no resident room lights were lit up as activated but the single intermittent beep was still audible. Staff W was asked to turn on a resident room call light. Staff W activated the call light in room [ROOM NUMBER], the light lit up above the room door but there was no audible change in the frequency of the single intermittent beep, the beep was the same if a call light had been activated or not. In an interview on 05/23/2025 at 9:36 AM, Staff A, Administrator, stated they expected staff to ensure the resident call light system was visible, audible, and in working order, as required. Reference WAC 388-97-2280 (1)(a) Refer to F 689 for additional information.

Based on observation, interview and record review, the facility failed to maintain an effective infection control program that identified, reported, and controlled the spread of communicable diseases for residents and staff during a Norovirus [a highly contagious gastro-intestinal (GI, affected the stomach and intestines) virus that caused nausea, vomiting and diarrhea] outbreak and to implement basic infection prevention interventions that included enhanced barrier precautions, transmission-based precautions, prompt reporting of a laboratory confirmed Norovirus outbreak to the State Survey Agency and local health departments, and exclusion of staff members from work according to the recommended standards. These failures facilitated a Norovirus the outbreak which spread to all 3 of 3 nursing units and 27 of 61 residents (Residents 50, 11, 40, 38, 43, 51, 19, 59, 46, 63, 28, 21, 41, 37, 23, 47, 67, 48, 34, 6, 32, 33, 3, 22, 20, 35, and 5) and 33 of 86 staff members (CC, JJ, Y, SS, J, AA, TT, UU, VV, A, F, WW, LL, GG, K, EE, G, D, N, FF, XX, U, YY, ZZ, AAA, II, RR, BBB, E, CCC, DDD, EEE, and FFF) and placed residents at risk for potential for unintended health consequences, and the potential spread of other infectious diseases or organisms resistant to antibiotics. Findings included . The Centers for Disease Control and Prevention (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, updated September 2024 and retrieved from https://www.cdc.gov/infection-control/hcp/isolation-precautions/index.html documented facilities were to implement contact + standard precautions for a minimum of 48 hours after the resolution of symptoms or to control institutional outbreaks. Standard precautions were based on the principle that all blood, body fluids and secretions may contain infectious agents, and included the use of hand hygiene, and donning (to put on) personal protective equipment (PPE) to include gowns, gloves, masks and eye protection if exposure could be anticipated, such as by splashes for example. Contact precautions prevented transmission of organisms spread by direct or indirect contact with the patient or their environment. Healthcare personnel were to don a gown and gloves when entering a room to care for a resident on contact precautions and discard the PPE before exiting the room. The CDC 2011 Norovirus Prevention and Control Guidelines for Healthcare Settings retrieved from https://www.cdc.gov/infection-control/hcp/norovirus-guidelines/index.html recommended ill staff be excluded from work for a minimum of 48 hours after the resolution of symptoms. The CDC 07/12/2002 Implementation of Personal Protective Equipment (PPE, gloves, disposable gowns, eye protection or masks, for example) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html recommended the use of Enhanced Barrier Precautions (EBP) as an infection control intervention. EBP recommended the use of gown and gloves during high contact resident care activities when Contact Precautions did not apply for residents with wounds or indwelling medical devices, such as feeding tubes or catheters. High contact care activities included dressing, bathing/showering, transferring, changing linens, providing hygiene, wound care and assisting with toileting. Review of the facility policy titled, Transmission-Based Precautions Conventional Plan dated April 2024, documented the Infection Preventionist was to be notified of the suspected infectious or contagious disease and surveillance was to be initiated. Transmission-based precautions were to be initiated, to include placing and maintaining an adequate supply of appropriate PPE at the resident room door and posting the appropriate precaution notice in a visible location outside the room. EBP was recommended for use high contact care activities in resident rooms where residents had wounds, indwelling medical devices, central lines, urinary catheters, feeding tubes or colonization with multi-drug resistant organisms and was intended for the resident entire length of stay unless the device was removed or the wound healed. Contact precautions were required upon identification of a positive culture or report of a diagnosis that required isolation. Staff were to immediately post corresponding precaution notices visibly outside the room. Gown and gloves were required upon entry to the resident's room. Residents were to be removed from transmission based precautions 24 hours after they no longer had symptoms or per disease specific directives, whichever was longer. <Norovirus Outbreak/EBP Precautions> On 05/12/2025 at 9:32 AM, a recertification survey commenced at the facility. Upon entry, Staff A, Administrator, stated there were no residents on isolation at that time but there had been residents isolated the week prior for suspicion of Norovirus. On 05/12/25 at 10:23 AM, the door to Resident 41's room had a red stop sign on the door and a yellow bag that hung on the doorframe that contained PPE. An unidentified male Nursing Assistant (NA) was observed entering the room and donned a pair of disposable gloves only. The signage on the door did not document what type of isolation was in place, only to ask the nurse before the room was entered. On 05/12/2025 at 11:23 AM, Resident 63 was observed in bed. An indwelling urinary catheter (a tube inserted into the bladder that allowed urine to drain) hung from the right side of their bed and the resident said it would eventually be removed when they became strong enough to go to the bathroom. The entry to the resident's room entry had no signage to instruct the staff that EBP was indicated or what PPE was to be worn during resident care. On 05/12/2025 at 11:28 AM, a SPECIAL DROPLET/CONTACT PRECAUTION signage was posted on the outside of Resident 58's room door, at eye level. The signage instructed persons to perform hand hygiene and wear a N95 respirator (a mask that filtered out organisms coughed into the air), eye protection, gloves, and a gown prior to room entry. Staff Y, NA, was observed entering Resident 58's room and did not perform hand hygiene or don PPE, as instructed on the posted sign. Staff Y approached Resident 58 in bed, pulled down their covers, adjusted Resident 58's feet then recovered them with their blankets. At 11:31 AM, Staff Y exited Resident 58's room. When asked about the isolation sign posted on Resident 58's room door, Staff Y stated they were not sure why the signage was there but acknowledged they should have donned PPE as instructed on the posted signage. On 05/12/2025 at 3:28 PM, Resident 54's entry had EBP signage on top of a PPE cart, but also a sign for Contact Precautions on the wall above the PPE cart. As the Surveyor donned PPE as required for Contact Precautions, Staff AA, Licensed Practical Nurse, approached and told the Surveyor that PPE for Contact Precautions was not required unless wound care was going to be completed. When asked what precautions Resident 54 was on, whether Contact or EBP, Staff AA said, EBP but if wound care then Contact. Upon entering Resident 54's room, the resident was observed in bed, with a dressing over an intravenous (IV, into the vein) line to their upper left arm dated 05/09/2025. The resident confirmed the IV line was for antibiotic administration twice a day. On 05/13/2025 at 8:48 AM, Resident 34 was observed eating breakfast in their room. They reported they had dialysis (medical procedure that removed waste and excess fluid from the blood when the kidneys were unable to do so) three times a week and had a dressing visible over a dialysis port (surgically created blood access to be used during dialysis treatments) on their chest. There was no signage at the entrance to the resident's room that notified staff that EBP precautions were indicated, and there was no PPE cart at the entrance for staff use. On 05/13/2025 at 8:56 AM, Resident 20 was observed sleeping in their bed. The resident had tube feeding formula (nutrition provided through a tube inserted into one's abdomen when one is unable to eat or swallow) that hung on an infusion pump. A large syringe used to insert liquid medications manually into the abdominal tube was on the resident's overbed table. There was no signage at the entrance to the resident's room notifying staff that EBP precautions were indicated and there was no PPE cart at the entrance for staff use. On 05/14/2025 at 8:32 AM, Resident 54's entry continued to have signage for both EBP and Contact Precautions remaining on the PPE cart and on the wall above the PPE cart respectively. On 05/14/2025 at 8:47 AM, the SPECIAL DROPLET/CONTACT PRECAUTION signage remained posted on Resident 58's room door. Staff HH, NA, was observed entering Resident 58's room and did not don PPE or perform hand hygiene as instructed and asked Resident 58 if they wanted to get up for breakfast. At 9:00 AM, an unidentified female staff entered Resident 58's room, without performing hand hygiene or donning PPE, and placed a breakfast tray on the bedside table. At 9:03 AM, Staff HH put on a pair of gloves without performing hand hygiene but did not put on a gown, N95, or eye protection and began to assist Resident 58 eat their breakfast. On 05/14/25 09:06 AM, Resident 5 was observed from the door of their room. The resident was in bed, unkempt and had a pink basin on the bed beside next to them. Resident 5 stated, You don't want to come close. I am sick. The resident stated the day prior, they had come down with that bug that was going around. Resident 5 then began retching into the basin after, they stated they were unable to keep even water down. There was no Contact Isolation signage at the entry to the resident's room, and no PPE cart near the room for staff use. On 05/14/2025 at 9:32 AM, review of the State Agency incident reporting application had no intakes from the facility for a GI or suspected Norovirus outbreak. A copy of the line list of residents ill with GI symptoms was requested at 9:47 AM. On 05/14/25 at 10:16 AM, Staff F, Infection Prevention, Licensed Practical Nurse (LPN), provided the list of residents affected by the GI outbreak. Staff F stated the first case was identified on 05/03/2025, and the last case was on 05/06/2025 so the outbreak resolved at that time. They stated stool samples were sent out on 05/03/2025 and resulted positive by culture for Norovirus four days later. Staff F stated most residents were ill for only 24 hours and the outbreak affected 24 residents, plus staff. Staff F stated they had become ill as well and had instructed staff they were able to return to work if they were free of fever or symptoms for 24 hours. Staff F stated they called the local health department three times, and was told Norovirus was not reportable to the county or the state and offered no guidance on managing the outbreak. A list of staff who were part of the outbreak was requested at this time. A review of the Resident outbreak line list documented Resident 37 had an onset of symptoms on 05/02/2025 and was the first case of 24 on the list. No other residents were added to the list after 05/06/2025. Resident 20 was not included on the line list but had documented illness, and Residents 5 and 35 became ill during the course of the survey. A review of the staff outbreak line list documented 14 staff (CC, JJ, Y, SS, J, AA, TT, LL, D, N, CCC, DDD, EEE, and FFF) became ill on 05/04/2025, three staff (WW, EE, BBB) became ill on 05/09/2025, and 33 staff in total became ill. On 05/14/2025 at 11:11 AM, Resident 20 was awake and resting in bed. The tube feeding pump remained in the room. Resident 20 stated they had been ill the week prior with diarrhea for four days but felt better. There was still no signage for EBP at the room's entrance. Across the hall, there was no EBP signage or PPE cart observed at the entrance to Resident 34's room. When reviewed, Resident 20 was not included on the outbreak line list. On 05/14/2025 at 4:15 PM, Resident 5 was observed from the entry to their room. Resident 5 stated they felt worse than they had earlier in the day and had vomited a large amount. The resident sipped water. There was no Contact precautions signage or PPE cart at the entrance to the resident's room. On 05/15/2025 at 9:17 AM, Resident 5 was observed and stated they were no longer vomiting or having diarrhea. They stated they were able to sip water now. There was no Contact precautions signage or PPE cart at the resident's entrance. On 05/15/2025 at 9:20 AM, the entries to Resident 20 and Resident 34's rooms had no EBP signage or PPE cart present. On 05/15/2025 at 9:25 AM, abbreviated record reviews were completed for the residents included in the Norovirus outbreak and it was confirmed that none of the residents required hospitalization related to GI symptoms. A review of Resident 40's record documented the resident had diagnoses that included stroke and depression with psychotic symptoms. From 05/05/2025 to 05/10/2025, the resident was placed on alert charting related to GI illness. A review of the May 2025 medication administration record documented the resident's vital signs were monitored related to the GI illness. On 05/06/2025, 05/07/2025, and 05/08/2025, blood pressures of 88/60 (extremely low, normal average BP 120/80) were recorded. On 05/09/2025, a blood pressure of 92/60 was recorded. There were no progress notes that documented if the resident had symptoms as a result of the low blood pressures, or that the provider had been notified of the low blood pressures. Resident 40 shared a room with Resident 5. During an interview on 05/15/2025 at 10:10 AM, the Community Health Specialist at the local county health department stated they had not been notified of the Norovirus outbreak at the facility and outbreak reporting was required. They stated their department assisted facilities during outbreaks by providing guidance on how long residents were to remain on isolation and recommended that staff be excluded from work for 48 hours after their symptoms resolved. They stated they followed the CDC guidance regarding Norovirus. During an interview on 05/15/2025 at 10:31 AM, Staff M, LPN, acknowledged they had been on the medication cart and passed medications on 05/14/2025 to Resident 5. They stated they had received recent education regarding hand hygiene, and how to manage residents that were actively ill. Staff M stated they did not know how many residents had been ill during the outbreak, but stated they were aware two residents had become ill since the week prior. They stated Resident 35 had vomited and had a high fever that started on 05/14/2025. Staff M stated they knew how to tell if a resident was ill because there was a PPE cart in the hall and there was usually signage on the resident's door. Staff M stated Resident 5 should have had Contact precaution signage on their door but there was none. Staff M stated staff told the Resident Care Managers (RCM) when a resident was ill, and the RCMs obtained the PPE carts and hung up the signage, but that any staff could do those things. Staff M had not told Staff F that Resident 5 had been vomiting, but thought Staff F was probably aware. Staff M was unsure if Staff F was aware that Resident 35 was now ill as well. During an interview on 05/15/2025 at 10:41 AM, Staff G, Registered Nurse (RN), stated they became ill with Norovirus and, was home for two days. Staff G stated the facility instructed them they could return to work when free from nausea, vomiting, diarrhea, or fever for 24 hours. During an interview on 05/15/2025 at 10:53 AM, Resident 5 stated while they had been sick, none of the staff had worn gowns when they helped take care of them. Resident 5 stated some staff sometimes wore gloves. During observation and interview on 05/15/2025 at 10:55 AM, Staff LL, LPN, stated they had gotten sick during the Norovirus outbreak. They stated they did not have to call in because they happened to be sick on their two days off. Staff LL stated they were able to tell what residents were sick because there would be a sign on their door and a PPE cart. Staff LL had not been told that Resident 5 was ill but had been told about Resident 35. At this time, the entry to Resident 35's room is observed with the surveyor, and there was no PPE cart or Contact precautions sign present. When asked how staff were made aware of resident illness, Staff LL stated they were told in report, or there might be an alert on the dashboard in the electronic medical record. Staff LL looked at the dashboard and saw there was an alert for Resident 35 on the dashboard, but none for Resident 5. Staff LL stated if the correct PPE was not worn, staff could spread illness to other residents and residents were vulnerable. On 05/15/2025 at 11:09 AM, a cart of PPE was now observed at the entry to Resident 35's room, however, there was still no Contact precautions sign. During an interview on 05/15/2025 at 11:10 AM, Staff F, Infection Prevention LPN, stated they had just been made aware that two residents were sick. They were aware that Resident 35 had vomited but had not been told that Resident 5 had been vomiting all day on 05/14/2025 and they were going to investigate why they were not informed. Staff F stated there was a difference between Contact precautions and EBP. Residents with wounds, tubes or drains were to require EBP. Staff F was not aware that Residents 20 and 34 had no signage indicating staff should use EBP. Staff F stated they usually made rounds to ensure the appropriate signage was in use when indicated but had not been able to complete their rounds that week. Staff F stated staff were instructed that they had to be free of Norovirus symptoms for 24 hours before they were to return to work. They had been keeping track of those employees that were ill but stopped after they got to about 25 staff because no one was reporting staff illnesses to them. Staff F stated they had notified the local health department both by phone and by email of their outbreak but was unaware the State Survey Agency was also supposed to be notified. Staff F stated they expected staff to wear the appropriate PPE, wash their hands, and notify them if residents were ill. They stated residents who have Norovirus could become dehydrated (body loses more fluids than were taken in), have electrolyte (body minerals) imbalances, or worse, could even die. On 05/15/2025 at 1:44 PM, an email correspondence was provided that documented Staff F contacted the State Department of Health on 05/12/2025 at 9:51AM, ten days after the first case of Norovirus was identified. The Department of Health recommended the facility contact their local health department. On 05/16/25 at 8:49 AM, observations of the nursing units were made. Resident 35's room had a white facility made EBP sign at the entry to their door. This was covered with a red stop sign that instructed persons to ask the nurse before entering. This was instead of a Contact precautions sign indicated because of the resident's GI illness. Resident 34 had a white facility made EBP sign at the entry to their room. Resident 20 continued to have no EBP signage. Resident 5 had no Contact precautions signage or PPE cart at their room and was still within the 48-hour window of their symptoms having resolved. There was one PPE cart in the entire hall, and this was positioned at the entry of Resident 35's room. During observation and interview on 05/16/2025 at 10:06 AM, Staff Y was observed entering Resident 58's room with an unidentified NA. A Special Droplet/Contact precaution sign was at the entrance of the room. Neither staff donned PPE. Staff Y exited the room and picked up an incontinence pad and re-entered the room. Upon exiting the room, Staff Y was asked if PPE was required at entrance to Resident 58's room, and Staff Y went to ask for clarification. Staff Y returned then stated they were to don PPE only if they provided care to the resident, but since they only took a tray in the room, it was not required. During an interview on 05/16/2025 at 10:34 AM with Staff A, Administrator, Staff C, Clinical Resource Nurse, and Staff MM, Regional Director. Staff C stated they had currently taken over infection control duties related to the continued Norovirus outbreak. Staff C stated care plans had been updated, orders for precautions had been entered, and signage was being hung at that time. Staff A stated they had been made aware of the outbreak when the first case was identified, and stated they assumed Staff F had also been notified and each morning in report, the outbreak and those residents that became ill were discussed. Staff C confirmed that staff who became ill should have been excluded from work for 48 hours after their symptoms resolved and confirmed that staff were to don PPE at any time a room on Contact precautions was entered. Staff C stated they had talked with the local health department on 05/15/2025 and the outbreak had now been reported and if Staff F or any of the RCMs were unaware of a Resident becoming ill, it indicated a problem with the facility communication regarding the outbreak. Staff MM stated the use of non-standardized precaution signage contributed to staff confusion regarding Contact precautions and EBP and stated if staff had to hunt for PPE supplies, they would not use them. Staff MM agreed that breaches in infection control practices could contribute to the spread of Norovirus. During an observation of medication administration and interview on 05/19/2025 at 7:31 AM, Staff BB, LPN, dispensed medications for Resident 5. A Contact precaution sign was now posted at the entrance to their room. Staff BB donned a pair of gloves without performing hand hygiene and entered the room and pulled the privacy curtain partially open. The posted signage with verbiage that instructed staff to don gloves and a gown prior to room entry was pointed out to Staff BB. Staff BB stated the contact precautions were for Resident 5's roommate, by the window, not for Resident 5., but they would seek clarification from Staff F. When asked what PPE Staff BB was to don when they passed medication to Resident 5, they slowly read the Contact precaution signage then donned the PPE as instructed on the sign. On 05/19/2025 at 9:55 AM, Staff DD, NA, was observed aiding Resident 5. The Contact precautions sign remained on the entrance to the room. Staff DD had no PPE on. During an interview on 05/20/25 at 12:23 PM, Staff NN, agency LPN, stated during the Norovirus outbreak they were instructed to work on 05/15/2025 when they were sick and had a fever. Staff NN showed a text message thread on their personal cell phone and had documented their fever of 101.3 degrees Fahrenheit with a picture of a thermometer. Staff NN stated they took acetaminophen (over-the-counter medication) to reduce their fever, arrived at the facility at 3:30 PM on 05/15/2025, and worked a double shift. Staff NN stated they had 05/16/2025 off. They worked a partial shift on 05/17/2025, but was still sick, so went to the hospital and had an evaluation. Staff NN provided a copy of their hospital after-visit summary which documented Staff NN was diagnosed with gastroenteritis (GI illness). During an interview on 05/22/2025 at 2:24 PM, Staff O, Nurse Practitioner, after review of CDC Norovirus guidelines, stated they would not expect a staff member with a fever to work. Staff O stated they were new to the facility and had seen Resident 40 once. They stated they had not been notified of any low blood pressures and in their professional opinion, any resident that had been ill with nausea, vomiting, diarrhea and a low blood pressures of 88/60 would require notification to the provider for concerns of dehydration. During an interview on 05/23/2025 at 10:51 AM with Staff A, Staff B, Director of Nursing, Staff C, and Staff Q, Regional Director of Clinical Services. Staff B acknowledged staff were to be excluded from work for 48 hours after Norovirus symptoms resolved. <Infection Prevention Annual Policy Review> A review of the facility Infection Prevention program policies revealed the following: -The policy titled, Transmission-based Precautions Conventional Plan had a revision date of 04/02/2024. -The policy titled, Surveillance of Healthcare Associated Infection was revised 09/10/2020. -The policy titled, Antibiotic Stewardship was revised 10/15/2022. -The policy titled, Employee Influenza Immunizations had a release date of 10/01/2027. -The policy titled, Influenza Program was revised on 08/01/2023. -The policy titled, Pneumococcal Program was revised on 05/31/2023. -The policy titled, COVID Vaccination for Residents and Staff was revised on 08/01/2023. During an interview on 05/23/2025 at 10:10 AM, Staff F stated they were unsure who was responsible for reviewing the infection prevention policies. They stated they thought the corporate office reviewed them. Staff F stated the policies they had been given were dated from late 2024 so they believed the policies were reviewed yearly. Reference WAC 388-97-1320 (1)(a)(2)(b-c) Refer to F684 for additional information. 40297 47328

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. Additionally, this failure resulted in 27 of 61 residents and 33 staff members contracted Norovirus (highly contagious, gastrointestinal (GI), infectious illness that caused nausea, vomiting, and diarrhea). Findings included . Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) revised April 2024 showed, the facility monitored quality deficiencies related to facility operations and practices causing negative outcomes through the QAPI process. The QAPI committee served as a preventative function by reviewing and improving facility systems and took actions toward enhancing quality of care and quality of life for facility residents. The committee was to consist of the Administrator, Director of Nursing, a physician, the infection preventionist, and three additional facility staff responsible for direct resident care and services. Review of the July 2024 through April 2025 QAPI Committee Minutes showed the following: - 07/21/2024 No input from the Infection Preventionist related to infection prevention and control data. The signature section for committee participants showed no documentation the Infection Preventionist attended the meeting, as required. - 10/29/2024 a soft tissue infection trend was identified, no other infection prevention and control data was found. The signature section for committee participants showed no documentation the Infection Preventionist attended the meeting, as required. - 01/21/2025 No input from the Infection Preventionist related to infection prevention and control data. The signature section for committee participants showed no documentation the Infection Preventionist attended the meeting, as required. - 04/30/2025 No input from the Infection Preventionist related to infection prevention and control data. The signature section for committee participants showed no documentation the Infection Preventionist attended the meeting, as required. Review of the facility GI outbreak line listing showed the facility identified a Norovirus outbreak on 05/03/2025. The outbreak included 24 residents and 25 staff who experienced GI symptoms. In an interview on 05/22/2025 at 4:09 PM, Staff F, Infection Preventionist, stated the QAPI committee met quarterly. Staff F acknowledged they were not monitoring any infection control practices for trends, did not have any infection control Performance Improvement Projects and had not participated in any QAPI meetings as of that date. Reference: WAC 97-388-1760(1)(2) Refer to F867, F865, and F880 for additional information.

Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance Program (QAA) that identified deficiencies and implemented appropriate preventative or corrective actions. The facility's QAA program failed to timely recognize already compromised care and services that resulted in a potential for a pattern of resident harm. Findings included . Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) revised April 2024 showed, the facility monitored quality deficiencies related to facility operations and practices causing negative outcomes through the QAPI process. The QAPI committee served as a preventative function by reviewing and improving facility systems and took actions toward enhancing quality of care and quality of life for facility residents. The QAPI framework was established through five elements: 1) design and scope, 2) governance and leadership, 3) feedback, data systems and monitoring, 4) Performance Improvement Projects (PIPs), and 5) systematic analysis and systemic action. The committee was to meet monthly to identify performance improvement opportunities through tracking and trending of data that necessitated quality assessment and assurance activities against state and national benchmarks. The QAPI committee was to prioritize action plans and evaluate effectiveness of the process improvement activities. The policy included a list of potentially preventable events the facility may monitor including various high-risk medication use to include blood thinners and diabetes medications, care events such as falls, elopements, instances of abuse, neglect or misappropriation and infection such as respiratory infections and infectious diarrhea. The facility QAPI committee reported routinely to the governing body. During the unannounced Recertification Survey conducted from 05/12/2025 to 05/23/2025, the following areas of deficiency were identified by the survey team: Free from Abuse and Neglect (Please refer to F600 for additional information): The facility failed to identify, report, protect, assess and prevent a pattern of resident-to-resident verbal and physical abuse. This included identifying a known pattern of aggressive behaviors by Residents 19. Abusive behaviors identified by staff included hitting, punching, kicking, ramming into other residents with a wheelchair (w/c), verbal abuse, threats and intimidation of other residents. The facility failed to recognize these instances as abuse, analyze the circumstances of these abusive behaviors, or implement plans for prevention or recurrence of abuse. Failure to recognize, analyze, and act upon multiple incidents of resident-to-resident altercations as abuse and provide adequate supervision and care planning with effective interventions placed all residents at risk of serious injury or harm and represented an immediate jeopardy (IJ) that was called on 05/20/2025. Specifically, residents expressed fear when they were subjected to repeat unpredictable outbursts of verbal abuse and actual physical injuries such as coffee thrown on them, grabbing, scratching, slapping, punching, kicking, and skin tears. Quality of Care (Please refer to F684 for additional information): The facility failed to ensure the staff notified the provider for 3 of 3 sampled residents (Resident 34, 40 and 61) reviewed for change in condition. Specifically, the staff failed to notify the provider when Resident 34 experienced extremely low blood sugars, Resident 40 experienced significantly low blood pressures (BP), and Resident 61 experienced elevated blood sugars. This failure precluded the provider's involvement in coordinating care and placed the residents at risk of further adverse or deteriorating clinical outcome. Free Of Accident Hazards/Supervision/Devices (Please refer to F689 for additional information): The facility failed to provide effective monitoring and supervision and implement adequate interventions to prevent Resident 19, Resident 50, and Resident 60 from falling and experiencing adverse and injurious sequalae related to falls, to include transfers to the hospital. Specifically, Resident 19 sustained repeated harm because of falls as evidenced by a dislocated hip on 09/12/2024, a right femur (leg bone) fracture on 01/14/2025, and a back fracture on 03/03/2025. Resident 50 fell a total of 36 times from 04/04/2024 to 05/17/2025 and experienced a range of injuries, to include hospital transfers for their treatment. Additionally, Resident 60 fell three times and experienced a fracture to their eye socket and left lower leg. These failures placed the residents at risk for further repeat serious injuries such as fractures, disability, or death and represented an immediate jeopardy (IJ) that was called on 05/20/2025. In addition, the facility failed to assess, evaluate, and implement interventions for potential risks associated with substance use disorders (SUD) for 1 of 3 sampled residents (Resident 49), reviewed for SUD. Behavioral Health Services (Please refer to F740 for additional information): The facility failed to ensure behavioral health services were provided for 2 of 8 sampled residents (Residents 34 and 40), reviewed for mood and behavior. This failure created risk for residents to experience a decline in their psychosocial well-being. Residents are Free of Significant Medication Errors (Please refer to F760 for additional information): The facility failed to ensure medications were administered as prescribed for 2 of 6 sampled residents (Residents 34 and 61), reviewed for medication administration. Resident 34 received an injection of Lantus insulin (a type of insulin used to treat high blood sugar that provided a consistent level of insulin over a 24-hour period and mimicked the body's natural insulin production) ordered for a different resident. Additionally, Resident 34 received the wrong dose of medication used to decrease diarrhea, and Resident 61 did not receive doses of a blood thinner and an injectable medication that managed weight and blood sugar. This failure caused harm to Resident 34 when they experienced an extended period of symptomatic hypoglycemia (extremely low blood sugar) and required administration of rescue medications on five different occasions and created the potential for unintended health consequences for the residents. Infection Prevention and Control (Please Refer to F880 for additional information): The facility failed to maintain an effective infection control program that identified, reported, and controlled the spread of communicable diseases for residents and staff during a Norovirus [a highly contagious gastro-intestinal (GI, affected the stomach and intestines) virus that caused nausea, vomiting and diarrhea] outbreak and to implement . Basic infection prevention interventions that included enhanced barrier precautions, transmission-based precautions, prompt reporting of a laboratory confirmed Norovirus outbreak to the State Survey Agency and local health departments, and exclusion of staff members from work according to the recommended standards. These failures facilitated a Norovirus the outbreak which spread to all 3 of 3 nursing units and 27 of 61 residents and 33 staff members and placed residents at risk for potential unintended health consequences, and the potential spread of other infectious diseases or organisms resistant to antibiotics. Sufficent Staffing (Please refer to F725 for additional information): The facility failed to repeatedly ensure the facility had enough staff to provide care according to the facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 3 of 7 sampled residents (Resident 19, 50, and 60), reviewed for falls. Specifically, Resident 19 sustained repeated harm because of falls as evidenced by a dislocated hip on 09/12/2024, a right femur (leg bone) fracture on 01/14/2025, and a back fracture on 03/03/2025. Resident 50 fell a total of 36 times from 04/04/2024 to 05/17/2025 and experienced a range of injuries, to include hospital transfers for their treatment. Resident 60 fell three times and experienced a fracture to their eye socket and left lower leg. Additionally, the facility failed to identify, report, protect, assess and prevent a pattern of resident-to-resident verbal and physical abuse by Residents 19 towards 10 different peers (Resident 31, 49, 21, 43, 27, 37, 33, 45, 3, and 41). Abusive behaviors identified by staff included hitting, punching, kicking, ramming into other residents with a wheelchair (w/c), verbal abuse, threats and intimidation of other residents. These failures placed all residents at risk for further repeat serious injuries such as fractures, repeat abuse, potentially avoidable accidents and diminished quality of life. QAPI Program/Plan, Disclosure/Good Faith Attempt (Please Refer to F865 for additional information): The facility failed to develop, implement and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program that identified deficiencies, implemented good faith efforts for corrective actions, and evaluated implemented corrective actions or performance improvement activities for effectiveness. The facility's QAPI program failed to timely recognize already compromised care and services that resulted in a potential for a pattern of resident harm. QAA Committee (Please Refer to F868 for additional information): 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. Additionally, this failure resulted in 27 of 61 residents and 33 staff members contracted Norovirus (highly contagious, gastrointestinal (GI), infectious illness that caused nausea, vomiting, and diarrhea). In an interview on 05/23/2025 at 11:34 AM, with Staff A, Administrator, Staff B, Director of Nursing, Staff C, Clinical Resource Nurse, and Staff Q, Director of Clinical Services, the above areas of concern were reviewed. Staff B acknowledged the facility was aware of the concerns identified by the survey team, but no corrective action had been attempted except for falls. Staff B explained a PIP for falls was initiated which included conducting weekly fall meetings, but it was not effective and needed to be drastically revised. Staff Q stated there was a change in the facility Administrator and Resource Nurse May 1, 2025. Summary The current facility QAA/QAPI process failed to identify critical areas of care that were ultimately elevated to the level of harm and immediate Jeopardy (IJ). The DNS and the Administrator stated the QAPI process needed to be revised, however, this showed the facility QAA/QAPI process evidently failed to provide early detection of these concerns. Reference WAC 388-97-1760 (1)(2)

Based on observation, interview, and record review, the facility administration failed to effectively use its resources to maintain facility compliance with Federal regulatory requirements to ensure potential situations of abuse were identified and proper measures were taken for 11 of 12 sampled residents (Residents 19, 31, 49, 21, 43, 27 37, 33, 45, and 3) reviewed for abuse, provide adequate nursing staff to supervise residents and complete care timely for 3 of 7 sampled residents (Residents 19, 50, and 60) reviewed for falls, provide behavioral and/or mental health services for 2 of 8 sampled residents (Resident 34 and 40) reviewed for mood and behavior, administer medications as prescribed for 2 of 6 sampled residents (Residents 34 and 61) reviewed for medication administration, and implement appropriate infection control measures for 3 of 3 nursing units reviewed for infection control. In addition, the Administration failed to effectively utilize their Quality Assurance and Improvement Program (QAPI) to address and follow up timely on identified concerns. These failures created multiple situations that caused harm to residents, and two separate situations of an immediate jeopardy (IJ: a situation that had occurred that could result in harm, serious injury and/or death). related to abuse and accident hazards. Findings included . Refer to F600 CFR 483.12, Freedom from Abuse and Neglect Administration failed to identify, report and assess a pattern of abuse related to resident-to-resident altercations by Resident 19. In addition, Administration failed to identify, assess or implement interventions for potential incidents of abuse for Residents 31, 49, 21, 43, 27, 37, 33, 45, 3, and 41. These failures created an IJ situation. Refer to F689 CFR 483.25, Accident Hazards and Supervision/Devices Administration failed to ensure there was adequate supervision to prevent accidents related to falls, which led to substantial injuries to Residents 19, 50, and 60. These failures resulted in harm to the residents and created an IJ situation. Refer to F 725, CFR 483.35, Sufficient Nursing Staff Administration failed to provide adequate nursing staff to ensure care and services were provided to residents timely and to keep residents free from falls and injuries. This failure caused harm to Residents 19, 50, and 60. Refer to F760, CFR 483.45, Residents are free of any significant medication errors Administration failed to ensure medications were administered as prescribed to avoid significant medication errors for Residents 34 and 61. This failure resulted in harm to Resident 34. Refer to F880, 483.80, Infection Control Administration failed to ensure the facility's infection control program was implemented according to acceptable standards of infection control practices to prevent and stop the spread of a contagious disease which caused illness to 27 of 61 residents and 33 staff members. REPEAT CITATIONS: Administration failed to ensure that previous citation's corrective measures were maintained and sustainable as evidenced by the following citations being repeated: - Refer to F689 CFR 483.25, Accident Hazards and Supervision/Devices, cited on 05/16/2024 and 05/25/2024. - Refer to F880, 483.80, Infection Control, cited on 05/16/2024 In an interview on 05/22/2025 from 10:53 AM to 11:17 AM, the following above concerns were discussed with Staff Q, Director of Clinical Services and Staff PP, Regional Director. During the interview, Staff PP stated they were aware of communication issues prior to the survey team's arrival at the facility and stated that the previous Administrator had not addressed some concerns, as a result, a new Administrator was hired around the beginning of this month (May 2025). Both Staff Q and Staff PP stated they were aware of issues concerning Resident 19 with regards to resident-to-resident altercations, but were not aware of the other concerns that the survey team had identified. Staff Q stated they were not aware of the depth of the identified issues until being informed by the survey team. Reference WAC: 388-97-1620(1)

Based on interview and record review the facility failed to ensure a Registered Nurse (RN) was on duty a minimum of eight consecutive hours a day, seven days a week, as required. This failure placed all residents at risk of lack of RN oversight for care provided, unmet care needs, and a diminished quality of life. Findings included . A review of the 30-day Staffing Pattern from 04/12/2025 through 05/12/2025 showed there was no RN on duty a minimum of eight hours a day, as required, for the following dates: 04/12/2025, 04/19/2025, 04/26/2025, 05/08/2025, and 05/10/2025. In an interview on 05/22/2025 at 11:35 AM, Staff M, Licensed Practical Nurse (LPN), acknowledged they had worked without an RN on duty. Staff M explained most LPNs can handle most of the same things as an RN but the facility contacted the Director of Nursing as needed, when there was no RN on duty. In an interview on 05/22/2025 at 3:00 PM, Staff D, Resident Care Manager, acknowledged there had been days without an RN on duty but they were on-call in case of emergencies. In an interview on 05/22/2025 at 3:12 PM, Staff X, Staffing Coordinator, reviewed the 30-Day staffing pattern. Staff X acknowledged some days had no RN on duty. Staff X stated, getting RN coverage is hard. Staff X explained they notified the Staff B, Director of Nursing, when unable to staff RN coverage, as required. In an interview on 05/22/2025 at 3:43 PM, Staff B reviewed the 30-Day staffing pattern. Staff B acknowledged some days did not have RN coverage, as required. Staff B further stated they expected staff to schedule an RN on duty, as required. In an interview on 05/23/2025 at 9:36 AM, Staff A, Administrator, stated they expected staff to schedule an RN on duty, as required. Reference WAC 388-97-1080 (3)(a) Refer to F725, F600, F689, F867 for additional information.

Based on interview and record review, the facility failed to develop and implement a system to evaluate staff competencies in skills and techniques related to diabetes management, medication administration, Post Traumatic Stress Disorder (PTSD), Substance Use Disorders (SUD), Gradual Dose Reductions (GDR), trauma informed care, fall management, or incident root cause analysis to ensure staff provided necessary care and responded to each resident's individualized needs for 8 of 10 sampled staff (Staff P, L, AA, BB, CC, DD, EE, and FF), reviewed for nursing services. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, unmet care needs, and diminished quality of life. Findings included . Review of the facility assessment reviewed May 2025 showed, the facility provided care to residents who were diabetic, received blood thinners, had histories of SUD, trauma/PTSD, anxiety, cognitive impairment, and other medical conditions related to mental health. The facility provided person-centered/directed care by building relationships, providing emotional and mental well-being support, support helpful coping mechanisms, determining resident preferences and routines and incorporating the information into the care planning process. The assessment further showed staff competencies were completed during new employee orientation for new hires. Staff received the mandatory 12 hours of required topic training and as needed training conducted when the need was identified. <Staff P> Review of Staff P's, Licensed Practical Nurse (LPN), personnel file showed they were hired on 04/17/2025. Review of Staff P's training records showed no training or competency documentation related to diabetes management, medication administration, PTSD (a mental health condition that could develop after witnessing or being part of an extremely stressful or terrifying event), SUD, GDR [when psychotropics (medications that affect the brain, feelings, and emotions) were slowly and carefully decreased to find the lowest effective therapeutic dose to prevent unnecessary medication use], trauma informed care, fall management, or incident root cause analysis. In an interview on 05/20/2025 at 11:37 AM, Staff P, LPN, acknowledged they did not receive adequate training and did not have their skills and/or competencies assessed. <Staff L> Review of Staff L's, Registered Nurse, personnel file showed they were hired on 03/31/2025. Review of Staff L's training records showed no training or competency documentation related to diabetes management, medication administration, PTSD, SUD, GDRs, trauma informed care, fall management, or incident root cause analysis. <Staff AA> Review of Staff AA's, LPN, personnel file showed they were hired on 11/14/2024. Review of Staff AA's training records showed no training or competency documentation related to diabetes management, medication administration, PTSD, SUD, GDRs, trauma informed care, fall management, or incident root cause analysis. <Staff BB> Review of Staff BB's, LPN, personnel file showed they were hired on 08/01/2022. Review of Staff BB's training records showed no training or competency documentation related to diabetes management, medication administration, PTSD, SUD, GDRs, trauma informed care, fall management, or incident root cause analysis. <Staff CC> Review of Staff CC's, Nursing Assistant (NA), personnel file showed they were hired on 03/12/2024. Review of Staff CC's training records showed no training or competency documentation related to PTSD, SUD, GDRs, trauma informed care or fall management. <Staff DD> Review of Staff DD's, NA, personnel file showed they were hired on 04/16/2024. Review of Staff DD's training records showed no training or competency documentation related to PTSD, SUD, GDRs, trauma informed care or fall management. <Staff EE> Review of Staff EE's, NA, personnel file showed they were hired on 03/18/2025. Review of Staff EE's training records showed no training or competency documentation related to PTSD, SUD, GDRs, trauma informed care or fall management. <Staff FF> Review of Staff FF's, NA, personnel file showed they were hired on 08/01/2022. Staff FF's training records showed no training or competency documentation related to PTSD, SUD, GDRs, trauma informed care or fall management. In an interview on 05/22/2025 at 3:01 PM, Staff D, Resident Care Manager, stated if they received any training related to PTSD, SUD, trauma informed care, or GDRs, documentation would be located in the computerized training record files. In an interview on 05/22/2025 at 3:43 PM, with Staff B, Director of Nursing, and Staff C, Clinical Resource Nurse. Staff B explained the facility reviewed staff competencies by holding a skills fair and utilized a computerized training system to complete annual trainings, as required. Staff B and C were asked if staff received training on PTSD, SUD, GDR, or trauma informed care. Staff C was unsure and would follow-up. In a follow-up interview on 05/22/2025 at 4:12 PM, Staff C, acknowledged the facility had no documentation staff received training on PTSD, SUD, GDR, or trauma informed care. In an interview on 05/23/2025 at 9:36 AM, Staff A, Administrator, stated they expected staff to receive adequate training in order to have adequate skills and competencies to meet the needs of the facility resident population. Reference WAC 388-97-1080 (1), 1090 (1) Refer to F600, F605, F684, F689, F699, F740, F760, F941, F944, and F946 for additional information.

Based on observation, interview and record review, the facility failed to coordinate with the State designated authority to ensure residents with a mental disorder received integrated care based on their needs for 3 of 7 sampled residents (Residents 34, 37, and 40) reviewed for Pre-Admission Screening and Resident Review (PASRR, a two part screening; Level I determined presence of a Severe Mental Illness, SMI, or Developmental Disability and if present required a Level II evaluation by a specialized evaluator to determine if nursing home placement was the appropriate level of care, and what behavioral health or other community services were recommended. A Level II was required to be completed prior to nursing home admission.) Specifically, the facility failed to ensure Resident 34's PASSR level II recommendations were implemented, Resident 40's Level II evaluation was completed timely, and Resident 37's Level I screening was not completed correctly prior to admission. These failures placed the residents at risk of decline in their psycho-social needs or inability to benefit from all services they were entitled to. Findings included . <Resident 34> The 04/08/2025 admission assessment documented Resident 34 had diagnoses that included anxiety, alcohol dependence, and history of other behavioral disorders. The resident was cognitively intact and made decision regarding their healthcare. A review of the record documented Resident 34 transferred to the facility from a nursing facility located in a neighboring county to be closer to family. A PASRR Level II Behavioral Health Notice of Determination completed on 02/14/2025 documented Resident 34 had a mental health diagnosis and may benefit from specialized behavioral health services. Upon further review of the record, there were no orders for a behavioral health referral and no behavioral health provider evaluations or progress notes. During an interview on 05/16/2025 at 9:09 AM, Resident 34 stated they wanted to get well and regain the ability to walk. Resident 34 stated they knew they would have to work hard because they were an alcoholic and addict and without support, it was easy for them to go back to their old ways, and Resident 34 stated they did not want to do that. <Resident 40> The 03/26/2025 quarterly assessment documented Resident 40 had diagnoses that included delusions (persistent belief in false thoughts in spite of contrary evidence) and major depression with psychotic symptoms (a disconnection from reality). Resident 40 was moderately cognitively impaired and took antipsychotic and antidepressant medications daily. A review of the record documented Resident 40 admitted to the facility 12/15 2022 from a neighboring state. The 12/16/2022 PASRR Level I screening indicated no Level II evaluation was necessary at that time. A 04/21/2024 Physician Assistant (PA) progress note documented Resident 40 was still delusional despite an increase in their antipsychotic medication. There were no recommendations for a behavioral health referral or changes to the resident plan of care. A new PASRR Level I was completed on 05/08/2024, indicated the resident had SMI, and a Level II evaluation was indicated related to behaviors of self-isolation, delusions and hallucinations. The Level I was submitted to the State evaluator agency. A review of Staff E, Social Services Coordinator progress notes documented the PASRR Level II request was resent on 05/08/2024. Resident 40 continued to have delusions, distressing hallucinations and dreams. In early December 2024, Staff E called the PASRR evaluator and was told they were back logged and concentrated on hospital patient evaluations first. There were no other progress notes that indicated the status of the Level II evaluation request was followed up on. During an interview on 05/19/2025 at 6:48 AM, Staff E stated they resubmitted a PASRR screening for Resident 40 in May of 2024. They stated if they had not heard back from the evaluators, they sent an email, and the evaluators had been good about answering. Staff E stated they had not reached out to the evaluators regarding Resident 40 since December of 2024, and acknowledged this was not timely. Staff E stated Resident 37 had Level II behavioral health recommendations but had not followed up and acknowledged Resident 37 had not been referred to any behavioral health services. <Resident 37> A record review documented Resident 37 was admitted on [DATE]. A 04/23/2025 quarterly assessment documented Resident 37 had diagnoses that included lung cancer and depression. Resident 37 was cognitively impaired, had a depression evaluation (PHQ9) score of 14 related to feeling bad about themselves, having little energy, having little pleasure or interest in doing things and feeling down. Resident 37 took an antidepressant medication daily. A Level I PASRR dated 01/14/2025 incorrectly documented Resident 37 had no SMI and a Level II evaluation was not indicated. During an interview on 05/12/2025 at 3:28 PM, Resident 37's spouse stated Resident 37 took antidepressant medicine and had been taking it for years because of depression. During an interview on 05/20/2025 at 2:07 PM, Staff E, Social Services Coordinator, stated PASRRs were reviewed by them and the admission nurse upon admission to ensure they were completed correctly. Staff E was unaware that Resident 37's PASRR Level I screening showed no SMI. Staff E stated Resident 37 began having behaviors in February 2025 so a request for a Level II evaluation was completed and submitted. Staff E agreed the Level II should have been completed prior to Resident 37's admission related to their history of depression. Reference: WAC 388-97-1915(4) Refer to F740 for additional information.

Based on interview and record review the facility failed to repeatedly implement the facility abuse prevention policy to include identification of potential instances of abuse, reporting allegations to the State Survey Agency as required, thoroughly investigate allegations, review interventions for effectiveness, revise interventions as needed, and communicate, coordinate, review, and track allegations of abuse through the Quality Assurance and Performance Improvement (QAPI) program for 1 of 11 sampled resident (Resident 19), reviewed for abuse. This failure placed residents at risk of abuse, psychosocial harm, and diminished quality of life. Findings included . Review of the facility policy titled, Preventing Abuse revised August 2023 showed, the facility would identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property was more likely to occur. Staff were to observe residents, visitors and staff to identify inappropriate behaviors and deploy sufficient staff on each shift to meet the needs of the residents. The policy instructed staff to assess, care plan and monitor residents who exhibited behaviors which might lead to conflict such as verbally aggressive behaviors such as screaming, cursing, intimidating, or demanding behaviors and physically aggressive behaviors such as hitting, kicking, grabbing, scratching, biting, pushing, wandering, rummaging, threatening gestures, or throwing objects. Review of the facility policy titled, Identification and Investigation of Abuse, Neglect, Misappropriation, and Injuries of Unknown Origin revised August 2023 showed, the facility reviewed reports of grievances, complaints, and allegations of abuse, neglect, injuries of unknown injury to identify a pattern or isolated incidents. The policy instructed staff to determine a root cause of any incident and evaluate the resident for signs of negative psychosocial impact of the incident to include fear of a person or place or extreme changes in behavior. The facility was to protect all residents from physical and psychosocial harm during and after the investigation by responding immediately to protect the alleged victim and provide increased supervision of the alleged victim and other residents as indicated. Staff were to immediately report all incidents and allegations of abuse to the CEO or designee, the State Survey Agency, and Law Enforcement if a crime was suspected. Once an incident was reported it was to be thoroughly investigated within five working days by conducting resident and staff interviews, determine root cause of the incident and implement corrective action to immediately address safety issues, updated care planned interventions based on the investigation findings, and complete staff training as indicated. According to the 04/10/2025 quarterly assessment, Resident 19 had severe cognitive impairment with inattention and disorganized thinking. The assessment further showed Resident 19 exhibited worsening verbal and physical behaviors directed towards others that significantly interfered with Resident 19's care, participation in activities or social events, placed others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or the living environment. Review of the facility October 2024 through May 2025 incident report tracking log showed Resident 19 was involved in 11 resident-to-resident altercations with 10 different peers (Resident 31, 49, 21, 43, 27, 37, 33, 45, 3, and 41) on the following dates: 10/16/2024, 11/07/2024, 01/11/2025, 01/13/2025, 02/10/2025, 02/27/2025, 03/08/2025, 04/04/2025, 04/11/2025, 04/25/2025, and 05/10/2025. Review of the facility resident-to-resident incident report investigations showed the following: -10/16/2024 contained only one statement, no other staff or resident interviews were included, and no documentation was found to show abuse or neglect was ruled out. -02/10/2025 (first altercation with Resident 31) contained only one statement, no other staff or resident interviews were included. -02/27/2025 contained only one statement, no other staff or resident interviews were included. Root cause was determined to be Resident 19 was agitated and within close proximity of another resident. The care plans were updated as indicated. Abuse and neglect was ruled out related to care plans being followed. Additional record review of Resident 19's care plan showed no documentation interventions were revised or new interventions implemented as indicated. -03/08/2025 Resident 19 initiated physical aggression towards Resident 21 and 43. The investigation did not contain staff or other resident interviews. Abuse and neglect was ruled out related to care plans being followed and incident occurred within line of site of staff. Resident 21 was educated to avoid Resident 19 and request staff remove Resident 19 from the vicinity. Resident 19's care plan was again updated as indicated. Additional record review of Resident 19's care plan showed no documentation interventions were revised or new interventions implemented as indicated. -04/04/2025 contained only one statement, no other staff or resident interviews were included, and no documentation was found to show abuse or neglect was ruled out. Root cause was determined to be Resident 19 had severe cognitive impairment with unknown situational comprehension. Resident 19 continued on 15-minute safety checks and the facility was refraining from adding 1 on 1 staff with [Resident 19] as it is believed this will cause further agitation. Care plan updated as indicated. Additional record review of Resident 19's care plan showed no documentation interventions were revised or new interventions implemented as indicated. -04/11/2025 Resident 19 initiated physical aggression toward Resident 45. The investigation contained no resident or staff interviews. Resident 45 was educated to avoid Resident 19 and not wear their headphones in the hallway. Abuse and neglect was ruled out because the care plan was being followed. Resident 19's care plan updated as indicated. -04/25/2025 (second altercation with Resident 31) while in the dining room with staff present but who did not observe the incident. The investigation contained no resident or staff interviews. Abuse and neglect was ruled out because the care plan was being followed. Resident 19's care plan updated to be within line of site of staff while in the dining room. -05/10/2025 (third altercation with Resident 31) while near the nurses' station. The investigation contained two staff statements but no other resident interviews. Resident 31 was provided television headphones. Root cause was not established, and abuse and neglect was not ruled out. The provider reviewed Resident 19's medical record on 05/16/2025, six days after the incident occurred, and made recommendations for blood work and recommended adding a vitamin. Additional record review of Resident 19's care plan showed no documentation interventions were revised or new interventions implemented. Review of the 09/10/2024 self-care deficit care plan showed Resident 19 was able to self-propel their wheelchair (WC) independently. The 10/17/2024 care plan showed Resident 19 had potential to yell and strike out at other residents related to dementia and poor impulse control. Interventions included to assess and anticipate Resident 19's needs, give positive feedback, frequent safety checks when out of bed, reapproached with different staff when agitated, and maintain a consistent routine. On 11/01/2024 Resident 19 was placed on 15-minute safety checks around the clock, on 03/27/2025 a basket of favorite things was placed at the nurses' station for Resident 19 to rummage through, and on 04/28/2025 Resident 19 was to be in staff's direct line of sight when in the dining room for meals. Additional record review showed the facility did not re-evaluate interventions for effectiveness, modify interventions or implement new interventions to prevent recurrence of resident-to-resident altercations each time a resident-to-resident altercation occurred. Review of October 2024 through February 2025 nursing progress notes showed Resident 19 was involved in eight additional resident-to-resident altercations on the following dates 10/28/2024, 11/28/2024, 12/06/2024, 01/01/2025, 01/26/2025, 02/11/2025, 02/19/2025, and 02/25/2025 not identified on the facility accident and incident log, not reported to the State Survey Agency, or investigated, as required. The incident investigations were requested on 05/19/2025 at 5:22 AM, from Staff A, Administrator. Only one of the eight requested incident investigation was provided, 01/26/2025. Review of the October 2024 through April 2025 QAPI committee minutes showed the following: -10/29/2024 No documentation found to show allegations of abuse, investigations, and corrective action was tracked by QAPI to ensure a thorough investigation was conducted, ensure residents were protected, an analysis was conducted as to why the situation occurred, review of risk factors contributing to abuse, and if there was a need for systemic action to be taken. -01/21/2025 The facility self-reported three allegations that were unsubstantiated. -04/30/2025 No documentation found to show allegations of abuse, investigations, and corrective action was tracked by QAPI to ensure a thorough investigation was conducted, ensure residents were protected, an analysis was conducted as to why the situation occurred, review of risk factors contributing to abuse, and if there was a need for systemic action to be taken. In an interview on 05/14/2025 at 10:25 AM, the resident council stated Resident 19 wandered, was disruptive, and aggressive towards others. The council explained Resident 19 was spontaneous, unpredictable, with quickly fluctuating behaviors and could be smiling and friendly one minute then flying off the handle at residents and staff the next minute. The council voiced feeling unsafe due to Resident 19's continued behaviors. In an interview on 05/19/2025 at 8:00 AM, Staff E, Social Service Coordinator, stated resident behaviors were tracked by nursing staff via nursing progress notes, social services and the provider would be notified of odd or abnormal behaviors so additional follow up could be done. Staff E further stated allegations of potential abuse were investigated by conducting resident and staff interviews to get a broader picture of the incident. Staff E was asked if instances of resident-to-resident altercations were considered abuse. Staff E explained if there was physical contact then yes that was definitely an allegation of abuse but instances of yelling back and forth were not considered potential abuse unless the yelling involved threats. Staff E stated Resident 19's mood and behaviors could quickly randomly fluctuate and escalate to the point of being too ramped up to calm down. Staff E explained Resident 19 enjoyed to self-propel their WC up and down the hall but that could create resident-to-resident altercations because Resident 19 would get upset when peers were in the way and lashed out physically. Staff E acknowledged Resident 19's behaviors placed them and others at risk for abuse and unfortunately Resident 19 was involved in the most resident-to-resident altercations. Staff E explained Resident 19 had been involved in resident-to-resident altercations even while on 15-minute safety check monitoring because Resident 19 was mobile, and it was difficult to anticipate what would trigger them. Staff E acknowledged staff should protect residents from abuse. In an interview on 05/19/2025 at 8:55 AM, with Staff B, Director of Nursing, and Staff C, Clinical Resource Nurse. Staff B reviewed Resident 19's medical record. Staff B acknowledged Resident 19 enjoyed self-propelling their WC throughout the facility, had quickly fluctuating verbally and physically aggressive behaviors towards others that placed them at risk for abuse. Resident 19 was involved in numerous verbal and physical resident-to-resident altercations even while on 15-minute safety checks. Staff B explained if a resident exhibited physical behaviors towards others it was reported, investigated, and addressed as potential abuse but verbally aggressive behaviors were documented and monitored per the facility behavior monitoring policy as behaviors experienced. Staff B acknowledged the facility had not been addressing verbally aggressive altercations as potential verbal abuse and should have. Staff B further acknowledged the facility had not protected residents from abuse. In an interview on 05/23/2025 at 9:36 AM, Staff A, Administrator, stated they expected staff to implement the facility's abuse prevention policy and identify, monitor, investigate, report, and protect residents from abuse, as required. Reference WAC 388-97-0640 (2) Refer to F600, F725, F867, and F865 for additional information.

Based on interview and record review, the facility failed to inform residents and/or their representatives about their right to have their bed held while hospitalized for 2 of 4 sampled residents (Residents 51 and 19), reviewed for hospitalization s. This failure precluded the residents and/or their representatives to participate in decisions regarding their right to return to the same facility upon hospital return, and the right to know how much the facility would charge for holding their bed. Findings included . Review of a revised April 2025 facility policy titled Bed-Hold Readmission showed, the facility issued two notices related to bed-hold policies. The first notice was given well in advance of any transfers such as information in the admission packet, and the second notice provided to the resident and/or the resident representative at the time of transfer to the hospital, or in cases of emergency transfer, within 24 hours of transfer. <Resident 51> Review of a 05/04/2025 admission assessment showed Resident 51 admitted to the facility on [DATE] with medically complex conditions. The assessment showed the resident had moderate cognitive impairment. Additional review of the medical record showed Resident 51 was their own responsible party. Review of a April 2025 nursing progress note showed on 04/30/2025 Resident 51 readmitted from the hospital. The note prior to 04/30/2025 was 04/24/2025 but showed no documentation of a change in condition or reason for hospital transfer. Review of a Census List showed Resident 51 went to the hospital on 04/25/2025. Additional review of the medical record showed there was no information that showed why Resident 51 was transferred to the hospital and no documentation was found to show staff informed the resident and/or their representative of their right to hold their bed at the time of or shortly after the 04/25/2025 hospital transfer. Further review of a May 2025 nursing progress notes showed on 05/11/2025 Resident 51 experienced a change in condition after a fall and required a transfer to the hospital. Additional review of the medical record showed no documentation staff informed the resident and/or their representative of their right to hold their bed at the time of or shortly after the 05/11/2025 hospital transfer. The above findings were shared with Staff N, Resident Care Manager (RCM), on 05/15/2025 at 8:56 AM. Staff N confirmed there was no documentation staff informed Resident 51 and/or their representative of their right to hold their bed or provided Resident 51 a notice of bed hold policy at the time of transfers to the hospital and it should have been offered and documented, as required. 47328 <Resident 19> According to the 04/10/2025 quarterly assessment, Resident 19 had severe cognitive impairment with inattention and disorganized thinking. The assessment further showed Resident 19 exhibited worsening verbal and physical behaviors directed towards others that significantly interfered with Resident 19's care, participation in activities or social events, placed others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or the living environment. Review of after visit hospital summaries showed Resident 19 was transferred to the hospital on 09/12/2024, 01/13/2025, 02/26/2025, 02/28/2025, 03/03/2025, and 03/08/2025 for various reasons. Review of September 2024 through April 2025 nursing progress notes showed the following: -01/14/2025 Resident 19 was transferred to the hospital after they sustained a fall. No documentation was found to show staff informed Resident 19 and/or their representative of their right to hold their bed or reviewed the bed hold policy at time of hospital transfer. -02/28/2025 Resident 19 was transferred to the hospital related to increased agitation. No documentation was found to show staff informed Resident 19 and/or their representative of their right to hold their bed or reviewed the bed hold policy at time of hospital transfer. -03/03/2025 Resident 19 was hospitalized . No documentation was found to show staff informed Resident 19 and/or their representative of their right to hold their bed or reviewed the bed hold policy at time of hospital transfer. -04/11/2025 Resident 19 was transferred to the hospital related to combative behaviors towards staff. No documentation was found to show staff informed Resident 19 and/or their representative of their right to hold their bed or reviewed the bed hold policy at time of hospital transfer. Review of December 2024 through March 2025 provider progress notes showed Resident 19 was transferred to the hospital on 12/27/2025 after they sustained a fall with a femur fracture, on 03/03/2025 after they sustained a fall out of their wheelchair, and on 03/25/2025 after they were involved in a resident-to-resident altercation. Additional review showed no documentation to show staff informed Resident 19 and/or their representative of their right to hold their bed or reviewed the bed hold policy at time of hospital transfer. Review of the 04/11/2025 emergent transfer assessment showed Resident 19 was transferred to the hospital for agitation and violent behaviors. Additional review showed no documentation staff informed Resident 19 and/or their representative of the notice of their right to hold their bed or reviewed the bed hold policy at time of hospital transfer. In an interview on 05/22/2025 at 10:56 AM, Staff D, RCM, reviewed Resident 19's medical record. Staff D acknowledged staff should document they informed residents and/or their representative of their right to hold their bed or provided a notice of bed hold policy at time of hospital transfer. In an interview on 05/22/2025 at 10:56 AM, Staff B, Director of Nursing, stated if a resident was transferred to the hospital, they expected staff to document they informed the resident and/or their representative of their right to hold their bed or provided a notice of bed hold policy at time of hospital transfer. In an interview on 05/23/2025 at 9:36 AM, Staff A, Administrator, stated if and/or when a resident was transferred to the hospital, they expected staff to document they informed the resident and/or their representative of their right to hold their bed or provided the a notice of bed hold policy. Reference WAC 388-97-0300(3)(a), -0260, -1020(4)(a-b).

Based on observation, interview, and record review the facility failed to ensure services provided consistently and routinely met professional standards of practice for 2 of 4 sampled residents (Resident 51 and 19), reviewed for hospitalization s. Specifically, the facility failed to repeatedly ensure resident hospital transfer documentation was completed as required to include the basis for hospital transfer, specific resident needs unable to be met by the facility, facility attempts to meet the needs, services available at the receiving facility to meet needs, and what information was conveyed to the receiving provider. This failure placed residents at risk of potential delays in emergent hospital treatment, unmet care needs, and potential complications. Findings included . Review of the facility policy titled, Documentation of Resident Health Status Needs and Services revised October 2022 showed, staff were to document in a resident's medical record as soon as the encounter concluded to ensure accurate recall of the data. The medical record must contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress including their response to treatments and/or services, and changes in their condition, plan of care goals, objectives and/or interventions. The policy instructed staff to record pertinent resident data that may include change of condition, infection, illness, actions taken, provider and family notifications, consultations, any unusual or abnormal outcomes, decline in activities of daily living, events and accidents and communications with others regarding the resident. The American Nurses Association (ANA) is a national professional organization that represents the interests of registered nurses in the United States and sets and promotes high standards of nursing practice to ensure quality and ethical care for patients. The ANA developed the document, Nursing: Scope and Standards of Practice, with its fourth edition released in 2021. The resource informs and guides nurses in providing safe, quality, and competent patient care. The resource outlined and described 18 standards of practice for nursing professionals to follow. Review of the Nursing: Scope and Standards of Practice resource showed the first six standards included: 1. Assessment: effectively collect data and resident information that is relative to their condition or situation. 2. Diagnosis: analyze the data gathered during the assessment phrase, to determine potential or actual diagnoses. 3. Outcomes Identification: effectively predict outcomes for the resident. 4. Planning: After identifying a diagnosis and outcomes, develop a plan or strategy to attain the best possible outcome for the resident in need. 5. Implementation: Implement the identified plan. This may be done by coordinating care for the residents, such as administering treatment, or implementing/following provider orders. 6. Evaluation: After implementation, a nurse must monitor and evaluate the patient's progress towards the expected outcome or health goals. <Resident 51> Review of a 05/04/2025 admission assessment showed Resident 51 admitted to the facility on [DATE] with medically complex conditions to include cancer, high blood pressure, and the presence of a pacemaker (a small, battery-powered device that is surgically implanted to help control the heart's rhythm). The assessment showed the resident had moderate cognitive impairment. Additional review of the record showed Resident 51 had two designated Emergency Contacts. Review of a 04/30/2025 progress note showed Resident 51 readmitted from the hospital. The note prior to 04/30/2025 was documented on 04/24/2025 and showed no change in condition. Review of a Census List showed Resident 51 went to the hospital on 04/25/2025. Additional review of the record showed no information that showed how the nurses assessed Resident 51 and the result of their assessment, what care needs were identified prior to the transfer, discussed the transfer with the resident and addressed their concerns, the reason for the resident's subsequent transfer to the hospital, that the provider or emergency contacts were notified, or what information was conveyed to the receiving hospital. The above findings were shared with Staff N, Resident Care Manager (RCM), on 05/15/2025 at 8:56 AM. Staff N said they expected the nurse to document information relevant to hospital transfers on the Emergent Transfer form. The Emergent Transfer form showed documents sent to the receiving hospital at the time of transfer including an assessment of the resident in a Resident Transfer Form (Evaluation or InterAct) and who was notified of the transfer event. Staff N stated there should be a progress note that detailed the account of the circumstances that led to Resident 51's transfer to the hospital, to include how the nursing process was applied to show an assessment of the resident, looking at the information gathered during the assessment phase, determining what could be causing the change in condition, and notifying the provider based on the likely outcome of the assessment. <Resident 19> According to the 04/10/2025 quarterly assessment, Resident 19 had severe cognitive impairment with inattention and disorganized thinking. The assessment further showed Resident 19 exhibited worsening verbal and physical behaviors directed towards others that significantly interfered with Resident 19's care, participation in activities or social events, placed others at significant risk for physical injury, significantly intruded on the privacy or activity of others and significantly disrupted care or the living environment. Review of after visit hospital summaries showed Resident 19 was transferred to the hospital on 09/12/2024, 01/13/2025, 02/26/2025, 02/28/2025, 03/03/2025, and 03/08/2025 for various reasons. Review of September 2024 through April 2025 nursing progress notes showed the following: -01/14/2025 Resident 19 was transferred to the hospital after they sustained a fall. No documentation was found to show the specific resident needs the facility was unable to meet, facility attempts to meet the needs, services available at the receiving facility to meet needs, and what information was conveyed to the receiving provider. -03/03/2025 Resident 19 was hospitalized . No documentation was found to show the specific resident needs the facility was unable to meet, facility attempts to meet the needs, services available at the receiving facility to meet needs, and what information was conveyed to the receiving provider. -04/11/2025 Resident 19 was transferred to the hospital related to combative behaviors towards staff. No documentation was found to show services available at the receiving facility to meet needs, and what information was conveyed to the receiving provider. Review of December 2024 through March 2025 provider progress notes showed Resident 19 was transferred to the hospital on 12/27/2025 after they sustained a fall with a femur fracture, on 03/03/2025 after they sustained a fall out of their wheelchair, and on 03/25/2025 after they were involved in a resident-to-resident altercation. Additional review showed no documentation the required information was conveyed to the hospital. Review of the 04/11/2025 emergent transfer assessment showed Resident 19 was transferred to the hospital for agitation and violent behaviors, documentation showed all the required information was not conveyed to the receiving facility. In an interview on 05/22/2025 at 10:56 AM, Staff D, RCM, reviewed Resident 19's medical record. Staff D acknowledged omissions in documentation related to hospital transfers. Staff D acknowledged staff should document the reason for hospital transfer and the information conveyed to the hospital which shows the nursing process and professional standards of practice. In an interview on 05/22/2025 at 11:07 AM, Staff B, Director of Nursing, stated if a resident was transferred to the hospital, they expected staff to document information conveyed to the hospital, as required. In an interview on 05/23/2025 at 9:36 AM, Staff A, Administrator, stated they expected staff to document information conveyed to the hospital when transfers to hospital occur, as required. Reference WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i). Refer to F552 and F745 for additional information.

Based on observation, interview and record review, the facility failed to ensure the staff notified the provider for 3 of 3 sampled residents (Resident 34, 40 and 61) reviewed for change in condition. Specifically, the staff failed to notify the provider when Resident 34 experienced extremely low blood sugars, Resident 40 experienced significantly low blood pressures (BP), and Resident 61 experienced elevated blood sugars. This failure precluded the provider's involvement in coordinating care and placed the residents at risk of further adverse or deteriorating clinical outcome. Findings included . The 11/28/2017 facility policy Resident Change of Condition documented that upon recognition of a potentially life-threatening condition or significant change in status, the nurse was to communicate with other health care providers. The physician was to be informed at the time of the event as soon as possible. Notification should occur immediately if any symptom, sign or apparent distress is sudden in onset, or a marked change in relation to usual symptoms and signs or unrelieved by measures already prescribed. In addition to others, staff were to document the resident assessment, care provided, physician response, orders, and resident status and response. <Resident 34> The 04/08/2025 admission assessment documented Resident 34 had diagnoses that included end-stage kidney disease dependent on dialysis (a mechanical way of ridding the body of toxins when the kidneys no longer functioned) and diabetes. Resident 34 was cognitively intact and received daily insulin injections. The 04/02/2025 Diabetes Care Plan instructed staff to consult with the Registered Dietician regarding dietary restrictions and compliance with nutritional regimen as indicated, administer diabetic medications as ordered and monitor for side effects. If hyperglycemic (a blood sugar level greater than 300 milligrams per deciliter, mg/dl) follow insulin medication orders or contact the provider and follow orders. If hypoglycemic (a blood sugar level less than 70mg/dl) treat according to the hypoglycemic protocol. Document the treatment, interventions, symptoms and assessment in progress notes. Resident 34 had the following provider orders: -04/02/2025 check fingerstick blood sugar levels before meals and at bedtime. If result is below 70mg/dl, initiate hypoglycemic protocol and notify the provider. If greater than 400mg/dl, notify the provider and follow directives. -04/02/2025 hypoglycemic protocol-if able to take oral, give 15mg fast-acting carbohydrate (a type of nutrition that contains sugar), recheck blood sugar in 15 minutes. If still less than 70, give another 15gm fast acting carbohydrate. Recheck in 15 minutes. If still less than 70mg/dl, notify the provider. Once above 70mg/dl, give a protein snack or assist to next meal. -04/02/2025 glucagon (a type of sugar) pen-type auto injector, inject 1mg as needed for blood sugar less than 70mg/dl and the resident is unable to swallow. Recheck in 15 minutes. If no improvement, notify the MD immediately. May repeat the process. On 05/06/2025 at 8:37 AM, Staff M, Licensed Practical Nurse (LPN), documented Resident 34 had a fingerstick blood sugar level of 46 and required two doses of fast-acting oral glucose gel (per the hypoglycemic protocol). At 8:49 AM, the resident moaned, groaned, was very lethargic, drifted off to sleep, then briefly woke to call out for water or help. Resident 34 stated at that time, I do not want to die. The progress note also documented Resident 34 had a low oxygen saturation level of 86% (normal level ranges from 95 to 100% on room air) while receiving supplemental oxygen at 2 liters (L). This required the supplemental oxygen to be increased to 3L. The Resident Care Manager was notified, and Staff M documented they would recheck the resident's blood sugar in 10 minutes. There was no documentation that the blood sugar level was rechecked, that the resident's oxygenation status was rechecked, or that the provider was notified of the resident's condition. The May 2025 Medication Administration record (MAR) had no documentation of the administration of the fast-acting glucose gel. Furthermore, Staff M's progress notes documented that at 11:27 AM, Resident 34 refused all oral medications. At 12:17 PM, the resident was ill with Norovirus and ate and drank poorly. At 12:36 PM, the resident's blood sugar was 118 mg/dl. The resident had large loose foul-smelling diarrhea. The resident continued to require extra supplemental oxygen for levels that hovered around 88-90%, and their oxygen levels dropped if the resident talked. The resident slept for long intervals, then moaned and groaned when awake and stated they did not want to die. The progress note did not document that the provider was notified. <Resident 40> The 03/26/2025 quarterly assessment documented Resident 40 had diagnoses that included stroke and high blood pressure. Resident 40 was moderately cognitively impaired and was dependent on staff for most of their activities of daily living. The 01/04/2023 stroke care plan instructed staff to give medications as ordered, monitor and document side effects and effectiveness, and obtain vital signs (heart rate, blood pressure, respirations or temperature, for example) per protocol, and document and advise the provider of abnormal findings. A review of the May 2025 Medication Administration Record documented Resident 40 required alert charting for gastroenteritis beginning 05/05/2025 and discontinued on 05/10/2025. Staff were to document signs and symptoms, if symptoms improved or worsened, vital signs, adverse side effects if antibiotics had been ordered every shift for monitoring. Further review of the MAR documented a blood pressure of 88/60 (extremely low) on 05/06/2025, 05/07/2025, and 05/08/2025. On 05/09/2025, blood pressures of 92/64 and 90/60 were recorded. Medication Resident 40 took for managing their high blood pressure met parameters and was held on 05/07/2025 and 05/08/2025. A 05/05/2025 at 1:05 AM nursing progress note documented the resident slept when checked, and their blood pressure was recorded as 142/64. At 2:42 PM, the resident had nausea and was given anti-nausea medication. There were no other progress notes until 05/09/2025 that documented the nausea/vomiting/diarrhea alert charting was discontinued. There were no progress notes that documented assessments of the resident when their blood pressure results were low, and no note that documented the provider was notified. During an interview on 05/22/2025 at 11:50 AM, Staff M, LPN, reviewed the blood pressures of 88/60 that Staff M had entered on the MAR. They stated they did not remember talking to any providers about the low blood pressures and stated Resident 40 did not normally run low and this would have indicated a change for the resident. Staff M stated if Resident 40 had been ill, the low blood pressures could indicate the resident was dehydrated and they would want the provider to know. Staff M stated they took care of Resident 34 on 05/06/2025. The resident was not eating, and medications were held. Staff M stated they thought they spoke to the Nurse Practitioner but was unable to see where that had been documented. Staff M stated any vital signs that were out of the normal range was to be reported to the provider and this was not done and should have been. Staff M acknowledged they also did not document the administration of the fast-acting glucose gel and should have. During an interview on 05/22/2025 at 2:24 PM, Staff O, Nurse Practitioner, stated when a resident was sick and had abnormal vital signs, it could signal that they were dehydrated or might require a visit to the emergency room and they would want to be notified of low blood sugars and low blood pressures. 40297 <Resident 61> Review of a 04/27/2025 admission assessment showed Resident 61 admitted to the facility on [DATE], was assessed as cognitively intact, and had the diagnosis of diabetes. Review of Resident 61's April and May 2025 Medication Administration Record (MAR) showed the staff administered insulin to the resident. The MAR instructed the nurses to check the resident's blood sugar before meals and at bedtime and to notify the provider if the blood sugar was greater than 300 and follow their instruction. Review of the April 2025 MAR showed the staff obtained blood sugars above 300 on 04/21/2025 at 4:30 PM at 401, 04/21/2025 at 8:00 PM at 401, 04/28/2025 at 8:00 PM at 315, and 04/30/2025 at 4:30 PM at 322. Additionally, no blood sugar measurements were recorded as obtained on 04/25/2025 at 8:00 PM. Review of the progress notes showed no documentation why the staff did not obtain the blood sugar on 04/25/2025 or that they notified the provider as ordered to obtain further instructions for the management of the elevated blood sugars. Review of the May 2025 MAR showed the staff obtained blood sugars above 300 on 05/10/2025 at 8:00 PM at 338. Additionally, no blood sugar measurements were recorded as obtained on 05/02/2025 at 8:00 PM. Review of the progress notes showed no documentation why the staff did not obtain the blood sugar on 05/02/2025 or that they notified the provider as ordered to obtain further instructions for the management of the elevated blood sugar. The above findings were reviewed with Staff C, Clinical Resource Nurse, on 05/16/25 at 9:57 AM. Staff C acknowledged the elevated blood sugars, the missing blood sugar measurements, and confirmed there was no documentation in the medical record that showed the nurses notified the provider of the elevated blood sugars above 300 as ordered. Reference WAC 388-97-1060 (1) Refer to F760 for additional information.

Based on interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for accidents, was free from injury. Resident 1 experienced harm when they were transferred in a sit to stand (designed to assist patients who have some mobility but need help to rise from a sitting position) by staff, the resident's arm sling got caught and wrapped around their neck causing them to become unresponsive; staff left the resident unattended in the lift to get help, the resident fell out of the lift, and was found on the floor. This failure placed the residents at risk for falls and serious injury Findings included . Review of a facility assessment, dated 04/01/2024, showed Resident 1 had diagnoses to include heart disease and Diabetes. The resident was able to make their needs known, required maximum assistance with bed mobility and was dependent with transfers. The resident used a sit to stand lift to be transferred. Review of the facility investigation, dated 06/10/2024, showed Resident 1 requested to use the bathroom. Staff A, Nursing Assistant, put the resident in the sit to stand lift to transfer them to the commode. The resident had a sling on their left arm. The resident was raised in the lift and stated their neck hurt. Resident 1's face then went red, they let go of the handles on the lift, and was hanging by the sling, unresponsive. Staff A went out to the hall to get help and heard the resident fall to the floor. Staff entered the room, the resident was on the floor, and remained unresponsive. Staff called 911 and sent the resident to the hospital. Review of hospital records, dated 06/10/2024, showed Resident 1 arrived at the hospital alert and oriented. The resident was able to explain what occurred prior to passing out at the facility. There were abrasive areas on the resident's neck, but staff were unable to determine if it was from the sling or a rash. The resident had no complaints of pain. It was documented that the resident had a strangulation event at the nursing facility due to being placed in a device to be transferred, their sling got caught in the lift, which went around the resident's neck. The resident was left alone in the room while staff got help and when staff entered the room, the resident was on the floor and unresponsive. During an interview on 06/25/2024 at 2:00 PM, Staff B, Resident Care Manager (RCM) and Staff C, RCM stated the staff member that completed the investigation no longer worked at the facility. Staff B and C stated Resident 1 was sent out to the hospital, the facility was not aware the sling had gone around the resident's neck until the hospital called with report. Resident 1 was evaluated by therapy after the incident and was changed to Hoyer lift (a lift for a person to be lifted and transferred with minimal physical effort). Reference: WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1), reviewed for accidents, was free from injury. Resident 1 was transferred by a Hoyer lift (a power lift using a sling) independently by Staff B, Nursing Assistant. The Hoyer sling was improperly placed which caused Resident 1 to slide down during the transfer and their arms were pulled upward. Resident 1 experienced harm when they had pain and was sent to the hospital for evaluation where it was determined they sustained a fracture of their left arm. This constituted a Past Non-Compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified) at harm. The facility immediately educated and completed traning by 12/04/2023 Staff B and all staff on the proper use of Hoyer lifts, emphasizing safe Hoyer lifts require two employees, along with skill and competency check offs. The facility was notified of the past non-compliance on 01/10/2024. Findings included . Review of a facility assessment, dated 12/05/2023, showed Resident 1 had diagnoses to include a disorder of movement and muscle tone. The resident was able to make their needs known. Per the assessment, Resident 1 was dependent for Activities of Daily Living (ADL's). Review of the resident's bedside plan of care, dated 01/05/2024, showed Resident 1 transferred with a Hoyer lift and two staff. Review of a progress note, dated 12/01/2024, showed Staff A, Registered Nurse (RN), was called to Resident 1's room. Staff B used a Hoyer lift to transfer the resident from their wheelchair to bed. When the Hoyer was elevated, Resident 1's body slid down the lift sheet which pulled their left arm in an upward motion. Staff A conducted an assessment and the resident complained of pain to the left arm/shoulder. Staff A could not perform Range of Motion (ROM) due to pain and was sent to the hospital. Review of the facility's event summary report, dated 12/07/2024, showed Staff B completed rounds and found Resident 1 required assistance with toilet hygiene. Staff B put Resident 1 in a Hoyer lift sling and began to transfer the resident to their bed. Resident 1 slid down the lift sheet and their left arm was pulled in an upward motion. Resident 1 was sent to the hospital and had sustained a fracture of their arm. The conclusion of the incident showed Staff B attempted the transfer independently, the Hoyer sling was improperly positioned below the resident's shoulder which caused the resident to slide down during the transfer. During an interview on 01/10/2024 at 11:16 AM, Staff C, Nursing Assistant, stated they would review resident bedside care plans to determine their transfer status. Staff C stated Hoyer lifts always required two staff members to use. Staff C stated they had recently received re-education on Hoyer lift use. On 01/10/2024 at 11:24 AM, Staff D, Nursing Assistant, was observed using the Hoyer lift for a resident being transferred from the bed to their wheelchair. Staff D had the resident roll side to side to place the sling underneath them and connected the sling to the Hoyer. Staff D stated they were getting a second staff member and used a facility radio to ask for assistance. A second staff member came into the room. The resident was instructed to cross their arms while the Hoyer was being lifted. The resident was properly transferred to their wheelchair. During an interview on 01/10/2024 at 11:45 PM, Staff F, Director of Nursing, stated they were notified of the incident and immediately went to the facility. Staff B had explained to Staff F they had called for assistance with the Hoyer and no one came. Staff B proceeded to transfer Resident 1 by themselves. Staff B was educated on Hoyer use, with return demonstration, and was suspended pending the investigation. Staff F educated other staff working that shift and proceeded to educate the remainder of the staff. This was a Past Non-Compliance at harm level and is no longer outstanding. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure one of eight sample residents (#9), reviewed for abuse, was free from verbal abuse, aggression, and intimidation, from her roommate. Failure to implement timely interventions to provide a safe environment, and to protect the resident from verbal abuse, after the resident expressed fear of her roommate on more than one occasion, resulted in psychosocial harm to Resident #9. Findings included According to the State Operations Manual (SOM), last revised 11/22/17, under F 600 Freedom from Abuse, Neglect and Exploitation, the facility must provide a safe resident environment and protect residents from abuse. In addition, the SOM states, Based on the presence of resident to resident altercations, if the facility did not evaluate the effectiveness of the interventions and staff did not provide immediate interventions to assure the safety of residents, then the facility did not provide sufficient protection to prevent resident to resident abuse. A grievance form dated 06/07/19 showed Staff K, Nursing Assistant, had reported Resident #9 and Resident #46 were having arguments. The residents were roommates, and per the grievance, staff felt they did not get along. According to the form, the concern was discussed in the stand-up meeting on 06/10/19, three days after initiallly expressed. No other action or information was documented on the form, and a review of both resident's records found no mention of the concern, or any follow-up. On 06/20/19, a second grievance form showed Resident #9 had informed Staff I,[NAME] Clerk, that Resident #46 was taking her belongings and when confronted, became argumentative and bullied her. Resident #9 stated she didn't feel she could move about her room freely, and was afraid Resident #46 would hurt her because of how the resident hit, kicked and bit staff. No other action or information was included on the form. No documentation of the concern, or interventions taken to provide a safe environment and/or protect Resident #9, were found in either resident's records. The facility failed to identify that Resident #9 was being verbally abused by Resident #46 , felt intimidated, and was fearful. In addition, the facility failed to take immediate steps to protect Resident #9 from further verbal abuse and intimidation by her roommate. On 06/24/19, a grievance form completed by Staff M, Speech Therapist, reported that Resident #9 had informed staff Resident #46 had thrown a rolled-up blanket at her the previous day (06/23/19), and stated she did not feel comfortable with Resident #46. The concern was changed to an incident report and facility investigation. A review of the facility investigation showed that Resident #9 had visitors the evening of 06/23/19, who had informed nursing staff the resident stated she was afraid of Resident #46, due to her throwing items and threatening her. Per the investigation, Resident #9 wanted Resident #46 be moved to another room. No documentation was found to show the facility took immediate steps to ensure a safe environment for Resident #9, to prevent additional incidents of verbal abuse and intimidation. A review of Resident #9's progress notes showed on 06/25/19 at 5:20 PM, five days after Resident #9 expressed being bullied and fearful of Resident #46 (and two days after the last altercation), Resident #9 was moved temporarily to another room for her safety. A progress note on 06/28/19 at 12:29 PM by Staff F, Social Worker, showed during a meeting with the resident and family, Resident #9 again stated she was fearful of Resident #46, and the resident was sleeping in a different room until staff were able to ensure her safety in her room. On 07/02/19 at 3:53 PM, Resident #46 was moved to a different room, and Resident #9 was returned to the original room, twelve days after first expressing fear of Resident #46, being yelled at by the resident, and having items thrown at her. On 07/11/19 at 9:45 AM, Resident #9 was observed sitting in her wheelchair in her room. When asked if there had been any problems with other residents, she slowly shook her head yes. The resident stated her previous roommate was mean and aggressive, and it took the facility a long time to address it. Resident #9 then got a worried look on her face, reached out and took the surveyor's hand, and stated she was worried if it was brought up again, the other resident would be mean to her again, and it would cause more problems. In an interview on 07/17/19 at 6:53 PM, an interested party stated she observed Resident #9 on 06/24/19, sitting in her wheelchair in the blue family room, which was located down the hallway from her room. Resident #9 stated she was frightened to go back into her room because of Resident #46. The interested party further stated she was concerned about Resident #9's safety, due to having to stay in the same room as Resident #46. On 07/18/19 at 9:26 AM, Staff I,[NAME] Clerk confirmed that on 06/20/19, Resident #9 had told her there were problems with Resident #46, and she was afraid. At 9:45 AM on 07/18/19, Staff O, Nursing Assistant, stated Resident #9 had told her she was afraid of Resident #46, and it was her understanding that Resident #9 had reported her concerns. In an interview on 07/19/19 at 9:40 AM, Staff F, Social Services, was asked if any other interventions had been considered aside from the room change, to provide for Resident #9's safety, Staff F stated to her knowledge, no other interventions/options had been considered. When asked if psychosocial harm had occurred to Resident #9, Staff F acknowledged that psychosocial harm had occurred, due to her being afraid of Resident #46. On 07/19/19 at 10:55 AM, Staff B, Interim Director of Nursing, stated the expectation was that interventions would be implemented timely, to ensure the resident's well-being and safety, when in an environment where she was exposed to verbal abuse, intimidation, and fear. See F609, F610, F677 and F740 for additional information Reference (WAC) 388-97-0640 (1)

Based on interviews and record review, the facility failed to ensure one of three residents (#1) reviewed for falls, was provided adequate supervision, and that care plan interventions were re-evaluated and followed to prevent falls. This failed practice resulted in actual harm to Resident #1 who fell while standing up, and sustained a head injury and [MEDICAL CONDITION]. Findings included . Resident #1. Review of the resident's medical record showed the resident was admitted to the facility's dementia care unit on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's minimum data set (MDS-a comprehensive nursing assessment), dated [DATE], showed the resident had severe cognitive impairments, and required extensive assistance of two staff for bed mobility, transfers, ambulation on the unit, dressing, toileting, and personal hygiene. The resident's in room care plan, dated [DATE], and updated [DATE], showed the resident at was at risk for falls. Nursing orders included to ensure the resident had her glasses on when awake, provide contact guard assistance with ambulation, non-skid foot wear, and frequent visual checks. Review of facility investigation reports for the resident's fall showed the following falls: -[DATE] at 12:50 PM. The resident sat on the arm of the chair, the chair tipped over, and the resident fell , landing on her right hip. Staff was present, and cushioned the resident's head during the fall. There were no apparent injuries. -[DATE] at 5:40 PM. Staff observed the resident seated in the TV room. Two minutes later, the resident was found on her knees, with left eye bruising, broken glasses, and a large laceration to the center of her forehead, which required treatment, and no stitches. -[DATE] at 7:30 AM. The resident was walking in her room with staff present. She tried to sit in her chair, missed, and landed on the floor, with no apparent injuries. The resident's comprehensive fall care plan, dated [DATE], showed the resident was at risk for falls due to history of falls, poor safety awareness, and unsteady gait. Additional nursing orders included use of gait belt, padded undergarments during the day to prevent hip injury, and one-to-one staff as needed (1:1 prn) for supervision, without any criteria for when 1:1 should be provided. Review of a progress note dated [DATE] at 11:49 AM, Staff D, Unit Manager, met with the resident's legal representative, who decided to transition the resident to a comfort care focus, with no aggressive treatment measures. Review of the facility investigation report showed on [DATE] at 12:38 AM, Staff A, Nursing Assistant (NA), was the assigned nursing assistant for the residents in the dementia unit. The resident had been awake and agitated, and Staff A sat with her until she fell asleep a little after midnight. Staff A then checked on and assisted other residents, talked with a family member, all while intermittently checking the resident. At 12:30 AM, Staff A was on her way to the resident's room when she heard a loud sound. Staff A found the resident out of bed by the closet. Staff A reached for the resident's gait belt, but the resident fell face first on the floor, sustaining a laceration to her forehead. Staff A stated the resident's forehead was bleeding, she kept touching her face, and wouldn't stay on the floor. Staff A activated the resident's call light, but the resident would not stay down, so Staff A walked the resident to the double doors of the unit, and screamed for help. Staff B, NA, responded, and summoned Staff C, Registered Nurse. The resident was agitated, had an approximately 2 centimeters (cm), by one cm, by .5 cm laceration in the center of her forehead, and was transferred to the emergency room . Review of Staff C's progress note, dated [DATE], showed he administered medication (antianxiety) at 11:23 PM because the resident was getting up without assistance, not responding to nursing interventions, or following any cues or direction. At approximately 11;38 PM, the resident was sleeping soundly. When Staff C was summoned to the resident's room after the fall, she was bleeding profusely from the [MEDICAL CONDITION], was alert, but unable to remain still, moving her arms and trying to walk, making a thorough assessment impossible. Review of the medical record showed the resident returned to the facility on [DATE] at 4:54 AM. She remained on comfort care measures, exhibited an overall decline in condition, and was deceased on [DATE] at 11:41 PM. Per telephone interview on [DATE] at 12:00 PM, the resident's collateral contact stated he was with the resident in the emergency roiagnom on [DATE], and had to help hold her down while she got stitches to the [MEDICAL CONDITION]. He stated she couldn't respond properly, and her menatl status was greatly diminished from his visit with her on [DATE] at approximately 2:00 PM. He stated she did not have further diagnostic testing because she couldn't stay still. She finally calmed down and returned to the facility later that morning. In an interview on [DATE] at 12:15 AM, Staff A stated because the resident had a rapid decline, she previously had 1:1 care, with the night float NA. She stated the night of [DATE], Staff B relieved her for breaks, and she sat with the resident as best she could, between caring for the other residents. In an interview on [DATE] at 12:45 AM, Staff C confirmed he was the night shift RN on [DATE] when the resident fell . When asked, he stated the resident required 1:1 care on the night shift, which the float NA usually provided. With no float NA, Staff A checked the resident as often as she could. There was a family member of another resident visiting late who wanted to talk with Staff A. The conversation lasted longer, and when Staff A when to check the resident, she was already up. Staff E, Licensed Practical Nurse, routinely provided the resident's care on day shift. During interview on [DATE] at 11:20 AM, Staff E, stated she had informed administrative staff on or about [DATE] that the resident's condition worsened, and she required constant 1:1 care, not just during waking hours, because she believed it was an emergent situation for the resident, who was experiencing rapid behavior changes, and rapid decline in her overall condition. Staff E stated on [DATE], the resident's physician evaluated the resident, and stated he agreed the resident needed constant 1:1 staff, and he would write an order. Per interview on [DATE] at 9:55 AM, Staff D stated she reviewed the resident's progress notes daily, and thought the 1:1 prn interventions were being met, so she did not re-evaluate the resident's supervision needs. When asked, Staff D stated she did mention to Staff F, Director of Nursing, on one or two occasions, about more night shift staff on the dementia unit. In an interview on [DATE] at 10:45 AM, Staff F stated the resident was care planned for 1:1 prn supervision, which was primarily during waking hours. After the resident fell on [DATE], the resident was care-planned for constant 1:1 supervision. Staff F stated when the night shift staffing pattern was short, the facility offered overtime, and checked with a staffing agency, and sometimes additional staffing was not available. Per telephone interview on [DATE] at 2:35 PM, the resident's physician stated in talking to staff, they knew she needed 1:1 supervision all the time because she could get so agitated. Refer to F725 for additional findings. Reference (WAC) [DATE](3)(g)

Based on observation, interview, and record review, the facility failed to provide necessary care and services to treat severe agitation and discomfort, for one of two sample residents (#1), reviewed for end of life/comfort measures. The facility's failure to timely notify the physician, and initiate timely treatment to address symptoms of severe agitation and discomfort, resulted in actual harm to Resident #1, who was transferred to the hospital by family, and was found to have severe agitation and discomfort, requiring hospitalization . Findings included: A review of the [DATE] admission assessment, and [DATE] quarterly assessment, showed Resident #1 had [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. Review of the Comfort Care Measures form, which indicated resident-specific preferences for comfort care orders, showed on [DATE], the resident's family signed care plan recommendations for comfort care measures. Measures included pain medications for comfort, and no intravenous fluids. On [DATE], the physician signed the comfort care orders, which included an antianxiety medication to be administered orally as needed, and no pain medication. The orders for the daily antipsychotic medication were continued. On [DATE], the physician ordered narcotic pain medication, to be administered orally, as needed. Review of the comfort care plan, initiated [DATE], showed a goal for the resident to remain comfortable. Interventions included no intravenous fluids, no hospitalization , and pain/anxiety medication per physician orders. Review of a fax communication (a piece of equipment used to copy documents by sending information electronically along a telephone line, and to receive copies that are sent in this way), sent to the physician on [DATE] during the day, showed Staff H, Registered Nurse, requested the antianxiety medication be discontinued, due to the resident exhibiting increased agitation and combativeness with use. Additional record review showed the physician discontinued the medication, without additional MEDICATION ORDERS FOR [REDACTED] Per review of the record, after the medication was discontinued on [DATE], there was no re-assessment, to determine if additional comfort measures for anxiety/agitation could be utilized. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of a physician note dated [DATE] at 4:31 PM showed the physician received information from Staff C, Resident Care Manager, indicating the resident was unable/unwilling to take oral medication due to aggressive behavior, and staff were unable to administer liquid narcotic pain medication. Additional review showed the physician documented the facility was unable to forcibly administer medications, and unable to forcibly administer injectable medication by the intramuscular route (into the muscle). The physician recommended the family help administer the liquid pain medication, as well as essential medications, to help with behaviors as well as pain. Review of a progress note dated [DATE] during the evening shift, showed Staff E, Registered Nurse, contacted the physician, and received new orders for a different antianxiety medication, to be administered rectally. Review of a progress note dated [DATE] during the night shift, by Staff G, Registered Nurse, showed the resident refused oral pain medication twice, and received the antianxiety medication rectally. Staff G contacted a family member, who came and stayed with the resident during the night. In an interview on [DATE] at 10:40 p.m., Staff G was asked about the resident's status during the night shift on [DATE]. Staff G stated the resident was agitated, and in a anxious, restless state, that he had seen before in people ready to expire. Staff G stated he called a family member, who came and sat with the resident. Staff G stated the family member was really supportive and attentive to the resident, and the resident did calm down, for an hour or two. Review of the day shift progress note on [DATE] showed the resident refused all care and medications, and the family's presence at the bedside did not calm the resident down. A review of the record for the same day showed facility staff did not notify the physician of the resident's unrelieved symptoms of agitation, or the lack of effectiveness, related to having family at the bedside, for over 12 hours. In a telephone interview with a family member on [DATE] at 12:00 p.m., the resident was in a car, being transported by family to a hospital. The resident could be heard moaning loudly during the telephone interview. The family member stated the resident was having severe discomfort, and the facility stated they would not administer medication by another route (such as in a muscle or vein). Per the family member, the facility stated if the resident refused the oral and/or rectal medication, it was a federal law that they would not administer medications by another route. The family member stated when they signed orders for comfort care in (MONTH) (YEAR), the facility said they would keep the resident comfortable, and they did not. During observation in an acute care hospital on [DATE] at 1:20 p.m., the resident was lying in bed with his eyes closed. A registered nurse was present in the room, attempting to provide oral care. The resident would not open his mouth, and moved restlessly. The registered nurse administered intravenous medication, through an intravenous catheter (a small catheter placed in a vein for intravenous therapy). When asked, the registered nurse stated the medication was an antianxiety medication, one milligram dosage, to be administered every hour as needed, and stated a narcotic pain medication was also ordered by the intravenous route every hour, as needed. Additionally the nurse stated, upon arrival on [DATE], the resident received a dose of antipsychotic medication, had not required more doses of the antipsychotic medication, and was not requiring hourly doses of pain and/or antianxiety medication, to remain comfortable. On [DATE] at 1:20 p.m., family members were present, and stated the resident's agitation upon arrival at the hospital was horrible. He was moaning, restless, and could not stay still. He was disheveled, and in need of bathing, which hospital staff provided. Review of hospital records showed on [DATE], the resident was placed on appropriate comfort care measures with good success. Additional record review showed the resident expired on [DATE]. During interview on [DATE] at 11:15 a.m., Staff A, Administrator, was asked whether the facility informed the resident's family that the facility could not administer intravenous medications. Staff A stated the resident was refusing medications, and he had a discussion with the family about the resident's medication refusals, informing them it was difficult to give medication by an intramuscular route, if the resident was refusing. In an interview on [DATE] at 1:35 p.m., with Staff I, Director of Nursing, Staff C, Resident Care Manager, and Staff J, Resident Care Manager, Staff I was asked about the resident's discomfort level on [DATE]. Staff I confirmed the resident's discomfort was severe. When asked for information related to additional measures offered by the facility on [DATE], Staff I and C stated the family was all there on [DATE], and had already decided to transfer the resident to the hospital. In a telephone interview on [DATE] at 2:00 p.m., the resident's physician confirmed staff contacted her by telephone during the evening on [DATE], and she ordered antianxiety medication to be administered rectally. When asked, the physician stated if the resident was not taking the medication, and was moderately to severely agitated, the next step would have been to have the resident evaluated in the emergency room . The physician stated on [DATE], the facility did not inform her the resident continued to refuse medications, and remained agitated; otherwise the physician stated she would have ordered facility staff to send Resident #1 to the emergency room for further evaluation and treatment. Reference (WAC) [DATE](1)

Based on interview and record review, the facility failed to ensure two of five sample residents (#322, 41), reviewed for anticoagulation therapy (blood thinning medication), received the medication appropriately, and in accordance with a valid physician's orders [REDACTED]. The State Agency informed the facility on 06/21/18 at 6:13 p.m. of the Immediate Jeopardy situation. The facility provided education to nursing staff, and performed an audit of all residents receiving anticoagulant medications. On 06/22/18 at approximately 12:30 p.m., the facility was notified of the removal of the immediate jeopardy. Additionally, the facility failed to ensure one of one sample residents (#6), reviewed for insulin administration, received insulin as per physician order. This failure placed Resident #6 at risk for low blood sugars, related to receiving insulin an hour prior to a meal. Findings included: Anticoagulant Medications Laboratory monitoring (INR) is used to determine if anticoagulant medication is providing a therapeutic effect. The INR measures the time it takes for blood to clot, and compares it to an average. According to the Nursing (YEAR) Drug Handbook (Wolters Kluwer, (YEAR), p.1495) Black Box Warning, [MEDICATION NAME] (an anticoagulant medication to prevent blood clots) can cause major or fatal bleeding .Regularly monitor INR in all patients. According to the facility policy for Anti-Coagulation Therapy, dated (MONTH) (YEAR), the INR results were communicated to the physician or nurse practioner by the lab, as well as the facility, either by facsimile (fax) and/or telephone. Communication was done with the physician or nurse practitioner who ordered the test, prior to the next scheduled anti-coagulation medication dose being given. Per the policy, the physician and/or nurse practioner would evaluate the INR, and facility nursing staff would obtain orders to either change the medication dose or keep it the same, as well as an order for [REDACTED]. 1. Per a facility assessment dated [DATE], Resident #322 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The assessment showed she used anticoagulant (blood thinning) medication daily. Resident #322's laboratory results, Medication Administration Records (MARs), progress notes, anticoagulant flow sheets, and physician orders [REDACTED]. According to Resident #322's physician orders [REDACTED]. The resident had an order for [REDACTED]. Resident #322's INR level on 06/08/18 was 1.6 (below the resident's identified therapeutic range). The physician was faxed on 06/08/18 with the results. The physician did not respond until 06/11/18, three days later. According to the resident's MAR, she received the current order of 3.0 mg. of [MEDICATION NAME] on 06/08/18, 06/09/18, and 06/10/18, prior to the physician responding with a new order. This was not in accordance with the facility anti-coagulant therapy policy. On 06/11/18, the physician ordered a one time dose of 5.0 mg. of [MEDICATION NAME], which was given, then directed staff to resume the 3.0 mg. dose, and re-check the INR in one week (on 06/18/18). This constituted significant medication errors, related to giving Resident #322 medication for three days, without a current physician order. In addition, per record review, there was no documentation of the physician ordered INR result, from 06/18/18. According to Resident #322's MAR, she continued to receive 3.0 mg. of [MEDICATION NAME] on 06/18/18, 06/19/18, and 06/20/18, until it was brought to the attention of the facility by the surveyor, that no INR level had been drawn. This constituted significant medication errors, related to giving Resident #322 medication for three days, without a current physician order. During an interview on 06/21/18 at 2:35 a.m., Staff D, Resident Care Manager, was unable to find the INR result from 06/18/18, and at 4:25 p.m., confirmed it had not been drawn. In an interview on 06/21/18 at 4:45 p.m., Staff W, Registered Nurse, stated some physicians did not respond timely when an INR level was faxed and/or called to them. Staff W stated if he did not hear back from the physician, he would give the resident the [MEDICATION NAME], based on the resident's INR level. Per Staff W, if the level was low, he would give the [MEDICATION NAME] the resident was currently taking, and if it was high, he would hold the medication. I try and communicate as quick as possible but they (physicians) don't call back all the time. On 06/21/18 at 5:42 p.m., Staff B, Director of Nursing, stated they had some physicians that were slow to respond to the licensed nurses. Per Staff B, residents were usually admitted with a physician order [REDACTED]. This was not in accordance with the facility anti-coagulant therapy policy. Staff B stated if nurses could not reach the physician, the medical director could be contacted. However, the medical director would only talk to the physician about responding, not give an order for [REDACTED].#322 had not had a INR level drawn, as ordered. Continuing the current [MEDICATION NAME] dose, and/or holding it, was not in accordance with the facility anti-coagulant therapy policy. In addition, because nursing staff were directed to get orders from the physician when the INR was completed, and before giving the next dose of blood thinning medication, significant medication errors occurred. 2. Per a facility assessment, dated 05/01/18, Resident #41 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment showed he used anticoagulant (blood thinning) medication daily. Resident #41's laboratory results, Medication Administration Records (MARs), progress notes, anticoagulant flow sheets, and physician orders [REDACTED]. According to Resident #41's physician orders [REDACTED]. On 05/08/18 the resident's INR level was 3.4. Staff W, Registered Nurse, documented the INR was 3.4 [MEDICATION NAME] ([MEDICATION NAME]) held for today. Fax out MD, awaiting new orders. The physician responded with new orders on 05/09/18, one day later, to lower the dose and re-check the INR on 05/14/18. This constituted a significant medication error, because the medication was held without a current physician order. On 06/08/18 the resident had a INR level of 3.1. Per a review of the record, there was no documentation to indicate the physician was notified, or new orders had been received. The resident continued on the current [MEDICATION NAME] order of 7.5 mg. for four days, until the next INR level was drawn, on 06/12/18. This constituted several medication errors, related to giving the resident medication without a current order. On 06/13/18 Staff W documented the resident's 06/12/18 INR was 1.9. The note showed Fax out to MD. [MEDICATION NAME] ([MEDICATION NAME]) administered as per current order. There was no documentation found to indicate when the physician responded with new medication orders. The next INR was drawn on 06/21/18, with a level of 2.9. This constituted several medication errors, related to giving medication without documentation of when the physician was notified, and if a new order was obtained. In an interview on 06/21/18 at 4:45 p.m., Staff W stated [MEDICATION NAME] was given on evening shift, after the INR results came back from the laboratory. Per Staff W, the results were faxed to the physician, and a follow-up phone call made. Staff W stated some of the physicians did not call back timely, and if he could not get ahold of the physician, he would give the current [MEDICATION NAME] dose if the INR was low, and hold the [MEDICATION NAME] if the INR was high. He went on to say he would continue to try and contact the physician to obtain new orders. On 06/21/18 at 5:42 p.m. Staff B, Director of Nursing, stated most residents on [MEDICATION NAME] are admitted with a standing order to keep the INR between 2.0 and 3.0. Staff B stated If the licensed nurses were not able to get ahold of the physician with the INR level, the nurse would either give or hold the [MEDICATION NAME], based on the INR level, until the physician could be reached. However, this was not in accordance with the facility anti-coagulant therapy policy. These repeated errors represented immediate, serious risk, to Resident #322 and Resident #41, who were at increased risk for clots and/or potentially dangerous bleeding, related to high and/or low INR values. Reference: WAC 388-97-1060(3)(k)(iii) Insulin Administration 3. Per the quarterly assessment, dated 03/08/18, Resident #6 was admitted with [DIAGNOSES REDACTED]. According to the Nursing (YEAR) Drug Handbook (Wolters Kluwer, (YEAR), pgs 764-766) , .[MEDICATION NAME] (short-acting) insulin has an onset of 15 minutes upon being administered .To give the medication around a meal . According to the (MONTH) (YEAR) phyiscian orders, the resident was to receive [MEDICATION NAME]5 units, before meals. On 06/19/18 at 10:44 a.m., Staff R, Licensed Practical Nurse, was asked when she would be giving the insulin injection to Resident #6. She stated she had already administered the insulin a few minutes prior, at 10:30 a.m. Staff R was asked if the noon meal was to be given to the resident, at the time she administered the insulin; she stated no. Staff R further stated she did not want to be late with the insulin, so she gave it early. When asked if a snack was given at the time she gave the insulin, she stated no. At 10:49 a.m., Staff R was then observed to check the resident's blood sugar level (by using a device which read the level from a drop of blood); the reading was 104 (high normal is approximately 100). Staff R was then asked when the noon meal was to be served, and she stated not for about an hour. She stated she would get the resident some yogurt to eat in the meantime. In an interview on 06/19/18 at 11:09 a.m., Staff B, Director of Nursing, stated the insulin should have been administered prior to the meal, not one hour before. This constituted a significant medication error, which placed the resident at risk for adverse effects, related to low blood sugar. WAC: 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to ensure one of five sample residents (#322), reviewed for anticoagulant (blood thinning) medication, received adequate monitoring to ensure appropriate administration of the high risk medication. This failure resulted in Immediate Jeopardy for the resident, who was placed at risk for blood clots and/or bleeding. The State Agency informed the facility on 06/21/18 at 6:13 p.m. of the Immediate Jeopardy situation. The facility provided education to nursing staff, and performed an audit of all residents receiving anticoagulant medications. On 06/22/18 at approximately 12:30 p.m., the facility was notified of the removal of the immediate jeopardy. Findings included: Per a facility assessment dated [DATE], Resident #322 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The assessment showed she used anticoagulant (blood thinning) medication daily. According to the Nursing (YEAR) Drug Handbook (Wolters Kluwer, (YEAR), p.1495) Black Box Warning, [MEDICATION NAME] (an anticoagulant medication to prevent blood clots) can cause major or fatal bleeding .Regularly monitor INR in all patients. Laboratory monitoring (INR) is used to determine if the anticoagulant medication ([MEDICATION NAME]) is providing a therapeutic effect (evidenced by an INR within the goal range for the resident). The INR is necessary, to ensure the resident does not receive excessive doses, which would increase the risk of bleeding, or too little medication, which would increase the risk of blood clots. According to the facility Anti-Coagulation Therapy policy dated (MONTH) (YEAR), all residents on anticoagulation therapy were to be monitored closely, to ensure proper care and treatment, related to the administration of that class of medication. The monitoring was to include periodic checking of lab levels, to ensure the medication remained within a therapeutic range. The policy further showed when INR levels were ordered by the physician, procedures would be followed, to ensure the lab is drawn per order. Resident #322's laboratory results, Medication Administration Record [REDACTED] Physician orders [REDACTED]. On 06/08/18, the resident's INR level was 1.6, below the goal/therapeutic range. On 06/11/18, three days later, the physician wrote orders to give a higher dose of the blood thinning medication for one day, and then resume the resident's current dose. The INR was to be re-checked in one week (on 06/18/18). The resident's record showed no INR level from 06/18/18. In an interview on 06/21/18 at 2:35 p.m., Staff D, Resident Care Manager, explained the facility had an anticoagulant flow sheet, to keep track of the resident's INR and [MEDICATION NAME] orders. Per Staff D, the process was to enter the date and result of the INR, the new orders received, and document the date the next INR was due. The nurse would then enter the date of the next laboratory draw in the laboratory book. Staff D was unable to find a result from the INR ordered to be drawn on 06/18/18, and at 4:25 p.m., confirmed the resident did not have a lab draw on that day, as ordered. Staff D stated the nurse was currently checking the resident's INR, via a device at the facility. On 06/21/18 at 4:55 p.m., Staff X, Registered Nurse, stated he obtained Resident #322's INR level, which had not been drawn on 06/18/18, and it was 1.7 (lower than the therapeutic level). Staff X stated he had a call out to the resident's physician for further direction. In an interview on 06/21/18 at 5:42 p.m., Staff B, Director of Nursing, verified Resident #322's flow sheet was not filled out correctly, the next INR was not placed in the laboratory book, and the INR had not been drawn, as ordered. Failure to ensure Resident #322's INR level was drawn as ordered, placed her at risk for blood clots related to low INR levels, or potentially dangerous bleeding, related to a high level. The delay in monitoring reflected an ineffective system in place, to safely administer the medication. Reference: (WAC) 388-97-1060(3)(k)(i)

Based on observation, interview, and record review, the facility failed to ensure care and treatment was provided to attain the highest practicable mental and psychosocial well-being, for one of five sample residents with dementia (#55), who resided on the secured dementia unit. This failure resulted in actual harm to Resident #55, who experienced extreme anxiety and psychological trauma from showers. Findings included: Resident #55 was admitted to the facility in (MONTH) (YEAR). Her re-admission comprehensive assessment of 11/20/17 showed [DIAGNOSES REDACTED]. The assessment also showed the resident was severely impaired in memory, had no behaviors, and required extensive assistance from two staff members for bathing. A nursing progress note, dated 03/11/18, documented, Showered and hair washed .Agitated during and after the shower .warm blanket placed . A nursing progress note, dated 03/12/18, documented the physician was notified of the resident's increased anxiety during events like showering, toileting, and when her husband left, after visits. Per the note, the escalated anxiety manifested itself as crying, and manic (rapid) pacing up and down the hallway. The physician responded on 03/13/18, by increasing the [MEDICATION NAME] (an antipsychotic medication), to two times daily. A nursing progress note, dated 03/25/18, documented, Resident had a shower early this AM which made her very upset and all she kept saying afterwards was, 'All they want to do is kill me.' She continued to be restless and anger (sic) most of the morning, going in and out of residents rooms pacing and angry. Staff tried to redirect resident offering food/fluids and one-to-one (supervision), but only helped for a few minutes. A (MONTH) (YEAR) Behavior Monitor Review showed the nurses noted 110 episodes of behaviors, which included: 28 episodes of heightened anxiety, especially after her husband left, 16 episodes of being combative with staff, and 25 episodes of refusing care. Staff used the additional interventions of long periods of one-to-one (supervision), and re-approaching at different times or with different staff. Interventions were effective for 84 episodes, and non-effective for 15 episodes. A nursing progress note, dated 04/22/18, documented the resident continued being combative during showers. The physician was updated, and an increase in the [MEDICATION NAME] was ordered (at bedtime). Per the note, staff also asked the resident's husband to bring pajamas without a button front, as that was a frequent cause of her anxiety. An (MONTH) (YEAR) Behavior Monitor Review showed the resident had 73 episodes of behaviors which included: 19 episodes of heightened anxiety after her husband left, 13 episodes of being combative with staff, and 16 episodes of refusing care; interventions were documented as effective only half the time. Staff continued to use additional interventions of long periods of one-to-one (supervision) and re-approaching her at different times with different staff. A nursing progress note, dated 05/06/18, indicated the resident was showered prior to dinner, and was yelling and tearful for 15 minutes afterwards. She was wrapped in a warm blanket and comforted. A nursing progress note, dated 05/10/18, documented, .Resident was given scheduled shower by Staff T, Shower Aide and Staff U, Nursing Assistant. The shower aide requested the nurse have a warm blanket ready for the resident, once they finished. Per the note, the resident was gently led into the shower room. She allowed staff to undress her, but her anxiety escalated sharply, when she realized she was getting wet. The aides worked as quickly and gently as they could. The note further showed the resident yelled out, and attempted twice to slide out of the shower chair onto the floor. Once they had finished the shower, the resident was wrapped in the warm blanket, but per the record, was still very agitated. The 05/11/18 care plan showed the resident had physically abusive behavioral symptoms (meaning staff were hit, shoved, and scratched, especially during showers). The care plan also showed her family reported she had a possible near-drowning incident, when she was young. The goal, related to the behaviors, was for the resident to accept assistance for showers, without physically abusing staff. Interventions for the behaviors during showering included: .When resident becomes physically abusive and care is not needed immediately, STOP and try the task later. Do not force resident to do task, again start low and slow then concentrate on the needed areas prone to skin break down. A quarterly assessment, dated 05/20/18, documented [DIAGNOSES REDACTED]. As compared to the re-admission assessment, which indicated she had no behaviors, the quarterly assessment now documented the resident had verbal and other behaviors, including rejection of care, for one to three days, out of the seven day observation period. When the surveyor entered the secured dementia unit for a random observation on 06/14/18 at 3:25 p.m., Resident #55 was heard screaming from the shower room. Staff S, Registered Nurse, when asked about the screaming and yelling coming from the shower room, stated the resident had received a dose of pain medication about 45 minutes prior to her shower, due to possible pain indicators (i.e., screaming and yelling). Staff S further stated there was a holistic approach to the resident's showers, and she received a warm blanket and hot chocolate, to minimize her anxiety after the showers. The resident was heard yelling through the door, Get out of there, and Please come! Please come! At 3:27 p.m. (two minutes later), Staff T and Staff V, Nursing Assistants, came out of the shower room with Resident #55. The resident was crying, and was dressed in her pajamas and a robe; her hair had not been washed. Staff V walked with the resident down the hallway, offering comfort and reassurance. At 3:37 p.m. (five minutes later), Resident #55 was observed lying on her bed awake, combing her hair. She was not crying, but talking out loud to no one in the room. Resident #55 was asked by the surveyor how she was at that time and stated, Oh, I feel just fine. A revised care plan intervention, dated 06/15/18, (after the shower on 06/14/18 as indicated above), showed staff were to simplify activities of daily living, and offer a bed bath to possibly help lower anxiety. The care plan intervention also showed the resident's spouse had offered to be present during showers, not to physically assist, but hold her hand, or would explain the way he had done her showers at home (although the record showed showering/bathing did not go well at times, when the resident was still at home). In an interview on 06/20/18 at 9:16 a.m., the resident's husband was asked if her showers had been a problem at home; he stated, forever. He was asked if she screamed at home, and he stated no. The resident's husband further stated he felt the problem with the showers was the resident got too cold. Per the husband, the resident meant cold when she said hot, and got very confused about things. In an observation on 06/20/18 at 3:12 p.m., Staff T and Staff V went to the resident's room, and quietly asked her to Come walk with us. The resident did not decline but asked, Who else is going to come? The staff made small talk with the resident as they walked her down the hallway to the shower room. There were no behaviors such as crying, or heightened anxiety observed. The staff did not offer the resident a bed bath, nor did they tell her what they were going to do. When the resident entered the shower room with the aides and the surveyor, she showed no adverse behavior. When Staff V pulled down her pants and brief, the resident started crying asking, What are you doing, what are you doing? and stated, I can't do it, I can't do it! Staff V explained they were going to take a shower. When the resident sat down on the shower chair, she said, Ouch, Ouch, and attempted to slide out of the shower chair. Staff T placed her leg between the resident's legs for safety, as the shower chair bar was placed in front of her, to hold onto for security. When Staff T attempted to remove the resident's blouse and bra, the resident was observed beating her head with her fists. After her clothes were removed, the resident stopped the fist beating of her head, but continued yelling, despite staff speaking softly and reassuringly. The water was allowed to run on her left hand so she could feel it, and then she yelled out, hot! hot! Despite the aide adjusting the temperature of the water, the resident continued to scream and cry. Staff were not observed to have stopped the shower, per the care plan, until 3:18 p.m. (6 minutes later) when Staff C, Resident Care Manager, entered the shower room, and told the staff to stop. The aides then stopped the shower, and began to dry and dress the resident. The resident angrily stated, My dad is there, let me down, as she attempted to slide out of the shower chair. The aides placed a towel on the floor, and the resident stood while they dressed her, continuing to cry. At 3:21 p.m., the resident left the shower room. She was observed to be confused, pacing up and down the hallway, trying to open locked doors, crying, saying, Why do I want to be here? Staff T was asked about the care plan intervention of having her husband with her during showers. She stated it had been discussed, but had not happened yet. At 3:23 p.m., Staff V walked with the resident back to her room, and asked her if she wanted hot chocolate, which the resident declined. Staff V lowered the lights, put the fall mat in place, and stayed with the resident until she was calm. At 3:26 p.m., the resident was observed lying in bed; no crying was noted. She was asked if she was doing ok now, and stated, Yes, it will have to be. Staff V stated the resident's bed was her safe place, and she always felt better when she came back to lie down. In an interview, with Staff B, Director of Nursing and Staff C, on 06/20/18 at 4:21 p.m., Staff C stated this was the first time she had heard the resident's crying and screaming during showers, which was why she stopped it. She further stated, that if the resident continued to refuse, we should respect that. Staff B stated they would find other ways to keep her clean, without causing her anxiety. WAC 388-97-1060 (3)(e)

Based on observation, interview, and record review, the facility failed to consistently implement the planned intervention of using of a gait belt with transfers, for one of three sample residents (#1), reviewed for injury prevention. This failure resulted in harm to the resident, who sustained a left ankle fracture during a transfer. Findings included: 1. According to the facility assessment dated [DATE], Resident #1 was alert, able to verbally express her needs, and make decisions. The resident had a permanently displaced right hip, and required extensive assistance of two staff for transfers and toileting. Additional record review showed the resident started physical therapy on 12/22/17. At discharge on 01/12/18, the resident required maximum assistance of one staff for transfers. Review of the 02/19/18 facility investigation showed at 10:05 a.m. on that day, Staff A, Certified Nursing Assistant, transferred the resident on and off the bedside commode for an episode of diarrhea. Staff A then provided personal care in bed, when the resident voiced an urgent need to use the bedside commode again. During the transfer out of bed, the resident became incontinent, and her legs could not support weight to complete the transfer to the bedside commode. Staff A lowered the resident to the floor, with the left leg bent, and the right leg extended. The licensed nurse evaluated the resident for injury, then staff assisted the resident to bed. The resident complained of left leg pain. An x-ray completed on 02/19/18 showed the left ankle was fractured in two places. Additional review of the 02/19/18 investigation showed the facility identified Staff A did not use a gait belt during the transfer, as required. Per review of the 02/05/14 in-room care plan, which was revised on 01/22/18, staff were not specifically directed to use a gait belt when transferring Resident #1. Record review of the facility orientation book for contract nursing assistants (which included Staff A) showed nursing assistants were directed to always use a gait belt for transfers. Additional record review showed Staff A signed the undated form, acknowledging review of the information. During observation and interview on 03/20/18 at 12:40 p.m., the resident was in bed with a cast on the left lower leg. She stated at present, she could not bear weight on both legs, and either stayed in bed or required a mechanical lift (a device to move those who could not stand), to transfer out of bed. During interview on 03/21/18 at 10:30 a.m., Staff B, Director of Nursing Services, confirmed use of the gait belt was not included in the resident's care plan, but Staff A was trained to use a gait belt with all resident transfers. During interview on 03/21/18 at 11:17 a.m., Staff A stated she did not use a gait belt during the resident transfer, because it was not listed on the care plan. When asked, Staff A stated the facility trained her to use a gait belt with all transfers. Reference (WAC) 388-97-1060(3)(g).

Based on interview and record review, the facility failed to provide necessary care and services for 1 of 3 residents (#1), related to pain management. Failure to timely identify, and adequately treat a [MEDICAL CONDITION], resulted in harm to Resident #1, related to unresolved pain. Findings included: Per the record, Resident #1 had [DIAGNOSES REDACTED]. Per review of an assessment dated [DATE], the resident had memory impairments, and difficulty making her needs known. She required extensive assistance with activities of daily living. The record indicated she was on comfort care, and had no falls since 03/24/17. A progress note, dated 05/25/17 at 8:42 p.m., documented direct care staff reported to the nurse (Staff A), that Resident #1's hip hurt. The nurse assessed the resident, asked if her hip hurt, she nodded yes, and rubbed her right hip. The resident was medicated with Tylenol, and was taken to dinner in her wheelchair due to her unwillingness to stand. This was a change for the resident since she would normally walk to dinner. The next progress note was on 05/26/17 at 6:50 a.m., almost 10 hours after Resident #1's first complaints of hip pain. It was documented the nurse went to assess the resident's right knee and right hip, due to complaints of pain. The resident wouldn't allow staff to touch or rotate her hip or knee. The resident's knee was noted to be swollen and red, with a diminished pulse in the right foot. Resident #1 was immediately sent to the hospital for an evaluation. An x-ray report, dated 05/26/17, identified the resident had a [MEDICAL CONDITION]. On 06/08/17 at 2:37 p.m., Staff A was interviewed, and said she was taking care of the resident the evening she complained of hip pain. Staff A said the resident had not had any falls reported during the day, or during that evening. She said the aides caring for the resident told her the resident did not want to walk to dinner because of hip pain, so she was taken in a wheelchair. Staff A said she assessed Resident #1, and did not notice any bruising or redness. She went on to say that after the resident returned from dinner, she was put into bed, at which time the pain increased. The resident was medicated with Tylenol which was somewhat effective. The pain was reported to the night shift nurse. The physician was not notified at that time. Staff B, licensed nurse, was interviewed on 06/09/17 at 8:50 a.m. She stated she came on shift the following morning, and immediately received a report from the night shift aides, who said Resident #1 had quite a bit of pain during the night. Staff B said she went to assess the resident, who was in extreme pain, and would not allow her leg to be touched or rotated. The resident was immediately sent to the hospital. During an interview on 06/09/17 at 1:00 p.m., Staff F, Director of Nursing, stated it was not determined how the resident fractured her hip. She stated there were no reports of falls which could have led to the fracture. She confirmed the resident should have been assessed more timely, the physician notified, and her pain managed during the night. Reference: (WAC) 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to monitor 2 of 9 residents (#1, 2) reviewed for abuse, for symptoms of psychosocial harm and address expressed concerns. This failure resulted in harm to Resident #1, who had unresolved anxiety and distress for several days. Findings included: 1. Resident #1 had [DIAGNOSES REDACTED]. He required extensive assistance with activities of daily living (ADL's). A progress note, dated 04/01/17 at 8:45 p.m., documented Resident #1 was placed on alert charting, after Resident #3 entered his room, cussing and yelling at him. Progress notes were reviewed from 04/01/17 to 04/04/17. On 04/02/17 at 3:38 a.m., a note indicated Resident #1 had been angry during the shift, due to a resident from the adjacent room coming into his room, and disrupting his sleep. However, there was no documentation found to indicate the resident was being monitored by staff for possible distress from the incident, and/or being provided support from staff. On 04/05/17 at 12:28 a.m., a progress note documented Resident #3 entered Resident #1's room, and pressed down on his foot causing him harm. Resident #1 received a pain pill, per his request, and staff offered a temporary room move to Resident #1, which he declined. According to a 04/05/17 facility investigation of the incident, on 04/04/17 at 11:30 p.m., a staff member found Resident #3 in Resident #1's room, after hearing Resident #1 yell get out of my room. Resident #1 reported Resident #3 had entered his room, and pressed down on his foot, causing him harm. It was noted Resident #1 appeared very anxious and upset. This was the second incident between Resident #1 and Resident #3 since 04/01/17. Progress notes were reviewed from 04/05/17 to 04/07/17. On 04/06/17 at 2:39 p.m., Staff B, licensed nurse, documented Resident #1 mentioned he had a problem with another resident a few days ago. However, no documentation was found to indicate Resident #1 had been monitored by staff, to determine if he remained distressed by the incident, and/or had been provided support from staff. On 04/13/17 at 9:45 a.m., Resident #1 was observed in bed watching television. On his bed side table was an air horn. When asked about the horn, he stated his wife brought it for him because his next door neighbor had entered his room on several occasions. He stated Resident #3 had a room next to his, with an adjoining bathroom. He described the 04/04/17 incident stating he woke up and Resident #3 had both hands on his leg, pushing down. Resident #1 then said, The man is definitely a threat, it hurt, I woke up screaming in pain. When asked if he felt safe in the facility he responded why would I? and felt staff didn't do as much as they could have to keep Resident #3 out of his room. Staff C, social services, was interviewed on 04/19/17 at 1:20 p.m. She stated she had only been employed at the facility for a few months. When there were was an allegation of resident to resident altercations, she was told by the Director of Nursing (DNS) what her role would be. When asked about the incident with Resident #1 and #3, she stated she interviewed residents in the same hall related to the incident, however, did not talk directly to the residents involved in the altercation. During an interview on 04/19/17 at 1:30 p.m., Staff A, resident care manager, stated licensed nursing staff were to monitor residents for psychosocial harm for 3 days. The staff were to document daily and should include any unusual behaviors the resident may be having, or at the least, a note mentioning no signs and/or symptoms of psychosocial harm found. Staff A was shown that no documentation for psychosocial harm had been completed on Resident #1, he confirmed he would have expected to see some. On 04/19/17 at 2:00 p.m., Staff B, licensed nurse, stated residents involved in resident to resident altercations would be placed on alert charting. She stated she cared for Resident #1 the day after the incident on 04/05/17. Resident #1 told her another resident entered his room and scared him. When asked if she had reported it, she stated no, because Resident #1 only mentioned it the one time. She also stated she did not document the conversation in the progress notes and probably should have. On 04/19/17 at 2:30 p.m., Staff D, director of nursing, was asked for any additional documentation related to Resident #1 and psychosocial monitoring. None was provided. 2. Resident #2 had [DIAGNOSES REDACTED]. The 03/07/17 facility assessment documented the resident was alert and oriented, and able to make his needs known. He was independent with most activities of daily living. According to an investigation, dated 04/03/17, Resident #3 had been thumping Resident #2 on the head. The residents were separated, and Resident #2 was placed on alert charting for psychosocial harm. Per review of progress notes on 04/03/17, the altercation was documented, but no indication of monitoring, to determine if Resident #2 had any distress related to the incident. The next entry was not until 04/12/17. During an interview on 04/13/17 at 10:05 a.m., Resident #2 said other residents sometimes came into his room. He stated one time a guy came in and hit my roommate on the leg (Resident #1). Resident #2 stated he didn't like the guy in his room, but was not afraid of him. Staff C, social services, was interviewed on 04/19/17 at 1:20 p.m. She stated she had only been employed at the facility for a few months. When asked about the incident with Resident #2 and #3, she stated she interviewed residents in the same hall related to the incident, however, did not talk to the residents directly involved in the altercation. On 04/19/17 at 1:30 p.m., Staff A, resident care manager, stated he would expect to see daily documentation from licensed staff, when monitoring for psychosocial harm. He confirmed there was no documentation for Resident #2. On 04/19/17 at 2:30 p.m., Staff D, director of nursing, was asked for any additional documentation for Resident #1 and psychosocial monitoring. None was provided. Reference: (WAC) 388-97-0960(1)

Based on interview and record review, the facility failed to consistently assess, treat, and revise pressure sore interventions, for 1 of 5 sample residents reviewed (#1), who were at risk for, or had skin breakdown. This failure resulted in actual harm, as Resident #1 developed pressure sores on both heels, and recurrent opening of a pressure ulcer on her coccyx. Findings include: The resident was readmitted to the facillity on 01/04/16, with [DIAGNOSES REDACTED]. Resident #1 required extensive assistance with most activities of daily living, including bed mobility. She had no memory impairments, and was able to make her needs known. Per record review, the resident received an order on 01/04/16, for a dressing to be placed on an open area to her right buttock, and for the dressing to be changed every 3 days (or as needed). The admission assessment of 01/11/16 documented the resident had a Stage I pressure sore (intact skin with non-blanchable redness over a bony prominence), and was at risk for developing additional pressure sores. The resident's most recent care plan, related to skin integrity, was reviewed. It was dated 12/10/15; the date of a prior admission, and included generic interventions such as: a pressure reduction device on her bed and chair, repositioning as the resident allowed, a Physical Therapy evaluation for pressure relief and/or positioning, and weekly skin assessments. There were no specific interventions in place, and the care plan had not been revised after her readmission on 01/04/16, when a pressure sore had been identified, and she was at increased risk. Per review of the facility's Treatment Flowsheets for January 2016 - March 2016, the resident went a total of 6 1/2 weeks with no documented skin assessments, despite having a pressure sore on her buttocks. In addition, in the month of February 2016, there was no documentation the dressing changes had been done every 3 days, as ordered by the physician, to the pressure sore on the buttocks . On 03/29/16 at 12:15 p.m., Staff A, Director of Nursing, said the resident was discharged [DATE], with a pressure sore on her buttocks that was open, and approximately the size of the tip of a pinky finger. There no documentation in the record to reflect this pressure sore, which by definition would be considered a stage II. She said Resident #1 had a long history of the pressure sore on her buttock, which would heal and then re-open. She said the resident's husband was aware of the area, and treatment instructions were sent with him on discharge. Per review of the resident's discharge instructions dated 03/08/16, no information was found identifying the resident had a pressure sore, nor were any instructions for treatment documented. The resident was discharged from the facility on 03/08/16. On 03/10/16, the resident was admitted to the hospital with [REDACTED]. Per review of hospital records, the resident had left and right heel wounds, and a sacral ulcer from a previous nursing home stay. These areas had not been identified by the facility on the day of discharge. On 03/11/16, a wound consult was done at the hospital. The resident's lateral left heel was described as having blisters, and measured at 0.4 x 5 cm.; the resident left medial heel wound measured 3 x 4 cm., was blistered and red, and was assessed as a Stage 2 pressure sore. The resident's right posterior heel wound was 0.3 x 0.5 cm., red in color, with the skin intact. The resident's buttock sore was described as red, with white edges, and separated (open).