Every finding on record at Colville Tribal Convalescent C

Based on observation, interview, and record review, the facility failed to ensure food was not stored on the floor, hand hygiene was performed when indicated during the lunch meal service, food was served at the appropriate temperatures, expired foods were discarded, and donated food were dated when received in 1 of 1 dry storage areas and 1 of 2 refrigerators (refrigerator 1). The facility further failed to ensure the microwave and oven were clean. These failures placed residents at risk for food-borne illnesses and food served from unsanitary conditions.Findings included . The 03/01/2022 Washington State Retail Food Code states food must be stored at 41 degrees or less for food safety.<Expired and undated food>During an initial observation of the kitchen on 06/22/2026 at 11:07 AM, the dry storage area contained 46 cans of tomato paste that expired on 05/28/2026, a full bag and an opened bag of Tostito chips that expired on 06/16/2026, a full bag and an opened bag of pretzels that expired on 06/16/2026, a bag of lentils that had no received or expiration date, a bag of soft tortillas that was open and exposed to air, and multiple cans of donated salmon that had no received or expiration dates. The walk-in refrigerator (refrigerator 1) contained a container of ranch dip that expired on 03/30/2026, an opened bag of shredded cheddar cheese and a bag of sliced cheese that had no received or expiration dates. In an interview on 06/23/2026 at 2:00 PM, Staff K, Assistant Dietary Manager, stated it was important to discard expired food to prevent foodborne illnesses if the food contained bacteria. Staff K stated it was important to date the food, so they knew when to discard it. Staff K stated the salmon was donated and they were unsure how old it was. <Food storage>In an observation on 06/22/2026 at 11:07 AM of the dry storage area there were two boxes of coffee sitting on the floor. The walk-in refrigerator had boxes of milk, water, pop, and butter stored on the floor. In an interview on 06/23/2026 at 2:06 PM, Staff K stated it was important to keep food off the floor because it was a safety hazard and rodents could get into the food. Staff K stated they had problems with mice in the past year. In an interview on 06/25/2026 at 12:56 PM, Staff L, Maintenance Director, stated they had a problem with mice because they are located next to a field. Staff L stated they had a mouse in the activities area last month. <Food temperatures>In an observation of the lunch meal service on 06/25/2026 at 11:38 AM, the temperature of the glasses of milk was 46 degrees. The milk had been sitting on the meal tray cart. At 11:51 AM a salad was removed from the refrigerator, and the temperature was 44 degrees. The salad was placed in the meal cart. At 11:54 PM, the meal cart was being pushed out of the kitchen to be delivered to the residents. Staff M, Cook, was asked what the temperature of cold items needed to be and they stated 41 degrees or below. Staff M stated it was important to serve food at the appropriate temperatures to prevent foodborne illnesses. <Sanitary Practices>During an observation of tray line on 06/25/2026 at 12:02 PM, Staff M was plating food with gloved hands. Staff M removed their gloves and threw them in the garbage. As the gloves started to fall out of the garbage can, Staff M placed their hands in the garbage can and pushed the gloves down into the can. Staff M put on a pair of gloves and continued to plate food, and no hand hygiene was performed after their hands were in the garbage can. In an interview on 06/25/2026 at 12:16 PM, Staff M stated hand hygiene was completed in between touching things. Staff M stated they should have completed hand hygiene after they shoved the garbage down with their hands and it was important to prevent foodborne illnesses. <Cleanliness>In an observation on 06/22/2026 at 11:40 AM, Staff N, Cook, opened the oven to pull out some meat and smoke came out of the oven. The bottom of the oven was covered in white and black debris. The microwave had splattered food that covered the inside. In an observation on 06/25/2026 at 12:25 PM, with Staff K, the inside of the oven had white and black debris and there was a screw sitting on the bottom shelf. The microwave had brown splatter on the inside. Staff K stated both items needed to be kept clean for sanitization reasons and the oven was a fire hazard. In an interview on 06/26/2026 at 11:58 AM, Staff O, Dietary Manager, stated it was important to discard expired food to prevent illness. Staff O stated it was important to write received dates on the food to know when to discard it and to prevent bacterial growth. Staff O stated hand hygiene needed to be completed before meal service and after removing their gloves. Staff O stated the cook should have completed hand hygiene after they put their hands into the garbage can and it was important to prevent cross contamination. Staff O stated it was important to keep the microwave and oven clean to ensure old food did not contaminate the new food and to prevent a fire. Staff O stated it was important to keep food off the floor to prevent rodents or bugs from accessing the food and to keep the floor sanitary. Reference: WAC 388-97-1100(3), 2980

Based on observation, interview, and record review, the facility failed to ensure interventions were followed as care planned for 1 of 1 sampled residents (Resident 23) reviewed for range of motion/mobility. This failure placed the residents at risk for possible declines in range of motion. Findings included.The 05/13/2026 quarterly assessment documented Resident 23 had diagnoses that included a subarachnoid hemorrhage (a life-threatening medical emergency where bleeding occurred in the space between the brain and the tissues that covered the brain) that affected their left side, hemiplegia and hemiparesis (paralysis on one side of the body), and high blood pressure. The assessment showed Resident 23 had a functional limitation in their range of motion to their upper extremities and required total assistance from staff to complete their activities of daily living. An active order dated 05/14/2015 from the occupational therapist showed a left-hand splint was to be worn 20 hours +/- per day. The 11/08/2023 functional maintenance care plan instructed nursing staff to apply a left-hand splint 20 hours per day. The splint was to be removed every morning at 7:00 AM and replaced at 11:30 AM. A 05/13/2026 restorative assessment showed Resident 23 had a left-hand splint that they wore 20 hours per day or as tolerated. Per the assessment the Restorative Aide was to remove the splint every morning at 7:00 AM, inspect the skin, wash and dry the hand and replace the splint at 11:30 AM. In an observation on 06/22/2026 at 1:46 PM, Resident 23 was sitting in the activities room. Resident 23's fingers were curled in toward the palm of their left hand, and they were not wearing a splint. In an observation on 06/23/2026 at 1:34 PM, Resident 23 was lying asleep in bed. Resident 23 was not wearing a splint on their left hand. At 3:48 PM, Resident 23 was lying in bed watching television and was not wearing a splint on their left hand. In an observation on 06/24/2026 at 1:00 PM, Resident 23 was lying in bed watching television. Resident 23 was not wearing a splint to their left hand.In an interview on 06/26/2026 at 10:42 AM, Staff H, Registered Nurse, stated Resident 23 had limitations to their left hand and wore a brace. Staff H stated Resident 23 did not refuse their brace. Staff H stated if Resident 23 did not wear their brace as ordered they were at risk for further impairment. In an interview on 06/26/2026 at 10:48 AM, Staff G, Rehabilitation, stated when residents refused their splints it was documented in their medical record. Staff G stated Resident 23 was admitted with limitations to their left hand and wore a splint. Staff G stated Resident 23 wore the splint for two hours per day. Staff G stated they were unaware Resident 23 was to wear their splint for 20 hours per day. Staff G stated it was important for Resident 23 to wear their splint to keep their fingers in line and to prevent contractures (stiffening of muscles or tendons that limited flexibility and movement of joints). In an interview on 06/26/2026 at 10:57 AM, Staff B, Director of Nursing, stated it was their expectation nursing applied the splint to Resident 23's left hand as ordered. Staff B stated it was important to maintain Resident 23's current range of motion and to prevent further decline. Reference: WAC 388-97- 1060(3)(d)(j)(ix)

Based on observation, interview and record review, the facility failed to ensure residents were given their medications as ordered and were free of significant medication errors for 2 of 5 sampled residents (Residents 3 and 22) reviewed for medication management. This failure placed residents at risk of exacerbations of their chronic health conditions, and unintended consequences when doses of their medications were omitted. Findings included .<Resident 3>The 06/17/2026 quarterly assessment documented Resident 3 had diagnoses that included end stage renal disease (ESRD, loss of kidney function), osteoarthritis (degenerative joint disease) and glaucoma (an eye disease that resulted in vision loss). Resident 3 was cognitively intact and was dependent on renal dialysis (a life sustaining treatment used to filter toxins, wastes and extra fluid from the bloodstream). Resident 3 had the following medication orders:-Brimodine eye drops, ordered to start on 01/27/2026, twice daily for hypertensive retinopathy (damaged blood vessels in the retina caused by high blood pressure)-Gabapentin, ordered to start on 03/06/2025, three times a day for knee pain-Sevelamer (a medication used to control high blood phosphorus levels), ordered to start on 12/06/2023, three times daily with meals and with snacks for ESRD-Vitamin D3 daily for ESRD The May 2026 medication administration record (MAR) showed Resident 3 did not receive their Brimodine on 05/01/2026, 05/06/2026, 05/11/2026, 05/13/2026, 05/15/2026, 05/25/2026, and 05/29/2026. Resident 3 did not receive their Gabapentin on 05/01/2026, 05/06/2026, 05/11/2026, 05/13/2026, 05/15/2026, 05/18/2026, 05/20/2026, 05/25/2026, 05/27/2026 and 05/29/2026. Resident 3 did not receive their Sevelamer on 05/04/2026 at 12:00 PM, 05/05/2026 at 12:00 PM and 4:30 PM and 05/20/2026 at 4:30 PM. Resident 3 did not receive their Vitamin D3 on 05/06/2026, 05/15/2026 and 05/29/2026. The June 2026 MAR showed Resident 3 did not receive their Brimodine on 06/01/2026, 06/03/2026, 06/17/2026, and 06/22/2026. Resident 3 did not receive their morning dose of Gabapentin on 06/01/2026, 06/03/2026, 06/09/2026, 06/10/2026, 06/12/2026, 06/16/2026, 06/19/2026, 06/22/2026, and 06/24/2026. Resident 3 did not receive their Sevelamer on 06/09/2026 and 06/16/2026. Resident 3 did not receive their Vitamin D3 on 06/01/2026, 06/09/2026, and 06/22/2026. The May and June 2026 MARs showed the comments made for the dates above were resident unavailable or resident at dialysis. A 05/15/2026 note from the dialysis center stated Resident 3's phosphorus level was 5.8 and the range was from 3.0 to 5.5 (high levels indicated the kidneys struggled to filter and excrete excess phosphate). The note instructed staff to remember to administer the Sevelamer tablets at the start of each meal and with snacks to prevent so much phosphorus absorption. A 06/12/2026 note from the dialysis center instructed staff to remember to administer the Sevelamer tablets at the start of each meal and with snacks. In an interview on 06/25/2026 at 3:14 PM, Staff C, Resident Care Manager, stated some residents on dialysis received their pain medication prior to dialysis and their Sevelamer if they had a snack. Staff C stated Resident 3 received their morning medications when they returned from dialysis and were documented as given late. Staff C stated it was important for the residents to receive their medications as ordered. Staff C stated the Sevelamer needed to be given because they monitored the residents' labs and they needed them to be at certain levels. In an interview on 06/26/2026 at 8:53 AM, Staff B, Director of Nursing, stated Resident 3 took anxiety medication prior to dialysis, and their other medications were given when they came back. Staff B stated it was important for Resident 3 to receive their medications for their overall health. Staff B stated their expectation was for nursing staff to administer the medications as ordered by the provider and stated Resident 3 should have received their medications. <Resident 22>The 04/15/2026 quarterly assessment documented Resident 22 had diagnoses that included delusional disorder (a mental illness characterized by persistent, fixed false beliefs), edema (swelling), and constipation. Resident 22 had severe cognitive impairments and was not able to make their needs known. Resident 22 had the following medication orders:-Divalproex (anticonvulsant), ordered to start on 01/18/2026, three times a day for delusional disorder-Lasix (diuretic), ordered on 02/13/2025 twice daily for edema-Miralax (laxative), ordered to start on 12/22/2023, every other day for constipation-Seroquel (antipsychotic), ordered on 07/13/2022, twice daily for delusional disorder The May 2026 MAR showed Resident 22 did not receive their Miralax on 05/14/2026, 05/20/2026, and 05/26/2026. The June 2026 MAR showed Resident 22 did not receive their Divalproex, Lasix and Seroquel on 06/18/2026. The MAR was blank on the above dates and there was no documentation in Resident 22's record that explained why the doses were omitted. In an interview on 06/26/2026 at 9:29 AM, Staff J, Registered Nurse, stated if a resident refused their medication, it was documented in the MAR. Staff J stated it was important for Resident 22 to receive their medications for their overall health and mood. In an interview on 06/26/2026 at 9:38 AM, Staff B, stated when medications were not given there should be a note explaining why. Staff B stated Resident 22 should have received their medications as ordered by the provider. Reference: WAC 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to refer a resident for a PASRR Level II screening (Pre-admission Screening and Resident Review, a detailed mental health screening completed by a specialized evaluator to determine if a resident benefitted from behavioral health services. The PASRR Level II screening was required when a resident's PASRR Level I screen showed a serious mental illness), for 1 of 6 residents (Resident 26) reviewed for PASRR. This failed practice placed the resident at risk for missing beneficial mental health services. Findings included.A quarterly assessment, dated 04/08/2026, documented Resident 26 had diagnoses of diabetes and depression. The resident had moderately impaired cognition and made their needs known.A PASRR Level I form dated 09/26/2024 was completed by the hospital prior to Resident 26's admission to the skilled nursing facility. The document showed that the resident did not have a serious mental illness at that time and did not need further evaluation. Review of the Resident 26's medical record showed that Zoloft (an antidepressant medication) was started on 09/17/2025 and depression was added to their list of diagnoses.No documentation of an additional PASRR Level I (that should have been completed when the resident was diagnosed with a new mental illness), or referral for a PASRR Level II was found in the medical record. During an interview on 06/25/2026 at 11:40 AM, Staff B, Director of Nursing, stated if they had any questions about the PASRR requirements, they would ask Staff I, Social Services Director. During an interview on 06/25/2026 at 2:23 PM, Staff I stated that if a current resident had a new serious mental illness, they would fill out a new PASRR Level I form. Staff I stated they had completed a new form at the time but could not remember if they sent it for a Level II evaluation. Staff I further stated the priority for the evaluators was new residents leaving the hospital, rather than residents currently in a nursing facility. During an interview on 06/25/2026 at 3:34 PM, Staff I provided a copy of a PASRR Level I, dated 09/17/2025 (over nine months ago). Staff I stated that they just scanned it into the resident's medical record now. Staff I acknowledged they had not sent it for a Level II evaluation, as required. During an interview on 06/26/2026 at 4:09 PM, Staff A, Administrator and Staff B, acknowledged the 09/17/2025 PASRR should have been sent for a Level II evaluation at the time. References: WAC 388-97-1975(7)

Based on observation, interview and record review, the facility failed to ensure a process for the use of compression stockings (specialized snug fitting hosiery that applied graduated pressure to lower legs and ankles designed to boost blood circulation toward the heart) was fully developed for 1 of 4 sampled residents (Resident 14) reviewed for non-pressure related skin conditions. This failure caused Resident 14 to sustain redness and blisters on their upper thighs and put residents at risk for unintended consequences of ill-fitting compression stockings.Findings included.Review of the 05/20/2026 quarterly assessment documented Resident 14 had diagnoses that included varicose veins (swollen, twisted veins caused by damaged valves that allowed blood to pool instead of flowing back to the heart) of the lower legs and peripheral vascular disease (narrowing or blockage of blood vessels outside the heart). Resident 14 was cognitively intact and was at risk for pressure ulcers. On 03/25/2025, a wound care provider progress note documented Resident 14 no longer needed to visit the clinic for venous ulcers (slow-healing ulcers caused by damaged vein valves) on both outer ankle bones. Staff were instructed to order compression stockings size 20-30 mmhg, (millimeters of hemoglobin, the amount of compression), to apply them daily and the resident was to continue compression therapy to prevent the formation of new venous ulcers. On 03/25/2025, an order was entered to apply A&D ointment, then lotion, then apply compression stockings daily, and to notify the nurse if wounds re-opened. The order did not contain information regarding what size of stocking was to be worn or if the stockings were knee-high or thigh-high.A 06/12/2026 Incident Report documented the nursing assistant (NA) had reported Resident 14 had redness to both of their upper thighs. A second NA had reported blisters and redness to both thighs on 06/09/2026. An order was placed to monitor the area until resolved and notify the provider of any signs of infection. On 06/15/2026, the care plan was updated to include a care area for pressure ulcer/injury: Resident 14 had fluid filled blisters to bilateral thighs. Staff were instructed to provide the Resident's diet as ordered, give a protein supplement twice daily and notify the primary care provider if signs or symptoms of infection developed. A review of the Care Plan report created on 06/24/2026 found no goals or interventions had been developed related to Resident 14's peripheral vascular disease, or the use, care of or size of compression stockings. On 06/23/2026 at 9:52 AM, Resident 14 was observed in their bed. Resident 14 stated, Let me show you something and pulled back their blankets to reveal bruising and bumps on both upper thighs. The bruised area had small square imprints in a waffle pattern and was approximately an inch wide and circled both legs. Resident 14 stated the bruises hurt and itched. Resident 14 stated they came from stockings. Resident 14 stated they had worn the stockings twice but refused to wear them anymore; no irritation had happened the first time they wore them.During an interview on 06/26/2026 at 12:35 PM, Staff E, Bath Aide, stated they were usually the one that put residents' stockings on them when they dressed them after their showers. Staff E stated Resident 14 did not wear their stockings. They stated Resident 14 had worn them once on an outing, and a second time when the blisters and bruises appeared. Staff E stated Resident 14 was not to have thigh-high stockings on and they were surprised to see them on the resident. Staff E stated if there was an order for a resident to have compression stockings, they notified Staff G, Rehabilitation, and Staff G obtained the correct size for them. During an interview on 06/26/2026 at 1:42 PM Staff F, NA, stated they worked one day a week in the Rehabilitation Department. Staff F stated they thought Resident 14 was supposed to have knee-high compression stockings and was unsure when the resident got the thigh-high ones. Staff F stated if residents were supposed to have the compression stockings, the style and size would be in their care plan. During an interview on 06/26/2026 at 2:23 PM, Staff G stated they had never fitted Resident 14 for compression stockings because of the condition of the resident's skin. Staff G was unsure where the thigh-high stockings came from; they did not usually keep a supply of thigh-high stockings. Staff G stated if a resident had an order for compression stockings, they measured the resident's legs and gave that size to the staff. Staff G stated they did not document what measurements they obtained or what size stockings they gave to the staff.During an interview on 06/26/2026 at 2:28 PM, Staff B, Director of Nursing, stated the order obtained for Resident 14's compression stockings did not contain enough information regarding what type of stockings were intended. They stated the order had additional items within it such as applying A&D ointment and was added as a nursing assistant task. Staff B stated the way the order was entered prevented it from showing up on the Medication Administration Record so that the nurses were able to check and document that the NA's had put on the compression stocking and removed them according to the order. Staff B acknowledged that the elastic of the thigh-high stockings had pressed into Resident 14's skin and caused the blisters and bruising. Staff B stated it was important to know the providers intentions for the stockings-if they wanted thigh high or knee high, how long the resident was to wear them, and how much compression the provider wanted. Reference: WAC 388-97-1060(1)-(3)

Based on observation, interview, and record review the facility failed to ensure infection control practices were followed during 1 of 1 meal services and 1 of 2 medication administration observations to include removal of gloves and performing hand hygiene (HH) when indicated and failed to sanitize a mechanical lift between resident transfers. Additionally, staff did not follow Enhanced Barrier Precautions when indicated for 2 of 3 sampled residents (Residents 13 and 21), reviewed for isolation precautions. These failures placed the residents at risk for the spread of infections, illnesses and unintended health consequences. Findings included . Review of the facility's undated policy titled, Hand Hygiene Guideline in Health Care Setting showed hand hygiene could be performed by washing hands with soap and water or using alcohol-based hand rub (ABHR) to reduce the number of microorganisms on the hands in order to prevent transmission of healthcare associated pathogens from one patient to another. The policy instructed staff to perform hand hygiene before direct contact with a patient's intact skin, before application of gloves, after contact with inanimate objects in the immediate vicinity of a patient and when moving from a contaminated body site to a clean body site during resident care. Review of the facility's undated policy titled, Handwashing Policy showed handwashing was the most effective method to prevent the spread of infection. The policy instructed staff to perform hand hygiene when arriving for duty, before applying gloves and after glove removal, before preparing and administering medication, after sneezing, coughing, blowing or wiping the nose or mouth. The Centers for Disease Control (CDC) Implementation of Personal Protective Equipment (PPE- gloves, disposable gowns, eye protection or masks) Use in Nursing Homes to prevent Spread of Multidrug-Resistant Organisms updated July 12, 2002, retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html recommended use of Enhanced Barrier Precautions (EBP) as an infection control intervention that employed targeted gown and glove use during high contact resident care activities when Contact Precautions do not apply for residents with wounds or indwelling medical devices such as feeding tubes (inserted tube that provides liquid nutrition) or catheters (flexible tube inserted into bladder to drain urine). EBP directs staff to put on gowns and gloves when dressing, bathing/showering, transferring, changing linens, providing hygiene, wound care and assisting with toileting. ENHANCED BARRIER PRECAUTIONS <Resident 21> The 03/12/2025 quarterly assessment documented Resident 21 had diagnoses including traumatic brain injury, dementia and malnutrition. Resident 21 had severe cognitive impairments and required a feeding tube. The 03/14/2025 care plan documented Resident 21 required enhanced barrier precautions related to their feeding tube and instructed nursing to use Enhanced Barrier Precautions. In an observation on 04/01/2025 at 8:53 AM, Staff I, Registered Nurse (RN), flushed Resident 21's feeding tube and no gown was worn. In an interview on 04/03/2025 at 10:51 AM, Staff L, Infection Preventionist (IP), stated gloves and a gown needed to be worn when a resident's feeding tube was flushed. Staff L further stated EBP were important for cleanliness and to prevent the spread of germs. <Resident 13> The 01/29/2025 quarterly assessment documented Resident 13 had diagnoses including end stage kidney disease and was dependent on dialysis (a treatment that filters waste and excess fluid from the blood). The 01/30/2025 care plan documented Resident 13 required Enhanced Barrier Precautions related to dialysis and their fistula (a connection made between an artery and [NAME]). In an observation on 04/01/2025 at 11:49 AM, Staff D, Nursing Assistant (NA), transferred Resident 13 into their wheelchair and no gown was worn. In an interview on 04/01/2025 at 11:50 AM, Staff D stated they transferred Resident 13 into their wheelchair and did not need a gown because they were not providing cares. Staff D read the EBP signage posted and acknowledged they should have worn a gown to protect the resident and themselves from germs. SANITATION In an observation on 04/02/2025 at 9:04 AM, Staff M, NA, brought the hoyer lift (a lift used to transfer residents unable to do so) out of Resident 21's room and parked it in the hallway. The lift was not sanitized and had been used to transfer Resident 21. In an observation on 04/02/2025 at 9:13 AM, Staff M grabbed the same hoyer lift and took it into Resident 9's room to assist them to transfer into a shower chair. In an interview on 04/03/2025 at 10:51 AM, Staff L, IP, stated mechanical lifts needed to be sanitized after each use to prevent the spread of germs. HALL TRAYS In an observation on 03/31/2025 at 11:57 AM, Staff N, NA, delivered a meal tray, picked up a piece of paper from the floor and put it in the meal cart on an empty tray and no hand hygiene was performed. The meal cart contained meals needing delivered to other residents. In an observation on 03/31/2025 at 12:17 PM, Staff M, NA, brought a meal tray from a resident's room and placed it in the cart. Staff M delivered another meal tray and hand hygiene was not performed. At 12:19 PM Staff M picked up a piece of garbage from the floor, no hand hygiene was performed, grabbed some mustard packets and took it to a resident's room. At 12:20 PM, Staff M brought a cup from the resident's room and placed it on top of the cart, no hand hygiene was performed, then they delivered Jello to another resident. At 12:25 PM, Staff M grabbed a meal tray and removed the resident's stop sign and entered the room and no hand hygiene was performed prior to the next tray being passed. In an interview on 03/31/2025 at 12:29 PM, Staff M stated hand hygiene was completed prior to serving meal trays and they tried to do it between rooms. When Staff M was asked if hand hygiene should be performed after picking things up from the floor they stated yes, and this was important to prevent the spread of bacteria. In an interview on 04/03/2025 at 10:51 AM, Staff L, IP, stated hand hygiene was completed after touching things, in between resident rooms and this was important to prevent the spread of germs. Staff L stated the nursing assistants should not have placed dirty meal trays in the cart until all trays were passed. 47328 SMALL ASSISTED DINING ROOM During observation on 03/31/2025 at 11:54 AM, Staff D, NA, did not perform hand hygiene, delivered a lunch tray to a resident in the small assisted dining room and placed a clothing protector on them. Staff D did not perform hand hygiene and put on a pair of gloves. Staff D grabbed another meal tray off the meal cart, delivered it to another resident in the dining room, placed a clothing protector on the resident, and adjusted their wheelchair closer to the table. Staff D removed their gloves, did not perform hand hygiene, and put on a new pair of gloves. During observation on 03/31/2025 at 11:56 AM, Staff J, Activities Assistant, did not perform hand hygiene, delivered a lunch tray to two different residents in the small assisted dining room, and put a pair of gloves on without performing hand hygiene. At 11:58 AM, Staff J removed their gloves and exited the dining room without performing hand hygiene. At 11:59 AM, Staff J returned to the dining room, did not perform hand hygiene and put on a new pair of gloves. In an interview on 04/02/2025 at 9:51 AM, Staff K, NA, stated hand hygiene should be performed before and after resident care was provided to prevent the spread of germs. Staff K further stated staff should perform hand hygiene when indicated. In an interview on 04/02/2025 at 9:55 AM, Staff E, Licensed Practical Nurse, explained hand hygiene was washing hands with soap and water or using ABHR until dry. Staff E stated hand hygiene should be performed any time before and after resident care. Staff E further stated staff should perform hand hygiene when indicated to prevent the spread of infections. In an interview on 04/02/2025 at 11:11 AM, Staff L, IP, stated hand hygiene was a tool used to limit the transfer of organisms from one thing to another. Staff L explained hand hygiene should be performed by washing hands with soap and water or using ABHR before entering a resident's room, before application of gloves, after glove removal, after touching any items in a resident room, before leaving a resident's room, and when passing meal trays. Staff L stated they expected staff to perform hand hygiene when indicated. In an interview on 04/02/2025 at 11:21 AM, Staff B, Director of Nursing (DNS), explained hand hygiene was the use of ABHR or washing hands with soap and water when visibly soiled. Staff B stated they expected staff to perform hand hygiene when indicated to prevent the spread of germs. MEDICATION ADMINISTRATION During observation on 04/03/2025 at 7:31 AM, Staff C, RN, did not perform hand hygiene and began to dispense medications for Resident 8. Staff C walked into Resident 8's room, touched the blue non-skid sock on Resident 8's left foot to get their attention, and administered Resident 8 their medications. Staff C exited Resident 8's room without performing hand hygiene. During observation on 04/03/2025 at 7:47 AM, Staff C, did not perform hand hygiene, grabbed a pair of gloves, dropped one glove on the floor, picked up the glove, put the pair of gloves on (including the glove that was picked up off the floor) and walked down the hall to room [ROOM NUMBER]. Staff C administered eye drops to Resident 15. During observation on 04/03/2025 at 7:51 AM, Staff C began to dispense medications for Resident 28. Staff C stopped briefly and blew their nose with a Kleenex and stated their nose ran. Staff C did not perform hand hygiene and continued to dispense medications for Resident 28. Staff C moved the medication cart down the hall and parked it outside the big dining room. Staff C administered medications to Resident 28. During observation on 04/03/2025 at 8:06 AM, Staff C did not perform hand hygiene and began to dispense medications for Resident 1. Staff C dropped a blood pressure pill, moved the medication cart looking for the pill, Staff C ran their fingers across the dusty bottom edge of the medication cart searching for the small pill but was unable to locate the pill and dispensed a new pill without performing hand hygiene. Staff C administered medications to Resident 1. In a follow-up interview on 04/03/2025 at 9:21 AM, Staff B, DNS, stated they expected staff to perform hand hygiene after they blew their nose. In an interview on 04/03/2025 at 1:51 PM, Staff A, Administrator, stated they expected staff to perform hand hygiene when indicated and follow EBP when implemented. Reference WAC 388-97-1320 (1)(c )

Based on observation and interview, the facility failed to ensure meals were served at palatable temperatures during 1 meal service observed. This failure put residents at risk of decreased enjoyment of their meals, and possible reduced dietary intake. Findings included . According to [NAME] Administrative Code [PHONE NUMBER]0, time/temperature control for safety of food, hot and cold holding (FDA Food Code 3-501.16), food must be maintained: At 135 F (57 C) or above, or at 41 F (5 C) or less. In an observation on 04/03/2025 at 11:46 AM of the lunch meal service, the temperatures (in degrees Fahrenheit) were as follows: Pureed (when food is turned into a paste) carrots = 129.5 F Pureed goulash = 129.3 F Mixed berries = 48.3 F Milk = 50.1 F These temperatures did not meet the requirements that hot food must be 140 F or greater and cold foods must be less than 41 F or less, when served. On 04/03/2025 at 12:04 PM, the food was placed on a cart and was ready to be served to the residents. Staff G, Dietary Manager, was asked what the temperatures needed to be for the hot and cold food items. Staff G stated the hot foods needed to be served at 135 F and the cold food at 40 F. Staff G reheated the hot food and said the cold items were fine to be served. In an interview on 04/03/2025 at 1:31 PM, Staff B, Director of Nursing, stated it was important to serve food at the appropriate temperatures to prevent foodborne illnesses. Reference: WAC 388-97-1100 (1)(2)

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, expired foods were not discarded for 1 of 2 refrigerators, 1 of 1 dry storage areas, and food items in the refrigerator and freezer were not dated when opened. These failures placed residents at risk for foodborne illnesses. Findings included . During an initial tour of the kitchen on [DATE] at 8:41 AM, the dry storage area revealed a can of bean sprouts that expired on [DATE], eight packages of nonfat dry milk that expired on [DATE], six boxes of corn starch that expired on [DATE] and a box of couscous that expired on [DATE]. The refrigerator in the main kitchen contained a bag of salmon with a use by date of [DATE], a bag of brown wilted lettuce that had no date, four containers of grape juice that expired [DATE], four half sandwiches and an opened bag of whipped topping that had no dates. The freezer contained opened bags of French fries, corn dogs, broccoli, and dinner rolls that had no open or expiration dates. In an interview on [DATE] at 9:29 AM, Staff H, Cook, stated dietary staff were supposed to put dates on items when they were opened, and this was important to know how long the product could be used for and to prevent foodborne illnesses. In an interview on [DATE] at 12:42 PM, Staff G, Dietary Manager, stated all food items needed to be dated when opened and it was important to discard food to prevent food poisoning. Reference: WAC [DATE] (3), 2980

Based on observation, interview and record review the facility failed to ensure medications were given as ordered for 1 of 6 sampled residents (Resident 13), reviewed for medication administration. This failure placed residents at risk for adverse health consequences and diminished quality of life when doses of medications were omitted. Findings included . <Resident 13> The 01/29/2025 quarterly assessment documented Resident 13 had diagnoses including diabetes, high blood pressure and end stage kidney disease, and had severe cognitive impairments. A review of active orders documented Resident 13 was to receive the following medications: -10/03/2024 Velphoro 500 milligrams (mg) with meals to help maintain calcium levels in the blood. -10/03/2024 Lispro insulin 5 units with meals, hold if blood sugar was less than 100 for diabetes. -01/29/2025 Semglee insulin 100 units daily when Lantus was used up for diabetes. -04/02/2024 Norvasc 5 mg daily for high blood pressure. A review of the March 2025 medication administration record (MAR) revealed omitted entries (blank spaces) for Resident 13's Velphoro on 03/18/2025, Lispro insulin on the evening of 03/16/2024 and morning of 03/18/2025, Semglee insulin on evening of 03/16/2025, and Norvasc on 03/16/2025. Further review of March 2025 nursing progress notes and the MAR revealed no documented progress notes or administration codes explaining the omitted medication entries in the MAR. In an interview on 04/02/2025 at 2:18 PM, Staff I, Registered Nurse, and Staff O, Social Service Director, reviewed Resident 18's MAR and acknowledged the above medications were not given as ordered. Staff I stated according to the MAR the medications should have been administered and if they were not given the reason should have been documented. In an interview on 04/02/2025 at 2:37 PM, Staff B, Director of Nursing, acknowledged Resident 13's medications were not given as ordered. Staff B stated it was important to administer medications as ordered for management of Resident 13's diabetes, blood pressure and absorption of nutrients. Reference: WAC 388-07-1069(3)(k)(iii)

Based on observation, interview, and record review the facility failed to ensure the call light (a device used to request help as needed) was accessible for 1 of 3 sampled residents (Resident 18), reviewed for environment. This failure placed the resident at risk for unmet needs, potentailly avoidable accidents, and diminished quality of life. Findings included . The 03/12/2025 quarterly assessment documented Resident 18 had diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement), arthritis and depression. In an observation and interview on 03/31/2025 at 10:12 AM, Resident 18 was lying in bed. Resident 18 stated they spilled their water and were wet. When asked if they had put their call light on for help, Resident 18 stated no. The resident tried to find their call light and could not find it. The surveyor attempted to hand Resident 18 the call light but it was stuck behind the bed. In an observation on 04/02/2025 at 9:16 AM, Resident 18 was sitting in their wheelchair. Resident 18 stated they wanted to lay down and reached for their call light on their bed. Resident 18 was unable to reach the call light. The resident was asked what they would do if they needed help, and Resident 18 stated they would try to yell out but they had a very low voice. In an observation on 04/03/2025 at 11:21 AM, Resident 18 was sitting in their wheelchair in their room. The wheelchair was not close to the bed where the call light was placed. Resident 18 attempted to reach the call light and stretched their arm out as far as they could but was unable to reach the call light. During an interview on 04/03/2025 at 9:49 AM, Staff D, Nursing Assistant, stated it was important to have the call light within reach to prevent falls, accidents, and for the resident to call for help. In an interview on 04/03/2025 at 9:51 AM, Staff E, Licensed Practical Nurse, stated it was important to have the call light within reach so the resident could communicate the need for help. Staff E stated some resident's had low voices and were unable to be heard. In an interview on 04/03/2025 at 10:34 AM, Staff B, Director of Nursing, stated it was important to keep the call light within reach so the resident could easily find it and call for help. Reference: WAC 388-97-0860(2)

Based on observation, interview and record review, the facility failed to ensure resident personal refrigerators were maintained in a clean manner, without expired foods and at the appropriate temperatures for 1 of 3 sampled residents (Resident 18), reviewed for a homelike environment. In addition, the facility failed to maintain a freezer in the dining room in a clean manner. This failure placed the residents at risk of eating spoiled foods and having an unclean environment. Findings included . During an observation and interview on [DATE] at 10:42 AM, Resident 18 was lying in bed. They had a personal refrigerator that had a container in the freezer. The container had a frozen hamburger with ice crystals inside. The resident stated it had been in there a month or more. The freezer was filled with ice crystals. Subsequent observations of the freezer with ice crystals and the frozen hamburger were made on [DATE] at 11:33 AM, [DATE] at 8:58 AM and [DATE] at 9:13 AM. In an interview on [DATE] at 8:48 AM, Staff E, Licensed Practical Nurse, stated the nurses and housekeepers were responsible for discarding expired food and the temperatures of the freezers were not monitored. Staff E added the housekeepers defrosted the freezers when needed. Staff E stated it was important to discard expired food because it could cause foodborne illnesses, and it was important to monitor the temperature of the freezer because the food could go bad. In an interview on [DATE] at 9:05 AM, Staff B, Director of Nursing, stated it was important to monitor the temperature of the freezer and to defrost them for routine maintenance and to prevent frostbite on food. Staff B added it was important to discard expired food to prevent foodborne illnesses. Staff B acknowledged the freezer temperatures were not being monitored. In an interview and observation on [DATE] at 1:04 PM, the freezer in the dining room had nutritional drinks that were frozen with ice crystals covering the walls of the freezer. Staff B stated the freezer in the dining room needed to be defrosted. Reference: WAC [DATE] (1)

Based on observation and interview, the facility failed to ensure expired medications were removed from inventory in 1 of 2 medication carts in use, and failed to ensure the temperature of the medication room was monitored in the facility medication room. These failures placed residents at risk of receiving medications that were expired or not properly stored. Findings included . <Expired Medications> During an observation of the medication cart on the 300 Unit on 04/03/2025 at 7:43 AM with Staff E, Licensed Practical Nurse, the following medications were found to be expired: -1 blisterpack sleeve of rosuvastatin calcium, expiration date 03/31/2025 for Resident 25, and -2 boxes of Debrox 6.5% ear wax removal solution, expiration 03/20/2025 for Residents 4 and 12. Staff E replaced the rosuvastatin with a new sleeve available in the overflow drawer and the Debrox drops were discarded. Staff E stated nurses were to check medication expiration dates prior to giving the medications. They stated the Debrox drops and rosuvastatin were given on the night shift at bedtime so Staff E had not administered them. Staff E stated residents rarely needed Debrox drops so that was likely why they were still in the medication cart, and the rosuvastatin just got missed. <Medication Room> During an observation and interview on 04/03/2025 at 7:29 AM, the medication room was observed with Staff F, Registered Nurse. There was no thermometer observed in the medication room where various medications were stored at room temperature. Staff F acknowledged the medication room did not have a thermometer to monitor the temperature of the room. In an interview on 04/03/2025 at 7:57 AM, Staff B, Director of Nursing, stated it was important to monitor the temperature of the medication room because it could impact the medications that were stored in there and could impact the temperature of the refrigerator which also contained medication. Reference WAC 388-97-1300 (2), -2340 46115

Based on observation, interview, and record review failed to ensure submission of the Payroll Based Journal (PBJ) per the Centers of Medicare and Medicaid (CMS) requirement for 1 of 1 Fiscal Year (FY) Quarter (Q4 2023 [July 1 through September 30, 2023]), reviewed for PBJ submission. This failure constituted 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). The facility implemented and completed a plan of correction which was verified by surveyors. The plan of correction included installation of a computer program that provided secure authenticated access for remote and mobile users, request and granted access to the CMS reporting system, staff education regarding CMS PBJ data submissions, and review of PBJ submission quarterly reports to ensure solutions were sustained. Findings included . Review of the CMS Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual, Version 2.6, June 2022, showed on page 6, 1.4 Methods of Submission, as entering data manually electronically in the CMS system, or by uploading the data directly from an automated payroll or time attendance system. Review of the CMS PBJ Staffing Data Report for FY Q4 2023 showed no data was submitted for the referenced quarter. Review of a document provided to the State Survey Agency on 08/14/2024 showed the facility name, state vendor number, and the quarter and year reporting (Q4 2023). In small print below the described facility-specific information, showed, Quarters are defined as: 1st Quarter (Jan[uary] - Mar[ch]), 2nd Quarter (Apr[il] - Jun[e]), 3rd Quarter (Jul[y] - Sep[tember]), 4th Quarter (Oct[[NAME]] - Dec[ember]), which was the defining of state quarters instead of federal or FY quarters required for use with PBJ data collection and submission. The document showed a grid which included job category (staff providing direct care hours), month, total reported hours per each month, total hours in quarter, total patient census for each month, total census in quarter, and hours of direct care per resident day (HPRD) calculations per month with a quarter total. There was no documented auditable and verifiable data included with the summarized hours. In an interview on 08/14/2024 at 11:05 AM, Staff A, Administrator, stated the facility had been unable to successfully submit PBJ data via the CMS software due to the facility network/systems blocking the usage of the software due to increased firewall (part of a computer system that is designed to block unauthorized access while permitting outward communication) protection. Staff A acknowledged the facility was submitting hours to the Department Office of Rates and not directly to CMS, as required. Staff A further stated a computer program was installed May 2024 to address the increased firewall protection issue. On 08/21/2024 a spreadsheet with columns for staff names, employee PBJ system identification number, position worked, role worked, date worked, and hours not previously submitted to CMS, was received via e-mail for July 2023. The spread sheet included 431 rows of facility data entries, and the e-mail included 69 pages of July 2023 payroll data and staffing invoices. A similar spreadsheet was received for August 2023 that included 423 rows of facility data entries, and 64 pages of August 2023 payroll data and staffing invoices. On 08/22/2024 another similar spreadsheet was received via e-mail for September 2023 that included 415 rows of facility data entries, and 62 pages of September 2023 payroll data and staffing invoices. During observation and interview on 09/16/2024 at 9:40 AM, Staff C, Business Office Manager (BOM), acknowledged the facility had been submitting data to the Department Office of Rates and not directly to CMS, as required. Staff C further stated the facility had been unable to successfully submit PBJ data via the CMS software due to the facility firewall protection, but the issue was fixed at the end of May 2024. Staff C verified access to the CMS reporting system was requested and accepted on 05/14/2024, demonstrated the secure authenticated access computer program was installed onto the BOM's computer with access to CMS, reviewed education received regarding CMS PBJ data submissions, and provided a CMS report showing the facility had begun submitting data. In an interview on 09/16/2024 at 10:03 AM, Staff B, Director of Nursing, acknowledged the facility had not been submitting PBJ data directly to CMS, as required, because of the firewall protection. Staff B stated a secure authenticated access computer program was added to the BOM's computer to allow access to CMS databases (collection of structured information, or data, that is organized and stored electronically in a computer system) in May 2024 and the facility had begun submitting data to CMS, as required. This was Past Non-Compliance and is no longer outstanding. Reference WAC: 388-97-1090(1)(2)(3)

Based on interview and record review, the facilty failed to ensure submission of the Payroll Based Journal (PBJ) per the Centers of Medicare and Medicaid (CMS) requirement for 1 of 1 Fiscal Year (FY) Quarter (Q1 2024 [October 1 through December 31 2023]), reviewed for PBJ submission. This failed practice resulted in CMS to have inaccurate data related to nursing home staffing levels which had the potential to impact the care and services provided to all the residents in the facility. Findings included . Review of the CMS Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual, Version 2.6, June 2022, showed on page 6, 1.4 Methods of Submission, as entering data manually electronically in the CMS system, or by uploading the data directly from an automated payroll or time attendance system. Review of the CMS PBJ Staffing Data Report for FY Q1 2024 showed no data was submitted for the referenced quarter. Review of documents provided to the state agency survey team on 04/22/2024 inlcuded a document that showed the facility name, state vendor number, and the quarter and year reporting (Q1 2024). In small print below the described facility-specific information, showed, Quarters are defined as: 1st Quarter (Jan[uary] - Mar[ch]), 2nd Quarter (Apr[il] - Jun[e]), 3rd Quarter (Jul[y] - Sep[tember]), 4th Quarter (Oct[[NAME]] - Dec[ember]), which was the defining of state quarters instead of federal or FY quarters required for use with PBJ data collection and submission. The document showed a grid which included job category (staff providing direct care hours), month, total reported hours per each month, total hours in quarter, total patient census for each month, total census in quarter, and hours of direct care per resident day (HPRD) calcuations per month with a quarter total. There was no documented auditable and verifiable data included with the summarized hours. During an interview via a virtual audio and video platform on 05/06/2024 at 1:05 PM, Staff A, Administrator, and Staff H, Business Office Manager, were shown documents as evidence of PBJ submission, provided by the facility to the survey team during the recertification survey. Staff A and Staff H explained the documents presented were the PBJ, which included a document with a summation of Q1 2024 hours. Staff H explained the routine method of submission was by email to the department Office of Rates, in which they understood it to be a successful submission of the PBJ. Staff A and Staff H explained they attempted to submit the PBJ via the CMS software one time (could not recall date) and was unsuccessful due to the facility network/systems blocking the usage of the software, mostly likely due to increased firewall (part of a computer system that is designed to block unauthorized access while permitting outward communication) protection. After the unsuccessful submission, Staff H stated they went back to submitting the hours to the department Office of Rates, thus not meeting the requirement for electronic PBJ submission directly to CMS. On 05/06/2024 at 1:33PM, the Residential Care and Services (RCS) Field Manager submitted an email to the CMS Nursing Home (NH) Staff email at NHStaffing@cms.hhs.gov to inquire on the facility's behalf, of the verification of the last successful PBJ submission per their data base. An email response was received from CMS NH Staffing on 05/13/2024 at 4:35AM that showed the facility had not submitted PBJ data in 2023 or 2024, thus far. WAC Reference: 388-97-1090(1)(2)(3)

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. Specifically, glove changes and hand hygiene was not done appropriately, contaminated gloves were set on a clean food prep counter during meal preparation and the sanitizing bucket solution was not monitored, as required. Additionally, meat sandwiches in the dining room refrigerator were not labeled with a made or discard by date. These failures placed residents at risk for consuming contaminated foods and food-borne illness. Findings included . <Hand Hygiene/glove changes during meal preparation on 04/24/2024> At 8:10 AM and 8:14 AM, Staff E, Cook, was observed touching/adjusting their shirt with their gloved hands. Staff E then continued to plate the food without changing their gloves. At 8:18 AM, Staff E opened the refrigerator, removed an item, then continued to plate the food without changing their gloves. At 8:19 AM, Staff E pushed up their eyeglasses with their gloved hand and did not change their gloves before they returned to plating the food. At 8:23 AM, Staff E opened the refrigerator to remove an item, then picked the raisin toast out of the toaster and buttered it, without changing their gloves or doing hand hygiene. <Discarded gloves on clean work surfaces> During the observation of the breakfast meal preparation on 04/24/2024 from 7:55 AM to 8:30 AM, Staff E set all their discarded/contaminated gloves in a pile on the clean counter, touching the tray with the buttered toast. During an interview following the observations, Staff E acknowledged that they should have performed hand hygiene and glove changes after touching clothing and the refrigerator door. When asked about discarded gloves on the clean counter, Staff E stated there was not enough room for a garbage can in the food prep area. Staff E stated that the clean counter was not a good place to put the dirty gloves. <Sanitizing bucket> During an interview and observation on 04/24/2024 at 8:25 AM, Staff E used a paper strip to check the concentration of bleach in the bucket of sanitizing solution. The reading was the highest level at over 200 parts per million (ppm). They stated they did not know what the level was supposed to be, and they did not log the results. During an interview on 04/30/2024 at 9:40 AM, Staff C, Food Service Manager, stated that the sanitizing bucket contained some bleach, cold water and a rag. They further stated that they try to test the sanitizer routinely, but were not sure if the results were recorded or what they should be. <Dining Room Refrigerator> On 04/25/2024 at 11:00 AM, observed four meat sandwiches, individually wrapped in plastic in the refrigerator. None were dated or labeled. On 04/30/2024 at 9:40 AM, Staff C acknowledged that if food was not labeled with a date, there was no way to determine if it was too old and should be discarded. Additionally, Staff C stated they expected staff to change gloves after touching contaminated surfaces, and to discard used gloves in the trash. References: WAC 388-97-1100(3)

Based on interview and record review, the facility failed to ensure the Food Service Manager had the required credentials. This failure placed all residents at risk for receiving dietary services from staff without the required competencies. Findings included . During an interview on 04/30/2024 at 10:17 AM, Staff C, Food Services Manager, stated that they did not have a kitchen manager certification. During an interview on 04/30/2024 at 12:41 PM, Staff A, Administrator, stated that the facility had a Registered Dietician employed that worked closely with Staff C, and came into the facility at least every three months. They further stated that Staff C had not done the education to become certified as a food manager. During an interview on 04/30/2024 at 1:39 PM, Staff A acknowledged that Staff C did not have the required certification to meet the regulation. Reference (WAC) 388-97-1160 (1)

Based on interview and record review, the facility failed to complete a discharge summary that included a physician recapitulation/summary of the resident's stay, as required, for 2 of 3 sampled residents (31, 82) reviewed for discharge. This failure placed the resident at risk for having an incomplete medical record. Findings included . <Resident 31> According to an admission assessment, dated 03/11/2024, Resident 31 was cognitively intact and had diagnoses which included anxiety and a psychotic disorder (mental disorder that caused abnormal thinking and perceptions) with hallucinations (hearing and seeing things that were not there). Per the medical record, Resident 31 was discharged from the facility on 03/20/2024. A Transition of Care/Discharge summary form, signed by the resident on the date of discharge, included instructions for them to follow up with the behavioral health clinic. The area for the Recapitulation of Stay (summary of the care and treatment the resident received at the facility) was blank. A physician summary of care was not found elsewhere in the medical record. <Resident 82> According to an admission assessment, dated 07/31/2023, Resident 82 had moderately impaired cognition and diagnoses of diabetes, heart failure and Schizophrenia (a mental disorder characterized by a misperception of reality). Per the medical record, Resident 82 was discharged from the facility on 10/16/2023. A Transition of Care/Discharge summary form included information on follow up appointments with their primary provider and two specialists, and an in-home care agency. The area for the Recapitulation of Stay was blank. A physician summary of care was not found elsewhere in the medical record. During an interview on 04/29/2024 at 3:18 PM, Staff F, Social Services, stated that they did not think the provider did summaries of resident care at discharge. During an interview on 04/30/2024 at 9:35 AM, Staff G, Registered Nurse, acting Director of Nursing, acknowledged that a physician recapitulation of stay had not been completed for Residents 31 and 82. Reference: WAC 388-97-0080(7)(a)

Based on interview and record review the facility failed to provide two staff supervision required for transfers for 1 of 3 sampled residents (Resident 1), reviewed for accidents. Resident 1 experienced harm when they sustained a painful inoperatable right femur (thigh bone) fracture after a staff assisted fall. This failure placed residents at risk of potentially avoidable accidents, injuries, and diminished quality of life. Findings included . Review of the undated facility policy titled, Fall Prevention Protocol, showed the facility would minimize risk for injury from preventable falls by assessing residents for fall risk and care planning safety interventions. According to the 12/06/2023 quarterly assessment, Resident 1 had diagnoses including stroke with hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness affecting one side of the body) affecting the right dominant side, and right arm contracture (fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement). The assessment further showed Resident 1 was dependent on staff to complete most activities of daily living including bed mobility and transfers. Review of Resident 1's provider orders showed a 06/28/2022 provider order for two staff assist with transfers using the sit to stand lift (assists a person, with some mobility and strenght, into a semi-standing position). A 09/26/2023 care plan evaluation note showed Resident 1 required extensive assist from two staff for transfers related to unsteady balance that required staff assist for stabilization. The note further showed Resident 1 had limited range of motion in their right arm and leg which were flaccid secondary to hemiparesis. Review of the 01/24/2024 care plan showed Resident 1 required assist from one staff for dressing and undressing but did not specify how much assist they required to complete other activities of daily living such as toileting, bed mobility, or transfers. Review of the 02/06/2024 facility fall incident report showed Resident 1 had a fall out of bed and was grimacing in excruciating 10 out 10 pain (on a scale of zero-10 with zero being no pain and 10 being the worst pain possible), and pointed to their right hip. The incident report contained a witness statement which showed Resident 1 slid off the edge of the bed when one staff prepared to transfer them with the sit to stand lift. Review of the 02/06/2024 hospital visit notes showed Resident 1 sustained a fall during a transfer and landed on their right side. The notes showed Resident 1 had right shoulder and hip pain. After assessment and imaging, Resident 1 was diagnosed with right hip bursitis (painful inflammation of the fluid filled sac near a joint) related to a ground level fall. A possible femur fracture was in question and recommended further imaging of the right hip. Review of the 02/07/2024 emergency department visit notes showed Resident 1 had further imaging completed and was diagnosed with a right femur fracture. Resident 1 was prescribed Oxycodone (narcotic used to treat moderate to severe pain) as needed for pain. Review of Resident 1's February 2024 progress notes showed: - 02/06/2024 at 12:51 PM, Resident 1 had a fall with reports of pain to right hip, imaging was ordered related to suspected fracture. - 02/07/2024 at 3:06 AM, Resident 1 continued to complain of right hip and leg pain that was only somewhat relieved by Hydrocodone (narcotic used to treat moderate pain). Resident 1 reported extreme pain during cares. - 02/07/2024 at 12:05 PM, Resident 1 was transferred to the hospital for further imaging related to extreme pain. Staff was notified Resident 1 had a right femur fracture. - 02/07/2024 at 3:04 PM, Staff was notified Resident 1 was not a surgical candidate and was transferred back to the facility with a knee immobilizer to be used during transfers or when up in their wheelchair. Resident 1 was prescribed Oxycodone as needed for pain management. - 02/07/2024 at 5:47 PM, Resident 1's pain was not controlled with one Hydrocodone and the provider increased the dose to one to two tablets. - 02/08/2024 at 4:12 PM, Resident 1 was administered Tylenol, Hydrocodone, and Oxycodone to attempt to decrease pain from the right femur fracture. Resident 1 spent all day in bed related to pain caused by the femur fracture. - 02/09/2024 at 4:08 PM, Resident 1 was out of the facility and return in intense pain related to right femur fracture. Resident 1 refused to eat related to being in pain and was medicated with two Hydrocodone tablets. An hour later, Resident 1 was still in pain and was then medicated with Oxycodone, which let Resident 1 nap for a while. When Resident 1 awoke they were again in pain, the provider was notified, and the Oxycodone dose was increased. - 02/11/2024 at 2:58 AM, Increased dose of Oxycodone was only effective for two hours when administered. - 02/15/2024 at 11:05 AM, Resident 1 had a significant change in condition related to a right femur fracture, increased pain with daily use of as needed pain medications, and increased use of Hoyer (machine that lifts a person completely) lift for transfers since the fracture. - 02/18/2024 at 12:40 PM, Resident 1 reported eight out of 10 right leg pain and was medicated with Hydrocodone. - 02/19/2024 at 5:10 PM, Resident 1 reported seven out of 10 right leg pain and was medicated with Hydrocodone. During an interview on 02/21/2024 at 10:39 AM, Resident 1 acknowledged they had a recent fall and hurt their leg. Resident 1 grimaced while they pointed to the right side of their body. During an interview on 02/21/2024 at 11:19 AM, Staff C, Nursing Assistant, stated staff should be able to find how much assistance a resident required in the care plan. Staff C stated Resident 1 had a recent fall during a transfer that caused a fracture, and the resident transferred using a sit to stand machine with one staff assist prior to their fall but used the Hoyer lift (a device where a person requires total assitance to stand or transfer) with two staff assist after the fall. During an interview on 02/21/2024 at 11:30 AM, Staff D, Licensed Practical Nurse, stated staff could find how much assistance a resident required in their care plan. Staff D acknowledged Resident 1 had a fall when a one staff assisted sit to stand transfer was being attempted. Staff D further stated Resident 1 returned from their outing early that day because they had significant pain and had just been medicated with two Hydrocodone tablets. During an interview on 02/21/2024 at 11:57 AM, Staff B, Director of Nursing, stated Resident 1 transferred with one to two staff assist using a sit to stand lift prior to their fall. Staff B acknowledged Resident 1 had a fall when the plastic incontinence pad they sat on slipped during a one staff assisted sit to stand transfer attempt. Staff B further stated Resident 1 could not sit up unassisted because they lacked core strength secondary to hemiplegia and hemiparesis. Staff B reviewed Resident 1's medical record. Staff B stated it appeared the provider order to use two staff assist during a sit to stand lift transfer was not followed and the care plan did not specify how much assistance was required to perform activities of daily living. Reference WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to put adequate safety interventions in place related to wandering behavior for 1 of 3 sampled residents (Resident 1), reviewed for elopement (leaving the premises unaccompanied, when assessed not to be safe to do so). This failure placed the resident at increased risk for accidents and injury. Findings included . According to Resident 1's care plan, dated 04/19/2023, they were admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) and dementia (a group of symptoms that affects memory, thinking and interfers with daily life) with hallucinations (an experience in which you see, hear, feel, or smell something that does not exist) and delusions (fixed, false conviction in something that is not real or shared by other people). Per the record, on 02/22/2023 a care plan was initiated to manage the resident's wandering behavior (movement with no rational purpose, seemingly oblivious to need or safety), which included placement of a Wanderguard (a device worn by a resident that alerted the facility staff when the resident was attempting to leave the building). Interventions to keep the resident safe during wandering included having all doors alarmed, with the front door having a Wanderguard alarm in place. On 04/17/2023 a care plan note, written by Staff B, Social Service Director, showed the resident had tried to leave the facility one time. Review of a facility investigation dated 06/02/2023 showed Resident 1 was found at 5:30 PM sitting outside on the ground in the facility parking lot, having sustained skin tears to their arms and forehead. A statement written by Staff C, Registered Nurse, on 06/05/2023 showed another resident told staff that Resident 1 had fallen in the parking lot. Staff C then exited through the back hall and went around to the parking lot where the resident was assessed and brought back in through the front door, at which time the Wanderguard alarm sounded. An interview with Staff D, Licensed Practical Nurse, at 2:11 PM on 06/29/2023 showed that the facility front door had a Wanderguard alarm, but the back hall door only had an alarm that sounded when it was opened by staff or residents, and a camera that showed the hallway and door on a monitor at the nurses station. When the door alarmed, the camera showed the hallway leading up to the back hall door, which staff could check to see who was going out or coming in. Staff D stated that residents who smoked used that door which exited into a fenced area with several gates, one of which exited into the parking lot. An interview with Staff A, Director of Nursing, at 2:38 PM on 06/29/2023, showed that Resident 1 had exited the facility through the back hall door, most likely when a resident who smoked was also leaving the facility. Per Staff A, when the back hall door alarmed, staff were supposed to silence the alarm at the front nurse's station and then either check the camera to see who was exiting the building, or check at the back door. Staff A confirmed that the door did not have a Wanderguard alarm on it, and based upon finding Resident 1 in the parking lot, staff present the day Resident 1 eloped must not have recognized a resident who had been designated as at risk for unsafe wandering had left the building. Staff A stated that not having a Wanderguard alarm on the back door was a big safety risk for wanderers to leave through the door when smokers where also exiting the building. Reference: WAC 388-87-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to acquire and administer the correct medication formulation for 1 of 3 sample residents (3), observed during medication administration. This failure placed the resident at risk for adverse side effects and diminished quality of life. Findings included . According to the 01/04/2023 annual assessment, Resident 3 had diagnoses including major depressive disorder and borderline personality disorder (a mental illness that severely impacts a person's ability to regulate their emotions). Review of Resident 3's physician orders showed an order dated 08/31/2022 for Depakote Extended Release (ER) [a formulation where medication is slowly delivered over a 24-hour period, typically administered once daily], for borderline personality disorder. On 03/01/2023 at 7:40 AM during medication administration observation, Staff D, Licensed Practical Nurse (LPN), administered Depakote Delayed Release (DR) [a formulation where medication has a special coating that prevents the drug from dissolving too early, typically administered twice daily]. Review of an undated Medication Administration Policy & Procedure showed: - Medications will be administered to residents as prescribed. - Preparation: Prior to administration, the medication and dosage schedule on the Electronic Medication Administration Record (EMAR) is compared with the medication label. If the label and the EMAR are different or if there is any reason to question the dosage or directions, the physician's orders are checked for correct dosage schedule. - Administration: Medications are administered in accordance with written orders of the attending physician or physician extender. Per interview on 03/02/2023 at 7:21 AM, Staff D, Licensed Practical Nurse, confirmed that the Depakote ER order had not been transcribed properly, and the formulation change from DR to ER was not sent to the pharmacy. In an interview on 03/02/2023 at 10:06 AM, Staff B, Interim Director of Nursing (DNS), confirmed that the original Depakote ER order was received on 07/03/2020. Staff B verified that pharmacy had the Depakote DR formulation on file, which they had been dispensing and last refilled on 02/15/2023. Staff B further stated that when orders were received, they needed to be faxed to the pharmacy, and the Depakote formulation change from DR to ER had not been. In an interview on 03/02/2023 at 10:06 AM Staff G, Pharmacist, confirmed that pharmacy had the Depakote DR formulation order on file for a long time, which they had been filling. Staff G further stated that the pharmacy did not receive the Depakote ER order until 03/01/2023. Review of pharmacy records showed that they had a Depakote DR order dated 04/12/2017 on file, and that was the medication Resident 3 was being given since that time. In an interview on 03/02/2023 at 10:30 AM, Staff A, Administrator, stated that the facility switched to electronic medical records in 2020, and the Depakote formulation transcription error could have occurred during the transition. Reference: WAC 388-97-1300 (1)(a)

Based on observation, interview, and record review, the facility failed to implement interventions to prevent elopement (an instance where a resident leaves the facility/safe area without authorization and/or any necessary supervision to do so) for two of five residents (#18, 21) reviewed for accidents, who had cognitive impairment. This failure resulted in Immediate Jeopardy for Residents #18 and #21, who eloped from the facility, which placed them at serious risk for harm or death, and placed all residents identified by the facility as at risk to wander outside at risk for elopements. Additionally, the facility failed to identify all hazards and risks, evaluate the current interventions, implement new interventions, and/or provide adequate supervision and assistance to prevent recurrence of falls, for one of five sample residents (#1), reviewed for accidents. This failure placed Resident #1 at risk for potential injury, related to continued falls. Findings included: The State Agency informed the facility on 10/03/18 at 2:47 PM, of the Immediate Jeopardy. The facility checked all resident Wanderguards to ensure they were functioning, replaced any that required replacement, updated the daily census sheet to ensure all residents at risk to wander were identified, and implemented documented 30 minute checks on residents at risk to wander out of the facility. Additionally, the facility contacted all staff working within the facility, and provided education on facility alarm systems, including the expectation that all doors have one or more types of alarms armed at all times, and staff responsibilities when door alarms sounded. The jeopardy was removed as of 10/04/18 at 2:15 PM. Review of the facility's policy titled, Facility Policy for Building Security, dated 04/09/15, showed staff were to lock the facility doors between 8:00 PM and 6:00 AM during summer (April 30 - (MONTH) 30). Additionally, door alarms would be set to the on position at all times, and staff were to frequently check the alarm panel, to ensure the alarms were set properly. 1. Review of the 08/15/18 assessment showed Resident #18 had a [DIAGNOSES REDACTED]. Additionally, the resident was not steady while walking, and required staff supervision when ambulating. Per the care plan, printed 06/19/18, the resident wore a Wanderguard (an alert system attached on or near a resident, which alarms when near an open door equipped with a matching alarm), and staff were to redirect him if he was observed standing at or near a door to the outside. Review of a facility behavior report, dated 08/06/18, showed the resident was found outdoors, on the east side of the building by a visitor, at approximately 7:00 PM the prior evening. Facility staff were unaware of the absence of the resident prior to his return by the visitor, and did not know how long the resident had been absent from the facility. Per the report, the resident exited out an unlocked and unalarmed back door, and walked around to the east side of the building. The report also noted a hallway barrier to the door was not in place. (See F-610 for additional information.) Observation of the outside perimeter of the building on 10/03/18 from 10:46 AM to 10:54 AM showed the following accident hazards: Upon exiting the facility through the rear service door, the surveyor observed broken equipment such as a picture frame, chairs, and electronic equipment, were stored out back near the dumpster, and presented a tripping or injury hazard, if residents accessed that area. To the right, there was a path of bumpy concrete, and it had an edge that crumbled in places and dropped off several inches to the dirt ground, posing a fall hazard. Directly behind the facility was a wooded area as far as the eye could see, which was accessible through an opening in the back fence. Continuing around the facility toward the northeast, the path met with the front of the facility on the right, and the parking lot straight ahead. Beyond the parking lot was a rural road, which led to the highway toward the right, or a group of buildings to the left. Observation on 10/01/18 at 1:54 PM showed Resident #18 walking in the hallway, led by both hands by an unidentified staff member. The resident did not pick up his feet with each step, but rather slid each foot forward across the floor, in a shuffling style. A Wanderguard was attached to a strap around one wrist. At 3:13 PM, the resident walked himself into the public bathroom on the hallway to the service entrance, using the same shuffling step. The end of the hall to the service entry door was blocked by a strip of yellow cloth tape, approximately three inches wide, marked, Caution - Do Not Enter. In an interview on 10/01/18 at 3:09 PM, Staff C, Registered Nurse, stated the facility had two door alarm systems: a Wanderguard alarm on the front door only, and the main alarm system for all the other doors. Per Staff C, residents who smoked went out the West Wing door to the smoking area, which triggered the alarm frequently throughout the day, but staff could see from the nurse's station if the alarm was triggered, due to the location of that door, via a video feed from a nearby camera. The alarm system required staff to manually reset it, once an open door triggered the alarm. In an interview on 10/02/18 at 3:54 PM, Staff S, Nursing Assistant, stated staff were notified of who was at risk to wander outside during orientation to the facility, and she was aware Resident #18 was at risk to wander in the facility, but was not aware of any residents who had wandered outside, without staff assistance. Staff S also stated there were two alarm systems, but stated in addition to the main alarm on all doors, the Wanderguard was also active for all facility doors. In an interview on 10/02/18 at 4:07 PM, Staff E, Licensed Practical Nurse, stated Resident #18 would go to the front door to let the facility dog in or out, or to look for the dog, but did not generally attempt to wander outside. Staff E was not aware of any instances of wandering outdoors without staff assistance for Resident #18. Additionally, Staff E stated the front door was alarmed with the Wanderguard system at all times, but the main door alarm was turned off for the front door from 6:00 AM to 5:00 PM, because there were more staff available during those hours to listen for the Wanderguard alarm. Per Staff E, night shift nurses checked the function of resident's Wanderguards nightly, and documented it in the medication record. In an observation and interview on 10/03/18 at 9:59 AM, Staff T, Maintenance, walked into the facility through the back service entrance door. No alarms sounded at any point while the door was open. A yellow strip of cloth barrier was across the hallway. Staff T stated neither the front nor back door was alarmed during the day, from 7:00 AM to 4:00 PM. Staff T was asked how staff know which door alarms were supposed to be turned on/off and at what times; he replied nurses were responsible for the alarms, and he believed they documented when and which alarms were turned off/on. On 10/03/18 at 10:24 AM Staff C demonstrated the Signaling Device Tester staff used to test resident Wanderguards, to ensure they were functioning. Following the manufacturer instructions printed on the device, Staff C tested the Wanderguard at the front door, Resident #21's Wanderguard, and Resident #18's Wanderguard. After testing Resident #18's Wanderguard, Staff C stated it was not functioning, and would be replaced later in the day. In an interview on 10/03/18 at 10:45 AM, Staff I, Resident Care Coordinator, stated the resident had previously exited the front door, to go to the parking lot with staff assistance, but he was not aware the resident exited the facility without staff assistance or knowledge on 08/05/18. Staff I stated if a resident wandered outside without staff assistance an investigation of the incident would occur, and the resident's care plan would be updated, with measures to prevent recurrence. He was not aware of any changes to Resident #18's care plan following the elopement. Additionally, Staff I stated there was no system in place to ensure staff were turning the main door alarms on/off at designated times, because nurses set the alarm as a matter of protocol. In an interview on 10/03/18 at 10:55 AM, Staff A, Administrator, and Staff B, Director of Nursing, stated all doors were alarmed after 5:00 PM with the main alarm, but during the day the main alarm was not in place for the front door or the back service entrance. They stated the front door was alarmed at all times with the Wanderguard system, and the back door had a yellow cloth barrier across it, to prevent residents from using the service hallway and door. Staff A stated the nurse on duty each day was responsible to turn the alarms on in the evening, and she would check to ensure the alarms were on when she left for the day on the days she worked, but there was no process in place to ensure the alarms were turned on other days. When asked what new interventions were put in place to prevent further elopements following Resident #18's elopement on 08/05/18, Staff A stated the staff on duty the night of the incident were verbally reminded to keep the yellow cloth barrier up across the service hall, and all staff were re-educated during the (MONTH) (YEAR) staff meeting, on the use of the main door alarms. Review of the 08/23/18 staff meeting notes showed only 22 of 46 staff attended the meeting, where wandering residents and the facility's alarms system were discussed. No further documentation showing education provided to the remaining 24 staff members was provided, including three nurses who would have been responsible for setting the alarm system. Additionally, review of the staffing schedules for August, (MONTH) and (MONTH) (YEAR) showed the facility routinely utilized staff from a staffing agency, who would not have been included in the facility all-staff meetings. No documentation showing how expectations for facility alarm systems were communicated to staff working in the facility, but not employed by the facility, was provided. 2. Per the 08/15/18 assessment, Resident #21 had a [DIAGNOSES REDACTED]. The assessment showed the resident's wandering placed her at risk to access areas of potential hazard, and significantly intruded upon the privacy of others. The care plan, printed 06/14/18, showed the resident wore a Wanderguard, which staff checked daily, and staff were to monitor the resident for wandering during waking hours. The care plan also showed interventions, both which had been discontinued on 06/22/18, for 1:1 staffing (one staff member directly observing and responsible for one resident), and close monitoring and redirection away from wandering into other resident rooms. Review of a 09/05/18 facility investigation showed the resident was seen walking herself from the activity room to her bedroom at an unspecified time, on the evening of 08/31/18. At approximately 9:00 PM, a community member approached the facility to inquire if a resident was missing, described Resident #21 to facility staff, and stated she was at an apartment building near to the facility. The resident was then returned, with the assistance of facility staff. Per the investigation, all alarms and safety devices were active, and no one heard an alarm. The investigation showed staff were assisting residents, but were intermittently available between tasks to respond to alarms. The report did not indicate how long the resident had been absent from the facility. (See F-610 for additional information.) Observation on 10/03/18 at 1:14 PM showed the facility was located on a single rural road that connected with the highway to the southwest, and led to cross streets and several series of buildings to the northeast. The closest apartment buildings were approximately 1500 feet away from the facility. In an interview on 10/02/18 at 4:07 PM, Staff E, Licensed Practical Nurse, stated Resident #21 would go out the front door to look for someone, but was easily redirected back inside, and the resident had an alarm that sounded when she did exit. She stated the resident had 1:1 staff for a few months, and often still had 1:1 staff during the day, or staff would take turns working with the resident. Staff E stated the resident had a 1:1 staff earlier that day, who had gone home already, and she would encourage the resident to stay with her as much as possible. Throughout the duration of the interview, Resident #21 was observed to wander up and down the 100 and 300 hallways, looking into resident rooms, and required multiple redirects from Staff E to stay in common areas, where she could be observed by staff. In an interview on 10/03/18 at 7:26 PM, Staff U and Staff V, Nursing Assistants, stated they were not working the night Resident #21 exited the building, but the facility door alarms were loud enough to hear, even when staff were in another resident's room. The nursing assistants stated if there were only two nursing assistants working, and both were in rooms caring for residents, it could be a couple minutes before they were able to check the alarm. However, there were usually three nursing assistants working in the evenings, and all staff were responsible for ensuring resident safety. In an interview on 10/03/18 at 10:55 AM, Staff A, Administrator, and Staff B, Director of Nursing, were asked what new interventions were put in place to prevent further elopements, following Resident #21's elopement on 08/31/18 (eight days after staff had received education on wandering residents and the building's alarm system). Staff A stated the nurses were educated during the (MONTH) (YEAR) staff meeting on the use of the main door alarms. Review of the 09/20/18 nurse meeting notes showed only six of 11 nurses attended the meeting, where wandering residents and the facility's alarms system were again discussed. No further documentation showing education provided to the remaining five nurses was provided, including the nurse on duty the night of the incident. Lack of consistency between written policies and administrative staff expectations for door alarms, lack of systems to ensure alarms were armed per the stated expectations, and lack of new resident-centered interventions to prevent further recurrence after elopements, placed vulnerable residents at continued risk for elopements, which could lead to complications including significant injury or death. 3. Review of the 09/19/18 assessment showed Resident #1 required assistance with activities of daily living such as bed mobility, transfers, dressing, and toileting. The assessment also showed that he had moderate cognitive impairment. According to his 03/22/18 care plan, the resident was unable to recognize his own deficits, such as those which would relate to balance and safety awareness. The care plan showed he was at risk for falls, and interventions included an easy-release alarming seatbelt, which was to be applied any time the resident was in his wheelchair, unsupervised. Review of the facility's accident and incident log and associated investigations, showed Resident #34 experienced the following falls: - On 03/30/18 at 9:55 PM, the resident was found lying on the floor in his room. The investigation showed the resident stated he was trying to reach a cookie he dropped. The investigation did not show when he had last been seen, and did not indicate what would change to prevent a similar occurrence in the future. - On 06/19/18 at 11:00 AM, staff discovered Resident #1 lying on his back on the floor, with his wheelchair on top of him. Staff I, Resident Care Coordinator's witness statement, showed when he entered the room, Resident #1 was lying naked on the floor, and had sustained two skin tears. The witness statement showed the nursing assistants told Staff I that they left the resident in the bathroom, and he fell when he tried to walk out of the bathroom unassisted. The investigation did not show how long the resident had been unattended. In an interview on 10/10/18 at 10:46 AM, Staff I, Resident Care Coordinator, stated the staff person who had been assisting Resident #1 on 06/19/18 was new, and that it was standard operating procedures not to leave the resident in the bathroom alone. - Per the facility investigation, on 06/21/18 at 4:40 PM staff found Resident #1 lying on the ground outside wing 3, with a skin tear to his left elbow. The investigation did not show when the resident had last been seen prior to the incident, or what the facility would change, to prevent another similar episode of the resident leaving the facility without supervision, and falling. In an interview on 10/05/18 at 1:02 PM, Staff A, Administrator was asked about the details of Resident #1's fall on 06/21/18, and was made aware the investigations for Resident #1's falls did not provide sufficient detail to ascertain what the resident was doing before the falls, the level of supervision he received, and/or the root cause of them. Staff A stated Resident #1 exited the building when he was looking for his pickup, and had not made it far, due to the door and seatbelt alarms. In an interview on 10/05/18 at 12:33 PM, when asked what level of supervision was required for Resident #1 if he wanted to go outside, Staff O, Licensed Practical Nurse, stated he would need to have someone with him, or be seated in the front of the facility, where they could see him from inside. She stated she had not heard of him going out the door and falling. In an interview on 10/05/18 at 11:51 AM, Staff M, Nursing Assistant, stated she was familiar with Resident #1. When asked if he went outside alone, she stated he didn't, and if he wanted to go outside, they would either go outside with him, or check on him frequently, while he was sitting out front. When asked if she was aware of an incident in which he fell while exiting the wing three side door, she said she was not working that day, and was not aware. In an interview on 10/09/18 at 9:56 AM, Staff E, Licensed Practical Nurse, stated she was the one who heard the alarms of the side door on wing three, and the seatbelt alarm, and found the resident right in the entryway, stating he had not made it far outside. She stated the resident used to live on a farm, and he said he was getting his truck. She said in that moment, he was mentally back in the days when he worked on the farm. Staff E stated at times the resident would try to stand or transfer independently, so she made sure to check on him about every 30 minutes. In an interview on 10/10/18 at 10:51 AM, when asked if the care plan was updated after Resident #1 attempted to leave the facility unsupervised, Staff I initially stated that would be the standard. After reviewing the resident's record with Staff A, Staff I stated the care plan was not updated, related to exit-seeking, but it was a one-time occurrence for Resident #1. He then looked in the nursing assistant flowsheets, and noted the resident was also not monitored for wandering behaviors. In an interview on 10/10/18 at 2:14 PM with staff including Staff A and Staff B present, the surveyor relayed concerns regarding Resident #1's potentially avoidable fall, when left alone in the bathroom on 06/19/18, the lack of a thorough evaluation of the resident's risk factors and effective interventions, as well as supervison to provide safety from falls and exit-seeking. Reference: (WAC) 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to prevent a decline in range of motion for one of three residents (#12), reviewed for range of motion, in a sample of 23. The decrease in the resident's ability to have full range of motion in her left hand, resulted in actual harm to the resident, who developed a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and experienced increased pain. Findings included: A 03/05/17 comprehensive asessment showed the resident had [DIAGNOSES REDACTED]. The assessment also showed the resident required extensive to total assistance with most activities of daily living, and had no functional limitations to the range of motion in her hands. During periodic observations on 11/01/17, between 10:45 a.m.- 4:00 p.m., Resident #12 was seen with her left hand partially clenched. The restorative care plan flow sheets for 2017 showed the resident was to have passive range of motion (PROM) exercises to the joints - movement of the joints by another person - to both upper extremities as tolerated, and restorative staff were to document the number of repetitions and minutes completed. A review of the flow sheets revealed the following: January 2017 - PROM was completed four of 31 days, with refusals documented twice. February 2017 - PROM was completed zero of 28 days, with no refusals documented. March 2017 - PROM was completed zero of 31 days, with no refusals documented. In April 2017, a review of the flow sheets showed Resident #12 was receiving restorative therapy for walking, but was no longer receiving restorative therapy for range of motion to her upper extremeties. On 05/12/17, a skin assessment showed the resident had developed a contracture in the third and fourth fingers of her left hand. A restorative care plan was then added, to soak the resident's left hand in warm water for 5 minutes or more, and massage it. Per record review, no other interventions or treatments had been implemented, to regain the full range of motion the resident previously had in her hand. A 05/22/17 progress note from the hospice nurse (the resident had been placed on hospice in March 2017) showed she had taken a picture of the resident's contracture, and requested a hand splint. In addition, the note documented the resident would be discharged from hospice services, on 05/30/17. A 06/15/17 interdisciplinary meeting note indicated the hand splint provided by hospice was too big for Resident #12. Per record review, there was no additional follow-up, related to attaining an appropriately fitting splint for her. A 06/22/17 physician's communication sheet showed the resident was experiencing pain related to the contractures; pain medication was ordered. On 08/03/17, almost three months after the contracture was initially identified, a physician's orders [REDACTED].#12's left hand. On 08/24/17, a physician's progress note documented the resident would need to see a hand specialist. An 08/28/17 nursing progress note showed the resident continued to experience pain, related to the contractures of the fingers on her left hand. Additional pain medication was ordered. On 10/09/17, a progress note showed an appointment with a hand surgeon had been scheduled for the resident on 12/12/17 - seven months after the contracture was identified. Per the record, the appointment was to discuss the possibility of a procedure to surgically release the tendons in Resident #12's hand, in order to relieve the contractures. During an interview on 11/07/17 at 11:26 a.m. Staff I, Restorative Aide, stated she was working with the resident on walking, prior to the contractures being identified, but had not been working on range of motion for the resident's upper extremities. Staff I stated she was not aware if any interventions were attempted with the resident, prior to the contractures developing. Staff I confirmed the contractures were painful to the resident and stated, when you try to open it up (the resident's left hand) she will swing out. She further stated the resident had a tendency to sit with her hands fisted up, and she believed this was the reason it took a while for it to be noticed. In an interview on 11/07/17 at 11:38 a.m. Staff J, Physical Therapist, stated he was unsure if Resident #12 would be a good candidate for tendon release surgery, but this would likely be her only option for relief at this point. Reference: (WAC) 388-97-1060(3)(d)

Based on observation, interview, and record review the facility failed to ensure hazardous chemicals were inaccessible to residents. Failure to ensure the tub room, where hazardous chemicals were stored, was consistently locked, placed 1 of 3 residents (#15), reviewed for accidents/wandering, at risk for injury. An immediate jeopardy was called on 01/23/17 at 11:41 a.m Findings include: Review of Resident #15's admission assessment, dated 08/17/16, documented the resident had [DIAGNOSES REDACTED]. The assessment also indicated the resident's cognitive skills for daily decision- making were severely impaired, he had no impulse control, poor safety judgement, and wandered. The resident's quarterly assessment, dated 11/16/16, documented the resident wandered daily. Resident #15's care plan, dated 08/11/16, directed staff to monitor him closely when up in a wheelchair, and direct him to high traffic areas. Per the care plan, if the resident refused to be directed/redirected, staff were to stay with him, talk to him, and then re-approach the issue of needing to be in high traffic areas. The care plan also indicated the resident had a wander guard (a device worn by the resident, that alarms when close to an exit) in place. On 01/22/17 at 11:02 a.m., the tub room on the 300 hallway was observed to be unlocked. A one quart bottle, labeled broad spectrum disinfectant was observed on the sink counter in the room. The bottle was half full, and had a regular (non-child-resistant) cap. The bottle had the following labels on the side: Hazardous to human and domestic animals, Keep out of reach of children; Corrosive; Causes irreversible eye damage, and skin burns; Harmful if swallowed; and Do not get on clothing or in eyes. Additionally, a half full, quart size, spray bottle of Comet Cleaner with bleach, was found in an unlocked cabinet under the sink. The warning Keep out of reach of children was observed on the bottle. Staff I, nursing assistant, was immediately alerted to the unlocked door by the surveyor. Staff I stated the tub room door was normally kept locked. At 2:11 p.m., the same day, Resident #15 was observed in his wheelchair, and was self-propelling in the hallway. No staff were observed in the immediate vicinity. Resident #15 tried to open the tub room door on the 300 hallway, which was now locked. On 01/23/17 at 9:10 a.m., the tub room on the 300 hallway was again observed to be unlocked. The 2 bottles of hazardous cleaners were in the same locations as observed on 01/22/17, and were readily accessible. On 01/23/17 at 9:12 a.m., Staff W, nursing assistant, was notified by the surveyor the tub room door was open. Staff W stated the tub room was not generally kept locked, as it was just used for storage of incontinence supplies. At 9:37 a.m. the same day, Staff X, nursing assistant, stated the shower and tub rooms were supposed to be locked when not in use. At 9:42 a.m. Staff Z, housekeeping, also confirmed the shower and tub rooms were to be kept locked. Staff Z further stated that no chemicals were kept in the shower and tub rooms. He added that Resident #15 wandered throughout the facility, and we have to keep an eye on him. At 9:49 a.m., Staff Y, nursing assistant, stated most chemicals were locked up, with the exception of a few spray bottles of cleaners, kept in the shower and tub rooms. Staff Y said those were used by the bath aides, to clean the area after bathing or showering residents. At 10:22 a.m., the 300 hallway tub room, with the accessible hazardous cleaners, was observed with Staff A, administrator, and Staff B, director of nursing. Both Staff A and Staff B confirmed the tub room door was to be kept locked. The cleaners were then removed, and the door was locked by Staff A and Staff B. Throughout the survey, including on 01/23/17 at 10:42 a.m. and 12:49 p.m., 01/24/17 at 1:22 p.m., and 01/25/17 at 11:06 a.m. and 11:45 a.m., Resident #15 was observed in his wheelchair self-propelling in the hallways, including the hallway near the 300 hall tub room. In an interview on 01/25/17 at 3:00 p.m., Staff K stated Resident #15 wandered throughout the facility. Staff K described the resident as busy, curious, not looking for anything in particular, just driven to move. On 01/26/17 at 7:17 p.m., Staff S stated the resident wandered up and down the halls of the facility. Staff S added the resident would sometimes go to the Activity Room (near the tub room) to watch TV. In an interview on the morning of 01/27/17, Staff A stated there had been an issue in the past in which a resident accessed the tub room and retrieved incontinent supplies that were stored there. The resident would then hoard the supplies in her room. The facility decided to lock the room to prevent the resident from doing this. Staff A added the housekeeping carts were stored in the tub room, and had been the source of the hazardous cleaners. The immediacy was removed on 01/23/17 at 1:30 p.m.

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (#23), identified at risk and/or with decreased range of motion, received accurate assessments and appropriate treatment, to prevent the development of a contracture. These failures caused harm to Resident #23, who developed contractures in his fingers. Findings include: Per review of the facility's significant change assessment, dated 10/26/16, Resident #23 had been admitted to the facility on [DATE], with multiple medical [DIAGNOSES REDACTED]. The assessment further indicated the resident required extensive to total assistance with activities of daily living, and was wheelchair bound. A physician's note on 07/22/16 (4 days prior to admission), documented the resident had gout in both hands, but no indication of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The resident's 08/01/16 admission assessment, and the 10/26/16 significant change assessment, documented the resident had no range of motion limitations in his upper extremities (hands/arms). An 08/02/16 admission assessment, completed by nursing staff, documented the resident was able to use both hands to grasp and release objects. Staff V, a nurse, wrote on the bottom of the document (dates of 10/26/16 and 1/18/17), there were no functional changes in the resident's initial admission assessment. A review of the resident's care plan, dated 10/26/16, documented the resident was to receive active range of motion to his upper extremities. The care plan contained no individual interventions, to specifically address the resident's risk for developing contractures, or direction to staff on alternative options, should the resident refuse range of motion. There was nothing in the care plan or clinical record regarding the potential use of splints, braces, or other alternatives, to prevent the development and/or worsening of contractures. Per a physician visit note on 11/16/16, an examination was completed of the resident's extremities. Saff CC, physician, noted the resident had mild [MEDICAL CONDITION] in his right hand, but did not indicate the resident had any contractures in that hand. In an observation on 01/22/17 at 2:35 p.m., the resident's right hand was closed, and the second and third fingers on that hand were observed to have contractures. During a staff interview on 01/23/17 at 8:46 a.m., when asked if the resident had any contractures, Staff T, a nurse, replied no. On 01/25/17 at 9:21 a.m., the same nurse completed an assessment of the resident's hands. She confirmed the resident appeared have contractures in two fingers on his right hand, which had previously gone unidentified. In an interview on 01/26/17 at 4:26 p.m., Staff L, nursing assistant, stated the resident's hands used to be better. He said the resident now needed to use built-up silverware for meals. On 01/27/17 at 10:29 a.m., Staff DD, physical therapist, stated he had never been asked to evaluate the resident's hands. At 10:50 a.m., Staff DD completed a brief evaluation. He stated two fingers on the resident's right hand were contracted, and indicated he would be happy to do a more in- depth evaluation, once he had recieved an order from the resident's physician to do so. In a follow-up interview with the resident on 01/27/17, he stated his fingers were not curled up like this, prior to his admission to the facility. He further stated he had not been offered a splint, brace, or any other treatment for [REDACTED]. The resident said he used to be able to play the piano, and would like to again some day. Per interview on 01/27/17 at 10:13 a.m. Staff A, administrator, said the resident was at high risk of developing contractures, due to his [DIAGNOSES REDACTED]. A physician note, dated 01/30/17, confirmed the resident had 2nd and 3rd fingers with significant flexion contractures of the right hand.

Based on observation, interview, and record review, the facility failed to consistently implement nutritional interventions for 1 of 3 residents (#19), reviewed for weight loss, in a sample of 24. Failure to ensure a nutritional supplement was provided, resulted in actual harm to the resident, who experienced a 15 pound (9.8%) weight loss, in less than 3 months. Findings include: Review of most recent quarterly assessment, dated 12/21/16, revealed Resident #19 had [DIAGNOSES REDACTED]. The resident was moderately cognitively impaired, had swallowing difficulties, and required assistance with eating. A physician's orders [REDACTED]. A care plan for nutrition, dated 10/08/15, included the intervention to provide diet as ordered, and did not include the intervention of a supplement. Resident #19's weight record documented the following: -10/12/16 - 152 pounds -11/11/16 - 148 pounds -12/06/16 - 142 pounds -12/21/16 - 141 pounds -12/26/16 - 137 pounds. This represented a 15 pound (9.8%) weight loss, in less than 3 months. A nutritional assessment was completed on 12/16/16, which identified the resident had lost 4% of his weight in the previous 30 days. The assessment documented the resident's appetite was fair, but energy and protein intake were inadequate. It further indicated the resident's weight had been trending down over the last 90 days, related to decreased intake of meals. The recommendation was to continue monitoring the resident's weight, and offering nutritional supplements at breakfast and dinner, for additional calories. Review of Resident #19's meal monitors for 2016 revealed the section documenting the provision of a nutritional supplement was blank for the breakfast meal 14 out of 31 times in October, 18 out of 30 times in November, and 18 out of 31 times in December. The supplement section for dinner was blank 12 out of 31 times for October, 10 out of 30 times in November, and 18 out of 31 times in December. On 01/26/17 at 5:03 p.m., Resident #19 was observed in his wheelchair in the assisted dining room. Staff K was assisting the resident with dinner. A dietary card, located on the resident's meal tray, documented the resident was to receive a supplement with his meal, but none was provided. Staff K was asked if the resident was supposed to get a supplement drink with dinner. After discussion with other staff members in the dining room, Staff K said a supplement should have been delivered with the resident's dinner. A supplement was subsequently brought to the resident, and 100% was consumed. At 5:28 p.m., the same day, Staff M, cook, confirmed Resident #19's supplement had been missed that night. Staff M said another dietary worker prepared the drinks for residents during the meal, and indicated a list in the kitchen showed which residents needed a supplement. On 01/27/17 at 8:24 a.m., Resident #19 was again observed seated in a wheelchair in the dining room, being assisted by Staff N with breakfast. Staff N confirmed a supplement drink had not been included with the resident's breakfast tray, as ordered. At 8:50 a.m., after the surveyor asked about the missing supplement, Staff K was observed requesting a supplement from the kitchen. When the supplement was given to the resident, he drank 100%. At 8:53 a.m. the surveyor observed the Drinks to Pour list in the kitchen. Resident #19 was listed as requiring a supplement at breakfast and dinner. In an interview on 01/27/17 at 9:13 a.m., with Staff O, registered dietitian, Resident #19's meal monitors were reviewed. Staff O confirmed nutritional supplement drinks were not consistently documented for the resident. She stated the facility had recently begun giving supplements with medication pass, instead of with meals, to some residents. Staff O explained this was done in an effort to increase the consistency with which supplements were given and documented. She added that Resident #19 was not currently on that program, but would be a good candidate for it. On 01/27/17 at 12:03 p.m., Staff K stated nutritional supplement drinks were documented on the meal monitor in box labeled supplement. If a resident refused the supplement a 0 was to be entered. When asked what an empty box would indicate, Staff K stated it could mean the resident did not get a supplement.

Based on interview and record review, the facility failed to ensure allegations of resident mistreatment and/or possible abuse were immediately reported to the facility administrator and/or designee as required, for 2 of 4 residents (#2, #3), reviewed for abuse. Failure to report, and subsequently protect residents while an investigation was in progress, resulted in an additional altercation between Resident #3 and a staff member, and placed other residents as risk for abuse. Findings include: Per the record, Resident #2 was admitted to the facility November 2016. The record also documented [DIAGNOSES REDACTED]. He was ambulatory, and able to make his needs known. Resident #3, per record review, had [DIAGNOSES REDACTED]. He was able to communicate his needs, required assistance with eating, and utilized a wheelchair for mobility. Per review of facility investigations, an alleged incident of an inappropriate verbal exchange occurred between Resident #2 and Staff B, on 12/10/16 at 8:30 a.m., in the hallway . Resident #2 and Staff B were overheard by other facility staff yelling loudly at each other, which caused further agitation of Resident #2. A witness statement indicated another staff member intervened, and the resident calmed down. The incident was not reported at that time. In addition to the morning incident, the facility investigation documented an alleged incident of inappropriate physical contact, between Resident #3 and Staff B on the same day, in the dining room. Per the investigation, Resident #3 was agitated, and grabbed Staff B's arm. When he let go, Staff B grabbed and shook the residents arm, attempting to prevent him from grabbing and/or striking her. A witness statement indicated this caused Resident #3 to become more agitated, and after Staff B let go of his arm, the resident calmed down. No injury occurred. The incidents of inappropriate verbal exchange, and physical contact, between Staff B and Residents #2 and #3 on 12/10/16, were not reported by the staff who witnessed the events, until another incident occurred on 12/13/16. The facility investigation documented another incident between Staff B and Resident #3 took place in the resident's room, at 10:30 a.m. on 12/13/16. Resident #3 had taped a pair of socks to his wall to dry. Staff B entered the room, removed the socks, and yelled at the resident. Because of Staff B's behavior, Resident #3 became agitated. After a witness alerted a nurse of the interaction, she returned to the room, and found Resident #3 and Staff B arm wrestling with each other. Shortly thereafter, the physical contact stopped. Staff B was removed from direct resident care the afternoon of 12/13/16, worked on 12/14/16 in a position with no resident contact, and was then suspended, pending an investigation. The facility concluded, after investigation, Staff B's .actions were aggressive, inappropriate, and may be considered abusive. Resident #2 was interviewed by the surveyor, during the on-site visit of 12/29/16. He did not have any concerns about the care he received at the facility, and did not answer any questions about the incident involving Staff B on 12/10/16. Resident #3 was not available for interview. In an interview on 12/29/16 at 10 p.m., Staff A, Director of Nursing, confirmed the facility did not suspend Staff B until all statements were collected and reviewed, rather than immediately after the incident with Resident #3 on 12/13/16, when they were also made aware of the previous incidents on 12/10/16.

Based on observation, interview, and record review, the facility failed to implement policies and procedures to protect 1 of 10 sample residents from sexual abuse (#8). Resident #5 had a change in behavior, that including actively pursuing Resident #8, in a sexual manner, over a number of days. Resident #8 had severe cognitive impairment, and was unable to give consent. At least 6 different staff were aware of the behaviors, and no specific plan was implemented to protect Resident #8. The staff redirected Resident #5 multiple times, yet the resident continued to pursue her, and ultimately made sexual contact. The lack of appropriate and/or effective interventions resulted in the sexual abuse of Resident #8 by Resident #5, which constituted an immediate jeopardy. Findings include: Resident #5 was admitted to the facility in September 2014 and had [DIAGNOSES REDACTED]. According to the assessment, he had behaviors including wandering that intruded on others' privacy. The resident was able to walk independently, and had little interest in activities. Resident #8 had [DIAGNOSES REDACTED]. According to the assessment she had behaviors, which interfered in her daily life, and included: delusions, resisting care, and wandering. The assessment also documented the resident's behaviors had worsened since her privious assessment. Resident #8 was observed intermittently on 12/3/14 and 12/4/14. She used a walker to ambulate, required staff direction to reach specific locations, and carried a baby doll with her at all times. She was interviewed on 12/4/14 at 10:30 am in her room. The resident repetitively referred to her need to care for the baby, gesturing towards the doll. She was unable to recall the date, time, and/or place. The resident's responses rambled, and were not relevant to the questions asked by the surveyor. Many of her responses were "I don't know" or "OK". The facility reported that an incident, which was sexual in nature, had occurred at approximately 9:00 a.m. on 12/2/14. The incident took place in a small bathroom inside the activity room, and involved Resident #5 and Resident #8. Per the facility's investigation, Nursing assistant #J provided a witness statement dated 12/2/14 at 9:00 am. She documented that she was looking for both residents, and could not find them. When she went to the activity room, she heard Resident #8's voice come from the bathroom, and went to help her. Staff #J said she found both residents with their pants down - Resident #5 was sitting on the toilet, and Resident #8 was sitting on his lap. She assisted Resident #8 with her clothing, removed her from the situation, and redirected Resident #5 to his room. Further review of the facility investigation indicated there were signs that Resident #5's behavior towards Resident #8 had recently changed, and he began "pursuing" her, starting on 11/27/14. Staff witness statements related to the behavior were as follows: -On 11/27/14 during evening shift, Licensed nurse (#D) documented Resident #5 was going into other resident rooms on the left side of the hallway. Staff #D documented she was concerned about a female resident who already had issues with behaviors. The nurse wrote that she redirected Resident #5 "more than 50 times" away from other resident rooms, and monitored him for the behavior. -Nursing assistant #F wrote that on 11/27/14, Resident #5 attempted to enter Resident #8's room at 2 separate times. On one occasion, when Staff #F got to Resident #8's room, Resident #5 was putting his penis back into his pants. The nursing assistant redirected Resident #5, but he went back into Resident #8's room again, and was found putting his penis back into his pants. The nursing assistant wrote she had never seen Resident #5 with these types of behaviors. A second facility report, dated 11/29/14 at 2:15 am, was reviewed on 12/3/14. Licensed nurse #D wrote that Resident #5 pulled a Velcro type stop sign (generally placed on doors to keep resident's from wandering in and/or out of rooms) off Resident #8's door, entered the room, and before staff could get intervene, pulled the covers off Resident #8 while she was in bed. Staff redirected Resident #5 back to his room. Witness statements related to this incident were as follows: -Nursing assistant #J documented that at 3:00 a.m. on 11/19/14, Resident #5 kept wanting to go into Resident #8's room, and "every time he did" he would pull out his penis. She indicated that Licensed nurse #D sat in the hallway to keep him from disturbing Resident #8. -On 11/30/14 at 9:10 a.m. and 2:25 pm, Activity staff #K wrote Resident #5 tried to get Resident #8 into the activity room bathroom "several times". She redirected Resident #8 to her room, and Resident #5 followed, so she took Resident #8 back to the activity room. -On 12/1/14 at 9:00 p.m., Nursing assistant #J documented she saw Resident #5 duck under the stop sign banner across his doorway, and slipped under the banner on Resident #8's doorway to enter her room. The nursing assistant wrote she "ran like crazy down the hall" to Resident #8's room, and when she got there, Resident #5 had his hand on her shoulder and was trying to push Resident #8 onto her bed. As he was pushing her, he was trying to undo his pants. The residents were separated, and Resident #5 was redirected back to his room. -Licensed nurse #L documented on 12/1/14 at 9:00 p.m. that she saw a nursing assistant run to Resident #8's room. The nurse received the above report and wrote Resident #8 was a "little shaken" and staff reassured her. She instructed Resident #5 not to go in female resident rooms, and relocated Resident #8 to another room in a different hall as a "safety precaution". She indicated the Director of Nurses was notified at that time. The licensed nurse documented that Resident #5 would peek down the hallway, but did not come out of his room after the incident. On 12/3/14, at approximately 10:00 a.m., the Director of Nursing (Staff #B) was interviewed regarding the 12/2/14 incident. She said the staff were actively "keeping an eye on" Resident #8, and during the weekend, staff stayed near her. She identified that Resident #8 had been moved to a room in a different hallway. Staff #B was unsure how Resident #8 was in the activity room that morning alone, because usually activity staff were present. She stated the administrative staff considered doing a one on one observation of the resident, but they did not have the staff to do that, so staff were on "high alert". Nursing assistant #H was interviewed on 12/3/14 at 10:35 a.m., and stated she was aware of the 12/2/14 incident. She stated the plan was to keep an eye on the 2 named residents, and keep them separated. When asked how often she was to check them, she stated "at least every 2 hours". Activity staff member #M was interviewed on 12/3/14 at approximately 10:50 am. She stated she did not work over the weekend, but was notified on Monday (12/1/14) that staff was on high alert because Resident #5 kept going into Resident #8's room. When the surveyor asked what the plan was, she stated to keep an eye on the residents, and that Resident #8 moved to a different dining room. Staff #M also said that residents were usually alone in the activity room, doing independent activities, until 10:00 a.m. - when structured activity usually started. She stated she had not really been provided with any specific instructions/interventions regarding how to deal with Resident#5's new behaviors. Nursing assistant #E was interviewed on 12/3/14 at 11:20 a.m. He said he was aware that Resident #5 was going in/out of other resident rooms, and commented it was mostly Resident #8's room. When asked what the staff were doing about the situation, he stated they were redirecting the residents, and keeping them apart. He said he escorted Resident #8 to the activity room the after breakfast on 12/2/14, and he did not see Resident #5 in the area. Staff #E stated he left Resident #8 in the activity room with a couple other residents that were sitting in there. Nursing assistant #J was interviewed on 12/3/14, at approximately 11:45 a.m. She said she had worked night shift over the weekend, and reiterated her observations as described in the above witness statement. The nursing assistant stated the staff were told to just watch Resident #5, and commented the resident was "fast and sneaky". She described Resident #5 as "honing in" on Resident #8, and she felt like more should have been done to protect the resident. Nursing assistant #F was interviewed on 12/3/14, and said she was aware of and witnessed Resident #5's behaviors over the previous weekend. She described the behaviors as "very different" for him, and said he was often times "fumbling with his pants in the groin area" when he was near Resident #8's room. Licensed nurse #G was responsible for providing social services at the facility, and was interviewed on 12/4/14 regarding the situation. She said she was alerted to the change in behavior by the Director of Nursing the morning of 11/29/14. At that time, she wrote a note to staff on the white board in the breakroom. The note was dated 11/29/14 - it identified Resident #5 by his room number, instructed the staff to monitor him, and keep him from entering any female resident rooms. Per the note, staff were to notify the charge nurse if it occurred. The nurse said they are currently trying to find an alternate facility for Resident #5 to move to. The facility's Abuse Prohibition Policy was reviewed. It indicated the facility was to protect residents from abuse by any person. The plan was to identify residents with a personal history that led them to be at risk, monitor for changes that would trigger abusive behavior, and determine the effectiveness of interventions on a regular basis. The facility did not implement this policy, and failed to protect Resident #8 from sexual abuse. The facility took action, and provided a written safety plan, including 1:1 monitoring of Resident #5 on 12/3/14, after the surveyor identified the Immediate Jeopardy.

Based on observation, interview, and record review, the facility administration failed to ensure policy and procedures to protect residents from sexual abuse were implemented for 2 of 10 sample residents (#5,#8). The lack of implementation resulted in an incident of sexual abuse, which constituted an immediate jeopardy. Findings include: See Ftag 226 for additional information. The facility's Abuse Prohibition Policy was reviewed. It indicated the facility was to protect residents from abuse by any person. The plan was to identify residents with a personal history that led them to be at risk, monitor for changes that would trigger abusive behavior, and determine the effectiveness of interventions on a regular basis. Per data collected during an Abbreviated and Partial Extended survey on 12/3/14 and 12/4/14, facility staff were aware Resident #5 was actively pursuing Resident #8, and was making inappropriate gestures, which were sexual in nature. The behaviors started on 11/27/14, and the facility plan was to monitor both residents; Resident #5 continued his pursuit. Resident #8 was left alone in the activity room the morning of 12/2/14, and was found in the bathroom with Resident #5 during a sexual interaction. The facility did not alter the plan to protect Resident #8 after monitoring was ineffective, and/or after a sexual interaction actually occurred on 12/2/14. The lack of increased supervision placed Resident #8 in harms way, and she was sexually abused by Resident #5. The Director of Nursing and the Administrator were interviewed on 12/3/14 regarding the 12/2/14 incident. They stated they had not come across anything like this before, and were unsure what to do.

Based on observation, interview, and record review, it was determined the facility failed to provide necessary supervision, and use the necessary equipment, to ensure that 1 of 3 sample residents (#1) was transferred according to the plan of care. This failed practice resulted in harm to Resident #1, who sustained a hip fracture as the result of a fall from a mechanical lift. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per the facility assessments dated 8/13/14 and 8/18/14, the resident did not bear weight on his legs, and required total assistance of 2 staff using a mechanical lift (an assistive device used to transfer between a bed and chair in a sling, using hydraulic power). Resident #1's care plan was modified on 10/25/14, and directed staff to use 2 people and a mechanical lift for transfers. The previous instructions to staff were to use 1-2 people when transferring the resident with the lift (despite the fact the August 2014 assessments indicated 2 people were needed). Review of the facility investigation dated 10/25/14 revealed Staff #A provided morning care, and transferred the resident from the bed to the wheelchair using the mechanical lift. A second staff person was not present, as directed in the plan of care. Staff #A pulled the lift away from the bed, with the resident suspended in the sling. As Staff #A pushed the lift forward toward the wheelchair, it tipped over. The resident fell on the floor with the sling under him, hitting his head on a refrigerator. The mechanical lift was lying sideways on the refrigerator. The resident sustained [REDACTED]. On 10/28/14 at 11:45 a.m., Staff #C stated the investigation determined that the resident's weight shifted in the sling during the transfer, causing the mechanical lift to tip over. In addition, she said the facility standard was to have 2 staff assist for all mechanical lift transfers. On 10/28/14 at 12:00 p.m., Staff #B stated she was responsible for care planning. She indicated that previously, only one person was required when transferring residents using a mechanical lift. Some staff then reported to her they did not feel comfortable with one person, so she changed the care plan to 1-2 staff for mechanical lift transfers. Staff #B said she was unaware that 2 people were required for safety with mechanical lift transfers. The facility failed to ensure that Resident #1 was safely transferred with a mechanical lift, following both the facility standard and care plan directive. As a result, the lift tipped, the resident fell , and he received a hip fracture requiring hospitalization and surgical repair.

Based on interview and record review, it was determined the facility failed to ensure safety measures and adequate supervision were consistently implemented by all staff related to potential hazards of hot beverages. The failed practice directly affected 1 of 4 sample residents (#1), who sustained an injury which resulted in harm. Findings include: Resident #1 had [DIAGNOSES REDACTED]. According to the record on 7/5/12 the resident burned himself with a hot cup of coffee after he spilled it on his thigh. The resident's thigh blistered after 24 hours and required a treatment for [REDACTED]. Per the facility investiation of the incident, Staff A stated he got the resident a cup of coffee in the activity room on 7/5/12 and then left the resident with the hot beverage. The investigation revealed the resident took a drink of the coffee and spilled it on his thigh and then started to scream in pain. Staff A reported he did not know the coffee in the activity room was that hot. The Activity Director said the usual process was to put cold water in the coffee it to cool it off before giving it to a resident. In an interview on 7/19/12 at 12:30 p.m., Staff B stated she worked the day the resident burned himself with the coffee. Staff B said she was in the activity room working with other residents and she heard Resident #1 yell out in pain. Staff B said the resident had sweat pants on and had spilled the coffee on himself. She said the outside of the coffee cup was still really hot when she held it after the resident spilled it. In an interview on 7/19/12 at 1:00 p.m., Staff C confirmed all staff should have been aware of the hot coffee in the activity room to ensure safety of the residents. The facility failed to ensure staff implemented safety measures of cooling the coffee down when serving coffee from the activity room and/or failed to provide adequate supervision when the resident was served hot coffee with resulted in a burn to the resident when Resident #1 spilled the coffee on his lap.

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (#32) received necessary care and services related to pain management in a sample of 17. This resulted in harm to the resident, who experienced unrelieved pain. Findings include: Resident #32 had [DIAGNOSES REDACTED]. The resident was alert, oriented and able to make her needs known. Per the quarterly assessment dated [DATE], the resident was noted to have frequent pain with transfers and the pain limited her walking. The resident received scheduled pain medication, as needed medication and it was noted that hot baths were helpful in relieving her pain. The resident's plan of care directed staff to monitor the resident's pain every shift, monitor for signs and symptoms of pain, let licensed staff know if resident refuses rehab or activities, and that the resident feels a warm bath would be beneficial in decreasing her pain. Per the physician orders [REDACTED]. Per review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Per record review, the first 5 days after admission the resident was rating her pain between 5 and 8. After 4/26/11, the resident was rating her pain consistently between 7-10. The resident did not receive an increase in the narcotic patch until 5/4/11. On 5/6/11 (2 days after the increase in pain medication) it was documented the resident did not show any improvement in pain control. Staff documented they would continue to monitor. On 5/8/11 (4 days after the increase in pain medication) it was documented the resident was requesting as much as needed medication as before the increase in her patch. The plan was to continue to monitor the resident for pain. No further evaluation or action was taken by the facility. There was no documentation the physician was contacted or consulted regarding the resident's continued poor pain control. During an interview on 5/11/11 at 11:30 a.m., the resident stated she was having a lot of pain and could hardly move her arms. She stated if she laid very still in bed without twisting it was bearable. The resident stated she noticed the change in pain and the weakness beginning on 5/8/11. The resident was lying in bed and would grimace with any type of movement. On 5/12/11 at 9:30 a.m., Staff #C stated the resident was able to walk to the nurses station when she was first admitted and the next day she couldn't because her knees would buckle. Staff #C stated she noticed the resident's pain had gotten worse the past week. She reported this to the licensed nurse. On 5/16/11 at 12:00 p.m., Staff #D stated he could tell the resident was getting weaker. She had to start taking rest periods between exercises and this was new for her. She refused rehab on 5/6/11 and 5/7/11 due to pain. Staff #D stated he reported this to the licensed staff. On 5/12/11 at 11:30 a.m., Staff #A stated the nurses had noticed a decline in the resident and she was going to go to a doctor appointment that afternoon. She confirmed there was no communication with the doctor about the resident's decline in condition and increase in pain prior to making the appointment that day. The facility identified the resident's pain had worsened, however, they failed to intervene in a timely manner.