Every finding on record at Covenant Shores Health Center

Based on observations, interviews, and record review the facility failed to initiate and/or thoroughly investigate the occurrences of events for 2 of 2 (Residents 10 & 5) sampled residents whose facility incident reports were reviewed. The facility failed to initiate an investigation for an injury of an unknown origin for Resident 10 and failed to thoroughly investigate falls for Resident 5. The failure to initiate and conduct thorough investigations left residents at risk for unidentified abuse and/or neglect, recurrence of events, and a decreased quality of life.Findings included.<Facility Policy>Review of the facility's Abuse Prevention Program policy, revised 09/22/2025, showed employees were required to promptly report all occurrences of possible abuse, mistreatment, or neglect of any resident. The policy showed all occurrences/accidents of unknown origin would be investigated and occurrence reports would be reviewed by the administrator and director of nursing. The policy showed the administrator or designee would conduct a thorough investigation within five days of the occurrence in accordance with state law.According to the facility policy titled, Accident and Incidents - Investigating and Reporting, dated July 2017, the facility would include circumstances surrounding the incident and any corrective actions as part of the investigation.<Resident 10> According to the 01/14/2026 admission Minimum Data Set (MDS – an assessment tool), Resident 10 admitted to the facility on [DATE] with diagnoses including arthritis, age-related osteoporosis without a current pathological fracture, and aftercare following a right hip replacement. The MDS showed Resident 10 did not have cognitive impairment. In an interview on 02/05/2026 at 9:03 AM, Resident 10 stated they originally came to the facility to receive therapy after hip surgery but suffered a right upper leg fracture and was now recovering from the fracture. Review of a 01/23/2026 social services progress note showed Resident 10 was making slow improvements and was not able to walk yet. The progress note showed the therapy department recommended Resident 10 have an x-ray as the resident was experiencing severe pain. Review of a 01/24/2026 x-ray report showed Resident 10's right upper leg bone was fractured. Review of a 01/26/2026 physician progress note showed Resident 10's physician gave orders to send the resident to the hospital for evaluation of their right leg fracture. Review of the facility provided incident log on 02/09/2026 showed there was no incident logged for January 2026 or February 2026 regarding Resident 10's right upper leg fracture. In an interview on 02/09/2026 at 9:37 AM, Staff A (Administrator) stated they did not have an investigation related to Resident 10's leg fracture. In an interview on 02/10/2026 at 10:40 AM, Resident 10 stated therapy was working with them and noticed one of their legs appeared longer than the other, so an x-ray was ordered. Resident 10 stated they did not have a fall and stated nobody hurt them. In an interview on 02/10/2026 at 1:48 PM, Staff B (Director of Nursing) stated Resident 10 did not experience trauma, falls, or any occurrence since their admission to the facility and the resident did not have any abnormal reports. Staff B stated the staff thought Resident 10 possibly admitted to the facility with the upper leg fracture, despite the x-ray being obtained two weeks after Resident 10 admitted to the facility. Staff B was asked how they determined Resident 10 did not experience trauma, falls, or other occurrences without an investigation. Staff B stated they went off reports from staff but did not complete a formal investigation or document staff reports. Staff B stated they did not interview Resident 10 regarding their leg fracture. Staff B stated they asked Resident 10 how everything was going upon their return from the hospital but stated they did not specifically ask Resident 10 if anyone hurt them. Staff B stated they did not complete an investigation regarding Resident 10's right leg fracture. In an interview on 02/11/2026 at 11:26 AM, Staff A stated they expected an injury of an unknown origin to be investigated. <Resident 5> According to the 01/24/2026 Quarterly MDS, Resident 5 admitted to the facility on [DATE]. The MDS showed Resident 5 had falls since admission. The MDS showed Resident 5 was Chinese and required an interpreter for communication. The MDS showed Resident 5 required one person assistance with transfers, mobility, toileting, and dressing. Review of a 10/18/2025 at risk for falls/fall related injury related to history of falls Care Plan (CP) showed Resident 5 had falls on 11/19/2025, 11/25/2025, 12/08/2025, 12/10/2025, 12/24/2025, 01/29/2026, and 02/02/2026. The CP showed interventions for Resident 5 included a well-lit room, frequent toileting, assessing physical needs such as repositioning, toileting, hydration needs, constipation, and pain. There were no new added interventions for the falls between 11/19/2025 and 12/08/2025. Review of the facility's investigation for Resident 5's fall on 11/19/2025 showed the resident stated they were trying to go to the bathroom and slid out of their chair. The section of the investigation report titled Care prior to fall included a review of the last time staff assisted Resident 5 to toilet, provided fluids, repositioned the resident, and medicated for pain. This section was marked N/A. The section of the investigation report titled Environmental conditions possibly related to fall prompted staff to review bed locks functioning, furniture needing repair, grab bar loose, lights on, noisy, obstacles in path, wet floor with/without sign in place, wheelchair locks not working, and quiet environment. This section was marked N/A. Review of the investigation for the 11/25/2025 fall showed Resident 5 stated they could not recall what happened or how they fell. The care prior to fall section of the investigation was not reviewed, marked N/A, and included last time staff assisted Resident 5 to toilet, provided fluids, repositioned, and medicated for pain. The environmental conditions possibly related to fall section of the investigation was marked N/A and included bed locks not working, furniture needs repair, grab bar loose, lights on, noisy, obstacles in path, wet floor with/without sign in place, wheelchair locks not working, and quiet environment. The investigation showed the fall occurred at 4:30 PM and the investigation report showed lights in room reviewed as N/A. The investigation did not identify if the call light was within reach for Resident 5. Review of the investigation for the 12/08/2025 fall showed staff marked N/A next to the residents' statement section of the investigation. An occurrence report showed Resident 5 told a family member they were trying to wash their clothes. Staff did not document if Resident 5's clothing issues were investigated. The care prior to fall section was not reviewed, marked N/A, and included last time staff assisted Resident 5 to toilet, provided fluids, repositioned, and medicated for pain. The environmental conditions possibly related to fall were marked as N/A and included bed locks not working, furniture needs repair, grab bar loose, lights on, noisy, obstacles in path, wet floor with/without sign in place, wheelchair locks not working, and quiet environment. The footwear reviewed section showed staff documented N/A for whether Resident 5 was wearing footwear. Staff did not document an assessment of injuries or pain. There was no investigation documented to show if Resident 5 was in their wheelchair or bed prior to the fall. Review of the investigation for the 12/10/2025 fall showed the conclusion to rule out abuse/neglect with general statements regarding Resident 5's abilities and previous CP interventions. There was no specific investigation related to the root cause of the fall. The incident report showed Resident 5 was toileted at 1:15 PM prior to the 2:00 PM fall. The investigation summary/conclusion statement was conflicting and showed Resident 5 was toileted five minutes prior to the fall. The care prior to fall section was not reviewed and marked N/A for this investigation and included the last time staff provided fluids to Resident 5, repositioned, and medicated for pain. The environmental conditions possibly related to fall section was marked N/A to include bed locks not working, furniture needs repair, grab bar loose, lights on, noisy, obstacles in path, wet floor with/without sign in place, wheelchair locks not working, and quiet environment. The investigation did not show if the call light was within reach for Resident 5. Review of the investigation for the 12/24/2025 fall showed the fall was unwitnessed. A neurological assessment was not included in Resident 5's health records or included with the investigation. Resident 5 stated they were trying to get to the bathroom. The care prior to fall section was not reviewed and marked N/A for this investigation. This section included the last time staff assisted Resident 5 to toilet, provided fluids, repositioned, and medicated for pain. The environmental conditions possibly related to fall section was marked as N/A and included bed locks not working, furniture needs repair, grab bar loose, lights on, noisy, obstacles in path, wet floor with/without sign in place, wheelchair locks not working, and quiet environment. The investigation did not include if Resident 5's call light was within reach. The investigation conclusion to rule out abuse/neglect showed general statements regarding Resident 5's abilities and previous CP interventions. There were no specific investigations related to the root cause of this fall. Review of the investigation for the fall on 01/29/2026 at 2:45 PM showed Resident 5 wanted to change clothes. The investigation showed no investigation regarding Resident 5's clothing, environmental conditions, or footwear. Cares prior to fall reviewed as N/A and included the last time hydration services were provided, the resident was repositioned, and last medicated for pain. The conclusion to rule out abuse/neglect showed general statements regarding Resident 5's abilities and previous CP interventions. The conclusion/investigation summary showed when asked why [they were] on the floor, the resident stated [they] were trying to get changed, get food, or go back to bed without assistance, thinking [they] could do it [themselves]. Review of the investigation for the fall on 01/29/2026 at 4:15 PM showed an incomplete neurological assessment of the unwitnessed fall. The investigation summary/conclusion showed Resident 5 stated [they were] trying to get changed, get food, or go back to bed without assistance, thinking [they] could do it [themselves]. The care provided prior to fall and environmental factors sections of the incident report were not investigated, no documentation of assisting Resident 5 with changing clothes or getting them food/fluids per their statement of reason for the fall. Review of the investigation for the fall on 02/02/2026 showed an incomplete neurological assessment for Resident 5's unwitnessed fall. Investigation summary showed Resident 5 again stated [they were] trying to get changed, get food, or go back to bed without assistance, thinking [they] could do it [themselves]. Resident 5's statement per assigned nurse at the time of the incident was they were hot and trying to get out of bed to take their jacket off. The investigation did not include investigating why Resident 5 was in bed with a jacket on. The investigation showed staff documented N/A for several of the care prior to fall and environmental factors as being investigated to rule out abuse/neglect. This investigation did not include documentation of the call light being within reach for Resident 5. Observation on 02/05/2026 at 8:33 AM showed Resident 5 sitting up in their wheelchair in the dining room. Resident 5's room showed their bed in low position, a perimeter mattress in place, and fall mats on the floor next to the bed. In an interview on 02/05/2026 at 5:10 PM, Resident 5's Power of Attorney stated Resident 5 was always hot, staff were aware and notified on several occasions to keep the resident cool. In an interview on 02/11/2026 at 10:22 AM Staff B stated they expected staff to thoroughly complete the incident report and investigate prior care provided, environmental factors, call light within reach, and reason for fall stated by Resident 5, but staff did not. Staff B stated they expected a neurological assessment to be completed for all unwitnessed falls, but they were not for Resident 5. Staff B stated the general statements in the 12/10/2025, 12/24/2025, 01/29/2026, and 02/02/2026 investigations were related to Staff B investigating the multiple recent falls. Staff B stated each investigation should reflect the specific incident, but they did not. Staff B stated they expected staff to complete a skin assessment, a fall risk assessment, assess the resident, document whether injuries were noted or not, and a pain assessment. Staff B stated they expected the resident's statement to be investigated to rule out abuse/neglect but they were not for Resident 5. Refer to F609 Reporting of Alleged Violations REFERENCE: WAC 388-97-0640(6)(a)(b).

Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) for 4 of 5 residents (Resident 3, 5, 17, & 20) who were assessed to be dependent on staff for ADLs. Failure to provide ADL assistance as required left residents at risk of poor hygiene, diminished feelings of self-worth, and other negative health outcomes.Findings included.<Facility Policy>Review of the facility's March 2018 Activities of Daily Living, Supporting policy showed the facility would provide the services necessary to maintain good grooming and personal hygiene, including bathing, mobility, and toileting in accordance with the care plan, for residents who were unable to perform ADLs independently.Review of the facility's May 2013 Repositioning policy showed repositioning was an effective intervention to prevent skin breakdown, promote circulation, and provide pressure relief, and was critical for residents who were dependent upon staff for repositioning. Residents who were in bed should be on a every two-hour repositioning schedule, and residents in a chair should be on an every one-hour repositioning schedule. Staff were to monitor the need for incontinence care when changing the resident's position.Review of the facility's August 2022 Urinary Continence and Incontinence - Assessment and Management policy showed residents who were incontinent and required a check and change strategy, staff would check the resident's continence status at regular intervals and use incontinence products, with the primary goal to maintain dignity, comfort, and protect the resident's skin.<Resident 3> Review of an 11/30/2025 Comprehensive Minimum Data Set (MDS – an assessment tool) showed Resident 3 admitted to the facility on [DATE] with diagnoses including dementia (a decline in mental ability that interferes with daily life) and a broken hip. Resident 3 was dependent on staff for bed and chair mobility, transfers, and toileting hygiene, and was at risk for developing pressure ulcers/injuries. Review of a Care Plan (CP), dated 11/14/2025, showed interventions included to check Resident 3 for incontinence and change if wet/soiled and encourage/assist with frequent repositioning. Observation on 02/09/2026 at 7:58 AM showed Resident 3 sitting in their tilt-in-space wheelchair (a mobility device with ability to recline) in the dining room eating breakfast. Resident 3 asked staff if they could lie down. Staff agreed they could lie down after breakfast. Observation on 02/09/2026 at 8:31 AM showed Staff K (Certified Nursing Assistant – CNA) wheeled Resident 3 back to their room. Resident 3 remained in their wheelchair. Staff K did not reposition Resident 3 or check the resident for incontinence. Observations from 02/09/2026 at 8:33 AM to 02/09/2026 at 10:05 AM showed Resident 3 remained in their wheelchair and no staff entered their room. Observation on 02/09/2026 at 10:05 AM showed Staff K assisted Resident 3 with leg exercises and stretching while Resident 3 sat in their wheelchair. Observation on 02/09/2026 at 10:12 AM showed Staff K left Resident 3's room. Staff K did not check Resident 3 for incontinence. Observations from 02/09/2026 at 10:12 AM to 12:03 PM showed Resident 3 sat in their wheelchair, and no staff entered their room. Observation on 02/09/2026 at 12:03 PM showed Staff L (CNA) wheel Resident 3 to the dining room in their wheelchair. Staff L did not check Resident 3 for incontinence. Observation on 02/09/2026 at 12:28 PM showed Resident 3 ask staff repeatedly if they could go lie down. Staff told Resident 3 they could lie down after they finished lunch. Observation on 02/09/2026 at 12:56 PM showed Staff K wheel Resident 3 back to their room. Resident 3 remained in their wheelchair. Staff K did not reposition Resident 3 or check for incontinence. Observations from 02/09/2026 at 1:00 PM to 02/09/2026 at 2:32 PM showed Resident 3 remained in their wheelchair and no staff entered their room. In an interview on 02/09/2026 at 2:13 PM, Staff K stated they were covering for Staff L while they were on break. Staff K stated Staff L would likely put Resident 3 down for a nap soon and was not sure if they typically transferred Resident 3 to bed to check/change for incontinence. In an interview on 02/09/2026 at 2:32 PM, Staff L stated they typically checked/changed Resident 3 for incontinence before lunch and when they laid them down, roughly every three hours. Staff L stated they changed Resident 3's brief that morning with morning care. Staff L stated they did not check or change Resident 3 after that because they had to go on break, and they would need to confer with Staff K to see if they checked Resident 3. Staff L stated it was important to check/change Resident 3 frequently to make sure they were not sitting in urine or fecal matter and to prevent skin breakdown. Staff L stated Resident 3 was able to verbalize if they were uncomfortable and wanted repositioning. In an interview on 02/11/2026 at 11:17 AM, Staff K stated they covered for other staff while on breaks and never helped check Resident 3 for incontinence. Staff K stated Resident 3 often complained about wanting to go to bed. Review of an ADL Verification Worksheet for observations between 02/05/2026 and 02/09/2026 showed bladder and/or bowel incontinence care was provided to Resident 3 on 02/05/2026 – two times, 02/06/2026 – two times, 02/07/2026 – three times, 02/08/2026 – two times, and 02/09/2026 – three times. In an interview on 02/10/2026 at 1:39 PM, Staff C (Resident Care Manager) stated they expected staff to reposition dependent residents and check/change incontinent residents frequently, at least every two hours. Staff C stated residents sitting in chairs should be repositioned more frequently. Staff C stated CNA staff needed reeducation regarding those expectations. In an interview on 02/11/2026 at 12:05 PM, Staff B (Director of Nursing) stated they expected staff to reposition Resident 3 and check to see if their brief needed to be changed every two hours. Staff B said they expected staff to assist Resident 3 back to bed if they asked to lie down. <Resident 5> According to the 01/24/2026 Quarterly MDS Resident 5 was admitted to the facility on [DATE]. The MDS showed Resident 5 required staff assistance with bathing. Review of a 02/05/2026 ADL Deficit CP showed Resident 5 required complete set-up and staff assistance with bathing. In an interview on 02/05/2026 at 5:10 PM, Resident 5's representative stated staff were supposed to assist Resident 5 with showers twice weekly but did not. Resident 5's representative stated they would assist them with bathing because when they asked staff to assist Resident 5 with the twice weekly scheduled shower, staff would say they were unable or too busy. Resident 5's representative stated they requested staff to offer and provide showers five times a week, but staff stated they only provide bathing two times per week. Resident 5's representative stated they enjoyed more frequent showers because it helped wake them up, so they were not so sleepy all day. Resident 5's representative stated more showers to wake them up could help decrease Resident 5's falls. Record review on 02/07/2026 at 9:50 AM showed Resident 5 was scheduled to receive showers every Tuesday and Saturday. Review of Resident 5's ADL bathing report showed staff did not offer/provide bathing on 10/25/2025, 10/28/2025, 11/08/2025, 11/15/2025, 11/18/2025, 11/29/2025, 12/01/2025, 12/09/2025, 12/20/2025, 12/23/2025, 12/30/2025, 01/03/2026, 01/06/2026, 01/17/2026, 01/20/2026, 01/24/2026, 01/31/2026, or 02/03/2026 per the bathing schedule. In an interview and record review on 02/10/2026 at 9:58 AM Staff B reviewed Resident 5's ADL bathing report and stated staff should be offering/providing showers to Resident 5 every Tuesday and Saturday but did not. Staff B stated they expected staff to offer and provide per bathing schedule and document if the resident refused. Staff B stated they informed residents and/or their representatives they can only guarantee bathing twice weekly and if they wanted more, they needed to ask the CNA assigned to the resident and if the CNA was not too busy, they might be able to provide additional bathing. Staff B stated they do not add resident requests for more bathing to their CP and only expect staff to accommodate twice weekly per schedule. <Resident 17> According to the 01/15/2026 admission MDS, Resident 17 was admitted to the facility on [DATE]. The MDS showed Resident 17 required staff assistance with bathing. In an observation and interview on 02/06/2026 at 9:53 AM Resident 17 was lying in bed and stated they were not offered a shower since their admission to the facility. In an interview and record review on 02/10/2026 at 10:07 AM, Staff B stated Resident 17 was scheduled for showers every Monday and Thursday. Staff B reviewed Resident 17's ADL bathing report which showed no bathing was offered or provided since admission to the facility, for over four weeks. Staff B stated it was important to offer and provide bathing for dependent residents for general hygiene and feelings of self-worth. <Resident 20> According to the 02/05/2026 admission MDS Resident 20 admitted to the facility on [DATE]. The MDS showed Resident 20 required staff assistance with bathing. Review of a 01/30/2026 ADL Deficit CP showed Resident 20 required complete set-up and staff assistance with bathing. Review of Resident 20's shower schedule showed staff were to provide bathing assistance every Wednesday and Saturday. Review of Resident 20's ADL bathing report showed no documented bathing was offered or provided since admission. In an interview on 02/05/2026 at 2:16 PM Resident 20 stated staff did not offer or provide them with a shower since their admission. In an interview on 02/10/2026 at 10:41 AM Staff B stated staff should offer Resident 20 showers every Wednesday and Saturday but have not since admission. Staff B stated it was important to offer residents bathing for hygiene and dignity. Refer to F605 Right to be Free from Chemical Restraints. Refer to F610 Investigate Abuse/Protect Resident During Investigation. Reference: WAC 388-97-1060(2)(c).

Based on interview and record review, the facility failed to ensure person centered care plans were completed to address all aspects of resident care for 1 of 1 closed records resident (Residents 41) reviewed for death and 1 of 1 sample resident (Resident 5) reviewed for accidents. The facility failed to conduct care conferences for residents with their representatives and the applicable Interdisciplinary Team (IDT) members for 2 of 4 sample resident (Residents 9 & 20) reviewed for care planning. These failures placed residents at risk for inconsistent and/or inadequate care and treatment, a diminished quality of care, unmet care needs, unnecessary care, frustration, and other negative health outcomes.Findings included.<Policy>According to the facility policy titled, Care Plans, Comprehensive Person-Centered, date March 2022, the IDT would develop and implement a comprehensive, person-centered Care Plan (CP) that included measurable objectives and timetables to meet each resident's physical, psychosocial, and functional needs, in conjunction with the resident and their representatives, no more than 21 days after admission. Each resident had the right to participate in the development and implementation of their care plan and to be provided advance notice of care planning conferences. Care plans were revised as information about the resident and the resident's condition changed.<Person Centered Care Plans> <Resident 41> According to the 01/01/2026 admission Minimum Data Set (MDS – an assessment tool) Resident 41 admitted to the facility on [DATE]. The MDS showed Resident 41 was not receiving hospice services upon admission to the facility. The MDS showed Resident 41 had diagnoses of malnutrition and heart disease. Record review showed a 01/08/2026 hospice visit note with Resident 41. Resident 41's health records did not show a hospice CP or physician order for the hospice services. In an interview on 02/11/2026 at 8:43 AM Staff B (Director of Nursing) stated they expected staff to develop and follow a CP for residents receiving hospice service. Staff B reviewed Resident 41's records and stated staff should create a hospice CP for them but they did not. Staff B stated it was important to implement a hospice CP for residents receiving those services to ensure staff met their specific goals related to their hospice care. <Resident 5> According to the 01/24/2026 Quarterly MDS Resident 5 admitted to the facility on [DATE]. The MDS showed Resident 5 had two or more falls since admission to the facility. Review of Resident 5's health records showed falls occurred on 11/19/2025, 11/25/2025, 12/08/2025, 12/10/2025, 12/24/2025, 01/29/2026 (two falls), and 02/02/2026. Review of Resident 5's fall CP showed no new interventions were added for the falls on 11/19/2025 and 12/08/2025. In an interview on 02/11/2026 at 10:22 AM Staff B reviewed Resident 5's CP and stated they expected staff to implement new interventions with each fall to continue decreasing falls, but they did not for Resident 5's 11/19/2025 and 12/08/2025 falls. Staff B stated it was important to revise fall CP to prevent further falls and injury. <Care Conference> <Resident 20> According to the 02/05/2026 admission MDS Resident 20 admitted to the facility on [DATE] with no memory impairment. The MDS showed Resident 20 was receiving intravenous antibiotics and had a diagnosis of, but not limited to, cancer. In an interview on 02/05/2026 at 2:13 PM Resident 20 stated staff had not offered or conducted a care conference with them. In an interview and record review on 02/10/2026 at 10:07 AM, Resident 20's health records showed no care conference documentation. Staff B stated they expected admission care conferences to be offered and discussed with residents within one week of admission. Staff B stated Resident 20 was not offered a care conference, but staff should have discussed and documented it in the residents' records. Staff B stated it was important to include the residents and/or representatives in their care conference with their interdisciplinary team to ensure they were included in their plan of care and goals. <Resident 9> Review of an 01/03/2026 comprehensive MDS showed Resident 9 admitted to the facility on [DATE] with diagnoses that included a condition involving the breakdown of skeletal muscle tissue often leading to symptoms such as severe pain and weakness. Resident 9 was able to understand and to be understood. In an interview on 02/05/2026 at 9:24 AM, Resident 9 stated they were not sure what medications staff were administering, and they were frustrated they could not get answers to questions about their condition. In an interview on 02/02/2026 at 09:53 AM, Resident 9 stated they have not attended a care conference. In an interview on 02/11/2026 at 8:51 AM, Staff E (Social Services Director) stated Resident 9 was cognitively intact and was able to direct their care. Staff E stated the normal timeframe to conduct care conferences was within one to two weeks after admission, and they tried to conduct them within the first week when possible. Review of a 01/06/2026 progress note showed Staff E spoke to Resident 9's family member, who asked to postpone Resident 9's care conference until 01/14/2026 so they could attend. No documentation was found to show a care conference was ever conducted for Resident 9. In an interview on 02/11/2026 at 9:15 AM, Staff E stated Resident 9 never had a care conference with the interdisciplinary team. Refer to F658 Services Provided Meet Professional Standards. Refer to F610 Investigate Abuse/Protect Resident During Investigation. Reference: WAC 388-97-1020(1),(2)(a-d),(4)(c)(i-ii),(5)(b).

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for residents with indwelling medical devices for 1 of 2 residents (Resident 20) reviewed with indwelling devices, properly store urinary catheter bags, and perform hand hygiene during catheter care for 1 of 2 residents (Resident 13) reviewed for urinary catheter use. Failure to implement EBPs, perform hand hygiene during urinary catheter care, and properly store a urinary catheter bag placed residents at risk of infection and other negative health outcomes.Findings included.<Facility Policy>Review of the facility's August 2022 Enhanced Barrier Precautions policy showed EBPs were used as an infection prevention and control intervention for residents with indwelling medical devices (such as central lines and urinary catheters) to prevent the spread of multi drug-resistant organisms. EBPs included staff use of gowns and gloves during high-contact resident care activities including device care or use. EBP's remained in place for the duration of the resident's stay or until discontinuation of the indwelling medical device.<Resident 20>According to 02/05/2026 admission Minimum Data Set (MDS - an assessment tool) Resident 20 admitted to the facility on [DATE]. The MDS showed Resident 20 had diagnoses of cancer and malnutrition.Review of Resident 20's health records showed a 01/30/2026 physician order for Intravenous (IV) medications. Resident 20's records did not show physician orders for EBP.Observation on 02/05/2026 at 9:30 AM and 02/06/2026 at 10:14 AM showed Resident 20 with a right chest IV device and no EBPs were in place.In an interview on 02/10/2026 at 9:45 AM Staff B (Director of Nursing) stated Resident 20 should be on EBP for their right chest central IV port but was not. Staff B stated it was important to implement EBP for residents with indwelling devices to prevent infection.<Resident 13>According to the 01/22/2026 admission MDS, Resident 13 admitted to the facility on [DATE]. The MDS showed Resident 13 had an indwelling urinary catheter.Review of Resident 13's health records showed a 01/16/2026 urinary catheter care plan instructing staff to monitor the catheter bag for proper placement. Resident 13's records showed a physician order to perform urinary catheter care.Observation on 02/06/2026 at 9:38 AM showed Resident 13's urinary catheter bag lying on the floor, on the right side of the bed, uncovered. Observation on 02/09/2026 at 10:03 AM showed Staff Q (Certified Nursing Assistant) cleaning Resident 13's urinary catheter and changing their brief. Staff Q did not perform hand hygiene or change gloves between dirty and clean care. During catheter care, Staff Q touched Resident 13's furniture, call light, and clothing with the same, dirty gloves.In an interview on 02/09/2026 at 10:27 AM, Staff Q stated they should have washed their hands and changed gloves between dirty and clean care. Staff Q stated it was important for good hygiene and to prevent infection.In an interview on 02/11/2026 at 8:40 AM Staff B stated they expected staff to cover and secure catheter bags off the floor. Staff B stated they expected staff to perform hand hygiene and change gloves between dirty and clean care. Staff B stated it was important to store catheter bags off the floor, perform hand hygiene, and change gloves between dirty and clean care to prevent infections.Reference: WAC 388-97-1320(1)(c)(2)(a)(b).

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals were secured for 2 (Residents 20 & 37) observed with medications in their rooms and failed to ensure proper storage of drugs on 1 (Rose Medication Cart) of 2 facility medication carts. These failures placed residents at risk for receiving the wrong medications, contaminated medications, and non-assessed self-administration of medications by residents.Findings included.<Facility Policy>Review of the facility's Medication Labeling and Storage policy, revised 02/2023, showed medications and biologicals would be stored in the packaging, containers, or other dispensing system in which they were received. The policy showed over-the-counter medication labels would contain the medication name, strength, quantity, lot number, and expiration date. The policy showed medications would be stored in drawers, cabinets, rooms, refrigerators, carts, and boxes that were locked when not in use.<Medications at Bedside> <Resident 20> Observations on 02/05/2026 at 9:14 AM and 02/06/2026 at 10:11 AM showed a medication cup at Resident 20's bedside with two capsules in it. Resident 20 stated that they were pancreatic enzyme medications, and the resident only took them if they ate. In an interview on 02/06/2026 at 10:14 AM Staff N (Registered Nurse) stated Resident 20 would take the medication if they ate a lot and if they only ate a little, they would not take them. Staff N stated Resident 20 was not assessed for safety related to self-administration of medications, did not have a physician order, and was not care planned to self-administer their medications, but should be. <Resident 37> Observation and interview on 02/06/2026 at 8:46 AM showed a bag of saline syringes hanging on Resident 37's intravenous pump pole, a bottle of eye drop medication, and multiple, single-use eye drop medication vials on their bedside table. Resident 37 stated the nurses stored the syringes on the pole for when they administered the IV medications. Resident 37 stated they would self-administer the eye drops from the bottle and single use vials when they needed them. In an interview on 02/06/2026 at 10:14 AM Staff N stated Resident 37 brought their eye drop medications in on their own and Staff N informed them to have family bring them home because they did not have a physician order for the medications. Staff N stated they saw Resident 37 did not have their family bring them home and that they were still on their bedside table. Staff N stated staff should remove the medications and store them in the locked medication cart, obtain a physician order, assess Resident 37 for safety to self-administer, and update the care plan if appropriate, but did not. In an interview on 02/10/2026 at 9:58 AM, Staff B (Director of Nursing) stated staff should complete a self-administration assessment for residents that wanted to self-administer their medications. Staff B stated they expected staff to provide residents with a key for a locked drawer to store their medications after completion of the assessment, obtaining a physician order, and care planning self-administration for the residents. Staff B stated staff should not leave medications at Resident 20's or 37's bedside. Staff B stated it was important to store medications behind locked drawers for resident safety. <Rose Medication Cart> Observation of the [NAME] Medication Cart on 02/10/2026 at 9:31 AM showed a medication cup containing 30 white, round medication tablets. The cup was unlabeled, did not show the name of the medication, strength, or expiration date, and did not have a lid to contain the medications. In an interview at that time, Staff M (Registered Nurse) stated unlabeled medications were not safe and the unidentified white tablets should be disposed. In an interview on 02/11/2026 at 11:44 AM, Staff B stated all medications should be properly labeled, stored, and locked in the medication cart. REFERENCE: WAC 388-97-1300(2).

Based on observation, interview, and record review the facility failed to ensure chemicals were stored safely for 1 (Rose Unit) of 3 units reviewed. The failure to ensure that chemicals were secured placed residents at risk of injury, an unsafe environment, and other negative health outcomes.Findings included.<Facility Policy>According to the undated facility policy titled, Chemical Storage Policies and Procedures, the facility did not instruct staff to store chemicals behind locked doors, out of reach of residents to avoid accident hazards.<Rose Unit>Observation and interview on 02/05/2026 at 9:23 AM showed chemicals in the bathroom of room [ROOM NUMBER], on the wall in the hallway, on the side of the medication cart, and on the hallway railing outside of room [ROOM NUMBER]. The observed chemicals showed labels indicating the chemicals should be kept out of reach of children. Staff N (Registered Nurse -RN) stated chemicals were okay to store in residents' bathroom. Staff N stated the chemicals on the railing in the hallway should not be stored there because staff could misuse them. Staff O (RN Manager) stated chemicals should not be stored in residents rooms or within reach of residents.Interview on 02/05/2025 at 9:35 AM Staff P (Lead Housekeeper) stated chemicals should be locked behind a locked cabinet/door.In an interview on 02/05/2026 at 9:39 AM Staff A (Administrator) stated they expected staff to store chemicals behind locked doors for resident safety.Observation on 02/09/2026 at 8:22 AM showed a disinfectant chemical cleaner on the precaution cart outside of room [ROOM NUMBER], on the hallway wall, and on the side of the medication cart.In an interview on 02/09/2026 at 8:22 AM, Staff B (Director of Nursing) stated they expected chemicals to be stored behind locked doors. Staff B stated it was important to store chemicals behind locked doors for resident safety.Reference: WAC 388-97- 1060(3)(g).

Based on observation, interview, and record review the facility failed to ensure accurate and complete skin assessments for 1 of 2 sample residents (Resident 3) reviewed for skin, implement the bowel protocol for 1 of 1 sample resident (Resident 5) reviewed for constipation, and manage fluid retention for 1 of 1 closed records (Resident 40) reviewed for hospitalizations. Failure to accurately assess and document skin conditions placed Resident 3 at risk of skin breakdown, infection, and decreased quality of life. Failure to implement the bowel protocol for constipation placed Resident 5 at risk of unmet care needs, bowel obstruction, pain, and decreased quality of life. Failure to manage fluid retention placed Resident 40 at risk of respiratory distress and other negative health outcomes.Findings included.<Facility Policy>Review of the facility's February 2014 Resident Examination and Assessment policy showed resident skin assessments included intactness, moisture, color, texture, and presence of bruises, pressure sores, redness, edema, and rashes. All assessment data obtained was documented in the resident's medical record.According to the facility policy titled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, dated September 2017, staff would identify risk factors related to bowel dysfunction such as alterations in Bowel Movements (BM). The policy showed nursing staff would assess residents for signs of fecal impaction, dehydration, perform abdominal assessments, digital rectal examinations, assess onset, duration, frequency, and severity of signs and symptoms. The policy showed staff would assess and treat residents for suspected bowel obstructions. According to the facility policy titled, Resident Examination and Assessment, dated February 2014, the staff would assess residents for stool consistency, constipation, and fecal impaction. The policy showed staff would notify the physician of any bowel abnormalities.According to the facility policy titled, Weight Assessment and Intervention, dated March 2022, the facility staff would evaluate undesired weight change from the resident's target weight range and the relationship between current medical condition or clinical situation. According to the facility policy titled, Nutrition (impaired)/Unplanned Weight Loss - Clinical Protocol, dated September 2017, the facility would report to the physician any significant weight changes or any abrupt persistent change from baseline. The policy showed the physician would evaluate for medical causes of the weight change. The policy showed residents with rapid weight gain, the staff would review for possible fluid and electrolyte imbalance as a cause. The policy showed staff and physicians would identify pertinent interventions based on identified causes and overall resident condition. According to the facility policy titled, Heart Failure - Clinical Protocol, dated November 2018, the physician would review and make recommendations on weight monitoring and when to report findings to the physician. The policy showed the physician would order medications with appropriate instructions, such as diuretic medications, for residents with heart failure. <Skin Assessments> <Resident 3> Review of an 11/30/2025 Comprehensive Minimum Data Set (MDS – an assessment tool) showed Resident 3 admitted to the facility on [DATE] with diagnoses including dementia (a decline in mental ability that interferes with daily life) and a broken hip. Resident 3 was dependent on staff for bed and chair mobility, transfers, and toileting hygiene, and was at risk for developing pressure ulcers/injuries. Review of Resident 3's 11/14/2025 Care Plan showed Resident 3 was at risk for pressure injury due to decreased mobility, extensive to total assistance with bed mobility and transfers, incontinence, and cognitive and communication impairment. Staff were to perform a complete assessment of the skin once weekly. Review of an 11/14/2025 physician's order directed staff to conduct a skin assessment for Resident 3 once weekly. Observations on 02/09/2026 from 7:58 AM to 2:32 PM showed Resident 3 continuously sat in their tilt-in-space wheelchair (a mobility device with ability to recline). Review of Resident 3's February 2026 Treatment Administration Record (TAR) showed a skin assessment was performed on 02/04/2026 with no documentation found to show the skin assessment findings. Review of Resident 3's January 2026 TAR showed skin assessments were performed on 01/07/2026, 01/14/2026, and 01/21/2026 with no documentation found to show the skin assessment findings. Review of Resident 3's December 2025 TAR showed skin assessments were performed on 12/03/2025, 12/10/2025, and 12/24/2025 with no documentation found to show the skin assessment findings. In an interview on 02/11/2026 at 11:46 AM, Staff C (Resident Care Manager) stated they were not aware of any skin problems for Resident 3. Staff C attempted to find documentation of Resident 3's skin condition in their record but could not. In an interview on 02/11/2026 at 12:05 PM, Staff B (Director of Nursing) stated residents had a skin check done on admission, and then every seven days. Staff B stated their electronic health records system prompted nurses to sign indicating Resident 3's skin check was completed but did not have a monitor set up for them to record their findings. Staff B stated nurses could document findings in progress notes. Staff B looked but did not find any progress notes showing skin assessment results for Resident 3. Staff B stated there was a new skin assessment form they instructed nurses to complete, but none were completed for Resident 3. Staff B stated it was important to document skin assessment findings to identify any problems that needed treatment and to determine interventions. <Bowel Management> <Resident 5> According to the 01/24/2026 Quarterly MDS Resident 5 admitted to the facility on [DATE]. The MDS showed Resident 5's bowel pattern was constipation. The MDS showed Resident 5 was dependent on staff assistance with toileting and transfers. In an interview on 02/05/2026 at 5:21 PM, Resident 5's representative stated Resident 5 was constipated frequently, and they would have to manually remove BMs that were the size of softballs and hard as a rock. Resident 5's representative stated they notified staff on several occasions but no new orders from the physician were obtained. Record review on 02/07/2026 at 11:13 AM showed Resident 5 had physician orders for an as needed laxative if no BM in three days, if no BM after that laxative, then a stronger laxative, and if no BM from that laxative, staff were to administer a stronger laxative and notify the physician. Resident 5's records showed no BM on 11/14/2025, 11/15/2025, 11/16/2025,11/21/2025, 11/22/2025, 11/23/2025, 11/28/2025, 11/29/2025, 11/30/2025, 12/01/2025, 12/06/2025, 12/07/2025, 12/08/2025, 12/09/2025, 12/20/2025, 12/21/2025, 12/22/2025, 12/23/2025, 01/03/2026, 01/04/2026, 01/05/2026, 01/21/2026, 01/22/2026, and 01/23/2026. These records showed staff did not offer or administer the bowel protocol medications as ordered by the physician. In an interview on 02/10/2026 at 10:08 AM, Staff B reviewed Resident 5's BM monitor and medication administration records and stated Resident 5 did not have BMs on 11/14/2025, 11/15/2025, 11/16/2025,11/21/2025, 11/22/2025, 11/23/2025, 011/28/2025, 11/29/2025, 11/30/2025, 12/01/2025, 12/06/2025, 12/07/2025, 12/08/2025, 12/09/2025, 12/20/2025, 12/21/2025, 12/22/2025, 12/23/2025, 01/03/2026, 01/04/2026, 01/05/2026, 01/21/2026, 01/22/2026, and 01/23/2026. Staff B stated staff did not administer Resident 5 laxatives per the facility bowel protocol or physician's orders but should for each incident of no BM for three days. Staff B stated they expected staff to notify the physician when residents had constipation or if the bowel protocol was ineffective to ensure proper care for a resident's constipation. <Fluid Retention Management> <Resident 40> According to the 01/11/2026 Discharge MDS, Resident 40 admitted to the facility on [DATE]. The MDS showed Resident 40 had a diagnosis of heart failure. Review of Resident 40's records showed physician orders for a diuretic medication (used in heart failure for fluid retention/overload) to be administered for a three Pound (lb) weight gain in one day or five lb weight gain in one week. Resident 40's records showed their weight on 01/06/2026 was 231lbs, on 01/07/2026 was 241lbs, on 01/08/2026 was 242lbs, on 01/09/2026 was 244lbs, on 01/10/2026 their weight was not obtained, and on 01/11/2026 was 245 lbs. Resident 40's records showed the as needed diuretic medication was not administered. Resident 40's records showed a nursing progress note on 01/11/2026 that Resident 40's family requested staff check their weight and it was 245lbs. The progress note showed the family stated Resident 40's weight upon discharge from the hospital on [DATE] was 228lbs. The progress note showed the family requested to take Resident 40 to the hospital for the weight gain/fluid retention. Resident 40's records showed a 01/12/2026 Social Service note stating Resident 40 was admitted to the hospital for heart failure exacerbation with significant weight gain of fluid retention. The Social Service note showed Resident 40's family was upset with the facility for the mismanaged heart failure with fluid retention and did not want Resident 40 to be readmitted to the facility. Review of Resident 40's hospital transfer records showed the hospital obtained a weight of 226lbs on 01/05/2026 for Resident 40. In an interview on 02/09/2026 at 11:05 AM, Staff B stated Resident 40 did not receive the as needed diuretic medication per physician orders but should have. Staff B stated they were unsure the hospital admission for heart failure exacerbation could have been avoided if facility staff had administered the diuretic medication as ordered for Resident 40, but possibly. Refer to F677 ADL Care Provided for Dependent Residents. Reference: WAC 388-97-1060(1).

Based on observation, interview, and record review the facility failed to ensure physician orders were obtained and clarified for 3 of 14 sampled residents (Residents 41, 17, & 6) reviewed. These failures placed residents at risk of unmet needs, and ineffective/or delayed treatments. Findings included.<Resident 41> According to the 01/01/2026 admission Minimum Data Set (MDS – an assessment tool) Resident 41 admitted to the facility on [DATE]. The MDS showed Resident 41 was not receiving hospice services upon admission to the facility. The MDS showed Resident 41 had diagnoses of, but not limited to, malnutrition and heart disease. Record review showed a 01/08/2026 hospice visit note with Resident 41. Resident 41's health records did not show a physician order for the hospice services. In an interview on 02/11/2026 at 8:43 AM Staff B (Director of Nursing) stated they expected staff to obtain a physician order for hospice service. Staff B reviewed Resident 41's records and stated staff did not obtain a physician order for the hospice services but should have. Staff B stated it was important to obtain a physician order for hospice services to ensure continuity of care. <Resident 17> According to the 01/15/2026 admission MDS Resident 17 admitted to the facility on [DATE]. The MDS showed Resident 17 was receiving Oxygen (O2) therapy during the assessment period. Review of Resident 17's 01/27/2026 Unable to Maintain O2 Saturation Care Plan (CP) showed staff were to administer O2 as ordered. Review of Resident 17's health records showed a 01/09/2026 physician order for one Liter per Minute (L/min) via nasal canula to keep blood O2 level greater than or equal to 92 percent. Resident 17's records showed they received 2-3L/min on 01/31/2026, 02/04/2026, 02/05/2026, 02/07/2026 with no documentation of physician notification. Resident 17's records showed no physician order to change O2 tubing. Observations on 02/06/2026 at 10:06 AM and 02/09/2026 at 9:50 AM showed undated O2 tubing connected to Resident 17's O2 machine. In an interview on 02/10/2026 at 10:24 AM Staff B stated they expected staff to obtain a physician order to change O2 tubing every Tuesday night shift and document. Staff B stated Resident 17 should have a physician order to change O2 tubing but did not. Staff B stated they expected staff to follow physician orders of O2 one L/min and if Resident 17 required more, Staff B expected staff to notify the physician and obtain an order. Staff B stated it was important to follow physician orders and update physicians of changes needed to ensure continuity of care. Staff B stated it was important to obtain a physician order to change O2 tubing or staff would not be notified of the need and not changing the tubing can place the resident at risk of infection. <Resident 6> Review of the 01/11/2026 admission MDS showed Resident 6 admitted with diagnoses including multiple trauma fractures. The MDS showed Resident 6 received a blood thinning, injectable medication during the assessment period. Review of Resident 6's 02/09/2026 physician orders showed a 01/05/2026 order directing staff to administer an injectable blood thinner to Resident 6 twice daily. The order did not have a stop date or direct staff on how many days/weeks to continue the blood thinning medication. In an interview on 02/11/2026 at 12:22 PM, Staff C (Resident Care Manager) reviewed Resident 6's order for the injectable blood thinner and stated staff should clarify the order with the physician. In an interview on 02/11/2026 at 1:15 PM, Staff B reviewed Resident 6's order for the injectable blood thinner and confirmed the injectable blood thinner was not usually prescribed for long term use and should be clarified with the physician. Reference: WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i).

Based on observation, interview, and record review, the facility failed to ensure acute medical delirium was ruled out prior to prescribing Antipsychotic (medications used to treat psychosis) medications for 1 of 3 sampled residents with Dementia (a decline in mental ability that interferes with daily life) (Resident 5) and to assess for adverse side effects related to the use of psychotropic medications for 3 of 3 sampled residents (Residents 5, 13, & 3) who were prescribed an Antipsychotic reviewed for unnecessary medications. Failure to rule out acute medical delirium prior to prescribing Antipsychotic medications placed Resident 5 at risk of medical complications, unnecessary psychotropic medication use, and a diminished quality of life. Failure to conduct/obtain an initial/baseline Abnormal Involuntary Movement (AIM) assessment for the use of antipsychotic medications and identify potential involuntary movement placed Residents 5, 13, and 3 at risk of unidentified presence and severity of AIMs related to Antipsychotic mediation side effects, medical complications, and a diminished quality of life.Findings included.<Policy>According to the facility policy titled Antipsychotic Medication Use, dated July 2022, residents would only receive antipsychotic medications when necessary to treat specific conditions for which they were indicated and effective. The attending physician and facility staff would identify acute (short-term) psychiatric episodes and differentiate them from enduring (long-term) psychiatric conditions. Antipsychotic medications would only be used if behavioral symptoms were not due to a medical condition or problem, such as pain, fluid or electrolyte imbalances, infections, vision or hearing impairment, or medication side effects which could be expected to improve or resolve with treatment or discontinuation of offending medications. Nursing staff were to monitor for adverse neurologic side effects, such as abnormal involuntary movements. <Resident 5> According to 01/24/2026 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 5 admitted to the facility on [DATE]. The MDS showed Resident 5 was without signs of delirium or behavioral concerns and had no indicators of psychosis. The MDS showed Resident 5 was compliant with cares and had a diagnosis of Alzheimer's Dementia without behavioral issues. The MDS showed Resident 5 was taking an Antipsychotic medication during the assessment period. The MDS showed Resident 5 required an interpreter for communication. The MDS showed Resident 5 had constipation and frequent pain that limited their day-to-day activities. Review of the 11/20/2025 Physiatrist (Physical Medicine/Rehabilitation Doctor) visit note, Resident 5 was a little agitated during the visit. The consultation report showed no interpreter was provided for communication. The consultation report showed the Physiatrist discontinued prescribed narcotics for pain management due to staff reporting intermittent confusion which was concerning for opiate induced delirium. The Physiatrist also recommended to continue monitoring Resident 5 for further behaviors as there may be underlying dementia. The report showed a recommendation for an Antipsychotic medication twice daily if no concerns for infectious process. Review of Resident 5's health records showed an Antipsychotic medication prescribed 11/20/2025 to be administered twice daily. Resident 5's records showed no behaviors documented from admission [DATE] through 11/20/2026. Review of November 2025, December 2025, January 2026, and February 2026 Medication Administration Records (MAR) showed Resident 5 was receiving the Antipsychotic medication. Resident 5's BM records showed they had a hard BM on 11/20/2025. Review of Resident 5's health records showed no AIMs assessment was completed prior to starting the Antipsychotic medication on 11/20/2025. Observations on 02/05/2026 at 8:33 AM, 02/06/2026 at 8:53 AM, 02/09/2026 at 9:21 AM, 02/10/2026 at 11:14 AM, and 02/11/2026 at 9:23 AM showed Resident 5 calm and cooperative with staff and care. Observation 02/05/2026 at 8:33 AM showed a sign in Resident 5's room stating they spoke Cantonese. Review of the11/26/2025 Intermittent/Restlessness related to Dementia Care Plan (CP) Resident 5 was taking a routine Antipsychotic medication for agitation. In an interview on 02/11/2026 at 12:22 PM Staff B (Director of Nursing) stated Resident 5s records showed no documentation of behaviors prior to starting the Antipsychotic medication. Staff B stated the Physiatrist made a recommendation for the Antipsychotic medication for Dementia with agitation, based on agitation during their visit on 11/20/2025, after ruling out possible infection. Staff B stated no tests to rule out infection were conducted but should have been prior to starting the Antipsychotic medication. Staff B stated when a consultant makes a recommendation, they expected staff to have Resident 5's primary physician review the recommendation before implementing it. Staff B stated there wasn't any documentation the Physiatrists recommendations were reviewed by Resident 5's primary physician. Staff B stated they expected staff to complete an AIMs assessment on residents who are prescribed an Antipsychotic at time of prescribing and every 6months. Staff B stated staff did not complete an AIMS for Resident 5 at time of prescribing but should have to obtain the resident's baseline. Staff B stated AIMs assessments were important to monitor residents for side effects to Antipsychotic medications. <Resident 13> According to 01/22/2026 admission MDS Resident 13 admitted [DATE]. The MDS showed Resident 13 had a diagnosis of Dementia without behavioral disturbances or psychotic disorder. Review of Resident 13's records showed a 01/16/2026 admission order that included an Antipsychotic medication to be administered daily. Review of Resident 13's record showed no AIMS assessment was completed. Observations on 02/05/2026, 02/06/2026, 02/09/2026, 02/10/2026, and 02/11/2026 showed Resident 13 calm and cooperative with staff and care. In an interview on 02/10/2026 at 10:21 AM Staff B stated Resident 13 admitted on the Antipsychotic medication. Staff B stated staff did not complete an AIMs assessment on Resident 13 upon admission but should have. <Resident 3> Review of an 11/30/2025 comprehensive MDS showed Resident 3 admitted to the facility on [DATE] with diagnoses that included dementia and received an antipsychotic medication (used to treat mental disorders by reducing symptoms like hallucinations, delusions, and severe agitation) on a routine basis. Review of Resident 3's physicians orders showed the antipsychotic medication was ordered on 11/14/2025, the dosage was reduced on 12/12/2025, and the medication was discontinued on 01/05/2026. Review of Resident 3's records showed an AIMS assessment was completed on 01/06/2026, after the antipsychotic medication was discontinued. No previous AIMS assessments were found. In an interview on 02/11/2026 at 11:46 AM, Staff C (Resident Care Manager) stated they completed AIMS assessments for residents with their quarterly assessments but did not complete AIMS upon admission. Staff C stated Resident 3 did not have an AIMS completed until 01/06/2026. In an interview on 02/11/2026 at 12:05 PM, Staff B stated they expected staff to complete AIMS assessments on admission to get the resident's baseline status, and at least every six months thereafter. Refer to F645 PASARR Screening for Mood Disorder. Refer to F684 Quality of Care. Reference: WAC 388-97-0620(1)(a).

Based on interview and record review the facility failed to log/report an allegation of neglect for 1 (Resident 10) of 1 residents reviewed. This failure placed residents at risk for unidentified neglect, avoidable pain, and other negative health outcomes.Findings included.<Facility Policy>Review of the facility's Abuse Prevention Program policy, revised 09/22/2025, showed all occurrences/accidents of unknown origin would be investigated and occurrence reports would be reviewed by the administrator and director of nursing. This policy showed the administrator or designee must report all reasonable suspicions of mistreatment including injuries of an unknown source.<Resident 10>According to the 01/14/2026 admission Minimum Data Set (MDS - an assessment tool), Resident 10 admitted to the facility on [DATE] with diagnoses including arthritis, age-related osteoporosis without current pathological fracture, and aftercare following a right hip replacement. The MDS showed Resident 10 did not have signs or symptoms of delirium and did not have cognitive impairment.In an interview on 02/05/2026 at 9:03 AM, Resident 10 stated they came to the facility to receive therapy after hip surgery but recently suffered a right upper leg fracture and they were now recovering from the fracture.Review of a 01/24/2026 x-ray report showed Resident 10's right upper leg bone was fractured, two weeks after their admission to the facility.Review of the facility provided incident log for January and February 2026 showed staff did not log or report the right upper leg fracture for Resident 10.In an interview on 02/10/2026 at 10:40 AM Resident 10 stated they did not have a fall and stated nobody hurt them.In an interview on 02/10/2026 at 1:48 PM, Staff B (Director of Nursing) stated Resident 10 was experiencing a high level of pain since their admission to the facility. Staff B stated there was no trauma or an occurrence since the resident's admission and staff felt Resident 10 possibly came with the fracture. Staff B stated they did not investigate Resident 10's fracture.In an interview on 02/11/2026 at 11:26 AM, Staff A (Administrator) stated injuries of unknown origins were reportable incidents.Refer to F610 Investigate/Prevent/Correct Alleged ViolationREFERENCE: WAC 388-97-0640(5)(a).

Based on record review and interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR - a mental health screening required before the transfer to a nursing home) assessments submitted for a Level II PASRR assessment after the 30 day exemption expired for 1 of 5 sample residents (Resident 4) and were completed for new mood disorders requiring antipsychotic medication for 1 of 5 residents (Resident 5) whose PASRRs were reviewed. This failure left residents at risk of inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.Findings included.<Policy>According to the facility policy titled, Antipsychotic Medication Use, dated [DATE], the facility would ensure PASRR would be completed for residents taking Antipsychotic medications.<Resident 4> According to the [DATE] admission Minimum Data Set (MDS – an assessment tool), Resident 4 had a diagnosis of depression and received antidepressant medications during the assessment look-back period. The MDS showed staff assessed Resident 4 was not considered by the state level II PASRR process to have a Serious Mental Illness (SMI). Review of Resident 4's [DATE] level I PASRR assessment showed facility staff assessed Resident 4 as having a SMI of a mood disorder. Staff checked on the form Resident 4 did not require a level II evaluation due to exempted hospital discharge. This section of the form stated, Level II must be completed if scheduled discharge does not occur. Review of Resident 4's comprehensive records on [DATE] showed the resident remained in the facility past their exempted hospital discharge timeframe. Review of Resident 4's record showed staff did not send the level I PASRR for a level II PASRR evaluation as required. In an interview on [DATE] at 1:42 PM, Staff E (Social Service Director) stated their process was to follow the hospital exemption requirements. Staff E provided a [DATE] email showing they sent Resident 4's level I PASRR for a level II evaluation. Staff E stated they did not receive an evaluation back and did not follow up with the PASRR evaluators since [DATE], nearly eight months after. <Resident 5> According to the [DATE] Quarterly MDS Resident 5 admitted [DATE]. The MDS showed Resident 5 was taking an antipsychotic medication. The MDS showed resident 5 had diagnoses of Alzheimer's (progressive neurodegenerative disease characterized by memory loss) disease and Dementia (a decline in mental ability that interferes with daily life) without behavioral disturbances. Review of Resident 5's physician orders showed they were started on a new antipsychotic mediation for dementia with agitation. Resident 5's records showed no PASRR was done for new mood disorder requiring an antipsychotic medication. In an interview on [DATE] at 11:32 AM Staff E stated they expected a new PASRR to be completed when a resident had a significant change to include new psychiatric diagnosis and psychotropic medications, but it was not done for Resident 5. Staff E stated it was important to complete PASRRs for new mood disorders requiring antipsychotic medications to ensure they received necessary services to meet their mental health care needs. Refer to F605 Right to be Free from Chemical Restraints. Reference: WAC 388-97-1915(1)(2)(a-c).

Based on interview and record review, the facility failed to implement a system by which residents received required written notices at the time of transfer or as soon as practicable for 3 (Residents 28, 5, & 7) of 4 residents reviewed for hospitalization . Failure to ensure notification to the resident and/or the resident's representative of the reason for transfer in writing and in a language and manner they understood, placed residents at risk for a transfer not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> Review of the facility's October 2022 Transfer or Discharge, Facility-Initiated policy showed for emergent transfers, the resident and their representative would be provided a Notice of Transfer as soon as practicable. The notice would be provided in a form and manner the resident could understand. <Resident 28> According to the 07/30/2024 Discharge Minimum Data Set (MDS - an assessment tool), Resident 28 transferred to the hospital on 07/30/2024 with their return anticipated. Review of Resident 28's records showed no documentation a written notice of transfer was provided to the resident, or their representative as required. <Resident 7> According to the 06/02/2024 Discharge MDS, Resident 7 transferred to the hospital on 06/02/2024 with their return anticipated. According to the 06/16/2024 Discharge MDS, Resident 7 transferred to the hospital on 06/16/2024 with their return anticipated. According to the 07/24/2024 Discharge MDS, Resident 7 transferred to the hospital on 07/24/2024 with their return anticipated. According to the 10/13/2024 Discharge MDS, Resident 7 transferred to the hospital on 10/13/2024 with their return anticipated. Review of Resident 7's records showed no documentation a written notice of transfer was provided to the resident, or their representative as required. <Resident 5> According to the 10/22/2024 Discharge MDS, Resident 5 transferred to the hospital on 10/22/2024 with their return anticipated. According to the 11/14/2024 Discharge MDS, Resident 5 transferred to the hospital on 11/14/2024 with their return anticipated. Review of Resident 5's records showed no documentation a written notice of transfer was provided to the resident, or their representative as required. In an interview on 12/12/2024 at 11:50 AM, Staff A (Administrator) and Staff B (Director of Nursing) confirmed the facility did not have a process for providing written transfers to residents and/or their representative at the time of transfer. REFERENCE: WAC 388-97-0120(2)(a-d). . 42203 44296

Based on interview and record review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs requiring further assessment/treatment) assessment was accurately completed for 3 (Residents 33, 7, & 2) of 5 residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely services to meet their mental health needs. Findings included . <Facility Policy> According to the facility's revised March 2019 Admission Criteria policy, all new admissions were screened to determine if the resident met the criteria for mental disorders, intellectual disabilities, or related disorders. This policy showed if the resident met any of the criteria, they would be referred to the state PASRR representative for a Level II evaluation and determination. <Resident 33> According to the 11/05/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 33 admitted to the facility on [DATE] and had a diagnosis of depression. The MDS showed Resident 33 received an antidepressant medication during the assessment period. Review of Resident 33's physician orders showed a 10/30/2024 order directing staff to administer an antidepressant medication daily. Resident 33 had a 10/30/2024 physician order directing staff to monitor the resident for signs/symptoms of depression every shift. Review of Resident 33's 10/30/2024 Level 1 PASRR under the section Serious Mental Illness Indicators showed depression was not marked for Resident 33, indicating Resident 33 did not have a serious mental illness. In an interview on 12/13/2024 at 9:34 AM, Staff C (Social Worker) reviewed Resident 33's PASRR and records. Staff C confirmed the PASRR did not capture Resident 33's depression diagnosis and required correction. Staff C stated it was important to have accurate PASRRs to ensure resident needs could be met at the facility. 44296 <Resident 7> According to the 04/30/2024 Admission MDS, Resident 7 admitted to the facility on [DATE] and had a diagnosis of depression. This assessment showed Resident 7 received an antidepressant medication during the assessment period. Review of Resident 7's physician orders showed a 10/21/2024 order directing staff to administer an antidepressant medication daily. Resident 7 had a 10/21/2024 order directing staff to monitor the resident for signs/symptoms of depression every shift. Review of Resident 7's 04/23/2024 Level 1 PASRR showed Resident 7 had anxiety. The PASRR did not capture Resident 7's diagnoses of depression. <Resident 2> According to Resident 2's 10/09/2024 Admission MDS, Resident 2 admitted to the facility on [DATE] and had diagnoses of anxiety, depression, and bipolar (mental disorder characterized by extreme mood swings). The MDS showed Resident 2 received antipsychotic, antianxiety, and antidepressant medications during the assessment period. Review of Resident 2's physician orders showed a 10/03/2024 order directing staff to administer an antianxiety medication twice daily, a 10/03/2024 order directing staff to administer an antipsychotic medication three times daily, and an 11/29/2024 order directing staff to administer an antidepressant once daily to the resident. A 10/03/2024 order instructed staff to monitor Resident 2 for signs/symptoms of depression, a 10/03/2024 order instructing staff to monitor the resident for signs/symptoms of behaviors of psychosis related to the antipsychotic medication, and a 10/03/2024 instructing staff to monitor Resident 2 for signs and symptoms of anxiety. Review of Resident 2's 10/03/2024 Level 1 PASRR completed by Staff C showed only Mood Disorders were marked. The PASRR did not capture Resident 2's anxiety diagnosis and the resident was not referred for a PASRR Level II evaluation. In an interview on 12/16/2024 at 11:51 AM, Staff C stated they were unaware of the new regulations regarding referring residents for Level II PASRR. REFERENCE: WAC 388-97-1915(1).

Based on interview and record review the facility failed to ensure residents had the appropriate Advanced Directive (AD) in place for 2 (Residents 31 & 2) of 3 residents reviewed for ADs. The facility failed to provide information indicating residents were informed, educated, or offered assistance to formulate an AD. This failure placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care. Findings included . <Facility Policy> According to the facility's September 2022 Advance Directives policy, if a resident had any ADs, the facility would obtain and maintain the document(s) to be readily available when needed to any facility staff. <Resident 31> According to the 10/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 31 admitted to the facility on [DATE] and had diagnoses including a history of stroke and one-sided paralysis. The MDS showed Resident 31 had a severe memory impairment. According to 07/01/2024 admission progress note, Resident 31's representative told Staff C (Social Worker) they were the resident's Durable Power of Attorney (DPOA - a legal surrogate for healthcare decision making). Resident 31's representative stated they would find and provide a copy of the DPOA paperwork. Record review showed no DPOA was on file for Resident 31. In an interview on 12/16/2024 at 10:27 AM, Staff C stated they inquired about AD paperwork upon admission and requested a copy for the records held at the facility, if they were in place. Staff C stated they documented efforts to obtain residents' ADs in admissions progress notes. Record review showed no further progress notes indicating any follow up to obtain the paperwork required to be maintained at the facility. 44296 <Resident 2> According to the 10/09/2024 Admission MDS, Resident 2 admitted to the facility on [DATE] and was assessed with intact memory. Record review showed Resident 2 had a DPOA identified on their Face Sheet (a document listing a resident's personal information, contacts etc.). Record review showed there was no DPOA paperwork in place at the facility. Record review showed Staff C wrote a 10/03/2024 progress note showing Resident 2 told Staff C their relative had their DPOA paperwork. This note showed Staff C would reach out to the relative for a copy. There were no further progress notes indicating Staff C followed up regarding the DPOA paperwork. In an interview on 12/10/2024 at 1:23 PM, Resident 2 stated a relative was their DPOA. Resident 2 stated the facility knew they had a DPOA but was unsure of what efforts were made by the facility to obtain it. In an interview on 12/16/24 11:58 AM Staff C stated having AD paperwork in place was important so when a resident could not make their needs known, the facility would know whom to communicate regarding the resident's healthcare decision-making. Staff C stated they did their best to obtain AD paperwork, but it did not always happen. REFERENCE: WAC 388-97-0280 (3)(c)(i-ii), -0300 (1)(b), (3)(a-c).

Based on observation, interview, and record review the facility failed to develop and implement comprehensive Care Plans (CPs) for 5 (Residents 5, 31, 33, 7, & 23) of 12 sample residents whose CPs were reviewed. The failure to develop and/or implement comprehensive CP interventions left residents at risk for unmet care needs and other negative health outcomes. Findings included . <Resident 5> According to the 11/27/2024 5-Day Minimum Data Set (MDS - an assessment tool) Resident 5 had medically complex diagnoses including a heart condition that could cause fluid in the lungs. The MDS showed Resident 5 used supplemental oxygen upon admission and during the assessment look back period. Observation on 12/09/2024 at 2:52 PM showed Resident 5 had an oxygen concentrator and a nasal cannula (tubing to deliver supplemental oxygen to the nostrils.) The nasal cannula was resting on Resident 5's bedside table Record review showed an 11/21/2024 physician's order directing staff to provide Resident 5 supplemental oxygen at two liters per minute via a nasal cannula. Review of the 09/25/2024 comprehensive CP showed the facility did not develop a CP addressing Resident 5's supplemental oxygen use. There was no goal developed, and there were no directions for settings for the concentrator, or care and cleaning of the cannula and concentrator. In an interview on 12/16/2024 at 9:39 AM Staff B stated as Resident 5 had an order for and received supplemental oxygen, there should be an associated CP. Staff B stated facility nurses should have but did not develop an oxygen CP. <Resident 31> According to the 10/03/2024 Quarterly MDS, Resident 31 had diagnoses including a history of stroke and one-side paralysis. The MDS showed Resident 31 had severe memory impairment, used a wheelchair for mobility, and depended on staff for most mobility needs. The MDS showed Resident 5 did not receive a restorative nursing program (a program to help residents with range of motion or other impairments maintain their current function). Observation on 12/10/2024 at 11:05 AM showed Resident 31 lying in bed. The fingers on Resident 31's right hand were curled into the palm of their hand. Review of the 07/03/2024 comprehensive CP showed a Restorative Nursing Program . CP with a goal to maintain Resident 31's upper and lower range of motion on their right side. This CP did not indicate who was responsible for completion of the goal or specify a frequency for either the upper or lower body restorative program. In an interview on 12/16/2024 at 9:56 AM, Staff B stated they were not sure if it was determined Resident 31 did not require a restorative program and that could be the reason why the restorative CP was incomplete. In an interview on 12/16/2024 at 10:42 AM, Staff J (Director of Rehabilitation) confirmed Resident 31 was on a restorative nursing program. 46479 <Resident 33> Review of Resident 33's 11/05/2024 Admission MDS showed the resident had diagnoses including a stroke resulting in difficulty with communication and diabetes (inability to control blood sugar levels). This MDS showed Resident 33 received anti-diabetic medications during the assessment period. Review of Resident 33's 12/11/2024 physician orders showed the resident had a 10/30/2024 order for an oral anti-diabetic medication to be administered once daily, a 10/31/2024 order for another oral anti-diabetic medication to be administered twice daily, an 11/19/2024 order directing staff to administer an injectable anti-diabetic medication at night, and an 11/21/2024 order directing staff to administer an injectable anti-diabetic medication three times daily. Review of Resident 33's 11/06/2024 Comprehensive CP showed a goal that the resident would not experience a fall with an intervention to monitor the resident for signs and symptoms of high or low blood sugar. Review of the Comprehensive CP showed there was no CP developed related to Resident 33's diagnoses of diabetes. There were no instructions to staff on what interventions to implement if the resident experienced high or low blood sugar, what labs should be monitored, or when and if the physician should be notified. 44296 <Resident 7> Review of the 10/21/2024 Readmission MDS showed Resident 7 was cognitively intact, had medically complex conditions including heart failure, kidney failure, and diabetes. The MDS showed Resident 7 required a diuretic (water pill) medication to manage their condition. In an observation and interview on 12/09/2024 at 2:47 PM, Resident 7 stated they had a lot of swelling in both feet. Resident 7 stated the nurses were not monitoring the swelling. Resident 7 stated the nurses gave them medication and the nurses must assume the medication was taking care of the swelling. Resident 7's representative removed the sheet and blanket to reveal Resident 7's bilateral swollen feet, ankles, and lower legs. Review of a 12/09/2024 Physician progress note showed Resident 7 had congestive heart failure, was prescribed a diuretic, was assessed with 1+ lower extremity edema, and trended towards fluid retention. The physician note showed the diuretic dose was doubled, a supplement was added, and orders for lab monitoring. Review of Resident 7's 05/01/2024 Comprehensive CP showed no instructions to monitor, document, or report changes in their edema. In an interview on 12/16/2024 at 9:14 AM, Staff B stated Resident 7 should have edema monitoring on their CP and document monitoring in the medical record. Staff B stated they relied on the nurses to monitor edema, report changes to the physician, and prevent skin breakdown. Staff B stated the nurses could update CPs but usually did not. Staff B stated the nurses should notify the care manager or the Director of Nursing for CP updates. <Resident 23> Review of a 09/08/2024 and an 11/07/2024 incident report showed Resident 23 obtained skin tears on their shins. The reports showed Resident 23 did not know how the injuries occurred. Resident 23's skin was assessed as fragile and easily bruised or torn. The reports showed Resident 23 was to wear skin protective sleeves on their arms and legs to protect their skin. The report showed staff was educated to make sure Resident 23 was wearing the sleeves at all times. Review of the 05/21/2020 Comprehensive CP showed Resident 23 had fragile skin, had prior skin tears on their lower legs, and was at risk for skin tears on their legs. The CP showed Resident 23 should wear Tubi sleeve (a protective covering for skin) to cover their shins and protect from injury. Observation on 12/09/2024 at 12:24 PM showed Resident 23 was sitting up in bed with legs exposed, feet covered by blankets with the bedside table placed over the bed. Resident 23 was eating lunch from the tray on the bedside table. Resident 23 did not have Tubi sleeves on their lower legs. An observation on 12/09/2024 at 1:46 PM showed Resident 23 was sitting up in bed awake with both legs covered with a sheet and blanket. The bedside table was placed over Resident 23's lap. Staff H (Registered Nurse) removed the blankets from Resident 23's legs to reveal both shins. The left shin had two scabs on the shin. The right shin had a large scab. Staff H stated the scabs were healed and did not know how or when they were obtained. Resident 23 did not have any Tubi sleeves on their lower legs. An observation on 12/11/2024 at 7:02 AM showed Resident 23 lying in bed sleeping. The bedside table was next to the bed. Resident 23's right foot was visible outside of the blankets. Resident 23 did not have any Tubi sleeves on the lower right leg. In an interview on 12/16/2024 at 9:14 AM, Staff B stated Resident 23 needed protection of their skin. Staff B stated the staff should follow the care plan and Resident 23 should have been wearing the skin protective sleeves. REFERENCE: WAC 388-97-1020(1),(2)(a)(b).

Based on observation, interview, and record review the facility failed to complete a formal assessment prior to use of a Tilt-in-Space wheelchair (a specialty wheelchair with a seat and back that can be readjusted by a second party to reposition the user for comfort and/or pressure relief) for 1 of 2 residents (Resident 26) reviewed for accommodation of needs, and 1 of 1 residents (Resident 31) reviewed for positioning. The failure to ensure residents' Tilt-in-Space wheelchairs prior to use placed residents at risk for use of an inappropriate wheelchair, discomfort, and loss of bodily autonomy. Findings included . <Facility Policy> According to the facility's January 2020 Assistive Devices and Equipment policy, the facility would provide certain mobility equipment including wheelchairs to residents needing mobility assistance. The policy showed equipment recommendations would be made based on the comprehensive assessment and documented in the resident's Care Plan (CP). The policy showed an order to decrease the risk of avoidable accidents, to the extent possible, the appropriateness of the resident's condition would be assessed for determining the safest device, and for personal fit. <Resident 26> According to the 11/06/2024 Admission Minimum Data Set (MDS - an assessment tool) Resident 26 was assessed with severe memory impairment and had medically complex diagnoses including dementia and a condition where brain function affected mental processing. The MDS showed Resident 26 used a wheelchair. The MDS showed Resident 26 required partial-to-maximal assistance with mobility. Observation on 12/09/2024 at 1:34 PM in the [NAME] dining room showed Resident 26 sitting at the dining table. Resident 26 was in a Tilt-in-Space wheelchair. The chair was labeled with another resident's name and room number. Record review showed there was no documentation that showed the facility assessed the suitability of a Tilt-in-Space wheelchair for Resident 26. Record review on 12/16/2024 showed the at risk for falls . CP included an intervention to assist Resident 26 with mobility using their Tilt-in-Space wheelchair for locomotion. Resident 26's comprehensive CP did not include any other interventions for the Tilt-in-Space wheelchair, did not explain why Resident 26 needed a Tilt-in-Space wheelchair, and did not include directions for appropriate use including positioning. In an interview on 12/12/2024 at 10:07 AM, Staff B (Director of Nursing) stated wheelchair assessments were completed by the facility's therapy department. In an interview on 12/16/2024 at 9:09 AM, Staff I (Physical Therapist) stated when residents discharged from therapy, the facility matched the resident with a chair of the appropriate size, but when a resident's needs were more specific, the facility worked with an Assistive technology provider. Staff I stated the purpose of a Tilt-in-Space wheelchair was to assist with redistributing weight for residents who needed periodic weight redistribution and could not redistribute their own weight. Staff I stated perhaps directions for use of the Tilt-in-Space wheelchair should be included in the CP. Staff I stated documentation of the assessment of the Tilt-in-Space wheelchair might be in the chart. Staff I stated in terms of a formal assessment of a Tilt-in-Space wheelchair for a resident, it was a matter of knowing what the resident needs. Staff I stated they would provide further documentation of the assessment process for Resident 26. No additional documentation was provided. <Resident 31> According to the 10/03/2024 Quarterly MDS, Resident 31 had diagnoses including a history of stroke and one-side paralysis. The MDS showed Resident 31 had severe memory impairment, used a wheelchair for mobility, and depended on staff for most mobility needs. Observation on 12/12/2024 at 10:04 AM showed Resident 31 seated in the [NAME] dining room. Resident 31 was in a Tilt-in-Space wheelchair. Record review showed there was no documentation that showed the facility assessed the suitability of a Tilt-in-Space wheelchair for Resident 31. Record review showed Resident 31's comprehensive CP provided instructions to use a Tilt-in-Space wheelchair for locomotion but did not explain why Resident 31 needed a Tilt-in-Space wheelchair, and did not include directions for appropriate use including positioning. In an interview on 12/16/2024 at 9:09 AM, Staff I stated they would provide any further documentation they could locate of the assessment process for Resident 31's. No additional documentation was provided. REFERENCE: WAC 388-97-1060(1).

Based on observation, interview, and record review, the facility failed to thoroughly investigate a fall for 1 (Resident 88) of 3 residents reviewed for accidents, and rule out abuse/neglect for 2 (Resident 23 & 33) of 3 sampled residents reviewed for abuse. Facility failure to complete thorough investigations placed residents at risk for further falls, potential abuse, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's Accidents and Incidents - Investigating and Reporting policy, all accidents and incidents involving facility residents should be thoroughly investigated. Review of the facility's September 2013 revised Skin Tears - Abrasions and Minor Breaks, Care of policy showed the facility would complete an in-house investigation of the cause of the skin injury. This policy showed when an abrasion/skin tear/bruise was discovered, an incident report would be completed. <Resident 88> According to the 12/06/2024 Admission Minimum Data Set (MDS - an assessment tool) Resident 88 admitted to the facility on [DATE] and was assessed with intact memory, and required supervision for transfers and moving from sitting to standing. The MDS showed Resident 88 was continent of urine and bowel. The MDS showed Resident 88 had medically complex diagnoses including a recent Urinary Tract Infection (UTI), Atrial Fibrillation (AFib - an irregular/rapid heart rhythm) and orthostatic hypotension (a condition where blood pressure drops when moving from lying to sitting or sitting to standing and cause dizziness). According to the 11/30/2024 Baseline Care Plan (CP), Resident 88 was identified to be at risk for falling. This CP did not identify any fall precautions. Review of the facility's December 2024 Incident Log showed Resident 88 fell on [DATE] and sustained an injury. According to a 12/03/2024 physician's progress note, Resident 88 fell at around 10 AM on that date. The physician noted Resident 88's fall was not witnessed, the resident bumped the back of their head with no loss of consciousness noted, and called family members who reported Resident 88 sounded confused. Review of the facility's investigation into the 12/03/2024 unwitnessed fall concluded Resident 88 fell while transferring from their bed to a chair independently. The investigation showed upon discovery of Resident 88's fall, the nurse on duty initiated neurological checks (periodic assessment for brain injury after head trauma). The investigation showed Resident 88's blood pressure was measured at 101/54 after the fall. The investigation's conclusion identified pertinent diagnoses from Resident 88's personal medical history including a UTI history and a prior history of fainting (related to their AFib diagnosis). The investigation did not identify Resident 88's orthostatic hypotension diagnosis as a potential risk factor in the fall. Observation on 12/10/2024 at 10:15 AM showed a document hung on the wall of Resident 88's room. The document showed staff began documenting neurological checks for Resident 88 on 12/06/2024 at 5:30 AM and had rows for nursing staff to do neurological checks every 15 minutes until 6:15 AM, then every half hour until 9:15 AM, with longer intervals after until a final row was scheduled for night shift on 12/10/2024. The last row completed by nursing staff was at 6:45 AM on 12/06/2024. Five neurological checks were completed and 18 were left blank. According to a 12/06/2024 progress note, at 5:30 AM a nurse heard Resident 88 crying out for help from their room. Resident 88 was found lying on the floor on their left side with their walker next to them. The note showed Resident 88 denied hitting their head, no new head trauma was noted, and the nurse initiated neurological checks. There was no further notes showing why neurological checks were not completed. Review of the facility's investigation into the 12/06/2024 unwitnessed fall showed Resident 88 stated they fell walking to the bathroom. The investigation showed Resident 88's blood pressure was low (99/43) immediately after the fall. The investigation's conclusion identified pertinent diagnoses from Resident 88's personal medical history including a UTI history and prior history of fainting. The investigation did not identify Resident 88's orthostatic hypotension diagnosis as a potential risk factor in the fall, despite the earlier observation that the resident's blood pressure was low at that time. In an interview on 12/16/2024 at 9:55 AM, Staff B (Director of Nursing) stated the investigation did not identify Resident 88's orthostatic hypotension could be a risk factor for the resident's falls. Staff B stated they did not know why nurses did not complete neurological checks after the 12/06/2024 fall. Staff B stated it was their expectation the neurological exams were completed. 44296 <Resident 23> According to the 10/02/2024 Significant Change MDS, Resident 23 was assessed with a severe memory impairment, and required substantial/maximal assistance to move in bed. The MDS showed Resident 23 had medically complex diagnoses including heart failure, peripheral vascular disease in their lower extremities, Diabetes, and dementia. The MDS showed Resident 23 had skin tears and required medical treatments for their skin. Observation on 12/10/2024 at 1:46 PM with Staff H (Registered Nurse - RN) showed Resident 23 had two scabbed areas on their left shin and a scab on their right shin. Review of the facility's incident reports from September through December 2024 showed a 09/08/2024 injury of unknown origin and an 11/07/2024 skin issue logged for Resident 23. Review of the 09/08/2024 injury of unknown origin investigation showed Resident 23 had a skin tear measuring six-by-three centimeters with bruising on their left lower leg. The aide stated they discovered the skin tear while providing care at 9:00 PM. The investigation showed Resident 23 told staff they did not know how the skin tear occurred. The investigation showed Resident 23 had increasingly fragile skin. The investigation did not identify a root cause of the skin tear. Review of the 11/17/2024 Skin Issue investigation showed the nurse's aide discovered a three-by-two-centimeter skin tear on Resident 23's right shin while providing care at 5:45 PM. The investigation showed Resident 23 could not describe how the skin tear occurred. The investigation did not identify a root cause of the skin tear. In an interview on 12/16/2024 at 9:14 AM, Staff B stated they expected all skin tears to be investigated. Staff B stated it was important to identify the root cause in order to prevent recurrence. Staff B stated the facility should have established root cause for Resident 23's skin tears. 46479 <Resident 33> According to the 11/05/2024 Admission MDS, Resident 33 had unclear speech, was sometimes understood by others, and could sometimes understand others. The MDS showed the brief interview for mental status could not be completed because the resident was rarely understood and had a short-term memory problem. This assessment showed Resident 33 did not have any current skin tears or skin problems. Observation on 12/09/2024 at 1:07 PM showed Resident 33 lying in bed. Resident 33 had two, undated foam bandages in place to their right forearm. A similar observation on 12/12/2024 at 10:54 AM showed Resident 33 in bed with two, undated foam bandages to their right forearm. An undated foam bandage was observed to the resident's left shin. Bloody discharge was observed soaking through the foam bandage on Resident 33's shin. In an interview on 12/12/2024 at 11:02 AM, Staff G (RN) stated they unaware of any skin treatments for Resident 33. Staff G reviewed Resident 33's physician orders and confirmed there were no treatment orders in place. In an observation and interview on 12/12/2024 at 2:32 PM, Staff B assessed removed the foam bandages and assessed the wounds to Resident 33's right forearm and left shin. Staff B asked Resident 33 if they knew what happened to their arm and leg, Resident 33 could not say. Review of Resident 33's physician orders on 12/11/2024 showed a 10/30/2024 order directing staff to perform a skin assessment for any new skin issues, notify the provider, obtain treatment orders, and complete an incident report. Review of Resident 33's progress notes showed an 11/01/2024 note indicating Resident 33 had a skin tear, the note did not specify the location of the skin tear. A 12/08/2024 progress note showed staff documented the resident had a foam dressing covering a skin tear on their right forearm. A 12/09/2024 progress note showed staff documented Resident 33 had a foam dressing to their right forearm. There were no details or other progress notes indicating how the injury occurred, if appropriate staff were notified, or that an incident report was completed regarding the injuries. Review of the facility's October 2024, November 2024, and December 2024 incident log showed staff logged three falls for Resident 33. A fall on 11/13/2024, 11/24/2024, and 11/25/2024. Review of the three fall investigations showed staff documented the resident did not obtain an injury from any of the falls. The facility's incident log showed there were no incidents logged for Resident 33 regarding the skin tears/injuries of unknown origin. In an interview on 12/16/2024 at 9:14 AM, Staff B stated Resident 33's injuries should be investigated at the time of occurrence. Staff B stated it was important to investigate Resident 33's injuries because the resident had impaired memory, and the facility needed to ensure the resident was not abused. REFERENCE: WAC 388-97-0640(6)(a)(b).

Based on observation, interview, and record review the facility failed to ensure medications and biologicals were secured for 3 (Residents 14, 29, & 88) of 12 sample residents. The failure to ensure medications were not left at the bedside with residents not assessed to be able to self-medicate placed residents at risk for receiving the wrong medications, incorrect dosages, and non-assessed, self-administration of medications by residents. Findings included . <Resident 14> Observation on 12/09/2024 at 9:32 AM showed Resident 14 lying in bed with their over-the-bed table across their lap. A bottle of lubricating eye drops was on the table next to them. Observation on 12/12/2024 at 2:19 PM showed Resident 14 lying in bed with their over-the-bed table across their lap. A medication cup containing two, white, oblong pills were observed as well as a bottle of lubricating eye drops sitting on the table. In an observation and interview on 12/12/2024 at 2:28 PM, Staff G (Registered Nurse) went to Resident 14's room and confirmed the medications at bedside. Staff G stated they were supposed to stay with the resident until the resident took the medications, but they did not. Review of Resident 14's records on 12/12/2024 showed no assessments or orders indicating the resident was able to self-administer or keep medications at their bedside. <Resident 29> Observation on 12/09/2024 at 8:40 AM showed Resident 29 with a tube of prescription ointment used for skin irritation, a prescription nasal spray, and a prescription inhaler at their bedside. Similar observations were made on 12/12/2024 at 2:16 PM. In an interview at that time, Resident 29 stated staff did not assess their ability to properly use the inhaler. In an interview on 12/16/2024 at 9:14 AM, Staff B (Director of Nursing) stated residents should have physician orders to keep medications at their bedside. Staff B stated staff should complete an assessment to ensure residents could correctly and safely self-administer medications. <Resident 88> Observation on 12/10/2024 at 1:16 PM showed a tube of oral anesthetic gel on the resident's bedside table. Similar observations were made on 12/11/2024 at 12:50 PM. In an interview on 12/16/2024 at 9:39 AM, Staff B stated Resident 88 should not have the oral anesthetic gel on their bedside table. REFERENCE: WAC 388-97-1300(2). . 44296 42203

Based on observation, interview, and record review the facility failed to ensure residents were provided informed consent (ensuring an explanation of the risks and benefits was provided) for the use of a medical device for 1 of 1 (Residents 31) residents reviewed for positioning, and 1 supplemental resident (Resident 26). The failure to provide informed consent placed residents at risk for loss of autonomy. Findings included . <Resident 31> According to the 10/03/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 31 had diagnoses including a history of stroke and one-side paralysis. The MDS showed Resident 31had severe memory impairment, used a wheelchair for mobility, and depended on staff for most mobility needs. Observation on 12/10/2024 at 8:20 AM showed Resident 31 sitting at a table in the facility's [NAME] dining room. Resident 31 sat in a Tilt-in-Space wheelchair (a specialty wheelchair where the angle at which the user of the wheelchair is seated could be easily adjusted using handles behind the seat). The angle could not be adjusted by the chair's user, which had the potential to restrain the user. Review of Resident 31's record showed the record had a section where informed consent documentation was stored. There was no consent included showing Resident 31's representative was informed of the potential risks and benefits of the Tilt-in-Space wheelchair use. <Resident 26> According to the 11/06/2024 Admission MDS, Resident 26 was assessed with a severe memory impairment and had medically complex diagnoses including dementia and a condition where brain function affected mental processing. The MDS showed Resident 26 used a wheelchair. Observation on 12/12/2024 at 10:04 AM showed Resident 26 seated in the [NAME] dining room. Resident 26 was in a Tilt-in-Space wheelchair. Review of Resident 26's record showed no consent was included showing Resident 26 or their representative were informed of the potential risks and benefits of the Tilt-in-Space wheelchair use. In an interview on 12/16/2024 at 9:39 AM, Staff B (Director of Nursing) stated they expected the informed consent process to be completed with the potential risks and benefits explained prior to use of a device such as a Tilt-in-Space wheelchair. REFERENCE: WAC 388-97-0260.

Based on observation, interview, and record review the facility failed to assess the resident's ability to self-administer their medications for 1 of 3 residents (Resident 29) reviewed. This failure placed residents at risk for overdose or under dose of medical treatment when self-administering of the wrong dose, frequency, route, and time. Findings included . Observations on 12/09/2024 at 8:40 AM and 12/12/2024 at 12:16 PM showed Resident 29 with an inhaler, a tube of ointment, and a nasal spray on their bedside table. Review of the 12/2024 Medication Administration Records (MAR) showed Resident 29 could keep their inhaler at the bedside. The MAR showed no authorization to keep the nasal spray or the ointment at the bedside. Review of Resident 29's medical record found no assessments were completed to ensure Resident 29 could self-administer their inhaler, nasal spray or ointment according to the physician's instructions. In an interview on 12/12/2024 at 2:16 PM, Resident 29 stated I have to use the inhaler all the time, I do not need anyone to tell me how to use it. I need it on the table because if I need it at 3:00 AM, I cannot wait 20 minutes for them to bring it to me. Resident 29 stated the staff did not provide them with instructions or have them demonstrate how to use the inhaler, the nasal spray, or the ointment. Resident 29 stated the nurses knew the medications were kept on the bedside table. In an interview on 12/12/2024 at 2:36 PM, Staff G (Registered Nurse) reviewed the physician orders for Resident 29. Staff G stated the orders showed the inhaler could be kept at the bedside, but the nasal spray and the ointment did not have a physician order to keep them at the bedside. Staff G immediately went into Resident 29's room and removed the nasal spray and the ointment. In an interview on 12/12/2024 at 2:41 PM, Staff B (Director of Nursing) stated there should be a physician order for all medications kept at the resident's bedside. Staff B stated residents should be assessed for their ability to self-administer medications if they are kept at the bedside. In an interview on 12/16/2024 at 9:14 AM, Staff B stated Resident 29 should have and did not have a self-medication assessment for the medications at their bedside. Staff B stated there was a change in the medical records a couple months ago which removed the resident self-medication administration assessment. REFERENCE: WAC 388-97-0440, -1060(3)(l).

Based on observation, interview, and record review the facility failed to implement Infection Control (IC) practices to prevent transmission of Norovirus (a highly contagious virus that causes uncontrollable vomiting and diarrhea and can lead to dehydration, hospitalization , and even death) for 27 of 39 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, & 28) reviewed who experienced signs and/or symptoms of the preventable, highly transmissible, communicable disease. The facility failed to effectively: implement a system for tracking resident and staff illnesses to timely identify clusters of illness and the outbreak; implement Transmission Based Precautions (TBP) for symptomatic residents; report the outbreak to the Local Health Jurisdiction (LHJ) and the State Agency (SA) as required; notify residents/responsible parties/visitors of the outbreak; and implement IC outbreak management interventions to prevent transmission and protect residents from serious harm that constituted immediate jeopardy. On [DATE] at 1:35 PM, the facility was notified of an Immediate Jeopardy at Code of Federal Regulations (CFR) 483.80(a)(1)(2) F880 for Infection Control related to the facility's failure to implement IC to prevent the transmission of Norovirus. The facility removed the immediacy on [DATE] with onsite verification by monitoring residents for symptoms, placing symptomatic residents on TBP, notifying the LHJ and SA, and educating staff regarding policies and procedures to ensure an effective IC system and prevent further spread. Findings included . Review of the [DATE], Norovirus illness: Key Facts sheet released by the CDC (Centers for Disease Control), Norovirus is a highly contagious virus. Norovirus infection causes gastroenteritis (inflammation of the stomach and intestines) with symptoms of diarrhea, vomiting, and stomach pain. Norovirus can spread quickly in enclosed places like nursing homes. People with Norovirus illness are contagious from the moment they begin feeling sick and for the first few days after they recover. Norovirus can stay on objects and surfaces and still infect people for days or weeks. Review of the facility [DATE], Norovirus Prevention and Control policy, showed the facility would implement strict infection control measures to prevent the transmission of Norovirus infection. During outbreaks, residents with Norovirus gastroenteritis would be placed on contact precautions for a minimum of 48 hours after the resolution of symptoms. Healthcare personnel who have symptoms consistent with Norovirus infection would adhere to sick leave policies. Ill personnel would be excluded from work for a minimum of 48 hours after the resolution of symptoms. Non-essential visitors would be restricted from affected areas of the facility during outbreaks of Norovirus gastroenteritis. If it is necessary to have continued visitor privileges during outbreaks, visitors with symptoms consistent with Norovirus infection would be screened and excluded. Review of the facility [DATE], Surveillance for Infections policy, showed the infection preventionist (IP) would conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require TBP and other preventative interventions. The purpose of the surveillance is to identify both individual cases and trends, to guide appropriate interventions, and to prevent future infections. Infections that would be included in routine surveillance include pathogens associated with serious outbreaks (e.g., Norovirus). Nursing staff would monitor residents for signs and symptoms that may suggest infection. If a communicable disease outbreak is suspected, this information would be communicated to the charge nurse and IP immediately. In an interview on [DATE] at 10:44 AM, Staff B, Director of Nursing (DNS), stated they had no residents with Norovirus. Staff B stated they had residents who experienced diarrhea, nausea, and vomiting which resolved in 24 hours. During an interview on [DATE] at 11:01 AM, Staff B stated if residents were placed on TBP it should be documented in the progress notes. At 11:13 AM, Staff B stated residents were removed from isolation 24 to 48 hours after the last symptoms, Most of the time 24 hours. Staff B stated if there were no symptoms in 24 hours, the resident was stable and not at risk of spreading the infection. During an interview on [DATE] at 4:10 PM, Staff C, Registered Nurse (RN), stated the residents started having nausea, vomiting, and diarrhea two weeks ago. Staff C stated if a resident had symptoms, they were placed on contact isolation by the floor nurse and the physician was notified. Staff C was asked if the facility closed for visitation and Staff C stated the facility was still allowing visitors since the residents were having symptoms here and there, not like five people in one day. During an interview on [DATE] at 4:25 PM, Staff E, Physician, stated the clinical staff were aware of the symptoms approximately three weeks prior. The resident's symptoms were sporadic, lasting a day or two. Staff E stated they were concerned for Norovirus and sent off studies, which took six days to get a positive result, and by then the residents were better. During an interview on [DATE] at 11:30 AM, Staff D, IP, stated they maintained the antibiotic stewardship log and Staff A, Administrator, maintained the surveillance log. Staff D stated Staff A showed them the surveillance log on [DATE] and Staff A told Staff D they wanted to add a few things to it and would make sure we all have access to it. In an interview on [DATE] at 12:13 PM, Staff A stated they initiated surveillance when Resident 1's positive Norovirus case was reported to them (after [DATE]). <Resident 1> During an interview on [DATE] at 10:47 AM, Staff B stated the first case was Resident 1, a couple of weeks prior. During an interview on [DATE] at 4:10 PM, Staff C said Resident 1 was the first positive for Norovirus. In an interview on [DATE] at 4:25 PM, Staff E stated they saw Resident 1 the night they experienced signs and symptoms and ordered a Norovirus test, which took five days to receive results. Review of the [DATE] bowel records showed Resident 1 had loose stools on [DATE]. A [DATE] 7:06 AM nurse Progress Note (PN) showed Resident 1 had vomited once and felt dizzy. A [DATE] 3:24 PM nurse PN showed Resident 1 vomited multiple times, was given ginger ale, refused to eat a meal or take their medications. A [DATE] 5:44 PM Physician PN showed the provider suspected the resident was experiencing viral gastroenteritis and ordered an anti-nausea medication and noted, may need to check for Norovirus. A [DATE] 5:43 PM nurse PN showed a physician order (PO) was received to collect a sample of Resident 1's stool to check for Norovirus. A [DATE] 6:33 AM nurse PN showed Resident 1 denied symptoms that shift. The sample was collected, and the lab notified for an unscheduled pick up, six days after the order was received. Review of Resident 1's lab result showed the stool sample was collected on [DATE] at 9:45 AM, the results were received on [DATE] at 9:06 PM, and Resident 1 was positive for Norovirus. During an interview on [DATE] at 2:53 PM, Staff B stated they didn't know Resident 1 was positive for Norovirus, it wasn't reported to me. Staff B stated at the time, Staff D was at the facility, and they did not know if the lab was reported to Staff D. Staff B was asked if the DNS should know there is Norovirus in the facility and Staff B stated, Yes I should know. They should have told me. During an interview on [DATE] at 4:10 PM, Staff C stated when residents were placed on TBP, it was documented in the Resident Summary Template (RST). Staff C reviewed Resident 1's [DATE] RST and verified TBP were not documented on the RST, and there was no documentation to show TBP had been implemented or discontinued. <Resident 2> On [DATE] at 11:44 AM, a personal protective equipment (PPE) cart was observed outside Resident 2's room without posted TBP signage. During an interview at that time, Resident 2 stated they were getting wiped out by the flu. Resident 2 stated the night before they had vomited and unable to eat. The nurse gave them a lemon carbonated beverage, which calmed their stomach. Resident 2 recalled on Sunday ([DATE]) their stomach started churning and they called for a staff member. Resident 2 stated they had a bowel movement (BM) and as they were being cleaned up, they had another. Resident 2 stated they had three BMs within one hour and slept most of the time after being cleaned up. Review of Resident 2's [DATE] 11:45 AM RST showed the resident was on 'Contact Isolation' TBP. Review of the [DATE] bowel records showed Resident 2 had loose stools on [DATE], [DATE], and [DATE]. A [DATE] 6:06 AM nurse PN showed Resident 2 had several episodes of vomiting and diarrhea, more than four on that shift. A stool sample was collected to test for Clostridium difficile (c. diff - bacterial infection of the large intestine) and Norovirus. A [DATE] 5:27 PM nurse PN showed Resident 2 vomited twice, the c. diff results were negative, and the Norovirus test was pending. A [DATE] 3:49 AM nurse PN showed Resident 2 had loose stool and a PO was received for anti-nausea and anti-diarrheal medication. A [DATE] lab update showed the Norovirus sample was collected on [DATE] and the results were pending. During an interview on [DATE] at 2:15 PM, Staff B stated Resident 2 had symptoms previously. Staff B stated the Norovirus results were not yet received. When Staff B was informed Resident 2 had documented symptoms on [DATE] and was not observed on posted TBP, Staff B stated Resident 2 did not have symptoms during the day shift on [DATE], or night shift of [DATE], so they may have removed the posted TBP. On [DATE] at 2:06 PM, an PPE cart was observed outside Resident 2's room without posted TBP signage. A [DATE] 7:07 AM lab result showed Resident 2 was positive for Norovirus. <Resident 3> A [DATE] 6:58 PM nurse PN showed Resident 3 vomited once and had a loose stool once. A [DATE] 1:01 AM nurse PN showed the resident had a loose stool once. There was no documentation to support the resident was placed on TBP. Review of the [DATE] showed Resident 3 had liquid stools on [DATE], [DATE] and loose stools on [DATE]. Review of the Resident 3's undated RST showed no indication the resident was placed on TBP. On [DATE], Resident 3 was not observed on posted TBP. In an interview on [DATE] at 4:25 PM, Staff E stated they had just assessed Resident 3, their nausea and vomiting seemed to be improving, however they still had diarrhea. Staff E stated they were getting better. Staff E stated they ordered a Norovirus test, which was collected and sent to the lab that day ([DATE]). On [DATE] at 2:03 PM, Staff F, Occupational Therapy Assistant, was observed providing therapy with Resident 3, seated in the common area. Staff F was observed to touch Resident 3's head, hands, and arms to provide physical cues to the resident. Staff F was wearing a surgical mask, eye protection, and no gloves or gown. An observation on [DATE] at 2:04 PM showed a piece of paper taped to Resident 3's door that read, Please keep the door closed. The door was observed open, and the resident was not in the room. A PPE cart was observed outside the room without posted TBP signage. During an interview on [DATE] at 2:21 PM, Staff G, Certified Nursing Assistant (CNA), stated Resident 3 preferred their door closed. Review of a [DATE] 7:07 AM lab result showed Resident 3 was positive Norovirus. <Resident 4> A [DATE] 7:25 AM nurse PN showed Resident 4 vomited five times and had diarrhea. Resident 4's oxygen saturation level was low (74 %), staff administered oxygen at 4-Liters per minute (LPM) which elevated the oxygen saturation level to 95 %. Resident 4 tested negative for COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death). A [DATE] 7:33 AM nurse PN showed Resident 4 had diarrhea and weakness and a [DATE] 6:15 PM nurse PN showed they had two episodes of liquid diarrhea, the physician was notified, and stool sample collected. Review of a physician PN dated [DATE] at 6:33 PM, showed Resident 4 had recent onset of diarrhea, likely viral, and a PO was placed for stool sample to check for Norovirus and c. diff. A [DATE] 5:00 AM nurse PN showed the resident had loose stools four times that shift. Review of a physician PN dated [DATE] at 4:30 PM, showed Resident 4's c. diff test result was positive, which explained the diarrhea, and a PO was written for anti-infective treatment. A [DATE] 3:41 AM nurse PN showed Resident 4 vomited once, was found to be diaphoretic (sweating heavily), cyanotic (bluish-purple hue to skin, indicative of critically low oxygen saturation in the blood) and was struggling to breathe. The physician and resident representative were notified and at 1:20 AM, Resident 4 died . During an interview on [DATE] at 1:08 PM, Staff B stated the family did not want to send Resident 4 to the hospital and wanted the resident to remain in the facility on comfort care. Staff B stated the facility placed Resident 4 on TBP and had a PPE cart outside the resident's room. Staff B was unable to provide documentation to support the facility implemented TBP. During an interview on [DATE] at 4:25 PM, Staff E stated Resident 4 had multiple comorbidities (two or more disease/diagnoses present) and had been on Hospice in the past. Staff E stated the c. diff had pushed Resident 4 over the edge. On [DATE] at 3:55 PM the facility informed the SA that Resident 4's lab result returned positive for Norovirus. <Resident 5> Record review showed Resident 5 admitted to the facility [DATE]. Review of Resident 5's [DATE] bowel records showed liquid/loose stools on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A nurse PN dated [DATE] at 10:53 AM, showed Resident 5 reported nausea and vomiting associated with diarrhea early that morning. A physician PN dated [DATE] at 8:05 PM, showed the resident had a rough last two days due to having nausea with some vomiting and loose stools. A nurse PN dated [DATE] at 5:22 PM, showed the nausea and vomiting was attributed to medication which the physician discontinued. A nurse PN dated [DATE] at 8:03 PM, showed Resident 5 had loose stools for the past two days, was administered anti-diarrhea medications, and a stool sample was collected to check for Norovirus, and the supervisor was alerted the sample was in the refrigerator ready for lab pick up. Review of Resident 5's [DATE] RST and PN showed no supporting documentation that indicated Resident 5 was placed on TBP with the onset of their symptoms. During an interview on [DATE] at 3:21 PM, Staff B was unable to locate the results of Resident 5's Norovirus lab result. Additional information regarding the status of the test was requested but no further information was provided. <Resident 6> During an interview on [DATE] at 10:53 AM, Staff B stated Resident 6 was currently ill. A nurse PN dated [DATE] at 6:43 AM, showed Resident 6 vomited, so the physician was notified, and they offered the resident ice chips. A [DATE] 1:38 AM nurse PN showed Resident 6's oxygen saturation was too low and was given supplemental oxygen at 2-Lpm. Review of Resident 6's PN for [DATE] and [DATE] showed no documentation to support they were placed on TBP with the onset of symptoms. Review of Resident 6's [DATE] 11:49 AM RST showed the resident was on 'contact isolation'. During an observation of Resident 6's room, on [DATE] at 11:17 AM, with Staff B present, showed a PPE cart placed outside the room without posted TBP signage. Staff B stated, They're on precautions. After Staff B was alerted that no TBP sign was posted, Staff B stated, They're supposed to put up a sign. Staff B retrieved an Enteric Contact TBP sign from the drawer of the PPE cart and went to obtain tape and post the sign. During an interview on [DATE] at 4:10 PM, Staff C stated Resident 6 was still on TBP. <Resident 7> During an interview on [DATE] at 10:53 AM, Staff B stated Resident 7 was currently ill. Staff B stated Resident 7 was sent to the hospital for abdominal pain, labs were performed, and the resident was sent back to the facility. A nurse PN dated [DATE] at 6:51 AM, showed Resident 7 reported nausea with abdominal pain and given an anti-nausea medication. A [DATE] 1:58 PM nurse PN showed Resident 7 continued to have abdominal pain and was sent to the hospital. A [DATE] 7:44 PM nurse PN showed Resident 7 was back in the facility and continued to complain of abdominal pain and no appetite for dinner. Resident 7 was offered warm tea and crackers. A nurse PN dated [DATE] at 9:27 PM, showed Resident 7 had three episodes of loose stool. The physician was notified and received a PO for an anti-diarrheal medication, as needed. Review of Resident 7's [DATE] bowel records showed they had extra-large liquid/loose stool on [DATE], [DATE], and [DATE]. Review of the Resident 7's PN for [DATE], [DATE], and [DATE] showed no documentation the resident was placed on TBP with the onset of their symptoms. Review of Resident 7's [DATE] 11:55 AM RST showed the resident was on 'contact isolation'. During an interview on [DATE] at 11:13 PM, Staff B confirmed Resident 7 had signs and symptoms on [DATE] and stated TBP were implemented. An observation of Resident 7's room on [DATE] at 11:17 AM, with Staff B present, showed a PPE cart placed outside the room without posted TBP signage. Staff B retrieved an Enteric Contact Precautions sign from the drawer of the PPE cart and posted it above the PPE cart. During an interview on [DATE] at 4:10 PM, Staff C stated Resident 7 was still on TBP. <Resident 8> Record review showed Resident 8 admitted to the facility [DATE]. Review of Resident 8's [DATE] bowel records showed they had extra-large liquid stools on [DATE]. A nurse PN dated [DATE] at 5:11 PM, showed Resident 8's representative was updated regarding the resident's status. A nurse PN dated [DATE] at 6:29 AM, showed a PO for an anti-diarrheal was received and the resident had a medical appointment out in the community with a scheduled pick-up time of 7:00 AM. Review of Resident 8's PNs and undated RST showed no indication they were placed on TBP with the onset of their symptoms. An observation on [DATE] at 11:41 AM, showed a PPE cart outside Resident 8's room without posted TBP signage. Resident 8 was observed ambulating with a gait belt around their waist and using a walker, while a therapist was pushing a wheelchair behind the resident. The therapist was wearing a surgical mask, no gloves, and no gown. An observation on [DATE] at 2:06 PM outside Resident 8's room showed a PPE cart without posted TBP signage. <Resident 9> Record review showed Resident 9 admitted to the facility on [DATE]. A nurse PN dated [DATE] at 4:57 AM, showed Resident 9 had loose stools twice. Review of Resident 9's [DATE] bowel records showed they had large liquid/loose stools on [DATE] and [DATE]. Review of Resident 9's [DATE] RST and PN for [DATE] and [DATE] showed no indication they were placed on TBP. Observations on [DATE] and [DATE] of Resident 9's room showed no PPE cart outside the room or posted Enteric Contact TBP signage. An observation on [DATE] at 10:31 AM, a visitor was seen in Resident 9's room without PPE on. The visitor left Resident 9's room without performing hand hygiene and went to join another visitor seated on a couch in the common area. An observation on [DATE] at 11:22 AM, Staff H, CNA, propel Resident 9 down the hallway and back to their room. In an interview at that time Staff H stated that they had just taken Resident 9 to get weighed. <Resident 10> A nurse PN dated [DATE] at 7:36 AM, showed Resident 10 had vomited once, and had loose stool twice the day before ([DATE]). Review of Resident 10's [DATE] bowel records showed they had loose/liquid stools on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of Resident 10's [DATE] RST and PN showed no indication they were placed on TBP. <Resident 11> A nurse PN dated [DATE] at 4:57 AM, showed Resident 11 had loose stools twice. A [DATE] 7:40 PM nurse PN showed Resident 10 had one episode of vomiting and diarrhea. A [DATE] 7:01 AM nurse PN showed Resident 10 had two small soft stools and no vomiting. Review of Resident 11's [DATE] bowel records showed they had loose stool on loose stools on [DATE]. Review of Resident 11's [DATE] 11:44 AM updated RST showed the Resident 11 was on 'contact isolation'. Observations on [DATE] and [DATE] of Resident 11's room showed no PPE cart placed outside their room or posted Enteric Contact Precautions signage. <Resident 12> Record review showed Resident 12 admitted to the facility on [DATE]. Review of Resident 12's [DATE] bowel records showed they had large liquid/loose stools on [DATE], [DATE], and [DATE]. A nurse PN dated [DATE] at 2:03 PM, showed Resident 12 was seen in the common area sitting up in a wheelchair. The resident had loose stools in the past 12 hours. Review of Resident 12's PM and undated RST showed no indication the Resident was placed on TBP. An observation on [DATE] at 10:28 AM of Resident 12's room showed an Enteric Contact TBP sign posted. The resident was not observed in the room. In an interview at that time, Staff I, Registered Nurse (RN), stated Resident 12 was in the dining room. Resident 12 was observed in the common area, fully dressed, with a gait belt on, and seated in a wheelchair. During an interview on [DATE] at 10:47 AM, Staff B stated Resident 12 was not having diarrhea anymore. Staff B stated Resident 12 was difficult to keep in their room, they wandered around, wouldn't stay in one place, and staff try to keep Resident 12 in the common area on that end of the unit. On [DATE] at 10:53 AM, Staff B stated Resident 12 was currently ill. During an interview on [DATE] at 1:25 PM, Staff B stated Resident 12 was on Contact TBP. Staff B was asked why Resident 12 was still on TBP if they had not had symptoms since [DATE] and Staff B stated they should not be, and the staff should have taken the resident off TBP. An observation on [DATE] at 2:10 PM showed Resident 12 had no PPE cart outside their room or posted TBP signage. Review of the facility every four-hour assessment resident log, initiated by the facility on [DATE], showed Resident 12 experienced diarrhea on [DATE] at 3:13 AM and 11:13 PM. <Resident 13> Record review showed Resident 13 admitted to the facility [DATE]. On [DATE] at 1:13 PM, Resident 13's room was observed with a PPE cart and posted Enteric Contact TBP signage posted. Staff J, agency CNA, wearing a surgical mask, entered the resident's room, picked up a meal tray, without donning gloves and/or a gown. Staff J left the room and placed the meal tray in a cart without performing hand hygiene. Staff J retrieved a seated scale from the room without donning a gown or gloves. Staff J did not disinfect the scale upon removing it from Resident 13's room. In an interview at that time, Staff J stated they weighed Resident 13 and confirmed they had not cleaned the seated scale after use. When asked why they did not use gloves or a gown, Staff J stated Resident 13 was not on TBP and did not have any symptoms. When shown the posted Enteric Contact TBP sign clearly posted at the entrance of the doorway, Staff J stated, Oh. Sorry, I didn't see it. In an interview on [DATE] at 1:24 PM, Staff K, RN, stated Resident 13 had experienced diarrhea, so they were placed on TBP. When asked if staff were expected to follow the posted TBP signage directions upon entering the room, Staff K stated, Yes. <Resident 14> A nurse PN dated [DATE] at 8:10 PM, showed Resident 14 experienced chills, nausea, and vomiting. A nurse PN dated [DATE] at 3:37 PM, showed Resident 14 had upper airway congestion, abnormal lung sounds, elevated breathing rate, and low oxygen saturation which required emergent oxygen. Resident 14 was urgently sent to the hospital and admitted . Review of Resident 14's [DATE] bowel records showed they had loose stools on [DATE] and [DATE]. Review of Resident 14's PN and undated RST showed no documentation they were on TBP. An observation on [DATE] at 10:29 AM showed Resident 14's door closed, a PPE cart outside the room and an Enteric Contact TBP sign taped to the top of the PPE cart. During an interview on [DATE] at 11:13 AM, Staff B stated Resident 14 vomited on [DATE] and was high risk for aspiration (inhalation of food/fluids into the lungs). Resident 14 was still at the hospital, diagnosed with aspiration pneumonia, and a bowel impaction (intestinal blockage). An observation on [DATE] at 2:12 PM, showed Staff Q, Occupational Therapist, put on PPE outside the door of Resident 14's room, a surgical mask, gown, and gloves. Taped to the top of the PPE isolation cart was an Enteric Contact Precautions sign. An Aerosol Generating Procedure (AGP) sign was hanging on Resident 14's door. The sign directed staff who entered to wear a fit-tested N-95 Respirator, gown, gloves, and eye protection during aerosol generating procedures and for 30 minutes after the treatment had been discontinued. In an interview on [DATE] at 2:13 PM, Staff Q stated they had been notified by their supervisor that the facility had an increase of resident illness, but all the residents tested negative for Norovirus. Staff Q stated Resident 14 was on Aerosol Precautions but was unsure why. Staff Q stated they were a contracted therapist and were not familiar with Resident 14. Staff Q stated Resident 14 just returned to the facility at 1:00 PM that day and it was their first time meeting the resident. Staff Q stated the PPE required to enter Resident 14's room was a fit-tested N-95 respirator, gown, gloves, and eye protection. Staff Q stated the cart did not contain N-95's and they would need to check with the nurse to find out why Resident 14 was on Aerosol Precautions and why the cart did not contain N-95's. At 2:17 PM, Staff Q stated they were sick two and a half weeks ago ([DATE]) with nausea, vomiting, and diarrhea. It was their third day working at the facility. Staff Q stated their symptoms started after they got home that evening, so they called their supervisor and stayed home the rest of the week. Staff Q stated they cared for other residents who also had nausea, vomiting, and/or diarrhea that day, and those residents were not on Enteric Contact TBP. At 2:16 PM, without putting on an N-95 or eye protection, Staff Q entered Resident 14's room. During an interview on [DATE] at 2:55 PM, Staff B stated Resident 14 tested positive on a COVID-19 rapid test at the hospital on [DATE] and was placed on Aerosol Precautions upon their return to the facility. At 3:00 PM, Staff B stated the AGP sign was the sign they used for Aerosol Precautions. Staff B was asked what PPE the staff were expected to wear when Resident 14 was not doing an aerosol generating procedure and Staff B stated someone must have posted the wrong sign. <Resident 15> A nurse PN dated [DATE] showed Resident 15 had poor appetite, nausea, and large/loose bowel movement. Review of Resident 15's PN and RST showed no indication the Resident was placed on TBP. <Resident 16> Record review showed a nurse PN dated [DATE] showed Resident 16 was incontinent with loose stool. On [DATE], Resident 16 had vomited and was given anti-nausea medication. On [DATE] the resident felt nauseated but did not vomit. Review of Resident 16's [DATE] bowel records showed they had loose stools on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of Resident 16's [DATE] RST and PN showed no indication they were placed on TBP. <Resident 17> Review of Resident 17's nurse PN dated [DATE] at 7:57 PM, showed that around 6:00 PM the resident was in the dining area when they suddenly had a large vomit. Resident 17 was taken back to their room. A COVID-19 test was performed and was negative. The resident was offered warm tea. A [DATE] physician PN showed the resident had no further vomiting and was able to eat. The physician attributed the vomiting to a pre-existing diagnosis and increased medications accordingly. The resident was discharged on [DATE]. Review of Resident 17's [DATE] bowel records showed they had loose stools on [DATE], [DATE], and [DATE]. <Resident 18> Review of Resident 18's nurse PN dated [DATE] at 5:51 AM, showed they had one episode of vomiting and one loose stool. On [DATE] at 9:29 PM the physician visited the resident and ordered anti-nausea and anti-diarrhea medications. Review of Resident 18's [DATE] bowel records showed they had extra-large liquid stools on [DATE]. Review of Resident 18's RST and PN showed no documentation to indicate the resident was placed on TBP. <Resident 19> Record review showed Resident 19 admitted to the facility on [DATE]. Review of Resident 19's [DATE] bowel records showed they had loose/liquid stools on [DATE], [DATE], [DATE], and [DATE]. During an interview on [DATE] at 10:34 AM Resident 19 stated they had experienced quite a bit of diarrhea, which started the night before, and continued that morning. Resident 19 stated the staff were aware and adjusted their medications. Resident 19 denied being instructed to stay in their room. Observation at that time showed Resident 19 was not on Enteric Contact TBP. During an interview on [DATE] at 10:53 AM, Staff B stated they were not aware Resident 19 was ill. Staff B stated staff usually send them an email and let them know. Review of Resident 19's PN showed no documented assessment or monitoring regarding loose/liquid stools, or that they were placed on TBP. Review of Resident 19's undated RST showed no indication they were placed on TBP. During an interview on [DATE] at 11:32 AM, Staff B stated Resident 19 had diarrhea due to a medication they were on. Resident 19 had diarrhea on Sunday ([DATE]) so the nurse held the medication. <Residents 21, 22, 23, 24, 25, 26, 27, & 28> Similar findings were noted for Residents 21, 22, 23, 24, 25, 26, 27, & 28 who experienced nausea/vomiting/diarrhea/abdominal pain, but review of their PN on [DATE] showed no assessment, documented monitoring of signs or symptoms, or implementation of TBP. Review of Residents 21, 22, 23, 24, 25, 26, 27, & 28 [DATE] bowel records showed: Resident 21 had loose stools on [DATE], [DATE], [DATE]; Resident 22 had liquid stools on [DATE] and [DATE]; Resident 23 had extra-large liquid stools on [DATE]; Resident 24 had loose stools on [DATE], ,d+[DATE] [TRUNCATED]

Based on observation, interview and record review, the facility failed to serve tea at a temperature that prevented [CONDITION(S)], for one (Resident 1) of three Residents, reviewed for accident prevention. Failure to serve food at a temperature that prevented second degree [CONDITION(S)] caused harm to Resident 1, that required medical intervention and placed Resident #1 at risk for a diminished quality of life. Findings included: The 01/2016 FOOD & NUTRITION SERVICES policy and procedure for serving hot liquids, read in part, . For dining services in remote dining areas, the temperature of hot beverages and soups will be recorded by the dining room server at the time of meal service. Temperature of hot liquids will not exceed 155 Degrees Fahrenheit (DF) at time of delivery to the resident . This policy and procedure instructed staff to take temperatures of hot beverages and hot foods prior to service to residents. This would ensure hot beverages and food were served to residents at temperatures that prevented [CONDITION(S)]. (135-155 DF). According to the 06/24/2021 admission Minimum Data Set (an assessment tool) Resident 1, ([AGE] years of age), admitted to the facility 02/22/2019 with disabling conditions including an altered mental status and confusion. Staff assessed the resident to be severely impaired for decision-making, and required supervision, oversight, cuing, and set up for the provision of meals. According to the 09/18/2021 Incident Investigation Report (IIR), Staff E, Certified Nurse Aide (CNA), was in the hallway outside Resident 1' s room when they heard a cup drop on the floor. When Staff E entered Resident 1's room, they found Resident 1 spilled a cup of tea on themselves. According to the 09/18/2021 IIR, Resident 1 complained of burning pain at the time of incident. The resident sustained redness and blisters to the right buttock and bilateral posterior thighs. In an interview on 10/12/2021 at 10:00 AM, Staff E a Certified Nurse's Aide (CNA) said, Resident 1 had requested a hot cup of tea. Staff E then made a cup of tea for Resident 1 with hot water from the hot water container which was just delivered from the facility kitchen. When Staff E was asked what the temperature of the tea was before serving the tea to Resident 1, they said I don't know Observation on 09/21/2021 at 2:45 PM, showed, 2nd degree [CONDITION(S)] to Resident 1's right buttock and bilateral posterior thighs measuring 58 cm (centimeters) x 19 cm covered in an Alocane dressing (medicated dressing used to stop burn pain on contact). Resident 1 grimaced in pain during the observation of the affected area as Staff I, Licensed Practical Nurse (LPN), removed and reapplied the dressing to the affected area. In an interview on 09/21/2021 at 3:20 PM, Resident 1's representative stated the facility always served Resident 1 hot tea. In an interview on 09/21/2021 at 4:00 PM, Staff G, Dietary Aide (DA) stated, the kitchen staff always took the temperature of the food but did not take temperatures of the hot water. Staff G stated, the hot water was obtained from the hot water dispenser and was delivered to the dining room for resident consumption without knowing the temperature of the water. 09/21/2021 at 4:00 PM, Staff F, Registered Dietician (RD), acknowledged the facility did not follow the guideline outlined in the facility's policy and procedure for serving hot liquids. On 09/23/2021 at 11:20 AM, in an interview Staff A, Administrator, acknowledged the facility did not follow their policy. Staff did not take the water temperature before serving to Resident 1. Observation was made of the hot water dispenser on 10/04/2021 at 10:00 AM. Staff H, Dietary Manager (DM), recorded the water temperature at 171 DF. This was 26 DF higher than the approved and safe temperature for serving hot beverages including tea, according to the facility's policy for serving hot liquids. Staff H, acknowledged they did not follow the facility's policy to ensure Resident 1's cup of tea was within the safe temperature range for resident consumption (155 degrees F or less). On 10/11/2021, at 1:50 PM, Staff B, Director of Nursing Services (DNS) acknowledged and said Staff D should not have served the cup of tea to Resident 1 without knowing it's temperature. Staff B stated that, the kitchen staff should have ensured the water temperature was safe for resident consumption prior to delivering the water to the dining room. Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to ensure interventions were in place to prevent an avoidable accident for one (#1) of four residents reviewed for falls with injuries. This failure resulted in a fall with multiple fractures when the resident opened an unsecured door to the stairwell and fell down a flight of stairs from the second floor (location of the resident) to the first floor of the facility. Findings included . RESIDENT #1 Review of 11/02/2020 Quarterly Minimum Data Set (MDS - an assessment tool) showed the resident was admitted on [DATE], assessed to have impaired cognition with confusion, required assistance from staff for Activities Daily Living (ADLs) including cueing, redirecting, transfers and toileting. This assessment also showed the resident used a wheelchair for mobility, a wanderguard to alert staff if the resident wandered to an unsafe environment, and was at risk for falls. Review of Resident #1's care plan dated 09/19/2018 showed, the resident had wandering and exit seeking behaviors and required staff close supervision and wanderguard to alert staff if the resident was wandering in unsafe environment. Review of an Investigation Report (IR) dated 12/22/2020 showed, the resident fell down a flight of stairs (10 steps) and was found lying on the bottom floor of the stairwell with the wheel chair next to her. According to the IR, the resident did not have a wanderguard on her, or attached to the resident's wheelchair. Review of the nurse's progress notes dated 08/29/2019 written by Staff C, the Resident care Manager, showed Resident #1's doctor issued a new order to discontinue the wanderguard from the resident's left Lower Extremity (LLE), and attach the wanderguard to the wheelchair due to increased [MEDICAL CONDITION] to the resident's lower extremity. Record review showed the wanderguard was discontinued from the left lower leg. Further record review did not show documentation, the wanderguard was attached to the wheel chair, and staff monitored for placement and function to ensure the resident's safety. In the interview on 01/25/2020 at 12:00 PM, when Staff C was asked, she was unable to provide documentation to show staff monitored the resident's wanderguard for placement and function from 08/29/19 (day when the doctor discounted it from the LLE) and 12/22/2020 ( the day the resident fell with injuries), and later acknowledged the documentation was missing. The IR dated 12/22/2020 showed and concluded Resident #1 might have removed the wanderguard from the wheelchair prior to the fall, resulting in the (door) alarm not going off to alert staff, the resident was attempting to exit the unit through the door leading to the stairwell. An observation on 01/07/2021 at 7:30 PM showed the door to the stairwell from the second floor (Resident Unit) did not have a locking mechanism to secure it, and opened without difficulty. This observation also showed a key pad besides the door which staff used to enter a code to stop the alarm from sounding off when activated by a resident wearing a wander guard. Further observation on 01/07/2021 at 7:35 PM showed, Resident #1 was last seen in the TV room located approximately 45 feet away from the door to the stairwell, leading to the first floor of the facility. In an interview on 01/08/2020 at 05:30 AM, Staff F, a Certified Nursing Assistant (CNA) who provided care regularly for Resident #1, and who found Resident #1 laying on the bottom of the stairwell after the resident's fall, stated that at approximately 9:30 PM on 12/22/2020, she heard a person crying out for help in the stairwell. When Staff F approached the person crying, she noted Resident #1 lying on the bottom floor of the stairwell next to her wheelchair, with blood oozing from the back of the head and the face. Staff F then called for assistance. In this interview, Staff F confirmed the door to the stairwell did not have a lock to secure it, and the resident did not have a wanderguard on her. Staff F also stated that the resident might have removed the wanderguard, because the wanderguard was attached to a part of the wheelchair where the resident could easily reach and remove it. In addition, Staff F stated Resident #1 was observed at times to get up from her wheelchair and walk short distances with an unsteady gait. Staff F stated that sometimes Resident #1 got behind her wheelchair and pushed the wheel chair from behind, using the wheelchair like a walker (a walking device). On 01/12/2021 at 11:00 AM, in the interview, Staff I, a nurse's aide assigned to the resident at the time of the resident's fall, stated she last saw the resident at 9:05 PM (30 minutes before the resident fell ). Staff I, further stated no one saw the resident leaving the common area (location of resident before the fall) as all the staff were providing care in other residents' rooms when Resident #1 fell . In an interview on 01/14/2020 at 11:00 AM, Staff G, a Unit Assistant, said that she received a physician's orders [REDACTED].#1's lower left leg and attach it to the wheelchair due to increased swelling to the resident's left lower leg. When asked where the wanderguard was attached to the wheel chair, and why that site was chosen, Staff G stated, I just ensured it was attached to the wheelchair, and that it was functional. When Staff G was asked if she consulted with licensed staff before attaching the wanderguard to the wheelchair, Staff G said she did not consult with anyone. When Staff G was asked if the resident was capable of removing the wanderguard, she said Yes and that Resident #1 was very energetic and creative, she could have removed the wander guard if she wanted to. On 01/15/2020 at 10:00 AM, Staff D, a Registered Nurse (RN) assigned to Resident #1 at the time of the fall, was asked how Resident #1's wanderguard detached from the resident's wheel chair. Staff D stated the resident might have removed it herself, as the resident was capable of removing the wanderguard if she could reach it, consistent with Staff F's statements. When further asked how she ensured the resident's safety when staff left the common area to provide care to another resident, Staff D did not answer and later said, the resident should have been within the staff members' line of sight to ensure safety. On 01/08/2021 at 12:00 PM, when asked what precautions were put in place to prevent residents with wandering behaviors from opening an unsecured door and falling down a flight of stairs, Staff C stated, The facility hired a contractor to secure the door to prevent further resident falls. On 01/15/2021 at 10:00 AM, in interview, Staff H, the facility's Maintenance Director acknowledged the door to the stairwell did not have a locking mechanism and that, the facility did not have a system in place to check the function of the residents' wanderguards. Staff H further stated, the facility was currently working on implementing a system of checking and documenting the function of the wanderguards at least once a week to ensure the safety of the residents. Despite facility awareness of Resident #1's ability to get up from her wheelchair and walk short distances and remove the wanderguard, and the presence of an unsecured door, the staff did not put interventions in place to mitigate these safety concerns. Because of these failures, Resident #1 fell down a flight of stairs, laid on the floor of the bottom of the stairwell for an undetermined amount of time until she was discovered, and sustained multiple fractures to bilateral wrists, vertebrae and the neck. The above findings were shared with Staff A, the facility's administrator on 01/15/2020 at 3:30 PM. Reference: WAC 388 97-1060(3)(g).

Based on interview and record review, the facility failed to ensure an environment that was free from accidents for one (Resident #1) of three sample residents reviewed for accidents. The facility failed to analyze root cause of the fall incidents and implement appropriate interventions to prevent further falls for Resident #1. This failure caused harm to Resident #1 when she experienced a fall and fractured the left hip, requiring hospitalization and surgical interventions to repair the [MEDICAL CONDITION]. Findings include . RESIDENT # 1 According to the admission Minimum Data Set (MDS) (an assessment tool) dated 10/19/19, Resident #1 admitted to the facility on [DATE] with medically disabling conditions including altered mental status, acute ischemic stroke with left sided weakness, dementia and history of falls. This MDS identified the resident had impaired cognition and required physical assistance of staff for all Activities of Daily Living (ADLs), including mobility, transfers and toileting. Review of Resident #1's Incident Investigation Report (IIR) dated 10/19/19 showed, Resident #1 had fallen and was found on the floor in the hallway close to her room at 8: 00 PM. According to IIR when asked, the resident said she did not know what happened. In interview on 11/21/19 at 4:00 PM, Staff F said he assisted Resident #1 to bed at around 07:45 PM and left the resident's room to assist another resident. Fifteen minutes later, Staff [NAME] found the resident had fallen and sitting on the floor of the hallway close to her room. Review of Resident #1's medical record showed that the resident's preference for bed time was 9:30 PM. On 12/05/19 at 12:30 PM when Staff B, the Director of Nursing Services (DNS) was asked why the resident was prepared and assisted for bed time prior to the resident's preferred bed time, and why the resident got out of bed 15 minutes later, Staff B did not know why the resident got out of bed and fell . On 12/05/19 at 12:00 PM, in interview Staff B, the Director of Nursing Services said the resident's preferred bed time was 9:00 PM, and not 7:45 PM, and acknowledged Staff [NAME] should not have put the resident in bed prior to the resident's preferred bed time. Review of the IIR dated 10/19/19 did not show staff identified the root cause of Resident #1's fall in the hall way, and did not implement appropriate preventative interventions to prevent further falls. In interview, on 11/19/19 at 2:00 PM, Staff B and Staff D, a Registered Nurse acknowledged staff did not investigate and identify the root cause of the resident's fall in the hallway, and did not implement appropriate preventative interventions to prevent further accidents. When Staff B asked who was responsible for ensuring accident prevention interventions were implemented, Staff B said, it was the responsibility of the charge nurse Staff I, but he did not implemement preventative measures. The failure to identify the root cause of the resident's fall and implement appropriate fall preventative precautions, placed the resident at risk for further falls and potential harm. Review of the IIR dated 10/21/19 showed Resident #1 experienced another fall at 5:30 AM (third fall within one week of admission) and sustained a left [MEDICAL CONDITION] requiring hospitalization with surgical intervention to repair the fractured left hip. Review of the IIR dated 10/21/19, showed that when asked, Resident #1 said she attempted to get up unassisted to use the bathroom and fell . Review of Resident #1's care plan dated 10/12/19, revealed the resident was identified as a fall risk, and instructed staff to offer Resident #1 toileting every two hours. Review of Resident #1's medical record (Care Tracker) did not show staff had been offering Resident #1 toileting as care planned, in order to prevent the resident from falling. In an interview on 11/27/18, at 2:30 PM, when Staff B, was asked to show how Resident #1 was offered toileting every two hours as care planned, Staff B could not provide requested information. Review of the resident's care plan did not show how staff were to anticipate the resident's care needs such as toileting. In interview on 12/05/19 at 12:30 PM, Staff B was unable to state how staff anticipated Resident #1's care needs e.g. toileting. On 11/19/19 at 2:00 PM, in interview, Staff F, a certified Nurse's Aide (CNA) who was assigned to care for the resident said she checked on Resident #1 at 5:15 AM (15 minutes before the resident fell ). When Staff F was asked if she offered the resident toileting assistance, Staff F said No. When Staff F was further asked what specific resident care needs she was checking for, when she went to the resident's room at 5:15 AM prior to the resident's fall, Staff F said she was checking for the location of the resident. Review of Resident #1's Care Tracker showed, the resident was last toileted at 2:45 AM (more than two hours before the fall at 5:30 AM) inconsistent with the resident's care directives which instructed staff to toilet the resident every two hours. The failure to not provide toileting needs of the resident as care planned, caused the resident to get up unassisted in an attempt to use the bathroom, causing the resident to fall and sustain a [MEDICAL CONDITION]. After the fall with injury on 10/21/19, Resident #1 was transferred to the hospital where she was admitted and underwent a surgical procedure to repair the fractured left hip. On 10/27/19, the resident was readmitted back to the facility. Review of nurse's progress notes on 10/25/19 and 10/26/19 ( two days of resident's re-admision to the facility after an acute hospitalization ), showed Residet #1 was confused and did not use the call light even with constance reminders and was noted to unsafely self transfer to use the bathroom during night shift. On 11/19/19 at 1:45 PM, in interview, Staff J said Resident #1 was forgetful, confused with poor safety judgement, and frequently attempted to self-transfer without assistance, and required close staff supervision for safety. Despite staff's awareness of the resident's confusion and poor safety judgement and non compliance of call light use, review of the resident's re-admission care plan did not show staff revised the resident's care plan to reflect the resident's fall interventions to prevent further falls. Review of nurse's progress notes dated 10/29/19, showed Resident #1 experienced a fall in her room (two days of readmission to the facility with a recently repaired fractured left hip). Review of the IIR dated 11/29/19 showed the resident attempted to self-transfer from the wheelchair to the bed, lost balance and fell at 5:30 AM. Further review of the IIR showed Staff H, a CNA was getting the resident ready for bed, then she stepped out of the resident's room and left the resident unattended, to get an incontinent brief inconsistent with the resident's care plan dated 10/21/19, which instructed staff to keep the resident within line of sight while up in the wheel chair. When Staff H returned, she found the resident had fallen out of the wheel chair and was sitting on the floor. When the resident was asked, the resident stated I wanted to go to bed. Despite multiple falls (four falls) within 17 days of admission to the facility, and staff awareness of the resident's impaired cognition and multiple attempts to self-transfer without assistance due to poor safety awareness, Staff H left the resident up in the wheel chair unattended, causing the resident to self transfer and fall. On 11/20/19 at 3:00 PM, in interview, Staff H was asked how she ensured the resident's safety while up in the wheel chair, when she stepped out of the resident's room to get an incontinent brief. Staff H did not answer, and later stated that in the future she would make sure all supplies are gathered before initiating an incontinent care task. On 11/19/19 at 2:00 PM, Staff B acknowledged and stated that the facility had since then in-served staff to investigate each fall incident, identify hazards and update the care plan with identified safety interventions, to reflect current resident care needs in-order to prevent further accidents. In an exit meeting on 12/05/19 at 12:00 PM., Staff C, the facility's interim Director of Nursing Services (IDNS) and Staff A, the facility's Administrator acknowledged, licensed staff should have revised the care plan to reflect identified hazards and preventative interventions to instruct staff on how to prevent accidents for Resident#1. The facility's failure to investigate and analyze root causes of each fall incident, identify accident hazards and implement interventions to prevent further falls, placed Resident #1 and all residents at risk for recurrent falls resulting in serious harm. Reference: WAC 388 97-1060(3) (g)

Based on record review, observation and interview the facility staff did not ensure a device was safe to meet 1 out of 3 resident's individual needs. Staff failed to identify the risk of a potentially avoidable accident hazard in a timely manner for Resident #1, the resident slid out of the wheelchair and fractured her leg; this resulted in harm to Resident #1. Resident #1 was admitted to the facility in (MONTH) of (YEAR). According to facility records, she had multiple complex [DIAGNOSES REDACTED]. Resident #1 had [MEDICAL CONDITION], a history of a total knee arthroplasty and falls. According to progress notes dated 11/13/2017 at 1:05 p.m., A restorative aide staff reported the resident had been seen occasionally slouching in her bedside chair in her room, staff had to reposition her. On 11/13/2017 staff documented at 3:36 p.m. A Licensed Nurse (LN) was doing rounds and found the resident sitting on 50% of the chair's surface from the front of the chair, and at risk of sliding off the bedside chair. According to the physician orders [REDACTED]. Physical therapy documented that they provided a wider and deeper bedside chair and added a cushionon the the chair for better standing up from the chair and was discharged from therapy on 11/22/2017. There was no evidence in the record to indicate that staff had monitored the effectiveness of this modification. Facility staff documented on 1/25/18 that Resident #1 was fearful with bed mobility and transfer, and required reassurance and two people assistance. Resident #1 supine sit required maximum assist of two staff to maintain sitting on edge of bed (EOB), for placement of sit to stand device it required 2 person assist and cues to stand up and hold on to the lift. According to staff investigative report and progress notes on 2/1/2018, Resident #1 was noted by staff to be slouching off the wheelchair. Physical therapy ( PT ) decided not to pursue getting a tilt and space wheelchair yet as she was still having days when she was ambulating and thought the tilt and space may restrain her from doing this. However, staff had documented on 11/30 and 12/7 and 1/23 that resident was fearful during transfers and needs lot of assurance and that the resident required 1-2 persons to assist with transfers. Facility staff also documented 2/2/18 resident needing max assistance 2 person for supine to sitting up at EOB, sit to stand device use to get resident up. The position of the resident was communicated for a second time about the observed hazard; however, the facility staff failed to evaluate and develop a resident specific intervention based on the resident's need for safety and to avoid accidents and injuries. Staff did not consider the risk associated with the use of the wheelchair when it was documented that Resident #1 had difficulty in maintaining upper body weight independently and slouching in the chair. According to staff investigative report, progress notes and interview, Staff A placed Resident #1 in the hallway in the wheelchair on 2/6/2018 around 8:00 a.m. Staff A was working in the resident's room when he heard a noise, Staff A came out of the room and saw Resident #1 sliding down from her wheelchair and landed on the floor. Resident #1 was assisted back to bed. While in bed there was an increased pain on right hip. According to the X-ray report dated 2/6/18, Resident #1 had a fracture and displaced arthroplasty in right leg. Resident #1 was placed in a wheelchair after staff had reason to know that is was a potential hazard. During an interview with the Director of Nursing (DON) on 2/8/2018 at 10:45 a.m., he stated, the resident has a history of sliding out of the wheelchair, she (Resident #1) was working with PT, and they deemed the wheelchair safe to use. During an interview with the physical therapist on 2/8/2018 at 11:30 a.m., she stated, the resident had her personal use the wheelchair and she (the therapist) was told by staff some time ago that she came close to sliding out of the wheelchair. When asked when and who reported that to her, she could not recall who told her that or when staff had told her. Facility staff failed to recognize that devices could pose a hazard if not fitted properly based on the individual need of the resident. The resident was observed on 2/8/2018 at 10:45 a.m. in bed awake and alert; the right knee area was swollen and was larger than the left knee. The resident was unable to respond appropriately to questions due to her cognitive disability. Facility notes dated 2/7/2018 indicated they called the vendor after Resident #1's fall and ordered a 22-inch wide tilt in space wheelchair. Facility staff failed to identify the risk of potentially avoidable accident hazards in a timely manner for Resident #1. WAC Reference: 388-97-1060 (3) (g)

Based on observation, interview and record review, the facility failed to ensure the resident environment was free from hazards created by locating a steam table in areas which were accessible to residents and created the likelihood for burns from hot surfaces. This created an immediate jeopardy situation for all residents residing on or accessing the Rose Unit. An Immediate Jeopardy was called on 03/27/17. The facility replaced the stationary steam table with one that could be moved to a secured area when not in use. The facility also revised policies, directing staff to be present at all times to prevent resident access when the steam table was heated. Staff responsible for these measures were trained on or before 03/28/17. The Immediate Jeopardy was removed on 03/28/17. Findings include: On 03/27/17 from noon until 1:05 p.m., a large electric steam table was present in a main hallway on the Rose unit, along the north side of the Rose dining room. The steam table was used to keep hot food well heated during meal service. Approximately 16 residents were seated here for lunch. During this time Staff E, a dietary aide, served resident meals from the heated steam table. At 1:00 p.m., Staff E removed pans of hot food from the steam table and loaded them into a cart, and took the food to a second dining room. After turning off the steam table, and covering portions of it with a padded blanket, Staff E left this area. The steam table, when checked by the surveyor at 1:17 p.m., was too hot to allow contact with a bare hand. No staff were in the area after the departure of Staff E to prevent residents in the area from touching the hot external surfaces as they exited the dining room or walked in the main hallway passed the steam table. The blanket covering the steam table was easily moved, allowing residents access to hot surfaces as well as the on/off switch located on the lower right side of the steam table that faced the hallway. When the lid covering one of the wells in the steam table was lifted, a cloud of steam was visible. The steam table continued to radiate heat, from the hot water still present in the table even though the unit was turned off. Areas of the table that were not covered by the blanket, as well as those accessed under the blanket were all extremely hot when touched at 1:17 p.m On 03/27/17 at 1:41 p.m., continued observations revealed parts of the steam table were still extremely hot with bare hand contact, for example the area on the top of the unit where food bins would be placed. This area was covered with a blanket, however, it could easily be removed. On 03/27/17 at 1:50 p.m., three nursing staff who were present in the area during lunch service were interviewed Staff L, M and N). When asked at what time the steam table was turned on and who was responsible for the steam table when in use or not in use, Staff L, RN (Registered Nurse), replied the kitchen- I don't know the exact time, but it is their responsibility. Staff N, an RN, stated, Kitchen, I don't know when it is turned on. Staff M, a nursing assistant, replied I think it is the kitchen. I don't really know. At 1:50 p.m. on 03/27/17, the dietary aide serving from the steam table (Staff E) was interviewed. He stated he turned on the steam table before breakfast and lunch at 7:30 a.m. and 11:30 a.m., respectively. He acknowledged he was not there continuously once the steam table was turned on, since he needed to go back and forth between kitchen and dining room to gather food to be served. He said he was responsible for turning the steam table off before going to the Lake View dining room. When Staff E was asked if he was aware of any residents who ate in the Rose Dining Room (RDR), who wandered, he said there was one in particular and identified Resident #23 by name. On 03/27/17 at 2:26 p.m., Staff C was asked if any residents wandered around the health center and into the RDR. Staff C stated there were and named Resident #s 35 & 2. According to Resident #35 and Resident #2's most recent quarterly MDS (Minimum Data Set) assessments both dated 01/04/17, these residents were not cognitively intact. At 1:55 p.m., the Chef (Staff D) was asked when the steam table had been permanently installed in the Rose dining room. She said she wasn't sure. She confirmed the steam table was used to serve all three meals in the RDR daily. When asked when this steam table was turned on to heat up before meal service, she said it was turned on 30 to 60 minutes before each meal. When asked if there was any type of an override switch for the steam table to ensure residents or anyone other than dietary staff could not turn the steam table on she said, No, just the on-off switch. At 2:15 p.m. on 03/27/17 the facility's Projects Manager (Staff G) was interviewed. He said the steam table in the RDR was permanently installed around December 2016. At 2:25 p.m. the Food Service Manager (Staff F) and Registered Dietitian were asked if there was a written policy and procedure regarding use and monitoring of the Steam table to protect residents from burns if they were to come in contact with the hot surfaces of the steam table. Staff F replied there was Nothing in writing. She also said we did put something into maintenance about putting a box over the switch. She also said the Administrator (Staff A) had been concerned about steam table as a safety issue. According to Staff F, the steam table had been installed in September 2016. At 2:37 p.m., Staff A was asked if there was a manual for the steam table; which he said he would locate. When Staff A was asked if he had identified any safety concerns in the facility since starting in late February 2017, Staff A said he had done safety rounds during his first week in the facility and noticed the steam table. He also said he had put in a work order to obtain protective shields for the steam table that could be keyed and locked so residents wouldn't be in contact w/ hot surfaces. No protective shields were present on or near the steam table on 03/27/17. When Staff A was asked what safety measures were implemented after identifying risk of burns/injury to residents, he said they added the padded blanket. He also said staff were told to observe the steam table before and after meals. Staff A said he and the DNS (Director of Nursing Services) physically keep an eye on the steam table every meal (even though during lunch on 03/27/17 he was observed feeding residents in the Lake View DR right after the meal cart left the Rose DR). At 2:55 p.m. after the above interviews with staff, Staff A stated staff would now unplug the steam table after each meal service, given the accessibility of the on/off switch to passers-by. A second plan which addressed the accessibility to residents to hot surfaces of the steam table (and likelihood of burns) was presented on the morning of 03/28/17. At that time, Staff A stated wheels had been installed on the steam table and it would be moved back to the main kitchen area at the conclusion of each meal service and stored in an area which would prevent residents from being in contact with the hot surfaces. On 03/29/17 a copy of the instruction manual for the steam table (dated 10/27/08) was provided. When reviewed, one page (p. 11) it contained the following information: WARNING: Steam can cause serious burns. Always wear some type of protective covering on your hands and arms when removing lids or pans from the unit. Lift the lid or pan in a way that will direct escaping steam away from your face or body . Failure by the facility to have procedures in place that consistently monitored for resident contact with the steam table did not ensure they were protected from the environmental hazard and potential burns if contact was made with hot surfaces. Reference: (WAC) 388-97-1060(3)(g) .

Based on deficient practices identified throughout the annual and extended survey process, the facility's administration failed to maintain a resident environment that was free from hazards. The facility failed to act on an identified hazard created by a steam table and ensure necessary supervision and monitoring was provided. This failure resulted in an Immediate Jeopardy related to accidents and supervision and related to the Administration of the facility resources to maintain each resident's safety. Findings include: Refer to CFR 483.25(h)(2), F-323, Free of Accident Hazards/Supervision The facility administration failed to act on the environmental hazards previously identified related to an unsupervised steam table accessible to residents and/or visitors in a resident dining room. Administration failed to put into place effective interventions to remedy the hazardous environment when first identified approximately three weeks earlier. The failure to protect residents from a hazardous environment created a liklehood [MEDICAL CONDITION] serious harm. Other areas of deficient practice which also indicated a lack of consistent Administrative oversight related to F323 include: F497 - 483.75(e )(8() - Nursing Assistant Inservice The administration failed to ensure continuing education curriculum addressed special needs of residents related to cognitive impairment and abuse prevention and failed to ensure no less than 12 hours per year of training for two of four nursing assistants reviewed. Reference: WAC 388-97-1620(1)

Based on observation, interview and record review the facility failed to implement written policies and procedures to report abuse of 2 of 3 residents (Resident #2, Resident #7) sexually molested by Resident #1 and failed to adequately respond to Resident #1's ongoing agitation, wandering and sexualized behavior. This resulted in Resident #1 frightening Resident #4, repeatedly kissing female resident's arms and faces, required security to remove Resident #1 from Resident #8 & #9's bed and room and resulted in an episode of sexual molestation of Resident #3, one month after he first molested Resident #2. These failures demonstrated a facility pattern of failing to protect residents from abuse and placed all residents in the facility at risk of abuse. Findings include: Facility policy maintained a zero tolerance for any form of abuse, neglect or exploitation. The policy directed residents would be protected from abuse, including abuse from other residents. The policy defined sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. The policy did not define sexual abuse further. According to facility policy, in cases of resident to resident abuse the facility would implement appropriate interventions. If the resident continued to pose a threat or danger to others discharge may be necessary. Facility policy stated When trends are identified, investigate further in order to determine if a problem exists. Employees were to report all abuse immediately to the healthcare administrator to report to appropriate authorities according to facility policy. Unmanageable behavior was to be immediately reported to the nurse supervisor/charge nurse who could require a family member remain with the resident until calmed or transferred. All incidents were to be documented in the resident record and .an occurrence report must be filed with the administrator. Observation on 08/08/16 at 9:15 a.m. noted residents with a range of care needs and conditions including cognitive impairment. Observation noted multiple 8 1/2 by 11 inch signs posted throughout the facility reminding staff they were Mandatory Reporters of abuse. Facility records documented the last annual training on abuse reporting and recognition was done in May 2015. Review of the facility incident reporting log for January through August 2016 found a single entry dated 07/23/16 reported to the state hotline. The entry was coded resident to resident altercation. DOCUMENTED INCIDENT OF ABUSE #1 Progress notes documented on 06/21/16 at 5:30 p.m. Resident #1 was found in Resident #2's room touching her chest. Progress notes documented steps were being taken to prevent something like this from happening again. Review of the 06/21/16 Incident Report (IR) documented witness statements from Staff H and I that Resident #1 opened Resident #2's blankets and started touching the resident's breast. Staff removed Resident #1 from Resident #2's room. According to the IR, Facility will provide 1:1 staff intervention for 8 hours to maintain (Resident #1) and other resident's safety. Staffing review found the 1:1 monitoring from 1:00 to 9:00 p.m. daily ended July 1, 2016. There was no assessment or evaluation documented in the record or reported by staff identifying why the 1:1 monitoring was discontinued or deemed no longer needed. The IR did not include original staff statements. Facility record review found this incident was not reported to the hotline as abuse. The incident was documented on the facility occurrence log as Behavior Problem. PATTERN OF AGITATION, WANDERING AND/OR SEXUALIZED BEHAVIOR Progress note review found that after the 06/21/16 incident, there were a pattern of incidents where Resident #1 wandered into resident rooms or approached or touched residents: 06/21/16 : Resident #10 was in his room sleeping in his recliner when Resident #1 entered the room, grabbed the chair controller and started pressing the control buttons causing the chair to rise up. Staff finally convinced him to let go and leave the room. 06/23/16, 06/26/16 & 07/10/16 : Enters other resident rooms when they are present, upsetting the resident(s). 06/29/16 : Observed taking a resident's arm and holding it. 07/01/16 : Resident #1 intrusively going into other residents rooms. Resident #1 refused to leave on staff request. The resident in (a specific room) asked him to leave .as he was leaving he took the lady's hand and kissed it. 07/12/16 : Resident #1 kissed Resident #6 on the forehead. Resident #6 was moved to an alternate dining room as this will separate her from the other resident during meal times. 07/15/16 : Resident #1 entered Resident #8 & #9's room and tried to lie down in the bed occupied by a female resident. Resident #1 was uncooperative when asked to leave the room. He became aggressive, striking out at staff who called security for assistance. 07/22/16 : Resident #1 continues to be very inappropriate with female staff and residents . continues to go into other resident's rooms and refuses to leave . He was also inappropriate with female residents, noted kissing arms . UNDOCUMENTED INCIDENTS: Interviews found there were undocumented incidents of residents affected by Resident #1's behavior. In an interview on 08/08/16 at 6:55 p.m., Resident #4 stated a male resident who walked around the facility frightened a visitor to her room when all of a sudden without warning he reached in and grabbed the visitor's shoulder. Resident #4 stated she was frightened of the male resident at the time due to the suddenness and intrusiveness of his actions. Resident #4 stated it was so upsetting her friend wrote a letter to the facility. There was no record of this event at the facility. In an interview on 08/08/16 at 10:18 a.m., Staff O stated Resident #1 would grab onto her, other staff and residents. Staff O stated Resident #1 would grope and kiss residents who could not defend themselves. Staff O referenced an 07/15/16 undocumented incident involving Resident #4 and an undocumented incident on 07/13/16 where Staff D witnessed Resident #1 grabbing Resident #7's breasts. There was no documented record of these events. UNDOCUMENTED INCIDENT OF ABUSE #2 In a telephone interview on 08/11/16 at 2:15 p.m. Staff D stated It wasn't grabbing, he put his hands on her breasts. Staff D stated she was walking down the hallway with Resident #7 when Resident #1 approached from the opposite direction. According to Staff D, Resident #1 stopped walking, put his hands on her (Resident #7's) breasts then both residents continued walking. In an interview on 08/08/16 at 7:17 p.m., Resident #7 was unable to recall the incident due to her cognitively disabling condition. DOCUMENTED INCIDENT OF ABUSE #3: Review of the 07/23/16 incident report (IR) documented at 5:00 a.m. on 07/23/16 Resident #1 entered Resident #3's room, sat down next to her on the bed and started inappropriately gently rubbing the sides and top of her left thigh saying Don't you feel anything? The IR documented Resident #1 had dementia, wandering behaviors and a history of touching female residents inappropriately. According to the IR, facility made appropriate notifications and provided 1:1 supervision to Resident #1. Original staff statements were not included with the investigation. Staff statements were provided to the surveyor on 08/15/16. Review of original staff statements related to the 07/23/16 incident found Staff C and Staff M both documented Resident #1 actively tried to get into Resident #3's bedroom their entire 7:00 p.m. to 7:00 a.m. shift. Staff C documented Resident #1 was found in room [ROOM NUMBER] after 8:00 p.m. Staff C documented security came to the unit because the unnamed resident in room [ROOM NUMBER] called 911. Both Staff C and M documented Resident #1 fought and argued with the security guard. Both Staff C and M documented Resident #1 was later found in Resident #3's room. The incident investigation did not include resident statements or interviews. Record review found after the touching of Resident #3 on 07/23/16, the facility monitored Resident #1 with 1:1 staff or family until his discharge on 07/24/16. FAILURE TO RECOGNIZE, REPORT OR PROTECT RESIDENTS FROM ABUSE: Interviews found that some staff failed to recognize the 06/21/16 incident where Resident #1 touched Resident #2 on the breast as abuse. Some staff recognized Resident #1's pattern of behavior as abuse but failed to report. For a period of more than a month, facility administration and staff failed to protect residents from abuse. In an interview on 08/08/16 at 10:18 a.m., Staff O stated staff told the Director of Nursing Services (DNS-A) about abuse incidents but DNS-A did not respond to protect residents. DNS-A left employment on 07/27/16. In an interview on 08/08/16 at 12:20 p.m., Staff A stated it was hard to follow Resident #1 as he was everywhere including resident rooms, sometimes touching or holding or kissing resident's hands. Staff A stated DNS-A told her there was nothing the facility could do as the resident was from the secure dementia unit and the facility cannot change behavior, we have to deal with it. Staff A stated she worked night shift on 06/21/16 and neither evening shift nurse (Staff B and C) reported the incident where Resident #1 touched Resident #2's breasts to her. Staff A stated she found out about the incident in the morning on 06/22/16 after hearing caregivers talking. Staff A identified the 06/21/16 event was molestation and stated she told DNS-A and the administrator specifically about the abuse and knew it needed to be reported to the State Hotline. Staff A stated she did not report the incident herself because she told the administrator and DNS-A. In an interview on 08/08/16 at 4:20 p.m., Staff C stated she was one of the nurses on duty on 06/21/16 but did not report the incident of Resident #1 touching Resident #2's breasts because staff got Resident #1 out of the room and she was overwhelmed. In an interview on 08/08/16 at 6:00 p.m., Staff B stated he was the nurse on duty 06/21/16 when caregivers saw Resident #1 placing his hands on Resident #2's breasts. Staff B said he did not really see this as abuse as Resident #1 is always on the hallway and tries to be extra friendly. Staff B stated he did not see the event as abuse because Resident #1 had dementia and did not mean it. Staff B stated he did not give report about the incident to the oncoming nurse. In a telephone interview on 08/11/16 at 2:15 p.m., Staff D stated she reported the incident where Resident #1 groped Resident #7's breasts to DNS-A. She asked me not to document it. Staff D said DNS-A categorized Resident #1's behavior as due to dementia. She was protecting facility . Everyone else was at risk and (Resident #1) was being protected. Staff D stated she thought what Resident #1 was doing was abuse but did not report because she was afraid of losing her job. Staff D stated when she documented information into the Risk Watch incident reporting, DNS-A would take out any incriminating language. In an interview on 08/15/16 at 5:00 p.m., Staff P (Social Services) stated the 06/21/16 event where Resident #1 touched Resident #2's breasts was investigated as sexual abuse but no call was placed to the hotline. According to Staff P, DNS-A was in charge of that and made the call not to report it. Staff P stated he did not agree with not reporting the incident but looked at it as she was my superior. In an interview on 08/17/16 at 9:30 a.m., Staff H stated on 06/21/16 she saw Resident #1 touching Resident #2 on the breast, head and shoulders. Staff H stated she pulled Resident #1 away and closed the door. Staff H identified this was sexual abuse and came under mandatory reporting rules. Staff H said she reported the abuse to the nurse and did not think to call the hotline as it was nighttime. In an interview on 08/15/16 at 12:10 p.m., the administrator stated she was not aware Resident #1 had fondled Resident #2's breasts on 06/21/16, only that he had gone into her room and was found at her bedside. The administrator stated she did not recall seeing the Risk Watch write up of the incident. The administrator stated she did not recall being told of the incident by staff. The administrator stated Resident #1 was on 1:1 staffing for behavior of going into resident rooms, kissing female residents and holding hands. The 1:1 staffing was for Resident #1 to stay safe and engaged. The administrator stated she did not know the 1:1 staffing was discontinued on 07/01/16. Investigation found a pattern of documented and undocumented incidents of abuse where the facility failed to identify, respond to, or report abuse and failed to protect vulnerable residents. Record review found that Residents #2, #5, #6, #7, #8 and #9 who staff identified Resident #1 touched or were affected by Resident #1 did not have the ability to recall or report how they felt due to cognitive impairment. The facility failed to protect vulnerable residents from an ongoing pattern of sexual touching.

Based on observation, interview and record review the facility failed to ensure 1 of 3 residents (#1) reviewed for dementia related behaviors received adequate care for an ongoing pattern of agitation, wandering and sexualized behavior. This resulted in other residents experiencing abuse and decreased quality of life. The facility failed to ensure 2 of 3 residents (#2, #16) reviewed for emergency hospitalization received adequate care and monitoring by nursing staff. This resulted in delay of medical attention and evaluation for acute medical conditions. Findings include: Refer to: CFR 483.13(c), F-226, Develop/implement abuse/neglect policies RESIDENT #1: Record review found Resident #1 admitted to the facility 04/25/16 with multiple medically disabling conditions and dementia. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented the resident was unable to complete cognitive testing due to his limited cognitive ability. The MDS assessed Resident #1 had physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) 1-3 days out of 7 days. According to the MDS, these behaviors significantly interfered with the resident's care. The MDS also identified Resident #1's behaviors did not put others at significant risk for physical injury, or intrude on the privacy of others or significantly disrupt care or the living environment. According to the MDS, Resident #1 rejected care 1-3 days out of 7 days and had no wandering (elopement) behavior. The resident required extensive assistance of 1-2 persons for activities of daily living and was incontinent of bowel and bladder. Investigation found a pattern of documented and undocumented incidents of abuse where the facility failed to identify, respond to or report abuse and failed to protect vulnerable residents. The first documented incident of sexual abuse occurred 06/21/16 where Resident #1 touched the breast of Resident #2 after wandering into her room. In an interview on 08/11/16 at 2:15 p.m. Staff D stated she witnessed Resident #1 touch the breasts of Resident #7 but did not document the incident in either resident's record. The third incident of sexual abuse occurred 07/23/16 when Resident #1 entered the room of Resident #3 at 5:00 a.m., sat down next to her on the bed and started inappropriately gently rubbing the sides and top of her left thigh saying Don't you feel anything? Record review and interview found for the time period of the first and third incident of abuse (06/21 to 07/23/16) there was a pattern of incidents where Resident #1 wandered into resident rooms or approached or touched residents. In addition to wandering into resident rooms, record review found there were two incidents where Resident #1 eloped from the facility. In the first elopement incident on 05/31/16 at 4:00 p.m., Resident #1 was witnessed leaving the facility and retrieved promptly by staff. In the second elopement incident on 07/17/16, Resident #1 was witnessed leaving through a stairwell at 4:20 p.m. Resident #1 was returned to the facility by Security at 4:50 p.m. Review of facility staffing found additional staff were in place to provide 1:1 monitoring of Resident #1 from 1:00 to 9:00 p.m. daily. This staffing pattern ended 07/01/16. There was no assessment or evaluation documented in the record or reported by staff identifying why the 1:1 monitoring was discontinued or deemed no longer necessary. Record review found that after the 2nd documented incident of abuse on 07/23/16, Resident #1 was placed on 1:1 monitoring until his 07/24/16 discharge to an Assisted Living Secure Dementia Unit. The recapitulation of stay did not identify any of Resident #1's pattern of behavior. Notes documented after discharge, Resident #1 continued exit seeking, elopement and agitation behavior including entering others rooms, attempting to strike or kiss staff and attempting to get into bed with female residents. Electronic behavior logs identified behaviors related to mood and physical or verbal behaviors directed toward others, behavior not directed at others, rejection of care and wandering. Behavior logs from the electronic record for June and July 2016 showed no entries for Resident #1's behaviors. Behavior logs are an assessment tool for noting frequency, timing and increasing or decreasing patterns of behavior. The facility did not make use of this tool. Interviews found that staff were concerned or frustrated by Resident #1's ongoing behavior and staff inability to keep Resident #1 from entering other resident's rooms and touching or kissing them. Staff recognized Resident #1's behavior as abuse but deferred to the Director of Nursing Services A (DNS-A) or other professionals for decision making instead of documenting incidents and assessing underlying causes of Resident #1's conduct and pattern of behavior. In an interview on 08/08/16 at 6:05 p.m. Staff P (Social Services) stated there were no behavior logs, nurses just documented in progress notes and information was reviewed at daily meetings. Staff P stated as far as he knew incidents with Resident #1 tended to be over the weekend. In a follow up interview on 08/15/16 at 4:58 p.m. Staff P stated the first incident of Resident #1 touching Resident #2's breasts on 06/21/16 was investigated as sexual abuse. Staff P stated the facility did not ignore the incident and tried to put some measures in place. Staff P stated DNS-A made the call to stop 1:1 staffing for Resident #1 on 07/01/16. In an interview on 08/15/16 at 10:43 a.m. Staff A stated she brought information about Resident #1 to the standup meeting every day. Staff A said DNS-A said we have to deal with this and touching Resident #2's breast was a first alert. Staff A said she thought DNS-A was obligated to keep the administrator updated but did not know if this was done. In an interview on 08/08/16 at 4:20 p.m. Staff C stated after the first incident of abuse the facility provided 1:1 care during a timeframe when the resident was most restless, up and about. According to Staff C, when the 1:1 caregiver stopped, there was no specific person assigned to monitor Resident #1. Caregivers were supposed to dedicate two hours of their shift to monitor the resident, which did not work. In an interview on 08/15/16 at 12:10 p.m. the Administrator stated she knew Resident #1 was entering resident ' s rooms, holding hands and kissing them but did not know that on 06/21/16 Resident #1 touched Resident #2 on the breast. The Administrator stated she did not know that 1:1 staffing was discontinued on 07/01/16. On 08/08/16 at 3:10 p.m. Resident #1's medical provider (MP) stated Resident #1 preferred to wander about and occasionally elope from the facility. The MP stated there were multiple medication changes to address behavior, but the facility no longer kept behavior logs. RESIDENT #2: Record review found Resident #2 admitted to the facility in 2013 with medically disabling conditions and dementia. Resident #2's recent medical history included [MEDICAL CONDITION] requiring hospitalization in May 2016, treatment for [REDACTED]. The resident received continues Oxygen (O2) at 2 liters per minute via nasal cannula (soft flexible tubing allowing O2 to flow directly into the nose). Resident #2's MDS assessment dated [DATE] identified the resident had severe cognitive impairment, depressed mood and behavior (such as verbal/vocal sounds) not directed at others which interfered with activities and social interactions and was disruptive and intruded on others. The resident was incontinent of bowel and bladder and required extensive assistance of 1-2 persons for activities of daily living. Resident #2's inability to say how she was feeling and medical history of [REDACTED]. On 07/18/16 Resident #2's medical provider-A (MP-A) documented Resident #2 was seen at request of nursing for a swollen left leg. The resident was determined to be clinically stable. There were no nursing notes following this visit documenting assessment or monitoring of Resident #2's swollen leg. On 07/21/16, Resident #2's medical provider B (MP-B) documented Resident #2 was seen at request of staff due to concern for increased [MEDICAL CONDITION] (fluid in tissue) of left lower leg. The MP-B documented significant [MEDICAL CONDITION] from the toes up to and involving the thigh. MP-B identified concern the [MEDICAL CONDITION] may have increased in size. MP-B also documented Resident #2 had frequent loose stools in the past several days and significant weight gain (21.6 pounds in one month). Orders included a diuretic, testing for [MEDICAL CONDITION], stool sample, and blood tests. Progress notes documented nursing monitoring of Resident #2's condition until 07/26/16 at 5:27 a.m. Staff F noted stable vital signs and no symptoms of discomfort. There were no subsequent nursing monitoring notes until Resident #2 was seen by MP-B on 07/28/16. On 07/28/16 MP-B documented at 12:41 p.m. Resident #2 was seen at request of staff for continued loose stools. MP-B documented staff reported the previous night Resident #2 had vomited in the evening. MP-B documented she was unable to find the results of the stool sample ordered on [DATE]. MP-B noted Resident #2's abdomen was significantly distended and firm documenting, I worry about a possible bowel obstruction. MP-B noted the resident's left lower leg [MEDICAL CONDITION] was perhaps increased over the previous week, [MEDICAL CONDITION] continues from the toes up through the left thigh. Orders included abdomen and chest x-ray. There was no documentation of nursing evaluation for the episode of vomiting, or evaluation of Resident #2's bowel condition or swollen leg. On 07/28/16, nursing Staff B (7:00 a.m. to 7:00 p.m. shift) documented Resident #2 had a fever that went up to 101.3 degrees. X-ray revealed double pneumonia and adynamic ileus (paralysis of the intestine). Staff B documented Resident #2's family member came in after lunch and discussed possible hospital transfer. Staff B documented MP-B was notified, 911 called and the resident was transferred to the hospital at 3:30 p.m. Hospital records documented on admission to the hospital Resident #2 had acute [MEDICAL CONDITION] requiring Oxygen at greater than 5 liters, acute [MEDICAL CONDITION], aspiration pneumonia and early ileus. In an interview on 08/17/16 at 2:15 p.m., MP-B stated when she came in the morning of 07/28/16 and examined Resident #2, She looked pregnant. This is not something that would happen overnight. It took days (to develop). MP-B said there was no charting in the record about the resident's condition. MP-B stated she called Staff E and T into the room but they said they did not see anything different about Resident #2. MP-B said no nursing assistants seemed to see anything either. Facility nursing staff did not monitor or assess Resident #2's medical condition and deferred to the family to determine the need for Emergency care. RESIDENT #16: Record review found Resident #16 admitted to the facility on [DATE] with medical conditions and difficulty walking after back surgery. Review of progress notes found on admit Resident #16 was alert and oriented and could make her needs known. The resident was able to use a walker and used her call light to call for help when needed. Staff noted the resident required one person limited assistance with activities of daily living. Medical provider notes on 06/27/16 documented the resident seems to have done very well after surgery. She will likely be able to go home in a week or so. There was no indication Resident #16 had difficulty breathing, needed Oxygen or had any distress at all. In a progress note dated 06/28/16 at 8:27 a.m., Staff F documented (at the end of 7 p.m. to 7 a.m. shift) Resident #16 reported feeling short of breath (SOB). Staff F noted slightly labored breathing with respiratory rate of 22 breaths per minute (normal range 12-16 breaths per minute). Staff F documented Resident #16's Oxygen Saturation (SaO2) dropped to 88% on room air (RA). Normally SaO2 should be greater than 95%. Values below 90% require immediate assessment and Oxygen. Staff F documented he offered Resident #16 Oxygen at 2 liters and the resident's SaO2 rose to 97%. Staff F documented Resident place on the list to be seen by the medical provider (MP). There was no call placed to the MP informing them that Resident #16 developed labored breathing and required Oxygen. In a progress note dated 06/28/16 at 3:01 p.m. Staff B (worked the 7 a.m. to 7 p.m. shift) documented She is noted to be weak and having sob at rest and Oxygen is dropping to 88% on ra. Staff B documented Resident #16's SAO2 increased to 94% on 2 liters of Oxygen, will continue to monitor. Staff B documented Resident #16 continued with fatigue, shortness of breath and need for Oxygen. Staff B documented family was at the bedside and is aware of the situation which she says bothers her. At that point, Staff B called the on-call MP who ordered a chest x-ray and inhaler medication to assist with breathing. Staff B documented the chest x-ray was done at 6:20 p.m. when the family changed their mind deciding that patient to be sent to the hospital. 911 was called and Resident #16 was transported out at 6:30 p.m. Staff B documented Resident was transferred to the hospital per family request. X-ray results showed Resident #16 had cardiomegaly (enlarged heart) with moderate [MEDICAL CONDITION], lung infiltrates on both sides and pleural effusions (excess fluid built up around the lung). In an interview on 08/17/16 at 5:40 p.m. Resident #16's MP said 06/28/16 was a Tuesday, which meant there was no medical provider coming to the building. The MP stated she would have expected Staff F to call, not just add Resident #16's name to the list to be seen because Resident #16 would not have been seen by an MP for at least 24 hours. The MP stated the only call she received was from Staff B at 4:15 p.m. on 06/28/16. Failure to notify the provider of Resident #16's onset of shortness of breath and ongoing need for Oxygen resulted in delayed medical attention for an acute condition. Facility nursing staff deferred to the family to determine the need for Emergency care, which resulted in a delay of emergent care.

Based on observation, interview and record review the facility failed to recognize, monitor and seek immediate medical attention for signs of significant injury for two of three sample residents (former Resident #1, current Resident #2) reviewed for falls from a current census of 42 residents. Delay in obtaining necessary medical attention resulted in pain, suffering, untimely medical treatment and harm to both residents. Findings include: RESIDENT #1: Record review found that Resident #1 was admitted to the facility from the hospital on [DATE] after suffering a stroke and fall at his home. The resident was diagnosed with [REDACTED]. The resident also had depression and anxiety. The purpose of admission was rehabilitation. Resident #1's minimum data set (MDS) assessment dated [DATE] identified a brief interview for mental status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS identified that Resident #1 required extensive one person assistance with activities of daily living, had occasional incontinence of bowel and bladder and was on a toileting program. Resident #1's care plan directed staff to assess and meet care needs and monitor for changes in mood/behavior such as sleep patterns, fatigue, appetite, ability to concentrate, participation in activities, crying. November 2013 progress notes documented Resident #1 was at baseline alert and confused. Staff documented using bed and chair alarms as the resident would attempt get up to toilet himself. Staff documented the resident self-propelled in the wheelchair and a Wanderguard electronic alarm bracelet was used starting 10/30/13 for exit seeking behavior. Caregiver notes for November 2013 documented Resident #1 was generally continent of bowel and bladder on every shift. The resident ate 75-100 % of 3 meals per day 80 % of the time. Medication and progress note documented the anti-anxiety medication [MEDICATION NAME] was prescribed to be given "as needed" (prn) starting 11/3/13 due to agitation/anxiety behaviors. The resident received [MEDICATION NAME] 2-3 times on 11/3 and 11/4 and then one dose on 11/14/13 and one dose on 11/19/13 (at 4:36 p.m.) Progress notes documented that during November 2013 Resident #1 fell 4 times with and without injury related to sliding out of his wheelchair or getting up without assistance Dates of falls were 11/2, 11/14, 11/15, and 11/19. Progress notes documented that on 11/20/13 at 5:00 a.m. Resident #1 had a "non-injury" fall. Staff H documented the alarm went off and Resident #1 was found on the floor by the side of the bed in front of the wheelchair, his head leaning on the wheelchair cushion. "Resident was sleepy and snoring." The resident was assessed as having no pain so was assisted back to bed. Resident #1 was medicated with [MEDICATION NAME] (06:20 a.m.) but continued to be restless. Staff H documented "Will continue to monitor for s/s (signs and symptoms) of latent injury." Progress notes and incident report documented at the start of day shift 07:00 a.m. on 11/20/13, Staff B found Resident #1 had bruising and swelling on the right shoulder and arm and a bruise on the right ear and was incontinent of bladder and stool requiring cleaning while in bed. Caregiver notes documented that during the day on 11/20/14 Resident #1 was incontinent of bowel and bladder all day, refused all meals and did not have documentation of any fluid intake. This is a significant departure from his baseline. Progress notes and/or incident report documented Staff B called the doctor and received an order for [REDACTED].#1 had a right arm fracture. Staff B documented "Resident very lethargic/snoring loud, then awaken and become restless and agitated." The resident was sent out by ambulance at 4:30 p.m. Review of Vital sign documentation found there was no documentation that Resident #1's neurologic status was monitored after the fall on 11/20/13 at 5:00 a.m., even though the resident had bruising on the ear, indicating he hit his head. No neurologic checks were documented even though the resident's level of consciousness and activity was significantly different than his baseline. Medical records documented that on evaluation at the hospital 11/20/13, Resident #1 was found to have skull fractures on the side and back of the head and both old and new bleeding into the brain. According to the medical record, Resident #1 was not expected to survive due to significant [MEDICAL CONDITION] from the fall or falls. Hospice was recommended. Resident #1 returned to the facility on comfort care and passed away on 11/22/13. On interview 1/21/14 at 3:15 p.m. Staff B said on first examining Resident #1 the morning of 11/20/13 she saw immediately that he was injured "My eyes were open...I saw there was injury." Staff B stated she generally does neurologic checks when a resident hits their head. Staff B said she did not do this because she was confused that the previous shift said it was a non-injury fall "There was no endorsement that he hit his head, they (night shift) said it was non-injury fall....I was about to do it (neurologic checks) for (Resident #1) but decided to send (him) to the hospital." Staff B stated she thought Resident #1 could be bleeding into his brain as he was so sleepy he could not wake up to take his regular medications or eat on 11/20/13. According to Staff B, she was so concerned she called the physical therapist (Staff D) to help evaluate the resident. "I called (Staff D) and told her it's really bad, what is going on?" Staff B stated she told the medical provider (MP) Resident #1 had bruising on the ear and shoulder and the resident was in bed sleeping. Staff B said she asked for an X-ray. According to Staff B, she thought she had done what was needed. On interview 1/20/13 at 4:20 p.m. Staff D stated that she was called to Resident #1's bedside on the afternoon of 11/20/13 to help immobilize the resident's shoulder due to the broken clavicle. Staff D said "(I) thought he probably hit his head along with the clavicle.... He had other days when he was not alert and would sleep all day but that day was different, mainly he would not open his eyes." Staff D stated the resident was sent to the hospital shortly after she saw him. RESIDENT #2: Observation 1/21/14 at 4:40 found Resident #2 seated in a wheelchair in his room. The resident was awake but unresponsive to greeting. A large foam wedge device used for leg positioning after [MEDICAL CONDITION] surgery was noted on the dresser. Record review found that Resident #2 was admitted to the facility 2/10/12 with medically disabling conditions affecting speech, walking, strength and eating. The resident had rigid gait and limited ability to communicate. Resident #2's MDS assessment dated [DATE] identified the Resident's BIMS was 4, indicating severe cognitive impairment. The resident required extensive one person assistance for activities of daily living, including walking. Resident #2's care plan identified staff would assist the resident with transfers and toileting and hand held walking. Progress notes and incident reports documented at 4:50 a.m. on 12/17/13 Staff F (nursing assistant) found Resident #2 kneeling on the floor net to the bed. Staff F assisted the resident back to bed but did not tell the nurse (Staff G) about the fall until 06:30 a.m. Staff G documented she assessed the resident at 06:30 a.m. and found Resident #2 was able to move all extremities and had no signs of injury or pain. Care notes documented that Resident #2 was up in the wheelchair and toilet during day shift. On interview 1/20/14 at 4:55 p.m. Staff E stated he thought Resident #1 was up in the wheelchair for breakfast. Staff E said he evaluated Resident #2 at 9:00 a.m. on 12/17/13 after the resident was back in bed. Staff E said when he evaluated Resident #2 at 9:00 a.m. on 12/17/13 he noticed that Resident #2 had pain on the upper leg and was not able to move his leg. According to Staff E, the resident's lower side of the leg was bent out at an unusual angle. Staff E said Resident #2 then stayed in bed the rest of the day and was given Tylenol for pain. According to Staff E, as long as the resident didn't move, he didn't demonstrate pain. Staff E documented an X-ray was ordered and completed at 10:40 a.m. Fax X-ray results returned to the facility at 1:30 p.m. showed femur (long leg bone) fracture at the hip. There was no notation on the Fax if or when staff called X-ray results to the doctor. Staff E documented in progress notes that Resident #2 was not able to transfer as before and was unable to bear weight. Resident #2 was sent out to the hospital at 4:40 p.m. This intervention was seven hours after the resident presented with symptoms consistent with [MEDICAL CONDITION] (pain and odd angle) and three hours after X-ray confirmed the [MEDICAL CONDITION]. On interview, when asked about the delay in sending Resident #2 out for an obviously broken femur, Staff E said he had to wait for X-ray results and then call a cabulance. According to Staff E, "it takes time." On interview 1/23/14 at 10:15 a.m. Resident #2's medical provider stated if told a resident had pain and rotation of the leg after a fall, these are signs of fracture and medical attention should be sought right away. There was no need or benefit to delay care. .