Every finding on record at Emerald Care

Based on observation, interview, and record review, the facility failed to provide hot liquids at a safe drinking temperature for 1 of 4 residents (Resident 1) reviewed for accident hazards. Resident 1 experienced harm in which they sustained burns on their right thigh from hot coffee. This failed practice placed the residents at risk for burn injuries, pain, and adverse health conditions.Findings included. Review of a policy titled, Free of Hazards/Supervision and Devices, dated 02/2025, showed the facility would ensure each resident received adequate supervision and assistive devices to prevent avoidable accidents and injuries. The facility would implement a systemic, interdisciplinary approach for identifying, evaluating, and mitigating risks, while maintaining resident safety, dignity, independence, and choice. Review of the Washington State Department of Labor and Industries guidance titled, Burn Injury Facts, dated 04/01/2009, showed scald burns occurred when skin comes in contact with hot liquids or steam. Water at a temperature of 155 degrees Fahrenheit [(F) a temperature measurement] would cause a third-degree burn (a burn that destroys the entire depth of the skin, damaging fat, muscle, organs, or bones) in one second. Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including quadriplegia (a loss of control of both arms and legs), heart failure, and anxiety. The 01/08/2026 comprehensive assessment showed Resident 1 required set-up assistance of one staff member for eating and dependent on one to two staff members for all other activities of daily living (ADLs). The assessment also showed Resident 1 had an intact cognition. Record review of a nursing progress note (PN) dated 03/22/2026 at 9:20 AM, showed Staff C, Registered Nurse, completed an assessment of Resident 1's wound. There was an area of redness that measured 4.5 centimeters (cm - a unit of measure) long by 13.0 cm wide, with three fluid filled blisters in the reddened area. Resident 1 reported to Staff C that they had spilled coffee on their lap the day before. Resident 1 stated they did not report the incident at the time because they had decreased sensation in their legs and did not feel the burn. Resident 1's provider was notified and the facility received orders to monitor the area and apply skin prep (a liquid film dressing used to protect skin from friction and trauma) daily. Record review of the facility investigation report, dated 03/21/2026 at 2:00 PM, showed Resident 1 had a red area with two blisters in the reddened area. Resident 1 stated they spilled hot cocoa (Resident 1's interview and record review show the hot liquid was coffee) on themselves earlier in the day but had forgotten about it until receiving cares at night. During a concurrent observation and interview on 03/24/2026 at 10:12 AM, showed Resident 1 sitting in the dining/activities room in their motorized wheelchair. Resident 1 had a cup of coffee with a lid on the cup sitting on the table next to them. They had a sweatshirt over their lap. Resident 1 stated they had a cup of coffee from the front coffee station a few days ago. They stated they were unable to get it for themselves; someone had gotten it for them. Resident 1 stated they usually have a tumbler with a lid but left it in their room that day. They stated they used a regular cup with a lid that had just tipped over while they were drinking it. Resident 1 stated they were burned by the coffee but didn't feel it because they had decreased sensation in their legs. Resident 1 stated they did not lay down during the day and stated they preferred not to show the burn to the State Agency investigator. During an interview on 03/24/2026 at 10:16 AM, Staff D, Dietary Staff, stated the kitchen refilled the resident coffee pots at scheduled times during the day: 6:00 AM, 9:00 AM, 11:00 AM, 1:30 PM, 3:30 PM, and 6:30 PM. They stated they refilled them more often than the scheduled times. Staff D stated they ensured the brewed coffee was at 155 degrees F before they took the coffee cart to the resident's area. They stated they kept logs of the temperature of the coffee to make sure it was not over 155 degrees F. During a concurrent observation and interview on 03/24/2026 at 12:25 PM, Staff B, Director of Nursing, obtained a cup of coffee from a coffee pot located on the coffee cart in the resident's common area. There was steam rising from the coffee in the cup. Staff B obtained the temperature of the coffee using the facility thermometer, which read 168.8 degrees F. Staff B stated the coffee was too hot and removed the coffee cart from the resident area. During a concurrent interview and record review on 03/24/2026 at 2:18 PM, Staff E, Dietary Manager, reviewed the coffee temperature log with Staff B present. Staff E stated the kitchen staff were only taking the temperature of one of the four pots on the coffee cart prior to leaving the kitchen. Review of the coffee temperature log entry for 03/21/2026 (the date of the incident) showed an entry at 4:40 AM with a temperature of 152 degrees F, 7:15 AM with a temperature of 155 degrees F, and 11:00 AM with a temperature of 155 degrees F. They stated they were unsure if the kitchen staff were taking the temperature directly from the pot or from a pitcher of coffee. Staff E stated the kitchen staff should be taking the temperature and recording the temperature of all the pots prior to leaving the kitchen. Staff B stated the kitchen staff needed to check the temperature of all coffee pots before the coffee cart left the kitchen and if the temperature was over 155 degrees F, they would need to ensure it was at a safe temperature before allowing residents access to it. During an interview on 03/24/2026 at 2:24 PM, Staff B stated the facility did not complete assessments or have a process in place to ensure residents were safe with handling hot liquids. During an interview on 03/24/2026 at 2:58 PM, Staff A, Administrator, stated the process for ensuring residents were safe with the coffee cart included checking the temperatures of the coffee in the dispensers before sending them from the kitchen. Staff should complete a second check before providing the coffee to the resident. There should be a thermometer located on the coffee cart to complete the temperature check. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure that unless the facility had a full-time Registered Dietician (RD), that the Dietary Manager (Staff H, Dietary Manager (DM)) had the competencies and skill sets to carry out food and nutrition services for their resident population. This failure placed residents at risk of receiving dietary services from staff who had not completed an academic program in nutrition or dietetics accredited by an appropriate national accreditation organization. Findings included. During an interview on 01/25/2026 at 9:28 AM, Staff H stated they were the DM in training. Staff H stated they would hope to have their required certification by March 2026. During an interview on 01/29/2026 at 10:23 AM, Staff I, Kitchen Manager, stated they would assist the DM if they needed help. Staff I stated they were not the oversight of the DM and that they assumed the Registered Dietitian (RD) was the DMs' oversight. Staff I stated the RD worked two to three days a week and was a consultant for the facility. Staff I stated they themselves carried no certifications. During an interview on 01/29/2026 at 1:39 PM, Staff H stated they had completed the Certified DM course, but when they took their test in September of 2025, they did not pass. Staff H stated they wanted to retake the test, but work got too busy during the holidays, and they did not have time to review or prepare for the test, so they were unable to reschedule the test. Staff H stated they had been the DM since June of 2024 with Staff I supervising them, because they have more experience. During an interview on 01/30/2026 at 9:56 AM, Staff A, Administrator, along with Staff B, Director of Nursing Services, stated Staff H had taken their Certified DM test in 09/2025 but did not pass the test. Staff A stated Staff I was the oversight of the DM. Staff A stated Staff H and Staff I worked side by side in the kitchen with the help of the RD. Staff A stated Staff H had to wait 90 days to retake the test and had not had the $500.00 it cost to reschedule the test. Staff A stated they offered to pay for Staff H to retake the test and Staff H could reimburse them, but Staff H had fears they were not ready or prepared to retake the test. Reference: WAC 388-97-1160 (2)(3)(a)(b)(i)

Based on observation, interview, and record review, the facility failed to discard expired foods in 1 of 1 walk in refrigerator, 1 of 1 stand-alone refrigerator, and 1 of 1 dry storage area used to store food items for the entire resident population, reviewed for safe and sanitary kitchen. Additionally, the facility failed to follow the thawing process of foods or consistently monitor cooked food temperatures prior to serving the food. This failed practice placed residents at risk for Food borne illness (caused by consuming foods that are contaminated with harmful pathogens [bacteria that reproduce rapidly once entered in the body and can damage tissues and cause illness]).Findings included.Review of a 02/2025 policy titled Thawing Frozen Food, showed ground beef could be thawed for one to two days and then once thawed, could be kept another one to two days (a total of four days from removing from a frozen state). The policy showed bacon or sausage could be kept up to seven days. Expired Foods During the initial tour of the kitchen on 01/25/2026 at 8:50 AM showed: Stand-alone Refrigerator: four prepared plates of fruit (blueberries, strawberries, and tangerines) and cottage cheese uncovered, unlabeled, and no dates. Three chef salads, one dated for 01/21 and no use by date and the other two had no label or dates. One resident meal tray, unlabeled, with a plate that contained pasta filled with a white filling, a breadstick, condiments, and juice, undated. One clear plastic storage container with eight single serving containers of a thick brown substance dated for 01/10/2026 and no use by date, and unlabeled. One 32-ounce container of Almond mild, half full, no opened and no use by date. One five-pound tub of sour cream with an open date of 12/20/2025 and no use by date. One five-pound tub of cottage cheese opened on 01/25/2025 but expiration date showed 01/24/2025 and was three quarters full. A metal bowl with more than two cups of a white substance with a date of 01/21, unlabeled. One 46-ounce carton of cranberry cocktail thickened liquid expired on 01/20/2026, no open date, full, and one that was half full, dated 12/27/2025. One full pitcher of dark liquid, unlabeled and undated Dry Storage Area: One large white plastic food bin with a dry white powder with no label or dates One large white plastic food bin with breadcrumbs dated 04/15/2025 and no use by date One gallon of [NAME] Vinegar with expiration date of 02/2024 Walk-in Refrigerator: Five prepared cups with fruit in them, sitting on a shelf, undated or labeled Two rectangle single serving cakes next to the fruit cups, undated or labeled One gallon container of Vinaigrette salad dressing, three quarters full, dated 03/28/2025 One gallon container of Blue Cheese salad dressing, full, dated 09/12/2025 One gallon Coleslaw dressing, one quarter full, no open date One gallon of tartar sauce, one quarter full, dated 10/01 and expired 07/19/2025 One half of a 32-ounce package of roast beef lunch meat dated 01/14/2026 and no use by date. Two 32-ounce packages of Roast Beef lunch meat, undated, but freeze by date on the package showed 01/23/2026 One 15-pound box of bacon, thawed, box opened and bacon was uncovered, half full, dated 01/13/2026. One box of honey bacon, opened, and dated 01/09/2026. Thawing Process: Five- five-pound ground beef rolls, in a container on the bottom shelf, thawed with a date of 01/20/2025, no use by date. Seven packages of turkey breast sliced lunch meat, 32-ounce, thawed, dated 01/13/2025. Five packages of sliced ham lunch meat, 32-ounce, unopened, thawed, and no dates. Food Temperatures: Review of logged food temperature forms, showed pureed food for breakfast, lunch, and dinner should range between 165-170 degrees (a unit of measure) Fahrenheit (F) from 01/01/2026 through 01/29/2026 showed: 01/03/2026- No pureed (food that has been blended or processed to a smooth, creamy consistency) food temperatures for dinner. 01/05/2026 and 01/06/2026-No pureed food temperatures for breakfast or lunch. 01/07/2026-No pureed food temperatures for lunch. 01/08/2026 - no food temperatures for lunch or pureed temperatures for breakfast 01/10/2026- no pureed food temperatures for dinner 01/12/2026-no food temperatures for breakfast or lunch and only pureed food and meat temperatures for dinner 01/13/2026 through 01/15/2026-no food temperatures for breakfast or lunch 01/20/2026- no pureed food temperatures for lunch, and no food temperatures for dinner 01/21/2026- no pureed food temperatures for breakfast 01/22/2026- no food temperatures for breakfast other than hot cereal, no temperatures for lunch. 01/25/2026-no pureed food temperatures for dinner 01/26/2026, 01/28/2026- no food temperatures for dinner 01/27/2026- no food temperatures for dinner other than soup 01/29/2026-no pureed temperatures for breakfast, or lunch During an interview on 01/25/2026 at 9:25 AM, Staff J, Cook, stated the ground beef was supposed to be kept no more than three days and there was no process for bacon, we usually use it every day until we use it all, no specific time frame. During an interview on 01/25/2026 at 9:28 AM, Staff H, Dietary Manager (DM), stated the lunch meat should be dated with the date it is removed from the freezer and used within seven days. Staff H stated salad dressings were good for one week from opening and should be dated when they were opened. Staff H stated the dried foods in the storage bins were flour and panko breadcrumbs I think were replaced with the last delivery and should have been dated and labeled. An interview on 01/29/2026 at 10:32 AM showed Staff I, Kitchen Manager, stated salad dressings once opened should be discarded within one month of open date and without dairy, they would be good for three months. Staff I stated kitchen staff were to check and discard expired foods twice a week, on Tuesdays and Fridays and those checks were not documented anywhere. Staff I stated foods and meats should have been labeled and had open dates and use by dates. An observation and concurrent interview on 01/29/2026 at 11:56 AM, Staff J, Cook, prepared six dishes of pureed cheeseburger casserole. Staff J was about to serve the pureed casserole into the dishes without checking the temperature. At 11:59 AM, Staff J prepared the pureed cold pasta salad and again was going to serve to the dishes and had to be asked to check the temperature. The temperature of the cold pasta salad was at 69.3 F and stated cold pasta salad should be less than 70 F. Staff I, who was standing close by and stated the cold temperature for pasta should be under 41 F. Staff J did not document the temperatures on the temperature food log. During an interview on 01/30/2026, Staff A, Administrator, stated the kitchen staff should be documenting dates when they received the product, then documenting the dates when they were opened. Staff A stated when foods were thawed out, they would expect a date of when to dispose of it or when it expired. Staff A stated staff should consistently check temperatures before each meal. Reference: WAC 388-97-1100 (2)(3)

Based on interview and record review, the facility failed to ensure a complete and thorough investigation had been completed for reported allegations of abuse and/or neglect for 3 of 3 residents (Residents 9, 35, and 40) reviewed for abuse and neglect. The failure to conduct a thorough investigation including root cause, contributing factors, and identifying preventative measures to rule out abuse/neglect placed the residents at risk for further unmet care needs and psychosocial harm. Findings included. Resident 9 Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including Amyotrophic lateral sclerosis (ALS) (a progressive, fatal, neurogenerative disease that destroys motor neurons leading to loss of movement, speech, swallowing, and breathing capabilities though cognition stays intact), depression, anxiety and chronic pain. The 11/17/2025 comprehensive assessment showed Resident 9's cognition was intact and required total assistance with bed mobility, transfers, dressing, toileting, feeding, and personal hygiene. Review of a grievance form dated 12/23/2025 showed Resident 9 had shared a complaint with Staff E, Social Services Director (SSD), stating that on 12/15/2025, Staff M, Licensed Practical Nurse, (LPN), had not responded to Resident 9's request to have their glasses put on. Resident 9 said Staff M only held the glasses out towards them for several minutes without saying anything or assisting with placing them on the face. Resident 9 reported Staff M then just put the glasses down and left the room without any further explanations or offers of assistance. Further review of the grievance form showed Staff B, Director of Nursing (DNS) wrote on the grievance form that Resident 9 reported feeling unsupported and mistreated by Staff M's interaction with them on 12/15/2025 and had educated Staff M in a one-on-one meeting on 12/29/2025 that showing empathy, resident centered care, therapeutic communication and appropriate assistance when caring for residents with significant physical limitations and communication difficulties were the expectations. During an interview with Staff E on 01/28/2026 at 11:40 AM, they stated after receiving Resident 9's concern of neglect, they had reported the grievance to Staff B. In addition, Staff E stated they had followed up with questioning six other residents on the hallway where Resident 9 resided, asking if they had any concerns of staff members not responding to their needs and if they felt safe in the facility with all responding they had no issues. During the same interview, Staff E stated Resident 9 reported to them they no longer wanted Staff M to come into their room or provide any care to them. Further, Staff M was removed from working in the facility from 12/23/2026 through 12/30/2026 while Staff B completed the investigation and provided staff education concerning the incident. During an interview with Staff M on 01/28/2026 at 12:20 PM, they reported they were told on 12/23/2025 of the allegations against them and said they would be taken off the schedule until further notice. Staff M stated they were then called on 12/29/2025 to go to the facility and speak with the DNS about expectations moving forward. Staff M stated the DNS told them they were not to have further contact with Resident 9 and the allegations of abuse and neglect were unsubstantiated and they could return to work the following day. Resident 35 Review of the resident's medical records showed they admitted to the facility with diagnoses to include dementia (a decline in mental function from a previously higher level that is severe enough to interfere with daily living), heart failure, and urge incontinence (a sudden, intense urge to urinate, often resulting in involuntary leakage of urine). The 12/05/2025 comprehensive assessment showed Resident 35's cognition was intact, and they required substantial to maximum staff assistance for toileting hygiene and dressing and partial staff assistance for personal hygiene. The assessment showed the resident was frequently incontinent. Review of a 12/23/2025 grievance form showed Resident 35's Representative (RR) reported an allegation that Resident 35 was found with dried toothpaste on their face, shirt, and pants when they arrived at their room to visit on 12/22/2025 at 10:00 AM. The RR reported they assisted the resident down to the day room, which was at the front of the building, and the resident's brief was so wet with urine that they leaked urine all the way down the hallway. The RR reported they wanted Resident 35 treated with dignity. The grievance showed the resident was interviewed by the Social Services (SS) staff on 12/24/2025, the day the concern was reported to them. The SS staff documented the resident had no concerns and felt their care was met timely. Staff B documented the allegation of lack of dignity and timely care could not be substantiated and that abuse and neglect were ruled out. The grievance showed no other interviews had been conducted, no other residents had been interviewed regarding timely care and dignity, no care plan (CP) changes, no alert charting was initiated, and no skin checks had been completed to ensure the resident's skin was still intact after sitting in their urine. The grievance investigation showed there had been facility wide education completed on resident dignity and a one on one write up with the staff involved. No staff member was identified on the grievance (later identified as Staff O, Nursing Assistant (NA)), and no staff statements were obtained. The grievance showed it was completed on 12/31/2025 (eight days after concern was reported to the facility) by Staff B. The grievance investigation showed no root cause or analysis as to why the resident was soaked with urine or why they went without personal hygiene. Review of a Dignity in-service that was attached to the grievance, was dated 12/16/2025, which was prior to this incident happening or being reported. During a telephone interview on 01/28/2026 at 1:56 PM, Staff O stated they did not get called or asked about the incident regarding Resident 35 until 12/29/2025 (six days after the concern was reported to the facility). Staff O stated they were not asked to complete a statement of the incident or what had happened. Staff O stated they were just asked to sign a one-on-one write-up. During an interview on 1/27/2026 at 12:20 PM, Staff B stated they did not investigate the grievance as a possible allegation of neglect because neglect would mean willful and purposeful and they knew that was not the case. Resident 40 Review of the resident's medical records showed they admitted to the facility with heart failure and a lung disease. The 11/20/2025 comprehensive assessment showed Resident 40's cognition was intact, and they were able to use the restroom independently. The assessment also showed Resident 40 was frequently incontinent of their urine. Review of a 12/15/2025 grievance form showed Resident 40 reported an allegation regarding a staff member (later identified as Staff N, NA), and how they spoke to them. The grievance showed the resident was upset and said Staff N entered their room and told them, Would you stop locking the dang door. Resident 40 stated they did not like how Staff N talked to them or blamed them for locking the shared bathroom door. The grievance investigation showed the resident stated the way the Staff N spoke to them was unprofessional and unnecessary. The grievance conclusion was Staff N was removed from the scheduled room and on 12/16/2025 was removed off the routine schedule to that unit. The grievance showed continued education was provided about sharing info on other residents (even though the grievance did not reflect anything about sharing information about other residents). There was no root cause or analysis completed to rule out abuse or neglect, nor were other residents interviewed regarding the interactions they had with Staff N were of a professional manner, no care plan changes, no alert charting to continue to monitor any adverse reactions the resident may have had over the incident. During an interview on 01/28/2026 at 11:13 AM, Resident 40 stated they reported an incident involving Staff N. The resident stated Staff N accused them of locking the shared bathroom door when they last used the bathroom and didn't unlock it when they were finished. The resident, who became tearful during this interview, stated it upset them because Staff N had spoken to them as if they were being scolded and when they attempted to explain to staff N that they had not used the restroom that day, Staff N made them feel as if they were lying, threw their hands up in the air, and walked out of the room while they were talking to them. Resident 40 stated Staff N was removed from their room but then a few days later came back in their room again, where they had an exchange of words again. Review of the Reporting Incident Log from 07/01/2025 through 01/25/2026 showed no allegations of abuse or neglect had been reported for Resident 9, 35 or Resident 40's allegations. During an interview on 01/30/2026 at 2:09 PM, Staff A, Administrator, along with Staff B, stated there was some staff confusion with what should be reported on the grievance log and what should be on the reporting log. Staff A stated they needed to review and revise the grievance policy to ensure they were protecting the residents involved right away and thoroughly investigating allegations of abuse and/or neglect. Reference: WAC 388-97-0640 (6)(a)(b)

Based on observation, interview, and record review, the facility failed to report potential allegations of abuse and/or neglect to the State Agency (SA) for 3 of 3 residents (Residents 9, 35, and 40) reviewed for abuse/neglect. This failed practice placed the residents at risk for unidentified and ongoing abuse and/or neglect. Findings included. Resident 9 Review of the medical record showed Resident 9 was admitted to the facility on [DATE] with a diagnosis of Amyotrophic lateral sclerosis (ALS) (a progressive, fatal, neurogenerative disease that destroys motor neurons leading to loss of movement, speech, swallowing, and breathing capabilities though cognition stays intact.) The 11/17/2025 comprehensive assessment showed Resident 9's cognition was intact and required total assistance with bed mobility, transfers, dressing, toileting, feeding, and personal hygiene. During a concurrent observation and interview with Resident 9 on 01/26/2026 at 1:16 PM, showed them sitting upright in their bed, eyeglasses in place and eyes cast downward looking at something on their iPad (a small computer like electronic device) which was on their lap. Resident 9 communicated by shaking their head yes or no, using a thumbs up signal and indicated by tapping the iPad that they could answer questions by writing on it as well. Attempts by Resident 9 to type on the iPad showed missed letters and spacing errors made it difficult to read the meaning in the writing. Resident 9 showed facial movements and nonverbal sounds that showed frustration at not being able to communicate effectively. Review of the facility grievance logbook on 01/27/2026 at 9:00 AM and the attached incident reports showed an incident occurred on 12/15/2025 between Resident 9 and a facility staff member. Resident 9 reported the staff member did not put their glasses on when they had requested them to do so and just held them out of reach of Resident 9 for a couple of minutes before putting them down on a table and exiting the room. The resident reported she had concerns about the way the staff member had treated them and did not want them to come into their room to provide care any longer. Further review of the grievance report showed Staff B, Director of Nursing, stated they were notified of the incident on 12/23/2025 from Staff E, the Social Services Director (SSD). The DON stated they met with Resident 9 and the staff members that were in the resident's room that day and had gotten their statements of what happened on 12/15/2025. The DON stated they suspended the staff member on 12/23/2025 until the investigation was completed and abuse or neglect could be ruled out. The staff member returned to work on 12/30/2025. During an interview with Staff E, SSD, on 01/28/2026 at 11:40 AM, they stated they had received an email on 12/22/2025 from a community health reporter stating that Resident 9 had made a complaint to their office that the staff at their facility did not know how to care for a person who had ALS and questioned why they had been admitted to this facility if they didn't know how to care for them. Staff E stated they had interviewed Resident 9 after receiving the email and they reported the incident with the eyeglasses at that time. Resident 9 further stated they did not feel cared for or safe in the facility and did not feel like the staff knew how to care for them. Resident 9 stated they felt they had choked several times, and staff did not know how to handle that and did not know how to position their head so it would stay in an upright position. Staff E stated they then reported the incident to the DON for a more thorough investigation and follow-up. Review of the Reporting log from 07/01/2025 through 01/25/2026 showed Resident 9's potential allegation of abuse and/or neglect had not been logged, nor had it been reported to the SA. Resident 35 Review of the resident's medical records showed they admitted with diagnoses to include dementia (a decline in mental function from a previously higher level that is severe enough to interfere with daily living) and Parkinson's (a progressive brain disorder that affects movement) disease. The 12/05/2025 comprehensive assessment showed Resident 35's cognition was intact and required substantial to maximum staff assistance with toileting hygiene, dressing, and partial to moderate staff assistance with personal hygiene. The assessment showed Resident 35 was frequently incontinent with their urine. Review of a 12/23/2025 grievance (a formal or informal complaint about care or living conditions) form showed Resident 35's Representative (RR) reported an incident that occurred on 12/22/2025 while they visited the resident. The grievance showed the resident was sitting in their wheelchair in their room with dried toothpaste on their shirt, pants, and face and when the RR assisted the resident to the dayroom at the front of the building, Resident 35 was so wet with urine that they left a trail of urine down the hallway. The grievance showed the RR stated they wanted the resident treated with dignity. The allegation of neglect was investigated as a grievance. Review of the Reporting log from 07/01/2025 through 01/25/2026 showed Resident 35's potential allegation of neglect had not been reported to the SA. Resident 40 Review of the resident's medical records showed they admitted with diagnoses to include heart failure and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities that were once enjoyable). The 11/12/2025 comprehensive assessment showed Resident 40's cognition was intact and was independent with their toilet transfers and required substantial to maximum assistance from staff for toileting hygiene. Review of a 12/15/2025 grievance form showed Resident 40 reported a concern with a staff member. The grievance showed the resident was upset and did not like the way a Nursing Assistant (NA) spoke to them and had blamed them for locking a shared bathroom door. The grievance showed the NA told the resident Would you stop locking the dang door? The grievance showed the resident stated the way they were spoken to by the NA was unprofessional and unnecessary. The potential allegation of verbal abuse was investigated as a grievance and not as an allegation of abuse. Review of the Reporting log from 07/07/2025 through 01/25/2026 showed Resident 40 had no potential allegation of abuse reported to the SA. During an interview on 01/27/2026 at 1:20 PM, Staff B, Director of Nursing Services, stated they did not report Resident 35 and Resident 40's concerns as allegations of abuse or neglect because they did not think they were allegations of abuse or neglect, allegations of abuse or neglect are purposeful and willful and I did not believe the staff were being either. Reference: WAC 388-97-0640 (5)(a)

Based on interview and record review, the facility failed to develop and implement a system to evaluate, and document demonstrated competencies (a series of knowledge, abilities, skills, experiences and behaviors, which leads to effective performance of staff regarding resident cares) and skill sets for 3 of 3 Licensed Nurses (Staff D,M and Q) reviewed for staff competencies. This deficient practice placed all residents at risk of receiving care from inadequately trained staff and unmet care needs.Findings included.Washington State Board of Nursing (an entity that regulates the competency and quality of nurses to protect the health and safety of the public) defined nurse competency in reference to [NAME] Administrative Code 246-840-210(5) titled, Continuing Competency .the ongoing ability of a nurse to maintain, updated, and demonstrate sufficient knowledge, skills, judgement, and qualifications to practice safely and ethically .Review of the Facility Assessment, updated January 2026, showed the facility maintains an ongoing process for staff training, education, and competency validation to ensure staff are prepared to meet resident care needs and regulatory requirements and staff education and competency needs are assessed through ongoing observation, quality assurance activities, incident review, and interdisciplinary team feedback.Review of staff personnel files showed the following:Staff D, Registered Nurse (RN), was hired on 10/18/2018 and had no documentation of demonstrated competencies, skills, or performance evaluations.Staff M, Licensed Practical Nurse (LPN), was hired on 12/19/2024 and had no documentation of demonstrated competencies, skills, or performance evaluations.Staff Q, LPN-Staff Development Director, was hired on 07/26/2020, and had no documentation of demonstrated competencies, skills, or performance evaluations.During an interview, on 01/27/2026 at 2:45 PM, Staff B, Director of Nursing Services (DNS), stated they were new to the DNS role and had not completed any competencies or skills evaluations of the LNs. Staff B stated they met with Human Resources (HR) staff and were unable to find any previous evaluations for the sampled LN staff. Staff B stated this was a process they needed to work on. Reference: WAC 388-97-1080(1)

Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) assessments were completed for residents following significant change in status or with newly evident or possible serious mental disorders for 3 of 7 residents (Resident 23, 59, and 31) reviewed for unnecessary medications. This failure resulted in a potential delay in access to Level 2 PASARR services and decreased quality of life. Findings included .Resident 31 Review of the resident's medical records showed they admitted to the facility with diagnoses to include heart failure and a stroke (when blood flow to the brain is interrupted from a blocked or burst of a blood vessel) with deficits to their right side. The 01/02/2026 comprehensive assessment showed Resident 31's cognition was severely impaired, had a diagnosis of dementia (the loss of cognitive functioning; thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and received anti-depressant (medication to help decrease symptoms of depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]). Review of a provider note dated 07/01/2025 showed Resident 31 experienced cognitive decline and increased behaviors and there was a concern for vascular dementia (a type of dementia that leads to cognitive impairment and behavioral changes) and ordered some diagnostic tests. A note on 07/15/2025 showed Resident 31 had yelling, cussing, and hitting staff and was could not be easily redirected. The note showed the resident was refusing meals and care at times and was given a new diagnosis of vascular dementia with behavioral disturbances and an anti-depressant medication was started to help with the resident's weight loss. A note on 08/18/2025 showed the resident refused cares and experienced angry outbursts. A note on 09/23/2025 showed Resident 31 experienced behaviors of yelling, cussing, and hitting staff. The note showed the resident was agitated with the provider during their visit. The note also showed a second anti-depressant medication was started for the dementia with behaviors. Review of Resident 31's Level 1 PASARR, dated 02/03/2023, showed a new one had not been completed to reflect Resident 31's significant change, new diagnosis, behaviors, or medications. Resident 23 Review of the medical record showed Resident 23 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of a broken right collar bone, repeated falls, and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) without behavioral disturbances. Review of the comprehensive assessment, dated 01/14/2026, showed Resident 23 had severe cognitive impairment and was taking antidepressant (medication to help decrease symptoms of depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) medication and anticonvulsant (a type of drug that is used to prevent or treat seizures or convulsions by controlling abnormal electrical activity in the brain) medication. Review of the PASARR, dated 07/23/2025, showed Resident 23 had no indication of a serious mental illness and did not require a level 2 evaluation (a process of evaluating a resident's current behavioral health conditions to identify the need for further support services). Review of the facility provider note, dated 07/29/2025, showed Resident 23 was started on an antipsychotic [a type of drug used to treat symptoms of psychosis such as hallucinations (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real), delusions (false beliefs), and dementia] medication for the management of aggressive behaviors toward staff, refusals of care, and impulsive behaviors. A new diagnosis of dementia with behavioral disturbance was listed as the indication for use. Review of the pharmacy Medication Regime Review (MRR), dated 11/07/2025, showed the recommendation of discontinuing the antipsychotic medication for Resident 23's behaviors and initiating an antidepressant and/or an anticonvulsant medication used to treat mood disorders. The MRR showed review of Resident 23's target behaviors (impulsive, irritable, verbally and physically aggressive toward staff) were only marginally improved with the antipsychotic medication and the antidepressant medication recommended was the drug of choice to manage dementia with behaviors. Review of Resident 23's physician's orders showed a new order, dated 11/10/2025, was received to taper and discontinue the antipsychotic medication and to initiate the anticonvulsant medication for the indication of dementia with behaviors. Review of the medical record showed no other PASARR completed for Resident 23. Resident 59 Review of the medical record showed Resident 59 admitted to the facility on [DATE] with diagnoses of dementia without behavior, history of deep vein thrombosis, and arthritis. Review of the comprehensive assessment, dated 12/31/2025, showed Resident 23 had severe cognitive impairment, was taking antipsychotic, antidepressant, and anticonvulsant medications. Review of the medical record showed Resident 23's PASARR was undated and showed no indication for a level 2 screening for serious mental illness. Review of the facility provider note, dated 07/29/2025, showed Resident 23 was started on an anticonvulsant medication used to treat mood disorders with the indication of dementia with behavioral disturbance. The provider note showed Resident 23 was showing an increase in aggressive and sexual behaviors toward others. Review of the facility provider note, dated 09/02/2025, showed Resident 23 showed a continued increase in aggressive and sexual behaviors and an antidepressant medication was started with the indication of use dementia with behavioral disturbance. Review of the medical record showed no other PASARR was completed for Resident 23. During an interview, on 01/26/2026 at 5:23 PM, Staff A, Administrator, stated the facility's process for reviewing and updating residents' PASARRs after admission was when there was a significant change or a change in medications. During an interview, on 01/30/2026 at 9:39 AM, Staff E, Social Services Director, stated psychotropic medications (such as antipsychotics, antidepressants, and anticonvulsants) were used to treat the residents' behavior and not their diagnosis of dementia. Staff E stated the actual behavior diagnosis should be listed as the medication's indication for use, and this would trigger a review and update to the resident's PASARR. Staff E stated they were not aware this was being done incorrectly. Reference: WAC 388-97-1975 (7)(9)

Based on interview and record review, the facility failed to implement 4 of 8 components (identify, protect, report, and investigate), of their abuse/neglect policy/procedure for 3 of 3 residents (Residents 9, 35, and 40) reviewed for allegations of abuse/neglect. This failure placed the residents at risk for unrecognized abuse and unmet care needs. Findings included .Review of a 01/2026 policy titled Abuse, Neglect and Exploitation, showed the facility would prohibit and prevent abuse, neglect, and.of residents. with ongoing oversight and supervision of staff to ensure policies were being implemented. Review of the grievance (a formal or informal complaint about care or living conditions) log, dated 07/01/2025 through 01/25/2026, showed allegations of abuse and/or neglect that had not been identified, reported, or investigated as allegations of abuse and/or neglect, nor were the resident's provided protection from further abuse and/or neglect. The logs showed: On 12/23/2025 a staff concern issue was logged for Resident 9 regarding lack of assistance/care was provided from Staff M, Licensed Practical Nurse when asked. The log showed a completed date of 01/30/2026 (seven days after concern was reported). On 12/15/2025 a staff concern issue was logged for Resident 40 regarding a verbal confrontation with Staff N, Nursing Assistant. The log showed a completed date of 12/22/2025 (seven days after concern was reported). On 12/22/2025 a staff concern issue was logged for Resident 35; the concern was made by the Resident's Representative (RR). The issue showed Resident 35 was left with a soiled face, clothing, and their brief was so wet with urine that they dripped urine all the way down the hallway. The log showed no completion date. Review of the reporting log (a record used to document incidents that may involve abuse, neglect, or mistreatment of residents), dated 07/01/2025 through 01/25/2026, showed none of the grievances for Residents 9, 35, and 40 had been logged or thoroughly investigated to rule out abuse or neglect. Therefore, Residents 9, 35, and 40 were not protected from the possibility of ongoing abuse or neglect. During an interview on 01/30/2026, Staff A, Administrator, along with Staff B, Director of Nursing Services, stated there was some confusion with what concerns should be put on the grievance log versus the Reporting log and the policies needed updated. Staff A stated the nursing staff should have been logging allegations of not receiving appropriate care concerns on the incident log, and not on the grievance log. Staff A and Staff B both stated the grievance log concerns of Residents 9, 35, and 40 were not identified as allegations of abuse and/or neglect and should have been thoroughly investigated as allegations of abuse and neglect. Reference: WAC 388-97-0640 (2)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure the call light and bedside table was within reach and easily accessible for 1 of 3 residents (Resident 13) reviewed for reasonable accommodations. This deficient practice prevented the resident from independently accessing personal items such as their bedside beverage, using the call light, and placed them at risk for unmet care needs.Findings included .Review of the medical record showed Resident 13 had diagnoses of anoxic brain injury (occurs when the brain received no oxygen), hemiplegia (paralysis) of the left side, and loss of vision to left eye. Review of the comprehensive assessment, dated 12/31/2025, showed Resident 13 had moderate cognitive impairment and was dependent on the assistance of one to two people for dressing, hygiene, incontinent care, bathing, and transfers using a mechanical lift.Review of Resident 13's care plan, on 01/29/2026, showed Resident 13 was blind in their left eye, had limited vision in their right eye, was able to use the call light appropriately, and their call light was to be left within reach. Additionally, the care plan showed Resident 13 liked to drink a Diet Coke daily.During observations, on 01/25/2026 at 8:58 AM, 01/25/2026 at 12:59 PM, 01/26/2026 at 9:59 AM, 01/26/2026 at 1:01 PM, and 01/27/2026 at 2:37 PM, showed Resident 13 sitting in their wheelchair in their room with their left side closest to the bed and their bedside table behind them. The call light was on the bed, and their bedside beverage was on their bedside table, and both were out of Resident 13's reach.During a concurrent observation and interview, on 01/28/2026 at 10:43 AM, showed Resident 13 sitting in their wheelchair in their room with their left side next to the bed. Resident 13 stated they would use their button to request assistance from staff and let them know they were ready for their Diet Coke. Resident 13 used their right hand to reach over their lap and touch the bed on their left side while asking where the call light was. Resident 13 was unable to locate their call light and was unable to access their personal belongings on their bedside table as the table was behind Resident 13's wheelchair.During an interview, on 01/30/2026 at 12:21 PM, Staff K, Restorative Director, stated Resident 13 had decreased range of motion to both of their upper extremities, but the left side was more significant. Staff K stated Resident 13's call light would need to be intentionally placed within Resident 13's reach due to their limited reaching ability and limited vision. Staff K stated Resident 13's bedside table needed to be placed in front of them, within reach, for them to access their personal belongings such as their bedside beverage.During an interview, on 01/30/2026 at 1:10 PM, Staff B, Director of Nursing, stated all residents should have their call light and their bedside table within reach.Reference: WAC 388-97-0860 (2)

Based on interview, and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews (PASARR), (an assessment to ensure individuals with serious mental illness (SMI) or intellectual/developmental disabilities are not inappropriately placed in nursing homes for long term care) were completed prior to admission and/or corrected or updated as required to reflect a Level 2 screening was completed for 2 of 7 residents, (Residents 4 and 9) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.Findings included .Resident 4 Review of the medical record showed Resident 4 was admitted to the facility on [DATE] with diagnoses including dementia (a decline in mental abilities, characterized by the loss of memory, language, problem solving and other thinking skills), psychotic disturbance (a severe mental disruption that causes a person to lose touch with reality causing impaired thinking, emotions and behaviors), mood disturbance (a mental health condition characterized by persistent, intense, and long lasting changes in emotional states that disrupts daily life), anxiety, and Post-Traumatic Stress Disorder. (PTSD) (a mental health condition that can develop after experiencing or witnessing a traumatic event that involved the threat of death, serious injury, or sexual violence). The 01/22/2026 comprehensive assessment showed Resident 4 was cognitively intact and required minimum assistance with ADLs. Review of a Level 1 PASARR screening form for Resident 4 dated 4/18/2025 from the discharging hospital, showed Section IA had no SMI indicators checked though dementia was written to the side of the form. In addition, Section IV showed a Level 2 evaluation was not indicated. Further review showed a Level 1 PASARR was corrected by facility staff on 04/23/2025 indicating in Section A1 that Resident 4 had a diagnosis of a mood disorder and PTSD. Section IV showed a Level 2 evaluation was not indicated. Resident 9 Review of the medical record showed Resident 9 was admitted to the facility on [DATE] with a diagnosis of Amyotrophic lateral sclerosis (ALS) (a progressive, fatal, neurogenerative disease that destroys motor neurons leading to loss of movement, speech, swallowing, and breathing capabilities though cognition stays intact.) depression, anxiety, and PTSD. The 11/17/2025 comprehensive assessment showed Resident 9's cognition was intact and required total assistance with ADLs. Review of a Level I PASARR screening form dated 08/21/2025, showed Resident 9 was admitted from home to the facility on [DATE] and in Section 1A had no diagnoses checked for serious mental illness by the physician who filled out the form, though diagnoses of depression, anxiety, and PTSD were listed as current diagnoses on Resident 9's admission paperwork. Section IV showed no Level 2 evaluation was indicated. Facility staff corrected the PASARR screening form on 08/21/2025 showing in Section IA that Resident 9 had diagnoses of depression, anxiety, and PTSD. Section IV showed a Level 2 evaluation was not indicated. During an interview on 01/26/2026 at 5:23 PM with Staff E, Social Services Director (SSD) and Staff A, Administrator, they stated the SSD was responsible for assuring that the PASARR forms were completed prior to admission from the hospital and corrected or updated the forms if the discharging hospital or provider were not accurate per the admission diagnoses. Staff E and Staff A stated they had received the Dear Administrator letter dated 07/06/2024 on changes to the Level 1 screening process though did not understand from the letters information that they needed to assure all residents in the facility should be evaluated with the new form for accuracy and sent out for a Level 2 assessment by evaluators if there were any diagnosis of a serious mental health indicator in Section IA of the form. During the same interview, Staff E and Staff A stated they thought they just had to assure new admissions or residents with a change in condition or medications had to have a new PASARR form be corrected or updated from their last completed form and sent to the PASSAR evaluators if necessary. Staff E stated they had not checked to see if all residents with SMI indicators needed to have an evaluation by the PASARR screeners because the facility's medical director was monitoring their mental health diagnoses and taking care of and evaluating any antipsychotic medications the residents were on and thought that was meeting the need for a Level 2 evaluation. In addition, Staff E stated they had been sending some new PASARR forms in for a Level 2 evaluation of new admissions with any mental health indicators that were not being followed by the medical director and those with a change in their mental health status and/or medications. The SSD stated the evaluators for a positive Level 1 PASARR requested a lot of resident information be sent to them and then it took them a long time to get anything back from them about a Level 2 determination of services. Reference: WAC 388-97-1915(1)(2)(a-c)

Number of residents sampled: Number of residents cited: Review of the resident's medical records showed they admitted to the facility with diagnoses to include hydronephrosis (one or both kidneys cannot drain from the kidney to the bladder) with obstruction from kidney stones (hard, pebble like pieces of material that form in the kidneys) and kidney disease. Review of the 01/02/2026 significant change comprehensive assessment showed Resident 31's cognition was severely impaired, required the use of an RC, and did not experience pain. Additional review of Resident 31's medical records showed they had been admitted to Hospice services on 01/02/2026 for a primary diagnosis of Cerebrovascular disease (conditions that affect blood flow to your brain). An observation and concurrent interview at 01/26/2026 at 5:21 PM, Resident 31 was observed lying in bed with their Resident Representative (RR) sitting in a chair at their bedside. The RC tubing and bag were hanging down to the left side of the bed and hanging on the bed frame. The RC bag had less than 100 milliliters (mL, a unit of measure) of red urine, mixed with yellow color. The tubing had more than 10 inches (in, a unit of measure) of thick, white, chunky sediment that appeared to be blocking the urine from flowing downward. The tubing also had red dried specks on the inside walls of the tubing and urine above the thick white sediment. There was no urine in the tubing below the area of sediment. The RR stated the resident experienced pain when urinating, burning pain and the resident was observed with their left hand over their body, grasping the right handrail on the bed so tightly that their finger color went white in color, and wincing (reacting with a slight involuntary grimace or shrinking movement of the body) with a slight moaning sound. The RR stated the resident was urinating. The RR stated the urine symptoms were new and so was the reddish color in the urine and stated they had reported the change to the nurse currently working (later identified at Staff D, Registered Nurse (RN), and on 01/25/2026 to the Charge Nurse (later identified as Staff C, Charge Nurse (CN)). The RR stated Staff C told them on 01/25/2026 they would see if they could culture the resident's urine to rule out a possible infection, but they did not get any follow up from that. The RR stated Staff D told them that day, 01/26/2026, they were conferring with the others (Licensed Nurses (LNs)) about what they could do for the resident. During an observation on 01/27/2026 at 9:56 AM, Resident 31 was lying in bed with their left hand over their body, grasping onto the right-side bed rail with grimacing to their face and their forehead in a frowning position. The RC continued to have thick, white, chunks sediment in it as seen on 01/26/2026 which appeared to have slightly moved down the RC tubing, 300 mL of reddish/yellow urine in the bag. Review of the Nursing progress notes from 01/25/2026 to 01/27/2026 showed no progress notes pertaining to the RR's urine symptoms reported to two LNs, ongoing monitoring of the urine symptoms and increased discomfort, or the sediment and reddish/yellow urine in the RC. The progress notes showed no documentation that notification to Hospice services had been made. The notes showed the Hospice Nurse had been in to see Resident 31 on 01/27/2026 at 11:38 AM and reviewed the efficacy of the pain medication recently prescribed and no new orders. Review of the physician orders showed an order on 12/23/2025 for Acetic Acid Irrigation (a procedure used to cleanse the inside of the bladder in people who use a catheter for a long period of time to prevent infection and calcium buildup) three times a day as needed for occlusion or blockage in the RC (this had not been used since ordered on 12/23/2025). Review of the 01/02/2026 Hospice care plan showed the Hospice nurse or the facility nurse could obtain a dipstick urine test for symptom management, and the Hospice RN could flush the RC as needed. The care plan showed the resident experienced non-verbal signs of pain with repositioning and grasping at the rails. Review of the Hospice Nurse visit notes that showed no assessment or knowledge of the urine symptoms, the catheter sediment, or the reddish/yellow colored urine, or the increased discomfort Resident 31 experienced. The note showed to continue the plan of care and call for changes, questions, or concerns. During an interview on 01/28/2026 at 3:29 PM, the Collateral Contact (CC) stated the communication process for changes in condition would be that the facility called Hospice and informed them of any issues the resident was having. The CC stated Resident 31's urine had been dark yellow with small bits of sediment in the RC tubing, and they had not visualized the RC on their visit on 01/27/2026. The CC stated they were not informed of the increased urine symptoms of discomfort and burning when urinating and had they known, they could have assessed the patency (the state of being opened or obstructed) of the RC and if it there was suspicion of a urine infection, they could have provided treatment without a dipstick urine test. The CC stated they were not aware the resident had an order for the Acetic Acid irrigations. The CC stated they did not plan to see the resident anymore this week and would be back to see them next Tuesday, 02/03/2026. During a telephone interview on 01/28/2026 at 3:46 PM, Staff D stated the RR reported to them that Resident 31 had experienced pain and burning when urinating. Staff D stated they assessed the RC and it had particles in the tubing. Staff D stated they attempted to give them pain medication, but the pill was too big, and Resident 31 could not swallow it. Staff D stated that 30 minutes later they returned and cut the pill in half and the resident was able to swallow it. Staff D stated the urine was blood tinged, but not blood tinged, maybe more of an amber color. Staff D stated they had notified Staff C on 01/25/2026 and had made a progress note the day before but Staff D was busy. Staff C stated they did not know Resident 31 had an Acetic Acid irrigation order and did not assess the patency of the catheter. Staff D stated their process for notification of changes in condition were to report to the CN, which they did, and then if there was no CN they were to complete a progress note. Staff D stated they were to notify Hospice if the resident needed a certain medication but did not know if they were to notify Hospice for a change in condition of the resident, I would not know that to be honest, this is a learning process for me. An observation and concurrent interview on 01/28/2026 at 5:23 PM, the RR was observed outside of the resident's room talking with a Nursing Assistant (NA). The RR stated Resident 31 was in pain when urinating and when they asked the resident if they were in pain, the resident yelled at me, yes! The RR stated the hospice nurse visited Resident 31 on 01/27/2026 and they had asked for them to be present when they visited but they did not know they would arrive earlier in the morning before they arrived. The RR stated they were sure the resident had a urine infection because they themselves had experienced one before and they were all the same symptoms, [Resident 31] needs to be treated. During an interview on 01/29/2026 at 11:13 AM, Staff K, Restorative Director, stated they observed Resident 31 in pain with repositioning, and they would also grab onto the bed rails when they were in pain, and then at the same time, deny they were in pain. Staff K stated they would have used the Acetic Acid irrigation if they had observed lower urine flow or increased sediment in the tubing. Staff K stated they did not know Resident 31 had an order for Acetic Acid. An observation and concurrent interview on 01/29/2026 at 11:33 AM, Staff L, NA, stated the nurse changed the RC this morning, 01/29/2026, and Resident 31 looked more comfortable today than they had in the past few days. The RC bag had no urine in the bag or the tube and no sediment in the tubing. The resident was lying in bed, no wincing or grabbing onto the bed rail. During an interview on 01/30/2026 at 3:06 PM, Staff C stated they were informed by Staff D that Resident 31 was having issues with their urine. Staff C stated their normal process would have been to assess the resident and communicate to Hospice, initiate alert charting and communications, but they did not follow that process this time. Staff C stated with Resident 31 and their verbal communication issues and language barrier, staff should have used the Advanced Dementia (AD, a pain assessment tool used for non-verbal pain indicators) pain tool to assess for pain and not just rely on asking them. During an interview on 01/30/2026 at 1:20 PM, Staff B, Director of Nursing Services, along with Staff A, Administrator, stated they would expect Nursing staff to communicate with Hospice any changes in condition with the resident and for there to be ongoing monitoring and charting. Staff B stated the resident had ongoing issues with their urine and catheter and did not feel that there was a change in their condition. Staff B stated Resident 31 would be asked if they had pain and denied having pain unless their RR was present. Reference: WAC 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to thoroughly assess, monitor, and identify the potential need for positioning and Range of Motion (ROM) services to prevent a contracture (a permanent tightening of the muscles, tendons, and skin often leading to rigidity of joints) or decrease in ROM to the affected hand of 1 of 2 residents (Resident 51) with hemiplegia (paralysis to one side of the body) reviewed for restorative services. This deficient practice placed residents at risk for unidentified contractures, decrease in ROM, and potentially the increase in dependence of others to complete Activities of Daily Living.Findings included.Review of the facility policy, Restorative Programs and Guidelines, dated 01/14/2026, showed all residents would be assessed for restorative potential when newly admitted to the facility, when discharged from therapy, and with every Minimum Data Set [(MDS) a standardized assessment tool that measures health status in nursing home residents] assessment.Review of the medical record showed Resident 51 admitted to the facility, on 07/22/2025, with diagnoses of left side hemiplegia and history of stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or ruptures). Review of the comprehensive assessment, dated 01/16/2026, showed Resident 51 had moderate cognitive impairment and required the assistance of one to two people with dressing, transfers, toileting, incontinent care, and bathing.Review of the Functional Safety Assessments dated 07/22/2025, 10/16/2025, and 01/16/2026, showed Resident 51 was assessed to have no contractures causing physical limitations and was at risk for developing contractures due to limited mobility.Review of the facility provider visit note, dated 07/29/2025, showed Resident 51 had some slight movement of left upper arm. (Left) hand with slight contracture. Able to move Left Lower Extremity.Review of the facility provider visit note, dated 09/23/2025, showed Resident 51's physical examination showed contracture to left hand and left arm weakness, is able to move slightly.Review of Resident 51's Restorative Program care plan, dated 11/26/2025, showed the goal of using the Omnicycle (a motorized rehabilitation device that uses a smart motor to help patients exercise when they have limited strength, endurance or muscle control) to prevent contractures and maintain upper body strength.During a concurrent observation and interview, on 01/26/2026 at 3:24 PM, Resident 51 stated they did not wear a splint or brace on their left hand and they try to remember to do the finger stretches but would forget. Resident 51 demonstrated the finger stretches to their left index, middle, ring, and pinkie finger independently, but was unable to stretch and extend their left thumb. Resident 51 stated, yep, it's starting to get stuck.During an interview, on 01/30/2026 at 12:21 PM, Staff K, Restorative Director, stated restorative programs were created by the therapy department when a resident was ready to discharge, and they implemented the program with periodic reassessments. Staff K stated Resident 51's ROM program was focused on their upper arms, and they had never assessed Resident 51's left hand for signs of contracture. Staff K stated Resident 51 was at risk for contracture due to their left side affected hemiplegia, but they did not currently have a restorative program focused specifically on Resident 51's left hand. Staff K stated they would not be able to determine if Resident 51's left hand was more or less contracted compared to when they admitted because they had never assessed it.During an interview, on 01/20/2026 at 1:21 PM, Staff B, Director of Nursing, stated Resident 51's left hand should have been assessed and monitored for potential or worsening contracture. Reference: WAC 388-97-1060(3)(d)

Based on observation, interview, and record review, the facility failed to provide the ordered therapeutic diet with modified texture of food and liquids for 1 of 3 residents (Resident 51) reviewed for nutrition. This deficient practice placed residents at risk of choking or aspirating (when food or liquid accidentally enters the airway and lungs instead of going into the stomach) on their food and liquids and potentially causing health complications including death.Findings included.Review of the facility policy, Diets/Diet Orders, dated 05/15/2024, showed the facility provided five modified texture food diets: mechanical soft (food made of moist and soft textures making it easier to chew and swallow), mechanical soft with chopped/shredded meats, mechanical soft with ground meats, pureed (blending or mashing cooked food into a completely smooth, thick, lump-free paste with the consistency of pudding) , and full liquid. The policy showed thickened liquids (modified liquid consistency) would be pre-made by the kitchen and placed on the residents' trays.Review of the medical record showed Resident 51 admitted to the facility, on 07/22/2025, with diagnoses of left side hemiplegia (paralysis of one side of the body) and history of stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or ruptures). Review of comprehensive assessment, dated 01/16/2026, showed Resident 51 had moderate cognitive impairment, required supervision while eating, and had coughing and choking during meals.Review of the nursing progress note (PN), dated 01/23/2026, showed Resident 51 was observed to be coughing while eating their meal near nurse's station. The PN showed Resident 51 was eating at a fast pace, required frequent cueing to slow down, and was coughing with eating and drinking. Review of Resident 51's Physician's Orders showed on 01/23/2026 a three-day trial for a downgraded (change to the next modified texture level for easier chewing and swallowing) diet of mechanical soft with ground meat and nectar thick (consistency of maple syrup or tomato juice) liquids was obtained.During an observation, on 01/25/2026 at 3:57 PM, Resident 51 was lying in bed watching TV and their bedside beverage cup was filled with ice water.Review of the nursing PN, dated 01/26/2026 at 1:30 PM, showed Staff K, Restorative Director reassessed Resident 51 after the three-day trial of the downgraded diet texture and found Resident 51 tolerated it well with less coughing while swallowing. The PN showed Resident 51 stated they liked the diet texture change and was agreeable to it ongoing. The PN showed a permanent diet order for mechanical soft with ground meat and nectar thick liquids was obtained for Resident 51 and a copy was provided to the dietary manager in the kitchen.During a concurrent observation and interview, on 01/26/2026 at 3:23 PM, Resident 51 stated they liked their new diet and had not been coughing as much during meals. Resident 51 stated they liked the nectar thick liquids because it made their drinks taste malted. When asked if their bedside beverage cup had nectar thick liquids in it, Resident 51 stated, no, its regular ice water.During a concurrent observation and interview, on 01/26/2026 at 5:41 PM, Resident 51 was sitting up in bed eating their dinner-a piece of pepperoni pizza cut into one-inch pieces, vanilla pudding, and a cup of juice. Resident 51 stated the pizza was kind of hard to chew, especially the crispy edges and the juice was not thickened.During a concurrent observation and interview, on 01/26/2026 at 5:50 PM, Staff R, Nursing Assistant (NA) reviewed and stated Resident 51's diet card from the kitchen showed the diet texture of mechanical soft and the liquid consistency of thin.During a concurrent observation and interview, on 01/27/2026 at 9:10 AM, Resident 51 was sitting up in bed and stated they just finished their breakfast. Resident 51 stated their food was chopped and easy to chew and swallow, and the beverages were thickened. When asked if their bedside beverage cup had thickened liquids, Resident 51 stated, no, its just ice water in there.During an interview, on 01/29/2026 at 1:42 PM, Staff K stated diet changes were communicated to kitchen staff with a diet change form and to nursing staff verbally or using the dashboard in the Electronic Health Record (EHR) system. Staff K stated they expected diet changes to be implemented immediately, especially when safety was a concern. Staff K stated they provided the diet change form for Resident 51 to Staff I, Kitchen Manager, on 01/26/2026, but did not place the update on the dashboard in the EHR. Staff K stated Resident 51's bedside beverage should not have been iced water.During an interview, on 01/29/2026 at 2:30 PM, Staff B, Director of Nursing Services (DNS) stated they expected diet changes to be implemented right away, and that information was communicated to the nursing staff by writing the update on the daily assignment sheet. Staff B stated Resident 51 being served the incorrect diet texture and liquid consistency must have been a miscommunication.During an interview, on 01/30/2026 at 12:35 PM, Staff I stated they messed up and did not update Resident 51's diet card on 01/26/2026, but made sure it was fixed when they worked on 01/27/2026. Reference: WAC 388-97-1060 (3)(h)

Based on observation and interview, the facility failed to maintain a bedside suction machine in a clean and sanitary manner that met infection control standards of practice for 1 of 2 residents (Resident 60) reviewed for infection control related to respiratory equipment. This deficient practice placed residents at risk of the transmission of infectious organisms (germs such as bacteria, viruses, fungi or parasites) with the potential of developing Healthcare Associated Infections [(HAIs) an infection a person gets while receiving treatment for a different condition].Findings included.Review of [NAME] Manual of Nursing Practice, 11th edition, showed the standard of practice for oropharyngeal (mouth and throat) suctioning was to use a clean (reduction of germs by using soap, water, and clean gloves) technique and to replace suction tubing and attachments at least every 24 hours. Review of the medical record showed Resident 60 admitted to the facility on [DATE] with diagnoses of stroke (occurs when the blood supply to part of the brain is blocked or reduced), hemiplegia (paralysis) of the right side, and dysphagia (difficulty swallowing).Review of the Medication Administration Records (MARs) for January 2026 showed Resident 60 had orders for oral suctioning as needed for excessive secretions.Observations on 01/25/2026 at 1:37 PM, 01/26/2026 at 10:58 AM, 01/27/2026 at 10:00 AM, and 01/28/2026 at 3:39 PM showed a bedside suction machine on the nightstand next to Resident 60's bed. The canister was labeled with the date 01/01/26, and was half full (400 milliliters [(mL) unit of measure] of a light-yellow liquid with multiple white particles floating at the top.During an interview, on 01/29/2026 at 2:00 PM, Staff R, Nursing Assistant (NA), stated the Licensed Nurses (LNs) were the only staff to use the bedside suction machine and they were responsible for cleaning it.During a concurrent observation and interview, on 01/29/2026 at 5:11 PM, Staff P, Infection Preventionist (IP), stated the facility process was to discard the suction machine canister, liners, and tubing after use and replace with new ones. Staff P stated Resident 60's bedside suction machine should not have been left like that.During an interview, on 01/30/2026 at 12:27 PM, Staff B, Director of Nursing Services (DNS), stated the LNs should have disposed of and replaced the bedside suction machine's materials and set it up for the next use.Reference: WAC 388-97-1320 (1)(a)(5)(a-c)

Based on observation, interview, and record review, the facility failed to ensure expired foods were discarded for 1 of 1 dry storage area and failed to consistently monitor refrigerator temperatures for 2 of 3 refrigerators (the kitchen snack refrigerator and a small black refrigerator), reviewed for food safety. These failures placed residents at an increased risk for food-borne illnesses. Findings include . Review of the undated policy titled, Receiving, Inventory and Storage, Food Storage showed food items should be received and handled in accordance with good sanitary practice. The dry foods would be rotated, labeled, dated, and discarded on the expiration date. The facility ' s policy further showed a temperature record was to be kept of all refrigerated items. <Expired Foods> During an observation on [DATE] at 8:16 AM, the initial kitchen tour with Staff K, Cook, showed the dry storage area contained the following expired foods: one box of spinach wraps; expiration date of [DATE]. two boxes of white corn tortillas; expiration date of [DATE]. seven packs of flour tortillas; expiration date of [DATE]. During an interview on [DATE] at 8:10 AM, Staff K, confirmed that the flour tortillas were served during the lunch meal on [DATE]. Staff K stated they mistakenly assumed that the tortillas were fresh. Staff K stated that the Dietary Manager disposed of them on [DATE]. <Refrigerator Temperatures> During an observation on [DATE] at 8:26 AM, the kitchen snack refrigerator did not have a temperature log of recorded temperatures. Staff K stated, We don't have a temperature log for that refrigerator right now. Staff K stated that the refrigerator held salads, snacks, juices, and milk for the residents. During an observation on [DATE] at 8:32 AM, a small black refrigerator contained more than 10 Mighty Health Shakes (a nutritional shake that can add protein and calories to a diet). The temperature log had one temperature recorded for [DATE] on [DATE] at 3:00 PM. During an interview on [DATE] at 8:54 AM, Staff L, Dietary Manager, stated upon a food delivery, it was the responsibility of the staff to organize the items. The process included moving the older food items to the front and placing the new items at the back to ensure proper food rotation. Staff L emphasized the importance of staff checking the expiration dates prior to usage. Staff L stated that the small black refrigerator, which had previously been designated for the nurses ' medication cart, was currently not in use. Additionally, Staff L acknowledged the temperature log had not been completed for the month of [DATE]. During an interview on [DATE] at 10:54 AM, Staff A, Administrator, stated there was an expectation for the dietary staff to rotate food items and ensure that any expired food was properly discarded. Staff A stated they were aware of the temperatures not being documented on the refrigerator temperature logs and indicated that the small black refrigerator would be removed. Reference: WAC [DATE] (3)

Based on observation, interview and record review, the facility failed to ensure that residents who had an indwelling urinary catheter (IUC, a tube placed in the bladder which drains urine out into a collection bag) received care and services to prevent urinary tract infections (UTI, a condition were bacteria enter through the urinary meatus [a passage or opening leading to the interior of the body] and infect the kidneys or bladder) for 1 of 3 residents (Resident 7), reviewed for urinary catheter care. This failure placed the residents at risk of developing medical complications, secondary to an infection in the bladder. Findings included . Review of the facility's policy titled, Indwelling catheter Insertion and Care, dated January 2025 showed that it was the policy of the facility to .provide for the use of indwelling catheters per physician orders . Review of the facility's policy titled, Catheter Management, revised 08/13/2019, showed IUC were .only changed as necessary (i.e., when it becomes occluded, contaminated, or the integrity of the catheter or the system is compromised). <Resident 7> Review of the resident's medical record showed that they were admitted on [DATE] with a recent readmission from the hospital on 11/20/2024 for diagnoses including UTI and dementia (a progressive disease that destroys the memory and other important mental functions). Review of the 11/21/2024 comprehensive assessment showed the resident had a severely impaired cognition and had a IUC for bladder elimination. Review of Resident 7's hospital records, dated 11/19/2024 showed the resident admitted due to septic shock (a life-threatening medical condition that occurs in the body when faced with a widespread infection that can lead to organ failure and extremely low blood pressure) after/resulting from a complicated UTI. The record showed a physician order to .continue foley (another name for an IUC) on discharge for suspected neurogenic bladder (a urinary bladder problem due to disease or injury to the body nervous system that controls when/how the bladder empties); change every four weeks, placed 11/10/2024, and to follow-up with a urologist (a specialist physician for urinary tract issues). Review of Resident 7's facility provider note, dated 11/25/2024 showed orders to changed r/c (retention catheter or IUC) and obtain urine, send for urinalysis (a laboratory test that examines the urine), culture and sensitivity (identification of the germs causing the infection and what antibiotic would be best to treat the infection identified) Review of Resident 7's November 2024 facility provider orders showed that on 11/25/2024 orders to changed IUC and obtain urinalysis (a laboratory test that examines the urine), one time, was completed for the resident. No other orders on the type/size of the IUC, frequency for changing the IUC/drainage collection bag nor if nursing staff were monitoring signs/symptoms (indications of illness, injury or condition) of complications/infection regarding Resident 7's IUC. Review of Resident 7's facility provider note, dated 12/05/2024 showed orders for nursing staff to follow the plan of care per urology. Review of Resident 7's urologist provider visit, dated 12/06/2024 showed the resident a neurogenic bladder with urinary retention (a condition where the body is unable to empty the bladder), recommended a long term IUC. Additionally, the urologist ordered, please change foley catheter every four weeks. (Resident 7) is due for change now. Review of Resident 7's December 2024 provider orders showed the orders for the resident IUC to be changed every four weeks and to have the IUC changed after the urologist appointment were not put in nor completed for the resident. During a concurrent observation and interview on 01/28/2025 at 11:29 AM, Resident 7 was lying in bed, with their half full catheter bag resting on the floor, below the resident bed, pulling downwards, putting tension at the clear/plastic drainage tube to rubber catheter tube junction point. The resident IUC junction point did not have a seal (a plastic wrapping around the junction point where the two-tubing meet and an indicator of an intact, closed, non-compromised drainage system) in place and the tension on the junction was pulling the tubing apart. Resident 7 stated the IUC had been changed before a while ago, can't really remember, maybe at the hospital. Review of Resident 7's provider orders, dated 01/29/2025 showed that orders for the residents IUC were placed. The orders showed change IUC as needed for blockage and other signs/symptoms, change IUC drainage bag every two weeks and as needed, change as necessary for blockages or to obtain a urinalysis and irrigate (flushing fluid through the IUC to prevent a blockage) the IUC for obstruction prior to replacing (these orders were placed 70 days after the resident's readmission with a IUC in place and 54 days after their urology visit). During an interview on 01/31/2025 at 3:14 PM, Staff S, Treatment Nurse, stated the process for IUC orders was to have them placed in a resident's chart after a IUC was inserted or if a resident had one place in the hospital. The orders included IUC change frequency, drainage bag change frequency and/or irrigation of the IUC if it was needed. Staff S stated they did not see orders for Resident 7's IUC until they were notified of the needed for IUC orders, which they had placed on 01/29/2025. Staff S stated the resident's IUC was changed on 01/30/2025. Additionally, Staff S stated that the correct process was not followed regarding Resident 7' IUC care/management and put the resident at an increased risk for further UTI's. During an interview on 01/31/2025 at 3:51 PM, Staff T, Licensed Practical Nurse, stated that Resident 7's orders for their IUC should have been placed in the resident chart back in November 2024. Staff T stated the resident IUC was not changed due to no orders to replace the resident's IUC and the correct process was not followed. During an interview on 02/03/2025 at 11:06 AM, Staff H, Registered Nurse/Resident care Manager, stated that orders for IUC were placed by either Staff H or Staff S and must have slipped through both of our hands. Staff H stated the IUC orders were normally put on the resident orders to help with care maintenance and prevent further IUC infections for the residents. During an interview on 02/03/2025 at 1:49 PM, Staff C, Assistant Director of Nursing Services/Infection Preventionist, stated the correct process was not followed regarding Resident 7's physician orders the day the resident returned from the hospital. Reference: WAC 388-97-1060 (3)(c)

Based on observation, interview and record review the facility failed to secure all medication in 1of 1 locked medication room and to limit access to authorized personal consistent with professional practice. This failure allowed one unauthorized staff member (Staff E) to access medication in the medication storage room and increasing the risk for diversion of controlled (narcotic) medication. Findings included Record review of the facility's policy titled, Storage of Medications, dated, 07/2021showed that the medication was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms were locked when not attended by persons with authorized access. During a concurrent observation and interview on 01/29/2025 at 1:20 PM, Staff H, Registered Nurse/Resident Care Manager (RN/RCM), used their key to open the medication room. Staff H stated that only nursing staff had keys to the medication room and there were no controlled medications stored in the room. On 01/29/2025 at 1:30 PM, during medication storage observation with Staff H, Staff E, Maintenance Director, used a key to open the locked door to the medication room to let the State Fire Marshal into the medication room. During an interview on 01/29/2025 at 2:29 PM, Staff I, Licensed Practical Nurse, stated nurses had keys to the medication room. If housekeeping needed in the medication room to clean, a nurse would let them in and stayed while thousekeeping cleaned. Staff I stated maybe Staff E had a key in case of emergencies; however, was not sure. During an interview on 01/29/2025 at 3:12 PM, Staff E stated they had a key to the medication storage room and got it from the previous Maintenance Director. Staff E stated they were not aware they should not have a key and had used it monthly to check the air conditioner unit. During an interview on 01/29/2025 at 3:20 PM, Staff A, Administrator, stated they were not aware Staff E had a key to the medication storage room, and they should not have key access to that room. Reference: WAC 388-97-2340(4)

Based on interview and record review, the facility failed to ensure the Director of Nursing Services (DNS) had an active nursing license while providing care to residents in the facility for 1 of 6 staff (Staff R) reviewed for staff qualifications. This failure placed residents at risk of receiving care from an unlicensed staff health professional and unmet care needs. Findings included . Review of the facility's undated document titled, Director of Nursing Job Description, dated 2023, showed that Staff B, DNS, had acknowledged/signed on as the responsible DNS of the facility. The document showed the required qualifications of the DNS was to have a current unrestricted license as a Registered Nurse (RN) . and to abide by all standards, polices, regulations and guidelines of the facility and the state and federal governing agencies .at all times. <Staff R> Review of Staff R's personnel records showed their professional RN license was no longer active and had expired on [DATE]. Review of Staff R's DNS schedule of days worked in the facility for [DATE] and [DATE] showed, that Staff R had worked a total of 17 days after their RN licensure had expired. During an interview on [DATE] at 3:34 PM, Staff A, Administrator, stated that Staff R had informed them that the staff members professional RN license was renewed prior to the expiration date but had then found out on [DATE] that it was expired. Staff A stated that Staff R should not have worked those 17 days after the staff members nursing license had expired and would not be working until a renewal of the professional RN license. Reference: WAC [DATE](10)(b)

Based on observation, interview and record review the facility failed to provide correct implementation of infection control practices for indwelling urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) equipment for 2 of 4 residents (Resident 29 and Resident 52) reviewed for use of urinary catheters. This failure placed residents with catheter bags at risk for infections and a diminished quality of life. Finding included Review of recommendations from the Centers of Disease Control, Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009), located at www.cdc.gov, showed a strong recommendation to maintain unobstructive urine flow and to not rest the catheter bag (a urine collection bag attached to the catheter) on the floor. Review of the Lippincott Manual of Nursing Practice 10th Ed. ([NAME], 2014) showed infectious organisms could move into the bladder along the outside of any urinary catheter, and the catheter bag should be kept off the floor (and other unclean surfaces), to prevent bacteria from entering the bladder (pg. 781-782). Record review of a facility policy titled Catheter Management dated 08/13/2019, showed that the retention catheter bag should never touch the floor. <Resident 29> Review of Resident 29's medical recorded showed they were a long-term resident with diagnoses to include diabetes mellites (damaged cells don't respond normally to insulin which cause high levels of glucose), dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), and obstructive uropathy (a condition where urine cannot flow normally through the urinary tract). The 12/18/2024 comprehensive assessment showed Resident 29 was cognitively impaired, had an indwelling urinary catheter and required a wheelchair for mobility. Record review of the resident's catheter care plan dated 01/08/2025 showed staff should keep the urinary catheter bag below the resident's bladder, cover for privacy and not to allow the bag to touch the floor. The resident had a history of urinary tract infections (UTI, infection of any part of the urinary system) with the last one dated 04/21/2024. During an observation on 01/30/2025 at 9:26 AM, Resident 29 was seated in their wheelchair and their urinary catheter bag and tubing was dragging on the floor as the resident was wheeled by Staff P, Nursing Assistant, from the room sink to their bed. During an observation on 01/30/2025 at 1:17 PM, Resident 29 was lying in bed with their eyes closed. Their catheter bag was attached to the left side of the bed frame with the bottom on the bag touching the floor. During an observation on 01/31/2025 at 8:37 AM, Resident 29 was seated in their wheelchair across from the nurse's station with their urinary catheter bag and tubing hanging under the wheelchair seat and touching the floor. During a concurrent observation and interview on 02/03/2025 at 12:15 PM, Staff Q, Registered Nurse, pushed Resident 29 in their wheelchair from the front lobby back to their room. The resident's catheter bag and tubing was dragging on the floor under the wheelchair. When brought to Staff Q's attention, they stated the bag and tubing should not be touching the floor, the tubing could get caught and it was an infection risk. <Resident 52> Review of Resident 52's medical recorded showed they were a long-term resident with diagnoses to include diabetes mellites, heart failure (a progressive heart disease that affects pumping action of the heart muscles) and obstructive uropathy. Record review of the 12/16/2024 comprehensive assessment showed Resident 52 was cognitively intact, had an indwelling urinary catheter and required a wheelchair for mobility. Review of the 01/10/2025 catheter care plan showed staff should monitor and report signs of a UTI such as foul-smelling urine, fever, and altered mental status. Review of Resident 52's physician orders showed they were treated for UTIs with antibiotics on 08/31/2024, 10/14/2024 and 11/14/2024. During an observation on 01/31/2025 at 7:30 AM, Resident 52 was seated in their wheelchair across from the nurse's station with their catheter bag touching the floor under their wheelchair and they were holding the catheter tubing in their right hand. During an observation on 02/03/2025 at 12:18 PM, Resident 52 was observed seated in their wheelchair across from the nurse's station with their catheter bag touching the floor under their wheelchair. During a concurrent observation and interview on 02/04/2025 at 11:05 AM, Resident 52 was seated in their wheelchair across from the nurse's station with their catheter bag touching the floor under their wheelchair and they were holding the catheter tubing in their hand. Resident 52 stated they held the tubing, so it did not pull or drag on the floor. During an interview on 02/04/2025 at 12:16 PM, Staff C, Licensed Practical Nurse and Infection Preventionist, stated that residents' catheter bags and tubing should not be touching or dragging on the floor. Reference: WAC 388-97-1320(1)(a), (2)(a)

Based on observation, interview, and record review, the facility failed to conduct a complete and thorough investigation into resident-to-resident altercations including protecting the residents involved from further physical or psychological harm for 4 of 6 residents (Residents 4, 5, 6, and 7) reviewed for abuse. This failed practice placed the residents at risk for continued exposure to unidentified physical and verbal abuse, unidentified injuries, and unmet emotional needs. Findings included . <Resident 4> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include kidney failure. The 08/29/2024 comprehensive assessment showed Resident 4's cognition was intact and independent with the use of their wheelchair (w/c). <Resident 5> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include kidney failure. The 06/11/2024 comprehensive assessment showed Resident 5's cognition was intact and independent with the use of their w/c. Review of the August 2024 Incident Reporting Log, showed on 08/03/2024 there was an incident involving Resident 4 and 5. Review of the 08/03/2024 incident investigation report, showed Resident 4 and Resident 5 had a verbal altercation that turned physical. The report showed an activities staff member reported to Staff I, Registered Nurse, that Resident 5 had called Resident 4 a m**********r so Resident 4 told Resident 5 to f **k off. Then, as the staff were separating the residents, they were .about to come to blows (fight) ., Resident 4 swung and hit Resident 5 on their shoulder. The report showed Staff I was pushing Resident 5 away in their w/c when Resident 4 swung but did not make full contact with Resident 5. The investigation showed no root/cause/analysis summary, witness statements, interventions that were initiated or changed, care plan changes, injuries, or education provided to staff or residents to protect both residents from further altercations. Additionally, the investigation did not show a complete description of the incident, who the activity staff was that reported it, which shoulder was hit, or which resident was name calling. During an interview on 09/09/2024 at 4:15 PM, Staff H, Resident Care Manager (RCM), stated they were not aware of the incident that took place between Residents 4 and 5 and that it would have been the responsibility of the Social Services department to follow up with the behaviors for resident-to-resident altercations. During an interview on 09/10/2024 at 1:56 PM, Resident 4 stated their room was located directly across the hall from the entrance to the dining room. Resident 5 was going to the kitchen, through the dining room, when Resident 4 informed them the kitchen staff were not in the kitchen. Resident 5 then turned to Resident 4 and called them a name which angered Resident 4 so they continued to call Resident 5 names and told them to f **k off and threatened Resident 5 that they would get them on the way back (out of the dining room). Resident 4 stated Resident 5 continued talking crap and coming towards them like they wanted to fight, so they felt they needed to defend themselves and swung at Resident 5. Resident 4 stated the staff intervened and took Resident 5 away just as they swung. Resident 4 then stated the next day, when they went to the restorative room for their exercises, Resident 5 was also in there at the same time. Resident 4 stated they were ready to hit Resident 5 if they had said anything to them, but they ignored each other. Resident 4 stated this would be the second time they have had an issue with Resident 5, and stated, if you talk to [Resident 5], they get angry and if you don't say anything to them, they are nice. During attempted interviews on 09/09/2024 at 12:30 PM, and again on 09/10/2024 at 1:51 PM, Resident 5 refused to talk about the incident and stated they did not have anything further to discuss about it. Review of Resident 4's care plan focus for behavior monitoring, last revised on 04/13/2021, showed the resident would use foul language towards residents and staff and make false statements towards other residents when they were upset. The care plan showed no focus for a physical/verbal resident-to-resident altercation and no additional interventions had been implemented or changed since the 08/03/2024 incident. Review of Resident 5's care plan focus for behavior monitoring, last revised on 05/10/2024, showed no focus for a physical/verbal resident-to-resident altercation and no additional interventions had been implemented or changed since last revised on 08/30/2022 or since the 08/03/2024 incident. <Resident 6> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include schizophrenia (a serious mental health condition that affects how people think, feel and behave). The 07/16/2024 comprehensive assessment showed Resident 6's cognition was intact and was independent with the use of their w/c. <Resident 7> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include severe vascular dementia with behaviors (caused by lack of blood/oxygen to the brain and causes changes in personality, behavior, and mood). The 07/23/2024 comprehensive assessment showed Resident 7's cognition was severely impaired, demonstrated verbal and physical behaviors that were directed towards others, and was independent with the use of their w/c. Review of the 09/01/2024 through 09/09/2024 Incident Reporting Log, showed on 09/01/2024 there was an incident involving Residents 6 and 7. Review of the 09/01/2024 incident investigation report, completed by Staff I, showed staff reported to Staff I that Residents 6 and 7 had a physical altercation during lunch time in the dining room. The report showed that Resident 6 had hit Resident 7 after they had been hit by that resident. The report showed Resident 6 tried helping Resident 7 with their butter when Resident 7 threw the butter at Resident 6 and then hit them, so Resident 7 hit Resident 6 back. The report showed Resident 7 was agitated earlier in the shift and had slapped the nurse when they attempted to administer their medications. The report showed no root/cause/analysis summary, what had been done about Resident 7's agitation earlier in the shift, where either resident had been hit/slapped, a skin check for Resident 7, monitoring for latent injuries, and no interventions or care plan changes were implemented. Review of Resident 6's care plan focus for behavior monitoring, last revised on 04/24/2023, showed no focus for a physical/verbal resident-to-resident altercation and no additional interventions had been implemented or changed since the 09/01/2024 incident. Review of Resident 7's care plan focus for behavior monitoring, last revised on 05/13/2022, showed the resident would strike out at staff with interventions to redirect the resident, offer them their baby doll, or a snack/drink of their choice. The care plan showed no focus for a resident-to-resident altercation and no additional interventions had been implemented or changed since the 09/01/2024 incident. During an interview on 09/10/2024 at 9:32 AM, Staff K, Nursing Assistant (NA), stated they were not made aware of any altercations that had taken place between Residents 4 and 5. Staff K stated Resident 4 got along with everybody and as far as they knew displayed no behaviors. Staff K additionally stated Resident 7 would consistently hit staff but was not aware of any altercations that took place with other residents. During an interview on 09/10/2024 at 12:17 PM, Staff G, RCM, stated they were not aware of the altercation between Residents 6 and 7 and that it must have happened on a weekend, and they didn't hear about it. Staff G further stated it was the responsibility of the Social Services department to update the care plans for behaviors. During an interview on 09/10/2024 at 1:46 PM, Resident 6 stated they had gone over to Resident 7's table to assist them with their butter. Then Resident 7 threw their butter at Resident 6, so Resident 6 threw it back. Resident 6 stated Resident 7 then slapped them in their forearm which then Resident 6 then slapped Resident 6 back on their forearm, which I think I hit their elbow, not their forearm. Resident 6 then stated the next day they approached Resident 7, and they acted as if nothing ever happened. Additionally, Resident 6 stated Resident 7 had memory issues and had observed the same interactions with other residents and staff. During an interview on 09/11/2024 at 9:26 AM, Staff E, Social Services Director, stated they would monitor and follow-up with residents involved in resident-to-resident altercations to ensure they are doing alright afterwards. Staff E stated it would be the responsibility of the nursing department to follow up on outcome, appropriate interventions, and investigation summaries. During an interview on 09/11/2024 at 12:07 PM, Staff L, NA, stated Resident 7 would hit staff and other residents and needed to be watched . Staff L stated if they see the resident coming close to another resident, they would move them away from the situation and give Resident 7 coffee or candy as a distraction. Staff L stated staff were not always there to monitor Resident 7 and they were not one on one care During an interview on 09/11/2024 at 12:21 PM, Staff I stated their normal practice for resident-to-resident altercations would be to interview residents, obtain witness statements, and ensure the residents were safe. Staff I stated they did not witness the incident with Residents 4 and 5 and was called to the dining room by staff. Staff I stated they did not assess either resident for injuries and verified it was Resident 5 that got hit by Resident 4. Staff I stated they did not do any education with staff regarding the incident or put any interventions into place because Residents 4 and 5 have had issues before so staff were already aware they needed to be kept apart. Also, Staff I stated they did not witness the altercation between Residents 6 and 7 and were called to the dining room where both residents had already been separated by staff. Staff I stated they assessed Resident 6 for injuries but did not assess Resident 7. Staff I stated when they initiated alert charting for both residents they would normally also monitor for latent injuries did I not do that? Additionally, Staff I stated their incident reports had not been very thorough as of late and admitted they needed to do better. During an interview on 09/11/2024 at 1:15 PM, Staff C, Director of Nursing Services (DNS), with Staff D, Assistant DNS, present, stated they would expect thorough and complete investigations to be completed along with interventions and staff education on the interventions. Staff C stated the residents not only needed to be protected at that moment of the incident but on-going as well. Staff C further stated there should have been a summary of the findings of the investigation, skin checks and monitoring, and witness statements obtained. Staff C further stated it should have been a collaborative effort of the Social Services department and the Resident Care Managers to implement appropriate interventions for resident-to-resident altercations and that did not happen. WAC Reference: 388-97-0640 (6)(a)(b)(c)

Based on observation, interview, and record review, the facility failed to carry out key components of an effective infection prevention/control program by implementing transmission-based precautions (TBP, safeguards to prevent spread of diseases) and use of full personal protective equipment (PPE) in protecting the safety/well-being for two of two residents (270, 72) not vaccinated against COVID-19 (a highly contagious virus) with one resident who received an aerosol-generating procedure (AGP, procedure that may generate potentially infectious particles into the air). This failure placed the residents and staff at risk for potential exposure to COVID-19 and increased the likelihood of serious harm or death, which constituted an Immediate Jeopardy (IJ). On 06/04/2021 at 5:00 PM, the facility was notified of an Immediate Jeopardy at CFR 483.80 (a)(2)(iii) F880 related to the facility's failure to implement TBP/airborne infection isolation or a private room along with proper use of PPE for a potentially infectious resident receiving AGP's. The facility removed the immediacy on 06/08/2021, with a validation date of 06/09/2021 at 2:30 PM, by implementing a removal plan with policy changes, moving the resident receiving aerosolizing treatments to a private room, and education for the nursing staff, to ensure protection of the residents during aerosolizing-generating procedures. Additionally, the facility failed to ensure staff compliance with infection control guidelines and standards of practice for three of five staff members, all Nursing Assistants (NA) (L, J, I) reviewed for proper implementation of PPE, hand hygiene and glove changing protocols, which included: 1. Observations on 06/01/2021 at 12:10 PM, showed Staff L failed to don (to put on) and doff (to take off) correct PPE prior to entering/exiting a quarantine/precautions room on three separate entries. 2. Observation on 06/02/2021 at 10:25 AM, showed Staff L failed to change gloves when they moved from a contaminated body site to a clean body site during resident care. 3. Observation on 06/04/2021 at 10:22 AM, showed Staff J and Staff I failed to perform hand hygiene in-between glove changes when they provided care to a resident. These additional findings further placed residents at undue risk for potential life threatening illnesses, spreading of infectious diseases and a diminished quality of life. Findings included . Review of the facility policy titled, Interim Policy for Precautions, dated 04/21/2020 and revised on 02/01/2021, stated .The facility would follow CDC (Centers for Disease Control and Prevention) guidelines for the use of PPE to contain and prevent the spread of infection . Review of the CDC guidelines, dated 02/23/2021, for nursing homes showed that .CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed [CONDITION(S)]-CoV-2 (COVID-19) infection .health care professionals should use PPE, N95 respirators (filtering face cover) or higher-level respirators for all aerosol-generating procedures .some procedures performed on patients with suspected or confirmed [CONDITION(S)]-CoV-2 infection could generate infectious aerosols. These procedures that pose such risk should be performed cautiously and avoided if possible. If performed, the following should occur: Heath Care Professional (HCP) in the room should wear an N95 or equivalent or higher-level respirator, eye protection, gloves and a gown. The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure. AGPs should take place in a specific air-filtered room if possible. Clean and disinfect procedure room surfaces promptly. Review of the medical record showed Resident 270 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident used oxygen as needed to keep oxygen saturation above 89% (optimal oxygen level is between 90-100%), had a [CONDITION(S)] that required suctioning, and the resident received breathing treatments as needed for secretions, which are both AGP. Review of the Admission Minimum Data Set (MDS) comprehensive assessment for Resident 270, dated 05/05/2021, showed no cognitive impairment, no depression symptoms, and the resident did not have any behavioral symptoms. The MDS showed the resident was independent with ambulation and needed minimal assistance with activities of daily living. Review of the physician orders, showed a 05/12/2021 order for a breathing treatment via [CONDITION(S)], as needed, every six hours for congestion/shortness of breath. Additionally, a 05/26/2021 order showed, suction [CONDITION(S)] as needed for increased secretions/patency, and a 05/28/2021 order showed, .suction [CONDITION(S)] (to get the secretions out of the airway) two times a day for patency/infection control. During an interview on 06/04/2021 at 1:45 PM, Resident 270 stated he was suctioned twice a day and received breathing treatments in his room when his secretions worsened. Record review of both Resident 270 and Resident 72 showed that they both refused to receive vaccinations for [CONDITION(S)]-CoV-2. The residents were roommates, in the same room with only a curtain between them. Review of a 05/05/2021 physician order showed that the resident could leave the facility independently but not off of the facility property without supervision. During an interview on 06/04/21 at 4:13 PM, Staff C, LPN/Infection Preventionist (IP), stated if a resident was receiving aerosolizing procedures, such as suctioning and breathing treatments, the staff would wear a mask (non N95 respirator) and face shield for PPE; if the resident had respiratory symptoms then the staff would wear full PPE. Staff C further explained the staff would also pull the curtain if there was a roommate in the same room. During an observation on 06/04/2021 at 1:40 PM, Resident 270 was sitting outside of the facility in the parking lot at a picnic table. During an observation on 06/04/2021 at 6:00 PM, Resident 270 was sitting at the same picnic table with two visitors from the community. They were not wearing PPE or social distancing. Personal Protective Equipment Observation on 06/01/2021 at 12:10 PM, showed Staff L, NA, entered a resident room that was identified as TBP and quarantined. The room had a plastic zipped doorway in place to ensure the potential airborne virus was contained. The sign on the zipped door instructed staff to don PPE which was a mask, face shield, gown and gloves prior to entering the room. The sign further instructed staff to remove contaminated PPE prior to exiting the quarantined room. Staff L opened the zippered plastic doorway and entered the quarantined room without donning the required PPE as indicated per the posted sign. Staff L entered with just a surgical mask and face shield on. Additionally, when Staff L exited the room back into the hallway she did not doff her potentially contaminated mask and face shield, which had been exposed to a potentially hazardous virus (COVID-19). During an interview on 06/01/2021 at 12:15 PM, Staff L stated that she should have donned a gown and gloves prior to entering the resident room that was identified as TBP. Staff L further stated she should have cleaned her face shield and changed her mask after exiting the TBP room. During an interview on 06/01/2021 at 1:30 PM, Staff C, IP, stated that Staff L did not use appropriate PPE for a resident who was on TBP and was in a quarantine room. Staff C further that she would be providing Staff L with additional one on one training for TBP and the use of PPE. Hand Hygiene/Glove Change During an observation on 06/02/2021 at 10:25 AM, Staff L, NA, did not perform hand hygiene nor glove change when providing incontinence care to an unnamed resident when changing from a soiled task to clean tasks. Staff L, stated that she should have changed her gloves in-between the soiled and clean tasks. During an observation on 06/04/2021 at 10:22 AM, Staff J and Staff I, NA's, were observed to provide incontinence care to an unnamed resident, and did not perform hand hygiene nor glove change when going from a soiled task to a clean task. During an interview on 06/04/2021 at 10:30 AM when informed of failures in infection control during incontinence care to the residents, Staff B, DON, and Staff C, LPN/ IP stated that all staff should be changing gloves and performing hand hygiene after soiled and prior to clean tasks. Reference: WAC 388-97-1320 1(a)(c)

Based on observation, interview, and record review, the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs in the area of [CONDITION(S)]/airway stoma sites (a tube or opening made in neck to help with breathing). This failure resulted in the lack of provision of care consistent with professional standards of practice to prevent negative outcomes, and placed two of two residents (270, 50) at an increased risk for respiratory infections, ineffective [CONDITION(S)] suctioning (a process that uses a small tube hooked to suction and clear fluid buildup within an airway), airway trauma and [CONDITION(S)] (low oxygen in your body). Additionally, the failure increased the likelihood of serious harm or death for residents reviewed for competency skill sets related to [CONDITION(S)]/airway stoma care, which constituted an Immediate Jeopardy (IJ). On [DATE] at 5:00 PM the facility was notified of an Immediate Jeopardy at CFR 483.35(a)(3) F726 related to the facility's failure to ensure that licensed nurses were trained, competent and qualified to care for residents with [CONDITION(S)]/airway stoma sites and provide emergency cares as needed; to include cardiopulmonary resuscitation (CPR) and replacement of a dislodged [CONDITION(S)] tube. Additionally, staff were unaware of how to perform CPR on a resident with a [CONDITION(S)]/airway stoma, nor how to replace a dislodged [CONDITION(S)], or where extra [CONDITION(S)] kits (supplies necessary to replace the [CONDITION(S)]) were in an emergent situation. Licensed staff did not understand that the procedure they were performing was deep suctioning (suctioning of airway through tube placed within the [CONDITION(S)]). The facility removed the immediacy on [DATE], with a validation date of [DATE] at 2:30 PM, by implementing a removal plan with policy changes, and education for the nursing staff, to ensure protection of the residents from further [CONDITION(S)] care/suctioning risks. Findings included . WAC [DATE] stated, The licensed practical nurse performs services requiring knowledge, skill and judgment necessary for carrying out selected aspects of the designated nursing regimen. The licensed practical nurse recognizes and is able to meet the basic needs of the client, and gives nursing care under the direction and supervision, to clients in routine nursing situations. A routine nursing situation is one that is relatively free of complexity, and the clinical and behavioral state of the client is relatively stable, requires care based upon a comparatively fixed and limited body of knowledge. In complex nursing care situations the licensed practical nurse functions as an assistant to the registered nurse and facilitates client care by carrying out selected aspects of the designated nursing regimen to assist the registered nurse in the performance of nursing care. Nursing Care Quality Assurance Committee, Registered and Licensed Practical Nurse Scope of Practice document, dated [DATE], stated .It is the nurse's responsibility to determine whether he or she is clinically competent to perform the nursing care required. The nurse should not accept the patient care assignment if the nurse is not clinically competent. In addition, the safety and competency part of the document stated .Documentation of appropriate education and competency assessment specific to the activity, safe to perform the activity for the specific patient, in a specific setting, and at a specific time, and specific environment or special equipment or personnel is needed in case of unexpected responses to assure patient safety and quality of care. Review of the policy titled, [CONDITION(S)] Care, dated ,d+[DATE], showed no instructions for emergent cares and states, .assess if suctioning is needed prior to site care. Resident 270. The medical record showed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident used oxygen as needed to keep oxygen saturation above 89% (optimal oxygen level is between ,d+[DATE]%), had a [CONDITION(S)] that required suctioning, and the resident received breathing treatments as needed for secretions (buildup of fluids in the airway). Review of the Admission Minimum Data Set (MDS) a comprehensive assessment, dated [DATE], showed no cognitive impairment, no depression symptoms, and the resident did not have any behavioral symptoms. The MDS showed that the resident was independent with ambulation and needed minimal assistance with activities of daily living. Review of the physician orders, dated [DATE] showed, to suction [CONDITION(S)] as needed for increased secretions and to keep the [CONDITION(S)] tube clear from a buildup of fluid. Additional orders, dated [DATE], stated, Suction [CONDITION(S)] two times a day for patency/infection control. During an interview on [DATE] at 1:45 PM, Resident 270 stated that Staff P, Licensed Practical Nurse (LPN), changed the inner cannula of his [CONDITION(S)], and described deep suctioning as one of the procedures that had been performed on him earlier by Staff M. In addition, the resident stated that he received breathing treatments when his secretions worsen. During an interview on [DATE] at 2:19 PM, Staff P stated that she thought she did not perform deep suctioning, but did go into/ through the [CONDITION(S)]/airway with a suctioning tube that was used for deep suctioning. Staff P stated, I don't go that far .just until I meet resistance. Staff P further stated that she had changed the inner cannula of the [CONDITION(S)] before, she had not received formal training on [CONDITION(S)] care. Staff P was not sure where an emergency [CONDITION(S)] kit was located if the [CONDITION(S)] was dislodged, and in the event of an emergent dislodgement she did not know how to put the new [CONDITION(S)] back in. During an interview on [DATE] at 2:30 PM, Staff M, LPN/Treatment Nurse, stated that the only [CONDITION(S)] training she received was from her formal education in nursing school. In addition, she stated that she did not receive formalized training for suctioning or emergent care of a [CONDITION(S)]/airway stoma. Staff M stated that she did not know where extra [CONDITION(S)] kits were located or how to replace the [CONDITION(S)] if it were emergently dislodged. During an interview on [DATE] at 3:21 PM, Staff H, Registered Nurse/Resident Care Manager, stated that she did not clarify the doctor's order for suctioning because she felt the orders were clear to suction twice a day. In addition, Staff H stated that she felt if the nurse did not know how to suction a [CONDITION(S)] or needed to clarify how to suction, they could just Google it and it was easy to do that. Resident 50. Review of the medical record showed Resident 50 admitted on [DATE] as a full code (in an emergency, perform cardiopulmonary resuscitation or CPR), with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident 50's medical record showed no individualized documentation for interventions in place for an emergent situation where the resident required CPR. Review of Resident 50's comprehensive assessment, completed on [DATE], showed no documentation of specialized treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's care plan regarding his airway stoma site, showed to monitor the site for signs and symptoms of infection. Review of Resident 50's physician orders, dated [DATE], showed only to monitor the trachea daily for sign/symptoms of infection until resolved. Observation on [DATE] at 10:04 AM showed that Resident 50 had an old [CONDITION(S)] stoma site, shown by audible hissing, when air would move in and out of his airway stoma while the resident was breathing/talking. During an interview on [DATE] at 2:02 PM, Resident 50 stated that in the case of an emergency he would want CPR performed. During an interview on [DATE] at 2:44 PM, Staff R, NA/Shower Aide, stated that she was unaware of any specialized instructions or care regarding Resident 50's showers. She did know of any interventions to implement in the event water entered the airway stoma site during a shower. During an interview on [DATE] at 2:56 PM, Staff C, IP, stated that she did not know of any additional/specialized care needs towards Resident 50's airway stoma site in the event of any emergency requiring CPR. During an interview on [DATE] at 3:05 PM, Staff G, Resident Care Manager (RCM), stated that nothing additional or specialized was in place for Resident 50's airway stoma, besides to monitor for signs and symptoms of infection. During an interview on [DATE] at 3:20 PM, Staff S, LPN, stated there was nothing in the care plan or any other specialized instructions on what to do in the case of an emergent situation that required CPR for Resident 50's airway stoma. Staff S further stated that she realized the stoma was an open airway, and that something should be in place so that she could perform CPR correctly and effectively. When asked about specialized training on [CONDITION(S)]/airway stomas, Staff S stated that she had no formal instruction on suctioning or replacing a [CONDITION(S)]. During an interview on [DATE] at 3:31 PM, Staff B and Staff C, both stated that they had a lack of knowledge towards Resident 50's airway stoma with CPR and that they would be doing additional training with [CONDITION(S)]/airway stomas and CPR. Staff C further stated we could do a better job. During an interview on [DATE] at 4:10 PM, Staff M, LPN/treatment nurse, when asked about specialized training towards [CONDITION(S)]/airway stomas, she stated that she had not received any training on [CONDITION(S)]/airway stomas since working for the facility. Staff M further stated that the facility utilized an online training program for specialized training on [CONDITION(S)] care, however none of the staff had been assigned the training. Reference: WAC [DATE](1)

Based on observation, interview and record review, the facility failed to ensure and provide consistent, appropriate [CONDITION(S)]/airway stoma care (a tube or opening made in the neck to help with breathing) and [CONDITION(S)] suctioning (a process that uses a small tube hooked to suction and clear fluid buildup) in accordance with professional standards of practice for two of three residents (270 and 50), reviewed for respiratory care. This failure placed the residents at increased risk for negative outcomes, including secretion build up, respiratory infections, and airway trauma. Additionally, the failure increased the likelihood of serious harm or death, which constituted an Immediate Jeopardy (IJ) and the facility need to take immediate action. On [DATE] at 5:00 PM the facility was notified of an IJ at CFR 483.25(i) F695 related to the facility's failure to ensure that licensed, trained, competent qualified staff were available to perform [CONDITION(S)]/airway stoma care, to include deep suctioning, for a newly admitted resident with a recent [CONDITION(S)] placement. Additionally, staff were unaware of emergent interventions in the case of accidental extubation (a removal of the [CONDITION(S)]) and clarification of specific physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included . Review of the policy titled, [CONDITION(S)] Care, dated ,d+[DATE], stated, .assess if suctioning is needed prior to site care. Review of the above policy did not reflect the process for oral suctioning versus deep suctioning and assessment of a newly placed [CONDITION(S)] with associated risk. In addition, the policy did not show key components in accordance with professional standards of practice for safe [CONDITION(S)] care, which placed the resident at risk. Resident 270. Review of the medical record showed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) comprehensive assessment, dated [DATE], showed no cognitive impairment, no depression symptoms, and no behavioral symptoms. The MDS showed the resident was independent with mobility and needed minimal assistance with activities of daily living. Review of the physician orders, dated [DATE], stated, Suction [CONDITION(S)] as needed for increased secretions/patency. In addition, a [DATE] order showed to suction the [CONDITION(S)] two times a day for patency/infection control. Further review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 1:45 PM, Resident 270 stated that Staff P, Licensed Practical Nurse (LPN), changed out the inner portion of his [CONDITION(S)] tube. The resident described the process for deep suctioning (putting a tube down the [CONDITION(S)] to suction fluid buildup) that was performed earlier by Staff M. In addition, the resident stated that he received breathing treatments when his oral secretions were excessive. Resident 270 also stated that he used to have a tonsil-tip suction device so he could suction his oral secretions out of his mouth by himself but the facility took that away a few days ago. During an interview on [DATE] at 2:19 PM, Staff P stated that she did not suction the outside of Resident 270's [CONDITION(S)], but did suction the inside of the [CONDITION(S)]. Staff P stated that she inserted the suction tubing with a deep suctioning kit but did not go that far, and stopped when resistance was met. She stated that she had changed the inner cannula of the [CONDITION(S)] and she had not received formal specialized training on [CONDITION(S)] care. Staff P stated that she was not sure where an emergency [CONDITION(S)] kit (supplies necessary to replace the [CONDITION(S)]) was if it was accidently dislodged, and she did not know how to put a new [CONDITION(S)] back in place. During an interview on [DATE] at 2:30 PM, Staff M, LPN/Treatment Nurse (TN), stated that the only training for [CONDITION(S)] care she received was from her formal education in nursing school. In addition, she stated that she did not receive formalized training for suctioning or emergent care of a [CONDITION(S)]. Staff M stated that she did not know where extra [CONDITION(S)] kits were or how to replace the [CONDITION(S)] if it was dislodged/extubated. During an interview on [DATE] at 3:21 PM, Staff H, Registered Nurse/Resident Care Manager (RCM), stated that she was unsure why a tonsil-tip suction was at Resident 270's bedside, and she stated that it would not fit down the [CONDITION(S)] to suction. She stated that she did not clarify the doctor's order because she felt the orders were clear to suction twice a day. In addition, Staff H stated that Resident 270 would refuse suction at times, so they decreased the suction from three times a day to twice a day. Staff H stated that she felt if the nurse did not know how to suction a [CONDITION(S)] or needed to clarify how to suction, they could just Google it and it was easy to do that. Resident 50. Review of the medical record showed the resident admitted on [DATE] as a full code (in an emergency preform Cardiopulmonary resuscitation or CPR), with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (a comprehensive assessment) completed on [DATE], showed no specialized treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's care plan regarding his airway stoma site showed to monitor the site for signs and symptoms of infection. Observation on [DATE] at 10:04 AM showed that Resident 50 had an old [CONDITION(S)]/airway stoma site, which exhibited a hissing sound as air would move in and out of his airway stoma when resident was breathing/talking. During an interview on [DATE] at 1:50 PM, Staff M, LPN/TN, stated that the only orders in place for Resident 50's airway stoma site was to monitor for signs and symptoms of infection. During an interview on [DATE] at 2:02 PM, with Resident 50, when asked about what he does when he was given a shower, the resident stated, When I take a shower I put my chin to my chest and cover the hole. Resident 50 further explained that water would get into the stoma opening during a shower, which made him cough. During an interview on [DATE] at 2:44 PM, Staff R, NA/Shower Aide, stated that she was unaware of any instruction or care for Resident 50's showers regarding the airway stoma site and what to do if water got in it. The NA further stated that they were only to monitor for signs and symptoms of infection with the airway stoma. During an interview on [DATE] at 3:31 PM, Staff B and Staff C, both stated that there was a lack of knowledge on the subject of the airway stoma and that they would be doing additional training with [CONDITION(S)]/airway stomas since this was brought to their attention. Staff C further stated we could do a better job. Reference: (WAC) [DATE] (3)(j)(iv)(v)(vi)

Based on observation, interview, and record review, the facility failed to ensure that one of two residents (63), reviewed for quality of life, received necessary interventions to alleviate her distress and maintain her dignity and well-being. This failure caused psychosocial harm to Resident 63 when the facility failed to ensure her need for an environment free from distractions and rather she remained in a room where her roommate's yelling, moaning and outbursts created an environment of agitation and distress for her. Findings included . Resident 63. Review of the [DATE] comprehensive assessment showed the resident readmitted on [DATE] and required extensive assistance and was dependant on staff for all care needs. The assessment showed the resident had severely impaired cognition with adequate hearing, and no speech. Review of the Resident's current care plan, dated [DATE], showed the resident had impaired cognitive function due to [CONDITION(S)] (deterioration of nerve cells in the portion of the brain which controls coordination) and dementia. I can verbalize to express my emotions but cannot speak .At times my sounds of noise are joyful noises .I enjoy listening to people talk to me and I have an infectious laughter when amused. The care plan showed the resident would continue to communicate my need w (with)/ emotions, facial expressions on a daily basis and the facility was to reduce any distractions as needed. The goal was to to remain happy (as evidenced by daily sounds of joy/pleasure) and show no s/sx (signs or symptoms) of .anxiety . and maintain the highst level of physical, mental and psychosocial functioning possible. During an observation on [DATE] at 9:53 AM, Resident 63 was seated in her wheelchair, her head was in a downward position and she was moving her head in a back and forth (no pattern) motion, while her face was grimaced. The room was shared with two other residents (1, 2). Resident 2, whose bed was closest to the door, was observed in her wheelchair which was tilted back, and was moaning loudly in a low tone. During a concurrent interview and observation on [DATE] at 10:25 AM, Staff L, Nursing Assistant (NA) was observed to provide care to Resident 1, who resided in the middle bed. The resident was yelling out, as the NA repositioned her to change her brief. The resident yelled ow, that hurts repeatedly and yelled out during the care she received. Resident 63, whose bed was furthest from the door, was seated in her wheelchair approximately 10 feet from Resident 1's bed. Her head down and she was moving it back and forth, and making moaning sounds, her eyes were closed tight. Staff L stated that she (Resident 63) gets upset, when Resident 1 yelled out. During an observation on [DATE] at 1:49 PM, Resident 63 was observed in bed, her eyes were open, brow was not furrowed and she she was heard making quiet, pleasant sounds (as though she was talking to herself). The resident's two roommates were quiet and the television was on, at a low volume. Observations and Interviews on [DATE] from 8:58 AM through 9:40 AM: -8:58 AM, five call lights were observed activated, on the North hall. Resident 2 was intermittently yelling/moaning from her room, which could be heard from the hallway. -9:10 AM, Staff O, Licensed Practical Nurse (LPN), entered the room and spoke in a calm soothing voice to Resident 2. The resident did not calm. Staff O told the resident that she would be laid down soon. Staff O stated once the resident was laid down, she would quiet down. -9:23 AM, Resident 2's moans had now increased in volume and intensity and were loudly audible from the hallway. Staff J, NA, entered the room and stated to the resident , We are going to lay you down. At that time, Resident 63 was observed her wheelchair, shaking her head back and forth with a grimace on her face and moving her arms towards her chest in a upward motion. - 9:27 AM, Resident 2 continued to moan out, which was more frequent and louder than previously. Resident 63 continued to move her head back and forth and was grimacing (eyes shut tight and brow furrowed). Her arms now were aggressively moving up and into her chest in a manner such that it was lifting her shirt, exposing her midriff. She then began to make moaning sounds. -9:29 AM, Resident 2 was now positioned in bed (via mechanical lift), and continued to make loud sounds and moaned. Staff I, NA stated that (Resident 63) might have perceived something's not right because when Resident 2 yelled and moaned she (Resident 63) gets upset. - 9:32 AM, no staff have intervened despite Resident 63's physical expressions and moans. Resident 2 continued to moan increased in volume and intensity, in succession, Resident 63's head continued to shake and her moans had now increased in volume and intensity. -9:36 AM. per Staff J, when one starts then it triggers the other . then once we lay her (2) down, sheshe'll calm down there are days when it does that - one will be yelling then the other will start getting upset. -9:37 AM, Resident 2 had stopped moaning and settled in her bed. Resident 63 was observed to quiet and become calm (moaning ended, arms dropped downward, no longer aggressive movements to chest. The face became less contracted and the grimacing, to extent previously observed, lessened and then the mouth and brow became more relaxed. -9:40 AM, Resident 63 was approached by Staff J and I and told she would be laid down, and at this time, the resident was quiet and staff readied her for mechanical lift transfer from her chair into her bed. During an interview on [DATE] at 9:47 AM, which occurred in the hallway outside of the Residents' (1, 2 & 63's) room, Staff O, LPN stated that at times one (either Resident 2 or 63 will yell out) and it will trigger the other to yell out. I think they are aware of the distress of the other and respond to it. She stated that usually with Resident 2, once she was laid down, she would quiet down. Resident 63 would track with her and seemed to respond to stimuli. She stated that she agreed that Resident's 63's response was because of her roommate's moaning and yelling. During an interview on [DATE] at 10:57 AM, Staff G, Resident Care Manager, stated that Resident 2 may be crying out due to pain or discomfort and when that happened, staff transfer her back into her bed. She stated that all three residents in the room, require mechanical lift transfers. She stated that she had not observed Resident 63's response to Resident 2, but that she had seen Resident 1 get triggered when Resident 2 would cry out. She stated she did not know why all three residents shared the the room. During an interview on [DATE] at 11:09 AM, Staff B, Director of Nurses, when informed of the observations of Resident 63's response to Resident #2, she acknowledged the surveyor's concern of psychosocial harm to Resident 63. Reference: WAC [DATE] (1)(a)

Based on observation, interview and record review the facility failed to prevent injuries during transfers for two of two residents (#3, 5) when staff did not follow the resident's care plan. This failure resulted in harm to both residents. Resident #3 sustained a re-fractured knee following a transfer performed by one staff when two staff were required. Resident #5 sustained a skin tear injury when staff failed to use a gait belt to transfer the resident. Findings included . Resident #3. Review of the resident's record showed an admission to the facility on [DATE] after surgical repair of the left knee. Review of the 08/01/19 mobility plan of care showed the resident was non-weight bearing on the left leg due to a fracture to the left knee. Transfers were one person assist except for toileting which required two person extensive assist. Review of the 08/07/19 comprehensive assessment showed the resident was cognitively intact, and had required the extensive assistance of two staff for transfers and toileting during the assessment period. Review of the 08/14/19 investigation report showed Resident #3 was assisted to the toilet by Staff C, Nursing Assistant (NA), around 3:15 PM. Per the NA's written narrative the resident wanted to use the restroom and I was told that he was a one person transfer .while transferring, the resident held on to the bar near the toilet seat and he bumped his knee against the wall and then it started to bleed. Further review of the report showed the resident stated he experienced a10 of 10 pain in the left knee at the time of the incident. An immediate x-ray showed there was a re-[MEDICAL CONDITION] and the resident had surgical repair on 08/16/19. During an interview on 08/27/19 at 10:30 AM, Staff B, Director of Nursing Services (DNS), stated that Resident #3 had just changed rooms from another hall and Staff C was not familiar with his care plan. She asked another NA what the resident's transfer status was and was told 'one person'. However, what she failed to do was look at the Kardex (care directions to NAs) in the closet that had Resident #3 as a 'two person assist' for toileting to provide stabilization to raise and lower his pants. Review of a room change notice showed the resident changed rooms from the 200 hall to the 100 hall on 08/13/19. During a concurrent observation then interview on 08/27/19 between 4:15 PM and 4:35 PM, Resident #3 was observed transferring with two staff to use the toilet without incident. The resident put weight on his right leg and relied on the two staff to stabilize him by holding the gait belt around his midsection. Afterwards, the resident stated the day he re-fractured his knee, the NA could not hold me up and my knee hit the wall. There were always two staff helping me before. Resident #5. Review of the resident's record showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care for transferring showed on 08/07/19 transfers were 1 person stand by assist with gait belt on me for safety, ensure wheelchair (w/c) is next to bed with arm of w/c off so I'm able to slide myself on the bed and/or w/c. On 08/22/19 the transfer plan changed to 1 person limited assist with gait belt, ensure wheelchair is in a position to where she can use it to assist in the transfer. Review of the State Reporting Log showed the resident sustained [REDACTED]. During an interview on 08/27/19 at 2:20 PM, the DNS stated that she was not aware of this incident and there was no investigation, only the initial injury report on 08/22/19 by the nurse. Review of the 08/22/19 injury report showed at around 9:00 PM Staff D, Licensed Practical Nurse (LPN), was asked to assess a skin tear on Resident #5 that occurred during the resident's transfer from the wheelchair to the bed. Staff D documented on the report the NAs failed to use gait belt as stated on Kardex. Review of the corresponding progress note by Staff D showed the resident had a large skin tear on left elbow . 5 cm (centimeters) by 2 cm over a dark purple older bruise. The wound was cleansed and steri stripped to hold the wound edges together. During concurrent observation and interview on 08/28/19 at 10:20 AM, Resident #5 was observed in the therapy room. While sitting on an Omni cycle, multiple deep purple bruises and dressings were observed. The resident stated she had real fragile skin and it bruised and tore very easy. She stated she had been in and out of the hospital a lot and many of her bruises were from her time at the hospital. When asked about the skin tear she got during the transfer on 08/22/19 she stated Oh honey, I don't know, I have so many. During an interview on 08/28/19 at 10:40 AM, Staff E, NA, stated Resident #5 did not like to lay down during the day. The NA described how she transferred the resident from her bed to the wheelchair this morning. She stated the resident is extensive assist 1 staff, but I like 2 staff. She sits on the edge of the bed and we put the wheelchair with the arm off next to the bed at the same height. With a gait belt on, she slides from one surface to the other while we assist. During an interview on 08/28/19 at 11:20 AM, Staff B stated after investigating the resident's injury, she found that the nursing assistants did a slide transfer with the resident. However, they used the pad she was sitting on to move her and not a gait belt. They did not follow the transfer care plan. Reference: WAC 388-97-1060(3)(g) This is a repeat deficiency from Statement of Deficiency dated 03/28/19.

Based on observation, interview, and record review, the facility failed to ensure a safe environment for one of three sample residents (#1), reviewed for accidents. Failure to follow the plan of care caused the resident to fall out of bed, sustaining a laceration to the left temple. Findings included: Resident #1. Review of the residents medical record revealed multiple [DIAGNOSES REDACTED]. On 7/26/18 the resident fell from his bed and sustained a laceration to the left temple. He was sent to the emergency room approximately six hours after falling as he was complaining of nausea and dizziness. He returned to the facility on [DATE]. The comprehensive assessment, dated 08/13/18, identified the resident was cognitively intact, but required extensive assistance for activities of daily living, including bed mobility and transfers. The plan of care, dated 02/06/17, noted the resident was at risk for falls related to his confusion and the interventions included to place his bed against the wall per the resident's request. On 08/28/18 at 3:40 PM the resident was observed sitting in his wheelchair in the hallway outside his room. He stated he recalled falling out of bed, hurting his head and feeling sick; however, he was not able to provide the details of the fall. He added they moved me to a new room but they did not put my bed against the wall; I do not know why. During an interview on 08/28/18 at 1:25 PM, Staff D, a Nursing Assistant, stated she observed the resident at 10:00 PM on 7/26/18 lying on his left side in bed and the next time she saw him around 10:30 PM he was on the floor. She added the nurse treated his head wound, we then got him back to bed using the hoyer lift (a mechanical lift used to transfer a resident). She added when he was moved to the new room his bed had not been placed against the wall per his preference. On 08/28/18 at 2:50 PM Staff C, a Charge Nurse, stated she was present on the night the resident fell out of his bed. She added she had concerns about his bed not being placed against the wall; however she did not ask staff to move the bed next to the wall as the plan of care directed. When the resident is lying in bed I have seen him place his right leg over his left leg and since he does not have his right foot he does not have good balance. She added the resident had sustained a laceration to his forehead from his fall, but the resident did not wish to go to the hospital. She acknowledged she was aware that prior to his room change his bed had been placed next to the wall. Review of the nursing progress notes, dated 07/27/18 at 1:09 AM, noted the resident was lying on the floor between his bed and the wall. The resident sustained [REDACTED]. Steri-strips (small adhesive tape) were applied to the resident's [MEDICAL CONDITION]. On 08/28/18 at 11:30 AM Staff B, the Social Service Director, stated the resident had been moved to a different room due to maintenance and cosmetic repairs being done in his previous room. She added the resident had been moved on 07/20/18 but his bed had not been placed next to the wall as directed on the plan of care. On 08/28/18 at 1:40 PM, Staff A, the Director of Nursing, stated it was the responsibility of the Resident's Care Manager to ensure the resident's care plan was implemented. Staff A acknowledged the resident's bed placement preference had not been implemented. On 08/28/18 at 3:45 PM Staff E, the Rehabilitation Nurse, stated he had developed the resident's fall risk care plan and had made a determination that the bed against the bed was best for him plus the resident likes his bed against the bed as he feels it helps him and his call light is always in place. He added the nursing staff are to follow the resident's plan of care to make sure things are placed correctly. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review the facility failed to ensure all measures to reduce the risk of falls and prevent injury were implemented for two of eight residents (#62, 43) reviewed for accidents and incidents. Failure to identify risks factors and develop a supervision plan to mitigate risks resulted in a fall with significant injury to Resident #62. Findings included: Resident #62. Per medical records the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident fell on [DATE] which resulted in a left [MEDICAL CONDITION]. She was transferrred to the hospital for treatment and was re-admitted to the facility on [DATE]. The comprehensive assessment dated [DATE] showed the resident required extensive assist for bed mobility, transfers, dressing, and eating. She required total assist for toilet use, personal hygiene and locomotion while in her wheelchair. The resident's Functional Safety assessment dated [DATE] showed the resident's anti-psychotic and anti-anxiety medications affected the resident's activities of daily living. The resident's functional safety assessment also identified a concern related to the resident not being able to move independently. The recommendations made were use of a wheelchair and a fall mat. The potential risks were identified as Increase injury: from trying to clib (sic) over rails/getting limbs caught in rails, tipping over wheelchair, incident of falls and other accidents, strangulation, choking or death. Per the resident record, prior to admission multiple Physician's Notes and health histories had been provided to the facility identifying the resident leaned forward and slid out of her wheelchair landing on her right side. The Health History dated 02/13/18 showed the resident has pretty severe dementia and anxiety. The physician added any change for this resident was difficult for her. He recommended keeping her schedule regimented and gentle re-direction was best for the resident. The nursing progress notes dated 03/06/18 at 1:49 PM showed the resident had increased agitation and distress related to move (new admit to facility) the resident was striking out at passersby, rambling intelligibility. The nurse obtained an order for [REDACTED]. Review of Medscape Medical literature on 04/25/18 showed a warning that these medications may cause dizziness, unsteadiness, and somnolence (excessive sleepiness), which may lead to falls and consequently, fractures or other injuries. A review of the resident's record did not reveal any monitoring for the adverse side effects of the medications after they were administered. The two fall investigations dated 03/07/18 showed the resident fell twice within a 15 minute span. In each of the unwitnessed fall investigations the resident was found lying in her room. The first fall showed no injury, the second fall the resident complained of pain with movement. An X-Ray was ordered and the resident was diagnosed with [REDACTED]. On 04/18/18 at 11:00 AM Staff T, Social Service Assistant, stated the resident has been aggressive since she was admitted , on the first day I had to bring her into our office to help calm her and she tried to hit me when I attempted to drink water. 04/18/18 at 11:20 AM Staff B, Director of Nursing Services (DNS), stated the nurses were aware of the resident's fall history and her behaviors. She added she was responsible for completing the fall investigations in the facility. She added the resident speaks constantly, has had six falls since admit and four resident- to- resident altercations. I feel that the resident needs a more structured activity and one- to- one. We have noticed that when she is at the nurses station and there is a lot of noise around her she will get agitated. She added the resident's anti-anxiety had been changed from as needed to routine to see if the resident's behavior improved. She is sleeping well and eating well. It is during the day that we need to offer more structured activities. On 04/18/19 at 11:30 AM Staff C, Social Service Director stated the resident is busy all day, she self propels throughout the facility. On 04/19/18 at 10:08 AM Staff D, Licensed Practical Nurse (LPN) Charge Nurse, stated when the resident fell the first time on 03/07/18 a Nursing Assistant (NA) came and notified her of the resident's fall. She added I assessed the resident, performed range of motion and checked for pain the resident was agitated, she did not verbalize pain, we than transferred the resident back to her wheelchair. She added she was unable to recall if the resident was left in the room or brought out to the front desk. LN added the fall intervention plans were to apply a Lap belt on the resident's wheelchair. but before completing the plans the resident fell a second time. She stated she had been called back again to the resident's room. Staff D, stated the resident had complained of pain after the second fall so she obtained an order for [REDACTED]. On 04/19/18 at 11:32 AM Staff B, DNS, stated she had reviewed the two NAs witness statements and she acknowledged there was no documentation showing anyone was with her on the first or second fall. She added someone should have been with her after she had her first fall, We should have been watching her a little closer. She added nursing staff were aware of her fall history and knew the resident had been experiencing increased agitation and confusion due to her dementia and new environment. Review of both Report of Resident Occurrence reports dated 03/07/18 and signed by two different NAs with times of occurrence of 4:30 PM and 4:40 PM showed the resident was in her room, staff were walking by her room and saw her on the floor. Both NAs documented the cause of her falls were related to the resident attempting to get out of her wheelchair. On 04/19/18 at 2:19 PM Staff U, NA, stated she has worked for the facility for about two years and is familiar with the resident. She stated she was aware of the resident having two falls on 03/07/18. She added she attended to the resident's second fall. I was walking by her room when I saw her on the floor, the resident was alone in her room. Since she was a new resident we had not been given instruction on her cares just that she was a 2 person assist for transfers. The resident was observed on 04/19/18 from 10:00 to 10:15 AM self-propelling throughout the facility constantly speaking in an incoherent manner. She was observed again between 2:20 PM and 2:30 PM, she was in her wheelchair self propelling, speaking loudly in an incoherent manner and was not able to focus on being interviewed. Resident #43. Review of the resident's medical record showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] showed the resident required a two-person physical assist for transfers. A progress note dated 03/10/18 showed the resident had a non-injury fall during a transfer. The NA stated she was trying to transfer the resident from the wheel chair to the bed and the resident slid to the floor. Review of the facility incident report dated 03/10/18, and updated on 03/16/18, showed that the NA involved was from an agency and not a routine caregiver. She did not review the residents closet care plan prior to attempting to transfer the resident from the wheel chair to the bed. This failure to follow the care directive resulted in the resident's fall. On 04/19/18 at 8:50 AM, Staff B, DNS, stated that the agency NA was supposed to be with a staff person for two days as part of her orientation to the facility. She further stated that the agency NA attempted to lay the resident down without reviewing Resident #43's in-room closet care plan. Reference: WAC 388-97-1060 (3) (g)

Based on observation, interview and record review, the facility failed to provide ongoing dental services for 1 of 2 residents (#6) reviewed for dental care. Failure to accurately assess and follow through with appropriate dental care caused the resident undo mouth pain, discomfort eating meals and embarrassment in social situations. Findings include: Resident #6. Per the medical record, the resident was readmitted on [DATE] with a primary [DIAGNOSES REDACTED]. The resident's most recent comprehensive assessment dated [DATE] revealed her to be cognitively intact and required minimal assist with her activities of daily living. An observation and interview with Resident #6 on 06/21/17 at 4:00 p.m., revealed her sitting in a wheelchair in her room looking through a magazine. She had an oxygen nasal cannula in place and appeared not to have any teeth in her mouth when she spoke. Resident #6 stated she had a top full denture and a partial bottom denture but she was not currently wearing them. She stated she forced herself to wear her dentures when she ate and was socially around other people but they hurt her mouth if she wore them for even a short time as they needed to be adjusted to fit her mouth. Resident #6 stated she had her dentures approximately one year and they have never fit well. She stated she last had work done by a denturist on her bottom partial at the end of last year. She stated whenever she complained to the dentist and facility staff that they still did not fit well and hurt her mouth, she was told that there was nothing more that could be done. She was told she had used up all of her Medicaid benefit for dentures. She stated she continued to wear them even though they caused pain and sores in her mouth when she ate. She explained she doesn't want to have to eat soft foods again as she did prior to getting dentures and because it is embarrassing to talk to others without teeth. She stated she was so excited to finally have nice looking teeth and be able to eat regular foods again when she first got them and was very disappointed that she had to live with them as they were. Resident #6 pointed out her dentures that were in a cup at her bedside. She described exactly where she felt they needed to be filed down or adjusted to make them comfortable to wear. The resident opened her mouth and on the roof of her mouth on the right side, was a red raised area approximately 1 cm by 1 cm (centimeter, approximately 1/4 inch). On the left lower gum was an approximate 1 by 1.5 cm area that was red, raised and had a white center. The resident described that these areas were where the dentures rubbed the inside of her mouth. On 06/26/17 at 10:30 a.m., Resident #6 was observed lying on her bed without her dentures in. She stated that she had repeatedly told different staff members that her dentures did not fit correctly and caused her mouth pain. She stated that no one specifically asked her questions about her dentures or looked in her mouth. She had been complaining since her last adjustment about how her dentures continued to hurt her mouth and how disappointed she was that nothing more could be done for her. In an interview with Staff Member W, a Licensed Nurse (LN) on 06/26/17 at 2:30 p.m., she stated that Resident #6 had told her that her teeth do not fit well and she had noted on many occasions that she was not wearing her teeth. She stated she did not think she told the administrative staff of Resident # 6's concerns as she figured they already knew. In an interview with Staff Member K, a LN, on 06/28/17 at 3:25 p.m., he stated that he noted she usually only wore her teeth at meal times. In an interview with an unidentified care giver on 06/26/17 at 12:30 p.m., she stated that Resident #6 had told her that her dentures don't fit well and noted she puts them in just prior to eating and takes them out after she is finished and puts them in her denture cup. She stated that Resident #6 does her own dental care. In interviews with the Staff Member C, a Patient Care Coordinator, the Social Services Director and the Director of Nursing on 06/27/17 between 1:20 p.m. and 1:40 p.m. all stated they did not have any knowledge that Resident #6's dentures did not fit well and hurt her mouth or that she had been told her medicaid benefits had been exhausted for dental care. Reference (WAC) 388-97-1060 (1), (3)(j)(vii)

Based on record review and interview, the facility failed to provide timely, appropriate care and services for 1 of 3 residents (#2) reviewed for a change of condition (#2). Failure to provide timely nutritional support, assessments, physician notification, and implementation of physician orders [REDACTED].#2 as his condition continued to deteriorate over time. Findings include but were not limited to: Resident #2: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The [DATE] care plan directed staff to report symptoms of low blood sugar and heart failure to the physician as needed. The medical record noted a [DATE] POLST (Physician order [REDACTED]. Physician orders [REDACTED]. Review of the [DATE] Medication Administration Record (MAR) revealed that on [DATE] the resident's blood sugar was 76 prior to breakfast. Previous early morning blood sugars had ranged from (,[DATE]). According to the MAR, the resident received the routine 7:00 a.m. dose of 1 unit of short acting insulin. Documentation related to the resident's [DATE] breakfast intake noted Resident #2 had not eaten breakfast and no substitute was offered per the documentation. There was no nursing assessment/documentation related to the resident's blood sugar value, the insulin administration, and his lack of food intake. Morning vital signs on [DATE] were entered at 8:23 a.m. and were within his usual range with a temperature of 97.6 orally, a pulse rate of 77, a respiratory rate of 22 breaths per minutes, and a blood pressure of ,[DATE]. The blood sugar reading prior to lunch was 62 (lower). A [DATE] nursing entry at 12:10 p.m. by Staff Member B, a Licensed Nurse (LN), documented she held the resident's routine insulin based on the blood sugar of 62. Thereafter, the resident received a narcotic pain medication for ,[DATE] abdominal pain at 12:57 p.m. and an injection for nausea at 12:58 p.m. The meal monitor documented the resident had refused his lunch meal and a substitute. There was no nursing entry assessing the resident's ongoing lack or food intake and low blood sugar or a vital sign check. The physician was not updated at that time related to the resident's blood sugar level and lack of intake. A [DATE] 2:15 p.m. entry by Staff Member C, the day shift Charge Nurse, noted the Team leader came in and notify (sic) charge nurse of low CBG (blood sugar) call dr. (named) with new order for Insta Glucon (oral concentrated sugar preparation) if not working use [MEDICATION NAME] MG IM. Resident for lunch was 64 given insta Glucon CBG went down to 56 given [MEDICATION NAME] IM will have team leader give evening charge nurse new results. No updated vital signs were identified despite the resident's downward trending blood sugars. Review of the new [DATE] physician orders [REDACTED]. The second [DATE] order was at 2:20 p.m. and documented, [MEDICATION NAME] Emergency Kit 1 mg (milligram) ([MEDICATION NAME](DNA)) (sic) Inject 1 mg intramuscularly as needed for [DIAGNOSES REDACTED]. Per the [DATE] MAR, the orders for the Insta Glucon and [MEDICATION NAME] were added to the MAR on [DATE] but there was no documentation on the MAR that either were administered. A [DATE] nursing entry (at 3:20 p.m.) by Staff Member D, the evening shift Medication LN, documented that a nursing assistant had reported the resident's blood pressure was ,[DATE] (very low) despite multiple attempts to check it. The resident's heart rate was 107 (elevated out of normal range). Staff Member D checked the resident and his blood sugar was 48. Skin dusky, finger tips mottled, respirations very moist sounding, 02 sat (oxygen saturation level) 76% (very low) on RA (room air). [MEDICATION NAME] 1 mg right biceps (sic). Legs and head of bed elevated, 02 (oxygen) applied at 6 L(liters)/per NC (nasal cannula). The next nursing entry charted by Staff Member D at 3:30 p.m. (on [DATE]), noted the resident's blood pressure was 62 systolic (the upper value) and his heart rate was 108. The resident was responding but lethargic. His oxygen saturation was 83% (still low) on 6 liters of oxygen. Documented as 10 minutes later, at 3:41 p.m., the resident's blood sugar was 76. On [DATE] at 3:45 p.m., Staff Member A, the evening shift Charge LN, documented the resident's blood pressure was ,[DATE] and his blood sugar was 49. The physician was contacted and he ordered that Resident #2 be sent to the hospital. The 911 agency was contacted and the resident was transported to the hospital. According to a [DATE] nursing entry later in the evening, the resident was admitted to the hospital intensive care unit [MEDICAL CONDITION], an infection impacting his entire body. Staff Member B, the day shift Medication LN on [DATE], was interviewed on [DATE] at approximately 3:00 p.m. The LN recalled giving Resident #2 his routine morning insulin. The nursing assistants were to report to the LN if resident did not eat his meal. Staff Member B stated she held the resident's routine lunch insulin due to his low blood sugar. The LN was not notified that the resident did not eat his breakfast or lunch. If she had known he had not eaten, she would have offered him a health shake. Staff Member B recalled the resident had nausea and provided medication for the nausea. Resident #2 did not vomit but coughed up phlegm. When asked about the administration of the Insta Glucose Gel (oral sugar) and the injectable [MEDICATION NAME], she stated she did not think she had given either of them on her shift on [DATE]. When interviewed on [DATE] at approximately 2:45 p.m., Staff Member C, the day shift Charge LN on [DATE], stated that toward the end of the day shift on [DATE] she heard from Staff Member B, the Medication LN, that Resident #2 had a low blood sugar. She called the physician and obtained orders for oral glucose and the injectable [MEDICATION NAME]. Staff Member C reviewed the [DATE] MAR and stated there was no documentation that either had been given. Staff Member C stated she thought Staff B, the day shift Medication LN had given them both. Additionally, Staff Member C reviewed the meal monitor and also stated she was unable to locate any documentation that the resident was offered snacks. Staff Member D, the evening shift Medication LN on [DATE], was interviewed on [DATE] at approximately 3:50 p.m. and stated she had read the written shift report from the day shift on [DATE] and read that Resident #2 had received glucose but his blood sugar was still low. Per the physicians' protocol, they could give the oral glucose if the resident was responsive but were to give the injectable glucose if the resident was unresponsive. The resident was reportedly somewhere between the two states so she gave the resident the injection, sometime between 2:50 p.m. and 3:20 p.m. The LN administered the [MEDICATION NAME], started the oxygen at 6 liters, and elevated the head/foot of the bed and foot of the bed. He looked really bad and he was a Full Code (wanted CPR and Full Treatment). The resident's blood sugar came up to 76 but then came down to 49 (per the medical record). The doctor was called and the resident was sent to the hospital.

Based on observation, record review, and interview, the facility failed to ensure 3 of 6 sampled residents (#8, # 9, & #12) were free of significant medication errors. The facility failed to administer the antibiotic, [MEDICATION NAME], in accordance with physician's orders [REDACTED]. The significant medication errors included Licensed Nurses (LNs) administering [MEDICATION NAME] when it was to be held, not administering the antibiotic when it was ordered to be given, administering the medication at too close of an interval, and administering the antibiotic without appropriate lab monitoring. Resident #8 received a dose of [MEDICATION NAME] when it was to be held. The resident experienced harm as a result of the medication error. Resident #8's was hospitalized for [REDACTED]. Findings include but were not limited to: Note: A blood test was used to monitor levels of [MEDICATION NAME] (an antibiotic medication) in the blood. When the blood sample was drawn, it is typically timed to be drawn just prior to the administration of the antibiotic, when the concentration of the antibiotic was at its lowest level. It is commonly called a trough. The goal was to keep a therapeutically effective amount of the drug in the bloodstream at all times, without having an excessively high concentration, which can pose a risk of toxicity. Resident #8: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. Hospital records documented that on [DATE] the resident was admitted with low blood sugar values and an altered mental status. After stabilization and medication adjustments, the resident was discharged back to the nursing facility. The resident arrived in the nursing facility late afternoon on [DATE]. Later that evening the lab was in to pick up a specimen for a [MEDICATION NAME] trough. The trough level was completed the morning of [DATE] and noted a high level of 20.5 with the range documented as ,[DATE]. A [DATE] nursing entry documented the pharmacist called and provided an order to continue [MEDICATION NAME] 1 gram intravenously (IV) daily with the next trough on [DATE]. Review of the ,[DATE] Medication Administration Record revealed that [MEDICATION NAME] was administered at 2:35 p.m. on [DATE]. On [DATE] at 12:19 p.m. a fax transmission was received from the pharmacy directing, Hold until trough below 15, then IV 2 grams Vanco Q (every) 48 hours. Next trough after 4 doses. The fax was noted as processed by Staff Member L, a Licensed Nurse (LN). However, the ,[DATE] MAR documented that a [MEDICATION NAME] 1 gram dose was given on [DATE] at 3:01 p.m., instead of being held as directed by the pharmacy. A [DATE] nursing entry at 4:58 p.m. revealed the Primary Care Physician (PCP) was notified that the [MEDICATION NAME] was given (a medication error) despite the medication hold directive. The hold directive had not been appropriately documented on the MAR. The physician directed the LN to contact the pharmacy for further directives. The LN called the pharmacy and was told to continue to hold the [MEDICATION NAME] and to do daily trough levels until the value was below 15. When the trough was below 15, staff were to call for new orders. Review of the [DATE] comprehensive metabolic panel revealed many abnormal lab findings. The [DATE] [MEDICATION NAME] trough level, drawn at 15.5 hours (earlier than usual) had a value of 33.3. On [DATE] the PCP was contacted to discuss the labs. The PCP discussed possible hospice services. The resident had poor oral intake but agreed to attempt to drink more. Two liters of IV fluids were also provided due to the resident's poor oral intake. On [DATE] the [MEDICATION NAME] trough was 25.8, 36 hours after the last dose. Another comprehensive metabolic panel lab study, on [DATE], showed worsening values, notably related to kidney function. The PCP was contacted once again to discuss the resident's condition. Despite the two liters of IV fluids infused, the resident was lethargic, ate poorly, had loose stools, and had only 2 ,[DATE] ounces of urine that appeared thick and brownish/red that shift. The [DATE] PCP's order summary noted, Transport to (specific hospital) to R/O (rule out) acute Kidney (sic) injury. The resident was sent to the hospital for further treatment. Observations on [DATE] at approximately 10:50 a.m. noted the resident was up in his wheelchair. His skin was pale and he leaned to one side against the arm of the wheelchair. Oxygen was running through a nasal cannula. When asked how he was doing, Resident #8 stated, I had a kidney problem. I almost died in the ICU (intensive care unit at the hospital). When interviewed on [DATE] at approximately 11:45 a.m., Staff Member L, a LN, stated she had not properly transcribed the new [DATE] [MEDICATION NAME] hold order. The [MEDICATION NAME] was to be held due to the high trough level. Staff Member L reported she thought the medication was scheduled to be given later. The LN working on the floor administered the [MEDICATION NAME] because the MAR did not document the hold, resulting in a medication error. Per hospital documentation, the [DATE] emergency room (ER) Physician documented that the resident's renal function had changed since his last visit on [DATE]. The resident apparently had a head [MEDICAL CONDITION] develop over the last week secondary most likely to [MEDICATION NAME] (sic). [MEDICATION NAME] trough levels were exceedingly high. (The [MEDICATION NAME] trough was 30.2 in the ER). The resident was sent to the ICU. Two other physicians who evaluated the resident on [DATE] diagnosed the resident with acute kidney injury or acute renal (kidney) failure likely related to a combination of factors including poor intake, medications, and antibiotics. One physician directly referenced the very high [MEDICATION NAME] trough levels that likely contributed to his kidney injury. Resident #9: According to the medical record, the resident was re-admitted on [DATE] following a hospitalization with [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident had drug resistant bacteria in the wound. Error #1: Review of physician orders [REDACTED]. Use 750 mg intravenously two times a day for abdominal abscess A second order, also dated [DATE], read, Trough prior to AM Vanco dose. (Laboratory) will be here at 8:30 a.m. Review of laboratory results documented a blood sample was collected for a [MEDICATION NAME] trough on [DATE] at 8:40 a.m. The sample was accessioned (formally received by the laboratory) on [DATE] at 9:28 a.m. and completed on [DATE] at 4:00 p.m. Review of the ,[DATE] MAR revealed the morning dose of [MEDICATION NAME] was administered on [DATE] at approximately 9:00 a.m. In an interview on [DATE] at approximately 3:30 p.m., Staff Member C, the Assistant Director of Nursing (ADON), stated she did not think the (trough) level could have come back in time to administer the morning dose of [MEDICATION NAME] on [DATE]. She stated she did not know about the error prior to this and would investigate. Errors #2 and #3: Review of a physician order [REDACTED]. Use 750 mg intravenously every 8 hours . Review of the ,[DATE] MAR revealed the administration times set up for the order were 500, 1300 and 2100 (in 24-hour time, corresponding to 5:00 a.m., 1:00 p.m. and 9:00 p.m. in standard time). Further review of the ,[DATE] MAR revealed the 5:00 a.m. dose was not given on [DATE] (Error #2, an omission), but the 1:00 p.m. dose was administered. Review of the physician orders [REDACTED]. The order was replaced with an order, also dated [DATE], which read, [MEDICATION NAME] HCl Solution Reconstituted 750 mg. Use 750 mg intravenously three times a day Review of the MAR revealed the administration times set up for the second order were 0800, 1600 and 2359 (8:00 a.m., 4:00 p.m. and 11:59 p.m.). Further review of the ,[DATE] MAR revealed the 4:00 p.m. and 11:59 p.m. doses were administered to the resident on [DATE]. The resident had a 16 hour gap between the last dose received on [DATE] at 9:00 p.m. and the first dose received on [DATE] at 1:00 p.m., then received two doses in a 3 hour time period (1:00 p.m., then 4:00 p.m., Error #3, administering doses too close together). On [DATE] at approximately 4:45 p.m., Staff Member C, the ADON, stated the resident should not have received the doses so close together. She noted the resident's small stature and difficulties staying well hydrated made her especially vulnerable to the effects of the medication. Errors #4 and #5: Review of a physician order [REDACTED]. Use 750 mg intravenously two times a day . Review of the ,[DATE] MAR revealed the resident received the medication according to the order on [DATE] and [DATE]. On [DATE], the morning dose was given, but the evening dose, scheduled for 8:00 p.m., was not given (Error #4, an omission). Review of a progress note, dated [DATE] at 2:37 a.m., revealed the facility was notified of a high trough reading. (Laboratory) called with critical lab on [MEDICATION NAME] trough 21.0. MD (physician) and pharmacy notified of lab, Vanco on hold until new dosing orders come in. Review of physician orders [REDACTED]. An additional physician order [REDACTED]. Next Vanco trough in AM [DATE]. Further review of the ,[DATE] MAR revealed both doses on [DATE] were held, as was the [DATE] morning dose. The afternoon dose was given at approximately 8:00 p.m., despite the order to hold the medication (Error #5). In an interview on [DATE] at approximately 3:30 p.m., Staff Member C, the ADON, stated she drew the blood sample on the morning of [DATE], and talked with the day shift nurse, reminding her to hold the antibiotic medication. She explained that apparently, the day shift nurse did not pass the information on to the evening shift. On [DATE] at approximately 4:45 p.m., the ADON stated she was reviewing the [MEDICATION NAME] administration for Resident #9, and noted she should have received the evening dose on [DATE], according to the orders. Resident #12: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. Multiple intravenous (IV) antibiotics were prescribed following the surgery. [MEDICATION NAME], one of the antibiotics, was ordered on [DATE]. The order directed that [MEDICATION NAME] one gram was to be administered daily in the morning. According to a laboratory report completed on [DATE], the [MEDICATION NAME] trough level was 24.8 (high). The physician was in to see the resident on [DATE] and wrote orders to reduce the [MEDICATION NAME] dose to 1.5 grams every other day. A trough level was to be checked on [DATE]. Review of the medical record failed to identify a [DATE] [MEDICATION NAME] trough level. The ,[DATE] MAR revealed the resident received doses of [MEDICATION NAME] 1.5 grams on [DATE] and [DATE] without the [DATE] trough level. On [DATE] at approximately 2:30 p.m., Staff Member B, the Director of Nursing, stated she had identified two medication errors for Resident #12. [MEDICATION NAME] was administered on [DATE] and [DATE] without the [DATE] trough level being obtained. A new [MEDICATION NAME] trough was to be obtained on [DATE]. Review of the [DATE] [MEDICATION NAME] trough level noted it was 17.7 (high).

Based on observation, interview and record review the facility failed to have a system in place to prevent residents from leaving the facility unsupervised. For 2 of 4 residents sampled to be at risk of elopement (#'s 1 & 2), the facility continued to use an electronic alarm system they had determined would not consistently alarm, which permitted these residents to leave the building without staff being aware they were out. This resulted in harm for Resident #1 when she exited the building after dark, fell and sustained a scalp laceration and pain. The failure to recognize the ongoing risk of an unpredictably functioning alarm system and failure to implement necessary supervision placed 3 of 3 residents evaluated to be at risk of elopement, at risk to be able to leave unsupervised. Resident #2, a resident diagnosed with [REDACTED]. This resulted in a finding of Immediate Jeopardy on 1/12/15. Findings include: 1) Resident #1. admitted on [DATE] with [DIAGNOSES REDACTED]. Her latest comprehensive assessment dated [DATE] revealed she had severe cognitive impairment, scoring 5 out of 15 on a mental status test. The assessment also noted she was able to walk about the facility with limited assistance from staff. The assessment documented she had wandering behaviors 4 to 6 days per week. Review of the resident's care plan revealed the resident was at risk of elopement, frequently wandered, packed her belongings in a pillow case and sought exits. The interventions to keep her safe included tagging her clothing with an E-tag (a system in which a device is attached to clothing. A radio frequency from the device activates a sensor when a resident gets near it, activating an alarm). Other interventions were tagging a vest with an E-tag, a walking program and an activity program. The plan noted the resident frequently removed the vest, and staff were to ensure an E-tag was present on her clothing or vest at all times. On 12/29/14 at 2:25 p.m., Staff Member B, the Maintenance Director, stated the E-tag system had been implemented approximately one year ago. He stated the E-tags worked on the front door only. The Maintenance Director stated when they started using the E-tag system, they attached 4 tags on the person's clothing, but now they attached only one tag. He stated the system should alarm if the tag was within a 3 foot radius of the sensor, which was located on the right side of the door if leaving the building, but the alarm did not always sound. He explained if the person's body was between the tag and the sensor, it did not always work. He noted this could happen if the tag was on the resident's right side, but they backed through the door. He explained a heavy garment, such as a winter coat, over the tag also prevented the system from working at times. The Maintenance Director stated one of the biggest impediments to the system working was staff becoming "tone deaf" to the alarm because staff heard so many different alarm sounds throughout their shifts. Review of an incident investigation prepared by Staff Member C, a licensed nurse (LN), revealed on 12/20/14 at approximately 10:15 p.m., Resident #1 was noted to be missing from the building. She had last been seen between 9:00 p.m. and 9:30 p.m. in her room. At approximately 10:30 p.m., the resident was found outside near a storage shed located on facility property. A witness statement completed by the Nursing Assistant (NA) who found her, described her "lying on her right side, covered in blood, wet (from rain), and she was telling me she was cold." The NA further noted in the report the resident told her she fell and stated she was in pain. Staff Member C noted in the incident investigation the resident sustained [REDACTED]. The investigation confirmed the E-tag was on her clothing during the evening shift. On 12/29/14 at approximately 2:15 p.m., Staff Member A, the Director of Nursing Services (DNS), stated they had concluded the E-tag system had not worked when Resident #1 left the building on 12/20/14, as no one reported hearing an alarm. She stated the next morning they re-activated the old keypad system on the front door, though it was not working at the moment due to an issue in the electrical panel. When the facility discovered the keypad system was not working, no other interventions were implemented to supervise residents at the front door. On 12/29/14 at 3:50 p.m., Staff Member D, a LN, stated Resident #1 tried to leave the building on a daily basis. She stated the resident changed her clothing independently, and could have changed out of E-tagged clothing and into non E-tagged clothing. She further noted the resident used a shawl at times, and the E-tag would not always alarm when the shawl covered the E-tag. On 12/30/14 at approximately 10:00 a.m., Resident #1's daughter stated in a phone interview her mother spent 8 days in the hospital, and then was transferred to a different nursing facility. She stated her mother sustained 2 cuts to her scalp requiring sutures and abrasions to her hand from the fall. 2) Resident #2. The resident was admitted to the facility on [DATE] with significant mental [DIAGNOSES REDACTED]. He was ambulatory and had a history of [REDACTED]. Review of the resident's plan of care and comprehensive assessment, dated 10/14/14, revealed that the resident had behaviors that included wandering/elopement, seeking cigarettes and was to be monitored by staff. Additionally, the resident was to wear a bright reflective vest and E-tag (alarm) to alert staff if the resident independently left the building through the front-main entry door. Other interventions included ensuring the resident is not out of the building unsupervised (this included the dining room, patio and front porch sitting area), close monitoring if visitors were in the facility and 2 care givers to re-direct the resident from exit seeking. No clear direction was provided to caregivers regarding how re-direction of the resident occurred or how the caregivers were to approach the resident. Additionally, the facility had not identified assigned caregivers to monitor the resident. On 12/29/14 at approximately 1:45 p.m., the State Investigator observed the resident exiting the building through the main entry way. The resident was wearing a dark blue jacket, not the bright reflective vest as directed on the care plan. The E-tag alarm was located on the resident's left lower pocket of his pants. The alarm did not sound. The facility staff did not respond to the resident exiting the building until the State Investigator notified them. At approximately 2:15 p.m., thirty minutes after the first unsupervised exit, the State Investigator observed the resident exiting the building. The resident followed visitors out the front door. Although the resident had an E-tag placed on his clothing, no alarm sounded. Again, the facility staff did not respond until they were notified by the State Investigator that the resident exited. According to Progress notes, dated 12/17/14 through 12/29/14, the resident had a past history of eloping 4 times from the facility. Additionally, the resident regularly wandered and paced the hallways. On 12/29/14 at approximately 2:20 p.m., Staff Member G, a registered nurse (RN), stated that she made the behavior and safety plans for the residents that were assessed as being at risk for elopement/wandering. She stated Resident #2 was to have a bright reflective vest and E-tag on his clothing, but didn't always keep the vest on and staff were to supervise the resident. Staff Member G was unaware that the E-tag alarm would not sound if clothing covered the E-tag alarm or if it was not placed in the correct position on the resident. On 12/30/14 at approximately 10:00 a.m., Staff Member E, a NA, stated that the resident became agitated when he couldn't get cigarettes and often went outside to "dig" in the ash trays for cigarette butts. If the resident went outside to the back patio by the dining room, there is no alarm. Staff would have to be in the dining room to visualize him being outside. If they were in other resident's rooms or other areas of the building, they would not know his whereabouts. Staff Member E further stated, during the evening shift, the resident typically exited through the main door of the building. The NA said she knew about him leaving the building at change of shift on 12/29/14. She noted all NA's were busy providing care in resident rooms during that time and couldn't always hear the alarm or know if a resident left the building. Despite the facility having had knowledge the alarm had variability in function and use of the E-tag system was the primary intervention for residents at risk of elopement from the facility, no changes were made to protect the residents to ensure they did not elope from the facility. This resulted in a determination that an Immediate Jeopardy situation existed.

Based on observation, interview and record review, the facility failed to administer operations and use resources to ensure resident safety, health, and well-being related to providing supervision and preventing accidents for residents leaving the building unsupervised. This failure resulted in harm to Resident #1 and an Immediate Jeopardy situation on 1/12/15, as issues identified on 12/29/14 and subsequent investigation into those issues were not recognized by the facility administration as posing a serious risk of imminent harm to residents. Findings include: 1) Resident #1 left the building unsupervised on 12/20/14 and was later found outside on the ground, injured. The E-tag system was used to try to prevent her leaving the building without staff knowledge, though staff was aware the E-tag did not always sound an alarm when the resident was within range of the sensor. The facility concluded the alarm did not sound at the time she left the building on 12/20/14. 2) Resident #2 left the building unsupervised twice on 12/29/14. An E-tag device was observed on the resident's clothing but was ineffective in alerting staff. He was escorted back to the building both times only after facility staff was notified of his departure by the State investigator. On 12/29/14, when initial findings were presented to Staff Member A, the Director of Nursing, who was in charge of the facility at the time (the administrator was not available or in the facility), her response of only providing 15 minute checks to one resident, which would be ineffective given the observations of survey staff, illustrated the fact that she did not recognize the immediacy of the situation and the risk of imminent harm to other residents. Refer to F323 for additional information.