Every finding on record at Emerson Health & Rehabilitation

Based on interview and record review, the facility failed to ensure the Director of Nursing (DNS) did not serve as a charge nurse when the facility had an average daily occupancy over 60. This failure placed all residents at risk of lack of oversight for care provided, unmet care needs, and a diminished quality of life.Findings included . Review of the facility assessment dated [DATE] showed the facility's average daily census was 75-80. The assessment identified Staff B as the DNS. The staffing plan showed the facility required one DNS to meet the care requirements of the facility resident population during day-to-day operations and during emergencies. The contingency staffing plan showed the facility would utilize interdepartmental staff support from various departments to meet staffing needs in another department, as long as such support does not violate licensure/certification requirements. In an interview on 07/21/2025 at 8:30 AM, Staff A, Administrator, stated Staff B, DNS, was not working that morning because there was a scheduling issue and they worked night shift last night. Review of the facility census for 07/21/2025 showed the facility had 80 current residents. In an interview on 07/25/2025 at 10:35 AM, Staff D, Resident Care Manager, stated nurse managers, including the DNS, rotated being on-call during weekends. Staff D explained the on-call manager received staff call-ins on the weekends, attempted to fill staffing needs, and were required to work on the weekends if unable to find needed staffing coverage. Staff D acknowledged Staff B worked the floor often and the facility average census was about 80. In an interview on 07/25/2025 at 11:27 AM, Staff M, Staffing Coordinator, stated nurse managers, including the DNS, rotated being on-call during weekends. Staff M explained the on-call manager attempted to staff open shifts and were required to come in and work the floor if unable to find needed coverage. Staff M stated the facility's daily average census was between 79-85. Staff M acknowledged Staff B should not work the floor as a charge nurse when the facility census was at a certain level. In an interview on 07/28/2025 at 8:46 AM, Staff B, DNS, stated the facility had a daily average census of 82-83. Staff B explained they and other nurse managers rotated being on-call during weekends; they received staff call-ins, attempted to staff open shifts, and were required to work if unable to find needed staffing coverage. Staff B acknowledged they should not work the floor as a charge nurse but did when needed, if unable to find needed staffing coverage, because they would not ask or require their staff to do something they were not also willing to do. Reference WAC 388-97-1080 (2)(a)

Based on observation, interview and record review, the facility failed to ensure gloves were changed and hand hygiene was completed when indicated during the lunch meal service, foods were served at the appropriate temperatures and food was labeled and dated as required. The facility further failed to maintain the required dish washing machine temperatures. These failures placed residents at risk for food-borne illnesses. Findings included .<Expired/undated food>During an observation on 07/21/2025 at 9:58 AM, the refrigerator on the Tucson Hall dining room revealed three frozen drinks. There was a name on one of the drinks, the other two drinks were not labeled and none of the drinks had dates of when they had been placed in the freezer. In an interview on 07/21/2025 at 12:24 PM, Staff N, Registered Nurse, stated the refrigerator in the dining room was for the residents. Staff N stated everything in the refrigerator should have had a name and date and it was important to put names and dates on items, so one knew who they belonged to and when to discard them, so they did not spoil. Staff N added it was the kitchen staff's responsibility to clean the refrigerator and to ensure food items were dated, however, whoever put items in the refrigerator needed to label and date them. <Food Temperatures>During observation of the lunch meal service on 07/28/2025 at 11:19 AM, Staff Q, Cook, had checked the temperatures of the cold food items. The pudding was 42.1 degrees Fahrenheit (F), cottage cheese was 43.5 degrees F, the fruit cup was 44.3 degrees F, and the salad was 41.2 degrees F, all above the recommended food temperature of 41 degrees. On 07/28/2025 at 11:40 AM, Staff Q was plating food and the aide placed watermelon on a meal tray. The watermelon came out of the refrigerator and the temperature was 42 degrees F. Once the meal trays were placed in the carts and ready to be served, the staff was asked what the temperature of the cold items needed to be and Staff O, Dietary Manager, stated 40 degrees or below. Staff O stated the cold items were cold in the refrigerator but were not staying cold and were not going to hold their temperature. Staff Q instructed staff to remove the cold items from the meal carts. Staff O stated the watermelon was fine to be served because it came out of the refrigerator and the temperature was subject to change. <Hygienic practice>During an observation of the meal service on 07/28/2025 at 12:10 PM, Staff O microwaved some food that was in mugs. Staff O had touched the microwave handles which had been touched by other staff members. Staff O gave the mugs of food to Staff Q who was wearing gloves and plating food. Staff Q did not remove their gloves and perform hand hygiene after they received the mugs. Staff Q then plated food and with their same gloved hands picked up fish and touched green beans that fell off the plate. On 07/28/2025 at 12:16 PM, Staff Q used their arm to push up their glasses while plating food. Similar observations of Staff Q using their arm to push up their glasses were made on 07/28/2025 at 12:19 PM, 12:20 PM, 12:23 PM, 12:24 PM, 12:25 PM, 12:30 PM, and 12:32 PM. Staff Q stated they needed new glasses because they had to keep pushing their glasses back onto their face. On 07/28/2025 at 12:33 PM, Staff Q wiped the side of their mouth on their shirt while plating food. <Dishwasher temperatures>During an observation of the kitchen on 07/28/2025 at 12:59 PM, Staff O stated the dishwasher was a high temperature dishwasher. This meant the dishes had to be rinsed at 180 degrees F or above to kill bacteria. An observation of the dishwasher showed the final rinse temperature was 170 degrees F. In an observation on 07/28/2025 at 1:11 PM, Staff P, Dishwasher, was putting away the dishes that came out of the dishwasher that did not reach the required final rinse temperature. In an observation on 07/28/2025 at 1:12 PM, another dishwasher cycle was observed, and the final rinse temperature was 170 degrees F. A third cycle was observed at 1:14 PM and the final rinse temperature was 172 degrees F. The temperature logs from May 2025 through July 2025 showed the final rinse temperatures were below 180 degrees on 34 different occasions in July, 41 occasions in June and 47 occasions in May. In an interview on 07/28/2025 at 1:23 PM, Staff O stated all items placed in the refrigerators should have names and dates and this was important to know who they belonged to and when the items needed to be discarded. Staff O stated cold food items needed to be served at the appropriate temperatures to prevent food borne illnesses. Staff O stated it was important to maintain hygiene during the meal service to protect the food and the residents. Staff O stated Staff Q should have performed hand hygiene and put on gloves after they touched the mugs of food that were reheated and prior to touching the food. Staff O stated Staff Q should have waited until after the meal service to adjust their glasses and wipe their mouth for infection control. Staff O stated they looked at the dishwasher temperature logs daily and should have notified maintenance. Staff O stated there was an issue with the hot water tank, and they thought things were fixed. Reference: WAC 388-97-1100 (3), 2980

Based on observation, interview and record review, the facility failed to ensure interventions developed to prevent the growth of waterborne bacteria or Legionella (a contagious bacteria that caused respiratory illness when water droplets or mist containing the bacteria were inhaled) as part of the Water Management Plan were monitored for completion as required. This failure placed residents and staff at risk of developing severe respiratory illness and unintended health consequences. Findings included.The undated facility Water Management Plan documented areas in the facility were identified that could encourage growth and spread of water borne bacteria or Legionella and included shower heads, sink aerators, dirty utility room hoppers (large basins where soiled linens or clothing were rinsed), tubs, and floor drains. Specific measures currently used to control the spread included:-flushing unused toilets weekly,-running water in unused sinks weekly,-Housekeeping was to clean shower heads with appropriate sanitizing agents,-Maintenance department was to flush basement floor drains weekly, and-the facility was to conduct Legionella testing of the water quarterly. On 07/28/2025 at 10:05 AM, a binder that contained completed logs that documented water temperatures were checked, and flushes of high-risk areas of the facility not in use were completed was observed with Staff G, Maintenance Director. The logs were dated from 12/22/2023 and ended 05/02/2025. Staff G looked for the logs from 05/02/2025 to the present and was unable to locate them. They stated they had assigned the water flushes to one of the staff in the Central Supply department to help them out, but they were unable to confirm that the logs and the water flushes had been completed. Reference: WAC 388-97-1320(1)(a)

Based on interview and record review, the facility failed to ensure the staff documented the information conveyed to the hospital at the time of 4 of 5 hospital transfers for 1 of 3 sampled residents (Resident 6) whose closed records were reviewed. Additionally, the staff failed to ensure bed hold notices were offered to Resident 6 or their representative in 4 of 5 hospital transfers and failed to notify the Office of the State Long-Term Care Ombudsman (an advocate for residents of nursing homes, adult family homes, and assisted living facilities who protect and promote the resident rights under federal and state law and regulations) of 5 of 5 hospital transfers. These failures placed the resident at risk for delayed services and a lack of knowledge regarding the right to a bed-hold while they were hospitalized , and detracted from the residents' rights being protected, the opportunity to explore other options, or provide them with support and advocacy during a potentially stressful and confusing time.Findings included. Review of an undated facility policy and procedure titled Room and Bed Hold Letter showed that when a resident transferred to the hospital, the nurse presented a Room and Bed Hold Letter to the resident, family, or responsible party upon transfer of the resident. If a resident could not participate in the transfer process, the nurse sent a copy of the Room and Bed Hold Letter with the resident to the hospital and made a copy of the letter and left it for the medical records staff to mail it on the next business day. The medical records staff attempted to contact the resident's family or responsible party by phone on the first business day following the transfer, explained the bed hold notice policy and informed them a copy was placed in the mail.On 07/24/2025 at 5:48 PM, Staff B, Director of Nursing Services, communicated to the Survey Team via e-mail that the facility did not have specific policies regarding Sending a resident to the hospital but the procedure was, an SBAR [Situation, Background, Assessment, and Recommendation, a structured tool used to facilitate clear and concise communication between healthcare professionals when reporting patient information] will be completed and sent with the ambulance team, along with MAR [Medication Administration Record], POLST [Physician Orders for Life-Sustaining Treatment, a document that outlines a person's wishes for medical treatment, particularly at the end of life], face sheet [details about a resident's identity, contact information, medical background], notice of transfer, and bed-hold information. This was sent in a print format with [the ambulance team]. Review of a 06/11/2025 admission assessment showed Resident 6 admitted to the facility on [DATE] with weakness, diabetes, and several heart conditions. The assessment showed Resident 6's cognition was intact and they required physical assistance from the staff to complete their Activities of Daily Living.<1st Transfer>Review of a 04/29/2025 progress note written at 9:07 AM showed Resident 6 required a hospital transfer due to abnormal blood work results. The progress note showed the staff called the hospital to give report. Review of the medical record showed no documentation of what information the facility communicated to the hospital, for example the SBAR, contact information for their provider, family or representative, POLST and/or advanced directives, plan of care and treatment, current medications and the reason for the hospital transfer. Additionally, review of the medical record showed no documentation the staff offered or provided a bed hold notice to Resident 6 or their representative. <2nd Transfer>Review of a 06/23/2025 progress note written at 1:01 PM showed Resident 6 was insisting to go to the ER [Emergency Room] because [they were] in excruciating pain and Paperwork given to resident to take to the ER. The note showed, Resident called 911 and left about [3:45 PM]. Review of the medical record showed no documentation of what information the staff conveyed to the hospital at the time of the transfer or that a bed hold notice was offered or provided to Resident 6 or their representative. <3rd Transfer>Review of a 07/01/2025 progress note written at 8:01 PM showed the staff was unable to flush Resident 6's urinary catheter (a flexible tube inserted inside the urinary canal to drain urine from the bladder) and assessed some blood in urine. The staff reported the change in condition to the provider who ordered a transfer to the hospital. Record review showed the staff conveyed information to the hospital using an SBAR form. Record review showed no documentation the staff provided or offered a bed hold notice to Resident 6 or their representative.<4th Transfer>Review of 07/04/2025 progress notes showed the provider was in the facility and assessed Resident 6, who appeared pale. After their assessment, the provider ordered a transfer to the ER for evaluation and blood transfusion. The notes showed, All paperwork along with order to transfer and recent labs sent with resident. Review of the medical record showed no documentation of what information staff conveyed to the hospital in all paperwork sent at the time of transfer or that a bed hold notice was offered or provided to Resident 6 or their representative. <5th Transfer>Review of a 07/20/2025 progress note written at 12:00 AM showed that when the nurse went to give Resident 6 an opioid (drug used to reduce moderate to severe pain) they found the resident sitting up in wheelchair sweating, mucus running out of [their] nose, eyes closed. The nurse, Held medications and took the resident's blood sugar which measured 29, a critically low reading. The resident's blood sugar rose to 83 after emergency medications were provided but remained unresponsive and was transferred to the hospital for further evaluation. Review of a 07/22/2025 progress note showed the facility, Called [Resident 6's representative] to offer a bed hold. Review of the medical record showed no documentation of what information the staff conveyed to the hospital at the time of transfer. In an interview on 07/25/2025 at 9:33 AM, Staff I, Licensed Practical Nurse, (LPN), stated that when a resident experienced a change in condition that required a hospital transfer, they provided the hospital with the resident's face sheet and copy of the POLST. Staff I stated the progress notes would show what information was conveyed to the hospital at the time of a transfer but, I don't generally type that in the progress note. I was not oriented to that form [SBAR]. I've never done one. Staff I stated the bed hold notice, Should be given immediately [to the resident]. Theoretically, before they ever leave the building.In an interview on 07/25/2025 at 10:11 AM, Staff J, LPN, stated that at the time of a hospital transfer, they provided the hospital with a face sheet, medication list, and a copy of the POLST form, and if they just had labs also send them out too or x-rays. Staff J stated the information conveyed to the hospital was located, In the progress notes. Not familiar with a transfer form, at least I haven't done one. Staff J stated that a bed hold notice was provided to the resident at the time of transfer or shortly after depending on how emergent the situation was and level of resident alertness, Or social services will call and ask them [afterwards]. The above findings were shared with Staff K, Resident Care Manager, on 07/25/2025 at 12:04 PM. Staff K stated they expected of the nurses to send a POLST, a face sheet, a medication list, and pertinent information of the change in condition, like the SBAR. Staff K stated, We like for our nurses to be detailed in a progress note about everything that was sent at the time [of the hospital transfer]. There should be a discharge-transfer out summary. Across the board, the assessment is the SBAR Transfer Form. Staff K stated the bed hold notice should be provided to the resident at the time of the hospital transfer, but that medical records or social services personnel reached out to the resident if unable to accomplish at the time of the transfer. Staff K stated bed hold notice provision was to be documented in the progress note, to include whether the resident accepted or declined the bed hold. Staff K acknowledged that in four of the five hospital transfers Resident 6 experienced, the medical record showed no documentation the staff provided a bed hold notice to the resident or their representative or communicated required and adequate information to the hospital. Review of a six-month list of Nursing Home Transfer or Discharge Notices provided to the Survey Team on 07/23/2025 showed no documentation the facility notified the Office of the Ombudsman of any of Resident 6's hospital transfers. On 07/25/2025 at 11:52 AM, the above findings were shared with Staff L, Social Services Director. Staff L stated they were not involved with bed hold notices. Staff L stated they notified the Ombudsman Office of a hospital transfer, As soon as I am aware of it.In a follow-up interview on 07/28/2025, Staff L stated they did not notify the Ombudsman Office of Resident 6's hospital transfers because they were under the impression that if the resident's stay at the hospital was under 24 hours, they did not need to notify the Ombudsman.Reference WAC 388-97- 0120 (2)(a-d), (4), -0140 (1)(a)(b)(c)(i-iii)

Based on interview and record review, the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 3 of 8 sampled staff (Staff AA, BB, and CC), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life.Findings included. <Staff AA>Review of Staff AA's, Nursing Assistant (NA), personnel file showed they were hired on 02/05/2016. No documentation of a performance evaluation was found on file. In an interview on 07/26/2025 at 1:58 PM, the yearly performance evaluation for Staff AA was requested from Staff A, Administrator. No documentation was provided. <Staff BB>Review of Staff BB's, NA, personnel file showed they were re-hired on 07/17/2020. No documentation of a performance evaluation was found on file. In an interview on 07/28/2025 at 8:32 AM, the yearly performance evaluation for Staff BB and Staff CC was requested from Staff B, Director of Nursing (DNS). None was received. <Staff CC>Review of Staff CC's, NA, personnel file showed they were re-hired on 08/21/2023. No documentation of a performance evaluation was found on file. In an interview on 07/25/2025 at 10:35 AM, Staff D, Resident Care Manager, stated staff performance evaluations were supposed to be completed yearly. In an interview on 07/28/2025 at 10:41 AM, Staff B stated they expected staff to complete performance evaluations yearly, as required. On 07/30/2025, an email was received from the DNS that included an evaluation for Staff BB. The evaluation documented it was completed on 07/29/2025, after the recertification survey was exited. Reference WAC 388-97-1680 (1)(2)(a-c)

Based on observation, interview and record review, the facility failed to ensure the staff provided required splints and positioning devices and adequately followed up with resident refusals of Restorative Nursing Programs for 3 of 3 sampled residents (Residents 12, 13, and 71) reviewed for Limited Range of Motion (ROM, the full movement potential of a joint) and positioning. These failures placed the residents at risk for worsening contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and a diminished quality of life.Findings included.Review of the October 2024 Resident Assessment Instrument User Manual (a comprehensive guide used in nursing homes and other long-term care facilities to assess residents' needs and develop individualized care plans) showed, Restorative nursing program [RNP] refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. Measurable goals and interventions were documented in the care plan and in the medical record. When the care plan was revised, the resident's progress with the RNP, goals, and duration/frequency were reassessed and the results of the reassessment documented in the resident's medical record. Evidence of periodic evaluation by a licensed nurse (LN) was present in the resident's medical record. A progress note written by the restorative aide (RA) and countersigned by a LN was sufficient to document the RNP once the purpose and objectives were established.Review of the April 2025 Facility Assessment showed the facility offered services to the residents that included walking, contracture prevention/care, and management of braces and splints. Review of an 11/15/2023 facility policy titled Restorative Nursing Policy and Procedure showed the facility provided RNP as needed to help promote optimal safety and independence. Restorative goals and objectives were individualized, resident-centered, and outlined in the resident's plan of care. The policy showed the facility was responsible for a monthly summary note completed by a LN.Review of an undated facility policy titled Resident Mobility and Range of Motion showed the facility provided the residents with the required treatment, services, equipment and assistance to increase and/or prevent a further decrease in ROM and maintain or improve mobility unless it was unavoidable. The care plan included specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM, to include the type, frequency, and duration of interventions, as well as measurable goals and objectives. Documentation of the resident's progress toward the goals and objectives included attempts to address any changes or decline in the resident's condition or needs.<Resident 12>Review of a 04/30/2025 Significant Change Assessment showed Resident 12 admitted to the facility on [DATE] with medically complex conditions, which included dementia and schizophrenia (a chronic and severe mental health disorder that affected how a person thinks, feels, and behaves). The assessment showed Resident 12's cognitive skills were moderately impaired for daily decision making, was dependent on the staff for completion of most Activities of Daily Living (ADLs), had limitations to both legs' range of motion, received no RNP in the last seven days of the assessment reference date period, and did not reject care.Review of a 07/09/2021 care plan showed Resident 12 was on a Restorative Program for Grooming. The goal of the RNP was to maintain or increase the ability to brush hair, wash hand/face and the ability [to] maintain oral care with cueing and setup. To achieve this goal, the care plan instructed the staff to, Provide all necessary items and Provide cuing or assistance if needed, and chart minutes of participation 15 minutes/day 6 days/week.Review of flow sheets associated with the grooming RNP showed that between 06/25/2025 and 07/23/2025, the staff documented they implemented the RNP twice a day, on day and afternoon shifts, but Resident 12 refused 22 of the 58 scheduled shifts. Review of the medical record showed no documentation why Resident 12 refused to participate in the RNP and how the staff addressed the refusals.Review of the medical record showed no periodic assessments related to the RNP from 01/2024 to 06/2025.In an interview on 07/25/2025 at 9:44 AM, Staff W, Nursing Assistant (NA), stated Resident 12 was, Not on any RNP and at times rejected cares.The above findings were shared with Staff K, Resident Care Manager, on 07/25/2025 at 12:28 PM. Staff K stated they expected the staff to, Notify [Staff K] of consecutive refusals so that it can be documented by the nurse. I would want the nurse to try and assist them in reapproaching and encouraging them to complete the task, then if the resident is completely disagreeable then I need to be made aware. Staff K acknowledged the medical record showed no documentation the facility evaluated and addressed Resident 12's refusals of their RNP. <Resident 13>Review of a 02/20/2025 Significant Change in Condition assessment showed Resident 13 admitted to the facility on [DATE] with medically complex conditions, which included a stroke and associated weakness or paralysis (the loss of muscle function in part of the body, resulting in the inability to move or feel that area) to the left side of the body. The assessment identified the resident's cognition was intact, had one-sided functional limitation in ROM to their upper and lower extremity, received no RNP in the last seven days of the assessment reference date period, and did not reject care.An observation and interview on 07/21/2025 at 11:04 AM, showed Resident 13 in bed with their left hand curled into the shape of a fist. The resident said the staff used to offer them exercises for the left hand, but not anymore. They stopped. Resident 13 was unable to open their left hand when asked. No splint or hand roll were observed to the left hand to prevent or manage the fingers from curling inward.Review of a 01/13/2025 Occupational Therapy Discharge Summary showed, Patient will safely wear a finger extension splint, a resting hand splint and a hand roll on left hand, left fingers and left wrist for up to 8 hours w/ [with] minimal s/s/ [signs and symptoms] redness, swelling, discomfort or pain. The note showed, Discharge therapy to restorative nursing program for splint donning [put on] and doffing [take off] and stretching LUE [left upper extremity].Review of the provider orders showed no direction or instruction on the splint application, to include frequency and duration.Review of a 02/14/2025 care plan showed the staff identified Resident 13 was at risk for contractures. The care plan showed the goal was the resident, will not have any increase in contractures in LUE during this review period. The intervention to achieve the goal showed the resident would have a LUE hand splint donned, that the resident often refuses splint donning. Splint is kept in therapy gym. The care plan showed no instruction to the staff about who applied and monitored the splint application, how often the splint would be applied, and how long the resident would aim to keep the splint on to prevent any increase in contractures in LUE. Review of the medical record showed no documentation the staff applied the splint to Resident 13's left hand as required.Review of a 02/19/2025 Care Conference Summary showed the resident, currently has a restorative nursing program for LE (lower extremity) strengthening and ROM for LE/UE [Upper extremity] ROM but refuses often. A 05/27/2025 Care Conference Summary showed the resident, currently refuses restorative therapies. [The resident] does wear a splint on LUE but refuses to wear it due to pain.Review of progress notes showed on 03/20/2025, Resident has some slight redness to left AC [antecubital, the front of the elbow, or the inner bend of the arm] due to contracture of arm and resident's refusals to allow splinting. Review of a 05/08/2025 note showed, Resident would not allow this ln [licensed nurse] to extend [their] left arm for assessment, left arm has a contracture as resident does not allow ROM or splint. Review of a 05/15/2025 note showed, Unable to fully examine L [left] inner arm as resident stated [they] could not open enough but no noted concern with the area at this time. Resident continues to refuse splints and ROM exercises with staff. Cont [continue] with encouragement and education. Review of a 06/05/2025 note showed, Skin to left AC remains red with a slightly musty smell due to resident's reluctance to have staff treat site. [The resident] also continues to refuse contracture splints.Further review of the medical record showed no periodic documentation or re-assessments pertinent to the splint program that therapy services discharged the resident with on 01/13/2025, including contracture management and monitoring, how the facility responded to the splint and ROM refusals, or that the staff notified the physician or therapy services of the refusals. Observations on 07/21/2025 at 10:35 AM, 07/21/2025 at 11:50 AM, 07/22/2025 at 8:53 AM, 07/22/2025 at 11:19 AM, 07/23/2025 at 8:43 AM, 07/23/2025 at 12:32 PM, and 07/24/2025 at 8:08 AM showed Resident 13 in bed, with no splint to manage the left-hand contracture as required by therapy's assessment.In an interview on 07/25/2025 at 9:54 AM, Staff W stated Resident 13's left arm and leg were impaired, [the resident] can't move it. Staff W said the resident used to have a splint to the left arm but, haven't seen it in a while and I think therapy was putting it on because it wasn't us. Staff W said when they cared for Resident 13, any kind of movement to the left side is painful. Not able to open left hand. Staff W stated the resident came in with a contracture to the left hand and, I would say it's about the same as when admitted .In an interview on 07/25/2025 at 10:03 AM, Staff I, Licensed Practical Nurse, stated Resident 13 had contractures to the left arm, specifically at the elbow, left hand, and possibly left leg. Staff I stated the left knee was straight, the resident did not bend it, and when in their wheelchair (WC) the resident supported the left leg by placing their right leg underneath it. Staff I said that when staff cared for the resident, it's pretty painful. Staff I recalled therapy, put a brace to that arm and couldn't tolerate it and had not seen a splint or brace on the resident since February 2025. Staff I expected the staff to notify them if the resident was not re-approachable and kept refusing a splint.In an interview on 07/25/2025 at 12:44 PM, Staff K confirmed Resident 13's left hand was contracted. Staff K said the RA or therapy personnel applied Resident 13's splint to the left hand, therapy personnel monitored the splint and ensured it was donned appropriately and were not sure where to find documentation that showed the staff complied with the left-hand splint application. Staff K said they were aware of Resident 13's refusal to wear the splint to the left hand, that the refusals were related to pain as, [The resident] doesn't like to have them stretch that hand out, and were unsure of the frequency of the refusals. Staff K stated Resident 13 ran the risk of, becoming more severely contracted and unable to use the left hand secondary to not wearing the splint and, The elbow is a little tighter. I could get [the resident] to go straight before but now it takes longer, its stiffer to extend. Staff K said no referrals were made to address the refusals related to the splint application and, Theres no documentation any of this information was relayed to anyone. In an interview on 07/25/2025 at 1:30 PM, Staff F, Lead RA, read Resident 13's care plan and Kardex (abbreviated instructions to nursing assistants for care) and acknowledged they were responsible for applying the splint to the resident's left hand. Staff F then stood up, went to the therapy cupboard, retrieved a neon-green splint and said, This is the one [the resident is] supposed to be wearing. Staff F said the splint was applied to Resident 13's left hand, a few times and It's been since, honestly, the end of April [2025], beginning of May [2025] since the splint's last application. Staff F explained that the number of times the RA was pulled from RNP duties to work on the floor as an NA, led to the inconsistency of [splint] application and added to the [resident] refusals. Staff F reviewed the care plan goal for the splint program and acknowledged it did not have pertinent information that directed the staff on the frequency and duration of splint application. Staff F stated the care plan for the splint should have been removed as the splint was discontinued but did not recall when that happened or what alternative measures were implemented to manage and prevent contracture worsening and associated pain. Staff F said, We are not consistent with evaluating the effectiveness of the program [RNP]. We are not meeting every quarter as we should.In an interview on 07/28/2025 at 8:27 AM, Staff Y, Therapy Director, stated Resident 13, is in an extension splint. But [the resident has] a lot of noncompliance. [The resident] doesn't like pain. [They're] really sensitive in that hand. Staff Y said Resident 13 had contractures to their left hand and leg, knee joint and hip. Staff Y said Resident 13 required the hand splint, Eight hours over night. It should be daily, to prevent worsening of contracture. Staff Y said the last time they assessed Resident 13's contracture status was in March or April 2025. I can tell worsening [of the contracture] if [the resident] could fit in a splint because of the way the hand is shaped. Staff Y said they expected staff to document if the resident refused their splint and bring the splint to therapy for evaluation. Staff Y said they received no referrals to evaluate Resident 13's refusals to wear the splint for contracture management.<Resident 71>Review of a 04/30/2025 quarterly assessment showed Resident 71 admitted to the facility on [DATE] with medically complex conditions, including hemiplegia [severe or complete loss of movement to one side of the body] or hemiparesis [weakness on one side of the body]. The assessment showed Resident 71's cognition was intact and had impaired functional limitation in ROM. The assessment showed the facility provided no RNP in the last seven days of the assessment reference date period and the resident did not reject care.Review of Resident 71's medical record showed a physician order dated 04/20/2023 for a left-hand splint for flexion contracture management in fingers.Review of an 11/02/2023 care plan showed an instruction to the staff to, Ensure black wedge is placed on [resident's] right side while up in [their] wheelchair to allow for correct posture in order to use both feet for self - propelling. The care plan showed no instructions to the staff about the presence of a left-hand splint, its purpose, goals for use, or its management.Review of a 05/06/2025 Care Conference Summary showed Resident 71, currently works with restorative nursing for LE [lower extremity] strengthening and ROM on UE [upper extremity] and splint placement.Observations from 07/21/2025 to 07/24/2025 showed:- 07/21/2025 at 1:36 PM no splint to left hand while at bingo,- 07/22/2025 at 11:21 AM in hallway propelling self in WC with their right hand while in a sliding backwards position making the corner around the nurses station, no splint to left hand, no wedge to right side of resident,- 07/23/2025 at 8:46 AM - in hallway visiting with another resident, no splint to left hand, used right hand to mobilize self in WC while leaning over to the right side of the WC, armpit directly above armrest,- 07/23/2025 at 10:32 AM in the main Dining Room, sitting in WC with the right hand holding on the wheel spoke of the WC and leaning sharply to the right side, no left-hand splint,- 07/23/2025 at 12:07 PM in dining room eating lunch, no splint to left hand,- 07/23/2025 at 3:27 PM in room sitting in WC and in front of laptop with no splint to left hand,- 07/24/2025 at 7:30 AM in the dining room, no splint on,- 07/24/2025 at 8:11 AM in dining room; leaning to the right side, no splint to the left hand,- 07/24/2025 at 12:37 PM leaning to right side as they propelled themselves coming from dining room towards room direction, armpit touching the arm rest,- 07/28/2025 at 12:52 PM, in the hallway where they resided, leaning over to the right side of the WC while propelling themselves, a blue cushion was between the resident's lower torso and the right side of the WC. Further review of the care plan showed, Resident started on Restorative Program: Date Initiated: 11/02/2023, showed no goal for the RNP, and the intervention included, Walk to dine: Using front wheeled walker with [their] wheelchair following, allow [resident] to walk from [their] room to dining room as tolerated. The intervention showed the RNP should occur two to six days a week with a distance of 130 feet.Review of the Tasks Section in the medical record showed an additional RNP program, not included in the care plan, that addressed Resident 71's ROM but showed no purpose of the RNP or resident goal. The Walk-to-Dine program was also included in the Tasks section. Review of the Walk-to-Dine flowsheet from 06/24/2025 to 07/23/2025 showed the staff offered the program at least twice a day for a total of 58 opportunities, predominantly at lunch and dinner. The flow sheet showed the staff documented Resident 71 participated in the walk-to-dine program only 8 of the 58 opportunities, refused 41 times and Not Applicable nine times. Record review showed no documentation why Resident 71 refused to participate in the Walk-to-Dine RNP, how the facility addressed the refusals, or what Not Applicable meant.Review of progress notes showed no mention of a splint or refusals of the walk-to-dine program from January 2025 to July 2025.In an interview and observation on 07/25/2025 at 10:28 AM, Resident 71 sat in their wheelchair inside their room. A blue cushion and not the black wedge mentioned in the care plan, was between the resident's lower torso and the right side of the WC. A black wedge was observed sitting on top of a walker inside the resident's bathroom. Resident 71 stated they had to ask the staff to place the wedge to the right side and that, even though it helped the resident not lean to the right side, it also made it difficult to propel themselves in the wheelchair; this being one of the reasons the resident did not ask for the wedge. When asked if the staff asked the resident why they did not want to use the wedge, the resident said, They haven't but they should ask me. Resident 71 said they did not walk because, both knees get painful.In an interview on 07/25/2025 at 9:47 AM, Staff W said staff waited for Resident 71 to ask for the wedge cushion to be placed in their WC. Staff W said, The wedge appears and does not appear. Sometimes therapy has it I'm assuming. Staff W said they were unaware of what placed the resident at risk for contracture development and sometimes saw them with a brace managed by therapy. Staff W said Resident 71 was dependent on the staff to maintain proper alignment and posture in their wheelchair because of the affected left arm and staff placed a wedge cushion when it was available or by boosting up the resident in their WC. Staff W said the last time the saw a splint on Resident 71's left hand was, A couple of weeks ago. I don't know when therapy decides to do it. It doesn't seem like it's daily.In an interview on 07/25/2025 at 10:03 AM, Staff I stated Resident 17 had a left frozen arm, used a wedge pillow whenever the resident allowed it and was difficult to maintain good positioning even with the use of the pillow. Staff I was unaware of any resident refusals but if made aware of such, they would offer the resident something different to maintain their posture correctly in the WC, like a towel or blanket. Staff I said the resident had a contracture to their left hand and a splint RNP. Staff I said they saw the splint on in the mornings but not at all during the current week, and when the splint was on it was applied for, A couple of hours but not extending past lunch. It's usually gone by lunch time.In an interview on 07/25/2025 at 12:55 PM, Staff K said they were aware Resident 71 refused their walking program secondary to issues with endurance and that it was solely up to the resident to ask for the wedge cushion placement. Staff K said they were not aware Resident 71 did not ask to use the black wedge as instructed in the care plan.In an interview on 07/25/2025 at 1:14 PM, Staff F said Resident 71 wore a splint intended to manage left-hand contracture and applied it themselves, although the staff have asked the resident not to do that. Staff F said that when the resident chose to wear the splint, the resident would bring it to them, and when it became uncomfortable to wear the resident removed it. Staff F acknowledged there were no instructions for the effective management of the left-hand splint to prevent worsening of a contracture. Staff F said the NA staff were responsible for walking Resident 71 to the dining room and observed the resident would take their walker out in the hall, whether from their room or the dining room, and wait for someone to come and walk them. Staff F said, As far as I know, [the resident] wants to walk. Staff F said they would like to be informed about resident refusals of their walk-to-dine program.In an interview on 07/28/2025 at 8:27 AM, Staff Y stated the Restorative Nursing Department implemented all the RNP and ensured the use of positioning devices as instructed or care planned. Staff Y said they were unaware of Resident 71's refusal of the walk-to-dine program, acknowledged the medical record showed no closure to the persistent refusals, and expected the staff to inform them of refusals. Staff Y said the resident would need the left-hand splint for at least four to six hours daily to prevent worsening of the contracture and acknowledged the provider order for the splint did not show the duration and frequency of the splint application and should be included in the care plan. Staff Y acknowledged there was no documentation to show the staff implemented the use of the left-hand splint for the management of Resident 71's contracture. Staff Y said they did not know why the staff used or from where they obtained a blue cushion instead of the black wedge care planned to maintain Resident 71's position in the WC.In the continued interview on 07/25/2025 at 1:14 PM, Staff F said the RNP in the facility was overseen by Staff Z, MDS (Minimum Data Set, an assessment) Coordinator. Staff F said, We used to keep really good close track of this [RNP] for billing purposes but now haven't billed for years. Our documentation probably isn't the best. When we get [the RNP] up and running as we are supposed to, then it will include goal setting that is specific, measurable, attainable, relevant, and time bound.In an interview on 07/28/2025 at 8:45 AM, Staff Z, said the facility did not have a Restorative Nurse currently and, I don't think we have anybody managing the restorative nursing program. Staff Z said, It's been a while, since the facility had a Restorative Nurse and that as the MDS Coordinator, I haven't coded restorative programs [as occurring] in over a year. Staff Z said the facility administration was aware of the deficient facility RNP. The above findings were shared with Staff B, Director of Nursing Services, on 07/28/2025 at 10:11 AM. Staff B stated that the RNP, It's a group effort. It is piecemeal to be honest. In theory, I have direct oversight but it's not enough participation from the residents to fit the MDS coding criteria for [an RNP]. When asked if the facility evaluated why there was not enough resident participation in the RNP, Staff B said, Probably not as much as we should be. Staff B stated that when refusals to an RNP were not reported, Outcomes are not measured. No further information was provided.On 07/28/2025 at 1:04 PM, Staff F presented a list of residents currently on RNP. The list did not show Residents 12, 13, and 71 received RNP services.Reference WAC 388-98-1060 (3)(d), (j)(ix).

Based on observation, interview and record review, the facility failed to ensure an effective system to deliver mail to the residents on the days mail was delivered. This failure placed the residents at risk for feelings of isolation, loneliness, anxiety, and depression. Findings included. In a resident group meeting on 07/22/2025 at 1:30 PM, a resident stated, I was told we don't get mail on Saturday because no one is at the front desk. Another resident stated, We don't have anybody here to let them in. Six of the six residents stated they did not get mail delivered to them on Saturdays.In an interview on 07/24/2025 at 11:50 AM, Staff S, Business Office Manager, stated, Mailman doesn't come on Saturday. I don't know why it's not delivered on Saturday.In a telephone interview on 07/24/2025 at 12:04 PM, a Collateral Contact (CC) from the Post Office that handled the facility mail stated, Mail is delivered on Saturdays unless the business is closed. The address of the facility was provided to the CC who confirmed, Mail is delivered there on Saturday.In an interview on 07/24/2025 in the afternoon hours, Staff T, Medical Receptionist, stated, We don't get mail on the weekends. The front door is locked on the weekends. The mail man doesn't come on Saturday and hasn't for years. They have to ring the doorbell for assistance and then a staff from the unit will come and let them in because there's nobody here at the front desk or at the offices. The doorbell is heard at the nurses station. When asked when the facility started locking the front door on the weekends, Staff T stated, For as long as I've been working here, years, you'd have to ask [Staff A, Administrator, or Staff B, Director of Nursing] about that.In an interview on 07/24/2025 at 12:52 PM, Staff U, Activities Assistant, stated they worked at the facility on Saturdays and, I think the front doors are locked because they don't want anyone coming in because it's kind of a bad neighborhood, but someone is usually here to unlock the doors. On weekends there is no front desk receptionist. Staff U stated, Maybe a couple months ago, [mailman] came once because I was at the door. I was letting someone else in, and [they] saw me, and I said I would take it [the mail] that one time.In an interview on 07/25/2025 at 9:44 AM, an express delivery services CC stated when the front doors were locked on Saturdays and there was no staff at the front desk, Then we will treat it as ‘Business Closed' and move on because we do not have time to wait.In an interview on 07/25/2025 at 10:40 AM, a Postal Service CC assigned to deliver mail at the facility stated they delivered mail to the facility since before 2020, to include Saturdays. The CC stated that when the COVID-19 (a contagious disease) pandemic started, the facility locked the doors of the building on Saturdays. The CC confirmed they knew there was a sign that asked of the public to Ring the doorbell if the doors were closed but, No one's at the door. The CC stated they did not stop by the facility anymore to deliver mail on Saturdays because of the door closure and there was no one at the front desk to readily accept the mail. The CC explained the Saturday mail is returned to the designated postal station and stayed there until the postal service's return to the facility the following week. The above findings were shared with Staff B, Director of Nursing, in lieu of Staff A's absence on 07/24/2025 at 1:02 PM. Staff B stated the front doors were locked ever since their employment at the facility, For 5 years they've locked up the doors on the weekends. Staff B said the doors were locked for security reasons and the Front Desk was not staffed on weekends. When asked what was required for a resident to receive their mail on Saturdays, Staff B said, That's a good question. I don't know the entirety of the answer and did not know if locking the front doors with no Front Desk attendant created a delay or hindrance for mail delivery to the residents on Saturdays. When asked if the facility explored ways to complete mail delivery to the residents on Saturdays, Staff B said, I've never had a concern brought to my attention. In a follow up interview on 07/28/2025 at 10:27 AM, Staff B said, I checked our video cameras, and they haven't delivered mail for the past three weekends. I can't make them [mailman] ring the doorbell and wait.General observations during the survey period from 07/21/2025 to 07/28/2025 showed a plaque on the side of the exterior wall before the front entry doors that instructed the public to Ring Bell for Admittance. There were no instructions to the mailman as to what to do when they encountered locked front doors and no staff readily available to take the mail from them and no mail receptacle visible for drop off. Reference WAC 388-97-0360, -0540(1-3), -0180(2).

Based on observation and interview, the facility failed to ensure the kitchen floor was maintained and torn linoleum was repaired when indicated. This failure placed staff at risk of potentially avoidable accidents, and infection control issues because the floor was not a cleanable surface.Findings included .In an observation of the kitchen on 07/21/2025 at 8:52 AM, the floor in the dishwashing area had a large area of the floor where the linoleum was torn off and missing, which created a possible tripping hazard for staff. The area was approximately 4 feet by 4 feet and had exposed wood which was not a cleanable surface. On 07/28/2025 at 1:23 PM, the floor in the dishwashing area was observed with Staff O, Dietary Manager. Staff O agreed the area was an infection control issue and a safety hazard and stated it was on their wish list to have it replaced. In an interview on 07/28/2025 at 1:51 PM, Staff B, Director of Nursing, stated they did not go past the yellow line in the kitchen (an area at the entrance of the kitchen where the staff entered to request items) so they were not aware of the floor in the dishwashing area. Reference: WAC 388-97-3220 (1)

Based on interview and record review, the facility failed to provide information of potential risks and/or benefits of psychotropic (medications that affect behavior, mood, thoughts, or perception such as antidepressants) medications prior to their use for 1 of 5 sampled residents (Resident 31), reviewed for unnecessary medications. This failure placed residents and/or their representatives at risk of not being fully informed of the risks, benefits or alternative treatment options available before decisions were made regarding medications. Findings included. According to the 06/03/2025 admission assessment, Resident 31 admitted to the facility on [DATE] with diagnoses including depression and received antidepressant medication. Resident 31 was cognitively intact and able to clearly verbalize their needs. Review of the 05/28/2025 depression care plan showed Resident 31 used antidepressant medication and instructed staff to administer medication as ordered, monitor for adverse reactions to the medication, and educate the resident about the risks versus (vs) benefits and/or toxic symptoms of medications as needed. Review of provider orders showed an active 05/31/2025 order for Resident 31 to be administered Duloxetine (antidepressant medication) daily for depression. Review of May 2025 through July 2025 Medication Administration Records showed Resident 31 was administered Duloxetine 55 times. Additional record review showed no documentation a consent for Duloxetine use was obtained prior to medication administration, as required. In an interview on 07/25/2025 at 9:56 AM, Staff E, Registered Nurse, stated a consent needed to be obtained prior to administration of psychotropic medications. In an interview on 07/25/2025 at 10:29 AM, Staff D, Resident Care Manager, stated staff needed to discuss psychotropic medications with the resident when ordered and a consent with risks vs benefits obtained prior to administration of psychotropic medications. Staff D reviewed Resident 31's medical record. Staff D acknowledged they were unable to find documentation a Duloxetine consent was obtained for Resident 31 prior to medication administration, as required. In an interview on 07/28/2025 at 8:38 AM, Staff B, Director of Nursing, stated psychotropic medication consents needed to be obtained prior to medication administration. Staff B reviewed Resident 31's medical record. Staff B acknowledged the Duloxetine consent for Resident 31 was not obtained until July 2025 and expected staff to obtain psychotropic medication consents prior to medication administration, as required. Reference WAC 388-97-0300 (3)(a), 0260, 1020 (4)(a-b)

Based on observation, interview, and record review the facility failed to maintain a clean, sanitary, and homelike environment free of institutional odors for 1 of 4 sampled residents (Resident 31), reviewed for environment. This failure placed residents at risk of lack of dignity, unmet care needs, and diminished quality of life.Findings included. According to the 06/03/2025 admission assessment, Resident 31 was frequently incontinent of urine and required substantial staff assistance for toileting hygiene. The assessment further showed Resident 31 rejected care four to six days a week, but less than daily. Resident 31 was cognitively intact and able to clearly verbalize their needs. Review of the 05/27/2025 activity of daily living care plan showed Resident 31 was incontinent, a heavy wetter, wore incontinence briefs, and required extensive staff assistance for bathing, bed mobility, and toileting. Interventions instructed staff to check and change Resident 31 every 90-120 minutes and as needed. The care plan further showed Resident 31 often refused care such as brief changes, bathing, and hygiene; staff were to notify the nurse of refusals and reapproach. No documentation was found to show how strong odors secondary to care refusals were minimized or addressed. During observation on 07/21/2025 at 10:09 AM, a strong urine odor was smelled coming from Resident 31's room, into the common hallway. Similar observations were made on 07/22/2025 at 10:06 AM and on 07/24/2025 at 2:07 PM. In an interview on 07/25/2025 at 10:49 AM, Staff F, Nursing Assistant, explained housekeeping deep cleaned resident beds on their shower day. Staff F stated they would notify housekeeping if strong odors were noted. Staff F further stated Resident 31 did not like to bathe. In an interview on 07/28/2025 at 11:29 AM, Staff H, Housekeeper, explained housekeeping deep cleaned resident beds on their shower day. Staff H acknowledged Resident 31's room had a really bad urine odor and explained Resident 31's mattress was exchanged on 07/22/2025; there was a puddle of urine under the bed, it was pretty bad. Staff H further stated the new mattress helped decrease the urine odor some, but the strong urine smell returned because Resident 31 refused to be changed and/or bathed. In an interview on 07/28/2025 at 11:48 AM, Staff G, Maintenance Director, acknowledged Resident 31's room had a strong urine odor, and the mattresses was exchanged recently because it was pretty saturated. In an interview on 07/28/2025 at 12:28 PM, Staff B, Director of Nursing, stated they were unsure how often housekeeping cleaned resident rooms or if housekeeping increased the cleaning frequency of resident rooms when the resident refused care and/or bathing. Staff B acknowledged Resident 31's room was odorous, and the facility recently threw out Resident 31's soggy mattress. Staff B explained Resident 31 often refused cares and the interdisciplinary team discussed possible odor eliminating interventions to attempt but nothing had been care planned. Reference WAC 388-97-0880

Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR, a screening that occurred prior to facility admission that determined if one met nursing home level of care and potentially required services for mental health needs once a resident. If one was expected to be at the facility less than 30 days, they were exempt. After 30 days, if still at the facility, a new referral and screening was required) was completed timely after an exempted hospital stay expired for 2 of 5 sampled residents (Residents 2 and 3) reviewed. This failure placed residents at risk for not receiving timely and necessary services to support their mental health care needs.Findings included.<Resident 3> A review of the record documented Resident 3 was admitted to the facility on [DATE] and had diagnoses that included end stage renal (kidney) disease and depression. The [DATE] PASRR documented Resident 3 had mood and anxiety disorders. Section III of the Screening form documented the resident did not require further behavioral health screenings; they had an exempted hospital discharge per the requirements listed in Section IIA of the form. However, Section IIA was not completed. A review of Resident 3’s census data documented the resident was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. On [DATE], a second PASRR was completed that documented Resident 3 had been a resident of the facility since [DATE], had diagnoses that included mood disorders, and the resident required further level II PASRR evaluations to determine their need for behavioral health services. During an interview on [DATE] at 11:57 AM, Staff L, Social Services Director, stated the admission Coordinator received initial admission paperwork and Staff L reviewed the PASRRs to ensure they were complete. Staff L stated initially, the plan was that Resident 3 was to reside at the facility for less than 30 days, but this changed after the resident returned to the hospital. Staff L stated they kept a list of those residents that had an exempted hospital stay so they ensured that another PASRR was completed timely when a resident remained at the facility longer than 30 days. Staff L stated a new PASRR should have been completed when the resident re-admitted to the facility on [DATE]. <Resident 2> The [DATE] quarterly assessment documented Resident 2 admitted to the facility from the hospital on [DATE], and had diagnoses which included medically complex conditions, depression, and dementia. On [DATE] at 10:04 AM, Resident 2 was observed sitting on the edge of the bed in their room. When asked how they were doing, Resident 2, laughed and stated, “Just fine”. Review of Resident 2’s record documented the hospital had completed a Level I PASRR on [DATE], prior to the resident’s arrival at the facility. The PASRR documented a Level II PASRR was not required since Resident 2 met the guidelines for an exempted hospital stay. Review of the progress notes from [DATE] through [DATE] documented ongoing conversations and discussions related to discharge planning occurred with the resident, their representative and the facility; the resident wished to remain at the facility. Additional record review found an updated Level I PASRR was completed on [DATE], two months past the time frame for the exempted hospital stay, and not within the 30 days as required. In an interview on [DATE] at 2:37 PM, Staff L stated an updated Level I PASRR needed to be completed when a resident with an exempted hospital stay did not discharge within the 30-day time frame. When informed an updated Level I was not found prior to [DATE] for Resident 2, Staff L stated they would review the resident records and follow-up. In a follow-up interview on [DATE] at 8:23 AM, Staff L stated they were unable to locate any documentation that showed an updated Level I was completed prior to [DATE] and acknowledged one should have been completed when Resident 2 did not discharge within 30 days of being admitted . Reference: WAC 388-97-1915(1)(2)(a-c)

Based on observation, interview, and record review, the facility failed to consistently provide shaving and nail care for 2 of 2 sampled residents (Residents 19 and13) reviewed for activities of daily living (ADLS). This failure placed the residents at risk for poor personal hygiene, unmet care needs, and a diminished quality of life.Findings included . <Resident 19> The 06/18/2025 quarterly assessment documented Resident 19 needed assistance from nursing staff to complete ADLS for personal hygiene such as shaving. In addition, the assessment showed Resident 19 had severe cognitive impairment and unclear speech. On 07/21/2025 at 9:14 AM, Resident 19 was observed standing in the hallway by the ward entrance doors. The resident’s face was clean and there was facial stubble present on the cheeks, chin and upper lip. Additional observations of Resident 19 with facial stubble were made on the following: 07/22/2025 at 9:02 AM, 07/23/2025 at 8:59 AM, 9:36 AM, and 11:52 AM, and on 07/24/2025 at 7:10 AM. Review of the ADL care plan included interventions that informed nursing staff of Resident 19’s care needs related to bathing, toileting, oral care and dressing, but no interventions or instructions related to Resident 19’s grooming/shaving needs, preferences or assistance required were included. Review of the personal hygiene/grooming records from 06/24/2025 through 07/22/2025 documented the type of assistance Resident 19 needed to maintain personal hygiene (shaving, combing hair, applying makeup, and washing/drying face and hands), but did not include what type of personal hygiene the resident received. In addition, the documentation indicated Resident 19 had refused assistance nine times but did not specify which type of personal hygiene was refused. In an interview on 07/23/2025 at 3:24 PM, Staff F, Nursing Assistant, stated the resident’s care plans informed them of the specific care needs for the resident. When asked when shaving was completed, Staff F stated it was done when the nursing staff got residents ready for the day, and when residents were bathed. In an interview on 07/23/2025 at 3:43 PM, Staff B, Director of Nursing, was informed of the observations of the resident with facial stubble, and the lack of interventions/instructions related to grooming/shaving in Resident 19’s care plan. Staff B stated the expectation was that shaving and personal hygiene were done with morning cares and the resident’s care plan was to include information that informed the staff of the resident’s specific care needs. <Resident 13> Review of the 05/22/2025 quarterly assessment showed Resident 13 admitted to the facility on [DATE] with medically complex conditions, to include a stroke and related weakness or paralysis (the loss of muscle function in part of the body, resulting in the inability to move or feel that area) to their left side, and had moderately impaired cognition. The assessment showed Resident 13 required partial to moderate assistance from the staff to complete personal hygiene (e.g., combing hair, shaving, applying makeup, washing/drying face and hands) and did not reject care. An observation and interview on 07/21/2025 at 10:35 AM showed Resident 13 in bed. The right hand had black matter under the fingernails that were visibly long and required trimming. The left-hand fingernails were unable to be properly visualized as the hand curled inward in a fist. When asked, Resident 13 said the staff did not clean their fingernails when they gave the resident their weekly evening shower. Subsequent observations of 07/21/2025 at 11:50 AM and 07/22/2025 at 8:53 AM showed similar findings. Review of the 05/17/2024 care plan showed the resident had “paralysis/deficits” to their left hand, arm, and shoulder due to a stroke, and staff were instructed to allow the resident time during tasks of dressing and grooming. Another care plan intervention instructed the staff to keep the resident’s fingernails short. Review of a July 2025 Treatment Administration Record showed an order that instructed the nurses to check Resident 13’s nails every two weeks on Thursdays and was signed by a nurse as completed on 07/10/2025. Review of a 07/13/2025 progress note showed the staff, “Trimmed fingernails on resident's contracted hand [left hand] without incident. Palm washed and dry washcloth placed for drying and separation of skin. Resident tolerated well.” Progress notes from 07/13/2025 to 07/23/2025 showed no documentation of staff attempts to provide nail care to Resident 13’s right hand. On 07/23/2025 at 12:32 PM, Resident 13 said they had a shower, “Two days ago”. The right-hand still showed black matter under the nails. Staff R, the Nursing Assistant who served Resident 13 their lunch and present during the observation stated, Yeah, they need to be cleaned and trimmed” and would let the nurse know. Staff R said that usually the nurse trimmed the nails to the left hand and then the nursing assistants completed nail care to the right hand on shower days. Resident 13 then interjected they preferred the nurse to trim the fingernails of both hands. The above findings were shared with Staff K, Resident Care Manager, on 07/25/2025 at 12:33 PM. Staff K stated that because of “behaviors” Resident 13 required two people for care provision. Staff K said that if a resident did not have diabetes or took an anticoagulant (blood thinner), the Nursing Assistants provided nail care, cleaned with an orange stick and trimmed the nails. Staff K said they expected staff to provide nail care in between shower days if the resident nails were long or had build-up noticeable under the nails. Reference: WAC 388-97-1060 (2)(c)

Based on observation, interview and record review, the facility failed to ensure care plan goals and interventions were developed and monitoring occurred for 2 of 2 sampled residents (Residents 11 and 22) reviewed for edema (swelling) management. This failure placed the residents at risk for worsening edema, unrecognized changes to their skin, and decreased quality of life. Findings included. <Resident 11> The 06/17/2025 Significant Change assessment documented Resident 11 had diagnoses that included lymphedema (swelling and fluid buildup caused by blockage in the lymphatic system, part of the immune and circulatory system) and osteomyelitis (infection of the bone). The resident was cognitively intact and made their needs known. The 03/11/2025 admission skin assessment documented Resident 11 had a surgical incision on their left heel and 4+ edema (a deep indentation of the skin that occurred when pressure was applied that required two to three minutes to fill back in once pressure was relieved) to both lower legs. The 03/11/2025 care plan documented Resident 11 had actual skin impairment to the left heel related to an incision and drainage (I&D), and edema. Staff were to keep body parts from excessive moisture, keep the resident’s fingernails short to avoid scratching, keep skin clean and dry, use lotion on dry skin, encourage good nutrition, and encourage and assist to turn and reposition every two to three hours and as needed. The care plan did not have a care area, goals or interventions developed related to Resident 11’s lymphedema and lower leg edema. A 03/17/2025 Nurse Practitioner progress note documented nursing reported concerns of lower leg edema. An order was given to apply Tubi-grips (special garments that applied compression to the affected areas that helped reduce swelling and edema) to both lower extremities for edema, on in the morning, off at bedtime. There were no other provider or nursing orders given related to the management or monitoring of Resident 11’s edema. Review of the medication administration records (MARS) for April, May and June 2025 documented the resident refused the Tubi-grips daily. On 07/21/2025 at 2:31 PM, Resident 11 was observed in their room seated in their wheelchair. The resident was dressed in a hospital gown, and their lower legs were visible. Resident 11 wore non-skid socks, and their calves were edematous and had purple/red discoloration, the left more-so than the right. On 07/22/2025 at 2:38 PM, Resident 11 rested in bed. The resident’s legs were positioned straight out in front of them resting on the mattress and not in an elevated position. Resident 11 stated when they were home, they wore a compression stocking on their left leg because after they had a stroke, that leg was the one that had worse edema. Resident 11 stated they were given Tubi-grips to wear at the facility, but stopped wearing them because when they did, the wound on their left heel reopened. They were unaware of any other things being done to reduce swelling. The resident stated they just kept their leg out in front of them when they were in bed. A policy for lymphedema and edema management was requested. On 07/28/2025 at 11:10 AM, Staff B, Director of Nursing, responded by email that the facility had no specific policies for lymphedema and edema management. They used standard practices and procedures. During an interview on 07/28/2025 at 12:10 PM, Staff B stated they created initial care plans based on admission orders. Then, specific diagnoses were reviewed and if needed, care areas were created, but not every diagnosis had a care area developed in the care plan. Staff B stated a lymphedema care plan might or might not be created, it depended on what the resident’s assessments looked like. Staff B stated they understood Resident 11 was not wearing their Tubi-grips, so expected there would need to be other interventions to monitor and manage their edema instead. <Resident 22> The 05/19/2025 admission assessment documented Resident 22 admitted with diagnoses that included high blood pressure and irregular heartbeat. The resident had severe cognitive impairment and was able to make their needs known. In an observation on 07/21/2025 at 10:29 AM, Resident 22 was lying in bed and pulled the sheet off their legs. Their lower extremities were edematous, red in color and dressings were in place to several different areas on their legs. The resident was not wearing any compression hose, and their legs were not elevated. Review of the provider orders showed Resident 22 received Lasix (a medication used to rid the body of fluid) from 05/13/2025 through 07/02/2025. A 07/02/2025 progress note documented the provider assessed Resident 22 with orders to discontinue the Lasix. The note stated the resident needed to be monitored for changes in their blood pressure and fluid status for three days. The only progress note made during those three days was on 07/03/2025. Review of the May, June and July 2025 MARs showed there was no edema monitoring. The care plan did not have a care area, goals or interventions developed related to Resident 22's lower extremity edema. In an observation on 07/22/2025 at 10:07 AM, Resident 22 was sitting on their bed. The resident’s lower extremities were edematous, and their sheets were wet at the end of the bed. Resident 22 stated it was from their legs oozing fluid. At 1:33 PM, Resident 22 was lying in bed, and both legs were resting flat on the mattress. The resident wanted the nurse to be notified because they felt they were drowning in fluid. The nurse entered the room and explained the resident was going to restart their Lasix. In an observation on 07/24/2025 at 9:12 AM, Resident 22 was lying in bed. Their feet were edematous, red and lying flat on the mattress. Similar observations were made on 07/24/2025 at 12:33 PM and 3:59 PM, and 07/25/2025 at 12:26 PM. In an interview on 07/24/2025 at 9:28 AM, Staff X, Nursing Assistant, stated when a resident had edema they reported it to the nurse. Staff X stated residents with edema received Lasix, wore compression stockings, and their legs were elevated. In an interview on 07/24/2025 at 1:23 PM, Staff V, Licensed Practical Nurse, stated edema was monitored daily and documented in the MAR or TAR. Staff V added it was important to monitor edema because that could indicate a sudden change in medical condition and if the edema decreased the medication might need to be adjusted. In an interview on 07/24/2025 at 10:19 AM, Staff D, Resident Care Manager, stated Resident 22 should have had a care plan in place with interventions to include compression stockings, edema monitoring, and elevation of their lower extremities. In an interview on 07/25/2025 at 8:50 AM, Staff B, Director of Nursing, stated Resident 22 should have had a care plan in place for edema and their edema should have been monitored. Staff B stated it was important to monitor edema for fluctuations so the provider could be notified. Reference: WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to maintain oxygen saturations per provider orders and failed to ensure respiratory equipment was cleaned and maintained for 1 of 1 sampled residents (Resident 70), reviewed for respiratory care. This failure placed the resident at risk for illness and decreased quality of life. Findings included .The 05/12/2025 admission assessment documented Resident 70 had diagnoses that included respiratory and heart failure. The resident was cognitively intact and was dependent on supplemental oxygen.In an observation on 07/21/2025 at 11:09 AM, Resident 70 was lying in bed asleep and was wearing oxygen. The resident had a CPAP (continuous positive air pressure, a machine that delivered pressurized air through a mask worn during sleep) on a table near their bed. The CPAP had a few white spots inside of the mask. In an interview on 07/21/2025 at 1:09 PM, Resident 70 was lying in bed wearing oxygen. Resident 70 stated the facility had not cleaned their CPAP.No further observations were made of Resident 70 as they were discharged to the hospital the morning of 07/22/2025.The 05/05/2025 comprehensive care plan documented Resident 70 had chronic obstructive lung disease (COPD, a group of lung diseases that made it difficult to breathe), received oxygen and wore a CPAP at bedtime. The nursing staff were to administer the medications as ordered by the physician. A review of the provider's orders instructed staff to administer 1-2 liters (L) of oxygen per minute and for the CPAP to be worn every night and removed in the morning. There were no orders to clean the CPAP mask in the medication or treatment administration record (MAR/TAR). A review of the July 2025 MARs showed Resident 70 was administered 3.5L of oxygen on 07/18/2025, 07/19/2025, 07/20/2025 and 07/21/2025. On 07/22/2025 the resident was administered 3L of oxygen. The orders also showed that Resident 70 wore her CPAP nightly. -On 07/19/2025 at 7:17 AM, Resident 70's oxygen saturation was 92%, at 5:24 PM it was 93%.-On 07/20/2024 at 1:27 PM, Resident 70's oxygen saturation was 94%.-On 07/22/2025 at 11:15 AM, Resident 70's oxygen saturation was 94%. A 07/19/2025 progress note stated Resident 70 was on 5L of oxygen.In an interview on 07/24/2025 at 1:30 PM, Staff V, Licensed Practical Nurse, stated they had a binder that contained standing orders from the providers, and they referred to that binder when administering oxygen. Staff V added in an emergent situation the resident's oxygen was increased without a provider's order and if non-emergent, they notified the provider and obtained an order to increase the oxygen. Staff V stated it was important to follow the provider orders for oxygen because the residents needed their oxygen saturations kept within a certain range because of their disease processes. Staff V stated they thought CPAPs were cleaned daily to weekly and that it would be optimal to have this information on the MAR or TAR. Staff V stated it was important to keep the CPAP mask clean to prevent bacteria. In an interview on 07/25/2025 at 8:53 AM, Staff B, Director of Nursing, stated the facility had standing oxygen orders from the providers. The standing order stated the residents were to receive between 0-4L of oxygen and for a resident with COPD the oxygen saturations were not to exceed 88-91%. Staff B stated nursing staff were trying to manage Resident 70's oxygen saturations by adjusting the resident's oxygen up and was unsure if staff had adjusted the oxygen back down after the resident exceeded the recommended saturations. Staff B stated nursing staff should have re-checked Resident 70's oxygen saturations and documented them in the progress notes. In an interview on 07/28/2025 at 9:06 AM, Staff B stated CPAP masks were washed and rinsed daily, and the orders were in the MAR. Staff B acknowledged there were no orders to clean Resident 70's CPAP and there should have been. Staff B stated it was important to perform routine cleaning on respiratory equipment to prevent the risk of infection. Reference: WAC 388-97-1060 (3)(j)(vi)

Based on interview and record review the facility failed to timely transcribe provider orders and administer medications as intended by the provider for 1 of 6 sampled residents (Resident 34), reviewed for unnecessary medications. Specifically, Resident 34 was routinely administered pain medication when the provider intended to change the prescription to as needed. This failure placed residents at risk of adverse side effects, unnecessary medications, and diminished quality of life. Findings included . According to the 03/18/2024 quarterly assessment, Resident 34 had frequent mild pain that did not affect their activities of daily living. Resident 34 was cognitively intact and able to make their needs known. Review of the 12/16/2021 care plan instructed staff to offer nonpharmacological pain interventions such as repositioning, diversional activities, food, toileting, music, and a quiet environment. The care plan also instructed staff to monitor frequency of pain and medication effectiveness. Review of provider orders in the medical record showed an active 03/15/2023 Hydrocodone (narcotic pain medication) order to be administered routinely three times daily. Review of the February 2024 pharmacist monthly medication regimen review showed that on 02/05/2024 the pharmacy received a signed prescription for Hydrocodone one tab every eight hours as needed but the facility electronic medical record showed Hydrocodone one tab routinely three times daily. The pharmacy requested clarification. Review of the facility provider communication book showed a 02/06/2024 entry for Resident 34 which stated the new Hydrocodone prescription was written for as needed, not routinely scheduled and asked if that was correct. A provider response of yes was written on 02/07/2024 in the provider communication book. Review of the February 2024 through March 2024 medication administration record showed the Hydrocodone order was not changed to as needed and Resident 34 continued to receive Hydrocodone routinely three times daily. After 02/07/2024, Resident 34 received 61 doses of Hydrocodone in February and 74 doses in March. Review of the February 2024 through March 2024 pain monitor showed Resident 34 had frequent 0-3 pain (on a scale of 0-10, 0 being no pain and 10 being the worst pain). On 03/25/2024 at 9:58 AM Resident 34 was observed in bed sleeping. Similar observations were made on 03/26/2024 at 10:18 AM and 2:17 PM, on 03/27/2024 at 8:50 AM and 3:44 PM, and on 03/28/2024 at 8:25 AM. In an interview on 03/29/2024 at 1:13 PM, Staff M, Registered Nurse, was shown the 02/06/2024 entry in the provider communication book for Resident 34 that requested clarification on the Hydrocodone prescription. Staff M acknowledged the provider responded on 02/07/2024 and wanted the prescription administered as needed, not routinely. Staff M further stated nurses typically did not review the provider book for provider responses or verify orders written in the provider book were processed. In an interview on 03/29/2024 at 1:33 PM, Staff B, Director of Nursing, was shown the 02/06/2024 entry in the provider communication book for Resident 34 that requested clarification on the Hydrocodone prescription. Staff B stated the 02/07/2024 yes entry was the provider acknowledging and addressing the concern. Staff B acknowledged nursing staff did not review the provider communication book for provider responses or new orders. A policy for processing provider orders was requested from Staff A, Administrator on 03/29/2024 at 1:48 PM. No policy was provided. In an interview on 03/29/2024 at 4:21 PM, Staff A, stated resident care managers and Staff B reviewed provider communication logs in the communication books but the facility had no policy for use of the provider communication books. Reference WAC 388-97-1060 (3)(k)(iii)

Based on interview and record review the facility failed to consistently monitor tolerance to dialysis (procedure to remove fluid and waste from the body when the kidneys stop working properly) treatments and collaborate care with the dialysis center for 1 of 2 sampled residents (Resident 51), reviewed for dialysis care. These failures placed residents at risk of unrecognized complications, unmet care needs and diminished quality of life. Findings included . Review of the Long Term Care Facility Outpatient Dialysis Services Coordination Agreement, between the facility and the dialysis center dated 04/05/2021, documented the facility should provide the dialysis center with an interchange of information useful and/or necessary for the care of the dialysis resident. The agreement further documented there should be documentation of collaboration of care and communication between the long-term care facility and the dialysis center. According to the 12/19/2023 quarterly assessment, Resident 51 had a diagnosis of end stage renal disease (kidneys stop working and are not able to remove waste or extra water from the blood) and was dependent on dialysis. Resident 51 was cognitively intact and able to make their needs known. Review of progress notes showed Resident 51 readmitted to the facility on [DATE] with newly initiated dialysis that was scheduled three times weekly on Tuesdays, Thursdays, and Saturdays mornings. Review of the 06/14/2023 care plan documented Resident 51 had end stage renal disease, was dependent on dialysis and was to receive dialysis three times weekly on Tuesday, Thursday, and Saturday mornings at an off-site dialysis center. The care plan instructed staff to monitor for changes in consciousness, changes in skin elasticity, signs of infection to dialysis access site, and changes to heart and lung sounds. Review of provider orders showed a 10/17/2023 order that Resident 51 was to attend dialysis three times weekly on Tuesday, Thursday, and Saturday mornings. Dialysis communication forms were found in Resident 51's medical record, the communication forms consisted of three sections. The first section of the form instructed the facility to complete prior to dialysis with the resident's vital signs, medication administered prior to dialysis, pain, any concerns, changes in condition since last visit, physician order changes since last visit, labs completed since last visit, the time the resident left for dialysis and a section for a facility nurse to sign. The second section was to be completed by the dialysis center with the resident's vital signs, medications given during dialysis, dialysis tolerance and events that occurred during dialysis treatment. The third section instructed the facility to complete upon return from dialysis with the resident's vital signs, pain, and dialysis access site assessment. Review of the dialysis communication forms December 2023 through March 2024 showed: - December: Only 9 of 13 dialysis communication forms were located. The facility pre-dialysis and post dialysis sections were blank on eight of nine forms. The facility pre-dialysis section was completed on one form, but the facility post-dialysis section was blank. - January: Only 9 of 13 dialysis communication forms were located. The facility pre-dialysis and post dialysis sections were blank on five of nine forms. The facility pre-dialysis section was partially completed on three of nine forms but the facility post dialysis section was blank. One dialysis communication form had the facility pre-dialysis section completed but the post-dialysis section was blank. - February: Only 9 of 13 dialysis communication forms were located. On all nine dialysis communication forms, the facility pre and post dialysis sections were blank. - March: Only 8 of 11 dialysis communication forms were located. The facility pre-dialysis and post-dialysis sections were blank on four of 11 forms. The facility pre-dialysis section was completed on one form, but the facility post-dialysis section was blank. The facility pre-dialysis section was blank on two of 11 forms with the facility post-dialysis section partially filled out. The facility pre-dialysis section was blank on one form with the facility post-dialysis section completed. Review of the December 2023 through March 2024 vital sign records showed Resident 51's vital signs were obtained infrequently and inconsistently by the facility: - December: 1 blood pressure and 1 heart rate obtained - January: 2 blood pressures and 2 heart rates obtained - February: 5 blood pressures and 5 heart rates obtained - March: 2 blood pressures and 2 heart rates obtained Review of the December 2023 through March 2024 progress notes showed Resident 51's dialysis tolerance was infrequently and inconsistently monitored. In an interview on 03/24/2024 at 11:02 AM, Resident 51 stated they were on dialysis and typically took paperwork with them to the dialysis center. The facility dialysis policy was requested on 03/24/2024 at 11:23 AM from Staff A, Administrator. No policy was provided. In an interview on 03/28/2024 at 9:26 AM, Staff K, Nursing Assistant, stated the nurses usually took care of monitoring residents on dialysis and any paperwork went straight to the nurse. In an interview on 03/28/2024 at 10:09 AM, Staff L, Licensed Practical Nurse, stated the facility communicated with the dialysis center via a communication form that accompanied the resident to each dialysis treatment. Staff L further stated the resident's vital signs should be obtained prior to a dialysis treatment and upon their return from dialysis. Staff L acknowledged if the dialysis communication form was not completed it made it difficult to assess a resident's baseline and tolerance to dialysis treatments. In an interview on 03/28/2024 at 10:32 AM, Staff B, Director of Nursing, stated monitoring a dialysis resident consisted of an assessment of the dialysis access site and obtaining the resident's vital signs prior to and after each dialysis treatment. Staff B further stated the facility communicated with the dialysis center via a communication form that went with a resident to their dialysis treatments and their expectation was for staff to complete the dialysis communication form each time. Reference WAC 388-97-1900 (1), (6)(a-c)

Based on observation, interview and record review, the facility failed to accommodate a resident's desire for a larger television that they could better visualize for 1 of 3 sampled residents (Resident 47) reviewed for environment. This failure placed the resident at risk of being unable to participate in their preferred activities and decreased quality of life. Findings included . A 01/15/2024 quarterly assessment documented Resident 47 had diagnoses including Parkinson's disease (nerve cell damage in the brain that causes stiffness, tremors, and difficult movement.) Resident 47 was cognitively intact, and it was very important for them to be able to listen to music and do their favorite activities. The 10/10/2023 Activities care plan documented Resident 47 enjoyed current events including the news on TV (television), music, assorted Westerns, talk shows, and comedy series with their personal room and recreational rooms as the preferred setting. The activity staff were to have 1 to 1 visits in the resident's room, help in selecting TV programs and music channels in the resident's room, and respect choices in regards to participating in an activity as opposed to observing an activity. On 03/24/2024 at12:57 PM, Resident 47 was observed in their room resting on their bed. The resident's head leaned to their left with their chin down towards their chest and they wore eyeglasses. Resident 47 had a video game controller in their left hand and used the controller to operate their TV. The head of the resident's bed was positioned on one wall and their TV was positioned at the foot end of the bed on the opposite wall. When interviewed, Resident 47 stated they had changed rooms recently because they did not get along with their previous roommate and wanted their old room back. Resident 47 stated they preferred the other room because the TV was much larger. They stated they had difficulty seeing their current TV because it was smaller and farther away. Resident 47 stated they enjoyed looking at You-tube videos on TV, but they were unable to read the titles and captions of the videos. Resident 47 stated they had requested the larger TV from maintenance and was told no. During an interview on 03/29/2024 at 10:16 AM, Staff F, Plant Operations Manager, stated Resident 47 had a 50 TV in their old room. Staff F stated they were asked if the TVs could be traded and they answered no, that they did not go around swapping the TVs. Staff F stated moving the TV was a two-person job and they did not want to swap them. Staff F viewed Resident 47's TV with the surveyor. Resident 47 was asked to read words that were currently on their TV screen and was unable. Staff F stated they had no other TV, shrugged their shoulders, and exited Resident 47's room. During an interview on 03/29/2024 at 11:39 AM, Staff E, Social Services Director, stated they had checked in with Resident 47 on 03/18/2024, and asked the resident how they were adjusting to their new room and the resident responded they did not know. Staff E stated they had not been made aware Resident 47 had concerns regarding their TV. During an interview on 03/29/2024 at 3:55 PM, Staff A, Administrator, stated they knew the TV was very important to Resident 47 and stated they would look for a solution so Resident 47 would be able to see their TV. Reference: WAC 388-97-0860(2)

Based on interview, and record review, the facility failed to ensure incidents of potential abuse, such as misappropriation of personal property, were identified as such and reported to the State Survey Agency as required, for 1 of 6 sampled residents (Resident 30) reviewed for abuse. Failure to report allegations/incidents of abuse placed the resident at risk for additional abuse. Findings included . Review of the facility Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy, last revised 09/21/2022, documented the policy of the facility was their residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy further showed, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (hereafter referred to as abuse) would be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Per the 02/26/2024 quarterly assessment, Resident 30 was cognitively intact and able to direct their care, required maximum assistance for Activities of Daily Living (ADLs) such as personal hygiene, dressing, and transferring, and had diagnoses including Stroke, Aphasia (a brain disorder where a person has trouble speaking or understanding), and hemiplegia (paralysis that affects only one side of the body). On 03/24/2024 at 01:56 PM, Resident 30 was observed to have left sided weakness, they were unable to speak clearly, and their voice was very quiet. They nodded or shook their head and used gestures to communicate. In addition, they communicated by writing in a notebook. During an interview on 03/24/2024 at 2:44, PM Resident 30 stated their phone was stolen by the previous roommate's family member. Resident 30 then wrote on a piece of paper that the former roommate's family member stole their new phone with a mint green case and a couple of the staff looked for it but didn't find it. During an interview on 03/27/2024 at 11:30 AM, Staff E, Social Services Director stated Resident 30 initially told them the roommate's family member stole the phone, then later Resident 30 told them it might have slipped into the trash. Staff E stated they had called Resident 30's family to find out if they had taken it and to discuss if they wanted to replace it and were waiting to hear back. In a follow up interview on 03/29/2024 at 12:40 PM, Staff E Social Services Director stated they were still waiting to hear from Resident 30's family and had planned on calling on them that day. When asked when they would report Resident 30's missing property to the state hotline, Staff E stated if the value of the missing phone was $500.00 or greater it would need to be reported. Staff E then stated they could follow up with resident to see what they wanted to do and how the ongoing service would be paid for and/or get them a prepaid phone. In a phone interview on 03/29/2024 at 2:30 PM with Resident 30's family, they stated they had obtained a replacement phone and were hoping to bring it to the resident in a couple days. They acknowledged they had not returned calls from the Social Services Director In a follow up interview on 03/29/2024 at 3:55PM, when asked if anyone from the facility had talked to them when the phone went missing, Resident 30 replied yes. When asked if they told the facility the phone might have fallen into the trash they said yes. When asked if they believed the phone fell into the trash they said no, it was stolen. A review of the facility Concern Log on 3/27/2024 at 11:13 AM, showed a report of a missing cell phone by Resident 30 on 3/5/2024. A review of the facility Accident/Incident log on 3/27/2024 at 11:16 AM, showed no documentation of Resident 30's missing cell phone. A review of Resident 30's record showed no progress notes related to the missing phone. On 03/29/2024 at 2:28 PM, a review of STARS, the Washington State computer program for tracking reports of incidents involving nursing home residents, showed no report had been made regarding the missing phone. Reference: WAC 388-97--0640(5)(a)

Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, homelike environment for 1 of 2 sampled residents (Resident 48), reviewed for environment. This failure placed residents at risk for possible illness from unclean equipment, a lack of dignity, and a decreased quality of life. Findings included . Resident 48 had diagnoses, including Vascular Dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to the brain). A 02/28/2024 quarterly assessment documented Resident 48 was severely cognitively impaired and did not walk, making the wheelchair (w/c) their only method of mobility. Review of a 03/27/2024 cleaning assistive device task documented Resident 48 was to have their w/c cleaned once a week on Sundays but there was no documentation found within the last 30 days. During an observation on 03/24/2024 at 03:02 PM, Resident 48 was sitting in their w/c in the dining room requesting a cup of coffee. An observation was made of Resident 48's w/c; the black seat cushion and lower components of wheelchair was unclean, with an unknown substance that appeared to be dried spilled liquid and food debris. Subsequent observations of the w/c being unclean was made on 03/25/2024 at 09:49 AM, 03/25/2024 at 11:03 AM, 03/26/2024 at 09:16 AM, 03/27/2024 at 08:51 AM, 03/27/2024 at 11:18 AM, 03/27/2024 at 03:55 PM, and on 03/28/2024 at 10:52 AM. On 03/29/2024 at 8:40 AM, an observation was made of a sign posted by nursing management in the dining room that documented the evening shift was to pull w/cs and walkers out for the night shift to facilitate cleaning every night. Resident 48 was not able to be interviewed related to their disease progression, but was alert, and able to freely move while in their wheelchair. During an interview on 03/29/2024 at 08:28 AM, Staff H, Nursing Assistant, stated that the evening shift was to pull out the residents w/c's for the night shift to clean and if it needed to be cleaned during the day, the staff on duty at that time would clean it. Staff H also stated that there was a sign in the dining room which indicated the process for cleaning assistive devices. Staff H verified Resident 48's w/c was unclean. During an interview on 03/29/2024 at 08:42 AM, Staff I, Registered Nurse, stated the nighttime staff was responsible for cleaning the w/cs. During an interview 03/29/2024 at 09:24 AM, Staff B, Director of Nursing, stated there was a schedule and the w/cs were supposed to be cleaned by the night shift. Reference: WAC 388-97-0880

Based on observation, interview and record review, the facility failed to ensure a significant change assessment was completed timely when a resident had several areas of decline for 1 of 21 sampled residents (Resident 8) reviewed for declines in activities of daily living (ADLs). This failure placed residents at risk for unrecognized and unmet changes in care needs. Findings included . Per review of the record, Resident 8 was admitted from the hospital on 11/15/2023 with diagnoses including dementia and adult failure to thrive. Review of the Minimum Data Set (MDS), a comprehensive assessment completed on 11/22/2023 documented Resident 8 was moderately impaired cognitively, required set up or clean up assistance for eating, substantial/maximum assistance for dressing their upper body, and completing personal hygiene, partial/moderate assistance when changing from a lying position to a sitting position and weighed 193 pounds (lbs.). In the Assessments area of the record, an interdisciplinary team (IDT) note completed on 11/29/2023 documented the discharge plan was for Resident 8 to go home with their spouse, the resident was working with therapies for strengthening and was slow to progress due to rapid dementia. The IDT note completed on 01/31/2024 documented the resident's spouse was unsure of discharge and little therapy progress was made in recent weeks. Resident 8 was to stay in the memory care unit. There were no other IDT notes after 01/31/2024. A review of the resident weights documented on 01/19/2024, Resident 8 weighed 197.8 lbs. On 02/20/2024, their weight was documented as 185.2 lbs., a significant loss of 6.4% in one month. The quarterly MDS assessment completed on 02/20/2024 documented Resident 8 was now severely cognitively impaired, was dependent for eating, dependent for upper body dressing, personal hygiene, and changing from a lying to a sitting position, and their weight was 189 lbs., Weight loss was none, or unknown. Provider progress notes reviewed from 01/2024 through the time of the survey did not document the resident's dementia was terminal or that the resident was end stage, that the provider had been notified of weight loss, or that the resident required more assistance with eating, dressing, personal hygiene and position changes. On 03/27/2024 at 11:05 AM, Resident 8 was observed in the dining room in a wheelchair. The resident was dressed, groomed and their legs were elevated on foot rests. The resident did not engage with other residents, or reposition themself in the wheelchair, or attempt to move their arms. A staff member asked Resident 8 how they were doing. Resident 8 took a few seconds to respond, then repeated several times I'm fine, I'm fine. then became tearful. They repeated this until the staff member offered them reassurance. Resident 8 remained in the same position at the table and looked around without engaging others. During an interview on 03/29/2024 at 9:38 AM, Staff H, Nursing Assistant, stated they had worked in the memory care unit for 3 years. Staff H stated Resident 8 had declined since their admission. They stated when the resident arrived, Resident 8 was able to stand, bear weight, and use a sit-to-stand transfer device (allowed the resident to participate when transferred from a seated position to a standing position). Staff H stated the resident now required a hoyer lift for transfers, did not roll in bed, or help with sitting up or getting dressed. Staff H stated Resident 8 no longer talked as much or at times said one word over and over. Staff H stated when they noticed changes in a resident's functioning, they notified the nurses. During a telephone interview on 03/29/2024 at 12:57 PM, Staff Q, Registered Nurse, MDS Coordinator, stated the team discussed resident changes in functioning every morning during their morning meeting. When asked if a decline in functioning from substantial assistance to dependent assistance was considered a significant change, Staff Q stated if a resident had been sick, it might not be a significant change; Staff Q watched those residents for 2 weeks and if they did not improve then did a significant change assessment. Staff Q stated that if a resident had dementia though, they did not initiate a significant change assessment because the decline was expected. Staff Q stated they did not notify the provider of changes in a resident's functioning, as it was the nurses responsiblity to do so. During an interview on 03/29/2024 at 2:08 PM, Staff B, Director of Nursing, stated Resident 8 had been making progress after their admission, but then became ill with a viral illness. Staff B stated Resident 8 recovered after their illness, but then plateaued in their therapy and since, had been on a steady decline. Staff B was unsure if the changes from the admission MDS assessment and the quarterly MDS assessment constituted a significant change, and deferred to the MDS Coordinator, Staff Q. Reference: WAC 388-97-1000(3)(b)

Based on interview and record review, the facility failed to ensure one of five sample residents (Resident 4), was free from verbal and physical abuse. This failure resulted in actual harm to the resident, who experienced a fall with a [CONDITION(S)], as a result of rough handling by a nursing assistant, who also verbally abused the resident during the transfer. Findings included . Review of the facility's policy titled Abuse-Washington, revised on 08/2019, showed abuse was defined as the willful infliction of injury with resulting physical harm. Willful was further defined as an individual who acted deliberately, not that the individual must have intended to inflict injury or harm. Additionally, verbal abuse was defined as the use of oral communication to a resident in a derogatory manner. Per the 02/16/21 annual assessment, Resident 4 was totally dependent on two staff for transfers, and was severely overweight. The assessment showed the resident was alert and oriented. Review of the care plan, initiated 02/06/2020, showed floor staff were to use a mechanical lift for her transfers. The care plan did not specify the size and/or type of lift required. Review of a facility investigation initiated on 04/01/21 showed Resident 4 fell from a mechanical lift during a transfer from the bed to the wheelchair, while being assisted by Staff D and E, Nursing Assistants. The investigation showed the staff used a normal sized lift, rather than a bariatric lift (a larger lift, designed to accommodate residents who were severely overweight), and it did not fit around the resident's oversized wheelchair. Per the investigation, during the attempted transfer, Staff D and E made multiple attempts to fit the lift around the resident's wheelchair, and attempted to remove the armrest of the chair in order to make more room, without success. Per the investigation, Staff D became agitated when the resident attempted to verbally direct the staff on the transfer, and cursed at the resident while handling the lift roughly and improperly, resulting in both the lift and the resident falling to the ground. The investigation showed the resident was assessed, and found to have a [CONDITION(S)], which required hospitalization for surgical repair. In an interview on 04/06/21 at 10:15 AM, Staff E, Nursing Assistant, stated Resident 4 was able to direct their own care, and was directing staff in the transfer that resulted in a fall on 04/01/21. Per Staff E, she and Staff D were attempting to transfer the resident into a wheelchair, but were not able to fit the legs around the wheelchair, so Staff E asked Staff D to try repositioning the lift, but instead he closed the legs at the base of the lift from a wide and open position (which created stability), to a closed and narrow position (with less stability), and continued attempting to move the lift. The resident told Staff D to guide her body over the wheelchair, to which Staff D replied with cursing at the resident, and stated that he knew what he was doing. Staff D then grabbed the resident, rather than the handles designed for staff to hold while gently guiding residents in the lift, and jerked the resident sharply towards himself, resulting in the entire lift and resident falling to the ground. Staff E stated Staff D became visibly angry during the transfer, and at the resident's verbal attempts to direct him, which contributed to the rough manner in which he handled the resident while in the lift. On 04/07/21 at 12:00 PM, a phone interview was conducted with Resident 4, while still in the hospital. The resident remembered the staff members conducting a transfer from bed to the wheelchair when the fall out of the mechanical lift occurred, and the stated a nursing assistant helping was angry with her, but did not recall any further details. In an interview on 04/08/21 at 9:42 AM, Staff A, Director of Nursing Support, stated Staff D was interviewed in person during the course of the investigation, with multiple staff members present: Staff A, Staff C, Resident Care Manager, Staff F, Administrator, Staff G, Human Resources, and an additional unidentified staff. Per Staff A, Staff D was asked about the interaction with Resident 4, and how he used the mechanical lift, with Staff D confirming he became frustrated and mishandled the resident while in the lift, causing the lift and resident to fall. Multiple attempts by the state surveyor to contact Staff D directly were unsuccessful. Reference: WAC 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to ensure assessments and a care plan for falls were timely and accurate, and failed to implement appropriate supervision to prevent falls for one of five sample residents (Resident 1), reviewed for falls. These failures resulted in actual harm to Resident 1, who sustained a [CONDITION(S)] during an unwitnessed fall. Findings included . Review of the 01/26/21 annual assessment showed Resident 1 was alert and oriented, required extensive assistance of two staff for transfers due to unsteadiness, and had prior falls in the facility. Per the electronic medical record, the resident was last assessed for falls on 01/24/2020. The fall assessment at that time showed the resident was at risk for falls. Review of the care plan initiated 01/24/2020 showed conflicting information: one section documented the resident was forgetful and did not always use the call light appropriately to request staff assistance; another section showed that she used the call light appropriately. Additionally, the care plan documented the resident was safe to use her mobility bars and manual wheelchair independently. Per a facility incident report dated 02/03/21, Resident 1 had become injured that day while self-transferring to the wheelchair. Per the report, the resident was reminded to use the call light for assistance, and staff were educated on where to place the wheelchair to minimize the potential for injury. There was no fall assessment included, to determine if the resident self-transferring represented an increased risk for falls requiring care plan updates. Review of the February 2021 progress notes showed the following: 02/09/21 - the resident was started on daily narcotic pain medication. 02/15/21 - the resident's narcotic pain medication was increased to three times daily. 02/21/21 - the resident showed signs of extreme confusion, and the resident's representative voiced concerns the resident's narcotic pain medication was causing the confusion. 02/22/21 - the narcotic pain medication was decreased to twice daily. 02/23/21 - the resident remained confused, and would not use the call light appropriately to call for staff assistance with transfers. 02/26/21 - the resident continued to show adverse side effects to the narcotic medication, which included forgetfulness. Per review of the record during this time, no assessments of the resident's fall risk, related to the identified increased confusion, were done. Per a facility incident report dated 03/01/21, Resident 1 again had become injured on the wheelchair during a self-transfer. The report documented the resident was not compliant with care, and staff were not always able to catch up with her, before self-transfers. Pads were placed on the wheelchair to prevent injury, but no assessments or interventions to address the resident unsafely self-transferring were done. Review of a facility incident report dated 03/09/21 showed the resident was found on the floor in her room, after self-transferring into the wheelchair without appropriate footwear. The resident was assessed and found to have a [CONDITION(S)], requiring transfer to the hospital for surgical repair. In an interview on 03/15/21 at 12:20 PM, the resident's representative stated Resident 1 remained in the hospital due to the fall and fracture the prior week. Per the representative, the resident had a long history of confusion when using narcotic pain medication, which had been communicated to the facility multiple times in the weeks prior to the fall. In an interview on 03/22/21 at 1:42 PM, Staff K, Nursing Assistant, stated the resident had a decline in cognition prior to the fall. Per Staff K, the resident didn't always know where she was, would forget to use the call light, and would yell out for staff help with the call light in her hand. At 2:15 PM the same day, Staff I, Licensed Practical Nurse, stated the resident was usually confused in the mornings until approximately 10:00 AM, when she would get up for the day, and needed to be reminded several times each day to use the call light for staff assistance with transfers. Per Staff I, the resident's fall on 03/09/21 occurred during the early morning hours, the time of day she was identified as a high fall risk, and the only intervention in place to prevent falls at that time was reminding the resident to use the call light, along with staff observation. Observation on 03/22/21 at 2:55 PM showed all doors to resident rooms on the unit where Resident 1 resided were closed, except for one. In an interview at the same time as the observation, Staff J, Nursing Assistant, stated the one door was open so staff could monitor an unidentified resident at high risk to fall. Staff J stated prior to Resident 1's fall, staff attempted to check on her frequently, but it was difficult because the door was closed, due to the facility's COVID-19 protocols. Staff J also stated the resident had increasing confusion in the weeks prior to the fall, which was reported to the nurse. In an interview at 3:02 PM, Staff L, Licensed Practical Nurse, stated the resident had been assessed for urinary tract infections multiple times in the weeks prior to the most recent fall, related to the increased confusion, however each urine test was negative. Per Staff L, the resident's increased confusion was reported to Staff C, Resident Care Manager. On 04/01/21 at 12:05 PM a phone interview was conducted with Staff C, who stated she had been responsible for facility investigations on the unit where Resident 1 resided, since January of 2021. Staff C confirmed awareness that the resident would frequently self-transfer due to confusion, and that it was inevitable. Staff C stated she thought the resident's door was required to be closed, even if the resident was identified as a high fall risk requiring close monitoring and frequent observations by staff, due to COVID-19 protocols, and had only recently learned that was not the case. When asked about the direct care staff concerns of the inability to frequently check on the resident with the door closed, Staff C stated it probably would have been safer to have the door open. When asked about fall assessments and checks for care plan accuracy, Staff C stated they were to be done quarterly, and Resident 1's assessments and care plan would have last been updated by the prior resident care manager. Staff C was also asked about fall assessments and care plan updates, after the resident's injuries from self-transferring on 02/03/21 and 03/01/21, as well as when the resident's representative verbalized concerns about increased confusion due to medication use; Staff C acknowledged no assessments of the resident's fall risk, or care plan interventions to prevent self-transferring unsafely were done. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to effectively implement actions to contain the spread of COVID-19, a highly contagious virus, by: 1) Failure to cohort residents (placing residents in a separate room/unit during infection outbreaks) who tested positive for COVID-19, in order to prevent transmission to residents without COVID-19 infections. 2) Failure to implement a system that ensured all healthcare personnel and/or essential visitors were screened for COVID-19, prior to being allowed to access resident care areas. 3) Failure to maintain an infection prevention and control program which demonstrated ongoing analysis and trending of COVID-19 infections. 4) Failure to ensure a communicable disease/outbreak was reported to the State Survey Agency, as required. These failures placed all residents and staff at risk for contracting COVID-19, during a global pandemic. The facility's failure to cohort residents with COVID-19, constituted a situation of an immediate jeopardy (IJ). On [DATE] at 5:25 PM, the facility was notified of the IJ related to CFR 483.80 F 880, Infection Prevention and Control. On [DATE] at 2:45 PM, the removal of the IJ immediacy was validated by ensuring residents with COVID-19 were cohorted together with dedicated staff on the COVID unit. Staff were educated on transmission and preventing the spread of COVID-19, and two screening areas were established for staff and essential visitors, which was being monitored by trained staff. On [DATE] at 4:00 PM, the facility was informed the immediacy of the IJ was removed. Findings included . COHORTING Per the CDC document titled Responding to Coronavirus (COVID-19) in Nursing Homes dated [DATE], nursing homes should ensure physical separation of confirmed positive COVID-19 residents from negative residents (separate floor, wing, or cluster of rooms) to minimize the risk of [MEDICAL CONDITION] spreading to non-infected residents. During an on-site observation on [DATE] at 1:55 PM, on the Meadow Wood unit, there were rooms with isolation carts and signage on the doors, showing the resident was in droplet precautions (patients known or suspected to be infected and transmitting [MEDICAL CONDITION] by respiratory droplets that are generated with coughing, sneezing, or talking), along with rooms without precautions in place. Between 2:05 PM and 2:30 PM, observations of the Tuscan Trail unit, the area deemed by the facility as the COVID unit, showed some rooms had isolation carts and signage on resident doors indicating they were in respiratory isolation, and some rooms did not. On [DATE] between 2:10 PM and 2:30 PM, Staff A, Registered Nurse, was interviewed and confirmed Tuscan Trail was identified as the COVID unit. She stated some residents on the unit were COVID positive, some had recovered from COVID, and some were negative for the [MEDICAL CONDITION]. Administration was not available for interview during the infection control visit. On [DATE] at 3:00 PM, a representative of the local health jurisdiction (LHJ), stated she had been working with the facility during the current outbreak. She stated it was not recommended to have residents who were COVID positive among residents that had recovered from COVID and were COVID negative. She stated she had had explained to the facility these residents needed to be separated the best they could. During an interview on [DATE] at 3:20 PM, Staff B, Resident Care Manager, stated there were COVID-19 positive residents in the COVID unit (Tuscan Trail) along with residents who were recovered from COVID-19, and residents without [MEDICAL CONDITION]. She went on to say each unit in the facility had positive COVID-19 residents, in private rooms, along with residents that were not infected with [MEDICAL CONDITION]. In a follow-up interview at 4:15 PM, Staff B stated it had been discussed to cohort the positive COVID residents, but there was no feasible way for it to be done. On [DATE] at 6:05 PM, Staff C, Director of Nursing/Infection Control Nurse, stated the last COVID testing of residents revealed how wide-spread the building was with COVID-19. Staff C confirmed the LHJ did recommend to cohort as much as possible, but they were at a grid lock, and the building was not conducive to doing so. On [DATE] at 10:15 AM, Staff D, Administrator, stated when the outbreak spread, the facility got direction from the Medical Director saying it was too wide-spread to move residents. Staff D stated they were told by the LHJ to cohort, the best they could, but chose to follow the Medical Director's direction. STAFF SCREENING On [DATE] at 1:45 PM, the surveyor entered the designated west door for screening, prior to entering the facility. No staff were present, and there was a table with different types of masks, some goggles, and face shields. Screening forms were on the table with questions regarding potential exposure, along with a thermometer. There were no specific directions seen, for staff or visitors to follow. At around 1:50 PM, an agency staff member entered. She asked the surveyor what she needed to do. Around the same time, a facility staff member entered. The agency staff asked what she needed to wear and do. The staff member directed her to the masks and face shields and stated you need to answer the questions and take your temperature. The agency staff stated now, or later? The facility staff stated whatever, and the agency staff member did not check her temperature or fill out the screening form, and entered the doors into the resident care area. During an interview on [DATE] at 6:05 PM, Staff C, Director of Nursing stated after 2:30 PM, the screening area did not have a staff member present to assist visitors or staff with screening. When asked who reviewed the screening logs for possible signs and symptoms of COVID-19, Staff C stated she was doing it daily but had not reviewed them recently, and confirmed an outside employee should be educated on the screening process. SURVEILLANCE Review of an undated facility policy, titled COVID-19, Prevention and Control of, the portion under surveillance showed, The infection Preventionist has established procedures for monitoring and reporting COVID-19 activity in the facility. All potential and confirmed cases will be reported to appropriate entities as indicated. The Infection Preventionist will track spread and timeline for infections in the facility. On [DATE] at 6:05 PM, Staff C was asked for documentation related to tracking of staff and residents to include who was tested , what the results were, and symptoms. On [DATE], Staff C sent an electronic mail (e-mail) titled Resident COVID-19 tracking. The document was opened by the surveyor, and it showed a resident census (a list of residents and room numbers), with a column next to the resident name labeled 14th day. A date was entered in the column next to the COVID positive residents, which indicated when the resident was done with their quarantine (restriction of movement to a specific area, to prevent the spread of communicable disease). On [DATE] at 2:50 PM, Staff C was not in the facility during an on-site visit. Staff D, Administrator was asked for a line listing of residents and staff who were tested for COVID-19, which would include a positive or negative result, and symptoms. Staff D stated Staff C would e-mail the information. On [DATE] an e-mail with a list of positive COVID-19 residents was sent by Staff C. The list had resident names, when the COVID test was collected, the date it was completed, the result of the test, and a column labeled recovered with a yes, active, or deceased entry. It was noted the list reflected positive residents, and those residents not listed had not tested positive. According to Staff C, with regard to recovered status, yes were residents with symptom resolution/quarantine complete, and active indicated the resident was still symptomatic/quarantined. There was no documentation on the list to include resident symptoms, when the symptoms started or ended, and no information for staff that tested positive for COVID-19. The list showed 68 residents had been positive, 28 were currently active with [MEDICAL CONDITION], and there were nine deaths. During an interview on [DATE] at 2:00 PM, Staff C, Director of Nursing, was asked about tracking and trending of symptoms for residents and staff. Staff C stated for residents, the floor nurses monitored vital signs daily. After a resident came back positive for COVID, vital signs and COVID symptoms were monitored each shift. Staff C confirmed there was no documentation for COVID positive staff, and nothing further to show tracking of resident symptoms. REPORTING Review of theNursing Home Guidelines - The Purple Book, dated [DATE], showed the facility must report any communicable disease/outbreak to the State Survey Agency, and the local Department of Health. According to the undated facility policy titled, COVID-19, Onsite Testing of, under reporting, Residential Care Services (RCS) will be notified/updated of current status of positive cases. Review of the facility's positive resident list identified residents were COVID positive on the following dates: [DATE] - 1 [DATE] - 1 [DATE] - 4 ,[DATE]//2020 - 4 [DATE] - 4 [DATE] - 25 [DATE] - 2 [DATE] - 1 [DATE] - 1 [DATE] - 22 and ,[DATE] - 3 There was no documentation provided showing when staff had tested COVID positive. On [DATE], the facility called the Complaint Resolution Unit (CRU - State Agency reporting system), reporting nine COVID-19 positive residents. Another report was not done until [DATE], at which time the facility reported 38 COVID positive residents, and 20 COVID positive staff. There was no further reports found. On [DATE] at 2:50 PM, Staff D, Administrator, was asked if the positive COVID residents from ,[DATE] /20 had been reported to the State Survey Agency. Staff D stated Staff C had not called them in yet, and he was aware it was a requirement. On [DATE] the CRU intakes were reviewed for the facility; the most recent positive COVID residents had still not been reported. During an interview on [DATE] at 12:29 PM, Staff C stated she was calling in the positive COVID residents and staff in batches, not at the time COVID was known or suspected, as required. Reference: WAC [DATE] (1) (a) (2) (a)

Based on observation, interview, and record review, the facility failed to ensure one of two sample residents (#1), reviewed for resident-to-resident altercations, was free from physical abuse. This failure resulted in actual harm to Resident #1, who sustained a hematoma on his head (localized swelling that is filled with blood, caused by a break in the wall of a blood vessel), after Resident #2 hit him over the head with a cane. Findings included . According to the State Operations Manual (SOM) as defined at 483.5, the term willful as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm, and having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. Resident #1 Review of Resident #1's 05/09/19 quarterly assessment showed he had [DIAGNOSES REDACTED]. Per the assessment, the resident had memory impairments, difficulty making his needs known, required supervision when ambulating, and physical and verbal aggressions directed towards others (from one to three days, in the seven day assessment period). Resident #2 Review of Resident #2's 04/11/19 assessment showed he was admitted on [DATE], and had [DIAGNOSES REDACTED]. In addition, the assessment showed Resident #2 had behaviors daily of physical and verbal aggression directed towards others, which placed others at significant risk for injury. Resident #2's most recent care plan, dated 04/02/19, instructed staff to separate residents, assure their safety, and report to the licensed nurse if Resident #2 had behaviors directed towards other residents. Staff were to approach Resident #2 in a calm, unhurried manner. Per record review, Resident #2's (MONTH) 2019 behavior monitor document showed the resident had target behaviors to include being resistive to care, verbally abusive, and physically abusive/aggressive. The interventions included to assess the resident's needs, assess for pain, offer reassurance, follow the behavior management plan, and offer 1:1. The resident's behaviors were monitored twice a day, and per record review, he exhibited behaviors at least daily. Review of the effectiveness of the interventions showed on 12 different occasions, there was no change in Resident #2's behavior. The (MONTH) 2019 behavior monitor had the same target behaviors and interventions. The resident had behaviors at least daily, and had 13 occasions of no change, after interventions were attempted. Review of progress notes for Resident #2 showed the following behaviors: - 04/10/19, the resident was aggressive towards residents in the dining room, telling them to shut up and get out of here! When redirected out of the dining room by staff, the resident became very aggressive and swung his cane at the nurse. - 04/11/19, Resident #2 was described as very agitated. Staff attempted to redirect the resident, who was verbally and physically aggressive. The resident began wandering into other resident's rooms, and was very resistive to being redirected out. - 04/16/19, Resident #2 was awakened by another male resident, who had wandered through the adjoining bathroom into his room. Resident #2 became very upset, staff heard a commotion, but there was no witness to the incident. It was noted no apparent physical contact between the two residents occurred. A facility incident investigation, dated 05/09/19, showed Resident #2 was involved in a physical altercation with his roommate, Resident #1. The incident was not witnessed, however, it appeared Resident #1 was using the bathroom and Resident #2 was waiting at the bathroom door for him to finish. When Resident #1 left the bathroom, Resident #2 hit him on the head with his cane, causing a hematoma on the back of his head. When Resident #1 was asked what happened he stated, that man attacked me and hit me on my head. Resident #1 was offered ice packs to help reduce the swelling on two separate occasions, but he declined. There was no conclusion of the investigation, and nothing documented to indicate additional interventions were put in place, to prevent further physical altercations. During an observation on 06/07/19 at 12:35 PM, Resident #1 was sitting in the hallway by the dining room, eating lunch. Other residents were sitting next to Resident #1; all residents appeared calm and interacted appropriately. Resident #2 was observed sitting on the edge of his bed in his room, with his lunch tray set up in front of him. When interviewed, neither resident recalled the incident. During an interview on 06/07/19 at 12:25 PM, Staff A, Social Services, stated residents with behaviors had behavior monitors and interventions in place. Staff A stated residents were reviewed at least quarterly, to evaluate their behaviors and ensure interventions were appropriate and effective. Per Staff A, when a resident was new to the facility, such as Resident #2, they were given time to adjust before a review of behaviors was done. Staff A stated with the incident between Resident #1 and Resident #2, it appeared the residents met at the bathroom door, and Resident #2 hit Resident #1 with his cane. She stated the residents were no longer roommates, and stated Resident #2's new roommate did not get up to the bathroom, so there wouldn't be a similar incident happening again. During an interview with Staff B, Registered Nurse, on 06//07/19 at 12:45 PM, he stated Resident #2's behaviors included being resistive to cares, and when in a noisy environment, he would become verbally aggressive towards others. Staff B went on to say when Resident #2 was startled, he would come up with fists clinched. On 06/07/19 at 1:00 PM, Staff C, Nursing Assistant, stated Resident #2 had aggression issues, including chasing after both residents and staff. Staff C stated the resident's behaviors had been that way since admission. She also stated Resident #2 used to have a cane, however, he would try and hit people with it, so no longer had it. On 06/14/19 at 9:00 AM, Staff D, Director of Nursing, stated on the day of the incident, Resident #2 had an outburst, which led to Resident #1 hitting him in the head with a cane. Staff D stated prior to the incident, the roommates had no issues. When asked about a conclusion to the investigation, or what was implemented to prevent further altercations, Staff D stated the unit currently did not have a resident care manager, so a conclusion was not assessed. Staff D stated she would determine additional preventative measures. Reference: WAC 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to ensure one of six sample residents (#1), reviewed for abuse/neglect, was free from a physical restraint during an incident of behavioral escalation. As a result of manual physical restraint by a staff member, the resident experienced actual harm, as evidenced by increased anxiety, and a skin tear to the left lower arm. Findings included . Review of the facility policy titled, Use of Restraints, revised 04/17, showed, Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body, that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Additionally, the facility restraint policy showed: -Restraints shall only be used to treat the resident's medical symptom (s). -Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. -Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). -Restraints shall be used in such a way as not to cause physical injury to the resident. -Emergency use of restraints require authorization from the Director of Nursing and notification to the Attending Physician. Per record review, Resident #1 was admitted to the memory care unit at the facility on 01/03/17, with [DIAGNOSES REDACTED]. Review of Resident #1's 10/04/18 behavior management care plan showed the resident had the following behaviors: increased agitation, combativeness, confusion, and verbal aggression. In response to these behaviors, staff were directed by the care plan to: approach the resident in a calm, unhurried manner, give one step directions, do not rush, give the resident time to respond to the request, and if Resident #1 seemed agitated, offer a snack, coffee and/or cocoa. Review of Resident #1's most recent comprehensive assessment, dated 11/27/18, showed the resident had severe cognitive impairment, and behaviors consistent with the admitting [DIAGNOSES REDACTED]. Resident #1's wound assessment, completed with the comprehensive assessment on 11/27/18, showed the resident did not have any skin impairments. Review of a facility incident report on 01/20/19 at 8:10 AM, showed Staff B, Registered Nurse (RN), heard a cup fall to the floor in the dining room. When Staff B entered the dining room, Staff C, Nursing Assistant Certified (NAC), was struggling with (Resident #1), holding (Resident #1) by (the) wrists. Staff B instructed Staff C to release (Resident #1) and step away. Staff C stated, (Resident #1) threw a glass of milk on me. Per the report, Staff B observed Staff C with a scratched left cheek and arms, and Resident #1 with a wound on the left forearm. No documentation was present in the facility investigation, showing the authorization for routine or emergency use of restraints (i.e., the staff member manually restraining Resident #1). Review of a progress note, written by Staff B on 01/20/19 at 9:57 AM, showed Resident #1 sustained a skin tear on the left forearm, measuring approximately 2.0 cm. x 2.5 cm. (centimeters). Further review of a progress note, written on 01/20/19 at 10:21 AM by Staff B, showed Resident #1's skin tear occurred during an altercation with a NAC. Per the note, Staff B provided first aid to Resident #1's skin tear, and documented the wound was only approximated (placed back into alignment) at 75%. In an observation on 01/25/19 at 12:35 PM, Resident #1 was sitting in the dining room in the memory care unit. The resident's left arm had a wound, consistent with a healing skin tear. The wound was open to air, and the wound edges were not well approximated. In an interview on 01/25/19 at 12:50 PM, Staff D, NAC, stated that the facility provided education during the orientation process on how to manage residents living in the memory care unit. Staff D said to de-escalate a situation, they are instructed to back away from residents that are combative, and report the behavior to the nurse on duty. In an interview on 01/29/19 at 9:22 AM, Staff E, RN, stated if a resident was lashing out she would give him/her space, and not force care or cooperation. In an interview on 01/29/19 at 9:28 AM, when asked about an injury, Resident #1 pointed to a wound on the left upper wrist/left lower arm. The resident was unable to recall the events that led to the injury. On 01/31/19 at 10:45 AM, in a phone interview, Staff B, RN, confirmed Resident #1 had a history of [REDACTED]. Per Staff B, following the incident, Resident #1 sustained a skin tear to his left forearm. Staff B further stated Resident #1 did not have any wounds prior to the incident. Staff B also stated Resident #1 did not have any medical conditions, restraint pre-assessments, or physician orders for restraint use, prior to the incident on 01/20/19. Staff B stated that it was not the expectation for staff to use physical force with residents, in any situation. Staff B did not recall an intervention on Resident #1's care plan to use a physical restraint. Staff B stated that Resident #1 rarely had any type of negative behavior with calm people. Staff C was unavailable for an interview, due to being terminated from the facility. Reference: (WAC) 388-97-0620(1) Refer to: CFR 483.40(b)(3), F-744 - Treatment/Services for Dementia -1060(1)

Based on observation, interview, and record review, the facility failed to ensure nursing staff provided pain medication in a timely manner to one of four sample residents (#1), receiving narcotic pain medication. This failed practice resulted in harm to Resident #1, who experienced increased pain and emotional distress, due to a delay in receiving his pain medication, upon request. Findings included . According to a facility assessment, dated 12/07/18, Resident #1 had [DIAGNOSES REDACTED]. The assessment showed the pain was described as frequent, limited his activity, and made it hard to sleep. Review of physician orders [REDACTED].)/325 mg. tablet, to be given every 6 hours as needed for pain. The order for the as needed narcotic pain medication was discontinued on 12/11/18, and an order was received for it to be given routinely, every 6 hours. On 01/09/19 at 2:55 PM, Resident #1 was observed in a wheelchair in his room. He stated he had a problem with a nurse, Staff A, who no longer worked at the facility. He stated he took [MEDICATION NAME] for pain, and was to get it every 6 hours as needed. He went on to say when Staff A was working, he would ask for the medication, and would be told it wasn't time yet, or go back to your room. Per the resident, this would happen whenever Staff A worked. Resident #1 stated he told the Administrator, Staff B, and was told to call him if the problem happened again. Resident #1 stated it happened again, so on a Saturday night, he called and reported it to Staff B. After the incident, the resident stated he was set up on an every 6 hour schedule to receive the pain medications. I don't know why he didn't like me (referring to Staff A). The resident stated when he didn't receive his pain medication on time, his pain level would be anywhere from a 7 to 10 (on a scale of 0 - 10, with 0 being no pain, and 10 being severe pain). I got fearful, scared he would slip me something. Resident #1 stated he felt Staff A's actions were abusive. Review of the facility investigation, dated 12/17/18, identified Resident #1 had reported to Staff B, Administrator, that Staff A continually did not give him his pain medications when requested. The resident was interviewed by the investigator, who confirmed the statements. The resident reported Staff A would make him wait an hour or more to receive scheduled pain medication. Per the investigation, Resident #1 stated Staff A would often say you'll get it when I give it to you. Resident #1 reported if he was not on his 6 hour routine with pain medication, it screws him up and made him hurt. According to the investigation, abuse/neglect were ruled out, due to Staff A administering pain medication within the parameters of the orders. It was determined Staff A was unprofessional, and his employment was terminated. During an interview on 01/14/19 at 2:30 PM, Staff C, Nursing Assistant, stated she had worked with Staff A. She stated she would report to Staff A when a resident had pain, and sometimes when she went back into a resident's room, they would say they never received any pain medication. On 01/14/19 at 2:40 PM, Staff D, Licensed Practical Nurse, stated she had residents voice concerns about not receiving medication when Staff A worked. Staff D stated the residents would say they finally received the medication, but only after a prolonged time. Staff D stated she had reported it to administration. Staff F, Investigation Nurse, on 01/15/19 at 3:15 PM, stated he had heard staff saying Staff A was reluctant to give narcotics, but had not heard concerns from residents, prior to this issue. He stated abuse/neglect was ruled out because the scheduled narcotics were given within the legal time frame. Staff F stated Staff A's employment was terminated because of customer service. When asked what the legal time frame meant, in reference to giving narcotic pain medication, Staff F stated he referred the investigation to the Administrator. On 01/15/19 at 4:00 PM, Staff B, Administrator, stated sometimes residents would come to him with concerns. Staff B stated Resident #1 had reported to him one day, on rounds, that Staff A was not giving pain medication on time. Per Staff B, Resident #1 never stated it was on purpose or neglectful. A second time, on a weekend, Resident #1 called him to say Staff A was not giving him his pain medication on time, but eventually would administer it. Per Staff B, the resident felt safe, and no allegation of abuse/neglect was made, so it was given to the investigative nurse to look into, when he returned to work after the weekend. On 01/15/19 at 4:00 PM, Staff D, Director of Nursing, was asked what was meant by administering medication within a legal time frame. Staff D stated when a medication was scheduled, then it could be given an hour before or an hour after it was due. When asked about the expectation of administering narcotic pain medication, Staff D stated pain medication should be administered as soon as a resident requested it, as long as it was time for another dose to be given. Reference (WAC) 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to identify, consistently assess, and provide timely interventions related to pain managment, for two of five sample residents (#79, #125), reviewed for pain, in a sample of 33. This failure placed the residents at risk for a decreased quality of life, and resulted in an Immediate Jeopardy situation for Resident #79, who experienced extreme distress related to the facility failing to recognize and address pain as a potential indicator of her increased behaviors. Findings Included: The State Agency informed the facility on 11/07/17 at 4:00 p.m. of the Immediate Jeopardy situation. The facility initiated a plan immediately to correct the situation, including having the resident evaluated by the physician, provided an all staff education on verbal and non-verbal signs and symptoms of pain, and updated their policy and procedures on pain management. On 11/08/17 at 9:00 a.m., the facility was notified of the abatement of the immediacy. According to the State Operations Manual (03/08/17, p.173) nonverbal pain indicators included verbalizations such as screaming, facial expressions such as grimacing, frowning, fright or clenching of the jaw, behavior such as resisting care, irritability or depressed mood, and loss of function or inability to perform Activities of Daily Living. Additional nonverbal pain indicators include guarding a limb or other body parts, as well as difficulty eating or loss of appetite. 1. Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 08/08/17 admission assessment, the resident was severely impaired in cognition for daily decision-making. The assessment further showed she was independent with supervision in transfers, ambulation, personal hygiene, and eating. The resident was also assessed, upon admission, to have occasional pain which was mild in nature, and was not being administered any routine scheduled pain medication. A potential alteration in comfort care plan, related to her [MEDICAL CONDITION], occasional headaches, and poor communication skills, was developed on 08/01/17. The goal for the resident was to demonstrate or voice an increased level of comfort. Care plan interventions to acheive pain relief included: staff to ask the resident the type, position, and frequency of pain, and to monitor for medication effectiveness. The care plan indicated the resident was sometimes able to use the zero to ten pain scale (zero being no pain, and ten being the worst pain). Additionally, the staff were to assist the resident with non-medication interventions to achieve pain relief. The care plan did not specifically identify for staff specific non-medication interventions to try, related to pain management. A mental health committee meeting note, dated 10/17/17, indicated during the previous two weeks, Resident #79 had some medication changes. The note showed the resident was having some sedation with the new medications, however, was also having frequent loud outbursts and seemed out of control. The report documented she seemed to be in pain at times, but was unable to specify where (because of her cognitive status). According to the report, the nurse practitioner wrote an order for [REDACTED]. A review of the nurse's progress notes from 10/17/17 to 10/25/17 indicated the resident did not show any verbal or non-verbal signs of pain, however, a review of the behavior monitoring sheets showed the resident continued with behaviors which included being resistive to care, being verbally/physically abusive, having socially inappropriate/disruptive behaviors, and exhibiting delusions and hallucinations (false beliefs that usually involve a misinterpretation of perceptions or experiences, and seeing and/or hearing things that are not there). The facility did not assess whether these behaviors could have been non-verbal pain indicators. According to the Medication Administration Record [REDACTED]. No other as needed Tylenol was documented as having been given until 10/25/17. A fall investigation report, dated 10/25/17, showed the resident tried to stand up from a chair, and fell to the floor, hitting her face. The resident sustained [REDACTED]. A subsequent review of the progress notes showed on 10/27/17, the resident was growing more care resistive, refused to take her bedtime medications, and screamed loudly whenever she was touched, or when care was given. She required encouragment from staff to eat and drink, and had a poor appetite and decreased fluid intake. There was no documentation to show pain had been assessed as a potential factor for the increased behaviors, and according to the MAR, the as needed Tylenol had not been administered. Progress notes from 10/28/17 through 10/31/17 showed the resident continued with screaming when she was touched, or when care was provided by staff, as well as displaying agitation and combativeness. There was no nursing assessment to show pain was considered as a potential factor for the increased behaviors, and no administration of additional Tylenol (to see if it decreased the behaviors). On 10/31/17, the mental health committee met, and identified the resident was having increased behaviors. [MEDICATION NAME] (an antipsychotic medication) was ordered. There was no documentation which showed the resident was evaluated for possible pain or other medical factors, which could have caused the increased behaviors. In reviewing the MAR indicated [REDACTED]. A review of the progress notes from 10/31/17 to 11/03/17 indicated the resident continued with screaming when touched and resisting cares when given by staff, being verbally aggressive, and was refusing to eat, when encouraged, despite having started a medication to specifically treat these behaviors. There was no documentation the resident was evaluated for potential pain due to the increased behaviors, nor did the MAR indicated [REDACTED]. The resident continued to receive medications for anxiety and behaviors. In multiple random observations of Resident #79, from 11/01/17 through 11/07/17, when the resident was not being transferred or provided cares by staff, she was observed to be asleep, and did not show signs or symptoms of pain indicators, including screaming or yelling out. In an observation on 11/03/17 at 9:16 a.m., Resident #79 was taken by staff to lie down. Staff M and Staff N, Nurse Assistants, transferred the resident out of her wheelchair, and she was heard to yell out as they sat her onto the bed, and again as she was turned to lay down. The yelling stopped after the resident was lying down and staff left the room. In an interview on 11/03/17 at 2:29 p.m., Staff M was asked why she thought the resident yelled out when she was touched during transfers, or when she was provided care. She stated the yelling out was a behavior, however, she yelled out the most when you touched her or transferred her to the bed or wheelchair. Staff M further stated she would let the nurse know if she suspected pain, and was aware there was medication available if she should need it. In an interview on 11/03/17 at 2:32 p.m., Staff O, Nurse Assistant, was asked why she thought the resident yelled out. She stated the resident may be dizzy, or sometimes she may be scared. The direct care staff, through interviews, stated they thought the yelling and screaming was more of a behavior, and did not indicate pain could be a contributing factor. In an interview on 11/04/17 at 2:51 p.m., the resident's daughter was asked why she felt her mother screamed out when transferred or provided care. She stated she felt her mother was in pain, and had even heard her scream. The daugher stated there was one time, after a fall, she had touched her mother's arm, and remembered her mother saying, Ow, that hurt. The daughter was asked if the facility had talked with her about her pain interventions. She stated no, she could not remember if they did or not. In an interview on 11/06/17 at 8:45 a.m., Staff P, Nurse Assistant, was asked if she was aware of any pain complaints, or signs and symptoms that could indicate the presence of pain with Resident #79. She stated that was a hard question to answer, and she was not sure whether it was pain or a behavior. Staff P stated when Resident #79 was in pain, her eyebrows would go up, and she would grimace. She stated she did not believe the resident was able to verbalize pain consistently, and Staff P said she lets the nurse know when she feels the resident is in pain. In an interview on 11/06/17 at 8:58 a.m., Staff Q, Nurse Assistant, stated the resident screamed a lot when cares were provided, however, did not know half the time if the resident was in pain or if it was just a behavior. Staff Q further stated the resident screamed out whenever we go near her. She stated the resident was at times able to say ouch, but sometimes cannot, and verified the screaming was getting worse. In an interview on 11/06/17 at 2:06 p.m., Staff K, Resident Care Manager, was asked if any pain assessments had been done, to determine if pain was a potential indicator for Resident #79's behaviors, especially after the five falls. He stated the facility did not do any formal pain assessments other than at the time of the admission assessment. Staff K stated, at the time of the admission assessment, the resident was able to tell them herself about her pain, and was able to indicate she had occasional mild pain, mostly from headaches. Staff K was asked if he had observed the resident during a transfer, and heard the screaming and yelling out; he stated no. Staff K stated when he had gone in to see the resident earlier that morning, she was sitting up and smiled at him (he indicated, upon questioning, that no cares were being provided at the time). In an observation on 11/06/17 at 4:10 p.m. Staff R, Licensed Practical Nurse, and Staff X, Nurse Assistant, lifted the resident from the wheelchair, and laid her down in bed. The resident screamed during the transfer. Her skin color was pale, her eyes remained closed throughout the transfer, and her chin and lower lip were shaking. The resident quieted after she was put in bed. In an interview on 11/07/17 at 9:22 a.m., Staff C, Nurse Practitioner, was asked about the resident's behaviors, and if pain had been considered as a potential causal factor. Staff C stated Resident #79 had pain medication available, as she was admitted with chronic pain issues. She stated in October 2017, the staff told her the resident hurt all over. Per Staff C, she then watched the resident ambulate with two staff, and she complained about pain. Staff C stated she then wrote an order for [REDACTED]. Staff C was asked if she had witnessed Resident #79 being transferred, and heard her screaming; she stated no. She further stated in the mental health meetings, staff did not make it clear to her that the resident's behaviors could be pain related, nor had they mentioned anything to her about the screaming during transfers, only that the resident was resistive to cares. Staff C was asked why pain issues were not addressed in the mental health meetings, as a possible reason for the behaviors. She reiterated she was unaware the resident was having signs or symptoms of possible pain. In an observation on 11/07/17 at 11:42 a.m., Staff C, Staff K, and the surveyor, observed Resident #79 transferred from the bed to the wheelchair. Staff T, Nurse Assistant and Staff S, Nurse Assistant, transferred the resident to a sitting position on the side of the bed; the resident yelled out. While the resident was sitting on the side of the bed, she buried her face into the upper arms of the staff, who were on each side of her, and was quivering. As she was moved from the bed to the chair, she screamed. After the resident was taken to the dining room, the surveyor and Staff C knelt down beside the resident. The surveyor asked the resident if she had any pain in her arm, as she was cradling it. The resident stated, yes and started to cry. The resident was asked if her pain was really bad or just mild. The resident tried to answer, however, her words did not make sense, and she continued to cry. After hearing the conversation and the resident's statement, Staff C stated she would obtain x-rays of her forearm, elbow, and shoulder, and schedule an increase in her pain medication. The facility failed to recognize and assess pain as a possible factor for the Resident #79's decline in condition (from independently ambulating to wheelchair bound), and increased behaviors. Observations of Resident #79 screaming, yelling out, and displaying signs of fear during transfers met the definition of having verbal and non-verbal pain indicators. For additional information, refer to: F-323; Accident Harzards and Supevision; and F-329; Unnecessary Medications. 2. According to the admission assessment dated [DATE], Resident #125 was cognitively intact. The assessment showed the resident had almost constant pain which made it hard to sleep, and limited his daily activities. In an interview on 11/02/17 at 9:01 a.m., when asked whether he had pain or discomfort, Resident #125 stated he had constant pain in his hip and leg. Review of the physician's notes revealed Resident #125 complained of pain on 08/10/17, and the nurse practitioner ordered medication changes and a neurosurgery referral. A note dated 08/17/17, from the neurosurgery office, showed the resident had a new prescription for steroid (anti-[MEDICAL CONDITION]) medication, and instructed, He is to call in 1 week to let me know if steroid helped. Review of the Medication Administration Record [REDACTED]. The nursing progress notes from the end of the steroid cycle time period did not note whether the medication was effective for the resident, and did not mention whether Resident #125 or the facility had contacted the neurosurgery office, after completing the doses. In an interview on 11/08/17 at 3:27 p.m. Staff H, Registered Nurse, looked through the resident's record, then confirmed she did not see if the facility knew whether the resident called back, or if the facility called the provider back, to discuss the effectiveness of the medication. Staff H stated the resident still complained of left leg pain; it was an ongoing problem him. When asked whether there was any documentation to show the facility monitored the effectiveness of the medication for Resident #125, or any additional follow up, she stated she did not see that. Reference: (WAC) 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to consistently review causal factors, and implement care plan interventions to prevent falls, for one of three sample residents (#79), who were reviewed for falls. This failure led to a number of falls, which occurred over a 6-week period, and led to bruising, a nosebleed, and abrasions, as well as a decline in overall function for Resident #79. Findings included: According to the admission assessment, dated 08/08/17, Resident #79 had [DIAGNOSES REDACTED]. The assessment also showed the resident was severely impaired in cognition for daily decision-making. Additionally, she required supervision to limited assistance with most activities of daily living, including transfers and ambulation, and had not sustained a fall in the six months prior to admission, or during the first eight days after admission to the facility. A potential for injury care plan, dated 08/01/17, was developed due to her dementia and possible history of falls, at the time of admission. The goal was for the resident to not have any new unassessed risks for falls. Interventions to prevent falls included doing a post fall assessment and/or interventions, as indicated. Staff was instructed to report signs and symptoms or complaints of dizziness, when rising, to the nurse for follow-up. According to a fall investigation report, dated 09/07/17, the resident sustained [REDACTED]. The report showed her legs became shaky, and she fell to the floor onto her left side; there were no signs or symptoms of injury. The root cause was identified as bending down to floor to pick up something on the floor. The care plan was reviewed by staff, determined to be appropriate, and no changes were made. According to a fall investigation report, dated 09/14/17 (seven days later), the resident sustained [REDACTED]. The report further indicated that prior to the fall, the resident had been confused, angry, and had been leaning to the right when ambulating. The root cause was identified as rolled out of bed. There was no fall assessment, per the care plan, to rule out reasons why she rolled out of bed (i.e., unmet needs to include toileting, pain, or thirst). The care plan was reviewed by staff, determined to be appropriate, and no changes were made to prevent further falls. On 09/15/17, progress notes showed the resident was moved from the general care area to the secured memory care unit, related to an increase in wandering and exit-seeking behaviors. According to a fall investigation report, dated 09/25/17 (ten days after the previous fall), the resident stumbled over another resident's wheelchair, and fell on to her knees. She was carrying a bowl of food for another resident when the fall occurred. No signs or symptoms of injury were noted at the time.The root cause was identified as the resident was wandering and restless. A plan to prevent further falls for Resident #79 included keeping other residents who were in wheelchairs, away from walkways. There was no documentation on the report which indicated an assessment of why the resident was wandering and restless. The resident's care plan was reviewed, determined to be appropriate, and no changes were made to prevent further falls. A fall assessment was documented as having been done, however, according to the checklist, there was no diagnostic work done, updated physician's orders [REDACTED]. A nursing progress note, dated 09/26/17 at 4:10 a.m., indicated a bruise was observed on the resident's right forearm, which might have been from the fall. The bruise was described as purplish in color, and measured 7.0 centimeters (cm.) x 3.0 cm. in diameter. A nursing progress note, dated 09/26/17 at 10:27 a.m., noted the bruise on the right forearm, close to the wrist, which could have been related, to the fall on 09/25/17. The progress note further documented the resident continued to wander in the dining room. According to the fall investigation report, dated 10/09/17 (14 days later) the resident had a fourth fall. The report showed the resident fell on to her right side while in the activity/dining room. Staff had witnessed the fall, and stated the fall was unavoidable (there was no other description to show why this determination was made). The resident sustained [REDACTED]. The root cause was determined to be the resident was impulsive, and stood up quickly from a sitting position in her chair, which precipitated the fall. The care plan was reviewed, determined to be appropriate, and no further updates or changes on how to keep the resident from falling were made. A fall assessment was not done, to show other possible reasons the resident fell . A review of the investigation checklist did not show diagnostic work, physician's orders [REDACTED]. A nursing progress note, dated 10/15/17 at 4:07 p.m. (6 days later) showed the resident complained of pain in her right hip. A bruise was found, which measured 4.0 cm. x 2.0 cm., and was purplish in color. Per the note, the resident was also leaning to the right side when sitting in a chair. The physician was notified, and x-rays were ordered to rule out a fracture (which were negative). According to a fall investigation report, dated 10/25/17 (16 days later from the previous fall) Resident #79 sustained her fifth fall. She was sitting in her wheelchair, in the memory unit dining room, when she tried to stand up, fell , and hit her face on the floor. She sustained bruises to her right forehead, both sides of her nose, and had a nosebleed. An analysis of causal factor(s) were not identified; only documentation the resident was unsteady with walking and standing. Per the report, interventions included to get an order for [REDACTED]. The resident's care plan was reviewed, and documented as appropriate. The report indicated there were changes in the resident's mobility and balance, however, the care plan was not updated with interventions on how the facility would keep her safe, and prevent further falls. On 10/27/17 (six weeks after the first fall), a fall risk reduction program was developed for Resident #79. The plan indicated the resident now had a decline in her ability to safely ambulate; she was unsteady and had a couple of falls. The record showed the resident was not safe to ambulate on her own at that time, did not realize she needed help at times, lacked safety awareness, insight, and may continue to get up on her own. Interventions included: having the bed against the wall, having the bed in it's lowest position, and having the resident wear non-skid socks. Additionally, staff were to attempt to assess why she was getting up such as; needing to go to the bathroom, being hungry/thirsty, in pain, or wanting to go back to bed. Additionally, staff were directed to not just tell her to sit down, to offer to walk her when she was restless, and to try and meet her needs. The intervention of the wheelchair not having footrests, to prevent tripping if she should get up, was also added. See F-309: Provide Care/Services for Highest Well Being, for more information In an observation on 11/03/17 at 8:22 a.m., Resident #79 was observed with healing bruises on both cheekbones. At 9:16 a.m., the resident was transferred from the wheelchair to bed. The bed was not against the wall, per the fall reducation program. During the transfer, the resident was observed to scream out when the nurse assistants transferred her. There was no pull-alarm observed on the resident's wheelchair (an intervention which was identified as being considered on the 10/25/17 investigation report). On subsequent observations from 11/03/17 to 11/07/17, the resident's bed was not placed against the wall, as per the injury prevention plan. In an interview on 11/04/17 at 2:51 p.m., the resident's daughter stated when the facility had called her on 10/15/17, to discuss the need for getting x-rays due to bruising, she asked them to also x-ray the right forearm, because of complaints of pain in that area. She was asked if the staff talked with her about getting a referral for physical therapy. She stated yes, however, she had told them that in the past, her mother had been non-compliant with therapy but, they could try. A review of the clinical record did not show the right forearm was x-rayed per the daughter's request, a physician's orders [REDACTED]. In an interview on 11/06/17 at 8:51 a.m., Staff P, Nurse Assistant was asked if the resident had any falls in the facility, and what the current interventions were to keep her safe. She stated the resident had quite a few falls, her bed was to be locked, and in the lowest position at all times. Staff P further stated the resident was now using a wheelchair, since about two weeks prior, and she did not feel her care directive had been updated yet. Staff P was asked if the resident had a pull-alarm; she stated no. In an interview on 11/06/17 at 2:06 p.m., Staff K, Resident Care Manager, stated the resident has had five falls since admission. He stated in a couple instances, her legs just gave out, and she sustained some abrasions. Staff K further stated the resident had been ambulating independently, up until the fall. Staff K was asked if the care plan had been updated, after each fall, to include interventions to keep her from falling. He stated they had developed the fall risk reduction program on 10/27/17, to address the falls. Staff K further stated Resident #79 was due for a quarterly assessment, and fall prevention would also be reviewed at that time. Staff K was asked what a fall assessment included. He stated fall assessments were not done per se, however, the nurse would assess the resident after falls, to ensure they were not injured, or to provide first aid. In an interview on 11/07/17 at 9:22 a.m., Staff C, Nurse Practitioner, stated the resident has had five falls since her admission, and said balance issues seemed to be the main theme. She stated she had seen the resident leaning to the left more. Resident #79 had experienced five falls, in a six week timeframe, since her admission on 08/01/17. There were no effective care planned interventions made, at the time of the falls, to prevent further falls or injury. The resident had a decline in her overall function, going from independently ambulating to being wheelchair bound. See F-329; Unnecessary Medications for more information. WAC: 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure adequate indications were present prior to starting an antipsychotic medication for one of five sample residents (#79), who were reviewed for unnecessary medications. The facility failed to thoroughly assess the possible causes of behaviors, but instead gave Resident #79 additional medications to control behaviors, which resulted in harm and subsequent decline in her condition. Findings included: According to the State Operations Manual (03/08/17 pg. 189) , When antipsychotic medications are used without an adequate rationale, or for the sole purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective, and they commonly cause complications such as movement disorders, falls, [MEDICAL CONDITIONS] adverse events ([MEDICAL CONDITION] and transient ischemic events) and increased risk of death. 1. According to the admission assessment, dated 08/08/17, Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment showed the resident was severely impaired in cognition for daily decision-making, had fluctuating inattention and disorganized thinking, delusions (false beliefs that usually involve a misinterpretation of perceptions or experiences), and wandered on a daily basis. Additionally, Resident #79 required limited assistance to supervision for most activities of daily living. She was frequently incontinent of bladder, and occasionally incontinent of bowel. Her admission weight was documented as 93 pounds, and she had not been administered an antipsychotic, antidepressant, or antianxiety medication during the seven day look-back period. A review of the August 2017 physician's orders [REDACTED].) two times daily, for a [DIAGNOSES REDACTED]. The resident also had an order for [REDACTED]. A review of the nursing progress notes indicated the resident was alert, confused, oriented only to her name, and had exit-seeking behaviors. There was no documentation in the nursing progress notes, as to a specific reason why the [MEDICATION NAME] was increased on 08/04/17. A behavior management plan was developed on 08/08/17, directing staff of interventions related to Resident #79's behaviors. At that time, there was no documentation the resident's representative consented to the behavior plan as written on the form, nor was a consent for the use of the [MEDICATION NAME] and [MEDICATION NAME] Sprinkles signed by the representative, indicating she had been informed of the risks and benefits by the nursing staff. According to a fall investigation report, dated 09/07/17, the resident had sustained a fall, as she bent down to pick up a washcloth off the floor. The report showed Resident #79 was an independent ambulator, and was generally stable with good safety awareness. The care plan was reviewed and deemed appropriate, so no changes occurred at that time. On 09/14/17 (seven days later), according to the fall investigation report, the resident rolled out of bed, and fell to the floor on her right side. She complained of pain in her right hand and right leg. The report stated she was independent with activities of daily living, had dementia and could be disoriented at times, however, it appeared to be an isolated incident. A review of the September 2017 behavior monitoring sheets showed the resident's behaviors had increased after this fall, with multiple entries from staff, from 09/17/17 to 09/30/17, of being resistive to cares, verbally abusive, physically abusive with aggressive behaviors, socially inappropriate/disruptive behaviors, delusions, and hallucinations (seeing and/or hearing things that were not there). Despite the increased behaviors after the second fall, there was no care plan revision or update. The behavior managment plan was unchanged. On 09/19/19, Resident #79 was reviewed in the mental health committee regarding her behaviors, and medications since admission. The committee reviewed the documentation and the provider agreed to increase her dose of [MEDICATION NAME] to 250 mg. two times daily. In addition, Trazadone (an antidepressant used to treat anxiety and [MEDICAL CONDITION]) had been initiated. There was no documentation in the meeting notes which indicated the committee reviewed other possible medical factors or pain, as a cause of her increased behaviors. On 09/29/17 (seven weeks after admission) the resident's representative consented to the use of [MEDICATION NAME] and Trazadone, and was made aware of the behavior management plan, as outlined on 08/08/17. According to a 09/25/17 fall investigation report, Resident #79 fell for the third time. This fall occurred approximately 11 days after the previous fall. The report stated she had been restless and was wandering at the time of the fall. There were no changes made to the care plan, no evaluation to determine if a medical factor, the increased dose of [MEDICATION NAME], or the addition of Trazadone had been contributing factor(s) to her falls. On 10/03/17, the provider reviewed the previous two week behavior documentation, and ordered an increase in the as needed dose of Trazadone, and the [MEDICATION NAME] was increased to 500 mg. two times daily. Documentation indicated the resident was having sun-downing symptoms (a symptom of dementia where confusion and agitation worsens in the evening) as the resident was becoming increasingly aggressive in the afternoon/evening. On 10/09/17, per the fall investigation report, the resident fell for the fourth time, approximately 14 days after the previous fall. The report indicated the resident had fallen onto her right side, and sustained an abrasion to her right arm. The report stated she was impulsive and stood up abruptly, lost her balance, and fell . Documentation in the progress notes at that time indicated Resident #79 was having increased high blood pressure and medication changes, however, there was no assessment of the adverse side effects of the increased [MEDICATION NAME] or Trazadone as possible contributing factors to the fall. (See F-309: Provide Care/Services for Highest Well Being, for more information.) On 10/25/17 (eight days after the last fall) documentation showed the resident, who was now using a wheelchair, tried to stand up and fell to the floor, hitting her face. She sustained bruises to her right forehead and nose, and had a small nose bleed. The report noted the resident had changes with her mobility and balance, however, no evaluation was done to determine if the medications were a factor for the repeated falls. Documentation indicated on 10/31/17, the [MEDICATION NAME] would be decreased back to 250 mg., the Trazadone continued at bedtime, and the additon of [MEDICATION NAME] (an antipsychotic medication) two times daily (in addition to her other medications). According to documentation, the resident was having behaviors related to her dementia which included resisting care, verbal and physical aggression, socially inappropriaten behavior, delusions and hallucinations. These behaviors were documented as occurring on a daily basis. There was no documentation in the record to indicate the resident had been reassessed for other causal factors, prior to starting an antipsychotic medication with possible severe side effects. According to the Nursing 2016 Drug Handbook (Wolters Kluwer, p. 1217), [MEDICATION NAME] carried the following Black Box warning: Drug isn't indicated for use in elderly patients with dementia-related [MEDICAL CONDITION] because of increased risk of death . Additionally, per the drug handbook, the drug carried potential side effects including somnolence (sleepiness), agitation, and anorexia (lack of appetite). In an observation on 11/03/17 at 9:16 a.m., Resident #79 was taken by staff to lie down. Staff M, Nurse Assistant and Staff N, Nurse Assistant, transferred the resident from her wheelchair to the bed (she now required one to two staff to transfer from the bed or wheelchair). During the transfer, the resident was observed to yell out. In an interview on 11/03/17 at 2:29 p.m., Staff M, Nurse Assistant was asked why she felt the resident screamed out when being transferred or provided care. She stated it was a behavior of hers, however, she yelled out the most when she was transferred or touched. In multiple observations of Resident #79 from 11/03/17 to 11/07/17, she slept most of the time either in her wheelchair, or in bed. She was not an active participant in the unit activities. Staff either encouraged her to eat (they needed to wake her up for the mea), fed her the meal, or the resident missed the meal altogther, due to being asleep in bed and refusing to get up. On 11/03/17 at 2:15 p.m., Staff N and Staff O, Nurse Assistants, weighed the resident. The weight was documented as 94.2 pounds which indicated a significant weight loss of 7.6% from her weight on 10/04/17, which was documented as 100 pounds. In an interview on 11/04/17 at 2:51 p.m., the resident's daughter stated she felt her mother was declining quickly. In an interview on 11/06/17 at 2:06 p.m., Staff K, Resident Care Manager, stated the resident had admitted to the facility with confusion, and it appeared her disease process was progressing. He stated the resident had been admitted on the [MEDICATION NAME] from a previous facility, and remember she had taken [MEDICATION NAME] also, however, it had been discontinued prior to admission for an unknown reason. Staff K admitted the resident had been striking out more, screaming, and had delusions and hallucinations. Staff K was asked if Alzheimers disease was an appropriate [DIAGNOSES REDACTED]. He stated he was not aware of the specific [DIAGNOSES REDACTED]. Staff K was asked what kind of delusions the resident was experiencing. He stated when she first admitted the resident was saying, This is not my home, I want to go home. Staff K was asked if social services was involved in her care. He stated he had just spoken to social services staff that day, about starting a behavioral managment plan, however, she was still working on it. Staff K was asked if the daughter had consented to the use of [MEDICATION NAME], to control her behaviors, and if the risks and benefits had been explained to her; he stated no. Staff K was asked if an AIMS (abnormal involuntary movement scale) had been done, when the resident started on the [MEDICATION NAME], to determine if she had any adverse side effects to the medication; he stated no. On 11/07/17, Staff J, Social Services, gave the surveyor a copy of the updated behavior managment plan for Resident #79. The only difference between the updated plan and the previous plan was the addition of potential pain indicators, due to her difficulty in expressing that she may be in pain. (See F-309 for additional information). In an interview on 11/07/17 at 9:22 a.m., Staff C, Nurse Practitioner, was asked about the clincial indications and rationale for the use of an antipsychotic medication for Resident #79. She stated the resident was having behaviors of scratching, aggression, and agitation towards staff. Staff C was asked if any other interventions were tried, before starting an antipsychotic medication, to rule out a medical reason for the increased behaviors; she stated no, she was not aware of any. On 11/08/17 at 8:30 a.m., Resident #79 was observed seated in her wheelchair in the dining room, independently eating breakfast, using her left hand. She was alert and smiled easily. According to the progress notes, the antispsychotic medications, including the Trazadone, had been discontinued the day before. Resident #79 experienced a decline in overall function, due to the addition of [MEDICAL CONDITION] medications without a clear indication for use. The staff did not try to rule out a medical reason for the increased behaviors, and continued to change and administer the [MEDICAL CONDITION] medications. Resident #79 experienced a significant weight loss in 30 days, with a loss of appetite, and went from indepedently ambulating to requiring a wheelchair and extensive staff assistance for acitivties of daily living. After the medications were discontinued, the resident showed improvement, by being more alert, and feeding herself. See F-323: Accident Hazards and Supervision for more information. WAC : 388-97-1060 (3) (g)

Based on interview and record review, the facility failed to consistently monitor, and report timely to the physician a significant change in condition for 1 of 6 sample residents (#2). This failure resulted in harm for Resident #2, as evidenced by hospitalization for unrecognized symptoms of [MEDICAL CONDITION] (severe infection). Findings include: Resident #2 had [DIAGNOSES REDACTED]. Per record review, the resident was alert, could make her needs known, and required extensive assistance with most activities of daily living. In addition, the resident had stable weight, fed herself, and did not require monitoring of her oral intake. Record review revealed on 11/18/15, the resident sustained [REDACTED]. Staff cleaned the skin, closed the wound edges with Steri-Strips, and applied a protective dressing. A progress note by Staff E, a licensed nurse, dated 11/24/15 at 8:15 p.m. (6 days after the injury occurred), noted a small amount of purulent drainage (pus) and redness at the site of the left leg skin tear, and increased pain. In addition, the resident developed lethargy (sleepiness), decreased appetite, and a fever of 101.2 degrees Fahrenheit (F) in the late afternoon. Per record review, the nurse practitioner evaluated the resident on 11/24/15 and documented the left leg wound appeared tender, with no [MEDICAL CONDITION] (infection), but with a hematoma (collection of blood). He ordered a dressing treatment, including cleaning the left shin wound with normal saline daily, and applying an antibiotic ointment. In addition, he ordered an oral antibiotic for a possible urinary infection [MEDICAL CONDITION]. There was no nursing evaluation of the resident's left leg drainage, pain, or weakness during the evening of 11/24/15, and night of 11/25/15. A progress note by Staff E dated 11/25/15 during the day shift, revealed the left leg skin tear had increased redness, clear drainage, and new drainage around the skin tear. The resident was lethargic, weak, and could not get out of bed to the toilet. The resident ate only bites of oatmeal for breakfast, bites of a frozen supplement for lunch, and drank fluids. Additional record review revealed no information to indicate the physician was notified of the resident's ongoing lethargy, poor intake, and change in appearance of the left leg. Per record review, there was no additional nursing evaluation and/or monitoring of the resident's left leg drainage, pain, or weakness during the evening of 11/25/15, and night of 11/26/15. On 11/26/15 during the day shift, Staff E documented the resident continued to be weak, and the left leg was less warm to touch, with less weeping around the skin tear. The resident again drank fluids, and ate only bites of food. Per record review, on the morning of 11/27/15, the resident again only ate bites of food, refused medication, and requested to sleep. At lunch, the resident's family member(POA)arrived. At that time, Staff E evaluated the resident's leg, and determined the leg was warm to touch, and tender, with new blistering filled with purulent drainage (indicating worsening from 11/26/15). The POA requested the resident be transferred to the hospital. The resident's hospital records revealed on 11/27/15 (the date of admission), the resident [MEDICAL CONDITION] (acute infection), a urinary infection, and a severe, infected skin tear on the the lower left leg. Per the record, the affected area was red, blue, and purple in color, and extended all the way down to the fore foot, measuring approximately 10 inches by 8 inches. The resident required medical treatment for [REDACTED]. Per record review, the facility did not consistently monitor the worsening of the resident's left leg, including the change in size, color, and drainage, which were symptoms of possible infection. The facility did not report timely to the physician the worsening leg wound, and the weakness, lethargy, and poor intake, which the resident had for 3 days prior to transfer to the hospital. The resident was not receiving physician ordered treatment for [REDACTED]. During interview on 12/03/15 at 2:45 p.m., Staff E stated on the morning of 11/27/15, the resident refused medication and wanted to sleep. Staff E confirmed she did not evaluate the condition of the resident's leg until after family arrived about noon. During telephone interview on 12/21/15 at 11:10 a.m., the POA stated when he arrived before noon on 11/27/15, the resident was nodding off, and couldn't wake up. The top sheet was wet, and underneath the leg, there was a stain from the left leg drainage. The left leg was red, and swollen, up to the knee and down the leg to the foot. The POA stated the facility did not notify him of a problem with the resident's left leg until he visited on 11/27/15. During interview on 12/22/15, Staff I stated the facility procedure related to management of non-pressure wounds included staff monitoring and documenting the condition of the skin problem each shift (12 hours shift). Staff I confirmed staff did not consistently document evaluation of the left leg wound. The lack of consistent and timely evaluation, and lack of timely reporting to the physician related to poor appetite, lethargy, and symptoms of wound infection resulted in harm, related to a delay in treatment of [REDACTED].

Based on observation, interview, and record review, it was determined the facility failed to monitor weight loss for 1 of 3 residents (#49), reviewed for nutrition, in a sample of 37. In addition, the facility failed to implement planned interventions, or put additional interventions in place in a timely manner, as the resident contined to lose weight. This resulted in actual harm to the resident, when he experienced a weight loss of 46 pounds in 4 months. Findings include: Resident #49 had [DIAGNOSES REDACTED]. The resident was also identified at risk for malnutrition, and required extensive assistance with most activities of daily living, and supervision with eating. The resident's most recent plan of care (initiated 5/6/14) indicated the resident had a alteration in nutrition, with planned interventions to include: meal monitoring, observation of self feeding, monitoring weight, avoiding foods which could irritate the esophagus, and using adaptive equipment (a large spoon with molded grip and lipped plate). In reviewing the facility weight records, Resident #49 weighed 200 pounds on 4/28/14. On 5/21/14, Staff #A (a Dietician) completed a nutritional assessment, noting the resident's weight fluctuated with [MEDICAL TREATMENT]. The resident's weight was expected to range from 190-200 pounds. Staff #A recommended a weight goal of 190 +/-5 pounds, and indicated she would re-evaluate as the resident's appetite improved. The plan was to continue the current care plan for nutrition, and to monitor weights closely. On 5/25/14 the resident weighed 189 pounds (an 11 pound weight loss). The record was reviewed - there was no dietary assessment to determine causal factors for the loss, or review/revision of the plan to prevent further weight loss. On 6/29/14, the resident's weight was 180 pounds (another 8 pound loss, making a 20 pound total weight loss). On 7/9/14, the Dietician, Staff #A, completed a nutritional assessment (10 days after the most recent weight loss). The dietician updated the care plan to include additional food preferences, but made no other changes. The new goal weight was revised to 180 +/-5 pounds, based on the 6/29/14 weight. The facility had no other weight records from 6/29-8/5/14, despite the fact the resident was losing weight. In addition, there was no other assessment of the causal factors for the weight loss, or new interventions put in place, from 7/9-8/5/14. On 8/5/14, dietary staff documented the resident lost another 13 pounds (from his previous weight on 6/29/14). The Dietician completed a nutritional consultation on 8/11/14, and identified the weight loss as unplanned. A temporary adjustment was made in the food consistency (to make chewing easier). A new goal was to stabilize his weight at 166 +/- 5 pounds. The dietician documented that the intervention of a vanilla ice cream snack in the evening would be added to the care plan. Per record review, this information was not added to the nutrition care plan. In review of the resident's meal monitoring (a document used by the facility to track food/fluid intake), there was no documentation of vanilla ice cream being provided to the resident in the evening. The Resident Care Manager, Staff #B also reviewed the record. He verified that the Dietician identified this intervention in her note, but did not transcribe the information in the form of an order (so that staff would be informed), or add it to the care plan. On 9/9/14 at 12:52 p.m., Staff #C, D, E confirmed the nursing aides do not document evening snacks and there would be no way of monitoring the resident's snack intake. Staff were not able to verify if the staff were aware of, or were providing the ice cream in the evening (in an effort to prevent further weight loss). On 9/9/14 at 12:52 p.m., Staff #B confirmed the facility had not received any current weights from the [MEDICAL TREATMENT] center since June 2014, and there were no facility weights in the record since that time. After questioning from the surveyor, Staff #B requested weights from the [MEDICAL TREATMENT] center. The most recent weight recorded by them was 154 pounds on 9/6/14. This was an additional 13 pound loss that the facility had not identified, or assessed. The resident had lost a total of 46 pounds from 4/28/14 to 9/6/14. The facility failed to monitor and identify the resident's significant weight loss, failed to ensure that interventions to prevent further weight loss were implemented, and failed to put additional measures in place to prevent additional weight loss.