Every finding on record at Enumclaw Health and Rehabilitation

Based on observation, interview, and record review the facility failed to ensure residents were served palatable meals for 6 of 7 sample residents reviewed for food (Residents 8, 50, 4, 28, 52, & 18). The failure to ensure palatable meals were served placed residents at risk for decreased dietary intake, weight loss, and a diminished quality of life. Findings included.<Resident 8> According to the 06/21/2026 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 8 had intact memory and was able to eat independently. The MDS showed Resident 8 had diabetes (a disease making controlling blood sugar more difficult). In an interview on 08/10/2026 at 3:34 PM Resident 8 stated the food the facility served them was bad. Resident 8 stated sometime the meal ticket did not match the food served. Record review showed Resident 8 had a 08/07/2026 order for a controlled carbohydrate diet. Review of the facility's lunch menu for 08/13/2026 showed residents requiring a controlled carbohydrate diet would be served Asian sesame chicken, rice, broccoli, a low sodium broth, and ice cream. Observations of a test tray of the 08/13/2026 controlled carbohydrate lunch at 1:37 PM showed the broccoli had a [NAME] green tint and a pronounced, unpleasant aftertaste. The rice had a rubbery texture. The low sodium broth had a yellow-brown clear appearance, lacked any discernable flavor, and felt watery in the mouth. In an interview on 08/14/2026 at 8:05 AM, Resident 8 stated the prior days lunch was awful. Resident 8 stated the broth tasted like nothing. <Resident 50> According to the 06/13/2026 Quarterly MDS, Resident 50 had medically complex diagnoses including diabetes. In an interview on 08/11/2026 at 7:18 AM, Resident 50 stated they did not like the food they were served. Record review showed a 06/25/2026 dietary order for Resident 50 to have a controlled carbohydrate diet. In an interview on 08/14/2026 at 8:44 AM, Staff G (Dietary Supervisor) stated it was important to serve meals that were palatable for resident satisfaction. Staff G stated they had to follow recipes to ensure appropriate nutrition but were allowed to augment for flavor if the nutrition was not affected. Staff G stated they did not taste the broth served to residents as they were not really a broth person. Staff G stated they could have but did not think to season the broth to improve its flavor. <Resident 4> According to the 06/12/2026 Quarterly MDS, Resident 4 had intact memory and had no vision issue. The assessment showed Resident 4 was independent with all daily needs including eating. In an interview on 08/10/2026 at 10:21 AM, Resident 4 stated the food at the facility was terrible. Resident 4 stated the food served to residents did not taste good. Observation on 08/01/2026 at 8:19 AM showed Resident 4 received breakfast and their toast was very hard. Resident 4 stated they could not eat this hard toast <Resident 28> In an interview on 08/10/2026 at 7:09 AM Resident 28 stated the food is poor at best and never hot. If it's hot there is a surprise. In an interview on 8/12/2026 at 9:32 AM Resident 28 stated that at breakfast the eggs were terrible. <Resident 52> In an interview on 08/10/2026 at 11:07 AM Resident 52 stated the food was not good and the vegetables were mushy. <Resident 18> In an observation and interview on 08/12/2026 at 3:12 PM, Resident 18 had their lunch tray in the room which had a plate with soft, cooked zucchini, cooked carrots, and a piece of meat covered in gravy. Resident 18 covered all the food in black pepper, there was a cup of canned fruit mixed with cream, two bowls of soup, and no drinks on the lunch tray. Resident 18 stated the zucchini was mushy, the food here is terrible, and it is always cold; it arrives cold, so it does not matter if I eat it when it is delivered or eat it now [3 hours after delivery]. Resident 18 stated they stopped eating the hot cereal at breakfast because it was cold and the bowl was only filled halfway. Resident 18 stated they talked with the dietary manager about the cold food served at breakfast and dinner and there has not been any improvement, the food is still cold and still tastes bad. Resident 18 stated they rarely are served any fresh fruit or vegetables and only get a salad about three to five times a month. Resident 18 stated they were served four cubes of melon yesterday and three of the pieces were too hard to chew, so they could only eat one bite of melon. Resident 18 pulled out their cell phone and showed pictures of the plates of food they were served over the past couple weeks: 06/29/2026 6:35 PM the picture showed a rolled tortilla with filling and pieces of yellow lettuce on the side; Resident 18 stated, What kind of meal is that? 07/01/2026 6:28 PM the picture showed rice, four sliced beets, a bread roll, and a piece of chicken smaller than the roll and smaller than the serving of beets; Resident 18 said that serving of chicken was too small. 07/21/2026 6:04 PM the picture showed a noodle casserole with white sauce and cauliflower; Resident 18 stated it was cold and who knows what that pile [casserole] was. 07/25/2026 6:08 PM the picture showed kidney beans, some type of noodle on top of the beans covered with a red/brown sauce; Resident 18 stated, I do not know what that [noodle] was, it was terrible, so I did not eat it. 07/28/2026 6:12 PM the picture showed a bun with a patty of meat, no other toppings, and smashed tater tots; Resident 18 stated, that was what they gave me, it was terrible. 08/04/2026 6:09 PM the picture showed an open sandwich with two pieces of white bread, two pieces of ham, two pieces of American cheese, no other toppings or condiments, three slices of cucumber in a white liquid, two bowls of soup, and a cup of chocolate pudding; Resident 18 stated they did not give me anything to put on the sandwich, the soup was cold, and the pudding does not even fill the bowl. 08/06/2026 1:04 PM the picture showed beans in liquid, and meat in a red sauce, with the food all on one side of the plate. Resident 18 stated, look at how they served that, why is it only on one side of the plate, who does that, I do not know what that meat was, it did not look good, so I did not eat it. In an interview on 08/14/2026 at 8:58 AM, Staff G stated they stated it was important to make sure resident meals were palatable. Staff G stated they met with Resident 18 to try to address the resident's food concerns. REFERENCE: WAC 388-97-1100(1)(2) .

Based on observation, interview, and record review the facility failed to ensure residents were provided care with dignity for 1 of 17 sample residents (Residents 49) shaving in the hallway and another supplemental resident (Resident 18) with dirty urinals at bedside. The failure to ensure residents were not groomed in the hall and to provide clean urinals placed residents at risk for feeling feelings of diminished self-worth and other negative health outcomes.Findings included .<Resident 18> In an observation and interview on 08/12/2026 at 3:45 PM, Resident 18 was observed in bed and had three urinals in their nightstand drawer next to the bed within the resident's reach. Two of the urinals had brown urine in them and one was empty. All three urinals had brown debris around the opening, urine in the handle of the urinal and none of them had lids to cover from spillage, odor, and to maintain infection control. Resident 18 stated the tow urinals had been sitting in the drawer since noon, three hours and 45 minutes prior to the interview. Resident 18 stated the staff emptied the urinals twice a day and only when the resident asked staff to empty the urinals. Resident 18 stated some, but not all, staff rinsed the urinals when emptying and none of the staff cleaned or disinfected the urinals. Resident 18 stated they had three urinals because when two were full, the resident would ask staff to empty them and still have a third urinal to use while they waited for staff to empty the other two. Resident 18 stated I get frequent kidney infections, look how dirty these are [pointing to the three urinals], no wonder I get infections. Resident 18 stated they would prefer clean urinals to keep at their bedside, and the dirty ones were gross. Review of the 08/12/2026 Kardex (care instructions to the nurse aides) showed Resident 18 was continent of urine and dependent on staff for toileting assistance. The Kardex showed no care instructions how to assist Resident 18 to manage the urinal, no directions for staff to empty, clean or manage the urinal, or how staff would assist Resident 18 with hand hygiene after using the urinal. In an observation and interview on 08/14/2026 at 9:35 AM, Staff B (Director of Nursing) observed the three urinals in Resident 18's room. Staff B stated the urinals were dirty and needed to be replaced. Staff B stated nursing staff should empty the urinals, rinse them out each time, and replace the urinal when soiled. <Resident 49> According to the 07/07/2026 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 49 had a severe cognitive impairment and was able to make themselves understood. The MDS showed Resident 49 was dependent on staff for bathing and personal hygiene. Observation on 08/13/2026 at 8:50 AM showed Staff K (Certified Nursing Assistant) shaving Resident 49 in the hallway next to the nurse cart, opposite the scale room. Resident 49 sat on a shower chair with only a sheet draped over their body while they were shaved by Staff K. Other residents, nursing aides, and nurses were present in the hall. None of the nursing staff identified a potential dignity issue In an interview on 08/14/2026 10:29 AM, Staff B stated residents should not be groomed in the hallway, including being shaved. Staff B stated a reasonable person would not want to be shaved in the hall wearing only a sheet. REFERENCE: WAC 388-97-0180(2).

Based on observation, interview, and record the facility failed to ensure resident dietary preferences were accommodated for 1 of 1 meal services observed and for 4 of 6 residents reviewed for food (Residents 50, 4, 9, & 8). This failure placed residents at risk for unwanted food items and frustration.Findings included.<Resident 50>According to the 06/13/2026 Quarterly MDS, Resident 50 had medically complex diagnoses including diabetes (a disease making control of blood sugar more difficult).In an interview on 08/11/2026 at 7:18 AM Resident 50 expressed frustration with the food he was served by the facility. Resident 50 stated they were not supposed to have juice because they were diabetic and juice was sugary. Resident 50 stated despite this, they were provided with a glass of orange juice with each meal.Record review showed a 06/25/2026 physician's order for a controlled carbohydrate diet for Resident 50. This order specified no juices.Observation of lunch preparation in the facility kitchen on 08/13/2026 at 1:08 PM showed Resident 50's tray being prepared. The meal ticket on the tray showed a standing order for four or more ounces of orange juice for Resident 50.In an interview on 08/13/2026 1:20 PM, Staff I (Dietician) reviewed Resident 50's meal ticket along with the resident's dietary orders and stated there was a discrepancy. Staff I stated if Resident 50 did not want juice with their meal they should not get juice. Staff I stated there was not a nutritional concern related to giving juice to residents with diabetes due to how the body metabolized fruit sugars.<Resident 4>According to the 06/12/2026 Quarterly MDS, Resident 4 had intact memory and had no vision issue. The assessment showed Resident 4 was independent with all daily needs including eating.In an interview on 08/10/2026 at 10:21 AM, Resident 4 stated the food in the facility was terrible. Resident 4 stated the food they serve to them did not always follow what they ordered.Observation on 08/11/2026 at 9:12 AM showed Resident 4 was eating fast food sandwich. Resident 4 stated the facility did not deliver what they ordered on the menu. Resident 4 stated most of the time the meal ticket did not match the food they ordered on the menu.In an interview on 08/12/2026 at 12:52 PM, Resident 4 stated they had to wait for their lunch because the kitchen sent them broccoli. Resident 4 stated they told the kitchen staff and wrote on menu they did not like broccoli, but the kitchen kept sending Resident 4 broccoli.In an interview on 08/14/2026 at 8:16 AM, Resident 4 stated they did not like broccoli and the kitchen continued to send them broccoli. Resident 4 stated they told the dietary staff they did not like broccoli multiple times. Resident 4 stated they marked their menu to indicate they wanted a substitute but did not get one. <Resident 9>In an interview on 08/10/2026 at 10:00 AM, Resident 9 stated they did not always get the food they ordered after they marked up the weekly menu.In an interview on 08/14/2026 8:17 AM, Resident 9 stated they missed the hashbrowns the facility used to serve.<Resident 8>In an interview on 08/10/2026 at 3:34 PM Resident 8 stated the food was not good. Resident 8 stated sometimes the food on the ticket doesn't match the food on their tray.In an interview on 08/14/2026 at 8:44 AM, Staff G (Dietary Supervisor) stated it was important to meet residents' food preferences.REFERENCE: WAC 388-97-1120(3)(a).

Based on observation, interview, and record review, the facility failed to implement pressure offloading interventions timely for resident's assessed to be at increased risk for skin breakdown to prevent the development of pressure injuries (PI) for 2 of 3 residents (Residents 1 & 2) investigated for development of new PI after admission. Resident 1 experienced harm when they developed two avoidable deep tissue pressure injuries (DTPI) after admission, one on each heel, that resulted in pain, affected their mobility and care routines, and delayed their rehabilitation and discharge goals. Resident 2 experienced harm when they developed a Stage 3 PI on their sacrum that resulted in pain, affected their ability to sleep, comfort, and decreased their bed mobility. These failures placed residents at risk for injury, infection, pain, and diminished quality of life. Findings included.The 2025 National Pressure Injury Advisory Panel (NPIAP, a leading expert in pressure injuries) defined PIs as localized damage to the skin and underlying soft tissues usually occurring over a bony prominence. The injury could present as intact skin or an open ulcer and may be painful. These injuries occurred from intense and/or prolonged pressure or pressure in combination with friction or shearing of skin tissues. The NPIAP defined a stage 3 PI as full thickness skin loss that extends below the top and middle layers of skin in which fat or connective tissue is visible in the ulcer. A Deep Tissue Pressure Injury (DTPI) was defined as intact or nonintact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or separation of multiple skin layers revealing a dark wound bed or blood-filled blister <Facility Policy> Review of the August 2009 policy for Skin Integrity, updated March 2026, showed residents who entered the facility without PI would not develop a PI, assessment of PI risk was completed at admission, a care plan would be established based on risk factors, and ongoing weekly skin assessments would be completed. The policy showed when a new PI was identified there would be an assessment, documentation, and implementation of interventions for PI treatment. <Resident 1> Review of the 04/01/2026 admission nursing assessment showed Resident 1 was admitted to the facility on [DATE], was dependent on staff for bed mobility, and required two staff to assist with movement in bed. Review of the 04/01/2026 admission skin assessment showed Resident 1 had no skin impairment on their heels at admission. Review of the 04/01/2026 Braden assessment for predicting pressure sore risk showed Resident 1 was at risk for PIs related to very limited mobility, unable to make body position changes independently, required assist by staff into a chair, risk of friction and shear to skin from sliding against sheets and surfaces in bed/chair. Review of the 04/02/2026 wound specialist progress note showed the facility made a referral for an at-risk skin consultation for treatment recommendations related to a risk assessment score placing Resident 1 at risk for skin related complications. The wound specialist note showed no skin impairment on the feet or heels, and muscle weakness to both feet. The specialist recommended change of position every two hours related to Resident 1 immobility, skin care with lotion to feet, and float heels off mattress using pillows or wedge. Review of the 04/08/2026 baseline care plan showed no care plan to prevent Resident 1 from developing PIs. The care plan did not show interventions to prevent skin breakdown identified in the Braden skin assessment or the wound specialists recommendations for PI prevention. Review of two late entry nursing progress notes for 04/09/2026 showed Resident 1 had a DTPI on the right heel measuring 3.5 centimeters (cm) long by 4.5 cm wide, dark red/purple in color, worsening since last evaluation. The left heel had a DTPI measuring 2.5 cm long by 3.3 cm wide, dark red/purple color and worsening since last evaluation. Review of a 04/10/2026 nursing progress note showed Resident 1had a follow up visit by the wound care specialist who assessed two new DTPIs, one on each heel. The note described the DTPIs as dark in color, non-blanching and tender when touched. The note showed the wound specialist recommended Resident 1's heels be floated to relieve pressure while in bed. The note showed the facility ordered an air mattress for Resident 1. Review of a 04/16/2026 wound specialist note showed Resident 1's right heel increased in size, measured 5 cm wide, 6.5 cm long, and was deteriorating by dimension and overall clinical impression. The note showed no changes to the left heel. The note showed recommendation was made to the facility, a second time, to implement a low air loss mattress for Resident 1's healing of both DTPIs. In an interview on 04/22/2026 at 4:39 PM, Resident 1's representative (RR) stated they visited Resident 1 daily and most days visited twice. The RR stated Resident 1 did not have any skin problems at home or in the hospital before coming to the facility on April 1, 2022. The RR stated they visited on April 3, 4, 5, 2026 and Resident 1 did not get out of bed for three days, there were no pillows in the bed, and the RR did not see Resident 1 be repositioned as was done in the hospital every couple of hours. The RR stated the staff just had Resident 1 lay on their back the whole time. The RR stated on April 6, 20026 the facility staff had Resident 1 in a wheelchair that did not have footrests that fit, so Resident 1's feet dragged on the floor when they were pushed in the wheelchair to and from the dining room. The RR stated they brought in Resident 1's personal wheelchair so they would have footrests. The RR stated facility staff informed them of the wounds on Resident 1's feet on April 9, 2026 and informed the RR that Resident 1 was not allowed to walk or put pressure on their heels and would use a wheelchair until the PIs healed. The RR stated when they looked at Resident 1's heels they were dark red and painful looking and Resident 1 winced and pulled away when the PI were touched. The RR stated Resident 1 was admitted to the facility to get stronger and walk so they could discharge home or to an adult home. The RR stated Resident 1 could use a walker and the toilet on admission but is now incontinent due to not walking to the bathroom. The RR stated Resident 1 had severe dementia and now the wounds on their feet had changed their mobility and care routines. The RR stated Resident 1 had significant setbacks to their rehab and discharge goals. In an observation and interview on 04/23/2026 at 8:50 AM, Resident 1 was sitting in a wheelchair in their room, was unable to answer questions, and had to rely on staff to hold their feet for the specialist to see the heels. The wound specialist removed Resident 1's socks and there was a piece of white foam on the right heel. The foam had dried red-brown drainage. The wound specialist stated they first observed the PIs on 04/09/2026 and saw them again on 04/16/2026 and the right heel was larger in size. The wound specialist assessed the heels and stated the right heel had started draining fluid from the dark purple wound. The wound specialist stated the right heel was not draining fluid the week prior. Observation of Resident 1's bed showed a standard mattress; there was not an air mattress on the bed. In an interview on 04/23/2026 at 1:11 PM, Staff B (Director of Nursing) stated Resident 1 was supposed to have an air mattress after the DTPIs were identified on 04/09/2026. Staff B reviewed Resident 1's medical record and stated there was no skin care or PI prevention care plan implemented on admission, when Resident 1 was assessed to be at risk for developing PIs. Staff B stated the 04/10/2026 progress note showed an air mattress was ordered and Resident 1 never received the air mattress. Staff B stated there was no follow up by staff to ensure the air mattress was ordered or implemented. <Resident 2> Review of a 03/20/2026 admission Braden assessment for predicting pressure sore risk showed Resident 2 was admitted on [DATE], was assessed at risk for developing PIs related to limited mobility, confined to bed, their skin had increased exposure to moisture, and was at risk of friction and sheer to skin from sliding against sheets in bed. Review of the 04/03/2026 nurse progress note showed Resident 2 reported to staff they had a sore on their buttocks. The nurse note described the wound as a friction tear to the skin. Review of the 04/09/2026 wound specialist note showed Resident 2 had a facility acquired stage 3 PI measuring 4.7 cm wide, 5.6 cm long and 0.2 cm deep on their sacrum. The note showed the wound specialist recommended treatment with a low air loss mattress discussed with Resident 2 and caregivers. Review of a 04/09/2026 late entry nurse progress note showed Resident 2 presented with a stage 3 PI to the sacrum, the abrasion had deteriorated with redness surrounding the wound. The note showed an air mattress was ordered to help with healing. In an interview and observation on 04/23/2026 at 10:56 AM, Resident 2 was observed lying on a standard facility mattress with a sheet, feet on pillows and able to move independently to reposition. Resident 2 stated they had a bedsore on their buttocks that hurt and was not there when they admitted to the facility. Resident 2 stated they could not sleep well because of the bedsore and could not get comfortable in their bed. Resident 2 stated their mattress had a hole in it and was caved in from the previous person that used it. Resident 2 stated they told a staff person a couple weeks ago and was told they would get a new mattress but had not received it yet. In an interview on 04/23/2026 at 12:25 PM, Staff D (Admissions Coordinator) stated the facility owns air mattresses and when one needs to be rented, they (Staff D) were the person responsible for renting the air mattresses for residents who needed them. Staff D stated the rental air mattresses are usually delivered on the same day. Staff D stated rental air mattresses were not ordered or obtained for Resident 1 or Resident 2. In an interview on 04/23/2026 at 1:22 PM, Staff B and Staff C (Resident Care Manager) stated they recalled discussion amongst the team to provide an air mattress to Resident 2. Staff B and C reviewed team discussion on their computers and stated Staff A (Administrator) asked the team to obtain an air mattress for Resident 2 on 04/09/2026. Staff B stated Resident 2 should have an air mattress as recommended by the wound specialist, documented in the nurse notes, and as requested by Staff A. Staff B stated there was no staff follow-up to ensure the air mattress was ordered or implemented for Resident 2. REFERENCE: WAC 388-97-1060(3)(b).

Based on observation, interview, and record review the facility failed to initiate, investigate, and resolve grievances for 6 of 12 sampled residents (Residents 2, 3, 4, 5, 6, 7, 8 ) reviewed for grievances. This failure placed residents at risk for emotional distress, unresolved frustration, and a diminished quality of life.Findings included .According to the facility's revised 03/2025 Grievance Procedure Policy, the Administrator oversees the grievance procedure and coordinates the center system for collecting, tracking, and responding to grievances. The Administrator is designated as the Grievance Official for the center. The policy showed grievances are resolved immediately, when possible, by the individual receiving the grievance. When immediate resolution is not possible, the grievance is routed to the Grievance Official promptly. If the grievance involves abuse, neglect, exploitation, or misappropriation of resident property, the Administrator is notified immediately, and an investigation begins. The policy showed the Administrator logs Grievances on the Grievance log.<Resident 2> According to the 06/19/2025 Annual Minimum Data Set (MDS-an assessment tool) Resident 2 had clear speech, was understood and understands others. Resident 2 has impairment on both sides of lower body, is dependent on staff for toileting, bathing, repositioning in bed, and transfers from bed to chair, chair to bed.According to the Self Care Deficit Care Plan, updated 07/02/2025, Resident 2 required the use of a mechanical lift, with 2 person assist, to transfer from bed to chair, and chair to bed.In an interview on 08/22/2025 at 1:45 PM Resident 2 stated the mechanical lift malfunctioned, dropped Resident approximately 6 inches, and caused pain to their left knee. Resident 2 stated they submitted 2 separate grievances that took over 2 weeks to get a response.In an interview on 08/22/2025 at 11:00 AM, when asked for a copy of the August Grievance Log, Staff A, Administrator stated the grievance log had not been updated in a couple weeks, believed the grievances were completed and documented on. The Grievance Log provided by Staff A was completely void of data entries. Staff A provided grievances filed in August 2025, 6 showed incomplete grievances. Staff A stated they have 5 days to resolve the issue but attempt to complete them in 2 days.In an interview on 09/03/2025 at 2:14 PM Staff A stated August's Grievance Log was not current, that it was important to track and manage resolutions, to follow up, and ensure Resident's need are met. In an interview on 09/03/2025 at 2:50 PM Staff B (Maintenance Director) stated they do not have a log for mechanical lift inspections.Review of August 2025 Grievance Log showed no entry for a grievance filed by Resident 2 on 08/14/2025 related to a faulty mechanical lift, that dropped Resident 2 into their wheelchair and caused increased pain after the incident.Review of 08/14/2025 Grievance form filed by Resident 2 showed incomplete resolution, actions, recommendations, or notification to Resident 2. <Resident 8> According to the 08/25/2025 Quarterly MDS Resident 8 had clear speech, understood, understands others, and is alert and oriented. Resident has diagnoses of anxiety and depression among others. Resident 8 able to provide all cares for self.According to the updated 06/06/2025 Behavior monitoring care plan, Resident 8 has a history of anxiousness that is triggered by the feeling of being unsafe and the approach of staff or others. In an interview on 09/03/2025 at 3:05 PM, Resident 8 stated they have not received feedback regarding the grievance they submitted a couple weeks prior.Review of August 2025 Grievance Log showed no entry for a grievance filed by Resident 8 on 08/18/2025 related to a staff member constantly standing outside their door, creeping them out, and attempted to remove Resident 8's comforter to take their vital signs.Review of 08/18/2025 Grievance form filed by Resident 8 showed incomplete resolution, actions, recommendations, or notification to Resident.Resident <4> According to the 07/09/2025 admission MDS Resident 4 had clear speech, understood, understands others, and is alert and oriented. Resident 4 requires partial/moderate assistance for toileting, transfers and required substantial/maximal assistance with perineal hygiene.According to the 07/03/2025 Baseline Plan of Care CP showed assistance needed with toileting and hygiene.In an interview on 09/03/2025 at 11:55 AM Resident 4 stated the grievance had not been discussed with them yet and they are worried about getting a rash or infection in the groin area.Review of August 2025 Grievance Log showed no entry for a grievance filed by Resident 4 on 08/18/2025 related to a staff member who does not clean them properly.Review of 08/18/2025 Grievance form filed by Resident 4 showed incomplete resolution, actions, recommendations, or notification to Resident.Similar findings of grievance not entered on log, no resolution, recommendations, or notification to Residents 5, 6, 7.REFERENCE: WAC 388-97-0460.

Based on observation, interview, and record review the facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs - i.e. grooming, bathing, eating, etc.) received the assistance they required for 1 of 4 sample residents (Resident 1) reviewed for ADLs. The failure to provide ADL assistance to dependent residents as required left residents at risk for poor hygiene, diminished feelings of self-worth, and other negative health outcomes.According to a 07/25/2025 Quarterly MDS, Resident 1 had clear speech, was able to understand, and be understood by others. This MDS showed Resident 1 was dependent on staff for bathing and required partial/moderate assistance from staff for personal hygiene, showers, transfers and mobility.Review of a revised 08/11/2025 Baseline Plan of Care (CP) showed directions to staff for Resident 1 to have a shower twice weekly and the resident required substantial maximum support from staff for bathing and dependent on 1 person assist with hair care and personal hygiene.During observations and interviews on 08/22/205 at 08:50 AM, 09/03/2025 at 4:50 PM, and 09/11/205 at 11:05 AM, Resident 1 was seen lying in bed, on their back, with unkempt hair. Resident 1 stated they requested 2 showers a week, they were supposed to happen on Mondays and Thursdays, but they do not they seem to be random. Resident stated their hair was so matted in the beginning a staff member had to cut it out. During an interview on 09/03/2025 at 2:10 PM Staff C stated they would expect the staff to follow the CP and give the two showers a week as written.During an interview on 09/11/2025 at 11:17 AM Staff A stated the shower aides are pulled to the floor occasionally, we try to get the shifts covered.During an interview on 09/11/2025 at 12:30 PM Staff D, Certified Nursing Assistant/Shower Aide (CNA) stated they get pulled from showers to work the floor on occasion.Review of Task Shower Sheets dated 08/18/2025-09/04/25 showed 2 bed bathes given, and 3 Resident Refusals over 18 days. Additional shower sheets for the remainder of the 30 days requested, none provided. No other refusals of showers documented.Reference: WAC 388-97-1060(2)(c).

Based on observation, interview, and record review the facility failed to ensure specialized rehabilitative services were provided as determined by the physician's orders for 1 (Resident 53) of 2 residents who were reviewed for position/mobility. This failure placed residents at risk for decline in physical and functional mobility, and a diminished quality of life.According to 07/25/2025 Quarterly MDS, Resident 1 had multiple diagnoses considered Medically Complex Conditions. This MDS showed Resident 1 required substantial/maximal assistance with upper and lower body dressing, rolling from side to side, sitting to lying, lying to sitting, toilet transfers, and wheelchair mobility. The MDS showed Resident 1 did not attempt to walk due to medical conditions or safety concerns.Review of a revised 08/11/2025 Baseline Plan of Care (CP) showed Resident 1 to ambulate with therapy only, dependent on 2 person staff for all mobility.During observations and interviews on 08/22/205 at 08:50 AM, 09/03/2025 at 4:50 PM, and 09/11/205 at 11:05 AM, Resident 1 was seen lying in bed, on their back, working on leg exercises while lying in bed. Resident 1 stated they missed some therapy sessions related to dialysis appointments in beginning of stay but did not understand why sometimes the therapists just didn't show up.During an interview on 09/11/2025 at 11:35 AM Staff A stated they would expect the therapy staff to treat as ordered and can't answer if therapy was short or not.During an interview on 09/11/2025 at 12:40 PM Staff E, Therapy Director stated they missed therapy sessions, they should have been documented why they were missed or refused but they did not see those entries. Staff E stated therapy provided 5 treatments weekly. When asked for the additional documented refusals of treatments, none were provided.Review of Occupational Therapy (OT) Evaluation and Plan of Treatment dated 06/06/2025 showed OT was ordered 5 times a week.Review of the Physical Therapy (PT) Evaluation and Plan of Treatment dated 06/06/2025 showed PT was ordered 3 times a week.Review of a therapy calendar provided by Staff A showed Resident 1 received PT 2x/week and OT 3xweek for week of 06/23/2025-06/27/2025. OT 4xweek and PT 2xweek for week of 07/07/2025-07/11/2025, OT 3xweek for week 07/28/2025-08/01/2025, OT 3xweek for week of 08/11/2025-08/15/2025, OT 4xweek for week of 08/25/2025-08/29/2025 REFERENCE: WAC 388-97-1280 (1)(a-b), (3)(a-b).

Based on observation, interview, and record review the facility failed to store, prepare, and serve food under sanitary conditions. Failure to ensure food items in the dietary department were properly stored, labeled, and out-of-date foods were identified and discarded, staff used appropriate hand washing and sanitation, placed residents at risk for consuming expired/contaminated foods, and potential exposure to food-borne illness. Findings included . <Facility Policy> According to the facility's updated October 2017 Food Storage policy, food storage areas would be kept clean at all times. The policy showed all food received by the facility would be dated with the month and year, except for perishable food with use-by dates of 30 days or less. The policy showed cold foods must be held at 41 degrees Fahrenheit (F) or less. The policy showed opened food packages must have a use-by date. The facility's updated October 2017 Food Temperature policy showed dietary staff should measure and record the temperature of all potentially hazardous foods served and ensure hot foods remained above 140 F and cold foods remained at 41 F or less. <Initial Rounds> During initial observations of the kitchen on 06/08/2025 at 8:15 AM the following was observed in the facility's walk-in refrigerator: -a bag of cut carrots with a use-by date of 05/18/2025, sixteen days prior. -an unsealed storage bag with sliced cheese inside, dated to be used by 08/02/2025. -an unsealed storage bag of cooked chicken, dated to be used by 06/20/2025. -two opened packages of pork without a date indicating when they were opened or when they should be used by. -an open package of a ham loaf without a date indicating when it was opened or when it should be used by. -two opened packages of boiled eggs without a date indicating when they were opened or when they should be used by. -two sealed packages of sliced roast beef with a received date of 4/25 without a use by date. In an interview on 06/08/2025 at 8:15 AM, Staff FF (Dietary Cook) stated the bag of carrots needed to be removed and all the food should be sealed for storage. Staff FF stated they were unable to tell how long the unlabeled food packages were in the refrigerator and stated they should be dated when opened and include the use by date. During initial observations of the kitchen on 06/08/2025 at 8:15 AM the following were observed stored on the same shelf next to each other: A bottle of sink and surface sanitizer with a label that said, keep out of reach of children sitting next to a bottle of powdered protein powder and a bottle of a lemon-flavored dietary supplement. Observation on 06/08/2025 at 8:41 AM showed Staff JJ (Registered Nurse) walk into the kitchen, pass the yellow tape marked on the floor, went to a counter with a toaster to prepare food, and then over towards some dry food product storage bins. Staff JJ was not wearing a hair net. Observations on 06/11/2025 at 9:20 AM with Staff GG (Dietary Manager) showed the same unsealed storage bag with sliced cheese previously observed on 06/08/2025 and a new unsealed bag of turkey breast. In an interview at this time, Staff GG stated it was their expectation food was sealed and labeled with the use by and open dates for food safety and so staff knew which items to use first. <Food Preparation> Observations at 06/11/2025 at 9:42 AM showed an open container filled with mushrooms soaking in water being set on a counter next to a bucket of sanitizer by Staff GG. Staff GG was observed washing their hands. While Staff GG dried their hands with a paper towel, their hands passed over and dripped above the open container of mushrooms when they went to throw the paper towels away in a garbage can. Staff GG then moved the container of mushrooms to another counter next to dirty containers of raw egg residue. In an interview on 06/11/2025 at 10:15 AM, Staff GG stated their expectation was for dirty items to be kept on the left side of the sink bins and indicated food should not be stored with dirty items on the counter to the left side. Observation on 06/11/2025 at 9:54 AM showed Staff II (Dietary Aide) scraping broccoli into a rinsing bin from a large produce box. Staff II removed their glasses, wiped their mouth with the back of their hand and returned the broccoli box to the walk-in refrigerator before washing their hands. Observation on 06/11/2025 at 10:04 AM showed Staff HH (Dietary Cook) patting and molding raw ground meat on a sheet pan right next to an open cart of clean trays. Pieces of raw meat were observed splattering out on to the nearby surfaces. This was observed at the same time by Staff GG who told staff to rewash the entire cart of clean trays. Observation on 06/11/2025 at 10:07 AM showed Staff HH place the sheet pan of raw meat on top of a lid and shelf of the steam table. Staff HH then placed the pan in the oven and did not sanitize the steam table counter after coming in contact with the sheet pan used for the raw meat. Staff HH removed their gloves, at the same level as the the food rinsing bin and counter area, raw meat was observed to splatter off of the gloves when staff removed them. Observation on 06/11/2025 at 10:08 AM showed Staff II wipe their nose with the back of their gloved hand before picking up a carton of milk to use in a can of cream of mushroom soup. Staff II lifted the lid of the pot of soup before adding the milk. <Food Service> Observation of lunch service on 06/11/2025 at 11:32 AM showed Staff HH measuring the temperature of the chilled drinks and dishes prepared for the lunch. Staff HH measured the temperature of the glasses of milk as 49 F, eight degrees F higher than the facility's policy stated was a safe holding temperature. The glasses of juice were at 45 F, and two desserts were at 44 F, all over 41 F. A plate of salad was measured at 55 F, 14 F higher than the policy showed was safe. Observation on 06/12/2025 at 11:50 AM showed the green handle of a ladle, previously touched with soiled hands, submerged in the brussel sprout pan it was placed in. Kitchen staff did not replace the dish At this time Staff GG was observed to measure more temperatures. Desserts were measured at 43 F and a second at 45.5 F. After measuring a glass of milk at 42 F, Staff GG wiped the thermometer with a dry rag before measuring a glass of juice at 42 F. Staff GG then recorded the temperature of a dessert at 55 F and a juice at 45 F, without sanitizing the thermometer between use. The dietary staff then began placing the drinks and desserts on to trays to distribute to residents, and placing the trays in carts to send out to the units. The lunch cart doors were closed and was heading to the unit to be delivered when the surveyor stopped to request a temperature check of one of the loaded trays for a resident. Staff GG tested the cold dessert from the tray which measured at 45 F, four degrees F higher than the policy showed was safe. At this time Staff GG confirmed cold food should be held at 41 F or lower and started pulling all of the drinks, desserts, and salads and placed the items in the freezer to cool. Observation on 06/12/2025 at 12:22 PM showed Staff GG re-enter the kitchen and head directly to the walk-in refrigerator. Staff GG did not wash their hands when they entered. Observation on 06/12/2025 12:55 PM showed a member of the nursing staff enter the kitchen and take several steps past the yellow tape placed just inside the door before putting on a hairnet. The tape was placed on the floor to indicate the point beyond which staff entering the kitchen must wear a hairnet. Observation on 06/12/2025 12:57 PM showed Staff GG preparing food on a counter with dirty trays placed on the same work surface. Observation on 06/12/2025 at 1:34 PM of the tray service showed Staff HH resting their elbows on the steam table counter in between preparing food plates, then placed tongs being used for food service on the steam table, without sanitizing the counter. In an interview on 06/13/2025 at 9:09 AM, Staff GG stated it was important for all staff who entered the kitchen beyond the yellow taped area by the door, to secure their hair in hair net, and that food was not left by dirty dishes to minimize the risk of food contamination. Staff GG stated dietary staff should wash their hands before preparing food and after any contact with potential food contaminants, including after touching their faces, using the bathroom, re-entering the kitchen, touching doors, and any other high contact surfaces in order to minimize the risk of food borne illness. Staff GG stated staff should not remove gloves contaminated with raw meat in the immediate proximity of food preparation areas such as the food rinsing bin and counter area, as raw meat was observed to splatter when staff removed their gloves. Staff GG stated the tray with raw meat should not be placed on the steam table counter without proper sanitation afterwards. Staff GG stated staff should not wipe their noses on the back of their gloved hands and then touch a milk container. Staff GG stated when serving food, staff should not touch residents' plates with their thumbs, place tongs on the soiled counter, or let scoops fall into the bins and come in contact with the food after being handled with bare, soiled hands. Staff GG stated cold foods must be held at a temperature of 41 F or lower. Staff GG stated when monitoring the temperature of food, staff should use an alcohol wipe to sanitize the thermometer between dishes, not a cloth or paper towel. REFERENCE: WAC 388-97-1100 (3). .

<Carpet> Observations on 06/08/2025 at 8:52 AM, 06/11/2025 at 5:54 AM, and 06/13/2025 at 11:29 AM showed a large carpet stain in the hallway across from room [ROOM NUMBER]. In an observation and interview on 06/13/2025 at 11:29 AM, Staff K stated it was their expectation housekeeping staff would address carpet stains promptly. <Blinds> Observations on 06/08/2025 at 8:52 AM, 06/11/2025 at 5:54 AM, and 06/13/2025 at 11:29 AM showed there were missing and broken window blinds to the windows at the end of the 100-hall and the 200-hall. An observation of the 200-hall window with Staff K on 06/13/2025 at 11:29 AM showed Staff K pick up a broken blind lying on the floor under the window. In an interview at this time, Staff K stated the broken blinds needed to be fixed and the missing blinds replaced. Staff K stated it was important for the facility to be clean and in good repair, so it felt like home for the residents and to keep everything functional. REFERENCE: WAC 388-97-0880. Based on observation, interview, and record review, the facility failed to provide necessary maintenance and housekeeping for 3 of 3 units and the main dining room. The facility failed to ensure residents' living environment was free from broken and/or missing window blinds, stained carpets, and air vents with debris accumulation. The failure to maintain window blinds, carpets, and ceiling vents in good repair and sanitary condition placed the residents at risk for diminished quality of life. Findings included . <Facility Policy> Review of the facility's Notice Of Resident Rights Under Federal Law, updated 11/2016, showed the facility would provide residents with a safe, clean, comfortable, and homelike environment. Review of the facility's admission Agreement and Resident Handbook, updated December 2023, showed the facility would provide daily housekeeping services and the maintenance department would regularly review the facility to identify and perform needed improvements. <Air Vents> Observation on 06/08/2025 at 12:25 PM, 06/10/2025 at 10:32 AM, and 06/13/2025 at 1:50 PM showed a buildup of debris on two ceiling air vents in the main dining room. Observations on 06/13/2025 at 1:49 PM showed a buildup of debris on the bathroom ceiling air vents in rooms 102, 309, 501, and 502. The air vent for the wall-mounted heater in the 100 unit hallway showed a buildup of debris. In an interview on 06/13/2025 at 1:53 PM, Staff K (Maintenance Supervisor) stated the air vents in the facility needed to be cleaned and would be taken care of the following weekend. Staff K stated a clean and homelike environment was important for residents to be able to feel comfortable, as the facility was their home. Staff K was unaware of the availability of records documenting regular facility reviews. The facility was unable to provide further documention.

<Resident 3> According to a 04/25/2025 Quarterly MDS, Resident 3 had multiple medically complex diagnoses including a history of falling, required substantial assistance with transfers, and was dependent on staff for toileting hygiene. In an interview on 06/09/2025 at 10:18 AM, Resident 3's family stated they were concerned about the resident having recent falls. Observations on 06/09/2025 at 12:38 PM, showed Resident 3 lying in bed with their call light in reach. Review of a revised 08/16/2024 risk for falls CP showed Resident 3 had a history of frequent falls and gave directions to staff to anticipate resident needs, ensure the resident's call light was within reach, and keep the room free of clutter due to poor eyesight. Review of a revised 05/18/2024 actual fall CP showed an intervention to assist Resident 3 with the bathroom upon awakening, before/after meals, and at bedtime. Review of a 01/05/2025 12:00 PM facility incident report showed Resident 3 was found in their room, lying on the floor face down, with their wheelchair nearby. The investigation was blank under the Predisposing Environmental Factors assessment section showing staff did not indicate if Resident 3's room was cluttered, if wheelchair locks were working, or if the resident had what they needed within reach. There was no information included in the report to show if Resident 3 needed assistance with toileting or other care needs and/or when the last time any assistance was provided to the resident prior to the fall. Review of a 01/20/2025 6:30 PM facility incident report showed Resident 3 was found on the floor by their bed with their wheelchair behind them. The investigation was blank under the Predisposing Environmental Factors assessment section of the incident report showing staff did not indicate if Resident 3's room was cluttered, if wheelchair locks were working, or if the resident had what they needed within reach. There was no information included in the report to show if Resident 3 needed assistance with toileting or other care needs and/or when the last time any assistance was provided to the resident prior to the fall. <Resident 26> According to an 04/16/2025 Significant Change MDS, Resident 26 had multiple medically complex diagnoses including diabetes (a disease that affects how your body regulates blood sugar) and a history of repeated falls. This MDS showed Resident 26 had a fall with injury since the previous assessment and required substantial assistance with transfers and toileting hygiene. Review of a revised 05/24/2024 fall CP showed Resident 26 had low blood sugars, confusion, poor balance, impulsive behavior, and received high-risk medications. Observations on 06/08/2025 at 12:21 PM showed Resident 26 sitting on their bed with their walker nearby. In an interview at this time, Resident 26 stated they had recent falls. Review of a 01/11/2025 4:04 AM facility incident report showed Resident 26 was found standing staring at the wall, and began lowering themselves to the floor. The staff in the room assisted Resident 26 to their knees. There was no information included in the report to show if staff assessed Resident 26's blood sugar, needed assistance with toileting or other care needs, and/or when the last time any assistance was provided to the resident prior to the fall. Review of a 03/24/2025 12:08 AM facility incident report showed Resident 26 was found on the floor in the hallway with injuries to their face. The investigation records showed Resident 26's call light was on at the time of the fall. There was no information included in the report to indicate how long the resident's light was on or how long it was since they received toileting assistance from staff, prior to the fall. There was no information to show if staff assessed Resident 26's blood sugar after the fall. Review of a 05/01/2025 10:00 PM facility incident report showed Resident 26 was found on the floor by their bed with a broken walker next to them and injuries to their finger. The investigation records showed Resident 26's call light was on at the time of the fall. There was no information included in the report to indicate how long the resident's light was on at the time of the fall or if staff assessed Resident 26's blood sugar after the fall. In a joint interview on 06/13/2025 at 11:34 AM with Staff B and Staff G (Regional Director of Clinical Operations), Staff G stated it was important to try and figure out the root cause of a fall so staff would know how to formulate the interventions to prevent further falls and decrease the risk for injuries. Staff B stated the incident reports for Residents 3 and 26 were not thorough and should have, but did not include more information and assessments. Refer to F689 - Free of Accidents Hazards. REFERENCE: WAC 388-97-0640(6)(a)(b). Based on observation, interview, and record review, the facility failed to ensure thorough and complete investigations for 4 of 7 residents (Resident 28, 42, 3, & 26) reviewed for falls. Failure to conduct a thorough investigation placed residents at risk for further injuries, potential abuse/neglect, and other negative health outcomes. Findings included . <Policy> According to a facility policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, dated March 2025, an example of neglect was failure to implement and monitor care planned interventions. The policy showed the facility would conduct a thorough investigation of potential neglect/abuse in accordance with state and federal regulations. According to a facility policy titled, Abuse Investigation, dated October 2022, the facility would determine if abuse/neglect had occurred and determine the extent and cause. The policy showed the facility would maintain complete and thorough documentation of the investigation. According to a facility policy titled, Resident Falls Management. Dated November 2016, the facility would assess and decrease clutter in the room, assess footwear and guarantee the resident's footwear fit appropriately, and evaluate lighting in the room and adjust as needed. <Resident 28> According to a 05/28/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 28 admitted to the facility on [DATE] with no memory impairment. The MDS showed Resident 28 had a history of falls. In an observation and interview on 06/09/2025 at 9:28 AM, Resident 28 was lying in bed with a bandage to their left knee and elbow. Resident 28 stated they had a fall the other day causing an abrasion to their left knee and elbow. Review of a 05/24/2025 investigation for a fall, showed the nurse answered Resident 28's call light and found the resident sitting on their bed and reported they fell, with skin injuries to their left knee and elbow. The incident report showed a Neurological Assessment (an assessment of the resident's level of consciousness, vital signs, mental status, motor response, and strength initiated and conducted over a minimum of 24 hours after a resident had the possibility of hitting their head or actually hit their head) was initiated with no documentation of the assessment being done. The investigation was blank under the Predisposing Environmental Factors assessment section of the incident report showing the environment was not assessed for causative factors such as clutter, wet floor, or appropriate footwear for Resident 28's fall on 05/24/2025. The investigation did not include a skin assessment of the left knee skin injury documenting the appearance, measurements of the injury, or any noted drainage. <Resident 42> According to an 11/18/2024 admission MDS, Resident 42 was dependent on staff for bed to chair transfers. The MDS showed Resident 42 had a diagnosis of, but not limited to, paralysis of the lower half of the body. Review of Resident 42's 12/26/2024 High Risk for Falls related to Paralysis Care Plan (CP), staff would anticipate and meet the needs of the resident. Resident 42's .had an actual fall with no injury CP showed neurological checks would be completed for the 05/22/2025 fall. In an observation and interview on 06/09/2025 at 10:23 AM Resident 42 was lying in bed with bilateral above the knee amputations. Res 42 stated they fell after staff placed them in their wheelchair crooked and they attempted to reposition themselves. Resident 42 stated the wheelchair tipped over backward and they hit their head so hard on the corner of the wall. Review of the investigation documents showed the incident report for Resident 42 identified they hit their head during a fall on 05/22/2025. The report showed Resident 42 was transferred by two staff with a mechanical lift to their wheelchair and Resident 42 attempted to self-adjust after the staff placed them in their wheelchair causing the wheelchair to tip over backwards with staff still present in the room. The report showed Resident 42 hit their head on the corner of the wall when their wheelchair tipped over backward. The investigation of Resident 42's fall showed neurological assessment initiated. Review of the 05/22/2025 investigation and Resident 42's records showed no neurological assessment was done. Resident 42's incident report showed there was no predisposing situation factors for the fall including whether the resident was uncomfortable in their wheelchair after the transfer. The investigation did not include statements from the two staff members that transferred Resident 42 investigating if they ensured the residents comfort after placing them in their wheelchair. In an interview on 06/13/2025 at 1:32 PM Staff B (Director of Nursing) stated they did not have documentation of a completed neurological assessment as part of the investigation file or in Resident 28 or 42's health records but should. Staff B stated a skin assessment documenting measurements and appearance of Resident 28's skin tear should have be done but was not. Staff B stated it was important to complete these assessments as part of the investigation to ensure the residents did not have further injuries or other negative health outcomes. Staff B stated they expected staff to complete all sections of the incident report as part of the investigation to include assessment of the environmental factors and predisposing situation factors, but staff did not for Resident 28 and 42's falls.

<Resident 24> Review of Resident 24's 07/15/2024 and 10/15/2024 Discharge MDS showed the resident was transferred to an acute care hospital on [DATE] and 10/15/2024, with their return anticipated. <Report to Receiving Facility> Review of Resident 24's records showed staff did not document the hospital was given report of the resident's condition at the time of transfer and no e-interact form was completed by staff for the resident's 10/15/2024 transfer. <Written Notice> Record review showed no documentation staff provided written notification to Resident 24 and/or the resident's representative regarding their discharge on [DATE] or 10/15/2024 as required. <LTCO Notification> Record review showed no documentation indicating the LTCO was notified of Resident 24's 07/15/2024 or 10/15/2024 transfer as required. <Resident 46> Review of Resident 46's 05/12/2025 Discharge MDS showed the resident was transferred to an acute care hospital on [DATE], with their return anticipated. <Report to Receiving Facility> Review of Resident 46's records showed staff did not document the hospital was given report of the resident's condition at the time of transfer and no e-interact form was completed by staff for the resident's 05/12/2025 transfer. <Written Notice> Record review showed no documentation staff provided written notification to Resident 46 and/or the resident's representative regarding their discharge on [DATE] as required. <LTCO Notification> Record review showed no documentation indicating the LTCO was notified of Resident 46's 05/12/2025 transfer as required. In an interview on 06/13/2025 at 9:26 AM, Staff C stated the nursing department was responsible for notifying the LTCO of hospital transfers. In a joint interview with Staff R and Staff J (RCM) on 06/13/2025 at 1:03 PM, Staff R stated the nursing department does not notify LTCO with hospital transfers and indicated the social services department was supposed to do that. Staff R stated it was their expectation staff call and provide a report to the hospital with all transfers and stated they would expect documentation of that in the resident's records. Staff J reviewed Resident 24's records and was unable to locate staff gave report to the hospital for the 10/15/2024 transfer, or provided written notice of discharge to the resident and/or representative for the 07/15/2024 or 10/15/2024 transfers as required. In an interview on 06/13/2025 at 2:54 PM, Staff R stated it was their expectation the notification to LTCO, hospital report from facility, and discharge notice be documented in Resident 46's records, no documentation was found.Based on interview and record review, the facility failed to offer bed holds upon transfer to the hospital for 1 of 5 residents (Resident 6), call report to the hospital regarding the resident's status for 4 of 5 residents (Residents 6, 24, 46, & 42), provide a written transfer notice to 4 of 5 residents (Residents 6, 24, 46, & 42), and notify the Office of the State Long Term Care Ombudsman (LTCO) for 4 of 5 residents (Resident 6, 24, 46, & 42) who were reviewed for hospitalization and notify the Office of the LTCO for 1 of 3 residents (Resident 71) reviewed for discharge process. Failure to offer bed holds placed residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized . Failure to call report to the receiving hospital placed residents at risk of a break in communication and continuity of care. Failure to notify the LTCO and ensure written notification was provided to the resident/resident representative, in a language and manner they understood, placed residents at risk for not having an opportunity to make informed decisions about their transfer/discharge rights. Findings included . <Facility Policy> According to the facility's Transfer and Discharge policy, updated 04/2025, when a resident was transferred outside of the facility, the facility would document the transfer in the resident's record and communicate with the receiving institution. The policy showed staff would provide a written notice to the resident/representative that included contact information for the LTCO. This policy showed a copy of the notice would be sent to the LTCO. According to the facility's Bed Hold policy, updated 05/2025, the facility would offer the resident/representative the option to hold the resident's bed upon transfer from the facility. <Resident 6> <Bed Hold> Review of the 08/31/2024 Discharge Minimum Data Set (MDS - an assessment tool) showed Resident 6 was transferred to a short-term hospital on [DATE] with their return anticipated. Review of Resident 6's records on 06/11/2025 showed no documentation a bed hold was offered to Resident 6. In an interview on 06/11/2025 at 10:34 AM, Staff S (Director of Admissions) stated bed holds were offered to residents/representatives within 24 hours of the resident's transfer. Staff S stated the document was done electronically and kept in the resident's record. At that time, Staff S was unable to provide documentation showing Resident 6 was offered a bed hold as required. <Report to Receiving Facility> Review of Resident 6's records on 06/11/2025 showed staff did not that the short-term general hospital was given report of the resident's condition. Resident 6's record did not include an e-interact form (document completed by staff that includes documentation showing staff gave report to receiving facility) completed by the staff for the resident's 08/31/2024 hospital transfer. In an interview on 06/13/2025 at 11:01 AM, Staff R (Resident Care Manager - RCM) stated it was their expectation staff called and gave report to the receiving hospital when a resident was transferred out. Staff R confirmed there was no documentation in Resident 6's record showing staff gave report to the hospital. <Written Notice> Review of Resident 6's record on 06/11/2025 did not show a written notice was completed and provided to the resident. In an interview on 06/12/2025 at 1:45 PM, Staff B (Director of Nursing) stated they expected staff to fill out the written notice, provide one copy to the resident and one copy for the residents' record. Staff B was unable to provide documentation that a written notice was completed for Resident 6's 08/31/2024 hospital transfer. <LTCO Notification> In an interview on 06/11/2025 at 9:21 AM, Staff C (Social Services Director) stated they did not notify the LTCO when residents were transferred to the hospital. Staff C stated the nursing staff was supposed to fax a copy of the written notice to the LTCO when they completed the form. In an interview on 06/12/2025 at 1:45 PM, Staff B stated it was their expectation social services department notified the LTCO of resident transfers to the hospital. <Resident 71> <LTCO Notification> Review of the 03/10/2025 Comprehensive MDS showed Resident 71 discharged from the facility on 03/10/2025 to home/community with their return not anticipated. In an interview on 06/13/2025 at 1:33 PM, Staff C reviewed their records and stated they did not notify the LTCO of Resident 71's discharge. Staff C stated if they did not receive a discharge packet from nursing staff, then they did not notify the LTCO. <Resident 42> According to a 12/18/2024 Discharge Return Anticipated MDS Resident 42 was transferred to an acute care hospital on [DATE]. The MDS showed Resident 42 presented with an acute change in mental status from their baseline. <Report to Receiving Facility> Review of Resident 42's records showed staff did not document the hospital was given report of the resident's condition at the time of transfer and no e-interact form was completed by staff for the resident's 12/18/2024 transfer. <Written Notice> Record review showed no documentation staff provided written notification to Resident 42 and/or the resident's representative regarding their discharge on [DATE] as required. <LTCO Notification> Record review showed no documentation indicating the LTCO was notified of Resident 42's 12/18/2024 transfer as required. In an interview on 06/13/2025 at 11:08 AM Staff B, Staff G (Regional Director of Clinical Operations), and Staff A (Administrator) reviewed Resident 42's records and stated a report was not called to the receiving hospital, notification of the LTCO was not done, and a written transfer notification was not provided to the resident or their representative for the 12/18/2024 transfer, but should have been. Staff B stated it was important to call report to the receiving hospital for continuity of care. REFERENCE: WAC 388-97-0120(2)(a-d)(3)(a)(4), -0140(1)(a)(b)(c)(i-iii). .

<Resident 24> According to a 05/09/2025 Quarterly MDS, Resident 24 had clear speech, understands, and was understood by others. In an interview on 06/08/2025 at 12:09 PM, Resident 24 stated they felt staff did not include them in their plan of care and did not have any recent care conference meetings with the different departments to discuss their care. Review of Resident 24's records showed a 04/04/2025 care conference was held with the only IDT members in attendance listed were Staff R (RCM) and Staff DD (Social Services Assistant - SSA). Staff documented, none for the other categories of: MDS, Executive Director, CNA (Certified Nursing Assistant) responsible; DNS (Director of Nursing), Therapy, FANS (Dietary department); and activities. Similar observations were noted of only the RCM and SSA attending care conferences with Resident 24 on 01/09/2025 and 09/11/2024. In an interview on 06/13/2025 at 9:26 AM, Staff DD stated they were involved in the care conference scheduling and sent out notice to the IDT members. Staff DD stated the only staff that attended with them was the RCM. In an interview on 06/13/2025 at 1:03 PM, Staff R stated the IDT members do not attend care conferences with the resident, only themselves and the SSA. REFERENCE: WAC 388-97-1020(2)(d-e), (4)(c)(i-ii). <Resident 53> According to the 05/12/2025 admission MDS, Resident 53 admitted to the facility on [DATE]. The MDS showed Resident 53 had minimal difficulty with hearing, was sometimes understood, and could sometimes understand others. Resident 53 had diagnoses including a brain bleed and limited mobility to one side of their body. The MDS showed Resident 53 received 51 percent or more of their nutrition via tube feeding (artificial nutrition delivered directly to the digestive system via a surgically placed tube). Review of Resident 53's 05/12/2025 Care Conference Evaluation form showed the only IDT members in attendance were Staff C and Staff J. The form showed Staff C completed the discharge planning section on 05/16/2025 and Staff J completed the care conference details, nursing, nutrition, social services, and activities sections on 05/21/2025. The care conference evaluation was not completed together by the IDT or within 72 hours of the resident's admission as required. In an interview on 06/13/2025 at 10:43 AM, Staff C confirmed the care conference only consisted of Staff J and Staff C and that the care conference was not done with the IDT. Based on interview and record review, the facility failed to conduct care conferences for residents with their resident representative and the applicable Interdisciplinary Team (IDT) members for 4 of 6 residents (Residents 28, 222, 53, & 24) and offer timely care conferences for 2 of 6 residents (Resident 28 & 53) reviewed for care planning. This failure placed residents at risk for unmet care needs, unnecessary care, frustration, and other negative health outcomes. Findings included . <admission Agreement> According to the facility's admission agreement, the resident and /or resident representative would be included in their plan of care during their care conference with their team. The admission agreement showed the facility would encourage the residents and representatives to attend the care conference for discussion with the resident care team about their plan of care. <Resident 28> According to the 05/28/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 28 admitted to the facility on [DATE]. The MDS showed Resident 28 could make themselves understood and understood others. Resident 28 had diagnoses of, but not limited to, a long-term degenerative neurological disorder and a life-threatening response to an infection. The MDS showed Resident 28 was receiving physical and occupational therapy services at the facility. The MDS showed it was very important to have their family or close friends involved in discussions about their care. Review of Resident 28's 05/27/2025 Care Conference Evaluation form showed the only IDT members in attendance were Staff C (Social Services Director) and Staff J (Resident Care Manager -RCM). The form showed Staff C completed the social services section on 05/27/2025, the discharge planning section on 05/29/2025, and the nutrition section on 05/30/2025. The Care Conference Evaluation form showed Staff EE (Activity Assistant) completed the activities section on 05/28/2025 but were not in attendance at the 05/27/2025 care conference. The Care Conference Evaluation form showed Staff J completed the care conference details and nursing sections on 05/28/2025. The care conference was not completed together with Resident 28's vital IDT members, the resident representative was not invited to the care conference, and it was not completed within 72 hours of the resident's admission as required. In an observation and interview on 06/09/2025 at 8:50 AM Resident 28 stated they had not had a care conference that included nursing, therapy, social services, dietary, and activities department. Resident 28 stated they were not included in their plan of care, had not received a copy of their care plan, and were visibly frustrated. Resident 28 stated they had an assigned power of attorney that should be involved in their care. Record review of Resident 28's health records showed demographic information obtained on admission with three resident representatives listed. <Resident 222> According to the 06/10/2025 admission MDS Resident 222 admitted to the facility on [DATE]. The MDS showed Resident 222 could make themselves understood and understood others. Resident 222 had diagnoses of, but not limited to, a stroke and a restrictive lung disease. The MDS showed Resident 222 was receiving physical and occupational therapy services at the facility. The MDS showed it was somewhat important to attend group activities. The MDS showed it was very important to have their family or close friends involved in discussions about their care. Review of Resident 222's 06/04/2025 Care Conference Evaluation form showed the only IDT members in attendance were Staff C and Staff J. The form showed Staff C completed the social services and discharge planning section on 06/09/2025. The Care Conference Evaluation form showed Staff U (Activities Director) completed the activities section on 06/05/2025 but were not in attendance at the 06/04/2025 care conference. The Care Conference Evaluation form showed Staff J completed the care conference details, nursing, and nutrition sections on 06/10/2025. The care conference was not completed together with Resident 222's vital IDT members and the resident representative was not invited to the care conference as required. In an observation and interview on 06/08/2025 at 12:23 PM Resident 222 stated they had not had a care conference that included nursing, therapy, social services, dietary, and activities department. Resident 222 stated they were not included in their plan of care, had not received a copy of their care plan, and were visibly frustrated. Resident 222 stated they had a representative that should be involved in their care. Record review of Resident 222's health records showed demographic information obtained on admission included a resident representative with their contact information listed. In an interview on 06/13/2025 at 12:42 PM, Staff C confirmed Resident 28 and 222's care conferences only consisted of Staff J and Staff C and that the care conferences were not done with the vital IDT members for the residents. Staff C stated all departments received invitations to the residents care conferences but did not attend the meetings with the residents. Staff C confirmed therapy, nutrition, and activities were a vital part of Resident 28 and 222's IDT but were not in attendance at their care conferences.

<Resident 24> According to a 05/09/2025 Quarterly MDS, Resident 24 had clear speech, was able to understand, and be understood by others. This MDS showed Resident 24 was dependent on staff for bathing, required substantial assistance from staff for personal hygiene, and had no rejection of care. Review of a revised 02/29/2024 functional abilities Care Plan (CP) showed directions to staff for Resident 24 to have a shower twice weekly and the resident required assistance from staff for personal hygiene. Observations on 06/08/2025 at 12:03 PM showed Resident 24 with facial hair on their chin and fingernails that extended past their fingertips with debris underneath. In an interview at this time, Resident 24 stated they preferred to be clean shaven and stated it was a couple of weeks since staff assisted them with shaving. Resident 24 stated they preferred their fingernails to be a lot shorter and stated, I have asked for help and I don't get it. Resident 24 stated they were only getting a bed bath once a week and preferred bathing more often. Similar observations of being unshaven with long dirty nails was noted on 06/10/2025 at 1:31 PM and 06/11/2025 at 10:44 AM. Review of Resident 24's May 2025 ADL documentation showed staff documented the resident only received three out of the eight opportunities scheduled for bathing. Review of Resident 24's June 2025 ADL documentation showed staff documented the resident only received one out of the three opportunities scheduled for bathing. In an observation with Staff H (Infection Preventionist) on 06/13/2025 at 11:01 AM, Staff H confirmed Resident 24 had untrimmed facial hair and fingernails. In an interview at this time, Staff H stated they expected staff to assist resident's as needed. In an interview on 06/13/2025 at 1:03 PM, Staff R (Resident Care Manager) stated it was their expectation staff provide assistance with shaving, nail care, and bathing as needed and/or document if a resident refuses.<Resident 9> According to the 04/18/2025 Quarterly MDS, Resident 9 had severe cognitive impairment with a diagnosis of a progressive memory loss disorder. The MDS showed Resident 9 required substantial/maximal assistance from staff with personal hygiene including shaving. Review of Resident 9's 03/07/2024 revised .Baseline Plan of Care CP directed staff to assist the resident with showers three times per week. The CP showed Resident 9 required substantial/maximal assistance with showering. Observation on 06/09/2025 at 11:09 AM showed Resident 9 self-propelling in their wheelchair around the nurse's station. Resident 9 had several long, black chin hairs. Similar observations were made on 06/10/2025 at 1:56 PM, 06/11/2025 at 8:35 AM, 06/12/2025 at 9:41 AM, and on 06/13/2025 at 10:57 AM. Review of Resident 9's June 2025 shower documentation showed the resident was only offered showers once per week and received a shower on 06/06/2025 and 06/13/2025. In an interview on 06/13/2025 at 11:27 AM, Staff R stated they expected staff to offer shaving to residents during their showers and as needed. Staff R stated they expected staff to document any refusals. <Resident 53> According to the 05/12/2025 admission MDS, Resident 53 had mild cognitive impairment and diagnoses including a brain bleed and weakness to one side of their body. The MDS showed Resident 53 required substantial/maximal assistance from staff for personal hygiene and that the resident did not receive showering/bathing assistance during the look back period. Review of Resident 59's .Baseline Plan of Care CP showed two staff were to assist the resident with bathing once per week, on Wednesdays. Observation on 06/09/2025 at 8:27 AM showed Resident 59 lying in bed. Their fingernails and toenails on their left side had dark debris underneath the nails. In an observation and interview on 06/11/2025 at 10:48 AM, Resident 59 had dark debris under their finger and toenails on the left side. In an interview at that time, Staff P (Registered Nurse) confirmed the nails were dirty and needed to be cleaned. Review of Resident 59's May 2025 bathing documentation showed the resident received two showers for the month of May, one on 05/10/2025 and the other on 05/20/2025. Review of Resident 59's June 2025 bathing documentation on 06/12/2025 showed staff documented the resident received one shower on 06/04/2025, 15 days after their last shower on 05/20/2025. In an interview on 06/13/2025 at 11:05 AM, Staff R stated it was their expectation staff follow the resident's CP and provide showers/bathing as care planned. Staff R stated they expected refusals to be documented if a resident refused the bathing assistance. <Resident 31> According to the 05/14/2025 Quarterly MDS, Resident 31 did not have cognitive impairment and had diagnoses including brain damage. The MDS showed Resident 31 had impairment to both arms and legs and was totally dependent on staff for bathing and personal hygiene. Review of Resident 31's 04/26/2024 Functional Mobility Plan of Care CP showed staff were to assist the resident with showers twice weekly in the evening time. In an interview on 06/09/2025 at 9:08 AM, Resident 31 stated they would love two or three showers per week, I get one if I am lucky. Review of Resident 31's March 2025 bathing documentation showed staff were to provide the resident with showers on Monday and Friday evenings. Staff documented Not Applicable on seven of nine opportunities. Two of nine opportunities were left blank and staff did not document. Resident 31's March 2025 Bathing As needed order showed staff provided Resident 31 one shower for the month of March. Review of Resident 31's April 2025 bathing documentation showed staff were to provide the resident showers on Monday and Friday evenings. On five of eight opportunities, staff documented Not Applicable. On one of eight opportunities, staff documented Resident 31 refused to have a shower. Staff documented Resident 31 received one shower for the month of April. Review of Resident 31's May 2025 bathing documentation showed staff were to provide showers to the resident on Monday and Friday evenings. Staff documented Not Applicable on four of nine opportunities. Staff documented Resident 31 refused showers on two of nine opportunities, staff left two of nine shower opportunities blank and did not document. On one of nine opportunities, staff documented Resident 31 received a bed bath. In an interview on 06/13/2025 at 11:05 AM, Staff R stated when staff documented Not Applicable it indicated staff did not offer the resident a shower and did not follow the plan of care for the resident. Staff R stated when a resident refused a shower, staff were supposed to approach the resident three times, if the resident continued to refuse, a refusal form was filled out and staff were supposed to report the refusal to management. <Resident 42> According to a 05/16/2025 Modified Quarterly MDS Resident 42 admitted to the facility on [DATE]. The MDS showed it was very important for Resident 42 to be able to choose between tub bath, bed bath, or showers. The MDS showed the functional ability and goals section dashed (-) on the assistance required for bathing assessment. The MDS showed Resident 42 required moderate assistance with hygiene. Review of Resident 42's 11/12/2024 Baseline Plan of Care CP showed the resident preferred showers or bed baths one time a week on Sundays. The CP showed Resident 42 required moderate assistance with bathing. Review of Resident 42's May and June 2025 bathing records showed no documentation of bathing offered. In an interview on 06/08/2025 at 9:38 AM Resident 42 stated they did not receive a shower since admission to the facility. Resident 42 stated they requested several times for weekend showers and even spoke to the administrator, and they agreed to accommodate Sunday showers, but they were still not offered or received a shower. <Resident 222> According to a 06/10/2025 admission MDS, Resident 222 admitted to the facility on [DATE]. The MDS showed it was very important for Resident 222 to be able to choose between tub bath, bed bath, or showers. The MDS showed Resident 222 required moderate assistance with hygiene. Review of Resident 222's 06/04/2025 Baseline CP showed they required staff assistance for bathing. Review of Resident 222's June 2025 bathing records showed no documentation of bathing offered since admission. In an interview on 06/08/2025 at 12:28 PM Resident 222 stated they were not offered a shower since admission. Resident 222 stated staff gave them baby wipes and informed them they could clean themselves up with them. In an interview on 06/13/2025 at 11:00 AM Staff B (Director of Nursing) stated they expected staff to offer bathing per the CP or residents request and document in the resident's records if they accepted, what type of bathing, or if the resident refused. Staff B stated residents records should not be left blank or documented NA. Staff B stated they expected staff to offer and assist residents per the CP with bathing. Staff B stated it was important to offer residents bathing for hygiene, skin breakdown, and infection prevention. REFERENCE: WAC 388-97-1060(2)(c). Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) related to bathing, shaving, nail care, and grooming for 7 of 7 dependent residents (Residents 64, 24, 9, 31, 53, 42, & 222) reviewed for ADLs. Failure to provide assistance with bathing, shaving, nail care, and grooming to residents who were dependent on staff for the provision of such care, placed residents at risk for unmet care needs, poor hygiene, decreased quality of care, and a diminished quality of life. Findings included . <Personal Hygiene> <Resident 64> According to the 05/06/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 64 was cognitively intact with clear speech, had no rejection of care behaviors and was dependent on staff for personal care including combing hair. In an interview on 06/09/2025 at 2:05 PM, Resident 64 complained they did not have their hair combed since their admission to the facility. Observations on 06/10/2025 at 10:23 AM showed Resident 64 had uncombed, greasy hair twisted into a bun on the top of their head. Resident 64's hair was matted in the back where their head touched the pillow. Observations on 06/13/2025 at 11:12 AM showed Resident 64's hair was unbrushed. In an interview at this time, Resident 64 stated staff only brushed their hair on dialysis days, and they would not brush it thoroughly to remove mats from their hair. Review of Resident 64's May and June 2025 ADL documentation showed no refusals of care for personal hygiene. Review of nursing assistant morning documentation for 05/02/2025, 05/04/2025, 05/09/2025, 05/13/2025, 05/15/2025, 05/19/2025, 05/23/2025, 05/24/2025, 05/26/2025, and 06/01/2025 showed staff did not provide assistance with personal hygiene to Resident 64. Review of nursing assistant evening documentation for 05/04/2025, 05/06/2025, 05/11/2025, 05/23/2025, 05/25/2025, and 06/01/2025 showed staff did not provide assistance with personal hygiene to Resident 64. In an interview on 06/13/2025 at 11:23 AM, Staff M (Licensed Practical Nurse) confirmed Resident 64's hair remained uncombed. Staff M stated they expected staff to assist dependent residents with ADLs daily upon waking in the morning and prior to residents' bedtime. Staff M stated residents had a right to care. In an interview on 06/13/2025 at 12:52 AM, Staff J (Resident Care Manager) stated their expectation was that nursing assistants should receive report in the morning to better understand residents care needs for ADLs and then providing the care. Staff J stated Resident 64 had rejection of care behaviors. Staff J stated rejection of care behaviors should be reported to the nurse for further intervention and documented in the residents' record.

Based on observation, record review, and interview, the facility failed to ensure treatments were done as ordered and documented by staff for 2 of 2 residents (Residents 52 & 28) reviewed for antibiotic use and 1 supplemental resident (Resident 47). Failure to change Intravenous (IV) dressings as ordered by the physician and as documented placed residents at risk for infection, skin impairment, and other negative health outcomes. Findings included . <Facility Policy> According to a facility policy titled, Dressing Change for Vascular Access Devices, dated 08/2021, central venous access device dressings would be changed every seven days and as needed. <Resident 52> According to a 05/20/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 52 had a central IV access and was receiving IV antibiotic therapy. The MDS showed Resident 52 had a diagnosis of, but not limited to, an infection in their bone. Review of Resident 52's health records showed a 05/18/2025 physician order to change IV dressing every seven days and as needed. Review of Resident 52's Treatment Administration Records (TAR) showed the IV site dressing was signed as done on 06/01/2025 and 06/08/2025. Observation on 06/09/2025 at 9:36 AM showed Resident 52's IV dressing with a last changed date of 05/31/2025. <Resident 28> According to a 05/28/2025 admission MDS Resident 28 had a central IV access and was receiving IV antibiotic therapy. The MDS showed Resident 28 had a diagnosis of, but not limited to, Sepsis (a life-threatening condition that arises when the body's response to an infection causes injury to its own tissues and organs). Review of Resident 28's health records showed a 05/22/2025 physician order to change IV dressing every seven days and as needed. Review of Resident 28's TAR showed the IV site dressing was signed as done on 06/01/2025 and 06/08/2025. Observation on 06/09/2025 at 9:36 AM showed Resident 28's IV dressing with a last changed date of 05/31/2025. <Resident 47> According to a 05/28/2025 admission MDS Resident 47 had a central IV access and was receiving IV antibiotic therapy. The MDS showed Resident 47 had a diagnosis of, but not limited to, infection of the heart chambers and valves. The MDS showed Resident 47 had a central IV line which was inserted directly into the heart valve for treatment of the heart infection. Review of Resident 47's health records showed a 04/21/2025 physician order to change IV dressing every seven days and as needed. Review of Resident 47's TAR showed the IV site dressing was signed as done on 06/01/2025. Observation on 06/09/2025 at 9:36 AM showed Resident 47's IV dressing with a last changed date of 05/31/2025. In an interview on 06/09/2025 at 10:01 AM Staff G (Regional Director of Clinical Operations) observed the IV dressings for Residents 52, 28, & 47 and confirmed the last changed date of 05/31/2025. Staff G stated they expected staff to change central IV dressings weekly and as needed. Staff G stated it was important to change central IV dressings weekly and when staff signed the residents TAR that they had changed the dressing to decrease the risk of skin complications, infections, and ensure residents were receiving appropriate care. Reference: WAC 388-97-1060 (1). .

Based on observation, interview, and record review the facility failed to ensure Narcotic Ledgers were accurate for 2 of 2 Narcotic Ledgers (500 cart & 200/300 cart) reviewed for accuracy. Failure to ensure accurate account of resident narcotic medications placed residents at risk for uncontrolled pain, decreased quality of life, and possible diversion of controlled substances. Findings included . <Facility Policy> According to the facility policy titled, Controlled Substances, dated 01/2023, the facility would establish a system of records to ensure accurate reconciliation to account for all controlled drugs. The policy showed at each shift change, a physical inventory of controlled medications would be conducted by two licensed staff and documented on the record. The policy showed any discrepancies in controlled substances would immediately be reported to Staff B (Director of Nursing). The policy showed controlled medications removed from a Narcotic Ledger would include the signatures of the nurse releasing the medication and the nurse or resident receiving the card of medication. <500 cart> Observation and record review on 06/11/2025 at 5:19 AM showed page 60 of the Narcotic Ledger for 500 cart with 21 tablets remaining but no card of the medication on the cart. In an interview at this time Staff O (Registered Nurse) stated they had not caught this missing card when they counted the controlled medications with the day shift. Staff O stated they are expected to go page by page throughout the Narcotic Ledger to ensure accuracy but only counted the physical cards in the lock box. Staff O stated it was important to account for every page in the Narcotic Ledger to ensure no cards of medication were missing. <200/300 cart> Observation and record review of 200/300 cart Narcotic Ledger on 06/12/2025 at 10:20 AM showed the following discrepancies: Page 1 - 63 tablets with one nurse initials transferred to another unit, not the required releasing and receiving nurse. Page 2 - 60 tablets with one nurse initials transferred to another unit, not the required releasing and receiving nurse. Page 3 - 36 tablets with one nurse initials transferred to another unit, not the required releasing and receiving nurse. Page 4 - 4 Milliliters (ml) with one nurse initials transferred to another unit, not the required releasing and receiving nurse. Page 5 - 79 tablets with one nurse initials transferred to another unit, not the required releasing and receiving nurse. Page 6 - 18 tablets with one nurse initials transferred to another unit, not the required releasing and receiving nurse. Page 8 - no name of medication or Prescription (rx) #, 84 ml with one nurse initials transferred to another unit, not the required releasing and receiving nurse. Page 9 - no name of medication or rx #, 240 ml with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 12 - no rx #, 30 tablets with a line crossed through the whole page, no nurse signature for medication card transfer. Page 16 - 68 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 21 - 13 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 22 - 39 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 23 - no rx #, 14 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 24 - no rx #, 8 remaining (form unidentified) with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 26 - 26 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 27 - 12 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 31 - 60 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 32 - 30 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 33 - 60 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 34 - 30 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 35 - 10 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 36 - 8 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 40 - 20 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 41 - 20 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 43 - no rx #, 32 tablets with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 44 - no rx #, 10 bottles with one nurse initials transferred to another unit not the required releasing and receiving nurse. Page 45 - no rx #, 23 remaining (form unidentified) with one nurse initials transferred to another unit not the required releasing and receiving nurse. In an interview on 06/12/2025 at 10:20 AM Staff N (Licensed Practical Nurse) stated there was no cards for these pages. Staff N stated both the releasing and receiving nurse should have signed the Narcotic Ledger but they did not. Staff N they were expected to go page by page in the Narcotic Ledger to ensure all controlled medications were accounted for but did not. Staff N stated it was important to go page by page to catch any missing cards of medications. In an interview on 06/13/2025 at 11:03 AM Staff B stated they expected staff to go page by page in the Narcotic Ledger when counting controlled substances to ensure no cards were missing. Staff B stated when a medication was transferred to another cart or sent home with a resident they expected both the releasing medication nurse and the receiving nurse or resident to sign the amount transferred in the Narcotic Ledger. Staff B stated this was important in prevention of Narcotic diversion and accounting for controlled medications. Reference: WAC 300-97-1300(1)(b)(i-ii). .

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 Percent (%). Failure to properly administer 5 of 28 medications for 2 of 5 residents (Resident 43 & 13) observed during medication pass resulted in a medication error rate of 17.86%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medication. Findings included . <Facility Policy> Review of a 01/2023 facility Medication Administration General Guidelines policy showed the following: medications were to be administered in accordance with written orders of the prescriber; If necessary, the nurse contacts the prescriber for clarification. This policy showed prior to medication administration, the nurse would review and confirm medication orders for each individual resident on the Medication Administration Record (MAR) with the medication label, if different, the prescriber's orders would be checked for the correct dosage schedule and labeled. <Resident 43> Observation of medication pass on 06/11/2025 at 8:53 AM showed Staff P (Registered Nurse) prepare and administer multiple medications to Resident 43, including a pain medication patch to their left hip. At the time of administration, Resident 43 requested the patch to be applied to their left hip. Review of a June 2025 MAR revealed directions to staff to administer the pain medication patch to Resident 43's right shoulder, rather than to the left hip as administered. In an interview on 06/11/2025 at 9:05 AM, Staff P stated they should have clarified the physician's order prior to administering the patch to a location different than directed in the order. <Resident 13> Observation of medication pass on 06/12/2025 at 9:45 AM showed Staff Q (Licensed Practical Nurse) prepare and administer multiple medications to Resident 13, including a low dose chewable medication used to prevent heart attacks, 25 milligrams (mg) of a blood pressure medication, and 30 mg of an antidepressant. Staff Q did not apply a pain medication gel during the observation. Review of a June 2025 MAR revealed directions to staff to administer an enteric (special coating to slow the release of a medication) coated low dose medication used to prevent heart attacks, rather than the chewable form that was administered by staff. The blood pressure medication showed directions to administer 75 mg, rather than the 25 mg that was administered. The antidepressant medication showed directions to administer 60 mg, rather than the 30 mg administered by staff. This MAR showed staff documented they administered a pain medication gel to Resident 13's shoulder, however no gel was administered during the med pass observations. In an interview on 06/12/2025 at 10:42 AM, Staff B (Director of Nursing) stated it was their expectation nursing staff complete the seven rights of medication administration, which included assuring the right medication, the right dose, and the right route were followed prior to administration. Staff B stated physician orders should be followed and administered as prescribed. REFERENCE: WAC 388-97-1060(3)(k)(ii). .

<100 Unit> <Resident 44> Review of Resident 44's 06/09/2025 physician orders showed the resident did not have an order directing staff to keep medications at the resident's bedside. Observation on 06/08/2025 at 8:33 AM showed a topical pain-relieving patch on Resident 44's nightstand. Observation on 06/13/2025 at 10:32 AM showed the topical pain-relieving patch remained on Resident 44's nightstand. In an interview at that time, Staff P (Registered Nurse) stated the topical pain-relieving patch should not be left on the resident's nightstand. Staff P removed the unsecured patch from the resident's room. Reference: WAC 388-97-1300(2), -2340. Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 2 of 2 medication carts (Medication carts 200/300 & 500), 1 of 1 medication rooms (Medication room [ROOM NUMBER]), and 3 of 3 units (Units 500, 200/300, & 100), 3 of 3 residents (Resident 11, 32 & 44) observed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective treatment, accidental ingestion of medication, and a diminished quality of life. Findings included . <Facility Policy> According to a facility policy titled, Medication Storage, dated 01/2023, the facility would store medications properly, following manufacturer or provider pharmacy recommendations, to maintain their integrity and effectiveness. The policy showed staff would date insulin products and nasal sprays upon opening for initial use and discard medications with shortened dates. The policy showed medication and supplies would be stored in a locked medication cart or room only licensed nurses would have access to. According to a facility policy titled, Enteral Feeding Tube, dated 05/2025, containers of tube feeding formula opened and not used in their entirety were to be labeled with the time and date, covered, and kept in the refrigerator when not in use. <200/300 Medication Cart> In an observation, record review and interview on 06/12/2025 at 10:20 AM, medication cart 200/300 showed one nasal spray opened on 04/21/2025, three opened nasal sprays without documentation of the open date on them, and one insulin pen opened without documentation of the open date on it. Staff N (Licensed Practical Nurse) stated the 04/21/2025 nasal spray should be discarded after 30 days of opening, the three bottles of nasal spray opened and being used should have an open date documented on them to ensure not administering past the 30 day limit for nasal sprays, and the one insulin pen should also have an open date documented on it to ensure it was discarded after 28 days of opening. Staff N stated it was important to discard nasal sprays after 30 days of opening and insulin after 28 days of opening to ensure effective treatment for these types of medications. <500 Medication Cart> In an observation, record review, and interview on 06/11/2025 at 5:19 AM, 500 medication cart showed a card of 30 tablets of a medication used to treat high blood pressure with an expiration date of 06/01/2025, another card of 75 tablets for high blood pressure expired on 05/21/2025, and nine bottles of medicated creams that are to be applied to the skin stored next to medications that are to be inhaled into the lungs. Staff O (Registered Nurse) stated the expired medications should not be destroyed to ensure staff were not administering them. Staff O stated skin creams should be separated from inhaled medications and stored on the treatment cart for infection prevention. <500 Medication Room> In an observation, record review, and interview on 06/11/2025 at 5:09 AM, 500 medication room showed two bottles of vitamins expired on 05/20/25, 32 syringes expired on 04/06/2024, 23 needles expired on 03/09/2023, and an intravenous device stabilizer expired on 02/28/2024. Staff O stated these medications and supplies should be discarded by the expiration date and not stored in the medication room. Staff O stated it was important to discard expired medications and supplies to ensure that residents were not receiving expired medications or treatments. In an interview on 06/13/2025 at 11:03 AM Staff B (Director of Nursing) and Staff G (Regional Director of Clinical Operations) stated their expectations of staff were to remove and destroy expired medications and supplies upon expiration. Staff B stated they expected staff to date nasal sprays upon opening and discard in 30 days of opening and date insulin upon opening and discard in 28 days after opening. <500 unit> In an observation, record review, and interview on 06/11/2025 at 10:22 AM, room [ROOM NUMBER] had multiple wound care supplies stored on their nightstand to include wound cleanser sprays and medicated skin protectant sprays. In an interview on 06/13/2025 at 9:32 AM Staff H (Infection Preventionist) stated they stored the wound care supplies in the residents room to prevent infection and to ensure all staff had access to the supplies. Staff H stated the nurses that required access to the supplies did have access to the locked treatment supply cart and there wasn't a concern of contamination of the supplies in the treatment cart. Staff H stated it was important to store wound care supplies in the locked treatment cart to prevent infection and for the safety of other residents. In an interview on 06/13/2025 at 11:06 AM Staff B stated they expected staff to store wound care supplies in the locked treatment cart and not in resident rooms. Staff B stated it was important to prevent contamination of the supplies and for resident safety. <Medications At Bedside> <Resident 11> Observation on 06/11/2025 at 7:33 AM showed a container of topical anti-fungal cream and a container of anti-fungal powder on Resident 11's bedside cabinet. Resident 11's name was on the label. Review of Resident 11's 06/10/2025 physician orders showed the resident did not have an order directing staff to keep medications at bedside. <Resident 32> Observations on 06/11/2025 at 7:35 AM showed a half-full container of tube feeding formula on Resident 32's bedside cabinet. The container was not labeled with Resident 32's name, date opened or timed. Review of Resident 32's health records showed a 05/07/2025 physician order to administer 300 ml of tube feeding formula two times a day at 8:00 AM and 8:00 PM. In an interview on 06/11/2025 at 7:35 AM, Staff I (Registered Nurse) stated that medications and opened containers of tube feeding formula should not be left in the residents' rooms. Staff I stated that topical medications should be dispensed into disposable cups prior to entering the resident's room and bottles should remain in the medication cart.

Based on observation, interview, and record review the facility failed to provide care in a manner that promoted dignity for 2 (Resident 13 & 18) of 17 sample residents reviewed. The facility failed to provide privacy during medication pass for Resident 13 and have washcloths available for staff and residents to use for personal care for Resident 18. These failures placed residents at risk for feelings of diminished self-worth and embarrassment. Findings included . <Resident 13> Observations during medication pass on 06/12/2025 at 9:45 AM showed Staff Q (Licensed Practical Nurse) prepare medications for Resident 13. Another staff member from the activities department went into Resident 13's room and brought the resident out in a wheelchair to join an activity. Staff Q stopped the staff member and let them know they needed to administer Resident 13's medications first, and stated, you can leave [them] here. Staff Q put on gloves, administered the medications, and handed the resident an inhaler to use. Staff Q then administered eye drops while Resident 13 remained in the hallway and other residents were walking by. In an interview on 06/12/2025 at 10:42 AM, Staff B (Director of Nursing) stated it was their expectation staff not administer medications in the hallway and that staff should offer the medication administration to be conducted in private to promote dignity for a resident. <Resident 18> In an interview on 06/08/2025 at 1:43 PM, Resident 18 stated they were frustrated the facility was often out of washcloths and reported they had to be, cleaned with a pillowcase. Resident 18 stated they were embarrassed that a pillowcase had to be used for their toileting hygiene care. Observations on 06/10/2025 at 8:47 AM showed the linen closet on the 100 and 500 units had no washcloths available. In an interview on 06/10/2025 at 1:35 PM, Resident 18 stated there were still no washcloths available the night before. Observations on 06/11/2025 at 5:00 AM revealed no washcloths were available in the laundry department. In an interview at this time, Staff Y (Housekeeping Supervisor) stated they did not have any washcloths currently available and stated, they are gone. Staff Y stated they put out 300 washcloths originally, but the linen closets were empty when they go to restock them. Staff Y stated they would be ordering linen this month but with the budget, they were not able to order as often. Staff Y stated the washcloths started slowly disappearing and have had a minimal amount for a few weeks. Staff Y stated they kept a log with outgoing linen counts which showed only 44-49 washcloths were going out to be used by the whole facility. Staff Y stated they had no washcloths to put out for the day, but would be washing some loads to have some back out on the floor within a couple hours. Observations on 06/11/2025 at 5:20 AM showed no washcloths for residents or staff were available in the 500-unit linen closet. In an interview on 06/11/2025 at 5:23 AM, Staff Z (Certified Nursing Assistant - CNA) stated they do not usually have washcloths available and stated, we have a tiny stack for the whole building. When asked how long they have been out of washcloths, Staff Z stated, at least a couple weeks. Observations on 06/11/2025 at 5:49 AM showed no washcloths were available for residents or staff in the 100-unit linen closet. Staff Y was observed restocking the 100-unit linen closet but had no washcloths. In an interview at this time, Staff Y stated, the director is going to buy them today to tide us over. In an interview on 06/11/2025 at 10:55 AM, Resident 18 stated there were no washcloths available, so staff had to use a towel for their toileting hygiene care and stated, at least it wasn't a pillowcase this time. In an interview on 06/11/2025 at 11:01 AM, Staff AA (CNA) stated they were frustrated with the lack of washcloths and stated, I don't know where they are going. Staff AA stated they only had five washcloths to start the day providing showers to residents and stated the supply was low, off and on for a while. In an interview on 06/12/2025 at 10:36 AM, Staff BB (CNA) stated the facility had finally ordered some washcloths but stated, we had zero for at least the past three weeks. Staff BB stated there were a couple of residents that expressed concerns regarding not having washcloths available for use. In an interview on 06/12/2025 at 3:28 PM, Staff CC (CNA) stated they struggled not having washcloths and it was hard explaining to residents when they asked why there are none. Staff CC stated they would often have to use towels, and at times, pillowcases, if they did not have the supplies they needed for resident care. In an interview on 06/13/2025 at 11:34 AM, Staff B stated it was their expectation towels and washcloths be readily available for use by staff and residents. Staff B stated not having the supplies needed for care was a dignity issue and stated this was the resident's home, they should be treated the way we would want to be treated. REFERENCE: WAC 388-97-0180(1-4). .

Based on interview and record review the facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 2 (Residents 73 & 74) of 3 discharged residents reviewed. This failure caused a delay in reconciling residents' accounts within 30 days as required. Findings included . <Facility Policy> According to a revised facility [DATE] Resident Trust Fund policy, the facility would maintain resident trust fund accounts in accordance with state and federal regulations. This policy showed when a resident discharged or expired, the balance of the resident's personal funds would be returned to the resident, responsible party, or as directed by state regulation. <Resident 73> Record review showed Resident 73 discharged from the facility on [DATE]. Review of the facility's trust records showed the resident had a balance of $229.61 which was not transferred to the OFR until [DATE], over three months after Resident 73's discharge from the facility. <Resident 74> Record review showed Resident 74 discharged from the facility on [DATE]. Review of the facility's trust records showed the resident had a balance of $55.84 which was not transferred to the OFR until [DATE], four days after the 30 day timeframe. In an interview on [DATE] at 2:32 PM, Staff E (Business Office Manager) reviewed the accounts and confirmed the trust balances were not transferred within the 30 day timeframe from the residents' discharges, as required. REFERENCE: WAC 388-97-0340(4)(5). .

<Resident 24> According to a 02/10/2025 Annual MDS, Resident 24 had no areas of concern for their dental status. In an interview on 06/08/2025 at 12:06 PM, Resident 24 stated they had some broken teeth that needed to be fixed for a while. Review of Resident 24's revised 02/29/2024 dental health CP showed tooth decay was found on an oral assessment and gave instructions to staff to coordinate arrangements for dental care, transportation as needed. Record review showed Resident 24 was seen by dental on 05/05/2025 with documentation showing the resident had several decayed and broken teeth and required a referral for evaluation and extractions. In an interview on 06/13/2025 at 10:31 AM, Staff D stated it was important to have an accurate MDS to provide a proper picture of the resident and to CP appropriately. Staff D reviewed Resident 24's 02/10/2025 Annual MDS and stated the dental status section was coded inaccurately and needed to be modified. <Resident 26> According to a 04/16/2025 Significant Change MDS, Resident 26 had multiple medically complex diagnoses including heart failure and a psychotic disorder (a severe mental illness that causes abnormal thinking) and required the use of an antipsychotic medication during the assessment period. This MDS showed staff did not mark Resident 26 was receiving a diuretic (water pill) medication and in a different section, staff marked No antipsychotics were received. Review of the April 2025 medication administration record showed Resident 26 was receiving diuretic medication daily and an antipsychotic medication twice daily. In an interview on 06/13/2025 at 10:31 AM, Staff D reviewed Resident 26's 04/16/2025 Significant Change MDS and stated the resident was receiving a diuretic and an antipsychotic medication during the assessment period and the MDS was coded inaccurately. <Resident 46> According to a 05/22/2025 Significant Change MDS, Resident 46 had multiple medically complex diagnoses including anxiety, depression, a mental illness characterized by extreme mood swings, and a mental health condition that developed after experiencing or witnessing a traumatic event. This MDS showed Resident 46 required the use of antipsychotic and antianxiety medications during the assessment period. This MDS showed staff indicated Resident 46 was not currently considered to have a serious mental illness. Review of a 04/16/2025 behavioral health notice of determination form showed Resident 46 had an evaluation and was determined to have a mental health diagnosis and may benefit from specialized behavioral health services. In an interview on 06/13/2025 at 10:31 AM, Staff D reviewed the 05/22/2025 Significant Change MDS and stated Resident 46 was identified with a serious mental illness and the MDS was coded inaccurately. REFERENCE: WAC 388-97-1000 (1)(b). Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) accurately reflected the status for 5 (Resident 6, 70, 24, 26, & 46) of 17 sample residents reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <Facility Policy> According to the facility's Resident Assessment Instrument (RAI) policy, revised 03/2019, showed the facility would complete MDS assessments per the RAI manual. <Resident 6> Review of Resident 6's 01/08/2024 alteration in gastrointestinal (bodily system involved in digestion and absorption of food) status . Care Plan (CP) showed the resident had a colostomy (surgical procedure creating an opening in the abdomen that collects bowel movements into an external pouch). The CP directed staff to care for the colostomy each shift and instructed nursing aides to empty the pouch every shift. Review of Resident 6's 03/26/2025 Quarterly MDS showed staff coded the resident as being occasionally incontinent of bowel instead of Not Rated, resident had an ostomy . In an interview on 06/12/2025 at 10:16 AM, Staff D (MDS Coordinator) reviewed Resident 6's record and confirmed the MDS was coded inaccurately. Staff D stated the 03/26/2025 MDS required modification. <Resident 70> According to Resident 70's 04/14/2025 Comprehensive MDS, the resident discharged from the facility with their return not anticipated. The MDS showed Resident 70 discharged to a short-term hospital on [DATE]. Review of Resident 70's nursing progress notes showed a 04/14/2025 progress note stating the resident discharged from the facility against medical advice. Staff explained the risks of leaving against medical advice. The resident left the facility at 4:45 PM that day. In an interview on 06/25/2025 at 10:15 AM, Staff D reviewed Resident 70's records and confirmed the 04/14/2025 MDS was coded incorrectly and required modification.

Based on interview, and record review the facility failed to ensure the correct type of sling was used to safely transfer 1 of 3 residents (Resident 1) reviewed for mechanical lift transfers. Resident 1 experienced harm when they were transferred incorrectly and sustained a spinal injury. Findings included . <Facility Policy> According to the facility's policy titled Fall Evaluation and Management, after a fall residents would be evaluated, cared for, and appropriate notifications made. Review of the Quarterly Minimum Data Set (MDS - an assessment tool) dated 04/20/2024, showed Resident 1 had adequate hearing and adequate vision with corrective lenses. The MDS showed Resident 1 had intact memory and diagnoses including a seizure disorder, brain damage, and a condition that caused convulsions (involuntary jerking movements). The MDS showed Resident 1 had functional limits to both the upper and lower extremities range of motion and was assessed to be totally dependent on staff for transfers. Review of the May 2024 Medication Administration Record (MAR) showed Resident 1 received a muscle relaxant continuously via a pump for convulsions. Resident 1 also received the same medication orally as needed. Record review of Resident 1's care plans and evaluations from admission on 08/04/2022 through 05/21/2024 showed no documented assessment to establish what kind or size of sling Resident 1 required for safety during transfers. Review of the Functional Mobility Care Plan (CP) revised 04/26/2024 showed Resident 1 required the assistance of two staff for transfers. The CP included an 11/27/2023 intervention that showed Resident 1 required the use of a mechanical lift for transfers. This CP did not document the size or type of sling Resident 1 required for transferring with a mechanical lift. The CP did not document which sling(s) should be used or were compatible with the lift Review of the 11/02/2023 risk for falls CP, revised 11/02/2023, showed Resident 1 was at risk for falls due to their brain injury, balance problems, use of psychoactive medications, and their seizure disorder. The CP included an 08/15/2022 goal for Resident 1 to be free of falls. Review of an alert charting progress note dated 05/21/2024 at 9:55 PM showed Resident 1 fell from their sling while being transferred by two Certified Nursing Assistants (CNAs) with a mechanical lift. The note showed the resident slid from the sling; the CNAs assisted the resident to the floor. The CNAs identified no injury at that time. The note showed on 05/21/2024 at 10:15 PM Resident 1 complained of back pain, and upon assessment by the nurse, a one-inch-long by one-inch-wide dark red bruise along the spine and a two-inch-by-two-inch closed abrasion on the back right rib cage were identified. The note showed the nurse informed the physician who ordered an X-ray as soon as possible. Review of the nursing progress note, dated 05/22/2024 at 2:53 PM, showed a spinal X-ray was obtained that morning and Resident 1 was noted to have a mild compression fracture of their T5 vertebra, and the resident was sent out to the hospital. A progress noted dated 05/22/2024 at 9:42 PM note showed Resident 1 returned to the facility later that day. Review of the 05/22/2024 emergency room (ER) notes showed Resident 1 was diagnosed with compression fractures to their T4 and T5 vertebrae. In an interview on 05/24/2024 at 9:35 AM Staff A (Director of Nursing) stated the two CNAs (Staff B and Staff C) assisting Resident 1 when they fell were new hires at the time. Staff A stated Resident 1 was assessed to require a medium whole-body sling for use with the mechanical lift. Staff A stated Resident 1 complained in the past of discomfort during transfers and was provided a split sling (a sling braces the body across the back and has straps that loop under the thighs for support) instead of the sling the resident was assessed to require. Staff A was unsure when this change occurred. Staff A stated Resident 1 began to have tremors during the transfer and slid through the sling and was guided by staff to the floor. In an interview on 05/24/2024 at 10:13 AM Resident 1 stated they did not think the sling was put on right. Resident 1 stated the sling felt different. Resident 1 stated they felt they were leaning more forward than normal when elevated in the sling that day. Resident 1 stated Staff C bumped the wheel of the lift with the resident's wheelchair, at which point Resident 1 began to move, and then slid through the sling on to the floor. Resident 1 stated the Staff B and Staff C placed them back in bed. Resident 1 stated both CNAs were upset, and the resident attempted to calm Staff C who was most upset. In an interview on 05/24/2024 at 10:40 AM Staff B stated Staff C asked for their assistance to transfer Resident 1 on the night of 05/21/2024. Staff B stated they used the split sling to transfer Resident 1 but was not sure if this was the resident's usual sling. Staff B stated after the wheelchair bumped the wheel of the lift Resident 1 began to spasm and fell to a sitting position on the floor. Staff B stated they and Staff C then moved Resident 1 back into their bed from the floor and informed the nurse. After this, the nurse came the Resident 1's room and assessed the resident for injury. In an interview on 05/24/2024 at 11:10 AM Staff D (Staff Development Coordinator) stated the therapy department was responsible for assessing lifts and slings for residents who required them for transferring. Staff D stated once therapy determined the type and size of sling required, they informed the resident care manager. In an interview on 05/29/2024 at 11:48 AM Staff E (Director of Rehabilitation) stated they did not know where an assessment for a sling would be located and that this process was not the therapy department's responsibility. Staff E stated in [AGE] years they had no recollection of therapy participating in this process. In an interview on 05/29/2024 at 12:24 PM Staff A stated the therapy department was responsible for sling assessments. Staff B stated they would have to double check with Staff E regarding sling assessments. Staff B stated the assessment would be reflected on the CP. Staff B stated Resident 1 used the split sling since they started working at the facility. Staff B stated if facility staff discussed the risks and benefits of using the split sling with Resident 1, it was done so orally and there was no record of that process. Review of the CP showed an intervention for a medium full body sling was added to Resident 1's CP on 05/22/2024, the day after the fall from the sling. There was no size and type of sling documented in the CPs prior to the fall. REFERENCE: WAC 388-97-1060 (3)(g).

Based on observation, interviews and record reviews the facility failed to take appropriate actions related to a COVID-19 outbreak. These failed practices may have contributed to multiple residents and staff contracting COVID-19. As of [DATE], based upon the facility's incomplete LTC (Long Term Care) Respiratory Surveillance Line List, and multiple staff interviews, 15 residents tested positive for Coronavirus disease (COVID-19) and 9 residents had pending lab results. Three residents who tested positive for COVID-19 remained at the local hospital. As of [DATE] 38 residents and 10 staff tested positive for COVID-19. Five residents expired. Additionally the facility failed to operationalize their infection prevention and control program to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases and infections, in particular COVID-19. These failed practices resulted in an immediate jeopardy on [DATE]. Findings included . On [DATE]th CMS (Center for Medicare & Medicaid Services) released a transmittal to nursing homes that directed nursing homes to monitor the CDC (Center for Disease Control) website which included a link to CDC. Upon clicking on the link it directs the facility to a Coronavirus Disease 2019 (COVID-19) Preparedness Checklist for Nursing Homes and other Long-Term Care Settings This checklist should be used as one tool in developing a comprehensive COVID-19 response plan. The checklist did not describe mandatory requirements or standards; rather, it highlights important areas to review to prepare for the possibility of residents with COVID-19. In general, when caring for residents with undiagnosed respiratory infection use Standard, Contact, and Droplet Precautions with eye protection unless the suspected [DIAGNOSES REDACTED].g., [MEDICAL CONDITION]). This includes restricting residents with respiratory infection to their rooms. If they leave the room, residents should wear a facemask (if tolerated) or use tissues to cover their mouth and nose. Continue to assess the need for Transmission-Based Precautions as more information about the resident's suspected [DIAGNOSES REDACTED]. Observations were conducted on [DATE] from 1:41 PM until 2:46 PM. VISITOR ENTRY Review of the facility February 2020 Infection Prevention and Control Recommendations for Patients with Confirmed Coronavirus Disease (COVID-19) or Persons Under Investigation for COVID-19 policy, showed the procedure directed staff to manage visitor access and movement within the facility. The Centers of Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings recommended, Limit points of entry to the facility. The back door was posted with the following signs; No Admittance - Use front door only, Attention: Due to recent outbreak of COVID-19 in our nation we are trying to minimize all-essential access to the center and a second posting to those with questions, regarding the facility's management of [MEDICAL CONDITION], to call Staff C with a listed phone number. The front door had one sign posted directing those with questions, regarding the facility's management of [MEDICAL CONDITION], to call Staff C with a listed phone number. On [DATE] Staff G, Housekeeping, was observed walking down the hallway, carrying a mask, looking for assistance as they were told to spray with disinfectant and bag the mask before going home. Administrative Staff assisted Staff G, who then exited the facility out the back door. Later on, during the onsite visit, Staff G was observed in the facility without wearing a protective facial mask. Staff G was not observed to have come into the facility by either the front or back entrance, nor observed to have been screened for symptoms of COVID-19. During an interview on [DATE] at 1:04 PM, Staff D stated that she did not know how staff G re-entered the facility, but she re-educated Staff G on the process. According to Staff D, the facility doors are locked but staff have a code to unlock the door and enter the facility. When asked why Staff G returned, Staff D stated that Staff G went to get a Burrito or Taco out of the break room. The Centers of Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings recommended, All visitors should be actively assessed for fever and respiratory symptoms upon entry to the facility. If fever or respiratory symptoms are present, visitor should not be allowed entry into the facility. Upon entrance to the facility, on [DATE] at 1:41 PM, the facility requested the surveyor to complete a health screening form at the reception desk, located in the foyer, directly to the right of the front entrance. Located at reception was a sign in sheet with visitors listed. During an interview with Staff A, the visitors listed included two plumbers on [DATE] and a hospice staff member on [DATE]. Staff A, Administrator, then escorted the surveyor, down the hallways, past ten resident rooms,and through resident care areas, to Nursing Station #2 located in the 500 unit the epicenter of the facility's COVID-19 outbreak, to be screened for the presence of a fever. The only thermometer available, at the nurse's station, was an oral thermometer, so the surveyor had to remove their face mask to be screened for the presence of a temperature. When questioned regarding the use of an oral thermometer, Staff A stated, That's all we have. INFECTION SURVEILLANCE HealthCare Workers A [DATE] letter to Long-Term Care Facility Director, from WA (Washington) State DOH (Department of Health), instructed the facility to Immediately notify the health department about anyone with COVID-19 or if you identify two or more residents or healthcare providers who develop respiratory infections within a week. Review of the facility COVID-19 Timeline showed that on [DATE] three staff (Staff H, I, J) were identified as symptomatic. The facility failed to notify the Department or DOH of healthcare workers with symptoms. According to the facility provided Timeline, on [DATE] Staff K exhibited symptoms of a fever and cough. Review of the line listing provided by the facility on [DATE] at 9:03 AM showed, Staff K was not entered on the line list. Further review of the facility Timeline showed on [DATE], Staff L, M, B, D and N were symptomatic. Review of the line listing, provided by the facility on [DATE] at 9:03 AM, showed the results of testing conducted were not noted for Staff L, M and N. Residents On [DATE] at 4:01 PM the Department received an anonymous Report that: Supposedly the facility is in lockdown yet they are admitting patients from St.(NAME)Hospital in Enumclaw where the coronavirus has affected a patient. According to the facility Timeline, On [DATE] Resident #14 and #15 were admitted to the facility. On [DATE] Resident #13 was readmitted to the facility from St.(NAME)Hospital. Staff B, interviewed on [DATE] at 10:00 AM, stated that the facility stopped admitting residents on [DATE] because residents exhibited symptoms of suspected COVID-19. On [DATE] at 7:18 PM the Department received notification from the facility of seven Residents (#s 8, 9, 10, 11, 12, 13 & 14) who presented with acute fever and/or respiratory symptoms. According to the report, Per Medical Director, all symptomatic residents were placed on Droplet/Contact isolation and sent to the Emergency Department for COVID testing. Review of the line listing showed Resident's #s 12, 13, & 14 first exhibited symptoms on [DATE], but review of the resident's clinical records showed on [DATE] that Residents #12 and #13 had elevated temperatures and Resident #14 had other reported symptoms that were present. During an interview on [DATE] at 1:04 PM Staff D stated that she and Staff B called the DOH on [DATE] after they received a resident's COVID-19 positive test result. The DOH representative sent the facility the Long Term Care (LTC) Tool Kit to use and said if the facility had questions or needed help to call. Staff D stated that she had been emailing the line lists, but the facility had not called and requested assistance, and had not spoken with a DOH representative since [DATE]. During an interview on [DATE] at 10:00 AM, Staff B stated that DOH called the facility back and said they wouldn't go out to the facility because there were only three COVID-19 positive residents of seven tested . Review of the documents provided by Staff C on [DATE] included the LTC (Long Term Care) Tool Kit included Aggressive Infection Prevention and Control Actions for Facilities with Suspected or Confirmed Cases of COVID-19, which directed the facility to Treat all other residents in that same section or unit as if they have been exposed and implement Droplet and Contact Precautions with eye protection in the entire unit. Review of facility Infection Control (IC) documentation showed Resident #1 was in room [ROOM NUMBER], bed B on [DATE]. On [DATE] Resident #2 was also in room [ROOM NUMBER], bed A. On [DATE] Resident #2 was symptomatic for COVID-19, and moved to room [ROOM NUMBER]A on the 200 unit, which the facility dedicated to the care of COVID-19 positive residents. Resident #2 tested positive for COVID-19 on [DATE]. Resident #1 remained in room [ROOM NUMBER], and was not placed on precautions until Resident #1 exhibited symptoms on [DATE]. Resident #1 tested positive on [DATE]. On [DATE] Resident #3 and Resident #4 were roommates in room [ROOM NUMBER]. On [DATE] Resident #3 exhibited symptoms, was moved to the 200 unit and tested positive for COVID-19. On [DATE] Resident #4 was not observed on precautions. During an interview on [DATE] Staff B stated that Resident #4 was exhibiting symptoms and was placed on isolation this morning. On [DATE] Resident #5 and Resident #6 were roommates in room [ROOM NUMBER]. On [DATE] Resident #5 was observed in room [ROOM NUMBER], on precautions, pending COVID-19 test results. On [DATE] Resident #5's COVID-19 test results were positive. On [DATE] Resident #6 was observed in room [ROOM NUMBER] still not on any isolation precautions. During an interview on [DATE] at 1:04 PM when asked why roommates of symptomatic residents were not placed on precautions until symptomatic, Staff D stated that they were told by corporate not to start the roommate on isolation, and continue with surveillance to conserve PPE (Personal Protective Equipment). Corporate Nurse, Staff C, interviewed on [DATE] at 1:45 PM, stated that roommates, of residents who were positive for the COVID-19 virus, were not placed on any isolation precautions unless the roommates presented with symptoms of COVID-19, to conserve PPE's. On [DATE] all staff were observed wearing masks. Review of documents Covid-19 Timeline provided by the facility showed that on [DATE] all staff that had contact with positive residents were issued a facemask to be worn, and education was provided. In an email on [DATE] at 3:11 PM, when asked when the facility implemented universal face masks were to be worn by all staff, Staff A replied, [DATE]. STANDARD and TRANSMISSION-BASED PRECAUTIONS On [DATE] Resident #7's room was observed with posted precautions, and an infection control (IC) cart outside the room. Staff F, Lead Aide was observed to donn and doff Personal Protective Equipment (PPE) to respond to Resident #7's request for potato chips. Staff F was wearing a N95 mask, donned disposable gown and gloves but there was no eye protection in the IC cart. Staff D went down the hallway and retrieved goggles, which Staff F donned over N95 mask. Staff F entered the resident's room, provided the potato chips, and removed the gown and gloves prior to exiting the room. Outside the room, Staff F removed the goggles, and disinfected them. Staff D cued Staff F that the removal and cleaning of goggles should have been conducted before leaving the room. Refer to WAC [DATE](1)(a)(2)(a)(b)(c)

Based on observation, interview, and record review, the facility failed to accurately assess and monitor facility water temperatures to ensure safe water temperatures. The likelihood of serious injury [MEDICAL CONDITION] to elevated water temperatures, constituted a situation of Immediate Jeopardy (IJ) on 02/26/2020. Additionally, the facility failed to thoroughly investigate accidents to determine the circumstances of resident accidents and implement measures to prevent reoccurrence for two (#23 & 42) of four residents reviewed for falls. These failures placed the residents at a potential risk of harm related to avoidable incidents. Findings included . REGULATION Water Temperature - Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident.[MEDICAL CONDITION] to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk [MEDICAL CONDITION] by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, [MEDICAL CONDITION], decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. According to regulatory guidance, based upon the time of the exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn, as follows: First-[MEDICAL CONDITION] the top layer of skin (e.g., minor sunburn). These may present as red and painful to touch, and the skin will show mild swelling. Second-[MEDICAL CONDITION] the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. Third-[MEDICAL CONDITION] the entire thickness of the skin and permanently destroy tissue. These present as loss of skin layers, often painless (pain may be caused by patches of first- and second-[MEDICAL CONDITION] third-degree burns), and dry, leathery skin. Skin may appear charred or have patches that appear white, brown, or black. CMS provides the following guidance for the amount of time which would cause a third degree burn at the following temperatures: 15 seconds at 133°F (Fahrenheit), one minute at 127°F, three minutes at 124°F, and five minutes at 120°F. CMS advises,[MEDICAL CONDITION] occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. FACILITY POLICY The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. According to the facility Preventative Maintenance Manual dated July 2008, Washington State Water Temperature Regulations reference, The facility must ensure: The hot water system maintains water temperatures at one hundred ten degrees Fahrenheit, plus or minus ten degrees F, at fixtures used by residents and staff. OBSERVATIONS Observation on 02/26/2020 at 8:05 AM, showed room [ROOM NUMBER] with water temperatures of 126 F, rooms #517/518 with water temperatures of 121 F; and at 9:40 AM room [ROOM NUMBER] was noted with a temperature of 125.8 F. During observations and interview on 02/26/2020 at 9:40 AM, Staff M, Maintenance Director, was noted to use a laser thermometer to test the water temperatures. Staff M pointed the laser through the running streams of water from the faucets, with the laser dot placed on the back of the sink. Using this method, at 9:45 AM, Staff M, confirmed a temperature of 117 F in room [ROOM NUMBER]. Upon changing the angle of the laser, Staff M obtained different water temperatures, confirming a temperature of 123 F, when aiming the laser at the bottom of the sink. According to the Raytek Minitemp MT2 Infrared Thermometer manufacturer's specification indicated the infrared thermometer allows user to accurately measure surface temperatures. An infrared thermometer measures the surface temperature of an object. Steps you need to take to measure the temperature of water using an infrared thermometer were identified as: Prepare a vessel with a strip of electrical tape on its side to prevent reflected infrared energy, which can to skew your readings; Pour the water that you want to get a temperature reading on into the vessel; Point the laser end of the infrared thermometer toward the strip of electrical tape at the side of the vessel; the temperature will be displayed in the digital screen; To verify the results, take at least two readings. Review of facility temperature monitoring logs showed that for January and February 2020, temperatures averaging 114-117 F. In an interview on the morning of 02/26/2020, Staff M stated he pointed the gun at the water and let it heat up to 117 and turn the gun off. According to facility provided documents, no water temperatures were monitored in December 2019. In an interview on 02/26/2020 at 9:52 AM, when asked if Staff M failed to accurately measure water temperatures, Staff B stated, I don't think you are wrong. Subsequent observations with Staff B, Director of Nursing, confirmed temperatures of 123.4 F in room [ROOM NUMBER] at 10:11 AM. At 10:14 AM, Staff M noted temperatures of 122.7 F in the 500 unit shower room and a temperature of 123.4 F in room [ROOM NUMBER] at 10:21 AM. In an interview on 02/26/2020 at 11:46 AM, Staff T, a facility contractor staff, stated that he altered the boiler that serviced the 500 hall and stated, The factory setting for the boiler says 120 degrees, that's the target, I turned it down to 115 degrees . When asked what the factory settings were, Staff T explained, It usually means (the boiler should be) set to 120 plus or minus. When asked, based on the manufacturers recommendations, what the boiler temperature should be set at, Staff T replied, I'd always set it at 120 degrees, that is what it comes (set) at. Staff T confirmed the boiler temperature should have been set at 120 degrees F, rather than 130 degrees F, the temperature at which facility maintenance staff had set the boiler. Observations on 02/27/2020 at 9:54 AM showed the boiler temperature for the 1-400 unit was set at 125 F. In an interview at 10:10 AM, Staff A, Administrator stated the staff method for testing water was, We are putting a cup in the bottom of the sink and putting in a submersible thermometer .Everybody's been in-serviced on that way .that's how (Staff T) does it. Maintenance staff failed to provide monitoring to ensure safe water temperatures. Maintenance staff utilized a temperature gun which assessed the surface temperature of the side of the sink, rather than the actual water temperature. Staff failed to document the location and times the temperatures were assessed. In an interview on 2/26/2020 at 10:26 AM Staff B, DNS, indicated the system for checking water temperatures was flawed and confirmed water temperatures, exceed regulation. RESIDENT INTERVIEWS In an interview on 02/26/2020 at 11:21 AM, Resident #63, in room [ROOM NUMBER], when asked if she had concerns with water temperature stated, Yes, it is hot. You have to turn the cold on and be careful. If you just turn the hot on, you better be ready. In an interview on 02/26/2020 at 11:38 AM, Resident #12, residing in room [ROOM NUMBER], stated, It's (water) damn hot, when asked about water temperature concerns. When asked why the resident thought the water was hot, Resident #12 stated, Well, when I put my hand under it, I couldn't hold it there. In an interview on 02/26/2020 at 11:29 AM, Resident #54, in room [ROOM NUMBER] stated, its hot (water), you have to do cold water with it. When asked how he determined the water was hot, the resident stated, I stuck my hand in it and said Oh[***] In an interview at 11:35 AM on 02/26/2020, Resident #45, in room [ROOM NUMBER], stated, It (water) tends to be rather warm. You have to be careful. I think it would take the hair off a pig. I would hesitate to let others here use it. When asked if she told staff about the hot water, the resident stated, No, I personally didn't (tell anyone) but they are aware it (hot water) happens. When asked about the showers, the resident stated, They are hot. They (staff) told me to be careful and temper it down. When asked how she knew it was hot, the resident stated because I use it. The fact that: 1. the facility failed to ensure water temperatures were below 120 degrees, 2. four cognitively intact residents had stated concerns about hot water. 3. five cognitively impaired residents were identified with the physical ability to have unsupervised access to water with unsafe temperatures. 4. According to the regulatory time and temperature relationship to serious burns, harm was likely. FALLS RESIDENT #42 According to the 11/07/2019 Quarterly Minimum Data Set (MDS - an assessment tool), staff assessed Resident #42 as independent with toileting, and two person extensive physical assistance with personal hygiene. According to a 12/22/2019 accident report, Resident #42 was found on her knees in her room with the walker in front of her and her pants were down around her knees and shoes were untied. There was urine on the floor. The plan to prevent recurrence was, get her Velcro shoes and updated care plan to offer assistance with toileting after meals and at bedtime routinely. Observations on 02/26/2020 at 11:50 AM showed Resident #42 ambulating down the hall to the dining room. A sock was noted hanging out of the back heel of the left shoe. The shoes were noted to be laced, not Velcro. Review of the resident's care plan revealed no interventions regarding the use of Velcro shoes or toileting after meals and at bedtime. In an interview on 03/02/2020 at 10:35 AM, Staff C, Assistant Director of Nursing, reviewed the resident's CP and confirmed the interventions identified on the 12/22/2019 fall investigation were not, but should have been, care planed and implemented. RESIDENT #23 According to the 01/01/2020 5-day MDS, the resident was cognitively intact, had [DIAGNOSES REDACTED]. During an interview on 02/25/2020 at 12:25 PM, Resident #23 indicated he had fallen multiple times since admission. According a 02/14/2020 05:52 AM nurse's note, at approximately 5:30 AM the nurse heard Resident #23 yelling for help. Upon entering the room, Resident #23 was observed lying on his stomach on the floor near his sink. Resident #23 reported he was trying to go to the bathroom but didn't make it, and indicated he felt weak and his legs gave out. After being assisted back to bed Resident #23 .started to seize. When the .[MEDICAL CONDITION] activity stopped, he became unresponsive. He was still breathing but was non-responsive to sternal rub and voice commands. The resident's oxygen saturation (Sp02) dropped into the 60s. Oxygen was placed and the resident's Sp02 went up to the 80s. The medics were called and Resident #23 was transferred to the hospital. Review of the 02/14/2020 fall investigation showed on 02/14/2020 at 5:30 AM, the resident was heard calling for help and was found lying on his stomach by the sink. The resident's walker and wheelchair were noted to be tipped over next to the resident. In the section that asked if Resident taken to the hospital staff documented No, despite a progress note written within 22 minutes of the incident indicating the resident was transferred to the hospital. Under Predisposing Physiological Factors staff checked the boxes for Gait imbalance and History of self-transfer. The boxes next to Recent change in medication/new, recent change in condition, hypotensive and weakness/fainted, were left unchecked. Although, the resident reported he fell due to feeling weak and his legs giving out. Review of the February 2020 Medication Administration Record [REDACTED]. Nurses were also directed to Check to see what the previous wts have been. Review of the daily wts showed on 02/12/2020 Resident #23 weighed 255.8 lbs. On 02/13/2020 (the day prior to the fall) his wt was 263.4 lbs, showing a 7.6 pound wt gain in one day. Record review showed no indication the nurse identified the wt gain, assessed the resident and/or notified the physician as ordered. In an interview on 03/02/2020 at 10:10 AM, when asked if there was any indication that nursing identified the wt gain, assessed the resident, and notified the physician of the change Staff B, Director of Nursing, stated, No. Review of the 02/13/2020 Complete Blood Count (CBC) showed the resident's Red Bloods Cells were 3.24 (low), Hematocrit-26.2 (Low) and Hemoglobin-8.1 (H&H, low) showing the resident was anemic (a condition in which you don't have enough healthy red blood cells to carry adequate oxygen to the body's tissues, with common symptoms of feeling tired and weak). Additionally, review of the 02/13/2020 BMP (Basic Metabolic Panel) showed then resident had a BUN (blood urea nitrogen) of -55 (high), creatinine- 2.84 (high), GFR (glomerular filtration rate) - 23 (low), and potassium level of 6.0 (high). This showed [MEDICAL CONDITION] and high potassium, both which have common symptoms of weakness and fatigue. Review of the fall investigation showed facility staff failed to identify, assess, or consider how the resident's clinically complex medical conditions and the multiple changes on 02/13/2020 (change in diuretic, 7.6 lbs wt gain in 24 hours, [MEDICAL CONDITION] requiring IV iron sucrate, [MEDICAL CONDITION], and [MEDICAL CONDITION]) may have contributed to the resident's fall. Facility staff did not identify the correlation of the residents reported symptoms of weakness/fatigue and his [MEDICAL CONDITIONS] and [MEDICAL CONDITION], or consider that the sudden onset of shortness of breath and oxygen desaturation, after being laid in bed, may have been related to [MEDICAL CONDITION] given his recent change in diuretic therapy and 7.6 lb weight gain in 24 hours. According to a 02/14/2020 3:10 PM nurses note Resident #23 returned to the facility from the emergency room at 10:00 AM, with a [DIAGNOSES REDACTED]. The investigation concluded that the resident makes poor decisions as he frequently self transfers, despite staff encouraging him to call for assistance. Plan was to educate and continue current plan of care. In an interview on 03/04/2020 at 8:42 AM, when asked if a fall investigation should include a record review to identify if the resident had any recent medication changes, a recent change in condition, or abnormal labs Staff C stated, Yes. When asked if the investigation identified on 02/13/2020 (the day before the fall) the resident had: new orders for diuretic therapy implemented; gained 7.6 lb in 24 hours; an elevated potassium level of 6.0; and an H&H of 8.1 & 26.2 Staff C stated, No. When asked if the fall was accurately and thoroughly investigated Staff C stated, No. REFERENCE: WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure two (#s 42 & 63) of four sample residents reviewed for nutrition, received adequate weight monitoring, to determine whether their nutritional status was stable. This failure led to unintended weight loss for Resident #42 who experienced significant weight loss in the absence of timely interventions. Findings included . FACILITY POLICY According to the facility Weight policy dated November 2012, guidelines for residents who may need to be weighed weekly include those residents who demonstrate slow trending of weight loss/gain, significant weight loss/gain of 5% in 30 days, 7.5 % in 90 days or 10% in 180 days. The policy specifies staff should re-weigh residents with, Any weight with a 5-lb (pound) variance is re-weighed within 24 hours. The policy directs, If a significant variance is actual after re-weigh, the nurse documents in the medical record, revises the care plan, refers to Nutritional Hydration Skin Committee and notifies the physician and resident/resident's authorized representative. These notifications are recorded in the nursing progress notes of the medical record. RESIDENT #42 According to the 02/27/2019 Annual Minimum Data Set (MDS - an assessment tool) showed Resident #42 required supervision and setup for eating and weighed 191 lbs. The resident's eating abilities remained the same with weights of 192 lbs, 183 lbs, and 174 lbs respectively for the 05/20/2019, 08/10/2019 and 11/07/2019 Quarterly MDSs. The 01/28/2020 Annual MDS showed no change in eating abilities, but a weight of 163 lbs, which was identified as a 5% or more weight (wt) loss. Observation of the lunch meal on 03/02/2020 showed the resident ate less than 50% of the meal and was not served ice cream or whole milk as indicated on the tray card. Interview on 03/02/2020 at 7:51 AM Staff G, Dietary Service Manager, stated the weight and skin (W & S) committee meet once a week for reasons including, if someone has wounds or is losing weight or gaining weight or [MEDICAL TREATMENT], anything they deem appropriate. Staff G explained that medical records ran the weight records and provided them to the RCM (Resident Care Manager) who determined if the resident required review by the W & S committee. Review of weight records showed the resident was assessed on 12/08/2018 to weigh 197 lbs, on 04/01/2019 to weigh 192.2 lbs and on 06/27/2019 to weight 183.2 lbs. A 05/13/2019 Nutrition Note identified the most recent weight was 04/01/2019 and the Registered Dietician (RD) documented, weight changes past 6 months not significant, po (oral intake) is adequate to prevent weight loss, request current weight. A 06/27/2019 NHSC (Nutrition Hydration Skin Committee) note showed, Res reviewed for weight loss .Weight loss is not significant. Resident usually refuses weights. Weight loss r/t (related to) normal fluctuations .no supplementation 76-100% (of meal intake) most of the time .Continue with POC (Plan of Care.) Review of meal intake monitors showed the resident ate less than 50% (including refusals) for 21 of the 90 meals offered in June 2019. A quarterly RD nutrition note dated 07/29/2019 reflected, wt 6/27/2019 183.2 weight changes past 6 months not significant, po is adequate to prevent weight loss, request current weight. There were no weights obtained for Resident #42 for almost three months from 06/27/2019 to 09/19/2019 when the resident was assessed to weight 170.9 lbs, a loss of 12 lbs / a 6.7% wt loss. There was no documentation in the record the facility identified the significant delay in obtaining weights, or acted to obtain said weights. There was no indication facility staff provided a reweight after any five pound deviation was noted, as directed in the policy. A 09/26/2019 NHSC note showed weight 9/19 170.9 weight loss r/t past UTI (Urinary Tract Infection) and poor tolerance to care and food. Appetite has improved. No change at this time to be made .76-100% po intake . According to meal intake records, the resident ate less than 50% (including refusals and missing documentation) of 28 of the 87 meals offered in September 2019. A nutritional RD evaluation dated 09/30/2019 identified the previous weight as 183.2 lbs on 06/27/2019 and showed current, weight 09/26/2019 174.8 # was on ABT (antibiotic therapy) for UTI. Resident was out of the facility 09/19/2019 and returned on 09/20/2019 abnormal bleeding, resident was refusing care .has a confirmed UTI and is on antibiotics to treat. PO intake is still good per her norm. The listed goal was, no significant unplanned weight changes but offered no interventions to stem the identified weight loss of nine lbs from June 2019 to September 2019. The note failed to identify how, if the oral intake was good, why the resident continued to evidence steady weight loss. Weight records showed that on 10/15/2019 the resident weighed 174.1 lbs. There were no further weights obtained for two months from 10/15.20/19 to 12/10/2019 when the resident was assessed to weigh 162.4 lbs, another 12 lbs / 6.72 % weight loss. There was no documentation in the record the facility identified the significant delay in obtaining weights, or acted to obtain said weights. There was no indication facility staff provided a reweight after any five pound deviation was noted, as directed in the policy. A 10/28/2019 Nutrition note documented, 1 month weight is stable. No 3 month weight available. 6 month weight shows 18.1 lbs weight loss, 9.4% weight change, borderline significant weight change .See NHSC note dated 9/26. PO intake is variable per her norm. 50-100% . No interventions were considered or implemented. A NHSC note dated 12/12/2019 showed, NHSC for weight loss .12.4 lbs weight loss, 7.1% weight change, not significant over 2 month window. Weight loss r/t recent bout with UTI she is currently on IV treatment where she had a bad appetite. No pressure ulcer per recent skin report .intake is 50-100% .No s/s (signs /symptoms) dehydration noted per nursing. Will follow up prn (as needed). However, according to the November 2019 meal intake records, the resident ate less than 50% (including refusals and missing documentation) of 45 of the 90 meals. On 12/16/2019 the resident weighed 163 lbs and was 163.2 lbs on 12/24/2019. There were no weights obtained for over six weeks from 12/24/2019 to 02/11/2020 when the resident was assessed to weight 150.8 lbs, a weight loss of over 7%. There was no documentation in the record the facility identified the significant delay in obtaining weights, or acted to obtain said weights. There was no indication facility staff provided a reweight after any five pound deviation was noted, as directed in the policy. According to NHSC records dated 06/27/2019, 09/26/2019 and 12/12/2019, Resident #42 was listed for review related to weight loss with No Change planned. While the NHSC failed to identify any interventions related to the continued identified weight loss, a provider visit on 12/12/2019 recommended the addition of NEM (Nutritionally Enhanced Meal, the addition of items such as butter and cream for the addition of calories). In an interview on 03/02/2020 at 12:55 PM, when asked why there were three consecutive quarterly reviews culminating in a 48 lb unplanned weight loss, with no change planned Staff B stated, We should have provided interventions. A physician order [REDACTED]. According to Medication Administration Records for December 2019 and January and February 2020, the resident consistently did not accept the HS snack. A 01/20/2020 Nutrition Evaluation documented the resident's most recent wt as 163.2 lbs obtained on 12/24/2019. The evaluation identified, hs snack offered but failed to identify this intervention was ineffective as the resident was not receiving it. The evaluation indicated the resident consumed 50-100% of all meals, when according to the meal monitor records, the resident consistently (30% of the meals) ate less than 50% of the meals provided. There was no assessment of if the resident was offered or consumed any replacement meals for those meals for which 50% were consumed. This evaluation documented, 1 month weight is stable. 3 month weight shows 6.6% weight change, not significant.10.9% 20 lb loss in 6 months significant .Her PO intake is fair but adequate enough to maintain her weight over the past month. The documented goal was no significant unplanned weight changes but there were no interventions to prevent what was already identified as an unplanned significant weight loss. The resident continued to evidence further weight loss of 13 lbs when, on 02/11/2020, the resident was assessed to now weigh 150.8 lbs. It was not until 02/13/2020, that a nutritional supplement was ordered. A 02/19/2020 Practitioner note showed, She has continued with weight loss currently at 150 pounds, witch (sic) is down 48 pounds from one year ago. Supplementation added, however, she is most likely going to be resistant to accepting. In an interview on 03/02/2020 at 11:13 AM, when asked what staff were expected to review for the residents at the nutrition at risk meetings, Staff B, Director of Nursing (DON), replied, Weight loss, pressure ulcers, poor intake .our policy is trend able weight loss or significant weight loss. Staff B elaborated that the nutrition committee looked at meal intakes, weights . When asked if there were no weights, Staff B stated, Then we should attempt to get one. In an interview on 03/02/2020 at 11:13 AM, When asked the expectation if a resident refused weights for more than three weeks, Staff B and C, RCM, interviewed together on 03/02/2020 at 11:18 AM, stated, Reapproach, have different staff try, show her pictures of dogs. When asked if any additional interventions would be implemented, Staff C stated, Possibly. When asked if she expected interventions for someone who lost 58 lbs in a year, Staff B replied, Yes. When asked if 58 lbs was a normal fluctuation, Staff B replied, No. After reviewing the resident's weight records, Staff B confirmed that each time three to seven weeks went without a weight, Resident #42 demonstrated a significant unplanned weight loss. RESIDENT #63 Resident #63 admitted to the facility on [DATE]. According to the 02/16/2020 Quarterly MDS, the resident had [DIAGNOSES REDACTED]. A Nutrition Hydration problem . CP, revised 02/24/2020, listed problems affecting nutrition as: Barret's esophagus, diverticulitis, depression, obesity, wt gain related to consistent supplement intake, and Variable oral intake/ poor appetite leading to wt loss. The goal was identified on 11/25/2019, as .will have No unplanned significant weight loss or gain. Interventions included: 2 handled cup with lid; NEM (nutritionally enhanced meals) diet; refer to RD (Registered Dietician) as appropriate; and Supplements per MD order. The CP did not identify or direct staff to monitor for symptoms of Barret's esophagus, functional dyspepsia,or diverticulitis such as: heartburn, difficulty swallowing food, vomiting, weight loss, bloating, belching, nausea, abdominal pain, feeling uncomfortably full, and loss of appetite. According to the 11/25/2019 Nutrition Evaluation Form (NEF) completed by the RD, Resident #63's wt was 175 pounds (lbs), she had no [MEDICAL CONDITION], and had an average intake of 25-50% for all meals. Under evaluation the RD stated, Resident wt has been stable since admit. Resident BMI (body mass index) is 32 which classifies her as obese. Gradual wt loss is desirable. Her po (oral intake) is not adequate to meet her needs . Recommend adding NEM to diet and adding Cal Dense 60 cc (nutritional supplement) BID (twice daily) . Record review showed a 12/11/2019 nurse's note stated Resident #63 Returned from an appointment with GI (gastrointestinal) MD. New order to increase [MEDICATION NAME] and plan EGD (Esophagogastroduodenoscopy, a test to examine the lining of the esophagus, stomach, and first part of the small intestine) in March. Indicating the resident was still experiencing some GI issues. Review of the resident's wts showed the following trend: 11/22/2019-175 lbs; 12/11/2019-166.4 lbs (-4.9%); and 12/17/2019-165.8 lbs (-5.26%). On 12/19/2019 Resident #63 was nutritional status was reviewed by the nutrition interdisciplinary team (IDT). The IDT identified Resident #63 had a significant wt loss of 5.3 % in less than 30 days. The MD and responsible party were notified and the wt loss was determined to be related variable intake. A recommendation to increase Resident #63's Cal Dense order to 90 cc TID (3x daily). The assessment did not include any indication that staff spoke with the resident to determine why her appetite was variable or if GI symptoms were affecting her appetite or intake. On 12/30/2019 Resident #63's wt was 153.6 (-12.3%) in approximately six weeks, and (-7.36%) from 12/17/2019 (two weeks), demonstrating continued significant and unplanned wt loss. Review of the meal monitor from 12/19/2019 (the last time the resident's nutrition was assessed) through 12/30/2019 revealed: of the 36 meals in the 12 day period, the resident refused or had no documentation of the meal 12 times (33% of meals). Of remaining 24 meals, 8 times the resident only ate 0-25%. Record review showed no indication that staff: identified the wt loss; notified the the MD/patient and/or responsible party; referred the resident to the RD for further evaluation; assessed the resident's meal intake; or assessed the resident to determine if she was experiencing GI symptoms, or if there were other factors affecting her intake. During a joint interview on 03/02/2020 at 12:11 AM with Staff B and C, it was explained that when a resident triggered for weight loss, the resident would be added to the weekly nutrition IDT meeting, and interventions would be implemented based off of the assessment. The resident would continue to be monitored weekly until stable. When asked if Resident #63 was monitored weekly until stable Staff C stated, No but acknowledged she should have been. When asked if there was any indication that staff reviewed the 12/30/2019 wt, identified the resident's continued significant and unplanned wt loss, assessed the resident's meal intake, spoke with the resident to determine factors contributing to her lack of appetite, notified the MD, referred the resident to the RD for further evaluation, and/or implemented nutritional interventions Staff C stated, No. On 01/06/2020 Resident #63's weight was 151.2 showing continued wt loss. On 01/08/2020 the a Physician Rectification note note stated the resident does report poor appetite and PO (oral) intake . the Physician then ordered [MEDICATION NAME] twice daily as an appetite stimulant. Resident #63's weights then stabilized between 151 and 154 lbs. REFERENCE WAC 388-97-1060(3)(h).

Based on observation, interview and record review, the facility failed to ensure eight (#8, 61, 24, 22, 50, 16, 53 & 47) of 19 residents interviewed about residents wandering into their rooms were free from abuse, and three (#35, 55 & 52) of three residents identified with behaviors were free from the risk of abuse. The facility failed to evaluate the effectiveness of current interventions (redirection after the fact) for trendable identified behaviors, and did not provide interventions to assure the safety of residents to prevent resident to resident abuse. Staff failed to adequately monitor for verbally and physically aggressive behavior, or behaviors that may provoke a reaction by residents or others, which include, wandering into other's rooms/space. Failure of the facility caused residents to be subject to emotional, verbal and physical abuse and placed all residents at risk of abuse. This failure resulted in an Immediate Jeopardy (IJ) related to abuse on 12/06/17. The facility placed Residents #35, 55 & 52 with one on one staff supervision and provided training to all staff, which led to the removal of the IJ on 12/06/17. Findings include: Refer to CFR: 483.12(b)(1)-(4), F-607, Develop/Implement Abuse/Neglect, etc. Policies 483.12 (c)(1)(4), F-609, Reporting of Alleged Violations 483.12 (c)(2)-(4), F-610, Investigate/Prevent/Correct Alleged Violation 483.40(b)(3), F-744, Treatment/Services for Dementia 483.95 (c)(1-(3), F-943, Abuse, Neglect, and Exploitation Training According to the facility September 2017 Abuse Prohibition policy and procedure, Each resent has the right to be free from abuse .The center implements policies and processes so that residents are not subjected to abuse by staff, other residents The policy defined; Mental Abuse as The use of verbal or non verbal conduct which causes or has the potential to cause the resident to experience . intimidation, fear .agitation, or degradation .It includes but is not limited to .harassment .verbal assault that includes ridiculing, yelling, or swearing Examples of mental and verbal abuse include, but are not limited to Harassing a resident .Threatening residents .Physical Abuse includes .hitting, slapping, punching, biting and kicking .Neglect: Failure of the Center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Facility identified education listed Risk factors of potential abuse victims, including, Elderly residents who may be at risk of becoming a victim of abuse may be exhibiting one or more of the following: .Wandering into other's rooms/space. RESIDENT # 8 Resident #8 admitted to the facility on [DATE] and according to the 08/15/17 Quarterly Minimum Data Set (MDS- an assessment tool), was able to understand and be understood in conversation, and had a BIMs score of 12, reflective of moderately impaired cognition. The resident was assessed with [REDACTED]. In an interview on 12/04/17 at 11:00 a.m. Resident #8 stated, Two women are sexually harassing me; DSHS (Department of Social and Health Services) has filed a suit against them, (Resident #35) is one and the other is, I think the other one is named (Resident #55). If you sit here long enough she'll be at the door. That's why there's the sign on my door (resident gestured toward the Velcro stop sign on the door). They try to come in when I am in the bathroom. They're just looking for sex. Review of facility investigative documents dated 07/12/17 revealed, (Resident #8) and his family made a concern stating that (Resident #55) had gone into his room and observed him urinating. Immediate actions taken included, .staff education on keeping (Resident #55) off unit. According to investigative documents dated 09/10/17, Resident #35 was observed, .making contact with an open hand to another resident's face. This document indicated Resident #8 was assaulted by Resident #35 stating also, that female resident kicked him in the leg. Record review revealed an 11/26/17 (2:59 a.m.) progress note which indicated, I saw (Resident #52) coming out of room [ROOM NUMBER] and was going to get his wheelchair and redirected him when (Resident #8) came out of his room and started yelling he came in my room and hit me keep him out of my room. Observations during medication pass on 12/05/17 at 11:56 a.m. revealed Staff S (Licensed Practical Nurse - LPN) pass medication to Resident # 8. At this time, the resident reported a bruise to the resident's right hand was caused by Resident #55. Resident #8 stated, I got this (bruise to right hand) from (Resident #55), she came in during the Auburn football game yesterday and I told her to get the hell out . Staff S at this time indicated Resident #55 comes in to other residents' rooms and that's why there is a stop sign on (Resident #8's) door. She's (Resident #55) down on the other end. Record review revealed a progress note dated 12/06/17 which reflected a 12/04/17 Resident to Resident altercation involving Resident #55 and Resident #8. Nursing staff documented, Resident was heard by this LN (Licensed Nurse) at approximately 1930-2000 on 12/04/17 yelling get out of here, this LN came immediately to resident doorway and saw (Resident #55) at (Resident #8's) doorway redirected resident back towards 100 hall asked resident if female resident hit him and he said no she tapped my back and swung at her because I didn't know who was behind me. In an interview on 12/06/17 at 9:10 a.m., the resident was asked about a bluish bruise on his right hand. The resident stated, It happened last Friday when (Resident #55) was here .well I was watching the football game, one of the two teams was college level .and all of a sudden I felt a tap on the shoulder. I jerked around because of my defensive nature, no one becomes up behind me. To be honest, with me, if I struck out like I been taught I could kill 'em. The resident indicated he, .may have hit the railing or the gal . I grabbed her wheelchair. I wanted people to see where she was. By that time the attendants were coming because I screamed, Help, help, help! and boy do they come running. This has been goin' on for months. RESIDENT #61 On 12/04/17 at 11:11 a.m. two residents were heard/observed screaming (indiscernible) at each other at the end of the 100 hallway. Upon approaching Resident #55 was observed at the threshold of Resident #61's room. Resident #61 at the doorway yelling, Get out of here .I am not doing that! Resident #55 yelled back, My a** looks like your face. On 12/04/17 at 11:12 a.m. Certified Nursing Assistant (CNA), Staff P, (who was in room [ROOM NUMBER]) was heard stating, I got to go before a brawl breaks out. At which time Staff P exited the room, approached Resident #55 asking .what's going on? Resident #55 stated, Everyone is yelling at each other. Staff P then stated, Lets go and wheeled Resident #55 down the hallway away from Resident #61's doorway. RESIDENT #24 In an interview on 12/06/17 at 8:03 a.m. when asked about the stop sign across the doorway, Resident #24 said a couple of times they tore it down. Resident #55, Gets mad and kicks something if it's in her way and she can't get out the door. Resident #24 said it made her feel kinda scared and I don't like it, you don't know when someone's going to come in when you're asleep and what they're going to steal. One day I caught her with my TV remote, she said it was hers and 'you get out of here this is my house.' I grabbed it and ran out. When asked how that incident made her feel, Resident #24 said she threatened me the cops were coming after me, were going to get and knife and cut you, I was really afraid and I went and asked someone and they said she was just blowing off steam, I was kinda new and was afraid she would follow me, we can't have locks .at night you just cant think about it or you can't sleep. RESIDENT #22 In an interview on 12/06/17 at 7:43 a.m. when asked about Resident #55, Resident #22 said She comes in and walks through .if we are watching TV she wants to watch TV with us, if we say no, she gets a little angry, she wants to kick me out, she says she owns the building .she can get nasty with her mouth. In addition, Resident #22 recalled another incident, involving another, unidentified resident, when I woke up the resident was going through my dresser drawer and rubbing something on his/her hair. I asked if it was a male or a female and they couldn't tell. It was like four in the morning about a month ago .I don't know what woke me up, I was sound asleep and woke up .there was an aid walking by and I waved her in, after they got him/her out of here I shed a tear, I felt violated, they had no right going through my things, like a home burglary. RESIDENT #50 In an interview on 12/06/17 at 7:52 a.m. when asked about Resident #55, Resident #50 said She scares me, I don't feel safe because she scares me. When asked if she had been touched, Resident #50 replied, No, but she's threatened a lot. Resident #50 said She wants to get my stuff. She says she owns this place. RESIDENT #16 According to the 09/09/17 MDS resident #16 was cognitively intact with a BIMS of 13, required extensive assistance of staff for mobility. In an interview on 12/04/17 at 8:10 a.m. Resident #16 recalled that the night prior, a resident had come into her room, and told me this was her home, her bed and she said she was going to take me out of my bed. She scared me. RESIDENT #53 In an interview on 12/06/17 at 8:10 a.m. Resident #53 recalled incidents involving Resident #55, she is one of the ones coming in here .she says 'this is my room, you guys get the hell out of here'. We say no, she says 'well I own the building and you have to pay', and that sort of thing there have been a couple of times we have gotten into a verbal argument and she has told me to go F myself and stuff like that. RESIDENT #47 Resident #47 was admitted to the facility on [DATE]. During an interview on 12/04/17 at 1:29 p.m., when asked if anyone had abused him Resident #47 stated yes, that foul mouth old Bit** named (Resident #35). She sneaks in my room and I don't want her to touch me. I've told the folks that work here I don't like her coming in my room, besides they all know about her, she's got a foul mouth. RESIDENT #35 According to the 07/14/17 MDS Resident #35 was assessed as having clear speech, able to be understood and usually understand conversation and had multiple [DIAGNOSES REDACTED]. According to this MDS, staff assessed the resident had physical behavioral symptoms directed toward others (e.g. hitting kicking punching scratching grabbing abusing other sexually), wandering, and verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) on 1-3 days of the lookback period. Staff determined these behaviors did not put the resident at significant risk for physical injury, or significantly interfere with the resident's care or interfere with the resident's participation in activities or social interactions. The Quarterly MDS dated [DATE] indicated the resident now had a BIMS of 0 (decline), had physical and verbal behaviors on 1-3 days of the lookback period. Staff indicated the resident's behaviors significantly intruded on the privacy or activities of others and demonstrated no wandering. Progress notes dated 06/22/17 indicated, .heard resident yell out curse words. I went out into the hall way and saw resident cursing at another resident .I verified with the other resident that she had been hit. According to progress notes dated 06/23/17, Rsd (resident) became upset throwing a brush at a therapist and kicking the nurse. Psychiatry notes of 06/25/17 indicate the resident is alert, irritable, yells, easily confused . Staff documented on 07/03/17 Lots of yelling, kicking, cussing and agitation noted this shift. On 07/27/17 staff documented, Rsd noted yelling, cursing, and kicking at staff. Rsd noted making inappropriate and/or sexual comments to staff and male visitors. Progress notes dated 09/11/17 indicated, Resident was witnessed by CNA slapping other male resident on the face in male resident room . Similar demonstrations of verbal and physical aggression were noted in 09/14/17 progress notes. On 09/23/17 Resident #35 was, .kicking, calling staff and other residents you goddamn son of a [***] she was going into other mens' rooms and this LN and other staff would have to run and try to redirect her as the male residents were swearing and yelling for her to be quiet and get out. Staff demonstrated awareness of the resident's trendable intrusive behaviors as evidenced by a 10/14/17 progress note, Rsd continuously attempting to enter other rsds's rooms. Looking for scissors, throwing any item she can get, taking off clothes in the hall, cursing at staff, scratching staff and hitting staff. On 10/25/17, staff documented, rsd placed on alert due to behaviors today. In dining hall earlier this morning she threw a cup of water at another resident during activities. Shortly, the CNA notified this LN that rsd's bedroom door was closed, and when she entered, rsd was calling her new roommate a name, and attempting to get closer to her roommate with her fist raised . Staff failed to ensure residents were free from abuse, and failed to implement interventions to mitigate behaviors which placed Resident #35 at risk of abuse from staff and other residents. RESIDENT #55 The 10/02/17 Quarterly MDS was not completed until 11/14/17. According to this MDS, Resident #55 had a [DIAGNOSES REDACTED]. The resident was assessed to have exhibited verbal behavioral symptoms directed towards others on one to three days of the look back period. In an interview on 12/12/17 at 8:30 a.m. Social Services, Staff E, indicated she had not completed this MDS reviewed the resident's record and said there is a chart note 09/27/17, resident awake, clapping, yelling, arguing with her roommate the majority of shift. Further review of the resident's record revealed progress notes dated 01/29/17 that Resident #55 threatened to hit another rsd if she bumped her w/c again. Rsd was removed from situation and (Resident #55) was redirected successfully . On 06/01/17 Resident #55 hit another res. in the head. Residents were separated .On 08/08/17 Res hit another res . On 09/07/17 Resident #55 was calling this LN names and other Rsd who passed by. Rsd slapped this LN in the arm when attempted to move rsd away from other rsd On 09/09/17 Resident #55 was yelling and calling other rsd's names. The facility failed to ensure residents were free from abuse. RESIDENT #52 According to the Admission MDS dated [DATE] Resident #52 was assessed as sometimes understood and sometimes able to understand, and had a BIMS score of 4 which was reflective of severe cognitive impairment. The resident was noted to demonstrate inattention, disorganized thinking, and rejection of care and wandering on 1-3 days of the survey. The resident was assessed to have a [DIAGNOSES REDACTED]. Staff failed to identify the resident's behaviors of wandering and entering other residents' rooms as intrusive on others or placing him at risk for assault due to these behaviors. The Care Plan (CP) did not include information that the resident demonstrated wandering behaviors or identify potential implications for these behaviors. In an interview on 12/04/17 at 1:42 p.m., Resident #52's family member indicated an awareness of resident to resident incidents and stated, he's pretty mellow .he's usually the one to get bopped, he says he does. Reference WAC 388-97-0640(1)

Based on observation, interview and record review, the facility failed to implement Abuse Prohibition policies and procedures including but not limited to prevention, identification, investigation and protection involving Residents #55, 61, 8, 9, 52, 35, 47, 33, 3, 19, 66, 17, 123, 121, 54, 18, 126, 127, 129, 16, 22, 50, 24, 53, 47, 7 & 28. Failure of the facility resulted in abuse of residents and placed all residents at risk of abuse. This failure resulted in an Immediate Jeopardy (IJ) related to implementation of an abuse prohibition policy on 12/06/17. The facility implemented preventative measures and provided training to all staff, which led to the removal of the IJ on 12/06/17. Findings include: Refer to CFR: 483.12(a)(1), F-600, Free from Abuse and Neglect 483.12 (c)(1)(4), F-609, Reporting of Alleged Violations 483.12 (c)(2)-(4), F-610, Investigate/Prevent/Correct Alleged Violation 483.95 (c)(1-(3), F-943, Abuse, Neglect, and Exploitation Training According to the facility September 2017 Abuse Prohibition policy, the procedure includes seven components; Screening, Training, Prevention, Identification, Investigation, Protection and Reporting & Response. RESIDENT #55 & #61 On 12/04/17 at 11:11 a.m. an altercation occurred between Resident #55 and Resident #61. Facility Staff intervened and separated the residents, but failed to identify the incident as abuse and failed to implement the facility abuse policy, including reporting the incident to the nurse. RESIDENT #61 On 12/04/17 at 11:11 a.m. two residents were heard/observed screaming (indiscernible) at each other at the end of the 100 hallway. Upon approaching, Resident #55 was observed at the threshold of Resident #61's room. Resident #61 was in her doorway yelling, Get out of here .I am not doing that! Resident #55 yelled back, My a** looks like your face. On 12/04/17 at 11:12 a.m. Certified Nursing Assistant (CNA) Staff P, (who was in room [ROOM NUMBER]) was heard stating, I got to go before a brawl breaks out. At which time Staff P exited the room approached Resident #55 asking, .what's going on? Resident #55 stated, Everyone is yelling at each other. Staff P then stated, Lets go and wheeled Resident #55 down the hallway away from Resident #61's doorway. Record review on 12/06/17 at 8:50 a.m. revealed no interdisciplinary note had been made addressing the resident to resident altercation. There was no indication the resident was assessed for psychosocial harm, interventions were put into place to protect others/prevent reoccurrence, or that the incident was investigated to determine if abuse had occurred. In a telephone interview on the morning of 12/06/17, Staff P acknowledged the above incident and separating the two residents. When asked who the incident was reported to Staff P stated, .It was really busy, I am not sure I let anyone know. Staff C (Residential Care Manager, who was present during the interview) acknowledged that the incident had not been reported to management no. Thus, not investigated. Facility staff's failure to identify, report, and investigate incidents of verbal abuse detracted from staffs' ability to determine the underlying cause, implement measures to prevent reoccurrence, identify the trend of Resident to Resident altercations perpetrated by Resident #55, and ensure the safety of others. This failure placed residents at risk for further abuse. RESIDENT #55 & #8 On 12/04/17 at approximately 7:30 p.m. - 8:00 p.m. a resident to resident altercation occurred between Resident #55 and Resident #8. A progress note was not written until 12/06/17, and an incident report & investigation was not initiated until 12/06/17. In an interview 12/06/17 at 12:45 p.m. Staff B, Director of Nursing (DNS) said She (the nurse) didn't do it timely and they should have been put on alert charting. RESIDENT #8 Observations during medication pass on 12/05/17 at 11:56 a.m. revealed Staff S (Licensed Practical Nurse - LPN) pass medication to Resident #8. At this time, the resident reported a bruise to the resident's right hand was caused by Resident #55. Resident #8 stated, I got this (bruise to right hand) from (Resident #55), she came in during the Auburn football game yesterday and I told her to get the hell out . At this time Staff S indicated, Resident #55 comes in to other residents' rooms and that's why there is a stop sign on (Resident #8's) door. She's (Resident #55) down on the other end. Record review revealed a progress note dated 12/06/17 which reflected a 12/04/17 Resident to Resident altercation involving Resident #55 and Resident #8. Nursing staff documented, Resident was heard by this LN (Licensed Nurse) at approximately 1930-2000 on 12/04/17 yelling get out of here, this LN came immediately to resident doorway and saw (Resident #55) at (Resident #8's) doorway redirected resident back towards 100 hall asked resident if female resident hit him and he said no she tapped my back and swung at her because I didn't know who was behind me. In an interview on 12/06/17 at 9:10 a.m., the resident was asked about a bluish bruise on his right hand. The resident stated, It happened last Friday when (Resident #55) was here .well I was watching the football game, one of the two teams was college level .and all of a sudden I felt a tap on the shoulder. I jerked around because of my defensive nature, no one becomes up behind me. To be honest, with me, if I struck out like I been taught I could kill 'em. The resident indicated he, .may have hit the railing or the gal . I grabbed her wheelchair. I wanted people to see where she was. By that time the attendants were coming because I screamed, Help, help, help! and boy do they come running. This has been goin' on for months. RESIDENT #55 & #9 As a result of the facility's failure to implement the facility abuse prohibition procedure including prevention, reporting, investigation, and development of a plan to protect residents, a resident to resident altercation between Resident #55 and Resident #9 occurred on 12/05/17 at 12:00 p.m. RESIDENT #9 According to investigative documents, on 12/05/17 at 12:00 p.m. Resident #9 was holding her stuffed animal in the dining room when Resident #55 wanted the stuffed animal and told Resident #9 that she was going to have her two sons kill her. Investigative documents dated 12/06/17 recommended, Resident #55 be placed on one to one supervision while awake . On 12/05/17 at 3:05 p.m. Resident #55 was observed self propelling in a wheelchair (w/c) up the hallway by the facility entrance. No staff were observed in line of sight of the resident. STAFF INTERVIEWS In an interview on 12/06/17 at 11:28 a.m., Staff V (LPN) stated she had worked at the facility for six years. When asked about any residents who wander into other residents' rooms, Staff V immediately stated, Oh yes, like that, (Resident #55), and (Resident #52), he does that a lot (go into other peoples rooms). I don't work on the other end that frequently. When asked about Resident #55's behaviors, Staff V stated, She slowly goes the hall and we all just keep an eye on her, she'll poke her head into the room. When asked if Resident #55 ever had altercations, Staff V stated, Yes, for some reason her and (Resident #8 ) are magnetic to each other, it's just like he is on her radar. When asked if she (Resident #55 ) went into his room, Staff V stated, Yes, a few times, including last night on night shift. They're on alert (charting). Staff V stated, We try to stop her (Resident #55) when she comes down here, I think it might be because she likes to look out that window, not just because of him (Resident #8). When asked if she was aware of, two horny old women? Staff V replied, (Resident #8) does always think women are after him and (Resident #35) does like men and she does try to pat their knee or elbow but not (Resident #55). When asked if any other residents went into Resident #8's room, Staff V stated, Oh yes, (Resident #35). She also likes to go into (Resident #47's) room. There was a gentleman who she knew who was in that room. I know (Resident #47) gets upset with her when she goes into his room. Staff V elaborated, (Resident #52) sometimes has issues with other residents . but indicated there had been no physical altercations stating, No he's harmless they'll just say hey he's in my room and we take him out . Staff did not identify Resident#52's persistent and trendable wandering behaviors as intrusive for other residents, or that it placed him at risk for assault. In an interview on 12/06/17 11:19 a.m., when asked about any residents who demonstrated wandering behaviors, Staff T (CNA) stated, Yeah, (Resident #55) and (Resident #52), I am thinking (Resident #35) sometimes she wanders too. When asked what the wandering behavior looked like. Staff T stated, They don't know where they are, they go in other rooms, yeah especially (Resident #55), that's why they put up that sign (gesturing toward the Velcro Stop sign on Resident #8's room). She wanders in her w/c. When asked how often Resident #35 demonstrated this behavior Staff T stated, Oh very often. Sometimes we have to get her back to her room when we notice that's she's been around that way. Staff T indicated that the resident's wandering was a problem because, .other people (residents), sometimes they are mad (about Resident #35 coming into their rooms), when we see her doing that we take her to the 100 hall. When asked if Resident #55 ever got into altercations with other residents, Staff T stated, Yelling, yes that is pretty common. Sometimes there is a one on one (1:1) watch on her. When asked how frequently Resident #55 received 1:1 supervision, Staff T stated, I really don't know. There is a hospitality aide who does that .sometimes she hits other residents that's why they watch her. When asked if Resident #35 had physical altercations with other residents, Staff T stated, Not as much, she don't hit, she just loves to go inside rooms. You tell her, (Resident #35), that's not your room. (Resident #52) does that (goes into other residents rooms) sometimes too. I tell 'em, You got to go back to your room or else they (other residents) get mad at you. In an interview on 12/06/17 at 11:19 a.m. Staff K (Housekeeping Manager) said in the morning meeting she had been told that Resident #55 went into a gentleman's room on the 500 hall .December 4th, the night before last. When asked what she had been directed to do, Staff K said If we see her (Resident #55) tootiling down that way we redirect her the other way. She's always active, likes to roam the hallways just try to redirect her away from him the best we can. In an interview 12/06/17 at 11:26 a.m. when asked if there were any rooms which Resident #55 targeted, Staff H (Registered Nursing Assistant - RNA) replied, Yes. That would be on 500, (Resident #8). When asked why, Staff H said She has a sensor or something, she says her car is down there, looks out the window, we go get something and she's in (Resident #8's) room. When asked what his reaction was, Staff H said he tells her to get out and screams at her. When I hear the F bomb I try to get there as fast as I can. In an interview 12/06/17 at 11:26 a.m. when asked what she does in regards to Resident #55's wandering behavior, Staff H said I'll ask if she wants snacks or to go to an activity. Staff H said she intervened about four or five times a day with her. She thinks she's going to say Hi to everyone. When asked how the other residents reacted, Staff H said some will communicate with her, some will get verbally aggressive. When asked if verbally aggressive what action was taken, Staff H said We interfere and redirect her out of their room, calm them down and provide care. In an interview on 12/06/17 at 11:36 a.m. Staff I (NAC) said she tries to keep Resident #55 away from 500 hall gentleman she's had an altercation with. In addition, Staff I said Resident #55 is on one on one right now, but previously she would, keep eye on, redirect .She goes into room [ROOM NUMBER] sometimes, they say get her out of here. In an interview on 12/06/17 at 11:32 a.m. when asked what residents wandered Staff F (LPN) stated, There's a few, (Resident #35, Resident #55, and Resident #52) .Resident #52 goes into others' rooms but he does nothing, he is usually looking for a bathroom and Resident #55 she usually goes in (other resident rooms) and then comes out. Resident #55 and #52 usually do it at night so I am unsure of the frequency. When asked what she had been instructed to do when a resident wandered into someone else's room, Staff F stated, We just redirect, they are usually easily redirected .Resident #55 can get mouthy but we just redirect her. When asked what staff were instructed to do if there was a verbal altercation between residents, Staff F stated, Remove the resident from the situation .usually that will fix it, if they are still yelling down the hallway (at each other) maybe take them to an activity so they don't focus on that .the whole out of sight out of mind thing. When asked if there was anything else that should be done?, Staff F stated, Not that I can think of. In an interview on 12/06/17 at 11:47 a.m. when asked if there were any residents with behaviors who wandered into other's rooms Staff G (Registered Nurse - RN) identified Resident #55, #52 and #33. Staff G stated, (Resident #55) she tries to go into rooms but I bring her back away from the door .we have stop signs but she just takes them off . RESIDENT INTERVIEWS RESIDENT #3 In an interview on 12/06/17 at 9:19 a.m. when asked if other residents wander into her room Resident #3 stated, Yes, it is a female named (Resident #55), she comes in and always wants to get out the window .she wants to find a way to escape .I tell her it is locked so she cant get out .she wants to go home, it doesn't bother me, but I know she scares my roommate. RESIDENT#19 In an interview on 12/08/17 at 9:01 a.m. Resident #19 indicated Resident #55 often wandered into his room. Resident #19 said that about a week ago, Resident #55 was in her w/c, wandering down the hall. If your room door were open, she would just come in. According to Resident #19, there have been a few times where she has actually threatened to hit me, but you always know if she going to hit you, because she will say POW but she didn't actually hit me. She has dementia, so I just ignore her and tell her this is not her room and then nurses will usually come and get her. RESIDENT #66 In an interview at approximately 9:00 a.m. on 12/06/17, Resident #66 stated, Well (Resident #52), he usually starts wandering if he has to go to the bathroom .he came in (my room) and peeked around the corner, he was looking for the bathroom. He really should be one on one. (Resident #52) comes in, (Resident #35) does too. I call her (Resident #35) Magpie. She takes shiny things. She's taken my tweezers. They (staff) are vigilant with (Resident #35) 'cuz they know she does things. There are three or four (residents who wander into others rooms). She doesn't realize she's doing it, she is harmless. Once (Resident #35) got in my room and closed the door. (Resident #52) gets up all the time. It's hard to keep an eye on him. Resident #66 elaborated, There are a couple of horny little old ladies. Some of them that talk to the guys, they don't talk to me. I think (Resident #35) is one of them. Because I am a girl they don't bother me . When asked what she meant by horny, Resident #66 stated, They talk to the fell ows all the time .you just can't park 'em next to a guy. They'll put their hand on 'em and say things I know some of the men don't like them because of what they say . RESIDENTS #17 & 123 In an interview on 12/06/17 at 9:18 a.m., when asked if any other residents came into their room, Resident #17 stated, A male resident comes into my room. I call, press the button and someone will come. A nurse came by and took him away. Resident #123 added, There was another time the same man wanted to go to the bathroom (in our bathroom). A nurse came and said, That is not your bathroom you need to go to your own room. Last week there was an elderly woman who walked into my room. There were no problems, but you never know what they are doing or what they can do, because I don't know them. The door is always open and they walk in. It was just for a few minutes, and then they got caught. RESIDENT #121 In an interview on 12/06/17 at 9:23 a.m., Resident #121 stated, There is a little lady, bright as a button who comes in (my room). She came in and upended a box of my beads and tried to use my TV at 3: 00 a.m. The resident indicated she was not happy about being woken up but stated, Oh, she isn't really a problem. RESIDENT #54 In an interview on 12/06/17 at 9:17 a.m. Resident #54 stated, Well there is this lady who comes in here and I tell her it is not her room, and she just says yes it is, finally an aide will come and get her. When asked if it frightened her Resident #54 stated, No, I don't even know her. RESIDENT #18 in an interview on 12/06/17 at 9:34 a.m., Resident #18 indicated she didn't have residents come into her room because, I keep my door closed . RESIDENT #126 In an interview on 12/06/17 at 8:53 a.m., Resident #126 stated, The first night we were here .I went to bed around 10:00 p.m. and when I woke up, there was a man on the other side of my table (over bed table). He scared the crap out of me. They didn't tell me they had (residents with) Alzheimers here . I guess he does it (goes into other resident rooms) all the time. I know who he is .they (staff) knew who he was. He thinks he knows me. He says, you don't belong here. He just kinda grunted at me, I was hollering, Come and help me! I don't think he's dangerous, it just scared me bad with him standing there. Resident #127, who shared Resident #126's room stated,They don't bother me, I am over in the corner. RESIDENT #129 In an interview on the morning of 12/06/17, Resident #129 stated, Yes, when I was here at first across from the nurses station, several times a man in a w/c came in (my room). I didn't feel threatened. He couldn't really maneuver his chair around. It happened about three times. RESIDENT #16 In an interview on 12/04/17 at 8:10 a.m. Resident #16 recalled that the night prior a resident had come into her room, and told me this was her home, her bed and she said she was going to take me out of my bed. She scared me. When asked what staff had done, Resident #16 said, They were watching her. They put that stop thing up there. The stop sign was observed velcroed across the resident's doorway. On 12/05/17 at 1:15 p.m. Resident #16 was observed eating lunch in her room. The Velcro stop sign was down. On 12/06/17 at 8:33 a.m. staff were observed passing breakfast room trays. The staff did not ensure the stop signs in the 200 hall were secure prior to leaving the area. The sign was observed down across Resident #16's doorway and for room [ROOM NUMBER]. On 12/06/17 at 11:24 a.m. two residents were in Resident #16's room and the stop sign was down. On 12/07/17 at 10:28 a.m. Resident #16 was observed in the hallway waiting to go out to smoke. The Velcro stop sign was down. A staff walked by the room and was observed to put the sign back up across the resident's doorway. RESIDENT #22 In an interview on 12/06/17 at 7:43 a.m. when asked about staff's response to residents who wander into her room, Resident #22 said We push our button and they come and get her. After they take her out they keep a closer eye on her so she doesn't come back in .she could intimidate others really easy. Resident #22 recalled staff put the stop sign up a week and a half ago, maybe two. Review of the resident's record revealed no documentation of any similar incident, and no documentation or Care Plan (CP) intervention indicating when the stop sign had been put up. On 12/06/17 at 8:33 a.m. Staff F was observed to put the sign back up across room [ROOM NUMBER] (Resident #22 & 50). RESIDENT #50 In an interview on 12/06/17 at 7:52 a.m. when asked what staff were doing to prevent residents from wandering into her room, Resident #50 replied, they take her out and there's a sign on the door that says stop. Review of Resident #50's record revealed a 10/04/17 CP which was initiated in 2015 Resident requesting Stop mesh banner at door. The listed goal was prevent wandering residents from entering room. Interventions included Staff to alert social services if Stop banner is not working and Use Stop barrier banner sign at door. On 12/06/17 at 8:33 a.m. Staff F was observed to put the sign back up across room [ROOM NUMBER] (Resident #22 & 50). RESIDENT #24 In an interview on 12/06/17 at 8:03 a.m. Resident #24 said There's a couple of older women who stroll around. There is one woman who thinks this is her room, she did it a few times and I complained and they said they could fix that and put a stop sign up .I don't like someone coming in when I'm not quite dressed. Review of the resident's record revealed a 05/22/17 progress note, Met with resident regarding incident where other resident wandered into her room. She states the other resident entered her room in wheelchair and thought that the belongings there (items in the room) belonged to her. Resident requested that a mesh stop sign be put on her door to prevent wandering residents from entering her room. There was no documented monitoring to determine if the stop sign was effective. On 12/06/17 at 11:24 a.m. Resident #24 & 53 were in the room and the stop sign was down. Similar observations were noted on 12/11/17 at 7:47 a.m. RESIDENT #53 In an interview on 12/06/17 at 8:10 a.m. Resident #53 said, There's a gentleman here who all three woman, (Resident #35, #55, and #22) have all gone into his room and try to climb into bed with him, at least that's what he said. When asked about the stop sign across the doorway, Resident #53 said It was put there because we were having people come into our room that didn't need to be in here. When asked what else staff do to prevent residents from wandering into the room, Resident #53 said The staff, if they come in here, the staff comes and takes them out., They had been doing one on one, they're not now that I know of, I haven't seen them doing one on one lately. Review of Resident #53's 12/06/17 CP revealed the resident was legally blind, but did not address the use of a stop sign or interventions to protect the resident from residents wandering into her room. On 12/06/17 at 11:24 a.m. Resident #24 & 53 were in the room and the stop sign was down. Similar observations were noted on 12/11/17 at 7:47 a.m. RESIDENT #47 Resident #47 was admitted to the facility on [DATE]. During an interview on 12/04/17 at 1:29 p.m., when asked if anyone had abused him, Resident #47 stated yes, that foul mouth old Bit@h named (Resident #35). She sneaks in my room and I don't want her to touch me. I've told the folks that work here I don't like her coming in my room, besides they all know about her she's got a foul mouth. A review of Resident#47's CP dated 04/21/17 revealed, staff would provide the resident with a mesh stop sign to deter wandering residents from entering the residents' room. Several observations were made of the resident's door without the mesh sign in place. On 12/07/17 at 12:44 p.m., there was no mesh stop sign across the resident's door to keep wanderers out of the resident's room. On 12/08/17 at 11:00 a.m., the resident was observed sitting in wheel chair in his room with no mesh stop sign across the door way. On 12/11/17 at 8:26 a.m., Resident #47 was observed sitting in his room eating breakfast with no mesh stop sign in place. In an interview on 12/08/17 at 11:25 a.m., Resident #47 stated no they don't have a mesh stop sign across the door cause as soon as the staff put it up there she comes along and tears it down faster than they can put it up. According to Resident #47 the sign was behind the blue laundry cart parked near his room. The facility response of putting up stop signs in an attempt to deter residents from wandering into other residents' room was ineffective. The facility failed to evaluate the intervention and implement further protective measures. RESIDENT #35 The facility failed to identify Resident #35's assaultive behaviors as placing residents in the facility at risk of abuse and implement preventative measures. According to the 07/14/17 Minimum Data Set (MDS - an assessment tool) Resident #35 was assessed as having clear speech, able to be understood and usually understand conversation. The resident was assessed with [REDACTED]. The resident experienced no hallucinations, no delusions, staff assessed the resident had physical behavioral symptoms directed toward others (e.g. hitting, kicking, punching, scratching, grabbing, abusing other sexually) on 1-3 days of the assessment period; verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) on 1-3 days of the lookback period; and demonstrated wandering on 1-3 days of the lookback. However, staff determined these behaviors did not put the resident at significant risk for physical illness or injury, significantly interfere with the resident's care or interfere with the resident's participation in activities or social interactions. According to the Quarterly MDS dated [DATE], Resident #35 was assessed with [REDACTED]. While staff continued to indicate the resident did not put others at significant risk for physical injury or significantly disrupt care or living environment, the staff did indicate the resident's behavior did significantly intrude on the privacy or activities of others. INCIDENT OF 06/22/17 According to an investigation dated 06/22/17 Service worker was in office and heard some swearing and name calling. She came out of her office and separated the two who were yelling, and brought this rsd (resident) back down to nurses station. The statement by (Resident #35) was, She said somethin' I didn't like, and I hit her. According to the investigation; there was no witness. but SS (Social Services - Staff E) intercepted the incident. It further indicated, Social worker (SW) heard cursing and yelling between (Resident #35) and another resident. SW immediately came out of her office into the hallway and separated residents. (Resident #35) stated, She said something I didn't like so I hit her. (Resident #35) indicated the other resident hit her on her left forearm, area was assessed and there was no visible injury .Staff were inserviced to attempt to keep them separated. There have not been any previous incidents between the two residents. The investigation indicated, Mental health to see today. Staff were inserviced on the incident between the two and to attempt to keep them separated. The two reside on separate wings of the building. The investigation indicated, hallway as the location but didn't specify that while the residents reside on different units, they still came in contact in the hallway. Facility staff failed to consider Resident #35's behavioral impact, not just on the resident in question, but other residents in the facility. According to a 09/10/17 incident report, Resident #35 was witnessed to slap Resident #8, in his room no injury noted Resident (#8) did say later that (Resident #35) kicked him in the leg. Offered to get his leg x-rayed but resident refused, no witness to resident being kicked by female resident . Staff documented, The two residents were immediately separated and there has not been previous incidents between the two residents. Again, staff failed to consider Resident #35's assaultive behaviors as potentially impacting all residents in the facility and implement preventative measures. INCIDENT OF 10/25/17 According to investigative documents dated 10/25/17 a resident to resident interaction between Resident #35 and Resident #7 occurred. Staff documented, Rsd (Resident) was upset about another resident yelling out. She then told other rsd to shut up and threw her water at her. According to the resident's statement on 10/27/17, I told her to shut up. The investigation indicated, Resident was sitting at nurses station one and another resident was talking loudly and (Resident #35) told her to shut up and threw water on her. The residents were immediately separated and monitored for psych harm. This investigation referenced a resident to resident altercation on 09/10/17. Facility staff recommended attempt to keep (Resident #35) in a quiet environment. She gets agitated with too much stimuli. Mental health to reevaluate on 10/31/17 and repeat labs to be drawn on 11/05/17. Staff educated to attempt to keep (Resident #7) and (Resident #35) away from each other as much as possible. Staff again failed to consider how keeping Resident #35 away from previous victims would be effective to prevent subsequent assaults on others. RESIDENT #8 AND 55 According to an incident investigation dated 07/12/17, Another resident and his family made a concern stating that Resident #55 had gone into his room and observed him urinating .Resident #55 does have a history of self-propelling around facility although normally keeps to herself. A subsequent psychiatry note dated 07/25/17 indicated Resident #8 had a recent increase in anxiety episodes, may be related to another resident coming into his room. While the psychiatrist clearly identified Resident #8's behaviors/mental health were negatively impacted by the intrusion of another resident entering his room, facility staff failed to identify and prevent repeat occurrences. Facility staff again, subsequently referred Resident #8 to Mental Health. On 10/17/17 the psychiatrist documented, asked to follow up due to episodes of agitation and continued delusions, he feels there are residents here who are after him sexually----which may be partially true per staff . The resident's antipsychotic was subsequently increased. According to investigative documents dated 12/04/17, At approximately at 1930-2000 (Resident #8) was heard yelling get out of here and Resident #55 was heard yelling I just want to talk to you. Resident #8 at the time stated, I swung at her because I didn't know who was behind me. Based on the presence of observed resident to resident altercations, as well as stated awareness of these behaviors by both staff and residents, the facility did not evaluate the effectiveness of current interventions (redirection after the fact) and staff did not provide interventions to assure the safety of residents. Redirection alone is not a sufficiently protective response to a resident who will not be deterred from targeting other residents for abuse once he/she has been redirected. The facility did not provide sufficient protection to prevent resident to resident abuse. Also,the facility failed to consider resident to resident abuse could involve a resident who has had no prior history of aggressive behaviors, since a resident's behavior could quickly escalate into an instance of abuse. For example, a resident pushes away or strikes another resident who is rummaging through his/her possessions. RESIDENT #28 The facility failed to identify an allegation of abuse and/or neglect, and failed to protect the resident pending investigation. Resident #28 was admitted to the facility on [DATE]. A review of the 30 day MDS dated [DATE] revealed the resident had multiple medical [DIAGNOSES REDACTED]. In an interview on 12/04/17 at 10:49 a.m., Resident #28 said she was upset because she had an accident w (TRUNCATED)

Based on observation, interview, and record review the facility failed to timely investigate allegations of abuse, neglect, resident to resident altercations, and trendable intrusive behaviors as potential abuse. Failure to thoroughly investigate detracted from the facility's ability to prevent further repeated and potential abuse for multiple residents including, but not limited to Residents #s 8, 55, 52, 61, 33, 28, 47, 16, 53, 35 & 7. This failure resulted in an Immediate Jeopardy (IJ) related to investigation of abuse on 12/06/17. The facility interviewed all residents in the facility, initiated investigations of all alleged abuse, and provided training to all staff, which led to the removal of the IJ on 12/06/17. Findings include: Refer to CFR: 483.12(a)(1), F-600, Free from Abuse and Neglect 483.12(b)(1)-(4), F-607, Develop/Implement Abuse/Neglect Policies 483.12 (c)(1)(4), F-609, Reporting of Alleged Violations 483.95 (c)(1-(3), F-943, Abuse, Neglect, and Exploitation Training According to the facility September 2017 Abuse Prohibition policy and procedure The Center conducts a thorough investigation of potential, suspected and/or allegations of abuse, neglect, and exploitation of residents .mistreatment, and injuries of unknown source, in accordance with state and federal regulations. RESIDENT #8 Observations during medication pass on 12/05/17 at 11:56 a.m. revealed Staff S (Licensed Practical Nurse - LPN) pass medication to Resident #8. At this time, the resident reported a bruise to the resident's right hand was caused by Resident #55. Resident #8 stated, I got this (bruise to right hand) from (Resident #55), she came in during the Auburn football game yesterday and I told her to get the hell out . Staff S at this time indicated Resident #55 comes in to other residents' rooms and that's why there is a stop sign on (Resident #8's) door. She's (Resident #55) down on the other end. As of 12/06/17, no progress note, subsequent investigation regarding the bruising, or the resident's allegation was initiated. Further review of Resident #8's record revealed, progress notes dated 10/21/17 indicated rsd (resident) was very upset for unknown reasons and was swearing obscenities towards resident and his wife. This carried on for awhile. PT (Physical Therapy) was in the room and witnessed the event. Family of bed A requested to move rooms as they felt uncomfortable with rsds behaviors. Review of the abuse log revealed no indication staff acknowledged or investigated a resident to resident incident of verbal abuse. In addition, progress notes dated 11/29/17 indicated, On 11/26/17 I was at the nursing station when I saw (Resident #52) coming out of room [ROOM NUMBER] and was going to get his w/c (wheelchair) and redirect him when (Resident #8) came out of his room and started yelling, he came in my room and hit me keep him out of my room. While staff documented, (Resident #8) and (Resident #52) were never close to each other, there was no evidence to support this. Review of the incident log revealed this allegation was never investigated to determine when Resident #8 alleged he was hit, where it took place and if staff were present at the time. RESIDENT ALTERCATION #8 AND #55 According to an investigation document, an alleged incident between Resident #8 and #55 occurred on 07/12/17 at 8:30 p.m. However, the incident report/investigation was not initiated until 07/13/17 at 3:00 p.m. when the residents' families were notified. The physician was not notified of the incident until 5:00 p.m. on 07/13/17. The Resident statement of what happened (documented as obtained on 07/14/17) indicated, Resident stated that another resident entered his room and pulled the curtain back and saw him urinating. Staff documented on 07/18/17 at 4:28 p.m. Another resident (Resident #8) and his family made a concern stating that (Resident #55) had gone into his room and observed him urinating. Staff recommendations included Offer (Resident #8) to move rooms to an area with less traffic and currently no roommate. Continue with stop banner in place. Continuous staff education about redirecting Resident #55 when she self propels down to five hundred hall. Staff failed to establish if the stop banner was in place at the time of the incident, failed to consider the effectiveness of continuous staff education about redirecting Resident #55. Additionally, the final review of this incident was not made by Staff B (Director of Nursing), until 07/18/17, six days after the alleged occurrence. When asked in an interview at 8:27 a.m. on 12/11/17 if the investigation was timely (within the required five days), Staff B indicated, it was late. RESIDENT #61 On 12/04/17 at 11:11 a.m. two residents were heard/observed screaming (indiscernible) at each other at the end of the 100 hallway. Upon approaching, Resident #55 was observed at the threshold of Resident #61's room. Resident #61 was in her doorway yelling, Get out of here .I am not doing that! Resident #55 yelled back, My a** looks like your face. On 12/04/17 at 11:12 a.m. Certified Nursing Assistant (CNA) Staff P, (who was in room [ROOM NUMBER]) was heard stating, I got to go before a brawl breaks out. At which time Staff P exited the room approached Resident #55 asking, .what's going on? Resident #55 stated, Everyone is yelling at each other. Staff P then stated, Lets go and wheeled Resident #55 down the hallway away from Resident #61's doorway. Record review on 12/06/17 at 8:50 a.m. revealed no interdisciplinary note had been made addressing the resident to resident altercation. There was no indication the resident was assessed for psychosocial harm, interventions were put into place to protect others/prevent reoccurrence, or that the incident was investigated to determine if abuse had occurred. In a telephone interview on the morning of 12/06/17, Staff P acknowledged the above incident and separating the two residents. When asked what she had been trained to do in incidences of resident to resident altercations, Staff P indicated she was educated to separate (the residents) and let someone know .usually the nurse. When asked who the incident was reported to, Staff P stated, .It was really busy, I am not sure I let anyone know. Staff C (Residential Care Manager, who was present during the interview) acknowledged that the incident had not been reported to management no. Thus, not investigated. Facility staff's failure to identify, report, and investigate incidents of verbal abuse detracted from staffs' ability to determine the underlying cause, implement measures to prevent reoccurrence, identify the trend of Resident to Resident altercations perpetrated by Resident #55, and ensure the safety of others. This failure placed residents at risk for further abuse. RESIDENT #33 Resident #33 admitted to the facility on [DATE] with care needs related to dementia. According to the 07/14/17 Quarterly Minimum Data Set (MDS - an assessment tool), the resident had moderate cognitive impairment and wandered daily. The resident's wandering significantly intruded on the privacy of others and the resident's overall behavior was identified as worse. Record review revealed a 08/17/17 clinical note that stated, Was told by the res(ident) in room [ROOM NUMBER] that he got pushed out of the BR (bathroom) by the res(ident) in 106. Res(ident) in 106 has been waiting for his wife to show up. Res(ident) is also very protective of the BR and does not like to share it. MD and res(idents) wife notified. Res(idents) were separated. Res(idents placed on alert. Additionally, a 08/24/17 note (late entry for 08/17/17) stated, Spoke with resident - ED (Executive Director) and SDC (Staff Development Coordinator) present - regarding alleged altercation with resident in room [ROOM NUMBER]. Resident denies physically touching resident, stated,'I told him to get out of my room or else!' Asked resident if he closed the door on resident 108A, again, resident denies any physicality during exchange. Resident in 108A was asked the same questions by myself, ED and SDC-he also states, 'No one hit anyone. Believe me, if he did, I'd defend myself.' There are no signs of physical harm on each resident-will place on alert and continue keeping lock on 108A's bathroom, per his request. Although the alleged victim denied being hit, there was no follow up on the original allegation of being pushed out of the bathroom. Review of the incident log revealed no entry for the above incident. In an interview on 12/12/17 at 7:03 a.m. Staff A (Administrator/Executive Director) stated, We had gotten a report that there was some altercation between them (Resident #33 and the unidentified Resident in 108A) . they were verbal but no pushing and shoving .I don't know why we (facility staff) did not do a incident report or follow up. When asked if an investigation/incident report should have been initiated, Staff A responded, yes. RESIDENT #28 Resident #28 admitted to the facility on [DATE]. A review of the 30 day MDS dated [DATE] revealed, the resident had multiple medical [DIAGNOSES REDACTED]. In an interview with the resident on 12/04/17 at 10:49 a.m., Resident #28 said she was upset because she had an accident with her bladder approximately a month ago and the staff made her feel as though she had done something wrong. They (facility staff) made me feel as though they didn't want to come near me to help me get cleaned up after I soiled my clothes. In an interview on 12/06/17 at 8:12 a.m., Staff B stated she was unaware of the incident with the soiled clothing. Staff B acknowledged that she was aware of the resident complained a staff member refused to assist her with meal set up on a Friday. According to Staff B, she checked in on the resident on Monday 12/04/17 at 8:16 a.m. On the same day Staff B stated the resident mentioned that the evening nurse was grumpy, Staff B stated she didn't complete an incident report for either incident because she said the resident was satisfied with the outcome of their meeting. The facility failed to conduct an investigation following an allegation of neglect and/or psychological abuse. RESIDENT #47 In an interview with Resident #47 on 12/04/17 at 1:29 p.m., Resident #47 complained that the woman across the hall would often sneak into his room. Resident #47 stated, that foul mouth old (Bit@h) from across the hall keeps sneaking into my room. I keep telling them that I don't want anything to do with her because she had a foul mouth. When asked if he had reported the incident to the facility staff, Resident #47 said these folks (Facility Staff) know all about her they have not done anything about her yet. Review of the abuse log revealed no entry or investigation regarding a resident to resident altercation involving Resident #47. RESIDENT #16 In an interview on 12/04/17 at 8:10 a.m. Resident #16 recalled that the night prior, a resident had come into her room, and told me this was her home, her bed and she said she was going to take me out of my bed. She scared me. When asked if the resident had touched her, Resident #16 replied, No. They (staff) got in here before then. Review of the facility abuse log from 06/02/17 through 12/09/17, revealed no resident to resident altercations involving this resident. In an interview on 12/12/17 at 12:59 p.m. Staff B indicated yes she would have expected an incident report and investigation to have been completed. RESIDENT #53 In an interview on 12/06/17 at 8:10 a.m. Resident #53 recalled incidents involving Resident #55 and said there have been a couple of times we have gotten into a verbal argument and she has told me to go F myself and stuff like that. when asked about the last verbal altercation, Resident #53 said it occurred around Halloween, down in the dining room .she was being bossy and everything, and I can't remember all the details, she said something to me and I responded, and she said something again, I said your being an old witch, she cackled and said see I'm an old witch. Review of the resident's record revealed no progress notes of this or a similar incident. Review of the abuse log revealed no resident to resident altercations involving Resident #53 around this time. RESIDENT #55 Review of Resident #55's record revealed multiple documented instances of potential abuse which were not on the facility abuse log and not investigated. On 09/07/17 was documented Resident became very agitated this afternoon. RSD was yelling at this LN .was calling this LN names and other RSD who passed by. RSD slapped this LN in the arm when attempted to move RSD away from other RSD . The facility failed to investigate the incident, determine who the other residents involved were, assess the other resident's for psychosocial harm including but not limited to fear. Similar findings were noted for a 09/09/17 progress note, RSD has been agitated this am. Yelling and calling other rsd's names. Had to remove rsd from hallway to keep away from others. On 09/27/17 was documented Rsd awake clapping, yelling and arguing with her roommate majority of shift. Rds wanted staff to remove the woman from her room because I don't like her. All attempts by staff to settle her appeared to agitate her . There was no incident investigation following the documented resident to resident altercation. In an interview on 12/06/17 at 12:45 p.m. when asked for examples of what constituted a resident to resident altercation, Staff E, Social Services replied, It depends and listed, Verbal abuse, name calling, yelling at each other, physical hitting, pinching, physical between the two of them. When asked what the expectation of staff was at the time, Staff E replied, PRIDE; Protect the resident, Report to supervisor and mandated reported, I is the investigation portion done by management, Develop plan, Evaluate to make sure that plan is working. RESIDENT #35 According to the 07/14/17 MDS Resident #35 was assessed as having clear speech, able to be understood and usually understand conversation, and had multiple [DIAGNOSES REDACTED]. According to this MDS, the resident experienced no hallucinations no delusions, and staff assessed the resident had physical behavioral symptoms directed toward others (e.g. hitting kicking punching scratching grabbing abusing other sexually), wandering, and verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) on 1-3 days of the lookback period. Staff determined these behaviors did not put the resident at significant risk for physical injury, or significantly interfere with the resident's care or interfere with the resident's participation in activities or social interactions. The Quarterly assessment dated [DATE] indicated the resident now had a BIMS of 0 (decline), had physical and verbal behaviors on 1-3 days of the lookback period. Staff indicated the resident's behaviors significantly intruded on the privacy or activities of others and demonstrated no wandering. INCIDENT OF 06/22/17 According to an investigation dated 06/22/17 Service worker was in office and heard some swearing and name calling. She came out of her office an separate the two who were yelling, and brought this rsd back down to nurses station. The statement by (Resident #35) was, She said somethin' I didn't like , and I hit her. According to the investigation; there was no witness, but SS (Social Services-Staff E) intercepted the incident It further indicated, Social worker heard cursing and yelling between (Resident #35) and another resident. SW immediately came out of her office into the hallway and separated residents. (Resident #35) stated, She said something I didn't like so I hit her. (Resident #35) indicated the other resident hit her on her left forearm, area was assessed and there was no visible injury .Staff were inservices to attempt to keep them separated. There have not been any previous incidents between the two residents. The investigation indicated, Mental health to see today. Staff were inserviced on the incident between the two and to attempt to keep them separated. The two reside on separate wings of the building. The investigation indicated, hallway as the location but didn't specify that while the residents reside on different units; they still came in contact in the hallway. Facility staff failed to consider Resident #35's behavioral impact, not just on the resident in question, but other residents in the facility. According to a 09/10/17 incident report, Resident #35 was witnessed to slap Resident #8, in his room no injury noted Resident (#8) did say later that (Resident #35) kicked him in the leg. Offered to get his leg x-rayed but resident refused, no witness to resident being kicked by female resident . Staff documented, The two residents were immediately separated and there has not been previous incidents between the two residents. Again, staff failed to consider Resident #35's assaultive behaviors as potentially impacting all residents in the facility and implement preventative measures. INCIDENT OF 10/25/17 According to investigative documents dated 10/25/17 a resident to resident interaction between Resident #35 and Resident #7 occurred. Staff documented, Rsd (Resident) was upset about another resident yelling out. She then told other rsd to shut up and threw her water at her. According to the resident's statement on 10/27/17, I told her to shut up. The investigation indicated, Resident was sitting at nurses station one and another resident was talking loudly and (Resident #35) told her to shut up and threw water on her. The residents were immediately separated and monitored for psych harm. This investigation referenced a resident to resident altercation on 09/10/17. Facility staff recommended attempt to keep (Resident #35) in a quiet environment. She gets agitated with too much stimuli. Mental health to reevaluate on 10/31/17 and repeat labs to be drawn on 11/05/17 Staff educated to attempt to keep (Resident #7) and (Resident #35) away from each other as much as possible. Staff again failed to consider how keeping Resident #35 away from previous victims would be effective and prevent subsequent assaults on others. Reference (WAC) 388-97-0640(6)(a)(b)

Based on observation, interview and record review, the Administration failed to effectively and efficiently manage facility compliance with federal regulatory requirements. The administrator failed to ensure compliance related to the prevention of abuse and neglect which resulted in psychological harm, as evidenced by patterned feelings of fear, anger, and frustration, to multiple residents, resulting in an Immediate Jeopardy situation. Findings include: Failed practice found during the standard and extended survey ending on 12/14/17 was as follows: F 552 - 483.10(c)(1)(4)(5), Right to be Informed The administration failed to ensure informed consent was obtained. F 561- 483.10(f)(1)-(3)(8), Self Determination The administration failed to ensure resident's choices were honored regarding bathing frequency. F 578 - 483.10(c)(6)(8)(g)(12)(i)-(v), Formulate Advance Directives The administration failed to inform and provide written information to residents concerning the right at the resident's option, to formulate an advance directive. F 580 - 483.10(g)(14)(i)-(iv), Notify of Changes The administration failed to consult with residents' physician and/or responsible party concerning non availability of medication and a change in a treatment. F 582 - 483.10(g)(17)(18)(i)-(v), Liability Notice The administration failed to provide residents' notice of their eligibility for additional services. F 584 - 483.10(i)(1)-(7), Safe, Clean, Homelike Environment The administration failed to ensure a safe, clean, and homelike environment. F 600 - 483.12(a)(1), Free from Abuse and Neglect The administration failed to ensure each resident was free from abuse/neglect. This resulted in an Immediate Jeopardy situation, related to unidentified abuse. F 604 - 483.10(e)(1), Right to be free from Physical Restraints The administration failed to ensure a resident was free from a physical restraint. F 607 - 483.12(b)(1)-(4), Develop/Implement Abuse/Neglect Policies The administration failed to implement an Abuse Prohibition policy which included prevention, identification, and resident protection. This resulted in an Immediate Jeopardy situation, related to ongoing abuse. F 609 - 483.12(c)(1)(4), Reporting of Alleged Violations The administration failed to ensure reporting of alleged abuse, resident to resident altercations and injuries of unknown origin. F 610 - 483.12(c)(2)-(4), Investigate/Prevent/Correct Alleged Violation The administration failed to investigate allegations of abuse and resident to resident altercations, resulting in an Immediate Jeopardy situation, related to ongoing abuse. F 623 - 483.15(c)(3)-(6)(8), Notice Requirements Before Transfer/Discharge The administration failed to provide a resident the required notices at the time of discharge. F 625 - 483.15(e)(1)(2), Notice of Bed Hold Policy Before/Upon Transfer The administration failed to provide residents' notices of bed hold policy upon transfer. F 636 - 483.20(b)(1)(2)(i)(iii), Comprehensive Assessments & Timing The administration failed to ensure comprehensive assessments were completed timely and accurately. F 637 - 483.20(b)(2)(ii), Comprehensive Assessment After Significant Change The administration failed to ensure for one resident a significant change assessment was completed. F 638 - 483.20(c), Quarterly Assessment At Least Every 3 Months The administration failed to ensure timely completion of quarterly assessments. F 641 - 483.20(g), Accuracy of Assessments The administration failed to ensure assessments were accurate. F 656 - 483.21(b)(1), Develop/Implement Comprehensive Care Plan The administration failed to ensure care plans were developed and revised as necessary to meet the needs of residents. F 658 - 483.21(b)(3)(ii)(iii), Services Provided Meet Professional Standards The administration failed to ensure facility staff provided care and services according to professional standards of practice. F 676 - 483.24(a)(1)(b)(1)-(5)(i)-(iii), Activities of Daily Living (ADL)/Maintain Abilities The administration failed to provide ambulation services to maintain residents' abilities. F 677 - 483.24(a)(2), ADL Care Provided for Dependent Residents The administration failed to provide ADL care, including showers and nail care to dependent residents. F 684 - 483.25, Quality of Care The administration failed to ensure facility staff provided care and services the resident's were assessed to require for [MEDICAL CONDITION], positioning, non pressure skin and constipation. F 688 - 483.25(c)(1)-(3), Increase/Prevent Decrease in ROM/Mobility The administration failed to ensure a resident received appropriate treatment and services to increase and/or prevent further decrease in range of motion. F 689 - 483.25(d)(1)(2), Free of Accidents/Hazards/Supervision/Devices The administration failed to investigate repeated trendable falls and implement preventative measures. F 690 - 483.25(e)(1)-(3), Bowel/Bladder Incontinence, Catheter, UTI The administration failed to assess a decline in urinary incontinence and implement measures to restore urinary function for one resident. F 692 - 483.25(g)(1)-(3), Nutrition/Hydration Status Maintenance The administration failed to ensure a significant weight loss was identified and interventions provided timely for one resident with weight loss. F 695 - 483.25(i), Respiratory Care The administration failed to ensure residents were provided respiratory care consistent with professional standards of practice. F 725 - 483.35(a)(1)(2), Sufficient Nursing Staff The administration failed to ensure the facility had adequate staff to provide basic care and services. F 730 - 483.35(d)(7), Nurse Aid Perform Review - 12 Hr/Year Inservice The administration failed to ensure a system which provided annual nurse aid review. F 744 - 483.40(b)(3), Treatment/Service for Dementia The administration failed to ensure appropriate treatment and services were provided to residents with dementia. F 757 - 483.45(d)(1)-(6), Drug Regimen is Free From Unnecessary Drugs The administration failed to adequately monitor and ensure adequate indications for medication use. F 761 - 483.45(g)(h)(1)(2), Label/Store Drugs & Biologicals The administration did not ensure drugs were stored in accordance with currently accepted principles. F 842 - 483.70(i)(1)-(5), Resident Records The administration failed to ensure facility records were complete and accurate in accordance with accepted professional standards and practices. F 849 - 483.70(o)()-(4), Hospice Services The administration failed to ensure coordination of care for residents receiving Hospice Services. F 880 - 483.80(a)(1)(2)(4)(e)(f), Infection Prevention & Control The administration failed to ensure effective infection control processes related to the use of barriers, laundry temperature and surveillance. F 883 - 483.80(d)(1)(2), Influenza and Pneumococcal Immunizations The administration failed to determine rationale behind residents refusals of pnumococcal immunizations. F 943 - 483.95(c)(1)-(3), Abuse, Neglect, and Exploitation Training The administration failed to ensure abuse training provided was effective. Reference (WAC) 388-97-1620(1)

Based on observation, interview and record review it was determined the facility failed to prevent, identify, and implement preventative measures for pressure ulcers for two of three residents reviewed for positioning. Failure to implement the interventions identified as required for Resident #147 caused harm as evidenced by the development of pressure ulcers. Failure to provide identified interventions to prevent pressure ulcers placed Resident #87 at risk for the development of pressure ulcers. Findings include: According to the facility policy for skin integrity definitions, a Pressure Ulcer (PU) is, localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Additionally, this policy indicates an Avoidable PU means that the resident developed a PU and that the Center did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. According to this policy, a Stage II PU is described as a partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed. RESIDENT #147 Resident #147 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 06/01/15 Minimum Data Set (MDS), the resident was assessed to require two person extensive assistance for bed mobility and transfers and was assessed to be at risk for Pressure Ulcers (PU). According to the resident's Care Directive form dated 05/27/15, interventions for Skin at Risk included .lotion to dry skin, barrier cream, turn/reposition routinely, elevate heels . The Potential for Skin Integrity Impairment CP, dated 05/15, had a listed goal of maintain skin integrity. A Pressure Ulcer Care Plan, dated 06/03/15, indicated the resident was now identified with a PU to the right ear. In an interview on 06/04/15 at 9:43 a.m. the resident indicated he did not consistently receive assistance with his activities of daily living. The resident was noted at that time to be lying on his back in bed requesting the air conditioning be adjusted. Similar observations of the resident positioned on his back were noted at 10:10 a.m. and 11:07 a.m. Observation on 06/05/15 at 9:00 a.m. revealed Resident #147 lying in bed on his back. The resident was observed lying in bed on his back with the head of bed elevated at 10:11 a.m., 11:02 a.m., 12:22 p.m. and 12:46 p.m. Observations on 06/05/15 at 1:00 p.m. revealed Resident #147 lying in bed with the head of bed elevated to approximately 45 degrees. His lunch tray was noted on an overbed table. Similar observations were made at 1:55 p.m. Observation on 06/08/15 at 9:05 a.m. revealed the resident lying in bed on his back. The resident was observed at 9:48 a.m. in the same position without benefit of position change. At 10:45 a.m., 11:03 a.m., and 11:55 a.m. the resident was in bed on his back with the head of bed elevated. At 12:39 p.m., Staff F and two other staff were noted to get the resident up from a lying position, weigh him, and put him back in bed lying on his back. The resident remained lying on his back in bed until 12:59 p.m. when therapy staff initiated transferring the resident to a wheelchair. Resident #147 remained in the wheelchair until 2:50 p.m. when the resident was placed in bed lying on his back. The resident was noted lying in bed on his back, absent of any change in position at 3:46 p.m. Observation on 06/08/15 at 7:02 p.m. revealed the resident lying in bed on his back, no evidence of pillows or any other positioning device which might provide side to side positioning. Similar observations were noted at 8:02 p.m., 8:34 p.m., and 9:01 p.m. Observations on 06/09/15 at 8:10 a.m., 8:50 a.m. and 9:23 a.m. revealed Resident #147 lying in bed on his back. Throughout these observations, staff were noted to be present in the resident's room and, barring the transfer to the wheelchair and the obtaining of weight, none were noted to attempt to reposition the resident off his back. Observation on 06/09/15 at 10:16 a.m. with Staff P revealed a previously unidentified open area to the resident's right buttock (over the approximate location of the ischial tuberosity) which Staff P described as 0.5 centimeters (cm) by 0.2 cm, an abrasion to the left hip and a scab to the left hip area. Also noted was brown dead skin to the left buttock. A progress note dated 06/09/15 at 4:30 p.m. identified an additional 0.5 cm x 0.2 cm open area to the left buttock and described the right buttock wound as 0.2 x 0.2 cm. These buttocks wounds were described on skin sheets as pink/beefy red. In an interview on 06/09/15 at 12:22 p.m., Staff Q (Nurse Consultant) spoke regarding the identified right buttock wound which was identified as caused by, .shearing . possibly related to being positioned up in bed, he's a tall man . According to facility policy, partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed . which is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear, is considered a Stage II pressure ulcer. Staff P stated at that time, If they (residents) are incontinent they should be turned every two hours, we need to look at the care plan. In an interview on 06/09/15 at 10:24 a.m., Staff B (Director of Nursing) was asked the operational definition of, turn/reposition routinely to which she replied, typically every two hours. In an interview on 06/09/15 at 12:22 p.m., Staff Q (Nurse Consultant) spoke regarding the identified left heel wound stating, He has severe vascular disease, I don't think that is new, they just missed (identification/documentation of) the heel. Staff Q stated, I talked to (Resident #147) and he indicated he can't turn to his sides, we will get him an air mattress. There was no indication facility staff had previously attempted to turn the resident as directed by the CP or that the resident had refused any such attempt. There was no indication facility staff identified/provided additional interventions considering his now identified difficulty turning from side to side. Failure to implement interventions that were consistent with identified resident needs, resident goals and recognized standards of practice caused Resident #147 to develop multiple avoidable Stage II pressure ulcers. RESIDENT #87 According to the 05/09/15 MDS, Resident #87 was assessed to require extensive two person assistance with transfers and bed mobility. Record review revealed the resident had functional limitation in range of motion on the upper right extremity related to a stroke. This resident was not interviewable. According to the Self-Care Deficit CP dated 05/22/15, Resident #87 was assessed to be unable to turn self in bed, transfer self, feed self, toilet self, do grooming. According to the care directive form, staff were directed to turn the resident every 2-3 hours and directed the application of a brace to the right foot. Observations on 06/03/15 at 2:39 p.m. revealed the resident lying in bed on her back, her right hand/arm elevated on a pillow. Observations on 06/04/15 at 10:12 a.m. revealed Resident #87 lying in bed on her back, her right hand/arm up on a pillow. Similar observations of the resident lying on her back without position changes were noted at 12:21 p.m., 1:17 p.m. and 1:38 p.m. Observation on 06/05/15 at 8:43 a.m. revealed Resident #87 lying in bed on her back receiving assistance with breakfast. The resident was noted with similar positioning (directly on her back) at 9:47 a.m., 10:09 a.m., 10:53 a.m., 12:03 p.m., 1:06 p.m., and 1:37 p.m. Observations on 06/08/15 at 9:05 a.m. and 9:56 a.m. revealed the resident lying in bed on her back. Similar observations were noted with the resident lying on her back without benefit of repositioning at 10:48 a.m., 11:04 a.m., 12:57 p.m., 1:13 p.m., 2:39 p.m. and 3:43 p.m. Observations on evening shift at 7:15 p.m., 8:05 p.m. and 9:00 p.m. revealed the resident lying in bed on her back. Observation on 06/09/15 at 9:02 a.m. revealed the resident lying in bed on her back. The head of bed was elevated and the resident was receiving assistance with breakfast. Observations on 06/09/15 at 10:40 a.m. revealed Resident #87 lying in bed on her back with a boot on the right foot, with the right arm partially on pillow. Failure to implement interventions that were consistent with identified resident needs, resident goals and recognized standards of practice placed Resident #87 at risk to develop a PU.

Based on observation, interview and record review the facility failed to provide adequate supervision and properly assessed to prevent potential hazard for burns due to accidental surface contact with an electric baseboard heater located near the Resident bed. This failure resulted in harm of third degree burns on both knees for Resident #1 and placed other residents at risk of burns. Findings include: RESIDENT #1 According to the 12/08/14 Minimum Data Set assessment, Resident #1 had [DIAGNOSES REDACTED]. He was assessed with [REDACTED]. In addition, the resident was six feet three inches tall and assessed with [REDACTED]. According to the 10/08/14 Physical Therapy Evaluation, the resident had bilateral knee contractures. Review of the resident's record revealed on 10/25/14 Resident #1 was found on the floor next to his bed. Staff implemented safety measures including placing the resident's bed in a low position as indicated on the 10/25/14 Fall Care Plan (CP). The 10/23/14 Dementia CP directed "staff to anticipate & meet unaddressed needs." Review of the resident's record revealed a 12/27/14 1:45 a.m. progress note, "Found res(ident's) knees against the heater. Bottom in bed and L(eft) shoulder in bed. Bed in low position. Resd knee noted with blisters. Removed res(idents) knees from heater and turned it off. Called 911." In an interview on 12/29/14 at 1:30 p.m. with Staff A and Staff B, Staff A indicated the resident was discovered in a low "bed that was too close to the heater", with a facility bedspread between his legs and the heater. The bedspread had melted "which caused his burns." The burns were to both knees, reported as third degree burns. (Third-degree burns penetrate the entire thickness of the skin.) In an interview on 12/30/14 at 9:23 a.m. a Social Worker at the hospital said the facility had been called and a staff nurse told the Social Worker that she reportedly walked by the resident's room, smelled burning flesh and found the resident in a low bed with his knees against the baseboard heater. In an interview on 12/30/14 at 10:00 a.m. another hospital Social Worker said the resident was admitted on [DATE] due to "full thickness burns, to 2% of his total body surface area", and was receiving treatments including cleaning, wound debridement and dressing changes with Silver Sulfadiazine. According to the Social Worker, the resident was a surgical candidate, but the family declined as the resident was on comfort care. Review of the facility's July 2008 Baseboard Heater Protocol revealed "Baseboard heaters are checked before use, at the onset of cold weather season". It directed the "MS (Maintenance Supervisor) performs random checks no less than daily in the following manner: MS places his/her hand on the outside of the unit. If the baseboard heater is too hot to touch, the MS verifies the actual temperature by using a Laser Thermometer and recording the temperature in degrees F(Fahrenheit - dF) on the Baseboard Heater Audit Map by room number and date. If the temperature is equal to or greater than 150 dF, the MS immediately provides for the safety of the resident by turning off the heater... Once a week the MS tests the temperatures of all baseboard heaters by use of a Laser Thermometer and documents temperature on the Baseboard Heater Audit Map, by room number and date. All Audit forms and maps are kept in the Maintenance Log." The facility policy failed to include actions to reduce resident exposure to the hot surfaces if they were not identified in the audits. In an interview on 12/29/14 at 1:30 p.m., Staff A indicated only the 500 Hall was on electric baseboard heaters. The rest of the building was on hydroponic boil heat. Following the incident, Resident #1's room's baseboard heater surface temperature measured 155 dF. Staff A said the breaker had since been shut off and the facility was monitoring the surface temperatures of the other baseboard heaters on the 500 Hall. In an interview on 12/29/14 at 3:12 p.m. the Maintenance Supervisor, Staff C, said prior to the incident he checked the baseboard heaters daily to ensure they were clean and working. Staff C denied monitoring the actual temperatures of the baseboard heaters or documenting on the Baseboard Heater Audit Map according to facility policy. Staff C was unable to identify what temperature reading, if any, would not be safe. Staff A acknowledged Staff C monitored that the baseboards worked, but not if they were safe. On 12/29/14 the baseboards in the resident rooms on the 500 Hall were measured using a Laser Thermometer and the following was noted: At 2:05 p.m. the Room 515 baseboard surface temperature measured 132 dF. A fall mat was observed to be placed less than five inches from the heater and two felt-like blankets were leaning against the right end of the heater. Staff B went into the room and reported the fall mat had been placed under the nightstand to keep it in place, 1 foot to 14 inches from the heater. In Room 522 the room control was set at 70 dF. The baseboard surface was hot to touch and the temperature measured 128-132 dF and appeared to be missing the front safety screen. Staff A indicated that was one of the "new" baseboard heaters, which was intact, but did not provide the same protective screens as the other units. In Room 520 heat was felt radiating from the baseboard and the surface measured at 135 dF. According to facility provided audits, the baseboard heater surface in Room 504 measured 136 dF on 12/28/14 at 8:00 a.m. and Room 516 measured 135 dF on 12/28/14 at 1800. The facility did not have a system in place to monitor, assess and supervise the risk factors for residents who resided in beds that were located next to the baseboard heaters. In addition, the facility did not develop and implement a procedure to reduce resident exposure and prevent possible burns which could occur from extended periods of direct skin contact. .

Based on observation, interview and record review the facility failed to provide services to dependent residents who required assistance for Activities of Daily Living. Failure to provide assistance with toileting, nail care, removal of facial hair, oral care, and/or personal hygiene for 12 (Resident #s 5, 3, 54, 55, 1, 56, 19, 104, 36, 9, 24, and 96) of 14 sample residents and five (#22, 49, 32, 69 and 48) of six supplemental residents reviewed who were dependent on staff for care caused inadequate hygiene, and could reasonably be expected to cause anxiety, and feelings of being ignored and not valued. These failures also placed residents at risk for body odor, skin breakdown, and a diminished quality of life. In addition, failure to provide nail care for Resident #32 caused physical pain. Findings include: Refer to CFR 483.15(a), F-241 Dignity PROVISION OF CARE RESIDENT #5 Resident #5 had a [DIAGNOSES REDACTED]. The ADL (Activities of Daily Living) Function care plan (CP), dated 10/05/11, indicated staff should "toilet resident, lay her down ... after meals". The Potential for Alteration in Elimination CP, dated 10/05/11, revealed staff should check and change the resident every two hours and as needed, due to incontinence of her bowel and bladder. On 10/04/11 at 2:00 p.m., Resident #5 was observed with multiple, curly, white hairs on her chin, approximately ? inch long. On 10/06/11 at 2:25 p.m., Resident #5 was observed sitting on the edge of her bed, calling out, "Help me." She had dark matter in her teeth, along her gumline, and multiple lengthy facial hairs. Resident #5 was asked what she needed and she replied she needed to go to the bathroom. The call light was placed on, and at 2:27 p.m. Staff O entered the resident's room. Staff O was informed that the resident had asked to go to the bathroom. Staff O laid the resident back in bed, and told her, "I'll be right back." Staff O left the room. At 2:37 p.m., she returned, and with the help of a second certified nurse's aide (CNA), proceeded to put the resident in her wheelchair and placed her in the hallway, without toileting the resident. From 2:37 p.m. until 2:47 p.m., Resident #5 propelled her wheelchair around the hallway. Several staff members redirected her out of other resident's room, but none offered assistance. At 2:47 p.m., the resident was observed picking at her teeth with her finger. She ran her tongue around her gumline, and stated, "This is bothersome." At 2:49 p.m., the resident cried out, "I need to go potty." At 2:50 p.m., Staff N, licensed nurse (LN), was informed that the resident had requested to go to the bathroom [ROOM NUMBER] minutes prior, had not been assisted, and continued to ask. Resident #5 was not assisted to the bathroom until 2:53 p.m. On 10/07/11, the resident was in the dining room for breakfast by 7:35 a.m. At 8:54 a.m., she was removed from the dining room and placed in the hallway, across from the nurse's station. Between 8:55 a.m. and 9:56 a.m., the resident propelled her wheelchair from the nurse's station to the dining room and down another hallway. Staff periodically propelled the resident back to the nurse's station, but no offers to lay the resident down or to toilet her were made. At 9:56 a.m. Resident #5 was observed in her room, propelling her wheelchair around her bed. The bed had been placed in a high position, which Staff Q, CNA, stated had been done to prevent the resident from self transferring. The resident continued to propel around her bed and said, "Help me." Staff R, LN, told Staff Q, "She may want to lay down." Staff Q removed the resident from her room and placed her in the hallway near the dining room, without offering to lay her down or toilet her. The resident continued to call out, "Help me", as she propelled through the hallway. At 10:02 a.m., Resident #5 stated, "I have to go potty." An off-duty staff member walking by propelled the resident to the hallway facing her room, stated, "There you go" and walked away. Resident #5 continued to call out, "Help me". The resident was finally assisted to the bathroom at 10:15 a.m., after the Dietary Manager informed a CNA of the resident's repeated requests. On 10/10/11, the resident was in the dining room for breakfast by 7:30 a.m. At 9:15 a.m. the resident was taken from the dining room directly to an alcove next to the nurse's station, where several residents were watching a movie. Resident #5, who was placed with a resident behind her and another next to her, blocking her way, stated, "I wonder if I can get through. I need to go potty." Resident #5 attempted to turn her wheelchair around for several minutes, bumping into the residents around her. At 9:21 a.m., a CNA walked past and assisted Resident #5 out of the alcove, but did not offer to toilet or lie her down. Resident #5 propelled herself towards her room. At 9:27 a.m. Staff K, LN, asked Resident #5 to to wait in the hallway so she could administer medication, but did not offer to toilet or lie her down. Later observation at 10:51 a.m. revealed Resident #5 propelled herself past the nurse's station at the opposite end of the building from where she resided. She was redirected out of other resident's rooms, however was not assisted to the wing of the building in which she lived, or offered or provided any care. At 11:10 a.m. Resident #5 stated she was tired and would like to go to bed. Staff J was alerted to the resident's request, and he stated he would assist her. On 10/11/10 at 9:00 a.m., the resident was observed with multiple, long, white curly hairs on her chin. When asked by the surveyor if she would like her chin whiskers shaved, she stroked her chin, smiled and said, "Oh, yes. That would be good." Staff K, LN, was informed of the request, but did not assist the resident or inform her CNA to provide grooming assistance at that time. On 10/11/11 at 10:45 a.m., the Director of Nursing Services (DNS) was informed of multiple days of the resident not being toileted on schedule or when she requested assistance, as well as the lack of personal hygiene care. The DNS stated the resident was to be toileted and laid down after each meal, and she was unaware it had not been occurring. She also stated women's facial hair should be removed as needed. RESIDENT #3 Resident #3 was admitted to the facility on [DATE] with care needs that required the use of a mobility restricting brace. According to the 9/16/11 MDS, the resident was totally dependent on two staff for bed mobility and toilet use. Additionally, staff assessed the resident with no cognitive impairments, able to understand others and be understood in communication. In an interview at 9:49 a.m., Resident #3 was observed lying in bed, which had no fitted sheet. The resident, who was visibly annoyed, stated she was waiting to be "cleaned up" because she "had to go but no one came to help me so I had to wet myself." The resident indicated she had used her call light, but staff had not responded in time, and she was now waiting for staff to assist her. GROOMING/HYGIENE According to the facility "Standards of Care", "Every resident, regardless of functional and cognitive ability will be dressed, clean and well groomed every day. Therefore, it is the responsibility of the CNAs on each shift to make sure that: Each resident has clean hands and a clean face before and after meals," "each resident will be shaved daily," "Nail & Toenail care is done daily and at bath time by Bath aid unless resident is diabetic. Licensed Nurse will provide Toenail care for Diabetics," and "Each resident has a bath/shower per schedule." RESIDENT #54 According to the 9/11/11 MDS, Resident #54 was assessed as totally dependant on two staff for activities of daily living, understood and able to understand in communication. In an interview on 10/05/11 at 2:34 p.m., Resident #54 stated he did not participate in choosing his bathing schedule and this was not acceptable stating, "I am overdue for a bath...I think they need a few more (people to help do baths)." Observations on 10/05/11 at 2:15 p.m. revealed the resident had hair which was oily with copious white flakes. Review of Resident #54's bathing schedule revealed the resident did not receive a bath for 20 days from 9/16/11 to 10/06/11. There was no evidence facility staff were aware of the extended period without bathing or attempted to accommodate the resident's needs. RESIDENT #1 Resident #1 had a [DIAGNOSES REDACTED]. The ADL function CP, dated 9/14/11, revealed the resident was totally dependent on staff for bathing. Observation on 10/05/11 at 9:34 a.m. revealed the resident to have coarse facial hair, long nasal hair protruding from his nostrils, food debris in the stubble around his mouth, and his hair and scalp appeared unclean with copious amounts of dead flaky skin. Review of Shower/Bath sheets revealed the resident was last showered on September 22, 13 days prior. Further review revealed the resident received a shower every nine to twelve days between June 4 and October 5, 2011. Similar findings for Resident #56 for whom review of the Shower/Bath sheet revealed the resident went 12 days without a shower from 9/08/11 through 9/21/11 and 15 days without a shower between 9/21/11 and 10/6/11. Similar findings were identified for Resident #19 who had not received a shower in the first ten days of October. RESIDENT #104 Resident #104 was admitted to the facility 9/30/11. In an interview on 10/04/11 at 10:51 a.m. Resident #104 was asked what staff assisted her with for morning care and she replied, "Nothing, they bring me my food, that's about it." The resident stated further "They don't give me baths, or pans with soap. Yesterday I asked the therapist to bring me a pan, soap, water, towel and washcloth and she did." When asked if this was acceptable, Resident #104 replied "Absolutely not!", " I need help," and "A person needs to freshen themselves up a bit." On 10/07/11 at 12:54 p.m. Resident #104 was observed in bed wearing a hospital gown with snaps. The resident stated she had "not washed up yet" as the staff told her they did not have any linen. "I asked for a new gown, but they don't have any. I want one without snaps...". She also reported her teeth had not yet been brushed, and "I asked them to change my sheets, pad on my bed, it smells bad and I'm getting a rash on my butt, they didn't have any so that was out." The 10/04/11 ADL Care Plan indicated Resident #104 required limited assistance with bathing. The CP did not provide directions for staff to set up and assist with personal hygiene, including oral care and showers. The bath/shower flow sheets indicated the first shower given since admission was on 10/08/11. In an interview on 10/11/11 at 1:44 p.m., the DNS stated staff should provide oral care twice a day, "...once in the morning, once in the evening...". RESIDENT #36 Observation on 10/05/11 at 9:50 a.m. revealed the resident was unshaven and had oily unkempt hair. The 8/22/11 ADL Function CP indicated Resident #36 was dependent on staff for bathing, and instructed staff to "Assist with shower as scheduled and as needed." The Nursing Care Directives indicated Resident #36 was to receive a shower every week. Review of the Shower/Bath Sheet revealed the last documented shower was given on 9/22/11. Review of the resident's record revealed the resident had been erroneously isolated on contact precautions for 12 days, from 9/28/11 through 10/10/11. In an interview on 10/11/11 at 11:29 a.m. Staff I said that because of the contact isolation order, Resident #36 did not receive a shower, but was given "a bed bath a couple of times." Observations of Resident #69 on 10/05/11 at 9:52 a.m. revealed hair that appeared greasy and ragged fingernails. The right pointer fingernail was observed to have dark matter under it. On 10/05/11 at 11:34 a.m., Resident #9's fingernails were ragged, with some broken off, but not filed, so that they presented with sharp edges. Her fingernail polish was badly chipped. Additionally, observation on 10/05/11 at 11:35 a.m. revealed Resident #24 with coarse facial hair that appeared to have not been shaved for several days, and whose hair was uncombed. On 10/12/11 at 9:25 a.m., Resident #96 was noted to have multiple course grey hairs on her chin approximately 1/8 th to 1/4 inch in length. At that time, Staff B indicated facial hair should be trimmed during bathing. RESIDENT #55 Resident #55 was observed on 10/05/2011 at 11:57 a.m. to have hair that looked greasy and unwashed. Record review revealed no documented bathing for this resident for ten days, from 9/02 through 9/20, and 13 days from 9/22/11 through 10/05/11. There was no evidence additional showers had been offererd or refused. Similar findings were identified for Resident #s 22 and 49 who had no bathing for a period of ten and nine days, respectively, and no evidence bathing had been offered or refused on additional days. In an interview on 10/11/11 at 11:15 a.m. Staff I stated, "every weekend I get pulled one day. It's hopeless to try and do baths on weekends. I only got six done yesterday, I was pulled (from doing baths) until 8:30 a.m., passing trays, feeding... I can usually get eight to 15 showers (in a day), eight if I am in the dining room. " NAIL CARE RESIDENT #32 Resident #32 was observed on 10/11/11 at 10:14 a.m. with a chipped right index nail and polish worn down on her other fingernails. The second toenail on the resident's right foot was elongated and needed trimming. As Staff U removed the resident's left sock, the resident kicked outwardly. The second toenail on the left foot was ripped partially off and Staff U commented, "Oh we have a hanger." When asked if it hurt, the resident replied "Yes." The third, fourth and fifth toenails were observed to be long, turning over the toes. The Nursing Care Directives indicated fingernail and toenail care was to be completed by the CNA. Staff U said the resident's nails were clipped by Staff I on shower days, unless it was care planned for the nurse to do. In an interview on 10/11/11 at 11:15 a.m. Staff I said residents' nail care was done "every other bath time, if the resident is agreeable." When asked specifically about Resident #32, Staff I said the "resident can be combative" and did not recall the last time he had clipped her toenails. Review of shower sheets revealed a shower was documented as given 10/09/11. Staff I said he did not cut the resident's nails then as he was "working short" and "backed up." RESIDENT #96 Resident #96 was admitted to the facility on [DATE] and was assessed to require extensive one person assistance with personal hygiene. Record review revealed the resident had a [DIAGNOSES REDACTED]. In an interview on 10/12/11 at 9:15 a.m., the resident stated, "I'd like my toenails cut, they catch on my socks". Observation on 10/12/11 at 9:25 a.m. with Staff B, the DNS, revealed the resident had elongated toe nails. The third and forth toenails bilaterally were curling upward. In an interview on 10/12/11 at 9:27 a.m., the DNS indicated that diabetic residents received nail care once a week from licensed nurses and the nurses were directed to provide this care on the treatment records. Review of the resident's treatment records revealed no direction to staff to provide nail care. In an interview on 10/11/11 Staff I, the shower aide, indicated he did not do nail care for diabetic residents, that it was performed by licensed nurses. Similar findings were identified for Resident #48 who was identified by staff as a diabetic and for whom toe nails were observed on 10/11/11 to long and whose fingernails contained brown debris. CARE CONCERNS Review of the facility Grievance Log and associated Concern/Comment Forms revealed the facility was notified by residents and/or resident representatives regarding lack of care provided. On 8/24/11, Resident #59's family member was concerned the resident's "teeth are not being brushed." On 9/12/11, Resident #46 stated, "teeth had not been brushed since admit." On 9/20/11, Resident #54 reported, "Not having teeth brushed daily" . On 9/22/11, Resident #59's family member was concerned of "whiskers on chin" and "teeth are not getting brushed daily." On 9/27/11, Resident #75 reported, "Staff is not setting up for oral care." After each of the reported concerns, the action taken by the facility included staff training to provide care per facility Standards of Care. .

Based on observation, interview and record review, it was determined the facility failed to have sufficient quantity of qualified nursing staff to provide and supervise care for residents with complex health care needs. Staff did not adequately assess, evaluate or document information needed to formulate effective and timely interventions. This resulted in a failure to provide timely response to calls for assistance, failure to bathe or shower, provide toileting and incontinent care, or the delivery of basic activities of daily living. Nursing assistants were not adequately supervised to ensure required interventions were implemented. These failures placed residents at risk for not attaining and/or maintaining the highest practicable physical, mental, and psychosocial well-being and caused harm to Resident #s 5, 3 and 32. Findings include: For one of 14 days reviewed the facility failed to ensure eight hours of Registered Nursing coverage. 1) Refer to CFR 483.10(e)(1-3), F-164, Privacy and Confidentiality, for specific examples of Nursing staff failure to meet resident rights for personal privacy of person for one of three residents observed during personal care. 2) Refer to CFR 483.15(a), F-241, Quality of Life, for specific examples of failure by facility staff to limit use of personal care signs, meet resident's incontinent care needs, or provide assistance with activities of daily living needs in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. 3) Refer to CFR 483.15(b), F-242, Accommodation of Needs, for specific examples of failure by Nursing staff to accommodate individual needs and preferences for bathing. 4) Refer to CFR 483.20(b)(i)(viii)(xi)(xiii)(xv), F-272, Comprehensive Assessment, for specific examples of failure by facility staff to conduct accurate or timely assessments. 5) Refer to CFR 483.20(k), F -279, Comprehensive Care Plans, for specific examples of staff failure to review and/or revise care plans to reflect resident needs. 6) Refer to CFR 483.20(k)(3)(1), F-281, Services Provided meet Professional Standards, for facility failure to ensure professional standards were followed for Licensed Nurses implementing physician orders, ensuring site rotation for injections or following facility practices and/or manufacturer recommendations. 7) Refer to CFR 483.25, F-309, Quality of Care, for failure of Licensed Nurses to provide bowel management and/or proper positioning for residents according to assessed needs. 8) Refer to CFR 483.25(a)(3), F-312, Dependent Residents Receives Care, for failure of Nursing Staff to provide required assistance for toileting, nail care, removal of facial hair, oral care, and/or personal hygiene. 9) Refer to CFR 483.25(k)(6), F-328, Special Respiratory care needs, for failure of Nursing staff to administer oxygen within the parameters of physician orders, ensure portable oxygen tanks used by residents contained oxygen, and failure to titrate or consider continued need of oxygen. 10) Refer to CFR 483.25(l)(1), F-329, Unnecessary Medications, for failure of Nursing staff to ensure monitoring and adequate indications for use of medications. 11) Refer to CFR 483.25(m)(1), F-332, Medication Error Rate, for failure of three of six Nursing staff observed, to ensure a medication error rate of less than 5%. 12) Refer to CFR 483.25(m)(2), F-333, Significant Medication Error, for failure of Nursing Staff to ensure residents were free from significant medication errors. .