Every finding on record at Fir Lane Care

Based on observation and interview the facility failed to prevent cross contamination during meal preparation services for 1 of 1 kitchen, reviewed for food service safety. The failure to prevent cross contamination placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life.Findings included . On 07/08/2026 at 11:29 AM, observations of tray line were conducted. Staff I, Dietary Manager, started plating food on dishes for lunch meal service. On 07/08/2026 at 12:03 PM, Staff I touched the chicken stripes on three different plates with a gloved hand and continued to dish up other plates. Staff I did not change their gloves. On 07/08/2026 at 12:05 PM, Staff I touched chicken with a gloved hand and continued to dish up other plates. Staff I did not change their gloves. On 07/08/2026 at 12:05 PM, Staff I touched the small over door (opening and closing) with a gloved hand and continued to dish up plates. Staff I did not change their gloves. On 07/08/2026 at 12:06 PM, Staff I donned (put on) a new pair of gloves. On 07/08/2026 at 12:09 PM, Staff I touched the chicken with a gloved hand and continued to dish up plates. Staff I did not change their gloves. On 07/08/2026 at 12:10 PM, Staff I touched small oven door (opening and closing) with a gloved hand and continued to dish up plates. Staff I did not change their gloves. On 07/08/2026 at 12:11 PM, Staff I touched the cheese on the plate and then opened the small oven door and grabbed burger patty with a gloved hand, then closed the door and continued to dish up plates. Staff I did not change their gloves. On 07/08/2026 at 12:13 PM, Staff I turned on a 2nd oven (the large oven) with a gloved hand. Staff I did not change their gloves. On 07/08/2026 at 12:14 PM, Staff I opened the small oven door with a gloved hand, grabbed beef burger patty with a gloved hand, closed the door and then continued dishing up plates. Staff I did not change their gloves. On 07/08/2026 at 12:15 PM, Staff I opened the small oven, grabbed 2 hot dogs with a gloved hand, closed the oven door and continued to dish up plates. Staff I did not change their gloves. On 07/08/2026 at 12:19 PM, Staff I touched the chicken with a gloved hand and continued to dish up plates. Staff I did not change their gloves. On 07/08/2026 at 12:23 PM, Staff I touched the chicken with a gloved hand. Tray line observations ended at 12:23 PM. On 07/08/2026 at 12:43 PM, when asked if staff should touch the food, Staff I said the food should not have been touched. When observations of food being touched and then touching environmental surfaces, Staff I said they had caught themselves doing it. Staff I said they should not have touched the food and the environmental surfaces; they should have changed their gloves too. Reference WAC 388-97 -1100 (3), -2980

Based on interview and record review, the facility failed to ensure restorative services (assessed nursing interventions to promote a resident's ability to maintaining functional abilities and independence) were provided for 3 of 3 residents (Resident 10, 6 & 32) reviewed for restorative services. This failure placed residents at risk of physical decline, loss of ability to perform activities of daily living, and a diminished quality of life.Findings included. Resident 10 was admitted to the facility on [DATE] with a diagnosis of paralysis/severe weakness to the left side following a stroke (interruption of blood flow to the brain causing brain damage and other complications). The Quarterly Minimum Data Set assessment (MDS), dated [DATE], showed they were cognitively intact and had received 2 days of restorative services during the assessment period. Review of Resident 10's care plan showed they had a restorative program, last revised on 05/05/2026, for a range of motion program for their left upper arm, as tolerated 6 days a week. Review of Resident 10's restorative evaluations, showed they had not had an evaluation since 03/02/2026, which said the program was on hold due to therapy services. Review of Resident 10's last 30 days of their restorative program task list, showed they only had restorative done on 06/13/2026, 06/27/2026, and 07/10/2026. Review of therapy documentation, showed Resident 10 was discharged from occupational therapy on 03/14/2026 with recommendations for restorative related to activities of daily living and range of motion. Further review showed Resident 10 was seen by physical therapy from 04/08/2026 to 05/07/2026, related to learning how to use a powered wheelchair. During an interview on 07/07/2026 at 08:29 AM, Resident 10 was unaware they were getting restorative services and said they wanted to get those services. During an interview on 07/10/2026 at 11:01 AM, Staff C, MDS Coordinator/Registered Nurse, confirmed they oversaw the restorative department. Regarding Resident 10's restorative program, Staff C said they were supposed to get a restorative program for their left upper arm 6 days a week, but due to staffing it may or may not occur only on Fridays or Saturdays. Staff C confirmed Resident 10 only participated in restorative therapy 3 times in the past 30 days, due to staffing limitations. Staff C said restorative evaluations should be done quarterly and as needed. When asked if Resident 10 had a current restorative evaluation, Staff C said they had missed the one in June and the last was done in March 2026. Regarding the March restorative evaluation saying Resident 10's restorative therapy was on hold, Staff C said they must have put Resident 10 back into the same program, they did not have the sheet from therapy, and it might have been the same program. Staff C was asked about Resident 10 restarting restorative therapy, if this happened when discharged on 03/14/2026 from occupational therapy. Staff C said Resident 10 went on therapy on 04/08/2026, and the date for restarting the restorative program was 05/05/2026. When asked if they had documentation that therapy agreed to the hold on the restorative program, Staff C said no, they would only have a conversation. During a joint interview on 07/10/2026 at 11:26 AM, Staff A, Administrator, and Staff B, Director of Nursing Services, were asked about Resident 10 and the restorative program. Concern was reviewed that Resident 10 only got restorative 3 times in 30 days, with an evaluation of 6 days a week, and there was an overall staffing concern related to the facility's restorative program. Staff A said their expectation related to meeting residents needs related to restorative services, was for them to meet the needs and recommendations of therapy, and to make a plan that was obtainable. Staff B agreed. When concern was reviewed that pauses of the restorative program were being done, due to an unrelated therapy concern which in then caused delays in services, Staff A said okay. When asked about Resident 10's restorative evaluation not being redone once restarted or quarterly, Staff A said it did not meet expectations. Resident 6 Resident 6 was admitted to the facility on [DATE] with diagnoses of arthritis due to other bacteria of the left shoulder, acute osteomyelitis (infection and inflammation of the bone) of left humerus, spinal stenosis (narrowing of the spaces within the spine) site unspecified, and osteomyelitis of vertebra, lumbar region. The Quarterly MDS assessment documented Resident 6 was cognitively intact. On 07/07/2026 at 9:29 AM, Resident 6 said their insurance had lapsed and Medicare would not approve therapy, but Medicaid would approve restorative therapy but no one from the restorative program had been to see them. Resident 6 said in January they had been to the hospital and could not use their back, it was horribly painful and facility staff were going to work with them but still had not been there. Resident 6 said the house doctor had not gotten an answer about the restorative program for Resident 6 either. Review of Resident 6's care plan, revised on 05/19/2026, documented Resident 6 had limited physical mobility related to a history of bacterial arthritis to their left shoulder, history of osteomyelitis to left humerus, diabetes mellites, congestive heart failure, and respiratory failure. The care plan had Restorative program goals that Resident 6 would participate in the restorative program for the right shoulder and left shoulder and have no decline through the review date. Interventions for the Restorative program were active range of motion with 2-pound weight on right upper extremity and 1 pound weight on left upper extremity through all planes of motion 2-3 sets of 5-10 reps as tolerated. On 07/09/2026 at 11:25 AM, Staff J, Director of Therapy, reported Resident 6 had been discharged from physical therapy on 05/14/2026 and she had referred them to the restorative program. Review of the Physical Therapy discharge summary, dates of service 04/16/2026-05/14/2026, documented Resident 6 had reached maximum potential with skilled services. On 07/09/2026 at 11:44 AM, Staff C, Minimum Data Set Coordinator/Registered Nurse, when asked if she oversaw the restorative department, said yes. Regarding Resident 6's restorative program, Staff C said it had been spotty because they did not have staff for the program. Staff C said they had been trying to have the program every day but lost 4 staff who had either quit or changed their positions at the facility. Staff C said they were now only offering Restorative one day a week, on Fridays. Staff C confirmed Resident 6 was on the Restorative program and said residents had not been getting their program with it only being offered once a week. Staff C said Resident 6 was discharged from Physical Therapy on 05/14/2026 and was picked up for the Restorative program on 05/19/2026. When asked how many times Resident 6 had received Restorative therapy services since 05/19/2026, Staff C said she could only see back in the record 30 days and Resident 6 had been seen 3 times in the last 30 days, and it had been documented the activity did not occur 5 times which Staff C explained meant there was no staff for those days. When asked how often Resident 6 was scheduled to receive the Restorative program, Staff C said what they did was schedule it every day when they had someone to do the program hoping the resident would get 5 days of restorative a week, and that they had to change the goal to 3 times a week because they weren't meeting the goal of 5 days a week. Staff C said Resident 6 was scheduled to receive the Restorative program 3 days a week. During this same interview Staff C, MDS Coordinator/RN was asked if this met her expectations for a restorative program for residents, and she said no, that it was hard because of staffing. Staff C provided the 30-day history of restorative visits for Resident 6 from 06/10/2026-07/082026, which were reviewed and showed between those dates 11 opportunities for the restorative program were recorded, with 1 visit documenting not applicable, and 5 visits documenting did not occur, and 1 visit documenting resident not available. The documentation showed Resident 6 received the restorative program 4 times in 30 days. Resident 32 Resident 32 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 32 was cognitively intact and was receiving restorative services during the assessment period. An order for June 2026 restorative program documented Range of motion perform BLE [bilateral lower extremities] seated exercises with light to mod [moderate] resistance 2-3 sets of 10 reps as tolerated 5-6 days per week. BUE [bilateral upper extremities [should exercises with 2 lb [pound] weights flexion, abduction shoulder press and bicep curls 1-2 sets of 10 reps as tolerated 5 days per week. The Task documentation for June 2026 (30 day look back), showed Resident 32 received restorative on 06/14/2026, 06/20/2026, 06/26/2026 & 06/27/2026. On 07/10/2026 at 10:57 AM, when asked about restorative services specifical listed above, Resident 32 said they had not received any of those specific services in months. Resident 32 said they had been working the physical therapy for the last month due to an ankle injury. Resident 32 said they have not been in or received restorative program services in months. On 07/10/2026 at 11:26 AM, Staff A, Administrator and Staff B, DNS were asked about restorative program services. Staff A said the restorative program was to meet the needs of the resident and to have an obtainable goal. Resident 32's specific restorative program goals were read out loud. Staff A reviewed June 2026's restorative dates and confirmed Resident 32 only received restorative services 4 times during the month of June 2026. Staff A said that did not meet expectations, Resident 32 should have gotten services as orders. Staff B agreed. Reference WAC 388-97 -1060 (3)(d), (j)(ix)

Based on interview and record review, the facility failed to ensure binding arbitration agreements were explained in a manner that residents understood, for 3 of 3 residents (Resident 64, 27 & 78) reviewed for binding arbitration (an agreement to use a third-party mediator and waives the right to a trial by jury). This failure placed residents at risk of signing away their rights, not understanding what they had signed, and a diminished quality of life.Findings included.Resident 64Resident 64 was admitted to the facility on [DATE]. Review of their brief interview for mental status form, dated 06/24/2026, showed they were cognitively intact. Review of Resident 64's arbitration agreement, showed they had signed the form on 07/03/2026. During an interview on 07/08/2026 at 12:18 PM, Resident 64 was asked what their understanding of the arbitration process was when a dispute came up. Resident 64 stated, I don't know. When asked if they knew they were giving up their right to litigation in a court proceeding, Resident 64 said no. Resident 64 then asked what an arbitration agreement was. Resident 64 stated, I don't remember what I signed. I just remember what I was told to sign. I have been suckered into so many things because I sign and don't ask what I am signing. Resident 64 said no, the arbitration agreement was not explained in a way they understood. Resident 27Resident 27 was admitted to the facility on [DATE]. Review of their brief interview for mental status form, dated 06/24/2026, showed they were cognitively intact. Review of Resident 27's arbitration agreement, showed they had signed the form on 07/03/2026. During an interview on 07/08/2026 at 12:21 PM, Resident 27 was asked what their understanding of the arbitration process was when a dispute came up. Resident 27 asked, What is arbitration?. Resident 27 said they did not know they were giving up their right to litigation in a court proceeding. When asked if they were told the facility could not require them to enter into an arbitration agreement to be admitted or remain at the facility, Resident 27 said there were a lot of things they did not understand, which is why their [AGE] year old son comprehends it for them, they had injured their head 5 years ago, and they have some days were they think pretty good and other days that were harder, and were working on getting a power of attorney. Resident 78Resident 78 was admitted to the facility on [DATE]. Review of their brief interview for mental status form, dated 06/26/2026, showed they were cognitively intact. Review of Resident 78's arbitration agreement, showed they had signed the form on 06/26/2026. During an interview on 07/08/2026 at 12:11 PM, Resident 78 was asked what their understanding of the arbitration process was when a dispute came up. Resident 78 said they were unclear on this and then asked, Does it have something to do with patient rights?. Resident 78 said arbitration was new to them. When asked if they were told the facility could not require them to enter into an arbitration agreement in order to be admitted , or to remain in the facility, Resident 78 stated, No, I was never told.During an interview on 07/10/2026 at 9:42 AM, Staff A, Administrator, said their expectation was for the arbitration agreements to have been explained in a way that was understandable to the residents or whoever was in charge of their care. No associated WAC

Based on interview and record review, the facility failed to maintain complete and accessible medical records of hospice nursing and hospice health aide visits for 1 of 1 Residents (Resident 3) reviewed for hospice. This failure placed residents at risk of not having a record of assessments and services provided and a decreased quality of care.Findings included.Review of the Nursing Facility Services Agreement with Assured Home Health and Hospice, effective as of 10/01/2019, documented under coordination of care that hospice and the facility should communicate with one another regularly and as needed for each particular hospice patient, and each party was responsible for documenting such communication in its respective clinical records to ensure that the needs of hospice patients were met 24 hours per day.Resident 3 was re-admitted to the facility on [DATE] with hospice services in place. The admission Minimum Data Set assessment, dated 06/17/2026, documented Resident 3 was severely cognitively impaired. On 07/10/2026 at 10:48 AM, review of Resident 3's hospice binder, kept at the nurse's station, showed the hospice certification and plan of care were in the binder but the binder contained no record of hospice nursing or health aid visits. The hospice plan of care showed that Resident 3 was to be seen by the hospice nurse 2 times a week for 13 weeks with 4 as needed visits for urgent symptom management needs or a change in condition. The hospice health aide was to visit 1 time a week for 1 week and then 2 times a week for 12 weeks.Review of the electronic health record (EHR) for Resident 3 showed no record of visits with subsequent visit notes from hospice staff were recorded since admission to the facility on [DATE]. On 07/10/2026 at 10:29 AM, Staff G, Resident Care Manager/Registered Nurse, when asked who was responsible for coordinating hospice care for residents on hospice, said the interdisciplinary team collectively looked at hospice patients but that she would coordinate with the hospice nurse regarding nursing services. When asked how hospice staff visits were recorded, Staff G said the hospice staff would write notes in the resident's hospice binder where the care plan, certificate period, orders and progress notes were written and then it would be uploaded into the resident's EHR. Staff G said Resident 3 received nurse visits, and bath aide visits. When asked if Resident 3 had regular visits from hospice staff, Staff G said that week the hospice nurse had come in 3 times, but Resident 3 had previously been having daily visits. Staff G said Resident 3 went onto hospice services on 06/09/2026. When asked where the hospice visit notes from hospice staff were located for Resident 3, Staff G looked in the EHR and said she would call the hospice and get the documentation.On 07/10/2026 at 10:42 AM, Staff G said the hospice nurse was going to send the documentation of the hospice visits. When asked if the hospice visits should have been documented and in the EHR, Staff G said yes.Review of the Hospice Client Coordination Note Reports (hospice visit notes), received from Staff G on 07/10/2026 at 11:40 AM, showed between 06/11/2026 and 07/09/2026, Resident 3 had 20 nursing visits that had not been recorded in the EHR. No records of health aide visits were provided.Reference WAC 388-97- 1720 (1)(a)(i-iv)(b)

Based on interview and record review, the facility failed to follow gradual dose reduction (GDR) requirements and/or to monitor psychotropic medications (altering the mental state) for 3 of 5 residents (Resident 2, 56 & 32) reviewed for unnecessary medications. This failure placed residents at risk of unnecessary medications, side effects, and a diminished quality of life. Findings included. Review of the facility's policy titled Psychoactive Medication Management, revised 08/2024, showed a GDR attempt should be made unless clinically contraindicated. These contraindications, for a resident with a diagnosis of dementia, were if the resident's target symptoms returned or worsened after the most recent attempt at a GDR within the center and the physician had documented the clinical rationale for why any additional attempted dose reduction at the time would be likely to impair the resident's function or increase distressed behavior. Resident 2 Resident 2 was admitted to the facility on [DATE] with diagnoses of dementia (decline in cognitive function severe enough to interfere with daily life) and depression. The Quarterly Minimum Data Set assessment (MDS), dated [DATE], showed Resident 2 had severe cognitive impairment. Review of Resident 2's GDR documentation, showed on 02/04/2026, the pharmacist had written that Resident 2's trazodone (an antidepressant that can also be used for sleep) medication for insomnia (difficulty sleeping at night) was due for a GDR review. The pharmacist wrote that the interdisciplinary team felt Resident 2 benefited from the current dose and no change was recommended to maintain condition stability. A provider signed the form on 02/11/2026 with no additional documentation or clinical rationale documented by the provider. Review of Resident 2's psychology follow-up progress note, dated 02/06/2026, showed the provider had documented Resident 2 had exhibited daytime sedation and would sleep during the day, which could have been related to the trazodone or their antipsychotic medication. Review of Resident 2's sleep monitor for January 2026, showed the following 14 dates had sleep amounts of 10 hours or greater: 01/01/2026- 14 hours, 01/07/2026-14 hours, 01/13/2026- 15 hours, 01/14/2026- 15 hours, 01/15/2026-15 hours, 01/16/2026- 13 hours, 01/19/2026- 11 hours, 01/20/2026- 16 hours, 01/21/2026-14 hours, 01/23/2026- 13 hours, 01/24/2026-20 hours, 01/27/2026- 13 hours, 01/30/2026- 12 hours, 01/31/2026- 20 hours Review of Resident 2's sleep monitor for February 2026, from 02/01/2026 to 02/11/2026 (date provider signed the GDR form), showed the following eight dates had sleep amounts of 10 hours or greater: 02/01/2026- 11 hours, 02/02/2026-13 hours, 02/03/2026-10 hours, 02/04/2026-15 hours, 02/05/2026-10 hours, 02/06/2026-20 hours, 02/09/2026-11 hours, 02/11/2026-12 hours During an interview on 07/08/2026 at 2:48 PM, Staff D, Resident Care Manager/Registered Nurse (RCM/RN), confirmed they were unable to find clinical justification by the provider for not completing the GDR. Staff D said there should have been documentation, and provider follow-up documentation should show the reason for agreeing or disagreeing with the recommendation. Staff D said they also did not see in Resident 2's clinical record why the trazodone dose could not have been decreased, as it was for insomnia and Resident 2 was sleeping for long periods of time. Resident 56 Resident 56 was admitted to the facility on [DATE] with diagnoses of dementia, mild, with other behavioral disturbance, major depressive disorder, insomnia, delusional disorders and anxiety disorder. The Quarterly MDS, dated [DATE], documented Resident 56 was moderately cognitively impaired. Resident 56 had the following active ordered psychotropic medications: Depakote (anti-seizure medication also considered a mood stabilizer), to be given two times a day for anxiety, agitation. Lorazepam (anti-anxiety medication) to be given every 6 hours for anxiety, agitation. Mirtazapine (anti-depressant) to be given at bedtime for depression. Risperdal (antipsychotic medication) to be given two times a day for delusional disorder. Review of Resident 56's Treatment Administration Record (TAR) from 07/01/2026-07/06/2026, showed the following monitoring of target behaviors: Target behavior related to insomnia-fatigue, low energy, irritable. for psychoactive medication. (Psychoactive, term sometimes used interchangeably with psychotropic medication. The monitoring did not specify which psychoactive medication or medication class the target behaviors were being monitored for.) Target behavior- combative behavior/aggression.for psychoactive medication related to dementia with behavior disturbance. (The monitoring did not specify which psychoactive medication or medication class the target behaviors were being monitored for.) Target behavior- may include restlessness, agitation, excessive worry/fear, rapid speech, insomnia, nausea. for psychoactive medication. (The monitoring did not specify which psychoactive medication or medication class the target behaviors were being monitored for.) Target behavior- resident may exhibit behaviors related to yelling towards staff, foul language, confusion. for psychoactive medication. (The monitoring did not specify which psychoactive medication or medication class the target behaviors were being monitored for.) On 07/09/2026 at 3:32 PM, Staff G, RCM/RN, when asked what their expectations were for target behavior monitoring for residents taking psychotropic medications, said for the behaviors to be care planned and monitored. Staff G said nurses would watch every shift to see if the behaviors were occurring and document them in a progress note. Staff G said target behaviors should be specific to the class of drug they were being monitored for. Regarding if a resident was on multiple medications for anxiety, agitation and if there should be specific symptoms and target behaviors for each medication to distinguish what the medication was treating, Staff G said if there were two different diagnosis there could be two different sets of behaviors. Staff G used the example of yelling and screaming with agitation, which she said would be different than crying with anxiety. On 07/09/2026 at 4:00 PM, Staff G was asked about Resident 56 being prescribed both Depakote and Lorazepam for anxiety and agitation and was asked if target behaviors were in place for each medication. Staff G said the target behaviors just indicated psychoactive medication and said she could see the issue. When asked if target behaviors were being monitored for anxiety, Staff G said there was monitoring in place for yelling, hitting staff, combative behavior, aggression, self-isolation, verbal outbursts, tearful, restlessness. When asked if those target behaviors were indicated on the TAR for psychoactive medications, Staff G said yes. When asked how it would be determined if each medication was still necessary if target behaviors were not tracked for the specific medication, Staff G nodded affirmatively. Resident 32 Resident 32 was admitted to the facility on [DATE] with diagnoses of unspecified psychosis (symptoms may include hallucinations, delusions, disorganized thinking or severely disorganized behavior) and dystonia (a movement disorder), unspecified. The Modification of Quarterly MDS, dated [DATE], documented Resident 32 was cognitively intact. Review of Resident 32's orders showed two daily psychotropic medications as follows: Quetiapine (antipsychotic medication), to be given at bedtime for psychosis, order dated 05/28/2026. Clonazepam (anti-anxiety medication) to be given at bedtime related to Dystonia, order dated 01/30/2026. Review of Resident 32's TAR, from 07/01/2026-07/06/2026, showed the following monitoring of target behaviors: Target Behavior: Delusions, increased agitation/aggression.for psychoactive medication. (The monitoring did not specify which psychoactive medication or medication class the target behaviors were being monitored for.) Further review of Resident 32's TAR, showed no side effect monitoring for the clonazepam. On 07/09/2026 at 3:32 PM, Staff G, RCM/RN, when asked if Resident 32 had target behaviors in place for the medication clonazepam prescribed to treat dystonia, said no, it was not being monitored because it was not on the TAR and it should have been. When asked if adverse side effects were being monitored for the clonazepam, Staff G said no, side effects should have been monitored. Reference WAC 388-97-0620 (1)(a)

Based on interviews and record review, the facility failed to ensure weekly skin evaluations were completed accurately and wound care was documented on the Treatment Administration Record (TAR) for 1 of 1 sampled Resident (13) reviewed for pressure ulcer (PU). These failures placed the resident at risk of a delay in treatment, deterioration of the PU, and a diminished quality of life. Findings included.Resident 13 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, dated [DATE], documented Resident 13 was cognitively intact and had a stage 2 PU. Skin EvaluationsA review of the Total Body Skin Evaluation Weekly, dated 06/17/2026 and 06/25/2026, documented no skin concerns noted and did not document a PU.On 07/10/2026 at 9:12 AM, Staff G, Registered Nurse (RN)/Resident Care Manager (RCM) said that nothing was documented about Resident 13's PU on 06/17/2026 and 06/25/2026's Total Body Skin Evaluation Weekly and it should have been. Staff G said the skin concerns were not documented accurately and their expectation was the nursing staff document wound care and PU as an issue on the evaluation. On 07/10/2026 at 10:36 AM, Staff B, Director of Nursing Services (DNS), said the Total Body Skin Evaluation Weekly on 06/17/2026 and 06/25/2026 were not charted correctly and said Resident 13's PU should have been documented.Wound Care on the [NAME] review of Resident 13's March 2026 TAR listed an order for:WOUND CARE TO STAGE 2 PRESSURE ULCER 3 times per week and as needed for if soiled/dislodged and the order was discontinued on 04/07/2026. And a blank box with no documentation was noted on 03/31/2026 of the TAR and no as needed wound care was documented on the TAR.A review of Resident 13's April 2026 TAR listed orders for: WOUND CARE TO STAGE 2 PRESSURE ULCER 3 times per week and as needed every day shift every Tue, Thu, Sat for wound care and the order was discontinued on 04/07/2026. A blank box with no documentation was noted on 04/02/2026 and as needed wound care was documented as provided on 04/05/2026.WOUND CARE TO STAGE 2 PRESSURE ULCER 3 times per week and as needed every day shift every Tue, Thu, Sat for wound care and the order was discontinued on 04/14/2026. A blank box with no documentation was noted on 04/14/2026 and PRN wound care was documented as provided on 04/16/2026 and 04/26/2026 on the TAR.A review of Resident 13's May 2026 TAR listed an order for: WOUND CARE TO STAGE 3 PRESSURE ULCER change 3 times a week and as needed every day shift every Tue, Thu, Sat for wound care and the order was discontinued on 06/29/2026. A blank box with no documentation was noted on 05/05/2026, 05/09/2026, 05/14/2026, and 05/30/2026 and as needed wound care was documented as provided on 05/04/2026 and 05/11/2026.A review of Resident 13's June 2026 TAR listed an order for: WOUND CARE TO STAGE 3 PRESSURE ULCER change 3 times a week and as needed every day shift every Tue, Thu, Sat for wound care and the order was discontinued on 06/29/2026. A blank box with no documentation was noted on 06/09/2026 and 06/13/2026 and no as needed wound care was documented on the TAR.On 07/10/2026 at 9:12 AM, Staff G, RN/RCM said they saw the dates without documentation on the TAR and Staff G said they should have been completed and signed off. Staff G said the resident could have received wound care from United Wound Healing on some of those days but the nursing staff could have documented the care provided on the TAR.On 07/10/2026 at 10:36 AM, Staff B, DNS said something should have been charted on the TAR even if Resident 13 was seen by United Wound Healing, was out of the facility, and/or there was an overlap in wound care orders. Staff B said their expectation was if there was an active order then something should have been documented in the box.Reference WAC 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to ensure residents requiring dialysis (procedure that filters out waste and excess fluid from the blood, helping to regulate blood pressure) were appropriately monitored and treated for blood pressure and fluid restrictions, and communication from dialysis was accurately recorded into their medical record for 1 of 1 resident (Resident 7) reviewed for dialysis. This failure placed residents at risk of medical complications including fluid overload, and a diminished quality of life.Findings included.Resident 7 was admitted to the facility on [DATE] with diagnoses of end stage renal disease (kidney failure) and dependence on renal dialysis. The Medicare 5 Day Minimum Data Set assessment, dated 06/07/2026, showed Resident 7 was cognitively intact. Review of Resident 7's orders, showed they had hydralazine, a blood pressure medication, ordered on 05/21/2026, to be used every 8 hours as needed for systolic blood pressure (top number) over 170 or diastolic blood pressure (bottom number) over 110. Review of Resident 7's blood pressure readings showed they had elevated blood pressure readings on: 06/26/2026-173/75, 06/28/2026- 174/80 and 182/90, and 07/06/2026-177/71. Review of Resident 7's June and July 2026 Medication Administration Records (MAR), showed hydralazine was not given on 06/26/2026, 06/28/2026, or 07/06/2026. Review of Resident 7's dialysis communication forms, showed on 05/25/2026, dialysis communicated they had given a pneumococcal vaccine. Review of Resident 7's electronic health record (EHR), showed on 06/23/2026 the facility documented under their immunization section that they offered Resident 7 the pneumococcal vaccine, provided education, and the resident refused. This section was not updated with Resident 7's vaccine date from dialysis. Further review of Resident 7's dialysis communication forms, showed on 06/29/2026 Resident 7 had more fluid than normal removed during dialysis. Their pre-dialysis weight was 50.8 kg (112 pounds (lbs.)) and their post-dialysis weight was 46.6 kg (103 lbs.).Review of Resident 7's orders showed a weight order, ordered on 05/15/2026, for post dialysis dry weights to be recorded Monday, Wednesday, and Friday after returning from dialysis. This order did not list the goal dry weight (ideal weight of a resident without excess fluid retention, allowing the body to function best without signs of fluid overload or dehydration) established by dialysis.Review of Resident 7's current fluid restriction order, showed it started on 06/08/2026 for 1,000 milliliters (ml) in 24 hours and nursing was to document the total amount of ml provided per shift. Nursing was to provide 280 ml total, 120 ml during day shift, 120 ml during evening shift, and 40 ml during nighttime shift. Dietary was to provide 720 ml total, 240 ml with breakfast, 240 ml with lunch, and 240 ml with dinner.Review of Resident 7's June 2026 MAR, showed the following total amounts were documented in June and below the 720 ml provided by dietary: 06/09/2026: 710 ml, 06/13/2026:160 ml, 06/14/2026: 160 ml, 06/15/2026: 470 ml, 06/19/2026: 100 ml, 06/20/2026:160 ml, 06/21/2026:470 ml, 06/25/2026:160 ml, 06/26/2026:160 ml, 06/27/2026: 470 ml, 06/28/2026:470 ml, 06/30/2026: 40 ml. The following total amounts were documented in June and above the 1,000 ml fluid restriction: 06/10/2026: 1,070 ml, 06/11/2026: 1,070 ml, 06/22/2026: 1,320 ml, 06/23/2026: 1,320 ml, 06/16/2026: 1,310 ml, 06/17/2026: 1,310 ml.Review of Resident 7's July 2026 MAR, from 07/01/2026 to 07/06/2026, showed the following total amounts were documented and below the 720 ml provided by dietary: 07/01/2026: 160 ml, 07/02/2026: 160 ml, 07/03/2026: 470 ml, 07/04/2026: 470 ml, 07/05/2026: 470 ml, 07/06/2026: 160 ml.During an observation on 07/08/2026 starting at 8:50 AM, Resident 7 was seen resting, with a coffee cup (with hot water in it) and no other drinks on their tray. Their bedside table had a bottled water and plastic cups for pouring the water into. At 9:54 AM, Resident 7 was seen up in bed and eating, now with an additional milk cup they used to pour into their cereal. During an observation and interview on 07/08/2026 at 12:39 PM, Resident 7 was seen eating lunch, had their hot water coffee cup and a 4-ounce unopened apple juice was seen by their water bottle. Resident 7 said they were keeping the apple juice for when they are thirsty. During an interview on 07/09/2026 at 1:28 PM, Staff O, Certified Nursing Assistant, said Resident 7 liked to drink hot water, liked milk with their cereal in the morning, and apple juice. Regarding their milk with breakfast, Staff O said that kitchen would bring milk on the tray, and if they did not then Resident 7 would request it. When asked if Resident 7 was on a fluid restriction, Staff O said they would have to check their run sheet, and then reported the restriction was for 1700 ml and showed their run sheet (observed to show Resident 7 was on a fluid restriction but did not list how much the restriction was, the 1700 number was next to but not part of the fluid restriction note).During an interview on 07/09/2026 at 1:45 PM, Staff I, Dietary Manager, said Resident 7 was supposed to only get one cup of fluids in the morning, and should not get milk unless the hot water was taken off their tray. Staff I confirmed the milk gets delivered in 240 ml cups. During an interview on 07/09/2026 at 1:47 PM, Staff H, Licensed Practical Nurse (LPN), said their role regarding the fluid restriction for Resident 7 was to give 120 ml of fluid with meds during their shift. Staff H did not know about the water bottle at Resident 7's bedside. When asked if they knew Resident 7's dry weight goal, Staff H said no. When asked if they were able to look up the dry weight goal, Staff H said they were not really weighing Resident 7, not since June 13th 2026. After being told about weights on the MAR instead of the vitals section in the EHR, Staff H said another shift was responsible for the weights as they were inputted after Resident 7 came back from dialysis. During an interview on 07/09/2026 at 2:39 PM, Staff N, Resident Care Manager/ LPN, reviewed Resident 7's July 2026 MAR and said the nursing staff was not adding in the breakfast, lunch, or dinner fluid. Staff N said their expectation was for staff to read the order and what it said, to use critical thinking, and to put the total ml for the shift and include the meal fluid as well. When asked if Resident 7 should have both water and milk for breakfast, Staff N said no because breakfast was only 240 ml, and confirmed they had not done a risk and benefits form related to the fluid restriction. After reviewing the observations, Staff N said that was too much fluid at breakfast, and the 4 oz apple juice was too much. Regarding Resident 7's dry weight, Staff N did not readily know what the goal was, did not see it in the care plan, and said they would contact dialysis. When asked how the facility was assessing the changes in how much weight was being taken off during dialysis, Staff N said they put the weights into the EHR and tried to look at Resident 7's whole picture. Regarding reevaluating if the fluid restriction was being followed, Staff N stated, clearly we missed on that. Staff N reviewed the dialysis communication form from 06/29/2026 and acknowledged a large amount of fluid had been taken off Resident 7 (more than baseline, which can indicate the resident had fluid overload). Staff N confirmed Resident 7 was not given hydralazine despite meeting parameters on 06/26/2026, 06/28/2026, and 07/06/2026 and said it should have been given. When asked if Resident 7 had a pneumococcal vaccine since being a resident here, Staff N said they would go to the immunization section, and it showed Resident 7 refused this on 06/23/2026. Staff N said their expectation was for any immunization to have been documented under the immunization section, and the nurse who reviewed Resident 7's dialysis communication form should have added this to the immunization section in the EHR. At 10:34 AM, Staff N said they had gotten a dry weight goal from dialysis of 47 kilograms/103.4 lbs. and they had now updated the care plan. During an interview on 07/10/2026 at 12:28 PM, Staff B, Director of Nursing Services, said their expectation for Resident 7's fluid monitor was for the staff to follow the fluid restriction. Regarding Resident 7's dry weight goal, Staff B said they had expected it in the dialysis documentation, and if there was a concern dialysis should have reached out to them. Staff B said their expectation for hydralazine, was for the doctor's orders to have been followed. Regarding communication from dialysis and the facility's role, Staff B said they expected dialysis forms to be followed up with after each dialysis session. Reference WAC 388-97 -1900 (1), (6)(a-c)

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications by failing to follow medication parameters, ensuring medications had a clear indication for use, re-evaluating necessity of scheduled opioid medication and/or addressing pharmacy recommendations for 3 of 5 sampled residents (Residents 56, 2 & 82) reviewed for unnecessary medications. This failure placed residents at risk of receiving unnecessary medications and at risk of medical complications.Findings included. Resident 56 Resident 56 was admitted to the facility on [DATE] with diagnoses of pain in right hip, pain in left hip, other chronic pain, pain in left shoulder, pain in left ankle and joints of left foot and hypertension (high blood pressure). The Quarterly Minimum Data Set assessment (MDS), dated [DATE], documented Resident 56 was moderately cognitively impaired. Review of Resident 56's orders showed the following order, dated 06/29/2026: Biofreeze Cool the Pain External Gel (pain relieving medication applied directly to the skin), apply to affected area (did not specify where) every 6 hours as needed for pain. Further review showed Resident 56 had a second order, dated 01/07/2026, as follows: Carvedilol oral tablet, give 1 tablet by mouth two times a day related to hypertension, hold for systolic (top number of blood pressure reading) blood pressure less than 110 or heart rate less than 60. Review of Resident 56's Medication Administration Records (MAR) from 07/01/2026-07/07/2026, 06/01/2026-06/30/2026 and 05/01/2026-05/31/2026 showed the medication Carvedilol was given outside of the ordered parameters on the following dates: 07/06/2026- blood pressure 106/66 06/19/2026- blood pressure 104/60 and heart rate 56 06/12/2026- blood pressure 106/60 and heart rate 56 06/01/2026- blood pressure 104/54 05/11/2026- blood pressure 104/60 and heart rate 56 05/25/2026- blood pressure 106/66 On 07/09/2026 at 4:00 PM, Staff G, Resident Care Manager/Registered Nurse (RCM/RN), when asked if Resident 56's ordered Biofreeze should have a location of where to place it, Staff G said it should and confirmed the order did not. Regarding Resident 56's Carvedilol, Staff G confirmed the dates the medication had been given outside of the ordered parameters and said this did not meet her expectations. Resident 2 Resident 2 was admitted to the facility on [DATE] with a diagnosis of dementia (decline in cognitive function severe enough to interfere with daily life). The Quarterly MDS, dated [DATE], showed Resident 2 had severe cognitive impairment. Review of Resident 2's pain medications, showed they had an order for 3 times a day scheduled oxycodone (opioid, strong pain medication), ordered on 06/01/2026, which only specified to be held for sedation. Resident 2 had an additional oxycodone order, ordered 06/01/2026, for as needed pain 3-10/10 pain. Resident 2 had an order for Tylenol, for mild discomfort, ordered on 04/14/2026. Review of Resident 2's June 2026 Medication Administration (MAR), showed scheduled oxycodone was given for 0/10 pain or not applicable (no pain) for 41 administrations: on 06/02/2026, 06/04/2026 (3 times), 06/05/2026 (twice), 06/06/2026 (twice), 06/07/20263 (3 times), 06/08/2026, 06/09/2026 (3 times), 06/10/2026 (3 times), 06/11/2026, 06/12/2026, 06/13/2026 (3 times), 06/16/2026, 06/17/2026, 06/18/2026, 06/19/2026 (twice), 06/20/2026 (twice),06/21/2026 (3 times), 06/22/2026, 06/23/2026, 06/26/2026 (twice), 06/27/2026 (twice), and 06/28/2026 (twice). As needed oxycodone- given 06/08/2026 and 06/20/2026 As needed Tylenol- not given Review of Resident 2's July 07/01/2026 to 07/06/2026 MAR, showed: Scheduled oxycodone was given for 0/10 pain or not applicable (no pain) on: 07/02/2026 (twice), 07/04/2026, 07/05/2026 (3 times), and 07/06/2026 (three times). As needed oxycodone- not given As needed Tylenol- not given Review of Resident 2's June 2026 sleep tracker, showed on days nurses completed the tracker, Resident 2 often exceeded 8 hours of sleep in 24 hours, and had days with longer amounts of sleep such as 06/01/2026 with 14 hours of sleep, 06/06/2026 with 18 hours of sleep (given their schedule opioid twice this day for 0/10 pain), 06/18/2026 with 14 hours of sleep. During an interview on 07/08/2026 at 2:01 PM, Staff F, RN, said Resident 2 was unable to verbalize their pain, they assumed Resident 2 had aches and ailments due to their age, and they found it hard to tell if the scheduled opioid was effective due to Resident 2's fast mood changes at baseline. Staff F was able to see in the record that Resident 2 had not received their as needed Tylenol medication since 05/26/2026. During an interview on 07/08/2026 at 2:48 PM, Staff D, RCM/RN, said for residents with a diagnosis of dementia, the process for reevaluating the necessity of schedule pain opioids, was for them to offer a non-pharmacological intervention first, Tylenol, then if those were ineffective then the opioid medication. The provider should review weekly if the medications were effectively working, look at the pain scales/staff documentation, and review sleep patterns. Staff D reviewed Resident 2's records and confirmed the scheduled opioid was given for 0/10 pain and without any Tylenol given for June or July 2026. Staff D said their expectation was for the opioid pain medication to have parameters (pain scale) for administering the medication, especially when non-opioid pain medications were available. At 4:13 PM, Staff D said they had followed up with the provider and they would schedule Tylenol, and the opioid medication should be held if not having any pain. During an interview on 07/10/2026 at 12:28 PM, Staff B, Director of Nursing Services (DNS), when asked about expectations regarding Resident 2's opioid being given for 0/10 pain, not giving any as needed Tylenol, and not reassessing for the necessity of the pain medication, said the orders for Tylenol and the opioid had been switched because they agreed with the concern. Resident 82 Resident 82 was admitted to the facility on [DATE] with a diagnosis of dementia. The Quarterly MDS, dated [DATE], documented Resident 82 was unable to complete the interview for cognitive status. A review of Resident 82's Electronic Health Record (EHR) showed an order for: Miralax Oral Powder Give 1 scoop by mouth two times a day for constipation, dated 01/14/2025. A review of the consultant pharmacist's medication regimen review, dated 02/24/2026, documented, Resident has scheduled order for Miralax. Please consider adding hold for loose stools'. On 07/09/2026 at 2:53 PM, Staff B, DNS, said the nursing staff usually put those orders in and it did not look like it was addressed for Resident 82. Staff B said their expectation was for the provider to be updated and the recommendation to be followed and appropriately adjusted. Reference WAC 388-97-1060 (3)(k)(i)

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than 5 percent (%). During observation of 25 opportunities for error, 1 of 3 Licensed Nurses (Staff H) made 2 errors, an error rate of 8%. This failure placed residents at risk for adverse side effects related to not following parameters and not receiving the correct medication according to the physician orders.Findings included .The facility policy titled Medication Administration updated 12/2024, stated 7. Hold medication per Provider orders if vital signs/blood sugars are outside of the parameters. Notify the Provider per Provider Orders. And 12. Verify the correct medication, expiration date, dose, dosage form, route, and time again by comparing to MAR [Medication Administration Record] before administering. ERROR 1During medication pass observation on 07/08/2026 at 7:51 AM, Staff H, Licensed Practice Nurse (LPN), administered a medication, Lasix (used to treat fluid retention by rapidly increasing urine output, reducing swelling, and lowering blood pressure), to Resident 35, with an order to notify the provider if the systolic blood pressure (the top number in a blood pressure reading and it measures the maximum force your blood exerts against artery walls when your heart beats.) was less than 110 or the pulse (heartbeat) was less than 60.On 07/08/2026 at 10:16 AM, Staff H, LPH, was asked if they took Resident 35's vital signs prior to giving Lasix and Staff H, LPN said no.On 07/08/2026 at 11:01 AM, Staff B, Director of Nursing Services (DNS), said the Lasix order had parameters for the blood pressure and pulse and they were not taken by the nurse prior to administering the medication. We have educated the staff to make sure they follow the parameters of medication orders.ERROR 2During a medication pass observation on 07/08/2026 at 7:51 AM, Staff H, LPN gave Resident 35, 5 ml (milliliter- a metric unit of volume equal to one-thousandth of a liter) of a cough medicine Geri-Tussin and the physician order was NyQuil Cold & Flu 30ml. On 07/08/2026 at 10:16 AM, Staff H, LPN, was asked if Geri-Tussin and NyQuil Cold & Flu were the same medications with the same ingredients. Staff H said no they do not have the same ingredients. Staff H said, the Geri-Tussin was house stock and this was what we had been giving. Staff H said while looking at the Geri-Tussin bottle, I have been giving 5 ml but it says 10 ml on the bottle. Staff H said they had not been giving the correct amount of Geri-Tussin.On 07/08/2026 at 11:01 AM, Staff B, DNS, said Geri-Tussin was the wrong medication, and the order was discontinued. Staff B said the provider was notified.Reference WAC 388-97-1060 (3)(k)(ii)

Based on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 3 of 5 sampled residents (Residents 82, 2 & 56) reviewed for quality of care. This failure placed residents at risk for discomfort, health complications and a diminished quality of life.Findings included .Per Facility Bowel Management Policy, entitled Management of Constipation, updated 9/2025 stated: When a resident is identified with No/small Bowel Movement documented for 48hrs, the LN [Licensed Nurse] will assess theresident and determine if the bowel protocol will be initiated.Standard bowel protocol to relieve constipation (in the absence of a bowel obstruction) with a providerorder to include the following unless otherwise specified by Provider order: MiraLax 17 grams with 8 ounces of fluid of choice x 1. Bisacodyl Suppository 10mg [milligrams] rectally if no results from the MiraLax in 24hrs. Fleets Enema (Saline Laxative Enema) 4.50z- Administer 1 bottle as needed rectally if no results from the Bisacodyl Suppository in 12hrs and notify Provider.Resident 82Resident 82 was admitted to the facility on [DATE] with a diagnosis of dementia (decline in cognitive function severe enough to interfere with daily life). The Quarterly Minimum Data Set, MDS- assessment tool, dated 03/31/2026 documented Resident 82 was unable to complete the interview for cognitive status. A review of Resident 82's Electronic Health Record (EHR) showed orders for:- Miralax Oral Powder Give 1 scoop by mouth two times a day for constipation Dated 01/14/2025- Miralax Oral Powder Give 1 scoop by mouth every 24 hours as needed for constipation Dated 01/14/2025- Dulcolax Suppository Insert 1 suppository rectally every 24 hours as needed for Constipation If no results from Miralax in 24hrs Dated 09/26/2025 - Fleet Enema Insert 1 application rectally every 24 hours as needed for Constipation If no results from Dulcolax in 4-6 hours. If no results from enema, notify Medical Doctor (MD). Dated 09/26/2025 A Review of the bowel record for Resident 82 from 06/08/2026 – 07/07/2026 showed no bowel movement (BM) documented from: -06/08/2026 – 06/15/2026 (8 days)-06/18/2026 – 06/23/2026 (6 days) A review of the June 2026 Medication Administration Record (MAR) showed:-an as needed Dulcolax Suppository was documented as given on 06/11/2026 and 06/16/2026-an as needed Miralax Oral Powder was documented as given on 06/23/2026 On 07/09/2026 at 2:43 PM, Staff D, Resident Care Manager (RCM)/Registered Nurse (RN) said Resident 82 did not have BM's documented per the record. Resident 82 has scheduled Miralax ordered and if that was ineffective the bowel protocol should have been initiated in addition to the scheduled Miralax. On 07/10/2026 at 10:35 AM, Staff B Director of Nursing (DNS) said their expectation was for the staff to follow the bowel protocol. Resident 2 Resident 2 was admitted to the facility on [DATE] with a diagnosis of dementia. The Quarterly MDS, dated [DATE], showed Resident 2 had severe cognitive impairment. Review of Resident 2's past 30 days of bowel movements, showed they went from 06/07/2026 to 06/11/2026 (5 days) and 06/16/2026 to 06/19/2026 (4 days) without a BM. Review of Resident 2's June 2026 Medication Administration Record (MAR), showed they had been given an as needed bowel movement stimulant, MiraLAX, on 06/10/2026 (day 4 of not having a bowel movement). Review of Resident 2's bowel medications, showed they had the following orders: Miralax- as needed for constipation Dulcolax suppository- every 24 hours as needed for constipation, if no results from Miralax in 24 hours. Fleet Enema- every 24 hours as needed for constipation if no results form Dulcolax in 4-6 hours. During an interview on 07/08/2026 at 2:48 PM, Staff D, RCM/RN, confirmed Resident 2 did not have any as needed bowel medications given on 06/09/2026 or 06/11/2026, or during the period from 06/16/2026 to 06/19/2026. During an interview on 07/10/2026 at 12:28 PM, Staff B, DNS, said their expectation was for doctor's orders to have been followed related to the bowel protocol for Resident 2. Regarding the period of no bowel movement from 06/16/2026 to 06/19/2026, Staff B said a as needed bowel medications should have been given on 06/18/2026 and 06/19/2026. Resident 56 Resident 56 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 56 was moderately cognitively impaired. Resident 56's care plan included alteration in bowel elimination constipation related to decreased mobility, medication(s) side effects, initiated 07/22/2024. The goal was for Resident 56 to have a normal bowel movement at least every 3rd day. Interventions included following facility protocol for bowel management. Resident 56 had the following orders for as needed medications for management of constipation. Polyethylene Glycol powder (Miralax), as needed for constipation, dated 09/25/2026 Dulcolax Suppository, every 24 hours as needed for constipation if no result from Miralax in 24 hours, dated 09/25/2025. Fleet enema, 1 application every 24 hours as needed for constipation if no results from Dulcolax in 4-6 hours. If no results from enema, notify MD. Review of Resident 56's bowel record for June 2026, showed they did not have a BM from 06/21/2026- 06/25/2026 (5 days). Review of the June 2026 MAR showed no as needed bowel medications were administered from 06/21/2026-06/25/2026. Review of Resident 56's bowel record for May 2026, showed they did not have a BM from 05/20/2026- 05/25/2026 (6 days). Review of the May 2026 MAR showed no as needed bowel medications were administered from 05/20/2026-05/25/2026. Review of Resident 56's bowel record for April 2026, showed they did not have a BM from 04/01/2026-04/09/2026 (9 days). Review of the April 2026 MAR showed no as needed bowel medications were administered from 04/01/2026-04/09/2026. On 07/09/2026 at 4:00 PM, Staff G, RCM/RN, confirmed Resident 56 had no BM recorded for 5 days in June, 6 days in May, and 9 days in April and had not been administered as needed bowel medications during those time periods. When asked if this met her expectations for management of constipation, Staff G said no, if staff were utilizing the bowel protocol the right way her expectations would have been met, but Resident 56 went many days without having a BM and so this did not meet her expectations. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to provide the notice of transfer or discharge and the bed hold policy in writing for 2 of 3 residents (Resident 1 and 2) reviewed for discharge notice. This failure placed residents and/or representatives at risk for lack of advocacy for discharge rights, housing options, and frustration.Findings included.Review of the provider's policy titled, Bed-Hold: Notification Notice of Bed Hold Policy and Return, dated 09/2022, showed when a resident was transferred to a hospital, a written notice will be provided to the resident, family member or responsible party regarding the resident's bed hold rights and the center's bed hold policy, a copy of the completed WA-Nursing Home Transfer or Discharge Notice would be provided to the resident/resident representative at the time of transfer and within 24-hrs after transfer contact the resident/resident representative to explain the bed-hold policy and elicit verbal communication regarding wishes of resident/representative regarding the bed - hold and document the decision in the progress notes of the resident's record or business office.Resident 1 was admitted to the facility on [DATE] and discharged from the facility on 05/04/2026.Review of Resident 1's Letters of Guardianship, dated 04/26/2023, showed Collateral Contact 1 (CC1), was appointed to serve as guardian for full person and conservator of the full estate for Resident 1.Resident 1's WA Nursing Home Transfer or Discharge Notice and Bed Hold Notification, dated 05/04/2026, showed the notice was presented to CC1 on 05/04/2026.Review of a grievance for Resident 1, dated 05/12/2026, showed CC1 had concerns that the facility had not sent the WA [[NAME]] State Transfer and Bed Hold evaluation to CC1 to confirm and sign upon DC [discharge]. The grievance showed the facility staff acknowledged they had provided verbal notification of the discharge to the guardian, but the guardian was not present at time of discharge, and the notice was completed via the phone. The grievance showed the resolution was education provided to SS [social services] to ensure the notice was provided physically to POA [power of attorney] and guardians moving forward.On 05/26/2026 at 11:09 AM, CC1 said the facility failed to notify CC1 that Resident 2 was discharged to the hospital and this was an ongoing issue at the facility for the residents they served. CC1 said they had previously discussed the issue with the facility and were frustrated that it was still an issue.Resident 2 was admitted to the facility on [DATE] and was transferred to the hospital on [DATE]. Resident 2's Minimum Data Set Assessment, dated 05/07/2026, showed the resident was severely cognitively impaired, had unclear speech, was sometimes understood and had a legal guardian.Resident 2's care plan, dated 04/28/2026, showed CC1 was Resident 2's guardian.Resident 2's WA Nursing Home Transfer or Discharge Notice and Bed Hold Notification, dated 05/24/2026, showed the notice was given to Resident 2.Review of Resident 2's medical record on 06/24/2026, showed no documentation CC1 was contacted regarding the WA Nursing Home Transfer or Discharge Notice and Bed Hold Notification and/or provided a written copy.On 06/24/2026 at 12:22 PM, Staff A, Social Service Director, said they were provided education on the WA Nursing Home Transfer or Discharge Notice and Bed Hold Notification policy following Resident 1's grievance. Staff A said they were educated to send a written copy to the residents' guardian in addition to verbal notification. Staff A said they were not involved with Resident 2's transfer to the hospital. Staff A said the transfer occurred on a weekend so they did not believe the notice would have been sent by the nursing staff.On 06/24/2026 at 3:03 PM, Staff B, Regional Director of Operations, said the facility followed their policy on transfer, discharge and bed hold. Staff B said the WA Nursing Home Transfer or Discharge Notice and Bed Hold Notification was completed in the medical record and they were able to print the notice and provide it upon request. Staff B said they provided the notification verbally to the resident and/or representative and offered it in written form. Staff B said if the residents and/or representative requested it in written form they would provide it. Staff B reviewed Resident 1's grievance and acknowledged the resolution was to provide the WA Nursing Home Transfer or Discharge Notice and Bed Hold Notification in written form and provided education to the social service staff to provide CC1 with a written copy of the notices. Staff B said Resident 2's WA Nursing Home Transfer or Discharge Notice and Bed Hold Notification was sent with the resident to the hospital. Staff B acknowledged Resident 2 had a guardian and could not comprehend the notice contents. Staff B said the facility had not provided education to the nursing staff and due to the transfer occurring on a weekend, nursing staff did not know to provide a written notice to CC1. Staff B said there was no evidence in Resident 2's medical record that staff followed up with CC1 to provide a written notice and/or to acknowledge CC1 had received the notice sent with Resident 2 to the hospital.Reference WAC 388-97-0120(1)(2)(a) -(d)(3)(a)(4)(b)(5), 0080, 0140(1)(a)-(c)(i)-(iii)

Based on observation, interview and record review, the facility failed to ensure a functional and/or sanitary environment for residents for 2 of 3 sampled residents (Residents 3 &4) reviewed for environment. This failure places residents at risk of discomfort, their environment being unhomelike and unsanitary, and of a diminished quality of life.Findings included.Resident 3's electronic health record showed they were admitted to the facility on [DATE], were in room [ROOM NUMBER], and were discharged on 05/21/2026.During an interview on 06/23/2026 at 9:46 AM, Collateral Contact 2 (CC2), Resident 3's family member, said the facility was filthy.Resident 4 was admitted to the facility on [DATE] and was in room [ROOM NUMBER]. Review of Resident 4's Medication Administration Record for 06/24/2026, showed they had received their morning doses of docusate (stool softener) and MiraLAX (stool softener and stimulant).During an interview and observation on 06/24/2026 at 12:22 PM, Resident 4 said their bathroom was a mess. The bathroom (a shared bathroom between rooms [ROOM NUMBERS]) was observed to have a plastic lining/bag over the toilet that had both urine and stool in it (the toilet should not be flushed with this on it). There was an unlabeled urinal on the floor with 600 milliliters (ml) of dark yellow urine in it, and an unlabeled urinal on the top of the toilet with 650 milliliters of dark yellow urine in it. Resident 4 said staff were supposed to bring them a commode and had not, so the stool and urine in the plastic lining in the toilet was theirs, and they were having diarrhea. Resident 4 said they had just gone pee in there during lunch, most of the stool was from overnight. They said a guy had put the plastic lining on the toilet the previous night, and they had asked staff if they were supposed to go in there. Resident 4 said staff had given them stool softeners. They also said the observed urinals (not theirs) had been present in the bathroom while they had used it. During an interview and observation on 06/24/2026 at 1:06 PM, Staff D, Licensed Practical Nurse, said urinary catheters (tube that goes into the bladder to drain urine) should have their collection bag drained using a urinal or cylinder, which should be dated and labeled with either initials or resident's name. Regarding if urinals with urine in them should be left in a shared bathroom, Staff D said no. Staff D said they were going to get Resident 4 a bedside commode but had not yet. The bathroom was observed to still have the two urinals with urine in them and the toilet with the plastic liner with stool and urine in it. Staff D asked Resident 4 about the toilet, Resident 4 stated, There was a bag there and I just went. Staff D said there may have been a plumbing issue.During an interview on 06/24/2026 at 1:24 PM, Staff E, Maintenance Assistant, said they were unaware of a current plumbing issue, they had gone to fix this toilet at 2:00 AM due to it being clogged, it was fixed, and they did not put the plastic bag over the toilet. During an interview on 06/24/2026 at 2:29 PM, Staff F, Certified Nursing Assistant, said they had been in this bathroom around 7:00 AM, they had emptied the catheter bag for room [ROOM NUMBER]. Their normal process was to empty the catheter bag, dump urine in the toilet, rinse the urinal with water and then rinse that in the toilet. They said they did not normally label urinals, as they would normally put them next to the resident after they were emptied. Staff F said when they had gone to the bathroom to dump the one urinal, there was a bag on the toilet with urine and faces in it, and there already was one urinal with urine in it in the bathroom (the one on the floor). Staff F was unsure what was going on with the toilet, had planned to talk to maintenance before emptying the urinal into the toilet, and left the urinal with urine on the toilet. Staff F said they were aware that Resident 4 needed a bedside commode, they had talked to Staff D about this around 7:00 AM or 7:30 AM, and they were unsuccessful at finding a clean commode for Resident 4. When asked what the plan was for letting Resident 4 use the bathroom, Staff F said it was to get them a clean commode from therapy when they got in at 8:00 AM. Regarding if they had checked in with therapy about the commode, Staff F said they did not check with therapy at 8:00 AM, it was around tray pass which took up a lot of their time. Staff F had just cleaned the bathroom and said they had tried to flush the urine and the toilet was still clogged. During an interview on 06/24/2026 at 3:23 PM, Staff C, Director of Nursing Services, said their expectation for resident bathrooms was for them to be clean and in working order, and if there were any safety issues for it to have been taken care of. Regarding shared bathrooms having urinals with urine left in them, Staff C said this should not happen, they had now addressed this, the nurse aide had put it down in the bathroom because of the condition of the bathroom. After the timeline was explained, Staff C was asked if it met expectations that Resident 4 had no alternative but to keep using the bathroom in this condition, Staff said no it did not meet expectations.Reference WAC 388-97-3220 (1)

Based on interview and record review, the facility failed to ensure residents were free from abuse from other residents in the facility for 1 of 3 residents (Resident 1) reviewed for abuse. This failure placed residents at risk of further abuse, injury, mental anguish and fear. Findings included.Resident 1 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease (a progressive disorder of the brain causing memory loss and poor judgement). The Minimum Data Set Assessment, an assessment tool, dated 03/28/2026 showed Resident 1 was severely cognitively impaired.Resident 1's care plan, dated 10/17/2025 and revised on 04/17/2026, showed Resident 1 had a behavior problem r/t [related to] confused, pacing and wandering with interventions to include approach calmly, redirect as needed, offer options and activities and rule out pain.On 04/30/2026 at 11:05 AM, Staff B, Certified Nursing Assistant (CNA), said they provided care for Resident 1 and Resident 2. Staff B said Resident 1's usual behavior was they ambulated in the hallway, hanging onto the handrails and often entered other resident's rooms. Staff B said Resident 2 was independent with ambulation. Staff B said Resident 2 stayed in their room a lot, but when Resident 2 came into the hallway and saw Resident 1 they made a beeline for Resident 1. Staff B said if Resident 1 was in the dining room and/or the activity room they would get in front of Resident 2 and not allow Resident 2 in. Staff B said they often had to block Resident 2 from getting close to Resident 1, I literally had to stand in the doorway and blocked them and tell them they could not go in. Staff B said on 04/17/2026 they were in the hallway with Resident 2 and witnessed Resident 1 ambulating down the hallway as they usually did. Staff B said Resident 1 entered Resident 2's room. Staff B said Resident 2 immediately headed toward their room and Staff B said they followed but Resident 2 entered their room and shoved Resident 1 to the ground. Staff B said they were able to catch Resident 1 before they hit the floor and lowered the resident to the ground. Staff B demonstrated Resident 2 facing Resident 1 in the room parallel to the door and Resident 2 pushing Resident 1 down. Staff B said this was the second time Resident 2 had shoved Resident 1.Review of Resident 2's care plan, dated 02/10/2026, showed Resident 2 had the history or potential to demonstrate physical behaviors: slams doors, has thrown the overbed table r/t anger, dementia will poor impulse control. The care plan goal was Resident 2 would not harm self or others.Review of Resident 2's medical provider notes, dated 02/26/2026, showed Resident 2 had walked up to another resident and pushed them down, unprovoked.Review of Resident 1's medical provider notes, dated 2/26/2026, showed a resident walked up and pushed Resident 1, unprovoked. The note showed Resident 1 had fallen and hit their head.Review of a facility incident report, dated 04/17/2026, showed Resident 1 was wandering in the hallway of the memory care unit and inadvertently wandered into Resident 2's room. The report showed that Resident 2 was known to be protective of their personal space, approached Resident 1 and to guide Resident 1 out of the room placed their hands on Resident 1's shoulders and pushed Resident 1 toward the exit. The report showed Resident 1 demonstrated mild backward leaning and gait instability and staff provided controlled assistance and lowered Resident 1 to the floor to prevent a fall.On 04/30/2026 at 12:20 PM, Staff B, Certified Nursing Assistant, said Resident 2 was not attempting to guide Resident 1 out of their room. Staff B said the residents were standing away from the door and facing each other and the opposite walls of the room as they relayed in their previous interview. Staff B said Resident 2 was not pushing Resident 1 out the door, Staff B said Resident 2 was pushing Resident 1 down to the floor.On 04/30/2026 at 3:26 PM, Staff A, Administrator, said Resident 2 deliberately shoved Resident 1 when they found Resident 1 in their room. Staff A said they did not believe Resident 2 intended to harm Resident 1 but due to their dementia they had reacted. Staff A said they had put interventions in place to keep Resident 1 safe but acknowledged this was the second time Resident 2 had shoved Resident 1.Reference WAC 388-97-0640(1)

Based on interview and record review, the facility failed to communicate, develop and implement an effective discharge plan and provide sufficient time and orientation prior to discharge for 1 of 3 residents (Resident 1) reviewed for discharge. This failure placed residents at risk of displacement, adequate housing and a decreased quality of life.Resident 1 was admitted to the facility on [DATE] with diagnoses including ankle infection, mood disorder and substance abuse. Resident 1 was discharged from the facility on 02/19/2026. Resident 1's Minimum Data Set Assessment, dated 01/04/2026, showed Resident 1 was cognitively intact.Resident 1's Mobility Care Plan, dated 12/29/2025, showed Resident 1 had limited mobility r/t [related to] weight bearing restrictions NWB [non weight bearing RLE [right lower extremity] for 6 weeks.Resident 1's Discharge Care Plan, dated 12/30/2025, showed Resident 1 wished to return/discharge to placement options and there was potential for complications r/t discharge planning to include health literacy, prior living environment may not be possible due to resident not having a home.Resident 1's admission Discharge Evaluation, dated 12/30/2025, showed Resident 1's discharge plan was unknown.Resident 1's Managed Care Resident Discharge Plan, dated 01/13/2026, showed Resident 1's projected discharge date was 02/27/2026 and the location was home with mother versus placement. The plan showed the barriers to discharge were placement and the foot injury and the plan to remove barriers was to work with resident to establish a discharge plan. The plan showed the alternate or back up plan if preferred discharge location was not attainable was LTC [long term care].Resident 1's Managed Care Resident Discharge Plan, dated 02/03/2026, showed Resident 1's projected discharge date was 02/27/2026 and the location was home with mother versus placement. The plan showed the barriers to discharge were non-weight bearing and placement. The plan to remove barriers was to work with DSHS [Department of Social and Health Services] for placement options and finalize dc [discharge plan]. The plan showed the alternate or back up plan if preferred discharge location was not attainable was LTC.Resident 1's orthopedic (bone doctor) consult, dated 02/03/2026, showed Resident 1 was NWB [non-weight bearing] for two weeks in boot and then begin WBAT [weight bearing as tolerated] in two weeks (02/17/2026).Resident 1's Managed Care Resident Discharge Plan, dated 02/11/2026, showed Resident 1's projected discharge date was 03/27/2026. The plan showed the discharge location was home with mother versus placement, barriers to discharge non-weight bearing on one foot and the plan to remove the barriers was f/u [follow up] appointment and monitor. The plan showed the alternate or back up plan if preferred discharge location was not attainable was LTC.On 02/23/2026 at 3:09 PM, Resident 1 said Staff C, Social Service Director (SSD), told them they had to leave the facility after they had a verbal altercation with a nurse. Resident 1 said they did not want to discharge from the facility but did not believe it was optional. Resident 1 said they asked Staff C what to do because they did not know where to go and Staff C said they would work on a location. Resident 1 said Staff C notified them they were being discharged to a shelter at the last second. Resident 1 said they thought they were going to another facility and/or senior housing, but Staff C gave them a pamphlet of where they were being discharged to, and they thought it was like transitional housing for the homeless. Resident 1 said they thought they would have a bed at the facility and be able to stay at the place for a while until they could find something else. Resident 1 said they were surprised when the facility van dropped them off in the streets of Olympia at a homeless shelter. Resident 1 said the doors to the shelter were locked but there were a lot of people outside waiting to go in. Resident 1 said the shelter opened and allowed them to go in for a meal but there were no beds available for the night. Resident 1 said that although they could bear weight on their leg it was painful and they could only take a few steps. Resident 1 said they were still utilizing a knee scooter to get around. Resident 1 said they were scared and had to wheel a long distance to find a restaurant open and contact family to come and pick them up.Resident 1's progress notes, dated 02/17/2026, showed Staff A, Administrator, overheard Resident 1 threatening to physically harm a nurse and making derogatory comments. The note showed the police were notified and spoke with Resident 1. The note showed Resident 1 denied making threats to staff but said it would not happen again.Resident 1's progress notes, dated 02/17/2026, showed Staff C, SSD, followed up with Resident 1 regarding how the Resident was doing, recent concerning behaviors and discharge planning. The note showed Staff C discussed discharge planning with Resident 1 and contacted the resident's mother. The note showed Resident 1's mother did not want the resident to return home. The note showed during the conversation the resident was making verbally aggressive comments to Staff C and overheard making statements about wanting to physically harm staff. The note showed Staff C addressed it immediately and informed the resident that such behavior and statements were inappropriate and would not be tolerated. The note showed Staff C reiterated that the goal was to support Resident 1 and ensure their care needs were met. The note showed Resident 1 was not receptive to further discussion. The note showed Staff C asked Resident 1 if they preferred a specific county for shelter placement, Resident 1 said it did not matter and requested they leave their room.Resident 1's Transfer and Discharge notice, dated 02/18/2026, showed Resident 1 was discharged because the safety of other individuals in the facility was endangered due to the clinical or behavioral status of the resident. The notice showed it was given to Resident 1 on 02/17/2026 and the date of the transfer/discharge was 02/19/2026. The notice showed the discharge location was the Olympia Union Gospel.Resident 1's Recapitulation of Stay, dated 02/19/2026, showed Resident 1's dc [discharge] was happening r/t Resident 1 was very aggressive and verbally abusive to staff on and off along with smelling ethoh [alcohol] on the resident. The Recapitulation showed Resident 1 was being discharged to a shelter.Resident 1's progress note, dated 02/19/2026, showed Resident 1 was anxious about d/c [discharge] and creating scenarios to delay the process. The note showed the resident was concerned they could not take all their belongings with them.On 02/24/2026 at 12:26 PM, Staff C, SSD, said Resident 1 was discharged for endangering the lives of others in the facility, specifically Staff D, LPN. Staff C said Resident 1 had made threats to physically harm Staff D. Staff C denied Resident 1 physically touched or harmed Staff D. Staff C said Resident 1's behavior had been escalating over the past two weeks prior to discharge. Staff C said Resident 1 would be derogatory towards other residents and had a verbal altercation with their roommate that resulted in the roommate moving out of the room. Staff C said they did not update the plan of care related to the escalating behaviors until 02/17/2026 when Resident 1 threatened to harm Staff D and the police were called. Staff C said they instructed staff to redirect Resident 1 to Staff C when they were having behaviors and staff adjusted Resident 1's medication times per the resident's request. Staff C said they would tell Resident 1 their behavior was unacceptable and the resident would reply they did not like Staff D. Staff C said Resident 1 would smell of alcohol. Staff C said they did not suggest Staff D no longer care for Resident 1 or explore substance abuse counseling. Staff C said they asked Resident 1 if they were okay with going to a homeless shelter. Staff C said Resident 1 didn't say no.On 02/24/2026 at 1:28 PM, Staff B, Resident Care Manager, said Resident 1 was discharged because they were verbally aggressive with a licensed nurse and had threatened to hurt them. Staff B said Resident 1's behavior had appeared to escalate in the past few weeks, and it was when the resident smelled of alcohol. Staff B said Resident 1 would make fun of the other residents, was short with staff and verbally attacked a particular nurse. Staff B said they did notify the medical provider about the suspected alcohol use. Staff B said they did not make changes to the care plan regarding the behavior. Staff B said they were not aware of any referrals to behavior health consultant and/or substance abuse programs. Staff B said the social work department made those referrals. Staff B said on 02/17/2026, Resident 1 threatened to harm Staff D, Licensed Practical Nurse (LPN), and the police were called. Staff B said a decision was made by the administration that Resident 1 was to be discharged . Staff B said Resident 1 was told on 02/18/2026 to get packed up and the facility van would be taking them to a shelter on 02/19/2026. Staff B said on 02/19/2026 when they went into Resident 1's room to review the medications and discharge paperwork with the resident, Staff B said it appeared Resident 1 was trying to delay the discharge. Staff B said they believed Resident 1 thought if they delayed the discharge process, they would be able to stay at the facility. Staff B said they did not know if Resident 1 had a choice to stay at the facility. Staff B said they did not know what would have happened if the Resident refused to leave the facility. Staff B said they did not offer Resident 1 to stay when they thought Resident 1 was attempting to delay their discharge because Staff B said they were told the resident was leaving that day. Staff B said the staff had discussed scenarios of the resident refusing to leave with the Administrator and they were told the resident was leaving that day.Resident 1's progress note, dated 02/18/2026, showed Staff D, LPN, provided care to Resident 1.Resident 1's progress notes, dated 02/18/2026 and 02/19/2026, showed Resident 1 was on alert for behavior. No documentation of behaviors was found in the notes except for talking loudly.On 02/24/2026 at 2:52 PM, Staff C, Social Service Director, said their discharge planning process was to determine the resident's goals for discharge on admission and to keep the residents on their radar during their stay, following their medical status and projected discharge date . Staff C said if a resident needed placement with the assistance of Department of Social and Health Services (DSHS), Staff C would discuss the resident's case with the DSHS case managers. Staff C said they tried not to jump the gun on discharge planning for placement if the resident had a medical issue and it was not clear the type and timing of discharge. Staff C said they had spoken to DSHS about Resident 1, but they were waiting to explore placement until Resident 1 was able to bear weight on their leg. Staff C said they did not have time to plan for placement with DSHS for Resident 1 because Resident 1 had to leave immediately.On 02/24/2026 at 3:42 PM, Staff A, Administrator, said the facility discharged Resident 1 because they were not receiving therapy and they were independent with their activities of daily living. Staff A said when Resident 1 was admitted they were unhoused so when the resident was ready for discharge they would go back to being unhoused. Staff A said Resident 1's Transfer and Discharge Notice that indicated Resident 1 was discharged due to the safety of other individuals in the facility was endangered was incorrect. Staff A said it was their understanding Resident 1 no longer needed services and they wanted to go to the homeless shelter. Staff A said the discharge was unrelated to Resident 1's behaviors. Staff A said Resident 1 was referred to their Behavioral Consult when they were admitted but the resident refused, the consultant said to monitor the resident and update the consultant if behavior changed. Staff A said they did not update the consultant when Resident 1's behavior had escalated. Staff A said they recognized they could not discharge someone due to their behaviors without going through a process. Staff A said the usual process for a resident that no longer needed services was the discharge planning process. Staff A said that process involved meeting with the residents, clearing them medically and involved their discharge goals. Staff A said the discharge process involved exploring placement if the resident wanted that. Staff A said they believed Resident 1 wanted to go to the homeless shelter. Staff A said they were not aware at the time of Resident 1's discharge that the Union Gospel Mission, where Resident 1 was discharged to did not have guaranteed beds for overnight stays. Staff A said they found out after Resident 1 was gone. Staff A said Resident 1's family contacted them after discharge about placement options and Staff A had social services contact them with information regarding facilities in the area. Staff A said exploring placement options should have occurred prior to discharge. Staff A said they did not believe staff told Resident 1 they had to leave and the resident never came and asked them if they could stay. Staff A said to their knowledge, Resident 1 did not initiate discharge from the facility. WAC 388-97-0120(1)(b)-(f)(2)-(4), 0140 (1)-(3)

Based on interview and record review, the facility failed to notify the Long-Term Care Ombudsman of a facility discharge for 1 of 3 (Resident 1) residents reviewed for discharge. This failure placed residents at risk of being inappropriately discharged and lack of advocacy regarding their options and rights.Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses including ankle infection, mood disorder and substance abuse. Resident 1 was discharged from the facility on 02/19/2026. Resident 1's Minimum Data Set Assessment, dated 01/04/2026, showed Resident 1 was cognitively intact.On 02/23/2026 at 3:09 PM, Resident 1 said Staff C, Social Service Director, told them they had to leave the facility after they had a verbal altercation with a nurse. Resident 1 said they did not want to discharge from the facility but did not believe it was optional. Resident 1 said they asked Staff C what to do because they did not know where to go and Staff C said they would work on a location. Resident 1 said Staff C notified them of where they were going at the last second. Resident 1 said they thought they were going to another facility and/or senior housing, but Staff C gave them a pamphlet of where they were being discharged to, and they thought it was like transitional housing for the homeless. Resident 1 said they thought they would have a bed at the facility and be able to stay at the place for a while until they could find something else. Resident 1 said they were surprised when the facility van dropped them off in the streets of Olympia at a homeless shelter. Resident 1 said the doors to the shelter were locked but there were a lot of people outside waiting to go in. Resident 1 said the shelter opened and allowed them to go in for a meal but there were no beds available for the night. Resident 1 said they were scared and had to wheel a long distance to find a restaurant open and contact family to come and pick them up.Resident 1's Transfer and Discharge notice, dated 02/18/2026, showed Resident 1 was discharged because the safety of other individuals in the facility was endangered due to the clinical or behavioral status of the resident. The notice showed it was given to Resident 1 on 02/17/2026 and the date of discharge was 02/19/2026.Resident 1's Recapitulation of Stay, dated 02/19/2026, showed Resident 1's dc [discharge] was happening r/t [related to] Resident 1 was very aggressive and verbally abusive to staff on and off along with smelling ethoh [alcohol] on the resident. The Recapitulation showed Resident 1 was being discharged to a shelter.Review of Resident 1's medical record on 02/25/2026, showed no documentation that the Long-Term Care Ombudsman had been notified of Resident 1's discharge.On 02/24/2026 at 3:40 PM, Staff C, Social Service Director, said they had not sent Resident 1's Transfer and Discharge Notice to the Long-Term Care Ombudsman, I send them at the end of the month.Reference WAC 388-97-0120 (5)(b)

Based on interview and record review, the facility failed to provide informed consent and communicate preferences for Cardiopulmonary Resuscitation (CPR) to the resident and/or representative for 1 of 3 residents (Resident 1) reviewed. This failure placed residents and/or residents' representatives at risk for not being fully informed of health care decisions and residents' health care advocates not available to assist them in decision making.Findings included.Review of the facility's policy, Advanced Directives, revised 12/2024, showed the definition of Advance Directive may include Portable Order for Life-Sustaining Treatment (POLST) (a medical order form designed to document patient preferences for end-of-life care-such as CPR, and medical interventions). The policy showed the facility staff would determine upon admission whether the resident had an Advance Directive and identify the primary decision-maker and place a copy of such Advance Directive in the permanent medical record. The policy showed it may include Durable power of attorney for health care (DPOA-HC) and POLST.Resident 1 was admitted on [DATE] with diagnoses including Alzheimer's dementia, paraplegia/functional quadriplegia (partial loss of sensation and control of body), and cancer. The Minimum Data Set, an assessment tool, dated [DATE], showed Resident 1 had severe cognitive impairment, was dependent on activities of daily living, transfers and bed mobility.Resident 1's POLST, dated [DATE], and uploaded to Resident 1's electronic medical record on [DATE], showed Resident 1 had chosen Do Not Resuscitate (DNR) and selective medical treatment.Resident 1's hospital care management assessment, dated [DATE], showed Resident 1 had a verified medical DPOA on file and had a POLST on file.Resident 1's Skilled Nursing Facility Transfer Orders, dated [DATE], showed Resident 1 had a DNR order and the resident had a POLST and an Advance Directive. On [DATE] at 3:46 PM, Collateral Contact (CC) said Resident 1 had a POLST and DPOA-HC, that designated CC as the designated decision maker, that was provided to the facility. CC said the POLST outlined Resident 1's wishes for DNR and selective medical treatment. CC said the facility had completed a new POLST on [DATE] with Resident 1 that indicated Resident 1 wanted to be resuscitated and had Resident 1's signature on the document. CC said Resident 1 could not sign a document legibly due to their quadriplegia. CC said they were not informed of the change in resuscitation orders until Resident 1 was readmitted to the hospital on [DATE] and the doctor inquired why the POLST had been changed and gave CC a copy of a POLST signed at the facility on [DATE].Resident 1's POLST, dated [DATE], showed Resident 1 had chosen to attempt resuscitation/CPR and full treatment. The POLST showed Resident 1's legible name on the signature line of the form.On [DATE] at 1:17 PM, Staff A, Resident Care Manager and Licensed Practical Nurse, reviewed the POLST dated [DATE]. Staff A acknowledged they had signed and dated the POLST form as the reviewer. When asked why a new POLST was completed with Resident 1, Staff A said facility staff reviewed new admissions in their morning meeting and gave them a list of documents they needed. Staff A said they were probably given a note that Resident 1 needed a POLST. Staff A said they usually go and talk with the residents and if they seemed with it they complete the POLST with them. Staff A said they were not aware Resident 1 had a POLST in the medical record uploaded on [DATE].Resident 1's Impaired Cognition Care Plan, dated [DATE], showed impaired cognitive function/dementia or impaired thought processes r/t [related to] Alzheimer's, BIMS score is 7 (cognitive test indicating severe cognitive impairment).Resident 1's speech therapy notes, dated [DATE], showed Resident 1 lacked insight into condition and risk factors and had reduced health literacy (understanding).Resident 1's Care Conference Evaluation, dated [DATE], showed a care conference was held with Resident 1 and their significant other. The evaluation showed under POLST/Advance Directives -CPR full code-husband states he is POA.On [DATE] at 4:04 PM, CC said they had attended the care conference at the facility with Resident 1. CC said the facility did not disclose they had completed a new POLST of attempt resuscitation/CPR and Full treatment with Resident 1 on [DATE]. CC said Resident 1 had always been firm in their preference of DNR.Resident 1's POLST, dated [DATE], showed Resident 1's CPR preference as DNR and selective medical intervention. The form indicated it was discussed with POA [power of attorney], CC, on phone. The form showed no documentation the POLST was discussed with Resident 1.On [DATE] at 12:26 PM, Staff H, Resident Care Manager, said they were filling in for another Resident Care Manager and had completed Resident 1's POLST on [DATE] with CC. Staff H said they had initiated a new POLST because the medical provider had told them Resident 1 did not have a POLST on file. Staff H said they called CC and CC said DNR and selective medical intervention so that is what they put on the POLST. Staff H said they were unaware Resident 1 had a POLST on file.On [DATE] at 3:45 PM, Staff G, DNS, said facility staff were expected to review hospital records when a resident was admitted and if the resident had a POLST they should review it with the resident to ensure it was still their preferences. Staff G said staff should review the records to determine if there was an active DPOA-HC and complete an assessment with the residents for cognitive status. Staff G said if there was an active DPOA-HC and/or a cognitive issue they expected the staff to reach out to the resident representative during decision making. Staff G reviewed Resident 1's medical record and said they believed the staff did not see and/or were not aware of the POLST form from the hospital records. Staff G said education needed to happen with staff to ensure they reviewed the records sent from the hospital on admission.Reference WAC 388-97-0260

Based on interview and record review, the facility failed to implement care plan interventions for low meal intake and diet modifications for 1 of 3 residents (Resident 1) reviewed. This failure placed residents at risk of malnutrition, clinical complications and a decreased quality of life.Findings included.Resident 1 was admitted on [DATE] with diagnoses including paraplegia/functional quadriplegia (partial loss of sensation and control of body), dementia and cancer. The Minimum Data Set, an assessment tool, dated 12/17/2025, showed Resident 1 had severe cognitive impairment, was dependent on staff for eating, transfers and bed mobility.Resident 1's nutrition care plan, dated 12/16/2025, showed Resident was at risk or potential nutrition risk r/t [related to] new environment, altered diet, poor appetite, and varied intake. Care plan interventions included monitor/document circumstances surrounding mealtimes/refusals to eat., attempt to determine pattern or cause, where possible alter or remove cause, monitor/record eating habits and patterns to assist in determining cause of limited intake, monitor /record/report to provider PRN [as needed] situations leading to decreased food consumption.Resident 1's progress note, dated 12/23/2025, showed resident was on alert for low meal intake and resident was triggering for skin conditions, low intake, low fluid intake. The note showed resident consuming 25-50% of meals with variable fluid intake along with episode of coughing with meal, weight was noted at 195 pounds down from 201 pounds in hospital, provider was aware and nutrition eval was pending. The note showed staff would continue to encourage oral intake, provide assistance with meals and monitor weights.Resident 1's meal intake record, dated December 15th through December 30th, showed Resident 1 consumed 0-25 % for the following meals:12-17-2025- Breakfast and lunch12-19-2025- Lunch and Dinner12-20-2025- Breakfast and Lunch12-21-2025- Breakfast Lunch and dinner12-22-2025- Breakfast and Lunch12-23-2025- Dinner12-25-2025- Lunch and Dinner12-26-2025- Breakfast, Lunch and Dinner12-27-2025- Dinner12-28-2025- Breakfast and Dinner12-29-2025- Breakfast and DinnerReview of Resident 1's medical record showed no documentation the facility attempted to determine circumstances around meals, patterns and/or causes of limited meal intake, or situations leading to decreased food intake.Resident 1's speech therapy treatment note, dated 12/23/2025, showed Resident 1 tolerated MT2 (mildly thick liquids a fluid consistency designed for safer swallowing with the viscosity similar to tomato juice and/or runny honey), in 100% of the opportunities compared to TN0 (thin liquids). The note showed nursing staff were instructed on the diet change and need to ensure no TN0 is accessible for patient during meals. The note showed the current drinks/liquid were mildly thick drinks MT2.Resident 1's physician order, dated 12/23/2026, showed Resident 1's diet was mildly thick consistency (level 2-MT2), no straws and upright for PO [oral intake] w/ [with] 1:1 assist.Resident 1's nutrition care plan intervention, dated 12/23/2025, showed Resident 1's diet was downgraded to minced and moist [food] and mildly thick [liquids].Resident 1's activity of daily living care plan intervention, dated 12/23/2026, showed Resident 1 required total assistance to eat, ensure patient was as upright as possible, ensure patient had swallowed bite before initiating the next one and no straws.Resident 1's medical provider notes, dated 12/24/2025, showed there was a concern with Resident 1's swallow ability. The note showed that speech therapy evaluated and moved the resident to thickened liquids. The note showed that unfortunately all the thin liquids had not been removed from Resident 1's tray.On 02/04/2026 at 4:04 PM, Collateral Contact, said they had brought Ensure (a liquid meal replacement) from home because that is what Resident 1 drank throughout the day at home. On 02/06/2026 at 4:10 PM, Staff I, Registered Dietician, said they completed an evaluation of Resident 1. Staff I said the resident had a lot of comorbidities and was on an appetite stimulant. Staff I said they did not know why Resident 1 had low intake. Staff I said they did not know how Resident 1 was feeling, if they were giving up or was the appetite stimulate helping, they did not ask. Staff I said they knew Resident 1 had snacks and Ensure that was brought from home in their room. Staff I said Resident 1 had a sippy cup and they were able to use it on their own. Staff I said they were unaware of what was in the cup. Staff I said they were not requesting the staff document or track what Resident 1 was consuming from their home snacks only what the facility was providing.On 02/10/2026 at 12:02 PM, Staff B, Certified Nursing Assistant, said they had cared for Resident 1 often during their stay at the facility. Staff B said Resident 1 was dependent for all activities of daily living and eating. Staff B said Resident 1 had a sippy cup that had a straw in it some days. Staff B said Resident 1 used the sippy cup to drink out of and could sometimes hold the cup but needed assistance at times. Staff B said there was Ensure in the room and they would pour it in the sippy cup. Staff B said they did not have to add anything to the ensure, they would just open the bottle and pour it in the cup. Staff B said Resident 1 refused to go to the dining room for meals and when there were limited aides on the floor it was hard to provide Resident 1 with the assistance they needed.On 02/10/2026 at 1:32 PM, Staff C, Licensed Practical Nurse, said they cared for Resident 1 during their stay at the facility multiple days per week. Staff C said there was a supplement the family brought in. Staff C did not recall the brand of the supplement but said they would put the supplement in Resident 1's sippy cup. Staff C said the cup was a two-handed cup with a lid that had an opening for a straw and they would put a straw in the cup and Resident 1 would drink out of the cup using the straw.On 02/10/2026 at 3:45 PM, Staff G, Director of Nursing, said they expected staff to follow the care plan interventions when caring for residents. Staff G said they did not know if the staff had determined the causes, patterns and/or circumstances of Resident 1's low intake. Staff G said Ensure straight from the container is not considered mildly thick and Resident 1 should not have been drinking it without thickening added to it. Staff G said Resident 1 required 1:1 assistance per the plan of care and no straws and staff should have followed the care plan.Reference WAC 388-97-1020 (1)(2)(a)(b)

Based on interview and record review, the facility failed to accurately and/or timely assess and monitor a pressure ulcer for 1 of 3 residents (Resident 1) reviewed for wounds. This failure placed residents at risk of worsening pressure ulcers, lack of treatment evaluation and decreased quality of life.Findings included.Review of the facility policy, Wound Prevention and Treatment, revised 02/03/2023, showed the facility monitored wounds weekly and documentation of size, color, odor, healing progression, notifications and other pertinent information will be documented in the electronic medical record. Physician notification and resident/resident representative notification will be completed as needed.Resident 1 was admitted on [DATE] with diagnoses including paraplegia/functional quadriplegia (partial loss of sensation and control of body), dementia and cancer. The Minimum Data Set, an assessment tool, dated 12/17/2025, showed Resident 1 had severe cognitive impairment, was dependent on activities of daily living (ADLs), transfers and bed mobility.Resident 1's admission Evaluation, dated 12/15/2025, showed a stage 2 pressure ulcer (a partial thickness skin loss presenting as a shallow, open ulcer from prolonged unrelieved pressure) 2.5-inch x 0.1 inch surrounded by blanchable redness on the coccyx (tailbone).Resident 1's Skin Assessment, dated 12/15/2025, showed a horizontal open area 2.5-inch x 0.10-inch x 0.1- inch to the coccyx.Resident 1's provider notes, dated 12/16/2025, showed SNF [skilled nursing facility] recommendations to reposition every two hours, monitor skin integrity, especially the sacral area (bony structure at base of the spine).Review of Resident 1's medical record showed no wound care orders for the stage 2 pressure ulcer from admission on [DATE] through 12/27/2025.Resident 1's progress notes, dated 12/27/2025, showed the nurse was notified by the CNA [certified nursing assistant] while providing ADL care to assess a sacral wound. The note showed the assessment revealed a sacral wound present.Resident 1's Skin Grid Weekly Skin Evaluation, dated 12/28/2025, showed a Stage 2 pressure ulcer on the sacrum 1CM (centimeter) x .20 CM x .15 CM.Resident 1's progress notes, dated 12/29/2025, showed the resident had a new stage 2 pressure area and the resident continued to be at risk for pressure areas r/t [related to] dx [diagnosis] of quadriplegia (the partial or total loss of sensory and motor function in all four limbs) along with a healed stage 4 (pressure ulcer that extends to muscle, tendon or bone) pressure area in same area.Resident 1's wound consultant initial assessment, dated 12/30/2025, showed Resident 1 had a wound to the left buttock with etiology listed as MASD [moisture associated skin damage], the severity was partial thickness (non-pressure).On 02/10/2026 at 10:57 AM, Staff A, Resident Care Manager and Licensed Practical Nurse, said licensed nurses were expected to complete skin assessments weekly and document their wound assessment. Staff A said they reviewed the medical record and said Resident 1 had no documentation of a skin assessment between 12/15/2025 and 12/28/2025. When asked if the documentation of a stage 2 pressure ulcer on the sacrum documented in the Skin Grid Weekly Skin evaluation on 12/28/2025 was the same wound as the MASD on the left buttock, assessed by the wound consultant on 12/30/2025, Staff A said they did not know, the record was not clear, the left buttock is not the same as the coccyx and/or sacrum.On 02/10/2025 at 12:02 PM, Staff B, Certified Nursing Assistant, said Resident 1 wanted to sit up in bed all the time. Staff B said Resident 1 did not want to transfer to their wheelchair and or reposition. Staff B said Resident 1 had an open wound on their bottom since admit and it was present throughout the stay.On 02/10/2026 at 1:32 PM, Staff C, Licensed Practical Nurse, said they did not complete wound care for Resident 1. Staff C said the Resident 1 often refused to allow staff to reposition them.On 02/10/2026 at 3:24 PM, Staff D, Wound Consultant/Physician Assistant, said they had not evaluated Resident 1 prior to the 12/30/2025 consultation. Staff D said they diagnosed Resident 1's wound on the buttock as MASD and not pressure related. Staff D said this was due to the appearance of the wound and the wound was not over a bony prominence. Staff D said the wound they evaluated was on the fleshy part of the buttock and extended from the left to the right buttock. When asked if they had evaluated a wound on the coccyx and/or sacrum, Staff D said they were unaware of a wound on the coccyx and/or sacrum. Staff D said they were unaware Resident 1 had a healed stage 4 pressure ulcer on their sacrum.On 02/10/2026 at 3:45 PM, Staff G, Director of Nursing, said their expectation was the licensed nurse would complete a weekly skin assessment. Staff G said Resident 1 should have had a skin assessment completed in the week after admission.Reference WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to accurately document the clinical condition for 1 of 3 residents (Resident 1) reviewed. This failure placed residents at risk of inaccurate medical records, inaccurate assessments and lack of continuity of care.Findings included.Resident 1 was admitted on [DATE] with diagnoses including paraplegia/functional quadriplegia (partial loss of sensation and control of body), dementia and cancer. The Minimum Data Set, an assessment tool, dated 12/17/2025, showed Resident 1 had severe cognitive impairment, was dependent on activities of daily living (ADLs), transfers and bed mobility.Suprapubic CatheterResident 1's physician orders, dated 12/16/2025, showed Resident 1 had a suprapubic catheter (a tube inserted through an abdominal incision directly into the bladder to drain urine).Resident 1's Documentation Survey Report (nursing assistant documentation), dated December 2025, showed the nursing assistants had documented Resident 1 was incontinent of urine on December 15th, 16th, 17th, 19th, 20th, 21st, 22nd, 23rd, 26th, 27th, 28th and 30th.On 02/10/2026 at 3:45 PM, Staff G, Director of Nursing, said the documentation in the documentation survey report was incorrect, Resident 1 was not incontinent of urine.Resident 1's Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 1 was always incontinent of urine.On 02/10/2026 at 1:51 PM, Staff E, Minimum Data Set Coordinator, said the MDS was coded incorrectly because Resident 1 had a suprapubic catheter and the resident was not incontinent of urine.Resident 1's wound consultant notes, dated 12/30/2025, showed Resident 1 had urinary incontinence.On 02/10/2026 at 3:24 PM, Staff D, Wound Consultant/Physician Assistant, said they had assumed Resident 1 was incontinent of urine because they were incontinent of bowel movement. Staff D said they were unaware Resident 1 had a suprapubic catheter.Peg TubeResident 1's medical provider notes, dated 12/16/2025, 12/22/2025, 12/23/2025, 12/24/2025, 12/26/2025 and 12/29/2025 showed the SNF [skilled nursing facility] recommendations included PEG tube feeds (a tube inserted into the stomach to instill liquid nutrition through) as ordered, assist with oral intake as needed; prefers eating in room.On 02/10/2026 at 2:17 PM, Staff F, Physician Assistant Certified, said Resident 1 did not have PEG tube feeds. Staff F said the SNF recommendations were pulled using Artificial Intelligence from the hospital records and they must have missed it when proof reading, it was an error.WoundsReview of the facility policy, Wound Prevention and Treatment, revised 02/03/2023, showed the facility monitored wounds weekly and documentation of size, color, odor, healing progression, notifications and other pertinent information will be documented in the electronic medical record. Physician notification and resident/resident representative notification will be completed as needed.Resident 1's admission Evaluation, dated 12/15/2025, showed a stage 2 pressure ulcer (a partial thickness skin loss presenting as a shallow, open ulcer from prolonged unrelieved pressure) 2.5-inch x 0.1 inch surrounded by blanchable redness on the coccyx (tailbone).Resident 1's Skin Grid Weekly Skin Evaluation, dated 12/28/2025, showed a Stage 2 pressure ulcer on the sacrum 1CM (centimeter) x .20 CM x .15 CMResident 1's wound consultant initial assessment, dated 12/30/2025, showed Resident 1 had a wound to the left buttock with etiology listed as MASD [moisture associated skin damage], the severity was partial thickness (non-pressure).On 02/10/2026 at 10:57 AM, Staff A, Resident Care Manager and Licensed Practical Nurse, when asked if the documentation of a stage 2 pressure ulcer on the sacrum documented in the Skin Grid Weekly Skin evaluation on 12/28/2025 was the same wound as the MASD on the left buttock, assessed by the wound consultant on 12/30/2025, Staff A said they did not know, the record was not clear, the left buttock is not the same as the coccyx and/or sacrum.On 02/10/2026 at 3:24 PM, Staff D, Wound Consultant/Physician Assistant, said the wound they evaluated was on the fleshy part of the buttock and extended from the left to the right buttock. When asked if they had evaluated a wound on the coccyx and/or sacrum, Staff D said they were unaware of a wound on the coccyx and/or sacrum. Staff D said they were unaware Resident 1 had a healed stage 4 pressure ulcer on their sacrum.Reference WAC 388-97-1720 (1)(a)(i)(ii)

Based on interview and record review, the facility failed to notify the Resident Representative of multiple falls for 1 of 3 (Resident 3) residents reviewed. This failure placed residents and their representatives at risk of not being able to participate in resident care decisions, providing support, delayed medical treatment, and a diminished quality of life.Findings included.Resident 3 was admitted on [DATE] with a diagnosis of a stroke with hemiplegia (paralysis affecting one side of the body). The Minimum Data Set, an assessment tool, dated 06/27/2025, showed Resident 3 required substantial assistance for bed mobility, transfers and had severe cognitive impairment.On 08/14/2025 at 3:32 PM, Resident 3's representative said when they met with facility staff about discharge, a staff member told them Resident 3 had five falls since admission. Resident 3's representative said they had been notified of one fall since Resident 3 had been admitted to the facility but had not been made aware of multiple falls, I did not know he had been falling; I was here every day, I don't know why they didn't tell me?Review of the facility incident report, dated 06/24/2025 at 2300 (11:00 PM), showed Resident 3 fell and was found on the floor next to their bed. The report showed Resident 3 sustained a scratch on their arm. Facility staff initiated neurological checks and obtained vital signs. The report showed the physician and Director of Nursing were notified on 06/25/2025. The report had a conclusion note, dated 06/26/2025, that showed the family and physician were notified.Review of the facility incident report, dated 06/26/2025 at 23:05 (11:05 PM), showed Resident 3 was found prone (face down) parallel to the bed. The report showed no notifications completed. In the notes section of the report, dated 06/27/2025, showed the family and physician were notified.Review of the facility incident report, dated 06/27/2025 at 04:45 (4:45 AM), showed Resident 3 was found prone on floor parallel to the bed. The report showed the family member was notified on 06/27/2025 at 12:47 PM.Resident 3's progress note, dated 06/27/2025, showed the resident discharged home with family member.On 08/20/2025 at 2:49 PM, Staff E, Regional Clinical Nurse, said they had reviewed the incident reports and completed the conclusion/note section of the report. Staff E said they had not contacted the family member to notify them of the falls. Staff E said they did not remember the details of the incident reports but assumed they asked the staff if the family had been notified. Staff E acknowledged they would not have interviewed the licensed nurses that were assigned at the time of the falls due to the falls occurring on night shift. Staff E said the expectation was that the staff notify the resident's representative at the time of the fall unless they had requested to not be notified.Reference WAC 388-97-0320

Based on interview and record review, the facility failed to ensure medications to prevent seizures were administered per physician orders for 1 of 3 residents (Resident 6) reviewed for quality care. Resident 6 experienced harm when they were found unresponsive, required Cardio-Pulmonary Resuscitation (CPR/an emergency procedure consisting of chest compressions combined with giving breaths of air) and was hospitalized when their medication for seizures were not administered for multiple doses due to the unavailability of the medications, resident refusals, and failure to notify the physician of the omissions. This failure placed all residents at risk for medical complications and a diminished quality of life. Findings included . Review of the facility policy titled, Medication Administration, revised ,d+[DATE], showed staff were to document if a resident refused and or a dose was omitted in the EMR [electronic medical record]. The policy showed that it was not acceptable to omit a dose by indicating NA for medication not available from pharmacy, staff were to remove a dose from emergency kit or contact the pharmacy, if the medication was not available, contact the physician for further orders. Review of the facility policy titled, Refusal of Medication, Treatment and/or Dietary restrictions, revised ,d+[DATE], showed the facility would review and offer alternative interventions as appropriate if medication was refused and notify physician and resident representative of resident's wishes. Resident 6 was admitted on [DATE] with diagnoses of dementia and seizure disorder. The Minimum Data Set Assessment, an assessment tool, dated [DATE] showed the resident had severe cognitive impairment. On [DATE] at 3:09 PM, Collateral Contact 1 (CC1) said in the evening of [DATE], they were called by a facility licensed nurse and were told Resident 6's eyes rolled back, and they attempted to arouse the resident with a sternal rub and were unsuccessful. CC 1 said the nurse indicated they initiated CPR, called 911 and the resident was taken to the emergency room . CC 1 said they contacted the emergency room nurse and were told they believed the resident had a seizure due to not receiving their medications for seizures. CC 1 contacted the facility, and the licensed nurse confirmed the resident hadn't received their seizure medications for a few days. CC1 said they had not been notified prior to this episode by the facility that there were problems with administering the resident's medications and were upset about what the resident was put through. Resident 6's care plan, alteration in neurological status with potential for seizure activity r/t [related to] epilepsy, revised [DATE], showed an intervention of; medications as ordered for seizure activity. Resident 6's behavior care plan, revised [DATE], showed the resident had a behavior problem r/t resisted care and refused to take medication. The target behavior care plan, dated [DATE], showed one of the interventions for refusals of care/medications was to refer to MD [medical doctor] as needed for additional treatment and eval [evaluation]. Resident 6's physician orders, dated [DATE], showed an order for Valproic Acid 250 milligrams (mg) per 5 milliliters (ml) give 5ml four times per day for epilepsy (seizure disorder). An order, dated [DATE], for Dilantin 200mg two times per day for epilepsy. An order, dated [DATE], for Levetiracetam 10ml two times per day for epilepsy. Resident 6's laboratory results, dated [DATE], showed the Valproic acid level low at 43 microgram (ug)/ml, normal reference range ,d+[DATE]. Keppra (Levetiracetam) level was within normal range at 37.5 ug/ml, (reference range 10XXX,d+[DATE].0 ug/ml). Laboratory results, dated [DATE], showed phenytoin levels elevated at 2.7 ug/ml (normal reference range 1XXX,d+[DATE].0). Resident 6's Medication Administration Record (MAR), dated February 2025, showed the resident refused their Valproic Acid medication, Dilantin medication and their Levetiracetam medication on [DATE] and [DATE] at bedtime. The resident's MAR, dated [DATE], showed the resident did not receive their Valproic acid medication on [DATE] at 12:00 PM, 4:00 PM and 8:00 PM and refused it on [DATE] at 8:00 PM. The MAR further showed the resident refused their Dilantin and Levetiracetam medication on [DATE] at bedtime. Resident 6's progress notes, dated [DATE], showed the following medication administration notes: at 14:26 (2:26 PM) the Valproic acid was not available in the cart at 18:37 (6:37 PM) re-check with pharmacy and will be coming in tonight at 23:45 (11:45 PM) follow up with pharmacy and will deliver tonight. Review of Resident 6's EMR on [DATE], showed no documentation the physician and/or resident representative was notified of the resident's refusal of medications on [DATE], [DATE], [DATE] and/or the unavailability of the valproic acid on [DATE]. Resident 6's progress notes, dated [DATE], showed the LN [licensed nurse] reported the resident had become unresponsive and pulseless (no heartbeat) they started CPR, and medics took the resident to the hospital. Resident 6's hospital emergency room records, dated [DATE] at 18:56 (6:56 PM), showed the chief complaint as, resident was brought to the emergency from the facility by EMS [emergency medical services] for a seizure, the facility staff started CPR for unknown amount of time, felt pulse, patient had pulse for medics. The record showed per EMS the patient had not taken seizure meds for 2 days. The record showed hospital laboratory results, collected on [DATE] at 18:58 PST (6:58 PM), showed Phenytoin (Dilantin) level low at 5.5 micrograms (mcg)/ml (normal reference range is 10.0 -20.0 mcg/ml) and Valproic Acid level low at 36 mcg/ml (normal reference range is 50XXX,d+[DATE].0 mcg/ml). The record showed the resident was given intravenous (medication administered into the resident's veins) Dilantin and Valproic acid. The record showed the subtherapeutic (a dose or concentration of a drug that is below what is used for treating disease or producing an optimal therapeutic effect) levels most likely led to seizure. The record showed the assessment/plan for the resident was acute UTI [urinary tract infection] and seizure secondary to subtherapeutic anticonvulsant (medication used to prevent or control seizures) medication. On [DATE], Staff A, Acting Director of Nursing, said they reviewed Resident 6's medical record and found no notification to the resident's physician and/or representative of the medication refusals or the unavailability of the medication. Staff A said the staff should have notified the physician of the refusals and the unavailability of medications, especially seizure medications. WAC Reference [DATE] (3)(k)(iii)

Based on interview and record review, the facility failed to accurately assess and take timely action to prevent the development of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure) experienced by 1 of 1 closed record Resident reviewed for wound care. Resident 1 experienced actual harm when they developed pressure ulcers to both heels which required hospitalization for surgical intervention, intravenous (administered through the vein) antibiotics and below the knee amputation (BKA) of their right lower extremity (RLE). These failures placed residents at risk for pressure ulcer development, deterioration of existing pressure ulcers, pain, and a decreased quality of life. Findings included . Review of the facility's policy titled, Wound Prevention and Treatment, revised 02/03/2023, showed that wounds including pressure injuries and significant skin tears would be monitored weekly and documentation of size, color, odor, healing progression, notifications and other pertinent information related to the skin conditions would be documented in the electronic medical record. Physician notification and resident/resident representative notification would be completed as needed. Resident 1 was admitted on [DATE] with diagnoses including developmental delay, diabetes and morbid obesity. The Minimum Data Set, an assessment tool, dated 01/27/2025, showed the resident was cognitively intact, at risk for pressure ulcers and required staff assistance for bed mobility and was dependent for out of bed transfers. Review of Electronic Health Record (EHR) showed Resident 1 had long standing orders since admission for weekly diabetic foot checks. The EHR showed Resident 1 had a history of pressure ulcers, the most recent to their left lateral foot that was documented as resolved 12/03/2024 by wound consultant team. Resident 1's skin evaluation, dated 01/13/2025, showed no skin impairments on the resident's feet and/or heels. Resident 1's skin evaluation, dated 01/20/2025, showed the resident's left heel was reddened with a 6.0 centimeters (cm) by 2.0 cm scabbed area. Resident 1's physician order, dated 01/26/2025, showed an order for staff to monitor bilateral heel wounds and apply dressings every Tuesday, Thursday and Friday. Resident 1's medical provider notes, from date of service of 01/27/2025, showed resident was seen by an Advanced Registered Nurse Practitioner (ARNP) and Resident 1's skin was noted to be warm, dry, pink, intact other than rash to the posterior of the left lower extremity and it was healing and no drainage on sheet noted. Resident 1's progress notes, dated 01/28/2025, documented a nursing assistant had noticed a small amount of blood on Resident 1's right heel and the skin looked pulled back, when nurse went to assess she noted an area around the resident's right heel wound that looked macerated (skin condition that occurs when skin softens and breaks down due to prolonged exposure to moisture) as if resident had been picking at it and they had pulled back a large layer of skin, presenting as a 5x4 area of skin tear. Resident was placed on alert and their care plan was updated. The progress note documented the resident would sit cross legged/duck style and lean their upper body over the lower body thereby applying pressure to the heels and was encouraged to reposition and staff placed pillows to help with pressure relief. Review of the EHR showed the following: On 01/29/2025, there were no notes found regarding Resident 1's feet. On 01/30/2025 at 1:24 AM, a note was made showing, dressings to feet are intact, foam booties in place. On 01/31/2025, there were no notes found regarding Resident 1's feet. The three times a week dressing changes on the January 2025 Treatment Administration Record (TAR) were checked off as having been completed throughout January. On 02/01/2025 at 1:37 AM, a note was made showing, dressings to feet are intact, foam booties in place. Resident 1's care plan, revised 02/02/2025, showed the resident had a pressure area on left foot at the lateral aspect (outside edge) of the 5th toe (pinky toe) with a goal the pressure ulcer would show signs of healing and remain free from infection. The care plan showed an intervention of assess/record/monitor wound healing weekly and prn [as needed] and measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress and report improvement and declines to the Medical Doctor (MD). The care plan showed the resident had a skin tear on the right heel, with a goal the skin tear would heal with no s/s [signs and symptoms] of infection and interventions to monitor/document location, size and treatment of skin tear, report abnormalities, failure to heal, signs and symptoms of infection, maceration to MD. On 02/02/2025 and 02/03/2025, there were no notes found regarding Resident 1's feet. The next formally documented skin evaluation (last was 01/20/2024), dated 02/04/2025, showed the bottom of the resident's right heel with a skin tear 5 x 4 and ongoing treatment of the resident's left heel that showed it was reddened with a 6.0 cm x 2.0 cm scabbed area. A physician order dated 02/05/2025, showed an order for wound consultant to evaluate and treat as indicated and a dressing to the right heel to be changed daily. Resident 1's progress notes, dated 02/05/2025, showed new orders were received for wound consultant to evaluate and treat. The note showed the LN [licensed nurse] asked the wound team consultant to look at the wound and wanted the resident to be on their rounds the next week. The wound consult was submitted and new treatment orders were received from the provider for cleansing and dressing daily. Review of Resident 1's progress notes, dated 02/06/2025 through 02/10/2025, showed no documentation of assessment or monitoring of Resident 1's skin which was ordered for daily monitoring and dressing changes during this time. Resident 1's wound consultant report, dated 02/11/2025, showed an assessment of large ulcers to the resident's bilateral feet with maceration and erythema (redness of the skin) with a concern for underlying osteomyelitis (infection in the bone), risk of amputation and the resident needed to be sent to the ED [emergency department] for evaluation. Resident 1's hospital records, with date of admission as 02/11/2025, showed when the resident presented to the hospital emergency room where the medical provider's assessment showed chronic, very foul-smelling decubitus (damage to an area of the skin caused by constant pressure on the area for a long time) ulcerations (open wounds) in the bilateral calcaneal (heel bone) areas. Resident 1's hospital records showed a podiatrist (medical doctor that specializes in feet and lower leg issues) consult, dated 02/12/2025, documented decubitus ulcer of heel bilateral, a right heel 6.0 x 6.0 centimeters (cm) full-thickness ulceration with necrotic tissue (dead tissue) with purulence (presence of pus) with the ability to probe deep to the bone, a left lateral heel with 4.0 cm x 4.0 cm area of necrotic purulent tissue with inability to probe deep to bone and a full thickness ulceration about the plantar left fifth metatarsal head (the long bone on the outside of the foot) with inability to probe deep to bone. The consult showed the right side with necrotic infected tissue and the left side had significant necrotic infected tissue loss. The consult showed the podiatrist did not think the right lower extremity was salvageable and they hoped the left lower extremity could be salvaged with aggressive tissue debridement (removal of damaged tissue from a wound), and long term intravenous (medication administered in the vein) antibiotic (medication for infection) therapy. On 02/20/2025, the hospital record showed the resident had a right BKA [below the knee amputation] on 02/19/2025 and received intravenous antibiotics. On 02/12/2025 at 12:03 PM, Staff A, Registered Nurse (RN)/Staff Nurse, said they worked the day shift, three days on and then three days off on a rotating schedule with Staff D, Licensed Practical Nurse (LPN)/Staff Nurse and were assigned to Resident 1. Staff A said Resident 1 would sit up in bed on their legs. Staff A said they reported it to the medical provider on 01/26/2025 when they found the resident's right heel with blood on it, and it had appeared that the resident had peeled the skin off the heel. Staff A said the left heel had scabs on it and it looked like it was forming a deep tissue injury (a type of pressure injury that occurs when prolonged pressure damages the underlying soft tissues). Staff A said the medical provider said to put pillows under the resident's legs so the resident could not sit on their legs and the medical provider was aware staff had asked the wound consultant to see the resident. Staff A said the wounds on both heels were soaking through the dressings. Staff A said after 01/27/2025, the wounds on both heels got worse and were deep tissue wounds and the previous week (week of 02/03/2025) both heels were draining and open wounds. On 02/12/2025 at 12:49 PM, Staff B, Unit Manager/LPN, said they would expect to see a wound assessment when wounds were discovered on a resident. Staff B said they had obtained the physician order for the wound consultant to see Resident 1 on 02/05/2025, for the wound on the right heel. Staff B said they were not aware the wounds had escalated and thought the wound consultant and/or Staff C would see the Resident, I thought the resident was on the weekly caseload with the wound consultant. On 02/12/2025 at 1:54 PM, Staff C, Unit Manager/RN, said they were assigned to accompany the wound consultants when they rounded on residents. Staff C said Resident 1 had a pressure wound on their left lateral foot that the wound consultants had resolved back in December of 2024. Staff C said they knew nothing about wounds on Resident 1's feet until the previous week (week of 02/03/2025) so they had mentioned to the wound consultant they needed to see the resident. Staff C said Resident 1 had COVID (had tested positive 01/24/2025) and the wound consultants would not see residents when they were on isolation. Staff C said they did not know Resident 1 had new wounds and did not assess the wounds until 02/11/2025 with the wound consultant. Staff C stated, I didn't now he had new wounds. I never saw them until yesterday. I did not go and assess; I had no idea they looked that bad. If I would have known, I didn't know it was to that extent. On 02/21/2025 at 11:04 AM, Staff D, said they were assigned to Resident 1 approximately three days per week and were very familiar with the resident's care. Staff D said they were completing dressing changes to the resident's left and right heel three times per week and then the right heel dressing was changed to daily on 02/05/2025. Staff D said on 02/04/2025, they were concerned that the resident's heels were getting worse. Staff D said they were darker in color with drainage and becoming larger in size. Staff D said that was why on 02/04/2025 they stopped the wound consultant in the hallway to ensure they had Resident 1 on their list to see. Staff D said the wound consultant confirmed they would see the resident the following week. Staff D acknowledged their only documentation of the wounds was signing the treatment administration record when they completed the dressing changes. On 02/21/2025 at 2:39 PM, Staff E, Director of Nursing Services/RN said Resident 1's skin assessments and documentation had not captured the resident's skin condition, stating, there were inaccuracies. Staff E said the nursing staff had not communicated the condition of Resident 1's wounds effectively to the interdisciplinary team to help the resident in a timely manner. WAC Reference 388-97-1060 (3)(b)

Based on observation, interview and record review the facility failed to ensure the resident environment was safe and free from hazards for 17 of 17 sampled residents (1 ,2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17) residing in the facility's locked dementia unit. Resident 1 experienced harm when they sustained a significant second degree burn (burn that affects the epidermis [outer layer of skin] and the dermis [middle layer of skin] to the left hip when they were found unsupervised seated on a baseboard heater. This failure placed all residents on the dementia unit at risk for serious injury and decreased quality of life and constituted an Immediate Jeopardy (IJ). On 12/10/2024, the facility was notified of an IJ at CFR 483.25, F 689, Accidents/Hazards/Supervision/Devices, when a resident sustained burns after being found unsupervised against a baseboard heater at the facility and placed other residents at risk of serious injury. The facility removed the immediacy on 12/13/2024 with an onsite verification by review of the temperature logs, staff education related to temperature checks and verification of repairs to the baseboard heaters which ensured an effective system was in place to safeguard, protect and prevent residents from hazards. <Dementia Unit> The dementia unit had 17 residents who resided on a locked dementia unit. Electronic health records indicated 16 of 17 residents had cognitive impairment and were at risk for wandering behaviors and indicated 17 of 17 residents had dementia or other cognitive impairing diagnoses. There were heaters in every resident room and in two common areas, that were accessible to all residents. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that can cause problems with memory, thinking and behaviors), dementia (a group of symptoms that affects memory, thinking and interfers with daily life) and hypertension (high blood pressure). The Minimum Data Set (MDS), an assessment tool, dated 09/07/2024, showed the resident had cognitive impairment with hallucinations and delusions, had wandering behaviors and had one fall since admission and required staff assistance for activities of daily living. Resident 1's care plan, dated 07/2022, showed Resident 1 required staff assistance for bathing, was independent with transfers and ambulation, had impaired safety awareness and was an elopement risk due to wandering. Resident 1's progress note, dated 12/06/2024 at 7:53 AM, showed Resident 1 was found on the floor with their back against the heater with redness to the left side of the back, left arm and the left hip initial accessment of the affected area showed a 4.5 inches by 1/2 inch white linear burn and reddened area of approximately 3 by 4 inches. Resident 1's hospital documentation, dated 12/06/2024, showed the resident sustained a three percent body surface area, partial thickness burn to their left buttocks and some redness to the skin on the left posterior arm and back with some broken blisters. Resident 1 was discharged back to the facility with wound treatment orders. Review of the facility's investigation, dated 12/06/2024, showed Resident 1 was found sitting on the baseboard heater in the resident's room by Staff F, Nursing Assistant (NA). Staff F moved the resident away from the heater and left the resident to find the nurse. Staff F and a nurse returned to the resident. The resident was assessed and sent to the hospital for evaluation and treatment. The facility was unable to determine why the resident was next to the baseboard heater. Resident 1's first documented skin assessment after return from the hospital, dated 12/08/2024, showed a 6 inch by 12 inch burn with blisters and open areas with yellow drainage. Resident 1's wound assessment, dated 12/10/2024, showed a large 11 cm x 18 cm x 0.12 cm (4.3 inch x 7 inch) second degree, partial thickness, deep burn on the left buttock wrapping around the hip. On 12/09/2024 at 10:52 AM, Staff F, said they were the NA on night shift on 12/06/2024. Staff F said she saw the resident out of her bed, sitting on the heater in the resident's room waving at her. Staff F said she moved the resident away from the heater and saw the resident's skin was between the panels of the heater and the left hip was burned. It was pretty bad .I freaked out and left the room to get the nurse .I had 16 residents that night by myself. Staff F said she and the nurse returned to the resident's room and Resident 1 had moved back against the heater. Staff F said they moved the resident away from the heater. Staff F said the resident was sent to the hospital for evaluation. Staff F said the resident was checked on at 2:00 AM and was found at approximately 3:30 AM. On 12/09/2024 at 12:23 PM, Staff E, NA said the baseboard heaters were hard to regulate in the dementia unit. On 12/09/2024 at 12:30 PM, Staff A, former Administrator, said since she had been administrator the facility had not had any issues related to the baseboard heaters and she was not aware of reported issues with the baseboard heaters. Staff A said prior to her working as the administrator she was aware that there was some issue with a heater but was not aware of the details. The Administrator said Resident 1 sustained a large second degree burn to the left hip from the baseboard heater in the resident's room. She said the facility completed an investigation and thought the resident sustained a burn after a fall onto the heater. On 12/09/2024 at 12:40 PM, Resident 1's wound care was observed with Licensed Practical Nurse (LPN), Staff D. Resident 1's left hip had a large burn over the left hip, red in color and a small fluid filled blister remained intact in middle of the burn. The wound care was completed by Staff D and tolerated well by the resident. On 12/09/2024 at 12:40 PM, Staff D said she felt like the baseboard heaters in the dementia unit were hard to adjust. Staff D said some heaters didn't work properly and were too hot or too cold, especially in the day room. On 12/10/2024 at 3:15 PM, observation of the following rooms baseboard heater temperatures with Staff A, C (Director of Nursing) and E (Maintenance Director): - room [ROOM NUMBER]- The top of the baseboard was touched and was too hot to touch as it would burn the skin. - Resident day room - The top of the baseboard was touched and was too hot to touch as it would burn the skin. - room [ROOM NUMBER] - The top of the baseboard was touched and was too hot to touch as it would burn the skin. It was determined at that time by Staff A, C and E that the facility infrared thermometer was not functioning accurately as the readings were coming up in the moslty mid 70 degree Fahrenheit (F) range despite being so hot to the touch, and the facility did not have a replacement infrared thermometer in the facility. On 12/10/2024 at 4:45 PM, observation of 10 resident rooms in the dementia care unit was completed with Staff A, C and E. Staff E said she had gone to the dementia care unit and turned all baseboard heaters down a short time prior. Rooms 40, 41, 42, 43, 44, 45, 47, 49 and the dining room baseboard heaters were still too hot to hold the hand on as it would burn the skin. Rooms 46, 48 and the day room were cooler to the touch. On 12/12/2024 at 11:00 AM, Staff B, Interim Administrator, said an electric company was in the facility and replacing all thermostats on the baseboard heaters in the dementia unit. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to ensure the resident environment was safe and free from hazards when a resident received a significant burn from hot coffee for 1 of 1 sampled residents, and failed to supervise resident interactions and implement interventions to prevent a resident-to-resident altercation for 2 of 2 sampled residents (1 & 2) reviewed for accident hazards and supervision. This caused harm to Resident 1 when hot coffee spilled on the resident causing blisters and redness. These failures placed residents at risk for burns, unwanted touching and a diminished quality of life. Findings included . <Burn> Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a disorder affecting the ability to move) and epilepsy (a disorder causing seizures). The quarterly Minimum Data Set (MDS), an assessment tool, dated 03/23/2023, documented Resident 1 has severe cognitive impairment and required total dependence from staff with activities of daily living (ADLs). The care plan, dated 04/14/2023, documented staff would assist the resident with meals and serve hot liquids in a mug with a lid. The Daily Production (meal temperature log), dated 04/28/2023 through 05/05/2023, documented staff were not consistently documenting hot beverage temperatures. The Facility Investigation, dated 05/05/2023, documented Resident 1 requested coffee at supper. The coffee carafes, used for resident coffee, were empty. Staff went directly to the kitchen coffee pot and poured the coffee for the resident. The coffee was very hot so the nursing assistant (NA) cooled the coffee for about 10 minutes. The staff then delivered the coffee to the resident. About 10 -15 minutes later, staff heard the resident yell and was found with spilled coffee with a burn to the chest. The burn was 4 centimeters (cm) x 15 cm and red with blisters. Resident 1 was evaluated at the emergency room and required dressing changes twice daily to the wound. The facility investigation found coffee temperatures in kitchen coffee pot ranged from 178-182 degrees Fahrenheit. Interventions included staff would use a sippy cup for Resident 1 for all liquids due to hand tremors. Staff would check temperatures on hot liquids before meal service. On 05/08/2023 at 2:25 PM, Resident 1 was observed in bed. A bandage was covering a burn to the chest. The resident was slouched in bed and leaning far to the right side. A tremor was noted to her hands. The resident said the burn was from spilled coffee. Resident 1 said she had some pain but it was manageable with pain medication. The resident declined an observation of the wound and was unable to answer any further questions. At 2:27 PM, Staff F, Nursing Assistant (NA), said staff were to get coffee from the carafes. Staff F said staff should not be getting coffee from the kitchen because the coffee was too hot. Staff F said Resident 1's hands shook so a sippy cup was always used with coffee. 06/08/2023 4:03 PM, Staff D, Dietary Manager, said the staff obtained the coffee from the kitchen instead of the carafes, which was much hotter. Staff D said she was unsure why the staff came into the kitchen to get the coffee instead of using the carafe. Staff D said dietary staff were not monitoring the hot liquid temperatures consistently. Staff D said they now monitor liquids every meal. Staff D said they implemented a resident safe temperature range for hot liquids of 125-155 degrees. They did not have a safe range prior to the burn. On 4:27 PM, Staff B, Registered Nurse (RN) and Director of Nursing Services (DNS), said Resident 1 was doing well and the burn was nearly healed. The facility implemented temperature checks and parameters for temperature ranges. Staff B said the carafes were empty which was why staff retrieved coffee from the kitchen. All staff have been educated on using the carafes and proper temperature ranges. <Resident to Resident> Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a disorder affecting the ability to move) and epilepsy (a disorder causing seizures). The quarterly MDS, dated [DATE], documented Resident 1 had severe cognitive impairment and required total dependence from staff with ADLs. Resident 1's care plan, dated 04/14/2023, documented Resident 1 had potential for psychosocial well-being related to allegations on 01/18/2023 and 03/30/2023. The care plan showed the guardian consented to hand holding and rubbing of shoulder. Staff were to ensure safety by providing reminders for only hand holding and shoulder rubbing by other resident. Resident 2 was admitted to the facility on [DATE] with diagnoses including end-stage kidney disease. The quarterly MDS, dated [DATE], documented Resident 2 had no cognitive impairment and required limited assistance with ADLs. Resident 2's care plan, dated 01/19/2023, documented Resident 2 had a history of verbally abusive behaviors towards other residents. Staff were directed to analyze triggers to determine how to de-escalate behaviors. The care plan did not provide interventions for staff regarding the touching behaviors towards Resident 1. The facility investigation, dated 01/18/2023, documented Resident 2 was observed touching Resident 1's breast. The allegation was reported to the State Agency and investigated. Another witness did not see touching and no witnesses were identified. Both residents denied inappropriate touching. Resident 2 agreed to limit his touching of Resident 1 and was placed on one-to-one monitoring. The facility investigation, dated 03/30/2023, documented Resident 2 was observed, while in the dining room, touching Resident 1's breast and putting hands down her shirt. The allegation was reported to the State Agency and investigated. Witnesses and Resident 1 and Resident 2 denied allegation. The facility was unable to substantiate the allegation and would monitor the residents for psychosocial harm. On 06/06/2023 at 9:45 AM, Resident 2 was observed in the dayroom with Resident 1. Resident 2 was caressing Resident 1's arm. Resident 2 ran his hand up and down Resident 1's arm and wrist, up the shoulder with Resident 2's hand up Resident 1's sleeve, then across their chest to below the collar bone. On 06/08/2023, at 10:15 AM, Resident 2 was observed in the dayroom next to Resident 1. Resident 2 caressed Resident 1's left hand. Resident 2's hand then followed up Resident 1's arm up to her shoulder across the upper chest putting his hand up Resident 1's sleeve. Staff B was notified of the observation. Staff B intervened and Resident 2 became angry, yelling out and swung his hand at Staff B. At 3:50 PM, Staff E, NA, said Resident 2 had some alleged behaviors of touching Resident 1. Staff E said staff were to monitor Resident 2's whereabouts in the facility and monitor Resident 2 when alone with Resident 1. The residents were allowed to sit by each other but could not touch. Staff E said if any inappropriate touching occurred, staff would separate the residents and report the observation. At 4:16 PM, Staff C, Licensed Practical Nurse and Resident Care Manager, said Resident 1 and Resident 2 had developed a friendship in the past. They like to sit by each other and rub hands which was the only acceptable form of touching. Staff C said staff had set aside time so the residents could spend time together while supervised. Staff C said today was the first day there was an issue related to rubbing of the arm. When asked about Resident 2 rubbing up under Resident 1's sleeve, Staff C said that would not be acceptable. Staff C said there were not any interventions on Resident 2's care plan related to the resident's behavior towards Resident 1. On 4:27 PM, Staff B said Resident 1 and Resident 2 were friends. They say they love each other as friends. Staff B said the staff caring for Resident 2 should be monitoring his whereabouts. Staff B said staff missed Resident 2 going into the day room on 06/08/2023. Staff B said Resident 2 was alert and oriented and continued to deny the allegation. Resident 1 had never shown any change in her behavior related to the relationship with Resident 2. Resident 1 had cognitive impairment and Resident 1's guardian was okay with appropriate touching. Staff B said it was not appropriate for Resident 2 to rub up under Resident 1's sleeve. Staff B said Resident 2 did not have a current care plan to direct staff how to manage the interactions with Resident 1. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure residents' care plans were followed for one of two sampled residents (1) reviewed for accident hazards and one of one sampled residents (2) reviewed for injury of unknown origin. This failure placed residents at risk for injury and a diminished quality of life. This caused harm to Resident 1 when the she rolled off the bed to the floor during cares and sustained an injury to her head that required transfer to a local hospital. Findings included . <Fall> Resident 1 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], dementia, and a stroke with left sided weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had no cognitive impairment and required extensive assistance from two staff with bed mobility. Resident 1's care plan, dated 05/20/2021, documented Resident 1 required assistance from two staff with bed mobility. Resident 1's progress notes, dated 08/07/2022, documented Resident 1 rolled out of bed during personal cares and staff had assessed Resident 1 and found no neurological (mental) changes or fracture and assisted the resident back into bed. Resident 1's progress notes documented the resident had a lump and redness of the skin to their forehead and began to experience confusion and had one episode of vomiting. Resident 1 was transferred to the emergency room for further evaluation. Resident 1's emergency room report, dated 08/07/2022, documented Resident 1 fell and rolled off the bed and had a hematoma (a collection of blood beneath the skin due to an injury) on their forehead. A CT scan (a device to view the soft tissue and blood vessels) did not show signs of further injury. The resident returned to the facility with no further concerns. The facility investigation, dated 08/07/2022, documented, Staff E, Nursing Assistant (NA), was assisting Resident 1 with incontinence care when Resident 1 rolled towards one side of the bed and lost their grip and then rolled off the bed onto the floor. Staff E said they immediately notified the nurse on duty who assessed the resident for injuries. The assessment documented Resident 1's forehead was red, and a lump was forming. The resident began to show signs of confusion and had an episode of vomiting. Resident 1 was transferred to the hospital with no new injuries found. The facility investigation documented Resident 1 used a drawer on the bedside table for support when turning away from staff on one side but when she turned to the opposite side, she had no support and rolled off the bed. Staff E was on the back side of the resident and was unable to prevent the resident from rolling off the bed. Resident 1's progress notes, dated 08/08/2022, documented Resident 1 had bruising to the forehead and to both eyes. Resident 1's progress notes, dated 08/09/2022, documented Resident 1 had bruising to both eyes getting deeper and darker in color, purple in nature. Resident 1's progress notes, dated 08/11/2022, documented Resident 1 had persistant bruising around their eyes. On 09/26/2022, at 12:00 PM, Staff E said he was assisting Resident 1 with incontinent care prior to her fall on 08/07/2022. Staff E said when the resident rolled to the side away from him, she continued to roll off the bed. Staff E said he could not stop her from rolling and had no other staff assisting him. Staff E said, prior to Resident 1's fall, he had usually assisted Resident 1 with bed mobility alone and had not had any incidents or concerns. Staff E said he was unaware Resident 1's care plan directed two staff to assist with Resident 1's bed mobility. Staff E said they were using two staff to assist Resident 1 now. On 09/27/2022 at 12:35 PM, Resident 1 said she recalled her fall. Resident 1 said she usually had only one staff assist her in bed, and she would just hold onto her bedside table. Resident 1 said she lost her grip and rolled off the bed. Resident 1 said two staff help her now. On 10/07/2022 at 2:10 PM, Staff C, Licensed Practical Nurse (LPN), said staff usually used one to two staff to assist Resident 1 with bed mobility. Staff C said it depended on how comfortable the staff felt with rolling Resident 1 because she is complicated to roll. Staff C said she was unaware of the care plan directing two staff to assist the resident. Staff C said she had not received education on any changes to Resident 1's plan of care or mobility needs. At 2:15 PM, Staff D, NA said they usually used one to two staff to assist Resident 1 with bed mobility prior to the fall. Staff D said she felt comfortable assisting the resident alone with bed mobility. Staff D said some staff were able to use one staff and others needed two staff. Staff D said it depended on how comfortable staff were with assisting Resident 1. Staff D said she was unaware Resident 1's care plan directed two staff to assist with bed mobility. At 2:40 PM Staff A, Director of Nursing (DNS) and Registered Nurse (RN), said Resident 1's care plan and MDS said the resident required two staff to assist with bed mobility prior to the fall on 08/07/2022. Staff A said staff should have been aware of this intervention. Staff A said when Resident 1 fell , only one staff was assisting the resident and the care plan was not followed. Staff A said she was not aware additional staff used an assist of one for mobility prior to Resident 1's fall. Staff A said she did not know Resident 1 was using the bedside table for support with bed mobility. Staff A said she would have added mobility bars sooner had this been reported to her. <Injury of Unknown Origin> Resident 2 was admitted to the facility on [DATE] with diagnoses including psychotic disturbance, [CONDITION(S)] disease, and chronic obstructive pulmonary disease (a progressive disease resulting inflammation of the lungs). The Quarterly MDS, dated [DATE], documented Resident 2 had severe cognitive impairment and requireed supervision with mobility. Resident 2's care plan, dated 02/12/2022, documented Resident 2 had an alteration (change) in skin integrity and staff would follow facility policies/protocols for any new areas of skin breakdown. Resident 2's progress notes, dated 08/12/2022, documented Resident 2 had swelling to the right hand with bruising up to the wrist and an x-ray of the injury was negative. A skin/wound note, dated 08/12/2022, documented Resident 2's right wrist injury measured 34 x 15. No unit of measurement was noted. The facility investigation, dated 08/12/2022, documented Resident 2 was found with swelling and bruising to her right hand and wrist in the morning when staff entered her room. The resident was unable to explain the cause of the injury due to her cognition. No injuries were noted on the previous shift. Staff reported Resident 2 would bang on the bedside table if woken during the night and get herself out of bed. The facility investigation documented staff had determined the resident hit the bedside table when positioning in bed or while banging on the bedside table. The intervention, to prevent injury, was to place padding on the bedside table. Resident 2's progress notes, dated 08/13/2022, documented Resident 2 had bruising with minimal swelling to the right hand and wrist. The resident complained of pain but refused pain medication. The resident allowed elevation of her hand on a pillow. Resident 2's progress notes, on 08/14/2022, documented Resident 2's swelling had almost resolved, and she continued to refuse pain medication. The progress note documented Resident 2's bedside table would be padded and therapy would follow. On 09/21/2022 at 2:45 PM, Resident 2 was observed sitting on her bed and the resident's bedside table was positioned next to her bed. Resident 2 could not recall an injury to her wrist. No signs of injury were observed. Resident 2's bedside table did not have padding, identified as an intervention to prevent injury in the facility investigation. Resident 2 was unable to describe how she could have injured herself. On 09/27/2022 at 12:45 PM, no padding was observed on Resident 2's bedside table. The resident's bedside table was positioned next to her bed. On 10/07/2022 at 1:38 PM, no padding was observed on Resident 2's bedside table. The resident's bedside table was positioned next to her bed. At 2:00 PM, Staff F, NA, said she remembered Resident 2 bruising her wrist. Staff F said she was unsure how it occurred but Resident 2 did bang around in her room at times. Staff F said she did not recall Resident 2 having padding on her bedside table. Staff F said they try and monitor the resident, so she would not injure herself when moving around independently. At 2:40 PM, Staff A said they determined Resident 2's injury was due to her hitting her wrist on her bedside table. Staff A said their intervention was to place padding around the bedside table. Staff A said she had observed staff bring the padded bedside table into the resident's room. Staff A said this intervention had been added to the care plan, but it had since been resolved and she was unsure why. The bedside table in Resident 2's room was observed with Staff A and she said the padding was no longer there. Staff A said Resident 2 was still at risk for injury and required an intervention to prevent further bruising. At 3:13 PM, Staff B, LPN and Resident Care Manager (RCM) said Resident 2 had been picking at the padding, so they removed it from the bedside table. Staff B did not think this was documented and did not implement new interventions. Staff B said there was a referral to therapy, but no other recommendations had been made. Staff B said Resident 2 was not at risk for bruising and the concern was resolved. Staff B said Resident 2 would bang around in her room at times but thought it was a behavior. Staff B could not state interventions implemented to prevent further injury. Staff A said Resident 2 should have had interventions to prevent new bruising. Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to operationalize all components of an effective infection control program to prevent and limit the spread of COVID-19 (an infectious virus causing respiratory illness with symptoms including cough, fever, nausea, loss of taste or smell and difficulty breathing that can result in severe impairment or death) throughout the facility for all residents at a widespread status, residing at the facility including cohorting and surveillance for nine of 21 sampled residents (9, 22, 11, 15, 17, 16, 20, 26 & 25) reviewed for infection control prevention and control. This failure placed all residents and staff at risk for exposure to COVID-19, related to serious medical complications, and diminished quality of life and death. This failure caused harm to all residents at a widespread status in the facility when the facility did not act promptly to the local health jurisdiction's (LHJ) directives, monitor potential and active infections, test and report residents and staffing according to LHJ directives, cohort and isolate residents exposed to or were positive with COVID-19, provide fit testing for N-95 masks, educate staff on COVID-19, initiate and follow transmission-based precautions (TBP), and perform frequent cleaning and disinfecting of the facility. An Immediate Jeopardy was called on [DATE] at 11:40 PM when the facility did not implement the LHJ's directive to prevent further spread of COVID-19, did not cohort residents in a manner to prevent spread of COVID-19, did not ensure housekeeping services were increased, did not manage testing stations and ensure staff were trained on how to self-test for COVID-19, did not ensure the staff working in the dementia unit (A3) had a station to screen and test prior to shift outside of the COVID unit, did not designate staff to the COVID unit, did not change PPE between resident care, and did not provide fit-testing for N-95 respirators. The facility removed the immediacy on [DATE] at 4:50 PM by separating COVID-19 negative residents from COVID-19 positive residents, completion of training for all staff on PPE and testing, increased housekeeping hours and staff, designating staff to each unit, managed testing stations for staff with supervision of testing, and education on infection control practices. Findings included . The State Agency received a report from the facility that seven residents were positive for COVID-19 on [DATE]. A facility report, dated [DATE], showed 64 residents and 20 staff tested positive for COVID-19. Facility records and LHJ documentation showed 13 residents died of COVID-19 during this [DATE] outbreak. On [DATE] at 11:22 AM, Collateral Contact (CC) A, RN and LHJ; and CC B, RN and LHJ, said they had many concerns with the facility's response to a COVID-19 outbreak. The facility had not acted on directives given starting on [DATE]. CC A and CC B indicated as a result, a letter was drafted to provide clear directives to the facility. The letter, resent on [DATE] and previously sent to the facility on [DATE], directed the facility to implement the following actions: --Staff should enter and exit a door on their assigned working unit. Staff working in the COVID (Red) unit should only enter and exit through the COVID unit doors. --The facility should set up a managed testing station at the unit entrance to test all facility staff for COVID-19 at the start of each shift. --Positive residents should be separated from negative residents immediately. --Complete a spreadsheet of new cases and status of current positive residents and send to LHJ daily. --Due to the rapid spread of COVID-19, staff should use full personal protective equipment (PPE) for all residents, between each resident encounter and before leaving the resident's room. This includes changing gowns and gloves and wiping face shields with a disinfectant. Set up extra carts of cleaning supplies. --The Director of Nursing Services (or designee) needs to ensure all staff members are competent with donning and doffing of PPE and staff are following infection control guidelines. --No visitors should be allowed in the building aside from essential support persons (ESP), who must be fully immunized or test negative for COVID within the past two days. --Schedule extra cleaning staff to respond to needs for immediate patient room changes (due to positive cases) and more frequent cleaning. --Provide extra sanitizing/cleaning supplies for all isolation rooms. --Post signs on residents' doors to follow isolation guidelines and specific PPE needed to care for the resident. --Please provide all residents, who consent, COVID-19 boosters by [DATE]. --Please review the infection control and response (ICAR) recommendations from the State Agency from [DATE] and [DATE] with specific guidance for the dementia unit. --Please provide the outbreak response plan to the LHJ. <Cohorting> Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, dated [DATE], documented staff will screen residents for signs and symptoms of COVID-19. Residents with known or suspected COVID-19, will be placed in a private room and with a dedicated bathroom. Cohorting (sharing space) will be consistent with State and Local public health authority. Staff will wear gloves, isolation gowns, eye protections, and an N-95 mask when caring for residents with positive COVID-19. Residents will be restricted to their room, with the door closed. Signage is posted related to PPE requirements for staff. 1) Resident 11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 11 was diagnosed COVID-19 positive on [DATE], seven days after her roommate was diagnosed COVID-19 positive, on [DATE]. Resident 11's roommate was not moved to another room. 2) Resident 15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 15 was diagnosed COVID-19 positive on [DATE], seven days after her roommate was diagnosed COVID-19 positive, on [DATE]. Resident 15's roommate was not moved to another room. 3) Resident 17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS, dated [DATE], showed Resident 17 was moderately cognitively impairment and required one-person physical assistance with bed mobility, transfers, eating, dressing, toileting, bathing and personal hygiene. Resident 17 was diagnosed COVID-19 positive on [DATE], eight days after her roommate was diagnosed COVID-19 positive, on [DATE]. Resident 17's roommate was not moved to another room. 4) Resident 16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 16 remained COVID-19 negative after her roommate was diagnosed COVID-19 on [DATE]. Resident 16 was moved out of the room on [DATE]. On [DATE] at 12:30 PM, Staff C, Registered Nurse (RN) and Infection Preventionist (IP), said one resident, who resided on the locked dementia unit (A3), tested COVID-19 positive. Staff C said the facility just identified four more residents in A3 who tested COVID-19 positive. Staff C said Staff B, RN and Director of Nursing Services (DNS), suggested making A3 a red unit (resident's active for COVID-19). Staff C said she was currently in discussions with the LHJ to determine the best way to manage these residents due to behaviors such as wandering. Staff C said the staff were currently limiting exposure and attempting to address co-mingling. Facility records and LHJ documentation showed two residents on A3 tested COVID-19 positive on [DATE]. Facility records and LHJ documentation showed three residents on A3 tested COVID-19 positive on [DATE]. On [DATE] at 4:55 PM, Staff C said she spoke with the LHJ and they agreed the facility could leave the negative COVID-19 residents in rooms with positive residents, only in A3 due to the unique needs of the residents in the dementia unit. Staff C said this decision was directed by the LHJ. At 5:15 PM, A3 staff and their residents were observed for infection control practices. Resident 15 was observed in her wheelchair. Staff M, Enrichment Director and NA, was attempting to encourage Resident 15 to wear a mask, to which she declined. Staff M said Resident 15 often refused and said the resident was COVID-19 negative. Staff M said she did not have concerns with implementation of COVID-19 precautions, but said it was challenging to ensure residents who were COVID-19 positive and COVID-19 negative were separated. Facility records and LHJ documentation showed six residents on A3 tested COVID-19 positive on [DATE], including Resident 11. On [DATE] at 11:22 AM, CC A said she was concerned with the COVID-19 cases in A3. CC A said the LHJ directed the facility to separate the positive and negative residents in all locations. CC A said they recommended separating the dementia unit with a barrier and provided a picture of an example. CC A and CC B said they were both concerned about how the facility responded to the COVID-19 outbreak, and said a letter with the specific directive to immediately separate residents was sent to the facility. CC A said the facility continued to expose negative residents to COVID-19. CC A said the response from the facility and the corporate leadership had been unacceptable. Facility records and LHJ documentation showed one resident on A3 tested COVID-19 positive on [DATE]. On [DATE] at 3:19 PM, Staff B, RN and Director of Nursing Services, said she did speak with the LHJ and they approved the plan to continue to cohort positive and negative residents in A3 because of the increased behaviors of the residents when they attempted to move them. Staff B said now all but three residents have tested COVID-19 positive. Staff B said they knew this was going to happen. On [DATE] at 11:30 AM, CC A and CC B said they consistently directed the facility to separate all positive and negative residents. Facility records and LHJ documentation showed two residents on A3 tested COVID-19 positive, Resident 15 and Resident 17. On [DATE] at 3:54 PM, Staff C said she continued to believe the LHJ told her it was okay to cohort positive and negative residents. Staff C said she was aware of the letter sent from the LHJ regarding separating the resident, but continued to believe there was an exception for the residents in A3. Staff C said Resident 16 remained in a room with a COVID-19 positive roommate and Resident 16 tested negative. On [DATE] at 2:26 PM, Staff B said residents were not moved when roommates tested COVID-19 positive. Staff B said now if a resident tested positive and the roommate was negative, they must be moved. Staff B said she was not in the building during much of the outbreak. Staff B said Staff C told them not to move the residents in A3, and it was okay with the LHJ. Staff B said this was against everything they knew about cohorting. Staff B said she backed off, and did not know there were any letters or guidance from the LHJ. Staff B said she never received any letters or directives. Staff B said she assumed Staff C knew what she was doing due to her experience as an infection preventionist. Staff B said she was not aware exposed residents shared rooms with other residents after exposure. On [DATE] at 1:34 PM, Staff A, Administrator, said she was told by Staff C, the LHJ told them they could leave the negative residents in A3. Staff A said it was the facility's job to keep everyone safe, but by then, it was too late. 5) Resident 20 was admitted to the facility on [DATE]. The MDS, dated [DATE], documented Resident 20 had no cognitive impairment and required extensive assistance with mobility, dressing, and toileting. 6) Resident 26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 7) Resident 25 was admitted to the facility on [DATE]. The MDS, dated [DATE], documented Resident 25 had no cognitive impairment and required extensive assistance with ADLs. On [DATE] at 2:45 PM, Resident 20 said he had initially been in a single room prior to the outbreak. Resident 20 was eventually moved to another shared room, which he was not happy about because he did not want COVID-19. The resident said he was unsure about the roommate's exposure status. One day, he went to an appointment, and he got back to his room, noting his roommate was gone. Sometime after being in his room, he was informed his roommate was COVID-19 positive. Resident 20 said he was upset he was not immediately informed. Resident 20 said the roommate's side was not cleaned until many hours later, which was also upsetting. Review of the Detailed Census Report showed Resident 26 was a roommate with Resident 25, who was COVID-19 positive on [DATE]. The facility moved Resident 26 and Resident 20 into the same room on [DATE]. No documentation was noted in Resident 20's chart regarding notification of Resident 26's exposure to COVID-19. On [DATE], Resident 26 tested COVID-19 positive. The facility did not provide documentation of daily COVID-19 testing on [DATE] and [DATE]. On [DATE] at 2:26 PM, Staff B said she was unaware exposed residents were placed with non-exposed residents. Staff B said she would have directed staff not to do this, had she known. <Surveillance> 1) Resident 9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS), an assessment tool, dated [DATE], showed Resident 9 was not cognitively impaired and required extensive assistance ADLs. The care plan, dated [DATE], documented Resident 9 was diagnosed with COVID-19 and required fluid therapy and monitoring for changes in condition. Progress notes, dated [DATE], documented Resident 9 complained of loss of taste. The note documented COVID test negative and provider notified. The resident was placed on Alert Charting (staff charting on a specific change in a resident's condition) but further monitoring did not address symptoms or indicate if the resident was placed on precautions. The note did not indicate when the resident tested for COVID-19. Provider notes, dated [DATE], documented Resident 9 reported loss of taste. The provider noted the resident had a negative COVID-19 test, but did not indicate when the test was obtained or what test method was used. Progress notes, dated [DATE], documented the resident displayed signs of low oxygen and was sent to the emergency room . While at the emergency room , Resident 9 tested COVID-19 positive. 2) Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS, dated [DATE], documented Resident 22 was not cognitively impaired and required extensive assistance with ADLs. The care plan, dated [DATE], documented Resident 22 was diagnosed with COVID-19 and required fluid therapy and monitoring for changes in condition. Progress notes, dated [DATE], documented Resident 22 complained of thick phlegm and a productive cough. The resident's right lung sounds were diminished. The provider was notified. Provider notes, dated [DATE], documented Resident 22 had a cough and breathing slightly labored. The resident was on 3 liters of oxygen. A [CONDITION(S)] PCR (test used to detect a virus) and lab tests were ordered. Progress notes, dated [DATE], documented Resident 22 was lethargic, had a productive cough with yellow sputum, and lung sounds abnormal. A rapid COVID-19 test was completed and was negative. The note did not indicate if the resident was placed on precautions. The LTC Respiratory Surveillance Line List did not include monitoring of residents or staff for respiratory illnesses in [DATE]. Provider notes, dated [DATE], documented Resident 22 was retested and found COVID-19 positive. On [DATE] at 2:26 PM, Staff B said if a resident had signs or symptoms of COVID-19, they would perform a rapid test on the resident. If it was negative, the medical provider would look at other possible reasons for symptoms. When asked if the resident would be placed on precautions or retested /monitored for COVID-19, Staff B said, if it was today, we would ask to retest and put residents in isolation. Staff B said she did not think this was happening before. Staff B said there was not a good system for reporting internally if there was a resident who they were monitoring for COVID-19 symptoms. Staff B said there was now heightened awareness. Staff B said they did not ensure residents and staff were consistently tested daily. Around [DATE], the facility ensured this was done daily. Staff B said a line listing and tracking of residents and staff with positive COVID-19 signs and symptoms, or any infectious disease was not completed routinely. On [DATE] at 1:34 PM, Staff A said she was unaware of residents with signs and symptoms prior to [DATE]. <Testing Stations> On [DATE] at 3:38 PM, a visitor was observed wandering near the desk in the common area of the building saying out loud I don't think I am supposed to be in here. Staff P, Dietary Aide, was observed sitting on a chair by the COVID testing supplies. At 3:39 PM, Staff B was notified of the visitor in the building. Staff B said Staff O, Business Office Manager, was supposed to be managing the testing station. At 3:44 PM, Staff P said he let the visitor into the building, had performed the COVID test himself, and was not informed prior he could not let visitors into the building. Staff B said staff were educated on performing the COVID test on themselves, but did not have documentation to validate this training had occurred. Staff B said they try to man the testing stations, but do not have someone constantly present. Staff B said she would go and check the test results, as staff leave them at the testing stations. Staff B said they did not have time to check them immediately, saying she checks the tests after the fact. On [DATE] at 3:55 PM, Staff M said not all staff were educated on performing the [MEDICATION(S)] test on themselves. They do not have a testing station in A3. Staff M said there was not a testing station in A3 for staff coming on shift to screen in on the red unit. At 4:30 PM, Staff R, NA, indicated he works at the screening and testing station in the Red Unit. Staff R said staff from A3 should test and screen in on A3, and said he believed they have their own testing station. <Isolation and PPE Use> On [DATE] at 10:38 AM, an unidentified staff member was observed in room [ROOM NUMBER] with an N-95 mask on and goggles placed on her forehead. At 10:41 AM, an unidentified licensed nurse was observed at the cart outside of the COVID unit wearing an N-95 mask and eyeglasses with a face shield lifted and placed on the forehead. At 11:15 AM, Staff N, Housekeeping Supervisor, said she has had times when gowns were low and stated, One day last week I needed a gown, and I couldn't find any. I recently found some cloth gowns that could be used for housekeeping staff. I didn't know we had them. I am new, and I don't always know where everything is. At 11:36 AM, a cart outside room [ROOM NUMBER] was observed without any gowns. At 11:45 AM, Staff YY, RN, said they have enough PPE. It is usually in the cart. Sometimes it is in central supply, or we look in the closet. Staff YY said she has always had gowns, but sometimes none on the unit and central supply will bring it to them. On [DATE] at 4:10 PM, Staff YY, NA, was observed with goggles which did not provide full protection for his eyes. Staff YY said he had not been educated on the need to fully cover/protect his eyes or offered different eye protection. Multiple disposable gowns were observed hanging on doors in rooms on B hall. Staff YY said he was not sure why the gowns were hanging on the doors but thought the staff who were working earlier were reusing gowns. Staff YY said he did not have any concerns with negative and exposed or positive residents sharing a room. At 4:35 PM Staff C said gowns should be disposed after use. Staff C said staff should wear googles that provide full eye protection. Staff C said the LHJ directed all staff to be tested each shift. They started this process this morning. Staff C said Staff D, Regional Corporate Director of Operations, filled out the request for emergency staffing. On [DATE] at 3:35 PM, the dementia unit/COVID unit was observed with multiple droplet precaution signs, indicating the doors should remain closed. The doors were observed to be open. A resident was observed walking the hallway without wearing a mask. A resident was observed in a wheelchair propelling in the hallway and entering the dining room. A resident without a mask was observed coming out of room [ROOM NUMBER] without wearing a mask. At 3:48 PM, Staff S, NA, was observed on the dementia/COVID unit exiting room [ROOM NUMBER] and entering the dining room without changing PPE. Staff S then walked down the hall to room [ROOM NUMBER] and entered wearing the same PPE she was wearing in room [ROOM NUMBER] and the dining room. Staff S then walked back down the hall and reentered the dining room. At 4:06 PM, Staff S was observed leaving room [ROOM NUMBER] without removing PPE; and entered the contact cart in the hall, removed a gown and gloves in the hall and placed them in a bag. Staff S then put new PPE on and entered room [ROOM NUMBER]; and then left room [ROOM NUMBER] and entered room [ROOM NUMBER] without changing PPE. At 4:25 PM, the COVID unit (A2) was observed without droplet precautions signs on the resident doors, and all the doors were open. A1 unit was observed to have nine rooms with contact precautions signs on the resident doors indicating doors should remain closed, and seven doors were open. The staff break room, located at the end of the A1 hall near the exit door, was observed with various forms of food and drink containers, clothing, and supplies located on the table including a COVID testing supply box. The tabletop was not visible due to these items and this breakroom was used for COVID testing. On [DATE] at 3:00 PM, facility staff were observed using isolation gowns that could not be put on without cross-contamination of their faceshield and mask. At 3:55 PM, on the Dementia/COVID unit, room [ROOM NUMBER] and room [ROOM NUMBER] were observed with a droplet precaution sign on the door indicating the door should remain closed. A male resident was observed coming from room [ROOM NUMBER] and entering room [ROOM NUMBER]. Staff quickly redirected the resident. On [DATE] at 2:00 PM, facility staff were observed using isolation gowns that could not be put on without cross-contamination of faceshield and mask. On [DATE] at 2:44 PM, Staff B said they removed the isolation gowns that were difficult to prevent cross-contamination. <Resident and Staff Testing> On [DATE] at 11:22 AM, CC A said she had directed the facility to test staff and negative residents daily when notified of the outbreak on [DATE]. Due to the concerns with implementation of testing and reporting results and the total number of cases reported to the LHJ, a letter was sent to the facility with directives related to outbreak management. Staff C was the only individual to respond to the directive. On [DATE] at 3:44 PM, Staff B said all positive COVID-19 test results should be in the medical record. A PCR test should be performed immediately after a positive [MEDICATION(S)] (rapid) test and should be reported to the State Agency, the LHJ, and mandated disease reporting agency. Staff B said this was not done consistently. Staff B said they did not ensure residents and staff were consistently tested daily. Around [DATE], the facility ensured this was done daily. Staff B said a line listing and tracking of residents and staff with positive COVID-19 signs and symptoms, or any infectious disease had not been completed routinely. On [DATE] at 1:34 PM, Staff A said prior to the outbreak, they tested staff twice the week of Thanksgiving and would provide documentation. The documentation provided did not show evidence of testing twice the week for [DATE] through [DATE]. <Staff Screening> A review of the Daily Staffing Schedules showed the following: 1) Staff T, Medical Assistant, tested positive for COVID-19 on [DATE]. Staffing assignments showed while positive with COVID-19, Staff T worked in the Red unit on [DATE], [DATE], and [DATE]. Staff T worked on A3 on [DATE]. On [DATE], Staff T's symptoms screening listed symptoms as tired. On [DATE] at 1:54 PM, Staff T, Medical Technician, said she did work in the building after testing positive. Staff T said she did have a headache, congestion and temperature. Staff T said she did not think she worked with any residents who were negative for COVID-19 but did work in A3 at some point. Staff T said she did think it was confusing why she was asked to work. She said at first she was told not to work and then asked to work. Staff T said it was very confusing. 2) Staff V, Medical Assistant, tested positive for COVID-19 on [DATE]. Staffing assignments showed while positive with COVID-19, Staff V worked in the Red unit on [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE], Staff V's symptom screening listed symptoms as cold. On [DATE] at 2:26 PM, Staff B said staff who were positive for COVID-19 were allowed to work Red unit with confirmed positive residents. Staff B thought this was acceptable practice and was a CDC thing. Staff B said she did not know if the LHJ was notified of this practice. On [DATE] at 1:34 PM, Staff A said she was aware staff who were positive for COVID-19 worked on the Red unit. Staff A said staff should not have signs or symptoms if working. Staff A said Staff C made this decision. Staff A said corporate leadership was aware positive staff were working. Staff A said she could not say if family or residents were made aware of this decision. Staff A said with the positive staff working, they did have enough staff. Staff A said if they did not have so many people calling in, they also would have enough staff. Staff A said she was not aware of the guidance related to positive staff working and did not know if this was discussed with the LHJ or State Agency. Staff A said they did not have a policy related to staff working while COVID-19 positive. <Housekeeping and Disinfection> On [DATE] at 3:19 PM, Staff B said as residents became positive for COVID-19, they could not clean the residents' rooms quickly enough due to limited housekeeping staff. This delayed the transfer of positive residents to the Red Unit. At 3:55 PM, Staff M said they had not had housekeeping in a while to clean A3, and housekeeping were not coming routinely. On [DATE] at 11:30 AM, CC A and CC B said they directed the facility to increase housekeeping staff. They would expect increased need in housekeeping from the norm. At 2:30 PM, PPE carts were observed throughout the facility. No disinfecting wipes were readily available to the staff. At 3:19 PM, Staff C said there was a formulary change and they did not have smaller disinfectant wipes anymore. Staff C said staff would have to either ask for help, if they needed disinfectant wipes or when doffing their PPE, leave the resident's room, get the disinfectant, return to the resident's room, and don PPE. At 3:55 PM, Staff M said not all staff were educated on how to perform the [MEDICATION(S)] test on themselves. They did not have a testing station in A3. Housekeeping has not been cleaning A3 and it has been a while since they cleaned A3. Staff M said if she did not stay and help, they would only have one NA assigned to care for the residents in A3. Staff Q, LPN and Resident Care Manager (RCM), said there were no testing stations on A3 and staff would screen in on the red unit. On [DATE] at 1:33 PM, Staff A said they had staff come over the weekend to do deep cleaning, but did not have increased staff assigned daily for housekeeping. Staff A said she expected every room to be cleaned daily and high touch areas cleaned hourly. Staff B said COVID-19 test results were not in the medical record, but would be going forward. Staff B said designated staff should work in the COVID-19 area. On [DATE] at 2:45 PM, Resident 20 said he had initially been in a single room prior to the outbreak. Resident 20 was eventually moved to another shared room, which he was not happy about because he did not want COVID-19. One day, he went to an appointment, and when he got back to his room, his roommate was gone. Sometime after being in his room, he was informed his roommate was COVID-19 positive. Resident 20 was upset he was not immediately informed. The resident said the roommate's side was not cleaned until many hours later, which was also upsetting. At 3:30 PM, Staff N, Housekeeping Manager, said they did not have enough staff to be able to clean resident and shared areas at an increased frequency. The facility had a crew come in and do a deep clean, but did not increase the number of staff to work on a day-to-day basis. <Fit Testing> On [DATE] at 9:48 AM, Staff R, NA said he had been wearing the original mask he was fit tested with for a while back. On [DATE] at 2:45 PM, Staff C said they are working on getting fit testing up-to-date. On [DATE] at 1:02 PM, Staff X, NA, said she had been fit tested for an N-95, but not for the one she was currently wearing. Staff X said it was hard for her to breathe with the fit tested mask, so she was given the one she is currently wearing. Staff X said she preferred the one she was wearing, but she had not been fit tested for it. At 1:34 PM, Staff R, NA, said he was fit tested for an N-95, but he was currently wearing a different mask. Staff R said he was not comfortable with the previous mask and preferred the one he was wearing, but he was not fit tested for it. Staff R said he did not realize he had to be fit tested to wear the N-95. When asked if he had the opportunity to fit test for the mask he preferred, Staff R said no, everyone was busy right then, so I just went back to using the other one. At 2:00 PM, When asked about Staff X and Staff R not being fit tested for the N-95 they were currently using, Staff B said she would see they got fit tested for the current mask. <Training> On [DATE] at 1:34 PM, Staff A said she was sure there had been training on COVID-19 in the past. Staff A indicated she was not sure when, but would check. Documents provided did not include staff training on COVID-19. On [DATE] at 4:30 PM, Staff L, Licensed Practical Nurse (LPN) and Resident Care Manager, and Staff XX, NA, asked the State Agency staff about procedures to don and doff PPE between rooms and wearing PPE in the hallway. Staff XX said everyone on the unit was positive [TRUNCATED]

Based on interview and record review, the facility failed to ensure repositioning was implemented and provided consistently to promote healing and prevent infection of pressure ulcers for one of three sampled residents (#1) reviewed for pressure ulcers. This failure placed residents at risk for worsening pressure ulcers, infection and a decline in quality of care. This caused harm to Resident #1 when she was hospitalized with an infected pressure ulcer. Findings included . An undated facility policy, entitled, Pressure Ulcer Prevention/Treatment, documented recommends the following . frequent turning. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set, an assessment tool, dated 02/02/2020, documented the resident was moderately cognitively impaired and required extensive two person assistance with bed mobility, was at risk for pressure ulcers and had a Stage 3 pressure ulcer (full thickness loss of skin related to pressure against skin). The resident's care plan, dated 12/11/2018, had a documented goal of, Pressure ulcer will show signs of healing and remain free from infection by/through review date with interventions including, Follow facility policies/protocols for the prevention/treatment of [REDACTED]. administer treatments as ordered. Skin Grid Weekly Skin Evaluation form, dated 01/04/2020, documented an in-house acquired Stage 3 pressure ulcer to the coccyx (tailbone) with measurements of 1 cm (centimeter) length by 1 cm width by 0.1 cm depth. The comments section documented, Recurring pressure area on coccyx. Already in (rounding wound specialist team) system. Will send new request for wound care. Skin Grid Weekly Skin Evaluation form, dated 01/07/2020 and 01/14/2020, showed the coccyx in-house acquired Stage 3 pressure ulcer increased to measurement 3 cm length by 1 cm width by 0.3 cm depth (taken on 01/14/2020). Skin Grid Weekly Skin Evaluation form, dated 01/21/2020, documented an in-house acquired Stage 3 pressure ulcer to the coccyx measured 4 cm length by 2 cm width by 0.4 cm depth. The comments section documented, wound has increased in size. Encourage reposition when in bed. Wound assessment, by the rounding wound specialist team, dated 01/21/2020 and 01/28/2020, documented a Stage 3 pressure injury to Resident #1's coccyx measured 4 cm length by 2 cm width by 0.4 cm depth (0.3 cm depth on 01/28/2020) with orders including to encourage repositioning every 2-3 hours . reposition patient when up in wheelchair every 2-3 hours for pressure relief. Skin/wound progress note, dated 01/28/2020, documented, .staff must anticipate needs. Physician/Provider progress note, dated 01/28/2020, documented, Pressure ulcer/Coccygeal (tailbone) area . nursing to turn patient from right to left sides only, every 2 hours; avoiding back. Wound assessment, dated 02/04/2020, documented Resident #1's coccyx Stage 3 pressure injury measured 3 cm length by 2 cm width by 0.6 cm depth with orders including to, encourage repositioning every 2-3 hours . reposition patient when up in wheelchair every 2-3 hours for pressure relief. Skin/wound progress note, dated 02/04/2020, documented, Continue with daily dressing changes, repositioning and off-loading area . dependent on staff for all needs. Wound assessment, dated 02/11/2020, documented Resident #1's Stage 3 coccyx pressure injury measured 3.5 cm length by 1.5 cm width by 2 cm depth with orders including to, encourage repositioning every 2-3 hours . reposition patient when up in wheelchair every 2-3 hours for pressure relief . encourage offloading of heels and bony prominences. Skin Grid Weekly Skin Evaluation form, dated 02/11/2020, documented in the comment section, Wound is continued high risk, wound appears to have [MEDICATION NAME] (a previously ordered treatment) in wound which is not the order. Staff is reminded of order. Wound may be a Stage 4 - given slough (non-viable tissue). Wound assessment, dated 02/18/2020, documented progression to a Stage 4 pressure injury to Resident #1's coccyx with measurements of 4.5 cm length by 2 cm width by 2.6 cm depth with exposure of bone. Recommendations included, Patient should be sent back to the Emergency Department for surgical evaluation/debridement (removal of dead/dying tissue and foreign matter from a wound to improve or facilitate the healing process). She was febrile (had a fever) last night and seen in Emergency Department with [DIAGNOSES REDACTED]. Skin Grid Weekly Skin Evaluation form, dated 02/18/2020, documented the in house acquired Stage 4 pressure ulcer to the coccyx had a foul odor and black eschar (dead/dying tissue). The comments section documented, Resident present with coccyx wound, this area has opened up multiple times and closed within a few weeks care. This time wound opened up on 01/04/20. Wound is getting larger each week. Foul odor from wound with 100% slough (non-viable tissue). Recommends resident be transferred to hospital for surgical debridement and assessment of wound. Physician/Provider progress note, dated 02/18/2020, documented, I was notified by a member of the wound care team, (Staff C, Licensed Practical Nurse/Wound nurse), that the wound care nurse was concerned about the patient's coccygeal pressure ulcer and felt the patient should be transferred to Emergency Department for surgical debridement. The wound care nurse was specifically concerned about the odor and sloughing from the wound. Restorative Evaluation, dated 02/19/2020, documented, Resident is at risk for skin breakdown related to being wheelchair bound and bed bound and being dependent with turning and reposition. She has a pressure ulcer to coccyx. She would benefit from bed mobility turning and repositioning program to assist her in resolving her pressure ulcer and prevent new ones. NAC (Nursing Assistant) program: bed mobility turn and reposition using 2 assist every 2-3 hours . The restorative care plan, updated 02/19/2020, documented interventions including Bed mobility turn and reposition using 2 assist every 2-3 hours . Task sheet for bed mobility (including turning and repositioning) for Resident #1, dated 01/27/2020 to 02/24/2020, documented bed mobility was provided 53 of 86 shifts. Alert charting progress note, dated 02/23/2020, documented, Dressing to coccyx changed this shift. Cleansed and packed with new gauze. Is all black inside with foul odor. Physician/Provider progress note, dated 02/24/2020, documented, Presenting problem - probably osteo[DIAGNOSES REDACTED] (infection to muscle and bone) . pressure ulcer/coccygeal area, transfer to (hospital) for surgical debridement. (Sedimentation) rate 101 (a high sedimentation rate can indicate inflammation in the body). Review of medical record did not show documentation by Physician/Provider or Wound Specialist that Resident #1's worsening pressure ulcer was unavoidable. On 02/24/2020 at 4:50 PM, Collateral Contact (CC) 1 said Resident #1 had been on isolation precautions for [DIAGNOSES REDACTED] ([DIAGNOSES REDACTED]) and staff had been leaving her in her room for two weeks. When describing Resident #1's wound observed on 02/18/2020, CC 1 stated, The smell that came from (the wound) was just awful. I don't know how long she'd been in that dressing. She was in urine and feces. Hospital Physician Note, dated 02/24/2020 at 8:02 PM, documented, overlying the sacrum (portion of lower spine that includes the tailbone) there is a large deep necrotic hole with bone visible and malodorous. Packing was removed, the wound is very malodorous (odorous). A scant (very little) amount of gauze packing was removed. No active bleeding. Alert charting progress note, dated 02/25/2020, documented, Resident was sent to the ER and will be admitted . On 02/25/2020 at 9:43 AM, when asked if residents needing to be turned were provided assistance with bed mobility and incontinent care in a timely manner, Anonymous Staff 1 stated, Not necessarily. It depends on staffing. Anonymous Staff 1 said she had worked with Resident #1. When asked about Resident #1 being turned every two hours, Anonymous Staff 1 said Resident #1 did not get turned every two hours because the facility was short staffed. Anonymous Staff 1 said she knew Resident #1 needed to be repositioned all the time, and it was difficult to get it done because she required two nursing assistants. At 9:50 AM, when asked about turning residents who needed assistance with bed mobility and incontinent care in a timely manner, Anonymous Staff 2 said, Yes and no. We are still short staffed. Anonymous Staff 2 said she had worked with Resident #1. When asked about turning Resident #1 every two hours, Anonymous Staff 2 said she was not always able to. Anonymous Staff 2 said she noticed when she came in the mornings that the resident had not been turned and had been incontinent. Anonymous Staff 2 said sometimes night staff would ask for help because they could not reposition or change Resident #1 during the night. Anonymous Staff 2 said Resident #1 was a two-person assist at all times and took a lot of assistance to reposition. It was difficult to provide incontinent care with one person for the resident. When asked if incontinent care and turning had been provided with one person, Anonymous Staff 2 stated, Yes, sometimes and it's very difficult. Hospital wound nurse notes, dated 02/25/2020 at 9:53 AM, documented, Old dressing removed, significant odor is noted, cleansed wound . wound bed is mostly drier necrotic tissue. Wound measures 5 cm x 4 cm x 3 cm deep. Bone is present and palpable to base . At 9:55 AM, when asked about Resident #1's pressure ulcer, Staff C, Licensed Practical Nurse and Wound Care Nurse, said the resident had a previous open area on her coccyx that would open up periodically and close up with treatment. Staff C said Resident #1 was placed on precautions for [DIAGNOSES REDACTED] and was in a single room. To me that is when it (the pressure ulcer) started. Before that she would be assisted out of bed for each meal and would then lay down after two hours. When asked about the resident being on a turn schedule, Staff C stated, (Resident #1) is one of the people we need to be turning . Usually under the direction of the nurses, the aides are good at turning; but we are short staffed. When asked if not turning the resident every two hours could have contributed to Resident #1's pressure ulcer worsening, Staff C said, Yes, and I think when she was on precautions. I really don't feel like she got the attention she needed. At 11:47 AM, when asked about her expectations for turning residents requiring assistance with bed mobility, Staff B, Registered Nurse and Director of Nursing Services, stated, That (staff) turn the resident every two to three hours. Staff B said if a resident required two-person assistance for bed mobility, staff should not assist the resident alone. Staff B said Resident #1 required two-person assistance with bed mobility. When asked if she was aware Resident #1 was in the hospital for debridement of her pressure ulcer, Staff B said, Yes. When asked if not turning Resident #1 could have led to the pressure ulcer worsening, Staff B stated, If she wasn't turned, it could have. Staff B stated, Turning a resident every two hours is something they need to be doing. It's a standard of care . We do have staffing issues. When asked where Nursing Assistance (NAs) documented they were turning residents, Staff B said NAs check off care was provided for the shift and it was documented in the (Electronic Health Record), and the information generated on the task sheet. Hospital physician note, dated 02/26/2020 at 9:50 AM, documented, .an extensive, infected sacral ulcer . subacute decline is likely related to infection of her sacral ulcer . initially started on antibiotics but will change to comfort focused care. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to provide a safe, sanitary and well maintained environment for residents, staff and visitors when they failed to act on reports of a black substance on the wallpaper and dry wall in the main dining area. This failure placed residents, staff and visitors at risk of exposure to an unknown black substance that could result in respiratory problems. This failure had the potential for serious harm to residents, staff and visitors when the facility did not determine if the black substance was a serious problem when it was first observed. On 01/09/20 at 4:15 PM, an Immediate Jeopardy (IJ) was called for F921 environment. The immediacy of the IJ was lifted on 01/21/19 at 9:15 AM when the facility provided documentation to show they had identified the substance in question and were working to correct the situation. Findings included . On 01/09/20 at 10:22 AM, Collateral Contact (CC) A asked if the survey survey team had heard anything about a mold situation in the building. CC A said he had just been given a tour of the building by a staff person. CC A said in the main dining area there was a large portion of a wallpaper area that was taped with packing tape. CC A said the staff member told him there was mold behind the tape and the wallpaper, and lifted the tape to show CC A there was a black substance on the wall. At 10:25 AM, the main dining room was observed. Just inside the main door to the main dining area to the right was a large section of wallpaper, approximately 2 foot by 2 foot, taped with packing tape over the seams of the wallpaper. The tape was peeling up as were the seams of the wallpaper. A brown/black color could be seen under the tape and in the creases of the wall paper. To the left of the main entrance to dining area, approximately 15 feet down the wall near a sink area, the wallpaper had been stapled at the seams. The edges were peeling back and a brown/black color could be seen. The same wall had multiple bubbled areas in the wall paper. Across the room, between the window area and where the piano was, there was area of wallpaper, approximately 2 inches by 2 inches, behind a chair that was peeling away from the wall. The wallpaper and the drywall had a brown/black color on them. At 10:31 AM, Staff L, Transportation Assistant, said a resident had told him he had seen the maintenance person taping up wallpaper in the dining room. Staff L said he had looked behind the area that had been taped and the area on the wall and the paper appeared black and looked like mold. Staff L said a kitchen person had also seen it and had taken a sample of it to her doctor and had it tested under her name. Staff L said the kitchen person had told Staff L it had been positive for mold, and the kitchen person had reported that to the administrator. Staff L was unsure what happened from there. At 10:40 AM, Staff G, Dietary Manager, stated, There's mold in the dining room. A resident reported wallpaper had ripped away from the wall in the dining room about a month ago. I noticed the whole wall was covered in black. I alerted my supervisor and the administrator. Staff G said she had taken a sample from the dining room to her doctor's office and had it tested under her name. Staff G said it had come back positive for mold. Staff G said she had told the administrator about the results. At 10:41 AM, Staff H, Healthcare Services Group District Manager, stated, I emailed (the corporation) on 11/12/19. The administrator told me maintenance had bleached the affected area on 11/15/19, and then they just taped the split wallpaper up in the dining room. Staff H stated, I asked the administrator if the mold had been tested , and he and his boss said no. At 11:00 AM, Staff O, Maintenance Director, said he had started working at the facility in (MONTH) 2019. When asked why the wallpaper in the dining area had been taped, Staff O stated, It was peeling off and the administrator said it was not a priority due to us working on life safety stuff first, so I taped it until I could back to it. I taped it in (MONTH) 2019. When asked if the wallpaper or wall had ever been tested for anything, Staff O stated, No, not while I have been here. Staff O stated, Our regional person would know more about what happened before I came here. At 11:07 AM, when asked if the walls and wallpaper in the dining room had been tested for anything since the facility had water issues, Staff P, Regional Environmental Specialist, stated, Not as far as I know. Our CEO (Cheif Executive Officer) did call Servpro after the flood and had them bring in big blowers to dry things out. Any testing that was done, the results were emailed or faxed to (Staff Q, Regional Administrator). At 11:10 AM, when asked if staff had reported there being mold in the building, particularly in the dining area, Staff A, Administrator, stated, I heard a staff member took a sample of something to her doctor, but he's a doctor, not a mold professional or anything. When asked what he thought the black substance on the wallpaper and wall could be mold, and if it had been tested , Staff A stated, No, no, nothing like that. No, I have not had it tested . The black is residue from the wallpaper and paste. That's all. It's an old building. At 4:30 PM, a Mold Remediation Plan and Job Hazard Analysis, dated 10/03/19, from an environmental service company, was provided to the survey team. The report documented the following: Scope of work to include: 1) The affected flooring in the main level; 2) The affected semi-porous joints and sub-flooring in the crawlspace; 3) Building components associated with the listed materials; and 4) Any other material with visible biological growth. The analysis documented, NOTE: No mold remediation activity is warranted until and unless the moisture problem is fixed. Multiple active leaks in the crawlspace. Discharge pipes are leaking which changes all wet materials to a black water protocol. Elevated moisture was found during mold inspection in the following areas and materials; Crawlspace, wood framing, bottom of subfloor, and insulation. At the time of inspection there was no suspect mold growth witnessed in the front lobby or dining hall area. The survey team was also provided a Servpro Disaster Recovery Authorization and Service contract, signed by Staff A on 09/21/19. On 01/10/20 at 1:45 PM, an environmental service company representative entered the facility to perform air quality tests in the main dining room and take samples of wallpaper/drywall. The representative placed two Bio pumps on either side of the room, explaining they would run for ten minutes to collect air samples. The representative peeled back the wallpaper just inside the doorway to the right and took samples. The representative then went to the wall between the window and where the piano was placed (an outside wall) and peeled back a large section of wallpaper, approximately 2 foot by 2 foot. The dry wall was observed to be covered in a brown/black substance. The representative stated, Oh, that's not good, and continued the inspection. The representative had tools which she used to test and record moisture around the lower 4 feet of the walls around the dining room. The representative had an infrared tool she used all around the walls to determine areas that had moisture, took pictures, measurements and recorded findings. The representative stated, The air quality and the quality of the drywall are two separate issues. You can have good air quality and still have mold on drywall. And you can have bad air quality and no mold on the dry wall. Mold needs nutrients and moisture, and water is that nutrient. As long as there is moisture any mold present will continue to grow. The kind of mold determines if it is fast or slow growing and if it is harmful. The representative said she would drive these samples to where their office is located today when she was done collecting them, and a preliminary result could be available later in the day. Record review of all residents' medical charts, currently in the building, showed one resident, Resident #67, had a documented allergy to mold. On 01/21/20 at 8:35 AM, Staff A, Administrator stated, We got a preliminary report on Friday night, 01/10/20, and we called an abatement team. On Saturday, 01/11/20, the abatement team arrived and began working on the dining area. They have been here the 13th, 14th, 15th, 16th, 17th and 20th and they are here today. The first day they scrubbed and such, then they began taking down the drywall. We have let no one enter. They have it taped up as a negative air flow room and have been entering with special masks on as they work. Today they are supposed to get a final air sample done and start putting the drywall back up. Staff A said he did not have any copies of any reports, those had all been e-mailed to the Corporate Staff and CEO. At 8:45 AM, two surveyors accompanied Staff A and Staff O to the back of the building to the fire door entrance to the dining area. The abatement team had advised they could unzip the plastic door and look in. Staff O unzipped the door and the surveyors looked into the dining room without crossing the threshold. The room had been stripped of drywall down to the studs. There were several industrial blowers on. There was no furniture in the room. At 8:50 AM, Collateral Contact C, Asbestos Supervisor of a local abatement service company, stated, We are on hold while we wait for the person from (the environmental service company) to come and test the air quality. She is coming sometime today. Once she gives the go ahead, we will begin to put up the new drywall. She should have everything she needs with her to test on site and give us that answer. At 9:15 AM, after contacting the CEO, Staff A provided the initial mold report, dated 01/10/20. The initial report, dated 01/10/20, from the environmental service company, who conducted the Mold Certificate of Analysis, documented four types of mold were present on the dry wall tested . Two tape lift samples were collected of the affected components and revealed that Cladosporium, Penicillium/Aspergillus Group, Stachybotrys, and Chaetomium species were present on the dining room walls. Moisture readings were between 20% and 38% present at the base of the walls on the floor and 99% at the sink. Walls alone were between 19% and 29%. The report noted these molds have the potential to cause allergic reactions and respiratory infections including inflammation of the lungs. Stachybotrys produces several types of mycotoxins that can irritate skin and mucous membranes. One of the mycotoxins is produces is called satratoxin which may be toxic when inhaled in large amounts. At 11:35 AM, Staff A was notified the IJ immediacy had been lifted as of 9:15 AM on 01/21/20. The dining room was observed to be closed off and not being used by residents. The drywall had been removed up to the ceiling. This is an ungoing unresolved situation. Reference WAC 388-97-3220 (1)

Based on observation and interview, the facility failed to ensure residents were free from an avoidable accident hazard for 1 of 3 sampled residents (#11) reviewed for accidents. This failure placed residents at risk of injury, anxiety, and a diminished quality of life. This caused harm to Resident #11 when his bed height often suddenly dropped causing the resident pain and anxiety. Findings included . Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 06/27/19, documented Resident #11 had a moderate cognitive impairment and required extensive two plus person assistance with bed mobility, transfers, and toilet use. Resident #11 used an overhead trapeze for mobility assistance. On 07/03/19 at 2:25 PM, Resident #11 said his bed was currently broken. Resident #11 indicated his bed height randomly dropped causing pain to his upper and lower back. Resident #11 said the facility had a new bed on order for two months. Resident #11 said his bed fell at least once or twice a day, and that was why he was always holding onto the trapeze, and had to wear a back brace 24 hours a day. Resident #11 said Staff L, Maintenance Supervisor, had looked at the bed, but was not able to fix the issue. Resident #11 said Staff A, Administrator, was in his room over three months ago and told him a new bed would be ordered. On 07/08/19 at 2:20 PM, during an interview, Resident #11's bed height suddenly dropped approximately 12 inches. Resident #11 was observed to yell out and wince. Resident #11 was tearful and said he had a 9/10 pain (pain scale-10/10 being the most severe pain) to his middle and lower back. At 2:23 PM, Resident #11 stated, That's why I have to wear this back brace. Resident #11 said his back would hurt the rest of the day. At 2:55 PM, Staff K, Licensed Practical Nurse, said Resident #11's bed would fall back if it was raised too high. Staff K said Resident #11 said it randomly fell , but Staff K had not witnessed it fall randomly. At 4:45 PM, Staff L, Maintenance Supervisor, said Resident #11 did not have a new bed on order. Staff L indicated Resident #11's current bed was fixed. Staff L said he put the bed back on track, and did not see anything wrong. Staff L said, he did not have any training on bed maintenance. Staff L indicated he was not aware if any routine safety inspections were being conducted on durable medical equipment in the facility. At 4:50 PM, Staff A, Administrator, indicated Resident #11 had informed him of his bed malfunctioning. Staff A said he had to go with his maintenance supervisor's assessment. Staff A said a new bed was not ordered. On 7/11/19 at 1:10 PM, Resident #11 indicated the facility replaced his bed late in the evening on 07/08/19. Resident #11 stated, I slept good for the first time since moving here. Resident #11 stated, I can finally relax. I have my back brace undone and can breathe. Reference WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure residents were free from physical abuse for 1 of 3 sampled residents (#1) reviewed for resident to resident altercations. This failure placed residents at risk for physical abuse and a diminished quality of life. This caused harm to Resident #1 when her lower legs were bruised and cut in a resident to resident altercation. Findings included . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS), an assessment tool, dated 2/03/19, documented Resident #1 was severely cognitively impaired and required extensive assistance with bed mobility, dressing, and personal hygiene. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's MDS, dated [DATE], documented Resident #2 was severely cognitively impaired, required one person physical assistance with dressing, and was steady at all times with walking. A psychiatric consultation, dated 06/07/18, documented, (Resident #2) has been having increased behaviors with staff and other residents. The resident's care plan addressed history or potential to demonstrate physical behaviors (related to) dementia, poor impulse control, resident to resident altercation, initiated on 07/05/18 and revised on 10/30/18, with interventions including If other residents wander into resident room, re-direct other resident from her room. Make sure that there is someone in the room to manage (Resident #2's) behaviors when this happens. (Resident #2) will physically hit other residents if they are in her room. Progress note, dated 10/31/18 at 3:48 PM, documented, (Resident #2) with history of altercation. Resident with no recollection of altercation . Progress notes; dated 01/12/19, 01/13/19, and 01/14/19; documented Resident #2 can be demanding of staff and bosses residents around . Progress note, dated 01/16/19 at 4:10 AM, documented, (Resident #2) showing increased behaviors tonight .Very confused at times. Progress note, dated 01/22/19 at 10:26 AM, documented, (Resident #2) with increased behaviors .Resident is difficult to redirect and is becoming verbally aggressive with staff. Interventions vary in effectiveness. Progress note, dated 01/22/19 at 11:01 AM, documented a focus of aggressive behavior. Resident #2 slapped (nurse assistant) on the forearm . Unable to redirect. Social Service note (care conference note), dated 1/23/19 at 11:04 AM, documented Resident #2's increased behaviors were discussed. Resident with increased exit seeking behaviors and physical aggression toward staff when staff provide redirection . Redirection is not effective at times. No nonpharmalogical interventions were documented. Progress note, dated 01/23/19 at 4:36 PM, documented a resident to resident altercation with a former roommate. Resident #2 became upset when (Roommate) had the door closed. (Resident #2) wanted the door open. (Resident #2) then insisted roommate leave. (Roommate) did not go so (Resident #2) pulled on her shirt. Roommate then hit (Resident #2) across her stomach and then (Resident #2) hit (the roommate) back. A facility incident report, dated 02/09/19, documented, Resident #2 was watching it snow out the window. Resident #1 entered Resident 2's room and Resident 2 became angry. Staff C, Nursing Assistant, heard Resident #2's walker repeatedly and aggressively hitting the ground. When Staff C entered the room, Resident #2 was shoving her walker into Resident #1 and yelling get out. A facility skin assessment, dated 02/09/19, documented a 5 cm x 2 cm bruise to Resident #1 right lower leg and a 4 cm x 1.5 cm cut to the left lower leg. Progress note, dated 02/10/19 at 10:42 AM, documented Resident #1 entered Resident #2's room. (Resident #2) became angry and started trying to get (Resident #1 out by ramming her walker into (Resident #1). An aide assisted Resident #1 out of Resident #2's room. Resident #2 was yelling, 'Get her out of here.' On 3/20/19 at 12:35 PM, Staff B, Nursing Assistant, said Resident #2 had a history of [REDACTED]. At 2:20 PM, Staff C said she had been taking care of another resident when she overheard the altercation between Resident #1 and Resident #2. Staff C said when she came into Resident #2's room, she saw Resident #2 shoving her walker into Resident #1's legs, and Resident #1's legs were bleeding. At 3:15 PM, Staff A, Director of Nursing Services, said Resident #2 had recently been given a new room due to aggressive behaviors towards her previous roommate. Reference WAC 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to ensure residents were free from accident hazards when adequate supervision to prevent unwitnessed falls was not provided on a closed dementia unit and a system of resident monitoring to ensure safety was not in place for 2 of 5 sampled residents (#63 & 27) reviewed for accidents. This failure placed residents at risk for falls, injury and a diminished quality of life. This failure caused harm to Resident #63. Findings include . 1) Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 02/03/19, indicated the resident was severely cognitively impaired, required supervision for transferring between surfaces and walking, and had a history of [REDACTED]. Resident #63's fall care plan, updated 06/22/17, documented interventions including to be sure call light is within reach and encourage resident to use it for assistance as needed, .provide a safe environment with .a working and reachable call light, the bed in lowest position at night; and personal items within reach. Resident #63's sleep disturbance care plan, initiated 02/19/18, documented interventions including to leave door open. Resident #63's Kardex (a care directive for Nursing Assistants), undated, documented to be sure call light was within reach and encourage resident to use it for assistance as needed, to provide a safe environment with a working and reachable call light, and to leave door open. An incident report for Resident #63, dated 09/14/18, documented, Unwitnessed fall with laceration to back of head and complaining of right hip pain 10/10 at 0700 . Resident was found lying on her right side with head between her roommate's nightstand and bed . Resident was transferred to (local hospital) via ambulance, [MEDICAL CONDITION] was ruled out, but the resident did receive two staples to the laceration on her scalp. Documentation showed the fall care plan was revised with new interventions to to include prompt to toilet at 5:00 AM and involved in activities that minimize the potential for falls. A progress note, entitled incident note, dated 01/31/19, documented, resident was found on the floor laying on her right side crying out in pain. This LN (licensed nurse) did not move her but called 911. Aids and LN stayed with (Resident #63) until medics arrived. She was given medication and transported to the hospital. A handwritten nurse practitioner progress note, dated 01/31/19, indicated Resident #63 sustained contusions (bruising) to her right forehead, right shoulder, and right knee and had two stitches to a laceration on the resident's right forehead. On 02/21/19 at 9:04 AM, Resident #63 was observed in her bed with the door shut. The resident's call light had a cord approximately six inches in length, hidden behind the resident's privacy curtain and approximately 2 feet from the resident's foot of the bed and at approximately shoulder's height, and outside of the resident's reach. Staff were not present in the hallway. On 02/22/19 at 8:42 AM, Resident #63 was observed in bed with the door closed ¾ of the way. Staff were not present in the hallway. On 02/27/19 at 12:29 PM, when asked if Resident #63 could use a call light, Staff F, Nursing Assistant Registered (NA), stated, No. When asked when Resident #63's door was shut, how Staff F would know if the resident needed assistance, Staff F said they check on her; and if the resident had closed the door, they open it after a while. At 12:39 PM, when asked if Resident #63 was capable of using her call light, Staff G, Licensed Practical Nurse (LPN) and Cart Nurse, said Resident #63 had used the bathroom call light, but he had not seen her use the call light in the room. When asked about the resident's history of falls and the door being closed, Staff G stated, It's kind of a two sided coin. If the door is closed, it is more likely she will stay in bed, but during that time, no one is able to see her move. It would be ideal for her to have the door open, but if it does not allow her to sleep then she gets wore out and tired. At 2:24 PM, when asked about her expectation for a resident with severe cognitive impairment, inability to use a call light, and being in a room behind a closed door; Staff B, Director of Nursing Services (DNS) and Registered Nurse (RN), stated, The resident has the right to fall, but we put interventions in place. Staff know to be checking on the residents regardless of what their risk for falls are. When asked about Resident #63's ability to use her call light, Staff B stated, I don't think she cognitively is able. 2) Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated the resident was severely cognitively impaired, required supervision with walking and had a history of [REDACTED]. Resident #27's activities of daily living care plan, updated 04/24/17, documented interventions including to, Transfer: Independent, sometimes stand-by assist or assist of one due to leg weakness, and dizziness. Resident #27's fall care plan, updated 08/14/18, documented interventions including to be sure call light was within reach, encourage resident to use it for assistance as needed, and updated 11/05/18, to provide a safe environment with a working and reachable call light. An incident report for Resident #27, dated 08/14/18, documented pertinent [DIAGNOSES REDACTED]. An incident report for Resident #27, dated 10/26/18, documented, resident has a PMH (past medical history) of falling . Resident was found lying on her R (right) side with her elbow in back of her holding her head, head was not on the floor . Because of her advanced dementia, she does not remember to wait for assistance. Resident #27's progress note, entitled Alert Charting/Follow Up, dated 02/19/19, documented, when she gets into bed she sometimes stays there and others she will repeatedly get out of bed (with or without proper footwear) and walk to the hallway without using her wheelchair. She has a weak, unsteady, shuffling lurching gait and has a hx (history) of falls. On 02/20/19 at 8:52 AM, Resident #27 was observed lying in a lowered bed, under a blanket, call light out of reach (call light was observed to be a cord approximately six inches in length on the wall at about shoulder's height. The cord was approximately three feet from the resident's head of bed and out of reach of the resident), behind a closed privacy curtain and could not be visualized from the doorway or hall. At 9:35 AM, Resident #27 was observed lying in bed behind a closed privacy curtain and call light out of reach. At 10:49 AM, Resident #27 was observed lying in bed behind a closed privacy curtain and call light out of reach. At 12:20 PM, Resident #27 was observed lying in bed behind a closed door and call light out of reach. At 2:40 PM, Resident #27 was observed lying in bed behind a closed door and call light out of reach. At 2:46 PM, when asked if residents were capable of using the call lights on the dementia unit, Staff R, Program Coordinator Non Nursing and NA, stated, Not necessarily back here (in the dementia unit). When asked how staff would know if the resident needed something if the door was shut, Staff R stated, Normally we would be checking continuously on the resident. When asked how she defined continuously, Staff R stated, I shouldn't have said continuously. We are actively checking on them throughout the day. If they're more independent, we let them have their door shut. When asked about Resident #27, Staff R stated, Resident #27 requires supervision and definitely needs more assistance. On 02/22/19 at 8:40 AM, Resident #27 was observed lying in bed behind a closed door, closed privacy curtain and call light out of reach. At 12:53, Resident #27 was observed lying in bed behind a closed door, closed privacy curtain and call light out of reach. Staff were not present in the hallway. On 02/25/19 at 8:48 AM, Resident #27 was observed lying in bed behind a closed privacy curtain and call light out of reach. At 10:27 AM, Resident #27 was observed lying in bed behind a closed privacy curtain and call light out of reach. On 02/27/19 at 12:39 PM, when asked if Resident #27 was capable of using the call light, Staff G stated, I've never had her use the call light. She could maybe reach it per-se, but I don't know that she would. When asked about the resident's history of falls and the resident being behind a closed door and/or closed privacy curtain, Staff G stated, We do the standard pop in and check on them. When the door is open, she gets up more and transfers herself more when it's open. When the curtain is drawn it's darker and she sleeps better. At 2:24 PM, when asked about her expectation for a resident with severe cognitive impairment, inability to use a call light and being in a room behind a closed door, Staff B stated, The resident has the right to fall, but we put interventions in place. Staff know to be checking on the residents regardless of what their risk for falls are. When asked about Resident #27's call light being within reach when the resident was in bed, Staff B stated, No, it's not in reach. Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure preparations were made for a safe and orderly discharge for 1 of 3 sampled residents (#1) reviewed for discharge requirements. This failure placed residents at risk for an unsafe discharge without community support to meet resident care needs. This caused harm to Resident #1. Findings include . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, a comprehensive assessment tool, dated 12/19/17, documented Resident #1 had difficulty with short-term memory, was severely impaired with daily decision making skills, and required assistance with activities of daily living. A nursing admission assessment, dated 12/12/17 at 11:37 PM, documented, New admit with [MEDICAL CONDITION](stroke) and changes due to that. Nursing note, dated 12/13/17 at 12:42 PM, documented, Resident alert and responsive, but not able to talk, was walking in the hallways this morning by self and was confused, received the order for wander guard (related to) poor safety awareness and exit seeking. The following nursing notes documented Resident #1's difficulties with communication and observations of frustration: On 12/13/17 at 11:00 PM, Is having a very hard time communicating. On 12/14/17 at 9:42 PM, Gets very frustrated being unable to make needs known. On 12/15/17 at 11:03 AM, Resident unable to say any word due to stroke On 12/17/17 at 6:50 PM, Some frustration noted with communication. On 12/18/17 at 3:21 PM, Social Services documented, Not able to hold conversation with this writer. Past interactions with resident have been tense, as SS provided resident with communication binder and explanation on how to use it. Resident ripped pages and threw the book away from him. On 12/21/17 at 5:59 PM, Resident became aggravated when he can't make his words or staff understand him. On 12/22/17 at 1:04 PM, Non verbal communication. Difficult to understand what resident wants. ON 12/24/17 at 1:00 PM, [MEDICAL CONDITION] - difficult to communicate with but able to make needs known with time. On 12/26/17 at 1:00 PM, Difficult to understand and communicate with. Dysphagia. Attempts to communicate fail at times (will not use book given by therapy). He gets frustrated and walks away. On 01/01/18 at 1:15 PM, Dysphagia (sic) continues but progress with words noticeable. Able to make needs known at times. Takes longer to ask questions r/t possible needs at other times. Refuses to use communication book. On 01/03/18 at 4:54 PM, Gets frustrated at times with speech communication, often hard to understand res verbalizations. On 01/05/18 at 10:00 PM, He is gaining some fine motor skills and is also able to speak a sentence now and then. On 01/06/18 at 1:00 PM, Able to make needs known - Staff needs to attempt to understand his requests at times .Word formation/communications improving. On 01/08/18 at 1:00 PM, Frustration with not being able to express himself. On 01/10/18 at 12:04 PM, .gets frustrated sometimes when not able to communicate with staff due to stroke On 12/30/17 at 5:45 PM, a nursing note documented Resident #1 was seen by a family member in town and was brought back to the facility. The LN documented, Resident has dysphagia, but was able to explain that he went out into the smoking area and exited through the gates that lead out into the parking area . A Care Plan, initiated 12/26/17, documented, Impaired cognitive function/dementia or impaired through processes r/t [MEDICAL CONDITION], recurrent TIAs (mini-strokes) with post-stroke [MEDICAL CONDITION] disorder presenting with new neurologic deficits. Understands consistent, simple, direct sentences. The goal was needs will be anticipated by staff 100% of the time, and interventions included administer meds as ordered, anticipate resident's needs, ask yes/no questions in order to determine needs, and be [MEDICATION NAME]. A Care Plan, initiated 12/29/17, documented, At risk for elopement r/t independently mobile wants to go home. The goal was will continue to wander safety in the center and will exit the center with authorized personnel. Interventions included allow for safe wandering; distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, book; and 1 on 1 at smoking door until wanderguard alarm installed. A Care Plan, initiated 12/31/17, documented, Has a behavior problem r/t wandering into potentially unsafe situations. Target Behavior: Wandering with purpose to attain cigarettes and smoke without monitoring. Unaware of personal boundaries and poor safety awareness. A Care Plan, initiated 12/31/17, documented, History per family and/or potential to demonstrate physical behaviors towards staff r/t anger, depression, poor impulse control, frustration due to inability to express wants/needs/frustrations. Interventions included, Analyze key times, places, circumstances, triggers, and what deescalates behavior and document; and assess and anticipate resident's needs: food, thirst, toileting needs. On 1/15/18 at 12:25 PM, the former DNS documented, resident insisting on dc (discharge) from facility against medical advice. I(n) spite of attempts by DON, ED and police to intervene when resident started swing at staff, while cursing. Resident dc'd AMA at this time and given ride to home . Hospital emergency room Documentation, dated 1/16/18, documented resident sent to (facility) for rehab. Left (facility) AMA yesterday after punching the director of nursing. They dropped him off at his old house that has no heat. A Hospital physician progress notes [REDACTED].#1) with severe expressive and mild receptive [MEDICAL CONDITION]. Cannot take medications independently. Cannot communicate effectively. Needs placement. Hospital Discharge Documentation, dated 1/18/18, documented Social Work was unable to come up with an acceptable disposition for him, so Resident #1 was admitted because it is felt he is not safe on the street. The physician documented (Resident #1) continues to have severe [MEDICAL CONDITION] (cannot verbalize well) and moderate receptive [MEDICAL CONDITION] (limited understanding of what he takes in). Secondary to this, he cannot read his medication bottles and cannot manage his own medications. He is ambulating well. Unfortunately I don't think he can live independently. On 2/12/18 at 4:55 PM, the Administrator (ADM) stated, On the day he left, .Resident #1 got frustrated and decided he was going to leave. I explained if he left AMA (against medical advice), you can't come back. He left anyway. He went outside, triggered the wanderguard. I sat with him for about 30-45 minutes. It was lunchtime. Maybe 45 minutes later, we took off his wanderguard. I talked him into coming back in and getting his wallet and ID. The police showed up and were unsuccessful in talking to him. The address we had was from the police. All we had was a PO Box. I don't know why we didn't have an actual address. The police gave us his address. We took him down there. When asked how the resident was transported, the ADM said, In the facility van. When asked who was present, the ADM said, Me and (Staff A), the bus driver. When asked what he saw when they got to the address, the ADM said there was a gate and Resident #1 wouldn't open the gate. When asked if he could see the house from the gate, the ADM said, No. When asked if he knew anyone was home or if he went up to the house, the ADM said, No. When asked if he had any contact with the resident's family or if they knew he was coming, the ADM said, The wife called me, close to close of business, and she gave me an earful, asking, Why did you let him go? On 2/28/18 at 10:14 AM, when asked if she knew Resident #1 was leaving the facility, the resident's spouse stated, No, I had no idea. The whole thing was just shady. The spouse stated she and Resident #1 had difficult interactions with Resident #1's roommate, and (The facility) filed a complaint against me. So while all of this was taking place, all of a sudden they say (Resident #1) is acting up. They loaded up his things and dropped him off at the gate where I used to live. It's 13 miles out of town in the woods. When asked if anybody was at the house, Resident #1's spouse said, That's where we lived when (Resident #1) had the stroke. Nobody was living there and there was no heat there. He went around the gate and walked 3 miles to the house. My brother was there painting the house getting it ready for sale. When my brother explained to him he can't stay there, there's no heat and he couldn't be alone, they stopped at the gate and picked his clothes up, they were all stuffed in garbage bags, and took them with them. When asked where the resident went, Resident #1's spouse stated, My brother brought him to (the local hospital). He didn't know what to do with him. He's not able to speak. He thinks about like an [AGE] year-old. On 2/28/18 at 2:09 PM, when asked about transporting Resident #1 on 1/15/18, Staff A (bus driver), said, (Resident #1) was trying to walk home. He was an AMA. The police were called. (The ADM) was trying to talk to him. (The ADM) asked me to drive the resident to that address. His belongings were in 3-4 plastic bags. He just wanted to go. He was a little frustrated. He didn't speak. You could only understand a little what he said. When asked how far they drove, Staff A said it was about 15 minutes away. Staff A said, At the driveway there was a gate. He didn't want to open the gate for us. When asked if he could see the house or if they went up to the house, Staff A said, No. When asked if it was normal to drive a resident who left AMA to their home, Staff A said, No, not that I can remember. Failure to make preparations for a safe discharge resulted in the resident being dropped off by the facility at a home where no one was living and resulted in the resident being left alone where he had to walk 3 miles to get to family. The family was not made aware of his discharge and no preparations of support for the resident's needs had been made. This caused harm to Resident #1. Reference WAC 388-97-0120 (3)(a)

Based on interview and record review, the facility failed to report and notify, and provide basic care for a burn for 1 of 5 residents (#1) reviewed for care and services. This failure resulted in potential harm for all residents, and actual harm to Resident #1 when he spilled hot coffee on his lap and the site was unmonitored and untreated for [REDACTED]. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple medical diagnoses, including diabetes, neuralgia and neuritis, and dementia. The Minimum Data Set, a comprehensive assessment tool, dated 7/4/17, documented Resident #1 was cognitively impaired, and required moderate assistance with activities of daily living. A statement dated 6/20/17 by Nursing Assistant (NA) D, documented, I brought (Resident #1) his lunch tray at 12:10. He grabbed his coffee and spilt it in his lap. He yelled. I notified the nurse immediately. NA D documented, I came back to work 6/25/17, (Resident #1) came out of room yelling that his inner thighs burnt. Resident stated 'someone burnt me.' I looked and noticed popped blisters on one thigh and a blister on the other. I notified the nurse. On 6/25/17 at 7:57 a.m., a nurses note by Licensed Practice Nurse (LPN) A documented, open blisters to bilateral inner thighs. CNA stated he spilled coffee in his lap Tues last week. Unable to measure looks like 4 cm long with broken blister skin on top, both sides. Area red, raw very painful. At 12:39 p.m., LPN A documented on an Interact form (reporting and communication tool) the presence of blisters on Resident #1's bilateral buttocks, and broken blisters on Resident #1's right and left thighs. LPN A documented Resident #1 exhibited negative vocalization by repeated troubled calling out, loud moaning or groaning, crying, facial grimacing, tense body language, distressed pacing, fidgeting, and unable to console, distract or reassure the resident. LPN A documented on a Pain Data Collection and Assessment, dated 6/25/17 at 09:50 a.m., Resident #1 had 2 open blisters to the inner thighs, was exhibiting loud moaning and crying almost constantly at a pain level of 10/10. Review of Resident #1's clinical record contains no description, assessment, monitoring or treatment of [REDACTED].#1's legs until 6/25/17, when a late entry was added effective 6/20/17, the day the resident was observed to have spilled coffee into his lap. The nursing note entered by LPN C on 6/25/17 at 2:20 p.m., and identified as a late entry effective 6/20/17 at 12:10 p.m., documented, During lunch time around 1210, when (Resident #1) was trying to eat his food, dropped all his food on the floor and spilled coffee on his thighs, resident was wearing jeans and took off his pants immediately, tried to wipe his thighs with towel, resident refused to touch it, no redness [MEDICAL CONDITION] that time, no complain of pain reported, told incoming nurse to monitor for any redness. Review of the facility's investigation documentation included a statement by NA E, dated 6/26/17, I was told from day shift that (Resident #1) had threw his tray some time that day and spilled coffee on him. They told me that the nurse was notified and they checked him and he was just red. The next day when I came on I got nothing in report about (Resident #1) [MEDICAL CONDITION] did I see them. A statement dated 6/27/17 by Registered Nurse (RN) B, documented, I worked noc shift 6/21, 6/22 and 6/23. I received no reports of abnormal behavior or wounds/rashes, etc. On 6/25/17 LPN A documented notification to the physician of two open blisters on Resident #1's inner thighs and reported hot coffee spill which had happened a few days ago. On 6/26/17 a physician's telephone order was received with wound care instructions for treatment of [REDACTED]. A physician Office/Clinic Note by Medical Doctor (MD) 1 dated 6/26/17 documented reason for visit is burn sustained . by hot coffee to the thigh area. MD 1 documented a burn of second degree of right thigh, approximately 6 cm long and about 3 cm wide. The physician noted (Resident #1) described pain and was reluctant to allow me to gently touch around the area. MD 1 documented the plan as, wound inspection and dressing changes daily. On 6/28/17, MD 2 documented, I am asked to see this [AGE] year-old patient as the medical director, although he is not my patient. On 6-20-17, the patient spilled warm coffee into his lap. In examining the patient, he has two almost elliptical what appear to be second-degree burns. I am seeing these for the first time. He has some peeling. Under Assessment and Plan, MD 2 documented, I do believe that these look like burns. They are mostly on his posterior leg. Review of the Treatment Administration Record for June 2017 document treatment of [REDACTED]. Numerous nursing notes from 6/25/17 to 7/5/17 document resident #1's complaints of pain to the area and when treatments were applied: 6/25/17 at 5:02 p.m., Focus: Open areas to inner thighs. C/o (complain of) pain all day, wants medication put there, crying and screaming all shift. 6/27/17 9:59 a.m., Focus: open blister to right inner thigh, closed blister on left side. Vaseline dressing applied and wrapped with cling to right thigh, very painful, yelling during treatment. 6/29/17 1:23 p.m., . yelling with pain to inner thigh during care. 7/3/17 4:35 p.m., c/o pain to injury on thigh. Dressing in place, gets mad when you try to clean the area . 7/5/17 6:57 a.m., Pt also complain of pain in inner thigh, blisters noted without improvement. On 8/3/17 at 2:42 p.m., when asked about the injury to Resident #1's legs, LPN C stated, The aides told me he spilled coffee. They called me in his room and I had to check it. When asked if his pants were still wet from the coffee, LPN C said yeah but I wiped it with a towel. He did not complain of pain at that time. When asked why there were no nursing notes entered on 6/20/17, the day of the incident, LPN C stated, Because when I checked him there was nothing so I didn't do any notes that day because he was fine. When asked why her nursing note was entered as a late entry, LPN C said, The nurse asked me about it when she found it. I just figured out I needed to do that. When asked if she had told anybody about the coffee spill into Resident #1's lap, LPN C stated, I told him we would be monitoring it. When asked if she put the Resident #1 on alert charting, LPN C said, No, I just told it to the next shift. Reference WAC 388-97-1060(1)

Based on interview and record review, the facility failed to ensure a safe environment for 1 of 4 residents (#6) reviewed for accidents, when a resident's floor was mopped while the resident was asleep in the room. This resulted in harm when the resident arose and fell on the wet floor, and sustained a fracture to her femur (upper thigh bone). Findings include: Resident #6 was admitted to the facility on [DATE], with numerous diagnoses, including cancer, epilepsy, and a knee replacement. The Minimum Data Set, a comprehensive assessment tool, documented Resident #6 was cognitively intact, transferred independently and required supportive and supervisory assistance with activities of daily living. On 10/6/17 at 4:20 p.m., Resident #6 stated on 9/3/17 at about 11:00 a.m., she was asleep in bed, then arose to walk to the bathroom. Resident #6 stated she could see the housekeeper standing in the doorway but did not know the floor was wet. When asked, Resident #6 said there was no signage to warn about the wet floor. Resident #6 said she made it approximately halfway across the room, almost to the other bed in the room, when she fell and landed with her right leg out to the side. Resident #6 stated she felt a sharp pain and knew something was wrong right away. Resident #6 said she was unable to move or bend her knee because of pain. The housekeeper notified the nursing staff and a mechanical lift was used to raise the resident off the floor. On 9/3/17 at 1:38 p.m., an xray of Resident #6's affected leg was obtained, and a radiologist documented Resident #6 sustained a fracture of the femur (upper leg/thigh bone). On 9/3/17, Resident #6 was transported to the hospital, where she underwent surgery to repair the fracture. Resident #6 stated after she returned from the hospital on [DATE], she was not able to put any weight on the affected side and was dependent on staff for mobility and transfers. Resident #6 stated she now has a metal rod in her leg and said, It'll be a good while before I can walk on it. On 11/21/17 at 12:35 p.m., Resident #6 stated she received physical therapy and was not back at her former level of function. Resident #6 stated her leg aches when she stands on it. Resident #6 stated she used to be independent and It gripes me not to be able to go to the bathroom by myself. I used to take myself. I'm not going to stay in this wheel chair. I'm not going to do it. On 11/21/17 at 11:20 a.m., when asked if housekeeping staff mop when a resident is in their room, Staff A said, It depends on the resident. If they get up, staff usually did everything else, mopped when the resident went to lunch, and put up a wet floor sign. When asked if a resident's room was mopped while the resident was in bed, Staff A said, If they can get up on their own, I would mop later. If they needed help to get up, I would probably go ahead and mop. On 11/21/17 at 11:35 a.m., another housekeeping staff member was asked when residents' rooms were mopped, Staff B stated, We usually try to mop when they're out of the room, unless they're bedbound. Review of nursing note dated 9/3/17 at 2:00 p.m., documented staff heard a loud bang, Resident #6 was observed on the floor with one leg out in front of her and the other leg bent out to the right. Housekeeper stated she was mopping the floor, that the resident was laying down in bed and that resident slipped on the wet floor. Resident stated she was unaware that the floor was wet. Resident assessed and reported she was unable to move/bend her knee due to sharp pain. Resident assisted into bed using the Hoyer lift. Review of the facility's investigation of the incident dated 9/15/17 documented, Housekeeping mopped the floor while (Resident #6) was sleeping. The resident woke up before the housekeeper was finished and did not notice that the floor was wet. The housekeeper did not realize that the resident had woken up and was not able to warn her of the wet floor. When the resident stood up, she slipped on the wet floor. On 11/21/17 at 2:15 p.m., the Director of Nursing Services (DNS) stated after Resident #6's fall, in-service education was provided to the whole building. Housekeeping staff were told to always ask nurses and nurse aides on the hall whether a resident was independently ambulatory. The DNS said the training included the guidance, If residents were independently mobile, to make them (Housekeeping staff) wait until they're out of the room. When asked if Resident #6's fall was preventable, the DNS stated, Yes, absolutely. It should not have happened. She was in bed asleep and they did not wake her up. It's horrible. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to provide necessary care and services for 5 of 6 sampled residents (#26, 30, 68, 73 and 46) reviewed for quality of care. The facility failed to ensure there was adequate, functioning equipment needed in case of an emergency for Resident #46. This was determined to be an immediate jeopardy and the facility was informed on 03/23/17. Findings Include: 1) Resident #46 was admitted with [DIAGNOSES REDACTED]. On 3/23/17 at 2:16 p.m., moist-sounding lung breathing sounds were heard in the hallway one room away from Resident #46's room. Resident #46 was observed to be in respiratory distress. The head of bed was flat, and the resident appeared uncomfortable, struggling to breathe, and was grabbing and pulling on the privacy curtain that was closed between he and his roommate's beds. Resident #46 appeared to be panicked, and was sweating profusely. He had oxygen on at 2.5 liters/minute. Nursing Assistant (NA) A was notified and went to the resident's room, put his head of bed up and went to get a Licensed Nurse. At 2:20 p.m., LN B went into Resident #46's room with NA A and obtained the resident's oxygen level, which was low at 74-81%. LN B attempted to use the bedside suction machine to get secretions out of Resident #46's airway, and there was no suction tubing, wand or canister on or near the machine. LN B stated, I will have to go get the supplies and left the room. At 2:23 p.m., LN B returned to Resident #46's room with equipment to be able to suction secretions from Resident 46's airway, who was struggling to breathe. At 2:30, after suctioning Resident #46's mouth for secretions, LN B stated, I will give him a nebulizer treatment. (A treatment administered via a machine that makes a mist out of a liquid (medication) and inhaled by the resident, typically used to administer medications that open airway to make breathing easier.) LN B got the medication for the nebulizer, and when she attempted to give it to the resident, the machine did not have the required tubing for the machine to administer the medication. LN B left the room to obtain the supplies. At 2:35 p.m., Resident #46 was given a nebulized medication to help with his breathing. After Resident #46 was receiving treatment and had been repositioned, LN B stated, They must have tossed the tubing when they checked it and didn't replace it. When asked if there was anything else she could do for Resident #46, LN B stated, He has [MEDICATION NAME] drops, but that's for secretions, and he doesn't have any now. When asked about the audible lungs sounds Resident #46 was currently having, LN B stated, Well, they are not in his mouth and sometimes with a neb he can cough it up and out. LN B indicated there were no further interventions she could provide at that time, as the Resident's oxygen level had improved to 90%. At 2:40 p.m., RCM A administered [MEDICATION NAME] drops (used for drying secretions) as ordered. At 2:45 Resident #46 appeared to be better, and still appeared to be struggling for adequate air exchange. LN B and RCM A did not listen to Resident #46's lungs during this time. At 2:52 p.m., the Corporate Nurse (CN) indicated the policy of the facility was to check suction machines for function and required equipment such as tubing, oral wand, and canister every 24 hours, and change used items at least weekly. The nebulizer tubing and oxygen tubing are to be changed weekly. The CN stated, Documentation of check and change of equipment is completed on the resident's Treatment Administration Record (TAR). At 3:15 p.m., the CN agreed there was no documentation of a daily (every 24 hours) check for equipment readiness (suction machine) on Resident #46's TAR. At 3:17 p.m., the CN observed Resident #46 and listened to his lungs, agreed he was in wet clothing and bedding from sweating, and stated, I'm going to get the doctor who is here on rounds to see (Resident #46). At 3:38 p.m., the Medical Doctor (MD) A stated I've ordered (medications) including [MEDICATION NAME] which he can have in a bit if he still needs it for secretions. Given his status and comfort care, we can expect to see this happen increasingly. When asked if comfort care would include assuring resident is comfortable and not struggling/panicking for air, MD A stated, Yes. MD A stated to RCM A and CN, Make sure his clothing gets changed he is soaking wet from all that work he was doing to breathe. Resident #46's record showed an order for [REDACTED].#46 received this medication for comfort at any time during the month of March through current date. At 4:42 p.m., Resident #46 appeared to be comfortable. On 3/31/17 at 2:35 p.m., the Director of Nursing Services (DNS) was unable to give information regarding Resident #46 not receiving ordered medication for shortness of breath. 2) Resident #68 was admitted in December, 2016, with [DIAGNOSES REDACTED]. On 3/24/17 at 11:15 a.m., Resident #68 was observed to be sitting on the side of bed, and he complained of nasal congestion, cough, and sore throat. The resident stated, No one has come to see me, they don't care, obviously. When asked if he had notified a staff member, Resident #68 stated, Yes, I've told them. On 3/27/17 at 8:15 a.m., Resident #68 was observed sitting on edge of bed, and said he still had head congestion, and sounded like he had nasal congestion and a cough. When asked if he was feeling better, Resident #68 stated, I don't know, am I any better? I must be because no one here cares. Resident #68's roommate (#30) stated, Yeah, and now I got his cold. When asked if they had let staff know of their cold symptoms, both residents stated, Yes. The (NA's) that come in here should know. They hear our stuffy voices and cough. We have told them. 3) Resident #30 was admitted in December 2016, with [DIAGNOSES REDACTED]. On 3/27/17 at 8:15 a.m., Resident #30 was observed lying in bed and said he had head and nasal congestion, and a cough and sore throat. Resident #30 stated, I got his cold, referring to his roommate (#68) who had symptoms of a cold since 3/24/17. When asked if he told staff, resident #30 stated, Yes, I mentioned it to some of the aides. A record review showed Resident #30 had orders to receive, on an as-needed basis, [MEDICATION NAME] which is a medication used for nasal congestion in seasonal allergies [REDACTED]. 4) Resident #73 was admitted in December 2016, with [DIAGNOSES REDACTED]. She required total assistance for all care. On 3/27/17 at 8:30 a.m., Resident #73 was observed in her chair at her bedside, with a worried look on her face. When asked how she was, she stated, I just don't know, and then put her head in her hands. When asked if she felt all right, Resident #73 shook her head, No. When asked what symptoms she had the resident shook her head No, and frequently coughed a dry cough. On 3/20/17 to 3/24/17 Resident #73 was observed to be confused, and happy and talkative during all other interactions. On 3/28/17 at 7:50 a.m., Resident #73 was observed in her room, sitting in her wheelchair by her bed. The resident did not answer when spoken to, and shook head, no when asked how she was. Resident #73 was asked if she still had a cough and nasal congestion and she shook her head yes, appeared uncomfortable and had an occasional dry cough. On 3/27/17 at 11:15 a.m., NA D indicated there were not any residents on the hall she was working that had signs or complaints of a cold. When asked what type of symptoms would she look for in someone complaining of a cold, NA D stated, I would look for runny or stuffy nose, cough, fever. If anyone had anything like that, I'd let the nurse know, but I don't have anyone with those symptoms right on this hall right now. At 11:22 a.m., Residents #68, #30 and #73 were again observed in their rooms, and all indicated they still did not feel well and had symptoms of a cold. At 1:30 p.m., LN E indicated the process for residents who have a change in condition, including cold symptoms, was to obtain vital signs, listen to lungs, notify physician and family and place on alert. At 2:15 p.m. LN C indicated she would put a resident on alert for anything different than usual such as pain, change in behavior or cognition, cough, etc. She would assess the resident, get vital signs, notify the physician, and place on alert and notify the DNS and RCM. On 3/27/17 at 4:45 p.m. the DNS stated he, Would expect that for any change in a resident status would be assessed and the resident placed on alert. He indicated his expectation was the process would include the steps of taking vitals signs, completing a physical assessment (specific to change), notify the physician, update the care plan, and more. When asked what would be expected of non-licensed staff noticing a change in condition, the DNS stated, I know we need to work on this .but I would want them to report it to the LN. The DNS indicated #68, #30 and #73 all had and were recovering from cold like symptoms. Record review from 3/27/17 through 3/30/17 showed Residents #68 and #30 were not given any [MEDICATION NAME] for possible discomfort due to cold symptoms. No assessments of listening to resident lungs were noted, though it was documented Residents #68, 30 and 73 had coughs. 5) Resident #26 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's Minimum Data Set, an assessment tool, dated 1/11/17, indicated the resident was cognitively intact and required extensive assistance with activities of daily living. The resident's Physician order [REDACTED]. Resident #26's nursing progress notes indicated the resident was sent to the emergency department (ER) for an evaluation on 1/21/17. The progress notes did not describe the reason for the evaluation and there were no progress notes regarding the resident's medical status between 1/13/17 and 1/21/17. A communication form to the physician, dated 1/21/17, indicated, abnormal vital signs .lethargy (decreased level of consciousness), hypotensive (low blood pressure), crackles lower lobes bilaterally (of lungs), wheezes bilateral upper lobes. Emergency medics documented the resident was in acute respiratory distress at the time the resident was transported to the ER. Documentation showed the resident reported shortness of breath with an unproductive cough and hurt all over. Hospital records indicated the resident was admitted to the hospital with [REDACTED]. The resident's Treatment Administration Record (TAR) indicated there was a current physician's orders [REDACTED]. The December and January MARs showed every shift had been crossed out and PRN remained. An order to discontinue monitoring the resident's oxygen saturation levels was not found. On 3/29/17 at 11:19 a.m., when asked if it would be important to follow a Physician order [REDACTED]. When reviewing the resident's TAR, the DNS said, I am seeing here they did not do a very good job of that in January. They should have been doing it every shift. It is very concerning. When asked why the order was crossed out, the DNS said, I don't know why, unless there was an order to discontinue it. I don't know why it was like that. At 12:49 p.m., the DNS said, We don't know who lined out the TAR. There was no order to discontinue monitoring the resident's oxygen level. The facility failed to provide necessary care and services when staff failed to follow a physician's orders [REDACTED]. prior to being transferred to the ER.

Based on observation, interview and record review, the facility failed to identify and implement interventions to reduce fire hazards, fall hazards and environmental hazards for 3 of 3 current residents (#148, 82 & 73) reviewed for accidents. The facility failed to ensure staff monitored and assessed residents for accident hazards placed residents at risk for injury from possible fire, falls and the environmental hazards. This was determined to be an immediate jeopardy and the facility was informed on 03/28/17. Findings include: 1) Resident #148 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 02/06/17, indicated the resident was alert and oriented. Resident #148 resided in a room that was shared with another resident who required oxygen therapy 24-hours a day. Rcord review showed on 02/23/17 at 4:10 p.m., Licensed Nurse (LN) G documented in the resident's progress notes, Res refused smoking assessment, stating, 'I know where the smoking area is, I will use it, I am not having an assessment, I am an adult, I am not five.' Record review indicated on 03/27/17 at approximately 4:00 p.m., Resident Care Manager (RCM) C documented, This nurse and Executive Director went to resident's room this afternoon and reviewed resident's smoking policy with resident at this time. Resident verbalized understanding and agreed to keep smoking supplies locked in lock box in room or on person. Spoke to resident about the importance of not leaving smoking supplies out and unsecured. Resident verbalized understanding and agreed to policy. Progress Note, dated 03/28/17 at 12:55 a.m., LN (F) documented, Staff noticed smell of tobacco smoke coming from resident's room, This LN went into assess situation. Noted a half smoked cigarette with lighter on bedside table, plastic cup with ashes. Resident denies smoking in room, states it must have been the roommate (who does not smoke). On 03/28/17 at 11:33 a.m., the Director of Nursing Services (DNS) indicated he was aware of Resident #148's situation the night prior of smoking a cigarette in his room. The DNS indicated it was his expectation there would be alert charting for the resident in the situation of a dangerous situation, and indicated there was no alert charting for Resident #148. The DNS said Resident #148 had been known to engage in risky behavior at the facility by evidence of drinking in his room on multiple occasions, after being explained that this was against facility policy. The DNS stated, I think he does have a history of risky behavior and disregard of rules. The DNS indicated if a resident does not have a smoking assessment done, they are not to be smoking or have smoking materials. On 03/28/17 at 11:33 a.m., the Administrator (ADMIN) stated Resident #148's sister agreed the resident had a history of [REDACTED]. On 03/28/17 at 2:14 p.m., Resident #148 indicated he had his first smoking assessment done today (03/28/17). Resident #148 stated, Today they did one, but never did one before. Resident #148 was asked if he had a smoking assessment done on 03/21/17 and the resident reiterated that he had his first one done today and denied having one prior. The resident said he refused prior as, he wasn't a 5 year old. 2) Resident #73 was admitted in December 2016, with [DIAGNOSES REDACTED]. The resident required total assistance for care. On 3/20/17 at 4:15 p.m., Resident #73 was observed to have a healing wound on her right hand between the first and second digits that she was scratching and picking at. Resident's #73 was unable to explain what the wound was from. On 3/22/17 at 2:30 p.m., a review of resident #73's record showed the injury to her right hand occurred on 3/6/17. At 11:23 a.m., when asked how the resident received the injury to her right hand, Licensed Nurse (LN) A stated, Maintenance had propped the window open with a wooden dowel, and the resident pulled on the dowel and window shut on her finger causing a laceration. We had to send her out to the hospital for sutures. The window was directly outside Resident #73's room. On 3/29/17 at 10:22 a.m., Maintenance Staff (MS) A said the window was held open by dowels. MS stated, It always has been. If the dowel was removed without holding up the window it would fall. After this happened, we fixed it and it has locks on it now until the whole window can be replaced. 3) Resident #82 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], showed the resident had experienced trouble falling asleep and felt tired or had little energy. Resident #82 had behaviors that placed the resident at significant risk for physical injury and interfered with the resident's care. The resident required extensive assistance with most activities of daily living and had moderate cognitive impairment. Incident and accident reports showed Resident #82 experienced 20 falls between 10/1/16 and 3/31/17. Three (3) of the twenty falls resulted in injuries to the resident that required first aid. On 10/15/16 a fall resulted in an open area to the resident's left fifth finger. On 1/25/17 a fall caused a superficial scratch. On 3/28/17 the resident received a 7 cm by 0.2 cm abrasion on the left hip. Review of the resident's care plans showed the resident was at risk for falls/injury, impaired cognitive function, history or potential to demonstrate physical behaviors, safety device: for poor safety awareness and signs of pain, directed staff to anticipate the resident's needs. The safety device care plan directed staff to Anticipate and intervene for potential causes which have precipitated prior falls or accidents. On 3/24/17 at 8:14 a.m., the BOM was observed to walk by Resident #82's room as the resident yelled, Help! The BOM did not slow her pace, look into the room and stop to assist the resident. At 8:16 a.m.; an unidentified staff member looked into the resident's room as she passed the doorway. The resident was lying sideways, face down with his upper body on his bed and lower body hanging off the bed. The left leg was bent with the foot flat on the floor and the right leg was partially under the wheelchair next to the bed. The staff member did not stop to assist the resident. At 8:19 a.m., Licensed Nurse (LN) E walked into the resident's room and assisted the resident to his bed. LN E stated no staff had told him the resident needed help, he was just checking on the resident. On 3/27/17 at 8:07 a.m., the resident yelled, I need help. The BOM entered the resident's room and asked if he was eating. The resident said, Yes, and the BOM left the room. The BOM did not ask the resident what he needed help with. At 8:08; Resident #82 called out, I need help again. The BOM went to the resident's doorway and asked, Are you eating your breakfast? The BOM stood in the doorway for a few seconds, turned and went back to passing meal trays. At 8:11 a.m., the resident shouted I need help. Resident Care Manager (RCM) B walked past the resident's room. RCM B did not stop walking. At 8:14 a.m., RCM B walked by the resident's room, a second time. The resident called out for help. RCM B did not stop to assist the resident. On 3/28/17 at 3:06 a.m., RCM C stated if staff heard a resident calling for help regardless of a staff's position or how frequently the resident called for help, the staff would be expected to stop and help, or call for the nurse, or whoever needed to be there. On 3/28/17 at 3:57 p.m., the DNS said the resident was a high fall risk and had multiple falls since his admission to the facility. The DNS stated the facility had attempted interventions to decrease the resident's falls that included hourly rounding, 15 minute checks, recently increased the resident's evening activities, and had been looking for trends. The DNS stated 1:1 supervision had not been attempted to reduce the resident's falls and he generally wanted that to be the last resort. The DNS did not feel they were there yet. The DNS stated the resident's vision problems had not yet been considered as a possible cause or contributor to the resident's falls. Refer to F313.

Based on observation, interview and record review, the facility failed to be administered in a manner to effectively use its resources to attain and/or maintain the highest practicable well-being of each resident. Failure to assess for care and services, accients, nutrition, dental services and address staff knowledge to meet resident needs resulted in harm for residents and placed residents with individualized and specific needs at risk for failure to reach the highest level of function and a decrease quality of life. Findings include: 1) Refer to 42CFR483.25, F-309 Care and Services/Highest Practicable, The facility failed to obtain emergent, immediate assistance for current sampled resident (#46) who was found to experience conditions that warranted emergency/physician interventions. The failure to obtain emergent, immediate help was determined to be an Immediate Jeopardy. 2) Refer to 42CFR483.25 (h) F-323, Accidents, The facility failure to ensure the resident environment remained as free from accident hazards and that each resident receives adequate supervision. Resident #148 was found to not have adequate supervision or assessment. This failure was determined to be an Immediate Jeopardy on 03/28/17. 3) Refer to 42CFR483.25(i) F-325 Nutrition, The facility failed to ensure current residents (#41, 76, 82 & 96) maintained acceptable parameters of nutritional status, such as body weight and protein levels, and received a therapeutic diet when there was a nutritional problem. This failure to ensure each resident received the nutritional support and assessment caused harm to the residents. 4) Refer to 42CFR483.55(b) F-412 Dental Services/Nursing Facilities, The facility failed to provide and/or obtain from an outside resource, in accordance with 42CFR483.75(h), the following dental services to meet the needs of each resident routine dental services, emergency dental services, and, if necessary, assist the resident in making appointments. Harm was caused to Residents (#82 & 86) when the facility failed to obtain dental services.

Based on observation, interview and record review, the facility failed to provide prompt dental services for 3 of 4 sampled resident's (#82, 86 and 97). This failure placed residents at risk for unmet dental needs and for decreased quality of life. This failure caused harm to Resident #97 when he experienced dental pain. Findings include: The facility's procedure, Dental Services - Referral to, effective July 2015, documented, The center will assist residents in obtaining routine and 24-hour emergency dental care. The procedure directed staff to, Identify those residents who needed routine services that included Taking impressions for dentures. Additional procedures listed showed the facility would Identify those residents who require a prompt referral. Some prompt referral examples included damage or lost dentures, acute pain in teeth and broken or otherwise damaged teeth. 1) Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Area Assessment (CAA), dated 5/3/16, identified the resident had, Obvious or likely cavity or broken natural teeth and mouth or facial pain discomfort or difficulty with chewing. Review of an Appointment Request Sheet, dated 5/6/16, showed the resident requested a dental visit due to missing teeth and mouth pain. A nursing progress note, dated 5/12/16 at 12:30 p.m., indicated a form needed to be completed, signed by the doctor, and faxed back to the surgeon before an appointment could be set up to have his teeth pulled. Review of the Denture Appliance Request form, documented the resident's medical provider did not sign the form until 8/18/16. A second appointment request, dated 1/19/17, documented the reason for the dental appointment as, Resident requesting. States he is having more pain in some of his teeth. Would like to see a local dentist if possible. On 2/9/17 at 3:34 p.m., the Social Services Director (SSD) documented a dental referral had been made on 2/9/17. That appointment was cancelled due to the resident being scheduled with a provider the resident had requested to not see again. That request was documented on the Appointment Request Sheet, dated 1/19/17. On 2/9/17 an oral/dental health problems care plan (CP) was initiated for Resident #97. The CP identified the resident had missing/broken teeth. The CP showed an intervention of, Monitor/document/report to MD PRN signs/symptoms of oral/dental problems needing attention. Pain, abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, tongue black, coated, inflamed, white or smooth and ulcers or [MEDICAL CONDITION] in mouth. A consultation form, dated 3/2/17, showed findings of, Rampant decayed teeth. Require multiple extractions due to non-restorable. On 3/21/17 at 1:27 p.m., Resident #97 stated he had seen a dentist not long after his admission to the facility, who told him he needed to see an oral surgeon. The resident said he was still waiting to see the surgeon. At 1:37 p.m., the Transportation Coordinator (TC), and the SSD, indicated the resident had not seen an oral surgeon for his dental issues. On 3/28/17 at 10:03 a.m., the resident stated he had tooth and mouth pain for about two years. When the resident opened his mouth and pulled his cheek away, a broken tooth on the left side of his mouth was observed. The resident said his tongue used to bleed from scraping or biting it on that broken tooth. The resident said there had been times when the mouth pain impacted his ability to eat due to pain and chewing difficulties. On 3/28/17 at 11:07 a.m., Resident Care Manager (RCM) C stated the oral/dental monitoring would have been done on the resident's treatment administration record (TAR) or the Medication Administration Record [REDACTED]. At 4:49 p.m., RCM C said the dental monitoring had not been done for Resident #97. RCM C said she added the oral/dental monitoring to the residents TAR that afternoon, 3/28/17. At 4:52 p.m., Social Services stated there was no documentation that showed the resident had seen the oral surgeon prior to 03/02/17. 2) Resident #82 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], indicated the resident had no natural teeth and was moderately cognitively impaired. Review of an outside provider's documentation documented Resident #82 was seen by a registered dental hygienist (RDH) on 8/21/14, 9/17/15 and 8/21/16. On 8/21/14 the RDH documented the resident stated his dentures were [AGE] years old and that he would really like new ones. On 9/17/15 the RDH documented the resident said he had no teeth. On 8/21/16 the RDH documented, Resident requested new dentures today. The 8/21/14 and 8/21/16 documentation included a check mark next to Referral. An untitled document, completed by Licensed Nurse (LN) H, dated 1/26/15, identified Resident #82 had missing teeth, wanted new dentures and that a referral was placed on 1/27/15. A facility appointment request sheet, dated 1/27/15, indicated the resident had an appointment on 2/11/15 for new dentures that was cancelled. The facility was unable to provide documentation that identified a reason for the cancelled appointment. Review of the resident's medical records indicated no appointment had been rescheduled. The facility initiated an Oral/Dental care plan for the resident on 11/30/16 with focus of, no teeth. No dental service interventions were indicated for the care plan. The resident's Activities of Daily Living (ADL) care plan, dated 9/21/16, identified a problem of potential oral pain due to missing teeth with an intervention of Dental visits/services. Social services progress notes, dated 1/24/17 and 3/16/17, showed Resident #82 was not in need of dental services. On 3/27/17 at 11:22 a.m., the transportation coordinator (TC) described the dental referral process as nursing or Social Services (SS) filled out an appointment request sheet. The TC would find a dentist who took the resident's insurance and arranged transportation to the appointment for the resident. Review of Resident #82's Social Service (SS) care conference notes, dated 7/7/15 at 11:45 a.m. and 10/26/15 at 11:35 a.m., showed documentation of, No dental referral requested. At 4:06 p.m., the Social Services Director (SSD) stated SS was made aware of a residents dental needs by the DNS's clinical tool. This tool was completed after a resident requested an appointment or the resident's name appeared on a list, provided by the dental person that identified residents who needed a dental referral. The SSD was not aware how a resident came to be on the list to see the dental person. When asked if residents were responsible for reporting dental needs and the facility was not actively identifying resident's dental needs, the SSD said, I see what you mean. On 3/28/17 at 3:57 p.m., the DNS stated the dental referral process could take up to 30 days, depending on the resident's insurance and the facility's acceptance. A Social services progress note, dated 3/28/17, documented, on 3/28/17 Resident #82's family member did not feel the resident would wear dentures, that she did not want to worry about dentures and felt Resident #82 was doing fine without dentures. On 3/29/17 at 11:58 a.m., the resident's family member stated she had not been asked if she wanted to pursue getting the resident an appointment to evaluate him for dentures. She was asked if the resident came to the facility with his own dentures. The family member indicated the resident's lower dentures were broken when he fell during his stroke, which was about one month before his admission to the facility. He did have upper dentures and did not want to wear them at that time. She did not think going through the process for new dentures would have been good for him just after his stroke but that was over two years ago. The family member had not been asked if she wanted the resident to have an appointment for his dentures since the facilities initial inquiry. The family member stated, It would be nice to know if dentures might help him speak clearer and/or help him eat more. The family member indicated she felt the resident would wear dentures. 3) Resident #86 was admitted on [DATE] with multiple diagnoses. The resident's MDS, dated [DATE], indicated the resident required limited assistance with dressing and personal hygiene, was cognitively intact and had obvious or likely cavity or broken natural teeth. On 3/22/17 at 10:48 a.m., when asked if she had any dental concerns, Resident #86 stated, I need dentures but I don't have an appointment yet. The resident was observed to have multiple missing teeth. On 3/27/17 at 3:52 p.m., the Social Services Director (SSD) stated, I am not aware of any dental concerns for this resident. At 4:03 p.m., when the resident opened her mouth, four lower teeth were observed. The resident stated, I want to get dentures, if I can ever get to the dentist. On 3/28/17 at 3:13 p.m., RCM B provided a document, dated 4/21/15, which indicated the dentist had recommended extractions of upper and lower teeth. RCM B stated the dental office indicated they had previously provided the resident a full set of dentures. On 3/29/17 at 10:05 a.m., RCM B said, We found the dentures. None of us had ever seen them. She was supposed to follow up with an oral surgeon to remove the remaining teeth and have the dentures set. For some reason it did not occur. RCM B said Maintenance Staff (MS) B, who is in charge of scheduling appointments, found the dentures and set up an appointment. Since it has been a year, we aren't sure the dentures will still fit. At 10:49 a.m., when asked where the dentures had been, MS B stated, In my drawer. Anesthesia was not covered by the resident's insurance and a previous DNS and Administrator were discussing how to pay for it. It was forgotten about.

Based on observation, interview, and record review, the facility failed to identify weight loss and implement interventions in a timely manner for 3 of 4 sampled residents (#41, 76 & 96) reviewed for nutrition. This failure placed residents at risk for experiencing unintended weight loss, delay in healing and/or decline in condition. This failure caused harm to Resident #41, #76 and #96 due to skin impairment and lack of assessments and followup. Findings include: 1) Resident #41 was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The MDS indicated the resident's normal/average body weight from her original admission date of [DATE] was approximately 108 pounds. The MDS indicated on her most recent admission on 07/17/15 Resident #41 weighed 101 pounds. Review of resident weight summaries indicated on 03/22/17 the resident weighed 86 pounds. Resident #41's care plan indicated on 01/16/17 a focus was documented, Therapeutic nutritional risk due to history of decreased appetite. Diet restrictions related to Level 1/pureed enhanced foods with all meals, inconsistent carbohydrate intake. Nutrition risk or potential nutrition risk due to dementia. Identified goals were, Will choose foods consistent with medical condition daily, will have gradual weight gain through review date. Will consume at lease 50-75% of meals and snacks daily, will eat at least one bite of food offered daily. Interventions included, Administer medications as ordered. Assist with developing a support system to aid in weight loss efforts develop an activity program that includes exercise, mobility, and offer activities of choice to help divert attention from food. Discuss feelings about weight and commitment to weight gain. Allow to express feelings. Monitor and record food intake at each meal, monitor weight weekly. Invite to food-related activities and offer food, beverages of choice to encourage food intake. On 03/20/17 at approximately 5:30 p.m., Resident #41 was observed in the dining room with food in front of her. Little assistance was given to the resident to encourage her to eat in the early stages of dining. Record review of nursing progress note, dated 2/28/17 at 5:02 p.m., documented, Open area between left and right gluts (buttock cheek) about 1.5 includes long with depth of approximately 1 centimeter and width of 1/8 inch. Record review noted on 03/07/17 at 9:48 a.m., nursing staff documented, Resident requires assistance with eating. She ate 75% of meal. If not assisted, she plays in food. On 03/22/17 at 9:45 a.m.; a nutrition progress note documented, new order received per RD (registered dietician) recommendation increase Med-Plus 2.0 (high calorie/high protein drink) from 90 cc to 120 cc to promote weight gain. On 03/27/17, record review provided by the RD indicated on 01/16/17 the resident was started on Med-Plus 2.0, 90cc four times a day. On 03/27/17 at 1:57 p.m.; the Registered Dietician (RD) indicated a best practice would be to start a resident out on a supplement early on and to have weekly IDT (interdisciplinary team) meetings to discuss weights. The RD stated, With recent things that are happening .this hasn't necessarily been happening. 2) Resident #76 was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], indicated the resident had a severe cognitive impairment. Resident #76's care plan indicated on 01/24/17 the resident had a focus documented, Nutrition risk or potential nutrition risk related to Alzheimer 's disease, altered nutritional related lab values, other dementia ., with goals, Will not have weight loss or complications related to refusing food, will consume 75% two of three meals/day through the review date. Interventions included, Needs encouragement/support to be independent with eating Allow choices in meal time, menu selection, dining location . On 03/20/17 at approximately 5:30 p.m., the resident was observed in her room, by herself, at mealtime. On 3/23/17, the resident was observed eating in her room with no staff present. Resident #76's weight summary documented the resident weighed 122.0 pounds on 9/17/16. On 2/21/17, the resident weighed 108.0 pounds indicating a negative 3% change over 30 days (comparison weight 112.0 pounds on 1/14/17). On 3/6/17, the resident weighed 106.0 pounds. And on 3/17/17 Resident #76 weighed 104.0 pounds indicating a negative 10.0% change over 180 days (comparison weight 122.0 pounds on 9/27/16). Resident #76's clinical progress notes noted on 02/14/17 at 5:06 p.m., the Registered Dietician (RD) documented, Resident flagged for steady weight loss trend and reviewed at weekly weight meeting. Weight loss has been ongoing over past few months and current weight is below IBW (ideal body weight) range. Recommend diet change to include enhanced foods with all meals and per MD (medical doctor), resident may benefit from daily appetite stimulant. Will continue to follow and monitor NTR status and reassess when necessary. Record review documented on 03/13/17 the Medical Director (MD) A, .Her weight went from 113 to 106. When she was admitted it was 122. I do not see a Physician notification. The patient cannot give me history .She has had significant weight loss so I am asking that sugars be brought to next rounds so I can do a thorough evaluation of her sugars. I have also asked that we do an RD referral .I am wondering if she needs an appetite stimulant. The resident's clinical records noted on 03/23/17 at 7:23 p.m., the RD documented, RD assessing residents flagged for significant weight change. Resident flagged for recent weight loss and current weight is just below IBW rant. Weight continue to follow weight loss trend and RD noted NTR status on 3/14 and initiated Med-Plus 2.0 120cc TID (three times a day) to help address weight loss and continue to recommend appetite stimulant to help increase oral intake On 03/27/17 at 1:57 p.m., the RD indicated there was an error in his knowledge base for the electronic medical charts and how referrals got viewed and received as well as his ability to document accurately. The RD indicated it was known there was an issue in need of repair. The RD stated, I definitely had to adjust my thinking to document all my steps and thinking . so his referrals could be seen by the nursing and medical staff. 3) Resident #96 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Residents' height was documented at 71 inches and weight at 183 pounds, he wore upper and lower dentures and was able to feed himself. Resident #96's Nutrition Risk Data Collection and Assessment record documented notes by the RD on 4/20/16 for admission, and 6/21/16 and 9/23/16 for quarterly update requirements. During this time there was no documented weight loss. Review of residents recorded weights from 5/02/16 through 3/20/17, showed on 12/22/16 the resident weighted 184.4 pounds, and on 1/30/17 the resident weight 174.0 pounds; a 10 pound weight loss in one (1) month. There was no documentation found by nursing services or Registered Dietician to indicate the weight loss had been identified and planned intervention were implemented to address the weight loss. Record review showed on 2/13/17 the resident weighed 176 pounds. On 3/4/17 the resident weighed 171.8 pounds. On 3/20/17 the resident weighed 165.8 pounds. These weights represented a 19 pound weight loss in 90 days. There was no documentation to indicate this weight had been identified or interventions were planned to address it. On 3/27/17 at 10:35 a.m., the Director of Nursing Services (DNS) stated they had lost their previous Dietician at the end of September and had a new Dietician come on board in October. The DNS was unable to locate any additional notes concerning this resident and his nutritional status. At 2:29 p.m., the Registered Dietician (RD) stated he came on board at the end of October 2016. He stated he had thought he was doing his job correctly and charting, and, I didn't know that I had to link things in the computer to get the results I wanted. This was a huge learning curve and I have since made adjustments. The RD was unable to provide any additional documentation on this resident from October 2016 through March 20, 2017.

Based on observation, interview and record review, it was determined the facility failed to maintain an Infection Control Program (ICP) that included surveillance, investigation, prevention, control and reporting to prevent the spread of infection; prevent and control outbreaks and to follow recommendations that were set in place by the local health department to further stop the spread of infection and viral illnesses. This failure resulted in at least 43 residents and at least 32 staff being infected with a highly contagious gastrointestinal (Norovirus) illness. This failure placed residents, family members, staff and the public at risk for spread of the illness and constituted an Immediate Jeopardy (IJ). Findings include: According to the Centers for Disease Control (CDC), 2016, Transmission and Contagion of Norovirus. Norovirus can be found in vomit and stool and can stay in the stool for 2 weeks or more after feeling better .Alcohol-based hand sanitizers can be used in addition to hand washing; however, they should not be used as a substitute to washing with soap and water. Healthcare Workers (HW) having direct contact should follow proper hand hygiene guidelines and use gowns and gloves when in contact. Residents who are positive for Norovirus may share a room with another resident who is positive for Norovirus; Residents should be isolated from residents who do not have the same infection .Norovirus is highly contagious among the elderly .in nursing homes . Food should be washed thoroughly prior to being eaten. Norovirus is relatively resistant and can survive temperatures as high as 140 degrees Fahrenheit (F). Sick food workers or staff should not be serving or preparing food, and HW who have symptoms with Norovirus should not be at work (CDC, 2016). After a person has vomited or had diarrhea, the surface and affected areas needs to be cleaned and disinfected with chlorine bleach solution with a concentration of 5-25 tablespoons of household bleach per gallon of water, or another approved disinfectant that is registered as effective against Norovirus by the Environmental Protection Agency (EPA). Laundry items should be immediately removed and washed at the maximum available cycle then machine dried (CDC, 2016). On 1/19/17 at 1:45 p.m., the Director of Nursing (DNS) stated they currently had an issue with Norovirus in the building having a few positive residents for the virus. Record review, on 1/12/17, showed 11 residents were positive for Norovirus out of a resident census of 102. On 1/13/17, ten (10) facility employees were positive for Norovirus. On 1/19/17, records showed a total of 29 residents and 21 facility employees were found positive with signs and symptoms of Norovirus. On 2/1/17, the virus had increased to approximately 43 residents and 32 staff members. Facility records indicated in-service training was conducted on 1/12/17 to include the training and mandatory use of proper hand hygiene/hand washing, and training on contact precautions (wearing personal protective equipment (PPE); gloves & gowns when providing direct care to residents experiencing vomiting and diarrhea). When training was conducted, all staff signed the in-service form to validate they understood the precautions and would follow protocol. On 1/19/17 at 4:30 p.m., Licensed Nurse (LN) B indicated the resident in room [ROOM NUMBER] was on isolation precautions for Norovirus. LN B stated, It's hard on the dementia unit to keep people in their rooms but staff should be taking precautions to do good handwashing. At 4:42 p.m., Nursing Assistant (NA) B was observed in room [ROOM NUMBER] sitting on the resident's bed and assisting her with taking fluids. NA B was not wearing gloves or PPE. NA B was asked what the STOP sign meant on the resident's door and she stated, It's for isolation and means we need to do good hand washing. On 01/19/17 at 4:30 p.m., Nursing Assistant Registered (NAR) A was observed in room [ROOM NUMBER] not using PPE. NAR A was observed to leave room [ROOM NUMBER] without washing hands or using alcohol hand sanitizer and enter the clean utility room. room [ROOM NUMBER] was observed to have a STOP sign with contact precautions in place on the door. Both residents were documented to be positive for signs and symptoms consistent with Norovirus. At 4:50 p.m., NA C was observed taking Resident #1 from her room to the nurse's station. Resident #1 was observed at the nurse's station barefoot and interacting with other residents. Resident#1 was documented to be positive for Norovirus with a contact precautions sign on her door. At approximately 4:55 p.m., NA C stated she did not know what contact precautions meant. When asked, NA C said Resident #1's wheel chair was not disinfected prior to being taken out of the room, and she believed the resident's roommate was on isolation precautions but was not sure about Resident #1. At 4:58 p.m., NA C was observed not washing her hands or using any alcohol hand sanitizer following her contact with Resident #1. NA C was observed to go from Resident #1's to Resident #2's room and was observed to get his pitcher of water on his bedside table. NA C was observed to take the water pitcher to the clean utility room, refilled it and return it to Resident #2's room. NA C was observed during this interaction without using hand sanitizer or washing her hands. Resident #2 was documented to be positive for signs and symptoms consistent with Norovirus and was on contact precautions. At 5:00 p.m., NA C was observed to leave Resident #2's room and go to the wall mounted computer screen and begin charting. NA C was not observed to wash her hands or use any form of hand sanitizer prior to or after touching the common use computer screen. At 5:03 p.m., NA C was observed in room [ROOM NUMBER] at the resident's bedside providing assistance. NA C was not wearing PPE or gloves. room [ROOM NUMBER] had a STOP sign on the door. Record review indicated the resident in room [ROOM NUMBER] was positive for signs and symptoms consistent with Norovirus. At 5:05 p.m., NAR A and NA C were both observed in room [ROOM NUMBER]. NAR A was observed in direct contact with Resident #1 rubbing the Resident's arm for comfort and hugged the resident. At 5:06 p.m., NA C was observed leaving the room without washing her hands or using any form of hand sanitizer. NAR A was observed to assist Resident #3 with her slippers without gloves. NAR A was observed to kneel on the ground, touch his scrubs and touch the ground. NAR A washed his hands following this contact and then patted the resident's arm on his way out of the room. At approximately 5:10 p.m., NAR A said he did not believe Resident #3 was positive for Norovirus and that the STOP sign on the door was there because so many are on isolation so it is just for everyone. Record review indicated Resident #3 was documented as positive for signs and symptoms consistent with Norovirus as of 01/12/17. At 5:29 p.m., NA B was observed in room [ROOM NUMBER] without wearing PPE and assisting the resident to eat. NA B was observed to be sitting next to the resident at his bedside. It was observed that a STOP sign was on the door for isolation precautions. At 5:29 p.m.; Licensed Nurse (LN) A was observed to be in room [ROOM NUMBER] sitting at Resident #4's bedside and assisting her to eat. LN A was observed to be without PPE gear on and using bare hands to assist in feeding the resident. At approximately 5:31 p.m., the DNS indicated both Rooms #1 and #2 were on isolation so the staff should be using PPE gear while in contact. At 5:33 p.m., when LN A and NA B were observed without PPE in rooms where PPE was required, NA B told the Regional Nurse (RN) she was unaware of the directions behind the STOP sign and that PPE was required for each resident. At 5:45 p.m., RN indicated it was her expectation that staff follow the contact precautions that they were instructed and signed off with human resources (HR) regarding PPE and hand washing. On 01/20/17 at 10:44 a.m., an individual not associated with the facility indicated they had been contacted on 01/12/17, and were only last contacted on 01/14/17 that a total of 22 people were affected by the illness. The individual was not informed of the totality of the situation. It was advised people affected with the illness should be isolated and away from healthy people for 48-72 hours after their symptom free, and not to share rooms with affected people. It was advised to not have visitors if the illness was increasing. On 01/23/17 at 9:00 a.m., record review indicated six (6) staff were not available to work due to signs and symptoms consistent with Norovirus illness, and returned to work after 24 hours. On 01/30/17 on or about 2:00 p.m. the facility had five (5) residents and 5 new staff with new signs and symptoms consistent with Norovirus. At 5:15 p.m., the DNS indicated he was, kind of struggling with the infection control program due to lack of time to invest into the program, and indicated the infection control program was coming secondary to other programs in the building. The DNS indicated the local Public Health had not provided the facility with, really any advice. The DNS said he has been referring to the CDC's website for resources/direction on the outbreak. On 2/01/17 at approximately 2:00 p.m., the DNS indicated there were no new cases of signs or symptoms consistent with Norovirus. At 2:05 p.m., room [ROOM NUMBER] was observed with a STOP sign on the door. It was observed this was new from 01/30/17. At 2:15 p.m., NA C was observed in room [ROOM NUMBER] and was not wearing any PPE gown or gloves. NA C was observed to leave the room with soiled material in a plastic bag without gloves. NA C indicated she did not need to wear any PPE as she was providing care for bed #2, and only bed #1 was on isolation. At 2:20 p.m., the DNS indicated NA C should have worn PPE regardless of what bed she was providing care for since the STOP sign was on the door for contact precautions. When asked about room [ROOM NUMBER] Bed #1, the DNS indicated this resident began to have signs and symptoms of Norovirus the night prior. At 3:00 p.m., room [ROOM NUMBER] (Resident #5) and room [ROOM NUMBER] (Resident #6) were identified for isolation which was new from the previous visit on 1/30/17. LN B stated both residents were newly placed on isolation precautions for signs and symptoms consistent with Norovirus. LN B stated, You know that stuff is going around in here. At 3:10 p.m., the DNS provided records indicating 7 new residents and 5 new staff members were symptomatic with signs and symptoms consistent with Norovirus. At 4:30 p.m., review of the infection control surveillance book was not updated to show all infections. The DNS stated, It's the same, I haven't done it. Review of the ICP log book indicated no tracking documentation of the symptomatic Norovirus residents in the facility were recorded. On 2/2/17, review of the hospital records for Resident #7 showed he was admitted to a local hospital with persistent nausea and vomiting. The resident was diagnosed with [REDACTED]. At 10:08 a.m., individuals not associated with the facility indicated the DNS had been advised hand washing was the biggest and most important aspect to the control the outbreak, and the reason this illness was continuing to spread was staff were not washing their hands. The DNS was informed residents with symptoms should not reside with those who do not display symptoms of Norovirus unless a valid situation was identified. The DNS was informed strong infection control practices should be in place, visitors should be limited to the best of their ability, .and good hand washing should be advised to all visitors. The DNS was advised sick staff members must stay home for at least 48 hours past the last time symptoms were no longer present. The DNS was informed about the use of disposable dishes, designate staff to sick residents, designate equipment and strict training and observation to control the spread of Norovirus. The DNS had reported the facility had 17 residents and 13 staff affected with signs and symptoms consistent with Norovirus on 1/12/17, and had not reported the continued increases in resident and staff members affected. On 1/19/17, 1/30/17 and 2/1/17, none of the advised prevention measures were demonstrated by staff during observations and from interviews. On 2/6/17 at 1:30 p.m., the facility provided a report that showed a 50% increase in residents and staff members affected by the virus from the previous week.

Based on observation, interview and record review, it was determined the facility failed to have sufficient, qualified staff to provide and supervise care for Residents #1,#2, #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47 & #48) and 6 discharged Residents (#7, #49, #50, #51, #52 & #53). Observations, interviews with residents and staff, combined with record reviews, revealed inadequate supervision of residents to ensure the care needs of these residents were met by licensed staff or certified nursing assistants in accordance with established clinical standards and their care plans. This failure resulted in harm to Resident #8 and impacted all residents' quality of life when lack of qualified staff members were available to meet residents' needs. Findings include: Record review of the 1/30/17 resident census showed had 100 residents, with 29 residents documented to have signs and symptoms consistent with Norovirus (a highly contagious gastrointestinal illness). All of these residents required substantial time and care from qualified staff. On 2/1/17, the facility indicated the illness affected approximately 43 residents and 32 staff members. 1) Refer to 42CFR483.25 (h) (2) F 323 Prevention of Accidents for facility failure to ensure the safety of residents in the secured dementia unit that resulted in harm to Resident #8 after she was found with [MEDICAL CONDITION] her back from lying against a baseboard heater after the facility had identified the heater as a safety risk. 2) Refer to 42CFR 483.65 Infection Control F 441 for facility failure to maintain an Infection Control Program (ICP) that included surveillance, investigation, prevention, control and reporting to prevent the spread of infection; prevent and control outbreaks and to follow recommendations that were set in place by the local health department to further stop the spread of infection and [MEDICAL CONDITION] illnesses that resulted in at least 43 residents and at least 32 staff being infected with a highly contagious gastrointestinal (Norovirus) illness and constituted an Immediate Jeopardy.

Based on observation, interview and record review, it was determined the facility failed to be administered in a manner to effectively use its resources to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility was in compliance with the following regulatory requirements which affected or potentially affected all residents in the facility. Failure to ensure compliance represented Immediate Jeopardy for Residents referrenced in F 441and harm to Resident #1 referenced in F 314. Findings include: 1) Refer to 42CFR483.35 F 353 Nursing Services for failure to ensure sufficient qualifired staff members were available to provide needed care and services to all residents who experienced a contagious illness identified in F 441 and to prevent harm to Resident #8 who resided on the secured dementia unit. 2) Refer to 42CFR483.75(i) F 501 Medical Director for facility failure to ensure the Medical Director provided coordination of care for residents in the facility and helped identify, evaluate and resolve/address medical and clinical concerns related to an outbreak of a highly contagious gastrointestinal (Norovirus) illness (affecting residents' medical care and quality of life as well as staff members who were affected). This failure created an unsafe environment for all residents, staff and the public. The administration failed to ensure Nursing Services had sufficient staff members available to protenct residents from a highly contagious illness, prevent harm to Resident #8 and to ensure the Medical Director was actively involved and readily available for residents and staff to resolve a highly contagious illness outbreak for resident's identified in F 441 that resulted in an Immediate Jeopardy.

Based on observation, interview and record review, it was determined the facility failed to ensure the Medical Director (MD) provided coordination of care for residents in the facility and helped identify, evaluate and resolve/address medical and clinical concerns related to an outbreak of a highly contagious gastrointestinal (Norovirus) illness affecting residents' medical care and quality of life as well as staff members who were affected. This failure created an unsafe environment for all residents, staff and the public and constituted an Immediate Jeopardy. Findings include: On 1/19/17, 1/30/17 and 2/1/17, record review of the facility's infection control program (ICP) showed at least 43 residents, from a census of 100, and at least 32 staff members presenting with signs and symptoms consistent with Norovirus. On 1/30/17 and 2/1/17, record review of the Infection Control Program (ICP) tracking log for December 2016 and January 2017 indicated no gastrointestinal illnesses were tracked in the facility for residents or staff. Record review of an email from the Director of Nursing (DNS) to the Medical Director (MD), dated 2/1/16, indicated, No identified cases from this morning .and some seem to be resolving. Record review of emails indicated on 1/29/17 the MD emailed the DNS, I gave explicit instructions for the LN (Licensed Nurse) to contact both yourself and the weekend supervisor to ensure the unit was appropriately isolated .I had not heard back anything from the center regarding status/progress/update. On 2/1/17 at approximately 4:30 p.m., when asked about the Medical Director's involvement in the outbreak, the DNS stated because the MD have so many buildings and residents .they cannot be everywhere. Without guidance and support from the MD, residents continued to get sick and were at risk for spreading illness to all residents in the facility. Refer to F 323, F 353 and F 441.

Based on observation, interview and record review, it was determined the facility failed to ensure adequate supervision was provided to 3 of 3 sampled residents (#8, #9 & #10) reviewed for accidents. This failure caused harm to Resident #8 when she suffered burns to her back from a baseboard heater and created the potential for other residents who resided in the dementia unit at risk of the same/similar injury. Findings include: Resident #8 was admitted on [DATE] with multiple health conditions including dementia and a mental health disorder. The resident lived in the secured dementia care unit. Resident #8's care plan, initiated on 12/02/16, indicated, (Resident) at risk for falls/injury related to advanced dementia, poor safety awareness, history of falls, desire to walk bent over and lay on the floor, desire to be near wall which may include baseboard heaters. According to the record on 1/14/17 at 9:30 a.m., 17 red areas found on the resident's back .indicating a burn. At 10:25 a.m. Licensed Nurse (LN) C documented, This nurse to resident's room. Noted red marks on resident's back from lower back to left shoulder with a burn like appearance. Noted floor heater cover was not on heater, nor in resident's room. Red marks match heater grates. On 1/19/17 at 3:24 p.m., Resident #8 was observed and found to have 17 red, dry burns still present on her back. The resident's bed was observed to be near the window by the heater. Black tape was observed on the floor around the baseboard heater. On 1/19/17 at 3:27 p.m., Nursing Assistant (NA) D stated the black tape was placed around all of the base board heaters to create a space barrier so that staff do not place anything around the heaters like slippers, shoes or chairs . NA D indicated it was understood that no furniture, equipment and other items would be allowed within this space. On 1/30/17 at 2:15 p.m., during an observation in the dementia unit, Room 47's baseboard heater was hot to touch and had a temperature of 190.2 degrees Fahrenheit (F). The dining room heater surface temperature measured 167.6 degrees F. It was observed both the dining room and Room 41's base board face plates easily pulled away in the middle to expose the heating coils. On 1/30/17 at 2:15 p.m., Resident #9 stated the black tape on the floor (around the heater) was to help keep the furniture straight. Resident #10 stated the black tape on the floor was where the floor was going to be repaired. At 2:15 p.m., the dementia unit was observed without a Licensed Nurses (LN) to be found on the unit. At 2:30 p.m., LN D and LN E both returned to the floor for shift change. The LNs indicated they were not aware of residents' locations. LN E stated she was just coming on shift. On 1/30/17 at 5:15 p.m., the administrator stated the black tape was placed on the floor to create a visual barrier for the residents with dementia so that it would create a hole-like appearance so Residents would avoid the area around the heaters. He said he was aware the baseboard heaters were unsafe and needed to be changed out. The facility had awareness the baseboard heaters were a potential hazard and were aware of the risk when Resident #8's care plan was updated on 12/2/16. This facility failure caused harm to Resident #8 when the resident incurred several burns to her back from the baseboard heater.

Based on observation, interview and record review, it was determined the facility failed to provide restorative services to maintain or improve function for 1 of 1 residents (#8) reviewed for restorative services. Failure to implement appropriate restorative services caused decline in Resident # 8's function related to overall mobility and strength, reducing independence and quality of life. Findings include: Resident #8 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of resident records indicate that Resident #8 was last seen by Physical Therapy and was discontinued from therapy in September 2015 with recommendations to have the resident on a Restorative Nursing program. Physical Therapy also recommended the resident have a walker available for use. Surveyor did not observe any walker in the resident's room for use. Resident #8 was observed to be sitting in her wheel chair with her neck in a backwards position resting on the back of her wheelchair during all days of survey. On 04/12/16 at 5:36pm, the resident indicated several times that she would like to be able to get up and walk but required assistance to do so. On 04/12/16 at 2:25pm Physical Therapy Assistant (PTA) indicated to Licensed Nurse (LN) B that Resident #8 was not on a walking program. On 04/12/16 at 5:40pm Nursing Assistant NA B indicated that she has, never walked Resident #8, and isn't sure if the resident is on a restorative program or not. On 04/12/16 at 5:58pm the Director of Nursing (DNS) indicated that there was no Restorative Nursing program at this time due to lack of staffing and nursing assistants. Failure to ensure that Resident # 8 received services to improve or maintain function represented harm for this resident and potentially other residents.

Based on observation, interview and record review, the facility failed to supervise staff to ensure staff were performing resident care safely, with dignity, and in accordance with facilities policies for 1 of 1 current sampled residents (#1) who were reviewed for rough handling . This failure placed residents at risk for exposure to potentially rough handling and a diminished physical, mental and psychosocial well-being. This failure resulted in harm to Resident #1 when she sustained a skin tear to her left hand. Findings include: Resident #1 is a [AGE] year old female admitted to the facility on [DATE] with a history of cancer and failure to thrive. The resident's Minimum Data Set (MDS), an assessment tool, dated 02/18/2016, indicated the resident was alert and oriented with a BIMs (Brief Interview Mental Status) score of 12/15, and required assistance with activities of daily living. On 02/26/16 Resident #1 was observed in her room watching television. She had light purplish in color bruising to both hands between the thumbs and index finger, broken/chipped off finger nails, and a healing skin tear on her left hand that had healed scabbing. On 02/26/16 Resident #1 was interviewed by state investigators. During her interview she was orientated to day and time and was able to make her needs known. The resident was able to follow along during the conversation and answered questions appropriately. Resident #1 indicated that she wanted to leave the facility and wanted to go home. The resident stated, I don't like them, I don't trust them, I don't believe anything they do! Resident #1 indicated during the conversation that the treatment was rough. Resident #1 explained that approximately 3 weeks ago during the night time a staff member came in to check and change her attends. Resident #1 indicated that she had refused this as she, had pain all over and the staff member was persistent with the care, the resident stated, but they (staff) would not stop (persisting to change her). Resident #1 indicated that she became combative with the staff member. Resident #1 indicated that they (staff) would keep at it and persist and then would eventually stop. Resident #1 indicated the staff would hold her hands back while providing care. Resident #1 indicated on another occasion, I'm lying there naked from the chest down, on my bed with no sheets, and they threw my wet sheets at my face. Resident #1 continued to state, Saying I'm having a bad day, you bet I am! I've been trying to get out of this damn place for weeks. I was so sad and embarrassed and in pain, I cried. On 03/01/16 Resident #2 indicated that she felt the way staff's approach to Resident #1 was rough and they would often startle her at night time when Resident #1 was asleep and would not fully explain what care was going to be performed when Resident #1 would inquire. Resident #2 indicated that approximately 3 weeks ago there was two Aides providing care to Resident #1 and she heard Resident #1 say, Owe you're hurting me. When she heard this it caught her attention. Resident #2 indicated that she could not see what was happening due to the privacy curtain and her poor vision; however, she was able to tell that Resident #1 was combative to care and that staff was not honoring her wishes to be left alone. On 03/01/16 Nursing Assistant (NA) A indicated that she had worked with Resident #1 and that Resident #1 was often combative with care. NA A indicated that there was an incident recently in which Resident #1 was combative with care and began kicking, slapping, and scratching at her. NA A indicated that she did not stop care even though Resident #1 was being combative and finished change and clean-up of the resident. NA A indicated that she held back Resident #1's hand so that she could finish cleaning her perineal area. NA A indicated that in an event of a resident refusing care she would just finish and then inform the nurse on staff of the combative resident. On 02/29/16 at 3:16p.m.: The DNS indicated that it would be her expectation that a staff would suspend care and reproach with the resident's permission later if the resident was combative to care. The DNS indicated that NA A should not have done care if she had to hold the hands of Resident #1 back from being hit and would have expected her to leave as long as the resident was safe, and that the resident has the right to refuse care. Review of facility policy indicates that Refusal of care policy indicates staff is to honor resident's right to participate in their decisions of care and when they decide to refuse care the facility will support the resident and their decision. The facility failed to give proper in-service and training to NA A to further prevent accidents and injury to Resident #1and failed to ensure the resident was being handled in a safe manner which ultimately resulted in injury to her hand.

Based on observation, interview and record review, it was determined the facility failed to obtain emergent medical evaluation and services for 1 of 1 sampled Residents (#1) who experienced a significant change of condition. This failure resulted in harm to Resident #1 when the facility failed to obtain immediate medical care when the resident demonstrated loss of alertness, drop in blood pressure/pulse rates and impaired respirations. This was determined to be an immediate jeopardy and the facility was informed on 7/17/2015. Findings include: Resident #1 was admitted to the facility from the hospital on June 25, 2015 following treatment for [REDACTED]. He had high blood pressure and kidney disease, as well as other medical conditions. According to the record, the resident was a full code. He was to receive rehabilitation services (speech therapy, ST; Occupational Therapy, OT; Physical therapy; PT) and was planned to discharge home in less than 90 days. On 7/14/15 and 7/15/15, the department received information from public complainants alleging the resident had recently attempted self- harm and had a significant change in condition. During the investigation of these allegations on 7/15/15 at approximately 5:45 p.m., the department's complaint investigators discovered the resident in bed, covered with a white sheet with a pink spot (the size of a grapefruit on the sheet) in the area covering his stomach. Resident #1 was not responsive to verbal stimuli. The resident's mouth was wide open and dry. He had periods of no respirations. The investigators immediately reported the resident's condition to the Director of Nursing Services (DNS) who was able to check the resident at 6:00 p.m. She was unable to obtain pulses or oxygen saturation. The resident was noted to have intermittent gasps for breath about 6 times per minute. At approximately 6:12 p.m., Licensed Nurse (LN) A, the resident's nurse, attempted to obtain a blood pressure on the resident's left arm and after the third attempt, s/he said: It is 86 over 40 (86/40) visual. When asked what visual meant, s/he said s/he saw the needle on the manometer tick down. S/he continued to check for a pulse. The resident did not respond during the attempted blood pressures. The LN did not make an attempt to assess the resident's level of alertness/arouse him and did not implement emergency measures. The LN was asked about the pink spot on the sheet and when s/he lifted the sheet it was noted the resident had a large amount of pink diarrhea. The LN told a Nursing Assistant (NA) the resident needed to be cleaned up. When two NAs performed personal care for the episode of diarrhea, the resident did not respond. The DNS was informed by the complaint investigator of the LN's findings and the resident's condition. The DNS initiated the 911 process at approximately 6:30 p.m. Review of the receiving hospital's emergency room (ER) physician's documentation indicated the resident was in life-threatening (code) status from the time of leaving the facility to arrival at the ER where the resident had a pacemaker placed for the slow heart rate. He had been intubated (tube inserted for breathing) during transport and was placed on a ventilator (mechanical respirator) at the hospital. The resident was admitted to the Intensive Care Unit (ICU) in critical condition. The ER physician's admission note further indicated the resident arrived: .with altered level of consciousness .apparently he was noted to be bradycardic (slow pulse rate) into the 30's for the past several days. Staff had been unable to get a blood pressure during this time. For reasons that are not clear, he was not transferred to an acute care facility until today .he arrived hypotensive (low blood pressure) and bradycardic. Review of the resident's vital signs record showed on 7/14/15 at 10:00 p.m., the resident's blood pressure was 102/50, his pulse rate was 38 beats per minute (BPM) and respirations were 16 breaths per minute. The nursing note at 10:00 p.m. indicated LN A faxed the physician the vital signs at 10:22 p.m. and documented the blood pressure medications were held. The physician faxed back a response the following morning on 7/15/15 at 8:56 a.m. with written direction to: Discuss with your RCM (Resident Care Manage). These vitals do not make sense to me. No vital signs were documented in the resident's record for 7/15/15. At approximately 6:18 p.m., NA B said she took the vital signs at 2:30 p.m. and had not documented them yet but remembered the pulse rate was 32 and the blood pressure was 94/46. She said she informed LN A at the time who told her s/he would check on the resident. The NA said she saw LN A go into the resident's room. There was no documentation to indicate the RCM or the physician had been informed/consulted/updated regarding the resident's vital signs. Review of the Medication Administration Records (MARs) indicated the resident was ordered 4 blood pressure medications daily to lower the resident's blood pressure. Despite the resident's low blood pressure and pulse rate on 7/14/15, 3 of the resident's 4 blood pressure medications were administered on 7/15/15. The resident also received a routine anti-anxiety ([MEDICATION NAME]) medication at 6 a.m. and noon. The MAR indicated [REDACTED]. All of these medications can impact a person's heart rate, blood pressure, respirations and level of alertness. There was no documentation related to blood pressures/pulses or alertness of the resident prior to or after being given the medications. On 7/16/15 at 5:00 p.m., during interview with the RCM, said she spoke to LN A after the event and Explained to her/him there was a problem with notification of the physician. I (RCM) was concerned s/he should have made a phone call instead of a fax. The RCM said if she would have seen a pulse of 38, I would have picked up the phone and called 911.

Based on observation, interview and record review, it was determined the facility failed to immediately inform residents and consult residents' physicians when serious changes in condition occurred for 1 discharged Resident (#1) and when changes were made to cardiopulmonary resuscitation (CPR) status for 1 of 4 sampled Residents (#2) reviewed for notification/consultation. These failures prevented residents, their physicians and/or guardians from being aware of changes in condition and treatment plans and resulted in harm to Resident #1, created the potential for harm to Resident #2 and placed all residents at risk of not receiving the most immediate and optimal care. Findings include: The facility's procedure for Notification of Resident Change in Condition, updated [DATE], indicated: Notify the physician and family or legal representative immediately if there is a significant change in condition, regardless of time. 1) discharged Resident #1 was admitted to the facility on [DATE] from the hospital following treatment for [REDACTED]. He was a full code (all life-saving measures to be implemented). On [DATE] at 10:00 p.m., Licensed Nurse (LN) A documented the resident had a low blood pressure of ,[DATE] and a pulse rate of 38. A fax was sent to the physician at 10:22 p.m. reporting the vital signs and that blood pressure medications had been held. The physician faxed back the morning of [DATE] at 8:56 a.m.,Discuss with your RCM (Resident Care Manager). These vital signs do not make sense to me. On [DATE], no documentation was found in the record to indicate any discussion occurred with the physician or RCM regarding the Resident's vital signs and change in condition. On [DATE] at 6:30 p.m., the resident was transferred to the hospital via ambulance. On [DATE] at 5:00 p.m., the RCM said she was not informed of the changes in vitals or condition of the resident. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was alert and oriented and could make her needs known. The care plan dated [DATE] indicated the resident's code status changed to comfort care . despite no documented changes in condition. Review of an Interdisciplinary Team (IDT) note dated [DATE] indicated: Resident has voiced to remain a full code . which contradicts the care plan. The physician's orders [REDACTED]. The resident did not sign the form to indicate she participated in a conversation about this change from a full code to a no code. The care plan dated [DATE] indicated the resident was placed on end of life care although no terminal condition was identified or that the resident's condition had worsened since [DATE]. The Resident's latest assessment dated [DATE] indicated she was alert, oriented, independent in all activities of daily living and could make her own needs known. On [DATE] at 2:58 p.m., Resident #2 was observed and interviewed about her code status. She said she did not even know her code status was changed for her. She said she never wanted to be a no code and her wishes were still the same as she expressed them on [DATE] for full code. She was still under the impression she was a full code. At 3:18 p.m., the Social Services Director (SSD) said she had not spoken to the resident since [DATE] about her code status and would do so immediately. Refer to F 250

Based on interview and record review, it was determined the facility failed to provide medically related social services for 1 of 3 sampled residents (#1) reviewed for discharge plans. This failure caused physical, mental and psychosocial harm to the resident when she experienced increased pain, inability to care for her facility-acquired pressure wounds at home and caused months of fear about potential loss of her foot. Findings include: discharged Resident #1 was admitted to the facility on [DATE] for short-term rehabilitation services following a surgical repair of her right knee. Additional [DIAGNOSES REDACTED]. She was alert, oriented, had clear speech and made all financial and health care decisions. She lived alone and was independent. The hospital discharge note dated 11/28/14 indicated the resident was ambulatory with a walker and 25% weight bearing on her right leg. Upon admission to the facility, she received physical therapy (PT), occupational therapy (OT) and speech therapy (ST-for cognitive linguistic therapy) 5 days each week. After 4 weeks of therapies, the resident was to discharge home. On 12/14/14 the Nursing Note (NN) indicated the resident developed pressure ulcers on her right and left buttocks and on 12/19/14 the resident complained of pain in her foot and was found to have a blister on her right heel that opened on 12/25/14. According to the record, the resident was discharged home on[DATE] with two dressings on her buttocks and one on her right foot. Review of the Social Services (SS) discharge documentation and physician orders [REDACTED]. There was no documentation as to which HHA or what/when services would be provided. On 6/8/15 at 2:00 p.m., Resident #1 was interviewed and stated: I have never had any trouble with my feet. I have been diabetic since 2007. I have never had any skin breakdown before this (validated in clinical records) and when I talked to the podiatrist after discharge, I really got scared. I didn't want to lose my foot! My regular doctor sent me to (named physician) for care of the wound. He explained as deep as the wound was it was getting too close to the Achilles tendon and then he sent me to the hospital to the wound care clinic and they started taking care of it. I never was told a nurse would be coming out to see my dressing changes. I did not get any paperwork for discharge or anything telling me to do anything. My doctor (orthopedic surgeon) released me on 12/22/14 and they (facility) came in and said you cannot go just because the doctor said so. They said they would not let me go for another week. They said if I left, that Medicare would not pay for anything. Facility documentation dated 12/24/15 indicated the resident's surgical wound had healed but the resident had developed pressure ulcers on her right and left buttocks and right heel. On 6/8/15 at 3:30 p.m., during interview with the 1st HHA staff, s/he said the facility did contact them on December 30, 2015 and they told the facility at that time, they were unable to care for the resident as they did not have staffing. She was not placed on their case load and they never saw her. On 6/10/15 at 3:00 p.m., the facility SSD said she thought someone had been in from the 1st HHA and had made copies from the records. She said she did not get the name of the HHA person who reviewed the record. When told the 1st HHA said they told the facility they could not provide the services, the SSD said she was not aware of which HHA was actually providing care to the resident but if it was not the 1st HHA, it must be the 2nd HHA. Documentation provided by the facility failed to indicate who/what services would be provided other than the need for nursing, PT, OT, an RN and a bathe aide. At 4:00 p.m. interview with the facility discharge nurse and nurse's assistant, revealed lack of documentation to know what the resident was told about discharge plans since the discharge nurse said she did not document that she gave dressing change instructions to the resident. When asked what dressings/supplies were needed and how the resident would change two wound dressings to her buttocks and right heel, she said she did not know but thought the HHA would be caring for the resident based on the SSD documents. On 6/11/15 at 3:00 p.m., during interview with the 2nd HHA staff, s/he said they specifically told the facility SSD on 12/30/14 that they did not have sufficient staff to place the resident on the roster. Review of the resident's primary physician follow-up office visit assessment on 1/6/15 revealed: Significant pressure ulcer of right heel .recommend urgent evaluation by (named physician) for probable debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of eschar (dead skin on sore or ulcer, usually thick/hard consistency and black or brown in color) and treatment. Clinical records indicated the resident required weekly treatment at the wound clinic with multiple debridement treatments through May 15, 2015. Failure to ensure the resident had clear, safe discharge plans in place beginning at admission, during her stay and at discharge caused harm to the resident who never received the medically related/ordered services for nursing, PT and OT and RN after discharge and resulted in 5 months of wound care, pain and emotional distress over the fear of losing her foot and decreased mobility. Refer to F 314.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled residents (#1) who admitted without pressure ulcers, did not develop them. This failure caused harm to discharged Resident #1 when she developed three facility-acquired pressure ulcers two weeks after admission that resulted in physical discomfort and emotional distress while in the facility and for 5 months after discharge. Findings include: discharged Resident #1 was admitted to the facility on [DATE] for short-term rehabilitation services following a surgical repair of her right knee. Additional [DIAGNOSES REDACTED]. She was alert, oriented with clear speech and made all of her own financial and health care decisions. She lived alone and was independent. The hospital discharge note dated 11/28/14 indicated the resident received specialized therapies and was ambulatory with a walker and stand-by assistance with 25% weight bearing on her right leg. She was to admit to the facility for a few weeks of continued rehabilitation and then would return home. During the resident's stay at the facility, she received physical therapy (PT), occupational therapy (OT) and speech therapy (ST-for cognitive linguistic therapy) 5 days each week. The facility's admission Minimum Data Set (MDS), a comprehensive assessment tool, indicated the resident required extensive assistance of two people for bed mobility (turning side to side, positioning in bed), transfers (from one surface to another) and for toileting. Mobility devices included a walker and wheelchair. Three Braden Risk skin assessments dated 12/1, 12/8 and 12/15/2014 indicated the resident was at moderate risk for skin breakdown. Moderate risk factors were: Some sensory impairment to feel discomfort to an extremity; has moist skin and required linen changes daily; chair fast as cannot bear own weight/must be assisted into chair or wheelchair; very limited ability to make frequent or significant changes in body positioning independently; eating less than optimal protein; has potential to slide down in bed/rub skin against sheets/chair when moving. Other than the surgical incision to her right knee, the resident's skin was intact. All facility nursing notes (NN) indicated the resident was continent of bowel and bladder; required the assistance of 1 person for bed mobility, ambulation, toileting and dressing. She was cooperative with care, used a walker and wheelchair and worked with all therapies several hours per day, 5 days each week. The resident's admission care guide indicated the resident positions self needed the assistance of 1 person for ambulation and transfers .cushion to wheelchair, used a walker and the resident was to have weekly skin care by the Licensed Nurse (LN). On 12/14/14 at 7:15 a.m., one day prior to the 12/15/14 Braden skin assessment, the NN indicated the resident was found with areas of skin breakdown noted as excoriation on her right and left buttocks. The NN indicated the resident Reports sitting up in chair much of the day. Educated to not stay up continuously but to change position -sit/lay-to prevent further breakdown .Request therapy screen for special wheelchair cushion. The PT assistant indicated the resident was already on their service. An additional NN noted dated 12/14/14 indicated the resident verbalized understanding of the need to stay side to side to avoid additional pressure to the area. On 12/15/14 the Braden skin assessment indicated no changes and the resident was still at moderate risk for breakdown. On this day, the same nurse's skin ulcer staging assessment indicated the right and left buttock partial thickness wounds with yellow slough (slough is indicative of full-thickness stage III or IV pressure ulcers and is non-viable tissue and requires debridement and may become thicker and harder to remove the longer it is present) and granulation (tissue that forms as an intermediate step in the healing process of full-thickness wounds) .entire area measured 5.0 cm (centimeters) x 5.5 cm .with tunneling (tunnels are often secondary wounds that occur as a side effect of an infection or other issue with a primary wound. Tunnels can develop in pressure ulcers due to the high volume of pressure being forced upon many tissue layers creating a sinkhole-like effect in the skin). The NN dated 12/15/14 at 10:30 p.m. indicated the resident was placed on a specialty bed. The next facility assessment on 12/24/14 indicated the surgical site on her right knee had healed. The assessments on 12/24/14 for both areas on the buttocks had worsened slightly. Two days before discharge, the last skin assessments dated 12/28/14 showed slight improvement to both buttock wounds with partial thickness and increased tunneling. Dressings were applied. On 12/19/14 at 9:30 a.m., the record indicated the resident complained of pain in her right foot. The physician was notified and wanted an assessment for a possible blood clot in her leg. Later that day, a nursing assistant (NA) reported to the nurse that the resident had a blister on her right heel. A specialty boot was applied and the resident's heels were to be floated (off the bed) at all times while in bed. Skin assessments were completed for the heel wound on 12/19/14 with some worsening noted on the next 12/24/14 assessment. The blister opened the evening of 12/25/14 with wound dressings ordered to the right heel. The last documented assessment of the right heel on 12/28/14 indicated the dressing was changed and the wound was open, draining serosanguineous (fluid that is usually yellowish with small amounts of blood) with maceration (softening of the skin from excessive wetness/moisture) of the skin .dressing applied. On 6/8/15 at 2:00 p.m., discharged Resident #1 was interviewed. She said she was very upset about all the wounds and lack of care and treatment .I kept saying my leg was swollen. I then looked with my hand mirror . on the right foot on the heel .I had black, scabbed and dead skin. I have never had any trouble with my feet. I have been diabetic since 2007 .I have never had any skin breakdown before this and when I talked to the podiatrist after discharge, I really got scared. I thought I would lose my foot! My regular doctor sent me to (named physician) and he explained as deep as the (heel) wound was it was getting too close to the Achilles tendon and then he sent me to the hospital to the wound care clinic and they started taking care of it. The resident continued: There were two areas on my butt! I thought you only got them (pressure sores) on your butt not your heels. No one changed the dressings for 4 or 5 days. I needed to tell them I needed them changed but they would not do it until I asked them to do it. If they had felt behind the heel they would have felt the ulcer side of it .it was wet and soupy. It had a gelatinous-like substance on it. I saw that it was black and about an inch to two inches from side to side and maybe about a 1/2 inch on the short side. They said nothing and came in and put something on it and wrapped it and said don't take it (dressing) off for 2 days and then they came in the following week and I had not taken it off and then they changed it again on 12/28/14 and then put a bandage all the way around my foot and put a date on it and walked out of the room .this was a horrible experience and I don't want anyone to go through what I did. The resident said when she discharged on [DATE] and got dressed, she took the dressing off her foot and left it on the bed. Review of the orders and treatment records failed to indicate the right and left buttock wound dressings or right heel dressings were changed every three days and as needed or what staff members had done to physically help the resident with positioning while in the wheelchair and/or bed to prevent skin breakdown and after skin breakdown occurred. Review of the resident's primary care physician's note dated 1/6/15 revealed the resident was in bed for several days after admission to the facility because of excessive pain medication and once the doctor reduced/changed the pain medication the resident was more awake. The note continued: Knee replacement surgery without complications but as a result of the surgery during her rehabilitation stay at the facility, she ended up developing bedsores on her bottom and a heel ulcer to her right heel. She (resident) does not recall wearing heel protectors or having a pillow under her ankles to keep her heels of the bed . The note further indicated: Significant pressure ulcer of right heel, at least a Stage II, in the setting of history of cardiovascular disease and type 2 diabetes .Recommend urgent evaluation by (named physician) for probable debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of eschar (dead skin on sore or ulcer, usually thick/hard consistency and black or brown in color) and treatment. Decubitus ulcers on the sacral area, Stage I, appear to have granulation tissue within the ulcers. According to the referred physician's records, the resident had a 2.5 cm ulceration of the right heel--needs more off-loading and better treatment of [REDACTED]. The resident's toenails were debrided to reduce deformity and pain. The resident was treated for [REDACTED]. She was allowed to wear a shoe on May 1, 2015. After 5 months of wound care treatment to her right heel ulcer, the resident was discharged from service on 5/15/2015. Failure to ensure measures were in place and implemented to prevent pressure ulcers from developing and that once pressure ulcers were identified, measures were implemented to prevent worsening caused months of pain and distress to the resident. Refer to F 250. .

Based on observation, interview and record review, the facility failed to ensure proper transfer procedures were followed for 1 of 3 sampled residents (#3) reviewed for accident prevention. This failure caused harm to Resident #3 and placed residents at risk for avoidable injuries. Findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #3's Minimum Data Set, an assessment tool, dated 7/29/10 the resident was dependent on staff for assistance with her activities of daily living including transfer. The resident was alert and oriented. The care plan dated 1/28/11stated the resident required assistance of two persons with a mechanical lift for transfers. This information was also in the nursing assistant care directive. According to the facility's documentation dated 3/2/11 the resident "complained of increased foot and knee pain ... it began on 2/26/11 on evening shift ..." A staff member transferred Resident #3 to her wheel chair without the assistance of another staff member and the resident's foot hit the pole on the mechanical lift. The facility investigated the incident, notified the resident's physician and family. On 3/2/11 the resident had her left foot and knee x-rayed. A fracture was found on her foot and treatment was initiated. According to the facility's documentation dated 3/3/11 Nursing Assistant (NA) B stated Resident #3's foot hit the pole on the mechanical lift during a transfer on 2/26/11. NA B stated she transferred Resident #3 from her bed to her wheel chair without the assistance of another staff member. On 3/8/11 at 11:55 a.m. Resident #3 was sitting in her wheel chair in her room. The resident's left foot was in a "foot stabilizer." The resident stated she had experienced more pain and had been taking more pain medications. The resident stated her left foot got caught in the mechanical lift during a transfer. The resident said she felt the pain and reported to the staff member. The resident stated the staff member transferred her without the assistance of another staff member. The resident stated not all of her transfers were done by one staff member but it "happened enough." At 2:00 p.m. NA C stated the residents' care directive had specific care and services including transfer assistance residents required. NA C stated the NA came on shift received either a report from the previous shift NA and/or by reviewing the resident's care directive. NA C stated the Licensed Nurse (LN) would inform her if there was a change in a resident's transfer status. NA C stated the NAs were expected to review and follow the residents' care directive when providing care for the residents. At 2:05 p.m. LN D and LN E stated a Hoyer (mechanical) lift transfer required assistance of two person and all staff members had been in-serviced. LN D said the resident's care plan which had all the care and services including Resident #3's transfer status. LN E stated there was no recent change in Resident #3's transfer status. LN E said she notified and in-serviced the NAs when there was a change in the resident's transfer status. LN D said Resident #3 required two person assist with a Hoyer lift transfer and the NA was expected to follow the care plan. LN E stated the LN on floor was responsible for ensuring the NAs followed the care plan. LN E said she routinely monitored staff for safe transfer and reminded the NAs to follow the care plan.