Every finding on record at Frontier Rehabilitation and Extended Care

. Based on interview and record review, the facility failed to protect resident's rights to be free of verbal and physical abuse for 2 of 5 residents [Residents 1 and 2] reviewed for abuse/neglect. This failure placed the residents at risk for experiencing intimidation, emotional distress, and potential for physical injury. Findings included.Review of the Washington State guidance titled, Nursing Home Guidelines - The Purple Book, dated October 2015, defines abuse as the willful action or inaction that inflicts injury, unreasonable confinement, intimidation, or punishment on a vulnerable adult.The facilities Abuse policy, dated December 2023 and revised on October 2022, states Each resident has the right to be free from abuse, including verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, misappropriation of resident property, exploitation, and any physical or chemical restraint not required to treat the resident's medical condition. The Center implements policies and processes so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members, and others who may have unsupervised access to residents. These policies address screening, training, prevention, identification, investigation, protection, and reporting/response.Resident 1 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, Unspecified. The admission Minimum Data Set, an assessment tool, dated 07/01/2026, documented Resident 1 was assessed as cognitively impaired.Resident 2 was admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia. The admission Minimum Data Set, an assessment tool, dated 06/05/2026, documented Resident 1 was assessed as cognitively impaired.Record review of an incident report, dated 07/07/2026, documented a resident-to-resident altercation between Resident 1 and Resident 2. Residents 1 and 2 were sitting at a table near each other. A magazine was on the table. Resident 2 grabbed the magazine. Resident 1 thought it was being stolen and slapped Resident 2 on the arm. Resident 2 reciprocated by slapping Resident 1 on the arm.Record review of an incident report, dated 07/14/2026, documented a resident-to-resident altercation between Resident 1 and Resident 2. Resident 2 was being wheeled into the dining room for a group activity. Resident 1 swatted and made contact with Resident 2's arm. A staff member placed themselves between Residents 1 and 2 to prevent further interaction.In an interview on 07/28/2026 at 3:00 pm, Staff C, Licensed Practical Nurse and Resident Care Manager said Resident 1 would be discharging to an alternate facility the next day. Staff C said they had tried moving Resident 2 to a different room on an alternate hallway. This was fine during the night when she was sleeping but upon awakening Resident 2 would mobilize about the facility and back to the hall where Resident 1 resided. After the most recent interaction the facility had placed a one-on-one caregiver with Resident 1. The facility had been looking for alternate placement for a few weeks after realizing that however hard they tried to keep Residents 1 and 2 apart the instances of disagreement continued to happen.Reference WAC 388-97-0640 [1]

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was completed accurately to reflect a resident's health status and/or care needs for 2 of 2 sampled residents (Residents 102 and 9) reviewed for accidents. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.Findings included . Resident 102 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS - an assessment tool), dated 02/23/2026, indicated Resident 102 was severely cognitively impaired. Record review of Resident 102's Elopement Risk Evaluation, dated 02/23/2026, indicated Resident 102 was at risk for elopement related to (r/t) dementia (a decline in cognitive function severe enough to impair daily life, caused by progressive brain damage). Record review of Resident 102's care plan, dated 03/09/2026, indicated the problem, Resident 102 has impaired cognitive function or impaired thought processes, short term memory loss r/t metabolic encephalopathy [brain dysfunction caused by systemic illness, such as liver/kidney failure, diabetes, or infections rather than direct brain damage] dementia. The intervention, Resident uses Wander Guard [a security system that uses a wearable tag and/or sensor designed to prevent people with cognitive impairments from leaving secure areas to ensure their safety, by triggering alerts to caregivers] for safety. Record review of Resident 102's MDS, dated [DATE], under the Restraints and Alarms section did not indicate whether a Wander/elopement alarm was used. In an interview on 04/22/2026 at 1:27 PM, Staff K, MDS Coordinator/Registered Nurse, said there was a section on the MDS to identify if a resident was using a Wander Guard. Staff K said Resident 102 was not identified as using a Wander Guard. When asked how they would find out if a resident was currently on a Wander Guard, Staff K said they would look it up on the Medication Administration Record (MAR). After reviewing Resident 102's MAR, Staff K said the MDS should have identified the use of the Wander Guard. Resident 9 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 9 was severely cognitively impaired, had Non-Alzheimer's Dementia (a type of dementia, a decline in mental ability), and did not use a wander/elopement alarm (Wander Guard). Record review of Resident 9's elopement risk care plan, dated 05/23/2025, documented an Intervention/Task area, revised 04/01/2026, .WANDER [Guard] ALERT.This will be on his w/c [wheelchair]. In an observation on 04/22/2026 at 3:09 PM, Resident 9 was observed in his w/c in the dining room with a Wander Guard alarm attached to the right underside of the w/c frame. In an interview on 04/23/2026 at 8:30 AM, Staff H, Resident Care Manager/Licensed Practical Nurse, said Resident 9 had a Wander Guard alarm. Staff H said use of a Wander Guard alarm should have been captured on the MDS and it was not. In an interview on 04/23/2026 at 8:59 AM, Staff B, Director of Nursing/Registered Nurse, said it was her expectation there was a physician's order for use of a Wander Guard and it was captured on the MDS. Refer to F552 Reference WAC 388-97-1000 (1)(b), (2)(o)

Based on interview and record review, the facility failed to obtain and/or maintain Advance Directives (AD) and/or Guardianship for 1 of 6 sampled residents (Resident 14) reviewed for AD. This failure placed residents at risk of not having their healthcare preferences honored and a diminished quality of life.Findings included. Resident 14 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated [DATE], documented Resident 14 had a diagnosis of Alzheimer's disease (a progressive disease that causes dementia, a decline in cognitive function), Non-Alzheimer's Dementia, Down Syndrome (a genetic condition that affects brain and body development leading to intellectual disabilities), and was severely cognitively impaired. Review of Resident 14's Electronic Health Record (EHR) showed Resident 14 had a Letter of Guardianship / Conservatorship from the Superior Court of [NAME], County of Cowlitz, dated [DATE]. Further review of Resident 14's EHR showed The Letter of Guardianship/Conservatorship expired on [DATE]. In an interview on [DATE] at 10:36 AM, Staff F, Social Services (SS) Assistant, said she did not have a process to get renewed guardianship papers after they expired. When asked about Resident 14's expired guardianship papers, Staff F said Resident 14 did not have a current guardianship in place. In an interview on [DATE] at 10:44 AM, Staff G, Community Relations/SS Director, said after Resident 14's guardianship expired, they should have obtained a new guardianship. In an interview on [DATE] at 1:37 PM, Staff B, Director of Nursing/Registered Nurse, said Resident 14 had a long-term guardianship in place, to include prior to admission to the facility. Staff B said they should have pursued a new guardianship for Resident 14 after it expired. Reference WAC 388-97-0280 (1)

Based on interview and record review, the facility failed to ensure residents and/or resident representatives received information about the risk and benefits and obtain informed consent prior to the use of a Wander Guard (a device that detects when a resident approaches or passes through a monitored exit door, preventing elopement) for 1 of 2 sampled residents (Resident 102) reviewed for Wander Guard use. These failures placed residents and/or their representatives at risk of not being fully informed about the care and treatment related to the risks and benefits associated with the use of a Wander Guard.Findings Included.Review of the facility's Elopement/Wandering policy, dated February 2025, documented, if monitoring systems are used: 1. If it is determined that the resident is at risk for elopement and the center has a resident monitoring system installed, the following protocol is followed: a. The center notifies the resident or resident's responsible party of the results of the evaluation.Resident 102 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 02/23/2026, indicated Resident 102 was severely cognitively impaired.Review of Resident 102's Elopement Risk Evaluation, dated 02/23/2026, indicated Resident 102 was at risk for elopement related to (r/t) dementia.Review of Resident 102's care plan, dated 03/09/2026, indicated the problem: Resident 102 has impaired cognitive function or impaired thought processes, short term memory loss r/t metabolic encephalopathy [an acute brain dysfunction], dementia [a decline in cognitive function severe enough to impair daily life, caused by progressive brain damage]. The intervention: Resident uses Wander Guard for safety.Review of Resident 102's Electronic Health Records (EHR) progress notes did not show a consent for the Wander Guard.In an interview on 04/22/2026 at 1:36 PM, Staff H, Resident Care Manager/Licensed Practical Nurse, said if a resident appeared to be an elopement risk the facility would do an evaluation, get an order, get a consent, and put on the care plan. Staff H said the consent was verbal and would cover the risk and benefits of the Wander Guard. Staff H said staff would document the conversation in the progress notes.In an interview on 04/22/2026 at 2:01 PM, Staff B, Director of Nursing/Registered Nurse, said the facility would do an elopement evaluation, get an order and put on the care plan if the resident was deemed to be an elopement/wander risk. Staff B said they would get consent from the responsible part. Staff B said it should be documented in the progress notes.Reference WAC 388-97-0260 (2)(a)(b)(c)(d) & (3)(a)(b)

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I, a screening tool used to identify mental health needs, was requested upon a significant change of condition for 1 of 5 residents (Resident 12) reviewed for PASRR. This failure placed the residents at risk of unidentified mental health needs, and a diminished quality of life. Findings included . Record Review of the facility's policy, titled, PASRR Process Policy and Procedure, revised January 2025, documented, .4. If there is a significant change of condition that affects their diagnosed need for a PASRR II, staff refer for a NEW PASRR level II. Resident 12 was admitted to the facility on [DATE], with multiple diagnoses to include major depressive disorder (mood disorder characterized by persistent depressed mood), anxiety disorder (disorder characterized by excessive fear and worry), and psychotic disorder (severe mental illness causing to lose touch with reality). The Quarterly Minimum Data Set (MDS, an assessment tool), dated 02/23/2026, showed Resident 12 was severely cognitively impaired and was exhibiting signs of physical and mental decline. Record review of Resident 12's Level I PASRR, dated 01/04/2018, documented Resident 12 did not require Level II PASRR. Record review of Resident 12's EHR (Electronic Health Record), documented Resident 12 was assessed for change of condition and started hospice care on 09/20/2024. Record review of Resident 12's EHR did not show documentation that a new Level I PASRR was completed upon Resident 12's significant change of condition. In an interview on 04/22/2026 at 9:42 AM, Staff F, Social Services Assistant, said the facility's practice was to complete a new PASRR following a significant change in condition. Staff F stated, We should have done a new one after significant change - especially when she went on hospice. During an interview on 04/22/2026 at 10:29 AM, Staff K, MDS Coordinator and Registered Nurse, said Resident 12 had a significant change assessment completed in 2024, due to a payor change and going on hospice services. In an interview on 04/03/2026 at 01:18 PM, Staff B, Director of Nursing and Registered Nurse, said it was the facility's practice to send new PASRR referrals following a significant change in condition. Staff B said Resident 12's new PASRR referral was not completed per facility policy. Reference WAC 388-97-1915 (4)

Based on observation, interview and record review, the facility failed to provide restorative nursing services for 1 of 2 sampled residents (Resident 106) reviewed for Rehabilitation and Restorative. This failure placed residents at risk for avoidable decline in function and a diminished quality of life.Findings Included. Resident 106 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated 02/03/2026, documented Resident 9 was cognitively intact. In an interview on 04/20/2026 at 12:07 PM, Resident 106 said he was concerned about his hip. Resident 106 said he needed a Hoyer lift (a mechanical device that uses a sling to safely lift and transfer people with limited mobility between surfaces) for transfers. Resident 106 said he was not getting any rehabilitation or restorative services. In an observation and interview on 04/22/2026 at 12:56 PM, Resident 106 was observed sitting up in bed eating lunch. Resident 106 said he still had not received any restorative therapy and he should have. Record review of Resident 106's Impaired Mobility care plan, revised 02/25/2026, documented a Goal, revised 10/08/2025, Resident will not demonstrate evidence of contracture [a permanent abnormal tightening of muscles, tendon and/or ligaments resulting in stiff often painful joints and range of motion] to LE [lower extremity] with ROM [range of motion] program through next quarter. Further record review of the care plan documented an Intervention/Task, revised 10/31/2025, NURSING REHAB/RESTORATIVE: ACTIVE ROM Program ACTIVE ASSIST ROM TO LEFT knee 20 REPS [repetitions] FOR 2 SETS. Record review of Resident 106's Electronic Health Record (EHR) POC (point of care) Response History for Intervention: NURSING REHAB/RESTORATIVE: ACTIVE ROM Program ACTIVE ASSIST ROM TO LEFT knee 20 REPS FOR 2 SETS, dated 03/24/2026 through 04/22/2026, showed Resident 106's restorative program was provided on 03/27/2026, 03/29/2026, and 04/04/2026; 24 days since the last program was provided. Further review of Resident 106's EHR did not show any refusals of the restorative program. In an interview on 04/22/2026 at 1:00 PM, Staff H, Resident Care Manager/Licensed Practical Nurse, said the facility had their own restorative department. Staff H said all long-term care residents were on a restorative program unless they refused. Staff H said they documented the restorative program under the POC charting. After looking at Resident 106's EHR, Staff H said he had not recently received restorative services. In an interview on 04/22/2026 at 1:04 PM, Staff I, Restorative Aide/Certified Nursing Assistant, said Resident 106 was on a restorative program. Staff I said residents on a restorative program were supposed to be seen three times per week. Staff I said she had not seen Resident 106 this week for restorative. After looking at Resident 106's health record, Staff I said the last time Resident 106 got restorative was on 04/04/2026. Staff I said she did not see any refusals from Resident 106 for restorative. In an interview on 04/22/2026 at 1:29 PM, Staff B, Director of Nursing/Registered Nurse, said the restorative schedule was for three times per week. Staff B said Resident 106 was out of the facility frequently and they did not work with him on a regular basis. Staff B said they should be trying to provide restorative services around his schedule. Reference WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to obtain and/or initiate physician orders for use of a Wander Guard alarm (a security system that uses a wearable tag and/or sensor designed to prevent people with cognitive impairments from leaving secure areas to ensure their safety, by triggering alerts to caregivers) for 1 of 2 sampled residents (Resident 9) reviewed for accidents. This failure placed residents at risk of injury, unmet care needs, and a diminished quality of life.Findings included. Record Review of the facility's policy titled, Elopement/Wandering, updated February 2025, documented, . If monitoring systems are used: . b. The center obtains a physician's order for the use of the device prior to application. c. The LN [Licensed Nurse] also obtains an order to complete an evaluation for placement and function every shift. Documentation to occur on the MAR [Medication Administration Record] or TAR [Treatment Administration Record] . Resident 9 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 03/17/2026, documented Resident 9 was severely cognitively impaired and had Non-Alzheimer's Dementia (a type of dementia, a decline in mental ability). Record review of Resident 9's elopement risk care plan, dated 05/23/2025, documented an Intervention/Task area, revised 04/01/2026, .WANDER [Guard] ALERT.This will be on his w/c [wheelchair]. In an observation on 04/22/2026 at 3:09 PM, Resident 9 was observed in his w/c in the dining room with a Wander Guard alarm attached to the right underside of the w/c frame. Record Review of Resident 9's active physician orders, dated 04/21/2026, did not show an order for the use of a Wander Guard alarm and/or evaluation by the LN to check for placement and function every shift. Record Review of Resident 9's April 2026 MAR and TAR did not show documentation of evaluation for placement and function of a Wander Guard alarm. In an interview on 04/23/2026 at 8:30 AM, Staff H, Resident Care Manager/Licensed Practical Nurse, said Resident 9 had a Wander Guard alarm. Staff H said residents that used a Wander Guard needed a physician's order for use and to check for placement and functioning every shift that the nurses signed off. Staff H said Resident 9 did not have a current order for the Wander Guard and there should have been. In an interview on 04/23/2026 at 8:59 AM, Staff B, Director of Nursing/Registered Nurse, said it was her expectation there was a physician's order for use of a Wander Guard and it was captured on the MDS. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing information was accurately posted and/or updated daily with resident census for 5 of 5 observed days posted, and with the facility name for 34 of 34 days reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of current staffing level and facility information.Findings included. In an observation on 04/20/2026 at 10:14 AM, two Daily Nursing Staffing Information postings, dated 04/19/2026 and 04/20/2026, were observed posted on the wall in the entrance lobby of the facility. There was no title and/or label observed on the wall near the postings with the facility name. Further review of both postings showed the resident census was blank and the facility name was not on the postings. In an observation on 04/21/2026 at 8:10 AM, two Daily Nursing Staffing Information postings, dated 04/20/2026 and 04/21/2026, were observed posted on the wall in the entrance lobby of the facility. Further review of both postings showed the resident census was blank and the facility name was not on the postings. In an observation on 04/22/2026 at 4:00 PM, two Daily Nursing Staffing Information postings, dated 04/21/2026 and 04/22/2026, were observed posted on the wall in the entrance lobby of the facility. Further review of both postings showed the resident census was blank and the facility name was not on the postings. In an observation on 04/23/2026 at 8:46 AM, two Daily Nursing Staffing Information postings, dated 04/22/2026 and 04/23/2026, were observed posted on the wall in the entrance lobby of the facility. Further review of both postings showed the resident census was blank and the facility name was not on the postings. Record review of the Daily Nursing Staffing Information postings, dated 03/21/2026 through 04/18/2026, showed no facility name on the postings. In an interview on 04/23/2026 at 11:11 AM, Staff J, Receptionist/Staffing, said she did not get the census information for the facility until the next day. Staff J said she received yesterday's census information this morning. Staff J said she would add the previous day's census information to the posting the next day. Staff J said she did not know the daily nurse staff postings were supposed to have the current day's census and name of the facility on it. In an observation and interview on 04/23/2026 at 11:21 AM with Staff C, Divisional [NAME] President of Operations, Staff C observed the two Daily Nursing Staffing Information postings, dated 04/22/2026 and 04/23/2026, on the wall in the entrance lobby of the facility with the resident census blank and no facility name on the postings. Staff C said he expected the title of the facility was on the nurse staff postings and the daily census was posted for the current day. No WAC Reference

Based on observation, interview and record review, the facility failed to provide activities of daily living (ADL) care for dependent residents to include nail care for 1 of 2 residents (Resident 67), reviewed for ADLs. This failure placed residents at risk of not receiving the care and services needed.Findings included . Resident 67 was admitted on [DATE]. Record review of Resident 67's care plan, dated 04/08/2026, documented the problem for Resident 67 was an ADL [activities of daily living - basic self-care task to include nail care] self-care performance deficit r/t [related to] Dementia [a decline in cognitive function-memory, thinking, and behavior-severe enough to impair daily life, caused by progressive brain damage]. The care plan intervention - Diabetic Nail care by LN [licensed nurse]. Record review of Resident 67's Kardex (a centralized record of resident's care plan), dated 04/08/2026, indicated Diabetic Nail care by LN. Record review of Resident 67's Treatment Administration Record's, dated 04/06/2026, 04/13/2026, and 04/20/2026, weekly skin audit documented the audits were completed but no documentation nail care had been performed. In an interview and observation on 04/20/2026 at 10:56 AM, Resident 67's fingernails were observed to be about an 1/8 inch long. When asked if he liked long fingernails, Resident 67 said he liked them short. Resident 67's said they told the facility his toenails needed clipped as well. In an interview and observation on 04/23/2026 at 8:12 AM, when asked if his nail care had been done, Resident 67 said no and showed his long fingernails. In an interview and observation on 04/23/2026 at 8:18 AM, Staff L, Resident Care Manager/License Practice Nurse, said diabetic nail care should be completed during the weekly skin assessment. When asked to look at Resident 67's toenails, Staff L removed Resident 67's right sock, with Resident 67's approval, the toenails were observed to be about 1/4 inch long. Reference WAC 388-97-1060 (2)(c)

Based on interview and record review, the facility failed to ensure adequate care planned supervision was provided, for an out of the facility appointment, to prevent accidents for 1 of 3 sampled residents (Resident 1) reviewed for accident hazards and supervision to prevent accidents. Resident 1; who was assessed with moderate cognitive impairment, poor safety awareness and required maximum assistance with transfer and mobility; experienced harm when left unattended at an out of the facility medical appointment and fell while attempting a toilet transfer/stand from a seated position in the bathroom, required transfer to the hospital and experienced a pelvic bone fracture. This failure placed residents at risk for falls with injury, pain and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a progressive brain disorder affecting memory, thinking and behavioral skills), Osteoarthritis (a degenerative joint disease where cartilage breaks down over time causing pain, stiffness and reduced mobility), and presence of bilateral artificial hips. Resident 1's Minimum Data Set (MDS) assessment, dated 12/03/2024, documented the resident had moderate cognitive impairment and required assistance with activities of daily living including transfers and mobility. Resident 1's care plan, dated 03/24/2024, documented Resident 1 was a high risk for falls related to a history of falls with right hip fracture, left humeral fracture, confusion, de-conditioning, weakness, gait/balance problems, incontinence, pain, medications, cognitive impairment, and impulsive with poor safety awareness. Resident 1's care plan, updated 10/09/2024, documented Resident 1 was an elopement risk due to poor safety awareness/dementia, would not leave the facility unattended and had been provided with a wander guard (a device worn by the resident that triggers alarms or locks doors preventing residents from leaving facilities unattended). Resident 1's care plan, updated 02/21/2025, documented Resident 1 required two person maximal assistance for toilet transfers and sitting to standing as well as one to two person maximal/substantial assistance for transfers. An Accident/Incident/Injury/Property Damage Report from the local clinic had the following written statements: --Dated 02/13/2025 at 12:30 PM, showed, [A clinic staff] came to get nursing staff for help with patient [Resident 1] in bathroom . Once door was opened we found patient on floor head facing toilet. --Dated 02/13/2025 at 12:30 PM to 12:40 PM, documented, When patient was done with [appointment] with [clinic doctor], [a clinic staff] took [Resident 1] out to the waiting room so her [facility ride] could pick her up. [The clinic staff] walked back into the office. [Resident 1's facility ride] from the [facility] arrived and patient was not in waiting room where [the clinic staff] left her. [The clinic staff] then go to check the bathrooms . When knocked on the door, [Resident 1] had locked herself in the bathroom. [Clinic staff] asked if she fell . [Resident 1] said yes . Patient was on the floor . --Dated 02/13/2025 at around 12:30 PM, documented, [Clinic staff] came back and said someone fell in the bathroom . Patient was on the floor, feet near the toilet and head near the sink/wall. Wheelchair was also in the bathroom. When asked how she fell , [Resident 1]said she pulled herself up at the sink and fell before she could get to the toilet. [Nursing staff] came in to evaluate patient and [they] decided it would be best to call 911 so [Resident 1] could be evaluated at the [emergency department]. [Clinic doctor] also came in to evaluate patient . [Clinic staff] talked with the patient . and it was unclear if she goes to the bathroom by herself at the nursing facility. [Clinic staff was] not sure if anyone helped [Resident 1] to the bathroom or how she got in there . --Undated, documented, Patient finished an appointment with [clinic doctor] for a distal humerus fracture . [Resident 1 was waiting in the waiting room for a ride. She went to the bathroom alone unknown to staff. Ride could not find her; door locked to the restroom. Could hear her yelling for help. The door was unlocked with a key. Unwitnessed fall. [Resident 1] was found lying on her back, alert and oriented, some baseline confusion. Complaining of right hip pain. No cuts or abrasions . Did not think she passed out. [Resident 1] is on a blood thinner. Had a history of right hip replacement. [Clinic doctor] evaluated . Called 911 to assist with transport to the hospital . A facility incident report, dated 02/13/2025, documented Resident 1 was out of the facility at a doctor's appointment and fell while using the bathroom resulting in hip pain. Clinic staff called 911 and Resident 1 was sent to the ER for evaluation. Predisposing physiological factors were documented as confused, gait balance, history of self-transfer, and impaired memory. Predisposing situation factor was documented as ambulating without assistance during transfer. The facility incident report documented Resident 1 had limited safety awareness and required assistance for safety in transfers. The facility investigation, dated 02/13/2025, documented, [Staff Member] from [local] orthopedic clinic states that the driver showed up to pick up [Resident 1] and she was no longer sitting in the lobby where the MA [medical assistant] had left her. Staff went looking for [the resident] and found her laying on the floor of the bathroom in front of the sink, WC [wheelchair] behind her. [Resident 1] was laying on her right side, but [Resident 1] reports landing on her bottom first. Resident was then assessed by nursing and the MD [doctor at Ortho clinic]. MD ordered to send [Resident 1] to hospital for possible fracture. A computed tomography (CT) scan of Resident 1's pelvis, dated 02/13/2025, showed Resident 1 had an acute fracture of the right inferior pubic ramus (a bone located in the pelvis). On 03/11/2025 at 1:20 PM, Staff D, Administrator, said there were problems with how the transport form had been filled out for Resident 1. The person who filled it out did not put in for caregiver assist. Staff D said the person who filled out the form did not put their name on it, so they were not able to address the issue with that staff member. At 1:40 PM, Resident 1 said she remembered having a fall while out at an appointment, and believed she was trying to wash her hands at the time. On 04/02/2025 at 3:39 PM, Staff B, Social Services Assistant, said when residents needed to be scheduled for out-of-facility appointments, nurses would notify her of where residents needed to go and if they needed a staff assist (staff would go with the resident to the appointment). Residents that were either cognitively impaired or unable to self-propel in wheelchair would get a staff assist for their appointment. At 3:44 PM, Staff C, Licensed Practical Nurse, said nurses would let social work know who needed to be scheduled for transportation and they would plan from there. At 4:00 PM, Staff A, Director of Nursing Services and Registered Nurse (RN), said outgoing appointments were discussed during morning stand up every morning. Which residents required staff assistance was decided by the group at that time. Staff A said she did not recall what had been discussed for Resident 1's transportation needs. Staff A said she would have thought Resident 1 would have been safe after the facility driver got Resident 1 to the appointment. On 04/10/2025 at 2:57 PM, Staff E, Facility Transportation Driver, said he was strictly a driver for the facility. Staff E said he brought Resident 1 to the clinic, checked her in and left her in the lobby. Staff E said if residents needed to have staff assistant to be with them, the facility would send one with them. Or residents may have a family member to go with them, which Resident 1 normally did. Staff E said this was the first time he had taken Resident 1 to an appointment that her daughter was not with her. On 04/11/2025 at 12:06 PM, Collateral Contact (CC), Clinic RN, said after Resident 1's appointment, the medical assistant wheeled Resident 1 out to the lobby and told her the driver would be here shortly. CC said about 10-15 minutes later, the medical assistant noticed Staff E was in the lobby, but Resident 1 was not where she parked her. CC said the medical assistant heard someone yelling for help from the bathroom and knocked on the door. Resident 1 said she had fallen. CC said the medical assistant was unable to get in the bathroom because Resident 1 had locked it from the inside. Clinic staff got the key and got the door open. Resident 1 expressed pain and 911 was called. CC said no clinic staff were waiting with Resident 1 after she was taken to the lobby. CC said normally if the driver was not there after an appointment, residents would wait in the lobby until the driver got there to pick them up. CC said if residents come from a facility and need assistance, then someone from the facility should come with them. CC said clinic staff were not responsible for patients waiting in the lobby. CC said when they have patients come from facilities that are not cognitively intact, they have a caregiver or family member sit with them. CC said Resident 1 appeared confused. On 04/14/2025 at 11:40 AM, Staff G, Certified Nurses Assistant, said prior to Resident 1's pelvic fracture, she required assistance for transfers and sitting to standing. Staff G said Resident 1 was not able to perform either activity safely without assistance, but had a history of attempting self transfers without assistance. At 11:40 AM, Staff A said prior to Resident 1's pelvis fracture, the resident was not safe to transfer or sit to stand without assistance. Reference WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure residents were free from verbal abuse when reported concerns about verbal abuse were not followed up on and preventative interventions were not initiated for 1 of 2 sampled residents (17) reviewed for abuse and/or neglect. Resident 17 experienced harm when a staff member verbally abused him with profanity and condescending comments; and when the resident's request, to not have the staff member provide care, was disregarded which continued to upset the resident. This failure placed residents at risk for psychological harm, verbal abuse and a diminished quality of life. Findings included . The facility policy entitled Prevention of All Types of Abuse, Neglect, Mistreatment, Involuntary Seclusion, Exploitation, and Misappropriation of Resident Property, revised October 2022, noted, Center supervisors and staff [as appropriate] correct and intervene in reported or identified situations in which abuse, neglect, or misappropriation of property is more likely to occur by analyzing the following [items that would make residents more vulnerable to abuse] . d. the supervision of staff to identify inappropriate behaviors such as using derogatory language, rough handling, ignoring residents while giving care, etc. Resident 17 was admitted to the facility on [DATE] with diagnoses including paraplegia (paralysis of the legs and lower body), pressure wounds and chronic pain. The Quarterly Minimum Data Set assessment, dated 01/23/2025, indicated Resident 17 was cognitively intact. The August 2024 Accident/Incident Log did not show an entry for Resident 17 regarding care concerns or verbal abuse. The August 2024 Grievance Log did not show an entry for Resident 17 regarding care concerns or verbal abuse. On 02/03/2025 at 2:10 PM, Resident 17 said he was cussed out by a staff member in August 2024. Resident 17 said he had recorded the date in his cell phone note pad which he used to record events for tracking purposes. Resident 17 said he was told by Staff E, Licensed Practical Nurse (LPN), on 08/20/2024, that his pain medication had been delivered by the pharmacy. The resident said later on 08/20/2024 when the evening nurse came in to give him his medications, the evening nurse told him the pain medication had not been delivered. Resident 17 said he subsequently missed a dose of a long acting pain medication that evening. The resident said on the morning of 08/21/2024, Staff E came into his room to give him his morning medication, and the resident said to Staff E, Hey, you lied to me. Resident 17 said Staff E smirked at him, and said what do you mean. Resident 17 said he told Staff E, you told me the pain medication had been delivered when it had not. Resident 17 said Staff E appeared to become upset, face turned red, and in a raised tone of voice stated, I don't give a f**k what you think. Resident 17 said he asked Staff E to calm down as Staff E's outburst had startled him. Staff E continued to make condescending comments toward the resident. Resident 17 said Staff E said no one would want to take care of Resident 17 since all he does is complain. The resident said he asked Staff E to leave his room. Resident 17 said he immediately called both Staff C, Social Worker, and Staff G, Resident Care Manager and Registered Nurse, to report the outburst and had asked them both to come to his room. Resident 17 said he told both Staff C and Staff G about the verbal attack he had received from Staff E. Resident 17 said he told Staff C and Staff G that he had lost trust in Staff E, and that he must be able to trust his nurses as he is dependent on them for care. The resident said he also asked for Staff E not to be his nurse after this incident. Resident 17 said Staff E came back into his room about an hour later and said I hear you told [Staff C and Staff G] on me. Well, I got your pain medication here. That is, if you trust me enough to take them. Resident 17 said he felt like Staff E's behavior was cocky, intimidating and vindictive; and it caused the resident mental anguish. Resident 17 said there were additional times Staff E was assigned to the resident. The resident would call Staff G each time to have Staff E reassigned. Resident 17 indicated how many times do I have to report that I do not want this nurse providing care for me. When the resident was asked how it made him feel, Resident 17 said it made him feel like crap, and said how many times did he have to feel disregarded. The September 2024, October 2024, November 2024, and February 2025 Medication Administration Record documented Staff E was assigned to work with Resident 17 on the following dates: 09/01/2024 09/02/2024 09/11/2024 09/12/2024 10/11/2024 10/12/2024 10/17/2024 10/18/2024 10/31/2024 11/04/2024 11/05/2024 02/04/2025 On 02/04/2024 at 12:31 PM, Staff G said if a resident voiced concerns with care, he would have them fill out a grievance form. When asked how the staff would know if a resident had a grievance or abuse allegation, Staff G said he would interview the resident. Staff G said back in August he got a voice message from Resident 17 wanting to talk to him about Staff E. Staff G said he went and asked Staff E what happened, and Staff E told me Resident 17 was upset about information he did not like, and the resident asked Staff E to leave the room. When asked about the process for handling an allegation of abuse, Staff G said he would notify the Director of Nursing Services (DNS) and the Administrator (ADM). Staff G said he did not interview Resident 17 because he trusted what Staff E had told him. At 12:50 PM, Staff B, DNS and RN, said she was not sure of the details of the event as reported by Resident 17. Staff B said Staff G had mentioned something about running out of medications and the resident not liking what the nurse had told him regarding the situation. When asked what types of concerns were considered a grievance, Staff B said food concerns, missing items, things not considered abuse. Staff B said they would follow The Purple Book (The state's guidelines for the protection of nursing home residents along with guidelines for preventing, investigating, determining, and reporting incidents of resident abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation or misappropriation of resident property.) for an allegation of abuse. Staff B said she did not interview Resident 17, and assumed Staff G would have. On 02/07/2025 at 12:30 PM, Staff E said if an allegation of abuse was reported to him, he would talk to the staff member and have someone else resume care of the potential victim. When asked what other measures he would take, Staff E said, none that he could think of. When asked if Staff E had been providing care for Resident 17, Staff E said not since August 2024. When asked about giving medication to Resident 17, Staff E said not since August 2024. When asked about providing treatment to Resident 17, Staff E said not since August 2024. Staff E said he had never been back in that room (Resident 17's room) until 02/04/2025. On 02/11/2025 at 9:10 AM, Staff A, Administrator, said he was in communication with Resident 17 on the date of the alleged verbal abuse had occurred. Staff A said he received a text message from Resident 17 on 08/21/2024, which asked the Administrator to come see Resident 17 as soon as possible when he got into work that day. Staff A said it had something to do with running out of medications. Staff A was unable to recall if he went down to see Resident 17 about his concern. Reference WAC 388-97-0640 (1)

Based on observation, interview and record review, the facility failed to ensure bowel management interventions were initiated and/or implemented for 2 of 5 sampled residents (61 & 295), failed to ensure physician orders were initiated and/or implemented for 1 of 4 sampled residents (57), and failed to ensure care plan interventions to elevate feet were implemented for 1 of 7 sampled residents (86) reviewed for quality of care. These failures placed residents at risk for unnecessary discomfort, health complications, and a diminished quality of care and quality of life. Finding included . <Bowel Management> The facility's policy entitled, Bowel Protocol, updated 03/2018, documented, If a resident does not have a bowel movement for three days, the nurse administers the physician ordered bowel program . in the event the center has no specific bowel program the nurse administers medication as ordered as followed: --Administer milk of magnesia per physician order on day four. --If milk of magnesia offers no results, administer a stimulant laxative suppository (Bisacodyl, etc.) per physician order on the next shift, during waking hours only. --If resident continues to have no results from suppository, administer an enema on the next shift, during waking hours only. --If no results from enema, notify physician. 1) Resident 61 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment, dated 01/02/2025, showed the resident was alert and oriented. The Bowel Movement (BM) task sheet documented Resident 61 had a BM on 01/10/2025 at 9:25 PM. Resident 61's next BM was on 01/15/2025 at 12:23 PM, almost 111 hours since the last BM (more than 4 1/2 days). The January 2025 Electronic Medication Administration Record (EMAR) did not show documentation Resident 61 had any interventions between 01/10/2025 and 01/15/2025. The BM task sheet documented Resident 61 had a BM on 02/02/2025 at 1:29 PM. Resident 61's next BM was on 02/07/2025 at 5:59 AM, about 112 hours since the last BM (more than 4 1/2 days). A progress note, dated 02/06/2025 at 10:37 AM, documented the administration of milk of magnesia (constipation medication). The bowel protocol was initiated about 105 hours after his last BM (about 4 days and 9 hours). On 02/07/2025 at 9:40 AM, Staff I, Resident Care Manager (RCM) and Licensed Practical Nurse (LPN), said the bowel protocol should be initiated if a resident did not have a BM after 72 hours. While reviewing the BM task sheet, Staff I said Resident 61 had a BM on 01/10/2025 and another BM on 01/15/2025. Staff I said the Bowel Protocol should have been initiated on 01/13/2025. Staff I said the Bowel Protocol should have also been initiated on 02/05/2025. 50416 2) Resident 295 was admitted to the facility on [DATE]. The Admission MDS assessment, dated 01/21/2025, documented the resident was alert and oriented. The January 2025 BM task sheet documented Resident 295 did not have a BM in 7 days from 01/16/2025 to 01/22/2025. Review of Resident 295's January 2025 EMAR documented Milk of Magnesia was administered on 01/20/2025 after 4 days with no BM but was ineffective. The EMAR showed Milk of Magnesia was administered again on 01/23/2025, 3 days later. A physician's order, dated 01/15/2025, documented Bisacodyl Suppository 10 MG (milligram). Insert 1 suppository rectally as needed for Constipation. If no results from Milk of Magnesia, administer per MD order on next shift, during waking hours only. On 02/05/2025 at 2:40 PM, Resident 295 said he had an episode of constipation where he had not had a BM in 8 days. On 02/07/2025 at 9:40 AM, Staff G, RCM and LPN, said per the bowel protocol and physician orders, Resident 295 should have received Milk of Magnesia on the fourth day of not having had a BM, but if Milk of Magnesia was ineffective, Resident 295 should have received a Bisacodyl Suppository. After reviewing Resident 295's EMAR to see if the resident received a Bisacodyl Suppository, Staff G stated, Doesn't look like he got anything. Staff G was unable to find documentation of Resident 295 refusing additional bowel interventions. At 9:51 AM, Staff B, Director Of Nursing Services and Registered Nurse (RN) said it was the expectation licensed nurses followed the bowel protocol and should have medicated Resident 295 with the PRN (as needed) Bisacodyl as ordered after Milk of Magnesia was ineffective. 47518 <Physician Orders> Resident 57 was admitted to the facility on [DATE]. The Annual MDS assessment, dated 11/25/2024, indicated Resident 57 was alert and oriented. A Nursing Progress Note, dated 01/03/2025 at 12:00 PM, documented Resident 57 had fallen. The Note documented, at 3:54 PM, a physician order for an x-ray of Resident 57's left foot, ankle, and knee. A Nursing Progress Note, dated 01/04/2025 at 6:34 PM, documented, Spoke with on-call . physician via phone call. She stated according to res. [Resident 57's] XR [x-ray]) results, she appears to have a fx [fracture] to her L [left] great toe. She stated res. needs to begin wearing a hard sole open-toe post-op [post operative] shoe. Res. notified. Messaged RCM about shoe request. The Secure Conversations Progress Note, dated 01/06/2025 at 8:05 AM, documented, .physician stated according to res. XR results, she has a L great toe fx. She stated res. needs to wear a hard sole open toe post op shoe . Review of the Fall with Fracture investigation note, dated 01/08/2025, documented, .X rays came back with left great toe fracture. New order for resident to wear hard sole platform shoe. Shoe ordered, waiting for arrival. Review of Resident 57's electronic health record (EHR) did not show a physician's order for a hard sole open toe post operative or platform shoe. On 02/03/2025 at 3:41 PM, Resident 57 said she had fallen last month and broke her big toe. Resident 57 said she was supposed to get a stationary shoe but never did. Resident 57 said the doctor ordered it, and stated, .he was surprised it wasn't here. Resident 57 was observed not wearing a hard sole open toe post operative shoe. On 02/05/2025 at 9:59 AM, Resident 57 said she asked facility staff about the shoe a couple of times when she did not get it. Resident 57 said the doctor was going to re-order it. Resident 57 said she wondered what she was supposed to be doing with her foot, and stated, I am just very careful and used my left footrest and kept this leg up. A Nursing Progress Note, dated 02/05/2025 at 11:06 AM, 33 days after Resident 57's fall, documented, resident never received a platform shoe for great toe fx r/t [related to] unavailable. Ordered through therapy. Resident aware . At 12:19 PM, Staff I said the doctor ordered a sturdy, platform shoe for Resident 57 after the resident fractured her toe. Staff I said the doctor was notified that Resident 57 did not get the shoe. Staff I said she did not find documentation the provider was notified and stated, .there was not an official progress note showing that he was notified . Staff I said it was their practice when conversations happened with the doctor, it should be documented to include any refusals, changes, or orders that cannot be followed through. At 2:39 PM, after reviewing Resident 57's record to see if the physician order was inputted into the resident's EHR for the hard sole shoe, Staff I said she could not find the order for the special shoe, and stated, .we failed to input it into the physician orders, the verbal order for the post op shoe. At 3:31 PM Staff B said it was her expectation nurses documented conversations with a physician, especially if they were given directions from the physician. Staff B said if they received a verbal order from the physician, she expected it would get into the physician orders, and stated, I mean that's the way we could follow up. 51254 <Care Plan Interventions> Resident 86 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease and a fractured right femur. The 5-day MDS assessment, dated 01/03/2025, showed Resident 86 was alert and oriented. The renal insufficiency care plan, dated 12/30/2024, noted the intervention to elevate feet when sitting up in chair to help prevent dependent edema [swelling caused by an accumulation of excess fluid in the body's tissue]. On 02/03/2025 at 9:46 AM, Resident 86 said she had swelling in both legs and her legs became painful when she sat up too long. Resident 86 said this swelling to her legs was new since her surgery. On 02/04/2025 at 10:00 AM, Resident 86 was observed sitting in the wheelchair with feet resting on the floor. Resident 86 said her legs were painful. Resident 86 said she tried to use compression stockings to help the swelling, but they were uncomfortable. At 12:13 PM, Resident 86 was observed sitting in the wheelchair with feet resting on the floor. On 02/05/2025 at 9:28 AM, Resident 86 was observed sitting in the wheelchair with feet on foot pedals of wheelchair. At 12:28 PM, Resident 86 was observed sitting in the wheelchair with feet on the floor. On 02/06/2025 at 8:32 AM, Resident 86 was observed sitting in the wheelchair with her feet on the floor. Resident 86 lifted her blanket to show her swollen legs and feet and said they start to ache when her legs were down. At 8:34 AM, Staff M, LPN, said the nurse would tell the Nursing Assistants (NA) to elevate legs for residents. Staff M said the residents also had care directives hung in the closet for the NAs to follow for direct patient care interventions. After reviewing the care directives for Resident 86, Staff M indicated the interventions for elevating the resident's legs were not identified in the care directive. Staff M said she would notify the RCM so they could update the form. At 10:00 AM, Staff G, RCM and RN, said the interventions should be on the care directive for the NA to follow. Staff G said whoever did the care plan must have missed it. Reference WAC 388-97-1060 (1)(3)(c)

Based on observation, interview and record review, the facility failed to ensure residents' medical information were maintained in a manner to ensure privacy and confidentiality when staff failed to properly secure the electronic health record (EHR) for 1 of 1 sampled resident (36) reviewed for privacy and confidentiality. This failure placed residents at risk for loss of confidential medical information and a diminished quality of life. Finding included . On 02/06/2025 at 9:11 AM, while walking past the Oceanside medication cart, Resident 36's EHR, the resident's personal health information, was observed being displayed on the medication cart computer. There were no facility staff around. At 9:12 AM, Staff O, Licensed Practical Nurse, was observed walking out of the nurse's station office and towards the resident hallway. At 9:13 AM, Staff A, Administrator, was observed walking past the medication cart. As Staff A walked by, Staff A was asked what the process was for protecting the EHRs of residents. Staff A walked back to the medication cart and attempted to lock the computer but was not able to do so. Staff A went to the Oceanside hallway and retrieved Staff O. At 9:14 AM, Staff O said she usually locked the screen but was distracted. Staff O said the medication cart computer with residents' EHR was supposed to be locked or closed. Reference WAC 388-97-0360 (1)(b)

Based on interviews and record review, the facility failed to ensure residents were able to use personal possessions in their room, including a personal refrigerator, that did not infringe on the rights of other residents for 1 of 1 sampled residents (17) reviewed for resident rights. This failure placed the resident at a risk of a diminished quality of life. Findings included . Facility policy entitled Resident personal refrigerators and food brought in by family and visitors, updated August 2020, documented, under procedure 6 Residents or responsible party may provide their own UL [Underwriters Laboratories, an organization that tests and certifies products to ensure public safety] approved personal refrigerator for use in their room, provided the room can accommodate the refrigerator's electrical load and physical space. Designated refrigerators are available in the Center for storage of resident foods. Resident 17 was admitted to the facility on [DATE] with diagnoses including paraplegia. The quarterly Minimum Data Set assessment, dated 01/23/2025, indicated Resident 17 was alert and oriented. The facility grievance log showed three entries for Resident 17; dated 08/13/2024, 10/07/2024, and 11/26/2024; for missing sodas (carbonated beverages). A grievance, dated 01/14/2025, was for leftover pizza being thrown out. On 02/04/2025 at 2:20 PM, Resident 17 said he had asked the facility for permission to bring in a personal refrigerator. Resident 17 said he was told by both social services and administration that this request was not allowed. Resident 17 said he filled out grievance forms several times due to his personal soda and food items disappearing from the shared resident refrigerator. At 3:29 PM, Staff G, Resident Care Manager and Registered Nurse, stated, Yes, I know that Resident 17 asked for a refrigerator, but the regulations don't allow it. On 02/06/2025 at 2:51 PM, Staff A, Administrator, said he was not sure if the facility had a policy about personal refrigerators. Staff A was aware Resident 17 had requested a personal refrigerator, but the request was denied. Staff A said he told Resident 17 he could bring in an ice chest. At 3:10 PM, Staff C, Social Services, said Resident 17 had requested to bring in a personal refrigerator. Staff C said Resident 17's soda kept coming up missing and the resident wanted to keep it in his room. Staff C said this request was denied because personal refrigerators were not allowed. Staff C said a personal refrigerator would have to be temped and logged. When asked about the facility's policy showing a resident could bring in their own UL approved personal refrigerator, Staff C said she was unaware of the policy and if that were the case, there would be no reason to deny Resident 17's request. Reference WAC 388-97-0860 (2)

Based on interview and record review, the facility failed to ensure allegations of verbal abuse were investigated to prevent further abuse for 1 of 2 sampled residents (17) reviewed for investigations of abuse. This failure placed residents at risk for abuse and a diminished quality of life. Findings included . The facility policy entitled Prevention of All Types of Abuse, Neglect, Mistreatment, Involuntary Seclusion, Exploitation, and Misappropriation of Resident Property, revised October 2022, noted, Center supervisors and staff [as appropriate] correct and intervene in reported or identified situations in which abuse, neglect, or misappropriation of property is more likely to occur by analyzing the following [items that would make residents more vulnerable to abuse] . d. the supervision of staff to identify inappropriate behaviors such as using derogatory language, rough handling, ignoring residents while giving care, etc. Resident 17 was admitted to the facility on [DATE] with diagnoses including paraplegia, multiple pressure wounds and chronic pain. The Quarterly Minimum Data Set assessment, dated 01/23/2025, indicated Resident 17 was cognitively intact. The August 2024 Accident/Incident Log did not have an entry for Resident 17 regarding care concerns or verbal abuse. A subsequent facility investigation was not completed. The August 2024 Grievance Log did not have an entry for Resident 17 regarding care concerns or verbal abuse. On 02/03/2025 at 2:10 PM, Resident 17 said he was cussed out by Staff E, Licensed Practical Nurse, on 08/21/2024. The resident said Staff E told him his pain medication had been delivered by the pharmacy on 08/20/2024. Later on 08/20/2024, the evening nurse gave Resident 17 his evening meds and told him the pain medication had not been delivered causing him to miss a dose of a long acting pain medication that evening. Resident 17 said when Staff E came into his room, on 08/21/2024, to give him his morning medication, the resident said to Staff E, Hey, you lied to me. Resident 17 said Staff E smirked at him and said what do you mean. Resident 17 said you told me the pain medication had been delivered when it had not been. Staff E appeared upset, face turning red, and in a raised tone of voice stated, I don't give a f**k what you think. The resident said he was startled by the outburst. Staff E continued to make condescending comments toward the resident. Staff E said no one would want to take care of Resident 17 since all he does is complain. The resident said he asked Staff E to leave his room. Resident 17 said he immediately called both Staff C, Social Services, and Staff G, Resident Care Manager, to report the outburst and had asked them both to come to his room. The resident said he told both Staff C and Staff G about the verbal attack he had received from Staff E. Resident 17 said he told Staff C and Staff G that he had lost trust in Staff E, and that he must be able to trust his nurses as he is dependent on them for care. The resident said he asked for Staff E not to be his nurse after this incident. Resident 17 said Staff E came back in his room about an hour later, and said I hear you told [Staff C and Staff G] on me. Well, I got your pain medication here. That is, if you trust me enough to take them. Resident 17 said he felt like Staff's behavior was cocky, intimidating, vindictive and it caused the resident mental anguish. The September 2024, October 2024, November 2024, and February 2025 Medication Administration Record documented Staff E was assigned to work with Resident 17 on the following dates: 09/01/2024 09/02/2024 09/11/2024 09/12/2024 10/11/2024 10/12/2024 10/17/2024 10/18/2024 10/31/2024 11/04/2024 11/05/2024 02/04/2025 On 02/04/2024 at 12:31 PM, Staff G, Resident Care Manager and Registered Nurse (RN), said if a resident voiced concerns with care, he would have them fill out a grievance form. When asked how the staff would know if a resident had a grievance or abuse allegation, Staff G said he would interview the resident. Staff G said back in August he got a voice message from Resident 17 wanting to talk to him about Staff E, Licensed Practical Nurse (LPN). Staff G said he went and asked Staff E what happened, and Staff E told me Resident 17 was upset about information he did not like, and the resident asked Staff E to leave the room. When asked about the process for handling an allegation of abuse, Staff G said he would notify the Director of Nursing Services (DNS) and the Administrator (ADM). Staff G said he did not interview Resident 17 because he trusted what Staff E had told him. At 12:50 PM, Staff B, DNS and RN, said she was not sure of the details of the event as reported by Resident 17. Staff B said Staff G had mentioned something about running out of medications and the resident not liking what the nurse had told him regarding the situation. When asked what types of concerns were considered a grievance, Staff B said food concerns, missing items, things not considered abuse. Staff B said they would follow The Purple Book (The state's guidelines for the protection of nursing home residents along with guidelines for preventing, investigating, determining, and reporting incidents of resident abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation or misappropriation of resident property.) for an allegation of abuse and abuse investigations. Staff B said she did not interview Resident 17, and assumed Staff G would have. Staff B indicated she did not understand that this had to do with an allegation of abuse. On 02/07/2025 at 8:58 AM, Staff P, Nursing Assistant, said she would tell a nurse if a resident reported to her being abused. Staff P said she would document it, tell a nurse, notify management and notify the mandatory reporter. Staff P indicated she was a mandatory reporter. At 9:32 AM, Staff Q, Staff Development Coordinator and RN, said staff were trained about abuse on hire and annually. The training included the different types of abuse and how to report any allegation to the abuse officer, which was the ADM or the DNS, so they can call it in. At 12:30 PM, Staff E said if an allegation of abuse was reported to him, he would talk to the staff member and have someone else resume care of the potential victim. When asked what other measures he would take, Staff E said, none that he could think of. On 02/11/2025 at 9:10 AM, Staff A, ADM, said he was in communication with Resident 17 on the date of the alleged verbal abuse had occurred. Staff A said he received a text message from Resident 17 on 08/21/2024, which asked the ADM to come see Resident 17 as soon as possible when he got into work that day. Staff A said it had something to do with running out of medications. Staff A was unable to recall if he went down to see Resident 17 about his concern. Reference WAC 388-97-0640 (6)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure the recommendations on the Preadmission Screen and Resident Review (PASARR) level II were followed for 1 of 7 sampled residents (35) reviewed for PASARR. This failure placed residents at risk of not receiving necessary mental health services and a diminished quality of life. Findings included . Resident 35 was admitted to the facility on [DATE]. The annual Minimum Data Set assessment, dated 01/09/2025, showed Resident 35 was severely cognitively impaired. Resident 35 triggered a significant change PASARR to be completed on 12/12/2024 for new/changed behaviors. This PASARR indicated Resident 35 now required a Level II PASARR assessment by a licensed mental health professional or mental health agency for individual services. The Level II PASARR recommendations were received on 01/02/2025 by the facility for implementation. Resident 35's medical record showed the recommendations were not fully implemented by the facility to assist staff with interventions and strategies to alleviate symptoms of agitation and aggression after received on 01/02/2025. On 02/06/2025 at 8:58 AM, Resident 35 was observed sitting on the side of the bed with hands folded in lap. When asked what he was doing, Resident 35 stated, Nothing . There is nothing to do. When asked what he would like to do, Resident 35 stated, I would listen to classic rock if I could. Resident 35 pointed to two pairs of headphones and said they did not work. Resident 35 said he was not sure why they stopped working. At 3:02 PM, Staff H, Social Services Assistant, said if there was a change to the Level I PASARR she would redo the form to indicate a Level II assessment was needed. Staff H said she would forward the revised form to the mental health assessor for interventions. Staff H said when the facility received the recommendations from the level II, they would put them into the care plan. Staff H was unable to find the completed recommendations for the behavior interventions located in Resident 35's electronic health record. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for 2 of 5 sampled residents (43 & 70) reviewed for care plans. This failure placed residents at risk for not receiving personalized care and a diminished quality of life. Findings included . 1) Resident 43 was admitted to the facility on [DATE] with diagnoses including Post Traumatic Stress Disorder (PTSD). The Annual Minimum Data Set (MDS) assessment, dated 11/20/2024, showed Resident 43 was alert and oriented. Review of Resident 43's electronic health record (EHR) did not show PTSD was not addressed in the comprehensive care plan. On 02/06/2025 at 1:33 PM, when asked if Resident 43 had a care plan for PTSD with measurable goals and interventions, Staff I, Resident Care Manager and Licensed Practical Nurse, after reviewing the care plan, stated, It doesn't look like he has a care plan for that. 2) Resident 70 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia. The Annual MDS, dated [DATE], documented Resident 70 was alert and oriented. Review of Resident 70's EHR did not address dementia in the comprehensive care plan. On 02/06/2025 at 1:40 PM, when asked if Resident 70 had a care plan for Dementia with measurable goals and interventions, Staff I said she did not see it in the EHR. On 02/07/2025 at 9:51 AM, Staff B, Director of Nursing Services and Registered Nurse, said it was the expectation that residents with Dementia or PTSD diagnoses had care plans that addressed the residents individual needs. Reference WAC 388-97-1020 (1)(2)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure altered consistency liquids were provided and consistent with the resident's care plan (CP) for 1 of 1 sampled residents (74) reviewed for hydration. This failure placed residents at risk for aspiration (accidental inhalation of food or liquid into the airways), dehydration, and a decreased quality of life. Findings included . Resident 74 was admitted to the facility on [DATE]. The 5-day Minimum Data Set assessment, dated 01/15/2025, documented the resident was alert and oriented and had a stroke history. Resident 74's diet order, dated 01/30/2025, documented, nectar thick liquid consistency. On 02/04/2025 at 9:12 AM, Resident 74's room was observed to have a water pitcher containing thin liquid water. Resident 74 said some of the staff who pass water did not know she was on thickened liquids. The resident's care plan, printed and posted in Resident 74's room closet, documented, FLUID CONSISTENCY: mildly thick. At 9:40 AM, Staff E, Licensed Practical Nurse (LPN), said there was some thin water in the resident's room. Staff E stated, That was a mistake on our part. Staff E said Certified Nursing Assistants (CNAs) would get information on resident diet orders during morning report, and also from the care plan on the resident's closet door. At 9:45 AM, Staff F, CNA, said a water pass was usually done with meal pass, and residents with thickened liquid orders get their liquids from the kitchen, who gives them to the nurses. Staff F said she was aware of Resident 74's thickened liquid orders from report given when she came on shift. On 02/06/2025 at 1:30 PM, Staff G, Residential Care Manager and LPN, said thickened liquid orders were on a resident's baseline care plan, as well as on the resident's tray cards/meal ticket slips as well. Staff G said Resident 74's thickened liquid orders had changed recently. Staff G said on 02/04/2025 Resident 74's diet order documented mildly thickened liquids. Staff G said residents on a thickened liquid order should not have thin liquids in their rooms. At 3:06 PM, Staff B, Director of Nursing Services and Registered Nurse, said residents should not have liquid at the bedside inconsistent with the MD (medical doctor) order. Reference WAC 388-97-1060 (3)(i)

Based on observations, interviews, and record review, the facility failed to ensure medically related social services (SS) were provided to attain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 sampled residents (17) reviewed for medically related social services. This failure placed residents at risk for unmet psychosocial care needs and a diminished quality of life. Findings included . Resident 17 was admitted to the facility on [DATE] with a diagnoses including paraplegia. The Quarterly Minimum Data Set assessment, dated 01/23/2025, indicated Resident 17 was alert and oriented. Review of the care plan, entitled Risk for psychosocial well-being r/t (related/to) [being in the facility for] long-term care, revised 01/10/2025, documented [Resident 17] is a younger resident . [Resident 17] should speak with SS to assist him in setting realistic goals. On 02/03/2025 at 2:10 PM, Resident 17 said he was cussed out by a staff member in August 2024. Resident 17 said he had talked with Staff C, SS, about numerous concerns with staff and care concerns within the facility. Resident 17 said he has talked to SS regarding incidents related to staff treatment (including the incident in August 2024), training concerns, personal items request, and personal challenges. At 3:24 PM, Staff C said she was aware Resident 17 did not wish to have certain staff take care of him. Staff C said Resident 17 was particular to how he wanted things done. Staff C said she was aware he had asked not to have certain staff take care of him for things like positioning, wound care, and did not like argumentative staff. When asked about SS role in advocating for Resident 17's complex medical condition and concerns, Staff C said she should have followed Resident 17 more closely. Staff C said she had not formally addressed concerns between nursing staff and Resident 17. Staff C said she should have done more charting and care plan interventions to assist staff with providing care to Resident 17. Staff C said she had not consulted with the Social Services Director to help mitigate the concerns for Resident 17. On 02/07/2025 at 9:50 AM, Staff D, Social Services Director, said she would expect a social worker to advocate, troubleshoot concerns, get family support, help resident reach out, and care plan items. Staff D said she would expect there to be an interdisciplinary approach to make sure Resident 17's concerns were being addressed. Staff D said she would expect SS to provide emotional support, help identify coping strategies and to be supportive of the resident. Staff D said each of these concerns should have been addressed in the care plan. Refer to F600 & F610 Reference WAC 388-97-0960 (1)

Based on observations and interviews, the facility failed to ensure the facility had comfortable noise levels for 2 of 3 sampled residents (86 & 244) reviewed for safe and comfortable homelike environment. This failure placed residents at risk for excessive noise levels and a diminished quality of life. Findings included . 1) On 02/03/2025 at 9:46 AM, Resident 86 said it was hard to relax or sleep because of the constant slamming door just outside of her room. Resident 86 said this caused her the inability to relax and sleep because it jolted her awake. On 02/04/2025 at 10:45 AM, the double doors that closed off the countryside corridor were observed to slam shut loudly. For the following 15 minutes, the doors opened and closed 22 times. At 12:55 PM, Staff J, Maintenance Director stated, Yes, the doors do slam, and they are loud. It's because they are solid and heavy. Staff J said the doors must be closed due to the flu outbreak. Staff J said the doors had to slam in order to latch closed. 2) On 02/06/2025 at 12:09 PM, Resident 244 said there was a lot of noise in the hall that sounded like a door slamming. Resident 244 said she had only been at the facility one day and hoped it did not continue. On 02/07/2025 at 9:51 AM, Staff A, Administrator, said to ask Staff J about the doors. Staff A said Staff J oversaw any maintenance concerns. Reference WAC 388-97-0880 (4)(b)

Based on interview and record review, the facility failed to ensure timely treatment and monitoring to prevent the development and worsening of pressure ulcers for 2 of 3 sampled residents (#1 and #4) reviewed for pressure ulcers. These failures placed residents at risk for worsening skin impairment, a change in health status, pain and a diminished quality of life. This caused harm to Resident #1 and Resident #4 when pressure ulcers developed and/or worsened after being identified. Findings included . <Resident #1> Resident #1 was admitted to the facility on [DATE]. The Minimum Data Set, an assessment tool, dated 10/31/18, documented the resident was cognitively intact, required extensive assist with bed mobility, was at risk of pressure ulcer development and had one (1) stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle). Resident #1's Admission/Readmission nursing evaluation, signed and dated on 08/29/18, documented the resident did not have pressure ulcer(s). Resident #1's Braden scale (assessment tool used for assessing pressure ulcer risk), dated 08/29/18, showed a score of twelve indicating the resident was at high risk for pressure ulcer development. A nurses progress note, dated 09/01/18, documented the resident had an open area noted to sacral (buttock) area. 0.2 (cm - centimeter) by 0.2 (cm), barrier cream applied. The resident's medical record documented the resident was sent to the hospital on [DATE]. A review of the resident's history and physical hospital records, dated 09/13/18 at 11:07 AM, documented pressure sores noted to her sacrum, inguinal (groin) region and left heel. Resident #1's hospital discharge summary, dated 09/14/18, documented key follow up issues including, Skin care and pressure ulcer care. She was noted to have pressure ulcers at the time of admission that are not acute but need to be treated. Resident #1's nurses progress note, dated 09/14/18, documented, Noted opened area to right buttocks and opened area to left heel. Will need to refer to (wound clinic). Buttocks shows excoriation (abrasion) area. Resident #1's Admission/ Readmission nursing evaluation, effective date 09/18/18 and signed on 09/20/18, documented the resident had a stage 2 (partial thickness loss of dermis) pressure ulcer to right buttock measuring 3 cm by 5.2 cm by 0.2 cm and an unstageable (ulcers covered with slough or eschar) pressure ulcer to the left heel measuring 3 cm by 1.5 cm by undetermined depth. The (MONTH) (YEAR) and (MONTH) (YEAR) Treatment Administration Record (TAR) did not show documentation of treatment and monitoring of pressure ulcer, including 09/01/18 and 09/14/18. The weekly skin audits marked a minus sign on 08/30/18, 09/06/18 and 09/20/18, indicating no new skin impairments. The column for 09/13/18 was blank. A nurses progress note, dated 09/21/18, documented, .Her pressure areas to the buttocks have worsened and are covered with eschar (black scab) . The resident would be seen by (a wound clinic) on Tuesday (09/25/18), P[NAME] (plan of care) updated. Resident #1's physician orders [REDACTED]. Resident #1 initial wound assessment by the wound clinic, dated 10/09/18, documented the presence of an unstageable pressure ulcer to the right sacrum measuring 5.5 cm by 3 cm by 4.6 cm. Compared to 09/18/18 measurements, the pressure ulcer had worsened. On 03/26/19 at 3:05 PM, Staff E, Licensed Practical Nurse (LPN), said when a new skin issue was identified, the floor nurse conducted a complete skin assessment, initiated a skin evaluation in the computer, notified the doctor and obtained treatment orders. Staff [NAME] said when they input the orders, TARS were automatically created for treatment and monitoring. At 3:10 PM, Staff C, RCM and Registered Nurse (RN), said when a new skin issue was identified, it was her expectation for floor nurses to complete a skin assessment, notify the doctor, obtain treatment orders, input the orders, and provide treatment and monitoring. When asked about Resident #1's wounds noted on 09/01/18, 09/14/18, 09/20/18 and 09/21/18, Staff C said there were no skin evaluations completed and there was no monitoring and treatment initiated until 09/21/18. Staff C said nursing should have obtained treatment orders from the doctor and pressure ulcers should have been on the TARs for monitoring. Staff C said she did not know why the above was not done. Staff C said the resident's comprehensive care plans should have been completed before 09/27/18. At 4:06 PM, Staff B, Director of Nursing Services, said when a new skin issue was identified she expected staff to initiate a complete skin assessment, to notify the doctor, obtain treatment orders, complete skin evaluation, initiate TARs for treatment and monitoring, and to document. Staff A, Administrator, said for Resident #1, all of the issues identified were not done, and should have been done. <Resident #4> Resident #4 was readmitted to the facility on [DATE] after surgery to his wrist and multiple tenotomies (surgical release or cutting of tendons), as well as additional diagnoses, including a stroke with one-sided paralysis. The Minimum Data Set (MDS), an assessment tool, dated 12/30/18, showed Resident #4 was alert and oriented and required extensive assistance with activities of daily living. The facility's Policy on Skin Integrity, updated (MONTH) (YEAR), documented, If allowed, the LN (Licensed Nurse) removes devices/braces/splints/dressing (and associated wrappings) 2 times per week and as needed (PRN). Risks and benefits of non-removal are discussed with the resident and MD. The LN [MEDICATION NAME] the skin under the device and document findings on the TAR (Treatment Administration Record) with their initials . A Braden Scale for Predicting Pressure Sore Risk, dated 11/16/2018, documented Resident #4's score as 12, which placed him at High Risk range of pressure sore development. Resident #4 had other areas of skin impairment. Review of Resident #4's clinical record documented on 1/4/2019, Resident #4 underwent surgical fusion and tenotomies due to contracture of the left hand. A nursing note, dated 01/18/2019 at 2:48 PM, documented Resident #4 returned from follow-up appointment with the orthopedist surgeon. New instructions read: Left wrist brace ok to remove for skin care, shower, and incision checks. Follow up in 4 weeks. Resident #4's (MONTH) 2019 TAR contained an entry, dated 01/18/2019: Left wrist brace ok to remove for skin care, shower and incision checks 2 times a day. The TAR documented the checks were to be done between 6 AM and 11 AM, and between 6PM and 10 PM. The (MONTH) 2019 TAR documentation for removal of Resident #4's brace and skin inspection contained a blank on 02/01/2019, 02/05/2019, 02/07/2019, 02/13/2019, and 02/14/2019. The days after 02/16/2019 were each blocked off with an X. A Weekly Skin Evaluation, dated 02/04/2019, documented the wound from Resident #4's surgical incision was well approximated (closed), and the wound was resolved (healed). A nursing note, dated 02/18/2019 at 2:36 PM, documented Staff F, a Registered Nurse, and Staff G, a Licensed Practical Nurse and the Resident Care Manager, unwrapped Resident #4's arm and assessed the surgical site. Upon unwrapping, Staff F documented, This nurse found a Stage 4 pressure sore to left lateral palm/wrist. Appears to be tendon exposed. Moderate serosanguinous (blood-tinged) drainage noted. 4 cm x 2 cm x 1.2 cm. Risk management complete. MD notified. Family notified. Ortho(pedist) notified. (Administrator) notified. Report with State complete. A Weekly Skin Evaluation, dated 02/18/2019, documented Resident #4's left palm had a left lateral wrist pressure wound. 4 cm x 2 cm x 1.2 cm. irregular shape, exposed tendon. Serosanguinous drainage. Under wound type, the wound was described as a pressure ulcer, Stage IV. A report, dated 03/04/19, by an contracted wound care provider documented, a Stage 4 Pressure Injury to Resident #4's left wrist, acquired on 02/18/19, with exposed tendon, and which measured 2.5 x 3 x 0.2 cm. On 02/21/19 at 4:45 PM, when asked how he got the wound on his hand, Resident #4 said, They didn't change the dressing for 5 days. Resident #4 stated it was noticed when drainage had gone through the dressing. On 03/15/19 at 2:45 PM, Staff G, the RCM in charge of Resident #4's nursing care, said Resident #4 was supposed to wear his splint except for skin checks two times a day. Staff G said nursing staff were supposed to take off the splint and look at the wound but that wasn't always the case, there were a few times that didn't happen. When asked how the wound developed when the site was monitored, Staff G said, there were some blank spots where staff did not document, and then the order dropped off the TAR for some reason. I looked at it on Wednesday (02/13/19), but then it didn't get looked at the rest of the week. I saw it again on Monday. And that's when I saw the new wound. On 3/20/19 at 5:10 PM, Staff B, the Director of Nursing Services, said the site should have been checked twice a day. Reference WAC 399-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to ensure pressure ulcers were identified and care and services were provided to prevent and treat pressure ulcers for 2 of 7 sampled residents (#29 & 23) reviewed for pressure ulcers. These failures placed residents at risk for avoidable and untreated pressure ulcers, and a diminished quality of life. This caused harm to Resident #29 and Resident #23. Findings include . 1) Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #29's care plan documented the resident was at high risk for skin breakdown and limited physical mobility. Care-planned interventions, dated 03/26/18, directed staff to reposition her frequently for preventative for skin breakdown. On 08/06/18, 08/07/18, 08/09/18 and 08/10/18, Resident #29 was observed lying on her back in bed. The resident was not observed lying on her left or right side and was not observed to receive care to off-load pressure points. The (MONTH) (YEAR) Treatment Administration Record documented the resident had a weekly skin audit on 08/07/18 with no skin impairments. On 08/09/18 at 7:41 AM, a red, non-blanchable area around 4 inches around with a dime-sized open area was observed on Resident #29's upper buttocks/coccyx area. At 7:50 AM, Staff F, RN and Resident Care Manager, assessed and measured the wound and surrounding areas. Staff F said there were 3 to 4 areas of concern. Staff F said she would expect staff to turn Resident #29 every 2 hours. The resident's medical record showed no documentation indicating Resident #29 refused to be turned. A skin evaluation sheet, dated 08/09/18, documented Resident #29 had a left buttock 4 centimeter (cm) long, 4.2 cm wide, with unknown depth, left buttock deep tissue injury stage 2 pressure ulcer; a coccygeal 1.8 cm long, 0.3 cm wide 0.1 cm deep stage 2 pressure ulcer and a right buttock 1.4 cm long, 0.5 cm wide, non-blanchable area, indicating a stage 1 pressure ulcer. On 08/13/18 at 9:59, Staff B, Registered Nurse and Director of Nursing Services, said turning a resident frequently meant turning them every 2 hours. Staff B said he expected residents at high risk for skin impairment to be turned every 2 hours while in bed. 2) Resident #23 was admitted to the facility on [DATE] with multiple diagnoses. The MDS, dated [DATE], documented the resident was cognitively intact, required extensive assistance for ADLs, and skin was intact. On 08/06/18 at 3:37 PM, the resident said she had a sore on her right hip/buttock area for a week or more. A progress note, dated 08/01/18 at 2:30 PM, documented, RCM in to provide skin check, .red non-blanch able area noted to left side of coccyx, appears to be over old scar tissue, boggy heels, will float in bed. A progress note, dated 08/02/18 at 10:20 PM, documented, Resident has a small skin issue in the coccyx region. A progress note, dated 08/03/18 at 10:56 PM, documented, Residents' skin is pink and moist and has a small, 1 centimeter (cm) X 1 cm pressure ulcer to her coccyx. A progress note, dated 08/04/18 at 9:46 PM, documented, Skin is pink and moist, with the exception of coccyx area, which has a tear approx. 3cm long. On 08/08/18 at 3:19 PM, Staff T, Licensed Practical Nurse (LPN), said the resident did not currently have any skin issues. Staff T said the process used when a skin issue was discovered was the discovering nurse did a skin sheet, made a copy and put it in the Resident Care Manager's (RCM) box. The RCM then observed the issue themselves, determine what treatment was needed, got an order for [REDACTED]. On 08/09/18 at 12:01 PM, the resident was observed to have a 4 cm X 2 cm non-blanchable area to her right mid-buttock area with no drainage present. Review of (MONTH) (YEAR) weekly skin audits, dated 07/06/18, 07/13/18, and 07/20/18, showed documentation of a minus (-) sign which indicated no new skin impairment. The weekly skin audit for 07/27/18 documented an X. There was no indication on the Chart Key to show what an X meant. Review of (MONTH) (YEAR) weekly skin audits, dated 08/01/18, showed with a minus sign (-) indicating no new skin impairment. The weekly skin audit for 08/08/18 documented an X. Review of care plan for potential pressure ulcer related to incontinence and immobility, dated 06/08/18, showed no updates regarding current skin issue and/or interventions. On 08/09/18 at 11:45 AM, Staff B said it was his expectation that if any staff found a skin impairment, first they would fill out a 'stop and watch' form. If an aide discovered it, they should report it to the nurse. The nurse should assess, including getting measurements. If the nurse was an LPN, they needed to get a Registered Nurse (RN) to assess. The resident would be put on the 24 hour alert charting report. Staff B said he expected the nurse to inform the physician and get any necessary orders and update the care plan. Staff B said he did not know what an X documentation on a weekly skin assessment meant. Staff B stated, We should be using the standard of a minus sign (-) indicated no new impairment and a plus sign (+) indicated a new impairment. Staff B said Resident #23's weekly skin audit sheets were incorrectly documented and the procedure for identifying and treating skin issues was not followed. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to identify the root cause for meal refusal to ensure acceptable parameters of nutrition were maintained for 1 of 8 sampled residents (#45) reviewed for nutrition. This failure placed residents at risk for malnutrition and a decline in health status. This caused harm to Resident #45. Findings include . Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set, dated dated [DATE], documented the resident experienced delusions, exhibited verbal behavioral symptoms, rejected care, was independent with eating and had experienced a significant weight loss. Resident #45's care plan, initiated on 01/25/18 and revised on 07/26/18, documented a problem of Resident #45 refusing to let staff remove old food and drinks and became verbally aggressive when staff attempted to intervene. The care plan's interventions included, Monitor and document circumstances surrounding mealtimes/refusals to eat and attempt to determine a pattern or cause for behavior and where possible alter or remove cause. Staff to call guardian if needed for interventions of behaviors. Resident #45's care plan, initiated on 03/05/18 and revised on 07/17/18, documented the resident had a nutritional problem with an intervention, initiated on 06/21/18, to identify food for resident. On 08/06/18 at 12:30 PM, an unidentified staff member was observed to place Resident #45's lunch on his bedside tray without set-up and/or identification of the meal. On 08/09/18 at 6:02 PM, Staff H, a Nursing Assistant, delivered Resident #45's dinner tray. Staff H did not identify the food to the resident. Record review of Resident #45's weights documented the following: 08/08/18 - 135 pounds 07/17/18 - 142 pounds 05/15/18 - 150 pounds 04/20/18 - 158 pounds 03/01/18 - 170 pounds From 03/01/18 to 08/18/18, Resident #45 had a 20.59% weight loss. Resident #45's (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. Resident #45's meal monitor, from 07/11/18 to 08/09/18, documented resident refused or ate 0-25% of his meal 75 of 87 times, 86% of the time. Resident #45 also refused an alternate meal 91% of the time during this same time period. physician progress notes [REDACTED]. The patient is not eating well, which is in my opinion is less a matter of a 'true' appetite disturbance and more an issue of his disorganized, poor thinking. A nutrition/dietary note, dated 07/05/18, documented, Resident is only eating 0-25% in a month. He has had a significant weight loss over the past month. physician progress notes [REDACTED].#45's primary physician, dated 07/11/18, documented, continued weight loss - refusal to eat offered diet - RD (Registered Dietician) working with him . documented decline in cognitive status over last several weeks - no recent cognitive evaluation feed whatever is appetizing. On 08/10/18 at 10:17 AM, when asked how much Resident #45 usually eats, Staff EE, Nursing Assistant, stated, Maybe a few bites, if nothing at all. When asked what is done if the resident refused his meal, Staff EE stated, Offer to get him something else. He doesn't like much of the food. At 10:30 AM, when asked if Resident #45 refused his meals, Staff I, Licensed Practical Nurse and Resident Care Manager (RCM), said Resident #45 refused his meals at times. When asked what was being done about the refusals, Staff I stated, (Staff DD) put him on [MEDICATION NAME] (an anti-psychotic medication) to help with behaviors. When asked what non-pharmacologic interventions were implemented for his refusals, Staff I stated, The social worker deals with behaviors. At 10:40 AM, when asked about Resident #45 refusing, or eating 0-25% of his meal, 86% of the time in the last 30 days, Staff L, Social Services Assistant, said Resident #45 had refused meals at times. When asked what non-pharmacological interventions had been attempted for Resident #66's refusals, Staff L stated, I'm not a part of weight meetings but I'd like to be. At the [MEDICAL CONDITION] meeting we talked about the carb cravings. I will definitely check back in with (Resident #45) now that I know there is an extensive pattern of refusals and see what I can do for him. At 1:51 PM, when asked about the expectation when a resident had a pattern of refusing meals and had a significant weight loss, Staff B, Director of Nursing, stated, I think there should be a root cause analysis and social services should be involved in this. He is very directive of his care. He's saying I'm in control. There might be something going on, depression or some organic process. Yes, he can be really self-isolating. I would expect more interventions there from social services to get a better conclusion of what the root is. When asked if he expected social services to be aware of the refusals, Staff B stated, Yes, we do go through it in clinical. There should be progress notes when you have someone repeatedly refusing. They should go in alert or to stand up where RCMs, social services, and others should be in involved. Resident #45's care plan, initiated on 12/11/17 and revised on 07/26/18, documented impaired cognitive related to dementia and did not address the resident's refusals. Behavior monitoring for refusals was not located in Resident #45's medical record. Failure to adequately assess, monitor, and intervene regarding resident's frequent refusals of meals, alternate meals, and supplements, and/or correlate the refusals as a possible symptom of Resident #45's [DIAGNOSES REDACTED].#45 when he had a significant 20.59% weight loss in 6 months. Reference WAC 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to provide treatment and services to prevent pressure ulcers from developing for 1 of 7 sampled residents (#3) reviewed for pressure ulcers. This failure placed residents at risk for avoidable and untreated pressure ulcers. This caused harm to Resident #3 when an unstageable pressure ulcer developed after admission to the left heel. Findings include . Resident #3 was admitted to the facility 03/20/18 with [DIAGNOSES REDACTED]. The Minimum Data Set, a comprehensive assessment tool, dated 03/27/18, documented the resident required extensive assistance with activities of daily living, including 2 person physical assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. The nursing admission evaluation, dated 03/20/18, documented Resident #3 had no skin issues to the left heel or the presence of the left ankle boot. The Braden Scale for Predicting Pressure Sore Risk, dated 03/20/18, showed the resident was at risk (a score of 16, the lowest risk) for pressure ulcers. Record review of the resident's care plan, initiated 03/21/18, did not address the resident being at risk for pressure ulcers and/or the boot to the left ankle including monitoring of the boot. A nursing note, dated 03/24/18 at 6:37 PM, documented Resident #3 was placed on alert for a 3 centimeter pressure area to the back of the left heel due to the resident's ankle boot. A physician's note, dated 03/26/18 at 3:13 PM, documented, Pressure ulcer, unstageable at left heel. Please paint with [MEDICATION NAME] 2 times a day and float left heel. On 4/11/18 at 11:30 AM, Licensed Nurse (LN) A, a registered nurse, said the resident developed a pressure ulcer after his admission to the facility due to a therapeutic boot that had been applying pressure to his left heel. LN A said there were no pressure relieving interventions implemented to prevent the pressure ulcer from developing. WAC 388-97-1060(3)(b)

Based on interview and record review, the facility failed to follow appropriate diet recommendations for 1 of 4 sampled residents (#1) reviewed for quality of care. This failure placed residents at risk for choking, aspiration and requiring lifesaving interventions. This caused harm to Resident #1. Findings include . Resident #1 admitted to the facility 11/17/17 with multiple health conditions. Resident #1's Minimum Data Set, a comprehensive assessment tool, dated 12/02/17, documented the resident required one person physical assist with eating. Resident #1's medical record documented, on 12/15/17, Resident #1 was on a soft texture diet with no bread per the Speech Therapy evaluation and recommendation. Resident #1 was served pizza for dinner. Nursing Assistant (NA) A noticed Resident #1 was choking and called for assistance. On 1/24/18 at 1:50 PM, Licensed Nurse (LN) A stated on 12/15/17 he was working at the nurse's station when he heard NA A call for help from the dining room. LN A stated Resident #1 appeared pale and was taking very shallow, ineffective breathes. Resident #1 was then lowered to the ground so staff could perform the abdominal thrusts. LN B arrived with suction and they were able to remove some food product from Resident #1's airway. EMTs arrived at this time and transported Resident #1 to the hospital. LN A stated the resident meal slip showed the resident was on a soft food diet with no breads/rolls. Resident #1's medical record documented, on 12/17/17, Resident #1 was difficult to rouse in the morning and oxygen saturation levels were in the 80's on room air. Chest X ray results showed a development of left perihilar infiltrate (an abnormal substance in the lungs). A nurse's note, dated 12/20/17 at 5:14 PM, documented Resident #1 was on 2 liters of oxygen related to aspiration pneumonia (a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs). On 1/05/18 at 12:30 PM, The Director of Nursing Services said pizza had been removed from non-bread diet recommendations and that all the resident's diet orders have been reviewed for appropriateness to the individual care needs. Resident #1 was provided immediate medical attention and evaluation and continues to be followed by Speech Therapy. An audit was conducted of the current resident's diet orders in the medical records and tray card and concerns were addressed. The licensed Speech Therapist reviewed the menu spreadsheet to identify any food items that were felt to be hazardous for the residents on the Speech Therapy caseload, specifically excluded item will be individually listed on the tray cards. Kitchen Staff, Nursing and Certified Nursing Assistants received in-service training on 12/17/2017 on reading the tray cards and the different diet types including textures. Tray accuracy in-service training occurred on 1/4/2018. Diet order and tray card audits will be reviewed routinely by DNS and/or designee for 30 days and as needed therafter. Results of audits will be brought to QAPI meetings for review to ensure continued compliance. Corrections and/or adjustements to the plan of correction will be made by the Administrator, as necessary through QAPI reivew. The Administrator will monitor compliance. This was Past Non-Compliance. WAC Reference 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to ensure acceptable parameters of nutritional status were maintained and resulted in a 17.5% weight loss in a six (6) month period of time for 1 of 2 sampled residents (#41) reviewed for nutrition. Failure to implement appropriate interventions resulted in an unplanned 33 pound weight loss. This caused harm to Resident #41. Findings include: Resident #41 was admitted to the facility on [DATE]. The resident's Minimum Data Set, an assessment tool, dated 5/12/17, indicated the resident was cognitively intact and required two person extensive assistance with activities of daily living. On 7/12/17 at 9:37 a.m., the resident was observed lying in his bed and appeared thin. Record review showed Resident #41 was assessed by the Registered Dietician (RD) on 12/6/16, one week after admission to the facility. The RD's evaluation indicated the goal was to have no significant weight change. The evaluation documented the resident had several missing teeth and ate independently in his room. The resident's weight record indicated the resident weighed 188 pounds on 12/6/16 and 178.6 on 12/22/17. In a clinical note, dated 12/30/17, the RD documented the weight loss was likely due to his use of diuretic medications. No new interventions were put into place. The resident's Nursing Admission Evaluation, dated 11/30/16, indicated the resident did not admit with [MEDICAL CONDITION] (excess watery fluid collecting in tissues of the body) and it was not documented in progress notes. Nursing progress notes showed the resident had signs of dehydration and impaired kidney function and the diuretic medications were discontinued on 12/29/16. On 2/24/17, the resident weighed 173 pounds. A Nutritional Note, written by the Dietary Manager (DM), dated 3/1/17, indicated the resident's weight was down and she planned to alert the RD for a referral. The note indicated a 7.7% weight loss had occurred. On 7/14/17 at 11:46 a.m., when asked about the 3/1/17 nutritional note, the RD said she did not receive a referral for Resident #41. On 4/18/17, the resident weighed 167.5 pounds. On 4/27/17, eight weeks after the 3/1/17 nutritional note, the RD documented the resident had a 12% weight loss over the previous 136 days possibly due to diuresis of hospital fluids and was now stable. The note indicated the resident was not on supplements and the plan was to continue the same plan of care. A Nutritional Note, written by the DM, dated 6/8/17, indicated the plan was to continue the current plan of care. On 6/9/17, the resident weighed 156.5 pounds. On 6/22/17, the RD documented a significant weight loss over 16 days and the cause was unknown. On 7/6/17, the resident weighed 155 pounds, 33 pounds less than his weight upon admission to the facility. On 7/14/17 at 11:14 a.m., the RD indicated she would assess residents upon admission to the facility, annually, and if a significant weight change occurred. The RD said the Dietary Manager (DM) completed quarterly evaluations. The RD said, I last saw him on 6/22/17. He had a significant weight loss and we were unsure why. We added cal dense (a nutritional drink) for a two week period. When asked why other interventions to prevent weight loss were not put into place, the RD said, We weren't sure of his usual weight. He was difficult to understand and unable to state his usual weight. We thought the weight loss was a result of receiving fluids at the hospital and then losing water weight. The RD said the resident had not taken diuretic medication since the end of December 2016 when the medications were discontinued. On 7/24/17 at 11:24 a.m., the resident's family member stated, He is usually about 180 but has weighed up to 200 pounds. This is the lowest I have ever seen him. It's very bizarre. It is obvious he has lost a lot of weight. Reference WAC 388-97-1060 (3)(h)

Based on observation, interview and record review, the facility failed to identify residents at risk of skin breakdown from developing pressure injuries and/or wounds increasing in size for 3 of 4 sampled residents ( 241, 276, &281) reviewed for pressure ulcers. Failure to recognize, assess, monitor, evaluate, accurately document and/or prevent and promote prompt healing of existing pressure ulcers placed all residents at risk of developing pressure injuries, and a diminished quality of life. This caused harm to Resident #281. Findings include: 1) Resident #281 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing notes, dated 7/9/17 at 8:27 p.m. and signed by Licensed nurse (LN) A, documented an 8 centimeter (cm) round blister to right heel was draining blood tinged fluid. LN A documented, Will initiate treatment after consult with physician tomorrow. Review of the Nursing Admission Evaluation Form, dated 7/10/17 at 1:11 p.m., signed by LN A, documented an 8 cm round blister on the right heel, a history of pressure/stasis ulcers, an actual pressure ulcer being present, was dependent on assistance for mobility with assist of one and was alert and oriented. The Braden scale, (an assessment tool used to assess skin risk), dated 7/10/17 at 1:35 p.m. and signed by LN A, documented a score of 15 indicating a high risk. The resident's records were reviewed from 7/09/17 through 7/17/17, and showed no wound or impaired skin integrity care plans. The resident summary sheet used by aides to direct care of the resident showed no intervention directing aides on care and/or positioning of the resident regarding the heel wound. On 7/12/17 at 11:41 p.m., nursing notes documented the resident complained of something hurting her bottom. After inspection, LN B discovered a dime size blister to her coccyx area. On 7/13/17 at 11:03 a.m., LN A stated she had reviewed records and there was not any treatment orders for the right heel. At 11:06 a.m., the resident's right heel was observed with an open area on the right medial heel that measured 3 cm x 2.5 cm and had dried drainage noted. There was an area of the wound that had some skin folded over on itself and was red. At 1:18 p.m., review of the Wound/Skin Evaluation form found documentation by the ARNP the pressure area to the right heel was a Stage 3, an increase in staging since admission. The National Pressure Ulcer Advisory Panel (NPUAP), used as the standard in pressure ulcer staging, defines a blister or partial thickness loss of dermis (Top layer of skin) as a Stage 2, and full-thickness loss of skin in which fat is visible in the ulcer and granulation tissue and epibole (rolled over wound edges) are often present as a Stage 3. NPUAP defines unstageable as obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed due to it be obscured. At 7:33 p.m., nursing notes by LN C documented evaluation of the right heel by MD indicating the wound was unstageable. On 7/17/17 at 10:21 a.m., a wound in the crease at the top of the buttock was observed. The top layer of skin was gone and there was no drainage and measured 8 cm x 1.8 cm. On 7/13/17 at 2:29 p.m., the Director of Nursing Services (DNS) stated when a wound was discovered on admission, the nurse should obtain any orders needed for treatment of [REDACTED]. Resident #281's wound to the right heel was present on admission, 7/09/17, and worsened to unstageable, and the resident developed a wound to her buttocks on 7/12/17 which she was not admitted with. 2) Resident #276 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Nursing Admission Evaluation Form, dated 6/23/17 and signed by LN F, documented the resident was alert and oriented, was not incontinent of bowel or bladder and had intact skin. On 7/11/17 at 11:54 p.m., review of nursing notes showed the resident had three (3) small open areas on the coccyx. Two were 1 cm x 1 cm in circle diameter and the third was 1 cm x 3cm oblong in shape. On 7/14/17 at 10:20 a.m., the resident stated he thought he got the sore here from the bed. It's plastic and makes you sweat, no air movement, you know. On 7/17/17 at 10:04 a.m., the resident's was observed with a wound in the crease of the buttocks. It measured 0.8 cm x 1 cm, was dry without drainage, and appeared as if the top layer of skin had been removed. Resident #276 developed a skin ulcer to the buttocks after he was admitted to the facility. 3) Resident #241 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented the resident required extensive assistance with positioning in bed and was always continent of bowel and bladder. No pressure ulcers were identified. The Nursing Admission Evaluation, dated 4/18/17, documented no wounds were present on admission. A wound/skin evaluation form, dated 5/23/17, documented Resident #241 was noted to have an abrasion to her left upper buttocks. The follow up skin assessments, on 6/30/17 and 7/3/17, documented the same wound as incontinent [MEDICAL CONDITION], a condition caused by continued exposure to moisture that looks like a red or bright red diffuse (spread over a wide area) rash. A wound/skin evaluation form, dated 6/30/17, documented the resident had a wound to her left buttocks identified as incontinent [MEDICAL CONDITION]. Follow up skin assessments, dated 7/3/17 and 7/10/17, documented the wound as an abrasion. On 7/13/17 at 11:27 a.m., Resident #241 indicated she believed she had gotten the wound at the facility and it was probably caused from laying or sitting on it for too long. On 7/14/17 at 9:45 a.m., Resident #241 was observed to have a dime sized circular wound to the left and right side of her buttocks and a pencil eraser sized circular wound below the larger on the left side. The surrounding skin was normal in appearance. At 10:07 a.m., LN G stated the resident developed the wounds in the facility and were identified as incontinent [MEDICAL CONDITION]. The skin integrity care plan documented the goal was for incontinent [MEDICAL CONDITION] on the buttocks to resolve with treatment. The interventions included encouraging the resident to change positions often and pressure relieving mattress which were consistent with the treatment of [REDACTED]. A physician order, dated 7/3/17, listed the [DIAGNOSES REDACTED]. On 7/18/17 at 12:14 p.m., the Administrator stated the facility had a lot of newer nurses that needed education related to pressure wounds and they were going to have the Nurse Practitioner provide training for them. Reference WAC 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of needs for 6 of 9 sampled residents (#1, 5, 6, 8, 9, and 10) reviewed for bathing. This failure placed residents at risk of not receiving reasonable accommodation of individual needs and a diminished quality of life. This failure caused psychological harm to Resident #1, 5 and 6. Findings include: 1) Resident #1 was admitted to the facility on [DATE] with multiple diagnoses. On 3/21/17 at 2:24 p.m., the resident's family member stated, He is finally healing after a massive UTI that he got while he was there. They were not giving him a shower. He was so sick. He was there a month, and they told me when we checked in he would have a shower every other day. I was there every day. He got some showers, but not like he was supposed to. His whole genital area was infected. I noticed a lot of people lying in bed and were crying out in help and felt they were ignored. While we were there they had a shower person that quit and walked out. I think she quit out of frustration. I noticed the clean clothes on him but then started to smell. The family member stated, I went to the RN. He had a very bad UTI infection. In his entire crotch there was poop and pee in his crotch .I went to several people, towards the end. I went to the top dog and .told her what had happened. She looked at the shower schedule and said they didn't keep up on our agreement. There were two long (gaps), it was almost a week. The ADL verification worksheet, dated 1/3/17 through 1/31/17, did not show showers were completed per resident's preference of every other day. The documentation showed the resident received 7 showers during the time he was in the facility. If the resident's preferences were followed, the resident would have received 14 showers. 2) At 11:30 a.m., Resident #5 stated, I was getting a shower 2-3 days a week. Now I hardly get a shower day a week. I am told that staff was not available. Review of Resident #5's shower bath form, dated 2/10/17, documented resident's preference for a shower on Monday/Wednesday/Friday early morning. ADL verification worksheets documented Resident # 5 received 7 showers in the last 30 days. 3) At 11:45 a.m. Resident #6 stated, I got here 2 weeks ago tomorrow. I have had one (1) shower since I've been here, (and I'm) not shaven. I'm used to the Marine Corps shower and shave every day. Resident # 6's shower/bath choice form, dated 3/9/17, documented resident's preference for showers Tuesdays and Saturdays early morning. ADL Verification worksheet, dated 3/9/17 through 3/22/17, had no documentation Resident #6 received a shower. 4) Grievance, dated 1/26/17, for Resident #8 documented resident hadn't had a shower for over a week. The grievance form noted there were certain times where staff were less available. Review of Resident #8's shower bath choice form, dated 1/14/17, documented the resident's preference for a bed bath 3 times a week. The ADL verification worksheet, dated 2/11/17 through 3/12/17, documented 6 times the resident received bathing. 5) Grievance, dated 3/14/17, regarding Resident #9 documented a voicemail for the administrator that the resident had requested a shower, and wanted showers 3 times a week. Findings indicated resident had been offered a shower Monday evening and staff did not have efficient time to provide a quality shower. Shower bath choice form, dated 3/10/17, documented the resident's bathing preference for showers 3 times a week. No documentation was found on showers given. 6) Grievance, dated 14/26/17, regarding Resident #10 documented the family member was upset that the resident had not received a shower since admission. In the resolution area on grievance form, it was documented the resident did not receive a shower but a bed bath, and resolution was for a shower to be performed. No documentation was found that bed baths or showers were given. At 3:26 p.m. the Director of Nursing Services (DNS) said, Shower preferences (forms) are done after a new admission comes in and incorporated by shower aid and then we do preferences on quarterly basis. When asked about the ADL verification worksheet, The DNS said they use the MDS language, the number 8 means did not occur . When reviewing the ADL verification worksheet the 8's in the columns, the DNS said it looked like bathing was not done. The DNS stated, I will have to look at the bath assignment sheets. The shower and bath assignment sheets provided by the DNS, did not show documentation bathing was completed for the residents. On 3/24/17 at 9:42 a.m., an email from the DNS documented, We have completed a plan of correction for showers and dignity. We have immediately addressed documentation and process related to showers.

Based on interview, observation and record review, the facility failed to ensure dignity was maintained for 1 of 1 sampled residents (#6) reviewed for dignity. The facility failure to provide care in a timely manner when the resident was incontinent and had to wait 45 minutes for assistance placed residents at risk for diminished self worth, embarraassment, decreased quality of life, and lack of dignity. This caused psychological harm to Resident #6. Findings include: On 3/22/17 at 11:45 a.m., Resident #6 stated, The first night was good. Second night was not very good. Tried to get ahold of management that I was treated like crap. This morning the same girl took care of me, I told her to tell the nurse I wanted [MEDICATION NAME]. She said I needed to wait three (3) days before [MEDICATION NAME] could be given. She got me up twice and then I crapped in my pants and called for help and they didn't come. I shouldn't have to lay in my own crap. It's embarrassing. She didn't tell the nurse anything then said they had a shift change. I laid in feces for 45 minutes. It was around 10:00 at night. At midnight they gave me [MEDICATION NAME]. I don't understand why we have to wait just because it is shift change. At 10:40 a.m., the Staffing Coordinator (SC) stated, We have open float position mountain side CNA position and shower aide. We do have a call in issue, but I usually get it covered. We don't use agency. We have on call employees and concierges. We have two temp and two full timed CNAs positions open. We have a CNA class monthly, 8-9 per class. At 11:21 a.m., Nursing Assistant (NA) A stated, I have been here 5 years, always work days. We have enough staff on occasion. At 11:30 a.m., Resident #6 stated, The girls are thoughtless. They don't listen to what the patient wants. They are always in a hurry. They don't have enough staff. It takes usually a half hour for call light to be answered. At 11:32 a.m., when asked if there was enough staff to assist residents, Licensed Practical Nurse (LPN) A stated, If short we have to go through the call list. We all have a part of getting staff in, have on call positions, and managers will work the floor in whatever way we can. The facility staffing form, dated 3/22/17, documented the facility had a census of 102 residents. Each nursing assistant had 9-10 residents assigned on dayshift, 6-9 residents assigned on evening shift and 17-19 residents assigned on night shift with one nursing assistant on night shift with 28 residents assigned. A grievance, dated 1/11/17, documented a nursing assistant telling a resident she had 20 people to take care of. The grievance indicated education was completed with nursing assistants about discussing staffing with families and residents, and verbal coaching if having a difficult time meeting all call light needs to let a residential care manager and assistance director of nursing services know. At 4:36 p.m., when asked about how many residents the nursing assistants have, the Administrator (ADM) stated, We are within the guidelines of the state. Wish we had Oregon ratios then we would be able to have more staff. When asked if they felt the CNAs had enough time to care for that many residents, the ADM stated, We meet the guidelines. We are well above what we are supposed to have.

Based on interview and record review, it was determined that the facility failed to ensure that its policies and procedures that prohibit abuse were implemented; including training employees to deal with aggressive and/or catastrophic reactions of residents and the reporting of abuse to the required agencies. At least 2 Licensed Nurses (LN) (LN A, LN B) and 2 Nursing Assistants (NA A, NA B) had direct observation or knowledge of an abusive act to 1 of 6 residents reviewed for abuse including physical abuse of resident (#1) by 1 NA B. This same licensed nurse (LN A) and 1 nursing assistant (NA A) failed to immediately report observations or knowledge of NA B ' s abusive act to their immediate supervisor, the facility Administrator or the Director of Nursing Services (DNS), and the state abuse hot-line per facility policy and procedure for abuse prevention. This failure by multiple staff to report abusive acts as required demonstrated the facility's Abuse Prevention Program was ineffective. The failure to ensure that a thorough Abuse Prevention Program was developed and implemented placed all residents in the facility at potential risk of abuse. Findings include: Policies and Procedures The facility's policy and procedure for abuse and neglect prohibition included a description of to whom the staff should report abusive incidents to. However, their Abuse Prevention Program did not evidence what management was doing to ensure that staff were implementing correctly the information on which they were trained. There was no evidence that the facility's prevention program focused on management responsibility to prevent abuse to include such factors as ensuring supervision of staff providing care. Nursing Assistant observation of Abuse On 8/30/16 LN B alerted the facility that an allegation of abusive act had occurred the day before on 8/29/16 and the facility began an investigation concerning the allegation immediately. According to an investigation report provided by the facility and interviews with the Director of Nursing Services (DNS) on 9/29/16, NA A observed NA B commit abusive action toward Resident #1 on 8/29/16 by placing her hands on Resident #1 ' s face (chin/jaw area) and stating to Resident #1 You don ' t bite! You don ' t do that! after Resident #1 had allegedly bitten NA B during a transfer. NA A did not immediately report the observed abuse to her immediate supervisor, facility administration or the state hotline for reporting abuse. NA A instead reported the observed abuse to NA C, who notified LN A who then assessed Resident #1 and found no injuries and decided the incident was more of a self-defense and a human reaction than abuse. The following day, 8/30/16 NA C notified LN B who then reported the incident to the DNS, who initiated an investigation. Multiple Staff ' s Failure to Report Abuse NA A- did not report the physical abusive action immediately when it was observed LN A- did not report the physical abuse immediately when it was reported by an NA The failure of the 2 staff to report abusive acts demonstrated the facility ' s failure to ensure the abuse prevention procedures were implemented. During an interview on 9/29/16 at 3:15 p.m. the DNS stated staff have been educated to Notify their supervisor, and the supervisor starts the investigation, and all staff can and should call in to the state because they are mandated reporters. The DNS also reported that NA B was terminated due to the abusive act, and all other facility staff were re-educated on abuse prohibition. In an interview on 9/29/16 at 4:00 p.m. with the Administrator and the DNS, they acknowledged that monitoring of staff to ensure abuse prohibition policy was implemented did not occur and they rely on all staff .housekeeping, nursing, therapy .everyone .to report anything , but were unable to verbalize how they monitor the policy is implemented. Staff members who witness to or had knowledge of abusive acts and failed to intervene or immediately report, demonstrated the facility failed to have an effective abuse prevention program, placing all residents at risk of abuse.

Based on observation, interview, and record review it was determined that the facility failed to implement interventions to reduce hazards and risk for 1 of 2 residents (Resident #6 who was reviewed for accidents and supervision. This failure caused harm to the resident( #6) and placed the resident at risk for further harm and injury. Findings include: Resident #6 was a [AGE] year old female with [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE]. Resident #6's care plan dated [DATE] listed that the resident was at risk for hemorrhage related to aspirin use, and problems indicated Resident #6 had falls related to dementia with poor impulse control, lack of safety awareness, memory impairment, and impaired decision making skills. This care plan indicated that interventions were staff will anticipate Resident #6's need to transfer and offer help, such as following a meal, or in the evening, offer to assist resident to lie down for rest after meals, and priority lay down after meals. A fall evaluation done on [DATE] indicated the resident had a high potential for falls. Resident record reflected that on [DATE] Resident #6 had a unwitnessed fall from her wheelchair in the dining room resulting in a large bruise and lump to her head. On [DATE] the resident had a witnessed fall in the hallway from her wheelchair, and on [DATE] the resident had another witnessed fall in the dining room from her wheelchair. The resident was documented to be asleep in her wheelchair and fell forward from her wheel chair and fell out. This fall caused the resident to strike her head on the hard floor and resulted in a laceration to her left eyebrow. Resident's care plan dated [DATE] indicated that she was a priority lay down. Meal schedule indicated that breakfast was served at 8:00a.m. on [DATE]. Review of the investigation of the fall taking place on [DATE] indicated the resident fell asleep in her chair with two staff (Nursing Assistants-NAC) in the dining room. Records indicated the fall took place at 9:40a.m. Review of the facility investigation included staff statements including NAC statements. NAC B indicated on her statement that she was writing down meal percentages when I heard a thump and Resident #6 was on the ground. NAC C indicated in her statement, NAC B and I were in the dining room feeding residents and that's when Resident #6 fell forward from her wheelchair and onto the floor hitting her left eyebrow. I did not witness the fall but helped with vitals. The Director of Nursing (DNS) indicated in her summary of the investigation that, on [DATE] at 0940 just as residents were finishing up breakfast, resident fell asleep in wheelchair and fell forward out of wheelchair on floor. Resident record reflected that the on call physician was notified and ordered neuro checks. The facility failed to follow the resident's care plan to assist the resident to lie down for rest after meals. Resident record reflects an entry by Nurse Practitioner (NP) on [DATE] at 10:06a.m, and placed the resident on terminal care. Resident record reflected Resident #6 expired on [DATE] at 11:00am. On [DATE] at 4:21p.m.; The DNS indicated that the resident fell asleep in her wheelchair often and that it was common. The DNS indicated that on [DATE] the resident fell asleep in her wheelchair again and fell head first to the ground. The DNS indicated that if a resident is priority lie down it should be done within the hour following meal service and if a resident is asleep that she would hope staff would check on them and then offer to lay them down in their room. The facility failed to put in aggressive interventions to mitigate the risk of any further accidents, injuries or falls from out of her wheelchair for this Resident. The facility did not provide adequate supervision to the resident to prevent these accidents or assess her environmental hazards. Two days after the resident was witnessed to fall from her wheel chair on [DATE] priority lay down was added to the care plan. On [DATE] the facility failed to follow the care plan directive of [DATE] and the resident fell out of her wheelchair and expired 26 hours later.

Based on observations, record review and interview, the facility failed to determine if a newly developed pressure ulcer was clinically avoidable, and/or to ensure interventions were reassessed to promote healing for 2 of 2 current sampled residents (#2 & 23) reviewed for pressure ulcer care and services. As a result of this failure, the facility failed to determine if the interventions in the plan of care were effective to prevent further pressure ulcers from developing. This caused harm to Resident #2. Findings include: <Resident #2> Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 1/22/12, indicated the resident required an extensive assist with bed mobility, transfers, toileting and limited assist from staff with locomotion. Resident #2's Resident Care Plan section, "Alteration in Comfort," dated 2/20/12, documented a potential in alteration in comfort related to the resident's pressure ulcers, arthritis, [MEDICAL CONDITION] (nerve pain), history of falls, decreased mobility and kyphosis. Goals were listed that the resident would have no signs or symptoms of facial grimaces, or distress. The "resident's comfort needs would be anticipated by staff and met with positioning and medications to the resident's tolerance with no exhibiting verbal or non-verbal signs and symptoms of pain." The Resident Care Plan section, "Skin Integrity," dated 2/20/12, documented Resident #2 had existing pressure ulcers. It listed an intervention of an air overlay on the resident's bed to help resolve the ulcers. An Interdisciplinary Progress Note, dated 1/25/12, stated the current approaches (interventions) provided for Resident #2 were "appropriate." It documented the air overlay mattress was not on the resident's bed. In 2010, the facility determined Resident #2 required a specialized wheelchair that she could self-propel in the facility. Review of a letter, dated 12/09/10, written by Physical Therapist (PT) A, was a response to a Department request for additional information regarding Resident #2's wheelchair needs. PT A documented a 20 degree tilt in space chair "was necessary as the resident was able to self-propel her wheelchair." The letter documented, "We cannot see her needing any other tilt than the 20 degrees to provide her with positioning as her condition is not expected to worsen." The letter noted the resident had a positioning cushion, and "there is currently no issues concerning any pressures areas because of the positioning cushion." The letter noted Resident #2 had pressure ulcers on her ankles. On 1/20/12, PT B documented in a physical therapy evaluation, "Nsg (nursing) requesting consultation regarding bed positioning secondary to wounds." The evaluation noted nursing staff requested assistance with bed positioning to alleviate pain and pressure on the coccyx (tailbone) and both trochanters (upper bone in thigh that connects to the hip bone). The clinical summary by PT B documented RCM A and NA D were present and understood the positioning recommendations of PT B. On 2/21/12 at 12:44 p.m., Resident #2 was observed with a black restraint vest that went over both shoulders, around her rib cage and attached at the back of the wheel chair. The resident was not able to release the restraint by herself at any time. Resident #2's wheelchair was a specialty chair that had an adjustable tilt back, a seat cushion that resembled a saddle and was tilted so the resident's knees were slightly higher than her hips displacing her weight toward the back of the wheelchair. The vest restraint was in place and the resident was observed positioned with the majority of her the weight on her sacrum (tailbone) and buttocks. The resident's current weight was approximately 85 pounds. At 3:05 p.m, Resident Care Manager (RCM) A stated the resident had 3 pressure ulcers. She indicated that one was a pinpoint blister, one pressure ulcer was on the resident's left buttock, and one was in the right peri-anal (genital/buttock region) area. She stated the resident had acquired them in the recent past months. The resident was observed from 12:44 p.m. until 4:03 p.m., in her wheelchair. When questioned if the resident laid down in bed during the day, Nursing Assistant (NA) B said the resident would tell the staff when she wanted to lie down. On 2/22/12 at 1:03 p.m., Resident #2 was observed in the hallway in her wheelchair with the restraint in place. When asked if she had pain, the resident stated, "my butt hurts." She denied pain in her back. Resident #2 attempted to shift her weight and was only able to move her upper torso slightly forward and back. On 2/23/12 at 8:50 a.m., Resident #2 was observed sitting in her wheelchair with the restraint in place. She was observed in her wheelchair until 2:24 p.m., when she was placed in bed. The wheelchair cushion was observed with folds of fabric in the center where the buttocks would be positioned. This was a potential pressure source. At 7:55 p.m., the Rehab Therapy Director (RTD) observed the resident in her wheelchair and stated the resident "definitely slid down," and was not positioned correctly. The resident had slid down creating approximately a 4 inch space between her back with her legs extended out in front of her. This position made it difficult for her to self-propel her wheelchair and provided no back support for proper body alignment. At 8:09 p.m., the Administrator was asked to take the resident back to her room because the resident stated she "wanted to lie down" because "my butt hurts." On 2/24/12 at 8:54 a.m., Resident #2 was observed in the hallway. Resident #2 stated she hurt "right down the middle toward the back," while pointing to her private area. When questioned if it was the front or in the back, she said the top of her buttocks hurt. At 9:08 a.m., NA C and NA D were observed toileting the resident. The resident was observed with two dark red/purple areas on her right greater trochanter region, two open areas at the top of each buttock, and a dressing to the right lower buttock. Her entire backside was dusky red. The resident was transferred to her wheelchair by both NAs. When Resident #2 was asked about her wheelchair cushion she said, "my cushion is hard" and "it could be softer." When questioned if she would like to lie down in bed, the resident said "sometimes on this side or that side (moving her hand side to side) and sometimes I just pop up on my feet." Both NAs said she preferred to lie on her side and would attempt to get out of bed so they placed a fall mat on the floor next to her bed. At 11:07 a.m., the Nurse Practitioner (NP) stated she wrote an order on 2/8/12 to keep the resident off her buttocks, and on her side in bed as much as possible. The order prescribed was to reduce chair time (wheelchair) as much as the resident could tolerate. The NP said she did not observe or assess the resident's skin or pressure areas at that visit. The NP was told the resident stated her wheelchair cushion was too hard and complained of pain in her buttock area. The NP was made aware of the condition of the resident's skin as observed on 2/24/12. The NP responded by saying the resident had complained of pain in her bowels and abdomen for at least 5 years. At 11:27 a.m., PT B stated she felt the restraints were a medical necessity that added to Resident #2's quality of life, ensuring she was in a more forced upright position. PT B said the wheelchair was appropriate and felt the wheelchair cushion, although tilted placing the resident's weight on her sacrum and coccyx, was appropriate. PT B was not aware of any other interventions attempted to reduce pressure for the resident and the resident's pressure ulcers. At 2:52 pm, the Director of Nursing Services (DNS) said she knew the resident had the wheelchair and tilt cushion for a long time and then acquired pressure ulcers. The DNS said she did not know if the degree of the tilt of the cushion and tilted back wheelchair was the cause of the ulcers. On 02/28/12 at 10:46 a.m. (after the survey team had notified the facility of the concerns regarding Resident #2 and exited), the facility had a Certified Wound/Ostomy Care Nurse (CWOCN) evaluate the resident for her pressure ulcers. At 4:39 p.m., a letter from the facility stated the resident had been in her current wheel chair and pressure relief cushion since March 2011. The letter stated the resident developed a pressure ulcer by 12/28/11 and two more pressure ulcers on 2/19/12. The letter documented the facility evaluated the resident for pain related to the pressures ulcers with a facility pain assessment. The DNS indicated she interviewed the resident herself regarding pain. The facility concluded they could not verify if Resident #2 understood and correctly identified pain. There was no documented pain assessment tool in the resident's chart. <Resident #23> Resident #23 was admitted to the facility 9/27/10 with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 1/3/12, indicated the resident required an extensive assist with bed mobility, transfers, toileting from staff . On 2/21/12 at 10:00 a.m. and 12:51 p.m., the resident was observed lying in bed on his back. At 2:55 p.m., RCM A stated the resident had pressure ulcers on his sacrum (tailbone area) and on his heel. She stated the resident was admitted to Hospice services on 2/1/12. At 4:15 p.m., the resident was observed lying in bed, on his back in the same position, asleep. There were pillows under his head, and no pillows were observed under his legs or heels. On 2/23/12 at 10:58 a.m., the Hospice Social Worker stated a new pressure ulcer had developed to the resident's knee, indicating the pressure of his two knees pressing against one another was the cause. At 2:28 p.m., NA F and the surveyor observed the residen's knees pushing together and difficult to pull apart. There was no pillow in between his knees. On the inner portion of the left knee, there was a blackened purple area. On the inner aspect of the right knee was a reddened purple area. A clear type dressing that was rolled on the edges had a date of 2/22/12 written on them. At 2:33 p.m., Licensed Nurse (LN) A stated it was not safe for the resident to be out of bed and he was kept in bed all day. She stated the resident did have pressure ulcers, one on his heel and on both knees. She said the knee pressure ulcers started about a week and a half ago. When questioned what interventions were provided to his knees, LN A said, "We try pillows between his knees, but he squeezes so hard, they come out. There is not much else to do." On 2/23/12 at 7:28 p.m., RCM A stated she forgot to mention the pressure ulcers the resident had acquired to his knees, and verified it was pressure from both knees pressing together. She indicated the only intervention provided was to offer a pillow, and the resident had refused at times. RCM A said she would then attempt to place a pillow case. She stated other intervention were not tried. .