Every finding on record at Gig Harbor Health and Rehabilitation

Based on observation, interview and record review, the facility failed to maintain a clean and comfortable environment for 4 of 4 hallways (hallways 100, 200, 300, and 400) reviewed for physical environment. This failure placed residents at risk of unsanitary conditions, less than a homelike environment , and a diminished quality of life.Findings included RESIDENT 1 Resident 1 admitted to the facility on [DATE] with multiple diagnoses. The admission minimum data set (MDS), an assessment tool, dated 07/10/2026, showed Resident 1 was cognitively intact. During an interview on 07/27/2026 at 01:05 PM, Resident 1 said during their stay, some orange juice was spilled on the floor. Resident 1 said staff wiped it up with a paper towel, but it was not mopped while they were living at the facility, leaving a sticky residue on the floor. Observation on 07/31/2026 at 09:55 AM showed the following:-A large brown stain on the carpet on 100 hall next to the nurses station approximately two feet in diameter.-Multiple large dark stains on the carpet on the front part of 200 hallway varying in size.-Multiple (approximately 10) dark brown spots on the floor approximately the size of a quarter between the doorway and bed A in room [ROOM NUMBER].-Five dark brown spots on the floor approximately the size of a quarter between the doorway and bed A in room [ROOM NUMBER].-Multiple dark stains on the carpet along the length of the back side of 200 hallway. Two of the spots were with a hardened substance on the surface of the stained area. -Six dark stains on the carpet in front of the nurse's station between 200 hall and 300 halls, varying in size from two inches to six inches.-A large dark grayish spot in the doorway approximately six inches in diameter in room [ROOM NUMBER].-A strong odor of urine at the end of 300 hall.-Light yellow food particles under a table in the dining area of 400 hall. -Multiple stains and light-yellow food particles in the sink of the dining area on 400 hall. Observation on 07/31/2026 at 10:27 AM showed room [ROOM NUMBER] with multiple items on the floor, including pillows, socks, a grocery bag, shoes, hospital gown, towels, books, shirt, basket, cups, wheelchair legs, and the call light. The items were spread across the room and near the bed. Observation on 07/31/2026 at 11:25 AM showed breakfast food trays remained on the bedside table of rooms 233B and 215B. Observation on 07/31/2026 at 01:13 PM showed multiple items on the floor such as boxes, a shirt, socks, and bags surrounding bed A. Observation on 07/31/2026 at 12:35 PM showed one housekeeper on 400 hall and one housekeeper on 100 and 200 halls. Observation showed no other housekeepers in the building. RESIDENT 2 Resident 2 admitted to the facility on [DATE] with multiple diagnoses. The admission MDS dated [DATE], showed Resident 2 was able to make their needs known. During an interview on 07/31/2026 at 10:54 AM, Resident 2 said they had been in the facility for 2 weeks and their room had been cleaned one time. Resident 2 said the room only got cleaned before their roommate moved in. RESIDENT 3 Resident 3 admitted to the facility on [DATE] with multiple diagnoses. The admission MDS dated [DATE], showed Resident 3 was able to make their needs known. During an interview on 07/31/2026 at 11:02 AM, Resident 3 said the facility did not clean their room on a routine basis. Resident 3 said they cleaned the room, not real often. RESIDENT 4 Resident 4 admitted to the facility on [DATE] with multiple diagnoses. The quarterly MDS dated [DATE], showed Resident 4 was able to make their needs known. During an interview on 07/31/2026 at 01:18 PM, Resident 4 said the facility cleaned their room about once a week. Resident 4 said their room was mopped every time they cleaned it. Review of the May 2026 resident council meeting minutes showed a resident requested their room be swept more often. Review of a grievance dated 04/21/2026 showed a resident had food spills on their floor on 04/18/2026 and were still present on 04/21/2026. Review showed a request was made to have housekeeping clean the room on 04/21/2026 around lunchtime and it had still not been cleaned as of 04/21/2026 during the evening. Review showed the floor was cleaned on 04/22/2026 in the morning. During an interview on 07/31/2026 at 01:37 PM, Staff C, Housekeeper, said they tried to clean every room daily, but could not always complete the tasks. Staff C said they usually had 19-20 rooms to clean every shift they work. Staff C said they tried to prioritize their work the best they can. Staff C said they would mop the floor every time they cleaned a room. Staff C said the facility has a company come in and clean the carpets and it was completed a couple of months ago. Staff C said them and one other housekeeper were currently working. During an interview on 07/31/2026 at 01:44 PM, Staff B, Housekeeping Supervisor, said they would stagger shifts and there was ongoing continual routine cleaning scheduled. Staff B said the housekeeping staff would try to mop the floors every day or every other day if there were no stains on the floor. Staff B said the dining rooms should have been swept and mopped after every meal and ideally within an hour of the meal ending. Staff B said a professional carpet cleaning company was scheduled to come in and clean the carpets. Staff B said two housekeepers were off on the day of this interview. Staff B said their expectation is a resident's room be cleaned timely and not to only be mopped once in two weeks. Staff B said the carpets would be cleaned the following week. Reference WAC 388-97-3220(1)

Based on observation, interview, and record review, the facility failed to provide nail care for 3 of 6 residents (Resident 1, Resident 2, and Resident 3) and failed to provide timely hygiene for 2 of 6 residents (Resident 4 and Resident 5) reviewed for ADLs (activities of daily living). This failure placed residents at risk of pain, infection, and a diminished quality of life.Findings included.Review of a facility policy titled Activities of Daily Living (ADLs), dated 10/01/2021, showed, Each resident shall be given proper daily personal attention and care, including skin, nail, hair, and oral hygiene, in addition to any specific care ordered by the attending physician.NAIL CARERESIDENT 1Resident 1 admitted to the facility on [DATE] with multiple diagnoses. The quarterly minimum data set (MDS), an assessment tool, dated 04/29/2026, showed Resident 1 was cognitively intact. Observation on 06/18/2026 at 11:31 AM, showed that Resident 1 had long fingernails with dark sediment under them. Observation showed Resident 1 had long, thick toenails.During an interview on 06/18/2026 at 11:31 AM, Resident 1 said they were supposed to see a podiatrist, but had not seen one in a long time. Resident 1 said their toenails were uncomfortable because of the length and thickness. Review of the electronic health record (EHR) showed no documentation was able to be found regarding fingernail care for Resident 1. Review of the EHR showed the last documented podiatry visit for Resident 1 was January 2026.Review of the care plan, dated 05/18/2026, showed Resident 1 required assistance with ADLs.RESIDENT 2Resident 2 admitted to the facility on [DATE] with multiple diagnoses. The 5-day Medicare MDS, dated [DATE], showed Resident 2 was moderately cognitively impaired. Observation on 06/18/2026 at 11:16 AM showed Resident 2 had long fingernails with dark sediment under them. During an interview on 06/18/2026 at 11:16 AM, Resident 2 said they had been in the facility for about a month and a half, and the staff had never trimmed their fingernails. Review of the EHR showed no documentation was able to be found regarding fingernail care. Review of the care plan, dated 04/12/2026, showed Resident 2 required assistance with ADLs. RESIDENT 3Resident 3 admitted to the facility on [DATE] with multiple diagnoses. The admission MDS, dated [DATE], showed Resident 3 was cognitively intact. Observation on 06/18/2026 at 02:02 PM showed Resident 3 had long fingernails and very long toenails. During an interview on 06/18/2026 at 02:02 PM, Resident 3 said their nails are not getting trimmed. Resident 3 said they had been in the facility for 10 months and their toenails had never been trimmed by the staff. Resident 3 said they want their fingernails and toenails trimmed. Resident 3 said they asked the facility staff for nail clippers, but the staff told them, there were none available. Review of the EHR showed no documentation was able to be found regarding nail care. Review of the care plan, dated 05/03/2026, showed Resident 3 required assistance with ADLs.HYGIENERESIDENT 4Resident 4 admitted to the facility on [DATE] with multiple diagnoses. The 5-day Medicare MDS, dated [DATE], showed Resident 4 was moderately cognitively impaired. During an interview on 06/12/2026 at 10:52 AM, Resident 4 said they did not receive a shower for two weeks. Resident 4 said the staff had multiple different excuses why a shower was not given. Resident 4 said their hair was getting greasy due to not having a shower for so long. Resident 4 said they finally received a shower on 06/12/2026Review of the May 2026 and June 2026 nursing assistance documentation showed Resident 4 received a shower on 05/30/2026. Review of the documentation showed no showers recorded after that date.Review of the EHR showed no documentation to show why Resident 4 did not receive a shower. Review of the care plan, dated 04/16/2026, showed Resident 4 required assistance for bathing. Review of the care plan showed Resident 4 was supposed to receive a shower every Wednesday and Saturday.RESIDENT 5Resident 5 admitted to the facility on [DATE] with multiple diagnoses. The admission MDS, dated [DATE] showed Resident 5 was cognitively intact. During an interview on 05/28/2026 at 12:24 PM, Resident 5 said they turned on their call light because they had soiled their brief. Resident 5 said they waited over an hour to be cleaned and changed. Review of the care plan dated 05/05/2026 showed Resident 5 was dependent on staff for toileting and changing.During an interview on 06/18/2026 at 01:01 PM, Staff C, Certified Nursing Assistant, (CNA), said their goal was to answer a call light within five minutes. Staff C said sometimes they were with another resident, and it could take some time to get to a resident to change them. Staff C said residents should receive a shower twice a week. Staff C said there was usually a shower aide, but they would sometimes get reassigned if there were call outs. Staff C said documentation is in the EHR and there should have been documentation whether the resident received a shower or not. Staff C said if a resident refused their shower, there would have been an option to document refusals. Staff C said after the resident received a shower, the CNA would document on a shower sheet any skin or nail issues and report to the nurse for follow up.During an interview on 06/18/2026 at 01:50 PM, Staff D, CNA, said they would respond to a residents needs as quickly as possible. Staff D said they would try to respond within five minutes but no longer then 15 minutes. Staff D said a resident should not have had to wait an hour to be changed after soiling themself. Staff D said showers were documented in the EHR under the shower task. Staff D said if a resident refused a shower, they would attempt to do another shower later that day or on the weekend. When asked about nail care, Staff D said some residents would request their nails to be trimmed. Staff D said, if the resident was diabetic, the nurse would trim their nails, otherwise the CNA could trim them. Staff D said they did not document when nails are trimmed. During an interview on 06/18/2026 at 01:56 PM, Staff E, Licensed Practical Nurse, (LPN), said if a resident had not received a shower, the nurse would go to the resident to find out why. Staff E said the staff would try to accommodate resident preferences to try to promote a shower. Staff E said they attempted to provide nail care during their medication pass. Staff E said the facility did not have a structured nail care protocol. Staff E said residents usually told them when they needed their nails trimmed. Staff E said if a resident needed to see a podiatrist, the staff would put them on the list to be seen. Staff E said if they had done nail care, they would document it in a progress note. During an interview on 06/18/2026 at 02:28 PM, Staff B, Registered Nurse/Director of Nursing Services (RN/DNS), said residents typically received a shower twice a week, but it was also based off preferences. Staff B said if a resident refused a shower, it would be reported to the nurse, then there would be an attempt to make the shower up on a different shift or day. Staff B said showers would be documented in the EHR under the shower task, including any attempts at offering a shower. Staff B said the facility did not have a nail care protocol. Staff B said nail care should have been done alongside bathing weekly and as needed. Staff B was unsure how often the podiatrist was in the facility, but residents would be referred by staff to have been seen. Reference WAC 388-97-1060(2)(c).

Based on interview and record review, the facility failed to prevent significant medication errors by administering medications to the wrong resident for 1 of 3 residents (Resident 1) reviewed for medication errors. Resident 1 experienced harm when they were transferred to the hospital for a life-threatening medication overdose requiring life support. This failure placed residents at risk for negative side effects of medications, hospitalization, and a diminished quality of life. Findings included.Review of the Lippincott Nursing Procedures 8th edition safe medication administration showed, To promote a culture of safety and to prevent medication errors, nurses must avoid distractions and interruptions when preparing and administering medications and adhere to the five rights of medication administration: identify the right patient by using at least two patient-specific identifiers; select the right medication; administer the right dose; administer the medication at the right time; and administer the medication by the right route.RESIDENT 1Resident 1 admitted to the facility on [DATE] with multiple diagnoses. The discharge minimum data set (MDS), an assessment tool, dated 05/19/2026, showed Resident 1 was moderately cognitively impaired.RESIDENT 2Resident 2 admitted to the facility on [DATE] with multiple diagnoses. The admission MDS, dated [DATE], showed Resident 2 was moderately cognitively impaired.Review of the progress note dated 05/19/2026 at 9:00 PM showed a nurse was training a new orientee and medications for Resident 2 were given to Resident 1. The medications given were Seroquel (an antipsychotic medication) 400 mg, Zoloft (a medication given for depression) 200 mg, and Tegretol (a medication given to prevent seizures) 200 mg. Review of the progress notes showed the error was identified immediately, the resident was assessed with no negative effects, and the physician was notified. Review of the progress notes showed Resident 1 was sent to the emergency department (ED) for evaluation. Review of the provider order dated 04/28/2026 showed Resident 1 received Seroquel 12.5 mg twice daily. Review of the orders showed Resident 1 did not take Zoloft or Tegretol.Review of the hospital Discharge summary dated [DATE] showed Resident 1 arrived in the ED on 05/19/2026. Review showed Resident 1 was initially sleepy and following commands. Review showed Resident 1 quickly went into severe distributive shock (a condition where the body's blood vessels lose their ability to constrict properly) and was administered Narcan without success. Review of the document showed Resident 1 had to be intubated (a breathing tube that is inserted into the windpipe when unable to breathe on your own) and admitted to the Intensive Care Unit (ICU). Review showed Resident 1 developed pulmonary edema (a serious condition where excess fluid accumulates in the lungs, leading to difficulty in breathing and inadequate oxygen supply to the body) and distributive shock secondary to a medication overdose. Review of a document titled notice of disciplinary action dated 05/26/2026 showed during orientation Staff C, Licensed Practical Nurse (LPN), administered medications to the wrong resident resulting in harm. Review of the documentation showed the five rights of medication were not followed. Review of a document titled notice of disciplinary action dated 05/26/2026 showed Staff D was orienting Staff C and left them unsupervised during medication administration. Review showed Staff C administered the medication to the wrong patient resulting in harm. Review of the document showed orientees were not to be left alone during medication administration until competency was validated. Review showed the five rights of safe medication administration were not followed and did not meet the expectations of the facility. During an interview on 05/29/2026 at 1:07 PM, Resident 2 said Staff C, LPN, came into the room and went to Resident 1 to administer medications. Resident 2 said Resident 1 asked Staff C why there were so many pills. Resident 2 said Staff C administered the medications to Resident 1 and then Resident 1 was quickly taken away by an ambulance. During an interview on 06/05/2026 at 12:16 PM, Staff C, LPN, said the day the medication error occurred was their second day working in the facility and their first day working on that hall. Staff C said this was their first job in long term care and they were a new nurse. Staff C said Staff D, LPN, the nurse training them, set up the medications and handed the prepared medications to them to administer to the resident. Staff C said they asked Resident 1 if their name was Resident 2's name. Staff C said Resident 1 said yes. Staff C said the picture on the electronic medication administration record (EMAR) was old and not accurate. Staff C said Staff D was outside the room preparing medications for another resident when they were administering the medications to Resident 1 and was not in the room with them. During an interview on 06/05/2026 at 12:22 PM, Staff E, LPN, said the five rights of medication administration are the right patient, right time, right dose, right route, and right medications. Staff E said these rights should be completed for every medication pass. Staff E said if a medication error is identified, they would check for allergies, notify the provider, and monitor based off of the provider orders. During an interview on 06/05/2026 at 12:28 PM, Staff F, Registered Nurse (RN), said the five rights of medication administration are right dose, right medication, right patient, right time, and right route. Staff F said the five rights should be done every time a medication is administered. Staff F said if a medication error was identified, they would assess the patient, compare what was given to the orders, report it to the provider, call 911 if it was an emergency, notify management, and document the event. During an interview on 06/05/2026 at 12:45 PM, Staff B, Registered Nurse/Director of Nursing Services (RN/DNS) said Staff D was training Staff C, set up the medications for Resident 2, then gave them to Staff C to administer. Staff B said Staff D went to get water, when they returned to the medication cart, and saw Staff C administering the medications to Resident 1. Staff B said when the error was identified there was an immediate assessment of Resident 1 completed, the provider was notified, and Resident 1 was sent to the ED. Staff B said Resident 1 was intubated when they got to the hospital. Staff B said the resident left the hospital and went to a memory care unit instead of returning to the facility. Staff B said there was not a structured training program for new nurses prior to the medication error, but as a result one was put in place to prevent further errors. Staff B said Staff C should not have administered medications they did not prepare. Reference WAC 388-97-1060(3)(k)(iii)

Based on interview and record review the facility failed to protect resident's right to be free from physical abuse for 2 of 4 sampled residents (Residents 1 and 3) reviewed for resident-to-resident altercations. This failure placed residents at risk for abuse, psychosocial harm, and a diminished quality of life.Findings included .Review of a facility policy titled abuse dated 10/20/2022 showed, the organization recognizes and respects that each resident has the right to be free from abuse . RESIDENT 1Resident 1 admitted to the facility on [DATE] with multiple diagnoses including dementia (a decline in cognitive function). The Medicare 5-day Minimum Data Set, (MDS-an assessment tool), dated 03/27/2026, showed Resident 1 was severely cognitively impaired.RESIDENT 2Resident 2 admitted to the facility on [DATE] with multiple diagnoses including dementia with agitation. The quarterly MDS, dated [DATE] showed Resident 1 was severely cognitively impaired.Review of the progress note, dated 03/27/2026 at 08:53 PM, showed Resident 1 was offered a marker by Resident 2. Review showed when Resident 1 attempted to take the marker, Resident 2 grabbed Resident 1 by the arm and pulled on it. Review showed Resident 1 and Resident 2 were immediately separated and Resident 2 was placed on a one-to-one observation for safety.During an interview on 04/22/2026 at 02:09 PM, Staff G, Certified Nursing Assistant (CNA), said Resident 2 was self-propelling their wheelchair in the hallway. Staff G said as Resident 2 passed by Resident 1, they grabbed Resident 1 by the arm. Staff G said they separated the residents, notified the nurse, and began every 15-minute checks on Resident 2.During a joint interview on 04/22/2026 at 02:30 PM Staff A, Administrator, and Staff B, Registered Nurse/Director of Nursing Services (RN/DNS), said Resident 1 was moved to a room at the end of the hall on the opposite side of the hall from Resident 2 to increase physical space between them. Staff A and Staff B said Resident 2 was discharged to an assisted living memory care facility on 03/30/2026.RESIDENT 3Resident 3 admitted to the facility on [DATE] with multiple diagnoses, including dementia. The quarterly MDS dated [DATE] showed Resident 3 was severely cognitively impaired.RESIDENT 4Resident 4 admitted to the facility on [DATE] with multiple diagnoses, including dementia. The quarterly MDS, dated [DATE], showed Resident 4 was severely cognitively impaired. Review of the progress note, dated 04/13/2026 at 5:13 PM, showed Resident 3 was witnessed being hit in the head by Resident 4.During an interview on 04/22/2026 at 11:16 AM, Staff C, Licensed Practical Nurse (LPN), said Resident 3 was returned to the unit during meal time by the restorative aide. Staff C said it was reported to them that Resident 3 had been hit in the head by Resident 4. Staff C said they assessed Resident 3 for injuries after the residents were separated. During an interview on 04/22/2026 at 01:30 PM, Staff H, Restorative Aide, said Resident 3 self-propelled themself to the table Resident 4 was sitting at. Staff H said they saw Resident 4 hit Resident 3 on the head. Staff H said they immediately separated the residents and reported the incident to the nurse. During a joint interview on 04/22/2026 at 02:30 PM, Staff A and Staff B said Resident 3 and Resident 4 were separated after the incident. Staff A and Staff B said ongoing interventions include having Resident 3 and Resident 4 eating at separate tables in the dining room and facing opposite directions to avoid further conflict. Reference WAC: 388-97-0640 (1).

Based on interview and record review the facility failed to thoroughly and accurately document incidents for 2 of 5 sampled residents (Resident 3 and Resident 5) reviewed for professional standards in quality of care. This failure placed residents at risk for unmet care needs, medical complications, and decision makers having an incomplete picture of resident progress. Findings included .RESIDENT 3Review of Resident 4's progress note, dated [DATE] at 05:13 PM, showed Resident 4 hit another resident in the head.During an interview on [DATE] at 11:16 AM, Staff C, Licensed Practical Nurse (LPN), said Resident 4 hit Resident 3 in the head while in the dining room.During an interview on [DATE] at 01:30 PM, Staff H, Restorative Aide, said they witnessed Resident 4 hit Resident 3 while in the dining room.Review of Resident 3's progress notes did not show documentation of the incident between Resident 3 and Resident 4.During a joint interview on [DATE] at 02:30 PM Staff A, Administrator and Staff B, Registered Nurse/Director of Nursing Services (RN/DNS), said documentation for Resident 3 should have been completed in the progress notes about the resident-to-resident altercation. RESIDENT 5Resident 5 admitted to the facility on [DATE] with multiple diagnoses. The annual Minimum Data Set, dated [DATE], showed Resident 5 was cognitively intact.Review of the progress note dated [DATE] at 07:36 PM showed Resident 5 began choking during lunch. The progress note read, Resident was in her bed throughout the day until this incident happened. I gave the resident her morning medication around 9am. During lunch time, the CNA [certified nursing assistant] called me saying that resident was choking. I was coming from room [ROOM NUMBER], I rushed in there, I found another nurse who had been called by the CNA when he couldn't see me (I was in room [ROOM NUMBER]). Resident was sitting at 90 degrees; Me and the CNA pulled her forward While the other nurse did hemlock maneuver x2. Resident said she feels something has moved down her throat. Within a minute, resident became unresponsive. Review of the progress noted did not show documentation of provider notification or what happened after Resident 5 became unresponsive. During an interview on [DATE] at 10:30 AM, Staff D, LPN, said on [DATE], during lunch time, they were coming out of a different room when the CNA told them that Resident 5 was choking. Staff D said Resident 5 was holding their neck, making sounds like they were trying to clear their throat, then they pulled Resident 5 forward in the bed. Staff D said Resident 5 told them something moved down in their throat, then became unresponsive. Staff D said they contacted another nurse for assistance, got the crash cart, put oxygen on Resident 5, called the family, and then started chest compressions. Staff D said another staff called 911 and the resident was taken to the hospital. During an interview on [DATE] at 01:21 PM Staff E, LPN, said on [DATE] during lunch time, Staff D had called them for assistance with Resident 5. Staff E said when they arrived, Resident 5 was sitting up in their bed at a 90-degree angle. Staff E said Staff D, LPN and Staff F, CNA were in the room. Staff E said they were told Resident 5 choked on their lunch and the Heimlich was attempted unsuccessfully. Staff E said they checked Resident 5 for a carotid pulse, which was absent. Staff E said CPR (Cardiopulmonary Resuscitation, an emergency lifesaving procedure performed when the heart stops beating or breathing is inadequate). Staff E said another staff called 911 and then the Emergency Medical Technicians (EMT, a person that provides out-of-hospital emergency medical care) arrived and took over care of Resident 5. Staff E said Resident 5 was transported to the hospital. During an interview on [DATE] at 10:37 AM, Staff F, CNA, said on [DATE] Resident 5 was eating lunch in their room when they noticed the call light on. Staff F said when they entered the room, they found Resident 5 coughing and making noise. Staff F said they notified Staff D, LPN that Resident 5 was choking on their lunch.During a joint interview on [DATE] at 02:30 PM, Staff A, Administrator, and Staff B, RN/DNS, said the progress note should have included information about provider notification, initiation of CPR, and transfer of Resident 5 to the hospital. Reference WAC 388-97--1720(1)(a)(i)-(iv)(b).

Based on interview and record review, the facility failed to report allegations of abuse timely for 1 of 3 sampled residents (Resident 1) reviewed for abuse. This failure placed residents at risk of abuse, mental anguish, and a diminished quality of life.Findings included.According to the Nursing Home Guidelines - The Purple Book, Sixth Edition, dated October 2015, page 25, staff to resident allegations should be reported to the Department of Social Health Services (DSHS) Hotline number, logged within five days, and Police or 911 called.Review of a facility policy titled Abuse, revised 10/20/2022, showed all alleged violations involving abuse would be reported immediately, but not later than two hours after the allegation was made. Review showed the allegation would be reported to the administrator, or designee, and to other officials, including the state survey agency and adult protective services. RESIDENT 1Resident 1 admitted to the facility on [DATE] with diagnoses that included myocardial infarction (heart attack), sepsis (the body's severe response to a massive infection), unsteadiness on feet, muscle weakness, cardiomyopathy (an enlarged heart), and presence of automatic internal cardiac defibrillator (AICD, a small battery powered device surgically placed under the skin used to treat life threatening heart problems). The 5-day Medicare minimum data set (MDS), an assessment tool, dated 03/04/2026, showed Resident 1 was moderately cognitively impaired.Review of a facility incident investigation, dated 03/08/2026 at 10:00 AM, showed on 03/07/2026, Resident 1 was assisted by Staff F, Registered Nurse (RN) to the bathroom. Review showed Staff F told Resident 1 they needed to transfer themself to and from the toilet. Review showed when Resident 1 asked Staff F if they would return to help them off of the toilet, Staff F told Resident 1 they would have to transfer themself or they would have to stay there forever. Review of the incident investigation showed Staff E, Certified Nursing Assistant (CNA) answered Resident 1's call light 03/07/2026 at 09:00 PM and found Resident 1 in the bathroom. When Staff E offered assistance to Resident 1, Resident 1 told Staff E they had already done it themselves because Staff F had told them to do it themselves or they would have to stay there forever. Review showed Staff E reported the incident to the oncoming CNA at shift change. Review of a written statement by Staff G, CNA, dated 03/08/2026 at 07:45 PM, showed Resident 1 reported significant pain in their left arm. Review of the statement showed Resident 1 disclosed the allegation from 03/07/2026 to Staff G. Staff G immediately reported the allegation to their supervisor.During an interview on 03/18/2026 at 12:49 PM, Resident 1 said they had recently had a AICD placed and they were not supposed to use their left arm for anything. Resident 1 said when Staff F came into their room to answer the call light, Staff F told them to transfer themself into the wheelchair. Resident 1 said it caused pain to transfer themself. Resident 1 said they had to transfer themself back to the wheelchair once they were done on the toilet because they did not think Staff F would assist them.During an interview on 03/26/2026 at 01:50 PM, Staff E, CNA said they returned from their break and seen the call light on for Resident 1's room. Staff E said they asked Resident 1 who helped them clean up and Resident 1 said they did it themself. Staff E said Resident 1 reported to them that Staff F said to them they had to wipe themself or they would have to stay there forever. Staff E said they reported the concern to the oncoming CNA during shift change. Staff E said they did not report the allegation to a supervisor because Resident 1 asked them not to. Staff E said they had received abuse training recently from Staff C, Registered Nurse/Assistant Director of Nursing Services (RN/ADNS). When asked what that training included, Staff E said they were supposed to report any allegation of abuse.Review of a document titled Summary Report of Education, dated 02/26/2026 at 01:30 PM, showed abuse education, including reporting of alleged violations. Review showed Staff E had signed the form, showing they had received the abuse education. During an interview on 03/26/2026 at 01:58 PM, Staff D, Licensed Practical Nurse (LPN), said they found out about the allegation on 03/08/2026, the following day, from Staff G. Staff D said Staff F was scheduled to work again that evening. Staff D said Resident 1 heard Staff F and seen them in the hallway, making Resident 1 upset. Staff D said Resident 1 told Staff G about the allegation but asked them not to report it to anyone. Staff D said Staff G reported the allegation of abuse despite Resident 1 asking them not too. Staff D said Staff E should have reported the allegation when they became aware of it even though Resident 1 did not want them to. During an interview on 03/26/2026 at 02:00 PM, Staff C, RN/ADNS, said abuse education was completed the end of February of 2026. Staff C said the education included immediate intervention for abuse and neglect allegations and reporting all allegations to the abuse coordinator and/or supervisor within 2 hours. Staff C verified Staff E's signature on the education roster. Staff C said abuse should be reported even if a resident requests it not be. During an interview on 03/26/2026 at 02:15 PM, Staff A, Administrator said all allegations of abuse should be reported immediately to the administrator, Director of Nursing, or any other available management. Staff A said allegations should be reported even if a resident tells them not to. Reference WAC 388-97-6040(5)(a).

Based on interview and record review, the facility failed to immediately report to the state agency, witnessed sexual abuse for 1 of 2 residents (Resident 1) reviewed for abuse. This failure placed residents at risk of further abuse, psychological distress, and a diminished quality of life.Findings included.According to the Nursing Home Guidelines - The Purple Book, Sixth Edition, dated October 2015, page 25, Resident to Resident incidents with sexual abuse/assault, should be reported to the Department of Social Health Services (DSHS) Hotline number, logged within five days, and Police or 911 called.Review of a facility policy titled Abuse showed all alleged violations involving abuse would be reported immediately, but not later than two hours after the allegation was made. Review showed the allegation would be reported to the administrator, or designee, and to other officials, including the state survey agency and adult protective services. Resident 1 admitted to the facility on [DATE] with diagnoses that included dementia (a decline in cognitive function) and anxiety disorder. The admission minimum data set (MDS), an assessment tool, dated 12/23/2025, showed Resident 1 was moderately cognitively impaired.Resident 2 admitted to the facility on [DATE] with diagnoses that included dementia, aphasia (a language disorder) and cognitive communication deficit. The MDS dated [DATE], showed Resident 2 was severely cognitively impaired.Review of an incident report, dated 02/02/2026 at 11:45 AM, showed Resident 1 was touched inappropriately by Resident 2.Review of a progress noted, dated 02/02/2026 at 12:45 PM, showed Resident 1 was found in the room of Resident 2 by a Certified Nursing Assistant (CNA), being touched on the breasts. Review showed the CNA notified the nurse. Review of the documentation showed the nurse wrote an alert report to inform the managers of the incident.Review of the state agency report showed the incident was reported on 02/03/2026 at 10:42 AM, which was outside of the two-hour time frame.Review of the incident investigation documentation for incident dated 02/02/2026, showed the nurse failed to immediately report the inappropriate touching to the administrator, state agency, and police, despite being a mandated reporter.During an interview on 02/04/2026 at 10:08 AM, Staff D, CNA, said if abuse occurs, they would report it to their supervisor.During an interview on 02/04/2026 at 10:09 AM, Staff C, Licensed Practical Nurse (LPN), said if abuse is suspected or occurs, they would report it to the manager, family, and report to the DSHS hotline.During an interview on 02/04/2026 at 12:40 PM, Staff E, CNA, said if they witnessed abuse they would immediately report to their supervisor and the DSHS hotline.During an interview on 02/04/2026 at 12:53 PM, Staff F, LPN, said if abuse occurred or is suspected, they would report it and document it within two hours. During an interview on 02/04/2026 at 12:56 PM, Staff G, Registered Nurse (RN), said if abuse was suspected or occurred, they would notify a supervisor as soon as possible.During a joint interview on 02/11/2026 at 01:12 PM, Staff A, Administrator, and Staff B, Director of Nursing Services (DNS)/RN, said they became aware of the incident the following morning on 02/03/2026, when Staff B was reviewing progress notes from the previous day. Staff A and Staff B said the incident should have immediately been reported verbally to the administrator and DNS. Staff A and Staff B said the incident should have been reported to DSHS and the police within two hours.Reference WAC 388-97-0640(5)(a)

Based on observation, interview and record review, the facility failed to protect a resident's right to be free from sexual abuse and timely put appropriate interventions in place to protect vulnerable residents for 1of 2 sampled residents (Resident 1) reviewed for abuse. This failure placed residents at risk of further abuse, mental anguish, and a diminished quality of life.Findings included.Review of the facility policy titled Abuse dated 10/20/2022 showed in the event of an allegation or observation of abuse, the facility would immediately assess the resident and protect the resident and other residents from further harm or incident. Review of the policy showed the resident's plan of care would be revised to reflect interventions to minimize recurrence. Review of the policy showed staff were encouraged to identify, correct, and intervene in situations in which abuse was more likely to occur. Review of the policy showed sexual abuse was defined as non-consensual sexual contact of any type with a resident.RESIDENT 1Resident 1 admitted to the facility on [DATE] with diagnoses that included dementia (a decline in cognition) and anxiety disorder. The admission Minimum Data set (MDS), an assessment tool, dated 12/23/2025, showed Resident 1 was moderately cognitively impaired.Review of the care plan, dated 12/18/2025, showed Resident 1 had a cognitive impairment. Review showed Resident 1 was on a locked unit due to wandering and exit seeking. Review of the care plan showed Resident 1 was able to ambulate independently without assistive devices.Review of the facility incident investigation, dated 02/02/2026 at 11:45 AM, showed Resident 1 was found in another resident's room and had been touched by that resident. Review of the investigation showed Resident 1 said the resident had taken them into the room (Resident 2's room) and touched them.Review of a progress note, dated 02/02/2026 at 12:45 PM, showed Resident 1 was in another resident's room and had been touched by that resident. The nurse took Resident 1 back to their room and was told by Resident 1 that Resident 2 had taken them into their room and touched them inappropriately. Observation on 02/04/2026 at 09:55 AM, showed Resident 1 ambulating independently in the hall with no assistive devices. During an interview on 02/10/2026 at 01:26 PM, Resident 1 said the other resident touched them and they did not want that to happen. Resident 1 said they could not understand why the other resident touched them. During an interview on 02/04/2026 at 10:08 AM, Staff C, Licensed Practical Nurse (LPN), said on 02/02/2026, Resident 1 was taken by the hand into another resident's room where they touched their breasts.RESIDENT 2Resident 2 admitted to the facility on [DATE] with diagnoses that included dementia, aphasia (a language disorder) and cognitive communication deficit. The 5-day Medicare MDS, dated [DATE], showed Resident 2 was severely cognitively impaired.Review of a facility incident investigation, dated 02/02/2026 at 11:45 AM, showed Resident 1 and Resident 2 were seen in the room of Resident 2 together. Review of the document showed a Certified Nursing Assistant (CNA) witnessed Resident 2 touching Resident 1 on the breasts.Review of a progress note, dated 02/02/2026 at 6:35 PM, showed Resident 2 was found touching Resident 1 inappropriately. Review of the progress note showed after the incident, Resident 2 was redirected back to their room whenever they tried to enter other residents' rooms.Review of the progress notes showed Resident 2 had sexually inappropriate behaviors as follows:01/31/2026 Resident 2 touched a CNA inappropriately02/01/2026 Resident 2 motioned a CNA to get into bed with them02/02/2026 Resident 2 rubbed the social workers arm and directed them towards their bed02/02/2026 Resident 2 was found touching Resident 1's breasts02/04/2026 Resident 2 exposed their genitals to a CNAReview of the behavior care plan showed Resident 2 did not have interventions put in place for sexually inappropriate behaviors until 02/02/2026, despite having documented sexually inappropriate behaviors prior to that. Review of the care plan showed one-to-one supervision with staff was initiated on 02/03/2026, the following day.Observation on 02/04/2026 at 10:00 AM showed Resident 2 walking in the hall using a front wheel walker with Staff D, CNA, following at a short distance, within line of sight providing one to one supervision. Observation showed Resident 2 approach the locked doors to the unit. Observation showed Resident 2 was speaking a foreign language with Staff D attempting to communicate with them using verbal and hand queues. Observation showed Resident 2 became anxious and began crying while walking away from Staff D. Observation showed Resident 2 began yelling out while walking down the hall towards the dining room. Resident 2 was unable to be interviewed due to poor cognition and memory recall.During an interview on 02/04/2026 at 10:08 AM, Staff D said Resident 2 was on one-to-one observation because sexual abuse had occurred.During an interview on 02/04/2026 at 10:09 AM, Staff C, Licensed Practical Nurse (LPN), said Resident 2 took Resident 1 by the hand, took Resident 1 into Resident 2's room, and touched Resident 1's breasts. Staff C said Resident 2 was then placed on one-to-one observation with a male CNA.Observation on 02/04/2026 at 10:43 AM showed Staff D sitting in a chair in the hallway talking to Resident 2. Observation showed Staff D continuing to sit in the chair while Resident 2 walked into the dining room way from them. Observation showed Resident 2 exited the dining room and entered their room while Staff D continued to sit in the chair, out of line of sight of Resident 2.Observation on 02/04/2026 at 12:14 PM, showed the door closed on Resident 2's room. Staff D was sitting in a chair in the hallway. Resident 2 was not visualized.Observation on 02/04/2026 at 02:17 PM, showed Staff E, CNA, assisting residents in the day room, walking around a corner and unable to constantly visualize Resident 2 while on one-to-one supervision until 02:25 PM.During an interview on 02/04/2026 at 12:40 PM, Staff E, CNA, said Resident 2 had been having behaviors with female staff and had been inappropriate with them.During an interview on 02/04/2026 at 12:45 PM, Staff H, CNA, said Resident 2 had shown inappropriate sexual behaviors towards CNAs. Staff H said they did not know what to do for Resident 2 if they had behaviors and would have had to ask the nurse or the manager for guidance if Resident 2 had behaviors.During an interview on 02/04/2026 at 11:20 AM, Staff I, activities/social services, said on the morning of 02/02/2026 they went into Resident 2's room to introduce themself. Staff I said Resident 2 grabbed by the arm and led them to the bed. Staff I said other staff had said Resident 2 had been sexually inappropriate with staff. Staff I said they let the nurse know Resident 2 had been handsy and tried to get Staff I into bed. When asked if care plan interventions had been put in place when staff noted Resident 2 was having sexually inappropriate behavior, Staff I said interventions had not been put into place. Staff I said Resident 2 had exhibited sexually inappropriate behaviors with female staff but had not been seen showing them to other residents.During a joint interview on 02/11/2026 at 12:56 PM, Staff J, Unit Manager/LPN, and Staff B, Director of Nursing Services/Registered Nurse (DNS/RN), said sexual abuse was substantiated. Staff B and Staff J said they knew the inappropriate touch happened. Staff B and Staff J said Resident 2 spoke a foreign language. Staff B and Staff J said communication with Resident 2 was difficult, even with an interpreter, making their ability to understand boundaries difficult due to cognition. Staff B and Staff J said Resident 2 was discharged to a sister facility on 02/05/2026 where they could better monitor them by staff with more training.During a joint interview on 02/11/2026 at 01:12 PM, Staff A, Administrator, and Staff B RN/DNS, said once they found out about the inappropriate touch, they put a one-on-one supervision in place for Resident 2. Staff A and Staff B said this was not immediately implemented because of a delay in notification to facility management. Staff A and Staff B said appropriate interventions should have been implemented immediately to protect Resident 1 as well as all other residents.Reference WAC 388-97-0640(1)

Based on interview and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program to correct identified noncompliance and ensure changes were maintained to ensure ongoing compliance. This failure placed residents at risk of lacking quality medical care, abuse/neglect, foodborne illness, preventable infections, and a diminished quality of life. Findings included.Review of the CASPER Report 0003D Provider History Profile, run dated 11/25/2025, showed the facility had the following repeated noncompliance on previous Long-Term Care Surveys/Complaint Investigations and continued to be out of compliance on the current 12/02/2025 Long-Term Care Survey:1. F552 - Right to be Informed/Make Treatment Decisions: 02/2024, 12/2024, and 12/2025.2. F610 - Investigate/Prevent/Correct Alleged Violation: 02/2024, 02/28/2024, 12/2024, 04/24/2025, and 12/2025.3. F641 - Accuracy of Assessments: 12/2024 and 12/2025.4. F645 - PASARR Screening for MD & ID: 02/2024, 12/2024, and 12/2025.5. F656 - Develop/Implement Comprehensive Care Plan: 12/2024 and 12/2025.6. F657 - Care Plan Timing and Revision: 02/2024, 12/2024, and 12/2025.7. F684 - Quality of Care: 02/2024, 07/17/2024, 12/2024, 07/24/2025, and 12/2025.8. F685 - Treatment/Devices to Maintain Hearing/Vision: 02/2024, 12/2024, and 12/2025.9. F688 - Increase/Prevent Decrease in ROM/Mobility: 12/2024 and 12/2025.10. F692 - Nutrition/Hydration Status Maintenance: 02/2024, 12/2024, and 12/2025.11. F745 - Provision of Medically Related Social Service: 12/2024 and 12/2025.12. F757 - Drug Regimen is Free from Unnecessary Drugs: 02/2024, 12/2024, and 12/2025.13. F761 - Label/Store Drugs and Biologicals: 12/2024 and 12/2025.14. F812 - Food Procurement, Store/Prepare/Serve-Sanitary: 10/2019, 01/2023, 02/2024, 12/2024, and 12/2025.15. F865 - QAPI Program/Plan, Disclosure/Good Faith Attempt: 12/2024 and 12/2025.16. F880 - Infection Prevention & Control: 02/2024, 12/2024, 06/18/2025, 08/27/2025, and 12/2025. During an interview on 12/09/2025 at 2:18 PM, Staff A, Administrator, stated the QAPI program met quarterly and followed an agenda which outlined what the QAPI program would review. Staff A stated the facility used corporate provided audit tools to determine problem areas and the QAPI would use this data to develop protocols to track and trend the area to ensure improvement. Staff A stated QAPI ensured compliance was maintained by monitoring problem areas until compliance was maintained and the expectation was when compliance was achieved it would become part of the standard. Staff A stated the facility was aware of the issues identified at F552, F610, F685, F692, F757, and F880 and were continuing to develop methods to ensure compliance. Reference WAC 388-87-1760(1)(2), -1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to offer, educate, and obtain consent for Covid-19 vaccines for 3 of 5 sampled residents (Residents 6, 15 and 23) when reviewed for immunizations. This failure denied residents the opportunity to make an informed decision regarding receiving immunizations and/or placed the residents at risk for communicable diseases, complications of other medical conditions, hospitalization, and death. Findings included.Review of the facility document titled Clinical Protocol for SARS COV-2, undated, showed All Residents to be offered resources and counseled about receiving the COVID-19 vaccine. Resident 6Review of the electronic health record (EHR) showed Resident 6 admitted to the facility on [DATE] with a diagnosis of adult failure to thrive. The resident was able to make needs known. Review of the Vaccine Consent Form dated 03/25/2025 showed the resident had requested any vaccine that is due. Review of the EHR on 12/08/2025 showed no documentation that the facility assessed the resident for the need for, educated the resident or administered the Covid-19 vaccine. Resident 15Review of the EHR showed Resident 15 admitted to the facility on [DATE] with a diagnosis of stroke (when blood flow to part of the brain is blocked). The resident was able to make needs known. Review of Resident 15's vaccines information sheet showed the resident was eligible, due on 08/22/2025 and had not received the Covid-19 Vaccine. Review of the Vaccine Consent Form dated 01/02/2025 showed no documentation that the resident was educated and offered the Covid-19 vaccine. Resident 23Review of the EHR showed Resident 23 admitted to the facility on [DATE] with diagnoses of pneumonia, adult failure to thrive and history of falls. The resident was able to make needs known. Review of Resident 23's vaccines information sheet showed the resident was eligible, due on 08/22/2025 and had not received the Covid-19 vaccine. Review of the EHR showed no documentation that the resident was assessed for the need for, educated on and/or consented to the Covid-19 vaccine. During an interview on 12/08/2025 at 11:18 AM, Staff B, Director of Nursing Services (acting IP), stated it was their expectation that residents were educated and offered the Covid-19 vaccine. Staff B stated Residents 6, 15 and 23's vaccinations for Covid-19 did not meet expectations. Reference WAC 388-97-1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to offer, educate, and obtain consent for influenza and pneumococcal vaccines for 3 of 5 sampled residents (Residents 6, 15, and 23) when reviewed for influenza and pneumococcal immunizations. These failures denied residents the opportunity to make an informed decision regarding receiving immunizations and/or placed the residents at risk for communicable diseases, complications of other medical conditions, hospitalization, and death. Findings included.Review of the facility policy titled Pneumococcal Vaccine, dated 05/02/2025, showed, Prior to or upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, would be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Review of the facility policy titled Influenza Vaccination, undated, showed the facility would educate, offer and obtain consent for influenza vaccines to residents upon initial admission and administer as appropriate. Resident 6Review of the electronic health record (EHR) showed Resident 6 admitted to the facility on [DATE] with a diagnosis of adult failure to thrive. The resident was able to make needs known. Review of the Vaccine Consent Form dated 03/25/2025 showed the resident had requested any vaccine that is due. Review of the EHR showed no documentation that the facility assessed the resident for appropriate vaccines or administered the influenza or pneumococcal vaccines Resident 15Review of the EHR showed Resident 15 admitted to the facility on [DATE] with a diagnosis of stroke (when blood flow to part of the brain is blocked). The resident was able to make needs known. Review of Resident 15's vaccines information sheet showed the resident was eligible and had not received the influenza or pneumococcal vaccines. Review of the Vaccine Consent Form dated 01/02/2025 showed no documentation that the resident was educated and offered the influenza or pneumococcal vaccines. Resident 23Review of the EHR showed Resident 23 admitted to the facility on [DATE] with diagnoses of pneumonia, adult failure to thrive and history of falls. The resident was able to make needs known. Review of Resident 23's vaccines information sheet showed the resident was eligible and due for but had not received the pneumococcal vaccine. Review of the EHR showed no documentation that the resident was assessed for the need for, educated on and consented to the pneumococcal vaccine. During an interview on 12/08/2025 at 11:18 AM, Staff B, Director of Nursing Services (acting IP), stated it was their expectation that residents were educated and offered the pneumococcal vaccine on admission and residents were offered and educated on the influenza vaccine during the flu season. Staff B stated Residents 6, 15 and 23's vaccinations for influenza and pneumococcal did not meet expectations. Reference WAC 388-97-1340(1)(2)(3)

Based on observation, interview, and record review, the facility failed to implement an infection control program to monitor for and manage infections for 2 of 3 months (September and October 2025) and 2 of 22 residents (Residents 73 and 12) when reviewed for infection control. Failure to collect and analyze the infection control data and implement measures to reduce infections for the months of September and October 2025 and failure to provide infection prevention measures for an indwelling urinary device and abdominal drain for Residents 12 and 73 placed the residents at risk for infections, poor clinical outcomes, and a decreased quality of life. Findings included.Findings included. Review of the facility policy titled Infection Control Surveillance, undated, showed the infection preventionist would collect and analyze the infection control data to identify trends by comparing the rates to previous months in the current year and to the same month in previous years, to identify trends and implement interventions to improve those rates. Review of the infection control log for September 2025 showed no documentation that the collected data was analyzed for trends or interventions were implemented to address trends. Resident 73 Review of the electronic health record showed Resident 73 admitted to the facility on [DATE] with diagnoses of brain cancer and seizures. The resident was able to make needs known. Review of the provider's orders showed an order for cephalexin (an antibiotic) for urinary tract infection (UTI) twice a day for 14 days with a start date of 10/30/2025. Review of the October 2025 infection control log showed this resident's infection was not included in the tracking. During an interview on 12/08/2025 at 12:45 PM, Staff B, Director of Nursing Service (DNS) stated they were the acting Infection Preventionist (IP) for the facility and it was their expectation that the IP collect the infection control data daily and analyze the data at the end of each month to look for trends and then apply changes to help improve infection control. Staff B also stated that all infections should be tracked, and Resident 73 should have been included in the October 2025 data. Resident 12 Review of the electronic health record (EHR) showed Resident 12 was admitted to the facility on [DATE] with diagnoses to include infection and inflammatory reaction due to indwelling urethral catheter (thin, flexible tube inserted into the bladder to continuously drain urine), anemia (condition where blood lacks enough healthy red blood cells or hemoglobin to carry sufficient oxygen to the body's tissue) and malnutrition. Resident 12 was able to communicate needs. Observation and interview on 12/04/2025 at 9:53 AM showed Resident 12 in bed with an abdominal drain (thin, flexible tube inserted into the abdominal wall to continuously drain secretion) bag draining dark red color fluid on the floor. Resident 12 stated the staff opened the bag to drain it and did not close it. Observation on 12/05/2025 at 9:09 AM showed Resident 12 in bed with blood stains on the floor under the abdominal bag and the table leg on top of the drain bag. During an interview on 12/05/2025 at 9:11 AM, Staff H, Licensed Practical Nurse, stated the drain bag should be pinned on the bed and not touching the floor. Observation on 12/08/2025 at 9:20 AM showed Resident 12 in their bed and the catheter bag laying on the floor and draining a large amount of urine on the floor. During an interview on 12/08/2025 at 9:22 AM, Staff Y, Registered Nurse/Resident Care Manager, stated the catheter bag should be closed and not drain on the floor. Staff Y stated that did not meet expectations. During an interview on 12/08/2025 at 12:32 PM, Staff B, Director of Nursing Services, stated the catheter and drainage bags were to be attached securely to the bed and not on the floor. Staff B stated the observations for Resident 12's catheter bag and drainage bag did not meet expectations. Reference WAC 388-97 -1320(1)-(2)(a)(c)

Based on observation, interview, and record review, the facility failed to maintain safe food storage in 3 of 3 resident refrigerators (100 Hall, 300 Hall, and Serenity Unit Refrigerators) and failed to ensure safe food re-heating for 1 of 2 re-heating microwaves (300 Hall Microwave) when reviewed for kitchen. This failure placed residents at risk of eating expired and/or contaminated foods, foodborne illness, and a diminished quality of life. Findings included.RefrigeratorsObservation on 12/03/2025 at 1:21 PM showed the Serenity Unit Refrigerator with a gallon jug of milk with a best by date of 11/27, a plastic container with an unidentifiable yellow food item with white growth on top, and a pitcher of facility made juice without a date label. Observation on 12/03/2025 at 1:26 PM showed the 300 Hall Refrigerator with an unopened bottle of brewed tea labeled as placed in the refrigerator on 11/15 and with a use by date of 11/04/2025. Observation and record review on 12/03/2025 at 1:31 PM showed the 100 Hall Refrigerator with a jar of salsa with a worn off use by date and labeled with a resident's name. Review of the facility's health record system showed the resident discharged from the facility on 10/21/2025. Observation showed a piece of cheesecake labeled as placed in the refrigerator on 11/29/2025. Observation on 12/08/2025 at 10:43 AM showed the Serenity Unit Refrigerator with a bowl of clam chowder dated as placed in the refrigerator on 12/03/2025. MicrowaveReview of a policy titled, Microwave Reheating, dated 10/01/2021, showed, After reheating foods in the microwave, allow standing time (approximately 2 minutes). Then, use a clean food thermometer to check that the food has reached 165 [degrees Fahrenheit]. Observation on 12/08/2025 at 10:33 AM showed the 100 Hall Resident Refrigerator area with a microwave and a temperature log for December 2025 to record the temperature of re-heated food. Review of the temperature log showed six of seven temperatures were more than 15 degrees below 165 F. During an interview on 12/08/2025 at 11:14 AM, Staff AA, Dietary Manager, stated food in the resident refrigerators should be labeled with the date placed into the refrigerator and should be thrown away after three days. Staff AA stated food re-heated using a microwave should reach 165 F to ensure it was safe to eat. Staff AA stated the observations of the resident refrigerators did not meet expectations for safe food storage. Staff AA reviewed the microwave temperature log and stated they were, a bit low and did not meet expectations. During an interview on 12/08/2025 at 11:20 AM, Staff A, Administrator, stated the observations of the resident refrigerators and the temperature log with low temperatures did not meet expectations. Reference WAC 388-97 -1100(3), -2980

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for 2 of 2 sampled residents (Residents 86 and 14) when reviewed for fluid restrictions. This failure placed the residents at risk for medical complications and a diminished quality of life. Findings included.Findings included. Resident 86 Review of the electronic health record (EHR) showed Resident 86 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease (kidneys cannot filter blood waste), renal dialysis (treatment that filters waste, salt, and fluid from the body), anxiety, depression, and hypertension (elevated blood pressure). Resident 86 was able to communicate needs. During an interview on 12/02/2025 at 1:31 PM, Resident 86 stated they were allowed to consume 1200 milliliters (ml) of fluids a day. Review of medication administration record (MAR) for December 2025 showed Resident 86 had consumed 240 ml of fluids for daytime and 240 ml for nighttime for the first four days in the month. Review of MAR for November 2025 showed Resident 86 had similar documentation. During an interview on 12/08/2025 at 9:19 AM, Staff CC, Certified Nursing Assistant, who was working on Resident 86's hall, stated the residents on fluid restrictions were identified by a symbol on the door, and they were not aware of anyone on fluid restrictions on this hall. Resident 86 did not have symbol on their door. During an interview on 12/08/2025 at 12:36 PM, Staff B, Director of Nursing Services (DNS), stated the staff were to follow the orders and document correctly in the MARs. Staff B stated the documentation of Resident 86's fluid restrictions did not meet expectations. Resident 14 Review of the EHR showed Resident 14 admitted to the facility on [DATE] with diagnoses of diabetes and end stage renal disease. The resident was able to make needs known. Review of the EHR showed a provider order dated 10/22/2025 for 1800 ml fluid restriction, 720 ml from dietary and 1080 ml from nursing. Review of the MAR documentation showed Resident 14 received an average of 794 ml daily in the month of November 2025. The daily total was not documented in the MAR. Observation on 12/02/2025 at 12:44 PM showed Staff Q, Certified Nursing Assistant (CNA), passing meal trays. Staff Q set out seven cups and poured liquids into the cups and placed the cups on each tray without looking at the diet slips. Staff Q, when asked if any residents were on a fluid restriction, stated No. Staff Q then delivered a tray to Resident 14 with one cup of fluids. During an interview and observation on 12/05/2025 at 8:45 AM, Resident 14 stated they were not on a fluid restriction because they got constipated. A full glass of clear liquids was noted on the bedside table. During an interview on 12/05/2025 at 8:50 AM, Staff S, Licensed Practical Nurse, stated they were aware Resident 14 was on a fluid restriction. Staff S stated the CNAs recorded the amount each meal and then the nurse records the total at the end of the shift. Review of the EHR showed a point of care task titled nutrition for 11/05/2025 through 12/05/2025, and the amount of fluids consumed was documented as percent of fluids offered and accepted. It did not document the amount in milliliters. During an interview on 12/05/2025 at 8:35 AM, Staff T, Regional Food Service, stated the kitchen did not manage the fluids that were provided. They put out a beverage cart, and the nurses managed any fluid restrictions. During an interview on 12/05/2025 at 8:38 AM, Staff U, CNA, who was passing meal trays on Resident 14's hall, stated the nurses gave them directions on how much fluids to give. They were not aware of any residents on a fluid restriction. During an interview on 12/05/2025 at 8:47 AM, Staff V, CNA, who was assigned to Resident 14 that shift stated no residents on their hall were on a fluid restriction. During an interview on 12/05/2025 at 9:10 AM, Staff D, Resident Care Manager, stated their expectation was for the CNAs to complete a form that calculated the amount of fluids residents on a fluid restriction drank on their shift and give it to the assigned nurse at the end of the shift to enter it into the EHR. Staff D stated the CNAs should look at the meal tickets when pouring fluids to see if a resident was on a fluid restriction. During an interview on 12/05/2025 at 11:08 AM, Staff B, Director of Nursing Services, stated it was their expectation that staff were aware of who was on fluid restrictions and reviewed the diet slips when delivering trays, and document the total at the end of their shifts and daily. Staff B stated Resident 14's fluid restriction did not meet expectations. Reference WAC 399-97-1060(3)(i)

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice and the comprehensive person-centered care plan for 4 of 22 residents (Residents 96, 24, 11, and 14) when reviewed for quality of care and/or Hospice services. Failure to provide bowel management for Resident 14, to obtain and review hospice services notes for Residents 96, 24, and 11, and to develop a collaborative comprehensive care plan involving Hospice service for Residents 24 and 11, placed the residents at risk for unmet needs, clinical complications and a diminished quality of life. Findings included.<Hospice Services Visit Notes> Resident 96 Review of the electronic health record (EHR) showed Resident 96 admitted to the facility on [DATE] with diagnoses to include kidney failure, depression, and dementia (a group of thinking and social symptoms that interfere with daily functioning). Resident 96 received hospice services and was able to make needs known. During an interview on 12/02/2025 at 1:07 PM Resident 96 stated they were not sure if they received hospice services because they did not know what hospice was. Review of Resident 96's provider order dated 07/10/2023 showed do not resuscitate (allow natural death) comfort measure/hospice. Review of the modification of quarterly minimum data set (MDS, a required assessment tool) dated 10/01/2025 showed Resident 96 received hospice care services. Review of the focused care plan for hospice services initiated on 07/10/2023 showed Resident 96 was admitted to hospice services for terminal progressive disease. Review of Resident 96's EHR showed hospice visit notes from January 2025 through May 2025; however, there were not any recent hospice services visit notes. During an interview on 12/09/2025 at 10:57 AM, Staff P, Unit Manager (UM), stated that they have been getting hospice documentation when they came in at times to visit and would give the documentation to Medical Records to scan into the EHR. Staff P stated that if there were any issues or changes hospice would verbally inform them. Staff P stated that there were no current hospice binders with logs located at the nurse's stations. Staff P stated they were unable to locate Resident 96's recent hospice visit notes in their EHR and the Medical Records department did not have the recent documentation. Staff P stated this did not meet expectations. During an interview on 12/09/2025 at 12:11 PM, Staff B, Director of Nursing Services (DNS), stated hospice visit notes were previously located in a binder at the nurse's stations. Staff B stated that Resident 96's recent hospice visit notes were not scanned into their EHR and this did not meet expectations. Resident 24 Review of the electronic health record (EHR) showed Resident 24 admitted to the facility on [DATE] with diagnoses to include dementia, high blood pressure, and diabetes (too much sugar in the blood). Resident 24 received hospice care services and usually was able to make needs known. Review of Resident 24's provider order dated 11/12/2025 showed to admit to hospice services on 11/03/2025 for advanced dementia. Review of the Significant Change MDS dated [DATE] showed Resident 24 received hospice care services. Review of Resident 24's EHR on 12/05/2025 showed no documentation of hospice services visit notes. During an interview on 12/09/2025 at 11:15 AM, Staff P, UM, stated Resident 24's hospice visit notes should have been scanned into the resident's EHR. Staff P stated that they had requested Resident 24's Hospice visit notes to be provided from hospice last week. Staff P stated there needed to be a system in place to fix this issue. During an interview on 12/09/2025 at 12:31 PM, Staff B, DNS, stated they were unable to locate hospice visit notes in Resident 24's EHR and they should have been obtained, reviewed, and located in the EHR prior to now. Resident 11 Review of the EHR showed Resident 11 readmitted to the facility on [DATE] with diagnoses to include unsteadiness on feet, Alzheimer's disease (a progressive brain disorder causing difficulty with daily activities), anxiety disorder, and bipolar disorder (a brain condition causing extreme mood swings). Resident 11 received hospice care services and was able to make needs known. Observation and interview on 12/02/2025 at 11:55 AM showed Resident 11 being provided care by an unidentified hospice aid who stated they had just finished providing a shower and assisted to dress Resident 11. Resident 11 was now resting in bed and showed no signs and symptoms of pain or discomfort. Review of Resident 11's provider order dated 08/29/2025 showed to admit to hospice with a diagnosis of senile degeneration of the brain. Review of the quarterly MDS dated [DATE] showed Resident 11 received hospice care services. Review of Resident 11's EHR on 12/05/2025 showed no documentation of hospice services visit notes. During an interview on 12/09/2025 at 11:45 AM, Staff P, UM, stated they needed to contact hospice to provide hospice visit notes for Resident 11 and that they should have been located in Resident 11's EHR. Staff P stated this did not meet expectations. During an interview on 12/09/2025 at 12:38 PM, Staff B, DNS, stated Resident 11's hospice visit notes documentation should have been obtained, reviewed, and located in the EHR prior to now, and this did not meet expectations. < Collaborative Comprehensive Care Plan Involving Hospice> Resident 24 Review of the focused care plan for hospice services due to terminal progressive disease revised on 11/13/2025 showed Resident 24 had an intervention initiated on 11/13/2025 that Resident 24 was admitted for hospice services. This care plan lacked documentation of hospice services related to who would be visiting and how hospice would be helping with Resident 24's plan of care. During an interview on 12/09/2025 at 11:15 AM, Staff P, UM, stated hospice was only mentioned in Resident 24's focused hospice and nutrition care plans and did not meet expectations for an integrated care plan, and needed to be revised. During an interview on 12/09/2025 at 12:31 PM, Staff B, DNS, stated Resident 24's hospice services were mentioned in the focused hospice and nutrition care plans to inform of hospice status and did not show who was visiting from hospice. Staff B stated this did not meet expectations for an integrated care plan and needed to be revised/updated. Resident 11 Review of the focused care plan for hospice services initiated on 09/03/2025 showed Resident 11 was admitted to hospice services for terminal progressive disease. This care plan lacked documentation of hospice services related to who would be visiting and how hospice would be helping with Resident 11's plan of care. During an interview on 12/09/2025 at 11:45 AM, Staff P, UM, stated Resident 11's care plan did not show who from hospice would be providing care and needed to be revised to be integrated with the hospice plan of care. During an interview on 12/09/2025 at 12:38 PM, Staff B, DNS, stated Resident 11's care plan had mentioned hospice in the focused hospice and falls care plans to inform on hospice status and to notify as needed; however, it did not reflect who from hospice would visit. Staff B stated this did not meet their expectations for an integrated care plan with hospice services and needed to be revised/updated. <Bowel Management> Resident 14 Review of the EHR showed Resident 14 admitted to the facility of 10/14/2025 with diagnoses of hemiplegia (weakness on one side of the body), diabetes (too much sugar in the blood), and kidney failure. The resident was able to make needs known. During an interview on 12/02/2025 at 2:35 PM, Resident 14 stated they had problems with bowel movements, especially when out at appointments. Review of the EHR showed Resident 14 had no documented bowel movements between 11/17/2025 and 11/23/2025 (five days). Review of the medication administration record showed the resident received loperamide (a medication for the treatment of loose bowel movements) as needed for loose stools on 11/17/2025 and 11/19/2025. No documentation was found showing the resident had reported or complained of loose bowels on those dates. Review of the Administration record showed the resident received MiraLAX and a Bisacodyl suppository (Laxatives) for constipation on 11/23/2025, five days after the last documented bowel movement. Review of the plan of care showed Resident 14 had a history of constipation and to follow the bowel protocol Review of the facility policy titled Bowel and Bladder Management dated 08/29/2024 showed: For diarrhea (loose stools) to perform a rectal check for impaction, hold laxative medications for 24 hours and if it continues to notify the provider, test the stool for c-diff toxin (an infection) and administer Loperamide one time. For constipation (lack of bowel movements) to encourage fluids to 2000 ml/day if able, consult nutrition services for recommendations and administer MiraLAX on day 3, day 4 and day 5 with no bowel movements. During an interview on 12/05/2025 at 10:22 AM, Staff D, Resident Care Manager, stated the facility followed the bowel protocol. During an interview on 12/05/2025 at 11:00 AM, Staff B, Director of Nursing Services, stated it was their expectation that the staff follow the bowel protocol for Resident 14. Reference WAC 388-97-1060(1)-3

Based on interview and record review, the facility failed to conduct timely care conferences with the resident/responsible party for 3 of 22 sampled residents (Residents 45, 11, and 6) when reviewed for care planning. This failure placed the residents at risk for unmet needs, not being involved or informed of their plan of care and a diminished quality of life. Findings included .Resident 45 Review of the electronic health record (EHR) showed Resident 45 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (lung condition caused by damage to the lungs), unsteadiness on feet, and major depressive disorder. Resident 45 was able to make needs known. During an interview on 12/03/2025 at 9:51 AM, Resident 45 stated they could not recall when they last attended a care conference. Review of Resident 45's medical record showed care conferences were conducted on 03/26/2025 and 09/19/2025. Resident 11 Review of the EHR showed Resident 11 readmitted to the facility on [DATE] with diagnoses to include unsteadiness on feet, Alzheimer's disease (a progressive brain disorder causing difficulty with daily activities), anxiety disorder, and bipolar disorder (a brain condition causing extreme mood swings). Review of Resident 11's medical record showed the most recent care conference was conducted 03/10/2025. During an interview on 12/04/2025 at 9:45 AM, Staff F, Social Services Director (SSD), stated that care conferences were offered to residents on admission and then quarterly. Staff F stated they had conducted care conferences late due to a staffing issue. Staff F stated the late care conferences did not meet their expectations. During an interview on 12/09/2025 at 9:00 AM, Staff A, Administrator (ADM), stated that the expectation was for residents to be offered care conferences on admission and then quarterly. Resident 6 Review of the EHR showed Resident 6 admitted to the facility on [DATE] with diagnoses of amputation of the right toe, chronic ulcer of heel and midfoot, and pressure ulcer of the lower back. Resident 6 was able to make needs known. Review of Multidisciplinary Care Conference assessments showed Resident 6 had care conference on 04/03/2025 and 09/29/2025. Review of the minimum data set assessments (MDS) showed Resident 6 had MDS assessments on 03/29/2025, 06/26/2025, 09/25/2025, and 11/15/2025. During an interview on 12/08/2025 at 12:46 PM, Staff F, SSD, stated care conferences were provided following the MDS schedule. Staff F stated Resident 6 should have had a care conference after their 06/26/2025 MDS assessment and the missing care conference did not meet expectations. During an interview on 12/09/2025 at 12:15 PM, Staff A, ADM, stated care conferences should occur quarterly and as needed. Staff A stated Resident 6's lack of care conference between 04/03/2025 and 09/29/2025 did not meet expectations. Reference WAC 388-97-1020(2)(c)(d) (5)(b)

Based on interview and record review, the facility failed to initiate a baseline care plan for 2 of 19 sampled residents (Residents 8 and 6) when reviewed for baseline care plans. Failure to timely initiate a dental or bathing care plan for resident 8 and/or a skin risk care plan for Resident 6 placed the residents at risk for unmet care needs and a decreased quality of life. Findings included . Resident 8Review of the electronic health record (EHR) showed Resident 8 admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing) and malnutrition. The resident was able to make needs known. Observation and interview on 12/02/2025 at 2:20 PM showed Resident 8 laid in bed and had no teeth. Resident 8 stated they had dentures but did not wear them often and staff did not assist them to put them in regularly. Resident 8 stated they did not get showers often enough and they had itchy skin because of it. Review of the progress notes dated 09/30/2025 showed an entry by the registered dietitian (RD) which stated, Resident with dentures. Resident reports that [they do] not always put them in for meals. When asked if this can cause difficulty with eating r/t no dentures, resident reported 'sometimes'. RD asked if resident would be open to nursing assisting with denture placement before meals, res agreeable. Review of the plan of care initiated 05/28/2025 showed a care plan entry for denture/dental care dated 09/30/2025 and a care plan entry for showers/bathing initiated on 09/03/2025 (three months after admission). Resident 6Review of the EHR showed Resident 6 admitted to the facility on [DATE] with diagnoses of pressure ulcer and non-pressure ulcer. The resident was able to make needs known. During an interview on 12/02/2025 at 1:01 PM, Resident 6 stated they had a pressure injury on their heel and bottom. The one on their heel had resolved but came back when they started walking on it. Review of the plan of care initiated 03/25/2025 showed an entry for skin impairment with interventions dated 04/02/2025 (eight days after admission). During an interview on 12/05/2025 at 10:28 AM, Staff D, Resident Care Manager (RCM), stated all activity of daily living (ADLs) should be initiated on admission in the baseline care plan. During an interview on 12/05/2025 at 11:00 AM, Staff B, Director of Nursing Services (DNS), stated the baseline care plan should be initiated on admission and include all ADLs. Staff B stated Resident 8 and 6's baseline care plans did not meet expectations. Reference WAC 388-97-1020(3)

Based on interview and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 4 of 22 sampled residents (Residents 45, 7, 5, and 83) when reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care and a diminished quality of life.Findings included. Resident 45 Review of the electronic health record (EHR) showed Resident 45 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (lung condition caused by damage to the lungs), unsteadiness on feet and major depressive disorder. Resident 45 was able to make needs known. Review of a progress note dated 09/04/2025 showed, MDS summary today resident has some deformity/contracture noted to (R) ankle-foot. Will notify physical therapy of this. Review of the quarterly MDS dated [DATE] showed the Functional limitation in range of motion section marked No. During an interview on 12/08/2025 at 10:23 AM, Staff J, Director of Rehabilitation, stated Resident 45 had limited range of motion in their right ankle. Review of a Physical Therapy evaluation dated 12/09/2025 showed Resident 45's right lower extremity range of motion was evaluated as impaired. During an interview on 10/22/2024 at 2:06 PM, Staff L, MDS Nurse, stated based on their assessment with Resident 45, they believed the coding was accurate. During an interview on 10/22/2024 at 2:30 PM, Staff A, Administrator (ADM), stated the expectation was for residents to be assessed according to the resident assessment instrument (RAI) manual and the MDS assessments were coded accurately. Resident 7 Review of the EHR showed Resident 7 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder (brain disorder causing extreme mood swings from manic highs to depressive lows), borderline personality (mental condition leading to impulsive actions intense fear and unstable mood), anxiety, and post-traumatic stress disorder. Resident 7 was able to communicate their needs. Review of the EHR showed Resident 7 had initial psychiatric evaluation summary related to a preadmission screen and resident review (PASRR, a mental health screening tool) as a level two, and providing certain requirements and recommendation for care and treatment. Review of the annual minimum data set (MDS, an assessment tool), dated 10/17/2025 showed Resident 7 was not marked for post-traumatic stress disorder and level 2 PASRR. During an interview on 12/08/2025 at 12:34 PM, Staff B, Director of Nursing Services (DNS), stated the expectations for MDS assessments were to be coded correctly and to include mental health conditions. Staff B stated Resident 7's MDS coding did not meet expectations. Resident 5 Review of the EHR showed Resident 5 admitted to the facility on [DATE] with diagnoses to include cerebral palsy (neurological disorders affecting movement, posture, and muscle tone), bipolar disorder (a brain disorder causing extreme shifts in mood, energy, and activity levels), schizoaffective disorder (a chronic mental illness blending symptoms of schizophrenia [like hallucinations, delusions, disorganized thinking] with symptoms of a mood disorder [depression or mania], and general anxiety disorder (GAD). Resident 5 was able to make needs known. Review of Resident 5's annual MDS, dated [DATE], showed question A1500 - Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? marked as No. Review of the EHR showed Resident 5 had a level II PASRR completed on 04/11/2025. Resident 83 Review of the EHR showed Resident 83 admitted to the facility on [DATE] with diagnoses of panic disorder (an anxiety condition marked by unexpected, recurring panic attacks), post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing a traumatic event, causing lasting stress and fear even when the danger is gone), and depression. Resident 83 was able to make needs known. Review of Resident 83's annual MDS, dated [DATE], showed question A1500 - Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? marked as No. Review of the EHR showed Resident 83 had a level II PASRR completed on 09/29/2022. During an interview on 12/08/2025 at 11:52 AM, Staff L, Licensed Practical Nurse/Minimum Data Set Coordinator), stated when coding question A1500, they would confer with social services to determine a resident's PASRR status. Staff L stated Resident 5 received a PASRR level 2 on 04/11/2024, their annual MDS dated [DATE] was coded No for A1500, and this was inaccurate. Staff L stated Resident 83 received a PASRR level 2 on 09/29/2022, their annual MDS dated [DATE] was coded No for A1500, and this was inaccurate. During an interview on 12/08/2025 at 12:08 AM, Staff B, Director of Nursing Services, stated the expectation was for the MDS to be accurate. Staff B stated Resident 5 and 83's annual MDS being inaccurate for PASRR status (A1500) did not meet expectations. Reference WAC 388-97-1000(1)(a)(b)(4)(a)

Based on interview and record review, the facility failed to address grievances brought by the resident council related to resident care, staff concerns, and dietary for 5 of 5 sampled months of resident council meetings (July, August, September, October, and November 2025) when reviewed for resident council. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the resident council minutes dated July 2025 showed concerns voiced by a member regarding call light wait times and staff not knocking prior to entering resident rooms. Review of the resident council notes dated August 2025 showed staff entering resident rooms was an ongoing concern. Review of the resident council notes dated September 2025 showed ongoing concerns with staff entering resident rooms without knocking, call lights not being answered timely on night shift and when answered, staff would tell the residents they would return but did not come back. Review of the resident council notes dated October 2025, showed staff entering resident rooms without knocking, call lights not being answered timely on night shift and when answered, staff would tell the residents they would return but did not come back were concerns with no improvement. Review of the Grievance Log dated 06/2025 through 11/2025 showed no grievances that corresponded with concerns verbalized at resident council meetings. During an interview on 12/05/2025 at 11:36 AM, Resident 83 stated that management did not follow up with grievances discussed in the resident council meetings. During an interview on 12/09/2025 at 1:18 PM, Staff R, Activities Director, stated, when residents voiced a concern, it was to be documented on a grievance form and provided to the department managers who had until the next resident council meeting (30 days) to respond to the concern. Staff R stated kitchen and nursing staff did not regularly return documentation related to the conclusion of the grievance. During an interview on 12/09/2025 at 10:13 AM, Staff A, Administrator, stated that they were unaware that resident council grievances were not being appropriately addressed. Staff A further stated it did not meet their expectation that specific concerns brought up in resident council had not been followed up on timely. Reference: WAC 388-97-0920

Based on interview and record review, the facility failed to obtain consent for mental health medications for 4 of 5 sampled residents (Resident 3, 7, 5, and 78) when reviewed for unnecessary medications. This failure placed residents at risk of unwanted side effects, lack of knowledge regarding medication side effects, and a diminished quality of life. Findings included.Resident 5 Review of the EHR showed Resident 5 admitted to the facility on [DATE] with diagnoses to include cerebral palsy (neurological disorders affecting movement, posture, and muscle tone), bipolar disorder, schizoaffective disorder (a chronic mental illness blending symptoms of schizophrenia [like hallucinations, delusions, disorganized thinking] with symptoms of a mood disorder [depression or mania]), and general anxiety disorder (GAD). Resident 5 was able to make needs known. Review of the provider's orders showed Resident 5 had orders for clonazepam (a medication used for seizure disorders and panic disorders), dated 11/07/2025 and 11/28/2025. Review of the EHR showed no consent was obtained for the use of clonazepam. During an interview on 12/08/2025 at 1:56 PM, Staff Y, Registered Nurse/Resident Care Manager, stated the facility provided risks/benefits and obtained resident consent when a psychotropic (affecting the brain) medication was ordered. Staff Y stated Resident 5 used clonazepam, clonazepam required resident consent before use, and Resident 5 did not provide consent for their ordered clonazepam. Staff Y stated this did not meet expectations. During an interview on 12/08/2025 at 2:17 PM, Staff B, DNS, stated residents receiving psychotropic medications should have the risks/benefits explained to them and consent of their use should be obtained. Staff B stated Resident 5's lack of consent for the use of clonazepam did not meet expectations. Resident 3 Review of the electronic health record (EHR) showed Resident 3 was admitted to the facility on [DATE] with diagnoses to include sleep disorder, depression, atrial fibrillation (heart rhythm disorder causing irregular heartbeat) and chronic kidney disease (kidneys cannot filter waste products in the blood). Resident 3 was able to communicate their needs. Review of the EHR showed Resident 3 had medication order for bupropion HCI ER (antidepressant medication with boxed warnings for increased risk of suicidal thoughts) dated 11/01/2025. Review of EHR showed Resident 3 had uncomplete form for informed consent for bupropion. During an interview on 12/09/2025 at 11:25 AM, Staff B, Director of Nursing Services (DNS), stated Resident 3's consent was not filled out correctly and did not meet expectations. Resident 7 Review of EHR showed Resident 7 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder (brain disorder causing extreme mood swings from manic highs to depressive lows), borderline personality (mental condition leading to impulsive actions, intense fear, and unstable mood), anxiety, and post-traumatic stress disorder. Resident 7 was able to communicate their needs. Review of EHR showed Resident 7 had a medication order for Clonazepam (medication with calming chemicals that suppress nerve activities) for anxiety, dated 08/14/2025. Review of EHR showed Resident 7 did not have informed consent for clonazepam. During an interview on 12/09/2025 at 11:30 AM, Staff B, DNS, stated that consent was missing from records and did not meet expectations. Resident 78 Review of the EHR showed Resident 78 readmitted to the facility on [DATE] and was able to make needs known. The annual minimum data set assessment (MDS, a required assessment tool), dated 11/12/2025, showed Resident 78 had diagnoses of dementia (a group of thinking and social symptoms that interfere with daily functioning), anxiety disorder, and diabetes (too much sugar in the blood). Review of Resident 78's December 2025 medication administration records (MAR) from 12/01/2025 - 12/05/2025 showed the resident was prescribed and provided Buspirone HCI (a medication used to treat anxiety). Review of Resident 78's form titled, Informed Consent for Use of Psychotropic Medication, dated 10/07/2025, showed Buspirone documented on the form; however, it showed anti-psychotics were checked for possible side effects instead of possible side effects for an anti-anxiety medication. The statement of consent on the form was left blank showing that no consent was obtained. During an interview on 12/05/2025 at 11:25 AM, Staff D, Resident Care Manager (RCM), stated Resident 78's informed consent dated 10/07/2025 did not meet expectations because side effects for an anti-psychotic was marked and the medication was an anti-anxiety medication. Staff D stated the form did not show if they consented or not because that section of the form was not marked and should have been. During an interview on 12/05/2025 at 11:39 AM, Staff B, DNS, stated Resident 78 received their first dose on Buspirone on 10/07/2025. However, the informed consent for use of psychotropic medication, dated 10/07/2025, actual statement of consent was not completed on the form. Staff B stated anti-psychotics were marked for possible side effects and the medication was not an anti-psychotic. Staff B stated this did not meet their expectations. Reference WAC 388-97-0260

Based on interview and record review the facility failed to ensure quality of care was provided by timely obtaining emergency services and thoroughly documenting alert charting for 3 of 3 sampled residents (Resident 1, 2, and 3) reviewed for falls. Resident 1, who was on a blood thinning medication, experienced harm when the facility failed to obtain immediate medical care after an unwitnessed fall with a head injury; the resident developed a latent post fall subdural hematoma (a brain bleed that can happen after a head injury) that required emergency room transfer, surgery, and hospitalization. This failure placed the residents at risk for medical complications, delay in care and services, potential death, and a diminished quality of life. Findings included . Review of a facility policy titled, Fall Protocols,, undated, showed, after a fall, the resident will be monitored for change in condition every shift for 72 hours. Monitoring may include physical assessment of the resident, vital signs, neurological checks, assessment for pain, swelling, redness, or impaired skin.Review of a document titled, Head Injury in Anticoagulated Patients Guideline, published by the Washington State Department of Health, dated 12/16/2024 showed any adult person (18 years or older) who are using anticoagulant (blood thinning) medication that have a mechanism of injury which places them at risk for intracranial (brain) injury (including any signs of external injury to the head or neck), should have a rapid triage(an assessment to determine the urgency of the need for care), labs to assess coagulation levels, emergent ordering of a head CT scan (medical imaging that uses a series of x-rays), and immediate interpretation of the CT scan by a radiologist (a doctor specializing in medical imaging.)Review of the Lippincott Manual of Nursing Practice, Eleventh Edition showed head injuries can include fractures to the skull and face, direct injuries to the brain (as from a bullet), and indirect injuries to the brain (such as concussion, contusion, or intracranial hemorrhage). Head injuries commonly occur from motor vehicle accidents, assaults, or falls. Intracranial hemorrhage is defined as a significant bleeding into a space or a potential space between the skull and the brain. This is a serious complication of a head injury with a high mortality (risk of death) because of rising intracranial pressure (ICP) and the potential for brain herniation. Intracranial hemorrhages can be classified as epidural hematomas, subdural hematomas, or subarachnoid hemorrhages depending on the site of the bleed. Review of the manual showed a head injury is a triage level 2: imminently life-threatening or emergent.DELAY IN EMERGENT CARERESIDENT 1Resident 1 admitted to the facility on [DATE] with multiple diagnoses that included acute embolism and thrombosis of deep veins of the right lower extremity (blood clots in the right leg), unsteadiness on feet, and muscle weakness. The admission minimum data set (MDS, an assessment tool), dated 07/17/2025, showed Resident 1 was moderately cognitively impaired, but was able to make their needs known. Review of the provider orders showed Resident 1 was receiving Apixaban 5 milligrams (mg) twice daily (a blood thinning medication)Review of the progress notes dated 07/25/2025 at 4:35 PM showed Resident 1 had a fall on 07/25/2025. Review of the progress notes showed Staff D, Infection Preventionist (IP) heard a crash then observed Resident 1 on the floor. Resident 1 was noted to have a laceration above the right eye which required steri strips (thin bandages applied to skin to help small cuts stay closed). The Nurse Practitioner (NP) was notified. New orders were received to monitor and to send to the Emergency Department (ED) if their condition worsened.During an interview on 08/04/2025 at 2:44 PM, Staff D, said they found Resident 1 on the floor with a small laceration (cut) above the left eye. Staff D said they assessed Resident 1, placed them back in bed, started neurological checks, and asked staff to do more frequent visual checks. Staff D said once they finished the incident report, they gave care over to the floor staff. Review of SBAR Communication Form, dated 07/25/2025, showed Resident 1 had a fall with a laceration to the head. The form showed Resident 1 was taking a blood thinner.During an interview on 08/04/2025 at 2:30 PM, Staff C, Resident Care Manager/Registered Nurse, (RCM/RN) said on 07/26/2025, the spouse called them into the room, Staff C said they assessed Resident 1, noted they had a delayed response and different sized pupils, notified the NP, and sent Resident 1 to the ED.During an interview on 08/04/2025 at 2:40 PM, Collateral Contact (CC) AA, said they were notified of the fall on 07/25/2025 and was told Resident 1 was ok. CC AA said they went to the facility to visit Resident 1 in the afternoon of 07/26/2025, noticed Resident 1 was not acting normally and had slurred speech, so they turned on the call light. CC AA said it took the staff at least 25 minutes to respond to the call light until Staff C entered the room to answer the call light. CC AA said Staff C said an ambulance needed to be called. CC AA said once Resident 1 arrived at the local hospital, they were prepared immediately to be transferred to a different hospital. CC AA said Resident 1 began having seizures. CC AA said Resident 1 needed brain surgery. CC AA said Resident 1 was removed from all life support on 08/04/2025 and they were expecting Resident 1 to pass away that day. CC AA further said Resident 1 was planning to discharge from the facility to home in the next week or two. Review of the hospital ED notes showed Resident 1 had a 19 millimeter (mm) right acute subdural hematoma with a 16 mm shift (a displacement of the brain structure due to the increased pressure caused by the amount of blood in the brain. A shift of greater than 5 mm is considered significant and requires surgical intervention) upon arrival at the ED. Review of the hospital ED notes showed Resident 1 had to be transferred to a different hospital for a higher level of care due to the severity of the bleed in their brain.Review of the hospital Discharge summary dated [DATE], showed Resident 1 was admitted to the hospital on [DATE]. Review of the hospital discharge summary showed Resident 1 was taken to emergency brain surgery. Review of the hospital discharge summary showed on 08/04/2025, the family elected against further aggressive treatment, and made Resident 1 comfort care (end of life care).Review of the nursing progress notes showed a note written by Staff C on 07/27/2025 at 2:33 PM that they Entered Resident 1's room, assessed the resident and notified MD due to change in condition. Review of the progress notes showed a note by a nurse on 07/27/2025 at 7:19 PM showing that Resident 1 was transferred to the ED. It is unclear what time Resident 1 left the facility to go to the hospital.Review of the following two sample resident records showed facility practice in similar situations of a fall with head injury. Residents 2 & 3 with a lower risk for brain bleeding, due to not taking a blood thinner, were sent to the emergency room for urgent evaluation:RESIDENT 2Resident 2 admitted to the facility on [DATE] with diagnoses that included fracture of the right Metatarsal (a broken bone in the toe) and syncope (a temporary loss of consciousness or fainting). The admission MDS, dated [DATE], showed Resident 2 was moderately cognitively impaired, but able to make their needs known. Review of the provider orders showed Resident 2 was not on any blood thinning medications.Review of the facility incident log showed Resident 2 had a fall on 07/27/2025.Review of the nursing progress notes dated 07/27/2025 at 2:48 AM showed Resident 2 had an unwitnessed fall with a head laceration. Review of the nursing progress notes showed Resident 2 was sent to the ED where they received a CT scan of the head to rule out a brain bleed.RESIDENT 3Resident 3 admitted to the facility on [DATE] with multiple diagnoses. The quarterly MDS, dated [DATE], showed Resident 3 was severely cognitively impaired and dependent on staff for their care. Review of the provider orders showed Resident 3 was not on any blood thinning medications.Review of the facility incident log showed Resident 3 had a fall on 07/21/2025.Review of the nursing progress notes dated 07/21/2025 at 11:02 AM showed Resident 3 had a witnessed fall from their bed. Review of the progress notes showed Resident 3 complained of head pain. Review of the progress notes showed 911 was called and Resident 3 was sent to the ED. ALERT CHARTINGRESIDENT 2Review of the facility incident log showed Resident 2 had a fall on 07/17/2025.Review of the nursing progress notes , 07/16/2025 through 07/19/2025 [72 hours post fall] showed no documentation or alert charting was completed every shift for 72 hours to monitor Resident after the fall.Review of the facility incident log showed Resident 2 had a fall on 07/23/2025.Review of the progress notes showed a note titled Alert Charting on 07/24/2025 at 1:42 AM to document post fall monitoring. Review of the progress notes showed no further documentation to monitor Resident 2 after the fall.Review of the progress notes 07/23/2025 through 07/26/2025 showed alert charting was not completed every shift for 72 hours to monitor Resident after the fall.Review of the facility incident log showed Resident 2 had a fall on 07/27/2025.Review of the nursing progress notes showed a note titled Daily Skilled Note on 07/28/2025 at 3:41 AM with no post fall monitoring. Review of the progress notes showed a note titled Daily Skilled Note dated 07/29/2005 at 3:39 AM with no post fall monitoring. Review of the progress notes showed alert charting was not completed every shift for 72 hours to monitor Resident after the fall. Review of the hospital ED notes dated 07/27/2025, showed Resident 2 was sent to the ED for a fall. Resident 2 returned to the facility at an unknown time on 07/27/2025.RESIDENT 3Review of a nursing progress note dated 07/21/2025 at 11:02 AM showed Resident 3 had a fall on 07/21/2025. Review of a progress note titled eINTERACT SBAR Summary for Providers (an inhouse communication form between nurses and providers) dated 07/21/2025 at 12:20 PM showed Resident 3 was sent to the ED per provider recommendations. Review of a progress note dated 07/21/2025 at 5:44 PM, showed Resident 3 returned to the facility from the hospital. Review of the progress notes showed fall follow up alert charting on 07/22/2025 at 8:37 PM, 07/23/2025 at 6:37 PM, and 07/24/2025 at 5:06 AM. Review of the progress notes showed alert charting was not completed every shift for 72 hours. During an interview on 08/04/2025 at 3:16 PM, Staff F, RN, said if a resident had a fall they would fill out an incident checklist, which included a head-to-toe assessment, pain assessment, and neurological assessment. Staff F said they would place the resident on alert charting. During an interview on 08/04/2025 at 3:19 PM, Staff G, Licensed Practical Nurse (LPN), said if a resident had a fall, they would use the incident checklist, then they would place the resident on alert charting to monitor for any changes in behavior or medical condition. During an interview on 08/07/2025 at 11:15 AM, Staff B, Director of Nursing Services (DNS)/RN said if a resident had a fall, they would be placed on alert charting for 72 hours. Staff B said alert charting should be completed every shift. Staff B said the nurses worked 12-hour shifts, so alert charting would be completed at least twice a day. Staff B said it is their expectation that alert charting should be completed at least twice a day after a fall. Reference WAC 388-97-1060 (1) .

Based on interview and record review, the facility failed to provide supervision of two person staff assistance with bed mobility while providing care to prevent accident/falls for 2 of 3 sampled residents (Resident 1 and 2) reviewed for falls. Resident 1 experienced harm when care was provided by one staff that resulted in a fall from bed and injury requiring hospital evaluation. This failure placed residents at risk of injury, unmet care needs and a diminished quality of life. Findings included <Resident 1> Resident 1 was admitted to the facility on [DATE] with multiple diagnoses. The Minimum Data Assessment, an assessment tool, dated 11/07/2024, documented Resident 1 was alert, had some cognitive impairment, and required substantial/maximal (helper does more than half the effort) assistance with activities of daily living. Review of Resident 1's physician orders showed an 12/07/2024 order for a low-air-loss mattress (a mattress filled with air to reduce pressure on a person's skin) to promote Resident 1's skin integrity. Review of Resident 1's record included directions for staff to monitor the function of the air mattress every shift. The comprehensive care plan, revised on 12/27/2024, showed Resident 1 required two caregivers to assist with bed mobility. On 12/31/2024 at 1:09 PM, Resident 1 said Staff C wanted to change him and he told her to get somebody else but she wouldn't do that. Resident 1 said the Staff C had him on the edge of the bed, pulled the draw sheet toward her and he fell out of bed. Resident 1 said he bruised his buttock and received a bump on the back of his head. Resident 1 said his butt and hip really hurt. Resident 1 said it made him angry and was upset about it. When asked if two staff came to assist him now, Resident 1 said sometimes it's two unless it's somebody who knows what they're doing, then it's one. Review of a 12/13/2024 11:54 PM nurse progress note showed Resident 1 fell on the floor during care around 9:30 PM. The note showed Resident 1 complained of pain to the right shoulder, back, and head. Emergency Services was called, and Resident 1 was transported to the hospital emergency room for further assessment of injuries. Review of the 12/18/2024 facility investigation documented the resident fell on [DATE] fell during incontinent care while a staff member was providing care alone to the resident in bed when the resident required a 2-person assist for in-bed care. The investigation documented the root cause of the fall as inadequate staff during in-bed care, which led to the fall. On 12/31/2024 at 2:10 PM, Staff C, a certified nursing assistant, said Resident 1 was supposed to have two caregivers for incontinence care but nobody else was available at the time. Staff C said they were almost done with care when the resident slid off the bed. After that happened, Staff C went out into the hall and called for help, the nurse came, 911 was called and the resident was sent out. On 01/14/2025, Staff B, a Registered Nurse and the facility Director of Nurses, said staff are expected to follow the resident's plan of care for resident safety. <Resident 2> Resident 2 was admitted to the facility on [DATE] with multiple diagnoses. The Minimum Data Assessment, an assessment tool, dated 11/07/2024, documented Resident 2 was receiving Hospice services, was cognitively impaired, and required substantial/maximal assistance with most activities of their daily living. Review of Resident 2's care plan documented a revision, dated 11/16/2022, to ensure two staff during care regarding the resident's fear of rolling off the bed. A nursing progress note, dated 12/17/2024 at 8:30 PM, documented Resident 2 had an assisted fall. The note documented, while the staff was changing the resident, the resident slide from the bed. The staff tried to catch the resident from falling but could not, and the resident fell . No injuries or discomfort were noted, the resident was assessed and monitored. Review of the facility investigation, dated 12/20/2024, identified the root cause as failure of staff to follow the plan of care to use two persons with cares. On 01/14/2025, Staff B, a Registered Nurse and the facility Director of Nurses, said staff are expected to follow the resident's plan of care for resident safety, Reference WAC 388-97-1060

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the transmission of a communicable disease by implementing facility policies and/or outbreak protocols timely for 10 of 94 sampled residents (Residents 15, 14, 83, 352, 9, 351, 91, 344, 346 and 81) when reviewed for infection control/outbreak management. Residents 14, 83 and 9 experienced harm when they were sent to the hospital for illness and/or treated for complications after the facility failed to recognize an illness related to an infectious disease. The facility failed to implement transmission-based precautions (TBP) for 2 of 4 halls (100 and 200 Halls) when reviewed for TBP and ensure sanitary use of washing machines when reviewed for laundry. These failures contributed to one third of the resident population to become ill with respiratory symptoms and placed residents, visitors, and staff at risk for communicable diseases, related complications, and potential death. <Outbreak Management> Review of the facility policy titled Outbreak of Communicable Diseases, dated 07/2023, showed An outbreak of influenza is defined as a single case if unusual for the facility and to report it to the local health jurisdiction. It showed that the infection preventionist and director of nursing was responsible for initiating TBP and communicating with the medical director. The medical director was responsible for overseeing the management of the outbreak. Review of an email communication with Staff C, Infection Preventionist (IP), dated 12/06/2024, showed the LHJ made recommendations to follow the Centers for Disease Control (CDC) Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities which showed Influenza testing should occur when any resident has signs and symptoms of acute respiratory illness or influenza-like illness. Implement Droplet Precautions for all residents with suspected or confirmed influenza. And, if exposed, residents on units or wards with influenza cases in the long-term care facility (currently impacted wards) should receive chemoprophylaxis (antiviral/Tamiflu) as soon as an influenza outbreak is determined . Antiviral chemoprophylaxis is meant for residents who are not exhibiting influenza-like illness but who may be exposed to prevent transmission. During an interview on 12/11/2024 at 11:33 AM, Staff Q, Nurse Practitioner, stated they followed the 2024-2025 Minnesota Association of Geriatrics Inspired Clinicians (MAGIC) Alliance for Clinical Excellence (ACE) influenza protocol and Staff R, Medical Director, had decided to not follow the LHJ recommendations and only provided antiviral/Tamiflu to residents with current symptoms. Review of the MAGIC ACE influenza protocol showed residents should be screened for new onset nonproductive cough, fever over 100 degrees Fahrenheit or myalgia (muscle aches), headache, nasal congestion, or new fatigue. If symptoms were identified, the resident should be tested for influenza and Covid-19. If positive or pending results, antiviral/Tamiflu should be started within 48 hours of symptom onset and place the resident on droplet precautions until no symptoms were present for 24 hours. Resident 14 Review of the EHR showed Resident 14 readmitted to the facility on [DATE] with diagnoses of pneumonia and sepsis (the body's life threatening response to infection). The resident was able to make needs known. Review of the progress note, dated 12/07/2024, showed Resident 14 stated they did not feel well with nausea, vomiting, wheezing, and shortness of breath. No documentation was found that the resident was tested for influenza or Covid-19, was placed on droplet precautions, or administered Tamiflu. Review of a progress note, dated 12/09/2024, showed Resident 14 started receiving fluids by clysis (administration of fluids through the skin) for dehydration. Review of a progress note, dated 12/10/2024 at 7:07 AM, showed Resident 14 had a decline in condition and oxygen saturation levels dropped to 90%. The resident was sent to the emergency room . Review of an emergency room visit note, dated 12/10/2024, showed the resident was admitted to the hospital for influenza, pneumonia, acute kidney injury, and hypoxia (lack of oxygen in the blood). Resident 83 Review of the EHR showed Resident 83 admitted to the facility on [DATE] with diagnoses of epilepsy (a chronic brain disorder that causes people to have recurrent seizures) and altered mental status. The resident was not able to make needs known. Review of a provider note, dated 12/05/2024, showed Resident 83 had new onset cough and a chest congestion. Review of the EHR showed a chest x-ray was obtained on 12/06/2024, but no follow-up documentation was found. No documentation was found that the resident was tested for influenza or Covid-19 infection or was placed on droplet precautions. Review of a progress note dated 12/09/2024 at 10:40 PM showed Resident 83 was assessed for fever, chills and malaise and was ordered chemoprophylaxis (Tamiflu), greater than 48 hours after symptom onset. Observation on 12/10/2024 at 8:59 AM showed Resident 83 was in bed coughing without being able to stop. Resident 83 yelled out, Help me! Review of a progress note, dated 12/10/2024 at 4:30 PM, showed Resident 83 had a decline in condition when their oxygen levels dropped to 85%. Resident 83 was sent to the emergency room for low oxygen levels and confusion. Review of EHR on 12/12/2024 showed Resident 83 had not returned from the hospital. Resident 9 Review of the EHR showed Resident 9 admitted to the facility on [DATE] with diagnoses of Alzheimer's and chronic kidney disease. The resident was unable to make needs known. Review of the EHR showed, on 12/07/2024, Resident 9 was ordered Levaquin (an antibiotic) to rule out infection and Ceftriaxone (an antibiotic) for possible infection on 12/09/2024, two days later. Review of the December infection control line listing for Resident 9 did not include Levaquin, did not include a symptoms onset date, or if criteria were met to be given an antibiotic. Review of the EHR showed Resident 9 was sent to the emergency roiagnom on [DATE] for a change in mental status. Resident 9 was noted to slide out of her wheelchair and be lethargic with a decreased level of alertness. Resident 9 returned with a diagnosis of influenza at 1:20 AM on 12/12/2024. Review of progress note, dated 12/12/2024 at 7:03 AM, showed Resident 9 was not placed on droplet precautions for six hours after return from hospital. Resident 15 Review of the electronic health record (EHR) showed Resident 15 admitted to the facility on [DATE] with diagnoses of diabetes, chronic obstructive pulmonary disease, and heart failure. The resident was able to make needs known. Review of a progress note, dated 11/26/2024 at 2:41 PM, showed Resident 15 complained of a non-productive cough, congestion, fatigue, generalized malaise (a general feeling of discomfort), and lung sounds with upper lobe wheezing and diminished bases (decreased lung sounds in lower lung). There was no documentation the resident was assessed for influenza or Covid-19, Tamiflu being started, or droplet precautions being implemented. Review of a progress note dated 12/02/2024 at 11:53 PM showed Resident continues on [antibiotic without any adverse side effects] reported. had an occasional moist cough. Cough drops were somewhat helpful. There was no documentation the resident was tested for influenza or Covid-19, Tamiflu being started, or droplet precautions being implemented. Review of a progress note, dated 12/07/2024 at 5:14 PM, showed Resident 15 complained of still not feeling well s/p abx [after antibiotic] therapy for URI [upper respiratory infection]. Resident with decreased appetite and poor hydration. Review of the electronic health record (EHR) on 12/10/2024 showed Resident 15 required clysis for dehydration and still had not been treated per facility protocol. Review on 12/10/2024 of the respiratory outbreak line listing showed Resident 15 was not included. Resident 352 Review of the EHR showed Resident 352 admitted to the facility on [DATE] with a diagnosis of acute kidney failure. Review of a progress note, dated 12/08/2024, showed the resident had complained of not feeling well and their oxygen saturation dropped to 85% and had wheezing breath sounds. Interview at 12/11/2024 at 9:43 AM, Staff DD, Licensed Practical Nurse, stated Resident 352 was having respiratory symptoms but was not isolated. Observation of Resident 352's door showed no signage for precautions and personal protectice equipment (PPE) was not available at the door. Observation at 10:34 AM showed housekeeping staff enter Resident 352's room without PPE use. Interview with Staff EE, Certified Nursing Assistant, stated Resident 352 was not on isolation precautions. Staff EE stated he provided assistance with the breakfast meal to Resident 352 without wearing PPE that morning. Review on 12/11/2024 (three days after symptom onset) showed no documentation that Resident 352 was tested for influenza or Covid-19, placed on droplet precautions or started on Tamiflu. Observation on 12/11/2024 at 10:40 AM showed staff entering room [ROOM NUMBER] without personal protective equipment which was required for droplet precautions. Resident 351 Review of the EHR showed Resident 351 admitted to the facility on [DATE] with a diagnosis of amyotrophic lateral sclerosis (ALS, a nervous system disease that affects nerve cells in the brain and spinal cord. ALS causes loss of muscle control.) The resident was able to make needs known. Review of a provider note, dated 12/02/2024, showed the resident had new respiratory symptoms of a cough and an order for Mucinex for congestion of respiratory tract was added. No documentation was found that the resident was tested for influenza or Covid-19 infection, was placed on droplet precautions, or administered Tamiflu. Observation on 12/05/2024 at 10:22 AM showed Resident 351 was laying in bed. They were flushed red and complained of a headache. The resident could be heard coughing and blowing their nose. Observation showed a staff in the room with a family member. There was no droplet precautions sign on the door. Review of the EHR on 12/07/2024 showed Resident 351 had not been started on Tamiflu. Resident 91 Review of the EHR showed Resident 91 admitted to the facility on [DATE] with diagnoses of breast cancer and left hip replacement. The resident was able to make needs known. Review of a provider note, dated 12/02/2024, showed Resident 91 was complaining of cough for past 2 days plus congestion. No documentation was found that the resident was tested for influenza or Covid-19, placed on droplet precautions, or started on Tamiflu. Review of an updated respiratory outbreak line listing, dated 12/12/2024, showed a total of 31 out of 94 residents with respiratory symptoms. During an interview on 12/06/2024 at 9:13 AM, Staff D, IP, stated it was their expectation that staff who identified new respiratory symptoms in residents would have notified the provider, tested for influenza and Covid-19 and placed the resident on droplet precautions but this had not happened. During an interview on 12/11/2024 at 12:04 PM, Staff D stated they had identified a higher number of residents receiving orders for chest x-rays and antibiotics for pneumonia but did not think of influenza or Covid-19. During an interview on 12/11/2024 at 12:28 PM, Staff D stated Resident 15's complications could have been prevented if treated sooner and Resident 14 and 83's complications could have been prevented if the outbreak protocols were implemented sooner. During an interview on 12/11/2024 at 12:12 PM, Staff B, Director of Nursing Services (DNS), stated it was their expectation that when a pattern of new onset respiratory symptoms was identified, the staff should have notified the provider, performed tests, and placed the residents on droplet precautions. Staff B stated it was their expectation that Staff D would start the outbreak protocol, notify the LHJ, and follow their recommendations. Review of the respiratory outbreak line listing, dated 12/10/2024, showed 31 residents were included for respiratory illness symptoms and assumed positive for influenza A. <Transmission Based Precautions> Review of the facility form posted on residents' doors titled Droplet Precautions, dated 08/10/2023, showed staff were to perform hand hygiene, wear a mask and wear eye protection prior to entering the room. Use patient dedicated equipment or clean and disinfect shared equipment. Residents should wear masks if transport out of the room is needed. Review of the Centers for Disease Control guidance for enhanced barrier precautions (EBP) showed Nursing facilities should use EBP for residents with infection or colonization with a targeted multidrug resistant organism (MDRO) when Contact Precautions did not otherwise apply and/or Wounds and/or indwelling medical devices even if the resident was not known to be colonized or infected with an MDRO. Observation on 12/05/2024 at 1:28 PM showed Resident 344 standing at their bedside. The resident had a tube attached to their side draining dark fluid. Observation showed the resident had a drain inserted into the side of their abdomen. No enhanced barrier precautions sign was posted on the door. Observation on 12/05/2024 at 1:29 PM showed Resident 346 was lying in bed. They had a urinary catheter attached to the side of the bed with clear yellow liquid. Resident 346 stated they had a large wound in their groin that required daily bandage changes. No enhanced barrier precautions sign was posted on the door. Observation on 12/05/2024 at 1:32 PM, showed Resident 81 was lying in bed. There was a tube connected into the resident's stomach for nutrition. No enhanced barrier precautions sign was posted on the door. During an interview on 12/05/2024 at 1:28 PM, Staff D, IP, stated Resident 344, 346 and 81 should have been placed on enhanced barrier precautions, but they were not and this did not meet expectations. Observation on 12/05/2024 at 1:29 PM showed a contact precautions sign posted outside of room [ROOM NUMBER] which showed staff were to wear a gown and gloves when entering the resident's room. Staff C, Assistant Director of Nursing, entered the room and set-up supplies for wound care, exited the room, performed hand hygiene, and obtained towels. Staff C then entered the room and set-up towels and supplies on the resident's bed. They exited the room and performed hand hygiene. No gown or gloves were used. Observation on 12/06/2024 at 8:12 AM showed room [ROOM NUMBER] with a droplet precautions sign on the door. Resident 351 was heard coughing from the hallway with the door open. Staff BB, Licensed Practical Nurse (LPN), entered the room wearing only a mask, no eye protection. When Staff BB exited the room, they did not change their mask and went back to the medication cart. At 8:19 AM, Staff H, Certified Nursing Assistant, entered the room to assist Staff BB with moving Resident 351 up in bed. Neither staff were observed wearing eye protection. Staff H left the room and failed to remove their mask. Staff H was observed to enter room [ROOM NUMBER] with the same mask. At 8:22 AM, Staff BB stated they did not wear eye protection because it was optional. Staff BB said they did not change their mask and should have. At 8:28 AM, Staff H said they did not know they had to wear full personal protective equipment adding they thought a surgical mask was fine. Staff H failed to identify the need to discard used masks when exiting a room with droplet precautions and wear eye protection. Observation on 12/09/2024 at 10:22 AM showed room [ROOM NUMBER] with a droplet precautions sign on the door. Unidentified staff was in the room in gown and gloves assisting the resident in the window bed and went from that resident to the resident in the bed by the door and assisted them to reposition in bed. They did not perform hand hygiene, change their gown or gloves, and did not wear eye protection. Observation on 12/11/2024 at 9:15 AM showed staff exiting room [ROOM NUMBER] with a Hoyer lift (a mechanical device to transfer residents). There was a droplet precautions sign on the door. The staff took the lift directly across the hall to room [ROOM NUMBER] and used the lift to transfer another resident. They Hoyer lift was not sanitized between residents. During an interview on 12/11/2024 at 9:37 AM, Staff O, Certified Nursing Assistant, stated they would usually use purple wipes for cleaning the lifts but they could not find any, and stated, There is none available at the moment. Observation on 12/11/2024 at 10:33 AM showed no purple wipes available for use on the 100/200 hall. Observations on 12/11/2024 at 11:45 AM showed in room [ROOM NUMBER] a staff member delivered a meal tray, exited the room and retrieved another lunch tray from the meal cart and delivered it to room [ROOM NUMBER]. Both rooms had droplet precautions signs posted on the doors. Hand hygiene was not performed, and the staff was not wearing eye protection. The staff member then went to room [ROOM NUMBER] and delivered a meal tray. There was no droplet precautions sign on room [ROOM NUMBER]'s door. During an interview on 12/05/2024 at 1:32 PM, Staff D, IP, stated it was their expectation that staff always followed the directions on the precautions signs and wiped down any shared equipment between patients. <Laundry> During an observation and interview on 12/09/2024 at 9:41 AM, Staff P, Laundry Worker, demonstrated the process for loading and unloading the front load washing machines. Staff P stated they did not sanitize the door/gasket between loads of laundry. There was a visible layer of debris in the edges of the door and on the seal gasket. Staff P began to pick out the debris and stated they did not feel it needed to be cleaned. During an observation and interview on 12/09/2024 at 9:48 AM, Staff M, Environmental Services Director, observed lint and grime buildup on the gasket and in the edges of the door and stated it did not meet their expectations and the gasket and door should have been wiped down and sanitized with each load. During an interview on 12/11/2024 at 12:14 PM, Staff B, DNS, stated the facility's outbreak response, enhanced barrier precautions, transmission based precautions, and the laundry machine sanitation did not meet their expectations. Reference WAC 388-97 -1320 (1) (c), (2)(a)(b), (3)

Based on observation, interview, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when a change of condition was not assessed timely and when wound closure device interventions were not consistently provided for a non-pressure skin conditions for 2 of 22 sampled residents (85 & 71) reviewed for quality of care related to change of condition and non-pressure skin condition. This caused harm to Resident 85 when the resident's change of condition was not assessed and monitored timely by staff and not reported to the medical provider for evaluation which delayed interventions and the resident being emergently transferred to the hospital for treatment. These failures placed residents at risk for unmet care needs, poor clinical outcomes and a diminished quality of life. Findings included . <Resident 85> Resident 85 was admitted to the facility on [DATE] with diagnoses including bacteremia (bacteria in the blood), sepsis (a life-threatening response to infection), staphylococcal arthritis (infection that spreads to joints and causes inflammation/swelling), and cellulitis (bacterial skin infection). Review of Resident 85's electronic health record (EHR) showed an order for intravenous (IV - directly into a vein) antibiotic on admission with a start date of 01/17/2024 and completed on 01/24/2024, and an order for an oral (by mouth) antibiotic with a start date of 01/26/2024 and completed on 02/02/2024. During an observation and interview on 02/20/2024 at 10:20 AM, Resident 85 was lying in bed and was able to answer questions. The resident said they had belly discomfort and requested to discontinue the interview. The resident stated they needed to urgently have a bowel movement. Staff R, Certified Nursing Assistant (CNA), assisted the resident to the bathroom. There was a strong unpleasant odor noted at the time. During an observation and interview on 02/22/2024 at 9:08 AM, Collateral Contact 1, stood outside Resident 85's room wearing an isolation gown and gloves and stated Resident 85 started having runny, smelly stools a couple of days ago, and the staff suspected a Clostridium difficile (C-diff, a germ that causes diarrhea and inflammation of the colon while taking antibiotics or not long after taking antibiotics which can be life-threatening) infection and a sample had been sent to the lab for testing. During an interview on 02/22/2024 at 2:17 PM, Staff F, Licensed Practical Nurse (LPN) and Unit Manager (UM), stated they were aware of the suspected C-diff infection and a sample should have been sent to the lab for testing, but they did not see a physician order. Review of Resident 85's EHR, on 02/22/2024 at 4:28 PM, showed the resident had loose diarrhea on 02/17/2024, 02/18/2024, 02/19/2024, and 02/22/2024. The EHR did not show an order to test for C-diff and no progress notes related to loose bowel movements or suspected C-diff documented in the EHR. During an interview on 02/26/2024 at 8:55 AM, Staff U, Infection Control Preventionist, stated they were not aware Resident 85 was suspected of having a C-diff infection until 02/24/2024. During an interview on 02/26/2024 at 10:42 AM, Staff R, Certified Nursing Assistant (CNA), stated Resident 85 had complained of abdominal/stomach pain and had dark colored loose watery stools last week on 02/17/2024 through 02/20/2024 and they had reported to the nurse. During an interview on 02/26/2024 at 10:44 AM, Staff S, CNA, stated they worked Saturdays through Tuesdays and had reported Resident 85 had loose watery stools to the nurses on multiple days last week. Review of Resident 85's progress notes, dated 02/24/2024 at 9:20 PM, showed, Resident's [family member] complained of delaying C-diff result. A STAT (urgent) sample was sent to the lab for testing. The lab results from the sample collected on 02/24/2024 showed testing was not completed as, The container has no or insufficient patient identification. Review of Resident 85's EHR, on 02/26/2024, showed a progress note dated 02/25/2024 at 10:36 AM, noting, Resident presents this day with [NAME] [bright red] blood and mucous in brief, hypotensive [low blood pressure] and unable to raise BP [blood pressure] with PO [oral] fluids. On call MD [Staff T, Medical Director MD] notified and orders to send resident out to hospital for eval [evaluation] and fluids. During an interview on 02/26/2024 at 10:55 AM, Staff F stated their expectation was the nurse on the floor would notify the provider of changes in condition and would enter any new orders from the provider into the resident's EHR, place the resident on alert monitoring and notify the family. Staff F stated they were made aware of Resident 85's change in condition on 02/21/2024 and there should have been documentation the provider was notified, and the resident should have been placed on alert monitoring when it was first reported by the CNAs, but this didn't happen for Resident 85. During an interview on 02/27/2024 at 9:44 AM, Staff C, Minimum Data Set (MDS) and Registered Nurse (RN), stated they had entered a new care plan into Resident 85's EHR on 02/21/2024 because it was reported they were having loose stools. Staff C stated the resident should have been assessed at that time, placed on alert monitoring and the provider notified, but this didn't happen for Resident 85. During an interview on 02/27/2024 at 10:03 AM, Staff V, LPN, stated for Resident 85 they recalled smelling the foul odor and observing loose watery stools on 02/21/2024. Staff V stated they suspected Resident 85 had a C-diff infection and reported to Staff F. Staff V stated they did not notify the provider or place the resident on alert monitoring. During an interview on 02/28/2024 at 10:30 AM, Staff B, Director of Nursing Services (DNS), stated it was their expectation when a resident had a change in condition such as suspected C-diff infection, nursing staff would complete an assessment, notify the provider to obtain orders, place the resident on alert monitoring, notify the family, document in the resident's medical record and report to the next shift. Staff B stated this should have happened for Resident 85 when the change in condition was first reported. During an interview on 02/28/2024 at 12:33 PM, Staff T, Medical Director, stated they were not notified of Resident 85's change of condition until 02/24/2024 and if they were made aware on 02/19/2024, 02/20/2024 or 02/21/2024, they would have ordered testing and started the resident on treatment. Staff T stated if they were notified of the change in condition timely, Resident 85's emergent transfer to the hospital for intervention could have possibly been prevented. 38344 <Resident 71> Resident 71's quarterly MDS, an assessment tool, dated 01/24/2024, showed Resident 71 readmitted to the facility on [DATE] with diagnoses including diabetes (a condition in which blood sugar levels are too high), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), anemia (the body does not have enough healthy red blood cells to provide oxygen to body tissues), non-pressure chronic ulcer (wound) of the left lower leg, diabetic foot ulcer, and complication of an amputation/stump (surgical removal of a body part that's left beyond a healthy joint). The MDS showed Resident 71 was able to make needs known. Review of the Resident 71's EHR, on 02/21/2024, showed the following provider orders prescribed: --Order, dated 02/08/2024, for the left below the knee amputation (BKA) wound VAC (Vacuum-assisted closure of a wound, a type of therapy to help wounds heal) to be in place and wound cleansed and treated twice a week on Thursdays and Saturdays for wound care. --Order, dated 02/08/2024, for the left knee wound to be cleansed, treated, and covered three times a week on Tuesdays, Thursdays, and Saturdays for wound care. --Order, dated 02/08/2024, for right lower leg wound to be cleansed, treated, and covered three times a week for wound care. --Order, dated 02/08/2024, for right great toe wound to be cleansed, treated, and covered three times a week on Tuesdays, Thursdays, and Saturdays for wound care. --Order, dated 06/12/2023, for weekly skin check to be documented in assessments and Treatment Administration Record (TAR) every Thursday for skin check. --Order, dated 11/13/2023, for Skin observation weekly to be documented in assessments and TAR every Tuesday for skin observation. Observation and interview, on 02/21/2024 at 9:52 AM, showed Resident 71's wound VAC was not in place to the BKA wound. Resident 71 stated the wound VAC was disconnected because it was leaking, and they wanted it disconnected because of the need to go to an appointment and staff were aware. Observation and interview, on 02/22/2024 at 12:27 PM, showed Resident 71's BKA wound was not connected to the wound VAC. Resident 71 stated they just got back from an appointment and was waiting for nursing to connect the wound VAC. Observation and interview, on 02/22/2024 at 3:51 PM, showed Resident 71 sat in a wheelchair, wound VAC was not in place. The wound VAC and supplies were located at the bedside. Resident 71 stated the nurse would let them know when the wound VAC needed to be connected. Observation and interview, on 02/23/2024 at 7:02 AM, showed Resident 71's BKA wound was not connected to the wound VAC. Resident 71 stated the wound VAC was not applied last night. The resident was told it would be connected sometime this morning. Observation, on 02/23/2024 at 9:27 AM, showed Resident 71's BKA wound VAC was connected (a little under two and a half hours from the last observation). Observation and interview, on 02/26/2024 at 10:04 AM, showed Resident 71 sat in a wheelchair and the BKA wound was not connected to the wound VAC and the left knee wound was exposed with dressing cover not in place. Resident 71 stated the dressing on the left knee had just come off when dressing this morning. The resident said the wound VAC alarm was going off Saturday evening (02/24/2024) and a nurse disconnected the wound VAC. Resident 71 stated the nursing staff each shift were aware and kept saying they would reconnect the wound VAC but never did. Review of the Resident 71's progress notes, dated 02/22/2024 to 02/26/2024, showed no documentation of an explanation of why Resident 71's wound VAC was not connected to the BKA wound during onsite survey observation dates and times when the wound VAC was not in place. Review of Resident 71's February 2024 TAR, dated 02/01/2024 to 02/26/2024, showed the following dates with blanks/missing documentation: --02/08/2024; treatment for left BKA wound VAC. --02/02/2024, 02/04/2024, 02/08/2024, and 02/24/2024; treatment for left knee wound. --02/08/2024 and 02/24/2024; treatments for right lower leg and right great toe wounds. --02/08/2024, weekly skin check order. During an interview on 02/27/2024 at 10:01 AM, Staff E, LPN and UM, stated Resident 71's BKA wound should be always connected to the wound VAC, except when being provided treatment per provider orders. Staff E stated Resident 71's progress notes should have had documentation to explain why the wound VAC was not in place and if the provider was notified for 02/22/2024, 02/23/2024, and 02/26/2024 when observed not connected. Staff E stated Resident 71's February 2024 TAR showed holes/blanks in the ordered wound treatment documentation and skin check which did not meet expectations. Staff E stated they were unable to locate recent weekly evaluations with wound measurements for Resident 71's right lower leg wound which was last documented on 01/10/2024 and there should have been. During an interview on 02/27/2024 at 11:23 AM, after reviewing Resident 71's EHR regarding wound treatments, assessments, and documentation, Staff C stated Resident 71's wound VAC should have been in place per provider orders. If not able to have it in place, then the provider should have been notified and documentation located in the progress notes. Staff C stated the TAR should not have had missing documentation. When asked if Resident 71's monitoring, assessments, and documentation for wound management met expectations, Staff C stated, No. Reference WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to have a system in place to prevent burn injuries from hot beverages served to the residents and to provide adequate supervision for 1 of 2 residents (Resident 1) reviewed for injuries and accident hazards. This failure resulted in actual harm to Resident 1 who suffered a second-degree burn (a burn that affect both the outer layer and the second layer of skin to their bilateral upper thighs from spilled hot coffee. Findings included . Review of an April 2022 facility policy titled Hot Beverages showed the residents were at an increased risk for injury from hot liquids due to less sensitive skin, reduced reaction time and impaired mobility. This policy stated to consider the use of a cup holder with a sealed cup and serve hot beverages in a mug with a spill-proof drinking lid. The policy showed to allow the hot beverage to cool before serving and consider the temperature range of 150-155 Fahrenheit as an approximate guide for a hot beverage before leaving the kitchen. The policy showed staff was to record the temperature taken on a food temperature log. Review of a 08/04/2022 Admission Minimum Data Set (MDS, an assessment tool) showed Resident 1 admitted to the facility with multiple medical diagnoses, to include a right wrist fracture. This MDS showed staff assessed Resident 1 was independent with eating and required extensive assist with transfers. Review of 09/02/2022 Occupational Therapy (OT) note showed Resident 1 had decreased hand strength and required occasional assistant for self-feeding due to decrease grip strength for use of utensils. This note showed the OT recommended the use of, Applied built-up grips on utensils to increase grip for resident self-feeding. Review of the incident report dated 09/19/2022 showed Resident states that she removed the lid off her coffee and spilled it in her lap. Immediately red areas, blisters developed on both inner thighs 6x6 centimeter (cm). On 09/24/2022 at 12:30 PM Resident 1 stated that on 09/17/2022, the staff served coffee and the cup did not have a lid on. The resident reached out to grab the cup of coffee from the bedside table and spilled on her lap through the bedding and got burned on the thighs. Resident 1 stated that the burned area developed blisters and later opened wounds. Resident 1 stated that the incident happened on 09/17/2022 and the nurse applied an antibiotic ointment to the area for one week. An observation on 09/24/2022 at 1:30 PM with Staff E, Licensed Practical Nurse (LPN) showed Resident 1 had open blisters that measured 2.5 cm x 12 cm and 1.5 cm x 6 cm to the right thigh and 2.5 cm x 8 cm to the left thigh. The observation showed open wounds with a red wound bed and no drainage noted. Staff E identified the wound as a burn with partial thickness (involved two top layers of skin) and stated that the physician saw Resident 1 on the same day and gave new orders. On 09/24/2022 at 1:30 PM, Staff F, Dietary Manager, stated that coffee was brewed in the kitchen and served in pots, then sent to the hallways to be served to the residents. Staff F stated that coffee was brewed, at 190 degrees. When asked if staff checked the coffee temperature before serving it to the residents, Staff F said, No. Staff F stated that they did not know if the coffee Resident 1 brewed in their room was facility provided. On 09/24/2022 at 2:30 PM, Staff B, Director of Nursing, stated that the resident was served coffee and it spilled on their lap while attempting to drink it. When asked where the coffee was obtained from, Staff B stated that according to the incident report, the resident had her own coffee maker machine. When asked if staff checked the coffee temperature before serving the residents, Staff B said No. When asked if the staff was trained on how to make coffee, Staff B said, Not sure. Staff B was not aware about the resident's coffee machine appliance and staff used to make coffee for the Resident 1. On 10/03/2022 at 11:55 AM, Staff D (Certified Nursing Assistant) stated that Resident 1 was served coffee which was brewed in the resident's room with the resident's instant coffee maker. When asked if the staff was trained to brew coffee, Staff D stated, No. When asked if the coffee's temperature was measured prior to serving coffee to Resident 1, Staff D said No. Staff D stated that the resident's cup had a lid but did not remember if it was used on the cup when the coffee was served to the resident. Staff D stated that the resident's right hand was weak from the fracture and the resident used the non-dominant hand (left hand). Staff D placed the coffee cup on the bedside table and left the resident's room. Staff D stated that they responded to the resident's call light and discovered Resident 1 spilled the coffee onto their bedding. Staff D notified the nurse. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in staff administering another patient's medications for a period of 20 days. This caused harm to Resident 1 who was subjected to unnecessary invasive procedures related to medication monitoring required for the unnecessary medications. Findings included . A 03/2018 facility policy entitled Medication Administration showed the facility administered medications in accordance with the Five Rights of Medication Administration. The five rights that ensured staff administered medications correctly included, the Right Patient, Right Medication, Right Dose, Right Route, and the Right Time. Additional rights of medication administration included the right documentation clinical indication. Review of admission notes, dated 08/02/2022, showed Resident 1 was admitted from the hospital to the facility with medically complex conditions, to include dementia, stroke, high blood pressure, and falls. Review of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pages 5 through 28 had the name of another patient who was not admitted to the facility, to include medication orders. Review of Resident 1's August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A. a cholesterol-lowering medication at bedtime B. Calcium supplement daily C. Vitamin D daily D. A cardiac medication daily for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] E. Iron to treat [CONDITION(S)] F. A hormone-based [CONDITION(S)] drug daily G. A high blood pressure medication daily H. Fiber I. Tylenol (analgesic) every four hours as needed J. A blood thinner with specific doses on certain days of the week. Record review showed on 08/03/2022, Resident 1 experienced an unnecessary blood draw to check for the blood thinner levels and vitamin D. Additional blood draws to check for blood thinner levels occurred on 08/08/2022, 08/15/2022, and 08/21/2022. Record review showed Resident 1 discharged to another nursing home on 08/22/2022. The receiving nursing home identified that Resident 1 had received multiple medications unrelated to their current diagnosis. Review of an 08/22/2022 facility Investigative Report (IR) showed, incorrect medications were ordered for Resident 1 on admission. Review of the IR showed, The resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/12/2022 at 2:20 PM, Staff D, Director of Admission, stated that all referrals from the hospitals are coordinated by an out of state team. The out-of-state team reviewed the resident's clinical needs and confirmed if the admitting facility was able to meet the resident's needs. Staff D stated that Resident 1's orders were received, printed and given to the Staff B, Director of Nursing Services, and the admission nurse. Staff D stated that the facility did not identify they received someone else's orders at the time of admission. On 09/23/2022 at 1:50 PM, Staff B stated that Resident 1's orders were, mixed with another resident's information received from the patient care team. Staff B stated that Resident 1 received the medication orders of another resident for 20 days. Staff B stated that medication error was identified when the resident was discharged to another facility on 08/22/2022. The two nurses were doing medication reconciliation. Staff B acknowledged significant medication errors occurred daily for almost three weeks. When asked if the resident received the right medication, Staff B said, No. Reference WAC 388-97-1060 (3)(k)(iii)

Based on observation, interview and record review, the facility failed to provide interventions and supervision to prevent falls for one of three residents (Resident 1) reviewed for falls/accident hazards. This failure contributed to Resident 1incurring multiple falls, that resulted in an acute fracture to the right clavicle (shoulder) and hospitalization . Findings included . Refer to both F-656 and F658 Review of a policy titled Fall Practice Guide dated 12/2011, showed the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. Fall management focus on minimizing falls risks factors and fall related injuries while continuing to promote the resident quality of life. The center utilizes Assess Plan Implement and Evaluate (APIE) framework as a systematic method to identify risk, select interventions to reduce the risk and monitor the effect on risk reduction. Review of a 2021 Lippincott Procedures associated with the Fall Management Policy dated 2021 and Procedure and titled Fall Prevention, Long Term Care, showed that if a resident were at risk for future falls, the facility would take steps to reduce the danger based on the factors creating the risk. This procedure showed that one of the interventions to prevent falls was to check on the resident every 30 minutes if the resident was at high risk for falls, and to document the times and frequency the resident was checked. This procedure also instructed the facility to consider providing close supervision. Review of the admission Minimum Data Set (MDS, a required assessment tool), dated 05/27/ showed that Resident 1 was admitted on [DATE] with diagnoses including history of right hip fracture, diabetes and memory loss. Resident 1 required two-person assistance for bed mobility, transfers, dressing, toileting, and hygiene. Review of the Care Area assessment dated [DATE] showed that Resident 1 was at a high risk for falls related to generalized weakness with unsteadiness, falls and poor safety awareness. No actual fall care plan was in place. Review of a 05/29/2022 Fall Risk Evaluation showed Resident 1 had physical performance limitations related to difficult maintaining standing position, impaired balance, and gait problem. Resident 1 required assistance with toileting, needed help to maintain balance, had three or more health conditions or medications that contributed to falls. Review of the nursing progress notes dated 05/21/2022 showed that Resident 1 was found on the floor by a caregiver at 1700 hours (5:00 PM). [Resident 1] was assessed and was transferred off the floor using a hoyer lift and two staff members. No injuries were noted, and the resident denied pain. Review of the nursing progress notes dated 05/29/2022 showed that staff was walking on the hallway and heard Resident 1 calling for help. After responding, staff found resident laying on the floor with nonskid socks on both feet at 18:17 hours (6:17 PM). The call light was not on. Staff nurse asked the resident what happened, the resident said, I don't know, not sure what happened. Resident 1 was assessed by two nurses and the resident complained of right shoulder pain of 9/10. Resident 1 was assisted by the two nurses using a gait belt back to resident's wheelchair. The on-call physician and family were notified, resident was sent to emergency room and was diagnosed with right clavicle fracture. Review of Hospital emergency room report dated 05/29/2022 showed [Resident 1] was admitted after unwitnessed fall in a nursing home and landed on right shoulder. The x-ray report showed right clavicle fracture. Review of Resident 1's comprehensive Care Plan (CP) dated 05/22/2022 showed the resident was at risk for falls due to impaired balance/poor coordination unsteady gait and impaired cognition (memory problems). Interventions were low bed and refer to therapy for treatment. No other intervention to address the resident's recent falls and associated injuries. No CP revision after the first or second falls in the facility to address the resident's fall risks and actual falls. An observation on 06/7/2022 at 11:55 AM showed Resident 1 sitting in a wheelchair in a private room, and wheeling towards the bathroom door. The call light was not on and the house keeping cart was outside the door. Resident 1 was observed with shoes on, no sling to the right shoulder, the bed was not on a low position. Resident 1's sling was observed on top of the nightstand. When the Complaint Investigator asked if they needed help, Resident 1 stated, Yes. Staff E was notified and responded to help the resident, but Resident 1 declined. In an interview on 06/21/2022 at 11:45 PM, Staff B Director of Nursing Service (DNS), stated that the nursing staff are expected to do fall evaluation and implement a fall care plan immediately when a new admission comes to the facility or within the first 24 hours. When asked if Resident 1's record showed the facility identified interventions to prevent falls recurrence and or associated injuries, Staff B, DNS, stated said No. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review the facility staff demonstrated a pattern of inability to recognize neglect occurred and concerns reported by residents were allegations of abuse or neglect. The facility failed to implement policies and procedures that included all components of abuse/neglect prohibition to identify, immediately report and protect residents and thoroughly investigate for nine of twenty residents (#s 2, 3, 4, 5, 6, 8, 9, 16, 19 and 20) when allegations of abuse or neglect occurred, and potential allegations were reported or observed. Staff failed to report to administration when Resident #4 fell . Three additional staff became aware the following day and failed to protect the resident or conduct a thorough investigation until inquiry by investigators twelve days later. These failures placed all residents at risk for unrecognized and continued abuse/neglect resulting in Immediate Jeopardy on [DATE]. The facility provided abuse/neglect retraining to all staff, assessed all residents and implemented ongoing monitoring and IJ was removed on [DATE]. Findings included: Refer to CFR: 483.12(a)(1), F-600, Free from Abuse and Neglect Refer to CFR 483.12 (c)(2)-(4), F-610, Investigate/Prevent/Correct Alleged Violation previously cited [DATE] Following a request made on [DATE] at 9:25 AM for the facility policy and procedure for abuse prohibition, Staff A, Administrator, provided a document titled Prevent Practice Guide Quality Assurance and Performance Improvement. Staff A stated that the practice guide was the abuse prohibition policy and procedure the facility used. The Prevent Practice Guide showed it contained a standardized process for near miss situations, concerns and trigger events and a seven step process to address potential or actual care and service issues. The guide did not include components required per CFR 483.12(b)(2) for screening, training, prevention, identification, protection, reporting and investigation. On [DATE] at 9:34 AM, Staff FF, Regional Director of Operations, (RDO) provided a different policy and procedure for abuse prohibition titled Patient Protection Abuse, Neglect & Misappropriation Prevention that included seven components required for the abuse prohibition process. RESIDENT #4 - FAILURE TO PROTECT RESIDENT AND INVESTIGATE FALL IN SHOWER An Admission MDS, (MDS, a required assessment tool) dated [DATE] showed Resident #4 admitted to the facility on [DATE] and muscle weakness, diabetes and a heart condition. A required 30 day MDS dated [DATE] showed the resident required extensive assistance from two staff to transfer, required assistance to stabilize during transfers, and did not have cognitive or communication impairment. A care plan dated [DATE] for falls showed the resident at risk for falls due to extremity weakness. During observation and interview on [DATE] at 10:58 AM, Resident #4 stated that she told Staff J, Certified Nursing Assistant, (CNA) staff used a mechanical lift to put her in a shower chair and she could not stand on her own. The resident also stated that Staff J, transferred her from the wheelchair to the shower chair with a stand/pivot transfer instead, could not get her to sit up straight and sat on the edge of the seat with legs extended in front to shower. Resident #4 stated that a different aide came into the shower and transferred her back into the wheelchair the same way, slipped and had to lower her to the floor. The resident stated her head lay with neck angled against one shower wall and legs and feet stretched toward the opposite wall. Resident #4 stated I am on blood thinners .I was totally naked and wet. Resident #4 stated that a nurse did not assess her before the first aide picked her up off the floor and her into the wheelchair. The resident also stated she did not know if they told the nurse what happened. The resident stated later, a nurse cleaned up blood from the elbow injury and the nurse never asked her how she got hurt. Resident #4 stated she continued to see Staff J work although the aide didn't care for her after that. A progress note dated [DATE] written at 10:10 PM, showed the aide told Staff DD, Registered Nurse, RN, Resident #4 transferred from a shower chair to the wheelchair and brushed arm against the wheel of the wheelchair and had a skin tear 3 cm by 0.3 cm. and provided treatment. The record did not contain evidence Staff DD conducted a full assessment of the resident for further injury or obtained a statement from the resident how the injury occurred. INCOMPLETE SKIN TEAR INVESTIGATION An investigation for the skin tear dated [DATE] included interviews with Staff I, Certified Nursing Assistant, (CNA), and Staff DD, Registered Nurse, (RN). The investigation did not contain a statement or interview with Staff J, Certified Nursing Assistant (CNA.) The investigation was incomplete and did not contain the following to rule out abuse or neglect: - Detailed interviews with Resident #4, Staff J or Staff I to determine what caused the difficulty aides had getting her into the shower; or if aides were asked how they transferred the resident and request staff to provide a return demonstration. -Review of the assessed method for transfer and care plan review to determine if aides followed the care plan. A thorough investigation would have discovered the care plan did not provide guidance for nursing aide staff how to transfer the resident for showers and discover aides could not use the slide board with a shower chair. The investigation concluded the resident was able to successfully transfer from the shower chair to the wheelchair using the slide board. Staff involved were allowed to continue to work and had access to residents following this incident. The facility did recognize neglect occurred and residents were not protected. The investigation did not show staff asked the resident what transfer method was used to transfer from the shower chair to the wheelchair and concluded the resident used a slide board The investigation was not signed completed until [DATE], eleven days after the incident occurred. During an interview on [DATE] at 3:05 PM, Staff H, Unit Manager, (UM,), stated that she did not ask Resident #4. Staff I or Staff J involved how they had transferred the resident in the shower room and wasn't aware aides used a mechanical lift to transfer into a shower chair. Staff H stated the investigation was supposed to be completed in five days and did not get direction on how to proceed from administration, if it should be one or two separate investigations. The next day, a progress note dated [DATE] written at 1:08 PM, showed the resident informed a provider an aide assisted her to the floor and something happened to her back and she was in pain the following day. The provider note showed the resident reported mild left shoulder pain and mid to low back pain rated as four to five out of ten, intermittent and achy in nature. The note also showed the provider ordered a pain patch for lower back and an x-ray. A progress note dated [DATE] written later at 9:21 PM, showed Resident #4 had five bruises found during a skin assessment. Bruises documented were 0.5 cm by 0.5 cm bruise on the left wrist; 3.5 cm by 4.0 cm purple bruise on the left medial ankle; 2.5 cm by 1.5 cm bruise to the right shin; 8.0 cm by 6.0 cm bruise to the coccyx and a 0.3 cm bruise to the left arm. The note did not identify the time nursing assessed the resident and found the bruises to determine if they assessed her immediately following the report of the fall or waited until the next shift. The facility investigation log did not identify the facility recorded the fall. During interviews on [DATE] at 6:20 PM with Staff B, Director of Nursing, (DON), and Staff A, Administrator, Staff A stated that the facility did not have a completed investigation for the fall yet. Staff B stated that she did not know Resident #4 had a fall when it happened and it should have been reported to her. Staff B stated that she knew about the skin tear and the nurse should have investigated how the skin tear occurred. Staff B reported that Staff H, Unit Manager, (UM,) did not begin the investigation for the fall before the provider saw the resident on [DATE] (day after the fall.) Staff A stated staff involved were not yet suspended and he didn't have a clear picture of the situation and there were lots of details missing in the entire situation. Later on [DATE] at 7:06 PM, Staff A stated that both staff involved, Staff J, CNA, and Staff I, CNA, were just suspended. The facility had knowledge the dall occurred on [DATE] and did not protect Resident #4 or other residents until eleven days later. Multiple staff failed to follow policies and procedures. Staff failed to report a fall when it occurred; investigate how Resident #4 received a skin injury when discovered and missed opportunity to determine what happened at the time it occurred; failed to conduct a thorough investigation of the skin injury or complete and thoroughly investigate the fall when reported within five days. Both Staff I and Staff J continued to work and have access to residents during that time. Staffing schedules showed Staff J worked directly with residents on [DATE]; [DATE]; [DATE]; [DATE]. During an interview on [DATE] at 6:30 PM, Staff B, Director of Nursing, (DON), stated that Staff I, CNA, still worked in another area of the facility since the incident. Residents were not protected since both staff still had access to vulnerable adults following the incident before the facility determined if abuse or neglect occurred. Residents were not protected from [DATE] until [DATE]. RESIDENT #6 FAILURE TO PROTECT, REPORT AND INVESTIGATE INCIDENTS DURING MECHANICAL LIFT TRANSFERS An Admission MDS dated [DATE] (MDS, A required assessment tool) and Quarterly MDS dated [DATE], both showed Resident #6 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS's showed the resident had frequent urinary incontinence and needed extensive assistance from two staff to meet transfer, toileting and personal hygiene, and did not have cognitive or memory impairments. A care plan dated [DATE] for self-care deficit showed Resident #6 required two staff to transfer with a mechanical lift sling. A Minimum Data Set Assessment (MDS, required assessment tool) dated [DATE], showed the resident totally dependent on staff for bathing activities. 1. A progress note dated [DATE] showed Resident #6 reported staff accidentally bumped the resident's knee into a side table with a mechanical lift and the resident only reported arthritic discomfort. No evidence was found staff conducted an investigation to determine how or why the incident occurred. 2. A nursing note dated [DATE] written at 11:37 PM, showed during preparation to shower, Resident #6 was suspended mid-air in a mechanical lift sling and without clothing when the lift battery died . The note showed the emergency release on the lift had not been reset from prior use. (This would not allow staff to lower the resident into a chair.) The note also showed the RN was called emergently into the room and the aide and resident were anxious. The note showed an aide left the room to obtain a new battery. Facility and resident records did not contain evidence staff reported the incident to administration, investigated why the lift battery died , protected the resident pending investigation results or ruled out abuse or neglect. The record did not show staff monitored the resident for ongoing psychological harm. During interview on [DATE] at 12:02 PM Staff G, Interim Director of Nursing, (IDON) stated that if a leg got bumped during transfer in a mechanical lift, she would fill out an incident report; check the plan of care and to see if the correct number of people transferred the resident; check the purple book for reporting requirements; obtain treatment orders and educate staff involved. Staff G also stated if suspended in a mechanical lift with a dead battery; she would log the incident; look for a root cause why the battery died ; check the resident for psychological harm and place them on alert monitoring. Staff G also stated that she would look at the process for charging batteries, education of staff and notifications. Staff A, Administrator, stated at this time, staff initially ruled out abuse and neglect related to the incident. Staff B, IDON, stated staff discussed incidents in Eagle room meetings twice a day. The investigator requested to see Eagle room notes of these incidents since the facility incident log did not contain record they occurred or were investigated and none were provided. Later on [DATE] at 4:15 PM, Staff B, stated that staff did not treat (being suspended in a mechanical lift) as an incident and contacted Staff HH, Registered Nurse, (RN) involved. Staff B stated that Staff HH left the room to get another battery and left the two aides in the room with the resident. Earlier during an interview [DATE] at 12:02 PM, Staff B stated the nurse should stay in the room with the resident. Facility nursing staff failed to immediately protect Resident #6 when suspended mid-air in a lift sling, and failed to immediately protect teh resident and investigate. Without an investigation, staff could not rule out if abuse or neglect occurred and implement preventive measures to assure residents were protected from repeat occurrences. FAILURE TO PROTECT RESIDENTS AND IDENTIFY NEGLECT [NAME]CURRED RELATED TO DELAYED PROVISION OF CARE RESIDENT #6 Refer to F 600 for observations, interviews and information related to incidents of long delay in receiving incontinence care on [DATE] for Resident #6. A facility investigation dated [DATE] showed Resident #6 informed staff at 6:30 AM she needed a wet brief changed at 6:30 AM and did not receive care until 10:15 AM, 3.75 hours later. Before Resident #6 received assistance at 10:15 AM on [DATE] the resident had multiple encounters with three different staff who could have provided care and didn't. The investigation also showed an unidentified activity assistant who asked the resident questions and never inquired why her call light was on. A progress note dated [DATE] written after the incident at 4:38 PM, showed staff found a non-blanchable area on the resident's buttocks. The note did not identify the time staff assessed the resident. The facility investigation did not contain thorough information such as time and who reported the allegation; times all staff involved were interviewed or determine if other residents were affected. The investigation did not show what measures were taken to assure residents were protected from further incidents. The investigation did not show the facility identified neglect occurred. During an interview on [DATE] at 3:59 PM, Staff F, Staff Development Coordinator, (SDC,) stated that a neglect allegation was when needs were not met like toileting. Staff F stated that if someone had an allegation of abue or neglect they wrote it on a concern form and it was discussed with administrartion in the morning meeting. Staff F also stated that if there is the possibility of neglect, staff should call the Director of Nursing or Administrator and be directed on what to do. RESIDENT #4 A facility investigation showed Resident #4 had the call light on [DATE] from 11:30 AM to 1:45 PM and did not receive incontinence care for two and a quarter hours. Multiple staff had contact with the resident during this time and did not provide care. The facility investigation showed Staff Y, Certified Nursing Assistant, (CNA,) stated that he left to cover the dining room at noon and the resident's call light was on and someone promised to come back and care for her and Staff Z, Certified Nursing Assistant, (CNA,) covered the run. The investigation also showed Staff L, Registered Nurse, (RN,) noticed a call light on and told the resident she would get an aide but could not locate one provide care. During an interview on [DATE] at 4:50 PM, Staff A, Administrator stated that staff addressed the resident's needs when Staff Y returned from dining room duties at 1:30 PM. and Staff Z, Certified Nursing Assistant, (CNA,) did not notice the light on. Staff A stated that Resident #4 said someone came into the room to pick up a tray and told her Staff Z would assist her. Staff A also stated that Staff L did not offer to help Resident #4. Staff A stated the facility did not substantiate neglect and it was difficult with conflicted reports and hard to put a stamp of neglect on it. The facility did not recognize neglect occurred when Resident #4 put on a call light on [DATE] at 11:30 AM for a brief change and did not recieve care until 1:30 PM to 1:45 PM. RESIDENT #5 ROUGH HANDLING NOT THOROUGHLY INVESTIGATED An Admission MDS dated [DATE] showed Resident #5 admitted to the facility on [DATE] following hospitalization , required extensive assistance to turn in bed and did not have short or long term memory impairment. A physician consult dated [DATE] showed the resident had multiple fractures of the right arm with a soft cast. An Admission/Readmission Screen dated [DATE] showed the resident had aching, throbbing, stabbing pain with levels of pain identified between three to six, using a rating scale of one to ten (ten being the worse pain.) The assessment also showed the resident's pain worsened with position changes. During observation and interview on [DATE] at 12:04 PM, Resident #5 sat in wheelchair in room and stated one night an aide turned her on her side in bed and told the aide during the turn I can't turn, it hurts my ribs. The resident stated the next night the same aide tried to turn her again and I said you can't do that. It hurt bad enough to say STOP IT and she insisted on doing it anyway. The resident stated that she told a nurse after the second night she didn't want the aide back because she didn't want to be hurt again but the aide was still assigned to care for her and no one asked her if that was okay with her. During an interview on [DATE] at 1:50 PM, Staff K, Registered Nurse, (RN,) stated that the resident needed to be turned gently in bed and would have expected staff to stop turning her if the resident said to stop. Staff K confirmed Resident #5 was alert and cognitive. A facility investigation showed Resident #4 reported the incident of rough handling on both nights to the facility interview on [DATE]. The investigation showed Resident #5 wanted the aide to turn her differently on the second night and the aide told her we did it this way last night so we needed to do it again. The facility investigation showed Staff EE, assigned to care for Resident #4 on [DATE] and [DATE], stated that the first night she was careful to turn the resident and the resident did not ask her to stop or express pain. Staff EE stated that the second night the resident asked her to raise her hips to provide care. The investigation did not contain a clear statement that described how Staff EE performed personal care the second night or if the facility asked Staff EE to provide a return demonstration. The facility did not substantiate abuse occurred and provided counseling to Staff EE on patient service and cleaning a patient. Without fully investigating how Staff EE provided to care to Resident #4 the second night, or why Staff EE did not listen to the resident's request to use a preferred method to move to provide care, the facility did not have enough information to conclusively rule out abuse did not occur. The investigation did not identify the facility asked Resident #4 if she agreed to receive care from Staff EE following the allegation. . FAILURE TO RECOGNIZE ALLEGATIONS OF ABUSE/NEGLECT ON CONCERN FORMS RESIDENT #8 and RESIDENT #9 The facility combined two residents concerns on the same form dated [DATE] Staff P and Staff CC did not recognize indicators of neglect when Resident #8 and #9 reported they asked to be showered after missing their shower day but the aids denied them a shower because it was not their shower day as documented on the Concern Form dated [DATE]. This form was completed by Staff P and signed by Staff CC and neglect was not ruled out using a process of investigation. On [DATE] during an interview at 3:40 PM, Staff P was asked about processing concerns as a grievance versus an allegation of neglect. Staff P indicated her understanding was neglect allegation is when there is harm. Staff P was asked if she asked residents about how it made them feel if they did not receive a shower or waited too long for assistance and responded I haven't specifically asked them that. RESIDENT #8 [DATE] Concern form dated [DATE] showed Staff P and Staff H failed to identify neglect allegations when Resident # 8 reported not showering for two weeks, not having bandages changed for five days, was in pain and was concerned that healing will be delayed due to nursing not changing it. Staff H filled out Concern form listing above allegations on [DATE] and Staff H documented she followed up on the allegation on [DATE], five days later. The allegation of neglect were identified and resident was not protected following allegations. There was no evidence that facility reviewed resident's pain management and assessed bandaged areas to rule out harm, psychological and physical. INCIDENTS OF FAILURE TO RECOGNIZE NEGLECT [NAME]CURRED NO ACCESS TO CALL LIGHT RESIDENT #16 Resident #16 required extensive assistance due to a broken right ankle and use of an immobilizer. Observations and interviews on [DATE] at 1:50 PM, 1:55 PM and at 3:45 PM with resident and staff members revealed the resident remained with nonfunctioning call light for 3 days. This facility demonstrated a serious disregard for consequences, especially when resident had a recent fall on [DATE]. During an interview on [DATE] at 1:50 PM, Resident #16 reported unmet basic physical needs when staff did not provide timely assistance resulting in resident wetting her bed. Refer to F600 for details specific to resident neglect. RESIDENT # 20 Resident #20 had [DIAGNOSES REDACTED]. Resident's care plan/guide reviewed on [DATE] directed to use 2 person assist using sit to stand mechanical lift. On [DATE] at 1:38 PM during observations Resident #20 was transfered via mechanical lift by one staff member. This facility practice demonstrated serious disregard for consequences by not folloiwng the care plan and creating a safety hazard situation. Refer to F600 for additional information. RESIDENT #19 Resident #19 admitted on [DATE] with [DIAGNOSES REDACTED]. The same assessment showed resident was able to understand others and make self understood, did not have cognitive problems and no presence of behavioral symptoms. The resident was required extensive 2 person assistance for bed mobility and one person physical assist for transferring between surfaces. On [DATE] at 1:40 PM Resident #19 reported she slid out of bed last night at 3:00 AM when her mattress moved, turned on the call light and waited for 45 minutes. Resident said while she waited she considered crawling out of the room so staff would notice her. Record review did not find any nurses notes about the incident, the facility started an investigation after being informed by the surveyor. Refer to F600 RESIDENT #3 Resident #3 had [DIAGNOSES REDACTED]. Resident had a BIMS (Brief Interview for Mental Status, cognitive assessment tool) scored 15 (cognitively intact). The same assessment showed the resident required extensive assistance with activities of daily living and toileting. Resident #3 was neglected when she was not assessed by nursing for over 15 hours during acute change of condition on [DATE] and [DATE]. This failure was a serious disregard for consequences related to lack of increased assessment and risk of unrecognized development [MEDICAL CONDITION] (life threatening complication of infections when chemicals are released into the bloodstream to fight infection trigger changes that cause organ failure.) Resident #3 waited between ,[DATE] hours to have her call light answered on [DATE] and [DATE] according to facility investigation dated [DATE]. The facility's evidence of investigation showed resident was interviewed on [DATE], 3 days after making allegation of neglect. This delay resulted in resident not being immediately protected from potential harm.The administrator interviewed a facility nursing assistant on [DATE] who reported staff was stressed out .almost in tears . almost going to cry, and felt like no one was going to help her. In an interview the agency aid on [DATE] informed the administrator it took her a long time to find a help (a second person) to assist Resident #3. The statement included, I had a hard time finding people to help me with anything. The facility investigation did not contain evidence that staff burnout was identified and a systematic approach to managing resident needs were implimented. Refer to F600 RESIDENT #2 MDS assessment on [DATE] identified Resident #2 was had no problems with cognition, was paralyzed and, required two person extensive assistance with toileting and hygiene. On [DATE] Resident #2 reported to the administrator she waited ,[DATE] hours to have the call light answered on evening shift on [DATE] and [DATE] according to the facility Investigation Report. The facility interviewed resident on [DATE] and [DATE], about allegation of neglect. Resident said she was soaking wet in the morning and it was cold. Facility investigation identified staff answered resident call light without completing the task and asked the resident to wait. WAC Reference [DATE](2)(a)(b)(5)(a)(b)(6(a)(b)(c)

Based on observation, interview and record review the facility demonstrated a pattern of allowing neglect to occurr by failing to provide goods and services to ensure residents' basic physiological needs were met. The facility administration failed to recognize and/or address ongoing staff burnout, which is known to create an environment that promotes neglect. This failure affected ten of twenty residents (Residents #'s 1, 2, 3, 4, 6, 8, 9, 16, 18, and 20). Residents # 1, 2, 16 and 18 were subjected to mental anguish and experienced harm due to emotional distress and placed other residents were at risk of harm. Findings included: According to CFR 483.5, neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Refer to F607 for additional information on facility failure to operationalize abuse/neglect policy and procedures and repeatedly demonstrated inability to identify neglect/abuse; failure to protect the residents and thoroughly investigate allegations of neglect/abuse, and implement interventions based on root cause analysis to prevent reoccurrence for residents (#s 2, 3, 4, 6, 8, 9, 16 and 20.) RESIDENT #16 Resident #16 admitted on [DATE] with a broken ankle. The Minimum Data Set (MDS, the required assessment tool) dated 8/04/18 showed resident was able to make self understood and understands others, and did not have cognitive problems. The resident required extensive assistance with hygiene and toileting. Resident #16 had a history of [REDACTED]. The facility demonstrated serious disregard for consequences constituting actual neglect when resident remained with a nonfunctional call light for three days, although the facility staff were aware of the problem but did not fix it until the surveyor brought it to facility's attention. On 9/17/18 at 1:50 PM, Resident #16 was observed in a wheelchair with an immobilizer device on the right leg. During observations, the resident's floor was wet after a spilled drink. Resident #16 asked the roommate to turn on the call light because her call light has been broken since Friday (09/14/18). Resident said she reported the problem to the nursing aides on 9/14/18. The surveyor tested the call light and it did not light up above the door and did not sound. The resident did not have an alternative way of calling staff. On 09/17/18 at 1:55 PM Staff R, NAC said she knew resident's call light was broken and said it was reported to Staff S, Maintenance Director on Friday (9/14/18.) Staff S at 3:45 PM tested Resident #16 call light and said it was dead and remove it. Staff S, said he was not told about a broken call light until surveyor informed him. During observations and interview on 09/17/18 at 2:35 PM, Resident #16 was visibly upset and had tears in her eyes when she reported waiting anywhere from 15 minutes to an hour to receive assistance with toileting resulting in repeatedly wetting her bed. Resident said it made her feel embarrassed. Resident said she was taking [MEDICATION NAME] (water pill) and could not wait a long time for assistance. Resident verbalized feelings of helplessness when she said she had no choice but to put weight on her right foot when she was not supposed to because she could not rely on staff for help. Resident also mentioned that her foot was not healing well and she was awaiting another surgery. RESIDENT #18 Resident #18 had a [DIAGNOSES REDACTED]. According to the MDS on 07/13/18, the resident made self understood and understood others. The resident did not have cognitive problems, memory problems or behaviors. On 09/17/18 at 2:05 PM during observations and interview, Resident #18 sat on the bed and was looking at her medical records. Resident was crying while describing her experience at the facility. A white 8x11 inch paper was hanging above the resident's head of the bed. A hand written note in part read Elder Abuse includes: intimidation . mental anguish and termination with Manor care . where needs (mental/physical) cannot be met by Manor Care. The resident said she hung it up sometime in the morning. During the same interview Resident #18 reported nursing staff interacted with residents like robots because they did not take the time to explain care. Resident described a particular staff member as cruel. Resident pointed to the physicians orders on her bed and asked why do I have orders for a happy hour? Resident #18 stated she has been in recovery for over [AGE] years and felt it was offensive that facility ordered alcohol for her. Staff P, Activity Director was interviewed on 9/17/18 at 3:40 PM. Staff P said Resident #18 did have orders for wine. Staff P was not aware resident was in recovery. RESIDENT # 20 Resident #20 had [DIAGNOSES REDACTED]. The facility staff neglected to follow resident's care plan placing the resident at risk for injury and did not demonstrate caring behaviors when resident showed feelings of extreme emotional dislike. Resident's care plan/guide reviewed on 09/17/18, directed 2 person assist using sit to stand mechanical lift. On 09/17/18 between 1:20 PM and 1:38 PM during observations Resident #20's call light was on for 18 minutes. Resident was interviewed at 1:37 PM and said he was tired and wanted to go lay down, and said he waited about 20 minutes for help. During the same time Staff Q entered Resident's room and at 1:38 PM transferring the resident from wheelchair to bed by himself. While suspended in the mechanical lift, the resident appeared frustrated and made a statement I hate this. I want more therapy. Staff Q did not acknowledge or respond to resident's statement. When Staff Q completed the transfer, he stated to the resident you're in bed now in a monotone voice. On 9/17/18 at 5:01 PM, Staff T, Registered Nurse reported facility protocol was to use 2 person for any mechanical lift transfer. RESIDENT#3 Resident #3 had [DIAGNOSES REDACTED]. The same assessment showed resident required extensive assistance with activity of daily living and toileting. Resident #3 was neglected when she was not assessed by nursing for over 15 hours during acute change of condition. This failure was a serious disregard for consequences related to lack of increased assessment and risk of unrecognized development [MEDICAL CONDITION] (life threatening complication of infections when chemicals are released into the bloodstream to fight infection trigger changes that cause organ failure.) On 09/06/18 at 2:11 PM, Resident #3 was observed in bed with eyes closed. Resident's skin appeared clammy and pale, oxygen was flowing through a nasal cannula. Resident was unable to be interviewed at the time. At 2:15 PM, Staff LL, Licensed Nurse reported the resident had high white blood cell count (indicator of an infectious process) and the infection was of unknown origin. Between 09/06/18 10:33 PM and 09/07/18 2:20 PM, there was no evidence a nurse conducted a physical assessment including listening to lung sounds, evaluation for signs [MEDICAL CONDITION] and dehydration. Resident #3's needs were neglected when facility when staff demonstrated obvious signs of burnout (caregiver fatigue) or stress and struggled to get help from other facility staff in order to provide care to the residents. Facility investigation showed on 08/13/18 Resident #3 reported to the administrator she waited 2-3 hours to have the call light answered on the evening shift on 08/11/18 and 08/12/18. According to the incident investigation the allegation occurred while an aid was on a break. The administrator interviewed a facility nursing assistant on 8/16/18. The interview contained indicators of staff burnout stating that a nursing assistant was stressed out .almost in tears . almost going to cry, and felt like no one was going to help her. The same investigation showed that on 8/17/18, the administrator was informed that it took a staff member a long time to find a second person to assist Resident #3. The facility investigation did not show how the facility ruled out sufficient staffing considering resident acuity and workload as a contributing factor to neglect allegations. The investigation failed to identify obvious signs of burnout. RESIDENT#2 MDS assessment on 8/10/18 identified Resident #2 was had no problems with cognition, was paralyzed requiring a two person extensive assistance with toileting and hygiene. On 08/13/18 Resident #2 reported to the administrator she waited 2-3 hours to have the call light answered on the evening shift on 8/11/18 and 8/12/18, according to the facility Investigation Report. The facility interviewed resident on 8/15/18 and 8/16/18, the Resident said she was soaking wet in the morning and it was cold. On 8/17/18 the administrator interviewed a licensed nurse about the incident. The nurse's witness statement described that Resident #2 wanted her care like now and the aids answered the call light but told the resident it may be a little while, 10 or 15 minutes. Resident #2 demonstrated psychological and/or emotional distress and worried that staff would not be being able to help her ailing roommate and worried about her own decline in health, creating an environment of fear. On 9/06/18 at 11:15 AM, Resident #2 said her roommate was sick in the past few days and she was concerned about staff not being able to help her on time. Resident showed the surveyor a bell and said she asked staff to respond right away and it would mean the roommate (Resident #3) was not doing well. Resident explained she wanted to make sure the staff heard a distinct sound because the call lights were on all the time. During the same interview, Resident reported she was concerned about getting weaker and in order to maintain muscle strengths in her hands she asked her friends to bring her coloring books. Resident became tearful and stated she was afraid of getting weaker. Record review did not find evidence that resident was receiving assistance with maintaining physical functioning after discharged from therapy in (MONTH) (YEAR). On 9/6/18 at 3:43 PM Staff B, Director of Nursing said there was no restorative program for Resident #2. On 9/7/18 at 10:03 AM, Staff A, Administrator said facility did not have a restorative program. RESIDENT #1 Resident #1 admitted on [DATE] with [DIAGNOSES REDACTED]. MDS dated [DATE] showed Resident #1 was cognitively intact. The resident required supervision and one person assistance with toileting. Facility failed to assist Resident #1 with toileting, a basic physiological need. On 09/06/18 at 11:15 AM, and on 09/07/18 Resident #1 was observed sitting in a wheelchair. Resident said she slept with a breathing device and needed help removing it at night when she needed to use a bathroom. Resident said she used the call light to get assistance but by the time staff responded she was already wet. Resident said she was continent of urine but had an occasional urgency issues because she took a water pill twice a day. Resident said she had wet herself on three occasions due to delayed response. The last incident occurred on 09/05/18. Resident said this made her feel angry. During the same interview Resident #1 said the staff came in to answer the call light but would ask her to wait because they were busy helping others. Resident felt the aids were stretched thin and said the facility was especially short-staffed on night shift. RESIDENTS #8 & #9 A Concern Form dated 8/21/18 showed Resident #8 and #9 reported allegations of neglect when they asked to be showered after missing showers and the aides responded to residents by denying showers and saying it was not their scheduled shower day. Refer to F607 for additional information for failure to identify neglect and protect the residents. Interviews were conducted with nursing staff about provision of care and meeting residents' needs on 09/06/18 between 2:15 PM and 3:15 PM, on 09/07/18 at 1:30 PM and on 09/17/18 at 12:42 PM with Staff C, D, E & O. Staff wished to remain anonymous, and reported diminished capacity to provide care and/or oversee residents' needs, chronic staffing problems, omissions of services, ongoing staff burnout and an environment that promoted neglect. -Staff C reported the facility had staffing crisis, and staffing levels were unsafe. -Staff E stated there was constant turnover of nursing assistants and there were new aids every few months. -Staff C said it was impossible to complete resident care tasks with the current resident assignment and acuity level. -Staff C reported there was missed care such as inability to timely administer medications complete skin assessments and monitor residents during change of condition. -Staff D said there were instances where there was only two nursing assistants assigned to care for 24 residents, 13 of which required a mechanical lift use and it was difficult to supervise resident care. -Staff D said although the facility used hospitality aids, their scope was limited to only answering call lights and they could not provide direct patient care such as transferring, toileting or feeding residents. -Staff D said the Director of Nursing was made aware of unsafe staffing and worked the floor as an aid but no permanent changes were made. -Staff E reported unsafe staffing because there were two residents who were experiencing a change of condition and the staff was unable to monitor and assess residents frequently. -Staff E said one nurse was assigned up to 27 residents, stating I can't assess 27 residents .I do the best I can. Staff E said some days all s/he could do was to make sure residents had stable vital signs. -Staff E said the unsafe staffing concerns had been reported to the Director of Nursing - Staff O, reported one nurse was assigned up to 27 residents and they were all heavy care. -Staff O reported the facility expected nurses to cover when aids went on breaks, do vital signs, weigh residents, administer medications, assess residents, and contact providers. Staff O said the assignment was unmanageable, as the nurse was unable to assess that many residents. -Staff O said there were two aids assigned to care for 24 residents, of those residents at least 13 used mechanical lifts, requiring two person assistance. -Staff O reported the working conditions created a situation where the aids cut corners including transferring patients in lifts without a second person. -Staff O said residents who could not talk were wiped in bed instead of getting a shower and the aids did not have time to get vital signs. -Staff O said residents who could talk were lucky because they can complain about not getting care. - Staff O reported seeing aids demonstrating burnout behaviors, stating they were stressed, angry and quick with the residents, and it's very unsafe. -Staff O said staff were reluctant to report concerns to administration due to fear of retaliation and they needed their jobs. Staff F, Staff Development/Educator and Staff B, Director of Nursing were interviewed about abuse and neglect on 09/07/18 at 10:17 AM and 10:23 AM. Staff F said neglect was not providing care and used an example of not changing the resident. Staff B said neglect was a pattern of unmet needs or not providing needs timely. RESIDENT # 6 An Admission Minimum Data Set assessment dated [DATE] (MDS, A required assessment tool) and Quarterly MDS dated [DATE] both showed Resident #6 had [DIAGNOSES REDACTED]. The MDS's showed the resident had frequent urinary incontinence and needed extensive assistance from two staff to meet toileting and personal hygiene needs. The assessments showed the resident did not have cognitive or impaired memory. During observation on 09/06/18 at 10:54 AM, Resident #6 lay in bed with the call light on above the room door, and looked into the hall while unidentified staff walked by. The resident yelled aloud toward the hall she needed help, and staff continued to walk past the room. At 10:55 AM Staff X, Social Services, (SS, ) walked into room and told Resident #6 she would get someone to help the resident as she left the room. Staff entered the room at 11:00 AM to assist the resident. During an interview on 09/06/18 at 2:22 PM Resident #6 stated that she put the call light on at 10:30 AM this morning, knew the time and watched the clock in the room. The resident stated she wanted to get up and waited a half an hour. Resident #6 also stated that on another day, she had the call light on and needed a brief change, and the aide told her she would come back after breakfast and didn't return. The resident stated that she had the call light on the whole time and waited a long time for help. The resident also stated often staff came in and turned off the call light and didn't return and I turn it right back on. It makes me feels ignored. A facility investigation showed on 08/15/18, Resident #6 asked to have a brief changed and had encounters six times with three different staff between 6:30 AM and 10:15 AM before care was provided. Resident #6 lay in a wet brief from 6:30 AM until 10:15 AM, a total of 3.75 hours before staff provided incontinence care. RESIDENT #4 An Admission MDS dated [DATE] showed Resident #4 admitted to the facility on [DATE] and required maximum assistance for bed mobility, transfers and toileting and experienced frequent incontinence of bowel and bladder. The assessment also showed the resident did not have cognitive or memory impairment. During an interview on 09/07/18 at 10:58 AM, Resident #4 stated that one day she had her call light on from 11:30 AM to 1:45 AM and needed to have a wet brief changed. The resident stated she had a clock she watched to tell the time it took for staff to come. During the 2.25 hour span of time waiting for help, the resident also stated she requested assistance from the following staff: -A hospitality aide came in and said she would tell someone. -A second aide came to pick up a meal tray and said her assigned aide would change her. -A nurse came in and told her she had a higher priority and she would tell her nursing aide. Resident #4 stated she felt frustrated laying in wet and could not move herself in bed and it would be different if she could do it herself. The resident also stated she got more wet as she waited. A facility investigation showed on 08/17/18, Resident #4 notified Staff A, Administrator, she needed her brief changed and turned her call light on around 11:30 AM and did not receive care until 1:45 PM. The investigation showed shortly after 11:30 AM, Resident #4's assigned aide left the hall to assist in the dining room and provided care to the resident when she came back from dining duties. During that time, a different aide and a nurse entered the room and did not provide care and said they would find someone else. During an interview on 09/13/18 at 4:50 PM, Staff A stated that Staff L, Agency Registered Nurse, (RN,) did not provide a reason why she did not provide care. Staff A also stated that Resident #4 gave a description of an aide (Staff Z, Certified Nursing Assistant, (CNA,) she asked for help and Staff Z did not remember seeing the call light on. Staff A stated that he did not substantiate neglect since statements conflicted. The facility investigation showed Resident #4 informed Staff A during an interview on 08/17/18, I was upset that it took so long to get help and they just keep saying they would find someone else. The investigation described staff was unavailable to assist the resident when a nurse was working on admitting a new resident and could not find anyone on the floor especially during the meal times.

Based on observation, interview and record review the facility failed to implement an effective fall prevention program that included comprehensive assessments and reassessments of fall risks; person centered initial care plans for fall prevention; evidence of interdisciplinary team (IDT) involvement to address risks and determine preventive fall interventions; and/or identify adequate levels of visual supervision needed to assist with fall prevention for three of seven residents (Residents # 1, 2 and 3) reviewed for falls. The facility failed to reassess Resident #1 for safe bed positioning and ability to safely access items on a bedside stand while lying in bed. Following the third fall off the edge of the bed, Resident #1 experienced harm due to injuries that required emergency hospital treatment. The facility failed to comprehensively assess Resident #2 to ensure safe independent travel in a power wheelchair in the local community setting. During an independent outing, the resident experienced harm from falling off a curb in the wheelchair which resulted in leg fractures. The facility failed to identify the frequency of visual staff supervision needed to assist with fall prevention for Resident #3 who experienced nine falls during self-transfers in three months. This had the potential to place the resident at risk for continued avoidable falls and injury. Findings included . Refer to F 610 for failure to thoroughly investigate falls for Resident #1. RESIDENT #1 A skilled nursing note showed Resident #1 admitted to the facility on [DATE] following hospitalization for a skin abscess and required specialized IV antibiotic treatments. Additional [DIAGNOSES REDACTED]. May (YEAR)'s Medication Record showed staff administered medications the physician ordered to treat the following conditions: aspirin and a blood thinning medication for an irregular heart rhythm; medication for [MEDICAL CONDITION]; treatment for [REDACTED]. A Minimum Data Set assessment dated [DATE] (MDS, required assessment tool,) showed the resident had functional loss of one side of the body (upper and lower extremities) and required two staff to assist with bed mobility, transfers, dressing and personal care. The MDS showed Resident #1 scored 3 on a brief interview for mental status to indicate memory impairment. A facility Admission/Readmission Screen completed upon admission, dated 05/19/18, showed Resident #1 had a history of [REDACTED]. The admission assessment did not contain an analysis of which risk factors Resident #1 had that increased her risk for falling or circumstances that led to prior falls. A fall risk care plan dated 05/19/18, included general fall risk prevention measures listed on the Admission/Readmission form which included for staff to place common items within easy reach. The care plan did not identify where to safely locate Resident #1's items in reach which considered the resident had loss of use of one side of the body. A care conference note dated 05/23/18 showed the resident's biggest barrier to reaching goals for discharge was fatiguing easily. Discharge plans included going home with family and caregivers. FALL #1 A facility incident report showed Resident #1 rolled out of bed on 05/24/18 at 7:00 PM. The investigation showed staff placed dinner on a bedside table with call light in reach and fell out of bed when reaching for the bedside table. The investigation showed the root cause of the fall was due to having the bedside table on the right side of the bed and the resident had a more moveable left hand than the right. Interventions to prevent future falls included to place the bedside table to the resident's left side of the bed and to order a bigger bed. The care plan showed staff initiated a bigger bed/mattress and bed in low position on 05/24/18. During observation and interview on 07/03/18 at 5:25 PM, Staff A, Administrator, and Staff B, Director of Nursing (DON), showed the investigator an APM XT mattress they stated Resident #1 received after the first fall. The mattress measured approximately six inches wider than a standard size bed. The investigation and analysis of the fall did not identify if or how staff initially assessed and care planned for Resident #1 to safely reach items on the bed table at the time of admission, or following this first fall, in an attempt to prevent further falls. During an interview on 06/26/18 at 2:10 PM, Staff P, Registered Nurse, (RN), stated that Resident #1's bedside table was not on the appropriate side of the bed. Staff P stated that if a resident did not have use of the right side of the body, the bedside table should be placed on the unaffected side of the bed. During an interview on 06/26/18 at 2:36 PM, Staff L , Unit Manager, Registered Nurse, (UM, RN,) stated that the night of the fall Resident #1 lay on the right side and reached over toward the table with her left arm. Staff L stated that the resident could only reach so far before losing balance and wasn't sure if the resident could stop the momentum. A fall team meeting note signed by one staff member on 05/28/18, documented the resident's care plan was reviewed and noted to be appropriate at the time of the fall. The fall meeting notes did not contain evidence interdisciplinary team members reviewed this fall that included therapy staff who provided services to the resident. FALL #2 A facility investigation showed on 05/27/18 at 3:00 AM, three days after the first fall, Resident #1 had a second fall out of the right side of the bed. The resident could not recall what happened and stated she reached for something but did not remember what. Staff C, Registered Nurse, (RN), wrote in the investigation, that the resident had a cup of water beneath her and a small amount of incontinence. A skilled nursing note written later that morning 05/27/18 at 8:47 AM, showed staff noted bruising to Resident #1's right temple and left knee and reported pain. Staff C, RN, concluded the root cause of the fall occurred when the resident reached for water on the bedside table and rolled out of bed when the resident reached too far. Staff C recommended an extra-large bed following this fall to prevent reoccurrence. An extra- large, or bariatric sized bed is approximately 16 inches wider than a standard bed. The bed Resident #1 currently had was approximately six inches wider than a standard bed. The investigation conclusion showed the resident had incontinence at the time of the fall (small amount of stool) and the facility added changes to the care plan to check and change the resident upon rising, before and after meals, before bedtime and as needed. The care plan showed staff initiated this care plan addition on 06/04/18, after the resident discharged from the facility. During an interview on 06/26/18 at 2:36 PM, Staff L, UM RN, stated that Resident #1 should have the bedside table located on the left side of the bed even when positioned on the right side. Staff L stated that the resident could reach with her left arm. During an interview on 07/03/18 at 12:15 PM, Staff G, Regional Rehab Director, (RRD), stated that Resident #1 did not know where her body was in space and did not have good trunk control. Staff G also stated that the resident may benefit using a Reacher (hand tool to reach items). During an interview on 07/06/18 at 11:51 AM, Staff L, UM, RN, stated that Resident #1 liked to lie on her side close to the edge of the bed, did not know why, and had to reposition the resident to the center of the bed at times. During an interview on 07/06/18 at 12:06 PM, Staff M, Certified Nursing Assistant, (CNA), stated that staff had to turn Resident #1 from side to side, and whichever side she was on we would put the table on that side. Staff M also stated that the resident would not always lay in the middle of the bed when lying on her side but closer to the edge. The investigation did not address why staff did not follow the care plan to place the bed table on the left side of the bed at the time of the second fall as care planned after the first fall on 05/24/18. The fall investigation and fall meeting notes did not identify the facility discussed both falls (05/24/18 and 05/27/18) with IDT members. The record did not contain evidence therapy staff were consulted regarding safety concerns regarding to Resident #1's preference to position herself near the edge of the bed, and recommendations and/or additional interventions to maintain safe positioning. Interventions to address the root cause of the fall, (falling when reaching for items), did not address the need to assess how Resident #1 positioned herself, how items were accessed items when reaching for them on the bed table to ensure safety. The facility did not assess to determine if the current bed size was adequate for the resident or if she would benefit from an extra-large bed requested by staff following the second fall. Resident #1's care plan did not address the frequency of staff supervision (visual checks) needed to promote safe bed positioning at all times (not lying on the edge of the bed). During an interview on 06/26/18 at 2:36 PM, Staff L, UM, RN, stated that after Resident #1 fell from bed the second time, we were trying to get her a bariatric bed. During an interview on 06/26/18 at 3:21 PM, Staff B, Director of Nursing (DON), stated that the facility had difficulty obtaining bariatric beds and supply companies were often out of stock. Following a request, the facility did not provide documentation to show when staff requested and attempted to locate a bariatric bed. FALL #3 Two days after the second fall, a skilled nursing note written 05/29/18 at 2:30 PM, showed Resident #1 became weak during therapy and staff had to lower the resident to the floor when the resident was on the parallel bars. A skilled nursing note written 05/29/18 at 2:23 PM, showed the resident was lethargic in the morning and became more alert throughout the day. A nursing note written 05/29/18 at 11:44 PM, noted the resident more lethargic that shift. The facility investigation for the controlled fall 05/29/18 contained an additional care plan intervention for therapy to be more aware of the resident's weakness. FALL #4 A facility investigation showed around 5:45 AM on 06/01/18, staff found Resident #1 fell on the floor next to the bed and due to cognitive impairment could not explain how the fall occurred. The investigation showed the resident was not incontinent and hit her eye on the IV pole next to the bed. A drawing made by staff of the fall scene showed the IV pole on the left side of the bed. A progress note dated 06/01/18 showed the resident had bruising and swelling to the left eye and forehead. When the resident's condition declined that included eye swelling, and could not be fully assessed, staff re-contacted the physician and obtained emergency transport to the hospital to evaluate and rule out a head bleed. Hospital records showed Resident #1 remained hospitalized from [DATE] through 06/08/18 following the fall and received a blood transfusion due to concern for hemorrhagic contusion of the left side of the head. Hospital records also showed the resident had a urinary tract infection and received antibiotic treatment. The facility investigation for Resident #1's second fall out of bed on 05/27/18 noted Staff C, Registered Nurse, (RN), requested an extra-large bed. The fall investigation dated 06/01/18 for Resident #1's third fall from bed, showed Staff C, RN, requested an extra-large bed again to prevent future falls. The investigation showed the facility did not order an extra-large bed for Resident #1 until after the third fall out of bed that resulted in injury. During an interview on 06/26/18 at 2:10 PM, Staff P, RN, stated that if a resident rolled out of bed it could be a problem with the size of the bed. Staff P also stated that the resident did not have enough room to move in the bed and could still roll some using the left leg. During an interview on 07/06/18 at 9:45 AM, Staff L, RN, UM, stated that staff worked on getting a full size bariatric (wider) bed for the resident as requested after the second fall. Staff L, stated that the bed arrived the day Resident #1 fell out of bed the third time and did not know what caused the delay. Staff L did not know exactly when it was requested and staff did not always fill out a slip to request one. INCOMPLETE FALL REASSESSMENTS Resident #1's initial fall assessment did not comprehensively reflect the resident's fall history and all risk factors. Assessment fall risk forms, contained options to check boxes that identified risk factors for falls. The assessments did not contain an analysis of how these factors affected the risk of falling. Fall reassessments completed following the first two falls out of bed on 05/24/18 and 05/27/18, did not identify all risk factors Resident #1 had. Risks not identified included [MEDICAL CONDITION]/[MEDICAL CONDITION]; cognitive impairment; infection; weakness; history of a [MEDICAL CONDITION] disorder and poor safety awareness. Reassessments did not include observation and analysis of how these risk factors affected Resident #1's bed positioning and ability to access items off the side of the bed. Skilled nursing notes dated 05/23/18 showed the physician ordered potassium supplements for a critical low potassium level. (MONTH) (YEAR)'s Medication Record showed the physician increased the dose of the supplement on 05/28/18. Resident #1's fall risk assessments did not address impact of an electrolyte balance and weakness the resident experienced during a therapy session on 05/29/18. Staff did not complete a fall reassessment after Resident #1 fell the second time on 05/27/18, until 06/04/18, after the resident fell the fourth time and discharged to the hospital. Fall meeting notes included in facility investigations did not contain evidence the facility utilized an inter-disciplinary approach to review the pattern and trend of falls to develop new interventions for fall prevention. Resident #1 rolled out of bed on three separate occasions, twice known while attempting to reach for items on the side of the bed affected by loss of bodily function. The facility did not provide evidence they assessed for safe bed positioning and ability to safely reach items from the bedside table to ensure they implemented effective interventions to address concerns with positioning to prevent a significant injury to the resident following the third fall from bed that required emergency treatment. RESIDENT #2 Resident #2 admitted to the facility on [DATE] following hospitalization . [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE] showed Resident #2 required one to two persons to assist with bed mobility, transfers, dressing and hygiene needs, and did not have cognitive impairment. The MDS showed the resident had bilateral upper and lower extremity functional limitations in range of motion, and independent with set up only to move in the wheelchair within the facility. A care area assessment for falls dated 01/31/18 showed the resident did not have any falls at the facility and had risk factors of difficulty maintaining sitting balance, impaired balance during transitions and received antidepressant medication. A Physical Therapy Evaluation and Plan of Treatment dated 01/25/18 showed Resident #2 was referred for wheelchair management in a power wheelchair. The evaluation contained a long term goal for Resident #2 to independently propel self in wheelchair unlimited distances outdoors, in hallway, across various surfaces and on inclines and declines. A Physical Therapy Discharge Summary dated 02/06/18, showed when discharged from therapy services, Resident #2 met goals for safe use of the power wheelchair in the facility and received education to be on turtle (slow moving) mode when inside the facility. The discharge summary showed community mobility was noted as not applicable. Therapy notes did not contain evidence therapy staff assessed Resident #2's ability to safely mobilize in the power wheelchair when outside the facility in the local community setting (such as crossing busy roads and outings to the local outdoor mall.) Resident #2's care plan in effect between 01/25/18 through 06/26/18, did not include interventions for staff to follow regarding independent outings in the community. A facility Leave of Absence form showed, Resident #2 signed out of the facility seven times between 05/09/18 to 06/24/18. The form did not identify where the resident went when he left the building. A facility investigation showed on 06/24/18 at 10:07 AM, Resident #2 left the facility to go offsite to a movie. The resident fell off the curb in the parking lot and the wheelchair fell on top of him when returning from the movie theater. The investigation showed paramedics took the resident to the hospital for evaluation and hospital notes identified the resident had non- displaced fractures of both lower legs. During an investigative interview conducted by the facility on 06/24/18, Staff D, Licensed Practical Nurse, (LPN), wrote, when staff arrived, Resident #2 lay on the ground, tearful and in pain and had a neck brace on. A hospital emergency room report dated 06/24/18 showed when the resident returned from radiology studies, pain in both feet increased to a ten, on a pain scale from one to ten (ten is the worst pain.) The facility investigation dated 06/24/18 showed Resident #2 exhibited competence and safety while self-driving in the wheelchair, in and around the facility and off site. During an interview on 07/02/18 at 2:32 PM, Staff E, Physical Therapist, (PT), confirmed a long term goal included for Resident #2 to safely maneuver the power wheelchair out of the facility and the record was not clear if the resident was safe on the streets. Staff E also stated that therapy staff do not always know if a resident plans to go outside the facility. During observation and interview on 07/02/18 at 2:55 PM, Resident #2 sat in a power wheelchair and wore foam padded boots on both feet and lower leg braces and a secured belt across the lap. The left and right hand third, fourth and fifth digits contained scabs. The resident stated he wore the lap belt to feel more secure. The resident stated that he had the wheelchair since (YEAR) and was capable of crossing the street, going to a bus station and the library before admission to the facility. Resident #2 stated when his wheelchair arrived at the facility (after admission), therapy staff had him drive around the inside of the building but did not go outside and drive in the community. Resident #2 stated that he told the nurse when he left the building and the receptionist and signed out in a book. On the day of the fall, Resident #2 stated that when he went out the door to the movie theater, he came out of a dark movie and sun got in his eyes and could not see. The resident stated he kept going and thought there was a ramp in front of him when he fell off a curb and blacked out for a few seconds. The resident stated the wheelchair fell on top of him. During an interview on 07/03/18 at 12:15 PM, Staff G, Regional Rehab director, (RRD), stated that during the course of therapy treatment, if a resident went out in the community occupational therapy assessed them before they came off of services. Staff G stated that if indicated, therapy would assess residents to navigate shuttles, cross streets, check speeds in wheelchairs; and judgement; problem solving; cognitive abilities to ensure they negotiated the environment safely. Staff G stated that therapy did not know Resident #2 planned to go out in the community. During an interview on 07/03/18 at 1:46 PM, Staff F, Certified Nursing Aide, (CNA), stated that before Resident #2's accident, he would fly around here and staff had to stop him and tell him to slow down. Staff F also stated that even alert residents would have him slow down at times. During an interview on 07/03/18 at approximately 6:15 PM, Staff A, Administrator, stated that the facility did not have a written policy and procedure to provide that addressed assessments and procedures for staff and residents to follow who went on outings. RESIDENT #3 During observations on 07/03/18 at 4:23 PM and 4:50 PM, Resident #3 lay in bed with eyes closed. A wheelchair located at the far end of the left side of the bed had an anti-roll device on the back visible. Resident #3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS dated [DATE] showed the resident did not have falls prior to admission, incontinence and severe cognitive impairment. A fall care area assessment dated [DATE] showed Resident #3 had risks for falls that included impaired balance during transitions; difficulty maintaining balance; incontinence; [MEDICAL CONDITION] disorder; cognitive impairment and depression. A care plan for self-care deficit initiated 03/02/18, showed the resident required extensive assistance from one staff to transfer and meet daily care needs. A care plan for cognitive loss initiated 03/08/18 showed Resident #3 required cueing and prompting for room location, personal care and activities and for staff to use simple words and statements. Resident # 3 experienced nine non-injury falls during three months between 03/06/18 through 06/09/18. All falls occurred when the resident attempted to get up out of bed unattended. Seven out of nine falls occurred on evening and night shifts. Multiple care plan interventions were implemented following falls that included the following: 2/27/18: adding an anti-roll device on the wheelchair; 02/27/18 leave door open to room to monitor resident and assist if necessary; 02/28/18: toileting before and after meals and bedtime; 03/07/18: educating staff regarding noise levels at bedtime; 03/15/18; priority toileting after dinner; 03/26/18: priority get up for meals; 04/09/18: reinforce wheelchair safety and locking brakes; 04/09/18: priority get up in the morning; 04/26/18: monitor hours of sleep; 06/05/18: offer early morning snack; 06/07/18: check and change. Resident #3's care plan did not identify the level of visual supervision staff should provide during each shift or times when falls were likely to occur. A Physical Therapy Discharge Summary dated 03/01/18, showed at the time of discharge from therapy, the resident demonstrated improved transfers and control with transition. Education to use the call light to make needs known remained limited and would continue to require limited assistance with transfers for safety. Review of all nine fall investigations between 03/06/18 to 06/09/18 and Resident #3's medical record, did not contain evidence the facility used an interdisciplinary approach to review the pattern and details of the resident's falls when they occurred, or if therapy staff had further recommendations for additional approaches or therapy that could assist in decreasing the likelihood of falls or injuries. Following the ninth fall that occurred during self-transfer on 06/09/18, the facility investigation showed staff added an additional care plan interventions for an IDT review and medication review on 06/30/18. During an interview on 07/03/18 at 3:15 PM, Staff K, Unit Manager, Registered Nurse, (UM, RN) stated that the facility discussed falls during Eagle room meetings (morning meeting), and did not always review information of each previous fall. Staff K stated more in depth discussions were done during IDT meetings. Staff K also stated nursing aides were not involved, therapy staff were not always there and activity staff did not always actively participate in Eagle room meetings. Staff K also stated that Eagle room discussions were not documented in the resident's record. During an interview on 07/06/18 at 9:45 AM, Staff L, Unit Manager, Registered Nurse (UM, RN,), stated that Unit Managers and nursing staff met and discussed falls during Eagle room meetings and therapy staff did not always attend. During an interview on 07/03/18 at 4:10 PM, Staff K, UM, RN, stated that Resident #3's care plan did not describe additional observational checks required other than to check for incontinence before and after meals, at bedtime and as needed. During an interview on 07/06/18 at 1:10 PM, Staff D, Licensed Practical Nurse, (LPN), stated that staff checked on Resident #3 at least every two hours. The record did not identify staff added increased visual monitoring and supervision to Resident #3's care plan, to increase opportunities for staff to intervene and attempt to prevent falls. During an interview on 07/06/18 at 2:59 PM, Staff K, RN, UM, also stated that frequency of when staff should check the resident was not added to the resident's care plan yet. Staff K also stated that staff did not identify timeframes when staff should check residents on care plans. Staff K stated that it was easy to supervise the resident; he is just impulsive.

Based on observation, interview and record review the facility failed to ensure residents were free from a significant medication error for 1 of 4 Sampled Residents (#1) reviewed for medications. Resident #1 experienced a decline in medical condition and decreased respirations after administration of the wrong dose of an opiate controlled medication ([MEDICATION NAME]). Resident #1 required medication to reverse overdose of [MEDICATION NAME] ([MEDICATION NAME]) that caused increased pain when awakened resulting in harm. Findings included: Resident #1 admitted to the facility 10/11/13 with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE], showed Resident #1 received tube feedings (a tube placed in the stomach to provide nutrition); received hospice services; required extensive or was total assistance from staff to transfer, move in bed, dress, toilet, provide personal hygiene and bathe. The assessment also showed the resident had unclear speech and limited functional range of motion of both upper and lower extremities on both sides of the body. Electronic current Physician order [REDACTED]. Two medications ordered to treat pain included narcotic medications [MEDICATION NAME] and [MEDICATION NAME] given through a tube placed into the stomach. A Physician order [REDACTED].#1 for chronic pain every 8 hours. The physician order [REDACTED]. A copy of the label on the narcotic bottle and the pharmacy label attached to a narcotic log dated 01/28/18 through 02/06/18, showed the concentration of [MEDICATION NAME] the pharmacy sent was different from what the physician prescribed. Both the label and the bottle of medication showed the concentration sent by the pharmacy was much higher and contained 10 mg of [MEDICATION NAME] per 1.0 ml, and to give 0.5 ml (to equal 5 mg) through the feeding tube. Licensed nursing staff documented 30 times from 01/28/18 at 12:15 AM through 02/06/18 at 4:30 PM, they administered 0.5 ml or 5 mg, the correct dose, using the more concentrated form of [MEDICATION NAME] than the physician originally ordered. When space ran out at the end of the narcotic page, Staff C, Licensed Practical Nurse, (LPN), started a new blank narcotic page. Staff C rewrote the strength of [MEDICATION NAME] was 10 mg per 1.0 ml and did not transcribe the directions to give 0.5 ml (equivalent to 5 mg.) Directions documented noted to see EMAR. On 02/07/18 at 01:00 AM, the narcotic log showed Staff C, LPN, documented he administered 10 ml and not 0.5 ml of [MEDICATION NAME]. Ten milliliters of [MEDICATION NAME] (10 mg per 1.0 ml) in this concentrated form equaled 100 mg of [MEDICATION NAME], and not 5 mg of [MEDICATION NAME] as ordered by the physician. A facility investigation dated 02/07/18, showed staff provided care every two hours throughout the night. When day shift staff arrived in the morning at 6:00 AM and completed narcotic count, staff discovered 10 ml of [MEDICATION NAME] was missing from the bottle. Staff immediately assessed Resident #1 who was unresponsive, pale and had respirations of 4 to 6 a minute. The investigation also showed nursing staff placed the resident on oxygen, notified the physician, hospice and family. Progress notes dated 02/07/18 written at 10:20 AM, showed the physician ordered [MEDICATION NAME] given and nursing administered two doses; one dose at 8:12 AM and the second dose at 8:46 AM. [MEDICATION NAME] is a medication given to quickly reverse effects of overdose of opiod medication. The same note showed at 8:12 AM after administration of the first dose of [MEDICATION NAME], Resident #1 started breathing at an increased rate and the resident moaned, muscles tensed up, and convulsed a little. Following the second dose of [MEDICATION NAME], the progress note showed, Resident #1 again started to convulse and appeared to be in pain. The following day, a progress note written 02/08/18 at 1:54 PM, showed Resident #1 did not respond to staff using thumbs up/down like he was previously. A progress note written 02/08/18 at 4:28 PM, showed Resident #1 had diminished bowel tones and the physician held tube feedings for the time being. A progress note written later on 02/12/18 at 2:05 AM, showed Resident #1 at baseline alertness and mentation, could make needs known using hand gestures in response to simple yes/no questions. During observation and interview on 02/21/18 at 4:32 PM, Resident #1 lay in bed toward left side with head of bed elevated. The resident did not respond while Anonymous Collateral Contact G, (ACC G) stroked his hair and spoke to him. ACC G stated the resident was overdosed about two weeks ago and had respiratory distress the first day and it was hard to see him gasping for air. ACC G also stated, I thought we would lose him but his heart and lungs improved. His bowel tones have not worked since and he became uncomfortable from tube feedings. Licensed staff documented they administered an equivilant of 100 mg of [MEDICATION NAME] and not 5 mg as ordered by the physician. As a result of the medication error, Resident #1 experienced a decline in respirations and unresponsive state that required medication to reverse the effects of [MEDICATION NAME]. The resident also experienced decreased bowel tones with decline in ability to tolerate tube feedings.

Refer to F 353 Sufficient Nursing Staffing for additional information for Resident #192 Based on observation, interview and record review the facility failed to provide care in a dignified manner for two of three Sampled Residents (# 192 & 78) reviewed for dignity. Failure to respond promptly to call lights and provide assistance with toileting resulted in psychological harm. Additionally, the failure to provide privacy during direct resident care and in the continued use of broken glasses and dentures for Resident #78 had the potential for decrease resident self-esteem. Record review of the admission Minimum Data Set (MDS, a required assessment tool) dated 08/19/17, showed Resident #192 admitted to the facility from an acute hospital on [DATE] with multiple [DIAGNOSES REDACTED]. The MDS showed that Resident #192 was cognitively intact and had control of both bowel and bladder. Observation on 08/25/17 at 5:10 AM, showed Resident #192 was lying in bed with eyes closed. Observation on 08/25/17 at 9:20 AM, showed Resident #192 anxiously motioning this surveyor from outside of the hallway into the resident room. Resident #192 facial expressions showed a furrowed brow and distress in her voice. During an interview on 08/31/17 at 9:22 AM, Resident #192, stated that she had an accident and had urinated in her bed because, no one assisted her when she rang her call light at 11:00 PM, at night for almost an hour. Finally, Staff E, Registered Nurse, (RN) answered the call light and provided incontinent care. Resident #192, further stated It defiantly made me feel horrible especially, when you have a male nurse that was younger then me had to assist me to get cleaned up. During an interview on 08/29/17 at 1:43 PM, Staff C, Registered Nurse / Unit Manger (RN/UM), stated that the expectation for answering a call light was that there was no specific time frame and if a call light goes on, they would answer it. In addition, Staff C RN/UM, stated that the nursing aide would be notified of the call light if they were unaware and if the facility's call light system alarms, all employees were expected to answer the call lights. Record review of the facility schedule for 08/30/17 showed that the night shift was scheduled to have two nurses, one registered nurse, one licensed nurse and three nursing assistance certified for a census of 92. During an interview on 08/31/17 at 12:29 PM, Staff B, DNS, stated, that on the night shift for 08/30/17 the facility resident population (census) was 92 and there were five nursing staff who worked (one RN, one LPN and three NACs). Staff B, RN/DNS, stated that Staff OO, NAC, notified her late on 08/30/17 at 10:00 PM that she could not come to work because of personal issues. According to Staff B, RN/DNS, stated that she called and asked all nursing staff if they could work the night shift but did not get anybody and tried calling a Nursing Agency but nobody answered. Staff B, RN/DNS said that none of the evening staff wanted to stay to work over. Staff B, RN/DNS, was asked if she came to the facility to oversee the staffing problem. Staff B, RN/DNS, replied that she could have done it but stated that at 11:00 PM majority of the evening shift staff were still in the facility. She further added that instead she came to work early in the morning. During an interview on 8/31/17, at 1:49 PM, Staff B, Director of Nursing Services (DNS), stated that her expectation is that call lights needed to be answered in fifteen minutes. Staff B, DNS stated that the have a policy of all staff are to answer call light and it is referred to a no pass zone. Resident #78 Record review of the admission Minimum Data Set (MDS, a required assessment tool) dated 05/30/17, showed Resident #78 admitted to the facility from an acute hospital on [DATE] with multiple [DIAGNOSES REDACTED]. The MDS also, showed that Resident #78 had no natural teeth (edentulous), was cognitively intact, had corrective lenses and her preferences included that it was very important for her to have books, newspaper, & magazines to read. Record review of the form titled Patient Admission / Readmission Screen dated 05/23/17, showed no corrective lenses and no to proceed to care plan. Record review of care area assessment (CAA) dated 05/30/17 showed that Resident #78 was edentulous without dentures times four years (choose not to have them). Record review of Resident # 78 current care plan showed no documentation for the need of corrective lens and showed Resident #78 had dental or oral cavity health problem related to edentulous (without dentures) times four years. There was no documentation that Resident #78 had upper dentures and broken lower dentures and that Resident #78 preferred to wear dentures to go to bingo and to church. During an observation on 08/25/17 at 11:58 AM, Resident #78 was lying in bed flat on her back with the bed elevated and her dress pulled up to where her disposable brief was visible from the hallway. There were two unidentified aides in the room when one of the aides saw this surveyor looking in from the hallway and shut the door to the room. During an interview and observation on 08/29/17 at 2:31 PM, when asked if she had her upper dentures when she first came to the facility Resident #78 stated yes. When asked when she wore her dentures, Resident #78 stated that she wore them when she went to bingo and or to church and did not need them to eat. Resident #78 stated that she broke her bottom lower dentures and it would be nice if they could be fixed. Resident #78 stated that her glasses broke a couple of weeks ago and that one of the aides fixed her glasses with tape. Resident #78 stated that staff saw her with taped glasses on. When asked when she needed to wear her glasses, Resident #78 stated that she needed to wear them to do crossword puzzles, read, and to color. When asked how it made her feel to wear taped glasses, Resident #78 stated Not too good, I was really sad when they broke. She went on to say that she had a stack of magazines on her table and pointed to the stack on the over bed table that she was not reading because of the broken glasses (Resident #78 lifted up the broken glasses to show this surveyor). When asked if she would like to have her glasses fixed, Resident #78 stated that she did know if that could be done. During an interview on 08/29/17 at 3:00 PM, Resident #78 was asked how she felt the on other day (08/25/17) when she was seen from the hallway, lying flat on her back with her dressed pulled up and her disposable brief exposed. Resident #78 stated that she did not know her dress was pulled up and stated I would not feel good if I knew that. During an interview on 08/30/17 at 2:53 PM, when asked if Resident #78 had dentures, Staff O, Nursing Assistant Registered (NAR), stated that she had top dentures that she wore when she went to bingo or to church however, was not aware that she had broken bottom dentures. Staff O, NAR, stated that she noticed that Resident #78's glasses were broken a couple of days ago and that Staff P, Nursing Assistant Certified (NAC), had put tape around them. When asked if she thought it was ok for Resident #78 to have taped glasses, Staff O, NAR, stated No, she (Resident #78) probably would not feel comfortable with it. During an interview on 08/30/17 at 8:51 AM, Staff L, Social Services (SS), stated that she was unaware of Resident #78's broken bottom dentures and broken taped glasses. Staff L, SS, stated that it was not dignified to wear tapped glasses. During an interview on 08/31/17 at 11:18 AM, Staff C, Registered Nurse (RN)/Unit Manager (UM), stated that she was unaware Resident #78 had dentures and that the bottom dentures were even broken. Staff C, RN/UM, was unable to locate the documentation of dentures in Resident #78's current care plan and stated they needed to get that addressed and fixed, and get Resident #78 to a denturist. During an interview on 08/31/17 at approximately 3:00 PM, Staff B, DNS, stated that she was unaware that Resident #78 had broken lower dentures (she was aware that Resident #77 had upper dentures) and had taped broken glasses. Staff B, DNS stated that it was a dignity concern. During a phone interview on 09/05/17 at 11:13 AM, Resident #78's Durable Power of Attorney (DPOA), stated that she was aware that Resident #78's glasses and dentures were broken; however, was under the impression that they had to wait to get them fixed until after Resident #78 was discharge from the facility. DPOA stated that there was a care conference on 08/30/17 and there was no discussion about Resident #78's broken glasses or dentures. DPOA stated that Resident #78 complained that the arm to the glasses kept falling off due to the tape did not hold it together. DPOA stated that due to the broken glasses Resident #78 was not able to read her magazines which she enjoyed. Reference WAC 388-97-0860 (1)(a)

Based on observations, interview and record review the facility failed to ensure pain management was provided for one of five Sample Resident (#194) reviewed for pain. This failure caused harm to Resident # 194 by delaying treatment and not managing pain for 10 hours. In addition, the facility failed to monitor skin conditions for three or five Sampled Resident (#'s 194, 191 and 196) reviewed for skin condition. This failure place the residents at possible risk for complication and infection. Findings included . Resident #194 refer to F 353 Sufficient nursing staff for additional information Pain management: Record review of facility's policy titled Patient Controlled [MEDICATION NAME] Administration dated January 2009, showed: the purpose was to provide procedure steps for safe medication administration and pump function for patients receiving patient controlled [MEDICATION NAME] (PCA) It also showed general information that included a PCA may be administration via either intravenous or subcutaneous routes/devices. A new administration set is added with each new PCA cassette / container initiated and adverse drug reaction to PCA include: sedation, respiratory depression, pruritus, constipation, and inadequate pain relief. Record review of the admission Minimum Data Set (MDS, a required assessment tool) dated 08/18/17, showed Resident #194 admitted to the facility from an acute hospital on [DATE] with multiple [DIAGNOSES REDACTED]. The MDS showed Resident #194 was cognitively intact and showed a pain level over the last five days was seven out of 10 and limited Resident #194 day to day activity. During an interview on 08/22/17 at 2:03 PM, Resident #194, stated that a female nurse took over an hour to refill the pain pump with pain medication on 8/17/17. Resident #194 also stated that the female nurse had to use her phone to google the information on changing the pain pump cassette instead, of asking another nurse. Resident #194 further stated that he was therefore unable to get his pain under control for 10 hours. Record review of the Medication Administration Record [REDACTED] Record review of the narcotic log dated 8/17/17 at 2:30AM, showed that Staff CC signed out [MEDICATION NAME] (pain medication to treat moderate to severe pain). -[MEDICATION NAME] (muscle relaxant) on 8/17/2017at 9:30 AM (ineffective per the documentation) -Tylenol ([MEDICATION NAME]) on 8/17/17 at 12:09 PM -[MEDICATION NAME] on 8/18/17 at 6:45 PM -[MEDICATION NAME] (anti-anxiety medication) on 8/18/2017 at 9:29 AM Record review of Medication Administration Record [REDACTED]. Record review of the progress noted dated 8/17/2017, and 8/18/17, no documentation of notification to the physician regarding pain management concerns. Record review of the care plan dated 8/11/2017 showed an intervention to notify physician if pain frequency/intensity is worsening or if current [MEDICATION NAME] regimen has been ineffective. During observation on 08/25/2017 at 5:19AM, Resident #194 was calmly lying in bed with eyes closed and with pain pump running. During an interview on 08/31/17 at 10:08 AM Staff B, Director of Nursing (RN/DNS) stated that the nurses that provided care to Resident #194 were provided a copy of the manual and guidelines for the operation of the pain pump that showed the staff how to monitor the pump. In addition the pamphlet showed what signs and symptoms to watch for and what to document when using the pain pump. Staff B, DNS stated that her expectation is, if a resident has pain that is unmanageable that the physician would be notified. During a phone interview on 8/31/17 at 8:31 PM, Staff D, RN, stated that she was provided a pamphlet that explained how to use the pain pump as well as an operational manual. Staff D, RN, stated that at one time when working with the pain pump she had had some difficulty on how to change the battery but stated that another nurse was able to assist her with it. When ask if this caused any delay Staff D, RN, stated well, yes. Monitor skin condition Resident #194 refer to F 353 related to sufficient staffing Record review of the Medication Administration Record [REDACTED]. The documentation showed that the dressing was not changed on 8/17/17and 8/22/17. On 8/27/17 the dressing was signed but, dressing was not changed as physician had ordered. During an interview on 08/31/17 at 9:46 AM, Staff H, RN, stated that he was unsure why he signed for the dressing change on 8/27/17 because, Staff H, RN, stated that he had not been trained to do the dressing change and had asked the incoming shift to complete the dressing change. Record review of the physician order [REDACTED]. During an interview on 08/31/17 at 10:08 AM Staff B, (RN/DNS) stated that her expectation was that skin concerns were to be monitored and care planned until resolved. In addition, Staff B RN/DNS, stated that on 08/17/17and 08/22/17, there was no documention completed. On 8/27/17 the dressing had been signed but was not completed as ordered by the physician. Resident #191 Refer to F279 for additional record review information and related to failure to develop a comprehensive care plan for actual non-pressure skin care needs for Resident #191. Record review of medical record showed Resident #191 was admitted to the facility from an acute hospital on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of facility admission assessment titled Patient Admission / Readmission Screen dated 8/19/17, showed that Resident #191 admitted with identified skin concerns as listed: -Resident has two centimeter length abrasion from fall on the back of her head. -Resident has bruises extending from just above her right elbow to the back of her hand. -Resident has a 4.5 centimeter by 1.5 centimeter on the left arm between the shoulder the antecubital. -Resident has a large bruise 2 centimeters on the back of her left hand. -Resident has a 1.2 centimeter x 0.3 cm scratch on the dorsal aspect of her right forearm. -Resident has several small bruises on her left lower leg. Record review of the Medication Administration Records dated August 2017, showed no documentation found for the monitoring of the [MEDICAL CONDITION] or bruising to ensure healing is occurring without any sign and symptoms of infection. During an interview on 08/31/2017 at 10:08 AM Staff B, (DNS) stated that her expectation is that skin concerns are monitored and care planned. Refer to F279 (comprehensive care plan) for additional information for #196 RESIDENT #196 Observation on 08/25/17 at 7:48 AM, Resident #196 sat in a wheel chair in her room with a bedside table in front of her eating breakfast. During an interview on 08/29/17 at 2:12 PM, Resident #196, stated that when she came out of the bathroom she had hit her left hand in the doorway and received a skin tear. (A bandage was noted on backside of Resident #196's hand by the base of the index finger and the thumb). During an observation and interview on 08/30/17 at 10:42 AM, Resident #196 was in her room reading a book and stated that she went to occupational therapy and they worked on taking showers and got her all cleaned up with teeth washed and hair combed. Record review of Resident #196 Treatment Administration Record (TAR), dated August 2017, showed a treatment order for the skin tear on the right arm. No other skin treatments were initiated. The TAR also did not include documentation that the following was monitored: - Multiple bruises to both arms and legs, no measurements or description of the color and sizes of the bruises to indicate healing or worsening. - Abrasion (scrape) on Left knee no monitoring of healing or monitored for signs and symptoms of infections - Chest tube site no treatment and or monitoring of healing or if monitored for signs and symptoms of infection. - Skin tear on the right upper arm no monitoring of healing or if monitored for signs and symptoms of infection. Record review of Resident #196 progress notes from 08/18/17 through 08/30/17 showed skin issues documented four times: 1. On 08/18/17 at 10:43 PM, Skilled nursing admit note showed Resident has multiple scattered bruises on bilateral (both) lower and upper extremities (arms and legs). 2. On 08/21/17 at 2:46 PM, Skin progress note showed Resident has a skin tear on upper right arm 3 centimeters (cm) by 1 cm, skin tear underside of right arm 7 cm by 4 cm. Wounds were cleansed with normal saline applied [MEDICATION NAME] (antibiotic medication) and covered with prempore dressing. 3. On 08/23/17 at 5:22 PM, Care plan progress note showed Skin: Daily wound treatment. 4. On 08/29/17 at 5:41 PM, General progress note showed Patient sustained a skin tear on the L (left) hand while opening the door in the bathroom. Her hands got caught on the edge of the door and caused a skin tear. It measures 2.0 cm horizontal and 1.0 cm across. During an interview on 08/31/17 at 9:30 AM, when asked how skin issues are monitored for Resident #196, Staff C, Registered Nurse (RN)/Unit Manager (UM), stated that there was daily monitoring and that they do not document unless the skin issues worsened. Staff C, RN/UM, stated that they do not measure bruises or describe the color of the bruises. When asked how one knows if the bruises and skin tears are healing or had worsened, Staff C, RN/UM, stated that it was important to look at the color for stages of healing and that was not done for Resident #196. When asked where the documentation for monitoring for signs and symptoms of infection related to Resident #196 wounds, Staff C, RN/UM, stated in the Medication Administration Record [REDACTED]. Reference WAC 388-97-1060 (1)

Based on observation, interview, record review, and policy review, the facility failed to ensure safety of residents who had lengthy waits for transportation to return from [MEDICAL TREATMENT] appontments for two of four Sampled Residents (#s 1 & 2) and in addition, caused Resident #3 to not want to use transportation services to go to [MEDICAL TREATMENT] appointments due to the failure of the facility to assure transportation was supplied within a half an hour of pick-up/drop off times. The facility failed to follow up with the [MEDICAL TREATMENT] center and ensure residents were safe when late from the appointments. The failed practice had the potential to negatively affect all current residents psycho-social needs attending appointments who required transportation, and caused psycho-social harm for Residents #1 and #2. Findings included: Record review of the facility's process titled, Appointment and Transportation, dated 02/28/12, showed that there was a 30 minute window in which the Shuttle may arrive for pick up (for an example, if the pick up time was 1:00 PM, it may be 1:30 PM by the time the Shuttle arrives, and the same was true with the return trip. During an interview on 03/16/17 at 3:25 PM, Staff A, Licensed Nurse (LN), stated the facility had a packet at the nurses station which included the expected time of arrival (on the outside of the packet in bold black marker) when residents were transported out of the facility for an appointment. The information was passed from nurse to nurse in shift report. When asked what the nurse would do if a resident did not arrive back to the facility on time, Staff A, LN, stated she would call the appointment and the transportation company to locate the resident. Staff A added, neglect meant not giving a resident a need or a needed service. RESIDENT #1 Resident #1 re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to a 5 day Minimum Data Set (MDS, an assessment tool) dated 03/29/17, the resident could not walk in the corridors of the facility and needed weight bearing assistance from one person and used a wheel chair for an assistive device. The MDS identified Resident #1 as cognitively intact. Per the Resident's care plan written 03/23/17, the resident had renal insufficiencies and [MEDICAL TREATMENT] three times a week. Interventions included to encourage to rest after [MEDICAL TREATMENT] treatments. During an interview and concurrent observation on 03/29/17 at 3:40 PM, when entering Resident #1's room, she was crying and complaining to Staff B, Ancilary and Transportation Staff, about transportation problems. The resident stated the most recent delayed pick up occurred last night on 03/28/17. The facility called her daughter who was 37 miles from the facility to pick up the resident at the [MEDICAL TREATMENT] center and only gave the daughter a 30 minute warning her mother needed a ride. It took the daughter an hour and a half to pick up her mother. Resident #1 stated the only complaint she had with the facility was the transportation back to the facility after her [MEDICAL TREATMENT] appointments. The resident stated she was left at her [MEDICAL TREATMENT] three times, and the first time it happened, she was left at the [MEDICAL TREATMENT] clinic for three hours. Resident #1 added she was very upset, as tears ran down her face while she spoke about it. The resident also stated she had anxiety about going back to [MEDICAL TREATMENT] with such unreliable transportation. Resident #1 stated she was depressed all day and woke up with heart burn in the middle of the night due to the anxiety she was feeling about being left at the [MEDICAL TREATMENT] appointments. The resident added the second time it happened, she was left for over an hour, and the facility, which was approximately a block away, sent a staff member on foot to push her back to the facility in a wheel chair. The resident stated she felt exhausted, as many residents were when going home from a [MEDICAL TREATMENT] treatment. During an interview on 03/29/17 at 5:40 PM, Staff C, the Administrator, stated one and a half hours would not be that unusual to wait to be picked up from an appointment. Staff C would expect the nurses to call the appointment to find out where the resident was. During the course of the facilities investigation into what happened with the transportation, the Administrator stated she didn't think to ask the floor nurses why some communication was not done to follow up on Resident #1's whereabouts; I was focused on the transportation. During an interview on 03/29/17 at 5:45 PM, Staff D, the resident's LN, stated that on 03/08/17, when the resident came back from the [MEDICAL TREATMENT] appointment between 6:30 PM and 7:00 PM, she did not seem upset. She missed the shuttle. It was not a big deal. Staff D stated that the facility did not receive any communication from the [MEDICAL TREATMENT] unit, nor did the nurse think to call and ask where the resident was. Staff D gave the following medications late that evening: [MEDICATION NAME] 5mg (millagrams) (a blood thinner) due at 5:00 PM. [MEDICATION NAME] (a vitamin for [MEDICAL CONDITION] residents), due at 4:00 PM. Carvedilol 3.125 mg (a blood pressure medication) due at 5:00 PM [MEDICATION NAME] Sodium 100mg (a stool softner) due at 4:00 PM During a telephone interview on 04/03/17 at 2:49 PM, with a Collateral Contact (CC), a representative from the transportation company, stated she had records the resident returned to the facility at 7:20 PM, and was to be picked up at 5:15 PM two hours after promised pick up time, but there was confusion about what door to pick up with resident at. RESIDENT #2 Resident #2 re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to a 30 day MDS dated [DATE], the resident did mobilize in the hall off the unit with extensive weight bearing assist from one person, and had limited range of motion to one lower extremity in his body. The resident used a wheelchair for an assistive device and was cognitively intact. Nursing progress notes written 03/27/17 at 2:51 PM, showed .resident very upset after [MEDICAL TREATMENT], stated he was very frustrated with the shuttle pick up and needed this issue fixed. In an anonymous complaint to the department dated 03/28/17, Resident #2 was left at [MEDICAL TREATMENT] and did not have a lunch, and the resident was afraid to go to [MEDICAL TREATMENT] again. During a telephone interview on 04/03/17 at 12:00 noon, Staff E, Licensed Nurse (LN) stated, the resident had a two hour wait at [MEDICAL TREATMENT] on 03/27/17 for the shuttle, and pick up time was noon. Staff E, LN stated that the resident was visibly upset crying and very frustrated with the transportation issue and it was management's responsibility to assure transportation was timely. Staff E, LN reported the problem to management, but not until after the resident returned to the facility. Staff E also stated staff did not inquire before returning to the facility as to the resident's whereabouts. Lunch and medication ([MEDICATION NAME] Hcl 100mg for hypertension) were given to the resident after his return to the facility late, according to Staff E. During a telephone interview on 04/03/17 at 2:49 PM, CC, stated that Resident #2's pick up time was at noon, and the driver arrived at 11:59 AM and waited by the front door, and no one was there. The policy was to wait for five minutes after a designated pick up time, so the driver left without the passenger at 12:06 PM. The shuttle policy also directed the driver not to leave the van out of line of vision, so the shuttle driver could not go into a building to retrieve a resident's at their appointment. During an interview on 04/03/17 at 1:30 PM, Staff E, Management, went to talk with Resident #2, but he didn't want to talk with me, as he was too upset. Staff E added the nurse on the floor was responsible to know where the residents were, and the facility had responsibility for the resident's safety and medications. Staff E stated that he would call the appointment to check on the resident, since it was neglectful to leave someone late at an appointment. During an interview on 04/03/17 at 1:54 PM, Resident #2's family member, CC#2, stated the resident was very upset about the shuttle, and it was always late. CC#2 added, 1) the resident did not have food that day and was hungry and thirsty. 2) Staff from the facility had to push him back to the facility. 3) There were no foot rests on the wheel chair, so one staff held his feet up while the other pushed the wheelchair. During an interview on 03/29/17 at 5:45 PM, Staff C, Administrator, stated that the residents were waiting by the wrong doors, and a one and a half hour wait to get back to the facility would not be that unusual. After that amount of time went by, she would expect the nurse to call the appointment to find the resident. Staff C added, she did not interview the nurse on duty to explore why the nurse did not call the [MEDICAL TREATMENT] center to locate the resident, I was focused on the problems with the transportation. RESIDENT #3 Resident #3 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Per the resident's care plan, dated 03/29/17 the resident had renal insufficiencies related to acute [MEDICAL CONDITION] and attended [MEDICAL TREATMENT] two times a week. The care plan included an intervention for the resident to rest after [MEDICAL TREATMENT] treatments. The Admission MDS, dated [DATE], identified the resident as cognitively intact, and used a walker with extensive weight bearing assistance from one person to walk in the facility corridors. During a concurrent interview on 04/03/17 at 1:00 PM, with Resident #3 and CC#3, family member, who were at Resident #3's bedside, both stated that they had heard of problems with transportation and CC#3 took the resident to [MEDICAL TREATMENT] appointments. She stated,I just do the transportation. CC#3 stated she wished the facility did have reliable transportation because it was not convenient for her to do the transportation herself. In addition, CC#3 stated there was always a problem in the facility with communication. The paperwork, medications, and meals were not ready when she got to the facility to transport the resident, and Resident #3 had been late for appointments.

Based on interview and record review, the facility failed to implement a care plan intervention related to unsafe footwear to prevent Resident (R#1) from falling and to identify root cause of falls for Resident (R#2). These failures resulted in R#1's fall with serious injury and placed R#2 at a potential risk of recurring falls with injury. Review of R#1's care plan (CP) revealed the resident was admitted to the facillity on 8/1/16 with falls risks including impaired balance, poor coordination, and history of falls with fracture. Falls interventions directed staff to ensure R#1 wore proper foot wear. R#1s CP was updated 8/23/16 to include Res to wear fitted shoes. Not slip on type shoe . Review of the 11/25/16 facility Incident report revealed R#1 fell on [DATE] while wearing sandles (open backed shoes). According to the incident report the resident sustained [REDACTED]. Nursing notes dated 11/25/16 indicated the resident was transfered to the emergency room . According to 11/25/16 incident report R#1 was 1:1 (one staff per one resident) with an LN observing the resident ambulating around the facility wearing improper foot wear. The fall was witnessed. The facilty identified R#1's fall was caused when she wore improper foot wear. In interview on 12/29/16 Staff A said the fall interventions were revised on 8/23/16 to include R#1's need for proper foot wear to prevent the resident from falling. According to Staff A R#1 prefered sandals, however, there was no documentation to show foot wear was addressed with the resident. Resident #2 Review of the 11/17/16 CP revealed, R#2 was admitted to facility on 11/17/16 with [DIAGNOSES REDACTED]. According to R#2's CP, the resident rquired hoyer mechanical lifting equipment with two people assissting with transfers. He utilized a motorized wheel chair for ambulation throughout the facility. R#2 was described as moderately intact cognitively. Review of facility Incident Reports found R#2 fell on [DATE] at 7:00 p.m. and on 11/22/16 at 2 :00 a.m. The CP was updated after the first fall on 11/21/16 to include Keep door open and remind Resident to use call light. Review of the resident's record found there was no assessment related to the resident's ability to use a call light. Review of R#2's 11/22/16 fall incident revealed the resident fell seven hours after the first fall. The interventions to prevent further falling was that staff were to remind the resident to use a call light. There was no documentation to show root cause for the falls, and there was no instruction to staff to anticipate the resident's needs. In interview on 12/29/16 at approximately 6pm, Staff A said the resident was not assessed for the use of his call light. In interview on 1/18/17 at appproximatley 1:30 p.m., Staff A said she reallized the facility did not identify root cause for the falls.

Based on observation, interview, and record review, the facility failed to ensure a wheel chair was safe to use for 1 of 1 sampled residents (R#1). This failure resulted in actual harm to the resident, when the Wheel Chair (W/C) was in dis-repair causing the resident to fall out of the WC, sustaining a fractured arm. Findings include: Resident #1 was originally admitted to the facility on [DATE], with current [DIAGNOSES REDACTED]. According to the annual Minimum Data Set (MDS, a comprehensive nursing assessment) dated 6/15/16, R#1 required extensive weight bearing assist for transfers and extensive assistance for mobility in a wheel chair. Review of the facility investigation dated 9/16/16, revealed R#1 was in the dining room the day before awaiting lunch when the front right wheel failed and caused the resident's W/C to tip over. R #1 fell on to the floor landing on his/her right shoulder. R #1 complained of pain, and an X-ray revealed a broken arm bone, written as an acute nondisplaced fracture of the humeral (upper arm) neck (area where the bone narrows before the head joint). During an interview on 9/23/16 at 2:10 p.m., Staff A stated the W/C was the resident's own W/C and was taken out of commission and was being stored in the Maintenance Director's space. During an observation at 2:35 p.m., R#1 was noted to have a sling to the right shoulder, as the resident was sleeping. R #1 used a spare chair, wheels were intact and did not deviate when moved. During a record review, a pain assessment was completed on 9/16/16, a day after the fall, which revealed a stabbing type of pain to the right shoulder area. During further record review, a progress note written on 9/23/16 at 11:25 p.m. revealed when the resident was asked about pain, .she said yes and reached up to touch right shoulder. In an interview at 2:40 p.m., Staff B stated, maintenance should be responsible to do work on W/C ' s, although he/she had never seen anyone working on or inspecting W/C ' s. During an interview at 2:57 p.m., Staff C stated previous to 9/15/16, there was not a maintenance program to inspect W/C's, and it was the facility's responsibility to assure equipment was being maintained no matter if it was the resident's equipment or the facility owned equipment. During an interview at 3:10 p.m., Staff D stated in most all facilities which he/she had worked in, the maintenance director was always responsible to maintain residents' equipment. Staff D added It is the responsibility of the facility to ensure resident safety. The facility did not reduce the risk of hazards for the resident, and did not ensure the W/C was maintained. An avoidable incident occurred related to a hazardous environment, and the resident suffered a fractured arm and subsequent pain.

Findings include: Based on interview and record review, the facility failed to ensure 1 of 4 sampled residents (R #1) being transported to appointments had food, water, medications, and a means to communicate with the facility. Resident #1 was out of the facility from 6:30 a.m. to 8:18 p.m., almost 14 hours with no food, no water, no money, no medications, and no phone to communicate with the facility. This failure resulted in actual psychological harm to the resident, related to hunger, thirst, no medications, and limited opportunities to toilet. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a record review of the resident's Minimum Data Set (MDS), a nursing assessment tool, dated 11/16/2015, Resident #1 complained of feeling tired and without energy 2-6 days weekly. In addition, the resident had constant severe pain which limited day to day activities. In addition, Resident #1 had 1 fall (11/2/15) since admission. Upon further record review, Resident #1's care plan found the resident was at risk for changes in mood as evidenced by sleeplessness, restlessness, agitation and acute [MEDICAL CONDITION]. The resident had care plan problems (focus) addressed such as paranoia/suspiciousness, activities of daily living (ADL) impairment, urinary incontinence, bowel incontinence, fall risk, anxiety, need to monitor endocrine system (related to diabetes), nutritional status, pain, and was at risk for pressure ulcers. Further record review revealed an appointment to a pain clinic was made at 10:50 a.m. on 11/24/2015. Review of nursing progress notes revealed, no notes reflected any psycho-social monitoring by the professional staff on 11/24/15 or 11/25/15. On 11/24/15 at 8:18 p.m., a note written by Staff F, verified by an interview with Staff F at 12:35 p.m., that this was the time of Resident #1's return. During an interview on 12/15/15 at 9:45 a.m., Staff A said all residents had escorts to appointments outside the faciilty, and the facility would re-schedule the appointment if an escort could not be found. Staff A added, an order would be made for a resident to leave with medications, and Staff A was not sure how to order the food from the kitchen. During an interview at 10 a.m., Staff B stated Medicaid resident's used public transportation. The staff would ask the resident if he/she wanted an escort, the family would be notified if the resident was going long distance, and the facility sent the resident out with medications and a lunch meal. During an interview at 10:10 a.m., Staff C said, appointments were not usually over in a few hours, and if the resident was in chronic pain, medications should be sent out. Staff C also added he/she was not sure what the protocol and procedures were on sending a resident out with food or water. In an interview with Resident #1 at 12:39 p.m., the resident stated she requested an escort, because she was unsure of the Seattle area, but the facility decided an escort was not required. Resident #1 said he/she did not get a lunch, and was scared to go. The resident stated he/she had to transfer buses to go from one county to another, and was in a wheel chair. The bus stopped at approximately 10:30 a.m. at the wrong address, which was approximately 1 block away from the appointment address. Resident #1 stated he/she had to depend on a Good Samaritan to assure his/her wheel chair would not get out of control down a hill while getting to the correct address in downtown Seattle. Resident #1 stated, I didn't get my medications because my pick up time was 11:00 a.m. It was a terrible day with anxiety, pain and crying, even into the next day. Upon further record review, and concurrent interview with Staff D at 2:40 p.m., a document called the Outside Appointment Scheduling for Resident #1 on 11/24/15, had time of appointment at 10:50 a.m., and time of pick up at 11:00 a.m. The question Is an escort necessary? was circled yes and no. The appointment was at a pain clinic downtown Seattle. Staff D said if a resident requested an escort, one was provided or the appointment was cancelled. In the case of Resident #1, the appointment ran longer and the resident was not there for pick up, so another bus ride was arranged, and Staff D had no idea it took 14 hours. Staff D added, That was a long time to be out. During an interview at 3 p.m., Staff E said Resident #1's shuttle took forever, and was a big mess. Staff E increased monitoring of Resident #1 the next day and stated the resident was in increased pain, had increased anxiety and was sick to his/her stomach. Review of the medication record, found Resident #1 had taken [MEDICATION NAME] 0.5mg (an anti-anxiety medication) on the 21st, 22nd, 23rd and 24th of November, consistently in the a.m. hours one time a day. On 11/25/15, the day after Resident #1's appointment, the dose was requested three times. In an interview at 3:50 p.m., Staff G stated the facility had a van, but there was no driver. He added, the facility was trying to fill the position with someone who could figure out logistics. Meanwhile, the facility used public transportation. During an interview on 12/17/15 at 6:40 a.m., Resident #1 stated she did call the facility from the pain clinic and said she was done with her appointment, and the pick-up time was arranged for 11:30 a.m. The resident had to be pushed by another Good Samaritan up the hill to be picked up in the same place he/she was dropped off, and waited until 2:30 pm when the bus finally arrived. From this point, it took 6 hours on the bus to get back to the facility. Resident #1 added, the only fluids consumed were a cup of coffee at the pain clinic, and the resident verified there was no cell phone or money taken with him/her. The facility did not offer any means of communication, money, food or water before Resident #1 left for the appointment. In an interview on 12/29/15 at 3:10 p.m., Staff H stated, the resident left with a medical information packet, and Staff H didn't know food or drink was to be offered. Staff H added, when resident's go to appointments, nurses were to get the packets ready, and were not told to gather anything else, and (Resident #1) didn't ask for anything. During an interview at 3:15 p.m., Staff I stated, it was the nurses' responsibility to assure the residents were sent with food and water. Staff I added, I don't like sending people out by themselves .(Resident #1) was stuck out there. In an interview at 4 p.m., Staff G said, this was the first attempt by the facility using public transportation from Pierce County to King County, and now that there has been this problem, the facility no longer used them. Staff G added, night shift did not usually get a resident ready for an appointment, and did not know what to do. And, from now on, the facility would not send residents without an escort, although Staff G stood by the decision to send Resident #1 independently. The facility failed to schedule Resident #1's pick-up prior to the appointment time. The facility did not send a resident to an appointment on public transport with an escort. The facility failed to coordinate services to assure Resident #1 was safe, by having food , water, medications and a means to communicate during a 14 hour bus ride to an appointment in a different county, which resulted in increased anxiety, psycho-social harm for Resident #1.

Based on observation, interview, and record review, the facility failed to implement interventions to reduce falls risks for a resident with known falls risks behaviors, in a time consistent with the resident's changed needs, for 1 of 5 residents sampled for falls (Resident #5). This placed the resident at risk for recurring falls and significant injury. Findings include: All observations and interviews were conducted on 12/1/15 unless otherwise specified. Observation at 9:40 a.m., revealed Resident #5 lying in bed, wearing a black boot on the left leg, and the left leg dangling off the left side of the bed. In interview, Resident #5 said s/he fell and broke his/her ankle recently. Review of Resident #5's care plan found the resident was first admitted to the facility in September 2013. The care plan was updated for falls risks on 10/14/15, and the falls risks included: altered safety awareness, weakness, medications, shortness of breath (SOB), congestive heart failure (CHF), slight vision and hearing impairments, attached oxygen tubing causing tripping hazard, unsteady gait, noncompliance with assistive devices, impaired balance, and history of falls. The goals included minimizing the risk of falls. According to the September 2013 falls interventions, staff were to encourage the resident to transfer and change positions slowly, staff were to provide assistance with transfer and walking when the resident needed assistance, staff were to reinforce the need to call for assistance, and reinforce wheelchair safety as needed such as locking brakes. The falls interventions were updated on 9/3/15 to include encouraging and educating the resident to call for assistance with walking if the resident felt weak. Review of Resident #5's fall incident report dated 11/15/15, revealed the resident fell and bumped his/her head, on 11/15/15 at approximately 6:00 p.m. while walking to the bathroom with a front wheel walker. According to the incident report, Resident #5 had poor safety awareness, had difficulty maintaining safe balance, and the call light was not activated. The facility concluded the fall was related to Resident #5's poor safety awareness and loss of balance. There were no updates to the care plan to modify current falls interventions, such as increasing supervision, consistent with the resident's needs. Review of the 11/15/15 fall incident report found the resident had a second fall on 11/15/15 at approximately 10:00 p.m.while self transferring, resulting in a fracture of his/her left ankle. According to the incident report, the fall was related to poor safety awareness and not fully locking the wheelchair brakes. The incident report indicated the resident did not activate the call light to call for assistance. Review fo the care plan found it was not updated after the second fall on 11/15/15 to modify interventions for adequate supervision, consistent with the resident's needs. Incident report dated 11/18/15 at 1:30 a.m., revealed Resident #5 sustained a fall while attempting to transfer herself out of bed to the wheelchair to go to the bathroom. The facility determined the fall was reasonably related to the resident's poor safety awareness and loss of balance. The care plan was updated on 11/20/15 to instruct staff to provide frequent checks to help reduce the risk of falls. Staff B said care staff were expected to keep an eye on the resident and identified Resident #5 as a high fall risk. When asked how to ensure staff monitored frequently, Staff B reported there was no documentation, but staff just knew. On 12/10/15 at approximately 2:00 p.m., the Administrator said Resident #5 was independent with decisions. According to the Administrator, after each fall, staff educated the resident and reminded her to call for help. Although the facility indicated poor safety awareness and loss of balance as falls risks, the care plan was not updated and did not address interventions for poor safety awareness and loss of balance. On 12/21/15 at approximately 3:00 p.m., the Administrator said change of shift occurred at approximately 10:00 p.m., and indicated it was a potential time of inadequate supervision. The facility failed to monitor and modify falls interventions for adequate supervision to mitigate falls risks, in a time consistent with a resident's needs, and the resident had a subsequent fall resulting in injury.

Based on observation, interview and record review, the facility failed to assess a resident to establish a root cause of an escalating behavior, and failed to provide individualized, behavioral interventions, resulting in a resident's physical violence toward another resident, and placed the resident at a potential risk of psychological harm, for 1 of 3 residents (Resident #1) sampled for behavior. This failure placed other residents on the dementia unit at a potential risk of physical and psychological harm, and elicited an increase in aggressive behavior and increased agitation for the resident. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's Minimum Data Set (MDS), a nursing tool dated 8/31/15, Resident #1 had severe cognitive deficits and required supervision and oversight with most activities of daily living (ADL's). The MDS indicated the resident had moderately severe depression, and it was very important for Resident #1 to keep personal belongings safe and for the resident to assure this was done by his/her self. During a record review of the facility investigation regarding an incident between Resident #1 and Resident #2 which occurred on 10/17/15, Resident #1 was punching Resident #2 in the arm repeatedly, and was separated by Staff A. Resident #2 had walked into Resident #1's room from the hallway. Staff had called 911 to take the resident out of the facility, but declined, as it was not a medical emergency. According to interview and record review, Resident #1 had increasing agitation toward others on the dementia unit, and especially toward his/her roommate. Resident #1 believed she/he and the roommate were in Resident #1's hotel or home and the roommate was not paying rent. Resident #1's agitation rose to barricading the room and threatening to kill the roommate on several occasions. Staff A stated a previous roommate, Resident #3 was moved from the room when Resident #1 threatened to choke the roommate on 10/6/15. According to Staff A, the root cause of Resident #1's behavior was related to the resident's delusions that the roommates were not paying rent to Resident #1, and continued to live with Resident #1 in her home or hotel room. However, the administration did not act on Staff A's findings. On 10/13/15, in nursing progress notes, Resident #1 was quoted as saying I don't know why the hell nobody told me about someone moving into my room. In addition, the note read staff was unable to redirect Resident #1 as she was going up to the side of the roommates (Resident #4's) bed and kept asking her why she was there. Staff B was notified of the situation. Three days later, a nursing progress note written on 10/16/15, revealed Resident #1 complained she had a roommate, and the nurse intervened prior to events becoming physical between the two roommates. Resident #1 was cursing, throwing and slamming items, and the roommate was moved out of the room for the night so he/she would remain safe. On 10/18/15 at 3:29 p.m., in nursing progress notes, Resident #1 was blocking the resident's room with a garbage can and was agitated and pacing in the room explaining that he/she was focused on the roommate and paying rent. At 9:28 p.m., nursing notes read Resident #1 was barricading the door with a garbage can, clip board, and blanket and was complaining about the roommate. In addition, the nursing progress notes dated 10/19/15 through the 10/25/15, revealed Resident #1 continued to have increased agitation at night, as evidenced by pacing, complaining of roommate and the roommates belongings, barricading and yelling at the roommate. Resident #1 threatened to kill the roommate in a progress note written by Staff C on 10/26/15. During an interview on 10/28/15 at 11:30 a.m., Staff A stated behaviors with Resident #1 had been going on for about a month, and had escalated to physical violence, and the behaviors were related to having a roommate. Staff A indicated she was fearful for the safety Resident #1's roommates, and moved roommates out of the room on several occasions. During an observation on 11/2/15 at 11:25 a.m., Resident #1 was standing in the doorway of his/her room, and appeared anxious. Resident #1 stated, Who may be in there? and cocked her head toward the inside of the room. On 10/28/15 at 4 p.m., in an interview with Staff C, he/she stated I was not in the discussion, but (Resident #1) should be in a room by herself. Staff C added, the resident should have a behavioral management plan, and it should be accessible to all nurses. In a communication form on 10/6/15 to Staff C, it was noted from Staff A that he/she was concerned about the esculating behaviors of Resident #1, and actually removed the roommate for safety reasons and wanted to adjust medications. It was at this time, Staff C wrote an order to complete a resident to resident threat investigation with a plan of action, a behavioral management (BMP) plan per Staff C during an interview on 10/28/15 at 4 p.m. Upon record review there was not a BMP present, there was no non drug behavioral interventions. In an interview at 4:10 p.m., Staff D revealed there was not a BMP in place for Resident #1. Staff interviews found they did not know what a BMP was. In the care plan, Resident #1's violent behaviors were acknowledged on 10/28/15 and the interventions were: administer medications, allow patient time to respond to directions, apporach slowly and slightly to the side, and to reduce [MEDICAL CONDITION] (mind altering) drugs. There were no individuallized interventions to help with the resident's behaviors related to her specific delusions. When asked during an interview at 4:30 p.m., Staff E stated, there were no issues with Resident #1, and the BMP was up to the nurses to redirect the resident when she was sun downing (increased night time behaviors). Staff E also stated she would not agree that Resident #1 did not want a roommate, and he/she did not recall any other roommate being discharged due to threats of violence. Staff E also stated she thought the care plan was adequate for the resident's needs. In an interview at 5:20 p.m., Staff B stated, the facility monitors behaviors, on a tool for quality assurance, but did not recall the threatening behaviors of Resident #1. In addition, when Resident #1 threatened to kill her roommate, Staff B minimized it and said Resident #1 did not mean what she said. The facility did not provide Resident #1 with a behavioral management plan, which placed all residents at risk for threatened and actual physical violence, and escalated behaviors of Resident #1.