Every finding on record at Highland Health and Rehabilitation of Cascadia

Based on interview and record review, the facility failed to complete a thorough investigation for 1 of 2 residents (Resident 26) reviewed for abuse investigations. This failure placed residents at risk of potential abuse, and a decreased quality of life.Findings included . Resident 26 admitted to the facility on [DATE] with diagnoses to include left pelvic fracture, weakness, and syncope (temporary loss of consciousness caused by a fall in blood pressure). Review of Resident 26's admission Minimum Data Set assessment (resident assessment tool), dated 06/24/2026, documented they had a BIMS of 15, which indicated they were cognitively intact. Review of the facility incident report log dated July 2026, Resident 26 made an allegation of staff to resident abuse on 07/19/2026. Review of the investigation summary, undated and by unknown author documented Resident 26 had reported concerns to the hospital staff regarding their care, rude staff, and inadequate customer service during their care at the facility. The investigation summary documented staff were interviewed related to Resident 26's abuse allegation, but the investigation contained no facility staff interviews. In an interview on 08/12/2026 at 2:57 PM, Staff B, Director of Nursing Services (DNS), stated their investigation process was to include interviews with facility staff. Staff B stated Resident 26 could not elaborate on the staff that were potentially involved and therefore had not completed staff interviews. In a joint interview on 08/12/2026 at 1:49 PM, Staff B, DNS, stated Resident 26 denied their statement/abuse allegation upon return to the facility, and Staff A, Administrator, stated Resident 26 was documented as being confused at the hospital and it was decided not to obtain facility staff interviews. Reference WAC: 388-97-0640(6)(a-b)

Based on interview and record review, the facility failed to ensure the nursing staff used professional standards of care and aseptic (to prevent healthcare associated infections, surgical site infections and laboratory contamination) technique when changing Resident 20's PICC line [a peripherally inserted central catheter (PICC) is a long, soft, flexible tube inserted into a vein in the upper arm and advanced to a large vein above the heart] dressing. Resident 20 experienced harm when they required an emergency transfer to the emergency department (ED) to have their PICC line replaced, and additional diagnostic procedures (ultrasound and Xray) performed when their PICC line was cut with unclean and unsterile scissors. Additionally, this failed practice placed the resident at serious risk for central line associated blood stream infection. Findings included .Review of the 2025 Facility Assessment showed the facility had specific types of care and practices that required nursing care for the facility's specific population which included intravenous (IV) peripheral or central lines. Monitoring of competencies would be accomplished through Senior Leader rounding, mentoring, return demonstration during monthly skills check and staff competencies would be completed annually. Review of the facility's policy titled, Dressing Change for Vascular Access Devices, dated [DATE], showed Central Venous Access Device Dressing Change Procedure, in the following order * using first pair of sterile gloves, *remove old dressing, use care to prevent skin tear, shearing, or bruising, *press skin away from dressing vs pulling up on dressing, *stretch TSM (transparent semi-permeable membrane) dressing to side, *work from the edge of the dressing toward the insertion site while stabilizing the catheter to minimize catheter movement, *use alcohol to help loosen adhesive. Resident 20 was admitted to the facility on [DATE] with diagnoses to include osteomyelitis (serious infection of the bone marrow and bone tissue) of vertebra, thoracic and lumbar region, type 2 diabetes, and resistance to vancomycin. Review of Resident 20's care plan showed the following focused problems: The resident had enhanced barrier precautions to reduce the risk of multi drug resistant organism transmission related to having a PICC line to their left upper arm dated [DATE]. The interventions included to use enhanced barrier precautions to prevent infection. The resident had a PICC line on their left upper arm dated [DATE]. Interventions included site change/treatment, and dressing changes as indicated to maintain site patency and infection free. Review of Resident 20's progress note dated [DATE] documented the resident's PICC line was accidentally cut while staff were changing the resident's dressing. A pressure dressing was applied and the resident left via stretcher to the ED. Review of Resident 20's progress notes with an effective date of [DATE] which was created on [DATE], documented the facility was notified the resident was discharged home to continue intravenous (IV) antibiotic therapy, with an in-home infusion agency who would be in contact with infection disease. Review of a grievance complaint dated [DATE], showed Resident 20's Collateral Contact 1 (CC1- resident 20s family member) wrote a letter to the facility's home office regarding Resident 20's PICC line being cut while at the facility. The facility's resolution and/or additional corrective actions documented an in-service would be provided to nursing staff related to PICC lines. Review of a letter dated [DATE], attached to the grievance complaint, showed CC 1 wanted to bring attention to the events and issues that occurred during Resident 20's stay at the facility. The serious issue on [DATE] when Resident 20's PICC line was cut was most troubling. They were concerned about the residents' care and the training of the facility's staff during the residents' stay, which CC1 stated was insufficient and should be addressed to prevent further repeated actions for other residents. **Nurse Competencies***Review of the facility's licensed nurses' competencies showed the last dates the following LN competencies were completed: Staff O, Licensed Practical Nurse (LPN) [DATE], Licensed Nurse Clinical Competencies including Central/PICC/CVAD Care Staff N, RN [DATE], Licensed Nurse Clinical Competencies including Central/PICC/CVAD Care Staff F, Registered Nurse (RN) [DATE], General Competencies including Central line/midline dressing changeAll past due as of the date reviewed on [DATE]. Review of an undated form titled, Staff Education Needed, included, All Nurses, PICC line dressing/protocols for dressing changes. In an interview on [DATE] at 1:16 PM, Staff N, Registered Nurse (RN), stated they were unaware of any facility in-services provided that instructed them not to use scissors during a PICC line dressing change but, I know we are not supposed to use sharps. In an interview on [DATE] at 1:43 PM, Staff F, RN, stated they were comfortable working with IV lines. Staff F stated they were taking off Resident 20's old PICC line dressing and tried to cut the tape and snipped the line. Staff F stated they called 911 directly afterwards, told their nurse manager when it happened and applied pressure as we did not have a clamp until emergency medical service arrived which took about 10 minutes after the line had been cut. Staff F stated the facility had them sign something and they said they were going to do general education on PICC line dressing changes. Staff F stated they signed an in-service sheet, but they only told them not to use scissors when changing a PICC line dressing. Staff F stated they thought if they could cut the tape on the dressing, it was not 100% they had cut the line as it did not feel like they cut the line. Staff F stated they felt it cut the dressing unless the line snapped. Staff F stated they have not had a lot of training but were certified to insert IVs while employed at another facility and graduated nursing school back in 2014. Staff F stated it was hard to do their job sometimes when they did not feel supported due to not receiving education. In an interview and record review on [DATE] at 3:02 PM, Staff L, Interim Chief Nursing Officer (CNO), brought the surveyor an in-service education summary form dated [DATE] that showed the topic was PICC line dressings, the content of the in-service was for prevention to not use scissors but to assist with removing a dressing use adhesive remover, with Staff F's signature. Staff L stated they were going to go over PICC line dressing and protocols for dressing changes in their monthly nursing in-service. Staff L stated they had not provided the in-service it was scheduled for upcoming Friday. In an interview on [DATE] at 12:42 PM, Staff F stated they had used a pair of general wound care scissors (unsterile) to snip a piece of tape which was on Resident 20's weekly PICC line dressing change. Staff F stated they did not notice blood but 911 was called to get the line replaced. Staff F stated they noticed the line was cut after they got the PICC line dressing removed. Staff F stated they were unsure if the line broke from pulling the dressing tape or from the cut. In an interview on [DATE] at 1:06 PM, Staff D, Licensed Practical Nurse/Resident Care Manager, stated Staff F had come into the morning meeting and they went into Resident 20's room to assess the situation. Staff D stated Staff F reported the PICC line had come apart but it looked cut and Staff F did not know what to do. Staff D stated the Director of Nurses at the time flipped out criticizing our nurses. Staff D stated it was pretty simple, Staff F knew they should have removed the dressing with adhesive remover. Staff D stated it seemed cut and dry and was an awful mistake. In a phone interview on [DATE] at 3:10 PM, CC1 stated the facility seemed to have only one nurse who knew how to work with a PICC line. CC 1 stated they seemed to waste the resident's IV antibiotic when they were trying to get air bubbles out of the IV line. CC 1 stated the worst day Resident 20 had at the facility was the day the nurse cut the resident's PICC line. CC 1 stated one of the nurses dropped a vial of medication and broke it. CC 1 stated it was unsettling. CC 1 stated Resident 20 had to have a new PICC line placed, an X-ray and an ultrasound to confirm placement. CC 1 stated the PICC line was like what broke the camel's back. CC 1 stated they were not going to bring Resident 20 back to that facility. CC 1 stated the facility should not have accepted Resident 20 if the nursing staff did not have the training to work with a PICC line. CC 1 stated if you made a mistake like that you would think you would know what to do. CC 1 stated it was a huge deal for Resident 20, and the hospital staff were all concerned that anyone would be using scissors like that near a PICC line. In an interview on [DATE] at 5:23 PM, Staff K, Interim Administrator, stated the licensed nursing competencies should be done annually and was not aware they were not up to date. In a phone interview on [DATE] at 3:36 PM, Resident 20 stated it did not seem like anyone at the facility knew how to care for my PICC line or my IV antibiotics. The resident stated the staff had a lot of problems administering my IV antibiotics, they had a lot of issues with the IV pump jamming, excessive air bubbles in the line and how the antibiotics were to be infused. Resident 20 stated that when they asked the staff how many residents had IVs like mine, they said theirs was the only one. The resident stated on the day my PICC line was cut, the nurse came in to change my dressing, and they were trying to get this gummy stuff off my dressing. The resident stated the nurse got a pair of what looked like gauze scissors out of the front pocket of their scrub top and they cut my line. Resident 20 stated the nurse just looked at me and stated, Oh it broke, it snapped, and I stated, No, you cut it. Resident 20 stated they began to freak out, and the nurse was freaking out too. The resident stated the nurse had removed most of the old dressing and then placed the new dressing over the insertion site, then told me to hold pressure on it and then they left the room. The resident stated if they knew that scissors were not supposed to be used around a PICC line they would have told them. The resident stated the nurse returned with an administration staff person and they were discussing whether to call 911, I was bleeding, I could feel the blood under my arm pit. Resident 20 stated the nurse came back in again asking if, I wanted to be revived, they did not seem like they knew what they were doing, which further freaked me out. The resident stated they were freaking out too because they were told repeatedly the PICC line was supposed to be clean, the PICC line was a serious thing as it went into their heart. Resident 20 stated when it happened, they looked at the nurse, thinking okay what do we do now but the nurse just looked at me in a panic. Resident 20 stated, I was telling myself not to freak out cause the nurse was freaking out but I did not know what to do and they did not know what to do. Resident 20 stated in the ED they had to remove the PICC line and then they had to have ultrasounds to both of their arms to check for blood clots before they could insert a new line which was uncomfortable. Resident 20 stated, I has already having anxiety from everything going on and now I had to learn to do everything on my own, as I was not going to discharge back to that facility. Reference WAC 388-97-1060 (1)(3)(ii)

Based on interview and record review the facility failed to ensure residents were provided all physician ordered medications on 13 of 14 days reviewed for 20 residents. This failed practice disrupted the residents' continuity of care and placed residents at risk of not having their medical needs met.Findings included. Review of the facility's Medication Not Available, report ran for the scheduled dates of 01/30/2026 through 02/12/2026, listed the following physician ordered medications were not administered due to not available along with correlating dispensing reference from the facility's contracted pharmacy:01/30/2026 Resident 1 - gabapentin (anticonvulsant medication), albuterol sulfate inhalation (respiratory medication) [available in pyxis (machine dispenser], metronidazole topical cream (antiprotozoal and antibiotic medication), fluticasone-salmeterol inhaler (respiratory medication) [no stat request], ranitidine (stomach acid medication) [Over the Counter (OTC), facility supplied stock] Resident 2 -clopidogrel bisulfate [an antiplatelet medication], [14-day supply delivered on 01/20/2026], biotin (vitamin supplement) [OTC] Resident 3 -slow-magnesium (mineral supplement) [OTC] 01/31/2026 Resident 1 - albuterol sulfate inhalation, metronidazole topical cream, fluticasone-salmeterol inhalation [no stat request], Excedrin Extra Strength (pain medication) [OTC] Resident 4 - duloxetine (antidepressant medication) [14-day supply delivered on 01/16/2026 refill request on 02/02/2026] Resident 3 - slow-magnesium [OTC] 02/01/2026 Resident 1- fluticasone-salmeterol inhalation, metronidazole topical cream, [no stat request, available in pyxis], ranitidine [OTC] Resident 5 - ipratropium-albuterol (respiratory medication) [7-day supply delivered on 01/29/2026] Resident 2 - biotin [OTC] 02/02/2026 Resident 1 -metronidazole topical cream, [no stat request] Resident 6 - levothyroxine sodium (thyroid medication) [30-day supply delivered on 01/03/2026 refill requested on 02/03/2026] Resident 7 - levothyroxine [14-day supply delivered on 01/17/2026 refill request on 02/04/2026] Resident 8 - semaglutide (diabetic hormone medication) [28-day supply delivered on 01/12/2026 -supply on hand] 02/03/2026 Resident 1- ranitidine [OTC] Resident 6 - levothyroxine sodium [30-day supply delivered on 01/03/2026 refill requested on 02/03/2026] Resident 4 - montelukast sodium (respiratory medication) [14-day supply delivered on 01/16/2026 refill request on 02/04/2026] Resident 9 - estradiol (hormone medication) [14-day supply delivered on 01/27/2026] Resident 19 - calcium carbonate - vitamin D (mineral/vitamin supplement) [OTC] 02/04/2026 Resident 1 - ranitidine [OTC] Resident 4 - montelukast sodium [14-day supply delivered on 01/16/2026 refill request on 02/04/2026] 02/06/2026 Resident 10 - Prolensa ophthalmic solution (anti-inflammatory medication) [dispensed 28-day supply on 12/24/2025 for start date of 01/24/2026, date of surgery] 02/07/2026 Resident 11 - diclofenac sodium (anti-inflammatory medication) [OTC] 02/08/2026 Resident 1 - esomeprazole magnesium oral packet (gastroesophageal reflux disease medication) [14-day supply delivered on 01/31/2026], calcium magnesium zinc tablet (multivitamin with minerals), [OTC] Resident 12 - duloxetine (antidepressant medication), clopidogrel bisulfate (antiplatelet medication), oxybutynin chloride (bladder medication), diltiazem (heart medication) [14-day supply delivered on 01/22/2026, refills requested on 02/10/2026] Resident 2 - escitalopram oxalate (antidepressant medication) [100-day supply delivered on 12/09/2025], isosorbide mononitrate (heart medication) [14-day supply delivered on 01/08/2026 refill request on 02/14/2026] 02/09/2026 Resident 1 - esomeprazole magnesium oral packet [14-day supply delivered on 01/31/2026], Excedrin Extra Strength, calcium magnesium zinc tablet [OTC] Resident 12 - oxybutynin chloride, diltiazem [14-day supply delivered on 01/22/2026, refills requested on 02/10/2026] Resident 3 - potassium chloride (electrolyte mineral supplement) [14-day supply delivered on 01/31/2026] Resident 13 - pantoprazole sodium potassium (gastroesophageal medication) and sodium phosphates packet (bowel medication) [OTC] Resident 11 - diclofenac sodium (non-steroidal anti-inflammatory medication) and lidocaine external gel (pain relief medication) [OTC] Resident 6 - cranberry vaccinium macrocarpon (herbal drug) [OTC] 02/10/2026 Resident 1- esomeprazole magnesium oral packet [14-day supply delivered on 01/31/2026] Resident 13 - potassium and sodium phosphates packet [OTC] Resident 14 - Liquacel amino acid (protein supplement) [OTC] Resident 15 - Liquacel amino acid [OTC] Resident 16 - Liquacel amino acid [OTC] 02/11/2026 Resident 17 - calcium citrate (mineral supplement) [OTC] Resident 13 - potassium and sodium phosphates packet [OTC] 02/12/2026 Resident 18 - alendronate sodium (osteoporosis medication) [14-day supply delivered on 02/05/2026] In an interview on 02/11/2026 at 1:20 PM, Staff J, Licensed Practical Nurse (LPN) stated the facility was not on track with ensuring resident continuity of care related to nursing following up on thing that should be taken care of by the nurse managers. Staff J stated there were issues with obtaining medications from both the pharmacy and OTC medications. Staff J stated there were times when medications were not ordered at all or the medication needed a renewed prescription refill order but unsure the issue with the problem. In an interview on 02/11/2026 at 1:43 PM, Staff F, Registered Nurse (RN), stated the OTC medications were not always available, and the management staff does not want us to document the medications that are unavailable. Staff F stated they told management they would not document something they did not do. Staff F stated they are told to talk to the Administrator about the unavailable medications, and the Administrator says to talk to Staff G, Human Resources (HR). Staff F stated then when they talked to Staff G about a needed medication that is not available, Staff G tells them, they do not have a card to purchase the needed medication. In an interview on 02/11/2026 at 3:12 PM, Staff N, LPN, stated they worked at the facility as an agency staff member. Staff N stated they sometimes notice a lack of OTC medications available at the facility. Staff N stated as an agency staff they are not allowed to use the pyxis machine, a regular staff nurse would have to pull the medication out of the pyxis machine. Staff N stated they had a resident who had a medication that was not available and they alerted the Resident Care Manager (RCM). Staff N stated they thought the RCM would have called the pharmacy, but the medication did not get ordered and the oncoming nurse was upset. In an interview on 02/11/2026 at 4:04 PM, Staff H, RN, stated the facility sometimes does not have OTC medications like lidocaine patches. Staff H stated the facility runs out of random items and they tell Staff G. Staff H stated if medication is not available for a day or two, we try to notify the residents' provider. In an interview on 02/12/2026 at 3:01 PM, Staff D, LPN/Resident Care Manager (RCM), stated they have continuous issues with the pharmacy and they have escalated it with the pharmacy in that they reordered items that are not delivered in a timely manner like high cost medications that have to get the administration's okay and a signature from the administrator. Staff D stated they might have to wait on medications till a Monday that were ordered on a Friday. In an interview on 02/12/2026 at 3:45 PM, Staff L, Interim Chief Nursing Officer, stated they did not know where the disconnect was with having medications available. In an interview on 02/13/2026 at 3:21 PM, Staff C, RN, stated there have been medications not available to administer and had to check with the pharmacy. Staff C stated they would check with the pharmacy, and they would be sent on the midnight round. Staff C stated there was a medication they had to sign for it to come in as soon as possible, it probably was for payment reasons. Staff C stated the medications not available are usually OTC medications. In an interview on 02/13/2026 at 4:00 PM, Staff D stated the Medication Not Available report is straight forward, those medications listed were just not available whether they were medications delivered from the pharmacy or OTC medications supplied from the facility. In an interview on 02/13/2026 at 3:46 PM, Staff B, LPN, stated the facility had to order medications before 3:00 PM, for the medications to be delivered on the first delivery rounds delivered around 7:00 PM, and the second delivery comes around midnight. In a phone interview on 02/13/2026 at 4:38 PM, Staff I, Contracted Pharmacist in Charge, stated they were not aware of any difficulties with medication delivery to the facility. Staff I stated lidocaine 5% (percent) had been back ordered and the lidocaine 4% is a facility house supplied medication. Staff I stated the pharmacy sent a 14-day supply of Resident 12's oxybutynin on 01/21/2026 and there was not a refill request until 02/10/2026 which was delivered on 02/11/2026, the resident should have been out on 02/04/2026. Staff I stated the pharmacy's refill turnaround time is five to seven days. Resident 1's respiratory medication was sent to the facility on [DATE] at midnight which should have been available for the next day's morning dose. Staff I stated the facility's cut off time to order medication for the early delivery is 1:00 PM, which will arrive at the facility at midnight. In an interview on 02/13/2026 at 3:55 PM, Staff A, RN, stated the unavailable medications are an issue with the pharmacy. Staff A stated they have to call the pharmacy as the pharmacy never sends the resident medications on time even though they called for medications for the prior day to be administrated for the next morning, the medication is never delivered. Staff A stated when they have a new order, for example, thyroid medication to be given the next morning. Staff A stated they called the pharmacy and requested the medication to be delivered on the first pharmacy delivery run but they do not know why there is a barrier or a problem, but the medication never makes it to the facility to be administered on time the following morning. In an interview on 02/13/2026 at 4:13 PM, Staff D, stated the medications listed on the Medication Not Available, report was not administered due to waiting on the pharmacy to deliver the medications. Staff D stated nursing would call the pharmacy for medication orders and the medication would not arrive and we would call again only to have the pharmacy it was not ordered when indeed it was ordered. Staff D stated the availability of medications has been an issue since before they went on leave, it has been an ongoing issue. In an interview on 02/13/2026 at 5:23 PM, Staff K, Interim Administrator, stated the issue with unavailable OTC medications had been brought to their attention in the daily morning meetings. Staff K stated they directed the staff to use petty cash to obtain the medications locally if they were going to take too long to arrive from the vendors. In a follow-up email on 02/19/2026, Staff I, Pharmacy Consulted, noted several medications on the Medication Not Available report should have been available as OTC facility stock. Staff I noted, Many medications should have been on hand based on previous delivery dates, and there were multiple cases where the refill requests were submitted well after the existing supply should have been exhausted. Staff I noted there was one admission where medication doses were missing on the evening of the residents' arrival. Staff I noted the facility submitted the resident's orders to the pharmacy at 5:00 PM on 01/30/2026 and were delivered at the standard delivery time at approximately 2:00 AM on 01/31/2026. Staff I noted there were three of five medications on the medication order that were available in the pyxis, and there was no facility rush request submitted to the pharmacy for the remaining two medications. Reference WAC 387-97-1300(1)(b)(i)(ii)

Based on interview and record review the facility failed to conduct a complete and thorough investigation of mistreatment for 1 of 1 resident (Resident 20) who was sent to the emergency department due to a Registered Nurse (RN) accidentally cutting a residents peripherally inserted central catheter (PICC) line during a PICC line dressing change. This failed practice prevented the facility from identifying why the incident occurred, identifying the nursing staff's competency improvement needs which placed residents at risk. Findings included .Review of the facility's policy titled, Abuse, Prevention, Identification, & Reporting, revised 10/31/2017, stated the facility will investigate patterns, trends, and events that suggest the possible presence of abuse, or neglect . if the allegation is verified, the report includes appropriate corrective action taken. Review of the facility's January and February 2026 incident logs showed no incidents related to Resident 20's incident of Staff F, Registered Nurse (RN) inadvertently cutting the resident's PICC line when attempted to change the dressing. Review of Resident 20's progress note dated 01/20/2026 showed the resident's PICC line was accidentally cut while changing the dressing. The resident was sent to the emergency department. In an interview and record review on 02/11/2026 at 3:02 PM, Staff L, Interim Chief Nursing Officer, brought an in-service sheet to the surveyor which showed Staff F was educated to not use scissors on a PICC line dressing and stated the resident did not return to the facility. Staff L stated no incident report was completed as the resident was discharged home from the hospital. In an interview on 02/11/2026 at 4:43 PM, Staff L stated they were going to do an incident report today. Staff L stated they had looked at the Purple Book and discussed it with the intradisciplinary team and had determined the incident did not meet the definition to complete an incident report. In an interview on 02/11/2026 at 4:23 PM, Staff O, Licensed Practical Nurse/Resident Care Manager, stated incident reports were usually started by the cart nurse, but the Nursing Managers could start them. [NAME] O stated they would discuss incidents in their stand-up meeting, I do not know if we intended to it to be a risk management or not. Staff O stated they were never directed to do an incident report. Staff O stated the incident was more like a mistake and the nurse was educated, then the resident went to the hospital and did not return. In an interview on 02/13/2026 at 5:23 PM, Staff K, Interim Administrator, stated they thought the incident report was in the facility's risk management electronic software system or they reviewed it in the facility's stand-up meeting regarding the PICC line event on 01/20/2026. Staff K stated they remembered the day Staff F made a mistake. Staff K stated they would expect an investigation to see what happened. In the facility's exit on 02/13/2026 at 5:52 PM, the facility's company Lead Chief Nursing Officer, Staff M, stated that they were told at the time of the incident involving the PICC line that an investigation was being conducted. Staff P stated they would expect an investigation to be done as there was room for improvement. Reference WAC 388-97-0640(6)(a)

Based on interview and record review the facility failed to ensure the daily nurse staffing posting was completed daily with the total number of actual nursing hours worked along with the resident census from 01/07/2026 to 02/13/2026 for a total of 37 days. This failed practice prevented the residents and visitors' ability to readily view the nurse staffing information. Findings included. In an observation on 02/11/2026 at 12:22 PM, the daily nurse staffing posting was dated 01/07/2026. In an observation on 02/12/2026 at 12:40 PM, the daily nurse staffing posting continued to be dated 01/07/2026. In an observation and interview on 02/13/2026 at 3:10 PM, Staff L, Interim Chief Nursing Officer, confirmed the nurse daily staffing was dated 01/07/2026, and stated it should be posted daily reflecting the actual nurse staffing hours along with the facility's current census number.No reference WAC

Based on interview and record review the facility failed to ensure 1 of 3 residents (Resident 1) who were at risk of pressure injuries (PI), did not develop an avoidable PI. The facility failed to implement preventive PI interventions for Resident 1. This failed practice resulted in the development of a deep tissue injury (DTI) of Resident 1's left heel which caused the resident significant discomfort. This failed practice placed other residents at risk of pressure injuries, pain and decreased quality of life. Findings included. The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (PI- also known as a PU) definition and stages of PU's include:-A PI (PU) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present itself as intact skin or an open ulcer and may be painful. The injury occurs as the result of intense and/or prolonged pressure or pressure in combination with sheer. The tolerance of soft tissue for pressure and sheer may also be affected by microclimate (the skin temperature, humidity, and airflow next to the skin's surface), nutrition, perfusion (measures how well the circulatory system is working), co-morbidities, and condition of the soft tissue. Unstageable PI (PU) is an obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury (DTPI) is a persistent non-blanchable deep red, maroon, or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often preceding skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness PI. Resident 1 was admitted to the facility 10/03/2025 with diagnosis to include a fractured left hip with surgical repair, morbid obesity, and neuropathy (a condition referred to damaged or diseased nerves, which may result in impair sensation). Review of Resident 1's admission Minimum Data Set (MDS- an assessment tool) assessment dated [DATE], showed Resident 1 was not admitted with a PI and was at risk of developing a PI. Review of the admission Care Area Assessment (CAA) dated 10/09/2025, showed Resident 1 would be care planned at risk of developing a PI related to limited mobility and incontinence. Review of Resident 1's Skin Inspection Evaluation dated 10/03/2025, documented green boots (heel protective device) were placed on both feet after assessment. Review of Resident 1's care planned focus problem of potential for alteration in skin health related to surgical site dated 10/03/2025, showed Resident 1 was to be assisted to off load (reduction or removal of pressure and friction on a specific area of the body to promote healing and prevent further tissue damage) heels or use heel protective device boots when in bed. Review of Resident 1's planned focus problem of activities of daily living self-care performance deficit dated 10/04/2025, showed Resident 1 was dependent on two staff members for bed mobility with use of a turn sheet and verbal cueing. Review of Resident 1's Skin Inspection Evaluation dated 10/07/2025, documented a boggy/soft spot to the resident's left heel still present from admission but remains closed and painless. Review of Resident 1's direct care staff documentation for the Month of October 2025 showed no assigned task to assist to off load heels or use of a heel protective device when in bed was completed. Review of Resident 1's Treatment Administration Record (TAR) from 10/03/2025 to 10/13/2025, showed no use of protective heel devices or off-loading of the resident's heels were completed. Review of Resident 1's Skin Event dated 10/13/2025, showed the resident had developed a 5 centimeter (cm) by 7 cm, closed blister to the resident's left heel. Resident 1's statement regarding the possible cause of the skin issue was, it was from rubbing on the bed. The ordered plan implemented at the time of the skin issue was a dressing and protective heel boots. Review of an incident report dated 10/13/2025, showed Resident 1's left heel injury root cause analysis was due to the rubbing of the resident's heel while in bed, the resident's immobility, the resident's bed was too small for proper positioning, and the resident would lay on their back and again noted the bed was too small. The interventions were noted to offload the resident's heels in green heel boots and use of an Alternating Pressure Pump (APP) mattress. Review of Resident 1's TAR from 10/13/2025 to 10/31/2025, showed an adhesive dressing for the residents left heel was ordered on 10/14/2025 to be applied every three days and as needed if soiled as well as heel boots to be on at all times, off-load the resident's heels with use of green off-loading boots initiated on 10/17/2025, and an APP mattress was applied to the resident's bed on 10/23/2025. Review of the Skilled Weekly IDT (Interdisciplinary team) Review dated 10/16/2025, showed Resident 1 had a DTI and was referred to a community wound care provider. Review of Resident 1's community wound care provider note dated 10/23/2025, showed staff noted a left heel DTI. The note documented Resident 1's Collateral Contact (CC) 1, reported the area started out as a blister. The note indicated serial debridement (a medical procedure to clean wounds by removing dead, infected, or unhealthy tissue (like slough, necrotic tissue, or biofilm) to promote healing and prevent infection) may be medically indicated due to slow wound healing, persistent infection, biofilm, and underlying comorbidities that are complicating the closure process. Review of an email sent by CC 1 to Staff A, Social Services, Staff B, Registered Nurse and Staff C, former Director of Nursing Services, dated 11/03/2025, showed CC 1 reported when they were visiting over the weekend, they noticed the resident's foot protectors were not on their feet and the resident's heels were rubbing on the foot of the bed. Review of an email sent by CC 1, to Staff A, Staff B, and Staff C, dated 11/10/2025, showed CC 1 expressed concerns regarding Resident 1's heel wound which was not properly taken care of where the staff had peeled back the dead skin on the resident's heel and then applied socks over the open wound. CC 1 noted on Saturday, 11/08/2025, the resident's wound was seeping and became stuck to the sock that had been applied over the open wound. In a phone interview on 12/11/2025 at 9:32 AM, CC 1 stated that the staff forgot to put the resident's offloading boots on and the resident would slide down in bed. CC 1 stated the staff had peeled back the skin on the resident's heel wound as they wanted it to air out. CC 1 stated the staff had placed a sock on the resident's left foot and it was stuck to the resident's wound which was weeping. CC 1 stated after therapy they did not see Resident 1 in the off-loading boots multiple times. In a phone interview on 12/16/2025 at 4:45 PM, Resident 1 stated, I am tall and the bed was short. The resident stated they would slide to the end of the bed where their heel would rub on the end of the bed. Resident 1 stated at one point someone noticed their heel was black. Resident 1 stated the pain to their heel was not good. Resident 1 stated the wound was uncomfortable to walk on and when the skin was taken off, it was really sore. The resident stated they were there to rehabilitate and the wound did not help their rehabilitation. In an interview on 12/17/2025 at 2:29 PM, Staff D, Licensed Practical Nurse/Resident Care Manager, confirmed Resident 1's admission documentation had no specific information on the resident's left heel. Staff D confirmed the skin check completed on 10/07/2025 showed the resident had a boggy soft spot and was not discolored. Staff D stated Resident 1's wound was weird, it was large and the skin was white. Staff D stated they were working the floor as a cart nurse when the resident was admitted . Staff D stated they were notified of the resident's heel and knew other nurses had seen the resident's heel. Staff D confirmed the medical record did not indicate off-loading boots were in use daily from admission. Staff D stated they recalled a Noc Shift nurse was the first who reported the resident's heel wound turned black on 10/13/2025 and an adhesive dressing was ordered. Staff D confirmed there was no documentation the staff applied the off-loading boots by the direct care staff. Staff D confirmed the off-loading boots were documented on the TAR as started on 10/17/2025. During the in person and phone exit interview, Staff E, Regional Nurse Consultant, stated the facility's MDS was completed by staff remotely. Staff E confirmed Resident 1 was not coded to have a PI on the admission MDS or on the CAA. Staff E stated Resident 1 was noted to be at risk of developing a PI. Reference WAC 388-97-1620(1)(3)(b)

Based on observation, interview, and record review the facility failed to ensure a safe, clean, comfortable and homelike environment on 2 of 2 units and the main dining room. Failure to ensure a comfortable interior in the dining room, unit halls free of unpleasant odors, adequate supply of linens, and perform needed repairs in resident's rooms placed residents at risk for decreased quality of life.Findings included .<LINEN SHORTAGE> During an interview on 08/07/2025 at 9:58 AM, Resident 14 reported that last week they had to go to bed with a draw sheet as the staff had told them there were no clean sheets available. Resident 14 reported last night there were no top sheets so they had to use a draw sheet for a regular sheet. <RESIDENT ROOMS> During an observation on 08/04/2025 at 9:07 AM, the bed in room [ROOM NUMBER]B did not have a mattress on the frame. During an observation on 08/05/2025 at 8:28 AM, the bed in room [ROOM NUMBER]B did not have a mattress on the frame. During an observation on 08/05/2025 at 8:28 AM, the bed in room [ROOM NUMBER]B did not have a mattress on the frame. During an interview on 08/05/2025 at 10:48 AM, Staff M, Maintenance Director, observed the bed frame in room [ROOM NUMBER]B. Staff M stated the bed was broken but they did not know why the mattress had been removed. During an interview on 08/05/2025 at 10:52 AM, Staff M observed the bed frame for 9B. Staff M reported that they had noted the mattress had been removed from the bed frame but had not had a chance to replace it. Staff M did not know why the mattress had been removed. In an observation on 08/04/2025 at 9:32 AM, Resident 4's left side curtain was observed to be propped on the curtain rod, the rings to the curtains piled on the resident nightstand. In an interview on 08/04/2025 at 9:55 AM, Collateral Contact (CC) 1 stated they had visited their mother over the weekend and noticed the curtain rings were lying on the ground beneath the window, and that the left curtain was not hung up. CC1 stated they spoke with a staff member about the broken curtain, and it was said they would let Staff M, Maintenance Director, know about it on Monday as they did not work at the weekend. In an observation on 08/04/2025 at 11:41, the curtain rings were lying on Resident 4's nightstand, and the left curtain was propped over the curtain rod. In observations on 08/05/2025 at 8:06 AM, and 11:15 AM the curtain rings were lying on Resident 4's nightstand, and the left curtain was propped over the curtain rod. In an observation on 08/05/2025 at 12:45 PM, Staff I, housekeeper was overheard in Resident 4's room state to the resident there are some rings on your nightstand, I think they go to your curtains, I am going to move them over here. In an observation on 08/05/2025 at 1:12 PM, unknown staff member was overheard in Resident 4's room state I can't really close your curtains, I will tell maintenance to fix them for you. In an observation on 08/05/2025 at 1:49 PM, the rings and curtains were lying on the table. In an interview and observation on 08/06/2025 at 9:54 AM, Staff D, Registered Nurse exited Resident 4's room, the curtain was observed to be fixed and hanging appropriately. Staff D stated that Resident 4 was anxious and tearful, Staff D felt it was due to curtain having been broken. <LINENS> In an interview on 08/04/2025 at 10:54 AM Collateral Contact 1, (CC1)-Resident 37's family member, stated there was often not enough linens for bed changes. CC1 stated the facility goes through a lot of bedding and the facility needs more bedding or more staff to help wash it. CC1 stated the staff had told them about the shortage of linen. In an interview on 08/06/2025 8:53 AM Staff F, Laundry Supervisor, stated the facility had problems with linen being stashed in resident rooms. Staff F stated, Staff E, Laundry Aide, had a good system in place and had been doing inventory for the linens. Staff F stated they needed to go through and find the stashed linens and then order more. Staff F stated the facility had enough linens for each bed, but did not want to get lower. When asked if any concerns had been brought up to them about availability of linens, they stated night shift had voiced running out of clean linen. In an interview on 08/06/2025 at 8:58 PM Staff E, Laundry Aide, stated there was enough linen and were waiting on orders for linen. Staff E stated they were working on the inventory of linens which had been in process for a few months. In an interview on 08/06/2025 at 8:59 AM Staff K, Nursing Assistant Certified (NAC) stated they thought the laundry department needed more staff. Staff K stated they typically have enough linen. Staff K stated the laundry gets behind due to their working schedules and when they come in the morning they are trying to catch up. Staff K stated they often had to remind other staff not to throw out linens that are soiled with fecal matter. In an interview on 08/06/2025 at 3:39 PM Staff J, NAC stated the facility is often short online, almost daily. Staff J stated they had brought the lack of linens to the attention of the Administrator, Director of Nursing and Maintenance, with no resolution. Review of the facility census dated 08/04/2025 showed there were 33 residents residing in the facility. In a review of the inventory, undated, showed the facility had the following: Draw Sheets: 17188 Fitted Sheets:13/33 Soaker Pads: 8/13 Top Sheets: 38/118 Blankets: 34/49 Fuzzy Blankets: 5/9 <ODORS> On 08/04/2025 at11:00 AM there was a strong urine odor in the south hallway between rooms [ROOM NUMBERS]. Observed Staff I, Housekeeper, exit room [ROOM NUMBER] where the strong urine odor poured out into the hallway. Staff I, stated the resident in room [ROOM NUMBER] did not like their room cleaned. On 08/05/2025 at 9:43 AM there was a strong urine smell in the hallway near nurse's station in between North and South halls. On 08/06/2025 at 9:37 AM there was an overpowering odor of feces coming from the end of the south hall permeating the entire hall. The smell lingered for approximately an hour until the surveyor notified Staff H, Resident Care Manager, of the odor. <DINING ROOM> On 08/04/2025 at 8:47 AM observed the only dining room (DR) in the facility. The dining room contained six tables. Two of the tables lined up on the right side of the DR wall room and had various items on top. To the left of those tables were two large vending machines. On the left side of the DR were two freezer chests and a piano which transitioned into an alcove. The alcove contained additional refrigeration and freezer units. The piano was blocked by tray carts which contained soiled dishes awaiting to be washed. The wall directly across from the DR entrance had chairs lining the walls with a small coffee table. The flooring under the coffee table did not match the rest of the flooring. The flooring was separating at the seams and showed visible gaps. In an interview on 08/04/2025 at 8:47 AM Staff L, Dietary Manager stated the space within the facility is limited and the facility had considered separating the alcove in the DR with a wall. Staff L stated the two tables on the right side of the DR were for activities. In an observation on 08/04/2025 at 11:58 AM observed DR service for lunch. Observed seven residents in the DR. There were two sets of tables (two pushed together) parallel to each other located in the center of the DR. There was little room left in the DR for other residents if requested to have their meal there. In an interview on 08/06/2025 at 2:22 PM Staff M, Maintenance Director, stated the flooring in the dining room was scheduled to be replaced within the year. Staff stated the flooring and mismatched flooring under the coffee table had been in the DR since before they were the maintenance director, three years. Reference WAC 388-97-0880(1)(2)

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of insulin (injectable medication that regulates blood sugar) in 2 of 2 medication carts (North and South carts) when reviewed for medication storage. This failure placed residents at risk of receiving expired medications, ineffective treatment, and a diminished quality of life.Findings included.On 08/06/2025 at 9:35 AM, an observation of the South medication cart was conducted with Staff D, Registered Nurse (RN). Three of six Glargine insulins (a man-made version of the human hormone insulin) were observed in individualized plastic bags, stored outside of the refrigerator. In an observation and interview on 08/06/2025 at 9:40 AM, Resident 4's Glargine insulin pen (a device that has a cartridge of insulin and a needle to administer insulin injections) was observed without a date which indicated when it was opened and/or removed from the refrigerator. Resident 26's had an open bottle of Glargine insulin, dated 07/04/2025, and an undated Glargine insulin pen. Staff D could not find any dates on the insulin pens when they were removed from the refrigerator and/or opened. Staff D stated the Glargine insulin bottle was expired. When asked how long insulin was good for when removed from the refrigerator and when opened, Staff D stated 28 days. On 08/06/2025 at 9:51 AM, an observation of the North medication cart was conducted with Staff C, RN. Resident 43's Glargine insulin pen was observed stored in the medication cart and was undated. Staff C stated insulin was good for 28 days when pulled from the refrigerator. Staff C stated Resident 43's insulin pen should have been dated.In an interview on 08/06/2025 at 10:34 AM, Staff B, Chief Nursing Officer, stated insulin was good for 28 days, and should be dated when removed from the refrigerator and opened.Review of Resident 4's physician order, dated 06/14/2025, showed administer Glargine insulin 20 units subcutaneously one time a day.Review of Resident 26's physician order, dated 07/10/2025, showed administer Glargine insulin 10 units every day. Reference WAC 388-97-1300(2)

Based on record review and interview, the facility failed to develop, implement and maintain a process to ensure annual performance reviews were completed for 3 of 5 staff (Staff P, Q, R) and that Nursing Assistant Certified (NAC) staff had the required 12 hour annual in-service training for 4 of 5 staff (Staff O, P, Q, R) reviewed for competent nursing staff. The failure to ensure NAC's had annual performance reviews to assess areas of weakness so the facility could provide in-service training and/or NACs received 12 hours annual in-service training placed residents at risk of less than competent care and services from staff.Findings included.Review of the facility assessment, dated 2025, showed the Staff Development Coordinator monitored the required education and required hours of education of staff. Education and training would include areas of weakness as determined by the NAC annual performance reviews.<STAFF P>Staff P, NAC, had a hire date of 01/10/2024. The facility provided documentation that showed Staff P had not had an annual performance review completed. Staff P had only 4.25 hours of in-service training. <STAFF Q>Staff Q, NAC, had a hire date of 11/11/2022. The facility provided documentation that showed Staff Q had not had an annual performance review completed. Staff Q had only 4 hours of in-service training. <STAFF R>Staff R, NAC, had a hire date of 08/31/2023. The facility provided documentation that showed Staff R had not had an annual performance review completed. Staff R had only 1.5 hours of in-service training. <STAFF O>Staff O, NAC, had a hire date of 01/31/2024. The facility provided documentation that showed Staff O had only 4.25 hours of in-service training. During an interview on 08/06/2025 at 11:47 AM, Staff A, Administrator, reported that staff performance evaluations and required 12 hours of education hours were not complete.During an interview on 08/06/2025 at 2:40 PM, Staff S, Human Resources/Payroll Coordinator, confirmed that Staff P, Q, and R did not have their performance review completed. Staff S stated the hours of education provided by the facility for Staff O, P, Q, and R was what the facility had documented for their annual in-service hours. Reference WAC 388-97-1680 (1)(2)(b)

Based on observation, interview, and record review the facility failed to initiate, investigate, and resolve a grievance for 1 of 1 sampled residents (Resident 3) reviewed for grievances. This failure placed residents at risk for emotional distress and a diminished quality of life.Findings included.In a review of the facility policy titled, Complaints and Grievances revised on 10/15/2022 showed complaints/grievances may be verbal or written, they are acknowledged, investigated and the complainant apprised of progress toward a resolution.In a review of the facility policy titled, Complaints and Grievances revised on 10/15/2022 showed complaints/grievances may be verbal or written, they are acknowledged, investigated and the complainant apprised of progress toward a resolution. In an interview on 08/04/2025 at 11:29 AM Resident 3 stated they were missing seven pairs of rubber pants for two weeks. Resident 3 stated they had reported the missing rubber pants to at least four or five staff members. Resident 3 stated Staff E, Laundry Aide (LA), was the only staff allowed to take and launder their clothing. Review of the grievance log from February 2025 through July 2025 showed no logged entries for Resident 3's missing rubber pants. In a joint interview on 08/06/2025 at 1:30 PM Staff B, Director of Nursing Services and Staff H, Resident Care Manager/Registered Nurse both stated they were not aware of Resident 3 missing rubber pants. In an interview on 08/06/2025 at 3:15 PM Staff G, Registered Nurse stated they had not received any reports from Resident 3 about missing rubber pants. In an interview on 08/06/2025 at 3:18 PM Staff E, LA, stated Resident 3 had reported missing rubber pants, they currently had one pair remaining and used to have more. Staff E stated Resident 3 had recently been at the hospital and their daughter had come to rearrange their room and directed Resident 3 to ask their daughter. Staff E stated they did not fill out a grievance form on Resident 3's behalf and did not know how to do it. In an interview on 08/06/2025 at 3:20 PM Staff F, Laundry Supervisor, stated if a resident was missing an item it needed to be put on a grievance form and tracked. Reference WAC 388-97-0460

Based on interview and record review, the facility failed to ensure professional standards were met for 3 of 5 residents (Residents 3, 6, and 26) reviewed for unnecessary medication review. The facility failed to recognize and ensure parameters were met for blood pressure medication administration and diabetes (blood sugar levels in blood are unmanaged) medication management for the residents. The facility failed to notify the medical provider when the resident's blood sugar levels and blood pressures were beyond the ordered parameters. These failures placed the residents at risk for adverse outcomes, medication errors, complications, and unmet needs.Findings included .Review of the facility policy titled, Oral medication administration, dated 01/01/2018, documented medication was administered per physician orders and manufacturer directives. Vital sign parameters and side effects are monitored as indicated. <RESIDENT 3> Resident 3 readmitted to the facility on [DATE] with diagnoses to include diabetes mellitus, type two (chronic condition in which the body does not produce enough insulin or can't properly use insulin, creating high blood sugar). In an interview on 08/04/2025 at 11:44 AM Resident 3 stated they were prescribed insulin to manage their diabetes. Resident 3 stated they had recently been hospitalized with a very low blood sugar. In a review of Resident 3's Medication Administration Record (MAR) for July 2025 showed an order to check their Blood Glucose (BG) before meals and if their BG was less than 70 initiate low blood sugar protocols and notify the provider and if their BG was above 300 to notify the provider and follow their directive. The MAR for July showed Resident 3 had BG over 300: 7/24/2025 at 4:00 PM BG 309 07/29/2025 at 4:00 PM BG 373 07/30/2025 at 4:00 PM BG 314 In a review of Resident 3's Electronic Medical Record (EMR) showed no documentation of the provider being notified of their BG's levels over the prescribed parameter. In an interview on 08/06/2025 at 12:46 PM Staff D, Registered Nurse (RN) stated they follow the physician's orders. Staff D stated if a resident had BG out of parameters, they would notify the physician by phone and complete a Situation, Background, Assessment and Recommendation (SBAR) form. Staff D stated they get report at shift change of any resident who had high or low BG levels. <RESIDENT 6> Resident 6 admitted to the facility on [DATE] with diagnoses to include diabetes mellitus type two and high blood pressure. Review of Resident 6's MAR for July and August 2025 showed they were prescribed medication for high blood pressure and insulin (a medication injected under the skin to regulate blood glucose level) for diabetic management. The MAR directed the staff to hold their blood pressure medication if Resident 6's Diastolic Blood Pressure (DBP-the pressure in the blood vessels between heartbeats) was less than 70 and notify the provider if their BG level was above 349. The MAR for July and August 2025 showed Resident 6 should have had their blood pressure medication held 24 out of 31 days for the month of July and on 08/01-08/03/2025 as their DBP was less than 70. The MAR showed that Resident 6 had BG levels above 349 as follows: JULY 2025: 07/07/2025 BG 365, 07/10/2025 BG 385, 07/14/2025 BG 542, 07/15/2025 BG 383, 07/23/2025 BG 354, 07/24/2025 BG 558 and 07/25/2025 BG 350 AUGUST 2025: 08/03/2025 BG 358 In a review of Resident 6's EMR showed no documentation of their provider being notified of low DBP or high BG or high blood pressure medication being held per physician orders. In an interview on 08/06/2025 at 1:09 PM Staff B, Director of Nursing Services, stated there was a dashboard in their electronic charting system that notified the nursing staff of high BG and low DBP to prompt the nursing staff to contact the provider. No other information was provided. <RESIDENT 26>Resident 26 admitted to the facility on [DATE] with diagnoses that included primary hypertension (high blood pressure). Review of Resident 26's physician orders showed the resident had an order for metoprolol tartrate oral tablet, give 37.5 milligrams twice a day, hold if the systolic (SBP – upper blood pressure number) was less than 120 or if their heart rate was less than 60 beats per minute (bpm). Review of Resident 26's electronic medication administration record (EMAR) for July 2025 documentation reflected the residents SBP was less than 120 on 4 of the 31 days in July. The licensed nurse administered the medication. Review of Resident 26's EMAR for June 2025 documentation reflected the residents SBP was less than 120 on 10 of the 30 days in June. The licensed nurse administered the medication. Review of Resident 26's EMAR for May 2025 documentation reflected the residents SBP was less than 120 on 9 of the 31 days in June. The licensed nurse administered the medication. In an interview on 08/07/2025 at 8:57 AM, Staff H, Registered Nurse/Resident Care Manager stated that if the licensed nurse found a resident's vital signs were outside the parameter of the physician ordered medication, they expected the staff to not administer the medication. Staff stated they should notify the physician and document in the medical record. In an interview on 08/07/2025 at 10:19 AM, Staff B, Director of Nursing Services stated their expectation for all licensed staff was if any resident's vital signs were outside the parameter of the physician order, they were to not administer the medication. Staff B expected their staff to notify the physician, and document in the medical record. Reference WAC 388-97-1060(3)(k)

Based on observation, interview, and record review, the facility failed to ensure 1 of 4 residents (Resident 13) reviewed for activities of daily living, received adequate bathing according to the resident's plan of care. This failure placed the resident at risk of poor hygiene and a diminished quality of life.Findings included.Resident 13 admitted to the facility on [DATE].During an interview on 08/04/2025 at 9:10 AM, Resident 13 reported they preferred two showers a week, but had not had a shower in the last month. Resident 13 reported that they needed their beard trimmed but the staff only did that when they received showers. Resident 13 was noted to have a long beard.Review of Resident 13's Kardex (specifies resident's care needs), dated 08/05/2025 showed they preferred two showers each week and if resident could not tolerate a shower, then staff were to provide a bed bath.Review of Resident 13's last 30 days of bathing documentation, dated 08/05/2025, showed they had received showers on 07/08/2025, 07/12/2025 and 07/15/2025. The documentation showed Resident 13 had refused a shower on 07/29/2025 and 08/02/2025. The documentation showed that a shower was Not applicable/Not attempted (NA) on 07/22/2025 and 07/26/2025. There was no documentation that a bed bath had been provided.During an interview on 08/05/2025 at 10:16 AM, Staff Q, Nursing Assistant Certified (NAC), reported Resident 13 did not typically refuse showers unless they had a visitor. Staff Q had documented the shower refusal for Resident 13 on 07/29/2025. Staff Q reported that it was an error in documentation as they had not worked in the hall where Resident 13 resided and resident had not refused any showers from them in the recent past.During an interview on 08/05/2025 at 10:42 AM, Staff K, NAC, reported if they did not have enough time to complete an assigned shower, they relayed that information to the oncoming shift to try to complete or try to do the next day. Staff K had documented NA for Resident 13's showers on 07/22/2025 and 07/26/2025. Staff K reported they had ran out of time on those two shifts and could not complete Resident 13's shower.During an interview on 08/05/2025 at 11:25 AM, Staff B, Chief Nursing Officer, reported they were not aware Resident 13 had not had a shower provided since 07/15/2025. Staff B reported they would check with the staff. No further information was provided. Refer to WAC 388-97-1060 (2)(c)

Based on interview and record review, the facility failed to ensure pharmacy recommendations were completed in the medical record for 2 of 6 residents (Residents 26 and 30) reviewed for unnecessary medications. This failure placed the residents at risk for delay in necessary medication changes, incomplete medical records, and adverse side effects.Finding included . Review of the facility policy titled, Pharmacy Services, dated 11/28/2017 documented the facility will collaborate with the pharmacist in a timely manner to develop an implementation of pharmaceutical services and address the needs of the residents consistent with state and federal requirements and standards of practice. Review of the facility policy titled, Unnecessary medications, revised date 04/22/2025, documented the facility will conduct an Abnormal Involuntary Movement Scale (AIMS) test of all residents receiving antipsychotic medications. Psychoactive medications should be evaluated after 14 days after admission or start date. <RESIDENT 26>Resident 26 admitted to the facility on [DATE] with diagnoses that included Review of Resident 26's physician orders on 08/05/2025 documented the resident was prescribed an anti-psychotic (treatment for psychosis) medication three times a day. Review of pharmacy recommendation dated 07/11/2025, for Resident 26 documented the facility had not conducted an AIMS test for the resident, and it was overdue. The document was noted by the nurse practitioner that they agreed it needed to be completed. The document was also had noted written at the bottom of the page, with unknown initials and dated 08/01/2025.Review of Resident 26's medical record on 08/07/2025 documentation showed the last AIMS conducted was in January/2025. <RESIDENT 30>Resident 30 admitted to the facility on [DATE] with diagnoses that included schizophrenia (sever mental disorder with delusions, hallucinations, and disorganized thinking and speech). Review of Resident 30's physician orders on 08/06/2025 documented the resident was prescribed an anti-depressant (treatment for depression) medication every four hours as needed, with start date of 06/15/2025 and no end date. Review of the pharmacy recommendation dated 07/11/2025, for Resident 30 documented that the resident had been on a psychoactive medication as needed past the 14-day evaluation date, and if necessary, what was new duration and rationale. The provider agreed to a 14-day duration and documented the rationale. The document was also had noted written at the bottom of the page, with unknown initials and dated 08/01/2025.Review of Resident 30's medical record on 08/07/2025 documentation showed the antidepressant medication had a start date of 06/15/2025 and no end date. In an interview on 08/07/2025 at 8:57 AM, Staff H, Registered Nurse/Resident Care Manager (RCM) stated that the pharmacy recommendations go to the Director of Nursing Services (DNS) and then they divide them up based on unit. Staff H was shown the pharmacy recommendations for Resident 26 and Resident 30 and stated that the unknown initials at the bottom of the document were theirs. Staff H stated they mark them when they are completed. Staff H was asked to look at the medical records for Resident 26 and Resident 30 to show where the recommendations had been completed in the medical record. Staff H was unable to locate the AIMS for Resident 26 anti-psychotic medication use, or a stop date for Resident 30's anti-depressant medication. Staff H stated I must not have completed them. In an interview on 08/07/2025 at 10:19 AM, Staff B, Director of Nursing (DNS) stated AIMS were to be completed every 6 months, however they usually do them every quarter as that was how often they review the resident's medical record. Staff B stated the RCMs were given the monthly pharmacy recommendation to ensure the provider reviews the recommendation and that they are completed timely. Staff B was not sure why the recommendations for Resident 26 and Resident 30 were marked noted, however not completed in the medical record. Reference WAC 388-97-1300(4)(c)

Based on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 4 staff members (Staff T, Nursing Assistant Certified - NAC) reviewed for hand hygiene, 1 of 3 residents (Resident 35) reviewed for transmission-based precautions (TBP), and 1 of 1 residents (Resident 5) reviewed for oxygen use. The facility failed to ensure the staff were wearing appropriate personal protective equipment (PPE) in accordance with recommended national standards, failed to ensure staff were compliant with appropriate hand hygiene practices during meal tray delivery, and failed to ensure oxygen tubing supplies were stored and maintained properly. These failures placed all residents and staff at risk of potential infection.Findings include .Review of the facility policy titled, Transmission Based Precautions Conventional Plan, revised 06/16/2025 documented enhanced based precautions (EBP) refer to infection control interventions designed to reduce transmission of multi-drug-resistant organisms that employ the use of targeted gown and gloves use during high contact resident care activities . residents recommended for EBP are residents with open wounds, and indwelling medical devices such at catheters (tubing inserted into the body to drain urine).Review of the facility policy titled, Hand Hygiene, revision 02/11/2022 documented hand hygiene is the single most important procedure for prevention the spread of infection . opportunities for hand hygiene such as before touching a resident, after touching resident, after leaving the residents room, after removing gloves, after any contact with residents belongs or objects.During an observation on 08/04/2025 at 11:49 AM, Staff T, NAC was observed to remove a lunch tray from cart in the hallway and brought it into room [ROOM NUMBER] and placed it on the resident’s bed table, remove the cover from meal tray, exited the room and did not perform hand hygiene. Staff T removed another lunch tray and entered room [ROOM NUMBER], placed the lunch tray on the bed table and exited the room and did not perform hand hygiene. Staff T removed another lunch tray from the cart and entered room [ROOM NUMBER]. Staff T placed the lunch tray on the bed table for the resident in 6B. Staff T was observed touching resident’s silverware with bare hands to cut up the food for them and applied seasoning to the food. Staff T then exited the room, did not perform hand hygiene, removed another lunch tray from the cart and brought it to the resident in room [ROOM NUMBER]A and placed it on their overbed table. The resident did not want lunch and asked Staff T to remove the tray. Staff T was observed to remove the lunch tray from the room and put it on the cart with the other lunch trays that still needed to be passed. No hand hygiene was performed. At 11:54 AM, Staff T removed a lunch tray from the cart and entered room [ROOM NUMBER]. Staff T was observed to place the lunch tray on the bed table, touched personal items in the room and readjusted the bed table. Staff T then used the silverware to cut up the resident’s food with their bare hands. Staff T exited the room and did not perform hand hygiene. Staff T removed another lunch tray from the cart in the hallway and brought it to room [ROOM NUMBER] where they were observed handling the silverware to cut up the resident’s food with bare hands. Staff T exited the room and did not perform hand hygiene. During an interview on 08/04/2025 at 11:59 AM, Staff T did not respond when asked when hand hygiene should be done during meal pass. Staff T reported that they had not done hand hygiene while passing lunch trays. <HAND HYGIENE>In an observation on 08/04/2025 at 11:39 AM, Staff T, Nursing Assistant Certified (NAC) was observed to remove a lunch tray from the meal cart in the hallway, no hand hygiene was observed prior to handling tray. Staff T entered room [ROOM NUMBER], where a resident resided placed lunch tray down in the resident room, exited and did not perform hand hygiene. Staff T then grabbed another lunch tray from the meal cart and entered room [ROOM NUMBER]. Staff T were observed to touch with their bare hands the residents belonging, including their walker, and personal items on their bed table. Staff T, then placed the lunch tray on the over the bed table and removed the cover off the plate. Staff T were then observed to touch with the bare hands the resident’s silverware and cut up the resident’s food for them. Staff T left the silverware for the resident to use. Staff T exited the resident room, was observed to not perform hand hygiene, and walked into room [ROOM NUMBER] and was observed to assist with repositioning of another resident with their bare hands. The staff then touched the residents’ linens to assist in scooting them up in bed. Staff T then left the resident room and did not perform hand hygiene and entered the kitchen. At 11:44 AM Staff T exited the kitchen, dropping two hot beverage containers to room [ROOM NUMBER], and were not observed to perform any hand hygiene. At 11:47 AM, Staff T grabbed another lunch tray from the meal cart and walked to room [ROOM NUMBER], placed the tray on the bed table, grabbed a cup from the resident’s room and walked to the kitchen, no hand hygiene was observed. At 11:49 AM, Staff T pushed a second meal cart down to the other unit, no hand hygiene was observed. <TRANSMISSION BASED PRECAUTIONS>In an observation on 08/06/2025 at 10:07 AM, Staff T, NAC were observed to enter room [ROOM NUMBER], where there was a sign outside that room that stated the resident was on EBP. Staff T were observed to place gloves on their hands and enter the room. Staff T were then observed to assist the Resident 35 from the bedside commode. Staff T was observed to only be wearing gloves for PPE. Staff T were asked what the sign outside the room was instructed. Staff T stated that it was just a precaution and that you may have to use some of the PPE in the bin (they pointed at a PPE bin filled with gloves, gowns, mask and eye protection). Staff T stated they assist Resident 35 to use the restroom all day, that Resident 35 had an indwelling device and they do not ever wear anything but gloves in the room. Staff T was not able to explain what the purpose of EBP was, or when it was the appropriate time to use it with a resident. In an interview on 08/07/2025 at 10:19 AM, Staff B, Director of Nursing Services and Infection Preventionist stated that their expectation for all staff in the facility about EBP, where they were implemented when a resident had an open wound or indwelling device for all high contact care areas. Staff B stated toileting would be considered a high contact care area. Staff B stated it was their expectation that all staff were performing hand hygiene either with hand gel or hand washings for all interactions with residents and their belongs, during meal tray pass and they should be gelling in and out of every resident room. Staff B was not aware of the observations made during meal tray pass or observations of care for EBP. <RESIDENT 5> Resident 5 was admitted to the facility on [DATE]. Review of a physician order, dated 11/29/2024, showed Resident 5 received supplemental oxygen (O2) as needed for comfort and/or a change in their respiratory status. A physician order was received on 07/12/2025 for the resident to receive medication via a nebulizer (a small machine that turns liquid medicine into mist that could be easily inhaled) as needed every six hours for shortness of breath or wheezing. Review of Resident 5’s 07/01/2025 through 08/05/2025 Medication Administration Record and Treatment Administration Record (TAR), showed no direction to the nurse to change the O2 and nebulizer tubing. In an observation on 08/04/2025 at 12:30 PM, Resident 5 was in their room. The O2 concentrator (a medical device that provides pure O2) was stored against the wall, not in use and the O2 tubing with a nasal canula (NC - a tube that delivers O2 into the nose) was touching the floor. Resident 5 stated they did not know the last time they used it, but thought they used it when having some difficulty breathing. In an observation on 08/05/2025 at 8:08 AM, Resident 5 was using their oxygen concentrator. The NC was draped over their nose. When asked about using the O2, Resident 5 placed the NC prongs were placed into their nares. In an observation on 08/06/2025 at 8:45 AM, Resident 5 was sitting on the side of their bed. The O2 tubing was hung across a positioning bar on the right side of the bed and the and was not in a plastic bag. There was a nebulizer machine observed on top of a nightstand in the corner of their room. The nebulizer tubing was not dated, the mask was connected to the tubing, appeared dirty, and was not in a plastic bag. In an observation on 08/06/2025 at 11:17 AM, Resident 5’s O2 tubing was observed hanging over the positioning bar on the bed, the NC was resting in a shoe next to their bed, and the nebulizer was in the same position. In an interview on 08/06/2025 at 11:18 AM, Staff C, Registered Nurse, stated O2 and nebulizer tubing was changed weekly and as needed. Staff C stated the tubing should be labeled, dated when changed, and stored in a bag when not in use. Staff C located the O2 tubing was dated 08/03/2025 with blue ink. Staff C observed Resident 5’s NC in the resident’s shoe. Staff C stated if O2 tubing was observed on the floor or touching any other surface, it should be replaced. In an interview on 08/06/2025 at 11:25 AM, Staff N, Nursing Assistant Certified (NAC), stated the nurse or the NAC could change the residents O2 tubing. Staff N stated the tubing was not labeled/dated when changed. In an interview on 08/06/2025 at 2:24 PM, Staff B, Chief Nursing Officer, stated O2 and nebulizer tubing were changed weekly. Staff B stated the nebulizer should be taken apart, cleaned, air dried, and stored in a bag. Staff B stated the nurse would document on the TAR when the O2 or nebulizer tubing was changed. Refer to WAC: 388-97-1320 (1)(a)(c)

Based on interview and record review the facility failed to ensure 1 of 1 resident (Resident 1) who had a history of hypersexuality, and inappropriate touching was sufficiently supervised resulted in a resident-to-resident sexual contact. This failed practice placed Resident 1 and Resident 2 at risk of diminished quality of life. Findings included . Review of the American Parkinson Disease Association at https://www.apdaparkinson.org/article/impulsive-compulsive-behaviors-in-parkinsons-disease dated 02/27/2024 showed the side effects of dopamine agonists (stimulate the parts of the brain influenced by dopamine) included Impulse control disorders (ICD) is a set of behavioral abnormalities in which a person is unable to control urges or compulsions. Compulsivity can manifest in many ways, including hyper-sexuality. Compulsivity can be displayed in any activity including work, hobbies, or exercise, so it is important to consider whether the extent that the activity is being conducted is impairing quality of life. It is important to address these behaviors as soon as possible with the health care team, as early intervention can lead to improved results. Resident 1 was admitted to the facility on [DATE] with diagnoses to include Parkinson's disease, dementia with other behavioral disturbances, psychotic disorder with hallucinations, anxiety and major depression. Review of Resident 1's current care plan showed the following focus problems and interventions: Inappropriate Behaviors: The resident had a potential to exhibit hypersexuality, inappropriate sexual comments, groping, sexual request, inappropriate touching, initiated on 05/12/2022. * Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed, initiated on 05/12/2022. * Minimize potential disruptive behaviors by offering tasks or activity of choice which would divert Resident 1's attention, initiated on 05/12/2022. Review of Resident 1's December 2024, Medication Administration Record (MAR), Treatment Administration Record (TAR) and Behavior Monitor Record, showed the following: - Amantadine medication twice daily for Parkinson's Disease which has dopamine agonist properties - Carbidopa-Levodopa medication four times daily for Parkinson's Disease - Parkinson's disease behavior monitors three times daily and as needed for 1) inappropriate sexual comments, 2) groping, and 3) sexual request. No behaviors were documented for the month of December 2024. Review of Resident 1's December 2024, Documentation Survey Report (Nursing Assistant Certified (NAC) documentation), showed a monitor for the number of episodes of sexually inappropriate behaviors or comments. Resident 1 had seven documented episodes on the evening shift (2:00 PM to 10:00 PM) on 12/02/2024, 12/07/2024, 12/15/2024, 12/16/2024, 12/17/2024, 12/23/2024 and 12/31/2024. Review of the December 2024, nursing progress notes showed no documentation of Resident 1's sexually inappropriate behaviors on 12/02/2024, 12/07/2024, 12/15/2024, 12/16/2024, 12/17/2024, 12/23/2024 or 12/31/2024. Review of Resident 1's January 2025, MAR, TAR and Behavior Monitor Record, showed the following: - Amantadine medication twice daily for Parkinson's Disease which has dopamine agonist properties - Carbidopa-Levodopa medication (has known hypersexuality side effects) four times daily for Parkinson's Disease - Parkinson's disease behavior monitors three times daily and as needed for 1) inappropriate sexual comments, 2) groping, and 3) sexual request. No behaviors were documented for the month. Review of Resident 1's January 2025, Documentation Survey Report showed a monitor for the number of episodes of sexually inappropriate behavior or comments. Resident 1 had five documented episodes on the evening shift (2:00 PM to 10:00 PM) on 01/05/2025, 01/06/2025, 01/08/2025, 01/25/2025, and 01/26/2025. Review of the January 2025, nursing progress notes showed no documentation of Resident 1's sexually inappropriate behaviors on 01/05/2025, 01/06/2025, 01/08/2025, 01/25/2025, and 01/26/2025. Review of Resident 1's 02/01/2025 - 02/20/2025, MAR, TAR Behavior Monitor Record, showed the following: - Amantadine medication twice daily for Parkinson's Disease which has dopamine agonist properties - Carbidopa-Levodopa medication four times daily for Parkinson's Disease - Parkinson's disease behavior monitors three times daily and as needed for 1) inappropriate sexual comments, 2) groping, and 3) sexual request. No behaviors were documented from 02/01/2025 - 02/20/2025. Review of Resident 1's Documentation Survey Report from 02/01/2025 - 02/20/2025, showed a monitor to document for the number of episodes of sexually inappropriate behavior or comments. Resident 1 had one documented episode on the evening shift, on 02/10/2025, from 2:00 PM to 10:00 PM. Review of a facility incident report investigation for Resident 1 dated 02/09/2025, showed a NAC had reported something was going on in the activity room. The LN stated they witnessed Resident 1 holding hands and kissing a resident on the lips several times. The female resident was leaning into Resident 1 and kissing Resident 1 back. Review of a witness statement dated 02/09/2025, showed Staff A, NAC documented in the past they had witnessed Resident 1 holding hands with and attempting to kiss another resident, Resident 3. The residents were separated and kept an eye on each resident to make sure it would not happen again. Review of Resident 2's nursing progress note dated 02/09/2025 at 12:38 PM, showed the NAC reported something was going on in the activity room. The LN witnessed Resident 1 holding hands and kissing Resident 2 on the lips several times. Resident 2 was leaning into Resident 1 and kissing them back. The LN intervened by providing separation of the residents and educating Resident 1 they could not kiss Resident 2 as they had dementia and was unable to consent. Review of Resident 1's nursing progress notes dated 02/10/2025, at 9:44 AM, showed a NAC notified the Licensed Nurse to look in the activity room. Upon inspection the LN observed Resident 1 kissing a female resident (Resident 2) multiple times on the lips and holding hands. Resident 2 had a diagnosis of dementia. Resident 1 had asked why they could not kiss Resident 2 as Resident 2 had initiated the contact. The LN separated the residents and educated Resident 1 they could not kiss Resident 2 as they had dementia, and they were unable to consent to the sexual touch. (The nursing progress note did not denote as a late entry) Review of the in-service staff training dated 02/12/2025, showed staff were to maintain line of sight when Resident 1 and Resident 2 were in the same vicinity and to redirect Resident 1 and Resident 2 when observed interacting in a physical contact manner. In an interview on 02/19/2025 at 12:35 PM, Resident 2 was sitting in the dining room and motioned the surveyor over. Resident 2 asked the surveyor if they were going to do anything with this and gestured with their arms to the dining room. Resident 2 proceeded to state they worked there and had to walk to work. Resident 2 stated they had made friends with the people they worked with there and knew most of them and they were good people. In an interview on 02/19/2025 at 1:47 PM, Staff A, NAC, stated in the past there had been a few times Resident 3 touched Resident 1 where they had to keep an eye on them. Staff A stated if a resident needed enhanced supervision, it would be in the resident's care plan, Kardex, or they could ask the nurse or nurse manager. In a phone interview on 02/19/2025 at 2:22 PM, Staff B, NAC, stated Resident 2 and Resident 1 were in the TV room on 02/09/2025. Staff B stated they saw Resident 1 and Resident 2 kissing through the window to the TV room when they were walking down the hallway and reported the incident to the nurse. In an interview on 02/19/2025 at 2:28 PM, Staff C, Registered Nurse (RN), stated they recalled on 02/09/2025, one of the NACs came by the nurses' station and stated to look in the TV room. Staff C stated they saw Resident 1 and Resident 2 kissing. Staff C stated that was the first time they had seen resident to resident contact between Resident 1 and Resident 2 . In a phone interview on 02/19/2025 at 2:38 PM, Staff D, RN, stated on 02/09/2025, a NAC had come up to them and said to look in the TV room. Staff D stated they saw Resident 2 leaning into Resident 1 and Resident 1 was kissing Resident 2 several times. Staff D stated they then separated the residents. Staff D stated they had seen Resident 1 and Resident 3 friendly in the past, holding hands and nursing would intervene as Resident 3 would lean in and motion a puckered kiss with their lips. In an interview on 02/19/2025 at 4:01 PM, Resident 1 was sitting in their recliner in their room. Resident 1 stated Resident 2 had leaned forward when they were in the TV room, and they had leaned away from Resident 2 but then leaned toward Resident 2 and kissed them. Resident 1 stated they were unaware Resident 2 had dementia . In an interview on 02/20/2025 at 1:23 PM, Staff E, NAC, stated the residents' behavioral interventions were on the residents' Kardex and in the MDS binder. Staff E stated the Point of Care (the NACs electronic documentation program) dashboard would notify them if a resident had any new alerts or changes in conditions. In an interview on 02/20/2025 at 1:47 PM, Staff F, NAC, stated the residents' behavioral interventions were on the Kardex where they could chart specific interventions that worked well with the residents. Staff F stated they try to make it not so obvious, but they would distract Resident 1 by offering to go watch a movie, offer snacks, black tea, or redirect the resident back to their room. In an interview on 02/20/2025 at 1:58 PM Staff G, Licensed Practical Nurse (LPN)/ Resident Care Manager, stated the staff should redirect Resident 1 if they saw them by a female resident. In an interview on 02/20/2025 at 2:36 PM, Staff H, LPN, stated if there was a situation where Resident 1 was with another resident, particularly a female resident, you would make sure not to leave the residents alone but would have staff there to redirect if needed. In an interview on 02/20/2025 at 3:22 PM, Staff I, RN/ Chief Nursing Officer, stated the staff should have Resident 1 in their line of sight. Staff I confirmed Resident 1 should be supervised when around female residents after reviewing the resident's care planned focus problem for inappropriate behaviors with potential to exhibit hypersexuality, inappropriate sexual comments, groping, sexual request, and inappropriate touching dated 05/18/2022. Reference WAC 388-97-1060 (3)

Based on observation, interview and record review, the facility failed to ensure there was sufficient nursing staff for 3 of 4 sampled residents (Residents 1, 2, and 4) reviewed for care and services. The facility had insufficient nursing staff to answer call lights and to provide care and services for a cognitively impaired resident resulting in the residents having unmet needs. These failures placed all residents at risk for accidents and diminished quality of life. Findings included . Definition: Reasonable Person Concept: a standard used to determine whether an individual's actions or responses align with what a hypothetical reasonable person would do under similar circumstances. It defines the behavior expected of an ordinary, prudent, and rational individual. <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include dementia (a condition where a person has a loss of cognitive functioning and has impairments with thinking, remembering and reasoning to such an extent it interferes with their daily life and activities). According to the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 07/31/2024, the resident had severe cognitive impairment, needed or wanted an interpreter to communicate with healthcare staff as English was their second language, and they were dependent (dependent - helper does All of the effort, resident does none of the effort to complete the activity) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/taking off footwear, and personal hygiene), were frequently incontinent of urine and occasionally incontinent of bowels, and they had a condition or chronic disease that may result in their life expectancy to be less than six months. In an observation/attempted interview on 08/06/2024 at 8:45 AM, Resident 1 was lying in bed, their call light was at the foot of the bed and not within their reach. The lower half of the resident's body was uncovered, their groin and legs were exposed and visible from the doorway, their incontinent brief was off them and laying on the bed. The bedside table with their drinks was positioned away from the bed and not within their reach. The resident was awake, but they did not respond when spoken to. An interpreter was obtained to assist with the interview and Resident 1 was unable answer interview questions appropriately despite the interpreter's assistance. In a joint observation on 08/06/2024 at 8:55 AM, Staff A, Director of Nursing (DON), was asked to come in the room to observe the resident. Upon entering Resident 1's room, Staff A observed the resident and immediately left and said they were going to get a nursing assistant. In an interview on 08/06/2024 at 9:45 AM, Staff A, DON, was asked their impression of the observation of Resident 1 on 08/06/2024 at 8:55 AM, they stated that it was disappointing but not out of the norm for the resident as they have had rejections of cares, they throw items, they undressed themselves, they threw their call light, and there was a language barrier. Based on the Reasonable Person Concept, a reasonable person in Resident 1's condition would not have wanted to be left with their legs and groin uncovered and visible from the doorway, they would have wanted their call light to be within their reach, and they would have wanted their bedside table with their drinks to be within their reach. <RESIDENT 2> Resident 2 admitted to the facility on [DATE] with diagnoses to include a below the knee amputation, bipolar disorder (a disorder that causes extreme mood swings that includes emotional highs and lows (depression), psychosis, morbid obesity, difficulty in walking, generalized muscle weakness and abnormalities of gait and mobility. According to the quarterly MDS assessment, dated 06/28/2024, the resident had no cognitive impairment. Review of Resident 2's care plan, print date 08/07/2024, showed they were at risk for falls due to impaired mobility. Review of an incident investigation, dated 06/05/2024, showed Resident 2 complained their call light had been on for over an hour. The facility concluded the resident was having increased behaviors and was manipulating staff with contributing factors of lack of communication between nursing assistants at lunch and break times and there was a miscommunication about who was supposed to be answering the resident's call light during a break. In an interview on 08/06/2024 at 12:35 PM, Resident 2 was asked about the incident where their call light went unanswered by staff for over an hour, they stated it was on dayshift, They couldn't get help, so they ended up having a bowel movement their pants. Resident 2 stated just that morning, I ended up peeing in my pants after they waited over 20 minutes for help to come take them to the bathroom and no staff came. Resident 2 stated call lights taking too long was not specific to a certain shift or day, but it happened a lot. Resident 2 stated there was just not enough help here. In an interview on 08/07/2024 at 9:03 AM, Staff A, DON, stated she had talked to Resident 2, and they were trying to figure out a solution for their toileting needs. <RESIDENT 4> Resident 4 admitted to the facility on [DATE] with diagnoses to include a fractured vertebra, generalized muscle weakness, difficulty in walking, and a history of falls. According to the admission MDS assessment, dated 05/16/2024, the resident had no cognitive impairments, they had a history of a fall in the last month prior to admission, and had a fracture related to a fall six months prior to admission. In a call light observation on 08/06/2024, Resident 4's call light was observed to come on at 12:45 PM, and it was turned off at 12:47 PM. In an observation/interview on 08/06/2024 at 12:52 PM, Resident 4 was asked if staff had taken care of their needs when they used their call light. The resident stated they had used their call light prior to this interview to get help to go to the bathroom, but the staff member that came in was informed of the resident's need to use the bathroom, turned the call light off, took their lunch tray and left the room without helping them go to the bathroom. Resident 2 stated they were supposed to have help to transfer, and they can't wait too long after they had fluids, or they would have to get themselves up. Resident 4 stated they had two falls since they admitted to the facility. Resident 4 stated they needed more help around here, that the staff want them to call for help to get up, but then no one came to help, then when they came, they just took their lunch tray away and didn't help them go to the bathroom. The resident pointed to a sign on their wall that read Call for assistance, do not attempt to self-transfer! Resident 4 was observed to get up out of bed and start walking toward the bathroom without assistance. Review of Resident 4's current care plan, as of 08/07/2024, showed they had a problem/focus area of an actual fall related to attempting to self-transfer and increased weakness. An intervention included in this focus area was to encourage the resident to request assistance when ambulating. In an interview on 08/06/2024 at 1:14 PM, Staff B, Shower Aide/Nursing Assistant Certified (NAC), stated there was not enough staff working to get all their work done, they stated they were currently working with just three nursing assistants. Staff B stated they were the shower aide but get pulled to work the floor as a nursing assistant, and it was difficult to get their showers done. Staff B stated Staff C, NAC, had gone home sick before breakfast today, but that they were on light duty anyway and not much help. In an interview on 08/06/2024 at 1:26 PM, Staff A, DON, stated staff were not supposed to turn off residents' call lights if they had not taken care of their needs. Refer to WAC 388-97-1080 (1)

Based on observation, interview and record review, the facility failed to ensure professional standards were met for 2 of 2 halls (North and South) reviewed for medication administration, and 1 of 1 (Resident 27) residents reviewed for physician consultations. The facility failed to ensure that the paper medication administration record (MAR) had the physician orders printed clear and complete to allow for licensed staff to properly administer the prescribed medications during an internet outage where the licensed staff were unable to access the electronic medication administration records (eMAR). The facility failed to ensure the licensed staff followed a physician order, and failed to obtain a specialist referral that was ordered by the physician. These failures placed the residents at risk for adverse outcomes, medication errors, complications, and unmet needs. Findings included . Review of the facility policy titled, Medication Management, revised 10/15/2022 stated medications are administered by staff as prescribed by the attending physicians or other licensed independent practitioner . licensed staff who administer medications are responsible for staying proficient in administering medication following evidenced-based practice guidelines . physician's orders are clear, legible, and transcribed appropriately. <MEDICATION ADMINISTRATION> NORTH HALL - RESIDENT 13 In an observation on 07/30/2024 at 8:50 AM, Staff D, Licensed Practical Nurse (LPN) and Staff J, Resident Care Manager were both working to pass medications on the North Hall. Staff D flipped through the Medication Administration Record (MAR) binder and Staff J would look at the orders before punching the medications out of the card. Staff D said that they had an internet issue and had to resort to printed out MAR's instead of an electronic medical record (EMR). Staff D said whoever printed out the MAR's printed them, but it cut off the first letters of each medication. At 8:55 AM Staff J dispensed Miralax 17 GM (gram) in a glass of water. Review of the MAR showed the medication Lax powder Miralax 17 GM in 8 oz (ounce) water. Staff J dispensed Spironolactone 25 MG (milligram) when the MAR indicated onolactone 25 MG to be given. Staff J administered Iptropium Bromide Monohydrate 18 micrograms (MCG), the MAR showed opium Bromide Monohydrate Similar observations were Vitamin C card as min C, Xaban for Apixaban, Sate Sodium for Docusate sodium, gabalin for Pregabalin, bicort for Symbicort, and Sorbide for Isosorbide. At 9:00 AM, Staff J and D reviewed the MAR which read Semide 60 MG Staff J located a card that showed the medication Torsemide. This surveyor asked how they knew the medication was Torsemide and not Furosemide. Staff G, LPN/IP (infection preventionist) was present at the medication cart and said, Well the Torsemide card says it was for CHF (congestive heart failure). Staff G said the facility knew there was going to be a scheduled EMR outage so they printed the MARS yesterday but whoever printed them, printed them incorrectly so the first few letters were absent. Staff D and G said the MARS were only incorrectly printed for Resident 13. Staff G said the person who printed the MARS should have set up the printer as print to screen so the entire medication orders were clear. Staff G said there were not physician orders printed for them to verify the orders. Staff G said they understood the accuracy of the MARS should have been verified before they were put out for the nurses. Torsemide 60 MG was dispensed and administered to Resident 13 with the only means of verifying the order as the pharmacy card. In an interview on 07/30/2024 at 12:28 PM, Staff A, Director of Nursing Services and Staff B, Resource Nurse were informed of the concerns with Resident 13's med pass this AM. Staff A did not know there was an issue with the nurses not knowing how to correctly print out MARS. Staff A said medical records printed them out but did not select the box for print to page. Staff A and B said they would in-service the nurses on being able to print MARS. They were not aware this issue until today. 44110 NORTH HALL - RESIDENT 10 Resident 10 admitted to the facility on [DATE] with diagnoses to include cancer of the pancreas, and dementia. The quarterly minimum data set (an assessment tool) (MDS) dated [DATE] showed the resident had severe cognitive impairment. In an interview on 07/30/2024 at 8:26 AM, Staff D, Licensed Practical Nurse (LPN) stated their internet was down and they were unable to access the EMAR system. Staff D stated that the facility had printed out the medication administration record (MAR) on paper for them to conduct their morning medication pass. Staff D stated the physician orders were hard to read and they had to keep flipping the papers back and forth as the copies were not in order. Review of the printed MAR on 07/30/2024 that Staff D had referred to showed that the first few letters of all the orders were cut off and missing. All the orders were missing various parts of physician orders such as: the medication names, the route, the dose, the duration, directions or reason for use. In a joint interview/record review on 07/30/2024 at 8:30 AM, Staff D used printed MARs to prepare Resident 10's medications. The MARs had multiple medications that were not printed in their entirety and showed the following: - casone propionate nasal 50 micrograms of actuation (mcg/act) - Staff D stated that the medication was Fluticasone Propionate Nasal Suspension (medication to treat allergies) 50 mcg/act and presented bottle with the resident's name on the label, - iple vitamin-minerals tablet one tab by mouth one time a day - Staff D stated that the medication was Resident 10's multivitamin with minerals and presented a bottle of house supply medication matching this name, - ium oral table 2 mg zepam) 0.5 tab by mouth on time a day for a neuroendocrine cancer - Staff D stated that the medication was diazepam (valium) (medication used to treat anxiety) and presented bubble medication pack with the resident's name on the label, - nna oral tablet 8.6 milligrams (mg) by mouth one-time as for constipation hold for loose ols, - Staff D stated that the medication was the resident's senna (stool softener) 8.6 mg and presented house supply medication matching this name, - oprolol tartrate oral tablet 50 (metoprolol tartrate) 25mg by mouth two times a related to essential imary) hypertension, - Staff D stated that the medication was Resident 10's metoprolol (medication for high blood pressure) for their blood pressure and presented bubble medication pack with the resident's name on the label, - atoprazole sodium oral tablet yed release 40 mg atoprazole sodium) 40 mg by mouth two times a related to storintestional morrhade, unspecified, - Staff D stated that the medication was pantoprazole (medication for stomach acid reflux) 40 mg and presented bubble medication pack with Resident 10's name on the label, - taminophen oral table 325 (acetaminophen) 650 mg by mouth three times related to malignant oplasm of pancreas, - Staff D stated that the medication was Tylenol (pain medication) and presented house medication bottle of Tylenol, - bapentine oral capsule 100 mg bapentin)100 mg by mouth three times for pain - Staff D stated that the medication was Resident 10's gabapentin (medication for nerve pain) 100 mg capsule and presented bubble medication pack with the resident's name on the label, - [NAME] aspart flex pen cutaneous solution pen ctor 100 unit per milliliter (ml) (insulin as per sliding scale -69 = 0 units, - 99 = 0 units, 0 - 150 = 0 units, - 200 = 2 units, - 300 = 4 units, - 400 = 6 units, - 999 = 6 units recheck in 2 rs and notify provider if -450 - Staff D stated that the medication was Resident 10's insulin (medication injected into skin to manage blood sugar levels) pen and presented the insulin pen in a bag with the resident's name on the label, - etiapine fumarate oral tablet mg (quetiapine fumarate) 50 mg by mouth three times a related to malignant oplasm of pancreas - Staff D stated that the medication was Resident 10's Seroquel (medication that manages psychosis) and presented bubble medication pack with the resident's name on the label. In an observation on 07/30/2024 at 8:40 AM, Staff D was observed to administer the prepared medications to Resident 10. In an interview on 07/30/2024 at 9:59 AM, Staff D stated that they were now able to use the internet and were accessing the eMAR system for medication administration. Staff D was asked for copies of the printed MAR from the previous observed medication administration, and stated they were available in the binder next to the medication cart. Staff D stated they had not signed off on all the medications yet, they would need to go back and do that, stating they were just trying to get the medication pass done. SOUTH HALL - RESIDENT 9 In an observation on 07/30/2024 at 8:45 AM, Staff L, RN and Staff G, LPN, SDC/IP were passing medications on the South unit. The MARs on this unit had similar findings that showed the beginning letters of the medications missing for each resident's medication orders. <PHYSICIAN ORDERS> RESIDENT 27 Resident 27 admitted to the facility on [DATE] with diagnoses to include diabetes (medical condition in which the body doesn't use insulin properly), and protein calorie malnutrition. The quarterly MDS dated [DATE] showed the resident had intact cognition. In an interview on 07/25/2024 at 9:45 AM, Resident 27 stated that they have had a lot of episodes of diarrhea, and that they have talked to the nurse and the physician, but no one has done anything about it. Review of Resident 27's bowel monitoring record for 07/01/2024 - 07/30/2024 showed the resident had loose stool eleven times. Review of Resident 27's physician notes on 07/29/2024, showed the physician noted that the resident was having increased chronic diarrhea (loose stools), loperamide (anti-diarrheal medication) was advised to be administered, and there was an order to refer the resident to a gastrointestinal (GI) specialist. Review of Resident 27's physician orders showed an order for loperamide 2 mg, give one tab by mouth as needed for diarrhea and not to exceed 16mg in a 24-hour period. Review of Resident 27's MAR for 07/01/2024 - 07/30/2024 showed the resident had been administered the medication Loperamide, 17 times in the month of July. Review of Resident 27's medical record on 07/29/2024 showed documentation that the resident had been seen by a GI physician related to the chronic diarrhea. In an interview on 07/30/2024 at 10:37 AM, Staff K, LPN/Resident Care Manager (RCM) stated they believed Resident 27's diarrhea and loose stools were related to the medications that they were taking for their diabetes. Staff K was asked if there had ever been a GI consult completed, as the physician had noted that in their provider note on 05/29/2024. Staff K stated they were unaware of any consultation orders and would follow up. In an interview on 07/30/2024 at 10:57 AM, Staff A, DNS stated they were aware that the resident was having diarrhea and/or loose stools. Staff A stated they had contributed the diarrhea/loose stools to Resident 27 ordering and having take-out food delivered. Staff A stated they were not aware that the provider had ordered a consult for a GI referral in May 2024. In a follow up interview on 07/30/2024 at 11:34 AM, Staff K stated they were able to locate the order and stated it had not been completed as ordered. In a joint interview on 07/30/2024 at 12:09 PM Staff A, DNS and Staff B Clinical Resource Nurse/Registered Nurse (RN), Staff A stated that the expectation when the internet or power was out was that medical records would print off the MARs from the emergency backup, for the licensed staff to administer medications and follow the physician orders. Staff A stated that they originally had printed MARs for the staff the day before (07/29/2024), as there was a schedule eMAR outage that was to occur from 11:30 PM (07/29/2024) - 1:30 AM (07/30/2024). Staff A stated the outage was to only be for a few hours, however the internet went down so they used the same printed MAR they had printed out on 07/29/2024. Staff A stated they were not aware that the printed MAR that was given to the licensed staff did not have the full orders and the copies were cut off and missing various parts of the physician orders including parts of the names of the medications, the route, the dose, the duration, directions or reason for use. Staff A stated there was no other way to confirm the physician orders were accurate, and that staff should not have used the pharmacy labels to verify the orders. Staff B stated the physician orders should have been clear, accurate, up to date, and there should have been a system in place to verify the orders. Refer to WAC 388-97-1620(1)(2)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure Nursing Assistants Certified (NACs) had the appropriate competencies, skills sets and proficiencies to provide nursing and related services for each resident in accordance with the facility assessment when nursing staff failed to demonstrate the knowledge, skills and abilities to perform nursing services for 5 of 5 sampled staff (Staff H, I, Q, R, and S) reviewed for competent nursing staff. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Employee Orientation, dated 11/28/2017 stated that the facility will validate nurse aide's competency in skills and techniques. Review of the facility assessment under the title Sufficiency analysis summary, dated 07/26/2023-07/25/2024, for resident population stated that education was provided through the orientation process, monthly competencies, and annual skills fairs. Monitoring of competencies was accomplished through senior leader rounding, mentoring program, return demonstration during monthly skills check, and staff coaching (mentorship program). Staff H, NAC, was hired by the facility on 02/22/2017. Staff H's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. Staff I, NAC was hired by the facility on 08/04/2023. Staff H's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. Staff Q, NAC was hired by the facility on 01/10/2023. Staff H's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. Staff R. NAC was hired by the facility on 11/10/2021. Staff H's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. Staff S, NAC was hired by the facility on 11/11/2022. Staff H's training records did not include documentation they were assessed to be competent to provide nursing services to the facility's resident population. In an interview on 07/26/2024 at 1:24 PM, Staff B, Registered Nurse/Clinical Resource Nurse stated the facility had not been completing competencies for their staff and they were unable to locate competencies for the five staff requested. In an interview on 07/30/2024 at 12:09 PM, Staff A, Director of Nursing Services stated that the Infection preventionist/Staff Development Coordinator role was responsible for completing competencies for all nursing staff. No further information was provided. Refer to WAC 388-97-1680(2)(a)(b)(i-ii)

Based on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 2 nurses (Staff D, Licensed Practical Nurse) during medication administration, for 1 of 1 laundry room, and failed to review and revise their infection control program annually. The facility failed to ensure the staff followed appropriate infection control practices during medication administration when the licensed staff did not use a barrier during medication administration or perform hand hygiene prior to administering medications. The facility failed to have a system in place where the staff were knowledgeable, trained and able to initiate appropriate processes for the handling of potential contaminated linens to prevent cross contamination. These failures placed all residents and staff at risk for potential infection. Finding included . Review of the facility policy titled, Infection Prevention and Control Program, revised 10/15/2022 stated the infection control prevention and control program was designed and implemented to identify and reduce the risk of acquiring and transmitting infections among residents, and staff. It was to maintain a safe and sanitary environment that involves all departments .the program will be reviewed at least annually and revise the infection control risk assessment when opportunities for improvement are identified . develop staff training and protocols to prevent the spread of infection. Review of the facility policy titled, Medication Management, revised 10/15/2022, stated authorized staff follows appropriate infection control practices when preparing and administering medications such as hand hygiene, and the use of barriers are utilized to promote infection prevention practices. <MEDICATION ADMINISTRATION> In an observation on 07/30/2024 at 8:28 AM, Staff D, Licensed Practical Nurse (LPN) entered the room of Resident 10 and placed an insulin (medication injected into the skin to regulate blood sugar levels) pen on the resident's bed on top of their blanket that was covering their body. Staff D then placed the nasal spray bottle and medication cup on top of the over the bed table next to the resident's food tray, no barriers were used. Staff D then administered the medications that were in the medication cup by placing medication cup at the resident's mouth and pouring in the pills with a bare hand, no hand hygiene was observed. Staff D then placed the medication cup back on the over the bed table and with a bare hand picked up the nasal spray and applied one squirt of medication spray into each nostril, placed the bottle back on the over the bed table, no hand hygiene was observed. Staff D then placed a pair of gloves on their hands, no hand hygiene was observed, lifted the shirt of the resident to expose their stomach, grabbed the insulin pen from the bed, wiped the skin with alcohol wipe and administered the injectable medication. Staff D then walked into the resident's bathroom, removed needle cap and disposed in an appropriate disposal bin, removed their gloves, no hand hygiene was performed. Staff D retrieved nasal spray from the over bed table and walked out of the room. Staff D walked to the medication cart placed nasal spray bottle and insulin pen on top of the medication cart, then performed hand hygiene. In an interview on 07/30/2024 at 8:34 AM, Staff D was asked if they were supposed to use a barrier when entering a resident's room with medications. Staff D stated I didn't use one, I forgot, and I should have. Staff D was asked about hand hygiene and stated they did when the left the room. Staff D did not offer any further information. <LAUNDRY PROCESSING> In an observation and interview on 07/30/2024 at 9:13 AM, Staff O, housekeeping attendant was observed to answer the door with sign that read soiled linen. Staff O was wearing an isolation gown and gloves. Staff O stated they were sorting and loading dirty linen. Staff O stated they used the soiled linen door side to enter the laundry room. Upon entering the door, the door was unable to open all the way as there were sorting bins behind and in front of the door. The flooring in the laundry room was observed to have numerous brown stains, and missing pieces of linoleum on the floor. The washing machines were observed to have thick dust and debris on top and the sides of the machines. Staff O stated they tried to periodically wipe the machines down when they had time, they stated there was no set time or procedure for wiping the machines down. Staff O was asked if they wiped the machines down between loads, and Staff O stated that was not what they were educated to do. The marked area for clean linen was very small area. The table where the clean linen was to be folded had only about 18-inch area to work in, as there was a large pile of clothes laying on top of most of the table. There were two laundry baskets full of clothes and linens, one basket was up against the clean linen door. Staff O stated, I don't really have any room in here, and all the piles of clothes are unlabeled, and they must find somewhere to put them. In an interview on 07/30/2024 at 10:38 AM, Staff P, Housekeeping Manager was asked what the process was for clean and disinfecting the washing machines between loads. Staff P stated they were not aware of any procedure. Staff P stated they were just promoted to the role of manager less than a month ago and had not had any training on infection control prevention policies and procedures for ensuring there was no cross contamination of infections through the washing process. <INFECTION CONTROL STANDARDS> Review of the facility policies and procedures for infection prevention and control on 07/26/2024 showed that all the policies and procedures requested had not been revised since October of 2022. In an interview on 07/30/2024 at 10:13 AM, Staff G, LPN/Infection Preventionist stated they were responsible for educating the staff on infection control practices at the facility. Staff G stated the expectation for licensed staff during medication administration was they should be performing hand hygiene appropriately, and always use a barrier for all items taken into the room to administer medications. Staff G stated they had not conducted any risk assessment or review of the infection control practices in the facility. In an interview on 07/30/2024 at 11:03 AM, Staff B, Registered Nurse (RN)/Clinical Resource Nurse stated they were trying to locate a risk assessment and review of the infection control practices. Staff B stated if they did not locate one, more than likely they did not have one. Staff B was unable to locate any information. In an interview on 07/30/2024 at 12:09 PM, Staff A, Director of Nursing Services stated that the expectation for all licensed staff performing medication administration was they were to use a barrier for all items brought into the resident's room. Staff A stated they were unaware that Staff P had not had any training for their new position as housekeeping manager, and that Staff P was unaware of the infection control practices related to laundry and processing of linens. Staff A was unaware that the infection control program and risk assessment of the facility had not been completed annually. Staff A stated Staff G was responsible for managing the infection control program and overseeing that all staff are educated and demonstrating proper infection control practices. Refer to WAC 388-97-1320(1)(a)(c)(2)(b)(3)

Based on interview and record review, the facility failed to ensure residents had access to Saturday mail deliveries for 2 of 6 sampled residents (Residents 27 and 2) reviewed for mail delivery. The failure to ensure residents had access to Saturday mail services placed them at risk for isolation, frustration and diminished quality of life. Findings included . Review of the facility policy titled Resident Rights, dated 10/15/2022, showed residents have a communication right of private and unrestricted communication that includes the right to receive, send and mail sealed, unopened correspondence. <RESIDENT 27> Resident 27 admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 06/24/2024, the resident had moderate cognitive impairment. In an interview on 07/29/2024 at 10:00 AM, Resident 27 stated they had received an email on Saturday that mail had been delivered by the postal service, but no one goes and gets the mail so they couldn't have that mail on Saturday, and they had to wait. <RESIDENT 2> Resident 2 admitted to the facility on [DATE]. According to the quarterly MDS, dated [DATE], the resident had no cognitive impairment. In an interview on 07/29/2024 at 10:00 AM, Resident 2 stated the postal service brings the mail into the building on Saturdays, but it's not distributed to residents until Mondays. In an interview on 07/29/2024 at 11:27 AM, Staff M, Business Office, confirmed that mail was not passed out on the weekends. In an interview on 07/29/2024 at 11:32 AM, Staff N, Hospitality Aide, stated they retrieve the mail from the box on the weekends, and they place it in Staff M's box until Monday. Refer to WAC 388-97-0500 (1)

Based on interview, and record review the facility failed to ensure staff provided the necessary assessment, interventions, monitoring of the impacted skin area, and care for 1 of 1 resident (Resident 1) who was identified to have a Deep Tissue Injury (DTI) from a knee brace/immobilizer and subsequently developed an avoidable unstageable pressure ulcer/pressure Injury (PU/PI). Resident 1 experienced harm when they developed an unidentified wound to the area under their brace (also known as an immobilizer - a medical device that stabilizes your knee joint and holds it in place) and this practice placed all other residents with a brace or appliance at risk of the development of a PU/PI. The facility corrected the above deficient practice prior to the initiation of the abbreviated survey on 12/21/2023. This failure was a past noncompliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified) situation of actual harm and was no longer outstanding. The facility removed the harm by completing the following: - Terminated Staff A, Licensed Practical Nurse/Resident Care Manager (RCM); - Conducted skin inspection evaluation on all residents; - Identified and audited all residents with splints and devices; - Audited all residents' bathing and bathing refusals; - Initiated a two licensed nurse skin check for all new admission; - Educated staff on the following: - Refusal of Treatment policy; - Pain Management policy; - Removable or Preformed Splint policy; - Prevention and Treatment of Pressure Ulcers; - Other Skin Alterations policy; - Physician Orders policy; - Timely charting; - Timely wound care orders; and Implemented a plan of correction to sustain ongoing compliance. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, includes the following definitions: - A PU is defined as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, because of intense and/or prolonged pressure or pressure in combination with shear. The PU/PI can present as intact skin or an open ulcer and may be painful. - A Deep tissue injury requires vigilant monitoring because of the potential for rapid deterioration. - Unstageable Pressure Ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed, should be classified as unstageable. - Moisture Associated Skin Damage (MASD) is a superficial skin damage caused by sustained exposure to moisture such as incontinence, wound drainage, or perspiration. Review of the facility's policy titled, Removable or Preformed Splint, dated 11/28/2017, showed to assess the area where the splint is to be applied to and check the resident's skin for open areas. Resident 1 was admitted to the facility on [DATE] with diagnoses to include fracture of the right and left femur (upper thigh bone), unspecified deformity of the right and left lower legs, anxiety, and depression. Review of the hospital Discharge Summary, dated 12/04/2023, showed the recommendations for the bilateral (right and left) femur fractures were to continue immobilization with bilateral knee immobilizer braces. A right lower extremity hematoma (a bad bruise) secondary to traumatic injury was noted to be managed with compression with the use of elastic wrap bandage wrapping. Review of the 12/04/2023 Admission Summary note, showed Resident 1 required a two-person assist with bed mobility, was incontinent of bowel and bladder and knee immobilizer braces were present on both of the resident's legs (there was no documentation to describe the length of the knee immobilizer braces). Review of the Skin Inspection Evaluation, dated 12/04/2023, showed in the Skin Health section bilateral lower extremity (BLE), Resident 1 had scattered bruising with edema (swelling), left lower extremity reddened spot noted to medial (midline) ankle area, immobilizer braces to BLE present on admission. The evaluation showed the house provider would address the skin issues, and the care plan section was blank. Review of Resident 1's Treatment Administration Record (TAR), dated 12/04/2023, showed Resident 1's weekly skin check had no new identified skin impairments/concerns. Review of Collateral Contact (CC) 1, Advanced Registered Nurse Practitioner (ARNP), progress note, dated 12/06/2023, showed Resident 1 had BLE immobilizers. Review of the facility's Skin and Wound Evaluation completed by Staff A, dated 12/08/2023, showed an incomplete evaluation with identified MASD to their coccyx (bottom). The evaluation did not address the hematoma to the resident's right lower extremity. Review of the Admission Minimum Data Set (MDS - an assessment tool) assessment, dated 12/10/2023, showed Resident 1 was admitted without a PU but was identified at risk for the development of a PU. Review of the PU Care Area Assessment (a systematic process to interpret the triggered information from the MDS assessment to assess the potential problem and determine if the area should be care planned), dated 12/10/2023, showed Resident 1 was admitted for rehab after a fall resulting in bilateral femur fractures, a right lower extremity hematoma, and would be care planned at risk of PU development related to the resident's incontinence, limited mobility oxygen tubing and lower extremity immobilizers. Skin was monitored during care, MASD was present, and a rash to the resident's chest and back. Review of the Skin Inspection Evaluation assessment completed by Staff A, dated 12/11/2023, showed Resident 1 had no new skin impairment. The assessment did not identify the resident's bilateral knee immobilizer devices and the Care Plan for potential or actual skin alteration was blank. Review of the 12/11/2023 TAR, showed Resident 1's weekly skin check had no new identified skin impairment/concerns. Review of a progress note, dated 12/11/2023, showed Staff A documented Resident 1 had BLE immobilizers, with no documentation the immobilizers were removed and the resident's skin was assessed. Review of a progress noted, dated 12/12/2023, CC2, Medical Doctor, showed Resident 1 had an extensive right lower extremity wound under the immobilizer that was actively oozing and was sent to the emergency department. Review of the nursing progress notes, dated 12/04/2023 through 12/11/2024, showed no documentation regarding Resident 1 had a PU under their brace. Review of a clinical progress note, dated 12/06/2023, showed CC1 assessed the resident and documented Resident 1's bilateral femur fractures were being conservatively managed with bilateral immobilizer. Review of an Addendum clinical progress note, dated 12/27/2023, showed that CC1 added to their 12/06/2023 progress note (the addendum added to the note was made 21 days ago), showed to continue Resident 1's BLE immobilizers, the resident was likely to have a DTI given features of wound such as palpability, dark purplish color, lack of blanching, presence of DTI risk (immobilizers). CC1 documented features unlikely to be hematoma as noted while the resident was in the hospital. Review of the hospital After Visit Summary from 12/12/2023 through 12/14/2023, showed Resident 1 reported their braces/immobilizers had not been removed since 12/04/2023. According to the summary, the resident's right lateral shin/calf wound was 11 cm (centimeters) by 5 cm by 0.4 cm. The wound bed was covered with dark black/red with non-viable tissue, with moderate amount of drainage, the wound edges were open and the skin surrounding the skin was purple, boggy, and painful with gentle touch. Review of the Care Plan printed on 12/28/2023, show no identified focus problem care planned to address Resident 1's braces/immobilizers or the risk of developing a PU. In a phone interview on 01/04/2024 at 5:14 PM, CC1 stated on 12/06/2023 they had observed Resident 1's right shin and stated it was hard to see with the immobilizer in place but felt the resident had a DTI and felt that standard DTI orders were in place at the facility. CC1 stated they presumed the standard orders were in place and had not order specific wound orders. CC1 confirmed they received education from the facility's Director of Nursing Services (DNS) to make sure their documentation was timely, specifically related to skin charting, and communication with the staff. In an interview on 01/09/2024 at 3:30 PM, Staff B, DNS, stated they were made aware of Resident 1's skin issues on 12/12/2023 and implemented a Performance Improvement Plan. Staff B stated in the facility's investigation they found that Staff A failed to follow through with clarifying Resident 1's physician orders regarding the resident's knee immobilizer, accurately assess the resident's skin, document a thorough and accurate skin assessment, and was terminated due to Staff A's lack of follow through with resident wounds. Staff B stated they had conducted audits of all recent admissions along with wound care treatments. Staff B stated they had provided education with the staff including CC1 on wound care treatments and timely documentation. Staff B stated they implemented a new admission procedure where two nurses, the Nurse Manager along with a Licensed Nurse, completed the resident's skin assessments. Staff B stated their audits were ongoing to ensure continued compliance with weekly audits for four weeks and monthly audits for six weeks. The Performance Improvement Project would continue to be reviewed at the facility's Quality Assessment and Assurance/Quality Assurance Performance Improvement meeting until no longer deemed necessary. Refer to WAC 388-97-1060(3)(b)

Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1), reviewed for falls, received supervision with two-person assist with transfers and was not left unattended while on a bedside commode (BSC), had the effectiveness of current interventions evaluated, and had additional fall measures implemented to prevent future falls. Resident 1 was harmed when they had five falls within a nine-week period from their admission to the facility while they were self-transferring to or from the toilet or BSC, and during the last fall, the resident experienced a fractured hip. This failed practice placed all residents at risk for prevention of falls and possible injury. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (brain dysfunctions due to problems with your metabolism), urosepsis (sepsis caused by infections of the urinary tract), Clostridium difficile (a bacterium that causes an infection in the colon), residual effects for prior stroke, heart failure, weakness, and adult failure to thrive (when a resident has a loss of appetite, loses weight and is less active than normal). Review of the 48-hour Care Plan, dated 08/23/2023, showed Resident 1 was care planned for a two person assist with toileting to a BSC, was incontinent of urine, transfers and mobility required two person assist, one person extensive assist for dressing, English was not their primary language, and used a communication board. Review of the first fall incident report investigation, dated 08/25/2023, showed at 7:30 AM Resident 1 was found lying on the floor next to their bed when the licensed nurse entered the room. The report showed five minutes prior to finding the resident lying on the floor, the resident had asked for their spouse. Resident 1 stated to the staff bathroom (BR), pointed to the BR, and asked where their spouse was when found on the floor. The report identified the resident was oriented to person only. The Predisposing Physiological Factors section of the report showed the resident to be confused with impaired memory, weakness/fainted, gait imbalance and incontinence. The fall prevention interventions documented showed the resident transferred to a two person assist (this was not a change or a new interventions implement that had been already identified on the initial 48-hour Care Plan dated 08/23/2023), encourage the resident to wear non-slip socks (specifically-designed footwear to reduce the risk for slipping) at all times, and to continue to work with Physical and Occupational Therapy (PT/OT) on safe transfers. Review of a provider note, dated 08/25/2023, showed the nursing staff noted Resident 1 had a ground level fall from their bed on 08/25/2023. The note showed the resident with persistent encephalopathy since discharge from the hospital, and their spouse reported their encephalopathy was unchanged from their recent hospitalization . The resident's history of present illness included unspecified cognitive impairment (presumed vascular dementia). Review of the Admission Minimum Data Set (an assessment tool) assessment, dated 08/28/2023, showed Resident 1 had moderate cognitive impairment of 10 out of 15 on the Brief Interview for Mental Status (BIMS - a structured cognitive interview). Review of the second fall incident report investigation, dated 09/12/2023, showed Resident 1 was found at 3:50 PM lying on the floor on their left side in front of the toilet. The post fall intervention, which was implemented to prevent the resident from falls in the future, documented to place a BSC due to the resident's increased weakness (this was not a change or a new interventions implement that had been already identified on the initial 48-hour Care Plan dated 08/23/2023). Review of the third fall incident report investigation, dated 09/14/2023, showed at 1:00 AM a Nursing Assistant Certified (NAC) walked into Resident 1's room and found them on the floor. The resident was still in a seated position on a BSC that had tipped over fell to the resident's left side. The facility's intervention to prevent future falls was to re-educate the resident of their unsafe behavior. (The resident was assessed on admission to have cognitive impairment, a diagnosis of vascular dementia which impaired the resident's ability to be re-educated on unsafe behavior). Review of the fourth fall incident report investigation, dated 10/25/2023, showed at 8:25 PM Resident 1 had fallen to the floor. The resident had been assisted up to the BR by a NAC and instructed the resident to use the call light when they were done using the bathroom. Five minutes later, Resident 1 was heard banging and yelling from their room and was found sitting on the floor with their back against the wall with their legs stretched out in front of them and their walker was beside them. The resident stated to the LN they were walking back to their bed, felt weak and slid to the ground. As an immediate intervention a NAC was directed to sit outside the resident's door to ensure they did not attempt to self-transfer throughout the night. Additional interventions put into place was remind Resident 1 to use the call light for assistance and not attempt to self-ambulate. The root cause analysis (the process of discovering the root causes of problems to identify appropriate solutions) identified Resident 1 was assisted to the BR and was instructed to use the call light when done. The resident was noted to not have used their call light and there had not been a deviation from the resident's care plan. The care plan was updated to not leave the resident unattended in the BR. Review of the fifth fall incident report investigation, dated 10/26/2023, showed Resident 1 was found sitting on the floor in their room near the sink at 6:00 AM. The resident had been observed in bed about 10 minutes prior to the fall. Review of a documented witness statement, dated 10/26/2023 at 6:03 AM, showed Staff H, NAC, observed the resident lying in bed, and Staff H needed to take the garbage out, which was directly across from the resident's room, when Staff H returned the resident was lying on the floor, their call light was on, and stated they had to go to the BR as, the poop was coming. The investigation showed the resident was had increased confusion due to their increased attempts to self-transfer and a test was ordered to rule out a urinary tract infection. Review of a documented staff interview, showed on 10/26/2023 a NAC was sitting outside the resident's room most of the night, the resident had used their call light, but had not waited for help. The investigation noted the resident needed a room closer to the nurse's station for better observation. Interventions implemented included to remind the resident to use their call light for assistance with each care encounter, request an order for PT and OT to evaluate the resident's transfer and ambulation status, place a sign in Resident 1's native language placed to remind them to call for assistance, a translation book to identify items in the resident's primary language, and frequent visual checks from staff. Review of the 10/26/2023 fall incident report, showed contributing factors identified to Resident 1's fall was they attempted to self-transfer and fallen related to their weakness, the resident had become more impulsive with self-transfers and forgot to call for assistance when they needed help. At 11:00 AM, Resident 1 had complained of leg pain and the provider was informed and ordered an X-Ray. The X-Ray showed a moderately displaced left femur facture. The root cause analysis identified they attempted to self-transfer, did not press their call light for assistance, fell , and there had been no deviation from their care plan. Review of the 10/26/2023 incident report investigation had conflicting information including: 1) the resident had used the call light but could not wait for help as they had to go to the bathroom, 2) the resident tried to transfer and had not called for assistance (Per the witness statement the resident had used their call light), 3) the resident was last seen 10 minutes prior to being found on the floor (the witness statement states they were last seen five minutes prior), and 4) there was information regarding after the 10/25/2023 fall an immediate intervention was to have a NAC outside the resident's room. no mention of the intervention implemented after the resident fell on [DATE]. In an observation and interview on 11/15/2023 at 12:50 PM, Resident 1 and their spouse were lying in bed. The resident stated they fell and thought they had broken their pelvis. Resident 1 stated when they moved it was very painful. The resident stated when they had fallen, stated the floor was wet, they had slipped, so they laid down to wait for someone to help them. In an interview on 11/15/2023 at 4:40 PM, Staff A, Licensed Practical Nurse (LPN), stated the NAC staff knew the resident care needs from their tablets when they logged into the resident's electronic medical record. Staff A stated the resident's Kardex (a guide for the direct care givers) had all the information from the resident's care plan. Staff A stated if there was a change or something was different in a resident's care plan, the nursing staff directed the NAC staff of the changes. In an interview on 11/15/2023 at 4:44 PM, Staff B, NAC, stated they used the Kardex to know the level of care needs for the residents. Staff B stated there was also a book that had the resident's transfer needs at the nurse's station. In an interview on 11/15/2023 at 4:59 PM, Staff C, Chief Regional Nurse/ Registered Nurse (RN), stated they had identified some of the nursing staff did not know how to enter care plan interventions electronically that would be pushed onto the resident's Kardex. Staff C stated the facility identified they had a failure with their electronic medical records care plan and Kardex system regarding information placed on the care plan was not automatically placed on the Kardex but had not implemented any interventions to address the concern. In an interview on 11/22/2023 at 2:18 PM, Staff E, LPN, stated since Resident 1 had a fractured hip they had not tried to get out of bed independently. Staff E stated when a resident fell , the nursing staff would complete the resident's fall assessments and management reviewed the fall packet. Staff E stated they were unsure who mainly completed the post fall follow up review or adjusted the care plan. In an interview on 11/22/2023 at 2:33 PM, Staff B stated they would complete witness statements when residents had a fall, would write down the last time they saw a resident or assisted a resident to toilet. Staff B stated they had sometimes provided care to Resident 1. Staff B stated the resident sometimes used their call light, but most of the time their spouse was with them in the evenings. Staff B stated, No, when asked if they were ask to document a resident toileting frequency (to document how often a resident went to the BR, if the resident had been incontinent or not, for the facility to establish a timed toileting plan to improve continence) program for Resident 1 or any other resident. In an interview joint on 11/22/2023 at 3:15 PM, Staff D, current Director of Nursing Services (DNS)/ RN, stated Staff C was the interim DNS when Resident 1 fell on [DATE], until they started at the facility. At 3:24 PM, Staff G, prior DNS/RN, stated they were the DNS at the time when Resident 1 had their first two falls. Staff G stated the resident had not understood to not self-transfer, and PT was working with the resident with a focus on safe transfers. Staff D stated they reviewed everything as a whole, interviewed staff who were on shift when a resident fell , looked at the incident packet, the witness statements, and reviewed the resident's care plan. Staff G stated Staff H, NAC, was sitting with the resident the morning of 10/26/2023, and was positioned to be stationed right outside of the resident's room when not answering call lights. Staff D stated they had noted the resident was in the bathroom with their fall on 10/26/2023. Staff D stated they had placed an intervention to stay with Resident 1 while they were in the BR. Staff G continued to state they reviewed Resident 1's care plan and Kardex, had not reviewed the resident's prior fall packets, but everything in the fall packets were in the resident's electronic medical record. Staff G stated, Yes, when asked if the facility had a bowel and bladder assessment which assessed the residents history, cognition, and was a generalized assessment. Staff G stated they had not conducted a bowel or bladder assessment themselves. Staff G stated the root cause for Resident 1's fall was the resident had self-transferred, and no one was there to assist them. Staff G stated they had not set up a timed toilet plan for Resident 1, but had looked at the lack of language barrier, understanding, and had placed a sign in the resident's native language to not self-transfer in their room. Staff G stated they had implemented the resident's language barrier and communication interventions on the resident's care plan with the resident's fall preventions regarding the fall on 10/26/2023. Refer to WAC 388-97-1060 (3)(g)

Based on interview and record review the facility failed to thoroughly provide professional standards of care and services, for 1 of 1 resident (Resident 1) reviewed for wound care. The facility failed to timely and accurately assess the resident's surgical wound site, follow physician orders as indicated post-surgical amputation of a toe on the resident's right foot, monitor and assess other open areas to the resident's right foot, left foot, and coccyx (tailbone), manage a wound vac (vacuum assisted closure device that assists in wound healing) device, and communicate concerns and status of the surgical wound to the surgeon. Resident 1 experienced harm, when they were hospitalized for significant worsening of their surgical wound site on their right foot that contributed to a below knee amputation (BKA) of their right leg. Findings included . Review of the facility provided wound vac information titled, 3M VAC Therapy, Patient information guide, undated, showed vac therapy should always be on. If the vac therapy was off for more than two hours, the directions were to contact the doctor right away. The old dressing must be removed, the wound should be irrigated, and a new dressing applied. Review of facility policy titled, prevention and treatment of pressure ulcers and other skin alterations, revised [DATE], showed the facility has a system in place to promote skin integrity, prevent skin alterations, promote healing of existing wounds consistent with professional standards of practice and prevent further development of additional skin alterations. Skin interventions are created in collaboration with interdisciplinary team and are implemented. Every dressing change or at least weekly the wound will be evaluated, at a minimum documentation would include location, size, drainage, pain, wound bed description, and the wound edges and surrounding tissue. Resident 1 admitted to the facility on [DATE] with diagnoses to include amputation and an infection of a toe to right foot, end stage kidney disease, and peripheral vascular disease (circulatory condition of narrowed blood vessels that reduces blood flow). Review of Resident 1's admission Minimum Data Set (MDS - an assessment tool) assessment, dated [DATE], showed the resident had moderate impaired cognition, no history of refusal of care, and had an infection to foot from a surgical wound. Review of the facility document located in Resident 1 chart, that occurred prior to admission to the facility, dated [DATE], showed the resident had a Stage 2 (a partial-thickness skin loss with exposed dermis, the wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister) pressure injury (PI) to their coccyx, a surgical wound to right fifth toe, and a vascular open wound to their left third toe. The consult notes included treatment directions as well as recommendations for pressure reduction measures and to allow for limited seat (sitting) time to one hour or less. Review of Resident 1's hospital discharge summary, dated [DATE], showed the vascular surgeon recommended continuous wound vac therapy (to the right fifth toe) for optimal wound healing, as healthy tissue was visualized during the surgery when the fifth toe was removed. Review of Resident 1's admission physician orders from the hospital, dated [DATE], showed the following: - Directions to ensure the wound vac to the right foot was on continuously. -Wound care directions for the resident's right amputation surgical site to be managed by the vascular doctor. - Wound care directions for an open area to the resident's left third toe. - Directions to the facility to contact vascular clinic if there were any changes to the wounds on the resident's feet. - Direction for the resident to always wear a special vascular boot to the right foot when the resident was in bed. Review of Resident 1's admission skin assessment, dated [DATE], showed a scabbed area to left foot, a wound vac device to the right foot, and an open area to the coccyx (no measurements of the wounds were documented). Actual skin impairments to be included in the care plan with a focus, goal, and interventions. Review of Resident 1's care plan, dated [DATE], showed a focus for open area to the right fifth toe related to an amputation. The goal was to show signs of healing and remain free from infection. Interventions included administer medications and treatments as ordered, monitor for effectiveness, assess, and monitor wound healing, wound vac to be applied to the right fifth toe area, and report updates to the provider. The care plan did not address the vascular boot that had been provided for right foot and the care plan did not direct staff to contact the vascular surgeon with changes or updates related to the surgical wound. The care plan did not address the open area to the left foot and coccyx. The care plan did not include any pressure reduction measures for the resident's feet or coccyx area. Review of Resident 1's physician orders in the electronic medication/treatment administration record (EMAR/ETAR), dated [DATE] through [DATE], showed the following: - The wound vac was to be changed three times a week with a start date of [DATE]. The documentation showed on [DATE], [DATE], and [DATE] the order was documented as completed by the nurse, on [DATE] it was left blank, and [DATE] it was documented as on hold. - Ensure the wound vac machine was running continuously with a start date of [DATE], order was placed on hold from [DATE] - [DATE]. - Wound care to left third toe to change gauze daily every evening shift with start date [DATE]. - Wet to dry dressing (no wound vac in use) to right fifth toe due to the facility was out of wound vac supplies with a start date of [DATE] was documented as completed on [DATE]. - Ensure wound vac was plugged in and charging with start date of [DATE], the day the resident was discharged from the facility. There were no orders to address the open area on Resident 1's coccyx or for pressure reduction measures. Review of Resident 1's nursing progress notes, dated [DATE] through [DATE], showed the following: - [DATE], nursing progress note stated the wound vac dressing was changed to a wet to dry dressing, no documentation if the vascular surgeon was notified or why a wet to dry dressing was implemented. - [DATE] at 7:53 AM, the wound vac was on hold due to it was not functioning properly, the nurse called the on-call facility provider and received an order for a wet to dry dressing. There was no documentation if the vascular surgeon was notified. - [DATE] at 11:28 AM, the wound vac was on hold due to facility does not have supplies. There was no documentation if the vascular surgeon was notified. - [DATE] at 1:22 PM, the wound vac was placed on the resident's right foot. There was no documentation if the vascular surgeon was notified. Review of facility provided document titled, Dialysis Transfer Form, dated [DATE], under follow up care the dialysis center documented they had trouble with Resident 1's wound vac, and the therapy was stopped while at the center. Review of facility provided document titled, Dialysis Transfer Form, dated [DATE], had follow up communication from the dialysis center to the facility to ensure Resident 1's wound vac machine was charged as the battery had died . Resident 1 was discharged on [DATE], when the resident was sent via a direct admission to the hospital by the vascular doctor from their vascular appointment. In an electronic communication on [DATE] at 1:26 PM, Collateral Contact 1 (CC1), Resident 1's family member, showed on [DATE] the resident reported their wound vac had not been working the entire time they were at dialysis (a treatment that removes toxins from the blood due to the kidneys no longer function) for over six hours. CC1 reported that on a Sunday, [DATE], while they were at the facility the resident reported the wound vac had been off since that Friday evening due to missing supplies. In an interview on [DATE] at 10:15 AM, Staff D, Registered Nurse (RN), stated they had not ever changed the wound vac for Resident 1. Staff D stated they were aware other nurses had a hard time with the wound vac, and they reported it would beep. Staff D clarified the beeping was either from a leak in the vac or a battery issue. Staff D stated if a resident had refused a treatment or was unavailable, they would notify the provider, and document that in the resident progress notes. In an interview on [DATE] at 1:38 PM, Staff E, RN/Resident Care Manager (RCM), stated Resident 1 had a wound vac that did not function very well. Staff E stated they had reviewed all the hospital documentation, such as the wound care notes, and orders for the wound vac. Staff E stated the wound had been managed by the vascular surgeon. Staff E stated they had some issues with the wound vac dressing supplies, and there were some days where the wound vac was not on the resident, and they used a wet to dry dressing. Staff E stated if a resident refused or was unavailable for a dressing change, they would reapproach, and then notify the provider and document in the progress notes. In a phone interview on [DATE] at 10:41 AM, Staff F, RN, was familiar with Resident 1's wound vac orders. Staff F stated they had worked at the facility since [DATE]. Staff F stated they had no education or training on wound vac's and had no prior experience managing wound vac dressing changes. Staff F stated on [DATE] they were scheduled to change the wound vac, however they did not have the correct supplies, so they used a wet to dry dressing instead. Staff F stated they did recall on [DATE], the wound vac dressing had to be changed, as the wound vac had been off while the resident was out of the facility receiving a dialysis treatment. Staff F stated the wound vac machine would beep all the time due to a leak or battery issue. On [DATE], Resident 1's physician orders were reviewed. There was no physician order located in the medical record for the wet to dry dressing done by nursing staff on [DATE] to replace the wound vac treatment due to the facility did not have the correct supplies. In an interview on [DATE] at 1:45 PM, Staff B, Director of Nursing Services (DNS), stated they did not have a facility policy for wound vac therapy, they followed the manufacturer guidelines. Staff B stated they were unaware of any training that was done with nursing staff related to wound vac therapy. In an interview on [DATE] at 2:03 PM, Staff G, License Practical Nurse (LPN), stated they had worked at the facility since [DATE]. Staff G stated they had not had any education or training on wound vac's and the last time I saw a wound vac was in nursing school. Staff G stated on [DATE] the wound vac was beeping and would not hold a charge. Staff G stated they tried to plug the machine into the power cord, however it would not hold a charge. Staff G recalled the machine was malfunctioning from 7:30 PM till after they gave the next shift report, around 10:30 PM (for three hours). Staff G recalled at one point the facility did not have supplies for the wound vac and the facility just stop using the wound vac for a few days. In a phone interview on [DATE] at 9:38 AM, CC2, clinical coordinator at the dialysis center, stated on [DATE] they were called to the reception area, as Resident 1 had just arrived for their dialysis treatment and their wound vac machine was beeping. CC2 stated the machine monitor screen showed air leak. CC2 stated it was their policy that they were unable to provide wound care, the center turned the machine off and placed a drainage pad around the foot to prevent leaking and cross-contamination. CC2 stated they communicated the issue with the wound vac to the facility. CC2 stated the total time of treatment and transportation could have been roughly about six hours. In a follow-up phone interview on [DATE] at 10:31 AM, Staff E stated on [DATE] they replaced the wound vac dressing for Resident 1 after they returned from their dialysis treatment. Staff E stated they were told the machine was not functioning. Staff E stated they did not contact the vascular surgeon that the wound vac treatment had been off for an unknown length of time. Staff E stated the wound vac dressing change on [DATE] was not completed as staff were unable to locate supplies and they changed the wound dressing to a wet to dry dressing. Staff E stated the order was from the in-house medical provider on call service, the facility did not contact the vascular surgeon. Staff E stated they were aware of the open area on the resident's coccyx, and open area to left third toe. Staff E acknowledged that when the resident admitted , and the open areas were identified the facility should have notified the provider and obtained any orders needed that were not included with the admission paperwork. Staff E stated the left third toe wound, right fifth toe wound, and open area to coccyx were never assessed and monitored per facility wound policy, which was on admission, then at least weekly or with every dressing change. Review of the facility assessment on [DATE], with a revised date of [DATE], under section titled, Acuity-Diseases, Conditions and Treatments, wound vac therapy was not listed. Under the section titled, Acuity-care requirements, it states the facility would supply all medical supplies required to provide appropriate level of care to the residents. Under the section titled Acuity - Sufficiency Analysis Summary, education, and competencies for nursing were determined through case mix, and acuity levels as, wound vac therapy was not an option listed. In an interview on [DATE] at 12:23 PM, Staff H, License Practical Nurse/Staff Development Coordinator (SDC), stated that admitting residents who required a wound vac usually never happens they are rare for us. Staff H confirmed they did not conduct any training or education with the nursing staff on wound vacs. Staff H stated had told some of the staff if they had concerns about the wound vac dressing change, to ask for assistance from them or the RCM. In a follow-up interview on [DATE] at 12:25 PM, Staff E was asked regarding the off-loading boot to Resident 1's right foot that was on the admission physician orders from [DATE]. Staff E stated they were aware the resident had a boot they would wear when in their wheelchair. Staff E was aware the physician orders and care plan did not reflect the resident should have a boot to the right foot for off-loading while in bed. Staff E was asked regarding the communication to the vascular surgeon on the status and concerns the facility had with the wound vac. Staff E stated the facility staff did not notify the vascular surgeon that the resident had not worn the wound vac continuously due to lack of wound supplies or when there had been concerns with the functioning of the wound vac. Staff E was aware Resident 1 went without the wound vac from [DATE] to [DATE], and [DATE] till [DATE]. Staff E stated the wound vac machine was off for over two hours without notification to the vascular surgeon. Review of Resident 1's hospital medical records on [DATE], for their re-admission to the hospital on [DATE], the following was documented: - On [DATE], the admitting physician stated the resident had been a direct admit from their vascular appointment on that day, due to slow healing of the fifth toe amputation site and new wound to the bottom of the resident's foot. - On [DATE], the vascular surgeon documented worsening wounds to right foot, no visible signs of healing at the amputation site. New wound to bottom of right foot. The amputation site appeared desiccated (withered) with no sign of healing. The wound was not expected to heal in the current condition. - On [DATE], the infectious disease physician documented the right foot wound had significantly worsened from their previous admission. - On [DATE], the surgeon documented they performed a bilateral (both) below knee amputation to the right and left leg. In a joint interview on [DATE] at 12:56 PM, with Staff A, Administrator, and Staff B, Staff B stated they were not employed at the facility at the time Resident 1 admitted to the facility. Staff B stated the expectation for wound care was when there was a concerns or problem the nursing staff would notify the RCM and/or the DNS, and the provider. Staff B stated in relation to the wound vac therapy their expectation was nursing staff would contact a manufacturer to troubleshoot the problem. Staff B was unaware the vascular surgeon was managing wound care for the wound vac therapy and had not been notified during Resident 1's admission of any concerns or lapse in treatment. Staff B stated their expectation was upon admission there were two nurses that reviewed the admitting physician orders to ensure there were no errors. Staff B was unaware Resident 1 had orders for a special off-loading boot that was not included in the orders, or that the vascular surgeon had requested all concerns related to the wound vac therapy be directed to their office. Staff B was unaware the resident had gone without the wound vac therapy on [DATE] to [DATE], and [DATE] till [DATE] due to lack of supplies. Staff B was unaware the resident had other open areas to left foot and coccyx that were not included in the plan of care. Staff A stated they were unaware that wound vac therapy had not been included in the facility assessment and confirmed that would have been a signal to the facility they were lacking education and training on wound vac therapy. Reference WAC [DATE](1)(3)

Based on observation, interview, and record review the facility failed to ensure a cognitively impaired resident (Resident 2) was free from physical abuse by an unsupervised cognitively impaired resident (Resident 1) who had a known history of physical aggression towards other residents and staff. Failure to maintain the supervision of Resident 1 lead to an actual physical assault to Resident 2's face and caused an injury to their lower lip and placed all other residents at risk for further abuse. Findings included . Review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Prohibition, updated November 2016, stated Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion The center implements policies and procedures so that residents are not subjected to abuse by staff, other residents. RESIDENT 1 Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had severe cognitive impairment and did not require staff physical assistance with transfers and ambulation. Review of the resident's incident history showed the following resident-to-resident encounters: · On 05/26/2021 the resident struck the head of another resident; · On 08/24/2021 the resident slapped the leg of another resident; · On 10/12/2021 the resident struck the face of another resident with a toy; · On 01/05/2022 the resident struck the leg of another resident with a shoe; and · On 03/16/2022 the resident struck the face and caused a bloody lip to another resident with a toy. Review of Resident 1's care plan showed a focused problem of aggressive behavior and history of resident-to-resident altercations beginning 06/29/2020. The one-to one supervision intervention was discontinued on 10/06/2021. The supervision log, to be completed hourly was discontinued on 10/12/2021. The care plan showed an intervention dated 03/11/2022, directing staff to closely monitor Resident 1 during waking hours, even though the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This intervention was discontinued on 03/16/2022. There were no interventions to provide supervision of Resident 1 around other residents on the care plan. Review of Resident 1's Treatment Administration Record (TAR) for March 2022, showed the resident averaged only four hours of sleep at night prior to the incident on 03/16/2022. RESIDENT 2 Resident 2 admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], showed the resident had severe cognition impairment and required extensive assistance with two staff members for bed mobility, transfers, and ambulation. Review of Resident 2's care plan dated 03/21/2019, showed a focus problem of cognition loss related to vascular dementia. Review of facility incident report dated 03/16/2022 at 6:29 AM, showed Resident 1 entered the room of Resident 2 and struck them on the face with a stuffed toy animal while they were sleeping. Review of a progress note dated 03/16/2022 at 7:17 AM, showed the nurse found Resident 2 with blood on their mouth as another staff member was directing Resident 1 out of the room. Resident 2 stated that Resident 1 struck them on the mouth with a doll. Review of a progress note dated 03/16/2022 at 2:40 PM, showed Resident 2 had bruising to their lower lip. Review of a progress note dated 03/16/2022 at 11:35 PM, showed Resident 2's lip had a purple discoloration and was swollen. Review of a progress note dated 03/17/2022 at 4:20 AM, showed Resident 2 had discoloration to the bottom lip and mild swelling. Review of a progress note dated 03/17/2022 at 10:02 PM, showed Resident 2 had purple discoloration to their lip. Review of a progress note dated 03/18/2022 at 2:46 AM, showed Resident 2 had discoloration to the bottom lip. Review of a progress note dated 03/30/2022 at 1:14 AM, showed Resident 1 had placed their hands around the neck of a staff member. In a continuous observation on 04/05/2022 at 9:49 AM, Resident 1 was observed to exit their room with their walker with no supervision and entered the room of Resident 2, where they were sitting in their wheelchair next to the bed. Resident 1 stood over Resident 2 with in arms reach for 1 minute before a staff member walked by the room and attempted to redirect Resident 1 away from the Resident 2. In an interview on 04/05/2022 at 10:15 AM, Staff A, Nursing Assistant Certified (NAC), stated Resident 1 wanders in and out of resident rooms all the time. Staff A stated, they can snap just like that; they are volatile and believed Resident 1 was a danger to other residents as the staff were not able to watch Resident 1 all the time. In an interview on 04/05/2022 at 10:45 AM, Staff B, Nursing Assistant in Training (NAT), stated they were familiar with Resident 1, however it could be tricky. Staff B clarified their emotions change so quickly; the resident can snap on you in a second and you never know what you are going to get. Staff B stated the resident was independent with ambulation with their walker. In an interview on 04/05/2022 at 11:15 AM, Staff C, NAC, stated they were familiar with Resident 1. Staff C stated Resident 1 could from here (gestured to raise their hand in the air) to here (gestured to lower their hand). They stated that Resident 1 could be extremely combative as they had observed them to be physically aggressive with staff. In an observation on 04/05/2022 at 11:22 AM, Resident 1 was observed to be sitting in a chair at the nurse's station with no supervision. Resident 1 was observed to get up out of their chair, walk down the hallway unsupervised and enter the room of Resident 4 where they were observed to be sitting in their (Resident 4's) recliner. Resident 1 proceed to stand over Resident 4 with in arms reach for two minutes before a staff member walked by and redirected the resident out of the room. In an interview on 04/05/2022 at 1:11 PM, Staff D, Registered Nurse (RN), stated Resident 1 had behaviors to include agitation and aggression, with no real triggers, behaviors appear random and unpredictable. In an interview on 04/05/2022 at 1:52 PM, Staff E, Medical Records/NAC, stated Resident 1 ambulated with their walker. Staff E stated the resident's mood could vary between, shifts, throughout the day, who their caregiver was, it really varied all the time. Staff E stated the resident had struck other residents in the past, they observed that Resident 2 had a bruise on their lip after the altercation that occurred in March. In an interview on 04/06/2022 at 10:42 AM with the Administrator, Chief Nursing Officer (CNO), and Regional CNO, the CNO stated they had placed the resident on a two-hour behavior monitoring after the incident on March 16th, 2022. The Administrator stated they did not reassess interventions on a regular schedule. The Regional CNO stated that after the January 5th, 2022, resident-to-resident altercation involving Resident 1, they did not put into place any interventions to prevent further physical abuse or educate the staff on Resident 1's behavior. The Administrator stated they were unaware if Resident 1's behaviors or physical abuse had been addressed in the Quality Assessment and Assurance (QAA) as the facility had taken new ownership. The Administrator stated the QAA meeting had occurred once since new ownership had taken over in February. No other information was provided to show the facility provided adequate supervision or evaluated the effectiveness of the interventions. Further, there was no reassessment of Resident 1's physical abusive behaviors towards other residents after the January 5th, 2022, incident and therefore the facility did not provide sufficient protection to prevent additional resident-to-resident incidents of physical abuse. Reference WAC 388-97-0640 (1)

Based on observation, interview and record review the facility failed to comprehensively assess and ensure the necessary care and services were provided to prevent the occurrence of an avoidable pressure ulcers for one of three residents (35) reviewed for pressure ulcers. These failed practices caused harm to Resident 35 who developed an unstageable pressure ulcer to Resident 35's coccyx (tailbone). Findings included . Record review of the facility's policy titled, Skin Integrity, updated (MONTH) 2009, showed: -The resident's skin integrity was evaluated using the Braden Scale Evaluation; -The Licensed Nurse (LN) completed the Braden Scale (an assessment for predicting pressure ulcer risk) at admission, then weekly for 3 weeks, annually and with significant change of condition; -The LN established a plan of care; - Ongoing evaluation continued weekly with the LN completing a full body skin audit which was documented on the Treatment Administration Record (TAR) with either a + indicating skin impairment or - indicating no skin impairment; and -Interventions were documented on the resident's care plan and care directive. The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury (PI) was a localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occured as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed was viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it was obscured by slough or eschar (non-viable tissue covering the wound bed) (the eschar was dry, adherent, and intact without redness). Resident 35 was admitted on [DATE] with a [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment dated [DATE], Resident 35 was cognitively impaired, required total assistance with two persons for bed mobility and transfers and total assistance with one person for toileting. Resident 35 was identified at increased risk for developing pressure ulcers (PU). Review of the Care Area assessment dated [DATE], indicated she was at risk for developing PU's related to her altered mental status, requiring assistance with toileting, turning, and [DIAGNOSES REDACTED]. Review of the admission care plan dated 04/05/18, did not show a care plan was developed to minimize the risk for developing PU's. Review of the nursing assistants care directive dated 04/18/18, showed under the skin at risk tab to turn and reposition the resident frequently, as the resident allowed. Record review of the Braden Scale dated 03/29/18, showed the resident was at low risk for developing a PU. There were no subsequent Braden scale assessments completed per the facility policy. Review of Resident 35's TAR from 03/29/18 through 07/29/18, showed no skin check had been completed by the Licensed Nurse (LN) weekly per the facility policy. Review of a physician facsimile order form dated 06/03/18 at 8:30 PM, showed notification to Resident 35's doctor of the stage 2 PU's. The LN stated the PU's were covered with a foam dressing and the Director of Nursing Services (DNS) was notified. Record review of the weekly skin evaluation sheet dated 06/04/18, showed Resident 35 developed a Stage 2 PU on the left sacrum (lower spinal bones) measuring 1centimeter (cm) by 0.5 cm with a depth of 0.1 cm and a Stage 2 PU on the right sacrum measuring 1.0 cm by 0.5 cm with a depth of 0.1 cm. Review of a physician facsimile order form dated 06/07/18 at 11:00 PM, showed an order to start house barrier cream to coccyx and to cover with foam dressing every day, three days after the pressure ulcer was identified. On 06/11/18, seven days later, a PU care plan was developed. Review of the weekly skin evaluation sheet dated 06/27/18, showed the 2 stage 2 PU's on the sacrum was now a one PU on the resident's coccyx. Review of Resident 35's weekly skin evaluation sheet dated 07/05/18, showed coccyx stage 2 PU. The PU measured 2.6 cm by 1.5 cm with a depth of 0.1 cm, had minimal drainage and a slight odor. Review of a physician facsimile order form dated 07/08/18, showed the resident's PU had deteriorated. The PU was identified as an unstageable ulcer. Record review of the weekly skin evaluation sheet dated 07/12/18, showed Resident 35's coccyx PU measured 3.2 cm by 2.0 cm with a depth of 0.2 cm, was unable to determine the stage, but had 100% slough (non-viable tissue) with moderate purulent drainage with slight odor. On 07/27/18 at 10:00 AM, a wound was observed on Resident 35's coccyx. The wound was pear shaped and approximately 3 inches long and the widest part approximately 2 inches wide. The wound was covered in slough, the surrounding tissue was pink and there was no odor identified. In an interview on 07/27/18 at 11:03 AM, Resident 35's spouse stated he visited his wife 3 times a week and his son visited her 3 times a week. The spouse stated every time they visit she was on her back on that sore and looked like she was in pain. At 1:05 PM, the hospice nurse stated the resident began hospice services on 07/13/18. The nurse stated she changed the PU dressing twice a week and the facility LN's changed the dressing as needed. In an interview on 07/29/18 at 11:00 AM, the Director of Nursing Services (DNS) stated all resident's skin was checked weekly for any skin abnormalities. The LN would document a + if there was a skin issue and a - if there was no skin issue. The DNS stated if a PU was found the physician and the family would be notified, a weekly skin evaluation sheet would be filled out and an assessment of the wound would be completed weekly. During an interview on 07/30/18 at 10:39 AM, the DNS stated all residents should be turned every 2 hours. The DNS stated the Braden scale assessment should be done weekly for 3 weeks and then quarterly or with a change of condition to assess risk factors. The DNS stated these were the current preventative measures for residents and the staff would find this information on the resident's care plan and the care directive. At 1:47 PM Staff H, Nursing Assistant (NA), stated she knew how to care for a resident by reading the care directive and shift to shift report. Staff H stated it was protocol to turn all residents every 2 hours if they were unable to do it by themselves. Staff H stated Resident 35 occasionally refused to turn but not often. Staff H stated if a resident was not turned throughout a day, they could get a PU. At 3:21 PM, Staff D, MDS nurse, stated she was responsible for the comprehensive assessment, the care area assessments and the care plan. Staff D acknowledged that Resident 35 should have had a skin care plan problem with interventions to minimize the risk of PU's occurring. Staff D stated she thought Resident 35 developed the PU because the resident would roll over the pillow and end up on her back. During an interview on 07/31/18 at 9:49 AM, the DNS stated if a pressure ulcer was not healing with the current treatment in 14 days, then a new treatment should be tried. The DNS stated the goal for Resident 35's PU was to heal it. The DNS acknowledged that the weekly skin checks were not completed from 03/29/18 to 07/30/18 and she would check into it. The DNS acknowledged that Resident 35 did not have the Braden scale assessments complete and they should have been, she acknowledged the lack of care planning not initiated with the comprehensive assessment. At 11:17 AM, Staff O, Licensed Practical Nurse (LPN), stated the floor nurses were responsible for doing the Braden skin assessment weekly for 3 weeks, then the MDS coordinator was responsible to complete them quarterly and with a change of condition. Staff O stated the nurse who admitted the resident was responsible to put the treatments and the skin checks on the TAR so the resident's skin was checked weekly for any problems. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview and record review the facility failed to ensure one of one residents (31) received the care and services to maintain the resident's functional use of his left upper extremity. This failed practice caused harm to Resident 31 who experienced the loss of the use of his left upper arm. Findings included . Resident 31 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Record review showed the resident was deemed incapacitated in 2011 by the Washington State Superior Court and had a guardian. In an interview on 07/23/18 at 1:29 PM, the resident's family member stated, (Resident 31) tries to make choices to but his choices are unreliable, he says no to almost everything. He seems depressed, last week he told me he needed to go to the hospital, he had insisted he had a stroke, we do not know why his arm is paralyzed. In observations on 07/25/18 at 11:59 AM, and 2:24 PM, and on 07/26/18 at 8:37 AM, the resident was lying in the bed with his left arm positioned across his chest with a brace on his left hand and his call light placed in between the resident's fingers of his left hand. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] showed the resident had limited range of motion to one upper extremity but the quarterly 03/19/18 and 07/06/18 MDS assessments did not show the resident had any limited range of motion to the upper extremity. Review of the Care Area Assessment for the annual MDS dated [DATE] showed the resident had a history of [REDACTED]. He refused care frequently, stayed in bed frequently and was a two person assist with mobility, turning, repositioning, dressing, grooming and incontinent care. He had assist bars on his bed which he was able to utilize and worked with restorative therapy. The care plan decision was to address the resident's functional status and to maintain the resident's current level of functioning. Review of the resident's active current care plan showed the resident had activity of daily living (ADL) problem with an initial date of 04/09/18 which identified a self-care performance deficit related to the contracture of his left hand and his bilateral lower extremity amputation. The goal was to maintain the resident's current level of function. The identified interventions were to provide the resident's ADL care needs. No identified interventions were listed related the resident's contracture of his left hand or the weakness and loss of use of the resident's left arm. Review of the Care Directive and the Bedside Individual Service Plan Report (both are a guide for the direct care givers to provide resident care) did not show identified interventions to address the resident's contracture of his left hand or his loss of use of his left arm. Review of a physician progress notes [REDACTED]. The resident had a history of [REDACTED]. The physician stated the left arm became stiffer and stiffer with time and now the resident could barely move it due to being stiff. According to the Licensed Nurse (LN), the resident refused to move the left arm. The physician documented the resident's behavior was normal and had increased confusion. The physician ordered Occupational Therapy (OT) and documented the resident was quite noncompliant and afraid he would refuse treatment again. Review of the Occupational Therapy evaluation dated 01/24/18 showed the resident was referred for evaluation and treatment for [REDACTED]. Review of the restorative program referral form dated 02/06/18 showed the resident plan was updated to preserve the resident's left upper extremity skin and joint integrity. The restorative program was set up for six times a week for the left upper extremity for passive range of motion for the resident's elbow and shoulder. Review of a physician progress notes [REDACTED]. The physician wanted to order either a CT scan of his head or an MRI of his head and consult neurology, but the resident refused all care. The resident did not want any further testing done and refused to go see a neurologist. The physician documented the resident's behaviors were normal. Review of a physician progress notes [REDACTED]. The resident still refused to have any tests done or to be seen by a neurologist. The resident's speech had decreased and became more soft, slow and a little slurry. The physician noted the resident's psychiatric mood and affect was normal, but was positive for behavioral problems, confusion and had decreased concentration. In an interview on 07/28/18 at 2:28 PM, the Administrator and SSD confirmed the lack of treatment for [REDACTED]. in decisions on medical follow up. During an interview on 07/30/18 at 11:16 AM, Staff S, Occupational Therapist (OT), stated she felt the resident could move his left arm and thought it was the resident's behavior. The OT continued to state that upon evaluation the resident said he could not do any of the movement. A Restorative Aide (RA) program was previously in place for passive range of motion to the left upper extremity along with bed rolling. The main goal for the evaluation was to assess the RA program. The legal guardian only approved three OT visits as this was being billed as private pay. The OT stated that during the RA evaluation, the RA was not completing the range of motion correctly to the resident's left elbow or shoulder. At approximately 11:25 AM, Staff F, Nursing Assistant/Restorative Aide, stated the resident does not refuse range of motion to his left arm. Staff F stated the resident could not move his left arm and had not been able to for a long time. At 12:50 PM, the physician stated that he did not know anything about the resident having a legal guardian and thus did not consult the legal guardian about the resident's decline in use of his left upper extremity or the medical recommendations. The physician stated the resident was getting more confused and the progress notes referencing the resident's behavior was normal was noted to be normal for the resident. No further information was provided. The lack of a person centered care to address the resident's self-neglecting refusal of care or acknowledging the resident was incapacitated to make his own decisions and the failure to consult with his court appointed guardian caused the resident avoidable harm due to the lack of medical care to address the resident's loss of function to his left upper extremity.

Based on interview and record review the facility failed to implement interventions to prevent significant weight loss for one of three residents (31) reviewed for weight loss. This failed practice caused harm for Resident 31 as evidenced of greater than a 14% (percent) weight loss in 180 days. Findings included . Resident 31 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Record review showed the resident was deemed incapacitated in 2011 by the Washington State Superior Court and had a guardian. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] showed the resident had significant weight loss which was not physician prescribed. Review of the Care Area Assessment for the annual MDS dated [DATE], showed the resident had weight loss. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident was severely cognitively impaired, had a significant weight loss which was not a physician-prescribed weight loss regimen, had delusions and rejections of care. Review of the resident's current care plan showed the resident had an alteration in nutrition and hydration related to abnormal laboratory values, weight loss, medication interactions, pressure injury, refused to be weighed, refused to eat and ate less than 75% of meals. The goal was for the resident to have no significant unavoidable weight loss and he would consume greater than 75% of his meals and liquids. The interventions were as follows: -Diet per the physician order; -Friends bring food from out of facility; -Honor food preferences as reasonable and update as needed; -Preferred to eat in his room; -Meal monitor, if intake less than 50% offer substitute or supplement; -Offer liquids between meals; -Refer to Occupational Therapy or Speech Therapy as appropriate; -Refused meals; -Refused supplements; and -Weigh per the facility protocol, resident refused to be weighed often. Review of the Care Directive and the Bedside Individual Service Plan Report (both are a guide for the direct care givers to provide resident care) showed the resident was independent with supervision/cueing for in room meals, to monitor and report loss of appetite, the resident refused to eat and had weight loss. Review of the care conference note dated 03/27/18, showed under the nutritional section that the resident wanted pizza and cheeseburgers. The care plan and care directive had not been up dated to reflect the resident's food preferences. Review of the resident's Weight Summary showed the resident weighed 149 pounds on 01/26/18. On 07/18/18 the resident weight 128 pounds. The resident lost 21 pounds or 14% in six months. Review of the meal monitor flow sheets showed: - (MONTH) 1 - 28th, the resident refused 51 meals and there was no documentation for 1 meal; - In (MONTH) (YEAR), the resident refused 34 meals and there was no documentation for 13 meals; - In (MONTH) (YEAR), the resident refused 25 meals and there was no documentation for 19 meals; - In (MONTH) (YEAR), the resident refused 24 meals and there was no documentation for 32 meals; - In (MONTH) (YEAR), the resident refused 24 meals and there was no documentation for 35 meals; - In (MONTH) (YEAR), the resident refused 17 meals and there was no documentation for 37 meals; and - In (MONTH) (YEAR), the resident refused 16 meals and there was no documentation for 36 meals. Review of the Nutrition Hydration Skin Committee Progress Notes dated 04/16/18, showed the Registered Dietitian (RD) met with the resident, explained his weight loss, his meal monitor and the risks of not eating. The resident was unable to list any foods he would be willing to eat and stated he would not consume supplements or pork. The RD documented the resident's weight loss was unavoidable related to refusal of meals and inadequate intake. No documentation was noted to attempt any behavioral health interventions or consult with the resident's legal guardian. Review of the RD note dated 06/27/18, showed the resident's weight loss to be unavoidable due to inadequate intake with no documented attempt for behavioral health interventions or consult with the resident's legal guardian. Record review of a mental health progress note dated 07/09/18, showed an independent mental health nurse consultant had been in to see the resident. The consultant noted surprise of the amount of weight the resident had lost. The resident's mother was just in and was in tears regarding the resident's decline, she just doesn't know what to do. The mental health nurse consultant documented she discussed the resident's status and some plans with the Director of Nursing Services, would see the resident monthly, and was thinking the resident's mom may want us to try something to stimulate the resident's appetite and would check back the next time she saw the resident. In an interview on 07/23/18 at 1:40 PM, the resident's family member stated, The resident tries to make choices but his choices are unreliable, he says not to almost everything. He seems depressed. He has lost a lot of weight. They (the facility) have agreed to keep items he likes. We bring in food, hamburgers and pizza. Review of the RD note dated 07/25/18, showed the resident's continued weight loss to be unavoidable yet no behavioral health interventions or nutritional interventions were noted. In an interview on 07/28/18 at 11:17 AM, Staff M, Activities Director (AD), stated that the resident responded to Staff A, Hospitality Aide. Staff M stated the resident always wanted cupcakes. Staff M stated she felt the resident was depressed. At 11:20 AM, Staff A stated that the resident was coming along slowly, he had noticed every week the resident did not want to go over the menu. Staff A stated the resident seemed overwhelmed by completing the menu weekly, so it was changed to obtained daily. Staff A stated the resident liked ice cream in the afternoon. Staff A stated he took the resident ice cream daily when he worked. At 12:52 PM, Staff G, Dietary Manager, stated she had only met with the resident a couple of times but he refuses so much. Staff G stated she had recently completed a food preference with the resident and he stated he loved ravioli, pasta and burritos. Staff G stated there was an all staff meeting and the staff were informed of the resident's preferences. Staff G was not aware where staff documented when a resident was offered a meal replacement. Staff G was aware of the resident's weight loss, along with the fact he was not on scheduled snacks. At 1:09 PM, Staff H, Nursing Assistant (NA), stated the resident had refused breakfast this morning. Staff H stated when a resident refused their meal, it was documented on the meal monitor along with if the resident accepted a substitution. At 1:24 PM, Staff I, NA, stated the resident was offered the alternative meal, he would usually take a sandwich that was usually what he wanted. Staff I did not know about the ravioli, pastas or burritos. He just says no a lot. At 2:09 PM, Staff R, NA, stated that the resident liked some sandwiches over other items and would talk to the nurse or dietary to see about an alternative meal. At 2:13 PM, Staff K, Social Service Director, stated that she had identified depression and frustration with Resident 35. At 2:46 PM, Staff P, Registered Nurse, stated that her understanding was the resident had a history of [REDACTED]. The staff do report the resident's refusal of meals. Staff P stated she would go in and offer the resident a sandwich, which he loves sandwiches. Staff P stated the resident would decline snacks and state he was not hungry. Staff P stated Today was a mix up, he wanted Ravioli but did not get them. Staff P stated staff followed the care plan to know how to care for the resident. Review of the medical record as of 07/28/18, showed no evidence the mental health nurse consultant had any noted recommendations for an appetite stimulant or behavioral health interventions for the resident's refusal of meals. In an interview on 07/29/18 at 1:18 PM, Staff Q, NA, stated that she follows the care directive in the resident's closet to know how to care for the resident. Staff Q stated the staff offered the resident supplements or a sandwich, or asked him what if would like if he ate less than 50%. In a follow up interview on 07/29/18 at 1:26 PM Staff P stated the resident's life was very small and he had control of very few things in his life. Staff P stated currently the resident enjoyed Gatorade. Staff P continued to state the resident's mental illness impairs his ability to make decisions and impairs his decision making process. In a phone interview on 07/30/18 at 10:59 AM, the RD stated that she had asked the resident what foods he would like to eat and he was unable to articulate what he would want. The RD felt the resident did not want to eat. The facility failed to implement interventions for Resident 31's food preferences which independent staff were aware of but were not implemented on the resident care plan or care directive. Additionally, the facility failed to address the resident's noted depression or follow up on the mental health nurse consultant's note about a possible appetite stimulant to help with the resident's weight loss. This failed practice caused harm to the resident due to the resident's significant weight loss. Reference WAC: 388-97-1040 (b)- 1060 (3)(h)

Based on interview and record review, the facility failed to protect 1 of 1 cognitively impaired residents (2) from potential exploitation when staff discharged the resident Against Medical Advice (AMA) to a person staff had previously identified as potentially wanting to exploit the resident. The facility also failed to ensure the cognitively impaired resident had the mental capacity to make an informed decision about whether to discharge AMA. Failure to utilize facility resources to ensure a safe discharge resulted in an Immediate Jeopardy (IJ) on 03/09/17. After the IJ was implemented, the facility submitted a removal plan that included auditing current residents for similar POA (Power of Attorney)/guardianship issues, surveying staff regarding abuse, reviewing and revising policies, and educating staff on policies related to transfer and discharge. The IJ was removed on 03/13/18. Findings included: Resident 2 admitted to the facility on [DATE] after an extended hospitalization due to her being hit by a car in a car vs pedestrian accident, while intoxicated with alcohol. Her [DIAGNOSES REDACTED]. Her Minimum Data Set assessment, dated 02/02/18, revealed she had severe cognitive impairment. Review of an Occupational Therapy evaluation, dated 11/13/17, revealed: - problem solving = severe impairment - follows directions = moderate impairment - sequences tasks = moderate impairment - safety awareness = moderate impairment - insight and judgement = severe impairment - attends to task = moderate impairment Review of a Montreal Cognitive Assessment (M[NAME]A)(screening assessment for detecting cognitive impairment), dated 11/14/17, revealed she scored an 11 out of 30. A score over 26 was considered normal, a score of 22 was considered mild cognitive impairment. Review of a Brief Cognitive Assessment Tool (BCAT)(a tool for assessing memory and cognitive impairments), dated 11/15/17, revealed the resident scored 16 out of 50, a score of 24 or below indicated moderate - severe dementia. On the BCAT Contextual Memory Factor, she scored 5 out of 15. Scores below 12 typically indicate significant memory problems that can interfere with independent living. On the BCAT Executive Control Functions Factor, she scored 1 out of 7. Scores below 5 indicate problems that could interfere with successful independent living, low ECFF scores serve as a red flag for safety concerns for those who were living in independent situations. Review of an unsigned and untimed progress note dated 11/16/17, revealed BCAT score 16 out of 50 suggestive of dementia/severe cognitive deficit. Review of a Social Service progress note, dated 11/21/17, revealed short and long-term memory loss, that affects all decision making, and a guardian may need to be considered. Review of an undated letter from a physician, on hospital letterhead, revealed a declaration In our clinical judgement, she does not have the capacity to make decisions about her care at this time. Review of a Discharge Care Plan, dated 11/21/17, revealed resident's desire was to be discharged to a lower level of care at an ALF (assisted living facility), Alaska with S.O. (significant other), and a problem/need guardianship explored. Review of another M[NAME]A, dated 01/23/18, revealed the resident scored 12 out of 30. Review of an email dated 02/05/18, revealed Staff E, Social Services Director (SSD), wrote She (Resident 2) may need a guardian. I have talked to Staff B and Staff F (Medical Records Director), they think I need to call APS . Review of an incident investigation report, dated 03/01/18, revealed the resident was found across the street from the facility with another resident. Review of an Elopement/Exit-seeking Evaluation, dated 03/01/18, revealed the resident had impaired judgement/lack of safety awareness that placed her at significant risk of getting into an unsafe situation. Review of the clinical record revealed no documentation the resident's physician had assessed the resident's mental capacity or her potential need for a guardian. There was no documentation the resident's physician was notified there were alleged safety issues regarding exploitation by AP1 and AP2. Review of the clinical record revealed no documentation the facility had assessed the risks/threat to Resident 2's safety and/or formed a plan to keep her safe from AP1 and AP2, or herself due to her own cognitive impairment. Review of the clinical record revealed no documentation the facility was making preparations for Resident 2's safe discharge. Review of a progress note, dated 03/05/18 at 11:19 AM, revealed the resident had discharged from the facility AMA (Against Medical Advice) with Alleged Perpetrator (AP) 2 and that the police were notified. In an interview on 03/06/18 at 10:30 AM, Staff C, Executive Director (ED), stated they felt good about the discharge because the resident was previously homeless, and was now discharged to a specific address with a friend. In a telephone interview on 03/07/18 at 3:25 PM, Resident 2 stated she did not know which medications she was taking. She stated she was staying with her friend until she got her check and then she would be getting her own apartment and living on her own. In a telephone interview on 03/08/18 at 12:05 PM, the resident's son stated he did not know his mother had recently eloped, as he was not contacted. He said he did not know his mother left the facility AMA. He said he received a call from Staff C whom he said told him his mother was regaining her memory and was ok to be released. He said Staff C told him he was comfortable with the person she was discharged with, and he was pleased she had a place to stay. He said at no time did Staff C tell him they had advised her to stay at the facility. He stated This was definitely not what was communicated to me. The resident's son stated No, when asked if he had been asked by the facility to set up a guardianship. He said he did set up a Guardian Ad-litem/Settlement Guardian because the insurance company told him she needed a Settlement Guardian to be able to settle the lawsuit related to being hit by a car. The resident's son said as far as he knew, that guardian was only for the settlement, not to make healthcare or other living arrangements. He stated it had been 4-5 years since anyone in his family had contact with his mother, and about 10-[AGE] years since he had last seen her. In a telephone interview on 03/08/18 at 12:55 PM, Resident 2 stated she still needed to get records from the nursing home and that no one from the nursing home went over her medications with her. She stated when she was hit by a car she lost her mind, didn't know much, and couldn't remember anything after that. In an interview on 03/09/18 at 10:45 AM, Staff G, Medical Director, was asked about facility systems/policy to assess cognitively impaired residents to ensure they were safe to sign themselves out AMA, he stated We have a social worker and the head nurse who will assess the resident on a regular basis. In this particular case this resident is very forgetful, but other than that, she is able to make her own decisions, other than that, she was totally functional, oriented to name and date of birth and location, .I believe she was able to safely discharge, she is an adult. When she left, I did not want her to leave until after I had assessed her. Staff G was asked why staff thought she needed a guardianship, he stated All I can tell you is she has a bad memory, probably it would have been good to have a guardian. Physically, she is totally capable. Mentally, she probably would not be able to make good decisions, but she did have memory problems. I did not want her to go. Why they let her go, I'm not sure. In an interview on 03/09/18 at 11:06 AM, Staff B, Business Office Manager, stated she had called in an anonymous complaint to Adult Protective Services (APS) about 1 ½ weeks prior to the resident's discharge. Staff B stated she was concerned the resident was easily manipulated and was being pressured by AP1 and AP2 to leave AMA because she had money and that she would be exploited. She stated AP1 called and warned the facility not to let the resident leave with AP2 because of what bad would happen. She stated the resident was very pliable. She stated AP2 was calling the resident excessively multiple times a day. Then, after hanging up with the resident, AP2 would call facility staff and Staff C saying he was coming to get the resident. Then, one day instead of calling, he showed up to get her, and she discharged AMA. Staff B stated she decided to call APS because nothing was being done. Staff B stated Staff C and Staff D, Director of Nursing Services (DNS), were aware of her concerns. In an interview on 03/09/18 at 12:26 PM, Staff E, Social Service Director, did not know if the resident's son had ever set up a guardianship. Staff E was asked about AP2 calling and wanting to come get the resident, she stated Staff C had asked her whether they should let the resident go or not, she said she reminded him of the BIMs score and the M[NAME]A . Then over 2-3 weeks, he (Staff C) tried to reach out to AP2 to let him know if he came they would have to call the police, we let him know he would have to sign her out AMA because of her cognition .Resident 2 was amping up in the last few weeks dropping the F-bomb a lot . Staff E was asked why the police were notified when the resident left AMA, she stated Because of her cognition and safety needs. In an interview on 03/09/18 at 1:44 PM, Staff D, DNS, did not know if there was a policy on what staff were to do if a cognitively impaired resident tried to leave AMA, she also did not know if there was a policy on what staff were to do to protect a resident from unknown persons that showed up at the facility and wanted to take vulnerable adults/cognitively impaired persons from the facility. Staff D was asked if the facility had employed a multidisciplinary approach to assessing the resident's mental capacity, she stated Not that I know of, it doesn't seem like we connected all of the dots. In an interview on 03/09/19 at 2:19 PM, Staff C stated he did not know if there was a facility system/policy in place to assess residents with cognitive impairments that were attempting to sign themselves out AMA. Staff C stated he would have to check, when asked the facility policy/process regarding how to keep a resident safe when a visitor/friend comes in and wants to take a vulnerable adult/cognitively impaired person from the facility. Staff C was asked what he told the police when he called them about the AMA discharge, he stated he told them they had a resident that was leaving AMA, They weren't too impressed, they didn't give me a case number or anything. Staff C was asked if he told the police Resident 2 was cognitively impaired, he stated I didn't tell them she was cognitively impaired. In an interview on 03/09/18 at 3:00 PM, Staff A, Occupational Therapist, stated the scores on the M[NAME]As indicated moderate to severe dementia or [MEDICAL CONDITION]. Staff A stated a person with those scores would not be recommended to do any higher level activities of daily living such as driving, cooking, medication management, or finances. She stated community mobility would need to be supervised due to judgement problems. Staff A also stated a person with those scores would not be able to respond appropriately in emergency situations if she lived alone. Staff A stated Resident 2 was not able to make an informed decision about leaving the facility AMA because she had poor insight into her own deficits. Refer to: CFR 483.21 (c)(1), F669 - Discharge Planning Process CFR 483.40 (d), F745 - Provision of Medically Related Social Services CFR 483.70, F835 - Administration Reference: (WAC) 388-97-0640 (1)

Based on interview and record review, the facility Administration failed to administer the facility in a manner that ensured the safety and well-being of 1 of 1 cognitively impaired residents (2) that staff discharged Against Medical Advice (AMA) with a known alleged perpetrator. The failure of facility staff to collaborate and to use the facility's resources to ensure a safe discharge resulted in an Immediate Jeopardy (IJ) on 03/09/17. After the IJ was implemented, the facility submitted a removal plan that included auditing current residents for similar POA/guardianship issues, surveying staff regarding abuse, reviewing and revising policies, and educating staff on policies related to transfer and discharge. The IJ was removed on 03/13/18. Findings included: The facility failed to: communicate and document pertinent information to the resident's son, to collaborate and document pertinent information to the resident's physician/facility medical director, to take necessary steps to obtain a guardianship, to implement discharge planning interventions, to collaborate and document staff concerns regarding alleged perpetrators, to utilize and communicate a multidisciplinary approach to assessing the resident's mental capacity, to thoroughly document in clinical records, and to have necessary policies in place for administering safe discharges. Refer to: CFR 483.12, F 600 - Free from Abuse and Neglect The administration failed to ensure residents were free from exploitation. CFR 483.21 (c)(1), F 660 - Discharge Planning Process The administration failed to develop, update and implement an effective discharge plan. CFR 483.35(d)(7), F 730- Nursing Aide Performance Review The administration failed to ensure nurse aides had yearly performance reviews and provided in servicing based on the evaluations. CFR 483.40 (d), F 745 - Provision of Medically Related Social Services The administration failed to provide medically related social services to advocate for a resident who was cognitively impaired. CFR 483.95(g)(1)-(4), F-947 - Required In-Service Training for Nurse Aides The administration failed to ensure the nurse aides received the required 12 hours of yearly training. Reference: (WAC) 388-97-1620 (1)

Based on interview, record review and observation the facility failed to thoroughly investigate allegations of abuse for 5 of 5 residents (1, 2, 3, 4 and 5) and report allegations timely for potential verbal abuse for Resident 2 reviewed for allegations of abuse. The facility failed to recognize psychosocial harm experienced by a Resident 5. This failure resulted in the facility's inability to recognize abuse and psychosocial harm and protect residents from potential abuse. Additionally, the facility failed to document all required components of the state reporting log. Findings Include: According to the Nursing Home Guidelines AKA The Purple Book sixth edition, stated facility's must maintain a state reporting log. The reporting log must contain the following information: date the incident was logged, resident name, date/time of the incident, nature of occurrence, incident location, type of injury, findings, action, hotline notified and by whom. This information must be logged (reported) within 5 days of discovery. Additionally, the results of all investigations must be reported to the administrator or their designated representative and to other officials in accordance with State law within 5 working days of the incident. In a joint interview on 06/21/17 at 1:05 PM with the Administrator, Director Nursing Services (DNS) and Regional Manager stated they follow the guidelines of the purple book. RESIDENT 5 Resident 5 had a verbal altercation with Resident 1 on 06/04/17. Resident 1 called resident 5 vulgar names and then threatened physical harm to Resident 5. Review of the investigation conclusion, dated 06/19/17, 15 days later, the facility did not rule out abuse or neglect. The incident report and the medical record both reported Resident 5 was tearful after the incident. In a progress note dated 06/05/17 at 3:27 PM, stated she does not want Resident 1 near her. She also stated she felt the resident would find her no matter where she was in the facility. She continued to be concerned about the incident. A progress note dated 06/05/17 at 3:40 PM, stated, he got right in my face, I know that he will get me. A progress note dated 06/08/17 at 6:00 AM, stated, afraid of resident she had altercation with and stated, I know he will get me if he can. A progress dated 06/09/17 at 3:50 PM, stated the resident had been seen alone in the dining room with the resident she had an altercation with last evening. When asked the resident stated I ignored him when I heard him come in. An investigation dated 06/10/17, revealed another verbal altercation with Resident 1. Resident 5 was in her room visiting with her son in law when resident 1 came into the room and turned off the light and started yelling at Resident 5. When staff approached the son in law was standing between the two residents. Resident 1 had again verbally threatened Resident 5. Per the investigation Resident 5 stated multiple times, I do not feel safe here. The conclusion to the 06/10/17 investigation was done on 06/20/17, done 10 days later, did not rule out abuse or neglect and was not completed in a timely manner. A progress note dated 06/10/17 at 9:55 PM, stated Resident 5 was reassured by staff that she was safe and Resident 1 was being supervised when he was out of his room. A progress noted dated 06/12/19 at 10:45 PM, Resident 5 had an episode of being upset about moving. The resident stated she felt like she was being punished and stated I am the victim. The resident was upset and angry verbalizing concerns that if she was approached by Resident 1 she will make a report against him for domestic violence. Resident 5 was transferred to another facility on 06/13/17. In an interview on 06/27/17 at 10:30 AM, Resident 5 stated what happened at the facility was a very unpleasant experience. Resident 5 stated she was the victim in the above two incidents and she was being punished by the facility. Resident 5 stated Resident 1 called her the C-word, and I have never in all my life been called that name. I do not understand why I was the one that had to be moved from my home and be punished. Resident 5 stated a facility staff member (she could not recall who) told her she had to move because no one would accept him with his behaviors but they would accept me, so off I went. The record continued to state the resident was not experiencing psychosocial harm after both incidents. The staff failed to identify psychosocial harm for Resident 5. RESIDENT 1 The resident's psychosocial well being/ behavioral disturbances care plan noted on 05/16/17 a door sensor in place to alert staff when resident was out of room and the resident was to be in direct supervision of the staff when out of room. On 06/10/17, the resident was placed on 1:1 supervision when out of room. The wandering care plan also noted the door sensor and direct supervision. On 06/21/17 at 11:30 AM, the resident was observed in the hallway near the nurses station, picking up items off the rug. The resident was alone no staff were within eyesight. In an interview at 11:40 AM, Staff D, Licensed Nurse (LN), was asked about the door alarm. Staff D stated the door alarm sounded at the nurses station alerting staff when the resident came out of his room. Staff D was aware the resident was alone in the hallway right now and was supposed to be under supervision. At 12:40 PM. the resident was again observed alone in the hallway self propelling in the hallway with Resident 3 nearby. There was no direct supervision provided by the staff. The resident was involved in verbal altercations with other residents on 01/13/17, 05/17/17, 06/04/17 and 06/10/17. The facility failed to recognize the resident's pattern of verbal abuse and ensure he was in direct supervision of staff when out of his room. RESIDENT 4 Review of the state reporting log revealed an allegation of abuse was made on 06/19/17 involving Staff B, Nursing Assistant (NA), towards Resident 4. On 06/19/17, the resident reported to Staff B she did not want her to give her a bed bath because Staff B was rough with her. Staff B reported the allegation to the facility. Review of the incident investigation revealed the facility failed to interview any other residents or staff regarding Staff B. The DNS concluded abuse did not occur. The DNS stated Staff B had recently returned to employment and there had been no prior allegations made by Resident 4 regarding Staff B. In an interview on 06/21/17 at 11:50 AM, Resident 4 stated she will not allow Staff B give her a bed bath because she was rough. The resident stated Staff B had been gone for about 6 months and was recently hired back. The resident stated Staff B was rough with her prior. Resident 4 she did not report this prior but I will not allow her to give me a bed bath. She (Staff B) is rough. I told her to get out of my room. Resident 4 stated the facility did not interview her regarding this allegation. The resident stated she thought they would with everything going on, but no one did. In a joint interview with the Administrator, DNS and Regional Manager at 1:05 PM, was made aware Resident 2 had allegations that were not reported regarding Staff B being rough with her when she worked at the facility prior. The DNS stated she did not interview the resident after the allegation of physical abuse. The DNS was not able to state why this was not done. The DNS stated she did not interview other residents or staff regarding Staff B's performance/care. RESIDENT 3 Review of the state reporting log revealed an allegation of abuse was made on 06/14/17. Resident 3 stated . that one girl (Staff A, NA) was snotty as hell to me . when the resident was requesting some food from the kitchen. Review of the investigation conclusion dated 06/20/17, six days later, the DNS, did not rule out abuse and neglect. The facility failed to interview other staff members who work with Staff A to rule out any changes in her behavior or work performance. In an interview on 06/21/17 at 9:50 AM, Resident 3 was lying in bed. The resident stated Staff A was very snooty towards her when she requested some food from the kitchen. At 1:05 PM, the DNS stated she forgot to put in the conclusion abuse and neglect was ruled out. The DNS was made aware the investigation was not thorough. RESIDENT 2 Review of the state reporting log revealed Resident 2 made an two allegations of abuse on 06/19/17 involving Staff C and D, Licensed Nurse. On 06/19/17, Resident 2 reported to Staff E, Activity Director, that Staff D talked to him . like I'm below her . Staff E filed a grievance report dated 06/19/17. On 06/19/17, Resident 2 also reported Staff C talked down to him. Review of the progress notes revealed no information regarding the allegation of potential verbal abuse/psychosocial harm until 06/21/17, two days later. The conclusion of the investigation revealed the facility had ruled out abuse and neglect. In an interview on 06/21/17 at 11:10 AM, Resident 2 was not able to recall the above two allegations. At 1:10 PM, the Administrator stated Staff E did not report the allegation of verbal abuse until 6/20/17 at around 4:00 PM or 4:30 PM, the next day. The Administrator stated the investigation was started at that time. At 1:15 PM, the DNS was not able to state why the allegation of verbal abuse was not documented in the resident's record, why the resident was not placed on alert charting for potential psychological harm or why the care plan was not updated. The facility failed to report potential verbal abuse/psychological harm to the Administrator immediately. Staff E waited over 24 hours to report the allegation to the Administrator. The facility failed to place the resident on alert for any potential psychosocial harm or that the allegation occurred. STATE REPORTING LOG On 06/21/17 at 9:40 AM, the DNS stated the state reporting log from 05/01/17 to 06/21/17 was completed. Review of the state reporting log revealed 28 out of 87 entries the facility failed to report the type of injury the resident sustained [REDACTED]. In a joint interview on 06/21/17 at 1:05 PM with the Administrator, DNS and Regional Manager stated they follow the guidelines of the purple book. The DNS was not able to state why the state reporting was not complete and lacked sufficient reporting information.

Based on interview and record review the facility failed to implement written policy and procedure components of thorough investigation, including identification of abuse, protection and reporting of allegations of abuse for eight (15, 19, 24, 26, 38, 41, 48 & 50 ) of eight residents reviewed for abuse. This failed practice resulted in residents continued exposure to alleged abusive caregivers or residents; thereby constituting a situation of immediate jeopardy. Findings include: Upon survey entrance on 05/15/17 the contact persons for abuse prohibition policies and procedures/complaints/grievances information listed in order were: The facililty Administrator, and if not available, the Director of Nursing Services (DNS) and/or Social Services Director (SSD). A Review of the facility's Abuse Prohibition Policy and Procedure: Abuse, Neglect, Exploitation and Misappropriation of Resident Property . The Policy and Procedure stated each resident has the right to be free from verbal, sexual, physical, and mental abuse . Allegations of abuse, neglect, or exploitation are reported immediately to the Administrator (or DNS/SSC), but not later than 2 hours after information of the suspicion, if the events that cause the suspicion involve abuse or result in serious bodily injury or not later than 24 hours . Verbal abuse is defined as: the use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. RESIDENT 19 Resident 19 admitted in July of 2014. According to the 04/13/17 Minimum Data Set (MDS, an assessment tool) the resident was understood, had clear comprehension, was cognitively intact, and demonstrated no verbal or physical behaviors directed at others. In an interview with Resident 19 on 05/15/17 at 2:17 PM, she was asked if staff had ever abused her. Resident 19 stated Yes, they are all very nice except Staff E (Nursing Assistant); I told the staff she is not to come near me. She didn't treat me right while changing me; she was rough with me. She just ignored me. I told the staff right away. She (Staff E) still tries to make up to me by being nice, like if she picks my tray up. She was rough and in such a hurry. On 05/16/17 at 9:51 AM, Resident 19 stated, She (Staff E) is barred from taking care of me but I won't let her. I don't care if she brings my tray but I don't want her to help me. A few months ago, she was very rough with me, I had urinated and had to be washed off and she was rough as heck. I told her I am not a car and that is my most delicate spot, quit being so rough. She said I am not rough. Then she tried to take care of me again and I said no, you can't take care of me, you are not to touch any part of my body, so I told my nurse and asked the big wig to come down. A couple staff came in and I told them (Administrator and Director of Nursing Services) she (Staff E) can never take care of me again. (The Administrator) asked if I wanted her fired and I said No, but I do not want her to take care of me and you better make sure she isn't hurting any other lady. This was not investigated or documented on the state reporting log or facility grievance log. In an interview on 05/16/17 at 1:54 PM, the Administrator stated I do not remember that at all. The Director of Nursing Services (DNS) stated, We moved Staff E to the other unit because she was high energy and residents felt rushed by her. When the DNS was asked why further investigation was not completed after Resident 19 requested Staff E not care for her, she had no response. Review of Staff E's personnel file did not contain any education or disciplinary action. The investigation of the allegation of abuse was not initiated until 05/16/17 at 2:25 PM. According to the investigation, Resident 19 indicated that she told Staff L, Licensed Nurse (LN), the Administrator and another nurse. Staff L, LN and the Administrator denied resident 19 had reported rough handling; just that she did not want Staff E to take care of her anymore. The summary concluded the Administrator denied having any knowledge this was reported to her and therefore it was never investigated nor reported, although Staff E was reassigned from caring for this resident. The facility summary stated unable to rule out abuse and neglect. The facility's failure to interview the alleged perpetrator (AP) to determine whether physical or psychosocial harm occurred precluded staff from determining that the allegation of abuse was unsubstantiated. The facility also failed to interview other residents and staff to determine if any others had been affected or had negative interactions with the AP. Additionally; the AP continued to provide care for vulnerable residents unsupervised placing all residents at risk for abuse. RESIDENT 26 Resident 26 admitted in April of 2016. According to the 03/10/17 MDS, the resident was cognitively intact. In an interview on 05/15/17 at 11:21 AM. Resident 26 was asked - Has staff, a resident or anyone else here abused you - this includes verbal, physical or sexual abuse? She responded, Yes, there was one NAC that would swear at my roommate. That girl is still here. Her name is (Staff E). She would say God d it and s .t when my roommate would grab at her during cares. She was being nasty so I turned her in Staff E is still here. She might even be here today. On 05/16/17 at 9:42 AM, Resident 26 requested we speak privately. Resident 26 indicated her roommate was Resident 24. Resident 26 stated, She (Staff E) used to yell at my roommate. She is a loud mouth, she is obnoxious .my roommate would grab her during cares and Staff E would say (roommate's name), God d it. She said several swear words. It made me very uncomfortable. I told Staff E -will you please stop swearing. I said- do you realize how much you swear when you come in here? I do not see her much anymore. I reported this to Staff I, Social Services Director (SSD). She (Staff E) brought me my lunch tray yesterday, that was OK. I was almost afraid for (Resident 24), really. Staff E made me nervous, she scared me a little bit and she does still work here. I don't think they fire anybody here. They are so short of help. I don't think that Staff E should be here at all. Review of the investigation started on 05/16/17 at 3:00 PM included a statement from Staff M, Nursing Assistant who stated She (Resident 26) expressed to me how worried she was about her roommate (Resident 24) and the caregiver (Staff E) was not being nice to her roommate. Resident 26 stated, Staff E was being mean to her and yelling at her. So I looked for someone that could help with this situation. I stopped Staff I and told her .I asked her (Staff I) to take her (resident 26) to a quiet room to talk with her .When Staff I was finished talking with Resident 26, I asked her if there was anything I need to do and she said -no, we just need to nip it in the bud and stop the situation before anything else happens . According to the completed investigation, Staff I, SSD denied having any knowledge of the allegation. It was not reported or investigated at the time. The facility was unable to rule out abuse. On 05/16/17 at 3:26 PM Resident 26 stated I just told the corporate nurse that I did tell Staff I about it. The lady told me it won't happen again. What a relief. Staff E scared me a bit. On 05/17/17 at 9:43 AM, Resident 26 stated I feel safer here now. I know they will address my concern. They didn't do nothing before, which is sad. The facility's failure to interview the alleged perpetrator (AP) to determine whether physical or psychosocial harm occurred precluded staff from determining that the allegation of abuse was unsubstantiated. The facility also failed to interview other residents and staff to determine if any others had been affected or had negative interactions with the AP. Additionally; the AP continued to provide care for vulnerable residents unsupervised placing all residents at risk for abuse. RESIDENT 24 Resident 24 admitted in August of 2016 and was receiving end of life care. She was assessed as rarely or never understood on her 03/23/17 MDS. She is not interviewable. Since the allegation was not reported or investigated in an immediate manner, signs of physical and or psychosocial abuse could not be ruled out. The facililty's failure to interview the AP to determine whether physical and or psychosocial harm occurred precluded staff from determining that the allegation of abuse was unsubstantiated. Staff also failed to interview other residents and staff to determine if any others had been affected or had negative interactions with the AP. Additionally; the AP continued to provide care for vulnerable residents unsupervised placing all residents at risk for abuse. On 05/16/17 at 1:48 PM, The Administrator and DNS confirmed there were no outstanding investigations or grievances that had not been logged. RESIDENT 50 Resident 50 was admitted in July of 2016 with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicated she was alert and oriented, able to make decisions and cognitively intact. In an interview on 05/15/17 at 2:05 PM, Resident 50 was responding to questions that were being asked of her roommate, Resident 48. Resident 50 stated that Staff E (NA) could be rude and that Staff E (NA) scrubbed her hair in the shower and the Administrator knows about it. Resident 50 stated Staff E (NA) was yelling at Resident 48 recently. Resident 50 reiterated that the Administrator knew all about it. In an interview on 05/16/17 at 9:20 AM, Resident 50 stated she had a bad migraine and thought a hot shower would help. She further stated Staff E took her to the shower and scrubbed her head so hard it felt like her nails were going into her head and she did not stop. Resident 50 additionally stated it made her migraine worse because she scrubbed so hard. The resident indicated this happened a month ago and the Administrator was aware of the situation, because Staff E no longer gives her a shower anymore. Review of the nursing progress notes dated 04/08/17, 04/09/17 and 04/18/17 revealed Resident 50 was medicated for complaints of a headache. In a combined interview with the Administrator, Director of Nursing Services (DNS), Staff I, Social Service Director (SSD) and Staff DD (Regional Vice President of Operations) on 05/16/17 at 2:08 PM, the Administrator stated she didn't do a 'full on' investigation because Resident 50 said she just scrubbed a little bit too hard and Staff E (NA) didn't cause her any pain. The Administrator additionally stated that the resident did not like Staff E. The Administrator further stated she should have recognized this as an 'allegation'. Staff I stated that Staff E was high energy and she can be too much for the more demented residents. The DNS pointed to the south side of the building where Staff E was moved to work with other residents. Resident 50 lived on the North side. This allegation was not documented on the state reporting log or grievance report. This allegation was not reported to the state hotline. The incident report was completed after this was brought to the Administrator, DNS, Staff I and Staff DD's attention on 05/16/17. Review of the incident report for the alleged allegation completed on 05/19/17 stated, Investigation into the allegation of abuse made by Resident 50 indicated that Staff E, NA, was assisting her with a shower and was scrubbing her scalp too vigorously. Resident 50 asked her to stop and Staff E, would not stop. Resident 50 indicates that she reported this to the Administrator. The Administrator admits that yes this was reported to her, but she did not take it as an allegation, she just thought that the resident did not want Staff E, to give her a shower anymore. Staff E, denies any wrongdoing and states she did not even touch the resident, she was only supervising the shower. Unable to rule out abuse. The facility's failure to interview the alleged perpetrator (AP) to determine whether physical or psychosocial harm occurred precluded staff from determining that the allegation of abuse was unsubstantiated. The facility also failed to interview other residents and staff to determine if any others had been affected or had negative interactions with the AP. Additionally; the AP continued to provide care for vulnerable residents unsupervised placing all residents at risk for abuse. RESIDENT 15 Resident 15 was a long term care resident with a [DIAGNOSES REDACTED]. In multiple observations on 05/15/17, 05/18/17 and 05/19/17 purple bruises were identified on the resident's left 4th finger measuring approximately 2 centimeters (cm) by 3 cm, right medial wrist area measuring approximately 2 centimeter (cm) by 3 cm and a bruise to right first knuckle measuring approximately 1 cm by 5 cm. In an interview on 05/19/17 at 10:48 AM the DNS stated all bruises should be reported to the LN and an investigation should be completed to rule out abuse, a skin sheet would be started and weekly rounds would be completed. The DNS was made aware of the resident's bruises to her bilateral hands and fingers. In an interview on 05/19/17 at 10:58 AM Staff M, NA, was performing daily hand therapy on the resident and stated the bruises had been there a while. Staff M stated the Licensed Nurse (LN) knew about the bruises but was unsure exactly which LN was aware. Record review of the state reporting log and nursing progress notes indicated the bruises were not identified and an investigation had not been started until it was reported by the surveyor on 05/19/17 The facility's failure to interview the alleged perpetrator (AP) to determine whether physical or psychosocial harm occurred precluded staff from determining that the allegation of abuse was unsubstantiated. The facility also failed to interview other residents and staff to determine if any others had been affected or had negative interactions with the AP. Additionally; the AP continued to provide care for vulnerable residents unsupervised placing all residents at risk for abuse. RESIDENT 41 Resident 41 admitted on [DATE] with [DIAGNOSES REDACTED]. According to the MDS dated [DATE] the resident had intact memory, and required extensive or total assistance for bed mobility and toileting needs. In an interview with Resident 41 on 05/15/17 at 11:13 AM, he was asked if staff treat him with respect and dignity and he stated he had a problem with a nursing assistant (Staff E) who he stated was abusive to him. He recalled an incident where he asked Staff E for a washcloth during cares and she handed him A dirty wipe that she had already wiped me with. He stated he called (Staff E) the C-word and since then she doesn't provide care for him. He further stated Staff E refused to empty his urinal telling him it was not full enough. He stated the facility Administrator and Staff I, Social Services Director (SSD) both talked to him about it and nothing happened, they only cared about me calling her a name; She (Staff E) is still here In an interview with the Administrator, Director of Nursing, Staff I, Social Services Director, and Staff FF, Regional Director of Clinical Operations on 05/16/17 at 2:08 PM, Staff I recalled the incident regarding the washcloth stating I do remember that It was a crumpled up washcloth I remember that, he stated Staff E gave him a crumpled up washcloth and he threw it back at her. He said he was aiming for the trashcan and he called her a name. Staff I denied knowing it was a dirty cloth. A review of the facility grievance and state reporting logs revealed no entry corresponding to an investigation of Resident 41's allegations. A facility investigation was not initiated until 05/16/17 which revealed the NAC did hand the resident a dirty wipe and the Administrator and Staff I had been in to discuss the issue with resident. The facility was unable to rule out abuse and neglect. The facility's failure to interview the alleged perpetrator (AP) to determine whether physical or psychosocial harm occurred precluded staff from determining that the allegation of abuse was unsubstantiated. The facility also failed to interview other residents and staff to determine if any others had been affected or had negative interactions with the AP. Additionally; the AP continued to provide care for vulnerable residents unsupervised placing all residents at risk for abuse RESIDENT 38 Resident 38 admitted in December of 2015 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] indicated the resident had cognitive impairment, required assistance for mobility and eating, and had delusional and verbal behavioral issues. Record Review of a facility incident report dated 5/16/17 revealed Staff EE, Dietary Aide, overheard Staff E in the dining room (about 3 or 4 days prior) lean over Resident 38 who was upset and say shut up and eat. Staff EE had stated in her statement that she had not known she should report this. Resident 38 is not interviewable related to dementia and does not recall the incident. The facility became aware of the allegation as a result of a pattern of allegations regarding Staff E and were questioning staff and residents regarding their experiences with Staff E. Staff EE did not recognize verbal abuse of a resident and the associated mandatory reporting requirements. The facility's abuse prohibition policy was not followed. The facility was not able to rule out abuse and neglect by Staff E. RESIDENT 48 Resident 48 admitted in June of 2016 with a [DIAGNOSES REDACTED]. According to the MDS dated [DATE], the resident is cognitively intact and requires extensive assistance with activities of daily living. In an interview with the resident on 05/15/17 at 1:49 PM, the resident was asked - Has staff, a resident or anyone else here abused you - this includes verbal, physical or sexual abuse? The resident responded, Yes and stated that another resident had gotten angry and called her (Resident 48) the C- word, then left the dining room loudly yelling F-U, F-U, F-U. She stated several staff were in the dining room and observed the incident. She stated this was a couple of weeks ago. Record Review of the state reporting log and the facility grievance logs revealed no investigation was done related to a resident to resident incident involving Resident 48 and any other resident. The facility administration again became aware of the allegation as a result of a pattern of allegations regarding Staff E and was questioning staff and residents. The resident had a complaint regarding Staff E that was also further investigated and abuse and neglect could not be ruled out. The facility staff failed to recognize and investigate verbal resident to resident abuse and this failure placed residents at risk for continued exposure to allegedly abusive staff and residents. The facility demonstrated a consistent failure follow policies and procedures to protect the residents from alleged abusive staff and/or residents and failed to investigate and report incidents and allegations which placed of investigation into allegations of abuse which placed all residents at risk of abuse and neglect. Reference: (WAC) 388-97-0640 (1), (2)(a)(b), (3)(a), (5)(a)(b), (6)(a-c), (7)(a), 8(a)

Based on observation, interview and record review, the facility was not administered in a manner to effectively use its resources to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility was in compliance with regulatory requirements which effected 24 of 34 residents (4, 8, 9, 14, 15,19, 21, 22, 24, 26, 30, 31, 32, 33, 34, 38, 39, 41, 45, 48, 52, 53, 56, and 57) reviewed. These failures had the potential to effect all residents' safety, dignity and quality of life. Findings include: The Administration failed to ensure residents representatives were notified of changes in residents condition. Refer to F 157 CFR 483.10 (g)(14) The Administration failed to operationalize their policies and procedures for protection of resident's and for the prevention, identification and investigation of abuse, neglect and/or mistreatment of [REDACTED]. Refer to F 226 CFR 483.12(b)(1)(2) The Administration failed to ensure residents were treated with respect and dignity. Refer to F 241 CFR 483.10 (a)(1) The Administration failed to ensure a resident was able to exercise their rights for self-determination. Refer to F 242 CFR 483. (f) (1)(2)(3) The Administration failed to ensure all residents had activities. Refer to F 248 CFR 483.24 (c) The Administration failed to ensure medical Social Services were provided to residents. Refer to F 250 CFR 483.15(g)(1) The Administration failed to ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Refer to F 253 CFR 483.10 (i)(2) The Administration failed to ensure revision of the comprehensive care plan reflected person-centered objectives and time frames to meet a resident's medical, nursing, and mental health needs. Refer to F 279 CFR 483.21 (b) The Administration failed to ensure the comprehensive care plan met professional standards of quality. Refer to F 281 CFR 483.20(k)(3)(i) The Administration failed to ensure the comprehensive care plan was completed by qualified persons. Refer to F 282 CFR 483.21 (b) (3) The Administration failed to ensure residents receive pre-admission screening and resident review (PASRR). Refer to F 285, CFR 483.20(m) The Administration failed to ensure quality of care for residents with skin issues. Refer to F 309 CFR 483.25 The Administration failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Refer to F 312 CFR 483.24 (a)(2) The Administration failed to ensure a resident did not develop pressure ulcer. Refer to F 314 CFR 483.25(b)(1)(i) The Administration failed to protect residents from accidents and provide adequate supervision. Refer to F 323 CFR 483.25(d)(1)(2) The Administration failed to ensure residents were free of unnecessary medication. Refer to F 329 CFR 483.45 (d) The Administration failed to ensure sufficient nurse staffing to meet the needs of all residents. Refer to F 353 CFR 483.35 (a) The Administration failed to ensure an infection control prevention program to monitor hand hygiene by staff. Refer to F 441 CFR 483.80 The Administration failed to ensure nurse aides received a performance review every year and provide regular in-service education based on the outcome of the reviews. Refer to F 497 CFR 483.35(d)(7) The Administration failed to ensure nurse aides received the required 12 hours of continued education, including dementia management training. Refer to F 498 CFR 483.95(g)(1)(2) The Administration failed to ensure records were complete and accurate. Refer to F 514 CFR 483.75(l)(1) The Administration failed to maintain an effective Quality Assessment and Assurance Program. Refer to F 520 CFR 483.75(g)(2)(i)-(iii) Reference: (WAC) 388-97-1620

Based on observation, interview and record review the facility failed to provide an environment that was free from hazards which the facility had control by not assuring safe storage of toxic chemicals on 1 of 2 hallways or securing medications in 2 of 2 medication carts. This failed practice placed 1 of 1 cognitively impaired resident (39) with intrusive wandering behavior at risk of serious injury, harm, impairment or death without immediate correction, constituting a situation of immediate jeopardy on [DATE]. The immediate jeopardy was removed on [DATE] with increased facility staff monitoring and supervision of Resident 39 along with removal of unsecured toxic chemicals throughout the facility. Additionally the facility also failed to implement preventative measures for residents at risk of harmful sun exposure for 1 of 1 resident (33). This failed practice resulted in a first-degree burn to resident 33. Findings include: RESIDENT 39 Resident 39 was a long term resident of the facility with [DIAGNOSES REDACTED]. On [DATE], Resident 39 was observed on multiple observations throughout the day self-propelling in a wheelchair wandering throughout the facility. HAZARDOUS CHEMICALS: In an observation on [DATE] at 11:40 AM, an oversized bottle of rubbing alcohol was sitting out on the Resident 37's nightstand along with a bottle of Biotène mouthwash and hair spray labeled keep out of reach of children sitting on the sink vanity in room 3 while Resident 37 was out of the room. In an observation and interview at 4:25 PM, Resident 37 stated rubbing alcohol was used for an ingrown toenail .the aides and nurses are aware . there have been residents in my room before going through my items. At 4:28 PM, the resident in room 10 was out of the room and a bottle of acetone nail polish remover was on the bedside table directly inside the doorway. In an interview at 5:24 PM, the Administrator confirmed the immediate risk of the unsecured toxic substances within reach of Resident 39, with the resident's wandering and rummaging behaviors throughout the facility. In an interview on [DATE] at 9:59 AM, Staff C, Registered Nurse (RN) stated if chemicals are out in the resident's room they are to be removed and secured. In an interview at 10:25 AM, Staff P, RN stated we are supposed to have nail polish remover or any chemical items in the medication room. In an interview at 11:06 AM, the Director of Nursing Services (DNS) stated her expectations are to maintain any toxic chemicals secured or keep in the top of the resident's closet and out of reach of cognitively impaired residents. Review of the facility's Continuous Quality Improvement General Observation of The Center Checklist stated: 6.) Hazards: Is the center as free of accidental hazards as possible? Are housekeeping/hazards, compounds, and other chemicals stored to prevent resident access? MEDICATION CARTS In an observation on [DATE] at 12:03 PM, Staff N, Licensed Nurse went to administer medications to Resident 52, leaving her medication cart unlocked and accessible to residents. Staff P, Licensed Nurse (LN) was alerted to the unlocked cart and secured the medication cart. The Administrator was in observation of the unlocked medication cart when the LN was alerted to the situation. In an observation on [DATE] at 2:53 PM, the medication cart of Staff T, LN was unlocked and accessible to residents. Multiple confused residents were observed in the area of the nurse's station during all dates of the survey. In an interview on [DATE] at 12:30 PM, the Director of Nursing Services stated the medication carts were to be locked when not attended by a nurse. Staff D, LN was notified of the unlocked medication cart and locked it. PREVENTION OF BURNS: Resident 33 admitted in [DATE] with a primary [DIAGNOSES REDACTED]. A review of the resident's Minimum Data Set (MDS) revealed the resident had intact memory, was independent for his activities of daily living such as getting up and dressed and walked without an Assistive device. The MDS further identified that the resident felt it was very important to go outside when the weather was nice. A review of the resident's care plan stated the resident was ok to go outside unsupervised and that he enjoyed sitting in the sun. An observation on [DATE] at 9:11 AM revealed the resident was sitting in the lobby with shiny, reddened skin on his face, head and hands. This surveyor stated to the resident that it looked like he had been out in the sun and he stated yes, too much, I got red on my nose; I was out tanning; It burns. When asked if the facility provided him sunscreen he stated that Staff Z (activities assistant) came outside and put some on my hands and I just rubbed it on. An Observation on [DATE] at 10:48 AM revealed expired sunscreen on the North medication cart. Expiration date was ,[DATE]. Staff P stated that the South cart did not have sunscreen and when asked regarding sunscreen for Resident 33 she stated I guess not; he got sunburned. In an observation on [DATE] on or about 11:30 AM revealed the container of sunscreen that Staff Z, Activities assistant, stated was used yesterday on Resident 33 revealed it was new with an expiration date ,[DATE]. She stated that he will put it on but you have to catch him. She stated the resident was already outside and she told him his nose was getting red so he needed it and she sprayed it all over him. The facility had no policy related to protecting residents during hot weather or sunscreen; specifically, whose responsibility it is to ensure it is applied before the resident goes outside. In an interview on [DATE] at 12:25 PM, the Director of Nursing stated that sunscreen is provided for anybody who wants to go sit outside. She stated that Resident 33 did not always want sunscreen and she was updating his care plan. Reference: (WAC) [DATE] (3)(g) .

Based on interview and record review, the facility failed to ensure 9 of 12 residents (8, 14, 19, 21, 22, 26, 34 41 and 48) choices were honored regarding important daily routines such as the frequency of bathing basic needs and grooming. This failed practice prevented the residents from exercising their right to make choices regarding their care, decreased the residents' quality of life and caused the residents' psychosocial harm as related to the reasonable person. Findings include: See F 353 for further details and examples. RESIDENT 22 Resident 22 was admitted in June 2011. Review of the MDS assessment dated [DATE], indicated the resident was able to state her preferences. She required extensive assistance of 1 person for most ADL. Review of the POS [REDACTED]. Review of the shower/bath preference dated 04/07/17 indicated the resident preferred one shower a week. Review of the most recent shower/bath sheet for May 2017 revealed her last shower was 05/13/17 and as of 05/23/17, she had not had a shower in 10 days. Review of March 2017 shower/bath sheets revealed she went from 03/22/17 until 04/03/17 with no shower (13 days). On 05/23/17 at 9:33 AM, Resident 22 was heard from the hallway repeatedly calling out When am I going to get a shower, It has been three weeks since my last shower. Upon entry to her room, the resident was asked if she was OK. She stated, No, I am not OK. I want a shower, it has been 3 weeks. In a follow up interview on 05/23/17 at 9:52 AM, the resident stated, I feel agitated, it has been 3 weeks since I have had a shower. It makes me feel like they passed me up. RESIDENT 19 Resident 19 admitted in July of 2014. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was able to state her preferences. She required extensive assistance of 1 person for most activities of daily living (ADL). Review of the POS [REDACTED]. Review of the shower/bath preference dated 04/17/17 indicated the resident preferred one to two bed or tub baths a week in the early morning. Review of the most recent shower bath sheet for May 2017 indicated her last shower was 05/10/17 and as of 05/23/17 she had not had a bath in 13 days. In a follow up interview on 05/23/17 at 2:47 PM, the resident stated, When the shift is short it makes the residents suffer. I waited one night on the bedpan for 40 minutes to get off the bedpan. It makes me feel like I was not anything to them. Review of March 2017 shower/bath sheets revealed she went from 03/17/17 until 03/29/17 with no bath (13 days). Similarly, in February 2017, she had no bath from 02/17/17 through 02/27/17 with no bath (11 days). RESIDENT 21 Resident 21 admitted in February of 2017. Review of the MDS dated [DATE], indicated she was able to state her preferences. She required supervision for bathing. Review of the POS [REDACTED]. Review of the shower/bath preference dated 04/20/17 indicated the resident preferred one to two showers a week. Review of the most recent shower/bath sheet for May 2017 revealed her last shower was 05/13/17 and as of 05/23/17, she had not had a shower in 10 days. Review of March 2017 shower/bath sheets revealed she went from 03/17/17 until 04/06/17 with no shower (20 days). RESIDENT 26 Resident 26 admitted in April of 2017. Review of the MDS dated [DATE], indicated she was able to state her preferences. She required physical help for bathing. Review of the POS [REDACTED]. Review of the shower/bath preference dated 04/20/17 indicated the resident preferred two showers a week. Review of the most recent shower/bath sheet for May 2017 revealed her last shower was 05/11/17 and as of 05/23/17, she had not had a bath in 12 days. Review of March 2017 shower/bath sheets revealed she went from 03/21/17 until 04/04/17 with no shower (13 days). In an interview on 05/23/17 at 8:20 AM, Resident 26 stated, It's been three weeks almost since my last shower. I feel grungy. In a follow up interview on 05/23/17 at 2:13 PM, the resident stated, They are short staffed all the time, on all shifts basically. There was an aide who was very short tempered, I reported the aide but it did not go anywhere, being short staffed irritated the situation. It has been 2 weeks since I have had a shower or a bath. They offered to give me a bath a few days ago but they did not come back. It makes me feel dirty, I feel like I need to be cleaned up. RESIDENT 8 Resident 8 admitted in December of 2016. Review of the MDS dated [DATE], indicated she was able to state her preferences. She required one person physical assistance for bathing. Review of the POS [REDACTED] Review of the shower/bath preference dated 04/08/17 indicated the resident preferred one to two bed baths a week. Review of the most recent shower/bath sheet for May 2017 revealed her last shower was 05/14/17 and as of 05/24/17, she had not had a bath in 10 days. Review of March 2017 shower/bath sheets revealed she went from 03/15/17 until 04/04/17 with no bath (21 days). RESIDENT 45 Resident 45 admitted in April 2016. Review of the MDS dated [DATE], indicated he was unable to state his preferences. On 04/17/17, his wife informed the facility his known preference for bathing was showers twice a week late morning. He required extensive assist for bathing. Review of the POS [REDACTED]. Review of the most recent shower/bath sheet for May 2017 revealed his last shower was 05/14/17 and as of 05/24/17, he had not had a shower in 10 days. Review of the March 2017 shower/bath sheets revealed he went from 03/22/17 until 04/04/17 with no shower (12 days). Resident 48 In an interview 05/15/17 at 1:56 PM, the resident stated, No, there is not enough staff, one time we timed them and we waited a half hour. If I am in my chair, I will go out and find them. You turn your light on because you need something, I have had to wait and wet myself. The staff tell you they cannot give you a shower, that they are doing their best. I want at least two showers a week. Last week I did not get a shower and the week before I only had one bath after I complained and complained. I am getting shortchanged. What is paid to stay here, they should be able to hire. RESIDENT 34 Resident 34 was a long-term care resident with cognitive impairment. Review of the MDS assessment dated [DATE] revealed the resident required assistance of 1 person for bathing. In a family interview on 05/17/17 at 2:14 PM, the residents daughter was asked, Does Resident 34 get bathed according to her past preferences? She stated that her mother requested 3 showers per week, but currently the building is having a hard time getting 1 done per week. Review of Resident 34's shower/bath preference form dated 04/20/17 revealed she was to receive 3 showers a week on Monday, Wednesday and Friday mid-morning. Review of the care directive form revealed the resident preferred 3 showers a week in the late mornings. Review of the residents shower/bath flowsheets revealed she received 6 of 12 showers in April 2017 and she received 2 of 11 showers from 05/01/17 through 05/24/17. RESIDENT 14 Resident 14 was a long term resident of the facility. Review of the MDS dated [DATE] indicated the resident's bathing frequency was very important to the resident and needed extensive assistance of one person to bath. In an interview on 05/15/17 at 11:16 AM, Resident 14 stated, No, I do not get to choose how many times I take a shower. The regular shower aide has quit, I'm suffering in the meantime. I would like a Monday, Wednesday, and Friday shower. I have to ask people to give me a shower; it is just a day to day situation. Review of the resident's Shower/Bath Preference Form indicated the resident preferred a shower, with circled times of 10:00 AM and 10:00 PM on Monday, Wednesday, and Friday. Review of the resident's Care Directive Form revealed the resident preferred three showers a week late in the morning on Monday, Wednesday, and Friday. Review of the resident's care plan revealed the resident required assistance to shower, to shower as scheduled and to offer showers every Monday, Wednesday and Friday. Review of the resident's Shower/Bath Flow Sheet revealed the resident received only 5 of 9 showers from 05/01/17 through 05/19/17. In an interview on 05/19/17 at 2:01 PM, Staff Q, Regional Director of Clinical Operations stated the shower assistant quit 2 weeks ago and the current nursing assistants were to implement their own showers until a new shower schedule was completed. In an interview on 05/24/17 at 12:36 PM, the Director of Nursing Services stated staffing had been challenged for the last month and a half. She stated the nursing assistants are supposed to attempt to give one shower on every shift. Reference: (WAC) 388-97-0900 (1)

Based on interview and record review the facility failed to provide sufficient qualified staff to provide care and services to answer calls lights in a timely manner, provide resident showers, provide personal hygiene and provide timely assistance with toileting for 10 of 14 residents (8, 14, 19, 21, 22, 26, 40, 41, 48, and 52) and 1 of 3 family members (34) interviewed for sufficient staffing. This failure resulted in a pattern of psychosocial harm creating feelings of frustration, vulnerability, diminished quality of life, and unmet care needs of the residents. Findings include: RESIDENT INTERVIEWS: RESIDENT 8 In an interview on 05/15/17 at 3:15 PM, the resident stated, Some days, No, there is not enough staff. Well there isn't enough people around in the morning. The helper girls come in around 6:30 to 7:00 AM but I am up at 4:00 AM. There is no sense in putting the light on if no one answers it. In a follow up interview on 05/23/17 at 2:02 PM, the resident stated, It depends on the time of day and time of month what you are going to get. Some of the staff take off at the end of the month and we are short, you have to wait a long time. The girls are supposed to shave my facial hair, I like it removed, I have tried several times to do it myself and failed. RESIDENT 14 In an interview on 05/15/17 at 11:24 AM, the resident stated, The call light does not work, they come in 1 ½ hours later, there is enough staff but they sit around and goof off. In a follow up visit on 05/19/17 at 10:46 AM, the resident stated, I'm not good, I need a shower and can't get it. They ignore me, makes me feel like I am a nobody or something, they do it all the time. RESIDENT 19 In an interview on 05/15/17 at 2:50 PM, the resident stated, No, there is not enough staff, Sometimes there are call ins at the last minute and they can't replace them. In a follow up interview on 05/23/17 at 2:47 PM, the resident stated, When the shift is short it makes the residents suffer. I waited one night on the bedpan for 40 minutes to get off the bedpan. It makes me feel like I was not anything to them. RESIDENT 21 In an interview on 05/16/17 at 11:55 AM, the resident stated, No, there is not enough staff, Well they are very busy and I understand. RESIDENT 22 In an interview on 05/17/17 at 10:51 AM, the resident stated, No, there is not enough staff, No, sometimes I wait all afternoon for help, It makes me mad, I put the call light on and nobody comes. My call light doesn't work. In a follow up interview on 05/23/17 at 9:52 AM, the resident stated, I feel agitated, it has been 3 weeks since I have had a shower. It makes me feel like they passed me up. RESIDENT 26 In an interview of 05/15/17 at 11:27 AM, the resident stated, No there is not enough staff. I am fortunate I can take myself to the bathroom and feel bad for those that cannot. I have had to wait up to an hour before. The staff work lots and often they are here all day until 10:00 PM or later. In a follow up interview on 05/23/17 at 2:13 PM, the resident stated, They are short staffed all the time, on all shifts basically. There was an aide who was very short tempered, I reported the aide but it did not go anywhere, being short staffed irritated the situation. It has been 2 weeks since I have had a shower or a bath. They offered to give me a bath a few days ago but they did not come back. It makes me feel dirty, I feel like I need to be cleaned up. There was a time when I could not toilet myself, I was incontinent and after I was toileted I was placed back in my bed, it was still wet. I reported that, but it did not go anywhere either. It made me feel like what I thought did not matter and what they did that it did not matter. Since the state has been here, I have seen some people leave that needed to leave. I felt like the administrative staff did not give a darn as long as people showed up. I felt like the administration staff just did not care. It is really frustrating when you cannot do anything yourself and you get put back into a wet bed. I complained over and over, nothing changed. RESIDENT 34 In an interview on 05/17/17 at 2:19 PM, Resident 34's family member stated, the facility was understaffed. Last week was extremely short staffed. Resident 34 used to get 2 to 3 showers a week now she is lucky to get one shower a week. RESIDENT 41 In an interview on 05/15/17 at 11:25 AM, the resident stated, No, there is not enough staff, I have to wait up to 1 hour and 15 minutes to 2 hours when I am trying to get ready to go out. In a follow up interview on 05/23/17 at 10:26 AM, the resident stated, There was a time I used the bedside commode (BSC), I needed assistance to get my legs back into the bed, I had to sit by the BSC for 45 minutes with a[***]in the BSC. I don't ask for much, I ask for very little, this is a rehab facility. I could be doing just as well living by myself. It makes me pissed. Within the past month, I had to wait to go pee and had to wait up to 2 hours to have my urinal emptied. I did not want a cup of pee spilled into my bed. It pissed me off because I am in a rehab facility and I am not getting the help. Two out of three nights I request my dinner to be saved and it is not, last night was one of those times. RESIDENT 48 In an interview 05/15/17 at 1:56 PM, the resident stated, No, there is not enough staff, one time we timed them and we waited a half hour. If I am in my chair, I will go out and find them. You turn your light on because you need something, I have had to wait and wet myself. The staff tell you they cannot give you a shower, that they are doing their best. I want at least two showers a week. Last week I did not get a shower and the week before I only had one bath after I complained and complained. I am getting shortchanged. What is paid to stay here, they should be able to hire. I am not impressed with the state people asking questions, I want to see results. You put your light on and you could wait 20 to 40 minutes or longer. My roommate and I have independently timed the call light response, what if I was on the ground. My roommate has [MEDICAL CONDITION], she fell 3 times, I pushed the button and it was 35 minutes before the staff came. It makes me feel helpless and angry. They state they are short staffed, so and so called in, well that is not my problem, and I am not getting the care. One of the new hires was trying to transfer me into bed, I ended up on the floor and the staff did not know what to do. What they were supposed to do is move the bedside commode and replaced it with the wheelchair. It makes me angry. The staff do not know how to care for me, I feel like a training officer. They are not adequately trained. I feel like I should not be doing the training. Today I spent most of my time at lunch trying to remove the wrapping from my cake, I spend a lot of time trying to get the lids off my drinks, and my roommate will come try to help me. I realize there are not enough help here and there are others that need help. RESIDENT 52 In an interview on 05/17/17 at 9:23 AM, the resident stated, No there is not enough staff most of the time. STAFF INTERVIEWS: In an interview on 05/18/17 at 3:18 PM, Staff U, Nursing Assistant (NA) stated works 2 doubles each week and have been short staff at times. In an interview on 05/19/17 at 11:02, Staff V, Medical Records Coordinator/ NA stated was working as a NA on the floor because survey is here. In an interview of 05/19/17 at 11:10 AM, Staff S, NA stated she had a wasn't feeling well, but had to come in cause it was so short staffed. In an interview with the Director of Nursing Services on 05/24/17 at 12:36 PM, she stated that staffing had been challenged for the last month and a half. RESIDENT COUNCIL MINUTES Review of the resident council minutes revealed in the meetings on 03/21/17, 04/18/17, and the 05/16/17 the staff had not been offering the snack cart to the residents and the residents continued to wait for a response from the facility. Review of the 04/18/17 and 05/16/17 meetings revealed the residents complained the shower aide was not available, requested more nursing assistants be trained to use the tub and the residents wanted a tub bath. The residents also complained there were not enough showers; one resident thought they were only allowed one shower per week. The resident council continued to wait for a response from the facility. 1) Refer to CFR 483.12(b)(1)(2), F 226 - Abuse prohibition policies & procedures. The Administration failed to operationalize their policies and procedures to protect 8 of 8 (4, 15, 19, 21, 24, 26, 38 and 48) resident's and for the prevention, identification and investigation of abuse, neglect and/or mistreatment of [REDACTED]. 2) Refer to CFR 483.25, F 309 - Care and services. The Administration failed to ensure quality of care for 1 of 4 (56) residents with skin issues. 3) Refer to CFR 483.24(a)(2), F 312 - Assistance to maintain Activities of Daily Living (ADL's). The Administration failed to ensure 1 of 3 (32) residents who were unable to carry out ADL cares received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 4) Refer to CFR 483.25 (b)(1)(i), F 314 - Pressure Ulcers. The Administration failed to ensure 1of 4(52) residents did not develop pressure ulcers. 5) Refer to CFR 483.25(d)(1)(2), F 323 - Accidents and supervision. The Administration failed to ensure adequate supervision to protect 2 of 2 (33 and 39) residents from incidents that placed residents at risk of serious injury and harm. Reference: (WAC) 388-97-1080(1)(2)(a), 1090 (1)

Based on observation, interview, and record review the governing body failed to provide oversight to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each residents' safety and well-being was not at risk. The facility's failure to ensure the implementation of written policies and procedures to identify and conduct a thorough investigation of abuse and neglect for 9 residents (7, 19, 24, 38, 41, 26, 48, 50 & 4) reviewed for allegations of abuse. The facility failed to ensure there were systems in place to ensure potential hazardous chemicals and medications were secured. These failures created immediate jeopardy conditions for the facility. Finally, review of the facility's compliance history reveals a pattern of failing to establish and maintain regulatory compliance across time. Findings include: Throughout the survey, the following deficiencies were identified which included repeat deficiencies. Refer to: F 157, CFR 483.10(g)(14), Notification of Changes F 226, CFR 483.12(b)(1)(2), Abuse Prohibition, Policies and Procedures This is a repeat deficiency from the annual QIS survey conducted on 07/13/16 F 241, CFR 483.10(a)(1),m The Facility Must Protect And Promote The Rights Of The Resident This is a repeat deficiency from a complaint survey conducted on 04/12/17 F 242, CFR 483.10(f)(1)(2) Self-Determination, The Right To Make Choices This is a repeat deficiency from the annual QIS survey conducted on 07/13/16 F 248, CFR 483.24(c) Activities F 250, CFR 483.40(d) Social Services F 253, CFR 483.10(i)(2) Housekeeping And Maintenance Services This is a repeat deficiency from the annual QIS survey conducted on 07/13/16 F 279, CFR 483.20(d) Comprehensive Plan of Care This is a repeat deficiency from the annual QIS survey conducted on 07/13/16 F 281, CFR 483.21(b)(3) Professional Standards of Care This is a repeat deficiency from a complaint survey conducted on 12/21/16 F 282, CFR 483.21(b)(3) Provided by Qualified Persons F285, CFR 483.20(k)(1) Preadmission Screening for Individuals F 309, CFR 483.25 Quality of Care F 312, CFR 483.24(a)(2) Assistance to Maintain Activities of Daily Living F 314, CFR 483.25 (b)(1)(i)(ii) Skin Integrity This is a repeat deficiency from a complaint survey conducted on 12/21/16 F 323, CFR 483.25(d)(1)(2) Accidents F329, CFR 483.45(d)(1)(2)(3)(4)(5)(6) Unnecessary Drugs F 353, CFR 483.35(a)(1) Sufficient Staff F 428, CFR 483.45(c)(4) Drug Regimen Review F 441, CFR 483.80 Infection Control F 490, CFR 483.70 Administration F 497, CFR 483.35(d)(7) Regular In-Service Education F 498, CFR 483.95(g)(1) Required In-Service Training For Nurse Aides F 514, CFR 483.70(i)(ii)(iii)(iv) Medical records F 520, CFR 483.75 Quality Assurance And Performance Improvement In an interview on 05/19/17 at 1:28 PM, Staff Q, Reginal Director of Clinical Operations stated the Reginal Director of Clinical Operations offers a lot of education on anything that comes up, reviews incident reports and plans, is kind of a double check. The Reginal Director of Clinical Operations offers support to the Director of Nursing Services. A mock survey is conducted twice yearly, we use focus interview and our company goes into infection, falls, skin care, there are 31different areas of focus. The facility had a mock survey last week; typically, it is done when the facility comes into their survey window and completed again 3 weeks after survey to assure compliance. The facility scored low in their mock survey; they have to do a plan of correction typically like a POC. Review of the Nurse Consultant job title revealed, This position is responsible for the quality of resident care services of region Centers. This position verifies region resources are adequate to meet the care needs of the residents. Reference: (WAC) 388-97-1620 (2)(c), (3)(b)

Based on observation, interview and record review the facility failed to provide social services interventions to protect, report and investigate allegations of verbal abuse and rough handling by residents, monitor and identify psychosocial harm, and address the psychosocial needs for four of eight (19, 24, 26 & 41) reviewed for abuse. Failure to intervene, address and monitor the residents for psychosocial harm, after allegations of verbal abuse and rough handling, placed them at risk for unresolved anxiety and distress and resulted in psychosocial harm for residents (19, 24, 26 & 41). Additionally, Social Services failed to ensure 3 of 5 residents (21, 24 and 26) were free from unnecessary medications, failed to complete a Level I Preadmission and Record Review (PASRR) prior to admission for 2 of 6 residents (24 and 57) and failed to ensure residents received dining in a dignified manner during 1 of 2 dining observations. Failure to ensure Social Services provided services to meet the physical, mental and psychosocial needs of the residents, had the potential of unidentified needs not being met, further decline in function, decreased quality of life, and/or continued abuse. Findings include: ABUSE ALLEGATIONS Upon survey entrance on 05/15/17 the contact persons for abuse prohibition policies and procedures/complaints/grievances information listed in order were: The facililty Administrator, and if not available, the Director of Nursing Services (DNS) and/or Social Services Director (SSD). A Review of the facility's Abuse Prohibition Policy and Procedure: Abuse, Neglect, Exploitation and Misappropriation of Resident Property . The Policy and Procedure stated each resident has the right to be free from verbal, sexual, physical, and mental abuse . Allegations of abuse, neglect, or exploitation are reported immediately to the Administrator (or DNS/SSSD), but not later than 2 hours after information of the suspicion, if the events that cause the suspicion involve abuse or result in serious bodily injury or not later than 24 hours . Verbal abuse is defined as: the use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. RESIDENT 19 Resident 19 admitted in July of 2014. The resident was cognitively intact. In an interview with resident 19 on 05/15/17 at 2:17 PM and 05/16/17 at 9:51 AM, she stated Staff E was rough with her and she did not want Staff E to touch her. This allegation of rough handling was not on the incident log or grievance log. Additionally, the resident was not placed on alert status to monitor for psychosocial harm. There was no assessment or follow up by the social worker to ensure the resident's needs were met. RESIDENT 26 Resident 26 admitted in April of 2016. The resident was cognitively intact. In an interview on 05/15/17 at 11:21 AM and 05/16/17 at 9:42 AM, Resident 26 was asked has staff, a resident or anyone else here abused you - this includes verbal, physical or sexual abuse? She responded Yes, there was one NAC that would swear at my roommate. That girl is still here. Her name is (Staff E). She would say God damn it and[***]when my roommate would grab at her during cares. She was being nasty so I turned her in. I reported this to Staff I, Social Services Director (SSD). The investigation was started on 05/16/17 at 3:00 PM. Review of the investigation included a statement from Staff M, NA She (Resident 26) expressed to me about how worried she was about her roommate (Resident 24) and the caregiver (Staff E) was not being nice to her roommate. Resident 26 stated Staff E was being mean to her and yelling at her. So I looked for someone that could help with this situation. I stopped Staff I and told her .I asked her (Staff I) to take her (resident 26) to a quiet room to talk with her .When Staff I was finished talking with Resident 26, I asked her if there was anything I need to do and she said no, we just need to nip it in the bud and stop the situation before anything else happens .: According to the completed investigation, Staff I, SSD denied having any knowledge of the allegation. It was not reported or investigated at the time. Unable to rule out abuse. This allegation of verbal abuse was not on the incident log or grievance log. Additionally, the resident was not placed on alert status to monitor for psychosocial harm. There was no assessment or follow up by the social worker to ensure the resident's needs were met and other residents were safe. RESIDENT 24 Resident 24 admitted in August of 2016 and was receiving end of life care. This allegation of verbal abuse referenced by Resident 26 to Resident 24 was not on the state reporting log or facility grievance log. Additionally, the resident was not placed on alert status to monitor for psychosocial and/or physical harm. There was no assessment or follow up by the social worker to ensure the resident's needs were met and all residents were protected. The Social Services Director's (Staff I's) failure to interview the AP to determine whether physical and/or psychosocial harm occurred precluded staff from determining that the allegation of abuse was unsubstantiated. The facility also failed to interview other residents and staff to determine if any others had been affected or had negative interactions with the AP. Additionally; the AP continued to provide care for vulnerable residents unsupervised placing all residents at risk for abuse. There was no evidence in the clinical records including progress notes and care plans, grievance log and records, incident logs and investigations that any interventions were in place to protect and monitor the residents by providing social services following the incidents. RESIDENT 41 Resident 41 admitted on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], the resident had intact memory, and required extensive or total assistance for bed mobility and toileting needs. In an interview with Resident 41 on 05/15/17 at 11:13 AM, he was asked - Do staff treat you with respect and dignity? He stated he had a problem with a nursing assistant (Staff E), who he stated was abusive to him. He recalled an incident where he asked (Staff E) for a washcloth during cares and she handed him A dirty wipe that she had already wiped me with. He stated he called Staff E the C-word, and since then she doesn't provide care for him. He further stated Staff E refused to empty his urinal telling him it was not full enough. He stated the facility Administrator and Social Services Director (Staff I) both talked to him about it and nothing happened, they only cared about me calling her a name; She (Staff E) is still here In an interview with the Administrator, Director of Nursing, Staff I, Social Services Director (SSD) and Staff FF, Regional Director of Clinical Operations on 05/16/17 at 2:08 PM, Staff I recalled the incident regarding the washcloth stating, I do remember that; It was a crumpled up washcloth; I remember that, he stated (Staff E) gave him a crumpled up washcloth and he threw it back at her. He said he was aiming for the trashcan and he called her a name. Staff I denied knowing it was a dirty cloth. A review of the state reporting log and facility grievance logs revealed no entry corresponding to an investigation of Resident 41's allegations. A facility investigation was not initiated until 05/16/17 which revealed Staff E did hand the resident a dirty wipe and the Administrator and Staff I had been in to discuss the issue with resident. The facility was unable to rule out abuse and neglect. Staff I failed to protect this resident and other residents, failed to fulfill the mandatory reporting requirement and failed to fully investigate and interview other residents and staff to determine if any other residents had been effected or had negative interactions with Staff E. Staff I further failed to place Resident 41 on alert charting, or in any way monitor for psychosocial harm related to alleged staff to resident abuse. Staff I failed to protect other vulnerable residents who had continued unsupervised exposure to Staff E. UNNECESSARY MEDICATIONS RESIDENT 22 Resident 22 admitted to the facility in June of 2011 with [DIAGNOSES REDACTED]. According to her admission orders [REDACTED]. During multiple observations on all days of survey, the resident was observed to have her tongue dart in and out of her mouth repeatedly, a sign of extrapyramidal side effects (a serious side effect of antipsychotic drugs which can become permanent). This was first assessed on 08/01/16 per the clinical record. Review of the February, March, April and May 2017 Medication Administration Records (MAR) found inaccurate monitoring of the medication side effects (each shift documented no extrapyramidal effects). Review of progress notes found sporadic mention of behavior concerns. There was no social services assessment or intervention in the clinical record in relation to the adverse side effect observed, inaccurate behavior monitoring or continued use of the anti-psychotic. RESIDENT 21 Resident 21 admitted to the facility February 2017 with [DIAGNOSES REDACTED]. The resident was receiving an antidepressant and an antipsychotic. The Abnormal Involuntary Movement Scale (AIMS) was not conducted on admission on 02/27/17. There was no social service follow up for the missing AIMS test for resident 21 who admitted on an anti-psychotic medication. RESIDENT 26 Resident 26 admitted April of 2016 without [DIAGNOSES REDACTED]. In an interview with the resident on 05/23/17 at 9:30 AM, Resident 26 stated, I have been on Amitriptyline for at least [AGE] years . It is to help me sleep It is not for depression. There was no completed social serviced assessment to include concerns with insomnia and the actual indications for the hypnotic use. There was no sleep monitor to evaluate the effectiveness of the Amitriptyline or side effect monitoring. PASRR RESIDENT 24 Resident 24 admitted in August of 2016. There was no Preadmission Screening and Resident Review (PASRR) completed prior to admission to ensure the resident received mental health services if necessary. Social services failed to identify the PASRR was absent. There was no follow up on the missing PASRR until 05/22/17. RESIDENT 57 Resident 57 admitted in December 2016 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Additionally, the facility Social Services Director (Staff I), completed a PASSR form which was in the chart incomplete, with no date and did not identify the resident's dementia diagnosis. In an interview on 05/24/17 at 10:22 AM, Staff X, interim Social Services Director, stated that the hospital social worker is to complete the PASSR prior to the resident admitting and if there was a problem getting the PASSR from the hospital there should be some type of progress note. She confirmed there were no notes in the chart and that the PASSR completed after admission at the facility was incorrect and needed to be re-done. In an interview on 05/24/17 at 10:42 AM, staff J, Regional Nurse and the Director of Nursing confirmed that the PASSR for Resident 57 was not done correctly and stated they would look into it. DIGNIFIED DINING In an observation on 05/15/17 at 12:24 PM, Staff I, Social Services initiated a 10 minute conversation with Staff H, Nursing Assistant that was personal in nature and that did not involve or include the cognitively impaired residents they were assisting. The Social Service Director created an undignified dining experience. The Social Service Director did not advocate for or protect the resident's physical, mental and psychosocial needs. Refer to F 226 CFR 483.12(b)(1)(2) Refer to F 241 CFR 483.10 (a)(1) Refer to F 285 CFR 483.20 (1) Refer to F 329 CFR 483.45 (d) Reference: (WAC) 388-97-0960 (1)

Based on observation, interview and record review, the facility failed to ensure licensed nurses and social services, provided appropriate care and services, in accordance with professional standards for 2 of 2 residents (22 and 52), reviewed for a change in condition. This failure resulted in actual harm to Resident 22, who experienced a significant decline in her ability to communicate with potential irreversible tardive dyskinesia along with a potential decline in ability to consume foods and fluids, and overall decline in condition and dignity. The facility's failure to recognize and accurately treat Resident 52's skin injuries resulted in multiple stage II pressure injuries with failed healing progression and increased pain and discomfort. Findings include: According to the Lippincott Manual of Nursing Practice, Tenth Edition (Lippincott, Williams & Wilkins, 2014, page 16), The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable. The facility's psychoactive drug policy updated November 2016, stated Resident's receiving these medications must be monitored for significant side effects with documentation, including: tardive dyskinesia . (Tardive dyskinesia is a difficult-to-treat and often incurable form of dyskinesia, a disorder resulting in involuntary, repetitive body movements). RESIDENT 22 Resident 22 admitted in June 2011 with [DIAGNOSES REDACTED]. According to her admission orders [REDACTED]. The resident was cognitively intact and able to make her needs known. The resident served as facility Resident Council President for several years before stepping down from her duties in January 2017. During multiple observations on all days of survey, the resident was observed to have her tongue dart in and out of her mouth repeatedly, impeding her ability to communicate in a continuous manner. The abnormal tongue thrusting also affected her ability to consume foods and fluids without frequent interruptions she was unable to control. The Abnormal Involuntary Movement Scale (AIMS) examination since admission revealed no abnormal involuntary movement or signs of extrapyramidal side effects (serious adverse side effects of antipsychotic drugs) until 08/01/16 when minimal tongue movements were assessed. The physician was not alerted to this serious side effect. There was no mention of this change of condition in the resident's progress notes. Resident 22 continued to receive the [MEDICATION NAME] medication. The care plan was not revised for this new adverse symptom. Additionally, there were no further AIMS assessments completed. On 05/23/17 at 10:30 AM, the Director of Nursing (DNS) stated, The tardive dyskinesia is recent. She indicated she was unable to locate a more recent AIMS test than 08/11/16. At 2:07 PM, Staff C, Licensed Nurse (LN) completed a new AIMS assessment. The assessment coded the resident as having minimal abnormal lip and perioral movements and moderate abnormal tongue movements, a further decline since 08/11/16 assessment. Staff C alerted Staff Y, MD who was in the facility on rounds of the tongue thrusting. At 2:19 PM, Staff Y, MD stated, This is new. It is almost constant. I never noticed this before. Staff C, LN commented, It is almost constant now, even when she eats. Staff Y wrote new orders to start the medication [MEDICATION NAME] (medication used to delay the potential irreversible involuntary movements) routinely to treat the extrapyramidal reactions, Staff Y directed staff to watch for somnolence, or any other side effects. He directed staff to update him in 2 weeks of improvement of tongue thrusting. In an interview with the DNS on 05/24/17 at 12:47 PM, she stated AIMS will be assessed on admission, quarterly, annually and also if change in the residents medication or condition. Although the nursing staff recognized the significant change in condition of Resident 22, they did not take appropriate actions, or act within professional standards of practice. RESIDENT 52 Resident 52 was admitted to the facility in October 2016 with [DIAGNOSES REDACTED]. Review of the 05/16/17 weekly skin evaluation revealed a 1.0 x 0.5 cm (centimeters) stage II pressure ulcer to the left buttock and 1.9 x 2.5 cm stage II pressure ulcer to the right buttock. Review of a Physician Facsimile Order Form dated 05/16/17 revealed communication to the physician; 1) Resident noted to have open areas on coccyx. Barrier cream applied. Frequent repositioning encouraged. Left 1.0 x 0.5 cm and right 1.9 x 2.5 cm. 2) Pustules reappearing on inner left thigh. Resident requesting PRN (as needed) order for [MEDICATION NAME] cream. The physician response dated 05/16/17 revealed 1) Okay 2) [MEDICATION NAME] 2.5% cream BID (twice daily) x 10 days & PRN. In an observation on 05/18/17 at 2:33 PM, Staff P, Registered Nurse applied [MEDICATION NAME] cream to the open areas on the right and left buttocks. In an interview on 05/22/17 at 10:11 AM, the DNS stated there were a 1.0 x 1.5 cm red beefy pressure ulcer to the left buttock and a 1.9 x 2.5 cm stage II pressure ulcer to the right buttock with rolled edges. The resident will only accept barrier cream to the buttocks. The DNS stated the [MEDICATION NAME] cream was for the pustules, there should not have been [MEDICATION NAME] cream applied to the pressure ulcers. If the nurses were using the [MEDICATION NAME] cream on the pressure ulcers, the treatment was not done accurately. Refer F314 and F329 Reference (WAC) 388-97-1620 (2)(b)(i)(ii), (6)(b)(i)

Based on observation, interview and record review the facility failed to ensure the necessary care and services were provided to treat and prevent the development of pressure ulcers for 1 of 4 residents (52) reviewed for pressure ulcers. Failure to accurately identify and assess skin changes, follow and update the care plan and implement interventions to treat and prevent skin breakdown caused harm to Resident 52. Findings include: The facility Policy: Skin Integrity updated July 2014 stated: In an effort to maintain the resident's optimal level of skin integrity and promote healing of skin ulcers/pressure ulcers/wounds. The Center has a systematic approach and monitoring process for evaluating and documenting skin integrity. In the event that a resident is admitted with or develops a skin ulcer/pressure ulcer/wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcers/pressure ulcers/wounds. 10). Weekly Wound Rounds are to be completed by a team consisting of the DNS and Resident care managers designee. If a wound condition fails to improve after 2 weeks of treatment or the condition of the wound deteriorates, the physician and resident's responsible party are notified. Re-evaluate the plan of care and the resident's condition. 12). Evaluate resident's compliance with plan of care (POC). When the resident chooses to not have specified treatments or interventions implemented, the center discusses the following with the resident and documents in the medical record; The POC, risk factors and why treatment is important to healing, discuss with the residents responsible party if resident does not make sound choices, notify physician, and updated the comprehensive care plan to include the resident's choice to decline treatments. Resident 52 was admitted in November 2016 with [DIAGNOSES REDACTED]. The resident's 05/10/17 minimum data set (MDS) assessment revealed the resident was cognitively intact and required extensive assistance of two persons to reposition. In an observation and interview on 05/18/17 at 2:33 PM, Staff P, Registered Nurse removed an incontinent brief with a visible bright red smear on the posterior upper portion of the brief. Staff P applied [MEDICATION NAME] cream to an observed shallow open pink area of partial thickness loss of dermis (the second layer of skin) injury on the right and left sacrum. Staff P then applied barrier cream over excoriated skin on the coccyx. Staff P stated the injuries were not pressure injuries just open areas. In an observation and interview on 05/19/17 at 2:30 PM, Staff Q, Regional Director of Clinical Operations, Registered Nurse, stated the resident's coccyx skin appeared a little yeasty, and stated it did not seem like pressure. The resident's coccyx appeared further excoriated and inflamed than observed on 05/18/17. Staff H, Nursing Assistant stated we have three different creams we can use for a barrier cream. The resident stated, My butt hurts, it's just like fire, it has been a while since I have been changed. In an interview on 05/22/17 at 10:11 AM, the DNS stated there were a 1.0 x 1.5 cm red beefy pressure ulcer to the left buttock and a 1.9 x 2.5 cm stage II pressure ulcer to the right buttock with rolled edges. The resident will only accept barrier cream to the buttocks. The DNS stated the [MEDICATION NAME] cream was for the pustules, there should not have been [MEDICATION NAME] cream applied to the pressure ulcers. If the nurses were using the [MEDICATION NAME] cream on the pressure ulcers, the treatment was not done accurately. Review of the resident's 05/10/17 MDS revealed the resident had moisture associated skin damage (MASD) no pressure injuries were identified (there was no documented evidence indicating the resident had MASD in the resident's medical record). Review of the resident's care plan revealed a potential for skin breakdown related to incontinence, immobility and poor nutrition, excoriation and history of pressure ulcers. The care plan interventions consisted of assist to turn and reposition frequently as resident agrees, pressure relieving mattress, clean the resident's skin after each episode of incontinence, and treatments as LN (licensed nurse) ordered by MD (medical doctor). There was no mention of Moisture Associated Skin Damage (MASD) or pressure injuries. Review of the resident's physician treatment administration record revealed: -Barrier Cream - apply to buttocks post cleansing and brief change (date ordered 01/28/17 [DIAGNOSES REDACTED]. -Right Buttock - monitor right buttock venous stasis ulcer, apply barrier cream and reposition as resident allows (date ordered 04/19/17 [DIAGNOSES REDACTED]. -Left Thigh - monitor upper, inner left thigh open area daily and apply barrier cream every shift (date ordered 04/21/17 [DIAGNOSES REDACTED]. -[MEDICATION NAME] Cream - apply topically to inner left thigh twice daily for 10 days (date ordered 05/17/17 [DIAGNOSES REDACTED]. -[MEDICATION NAME] Cream - apply topically to left inner thigh twice daily as needed (date ordered 05/17/17 [DIAGNOSES REDACTED]. -[MEDICATION NAME] Cream - apply topically to inner thigh twice daily as needed (date ordered 05/17/17 [DIAGNOSES REDACTED]. Review of the resident's alert charting revealed: -04/17/17 open area right buttock -04/20/17 buttock excoriation and open area left gluteal fold on thigh -04/29/17 left buttocks 2 cm area with eight - 0.1cm (centimeters) pustules -05/05/17 buttocks/ perineal redness/ excoriation -05/17/17 open areas on buttocks Review of weekly skin evaluation dated 05/16/17 revealed a left buttock stage II pressure ulcer, pink/beefy red wound bed measuring 1.0 x 0.5 cm and a right buttock stage II pressure ulcer, pink/beefy red wound bed measuring 1.9 x 2.5 cm. Review of a 05/16/17 physician facsimile order form revealed a message was sent to the resident's physician indicating: 1) Resident noted to have open areas on coccyx. Barrier cream applied. Frequent repositioning encouraged, Left 1.0 x 0.5 cm, Right 1.9 x 2.5 cm. 2) Pustules reappearing on inner Left thigh. Resident requesting PRN (as needed) order for [MEDICATION NAME] cream. The physician subsequently documented a reply: 1) okay and 2) [MEDICATION NAME] 2.5% cream BID (twice daily) x 10 days & PRN. Review of the resident's progress notes revealed the following documentation: -04/17/17 indicating an open area to the resident's right buttock measuring 2.5 x 0.6 cm was found. The wound was noted to be red with minimal serous- sanguineous drainage. - 04/18/17 the physician ordered a wound care evaluation and treatment (there was no evidence the resident received a wound care evaluation). The resident was discharged from the facility to the emergency roiagnom on [DATE]. Review of the 05/20/17 Hospital History and Physical revealed the resident had a sacral decubitus ulcer that had been present over a month. A Decubitus ulcer of sacral region, unstageable was listed under the resident [DIAGNOSES REDACTED]. The assessment and plan indicated a sacral decubitus ulcer . with a wound care RN consult. In a phone interview on 05/30/17 at 2:45 PM, the Wound Care Clinic staff stated Resident 52 had no record of a wound evaluation by the wound clinic. Review of the resident's medical record failed to demonstrate evidence the physician or resident's family had been informed of the resident's progression of wounds and failed to demonstrate evidence the facility educated the resident or resident's family regarding the facility's statement regarding the resident's choice to only have barrier cream for a treatment. The facility failed to follow their policy for skin care and did not provide the necessary care and treatment to promote healing of Resident 52 pressure injuries through recognized current standards of practice. The facility failed to follow their policy for wounds that failed to improve or deteriorate after 2 weeks of treatment, to notify the physician and resident's responsible party. The facility failed to follow their policy for residents who choose not to have specific treatments or interventions to document resident education of risk factors, importance of healing. See also F 281 for further information .

Based on observation, interview and record review the facility failed to ensure 4 of 6 residents (22, 21, 26, and 57) reviewed for unnecessary medications were free from unnecessary medication due to the failure to monitor and report adverse side effects, and lack of appropriate and timely assessments in place to ensure that residents were administered medication safely and at the lowest effective dose. Failure to adequately monitor for potential adverse side effects, monitor hours of sleep had the potential to place residents at risk for possible unidentified needs, unwanted medical complications [REDACTED]. This failure resulted in harm for resident 22 for continued use of an anti-psychotic when she was exhibiting serious adverse effects. Findings include: According to the facility's psychoactive drug policy updated November 2016: If a resident is experiencing sleeping difficulties, nursing monitors hours of sleep on all shifts for a minimum of five days to determine if resident is getting adequate sleep. When the resident is sleeping, and/or has sufficient level of activity .Resident receiving these medications must be monitored for significant side effects with documentation, including: tardive dyskinesia . Documentation showing a resident decline or deterioration is evaluated by the interdisciplinary team (IDT) to determine whether a particular drug or a particular dose or duration of the medication may be the cause. Hypnotics: Prescribed for [MEDICAL CONDITION] are not used for greater than 10 consecutive days unless ordered by physician otherwise. Daily use is less than 4 continuous months unless an attempt at a Gradual Dose Reduction (GDR) is unsuccessful. This is documented in the medical record. GDR should be attempted at least twice in one year before it can be determined the GDR is clinically contraindicated. RESIDENT 22 Resident 22 admitted in June of 2011 with [DIAGNOSES REDACTED]. According to her admission orders [REDACTED]. During multiple observations on all days of survey, the resident was observed to have her tongue dart in and out of her mouth repeatedly, impeding her ability to communicate in a continuous manner and consume food and fluids without frequent interruptions The Abnormal Involuntary Movement Scale (AIMS) examination since admission revealed no abnormal involuntary movement or signs of extrapyramidal (EPS) side effects (serious side effects of antipsychotic drugs) until 08/01/16 when minimal tongue movements were assessed. The Physician was not alerted to this serious side effect. There was no mention of this change of condition in the resident's progress notes. The care plan was not revised for this new adverse symptom. Additionally, there were no further AIMS assessments completed. On 05/23/17 at 10:30 AM, Staff G, Director of Nursing stated The tardive dyskinesia is recent. She indicated she was unable to locate a more recent AIMS test than 08/11/16. At 2:07 PM, Staff C, Licensed Nurse (LN) had completed a new AIMS assessment. The assessment coded the resident as having minimal abnormal lip and perioral movements and moderate abnormal tongue movements, a further decline since 08/11/16 assessment. Staff C alerted Staff Y, Medical Director, who was in the facility on rounds, of the tongue thrusting. At 2:19 PM, Staff Y stated, This is new (tongue thrusting). It is almost constant. I never noticed this before. Staff C, LN commented It is almost constant now even when she eats. Staff Y wrote new orders to start [MEDICATION NAME] routinely to treat the extrapyramidal reactions and directed the staff to watch for somnolence, or any other side effects. He directed the staff to update him in 2 weeks of improvement of tongue thrusting. In an interview with the Director of Nursing Services (DNS) on 05/24/17 at 12:47 PM, she stated AIMS will be assessed on admission, quarterly, annually and also if change in the residents medication or condition. Review of the February, March, April and May 2017 Medication Administration Records (MAR) found inaccurate monitoring of medication side effects (each shift documented no Extrapyramidal effects). Review of progress notes found sporadic mention of behavior concerns. RESIDENT 21 Resident 21 admitted to the facility February 2017 with [DIAGNOSES REDACTED]. The resident was being administered [MEDICATION NAME] (for depression) and Quetiapine (for [MEDICAL CONDITION]). Review of the care plan found the resident demonstrated behaviors including striking out at others verbally and physically, hallucinations, and tearfulness. Interventions included eliminating possible causes of distress such as loud noises, too much light etc. Review of March monitoring of targeted behaviors noted verbally lashing out and striking out on 2 occasions. The April behavior monitor did not have any behaviors documented. Review of progress notes found sporadic mention of targeted behaviors. The AIMS test was not conducted on admission on 02/27/17. On 03/14/17 the facility Pharmacist recommended performing an AIMS test at baseline and every 6 months as recommended to help monitor potential EPS since the resident was on an antipsychotic. The AIMS test was performed 3 days later on 03/17/17. RESIDENT 26 Resident 26 admitted April of 2016 without [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. In an interview with the resident on 05/23/17 at 9:30 AM, resident 26 stated I have been on [MEDICATION NAME] for at least [AGE] years. It is to help me sleep and help me not lose control of my bowels. The doctor said I have irritable bowels. It is not for depression. Review of the clinical record does not contain a sleep monitor to evaluate the effectiveness of the [MEDICATION NAME] or side effect monitoring. In an interview with Staff D, LN on 05/22/17 at 2:55 PM, she confirmed there was no sleep monitor or side effect monitoring in place for Resident 26. In an interview on 05/24/17 at 12:50 PM with the DNS, she stated residents on hypnotics should have sleep monitors in place. RESIDENT 57 Resident 57 admitted in December 2016 with [DIAGNOSES REDACTED]. The resident was cognitively impaired and required medication administration assistance from the licensed nurses. A review of the physician's orders [REDACTED]. · -Aspirin once a day (blood thinner) · -[MEDICATION NAME] twice a day (dilates blood vessels) · -Losartan once a day (blocks blood vessel [MEDICATION NAME]) A review of a physician's visit dated 04/18/17 directed LN's to continue these medications at the current dose and stated continue to monitor blood pressures. A review of the resident's hypertension care plan updated on 03/31/17 revealed approaches including: to give meds as ordered by physician and to monitor resident's adverse reactions to medications. A review of the resident's progress notes revealed a note dated 03/22/17 stating the daughter was concerned related to feeling that her mother's pulse felt thready. Vital signs were documented at that time and were within normal limits. In the month of May, the resident is noted to have missed 9 doses of all three medications with no blood pressure monitoring to determine the effect of the missed doses on the resident's blood pressure. A review of the resident's treatment administration record revealed nurse's initials in the weekly vital signs documentation but no corresponding vital sign values are found in the record since 03/22/17. In an interview with the Director of Nursing Services (DNS) on 05/23/17 on or about 12:35 PM, the DNS stated she saw that according to the record, the weekly vital signs are being signed as done. When shown the blank vital signs flowsheet and asked where the nurses are documenting the results, the DNS could not find any documentation of the vital signs. The DNS further confirmed the vital signs flowsheet in the record is where it should be documented. Lack of monitoring of the effectiveness of cardiac medications placed the resident at risk for complications resulting from unstable blood pressure. Reference: (WAC) 388-97-1060 (3)(k)(i), (4)

Based on observation, interview, and record review, the facility failed to identify deficiencies and implement appropriate preventative corrective actions in the Quality Assessment and Assurance Program (QA&A). The facility failed to recognize care and services which resulted in a severity of immediate jeopardy, resident harm, and substandard quality of care. Findings include: The QA&A committee failed to identify deficiencies in regards to informing the physician of the need for change of orders for resident care. Refer to F 157, CFR 483.10(b)(11) The QA&A committee failed to identify deficiencies in regards to implementation of policies and procedures to prevent abuse and neglect. Refer to F 226, CFR 483.13(b) & (c) This is a repeat deficiency from the annual QIS survey conducted on 07/03/16. The QA&A committee failed to identify deficiencies in regards to treating residents with respect and dignity. Refer to F 241, CFR 483.15(a) This is a repeat citation from a complaint suvey conducted on 04/12/17 The QA&A committee failed to identify deficiencies in regards to honoring resident's rights to make choices about aspects of life important to the resident. Refer to F 242, CFR 483.15(b) This is a repeat deficiency from the annual QIS survey conducted on 05/07/15 and 07/03/16. The QA&A committee failed to identify deficiencies regarding provision of individualized activity programs. Refer to F 248, CFR 483.15(f)(1) The QA&A committee failed to identify deficiencies regarding provision of medically-related social services. Refer to F 250, CFR 483.15(b) The QA&A committee failed to identify deficiencies in regards to maintenance and housekeeping. Refer to F 253, CFR 483.15(h)(2) This is a repeat deficiency from the annual QIS survey conducted on 07/03/16. The QA&A committee failed to identify deficiencies in regards to development of resident's comprehensive care plans. Refer to F 279, CFR 483.20(k) This is a repeat deficiency from the annual QIS survey conducted on 07/03/16. The QA&A committee failed to identify deficiencies related to assuring services meet professional standards. Refer to F 281, CFR 483.20(k)(3)(i) This is a repeat citation from a complaint survey conducted on 02/13/17 The QA&A committee failed to identify deficiencies related to assuring services provided by qualified persons. Refer to F 282, CFR 483.20(k)(3)(ii) The QA&A committee failed to identify deficiencies related to pre-admission screening and resident review (PASRR). Refer to F 285, CFR 483.20(m) The QA&A committee failed to identify deficiencies in regards to residents receiving the necessary care and services to attain or maintain their highest practical level of physical, mental and psychosocial well-being. Refer to F 309, CFR 483.25 This is a repeat deficiency from the annual QIS survey conducted on 07/03/16. The QA&A committee failed to identify deficiencies in regards to dependent residents receiving the care and services they need. Refer to F 312, CFR 483.25(a)(3) The QA&A committee failed to identify deficiencies in regards to provision of care to prevent the development of pressure ulcers. Refer to F 314, CFR 483.25(c) This is a repeat citation from a complaint survey conducted on 02/13/17 The QA&A committee failed to identify deficiencies regarding safe security of chemicals and medications and safe exposure to the sun. Refer to F 323, CFR 483.25(h)(1)(2) The QA&A committee failed to identify deficiencies in regards to consistently assessing, monitoring and/or evaluating the use of [MEDICAL CONDITION] medications. Refer to F 329, CFR 483.25(l)(1) This is a repeat deficiency from the annual QIS survey conducted on 07/03/16. The QA&A committee failed to identify deficiencies in regards to assuring sufficient nurse staffing. Refer to F 353, CFR 483.(30)(a)(1)&(2) The QA&A committee failed to identify deficiencies in regards to assuring the facility acts upon the recommendations of the pharmacist. Refer to F 428, CFR 483.60(c)(2) The QA&A committee failed to identify deficiencies in regards to ensuring proper handwashing and glove use when providing personal care and delivery/set-up of meal trays. Refer to F 441, CFR 483.65(b)(3) This is a repeat citation from a complaint survey conducted on 02/13/17 The QA&A committee failed to identify deficiencies in regards to ensuring the completion of the required performance reviews for nursing assistants (NA) at least once every 12 months form the NA's date of hire including in-service education for areas of weakness identified in the performance reviews, special resident needs and needs of residents with cognitive impairments. Refer to F 497, CFR 483.75(e)(8) The QA&A committee failed to identify deficiencies in regards to ensuring the completion of the required 12 hours of in-service and/or the inclusion of mandatory abuse and dementia training for the facility's nursing assistants. Refer to F 498, CFR 483.75(f) The QA&A committee failed to identify deficiencies in regards to ensuring resident records were complete and accurate. Refer to F 514, CFR 483.75(l)(1) This is a repeat citation from a complaint suvey conducted on 04/12/17 In an interview on 05/24/17 at 1:19 PM, the interim Administrator stated the QA&A committee were required to meet on a quarterly basis, but usually the team meets on a monthly basis. The interim Administer was made aware of the repeat citations. The interim Administrator had only been in the building since 05/18/17. Reference (WAC) 388-97-1760 (1)(2)

Based on interview and record review the facility failed to ensure services that were provided met professional standards of quality for 8 of 8 residents (1, 2, 3, 4, 5, 6, 7 & 8) when they failed to consistently and thoroughly assess and document skin assessments. The Licensed nurses failed to follow standards of practice for skin breakdown. The inability to identify a pressure ulcer and the lack of documented monitoring caused the harm of unrecognized/undocumented skin breakdown for residents identified to be at risk of skin breakdown. Findings Include: The Washington State Nurse Practice Act, WAC 246-840-710 (2) in part indicates nurses violate standards by: (2) Failure to adhere to the standards enumerated in WAC 246-840-700 which may include, but are not limited to: (a) Failing to assess and evaluate a client's status or failing to institute nursing intervention as required by the client's condition; (b) Willfully or repeatedly failing to report or document a client's symptoms, responses, progress, medication, or other nursing care accurately and/or legibly; Resident 1 Resident 1 was admitted in November 2016 with [DIAGNOSES REDACTED]. The admission assessment dated [DATE] noted there was an ulcer on the assessment paperwork. A nurse's progress note dated 11/17/16 stated the Licensed Nurse (LN) did not assess the wound but did document because the resident told her about the wound. There was no other documentation of an assessment about a wound, the size, drainage, measurements, or if a wound was present upon admission. On 12/21/16 at 11:30 A.M., in an observation it was noted the resident had four open areas in total, on left and right buttocks and had dark red skin from ribs to knees. The DNS and the Administrator were made aware of this skin concern noted on the observation. The resident was at high risk for skin breakdown, was identified as having a pressure ulcer per documentation and did continue to have painful, skin breakdown. The nurses did not follow policy and did not perform weekly skin checks, nor did they document the wound and there was no care plan for skin. Resident 2 Resident 2 was admitted to the facility with [DIAGNOSES REDACTED]. The resident was identified by the facility to be at risk of pressure ulcers. The resident was dependent on staff for all cares. Per the care plan the resident was to be checked every 2 hours related to incontinence. The resident had a stage 2 pressure ulcer to the right buttocks from 08/31/16 until 11/03/16 when it healed. On 12/19/16 it was noted that Resident 2 developed a re-occurrence of a stage 2 pressure ulcer on the right buttocks. The resident did not have a current care plan for his most recent pressure ulcer. Resident 3 Resident 3 has [DIAGNOSES REDACTED]. The resident had a catheter and was incontinent of bowel. The resident was dependent on staff for care and did have behaviors noted on the care plan. Resident 3 was sent to the hospital on [DATE] with left sided weakness. The nurse documentation stated, patient's catheter bag was replaced because the old one was getting clogged with sediment. Hospital documentation showed that the Resident had what appeared to be seborrheic [MEDICAL CONDITION] as he has yellowish scale to hands, face and ears. Skin is pale and warm. Upon further skin inspection it was noted that Patient had a large amount of dried feces to incontinent brief, rectal area, buttocks and lower back. A saturated non adhesive dressing was removed from coccyx area revealing a deep ulcer with packing present, packing was not removed. Entire backside was cleansed, open area had a moderate amount of frank blood, and a foul odor. Bilateral buttocks and bilateral backs of thighs were macerated with several small sheared open areas. Clean brief was placed and pt. was placed slightly on his side to relieve pressure to area. Supra pubic Cath present, split gauze present with moderate amount of yellow, bloody drainage noted around insertion site. Writer cleansed area with normal saline and gauze dressing replaced. The physician's documentation stated, Patient was noted on admission to be poorly cared for with stool covering his bottom. Patient's redness on his buttock and proximal thigh was likely from poor hygiene and care. In an interview at the hospital the resident reported he was changed about 3 times a day. The resident felt he received good care. On 12/21/16 at 1:30 P.M., with the Administrator about the hospital's concerns. The Administrator reported she was aware of the hospital's concerns and thought that it was the Manuka honey and not feces on the resident's backside because this was the current wound care for the resident's stage 4 ulcer. Resident 4 A review of the weekly skin sheets for Resident 4 revealed there was no skin care plan for a resident who admitted with a stage 3 pressure ulcer on her foot. The resident was seen at the wound clinic. The weekly skin check was last performed on 12/09/16. Resident 5 From documentation provided from the facility on 12/23/16 the resident was identified as having a Stage 2 on her coccyx 8 x 5 cm. There was no skin sheet for this resident. Resident 6 From documentation provided from the facility on 12/23/16 the resident was identified as having a 2 x 2.5cm area on right buttock cheek and .5 [MEDICAL CONDITION] area on left buttock, the wounds were not staged in the documentation. There was no skin sheet for this resident. Resident 7 From the documentation provided from the facility on 12/23/16 the resident was identified as having a re-opened area on coccyx 3.5.x 1.5cm covered with slough- Stage 2. There was also no skin sheets for this resident. Residents 5, 6, 7 were identified to have pressure ulcers after skin was brought to the facilities attention. Resident 8 -Unknown Resident with a Stage 2 Pressure Ulcer on skin sheet. On 12/21/16 at 1:05 P.M. the DNS was asked to identify a skin sheet with no resident name on it. The DNS was unable to identify the resident and said she would call the nurse who signed the assessment. No further information had been provided about this skin assessment. The licensed nurse documented a wound she had not assessed, this is not standard practice. The hospital told the facility there were care concerns for a resident with a chronic stage 4 pressure ulcer. A skin sheet for a resident with a stage 2 pressure ulcer which did not have a name on the skin sheet and no further information was given by the facility. Care and services to promote healing and prevent pressure ulcers was not a functioning system in the facility, which led to additional residents developing pressure ulcers which were only identified during a whole facility skin audit as requested by the surveyors. See also F 314 for further information

Based on observation, interview and record review the facility failed to document, monitor and prevent the development of pressure ulcers for 8 of 8 residents (1, 2, 3, 4, 5, 6, 7 & 8) reviewed for pressure ulcers. Resident (3) was sent to the hospital with dried feces in/around a Stage 4 pressure ulcer; Resident (4) had a stage 3 ulcer that did not have a care plan. These failures resulted in harm of the development of additional pressure ulcers for Residents 1, a re-occurrence of a pressure ulcer for Resident 2, a documented care concern for Resident 3, a lack of a skin care plan for Resident 4 and the facility identified several additional residents (5, 6 & 7) with pressure ulcers after the investigation. Findings Include: The facility policy stated: 1). The nurse completes the Braden Scale/Skin Integrity Evaluation at admission and weekly for the next 3 weeks following admission. 2). The nurse establishes a Plan of Care based on risk factors. 5). The resident's skin is inspected daily with completion of ADL's. Changes in the resident's skin are reported to the Licensed Nurse. 6). Ongoing evaluation continues weekly with the LN completing a full body skin audit. Completion of the skin audit is documented on the treatment administration record (TAR) with their initials and a - or +. 7). Upon discovery of newly identified skin impairment the LN documents measurements, notifies the physician, evaluates the environment to identify interventions to promote healing and implements interventions and documents on the resident's care plan and care directive. 10). Weekly Wound Rounds are to be completed by a team consisting of the DNS and Resident care managers designee. If a wound condition fails to improve after 2 weeks of treatment or the condition of the wound deteriorates, the physician and resident's responsible party are notified. Re-evaluate the plan of care and the resident's condition. 12). Evaluate resident's compliance with plan of care (POC). When the resident chooses to not have specified treatments or interventions implemented, the center discusses the following with the resident and documents in the medical record; The POC, risk factors and why treatment is important to healing, discuss with the residents responsible party if resident does not make sound choices, notify physician, and updated the comprehensive care plan to include the resident's choice to decline treatments. Per the facility Skin Integrity Policy which stated: In an effort to maintain the resident's optimal level of skin integrity and promote healing of skin ulcers/pressure ulcers/wounds. The Center has a systematic approach and monitoring process for evaluating and documenting skin integrity. In the event that a resident is admitted with or develops a skin ulcer/pressure ulcer/wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcers/pressure ulcers/wounds. Resident 1 Resident 1 was admitted [DATE] with [DIAGNOSES REDACTED]. The record showed the resident was incontinent of bladder and depended on staff for all care. A physician's orders [REDACTED]. For the [MEDICAL CONDITION]: the order included a technique to use but directed staff that if it was not helpful then switch to barrier cream. Another order dated 11/14/16, explained the crusting technique for buttocks [MEDICAL CONDITION] that directed staff to repeat several times to make a crust, repeat as needed. An admission note dated 11/17/16 and signed by Staff A, licensed nurse (LN) noted, there was a Stage 2 ulcer on the coccyx area. The note also stated, the resident has reported a stage 2 sacral ulcer. This RN did not visualize, but passed the info onto the next shift. The RN did not assess the pressure ulcer. Discharge orders from hospital stated there was a Sacral decub (pressure ulcer). The physician order's for the wound care was not transcribed to the medication or treatment record. The Medication Administration Record [REDACTED]. No details related to the discharge order nor the technique ordered for application of the powder to address the resident's [MEDICAL CONDITION] (skin inflammation) was found. A review of the nursing notes from 11/17/16 to 12/16/19 revealed no mention from nursing about the pressure ulcer. The nursing notes mentioned irritated buttocks and a raw coccyx but documentation did not show an assessment of the pressure ulcer. The facility's weekly skin sheets were reviewed and there was no documentation found on the skin sheets for the resident's pressure ulcer and no weekly monitoring for Resident 1's stage 2 pressure ulcer. The care directive for the certified nursing assistants (CNA) to follow did not mention a pressure ulcer. Review of Physician's notes dated 11/1716 and 11/22/16 did not have any documented assessment of the resident's buttocks, nor did they mention any skin concerns. There was no care plan developed for Resident 1's pressure ulcer. A review of the nursing note dated 11/20/16, indicated a small scabbed area to coccyx covered with cream. An undated note indicated the coccyx area was raw and a dressing had been applied. On 11/22/16 a note showed the resident had a Foley catheter for two weeks related to maceration of skin to buttocks. Documentation on 11/22/16, also indicated the resident requested her foam boots be removed. An open area was identified on her left calf. The area measured 0.4 x 0.5 cm. The area was cleansed and a foam dressing was applied. There was a treatment/dressing ordered the skin wound on 11/23/16, but there was no documentation of the care until, two days later on 11/25/16, which had a circle around the initials, then initials again on the 28th. A skin sheet dated for 11/25/16 was submitted by the facility on 12/23/16. This skin sheet was not in the skin book nor in the record when reviewed on 12/21/16. There was no additional documentation in the record of assessments for this open area. Documentation noted an assessment of buttocks but it was not thorough and did not specifically mention the status of the pressure ulcer. Documentation on the Care Area Assessment (CAA), an assessment that aids in the development of a care plan, dated 11/28/16, indicated the resident was at risk for pressure ulcers. The CAA stated, the resident was admitted with sacral and coccyx open areas and an open area on the left calf that nurses are treating as ordered. The resident is at risk of skin breakdown due to multiple co-morbidities. A fax dated 12/15/16 was sent to the physician and stated the resident had very raw buttocks and currently had an order for [REDACTED]. Can we have an order for [REDACTED].? The Nurse responded, no, resident refused, but will re-approach. There was no further documented information about wound care or if the resident was re-approached, and there was no documentation that the physician was notified of the resident's refusal to see a wound care specialist. In an observation on 12/21/16 at 11:30 A.M, the resident was observed to have four stage 2 pressure ulcers on her buttocks. They were on the right buttocks and measured approximately 1 x 1 cm (centimeters), 3 x 2 cm, and another 1 cm x 1 cm close together in presentation. There was also a pressure ulcer on the left buttocks that was approximately 2 x 2 cm. In addition, the entire buttocks and perineal area was observed to be dark red and had white patches. The dark redness extended from the residents upper abdomen to her knees. Staff B, Licensed Nurse (LN) stated this is different from the last time I looked, her whole bottom is much darker red and it has spread up and down to her knees. The LN also stated the open areas were not there previously. In an interview on 12/21/16 at 11:40 A.M., Resident 1 stated she had 4 abdominal surgeries in 4 weeks. It has gone from bad to worse, I can't move well. We tried an air mattress and it didn't work I kept slipping around on it and it hurt my stomach. The resident did not know if she had a pressure ulcer. The resident reported her bottom was very itchy and caused her constant discomfort. In an interview on 12/21/16 at 11:50 A.M. the Administrator and the Director of Nursing Services (DNS) were made aware of the concerns with Resident 1's lack of monitoring for the pressure ulcer, the changed rash and the additional 4 pressure ulcers on Resident 1's right and left buttocks. The DNS stated, it wasn't like that last week when I looked at it. When asked about the skin sheets, the DNS stated, I'm sorry I am behind, they (skin sheets) may not be in there. When asked about a care plan for this resident, the DNS was also unable to locate it in the record. The Administrator stated, We offered her an air mattress and she refused it. There was no documentation in the record of the resident's refusal of the bed and per interview with the resident on 12/21/16 she stated, the mattress caused increased discomfort. On 12/21/16 at 1:20 P.M., during an interview with Staff C, MDS Coordinator stated she was responsible for the immediate care plan after a resident was admitted and the quarterly care plan. The LN's are responsible for the admission assessment and skin checks. On 12/21/16 at 1:25 P.M., Staff C, MDS Coordinator gave a copy of the care plan and stated she had to re-create the care plan for Resident 1 because she did not know where the original one went. The skin integrity care plan provided again, and still did not address the pressure ulcer on admit. Additional information provided by the facility dated 12/22/16 stated the regular system of skin documentation was not in place. The reddened skin was from a reaction to the resident's body cream. At that time, the rash had improved and it was once again clear. The macerated skin on the resident's buttocks had two very small open areas - not pressure ulcers. Additionally, at no time was there any evidence of pressure ulcers on this resident. The nurse documented one stage 2 pressure ulcer on the admission assessment based on information given by the resident herself, the nurse did not visualize any pressure areas. A fax also provided by the facility dated 12/21/16, showed open areas on the left and right buttocks measuring 1.0 x 0.9 cm and 2.9 x 1.0 cm with no drainage or odor noted. The physician replied wound care in house for those wounds ASAP. Watch these daily! Dietary consult. Additional information provided from the facility dated 12/23/16, showed documentation from the physician who stated he was notified of maceration of her buttocks which was present since admission and the physician was examining the resident today. The physician noted maceration per the resident, but did not document an assessment of her skin in his notes dated 11/17, 11/22 nor 11/29/16. The note also stated the resident had asked for a foley catheter to assist in keeping her buttocks dry. The physician further stated the open areas were satellite [MEDICAL CONDITION] and not decubitis ulcers. The plan now was to give the resident [MEDICATION NAME] powder twice a day and [MEDICATION NAME] (an antifungal) by mouth, continue to switch from side to side every 2 hours. He further stated the briefs were contributing to keeping her area very moist and discontinue the briefs as she did not need them, as she has a foley and an ostomy bag. Resident 1 was admitted with an identified stage 2 coccyx pressure ulcer per hospital documentation. Per the CAA the resident was admitted with a wound on her sacral area as well as developing a leg wound in the facility from her boots. There was no evidence of weekly skin checks, no documented evidence of the LN's monitoring and no skin care plan. The information identified in the CAA was not used to assess risks or develop interventions for Resident 1 which resulted in no monitoring for her pressure ulcer and the harm of developing 4 additional skin injuries on her buttocks. The original order for treatment of [REDACTED]. The harm resulted in the development of additional skin breakdown when risk was present, identified but not consistently assessed. Resident 2 Resident 2 was admitted to the facility with [DIAGNOSES REDACTED]. The Braden Scale assessment identified the resident as being at high risk for pressure ulcers from June to present. Per the care plan the resident was to be checked every 1-2 hours related to incontinence and the resident was dependent on staff for all cares. The resident was identified to be at risk for pressure ulcers from his CAA which stated he was at risk related to decreased mobility and wheelchair use and incontinence. The skin care plan had a date of 08/31/16 and the Braden score which was not filled out, and open area to right buttocks with no date of which pressure ulcer it is referring to. The goal date was for 11/30/16. There was no information on the care plan about the most current ulcer. The resident had a stage 2 pressure ulcer to the right ishium (buttocks) from 08/31/16 until 11/03/16 when it healed. On 12/19/16 it was noted Resident 2 had developed another stage 2 pressure ulcer which re-occur on the right ishium. In an interview on 12/21/16 at 1:40 P.M., with Staff D, LN she stated he had a pressure ulcer before and it healed and the new ulcer was on the same area. In an observation at 1:45 P.M., Staff D, LN, reported the area was a stage 2 pressure ulcer. There was a noted pressure ulcer and approximate size was 1 cm x 1 cm. The wound was not measured during the observation. Resident 3 Resident 3 has [DIAGNOSES REDACTED]. The record indicated the resident had a catheter and was incontinent of bowel. The resident was dependent on staff for care and did not have any identified behaviors noted on the care plan. Resident 3 was sent to the hospital on [DATE] with left sided weakness. Review of hospital documentation showed the patient's catheter bag was replaced because the old one was getting clogged with sediment. Patient has what appears to be seborrheic [MEDICAL CONDITION] as he has yellowish scale to hands, face and ears. Skin is pale and warm. Documentation continued that upon further skin inspection it was noted that Patient had a large amount of dried feces to incontinent brief, rectal area, buttocks and lower back. A saturated non adhesive dressing was removed from coccyx area revealing a deep ulcer with packing present, packing was not removed. Entire backside was cleansed, opened area had a moderate amount of frank blood, and a foul odor. Bilateral buttocks and bilateral backs of thighs were macerated with several small sheared open areas. Clean brief was placed and patient was placed slightly on his side to relieve pressure to area. In addition, there was a Supra pubic catheter present, a split gauze was present with a moderate amount of yellow, bloody drainage noted around the insertion site. Writer cleansed area with normal saline and gauze dressing replaced. The physician's documentation stated, patient was noted on admission to be poorly cared for with stool covering his bottom. Patient ' s redness on his buttock and proximal thigh is likely from poor hygiene and care. In an interview at the hospital the resident reported he was changed about 3 times a day. The resident felt he received good care. In an interview on 12/21/16 at 1:30 P.M., about the hospital's concerns, the Administrator reported she was aware of the hospital's concerns and thought that it was the manuka honey and not feces on the resident's backside because this was the current wound care for the resident's stage 4 ulcer. Resident 4 A review of the weekly skin sheets for Resident 4 revealed there was no skin care plan for a resident who admitted with a pressure ulcer. The resident was seen at the wound clinic. The weekly skin check was last performed on 12/09/16. Resident 5 From documentation provided from the facility on 12/23/16 the resident was identified as having a Stage 2 on her coccyx measuring 8 x 5 cm. There was no skin sheet for resident 5. Resident 6 From documentation provided from the facility on 12/23/16 the resident was identified as having a 2 x 2.5 cm area on right buttock cheek and .5 x .5 cm area on left buttock, the wounds were not staged in the documentation. There was no skin sheet for this resident. Resident 7 From the documentation provided from the facility on 12/23/16 the resident was identified as having a re-opened area on the coccyx measuring 3.5 x 1.5 cm covered with slough - Stage 2. There was also no skin sheets for this resident. Residents 5, 6, 7 were identified to have pressure ulcers after skin was brought to the facility's attention. Resident 8 - Unknown Resident with a Stage 2 Pressure Ulcer on skin sheet. On 12/21/16 at 1:05 P.M. the DNS was asked to identify a skin sheet with no resident name on it. The DNS was unable to identify the resident and said she would call the nurse who signed the assessment. No further information had been provided about this skin assessment. Staff Education Located on a clipboard at the nurses station two documents were noted one dated 11/30/16 which stated - Attention All NAC's we have been having some serious problems with proper care getting done. We have had several unnecessary skin breakdown issues and peri care that is not being provided as it should be. There is no one particular person or shift that this is happening on, it is just happening and this is unacceptable behavior and poor care is unacceptable! The second document dated 12/19/16 stated - it has come to my attention that our residents are being double briefed between evenings and nights. This is not ever ok. If someone is indeed a heavy wetter than let me know. We can provide overnight briefs which are more effective. Double briefing causes skin issues and is wasteful. These documents were to be initialed by staff. As part of the investigation the facility was asked to check all residents and assess and document skin concerns. Paperwork received by the facility on 12/23/16 noted 3 additional residents with pressure ulcers in the facility. These residents did not have documented concerns of pressure ulcers prior to the skin check being requested. The facility failed to follow it's policy for skin and did not provide the necessary care and treatment to promote healing and prevent new ulcers from developing. The facility was not following it's own policy on aggressively assessing, care planning and providing care for the prevention of pressure ulcers. See also F 281 for further information