Every finding on record at Josephine Caring Community

Based on observation, interview, and record review the facility failed to ensure resident choices/preferences regarding their bathing schedule were honored for 3 of 4 sampled residents (Residents 2, 3, and 4) reviewed for choices. These failures placed the residents at risk for decreased cleanliness, increased risk of infection and diminished quality of life. Findings included .<RESIDENT 2>Resident 2 admitted to the facility on [DATE] with diagnosis to include a stroke with right side hemiplegia (paralysis to one side of the body) and hemiparesis (a condition that causes weakness or partial paralysis on one side of the body). Review of the quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 12/08/2025, documented the resident was moderately impaired in decision making skills, dependent with showers/bathing and shower transfers. Review of Resident 2's Preference care plan, with a target date of 03/05/2026, documented the resident preferred to take a shower two times a week before breakfast. Review of Resident 2's November 2025 Documentation Survey Report v2 (v2 report), documented the resident received a shower on 11/03/2025, refused on 11/06/2025, received a shower on 11/11/2025 (seven days in between showers), 11/14/2025, 11/19/2025, refused on 11/21/2025, and received a shower on 11/25/2025. There was no documentation regarding if the resident was offered a shower after they refused on 11/06/2025. Review of Resident 2's December 2025 v2 report, documented the resident received a shower on 12/05/2025 (eight days since their last shower), 12/08/2025, 12/09/2025 (nine days since their last shower), and 12/23/2025. Review of Resident 2's v2 report, dated 01/01/2026 to 01/22/2026, documented the resident received a shower on 01/02/2026 (10 days since their last shower), 01/06/2026, 01/15/2026 (nine days since their last shower, refused a shower on 01/14/2026), and received a shower on 01/21/2026 (six days since their last shower). In an interview and observation on 01/21/2026 at 12:35 PM, Resident 2 was lying on their back slightly turned to the rights side. The resident was dressed in a hospital gown and their hair was disheveled. Observation on 01/21/2026 at 12:57 PM and 2:55 PM, Resident 2 was lying in bed, their hair was disheveled. Observation on 01/22/2026 at 9:30 AM, 10:10 AM, 12:00 PM, 2:02 PM, and 3:07 PM, Resident 2 was lying in bed, hair disheveled, and in a hospital gown. <RESIDENT 3>Resident 3 was a long-term care resident. Review of Resident 3's Quarterly MDS assessment, dated 11/26/2025, documented the resident had no cognitive impairment and was dependent on staff for showers. Review of Resident 3's Resident Preferences care plan, revised on 07/07/2021, documented the resident preferred to take a shower twice a week. Review of Resident 3's November 2025 v2 report, documented received a shower on 11/06/2025 and on 11/13/2025 (six days between showers). The resident received showers per their preference 11/13/2025. Review of point of care Nursing Assistant Certified (NAC) documentation from 12/21/2025 to 12/31/2025, documented Resident 3 received a shower on 12/25/2025 and 12/30/2025. Review of Resident 3's January 1 through 21, 2026 v2 report, documented the resident received a received a shower on 01/05/2026, 01/13/2026 (seven days in between showers), and as of 01/22/226, it had been 8 days since the resident was last showered. In an interview and observation on 01/22/2026 at 8:50 AM, Resident 3 was dressed, sitting in their wheelchair in their room. Resident 3 stated they preferred to be showered twice a week, and they barely get one a week. <RESIDENT 4>Resident 4 was a long-term care resident. Review of Resident 4's Annual MDS assessment, dated 01/13/2026, documented the resident was able to make their needs known, and required substantial assistance from staff for bathing. Review of Resident 4's Preference care plan, revised on 07/25/2025, documented the resident preferred to a shower twice a week. In an interview on 01/21/2026 at 12:03 PM, Resident 4 was sitting in their room sitting in a wheelchair. When asked if they were bathed per their preferences, Resident 4 stated no. The resident stated they were bathed on Tuesday's and Friday's. Resident 4 stated it had been eight days since their last shower. The resident stated that last week they went to a doctor's appointment and their family member told them they smelled like urine. Resident 4 stated, this was embarrassing, I can only do so much from a wheelchair. Review of Resident 3's December 2025 v2 report, documented the resident received a shower on 12/02/2025, 12/09/2025 (six days since their last shower), 12/17/2025 (seven days since their last shower), 12/23/2025 (five days since last shower), 12/26/2025 and 12/30/2025. Review of Resident 3's January 1 through 22, 2026 v2 report, documented the resident received a shower on 01/06/2026 (six days since last shower), 01/13/2026 (six days since last shower) and 01/22/2026 (eight days since their last shower). <INTERVIEWS>In an interview on 01/21/2026 at 10:00 AM, Staff F, NAC/shower aid, stated the Kardex (a guide used by the NAC to help direct the residents individualized care) should obtain information on what day and time of day a resident preferred their shower. Staff F stated Monday through Friday they have a shower sheet they documented the residents' weight and when a shower was done. This shower sheet was turned into Staff C, Licensed Practical Nurse/Assistant Director of Nursing. Staff F stated they documented in the resident's electronic medical record (EMR) when a shower was completed. If a resident refused, Staff F stated they reported the refusal to the Licensed Nurse (LN) and documented the refusal in the EMR. In an interview on 01/22/2026 at 9:19 AM, Staff H, NAC, stated the shower NAC showered the residents. If the shower NAC could not complete the resident's shower, they would attempt to provide the shower and documented this information in the resident's EMR. In an interview on 01/22/2026 at 9:46 AM, Staff I, NAC, stated there was a shower NAC on each section of the facility. Staff I stated they occasionally would be directed to shower a resident. Staff I stated showers were documented in the resident's EMR. Staff I stated if a resident refused care, this would be documented in the EMR and reported to the LN. In an interview on 01/22/2026 at 11:33 AM, Staff D, LPN/Nurse Manager, stated a resident's shower preferences were obtained upon admission and as needed. This information included the type of bathing (shower, bath, or bed bath) and how often the resident preferred to be bathed. This information was placed on the resident's care plan. The expectation was when a shower was completed, the NAC documented the information in the resident's EMR. When a resident refused, the NAC reported the refusal to the LN and documented the refusal in the EMR. A joint interview was conducted on 01/22/2026 at 12:14 PM with Staff B, Registered Nurse (RN)/Director of Nursing Services (DNS), and Staff C. Staff C stated that residents were asked what their bathing preferences were upon admission (which included the type of and frequency of being bathed) and was placed on the resident's care plan. Staff C stated there were usually four shower NAC's working five days a week. Staff B stated the expectation was the shower NAC documented when a shower was completed in the resident's EMR, and if they refused the LN was notified and the refusal was documented in the EMR. Reference WAC 388-97-0180(2)

Based on observation, interview, and record review, the facility failed to ensure quality of care and services was provided for 2 of 3 sampled residents (Residents 1 and 2) reviewed for skin, positioning, and assistance with meals. These failures placed residents at risk of medical complications and a diminished quality of life. Findings included .<RESIDENT 1>Resident 1 re-admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease (a disorder of the nervous system affecting movement), Cerebellar ataxia (damage to the brain causing poor coordination and balance problems), Dementia (affects memory), and Muscle Weakness. Review of quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 12/23/2025, the resident had no cognitive impairment. In a joint interview on 01/21/2026 at 12:37 PM, with Resident 1 and (Collateral Contact) CC1, Resident 1 stated they had talked to CC1 on 01/18/2026 and reported the rash to her toes and feet had worsened and was painful. Resident 1 stated that staff do not clean their feet prior to applying the ointment for the rash. CC1 stated during a visit with Resident 1 on 01/18/2026, when observing the resident's toes and feet they were red, discolored with skin breakdown. Review of Resident 1's skin care plan, undated, documented the resident had chronic dermatitis to lower extremities. on 1/19/2026 the skin care plan reflected a fungal rash to bilateral toes. Review of Resident 1's physician orders showed an order for Triamcinolone Acetonide External Ointment 0.1 % (Triamcinolone Acetonide (Topical)), apply to affected area topically two times a day for rash, dated 07/13/2025 and discontinued 01/20/2026. The order did not indicate where to apply the ointment or how long the ointment should be used. Review of Resident 1's Medication Administration Record (MAR) dated October 2025, November 2025, December 2025, and January 1st through 21st 2026, did not show monitoring of skin issue to feet/toes or cleaning of skin prior to application of ointment to the resident's feet/toes. Review of Resident 1's Treatment Administration Record (TAR) dated October 2025, November 2025, December 2025, and January 1st through 21st 2026, did not show monitoring of skin issues to feet/toes, or cleaning of skin prior to application of ointment of the resident's feet/toes. In an interview and observation on 01/21/2026 at 3:31 PM Staff E, Licensed Practical Nurse (LPN), stated Resident 1 had a rash to their feet/toes, had an ointment that was applied to their toes/feet, and their feet had not been cleaned prior to applying the ointment until 01/20/2026. Observation of Resident 1's feet showed the resident's toes were red with some areas of lighter skin on the top of the toes with moisture between the 2nd and 3rd toes on the right foot, a crusted yellowish flakey skin across the bottom of the toes on the top of both feet, and a red rash to the inner ankle area of the right foot. In an interview and record review on 01/22/2026 at 12:31 PM, Staff D, LPN/Nurse Manager, stated while working on 01/19/2026 Resident 1 had reported that their toes were red and uncomfortable and they were afraid they would lose her toes. Staff D stated they observed the resident's feet and their toes were red and there was a crusty area at the bottom of the toes at the top of the foot, the doctor was notified. Staff D stated the resident was being treated for a stasis dermatitis rash to their feet. Staff D stated skin issues would have been monitored when the ointment was applied and if a change was identified the nurse would make a note. Staff D reviewed the resident's electronic medical record (EMR) and stated the Triamcinolone Acetonide External Ointment instructions showed to apply to affected area, the ointment was for itching and would be applied to the skin area that the resident said was itching. Staff D stated the ointment was being applied to both of the resident's feet. Staff D stated if the resident's feet were to be cleaned prior to administration of the ointment it would have been included in the order. In an interview and record review on 01/22/2026 at 2:30PM, Staff B, Registered Nurse/Director of Nursing, when asked if treatment orders would have an end date, stated treatment orders would usually include application site and have an end date. Staff B reviewed the resident's Triamcinolone Acetonide External Ointment order and acknowledged there was not a specific application site or end date for use. When asked if skin would be cleaned prior to application of an ointment Staff B stated not necessarily. When asked what the expectation was for documenting description of skin issue and monitoring of skin issues, Staff B stated they were looking for information. When asked how skin treatments were monitored and evaluated for effectiveness, Staff B stated they were looking for information. No further information was provided. <RESIDENT 2>Resident 2 admitted to the facility on [DATE] with diagnosis to include a stroke with right side hemiplegia (paralysis to one side of the body) and hemiparesis (a condition that causes weakness or partial paralysis on one side of the body). Review of the quarterly MDS assessment, dated 12/08/2025, documented the resident was moderately impaired in decision making skills, required substantial/maximal assistance to turn side to side in bed, required supervision or touching assistance with meals, was at risk for developing pressure ulcers (PU's – also known as a pressure injury, was a localized injury to the skin and/or underlying tissue caused by prolonged pressure), and was dependent with dressing needs. Review of Resident 2's care plan titled, Resident Status in Bilateral Activities of Daily Living and Functional Mobility, dated 08/02/2025, documented the resident required substantial/ maximal assistance with two people for bed mobility. The resident was able to feed themselves after set up assistance and required occasional monitoring and cueing. Review of Resident 2's at risk for developing pressure injuries (PI's), dated 01/13/2026, documented the resident current open PI's to include their right outer ankle and left heel. Staff were directed to float (elevate the heels off a surface to prevent PI's) the resident's heels when in bed as they allowed. In an interview and observation on 01/21/2026 at 12:35 PM, Resident 2 was lying on their back slightly turned to the rights side, their lower legs were uncovered, and their heels were lying directly on the surface of the bed. There was an untouched lunch meal tray observed on the over the bed table. The resident could not accurately answer interview questions. In an observation on 01/21/2026 at 12:57 PM, Resident 2 was lying supine in bed, feet were covered and an unidentified staff member was standing on the left side of the bed observed assisting them with their meal. In an observation on 01/21/2026 at 2:55 PM, Resident 2 was lying on their right side, with the head of the bed elevated, the resident was positioned down in the bed with their torso leaning back towards the left edge of the bed, their knees were hanging over the right side of the mattress edge. Their lower legs were observed positioned bent back at the knee with the left leg resting on the right leg, and the right outer ankle was lying directly on the mattress. In an interview on 01/22/2026 at 9:19 AM, Staff H, NAC, stated they knew how to care for a resident by reviewing their Kardex (a guide used by the nursing assistant to help direct the residents individualized care) that was handing inside of their closet. If they had any further questions, they would ask the Licensed Nurse (LN). When there was a change to the residents' Kardex this was communicated to the care staff by a typed in-service that the staff read and signed. In an interview on 01/22/2026 at 9:37 AM, Staff L, NAC, stated that they knew how to care for a resident by the Kardex inside of their closet. If there were changes to their care plan this was communicated to them by either the LN or the nurse manager. In an interview on 01/22/2026 at 9:46 AM, Staff I, NAC, was asked how they knew how to provide care to each resident and meet each resident's specific needs. Staff I stated refer to the Kardex in the EMR. In an observation on 01/22/2026 at 10:10 AM, Resident 2 was lying in bed, lower legs uncovered with a pillow observed under their calves, their right foot was lying on the pillow, and their left heel was lying directly on the surface of the bed. In an observation on 01/22/2026 at 12:00 PM, Resident 2 was lying on their back, both feet/heels were observed directly lying on the surface of the bed. There was a full lunch tray sitting uncovered on the overbed table and was within reach. There were no staff members present. In an observation on 01/22/2026 at 2:02 PM, Resident 2 was observed in the same position with an untouched lunch tray, and no staff member was present. In an observation and interview on 01/22/2026 at 3:07 PM, Resident 2 was lying in bed in the same position, with an untouched lunch tray. There were no staff present. Resident was asked if they had eaten lunch and replied yes. In an observation and interview on 01/22/2026 at 3:11 PM, Staff K, NAC, was in the hallway. When asked when lunch was usually served, Staff K stated around noon. Staff K was informed Resident 2 had an uneaten lunch tray present in their room. In an interview on 01/22/2026 at 3:13 PM, Staff J, LPN/Nurse Manager, was informed Resident 2 had their untouched lunch tray on their bedside table. Staff J stated that it had been a long time and would take care of it immediately. Reference WAC 388-97-1060 (1), 2 (b), (c), 3 (b), (h), (j)(viii)

Based on observations and interview the facility failed to ensure drugs and biologicals were stored in accordance with the state and federal laws appropriately for 1 of 2 (Rehab Unit) Medication Storage Rooms. The facility failed to ensure Schedule II-V (Substances with high potential for abuse which may lead to severe psychological or physical dependence) controlled medications were in separate locked, permanently affixed compartments not accessible to others. These failures left controlled substances unattended with potential of unauthorized access to drugs that should have been securely stored.Findings included . In an observation and interview on 09/10/2025 at 9:50 AM, Staff H, Registered Nurse/Case Manager opened the refrigerator in the Medication Room in the Rehab Unit, inside the refrigerator was a locked metal box not permanently affixed to the refrigerator. They took the locked box out of the refrigerator and Staff H opened it with a key. Observed in the box were 2 unopened bottles of Lorazepam (Scheduled IV medication that treats anxiety) oral liquid and 1 unopened injectable vial of Lorazepam. According to Staff H, they store controlled medications in the locked box. Staff H was not aware that the storage for Scheduled substances should be permanently affixed in the refrigerator. Refer to WAC 388-97-1300(2)

Based on interview, and record review, the facility failed to ensure a system was in place in which residents' records were complete, accurate, accessible, and systematically organized for 5 of 11 residents (Residents 5, 8, 74, 78, and 100) reviewed for accurate and complete medical records. The facility failed to ensure the medical records reflected the physician visit documentation for 3 of 6 residents (Residents 5, 78, and 100), failed to include dialysis provider notes for 1 of 3 residents (Resident 74), failed to ensure accurate documentation for advanced directives for one of one resident (Resident 8). This failure placed residents at risk for medical complications, unmet care needs, and diminished quality of life. Findings included .Review of the facility policy titled, Medical Records, revised date 12/06/2024 stated the medical records department will maintain the records on each resident as complete, accurately documented, readily accessible and systematically organized.Review of the facility policy titled Physician Visits, revised date 12/06/2024 documented that Health Information personnel should remind the physician to write a progress note. The Physician should write or dictate a progress note for each visit.Upon entrance to facility on 09/09/2025 the facility provided Entrance Conference Worksheet, Electronic Health Record (EHR) Information dated 04/04/2025, that showed all information was located on the Electronic Health Record (EHR). <DIALYSIS> Review of Resident 74's care plan on 09/12/2025 documented they received dialysis services and were seen by their nephrologist (medical doctor specializing in kidney diseases) every three months, had labs weekly, and communication packets to/from the dialysis center (including vitals and weight) on dialysis days. Review of Resident 74's electronic medical record showed no visit notes/progress notes from their nephrologist, lab results, or communication packets. In an interview on 09/12/2025 at 9:27 AM Staff Q, RN/Nurse Manager stated the nephrologist completed their visits with Resident 74 at the dialysis center. Staff Q stated they asked for Resident 74's labs every week, they were not uploaded and placed in the paper chart. Staff Q stated they had not put any nephrology notes or labs in Resident 74's EHR but could. Staff Q stated the physicians in the facility had access to Resident 74's facility EHR, but not all had access to records from other entities. In an interview on 09/12/2025 at 10:20 AM Staff I, Health Information Manager, stated they had not been asked to upload dialysis communication forms into Resident 74's EHR and would upload them when the resident discharged . Staff I stated the facility had a hybrid system of electronic records and paper charts. When asked how records from appointments were entered into a resident's medical record, Staff I stated they would obtain the record and upload it into the EHR when they were aware an appointment had occurred. <ADVANCE DIRECTIVE> Review of Resident 8's care plan on 09/12/2025 documented they had a Power of Attorney (POA) appointed. Review of the POA document on 09/12/2025 documented the POA would become effective when Resident 8's primary physicians determined they were unable to make their own health decisions. In a joint interview on 09/15/2025 at 8:55 AM with Staff M, Social Services and Staff P, Social Services, Staff P stated their understanding of Resident 8's decision making was that it was impaired by their severe dementia. Staff P, stated Resident 8 had conversations and would reminisce but relied on their son, who was also their POA, to assist with their decision making. When asked if there was notation by Resident 8's physician regarding their decision-making ability, Staff P deferred to the most recent physician progress note that described Resident 8 as having mild dementia. Staff M stated they would review Resident 8's medical record and provide additional information if they found it. On 09/15/2025 at 9:55 AM Staff M and Staff P provided a signed letter by Resident 8's physician, dated 1/13/2025, which indicated Resident 8 was unable to make healthcare decisions for themselves. Staff M stated the letter was found in Resident 8's paper chart. Staff M stated the letter should have been in Resident 8's EHR. <PHYSICIAN NOTES> <RESIDENT 100> Review of Resident 100's order summary on 09/15/2025 documented they had a neurology appointment on 06/02/2025. Review of Resident 100's EHR showed no documentation related to an appointment on 06/02/2025. In an interview on 09/15/2025 at 1:30 PM Staff D, LPN/Care Manager, stated Resident 100's neurology appointment scheduled for 6/02/2025 was cancelled by the clinic and rescheduled for a virtual appointment on 07/17/2025. Staff D stated they were unable to find the visit note for Resident 100 for their 07/17/2025 virtual visit. Staff D stated the process of obtaining visit notes was for medical records to request them and upload them into the residents' EHR. <RESIDENT 78> Resident 78 was re-admitted to the facility on [DATE] with diagnoses to include sepsis (body's extreme reaction to an infection that can lead to organ failure, tissue damage and death), and enterocolitis due to clostridium difficile (infection of the colon caused by bacterium Clostridium Difficile [C. Diff]). In a record review on 09/11/2025 at 2:42 PM, Resident 78's EHR did not have any progress notes from the provider since their admission on [DATE]. In an interview on 09/12/2025 at 11:50 AM, Staff H, Registered Nurse/Case Manager stated that providers come in every Monday, and any residents admitted after a Monday, the providers will see them the next Monday. Staff H stated that Medical Records prints out the provider progress notes and hands them to the Case Manager for review, then they return them to Medical Records to be scanned and placed in resident's EHR. Requested Staff H provide the provider progress note for Resident 78 after their admission on [DATE]. Staff H stated they would look for the provider progress note. In a record review on 09/15/2025 at 8:51 AM, Resident 78's chart did not have any progress notes from the provider since their admission date on 08/05/2025. In an interview on 09/15/2025 at 9:03 AM, Staff I, Health Information Manager stated that the provider usually sends their progress notes the same day of the visit or the next day. If they have not received the progress note after 4 days, they usually send a fax to the provider to remind them that they were still waiting for their progress notes from their last visit. Requested Staff I to review when the provider had seen Resident 78 and if they could get a copy of the progress note. Staff I stated that the provider was at the facility on 08/11/2025 and that would have been the date the provider had seen the resident. Requested a copy of the provider progress note for Resident 78 on 08/11/2025. Staff I could not provide a copy of the document requested. In an interview on 09/15/2025 at 10:00 AM, Staff H provided a printed copy of the provider's progress note for Resident 78 signed on 09/08/2025. The copy was not in Resident 78's EHR. Per Staff H, they were not able to provide a copy of the provider progress note for the visit on 08/11/2025. <RESIDENT 5> Review of Resident 5's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure, diabetes and chronic pain. Review of Physician's visits documentation dated 09/15/2025 at 9:57 AM, showed Resident 5 was last visited by the physician on 09/08/2025. Review of Resident 5's EHR showed they were seen by a physician on 11/25/2024, 01/27/2025 and 06/23/2025. The EHR showed that Resident 5 was not seen by a physician in March 2025 or August 2025. The EHR did not include dictation from the 09/08/2025 visit. Reference WAC 388-97-1720(1)(a)(i-iv)(b)

Based on observation, interview and record review, the facility failed to assess and provide pain management to adequately control residents pain for 1 of 3 residents (Resident 63) reviewed for pain management. This failure put residents at risk of uncontrolled pain and a diminished quality of life. Findings included . Review of the facility policy titled, Pain Management, revised 01/22/20205 stated all resident would receive appropriate assessment and management for pain. Appropriate measures for pain control would be documented, then implemented according to a resident's plan of care. when a resident has pain, a pain assessment would be completed. Case Managers and the Minimum Data Set (MDS - an assessment tool) nurse will assess that the residents pain medication and management are effective, and update for further interventions and notifications. Resident 63 admitted to the facility on [DATE] with diagnoses to include osteoporosis, dementia, and muscle weakness. The Quarterly MDS dated [DATE] documented that the resident had severe cognitive impairment, required only supervision for transfer and walking, had no signs of pain, and was not on any medications for pain. Review of Resident 63's progress notes dated 08/28/2025 at 8:20 PM, the licensed nurse documented that the resident had complained of left side lower back pain. The note stated the resident described the pain as stabbing and spasms; resident was observed hunched over holding left side of their back. The note stated the medical provider ordered a urine analysis and started the resident on an antibiotic for five days. Resident 63 was given as needed Tylenol for back pain. Review of Resident 63's progress note dated 09/01/2025 at 8:12 PM, the licensed nurse documented that the resident continued to experience pain to their lower back, the urine analysis showed no infection, and an x-ray was ordered. Review of Resident 63's progress note dated 09/02/2025 at 7:34 PM, the licensed nurse documented the x-ray of lower back was negative. The resident continued to experience lower back pain. The medical provider assessed the resident and started the resident on ibuprofen (non-steroid anti-inflammatory medication). Review of Resident 63's progress note dated 09/02/2025 - 09/06/2025 the resident continued to have severe lower left back pain. Review of Resident 63's medical record documented the resident was seen by the medical provider a second time for severe left lower back pain with new orders for a stool softener and monitor for the pain. Review of Resident 63's progress note date 09/08/2025 at 5:44 PM, the licensed nurse documented the resident was having severe left lower back pain, refused shower due to pain, and their back was uncomfortable to touch. In an observation on 09/09/2025 at 11:46 AM, Resident 63 was observed in the memory care unit living space sitting in a chair. The resident was observed to reach to their left side and rub their lower back several times. They had a grimace look on face, then would lower their head and place their hands over their face with look of discomfort. In an observation on 09/10/2025 at 9:47 AM, Resident 63 was observed to walk back into the memory care unit with a staff member, the resident was teary and had look of discomfort on their face. In an observation on 09/10/2025 at 1:34 PM, Resident 63 was walking around the memory care unit telling staff their back was hurting, they would point to the left lower side. In an observation on 09/11/2025 at 8:26 AM, Resident 63 was observed walking around the memory care unit, they had a distressed look on their face, rubbing their back. In an observation on 09/11/2025 at 2:26 PM, Resident 63 was observed in the memory care unit living space sitting in a recliner. They had their eyes closed, they were rocking back and forth, and they were grimacing. Review of Resident 63's progress note dated 09/11/2025 at 3:27 PM, the licensed nurse documented the resident continued to have severe left lower back pain with no relief from the Tylenol or ibuprofen. The note stated the resident was having trouble sleeping due to pain. Review of Resident 63's care plan on 09/11/2025, 15 days after the severe left lower back pain started, there was no focus area for pain, no updated goal of care or interventions to treat the resident's new onset of pain. In an interview on 09/12/025 at 11:21 AM, Staff N, Nursing Assistant Certified (NAC) stated Resident 63 had been having an increase in left lower back pain. Staff N stated they had observed them grimace and rub the area. Staff N was not aware of the source of their pain, they stated they would wander around the memory care unit. In an interview on 09/12/2025 at 11:29 AM, Staff E, Licensed Practical Nurse (LPN) stated Resident 63 had new ongoing left lower back pain. Staff E stated they had just received more orders from the medical provider to start a topical lidocaine (numbs) patch to their back. Staff E stated they were aware their urine analysis was negative and were unaware if there had been further testing to locate the source of their pain. In an interview on 09/12/2025 at 1:00 PM, Staff O, NAC stated they are educated to follow the care plan or the Kardex (shortened version of the care plan) that is located either in the electronic medical record, or they will place a copy of the Kardex in the residents' closet. Staff O stated that was how they know what level of care to provide each resident. In an interview on 09/12/2025 at 1:39 PM, Staff F, LPN stated that the Case Managers were responsible for updating the plan of care for each resident. In an interview on 09/15/2025 at 9:08 AM, Staff D, LPN/Case Manager stated that the Case Manager for the memory care unit was out. Staff D stated that the Case Manager was the primary staff member that would update the plan of care for the residents. Staff D stated they were not aware that Resident 63 had severe left lower back pain. Staff D stated that if a resident was having an acute change in condition that had not been resolved that focus area should be addressed on the plan of care. In an interview on 09/15/2025 at 9:21 AM, Staff B, Director of Nursing Services (DNS) stated the Case Managers were responsible for updating and revising the plan of care for the residents. Staff B was not aware that Resident 63 was having severe left lower back pain that had gone unresolved for 19 days. Staff B was not able to provide any further information and confirmed that problem should be addressed on the care plan. Reference WAC 388-97-1060(1)

Based on interview and record review the facility failed to coordinate with the preadmission screening and resident review program (PASARR) for 1 of 5 residents (Resident 8) reviewed for PASARR coordination. Resident 8 required a level II evaluation (in depth evaluation of a resident by the state designated authority) for a serious mental disorder which was not completed which placed residents at risk for unmet behavioral care needs. Findings Included.Resident 8 was admitted to the facility on [DATE], discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. Resident 8's diagnoses included Parkinson's disease, depression and dementia with psychotic features (hallucinations or delusions). Review of Resident 8's PASARR Level I (screening tool for possible serious mental illness) dated 01/10/2025 documented they required a level II evaluation. Review of Resident 8's PASARR Level II invalidation statement dated 03/06/2025 documented a level II evaluation could not be completed as they were not in the facility. Review of Resident 8's progress notes dated 04/28/2025 written by Staff P, social services director, documented a level II PASARR invalidation was received, dated of 03/06/2025. In an interview on 09/15/2025 at 8:51 AM, Staff M, Social Services, stated there was a miscommunication and the level II evaluation was not completed for Resident 8. Staff M stated there were audits in place to ensure PASARR Level I and II were completed. Staff M stated Resident 8 required a level II evaluation and it was not done. Reference WAC 388-97-1915 (4)

Based on interview and record review, the facility failed to ensure resident care plans were updated for 1 of 1 residents (7) reviewed for Hospice services and 1 of 1 residents (100) reviewed for dental services. This failure placed residents at risk for decreased quality of care. Findings included .<DENTAL> Review of Resident 100's care plan dated 07/09/2024 documented they had no natural teeth. The goal was Resident 100 would have no signs or symptoms of improper fit of their dentures. Interventions included assisting Resident 100 with cleaning their dentures and monitor for any oral discomfort. Review of Resident 100's progress notes documented: - On 01/09/2025 Resident 100 met with social services and reported their bottom dentures did not fit properly. -On 01/30/2025 Resident 100 was placed on alert charting related to irritation on their gums. Resident 100 reported their gums were hurting. -On 03/22/2025 Resident 100 was placed on alert for an ulcer to their lower gum and complained of sore spots on their left upper side of their mouth. Resident 100 was provided with an oral/topical anesthetic. -On 05/19/2025 Resident 100, during a care conference social services would coordinate a denturist visit to have their upper and lower dentures fitted. Review of the dental hygienist notes dated 04/17/2025 documented Resident 100 was seen for their dental care. A referral was recommended for Resident 100 to see a denturist related to ill-fitting dentures and their primary care to assess their tissue under their upper denture for possible thrush. In an interview on 09/15/2025 at 9:47 PM Staff D, Licensed Practical Nurse/Resident Care Manager, stated Resident 100 had seen a denturist on 08/22/2025. Staff D stated care plans were reviewed and revised quarterly and annually. Staff D stated Resident 100's care plan should have been updated to reflect their dental needs. <HOSPICE> Resident 7 readmitted to the facility on [DATE] following hospitalization. Review of Resident 7's medical record showed they elected Hospice Services effective 08/15/2025. Review of Resident 7's medical record showed a Hospice plan of care filed in the resident's hard chart. Review of Resident 7's comprehensive care plan on 09/10/2025 showed the Hospice plan of care elements had not been incorporated into the resident's plan of care. The care plan's only mention of Hospice services was included in the care plan's smoking problem. In an interview on 09/10/2025 at 3:08 PM, Staff B, Director of Nursing Services (DNS) stated nursing received the Hospice plan of care and was supposed to review it and incorporate the interventions into the comprehensive care plan. Reference WAC 388-97-1020 (2)(a)(5)(b)

Based on observation, interview and record review, the facility failed to ensure professional standards were met for 1 of 1 resident (Resident 38) reviewed for oxygen, and 1 of 3 residents (Resident 13) reviewed for diabetic (disease that affects the blood sugar levels in blood) management. The facility failed to follow physician's orders for oxygen administration and failed to ensure appropriate monitoring for diabetes was completed based on national standards. These failures placed the residents at risk for adverse outcomes, medication errors, complications, and unmet needs. Findings included . Review of the facility policy titled, Oxygen Safety, reviewed 12/09/2024, documented the licensed nurse will verify the order and adjust the oxygen flow rate as determined by the physician. Oxygen was administered by a licensed nurse under the order from the attending physician. Review of the American Diabetes Association website on 09/15/2025, documented the national standards for monitoring a hemoglobin A1c (type of blood cell that binds with glucose - standard measurement for average blood glucose levels) recommendations were the levels should be monitored every six months when the last A1c was in the goal range, or every three months if the medication had changed or out of goal range. <RESIDENT 38>Resident 38 admitted to the facility on [DATE] with diagnoses that included respiratory failure and chronic obstructive pulmonary disease (COPD - airflow disruption and damage to lungs). The Quarterly Minimum Data Set (MDS - assessment tool) dated 08/18/2025 documented the resident had no refusal of care and required the use of oxygen. Review of Resident 38's care plan focus area dated 06/02/2025, documented the resident had an alteration in their respiratory status related to their history of COPD, and respiratory failure. Interventions included that the resident was on supplemental oxygen, the resident was dependent on the staff for all tasks, and that the oxygen settings were to administer 2 liter (L)/per min continuously to keep the oxygen saturation level above 88%. Review of Resident 38's physician order dated 08/13/2025, documented to administer supplemental oxygen to resident continuously to the nasal passageway at a rate of 2 L/per minute. In an observation on 09/09/2025 at 11:37 AM, 09/10/2025 at 8:20 AM, 09/11/2025 at 8:24 AM, and 09/12/2025 at 9:34 AM, Resident 38 had oxygen tubing to their nasal passage area, and the oxygen cannister was set to 1 L/per minute. In an observation on 09/12/2025 at 12:48 PM, Resident 38 was lying in the bed, oxygen tubing applied to nasal passage. The setting on the oxygen concentrator was set to 1 L/per minute. In an interview on 09/12/2025 at 1:39 PM, Staff F, Licensed Practical Nurse (LPN) stated Resident 38 was fully dependent on staff for all cares. Staff F stated that the resident was on oxygen supplementation at the rate of 1L/per minute. Staff F was asked to verify the physician oxygen administration order. Staff F confirmed the order was for 2L/per minute. Staff F stated they thought the resident had previously been on 1L/per minute and did not verify the order. At 2:49 PM, Staff F stated they followed up on the physician order for oxygen and the resident was indeed on 2L/per minute, and stated I was following the old orders, that was my error. <RESIDENT 13>Resident 13 was admitted to the facility on [DATE] with diagnoses that included diabetes. The Quarterly MDS dated [DATE], documented the resident received insulin (premade hormone that was injected into the skin to manage blood sugars) all days of the look back period. Review of Resident 13's physician orders dated 11/11/2024, documented the resident was prescribed two oral medications to manage their diabetes, and they received a sliding scale (dose depends on the blood sugar level) injection once a day to manage their diabetes. Review of Resident 13's care plan focus area dated 11/19/2024, documented the resident had an impaired hormone function related to diabetes. Interventions were to monitor blood glucose levels, and lab work to be completed as needed. Review of Resident 13's medical record on 09/12/2025, there was no documented lab work completed for monitoring of the resident's hemoglobin A1c. In an interview on 09/15/2025 at 9:08 AM, Staff D, LPN/Case Manager stated the facility did not have a specific policy as to when to monitor residents A1c levels and stated if they noticed a resident had not had one during the quarterly review, they would notify the provider. Staff D confirmed there had been no A1c level check since the resident was admitted to the facility in November/2024. Staff D confirmed Resident 38's physician orders were to administer oxygen supplementation at a rate of 2L/per minute. Staff D stated their expectation was that the staff were verifying and following the physician orders. In an interview on 09/15/2025 at 9:21 AM, Staff B, Director of Nursing Services stated their expectation was that staff were verifying and administering oxygen supplementation as ordered. Staff B was unaware that Resident 38 had been receiving oxygen at a rate of 1L/per minute, which had not what had been ordered by the physician. Staff B confirmed that Resident 13 should have had a A1c lab level completed. Refer to WAC 388-97-1060(3)(vi)

Based on observation, interview and record review, the facility failed to identify, assess, and address potential signs and/or symptoms of Post Traumatic Stress Disorder (PTSD) for 1 of 1 sampled resident (Resident 28), reviewed for mood and behavior. This failure placed residents at risk of re-traumatization, unmet behavioral health needs, and diminished quality of life.Findings included .According to the website www.mayoclinic.org Post Traumatic Stress Disorder (PTSD) was a mental health condition that could develop after witnessing or being part of an extremely stressful or terrifying event. Symptoms could include flashbacks (feelings that the traumatic event was occurring again), nightmares (repeated disturbing dreams), intrusive thoughts, severe anxiety, avoidance (not wanting to think or talk about a traumatic event), changes in mood or thinking and physical and emotional reactions. These symptoms last more than one month, cause major problems in social or work situations and affect how well a person gets along with others.Review of the facility policy titled, Trauma Informed Care revised 12/06/2024 documented the policy was to ensure there were sufficient staff to provide services or referrals to residents who had a history of trauma. The procedure included screening residents on admission and at any time afterward to ask questions to assess for possible experiences of trauma and to develop a care plan to assist in trauma informed care to avoid re-traumatization. Resident 28 admitted to the facility on [DATE] with diagnoses to include dementia, depression, anxiety and PTSD. Review of Resident 28's Quarterly Minimum Data Set (an assessment tool) dated 07/08/2025 showed their brief interview for mental status (a screening tool to identify cognitive condition) was three out of 15, severe cognitive impairment. Review of Resident 28's care plan on 09/10/2025 documented they had: - Impaired cognition related to PTSD and dementia and they would be able to communicate appropriately with others using yes/no questions. Interventions included staff anticipating Resident 28's needs and limiting background noise. -Refusals of personal care to include bathing and personal hygiene related to their dementia and depression. Interventions included staff to reapproach Resident 28 if they refused a shower. -Ineffective mood and behavior regulation related to their diagnoses of dementia, depression, anxiety and PTSD. Interventions included encouraging Resident 28 to participate in out-of-room group activities. Review of Resident 28's clinical record from 1/25/2025 through 9/10/2025 showed no documentation of a trauma screening, details of their PTSD diagnosis, their experiences or triggers that may impact their care or potentially cause re-traumatization. In an attempted interview on 09/10/2025 at 9:36 AM, Resident 28 was sitting in a recliner, outside of their room, in the unit hallway with a television in front of them. Resident 28, when greeted, responded slowly with a flat affect (diminished emotional response) and did not engage in conversation. In an interview on 09/10/2025 at 3:13 PM Staff P, Social Services, stated they had not discussed or gathered information about Resident 28's PTSD diagnosis or triggers with their representative or family. In an interview on 09/11/2025 at 9:37 AM Collateral Contact 2 (CC 2), Resident 28's family member stated they had not been interviewed by facility staff until 09/10/2025 at 5:30 PM about Resident 28's diagnosis of PTSD. CC 2 stated Resident 28 had been sexually abused as a child. Reference: (WAC) 388-97-1060(3)(e)

Based on interviews and record review the facility failed to ensure timely physician visits (once every 30 days for the first 90 days after admission) were completed for 4 of 7 residents (5, 49, 79 and 84) reviewed for physician visits. This failure placed residents at risk of being denied face-to-face contact with a physician, comprehensive reviews and physician assessments of their health and well-being. Findings included .According to CMS (Centers for Medicare and Medicaid); The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. After the initial physician visit in SNFs (Skilled Nursing Facility), where States allow their use, a NPP (Nurse Practitioner) may make every other required visit. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.Review of the facility policy titled, Physician Visits reviewed and revised on 12/06/2024, showed it was the policy of the facility to ensure the physician takes an active role in the care of the residents. Health Information personnel should track due dates of physician visits and notify the resident when a physician visit was due. The resident must be seen at least once every 30 calendar days after admission and at least every 60 days thereafter with a physician delegate as appropriate by State law. The physician should review the resident's total program of care including medications and treatments at each visit.<RESIDENT 5> Review of Resident 5's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure, diabetes and chronic pain. Review of Resident 5's electronic health record (EHR) showed they were seen by a physician on 11/25/2024, 01/27/2025 and 06/23/2025. The EHR showed that Resident 5 was not seen by a physician in March 2025 or August 2025. <RESIDENT 49> Resident 49 admitted on [DATE] with diagnoses to include hypertensive kidney disease (condition when high blood pressure damages the kidneys over time) and diabetes. Review of Resident 49's EHR showed they were last seen by a physician on 06/23/2025. The EHR showed that Resident 49 was not seen by a physician in August 2025. <RESIDENT 84> Resident 84 admitted on [DATE] with diagnoses which included dementia. Review of Resident 84's required physician's visits for 2025 showed: -02/24/2025, -06/16/2025, -09/08/2025. There was no required provider visit in April of 2025. The provider visit due in August of 2025 was not completed within the required 60 days plus the 10-day grace period. <RESIDENT 79> Resident 79 admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disorder and major depressive disorder. Review of Resident 79's EHR showed they were last seen by a physician on 06/16/2025. The EHR showed that Resident 79 was not seen by a physician in August 2025. In an interview on 09/15/2025 at 9:03 AM, Staff I, Health Information Manager stated that they audit charts to ensure residents have been seen. They update Collateral Contact (CC) 1 of the need for visits by phone or email and provide a list of residents to be seen on Mondays. Staff I stated they had notified CC 1 of missed visit documentation last week. In an interview on 09/15/2025 at 10:51 AM, Staff H, Registered Nurse/Nurse manager stated Collateral Contact (CC) 1's Residency doctor (physician in training) was supposed to complete the dictations for the 09/08/2025 visits. The visit list provided was reviewed and showed 18 residents were seen on 09/08/2025. Staff H stated they would let CC 1 know of the other missing dictations. Staff H was asked about Resident 79's medical record that showed they were last seen by their doctor on 06/16/2025 and Resident 49 had last been seen on 06/23/2025. Staff H stated they would look into that. In a joint interview on 09/15/2025 at 1:05 PM, Staff A, Administrator Staff B, Director of Nursing Services and Staff C, Licensed Practical Nurse/Assistant Director of Nursing Services were informed of missed physician visits. Staff A stated they had not been aware of missed physician visits. In an interview on 09/15/2025 at 1:47 PM, CC 1 stated they rounded on their residents on Mondays and are accompanied by 2nd and 3rd year Residency doctors. CC 1 stated the resident doctors were responsible to see their assigned residents, write the notes and they would sign off on their notes. CC 1 said they first became aware of missed visit notes last week. CC 1 stated the facility provided a list of scheduled visits that were due. CC1 stated that they tried their best to see the residents every 60 days, but it might go a week or two over that. No additional information was provided. Refer to WAC 388-97-1260(4)(c)(10)

Based on interview and record review, the facility failed to provide timely laboratory results to meet the needs of one of two residents (121) reviewed for laboratory services. This failure had the potential for negative complications related to delay of obtaining and receiving follow up of laboratory results placing residents at risk for delay in treatment and adverse outcomes.Findings included.Review of the facility policy titled Laboratory Services, (revised date 12/09/2024), documented the facility would obtain ordered laboratory testing according to provider's orders and would promptly notify providers of results that fell outside of clinical reference ranges.Resident 121 readmitted to the facility on [DATE] with diagnoses which included acute and chronic wounds with infection of the bone. Review of Resident 121's physician's orders dated 08/29/2025 showed orders for laboratory testing to be completed every week on Tuesday. Review of the resident record on 09/12/2025 showed that the resident should have had two sets of laboratory testing (on 09/02/2025 and 09/09/2025) since their readmission. Review of Resident 121's Treatment administration record showed that the ordered labs were signed as having been completed on 09/02/2025 and 09/09/2025, but further review of the record showed no results or progress notes regarding any lab results. In an interview on 09/12/2025 at 1:45 PM, Staff F, Licensed Practical Nurse, (LPN) stated hard copy results should be under the laboratory section of the resident's hard chart or scanned in to the results tab of the electronic health record. Staff F confirmed that results were not in Resident 121's record. Staff F stated the facility was not receiving results from their lab and staff were having to go into the system to print them. Staff F was not aware of any particular process or system to remind staff to follow up on pending labs. Record review on 09/15/2025 showed Resident 121's 09/02/2025 and 09/09/2025 labs were still not filed in either the hard chart or the electronic medical record. In a joint interview on 09/15/2025 at 10:40 AM, Staff G, Licensed Practical Nurse (LPN), Unit Manager, and Staff C, LPN/Assistant Director of Nursing, stated there had been a change to the lab process at the beginning of the month. Staff G reviewed the resident record and confirmed there were no laboratory results found. Staff G logged in to the laboratory portal to view the resident labs and stated the labs on 09/02/2025 showed a partial result but that the 09/09/2025 were in the system. Staff C stated they would have to contact the lab and stated the nurses should be aware of pending labs through shift report and chart documentation. Refer to WAC 388-97-1620 (2)(6)(a)(b)

Based on observations, interviews and record review, the facility failed to ensure staff adhered to infection control practices when providing care to 1 of 3 (Resident 78) residents that were on Transmission-Based Precautions. The facility failed to ensure staff used appropriate hand hygiene and personal protective equipment (PPE - equipment worn to minimize exposure to infections or diseases) when entering a room that had a sign of Contact Enteric Precaution (combination of contact precaution and enteric precautions used for infections that spread through contact with fecal matter or contaminated objects). This failure placed residents and staff at risk for potential infections.Findings included .Review of the facility policy titled Infection Control Policy/Procedure, Transmission-Based Precautions, revised date 08/28/2025 documented, Contact Enteric Precautions should don (put on) a gown and gloves prior to entry for all interactions that may involve contact with the resident or the resident's environment. Hand hygiene is performed with soap and water. Resident 78 was re-admitted to the facility on [DATE] with diagnoses to include sepsis (body's extreme reaction to an infection that can lead to organ failure, tissue damage and death), and enterocolitis due to clostridium difficile (infection of the colon caused by bacterium Clostridium Difficile [C. Diff]). In an observation on 09/09/2025 at 10:15 AM, at the side of Resident 78's door, there was a sign posted - Contact Enteric Precaution, the sign stated: prior to entering: wash or gel hands prior to entry, wear gown and gloves, use soap and water upon leaving the room. In an observation and interview on 09/09/2025 at 11:28 AM, Staff J, Nursing Assistant Certified (NAC), went in the room of Resident 78 to answer the call light. Staff J did not don any PPE. After a few minutes, Staff J left the resident's room and went directly to the clean utility room. Staff J did not perform hand hygiene after leaving the resident's room. Staff J came out of the clean utility room with a blanket and went back to Resident 78's room without any PPE. A few minutes later, Staff J came out of the room and used hand gel outside of the resident's room. Staff J was asked what the sign Contact Enteric Precaution that was posted at the side of Resident 78's door meant, Staff J stated that the only time they wear PPE was when they provided contact care to resident. In an interview on 09/09/2025 at 11:32 AM, Staff K, NAC stated that Contact Enteric Precaution meant they wear gowns and gloves when they were doing high contact care such as peri-care (washing of the genital and anal areas) or handling soiled things. They added they only wear gowns when they were doing peri-care or handling soiled things. In an interview on 09/09/2025 at 11:40 AM, Staff H, Registered Nurse (RN)/Case Manager stated that Contact Enteric Precaution sign meant to only wear PPE when they were touching the resident. When asked to clarify what was posted outside of the room with Staff H, Staff H then added that they would get back with me and would get clarification from the Infection Control nurse. At 11:53 AM, Staff H stated that what they informed me earlier was for residents who were on Enhanced Barrier Precaution (EBP -an infection control strategy that uses gloves and gowns during high-contact care activities for residents colonized or infected with specific multidrug-resistant organisms or those with wounds or indwelling devices that increase the risk of transmission) and for residents that were on Contact Enteric Precaution, anyone entering should be wearing PPE (gown and gloves). Staff H added that they had educated the other staff members on the floor about Contact Enteric Precautions. Staff H stated that the staff that went in Resident 78's room should have worn PPE prior to entering the room. In interview on 09/12/2025 at 2:16 PM, Staff L, RN / Infection Preventionist stated that the staff at the facility get a lot of training regarding transmission-based precautions. Staff L stated that the notice posted by the door of a resident should explain what type of PPE the staff should use and that staff should follow what was posted. Refer to WAC 388-97-1320(1)(a)(c)

Based on observation, interview, and record review the facility failed to consistently and accurately obtain weights, recognize significant weight loss, and provide consistent assistance with eating and cueing for 1 of 4 sampled residents (Resident 33) reviewed for nutrition. Resident 33 experienced a significant 14.6% weight loss from 05/27/2024 to 07/10/2024. This failure placed the resident at risk for further decline in their weight, unintended consequences of poor nutrition, and decreased quality of life. Findings included . Review of the facility policy titled Nutritional Management, dated 12/27/2023, showed that weekly weights would be obtained on new admissions for 4 weeks. After assessing the weight accuracy, the Licensed Nurse or Nursing Assistant would record the weight in the resident's electronic medical record under vital signs. Re-weighs were required for any unplanned 3-pound (lb) variance from week to week. Resident 33 admitted on [DATE] with diagnoses which included protein calorie malnutrition, fractured hip, fractured left arm and advanced dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of the hospital records showed a weight of 110 lbs. on 05/22/2024 and 114 lbs. on 05/24/2024. The resident's height was documented as 66 inches. The resident's Body Mass Index (BMI) was 18.4 which was underweight (below 18.5) for their height. Review of the facility's Registered Dietician (RD) admission assessment dated [DATE] used the hospital admission weight of 110 lbs. and goals were identified as: 1. Maintain current weight of 110 lbs. +/- 3% with no significant weight changes through the next review date. 2. Gradual weight gain is permissible due to low BMI. 3. Provide support, encouragement for resident to comfortably consume as much foods, and beverages as possible The RD assessment further stated Resident 33's average daily intake was likely not meeting the requirements for calories and protein and an appetite stimulant may be appropriate if the resident's weight continued to trend down and appetite was poor. Review of the care plan dated 06/06/2024 showed the RD goals were included with the following interventions: Monitor, record, report to Provider as needed signs and symptoms of malnutrition: Needs cueing and cleanup with meals/fluids, Assist with meals as (they) allow. Needs to Eat where (they) can be monitored by nursing. Provide and serve supplements as ordered: Ensure (nutritional supplement) with all meals. RD to evaluate and make diet change recommendations as needed. Resident eats in dining area. Resident eats in room. Review of Resident 33's POLST (Physician's Orders for Life Sustaining Treatment) form dated 05/25/2024 showed a check mark in the box next to preference is to discuss medically assisted nutrition options, as indicated. The POLST was signed by the resident's Power of Attorney and provider on 05/25/2024. Review of facility's nutrition at risk assessment dated [DATE] showed Resident 33 was identified as being at risk for malnutrition due to age, impaired cognition, need for assistance with activities of daily living, low BMI, intake less than 50%, three or more medications, inflammation and current diagnosis impacting the resident's ability to eat. In an observation on 07/09/2024 at 9:12 AM, Resident 33 was observed lying in bed with their breakfast tray in front of them. Their eyes were closed. A bowl of hot cereal and hard cooked egg were on the tray, both untouched. The utensils were still lined up neatly on a clean folded napkin. There were three full lidded cups on the tray. One contained a chocolate shake and the other two contained water. There were no staff present in the room at the time of this observation. An observation on 07/09/2024 at 12:12 PM, showed Resident 33 was in their wheelchair. The resident appeared thin and frail. The resident was wearing a loose fitting t-shirt. Their left arm was in a sling (a bandage that supports and protects an injured arm, wrist, or hand) and they were fidgeting with the strap. The resident's lunch tray arrived and was placed in front of the resident who was sitting alone at a round table in the small common TV area of the unit. The meal was meatloaf, bread, scalloped potatoes, zucchini and a bowl of fruit. There was one full glass of a nutrition shake and one full glass of water. At 12:25 PM, the resident picked up a spoon and attempted to pick up a piece of fruit. After several attempts, they were able to pick up one grape and eat it. At 12:30 PM the resident was able to pick up a piece of pineapple with the spoon and it dropped, but after a few attempts, they were able to pick it up and eat it. At 12:35 PM they were able to cut into the corner of the scalloped potatoes and get a small piece; they were having difficulty as it was sticky and had not been cut up for the resident. At 12:38 PM the resident picked up the nutrition shake and took a few drinks. No staff were observed to cue, encourage or assist the resident with eating their meal. In an observation on 07/11/2024 at 12:42 PM, Resident 33 had their lunch tray in front of them which was untouched. The resident was looking at the TV and noted to be preoccupied with the sling on their left arm, the strap had slid down over their other arm, and they were pulling on the Velcro. Their hands were underneath the clothing protector and lap blanket they had on. The resident reached for the cup of nutrition shake and took a drink of it. The resident began hitting their armrest with the closed fist of their right hand and stated Please, please, then sighed, and began to push their wheelchair away from the table. Staff S, Certified Nursing Assistant (CNA), walked by and whispered in the resident's ear, then wheeled the resident into their room. Staff S exited the room and stated they took the resident to the restroom and the resident had stated they were done eating. The tray was observed to have one cracker missing from a saltine cracker package and the cup of nutrition shake was almost gone. No staff were observed to cue, encourage or offer to assist the resident during this meal. Record review of Resident 33's meal intake records for 05/25/2024 through 07/09/2024 showed there were 137 total meals: 45 breakfast meals- only 11 total breakfast meals showed the resident consumed 50% or greater of the meal. 46 lunch meals- only nine total meals showed the resident consumed 50% or greater of the meal. 46 dinner meals- only 11 total meals showed the resident consumed 50% or greater of the meal. There were 31 meals during this period that the resident was documented as having consumed 50% or greater of the meals. The other 106 meals were all documented as refused, blank (no documentation of the meal), 0%, or 25%. Review of Resident 33's clinical record on 07/09/2024 showed the vital signs section had one weight of 140 lbs. documented on 05/27/2024. No progress notes or other documentation of the discrepancy (26 lbs.) between the hospital's most recent weight and the facility's admission weight were found. Review of Resident 33's clinical record showed a pre-admission hospital weight of 114 on 05/24/2024 and a facility weight on 05/27/2024 of 140 lbs., which showed a 26 lb. weight gain which had not been reviewed by the facility. The facility had no other weights documented in the resident's record. In an interview on 07/10/24 at 11:24 AM, Staff B, Director of Nursing (DNS), stated there were worksheets filled out by the shower aids that included weights and they kept those in their office. The worksheets were not considered part of the medical record. Staff B stated that the showers and weights were supposed to be entered into the system after they were reviewed by the nurse. On 07/10/2024 at 11: 45 AM, Staff C, Assistant DNS (ADON) provided copies of worksheets titled (Staff E's) showers, or (Staff O's) showers and the dates. The worksheets contained a list of all the showers and weights that were assigned to be done by that shower aid (CNA) on a given day. The following dates showed handwritten weights for Resident 33: 05/27/2024= 140 lbs. (Staff O's showers) 06/05/2024= 140.2 lbs. (Staff E's showers) 06/12/2024= 141.2 lbs. (Staff E's showers) 06/18/2024= 141.2 lbs. (Staff O's showers) 06/26/2024= 143 lbs. (Staff E's showers) 06/27/2024= 141.6 lbs. (Staff E's showers) 07/03/2024= 142.5 lbs. (Staff E's showers) There were no signatures to indicate who had obtained the weights, only the name of the assigned shower aid printed at the top of the sheet. There were observed to be different styles of handwriting on the sheets. There was no documentation showing what type of scale was used for each weight. There was a space for nurse's initials on the far right but none of the entries for Resident 33 included a nurse's initials. In an interview on 07/11/2024 at 9:14 AM, Staff D, Registered Nurse (RN)/Case Manager, stated (Staff O, CNA) was no longer employed at the facility. Staff D stated that Staff E, CNA assisted with showers on their unit and the process was for the shower aids to weigh residents on their shower day and when they entered the weights in the computer there was a place to document what type of scale was used. The nurses were responsible to obtain weights for residents who had a daily weight or other weights that needed to be done at a specific time or more often than with their shower. Staff D was asked to review the weight documentation in the computer for Resident 33 which showed only the one weight which was 26 lbs. greater than the most recent hospital weight. Staff D stated they reviewed the weights for the unit weekly and was not aware of the weight discrepancy and missing weight documentation for Resident 33. In an interview on 07/11/2024 at 09:47 AM, Staff D (accompanied by Staff C) stated they had reviewed the weights for Resident 33 and stated the weight (140 lbs.) was entered into the system incorrectly. Staff D stated the weight for Resident 33 was entered as 140 lbs. and it should have been 114 lbs. The incorrect weight had been struck out and a weight of 114 lbs. was now in the system. Staff D was shown the shower worksheets which contained weights that were never entered into the computer system and were showing as consistent with the (now) struck out weight, and discussed observations of the resident's poor intakes and observation of the general thin appearance of the resident which did not match what the shower worksheet weights documented. Staff D stated they were not sure what the resident's correct weight was. In an observation with Staff D on 07/11/2024 at 10:05 AM, Resident 33 was weighed in the shower room on the wheelchair scale. Staff D was observed to zero the scale and the resident was in their chair with the footrests on. The resident was wheeled onto the scale and the combined weight was observed to be 169 lbs. and was verified several times. The wheelchair was weighed separately with the footrests and weighed 71.7 lbs. After subtracting the wheelchair weight, the resident's actual weight was 97.3 lbs., which was a 16.7 lb. (14.6%) weight loss since admission based on the baseline hospital weight of 114 lbs. The resident's BMI was now 15. Review of the medical record, care plans through 07/10/2024 showed no documentation of notification to the provider, POA or additional interventions related to the inaccurate weights. In an interview and observation on 07/12/2024 9:22 AM, Staff E, CNA, Shower Aide, reviewed the process for weights and weight documentation during shower assignments. Staff E stated they assisted with showers on Resident 33's unit sometimes and the weights were done using the shower chairs. Staff E demonstrated obtaining the weight of a shower chair, zeroing the scale and noted the weight of the shower chair was 17 lbs. which Staff E stated was close to what all the shower chairs weighed. Staff E stated if a resident received a bed bath, they used the Hoyer (mechanical) lift to get their weight. Staff E stated they would enter the weights into the computer at the end of their shift. Staff E was asked about weights for Resident 33 and said they did not remember being the one to obtain any of Resident 33's weights. Staff E stated that sometimes the nurses or the CNAs on the floor would get the weights and write them on the shower worksheets and suggested that was what may have occurred. In an interview on 07/12/2024 at 10:11 AM, Staff N, LPN, stated the nurses or CNAs did not get the weights on their unit. Staff N stated there would have been no reason for them to get (Resident 33's weight) as they were not on a daily weight (or other specifically ordered weight) so the shower aids would have been the ones to get weights for Resident 33. Staff N stated all residents should be getting weighed once a week but there was nothing in the system that notified them if someone did not have a weight. Staff N stated the unit managers reviewed the weights. In an interview on 07/12/2024 at 12:09 PM, with Staff B, DNS and Staff C ADON, Staff B stated the goal was for residents to be weighed weekly and those weights documented in the computer system along with the type of scale used. Staff B stated residents should be re-weighed if there was a discrepancy. The Unit Managers reviewed weights weekly and if there was a change of three lbs. up or down, or if they triggered for weight loss of 5%, or 10%, they would be discussed in the facility team meeting, they would assess the resident and notify the provider, the RD, and the family. Staff B and C stated they had not been aware of Resident 33's weight loss and did not know why the weight documentation was consistently inaccurate for the resident on the worksheets, or how their weights had not been entered into the system or reviewed by any licensed nurses or the Unit Manager according to the policy. Refer to WAC 388-97-1060 (3)(h) This is a recurring deficiency previously cited on the Statement of Deficiencies dated April 25, 2023.

Based on observation, interview, and record review, the facility failed to ensure a system was in place in which residents' records were complete, accurate, accessible, and systematically organized for 6 of twelve residents (33, 49, 78, 92, 103, and 107) reviewed for accurate and complete medical records. The facility failed to ensure the medical records reflected the accurate, and complete weights and bathing documentation for 2 residents (33, and 49), failed to contain the consents for use of restraints for 1 resident (92), failed to include consultant provider notes for podiatry and wound clinic documentation for 2 residents (78, and 103), failed to ensure accurate documentation for meal tray monitoring for 1 resident (92), and failed to ensure accurate documentation for a urinary catheter for one resident (107). This failure to not maintain complete and accurate medical records placed residents at risk for medical complications, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Medical Records, revised 12/27/2023 stated the medical records department will maintain the records on each resident as complete, accurately documented, readily accessible and systematically organized. <WEIGHTS AND SHOWERS> <RESIDENT 33> Resident 33 admitted to the facility on [DATE] with diagnoses which included protein calorie malnutrition, fractured hip, fractured left arm and advanced dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of Resident 33's electronic medical record on 07/09/2024 showed one weight had been documented in the resident's clinical record on 05/27/2024. No other weights were documented in the record. <RESIDENT 49> Review of the resident's electronic medical records on 07/11/2024 showed Resident 49 received three showers in the past 2 months. In an interview on 07/10/2024 at 11:24 AM, Staff C, Assistant Director of Nursing (DNS), stated there were worksheets filled out by the shower aides that included weights and they kept those in their office. Staff C stated the worksheets were not considered part of the medical record. The showers and weights were supposed to be entered into the system after they were reviewed by the nurse. At 11:45 AM, Staff C provided copies of handwritten worksheets with names and dates of seven additional showers and weights for Resident 33 and eight additional showers for Resident 49, these were not easily accessible or part of the medical record. 47104 <RESIDENT 92> Resident 92 admitted to the facility on [DATE] with diagnoses to include dementia, dysphagia (difficulty swallowing), and muscle weakness. Review of the Quarterly Minimum Data Set (MDS, an assessment tool) assessment, dated 07/11/2024 showed the resident had severe cognitive impairment. A review of Resident 92's care plan on 07/11/2024 showed Resident 92 used a tilt n space wheelchair (a wheelchair that can recline and is classified as a restraint), initiated on 04/29/2024 and was at risk for weight loss. A review of Resident 92's electronic health record on 07/11/2024 showed no documentation of a Physical Restraint Informed Consent form for Resident 92's tilt n space wheelchair. A review of Resident 92's electronic health record on 07/11/2024 showed Resident 92's tray monitoring (documentation of percentage of meal consumed) dated 06/12/2024 through 07/10/2024 (for 30 days) showed seven missing entries for breakfast, seven missing entries for lunch, and five missing entries for dinner. In an interview on 07/12/2024 at 10:03 AM, Staff Q, Certified Nursing Assistant (CNA) stated the resident used a tilt n space wheelchair. Staff Q stated resident meals were documented by the CNA in point of care (PCC) charting. Staff Q stated each meal is documented individually by the percentage eaten. In an interview on 07/12/2024 at 10:20 AM, Staff M, Licensed Practical Nurse (LPN), Case Manager, Restorative Program Manager, stated the resident used a tilt n space wheelchair and they were responsible for obtaining the consent for that device. Staff M stated they were unable to find the consent form for Resident 92's wheelchair in the electronic medical record or paper chart and would check medical records. Staff M stated CNAs chart resident meal intake in PCC. Staff M stated there was missing documentation in Resident 92's medical record for tray monitoring. On 07/12/2024 at 11:00 AM, Staff M provided a copy of the consent form for Resident 92's tilt n space wheelchair dated 05/13/2024, fourteen days after the restraint was initiated. In an interview on 07/12/2024 at 12:20 PM, Staff G, Medical Records, stated consents were scanned into the medical record. In an interview of 07/15/2024 at 9:50 AM, Staff B, DNS stated the CNAs were responsible for documenting the percentage of meal consumed for each meal in PCC. Staff B stated tray monitoring should be audited for missing documentation. 50725 <RESIDENT 107> Resident 107 admitted to the facility on [DATE]. According to the end of Medicare Part A stay MDS assessment, dated 06/12/2024, the resident had severe cognitive impairment. In an observation on 07/10/2024 at 10:00 AM Resident 107 did not have a urinary catheter (a tube used to empty the bladder). Review of the progress note, dated 06/10/2024, showed Resident 107's urinary catheter had been discontinued. Review of Resident 107's current care plan, dated 05/28/2024, showed the resident was care planned that they had a urinary catheter. Review of Resident 107's Treatment Administration Records, dated 07/11/2024, showed a licensed nurse had annotated they had changed their urinary catheter and drainage bag on 07/10/2024. In an interview on 07/12/2024 at 9:08 AM, Staff L, Registered Nurse, stated they had signed the treatment administration records in error, documenting that they had changed the urinary catheter and drainage bag, and that the catheter had been discontinued in June 2024. In an interview on 07/11/2024 at 1:19 PM, Staff M, LPN/Resident Care Manager, stated Resident 107's care plan and treatment administration records should have been updated when the urinary catheter was discontinued. 44110 <CONSULTANTS> <RESIDENT 78> Resident 78 admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (slow and progressive disorder of the blood vessels), diabetes, and multiple wounds to right foot. The quarterly MDS assessment dated [DATE] showed the resident had intact cognition and open foot wounds to bilateral feet. In an interview on 07/09/2024 at 12:00 PM, Resident 78 stated they had a couple wounds to both of their feet. Resident 78 stated that they went out to see an outside wound provider for management of their wounds. Review of Resident 78's progress notes on 07/10/2024, showed a communication note dated 05/21/2024, documenting that an outside wound clinic provider was contacted regarding updated orders for the resident's wound care management. Review of Resident 78's medical record showed no record or documentation from an outside wound clinic and/or wound care provider. In an interview on 07/11/2024 at 11:36 AM, Staff F, LPN/Case Manager stated Resident 78 was out of the facility at that time at their wound clinic appointment. Staff F stated that when the resident returned from the wound clinic, they would review the documentation from the wound provider, update any orders, and then place in the medical records box for filing. Staff F stated they were not aware there was no wound clinic documentation in the resident's medical records. In an interview on 07/11/2024 at 1:01 PM, Staff C stated Resident 78 was attending the wound clinic weekly, and they are not going every other week. Staff C provided wound clinic documentation for visits on 06/27/2024, 06/13/2024, 05/30/2024 and 05/16/2024. None of the documentation provided was included in the medical record for Resident 78. <RESIDENT 103> Resident 103 admitted to the facility on [DATE] with diagnoses including muscle weakness, depression, and heart failure. The quarterly MDS assessment dated [DATE] showed that the resident had intact cognition and required substantial to maximum assistance for all personal hygiene care. In an observation and interview on 07/08/2024 at 1:47 PM, Resident 103 was lying in their bed, their feet were exposed from under the sheet. The resident's toenails were observed to be long, and some were curling over the skin of the toe. Resident 103 stated that their toenails needed to be trimmed, and that the toenail on their right big toe had recently fallen off. The right great toenail bed was observed to be pink, and there was no nail present. Review of Resident 103's progress notes on 07/09/2024 showed a progress note dated 05/17/2024, documenting that the resident had been seen by a podiatrist. The note stated the resident had an infection to their right great toe. In a review of Resident 103's medical record showed no record or documentation from a podiatrist, or the infection to the resident's right great toe. On 07/11/2024 at 1:01 PM, Staff C provided the podiatry documentation for Resident 103. Staff C was not sure why it was not in the medical record and was unable to provide any additional information. In an interview on 07/12/2024 at 12:20 PM, Staff G, Medical Records, stated that all documentation placed in the medical records box at the nurse's stations were scanned into the medical record. Staff G stated all consults with providers, such as wound clinic or podiatry notes should be scanned into the medical record. Staff G stated they were instructed not to scan anything into the medical record until the case managers had signed off on it. Staff G stated the wound clinic documentation for Resident 78 and Resident 103's podiatry notes were probably still on the case manager's desk, and therefore had not been signed off or released to them to scan into the record. In an interview on 07/12/2024 at 1:46 PM, Staff B, DNS stated the process was that all documentation should be scanned into the electronic medical record timely. Staff B stated there could be a delay of a week or two at times. Staff B confirmed that consults from May, included Resident 78's wound clinic visits, and Resident 103's podiatry visits should have been in the resident's medical record. Staff B was not aware that the case managers were holding onto documentation and not getting things scanned into the medical record timely. Refer to WAC 388-97-1720 (1)(a)(i)(ii)(iii)(2)(d)(e)(f)(j)(m)

Based on observation and interview, the facility failed to transport and serve food in a sanitary manner in 3 of 3 units (East, West, North) reviewed for food service. The failure to cover cold foods like fruit cups and desserts placed residents at risk for receiving contaminated foods and for diminished quality of life. Findings included . In an observation on 07/08/2024 at 12:05 PM, the East unit hall tray cart had trays with uncovered mandarin oranges that were served to residents. In an observation on 07/08/2024 at 12:08 PM, the North unit hall tray cart had trays with uncovered mandarin oranges that were served to residents. In an observation on 07/09/2024 at 12:00 PM, the East unit hall tray cart had trays with uncovered fruit that were served to residents. In an observation on 07/09/2024 at 12:09 PM, the East unit had uncovered fruit cups with melon and mandarin oranges that were served to residents. In an observation on 07/10/2024 at 12:15 PM, the East unit hall tray cart had trays with uncovered cups of apricots that were uncovered and were served to residents. In an observation on 07/15/2024 at 11:17 AM, the [NAME] unit hall tray cart had trays with uncovered cake and whipped cream that were served to residents. In an interview on 07/12/2024 at 1:05 PM, Staff T, Dietary Manager, stated they didn't cover their dessert bowls or small cups of condiments. 47104 Refer to WAC 388-97-1100 (2)

Based on interview and record review, the facility failed to develop and implement comprehensive, person-centered care plans to meet the needs and preferences for 1 (Resident 92) of 6 sampled residents reviewed for nutrition, 1 (Resident 7) of 5 sampled residents reviewed for unnecessary medications, 2 (Resident 87 and 92) of 2 sampled residents reviewed for restraints, and 1 (Resident 73) of 1 sampled resident reviewed for bowel and bladder. This failure placed residents at risk for not receiving needed, preferred care and services and a diminished quality of life. Findings included . <RESIDENT 7> Resident 7 admitted to the facility with diagnoses to include congestive heart failure (a condition of the heart not pumping blood efficiently which can cause extra fluid in the body), and hypertension (high blood pressure). A review of Resident 7's current care plan printed on 07/14/2024 showed no care plan problem or interventions related to the resident's congestive heart failure or hypertension. In an interview on 07/15/2024 at 10:15 AM, Staff F, Licensed Practical Nurse (LPN)/Case Manager, stated they were responsible for creating Resident 7's care plan. Staff F stated there was not a care plan created for diagnoses of congestive heart failure or hypertension. <RESIDENT 87> Resident 87 admitted to the facility with diagnoses to include stroke and hemiplegia (loss of strength) and hemiparesis (muscle weakness or partial paralysis on one side of the body). A review of Resident 7's current care plan printed on 07/10/2024 showed Resident 87 used a tilt n space wheelchair (a wheelchair that can recline). The care plan did not include information for how to position the resident in the wheelchair. In an interview on 07/12/2024 at 10:15 AM, Staff U, Certified Nursing Assistant (CNA), stated Resident 87 used a tilt n space wheelchair. Staff U stated there was no specific way to position the resident in the wheelchair. In an interview on 07/12/2024 at 10:30 AM, Staff M, LPN/Case Manager, Restorative Program Manager, stated that Resident 87 used a tilt n space wheelchair and they were responsible for updating the resident's care plan. Staff M stated there was no care plan for wheelchair positioning. <RESIDENT 92> Resident 92 admitted to the facility on [DATE] with diagnoses to include dementia (loss of memory), dysphagia (difficulty swallowing), and muscle weakness. A review of Resident 92's current care plan printed on 07/10/2024 showed the resident used a tilt n space wheelchair and was at risk for weight loss. The care plan did not include information for how to position the resident in the wheelchair or monitoring and who to notify wf the resident experienced weight loss. In an interview on 07/12/2024 at 10:03 AM, Staff Q, CNA, stated resident specific information for care or resident preferences would be listed on the care plan. Staff Q stated Resident 92 sits straight up in their wheelchair when eating and when they were not eating the wheelchair was tilted slightly back with legs elevated. In an interview on 07/12/2024 at 10:20 AM, Staff M, LPN/Case Manager, Restorative Program Manager, stated Resident 92 used a tilt n space wheelchair and they were responsible for updating the resident's care plan. Staff M stated if Resident 92 had specific guidelines for wheelchair positioning it should be on the care plan so staff would know how to position the resident. Staff M stated the care plan did not include interventions and/or how to position the resident in the wheelchair. Staff M stated the resident's nutrition care plan did not show interventions, monitoring or who to notify if the resident experienced weight loss 37890 <RESIDENT 73> Resident 73 was a long-term care resident with diagnoses that included diabetes. In an interview on 07/08/2024 at 10:58 AM, Resident 73 stated they had been experiencing diarrhea for approximately 17 weeks. Resident 73 stated they didn't know what the cause was but they had seen a doctor, had testing, and they were now taking a probiotic (a supplement to improve digestion and treat stomach issues such as diarrhea). The resident stated they were often worried they would not make it to the bathroom in time or they would have irritated skin from the diarrhea. Review of the resident record on 07/10/2024 showed that Functional diarrhea was added to the resident's diagnosis list on 03/04/2024 and a referral to a Gastrointestinal (GI) physician was also ordered. Review of the GI visit summary for Resident 73, dated 06/06/2024 showed medication orders to firm stool had been increased. Review of Resident 73's current care plan on 07/17/2024 showed there was no care plan problem or interventions related to the resident's chronic diarrhea. In an interview on 07/15/2024 at 11:30 AM, Staff B, Director of Nursing, stated the case managers were responsible for initiating and updating resident care plans. Refer to WAC 388-97-1020 (1)

Based on observation, interview, and record review the facility failed to provide the assistance with activities of daily living (ADL's) for 2 of 7 sampled dependent residents (10 and 33) reviewed for ADL's. The facility failed to provide showers/bathing assistance to a resident (Resident 10), who was dependent on staff for bathing, and failed to ensure a resident that was dependent for assistance with meals was provided the necessary assistance. These failures placed the residents at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Shower/Bed-Bath, revised 12/28/2023 stated the facility was to provide bathing assistance by the shower team to ensure and maintain the resident's dignity. Review of the facility policy titled, Standards of Care, revised 03/29/2024 stated care was provided based on the residents physical and mental capabilities. Staff are to offer assistance for dining, feeding assistance, nail care every week, and bathing. <RESIDENT 10> Resident 10 admitted to the facility on [DATE] with diagnoses including depression, and instability of the right knee. The quarterly Minimum Data Set (MDS, an assessment tool) assessment dated [DATE] showed the resident had intact cognition and required partial to moderate assistance with bathing and transfers. In a review of Resident 10's care plan on 07/10/2024 showed a focus point that Resident 10 had ADL self-care performance deficits related to dementia, and weakness (Initiated 05/27/2021). Interventions dated 03/06/2024 showed the resident required substantial assistance for both transfers into the shower, and bathing tasks. The resident preferred to shower twice a week. In a review of Resident 10's documentation report, dated 06/01/2024 - 07/15/2024 for showers twice a week showed the following: - June 2024: offered three times (06/04, 06/11, and 06/25) out of eight opportunities, - July 2024: offered twice (7/2, and 7/9) out of four opportunities. There were no refusals documented. In an observation and interview on 07/08/2024 at 1:09 PM, Resident 10 was observed to have disheveled, greasy hair, and unkempt facial hair. The resident could not recall the last time they had a shower and stated they hoped it was soon. In an interview on 07/12/2024 at 8:53 AM, Staff I, Nursing Assistant Certified (NAC) stated that the facility usually had a shower aide that would do the showers. Staff I stated they will try to assist with showers if there was a call in, and the shower aide was pulled to the floor. Staff I stated they will assist residents to be bathed and shaved based on their preferences. Staff I stated they were familiar with Resident 10 and they did not refuse care very often. Staff I was not aware that the resident required a shower twice a week, or that they needed to be shaved. In an interview on 07/12/2024 at 9:20 AM, Staff E, NAC/shower aide stated they were the primary shower aide for the unit where Resident 10 resided. Staff E stated recently they had been pulled to work as an NAC on the floor due to call offs. Staff E stated Resident 10 will always take a shower when offered, and they preferred to use their electric razor in their room for shaving. In an interview on 07/12/2024 at 10:35 AM, Staff J, License Practical Nurse (LPN) stated they usually had a shower aide on the unit to assist with showers, however if there was a call off's, they would divide the showers among the NACs on the floor to get done. Staff J stated if a resident was refusing a shower or to be shaved the NACs were to report to the nurse, and they would attempt to reapproach. Staff J stated Resident 10 does not refuse, however liked to do things on their time, so your approach really matters with them. In an interview on 07/12/2024 at 10:50 AM, Staff K, Registered Nurse (RN)/Case Manager stated that lately the shower aide had been pulled from showers to assist on the floor. Staff K stated that if a resident was refusing care frequently the staff should notify them so they can try and get to the root of the refusal. Staff K stated that Resident 10 was easy going and was not aware that they were refusing any care. Staff K stated the resident was probably not getting their preferred showers twice a week due to the staffing call offs. In an interview on 07/12/2024 at 1:46 PM, Staff B, Director of Nursing, stated the shower aides and the NACs on the floor were responsible to ensure the residents were getting the showers and shaving done per the resident's preferences. Staff B stated when a resident preferred a shower twice a week, the medical record should show that the facility was at least offering the shower twice a week. Staff B was not aware that Resident 10 was not receiving their preferred number of showers a week. 37890 <RESIDENT 33> Resident 33 admitted to the facility on [DATE] with diagnoses which included protein calorie malnutrition, fractured hip, fractured left arm and advanced dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Review of the Admission MDS assessment dated [DATE] showed Resident 33 required supervision and setup assistance with eating during the prior assessment period. Review of Resident 33's care plan dated 06/06/2024, showed the following interventions: Needs cueing and cleanup with meals/fluids, Assist with meals as (they) allows. Needs to eat where (they) can be monitored by nursing. Review of Resident 33's documentation survey report for 05/25/2024 through 07/09/2024 showed there were 137 total meals: 45 breakfast meals- only 11 total breakfast meals showed the resident consumed 50% or greater of the meal. 46 lunch meals- only 9 total meals showed the resident consumed 50% or greater of the meal. 46 dinner meals- only 11 total meals showed the resident consumed 50% or greater of the meal. There were only 31 meals that the resident was documented as having consumed 50% or greater of the meal. The other 106 meals were all documented as refused, blank (no documentation of the meal), 0%, or 25%. The documentation survey report also showed the level of assistance documented for each meal. The report documentation showed only eight total documentations that the resident received partial or extensive assistance with eating. In an observation on 07/09/2024 at 9:12 AM, Resident 33 was observed lying in bed with their breakfast tray in front of them. Their eyes were closed. Their breakfast tray was on the overbed table, untouched. There were no staff in the room at the time of this observation. In an observation on 07/09/2024 at 12:12 PM, Resident 33 was sitting in their wheelchair. Their left arm was in a sling, and they were fidgeting with the strap. The resident's lunch tray arrived and was placed in front of the resident who was sitting alone at a round table in the small common area of the unit. There was one full glass of a nutrition shake and one full glass of water. At 12:25 PM, the resident picked up a spoon and attempted to pick up a piece of fruit. After several attempts, they were able to pick up one grape and eat it. At 12:30 PM the resident was able to pick up a piece of pineapple with the spoon and it dropped. After a few attempts, they were able to pick it up and eat it. At 12:35 PM they were able to cut into the corner of the scalloped potatoes and get a small piece; they were having difficulty as it was rather stuck together and had not been cut up for the resident. At 12:38 PM the resident picked up the nutrition shake and took a drink, then another drink. No staff were observed to cue, assist or encourage the resident during this meal. In an observation on 07/11/2024 at 12:42 PM, Resident 33 had their lunch tray in front of them which was untouched. The resident was noted again to be preoccupied with the arm sling, the strap had slid down over their other arm, and they were pulling on the Velcro. Their hands were underneath the clothing protector and lap blanket they had on. The resident then reached for the cup of nutrition shake and took a drink of it. The resident then began hitting their armrest with the closed fist of their right hand and stated Please, please, then sighed, and began to push their wheelchair away from the table. Staff S, NAC, walked by and whispered in the resident's ear, then wheeled the resident into their room. Staff S exited the room and stated they took the resident to the restroom and the resident stated they were done eating. The tray was observed to have one cracker missing from a saltine cracker package and the cup of nutrition shake was almost gone. No staff were observed to cue, assist or encourage the resident during the meal. In an interview on 07/11/2024 at 9:16 AM, Staff D, LPN/Care Manager, stated Resident 33 was able to feed themselves and had spurts where they would eat well. The staff were supposed to check in and offer assistance as needed. Staff D was made aware of observations of the resident's poor intakes, distracted fidgeting and the lack of observations of the staff providing any cueing, encouragement or assistance to the resident according to the care plan. In an interview on 07/12/2024 at 12:09 PM, with Staff B, DNS and Staff C (Assistant DNS), the observations and documentation findings were discussed regarding Resident 33. Staff B and Staff C did not have further information regarding Resident 33's lack of assistance with meals. Staff C and Staff B stated that staff were expected to offer assistance as needed to residents. Refer to WAC 388-97-1060(2)(a)(i)(iv)

Based on interview and record review, the facility failed to offer appropriate services and assistance to maintain or improve mobility and range of motion for 1 of 1 sampled resident (Resident 107) reviewed for restorative nursing program. This failed practice placed the resident at risk for losing strength and range of motion they gained while receiving therapy services. Findings included Review of the facility policy titled Restorative Nursing Program, dated 12/27/2023, showed the facility would provide maintenance and restorative services designed to maintain and improve residents' abilities to the highest practicable level. It also stated residents may receive restorative nursing services upon discharge from skilled therapy. Resident 107 admitted to the facility on [DATE] with diagnoses to include multiple facial fractures from a fall, iron deficiency anemia (low red blood cells in the blood), and essential tremors. According to the admission Minimum Data Set (MDS- an assessment tool) assessment dated [DATE], showed the resident had severe cognitive impairment and required assistance with self-care, mobility/ambulation, dressing, standing and transfers. Review of a form titled Physical Therapy Discharge Summary, dated 06/11/2024, showed Resident 107 was discharged from physical therapy services and Collateral Contact 1 (CC1)/ Physical Therapy Assistant (PTA) recommended Resident 107 receive restorative nursing services to maintain their abilities they had attained during therapy. In the review of Resident 107's clinical record for 06/10/2024 through 07/11/2024, showed no documentation that they received or refused restorative nursing care and services. In an interview on 07/10/2024 at 1:55 PM, Staff R, Certified Nursing Assistant (CNA), stated that resident needed more care than what is seems. Staff assist Resident 107 in his dressing and grooming. In an interview on 07/11/2024 at 1:19 PM, Staff M, Licensed Practical Nurse (LPN)/Restorative Program Manager, stated physical therapy staff usually notified them when they recommended restorative nursing care for a resident, but they had not received a recommendation for Resident 107. Staff M stated they were unsure why they had not received a restorative nursing care referral for this resident. In an interview on 07/12/2024 at 11:09 AM, CC1/PTA stated they recommended restorative nursing services for Resident 107 on 06/11/2024 but currently resident is not receiving restorative nursing program. They stated they should have addended their note if they have changed their recommendation. In an interview on 07/12/2024 at 1:02 PM, Resident 107 stated they wouldn't mind doing some exercises and walking with staff. Refer to WAC 388-97- 1060(3)(d)

Based on interview and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 15) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure a medical provider assessed and documented a rationale for extended use of an as necessary (PRN) anti-psychotic (medication that treats symptoms that affect the mind, and reality) medication for use over 14 days and provided no duration of use of the anti-psychotic medication. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication. Finding included . Review of the facility policy titled, Psychoactive Medications, revised 12/27/2023 stated any psychotropic medication prescribed as a PRN will be for 14 days and will be re-evaluated for discontinuance or justification from the provider. Resident 15 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, and dementia. The quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 06/22/2024 showed they had severe cognitive impairment. Review of Resident 15's physician orders showed an order for Quetiapine Fumarate 25 milligrams (mg) every four hours as needed for agitation, started 03/27/2024. Review of Resident 15's electronic medication administration record (EMAR), dated 05/01/2024 - 07/10/2024 showed the following: - May 2024: was not administered, - June 2024: was administered twice, - July 2024: was administered eight times (resident passed away on 07/10/2024). Review of Resident 15's medical record showed no assessment, rationale or review for the use of a PRN anti-psychotic medication, the medical record showed no duration or stop date. In an interview on 07/12/2024 at 1:22 PM, Staff P, Registered Nurse (RN)/Case Manager stated Resident 15 had the order for the Quetiapine which was originally prescribed by hospice for agitation. Staff P confirmed that all PRN psychotropic medications required review every 14 days for rationale, and continued usage. Staff P was unable to provide documentation that the PRN medication had been reviewed every 14 days. In a joint interview on 07/12/2024 at 1:46 PM, Staff B, Director of Nursing Services (DNS) stated Resident 15 was receiving the PRN Quetiapine for agitation and it was a part of the hospice orders. Staff B was not aware that the PRN medication had not been assessed or reviewed by a provider for rationale or duration since the start date. Further documentation was requested, Staff B was unable to provide any further information. Refer to WAC 388-97-1060(3)(k)

Based on observation, interview and record review the facility failed to ensure dependent residents received assistance with activities of daily living to include grooming for 1 of 1 resident (18) and bathing for 4 of 6 residents (61, 84, 91, and 102) in accordance with their needs and preferences reviewed. This failure placed residents at risk for diminished dignity, decreased quality of life and poor hygiene. Findings included . <Grooming> Resident 18 Resident 18 admitted to the facility on [DATE]. The resident had diagnoses that included Parkinson's Disease (a disorder that affects movements often including tremors) and Dementia. Review of Quarterly Minimum Data Set (MDS, an assessment tool) dated 3/13/2023, showed Resident 18 had moderate cognitive impairment and required one person extensive assistance with personal hygiene. In an observation on 04/18/2023 at 2:15PM, the resident's hand and fingers nails were soiled with dried food. On 04/19/2023 at 10:35 AM, Resident 18 was observed to have dirty fingernails with dried food. On 04/21/2023 at 10:19 AM, Resident 18's fingernails were observed with some dried red/orange food on their thumbs. In an observation/interview on 04/21/2023 at 10:20 AM with Staff T, Licensed Practical Nurse (LPN), regarding resident's hand hygiene, the nurse stated they can help them and obtained a wash cloth and assisted the resident to wash their hands thoroughly. In an interview on 04/21/2023 at 1:55PM with Staff U, Nursing Assistanct Certified (NAC), stated that the resident often eats with their fingers and is offered a sani-wash cloth to wash their hands after meals and may not always get everything. <Bathing> Review of facility form titled, Standard of Certified Nursing Assistant (CNA) Practice, dated revised 01/18/2023, staff are required to provide Shower/tub per care plan. Resident 91 Resident 91 admitted to the facility on [DATE] with diagnosis that included need for assistance with personal care. Review of the Quarterly MDS dated [DATE], showed Resident 91 had mild cognitive impairment and required one-person physical assistance with bathing. In an interview with Resident 91 on 04/18/2023 at 2:20 PM, stated they had not been getting enough showers, and it had been 32 days between his last 2 showers. They stated their preference was to receive a shower at least every seven to ten days. Review of Resident 91's current care plan showed the resident's preference was to take a shower once a week and that he required extensive assist with bathing. Review of Documentation Survey Reports for bathing records showed they had received one shower in January on 01/12/2023, two showers in February on 02/07/2023 and 02/20/2023, one shower in March 03/10/2023 and one shower in April on 04/11/2023. 43954 RESIDENT 102 Resident 102 was admitted to the facility on [DATE] with diagnoses to include Amyotrophic Lateral Sclerosis (a disease that affects the nervous system, and spinal cord which causes progressive weakness and atrophy, (wasting) of muscles), depression, and muscle weakness. Review of Resident 102's Quarterly Minimum Data Set (MDS) (an resident assessment tool) dated 03/29/2023 showed that the resident is cognitively intact, did not reject care and that they were totally dependent for showers requiring one person assist. Review of Resident 102's care plan showed the resident requires 1-2 person assist for Activities of Daily Living (ADL's), and an intervention to notify the resident of day and time their bathing will take place and has required mechanical lift to move from bed to shower chair. Focus of preference and an intervention that the resident prefers two showers per week after breakfast. Review of Resident 102's Kardex (snapshot of care needs to direct NAC. dated 04/18/2023. showed that the resident was to be notified of day and time bathing would take place and prefers two showers per week after breakfast. Review of Resident 102's survey V2 documentation (NAC documention) on 04/24/2023 for February, March and April of 2023 that showed the resident had accepted bathing on 02/09/2023, and 02/21/2023 and that it was offered and refused on 02/10/2023, 02/17/2023, 02/27/2023. March 2023 documentation showed that the resident was offered 3 showers and refused all 3 on 03/06/2023, 03/17/2023 and 03/28/2023, all having 11 days in between offers. April 2023 showed that the resident refused a shower on 04/05/2023 and received a shower on 04/10/2023. In an interview on 04/18/2023 at 11:11 AM, Resident 102 stated that they have had one shower per month, and they would not ask for more since they don't even get one shower a week. In an interview on 04/19/2023 at 12:00 PM, Staff N, nursing aide registered (NAR) stated that the facility has shower aides and that they get pulled to the floor sometimes to work as an NAC and that if that happens, their shower is moved to another day, stated that the floor NAC working with the resident would not be responsible to complete it. In an interview on 04/24/2023 at 10:54 AM, Staff M, LPN, Nurse Manager (NM), stated that residents should have showers at least once per week, and if the shower aide is pulled to the floor to work as an NAC, then the showers should be caught up on evening shift. In an interview on 04/24/2023 at 2:00 PM, Staff O, NAC stated that when the shower aides get pulled to the floor that they will sometimes stay late to get showers done or the scheduled floor NAC can assist by giving the resident a shower or bed bath. 42927 RESIDENT 68 In a resident group interview on 04/21/2023 at 9:20 AM, Resident 68 stated that they went two weeks without a shower. Review of Resident 68's Health Wellness and Resident Preference care plan showed an entry, dated 08/24/2021, that resident wanted a shower twice a week. Review of the Documentation Survey Report, dated March 2023, showed that Resident 68 had two showers in March, on 03/09/2023 and 03/28/2023. Review of the Documentation Survey Report, dated 04/01-04/25/2023, showed that Resident 68 had two showers this month; 04/19/2023 and 04/24/2023. Resident 68 had been offered a shower on 04/10/2023 but declined at that time. Review of documentation showed no record of shower being reoffered. RESIDENT 84 In a resident group interview on 04/21/2023 at 9:20 AM, Resident 84 stated that they wait 5-20 days to get a shower. Review of Resident 84's Health Wellness and Resident Preference care plan showed an entry, dated 02/08/2021, that resident wanted a shower twice a week. Review of the Documentation Survey Report, dated March 2023, showed that Resident 84 had four showers in March, on 03/08/2023, 03/14/2023, 03/21/2023 and 03/30/2023. Review of the Documentation Survey Report, dated 04/01-04/25/2023, showed that Resident 84 has had only one shower on 04/11/2023. WAC reference 388-97-1060 (2)(c)

Based on observation, interview and record review the facility failed to implement written policy and procedure components of screening, prevention, protection, investigation and reporting abuse for 2 of 2 residents (1 and 2) reviewed for abuse. The facility failed to review the agency nurse references were verified and ensure adequate preparation and abuse training to meet the resident's needs. Facility staff failed to appropriately intervene and protect Residents 1 and 2. Failure to recognize abuse and implement the policy and procedure as required resulted in physical injury, mental abuse and corporal punishment for Resident 1 and placed all residents at increased risk for serious injury and psychological harm. Findings included: Review of the facility's Abuse Prohibition policy, dated 11/21/17, include the following: - systems, procedures and a program of employee training and supervision were in place to foster dignified treatment, respect and [MEDICATION NAME] for residents - any form of mistreatment of [REDACTED]. - the Administrator had overall responsibility and accountability and was the Abuse Prevention Coordinator - all applicants/employees must pass criminal background and reference check - all employees received upon hire and annually included training on the definitions of abuse/neglect, interventions to deal with aggressive and/or catastrophic reactions of residents - any staff member involved in potential abuse/neglect would be suspended pending the outcome of the investigation - if there was suspected abuse (including physical, verbal, or mental) .the mandated reporter, any witnesses, and the LN will contact the police, state hotline, and the DNS, ADNS or Administrator immediately. The policy identified physical abuse included pinching, controlling behavior through corporal punishment, non-accidental use of physical force that results in bodily injury, pain or impairment (including but not limited to bruising, skin tears ). Verbal abuse included disparaging and derogatory terms within hearing distance of residents regardless of the residents ability to comprehend. Mental abuse included humiliation and harassment. Review of the Maxim Staff Solutions agreement, dated 12/04/17, between the facility and Maxim Healthcare revealed Maxim will supply facility with personnel who meet the following criteria and will provide evidence of the following to facility upon written request: current skills competency to include (i) written exam; (ii) skills checklist; and (iii) verified work history. The facility will promptly provide Maxim personnel with an adequate and timely orientation to the facility and specific facility policies and procedures. RESIDENT 1 Resident 1 admitted to the facility August 2016 with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment, dated 12/22/17, the resident was cognitively impaired. On 12/23/17 at approximately 4:00 PM, an allegation of abuse occurred between Staff M, agency Registered Nurse, and Resident 1. Review of a written witness statement, Staff A, Nursing Assistant (NA), revealed on 12/23/17 at approximately 4:00 PM, Resident 1 was heard screaming in the hallway. Resident 1 was sitting her wheelchair and Staff M was administering medications to the resident. Resident 1 looked visibly upset and was trying to spit out her medication. Staff M stated to the resident you are being nasty. Resident 1 began to raise her arms to hit Staff M. Staff A walked over to the resident and placed her left hand on top of the resident's right hand and began to talk calmly trying to get the resident to relax. Staff M continued to administer the medication, with a spoon, into the resident's mouth. Resident 1 stated Ow your hurting me, let go! Staff A noticed Staff M was holding onto the resident's left hand with her thumb pressing down on Resident 1's skin. Staff M then stated to the resident I'll let go of you when you let go of me. Staff A witnessed Staff M dig her thumb nail into the back of the resident's hand. Staff M then let go of the resident's hand and stepped away and stated I don't give a rats ass if she takes them or not. Staff A noticed a huge blue bruise on the back of the resident's hand where Staff M had been holding. Staff A stated it was the size of a half dollar. Review of Staff M's written witness stated revealed she was attempting to administer Resident 1 her medicaitons when the resident became combative, trying to slap, bite and pinch. Staff M, to protect herself, pushed the resident's hand out of the way and held her hand away from her with an open palm. Staff M stated Resident 1 asked her to let go of her. Staff M she replied to the resident .calmly, let go of me and I'll let go right away . Staff M stated Resident 1 removed her hand. Staff M stated she was . significantly injured by a resident at another facility, so it was instinctual to put my hands out to protect myself . Review of Staff C, NA, written witness statement, dated 12/23/17, revealed The new nurse (Staff M) was having difficulty with Resident 1 and had aggressive body language towards the resident. The new nurse said statements such as She is spitting her medication all over herself. And I can't get her to take anything and it's not my problem .I did see that the new nurse would not approach at eye level or explain to Resident 1 what the situation was. This occurred between 3 & 4 PM. Aggressive body language constituted of a wide stance with shoulders back and hands on hips. Review of Staff D, NA, written witness statement, dated 12/23/17, revealed While using the East 1 bathroom, I could hear Resident 1 yelling and refusing medication. I heard the nurse yelling back and calling her nasty. She also yelled at her to calm down. I also heard Resident 1 say Ow. While still in the bathroom, I heard You're being nasty, calm down, and be quiet. After the incident, Resident 1 showed me the bruise and said, Can you believe that? The girl did this to me. Review of Staff E, NA, witness statement, dated 12/23/17 at 4:00 PM, revealed I walked out of a residents room and heard the nurse (Staff M) ask Resident 1 if she (Staff M) got her medication again, if she would take it. Resident 1 told her No. Staff M said, Well it's not any skin off my back and walked away. I didn't see any physical contact between the nurse and Resident 1 only verbal. Review of Staff F, NA, witness statement revealed Overheard the nurse (Staff M) talking to Resident 1. The nurse sounded agitated and said, Will you take your medicine if I go back to the cart. I won't do it if you won't take it. I also heard the F word but cannot clearly say with confidence exactly word for word for the reason .She (Staff M) walked away .I was in the process of getting dinner orders as she walked by I asked Are you ok with Resident 1? Do you need help? Sometimes the nurse needs us to help with medication to calm her down so you can give her medicine. She (Staff M) stated back something along the lines that it was not worth it or it doesn't matter. In a written statement from Staff G, NA revealed I could only see the nurses back and hear Resident 1 yelling. Review of the facility's incident/accident report summary, dated 12/23/17, listed precipitating factors identified: 1). Licensed nurse was not familiar with resident attempting to give medications and using tactile gestures to keep resident from strike her; 2). Upon review of statements from caregivers there was a pattern that caregivers noted the nurse was not familiar with the resident; the nurse was frustrated as evidence(d) by body language and comments to caregivers; 3). Caregivers did not provide appropriate guidance to the new nurse; it was witnessed by another resident at the scene who confirmed the residents was striking the nurse and has a pattern of striking staff; 4). Caregivers involved did not seek help or guidance from charge nurse to avoid altercation or injury. In an interview on 01/09/18 at 1:15 PM, Staff B, Licensed Practical Nurse/Assistant Director of Nursing, was asked what abuse and neglect training was completed prior to agency staff working with the residents. Staff B stated We had background info. And checks and I will call her agency to see if they have anything on this. At 1:33 PM, the Facility Clinical Consultant stated We identified an issue during this investigation. The agency nurse did not have competencies prior to working .the agency nurse was taking direction from the aides .the staff could have responded better. At 1:45 PM, the Director of Nursing (DNS) confirmed Resident 1 sustained a physical injury. She confirmed the facility did not verify her reference checks or ensure the agency nurse received abuse/neglect and mandatory reporting training prior to working unsupervised with vulnerable residents. The DNS stated That should be on the agency. At 3:30 PM, Resident 1 was asked if anyone ever hurt her. Resident 1 stated Well some little girl (short one) did it. She hit it. I was so surprised since she was so little. It is still tender right here as the resident was rubbing her left hand between thumb and forefinger. In a phone interview on 01/18/18 at 10:15 AM, Staff M stated I got one shift of orientation on same unit I worked. Basically they didn't warn me about this woman. The day before she didn't take her med's so I just circled them to document she refused. The day before she got agitated but not combative. I wasn't told how to approach her and no one told me she was combative. Staff M was asked why her approach was different on 12/23/17 from the day prior. Staff M replied the difference was she was combative this time, not just refusing. If I knew she was combative I would have been more cautious. I should have backed off sooner. Staff M confirmed she had no abuse and neglect training, reviewed any facility policy's or resident care plans prior to independently working with residents. She acknowledged she could have gone to the charge nurse or director with issues. Multiple staff failed to intervene when Staff M was observed to show signs of anger, aggression and agitation with the result of Resident 1 experiencing continued distress, hearing disparaging comments, and sustaining an injury. Staff failed to adequately intervene when Resident 1 exhibited verbally and physically aggressive behavior and was subject to emotional, verbal and physical abuse. The facility failed to identify that verbal and physical abuse had occurred. RESIDENT 2 Resident 2 admitted to the facility March 2017. She was alert and oriented and able to make her needs known. The incident investigation overview revealed On 01/07/18 at 10:30 AM, Staff J, NA, was told by Resident 2 of an incident that occurred that morning. Resident 2 stated to Staff J My aide (Staff K) had thrown a bed sheet at her and it was dirty at that. She is clumsy, trips on everything, doesn't walk with me to the bathroom, she is rough. She picks my legs up and drops them. Staff J informed Staff K, NA, what was said about her. Staff K informed Staff H, LPN/Charge Nurse, and Staff I, unit nurse. Staff H stated, Staff K came to him and stated she heard that Resident 2 had made a statement about her and that she did not want her to take care of her, she wanted someone else to assist her. Staff H informed Staff K .to switch out with another NA and have Resident 2 assisted with two staff members as she allows . Review of the written statement on 12/23/18 by Staff J, NA stated Resident 2 said Staff K had thrown her bed sheet and it was dirty at that. She says she is clumsy, trips on eveything. Resident 2 also said Staff K does not walk her to the bathroom. She is rough and picks her legs up and drops them. Staff K wrote a statement regarding this to the Administrator. On 01/07/18 around 10:00 AM, Staff K asked Staff L, Receptionist, if the Administrator was available. Staff L stated the Administrator was in a meeting and informed Staff K she would give the Administrator the letter, which was in a sealed envelope. The Administrator checked her mail around 4:00 PM. An investigation was started at that time. Review of a facility meeting quiz on 04/10/17 revealed Staff H completed a quiz on what is the first thing you do if you observe or suspect abuse. Staff H, wrote in Hotline/notify supervisors and protect the residents. Review of an abuse and neglect in-service signed by Staff H, with hand written title RCM (Resident Care Manager) on 12/27/17, confirmed acknowledgement of directives Supervisors role is protecting residents and starting investigation .Supervisors must immediately notify Administrator and or Director of Nursing. Review of a statement completed on 01/11/18 by Staff J, NA revealed, Description of what I failed to do a a mandatory reporter: Call hotline immediately # 2, #1 protect the resident , report to supervisor # 3. Review of the incident/accident report summary, dated 01/12/18, revealed The facility did identify that the staff members the day of the concern did not follow facility protocol for responding to allegations of abuse/neglect. Each of these staff members has been reprimanded, placed on probation for failure to follow proper response protocol and educated. Each of these staff members has articulated their response deficit and stated the correct course of action In an interview on 01/17/18 at 2:15 PM, The Administrator confirmed she received the allegation on 01/07/18 at 4:00 PM (over 5 hours after allegation reported) at which time the investigation was started. Reference: (WAC) 388-97-0640(1)

Based on observation, interview and record review, the facility failed to provide sufficient and competent staffing for dementia care for one of one residents (1) reviewed for resident abuse. This failure denied appropriate intervention when the resident was distressed and resulted in mental and physical harm to the resident and placed all residents at risk of abuse. Findings included: Resident 1 admitted [DATE] with [MEDICAL CONDITION] and major [MEDICAL CONDITION]. Review of Staff M, agency Registered Nurse, time sheets revealed she worked at the facility on 12/20/17 from 1:30 PM to 10:00 PM with another nurse in orientation. On 12/22/17, she worked 1:57 PM to 11:09 PM independently. On 12/23/17, she worked 2:00 PM and left at 5:30 PM pending investigation. In an interview on 01/09/18 at 1:15 PM, Staff B, Licensed Practical Nurse (LPN)/Assistant Director of Nursing, was asked what abuse and neglect training was completed prior to agency staff working with the residents. Staff B stated, We had background info. And checks and I will call her agency to see if they have anything on this. At 1:33 PM, the Facility Clinical Consultant stated We identified an issue during this investigation. The agency nurse did not have competencies prior to working .the agency nurse was taking direction from the aides .the staff could have responded better. At 1:45 PM, the Director of Nursing Services (DNS) confirmed Resident 1 sustained a physical injury. The DNS confirmed the facility did not verify her reference check or ensure the agency nurse received abuse/neglect and mandatory reporting training prior to working unsupervised. The DNS stated, That should be on the agency. In a phone interview on 01/18/18 at 10:15 AM, Staff M stated I got one shift of orientation on same unit I worked. Basically they didn't warn me about this woman. The day before she didn't take her med's so I just circled them to document she refused. The day before she got agitated but not combative. I wasn't told how to approach her and no one told me she was combative. Staff M stated I should have backed off sooner when Resident 1 became combative. Staff M confirmed she had no abuse and neglect training, policies or care plans prior to independently working with residents. Staff M acknowledged she could have gone to the charge nurse or director with issues. The facility lacked competent staff with the knowledge and skills sets to support and assist Resident 1 who was experiencing agitation and confusion by failing to verify competency and skill sets prior to unsupervised access to vulnerable residents. Staff M did not appropriately respond to Resident 1's distress when she exhibited aggressiveness and agitation as evidenced by yelling, striking out and pinching. Additionally, Staff M pushed Resident 1's hand away and failed to provide Resident 1 space and immediately react to Resident 1's statement Let go of me. Staff M statement revealed I replied let go of my arm and stop pinching me and I'll let go right away. Refer to CFR 483.12(a)(1)- F600 = Freedom from Abuse, Neglect and Exploitation Reference: (WAC) 388-97-1080 (9)

Based on observation, interview, and record review, the facility failed to implement a Dementia Care Plan which included interventions for 1 of 1 resident (1) reviewed for dementia with behaviors. This failure resulted in harm related to a pattern of behaviors which included agitation and refusal of care and no clear plan identified to direct staff on how to care for the resident. Findings included: Resident 1 admitted to the facility in August of 2016 with primary [DIAGNOSES REDACTED]. Review of the 12/23/17 facility investigation, Resident 1 was involved in an incident with Staff M, agency Registered Nurse. At approximately 4:00 PM, Staff M went to give medications to the resident when the resident became combative and was attempting to slap, bite and pinch Staff M. The nurse failed to react and respond appropriately to Resident 1's behavior resulting in continued distress and an injury. In a phone interview on 01/18/18 at 10:15 AM, Staff M stated she did not review care plans prior to working with the residents. Review of Resident 1's progress notes from 11/03/17 onward included nursing notes about observed agitated behaviors. Resident 1's care plan revealed a new At risk for injury to self and others care plan was developed on 12/26/17 after the incident. The care plan listed problem altered cognitive patterns related to memory issues ask yes/no questions, I have STM (short term memory) deficits, offer cues and reminders PRN, I keep my mind active with my TV family and friends, games, activities social hour, notify SS, LN, MD W/(with) changes to cognition or decreased participation with decisions, offer choices to simplify decision making and encourage independence. The care plan did not include specific dementia care approaches to guide staff how to care for the resident when she exhibited agitation, felt threatened as evidenced by slapping, yelling, biting, pinching or refusing medications. Specific interventions for taking medications and to seek further assistance with behaviors was added on 12/26/17. Review of a facility in-service dated 12/24/17 revealed, Resident has refusal behaviors that are not on care plan. Please fill out the columns as what works for you and what doesn't when working with the resident. Several staff identified calm tone of voice, getting down to her level, starting a conversation, talk very slow and clear as approaches that work for Resident 1. Approaches identified by staff as not working were listed as: telling her what to do, yelling, talking loudly, overcrowding and don't try and force things. The dementia approaches were added 3 days after the incident on 12/26/17 although the resident admitted with dementia on 08/17/16. Refer to CFR 483.12(a)(1)- F600 = Freedom from Abuse, Neglect and Exploitation Reference (WAC) 388-97-1060(1)

Based on interview and record review, the facility failed to assertively advocate for immediate emergency assessment services and demonstrate professional recognition that a resident was at higher risk for acute complications related to recent falls with head injuries and a critical anticoagulant (blood-thinning medication) level for 1 of 1 residents (1). Failure to fully recognize, analyze, and communicate all pertinent information to medical provider in order to promote timely emergent assessment services immediately after a third fall with head impact, and then the failure to recognize the value in extending the frequency of in-depth neurological assessments resulted in staff not timely identifying acute neurological changes and/or a delay in immediate emergency assessment and possible treatment for [REDACTED]. Findings include: Hematoma in Head Symptoms The symptoms of head injury can vary from almost none to loss of consciousness and coma. The symptoms may not necessarily occur immediately at the time of injury. While a [MEDICAL CONDITION] occurs at the time of trauma, it may take time for enough swelling or bleeding to occur to cause symptoms that are recognizable. Initial symptoms may include a change in mental status, meaning an alteration in the wakefulness of the patient. There may be loss of consciousness, lethargy, and confusion. http://www.medicinenet.com/hematoma/article.htm Resident 1 had resided at the facility for more than a year. The [DATE] Minimum Data Set assessment (MDS) of noted he had moderate cognitive deficits. His MDS dated [DATE] noted a decline indicating severe cognitive impairment. Resident 1 required 1 person extensive assist for activities of daily living, and received an anticoagulation medication (blood thinner). The resident had three falls with head injury/impact within 7 weeks; the most recent fall being [DATE]. Resident 1 had a preventable unwitnessed fall on [DATE] and sustained a hematoma (bruise & swelling) to his forehead. Neurological (neuro) assessments were done as per the facility's routine frequency with no change in condition noted. On [DATE] Resident 1 had a second preventable unwitnessed fall and sustained an abrasion to his left (L) eyebrow to which steri-strip bandages were applied. Neurological assessments were done as per the facility's routine frequency with no change in condition noted. On [DATE], a progress note indicated the bruising around the eye was resolving. The plan of care was revised to encourage the resident to stay in bed at nighttime or have the resident stay near staff if he chose to be in his wheelchair. On [DATE], the resident's anticoagulant medication dose was increased due to having a below normal INR level of 1.8 An INR (International Ratio) is a lab value used to establish baseline parameters for [MEDICATION NAME] therapy (a medication used to thin blood/prevent blood clots). The INR level should be monitored regularly while a resident is on [MEDICATION NAME] as the medication can cause major or fatal bleeding. The recommended INR range is usually between 2 - 3. A lower INR means the blood clots more quickly. When the INR is higher than the recommended range, the blood clots more slowly which increases the risk of bleeding. On [DATE], the resident was seen by a nurse practitioner (NP) due to possible symptoms of norovirus ([MEDICAL CONDITION] that causes vomiting and diarrhea). Orders were written for intravenous fluids for hydration and to monitor Resident 1's neurologic status due to his recent fall while on the anticoagulant medication. There was no specific neurologic assessment documentation for [DATE] - [DATE], other than notes indicating the resident was alert and oriented x2 with baseline confusion, denied having headache, dizziness or nausea. On [DATE], the resident's anticoagulant medication was held (not administered) for 1 day, due to an above normal INR level of 4.2 On [DATE] on day shift, the resident had an episode of emesis and was seen by another NP, who noted the resident's neurologic status appeared intact & had bruising to L face. An INR level collected that day came back at a Critical level of 7.4 and the NP ordered his anticoagulant medication be held for 2 days. The nursing progress note indicated the plan was to continue to monitor the resident for diarrhea, emesis and bleeding. That evening, a progress note indicated the resident was Alert & Oriented x2 (person & place) with baseline confusion .'has to be frequently oriented to time of day .and staff are anticipating his needs as resident is not using his call light at this time .resident will occasionally try to toilet and transfer by self . Plan to continue to monitor for loose stools, emesis, pain or nausea and signs of hyper/[DIAGNOSES REDACTED] '(specific monitoring for bleeding was not documented in note). On [DATE] at 7:15 pm (evening shift), Resident 1 had another preventable unwitnessed fall, and landed on his left side of body with head impact .Resident has bruising to L side of face & bruising to L hip Has full range of motion and bears weight .denies pain .Resident is normal per baseline, denies headache, nausea, dizziness. Neuro checks initiated and placed on alert charting .will continue to monitor for pain, post-fall, and continue neuro checks. Vital sign reading appeared within normal limits. The nursing note written by nurse Staff B did not describe the extent of Resident 1's facial bruising, in comparison to what had already been present from the previous [DATE] fall. The on-call NP was called and new telephone orders were written at 9 pm for blood tests to be drawn in the morning of [DATE], along with a scheduled INR & L hip x-ray. During an interview on [DATE] at 2:20 pm, Staff B said the resident seemed okay and seemed like his usual self after the fall on [DATE]. She said she followed and obtained the needed information as listed on facility incident form, such as descriptions, notifications, neuros, vital signs, etc. Staff B did not recall whether her phone call to the NP had any discussion regarding sending the resident out to the ER, just got orders for blood tests and hip x-ray because of a new bruise to his hip. During an interview on [DATE] at 2:20 pm, Staff C said that Staff B had asked her to help assess the resident after his fall on [DATE]. She said the resident was already back in bed and all she did was do a visual assessment for any injuries. Staff C said she observed that Resident 1 had a yellow bruise to the L side of his face and a purple bruise to his L hip, Staff B did all the rest of the stuff such as neuros, vitals, MD notification. Further review of the record revealed a night shift progress note of [DATE] at 7:18 am indicated the resident 'said he was all right and had no pain.' It was noted the resident was alert & oriented x2, had bruises on L side of face, and a large bruise on his L hip. The plan was to continue to continue to monitor neuros & signs of pain. Review of the neurologic assessment flowsheet initiated on [DATE] revealed the routine frequency(unless specified by an MD) was to do a neurological assessment every 15 minutes for the 1st hour, then every 30 minutes for 4 hours, then once an hour times 2, and then every shift for 72 hours. A neurological assessment included monitoring level of consciousness, (eye) pupil response, hand grasp, ability to move extremities, pain, vital signs, and observations such as nausea, vomiting, headache, or dizziness. Resident 1's neuro assessments were completed as per the routine frequency and did not indicate obvious changes in the resident's neurological status from up through night shift at 02:15 a.m. Per the routine frequency, the next neurological assessment was to be done once every shift starting with day shift [DATE]. According to facility documentation, Resident 1 was observed by the night nurse to be alert and able to receive an oral medication at 5 a.m. There was no documentation of an in-depth neurological assessment at that time. After that, staff indicated the resident appeared to be sleeping during several visual checks. Nursing staff did not attempt to wake Resident 1 up or physically evaluate him until around 9:30 am. During an interview on [DATE] at 1:15 pm, Staff A indicated he was familiar with Resident 1. He said the resident's morning routine had changed some in the past few months in that he used to get up at 6 am, but more recently had getting up later waking up for breakfast around 9 am wasn't unusual for him. Staff A indicated he had looked in on the resident several times on the morning of [DATE], 6:30 am & 7:30 am and the resident just looked like he was sleeping as per usual. But around 9 am, Staff A decided it was a good time to get his neuro & vitals for day shift, and when I went in there, there was something odd about his breathing. I didn't get any response from the resident when I called to him & touched him, then I took a look at his pupils and knew it was not good, and then did further assessment called MD, and he was sent to the ER. Further review of the record revealed a [DATE] progress note at 10:20 am that indicated at approximately 9:35 am, Staff A went to assess Resident 1's neuros and vital signs following his fall last evening. Resident 1 was found to be unresponsive to verbal or physical touch, pupils non responsive to light, with stable vital signs. The physician was notified and the resident was sent to the hospital at 10:10 am. A CT brain scan was done at 11: 08 am. The emergency room report documented the CT showed a massive [MEDICAL CONDITION] present that is a life-ending event. The resident was sent back to the facility, placed on comfort measures, and expired that evening. During an interview at 4 pm with a nurse manager, Staff D. Staff D said, she believed her staff did all what they were supposed to do: they assessed, called the physician, got orders, etc. She said the physician knew about the critical level INR, and didn't order that the resident be sent to the ER after the fall on [DATE]. Staff had done the neuros which were okay and staff checked on him. Resident (1) was able to take his medicine at 6 am the next morning, so the nurse had obtained neuroloic information that he wasn't throwing up and was able to swallow & talk. Staff continued to check on him until they found him unresponsive. Even then, family wasn't sure if they wanted him sent to the ER, but the MD said to send him. The ER did the scan and then family chose to have him sent back. You should talk to the NP about the resident. A telephone call to the NP on [DATE] at 11:22 am indicated NP was presently unable to provide any information. Review of the medical record did not reveal any facility medical provider notes in the medical record regarding the resident's condition on [DATE] or [DATE]. A fax form dated [DATE] at 19:15 to the resident's new physician indicated the resident had a fall landing on L side including head. It indicated there was minor physical injury of bruising to head, bruised swollen L hip, and that the following first aid was administered: neuro checks, orders from on-call provider for blood tests and hip x-ray. It did not list any additional information such as the resident's recent critical INR level or of his recent history of other falls with head injury/impact. The form had a statement indicating the fax was the chosen method of communication rather than by phone. The fax form did not provide a time or date of actual transmittal. A SBAR communication form/progress note dated [DATE] on 11:56 pm indicated a report to the physician was made. (The fall was at 7:15 pm) The SBAR did not clearly document when the physician was notified or by what format (phone versus fax). The SBAR indicated the resident fell landing on L side of body with head impact with bruising to face & L hip. It listed the [DATE] INR result, current vital signs, and noted mental status changes as not applicable. It did not document information regarding the resident's other recent falls with head injury. The form indicated a request for lab work & x-ray, it did not indicate a request for provider visit or transfer to hospital. There was no indication of any specific discussion(s) with a medical provider on [DATE] regarding whether Resident 1 should be sent out to be immediately, evaluated at a hospital after his third fall with head impact and/or whether his neurological checks should be completed more frequently for a longer period of time than the usual routine. Staff did not fully recognize, assessed, and communicated that Resident 1 was at a much higher risk for developing complications, such as neurological symptoms and/or internal bleeding, after having a 3rd unwitnessed preventable fall with head injury/impact in conjunction with a critically high INR level nor that staff advocated for more timely emergent services and/or more closely monitored Resident 1 with thorough neurologic assessments.

Based on observation, interview and record review the facility failed to maintain an effective Infection Control Program (ICP) for proper cleaning of blood glucose meters to prevent cross contamination and spread of infection. The failed practice placed 26 of 49 residents (2, 13, 17, 24, 28, 41, 55, 56, 63, 86, 97, 104, 109, 127, 130, 143, 153, 174, 182, 232, 233, 237, 241, 254, 256, and 261) reviewed for blood glucose monitoring at risk. Immediate Jeopardy was determined on 01/06/17 related to the deficient practice. Additionally, the facility failed to follow current standards of practice for suspected Norovirus outbreak, cleaning of coagulation meters (CoagChek), and failed to properly clean table tops in 1 of 4 dining rooms. These failed practices placed residents, staff and visitors at risk for infectious diseases. Findings include: BLOOD GLUCOSE METERS Review of the facility's Blood Glucose Monitoring policy dated 06/04/15 , directed the Licensed Nurse (LN) to disinfect the meter between each resident use with a germicidal bleach disinfectant wipe and allow meter to air dry. Review of the Even Care G2 Blood Glucose Monitoring System user's guide revealed the meter should be cleaned and disinfected between each patient and allowed to air dry. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. During review of medication storage, it was revealed the facility had 7 glucose meters, one meter on each medication cart. In interviews on 01/06/17, Staff A, B, C, D, E, and F, Licensed Nurse's (LN) stated they only used alcohol wipes to clean the glucose meters between resident uses. In an interview on 01/06/17 at 2:20 PM, Staff G, LN stated he cleaned the glucose meter with alcohol wipes at the end of his shift or when the meter was visibly soiled. In an interview on 01/06/17 at 3:48 PM, Staff H, LN, Staff Development stated all LN staff was in-serviced on cleaning of glucose meters in June 2015 and new employees were in-serviced when hired. In an interview on 01/06/17 at 3:48 PM, the Director of Nursing Services and Staff H, was unaware LN staff was not properly cleaning the glucose blood meters. In an interview on 01/17/17 at 9:50 AM, Staff H stated there was no in-service documentation regarding cleaning glucose blood meters since January 2015. RESIDENT RECORD REVIEW Review of the clinical records for Resident's 2, 13, 17, 24, 28, 41, 55, 104, 109, 153, 232, 237, 241, 256, 261, and 254 revealed their blood glucose was monitored four times a day. Review of the clinical record for Resident 130 revealed a [DIAGNOSES REDACTED]. Resident 130 received blood glucose monitoring four times a day. Review of the clinical records for Resident's 56, 86, 97 and 174 revealed their blood glucose was monitored two times a day. Review of Resident 233's clinical record revealed the resident had a [DIAGNOSES REDACTED]. Review of Resident's 63, 127, 143, and 182 clinical record revealed the resident's blood glucose was monitored one time a day. The facility failed to implement their own policy or follow the manufacturer's recommendations regarding cleaning multi-use meters placing all 26 residents at risk for blood borne infection transmission. The 7 LN's on duty on 01/06/17 did not recognize how to properly clean the meters after use. The facility had 2 residents with known blood borne diseases. The posted 08/26/10 FDA Safety Alert on finger stick devices and point of care (P(NAME)) blood testing devices (e.g., blood glucose meters) recommendation: Finger stick devices should never be used for more than one person. P(NAME) blood testing devices should be used only on one patient and not shared. If dedicating P(NAME) blood testing devices to a single patient is not possible, the devices should be properly cleaned and disinfected after every use as described in the device labeling. COAGULATION METERS Review of the CoaguChek manufacturer recommendations for cleaning of the meter, revealed the exterior and test strip guide of the meter was to be disinfected with 10% bleach solution or 70% [MEDICATION NAME] alcohol and allowed to dry for at least 10 minutes before performing a test. The test strip guide was to be opened and cleaned with a cotton tip swab and then allowed to dry for 10 minutes. In an interview on 01/20/17 at 10:33 AM, the Director of Nursing stated the facility had 5 CoaguCheck machines that were shared between residents, and staff was cleaning them with alcohol prep pads. She stated they were unable to use the Sani-Wipes and the alcohol wipes would not achieve the needed drying time. CONTACT PRECAUTIONS Norovirus is a highly contagious form of viral gastroenteritis causing nausea, vomiting and diarrhea. Clostridium Difficile is a spore forming bacteria causing diarrhea, fever and abdominal cramping. Both organisms are often spread through person to person contact with contaminated surfaces. Per the Centers for Disease Control (CDC), alcohol gel is considered ineffective for both Norovirus and Clostridium Difficile and the CDC recommendations to prevent the spread of infection are for healthcare workers to perform hand hygiene using soap and water. Contact Isolation precautions specific to [MEDICATION NAME] pathogens such as Clostridium Difficile and Norovirus must be posted and visible to all staff and visitors. In a joint interview with the DNS and Staff H on 01/17/17 at 10:36 AM , both stated the facility follows CDC guidelines. In an observation on 01/18/17 at 8:27 AM, one room with suspected Norovirus infection had no isolation precaution signage posted. A small cart outside the door included general instructions regarding personal protective equipment (PPE) such as gloves, gowns and masks with no specific instruction regarding what was needed for each particular patient. The instructions stated to wash hands or use hand sanitizer after removing PPE. In an observation on 01/18/17 at 11:00 AM revealed one room with active Clostridium Difficile (C.Diff) infection (room [ROOM NUMBER]) with a posted contact precautions sign on the door which directed staff to perform hand hygiene. The PPE instructions which instructed to wash hands or use hand sanitizer were outside the room. In an interview on 01/18/17 at 11:05 AM, Staff W, LN stated there had recently been an inservice led by Staff H for Norovirus and staff were instructed to wash their hands with soap and water. Staff W stated that although he was aware of the need to use soap and water for both C.Diff and Norovirus, the current signs indicated hand washing or hand gel could be confusing to staff or visitors. In an observation on 01/18/17 at 8:27 AM, Staff AA delivered a meal tray to a resident with suspected Norovirus and used only hand gel before leaving the room. In an interview on 01/18/17 at 8:54 AM, Staff H, Staff Development, stated the contact precautions sign for Norovirus and Clostridium Difficile should be on the door. This surveyor notified Staff H of the room lacking precaution signage on the door. Additionally, the PPE information on the rolling carts outside the rooms was inconsistent with CDC guidelines with respect to C.Diff, Norovirus and handwashing. Staff H provided no further information and stated that is what they have been using. WEST ASSISTED DINING ROOM In an observation on 01/18/17 at 8:38 AM, in the West Assisted Dining Room, the four table tops and the bedside tables used during the breakfast meal were not cleaned in-between residents. In an interview on 01/18/17 at 11:25 AM, Staff V, Restorative Aide stated, Usually the tables are wiped in-between residents. In the main dining room, the kitchen staff washes and wipes the tables in between residents. In the West Assisted Dining Room the Aides or the helping staff would wipe the tables in between residents with the wipes that are kept at the nurses station.

Based on observation, interview and record review for 1 of 1 resident (7) reviewed for dignity and for 1 resident (49) in 1 of 3 dining rooms (West Assisted Dining) observed, the facility failed to provide care and services including incontinent care and meal and beverage service in a manner that promoted and enhanced dignity. This failed practice placed Resident 7 and 49 at risk for frustration, feelings of diminished self-worth, and psychosocial harm. Findings include: RESIDENT 7 Resident 7 was admitted to the facility in February 2015 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed Resident 7 was dependent upon 2 staff for transfers, bed mobility, toileting, and hygiene. She required a Hoyer lift for transfers. Her Brief Interview for Mental Status revealed a score of 8 (moderate cognitive impairment). Review of the Care Area assessment dated [DATE] revealed Resident 7 was always incontinent of bowel and was unable to identify her toileting needs. On 01/17/16 at 11:26 AM, Resident 7 was observed sitting in her wheelchair in the day room talking to a staff member who was assisting another resident. Resident 7 smelled strongly of stool. At 1:14 PM, Resident 7 was observed sitting alone in the day room. She continued to smell very strongly of stool. At 1:28 PM, Resident 7 was sitting in the day room. She continued to smell strongly of stool. She stated she was hot and her back felt wet. An unidentified resident came in the room, grimaced and stated I have to get back to my room. At 1:55 PM, Resident 7 was still in the day room. She again smelled very strongly of stool. At 2:15 PM, Staff CC and EE, NA's used a Hoyer lift to transfer Resident 7 from her wheelchair to her bed. The incontinent pad under the resident was saturated with stool and her pants were visibly soiled with stool. Staff CC stated I came on shift and was told Resident 7 needed me. Staff CC and EE began caring for the resident when Staff H, Staff Development Nurse,(SD) entered the room and began helping the NA's. Stool was observed down the resident's legs and up her back, almost to her neck. The resident repeatedly stated I'm sorry during incontinent care. At 2:58 PM, the surveyor informed Staff H, SD, Resident 7 had been observed with the odor of stool since 11:26 AM. Staff H stated that she would be talking to the day shift NA's about this. On 01/17/17 at 3:53 PM the Director of Nursing Services (DNS) was informed that Resident 7 smelled strongly of stool since 11:26 AM and incontinent care had not been initiated until after 2:13 PM, close to 3 hours later. In an interview at 2:00 PM on 01/19/17, Staff H , SD stated the NA who saw her right after lunch confirmed she smelled like stool. Review of the facility Standards of Routine Resident Care included 3. Provide incontinent care to each resident after each incontinent episode. Review of the resident's current Bedside Kardex Report and the Care Plan revealed directive to Check and change my brief during rounds and as needed (PRN) to keep me clean and dry. Additionally, included in care plan goals for alteration in elimination of bowel was Resident will remain odor free and clean and dry as possible. In an interview on 01/19/17 at 11:25:04 AM, The DNS was asked for an update on the investigation regarding day shift NAC not changing resident in a timely manner on 01/17/17. She indicated someone was working on it. RESIDENT 49 Resident 49 admitted to the facility in August 2015 with [DIAGNOSES REDACTED]. In an observation on 01/18/17 at 7:53 AM, Resident 49 was sitting in the West Assisted Dining Area during the breakfast meal with ten other residents. The facility staff served the first breakfast tray at 7:54 AM to a resident sitting at an adjacent table from Resident 49. The staff served the second breakfast tray to a resident seated at Resident 49's table at 7:54 AM. The staff completed serving breakfast to all other resident's in the dining room by 8:06 AM except Resident 49. Resident 49 continued to sit in the dining room without anything to eat or drink, across from other residents while they ate their breakfast. At 8:16 AM Resident 49 asked, What happened to my breakfast? The resident asked again, at 8:29 AM, Staff U, NA stated, It is on the next cart. The facility staff served Resident 49's breakfast tray at 8:37 AM. The resident had been watching all other residents eat for 43 minutes without anything to eat or drink. Resident 49 requested a cup of coffee at 8:43 AM and again at 8:45 AM. The facility staff brought in a cup of coffee to the resident at 8:53 AM in a single handled cup with a lid; the resident stated, I am unable to drink out of this cup. At 8:57 AM, a suitable cup of coffee was brought to and accepted by the resident. In an interview on 01/18/17 at 11:25 AM, Staff V, NA Restorative Aide stated, Usually drinks are served first followed by the residents' meals. We just serve tables as the trays come out, the kitchen does not send all the trays at the same time. In an interview on 01/18/17 at 10:49 AM the resident stated, It is common not to be served in the dining room, it makes me feel terrible.

Based on observation, interview, and record review, the facility's administration failed to ensure a system for the cleaning of glucometers and failed to assure residents received dignified personal care. These failed practices resulted in harm for Resident 7 as referenced in F 241 and for Resident 267. Findings include: Refer to 42CFR 483.10(a)(1) - F241 Dignity and Respect of Individuality The administration failed to ensure the facility staff provided dignified care in a Manner acceptable to the reasonable person for 1 of 1 resident (7) reviewed for dignity. This failed practice resulted in psychosocial harm for Resident 7. Refer to 42CFR 483.65 - F441 Infection Control The administration failed to ensure the facility staff were maintaining an effective Infection Control Program (ICP) for proper cleaning of blood glucose meters to prevent cross contamination and spread of infection. This failure resulted in an immediate jeopardy for 26 residents.

Based on interview, and record review, the facility failed to ensure 1 of 3 residents (17) reviewed for accidents remained free of accident hazards and received adequate supervision and assistance to prevent accidents. The failed facility practice resulted in an avoidable incident and harm for Resident 17, who sustained a second degree burn on her right thigh. Findings include: Resident 17 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was alert and oriented. Observation on 10/25/12 at 10:00 a.m., revealed the resident was sitting up in bed, wearing a night gown that had spills on the chest area. A bedside table was in front of her. On top of the table were 4 cups with no handles and a pitcher filled with iced tea. The bed side table had many spills on it, the resident's floor was wet and sticky. When the resident was asked why the floor was sticky, she replied, "Oh, I probably spilled some iced tea." On 10/29/12, the resident was again observed to be sitting up in her bed, her bed side table in front of her bed. It had a pitcher of iced tea on top of it and 3 cups with no handles. The resident was observed to have spills down her shirt, on her lap, her bedside table and on the floor. In an interview with the resident on 10/30/12 at 11:00 a.m., the resident was observed to be lying on her bed. She had her bedside table in front of her bed. On top of the bedside table was a pitcher of iced tea, multiple cups with no handles filled with ice tea and an opened bottle of Mountain Dew. The table had liquid spills over it and the floor was again sticky. During the interview, the resident spoke about a burn incident and stated she was in a lot of pain. She stated on the day of the incident, she asked an aid to make her a "cup-o- noodle soup." When she was eating the soup, she lost her grip on it and the soup fell on to her lap. "It felt like it was cooking my lap." She further stated, "I have never experienced such pain." review of the resident's medical record revealed [REDACTED]. The spill resulted in a burn/blistered area. First aid was administered and a treatment order was received to apply a cream to the affected area until it healed. A second nursing noted dated 10/24/12 documented: blister from leg burn now broken open and causing increased pain. New orders received to give 1 extra Percocet (medication to relieve pain). A third nursing note dated 10/26/12 documented: burn blister on right thigh very dry and dressing does not stay in place. A large red area developed covering entire front of right thigh from blister to knee. New order received for treatment of [REDACTED].dressing removal very painful to resident. Review of the facility investigation dated 10/23/12, revealed that on 10/22/12 at approximately 5:30 p.m., staff heard the resident yell out loudly. Staff responded to the resident's room, the resident was screaming, stating she was burning. The staff noted a "cup of noodles" soup spilled on her bed and the floor. The resident had spilled the hot "cup o noodles" on her lap, resulting in a red, blistered area. On 10/31/12 at 2:20 p.m., the Nursing Assistant involved with the incident, NA G was interviewed. The NA stated, the resident asked her to warm the soup. NA G took the soup into the clean utility room and microwaved it for about a minute and a half. She then took the temperature of the soup and it was between 125 to 130 degrees Fahrenheit. NA G then took the soup to the resident's room and set it on the resident's bed side table. Approximately 10 minutes later the NA heard the resident scream. She went to the resident's room and saw the resident had spilled her soup on her leg. An abnormal involuntary movement scale assessment (AIMS) was completed on 9/18/12 (a month prior to the incident). This indicated the resident experienced involuntary spasmodic twitching or jerking of the hands. Review of the resident's clinical record revealed the resident had not been referred to Occupational Therapy (OT). In an interview with OT Staff H on 11/1/12 at 9:30 a.m., he stated that residents were referred to OT for assessments and treatment that included the areas of self-feeding and adaptable equipment. He further stated if a resident had a hot liquid spill, the nurse would refer the resident to OT and ST for evaluation. When asked if Resident 17 had been referred to OT, he stated "No, the resident has not been referred to us." Even though the resident's characteristics and abilities indicated the resident was at risk of a potential hot liquid spill, the facility failed to identify and address the hazard. .