Every finding on record at Lacamas Creek Post Acute

. Based on observations, interviews and record review, the facility failed to ensure that allegations of abuse were reported timely for 1 of 3 (Resident 1) sampled residents reviewed for abuse/neglect. This failure placed residents at risk for potential physical abuse, and a diminished quality of life. Findings included.Policy entitled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated September 2022, showed All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.Resident 1 was admitted to the facility on [DATE] for rehabilitation following hospitalization. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 09/29/2025, indicated that Resident 1 was cognitively intact.Review of Resident 1's Electronic Health Record (EHR) dated 11/08/2025, at 6:49 PM, showed a facility Registered Nurse (RN) documented in the progress notes that Resident 1 had told the night shift Licensed Practical Nurse about someone entering her room in the middle of the night, and by the afternoon she was stating that a huge black man who looked like Urkel and sometimes [NAME] had been repeatedly raping her over the course of the previous nine months of being in the facility, including multiple times that day. Resident 1 called 911 to state this, and they called facility saying that she had called and was suicidal.In an interview on 11/25/2025 at 1:49 PM Staff C, Social Services Director said she was not aware of any allegations of sexual assault made in the facility. Staff C said she would generally hear this information in a morning meeting or directly by staff.In an interview on 11/25/2025 at 2:01 PM Staff D, RN and Resident Care Manager (RCM) said they were not aware of an allegation of sexual assault. Staff D said they would hear about this type of concern directly from staff, or during the managers' meeting. Staff D said Staff B, Registered Nurse and Director of Nursing (DNS) would generally investigate an allegation such as this.In an interview on 11/25/2025 at 2:15 PM, Staff B, DNS said the facility did not report this allegation of sexual assault by Resident 1. Staff B said the facility did not think this was a real allegation because no staff fits the description of the alleged perpetrator.In an interview on 11/25/2025 at 2:52 PM with Staff A, Administrator said she was not aware of an allegation of sexual assault, and the DNS would know more. Staff A said Resident 1 had a history of hallucinating and this would likely be why the allegation was not reported. Staff A said they were going to report it right now.Reference WAC 388-97-0640(2)(b)(6)(a)

.Based on observations, interviews and record review, the facility failed to ensure that trauma informed care was integrated into the care plan for 1 of 3 (Resident 1) sampled residents reviewed for trauma informed care. This failure placed residents at risk of not receiving mental health (MH) interventions that therapeutically supported the resident and could lead to a diminished quality of life.Findings included.Policy entitled Trauma Informed Care and Culturally Competent Care, dated August 2022, showed Trauma-informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization.Resident 1 was admitted to the facility on [DATE] for rehabilitation following hospitalization. The Quarterly Minimum Data Set, an assessment tool, dated 09/25/2025, indicated that Resident 1 was cognitively intact.Resident 1's Pre-admission Screening and Resident Review (PASRR), dated 09/24/2025, indicated Resident 1 should have been evaluated for mental health services based on a mood disorder.Review of a Mental Health assessment dated [DATE], showed Resident 1 had a history of trauma from adolescence into adulthood.Reviews of Resident 1's Electronic Health Record showed no care plan for trauma informed care.In an interview on 11/25/2025 at 1:49 PM Staff C, Social Services Director said she was not aware of a history of trauma for Resident 1. Staff C said she would think the Psychology provider would inform the facility if there were concerns noted during sessions with the mental health provider. Staff C said she was unsure how the communication occurs for mental health service coordination. Staff C said the Resident Care Managers (RCM)s would likely be notified directly. In an interview on 11/25/2025 at 2:01 PM Staff D, RN and Resident Care Manager said they were not aware of the history of trauma for Resident 1. Staff D said the mental health provider meets with them directly prior to seeing patients on each visit. Staff D said she was not aware of how information would be shared if discussed by mental health. Staff D was not aware of concerns with suicidality or childhood trauma for Resident 1.In an interview on 11/25/2025 at 2:15 PM, Staff B, Registered Nurse and Director of Nursing, was not aware of Resident 1's trauma or mental health notes regarding suicidality. Staff B said she was not sure how the MH provider communicates with the facility to ensure concerns were included in the residents' care plan.Reference WAC 388-97-1620(2)(b)(i)(ii)

Based on interview, and record review, the facility failed to follow physician orders to obtain daily weights, for 2 of 3 sampled residents (Resident 1 and Resident 2), with diagnosis of heart failure. This failure placed the residents at risk of worsening heart failure, unmet care needs, and a diminished quality of life.Findings included . Resident 1Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment (an assessment tool), dated 08/04/2025, documented the resident had severe cognitive impairment and the Electronic Health Record (EHR) Medical Diagnosis list included congestive heart failure (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), chronic osteoarthritis (a degenerative joint disease leading to breakdown of cartilage in joints), and unspecified cognitive impairment. Record review of Resident 1's physicians' order, dated 7/30/2025, documented, Daily Weights: Weigh resident in the morning before breakfast and after first void, notify MD [medical doctor] if gains 3 pounds in 1 day or 5 pounds in 1 week. Record review of Resident 1's EHR Weight Summary, reviewed 10/07/2025, showed three occasions (09/18/2025, 09/21/2025, 09/22/2025) when Resident 1 was not weighed per physician orders. Record review of Resident 1's Treatment Administration Record (TAR), dated September 2025,, showed three occasions in September 2025 (09/18/2025, 09/21/2025, 09/22/2025) when Resident 1 was not weighed per physician orders; each date Resident 1's daily weights were omitted was accompanied by a documented chart code, 9, indicating, other/see nurses notes. Record review of Resident 1's Progress Notes, reviewed 10/10/2025, show no nurses notes on 09/18/2025, 09/21/2025, nor 09/22/2025 pertaining to the omission of daily weights. Resident 2Resident 2 was admitted to the facility on [DATE]. The 5-Day Minimum Data Set (MDS) assessment, dated 08/16/2025, documented the resident was cognitively intact and the Electronic Health Record (EHR) Medical Diagnosis list included unspecified heart failure (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). Record review of a physicians' order for Resident 2, dated 08/20/2025, documented, Daily Weights: Weigh resident in the morning before breakfast and after first void, notify MD if gains 3 pounds in 1 day or 5 pounds in 1 week. Record review of Resident 2's EHR Weight Summary since admission, reviewed 10/07/2025, showed six occasions in September 2025 (09/14/2025, 09/18/2025, 09/19/2025, 09/20/2025, 09/21/2025, 09/22/2025) when Resident 2 was not weighed per physician orders. Record review of Resident 2's Treatment Administration Record (TAR), dated September 2025, showed six occasions (09/14/2025, 09/18/2025, 09/19/2025, 09/20/2025, 09/21/2025, 09/22/2025) when Resident 2 was not weighed per physician orders; each date the daily weights were omitted was accompanied by a documented chart code. On 09/14/2025 the documented chart code was 7, indicating, sleeping. On 09/14/2025, 09/18/2025, 09/19/2025, 09/20/2025, 09/21/2025, and 09/22/2025 the documented chart code was 9, indicating, other/see nurses notes. Record review of Resident 2's Progress Notes, reviewed 10/10/2025, show no nurses notes on 09/14/2025, 09/18/2025, 09/19/2025, 09/20/2025, nor 09/21/2025 pertaining to the omissions of daily weight. A nursing note on 09/22/2025 said, not able to check resident's weight due to wheelchair scale is broken.In an interview on 10/10/2025 at 3:00PM, Staff B, Director of Nursing Services (DNS) and Registered Nurse (RN), stated that if a resident had an order to obtain daily weights, they should be taken daily as the resident allows. WAC 388-97-1060(1)

Based on interview and record review, the facility failed to notify the resident representative of a need to alter treatment significantly, for 1 of 3 sampled residents (Resident 1) reviewed for change in condition. This failure placed Resident 1 at risk of continued pain, unmet care needs, and a diminished quality of life.Findings included . Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment (an assessment tool), dated 08/04/2025, documented the resident had severe cognitive impairment and a BIMS (Brief Interview for Mental Status- a cognitive assessment) of 00/15 indicating, severe impairment. Resident 1's Electronic Health Record (EHR) Medical Diagnosis list included congestive heart failure (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), chronic osteoarthritis (a degenerative joint disease leading to breakdown of cartilage in joints), and unspecified cognitive impairment. Record review, completed on 10/07/2025, of Resident 1's EHR showed Resident 1 had a legal guardian.Record review of Resident 1's hospital physicians' Progress Note, dated 07/28/2025, showed Resident 1 had been diagnosed with bilateral knee pain related to chronic osteoarthritis.Record review of Resident 1's Physical Medicine and Rehabilitation Evaluation note, dated 07/31/2025, stated, Right knee osteoarthritis.hospital records indicate that she recently received an x-ray which showed right knee osteoarthritis.The patient was offered steroid injections for the right knee; however, she states that she did not want it as she is afraid of needles. Due to her intellectual disability, if she becomes more amenable to the idea of an injection or if she is unable to participate in physical therapy as a result of the knee pain, then I will reach out to her guardian to discuss consent for an injection.Record review of Resident 1's Physical Medicine and Rehabilitation Evaluation note, dated 08/12/2025, stated, Right knee osteoarthritis.hospital records indicate that she recently received an x-ray which showed right knee osteoarthritis. offered a right knee cortisone injection again; however, the patient is afraid of needles. The patient is eligible for right knee cortisone injection if or when she decides she wants one.Record review of Resident 1's Physical Medicine and Rehabilitation Evaluation note, dated 08/14/2025, stated, She [Resident 1] reports that she is still dealing with right knee pain. Right knee osteoarthritis. After reviewing multiple PT [physical therapy] notes, it is evident that her ability to participate in physical therapy is hindered by her right knee pain. Had a lengthy conversation with the patient today regarding injections and her safety concerns with them. Due to her cognitive impairment, I do not believe she fully understands the procedure and the potential outcomes, as she is still declining the procedure entirely.Record review of Resident 1's Physical Medicine and Rehabilitation Evaluation note, dated 08/19/2025, stated, The patient was crying upon arrival to her room. When asked why, she stated that her right leg hurts her. Right knee osteoarthritis.hospital records indicate that she recently received an x-ray which showed right knee osteoarthritis. Discussed a right knee injection once again and tried to address any potential concerns the patient may have regarding the procedure. The patient stated that she is afraid of needles and still denies the injection at this time. She was told that this injection may provide her with a significant amount of relief and given she seems to be very upset about this issue, it may greatly benefit her.Record review of Resident 1's Physical Medicine and Rehabilitation Evaluation note, dated 08/24/2025, stated, .she still has pain in her right knee, she has no other acute pain.pt [patient] after sitting becomes very emotional and starts crying due to knee pain. Right knee osteoarthritis.the patient remains apprehensive towards injections. She is eligible for one if or when she decidesRecord review of Resident 1's Physical Medicine and Rehabilitation Evaluation note, dated 09/09/2025, stated, She reports ongoing right knee pain. Right knee osteoarthritis.the patient remains apprehensive towards injections. She is eligible for one if or when she decidesRecord review of Resident 1's EHR, completed 10/07/2025, showed no documented notification from the facility to the guardian for Resident 1 regarding treatment options to address their right knee pain related to chronic osteoarthritis until a Progress Note, dated 09/17/2025-nearly seven weeks after admission, stated, This LN [licensed nurse] and SS [social services] spoke with guardian, guardian gave verbal consent to perform injection to knee for pain. Provider notified of consent and ordered injection.In an interview on 10/10/2025 at 3:00 PM, Staff B, Registered Nurse and Director of Nursing, confirmed Resident 1 had been diagnosed with an intellectual disability, had a BIMS of 00/15, had a legal guardian, and said the guardian should have been notified by the provider or RCM (Resident Care Manager) regarding treatment options and decisions to address Resident 1s' right knee pain related to chronic osteoarthritis.WAC 388-97-0320

Based on interview and record review, the facility failed to initiate bowel interventions for 1 of 5 residents (Resident 27) reviewed for constipation. This failure to initiate interventions placed residents at risk of discomfort, experiencing health complications and a diminished quality of life. Findings included.Record review of the facility policy, titled, Bowel Protocol, dated February 2019, showed it was the facility policy to monitor and provide interventions to ensure routine bowel elimination by residents of the facility. At the beginning of each shift the Licensed Nurse would pull the resident bowel management report and identify residents that had not had a bowel movement for three days. The Licensed Nurse would review the residents Medication Administration Record to determine if the as needed bowel protocol had been initiated by the previous shift. Residents that did not have a bowel movement for three days would be given Milk of Magnesia (medication to help with constipation). If there was no bowel movement by the next shift, a Dulcolax suppository (medication to help with constipation) would be given. If a resident exceeded four days without a bowel movement, the licensed nurse would complete an abdominal assessment, and the physician would be notified.Resident 27 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 05/29/2025, showed Resident 27 was alert and oriented. Review of the Bowel Movement (BM) task sheet, dated 06/25/2025 through 07/24/2025, documented Resident 27 had a BM on 07/01/2025 at 4:29 AM. Resident 27's next BM was on 07/05/2025 at 1:59 PM, approximately 105.5 hours since the last BM.Review of Resident 27's Medication Administration Record, dated July 2025, did not show documentation of medication intervention for no BM after 72 hours. In an interview on 07/24/2025 at 1:31 PM, Staff F, Registered Nurse, said the bowel protocol should be initiated 72 hours after the last BM. In an interview on 07/24/2025 at 1:35 PM, Staff B, Director of Nursing Services/Registered Nurse, said the bowel protocol should be initiated 72 hours after the last BM. Staff B said after reviewing the medical records the bowel protocol for Resident 27 should have been initiated on 07/04/2025. Reference WAC 388-97-1060(1)(3)(c)

Based on interview and record review, the facility failed to provide assistance with completing the advance directives (AD); and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for 1 of 5 sampled residents (Resident 27) reviewed for ADs. This failure placed residents at a potential risk for losing their right to have their healthcare preferences and/or decisions honored.Findings included.Resident 27 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (an assessment tool), dated 05/29/2025, showed Resident 27 was alert and oriented. Record review of Resident 27's Social History Assessment, dated 11/26/2024, documented Resident 27 was their own responsible/legal guardian, had a Living Will and Do Not Resuscitate (DNR).Record review of Resident 27's electronic record did not have documentation the advanced directive had been reviewed on a quarterly basis.In an interview on 07/24/2025 at 9:51 AM, Staff E, Social Services Director, stated advanced directives were reviewed quarterly and annually for long term residents. Staff E stated advanced directives were reviewed during the care conference which were reviewed quarterly and annually. Staff E stated she could not find any additional information regarding an advanced directive for Resident 27.Reference WAC 388-97-0280(3)(c)(i)

Based on observations, interviews and record review, the facility failed to implement infection control practices when providing wound care for 1 of 1 residents (Resident 28) reviewed for pressure ulcers. This failure placed residents at risk for potential infection and a diminished quality of life. Findings included.Resident 28 was admitted to the facility on [DATE]. The Medicare quarterly Minimum Data Set assessment, dated 07/09/2025, documented Resident 28 was severely cognitively impaired and dependent for activities of daily living. Record review of Resident 28's electronic health record, titled, UNITED WOUND HEALING Wound, Ostomy, Lymphedema, Burn, and Dermatological Medicine, dated 06/18/2025, documented Resident 28 had an unstageable bilateral sacrococcyx [tail bone] pressure ulcer.Record review of Resident 28's physician's order, dated 07/02/2025, documented, Wound care: Bilateral sacrococcyx c/f [concerning/for] terminal skin failure - Cleanse wound with NS [Normal Saline]/Wound cleanser and gauze - Treat periwound [around the wound] with skin prep and allow to dry - Apply anasept gel to the wound bed, followed by collagen - Cover with bordered dressing Change: Daily and as needed for accidental removal, saturation and/or soiling as needed for soilage, dislodgement.In an observation on 07/24/2025 at 12:55 PM, Staff D, Resident Care Manager/Licensed Practical Nurse (LPN), provided wound care to Resident 28. Staff D had a clean field [clean area with wound supplies] set up on Resident 28's bedside table. Staff D was observed moving wound dressing packages from the clean field and placed them on Resident 28's bed. Staff D proceeded to open the dressing packages and provide wound care. Resident 28 was observed to have a bowel movement (BM). Staff D provided incontinence care and proceeded to apply anasept gel to the wound bed. Staff D was asked if Resident 28's wounds needed to be cleansed after having a BM and prior to applying Anasept gel to the wound. Staff D stated, I probably should clean it, and proceeded to clean the wound with NS.In an interview on 07/25/2025 at 10:29 AM, Staff C, Infection Control Nurse/LPN, said it was the expectation when licensed nurses provided wound care, they maintained a clean field and reclean sacral wounds with NS or wound cleanser if a resident had a BM.Reference WAC 388-97-1320 (2)(a)

Based on observation, interview and record review, the facility failed to ensure bed rails were securely fastened to the bed and without gaps between the mattress and bed rails for 1 of 3 sampled residents (22) reviewed resident beds. This failure placed residents at risk for injury. Findings included . Resident 22 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 07/28/2024, indicated Resident 22 was moderately cognitively impaired. The bed rail care plan, revised 08/29/2024, indicated, bilateral 1/4 side rails to aid in bed mobility and to increase independence. On 09/23/2024 at 2:46 PM, Resident 22's left side bed rail was observed to be loose. The bed rail had approximately 9 to 10 inches of movement. On 09/27/2024 at 8:50 AM, Resident 22's left side bed rail was observed to be loose. The bed rail had approximately 9 to 10 inches of movement. At 8:57 AM, Staff I, Resident Care Manager and Registered Nurse, said the nursing assistants and floor nurses were supposed to monitor bed rails and report to maintenance if there were issues. At 9:16 AM, Staff J, Maintenance Director, said he tried to audit bed rail every other week. Staff J said the clip had popped out causing the bed rail to be loose. Reference WAC 388-97-2100

Based on interview and record review, the facility failed to ensure facility staff received Dementia training for 1 of 5 sampled staff (F) reviewed for staff in-service trainings. This failure placed residents at risk for receiving necessary care from unskilled staff. Findings included . Staff G, Nursing Assistant, was hired on 03/29/2014. Provided training or in-service training records did not show Dementia training was completed over the past year. On 09/26/2024 at 2:51 PM, Staff H, Staff Training Coordinator, said dementia training was covered in the new employee orientation and then annually. An email from Staff A, Administrator, dated 09/30/2024 at 9:49 AM, noted, Staff G should've had it [dementia training] as she's been a long standing employee so that is an error on us. Reference WAC 388-97-1680(2)(b)

Based on interview and record review, the facility failed to explain the arbitration agreement in a manner that residents understood for 2 of 3 sampled residents (28 & 46) reviewed for arbitration agreement. This failure placed residents at risk of forfeiting their right to a trial without consent, lack of adequate resolution of violation of rights and a diminished quality of life. Findings included . 1) Resident 28 signed the Alternative Dispute Resolution Agreement on 02/16/2024. On 09/27/2024 at 1:51 PM, Resident 28 said she did not recall signing the arbitration agreement document. Resident 28 said her daughter handled that kind of stuff. 2) Resident 46 signed the Alternative Dispute Resolution Agreement on 09/10/2024. On 09/27/2024 at 1:38 PM, Resident 46 said she did not recall signing such a document and said her sister was her Power of Attorney (POA). At 1:58 PM, Collateral Contact 1 (CC1), POA, said Resident 46 should not be signing legal documents because she did not know what she was signing. CC1 said Resident 46 had gotten herself into trouble because people had taken advantage of her. At 2:22 PM, Staff F, Marketing Director, said the arbitration agreement was the last thing she covered during the admission's paperwork. Staff F said she went over the arbitration agreement with the resident or their POA before having them sign the paperwork. When asked about the revocation clause, Staff F said she was not aware of what it was. No Reference WAC

Based on interview and record review, the facility failed to complete performance reviews for 1 of 2 sampled Nursing Assistants (NA) (Staff G) whose personnel and training record were reviewed. These failures placed residents at risk for receiving care from unskilled staff. Finding included . Staff G, NA, was hired on 03/29/2014. Staff G's personnel records did not have a Performance Evaluation for the previous year. On 09/26/2024 at 3:40 PM, Staff A, Administrator, said she was not able to locate a performance evaluation for Staff G. Staff A said performance evaluations should be completed annually. Reference WAC 388-97-1680 (2)(b)(i)

Based on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 2 of 6 sampled residents (5 & 32) reviewed for quality of care. This failure placed residents at risk for discomfort, health complications and a diminished quality of life. Findings included . Per Facility Bowel Management Policy, entitled Bowel Protocol, updated 02/2019: 1. At the beginning of each shift (based on an eight-hour shift), the Licensed Nurse will pull the Resident Bowel Management Report and identify residents that have not had a BM for 3 days. (please run the report for last 7 days and check the box Include residents regardless of Bowel Alert Status). The Licensed Nurse will review the residents MAR to determine if the PRN Bowel Protocol had been initiated by the previous shift. Bowel movements are charted every shift by CNA (Certified Nursing Assistant). 2. Residents who have not had a bowel movement in three days will be given Milk of Magnesia. 4. If no bowel movement by the following shift, a Dulcolax suppository is given. 5. If resident continues without bowel movement by the next shift a Fleets enema will be given. 1) Resident 5 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment, dated 08/12/2024, documented the resident was alert and oriented. The Bowel and Bladder Elimination task sheet showed Resident 5 had a Bowel Movement (BM) on 08/29/2024 at 9:59 PM, and did not show another BM until 09/14/2024 at 1:59 PM, over 15 days since his last documented BM. The Bowel and Bladder Elimination task sheet showed Resident 5 had a BM on 09/19/2024 at 8:04 PM, but did not document another BM (as of 09/24/2024 during the survey process). Review of Resident 5's August 2024 and September 2024 Medication Administration Record (MAR) showed the bowel protocol was not initiated. 2) Resident 32 was admitted to the facility on [DATE]. The Annual MDS assessment, dated 07/23/2024, documented the resident was alert and oriented. The Bowel and Bladder Elimination task sheet documented Resident 32 had a BM on 09/08/2024 at 9:59 PM, and did not have another BM until the evening of 09/12/2024, over 90 hours since his last BM. Review of Resident 32's September 2024 MAR showed the bowel protocol was not initiated. On 09/27/2024 at 2:29 PM, Staff K, Registered Nurse (RN), said after three days of no BM, the resident is to be started on either Miralax (a laxative) or Senna (a laxative), and if not effective, a suppository. Staff K was unable to provide documentation of BM protocol being initiated for both Residents 5 and Resident 32. Staff K stated, I am not seeing alert charts for them. We would document this on the MAR. At 12:14 PM, Staff B, Director of Nursing Services and RN, said the BM protocol should have been triggered per policy. Staff B was unable to provide documentation of bowel interventions being initiated for Residents 5 and Resident 32. Reference WAC 388-97-1060 (1), (3)(c)

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected residents' health status and/or care needs for 3 of 21 sampled residents (39, 41, & 59) reviewed for assessment accuracy. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . 1) Resident 39 was admitted to the facility on [DATE]. The Significant Change MDS assessment, dated 07/14/2024, showed Resident 39 was moderately cognitively impaired and was not receiving hospice care. Review of Resident 39's physician orders, dated 07/09/2024, documented, Admit for Hospice End of Life Care. Review of Resident 39's care plan documented, The resident has a terminal prognosis r/t [related to] acute kidney failure with no further treatment wanted. Hospice/comfort care only . Date Initiated: 07/09/2024 . On 09/23/2024 at 3:55 PM, Resident 39 said she was on hospice. On 09/27/2024 at 10:08 AM, Staff C, Resident Care Manager (RCM) and Licensed Practical Nurse (LPN), said Resident 39 was on hospice. Staff C said hospice was not marked on the Significant Change MDS. At 10:36 AM, Staff C said hospice visited Resident 39 on 07/08/2024. Staff C stated, Hospice should have been marked on the MDS. That was incorrect. 2) Resident 41 was admitted to the facility on [DATE]. The Quarterly MDS assessment, dated 08/07/2024, showed Resident 41 was alert and oriented, and received 7 days of insulin (a medication used to help regulate blood sugar levels and used to treat diabetes) injections during the last 7 days. Record review of Resident 41's Electronic Health Record (EHR) did not show a diagnosis of diabetes, a physician orders for insulin, or a care plan for diabetes or insulin. On 09/23/2024 at 3:14 PM, Resident 41 said she was not on insulin. On 09/27/2024 at 10:19 AM, Staff D, RCM and LPN, said she did not think Resident 41 was ever on insulin and would need to look at Resident 41's EHR. At 10:27 AM, after checking Resident 41's EHR, Staff D said Resident 41 was not on insulin and stated, The MDS was incorrect. 3) Resident 59 was admitted to the facility on [DATE]. The Admission/Medicare - 5 day MDS assessment, dated 09/13/2024, documented Resident 59 was severely cognitively impaired and used bed rail physical restraints daily. The MDS assessment documented in the Care Area Assessment Summary, [Resident 59] currently has 1/4 rails for bed mobility independence . Record review of Resident 59's Admission Summary progress note, dated 09/07/2024, documented, .Bed side rails assist with bed mobility and aids in assisting during personal care . Record review of Resident 59's Informed Consent, dated 09/11/2024, documented, .1/4 mobility rail . increased independence with bed mobility . improved independence with ADLs [activities of daily living] . Record review of Resident 59's impaired functional mobility care plan, dated 09/11/2024, documented, .Bed Rails/Device: 1/4 rails to aid with bed mobility . On 09/24/2024 at 10:09 AM, Resident 59's bed was observed with quarter length padded rails on both upper sides of the bed. On 09/25/2024 at 2:23 PM, Resident 59 was observed lying in bed on his back with quarter length padded rails on both upper sides of the bed. On 09/26/2024 at 8:30 AM, when asked about the quarter length rails on his bed, Resident 59 said he used them to help move around in bed. Resident 59 said the rails do not get in his way or keep him from moving around or getting in or out of bed. At 1:47 PM, Staff D said Resident 59's quarter bed rails were used to aide with bed mobility and stated, [Resident 59's bed rails] are not considered a restraint. At 1:51 PM, Staff B, Director of Nursing Services and Registered Nurse, said if it was determined bed rails were used as enablers to assist with bed mobility, it should not be coded as a restraint on the MDS assessment stating the MDS .will need to be modified. On 09/27/2024 at 12:09 PM, Staff A, Administrator, said it was her expectation the MDS assessment was coded to accurately reflect the resident. Reference WAC 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when medications were not administered in accordance with provider orders for 2 of 6 sampled residents (Residents 1 & 2) reviewed for significant medication errors. This failure placed residents at risk of adverse medical conditions, a change in health condition and a diminished quality of life. Findings included . Review of the facility policy Medication Administration-Errors, dated 11/2004 and revised 02/2019, noted, Policy: It is the policy of this facility that practices will be in place to ensure . 2. Residents are free of any significant medication errors . Medications will be prepared and administered in accordance with: 1. Physicians orders . 3. Accepted professional standards and principles which apply to professionals providing services . 1) Resident 1 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm leading to blood clots in the heart and increases risk of stroke and heart failure) and hypertension (elevated blood pressure which increases the risk of heart attack and stroke). Review of Resident 1's April 2024 Medication Administration Record (MAR), a comprehensive record of medication orders and the medications administered to a resident, showed on 04/09/2024 at 10:00 PM, the following medications were omitted/not administered: -Apixaban, 5 milligram (mg), ordered to address atrial fibrillation. -Metoprolol 12.5 mg, ordered to address atrial fibrillation and hypertension. 2) Resident 2 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the prostate and bone (prostate cancer and bone cancer), neoplasm related pain (pain from cancer), benign prostatic hyperplasia (enlarged prostate gland resulting in urinary frequency), hypertension (elevated blood pressure increasing the risk of heart attack and stroke), and gastro-esophageal reflux (occurs when stomach acid repeatedly flows into the esophagus irritating the lining of the esophagus). Review of Resident 2's March 2024 MAR showed on 03/06/2024 at 6:00 AM, the following medications were omitted/not administered: -Amlodipine 10 mg, ordered to address hypertension. -Methadone HCI 5 mg, 2 tablets, ordered to address pain. -Omeprazole 20 mg, ordered to address gastro-esophageal reflux disease. -Tamsulosin HCI 0.4 mg, ordered to address benign prostatic hyperplasia. -Tizanidine HCI 2 mg, 2 tablets, ordered to address muscle spasms and pain. -MiraLAX 17 grams, ordered to address bowel health. On 04/29/2024 at 3:15 PM, Staff B, Director of Nursing Services, said if there was a valid reason a resident had not been administered their medication, there would be a progress note written. When asked about Resident 1's medication omissions per the MAR on 04/09/2024 for Apixaban and Metoprolol, Staff B said she could not locate any progress notes explaining why the medications were not administered. When asked about Resident 2's medication omissions per the MAR on 03/06/2024 for Amlodipine, Methadone, Omeprazole, Tamsulosin, Tizanidine, and MiraLAX, Staff B said she could not locate any progress notes explaining why the medications were not administered. At 3:15 PM, Staff A, Administrator, said these medication errors are a practice we need to correct. We need to do right by the residents. Reference WAC 388-97-1260 (3)(k)(iii)

Based on observation and interview, the facility failed to ensure food preparation dishes were properly cleaned and air dried to provide safe, sanitary food preparation when the kitchen was reviewed for sanitization and storage. This failure placed residents at risk of foodborne illness and a diminished quality of life. Findings included . On 10/23/2023 at 10:30 AM, observations showed a rack of food preparation dishes including wet quarter pans and wet 6-inch pans stacked on top of each other; stacking of the wet pans would not allow for required air drying. Additionally, two quarter pans were noted to have food debris in the bottom and on the sides of the dish. At 10:45 AM, Staff U, Food and Nutrition Services Manager, observed the stacked wet food preparation dishes and the food debris in the dishes and said that the dishes in the rack were supposed to be clean and dry. Staff U said that the dishes were quarter pans and 6-inch pans, and they were used for food preparation for resident meals. Reference WAC 388-97-1100 (3), -2980

Based on interview and record review, the facility failed to ensure comprehensive care plans were individualized to promote the highest physical, emotional and psychosocial well-being and failed to ensure an anticoagulant care plan was in place for 4 of 7 sampled residents (2, 4, 8 & 45) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a negative impact on their quality of life. Findings included . 1) Resident 2 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 09/14/2023, documented Resident 2 was incontinent of bowel and bladder. Review of Resident 2's Care Plan, dated 09/26/2023, showed interventions requiring editing, as indicated by the word SPECIFY within the Care Plan, had not been edited with individualized resident information. The care plan did not show individualized interventions. 2) Resident 4 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 4 had psychiatric mood disorders, and neurological diagnoses. Review of Resident 4's Care Plan, dated 09/19/2023, showed the intervention of monitoring target behavior symptoms required editing, as indicated by the word SPECIFY within the Care Plan, had not been edited to include individualized resident behavior symptoms. This care plan did not show individualized interventions. 3) Resident 45 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 45 was cognitively intact. Review of Resident 45's Care Plan, dated 10/24/2023, showed interventions requiring editing, as indicated by the word SPECIFY within the Care Plan, had not been edited with individualized resident information. This care plan did not show individualized interventions. On 10/26/2023 at 11:25 AM, Staff B, Director of Nursing Services and Registered Nurse, said the Resident Care Managers (RCMs) wrote the care plans and the expectation was care plans were individualized. At 2:06 PM, Staff M, RCM and Licensed Practical Nurse, said care plan interventions should be individualized. After reviewing the care plans with interventions requiring editing, as indicated by the word SPECIFY within the care plan, Staff M said these areas of the care plan should have been edited to include individualized information. 46244 4) Resident 8 was readmitted to the facility on [DATE] with diagnoses including stroke, difficulty expressing himself with verbal communication, and dementia. The quarterly MDS, dated [DATE], showed Resident 8 was unsteady while walking, was assessed to have two or more falls in the last quarter, and received an anticoagulant daily. Review of Resident 8's orders showed a prescription, dated 01/23/2023, for a twice daily anticoagulant. Review of Resident 8's electronic medical record did not show a care plan addressing anticoagulant therapy. On 10/27/2023 at 8:44 AM, Staff M said if a resident admitted with an anticoagulant, the care plan was triggered by the MDS, then the RCM reviewed and made changes as needed. Staff M was observed pulling up Resident 8's care plan, which pulled up a different view from the previously reviewed care plan. Staff M said her version showed the issue 'anticoagulant therapy' but failed to include a goal or interventions. Staff M said Resident 8 should have had an anticoagulant care plan. At 9:48 AM, Staff B said an anticoagulant care plan should have been in place for Resident 8. Reference WAC 388-97-1020 (1)(2)(a)(b)

Based on observation, interview and record review, the facility failed to ensure there was an activity program to meet individual resident needs for 3 of 3 sampled residents (26, 17 & 51) reviewed for activities. This failure placed residents at risk for becoming bored and depressed when not provided meaningful engagement throughout the day, and a diminished quality of life. Findings included . A facility policy, entitled Activity Assessment and Documentation, dated January 2012 and revised March 2019, documented, The AD [Activity Director]/designee assures that participation records are completed for each resident as well as level of engagement . All participation records will be kept according to state regulation. PCC [an electronic medical record program]: Participation records are recorded and stored in EHR [electronic health record]. 1) Resident 26 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 08/25/2023, documented the resident was severely cognitively impaired. Resident 26's Activities Care Plan, dated 02/20/2023, documented, The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs. The interventions included, [Resident 26] enjoys TV, music, one to one, visits from friends and family, some reading, some group activities, and snacks. Resident 26's Activity Logs, dated 09/25/2023 to 10/25/2023, documented one activity on 10/19/2023 which was documented as an off-site outing. On 10/23/2023 at 3:04 PM, Resident 26 said she was not happy with the amount of activities in the facility. Resident 26 said she found herself being bored in her bed all the time. On 10/25/2023 at 8:49 AM, Resident 26 was observed in bed with the television (TV) on. Resident 26 asked the surveyor to turn off the TV and stated she was not a big TV watcher. Resident 26 said she did not know what activities were taking place today, and she hoped someone would tell her about the activities taking place that day. At 1:47 PM, Resident 26 was observed in her room, eyes closed with the TV on. A activity calendar or list of activities was not observed in the resident's room. At 8:16 PM, Resident 26 said she was bored and was not ready to sleep, though the room light was observed turned off. Resident asked the surveyor to turn on her room lights. On 10/26/2023 at 8:55 AM, Staff G, Activities Director, said Resident 26 liked group activities when she first admitted to the facility, but would appear to get anxious and want to leave the room. Staff G said she would then perform 1:1 (one to one) activities such as listening to music or going outside with the resident. Staff G said 1:1 activities were hard to do daily. Staff G said the resident would participate in religious services on Tuesdays. Staff G said Resident 26's family also had concerns about the resident's activities. When asked about where resident activities were documented, Staff G said she would document in PCC under progress notes. Staff G was unable to provide a progress note related to activities for Resident 26. When asked how many activity encounters residents should receive, Staff G was unable to verbalize a goal for resident activity encounters. At 9:32 AM, Staff B, Director of Nursing Services and Registered Nurse, said resident activity encounters should be documented in POC (plan of care) charting. At 9:47 AM, Staff A, Administrator, said residents should be receiving three documented activity encounters per day. Staff A said she reviewed Resident 26's activity log, and documentation for Resident 26's activities had not been happening. 46244 2) Resident 17 was admitted to the facility on [DATE]. The annual MDS, dated [DATE], showed Resident 17 was moderately cognitively impaired and felt it was very important to have access to books and do favorite activities. Review of Resident 17's Activities Care Plan, dated 08/24/2022, showed staff were to invite her to group activities and provide her with an activities calendar. Resident 17's Activities Task sheet showed Resident 17 participated in two activities from 09/26/2023 to 10/26/2023. On 10/23/2023 at 3:36 PM, Resident 17 said she did not have activities in her room or have them as a group. Resident 17 said no one brought her an activities calendar. Resident 17 was observed to have several piles of books in her room. Resident 17 said it would be nice if they exchanged them because she liked to read. Resident 17 said she had read all the books in her room. On 10/26/2023 at 8:40 AM, Staff G, Activities Director, said there was no coverage for her when she was gone. Staff G said Resident 17 had a lot of books and had not said anything about needing new ones. Staff G said they frequently went to the library, and residents went to library or she took a list of books for residents. At 9:36 AM, Resident 17 said she did not know what the last facility activity was; she had not been invited. Resident 17 said she would like to go to bingo. When asked how she knew when activities were occurring, Resident 17 stated, I just know. Resident 17 said she did not have an activities calendar. Resident 17 said no library services were offered and she would like a book exchange. No activities calendar was observed in the room for Resident 17 or her roommate. Review of October 2023 activity calendar showed Bingo was scheduled for Thursday 10/26/2023. 3) Resident 51 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 51 was moderately cognitively impaired and felt it was very important to participate in his favorite activities. Resident 51's Activities Task sheet showed Resident 51 participated in two activities from 09/26/2023 to 10/26/2023. On 10/24/2023 at 9:35 AM, Resident 51 said for activities he watched cars in the parking lot and watched TV. Resident 51 said he did not know the activities staff. On 10/25/2023, there was not any activity staff observed at the facility. On 10/26/2023 at 8:40 AM, Staff G, Activities Director, said there was no coverage for her when she was gone. Staff G said she provided Resident 51 with snacks because he did not want to participate or be bothered. Staff G said she documented as much as she could. At 9:21 AM, Resident 51 said he wanted a calendar in his room. Resident 51 said he was not invited to activities and had not participated. Resident 51 said he should start participating. At 9:24 AM, Staff G said she normally handed residents a folded activities calendar because they cannot see the calendar far across the room. When asked about Resident 17's and Resident 51's two activity entries for the last 30 days, Staff G said that was her fault for not charting better. Staff G said things moved fast around there. Reference WAC 388-97-0940 (1)

Based on record review and interview, the facility failed to ensure the facility's activity program was directed by a trained and qualified activities professional for the ongoing assessment, development, and/or revision of individualized activity programs for the current activities scheduled in the facility for 1 of 1 Activity Directors (Staff G) reviewed for activities professional qualifications. This failure placed residents at risk for unmet recreation needs, boredom, and decreased quality of life. Findings included . The Activities Director Position Description, dated July 2022, documented, Qualifications and Experience: Must meet certification requirements by the local and state regulations. Minimum of two years' experience in social or recreation programming for seniors. The position description documented under educational requirements, Associates Degree or equivalent knowledge and skills obtained through a combination of education, training, and experience. Review of Staff G's (Activity Director) application for Activity Director, dated 02/01/2023, did not show documentation of previous activity department experience and did not show documentation of requisite education for the position of Activity Director. On 10/26/2023 at 8:55 AM, Staff G said she was unsure how to see if a resident's activity care plan had been revised. Staff G said she was unsure of how to view when a resident's last activity assessment took place. When asked how many encounters with activities she expected residents to receive, Staff G was unable to verbalize a goal for frequency of activity encounters. On 10/27/2023 at 9:21 AM, Staff A, Administrator, said Staff G was a Certified Nursing Assistant in the building and moved into the Activity Director role before Staff A was employed by the facility. Staff A said she was unsure of Staff G's qualifications. Staff A said she had presented Staff G with an Activity Director's educational course, but Staff G had not completed the course. At 9:29 AM, Staff B, Director of Nursing Services and Registered Nurse, said Staff G had certifications as a medical assistant and as a Certified Nursing Assistant but did not have the educational requirements needed for the Activity Director position. Reference WAC 388-97-0940 (3)(a-c)

Based on interview and record review, the facility failed to ensure a written notice of transfer was provided to the resident and/or resident's representative describing the reason for transfers for 9 of 13 sampled residents (2, 4, 10, 26, 48, 316, 318, 319 & 320) reviewed for transfer notifications regarding hospitalization . This failure placed residents and/or their representatives at risk of not being informed of the resident's condition, unmet care needs and a diminished quality of life. Findings included . 1) Resident 2 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS), an assessment tool, dated 09/14/2023 documented Resident 2 was moderately cognitively impaired. Resident 2's Electronic Medical Record (EMR) documented a transfer to an acute-care hospital on 05/16/2023 and 08/11/2023. Resident 2's EMR did not show documentation a written notice of transfer was provided to Resident 2 or their representative for the 05/16/2023 and 08/11/2023 transfers. Resident 2's eINTERACT forms, a form used to document a transfer from the facility to an acute care hospital, dated 05/16/2023 and 08/11/2023, did not document the resident's right to appeal the transfer, and did not document resident advocacy information, such as ombudsman contact information. 2) Resident 4 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE] documented Resident 4 was cognitively intact. Resident 4's EMR documented transfers to an acute-care hospital on 05/15/2023, 05/18/2023, 06/04/2023, 06/14/2023, 07/05/2023, 07/13/2023, 08/04/2023, and 09/25/2023. Resident 4's EMR did not show documentation a written notice of transfer was provided to Resident 4 or their representative for any of the acute-care hospital transfers as listed above. Resident 4's eINTERACT forms, dated 05/15/2023, 05/18/2023, 06/04/2023, 06/14/2023, 07/05/2023, 07/13/2023, 08/04/2023, and 09/25/2023, did not show documentation of the resident's right to appeal the transfer, and did not document resident advocacy information, such as ombudsman contact information. 3) Resident 10 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 10 was severely cognitively impaired. Resident 10's EMR documented a transfer to an acute-care hospital on 10/19/2023. Resident 10's EMR did not show documentation of a written notice of transfer was provided to Resident 10 or their representative for the 10/19/2023 transfer. Resident 10's eINTERACT form, dated 10/20/2023, did not document the resident's right to appeal the transfer, and did not document resident advocacy information, such as ombudsman contact information. 4) Resident 316 was admitted to the facility on [DATE]. The admission MDS, dated [DATE] documented Resident 316 was moderately cognitively impaired. Resident 316's EMR documented a transfer to an acute-care hospital on 07/03/2023, 07/11/2023, 07/28/2023, and 09/08/2023. Resident 316's EMR did not show documentation a written notice of transfer was provided to Resident 316 or their representative for any of the acute-care hospital transfers listed above. Resident 316's eINTERACT forms, dated 07/04/2023 and 07/22/2023, did not document the resident's right to appeal the transfer, and did not document resident advocacy information, such as ombudsman contact information. 5) Resident 318 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], did not document Resident 318's cognitive status. Resident 318's EMR documented a transfer to an acute-care hospital on 02/25/2023, 08/28/2023, 09/13/2023, and 09/21/2023. Resident 318's EMR did not show documentation a written notice of transfer was provided to Resident 318 or their representative for any of the acute-care hospital transfers list above. Resident 318's EMR did not have any transfer forms for the 08/28/2023, 09/13/2023, or 09/21/2023 transfers; including the resident's right to appeal the transfer, and resident advocacy information, such as ombudsman contact information. 6) Resident 319 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 319 was cognitively impaired. Resident 319's EMR documented a transfer to an acute-care hospital on 07/26/2023. Resident 319's EMR did not show documentation a written notice of transfer was provided to Resident 319 or their representative for the 07/26/2023 transfer. 7) Resident 320 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 320's was severely cognitively impaired. Resident 320's EMR documented a transfer to an acute-care hospital on 08/16/2023. Resident 320's EMR did not show documentation a written notice of transfer, dated 08/16/2023, was provided to Resident 320 or their representative. Resident 320's EMR did not show documentation any transfer forms for the 08/25/2023 and 09/04/2023 transfers, including the resident's right to appeal the transfer and resident advocacy information, such as ombudsman contact information. 40916 8) Resident 26 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired. Resident 26's EMR documented a transfer to an acute care hospital on 10/18/2023. Resident 26's eINTERACT form, dated 10/18/2023, did not document the resident's right to appeal the transfer, and did not document resident advocacy information, such as ombudsman contact information. 9) Resident 48 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was cognitively intact. Resident 48's EMR documented a transfer to an acute care hospital on 08/16/2023. Resident 48's eINTERACT form, dated 08/16/2023, did not document the resident's right to appeal the transfer, and did not document resident advocacy information, such as ombudsman contact information. On 10/26/2023 at 11:25 AM, Staff B, Director of Nursing Services and Registered Nurse, said nurses were expected to complete transfer forms electronically and social services followed up the following day. At 3:57 PM, Staff D, Social Services, said written transfer notices were not provided to the resident or resident representative. On 10/27/2023 at 11:10 AM, Staff A, Administrator; Staff B; and Staff C, Social Services Director; said written transfer notices were not being provided to residents or resident representatives. At 12:08 PM, Staff B said the facility transfer notices were supposed to be completed by nursing, then medical records would follow up with the resident regarding ombudsman information. After reviewing the transfer notices for Resident 26 and Resident 48, Staff B said the transfer notices did not contain resident appeal rights or ombudsman information. Staff B said there were different transfer forms used for different facilities, and the eINTERACT form was used was a broad transfer form. Staff B said the facility would need to revise their process to meet regulation. Reference WAC 388-97-0120 (2)(a-d)

Based on interview and record review, the facility failed to provide a written bed hold notice to the resident and/or the resident's representative at the time of transfer to the hospital for 9 of 13 sampled residents (2, 4, 10, 316, 318, 319, 320, 26 & 48) reviewed for bed hold notifications. This failure placed residents and/or their representatives at risk of not being informed regarding their right to hold their bed while in the hospital. Findings included . 1) Resident 2 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS), an assessment tool, dated 09/14/2023, documented Resident 2 was moderately cognitively impaired. Resident 2's Electronic Medical Record (EMR) documented a transfer to an acute-care hospital on 05/16/2023 and 08/11/2023. Resident 2's EMR did not show documentation a written bed hold was provided to Resident 2 or their representative for the transfers listed above. 2) Resident 4 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 4 was cognitively intact. Resident 4's EMR documented a transfer to an acute-care hospital on 05/15/2023, 05/18/2023, 06/04/2023, 06/14/2023, 07/05/2023, 07/13/2023, 08/04/2023 and 09/25/2023. Resident 4's EMR did not show documentation a written bed hold was provided to Resident 4 or their representative for the transfers listed above. 3) Resident 10 was admitted to the facility on [DATE]. The MDS, dated [DATE], documented Resident 10 was severely cognitively impaired. Resident 10's EMR documented a transfer to an acute-care hospital on 10/19/2023. Resident 10's EMR did not show documentation a written bed hold was provided to Resident 10 or their representative. 4) Resident 316 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 316 was moderately cognitively impaired. Resident 316's EMR documented a transfer to an acute-care hospital on 07/03/2023, 07/11/2023, 07/28/2023, and 09/08/2023. Resident 316's EMR did not show documentation a written bed hold was provided to Resident 316 or their representative for the transfers listed above. 5) Resident 318 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], did not document Resident 318's cognitive status. Resident 318's EMR documented a transfer to an acute-care hospital on 02/25/2023, 08/28/2023, 09/13/2023, and 09/21/2023. Resident 318's EMR did not show documentation a written bed hold was provided to Resident 318 or their representative for the transfers listed above. 6) Resident 319 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 319 was cognitively impaired. Resident 319's EMR documented a transfer to an acute-care hospital on 07/26/2023. Resident 319's EMR did not show documentation a written bed hold was provided to Resident 319 or their representative for the 07/26/2023 transfer. 7) Resident 320 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 320's was severely cognitively impaired. Resident 320's EMR documented a transfer to an acute-care hospital on 08/16/2023. Resident 320's EMR did not show documentation a written bed hold was provided to Resident 2 or their representative for the 08/16/2023 transfer. 40916 8) Resident 26 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired. Resident 26's EMR documented a transfer to an acute care hospital on 10/18/2023. Resident 26's bed hold notice, dated 10/18/2023, did not document the amount the facility would charge to hold the resident's bed. The bed hold notice documented, Whether or not the resident or responsible party chooses to secure a bed hold, the information below will be filled out and signed. The bed hold documented Resident 26's family member was contacted and did not document whether or not the family member accepted or declined the bed hold. 9) Resident 48 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was cognitively intact. Resident 48's EMR documented a transfer to an acute care hospital on 08/16/2023. Resident 48's bed hold notice, dated 10/18/2023, did not document the amount the facility would charge to hold the resident's bed. The bed hold notice documented, Whether or not the resident or responsible party chooses to secure a bed hold, the information below will be filled out and signed. On 10/26/2023 at 11:25 AM, Staff B, Director of Nursing Services and Registered Nurse, said nurses were expected to complete the bed hold forms electronically and social services followed up the following day. At 3:57 PM, Staff D, Social Services, said written bed hold notices were not provided to the resident or resident representative. On 10/27/2023 at 11:10 AM, Staff A, Administrator; Staff B; and Staff C, Social Services Director; said written bed hold notices were not being provided to residents or resident representatives. Reference WAC 388-97-0120 (4)

<AMENDED CITATION> Based on observation, interview and record review, the facility failed to identify and implement appropriate measures to reduce the risk of avoidable accidents from a steep unmaintained fire access road off the facility's patio, for one of three sampled residents (#1) reviewed for accident hazards. This failure placed residents at risk for falls, injury, diminished quality of life and death. These failures caused harm to Resident #1 when the resident was able to exit the facility patio to the steep unmaintained fire access road in his wheelchair, and fell , resulting in a fractured nose, and multiple trauma to the face and hands. Findings included . Resident #1 was admitted to the facility on [DATE] with diagnoses including left hip replacement. The Minimum Data Set, a comprehensive assessment tool, dated 07/06/2021, documented Resident #1 had moderate cognitive impairment, required one to two person extensive assistance with activities of daily living and the resident self-propelled with a wheelchair. Hospital records, dated 7/21/2021 at 5:42 PM, documented [Resident #1] was outside of his facility on a hill in his wheelchair when he started going too fast and fell out injuring his face and right wrist. Hospital records, dated 7/21/2021 at 5:43 PM, documented Mildly displaced fractures of nasal bones. Hospital records, dated 7/21/2021 at 9:22 PM, documented [Resident #1] states that he was in his wheelchair outside that was on an incline/hill. The wheelchair started to roll down the hill very quickly and he was ejected from the wheelchair landing on his face. Facility Investigative Summary, dated 7/25/2021, documented Resident #1's nose was noted to be broken and requiring surgery. The resident was determined not to be a surgical candidate and was moved towards hospice. Resident #1's Certificate of Death documented Resident #1 passed away on 08/03/2021. The Death Certificate listed Cause of Death as delayed complications of left hip fracture. The Cause of Death noted other conditions contributing to death including recurrent falls with facial injuries. On 09/01/2021 at 3:00 PM, the facility's outside patio area was observed. Observation of the outside patio area of the facility showed, the door going out was not locked and did not alarm when going out. When coming back in the building, the door locked and residents must push a doorbell to be let back into the facility. To the right of patio area appeared to be a steep paved walkway, which was actually a steep unmaintained fire access road, that led to the road below. The fire access road started out to be fairly level and then became steep for the last two thirds of the way to the main road. At 3:10 PM, Staff A, Registered Nurse (RN), said she discovered Resident #1 was outside when a family member of another resident told her to come outside after Resident #1 had fallen. Staff A said Resident #1's body position was that the resident was face down, about two feet in front of his wheelchair. The wheelchair and Resident #1 were both facing downhill. At 3:25 PM, Certified Nurse Assistant (CNA), Staff B said Resident #1 said he was going forward and could not stop. Staff B said Resident #1 did not normally wander that far from his room and was not known to go to the outside patio. The outside patio had no barriers set up to detour residents from going down the hill until after the incident. On 9/02/2021 at 2:39 PM, Resident #1's daughter said Resident #1 had not been to the back patio before. Resident #1 would visit with family in a patio area in the front of the facility where there was a walkway with a handrail that Resident #1 would use when on his visits. On 9/03/2021 at 12:55 PM, Staff A said prior to Resident #1's fall on 07/21/2021, no barriers were in place blocking the fire access road from the facility patio. There were no designated staff to open the door for residents coming in from patio. Any staff available could open the door for residents if they heard the doorbell. Staff A said she was not aware if Resident #1 had attempted to re-enter the facility through the locked door. On 9/10/2021 at 3:35 PM, the Director of Nursing (DON) said no barrier or physical deterrents had been placed between the patio area and the steep unmaintained fire access road where Resident #1 had fallen until the day after the incident. Reference WAC 388-97-1060(3)(g)

Based on interview, observation and record review, the facility failed to ensure residents had safe functioning equipment for 1 of 3 sampled residents (#52) reviewed for safe patient care equipment. This failure placed residents at risk for injury and a diminished quality of life. This caused harm to Resident #52. Findings include . Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), dated [DATE], showed the resident required extensive 2-person physical assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. On 02/22/18 at 2:55 PM, the resident was observed with a cluster of pencil eraser size scabs on the right leg just above the knee, and an oval shaped larger scab a few inches above the pencil eraser size scabs. The resident said the scabs were from wounds she obtained while receiving treatment to stimulate the leg nerves. The resident said she was not experiencing pain and had no feeling in the right leg since the stroke. On 02/28/18 at 7:54 AM, Resident #52 stated the scabs on the right leg were [MEDICAL CONDITION] received while physical therapy was performing some kind of electro therapy to the right leg. The resident said she had not received that therapy for a while, and said that made her sad because the only time the resident was able to move any part of the right leg was during that electro therapy. Physical Therapy documentation showed Resident #52 received Electrical Stimulation (ES) five (5) times between 01/28/18 and 02/04/18. At 8:04 AM, a Physical Therapy Assistant (PTA) said Resident #52's ES treatment stopped on 02/04/18 because it was noted there was redness and burns. At 8:17 AM, a Physical Therapist (PT) said she observed the redness prior to starting the resident's ES treatment and changed locations of the electro pads. When asked if she notified anyone of the resident's injuries, the PT stated, Yes. When asked who she reported the information to, the PT said she could not recall. A Physical Therapy treatment encounter note, dated 02/04/18, documented, Attempted Russian e-stim to R quad for neuro re-ed strength. (Resident's) skin appears red irritated over usual pad placement so adjusted pad placement to intact skin. Attempted multiple placements but pt unable to feel stimulus, even with very high intensity. Aborted e-stim trial for safety and to avoid further skin irritation. At 8:22 AM, the Physical Therapy Manager indicated therapy staff had not reported any adverse reaction from treatment related to the e-stim machine, and the equipment was still in use on other residents. At 8:33 AM, the Administrator (ADM) stated the expectation would be for staff to tell nursing, nursing would contact the provider and the resident would be placed on alert. The ADM said the e-stim machine should have been removed from use immediately after the staff discovered the redness to ensure resident's safety. An undated skin sheet for Resident #52 showed the resident had three (3) red spots on the same locations of the resident's scabs. Review of the resident's (MONTH) (YEAR) Treatment Administration Record and Medication Administration Record [REDACTED]. The resident's progress notes and provider notes did not show documentation related to the resident's right leg wounds and/or related treatment. At 9:17 AM, the Director of Nursing Services (DNS) stated if a resident was injured while care was being provided, non-nursing staff should immediately report the incident to their manager and the resident's nurse or the Resident Care Manager (RCM). The nurse or RCM should notify the provider and the DNS. The DNS said she was not aware the resident had experienced a skin-related injury. If nursing staff discover a skin-related issue, it was expected they would notify the provider and document any ordered monitoring and/or treatment on a resident's TAR. The DNS stated there was no incident report, a care plan was not initiated, the provider was not notified and no monitoring and/or treatment orders had been received. At approximately 9:45 AM, the five (5) scabbed areas on the resident's right lower thigh were observed with the DNS and PTM. At approximately 12:30 PM, the DNS provided Skin Grid documentation, dated 02/28/18, that showed the facility identified the right thigh wounds and notified Resident #52's medical provider of the wounds on 02/28/18, 24 days after documentation showed the resident had received the wounds. All five (5) wounds were documented as partial thickness and showed the following measurements: Two of the wounds measured Length (L) 0.1 centimeter (cm), Width (W) 0.1 cm, Depth (D) <0.1 cm One wound measured L 0.5 cm, W 1.5cm, D <0.1 cm One wound measured L 0.5 cm, W 0.4 cm, D <0.1 cm One wound measured L 0.3 cm, W 0.3 cm, D 0.3 cm Treatment provided by the facility caused harm to Resident #52 and the facility did not communicate or document the injury. The provider was not notified and the resident did not receive treatment for [REDACTED]. Reference WAC 388-97-2100 (1)

Based on interview and record review, the facility failed to provide services in accordance with each resident's written plan of care for 1 of 5 residents (#1, former/discharged ) when they failed to have 2 caregivers (deemed necessary according to the assessment and care plan) provide bedside care. This failure caused harm when the resident sustained [REDACTED]. Findings include: Resident #1 was admitted to the facility on [DATE] and had resided there continuously with the exception of brief hospitalization s with [DIAGNOSES REDACTED]. Resident #1 was discharged to the hospital on [DATE] for an acute respiratory problem. According to the Minimum Data Set (MDS), as assessment tool, dated 08/07/13, the resident was totally dependent on staff for activities of daily living (ADLs). The resident was moderately cognitively impaired and was not able to walk. The resident was on an air mattress while in bed to prevent skin breakdown, to provide comfort and because of immobility. The residents plan of care (based on assessment), dated 8/9/13, specified to "Place resident on center of bed for safety" and "Assist resident to reposition as needed every 2-4 hours" and "Provide care per in room care plan". According to the in-room care directive, the resident required 2 person assist for transfers, was non-ambulatory (not able to walk) and required 2 (two) person assist for bed mobility. The in-room care directive also called for 2 persons to assist with bowel and bladder care. On 9/28/13 at 03:45 a.m., according to a facility incident investigation form regarding the resident falling onto the floor, Nursing Assistant (NAC) A "Called for help, staff immediately responded and found resident on the floor". The physician and family were immediately notified and the resident was sent to the hospital for treatment. Chart notes indicated the resident sustained [REDACTED]. Investigation revealed NAC A "Did not follow the care plan and provided the resident care with bed mobility and no other staff assistance. The resident was receiving incontinence care and was rolled too far to one side, resulting in falling out of bed. The resident sustained [REDACTED]. On 10/29/13 at 10:15 a.m., the Director of Nursing stated "The NAC (A) did not follow the care plan. The resident (#1) required 2 persons for care. The NAC tried to provide care by self. The NAC had received proper training and knew the importance of following the care plan. The resident was sent to the hospital. The resident probably should have had surgery to repair the fracture, but it was determined to use pain medication and a splint instead, because it was thought the resident would not be able to tolerate surgery. The resident returned to us after the fall, but is currently hospitalized for [REDACTED]. At 11:45 a.m., Licensed Nurse (LN) D stated "We usually do 3 days of orientation for our newly hired NAC staff, but we had extended the orientation for NAC A because he was a new nursing assistant. Our policy is that any resident on an air bed is always a 2 person assist with care because residents can fall during repositioning if they get too close to the edge of the bed." At 2:40 p.m., NAC A was interviewed by telephone regarding the above incident, and stated "I should have had another person help me. I got in a hurry and made a mistake. I did not read the in-room care directive."

Based on observation, interview and record review, the facility failed to supervise, implement current interventions and take additional corrective actions to prevent further occurrences of falls for 2 of 5 current samples residents (#s 9 & 55) reviewed for accidents. This failure caused harm to Resident #9 and placed Resident #55 at risk for further falls. Findings include: 1) Resident #9 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 6/2/11 documented the resident had severe cognitive impairment and required extensive assistance with bed mobility, transfers and toileting. The resident was not interviewable. On 8/23/11 at 2:50 p.m., Resident Care Manager (RMC) A stated the resident had fallen in the facility during the past month. Review of facility documentation indicated: 1) On 7/15/11, the resident was found lying on his back in the bathroom doorway of his room. The incident investigation indicated the resident stated he lost his balance. 2) On 7/31/11, the resident was found lying on the floor of his room. The incident investigation documentation indicated he had a skin tear to his right inner ankle measuring 0.5 centimeters (cm) by 0.5 cm, and a bruise on his right shin to ankle measuring 10 cm by 10 cm. The Witness/Caregiver statement documented the resident removed his alarm. 3) On 8/1/11, the resident was found lying on his back on the floor in his room. According to the incident investigation, "According to roommate resident removed tab alarm (alarm that sounds when the resident leaves a bed or chair)" 4) A second fall occurred on 8/1/11. Nursing progress notes documentation indicated the resident stated he was trying to self transfer from his chair to his wheelchair. 5) On 8/18/11, the resident was found lying on the floor of his room. The incident investigation documented the resident had an abrasion and scratch were present on the back of his head which measured 1 cm by .25 cm. Documentation indicated the resident's alarm did not sound because, "Res (resident) removed alarm - alarm was attached." 6) On 8/24/11, the resident was found sitting on the floor with his back against his bed. Nursing notes documentation indicated the resident had reported he tried to self transfer to another chair for dinner. 7) A second fall occurred on 8/24/11. While being assisted from the recliner chair to a shower chair by Nursing Assistant (NA), the resident's legs buckled. Nursing notes documentation indicated the resident had a sheared area on his left shin which measured 1 cm with a small amount of bleeding and a 2 cm area below his left knee. Resident #9's care plan for falls documented the resident was at risk for falls related to weakness, ataxic gait (lack of coordination/unsteady walking) and history of falls. The care plan interventions were updated on 6/3/11 and included to ensure resident used a front wheel walker to ambulate, stand-by assistance with transfers and ambulation, encourage the resident to wear non-skid socks and remind the resident to call (use call light) when needing assistance. No documentation was present indicating additional interventions were implemented following the falls in July and August. The resident's care plan for impaired mobility documented the impaired mobility was related to stroke, left [DIAGNOSES REDACTED], difficulty walking and dementia. The care plan interventions were updated on 6/3/11 and included to monitor the resident and cue for safety. The care plan did not indicate how the monitoring would occur or the frequency of the monitoring. The In-Room Care directive (directive for NAs) indicated it was updated on 7/18/11 and included stand by assistance with ambulation, tab alarm in wheelchair and in bed, independent with wheelchair and non-skin socks and shoes. The form also documented an additional entry dated 8/25/11 noting two person transfer related to sore left foot and increased weakness. On 8/26/11 at 10:45 a.m., RCM A stated she did not update the care plan following the falls because she believed the current care plan was appropriate. The RCM said she normally only updated the In Room Care Directive if the care plan was appropriate. The RCM said initially the resident's falls were attributed to his sore foot and discomfort which limited his walking but the In-Room Care directive did not address the resident's left foot being sore until 8/25/11. Although nursing notes documented each of the falls in July and August were investigated, no documentation was present indicating the interventions were reviewed or updated to determine if the care plan and/or care directive was appropriate to prevent further incidences of falls. When asked what was done to prevent falls for Resident #9, on 8/29/11 NA A stated, "I check on him frequently." The NA said the resident had a personal alarm and if it went off, she checked on him quickly. At 12:10 p.m., NA B stated the resident had a "fall alarm." The NA said, "I check on him frequently, ask him if he is comfortable and offer to take him to the bathroom so he does not try to get up." A safety plan was received from the facility on 8/26/11 at 4:20 p.m. The plan included a NA providing one to one (1:1) supervision for the resident. On 8/29/11 8:15 a.m., 9:00 a.m., 2:00 p.m., 9:30 p.m. and 11:30 p.m., the resident was observed having 1:1 supervision in his room. During random observations on 8/30/11, the resident was observed wearing shoes and the tab alarm was attached to his wheelchair. The resident had 1:1 supervision in his room. 2) Resident #55 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had sustained a fall with a hip fracture prior to admission. Addordint to the Minimum Data Set (MDS), an assessment tool, the resident was alert and oriented, but forgetful. Resident #55 required some assistance with Activities of Daily Living (ADL) care, was on a scheduled pain management program and was independent with walking in the room and hallways with a front wheeled walker. The resident was identified as being at risk for falling due to history of falls, generalized weakness,use of high risk medications, multiple cardiac [DIAGNOSES REDACTED]. The resident had not experienced falls or fractures since admission to the facility. On 8/21/11 at 1:00 p.m., the resident sustained [REDACTED]. The resident reported the wheelchair brake was not fully locked and the chair slid away as she tried to sit down. The resident complained of soreness and tenderness over the area of the right hip upon standing. Nursing notes reflected "A 3 centimeter red, firm area to right buttock with tenderness to touch when sitting. Ambulates with walker with good balance." The resident was offered ice and pain medication. Resident #55 was taking several medications to lower the blood pressure with medications being held 3 times recently because of low pulse. The resident's medical record did not reflect the pacemaker had been monitored since placement in 2007. The resident took several psychotropic medications having the effect of causing lowered blood pressure. The resident had arthritis and a history of a prior fractured hip. Following the fall on 8/21/11, an assessment of these potential hazards was not conducted to prevent possible future falls. On 08/25/11, Resident #55 experienced another fall at 6:45 p.m. The resident stated "I slid down to the floor from the edge of my bed. My bottom still feels sore." On 08/26/11, during interview, when asked, RCM A stated, "I didn't think about assessing the resident's hip for internal /external rotation. I didn't think about hypotension, blood sugar or medications contributing to the resident's fall. I just took the resident's word for what happened." Refer to F 272