Every finding on record at Lakeland Village Nursing Facility

Based on interview and record review, the facility failed to ensure a resident remained free from verbal and physical abuse for 1 of 3 sample residents (Resident 1). This failure placed the residents at risk for physical and psychological harm.Findings included. Review of Resident 1's electronic medical record, on 05/04/2026 at 11:42 AM, showed they had been admitted to the facility on [DATE], and had moved to the nursing facility area on 10/28/2020, with diagnoses of ataxia (unsteady gait), severe intellectual disability (marked impairments in cognitive abilities and practical life skills that affect an individual's ability to perform everyday tasks independently), and a history of psychological trauma. Review of Resident 1's care plan, dated 02/07/2022 to present, showed they used a wheelchair for locomotion related to their unsteady gait, and had no safety awareness. Resident 1's care plan also showed they were verbal, could express their personal preferences and many of their wants/needs, and were most receptive to calm, familiar staff, who gave them opportunities to make choices. The care plan showed if the resident was resistive to requests, staff were to use a calm and positive approach. Record review of an investigation completed by another state agency, dated as completed on 04/29/2026, showed on 04/22/2026 at 9:40 AM, Staff D, nursing assistant (NA), was standing at the front entrance area of a cottage (house where up to 12 residents live as their primary residence), grabbing a coat for another resident, when Resident 1 self-propelled their wheelchair around the corner toward Staff D, asking how about [Resident 1's name], indicating they would also like to go outside. Staff E, NA, Staff F, custodian, and Staff G, NA, all witnessed Staff D quickly tilt the backrest of Resident 1's wheelchair back, which caused the resident's upper body to recline and their feet to come off of the floor, push Resident 1's wheelchair toward the living room area, and release the wheelchair, with Resident 1 still in the reclined position. The wheelchair rolled into the living room wall where Resident 1's lower legs struck the wall. Staff E then saw Staff D spin Resident 1's wheelchair to face them, point their finger in Resident 1's face and state you need to f**king stop. Staff D then left the cottage through the front door. Staff E stated they then approached Resident 1, who was still in their wheelchair in the reclined position with their feet off the floor, asked them if they were alright, repositioned their wheelchair to the upright position and checked for any visible injuries. Staff E then notified the nurse to check for injuries and none were found. Record review of an independent investigation conducted by another state agency showed an interview with Staff C, Psychology Associate, on 04/24/2026 at 8:53 AM, where they indicated they had visited Resident 1 shortly after the incident of abuse on 04/22/2206. Staff C stated they did not have knowledge of the incident that had occurred, and they documented that Resident 1 seemed pretty reclusive, shocked, wasn't talking, and [they] just seemed scared in my opinion. Staff C further stated that they visited Resident 1 the next day, 04/23/2026, and they seemed to be back at baseline, repeating familiar phrases and interacting with staff. During an interview with Staff B, Developmental Disability Administrator, on 05/04/2026 at 11:00 AM, they stated the investigation completed by the outside state agency, on 04/29/2026, substantiated verbal and physical abuse by Staff D to Resident 1. Staff B stated that Staff D had been reassigned to an alternate position away from direct resident care following the incident and would remain in that position until the facility discipline process was completed, which could take two to four weeks.In an interview, on 05/04/2026 at 12:39 PM, Staff A, Director of Nursing, confirmed the facility had substantiated verbal and physical abuse of Resident 1, on 04/22/2026, by Staff D. Reference: (WAC) 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to consistently implement interventions to prevent a resident from ingesting an exam glove for 1 of 3 residents (Resident 1) reviewed for accidents and supervision. This failure placed residents at risk for medical complications and decreased quality of life.Findings included .Review of Resident 1's care plan, dated as effective 02/04/2022 to present, showed they had diagnoses which included profound intellectual disability and PICA (an abnormal desire to eat substances not normally eaten), with the following detail, [Resident 1] has severe PICA and can be very sly and will obtain items of [their] choice and they often are not digestible. [Resident 1] has a 1:1 staff to ensure that [they] do not ingest anything that [they] shouldn't. The care plan also showed that Resident 1 had severely impaired cognition and required limited assistance with mobility while in their wheelchair.Review of a facility investigation, dated 12/06/2025, showed that Resident 1 had an ileostomy (an opening in the abdomen that bypasses the intestine, allowing waste (stool and gas) to flow into a pouch that is worn externally). On 12/06/2025 at 2:12 PM Staff D, Nursing Assistant, wrote that while emptying the resident's stool pouch they found a glove inside. Further review of the same investigation showed that Resident 1 was found to have an intact nitrile exam glove in their stool pouch.Further review of the facility investigation found an interview on 12/11/2025 at 2:37 PM, with Staff C, Physical Therapy Supervisor, where they reviewed photos of the resident's room showing placement of nitrile exam gloves in a bathroom storage drawer and a small trash can in the resident's room that staff used to dispose of paper towels and used exam gloves. Staff C stated during the interview that Resident 1 had good hand dexterity and will grab items from staff or within [their] vicinity. Staff C further stated that upon review of the photos they felt that Resident 1 could easily independently access the trash can in their room and the drawer in the bathroom with the gloves.On 12/15/2025 at 2:35 PM, Resident 1 was observed in the hallway of the facility near the central nurses' station, self-propelling in their wheelchair, with a seatbelt fastened at their waist. Their 1:1 staff were observed following behind the resident holding a laptop and typing. The resident was not able to answer any questions, but was observed to self propel in their wheelchair using their feet and interact with the staff present, reaching out and pulling on a staff member's arm and touching another staff on their leg with their foot.During an observation of Resident 1's bedroom, on 12/15/2025 at 2:38 PM, a small metal trash can with a foot pedal to open and close the container, was observed within about 4 feet of the resident's recliner with used paper towels inside. An observation of the resident's bathroom found a wooden bedside table with a drawer, that, when easily slid open, had three boxes of nitrile exam gloves inside. The storage table was of a height made for a seated person to access the drawer and was within 3 to 4 feet of the toilet.During an interview on 12/15/2025 at 2:35 PM, Staff D, Nursing Assistant, stated that they had to always be within arm's reach of Resident 1 and that Resident 1 would reach out and try and grab items and could move very quickly. They further stated that Resident 1 could unbuckle their wheelchair seatbelt and reposition themselves to the floor very quickly. The resident was described as moving fast, especially if there was an item they wanted. Staff D stated they were to never leave the resident's side, and the resident was to be within their constant eyesight. Staff D further stated that on 12/06/2025 they had found an intact blue exam glove in the resident's stool pouch when they emptied it, and that the resident must have, at some point, eaten it.During an interview on 12/15/2025 at 11:34 AM, Staff B, Director of Nursing, stated that changes had not been made to the drawer with gloves in it in the resident bathroom or to the small trash can in the resident room. They further stated that the facility investigation was unable to determine how or when, beyond a general time frame, the resident had ingested the exam glove.During an interview on 12/15/2025 at 2:50 PM, Staff A, Administrator, stated that the facility was aware of the failure as the resident had ingested an exam glove and they had made and were in the process of making changes to prevent the same thing from reoccurring. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to follow professional standards of practice to prevent a medication error for 1 of 5 sampled residents (11), reviewed for unnecessary medications. Specifically, Resident 11 received a dose of an antibiotic that was on their list of allergies. This failure placed the resident at risk for health complications and possible anaphylaxis (a serious and potentially fatal allergic reaction).Findings included.The website www.nurseslabs.com (an online nursing resource site), documented the Five Rights of Medication Administration (right patient, right drug, right dose, right route and right time) was a foundational framework in nursing, that ensured patient safety and minimized medication errors. A part of ensuring that a patient was given the right medication was to routinely check on previous allergic reactions to medications. Additionally, the staff should always verify any uncertainty about the medication with the prescriber, prior to administration.According to the quarterly assessment, dated 08/04/2025, Resident 11 had a diagnosis of schizophrenia (a mental disorder characterized by incoherent or illogical thoughts, bizarre behavior and withdrawal from reality) and severe cognitive impairment.A review of their medical record showed an allergy to Augmentin (an antibiotic) which caused edema (swelling) to hands and face, was documented on 02/20/2025.Review of the resident's record documented an order for Augmentin for pneumonia (a lung infection) was prescribed by Staff D, Advanced Registered Nurse Practitioner (ARNP), on 10/07/2025, and the first dose was given by Staff C, Registered Nurse (RN) that same day. A facility investigation, dated 10/09/2025, showed the following:1) Staff D had forgotten Resident 11 was allergic to Augmentin and did not check the resident's list of allergies when they ordered it.2) Staff K, Pharmacist noted the Augmentin was on the allergy list and had reached out to Staff D for clarification, but Staff D did not respond. Although Staff K questioned if the medication was a true allergy, they filled the prescription.3) Staff C administered the dose of Augmentin on 10/07/2025 at 11:20 AM.4) Staff L, Case Manager Registered Nurse (CMRN) reviewed the order, noted Augmentin was listed as an allergy, and went to Resident 11's cottage to prevent administration. Staff L discovered the first dose had been given and informed Staff D. Staff D discontinued the Augmentin and ordered Benadryl (a medication to treat allergic reaction) to be given immediately and as needed for signs of an allergic reaction. The Benadryl was administered the same day at 1:48 PM.5) Resident 11 was monitored for any signs or symptoms of adverse reaction to the dose of Augmentin, none was experienced and no further Benadryl was needed.During an interview on 10/24/2025 at 2:22 PM, Staff B, Director of Nursing, stated that neither Staff D or Staff K followed the process to avoid a medication error. Staff B also stated they expected nursing staff to check allergies before giving a new medication. Reference: WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to maintain respiratory equipment in a clean manner for 2 of 3 sampled residents (Residents 1 and 69) reviewed for respiratory care. This failure placed the residents at risk for illness and decreased quality of life.Findings included .<Resident 1>The 09/07/2025 quarterly assessment documented Resident 1 had diagnoses including sleep apnea (when your breathing stops and restarts during sleep, preventing the body from getting enough oxygen) and pneumonia. The resident had severe cognitive impairments, and oxygen was not coded on the assessment. In an observation on 10/20/2025 at 10:42 AM, Resident 1 was sitting in their room in their wheelchair. The resident had an oxygen concentrator (a machine that delivers oxygen) in their room that was covered in thick dust debris over the area where the filter was, and the machine was unclean with dust and white splatter. The resident's oxygen tubing and nasal cannula were lying on the floor.The 01/28/2025 sleep apnea care plan instructed nursing staff to apply oxygen when Resident 1 was in bed.A 01/29/2025 provider order instructed nursing staff to administer 1-6 liters of oxygen continuously and to titrate the oxygen to maintain saturations above 90 percent. Review of the October 2025 Nursing Flowsheet showed Resident 1's oxygen equipment to include their mask, nasal cannula, and tubing was to be changed weekly. The flowsheet showed the oxygen equipment was changed on 10/02/2025 and 10/16/2025. On 10/09/2025 there was an = sign documented which meant there was no documentation whether it was completed or not. There were no flowsheets or documentation for cleaning the equipment.Similar observations of the oxygen concentrator being unclean with thick dust debris over the area where the filter was and white splatter were made on 10/20/2025 at 3:44 PM, 10/22/2025 at 10:15 AM and 3:08 PM, 10/23/2025 at 11:07 AM and 3:10 PM. On 10/24/2025 at 10:06 AM, the concentrator did not have dust over the filter area but remained with dust and white splatter on the front of the machine. A 10/20/2025 physician progress note stated Resident 1 had a chest x-ray that showed possible bilateral pneumonia and due to congested cough and intermittent shortness of breath was going to treated for pneumonia. In an observation on 10/22/2025 at 10:56 AM and 12:05 PM, Resident 1 was lying in bed, and their oxygen was not in their nose as instructed. <Resident 69>The 08/04/2025 quarterly assessment documented Resident 69 had diagnoses including a stroke and pneumonia. The resident had severe cognitive impairments, shortness of breath when lying flat and oxygen was not coded on the assessment. In an observation on 10/20/2025 at 10:09 AM, Resident 69 was lying in bed. Resident 69's oxygen concentrator was covered in dust debris over the area where the filter was and the machine was unclean with dust and white splatter. The resident's small volume nebulizer (SVN, a device used to deliver liquid medications to assist with breathing) was unclean with splatter inside of the mask and was dated 10/09/2025. A 05/28/2025 provider order instructed nursing staff to administer 0.5-1 liters of oxygen continuously. The 02/01/2022 care plan instructed staff to notify nursing immediately for difficulty breathing, shortness of breath, unable to clear secretions or bluish color to lips and mouth. Review of the October 2025 Nursing Flowsheet showed Resident 69's SVN was to be changed weekly. The flowsheet showed the SVN tubing equipment was changed on 10/01/2025 and 10/08/2025. There was an = sign documented on 10/15/2025 and 10/22/2025 There were no flowsheets or documentation for cleaning the equipment or changing the oxygen tubing. Similar observations of the oxygen concentrator being unclean with dust debris over the area where the filter was and white splatter were made on 10/22/2025 at 10:09 AM and 3:10 PM, 10/23/2025 at 11:16 AM and 3:04 PM, 10/24/2024 at 10:00 AM, and 10/27/2025 at 9:27 AM. In an interview on 10/21/2025 at 11:30 AM, Staff N, Registered Nurse, stated the = sign meant there was no documentation to indicate whether it had been completed or not. In an interview on 10/23/2025 at 11:44 AM, Staff J, Registered Nurse, stated the night shift nurse was responsible for changing the oxygen tubing and cleaning the equipment. Staff J stated it was important to keep the equipment clean to get pure oxygen to the residents and to ensure the oxygen concentrator was working properly. Staff J observed the oxygen concentrator and filter area and stated they should have been kept clean as they could have contributed to Resident 1's pneumonia. In an interview on 10/27/2025 at 12:47 PM to 12:53 PM, Staff B, Director of Nursing, stated it was important to keep the oxygen concentrators clean to ensure they were functioning appropriately and if they were not it could contribute to a resident's respiratory status. Upon review of both Residents 1 and 69's record, Staff B was unable to provide documentation on cleaning of the oxygen equipment. Reference: WAC 388-97-1060(3)(j)(vi)

Based on observation, interview, and record review, the facility failed to perform hand hygiene when indicated during 1 of 4 medication administration observations. Additionally, the facility failed to ensure PPE (personal protective equipment, gowns and gloves) and incontinence pads were disposed of properly and a hoyer lift (a lift used to transfer residents) was sanitized between resident transfers to prevent the spread of bacteria.Findings included.In an observation on 10/22/2025 at 10:52 AM, Staff F, Attendant Counselor, came out of Resident 2's room carrying unclean incontinence pads that were not contained and carried them down the hall and discarded them in a garbage can. At 10:53 AM, Staff F brought the Hoyer lift out of Resident 2's room into the hall and took it into Resident 10's room without sanitizing it in between transferring the residents. In an observation on 10/22/2025 at 11:22 AM, Staff J, Registered Nurse, entered Resident 69's room to hang a new bag of tube feeding formula. Staff J put on a pair of gloves, removed the old bag of tube feeding formula, and left the room wearing the gloves and then threw the used formula bag in the garbage. Staff J returned to Resident 69's room still wearing the same gloves, then removed the gloves, sanitized their hands and put on new gloves. Staff J then flushed the resident's feeding tube with water, hooked up the new formula bottle, and left the resident's room again without removing their gloves. Staff J walked down the hall wearing the gloves and discarded them once they got to their medication cart. During an observation on 10/24/2025 at 7:54 AM, Staff E, Registered Nurse, entered Resident 69's room and put on a gown and gloves. Staff E pulled the curtain with their gloved hands, swabbed Resident 69's abdomen with an alcohol wipe and administered insulin (an injectable medication used to treat diabetes). Staff E then adjusted the resident's sheet over them and pulled up water in a syringe and flushed the resident's peg tube (a thin, flexible tube inserted into the stomach through a small incision in the abdominal wall that delivered nutrition) and administered their medications. Staff E removed their gloves, sanitized their hands and put on new gloves. Staff E adjusted the resident's oxygen tubing in their nose, removed their glasses, administered eye drops and wiped Resident 69's cheek and eyes with the same gloved hands. Staff E finished Resident 69's medications, walked across the hall wearing their gown and gloves and disposed of them in the garbage can. In an interview on 10/24/2025 at 8:01 AM, Staff E stated they probably should have put on new gloves after they pulled the curtain prior to administering the resident's medication. Staff E stated they were unsure if they should have removed their gloves and performed hand hygiene after adjusting Resident 69's oxygen tubing and removing their glasses prior to giving the resident their eye drops and wiping their cheek and eyes with the same gloved hands. Staff E stated they were unsure of the policy for removing their PPE in the resident's room. In an interview on 10/27/2025 at 12:25 PM, Staff G, Infection Preventionist, stated unclean incontinent supplies should be contained by folding the pad inward or placed in a bag and then disposed of. Staff G stated the Hoyer lift needed to be sanitized between each resident. Staff G stated during medication administration gloves needed to be changed and hand hygiene performed when going from dirty to clean and PPE needed to be contained prior to walking across the hall to dispose of it. Staff G stated all these things were important to prevent the spread of germs. References: WAC 388-97-1320(1)(c)(3)

Based on observation and interview, the facility failed to ensure chemicals and tools were secured in 2 of 3 rooms observed and 1 of 1 supply cabinets. In addition, the facility failed to ensure wheelchairs, seatbelts and foot troughs (a device used to hold a resident's lower extremities in place) were maintained in a clean manner for three residents (Residents 1, 10, 69), a fan for one resident (Resident 1) and a tube feeding pole for one resident (Resident 69) reviewed for physical environment. In addition, the facility failed to maintain clean refrigerators and a freezer on 1 of 6 cottages. This failure placed residents at risk of potentially avoidable accidents, lack of dignity and diminished quality of life.Findings included .<Chemicals/Tools>During an observation on 10/20/2024 at 10:05 AM, the supply cabinet near the shower room was unlocked and contained a chemical cleaner on the bottom shelf. The cleaners label stated to call poison control center if ingested. There were no residents wandering near the area or the vicinity of the supply cabinet.In an interview on 10/20/2025 at 10:55 AM, Staff H, Attendant Counselor, stated Residents 18, 38 and 72 were the only ambulatory resident in the cottage. Similar observations of the unlocked supply cabinet and the chemical cleaner on the bottom shelf were made on 10/20/2025 at 3:59 PM, 10/22/2025 at 3:13 PM (the cabinet door was open), and 10/23/2025 at 11:13 AM (the cabinet door was open). There were no residents wandering near the supply cabinet during these times. During an observation on 10/20/2025 at 10:07 AM, the custodial supply door was open and contained a different chemical cleaner that instructed to keep out of reach of children. A similar observation of the door open containing the cleaner was made on 10/22/2025 at 3:13 PM. During an observation on 10/20/2025 at 10:58 AM, there was an emergency supply room that contained scissors and tools to include screwdrivers, wrenches and screws. The door contained no locking mechanisms to ensure it was secured. There were no residents wandering near the area. Similar observations of the emergency supply room containing the scissors and tools were made on 10/20/2025 at 4:00 PM, 10/22/2025 at 10:14 AM and 3:06 PM, 10/23/2025 at 11:06 AM and 3:08 PM. In an interview on 10/23/2025 at 11:56 AM, Staff I, Attendant Counselor, stated Resident 38 wandered on the cottage but did not attempt to open doors. Staff I stated any rooms or cabinets that contained cleaning supplies and tools needed to be kept locked as those items were dangerous and could hurt the residents or staff. In an interview on 10/23/2025 at 12:09 PM, Staff J, Registered Nurse stated Resident 38 wandered on the cottage, but they had not witnessed them attempt to open any doors. Staff J stated the doors and cabinets should be locked when not in use for safety reasons. In an interview on 10/27/2025 at 12:47 PM, Staff B, Director of Nursing, stated the doors and cabinets should be kept locked at all times when not in use and this was important for resident safety. <Refrigerators and freezer>In an observation on 10/22/2025 at 11:45 AM, the refrigerator on the 62 side of the Laurel Cottage was unclean with food spilled throughout the refrigerator. The refrigerator on the 63 side was unclean with food debris and spilled liquid. The freezer had spilled liquid and crumbs inside. In an interview on 10/22/2025 at 12:00 PM, Staff M, Attendant Counselor, stated the refrigerators and freezer were cleaned once a day. Staff M stated it was important to keep them clean to prevent food contamination. In an interview on 10/27/2025 at 9:17 AM, Staff I, Registered Nurse, stated they were not entirely certain how often the refrigerator and freezers were cleaned but thought night shift completed it weekly. Staff I stated it was important to keep them clean to prevent the spread of germs. <Wheelchairs, seatbelts, foot troughs, feeding tube pole, fan><Resident 1>The 09/07/2025 quarterly assessment documented Resident 1 had diagnoses including Cerebral Palsy (damage that occurred to the developing brain that affected movement and posture) and a stroke. The resident had severe cognitive impairments and was dependent for all cares. The 03/06/2019 care plan documented Resident 1 was wheelchair bound and had a cushioned footrest. In an observation on 10/20/2025 at 10:42 AM, Resident 1 was sitting in their wheelchair in their room. The wheelchair was unclean with brown matter crusted into the side pieces and the trough had white splatter. There was a fan that was on that was covered in thick dust debris.Similar observations of the wheelchair and trough being unclean were made on 10/20/2025 at 3:55 PM, 10/22/2025 at 3:08 PM and at that time the trough was observed to have a section torn off where Resident 1's feet rested and the area was not a cleanable surface, 10/23/2025 at 3:12 PM, and 10/24/2025 at 10:06 AM. Similar observations of Resident 1's fan being covered in thick dust debris were made on 10/20/2025 at 3:44 PM, 10/22/2025 at 12:05 PM and 3:22 PM, 10/23/2025 at 11:07 AM and 3:10 PM.<Resident 10>The 10/05/2025 quarterly assessment documented Resident 10 had diagnoses including Cerebral Palsy and osteoporosis (bone loss). The resident had severe cognitive impairments and was dependent on staff for all cares. The 05/08/2019 care plan documented Resident 10 was wheelchair bound and wore a seatbelt for safety while in the wheelchair. In an observation on 10/20/2025 at 10:35 AM, Resident 10 was sitting in their wheelchair in the activity area. The resident's seatbelt was unclean with white debris on it. At 3:54 PM, that same day, Resident 10 was sitting in the dining room in their wheelchair. The wheelchair had blue foam padding on the left arm that was unclean with white splatter and the wheelchair had white splatter and dirt. In an observation on 10/22/2025 at 10:30 AM, Resident 10 was asleep in bed. Their wheelchair, seatbelt and trough had white splatter and dirt. The blue foam padding on the left arm of the wheelchair had tape remnants and a yellow substance on it. Similar observations of Resident 10's wheelchair, seatbelt, foam padding and foot trough being unclean were made on 10/22/2025 at 12:00 PM and 3:05 PM, 10/23/2025 at 11:22 AM and 3:14 PM, 10/24/2025 at 10:03 AM, and 10/27/2025 at 9:32 AM. <Resident 69>The 08/04/2025 quarterly assessment documented Resident 69 had diagnoses including Cerebral Palsy and a stroke. The resident had moderate cognitive impairments and was dependent on staff for all care. The 02/01/2022 care plan documented Resident 69 was wheelchair bound, required a seatbelt for safety and received nutrition through a feeding tube.In an observation on 10/20/2025 at 10:09 AM, Resident 69 was lying in bed hooked up to a tube feeding. The tube feeding pole and the base were unclean with white splatter and dirt debris. In an observation on 10/22/2025 at 10:09 AM, Resident 69 was sitting in their wheelchair in the dining area. The resident's wheelchair and seatbelt were unclean with white splatter. The tube feeding pole had white splatter and the base was unclean with dirt debris. Similar observations of the wheelchair and seatbelt being unclean were made on 10/24/2025 at 10:00 AM and 10/27/2025 at 9:27 AM. Similar observations of the tube feeding pole being unclean were made on 10/23/2025 at 11:16 AM and 3:04 PM, 10/24/2025 at 10:00 AM and 10/27/2025 at 9:27 AM. In an interview on 10/23/2025 at 11:36 AM, Staff I, Attendant Counselor, stated if they saw something unclean in the resident's environment, they would either clean it or report it to their manager. Staff I stated night shift was responsible for cleaning the resident's wheelchairs. In an interview on 10/23/2025 at 11:44 AM, Staff J, Registered Nurse, was unsure who was responsible for cleaning the wheelchairs. Staff J stated night shift was responsible for cleaning the tube feeding poles and it was important to keep the tube feeding poles clean to prevent the spread of germs and bacterial growth. Staff J observed the fan in Resident 1's room and stated they were unsure who was responsible for keeping it clean. Staff J stated it could have contributed to Resident 1's diagnosis of pneumonia. In an interview on 10/27/2025 at 12:47 PM, Staff B, Director of Nursing, stated it was important to keep the wheelchairs, seatbelts, and troughs clean and free of tears for hygiene and skin integrity. Staff B stated it was important to keep the fans clean as the residents are compromised and the tube feeding poles clean for hygiene, and it was important to keep the refrigerators and freezers clean as it could harbor bacteria.Reference: WAC 388-97-3220 (1)

Based on interview and record review, the facility failed to protect the residents' right to be free from neglect for 1 of 3 residents (Resident 2). The failure to provide medical care, as ordered by the facility medical provider, resulted in a possible diminished quality of life. Findings include: Record review showed Resident 1 was admitted to the facility in August of 2023 with diagnoses of Moderate Intellectual Disability (characterized by an average mental age of 6 to 9 years old, with adaptive, social and cognitive skills at that level) and dementia (a loss of thinking, remembering and reasoning skills). Review of Resident 2's medical record showed that on 06/02/2025 at 1:34 PM Staff H, Registered Nurse, notified the facility physician, Staff F, that Resident 2's right great toe was discolored and tender to touch. Staff C then wrote in a progress note that they had received a verbal order from Staff F to start Epsom salt soaks for 15 minutes, two times per day, for three days. Further review of Resident 2's medical record showed that on 06/04/2025 at 11:20 AM Staff F, assessed Resident 2's right great toe, continued the foot soaks for another three days, added an antibiotic for treatment of right great toe that was diffusely erythematous (red -indicating possible infection), open drainage from prior wound, serous (clear) fluid. Review of Resident 2's medication administration record showed a treatment order started on 06/04/2025, to begin at 4:00PM the same day, for two times daily for three days beginning 06/04/2025 soak right foot in warm water bath with Epsom salt x 15 min[utes] twice a day: try to gently express any drainage. Review of a facility incident report, dated 06/05/2025, stated that on the evening shift of 06/05/2025, Staff I, Registered Nurse, was told by Staff K, Nursing Assistant, that Staff J, Licensed Practical Nurse was blowing off the foot soak for Resident 2 and that it had not occurred on the evening shift of 06/04/2025. Review of Resident 2's medication administration record showed that the foot soak ordered on 06/04/2025 for 4:00 PM was signed off as completed by Staff J. Review of the facility investigation into the incident showed a statement from Staff K, on 06/06/2025 at 8:10 PM, stating that they had worked on the evening shift of 06/04/2025 and that Resident 2 had remained near the kitchen to watch them prepare dinner, ate dinner and afterwards they went to the living room area of the building to watch television and that the foot soak had not occurred during that period of time. Review of the facility investigation into the incident showed a statement from Staff L, Nursing Assistant, on 06/06/2025 at 8:25 PM, stating that they had worked on the evening shift of 06/04/2025, had been in the living room area of the building after dinner with another 1:1 resident (staff remains within arm's length distance of a resident for safety), who was watching television, where Resident 2 was also present watching television, and that the foot soak had not occurred. Review of the facility investigation into the incident showed a statement from Staff M, Nursing Assistant on 06/09/2025 at 3:11 PM, stating that they had been assigned to work with Resident 2 on the evening shift of 06/04/2025, had been aware that Resident 2's foot soak had not occurred prior to Resident 2's preferred bedtime. They further stated that Staff J had stopped by Resident 2's bedroom, as they were preparing for bed, and had stated that the foot soak had been completed earlier in the shift, but they needed to change the bandage on Resident 2's right great toe. Staff M stated they thought it was strange that Staff J would need to change the bandage, that appeared used and dry, when the foot soak had occurred earlier in the evening. Review of Resident 2's medical record showed a progress note written by Staff G, Advanced Practice Nurse Practitioner, on 06/05/2025 at 3:57 PM, which stated that they had seen Resident 2's right great toe on the morning of 06/05/2025 and that upon removal of the bandage, purulent (thick, yellow/green - a sign of infection) drainage was noted. Review of the facility investigation showed a statement from Staff J, Licensed Practical Nurse, on 06/11/2025 at 11:15 AM, who stated that the foot soak for Resident 2 had been completed on 06/04/2025, in the kitchen/dining area of the building prior to dinner and that they didn't think any other staff had seen it occur. They further stated that they had changed Resident 2's foot bandage in the bathroom, not in their bedroom, after dinner on 06/04/2025. Review of the facility investigation summary, dated 06/11/2025, stated that it was more likely than not that the foot soak for Resident 2 had not occurred on the evening shift of 06/04/2025. During an Interview with Staff A, Director of Nursing, on 06/16/2025 at 12:45 PM, they stated that they believed that Staff J had neglected to complete the foot soak for Resident 2, and that Staff J remained reassigned from resident care and that they had extensive training planned for Staff J prior to returning to direct resident care, to include completing treatments as ordered by the medical provider. Reference (WAC) 388-97-0640(1)

Based on interview and record review, the facility failed to ensure timely reporting of an allegation of neglect for 1 of 1 resident (Resident 1). This failure resulted in potential harm and decreased quality of life for the resident. Findings included: Based on the 04/01/2025 assessment, Resident 1 was cognitively impaired and had diagnoses including moderate intellectual disabilities and schizoaffective disorder. They required maximum assistance for activities of daily living such as transferring in and out of bed and wheelchair, standing, toileting, and personal care. In an interview on 06/04/2025 at 1:00PM, Staff B, Attendant Counselor 1 (AC1) stated they witnessed Resident 1 fall out of bed onto the floor. Staff B could not remember the date of the occurrence. Staff B then called out to Staff C, AC1 to get the nurse. While waiting for the nurse Staff E, Attendant counselor Manager (ACM) entered the room and Staff B informed them that the resident had fallen. Staff E then proceeded to pick up the resident and put them on the bed and told Staff B to not complete an incident report because Resident 1 was able to reposition themself from the bed to the floor and it was in the resident's care plan. Staff B stated they told Staff E multiple times the resident had fallen, and Staff E continued to state an incident report was not to be completed. When asked what the usual procedure was for a resident fall, Staff B stated the resident was not supposed to be moved until the licensed nurse has assessed them and given approval, an incident report was supposed to be completed, and the shift lead and/or manager notified. Staff B stated they did not complete an incident report and/or report their concern about Staff E telling them not to do an incident report. When asked, Staff B stated they should have reported it. In an interview on 06/02/2025 at 2:20PM, Staff C, AC1, was unable to recall the exact date Resident 1 fell and stated they were working with another resident, across the hall from Resident 1's room, and heard a loud bang come from Resident 1's room and when they entered Resident 1's room, the resident was lying on the floor beside the bed and complaining about their head hurting and stated they hit their head on the table. Staff C then went to get the nurse, encountered Staff E and told them Resident 1 had fallen. Staff E then entered Resident 1's room, told Staff B and Staff C that Resident 1 had repositioned themself to the floor intentionally. Staff E then picked up Resident 1 and put them on the bed. Staff C told Staff E that Staff B saw Resident 1 fall and hit their head, Staff E continued to instruct them not to complete an incident report. Staff C stated the procedure when a resident had a fall was to get the nurse and to not move the resident until the nurse said it was ok, get a full set of vital signs (measurements of the body's most basic functions, such as temperature, heart rate, breathing rate, and blood pressure), and complete an incident report. Staff C stated they told the nurse that Resident 1 had fallen but the nurse did not assess the resident because Staff E told them not to. Staff C stated they could not remember who the nurse was at the time of the incident. When asked why they did not report the incident, Staff C stated they did not want Staff E mad at them. Staff C stated they should have reported the incident, they said it was their mistake, and they knew they should have reported it. In an interview on 06/03/2025 at 949am, Staff D, ACM stated they were not working the day Resident1 fell but when they returned to work, they could not remember the exact date, Staff B told them Resident 1 had fallen, and Staff B stated they wanted to do an incident report at the time, but Staff E told them not to do it. Staff D stated, in their opinion, an incident report should have been done, and they told Staff B they should talk to Staff E about it. When Staff D was asked if they ever considered talking to Staff E's supervisor they replied, no. When asked if they should have reported it, Staff D replied Yes, they should have and will do it in the future. In an interview on 06/18/2025 at 9:04AM, Staff E stated at the time of Resident 1's alleged fall, could not remember the date, either Staff B or Staff C told them Resident 1 was on the floor. Staff E asked if they had heard a klunk and they replied they had not. Staff E stated they then asked the staff member if the resident had said they had fallen and was told the resident didn't say anything. Staff E then went to Resident 1's room and found the resident on the fall mat on the floor beside the bed and the resident was giggling. Staff E asked Resident 1 if they were hurt and the resident laughed. Staff E stated they then assisted Staff C to put the resident back on the bed then did a visual check of Resident 1 for injuries and found none. Staff E stated that neither Staff C nor Staff B told them they saw Resident 1 fall or voiced an opinion that they thought the resident had fallen. Staff E stated they didn't know if the nurse was notified of Resident'1's alleged fall. When asked, Staff E stated when a resident fell they would stay with the resident, call for a nurse to assess the resident, wouldn't move the resident until nurse says ok, complete an incident report, and follow the incident report process. When asked if the occurrence was reportable, Staff E stated No, they did not believe so. Upon review of the record, no documentation was found by nursing staff or attendant counselors between December 2024 and 04/16/2025 regarding Resident 1 falling and /or hitting their head. No incident reports were completed for Resident 1 experiencing a fall. Reference: 483.12(c)(1)(4) -0640(5)(a)

Based on interviews and record review the facility failed to protect 2 of 5 sampled residents (Resident 1, 2) from abuse. These failures resulted in the potential for physical and psychological harm, and decreased quality of life for all residents. Findings included: <Resident 1> Per record review Resident 1 was cognitively impaired, required assistance for most activities of daily living (ADLs), required one to one direct supervision at all times, and had diagnoses including intellectual disability, and fracture of a finger on the right hand. Per review of a Facility Resident Incident Witness Statement dated 01/15/2025, Staff D, Attendant Counselor (AC) documented they witnessed Staff C, Registered Nurse (RN), on 01/15/2025 at approximately 9:15pm pushing on Resident 1's chest, with their hand, while Resident 1 was lying on their bed, and attempting to put medication into Resident1's mouth. Per review of the Developmental Disabilities Administration 5-Day Investigation Report an interview was documented on 01/21/2025 at 10:42am with Staff E, AC in which they stated they witnessed on 01/15/2025 at 9:15pm Resident 1 being held down against the bed by Staff C who was attempting to give Resident 1 medication. Staff E stated Resident 1's left arm was pinned against their chest by Staff C's hand, who was leaning over Resident 1. Staff E stated they physically removed Staff C's hand from Resident 1 and that is how Staff E knew Staff C was applying pressure to Resident 1's chest. In review of a nursing assessment dated [DATE], Staff F, RN assessed Resident 1 at 10:15pm and documented observation of a red circular mark on Resident 1's upper right chest. Per review of the Developmental Disabilities Administration 5-Day Investigation Report an interview was documented on 01/22/2025 at 3:25pm with Staff F, RN and they stated the red mark they observed on Resident 1's right upper chest on 01/15/2025 was consistent with pressure being applied to that area. Per review of Resident 1's record, photographic documentation dated 01/16/2025 at 12:44am showed a red area on Resident 1's right upper chest. Per review of the Developmental Disabilities Administration 5-Day Investigation Report an interview was documented on 01/21/2025 at 2:41pm with Staff D who was shown the photograph of Resident 1's chest and confirmed the red mark on Resident 1's chest coincided with where Staff C was holding down Resident 1. Per review of the Developmental Disabilities Administration 5-Day Investigation Report an interview was documented on 01/21/2025 at 10:42am with Staff E who was shown the photograph of Resident 1's chest and confirmed the red mark on Resident1's chest coincided with where Staff C was holding down Resident 1. In an interview on 2/7/2025 at 12:04pm, Staff C, RN stated Resident 1 was lying on their bed. Staff C stated they were leaning over Resident 1 attempting to give Resident 1 their medication while holding Resident 1's left hand. Staff C denied leaning on Resident 1 or exerting any pressure on Resident 1's body. On 2/19/2025 at 2:00pm attempted to interview Resident 1 but they did not respond. In an interview on 03/11/2025 at 3:58pm Staff B, Attendant counselor manager (ACM) stated she the red area on Resident 1's right upper chest was still present when she looked on 01/16/2025, the day following the alleged abuse. <Resident 2> According to the 11/25/2024 Assessment, Resident 2, was unable to direct their own care, was dependent on staff for most activities of daily living (ADLs) including moving their wheelchair, and had diagnoses which included, profound intellectual disabilities, cerebral palsy (a brain disorder that permanently affects body movement and muscle coordination), and depression. Per review of RHC Incident Report dated 01/16/2025, Staff J documented they had clocked out for lunch and went into the kitchen in the resident cottage to use the microwave and happened to look down the hall and saw Resident 3 hitting Resident 2 toward their face. Per review of the developmental disability administration 5-day investigation report Staff K stated that on 01/16/2025 at approximately 6:30pm they witnessed Staff J separating Resident 3 and Resident 2. Staff K stated Resident 3 was facing Resident 2 and assaulting Resident 2 with their right hand. Per review of a nursing assessment of Resident 2, Staff K documented on 1/16/2025 at 6:30pm they observed Resident being hit by another resident which resulted in a reddened area and scratches at the base of the left side of Resident 2's neck. In an interview on 03/13/2025 at 2:36:18 PM, Staff I, Attendant Counselor Manager (ACM), stated the expectation for staffing in the cottage where Resident 2 and 3 lived was always at least one staff member on each side of the resident cottage to monitor the residents and keep them within line of sight. This requirement was due to residents, like Resident 3, who needed to be monitored because of their behavior. Staff I stated that the incident would have been avoided if Staff J had not left to take their lunch break without another staff member present to monitor the residents. Reference: WAC 483.12(a)(1)-0640 (1)

Based on interview and record review the facility failed to meet professional standards of practice in provision of providing timely incontinence care for 2 of 3 sampled residents (Resident 1 and 2). This failure placed residents' requiring incontinence care at risk for potential skin injury and decreased quality of life. Findings included: <Resident 1> Per the assessment dated [DATE], Resident 1 had severe cognitive impairment, was dependent on staff for most activities of daily living such as personal hygiene, toileting, and transferring, was incontinent of bowel and bladder, was at risk of skin injury, and had diagnoses including moderate intellectual disability, hypersomnia (excessive sleepiness) with long sleep times, and ataxia (a condition which causes poor muscle control). The care plan dated 11/22/2024 documented staff was to offer Resident 1 the toilet upon awakening, before & after meals, before bedtime, & prn (as needed), and that Resident 1 used bedside commode for toileting. A skin assessment for resident 1 dated 01-12-2025 showed no documentation of any injury to the skin of the buttocks or perineum (area of skin between the genitals and the anus). A nursing progress note dated 01/14/2025 documented Resident 1 had pink, excoriated skin on their buttocks, and an acute plan of care was initiated. A physician progress note dated 01/15/2025 documented the skin of resident 1's buttocks was red and inflamed. In an interview on 01/15/2025 at 3:31pm Staff H, Attendant Counselor 1 (AC1) stated on 01/13/2025 at approximately 6:30pm Resident 1 complained their buttocks was hurting, and when staff checked, Resident 1's buttocks was red and bleeding. During an interview on 01/15/2025 at 4:01pm, Staff D, Attendant Counselor Manager (ACM) stated on 01/13/2025 at approximately 1:20pm they were informed Staff G, AC1 had been floated to a different work site and that the residents Staff G had been caring for, including Resident 1, were wet with urine that had soaked through their clothing. During an interview on 01/16/2025 at 2:07 pm Staff E, AC1 stated they found Resident 1 in urine-soaked clothes and chair pad on 01/13/2025 at 1:00pm when they took over resident care from Staff G, AC1. They stated upon removing Resident 1's wet clothing and brief, the skin on Resident 1's buttock was red and bleeding. When asked how often the residents were checked and changed, Staff E stated it was supposed to be every 2 hours. In an interview on 01/21/2025 at 2:41pm Staff G, AC1 stated they were working with Resident 1 on 01/13/2025 and at approximately 11:00am noticed the resident was wet from urine but did not change them at that time. Staff G stated they were sent to a different work site at 12:00pm that same day and when they left, Resident 1 was still wet and had not been changed. They stated the lead attendant counselor, Staff I Attendant Counselor 2 (AC2) was also aware Resident 1 was wet. When asked if Resident 1 should have been changed, Staff G stated they knew the resident should have been changed and that it was unacceptable to leave a resident wet. During an interview on 01/16/2025 at 1:46pm when asked how often residents are checked and changed, Staff D stated, at least every two hours. When asked if Resident 1 had skin injury on their buttocks prior to being left in a wet brief and clothing on 01/13/2025, Staff D stated the redness was new and was the result of being left wet. <Resident 2> Per the assessment dated [DATE], Resident 2 had severe cognitive impairment, was dependent on staff for activities of daily living including personal hygiene, toileting, and transferring, was incontinent of bowel and bladder, was at risk of skin injury, and had diagnoses including profound intellectual disabilities, quadriplegia ( a type of paralysis that affects all a person's limbs and body from the neck down), and moisture associated skin damage. The care plan dated 11/12/2024 for Resident 2 documented they had no concept of the need to use the restroom and were unable to communicate when they had been incontinent. Staff were to check for incontinence frequently and were to provide all peri-care (cleaning of the private parts area) to reduce risk of skin breakdown. A nursing progress note dated 01/13/2025 documented, Resident 2 had a moisture associated rash, pink in color, with no open areas to bilateral groin, peri area (area of skin between the genitals and the anus), and buttocks. An acute plan of care was initiated to monitor rash. A nursing progress note dated 01/14/2025 documented, Resident 2 continued to have redness to bilateral groin and a pink area on the right buttock. During an interview on 01/15/2025 at 4:01pm, Staff D stated on 01/13/2025 at approximately 1:20pm they were informed Staff G had been floated to a different work site and that the residents Staff G had been caring for, including Resident 2, were wet with urine that had soaked through their clothing and wheelchair pads. During an interview on 01/16/2025 at 2:07pm Staff E stated they arrived at work at 1:00pm on 01/13/2025 and took over the residents that Staff G, AC1 had been caring for that day. Staff E stated shortly after starting their shift they went to check on Resident 2 and found them in urine-soaked clothing and the wheelchair pad also soaked with urine. When asked how often the residents get checked and changed, Staff E stated it was supposed to be every two hours. In an interview on 01/21/2024 at 2:41pm, Staff G stated on day shift, checking and changing residents was supposed to be performed upon the employee's arrival in the morning, after breakfast, after lunch, and right before end of shift. Staff G stated they knew Resident 2 was wet after breakfast at approximately 8:35am and did not change them at that time. Staff G stated they were sent to a different work site at 12:00 that same day and when they left, Resident 2 was still wet and had not been changed. They stated the lead attendant counselor, Staff I Attendant Counselor 2 (AC2) was also aware Resident 2 was wet. When asked if Resident 2 should have been changed, Staff G stated they knew the resident should have been changed and that it was unacceptable to leave a resident in a wet incontinent brief. During an interview on 01/16/2025 at 1:46pm when asked how often residents are checked and changed, Staff D stated, at least every two hours. Reference: WAC: 388-97-1060 (1)

Based on observation, interview, and record review the facility failed to test modified fluid consistencies after preparation and before serving to vulnerableresidents at risk for aspiration (inhalation of food, liquid, or other material into the airway or lungs) in accordance with professional standards of practice and resident needs for 3 of 9 sampled residents (Residents 8, 30 and 43), reviewed for food and nutrition services. In addition, the facility failed to ensure that foods were stored and prepared in a safe manner, and dishwasher temperatures met the required standard which placed residents at risk for food borne illness and diminished quality of life for all 75 residents. The failure if the facility to make sure that residents at risk of aspiration received the correct fluid consistency represented an immediate jeopardy (IJ). On [DATE] at 8:01 PM, the facility was notified an IJ was identified related to F812 CFR S483.60 Food Procurement/Store/Serve/Sanitary. The facility removed the immediacy on [DATE] with an onsite verification by surveyors ensuring the facility tested thickened fluids after preparations and before serving to the residents, completed audits and training for staff. Findings included . <MODIFIED FLUID CONSISTENCY> Review of the facility policy titled, Liquid Consistencies, revised ,d+[DATE], showed the facility followed the International Dysphagia (swallowing difficulties) Standardization Initiative (IDDSI) for texture descriptions and terminology. The policy categorized liquids into 4 levels from ,d+[DATE]; Level 0- thin: liquid consistency that has not been altered. Level 2- nectar thick/mildly thick: liquids that in their natural state were similar to a nectar consistency or other liquids that have been thickened to that consistency. When poured from a spoon, the nectar thick would coat the spoon then quickly drain off, but slower than thin liquid. Level 3- honey thick/moderately thick: liquids were thickened to a consistency similar to honey. When poured from a spoon, honey thick/moderately thick liquids would not stick to the spoon. Honey thick/moderately thick liquids drip slowly in dollops through the prongs of a fork and could be drank from a cup or glass. Level 4- spoon thick/extremely thick: this consistency was also called pudding thick because these liquids were thickened until they resemble a pudding texture. These liquids do not pour and show only slow movement under gravity. This consistency fell off of a spoon and held its shape when dropped onto a plate without spreading out. The policy instructed staff to use commercially prepared thickened liquids or create different thickened liquid consistencies by using a thickening gel thickener via a pump dispenser. The policy directed staff to use one pump of gel thickener in four ounces of thin liquid to produce a nectar thick liquid, use two pumps of gel thickener in four ounces of thin liquid to produce a honey thick liquid, and use four pumps of gel thickener in four ounces of thin liquid to produce a spoon thick consistency. The policy further showed a resident could chose a more modified liquid but not one that was less modified and included the example a resident on a honey thick liquid could choose a spoon thick liquid but not a nectar thick or thin liquid. The International Dysphagia Diets Standardization Initiative website, IDDSI.org showed with regard to modified drink thicknesses showed some people have problems feeding, chewing or swallowing. This means some food and drinks are a danger for choking or for material to 'go down the wrong way' and into the airway. The International Dysphagia Diet Standardization Initiative, through consultation and following best practice principles, has developed a global standardized way of describing food and drinks that are safest for people with feeding, chewing or swallowing problems Simple measurement methods are included in the framework. These methods confirm the IDDSI level a food or drink belongs to, or if it is unsafe for people with feeding, chewing or swallowing problems The IDDSI Funnel [a 10-millimeter (ml) syringe with a larger whole on the top syringe end with a funnel attached to pour fluid into and a small nozzle hole on the lower end to allow fluid to flow through, and syringe labeled from bottom to top with zones for level ,d+[DATE] fluid thickness] is intended to check the flow rate of a liquid. The IDDSI level depends on liquid remaining after 10 seconds flow: cover [small lower] nozzle with finger, pour [liquid] to fill line, remove finger from nozzle as you start the stopwatch, stop at 10 seconds [plug small nozzle whole with finger] . Fluids are categorized by thickness from ,d+[DATE]; Level 0 - thin fluids, flow like water, fast flow, can drink through any typer of teat/nipple, cup or straw. Less that 1 ml remaining in the 10ml slip tip syringe after 10 seconds of flow. Level 1- slightly thick, thicker than water, requires a little more effort to drink than thin liquids, flows through a straw, syringe, teat or nipple. ,d+[DATE] mls remain in the syringe after 10 seconds of flow. Level 2- mildly thick, flows off a spoon, skippable, pours quickly from a spoon, but slower than thin liquids. Mild effort is required to drink this thickness through standard bore straws. ,d+[DATE] mls remain in the syringe after 10 seconds of flow. Level 3- moderately thick, moderate effort is required to suck through a standard bore straw, cannot be eaten with a fork because it drips slowly in dollops through the prongs, can be eaten with a spoon. Over 8 mls remain in the syringe after 10 second of flow. Drips slowly in dollops through the prongs of a fork, easily pours from spoon when tilted; does not stick to spoon. Level 4- extremely thick, usually eaten with a spoon (a fork is possible), cannot be drunk from a cup because it does not flow easily, cannot be sucked through a straw, falls off spoon in a single spoonful when tilted and continues to hold shape on plate, not sticky. Cannot test using the IDDSI flow test, must use the fork drip test or spoon tilt test. When a fork is pressed on the surface of a level 4 extremely thick liquid, the tines/prongs of a fork can make a clear pattern on the surface, and/or the food retains the indentation from the fork. Fork drip test, sample sits in a mound/pile above the fork; a small amount may flow through and form a short tail below the fork tines/prongs, but it does not flow or drip continuously through the prongs of a fork. Using the spoon tilt test, a spoonful must plop off the spoon if the spoon is tilted or turned sideways; a very gentle flick (using only fingers and wrist) may be necessary to dislodge the sample from the spoon, but the sample should slide off easily with very little food left on the spoon. The National Institute of Health (NIH) website nih.gov showed with regard to aspiration showed aspiration occurs secondary to swallowing dysfunction, reflux [when stomach contents such as food or acids flow back into the throat], or inability to protect the airway adequately. The presence of foreign material in the lungs subsequently initiates an inflammatory response. On physical exam, early signs can include wheezing [high-pitched whistling sound that occurs when air moves through narrowed or blocked airways in the lungs], chronic cough, nocturnal [occurring at night] cough, and/or recurrent pneumonia [lung infection], as well as abnormal lung sounds, including rhonchi [low-pitch snoring or gurgling noises caused by generalized obstruction in the airway] or crackles [bubbling, rattling, or clicking lung sounds caused by air passing through fluid, mucus, or pus] on auscultation [listening to body sounds during examination]. Decreased or lack of breath or sounds can be a finding if a complete obstruction [blockage] has occurred. Desaturation [blood oxygen levels drop below normal levels] on pulse oximetry [a way to measure the amount of oxygen in one's blood] can demonstrate a worsened aspiration syndrome, given that a significant portion of the respiratory tract must be knocked out to cause overall hypoxemia [condition that occurs when there is not enough oxygen in the body's tissues or cells]. <Resident 8> Review of the quarterly assessment, dated [DATE], showed Resident 8 had diagnoses including cerebral palsy (condition that affects muscle tone, movement, and coordination), microcephaly (when a baby's head is smaller than normal), and legal blindness. Resident 8 was dependent on staff assistance to perform most activities of daily living (ADLs) including eating. Resident 8 had severe cognitive impairment and needed a mechanically altered diet that required a change in food texture or liquid consistency. The assessment further showed Resident 8 did not show signs and/or symptoms of a possible swallowing disorder such as loss of liquids/solids from mouth when eating or drinking, holding food in mouth or cheeks, coughing or choking during meals, or complaints of difficulty or pain with swallowing. Review of the [DATE] comprehensive nutritional assessment showed Resident 8's diet consistency was puree for solid foods and pudding/spoon thick liquids. The assessment showed Resident 8 required feeding assistance to be at a slow rate to minimize coughing, allow time between bites for oral clearance, and staff were to encourage a second swallow for each bite. Staff were to encourage fluid intake. The assessment further showed Resident 8 had no changes in appetite or fluid intake, but staff noted increased coughing. Review of the [DATE] Resident Diet Cardex showed Resident 8's diet was puree for solids and level 4 extremely thick liquids. Resident 8 was to receive 16 ounces (oz) of water/flavored water with meals, three times daily. Review of [DATE] provider progress note showed Resident 8 had diffuse rhonchi, and decreased oxygen saturation levels that resolved within 24 hours that was likely related to position or possible mild aspiration. Review of [DATE] nutrition notes showed Resident 8's diet consistency was puree for solids and spoon thick (level 4) liquids. Resident 8 was observed eating breakfast. Staff prepared and served Resident 8's meal then provided 1:1 feeding assistance. Resident 8 ate all of their meal and drank almost all of their fluids. Resident 8 had occasional coughing throughout the meal and staff encouraged Resident 8 to clear their throat. Review of [DATE] provider orders showed Resident 8's diet consistency was puree texture with spoon thick level 4 liquids. During observation, interview, and record review on [DATE] at 11:25 AM, Staff J, Attendant Counselor (AC), was observed preparing thickened fluids using a gel thickener via a pump dispenser. Staff J stated the side of the thickening agent bottle had directions on how many pumps to use when making 4 oz, 6 oz, and 8 oz of thickened fluids. Staff J stated that some fluids reacted to the thickening agent and required either more or less pumps of thickener. Staff J further stated cottage staff made thickened fluids every meal and used approximately one 55oz bottle of gel thickener a day because staff made so many thickened fluids. Staff J was asked to verify the thickened fluid consistency created was accurate. Staff J stated they had not done that in a long time, pulled out a quick reference guide card, and a fork. Review of the directions for use on the side of the thickening agent gel bottle directed staff to follow and use the usage chart to dispense appropriate amount of gel thickener into beverages. The directions included a strokes per beverage chart for 4 oz, 6 oz, and 8 oz. For nectar thick consistency, the chart showed one pump was required to make 4 oz of nectar thick, no pump guidelines were included for 6 oz of nectar thick fluid, and showed two pumps was required to make 8 oz of nectar thick fluids. For honey thick consistency, the chart showed two pumps were required to make 4 oz of honey thick, no pump guidelines were included for 6 oz of honey thick fluid, and showed four pumps were required to make 8 oz of honey thick fluids. For pudding thick consistency, the chart showed four pumps were required to make 4 oz of pudding thick fluid, no pump guidelines were included for 6 oz of pudding thick fluid, and eight pumps were required to make 8 oz of pudding thick fluids. The directions did not specify some fluids reacted to the thickening agent differently and would require either more or less gel thickener to create the appropriate desired consistency. During an observation on [DATE] at 11:32 AM, Resident 8 had a clear cup of red and orange thickened fluids on the table in front of them. Staff K, AC, assisted Resident 8 with their meal and Resident 8 began to cough. During continuous observation, interview, and record review on [DATE] from 5:20 PM until 05:55 PM, Staff L, AC, was observed pumping gel thickener into different size cups, placing them on the kitchen counter, pouring colored fluids into the cups, and mixed fluids. Staff L was not observed verifying or testing any fluids made for accurate consistency. At 5:39 PM, Staff K, served Resident 8 a plate of food and two cups of thickened fluids without testing or verifying the liquid consistency was accurate, one cup contained a red thickened fluid, and one cup contained an orange thickened fluid. At 5:41 PM, Staff K, spooned the red thickened fluid into Resident 8's mouth, the red thickened fluid dripped down the front of Resident 8's mouth down to their chin. Review of Resident 8's Diet Cardex used by staff for reference when they made the thickened fluids during this meal service, showed Resident 8 was to be served extremely thick fluids. At 5:45 PM, Staff K was asked if they verified the thickened fluid consistency was accurate prior to serving Resident 8, Staff K stated they could tell what consistency a fluid was by looking at it, as they mixed the red thickened fluid in the cup with a spoon and red thickened fluid dripped off the spoon when turned over. Staff K stated Resident 8 was to receive extremely/pudding thick fluids while they continued to stir the red thickened fluid in front of them, turned a spoonful of red thickened fluid over and red fluid dripped off the spoon. Staff K was asked to test and verify the thickened fluid consistency was accurate for the fluid they were assisting Resident 8 drink. Staff K was prompted to pull out their name badge that contained a quick reference guide on modified liquid consistencies and how to test/verify consistency using the syringe drip flow, fork drip or spoon tilt tests. Staff K placed the red thickened fluid they had given to Resident 8 on top of fork prongs, the red thickened fluid proceeded to slowly drip through the fork prongs into the cup in a long continuous drip. Staff K was then asked to test and verify the orange thickened fluid consistency was accurate. Staff K placed the orange thickened fluid on top of fork prongs, and it immediately dripped through the fork prongs, quicker than the red thickened fluid that was just tested . Resident 8 was observed coughing. Staff K stated they were unsure how to determine what size a cup was. Review of [DATE] nursing progress notes showed on [DATE] Resident 8 coughed during their dinner meal related to possibly having the incorrect liquid consistency. A 11:23 PM, Resident 8 had some rhonchi to their right lung. In an interview on [DATE] at 10:37 AM, Staff B, Director of Nursing (DNS), stated the facility used a variety of cup sizes and direct care staff were trained by their managers on how to identify a cup's size. In a follow-up interview on [DATE] at 10:45 AM, Staff B, stated they expected staff to appropriately thicken fluids and verify proper consistency each time fluids were thickened. <Resident 30> Per the [DATE] quarterly assessment, Resident 30 had diagnoses which included profound intellectual disabilities, seizures and arthritis. Resident 30 had severe cognitive impairment, needed total assistance for eating and required moderately thickened fluids. Per the [DATE] nutrition assessment, Resident 30 was to be given one bite/sip via spoon, wait for swallow and then provide them with an empty spoon bite to elicit dry swallow to assist with residue clearance and decrease risk of aspiration. Review of the [DATE] Diet Cardex documented Resident 30's diet was puree for solids and level 3 moderately thick liquids. Resident 30 was to be offered an 8 to 12 oz glass of water prior to food and 8 oz of water with meals, three times daily. Review of [DATE] provider orders showed Resident 30's diet consistency was puree texture with moderately thick level 3 liquids. During an observation on [DATE] at 5:50 PM, Staff Y, AC, was observed making thickened fluids using a gel thickener via a pump dispenser. Staff Y tested the crystal light drink with a fork and the fluid trickled through the fork prongs very quickly (Faster than moderately thickened fluids) and Resident 30 was served the fluid. In an interview on [DATE] at 5:50 PM, Staff Y stated the fluid was moderately thick and it could be checked for the correct consistency by using a fork or a dropper. Staff Y stated if the fluid went through the fork tongs, it was considered moderately thick. During an interview on [DATE] at 5:51 PM, Staff Z, ACM, stated they have thickened fluids for so long that they can eyeball the fluids for the correct consistency, or they can check the fluids with a spoon or the dropper. Staff Z stated the fluids could be checked by using a fork and for moderately thickened fluids it would look like honey falling off the fork. Staff Z added it was important to thicken fluids to the correct consistency to prevent aspiration. <Resident 43> Per the [DATE] annual assessment, Resident 43 had diagnoses which included intellectual disabilities and serious mental illness. Per the [DATE] nutrition assessment, Resident 43 required moderately thickened liquids and fluids served in a cup with a straw. The resident needed staff assistance to maintain the straw in the cup and intermittent supervision for eating. Resident 43 was to alternate bites of solids with liquids, decrease bite size, slow down while eating, and take a break between every one to two sips of liquids from the straw. During the initial dining observation in the kitchen and dining area on [DATE] at 11:24 AM, Staff CC, AC, prepared thickened liquids for Resident 43. Staff CC was observed stirring thin liquids mixed with thickener with a spoon in two different cups (red and blue). After they finished stirring the liquids, Staff CC did not test the consistency of either fluid cups. At 11:26 PM, Staff CC placed the lids on the cups. At 11:29 AM, Staff DD, Attendant Counselor, placed the now covered blue and red cups in front of Resident 43 on the table and put a straw in each cup. At 11:31 AM, Resident 43 picked up one of the cups, sipped from the straw and immediately coughed. The resident coughed at various time while drinking from the straw. FOOD STORAGE AND LABELING Review of the facility policy titled, Food Storage updated ,d+[DATE], showed when food was stored improperly it could allow harmful bacteria to grow and cause illness. Food must be stored at appropriate temperature for those that require temperature control and foods must only be stored for a certain amount of time for both product safety and quality. Marking the date on food items was essential so that others knew when items should be discarded. The policy showed each cottage refrigerator (fridge) and freezer would be monitored continuously via use of an electronic thermometer with a display outside of the cold-holding unit in which an alarm would sound if the temperature(s) traveled outside of appropriate pre-set ranges. Additionally, refrigerators and freezers would have a secondary internal thermometer to use as a backup. The policy instructed staff to check the back up thermometer, if the temperature was found to be out of parameters (between 32 and 41 degrees Fahrenheit (F) for refrigerators and 32 degrees F or below for freezers). The policy included a food algorithm decision tree chart to help staff identify and assign food discard dates. The policy specified food delivered from the facility's main kitchen was to be discarded by midnight the day it was received, read-to-eat foods brought by residents or leftovers brought back to campus were to be discarded within 24 hours of arriving on campus, food items delivered from an outside retailer or packaged food from a retailer should be verified for manufacturer's best by dates. The policy further showed unopened foods may be stored until the manufacturer's best by date and stored in the refrigerator, freezer, or other food-safe area for shelf-stable items as appropriate. If an item did not require refrigeration after opening, it was to be used within 3-months of opening or the manufacturer's best by date, whichever came first. If an item required refrigeration after opening it was to be dated and used within seven days of opening or the manufacturer's best by date, whichever came first. For items that required freezing were to be used within one month of opening or the manufacturer's best by date, whichever came first. <Main Kitchen> During an observation on [DATE] at 10:01 AM, the main kitchen refrigerator had a roux (Mixture of fat and flour used in making sauces) dated [DATE], and a cake that had no date. Staff G, Cook, stated items were looked at weekly for expiration dates and the roux was missed. Staff G further stated it was important to discard expired foods to prevent bacteria. In an interview on [DATE] at 10:22 AM, Staff D, Dietary Manager, verified there was no date on the cake. Staff D stated food should be labeled with the date it was prepared and a use by date to prevent bacteria and illness. <Ponderosa Cottage> During observation on [DATE] at 9:06 AM, the cottage fridge contained an undated white to go container labeled with ,d+[DATE] cup apricots lunch, and a square box of prune juice labeled in black sharpie with O- ,d+[DATE] and X- ,d+[DATE]. During observation and interview on [DATE] at 9:13 AM, Staff M, Cottage Manager, stated prune juice box labeled with O was for the open date and the X was the expiration date. Staff M explained refrigerator and freezer temperatures were checked every shift and documented on the back of the cottage shift exchange form. Staff M reviewed [DATE] through [DATE] shift exchange form documentation with the surveyor. Staff M acknowledged the refrigerator and freezer temperature verification line was not transferred over from [DATE] to [DATE]. Staff M was unable to locate refrigerator or freezer temperature verification documentation for [DATE]. <Tamarack Cottage> During observation on [DATE] at 9:25 AM, the cottage refrigerator had a digital thermometer attached to the side with two cords, one ran into the fridge and the second ran into the freezer. Probe one read 29 F and probe two read 82 F, no visual alarm on the thermometer was seen nor an audible alarm heard. Upon opening the fridge, the temperature probe was noted to be attached to the inside of the fridge with a suction cup. Upon opening the freezer, the thermometer probe was missing the suction cup and probe dangled below the freezer door seal. The freezer contained an undated and unlabeled bag of green beans and French toast that were frozen solid. In an interview on [DATE] at 9:29 AM, Staff N, AC, and Staff O, Licensed Practical Nurse (LPN), acknowledged the thermometer attached to the side of the refrigerator read 81 F and there was no visual alarm seen nor audible alarm heard. Staff O obtained a different thermometer to verify temperatures. Staff N acknowledged the freezer thermometer probe was not attached to the freezer and dangled outside the freezer right above the floor. During observation, interview, and record review on [DATE] at 9:41 AM, Staff P, Cottage Manager, stated freezer items were to be labeled the day they arrived on the cottage. Staff P was shown the freezer thermometer probe dangled outside the freezer. Staff P stated fridge and freezer temperatures were checked by staff every shift and initialed on the back of the shift exchange form. Staff P reviewed [DATE] through [DATE] refrigerator and freezer temperature verification documentation. Staff P acknowledged there were only staff initials for one shift on [DATE] and [DATE]. <Harvest Cottage> During an observation on [DATE] at 2:03 PM, the cottage refrigerator had an undated open bag of frozen waffles, no open or use by date was found. In an interview on [DATE] at 2:03 PM, Staff K, LPN, acknowledged there should be an open date on the package of waffles. <[NAME] Cottage> During an observation on [DATE] at 11:22 AM, the cottage refrigerator contained tater tots and chicken nuggets dated [DATE], two containers of prune juice, one container of prune juice was labeled as opened on [DATE] and the second had no open date. Staff I, ACM, stated the tater tots and chicken nuggets were good for three months and the prune juice was good for seven days after it was opened. Staff I stated the food, and juice should have been discarded as it could cause illness. <Dishwasher Temperatures> During an observation of the kitchen on [DATE] at 3:43 PM, Staff D, Dietary Manager, ran the dishwasher twice and the final rinse was 167 degrees, not 180 degrees as required. Staff D stated they thought the dishwasher was a high temperature dishwasher but would have to check. In an interview on [DATE] at 3:32 PM, Staff D stated when the dishwasher temperature was out of range, the staff needed to let it cool down and run it again. Review of the dishwasher temperature logs from August through [DATE] documented the following: [DATE] 160 degrees in AM [DATE] 165 degrees in AM, 175 degrees in pm [DATE] 160 degrees in AM [DATE] 160 degrees in AM [DATE] 165 degrees in PM [DATE] 160 degrees in PM [DATE] 175 degrees in AM [DATE] 175 degrees in AM [DATE] 175 degrees in AM [DATE] 177 degrees in AM [DATE] 175 degrees in AM, 176 degrees in PM [DATE] 178 degrees in PM In an interview on [DATE] at 1:48 PM, Staff D confirmed the dishwasher was a high temperature dishwasher. Staff D stated it was important for the dishwasher to reach the final rinse temperature of 180 degrees to kill the bacteria. <Facial and hair coverings> During the initial kitchen tour on [DATE] at 9:21 AM, it was observed that Staff E, Food Service Supervisor, had a long goatee and was baking cookies. Staff E's goatee was not covered by a hair net. During an observation on [DATE] at 10:16 AM, Staff F, Cook, had a beard and was preparing food for lunch. Staff F's beard was not covered by a hair net. During an interview on [DATE] at 12:35 PM, Staff D, Dietary Manager, stated hair nets were to be worn on facial hair when working with food. Staff D added this was important to prevent contamination and bacteria. Reference WAC: [DATE] (3), -2980 46115

Based on observation, interview, and record review the facility failed to review policies yearly as required, perform hand hygiene and/or glove changes when indicated, handle, store, and transport laundry in a manner to prevent the spread of infection. In addition, the facility failed to place signage in a conspicuous location outside the residents' room to clearly identify transmission based precautions implemented and appropriate personal protective equipment (PPE) to be used, and implement enhanced barrier precautions to prevent the spread of multidrug-resistant organisms (MDROs) for 1 of 3 sampled residents (Resident 14), reviewed for infection control. This failure placed residents at risk of development of a MDROs, communicable diseases, and diminished quality of life. Finding included . POLICIES Review of facility policy titled, Antibiotic Stewardship Program showed the policy was last reviewed 08/24/2022. In an interview on 09/26/2024 at 1:12 PM, Staff Q, Infection Preventionist, stated infection control policies were typically reviewed yearly, and the last review date would be documented on the policy itself. In an interview on 09/26/2024 at 2:39 PM, Staff B, Director of Nursing (DNS), stated nursing related policies and procedures were reviewed yearly and as needed. Staff B further stated the last review date would be documented on the policy itself. In a follow-up interview on 09/26/2024 at 2:54 PM, Staff B, reviewed the Antibiotic Stewardship Program policy and acknowledged it was last reviewed 08/2022. Review of facility policy titled, Infection Prevention and Control Program showed the policy was last reviewed and/or updated on 08/24/2022. In a follow-up interview on 09/26/2024 at 2:57 PM, Staff B, reviewed the Infection Prevention and Control Program policy and acknowledged it was last reviewed 08/2022. Review of facility policy titled, Resident Health Program showed the policy was last reviewed 11/22/2022. In a follow-up interview on 09/26/2024 at 3:03 PM, Staff B, reviewed the Resident Health Program policy and acknowledged it was last reviewed 11/2022. Review of facility policy titled, Surveillance for Healthcare Acquired Infections showed the policy was last reviewed/updated on 03/03/2023. In a follow-up interview on 09/26/2024 at 3:02 PM, Staff B, reviewed the Surveillance for Healthcare Acquired Infections policy and acknowledged it was last reviewed 03/03/2023. Review of facility policy titled, Handling and Washing Soiled Laundry revised 05/26/2022, showed all used linen and/or laundry was considered contaminated. Laundry was defined as a resident's personal clothing, linens (sheets, blankets, pillows), towels, and washcloths. The policy showed staff were to use PPE that was adequate to prevent exposure while handling or sorting. The policy required staff to wear gloves and clothing protection when sorting soiled laundry. In a follow-up interview on 09/26/2024 at 3:05 PM, Staff B, reviewed the Handling and Washing Soiled Laundry policy. Staff B stated staff were required to wear gloves and clothing protection when sorting soiled laundry. Staff B acknowledged the policy was last reviewed 05/26/2022. LAUDNRY <Ponderosa> During observation and interview on 09/20/2024 at 10:12 AM, Staff M, Cottage Manager, walked through the laundry room with the surveyor. The laundry room had a yellow taped line to separate the dirty side of the laundry room with the washers and the clean side of the laundry room with the dryers. A large barrel full of dirty clothes, above the rim without a lid was observed next to the washer. Numerous cabinet and cupboard doors were open, with piles of clean folded clothes sitting inside open cabinets, on the counters, on top of the dryer and on top of the washer. Staff M stated resident's personal clothing and mechanical lift transfer slings were washed in the cottage. Staff M stated staff were only required to wear gloves when sorting dirty laundry. Staff M acknowledged the laundry room was not very organized and began to shut cabinet doors. <Tamarack> During observation and interview on 09/23/2024 at 9:16 AM, Staff N, Attendant Counselor (AC), walked through the laundry room with the surveyor. The laundry room did not have a visual line to separate the dirty side of the laundry room with the washers and the clean side of the laundry room with the dryers. Staff N stated the laundry room was not separated by clean or dirty, it was separated by right and left side of the cottage. Staff N explained that the washer and dryer on the left side were used to wash resident's personal clothing from the left side of the cottage and the washer and dryer on the right side were used to wash resident's personal clothing from the right side of the cottage. Staff N further stated staff were only required to wear a pair of gloves when sorting dirty laundry. Staff N explained clean clothes was either hung up or folded per load then delivered to each resident individually and acknowledged staff did not cover clean clothing when it was transported back to the resident's room. In an interview on 09/26/2024 at 12:28 PM, Staff R, Case Manager Registered Nurse (CMRN), stated they were unsure of the laundry process but expected staff to wear appropriate PPE for handling soiled laundry and handle, store, and transport laundry in a way to prevent infection. In an interview on 09/26/2024 at 1:17 PM, Staff Q, Infection Preventionist, explained laundry rooms should be separated by clean and dirty side to prevent cross contamination, air should not flow from the dirty side to the clean side, staff should wear gloves and a gown if soiled laundry may touch staff's clothing, once washed clean laundry should be stored and transported covered to be shielded from recontamination. Staff Q was unsure of the laundry process on the cottages and acknowledged they had not assessed the cottage laundry rooms to ensure staff followed appropriate infection control procedures. Staff Q acknowledged clean clothing should not sit out exposed and uncovered. Staff Q expected staff to follow appropriate infection control procedures when handling, storing, processing, and transporting laundry. In an interview on 09/26/2024 at 3:06 PM, Staff B, DNS, stated resident's personal laundry was washed on the cottages. Staff B reviewed the handling and washing soiled laundry policy and acknowledged staff should wear gloves and a gown when sorting soiled laundry. Staff B further stated laundry rooms had to be separated by clean and dirty sides, once clean laundry should be stored and transported covered. Staff B acknowledged the washer was considered dirty and clean laundry should not be stored on the dirty washer. Staff B expected staff to wear appropriate PPE when handling soiled laundry and handle, store, process, and transport laundry in a manner to prevent the spread of infection. HAND HYGIENE The website CDC.gov - in which CDC refers to Centers for Disease Control and Prevention- with regard to hand hygiene showed, hand hygiene protects both healthcare personnel and patients. Hand hygiene means handwashing with water and soap or antiseptic hand rub (alcohol-based foam or gel hand sanitizer) . gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning [applying] gloves and touching the patient or the patient's surroundings recommendations for hand hygiene in healthcare settings . immediately before touching a patient, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal cleaning hands at key times with soap and water or hand sanitizer that contains at least 60% alcohol is one of the most important steps you can take to avoid getting sick and spreading germs to those around you. There are important differences between washing hands with soap and water and using hand sanitizer When washing hands with soap and water rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and use disposable towels to dry. Use a towel to turn off the faucet to use alcohol-based hand sanitizer, put product on hands and rub hands together cover all surface and rub until hands feel dry, this should take around 20 seconds. During observation on 09/18/2024 at 11:07 AM, Staff S, AC, served food onto a red divided plate, checked the temperature, rinse the thermometer with water, wiped the thermometer with a brown paper towel, then discarded the paper towel in the trashcan touching the trashcan lid. Staff S did not perform hand hygiene then proceeded to deliver resident meals. At 11:09 AM, Staff S returned to the kitchen to serve up more food without performing hand hygiene, checked food temperature, rinsed the thermometer with water, wiped the thermometer with a brown paper towel, then discard the paper towel in the trashcan, again touching the trashcan lid. Staff S did not perform hand hygiene and returned to the kitchen to place the thermometer in a protective sheath. At 11:13 AM, Staff S assisted a resident with their mobile device, washed their hands with soap and water, discarded the paper towel in the trashcan, again touching the trashcan lid, did not perform hand hygiene, proceeded to check food temperature, then used alcohol-based hand rub (ABHR) on the palm of their hands for five seconds. During observation on 09/20/2024 at 10:59 AM, Staff M, Cottage Manager, put a pair of purple gloves on without performing hand hygiene prior. During observation on 09/23/2024 at 11:33 AM, Staff T, AC, did not perform hand hygiene, adjusted a resident's wheelchair, removed the residents protective arm sleeves, placed a spoon in the resident's right hand, and assisted them with their lunch meal. During observation on 09/23/2024 at 3:19 PM, Staff U, Licensed Practical Nurse, rolled a gray rolling cart into the living room with an uncovered jug of water, placed a pair of purple gloves without performing hand hygiene, pulled out and unfolded a rolling white privacy curtain without removing gloves or performing hand hygiene, then proceeded to administer water via a feeding tube to a Resident. In an interview on 09/26/2024 at 12:32 PM, Staff R, CMRN, stated hand hygiene was cleansing hands with soap and water for at least 20 seconds or using alcohol-based hand rub (ABHR). Staff R further stated hand hygiene should be performed in between residents, between care, or when moving from a dirty site to a clean site on the same residents. Staff R stated if hand hygiene was not performed when indicated there was a potential for infection to spread and expected staff to perform hand hygiene when indicated. In an interview on 09/26/2024 at 1:35 PM, Staff Q, Infection Preventionist, stated hand hygiene was washing hands with soap and water or using ABHR. Staff Q explained hand hygiene was the first and last step when applying or removing PPE such as putting on and removing gloves. Staff Q stated staff should perform hand hygiene after they perform any task that is considered dirty such as using the bathroom, eating, or dealing with trash. Staff Q acknowledged if hand hygiene was not performed when indicated it could cause cross contamination, spread multi-drug-resistant organisms, and infections. Staff Q expected staff to perform hand hygiene when indicated. In an interview on 09/26/2024 at 3:16 PM, Staff B, stated hand hygiene was washing hands with soap and water for at least 20 seconds or use of ABHR with proper techniques. Staff B stated hand hygiene should be performed before and after contact with a resident or their immediate environment, before and after eating, and if moving to a contaminated body area to a clean area on the same resident. Staff B expected staff to perform proper hand hygiene when indicated because proper hand hygiene prevents the spread of infection. TRANSMISSION BASED PRECAUTIONS The website CDC.gov - with regard to enhanced barrier precautions showed, Enhanced Barrier Precautions [EBP] are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents know to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) . Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated EBP is a less restrictive approach to MDRO prevention that places fewer limitations on resident activities Enhanced Barrier Precautions are currently recommended to be used broadly, in all units across the whole facility, for resident who meet the above criteria. This broader application includes facilities where targeted MDROs have not yet been identified and is intended to minimize the transmission of MDROs in nursing homes Indwelling medical devices and wounds are risk factors for colonization with a MDRO. Once colonized, these residents can serve as sources of transmission within the facility. The expansion of EBP for all resident with wounds or indwelling medical devices is intended to protect these high-risk individuals both from acquisition and from serving as a source of transmission if they have already become colonized An indwelling medical device provides a direct pathway for pathogens in the environment to enter the body and cause infection. Examples of indwelling medical devices include, but not limited to, indwelling urinary catheters, feeding tubes, peripherally inserted central catheters [PICC] Enhanced barrier Precautions is primarily intended to apply to care that occurs within a resident's room where high-contact resident care activities, including transfers, are bundled together with other high-contact activities, such as morning or evening care Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of precautions and the recommended PPE to be worn when caring for the resident. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure precautions are followed. Signs should not include information about the resident's diagnosis or the reason for precautions. CDC has created exampled of signs that can be used by facilities to communicate information about Transmission-Based and Enhanced Barrier Precautions. Review of facility policy titled, Enhanced Barrier Precautions dated 05/14/2024, defined high contact care activities as dressing, bathing/showering, transferring in a resident's room (common areas not included since duration is anticipated to be short), providing hygiene, changing linens, changing briefs, or assisting with toileting, device care or use, and wound care. Indwelling medical devices were defined as indwelling catheters, feeding tubes, and PICC lines. The policy instructed staff to perform hand hygiene prior to applying PPE, apply a gown and gloves before entering a EBP identified resident's room to perform high-contact activity, remove gown and gloves immediately after activity and before exiting the room, dispose of used PPE in the garbage can, use ABHR after removing gloves or wash hands with soap and water if visibly soiled. The policy further showed CDC EBP signage would be posted in a designated common area close to a PPE source supply for staff reference but were not to be placed on a resident's room door, a laminated blue glove sign would be hung above the resident's bed to direct staff the need for EBP. <Resident 14> Review of the quarterly assessment, dated 07/03/2024, showed Resident 14 diagnoses included spastic quadriplegic cerebral palsy (condition that affects muscle tone, movement, and coordination) and gastritis stomach lining is inflamed or irritated). Resident 14 was dependent on staff to perform all of their activities of daily living (ADLs). The assessment further showed Resident 14 received nutrition via a feeding tube (flexible tube that provides nutrition to people unable to eat or drink enough by mouth). Review of the nutrition care plan showed Resident 14 was not to have oral intake by mouth, fluids, nutrition, and medications were to be administered via a J-Tube (flexible tube inserted through the abdomen into the small intestine). The care plan further showed Resident 14 also had a G-tube (flexible tube inserted through the abdomen into the stomach). Review of the 12/05/2023 annual health assessment showed Resident 14 required assistant of two staff to transfer using a mechanical lift using a specialized supine (lying on back with face up) sling. Resident 14 received hydration, nutrition, and medications via a J-Tube. The assessment further showed Resident 14 intermittently had rust-colored or coffee ground like output from their G-Tube. Review of the 12/29/2023 comprehensive nutrition assessment showed Resident 14 was received hydration, nutrition, and medications via a J-Tube. During continuous observation on 09/20/2024 from 8:51 AM until 9:06 AM, Staff V, AC, exited Resident 14's room wearing a yellow gown and purple surgical mask. Staff V walked across the hall wearing the yellow gown to dispose of a pair of purple gloves they removed while exiting the room, briefly used ABHR, unlocked a hygiene cabinet that contained toothbrushes, grabbed an item, handed the item to Staff N, AC, who was in Resident 14's room, briefly used ABHR, applied a new pair of purple gloves, then reentered Resident 14's room to assist Staff N. No transmission-based precaution or EBP signage was observed posted on or near Resident 14's room entrance. At 8:55 AM, Staff N, exited Resident 14's room wearing a yellow gown and walked down the hall past the kitchen to the area to the area where the nurse kept their medication cart. At 8:56 AM, Staff N returned to Resident 14's room wearing the same yellow gown, holding a cup with a dollop of tan colored semi translucent cream, and entered the room. At 8:59 AM, Staff V exited Resident 14's room removed their gloves but did not remove their gown. Staff N was heard telling Staff V you do not need to remove your gown because we are still taking care of [Resident 14]. Staff V walked down the hall wearing the yellow gown. At 9 AM, Staff V returned to Resident 14's room holding a mechanical lift sling. At 9:05 AM, Staff V exited Resident 14's room, walked across the hall to common resident grooming/hygiene area to remove their gown and gloves. At 9:06 AM, Staff N exited Resident 14's room wearing a yellow gown and gloves, pushed Resident 14 across the hall to the common resident grooming/hygiene area to perform oral care on Resident 14's. Resident 14 had a blue privacy bag covering a plastic collection bag hanging on an elevated footrest and a feeding tube formula delivery machine attached to their wheelchair. In an observation and interview on 09/20/2024 at 9:14 AM, Staff O, LPN, stated the facility posted EBP signage in a common area near a PPE source supply but did not post EBP signage outside a resident's room for privacy reasons, instead a picture of a blue glove was hung at the bedside. Staff O demonstrated where PPE was stored in the common resident bathing/hygiene area and an CDC EBP sign was posted on the closet door that contained PPE. Staff O then demonstrated the picture of a blue glove posted at the bedside. Staff O stated Resident 14 had a drainage collection bag because they had a J-tube to drain out extra gastric fluids. During observation on 09/20/2024 at 9:27 AM, a picture of a blue glove was hung at the bedside in Resident 14's room, right above the head of the bed. The sign did not contain any wording or direction for staff to follow. In an interview on 09/20/2024 at 9:34 AM, Staff P, Cottage Manager, stated the facility posted a CDC EBP sign in a common area near a PPE supply source and posted a picture of a blue glove at the bedside to indicate the resident was on EBP. Staff P further stated staff were trained that a picture of a blue glove hung at the bedside indicated the resident was on EBP, and staff needed to wear gloves and a gown when providing care. Staff P stated staff were to remove gloves, gown, and perform hand hygiene prior to exiting a room of a resident on EBP. Staff P was informed of the PPE observation from earlier that morning. Staff P asked Staff N if she exited Resident 14's room wearing a gown. Staff N acknowledged they left Resident 14's room wearing a yellow gown to obtain bag balm. Staff P informed Staff N they would grab items for them if needed when providing care to a resident on EBP, so they did not have to leave the room. During observation on 09/23/2024 at 3:01 PM, Staff T, AC, had a purple surgical mask on with their nose exposed, the mask only covered their mouth. During observation on 09/23/2024 at 3:07 PM, Staff L, AC, exited a resident's room holding a yellow gown bunched up into a ball against their blue shirt, walked across the hall to the common resident bathing/grooming area, placed the gown in the trashcan touching the lid, did not perform hand hygiene, then walked to the living room to pick toys off the floor and place them in a square cloth basket. In an interview on 09/26/2024 at 12:34 PM, Staff R, CMRN, was unsure what the facility process was for EBP. In an interview on 09/26/2024 at 1:38 PM, Staff Q, Infection Preventionist, stated EBP required staff to wear gloves and a gown when providing high contact care activities. Staff Q explained that a gown was not required if staff were only transferring a resident in the common area but was required if the transfer occurred in the resident's room because typically more than one care activity occurred in the resident's room. Staff Q further explained the purpose of EBP was to prevent the transmission of an MDRO from one resident to another via staff hands and/or clothing. Staff Q stated CDC EBP signage was posted in a common resident area near a PPE supply source and a blue glove picture was posted right above a resident's bed that was determined to require EBP. Staff Q acknowledged if transmission-based precautions were not followed then infection transmission could occur and expected staff to follow any precautions implemented. In an interview on 09/26/2024 at 3:22 PM, Staff B, reviewed the EBP policy. Staff B explained EBP expanded the use of gowns and gloves during high contact resident care in addition to standard precautions when other transmission-based precautions did not apply. Staff B further explained the facility posted CDC EBP signage in a common area near a PPE supply source but posted a picture of blue hand above a resident's bed determined to require EBP during cares. Staff B acknowledged staff should not leave an EBP resident room wearing a gown, should remove PPE prior to exiting the room, and perform hand hygiene. Staff B stated they expected staff to follow any precautions implemented because not following precautions could lead to the unnecessary spread of disease. Reference WAC 388-97-1320 , (1)(a), (1)(c ), (3) 46115 <Hand hygiene> During an observation on 09/23/2024 at 9:38 AM, Staff H, Licensed Practical Nurse, applied gloves, removed a dressing and cleansed the wound on Resident 32's coccyx. Staff H placed a new dressing over the coccyx wound without removing their soiled gloves or performing hand hygiene. In an interview on 09/23/2024 at 9:51 AM, Staff H stated they should have changed their gloves and performed hand hygiene after cleansing the wound and this was important to prevent the spread of bacteria.

Based on observation, interviews and record review, the facility failed to ensure all staff had food handler's cards (a certification that showed staff had completed training on food safety) to prepare food for facility residents. Specifically, in 6 of 7 cottages, the staff were occasionally preparing and cooking some foods, without food handler's cards. In addition, 1 of 24 dietary staff (C) had an expired food handler's card. This failed practice had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness. Findings included . <Cottage Staff> On [DATE] at 9:06 AM, two flats of uncooked, pasteurized eggs were observed in the Ponderosa Cottage refrigerator, and at 9:24 AM uncooked, pasteurized eggs were observed in another refrigerator in the Ponderosa Cottage. On [DATE] at 9:24 AM, a flat of uncooked, pasteurized eggs were observed in the Rosewood Cottage refrigerator. During an interview on [DATE] at 4:56 PM, Staff W, Attendant Counselor Manager (ACM), stated that some residents wanted eggs made in the cottages, as they would be cold and rubbery by the time they arrived from the kitchen. Resident 15 wanted eggs instead of meatloaf that night, and Resident 57 often liked scrambled eggs with cheese. Staff W further stated that all the attendant counselors (AC's) take food handler's training upon hire and annually, but they weren't required to get the food handlers card from the State. During an interview on [DATE] at 10:20 AM, Staff I, ACM, stated that they cooked food for residents when they requested. During a phone interview on [DATE] at 12:02 PM, a staff member from the food program at Spokane Regional Health District stated that any staff that cooked eggs, made a salad or sandwich needed a food handler' card. During an interview on [DATE] at 1:15 PM, Staff X, Licensed Practical Nurse (LPN), stated they cooked a lot on the cottages. One resident loved eggs with cheese, or grilled cheese. Staff X further stated that they got food service training, but did not have a food handler's card. During an interview on [DATE] at 9:43 AM, Staff B, Director of Nursing stated that the staff did not have food handler's cards for staff working in the cottage, as they were not preparing food, were just serving. They further stated that some cottage staff got training similar to the food handlers and acknowledged awareness that raw eggs were in the cottages. During an interview on [DATE] at 10:57 AM, Staff A, Administrator, acknowledged that if staff were preparing food, they should have food handler's cards. <Dietary Staff> A review of the dietary cards on [DATE] at 2:51 PM, showed Staff C, Dietary Aide (hire date [DATE]) did not have a current Washington State Food Handler's card. On [DATE] at 11:30 AM, Staff C was observed preparing food in the main kithen for the lunch service. During an interview on [DATE] at 12:44 PM, Staff D, Dietary Manager, stated a Washington State Food Handler's card was required for all kitchen staff working with food and acknowledged Staff C's card had expired. Staff D added it was important to have a current card to keep updated on food safety. Reference: WAC [DATE]

Based on interview and record review, the facility failed to ensure 1 of 5 sampled residents (72), reviewed for unnecessary medications, was informed of the potential risks associated with the use of psychotropic medications (medications that can affect the mind, emotions, and behaviors). This failure placed the resident and/or their representative at risk of not being fully informed of the potential risks and benefits of taking the medications. Findings included The 07/01/2024 quarterly assessment documented Resident 72 had diagnoses which included psychotic disorder, a severe mental illness that caused a person to lose touch with reality and experience abnormal perceptions and thinking. In addition, the assessment documented the resident had received psychotropic medication. Reviews of the September 2024 Physician Order Sheet and the September 2024 Medication Administration Record documented on 03/27/2024, a psychotropic medication, Duloxetine, had been prescribed and Resident 72 had received the medication daily. Review of Resident 72's record found no documentation and/or an informed consent form had been completed that explained the risks and benefits of taking a psychotropic medication were discussed, either verbally or written, with the resident and/or their representative prior to the resident receiving the medication. In an interview on 09/26/2024 at 10:04 AM, Staff B, Director of Nursing, stated informed consents for psychotropic medications needed to be completed before the resident received the medication, and confirmed an informed consent had not been done for the Duloxetine. Reference (WAC) 388-97-0260

Based on interview and record review the facility failed to encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for 2 of 3 sampled residents (Residents 12 and 60), reviewed for timeliness in encoding and transmission of Minimum Data Set (MDS - an assessment tool). This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life. Findings included . Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 revised October 2023, showed the RAI consisted of three basic components: the Minimum Data Set (MDS), the Care Area Assessment (CAA) and the RAI utilization guidelines. The utilization of the three component of the RAI yields information about a resident's functional status, strengths, weaknesses, and preferences, as well as offered guidance on further assessment once problems were identified. All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). After completion of the required assessment and/or tracking records, each provider must create electronic transmission files that meet the requirements detailed in the current MDS 3.0 Data Submission Specifications. For submission, the MDS data must be in record and file formats that conform to standard record layouts and data dictionaries, and pass standardized edits defined by CMS and the State. Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. <Resident 12> Review of the quarterly assessment, dated 07/10/2024, showed Resident 12 admitted to the facility on [DATE] with diagnoses including idiopathic hydrocephalus (condition that caused accumulation of brain fluid to build up in the brain) and autistic disorder (condition that affects how a person communicates, interacts, and learns). Resident 12 had severe cognitive impairment and required substantial assistance of staff to complete most activities of daily living (ADLs). The assessment further showed it was completed 07/20/2024 at 12:43 PM. Review of Resident 12's electronic health record showed a 07/10/2024 quarterly MDS assessment with the status listed as completed, it did not show accepted. In an interview on 09/26/2024 at 11:03 AM, Staff R, Case Manager Registered Nurse (CMRN), explained the MDS process and acknowledged a completed MDS should be submitted to CMS within two weeks. Staff R reviewed Resident 12's record. Staff R acknowledged the 07/10/2024 quarterly MDS assessment status showed it was completed, it did not show accepted. Staff R reviewed CMS' iQIES but was unable to find a submission for the 07/10/2024 quarterly MDS. <Resident 60> Review of the annual assessment, dated 07/10/2024, showed Resident 60 admitted to the facility on [DATE] with diagnoses including tuberous sclerosis (rare genetic disorder that caused tumors to grow in the brain and other organs) and mental disorders due to known physiological condition. Resident 60 had severe cognitive impairment and required substantial assistance of staff to complete most ADLs. The assessment further showed it was completed on 07/20/2024 at 10:40 AM. Review of Resident 60's electronic health record showed a 07/10/2024 annual MDS assessment with the status listed as completed, it did not show accepted. In an interview on 09/26/2024 at 11:14 AM, Staff R, CMRN, reviewed Resident 60's record. Staff R acknowledged the 07/10/2024 annual MDS assessment status showed it was completed, it did not show accepted. In an interview on 09/26/2024 at 11:19 AM, Staff B, Director of Nursing, stated MDS assessments should be submitted to CMS per the required timeframe. In a follow-up interview on 09/26/2024 at 12:18 PM, Staff R, explained Resident 12's and Resident 60's MDS assessments were compressed into a batch file that was sent to CMS through iQIES on 07/22/2024 but for unknown reasons both of the assessments were lost and not accepted. Staff R acknowledged they had no documentation to show Resident 12's 07/10/2024 quarterly MDS or Resident 60's 07/10/2024 annual MDS assessment were accepted by CMS. Reference WAC 388-97- 1000 (4)(b), (5)(b)

Based on observation, interview, and record review the facility failed to implement interventions to prevent and heal pressure ulcer/injury for 1 of 1 sampled resident (Resident32). This failure placed other residents at risk for development of pressure ulcers, medical complications, and unmet care needs. Findings included . The National Institutes of Health (NIH) website nih.govshowed a pressure injury was localized damage to the skin and underlying soft tissues usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 1 pressure injury: intact skin with a localized area of non-blanching erythema [redness that does not disappear when pressure is applied to the area] Stage 2 pressure injury: partial thickness [involving epidermis and/or dermis] loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister Stage 3 pressure injury: full thickness [wound that extends below the epidermis and dermis into the subcutaneous tissue or deeper] skin loss, in which adipose (fat) or granulation [new connective tissue] tissue is visible in the ulcer Stage 4 pressure injury: full thickness skin and tissue loss with exposed or directly palpable fascia [connective tissue], muscle, tendon [strong cords of tissue that connect muscle to bones], ligament [bands that connect bones and joints], cartilage [tough, flexible connective tissue that protects bones and joints, and provides structure to the nose and ears], or bone in the ulcer . unstageable pressure injury: full thickness skin and tissue loss in which the extent of the tissue damage within the ulcer cannot be confirmed because it is obscured by slough [dead skin or tissue that can appear in a wound] or eschar [dead tissue that forms over healthy skin and eventually falls off] Deep Tissue Pressure Injury [DTPI]: intact or nonintact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation reveling a dark wound bed or blood filled blister The NIH website showed it is essential that the intended staging or classification system be used for each type of injury to ensure appropriate treatment. Review of the facility's policy titled, Pressure Ulcers, revised April 2022, documented all residents will be evaluated at least quarterly for a skin ulcer/pressure ulcer/wound, care would be provided to assess, classify staging, treat, heal, and prevent further development of pressure ulcers. The policy documented that a pressure ulcer was defined as any lesion caused by unrelieved pressure that results in damage to underlying tissue. The policy documented that a Stage 1 wound was non-blanchable (area of redness on the skin that does not disappear under applied pressure). Review of the 01/29/2022 care plan documented Resident 32 was at risk for skin breakdown and instructed the nursing staff to assist with ADL care (bathing, grooming, toileting), ensure an anti pressure mattress was in place, utilize reusable cloth incontinent pads only and assist the resident with turning and repositioning. Further review of the careplan found no documentation that Resident 32 had a pressure ulcer. Review of the 05/23/2024 skin assessment documented Resident 32 had a red and blanchable area to their coccyx that measured 1 cm (centimeter) x 1 cm, but the skin was intact with no open areas. The assessment incorrectly identified the skin issue as a pressure ulcer. Review of a progress note dated 05/23/2024 at 11:19 AM, documented a pressure ulcer was found on Resident 32's coccyx area measuring 1 cm x 1 cm after returning from the hospital on the same day. A progress note dated 05/24/2024 at 2:32 PM, documented that the area to Resident 32's coccyx was now open and a plan of care was initiated that staff were to monitor and keep the area covered with a dressing. The 05/26/2024 skin assessment documented that Resident 32's pressure ulcer had decreased in size (0.2 cm x 0.1 cm), but now a faint small black scab with pinkish red tissue surrounding the wound. The 05/29/2024 skin assessment documented that Resident 32's pressure ulcer increased measured 0.5 cm x 0.5 cm, an increase in size from the previous assessment and the wound bed was now white in color. A progress note dated 06/14/2024 at 2:00 PM, documented that Resident 32's coccyx wound was red and yellow with a thin dark red scab measured at 1 cm x 1.2 cm. Review of the 06/25/2024 comprehensive assessment showed Resident 32 had a pressure ulcer on their coccyx (small triangular bone at the base of the spine that supports body weight and helps with balance while sitting). On 09/20/24 at 08:46 AM, Resident 32 was observed in their room and alert with a flat affect. The resident was dressed, sitting in their wheelchair, a gray hoyer sling was under them and a cloth pad was under the sling. This created multiple layers and increased the risk of pressure. Similar observations were made of Resident 32 sitting upon multiple layers on 09/23/2024 at 8:54 AM and 11:46 AM, 09/25/2024 at 9:56 AM. In an interview on 09/27/2024 at 10:32 AM, Staff AA, Attendant Counselor, stated after transferring a resident to their wheelchair, it was important to remove the Hoyer sling from underneath a resident because the sling can cause pressure. Staff AA confirmed that they do keep the Hoyer lift sling underneath the residents while sitting in their wheelchairs. In an interview on 09/27/2024 at 12:10 PM, Staff BB, Case Manager stated that Resident 32 returned from the hospital on 05/23/2024 with a red blanchable area of skin on their coccyx. Staff BB confirmed that skin described as red and blanchable was not considered a pressure ulcer. Staff BB stated that laying cloth pads on top of a mattress and leaving a Hoyer lift sling directly underneath a resident would interfere with pressure relief. Staff BB stated that removing them would improve healing of Resident 32's pressure ulcer. In an interview on 09/27/2024 at 12:53 PM, Staff B, Director of Nursing, stated that a resident should not sit on or lay on cloth pads or Hoyer lift slings because it reduced the pressure relief from the cushion and mattress, delayed wound healing and worsens the pressure ulcer. Reference: WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to ensure allegations of potential abuse were reported immediately to the State Agency as required, for 1 of 3 sampled residents (Resident 1) reviewed for abuse. This failure placed residents at risk for possible abuse. Findings included . Record review showed that on 08/06/2024 at 7:25 AM, Staff B, Attendant Counselor Manager, received an email from Staff C, Certified Nursing Assistant, that they had overheard Staff D yell at Resident 1 on 08/05/2024 at about 4:30 AM. Further record review found that the facility did not report the incident to the required State Survey Agency until 08/06/2024 at 12:13 PM. In an interview at 12:28 PM on 09/11/2024, Staff A, Director of Nursing, stated that the time frame for reporting abuse allegations to the required State agency is two hours and in this instance, there was a delay in reporting the possible abuse. Reference: (WAC) 388-97-0640 (5)(a)

Based on interview and record review, the facility failed to protect, assess and monitor 1 of 3 sampled residents (Resident 1) after an allegation of verbal abuse. Failure to immediately protect the resident, failure to immediately assess the resident and failure to start monitoring for any potential harm related to the abuse allegation, placed residents at risk for diminished quality of life, and continued possible abuse. Findings included . Record review showed Resident 1 had a diagnosis of Rapid Cycle Type 2 Bipolar Disorder (frequent changes in mood from very active to almost no activity with marked impairment in social and occupational functioning) and Moderate Intellectual Disability (a condition that affects learning, behavior and adaptive skills). According to a facility incident report, dated 08/06/2024 at 12:13 PM, on night shift (started on 08/04/2024 into 08/05/2024) of 08/05/2024 at about 4:30 AM Staff C, Nursing Assistant, overheard Staff D, Licensed Practical Nurse, yell at Resident 1 to wake up and take their medication after which the resident appeared to be upset. On 08/05/2024 at 7:00 AM Staff C wrote an email to their direct supervisor, Staff B, Attendant Counselor Manager, saying they were concerned that Staff D had yelled at Resident 1 and that the resident appeared agitated after the interaction. Record review showed that Staff D continued to work with Resident 1 on the night of 08/05/2024 into 08/06/2024 and no further action was taken to protect that resident. Further record review showed that Resident 1 was assessed for psychological harm related to this incident on 08/06/2024 at 8:45 AM, had a nursing assessment to look for any physical injury on 08/06/2024 at 10:00 AM during which a care plan update was completed to monitor for any latent injuries (an injury that may appear after the event). In an interview on 09/11/2024 at 12:28 PM Staff A, Director of Nursing, stated that after the allegation of abuse on 08/05/2024 there was a delay in protecting, assessing and monitoring Resident 1. Reference: WAC 388-97-0640 (6)(a)(b)

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 5 residents (Resident 1) reviewed for abuse and/or neglect. The failure to provide incontinence care to a resident who was identified to be incontinent of bladder and required staff assistance for toileting, as well as the failure to provide an adequate morning meal resulted in emotional distress and a diminished quality of life. Findings included . Record review showed Resident 1 had been a long-term resident at the facility and on 03/20/2024 had moved to the nursing facility in response to increased medical and physical needs. Resident 1's diagnoses included moderate intellectual disability (a generalized neurodevelopmental disorder characterized by significant impairment in intellectual and adaptive functioning diagnosed in childhood), schizoaffective disorder (a mental disorder characterized by abnormal thought processes and unstable mood) and bipolar disorder with severe manic episodes and psychotic symptoms (a mental disorder characterized by severe mood swings, hallucinations, delusions, periods of extreme activity and extreme depression). Review of Resident 1's care plan, dated 03/20/2024, showed that Resident 1 was dependent on staff for toileting and setup for meals. Record review of Resident 1's June medication administration record showed they received a medication from 06/04/2024 through 06/06/2024 called Pyridium used to treat pain related to a urinary tract infection (infection in the bladder). A side effect of this medication is the urine passed by the resident would be bright orange or red. Review of an initial facility incident report, dated 06/08/2024, stated that on 06/07/2024 at 7:00 AM Staff E, Nursing Assistant had gone into Resident 1's room to take their daily vital signs. While they were in the room, they noticed that Resident 1 was awake, asking to get out of bed and incontinent of urine and their incontinence brief was soaked and leaking onto the bed. The incident report went on to say that Staff E told Staff D, Assistant Lead Nursing Assistant of their finding Resident 1 incontinent and that Staff D responded that they would get to them. Per a witness statement, dated 06/08/2024 at 2:55 PM, Staff E stated that they had notified Staff D of Resident 1 being incontinent and in need of care at about 7:15 AM. They then noticed about 8:00 AM that Resident 1 was not out of bed and their breakfast meal was sitting on the counter uneaten. At 10:30 AM they noticed Resident 1 was not out of bed and went to check on them and found them soaked in a stained bed. They then wrote that Staff D came in and took over care of resident 1 and threw out their breakfast and gave them a portion of fruit as their breakfast. Per a witness statement, dated 06/13/2024, Staff F, Nursing Assistant stated that at 7:10 AM they were helping to prepare breakfast for the residents and could hear Resident 1 talking in bed and that they were awake and ready to get up. At 9:00 AM Staff D told Staff F they were leaving the building for a break. At about 10:15 AM Staff E asked if they could help get Resident 1 out of bed. At 10:20 AM Staff D returned from their break and took over care of Resident 1. At 10:35 AM Resident 1 was seated at the dining table and Staff D had grabbed a replacement meal but then did not make it and gave Resident 1 some strawberries for breakfast. They stated that Resident 1 appeared very sad and emotional. Per a witness statement, dated 06/13/2024, Staff G, Nursing Assistant wrote that Staff E had asked them to assist to get Resident 1 out of bed at about 10:30 AM. Upon entering Resident 1's room they repeatedly asked to get up and had soaked through their incontinence brief. Staff D then entered the room and told them to leave and Staff D and E assisted to get Resident 1 out of bed. Per a witness statement, dated 06/11/2024, Staff C, Registered Nurse Case Manager, wrote that they saw resident 1 at about 11:30 AM on 06/07/2024, and that they were upset and crying. They then spoke with Staff E who told them that Resident 1 had not gotten out of bed until close to 11:00 AM, that they had been soaked with urine at that time and that they had only fruit for breakfast. They then spoke to Staff F who stated that Resident 1 had not been out of bed until about 11:00 AM, had been soaked in urine, that Staff D was aware Resident 1 needed incontinence care, that Staff D had left the building for over an hour, starting at about 9:00 AM, and that Resident 1 only had fruit for breakfast. Per a witness statement dated 06/11/2024, Staff B, Developmental Disability Administrator, stated that they spoke with Staff D and that Resident 1 had not wanted to get out of bed and that Staff D had given Resident 1 a replacement meal when they did get out of bed around 10:30 AM. Staff F was interviewed on 06/20/2024 at 1:27 PM. They stated that at about 10:15 AM Staff E had come and asked if they could get Resident 1 out of bed. Staff F stated they were surprised Resident 1 was still in bed as this was not usual and told Staff E to get them up. Staff E then returned and asked Staff F to come look at Resident 1 and both staff went back to Resident 1's room where they both observed Resident 1 laying on two pink pads (disposable pads meant to catch and hold urine) both soaked in urine, the bed sheet was wet with urine top to bottom and Resident 1's cotton t-shirt was also soaked with urine. They stated that Resident 1 did often have to have bed changes, but this situation was not typical, it was usually just a small area around their incontinence brief. They further stated that Staff G then came to assist Staff E and they left the area. They stated that they witnessed Staff D only give Resident 1 strawberries for breakfast and that no replacement meal was given to the resident and that resident 1 was crying and appeared sad. They further stated that Staff B did come to the building but did not talk to them. Staff E was interviewed on 06/20/2024 at 1:46 PM. They stated that they had gone in to do vitals on Resident 1 at about 7:15 AM on 06/07/2024. They stated that they could smell urine strongly and pulled back the sheet to check and found Resident 1's incontinence brief was soaked, there was urine on the sheet around their brief and the urine was easy to see because it was orange. They stated that the resident was wearing a cotton t-shirt, and it was not wet. They stated that they then told Staff D that Resident 1 was awake, incontinent of urine and ready to get up. Staff D responded that they would get to them. They further stated they went back to that area of the building about 8:30 AM and noticed Resident 1 was not out of bed and thought it was strange as they were always up for breakfast. At about 10:15 AM they heard Resident 1 yelling help me, I'm wet repeatedly, and went and asked Staff F if it was okay to get them out of bed. Staff F told them to go ahead as Staff D had been gone for over an hour and had not returned. Staff E then found Resident 1 in bed soaked with urine from head to foot and the sheet was stained orange. They then asked Staff F to witness the situation and asked Staff G to help get Resident 1 out of bed as Staff F was not able to assist. Staff E and G then started to get resident 1 out of bed when Staff D returned and told them to leave. Staff E then stated they saw Resident 1 at the dining table, and they only had strawberries and were crying. They stated that they were working on the side of the building with the microwave and that no one had heated up a replacement meal for Resident 1. They further stated that they saw Staff B come onto the building and talk to Staff D, but that they did not ask them any questions or talk to them. Staff A, Administrator, was interviewed on 06/20/2024 at 2:40 PM. They stated that Staff B had made them aware of the situation with Resident 1 and they had asked them to go to the building and find out what was happening. Upon their return Staff B told them that Resident 1 had been offered additional food items by Staff D and that they had also been changed several times. At that point they did not feel an abusive act had occurred and nothing more was done that day. They stated that they knew it would have to be investigated further and on 06/10/2024 after more statements from staff had been collected, they realized that the situation should have been looked into more at the time it occurred. They stated that typically the witnesses would be interviewed at the time of the event and not just the alleged perpetrator. Refer to WAC 388-97-0640 (5)(a) and WAC 388-97-0640 (6)(a)(b) for 06/20/2024. Reference (WAC) 388-97-0640(1)

Based on interview and record review, the facility failed to ensure allegations of potential abuse and/or neglect were reported immediately to the State Survey Agency, as required, for 1 of 5 sample residents (Resident 1). This failure placed residents at risk for abuse and/or neglect. Findings included . Record review showed Resident 1 had been a long-term resident at this facility and on 03/20/2024 had moved to the nursing facility portion of the facility in response to increased medical and physical needs. Resident 1's diagnoses included moderate intellectual disability (a generalized neurodevelopmental disorder characterized by significant impairment in intellectual and adaptive functioning diagnosed in childhood), schizoaffective disorder (a mental disorder characterized by abnormal thought processes and unstable mood) and bipolar disorder with severe manic episodes and psychotic symptoms (a mental disorder characterized by severe mood swings, hallucinations, delusions, periods of extreme activity and extreme depression). According to a facility incident report, dated 06/08/2024, about 7:00 AM on 06/07/2024, Resident 1 had been alleged, by three Nursing Assistants (Staff E, F and G), to have been neglected by Staff D, lead Nursing Assistant. Staff E and F told Staff C, Registered Nurse Case Manager about their concerns around 11:30 AM who then told Staff B, Developmental Disability Administrator who went and spoke to Staff D about that same time. According to the facility intake the allegation of neglect was not called in to the State Agency until 06/07/2024 at 5:46 PM, well beyond the two-hour window for reporting allegations of abuse and/or neglect required by State Law. In an interview on 06/20/2024 at 1:46 PM Staff E stated that they felt Resident 1 had been neglected by Staff D and had relayed their concerns to Staff C around lunch time. Staff E further stated that they were not aware that abuse and/or neglect allegations needed to be reported to the State Agency within two hours of discovery. In an interview on 06/20/2024 at 1:27 PM, Staff F stated that they had been told by Staff E about their concerns and had witnessed what they thought was possible neglect of Resident 1. They stated that they thought Staff E was going to report the situation to the State Agency and that they were not aware of the two-hour reporting timeline for abuse and/or neglect. Refer to WAC 388-97-0640(1) and WAC 388-97-0640 (6)(a)(b) for 06/20/2024 Reference: (WAC) 388-97-0640 (5)(a)

Based on observation, interview, and record review, the facility failed to ensure nursing staff used safe lifting techniques while transferring residents for one of three sample residents (1), reviewed for accidents. Failure to transfer Resident 1 as per the care plan resulted in actual harm, when the resident sustained bruising and swelling to the leg and perineal area, which required two emergency room (ER) visits for evaluation. Findings included Per the 03/17/2021 quarterly assessment, Resident 1 had diagnoses which included profound intellectual disability, was non-verbal, and communicated needs and pain through facial expressions, reaching out, and making noises. The assessment further showed Resident 1 required extensive assistance of two persons for transfers. On 05/22/2021, a facility investigation showed that on 05/22/2021 at 1:30 AM, facility staff noticed a bruise to Resident 1's left groin area. Over the course of several hours, the bruising increased in size and depth, to include the entire pubic area, including the genitals, as well as the left thigh. The resident was sent to theER on [DATE] for evaluation. The Hospital Transfer Form showed the resident had bruising and swelling in the left groin area migrating down the left leg with swelling to the genitals, and the areas were painful to touch. On 05/24/2021 Staff D, Medical Doctor (MD), sent the resident back to the ER for additional evaluation, to determine the cause of the bruising. Per Staff D's assessment, the bruising was believed to be caused by trauma. In a witness statement dated 05/25/2021, Staff C, Attendant Counselor (AC) - a person who provides direct care to residents - described an observation of Staff B, Attendant Counselor, using her knee as leverage, while transferring Resident 1 from the wheelchair to the bath gurney. Per Staff C's statement, the resident was nude at the time, and Staff B's knee was pressed up against the resident's genitals, and Staff B was using the knee to assist in lifting the resident during the transfer. An email correspondence dated 05/25/2021 showed the transfer was inappropriate, and did not follow the resident's care plan. The facility investigation determined it was possible the staff member's knee pressed against the resident's groin during the transfer, possibly causing the injury. Staff B was removed from resident care pending investigation. A review of the progress notes, from 05/22/2021 through 05/29/2021, showed Resident 1 had been assessed and monitored daily for changes and pain. Documentation further showed the resident had expressed pain (grimacing and yelling out), when staff assisted with incontinence care and position changes. On 06/08/2021 at 2:55 PM, Staff E, Attendant Counselor (AC), and Staff F, Attendant Counselor (AC), were observed providing incontinence care to Resident 1. An observation of the left upper thigh showed the bruising to be yellow and purple in color, and no bruising or swelling was observed in the genital area. The resident did not cry out during care. In an interview on 06/10/2021 at 9:50 AM Staff G, House Manager, stated Resident 1 expressed pain during incontinence care and position changes from the bruising. Staff G further stated if a resident could not be safely transferred, then a Hoyer lift (a device used which requires no resident participation) should be utilized to ensure resident safety, and stated it was never appropriate to use a knee to the groin to assist with a transfer. Per an interview on 06/10/2021 at 3:00 PM, Staff C stated she observed Staff B transfer the resident multiple times throughout the day on 05/21/2021. Staff C stated Staff B's knee was resting on Resident 1's private parts during the transfer, and the resident's feet came off the floor a couple of times during the transfer when the knee was utilized as leverage. Staff C stated it looked like the resident didn't want to stand, so she offered to assist Staff B with the transfer, and suggested using the Hoyer. Per Staff C, Staff B said it would be faster to just continue the transfer without assistance. In an interview on 06/08/2021, Staff A, Director of Nursing, stated it was never acceptable to use a knee to the groin during a transfer - especially with a male resident. Staff A confirmed the transfer of Resident 1 from a wheelchair to the bath gurney was unsafe, and likely caused the resident's injuries, which resulted in harm to the resident. Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to develop and implement an antibiotic use protocol, which included reporting results of laboratory data to the ordering practitioner for one of three sample residents (#1), reviewed for antibiotic use. The prescribing practitioner ordered an antibiotic for treatment of [REDACTED]. After receiving laboratory test results, which indicated the bacteria was resistant to a specific antibiotic, the facility failed to provide the information to the practitioner, and the resident received the full course of an ineffective antibiotic. This failure constituted an immediate jeopardy situation, when the resident had difficulty breathing, required artificial ventilation by emergency personnel, and required hospital admission for treatment of [REDACTED]. The jeopardy was removed on 08/09/19, after the facility provided education to staff regarding reporting laboratory results directly to the prescribing practitioner, and the facility implemented a new facility-wide antibiotic surveillance tool, as required, to effectively track antibiotic use. Findings included . Record review of Resident #1's progress notes and 06/18/19 assessment, showed the resident was admitted with urinary incontinence, and no recent UTIs. Two days after admission, nursing staff identified [MEDICAL CONDITION] (the inability to completely empty the bladder). Nursing staff was unable to insert an indwelling urinary catheter (a tube inserted into the bladder to drain urine to an outside collection bag), the resident was transferred to the emergency room , and returned to the facility with an indwelling urinary catheter. Record review of a 07/12/19 progress note by Staff H, Registered Nurse, and laboratory order form showed on that day, the resident was lethargic (sleepy), his urine had an odor, and contained a large amount of visible particles. Staff H obtained a urine sample to identify any bacteria causing the infection, and to identify the effective antibiotics. Additional record review of progress notes, dated 07/12 and 07/13/19, showed the resident's lethargy continued, requiring transfer to the emergency room , where a UTI was identified, and Keflex (an oral antibiotic) was ordered. Record review of the (MONTH) 2019 Medication Administration Record [REDACTED]. According to progress notes dated 07/23/19 at 9:03 AM, the resident was found in a common area unresponsive. Staff provided emergency care until emergency personnel arrived, and transported the resident to the hospital. According to hospital records, dated 07/23/19 through 07/30/19, the resident had difficulty breathing, and required artificial ventilation by emergency personnel, prior to transport to the hospital. At the hospital, the resident required intensive care treatment for [REDACTED]. Additionally, the hospital record showed the Keflex the resident received at the facility would not treat the identified bacteria. The resident's condition improved with proper treatment, and he was transferred back to the facility on [DATE]. Record review of the initial facility investigation, dated 07/23/19, showed the following information: On 07/15/19, Staff C, Clinic Nurse, and Staff G, Clinical Pharmacist, received the urine culture report, for the urine sample report obtained 07/12/19. The report showed the identified bacteria, and listed multiple antibiotics that would treat the infection. Keflex, the antibiotic prescribed since 07/12/19, was not on the list. Staff C documented on the Nurse-Physician on-line log, that orders for one of the listed antibiotics were written. Record review showed Staff C did not contact Staff F, Advanced Registered Nurse Practitioner, for orders. The resident completed Keflex, as originally ordered, which was not an effective antibiotic to treat the infection. In an interview on 08/07/19 at 12:45 PM, Staff C was asked how laboratory results were provided to prescribing practitioners. Staff C stated the laboratory technician delivered laboratory results to her daily, and she sorted them to give to Staff E, facility Physician/Medical Director. Additionally, Staff C stated she and Staff G reviewed laboratory results for residents with infections, and made recommendations to Staff [NAME] about antibiotic orders. Regarding Resident #1, Staff C stated she remembered talking with Staff G, who recommended a different antibiotic. Staff C confirmed she documented on the Nurse-Physician on-line log, that she had contacted Staff F, but did not remember doing so. Additionally, she did not know the orders were not changed until notified by Staff B, Director of Nursing, or Staff I, Case Manager, on 07/23/19, the day the resident was hospitalized . During the interview, Staff C was asked about the facility's antibiotic stewardship program. Staff C stated she, Staff G, and Staff [NAME] reviewed residents with infections, and determined appropriate antibiotic orders. When asked about the involvement of Staff D, Infection Control Practitioner, Staff C stated stewardship was not Staff D's role, and stated that infection prevention was more Staff D's role. When asked if the cottage nurses had access to laboratory results, or were notified regarding decisions about antibiotics, Staff C stated she did not always have time to notify the cottage nurses about treatment decisions. In an interview on 07/07/19 at 1:30 PM, Staff I, Case Manager, stated on 07/15/19, she was contacted by a resource nurse (clinical resource nurses were available to staff all shifts) that the resident's urine culture report showed the identified bacteria. She stated she then called Staff C, who informed her they were switching antibiotics. When the resident was admitted to the hospital on [DATE], Staff I stated she reviewed the resident's electronic hospital record, and informed Staff C of the hospital's finding that the resident did not receive an effective antibiotic at the facility. In an interview on 08/07/19 at 1:40 PM, Staff B, Director of Nursing, stated in the past, copies of laboratory results were forwarded directly to the prescribing practitioners. When Staff C and [NAME] were employed, Staff C started providing laboratory results to Staff E. When asked about measures the facility took after 07/23/19, Staff B stated he viewed the situation as an isolated occurrence. He stated he issued an electronic communication, directing designated staff to forward copies of all laboratory results to the prescribing providers, rather than to the clinic nurses. Additionally, Staff B stated the facility did not complete the investigation, due to the organizational requirement that the investigation was to be completed by an independent party. As of 08/07/19, the independent investigation results were not available. In interviews on 08/07/19 at 11:30 AM, and 08/08/19 at 10:40 AM, Staff D, Infection Control Practitioner, stated she was aware on 07/12/19 the resident had a new order for Keflex. On 07/15/19, the cottage nurse contacted her with information that the bacteria in the urine had been identified. She directed staff to institute proper precautions to prevent the spread of infection. On 07/16/19, Staff D stated she checked the Nurse-Physician on-line log, saw the 07/15/19 note from Staff C, that the resident's antibiotic was changed, even though it was not. During Staff D's interviews, the infection surveillance log (a facility-wide system to monitor the use of antibiotics) was requested. Staff D stated the facility did not keep one. She stated the pharmacist distributed electronic records which showed resident names, diagnoses, and antibiotics ordered, without additional information, including identified bacteria, resident symptoms, and antibiotic effectiveness. Staff D stated on 07/29/19, she started tracking all residents' laboratory results and antibiotic use, and initiated a written surveillance log, as required, on 08/08/19. When asked, Staff D confirmed the use of a facility-wide surveillance log system would have more likely resulted in more timely detection of Resident #1's ineffective antibiotic orders. When the surveyor requested facility protocols, to ensure residents who required an antibiotic, were prescribed the appropriate one, Staff D provided draft policies regarding antibiotic stewardship, dated 02/2018, and infection surveillance, updated 09/19/2013. Staff D stated the antibiotic stewardship committee met monthly, was discussing the need for protocols, had identified protocol goals, but had not implemented new protocols. During observation on 08/07/19 at 4:00 PM, the resident was in a private room, with continuous staff supervision for safety. The room lights were low, and the resident was dozing. Staff G was not available for interview during the facility investigation. In an interview on 08/08/19 at 4:00 PM, Staff E, Medical Director, stated she evaluated the resident on 07/12/19, and was not working the following week. Staff [NAME] stated the resident was at risk for development of severe infection, and stated changing to a different oral antibiotic may not have prevented the severe infection, however a practitioner would never want to increase the potential of something happening. In an interview on 08/08/19 at 5:15 PM, Staff F, Advanced Registered Nurse Practitioner, stated he did not know a urine culture result was pending. He stated the first time he observed the resident was on 07/23/19, when the resident was found unresponsive. He stated the resident showed visible signs [MEDICAL CONDITION], including elevated heart and respiratory rate, low blood pressure, fever, and lack of response to verbal/physical stimulation. When asked about procedures regarding notification of laboratory results, Staff F stated practitioners would be notified right away, but he did not know more about the procedures. No associated WAC reference.

Based on observation, interview, and record review, the facility failed to provide necessary services in use of a drainage Gastrostomy (G) tube (tube passed into a person's stomach through the abdominal wall, to provide a means of draining gastrointestinal (GI) secretions), for one of one sample residents (#1) reviewed, with a drainage G tube. Failure to timely release the G tube clamp after medication administration, resulted in harm to the resident, who required multiple medications, including intramuscular (IM) medication injections, to prevent complications related to possible aspiration of GI secretions into the lungs. Findings included . According to the quarterly assessment dated [DATE], Resident #1 had severe cognitive impairment, was unable to speak, was unable to swallow safely, and required physical assistance to complete all activities of daily living. Current care plan, reviewed 05/19/19, showed the resident was at high risk for aspiration pneumonia (aspiration of secretions into the lungs), and received all nutrition/fluids/medications through a jejunostomy tube (tube passed into the small intestine, below the stomach). Due to experiencing persistent reflux of GI secretions, he had a drainage G tube, which drained GI secretions from the stomach into a drainage bag, by gravity. Record review of the current physician order [REDACTED]. According to the facility investigation, dated 06/27/19, Staff A, Licensed Practical Nurse, administered the scheduled midnight dose of GI cocktail, and clamped the G tube. By 3:00 AM, the resident's blood pressure was elevated (200/114), and the resident appeared agitated. At 5:30 AM, the resident vomited, and Staff A contacted Staff B, Resource Nurse. Staff B evaluated the resident, and attempted to obtain the resident's blood pressure (difficult to obtain due loss of joint motion in both arms). Staff B agreed that Staff A should stop the tube feeding, hold the scheduled 6:00 AM GI cocktail, and try to obtain another blood pressure reading. Record review of Staff H, Resource Nurse, investigative interview, dated 06/27/19, showed she was called to the cottage at 7:30 AM because the resident had a second large emesis, elevated blood pressure, and low oxygen levels. The physician was contacted and ordered oxygen, inhaled respiratory medications, a bowel suppository (in case of constipation), and the scheduled blood pressure medication. The physician evaluated the resident shortly after, and ordered doses of an antiemetic, a steroid, and an antibiotic, all three administered by the IM route. Record review of Staff D and E, both Nursing Assistants, investigative interviews, dated 06/27/19, showed Staff D was assigned to provide 1:1 supervision, and check the resident's vital signs every 30 minutes. At 10:40 AM, Staff D came to assist Staff E. Staff D checked the [DEVICE] drainage bag, and noted the bag was empty. Staff [NAME] suggested checking for a clamp in the tubing. Staff D checked the tubing, and found a clamp in place. Staff [NAME] notified Staff C, the day shift Registered Nurse. Record review of Staff C's investigative interview, dated 06/27/19, showed Staff C administered the inhaled respiratory medication, the three medications by IM injection, and noted they were minimally effective in treating the resident's symptoms. At 10:40 AM, Staff [NAME] reported the G tube was clamped. When the clamp was released, (10 hours and 40 minutes after being clamped), Staff C noted gastric secretions flowed into the drainage bag. Additional review of the facility investigation showed the resident was in stable condition the remainder of 06/27/19, after the G tube clamp was released. Staff A was not available for interview. Record review of Staff A's investigative interview, dated 07/09/19, showed Staff A confirmed she clamped the resident's G tube at midnight, after administering medication, and did not release the clamp at 12:30 AM, as ordered. Additionally, Staff A stated multiple licensed nurses provided resident care, and also did not release the G tube clamp. In an observation on 07/17/19 at 11:40 AM, Staff I, Registered Nurse, administered 10 ml of GI cocktail into the resident's G tube, clamped the tube, and released the clamp at 12:15 PM. During interview after the observation, Staff I confirmed nutritional tube feeding was infusing into the jejunostomy tube.

Based on interview and record review, the facility failed to ensure safety interventions were followed during a transfer, for 1 of 3 sample residents (#1). Failure to follow the care planned interventions, and failure to immediately report the incident to a nurse resulted in harm for Resident #1, who sustained a leg fracture. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per record review, she required extensive assist with tranfers. The resident is able to communicate her needs through gestures, simple signs, and some language. Per review of the resident's long-term care plan, dated 12/12/13, the resident was at risk for falls, secondary to her intellectual disability with no safety awareness. The care plan directed staff to have the resident wear supportive shoes when being transferred, and for staff to use a gait belt (a belt placed around the resident's waist for added support) during transfers. Per review of the facility's investigation dated 10/21/15, it had been reported the resident had received an abrasion on her left foot, during a transfer on the evening of 10/20/15. On the morning of 10/21/15, staff reported to the oncoming nurse the resident was refusing to get out of bed. The nurse went to assess the resident, and found her left leg was swollen, warm, and red. The resident stated her leg hurt. An x-ray was ordered, which revealed a fractured lower left leg. Per interview on 11/05/15 at 12:25 p.m., Staff A stated she had been asked to look at the resident's leg on the morning of 10/21/15. She stated the resident's leg was swollen and warm. Staff A said nothing had been mentioned about the resident's leg prior to that time. Staff A interviewed the staff who had worked the evening before, to try and determine what had happened with the resident. During the interviews, Staff B told her she had transferred the resident from her wheelchair to the bed, without proper footwear or a gait belt (as directed in the plan of care), and the resident had fallen. Staff B stated she did not notify the nurse to assess the resident after the fall, and got other staff to assist her in putting the resident in bed. Per observation on 11/05/15 at 2:00 p.m., Resident #1 was in bed; her left leg had a cast on from her toes to below her knee. The resident appeared to be comfortable. On 11/05/15 at 2:10 p.m., a licensed nurse, Staff C, stated on 10/21/15, she received report from the night shift nurse that the resident had an abrasion on her toe from the previous evening . No information was provided to her relating to a fall or improper transfer. She stated after report, a staff member told her the resident did not want to get out of bed. Staff C confirmed Staff A then went into the room, assessed the resident's leg, got an x-ray ordered, and it revealed the resident had a fractured leg.

Based on observation, interview, and record review, the facility failed to ensure safety interventions were implemented for 1 of 3 sampled residents (#1), reviewed for falls. Resident #1 experienced actual harm, as evidenced by a fall, with the resulting injury requiring stitches. Findings included: Resident #1 had [DIAGNOSES REDACTED]. The 05/12/15 assessment documented the resident required extensive assist for transfers, and most activities of daily living. The care plan, dated 05/12/15, directed staff to ensure the bed was lowered to the floor, with a mat at the bedside, when staff was not providing 1:1 care. Per nursing note on 05/22/15, Resident #1 had repositioned himself, from his bed to the fall mat, and required assistance back into bed. A fall investigation documented an incident on 06/15/15. Staff B provided care for Resident #1, and turned away to go to the sink, leaving the resident unattended. Staff B had not lowered the bed, or placed the mat at the bedside. Resident #1 fell from his bed, hitting his chin on a metal pole base, which was next to his bed. The resident was transported to the hospital for treatment. Per hospital records on 06/15/15, Resident #1 required stitches for a 5 centimeter laceration (deep cut in the skin) under his chin, and had an abrasion on his forehead. Per observation on 06/23/15 at 10:30 a.m., a sign on resident #1's wall indicated - Due to safety risk, bed must be kept in low position with mat at bedside when occupied. Staff A was interviewed on 06/23/15 at that time, and said Resident #1 had a history of [REDACTED]. Staff A stated the safety notice on the wall had been there for as long as he could remember.

Based on observation, interview and record review, it was determined the facility failed to provide appropriate treatment and services for 1 of 3 sample residents (#1) with a gastrostomy tube used for tube feeding. This failure resulted in actual harm to the resident, as evidenced by nausea and vomiting, which caused aspiration pnuemonia and the need for hospitalization . Findings include: Resident #1 had [DIAGNOSES REDACTED]. In addition, the resident had gastric reflux disease - a condition in which stomach acid backs up into the esophagus. The record indicated the resident was severely cognitively impaired, was rarely/never understood, and was totally dependent on staff for all activities of daily living. Resident #1 received all medications and feedings through a jejunostomy tube (a small tube leading into the small intestine). He also had a gastric tube used for draining body waste. A progress note on 8/27/14 at 12:25 a.m. documented that Resident #1 vomited, and was intermittently groaning and burping. At 3:05 a.m. the vomiting continued, and the resident continued to groan and call out. Resident #1 was then placed on the facility "emesis protocol" (a standing order for medications and treatment, which are put in place after a resident vomits). At 1:00 p.m. that day, Staff #A - the facility nurse practioner - assessed the resident. Staff #A wrote an order to hold the tube feeding for 24 hours (because of the nausea and vomiting). On 8/28/14 at 1:00 a.m., a nurse discovered the tubes used to feed the resident and to drain body waste were connected backwards. Not only was Resident #1 receiving the tube feeding (after the order was written to hold it), but it was being administered through the wrong tube. The facility was unable to determine how long the resident had been receiving the feeding, or to assess the amount of time it was connected to the wrong tube. At 2:53 a.m., Resident# 1 was found to be hypoxic (low on oxygen) and was non-responsive. He was transported to the hospital by ambulance. According to the hospital discharge documentation dated 8/30/14, Resident #1 was diagnosed with [REDACTED]. During an interview on 9/9/14 at 12:00 p.m., Staff #B indicated he could have inadvertantly switched the tubes when caring for the resident, but did not know for sure. Staff #B stated that he did not feel training for new staff was always adequate. At the time of the interview, Staff #B was able to describe the difference between the tubes, and the color coding system the facility had in place to differentiate them. The facility failed to provide appropriate treatment and services for a resident with a gastrostomy tube. This resulted in Resident #1 having nausea and vomiting, acquiring aspiration pneumonia, with an associated decline in condition, and requiring hospitalization .

Based on interview and record review, it was determined the facility failed to ensure the residents environment was free from accident hazards for 1 of 5 (#1) residents related to toxic chemicals not being locked and within reach of a resident. Resident #1 ingested the chemical which resulted in harm. Findings include: Resident #1, per record review, had [DIAGNOSES REDACTED]. The resident needed limited assistance with activities of daily living (ADL'S) and was able to self propel her wheel chair for short distances. Per facility investigation, on 6/28/14 the resident was placed in the dining room area about 2:00 p.m. The resident told a staff member she was thirsty and was told by staff she needed to wait because the staff member was attending another resident. A student witnessed the resident holding a Dixie cup that contained detergent and noticed the detergent on her clothing protector. The resident had a red face and red eyes. Staff assisted the resident to rinse and spit the detergent out and contacted the physician and poison control. Staff looked the detergent up in the Material Safety Data Sheet (MSDS) book and it was documented the detergent wasn't toxic. The resident was ordered to be monitored for 24 hours for nausea/vomiting/diarrhea and she was to drink dairy products. On 6/28/14 at 4:45 p.m., a nurse was called to assess the resident because the resident's lips had increased in swelling, her right lower jaw appeared swollen and she was drooling. Her mouth appeared bright red with white areas around the outer edges of her tongue. She was showing signs of respiratory distress. The nurse looked at the label on the container of detergent and called poison control to inform of them of the product name. The label documented the powder was toxic and the staff was instructed to send the resident to the hospital for evaluation. Per hospital notes dated 6/29/14, the resident was intubated (a tube inserted to provide an airway) and was on a ventilator (a machine to assist with breathing). The resident was noted to have chemical burns in her mouth and throat and some swelling around her eyes. On 7/17/14 at 2:10 p.m., Staff #A stated she took the resident to the dining area and the resident told her she was thirsty. Staff #A told the resident she would help her in a minute because she needed to attend to another resident. While in a resident room, she heard screaming from Resident #1 and when she went out to the dining area she saw the nurse flushing out the resident's mouth. She stated the nurse contacted poison control and the information they had for the product in the MSDS stated it wasn't harmful so they were instructed to give the resident dairy products and monitor her for 24 hours. She stated the container of detergent was kept under the sink and a Dixie cup or spoon was used to scoop out the detergent into the dishwasher. On 7/17/14 at 2:35 p.m., Staff #B stated she was told by a student that the resident had eaten detergent. She stated she saw the resident in the entry way of the kitchen and she had saliva on her clothing protector with detergent in it. The student showed the nurse the Dixie cup with about 1/4 to 1/3 cup of detergent in it. She rinsed out the resident's mouth and flushed the resident's eyes with saline. The resident was crying and her lips and tongue were red. The nurse contacted the doctor and the poison control center and stated when she called the poison control center they didn't have the specific name of the detergent and was instructed to give dairy products and monitor the resident for 24 hours. During an interview on 7/17/14 at 3:25 p.m., Staff #C stated it was discovered that the MSDS was outdated and had a non toxic detergent as the agent being used when it was actually a toxic detergent. The facility failed to provide a safe environment with unsecured chemicals for a resident whom consumed a toxic detergent which led to harm for Resident #1.

Based on interview and record review, the facility failed to ensure 1 of 13 sample residents (#1) was free of a significant medication error. The failed practice resulted in actual harm to Resident #1 who was hospitalized as a result of receiving medication that was not ordered for her. Findings include: Resident #1, had [DIAGNOSES REDACTED]. She was dependent on nursing staff for medication administration. Per record review of nursing notes dated 4/23/14, at 12:15 p.m., the nurse was called by staff to assess Resident #1 because she was unresponsive, and her color was " off " . According to other staff this was not her normal behavior. At 12:45p.m. Resident #1 was sent to the hospital via ambulance after being assessed by the facility Nurse Practioner; she remained in the hospital until 4/25/14. Per nurse 's notes dated 4/24/14 at 2:30 a.m., a call was received from the hospital intensive care unit, stating a toxicology test result came back for Resident #1 positive for opiates (narcotic [MEDICATION NAME]) and tricyclics (antidepressants). Resident # 1 did not MEDICATION ORDERS FOR [REDACTED]. Per the facility investigation, it was determined the nurse responsible for delivering a.m. medications on 4/23/14 gave Resident #1 medication that was ordered for a different resident. On 4/29/14 at 11:20 a.m., Staff # A confirmed the facility had made a significant medication error and the nurse involved was no longer working at the facility. The facility's failure to administer the correct medication to Resident #1 resulted in actual harm to the resident who endured hospitalization related to receiving medication not ordered for her.

Based on interview and record review, the facility failed to ensure 1 of 4 residents (#3) was free from accident hazards when allowed to use a seatbelt in a rocking chair without an assessment with minimal staff supervision. As a result Resident #3 susained a fall with injury. Findings include: Resident #3, per record review, was profoundly developmentally delayed. She used a seat belt when she was in a recliner and wheel chair for positioning. She was not able to self release the seat belt. Per the care plan, staff were directed to utilize the seat belt while she was in the wheel chair and recliner. They also needed to reposition her every 2 hours as needed. During interview on 5/2/13 with Staff #B and #C, Resident #3 normally used a recliner or wheelchair with an attached seat belt. Recently a caregiver who worked with the resident in another facility was aware the resident enjoyed sitting in a rocking chair. A rocking chair was donated by another resident which was then used for Resident #3. The rocking chair was located in the resident's room down the hall from the nurses station and not easily viewable by staff. A seatbelt was attached to the rocking chair and staff had placed the resident in the rocking chair with the seat belt. Staff had placed a mat in front of her. The resident was found on the floor with the rocker tipped over. Per the investigation dated 4/26/13, the resident's rocking caused the chair to move forward and she slip under the seat belt. When she landed on the floor the chair tipped forward. She sustained superficial abrasions and welting on her abdomen. On 5/3/13 at 10:55 a.m., Staff #A reported he was not aware the rocking chair was in place and the facility never assessed the use of the rocking chair until after surveyor visit on 5/2/13. On 5/7/13 at 2:56 p.m., Staff #A said nobody was aware of the use of the rocking chair. He reported normally the managers of the cottages knew not to implement medical devices until they were assessed, but this cottage manager's last day was 4/26/13 and it got over looked. The facility failed to ensure this resident was assessed to safely use this equipment and was provided the proper supervision during its use.

Based on interview and record review, the facility failed to ensure that staff implemented planned interventions for 2 of 3 residents (#1, 3) related to safety. This failure caused harm for Resident #3. Findings include: Resident #1, per record review, had chronic mental health conditions, profound developmental disabilities, dementia, and an extensive history of behaviors. He required extensive assistance with activities of daily living (ADL's). Per record review, Resident #1 exhibited aggression, agitation, self-injurious behaviors, and property destruction. He also got upset when other residents used the bathroom. In May of 2012, the resident was moved to a cottage with fewer residents and placed on 1:1 supervision to ensure he and other residents were safe. Per review of the facility investigation dated 3/7/13, Staff #B was assigned to Resident #1 and put him to bed after lunch. Staff #B told Staff #C that she needed to talk to Staff #D and asked Staff#C to listen for Resident #1 to wake up. Staff #D tookt Resident #3 to the toilet. When she returned to the bathroom, Resident #1 was in the bathroom with Resident #3. Resident #1 had blood on his hands and under his fingernails and Resident #3 had multiple abrasions around both eyes. Resident #3 was sent to the hospital and diagnosed with [REDACTED]. On 3/20/13 at 10:00 a.m., Staff #B reported that she knew the resident was 1:1 supervision, but it did not indicate if the resident needed 1:1 supervision while he was in bed. Staff #D reported the plan was not specific when he needed 1:1 supervision and this could have happened with any of the staff that worked on the cottage. They reported the resident usually announced, "I'm up" when he woke up which alerted staff that he was awake, but 2 days prior to the incident that occurred on 3/7/13, he "eloped" from his room without announcing to the staff that he was up. They said this was new and unusual for him. On 3/29/13 at 11:55 a.m., Staff #E reported that at the time of the incident on 3/7/13 she felt the plan for the 1:1 supervision was not clear. She said the facility made some changes since the incident and she felt it was now clear. On 3/29/13 at 12:05 p.m., Staff #F reported he did not feel Resident #1's care plan was specific for his 1:1 supervision. He said the facility revised his plan and it was now "crystal clear." On 3/29/13 at 1:45 p.m., Staff #A confirmed that Resident #1 was ordered to have a 1:1 since they opened the cottage last year. The facility failed to ensure that planned interventions to protect residents were clear for the facility staff to understand, which resulted in harm for Resident #3.

Based on interview and record review, the facility failed to implement planned interventions for safe transfer techniques for 1 of 4 residents (#2) related to transfers. This failure resulted in harm by causing a fractured leg for Resident #2. Findings include: Resident #2, per record review, had [DIAGNOSES REDACTED]." Per record review she was dependent on staff for all activities of daily living (ADL's), including transfers. The resident weighed 90 pounds and was care planned to utilize a mechanical lift or use 2 people for the transfer. Per review of the facility investigation dated 8/30/12, Staff #C transferred the resident from her bed to her wheelchair by herself. She noticed the resident displayed signs of pain following the tranfer and reported to the nurse. The resident was evaluated by the doctor and sent to a local hospital emergency room where a fracture of her leg was confirmed. On 9/5/12 at 3:10 p.m., Staff #B reported the resident's care plan called for a mechanical lift or 2 person assist with her transfers. She confirmed the care plan was not followed. On 9/5/12 at 4:55 p.m., Staff #A confirmed the care plan was not followed. The facility failed to implement planned interventions for a resident at increased risk for fracture. This caused harm to Resident #2.

Based on record review and interview the facility failed to provide supervision to prevent accidents for 1 of 4 sampled residents (# 1), who was left alone on a table top and fell off sustaining injuries. This resulted in harm to resident # 1. Findings include: Resident # 1 had [DIAGNOSES REDACTED]. Per his record he was able to reposition himself and move around in bed. He required two plus persons for transfers out of bed and/or his wheelchair. Per the resident's plan of care he was to have 2-3 persons transfer him to the dressing table after his bath to get dressed. Per the resident's plan of care only one person was required to dress the resident and if staff needed to turn away, a safety strap was to be used to prevent the resident from falling off the table. The dressing table in the Bath/shower room had one side placed against the wall. An anti roll bolster was used for all resident's to help prevent rolls off the table during routine care. Per the facility investigation dated 5/21/11 Staff A, B, C had transferred the resident to the dressing table. Staff B and C, were about to leave the bath/shower room when they heard the resident fall off the dressing table. Per the facility investigation, Staff A had turned around to do something by the tub (which was approximately 3 feet from the dressing table) and the resident rolled off the table and landed on his hands and knees. Staff B and C picked the resident up and placed him in his wheelchair before the licensed nurse could assess the resident. The resident was taken to his room and the Licensed Nurse assessed him and found some scrapes to his forearm, and swollen knees. The resident was assessed by the physician and x-rays were negative for any fractures. Staff A, B, C could not remember if the bolster was used, and/or the safety strap. Interviews with Staff B on 6/8/11 noted he could not remember what happened except he did move the resident before the licensed nurse could assess him. Staff B confirmed he was counseled and had further training. The facility staff failed to follow the resident's plan of care to prevent injuries. Resident # 1 was left alone on the dressing table without planned interventions and rolled off sustaining injuries to his arm and knees which resulted in harm.