Every finding on record at Life Care Center of Port Townsend

Based on interview and record review, the facility failed to screen residents for mental health conditions prior to admission for 2 of 5 sampled residents (Resident 12 and 47) residents reviewed for Preadmission Screening and Resident /review (PASRR). This failure placed residents at risk for unidentified mental health conditions, lack of appropriate mental health care and a decreased quality of life. Findings included . Resident 12 was admitted on [DATE]. Resident 12's Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 12 had a diagnosis of anxiety disorder. Resident 12's physician orders, dated 02/03/2026, showed Resident 12 had lorazepam (medication for anxiety) ordered every four hours as needed for anxiety related to anxiety disorder. Resident 12's Level 1 PASRR, dated 01/26/2026, showed Resident 12 was anticipated to be admitted to the facility on [DATE] and had no serious mental illness indicators and anxiety disorder was not documented. On 03/12/2026 at 1:13 PM, Staff C, Social Service Director (SSD), said they had reviewed Resident 12's PASRR Level 1 that was completed prior to admission and determined it was not correct due to Resident 12's diagnosis of an anxiety disorder. Staff C said they had been busy and had not completed a corrected PASRR until 03/11/2026. Resident 47 Resident 47 was admitted to the facility on [DATE], with no mental health diagnoses documented on diagnoses list. The admission MDS, dated [DATE], documented Resident 47 was cognitively intact and showed no mental health diagnoses or history. The PASRR Level I form, upon admission, documented Resident 47 had no mental health diagnoses or concerns, a Level II was not required. On 03/12/2026 at 11:19 AM, Staff B, Director of Nursing Services, reviewed Resident 47's diagnosis list and confirmed Resident 47 had no mental health diagnosis listed. Staff B then reviewed Resident 47's medication list that included an antidepressant and an antianxiety medication. Staff B reviewed the hospital discharge record and confirmed the hospital had a diagnosis of anxiety. Staff B said Resident 47 had been admitted to the facility on both medications, the diagnoses should have been caught and a new PASRR should have been completed and submitted to include the correct diagnoses. Reference WAC 388-97- -1915 (1)(2)(a-c)

Based on interview and record review, the facility failed to coordinate and follow-up on a preadmission screening and resident review (PASRR, a mental health screening tool) level 2 evaluation for residents diagnosed with a significant mental illness for 2 of 5 residents (3 and 4) reviewed for PASRR. This failure placed the residents at risk for unmet care needs and a decreased quality of life.Findings included .Resident 3Resident 3 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 12/05/2025, showed Resident 3 was cognitively intact and needed set up assistance with oral hygiene and partial/moderate assist to dependent with dressing and showering.Resident 3's PASRR, dated 07/03/2025, showed serious mental illness indicators were checked for psychotic disorder (severe mental illnesses characterized by a loss of touch with reality) depressive disorder (mental health condition characterized by persistent low mood, loss of interest, and low energy), delusion disorder (false beliefs) and neurocognitive disorder with Lewy bodies(a progressive disease associated with abnormal deposits of alpha-synuclein protein, causing cognitive decline, hallucinations, movement issues (parkinsonism), and fluctuating alertness). Level 2 evaluation referral was checked.A review of Resident 3's electronic health record (EHR) showed no level 2 evaluation. A review of Resident 3's EHR showed a progress note, dated 07/03/2025 at 12:03 PM by Staff D, Social Services Director (SSD, previous SSD), documented a request for Level II PASRR review was emailed to Acentra Health on the Resident.On 03/11/2026 at 12:02 PM, Staff C, Social Service Director, said they had been with facility since October 2025, and was still getting up to speed. Staff C said she was trying to figure out if they had received a Level 2 evaluation for Resident 3 and sent an email to the state and asked them to send an invalidation letter. Staff C said there had not been documentation or follow up with the state before this day.On 03/13/2026 at 8:32 AM, Staff A, Administrator, said there has not been follow-up on the PASRR sent until they were audited and brought up by the survey team this week. Resident 4Resident 4 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], showed the resident was cognitively intact and needed setup to supervision assistance with hygiene and dressing and partial to moderate assistance with bathing.Resident 4's PASRR, dated 04/30/2025, showed serious mental illness indicators checked were for major depressive disorder (a serious, common mood disorder characterized by persistent sadness, low energy, and loss of interest in activities) and anxiety disorder (persistent, excessive fear or worry that interferes with daily life). Level 2 evaluation referral was checked.A review of Resident 4's EHR showed no level 2 evaluation.On 03/11/2026 12:02 PM Staff C, SSD, said they had not received an invalidation from 04/30/2025. Staff C said she sent the state an email today and Resident 4 was in the queue for an evaluation.On 03/13/2026 at 8:32 AM Staff A, Administrator, said there was follow-up in July 2025 for Resident 4 but no follow-up since and should have been to make sure Resident 4 was still on the list for a level 2 evaluation. Staff A said their new Social Services Director was now contacting the state and following up on all the PASRRs sent.Reference WAC 388-97-1915(4)

Based on interview and record review, the facility failed to reassess current nutritional interventions and implement new nutritional interventions for 1 of 1 sampled residents (Resident 6) reviewed to weight loss. This failure placed residents at risk for continued weight loss, malnutrition, medical complications and a diminished quality of life. Findings included .Resident 6 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, as assessment tool) dated 01/07/2026, documented Resident 6 was severely cognitively impaired, had communication deficits, had a 5 % weight loss and was not on a prescribed weight loss regimen.Resident 6's diet order, dated 07/09/2025, was regular diet, regular texture, thin consistency, finger foods/sandwiches when available. The electronic health record (EHR) documented no change in diet type to include nutritionally enhanced meals (NEM), fortified foods or calorie dense meals.On 10/11/2025, Resident 6 weighed 108 pounds (lbs.) On 03/07/2026, Resident 6 weighed 90.8 lbs, resulting in a 15.93% weight loss in 5 months.The EHR documented no food preference evaluations had been completed for Resident 6. The Amounts Eaten task documented Resident 6 usually only ate 0-25% of all their meals (reviewed for the last 30 days). The Snacks task documented Resident 6 only received 10 snacks in the last 30 days, in which 76-100% of them were consumed. A physician's order dated 07/11/2025-10/20/2025, documented Resident 6 was to receive 2Cal Med Pass Supplements, 120 milliliters (ml) three times a day for nutritional support. A physician's order dated 10/20/2025-11/20/2025, documented Resident 6 was to receive 2Cal Med Pass Supplements, 120 ml three times a day for nutritional support.A physician's order dated 11/21/2025-11/21/2025, documented Resident 6 was to receive House Shake, 120 ml, three times a day for nutritional support. A physician's order dated 11/22/2025-11/22/2025, documented Resident 6 was to receive Frozen Nutritional Supplement, 120 ml with meals for at risk of malnutrition. A physician's order dated 11/22/2025-12/19/2025, documented Resident 6 was to receive House Shake, 118ml, three times a day for nutritional support. A physician's order dated 12/19/2025-02/15/2026, documented Resident 6 was to receive House Supplements, 118ml three times a day and finger food when available for at risk of malnutritional.A physician's order dated 02/15/2026-Current, documented Resident 6 was to receive House Supplements, 90-120 ml three times a day for at risk of malnutrition.Resident 6's continued to lose weight during the previous five months. The nutritional supports, started on 07/09/2025 had not been reevaluated, changed or increased to support increase in nutrition.A Mini Nutritional Assessment, dated 10/02/2025, documented Resident 6 had no decrease in food intake, lost 2.2-6.6 lbs. in the previous three months and the resident's BMI was less than 19 and was at risk of malnutrition. No follow up was documented nor recommendations made. Resident 6's nutritional care plan, revised on 12/01/2025, by Staff B, Director of Nursing Services, documented at risk for unavoidable fluctuations/loss r/t [related to] continued decline in health status. Interventions included encouraging resident to go to the dining hall, ensuring no pocketing of food, oral care after meals, supervision for meals, and diet as ordered. The care plan showed no documentation of food preferences or that alternate interventions were attempted for weight gain such as Nutritional Enhanced Meals, diet change or an increase in nutritional supplements. A Mini Nutritional Assessment, dated 01/06/2026, documented Resident 6 had a severe decrease in food intake, a weight loss greater than 6.6 lbs. in three months, BMI less than 19 and documented Resident 6 was malnourished. No follow up was documented nor recommendations made.A Nutrition Dietary note, dated 02/25/2026, documented Resident 6's BMI was 14.5, indicating malnutrition, the resident received 90-120ml nourishments three times a day to help promote weight maintenance. Resident 6 had comfort focus for care and did not like staff to encourage her too much to eat or drink. Interdisciplinary team would continue with regular, regular, thin liquids diet and offer finger foods. No recommendations were made to address continued weight loss. Review of the March 2026 Medication Administration Record documented Resident 6, on average, consumed 90-110 ml of the House Shake three times a day, with two refusals and one unavailable to give.On 03/12/2026 at 11:00 AM, when asked about Resident 6's weight loss, Staff K, Registered Nurse, said they had not seen any weight loss but, they only work one day a week and they usually work on the other hall. Staff K said they knew the resident often refused to get out of bed or exercise. Staff K said the resident sometimes had a good appetite and other times not and she did get three house supplement drinks a day. Staff K said Resident 6 received snacks to boost calories and required one-to0one level assistant with eating. Staff K was not able to provide any further details about Resident 6's weight loss.On 03/12/2026 at 11:05 AM, Staff B, DNS, said Resident 6's weight loss had been progressive, the resident admitted to the facility malnourished and was on comfort care now. Staff B said the facility was trying to help obtain a guardian for Resident 6, so the resident could be placed on hospice care. When asked what interventions were currently implemented for Resident 6, Staff B said Resident 6 was on House supplement three times a daily and reviewed at the Resident at Risk (RAR) meeting weekly. When asked about the care plan statement, unavoidable weight fluctuation/loss r/t continued decline in health status, Staff B said before Resident 6 would sit in a wheelchair, but not anymore, they admitted on liquid morphine and has refused to work with us and had now been identified as malnutrition. Staff B reviewed Resident 's weight chart confirmed Resident 6 had a 15.93% weight loss in 5 months. When asked about food preference, Staff B reviewed the EHR and confirmed the food preference evaluations had been documented. Staff B said they know Resident 6 likes sweets, chips and ice cream. When asked what interventions were in place to prevent weight loss, Staff B said I don't know. When asked what interventions had been put into place since the identified weight loss, Staff B said she was on a house supplement (the same House supplement since admit, before the weight loss started). On 03/12/2026 at 12:09 AM, Staff L, Registered Dietitian, said Resident 6 did not like staff to encourage them to eat, but had received House Supplement drinks three times a day. Staff L was asked to review the food preference evaluations and confirmed no food preference evaluations had been completed. Staff L said one of the dietary aids used to be a Certified Nursing Assistant and knew what Resident 6 liked as far as foods, but it was not documented. Staff L said Resident 6 liked soup in a mug, sandwiches, and they would usually have soup and sandwiches for dinner and cookies. Staff B said the finger foods gave the resident a sense of independence when eating. Staff L was asked to review Resident 6's weight for the previous five months. Staff L confirmed Resident 6 had lost 15.93% of their weight in five months, putting them under the severe weight loss category. Staff L confirmed Resident 6 had a variety of orders for nutritional support since admit, but it was never increased, always remained between 90-120ml three times a day and no other intervention had been recommended. When asked what other nutritional interventions had been in place prior to the weight loss, Staff B said they had been trying to get a guardian for Resident 6 because the facility believed Resident 6 needed to be on hospice care. When asked what additional interventions had been implemented in the meantime for the resident's 16% weight loss, Staff L was unable to answer the question. Reference WAC 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to ensure psychotropic medications (any drug that affects the brain activities associated with mental processes and behavior) were regularly monitored for side effects and target behaviors and provided justification for use of the psychotropic medications and non-pharmaceutical interventions were used prior to utilizing psychotropic medications for 3 of 5 sampled residents (Resident 22, 47 & 12) reviewed for unnecessary medication. This failure placed residents at risk of unnecessary medication usage, increase in side effects without interventions, and a diminished quality of life.Findings included.Review of the facility policy titled, Psychotropic Medication Use, revised 03/01/2025, showed the facility staff should take a holistic approach to behavior management that involved a thorough assessment of underlying causes of behaviors and individualized person-centered non-drug and pharmaceutical interventions and psychotropic medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use. The policy showed all medications used should be monitored for harm and adverse consequences. Resident 22 Resident 22 was admitted to the facility on [DATE], with diagnoses that included depression (persistent feelings of sadness and loss of interest) and unspecified dementia, with other behavioral disturbances (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities). The admission Minimum Data Set (MDS, an assessment tool), dated 02/19/2026, documented Resident 22 was severely cognitively impaired. A physician's order dated 02/17/2026, documented Resident 22 was prescribed quetiapine (an antipsychotic) for unspecified dementia. A physician's order dated 02/17/2026, documented Resident 22 prescribed Trazadone (an antidepressant) for depression. Resident 22's electronic health record (EHR) showed no documentation of target behavior monitoring for the Trazadone. On 03/12/2026 at 10:55AM, Staff B, Director of Nursing Services (DNS) reviewed Resident 22's Electronic Health Record (EHR) and confirmed there was no target behavior monitoring in place or documented for Resident 22's antidepressant medication and said there should have been. Resident 47 Resident 47 was admitted to the facility on [DATE], with no mental health diagnoses documented on the diagnoses list. The admission MDS, dated [DATE], documented Resident 47 was cognitively intact and showed no mental health diagnoses or history. A physician's order, dated 02/12/2026, documented Resident 47 was prescribed escitalopram (an antidepressant) routinely for anxiety. A physician's order, dated 02/27/2026, documented Resident 47 was prescribed lorazepam (an antianxiety) as needed for anxiety. A progress note, dated 03/02/2026, documented Resident 47 told the facility they did not have depression, but sometimes had anxiety. On 03/12/2026 at 11:19 AM, Staff B, DNS, reviewed Resident 47's diagnosis list and confirmed Resident 47 had no mental health diagnosis listed. Staff B then reviewed Resident 47's medication list that included an antidepressant and an antianxiety medication. Staff B reviewed the hospital discharge record and confirmed the hospital had a diagnosis of anxiety. Staff B said Resident 47 had been admitted to the facility on both medications, the diagnoses should have been caught and listed under diagnosis that also included justification of use. Resident 12 Resident 12 was admitted on [DATE] with diagnoses including Alzheimer's (type of dementia) with behavior disturbances and anxiety disorder. The admission MDS, dated [DATE], showed Resident 12 was severely cognitively impaired, exhibited physical behaviors toward others that interfered with care, put others at significant risk for physical injury and was dependent on staff assistance with activities of daily living. NON-DRUG AND PHARMACEUTICAL INTERVENTIONS Resident 12's change in mood or behavior due to late onset Alzheimer's disease care plan, dated 02/03/2026, showed staff were to explain each task before beginning and during the task and if resident was resistant to care to not contradict resident, ensure safety and reapproach. Resident 12's physician orders, dated 02/03/2026, showed risperidone (psychoactive medication) one tablet every 24 hours as needed for agitation related to Alzheimer's disease with agitation. Resident 12's physician orders, dated 02/03/2026, showed to monitor and document number of episodes of agitation were present and documented behavioral interventions attempted and the outcome of the behavioral interventions. Resident 12's physician orders, dated 02/03/2026, showed to monitor and document number of episodes of anxiety were present and documented behavioral interventions attempted and the outcome of the behavioral interventions. Resident 12's physician orders, dated 02/05/2026, showed lorazepam (psychoactive medication used to treat anxiety) 0.25 ML [milliliters] every four hours as needed for anxiety. Resident 12's physician orders, dated 02/05/2026, showed haloperidol (psychoactive medication) 0.25 ML every four hours as needed for agitation related to Alzheimer's disease with agitation. Resident 12's potential to be physically aggressive during care r/t [related to] dementia care plan, revised 02/11/2026, showed staff were to analyze times of day, places, circumstances, triggers, and what de-escalated the resident's behavior and document it. The care plan showed when the resident became agitated: intervene before the agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff are to walk calmly away and approach later. Resident 12's progress notes, dated 02/13/2026 at 2:31 PM, showed Resident 12 was administered haloperidol prior to a shower d/t [due to] aggressiveness during showers. Resident 12's Treatment Administration Record (TAR), dated 02/01/2026 through 02/28/2026, showed no documentation on 02/13/2026 of episodes of agitation and/or behavioral interventions prior to the administration of haloperidol. Resident 12's progress notes dated 02/16/2026 at 3:20 AM, showed Resident 12 was administered lorazepam for agitation. Resident 12's Treatment Administration Record (TAR), dated 02/01/2026 through 02/28/2026, showed no documentation on 02/16/2026 of episodes of agitation and/or anxiety. The TAR showed no documentation of behavioral interventions prior to the administration of lorazepam. Resident 12's progress notes, dated 02/17/2026 at 7:08 PM, showed Resident 12 was administered lorazepam prior to HS [bedtime] care. Resident 12's TAR, dated 02/01/2026 through 02/28/2026, showed no documentation on 02/17/2026 of episodes of anxiety and/or behavioral interventions prior to the administration of lorazepam. Resident 12's progress notes, dated 02/18/2026 at 7:25 PM, showed Resident 12 was administered lorazepam prior to personal care. Resident 12's TAR, dated 02/01/2026 through 02/28/2026, showed no documentation on 02/18/2026 of episodes of anxiety and/or behavioral interventions prior to the administration of lorazepam. Resident 12's progress notes, dated 02/20/2026 at 2:58 AM, showed Resident 12 was aggressive during care, scratching staff, staff was encouraged to use two people to assist and to let the LN [licensed nurse] know to medicate resident with PRN [as needed] lorazepam prior to care. Resident 12's progress notes, dated 02/20/2026 at 7:16 AM, showed Resident 12 was administered risperidone because they were agitated and needed care done, attempting to help relax resident so they would allow care at this time. Resident 12's Resident 12's TAR, dated 02/01/2026 through 02/28/2026, showed no documentation on 02/20/2026 of episodes of agitation and/or behavioral interventions attempted prior to risperidone being administered. Resident 12's progress notes, dated 02/23/2026 at 7:18 PM, showed Resident 12 was administered lorazepam prior to personal care. Resident 12's Resident 12's TAR, dated 02/01/2026 through 02/28/2026, showed no documentation on 02/23/2026 of episodes of anxiety and no behavioral interventions were documented attempted prior to lorazepam being administered. Resident 12's progress notes, dated 03/08/2026 at 8:11 AM, showed Resident 12 was administered lorazepam for anxiety. Resident 12's Resident 12's TAR, dated 03/01/2026 through 03/31/2026, showed no documentation on 03/08/2026 of episodes of anxiety and no behavioral interventions were documented attempted prior to lorazepam being administered. Resident 12's physician orders, dated 03/11/2026, showed a new order for an additional dose of risperidone 0.25 MG every day in the morning for dementia with agitation. On 03/11/2026 at 3:51 PM, Staff H, Licensed Practical Nurse, said they administered lorazepam to Resident 12 in anticipation of care and/or a bath. Staff H said they did not want Resident 12 to become anxious. Staff H said they did not administer the medication to sedate Resident 12 but to relax them and enable them to receive care. On 03/12/2026 at 1:13 PM, Staff C, Social Service Director, said they complete the behavior section of the MDS and the behavior care plan. Staff C said there seemed to be a pattern to Resident 12's physical aggressiveness. Staff C said it seemed to occur when showering/bathing and/or later in the day. Staff C said they had seen most of the behaviors in the evening, but they had not made changes to the behavioral interventions in the care plan. Staff C said when Resident 12 became aggressive the staff should stop and walk away and come back later and try other tactics. Staff C said they did not know if those interventions were working but they had not heard otherwise. Staff C said they were not involved in any medication changes for Resident 12 and did not know why Resident 12's risperidone medication had been increased, I was wondering that too, I figured hospice but wasn't sure, I was not brought into the discussion. On 03/12/2026 at 10:17 AM, Resident 12 was observed during care. Staff F, Certified Nursing Assistant (CNA) and Staff G, CNA were completing the care. Staff F and G changed Resident 12's brief and changed their clothes. During the care Resident 12 patted Staff G's chest, Staff F gave Resident 12 a stuffed animal to hold. Resident 12 hit Staff G with the animal. Staff F and G continued to provide the care, they did not pause and/or step back when Resident 12 hit them with the stuffed animal. Resident 12 was placed in the manual lift and placed in the wheelchair. Staff G leaned over Resident 12 to put their shoes on. Resident 12 walked the animal across Staff G's back and then patted Staff G's face. Staff G continued to put the resident's shoes on. Resident 12 smiled when Staff G was done. On 03/12/2026 at 1:42 PM, Staff B, DNS, said if Resident 12 was exhibiting agitation, anxiety and/or physical behavioral symptoms, they expected the licensed nurses to ask the nursing assistants if they had attempted the behavioral interventions and if the interventions were ineffective, they would administer the medication. Staff B reviewed Resident 12's progress notes and TARs and said it appeared the staff had not been doing that. Staff B said Resident 12's risperidone was increased on 03/11/2026 because they were speaking with the Hospice nurse and they said Resident 12 had grabbed them during care. Staff B said the staff had not reviewed the behavior care plan interventions for effectiveness and/or analyzed what interventions were effective and/or reassessed what other approaches would work. Staff B said they had wondered if Resident 12 was in pain during care but was unaware if the staff had assessed for pain. Staff B reviewed Resident 12's Medication Administration Record and said Resident 12 had not been given any medication for pain. Staff B said they had not done enough to assess and/or analyze Resident 12's behavior and what non-pharmacological interventions would be effective prior to increasing their psychoactive medication. SIDE EFFECT MONITORING On 03/09/2026 at 1:40 PM, Resident 12 was observed sitting in their wheelchair. Resident 12 was thrusting their jaw forward repetitively. On 03/10/2026 at 2:56 PM, Resident 12 was observed puckering their mouth, smacking their lips and rolling their tongue in their mouth, around their lips and outside of their mouth. Resident 12's antipsychotic medication care plan, dated 02/13/2026, showed Resident 12 was administered antipsychotic medications and was to be observed for side effects and adverse reactions to include tardive dyskinesia (a neurological syndrome characterized by involuntary, repetitive body movements-such as lip-smacking, tongue thrusting, puckering and jaw swinging, finger tapping or wiggling and/or rocking). Resident 12's physician orders, dated 02/03/2026, showed the antipsychotic medication was haloperidol and risperidone and staff were to monitor Resident 12 for side effects to include tardive dyskinesia every shift and if present document a plus symbol and write a progress note. Resident 12's TAR, dated 02/01/2026 through 02/28/2026, showed no documentation of side effects including tardive dyskinesia, from the antipsychotic medication. Resident 12's Abnormal Involuntary Movement Scale Assessment (AIMS) (tool used to screen for and monitor the severity of tardive dyskinesia), dated 02/05/2026, showed no observations of movements in the lips and perioral area (puckering, pouting and smacking) the jaw and/or the tongue. During an observation on 03/10/2026 at 3:00 PM, with Staff B, DNS, Resident 12 was observed thrusting their jaws outward, puckering their lips and rolling their tongue in their mouth and lips. Staff B observed Resident 12 and said they saw the jaw thrusting and tongue movements. Staff B said they would review the AIMS test. Resident 12's AIMS assessment, dated 03/11/2026, showed moderate observations of the lips and perioral area and jaw and mild movement of the tongue. Resident 12's TAR, dated 03/01/2026 through 03/31/2026, showed no documentation of side effects, including tardive dyskinesia, from the antipsychotic medication including tardive dyskinesia. On 03/12/2026 at 1:10 PM, Staff E, Licensed Practical Nurse, said they had cared for Resident 12 many times since admission. Staff E said they were monitoring Resident 12 for side effects from their antipsychotic medications. Staff E said that Resident 12 exhibited signs of tardive dyskinesia with their mouth and tongue. Staff E said they did not document their observations on Resident 12's TAR and/or progress notes because this was Resident 12's baseline and Resident 12 had the movements since admission to the facility. On 03/12/2026 at 1:42 PM, Staff B, DNS, said the staff had completed Resident 12's initial AIMS test incorrectly and they had corrected it. Staff B said the nursing staff should have documented Resident 12 was observed with side effects due to their oral facial movements and notified the medical provider of their observations. Staff B said it did not matter that Resident 12 had the movements since admission to the facility. Reference WAC 388-97-1060(3)(k)(i), 0620(1)(a)

Based on interview and record review, the facility failed to prevent facility acquired pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure) from developing for 1 of 3 sampled residents (Resident 6) reviewed for pressure ulcers. This failure placed residents at risk for developing pressure ulcers, worsening pressure ulcers, increased pain, and a diminished quality of life.Findings included .Resident 6Resident 6 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, as assessment tool) dated 01/07/2026, documented Resident 6 was severely cognitively impaired, had communication deficits, was at risk for developing pressure ulcers and had two Stage 2 pressure ulcers. The skin integrity care plan, initiated on 07/10/2025, documented Resident 6 had an air overlay mattress (a medical device designed to prevent and treat pressure ulcers by redistributing pressure across the body. It typically consists of air-filled cells that inflate and deflate in a cyclical pattern, providing alternating pressure to reduce the risk of pressure injuries). A Nursing Wound Observation Tool, dated 07/10/2025, documented Resident 6 had one Stage 2 pressure ulcer on the left ischium (is a paired bone forming the lower and back part of the hip bone). The pressure ulcer was documented to be dry and intact with flaky skin, appears to be healing. The admission MDS, dated [DATE], documented Resident 6 had admitted to the facility with two Stage 2 pressure ulcers.A Nursing Wound Observation Tool, dated 07/23/2025, documented Resident 6 had one Stage 2 pressure ulcer on the right ischium. The pressure was documented to be healed. The Quarterly MDS, dated [DATE], documented Resident 6 had no pressure ulcers at the time of the assessment.A progress note, dated 12/01/2025, documented two new Stage 1 pressures ulcers, to the central coccyx (tailbone) and left coccyx with recommendations for air mattress and barrier cream. A Nursing Wound Observation Tool, dated 12/01/2025, documented Resident 6 had a Stage 1 develop at the central coccyx measuring 3 centimeters (cm) by 1.7cm. The treatment plan included barrier cream to coccyx every shift and air mattress to maintain skin integrity.A Nursing Wound Observation Tool, dated 12/01/2025, documented Resident 6 had a Stage 1 develop at the left coccyx bony prominence measuring 1.5cm by 1.5cm. The treatment plan included barrier cream to coccyx every shift and air mattress to maintain skin integrity.The skin integrity care plan, revised on 12/01/2025, documented bridge and reposition as allowed and for the registered dietitian to review. Progress notes, dated 12/04/2025, documented the area's (both areas on the coccyx) had opened, now staging as two new Stage 2 pressure ulcers. A Nursing Wound Observation Tool, dated 12/04/2025, documented Resident 6's Stage 1 pressure ulcer had developed into a Stage 2 at the central coccyx measuring 2cm by 1cm. The treatment plan included Cleanse with normal saline, pat dry, apply skin prep and cover with 4x4 silicone dressing every three days and PRN [as needed] soilage or dislodgement.A Nursing Wound Observation Tool, dated 12/04/2025, documented Resident 6's Stage 1 pressure ulcer had developed into a Stage 2 at the left coccyx bony prominence measuring .5cm by .3cm by .1 cm. The treatment plan included Cleanse with normal saline, pat dry, apply skin prep and cover with 4x4 silicone dressing every three days and PRN soilage or dislodgement.A Nutrition Dietary note, dated 12/06/2025, documented Resident 6 was reviewed by the Resident At Risk (RAR) Interdisciplinary Team Meeting (IDT) on 12/04/2025. Juven (a therapeutic nutrition powder with key ingredients to help support wound healing) was order once daily for 14 days. A physician's order, dated 12/08/2025, documented Resident 6 was ordered an air mattress to maintain skin integrity.A Nutrition Dietary Note, dated 01/11/2026, documented Resident 6 was receiving 118 milliliters house nourishments (supplement drink) three times daily for weight gain and skin healing of coccyx. No other pressure ulcer interventions implemented at that time. On 03/12/2026 at 11:05 AM, Staff B, Director of Nursing Services, said Resident 6 had admitted with two Stage 2 pressure ulcers that healed shortly after the resident arrived. Staff B said on 12/01/2025, Resident 6 was identified to have two Stage 1 pressure ulcers and developed into two Stage 2's by 12/04/2025. Staff B said an air mattress was ordered on 12/01/2025. When asked about inventions that were in place prior to the development of the 12/01/2025 pressures ulcers, Staff B said Resident 6 had been working with therapy prior to that, but the resident stopped getting out of bed, and the facility gave the resident nutritional supplements to help wound healing. When asked specifically what interventions were in place prior, to prevent the development of the 12/01/2025 pressure ulcers, Staff B said none. Reference WAC 388-97-1060 (3)(b), -1060 (3)(j)(viii)

Based on observation, interview, and record review, the facility failed to provide the necessary services for a dependent resident for 1 of 2 sampled residents (3) reviewed for activities of daily living (ADL). This failure placed the resident at risk for a decline in health status and a diminished quality of life. Findings included.Resident 3 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 12/05/2025, showed Resident 3 was cognitively intact and needed set up or clean-up assistance with eating.On 03/09/2026 at 1:37 PM, Resident 3 said sometimes they could not reach their call light. Resident 3 was asked what they do when they cannot reach their call light and Resident 3 said, I have to wait.On 03/09/2026 at 1:51 PM, Resident 3 said they needed the staff to help them drink. Resident 3 was asked what they did when they needed a drink, Resident 3 said sometimes I must wait. Resident 3 said, they tell me I am dehydrated and I do want to drink more.On 03/11/2026 at 8:02 AM, Resident 3 was observed in bed and appeared asleep with their eyes closed. Resident 3's call light was hanging down the side of the bed from the bed rail and appeared out of reach. Their water container with a straw was placed at the far edge of the bedside table and appeared out of reach. On 03/11/2026 at 8:07 AM, Resident 3 awoke and was asked if they could reach their call light? Resident 3 said no. Staff J, Certified Nursing Assistant (CNA) came into the room and Resident 3 asked the CNA for a sip of water, Staff J reached for the water container and helped Resident 3 drink from the straw of the water container. Staff E, Licensed Practical Nurse came into the room to give Resident 3 their medications. Staff E was asked where Resident 3's call light was placed? Staff E lifted the call light that was dangling down the side of the bed and placed it in Resident 3's lap. Staff E was asked where Resident 3's call light should be? And Staff E said, where [Resident 3] can touch it.On 03/11/2026 at 10:04 AM, Resident 3 said they waited when they needed the call light and sometimes, they needed a drink of water. Resident 3 was asked what they did when they needed a drink of water? And Resident 3 said, sometimes I wait until the morning.On 03/11/2026 at 3:16 PM, Staff B, Director of Nursing Services, said she would expect the staff to make sure Resident 3's call light and water was in reach before they left the room. Staff B said staff should say to Resident 3 Is there anything else you need before I leave? Staff B said she would add to Resident 3's care plan: Ensure before you leave [Resident 3] has water and their call light within reach. Reference WAC 388-97-1060(2)(c)

Based on observation, interview, and record review the facility failed to ensure that potential restraints were appropriately assessed for safety, care planned, and/or documented on for 3 of 3 residents (Residents 14, 16, & 29) reviewed for physical restraints. This failure placed residents at risk for unidentified risks and care needs, of the potential for restraint, and for a diminished quality of life. Findings included . 1) Resident 14 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 14 was cognitively intact, was not in any therapies, had lower extremity impairment, and was dependent on staff for toileting/dressing. On 04/07/2025 at 10:42 AM, Resident 14 was observed with their bed against the wall. Review of the Electronic Health Record (EHR) showed Resident 14 had not had a physical restraint evaluation done for the bed against the wall. Review of Resident 14's care plans showed there was not a care plan for the bed against the wall. On 04/10/2025 at 10:15 AM, Staff F, Resident Care Manager (RCM), said for the bed against the wall there should be consent, an assessment done, and a care plan. Staff F was unable to locate an assessment for the bed against the wall or a care plan for Resident 14, and said there should be. On 04/11/2025 at 9:37 AM, Staff J, Rehabilitation Director, and Staff B, Director of Nursing (DNS), were jointly interviewed. When asked if Resident 14 had an order for their bed against the wall, Staff J said there was an order now and Staff B said it should have been done before. When asked if it met expectations that Resident 14 did not have an assessment done to show the bed against the wall was not acting as a restraint, Staff B said it did not. 2) Resident 16 was admitted to the facility on [DATE], and had diagnoses of right femur facture and difficulty in walking. The Modification of Significant Change MDS, dated [DATE], showed Resident 16 was moderately impaired cognitively. On 04/07/2025 at 2:06 PM, Resident 16 was observed to have their bed against the wall and one mobility bar (side rails on the upper part of the bed to assist with moving in the bed) attached to the bed. Review of the EHR showed Resident 16 did not have a physical restraint evaluation done for having a mobility bar, or for having their bed against the wall. On 04/10/2025 at 10:15 AM, Staff F, RCM, when asked if there was an assessment for Resident 16's bed against the wall to show it was not acting as a restraint, said it should have been done, and they would fix it. When asked about if there was an assessment done for the mobility bar to show it was not acting as a restraint, said they would need to do a new assessment on Resident 16 for the bed rail and there should have been one already. On 04/11/2025 at 9:37 AM, Staff J, Rehabilitation Director, and Staff B, DNS, were jointly interviewed. Both staff agreed that an order should have been placed for Resident 16 to have their bed against the wall. When asked if it met expectations that there was not previously an assessment done for the bed against the wall, said no it did not meet expectations. 51907 3) Resident 29 admitted to the facility on [DATE] with diagnoses that included dementia, depression, anxiety, and muscle weakness. The Significant Change MDS, dated [DATE], showed Resident 29 was confused but could make their needs known. Observation on 04/07/2025 at 12:44 PM, showed Resident 29's bed was against the wall on the left side. Review of the EHR showed Resident 29 had not had an assessment for restraints completed for the bed against the wall. Review of Resident 29's care plan showed there was not a care plan in place for the bed against the wall. During an interview on 04/10/2025 at 10:34 AM, Staff U, Licensed Practical Nurse, stated if a resident had their bed against the wall, a consent would have been obtained, and a restraint assessment would have been done. During an interview on 04/10/2025 at 11:30 AM, Staff F, RCM, stated the facility did not have a restraint assessment for the bed against the wall, therefore Resident 29 did not have a restraint assessment completed. On 04/11/2025 at 9:37 AM, Staff J, Rehabilitation Director, and Staff B, DNS, were jointly interviewed. When asked if it met expectations that there was not an assessment done for Resident 29's bed against the wall, they said no it did not meet expectations. Reference WAC 388-97-0620(1)

Based on interview and record review, the facility failed to provide non-pharmacological interventions (health interventions/approaches used instead of medication), to implement and/or follow parameters for medications, and/or to reassess necessity of medication when vitals were abnormal for 3 of 6 sampled residents (Residents 19, 23 & 16) when reviewed for unnecessary medications and/or pain management. This failure placed the residents at risk for receiving unnecessary medications, avoidable medication side effects, and a diminished quality of life. Findings included . 1) Resident 19 was admitted to the facility on [DATE]. The Annual Minimum Dated Set (MDS, an assessment tool) , dated 02/07/2025, documented Resident 19 was cognitively intact. Resident 19 received an opioid medication for pain. A physician's order, dated 02/02/2023, documented Resident 19 was to be given the opioid medication when the pain level was above 3. Non-pharmacological interventions were to be offered and completed prior to medication administration. The non-pharmacological interventions included repositioning, use of pillows, diversional activities & rest. Resident 19's March and April 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed no documentation that non-pharmacological interventions were offered or completed. On 04/10/2025 at 9:57 AM, Staff F, Resident Care Manager (RCM), said non-pharmacological interventions should be documented on the TAR, they have a system that automatically codes for pain, staff should be entering the effectiveness of the pain medication and other interventions used. When asked to provide Resident 19's non-pharmacological interventions documentation, Staff F said the non-pharmacological interventions were not entered on the TAR and they should have been. At 11:52 AM, Staff B, Director of Nursing Services (DNS), said staff should be asking the resident if they have pain and documenting the pain score. Staff F said staff should have been asking, providing and documenting all non-pharmacological interventions used. When asked to provide Resident 19's non-pharmacological interventions documentation, Staff B said the non-pharmacological interventions were not entered on the TAR and they should have been. 50392 2) Resident 23 admitted to the facility 03/27/2025. The Admission Medicare 5-day MDS dated [DATE], documented Resident 23 was cognitively intact. Resident 23 had diagnoses that included Unspecified Systolic (Congestive) Heart Failure (CHF, a condition where the heart can't pump blood effectively, leading to fluid buildup in the lungs and other parts of the body). Resident 23 had an order, dated 03/31/2025, for Oxycodone (pain medication) 5 milligram (mg) tablet, give 0.5 tablet (half of a tablet, or 2.5 mg) by mouth every 12 hours as needed for pain 4-6/10 (Pain scale 1-10, 1 being very little pain, and 10 being severe pain). Nonpharmacological interventions were to be attempted prior to administering the pain medication. Nonpharmacological interventions to have been attempted included repositioning, distracting activity, ice and offer a snack. Resident 23 had a second order, dated 03/31/2025, for Oxycodone 5 mg tablet, give 1 tablet by mouth every 12 hours a needed for pain 7-10/10. Nonpharmacological interventions were to be attempted prior to administering the pain medication. Nonpharmacological interventions to have been attempted included repositioning, distracting activity, ice and offer a snack. Review of the April 2025 MAR showed Resident 23 was administered Oxycodone 5 mg tablet when pain was below 7/10 on: 04/01/2025- pain level documented at a 3/10, 1 tablet given (5 mg) 04/03/2025- pain level documented at a 3/10, 1 tablet given (5 mg) 04/05/2025- pain level documented at a 5/10, 1 tablet given (5 mg) 04/07/2025- pain level documented at a 3/10, 1 tablet given (5 mg) Review of the April 2025 MAR and TAR showed no documentation that nonpharmacological interventions had been attempted prior to the Oxycodone administration as ordered for the following administration dates: 04/01/2025, 04/02/2025, 04/03/2025, 04/05/2025, 04/06/2025 & 04/07/2025. On 04/09/2025 at 9:31 AM, Staff F, RCM, acknowledged that 5 mg tablets were given on the above dates when pain levels were under 7-10/10. Staff F said this did not meet her expectations, and said 2.5 mg (half of a tablet) should have been given. Regarding the nonpharmacological interventions, Staff F said once a resident says they are in pain, staff would find out where the pain was and then apply the nonpharmacological interventions, if the interventions were unsuccessful then staff would give the pain medication. When asked to show documentation that nonpharmacological interventions had been attempted prior to the above Oxycodone administration dates, Staff F said that the order needed to be updated as staff did not have the option to document the interventions. When asked if the lack of documentation met her expectations, Staff F said, no. Resident 23 was receiving three different anti-hypertensive medications (medications that can lower blood pressure) and two diuretics (medications that can remove excess fluid and lower blood pressure). Record review of Resident 23's blood pressure documentation from 04/01/2025 through 04/09/2025 showed they had the following low blood pressure readings on: 04/02/2025- 99/55 04/04/2025- 99/54 04/06/2025- 96/50 On 04/09/2025 at 9:31 AM, Staff F, RCM, regarding Resident 23 being on three anti-hypertensive medications and two diuretics that could all lower blood pressures, Staff F said, there should have been parameters (blood pressure guidelines for when to hold the anti-hypertensive medications) on all anti-hypertensive medications. Staff F acknowledged the low blood pressure readings for Resident 23 and when asked if there were parameters on the three anti-hypertensive medications Resident 23 was taking, Staff F acknowledged that there was not and said there should have been. 50945 3) Resident 16 was admitted to the facility on [DATE]. The Modification of Significant Change MDS, dated [DATE], showed Resident 16 was moderately impaired cognitively. Review of the MAR showed Resident 16 had an order for hydromorphone (an opioid pain medication) for every 12 hours as needed for severe pain of 7-10/10, with an order to attempt non-medication (non-pharmacological interventions) prior to administering as needed pain medications. Non-pharmacological interventions were listed as repositioning, distracting activity, ice, and offering a snack. Hydromorphone was administered without documentation of non-pharmacological interventions. Hydromorphone was adminstered with a pain score less than 7 on the following days: 04/03/2025 for a pain score of 5 04/04/2025 for a pain score of 6 04/05/2025 for a pain score of 5 04/08/2025 for a pain score of 4 04/09/2025 for a pain score of 6 Further review of the MAR showed Resident 16 was receiving a diuretic (increases the need to urinate to remove excess fluid and can decrease blood pressure) named torsemide. When comparing the MAR to the blood pressure (BP) vital signs, Resident 16 was found to have received doses of torsemide, despite having low blood pressure readings. The MAR and BP vitals showed the 4:30 PM dose of torsemide was given without provider notification or a recheck of blood pressure, on the following dates: 02/11/2025 at 11:31 AM, Resident 16's BP was 85/48 03/03/2025 at 11:22 AM, Resident 16's BP was 98/50 03/12/2025 at 12:25 PM, Resident 16's BP was 96/50 On 04/10/2025 at 10:15 AM, Staff F, RCM, said there was a protocol for if the systolic BP (number on top) was less than 100, or HR was less than 55. For Resident 16, Staff F said staff should have informed the provider when the BP was that low. In regards to the hydromorphone being given for pain scores of 4-6, Staff F said that did not meet expectations. When asked their expectations for non-pharmacological interventions, Staff F said they should have documented on that they were done before every opioid administration. On 04/11/2025 at 12:20 PM, Staff B, DNS, said they expected non-pharmacological interventions to be documented. Staff B, when asked if it met expectations Resident 16 received hydromorphone for pain scale values outside of parameters, said no. When asked about the low BPs and Resident 16 receiving torsemide doses, said their expectation for staff was to have rechecked the BP and reassessed the situation, and to have called the provider if the BP remained low to see what they should do about medications that could impact the BP. Reference WAC 388-97 -1060 (3)(k)(i)

Based on interview and record review, the facility failed to ensure services provided met professional standards of practice related to performing daily weights and accurate documentation of side effects for 1 of 5 residents (Resident 23) reviewed for unnecessary medications, failed to follow hospice (end of life care) recommendations for 1 of 1 resident (Resident 28) reviewed for hospice, and failed to monitor after a change in status for 1 of 2 residents (Resident 29) reviewed for hospitalization . These failures placed residents at risk for unmet care needs,the provider not being aware of resident conditions, and potential negative outcomes. Findings included . <Daily weights> Resident 23 admitted to the facility on [DATE]. The Admission Medicare 5-day Minimum Data Set (MDS, and assessment tool), dated 04/01/2025, documented Resident 23 was cognitively intact. Resident 23 had diagnoses that included Unspecified Systolic (Congestive) Heart Failure (CHF, a condition where the heart can't pump blood effectively, leading to fluid buildup in the lungs and other parts of the body) and adjustment disorder with depressed mood. Review of Resident 23's physician orders showed an order for CHF Protocol - Weight every day shift before breakfast. Report three pounds (lb.) weight gain in a day or five pound weight gain in a week to the medical doctor. Review of Resident 23's weight record from 03/27/2025 through 04/09/2025 showed the following two weights had been taken. 03/27/2025 252.0 lbs. 04/03/2025 244.2 lbs No weight had been recorded on the following dates: 03/28/2025, 03/29/2025, 03/30/2025, 03/31/2025, 04/01/2025, 04/02/2025, 04/04/2025, 04/05/2025, 04/06/2025, 04/07/2025, 04/08/2025, and 04/09/2025. On 04/09/2025 at 9:31 AM, Staff F, Resident Care Manager (RCM), acknowledged the physician order for daily weights for Resident 23. Regarding the days with missed weights Staff F said some of the dates were missing because Resident 23 could not be weighed due to the location of their surgical incision. Staff F said when a weight could not be obtained staff should have let the provider know. When asked if daily weights should have been done when Resident 23 was able to be weighed, Staff F said yes, they should have been done and for the missing weights she did not see documentation that the provider had been notified. <Failure to complete documentation> Review of Resident 23's orders showed an order for Trazadone (antidepressant), give 100 milligrams at bedtime for situational depression. Review of Resident 23's April 2025 Treatment Administration Record (TAR) showed the following order: Anti-Depressant Medication: Trazodone. Side effects: Common - Sedation, Drowsiness, Dry Mouth, Blurred Vision, Urinary Retention, Tachycardia (elevated heart rate), Muscle Tremor, Agitation, Headache, Skin Rash, Photosensitivity (sensitivity to light), Excess Weight Gain. Special Attention for: Heart Disease, glaucoma (eye disorder), Chronic Constipation, Seizure Disorder, Edema (fluid retention). Monitor every shift Document: (+) if side effects present and write a progress note (-) side effects not present. Review of the documentation for side effects showed positive (+) side effects were documented by staff on the following dates: 04/06/2025 (day and night shift), 04/07/2025 (day and night shift), 04/08/2025 (day and night shift) and 04/09/2025 (day shift). On 04/09/2025 at 9:31 AM, Staff F, RCM, reviewed the documentation in the TAR and acknowledged staff had documented that Resident 23 was positive for side effects on the above dates. Staff F said staff probably checked positive for side effects in error, and if a positive result was documented staff should have documented in a progress note the positive symptoms. Staff F was unable to locate progress notes for the dates in question and said progress notes should have been written either way. 51907 <Hospice recommendations> Resident 28 admitted to the facility on [DATE] with diagnoses that included dementia and neoplasm of the oral cavity (mouth cancer). The Significant Change MDS, dated [DATE], showed Resident 29 was able to make their needs known. Observation on 04/08/2025 at 10:09 AM, showed Resident 28 had visible lesions on their bottom lip into the gum line. Review of the Electronic Health Record (EHR) showed Resident 28 was on hospice care with comfort measures. Review of the Hospice admission summary, dated 01/11/2025, showed hospice had made a recommendation for A&D ointment (a moisturizer and skin protectant) to be applied to the cancer lesions to prevent drying and cracking to the wounds. Review of the provider orders showed there was no order for the recommended ointment to the cancer lesions and no orders for wound care to the cancer lesions. Review of the progress notes on 04/08/2025, showed no notes regarding the hospice recommendation. During an interview on 04/10/2025 at 9:36 AM, Staff Q, Certified Nursing Assistant, said the staff provided oral care with green sponges and used a mouthwash to cleanse Resident 28's mouth. During an interview on 4/10/2025 at 10:37 AM, Staff U, Licensed Practical Nurse (LPN) said care of Resident 28's cancer lesions was pain management and oral care. Staff U said there was no further orders for wound care. In an interview on 4/10/2025 at 11:30 AM, Staff F, RCM, said the care of the cancer lesion wounds was pain management and oral care. When the hospice admission assessment was showed to Staff F, they stated the recommended treatment had not been transcribed to the provider orders and the provider should have been notified of the recommendations. During and interview on 04/11/2025 at 10:35 AM, Staff B, DNS, said the recommendations should have been reviewed, reported to the provider, and transcribed if approved by the provider. Staff B said that did not happen and does not meet their expectations. <Failure to monitor> Resident 29 admitted to the facility on [DATE] with diagnoses that included dementia, depression, anxiety, and muscle weakness. The Significant Change MDS, dated [DATE], showed Resident 29 was confused but could make their needs known. Review of the EHR showed Resident 29 was transferred to the hospital on 02/23/2025 for nausea and vomiting. Review of the hospital records showed Resident 29 was diagnosed with a gastrointestinal bleed and pneumonia. Resident 29 readmitted to the facility on [DATE]. Review of the progress notes showed Resident 29 was not started on alert charting upon readmission to the facility. During and interview on 04/10/2025 at 10:31 AM, Staff U, LPN, said if there was a change in status, a resident would be placed on alert charting, and charted on every shift. During an interview on 04/10/2025 at 11:30 AM, Staff F, RCM, said alert charting should be completed daily on any change of condition. Staff F said Resident 29 should have been placed on alert when they readmitted to the facility. During an interview on 04/11/2025 at 10:35 AM, Staff B, DNS, said alert charting should be done every shift. Staff B said Resident 29 had not being placed on alert upon readmission did not meet their expectations. Reference WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i)

Based on interview and record review, the facility failed to obtain an updated preadmission screening and resident review (PASRR, a mental health screening tool) when a diagnosis of significant mental illness was identified for 2 of 5 residents (Resident 4 & 1) reviewed for PASRR. This failure placed the residents at risk for unmet care needs and a decreased quality of life. Findings included . 1) Resident 4 admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety, depression, and bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood). The Quarterly Minimum Data Set (MDS, an assessment tool), dated 02/21/2025, showed Resident 4 was confused with poor memory recall. Review of Resident 4's Level 1 PASRR, dated 03/07/2025, showed Serious Mental Illness indicators of mood disorders and anxiety disorders had been selected. During an interview on 04/10/2025 at 1:19 PM, when reviewing guidance from the PASRR dear provider letter (a letter that provides facilities with updated regulation changes) with an amended date of 08/23/2024, Staff H, Social Services Director (SSD) said Resident 4 should have been referred for a Level 2 PASRR. 50945 2) Resident 1 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder. Review of Resident 1's Level 1 PASRR evaluation, dated 04/04/2023, showed the evaluator had selected yes for a serious mental illness indicator, with mood disorders (depressive or bipolar) selected. During an interview on 04/10/2025 at 1:19 PM, Staff H, SSD, after reviewing guidance from the PASRR dear provider letter, said Resident 1 should have had a referral placed for a Level 2 PASRR evaluation. Reference WAC 388-97-1915 (4)

Based on observation, interview and record review, the facility failed to ensure dependent residents were provided with oral care for 2 of 3 residents (Resident 42 & 14) reviewed for dental care related to activities of daily living. This failure placed residents at risk for poor oral hygiene, worsening dental condition, and a diminished quality of life. Findings included . A facility provided policy titled, Activities of Daily Living (ADLs), reviewed 09/10/2024, documented, the resident would receive assistance as needed to complete ADLs. 1) Resident 42 was admitted to the facility on [DATE]. The Modification of Admission/Medicare 5-day Minimum Data Set (MDS, and assessment tool), dated 03/08/2025, documented Resident 42 required supervision or touching assistance for oral hygiene, and required partial/moderate assistance to transfer from chair/bed-to-chair. On 04/07/2025 at 2:21 PM, Resident 42 said one great deficiency the facility had was dental hygiene. Resident 42 said they had not brushed their teeth in two months, and said staff had only offered one time to help them. Resident 42 said their brother had brought in a toiletry bag with a toothbrush, and that they could brush their own teeth if staff brought their supplies and stuff so they could rinse and spit. Resident 42's teeth were observed to be yellow in color with a whitish substance near their upper and lower gums. On 04/08/2025 at 11:11 AM, Resident 42 said he still had not had dental care offered or provided since the previous day. Resident 42's teeth were observed to be yellow in color with a whitish substance near their upper and lower gums. On 04/10/2025 at 10:45 AM, Staff S, Certified Nursing Assistant (CNA), said she provided oral care to the residents as part of her day. When asked how often oral care was provided to residents, Staff S said every meal. When asked about toothbrushing, Staff S said it was dependent on the care plan for that resident and if the resident had natural teeth staff would brush them if they could not do it themselves. When asked where the toothbrushing that was provided would be documented, Staff S said there was a 'Personal Hygiene' area in the electronic health record (EHR) where they documented it. When asked if she had provided oral care to Resident 42, Staff S said she was not normally on Resident 42's hallway, she was just helping that day and said, I think they are doing it. Review of Resident 42's Care Plan, did not show a focus or intervention regarding oral/dental care. Review of the EHR showed no specific area/direction for documenting/providing oral care. Review of Resident 42's orders showed nothing regarding oral/dental care. On 04/10/2025 at 11:00 AM, when asked about Resident 42's oral care and assistance, Staff F, Resident Care Manager (RCM), said Resident 42 would not allow anyone near their mouth and wanted to remain independent. When asked if dental/oral care was on their care plan, Staff F said no, it was not on the care plan but should be. Staff F said Resident 42 would need someone to set up oral care supplies for them since they could not get out of bed and was visually impaired. Staff F said oral care should have been offered and done after every meal. When asked how the CNAs would know to provide oral care and document they had provided oral care for Resident 42, Staff F said it should be on their KARDEX (an area in the EHR with tasks for CNAs to complete and document). When asked if Resident 42 had an area for oral hygiene/care on the Kardex to indicate to staff to provide oral care, Staff F looked in the EHR and said no, and that it should have been there. At 11:06 AM, Staff F, RCM, entered Resident 42's room to observe his oral cavity. Upon leaving the room, Staff F said she was able to observe plaque and food build up along Resident 42's gums. When asked if this was acceptable, Staff F said no, and that she could even smell Resident 42's mouth. 50945 2) Resident 14 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], said Resident 14 needed set up or clean- up assistance for oral hygiene (oral care). Resident 14 was dependent on staff to get out of bed. Review of Resident 14's care plans showed that dental care was identified as a concern, with a note that the resident would comply with mouth care at least daily through the review date, and for staff to provide set up assistance after meals. On 04/07/2025 at 11:52 AM, Resident 14 said they were independent with oral care but did require set up assistance, and they did not currently have supplies to brush their teeth. On 04/10/2025 at 9:34 AM, Staff G, CNA, said they had been working with Resident 14 since they were admitted to the facility, Resident 14 did not independently do much oral care, and if offered that Resident 14 probably would perform oral care. Staff G said they had not recently seen Resident 14 perform oral care, did not think oral care was happening daily, and when asked what time Resident 14 was supposed to have oral care done, said probably in the morning. When asked what kind of assistance Resident 14 would need, Staff G said said set up assistance. Staff G said there was no place for staff to document oral care was done. When asked where the supplies were in the room, Staff G was unable to locate supplies, then offered Resident 14 supplies and said they would go get them. At 10:15 AM, Staff F, RCM, said it did not meet expectations that Resident 14 did not have oral care supplies in their room. Staff F said their expectation was for oral care to occur after every meal. At 1:37 PM, when told of Staff G being unable to readily locate Resident 14's oral care supplies in the room, Staff B, Director of Nursing Services, said it did not meet expectations. Reference WAC 388-97-1060 (2)(c)

Based on observation, interview, and record review, the facility failed to ensure proper storage and labeling of medications in 1 of 2 medication carts (B Hall medication cart) and 1 of 1 medication rooms when reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective treatment, and a diminished quality of life. Findings included . Observation of the medication cart on B hall on 04/09/2025 at 11:05 AM, with Staff O, Registered Nurse (RN), showed an open insulin pen with no date on it. During an interview on 04/09/2025 at 11:05 AM, Staff O, RN, said they had just opened the insulin pen that morning and forgot to date it. During an interview on 04/10/2025 at 8:35 AM, Staff F, Resident Care Manager (RCM), said all insulin should be dated as soon as it is opened. Observation of the medication room on 04/10/2025 at 8:33 AM, with Staff F, RCM, showed the temperature log for March 2025 was missing 11 of 62 opportunities. Review of the refrigerator showed storage of medication and emergency medication supply. During an interview on 04/10/2025 at 8:33 AM, Staff F said the refrigerator temperature should be monitored twice a day by nursing staff and documented on the log. Observation of the B Hall medication cart on 04/10/2025 at 10:16 AM, showed a cup with food items in it, partially covered with a paper towel, with crumbs on the top surface of the medication cart and three nurses close by the medication cart with no intervention noted. During an interview on 04/11/2025 at 10:16 AM, Staff B, Director of Nursing Services, said the refrigerator temperatures in the medication room should have been documented at assigned times during the day in the morning and evening. Staff B said missing temperatures did not meet expectation, and the insulin pen should have been dated as soon as it was opened. Staff B said food should not have been left on top of the medication cart and this did not meet their expectations. Reference WAC 388-97-1300 (2)

Based on observation, interview and record review the facility failed to ensure dishwasher temperatures were maintained within required ranges for 1 of 1 dishwasher and failed to ensure appropriate personal protective equipment (PPE) was worn for 1 of 4 (Staff I) kitchen staff observed. These failures placed residents at risk of food-borne illness, unsanitary conditions, and a diminished quality of life. Findings included . A facility provided policy titled, Associate Conduct and Dress Code, with a revised date of 04/30/2024, documented dietary staff must wear hair restraints (e.g. hairnet, hat, and/or beard restraint) to prevent hair from contacting food. <Failure to wear PPE> On 04/07/2025 at 10:36 AM and at 12:09 PM, Staff I, Dietary Manager, was observed in the kitchen without a hair restraint on. On 04/09/2025 at 8:57 AM, Staff I was observed in the kitchen without a hair restraint on. At 1:23 PM, Staff I said the expectation was for dietary staff to have their hair covered in the kitchen. When asked about the observations without a hair restraint in the kitchen, Staff I said it should have been covered. <Failure to maintain dishwasher temperatures> Review of the dishwasher temperature logs showed the following out of perimeters temperatures: March 2025 under 150 degrees Fahrenheit Records-Breakfast Wash cycle: 1st, 3rd, 4th, 8th, 9th, 10th, 18th, 20th, 23rd, 26th, 27th, 29th, 30th, 31st. March 2025 under 180 degrees Fahrenheit Records-Breakfast Rinse cycle: 1st, 2nd, 9th, 10th, 14th, 18th, 19th, 23rd, 27th, 28th, 30th, 31st. March 2025 under 150 degrees Fahrenheit Records-Lunch Wash cycle: 1st, 7th, 8th, 9th, 18th, 23rd, 26th, 27th, 28th, 29th, 30th, 31st. March 2025 under 180 degrees Fahrenheit Records-Lunch Rinse cycle: 1st, 7th, 8th, 14th, 20th, 22nd, 23rd, 27th, 29th, 31st. March 2025 under 150 degrees Fahrenheit Records-Dinner Wash cycle: 1st, 2nd, 4th, 5th, 6th, 7th, 8th, 9th, 11th, 12th, 13th, 14th, 18th, 20th, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 31st. March 2025 under 180 degrees Fahrenheit Records-Dinner Rinse cycle: 1st, 4th, 5th, 6th, 7th, 8th, 11th, 12th, 14th, 18th, 21st, 26th, 27th. February 2025 under 150 degrees Fahrenheit Records-Breakfast Wash cycle: 1st, 2nd, 3rd, 4th, 7th, 18th, 9th, 10th, 11th, 13th, 14th, 15th, 16th, 17th, 21st, 22nd, 23rd, 28th. February 2025 under 180 degrees Fahrenheit Records-Breakfast Rinse cycle: 1st, 3rd, 4th, 5th, 6th, 8th, 9th, 10th, 11th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 22nd, 23rd, 24th, 26th, 18th. February 2025 under 150 degrees Fahrenheit Records-Lunch Wash cycle: 1st, 2nd, 3rd, 4th, 6th, 7th, 8th, 10th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 21st, 22nd, 23rd, 24th, 25th, 28th. February 2025 under 180 degrees Fahrenheit Records-Lunch Rinse cycle: 1st, 2nd, 3rd, 6th, 7th, 9th, 10th, 11th, 13th, 14th, 15th, 16th, 17th, 18th, 22nd, 23rd, 24th 26th, 28th. February 2025 under 150 degrees Fahrenheit Records-Dinner Wash cycle: 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 11th, 12th, 13th, 14th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th. February 2025 under 180 degrees Fahrenheit Records-Dinner Rinse cycle: 1st, 2nd, 3rd, 4th, 5th, 6th, 8th, 12th, 13th, 14th, 18th, 19th, 25th, 26th, 27th. January 2025 under 150 degrees Fahrenheit Records-Breakfast Wash cycle: 5th, 6th, 7th, 8th, 9th, 10th, 11th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 29th, 31st. January 2025 under 180 degrees Fahrenheit Records-Breakfast Rinse cycle: 6th, 7th, 9th, 10th, 11th, 14th, 15th, 16th, 17th, 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 31st. January 2025 under 150 degrees Fahrenheit Records-Lunch Wash cycle: 5th, 7th, 8th, 9th, 10th, 11th, 12th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 31st. January 2025 under 180 degrees Fahrenheit Records-Lunch Rinse cycle: 7th, 8th, 9th, 11th, 15th, 16th 17th, 19th, 21st, 22nd, 23rd, 26th, 27th, 29th, 31st. January 2025 under 150 degrees Fahrenheit Records-Dinner Wash cycle: 1st, 3rd, 4th, 5th, 6th, 7th, 10th, 11th, 16th, 17th, 18th, 19th, 20th, 23rd, 24th, 25th, 26th, 28th, 29th, 30th, 31st. January 2025 under 180 degrees Fahrenheit Records-Dinner Rinse cycle: 1st, 5th, 10th, 11th, 17th, 20th, 21st, 24th, 25th, 28th, 29th, 31st. On 04/09/2025 at 9:00 AM, Staff I, Dietary Manager, said 155-165 degrees was what the wash cycle was ran at (wash cycle should be 150 degrees to ensure sanitization). When asked what the target temperature for the dishwasher rinse cycle was, Staff I said 175-180 degrees (rinse cycle should be 180 degrees to ensure sanitization). When shown the January 2025, February 2025, and March 2025 temperature logs, Staff I acknowledged the temperatures were repeatedly outside of the required ranges to ensure that kitchenware was properly sanitized. At 9:03 AM, Staff I, ran a cycle of the dishwasher with the a wash cycle temperature reading 139 degrees, and the rinse cycle temperature reading 175 degrees, both temperatures outside of sanitizing range. On 04/09/2025 at 10:27 AM, Staff I, Dietary Manager with Staff D, Regional [NAME] President present, said they had ECOLAB (Dishwasher maintenance representative) coming to do maintenance on the dishwasher the next day. Staff I said, for whatever reason you have to run it multiple times to get it to reach temperature. Reference WAC 388-97-1100 (3)

Based on observations, interviews and record review, the facility failed to properly store oxygen equipment for 1 of 1 sampled resident (Resident 39) reviewed for oxygen, and to ensure staff performed hand hygiene for 1 of 1 dining room reviewed for dining services. The facility also failed to use personal protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines when caring for residents on enhanced barrier precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs)) for 1 of 3 sampled residents (Resident 26), and 1 of 3 kitchen staff members (Staff I) reviewed for infection control. Additionally, the facility failed to handle, store, and transport linens appropriately for laundry services reviewed for infection control. These failures placed residents at risk for facility acquired infections, spread of organisms and MDROs, contamination, related health complications, and a decreased quality of life. Findings included . The facility provided policy titled, Hand Hygiene, reviewed 06/03/2024, documented Hand Hygiene (HH) refers to a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub. This policy further directs an associate to perform hand hygiene before and after contact with the resident and after contact with objects and surfaces in the resident enviorment. <Oxygen Equipment Storage> Resident 39 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 03/08/2025, documented Resident 39 was cognitively intact and was receiving oxygen therapy. On 04/07/2025 at 2:43 PM, Resident 39 was sitting in their wheelchair.Staff K, Housekeeping, entered Resident 39's room to assist Resident 39 in being able to hear and answer interview questions. Staff K removed Resident 39's nasal cannula (NC, a medical device used to deliver supplemental oxygen or increased airflow to the nostrils) and set it on the floor between Resident 39 and the bed. After transferring Resident 39 to the portable oxygen machine located on the back of Resident 39's chair, Staff K was asked about the NC and tubing storage. Staff K picked up the NC tubing off the floor, wrapped it around their hand and then placed it on the top, of the inside of the oxygen concentrator, and said this was where the NC tubing was usually stored when it was not in use. Staff K said they would step out of the room and let Resident 39 finish the interview questions. Before Staff K exited the room, Staff K, when asked about the NC and tubing being placed on the floor, said they should not have placed the NC on the floor. When asked about storing the NC after it had been on the floor, Staff K said the tubing should not have been placed there. At 2:52 PM, Staff K returned to Resident 39's room with a sealed package containing and new NC and oxygen tubing. Staff K replaced the NC, but did not wipe down the oxygen concentrator before replacing the NC and oxygen tubing. On 04/10/2025 at 9:57 AM, Staff F, Resident Care Manager, said all oxygen tubing, including NC and tubing, should be stored in a clean bag and placed on the oxygen concentrator. Staff F said oxygen tubing was not to be draped over the furniture. When the observation was explained, regarding the NC being placed on the floor, Staff F said none of that should have happened, the NC should have been placed on the floor, the oxygen tubing should not have been stored in the handle of the oxygen concentrator and the machine should have been wiped down before replacing the oxygen tubing. At 11:52 AM, Staff B, Director of Nursing Services, said all oxygen equipment should be stored in the storage bags and oxygen tubing was changed weekly. When the observation was explained, regarding the NC being placed on the floor and improperly stored, Staff B said the NC being placed on the floor and stored incorrectly was not acceptable and the oxygen concentrator should have been wiped down. 50392 <Failure to perform hand hygiene> During the following observations of dining room service Staff L, Activity Assistant, missed opportunities to perform hand hygiene (HH) as follows: On 04/07/2025 at 11:54 AM, Staff L delivered two drinks to a table, picked up a wet floor sign, and then pushed her eyeglasses up on her nose (missed opportunity for HH). Staff L picked up cups from the drink cart, placed them back down on the drink cart, went to a cupboard, retrieved linens and then placed the linens on the cart on resident food trays. Staff L pushed up her eyeglasses on her nose (missed opportunity for HH), opened a door on the drink cart, pushed eyeglasses up on her nose (missed opportunity for HH) and went to the cupboard and got more linens out. Staff L then set the linens on the cart on resident food trays, pushed up her eyeglasses on her nose (missed opportunity for HH), closed a door on the drink cart, and touched here eyeglasses again. Staff L stepped into the kitchen doorway, walked to a food tray on a side table, picked up a plate of food and delivered it to a resident. Staff L pushed her eyeglasses up on her nose (missed opportunity for HH) and exited the dining room. At 12:08 PM, Staff L returned to the dining room with no HH observed upon entering dining room, pushed eyeglasses up on her nose (missed opportunity for HH), then picked up a plate of food and delivered it to a resident. Staff L pushed her eyeglasses up on her nose (missed opportunity for HH), then picked up another plate of food, a dessert plate, and a bag of chips and delivered these to another resident. Staff L went to the drink cart, opened a drawer, got packets of condiments and delivered to a resident. Staff L pushed her eyeglasses up (missed opportunity for HH), went to the kitchen and took a plate of food from on top of the steam table, and delivered it to another resident. Staff L went to the kitchen doorway, put her hands in her pants pockets, removed her hands from her pockets, and then pushed up her eyeglasses on her nose (missed opportunity for HH). Staff L asked kitchen staff for parmesan cheese, received a plastic cup of parmesan cheese and delivered it to a resident, then went back to the kitchen and picked up a plate of food and delivered it to another resident. On 04/11/2025 at 3:06 PM, Staff I, Dietary Manager, when asked if staff should perform HH after touching self or eyeglasses said, absolutely, after every time they touch themselves or anything on their person. Staff I said the dining room observations of lack of HH did not meet his expectations. On 04/11/2025 at 3:08 PM, Staff E, Infection Preventionist (IP), when asked her expectations of staff performing HH while serving food and drinks, said she would have to look at the policy. When asked if she would expect HH in between staff touching their eyeglasses or self then serving food, said, yes, my expectation was that they would be following policy. 50945 <EBP> Resident 26 was admitted to the facility on [DATE]. Resident 26's Admission MDS, dated [DATE] showed they were cognitively intact and had a urinary catheter (thin tube that drains urine). Resident 26 was on EBP for having a urinary catheter. On 04/11/2025 at 1:30 PM, Staff M, Certified Nursing Assistant, was observed to provide catheter care without wearing a gown. At 1:45 PM, Staff M, when asked about EBP said a gown should be worn. Staff M also acknowledged they did not hand hygiene with every glove change. At 2:17 PM, Staff E, IP, said a gown should have been worn for catheter care for Resident 26, and their expectation for EBP was that a gown and gloves would be worn during high contact resident care activities. <Laundry Services> On 04/07/2025 at 1:47 PM, Staff N, Laundry Aide, was observed to move a linen cart down the hall with one side of cart exposed/open, with the cover draped over the top of the cart and with dirty hangers on top it. Staff N was observed to come out of a room, to put dirty hangers on top of the cart, to grab a clean blanket from the linen cart, and to go into a different room. Then Staff N gathered hangers to remove from the room, was seen to have touched the wheelchair in the room, left the room, put dirty hangers on the linen cart, and then touched clothes for the next resident from inside of the linen cart. Staff N was not observed to hand hygiene as they left the rooms. At 2:01 PM, when asked when they should hand sanitize, Staff N said between residents, when handing out clothes, and when handling dirty laundry. With the dirty hangers on top of the linen cart, Staff N reported they could not close the cart. On 04/10/2025 at 12:28 PM, when informed of the observation of the linen cart going down the hallway with one side open, Staff P, Director of Environmental Services, said, no it should not have been open while moving down the hallway, once it leaves the laundry room it was to remain closed and opened only for the immediate room. When asked about the storage of dirty hangers on top of the cart, Staff P showed that the dirty hangers were normally kept in the same cart as the clean but divided by clean/dirty. When asked if they should store dirty and clean in the same linen cart at the same time, Staff P said, no we should not have dirty and clean together. When asked about the observation of no hand hygiene between dirty and clean, Staff P said they have now in-serviced the housekeeping staff on hand hygiene. Reference WAC 388-97-1320 (1)(c),(2)(a)(b),(3)

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan included resident specific interventions for 5 of 12 sampled residents (Residents 42, 14, 16, 26 & 29) reviewed for care plans. This failure to establish care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individual needs. Findings included . 1) Resident 42 was admitted to the facility on [DATE]. According to the Modification of Admission/Medicare 5-day Minimum Data Set (MDS, and assessment tool), dated 03/08/2025, Resident 42 required supervision or touching assistance for oral hygiene. Resident 42's diagnoses included Malignant Neoplasm of Rectum (cancer of the rectum). Review of Resident 42's physician orders showed three medications prescribed to treat chronic diarrhea. Review of Resident 42's care plan showed Resident 42 had occasional bowel incontinence related to rectal cancer, was incontinent, and wore a brief. There was nothing on the care plan regarding chronic diarrhea. On 04/09/2025 at 2:42 PM, Staff T, Certified Nursing Assistant (CNA), when asked to describe Resident 42's bowel movements, said they were always loose and they had never seen formed stools. On 04/09/2025 at 2:44 PM, Staff F, Resident Care Manager (RCM), said staff would know if a resident had chronic diarrhea if there was a diagnosis or from looking at the prescribed medications. When asked if Resident 42's chronic diarrhea should be on the care plan, Staff F said if related to rectal cancer then yes, I think so. Staff F said Resident 42 sometimes refused their medication to treat diarrhea and that refusals should also have been care planned. Review of the Modification of Admission MDS, showed Resident 42 required supervision or touching assistance for oral hygiene. Review of Resident 42's care plan showed there was no plan for their oral hygiene. On 04/10/2025 at 11:00 AM, Staff F, RCM, said Resident 42 would need someone to set up their oral hygiene supplies for them since they couldn't get out of bed and were visually impaired. When asked if oral hygiene was on Resident 42's care plan, Staff F said she did not see that dental care was on their care plan and it should have been there. 50945 2) Resident 14 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed Resident 14 was cognitively intact. On 04/07/2025 at 10:42 AM, Resident 14 was observed with their bed against the wall. Review of Resident 14's care plans showed there was not a care plan for the bed against the wall. On 04/10/2025 at 10:15 AM, Staff F, RCM, when asked if the bed against the wall should be care planned, said yes. Staff F was unable to locate a care plan for Resident 14's bed against the wall and said there should be one. On 04/11/2025 at 9:37 AM, Staff J, Rehabilitation Director, and Staff B, Director of Nursing (DNS), were jointly interviewed. When asked if it met expectations the bed was against the wall and was not on the care plan, Staff J said it was now on the care plan. 3) Resident 16 was admitted to the facility on [DATE] and had a diagnosis of chronic heart failure. The Modification of Significant Change MDS, dated [DATE], showed Resident 16 was moderately impaired cognitively, and was taking a diuretic (increases the need to urinate to remove excess fluid and can decrease blood pressure). Review of Resident 16's medications showed they were receiving torsemide (a diuretic). Review of Resident 16's Treatement Administration Record for April 2025 showed they had edema (excess fluid causing swelling) present on assessments. On 04/10/2025 at 10:15 AM, Staff F, RCM, when asked if Resident 16's diuretic usage should be care planned, said it was not on the care plan and should have been due to the potential for fluid loss and dehydration prevention. When asked about Resident 16's edema and if goals/interventions should have been on the care plan, said they did not see anything and yes, the edema should have been care planned with goals and interventions. 4) Resident 26 was admitted to the facility on [DATE]. Review of the Admission MDS, dated [DATE], showed Resident 26 was cognitively intact. Review of the Admission Collection Tool, dated 03/01/2025, showed it was identified that Resident 26 was missing teeth. On 04/07/2025 at 3:01 PM, Resident 26 reported that they were missing some teeth and would like to go to the dentist if they could. On 04/10/2025 at 10:15 AM, Staff F, RCM, reviewed the Admission Collection Tool and said yes Resident 26 was missing natural teeth. Staff F reviewed Resident 26's care plans and said the missing teeth were not on the care plan and should have been. 51907 5) Resident 29 admitted to the facility on [DATE] with diagnoses that included dementia, depression, anxiety, and muscle weakness. The Significant Change MDS, dated [DATE], showed Resident 29 was confused but could make their needs known. Observation on 04/07/2025 at 12:44 PM, showed Resident 29's bed was against the wall on the left side. Review of the provider orders, dated 02/26/2025, showed Resident 29 had an order in place for bed against the wall to increase environmental space. Review of the care plan on 04/09/2025 showed Resident 29 did not have a care plan in place for the bed against the wall. During an interview on 04/10/2025 at 11:30 AM, Staff F, RCM, said if a resident has a bed against the wall, it should be care planned. On 04/11/2025 at 9:37 AM, Staff J, Rehabilitation Director, and Staff B, DNS, were jointly interviewed. When asked if it met expectations the bed being against the wall was not on the care plan, Staff J said it now was on the care plan. Reference F604. Reference F677. Reference WAC 388-97- 1020(1), (2)(a)(b)

Based on interview and record review, the facility failed to ensure nursing assistants were screened through the nurse aide registry prior to providing care to residents for 1 of 2 staff (Staff B) reviewed for staff qualifications. This failure placed residents at risk for abuse and unmet care needs. Findings included . Staff B was hired on 07/30/2024 as a Certified Nursing Assistant. Review of Staff B's employee record did not include documentation from the nurse aide registry. On 08/12/2024 at 2:00 PM, Staff A, Administrator, said Staff B was currently working as a nursing assistant providing resident care at the facility. Staff A said the facility had not received verification from the nurse aide registry for Staff B. Staff A said they had sent another email to the registry requesting verification. Reference WAC 388-97-1660(3)(c)

Based on observation and interview the facility failed to ensure appropriate personal protective equipment (PPE) was doffed (taken off) for 1 of 4 sampled rooms (room [ROOM NUMBER]) observed for Transmission Based Precautions. The facility also failed to ensure proper signage was placed in front of the entry doors to residents' rooms (room [ROOM NUMBER]A, 127B, 112, 103 & 101) for 2 of the 4 days. These failures placed residents at risk for facility acquired or healthcare associated infections and related complications and a diminished quality of life. Findings included . <[NAME] PPE Usage> On 02/20/2024 at 12:15 PM, Staff E, Certified Nursing Assistant (CNA), was observed exiting room [ROOM NUMBER], after doffing gown and gloves. Staff E stepped into the hallway, placed her eye protection on top of her head. Staff E did not clean the eye protection and did not change her mask. Staff E completed hand hygiene with alcohol-based sanitizer and then proceeded to pass out lunch meal trays to other resident rooms. On 02/22/2024 at 9:35 AM, Staff F, Licensed Practical Nurse (LPN), was observed wearing a N95 mask, with the mask worn under her nose. Staff F readjusted her mask when spoken too. Staff F, said doffing started with removing the gown and gloves first, then hand sanitize before removing the mask and face shield. At 10:25 AM, Staff B, Director of Nursing Services (DNS), said staff were expected to remove gown and gloves first when doffing. Staff B, said staff were then expected to sanitize their hands, remove their mask, and sanitize their hands again. When both observations were explained about wearing PPE inappropriately, Staff B stated, wearing PPE inappropriately is not acceptable and we will be doing more education. 49926 <Room Signs> On 02/20/2024 at 10:42 AM, room [ROOM NUMBER]A had aerosol and contact signs on the door, and the connected room [ROOM NUMBER]B had no instructions about infection control. room [ROOM NUMBER] had no sign about infection control instructions until lunch time despite positive test results for COVID-19. On 02/21/24 at 9:24 AM, rooms 127A, 127B, 112, 103, 101 had multiple signs attached to the door frames that had aerosol, droplet, and contact precautions. On 02/22/2024 at 9:30 Staff C, Infection preventionist for the facility said that she had the correct signs from Department of Health and has initiated education for staff. Reference WAC 388-97-1320(1)(a).

Based on interview and record review, the facility failed to ensure dental services were provided for 1 of 2 Medicaid residents (Residents 17) reviewed for dental services. Failure to follow up on dental referrals and timely assistance with appointment scheduling extended the time residents had to use ill-fitting dentures and/or go without dentures. These failures placed residents at risk for difficulty chewing, oral pain, decreased self-image, and diminished quality of life. Findings included . Resident 17 admitted to the facility on [DATE]. Review of the 04/17/2023 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact and had no natural teeth. A dental care plan, initiated 04/25/2023, showed Resident 17 was endentulous (no natural teeth) and had a Denturist referral pending. The care included direction to staff tocoordinate arrangements for dental care, appointments and transportation as needed/as ordered. Review of a dental consult, dated 04/24/2023, showed Resident 17 had no upper natural teeth, had five root tips present to the lower jaw, and was requesting dentures. The dentist recommended Resident 17 have a follow-up dental appointment scheduled as soon as possible (ASAP) to address the root tips, and to refer the resident to a denturist for dentures. Review of the electronic health record showed there was no documentation present that indicated staff followed up on the recommendation(s) to schedule a follow-up dental appointment ASAP and to refer Resident 17 to a denturist. No further dental documentation was found until a nurse's note on 10/25/2023 documented Resident 17 declined to be seen by the facility dentist. On 02/23/2024 at 12:09 PM, when asked if there was documentation to show staff followed-up on the recommendation to refer Resident 17 to a denturist and/or assisted with scheduling a follow-up dental appointment ASAP, Staff G, Social Services Director (SSD), said they were unable to find any documentation. At 12:34 PM, Staff B, Director of Nursing, said Resident 17's appointment with the denturist was scheduled, but Resident 17 had canceled it. When asked if there was documentation to show the denturist appointment was scheduled and Resident 17 canceled it Staff B, stated, No. Reference WAC 388-97-1060(1), (3)(j)(vii)

Based on interview and record review, the facility failed to ensure Pre-Admission Screening and Resident Review (PASRR) Level II evaluation treatment recommendations were incorporated into a resident's plan of care for 1 of 3 residents (Resident 16) who were reviewed for Level II PASRRs. This failure placed residents at risk for unmet mental health and psychosocial needs. Findings included . Resident 16 admitted to the facility on [DATE]. Review of the 09/04/2023 significant change Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had diagnoses of anxiety and depressive disorders, received antipsychotic medication (class of medications used to manage delusions, hallucinations, paranoia or disordered thought), and was determined to have a serious mental illness (SMI) through the Level II PASRR evaluation process. Review of a Level II PASRR Initial Psychiatric Evaluation Summary, dated 05/02/2022, showed the resident had SMIs of major depressive disorder with psychotic features, anxiety disorder and neurocognitive deficits related to Wernicke's encephalopathy (a degenerative brain disorder caused by the lack of vitamin B1, often related to alcohol abuse) versus Korsakoff's amnesic syndrome (a memory disorder that results from vitamin B1 deficiency and is associated with alcoholism). Wernicke's encephalopathy represents the acute phase of the disorder and Korsakoff's amnesic syndrome represents the disorder progressing to a chronic or long-lasting stage. The evaluation also identified Resident 16's ongoing struggle with alcohol and marijuana abuse as potentially contributing to the resident's altered mental health. The following recommendations were made for Resident 16's treatment plan: a) Continue mental health counseling services. b) Refer to a psychiatric prescriber for a diagnostic and medication review to assess the resident's psychotropic medication (exert an effect on the chemical makeup of the brain and nervous system) regimen. c) May benefit from an alcoholic anonymous or narcotic anonymous (AA/NA) sponsor to provide support during times of risk for relapse, while celebrating recovery from positive decision making. d) Consider pet therapy. Review of Resident 16's electronic health record (EHR) showed the resident was receiving counseling services from their personal psychologist. However, there was no documentation that showed facility staff referred Resident 16 to a psychiatric prescriber for a diagnostic and medication review, assisted the resident with obtaining an AA/NA sponsor, or that pet therapy was offered/provided as recommended. Review of a Level II PASRR Significant Change in Condition Assessment, dated 06/30/2023, showed the evaluator identified the facility failed to refer Resident 16 to a Psychiatric prescriber for a diagnostic and medication regimen review as was recommended on the 05/02/2022 evaluation. The evaluator documented this writer recommended [Resident 16] could also benefit from being seen by a Psychiatric Prescriber, which has not been implemented to date. The evaluator then made the following treatment plan recommendations: a) Refer to a psychiatric prescriber for a psychiatric assessment and medication evaluation for management of anxiety and depressive disorders. b) Speak with Resident 16 about the benefits of obtaining an AA/NA sponsor who can provide support during times of greater risk for relapse, while celebrating recovery due to positive decision-making skills. c) May benefit from being assessed by a Certified Alcohol/Substance Use Disorder Specialist, to help determine the level of services they made need to help maintain recovery. d) Contact the Mental Health service provider that followed the resident in Oregon to find out what they observed that justified their diagnostic impression. e) The assessment documented that it was unclear if the Resident 16 had Wernicke's encephalopathy or if they had progressed to Korsakoff's syndrome. A recommendation was made for a neurology referral to assess possible underlying neurocognitive problems. Review of Resident 16's EHR revealed no documentation was present in the record that showed staff carried out/implemented the treatment plan recommendations from the 06/30/2024 Level II PASRR evaluation. On 02/23/2024 at 10:16 AM, when asked for documentation that showed facility staff carried out the 05/02/2022 and/or 06/30/2023 Level II PASRR treatment plan recommendations, Staff B, Director of Nursing Services (DNS), said they could not locate any documentation in Resident 16's EHR, but indicated Staff G, Social Services Director (SSD) might have more information. On 02/23/2024 at 12:00 PM, when asked if there was documentation to show facility staff carried out the 05/02/2022 and/or 06/30/2023 Level II PASRR treatment plan recommendations Staff G, SSD, stated, No. Reference WAC: 388-97-1915(4)

Based on observation, interviews, and record review, the facility failed to maintain and document refrigerator temperatures for 1 of 3 facility refrigerators (snack refrigerator) reviewed for food service. These failures placed residents at risk of food-borne illness, unsanitary conditions, and a diminished quality of life. Findings included . On 02/22/2024 at 12:30 PM, review of the facility's refrigerator temperature logs, documented the snack refrigerator located behind the nurses' station had multiple missing entries for the month of February 2024, including: 02/04/2024, 02/05/2024, 02/06/2024, 02/11/2024, 02/12/2024, 02/13/2024, 02/18/2024, 02/19/2024, 02/20/2024 & 02/22/2024. On 02/22/2024 at 12:38 PM, Staff D, Food Services Director, said kitchen staff were responsible for maintaining the refrigerator temperature logs. When shown the missing temperature log dates, Staff D, said the missing dates were unacceptable. At 2:38 PM, Staff B, Director of Nursing Services, said the missing refrigerator temperature logs were not acceptable. Reference WAC 388-97-2980 (1)

Based on interview and record review, the facility failed to ensure residents were free from accident hazards when staff provided a one-person transfer with toileting assistance instead of the care planned two-person transfer with toileting assistance for 1 of 3 sampled residents (Resident 1) reviewed for accident hazards. This failure placed residents at risk for injury and a diminished quality of life. Resident 1 experienced harm when he was assisted with one staff rather than two and sustained three rib fractures and subsequent pleural effusion (a build-up of excess fluid between the layers of the pleura outside the lungs), pain, and bruising. Findings included Resident 1 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 07/26/2023, documented Resident 1 had severe cognitive impairment and required two-person extensive assistance with transfers and toileting. Resident 1's Activities of Daily Living (ADL) care plan, initiated on 03/02/2021, included interventions for toilet use and documented the resident required extensive assistance of two staff. Interventions for transfers were documented as requiring a two-person stand-pivot when the resident was alert and able to follow cues. Resident 1's urinary and bowel incontinence care plan, initiated on 03/02/2021, documented the resident required assistance of two persons for toileting needs. An event note, dated 09/06/2023 at 7:55 PM, by Staff D, Licensed Practical Nurse (LPN), documented Resident 1 was assisted to the floor while tranferring to the toilet and slid off the seat and on to the floor. The note documented staff called for assistance, the resident was assessed and assisted back to their wheelchair. Resident 1 reported pain of 2 out of 10 to their right flank (side) and had denied hospital transport for evaluation. A facility investigation report, initiated 09/06/2023 by Staff D, documented they (the nurse) had been notified Resident 1 was assisted to the floor after slipping on feces on the toilet seat. The report documented the event happened during transfer/while transferring to the toilet in the shower room and resident was assisted to the floor. A staff witness statement, completed by Staff F, Nursing Assistant (NAC), reported they were the only staff providing care and documented the type of incident was an assist to the floor and resident had slid from the toilet seat. An event note, dated 09/07/2023 at 12:22 PM, documented Resident 1 was not able to take deep breaths and recommended staff listen to lung sounds especially on the right side. An event note, dated 09/08/2023 at 5:40 AM, documented Resident 1 reported soreness on his right side, rating his pain a 3 out of 10. An event note, dated 09/09/2023 at 5:40 AM, documented Resident 1 had appeared to have difficulty with bed repositioning and cares and slept very little. An event note, dated 09/11/2023 at 3:24 PM, documented Resident 1's restorative program (program to improve or maintain level of function) was discontinued due to bruising and pain to his side. An event note, dated 09/13/2023 at 1:21 PM, documented Resident 1 was transferred to the ER for increased pain related to the fall and was admitted for evaluation. A hospital chest Computed Tomography (CT) scan (shows detailed images of inside the body) report, dated 09/13/2023 at 5:14 PM, documented Resident 1 had acute (sudden injury) and displaced (out of normal position) right posterior (back) rib fractures 9, 10, 11 (3 different ribs affected) and adjacent reactive pleural effusion (a build-up of excess fluid between the layers of the pleura outside the lungs). Resident 1 was readmitted to the facility on [DATE]. An alert note, dated 09/17/2023 at 12:25 AM, documented resident rated his knife like pain laying still an 8 out of 10 and he had difficulty sleeping and movement increased his pain. On 10/02/2023 at 4:41 PM Staff D said Resident 1 was care planned for two-persons to assist the resident with toileting and transfers stating, [Resident 1] is a heavy load. When asked about Resident 1's fall on 09/06/2023, Staff D said the resident was being transferred from their wheelchair to the toilet and normally the resident would stand up and staff would assist resident to pull their paints down and assist onto the toilet and in this instance there was feces on the toilet seat and the resident slid off the toilet on to the floor. Staff D said Resident 1 was being assisted by Staff F, and he was a large guy and must have thought he could do it himself. Staff D said she assessed the resident for injuries, and the resident declined to go to the ER, but the resident later developed a huge bruise and the pain had worsened and Resident 1 eventually agreed to go to the ER. On 10/03/2023 at 5:15 PM, Staff E, NAC, said staff knew what level of assistance to provide for toileting and transfers by what was on the care plan. Staff E said Resident 1 was a two-person assist. When asked about Resident 1's fall on 09/06/2023, Staff E said Staff F had been transferring Resident 1 in the bathroom and the resident was already on the floor when she arrived but it was her understanding that when Staff F tried to transfer Resident 1, the resident slid and hit a bucket that was on the floor. On 10/04/2023 at 12:59 PM, Staff F, NAC (agency), said staff knew what level of assistance residents required by what was on the care plan. Staff F said Resident 1 was a one to two-person assist depending on how the resident was doing. Staff F said he was familiar with the resident and he felt the resident was good to transfer with one person that day. When asked about Resident 1's fall, on 09/06/2023, Staff F said Resident 1 was taken to the bathroom, the resident stood up, and Staff F pulled the resident's pants down and the resident sat on the toilet. Staff F said as the resident was trying to get up, the resident slid. Staff F said he tried to support Resident 1, but it exceeded his strength. When asked if the resident was done using the bathroom or if the resident had stood up unexpectedly, Staff F said Resident 1 was done and Staff F was assisting the resident to stand up and resident was weaker at that time and slid/landed on right side of their body where there was a bucket on the floor. Staff F said he was unable to hold the resident up and the resident came down on the bucket. At 1:22 PM, Staff C, LPN, Resident Care Manager, said staff knew what level of assistance a resident needed by the care plan. Staff C said Resident 1 could be a one or two-person assist for toileting and transfers depending on his Parkinson's that day and Resident 1 could sometimes tell staff, or staff could tell if the resident was going to be able to stand or if they would need a second person. On 10/04/2023 at 1:52 PM, Staff B, Registered Nurse and Director of Nursing, said staff knew what level of assistance was required by accessing the chart and clicking on the task. Staff B said Resident 1 was a two-person assist for transfers. When asked if two staff had provided toileting assistance, Staff B said she did not know if one or two staff provided assistance for the toileting and transferring at the time of Resident 1's fall. Staff B said she did not interview Staff F, as the nurse on the floor at the time of the fall (Staff D) did that. Staff B said Staff F would definitely need to be in-serviced if he was transferring Resident 1 with only one staff. Staff B said Resident 1 was a big guy and sometimes able to tell staff when resident had to have a bowel movement and sometimes staff would use a shower chair but at the time of the fall he was transferred to the toilet. Staff B said she updated the care plan to include the use of the shower chair for toileting and no other changes were made. Review of care plan revision history showed the toilet use intervention changed on 09/14/2023 to; The resident needs extensive assist of two to be changed. Use shower chair in corner with grab bars when needing to have a BM [bowel movement]. At 2:04 PM, Staff A, Administrator, said staff knew what level of assistance a resident required by the care plan. Staff A said Resident 1 had slid off of the toilet. Staff A said they were not sure what Resident 1's care plan indicated but the resident was able to pull himself up with the bar but could become shaky after toileting due to his Parkinson's. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to maintain hot water temperatures at safe levels in 4 of 18 occupied resident rooms (124, 126, 127 & 128) reviewed for accident hazards. This failure placed residents at risk for serious burns and decreased quality of life. An Immediate Jeopardy was called on 03/05/2023 at 7:20 PM when the facility's hot water temperatures in four occupied resident rooms exceeded temperatures of 110 +/- 10 degrees (124.5 degrees in room [ROOM NUMBER], 129.9 degrees in room [ROOM NUMBER], 130 degrees in room [ROOM NUMBER] and 130 degrees in room [ROOM NUMBER]) affecting 12 residents (8 of which had cognitive decline and 4 of which could access water independently). The immediacy was removed on 03/06/2023. The provider removed the immediacy with the completion of training, assessing residents for burns, reducing the temperature of the mixing valve (provides the ability to have the boiler set at a higher temperature and then have the radiant circuit supplied with a lower water temperature) in boiler room, and testing the water temperatures in resident rooms. Findings included . The facility's, undated, TELS Masters (a building management program) document showed, 1. Ensure patient room water temperatures are between 105* and 115* Fahrenheit (F) . 3. Test temperature at the mixing value . TELS Masters noted, Record results in the water temperature log 1. Note any discrepancies 2. Adjust water heater settings as required . The American Burn Association, Scald Injury Prevention Educator's Guide, ameriburn.org/wp-content/uploads/2017/04/scaldinjuryeducatorsguide.pdf, Time and Temperature Relationship to Severe Burns, showed the following water temperatures and the time for a 3rd degree burn to occur: 120 degree F 5 minutes 124 degree F 3 minutes 127 degree F 1 minute 133 degree F 15 seconds On 03/05/2023 at 3:26 PM, room [ROOM NUMBER]'s water temperature was observed to be 130 degrees F from the sink. At 3:30 PM, room [ROOM NUMBER]'s water temperature was observed to be 129.9 degrees F from the sink. At 3:40 PM, room [ROOM NUMBER]'s water temperature was observed to be 130 degrees F from the sink. At 3:42 PM, room [ROOM NUMBER]'s water temperature was observed to be 124.5 degrees F from the sink. At 5:50 PM, Resident 22 said the water got too hot if ran for a long time. At 6:14 PM, Staff A, Administrator, said water temperatures were checked randomly on a weekly basis. Staff A said the hot water temperatures were supposed to be between 105 - 115 degrees F. Staff A said she would expect the boiler to be adjusted if the water temperatures were too high. At 7:28 PM, Staff A and Staff F, Maintenance Director, took the Survey team to the Boiler Room. The mixing valve's temperature was observed to be set at 126 degrees F. Staff F said the residents' room temperatures should not be any higher than 126 degrees F from the mixer. At 7:30 PM, Staff F was observed testing the hot water temperature from room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. The temperatures measured above 128 degrees F in all rooms. Staff F said the temperatures were too high. Reference WAC 388-97-3320 (1)

Based on observation, interview and record review, the facility failed to accurately monitor meal intake and resident weights and failed to implement and evaluate the effectiveness of weight loss interventions to determine if additional interventions were needed for 2 of 2 sampled residents (22 & 30) reviewed for nutrition. This caused harm to Resident 22 when the resident felt fatigued and weak after a 11.78 % weight loss in 98 days, just over three months. This failure placed residents at risk for weight loss, inadequate nutrition and diminished quality of life. Findings included . Review of the facility policy, undated, entitled Resident at Risk (RAR) Policy showed the facility conducted weekly resident at risk meetings to review residents who were identified or had the potential for developing nutritional issues. A list of actions or reviews were listed for different members of the team to complete prior to the meeting. For the nurse designee, one task included reviewing current snack/supplement intake and considering the cause to review pain management, psychosocial needs, and/or mood/depression. During the meeting, the care plan was to be updated with interventions that were resident specific and individualized. 1) Resident 22 was admitted on [DATE] with diagnoses including rehabilitation, pain management from a sacrum fracture, multiple myeloma in remission (a cancer that forms in plasma cells then accumulates in the bone marrow), Gastro-Esophageal Reflux Disease (a condition in which acid from the stomach comes up into the esophagus causing irritation), dysphagia- pharyngoesophageal phase (difficulty swallowing food), nausea with vomiting, anxiety and depression. The significant change Minimum Data Set (MDS), an assessment tool, dated 02/09/2023, showed Resident 22 was cognitively intact, able to make needs known, had a swallowing disorder, and had a weight loss of more than 5% or more in a month or 10% or more in six months that was not physician prescribed. Review of hospital discharge documents, dated 11/02/2022, showed Resident 22's multiple myeloma was considered to still be in remission and she was to follow up after discharged from the skilled nursing facility. The hospital discharge documented Resident 22 did not have edema and appeared distressed and remained tearful. Review of Resident 22's weights showed a 5.9 pound increase after admission over the month of November 2022. Starting in December 2022 to March 2023, Resident 22's weights started a decrease from 203 pounds on 11/24/2022 to 173 pounds on 03/02/2023. This was a 30 pound decrease in 98 days. The nutritional care plan, dated 11/15/2022, showed Resident 22 was at nutritional risk with a goal to not have significant weight loss. A revision, dated 02/16/2023, after Resident 22 had significant weight loss, did not include additional goals and interventions. A Nutrition Assessment, dated 11/30/2022, showed the assessment was based off of a weight of 199 pounds, taken one day prior on 11/29/2022. Resident 22 was deemed at risk for nutritional issues based on age, past medical history, wight status and status post fracture. The goal was to monitor intake and weights, meals to be consumed greater than 65 percent and maintain the current weight of 199, +/- three pounds. A Nutrition Assessment, dated 02/14/2023, showed the assessment was based off a weight of 183 pounds, taken one month prior on 01/17/2023. The risk factors were unchanged. The interventions provided by Staff G, Registered Dietitian, included offering a nutritional supplement to aid in healing and add a multivitamin to aid in micronutrient profile. The goal was to monitor intake and weights, meals to be consumed greater than 65 percent and maintain current weight of 183 pounds, +/- three pounds. Weights showed Resident 22 weighted 173.5 pounds on 02/09/2023. Resident 22's medical record showed on 03/04/2023, 23 days after the dietitian's recommendation, an order for the nutritional supplement (ProSource) was obtained. Nutritional meeting notes, dated 01/06/2023, showed the team recommendations: diabetic snack, re-weigh, Ensure (a dietary supplement) one can daily and monitor. The Ensure was not listed as a meal replacement. Nutritional note, dated 01/13/2023, showed a team recommendation included the previous items, from 01/06/2023, except the Ensure needed to be increased to twice daily. Nutritional notes, dated 01/20/2023 and 01/27/2023, showed the recommendations were the same as on 01/06/2023. Nutritional meeting note, dated 02/24/2023, showed the same recommendations as 01/06/2023 with the addition that the Ensure could be changed to four ounces three times a day. Nutritional meeting notes, dated 01/20/2023, 01/27/2023 and 02/24/2023, referenced the same 01/17/2023 weight of 183 pounds, five weeks old. No other nutritional meeting notes were found in the resident's medical record. The January 2023 and February 2023 Medication Administration Record showed nutritional meeting recommendations were not implemented or updated. A dietitian note, dated 01/13/2023, showed the current interventions included one can of Ensure a day and a diabetic snack. New recommendations by Registered Dietitian were to monitor weight and could increase frequency of Ensure if weight was still down after reweight next week. Review of the dietitian notes, dated 01/13/2023 and 03/03/2023, showed recommendation to increase the Ensure frequency, if weight was still down, was not implemented while weight loss continued. A dietitian note, dated 03/03/2023, documented Resident 22's current weight was 173 pounds, showing a 30 pound weight loss from the 90 day weight of 203 pounds. The current physician orders continued to say one can of Ensure per day and a diabetic snack. A nutritional order, dated 03/03/2023, was for ProSource Oral Liquid, Give 30 ml by mouth one time a day for Weight loss for 14 Days. Laboratory work was ordered for weight loss that same day. Meal monitoring, dated 02/09/2023 to 03/08/2023, showed 69 entries out of 81 meal opportunities. Only 5 of the 27 days had three meal entries consistent with the facility's meal times. On 03/05/2023 at 11:49 AM, Resident 22 said she had lost weight and was surprised she had not lost more. Resident 22 was observed to be sitting on her bed, leaning over a trash can which was between her feet. The resident said she had just thrown up. Resident 22 said the food was terrible and they did not give her alternatives to eat when nauseated. Resident 22 said the staff did not give her easy items to eat when the food smell made her sick. At 12:00 PM, Staff I, Certified Nursing Assistant (CNA), was observed bringing Resident 22 her lunch tray. Resident 22 told Staff I she had just thrown up. Staff I offered water as an alternative to the lunch tray. No food alternatives were offered or provided. At 12:40 PM, Resident 22 was observed sitting on her bed and pushed away the lunch tray. The food was not eaten but a few small bites in total. Resident 22 said she could ask for Ensure but she had forgotten. Resident 22 said she wished they could do something about her appetite. Review of meal monitoring on 03/05/2023 showed the second entry/lunch meal was recorded as 25-50 percent when the resident ate less than 25 percent. On 03/06/2023 at 10:51 AM, Resident 22 said she was nauseated again, and her appetite was gone. Resident 22 gave the example of how she used to love scrambled eggs but now when she ate them, they got down about halfway, then came up. There was a high calorie nutritional supplement on the table and Resident 22 said she had not drunk it yet but would. At 2:12 PM, the pasta lunch meal was observed and appeared to have only bites taken out, less than 25 percent. Resident 22 said she didn't eat much lunch, she tried but it wouldn't go down. Resident 22 said she drank the [nutritional supplement] that was given to her this AM instead of eating lunch. Review of meal monitoring on 03/06/2023, the second entry/lunch meal was recorded as 51-75 percent when the resident ate less than 25 percent. On 03/07/2023 at 2:51 PM, Staff K, CNA, said Resident 22 ate cereal in morning and drank the Ensure. Staff K said Resident 22's meal consumption depended on how much she liked it, and she documented 51-100 percent of meals in the computer. On 03/08/2023 at 10:49 AM, Staff L, CNA, said if Resident 22 did not eat a meal, they offered Ensure. At 11:08 AM, Staff E, Director of Rehab, said the facility had been monitoring Resident 22 during weekly meetings. When asked if Staff E had concerns with weight loss for Resident 22, Staff E declined to answer. Staff E said the resident did not eat much for meals, she snacked throughout the day. Staff E said yesterday Resident 22 was eating popcorn instead of her lunch. Review of the meal monitoring for 03/07/2023 showed 51-75 percent of the meal was consumed. At 11:18 AM, Collateral Contact 1 (CC1), Family, said Resident 22's appetite was really off and she had a lot of fatigue and weakness. From day one, Resident 22 complained of the food, they could not get her to eat. Resident 22 had strong food preferences. She could not or would not make herself eat. CC1 said recently Resident 22 had not been eating the desserts which was not her normal. CC1 said she brought a few meals from home and Resident 22 ate those. When asked what the staff did about the resident not eating meals, CC1 said they did not do a whole lot. They bring it in and come back to remove the tray. CC1 said it looked like Resident 22 had lost weight. At 12:38 PM, Resident 22 said the lunch was terrible; greens were not salted and the mashed potatoes were too salty. The resident said she would not touch the meatloaf. Resident 22 was observed to have eaten about 1/3 of the dessert and a few bites from each side dish. The amount eaten was less than 25 percent. At 12:50 PM, Staff J, CNA, was observed with Resident 22's meal tray and said Resident 22 ate about zero to 25 percent of her meal, then removed the tray. The amount eaten was similar to the amounts eaten on the previously observed trays. Review of meal monitoring on 03/08/2023, the second entry/lunch meal was recorded as 76-100 percent when the resident ate zero to 25 percent. At 1:25 PM, Staff B, Registered Nurse and Director of Nursing Services, said for a resident with significant weight loss, it was not appropriate to be on monthly weights. She expected them to be weighed weekly. Staff B said the CNAs inaccurately documented higher percent consumption and only offered an Ensure (ordered daily) instead for a meal alternative. Staff B said she spoke to Resident 22 on 03/05/2023 and found out the resident thought she could only get the alternative (Ensure) three times a week. Staff B said the CNAs had received training on how to accurately document the percent of meals eaten. At 1:45 PM, Staff G, Registered Dietitian, said this was not an expected weight loss. We did not expect this on admit. Staff G said Resident 22's weight of 170 pounds was concerning to him. Staff G said when a resident triggered for weight loss, he recommended more frequent weight checks than monthly to prevent a big loss in between checks. Resident 22's appetite was fair, some days were better than others. When asked if the CNAs marked greater than 51 percent eaten per meal when the resident ate less than 25 percent, would it change his plan of care, Staff G stated, Yes. That absolutely would change the plan of care. Staff G said he was dependent on accurate meal monitoring to create an effective care plan. Staff G said Resident 22 would require extra protein and oral supplements. Ensure was not an adequate replacement for a meal. Staff G said he had identified the issue of inaccurate meal monitoring last March 2022 and had talked to the facility staff regarding its importance. 46751 2) Resident 30 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was cognitively intact and required extensive assistance with activities of daily living. A Nutritional Assessment, dated 10/12/2022, documented, Met with resident in her room during lunch meal. Reports feeling poor to fair. Intake appears to be fair to good with complaints of constipation. Weight appears to be relatively stable. Resident 30's weight record showed he weighed 228 pounds on 10/12/2022, and when weighed again on 11/07/2022, resident weighed 194 pounds. This demonstrated an actual weight loss of 34 pounds, 14.91%, in 26 days. Resident 30's EHR (electronic health records) did not show an adjustment to the resident's meal plan, further investigation, or documented evidence the resident 30's weight loss was triggered or addressed at a weight meeting. On 03/05/2023 at 2:19 PM, Resident 30 stated, They bring me lunch and set it here, and I sleep through it. I don't eat it. I am okay with that, I guess. On 03/07/2023 at 9:47 AM, Staff E, Director of Rehabilitation, stated, If there is weight loss, the resident is going to be discussed at our Friday's meeting to see how to address it. Staff E said Resident 30 had swelling and went to the hospital. Staff E said she would provide additional information, including meeting notes on Resident 30's weight loss. No additional information was provided. At 10:43 AM, Staff B stated, When there is a weight loss, it triggers, and we discuss it at a meeting. Staff B said Resident 30 was hospitalized numerous times with hip and sepsis, and that is probably why the weight loss. Staff B stated, We should have put a note in. On 03/08/2023 at 1:50 PM, Staff G said Resident 30 was not weighed after returning to the facility after hospitalization . Staff G stated, There was no base line. If these weights are not accurate, then we need to get in there to provide some sort of intervention. Reference WAC 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to identify, assess, and intervene to prevent a significant weight loss for two of seven sampled residents (#12 & 48) reviewed for weight loss. This failure placed residents at risk of poor nutrition and a diminished quality of life. This caused harm to Resident #12 who experienced a significant weight loss of 41.5 pounds (19.17% over three and a half months) and Resident #48 who experienced a significant weight loss of 15.3 pounds (16.63% over five months). Findings included . The Facility's Resident At Risk (RAR) Policy, dated 01/22/2019, defined a significant weight loss as either 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. 1) Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admissions Minimum Data Set (MDS), an assessment tool, dated 01/18/2021, documented the resident had AMS [Altered Mental Status] with impaired cognition, required a mechanically altered therapeutic diabetic diet, required set up assistance and supervision for eating, and was at risk for weight loss. Resident #12's weight record showed the resident weighed 216.5 pounds on 01/11/2021. Resident #12's Nutrition Assessment, dated 01/20/2021, showed Staff P, Registered Dietician, did not review the resident's laboratory data. Staff P documented he was unable to review labs as they are located in paper chart, and this worker is charting remotely due to COVID-19 precautions. Resident #12's Nutritional Risk Care Plan (CP), dated 01/21/2021, documented Resident #12's goal was to have no significant weight changes. The CP directed staff to provide a CCHO (consistent carbohydrate) diet with a pureed texture. The CP directed staff to provide supervision and cuing for all meals, to observe and report as needed refusals to eat, and significant weight loss: 3 lbs in 1 week, > [greater than] 5% in 1 month, >7.5% in 3 months, >10% in 6 months. The CP directed staff to collect weights per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #12's January 2021 Meal Intake Monitoring documented Resident #12 ate less than 50% of her meal for 18 of 60 meals with no documented refusals. Resident #12's weight record showed the resident weighed 191.5 pounds on 02/17/2021, a weight loss of 11.5% over 37 days. Resident #12's February 2021 Meal Intake Monitoring showed Resident #12 ate less than 50% of her meals 68 of 84 meals (80.9%), including eight refusals. Resident #12's weight record showed the resident weighed 187.0 pounds on 03/03/2021, another 4.5 pounds of weight loss since 02/17/2021. Resident #12's Quarterly Nutritional Data Collection Form, dated 04/14/2021, documented Resident #12 had experienced a weight loss of over 10%, and identified the weight loss as planned/expected/desired. Resident #12's weight record showed the resident weighed 175.0 pounds on 04/22/2021, a total weight loss of 41.5 pounds (19.17%) since 01/11/2021. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #12] twice weekly. Resident #12's medical record, dated 04/27/2021 to 07/20/2021, showed five weights obtained out of 20 opportunities. Resident #12's progress notes documentation did not show a weight loss until 05/18/2021. On 07/20/2021 at 3:13 PM, Staff P said he did not review Resident #12's laboratory data, and said the assessment was incomplete. Staff P was unable to provide documentation showing Resident #12's weight loss was planned, expected or desired. On 07/21/2021 at 9:18 AM, Staff B, Director of Nursing Services and Registered Nurse, said Resident #12's significant weight loss should have been addressed on the resident's care plan, but it was not. Staff B said resident food consumption was reviewed quarterly as part of the re-assessment process. Staff B said Resident #12's decreased intake from January 2021 to February 2021 should have been identified, but was not. Staff B said there was no evidence indicating Resident #12's eight refusals of meals in February 2021 were addressed. At 9:21 AM, Staff B said for a newly admitted resident, weights should be collected for three consecutive days and then weekly for a month or until the resident's weight had stabilized. When asked if this had occurred for Resident #12, Staff B said it had not. 2) Resident #48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #48's weight record documented resident was weighed five times since 02/11/2021. Resident #48 weighed 92 pounds on 02/11/2021. Resident #48 weighed 76.7 pounds on 07/15/2021, a weight loss of 16.63% in five months. Resident #48 had five weights obtained out of 22 opportunities to weigh from 02/11/2021 to 07/15/2021. Resident #48's weight fluctuation care plan, dated 05/28/2019, documented, At risk for weight fluctuations related to current health status. The interventions included, Weights per recommendations. RD [Registered Dietician] to review quarterly. On 07/14/2021 at 11:38 AM, Staff P said Resident #43 was on a downward trend with her weight. Staff P said he would expect a re-weigh if a weight could not be obtained. At 1:33 PM, Staff B said Resident #48's weight order stated to weigh weekly and document. Staff B said the resident's last weight was on 05/28/2021. Staff B said she would expect a progress note detailing why a resident's weight was not obtained. Staff B said if the resident refused to weigh, the reason for the refusal should be documented, and a re-approach to weigh the resident should also be documented. At 1:58 PM, Staff Q, Dietary Manager, said she would contact the dietician and meet with the nurses to develop a plan during a nutrition at risk meeting to address residents who were losing weight. Staff Q said she did not have documentation of a nutrition at risk meeting for Resident #48. Reference WAC 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to implement preventive action to ensure residents were free from resident to resident altercations for 1 of 3 sampled residents (#1) reviewed for abuse. This failure placed residents at risk for abuse and neglect and a diminished quality of life. This caused harm to Resident #1. Findings include . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 12/23/18, documented the resident was alert and oriented, and required extensive assistance with activities of daily living (ADLs). Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented the resident had moderate cognitive impairment and required limited assistance with ADLs. Resident #2's care plan, initiated 05/02/18, documented non-pharmacological interventions for aggressive behaviors including 1) intervene as needed to protect the rights and safety of others, 2) approach in calm manner, 3) divert attention, 4) take to another location as needed, 5) allow her to discuss concerns and validate if appropriate, 6) avoid several persons coming to her at one time, 7) evaluate for non-medicinal interventions that may be effective in minimizing behaviors, and 8) report to physician changes in behavior status. A nursing progress note, dated 12/10/18, documented Resident #2 made verbal threats, raised her fist at staff, entered other residents' rooms going through their belongings, and made accusations. The progress note documented to reapproach, redirection, and distraction were unsuccessful, and the resident became more physically and verbally aggressive. The licensed nurse documented an intervention, will continue to monitor. A nursing progress note, dated 12/12/18, documented Resident #2 was verbally aggressive towards staff and residents from 3:00 PM through 6:00 PM. No interventions were documented. A nursing progress note, dated 12/15/18, documented Resident #2's behavior began to escalate with aggression and agitation, and at 5:00 PM the resident was given an anti-anxiety medication. The progress note showed physical and verbal aggression, including striking out at Resident #1 with a coffee cup and hitting staff with her closed fist, continued for three and a half hours. The progress note showed staff tried to redirect Resident #2 but the behaviors continued for 90 minutes. No interventions were documented after the staff tried to redirect the resident. On 01/04/19 at 1:30 PM, Staff A, a registered occupational therapist, said on 12/15/18, he witnessed a big commotion in which Resident #2 was very angry, pulling the hair of staff. Staff A said staff redirected Resident #2 with a cup of coffee and she sat in a chair. Staff A said 10 minutes later Resident #2 hit Resident #1 with a paper coffee cup as Resident #1 passed by, ambulating with her walker. At 1:40 PM, Resident #1 stated, (Resident #2) hit me with a cup .I thought she deliberately hit me .it was not an accident .it didn't hurt .it was a paper cup. At 2:45 PM, Staff B, the Director of Nursing Services, said she expected the licensed nurse would intervene and stop those behaviors, and document interventions to show what they were doing to prevent harm to another resident. Staff B stated, If they can't redirect her and she is a danger, then call EMS. Staff B indicated when a resident was allowed to have aggressive behaviors for 90 minutes or more without nursing intervention, it would not be a safe and comfortable environment for other residents. At 3:31 PM, Staff C, the Administrator, stated, We need to do some education on charting to ensure our practices are known through our documentation. WAC Reference 388-97-0640(1)

Based on interview and record review, the facility failed to ensure adequate supervision was provided for 1 of 3 sampled residents (#1) reviewed for accidents. This failure placed residents at risk for burns, injury and a diminished quality of life. This caused harm to Resident #1 when she [MEDICAL CONDITION] the arm, groin, and hip area. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, a comprehensive assessment tool, dated 11/25/17, documented Resident #1 was severely cognitively impaired and required guided maneuvering of limbs for eating. Resident #1's care plan, initiated on 9/25/17, indicated, (Resident) at risk for falls/injury related to advanced dementia, poor safety awareness, and stroke. Resident #1's nutrition care plan documented, Provide a quiet, calm setting, needs assistance throughout meal with supervision and cues and encouragement. A progress note, dated 12/08/17 at 11:40 a.m., documented, Resident with first degree burn on left lower arm and second degree burn (groin and hip). The facilities Incident and Follow-up form, dated 12/12/17, documented on 12/8/17 at approximately 5:50 during the evening meal, Resident #1 was burned on her left lower arm and (groin and hip). Interviews of staff present in the dining room, showed no staff and/or residents witnessed the soup being spilled. The soup had been served a few minutes prior to the incident. The Food Temperature Log, dated 12/8/17, documented the soup had a temperature of 141 degrees Fahrenheit (F). At 140 degrees F, a spilled liquid will result in a 3rd degree burn in 5 seconds (Moritz AR, Henriques FC Jr., Studies of thermal injury II, 1947). On 1/4/17 at 4:00 p.m., the Dietary Manager (DM) stated, Our procedure is to check the temperature of the soup immediately before it is sent out the dining area. DM said the day the soup was spilled on Resident #1, the soup was temped just prior to being served in the dining area. Resident #1's Non-Pressure Skin Condition Record (NPSCR), dated 12/8/17, [MEDICAL CONDITION] left groin 3cm x 2cm and left hip 2cm x 1cm. Resident #1's NPSCR, dated 12/29/17, documented burn to the left groin had deteriorated and measured 5.7cm x 1.3cm, and burn to the left hip has deteriorated and measured 2cm x 1.4cm. At 4:35 p.m., Resident Care Manager (RCM) A stated Resident #1 was cognitively impaired and ate at the assisted dining table with other cognitively impaired residents requiring supervision. RCM A said staff were not present at the table when the burn occurred. At 4:45 p.m., the Director of Nursing Services said staff were busy handing out trays when [MEDICAL CONDITION]. No staff were at the assisted dining table. The facility failed to supervise a cognitively impaired resident during dining. This caused harm to Resident #1 when hot soup was spilled resulting in a minor burn to her arm and [MEDICAL CONDITION] her, groin and hip. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to implement policies and procedures to protect 1 of 5 sampled residents (#1) from psychological abuse. The failure of the facility to identify actual and/or potential psychological abuse, immediately protect residents from repeated occurrences, implement effective interventions to prevent further abuse, and immediately report the occurrence and begin an investigation of the psychological abuse constituted an Immediate Jeopardy. Findings include: The State Operations Manual (SOM) documents the reasonable person concept can be applied when there is no discernable response, or when circumstances obstruct the direct evaluation of the resident's psychosocial outcome. Such circumstances may include, but are not limited to, the resident's death, subsequent injury, cognitive impairments, physical impairments, or insufficient documentation by the facility. The SOM Appendix Q- Guidelines for determining Immediate Jeopardy, lists failure to protect Residents' from Psychological harm by lack of intervention to prevent individuals from creating an environment of fear as a situation likely to create jeopardy to an individual's psychological and/or physical health and safety. On 6/05/17, between 10:00 p.m. and 11:30 p.m., the Administrator (ADM), Social Services Director (SSD), and Registered Nurse (RN) A said the facility did not have written abuse prohibition policies and procedures for off hours. The ADM stated the facility referenced the State's Purple Book (PB, Nursing Home Guidelines, 6th Edition, Partners in Protection, October 2015). The PB, page 1, noted, This document contains guidelines for the protection of nursing home residents along with guidelines for preventing, investigating, determining and reporting incidents of abuse .including reporting reasonable suspicion of a crime .these guidelines are intended to assist facilities in developing and implementing principles and procedures to help prevent resident abuse of all types . Page 6-7 of the PB: Immediate telephone reporting is required when there is reasonable cause to believe abuse .has occurred. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1 was admitted for end of life care. Resident #1's Minimum Data Set, a comprehensive assessment tool, dated 3/30/17, documented Resident #1 was diagnosed with [REDACTED]. Resident #1 required 2+ persons assistance with most activities of daily living including personal hygiene, toilet use, dressing, transfers and bed mobility. On 6/1/17 at 12:08 p.m., Resident #1's advocate and power of attorney (POA) stated on multiple occasions the facility had escorted her out of the building after 10:00 p.m. The POA stated on each if these occasions she identified herself as Resident #1's advocate and POA. The POA stated Registered Nurse (RN) B informed her visiting hours were over at 10:00 p.m., and she needed to leave the facility. The POA said that Resident #1 had two end of life wishes. Resident #1 was Obsessively fearful of dying alone and considered leaving the facility due to fears of dying alone. The POA stated Resident #1 experienced anxiety and fear every time RN B came on shift due to her being fearful of dying alone and knowing RN B would escort her friend and advocate out of the facility. Resident #1's Care Plan Conference Record, documented a care conference was conducted on 4/13/17 with SSD, RN C, and POA present. The summary documented the POA discussed some of her concerns and observations and was given comment cards to address items she wants addressed. (The care conference occurred 10 days prior to Resident #1 passing away.) On 6/6/17 at 11:00 a.m., the POA indicated on 4/22/17 Resident #1's condition had significantly deteriorated and the POA just knew Resident #1 would pass away soon. At approximately 10:30 p.m., RN B asked the POA to leave the facility. The POA told RN B she was committed to honoring Resident #1's wish of not dying alone and did not want to leave the facility. POA said RN B forced her to leave the building and was told she would receive a call if Resident #1's condition changed. The POA said on 4/23/17 at approximately 2:20 a.m., Resident #1 passed away in her bed alone with no one at her side. RN B called the resident's son to inform him of his mother's passing despite him not being involved with her care while in the facility. The facility never contacted POA. On 6/6/17 at 5:10 p.m., RN C indicated the POA's concerns around visiting hours were discussed during the care conference. RN C stated she was too late with addressing the issue with RN B. RN C stated she did not have time to discuss the escorting of Resident #1's POA out of the facility with RN B prior to Resident #1 passing away. On 6/6/17 at 8:11 p.m., RN B said she escorted POA out of the facility on three separate occasions. RN B stated Residents were sleeping and it was time for her to go. RN B stated she did not call the POA because she was not the next of kin, despite Resident #1's medical record indicating the POA as the durable power of attorney for healthcare. At 8:44 p.m., the SSD indicated she was present at the 4/13/17 care conference when the POA discussed being escorted out of the building by RN B. SSD stated she had been backed up at work since her vacation and had not reported and/or addressed the concern. At 9:50 p.m., the Administrator (ADM) referred to RN B as an interesting one. The ADM indicated she had concerns about RN B that had not yet been addressed. When referring to meeting the needs of Resident #1, the ADM stated, It's my frustration that staff are lazy and don't take the time. At 10:15 p.m., a confidential supervisory staff indicated RN B was not warm and fuzzy and not particularly accommodating to residents. The staff indicated being fearful to bring concerns to the administration due to potential retaliation. I need my job. On 6/6/17, a second confidential supervisory staff indicated being fearful of retaliation by administration. The staff stated unless there was hard evidence of wrong doing, they were not comfortable bringing concerns up to the administration. I have always had a concern with RN B, but could never put my finger on it. At 10:30 p.m., RN A stated she was aware the POA had been escorted out of the facility. RN A stated she did not discuss the event with anyone from administration nor did she discuss it with RN B. On 6/7/17 Resident #1's son said he was not a legal decision maker and never has been. He said the POA was Resident #1's legal decision maker for healthcare. He referred to the POA as an angel and we are all grateful that she has been there for Mom. Despite multiple staff knowing RN B was an interesting one, not warm and fuzzy, and had an uninvestigated allegation of escorting the POA of an actively dying resident out of the facility on multiple occasions, RN B continued to care for vulnerable, confused residents without guidance, education and/or disciplinary action. By failing to implement its policy on abuse/neglect prevention and reporting, the facility deprived Resident #1 of her final wishes to not die alone and have her POA at her side during her final days causing her anxiety and mental anguish. This failure also placed other residents at risk for harm. Reference (WAC) 388 97-0640 (2) (a) (b), (3) (a)

Based on observation, interview and record review, the facility administration failed to monitor and effectively administer services to attain and/or maintain residents' highest level of function and optimal well-being. The facility failed to investigate an allegation of a staff member not honoring a dying resident's wish to not be left alone before dying, develop and implement abuse/neglect/misappropriation of property policy and procedures, failed to treat residents with respect and dignity, provide medically related social services, and provide residents the necessary care and services. These failures caused harm to Resident #1 and #2 and placed all residents at risk of diminished quality of care and quality of life. Findings include: 1) Refer to 42CFR 483.12(b)(1) F224 Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. 2) Refer to 42CFR 483.12(b) F226 The facility must develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. 3) Refer to 42CFR 483.10(a)(1) F241 A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. 4) Refer to 42CFR 483.40(d) F250 The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. 5) Refer to 42CFR 483.25 F309 Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Reference (WAC)388-97-1620(1)

Based on observation, interview and record review, the facility failed to provide medically-related Social Services (SS) for 2 of 5 sampled residents (#1 & 2) reviewed for social services. The facility's failure to follow up on resident/family concerns and not recognize potential abuse/neglect and misappropriation of property caused anxiety and lack of medically related social services for residents, and placed residents at risk of not maintaining and/or improving their ability to manage their physical, mental and psychosocial needs. This failure resulted in harm to Residents #1 and #2. Findings include: On 6/6/17 at 8:44 p.m., the Social Services Director (SSD) stated she had never met Resident #2. The SSD stated she had been backed up with work and had not had time to meet with the resident. The SSD states she should have, and at the very least, referred Resident #2 to the Behavior Health Team. I just did not have time. The SSD stated she was Resident #1's guardian angel (facility program that assigns staff to a specific resident to visit and address concerns). The SSD states she was unaware Resident #1 had requested a Chaplin prior to her death and there was a Chaplin that saw residents in the facility. The SSD said she did not reach out to any of Resident #1's children. The SSD said she did not follow up on the allegation of Resident #1's advocate being escorted out of the building. Refer to 42CFR 483.12(b)(1) F-224 Refer to 42CFR 483.12(b) F-226 Refer to 42CFR 483.25 F-309 Reference (WAC)388-97-0960(1)

Based on observation, interview and record review, the facility failed to provide the necessary care and services for 1 of 5 sampled residents (#2) who experienced a significant change of condition. This failure placed residents at risk for delay in treatment. This failure resulted in harm to Resident #2 when the facility failed to obtain immediate medical care when the resident demonstrated loss of alertness, and continued decline. Findings include: Resident #2 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #2's care plan, dated 5/15/17, documented Resident #2 had acute and chronic pain related to her recent back surgery on 5/9/17, spinal stenosis (narrowing of the open spaces within the spine, which can put pressure on the spinal cord), and [MEDICAL CONDITION] (a chronic disorder characterized by widespread musculoskeletal pain). Interventions included frequent monitoring, pain medications, and medications for muscle spasms. On 6/6/17 at 8:11 p.m., Registered Nurse (RN) B indicated on 5/22/17 at approximately 7:30 a.m., she entered Resident #2's room and had to sternal rub the resident to wake her. RN B stated she was concerned Resident #2 was difficult to arouse so she confiscated the resident's purse while she was sleeping and found a bottle of narcotic pain medication. RN B stated she reported to the oncoming shift, counted the confiscated medications and left without further action. A nursing note, dated 5/22/17 at 3:39 p.m., documented no pain medications given this shift, resident alert and drowsy. A nursing note, dated 5/22/17 at 3:39 p.m., documented new orders received, reduce [MEDICATION NAME] from 5-10mg every 4 hours to 5mg every 4 hours and discontinue trizanidine (medication used for management of [DIAGNOSES REDACTED]). The FDA approved package insert for trizanidine documented, If medication needs to be discontinued, particularly in patients who may be on concomitant treatment with narcotics the dose should be decreased slowly to minimize the risk of withdrawal and rebound hypertension, [MEDICAL CONDITION] and hypertonia. Withdrawal symptoms include hypertonia, tremor, and anxiety. A nursing note, dated 5/22/17 at 9:45 p.m., documented, Hold all narcotics, trazadone, muscle relaxers. A physician order, dated 5/22/17 at 9:30 p.m., documented discontinue [MEDICATION NAME] 5mg every 8 hours (muscle relaxer), [MEDICATION NAME] every 8 hours (strong extended release narcotic pain medication), [MEDICATION NAME] 900mg every 8 hours (medication used to treat [MEDICAL CONDITION] and nerve pain), and trazadone 200mg daily at bedtime (non-narcotic medication used as a sleep aide). The FDA approved package insert for [MEDICATION NAME], when the patient no longer requires therapy with [MEDICATION NAME], doses should be tapered gradually to prevent signs and symptoms of withdrawal in the physically dependent patient. (Resident has been taking [MEDICATION NAME] more than 2 years) The FDA approved package insert for [MEDICATION NAME] documented, If [MEDICATION NAME] dose is reduced, discontinued or substituted with an alternate medication, this should be done gradually over a minimum of 1 week. On 6/6/17 at 4:30 p.m., RN D said she was Resident #2's resident care manager and she made several calls to the Medical Director who was the attending physician for Resident #2 while in the facility. RN D stated the Medical Director declined to reinstate resident's pain medications despite clearly being in withdrawal. RN D stated she did not consult the facility pharmacist and/or Resident #2's Primary Care Provider. On 6/11/17, the facilities on call pharmacist (Pharm) stated the abrupt discontinuation of MS Contin, [MEDICATION NAME], and trizanidine was not recommended. It would be appropriate to hold the medications temporarily then taper the doses. Pharm stated if the facility had called, a pharmacist would have been sent to the facility either the same or next day to conduct a review of the resident's full record and to make recommendations to the physician. On 6/11/17 at 11:48 a.m., Resident #2's family member stated she has been the resident's primary caregiver at home for the past several years. The family member said on 5/23, and 5/24 she visited the resident in the facility and Resident #2 was confused and actively vomiting. Resident #2 had random jerking movements of her upper and lower extremities. During the visits no facility staff informed her the resident's medications had been discontinued. Nursing notes from 5/22/17 at 10:59 p.m. through 5/25/17 at 3:36 p.m., documented, mild extrapyramidal movements noted of arms, legs and face, very vocal throughout the night, whimpering and yelling out . frequently on call light requesting pain medication, speech incoherent at times. Complains of nausea with emesis pain 10/10, Resident yelling out continuously and having signs of nausea not relieved by [MEDICATION NAME], Cannot complete a sentence or state where her pain is located . yelling and hooting throughout the night and morning; sometimes calls out 'Ow' and 'I can't,' moaning and yelling out, and was unable to follow command, and was having excessive uncontrollable moderate jerking to her trunk and extremities while yelling out. A review of the facilities documentation showed Resident #2's son was contacted by the facility on 5/25/17 regarding a change in cognition and involuntary muscle movements. When Resident #2's son arrived he found the resident to be acting severely abnormal and contacted emergency services to transport the resident to the hospital for treatment. Hospital records, dated 5/25/17, documented Resident #2 was admitted to emergency department in acute narcotic withdrawal. Resident #2 was writhing, turning left and right, inconsolable and unable to follow and commands. Resident #2 is yelling, thrashing, and moaning. On 5/25/17 Resident #2 was admitted to the hospital with [REDACTED]. Reference (WAC)388-97-1060(1)

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 former Residents (#1) was provided the services required to attain/maintain the highest level of function in accordance with the Comprehensive Care Plan (CCP). This failure occurred when the facility failed to timely assess for a TLSO back brace (corset-style brace designed to restrict the movement of the torso following spinal surgery/injury), report blood pressure (BP) and blood sugar changes and to notify the physician of abnormal lab results. This failure resulted in harm to Resident #1 from delay in recognition, assessment and timely treatment of [REDACTED]. Findings include: Former Resident #1 was admitted to the facility from the hospital on [DATE] following a fall at home that resulted in a broken back. Additional health conditions included diabetes, high blood pressure and generalized weakness. She was alert, oriented, made her own care decisions and wanted all life-saving measures implemented if necessary. She was to receive specialized physical and occupational therapies to gain more independence and return home. On 6/14/16, review of the Resident's clinical record revealed hospital transfer documentation, dated 4/8/16, that indicated the resident was assessed at high risk for falls; had a significant change in mobility and activity tolerance due to pain (consistent pain levels of 8 out of 10); recommended equipment for Physical Therapy (PT) shower chair, toilet safety frame, brace (may benefit from soft TLSO brace for comfort). The transfer note included: Transfers, bed-chair, contact guard assist of 1 person, utilizes 4 wheeled walker (FWW). Independence level: supervision required. On 6/14/16, review of the Nursing Notes (NN) and Medication Administration Records (MAR) showed the resident received continuous medications/narcotics for complaints of back pain. A physical exam note, dated 4/11/16, indicated the resident was having problems with severe pain and unable to ambulate with PT, check for fit of TLSO brace. Review of the PT, NN, assessments and comprehensive care plan (CCP/interim care plan) failed to indicate the fitting of the TLSO brace until 4/16/16 (8 days after admission). Once fitted with the brace, the PT wrote: She (resident) sat, stood and ambulated in reduced pain. After this date, there was still no documentation in the NN/CCP/interim care plan to indicate the use, care or evaluation of the resident using the TLSO brace or her response. <Significant Change in Condition> Review of the MAR indicated [REDACTED]. These were not found to be documented/performed. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The resident received other medications that could cause problems with blood pressure such as: [MEDICATION NAME] (diuretic) twice each day; two antidepressant medications daily and numerous daily doses of narcotic medications for pain that were not consistently monitored for effectiveness/side effects. The resident also received a [MEDICATION NAME] 5% patch ordered to apply daily to the skin for 12 hours and remove for 12 hours for pain. The MAR indicated [REDACTED]. This was important because; according to the manufacturer: the patch should not be applied to the same area for 12 hours; do not apply another patch to the same area of skin for 12 hours and do not use for more than 12 hours in a 24-hour period. Do not use 2 doses sooner than 12 hours apart. Failure to know the adverse effects such as; dizziness/mood/behavior changes, location of the patch, duration/time of the application and discontinuance placed the resident at risk of receiving too much and/or too little medication. The MAR indicated [REDACTED]. Several days showed 0 as the blood sugar level and many of the documented levels were illegible. The times and who performed the measurements were not consistently legible so other providers would know potential problems. On 6/14/16 at 3:30 p.m., when asked, the Director of Nursing Services (DNS) could not validate the documentation to determine accurate values nor when the [MEDICATION NAME]es were applied/removed. She was aware of the lack of documentation and lack of physician notification related to medications and treatments and had been reviewing the resident's record with staff to provide in-service and education regarding professional practice and resident care. The record also indicated the resident had long and frequent episodes of crying uncontrollably. The resident's mental status and physical function had noticeably deteriorated and the facility was aware of the changes in condition. The record revealed on 4/19/16 at 7:00 p.m., the resident's blood count was reported to the facility with a 14,600 white blood count indicating infection but the LN did not notify the physician. According to the LN on duty, she was extremely busy and did not even get to the unit until 11:00 p.m. Review of the Fall Risk assessment dated , 4/8/16, indicated the resident was at high risk for falls but the, physician ordered, orthostatic blood pressures were not done to show differences when the resident was lying down, sitting or standing and resulted in an incomplete fall-risk assessment. The Fall Risk assessment also indicated to document interventions on the assessment form and on the care plan ( .) inform the resident of the risks/benefits associated with the interventions. There were no interventions identified on the form or care plan or indication that any interventions were discussed with the resident. The fall investigation report indicated on 4/20/16 at approximately 4:00 a.m., a Nursing Assistant (NA) found the resident on the floor in her room. The NA left the resident to get Licensed Nurse (LN) A, who found the resident face down on the floor and bleeding. On 6/14/16 at 2:00 p.m., during interview with LN A, she stated she applied pressure to the resident's head to stop the bleeding. When asked why no documentation was in the record to show what the resident's condition was prior to the fall, what assessments she performed or when 911 was notified and the condition of the resident during this time, she said she had documented the event via the computer but when the DNS called her to ask about the fall, there was no documentation in the computer record. She said she completed the handwritten note and dated it 4/20/16, night shift but could not remember when the document was created because it was a late handwritten report after the fall created for the investigation report. The hospital record indicated the resident arrived in the emergency room (ER) on 4/20/16 at 4:51 a.m.The x-rays revealed: multiple traumatic brain hemorrhages/bleeding ( .) more on left than right. The resident was airlifted to a trauma center where she passed away. The resident incurred harm when the facility failed to: 1) Recognize, assess, and ensure treatment when changes in the resident's mental and physical function were reported and/or observed. 2) Ensure the TLSO brace was fitted in a timely manner to prevent unnecessary pain 3) Consult with the physician regarding the resident's low blood pressures/withholding the resident's blood pressure medications; abnormal blood sugar levels, abnormal white blood count and no bowel movements for days. Refer to F 505 and F 514

Based on observation, interview and record review, it was determined the facility failed to ensure 3 of 3 sampled Residents (#2 - current resident and Residents ,#1 and #3 former residents) reviewed for accidents, received adequate supervision to prevent repeated falls and harm. This failure resulted in harm to Resident #1 and # 3 and created the potential for other residents to incur new and/or repeated accidents with injuries. Findings include: 1) Former Resident #1 was admitted to the facility from the hospital on [DATE] following a fall at home that resulted in a broken back. She was to receive specialized physical and occupational therapies to gain more independence and return home. On [DATE], review of the Resident's clinical record revealed hospital transfer documentation dated [DATE] that indicated the resident was assessed at high risk for falls and had a significant change in mobility and activity tolerance due to pain. The resident was to utilize a toilet safety frame, back brace, and required one person assistance and supervision for transfers and ambulation. Review of the Fall Risk assessment dated [DATE] indicated the resident was at high risk for falls and also indicated to document interventions on the assessment form and on the care plan .inform the resident of the risks/benefits associated with the interventions. There were no interventions identified on the form or care plan, nor any indication that any interventions were discussed with the resident. The resident had a fall with significant injury on [DATE]. There was no evidence of what kind of supervision or assistive devices or specific interventions were in place on [DATE] to decrease fall risk. Please refer to F 226 & F 309 for further details of Resident # 1's fall tisks that were not addressed by the facility. 2) Former Resident #3 was an [AGE] year-old male who was admitted to the facility on [DATE] at approximately 1:30 p.m. from the hospital following a fall at home resulting in a head injury with bleeding in the brain and a broken finger in his left hand which required a splint be in place for healing. [DIAGNOSES REDACTED]. A Fall Assessment was completed on [DATE] and resident was assessed to be at high risk for falls. A care plan initiated on [DATE] had minimal interventions in place for a resident who was admitted due to falls with injury, as well as being assessed to be at high risk for falls; hospital discharge orders dated [DATE] also indicated the resident was at risk for falls. There were no interventions in place that would alert staff to check on resident frequently or documentation to indicate that resident was checked more than once a shift. The generic interventions in place included Educate resident/family on fall risk, Assist of ,[DATE] for transfers (and ambulating and toileting), low bed and non-skid socks, walker by foot of bed. Per progress notes dated [DATE] at 5:50 a.m. the resident was found to be yelling for help and LN C saw the resident lying on the floor with his body half way in the hallway and half way in the resident's room. LN C's progress notes reflect that resident had no obvious injuries noted upon assessment and that resident was assisted back to bed and neuro checks were initiated. On [DATE]. at approximately 10pm. the resident expired. This failure to initiate interventions that would provide direction for staff to increase visualization and/or assistance placed this and all residents that are assessed to be at high risk for falls to have falls resulting in injury and/or death. 3) Resident #2 was admitted to the facility on [DATE] with multiple medical conditions including a stroke with speech difficulty (aphasia). She was at high risk for falls related to decreased safety awareness; inability to communicate and poor cognition. She had muscle weakness, an indwelling urinary catheter and a gastric feeding tube. She required mechanical lift (Hoyer) for transfers. On [DATE] at 1:00 p.m., she was observed totally dependent on staff for all care and services. The post fall report dated [DATE] at 6:45 a.m., indicated the resident was found on the floor. The brakes on the bed were unlocked and the bed was pushed away from the wall/window where the resident was found. The resident could not answer when asked what happened. It was determined the resident rolled out of bed and pulled her urinary catheter out. She had redness to her knees. The post fall report dated [DATE] at 6:40 a.m. indicated the resident was found in a crab-walk .scooted on her bottom to the doorway of her room. The resident was unable to respond to say what happened and the report noted: appears intentional, restless, waiting for spouse to arrive . No new interventions were identified. The Comprehensive Care Plan (CCP) had notations written insuch a manner that it was difficult to determine specific interventions that were implemented, evaluated and/or revised to prevent repeated occurrences. The post fall report dated [DATE] at 7:00 p.m. indicated the resident was found kneeling in front of the sink. She was assisted to a standing position and escorted to bed. She was disoriented but speech was clear and she said she crawled out of bed. It was determined the resident was upset about not wearing clothes and was looking for her pants. No new interventions were identified on the CCP to address the resident's needs for this incident. The post fall report dated [DATE] at 4:00 a.m. indicated the resident was found on the floor in a sitting position .rail up .resident had turned herself upside down in bed at some point . Review of the CCP revealed the same plan was in place with each occurrence without evidence of revision, evaluation of interventions and/or what supervision/measures were in place to prevent repeated falls and to keep the resident safe. .

Based on interview and record review, it was determined the facility failed to operationalize its abuse/neglect policies and procedures related to inappropriate touching by a staff member of 1 of 3 sampled Residents (#3) and an unwitnessed fall with significant injury for 1 of 3 former/discharged Residents (#1) reviewed for abuse and neglect. The facility failed to identify, protect, investigate, prevent and/or report allegations of abuse and/or neglect in a timely manner resulting in emotional distress to Resident #3 and failed to thoroughly investigate and report to the state hotline a significant unwitnessed injury to Resident #1. The failure placed all residents at risk of the same/similar deficient practice. Findings include: 1) Resident #3 was admitted to the facility from the hospital on [DATE]. She required extensive assistance from staff for activities of daily living (ADLs). She was alert and oriented, requested all life-saving measures be implemented, signed her own care decisions and could make her needs known. On 6/14/16, review of the clinical record and investigation reports, indicated that, through hearsay, Resident #3 had made comments about a Nursing Assistant (NA) kissing/touching the resident inappropriately. The facilities report documented that Resident #3, when interviewed about the incident, said the NA kissed her on the cheek The date of the occurrence(s) was not clear since it was not reported or investigated at the time a Licensed Nurse (LN) was notified. The Resident's roommate reported she overheard Resident #3 reporting the event to the LN but could not remember the date. The NAs thought the resident was joking and did not report the allegation to the facility at the time. On 6/14/16 at noon, Resident #3 said she did request to have only female caregivers at night but it was unclear when that request was made. The care plan indicated this request/agreement to have only female caregivers at night was made on 4/20/16 after the Director of Nursing Services (DNS) intervened with an investigation when she learned of the allegations. On 6/14/16 at 3:30 p.m., The DNS stated the male NA and male LN continue to work in the facility. The male NA admitted to kissing the resident on the cheek and was educated about boundaries with residents. The administrator stated one of the female NAs, who also had previous abuse/neglect training and initially failed to report the allegation in a timely manner, was terminated. The facility failed to ensure that Resident # 3 was free from unwanted physical contact and they failed to ensure that their abuse and neglect policy was implemented timely to protect residents. 2) Former Resident #1 was admitted to the facility from the hospital on [DATE] following a fall at home that resulted in a fracture to her back. She was to receive specialized physical and occupational therapies to gain more independence and return home. She was alert, oriented and made her own care decisions. The investigation documents indicated the resident incurred a fall to the floor on 4/20/16 at 4:00 a.m. The resident was found face down and bleeding from her head. The nurse rolled the resident to her back, applied pressure to the resident's head wound and waited for the ambulance. The resident arrived in the emergency room (ER) on 4/20/16 at 4:51 a.m. The x-rays revealed multiple traumatic brain hemorrhages/bleeding ( .) more on left than right. The resident was airlifted to a trauma center for continued, where she passed away. Review of the reporting log failed to show the incident was reported to the state agency hot line although it was an unwitnessed fall with substantial injury and death. Review of the facility's investigation into this incident was not thorough. The facility investigation into this incident did not establish if all the interventions related to injury fall risks had been implemented for this resident. The resident was determined on admission to be a high fall risk due to pain. The Summary of Investigative Facts document related to the resident's fall of 4/20/16 revealed that the resident had had a recent medications change. The medications that the resident was receiving had potential side effects to include dizziness, drowsiness and weakness. In addition, the resident's blood pressure had been significantly lower in the mornings so the staff had held the resident's blood pressure medication. Earlier on the evening of 4/19/16 before the resident's fall at 4 am on 4/20/16, the resident had received [MEDICATION NAME] and [MEDICATION NAME], a pain pill. The medications the resident had received that evening have side effects to include dizziness, weakness and forgetfulness. Review of the investigation report indicated the floor was wet but failed to indicate the substance. The DNS reported on 6/22/16 that she spoke to the LN who found the resident and she reconfirmed in their discussion that the floor was wet from blood that had come from a laceration above the resident's eye. On 6/14/16 at 2:00 p.m., during an interview with LN A, she stated she completed the handwritten note of the fall and dated it 4/20/16, night shift but could not remember when the document was created because it was a late handwritten report after the fall created for the investigation report. On 6/14/16 at 4:00 p.m., the DNS stated she thought she should have reported to fall to appropriate agencies but had guidance from others who reviewed The Purple Book (guide to assist facilities in identification, investigation and reporting events in order to comply with state, Federal, law enforcement requirements) that determined the fall to be an accident and not abuse or neglect because the investigation concluded the resident attempted to get up from bed to use the bedside commode and slipped and fell . The facility incident investigation did not establish if: All care planned interventions were in place and implemented to reduce injury falls; New interventions for monitoring the resident were added to the care plan given the recent medications changes, lower blood pressures, and the resident's emotional state of anxiety and prolonged crying episodes documented on 4/18/16 and 4/19/16 in the nursing progress notes; or What environmental factors including lighting, stability of the bed and bedside commode, condition of the floor before the resident fell and call light response to include assessing sufficient staffing were reviewed as possible contributing factors. Failure to thoroughly investigate the injury fall incident prevented the facility from clearly ruling out potential neglect. The Purple Book in explaining accidents states that Foreseeable incidents are not unavoidable accidents. The Purple Book requires that Substantial injuries of unknown source must be reported within 24 hours if, through the process of a thorough investigation, the injury is not considered reasonably related to a disease process or known sequence of events. And to report, Substantial injuries of unknown source not related to suspected abuse or neglect (because under some circumstances the failure to take preventive measures may constitute abuse or neglect). The facility did not report this unwitnessed injury fall incident based on determining the resident slipped and fell . As the condition of the floor prior to the resident ' s fall (which resulted in a bleeding head injury), was not established during the facility ' s investigation, the conclusion of this injury fall incident meeting the definition of accident was unclear. The facility failed to thoroughly investigate and report this significant unwitnessed injury as required. Refer to F 309 for further information regarding Resident # 1's medical conditions.

Based on observation, interview and record review, it was determined the facility failed to accurately assess and implement interventions to promote wound healing and/or prevent worsening pressure ulcers for 3 of 6 current sampled residents (#129, 128 & 14) reviewed for pressure ulcers (PU). This failure placed residents at risk of avoidable and untreated PU. Findings include: 1) Resident #14 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's Minimum Data Set, an assessment tool, dated 09/12/15, indicated the resident was alert and oriented, required extensive assistance from two (2) staff with activities of daily living, and had two (2) Stage 2 PU, and two (2) Unstageable PU. The resident's care plan addressed skin integrity and PU with interventions including assist PRN (as needed) to reposition/shift weight to relieve pressure, and position with pillows to maintain proper body assignment PRN. Pressure relieving devices were not included on the care plan. Record review of the Pressure Ulcer Status Record documented a Stage 2 PU to the right buttock was first observed on 09/17/15. On 10/06/15 at 8:59 a.m., Licensed Nurse (LN) A stated, On the right buttock was a stage 2. LN A said, It was hard to move her because of her pain. LN A indicated the resident went to [MEDICAL TREATMENT] three times a week and sat on the hoyer (mechanical lift) sling while she was there. LN A indicated the wound was getting better. On 10/08/15 at 10:17 a.m., Resident #14's PU were observed with the physician, Director of Nursing Services (DNS) and LN A. There was a wound on the coccyx and a wound on the right buttock. The physician stated the wounds were from pressure, and asked about a roho (special) cushion. The DNS stated, It came in yesterday. I haven't had a chance to put it in her chair. When asked about [MEDICAL TREATMENT], the resident stated, They don't turn or reposition me. They say they are not allowed to turn or touch me. They have to use a hoyer and I always have the hoyer sling underneath me. The physician indicated the resident had dead tissue in the center of the wound on the buttock that would slough off, and the resident needed to keep off of it as it was caused by pressure. On 10/09/15 at 11:54 a.m., when asked about the wounds on the resident's coccyx and buttock, the DNS said, It's a stage 3 as she has some areas of slough and redness, and the tissues are so fragile. They are probably going to merge and get larger. When asked about the resident's mattress, the DNS stated, The mattress is a regular mattress and it doesn't have any pressure relief .I am asking the physician for an alternating air mattress because it is too hard to turn her. It takes three (3) people to turn her. There was not any documentation to show the facility had worked with the [MEDICAL TREATMENT] unit to address the resident's risk of pressure sores developing or worsening. Failure to coordinate with the [MEDICAL TREATMENT] unit to adjust her positioning to ensure the resident's PU did not advance, resulted in a Stage 2 PU to increase to a Stage 3 PU. This caused harm to Resident #14. 2) Resident #129 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. On 10/04/15, record review showed the resident had a red area on the mid-spine. The care plan recommended interventions including encouraging the resident to reposition. On 10/04/15 through 10/09/15, during multiple observations, the resident was frequently observed up in her wheelchair. When observed in bed, the resident was on her back. On 10/08/15, the resident was observed, with Licensed Nurse (LN) A, to have two (2) open areas on the resident's mid-spine. LN A assisted the resident to turn onto her left side without objection. Resident #129 was admitted with a risk for PU to the spine due to her spinal contracture. The facility failed to ensure pressure was sufficiently reduced to avoid breakdown. 3) Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/05/15, observations showed a thin appearing man lying on his left side facing the doorway of his room. On 10/06/15 at 12:13 p.m. to 5:00 p.m., the resident was observed in the same position, on his left side, in bed during random observations. On 10/07/15 at 8:40 a.m., the resident was observed to be facing the door lying on the left side. At 9:00 a.m., the resident's skin was observed with LN A. There was a reddened area on the resident's left hip, back and ankle. The reddened area on the resident's left hip bone was approximately 1 ¼ inch in diameter. The area did not blanche when LN A pushed on the site. The resident was observed to have a standard mattress on his bed, the same mattress of other sampled residents. At 4:48 p.m., the resident was observed to be on his right side sleeping in bed. This was the first observation of the resident off his left side. On 10/07/15, record review and LN A indicated the resident was on comfort care. The resident was at high risk of skin breakdown given his [DIAGNOSES REDACTED]. Delay of preventative measures being implemented placed the resident at risk of skin breakdown.

Based on observation, interview and record review, it was determined the facility failed to ensure residents received the appropriate care and services for 1 of 30 current sampled residents (#14) reviewed for pain. This failure placed residents at risk for inadequate care and services and a delay in medical treatment for [REDACTED].#14 when the facility failed to address the resident's verbal and non-verbal complaints of pain. Findings include: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set, an assessment tool, dated 09/12/15, indicated the resident was alert and oriented, required extensive assistance from two (2) staff with activities of daily living, and received pain interventions for frequent pain. The resident's care plan addressed the resident's pain with the goal pain will be minimized with medication and positioning, and the resident will state/demonstrate relief or reduction in pain intensity within one hour after receiving interventions. The October 2015 Physician order [REDACTED]. On 10/04/15 at 6:02 p.m., Licensed Nurse (LN) C stated the resident can receive [MEDICATION NAME] twice daily (bid) and [MEDICATION NAME] every 4 hours (q4hr) PRN. LN C stated they had not been given. LN C said the resident can receive [MEDICATION NAME] every 4 hours PRN and received her last dose of [MEDICATION NAME] last night. LN C said she gave the resident Tylenol at this time. LN C was observed giving the Tylenol to Resident #14, and stated, We will see how that does since your pain level is a 2-3 (out of 10). The resident was observed grimacing and stating she was in pain. On 10/06/15 at 10:03 a.m., the resident stated her pain was atrocious when she returned from [MEDICAL TREATMENT], and she had to wait for an aide to help her lay down. The resident said she does not take medication with her to [MEDICAL TREATMENT] and was not aware if she could. The resident stated she has to ask for pain medications. The resident said she sits for four (4) hours while she is at [MEDICAL TREATMENT] three (3) days a week. The resident said after she returns to the facility, I have had to wait more than a half hour for pain medications. If they are not busy or with someone else, its usually five (5) minutes. Sometimes I have to tell them to hurry up. I have to ask for the medication. The resident said if she had not had pain medication in six (6) hours, the Tylenol doesn't touch it. This failure to recognize, anticipate and provide measures to minimize and/or prevent pain through pain medications and repositioning (being able to lay down), both on the resident's [MEDICAL TREATMENT] days and days spent at the facility, resulted in harm to Resident #14 when she had to wait for pain medication, and was not provided pain interventions whether in the facility or returning from [MEDICAL TREATMENT].

Based on observation and interview, it was determined the facility failed to provide an environment that promoted respect and dignity for 2 of 30 current sampled residents (#131 & 38) reviewed for dignity. The facility failed to ensure dignity was maintained for facility residents during dining experiences. These failures placed residents at risk for diminished self-esteem and self-worth, and a decreased quality of life. The facility's failure to treat Resident #131 with respect and dignity resulted in psychological harm when the resident felt embarrassed and unimportant, and had a decline in self-worth and quality of life. Findings include: 1) Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review showed the resident required extensive assistance of two staff for activities of daily living. On 10/04/15 at 5:05 p.m., Resident #131's call light was observed to be on. At 5:22 p.m., Licensed Nurse (LN) C walked past the surveyor and did not respond to Resident #131's call light. Nursing Assistant (NA) B was in hallway by the resident's room and did not respond to the call light. At 5:26 p.m., NA C was in the hallway by the resident's room and did not respond to the resident's call light. At 5:27 p.m., LN C walked by Resident #131's room and did not respond to the resident's call light. At 5:30 p.m., Resident #131 stated it had already been an hour since she had pushed her call light for assistance (toileting and pain medication). The resident indicated she had to go to the bathroom and had to go for a long time. The resident stated, An aide was here at 4:40 p.m., and stated she would be back and hasn't returned. I haven't seen the nurse since their shift started. At 5:38 p.m., LN C was told the resident needed pain medication, and NA C was told the resident needed assistance. At 5:44 p.m., Resident #131's meal tray was delivered and LN C took pain medication to the resident. LN C was observed to tell the resident to go ahead and finish her dinner and then call and they would come assist her. At 6:05 p.m., Resident #131's call light was observed to be off. The resident stated she had not been assisted, and said, They keep coming in and turning my light off. At 6:45 p.m., the resident's call light was observed to be off. At 6:48 p.m., Resident #131 said she had not had assistance, and stated, I am miserable. It feels like I'm going to explode. At 7:00 p.m., Resident #131's room door was closed, and the Director of Rehabilitation stated two people were in the resident's room assisting her. On 10/08/15 at 10:53 a.m., Resident #131 stated, I got really depressed. I am all the way at the end of the hall, and I am not worth or not important, and felt left behind. When you have to go to the bathroom and no one can help you, it is very demeaning. The resident was tearful and stated she was afraid she would be retaliated against if she reported it. The resident said she was very uncomfortable and in pain. She had an accident on the way to the commode because she had to wait so long. The resident stated, I am really trying to keep my spirits up. I didn't think my life would be like this. I am concerned that when you (surveyors) leave its going to go back to the way it was before. The resident said sometimes there were only two (2) aides for the whole building, and one nurse who refused to help transfer residents. The resident indicated there were three (3) supervisors that never answered call lights who are now tripping over themselves to help. At 4:03 p.m., LN A stated, Three (3) to five (5) minutes is a reasonable time and nothing more (for call light response). LN A said eight (8) minutes was pushing it. On 10/09/15 at approximately 12:00 p.m., stated after she had shared some information about waiting an extended period of time the evening of 10/04/15 to be assisted with toileting needs, she was questioned by the Administrator (ADM) and the Director of Nursing Services (DNS) about her long wait to be assisted to the commode a few days before. Resident #131 said the tone of the questioning by the ADM and the DNS was accusatory causing her some distress. The resident stated she denied telling the survey staff about the care wait for assistance. The survey staff observed Resident #131's call light not being answered, and facility staff walking past the resident's room without responding to the call light. Failure to respond to the resident's call light resulted in the resident feeling embarrassed, unimportant, tearful, and afraid of retaliation. When questioned by the facility staff, the resident felt uncomfortable and denied what occurred. The undignified and disrespectful treatment of [REDACTED].#131. 2) Resident #38 was readmitted to the facility on [DATE] with multiple diagnoses. The resident ' s Minimum Data Set, an assessment tool, dated 09/06/15, indicated the resident was alert and oriented, and required extensive assistance with activities of daily living. On 10/05/15 at 9:05 a.m., the resident indicated he was concerned about what had occurred a few days earlier. Resident #38 stated, I can work with anybody, but some of them (nursing aides), you just would rather not be your aide. At 10:19 a.m., Resident #38 said an aide told him, I ' ll be glad when you ' re out of here. The resident stated, She still works here. Record review of the facility ' s investigation documentation showed on 09/29/15 the resident reported an aide came into the resident ' s room, three to four days prior and had been mean to him. The aide told him she would be glad when he ' s gone and for him not to talk to her again. The facility documentation noted the event had occurred .and there were some aides the resident preferred not to work with. Progress note, dated 09/29/15, noted the resident said three to four days ago an aide told him she would be glad when he got out of here, and that he should not talk to her. The resident was placed on alert on 09/30/15 for possible psychological harm due to the statements allegedly made by the aide. On 10/08/15 at 9:30 a.m., Resident #38 stated the evening before, 10/07/15, the aide who had told him she wished he ' d be gone came into his room to give the resident a shower. The resident said he told the aide he didn ' t feel comfortable having her give him a shower. The resident said then Licensed Nurse (LN) C came into his room, said the resident was a liar, and asked the resident why he was saying things about the aide. On 10/09/15 at 9:48 a.m., the Social Service Director (SSD) indicated she spoke with Resident #38 about the incident when the nurse called the resident a liar. The SSD said the resident told the SSD he was not a liar and the original offense of the aide saying she ' d be glad when the resident was gone had occurred.

Based on interview and record review the facility failed to ensure 1 of 4 residents (#1 former resident) received assistance to prevent accidents in accordance with the resident's plan of care. Failure to provide care and services according to Resident #1's plan of care resulted in harm when the resident fell during a transfer and sustained a fractured arm. Findings include: All interviews took place on 5/31/11 unless otherwise stated: Resident #1 had multiple medical conditions including knee pain, obesity, history of a stroke, degenerative bone disease and heart disease. On admission to the facility, the resident was able to stand with assistance and take a few steps. The facility assessed the resident during the admission process and found the resident to be at high risk for falls due to her medical conditions. The resident ' s plan of care indicated two staff members were required to transfer the resident. Staff stated gait belts are used for each resident during walking or transferring. On 5/20/11 two Nursing Assistants (NAs) attempted to transfer the resident from her bed to a bedside commode. The facility policy stated to use a gait belt with all transfers or while walking a resident (a gait belt is a thick canvas type belt placed around the resident ' s waist for staff to grasp). Resident #1 was transferred without the use of a gait belt. The resident was held under her arms (no gait belt on the resident for staff to grasp to steady the resident) during the transfer. The resident stood and fell during the transfer and fractured her arm.