Every finding on record at Life Care Center of Skagit Valley

Based on interview and record review, the facility failed to ensure 5 of 5 sampled residents (11, 13, 20, 44, and 59) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to comprehensively assess the risks, benefits and parameters of use and to ensure the least restrictive alternatives were attempted. The facility further failed to ensure consent was obtained prior to administration, and appropriate indication and monitoring of psychotropic medications. This failure placed residents at risk of experiencing unnecessary side effects such as sedation, falls, decline in physical functioning, and adverse medical events including stroke and death and placed residents at risk of experiencing an undignified life. Findings included .As referenced in the Food and Drugs/Drug (FDA) Safety Information, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the cause, there was little chance that they would be effective, and they commonly cause complications such as movement disorders, falls with injury, stroke, and increased risk of death. The FDA Boxed Warning, which accompanied, second-generation anti-psychotics stated, Elderly patients with dementia-related psychosis treated with atypical anti-psychotic drugs are at an increased risk of death. Review of the facility policy titled, Psychotropic Medication Management, reviewed 12/02/2025 showed the facility must ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. With regards to psychotropic medications, the regulations additionally require: -Giving psychotropic medications only when necessary to treat a specific diagnosed and documented condition -Implementing gradual dose reduction (GDR) and other non-pharmacologic interventions for residents who receive psychotropic medications, unless contraindicated; the resident's medical record must show documentation of adequate indications for a medication's use and the diagnosed condition for which a medication is prescribed. -When selecting medications and non-pharmacological approaches, members of the interdisciplinary team (IDT), including the resident, his or her family, and/or representative(s), participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition. -Involvement of the resident, his or her family, and/or the resident representative in the medication management process. (A consent is required for each medication)Selection of medications(s) based on assessing relative benefits and risks to the individual resident. -Evaluation of a resident's physical, behavioral, mental, and psychosocial signs and symptoms, in order to identify the underlying cause(s), including adverse consequences of medications; Selection and use of medications in doses and for duration is appropriate to each resident's clinical conditions, age, and underlying causes of symptoms and based on assessing relative benefit and risks to, and preferences and goals of, the individual resident. -The use of non-pharmacological approaches, unless contraindicated, to minimize the need for medications, permit use of the lowest possible dose, or allow medications to be discontinued; and the monitoring of medications for efficacy and adverse consequences. -An evaluation of the resident by the IDT helps to identify his/her needs, goals, comorbid conditions, and prognosis to determine factors (including medications and new or worsening medical conditions) that are affecting signs, symptoms, and test results. This evaluation process is important when selecting initial medications and/or non-pharmacological approaches and when deciding whether to modify or discontinue a current medication. The evaluation also clarifies: Whether other causes for the symptoms (including expressions or indications of distress that could mimic a psychiatric disorder) have been ruled out. Whether the physical, mental, behavioral, and/or psychosocial signs, symptoms, or related causes are persistent or clinically significant enough (e.g., causing functional decline) to warrant the initiation or continuation of medication therapy. Whether non-pharmacological approaches are implemented, unless clinically contraindicated for the resident or declined by the resident. Whether a particular medication is clinically indicated to manage the symptom or condition. Whether the intended or actual benefit is understood by the resident and, if appropriate, his/her family and/or representative(s) and is sufficient to justify the potential risk(s) or adverse consequences associated with the selected medication, dose, and duration. <RESIDENT 20> Resident 20 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), dementia with agitation (a decline in mental abilities), and diagnosed with major depressive disorder (MDD) on 03/02/2026. Review of Resident 20's care plan, dated 03/25/2026, documented that they use antipsychotic medications related to terminal agitation (end of life agitation). Review of Resident 20's active physician orders documented Quetiapine (a second-generation antipsychotic medication that calms the brain to treat mental health conditions like schizophrenia, bipolar disorder, and severe depression) 25 milligrams (mg) one tablet every eight hours related to MDD active as of 05/11/2026 and one 25mg tablet two times a day related to MDD active as of 05/13/2026. Resident 20 had active orders for Depakote Sprinkles (a medication primarily prescribed to treat seizure disorders, manage the manic phases of bipolar disorder, and prevent migraine headaches) 125 mg three capsules at bedtime related to MDD with an order date of 02/27/2025. Review of discontinued physician order documented Quetiapine first being ordered on 01/30/2025 through 04/05/2026 for terminal agitation. Quetiapine was ordered on 04/05/2026 through 05/11/2026 for terminal agitation. Review of Resident 20's Minimum Data Set (MDS) (a required assessment tool) dated 02/25/2025, 11/28/2025 and 02/26/2026, all documented that the resident did not experience hallucinations or delusions. The MDS's documented no physical or behavioral symptoms were exhibited. Active diagnoses for MDS's dated 02/25/2025 and 11/28/2025 included Alzheimer's and dementia but documented no to anxiety, depression, bipolar disorder, psychotic disorders, and schizophrenia. Active diagnoses for MDS dated [DATE] included Alzheimer's, dementia, and depression but documented no to anxiety, bipolar disorder, psychotic disorders, and schizophrenia. Medications documented yes to taking antipsychotics and no to antidepressants. Review of February 2026 pharmacy recommendations for Resident 20 recommended to update diagnosis for quetiapine and Depakote from dementia with behaviors (not a Centers for Medicaid and Medicare Services (CMS) approved diagnosis) to agitation associated with dementia due to Alzheimer's disease. The pharmacy recommendations were signed by the provider on 03/09/2026 and signed as completed by the facility on 03/16/2026. In an interview on 05/14/2026 at 9:53 AM, Staff R, Certified Nursing Assistant (CNA), stated that Resident 20 does have dementia and can be combative sometimes in the evening but can be easily redirected. In an interview on 05/14/2026 at 1:26 PM, Staff L, Social Services Director (SSD) stated they were in charge of the psychotropic meeting that they have monthly. Staff L stated that pharmacy would let the facility know if they did not have a proper diagnosis for psychotropic medications. In an interview on 05/14/2026 at 2:08 PM, Staff D, Licensed Practical Nurse, Resident Care Manager, (LPN/RCM), stated that Resident 20 had been doing better than when they first admitted and that they did not have a lot of behaviors anymore. In an interview on 05/14/2026, at 3:40 PM, Staff B, Director of Nursing Services (DNS), stated that they were in charge of the pharmacy recommendations for all residents. Staff B stated Resident 20's pharmacy recommendations from February 2026 to change the diagnosis was completed but the diagnosis did not get attached to the medications. <RESIDENT 13> Resident 13 re-admitted [DATE] with diagnoses to include major depressive disorder (MDD) with psychotic symptoms and adjustment disorder with depressed mood. Review of the physician's orders showed Resident 13 received the anti-depressant Bupropion 150 MG once a day since 10/28/2022 and a second-generation antipsychotic Aripiprazole 1 MG once a day beginning 05/09/2025. Review of the psychotropic care plan initiated 02/29/2024 showed Resident 13 used Bupropion and Aripiprazole for management of MDD and directed staff to consult with pharmacy and doctor to consider dosage reduction when clinically appropriate, at least quarterly and discuss with the doctor and family the ongoing need for use of medication. Nursing staff were directed to review behaviors, interventions and alternate therapies attempted and their effectiveness as per facility policy. Review of Resident 13's quarterly MDS, dated [DATE], showed the resident did not experience signs of psychosis, such as hallucinations (perceptual experiences in the absence of real external sensory stimuli) or delusions (misconceptions or beliefs that are firmly held, contrary to reality). The resident was taking an antipsychotic medication, and a GDR had not been attempted since 05/09/2025. The physician did not document that a GDR was contraindicated. Review of a provider note on 04/15/2026 at 10:23 PM directed staff to monitor mood and behavior for any changes or signs of worsening depression and continue mental health follow-up and discuss at GDR rounds. Review of progress notes beginning 05/15/2025 to 05/15/2026 showed no documentation Resident 13 exhibited psychosis (delusions or hallucinations). Review of the clinical record did not contain psychoactive medication evaluations or documentation of GDR meetings. There were no pharmacist recommendations in the past six months. <RESIDENT 44> Resident 44 admitted on [DATE] with diagnoses to include MDD, dementia unspecified severity with behavioral disturbance. The resident was not taking an antipsychotic medication on admission. Review of the current physician orders showed Resident 44 was receiving a second-generation anti-psychotic Seroquel 25 MG twice a day for dementia, unspecified severity, without behavioral disturbance, mood disturbance and anxiety since 03/20/2025. Review of the 08/30/2025 Psychotropic Care Area Assessment showed Resident 44 received an antipsychotic to manage dementia with other behavioral disturbance and to GDR per protocol and interdisciplinary team (IDT) determination. Review of a psychiatry provider note on 01/07/2026 at 9:30 AM, showed Resident 44 had a history of delusions 2 weeks ago, believing people wanted to hurt them. Currently reports resolution of these paranoid thoughts, stating I pushed them out, and has no memory of who the perceived threats were. This improvement suggests possible medication response or natural fluctuation in psychotic symptoms. The provider plan was for nursing to continue all medications as necessary, monitor for return of delusional thinking and follow-up in 2 weeks Review of the Medication Administration Record beginning January 2026 until 05/15/2026 showed there was no monitor in place for delusions. Review of the quarterly MDS dated [DATE] showed Resident 44 experienced delusions and had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) one to three days in the 7-day lookback period. The MDS showed Resident 44 received antipsychotic medication and the last GDR was 01/18/2025 and the physician had not documented a GDR was clinically contraindicated. Review of Resident 44's care plan initiated 12/03/2024 showed the resident received antipsychotic related to dementia with psychotic disturbances. The care plan showed Resident 44 failed a GDR on 03/18/2025. Review of the clinical record did not include adequate monitoring for delusions and without adequate indications for its use and did not contain psychoactive medication evaluations or documentation of GDR meetings. There were no pharmacist recommendations in the past six months. In a joint interview on 05/14/2026 at 2:12 PM, Staff F, LPN/RCM, stated they attend psychotropic meeting if they are available and sometimes the meeting was just the provider and social services. Staff C, Assistant Director of Nursing (ADNS), stated their pharmacist provided education and made sure they had the necessary components for psychotropic medications. Staff C stated they were aware of the need for proper diagnosis for psychotropic orders. Staff C stated Resident 44 failed their GDR and there should be documentation to that. They were asked about the lack of delusion monitoring and stated they would look into their behavior monitoring. In a joint interview on 05/15/2026 at 10:31 AM, Staff B, DNS, Staff N, (Regional Director of Clinical Services/RDCS), and Staff A, Administrator were informed of lack of delusion monitoring for Resident 44 and that lesser alternatives were not attempted prior to antipsychotic use for Resident 13 and 44. Staff A stated there needed to be better documentation for psychotropic use in the resident records. Staff A, B and N were asked for documentation of psychotropic GDR meetings as they were not located in the clinical records. No additional information was provided. <RESIDENT 11> Resident 11 admitted [DATE] with diagnoses which included anxiety and depression. Review of Resident 11's physician's orders on 05/12/2026 documented an order for a second-generation antipsychotic medication with an indication of hallucinations related to major depressive disorder. Review of Resident 11's behavior monitoring for the antipsychotic medication with an initiation date of November 2025, documented the target behaviors as negative statements and self-isolation. There was no monitoring for hallucinations. Review of Resident 11's care plan on 05/12/2026 documented the resident was taking an antipsychotic medication related to depression. In an interview on 05/14/2026 at 12:39 PM, Staff D, LPN/RCM stated residents on antipsychotics should have behavior monitoring and be on alert for documentation if they exhibit behaviors. Staff D stated they do not believe Resident 11 has ever exhibited hallucinations, stating this medication was one that the resident had ordered on admission. Staff D stated we should be reviewing to make sure there were monitors in place for the target behaviors. <RESIDENT 59> Resident 59 admitted to the facility on [DATE] with diagnoses that included dementia, history of mental and behavioral disorder (non-specified), and major depressive disorder. The admission MDS dated [DATE] documented the resident had severe impaired cognition, with no behaviors. Review of Resident 59's physician orders, dated 04/22/2026 documented an active order for quetiapine three times a day for agitation and dementia. Review of the administration record the resident received all doses administered. Review of Resident 59's medication informed consent form dated 05/05/2026 (14 days after the medication was started), documented the resident consented to an antipsychotic medication three times a day for dementia, severe behavioral disturbances and history of mental and behavioral disturbances. The consent was signed by the resident who has severe cognition impairment. Review of Resident 59's behavioral monitor documentation from 04/22/2026 to 05/15/2026, showed there was no behavior monitoring in place until 04/29/2026. The behaviors that were added to monitor every shift (three times a day) were agitation, aggression, and combativeness. There were no behaviors documented until 05/11/2026. Review of Resident 59's care plan, dated 04/23/2026 documented the resident used an antipsychotic medication related to behavior management. There were no individualized goals or interventions related to an appropriate rationale or indication for the use of psychotropic medication. In an interview on 05/14/2026 at 8:44 AM, Staff J, CNA, stated that Resident 59 has been combative with care and have severe cognition impairment. Staff J added they cannot understand basic directions like, go to bathroom, or get out of bed. In an interview on 05/14/2026 at 9:41 AM, Staff K, LPN/Infection Preventionist (was working the medication cart the week of 05/11/2026 – 05/15/2026) stated the admission nurse should review consents and ensure diagnosis were appropriate for all psychotropic medications, then the RCMs would review and verify for accuracy. Staff K stated all licensed staff were responsible for updating care plans as needed, and the RCM's review for accuracy. Staff K stated Resident 59 has had some combative behaviors, and any behaviors demonstrated should be documented in the medical record. Staff K was not aware that Resident 59 had an inappropriate indication for use of an antipsychotic, was not aware they had signed their own consent for that medication. Staff K stated Resident 59 was did not know what was going on and was not aware that the consent was dated 14 days after the medication had been started. In an interview on 05/14/2026 at 10:32 AM, Staff B, DNS stated they located another consent for Resident 59's antipsychotic medication dated 04/22/2026, that was found in the medical records office. Staff B stated they were not sure why the consent had not been included as part of Resident 59's medical record. In an interview on 05/14/2026 at 12:29 PM, Staff E, LPN/RCM stated they were the nurse manager responsible for Resident 59. Staff E stated the admission nurse would initiate a basic care plan, then the RCM would update based on assessments to ensure they were accurate. Staff E stated they reviewed consents and proper diagnosis for medications when a resident was admitted to the facility. Staff E stated they were not aware that the consent for Resident 59's antipsychotic medication was not in the medical record until 14 days after the resident was admitted . Staff E stated they were not aware the diagnosis was not appropriate indication for use of an antipsychotic and would usually try and ensure they were. In an interview on 05/14/2026 at 1:30 PM, Staff L, SSD stated they were responsible for the gradual dose reduction/psychotropic meeting that they had monthly with the pharmacist, medical director, DNS, and nurse managers. Staff L stated the pharmacist would send over a spreadsheet with all the residents in the facility on psychotropic medication. Staff L stated they did not usually review new admits in this meeting and waited a quarter cycle for documentation to be in the medical record. Staff L stated the form provided, the diagnosis, behavior monitors, and the pharmacists reviewed those for accuracy. Staff L was not sure if the pharmacist reviewed the consents. Staff L was not aware that Resident 59's diagnosis was inappropriate, that the target behaviors were for agitation, and that the consent for their antipsychotic was not loaded into the medical record timely. Staff L agreed they should review new admissions sooner rather than waiting a quarter cycle to review. In a follow up interview on 05/14/2026 at 3:14 PM, Staff B, DNS stated they were not aware that the new admissions were not reviewed for accuracy in the psychotropic meeting. Staff B stated that Resident 59 had major depressive disorder, and agreed with the findings that the diagnosis, behavior monitoring and care plan did not support the reason for administering the medication. Staff B stated it was their expectation that the consents were completed prior to administering medications and were included in the medical record timely. Reference WAC 388-97-0620 (1)(a)

Based on observation, interview and record review, the facility failed to provide assistance with bathing and grooming for 6 of 7 residents (Residents 8, 13, 15, 44, 63, and 79) reviewed who were dependent on staff to carry out their ADL's (activities of daily living). Failure to provide the residents assistance with bathing and grooming, placed the residents and others at risk for poor hygiene, unmet care needs and a diminished quality of life. Findings included . <RESIDENT 8> Resident 8 was admitted to the facility on [DATE] with diagnoses to include stroke that affected their ability to speak, write, and understand language, and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting right dominant side. Review of Resident 8's MDS dated [DATE] documented that they needed substantial/maximal assistance with showering. Review of Resident 8's care plan dated 05/12/2026 documented that they preferred a shower twice a week and that they required substantial assistance from one staff to provide a shower. Review of Resident 8's progress notes from 01/01/2026-05/13/2026 did not have documentation of refusals of showers. In a review of Resident 8's May 1st-13th 2026 bathing documentation showed Resident 8 preferred a shower twice a week and was only scheduled for once a week. Resident 8 received a shower on 05/04/2026, 05/11/2026 and had a shower scheduled for 05/18/2026 and 05/25/2026. In a review of Resident 8's April 2026 bathing documentation showed Resident 8 preferred a shower twice a week and was only scheduled for once a week. Resident 8 received a shower on 04/06/2026, 04/11/2026, 04/13/2026, 04/20/2026 and 04/29/2026. Resident 8 had documented as activity did not occur on 04/10/2026 and 04/27/2026. In a review of Resident 8's March 2026 bathing documentation showed Resident 8 preferred a shower twice a week and was only scheduled for once a week. Resident 8 received a shower on 03/02/2026, 03/10/2026, 03/16/2026, 03/24/2026 and 03/30/2026. Resident 8 had blank documentation for bathing on 03/09/2026 and 03/23/2026. In a review of Resident 8's February 2026 bathing documentation showed Resident 8 preferred a shower twice a week and was only scheduled for once a week. Resident 8 received a shower on 02/09/2026 and 02/16/2026. Resident 8 had blank documentation for bathing on 02/02/2026 and 02/23/2026. In a review of Resident 8's January 2026 bathing documentation showed Resident 8 preferred a shower twice a week and was only scheduled for once a week. Resident 8 received a shower on 01/12/2026 and 01/19/2026. Resident 8 had blank documentation for bathing on 01/05/2026 and 01/26/2026. In an interview on 05/13/2026 at 10:04 AM, Collateral Contact 3 stated that Resident 8 used to take a shower everyday at home and would like more showers. When asked if Resident 8 would like showers twice a week they nodded their head yes. <RESIDENT 79> Resident 79 was admitted to the facility on [DATE] with diagnoses to include heart failure, muscle weakness, and limitation of activities due to disability. Review of Resident 79's MDS dated [DATE] documented that they needed substantial/maximal assistance with showering. Review of Resident 79's care plan dated 03/05/2026 documented that they preferred a shower twice a week and required substantial assistance for bathing. Review of Resident 79's progress notes from 01/01/2026-05/13/2026 did not have documentation of refusals to showers. In a review of Resident 79's May 1st-14th 2026 bathing documentation showed Resident 79 preferred a shower twice a week. Resident 79 received a shower on 05/07/2026 and had bathing documented as activity did not occur on 05/05/2026, 05/09/2026 and 05/12/2026. Resident 79 had blank documentation for bathing on 05/12/2026. In a review of Resident 79's April 2026 bathing documentation showed Resident 79 preferred a shower twice a week and was only scheduled for once a week. Resident 79 received a shower on 04/21/2026 and 04/18/2026 and bathing documented as activity did not occur on 04/07/2026, 04/09/2026, and 04/12/2026. Resident 79 had blank documentation for bathing on 04/14/2026 and 04/28/2026. In a review of Resident 79's March 2026 bathing documentation showed Resident 79 preferred a shower twice a week and was only scheduled for once a week. In a review of Resident 79's February 2026 bathing documentation showed Resident 79 preferred a shower twice a week and was only scheduled for once a week. Resident 79 received a shower on 02/10/2026, 02/21/2026 and 02/24/2026 and blank documentation for bathing on 02/03/2026 and 02/17/2026. In a review of Resident 79's January 2026 bathing documentation showed Resident 79 preferred a shower twice a week and was only scheduled for once a week. <RESIDENT 13> Resident 13 readmitted to the facility on [DATE] with diagnoses to include stroke with hemiplegia (paralysis on one side of body) and hemiparesis (weakness on one side of body), muscle contractures (tightening and shortening of muscles), and difficulty walking. Review of the quarterly minimum data set (MDS - a required assessment tool) assessment dated [DATE] showed the resident had no cognitive impairment, required extensive assistance for bathing and did not refuse care. Review of the Kardex (guide to show nurse aides how to care for resident) showed the resident preferred showers two times a week and to provide a sponge bath when a full bath or shower could not be tolerated. In an interview on 05/14/2026 at 9:28 AM, Resident 13 stated they were only getting one shower a week, and they wanted two a week. They stated they were in need of a shave. The resident denied refusing showers and stated, I never refuse, that is not true. Review of Resident 13's February bathing documentation showed they wanted two showers a week and received bathing on 02/11/2026,02/15/2026, 02/18/2026, refused on 02/25/2026 and received bathing on 02/28/2026. Review of Resident 13's March bathing documentation showed they received bathing on 03/04/2026, refused 03/11/2026, received on 03/13/2026, and 03/18/2026. Review of Resident 13's April bathing documentation showed they refused bathing on 04/01/2026, received bathing on 04/04/2026, 04/15/2026, refused 04/22/2026, received on 04/24/2026. Review of Resident 13's May bathing documentation showed they received bathing on 05/01/2026, refused 05/06/2026, received on 05/08/2026, refused on 05/10/2026 and received on 05/13/2026. In a joint interview on 05/14/2026 at 2:18 PM, Staff C, Assistant Director of Nursing (ADON) and Staff F, License Practical Nurse (LPN)/ Resident Care Manager (RCM), Staff C stated Staff B, Director of Nursing audited showers and the facility had a performance improvement plan (PIP) on showers. Staff C stated they were unsure when the PIP was developed. Staff F verified that Resident 13 wanted 2 showers a week and bathing was received on 03/04/2026, 03/13/2026 and 03/18/2026, 04/04/2026, 04/15/2026, 04/24/2026, 05/01/2026, and 05/08/2026. Staff F acknowledged there was no documentation about bed baths. Staff F stated Resident 13 was agreeable to care. <RESIDENT 15> Resident 15 admitted on [DATE] with diagnoses to include hemiplegia and hemiparesis, respiratory disease, difficulty walking and muscle weakness. Review of the quarterly MDS dated [DATE] showed the resident had mild cognitive impairment, required extensive assistance for bathing and refused care one to three days in the 7-day lookback period. In an interview on 05/11/2026 at 11:08 AM, Resident 15 stated their bath was never done yesterday and they missed three showers. They stated they were supposed to have lotions on their feet and back every week, but they don't get it. They stated they were supposed to be turned on their side and that happened only when they changed their brief twice a day. The resident stated they went weeks in a row without a shower, and they should have had one on Friday but didn't. They stated the staff say they are just busy. In an interview and observation on 05/12/2026 at 8:50 AM, Resident 15 was in bed. Their hair was greasy and body odor was present. They stated they did not get a shower yesterday. In an interview and observation on 05/13/2026 at 9:36 AM, Resident 15 was in bed. Their hair was greasy and body odor was present. They stated they had not had a bath yet. They stated they wanted a bed bath once a week, but it did not always happen. Review of the Kardex showed the resident preferred showers once a week and to provide a sponge bath when a full bath or shower could not be tolerated. Review of Resident 15's February bathing documentation showed they wanted one shower a week and received bathing on 02/10/2026, refused 02/18/2026, received bathing on 02/21/2026, refused on 02/25/2026 and received 02/28/2026. Review of Resident 15's March bathing documentation showed they refused bathing on 03/01/2026 and 03/04/2026, received bathing on 03/07/2026, 03/11/2026, and 03/20/2026. Review of Resident 15's April bathing documentation showed they refused bathing on 04/01/20206, received bathing on 04/04/2026, 04/15/2026, refused 04/22/2026, received on 04/24/2026. Review of Resident 15's May bathing documentation showed they received bathing on 05/02/2026, refused 05/06/2026 and 05/10/2026, received on 05/13/2026. In an interview on 05/13/2026 at 2:15 PM, Staff C, stated Resident 15 refused showers. Reviewed the 30-day bathing record with Staff C. Staff C stated they had encouraged the resident to shower related to their skin condition, but they liked to stay in bed. <RESIDENT 44> Resident 44 admitted on [DATE] with diagnoses to include dementia, muscle weakness and difficulty walking. Review of the quarterly MDS dated [DATE] showed the resident had severe cognitive impairment, required extensive assistance for bathing and did not refuse care. Review of the Kardex showed the resident preferred showers two times a week and to provide a sponge bath when a full bath or shower could not be tolerated. Review of Resident 44's February bathing documentation showed they wanted two showers a week and refused bathing on 02/08/2026, received bathing on 02/13/2026, refused bathing on 02/18/2026, received bathing on 02/21/2026, refused 02/22/2026, received bathing on 02/25/2026 and 02/28/2026. Review of Resident 44's March bathing documentation showed they refused bathing on 03/04/2026, received on 03/07/2026, refused on 03/08/2026, and 03/11/2026, received bathing on 03/15/2026, refused 03/18/2026, received on 03/21/2026, 03/25/2026, and 03/28/2026. Review of Resident 44's April bathing documentation showed they refused bathing on 04/01/20206, received bathing on 04/04/2026, refused on 04/12/2026, received 04/19/2026, refused 04/24/2026, received on 04/26/2026. Review of Resident 44's May bathing documentation showed they received bathing on 05/01/2026, refused 05/06/2026 and received on 05/10/2026, and 05/11/2026. <RESIDENT 63> Resident 63 admitted on [DATE] with diagnoses to include upper spinal degeneration, bilateral artificial knee joints, muscle weakness and limitation of activities due to disability. Review of Resident 63's quarterly MDS dated [DATE] showed the resident had no cognitive impairment, required extensive assistance for bathing and did not refuse care. In an interview on 05/11/2026 at 10:12 AM, Resident 63 stated the facility was short staffed and their aide last night told them they only had half of the staff they needed that shift. The resident stated they did not know when their shower was and showers were offered when they wanted to go to activities. They stated they get a shower once a week but sometimes went for two weeks without a shower. They stated the shower aide left at 2 PM or noon sometimes so when they are ready for a shower, they are gone. Review of the Kardex showed the resident preferred showers once a week and to provide a sponge bath when a full bath or shower could not be tolerated. Review of Resident 63's February bathing documentation showed Resident 63 wanted one shower a week and received bathing on 02/11/2026 and 02/18/2026. Review of Resident 63's March bathing documentation showed they received bathing on 03/07/2026, 03/15/2026 and 03/18/2026. Review of Resident 63's April bathing documentation showed they received bathing on 04/04/2026, 04/18/2026, and 04/26/2026. Review of Resident 63's May bathing documentation showed they received bathing on 05/10/2026 as of 05/15/2026. In an interview on 05/12/2026 at 3:20 PM, Staff A, Administrator stated they knew showers were an issue and they had a performance improvement plan (PIP) on it. Review of the facility's document titled, performance improvement action plan (PIAP) for showers initiated on 10/24/2025, reviewed 11/04/2025 and action plan completed 02/12/2026. The PIAP included opportunity for improvement related to bathing with an action plan to complete audit of all resident preferences and with evaluation on 03/02/2026. The PIAP included care plans were not accurate, poor communication related to shower aides, lack of consistent oversight, with plan to designate a shower champion and hold staff accountable to tasks, poor documentation requiring an audit of documentation daily, and shower meetings not occurring with plan for Administrator to hold staff accountable for attendance. In an interview on 5/13/2026 at 2:09 PM, Staff B, DNS stated they oversaw showers and looked at them every day. Staff B stated the staff documented in the medical record for all bathing charting and if there was no shower documented then a shower did not occur. Staff B stated their expectation was when bathing was refused, staff were to offer again the next day. They stated the nurse should put a note in if they refused. They said if the resident missed a shower it was added to the next day and Fridays, Saturdays, Sundays were for makeup showers. In an interview on 05/15/2026 at 10:02 AM, Staff Q, Registered Nurse stated the expectation was if a resident refused a shower, the aide needed to attempt two more times and inform the nurse. Staff Q stated they would then check with the resident to see why they refused. Staff Q stated the aide should work around the resident's activity times. They stated they would try to talk them into a bed bath, if they adamantly refuse to be showered. They stated if they still refused, nurses were to document the refusal in the progress notes. They stated most residents were set up twice a week for showers. Staff Q stated there were a lot of residents who told them they did not get their showers. Staff Q stated shower aides were pulled to the floor a lot. In a joint interview on 5/15/2026 at 10:31 AM, with Staff B, DNS, Staff N, Regional Director of Clinical Services, Staff A, Administrator. Staff A stated their shower PIP continued as they were not able to have substantial compliance so then continued to 03/08/2026. Staff A stated shower aides were pulled to work the floor related to call ins and they could not staff with agency at the last minute. In an interview on 05/15/2026 at 10:46 AM, Staff V, CNA/Shower Aide, stated that they do day shift showers about three or four times a week and can do an average of nine showers a day. Staff V stated if a resident refuses a shower, they do try to reapproach and it was documented on the shower sheet, in the electronic medical record (EMR) and the nurse documented in a progress note. Staff V stated that if a scheduled shower was blank on the EMR it could mean that either someone did not document or it did not happen but do offer showers as needed. Reference: (WAC) 388-97-1060 (2) (c)

Based on observation, interview and record review the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for 1 of 1 resident (Resident 17) reviewed for edema and 2 of 5 residents (Resident 44 and 59) reviewed for unnecessary medications. The facility failed to implement physician orders for edema management and daily weights and failed to implement the facility bowel protocol. These failures placed the residents at risk for decline and diminished quality of life. Findings included .Review of the facility policy titled, Bowel Protocol, reviewed 09/15/2025, documented the facility would provide effective interventions for signs and symptoms of constipation that were consistent with standards of practice. the facility would implement standing orders to address lack of bowel movement. Review of the facility policy titled, Therapeutic Compression Application, print date 05/14/2026 documented compression bandages were used to manage lower extremity edema and venous insufficiency (poor blood circulation back to heart) .educate resident on purpose and use of wraps. document application of use. <EDEMA> Resident 17 was admitted to the facility on [DATE] with diagnoses that included edema (swelling caused by excess fluid trapped in the body's tissue), and Prader-Willi syndrome (rare genetic disorder caused by the loss of function of specific genes that can cause poor muscle tone). The admission Minimum Data Set (MDS – an assessment tool) dated 04/20/2026 documented the resident had impaired cognition and was dependent on staff for dressing their lower body, mobility, and transfers. Review of Resident 17's physician orders, dated 04/28/2026 documented an order for ace wraps to be applied to both lower extremities daily in the morning and removed at night. Review of Resident 17's care plan dated 04/16/2026 documented the resident had an actual skin impairment to their skin which included lower extremity edema. The care plan did not have any individualized goals or interventions that addressed the edema to their lower extremities. In observations on 05/11/2026 at 9:19 AM, 1:18 PM, and 2:00 PM – 3:30 PM, Resident 17 was observed in their electric wheelchair. The resident's both lower extremities had severe edema; they were wearing non-skid socks that were observed to be tight and stretched to capacity. The top of the sock was observed to be slightly indented on the resident's lower legs. At 1:18 PM ace wraps were observed in pile on a chair in the residents' room. In an observation on 05/12/2026 at 8:08 AM, Resident 17 was lying in bed, had non-skid socks on and ace wraps were observed in a chair. In observations on 05/12/2026 at 10:04 AM and 12:23 PM, Resident 17 was observed in their electric wheelchair headed to the main dining room. Resident 17 had non-skid socks to bilateral lower extremities, socks appeared tight on their feet. At 12:23 PM, Resident 17 was observed in an alcove working on a puzzle in their wheelchair, wearing socks, legs observed to have severe edema, skin above the socks were discolored and red. In observations on 05/13/2026 at 8:20 AM Resident 17 was lying in bed, had non-skid socks on and ace wraps were observed in chair. In observations on 05/13/2026 at 10:14 AM and 12:45 PM, Resident 17 was up in their electric wheelchair, wearing non-skid socks tightly on their feet. In a review of Resident 17's electronic medication/treatment administration record (MAR/TAR) 05/11/2026 – 05/13/2026 for the physician order to wear ace wraps daily in at the morning, the 11th and 13th were blank, and the 12th the license nurse documented that the resident had ace wraps on. In an interview on 05/14/2026 at 9:41 AM, Staff K, License Practical Nurse (LPN)/Infection Preventionist (IP) the assigned floor nurse for Resident 17 on day shift (6:00 AM – 2:00 PM) was asked if Resident 17 wore ace wraps to their lower extremities. Staff K reviewed the electronic physician orders and stated that yes they are to go on in the morning. Staff K was asked why they had not been applied to Resident 17's lower extremities on 05/11/2026, 05/12/2026 and 05/13/2026, Staff K did not have a reason. Staff K stated they were not aware they had documented they applied the ace wraps on 05/12/2026 in the medical record. In an interview on 05/14/2026 at 12:29 PM, Staff E, LPN/Resident Care Manager (RCM) stated they were familiar with Resident 17. Staff E stated they were not aware of any refusal of care since Resident 17 admitted . Staff E stated Resident 17 has severe edema to their lower extremities and was to wear ace wraps daily. Staff E stated they were not aware they had been observed for three days without their wraps on. Staff E stated it was the expectation that the licensed nurse was documenting physician orders correctly. In an interview on 05/14/2026 at 3:13 PM, Staff B, Director of Nursing Services (DNS) stated Resident 17 had edema to their lower extremities and that it was their expectation that the licensed staff were following physician orders, and if they refused, they needed to notify the provider. Staff B was not aware that Resident 17 had gone without ace wraps to lower extremities for three days, and that documentation was not completed accurately in the medical record. <UNNECESSARY MEDICATION REVIEW> <RESIDENT 59> Resident 59 admitted to the facility on [DATE] with diagnoses that included dementia, and cognitive communication deficit. The admission MDS dated [DATE] documented the resident had severe impaired cognition, was prescribed medication for pain management, and was frequently incontinent of bowel movements. Review of Resident 59's physician orders documented the following: - oxycodone, an opioid (strong pain medication that caused constipation) one to two tabs every four hours as needed for pain dated 04/22/2026, - milk of magnesia, given by mouth as needed if the resident does not have bowel movement for three days, - bisacodyl (stool softener), give rectally as needed for constipation if no results from the milk of magnesia, - fleet enema, give rectally as needed for constipation if no results from the stool softener. Review of Resident 59's bowel monitoring from 04/22/2026 – 05/14/2026 showed that the resident had no bowel movement 04/29/2026 until 2:00 PM on 05/04/2026 (5 1/2 days). Review of Resident 59's electronic medication/treatment record 04/29/2026 – 05/04/2026 showed there was no bowel medication administered to the resident for their constipation. Review of Resident 59's medical record 04/29/2026 – 05/04/2026 showed there was no documentation the resident was assessed for constipation, no notification the resident had refused treatment of constipation, or that the provider was notified that the resident had experienced constipation. In an interview on 05/14/2026 at 8:44 AM, Staff J, Certified Nursing Assistant (CNA) stated the facility had a bowel management program. Staff J stated the nurse would inform the CNAs in the morning who was on the list and were to let them know if the resident did not have a bowel movement so they could administer medication. Staff J stated Resident 59 had severe cognitive impairment and did not understand basic care directives. In an interview on 05/14/2026 at 9:41 AM, Staff K, stated they were notified on the electronic medical record system if a resident had not had a bowel movement documented in three days. The nurse would then administer milk of magnesia, if nothing happened the next day they would get a stool softener suppository, and then on day 5, if no bowel movement they would get an enema. Staff K stated the nurse should also document a bowel assessment, listen to the abdomen for bowel tones, and if they have continued constipation often notify the provider. Staff K was not aware Resident 59 had gone 5 1/2 days with no treatment for their constipation. In an interview on 05/14/2026 at 12:29 PM, Staff E, LPN/RCM stated the facility had a bowel management protocol, three days no bowel movement they get a treatment, day 4 a suppository, and by day 5 an enema. Staff E stated they got an alert in the electronic medical record and those were discussed in the morning clinical meeting. Staff E was unaware that Resident 59 had their constipation untreated for 5 1/2 days and stated there should have been an assessment of the resident, medication provided and follow up as needed. In an interview on 05/14/2026 at 10:32 AM, Staff B, DNS stated it was their expectation that all staff were following the bowel protocol and that Resident 59 should have had an assessment of their abdomen, medication provided as ordered and follow up as needed. <RESIDENT 44> Resident 44 admitted on [DATE] with aortic valve stenosis (narrowing or blockage of the heart valve), hypertension and edema. Review of Resident 44's quarterly MDS assessment dated [DATE] showed the resident did not reject care. Review of Resident 44's admission orders directed staff to obtain a daily weight for increasing edema beginning 10/16/2024. Review of the March MAR/TAR showed weights were documented on 03/01/2026, 03/03/2026, 03/05/2026, 03/08/2026, 03/10/2026, 03/11/2026, 03/12/2026, 03/16/2026, 03/19/2026 to 03/25/2026 and 03/28/2026 to 03/30/2026. Review of a provider note on 03/23/2026 at 10:48 PM, Resident 44 had a high critical and urgent blood pressure reading and directed staff to monitor weights, blood pressure, heart rate, and symptoms of fluid overload or heart failure. Review of the April MAR/TAR showed weights were documented on 04/01/2026, 04/04/2026, 04/05/2026, 04/07/2026, 04/08/2026, 04/10/2026 to 04/15/2026, 04/17/2026-04/22/2026, 04/25/2026, 04/28/20 to 04/30/2026. Review of the May MAR/TAR showed weights were documented on 05/01/2026 to 05/04/2026, 05/06/2026 to 05/08/2026, 05/11/2026 and 05/13/2026. Review of the progress notes 03/01/2026 to 05/14/2026 did not show documentation about the refusals or provider notification or refusals. In an interview on 05/14/2026 at 2:18 PM, Staff F, LPN/RCM stated they were unaware of weight issues. Staff F stated they did not audit MARS/TARS for any omissions, refusals or concerns. In an interview on 5/15/2026 at 10:31 AM, Staff B, DNS stated they did periodic MAR/TAR audits. Reference WAC 388-97-1060(1)(2)(b)(3)(b)(k)

Based on observation, interview, and record review, the facility failed to provide the necessary care and services related to restorative nursing programs (RNPs) for 3 of 4 residents (Residents 15, 63 and 79) reviewed for positioning, mobility, and range of motion. This failed practice placed residents at risk for decline in function, contractures (shortening and hardening of muscles, tendons leading to deformity and rigidity of joints), pain and increased dependency on caregivers. Findings included .According to the Resident Assessment Instrument Manual (provides guidance for completion of the Minimum Data Set - MDS) the following criteria must be met for RNPs: - The program must have measurable objective goals and interventions must be documented in the care plan and in the medical record. - There needs to be evidence of periodic evaluation by the licensed nurse that must be present in the resident's medical record. - Nursing Assistants (NAs) must be trained in the techniques that promote resident involvement in the activity; and - A Registered Nurse (RN) or a Licensed Practical Nurse (LPN) must supervise the activities in an RNP. Review of the facility policy titled, Restorative Nursing, reviewed 09/18/2025, documented the facility would develop restorative nursing programs and residents would be provided the appropriate treatment and services to maintain or improve their ability to carry out activities of daily living (ADL's). <RESIDENT 15> Resident 15 was re-admitted to the facility on [DATE], with diagnoses to include repeated falls, hemiplegia and hemiparesis (weakness and paralysis on one side of the body), degenerative joint disease, arthritis, difficulty walking, muscle weakness and limitation of activities due to disability. Review of the physical therapy (PT) evaluation and plan of treatment on 09/12/2024 showed Resident 15 lived alone and their prior level of function was independent with all ADL's prior to admission. The focus of the treatment was restoration, compensation and adaptation. The assessment showed Resident 15 had functional limitations due to a hip contracture and PT would address the contracture impairment by further assessing and ordering or fabricating an orthotic device. Review of the occupational therapy (OT) Discharge summary dated [DATE] showed the resident continued to require significant assistance with self-care tasks. Review of the quarterly minimum data set assessment (MDS-a required assessment tool) on 03/20/2026 showed the resident had limited range of motion in both lower extremities and they did not receive a restorative nursing program. In an interview and observation on 05/11/2026 at 11:08 AM, Resident 15 stated they had limited range of motion in their ankles while demonstrating they could not dorsiflex (bending the ankle so the foot moves closer to shin). They stated they did not get exercises, or range of motion (ROM) and were not on an RNP. In an interview on 05/13/2026 at 9:36 AM, Resident 15 was in bed and stated the Hoyer lift hurt their joints, and they could really only move their ankles. In a follow up interview and observation on 05/13/2026 at 3:17 PM, Resident 15 stated they had arthritis and a history of falls. The resident again demonstrated their limited range in their bilateral ankles and inability to dorsiflex. Review of the clinical record on 05/13/2026 showed the resident did not have contracture management, or an orthotic device and was not on an RNP. In an interview on 5/13/2026 at 1:50 PM, Staff C, Assistant Director of Nursing Services (ADNS) stated Resident 15 did not have an RNP but that did not mean they did not need one. Staff C stated they would get a referral back to therapy for them. Staff C stated they currently had 15 restorative programs ordered. They stated there were issues when restorative staff were off for six weeks. Staff C stated they needed to review the policy. The RNP binder was requested but not provided. <RESIDENT 63> Resident 63 admitted on [DATE] with diagnoses to include upper spinal degeneration, bilateral artificial knee joints, muscle weakness and limitation of activities due to disability. Review of the OT Discharge summary dated [DATE] showed Resident 63's prognosis to maintain their current level of function was excellent with consistent staff support and showed an RNP was established. In an interview on 05/11/2026 at 10:12 AM, Resident 63 was up in their wheelchair and stated they only got restorative once or twice a week because that was all the time Staff U, Restorative Aide (RA) had for them. The resident stated Staff U was the only restorative aide and they were busy helping the aides on the floor. The resident stated they tried to work their exercise bands at night to avoid a decline and to get their legs stronger. Review of Resident 63's clinical record showed there were two restorative programs ordered; ROM (Range of Motion) Program #1 Provide resident with passive range of motion (PROM) to lower extremities (LE), 3 to 6 days/week. Staff were to document repetitions and minutes engaged in the activity. ROM Program #2 Encourage resident to participate in group exercise program 3-5 days a week for at least 15 minutes. Document total time in participation. Review of the February restorative documentation showed Resident 63 received Program # 1 four times and received Program # 2 seven times. Review of the March restorative documentation showed Resident 63 received Program # 1 six times and Program # 2 five times. Review of the April restorative documentation showed Resident 63 received Program # 1 and # 2 twice. Review of the May restorative documentation showed Resident 63 received Program # 1 six times and Program # 2 three times. Review of Resident 63's clinical record from 05/14/2025 to 05/14/2026 showed there was no evidence of any periodic evaluation of the RNP by the licensed nurse. In an interview on 05/13/2026 at 10:17 AM, Staff N, Regional Director of Clinical Services (RDCS), stated Staff C, ADON, oversaw restorative and stated they knew the facility was working on the restorative process. In an interview on 05/15/2026 at 10:02 AM, Staff Q, Registered Nurse stated the facility had been down to one restorative aide and Staff T, RA was pulled today from their RA duties to work the floor. Staff Q stated restorative was often pulled to the floor. <RESIDENT 79> Resident 79 was admitted to the facility initially on 10/24/2024 with the most recent admission of 03/19/2026 and with diagnoses to include muscle weakness, difficulty in walking, both knees joint replacement and limitation of activities due to disability. Review of Resident 79's MDS dated [DATE] documented impairment on both sides of lower extremities. Review of Resident 79's progress notes from 01/01/2026 - 05/15/2026 documented no refusals for restorative program. Review of Resident 79's restorative nursing documentation for January 2026 - May 2026 did not have restorative tasks for charting. Review of Resident 79's care plan dated 03/05/2026 documented functional goal care plan interventions as restorative active range of motion (AROM) program #2 daily and to document the time and repetitions completed with a start date of 04/28/2025. Restorative AROM program #3 upper extremity AROM daily and to document the time and repetitions completed with a start date of 04/28/2025. Both interventions were system cancelled on 03/16/2026. In a review of the restorative documentation, Resident 79 had documentation to include restorative program #2 and #3 completed twice in March and once in April. The resident was documented as out of facility five times. No further documentation was provided. In a review of the facility's daily schedule from 05/01/2026-05/15/2026 documented the RA's were pulled from their restorative duties to work the floor five times. On 05/02/2026 and 05/05/2026 no RA was scheduled. In an interview on 05/13/2026 at 2:43 PM, Staff C, stated they are in charge of the restorative program until the new Staff Development Coordinator had been trained and can take it over. Staff C stated that one of their two RA's were on leave, so they have been short on RA's during that time and the other RA was pulled from restorative duties due to other staff calling off. Staff C stated restorative duties cannot be picked up by other aides due to needing the restorative aide training. Staff C stated that restorative programs will be documented in the resident's care plan and then should go onto the aides tasks for them to document in the electronic medical record. Staff C stated they asked for a PIP (Performance Improvement Project) to be initiated for this to improve this process as they were frustrated there were so many pieces in place to get a functioning RNP. Staff C stated the program needed help and they needed more restorative aides to make the program successful. In an interview on 05/14/2026 at 10:41, AM Staff B, Director of Nursing Services (DNS) stated that Resident 79's restorative care plan was cancelled by the system and that they had not seen that issue before. Staff B stated they believed this may have happened due to the resident going out to the hospital in March 2026 and then readmitting to the facility. In an interview on 05/15/2026 at 9:39 AM, with Staff T, RA, stated they are both pulled from their restorative aide duties to work on the floor as a certified nursing assistant (CNA) and other times were scheduled to work the floor instead of doing restorative. In an interview on 05/15/2026 at 11:00 AM, Staff U, RA stated they were on leave and came back a week ago and did have days they were pulled from their restorative duties. In a joint interview on 05/15/2026 at 10:31 AM, with Staff B, Staff N, and Staff A, Administrator were informed of restorative concerns with Resident's 15, 63 and 79. Staff B stated they would see if Resident 15 would be agreeable to a restorative program. Staff A stated restorative and shower aides were pulled related to call ins, but they cannot get agency staff scheduled at the last minute. Reference WAC 388-97-1060 (3)(d)

Based on interview and record review the facility failed to act, respond, and resolve the organized resident group's concerns for 1 of 1 Resident Council groups. The facility's failure to provide assistance, respond to written requests from the group meetings, and maintain accurate meetings minutes, resulted in reported concerns going unidentified and uninvestigated, and placed residents at risk for unidentified, unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy, Grievance Program, dated 09/26/2025, documented the facility was responsible for ensuring that all grievances have been reviewed and addressed in a timely and appropriate manner and the residents feel that some type of resolution has been communicated, achieved, and maintained. The policy also documented maintaining a recordkeeping system of all complaints. <RESIDENT COUNCIL MEETING MINUTES> Review of the resident council minutes from April 2026 documented grievances for meal trays arriving late, shower frequency, and that chicken and pork were hard to cut. Meeting minutes documented that residents were reminded to complete blue card grievance forms when they were experiencing issues. Review of the resident council minutes from February 2026 documented grievances for shower frequency, meat was tough to cut, meal trays late, not getting condiments with meals and food requests not being followed. Meeting minutes have documented that residents were reminded to complete blue card grievance forms when they were experiencing issues. Review of the resident council minutes from January 2026 documented grievances for not receiving condiments during meals and wanting more fresh fruit options. Meeting minutes have documented that residents were reminded to complete blue card grievance forms when they were experiencing issues. Review of the facility's grievance log from January 2026 through April 2026 had no entries associated with the above resident council concerns, nor were any grievance forms completed as per the facility's grievance policy. In an interview on 05/12/2026 at 11:15 AM with Resident Council group stated that the shower concerns have not improved and the food concerns with late meal trays, tough meats, and not getting condiments had also not improved. In an interview on 05/12/2026 at 2:48 PM, Staff W, Activity Director stated that they did not do grievances for resident council as a whole. Staff W stated they did grievance cards for individuals sometimes, and other times the resident said they would do it themselves. Staff W stated they brought the resident council concerns to the following months Quality Assurance and Performance Improvement (QAPI) meeting. In an interview on 05/12/2026 at 3:40 PM, Staff A, Administrator stated they had educated the Activity Director on the grievance process for Resident Council. In an interview on 05/15/2026 at 10:30 AM, Staff A stated resident council grievances had been started with the most recent month and will go back as needed and an updated grievance log was not provided. Reference WAC 388-97-0920 (5)

Based on interview and record review the facility failed to ensure 2 of 5 residents (Residents 13 and 63) were free from significant medication errors. The residents' medication orders were not followed per physicians' orders. Failure to properly hold and/or administer medications placed the residents at risk for complications including increased low blood pressure, low pulse, adverse health events and a potential decline in their condition. Findings included . Review of the facility's policy titled, Administration of Medications, revised 05/06/2020, showed medications were to be administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. <RESIDENT 13> Resident 13 re-admitted on [DATE] with diagnoses to include heart disease and high blood pressure. Review of the current physician's orders documented the resident was to receive Amlodipine 5 milligrams (mg) and Lisinopril 10 mg once a day for high blood pressure beginning 08/16/2024. There were hold parameters for the Lisinopril if the systolic blood pressure (SBP, top number) was less than 110 and/or the heart rate was less than 60. Another order was in place for Hydralazine 25 mg once a day for high blood pressure beginning 08/20/2025. The order directed nurses to hold the medication for SBP less than 140 or pulse less than 60. Review of the Medication Administration Records (MARS) beginning 03/01/2026 showed Amlodipine and Lisinopril doses were not held as the physician ordered on: -03/16/2026 Pulse 57, -03/23/2026 Pulse 52. Lisinopril was administered on 04/23/2026 when the SBP was below 110. Hydralazine was held on 03/02/2026 when the blood pressure (BP) was 142/60 and pulse 60. Hydralazine was administered 03/06/2026 when the blood SBP was below 140. Review of the April and March 2026 MARs showed there was no location to document vital signs (VS) prior to the evening doses of Hydralazine. Hydralazine was administered 10 evening shifts in April and two evening shifts in May. In addition, Resident 13 received Tylenol 650 MG on 03/14/2026 and 03/27/2026 when the resident had already received 3,000 mg of Tylenol with a parameter not to exceed order of 3,000 mg per day. <RESIDENT 44> Resident 44 was admitted to the facility on [DATE] with multiple cardiac diagnoses including high blood pressure. Review of the current physician's orders showed the resident was to receive Losartan Potassium twice a day for high blood pressure beginning 01/02/2026. The medication was to be held for SBP less than 100 or pulse less than 50. Review of the MARS beginning 03/01/2026 showed Losartan Potassium doses were not held as the physician ordered on: -03/18/2026 Pulse 49, -03/22/2026 Pulse 48, -04/12/2026 Pulse 49, -04/22/2026 Pulse 49, -04/29/2026 Pulse 45, -05/10/2026 Pulse 49, -05/11/2026 Pulse 45. In a joint interview on 05/14/2026 at 2:18 PM, Staff C, Assistant Director of Nursing and Staff F, Licensed Practical Nurse (LPN/RCM, stated they were unaware of any parameter issues. Staff F stated they did not audit MAR's. In an interview on 05/15/2026 at 10:02 AM, Staff Q, Registered Nurse stated if the residents blood pressure or pulse was low, they would hold the medication per doctors' orders. They stated they would then review their vital sign history and notify the doctor if there was a pattern. In an interview on 05/15/2026 at 10:31 AM, Staff B, Director of Nursing Services, stated they did periodic MAR audits and reviewed blood pressures in clinical meeting. Staff B stated they needed to re-educate the nurses on parameters. They stated they had completed an audit recently after they became aware there were issues with medication parameters. Reference WAC 388-97-1060 (3)(k)(iii)

Based on interview and record reviewed, the facility failed to ensure notification to the Office of the State Long-Term Care Ombudsman (LTCO - resident advocates) occurred for 2 of 4 sampled residents (Residents 9 and 12) reviewed for hospitalization. The failure to notify the LTCO and ensure written notification was provided to the resident/resident representative, in a language and manner they understood, placed residents at risk for lack of advocacy, to have the opportunity to make informed decisions about their transfer/discharge rights and possible unidentified or unmet care needs. Findings included .<RESIDENT 9> Resident 9 initially admitted to the facility on [DATE]. Resident 9 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident 9's progress notes documented on 04/18/2026 at 3:01 PM, by Staff S, Licensed Practical Nurse (LPN), Resident 9 was transferred emergently to the hospital. Review of Resident 9's electronic medical record (EMR) had no documentation of a notice of transfer and discharge (NOTD) form or Ombudsman notification related to the hospital discharge. <RESIDENT 12> Resident 12 initially admitted to the facility on [DATE]. Resident 12 was transferred to the hospital on [DATE] and had not returned to the facility. Review of Resident 12's progress notes documented on 05/07/2026 at 5:16 PM, by Staff S, LPN, Resident 12 was emergently transferred to the hospital. Review of Resident 12's EMR had no documentation of an NOTD form or Ombudsman notification related to the hospital discharge. In an interview on 05/14/2026 at 9:38 AM, Staff S, LPN stated when a resident was transferred to the hospital they are expected to do a bed hold form. Staff S was unaware of what an NOTD form was and assumed the Resident Care Manager (RCM) would know and be the one to do it. In an interview on 05/14/2026 at 2:05 PM, Staff Y, Social Services Assistant stated they did the NOTD for planned discharges and notified the Ombudsman via email and that was scanned into the resident's EMR. Staff Y stated they believed the RCMs would do the NOTD for emergency discharges such as to the hospital. In an interview on 05/14/2026 at 2:10 PM, Staff B, Director of Nursing Services, stated they were unaware they had to complete the NOTD and Ombudsman notification for residents transferred to the hospital. In an interview on 05/14/2026 at 2:17 PM, Staff D, LPN/RCM, Staff F, LPN/RCM, and Staff C, Assistant Director Of Nursing (ADON) were asked about the process of residents being transferred to the hospital regarding the NOTD and Ombudsman notification and Staff D and Staff F were unaware of the process. Staff C stated they would be doing education with the nurses about the process and would try to find Resident 9's and Resident 12's NOTD documentation for their hospital transfers. Reference WAC 388-97-0120(2)(a-d)(5)(b)(i), -0140

Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident (Resident 1) reviewed for activities received an ongoing program of activities to meet the individual resident's physical and mental needs. Based on the reasonable person concept, not having adequate recreation and/or sensory stimulation placed the resident at risk for social isolation, lack of stimulation and diminished quality of life. Findings included .Resident 1 was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS)(an assessment tool) dated 04/02/2026, Activity preferences that were documented as very important to Resident 1 included: books, newspapers, magazine, music, news, doing things with groups of people and going outside. The MDS assessed the resident with severely impaired cognition.Record review of Resident 1's activities care plan on 05/13/2026 documented none of Resident 1's preferred activities were included. During observations on 05/11/2026, 05/12/2026, 05/13/2026 and 05/14/2026, Resident 1 was observed in their room with no TV, no music available, no books, magazines, no forms of stimulation observed to be provided in the room. In an interview on 05/14/2026 at 10:58 AM, Collateral Contact 2 (CC2) stated that Resident 1 had a TV, but it was never turned on for them when they visited. CC2 stated they visited about once a week. CC2 also stated Resident 1 liked music. In an interview on 05/14/2026 at 9:51 AM, Staff W, Activity Director, stated they conducted the activities interview for the MDS and tried to communicate with family to gather information for residents who were not interviewable and the care plans were based on those responses. Staff W stated that for residents who were not able to attend groups they provided one to one visits. Staff W stated they also had radios and other items available. Staff W stated they would visit Resident 1 in their room and would talk with them. Resident 1 was bedbound. Staff W stated they had not provided any music or other activity items to Resident 1. Staff W did not know why none of Resident 1's stated preferred activities had been implemented. Reference WAC 388-97-0940(1)(2)

Based on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 2 of 3 residents (Residents 57 and 92) reviewed for transmission-based precautions (TBP), 1 of 2 staff (Staff O, Certified Nursing Assistant - CNA) reviewed for environmental disinfection of equipment. The facility failed to ensure the staff were wearing appropriate personal protective equipment (PPE) in accordance with recommended national standards and failed to ensure staff were compliant with appropriately disinfecting reusable resident equipment. These failures placed all residents and staff at risk of potential infection. Findings included .Review of Center for Disease and Control (CDC) guidance titled, Viral Respiratory Pathogens Toolkit for Nursing Homes, revised 03/30/2026, documented to apply appropriate TBP based on suspected cause of the infection and the use of Droplet precautions (facemask/respirator, gowns, gloves, and eye protection). Review of the facility policy titled, Enhanced Barrier Precautions, revised 08/19/2025 documented the facility should use enhanced barrier precautions (EBP) as an additional strategy for residents that meet certain criteria during high contact resident care activities.residents with indwelling devices such as urinary catheters, and feeding tubes. high contact resident care activities required the use of gown and gloves while transferring, dressing, providing hygiene, and changing linens. Review of the facility policy titled, Cleaning and disinfection of non-critical patient care equipment, revised 07/15/2025 documented non-critical reusable equipment will be cleaned daily and before and after every use. Review of the facility policy titled, Transmission Based Precautions and Isolation Procedures, revised 12/23/2025 documented the facility must utilize TBP when a resident arrived at a nursing home with a confirmed infection.The facility should refer to the CDC for guidance on isolation precautions.use of droplet precautions applied when respiratory droplets contain pathogens such as respiratory viruses. In a continuous observation on 05/12/2026 at 11:57 AM, resident room [ROOM NUMBER] was observed to have a Contact Isolation Precautions (which requires all that enter to wear gown and gloves) sign outside the door, there was a cart with PPE supplies next to the door entry. The door to the room was open, there were two staff members observed in the room with gowns and gloves on, they were assisting a resident into the bed. Around 12:30 PM, there was a sign on the door that stated it was the room of Resident 57, according to the electronic medical records the resident was sent to the hospital on [DATE] and had now readmitted to the facility with a diagnosis of Respiratory Syncytial Virus (RSV - required droplet precautions). Observations continued until 2:00 PM of room [ROOM NUMBER], the residents call request light was observed to go on several times, with multiple staff responding. All the staff that entered the room were observed to wear gowns and gloves, at no time was the staff observed wearing face masks or face shields. In a continuous observation and interview at 05/12/2026 at 1:10 PM, Staff P, Certified Nursing Assistant (CNA) and Staff O, CNA, were observed to enter room [ROOM NUMBER], for Resident 92. Outside the door of room [ROOM NUMBER] was a sign for EBP isolation precautions. Staff P and Staff O were observed to enter the room without any PPE, with the mechanical lift machine, they were overheard telling Resident 92 they were going to transfer them back into the bed from the wheelchair. At 1:16 PM, Staff O exited the room and pushed the mechanical lift down to another room and entered the room and shut the door. Staff P exited the room and was asked what the protocol was for EBP. Staff P stated that Resident 92 was on EBP as they had a catheter and a feeding tube. Staff P stated if they would have provided peri care (cleaning of the genitals, groin, and anal area) then they would have worn a gown and gloves. Staff P was then asked to review the EBP sign that stated all staff were to wear a gown and gloves for high-risk care activities that included transferring. Staff P stated they agreed with what the guidance stated and stated they would go ask and come back. At 1:18 PM, Staff P returned and stated, I was apparently wrong, and yes we should have been wearing gowns and gloves. At 1:28 pm, Staff O exited the room with the mechanical lift and parked it in the hallway. Staff O was asked what education they had received at the facility regarding disinfection of reusable equipment. Staff O stated they were told they were to disinfect the mechanical lift if someone had an infectious disease, other than that they do not have to disinfect after each use. In an observation on 05/13/2026 at 10:47 AM, room [ROOM NUMBER] for Resident 57 was observed to now have a Droplet Isolation Precautions sign outside the door. In an interview on 05/13/2026 at 12:30 PM, Staff K, Licensed Practical Nurse (LPN)/Infection Preventionist (IP) was asked why the isolation had changed for Resident 57. Staff K stated they were busy working the floor as a cart nurse yesterday and had not had time to review the precautions for Resident 57 until sometime after 3:00 PM. Staff K stated Resident 57 had RSV and that required droplet precautions not contact. In an interview on 05/14/2026 at 2:37 PM, Staff K stated they were the full-time IP for the facility. Staff K stated they had to work on the floor as a cart nurse on day shift (6:00 AM - 2:00 PM) the week of 05/11/2026 - 05/15/2026. Staff K was asked who supported them when they were sick or pulled to work on the floor, they stated the Director of Nursing Services (DNS) was also certified and would assist. Staff K stated that the expectation for all staff was to follow any isolation signs that are placed outside of the room. Staff K stated they were informed that staff had not been following the EBP guidance and would follow up on that. Staff K stated that regarding Resident 57's isolation, they had mistakenly thought it was contact precautions, but later double checked once they were not working the floor and corrected the problem. Staff K stated they were aware several staff had been in the room for several hours working closely with Resident 57 without the proper PPE (mask and face shield) and stated they made a mistake. Staff K stated the facility expectation was staff were disinfecting the reusable equipment such as mechanical lifts after every use regardless of an infection or not. In an interview on 05/14/2026 at 3:14 PM, Staff B, DNS, stated the expectation was staff were following the correct isolation guidance that was recommended by the CDC, and equipment was disinfected after every use. Reference WAC 388-97-1320(1)(a)(2)(b)(5)(c)

Based on observation, interview and record review, the facility failed to maintain residents' rights to privacy and choices for 2 of 3 residents (Residents 1 and 2) reviewed for dignity. Failure to ensure Resident 1 was provided privacy during cares and to determine preferences for Resident 2, placed the residents at risk for diminished dignity and decreased quality of life. Findings included.<RESIDENT 1>Review of Resident 1's medical record on 05/11/2026 documented severe cognitive impairment, on hospice services with anticipated decline in condition. In observations on 05/11/2026, 05/12/2026 and 05/13/2026, Resident 1's room had space for three beds, with two beds in the room. Resident 1's bed was closest to the door, and Resident 1's roommate was closest to the window. There was no bed in the center space. It was observed that the window bed and the middle space had privacy curtains hung on tracks that could extend around the end of the bed. Resident 1 did not have a privacy curtain for their bed. There were metal chains hanging from a track in the ceiling where a curtain should be attached. In an observation and interview on 05/13/2026 at 10:33 AM, Staff G, Certified Nursing Assistant (CNA) knocked on Resident 1's closed door and opened it. From the hallway, Staff H, CNA was observed inside the room next to Resident 1's bed providing care to Resident 1, who was observed lying on their bed with the side of their unclothed body observable from the hall. Staff G stated they provided privacy by always making sure the door was closed and stated they pulled the privacy curtain between the beds. Staff H then looked up at the ceiling where the privacy curtain would be, shook their head, and stated they would tell housekeeping a privacy curtain was missing. Applying the reasonable person's concept, a reasonable person would not feel treated with dignity or respect if their privacy was not ensured during personal care and they were able to be observed by passersby in the hallway.In an observation and interview on 05/13/2026 at 1:37 PM, Resident 1's privacy curtain remained missing. Staff I, Housekeeping, was observed with their cart outside Resident 1's room. Staff I stated they replaced privacy curtains when they deep cleaned, if they were visibly soiled, or when residents discharged . Staff I stated they had not been made aware of Resident 1's privacy curtain being missing and had not noticed it was missing when cleaning the resident's room. In an interview on 05/14/2026 at 12:32 PM, Staff E, Licensed Practical Nurse, Resident Care Manager, stated the managers did Angel Rounds and part of those rounds included looking for maintenance issues. Staff E stated the missing curtain should have been caught and the CNAs should be pulling privacy curtains around the bed when providing care. <RESIDENT 2>Record review on 05/12/2026 documented Resident 2 had severe cognitive impairment and was totally dependent on staff for activities of daily living such as transferring in and out of bed, and mobility.In an observation on 05/11/2026 at 11:22 AM, window installers were working on replacement of Resident 2's window. A large plastic sheet was removed to expose the window opening to the outside. Resident 2 was observed in their bed which was located next to the window. There were two men speaking loudly, laughing and playing music while working on the window. One man was observed stepping into the resident's room through the window opening several times as the workers prepped for the new window. The outdoor temperature was 55 degrees Fahrenheit, and a moderate wind was blowing into the room. Resident 2 was in bed with a light sheet and blanket and had their eyes closed. The bed and the window were less than three feet apart. There was an (undated) paper noted lying on the resident's bedside table that read: you are receiving this notice because your room windows will be replaced within the next 2 weeks.you have the option to remain in your room while the window replacement crew works, or to pass the time in another area of the building. Please report concerns to a staff member as soon as possible.In a continued observation, at 12:00 PM, Resident 2's window remained open with wind coming in. Resident 2 remained in bed. A resident in a nearby room was overheard to state it's cold in here. Staff M, Registered Nurse, brought Resident 2 an extra blanket only after having it brought to their attention to consider that the resident might be cold. There were frequent loud banging sounds from the workers using nail guns right next to the resident's bed.In an interview on 05/12/2026 at 2:48 PM, Collateral Contact 1(CC1), Power of Attorney (POA), for Resident 2, stated they had not been notified that the windows were going to be replaced, and stated Resident 2 would not have been able to read or comprehend that paper notification. CC1 stated Resident 2 had recently moved to this room, and they were not notified until after the move had already occurred. CC1 stated Resident 2 had been sleeping a lot but could be easily irritated by noise and commotion. Applying the reasonable person concept, since the resident was not able to advocate for themselves, one would have expected the facility to have notified the resident's POA to determine if the resident would have preferred to have been moved from the area while window replacement occurred. Reference WAC 388-97-0180 (1)-(4)

Based on interview and record review the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a federally required screening of all individuals who has both an Intellectual Disability (ID) or Related Condition (RC) and a serious mental illness (SMI) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) form was completed prior to admission and according to the guidelines specified for 1 of 5 sampled residents (Resident 1) reviewed for PASRR. Failure to obtain the PASRR and PASRR determination letter prior to admission placed the resident at risk for inappropriate placement and/or lack of access to specialized services for residents with identified mental health diagnoses or disability. Findings included.Review of a facility policy titled Pre-admission Screening and Resident Review (PASARR) documented the facility will ensure that potential admissions are to be screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASARR Level I and is completed prior to admission to a nursing facility. A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, know as PASARR Level II, which must be conducted prior to admission to a nursing facility.Ensure Level I PASARR screening has been completed on potential admissions prior to admissionA positive Level I screen necessitates and in-depth evaluation of the individual by the state-designated authority know as PASARR Level II, which must be conducted prior to admission to a nursing facility.When a Level II PASARR screening is warranted it must be obtained as well as determination letter prior to admission.<RESIDENT 1>Resident 1 admitted to the facility on [DATE] with diagnoses including depression and Prader-Willi syndrome (a rare genetic condition that leads to physical, mental and behavior problems). Review of Resident 1's record showed a Level 1 PASRR dated 04/14/2026 and showed mood disorder was checked as a mental illness indicator category. Section B showed the resident had received services from the Developmental Disability Administration (DDA) and had impairments in adaptive functioning that was a condition expected to continue indefinitely. Section B, questions 6-9 were answered yes. Instructions showed if the answers to B 6-9 were all marked yes, the form should be forwarded to the regional DDA Intellectual Disability (ID)/Related Condition (RC) PASRR Team, follow up by DDA is required before this individual can be admitted to a nursing facility. Review of Resident 1's record showed a Level I PASRR was uploaded into the resident's medical record on 04/16/2026. Review of Resident 1's record showed a DDA PASRR Level 2 Determination dated 4/16/2026. Review of a progress note dated 04/16/2026 at 8:43 AM showed the resident had admitted to the facility without a PASRR, the facility requested the PASRR from the hospital with no response. The social services director (SSD) emailed the DDA PASRR coordinators to request assistance with obtaining the PASRR.In an interview and record review on 05/01/2026 at 12:18 PM, Staff C, Social Services Director, stated the facility is supposed to have the PASRR prior to a resident admitting to the facility and the admissions director is responsible obtaining the PASRR prior to admission. Staff C stated Resident 1 admitted to the facility on [DATE] without a PASRR. Staff C stated they notified Staff A, Administrator, who instructed them to contact the DDA PASRR coordinator to assist in obtaining the PASRR. Staff C reviewed the resident's record and stated there was a PASRR dated 04/14/2026 but it was not uploaded into the resident's record until 04/16/2026 and a DDA PASRR Determination dated 4/16/2026. In an interview on 05/01/2026 at 12:37 PM, Staff A, stated admissions is responsible for making sure the PASRR is received prior to a resident's admission. Staff A stated they admitted Resident 1 and were unable to find the PASRR, so they asked Staff C to contact the DDA PASRR coordinator. Staff A stated the DDA PASRR coordinator told them residents should not be admitted if the PASRR is not received prior to admission.

Based on observations, interviews, and record reviews, the facility failed to implement measures to prevent development of an avoidable pressure ulcer (PU) and provide ordered treatment for the PU for 1 of 3 residents (Resident 1) reviewed for PU's. Resident 1 experienced harm when they developed an avoidable unstageable PU (a full-thickness skin and tissue loss where the actual depth of the wound is hidden by slough (yellow, tan, gray, green, or brown necrotic tissue) or eschar (tan, brown, or black, hard, necrotic tissue) which caused pain and discomfort. this failure placed residents at risk for skin breakdown, unmet care needs and diminished quality of life. Findings included .The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, showed a PU/Pressure Injury (PU/PI) definition and stages as:-A PU is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear (a combination of downward pressure and friction).-Medical device related PU/PIs were a result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.- Moisture Associated Skin Damage (MASD) was superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration.Review of the facility policy titled, Pressure Injury Prevention and Unavoidable Pressure Ulcer/Injury, revised 06/12/2025 documented nursing staff would be provided with procedures to manage skin integrity and prevent PU. Procedures included residents were provided at a minimum pressure redistribution mattress, wheelchair cushion and repositioning.Review of the facility policy titled, Skin Integrity & Pressure Ulcer/Injury Prevention, revised 07/09/2024 documented nursing staff would be provided with procedures to manage skin integrity, prevent pressure ulcer/injury, and provide treatment and care of skin and wounds utilizing professional standards. Measures to maintain and improve the resident's tissue tolerance to pressure were implemented in the plan of care. All residents were at risk for PU/PI development upon admission, were to be provided, at the minimum, a pressure redistribution mattress, repositioning at least every two to four hours, and education to resident and significant others of the preventative skin care plan.Resident 1 admitted to the facility on [DATE] with diagnoses to include history of falling, muscle weakness, osteoarthritis (breakdown of cartilage in the joints), and scoliosis (curvature of the spine).Review of Resident 1's discharge summary from the hospital dated 09/03/2025 documented they had impaired mobility, had recent falls with no notation of skin issues.Review of Resident 1's facility admission nursing assessment dated [DATE] documented they had blanchable redness (red area of skin that turns paler when pressed-an early warning sign of potential PI) to their buttocks.Review of Resident 1's admission Minimum Data Set (MDS-an assessment tool) dated 10/13/2025 documented the resident was at risk for development of a PU. The MDS noted no refusals of care or behavioral issues. The Care Area Assessment (CAA-a tool to develop individualized care plan for a resident) dated 10/15/2025 documented the resident had pressure injury development risk factors due to their limited ability to participate in incontinence care as well as physical dependence on staff for position changes and offloading of bony prominences. The documented goal for Resident 1 was to minimize risk factors through assisted mobility, incontinence care and routine skin monitoring to detect early signs of pressure injury formation. Resident 1's was documented to need a special mattress or seat cushion to reduce or relieve pressure.Review of Resident 1's Braden Scale Assessment (assessment tool for predicating PU risk) documented on 10/7/2025 a score of 17, 10/19/2025 a score of 17, 10/27/2025 a score of 17, 11/03/2025 a score of 17, 12/03/2025 a score of 15, and 01/04/2026a score of 15 (scores of 15-18 indicated mild risk of developing a PU, the lower the score the higher the risk).Review of Resident 1's care plan dated 10/07/2025 documented that they were at risk for break in skin integrity with the goal for them to maintain intact skin with no skin breaks. Interventions included clean and dry skin after each incontinent episode and weekly skin checks. There were no other documented individualized interventions related to their redness to their buttocks at admission or risk for the development of a PU/PI.Review of Resident 1's facility progress notes dated 10/07/2025 through 01/08/2026 contained no documentation regarding education to the resident or their representative regarding repositioning, refusals of repositioning, their mattress, their wheelchair cushion or what measures were in place to prevent PU/PI.Review of Resident 1's facility nursing weekly skin integrity data collection dated 01/08/2026 documented the night nurse noted a small opening to the top of their gluteal fold.Review of the provider note dated 01/08/2026 documented Resident 1 had an open area to the top of their gluteal fold which was painful. Resident 1's skin was examined and the open area was described as a very small and deep open area to the top of the gluteal fold, surrounding skin red, blanchable, with no signs of infection, no drainage, no odor.Review of Resident 1's wound care assessment provided by an outside wound healing company, dated 01/13/2026, documented that they had a PU/PI to their bilateral sacrum (tailbone) measuring 1.5 centimeter(cm) by 0.4 cm, unstageable. Recommendations included treatment with wound cleaner, skin prep, and use of Santyl (a prescription topical debriding agent used to remove dead tissue from chronic PU/PI), and covered with bordered form three times a week and as needed. Plan included support surfaces with pressure reducing mattress and wheelchair cushion.Review of Resident 1's medical record from 01/13/2026 through 02/19/2026 showed no physician's orders for a pressure reducing mattress or wheelchair cushion.On 02/20/2026 at 12:33 PM observed Resident 1's PU with Staff C, Licensed Practical Nurse, present. Staff C stated Resident 1 was not admitted with the PU. Resident 1 was initially lying down then positioned on their right side by Staff C, they were observed wearing an incontinent brief. The mattress was observed to be a standard mattress approximately three inches in height. Resident 1 was observed to have a 2.5 cm by 2.5 cm irregular bordered purple/yellow bruise on their left thigh. Resident 1's PU on their sacrum was observed with a dressing that was wrinkled and clumped up rather than smooth and stationary dated 02/12/2026 which contained moderate red/green/ brown drainage. Resident 1's PU was linear 1.0 cm by 1.5 cm with 0.3 cm depth, the wound bed light pink, 1 cm slough (dead tissue) visible at top of wound, no odor appreciated, and no signs of infection. Staff C stated the dressing was dated 02/12/2026.Review of Resident 1's Treatment Administration Record (TAR) for February 1-19, 2026, documented a physician's order dated 01/13/2026, to apply Santyl to sacrum topically every evening shift every three days for wound care. Wound Care orders documented to cleanse Resident 1's sacrum with normal saline, pat dry, apply skin prep to periwound (skin area surrounding a wound), apply Santyl and cover with foam dressing every evening shift for wound care. The TAR showed Staff D, Registered Nurse (RN), documented they had completed wound care/dressing change for Resident 1 on 02/15/2026 and 02/18/2026.In an interview on 02/20/2026 at 2:29 PM Staff D, RN stated they thought they had completed the dressing changes on 02/15/2026 and 02/18/2026 but could not remember. When asked why the dressing was dated 02/12/2026 during wound care on 02/20/2026, Staff D stated they were new to the facility, could not find dressing supplies at the time of the ordered wound care (02/15/2026 and 02/18/2026) and applied Santyl to Resident 1's PU. Staff D provided no explanation as to why the dressing to the Resident 1's PU was dated 02/12/2026.In an interview on 02/20/2026 at 12:38 PM Staff B, Assistant Director of Nurses (ADON) stated Resident 1 admitted to the facility with their own bed and mattress. Staff B stated they did not know what kind of mattress was brought into the facility by Resident 1's family, the mattress was inspected by maintenance and Staff B did not know if nursing had evaluated the mattress. When asked what preventative measures were taken to prevent Resident 1 from development of a PU, Staff B stated the staff used standards of care to include offloading (removing pressure from bony parts of the body). Staff B stated Resident 1's care plan interventions included a wheelchair cushion, weekly skin checks, clean and dry skin after incontinent episodes, positioning them correctly with respect to the wheelchair cushion, encouraged repositioning and nutrition. When asked about the wheelchair cushion Resident 1 used prior to the development of their PU, Staff B stated they would need to locate the information and provide it later. Staff B stated Resident 1's PU was unavoidable, was not an injury of unknown source, and their age and comorbidities (presence of two or more diseases or medical conditions) resulted in the development of their PU. Staff B stated Resident 1 was very active within the facility, prior to the development of the PU and used their wheelchair throughout the facility to attend multiple activities and was educated about the importance of offloading. No information was provided with respect the Resident 1's wheelchair cushion prior to the development of their PU.In an interview on 02/20/2026 at 2:50 PM Staff E, Nursing Assistant Certified, stated they were familiar with Resident 1 and their care. Staff E stated they watched Resident 1 closely, helped them to the toilet and provided pericare. Staff E stated they had no knowledge of any PU for Resident 1, but if there were concerns about their skin, they would report it to the nurse. When asked about repositioning Resident 1, Staff E stated they do not reposition them when they are sleeping, but when they were awake, they helped them and kept them clean.In an interview on 02/23/2026 at 9:02 AM Collateral Contact 2 (CC2), Resident 1's family member stated they became aware of the PU on Resident 1's sacrum when they were using the bathroom. CC 2 stated Resident 1 was being assisted in the bathroom by facility staff when they heard Resident 1 complaining of pain to their sacrum. CC 1 stated they asked the facility staff why Resident 1 was in pain and they stated it was due to the PU on their sacrum.In an interview on 02/23/2026 at 11:45 AM Staff F, RN, stated Resident 1 had a pressure ulcer and there were treatment orders in place. When asked what interventions were put into place for Resident 1 related to their pressure ulcer, Staff F stated there were orders for wound care and dressing changes and the nurses and nursing aids would monitor them to ensure they were not positioned on the PU. Staff F stated they did not have any charting system to document when they monitored Resident 1's positioning.In an interview on 02/23/2026 at 11:55 AM Staff G, NAC stated Resident 1 had a wound on their sacrum and they complained of pain from it. Staff G stated they assisted Resident 1 in repositioning with pillows when in bed. Staff G stated Resident 1 had no refusals to reposition when working with them and if they had they would notify the nurse. Staff G stated there was no specific charting/documentation for repositioning for Resident 1. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview, and record review the facility failed to ensure broken window locking devices were repaired and window screens were available and repaired timely for 2 of 3 rooms (rooms [ROOM NUMBERS]) reviewed for safe, functional and comfortable environment for residents, staff and the public. These failures placed residents and the public at risk of potentially avoidable accidents, lack of dignity and diminished quality of life.Findings included . In an interview on 02/19/2026 at 12:50 PM Collateral Contact 1, (CC1) Resident 1's family member stated there was a concern about the window in Resident 1's room, room [ROOM NUMBER]. CC 1 stated Resident 1 moved into the room on 10/30/2025 and the window locking mechanism on the left window panel was broken and there was no window screen. CC1 stated there was nothing in place to secure the window and posed a safety risk as anyone from inside or outside could push the window to the side to enter or exit Resident 1's room. CC1 stated instead of fixing the window by replacement of a new locking mechanism, the facility placed a screw in the window frame so the window could not be opened all the way, however the window could be tilted in the frame to bypass the screw, which allowed access to enter or exit Resident 1's room and posed the same safety concern. CC1 stated the most recent solution was a placement of a wooden dowel (wooden rod) placed between the sliding windows to prevent any access from outside the building. CC1 stated they had spoken to Staff A, Administrator, several times and had received communication that the window had been fixed.In an observation on 02/23/2026 at 10:48 AM observed the windows in rooms 106, 107 and 108 with the permission of the residents residing in each room. Observed room [ROOM NUMBER] to have a screw in the left side window frame, no window screens, no locking mechanism for the left side, and a dowel placed between the two windows. Observed room [ROOM NUMBER] to have window screens and functional locking mechanisms in both the right and left windows. Observed room [ROOM NUMBER]'s window to have a locking mechanism on the left side of the window, which was intact and functional, however the right side of the window had a locking mechanism which was missing the knob that was used to lift the lock up (open) and down (close). The window on the right was in a locked position. The windows had screens in each of the windows, the left window screen with a hole in the bottom left corner.In an electronic communication with Staff A on 02/23/2026 at 11:15 AM documented there were no maintenance requests documented for room [ROOM NUMBER] related to the window and communication was made in person to the maintenance director.Review of an electronic communication received 02/23/2026, documented and email between CC 1 and Staff A dated 11/07/2025 at 6:17 PM documented Resident 1's room, left window has a lock and is secured.In an interview on 02/23/2026 at 12:38 PM Staff H, Maintenance Director, stated they had worked at the facility since June of 2025. When asked about information they could provide about room [ROOM NUMBER] and the locking mechanism missing from the window. Staff H stated they had heard about the window locking mechanism missing a few weeks ago and placed a screw in the frame where the locking mechanism would lock into. When asked if the window could be tilted to bypass the screw and from the inside or outside, the stated essentially yes. Staff H stated there is now a wooden dowel set between the windows. Staff H stated there was no documentation or maintenance requests only conversations with nursing staff and Staff A.Reference: WAC 388-97-3220 (1)

Based on interview and record review, the facility failed to provide medically related social services and to advocate for 1 of 2 cognitively impaired residents (Resident 1) reviewed for advanced directives. The facility failed to advocate, educate, and obtain appropriate legal assistance in the development of an advanced directive and placed residents at risk of not having their rights and wishes honored. Findings included. Review of a facility policy titled, Advanced Directives and Advanced Care Planning (ACP) last reviewed 09/26/2025 documented each time a resident was admitted to the facility, quarterly, and when a change in condition was noted in the resident's condition, the facility reviewed the advance directive and advance care planning information. The review focused on if the existing advanced directives and ACP matched the current goals of care for the resident. The social services director or designee documented conversations in the medical record and assisted as needed with updating the documents that need revision in accordance with state and federal requirements. Review of the facility job description titled, Social Services Assistant revised 05/11/2026 documented in the position summary, that the Social Services Assistant provided assistance to the Social Services department to ensure all medically related emotional and social needs of patients are met in accordance with all applicable laws, regulations, and Life Care standards and must be able to assist social worker(s) in supporting patients and families through education, financial planning assistance, liaison with community agencies, etc.Resident 1 admitted to the facility on [DATE] with diagnoses to include developmental/intellectual disability, anxiety, depression, and obstructive and reflux uropathy (urinary blockage causing urine backup). Review of Resident 1's Brief Interview for Mental Status (BIMS-cognitive screening tool) documented on 05/07/2025 and 03/26/2025 a score of 2 out 15 indicating severe cognitive impairment , on 11/04/2025 and 07/02/2025 a score of 3 out of 15 indicating severe cognitive impairment, and on11/28/2025 a score of 15 out of 15 indicating no cognitive impairment. Review of Resident 1's Physician Order for Life Sustaining Treatment (POLST) dated 03/24/2025 documented the resident (Indicated by signature) wanted Cardiopulmonary Resuscitation (CPR) done as a life sustaining measure; no other medical interventions were marked. Review of Resident 1's progress notes from 03/24/2025 through 11/28/2025 documented the following:- On 10/03/2025 at 10:31 PM the nurse notified the provider that resident had appeared to be less interactive and decreased appetite and noted resident was a full code (all life sustaining measure to be taken) and refused some of their medications.- On 10/05/2025 at 3:51 PM the nurse obtained new orders for Resident 1 from the provider and notified the Power of Attorney (POA).- On 10/05/2025 4:03 PM Resident1 was noted to refuse their oral and intravenous (IV) medications and pulled out their IV access but allowed blood glucose check.-On 10/06/2025 at 8:30 AM Resident 1 was seen by the psychiatric provider with noted refusals to eat or drink and non-communicative behavior. Resident 1 was noted to be hospitalized and presented with severely altered mental status and declining physical health. The provider noted nursing staff reported that their mental functioning was now comparable to that of a 3-4-year-old child, had become increasingly withdrawn, and often maintaining a statue-like posture with limited eye contact. Additionally noted that Resident 1's presentation represented a decline from their condition a month ago when they were still able to communicate to some degree and they were now largely non-verbal and unresponsive to attempts at interaction.- On 10/06/2025 at 5:56 PM Resident 1 was noted to return from the hospital and to be apathetic towards others and self, and unwillingness to interact with most providers or support staff. Resident 1's emergency contact was notified and information provided about their recent changes and concerns noting the contact was with Collateral Contact 3 (CC 3 -Resident 1's family member) who voiced concern and planned to visit tomorrow evening and speak with resident. -On 10/06/2025[SW3] a provider note documented that Resident 1 had worsening medical status starting 10/2/2025, they had been refusing care, oral medications and interactions with a noted change in her mental status, presented as staring in space on our interaction which was unusual to them as at their baseline as they had been able to communicate basic needs.-On 10/07/2025 at 8:33 PM CC 3 was noted to be in the facility visiting Resident 1 and reported to nursing they were trying to become Resident 1's POA and responsible party. CC 3 reported that they would bring a Notary Public for Resident 1 to sign papers to grant them POA. Resident 1 was noted to be confused about who CC 3 was and could not recall their name only stated that were their very good friend. -On 10/14/2025 at 10:34 AM Staff C, Social Services Assistant called CC 3 and asked if they were able to attend Resident 1's procedure scheduled for 10/20. CC 3 stated they would meet Resident 1 at the office. Staff C provided location and time.- On 10/20/2025 7:22 PM A written order was received from the physician for the Social Worker to evaluate Resident 1 for POA paperwork for their friend. -On 10/21/2025 at 9:43 AM Staff C, Social Services, documented they left a voicemail to CC 3 asking if they were interested in receiving information on obtaining POA.-On 10/28/2025 at 4:04 PM noted care conference with Resident 1's POA, Resident 1 documented as present.-On 11/21/2025 at 11:39 AM documented POA called and asked for Resident 1's POLST to be changed from Full Code (use of all life sustaining measures) to Do Not resuscitate (DNR) with comfort care. There were no care conference notes that included a discussion with Resident 1 regarding their advanced directives, wishes, or their rights. There were no documented conversations with CC 3 by social services regarding Resident 1's status, advanced directives, rights, or wishes, information of other family members, outside of one voicemail and request to attend an appointment. Review of Resident 1's care plan dated 04/04/2025 documented that they had a communication problem and impaired cognitive ability related to their developmental delay with a goal of maintaining current level of communication function by using appropriate gestures and responding to yes/no questions appropriately through the review date. Interventions included allowing adequate time for Resident 1 to respond, repeat information as necessary, not to rush, ask for clarification from the resident to ensure understanding, face when speaking, make eye contact, turn off TV/radio to reduce environmental noise, ask yes/no questions if appropriate, use of simple, brief, consistent words/cues, and use alternative communication tools as needed. In an interview on 12/11/2025 at 12:11 PM CC 1, Community Support Service, stated they had known Resident 1 prior to their admission to the facility and had provided life coaching services prior to and during their stay at the facility. CC 1 stated Resident 1 had passed away on 12/05/2025. CC 1 stated Resident 1's cognition fluctuated and had difficulty determinizing what was real and not at baseline and they had altered perceptions and when they became ill was confused, not making any sense. CC 1stated when Resident 1 obtained a POA it was suddenly. In an interview on 12/15/2025 at 3:00 PM CC 2, Transition Case Manager, stated they had been working with Resident 1 to transition to an Adult Family Home while at the facility. CC 2 stated Resident 1 had been refusing care and surgery and there was nothing medical that could be done for them. CC 2 stated in an assessment completed in March 2025 documented Resident 1 as making poor decisions and they were unaware of consequences of decisions. CC 2 stated Resident 1 did not have a guardian however required the help of informal supports to make decisions. CC 2 stated they participated in a care conference, that was held in Resident 1's room, October 28, 2025, to discuss the goal to move to the community. CC 2 stated Resident 1 seemed interested in moving to an Adult Family Home, they talked about what it was like at the Adult Family Home. CC 2 described Resident 1 as silent during the care conference. CC2 stated Resident 1 would not give consent for a surgery, so that is why they got a POA to make that decision. In an interview on 12/18/2025 at 11:48 AM CC 3, they stated they visited Resident 1 every other week while they resided in the facility. CC 3 stated they attempted numerous times to contact Staff C by phone to coordinate getting POA documents signed and their advanced directives but did not receive any return calls. CC 3 stated the only conversation, by phone, they had with Staff C was to accompany Resident 1 to an appointment. CC 3 stated they came to the facility in the evening to obtain assistance with getting POA signed and provide Resident 1's advanced directives and were told by the nursing staff they could not assist and would not take the paperwork being provided. CC 3 stated they were not invited to care conferences for Resident 1 and therefore did not attend any. When asked about Resident 1's other family members, CC 3 stated Resident 1 had a brother who resided out of state. When asked about Resident 1's advanced directives, CC 3 stated when Resident 1 was in the hospital in January 2025 they went through their preferences and wrote down their wishes and everything. CC 3 stated Resident 1 wanted their life to be prolonged if feasible and not to withdraw water and other life sustaining measures. In an interview on 12/23/2025 at 1:35 PM Staff B, Registered Nurse/Unit Manager, stated they were familiar with Resident 1. Staff B stated Resident 1 had complicated medical conditions related to their urinary tract. Staff B stated they were their own decision maker POA and their mentality was one of a five-year-old. Staff B stated Resident 1 would say no to a lot of things and had a pattern of rejecting medications, food, water and not interact or speak when they started showing symptoms of a urinary tract infection. Staff B stated they were saying Resident 1 needed a POA because they could not make decisions for themselves. Staff B stated the physician reached out to a friend of Resident 1 and they became POA, placed them on hospice and moved to an Adult Family Home. In an interview on 12/23/2025 at 2:10 PM Staff C stated they had spoken to Staff B, Administrator, a few times about Resident 1's cognition when they were admitted to the facility. Staff C stated it was difficult to obtain a baseline for Resident 1's cognition due to them being in/out of the facility for hospitalizations. Staff C stated Resident 1 cognition fluctuated with changes in their medical condition. Staff C stated Resident 1 had an obvious developmental disability and they often played possum (pretended they were asleep) and would not talk for days. Staff C stated Resident 1 had a POA in the past, CC 3, who decided they would not be willing to act as POA, when Resident 1 was in the hospital prior to their admission in March 2025. Staff C stated CC 3 remained Resident 1's emergency contact. CC 3 stated they were only able to connect with CC 3 once and reached out to them quite a few times. Staff C stated it was passed along to them through physician direction to start the POA process for Resident 1's friend as Resident 1's family had not completed POA paperwork. When asked about discussion with Resident 1 about the physician's request to have their friend be their POA, Staff C stated there was some conversation in passing, had not documented any conversations, and only witnessed a conversation between Resident 1 and their friend about being the POA. Staff C stated Resident 1 POLST was full code at admission. Staff C stated there was some discussion about potential guardianship for Resident 1 but did not know if the process had started. Reference WAC 388-97-0960

Based on observation, interview and record review, the facility failed to ensure clinical records were accurate for 2 of 3 residents (Residents 4 and 9) reviewed for wounds. The failure to ensure the residents' clinical records were accurate placed them at risk for unmet care needs, and for having records that did not reflect the actual care provided. Findings included . Review of the facility's Area of Focus: Basic Skin Management policy, revised on 11/21/2024, showed the resident would have:-A head-to-toe skin inspections upon admission/readmission, completed weekly and as needed by the nursing documented on the NRSG: Weekly Skin document in Point Click Care (PCC).-If a new [NAME] alteration/wound was identified, the nurse performed and documented an assessment/observation of the resident's skin.-Wound assessments/observations were required at a minimum of weekly and when there was a change. This was documented utilizing the PCC assessment NRSG WOT.<RESIDENT 4> Resident 4 was admitted to the facility on [DATE] with diagnoses to include perineal (area between the genitals and the anus) and sacral (area between the bottom of the spine and tailbone) wounds. Review of the admission Minimum Data Set (MDS – an assessment tool), dated 04/16/2025, showed the resident had: one stage I (intact skin with a localized area of non-blanchable redness) PU, three stage II (a partial thickness skin loss with the top inner layers of the skin exposed) PU's, one stage III (a PU with full thickness tissue loss. Subcutaneous, which means under the skin, fat may be visible, but bone, tendon or muscle are not exposed. Slough, which means dead tissue, may be present but does not obscure the depth of tissue loss PU), five Deep Tissue Pressure Injury (DTPI or DTI - intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue), and Moisture Associated Skin Damage (MASD - superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration) Review of the Quarterly MDS assessment, dated 08/05/2025, Resident 4 had a current stage III PU. Review of late entry progress noted, dated 05/28/2025 for 04/11/2025 (48 days late), showed Resident 4 had: - A 0.7 centimeter (cm) by 0.4 cm by 0.3 cm left buttock stage II PU. - A 3.6 cm by 1.5 cm by 0.2 cm left buttock stage II PU. - A 2 cm by 2 cm left buttock DTI. - A 2 cm by 0.5 cm excoriated, red, purple non-blanchable area on their left buttock. - A 7 cm by 5 cm with a “0.3 cm by 0.3 cm open, dark purple skin in center on-blanchable DTI on their coccyx and a 7 cm by 4 cm DTI on their coccyx - A 2.4 cm by 2.2 cm right ankle DTI. - A 6.3 cm by 5.8 cm by 0.3 cm right buttock stage II. - The entire right buttock was documented as dark purple, non-blanchable, indicative of a DTI extending from left buttock down into groin area with varying shades of dark purple non-blanchable skin. Review of Resident 4's skin integrity care plan, revised on 05/06/2025, showed the resident had a stage III PU on their sacrum (a triangular bone at the base of the spine and connects the spine to the pelvis) and their at risk for unavoidable pressure injury development or decline of skin integrity, date initiated on 04/17/2025. Interventions included performing weekly skin assessments. Review of Resident 4's “NRSG: Weekly Skin” in PCC showed the following skin checks documented: -04/17/2025 – refused. No other weekly skin assessment documented in PCC. -04/30/2025, 13 days after last weekly skin assessment, – blank. No other weekly skin assessment documented in PCC -05/08/2025 – refused. No other weekly skin assessment documented in PCC -05/19/2025, 10 days after last weekly skin assessment, – three inches of MASD on right inner buttock. -05/25/2025 – 50 cent piece size open wound to their right buttock. -06/08/2025, 14 days after last skin assessment, – dressing to buttocks/left hip region. -06/22/2025, 14 days after last skin assessment, – open area to right buttocks, two thin cuts on right buttocks. -06/29/2025, 07/06/2025, 07/13/2025, 07/21/2025, 07/27/2025, and 08/03/2025, – open area to right buttock. -08/17/2025, 14 days after last skin assessment, – right buttock open area was decreasing in size, and measured approximately 1 cm by 2 cm. -08/24/2025– open area dressing was clean, dry and intact. Refer to wound observation tool. -08/31/2025, and 09/04/2025 - open area dressing was clean, dry and intact. Followed by United Wound Healing (a contracted wound care company), refer to observation tool for measurements. Review of Resident WOT's in PCC showed assessments completed on: - 04/11/2025, refer to above late progress note. - 05/28/225 (48 days after last WOT assessment), 8.0 cm by 6.0 cm by 0.1 cm right buttock “pressure.” - 08/05/2025 (69 days after last WOT assessment), 1.2 cm x 0.7 cm by 0.2 right buttock stage III. - 08/12/2025, 0.6 cm by 0.5 cm by 0.1 cm right buttock stage III. - 08/19/2025, 1.2 cm by 0.5 cm by 0.2 cm right buttock wound. - 08/26/2025, 2.5 cm by 1.7 cm by 0.2 cm right buttock wound. - 09/02/2025, 2.0 cm by 1.5 cm by 0.2 cm right buttock wound. In an observation and interview on 09/04/2025 at 8:40 AM, Resident 4 was lying in bed, and Collateral Contact 1 (CC-1) and CC-2, the resident's family members, were present in the room. Resident 4 stated she had a sore on the right side of their bottom, and it was a “little bugger.” When asked how long they had the wound, Resident 4 and CC-1 stated the resident developed several wounds prior to their admission to the hospital. In an observation and interview on 09/04/2025 at 10:15 AM, Resident 4 was sitting on the edge of the bed. Staff G, Licensed Practical Nurse (LPN), performed wound care to the resident's sacral area. Two small pinpoint open areas were observed on the right side of the buttocks. The wounds were clean, with no drainage, and the base of the wound bed had red tissue. Staff G stated the two wounds were visibly approximately 0.1 cm to 0.2 cm. Staff G stated the wounds have improved significantly since admission to the facility. In an interview on 09/04/2025 at 12:42 PM, Staff A, Administrator, was asked about the facility's documentation process regarding skin concerns. Staff A stated the PU's/Pressure Injuries were documented using the wound observation tool in PCC. In an interview on 09/04/2025 at 1:43 PM, Staff J, LPN, stated weekly skin checks were done weekly and documented on the weekly skin check assessment tool. Staff J stated PU's were documented weekly using the WOT. In an interview on 09/04/2025 at 2:35 PM, Staff E, RN/Care Manager, was asked about the skin assessment tools in PCC and when they were to be completed. Staff E stated weekly skin assessments were done by the floor Licensed Nurse (LN) every week and documented on the weekly skin tool, the WOT's were done with assessment of the resident's PU's by Staff C, RN/Assistant Director of Nursing, and the skin integrity update form was completed by the floor LN as needed. <RESIDENT 9> Resident 9 was admitted to the facility on [DATE], with the most recent admission on [DATE], with diagnoses to include Multiple Sclerosis (MS) (chronic autoimmune disease that affects the central nervous system), Chronic Obstructive Pulmonary Disease (COPD) (lung disease that cause airflow obstruction and breathing problems) and malnutrition. Review of Resident 9's quarterly MDS assessment showed they had moisture associated skin damage (MASD) and no pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time). Review of Resident 9's weekly skin check dated 06/10/2025 showed they had an open area on their coccyx, approximately the size of a quarter. Review of Resident 9's provider note dated 06/13/2025 showed the resident had a pressure ulcer of their sacral region that was not visualized that day and family had requested a wound care referral. Review of Resident 9's weekly skin check dated 06/15/2025 showed they had an open area with no further description. Review of Resident 9's weekly skin check dated 06/24/2025, 07/01/2025, 07/08/2025, 07/15/2025 showed the same documentation, that they had an open area to their coccyx that measured 1.6cm long and 3cm wide. Review of Resident 9's care plan showed they had a pressure ulcer and was followed by the wound care clinic, initiated on 06/25/2025. Review of Resident 9's medical record showed no wound note documentation during the month of June, 2025. Review of Resident 9's wound note, dated 07/09/2025 showed they had an open wound which had progressed to a Stage II Pressure Ulcer. In a joint interview on 09/04/2025 at 3:30 PM, Staff A, Staff B, and Staff C. Staff C stated their expectation was that if a nurse documented the resident had an open area, it would be documented clearly and measured. Staff C stated the nurse that documented Resident 9's weekly skin was a brand-new nurse who did not know how to document skin conditions correctly. Staff C stated they had completed teaching related to skin documentation with that specific nurse due to incorrect documentation. Staff C stated Resident 9 had MASD and their skin was excoriated and had no wound/pressure ulcer until documented on 07/09/2025. Staff A stated Resident 9's family had a history of taking the resident to appointments without facility staff knowledge. Staff C stated the resident did have a wound care referral due to family request of the provider on 06/25/2025 but did not actually have a pressure ulcer at that time. Staff C stated it was understandable that the documentation related to Resident 9's skin was confusing and inaccurate. Refer to WAC 388-97-1720 (1)(a)(i-iv)(b) (2)(a-m)

Based on observation, interview, and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 1 of 3 sample residents (Resident 4) whose CP was reviewed for discharge planning and urinary status. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included.Resident 4 was admitted to the facility on [DATE] with diagnoses to include perineal (area between the genitals and the anus) and sacral (area between the bottom of the spine and tailbone) wounds, urinary incontinence, and cognitive impairment. Review of the Quarterly Minimum Data Set (MDS - an assessment tool) assessment, the resident had no cognitive impairment, was continent of their bowel and bladder, and did not have an indwelling urinary catheter. Review of Resident 4's discharge CP, date initiated 04/10/2025 and revised on 04/17/2025, showed the goal was to develop and follow full discharge plan with comprehensive assessment (the comprehensive assessment was completed with the admission MDS assessment dated [DATE]). The intervention was the resident wished to return home. Review of Resident 4's indwelling urinary catheter CP, revised on 04/28/2025, showed the resident had an indwelling Foley (a medical device that helps drain urine from the bladder) catheter present. Staff were directed to perform catheter care every shift. Review of Resident 4's July 2025 Medication Administration Record, showed the indwelling urinary catheter was removed on 07/25/2025. Review of Resident 4's nursing assistant documentation for the last 30 days, from 08/04/2025 to 09/02/2025, showed the resident was incontinent of bladder and no documentation the resident had an indwelling urinary catheter. In an observation and interview on 09/04/2025 at 8:35 AM, Resident 4 was lying in bed with no indwelling urinary catheter observed. The resident stated they wanted to go home. At 8:40 AM, Collateral Contact 1 (CC-1) and CC-2, the resident's family members, entered the room. The resident stated the doctor told them they needed a safe discharge. CC-1 and CC-2 stated the resident could not be discharged to their prior living situation because it was unsafe. In an observation and interview on 09/04/2025 at 10:15 AM, Resident 4 was sitting on the side of the bed with a hospital gown in place. There was no indwelling urinary catheter observed. In an interview on 09/04/2025 at 3:02 PM, Staff D, Registered Nurse/MDS Coordinator, was asked about Resident 4's continent status. Staff D stated their most recent MDS assessment showed the resident was continent of bowel and bladder. Resident 4's CP was reviewed with Staff D which showed the resident had an indwelling urinary catheter in place. Staff D acknowledge the CP should be updated. In an interview on 09/04/2025 at 3:20 PM, Staff I, Social Service Director, was asked about the discharge planning process and the discharge CP. Staff I stated the initial meeting to discuss the resident's status was done within the first 48 hours of admission and when the discharge CP was started. Resident 4's discharge CP was observed with Staff I. Staff I acknowledged the CP did not reflect the resident's current discharge goal and should be updated. Refer to WAC 988-97-1020 (2)(c )(d)(5)(b)

Based on interview, observation and record review, the facility failed to ensure resident preferences for food were obtained and honored for 4 of 4 residents (Residents 5, 21, 35, and 45) reviewed for choices. The facility refused to allow residents the ability to safely consume food items that were brought from outside sources when they removed the ability to heat up their food. This resulted in the residents losing their ability to choose their meal of preference and snacks of choice. These failures placed residents at risk for decreased quality of life. Review of the facility policy titled Resident Rights, reviewed 09/10/2024 stated residents had the right to self-determination with access to people and services in and outside of the facility. Residents had the right to make choices about aspects of their life in the facility that are significant to the resident. Review of the facility policy titled Food from Outside Sources, dated 06/03/2024 documented that when there was food that required heating the facility should use a food thermometer and alcohol wipes to ensure food was heated properly .additionally facility staff should receive proper education on required food temperatures, and proper use of food thermometer. <RESIDENT 5> Resident 5 was admitted to the facility on [DATE] with diagnoses that included history of stroke, dysphagia (trouble swallowing), and diabetes. The Significant Change Minimum Date Set Assessment (MDS - an assessment tool) dated 04/11/2025 showed the resident had intact cognition, and behaviors. Review of an undated letter from Staff A, Administrator, addressed to residents, staff and family members. The letter stated that the facility had recent issues regarding purchasing and storage of food items. The letter stated the facility was happy to store appropriate items in the refrigerator, they would not be able to accommodate leftovers, frozen meals or hot dogs (or similar items) due to the are unable to store them per food safety guidelines. The letter included a guideline that stated small amounts of perishable food for a limited space were allowed, and they would not be able to accommodate any food that required heating. Review of Resident 5's care plan with a print date of 06/13/2025, showed a focus area related to their diabetes that due to the resident's stroke, resident states some foods seemed tasteless; therefore, the resident had been purchasing food from outside sources. The care plan dated 03/07/2025 instructed staff to provide them with choices about the residents' daily care and activities . In an interview on 06/12/2025 at 1:44 PM, Resident 5 stated the facility stopped heating up food for them a few months ago. Resident 5 stated they were told by the facility the state would not allow it due to risk of burns. Resident 5 stated they used to like the food here at the facility, but due to their stroke their taste buds have changed, and they only prefer certain foods now. Resident 5 stated they started purchasing food from the grocery store to eat, the facility was heating their food up until recently when they told the residents they could no longer do that. Resident 5 stated there were other residents that were upset about the facility not heating up food and provided a name (Resident 35). <RESIDENT 35> Resident 35 admitted to the facility on [DATE] with diagnoses that included chronic pain, depression and diabetes. The Annual MDS dated [DATE] showed the resident had intact cognition. In a resident council meeting on 06/16/2025 at 2:48 PM, Resident 35 stated they were denied the choice to have microwave popcorn, as they were told recently by the facility in a letter that they could no longer heat up the microwave popcorn. Resident 35 stated they were offered pre-popped popcorn instead but stated that it did not really equal their preference to have microwave popcorn. <RESIDENT 21> Resident 21 was admitted to the facility on [DATE] with diagnoses that included malnutrition, depression and anxiety. The Quarterly MDS dated [DATE] showed the resident had intact cognition. In a joint interview on 06/17/2025 at 12:51 PM, Resident 21 and Collateral Contact 1 (CC1- residents family member), CC1 stated they had been bringing in frozen single meals for Resident 21 for a long time, as the resident does not like the food that much here at the facility. CC1 stated they would only bring a few at a time, label and date them for the facility. Resident 21 would then request one of the meals instead of what was offered at times for lunch or dinner. CC1 stated that a couple of months ago they were told they could no longer store or heat up the frozen dinners. CC1 was told the staff do not have time to heat up meals and the state regulations prevented them from doing so. Resident 21 stated they are making do. <RESIDENT 45> Resident 45 was admitted to the facility on [DATE] with diagnoses that included a stroke with right side weakness, and muscle weakness. The Quarterly MDS dated [DATE] showed that the resident had intact cognition. In an interview on 06/12/2025 at 2:09 PM, Resident 45 stated they were very unhappy with the facility, as they recently took away the ability for them to heat up food. Resident 45 stated they really enjoyed having their microwave popcorn for a snack, and now they are not able to have that. In an interview on 06/17/2025 at 9:57 AM, Staff K, Nursing Assistant Certified (NAC) stated they were aware that previously they were heating up food for residents. Staff K stated that management had put a stop to that, and no one was allowed to heat up food for the residents. In an interview on 06/17/2025 at 10:23 AM, Staff L, Licensed Practical Nurse (LPN) stated they have worked at the facility for over a year and was aware they were heating up food for residents but that it had recently changed. Staff L stated its hard telling residents they are not allowed to heat popcorn, many of them have so little left that it was hard to deal with. In a joint interview on 06/18/2025 at 11:03 AM, with Staff A and Staff B, Director of Nursing Services, Staff A stated the sometime in May of this year they changed their policy for food from outside sources because too many residents were having food either delivered from outside of the facility or family was bringing in frozen entrees. Staff A stated the staff were having to heat up a lot of food in the microwave. Staff A stated they did not have a place to store all the food or a centrally located microwave, and they were worried a resident may get a burn from food that was too hot, so they stopped heating up the food. Staff A stated they did not feel it was a sustainable task to ask their staff to do, and they (facility) had to decide between resident safety over resident rights. Staff B stated they did not feel their staff were capable of safely heating up food that followed the safety guidelines. Refer to F813 Reference WAC 388-97-0900(3)

Based on observations and interviews, the facility failed to ensure a clean, comfortable, homelike environment in 2 of 4 halls (shared bathroom between room [ROOM NUMBER]-215, and 114-115), in 1 of 3 shower rooms (community shower room for 400/500 halls), and 1 of 1 dining rooms. Failure to ensure the facility was clean, comfortable, and homelike placed residents at risk for decreased quality of life, compromised dignity, and potential infection control issues. Findings included . Review of the facility policy titled Resident Belongings and Home Like Environment, reviewed 05/15/2025 states the facility will provide a clean, safe, comfortable, homelike environment to the residents .homelike environment de-emphasizes the institutional character of the setting to the extent possible and supports a more home like environment .it was the responsibility of the facility staff to create and provide a homelike environment. <RESIDENT BATHROOMS> During an observation of the shared bathroom between rooms [ROOM NUMBERS] on 06/12/2025 at 10:13 AM, the bathroom had a powerful, unpleasant odor, the floor appeared to be sticky when walking on it, and there was an area of damaged tiles that appeared black/brown under the toilet, with gaps in tiles that had broken apart. The bathroom was dim and only had one working light bulb in the fixture. During an interview/observation on 06/12/2025 at 11:18 AM, Resident 22, in room [ROOM NUMBER], stated that they were informed by the housekeeper that their bathroom was dirty, and the housekeeper came in and cleaned it. It was observed to still have a heavy odor, broken tiles with brown/black stains under the toilet. During an interview on 06/17/2025 at 10:39 AM, Staff X, Nursing Assistant Certified (NAC), stated the resident bathroom between rooms [ROOM NUMBERS] smelled like urine, possibly, the tiles under the toilet appear to be broken and moldy, and the bathroom is dim from light bulbs being burned out. During an interview on 06/17/2025 at 10:57 AM Staff B, Director of Nursing Services (DNS), stated the resident bathroom between room [ROOM NUMBER] and 114's smells like urine, they were unsure of what the black /brown stains on the tile under the toilet were but it looks terrible and needs to be replaced, the burned out light bulbs needed to be changed and the floor was sticky. During an observation of the shared bathroom between rooms [ROOM NUMBERS] on 06/12/2025 at 11:39 AM, the bathroom had poor lighting, extremely strong odors, and broken floor tiles that were stained brown to black in a 4-foot by 3-foot area under the toilet. The wall on the right side of the toilet had paint scraped off the wall and the floor was sticky when walked upon. During an interview on 06/18/2025 at 8:32 AM Staff Y, NAC, stated the bathroom between rooms [ROOM NUMBERS] doesn't smell clean or good, there are scuff marks on the wall where the paint is coming off. Staff Y stated they were unsure what the black area was on the floor under the toilet, and that it doesn't feel home like. <SHOWER ROOM> During an observation on 06/17/2025 at 10:30 AM, the large community shower room for hall's 300 and 400, had missing tiles in the shower area and lacked grout between the existing floor tiles. A small divider wall separating the shower area from a locker had broken tiles along the bottom. There was a strong musty odor possibly mold and mildew upon entering the room. The bathroom floor was uneven and sunken in some areas by two inches. Dust and dirt covered the floor outside the shower stall, medical equipment was disorganized throughout the bathroom, and trash cans were overflowing. During an interview on 06/17/2025 at 10:39 AM, Staff X stated that the bathroom smelled like someone had left a wet towel too long, causing mold, and that the shower stall had missing tiles, the floor was dirty, and the room needed a whole cleaning. During an interview on 06/17/22025 at 10:57 AM Staff B stated that the floor is uneven and there was no grout, missing tiles in the shower area, floors are unclean in the whole bathroom, the equipment needs to be organized, and that the bathroom does not feel home like. <DINING ROOM> In a continuous observation on 06/12/2025 at 12:12 PM, lunch meal service was scheduled for 12:20 PM in the main dining room. There were eight tables in the main dining room, the room was quiet, tables were bare, with only a tablecloth, a soda vending machine was in the corner of the dining room. The walls are stark with a few paintings scattered on the walls. There were eight residents in the room, several were sitting alone at table by themselves, several residents observed staring at the wall while they were waiting for their meal. There was no music playing, the television was turned off, the residents had no engagement while they waited for a meal. Several staff stood against the counter at the end of the dining room, with no engagement with the residents in the room. At 12:25 PM unknown staff member was observed standing over Resident 58 trying to get the resident to take a bite of food. At 12:41 PM, Staff M, Licensed Practical Nurse (LPN) was observed entering the dining room and administered medications to Resident 46 who was eating their lunch. In an observation on 06/13/2025 at 12:05 PM, there are five to six residents at various tables in the dining room, all sitting alone. There was no music heard, the television was turned off, no engagement, and no staff were present in the dining room. The meal was scheduled to be served at 12:20 PM. In a group interview at resident council on 06/16/2025 at 2:48 PM, Resident 3 stated it was difficult to get any assistance in the dining room as staff are not present or stand far away and do not engage with the residents. In an observation at 06/17/2025 at 12:05 PM, there were seven residents in the dining room waiting for lunch service, and three were sitting alone. There was no music heard, the television was turned off, no engagement in the dining room. The meal was scheduled to be served at 12:20 PM. In an interview on 06/17/2025 at 9:57 AM, Staff K, NAC stated staff duties in the main dining are to offer clothing protectors, provide drinks, serve the residents their meal, and then they wait to see if any resident may need anything or assist with eating if necessary. Staff K stated they used to play music or have a movie on while the residents waited for meals, they were not sure why that was not offered anymore. In an interview on 06/17/2025 at 10:23 AM, Staff L, LPN stated they will turn on the music or television if a resident requested it and added the dining room can be pretty dead. Staff L stated they used to have movies on often, and on Sundays they will have church music on after the service that was right before lunch. Staff L added that a lot of the residents there just sat and stared at nothing until the meal was served. In an observation on 06/18/2025 at 7:32 AM, there were six residents sitting in the dining room, no staff present, two of the residents were alone, and two were just staring at each other. There was no music heard, the television was turned off, no engagement in the dining room. The meal was scheduled to be served at 7:40 AM. In an interview on 06/18/2025 at 11:03 AM, Staff A, Administrator, was not aware the dining room was not homelike. Staff A stated the expectation was that staff would sit next to the residents if they needed assistance eating, and that nurses should not administer medications in the dining room during the meal service unless it was the resident's preference. Staff A stated they would expect the staff to engage with the residents during the meal service. Reference WAC 388-97-0880(1)(2)(5)

Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs - daily hygiene and other self-care tasks) for 4 of 7 residents (Residents 6, 7, 17, and 8) reviewed for ADLs. The failure to provide ADL assistance to residents placed residents at risk for poor hygiene, diminished feelings of self-worth, and other adverse health outcomes. Findings included . Review of a facility policy titled Activities of Daily Living (ADLs) review date of 09/01/2024, documented 'The resident will receive assistance as needed to complete activities of daily living (ADLs).' <RESIDENT 7> Resident 7 was a long-term resident at the facility. According to the Annual Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], the resident was cognitively intact and was dependent (helper does all the effort) on staff for shower assistance. During observations on 06/13/2025 at 12:33 PM, 06/16/2025 at 8:33 AM, and 06/17/2025 at 8:36 AM, Resident 7's hair appeared greasy. Review of shower documentation in the electronic medical record, dated 05/17/2025 through 06/16/2025 with a print date of 06/16/2025, documented Resident 7 preferred to shower two times a week. It was documented that Resident 7 received showers on 05/19/2025, 05/26/2025, 05/29/2025, 06/02/2025, and 06/09/2025 and 1 refusal on 06/07/2025. <RESIDENT 6> Resident 6 was a long-term resident at the facility. According to the admission MDS dated [DATE], the resident was dependent on staff for showers and had mild cognitive impairment. During an observation on 06/13/2025 at 12:30 PM, on 06/16/2025 at 8:29 AM, and on 06/18/2025 at 8:22 AM, Resident 6's hair appeared greasy. Review of shower documentation in the electronic medical record, dated 05/18/2025 through 06/08/2025 with a print date of 06/16/2025, documented Resident 6 preferred to shower two times a week. It was documented that Resident 6 received a shower on 05/25/2025, 05/31/2025, 06/04/2025, and 06/07/2025, with one resident refused on 06/08/2025, one resident not available on 05/18/2025, and 06/01/2025, and one not applicable. <RESIDENT 17> Resident 17 was a long-term resident at the facility. According to the Annual MDS dated [DATE], Resident 17 had mild cognitive impairment and needed supervision or touching assistance (helper provides verbal cues or touch/steady assistance as resident completes activity) for showers. During an interview on 06/12/2025 at 2:27 PM, Resident 17 stated that they had tried to ask for a shower two different times, but staff said they were busy. Resident 17's hair appeared greasy. During an observation on 06/16/2025 at 8:28 AM, on 06/17/2025 at 10:00 AM, and on 06/18/2025 at 8:21 AM Resident 17's hair appears greasy. Review of shower documentation in the electronic medical record, dated 06/11/2025 through 05/21/2025, with a print date of 06/16/2025, documented Resident 17 prefers to shower one time a week. It was documented that Resident 17 received a shower on 06/11/2025 and Resident refused on 05/21/2025 and 05/28/2025. <RESIDENT 8> Resident 8 was a long-term resident at the facility. According to the admission MDS dated [DATE], Resident 17 was severely cognitively impaired and was dependent on staff for showers. During an observation on 06/18/2025 at 10:05 AM, Resident 8's hair appeared greasy. Review of shower documentation in the electronic medical record, dated 05/18/2025 through 06/01/2025, with a print date of 6/16/2025, documented Resident 8 prefers to shower 1 time a week. It was documented that Resident 8 received a shower on 05/25/2025 and 06/01/2025, and one not applicable on 05/18/2025. During an interview on 06/18/2025, Staff AA, Nursing Assistant Certified (NAC), the primary shower aid, stated that if a resident refuses a shower, staff should re-approach the resident, and if they still refuse, nursing staff should be alerted, and it should be charted. However, shower aids get pulled to the floor to work frequently. Staff AA then looked in the schedule book and stated that Resident 8 had only received a shower 2 times in 30 days, with no other documentation. During a joint interview on 06/18/2025 at 10:05 AM, Staff A, administrator, and Staff B, Director of Nursing, stated that the facility does not use contract NACs, and if a callout happens, they pull the shower aid or the restorative aid. They would expect that the staff shower the residents the next day if they are pulled, but if it's not documented in PCC then it was not done. Reference WAC 388-97-1060(c)

Based on observation, interview and record review, the facility failed to provide meals that were palatable and at an appetizing temperature per 1 of 1 resident groups (Residents 3, 19, 35, 46, 59, and 182), 3 resident interviews (Residents 19, 37, and 45), and 2 of 3 resident dietary grievances (Residents 46, and 50) reviewed. These failures resulted in residents experiencing dissatisfaction with their meals and placed residents at risk for decreased quality of life and weight loss. Findings included . In an interview on 06/12/2025 at 2:15 PM, Resident 45 stated they did not think the fish was fresh and stated the facility uses the wrong seasonings, and the meats are too tough. Resident 45 stated they took the microwave away and we can't have popcorn anymore. In an interview on 06/12/2025 at 2:20 PM, Resident 19 stated food options were limited, lots of chicken fried or country fried, not a lot of variety. In an interview on 06/12/2025 at 10:06 AM, Resident 37 stated the food tasted bad, they offer other options, but the options are also not good. In an observation of the facility lunch meal service and tasting of a facility test tray on 06/16/2025 at 12:50 PM, the test tray left the kitchen at 12:43 PM. The meal included a barbecue burger which was a burger patty which had been hot held in a metal tray of barbecue sauce, French fries, and included the alternate main meal option of a hot dog in a bun. The burger temperature had cooled to 115 degrees (f) and was very thick with barbecue sauce, the bun was smashed and not visually appealing. The hot dog bun was wet and soggy. The French fries were dry and cardboard like, not palatable at all and barely warm. In a group meeting during the facility resident council on 06/16/2025 at 2:48 PM, Resident 46 stated the facility toaster was broken, we can't get toast, and stated the food quality was inconsistent. All residents in attendance (Residents 3, 19, 35, 46, 59, and 182) stated the lunch today was terrible, heavy with barbecue sauce and the French fries were hard you could use them as nails. This was stated to be typical. Resident 182 stated they would like their food to be heated; it arrives very cold and that they are upset that they cannot use a microwave. Residents are buying their own food because they don't like the food here but then can't have their food heated. All residents (Residents 3, 19, 35, 46, 59, and 182) stated that they eat their food cold, and they were told by the kitchen that food is warm when it leaves the kitchen but sits in the hall way too long until it is cold and then staff are not allowed to heat it up. Refer to F 813 related to facility policy regarding heating of resident foods. Review of the facility grievance log and grievance investigations documented Resident 46 filed a grievance dated 05/08/2025 stating they received chicken that was not cooked and asked for another piece that they did not receive. Review of the facility resolution of the grievance stated they would ensure communication between the resident and kitchen regarding meal corrections but did not address the stated issue of chicken being undercooked. Resident 50 filed a grievance dated 06/07/2025 stating meals were cold or overcooked, French fries were overbaked and hard or undercooked. The grievance also included numerous specific complaints about preferences. The grievance resolution per the facility was that the residents' preferences would be updated but did not address the concern related to food temperature or quality. In an interview on 06/17/2025 at 12:36 PM, Staff E, Food Services Director, confirmed the kitchen does not reheat resident foods. Staff E stated they were involved in concerns or grievances related to the resident foods and stated they recalled Resident 46's grievance related to raw chicken and stated it was not possible, as the facility received pre-cooked chicken from that food vendor. Staff E stated they had not been directly involved so could not speak to whether there had been an issue with the temperature. Staff E stated there was a food committee where they meet with residents to discuss food issues. Staff E stated the facility had no fryer, so things like French fries specifically which are frozen, are baked in the oven, then held on the steam table under foil. Staff E also stated they also had onion rings that they had not ordered before, but they were also baked and held, and they do not keep well on the steam table. Staff E stated they were not sure why the menu included so many fried items when they had no fryer, but the menus come from corporate. Staff E stated they had just gotten permission to order a toaster, and the complaint of not having toast was accurate. In an interview on 06/17/2025 at 1:49 PM, Staff A, Administrator, stated they reviewed the grievances and were aware of some of the resident specific food complaints, and stated they believed that the resident concerns had been addressed. On 06/18/2025 at 11:03, Staff A stated they had not tried any of the facility food themselves. Reference WAC 388-97-1100(1)(2)

Based on observation, interview and record review, the facility failed to develop and implement an effective policy and procedure related to hot beverages and failed to provide adequate supervision 1 of 1 resident (Resident 52) and failed to ensure a bathing area with chemicals and sharp razors was locked for 1 of 3 bathing areas (Tulip Shower Room) reviewed for avoidable accidents and supervision. These failures caused harm and injury to Resident 52 who sustained a second-degree burn from an airpot [NAME] (a portable vacuum insulated thermos dispenser for hot beverages) in the dining room and placed other residents at risk for injury related to hot beverages left in unsupervised airpot flasks in the dining rooms and had unlocked bathing areas accessible to residents with hazardous chemicals and sharp items that placed resident at risk for avoidable accidents and injury. Findings included . <BURN> Review of the State Operations Manual, Appendix PP, dated 02/03/2023, showed the time of exposure and the temperature of the fluid can determine the severity of injury to the skin. A second-degree burn involves the first two layers of skin. The injury may present with reddening of skin, pain, blisters, and/or glossy appearance from leaking fluid. Review of facility policy titled, Water Temperature Inspection, reviewed on 12/19/2022, showed hot beverage temperatures should be 145 (degree) Fahrenheit (F) to 155 F at delivery and the facility should conduct an audit at least monthly to ensure the temperature was appropriate. There was no documentation in the policy to address risk factors or supervision with hot beverages. was this updated on 12/19 or they reviewed it on 12/19 Resident 52 admitted to the facility on [DATE], diagnoses including right side hemiparesis (weakness or loss of strength and function to one side of the body), glaucoma (eye disease that causes loss of vision), muscle weakness, and limitations of activities due to disability. The Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 07/26/2023, showed the resident had intact cognition, and required supervision with one staff member assist for personal hygiene, and supervision with set up for eating. Review of Resident 52's care plan showed an intervention for wound care from spilled coffee, dated 05/24/2023, showed the resident felt the coffee spill was a result of their poor vision. The intervention directed staff to educate the staff to assist the resident with coffee. Review of the facility state reporting log for May 2023, showed on 05/26/2023 an entry for Resident 52 which showed the resident substantial injury related to a coffee burn to their right hand on 05/24/2023 at 3:30 PM. Review of the facility investigation, dated 05/24/2023 at 3:30 PM, showed staff were notified by Resident 52 they were getting coffee from the airpot [NAME] in the dining room independently when they over poured the coffee onto their right hand. The resident was requesting a bandage as their skin had begun to peel off their thumb. The nurse documented the resident had an area of pink skin that measured 6.0 centimeters (cm) wide by 5.5 cm long between the webbing of the resident's right index finger and thumb. Interventions to prevent reoccurrence was to remove the airpot flasks from the dining room, except during mealtimes, so staff would be able to assist residents to obtain coffee. In an observation on 08/16/2023 at 2:41 PM, in the Cascade Dining Room (Main dining room), three doors into the dining room were open, there were no staff present. On the counter (accessible to residents at wheelchair level) along the wall were two pots, one was labeled hot water, and the other labeled coffee. The temperature of the hot water was taken and read 149 F, the temperature of the coffee was taken and read 151.5 F. In an interview on 08/16/2023 at 3:30 PM, Resident 52 stated they did not remember the exact day they burned themselves but had been a few prior to when they asked for a bandage. The resident stated they had gone into the dining room to get coffee around 7:30 AM, they overpoured the coffee onto their hand. The resident stated a few days later a blister formed and then they were picking at it and the skin began to peel, that was when they went to the nurse. The resident stated they started treating the injury with some cream, the staff would wrap it, and they wore a glove over the bandage until it healed. In an interview on 08/16/2023 at 3:38 PM, Staff C, Cook, stated they placed airpot [NAME] in the dining room after meals. In an interview on 08/16/2023 at 3:42 PM, Staff E, Nursing Assistant Certified (NAC), was asked to go to the dining room. When Staff E was asked where the residents get their coffee, Staff E responded we can get it from these (pointed to the airpot [NAME] sitting on counter that were temped at 2:41 PM). Staff E stated, honestly I do not think these are supposed to be in here. Staff E did not remove the airpot flasks. In an observation and interview on 08/16/2023 at 4:10 PM, Staff F, NAC, stated residents could independently get their own coffee if they do not have any cognition problems. Staff F stated they have observed residents obtain coffee from the airpot flasks that sit in the dining room between meals. The airpot flasks were observed to be on the counter. In an observation and interview on 08/17/2023 at 8:06 AM, the airpot [NAME] with coffee and hot water were sitting on the counter. Staff Q, NAC, stated independent residents would get their own coffee from the airpot flasks in the dining room. In an observation on 08/17/2023 at 8:23 AM, in the back dining room (Valley) there were two residents eating breakfast, and there was a rolling cart in the middle of the dining room with two airpot flasks of coffee with hand pumps engaged for distribution. There were no staff present. In an interview on 08/17/2023 at 9:15 AM, Staff P, NAC, stated residents have access to coffee and hot water. The staff try to discourage the residents from helping themselves. In an interview on 08/17/2023 at 9:18 AM, Staff T, NAC, said there was almost always airpot [NAME] out for the residents in this dining room (pointed to the Cascade dining room) or the Valley dining room. Staff T said the residents can ask for coffee and staff could get it for them. If the coffee was out (gone) they told the kitchen and they would make more. Staff T said they were not sure about what happens with the coffee at night. In a continuous observation on 08/17/2023 at 9:27 AM - 10:42 AM, in the main dining room (Cascade) there were two airpot flasks sitting at the edge of the counter. There were no staff present. In an interview on 08/17/2023 at 9:45 AM, Staff G, Licensed Practical Nurse (LPN), stated the airpot flasks were out in the dining room and staff were to assist the residents to get their coffee. When asked if there were residents that would get their coffee independently, Staff G stated yes, they would. In an observation on 08/17/2023 at 2:38 PM, airpot flasks were observed sitting on the counter unsupervised in the dining room (Cascade). In an interview on 08/17/2023 at 2:47 PM, Staff R, Registered Nurse, stated the airpot flasks were always out in the dining room. In observations on 08/18/2023 at 9:52 AM and 11:24 AM, the airpot flasks were observed sitting on the counter unsupervised, there were no staff present. In an interview on 08/18/2023 at 11:44 AM, Staff O, NAC, stated they were aware that Resident 52 had burned their hand while getting themself coffee. Staff O stated they were unsure how long the airpot flasks had been sitting in the dining room as they had not worked at the facility for a few weeks. The following interviews occurred during the Resident Council meeting on 08/18/2023 at 10:00 AM: - Resident 43 (admitted [DATE] with diagnoses including muscle weakness, and difficulty walking) stated there were usually airpot flasks in the dining rooms, they have gotten it themselves before. - Resident 14 (admitted [DATE] with diagnoses including joint pain, muscle weakness and difficulty walking) stated they obtained their own coffee in the dining room. - Resident 50 (admitted [DATE] with diagnoses including muscle weakness, limitation of activities due to disability, difficulty walking, and cognition communication problems) stated coffee was available to them. - Resident 52 stated they were still going into the dining room to get themselves coffee. In an interview on 08/21/2023 at 10:40 AM, Staff H, LPN/Resident Care Manager (RCM), stated they were aware Resident 52 had obtained a burn while obtaining their coffee independently. Staff H stated they were not aware the airpot flasks were in the dining room unsupervised. At 1:13 PM, Staff H followed up and stated the airpot flasks were not supposed to be in the dining room unsupervised. In an interview on 08/22/2023 at 10:23 AM, Staff B, Director of Nursing Services (DNS), stated based on the incident investigation the airpot flasks should not have been in the dining rooms unsupervised as that was the intervention the facility had put in place to prevent further potential accidents. 47104 <SHOWER ROOM> In an observation on the 100-hall shower room on 08/15/2023 at 2:23 PM, Unit 1 shower room door was observed to be unlocked and unattended. The shower room was observed to contain storage shelving with no lock. During the observation there were nine nail clippers, one disposable razor, two uncapped shaving cream containers, one bottle of Hibiclens (an antiseptic [prevents the growth of disease-causing microorganisms] that fights bacteria on the skin) medicated skin cleanser, shampoo, lotion, deodorant, hair dryer, and electric clippers unsecured. A hairdryer and fan were observed plugged in to an extension cord next to the storage container. One spray bottle labeled Unit 1 shower room bleach mix with water was observed sitting on the top of the storage shelving. During an observation on 08/16/2023 at 12:35 PM and 5:01 PM, the Unit 1 shower room door was observed to be unlocked and the contents previously observed were not secured and accessible. During an observation on 08/17/2023 at 8:20 AM, the Unit 1 shower room door was observed to be unlocked. During an observation and interview on 08/17/2023 at 2:46 PM, Staff B, stated the Unit 1 shower room door was unlocked, and acknowledged the door should be locked. This is a repeat deficiency from 03/28/2023. Reference: (WAC) 388-97-1060(3)(g).

Based on observation, interview, and record review, the facility failed to implement preventative measures identified weight loss, offer alternative meals when a resident ate less than 50% of their meal, supervision with meals, and evaluate the effectiveness of weight loss interventions to determine if addition interventions were needed for 1 of 4 residents (Resident 56) reviewed for nutritional needs. These failures caused harm to Resident 56 who experienced a 12.2% severe weight loss in 4 months and placed the resident at risk for additional weight loss and a decline in their nutritional status. Findings included . Review of facility policy titled, Resident at Risk (RAR), revised 04/25/2023, showed the facility conducts a weekly resident at risk meeting to review residents identified with problems or concerns related to their nutritional status or have an identified risk factor that may lead to nutrition issues. The RAR team will review residents with significant weight changes and make necessary care plan interventions. Review of the facility policy titled, Hydration and Nutrition, revised 08/25/2022, showed a minimum of three meals are provided each day and if a meal was refused the resident would be offered an alternative. Resident 56 admitted to the facility on [DATE] with diagnoses including dysphagia (swallowing difficulty), hemiplegia and hemiparesis (weakness or loss of strength and function to one side of the body) to the left side. The Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 07/13/2023, showed the resident had moderate impaired cognition, no refusal of care and required supervision for eating. Review of Resident 56's electronic medical record (EMR), showed the following documented weights: - On 04/05/2023, 167.3 pounds (lbs.) admission weight, (165 lbs. was the residents baseline weight). - On 05/03/2023, 158.5 lbs., a 3.9% weight loss from their baseline weight. - On 06/21/2023, 153.2 lbs., a 7.2 % significant weight loss from their baseline. - On 07/29/2023, 145.0 lbs., a 12.1% severe weight loss from baseline. Review of Resident 56's care plan showed a focus for at risk for weight fluctuation related to current health status, dated 04/04/2023. The care plan interventions, updated 05/04/2023, included to prevent weight loss was to assist the resident with meals as needed, educate the resident and family on storage of outside food, educate the resident and family on potential weight fluctuations, and resident preferred not to eat breakfast. Review of Resident 56's monthly nutritional notes showed the following: - On 05/04/2023, the reason for the review was the resident's weight was down 3%, the intervention was to offer a bedtime snack due to their preference of not eating breakfast. - On 05/18/2023, the reason for the review was the resident's weight was down 3%, no changes were recommended to their plan of care. - On 06/01/2023, the reason for the review was the resident had weight loss, no changes were recommended to their plan of care. - On 06/08/2023, the reason for the review was weight loss, no changes were recommended to their plan of care. - On 08/10/2023, the reason for the review was weight loss and recommended an Occupational Therapist (OT) referral to assist with self-feeding and nursing to follow up with Resident 56 and their family about a possible medication to stimulate their appetite. Review of Resident 56's 04/05/2023 through 08/22/2023 meal intake record, showed the following: - 08/01/2023 through 08/22/2023, showed 13 refusals, one blank (no documentation provided), and 24 meals where the resident at less than 50% with no alternative offered. - July 2023, showed 25 refusals, 22 blanks, and 24 meals where the resident at less than 50% with no alternative offered. - June 2023, showed 28 refusals, one blank, and 12 meals where the resident at less than 50% with no alternative offered. - May 2023, showed 11 refusals, three blanks, and 18 meals where the resident at less than 50% and no alternative was offered, - 04/05/2023 through 04/30/2023, showed 1 refusal, 8 blanks, 14 meals where the resident at less than 50% and no alternative was offered. Review of the facility documented titled, Mini Nutritional Assessment, dated 07/05/2023, showed Resident 56 was malnourished. In an interview on 08/14/2023 at 2:35 PM, Collateral Contact (CC) 1, Resident 56's family member, stated they wished the facility would try and assist Resident 56 more with meals. CC1 stated they had written a note and placed it on the bulletin board above the resident's bed, a note was observed on white paper, handwritten, and stated, please help my [the resident] eat, thank you. In an observation on 08/15/2023 at 9:00 AM, Resident 56 was asleep in bed, the breakfast tray was observed to be sitting on the over the bed table on the side of the bed. The tray had a lid on it and was untouched. No staff were observed in room to assist the resident. In an observation on 08/16/2023 at 1:19 PM, CC1 was observed to ask the staff if anyone had been in to offer to help Resident 56 eat their lunch. The lunch tray was observed to be sitting in the room, with the lid on and untouched. No staff were observed in room to assist the resident. In an interview on 08/17/2023 at 1:06 PM, Staff X, Registered Dietician (RD), stated they had been the RD at the facility since March of 2023. Staff X stated the facility would notify them if there was a resident with weight loss and then they would discuss that in the RAR meeting they had once a week. Staff X stated Resident 56 had loss quite a bit of weight, like 10 lbs. or so recently. Staff X stated the interventions that had been tried was they offered a medication to stimulate their appetite and the resident refused due to it was an anti-depressant. Staff X stated they had offered ice cream and would encourage the resident to eat. In an interview on 08/17/2023 at 1:26 PM, Staff G, Licensed Practical Nurse (LPN), stated they tried to assist Resident 56 to eat, however if they refused there was not much staff could do. Staff G stated the facility had not placed Resident 56 on alert monitoring for weight loss and refusal of meals. In an interview on 08/17/2023 at 1:32 PM, Staff H, LPN/Resident Care Manager (RCM), stated the facility was aware Resident 56 had significant weight loss. Staff H stated the resident continued to refuse assistance to eat. In a continuous observation and interview on 08/18/2023 from 8:32 AM - 9:25 AM, the food tray was observed to be on Resident 56 over the bed table, the lights in room were off and the resident was asleep. At 9:15 AM, the tray was still sitting in the room untouched, lights off and the resident was asleep. At 9:25 AM, Staff P, Nursing Assistant Certified (NAC), stated if Resident 56 does not wake up, they just leave the tray in the room. Staff P was then observed to go into the room and pick up the untouched tray and place in the meal cart. The resident was not offered an alternative meal or snack. In an interview on 08/18/2023 at 12:16 PM, Staff K, LPN, stated Resident 56 required guidance and encouragement for meals. Staff K stated if a resident refused their meal or ate less than 50%, staff were supposed to offer an alternative and let the nurse know. In an observation on 08/18/2023 at 12:49 PM, Staff Y, Restorative Aide (RA)/NAC, was observed sitting in the room with Resident 56 providing extensive assistance feeding the resident. The plate on the meal tray was observed to have over 75% of the meal was gone, the resident was observed to accept the food from Staff Y as they scooped spoonful of food on to the spoon and place into the residents mouth. In an interview on 08/21/2023 at 10:40 AM, Staff H, LPN/RCM, stated when a resident refused a meal or ate less than 50% the staff would offer an alternative meal. Staff H stated there was a weekly RAR meeting with the RD, and the RD was responsible to document on the RAR meeting form. Staff H was not aware Resident 56 had no RAR meeting documentation between June - August of 2023. In a follow-up interview at 1:13 PM, Staff H confirmed there was no documentation Resident 56 had been offered any alternatives for all the refusals and when the resident ate less than 50% meal intake entries. Staff H was unable to offer any reason for no documentation for RAR meetings between June and August 2023 and was unable to validate if the resident had been reviewed in the RAR meetings during that time. In an interview on 08/21/2023 at 10:50 AM, CC 4, Nurse Practitioner (NP), stated they had asked the RD to continue to follow Resident 56 related to weight loss. CC4 stated the resident adamantly hates the food at the facility and that a lot had to do with their culture. CC4 stated they had asked the kitchen to make ice cream shakes for the resident, however it was not something they could provide all the time. In an interview on 08/22/2023 at 10:15 AM, Staff B, Director of Nursing Services (DNS), stated Resident 56's family refused to place the resident on comfort care for their weight loss. Staff B stated they were aware the resident was depressed; however, they did not have any mental health services in the facility. Staff B stated they had not considered culturally preferred foods that may improve the resident's acceptance and intake. Reference: (WAC) 388-97-1060(3)(h)

Based on observation, interview, and record review, the facility failed to ensure staff used safe technique for bed mobility for 3 of 3 residents (Resident 1, 4 and 12) reviewed for accidents and supervision who utilized a bariatric bed. This failure caused harm to Resident 1 who was being turned in bed by one staff member, rolled off bed on the unsupervised side, sustained a subdural hematoma (pool of blood between the brain and it's outermost covering), tension pneumothorax (collapsed lung), scalp laceration, and subsequently expired. This failure additionally placed other residents at risk for potential harm and injury. Findings included . <Resident 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include hydrocephalus (abnormal cerebrospinal fluid in the brain) and epilepsy (seizure disorder). Review of Resident 1's quarterly Minimum Data Set (MDS) assessment, dated [DATE], showed the resident had moderately impaired cognition. The resident was coded as needing two person assist with bed mobility and toileting, and was totally dependent on two for bathing and transferred with a Hoyer (a type of mechanical transferring device) lift. Review of Resident 1's annual MDS and Care Area Assessments (CAA's), dated [DATE], for activities of daily living, showed the resident had risk factors for falls, including mobility dependence, incontinence, and cognitive impairment. The facility documented that Resident 1 had a high level of mobility dependence and was anticipated to remain at high level of dependence going forward, requiring a Hoyer lift for transfers and was dependent for most ADL's and mobility. The goal was to avoid complications related to dependence. Review of progress notes since Resident 1's most recent MDS assessment, dated [DATE], showed no documentation related to the facility's assessment of the resident's ability for a one person assist for side-to-side bed mobility. Review of the [DATE] through February 23, 2023 Nursing Assistant's (NAs) documentation of bed mobility, showed Resident 1's assistance required from extensive assistance of one or two staff members to dependent of one or two staff members. Review of Resident 1's weight records, showed the resident's most recent weight on [DATE], was 244.5 pounds. Review of progress note, dated [DATE], showed the nurse was called to Resident 1's room and observed them lying face down on the floor between the wall and the bed. The resident was noted with trauma and bleeding from their head and was sent to the hospital per 911. Review of facility investigation, dated [DATE], showed Resident 1 rolled out of bed to the floor at approximately 8:40 PM, while care was being provided. The NA assisted the resident to roll to their side in bed for care. The resident was asked to assist the NA to turn onto their back and the resident was unable. The NA had pulled the resident's bed away from the wall, walked to the other side of the bed, when the resident rolled forward off the bed, fell to the floor between the wall and the bed in the prone (lying flat with their face downward). The nurse observed the resident had sustained a laceration to their head, provided first-aide, called 911, and the resident was sent to the hospital. Review of fall scene investigation form showed the resident had last received lorazepam (an anti-anxiety medication) at 6:30 PM; the resident received this medication six times daily for seizure prevention. Review of Advanced Registered Nurse Practitioner note, dated [DATE], showed the resident should be monitored for oversedation, dizziness and confusion due to the dose of lorazepam prescribed. Review of hospital records and diagnostic test results, dated [DATE], showed the resident sustained a subdural hematoma, right front scalp swelling and laceration (a deep cut or tear in the skin), a large right side pneumothorax with a shift suggesting tension pneumothorax (air trapped between chest wall and lungs which increases pressure in the chest, reducing the amount of blood returned to the heart), and probable right side rib fractures. Resident 1 expired at the hospital at midnight on [DATE]. In an interview on [DATE] at 2:00 PM, Staff A, NA, stated they had provided care for Resident 1 a couple times prior to their fall on [DATE], however the resident was a two person assist at that time. Staff A stated after the first-time providing care which required turning the resident side-to-side alone, they requested assistance from another NA. Staff A stated an unidentified NA agreed to do it that time but informed them the resident was care planned for one-person assist for side-to side bed mobility. Staff A stated Resident 1 was quite large and was in a bariatric bed with one side of the bed against the wall. Staff A stated on the evening of [DATE], they pulled Resident 1's bed out to gain access to both sides while providing care. Staff A stated they started from the open side of the bed assisted Resident 1 onto their side facing the wall and provided care. Staff A stated they asked the resident to assist to roll onto their back or to scoot closer to them, however the resident stated they were unable to do so. Staff A stated they could not pull the resident closer to the middle of the bed or roll them onto their back. Staff A stated they left the resident's side and by the time they reached the foot of the bed on the other side, the resident rolled over and fell face-down onto the floor between the wall and the bed. Staff A stated if there had been two staff present, the fall would not have happened. Staff A stated often it was very busy and difficult to find help. Staff A stated they called out for help with no response, so had to leave the room and shout out for the nurse. The resident was sent to the emergency room via ambulance. In a telephone interview on [DATE] at 11:10 AM, the coroner's office reported Resident 1's cause of death was subdural hematoma and tension pneumothorax. In an interview on [DATE] at 12:10 PM, Staff B, NA, stated Resident 1 had often been able to assist with turning and would hang onto the mattress, but at times the resident had been unable to help. In an interview on [DATE] at 2:15 PM, Staff C, Licensed Practical Nurse/MDS Nurse, stated for bed mobility, if a resident was unable to move at all they coded them on the MDS as dependent, and if they could help at all they coded them for extensive assist. Staff C stated the way they coded depended upon how the NA's documented. Staff C stated if the resident had any ability to participate in bed mobility, they could be a one-person assist, if unable to help at all they were a two-person assist on their care plan. Staff C stated the reason Resident 1 had their bed against the wall was so one person could roll them side to side, and stated the NA's should call for help from another staff member, if they needed to pull the bed away from the wall. Staff C stated because of Resident 1's fall and death, they needed to review and change care plans for bed mobility for all residents who were coded on their MDS assessment as extensive two person assist and dependent two-person assist. In an observation on [DATE] at 2:45 PM, Staff A showed the approximate placement of Resident 1 when they rolled off the bed; it was less than a foot away from the edge of the bed. In an interview (undated to maintain anonymity), Anonymous Staff (AS), Licensed Staff, stated the NA should not have used one-assist for this resident with the bed pulled away from the wall. Staff AS stated Resident 1's ability to help with mobility varied, and additionally the resident carried a lot of weight in their abdomen, making it easy for them to just roll over, and off the bed. On [DATE] at 1:40 PM, Staff D, NA, stated Resident 1 had a difficult time rolling side to side and never was as able to help as much since they had returned to their room after being on isolation precautions for a skin infection (from [DATE] to [DATE]). Staff D stated they had informed the nurse of this. Staff D stated when Resident 1 had a difficult time with bed mobility and felt the bed needed to be pulled out to approach the resident from the other side, they would get a second staff to assist. Staff D stated, you never pulled the bed out without getting someone to help. Staff D stated aside from the risk of the resident just rolling off the bed during cares, locking the brakes was not sufficient to keep the bed stable, and increased the risk of the resident rolling off the bed. <Resident 4> Resident 4 admitted to the facility on [DATE] with diagnoses to include morbid obesity and adult failure to thrive. Review of Resident 4's quarterly MDS assessment, dated [DATE], showed the resident was cognitively intact. The resident required two person extensive assist with bed mobility and was dependent on two-person assist for transfers. On [DATE] at 11:52 AM, Resident 4 was observed lying in a bariatric bed. The resident stated often just one NA assisted them to roll side to side in their bed, and it is scary. The resident stated they could usually roll themself back, but not always, and stated they get me too close to the edge of the bed when they turn me and I don't like it. Resident 4 stated the other night, the NA kept pushing me and rolling me to get me changed; it was just the one NA, I was so scared I was going to roll off the bed. In an interview on [DATE] at 12:10 PM, Staff B stated sometimes Resident 4 had been able to turn with one staff assistance, but sometimes the resident was weak, and they really needed two staff assist with bed mobility. Staff B stated the resident preferred two staff to assist them with their bed mobility. <Resident 12> Resident 12 admitted to the facility on [DATE] with diagnoses to include a stroke with left hemiplegia/hemiparesis (weakness and/or paralysis on one side of the body). Review of Resident 12's MDS assessment, dated [DATE], showed they were cognitively intact. The resident required extensive assist with bed mobility and were dependent on two staff for transfers. On [DATE] at 3:00 PM, Resident 12 was observed lying in a bariatric bed. Resident 12 and their spouse stated the resident had a fallen off their bed in 2021 and now required two staff for bed mobility and cares. Resident 12 stated on an earlier occasion there had been just one staff member who assisted them with bed mobility but felt much safer with two staff due to fear or rolling off the bed. Resident 12 stated they had two strokes affecting their left side, so only have use of one hand to hang on. Reference (WAC): [DATE](3)(g)

Based on interviews and record review, the facility failed to protect one of three residents' (Resident 1) visitation rights under the state Safe Start Plan for long term care facilities. Additionally, the facility failed to ensure staff were consistent with knowledge, interpretation, and/or adherence to the facility visitation policy. This failed practice resulted in harm as Resident 1 died alone, with no visits from family or loved ones during her stay at the facility. Findings included . Review of the state document titled, Safe Start for Long Term Care Recommendations and Requirements, revised on [DATE], showed the following requirements for compassionate care visits: Examples of situations where residents would meet the criteria for compassionate care visits included residents at end of life, residents who had lived with their family before recently being admitted to a nursing home, were struggling with the change in environment and lack of physical family support. Compassionate care visits should be permitted at all times including when residents are in quarantine (isolation) status, whether residents or visitors are vaccinated or unvaccinated, and when residents are confirmed to have COVID-19 (an infectious, [CONDITION(S)] disease causing respiratory illness and in severe cases severe impairment or death). Review of the facility policy Phase Reopening Plan Update: [DATE] showed, We ask families to wait 72 hours after admit so that we can test for covid-19 . The policy also included the compassionate care (end of life companionship) requirements listed in the Safe Start plan. Resident 1 admitted to the facility on [DATE] for a hospice, five-day respite stay. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired at the facility on [DATE]. Review of a progress note, dated [DATE], showed Resident 1 was alert, confused, and seemed to understand simple questions. Review of the resident's care plan, dated [DATE], showed the resident had a terminal prognosis and was at the facility for hospice respite. The goal was comfort with dignity. The care plan did not include any information about visitation. Review of hospice notes for certification period [DATE]- [DATE] showed Resident 1 had been living at home with their daughter. Goals were for compassion and dignity every moment of life. Review of an electronic mail (e-mail) communication, dated [DATE],the reporter documented: Both the son and daughter were very close with their mom and were in shock and traumatized by the denial of family visits after having been told that they could have one family visitor per day. They feel haunted that they couldn't say good-bye and that she died alone. In an e-mail conversation with the reporter on [DATE], they stated that when they spoke with an unidentified staff member upon Resident 1's admission, the staff member never mentioned anything about no visitors for the first 72 hours. The staff member had informed the reporter that family visits were limited to one family member visit per day and limited number of family outside patients window. In an interview on [DATE] at 1:00 PM, the Administrator stated that, in order to make sure the resident was negative for COVID-19, and to have time to screen, educate, and test visitors, the facility asked for a 72 hour period before any visitors were permitted. The Administrator stated regardless if it was a compassionate care visit, there was a 72 hour wait for visits for new admissions, and stated hospice was aware of the visiting policy. In an interview on [DATE] at 2:35 PM Staff A, Licensed Practical Nurse stated they would have never turned anyone away from visiting a hospice resident. In an interview on [DATE] at 2:25 PM, Staff B, Registered Nurse/Unit Care Coordinator stated they would not have limited visitors for hospice residents. On [DATE] at 2:45 PM, Staff C, Admissions Director, stated she did not specifically recall a conversation with hospice or family about visitation for Resident 1, but would have told them they could visit after 72 hours if either the resident or visitor was vaccinated. Staff C then stated staff had wondered why Resident 1's family did not visit during the couple of days the resident was at the facility. In a telephone interview on [DATE] at 3:20 PM, Family Member 1 (FM1) stated Resident 1 admitted to the facility about noon on [DATE]. They stated they called the facility at approximately 5:00 PM to let them know they were coming to visit and were told they could not visit. FM1 stated the resident's family had promised their mother they would visit, and then the resident died the next night, with no family visits. FM1 stated this was just devastating to them. FM1's voice was trembling as they spoke. In a telephone interview on [DATE] at 3:30 PM, Family Member 2 (FM2) stated that prior to admission, family was told a family member could visit daily. FM2 stated the resident was going to be at the facility for a short stay to give FM1 a break. FM2 stated they had to go out of state the day the resident was admitted and the resident was worried, so they promised to stop by to visit on the way home. FM2 stated they called the facility at approximately 3:00 PM on [DATE] and were told they must have an appointment to visit, and the scheduler was not at the facility. FM2 stated that really upset me, I promised my mother I would come and I didn't; then she died that night. In a telephone interview on [DATE], the Director of Nursing Services (DNS) stated there was a 72 hour waiting period for visitation for all new residents including compassionate care/hospice residents. The DNS stated staff education for visitation was ongoing and had been a struggle due to all of the changes. Reference (WAC) [DATE](1)(g)(2)

Based on interview and record review, the facility failed to activate Emergency Medical Services (EMS) assistance in a timely manner for one of one resident (#1) reviewed for death at the facility. This failure delayed EMS assessment and assistance in treating Resident #1. Findings included . Review of the American Heart Association Basic Life Support for Healthcare Providers dated (YEAR), showed Adult Chain of Survival for Foreign Body Airway Obstruction included to shout out for nearby help and to activate the emergency response system. In an interview on [DATE] at 10:13 AM, the Administrator stated the facility staff follows the American Heart Association recommendations for Basic Life Support. Review of the facility policy, Removing Foreign Body Airway Obstruction-[MEDICATION NAME] Maneuver dated [DATE] stated: --Determine whether the resident was choking . --Activate the emergency response system . Resident #1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set assessment dated [DATE], he was cognitively intact, required two person physical assist with transfers and required one person physical assist with eating his meals. Review of Resident #1's current care plan under eating stated the resident may need extensive assistance due to his impaired vision and hand dexterity. The resident was able to drink fluids at times independently when using a special cup with a handle and at other times required extensive assistance with his fluids at his bedside. Review of the current swallowing care plan, showed the resident had a swallowing problem related to complaints of difficulty or pain with swallowing, coughing or choking during meals or swallowing medications. The resident was encouraged to eat in an upright position, to eat slowly, and to chew each bite thoroughly. The resident required 1:1 assistance with meals when eating in bed. Staff were to remind him to tuck his chin as needed with swallows and to swallow hard. Review of the diet order dated [DATE], Staff K, Speech Therapy, changed the resident's diet to a regular texture with thin liquids. Review of the Nutrition/Dietary Note dated [DATE] at 1:50, stated the resident was on a regular diet texture. Review of the facility incident/investigation report dated [DATE], revealed the resident had a choking episode while being assisted with his meal by Staff A, Nursing Assistant Certified. Staff A, called for assistance and Staff B, Licensed Practical Nurse (LPN), Staff C, LPN and Staff D, Registered Nurse, went to the room to assess Resident #1. Staff D, then left the room and checked the resident's resuscitation order and called the physician. At this time Emergency Medical Services/911 was not called. Review of a physician order dated [DATE] stated, Bed-bound for healing of boil/failed flap to right ischium, remind/educate on reason for bedbound status for healing. In a phone interview on [DATE] at 2:50 PM, the County Coroner stated, The resident had a piece of food in his airway and the cause of death was asphyxiation, and the death was being ruled an accident. In an interview on [DATE] at 8:50 AM, the DNS acknowledged the staff did not call 911/EMS for assistance. In an interview on [DATE] at 9:43 AM, Staff B stated she was working on the opposite hall and an aide came out of the dining room and said they needed assistance. I went to the room and the resident was coughing. I then went and got the nurse that was assigned to the resident. I was standing by only and did not call 911 or touch the resident. Staff B stated Staff C was doing abdominal thrusts and Staff D was suctioning the resident. Staff D then left the room to call the physician. In an interview on [DATE] at 10:02 AM, Staff D, stated she saw Staff B, with the crash cart and followed her to the resident room. The resident was coughing and saw Staff C, giving back blows and encouraging the resident to cough. I then set up the suction and went to call the physician. When I returned to the room, he was in bed and Staff C, was giving [MEDICATION NAME] and back blows. We then moved him to the floor and continued with back blows and [MEDICATION NAME]. I checked for a pulse and he did not have one. Additionally, when asked if she called 911 she stated, No, it happened so quickly. In an interview on [DATE] at 10:15 AM, the Director of Nursing Services (DNS) stated, 911 was called after the resident's death to let the Police know of the death in the facility. In an interview on [DATE] at 10:21 AM, Staff A stated she was assisting Resident #1 with his meal and cut up his food for him. She recalled he had meat that she cut up and stated, I shredded the meat. Staff A stated the resident indicated he had something in his throat and then said he could not breathe. Staff A then called for assistance of the nurse. When asked if she called 911 she stated, No. In a phone interview on [DATE] at 11:15 AM, Staff K stated Resident #1 had no swallowing problems, he had no problems handling food bolus, he could feed himself in the dining room, and he had standard precautions only. Staff K had no concerns with the NACs assisting the resident with his meals. In an interview on [DATE] at 2:30 PM, Staff C stated, The nursing assistant called for help and I saw Staff B coming out of the resident's room. I and Staff D, went into the resident's room and Staff B went to get the crash cart. I gave the [MEDICATION NAME] and back thrusts while Staff D set up the suction machine. Staff D, then left the room to call the physician and he expired. Staff C stated there had been no time to call 911 because everything happened very quickly. Review of the facility interventions on [DATE] through [DATE] revealed the facility documented the following: 1. Education was provided to staff on duty immediately following the incident. 2. Audit performed on [DATE] to verify all resident code status, presence of advance directives and physician orders in the medical record. 3. Education of all staff in the facility concluded on [DATE]. Additional education for all new hires will be provided on hire. 4. The facility conducted an audit to verify nursing staff current CPR training. 5. The facility plans to conduct ongoing random audits of CPR training and skills for staff. This was a past non-compliance situation and is no longer outstanding. Reference: (WAC) [DATE] (1)(3)(k)

Based on interview and record review, the facility failed to ensure 1 of 3 residents (93) reviewed for bladder and bowel functions received appropriate care and services to maintain and avoid a decline of bowel and bladder functions. This failure caused harm to Resident 93 who had a documented decline in her bowel and bladder continence and the facility failed to implement a toileting schedule to improve her continence to her prior status. Findings included: Resident 93 readmitted to the facility November 20, 2017 with [DIAGNOSES REDACTED]. According to the significant change Minimum Data Set (MDS) assessment, dated 11/27/17, the resident required extensive assist of two for bed mobility, transfers, and toileting. Resident 93 had a mild cognitive impairment. There was no documented toileting program despite documentation which noted the resident as frequently incontinent of bowel and bladder. Review of the incontinence Care Area Assessment (CAA) summary, dated 12/06/17, showed Resident 93 had a significant change in condition since she readmitted to the facility. Prior to the fall, the resident was mostly independent with her Activities of Daily Living. The CAA identified the resident as frequently incontinent of bladder and had an episode of bowel incontinence, but did not state what the facility was going to do to improve her bowel and bladder continence to prior level. Review of the incontinence care plan, dated 12/17/16, identified the resident had incontinence due to impaired mobility. The goal was to improve continence pattern to occasionally incontinent. Interventions included assess for a possible toileting schedule. Review of the Nursing Assistant (NA) Monthly Flow Record from November 1 -15, 2017 showed the resident was totally continent of bowel and was incontinent of bladder only twice. Review of the NA Monthly Flow Record from November 20 - December 14, 2017 showed the resident was incontinent of bowel three times and urine daily (multiple times a shift). This was a noted decline in urinary incontinence. Review of the medical record revealed no information the facility had recognized the resident had a decline in her bowel and bladder continence. There was no information indicating what the facility's plan was to regain the resident back to her prior level of continence. There was no evidence of a toileting schedule in place or attempted. In an interview on 12/17/17 at 10:48 AM, the resident stated since she fell she could not get up any longer on her own. She stated she had to wait on staff to use the bathroom, and sometimes it took too long and she would just go in my brief. The resident stated she was not on a toileting program but felt that it was a good idea. The resident stated she wanted to regain her continence of her bowel and bladder. In an interview on 12/18/17 at 1:34 PM, Staff I, NA stated the resident required increased assistance from staff since she had fallen. Staff I stated the resident was not on a scheduled toileting program. At 1:49 PM, Staff G, NA, stated Resident 93 was continent and able to toilet herself prior to the fall. Staff G stated the resident required increased assistance to meet her needs. Staff G stated the resident was able to state when she needed to use the bathroom, and staff would offer her a bedpan in the morning. At 2:14 PM, Staff K, Licensed Nurse (LN), stated Resident 93 required increased assistance since she had fallen. Staff K stated the resident was continent of her bowels and at times was incontinent of urine. Staff K stated the resident was not on a scheduled toileting program. At 2:25 PM, Staff N, LN, stated the resident was continent of her bowel and bladder but did wear pull-up type briefs to meet her needs. Staff N stated the resident required extensive assist of two for her needs. Staff N stated the resident was not on a scheduled toileting program. In an interview on 12/20/17 at 4:10 PM, the Director of Nursing Services (DNS) and Staff Q, Corporate Nurse, were made aware the facility failed to regain Resident 93's continence back to the prior level. No further information was provided. Reference: WAC 388-97-1060(3)(c) This was a repeat citation from the annual survey conducted on 11/07/16.

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent avoidable pressure ulcers for 1 of 2 residents (93) reviewed for pressure ulcers. The facility failed to evaluate the resident's clinical condition and identify pressure ulcer risk factors. The facility failed to comprehenisvely assess the resident's clinical condition and provide pressure ulcer care which was consistent with the professional standards of care. These failures resulted in a change to Resident 93's skin which resulted in the development of three Deep Tissue Injuries (DTI), in which one deteriorated to an unstageable wound, while in the facility. Findings included: The Resident Assessment Instrument (RAI) Manual defined the stage of a pressure ulcer (PU) as followed: -A stage III pressure injury (ulcer) was described a full thickness loss of the skin. - An unstageable pressure injury (ulcer) was full thickness skin and tissue loss was obscured by slough or eschar. -A Deep Tissue Injury (DTI) was described as intact or non-intact skin with localized area of persistent non-blanchable deep red, marron, or purple discoloration. Resident 93 readmitted to the facility November 20, 2017 with [DIAGNOSES REDACTED]. According to the Minimum Data Set assessment, dated 11/27/17, the resident required extensive assist of two for bed mobility, transfers and toileting. Resident 93 had mild cognitive impairment, was frequently incontinent of bowel/bladder and was at risk for PU development. Review of the PU Care Area Assessment (CAA) summary, dated 12/06/17, showed the resident had a significant change in condition and required increased assistance from the staff. The resident was toe touch weight bearing on the left lower extremity and non-weight bearing on the left upper extremity. The CAA identified the resident had a DTI on her coccyx. There was no further assessment on what the facility was going to initiate or change to prevent further skin breakdown or promote wound healing. Review of the PU care plan showed the resident was at risk for developing a pressure ulcer. Interventions included to assist the resident in repositioning, discuss non-compliance issues with the resident, discuss risk factors and prevention and to position with pillows to maintain proper body alignment. Review of the hospital Patient Care Transfer Summary, dated 11/20/17, showed Resident 93 had no skin impairment on the coccyx. On the Initial Data Collection Tool, dated 11/20/17, Staff L, License Practical Nurse (LPN)/Resident Care Manager, documented the resident had a left hip incision, bruising on the inner aspect of both upper arms and old scarring on the coccyx. Review of the facility Weekly Skin Integrity Data Collection (WSIDC) sheet, dated 11/20/17 (the same day as the initial assessment), Staff L documented the resident had an incision on the left hip and a sling on the left shoulder. There was no documentation indicating the resident had old scar tissue on the coccyx or bruising. The Braden Scale assessment (a standardized assessment tool), dated 11/20/17 (and subsequent assessments done on 11/25/17 and 11/28/17), showed the resident was at risk for PU development. The resident was not identified as having a history of PU's or old scarring on any of the three different Braden Scale assessments. The WSIDC sheet, dated 11/26/17, showed the resident had a left hip incision, bruising on both arms and no skin impairments on the coccyx. Review of a progress note, dated 11/28/17 at 12:02 PM, showed the Licensed Nurse documented .area to coccyx surface area 2.0 x 2.0 cm with dark maroon area to center measuring 0.4 x 0.2 cm . The nurse did not indicate if there were two different areas on the resident's coccyx or if the skin was intact. Review of the facility PU investigation, dated 11/28/17, revealed when the resident readmitted to the facility, she required increase in staff assistance to meet her needs. The investigation stated the PU was unavoidable due to the resident's overall decline in condition, newly on [MEDICATION NAME] (a blood thinner), WB (weight bearing) restrictions, advanced age and due to her noncompliance. The investigation stated the resident's care plan was changed to require extensive assist of two people for bed mobility and transfers to further decrease the risk of shearing/pressure. Review of the Nursing Assistant (NA) Monthly Flow Report from November 28 through December 14, 2017 showed the NA performed bed mobility with one staff member every day on the day shift, 7 days on the PM shift and 2 times on the Night shift. The resident transferred with one staff member 12 out of 17 days on the AM shift and 2 out of 14 days on the PM shift. Review of the November 20 through December 20, 2017, nursing progress notes showed the resident refused therapy once, medications once, to get up twice, refused boots in bed twice and coccyx dressing change once. The Licensed Nurse documented consistently the resident was pleasant and cooperative with care. Review of the PU status record, dated 12/05/17, showed the coccyx PU was a stage III and measured 3.0 cm by 1.2 cm. Review of the PU status record, dated 12/12/17, showed the stage III PU was 1.7 cm by 0.5 cm by 0.1 cm deep. On 12/19/17, the coccyx PU was 1.2 cm by 0.5 cm by ? depth. The PU was now unstageable. Review of a progress noted, dated 12/14/17, showed the resident had a dressing on the right outer ankle due to a red area. The documentation did not show if the red area was blanchable or what the staff did to protect from further skin breakdown. Review of a progress note, dated 12/15/17, showed the resident had a red area to the right ankle and a dressing placed to protect the skin. The documentation did not show if the red area was blanchable or what the staff did to protect for further skin breakdown. Review of a progress note, dated 12/19/17, showed the resident had a 1.2 cm by 1 cm, maroon colored area with darkened center new area on the right ankle and a 2.5 cm by 3 cm dark area to the left heel. Review of the PU status record showed the left heel PU was a DTI and developed on 12/19/17. Review of the PU status record showed the right ankle PU was a DTI and developed on 12/19/17, even though the right ankle was first observed on 12/14/17. In multiple observations on 12/11/17, 12/12/17, 12/14/17, 12/15/17 and 12/18/17, the resident was in sitting in the wheelchair (not tilted back) watching television, listening to music or slouched over sleeping. In an interview on 12/18/17 at 1:34 PM, Staff I, NA stated the resident needed reminding to lay down between meals and to change position. Staff I was not aware the resident had a current pressure ulcer. At 1:49 PM, Staff G, NA, stated the resident did not refuse to reposition or lay down between meals. At 2:03 PM, Staff O, LN, stated the resident did not refuse care, but would at times state not right now. When this occurred, staff would re-approach and the resident would lay down or reposition. At 2:14 PM, Staff K, LN, stated Resident 93 was very re-approachable when she exhibited any type of behavior. At 2:25 PM, Staff N, LN, stated the resident did not refuse care. Staff N stated the resident's dressing was changed at bedtime. The resident usually worked with therapy in the afternoon, stayed up for dinner and then laid down. Staff N stated Staff L, LN, measured the wound weekly. The resident's wound was not observed due to supporting the resident's preferences. During an interview on 12/20/17 at 4:10 PM with the DNS and Staff Q, Corporate Nurse, the DNS stated the resident had a history of [REDACTED]. The DNS was made aware the documentation in the resident record, recent MDS assessment, and interviews did not collaborate the resident had refused care since her return to the facility. The DNS stated when the resident was readmitted , the care plan was changed to have two people assist her with bed mobility and transfers. The DNS was made aware the nursing assistant daily documentation did not reflect two staff were used to help with bed mobility and transfers. The DNS was made aware the documentation did not reflect what interventions the facility implemented regarding the development of the additional pressure ulcers on the right ankle and left heel. The facility failed to provide care to the resident which was consistent with professional standards of care to prevent pressure ulcers. The facility failed to identify risk factors and implement interventions that were consistent with the residents needs, goals, and professional standards of care. The development of these pressure ulcers was an avoidable situation. Reference: WAC 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to consistently implement interventions for 3 of 6 residents (48, 93 and 63) reviewed for nutrition. This failure of not consistently implementing individualized interventions, following Registered Dietician (RD) recommendations caused to Resident 48 who experienced a 7.5% severe weight loss in one month. Findings included: RESIDENT 48 Resident 48 was a long-term care resident with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment, dated 10/20/17, the resident had significant cognitive impairment, sometimes understood/understands what was said, required extensive assistance with meals and had weight loss (which was not physician prescribed). Review of the nutritional care plan showed the resident was at risk for weight loss. The goal was the resident would sustain no significant weight loss or gain through the next review date. Interventions included offering a substituted if ate less than 50% of the meal, provide the resident/responsible party nutritional updates and education as needed (has a nephew who lived nearby), family encouraged to bring her favorite Indian dishes, small portions at breakfast and lunch to deter further weight gain, monitor weights and notify the physician and RD of significant changes. Review of the medical record showed the resident had been exhibiting nausea and vomiting at the beginning of the year. A cat scan was done on 01/31/17. The results showed there was no explanation for why they resident had nausea and vomiting. No further gastrointestinal (GI) work up was done. On 06/06/17, the resident weighed 163 pounds. On 11/05/17, the resident weighed 142 pounds, which was a 10-pound or 7.5% severe weight loss in 1 month. On 12/07/17, the resident weighed 132 pounds, which was a 31-pound or 23% severe weight loss in 6 months. Review of a physician progress notes [REDACTED]. The Certified Nursing Assistant (CNA) reported to the physician, the resident seemed to vomit only when she ate too fast or drank really hot coffee. The physician did not make any changes to her plan of care. Review of an RD noted, dated 08/03/17, showed the resident had weight loss and recommended small portions for weight control. The goal was for weight loss of 170 pounds +/- 5 pounds. Review of a RD note, dated 09/07/17, the resident, with an interpreter present, was asked why her intake was low, if she was depressed or if she felt ill/lethargic. The resident did not answer the questions. When asked if she wanted any ethnic foods, she stated she would like Roti bread, but not when she was served rice. The RD updated the resident's preferences. Review of a RD note, dated 10/05/17, showed the resident had episodes of vomiting after eating. The nursing staff reported to the RD the resident did not always accept the boost breeze or a snack. The RD recommended to change the boost breeze to Xtra-cal plus twice daily at AM and PM snack. Review of the October Medication Administration Record [REDACTED]. The LN documented the resident consumed 100% of the boost breeze and did not document to the Xtra-Cal supplement. Review of a RD note, dated 11/02/17, showed the resident continued with episodic vomiting. Weight loss was identified. The RD stated the Xtra-cal plus supplements were in place but the resident had been refusing. The RD recommended to discontinue the Xtra-cal and implement 4 ounces of med pass 2.0 supplement twice daily. Review of an RD noted, dated 11/09/17, showed the resident with weight loss and vomiting. The RD stated there were supplements in place but the resident no longer accepts the Xtra-cal and generally consumes only 25% of the boost breeze. The RD recommended discontinue the boost breeze and Xtra-cal and add med pass 2.0 four ounces twice daily. Review of the November 1 through 10th MAR indicated [REDACTED]. The LN documented the resident accepted 100% of the Xtra-cal supplement and 25% of the boost breeze. Further review of the November MAR indicated [REDACTED]. The LN documented the resident consumed all of the Ensure clear, and zero to 100% of the med pass. Review of a physician progress notes [REDACTED]. The physician did not address any weight loss the resident had been experiencing. Review of a RD noted, dated 12/01/17, showed the resident continued to have occasional vomiting and continued weight loss. The resident's BMI was 25, which remained normal-overweight. The RD reviewed supplemental acceptance with nursing and recommended to change med pass 2.0 to three times a day with medications and Ensure clear twice daily. Review of the MAR indicated [REDACTED]. The LN documented the resident consumed zero to 100% of the supplements. Review of the November to December 14 meal monitor showed the resident at less than 50% of breakfast 8 times, lunch 7 times and dinner 21 times with no meal replacement being offered or documented. On 12/11/17 at 12:50 PM, 12/14/17 at 12:45 PM, and 12/15/17 at breakfast, the resident was observed to feed herself. In an interview on 12/18/17 at 1:34 PM, Staff I, NAC, stated when a resident ate less than 50% of their meal, she would alert the nurse. When she offered a health shake or a meal replacement, this information was documented on the meal monitor under the snack column. Staff I stated Resident 48 was able to feed herself with set up assistance. Staff I stated the resident was prone to vomiting after meals or when she consumed hot liquids. At 1:49 PM, Staff G, NAC, stated Resident 48 had some frequent vomiting. Staff G stated the resident could answer simple yes or no questions, and if she needed the basin (because she was going to get sick) she would point at it. Staff G stated the resident seemed to vomit if she ate her meal or drank her fluids too quickly. Staff G stated when a resident ate less than 50% of their meal, she would alert the nurse and offered a replacement. Staff G stated there was no place on the meal monitor to document when a replacement was offered. At 2:03 PM, Staff O, Registered Nurse, stated when a resident ate less than 50% of their meal, they would offer a meal replacement or alternative. Staff O was not sure where the NAC would document when a meal replacement was offered. Staff O stated there was a correlation between when the resident ate too fast and vomiting. Staff would cue the resident to slow down, but over this past month having her slow down did not seem to matter. At 2:14 PM, Staff K, Licensed Practical Nurse (LPN), stated when a resident ate less than 50% of their meal a health shake was offered. Staff K was not aware where this information was documented. Staff K stated Resident 48 had a gastrointestinal consult coming up related to her occasional vomiting. Staff K stated they have attempted to have her slow down with meals and that helped for awhile, but no longer does. At 2:25 PM, Staff N, LPN, stated Resident 48 had on and off vomiting. Staff N stated the resident would pocket her food or put too much food in her mouth and that would cause her to vomit. Staff N stated the resident liked clear Ensure and did not care for the supplement Xtra-cal. In an interview on 12/20/17 at 8:56 AM, Staff L, LPN/Resident Care Manager (RCM), stated the RCM was responsible to follow through on all RD recommendations. Staff L was made aware of the missed RD recommendations. Staff L stated the resident's family had not been involved for several months. Staff L stated the facility had been working with the RD and physician on increasing the resident's caloric intake. Resident 48 had a gastrointestinal consult next week. Staff L stated the facility gave the resident the Indian flat bread, but she did not like it. Staff L stated the family had not been involved in her care for about six months. Staff L was not able to state if the resident had ever been asked what the resident's nutritional/weight goals have been. Staff L was not aware when the resident gained weight and weight 170 pounds, if the resident wanted to loose weight. In an interview on 12/20/17 at 9:24 AM, the Director of Nursing Services (DNS) stated she was involved in the care conference on 12/13/17. The DNS stated there was an interpreter present and they did ask her about her code status and a feeding tube. The DNS stated when the resident asked if she wanted her code status changed, the resident responded I want to live. The DNS stated the resident was asked about a feeding tube, but was not able to understand what a feeding tube was. The DNS was informed there was no information in the progress notes that the resident was asked about a feeding tube. The DNS was asked if the resident was ever asked what her nutritional/weight goal was. The DNS was informed the RD consults were not consistently followed up on. The DNS stated the facility was working on where the staff documented the meal replacement. The DNS stated she would follow up on the concerns. In an interview on 12/21/17 at 930 AM, the DNS, Staff Q, Corporate Nurse and the RD stated not following the RD recommendations would not have affected the amount of calories the resident took in. The staff was not able to answer why the RD recommendations were not followed up on or if there was a potential systematic concern. The staff were not able to state if the resident was ever asked what her nutrition/weight goal was. The DNS stated the facility had not been able to get a hold of the resident's family members for the last six months. RESIDENT 93 Review of the MAR indicated [REDACTED]. Review of the nutrition care plan revealed the resident was identified at risk for weight loss due to malnutrition. An intervention included to offer a meal replacement when she ate less than 50% of her meal. Review of the meal monitor from November 20th through December 14, 2017 showed the resident ate less than 50% of her breakfast 13 times, lunch 15 times and dinner 12 times. The NAC documented a meal replacement was offered 5 times for lunch, 4 times for dinner and none for breakfast. In an interview on 12/18/17 at 1:29 PM, Staff M, NAC, stated when a resident ate less than 50% of their meal she would offer the resident something different to eat, offer a health shake and alert the nurse. Staff M stated when a replacement was offered this was not documented anywhere. During an interview on 12/20/17 at 4:10 PM with the DNS stated when a resident ate less than 50% of their meal there was no place the staff documented this information. The DNS was aware Resident 93 was at risk for weight loss and the staff did not offer her a meal replacement when she ate less than 50% of her meal. RESIDENT 63 Resident 63 was admitted in October 2017 with [DIAGNOSES REDACTED]. In a review of the MDS assessment, dated 10/18/17, revealed Resident 63 required 1 person physical assist with personal hygiene and activities of daily living. In a review of the nursing care plan for eating included the following intervention Supervision with setup, encourage self-performance, provide cues. Assist with feeding PRN (as needed) to complete meals. In a review of the nutritional care plan intervention included to offer the resident substitutes if eating less than 50% of the meal. In a review of the Nursing Assistant (NA) meal consumption documentation revealed in October 2017 there were 15 meals with less than 50 percent of the meal consumed. In November, there were 14 meals with less than 50 percent consumed and in December, there were 14 meals with less than 50 percent consumed. In a review of the Registered Dietician progress note, dated 11/21/17, revealed a weight loss of 10 pounds in one month. In an interview on 12/18/17 at 10:51 AM, Staff Z, Registered Nurse, stated she was unsure if there is any documentation of meal replacement when a resident ate less than 50 % of a meal or refuses a meal. At 12:49 PM, Staff X, NAC, stated when a resident ate less than 50 percent of a meal the resident was offered a replacement. Staff X stated they do not chart when a resident is offered a replacement and do not document how much of the replacement was consumed. Reference: (WAC) 388-97-1060 (3)(h)

Based on interview and record review the facility failed to provide necessary care and services to maintain the highest level of well-being for 1 of 7 residents (1). The facility failed to thoroughly assess the etiology of the resident's behavioral symptoms, medical conditions and treatments, falls and weight loss. These failures resulted in harm of clinical compromise, mental anguish, and subsequent decline of Resident 1's condition. Findings include: According to the Centers for Medicare and Medicaid Services, [MEDICAL CONDITION] and dementia are now recognized as being related. Individuals with dementia are at higher risk for developing [MEDICAL CONDITION] and it now appears that [MEDICAL CONDITION] increases the risk of developing dementia over time. Recognizing [MEDICAL CONDITION] is critical, as failure to act quickly to identify and treat the underlying causes which may result in poor health outcomes, hospitalization or even death. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with an order for [REDACTED]. A record review for April revealed, the resident had multiple times when she suffered from anxiety. The resident had the frequent need to urinate and would call out to make her needs known. On 04/14/17 the resident received a medication called [MEDICATION NAME] (used to decrease irritation of the urinary tract). On 04/08, 04/19, 04/20 and 04/26/17, it was noted by licensed staff the resident had crackles, wheezes and lower extremity [MEDICAL CONDITION]. There was no record of the physician being notified of these changes. Licensed staff failed to acknowledge that changes in her breathing patterns has been known to increase a person's anxiety. On 04/21/17, the resident continued to have urinary frequency and the physician ordered a medication called [MEDICATION NAME] (used to decrease bladder spasms). The resident was placed on alert charting for three days to monitor for the side effects of the medication. Unfortunately, the resident did not receive this medication in the month of April. During the month of April the resident received [MEDICATION NAME] (an antianxiety medication) 23 several times for behaviors of calling out and frequent urination. No interventions were put into place to address the resident's frequent need to urinate. The resident fell on [DATE] while attempting to toilet herself. In May the resident continued to call out and experience frequent urination. The [MEDICATION NAME] was started on 05/01/17. Another medication called [MEDICATION NAME] (an anti-depressant) was started. On 05/31/17 in a progress note [MEDICATION NAME] was ordered again for the resident's increased urinary frequency and the residents increased agitation. The resident had 3 falls in the month of May. Behaviors of screaming and frequent need for care continued. In June the resident had 6 falls. The fall on 06/13/17 had her going to the hospital for a head scan. On 6/28/17 it was discovered the resident had not been receiving her [MEDICATION NAME] (used for [MEDICAL CONDITION]). The resident was also started on [MEDICATION NAME] (an anti-psychotic) on 06/27/17. It was also noted the physician had ordered lab work for the resident's [MEDICAL CONDITION] on 06/16/17, the test was not completed until 06/29/17. In an physicians order dated 06/29/17 the physician wrote hyperthroidism is making her scream, needs endocrine consult and labs. On June 30th it was also discovered that the resident was not receiving her ordered [MEDICATION NAME] (a diuretic). This was another error that occurred where the resident was experiencing [MEDICAL CONDITION] in her extremities and it was because she was not receiving her ordered medications. Three essential medications were not administered to this resident who experienced negative physical and mental changes as a result of the omissions. The resident fell 5 times in the month of July. As of 07/18/17 the resident was still waiting to see mental health and was still waiting to be seen by an endocrinologist (a physician who takes care of diseases of the endocrine system and the glands of the endocrine system that produce hormones, which are chemical substances that regulate many important body functions. an order for [REDACTED]. Shut the door and check on her every 30-60 minutes. This order was placed on the resident's treatment administration record (TAR) as information for staff. an order for [REDACTED]. Review of the resident's care plan in the paper chart on 07/21/17 revealed the lack of care planning for the resident's [MEDICAL CONDITION], dementia, and distressing behaviors. In an interview on 07/27/17 at 10:51 AM, Staff A, RN stated, I would look in the resident's hard (paper) chart to reference the resident's care plan. At 11:04 AM, Staff B, Licensed Nurse (LN) stated, the resident's care plan in the resident's chart under the care plan tab in the paper chart. At 11:06 AM, Staff C, LN stated, I would access the resident's care plan in the resident's hard chart. In an interview at 12:30 PM, Staff E, LN and Staff D, LN both confirmed the care plan the staff referenced is located in the residents hard paper chart kept at the nurses stations. Staff E, LN stated, I hopefully remember to print the updated care plan, there have been a couple of times where I was interrupted and did not print the updated care plan. Staff D, LN stated, that is part of the problem with having a hybrid chart. On 07/21/17 at 12:24 PM, the Director of Nursing Services (DNS) confirmed the staff are supposed to look in the hard chart to reference the resident's active care plans. The DNS was asked if the resident had any behavioral or dementia related care planned interventions. The DNS stated all interventions should be on the care plan. The DNS looked through the care plan and stated the actual dementia or behavioral care approaches are not in this care plan. The facility administrator provided a care plan from the computer, but per the DNS and the staff, neither were currently using this version of the care plan, they rely on the hardcopy in the resident's chart. The copy in the chart was not current. The resident also experienced weight loss which can be a symptom of [MEDICAL CONDITION]. The Registered Dietitian noted the weight loss was from [MEDICATION NAME] use. The [MEDICATION NAME] was not given for 30 days, so this was not a reason for the resident 8% weight loss in three months. Per Lippincott 10th edition (2014), the signs and symptoms of [MEDICAL CONDITION] are nervousness, emotional liability, irritability, difficulty sitting quietly. It may progress to emaciation (being abnormally thin), extreme nervousness, [MEDICAL CONDITION], disorientation, [MEDICAL CONDITION] crisis, and or death. The resident was exhibiting all the above symptoms and she was not receiving her ordered medications. Her distressing behaviors were medicated and the reason for her distress was not assessed by licensed staff. Staff did not have interventions on the care plan to utilize. The resident had mental anguish for months, as the staff monitored screaming as the primary behavior. The facility failed to give ordered medications, notify the physician, and perform ordered lab work which was necessary to treat medical conditions. The resident also lost weight during the three months she has been at the facility These failures had a negative effect on the resident's health and behaviors. The facility failed to maintain the resident at the highest practicable level of health. Refer to WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 2 residents (1 and 2). Failure to review and transcribe physician's orders [REDACTED]. Findings included: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In a review of the resident's medical chart and incident reports showed: The resident had an order for [REDACTED]. In an interview with the Director of Nursing Services on 07/28/17 at 11:30A.M., she stated she was unaware of the medication error. The resident also received an order for [REDACTED]. The resident received an order for [REDACTED]. On a Fax Order Request/Notification Form dated 6/28/17, an LPN documented it was discovered that the medication ordered on [DATE] for [MEDICAL CONDITION] was never started. The physician responded on 6/29/17: She is [MEDICAL CONDITION] - that's why she is screaming. In an interview with the Director of Nursing Services on 07/28/17 at 11:30A.M., she stated she was unaware of the medication error and there was no investigation into the missing medication. Per Lippincott 10th edition (2014), the signs and symptoms of [MEDICAL CONDITION] are nervousness, emotional liability, irritability, difficulty sitting quietly. It may progress to emaciation (being abnormally thin), extreme nervousness, [MEDICAL CONDITION], disorientation, [MEDICAL CONDITION] crisis, and or death. The resident was exhibiting all the above symptoms and she was not receiving her ordered medications. The resident had mental anguish for months, as the staff monitored screaming as the primary behavior. The facility failed to give ordered medications, notify the physician, and perform ordered lab work which was necessary to treat medical conditions. These failures had a negative effect on the resident's health and behaviors. The facility failed to maintain the resident at the highest practicable level of health. The facility failed to transcribe 3 physician ordered medications to treat the resident's medical conditions. This failure resulted in the resident experiencing frequent need for urination, multiple falls, and increased behaviors from the lack of appropriate medications being transcribed and dispensed as ordered. The facility failed to provide ordered medications for an extended amount of time for the same resident. The facility also failed to fill out behavior and medication monitoring sheets for resident 1. Resident 2 Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A medication error report dated 06/28/17 revealed an order for [REDACTED]. The resident had to restart the antibiotic because of this error. A failure to recognize the importance of checking the orders to ensure the residents are getting the correct medications resulted in a resident receiving an additional course of antibiotics. On 07/21/17 at 12:24 PM, the Director of Nursing Services (DNS) was unable to provide any further information. Refer to F 281, F 309 and F 514 for additional information Reference (WAC) 388-97-1060 (3)(k)(iii)

Based on observation, record review and interview the facility failed to ensure adequate indications were indicated prior to starting mind altering medications for 1 of 7 residents (1) reviewed. The facility failed to thoroughly assess the possible causes of behaviors, but instead gave the resident additional medications to control behaviors which resulted in harm of clinical compromise, mental anguish, and subsequent decline of Resident 1's condition. Findings Include: Resident 1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. D(NAME)UMENTATION OF BEHAVIORS Behavioral sheets on 04/07/17 monitored the resident for auditory hallucinations, visions, screaming, and refusals of care. In April the documentation for screaming behaviors interventions were to toilet, give food, give fluids, change position, to re-direct and 1 to 1. In April the resident had no auditory hallucinations, no visions, no delusions, and no refusals of care. The resident did scream out during the month, it is difficult to numerically asses the amount of times as the staff did not fill out the monthly behavioral intervention sheet as per the directions on the sheet. There is one time the sheet noted to refer to a nurses note, but the note did not refer to any screaming behaviors. Five times it was noted the resident had continuous screaming on the night shift. The resident received [MEDICATION NAME] 0.5 mg by mouth 25 times in April for increased anxiety- no description of what the symptoms the resident was displaying. Interventions to decrease anxiety included toileting, food, fluids and changing position. In May the resident received [MEDICATION NAME] 0.5 mg for increased anxiety 28 times, again screaming was the only behavior with noted on the behavior sheets in May. In June the resident received [MEDICATION NAME] 0.5mg for increased anxiety and yelling 22 times. Whether the medication was effective was incomplete twice on the medication notes. The medication was discontinued 06/19/17. The June Medication Administration Record [REDACTED]. There was no documentation on the nurses medication notes as to why the resident received the medication nor if it was effective. In a physician's orders [REDACTED]. This was when it was realized the resident did not receive her [MEDICATION NAME]. In an a faxed order dated 07/09/17, staff documented in addition to falling twice in 24 hours, she has been extremely agitated, she calls out help me constantly, even when being helped. We have redirected, given snacks, taken to the bathroom. Ignored her and asked repeatedly what she wants. Can we have an antianxiety medication? The physician's response to the fax was: [MEDICATION NAME] 30mg by mouth twice a day. Do not reinforce this behavior by responding repeatedly. Shut the door and check on her every 30-60 minutes. The staff placed this on the treatment administration record (TAR) as information for the staff. The facility failed to recognize the importance of the resident receiving her ordered medications and failed to transcribe several vital medications. A variety of medications were used to control behaviors that may not have existed, had the primary medical issues been treated as ordered. The nursing staff gave [MEDICATION NAME] for screaming in a three month period, a total of 75 times. See also F 281, 309 and 323. Refer to WAC 388-97-1060 (3)(k)(i)

Based on observation, record review and interview the facility failed to provide prescribed medications as ordered for 2 of 7 residents (1 and 2) reviewed, failed to assess Resident 1 for symptoms that may have contributed to behaviors and failed to provide ordered medications but instead gave the resident additional medications to control behaviors. This caused the resident harm as some of the symptoms may have contributed to the increase in falls that lead to a head injury, who had a history of [REDACTED]. Findings included: Per Lippincott 10th edition (2014), the signs and symptoms of [MEDICAL CONDITION] are nervousness, emotional liability, irritability, difficulty sitting quietly. It may progress to emaciation (being abnormally thin), extreme nervousness, [MEDICAL CONDITION], disorientation, [MEDICAL CONDITION] crisis, and or death. Per the National Institutes of Health (NIH) [MEDICAL CONDITION] is a mental state in which a person is confused, disoriented, and not able to think or remember clearly. The person may be agitated and have hallucinations. It is characterized by indecision, general disorientation, cognitive impairment, mood shift, and inability to focus. The longer the [MEDICAL CONDITION] goes untreated, the more progressive the disorientation becomes. Metabolic disorders can cause [MEDICAL CONDITION]. One of the most frequent causes of [MEDICAL CONDITION] in the elderly is overmedication. Resident 1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident did not receive the ordered medications of [MEDICATION NAME] (a diuretic), oxybutin (used for bladder spasms), and [MEDICATION NAME] (to treat [MEDICAL CONDITION]). The resident exhibited all of these symptoms and instead assessing the resident for exhibited symptoms and receiving her ordered medication the resident received the following unecessary medications without clinical justifications. [MEDICATION NAME] as needed for anxiety was ordered on [DATE]. [MEDICATION NAME] (used to treat anxiety) was ordered on [DATE] and given on 06/21/17. [MEDICATION NAME] (an anti-depressant) was started on 05/10/17. [MEDICATION NAME] 3 mg to be given for sleep was ordered on [DATE]. On 06/12/17, the [MEDICATION NAME] was increased to 6 mg every night for sleep. [MEDICATION NAME] (used to treat overactive bladder) was ordered on [DATE] but the resident did not receive the medications until 11 days later 05/01/17, due to a transcription error. Osphena (used for vaginal pain) was added on 06/23/17, and started on 06/24/17. [MEDICATION NAME] (used to relieve symptoms of urinary problems) 200mg by mouth three times a day for urinary frequency on started on 06/16/17. [MEDICATION NAME] (a diuretic) was ordered 05/12/17 and was not given to the resident from 06/01/17 until 06/27/17 because of a transcription error. On 06/26/17 a new order for [MEDICATION NAME] was received and the medication was finally given. The resident continued to have extremity [MEDICAL CONDITION] while not receiving the ordered [MEDICATION NAME]. In a third missed medication for resident 1, the investigation noted [MEDICATION NAME], a diuretic, was ordered on [DATE] and was not transcribed to the June MAR. A new order for [MEDICATION NAME] was received on 06/26/17, when the error was noted. The Registered Dietician documented the resident's weight loss was attributed to the use of [MEDICATION NAME], a decrease in fluid retention could attribute to the weight loss. The resident did not receive the physician ordered [MEDICATION NAME] from 06/01 until 06/27/17, therefore weight loss in June was not related to this medication use. In addition, a lab was ordered on [DATE] to check on [MEDICAL CONDITION] levels, the lab was not completed until 06/29/17. [MEDICATION NAME] (for [MEDICAL CONDITION]) was ordered on [DATE]. The resident received the first dose almost 6 weeks after being ordered on [DATE] related to a transcription error. On a Fax Order Request/Notification Form dated 6/28/17, an LPN documented a request for lab work and a urinalysis, because it was discovered that the medication order 5/15/17 for [MEDICAL CONDITION] was never started. The physician responded on 6/29/17: She is [MEDICAL CONDITION] - that's why she is screaming. The facility failed to transcribe 3 physician ordered medications to treat the resident's medical conditions. This failure resulted in the resident experiencing frequent need for urination, multiple falls, and increased behaviors from the lack of appropriate medications being transcribed and dispensed as ordered. The facility failed to provide ordered medications for an extended amount of time for the same resident. The facility also failed to fill out behavior and medication monitoring sheets for resident 1. See also F 329 for additional information related to medications and F 309 for additional information related to failure to assess and medications. Resident 2 Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A medication error report dated 06/28/17 revealed an order for [REDACTED]. The resident had to restart the antibiotic because of this error. A failure to recognize the importance of checking the orders to ensure the residents are getting the correct medications resulted in a resident receiving an additional course of antibiotics. On 07/21/17 at 12:24 PM, the Director of Nursing Services (DNS) was unable to provide any further information. See also F 309, F329, F 333 and F 514 for further information. WAC reference: 483.25(l)(1)

Based on observation, interview, and record review the facility failed to provide necessary care and services for 5 of 7 residents (1, 58, 60, 13 and 10) when the facility failed to accurately assess and treat Resident 1's pain, ensure Resident 58 and 60's fluids were consistently monitored, Resident 13's call light was within reach and splints were properly placed on her bilateral upper extremities (BUE) and ensure coordination of hospice services for Resident 10 were in place. This failure caused harm to Resident 1 who experienced pain when range of motion services was provided. Findings include: PAIN Resident 1 had [DIAGNOSES REDACTED]. Resident 1 was severely cognitively impaired and was not interviewable. Review of the Minimum Data Set (MDS) assessment dated [DATE], Resident 1 required extensive assistance of two people for bed mobility and dressing and was dependent with transfers. The MDS revealed the resident had no pain indicators. Review of the care plan dated 10/24/16, directed staff to monitor the resident for non-verbal indicators of pain which included facial grimacing, restlessness, tearfulness and body rigidity. If the resident was restless, agitated, screaming, pinching or scratching during care to stop and re-approach. Additionally, if the resident tensed up or pulled away, staff were directed to allow the resident to calm down before resuming care. Review of the resident's restorative program revealed the resident received daily passive range of motion (PROM) to her upper and lower extremities. On 11/02/16 at 10:23 AM, Staff E, Restorative Aide (RA), was observed to provide PROM to Resident 1. Staff E removed a soft splint from the resident's left hand, provided hand hygiene and then placed the soft splint back on. Resident 1's body was observed to be rigid and she was noted to wince several times during the activity. Staff E then performed PROM to the resident's left upper extremity. After the 3rd repetition, the resident started to squirm and attempted to pinch Staff E with her right hand. Staff E continued to stretch out the resident's left arm/elbow while the resident was moaning and squirming. At no time did Staff E stop or ensure the resident was not in pain. Staff E then performed PROM to the resident's right arm. The resident was observed to moan, squirm and held her body rigid. Staff E then proceeded to the resident's right lower leg. Again, the resident was moaning and rigid. As Staff E started to perform PROM to the resident's right toes, Resident 1 screamed out three times and pulled her right leg away. Staff E did not stop, per the care plan, but moved to the resident's left side and started to perform PROM to the left lower leg. At 12:47 PM, Staff E stated she was aware of the resident's plan of care. Staff E further stated when the resident screamed this was related to a behavior and not to pain. Staff E stated the resident was quieter this particular day. Staff E did not report any of the above observation to the Licensed Nurse (LN). Review of the Medication Administration Record (MAR) indicated the resident received [MEDICATION NAME] (a pain medication) every morning, [MEDICATION NAME] every day at 11:30 AM ( prior to getting up), [MEDICATION NAME] (a muscle relaxant) every six hours and [MEDICATION NAME] as needed for pain. The MAR directed the LN to monitor the resident's pain every shift. Review of the September through October MAR reveled the LN documented a 0 every shift. This indicated the resident had no pain. Further review of the MAR revealed the resident received no as needed pain medication. In a prior observation on 11/01/16 at 10:49 AM, Staff F, RA, was observed to perform PROM to the resident's left hand. The resident was observed to call out, and Staff F stopped, talked with the resident in a soothing voice and waited before she continued with the PROM. In an interview on 11/02/16 at 1:36 PM, Staff H, LN, stated the the Abbey Pain Scale (which assessed the resident's body language, facial expressions and verbalizations) was used to assess pain for non-communicative residents. The LN was to assess the resident's pain and administer as needed pain medication. Staff H stated the NA was responsible to report any verbal and non-verbal signs of pain to the LN. In an observation on 11/03/16 at 11:40 AM, after the resident received her routine dose of pain medication, Staff AA, NA, transferred the resident out of bed to her chair with no grimacing, yelling or rigidity. The resident was smiling at Staff AA. On 11/03/16 Staff O, Physical Therapist, assessed the resident's range of motion (ROM). When Staff O performed ROM to the resident's left hand, the resident pulled her hand away and shook her head no. Staff O did not attempt any further ROM to left hand. Review of the medical record revealed the resident was not pre-medicated for her pain prior to Staff O providing ROM. On 11/04/16 Staff J, Speech Language Pathologist, evaluated the resident for speech sound production and language comprehension. Staff J stated the resident demonstrated a reliable yes gesture (shaking her head) in 5/5 opportunities when she was asked direct questions related to the resident's personal demographic information (for example, was your date of birth 07/28/45). When Staff J asked the resident a no type question, the resident often would not respond. Staff J stated the nursing staff relied on the resident's body language (for example facial grimaces) in order to determine if the resident was experiencing pain. The facility failed to identify Resident 1 was experiencing pain when PROM was being performed. Staff E was observed to continue with the PROM even when the resident expressed verbal and non-verbal indicators of pain causing pain and distress to the resident. [MEDICAL TREATMENT] RESIDENT 58 Resident 58 received [MEDICAL TREATMENT] three times a week. Review of a physician order [REDACTED]. Review of the MAR, weight record and progress notes for September and October revealed the resident was not consistently weighed on non-[MEDICAL TREATMENT] days. Review of the September and October MAR revealed the LN did not accurately document the resident's fluid intake. The MAR directed the LN to document the total ml's consumed at each meal and with each medication administration. The LN would document their initials and not the total milliliters the resident consumed. In an interview on 11/03/16 at 1:24 PM, Staff BB, NA, stated Resident 58 was on a fluid restriction. Staff BB stated the LN was responsible to document the resident's total fluid intake. At 1:38 PM, Staff S, LN, stated Resident 58 was on a fluid restriction. The LN was responsible to documented in the MAR what the resident consumed with each meal and medication administration. Staff S stated this was not consistently done for Resident 58. Staff S stated the LN documented the resident's weight on the MAR or in the electronic weight record. Staff S was not able to provide any additional information regarding why this was not consistently done for Resident 58. RESIDENT 60 Resident 60 received [MEDICAL TREATMENT] three times a week. The resident received all medications, nutrition and fluids through a feeding tube. Review of a physician order [REDACTED]. The LN administered 30 ml's of water before and after (with 5 ml of water between each medication) medication administration and 50 ml's of water every four hours. The order did not clarify if the 1,220 ml of water included how much water was in the resident's tube feeding formula. Review of the September and October MAR revealed the LN did not accurately document how much fluids the resident received during their shift. The resident did not receive 1,220 ml's of fluid (not including the water in the tube feeding formula) daily. Review of the MAR, weight record and progress notes for September and October revealed the resident was not consistently weighed on non-[MEDICAL TREATMENT] days. In an interview on 11/03/16 at 12:42 PM, Staff R, LN, thought the 1,220 ml of fluid included the water in the tube feeding formula but was not sure. Staff R stated the LN documented on the MAR how much fluid was administered during their shift, which did not include how much water was in the tube feeding formula. Staff R was not able to provide any additional information regarding documentation that stated how much fluid the resident did receive every shift. Staff R stated the resident was weighed on non-[MEDICAL TREATMENT] days. Staff R was made aware the resident was not consistently weighed. At 1:05 PM, Staff D, LN, stated the LN documented how much water was administered during their shift. This information was documented on the MAR. Staff D stated the fluid order was confusing and needed to be clarified. SPLINTS Resident 13 had [DIAGNOSES REDACTED]. Review of the Occupational Therapy (OT) plan of treatment dated 10/05/16, indicated the resident was discharged from OT services and placed on a BUE restorative program and splints were being ordered for the resident's BUE. The OT stated the caregiver and resident would require additional training after the BUE splints arrived. This would include how long the resident would be able to tolerate the splints, and caregiver training regarding how to place the splints on/off and monitor the resident skin. Review of the medical record indicated the BUE splints arrived 10/16/16. There was no direction in the resident's electronic and paper medical record directing staff on the BUE splints. Staff was not aware how long the splints were to be on, who was to put the splints on/off and who was responsible to monitor the resident's skin for potential skin breakdown. On all days of the survey the resident was observed to have BUE hand splints in place. In an interview on 11/02/16 at 1:00 PM, Staff E, RA, stated she was not responsible for the resident's BUE splints. In an interview on 11/03/16 at 9:15 AM, Staff F, RA, stated she performed range of motion exercises on the resident's BUE's and then applied the splints. Staff F stated she was not sure who was responsible to put the resident's BUE hands splints on and off. At 10:33 AM, Staff I, OT, stated the resident used the BUE hand splints for comfort. Staff I stated he did not provide direction to the staff on who was responsible to assess and monitor the residents BUE hand splints. Staff I was going to establish a program for the staff. At 12:52 PM, Staff G, LN, stated the resident's BUE hand splints were not part of the restorative program. Staff G stated the LN was responsible to ensure the hands splints were applied correctly and check the resident's skin for any breakdown. Staff G stated Staff I was going to write something up today. The information was going to be placed on the monthly Treatment Administration Record for the LN to oversee. HIGHEST LEVEL OF WELL-BEING Resident 13 had a progressive [DIAGNOSES REDACTED] disease that impacted her over all functional status. Review of the progress notes revealed over the past two months the resident had lost the ability to use her upper extremities and was totally dependent on staff for her needs. Review of the care plan revealed the resident was to have her call light positioned between the resident's chin and shoulder. In an interview on 11/03/16 at 9:15 AM, Staff F stated the resident used her chin to activate the call light. At 10:33 AM, Staff I stated the resident was not able to use her hands to press the call bell. Staff I obtained a light touch call bell and staff were to place the call light under the residents chin. The resident was able to use her chin to activate the call light. At 1:24 PM, Staff BB, NA, stated the resident had no use of her hands. Staff was to place the call light close to her chin so she could use her chin to activate the button. On all days of the survey the resident's call light was positioned out of her reach. The Resident was not able to activate her call light. The resident stated she would have to call out to get help. HOSPICE Review of the facility hospice agreement revealed hospice and the facility shall communicate regarding the provision of care for each hospice resident. Resident 10 admitted to the facility September 11, 2016 and received hospice services. In an interview on 11/01/16 at 11:24 AM, the resident's family stated the resident did not receive the same number of showers the resident received at home. In an interview on 11/02/16 at 9:29 AM, the resident stated, I would like a bath every 2 to 3 days. review of the resident's medical record revealed [REDACTED]. Review of the facility care plan did not indicate the resident preferred two to three showers a week. Review of the resident's hospice plan of care revealed the resident needed assist with personal care. No other interventions were indicated. In an interview on 11/02/16 at 1:43 PM, Staff U, Hospice LN, stated a hospice care aide (HCA) came in weekly to provide the resident with personal care. Staff U stated personal care included anything from bathing to combing the resident's hair. In an interview on 11/04/16 at 9:55 AM, Staff A, LN, stated the HCA would leave a note in the facility's shower scheduler box documenting when care was provided to the resident. At 10:08 AM, Staff B, shower scheduler, stated she had not received a copy of the HCA notes for months. At 3:29 PM Staff A stated the HCA usually bathed the resident on Mondays. The facility would provide any additional bathing the resident requested. Staff A stated when a resident received a shower it was documented in the electronic medical record. On 11/04/16, the facility provided HCA clinical notes faxed from the hospice agency on 11/04/16 for HCA visits on 10/10/16, 10/17/16, 10/24/16 and 10/31/16. All HCA notes indicated the resident refused HCA services. review of the resident's medical record revealed [REDACTED]. The facility and the hospice agency failed to coordinate and communicate the care and services for Resident 10. .

Based on interview and record review, the facility failed to provide sufficient qualified staffing to provide supervision, prevent accidents, ensure residents had hydration, develop care plans, ensure tests and treatments were provided, answer call lights in a timely manner, provide timely assistance with toileting and provide care and services in a manner that promoted respect and dignity for 20 of 30 sampled residents (2, 7, 9, 11, 14, 16, 34, 43, 45, 70, 78, 112, 116, 119, 121, 134, 150, 173, 181 and 183). This failure resulted in actual harm, feelings of frustration and humiliation, diminished quality of life and unmet care needs of the residents. Findings include: RESIDENT INTERVIEWS 1). During interviews with residents and a family member, residents complained of problems with receiving care or assistance from staff due to a lack of sufficient staffing. On 9/14/15 at 2:02 PM, Resident 9 stated when I go potty, they put me on the potty and leave me. One time I had to wait 15 min before someone had come to assist her. At 3:18 PM, Resident 121 stated that on the day shift and early morning it takes a long time to get help. On 09/15/15 at 8:59 AM, Resident 181 stated there is not enough help. 2 aides for 28 people that is not enough. At 10:25 AM, Resident 119 stated you can turn my light on and if you had a [MEDICAL CONDITION] or something you should not have to wait 45 minutes. I hardly ever call anymore. At 10:38, Resident 45 stated sometimes I've had to wait up to 45 minutes for help. They do need more staff here. At 10:49 AM, Resident 183 stated sometimes I have to wait 45-60 minutes for someone to come in and help me. At 10:54 AM, Resident 70 stated they are times they are just so busy. I can't state a time, but maybe an extra staff member at times during the busy times. If I have to go to the bathroom I will give them 20 minutes before Resident 70 put the call light on for assistance. During a family interview for Resident 134 at 11:22 AM, the family member stated no when asked if there was enough staff to meet the resident's needs. When asked to clarify, the family member stated they have had to wait 30-40 minutes for the call light to be answered. On 09/18/15 at 2:35 PM, Resident 16 stated during the day you never know if someone is coming. Sometimes they forget to give me the call light and I had to call out in the hall. It makes me feel kinda sad. At 2:44 PM, Resident 34 stated I fall very easily and I fall sometimes. When I need help I put on the call light and no one comes to help and I fall. At 2:55 PM, Resident 43 stated it happens about 3 or 4 times in the last month he had to wait for his call light to be answered when he needed to use the bathroom. When asked how that made him feel, Resident 43 replied it makes me feel really down, really bad, like I am not a real person. On 09/21/15 at 8:37 AM, Resident 14 stated my roommate went to the hospital yesterday and she cannot come home until there is enough staff to take care of her. Nothing negative has happened to me. I feel neglected because the staff take too long to answer the call light. My roommate needs help and has to wait, wait and wait. At 9:28 AM, Resident 112 stated I wonder what is wrong when my call light is not answered. At 10:00 AM, Resident 78 stated it makes me feel upset if I have to wait too long. Sometimes I fall asleep while I am waiting. At 10:58 AM, Resident 116 was asked to clarify when she commented the facility was understaffed. Resident 116 stated I am not real sure if there was a problem because I had to wait. I was waiting for an aide and ended up falling out of bed. When I have to wait, I feel aggravated. At 12:32 PM, Resident 2 stated it scares the hell out of me. There are 2 staff for two halls. I have times the call light response time and it is from 1 hour to 4 hours. That is why I stay up at night. STAFF INTERVIEWS In an interview, anonymous Staff AA stated we do not have enough staff to meet the needs of the residents. In an interview, anonymous Staff BB stated they think we don't need help, but we do. I just don't think there is enough staff to do our job. In an interview, anonymous Staff CC stated there is never enough staff available. I get pulled to the floor. In an interview, anonymous Staff DD stated there was not enough staff to provide care to the residents. In an interview, anonymous Staff EE stated we could use one more person; if we are on vacation there is no one to fill in. Sometimes we get scheduled for showers or help on the floor. Anonymous Staff EE stated this happened once or twice a month. 2.). On 09/22/15 at 11:35 AM, during the exit conference with the residents, family members and staff, Resident 115 asked how the facility could get more funding, so the facility could have more staff because we need it, we really do. 3). Review of the resident Comment/Concern Log from 04/02/15 - 09/08/15 revealed at least 39 resident comment/concerns regarding excessive call light response times, on toilet too long, inadequate staffing, receiving meals too late, and other care related concerns. 4). Review of the Resident Council Minutes, dated 04/14/15 revealed concerns about residents missing appointments because they have not been ready, call lights not answered in a timely manner, and not enough staff. 5) Review of Resident Council Minutes, dated 08/11/15, revealed resident concerns about facility understaffing. 6) Review of Resident Council Minutes, dated 09/08/15, revealed resident concerns the facility is understaffed. Refer also to for other examples of lack of qualified staffing and harm to residents at: 42CFR 483.15(a), F241, Dignity (Resident harm) 42CFR 483.15(h), F252, Safe / Clean / Comfortable Homelike Environment 42CFR 483.20(k), F279, Develop Comprehensive Care Plans 42CFR 483.20(k)(3)(ii), F282, Services by Qualified persons 42CFR 483.25, F309, Provide Care/services for highest well-being 42 CFR 483.25(H) (1)(2), F323, Accident Hazards / Supervision (Resident harm) 42 CFR 483.25(j), F327, Sufficient Fluid to Maintain Hydration 42 CFR 483.25, F329, Drug Regimen is Free from Unnecessary Drugs 42 CFR 483.65, F441, Infection Control, Prevent Spread

br>Based on interview and record review, the facility's administration, through its supervisory staff, failed to ensure the facility effectively and efficiently attained, and/or maintained each resident's optimal physical, mental, and psychosocial well-being in the areas of dignity, supervision for accident prevention, and in providing sufficient staff to maintain needed care and services. These failures resulted in actual harm to Residents 72 and 150 and placed all residents at risk for unmet needs and decreased quality of life. Findings include: 1. The administration failed to implement their fall prevention program for a high fall risk resident who had poor safety awareness and a history of multiple falls. Refer to CFR 483.25 (h), F323 Accidents 2. The administration failed to promote care for residents in a manner and in an environment that maintained and/or enhanced each resident's dignity and respect. Refer to CFR 483.15 (a), F241 Dignity 3. The administration failed to ensure sufficient staff was available to provide care and services to residents in the facility in order to help them attain or maintain their highest practicable physical, mental, and psychosocial well-being. Refer to CFR 483.30, F353 Nursing Services

Based on observation, interview and record review, the facility failed to provide care and services in a timely and respectful manner in dinning toileting and call light responses for 4 of 6 sampled residents (150, 7, 173 and 43) who voiced concerns. These failures resulted in harm to Resident 150 as evidenced by her complaints she felt degraded, humiliated, and was depressed because she was left to urinate and defecate in her bed when her call light was not answered after over a 1 hour wait. Findings include: RESIDENT 150 Resident 150 was admitted to the facility June 2015 with [DIAGNOSES REDACTED]. According to the MDS assessment, dated 08/11/15, Resident 150 was frequently incontinent of her bowel and bladder, required extensive assist of one person for toileting needs and no cognitive impairment. In an interview on 09/16/15 at 2:41 PM, Resident 150 stated there were not enough staff available to meet her needs without having to wait a long time. The resident stated the staff take too long to answer her call light. One time she put on her call light, but urinated and had a bowel movement in her bed because she could not wait an hour for her call light to be answered. Resident 150 stated she felt degraded, humiliated and was now depressed because this occurred. RESIDENT 7 Resident 7 was readmitted to the facility 08/16/15 with [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set (MDS) assessment, dated 07/22/15, Resident 7 was continent of urine and required no assistance for toileting needs. Review of the nursing progress notes revealed the resident was often fatigued and required assistance with her activities of daily living. Resident 7 used a wheelchair to meet her mobility needs. In an interview on 09/14/15 at 2:47 PM, Resident 7 stated she needed assistance to the use the bathroom at times. The resident stated on the night shift, she had to wait to use the bathroom because her wheelchair was out of reach. The resident stated she put her call light on to ask for help and after waiting 45 minutes she urinated in her brief. Resident 7 stated she felt degraded. RESIDENT 173 In an interview on 09/14/15 at 2:00 PM, Resident 173 stated staff will knock on her door but they do not wait for her to respond and multiple times she's been sitting on the toilet when they would just walk in. The resident stated this irritated her and she's entitled to her privacy. RESIDENT 43 Resident 43 was admitted to the facility in August 2009 with [DIAGNOSES REDACTED]. According to his Minimum Data Set (MDS) assessment, dated 06/02/15, he did not have any cognitive impairment. In an interview on 09/15/15 at 9:10 AM, the resident was asked if facility staff treat him with respect and dignity. The resident stated that most of the staff treated him with respect and dignity, but to some of the dayshift staff he just felt like he was a bother or trouble to them. The resident was unable to recall any names. In an observation on 09/18/15 at 9:14 AM, Resident 43 turned on his call light. At 9:26 AM, Staff V, Nursing Aide (NA), walked by the room without looking into the room. At 9:28 AM, Staff W, NA, walked by the room without looking in the room. At 9:33 AM the resident's call light was answered by Staff X, NA. At 9:35 AM, the resident turned his call light on again. The surveyor asked what he had wanted. Resident 43 stated he had requested some Kleenexes and bed pads, but no one brought them so he turned his call light on again. At 9:43 AM, Staff V, NA, answered the call light and was observed bringing Kleenexes (not the bed pads) immediately back into the room. 29 minutes had elapsed before the resident's needs were even partially met. In an observation on 09/18/15 at 2:28 PM, Staff U, NA, was observed to answer Resident 43's call light. The resident requested a box of Kleenexes and some waterproof bed pads. Staff U said Ok and left the room. Resident 43 said to the surveyor Watch, she won't be back. As of 2:50 PM, Staff U had not returned. In an interview at 2:50 PM, Staff U stated she had got busy in another resident's room. In an interview on 09/22/15 at 9:26 AM, the Director of Nursing Services stated an acceptable call light response time was 15 minutes or less. LATE LUNCH HALL TRAYS On 09/14/15, lunch meal hall tray service was observed. Unit 1 was scheduled to start at 12:15 PM, the first trays were distributed starting at 12:48 PM, which was 33 minutes late based on the Dining Times schedule provided by the administrator in the entrance conference. Unit 2 hall trays were 35 minutes late. Unit 4 hall trays were 18 minutes late. Similar findings were observed during the 09/16/15 lunch hall tray service. On 09/14/15 at 1:01 PM, the Dining Times schedule was jointly reviewed with Staff J, Dietary Manager, who confirmed the schedule was accurate. Staff J stated the hall tray lunch service was late due to the nursing staff not having the residents ready to eat yet. In an interview on 09/18/15 at 9:30 AM, the Director of Nursing Services stated the lunch hall trays were late because the kitchen wasn't ready to send them out yet and also the nursing staff had pushed back because they were not yet ready to receive and distribute them.

Based on interview and record review, the facility failed to implement their fall prevention policies which included providing diligent supervision for 1 of 6 sample residents (72) reviewed for falls. This failed practice resulted in harm to Resident 72 when he experienced a fall that resulted in a hip fracture and a compression fracture of his back. Findings include: Review of the facility's Falling Star/Falling Leaf Program policy, with a revision date of 12/10, revealed: If a resident scores a 10 or above on the Fall Risk Assessment, the resident is assessed for participation in the Hip Protection Program (FallGard or Posey). If two or more of the following is true for the resident, he or she must participate in the Falling Star/Falling Leaf Program: 1. The resident scored 12 or above on the Fall Assessment. 2. Unsafe behaviors, such as impulsivity, or poor judgment skills were identified or observed. 3. The resident is unwilling to comply with safety standards. 4. The resident has had a fall within the last 90 days. The policy also indicated that facility staff would be educated to recognize residents participating in Falling Stars/Falling Leaf Program (as identified by a star/leaf) may be limited in safety awareness, have a greater potential to fall, and require more diligent supervision. Lastly, the policy also stated: ongoing meetings would be held to discuss the progress of Falling Star/Falling Leaf participants and any potential candidates that might benefit from the program. Resident 72 was admitted to the facility in July 2015 with [DIAGNOSES REDACTED]. The record showed that the resident had a history of [REDACTED]. A review of Resident 72's Minimum Data Set (MDS) assessment, dated 07/22/15, revealed the facility had assessed the resident as having impaired balance and poor safety awareness. A review of a facility incident report showed that on 09/03/15, Resident 72, fell fracturing his hip and back. He was hospitalized for [REDACTED]. Review of the resident's physical therapy Plan of Treatment, dated 07/15/15, revealed standardized tests were performed and the Resident was a high fall risk. Review of the resident's Fall Risk Evaluation, dated 07/14/15, revealed he had scored 16, which qualified the resident to be in the Hip Protection Program. Review of the facility Fall Team Meeting Minutes for 07/16/15, 07/23/15, 07/30/15, 08/14/15, 08/19/15, and 08/26/15 revealed the facility had not discussed Resident 72 or his high fall risk in any of those meetings. There was no evidence the resident was participating in the facility's Falling Star/Falling Leaf fall prevention program prior to his fall on 09/03/15. Review of Resident 72's Interim Care Plan, dated 07/14/15, revealed the section of the care plan At risk for physical injury was completely blank. There was no fall prevention interventions in place 07/14/15 - 07/31/15. Review of Resident 72's permanent Care Plan, dated 07/31/15, revealed the facility documented the resident was at risk for fall related injury. The permanent Care Plan did not indicate the resident was participating in the Falling Star/Falling Leaf fall prevention program. The care plan also did not indicate the resident required any increased level of supervision related to his impaired safety awareness. In an attempted interview on 09/14/15 at 3:30 PM, the resident was unable to participate. He was awake with his eyes open looking around the room, but did not respond to any questions. In an interview on 09/18/15 at 9:35 AM, the Director of Nursing Services (DNS) stated on 09/03/15 a Nurse Aide (NA) had helped transfer the resident to his wheelchair, the resident wheeled himself down the hall and sat by the nurse's station. The wheelchair brakes were not set, the resident attempted to stand and fell when the wheelchair rolled away from him. The DNS also stated if the facility put everyone on it (the Falling Start/Falling Leaf program) right away, then it would detract from the program's effectiveness. The DNS did not provide an answer as to why the resident was not enrolled in the Falling Star/Falling Leaf fall prevention program even though the resident had a history of [REDACTED]. A review of the facility Fall Team Meeting Minutes, dated 09/15/15, revealed the facility Fall Team had not discussed Resident 72, or his fall risk, even after his readmission from the hospital (for hip surgery) on 09/11/15. On the same day at 1:02 PM, the DNS did not have any information as to why Resident 72 was not discussed in the Fall Team Meeting on 09/15/15. In an interview on 09/22/15 at 2:20 AM, Staff G, NA, stated a silver star on a resident's door meant the resident was identified as a high fall risk and staff had to keep an eye on them. In an interview at 2:25 AM, Staff H, LN, stated residents who were on the falling star program were identified as a high fall risk, checked frequently and the staff had increased awareness of the resident's whereabouts. In an interview on 09/22/15 at 9:01 AM, Staff F, Licensed Nurse, stated the facility had not done the Hip Protection Program (See FallGard or Posey) for the last year even though the policy indicated if a resident scored 10 or greater on the assessment, the nurse was to consider the program. In an interview at 9:45 AM, the DNS stated the hip protection program was no longer in place and we need to update that policy. Resident 72 had a known history of multiple falls prior to admission with a head injury, was a high fall risk, had severely impaired cognition and poor safety awareness. The facility failed to follow their policy that indicated they must participate in the facility's Falling Star/Falling Leaf fall prevention program that would have provided the resident with more diligent supervision.

Based on observation, interview and record review, facility staff failed to follow the care plan and provide the necessary supervision to prevent injury to Resident 1. The resident fell out of bed while being turned, and sustained injuries including a fractured nose and knee laceration, requiring outside medical treatment. Findings include: Resident 1 Resident 1 had a history of [REDACTED]. She was alert and oriented, and required the assistance of two staff persons for turning in bed. On 02/09/2015 at 12:30 p.m., the resident was observed sitting in bed. Her face had multiple areas of dark-colored bruises. She was alert and oriented. Her bed had an air mattress, with no side rails. The air mattress placed the resident at a higher height than a regular bed mattress. During an interview at the time of this observation, the resident said "I am supposed to get bed rails today--I signed a release to have them put on, at my son's insistence." The resident said the bed rails were "for my protection." The resident said when she fell out of bed on 02/05/2015, Staff B, a registered nursing assistant (NAR) working alone, turned her onto her left side and "couldn't do it." The resident said the turning caused her to fall out of bed onto her right knee and face, directly onto the floor. "Now my neck hurts to turn it. Occupational therapy started diathermy on it." The resident said the hospital had done a CT scan of her head, and put sutures in her right knee. According to the facility incident intake report dated 02/05/2015, the resident had a nose fracture, forehead bump, and skin tears to the right knee and left wrist. The hospital records were not found in a review of the resident's medical record. The nursing assistant flow reports indicated the resident required extensive assistance or was totally dependent upon staff for bed mobility in January and February prior to the incident. The facility conducted a staff inservice about following resident care guides following this incident. During an interview on 02/09/2015 starting at 1:07 p.m., Staff A was asked about the incident. Staff A said Staff B "was not following the care guide," when the incident occurred, and that Resident 1 required 2 staff for turning in bed. Staff A said the facility was going to be getting bed rails on the resident's bed as a safety measure. When asked if the air mattress was on the care plan as a fall risk, Staff A checked the care plan and said it was not. Staff A asked Staff C, also present at this interview, to ensure that the air mattress was added to the care plan as a fall risk. Staff A said the hospital records from the injury were not in the chart, and she would send a request for those records.

Based on observation, interview and record review, the facility failed to provide adequate assistance during a transfer for one of 6 sample residents (Resident 1). Failure to follow the plan of care resulted in harm for Resident 1 who sustained a head injury and a chest wall contusion. Findings include: The facility's policy directed staff to use gait belts during transfers to ensure safe transfers. RESIDENT 1: Resident 1 was admitted to the facility 4/22/13 with [DIAGNOSES REDACTED]. On 10/29/13, she had surgery for [REDACTED]. The plan of care (POC) for Resident 1 directed staff to use 2 person assist with transfers and the Nursing Assistant (NAC) Care Directives, dated 11/1/13, read "assist of two with gaitbelt to transfer with no weight bearing on the left arm. On 1/13/14 at noon, Resident 1 stated she had a fall and hit her head on the floor when the NAC transferred her by himself. The nursing note, dated 12/11/03, documented when the fall occurred, Resident 1 complained of her left arm being sore, and her a bruise with swelling that measured 4.5 centimeters (cm) by 3 cm in size was noted on her forehead. Another nursing note entry, dated 12/12/13, documented Resident 1 was experiencing rib pain. The physician was notified. The physician's visit on 12/19/13, documented Resident 1 had right rib tenderness due to a fall on her right chest/flank area. The physician documented she had a "right chest wall contusion". The facility's investigative report, dated 12/11/13, concluded the NAC had not followed Resident 1's plan of care requiring assistance of 2 for transfers, and not using a gait belt with transfers per facility policy, which resulted in a fall with a head injury with swelling and bruising to her forehead and rib pain (chest contusion). On 1/24/14, at 11:50 a.m., the Resident Care Manager (RCM L) stated the facility's policy if for staff to use gait belts with all transfers was mandatory. On 1/24/14, at 1:00 p.m., the Director of Nursing verified the NAC had not followed Resident 1's plan of care or used a gait belt during a transfer.

Based on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit abuse of residents and to protect them from recurrence of abuse. Due to the facility's failure to recognize Resident 63's behaviors of hitting, kicking, pinching and squeezing of Residents 45, 83, 112, 114 and 124 as acts of abuse, the facility failed to investigate and report the incidents as abuse. Failure to consider the incidents as abusive also resulted in the facility not implementing effective protective interventions to prevent recurrence. This created an unsafe and intimidating environment for residents and placed residents at imminent risk for experiencing harm from Resident 63's abusive outbursts. This failure was determined to be Immediate Jeopardy. Findings include: Per the Department's Nursing Home Guidelines, Fourth Edition, "it must be presumed that abuse has occurred whenever there has been some type of impermissible, unjustifiable, harmful, offensive or unwanted contact with a resident. This means that instances of abuse of any resident (whether comatose, cognizant or not), cause physical harm, pain or mental anguish." The facility's Policy and Procedure on Abuse and Neglect (undated), defined physical abuse as: "Hitting, slapping, prodding, poking or sticking a client with a sharp object, pushing, shoving, spitting, twisting, squeezing, pinching and kicking." It also stated, the facility's first priority was "to protect the victim/residents from further harm." On 5/2/11 at 11:00 a.m., the Director of Nursing services (DNS) and the Regional Clinical Director, reported the facility also used the Department's Nursing Home Guidelines (also referenced above) for identification, investigating and reporting abuse and/or neglect. The Guidelines included: "Each resident has the right to be free from mistreatment..this includes the facility's identification of residents whose personal histories render them at risk for abusing other residents and the development of intervention strategies to prevent occurrences, monitor for changes that would trigger abusive behaviors, and reassessment of the interventions on a regular basis." The facility's policy did not specifically address resident to resident altercations. The DNS stated if resident to resident altercations occurred that resulted in abuse, the facility would follow their general abuse protocol. RESIDENT TO RESIDENT ABUSE Resident 63 was admitted in November 2005 with [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS), dated [DATE], indicated Resident 63 had unclear speech, responded to simple and direct communication only, was rarely understood, had memory problems with poor recall and was severely impaired in his decision making abilities. Resident 63 was assessed as being short tempered and easily annoyed, had physical and verbal behaviors directed at others which put them at significant risk for injury and intruded on their privacy. These behaviors were not addressed in his care plan. Resident 63 was dependent on a wheelchair for mobility and was [AGE] years old. On 4/27/11 at 9:56 a.m., the Resident Care Manager 1 (RCM 1) for Resident 63 stated he had a problem with anger and "certain things will set him off". On 4/28/11 at 5:10 p.m., Licensed Nurse 1 (LN 1) reported Resident 63 was impulsive and will get agitated when certain things set him off. LN 1 stated people yelling or getting bumped into will "set him off". LN 1 reported the facility staff "tries to protect the perimeter" when Resident 63 gets agitated but "it's not always easy." On 4/28/11 at 5:20 p.m., LN 2 reported the facility staff would try to remove him from altercations with other residents "If he lets us. It is not always easy." On 4/28/11 at 5:45 p.m., Nursing Assistant 3 (NA 3) reported Resident 63 got agitated when residents bumped him in their wheelchairs or when he bumped into other residents. When asked if staff moved other residents out of the way of Resident 63 he replied "No. Only if he's agitated." On 4/28/11 at 5:45 p.m., Resident 24 reported she "learned to just go around (Resident 63) because he can kick." Resident 24 reported she had not been physically hurt by Resident 63 but had seen him kick other residents. INCIDENT REPORTS Review of the facility Incident Reports (IR) indicated Resident 63 had 6 incidents involving abusive behaviors directed at six other residents between 7/22/10 and 4/24/11. None of them were reported to the Department's hotline as incidents of potential abuse. Resident 124 July 22, 2010: Resident 124 was sitting in the hallway in front of the nurses station. Resident 63 was wheeling his chair around the corner and hit Resident 124's right foot. The IR explained "Resident 63 began kicking at Resident 124 and trying to push his wheelchair away... Resident 63 was angry." Interventions added to the plan of care were to separate the residents, assess for injury, notify MD and family, redirect residents, remove Resident 124 from Resident 63's line of site and "assist with propulsion when in hallways around other residents." The plan of care goal was updated to "Not have emotional distress or injure other residents." Neither resident was injured. Resident 114 November 8, 2010: Resident 114 was sitting in the hallway. The witness statements from the IR explained "Resident 114 was yelling "I want to go home" sitting in his wheelchair close to his room. Resident 63 wheeled up to Resident 114 and grabbed the oxygen tubing that Resident 114 was wearing on his face. Resident 63 continued to pull on it. Resident 63's knee rubbed up against Resident 114's knee. I had to disconnect Resident 114's oxygen tubing because Resident 63 would not let go. I did not see any marks on Resident 114 and he just kept saying "I want to go home." Another witness statement explained "I walked out of the room and witnessed Resident 63 pulling off the oxygen tubing from Resident 114. Resident 63 was cussing and getting ready to hit Resident 114. I know if I wasn't there to help with the situation Resident 63 would have hurt Resident 114. Resident 114 was shook up by the incident and he told me he was scared." The interventions added to the plan of care included: Call family for assistance to calm Resident 63 down, turn on the TV in the room to block out noises in the hallway that may disturb him. The facility also assessed the residents blood sugar levels, communication techniques and swallowing ability. On the "Behavior/Intervention Monthly Flow Record" for 11/08/10, the behavior of being aggressive was monitored. When requested to document the number of behavior episodes for that day, staff placed a "+" sign. No interventions, outcomes or side effects were documented when asked for on the form. Resident 83 December 15, 2010: Resident 83 was in the dining room for breakfast and bumped into Resident 63. The witness statement from the IR explained "Resident 83 was propelling in her wheelchair behind Resident 63 and bumped into his wheelchair making him angry. Resident 63 grabbed Resident 83 on the right thigh by her pants...Separated both residents. No injury noted to her thigh." Resident 112 January 10, 2011: Resident 112 was in the dining room when Resident 63 had become upset and started yelling. The witness statement in the IR explained "Resident 63 got upset about the menu choices and started cursing and screaming and headed for the door to leave. Resident 112 went to see what was wrong and comfort him and he kicked her in her leg three times before I grabbed him to pull him away." Resident 112 complained of right knee pain and had an Xray which revealed there was no fractures. Resident 63's family was in the dining room with the resident at the time of the incident. The interventions added to the plan of care included: Resident 63 (who was severely cognitively impaired) was to be educated about kicking others and the family was requested to be present during meals (which they had been at the time of the incident). The "Behavior Flow Record" for 01/10/11, indicated Resident 63 had not exhibited any aggressive behaviors that day. Resident 83 (recurrence) February 15, 2011: Resident 63 was in the dining room with his family present. Resident 83 wheeled past his table and got her wheelchair caught on his table. The table began to move. Resident 63 grabbed Resident 83's arm and they yelled at one another. The witness statement on the IR explained "I ran over and pried his hand from her wrist." No injuries were noted to either resident. The interventions added to the care plan included adjusting the mealtimes for Resident 83 to avoid behavior triggers for Resident 63. The "Behavior Flow Record" for 02/15/11 indicated Resident 63 had not exhibited any aggressive behaviors that day. Resident 45 April 24, 2011: The IR read "Resident 63 went after Resident 45. Resident 45 had been acting confused and was yelling at me to get out of her house that her husband will be very upset at me. Resident 45 followed me to the hallway where Resident 63 was and he heard Resident 45 yelling at me and went towards her and started hitting and kicking her. I got her in her room and was able to shut the door. After I checked on Resident 45 I went back in the hall and Resident 63 was still upset and trying to get in the room. We kept them apart until dinner." Another witness statement read "...Resident 45 taken into her room and Resident 63 attempted to enter the room with concurrent kicking motion. Nurse intervened and Resident 63 became combative and hit nurse and started to propel wheelchair towards the nurse. Male caregiver intervened to give 1 on 1 supervision to Resident 63 for 1/2 hour." No injuries were noted to either resident. The interventions added to the plan of care included place on 1:1 until calm and to separate resident from the cause of the agitation. The "Behavior Flow Record" for 04/24/11 indicated Resident 63 had not exhibited any aggressive behaviors that day. On 4/28/11 at 5:15 p.m., Resident 45 reported she remembered being "kicked hard but it only hurt for awhile. You just move on from those things. It scared me only because it was so sudden and I didn't expect it." Record review indicated the Social Services Department did an annual assessment on 9/24/10 with no further documentation present. The annual assessment did not address aggressive behaviors. On 5/2/11 at 11:45 a.m., the Social Services Director (SSD) reported she had not been informed of the incidents with Resident 63 except for 1/10/11. She reported usually the incidents were discussed in a daily meeting and then the Resident involved would be added to the weekly "behavior" meeting. Resident 63's behaviors were discussed at the "behavior" meeting in October 2010 and January 2011 and the personal interventions related to why he had outbursts were discussed. The SSD reported no interventions to protect other residents were discussed. Resident 63 was observed to be moving his wheelchair freely and unsupervised throughout the 300 and 400 hallway, the "Cascade" dining room and the common hallway of the facility during observations made on 4/25/11 through 4/28/11. On 4/25/11 at 11:15 a.m. to 11:32 a.m., Resident 63 and Resident 83 were observed to be in the dining room at the same time with staff present only intermittently. On 4/27/11 at 10:10 a.m., Resident 63 was observed to wheel his wheelchair into the wheelchair of Resident 211 and hit her chair twice. Facility staff immediately responded, separated the residents, asked Resident 211 "Are you OK?" and informed Resident 63 to "be nice." There was no contact made between the two residents and Resident 63 continued down the 400 hallway unsupervised. On 5/2/11 at 11:00 a.m., the DNS reported the seven incidents with Resident 63 had been determined to not be abuse because Resident 63 did not willfully harm any residents and that there had not been any bodily harm inflicted. The DNS reported bodily harm consisted of visible injuries like bruising, bleeding or a fracture. When asked what interventions had been put in place to protect residents from physical abuse during an altercation with Resident 63, she reported 1:1 supervision since 4/28/11 and she added, "our approach had been to determine why Resident 63 was having these altercations and to try to prevent them." Resident 63's abusive behaviors such as hitting and kicking of other residents, created an environment for residents which included fear, uncertainty and intimidation. The facility responded to each altercation with a reactive approach by investigating why Resident 63 had the altercations, but did not proactively develop a plan to protect other residents from recurrence of abuse.

Based on observation, interview and record review, the facility's administration failed to ensure the facility's policies regarding recognition and prohibition of abuse were implemented to allow residents to attain their highest practicable level of physical and mental well being. This failure resulted in harm for residents and placed all residents at imminent risk for experiencing abuse and a decreased quality of care. Findings include: 1. Administration failed to implement their written policies and procedures to prohibit abuse of residents and to protect them from recurrence of abuse. Due to the facility's failure to recognize behaviors of hitting, kicking, pinching and squeezing of Residents as acts of abuse, the facility failed to investigate and report the incidents as abuse. Failure to consider the incidents as abusive also resulted in the facility not implementing effective protective interventions to prevent recurrence. This created an unsafe and intimidating environment for residents and placed residents at imminent risk for experiencing harm from a resident's abusive outbursts. This failure was determined to be Immediate Jeopardy. Refer to F226 - Develop/implement/abuse/neglect, etc. Policies

Based on observation, interview and record review, the facility failed to maintain an acceptable nutritional status for 1 of 4 residents (Resident 213) reviewed for weight loss. The failure to recognize, evaluate and address the nutrition needs for Resident 213 led to a significant weight loss. Findings include: 1. Resident 213 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS), dated [DATE], indicated Resident 213 had memory problems, was severely impaired in her decision making abilities, had no assessed behaviors and used a wheelchair for mobility. Resident 213 required extensive assistance with all of her daily care needs. Resident 213 was taking an antipsychotic medication when admitted and had an antianxiety medication, 3 times a day, and at night, as needed for anxiety, added the day after admission to the facility. Resident 213 received the antianxiety medication 28 times between 4/14/11 and 4/30/11 and six times between 5/1/11 and 5/5/11. During the observation period of 4/25/11 to 5/06/11, Resident 213 was noted to be either in bed napping or sitting up in her wheelchair in the hallway or the dining room. Resident 213 was not observed to be anxious and was either sitting quietly or had her eyes closed when observed in her wheelchair. Resident 213 was not noted to be engaged in any activities. The"Weekly Care Management Review", dated 4/27/11, indicated Resident 213 had "signs of increased lethargy and decreased cognition" and "weight stable-eating independently without problems." Resident 213 weighed 105.2 pounds upon admit on 4/18/11 and was 97.8 pounds on 4/29/11. Resident 213 had lost 7% of her weight in 11 days. Weights listed on the residents weight log were: 4/18/11: 105.2 pounds 4/21/11: 102.9 pounds 4/24/11: 98.1 pounds 4/29/11 97.8 pounds On 5/5/11 at 10:45 p.m., Licensed Nurse 8, (LN 8) reported when a resident was having weight loss the facility referred the resident to the facility dietician by making an entry into the "Nutritional Referral" book. Resident 213 was not in the "Nutritional Referral" book. Resident 213 had a "Nutrition Data Collection Assessment" completed by the facility Dietician on 4/18/11. Resident 213's weight was listed as 109 pounds. The facility "Weight Log" for 4/18/11 listed Resident 213's weight as 105.2 and there was no documentation indicating the discrepancy in weights had been assessed. The "Nutrition Intervention" plan was listed as: 1. Continue current diet. 2. Whole milk and fortified cereal. 3. Ice cream at dinner. A "Nutritional Progress Note", dated 4/20/11, reported Resident 213 as having a weight of 111.1 pounds, was to receive whole milk, fortified cereal and ice cream, and that "resident is at nutritional risk secondary to her increased age and dementia." The facility "Weight Log" for 4/21/11 listed Resident 213's weight as 102.9 and there was no documentation indicating the discrepancy in weights had been assessed. On 4/26/11 at 10:00 a.m., LN 8 reported Resident 213 was not receiving a nutritional supplement for her weight loss. The "Monthly Flow Report for Diet", from 4/13/11 to 4/30/11, indicated Resident 213 had consumed on average 47% of breakfast, 62% of lunch and 34% of dinner. Resident 213 had been assessed by the facility Speech Therapist for a swallowing problem. Resident 213 had significant weight loss in 11 days. The facility did not recognize the weight loss, assess possible causes of the weight loss including medication or adjustment difficulties, place appropriate interventions in place to prevent further weight loss or evaluate the interventions for effectiveness.