Every finding on record at Linden Grove Health Care Center

Based on interview and record review the facility failed to protect resident's right to be free from physical abuse for 1 of 4 sample residents (Resident 1) reviewed for Resident-to-Resident altercations. This failure placed residents at risk for abuse, psychosocial harm, and a diminished quality of life.Findings included.Review of the facility policy titled, Coordinating/Implementing Abuse, Neglect and Exploitation Policies and Procedures, dated April 2021, documents 1. Policies are in place that: a. prohibit and prevent resident abuse, neglect, exploitation and misappropriation of resident property. The policy further documents 2. Policies address the following as part of abuse, neglect, misappropriation prevention: c. Prevention.Resident 1 was originally admitted to the facility on [DATE] with multiple diagnoses including Parkinson's Disease with dyskinesia with fluctuations (a condition where a person has uncontrolled, involuntary, movements, which are side effects of long-term dopamine [a chemical that helps nerve cells in the brain send signals] replacement therapy rather than symptoms of the disease itself). The Quarterly Minimum Data Set, (MDS-an assessment tool), dated 07/16/2026, documented Resident 1 as moderately cognitively impaired.Resident 2 was admitted to the facility on [DATE] with multiple diagnoses including chronic kidney disease stage 3 unspecified (moderate kidney damage and working at 30 percent to 59 percent capacity). The Quarterly MDS, dated [DATE], documented Resident 2 as cognitively intact.Review of the Alleged Resident to Resident Altercation packet number 2558, dated 07/17/2026 at 04:10 PM, documents, A female resident came up behind male resident and punched him on the right side of his face several times. The immediate intervention was to separate the residents and place Resident 2 on 1 to 1 supervision with a staff member. Resident 1 was offered to be transported to the hospital for evaluation and treatment (Resident 1 declined); Resident 2 sent to hospital for evaluation and treatment. In-house provider ordered x-ray of skull for Resident 1 and placed on alert status to monitor for any changes in mentation. Resident 2 was moved to a room on the opposite hall, and Resident 2 was offered to be seen by the Behavioral Health Services but declined.On 07/29/2026 at 11:30 AM, Resident 1 said He was in the main dining room enjoying a planned activity with a live band when he caught out of the corner of his eye someone slightly behind him. Resident 1 said he turned to that person and before he knew what was happening a female resident began hitting him several times on the side of his face/head and neck. Resident 1 said he is unsure how many times he was hit. Resident said this really caught him off guard because he was just minding his own business listening to the music. On 07/29/2026 at 12:00 PM, Resident 2 said she entered the main dining room after being outside and heard Resident 1 making racial slurs towards her and she snapped. Resident 2 said she knew it was wrong to hit Resident 1 but her body just did it. Resident 2 said Resident 1 made several comments using the 'N' word and using profanity. Record review of progress note, dated 07/17/2026 at 17:37 PM, for Resident 1 documented during a scheduled activity in dining room Resident 2 became verbally agitated and yelled at Resident 1. Resident 2 then struck Resident 1 multiple times in the facial area. Staff immediately intervened, separated the residents, and ensured their safety. The Resident Care Manager, Director of Nursing and Executive Director were notified of incident. Skin assessments were completed. Resident and staff interviews completed. Resident 1 expressed desire to press charges; law enforcement notified. Vulnerable Adule abuse reports were filed online.During an interview on 07/29/2026 at 01:30 PM, Staff A, Executive Director, said Residents 1 and 2 were involved in a Resident-to-Resident altercation which involved Resident 2 hitting Resident 1 while in the main dining room during an activity. Staff were able to intervene and separate the residents immediately. Resident 2 was placed on a 1 to 1 monitoring and moved to a window bed on the other hallway for separation. Staff A said he was the facility abuse coordinator and after any type of abuse incident there was a risk call held. Staff A said this was a TEAMS meeting that included the Executive Director, Director of Nursing Services, Social Services Director, Corporate Compliance, Corporate Social Services, Corporate Human Resources, Regional Consultant, and legal if necessary. Staff A said Resident 2 had not been identified as a behavior risk prior to the incident. Staff A said all admissions were screened at the facility and corporate level to identify any potential behaviors prior to admission. Staff A said new admits were also reviewed during the clinical meeting to ensure staff are aware of any potential behaviors towards others, history of behaviors, and to review the residents' room to ensure a good fit. Reference WAC: 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to provide showers/bathing for 2 of 5 sampled residents (Residents 1 and 2) and implementation of orders for 1 of 3 sampled residents (Resident 3) when reviewed for quality of care. This failure placed residents at risk for unmet needs, poor personal hygiene, and a decreased quality of life.Findings included.<Showers>Policy titled [NAME] Grove Healthcare Center Resident Shower and Personal Hygiene Policy Level II, review date: March 2021, under Policy documents [NAME] Grove Healthcare Center will provide showers, bathing assistance, and personal hygiene services according to each resident's preferences, care plan, physician orders, and individual needs while maintaining privacy, dignity, safety, and infection control standards.Resident 1 was originally admitted to the facility in 2014 with the latest readmission on [DATE] with multiple diagnoses including multiple sclerosis (a chronic autoimmune disease of the central nervous system). The Quarterly Minimum Data Set, (MDS-an assessment tool), dated 04/09/2026, documented Resident 1 as cognitively intact.Record review documented Resident 1 was care planned for two showers a week with a preference for evening showers by a female caregiver.On 06/17/2026 at 11:40 AM, Resident 1 said she gets a shower a week. Resident 1 said she has reported to staff multiple times that she wants at least two showers a week. Resident 1 said sometimes she will go for 8 or more days without a shower as the shower aides get pulled to the floor to work as a floor aide if someone calls out. Resident 1 said when that happens no one gets a shower. Resident 1 said she looks and feels good today because she had her first shower in 8 days last night and her hair was washed.Resident 2 was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with multiple diagnoses including type 2 diabetes mellitus without complications (a chronic metabolic condition in which your body either resists the effects of insulin or doesn't produce enough insulin to maintain normal glucose levels). The Quarterly MDS, dated [DATE], documented Resident 2 as cognitively intact.Record review documented Resident 2 was care planned for a tub bath on evening shift and has no preference on gender providing assistance. Resident 2 prefers a tub bath twice a week.On 06/17/2026 at 12:14 PM, Resident 2 said there are times he will get a weekly shower but sometimes it might be closer to every other week. Resident 2 said his preference would be to have 2 showers a week every week especially now that the weather is getting warmer.On 06/17/2026 at 12:35 PM, Staff D, Certified Nursing Assistant (CNA) / Shower aide, said he works the North Hall (200 hall) day shift and works 8 hours a day. Staff D said there is a weekly tally of who had a shower and who haven't. Staff D said he would prioritize those who had not had a shower lately and shower them. Staff D said the residents get 1 or 2 showers a week but honestly it is closer to 1 shower a week. Staff D said the shower aides get pulled to the floor a lot and when that happens showers will not get done. Staff D said after a shower or at least by the end of the shift he will try to chart in the computer what showers were completed and fill out a shower sheet for each shower.On 06/17/2026 at 1:44 PM, Staff E Licensed Practical Nurse (LPN) / Resident Care Manager (RCM), said there is a shower schedule for each side of the building. The shower schedule usually has the residents scheduled for 2 showers a week. If a resident wants more or less showers this preference is accommodated. After a shower a shower sheet should be filled out. The Point Of Care (POC-a computer system acting as a real-time hub for patient care) charting is not always completed, but the shower sheets usually are. Staff E said showers will be done by the shower aides unless they are not working then the showers are supposed to be completed by the floor aides. Staff E said sometimes there are several floor staff call outs and the staff will try to do what they can for showers and the ones not done will be made up later. <Medication orders>Resident 3 was admitted to the facility on [DATE] with multiple diagnoses including type 1 diabetes mellitus with foot ulcer (a lifelong autoimmune disease where the body's immune system mistakenly attacks and destroys the insulin producing cells in the pancreas). The admission MDS, dated [DATE], documented Resident 3 as cognitively intact.Record review of Resident 3's progress notes documented, on 05/17/2026 at 8:11 PM Resident 3 arrived back to facility with the dad and her belongings (carry-on suitcase several paper bags). Resident 3's father reported that from her visit with the provider on Friday, the medication Trazadone (an antidepressant medication) dose was increased to 150mg from 100mg and a new medication Naltrexone (medication used to treat alcohol and opioid use disorder) 50 mg, 1 tablet daily by mouth was prescribed and the resident had it on hand and gave to this RN (Registered nurse). An SBAR (Situation Background Assessment Recommend communication form) about the medication update will be done for the NP (Nurse Practitioner).The SBAR was located in the eChart dated 05/17/2026 documenting Resident 3 has new medication prescribed Naltrexone and trazodone dose increased from 100 to 150mg summary notes attached to SBAR. NP responded to SBAR documenting will review with resident this AM. Discussed with Resident 3. Will update meds dated 05/18/2026.Provider note dated 05/18/2026 and uploaded to eChart on 05/19/2026 at 4:52 PM, documented Provider discussed Kaiser recommendations to increase Trazodone 150 milligrams (MG) at HS (hour of sleep) and Naltrexone 50 MG daily. Resident 3 agreeable.Physician orders for Resident 3 updated with Natrexone 50 MG by mouth daily DX (diagnosis) substance use with a start date of 05/19/2026. A Trazodone order for increase to 150 MG was not located in physician orders.On 06/17/2026 at 1:44 PM, Staff E, LPN/RCM, said if a resident goes to an outside provider and comes back with orders the new orders are looked at as recommendations. These new orders will be put on an SBAR for the in-house provider to review. The in-house provider will then talk to the resident about the new medications. The in-house provider might put in the orders themselves into Point Click Care (PCC-a cloud-based electronic health record) or place the SBAR in the box for the nurses to complete. Staff E said the trazodone order was approved by the in-house approved to be increased to 150mg and the order should have been put into PCC for the resident to get. Staff E said he doesn't see where the trazodone order was increased and it should have been.Reference WAC: 388-97-1060 (1) - (3)

Based on interview and record review, the facility failed to ensure 6 of 6 residents (Residents 4, 5, 6, 7, 8, and 9) reviewed for insurance disenrollment were informed of the risks/benefits, options, and alternative changes in their insurance, in ways that were easy for the residents and/or the residents' representative to understand. The facility failed to develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage, including the need to obtain a document signed by the beneficiary or representative that acknowledges that the specific information regarding the impact of a change in coverage was provided to them orally and in writing, and that they understood the information. Failure of the facility placed residents at risk of non-coverage, increased cost out of pocket, and caused undue stress to residents and/or resident representatives and placed Managed Medicare residents at risk of the facility disenrolling them without their request, consent knowledge, or complete understanding.Findings included.Review of the Skilled Nursing Facility admission Agreement showed that the facility was an in-network provider for some Medicare Advantage Plans. If a Resident's care was covered by a Medicare Advantage Plan (Managed Medicare), Resident's skilled nursing care was managed through the insurance company. The needs and services were authorized and managed by the insurance provider's case managers and physicians. The facility participated in the Medicare program. If eligible, Medicare would pay 100% of Resident's costs in a semi-private room for the first twenty (20) days. The next eighty (80) days were known as coinsurance days, which meant the Resident was responsible for paying coinsurance on day 21 forward. According to the admission Agreement, the facility assured Residents all the rights in the Resident's [NAME] of Rights.The Centers for Medicare and Medicaid Services Memo to Long Term Care facilities on Medicare Health Plan Enrollment, dated October 2021 documented Only a Medicare beneficiary, the beneficiary's authorized or designated representative, or the party authorized to act on behalf of the beneficiary under state law can request enrollment in or voluntary disenrollment from a Medicare health or drug plan. It further explains the facility's responsibility as the following: Explain orally and in writing the impact to the beneficiary if they change coverage (e.g., to a stand-alone prescription drug plan (PDP) and Original Medicare, or to a different Medicare health plan). Develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage.<RESIDENT 4>Resident 4 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (weakness or paralysis to the left side of the body following tissue death in the brain caused by a blocked or severely restricted blood supply). The Quarterly Minimum Data Set, (MDS-an assessment tool), dated 04/27/2026, documented Resident 4 as cognitively intact. Review of Resident 4's record showed they were originally admitted to the facility on [DATE] on Medicaid. Resident 4 was sent to the emergency room on [DATE] and re-admitted to the facility on [DATE] under a managed Medicare plan and transferred to Traditional Medicare effective 05/01/2026. Further reviews showed no documentation to support the resident or POA was explained orally and in writing the impact to the beneficiary if they changed coverage.On 05/19/2026 at 1:09 PM, Resident 4 said she does not handle any of her finances and to call her daughter who is her Power of Attorney (POA). Resident 4 denied receiving anything in writing about the change in insurance.At 2:48 PM POA was interviewed. POA said she had not been aware that Resident 4's insurance had been changed to Medicare A but she is OK with it if Resident 4 is getting the care and services she needs. POA said this was not a good time to talk as she was on vacation and would reach out to the facility upon her return. <RESIDENT 5>Resident 5 was admitted to the facility on [DATE] with multiple diagnoses including unspecified fracture of upper end of right humerus (right upper arm fracture). The admission MDS, dated [DATE], documented Resident 5 as cognitively intact.Review of Resident 5's record showed they were admitted to the facility on [DATE] on a Medicare Advantage plan and transferred to Traditional Medicare effective 05/01/2026. Further review showed no documentation to support the resident or POA was explained orally and in writing the impact to the beneficiary if they changed coverage.Progress note date 04/29/2026 at 4:27 PM, documented Social Services met with Resident 5 to discuss insurance coverage options. Resident 5 in agreement to enroll in traditional Medicare A and B benefits and disenroll from Medicare Advantage plan.On 05/19/2026 at 3:17 PM, Resident 5 said she knows about the insurance change that took place at the beginning of the month. Resident 5 said she feels that it was a better option for her. Resident 5 said it was explained to her that she would receive more therapy allowing her to get home faster. Resident 5 said she is now having a hard time making an appointment with her normal doctor because of the insurance change. Resident 5 said instead of getting in right away she will have to wait almost a month. Resident 5 said she had not received anything in writing about the insurance change. <RESIDENT 6>Resident 6 was admitted to the facility on [DATE] with multiple diagnoses including chronic combined systolic (congestive) and diastolic (congestive) heart failure (pumping and filling heart failure). The Quarterly MDS, dated [DATE], documented Resident 3 as cognitively intact.Review of Resident 6's record showed they were originally admitted to the facility on [DATE] on a Managed Medicare plan. Resident 6 was sent to the emergency room on [DATE] and re-admitted to the facility on [DATE] under a managed Medicare plan and transferred to Traditional Medicare effective 05/01/2026. Further reviews showed no documentation to support the resident or POA was explained orally and in writing the impact to the beneficiary if they changed coverage.Progress note date 04/29/2026 at 4:28 PM, documented Social Services met with Resident 6 to discuss insurance coverage options. Resident 5 in agreement to enroll in traditional Medicare A and B benefits and disenroll from Medicare Advantage plan.Multiple attempts were made to interview resident on 05/19/2026, 05/20/2026, and 05/21/2026 with resident declination. <RESIDENT 7>Resident 7 was admitted to the facility on [DATE] with multiple diagnoses including unspecified Atrial fibrillation (a common heart arrhythmia). The admission MDS, dated [DATE], documented Resident 7 as cognitively intact.Review of Resident 7's record showed they were originally admitted to the facility on [DATE] on a Managed Medicare plan. Resident 7 was sent to the emergency room on [DATE] and re-admitted to the facility on [DATE] under a managed Medicare plan and transferred to Traditional Medicare effective 05/01/2026. Further reviews showed no documentation to support the resident or POA was explained orally and in writing the impact to the beneficiary if they changed coverage.Progress note date 04/29/2026 at 3:47 PM, documented Social Services met with Resident 6 to discuss insurance coverage options. Resident 5 in agreement to enroll in traditional Medicare A and B benefits and disenroll from Medicare Advantage plan.Resident 7 discharged from the facility on 05/18/2026 and has not returned any calls.<RESIDENT 8>Resident 8 was admitted to the facility on [DATE] with multiple diagnoses including spondylosis without myelopathy or radiculopathy lumbosacral region (an age-related degenerative arthritis of the lower spine). The Quarterly MDS, dated [DATE], documented Resident 9 as moderately cognitively impaired.Review of Resident 8's record showed they were originally admitted to the facility on [DATE] on a Managed Medicare plan and transferred to Traditional Medicare effective 05/01/2026. Further reviews showed no documentation to support the resident or POA was explained orally and in writing the impact to the beneficiary if they changed coverage.On 05/19/2025 at 3:23 PM, Resident 8 said he switched to Medicare at the beginning of the month. Resident 8 said he wanted this change as he would get more therapy. Resident 8 said so far, he is very glad he switched to Medicare. Resident 8 said he had not been provided anything in writing explaining either disenrolling from his old plan or enrolling in the new plan.<RESIDENT 9>Resident 9 was admitted to the facility on [DATE] with multiple diagnoses including cerebral edema (the dangerous accumulation of fluid in the brain tissue). The admission MDS, dated [DATE], documented Resident 9 as moderately cognitively impaired.Review of Resident 9's record showed they were originally admitted to the facility on [DATE] on a Managed Medicare plan and transferred to Traditional Medicare effective 05/01/2026. Further reviews showed no documentation to support the resident or POA was explained orally and in writing the impact to the beneficiary if they changed coverage.Resident 9 had been sent to the ER and then admitted to the hospital on [DATE]. Unable to be interviewed.On 05/20/2026 at 10:13 AM, Staff A, Executive Director, said it was presented as how can we provide a better level of care by increasing the residents baseline function. Through the IDT process the residents were identified as possibly benefiting by changing insurance to Medicare so the residents might improve beyond their baseline. The Social Services Director then reached out to the identified residents and discussed their insurance options. The residents who wanted to change their insurance from a managed insurance to traditional Medicare were then processed. Oral discussion was provided on what the change in insurance would entail. Staff A said, no written material was given to the residents. Staff A said, there is not a policy addressing this issue.REFER TO: WAC 388-97-0260, -0300(3)(a)

Based on interview and record review the facility failed to protect resident's right to be free from physical abuse for 2 of 4 sample residents (Residents 1 and 2) reviewed for resident-to-resident altercations. This failure placed residents at risk for abuse, psychosocial harm, and a diminished quality of life.Findings included.Review of the facility policy titled, Coordinating/Implementing Abuse, Neglect and Exploitation Policies and Procedures, dated April 2021, documents 1. Policies are in place that: a. prohibit and prevent resident abuse, neglect, exploitation and misappropriation of resident property. The policy further documents 2. Policies address the following as part of abuse, neglect, misappropriation prevention: c. Prevention.Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including unspecified Dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with other behavioral disturbances. The admission Minimum Data Set, (MDS-an assessment tool), dated 03/1/2026, documented Resident 1 as severely cognitively impaired.Resident 2 was originally admitted to the facility on [DATE] with multiple diagnoses including unspecified Dementia (a condition characterized by progressive or persistent loss of intellectual functioning) with other behavioral disturbances. The Quarterly MDS, dated [DATE], documented Resident 2 as severely cognitively impaired.Review of the Alleged Resident to Resident Altercation packet number 2444, dated 05/09/2026 at 7:15 PM documented Resident 2 struck Resident 1 in the activity room. Resident 1 had been sitting at a table in the activity room when Resident 2 told Resident 1 she was sitting in the wrong spot and threatened to hit her. Resident 1 told Resident 2 she would get in trouble if she hit anyone. Resident 2 then struck Resident 1 on the right arm. The immediate intervention was to separate the residents and place Resident 2 on 1 to 1 supervision with a staff member.On 05/19/2026 at 2:24 PM, an interview was conducted with Resident 1. Resident 1 did not remember the incident.On 05/19/2026 surveyor unable to interview Resident 2 as Resident 2 was unreachable due to having been admitted to the hospital. Record review of Resident 1's progress notes, dated 05/09/2026 at 10:48 PM, documented Registered Nurse was notified by facility staff that Resident 1 was physically hit on her right arm by another female resident (Resident 2) with her hand. Upon assessment Resident 1 denied pain or discomfort to area of concern. No skin discoloration or skin tear noted upon skin assessment. Nursing managers and facility Administrator notified of situation.Record review of Resident 2's progress notes, dated 05/10/2026 at 3:03 AM, documented At approximately 7:15 PM, Certified Nursing Assistant (CNA) reported to Registered nurse that Resident 2 struck a peer in the activity room. Residents 1 and 2 were separated, and 1 to 1 supervision was initiated at that time (for Resident 2). Resident 1 said she had been sitting at a table in the activity room when Resident 2 entered, Resident 2 told Resident 1 she was sitting in the wrong spot and threatened to hit her. Resident 1 also stated she told Resident 2 that she would get into trouble if she hit anyone. Resident 2 then struck Resident 1 on the right arm. During interview of Resident 2, Resident 2 said I'm going to kick her mother fucking ass! Resident 2 was educated that violence was not acceptable and that she needed to stay away from Resident 1. Resident 2 was placed on 1 to 1 supervision and redirected to stay away from Resident 1. A head-to-toe assessment was completed with no injuries noted. 911 was called with Puyallup Police response at 7:45 PM. The Police assessed the situation and transported Resident 2 to Good Samaritan Hospital. Family, Administrator, Director of Nursing Services, Resident Care Manager, the state hotline and the provider were notified.During an interview on 05/20/2026 at 10:13 AM, Staff A, Executive Director, stated Residents 1 and 2 were involved in a Resident-to-Resident altercation which involved Resident 2 hitting Resident 1. Staff were able to intervene and separate the residents. Resident 2 was placed on 1 to 1 monitoring. Resident 2 was subsequently assessed by the police and taken to the hospital. Staff A said he was the facility abuse coordinator and after any type of abuse allegation there was a risk call. Staff A said this was a TEAMS meeting that included the Executive Director, Director of Nursing Services, Corporate Compliance, Corporate Social Services, Corporate Human Resources, Regional Consultant, and legal if necessary. Staff A said in this case Resident 2 has been accepted into an Adult Family Home (AFH) and the facility is waiting for an assessment to be provided by the state. Staff A said family is in agreement.Reference WAC: 388-97-0640 (1)

Based on interview and record review the facility failed to provide the necessary care and services for 1 of 4 residents (Resident 3) reviewed for quality of care when new skin impairments were not investigated to rule out abuse/neglect, investigation conclusions were not accurate to the identified skin impairment, treatment orders were not implemented at the time of the skin impairment identification and wound team recommendations were not followed. This failure placed residents at risk for unmet care needs, worsening wounds, and a decreased quality of life. Findings included.Resident 3 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease (a progressive mental deterioration of the brain). The Quarterly Minimum Data Set, (MDS-an assessment tool), dated 04/24/2026, documented Resident 3 was severely cognitively impaired.Review of the United Wound Healing (UWH) note, dated 03/06/2026 at 9:48 AM, documented Patient would benefit from formal vascular assessment with arterial duplex (a noninvasive, painless diagnostic test that uses high-frequency sound waves to evaluate blood flow and structural integrity of the arteries in the body) based on prior Ankle Brachial Index (ABI) results (a quick, noninvasive test that compares the blood pressure in the ankle to the blood pressure in the arm).Review of the electronic medical record (eChart) on 05/19/2026, did not show an order having been received, implemented, or results for an arterial duplex. Progress note, dated 04/01/2026 at 7:53 PM, documented Resident has new right side knee wound, 4 X 3 centimeters (CM). Resident had redness and strips of blisters (small fluid filled sac or pocket that forms within the outer layers of the skin) on the right shoulder and hip. Resident does show some discomfort with the skin issue. Nurse Practitioner (NP) assessed resident and new order for zinc oxide twice a day are in place. Resident continues to be repositioned in bed every 2 hours and safely transferred to wheelchair with a Hoyer life. Resident wound care continues per MD orders. Review of the Incident Log dated April 2026 did not include an investigation for the above-mentioned skin impairment of redness and strips of blisters on the right shoulder and hip. Abuse/neglect was not ruled out Review of the Skin Alteration - Other Type packet number 2411, dated 04/08/2026 at 11:11 AM, documented, The resident was found to have a reddened area on the right hip, concerning for early pressure injury (localized damage to the skin and underlying soft tissue) formation . The Notes heading for packet number 2411 documented, During routine care and a scheduled dressing change, a small skin tear (a traumatic wound where the top layers of the skin separate from the underlying layers) was noted on the side of the groin area, measuring approximately 1 x 0.1 CM. This area had not been previously identified and given the number of existing wounds and his fragile skin condition, it appears to be a newly developed finding. The Notes area does not address the reddened area on the right hip. Abuse/neglect was not ruled out for the reddened area on the right hip Review of the UWH note, dated 04/10/2026 at 04:25 PM, documented Patient presents today with new area of maceration (the softening and breakdown of the skin caused by prolonged exposure to moisture) and ulceration (the medical process where the surface of the skin or a mucous membrane breaks down, sheds dead inflamed tissue, and creates an open sore known as an ulcer) on ventral (front or anterior side) penis most likely caused by incontinence (the involuntary loss of control over bodily functions). Patient had severe contractures (the permanent tightening or shortening of muscles, tendons, ligaments, or skin that prevents normal movement of a joint) and had to be repositioned by nursing. Recommend aggressive application of zinc oxide to buttocks, groin, and around penis to protect against Moisture Associated Skin Damage (MASD-an inflammatory condition that occurs when the skin is repeatedly exposed to bodily fluids) and facilitate wound healing.Review of the Incident Log dated April 2026 did not include an investigation for the ulceration on ventral penis Review of the Skin Alteration - Acquired Pressure injury packet number 2431, dated 04/24/2026 at 07:00 AM, documented, Upon doing wound care, UWH [NAME] found another wound on [Resident 3]. The notes heading for packet number 2431 documented the same investigation conclusion as Skin Alteration - Other Type packet number 2411. It documented during a routine care and a scheduled dressing change, a small skin tear was noted on the side of the groin area, measuring approximately 1 x 0.1 CM. The identified skin impairment for the new stage 3 pressure ulcer (PU-a severe skin injury featuring full-thickness skin loss that exposes the underlying fatty tissue) to left posterior thigh is not addressed. Abuse/neglect was not ruled out for the stage 3 PU to left posterior thigh.Review of the UWH note, dated 04/24/2026 at 03:36 PM, documented Wound to the Left lateral knee is on its way to full closure and is resolving. No signs of infection today. New stage 3 PU on left posterior thigh found on exam at today's visit. Sharp debridement (a medical procedure used to clear wounds of dead, damaged, or infected tissue) conducted to remove slough (yellowish, soft, and often stringy material that forms in wounds of dead or dying tissue, protein buildup, or bacterial contamination) and initiate proliferation (the stage where the body rebuilds the damaged area with new tissue). No signs of infection at today's visit.Review of the electronic Treatment Administration Record (eTAR) dated April 2026 documented, Zinc Oxide Ointment 10%. Apply to per additional directions topically two times a day for skin condition apply to affected area: right shoulder, right hip and as needed. The start date for the above order is 04/01/2026 with a discontinuation date of 05/06/2026. No provider treatment order for Moisture Associated Skin Damage, ulceration on ventral penis, or stage 3 pressure ulcer to left posterior thigh was documented Review of the UWH note, dated 05/01/2026 at 08:36 AM, documented Wound to the Left knee is resolved at today's visit with discoloration still evident but with 100% intact epithelial (body tissue that forms the protective covering on all internal and external body surfaces). Wound to the left medial lower extremity added today that shows no signs of infection. Wound to right buttocks is better visualized at today's visit and is reclassified as a stage 3 PU. Patient also presents with left buttock stage 3 PU at today's visit. No signs of infection in any wounds.Review of the incident log dated May 2026 did not include an investigation for Resident 3 Review of the eTAR dated May 2026 documented the following provider orders with a start date of 05/05/2026 and a discontinuation date of 05/06/2026:1. Wound care: bilateral gluteal fold (the prominent horizontal crease located just below the buttocks) clean with normal saline, apply thick layer of zinc every day shift2. Wound care: Left ankle clean with normal saline, apply medihoney (medical-grade, sterilized honey used for managing wounds, burns, and skin ulcers), cover with foam dressing every day shift3. Wound care: Left knee skin tear clean with normal saline, apply skin prep very day shift. Review of care plan documents, on 05/19/2026, under the focus open areas to bilateral buttock and penis and redness to right hip. showed the care plan was not updated to reflect skin impairment to right shoulder, MASD, left medial lower extremity, or left ankle.On 05/21/2026 at 1300, Staff B Resident Care Manager (RCM) / Licensed Practical Nurse (LPN) said, when a new skin condition is identified the floor nurse assigned to the resident should start an incident report and notify the Resident Care Manager and the Director of Nursing Services. Staff B said once she is notified of the new skin condition, she observes the wound and takes measurements. Staff B said the provider would be notified and a treatment order would be obtained. Staff B said the treatment should be uploaded to the eMAR and the care plan should be updated to what the skin condition is and an intervention should then be placed. Staff B said all recommendations from the UWH notes should also be processed. Staff B said UWH comes in early on Fridays, and she will print off the UWH notes after UWH uploads their notes later in the day. Staff B said she reviews the notes for her residents and will update the eTAR for any new recommendations. Staff B said the other side of the building will do the same thing. Staff B said the recommendation made by UWH on 03/06/2026 for arterial duplex should have been ordered and completed. Staff B said the progress note on 04/01/2026 describing strips of blisters to the right shoulder and right hip should have had an incident report. Staff B said the incident reports on 04/08/2026 and 04/24/206 should have had conclusion in the note section pertaining to the skin impairment identified in the incident report. Staff B said treatments should be added to the eTAR when the skin condition is identified and not days later. Staff B said she will be coming in on Friday to give instruction to the other RCMs as to the process when UWH is in the building. Reference WAC: 388-97-1060 (1) - (3)

Based on interview and record review the facility failed to protect resident's right to be free from physical abuse for 3 of 4 sample residents (Residents 1, 3, and 4) reviewed for resident-to-resident altercations. This failure placed residents at risk for abuse, psychosocial harm, and a diminished quality of life.Findings included.Based on interview and record review the facility failed to protect resident's right to be free from physical abuse for 3 of 4 sample residents (Residents 1, 3, and 4) reviewed for resident-to-resident altercations. This failure placed residents at risk for abuse, psychosocial harm, and a diminished quality of life.Findings included.Review of the facility policy titled, Coordinating/Implementing Abuse, Neglect and Exploitation Policies and Procedures, dated April 2021, documents 1. Policies are in place that: a. prohibit and prevent resident abuse, neglect, exploitation and misappropriation of resident property. The policy further documents 2. Policies address the following as part of abuse, neglect, misappropriation prevention: c. Prevention.Resident 1 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease (a progressive mental deterioration of the brain) late onset. The Quarterly Minimum Data Set, (MDS-an assessment tool), dated 03/19/2026, documented Resident 1 as moderately cognitively impaired.Resident 2 was admitted to the facility on [DATE] with multiple diagnoses including unspecified Dementia (a condition characterized by progressive or persistent loss of intellectual functioning) without behavioral disturbance. The admission MDS, dated [DATE], documented Resident 2 as cognitively intact.Review of the Alleged Resident to Resident Altercation packet number 2385 dated 03/28/2026 at 04:30 PM documents, Resident 1 was involved in a resident-to-resident altercation in which an alternate resident (Resident 2) grabbed his (Resident 1's) wrist and Resident 1 hit the alternate resident (Resident 2) in the face. The immediate intervention was to separate the residents and place Resident 1 on 1 to 1 supervision with a staff member.On 04/02/2026 at 12:52 PM, Resident 2 stated, about a week ago he was in the main dining room, and the meal was almost over, and trays were being picked up when Resident 1 came in and took a piece of cornbread off a used tray. Resident 2 said, he told Resident 1 You can't take food off of trays. Resident 2 said Resident 1 clocked him in the face and he fell to the ground. On 04/02/2026 at 02:00 PM, Resident 1 said he took a piece of cornbread off a tray that had been picked up already. Resident 1 said the guy (Resident 2) that lived down the hall was in the dining room and was telling me to put it back. Resident 1 said tempers flared, he hit Resident 2 in the face, and Resident 2 fell to the ground. Resident 3 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease. The Quarterly MDS, dated [DATE], documented Resident 3 as severely cognitively impaired.Resident 4 was admitted to the facility on [DATE] with multiple diagnoses including unspecified Dementia with other behavioral disturbances. The admission MDS, dated [DATE], documented Resident 4 as severely cognitively impaired.Review of the Alleged Resident to Resident Altercation packet number 2376 dated 03/23/2026 at 11:00 AM, documents Resident 3 was trying to get a wheelchair away from Resident 4. Resident 3 and Resident 4 pushed each other. Resident 3 fell to the ground. The immediate intervention was to separate the residents by offering a room move. Resident 3 accepted the room move and is now in a private room. On 04/02/2026 at 01:01 PM, an interview was conducted with Resident 3. Resident 3 did not remember the incident.Record review of progress note, dated 03/23/2026 at 11:45 AM, for Resident 3 documented, RN received report that resident was involved in altercation. Resident reported that her roommate pushed her down causing her to hit her head and back. Resident unable to remember what occurred during incident.On 04/02/2026 at 01:14 PM, an interview was conducted with Resident 4. Resident 4 did not remember the incident.Record review of progress note dated 03/23/2026 at 11:41 AM, for Resident 4 documented, Resident reported that her roommate was attempting to touch her wheelchair and pushed roommate away from the wheelchair. Resident reports she pushed her roommate back which caused her to fall. Resident reports she didn't mean to push her down, that she accidentally pushed too hard. Residents separated and Resident was assisted to activities.During an interview on 04/14/2026 at 01:30 PM, Staff A, Executive Director, stated Residents 1 and 2 were involved in a Resident-to-Resident altercation which involved Resident 1 hitting Resident 2. Staff were able to intervene and separate the residents. Resident 1 was placed on a 1 to 1 monitoring. Staff A stated Residents 3 and 4 were also involved in a Resident-to-Resident altercation which involved Resident 4 pushing Resident 3, causing her to fall. Staff A said it was determined that Resident 4 thought all belongings in her room belonged to her, therefore she was moved to a private room to minimize any further occurrences. Staff A said he was the facility abuse coordinator and after any type of abuse allegation there was a risk call. Staff A said this was a TEAMS meeting that included the Executive Director, Director of Nursing Services, Corporate Compliance, Corporate Social Services, Corporate Human Resources, Regional Consultant, and legal if necessary. Reference WAC: 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff and functional call light systems were in place across multiple units and shifts to meet residents' basic care needs, including timely response to call lights and assistance with activities of daily living. This deficient practice was systemic in nature, resulting in delayed responses, unmet care needs, and inadequate supervision for residents, and placed residents at risk for an unsafe environment, avoidable discomfort, incontinence, skin breakdown, delayed medication administration, and diminished quality of life.Findings included .Observation on 01/07/2026 at 10:47 PM showed the 100 and 200 Hall call light boards disconnected and showed blue screens saying Disconnected: click to configure connection with constant beeping. Observation on 01/13/2026 at 8:26 AM showed the [NAME] Care (call light system) at the North and South nursing station showed call lights for resident rooms were visually seen on the screen but were not audible. Observation showed the audible display on the screen with an X through it. During an interview on 01/05/2026 at 2:40 PM, Resident 19 stated sometimes they waited more than an hour for their call light to be answered and when staff arrived, they would turn the light off, not meet the need and leave. During an interview on 01/06/2026 at 10:09 AM, Resident 17 stated they had an hour wait for their call light to be answered on day shift. Resident 17 stated one night they waited four hours in a wet brief before staff came to assist. During an interview on 01/06/2026 at 9:51 AM, Resident 99 stated, They take long time to answer my call light, sometimes it can take a half hour to get help mostly on evenings and night shifts. During an interview on 01/05/2026 at 4:10 PM, Resident 41 stated, They do not have enough staff, the wait is a long time for medications. During an interview on 01/06/2026 at 8:57 AM, Resident 6 stated, They need more staff, sometimes other residents have to call out for help because they wait too long and Sometimes I wait over a week to get a shower and have my sheets changed. Review of Resident Council Minutes for the months 07/2025, 09/2025, 11/2025 and 12/2025 showed the following resident concerns: Long call wait times during night shift, lack of staff to assist residents to activities, call lights being turned off prior to needs being fulfilled, and lack and difficulty finding nursing aides following breakfast. During an interview on 01/13/2026 at 8:42 AM, Staff EE, Certified Nursing Assistant (CNA), stated staff call outs were a problem at the facility. Staff EE stated the North Hall shower aide quit due to regularly being required to work the floor when staff called out. Staff EE stated while working short staffed they were not able to provide all necessary care to their assigned residents. During an interview on 01/13/2026 at 8:30 AM, Staff GG, Restorative Nursing Aide, stated they had been regularly providing resident care on the floor due to short staffing for the past few weeks. Staff GG stated they had residents scheduled for restorative that they would not get to that day due to working the floor. Staff GG stated residents who did not get their restorative would be scheduled for the next available shift they were not working the floor. During an interview on 01/12/2026 at 3:13 PM, Staff Q, CNA, stated they often worked short staff and were unable to provide showers to residents. Staff Q stated the shower aid quit about two months ago and had not been replaced. During an interview on 01/12/2026 at 2:38 PM, Staff FF, Staffing Coordinator, stated adequate staff were scheduled daily; however, staff call outs were an ongoing problem. Staff FF stated the facility has had as many as four CNAs call out on the same shift. During an interview on 01/13/2026 at 11:40 PM, Staff A, Administrator, stated they were aware of long call wait times and were currently in the process of hiring additional nursing staff. Staff A stated short staffing was caused by staff callouts and the facility had implemented new disciplinary policies related to staff who 'no call no show' or habitually call out. FOR ADDITIONAL INFORMATION REFER TOFed - F - 0677- Activities of Daily Living for Dependent ResidentsFed - F - 0730- Nurse Aide Performance Review and 12 Hours and year In-Service Reference WAC 388-97-1080 (1), 1090 (1)

Based on interview and record review, the facility failed to conduct performance evaluations for 5 of 5 Certified Nursing Assistants (CNA) (Staff D, F, GG, EE, and PP) in the last 12 months. These failures placed the residents at risk of receiving less than optimal care. Findings included .Review of Staff D, F, GG, EE and PP, CNAs, employee files found no documentation that the annual performance evaluations had been conducted. During an interview on 01/12/2026 at 3:28 PM, Staff AA, Human Resources/Payroll, stated that they were aware that the CNAs needed performance evaluations yearly; however, they had not been completed. During an interview on 01/13/2026 at 11:40 AM, Staff A, Administrator, stated due to staff changes, performance evaluations were not completed, and this did not meet expectations. Reference WAC 388-97-1680

Based on observation, interview, and record review, the facility failed to ensure foods were palatable, prepared, and served in a manner acceptable to residents across the facility, as evidenced by widespread and ongoing resident complaints regarding food quality, taste, temperature, portion size, and accuracy of meal trays. This deficient practice affected multiple residents over an extended period of time, resulting in residents refusing meals, requesting frequent substitutions, and reporting unmet nutritional needs, placing residents at risk for reduced nutritional intake, avoidable weight loss, delayed medical improvement, and diminished quality of life. Findings included.<RESIDENT INTERVIEWS> During an interview on 01/05/2026 at 12:26 AM, Resident 19 stated they would not feed the facility's food to their pet because it did not taste good. During an interview on 01/05/2026 at 3:51 PM, Resident 115 stated the facility's food was terrible and was often greasy so they could not eat it. During an interview on 01/05/2026 at 1:20 PM, Resident 40 stated the facility's food was terrible because it did not taste good, was bland, and the vegetables were mushy. Resident 40 stated the facility's administration was aware of resident complaints regarding food but failed to improve the food quality. During an interview on 01/05/2026 at 3:53 PM, Resident 15 stated the facility's food was not good and rated it 2 out of 10. Resident 15 stated the food was bland. During an interview on 01/05/2026 at 11:20 AM, Resident 53 stated the facility's food did not taste good and when alternative items were requested from the kitchen it was not provided. During an interview on 01/05/2026 at 11:31 AM, Resident 117 stated they did not eat pork, but would still be served pork. Resident 117 stated the food items provided were frequently not the same as the menu and sometimes items would be missing from the tray. Resident 117 stated the food portions were small. During a follow-up interview on 01/06/2026 at 9:25 AM, Resident 117 stated their breakfast was not good as the eggs were bland. Resident 117 stated the meal ticket showed cold cereal, but they did not receive it. During an interview on 01/05/2026 at 2:43 PM, Resident 72 stated all meals at the facility were terrible. During an interview on 01/06/2026 at 9:01 AM, Resident 6 stated sometimes they were unable to identify what food items they had been served and they did not match what items were on the menu. Resident 6 stated they did not get enough to eat because of concerns about the facility's food. During an interview on 01/06/2026 at 10:04 AM, Resident 3 stated the facility's food was disgusting. Resident 3 stated they told facility staff about their food concerns, but they don't listen. During an interview on 01/05/2026 at 9:33 AM, Resident 13 stated the food arrived warm and they had to ask staff to microwave their food to increase the temperature. During an interview on 01/05/2026 at 3:05 PM, Resident 14 stated the facility's food was really bad. Resident 14 stated the food was mushy and not edible. Resident 14 stated they had to request a sandwich for lunch because the food served was not palatable. During an interview on 01/05/2026 at 11:48 AM, Resident 11 stated the facility's food was not good and they frequently had to request substitutions. During an interview on 01/05/2026 at 11:10 AM, Resident 96 stated the facility frequently ran out of items on the menu, so they were served a substitute two to three times a week. During an interview on 01/05/2026 at 3:31 PM, Resident 98 stated the facility's food was terrible and they often sent the food back to the kitchen. During an interview on 01/06/2026 at 9:56 AM, Resident 99 stated the facility's food was bland and usually did not taste good. Resident 99 stated the portion sizes were small, and they had to request more food from the kitchen. <FOOD COMMITTEE> Review of Resident Council Minutes, dated 07/07/2025, showed the following concerns during the Dietary Committee section: 1) Watery scrambled eggs; 2) French toast regularly undercooked; 3) Brussel sprout and cauliflower were served burnt; 4) Carrots were mushy and overdone; 5) Coffee was often served colder than preferred; and 6) Breakfast was served colder than preferred. The Improvements area showed, R.C.'s [Resident Council] perception is that there has been a rapid decline in the quality of the product. Review of Resident Council Minutes, dated 08/11/2025, showed the following concerns during the Dietary Committee section: 1) [NAME] was served too often; 2) Meals with only starches and no meat (i.e. mac and cheese with scalloped potatoes); 3) Hardboiled eggs being too firm; 4) Meals with double noodles; 5) Scrambled eggs described as sour; and 6) Gilled cheese sandwiches served under grilled. Review of Resident Council Minutes, dated 09/08/2025, showed the following concerns during the Dietary Committee section: 1) Food served at appropriate temperatures 75% of the time; 2) Requesting less rice and more variety; 3) Chicken with rice served for lunch and chicken and rice casserole served for dinner; and 4) Constantly served items not on the menu with missing or substituted items. Review of Resident Council Minutes, dated 10/06/2025, showed the Dietary Committee section requested better presentation of food to include receiving dry napkins and items placed uniformly on the tray. Review of Resident Council Minutes, dated 11/10/2025, showed the following concerns during the Dietary Committee section: 1) [NAME] served too often; and 2) Vegetables regularly overcooked. Review of Resident Council Minutes, dated 12/08/2025, showed the following concerns during the Dietary Committee section: 1) Vegetables often served overcooked; 2) [NAME] served too often; 3) Breakfast frequently served cold; and 4) Not receiving requested alternative items. Review showed the Resident Council requested an explanation why they were told basic items were unavailable and reported they had been told by staff there was no sugar, bread, jelly, fruit, etc at various times the previous month. <GRIEVANCES> Review of a Complaint/Grievance Report, dated 07/02/2025, showed Resident 120 reported, When my meals come, they're cold, but my liquids are warm. Review of a Complaint/Grievance Report, dated 07/09/2025, showed Resident 121 reported, Food is crap. Review of a Complaint/Grievance Report, dated 07/18/2025, showed Resident 49 reported, I haven't been able to eat any of the meals for five days. No silverware, only plastic. I wouldn't serve it to a dog. Review of a Complaint/Grievance Report, dated 07/18/2025, showed Resident 102 reported, No silverware. The food is awful here. Not edible. It tastes like [expletive]. Review of a Complaint/Grievance Report, dated 07/29/2025, showed Resident 122 reported, Kitchen is serving foods [they are] not able to eat. Review of a Complaint/Grievance Report, dated 07/31/2025, showed Resident 123 reported, I never got a dinner tray last night. Review of a Complaint/Grievance Report, dated 08/03/2025, showed Resident 123's family member reported Resident 123 had arrived at the facility at 3:00 PM and called them at 8:30 PM to report they had not received a food tray. Resident 123 stated they called the facility at 9:00 PM to request Resident 123 receive food, but they were not provided with a meal until after midnight. Review of a Complaint/Grievance Report, dated 08/07/2025, showed Resident 123 reported, Filled out menu daily, did not get what they ordered, or they would write it on the ticket in big red letters they ran out. Review of a Complaint/Grievance Report, dated 08/20/2025, showed Resident 124 reported, Food is horrible and tasteless. Review of a Complaint/Grievance Report, dated 10/03/2025, showed Resident 37 reported they sometimes received pureed diet, but their ordered diet was regular soft and bite sized. Review of a Complaint/Grievance Report, dated 10/26/2025, showed Resident 122 reported they were not receiving enough food. Review of a Complaint/Grievance Report, dated 12/21/2025, showed Resident 78 reported, Not the right breakfast items according to the menu and tray ticket. Review of a Complaint/Grievance Report, dated 12/29/2025, showed Resident 125 reported concerns about food not being on tray as stated on meal ticket. Review of a Complaint/Grievance Report, dated 12/31/2025, showed Resident 125 reported they did not like the food they received. During an interview on 01/14/2026 at 9:17 AM, Staff CC, Dietary Manager, stated the facility held a dietary committee meeting monthly to ensure residents found the facility's food palatable. Staff CC stated they were aware of concerns related to food quality and felt the issue was with the quality of the product the kitchen was allowed to purchase. Staff CC stated the frequent concerns with food quality and not receiving requested items did not meet their expectations. During an interview on 01/14/2025 at 10:22 AM, Staff A, Administrator, stated the expectation was for residents to consider the facility's food to be palatable. Staff A stated they were aware of the residents' concerns related to palatability of the facility's food and they were working with their regional group to resolve the issue. Staff A stated the residents' statements, dietary committee concerns, and grievances related to food did not meet expectations. Reference WAC 388-97-1100(1)(2)

Based on interview and record review, the facility failed to maintain a full-time qualified social worker. This failure placed residents at risk of lacking medically related social services and a diminished quality of life. Findings included.Review of facility licensing data, effective 06/01/2020, showed the facility was licensed for 130 beds.During an interview on 01/08/2026 at 2:13 PM, Staff V, Social Services Assistant, stated the facility's Social Services Director had been on maternity leave for two weeks and they were handling the qualified social worker duties until they returned. Staff V stated they were told they would receive assistance during the social services director's leave but were unsure when this help would arrive. Staff V stated they did not have formal education in the field of social work.During an interview on 01/08/2026 at 2:29 PM, Staff A, Administrator, stated the facility was licensed for 130 beds. Staff A stated the facility employed a qualified social worker to ensure residents had access to medically related social services. Staff A said the qualified social worker should have a bachelor's degree in social services and be employed full-time. Staff A stated the social services director has been on leave since around 12/19/2025 and would be on leave for at least two more weeks. Staff A stated they were a qualified social worker, and a qualified social worker was available via phone or email, but they were not serving as full-time qualified social worker at this time.Reference WAC 388-97-0960(2)(a)(b).

Based on observation, interview, and record review, the facility failed to ensure safe and appropriate medication practices by leaving medications unattended at the bedside for residents who were not assessed or approved to self-administer medications for 3 of 3 sampled residents (Residents 40, 15, and 114) reviewed for accident hazards. This practice was inconsistent with the residents' interdisciplinary team (IDT) assessment and care plan and placed the residents at risk for adverse medication outcomes.Findings included. Review of the facility's policy titled, Self-Administration of Medications, dated February 2021 showed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. It showed, Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. Resident 40 Review of the electronic health record (EHR) showed Resident 40 readmitted to the facility on [DATE] with diagnoses to include respiratory failure, schizophrenia (mental disorder that affects how a person thinks, feels, and behaves, leading to disorganized thinking), and post-traumatic stress disorder (PTSD, a mental health condition where someone feels stressed and scared long after a traumatic event). Resident 40 was able to make needs known. Observation and interview on 01/05/2026 at 10:09 AM, showed Resident 40 sitting at the bedside with a bottle of multiple vitamins with minerals (a supplement used to treat or prevent general nutritional deficiencies) and a bottle of Prevagen oral capsules (a supplement used to support memory and brain function) on the overbed table next to the bed. Resident 40 stated they gave those medications to themself and the nurses were aware. Observation and interview on 01/07/2026 at 1:11 PM showed a tube of Preparation H medicated cream (used to treat hemorrhoids/inflamed or swollen veins in the anus or lower rectum) on the bottom shelf in the bathroom and Resident 40 stated it was their personal item. Review of the focused care plan for self-administration of medications, initiated on 12/28/2022 and revised on 09/10/2025, showed Resident 40 would self-administer supplements in accordance with the dosage and frequency prescribed by the physician and to complete the self-medication assessment per protocol. Review of Resident 40's order summary report, dated 01/06/2026, showed an order for, Resident MAY NOT administer own meds [medications], dated 09/18/2025. Review of the medication self-administration evaluation form, dated 12/29/2025, showed Resident 40 was not approved to self-administer medications and a licensed nurse was to administer medications to the resident. Review of Resident 40's January 2026 medication administration record (MAR) from 01/01/2026 - 01/06/2026 showed an order with a start date 09/19/2026 for multiple vitamins-minerals one tablet orally one time a day supplement and to supervise self-administration. Documentation showed it was provided per the order. Review showed an order with a start date of 09/19/2026 for Prevagen oral capsule 20 milligrams (mg) orally one time day supplement, unsupervised self-administration/this medication included: vitamin D 50 micro gram (mcg) and apoaquorin 20 mg, and for resident to self-administer the supplement, scheduled for 7:00 AM. Documentation showed U-SA (unsupervised self-administer), not initialed/signed by a licensed nurse. This MAR showed no orders for Preparation H medicated cream. During an interview on 01/07/2026, Staff L, Registered Nurse (RN), stated Resident 40 had active orders for multiple vitamins with minerals that was provided in a medication cup and the resident supervised while taking it and should not have been left at the bedside. Staff L stated that the order for the Prevagen oral capsule supplement was able to be self-administered unsupervised. Staff L stated that they only provided Resident 40 with the multiple vitamins with minerals and not Prevagen. Staff L stated the medication self-administration evaluation form dated 12/29/2025 showed Resident 40 was not approved to self-administer medications. Staff L stated once Resident 40's medication self-administration evaluation form was completed on 12/29/2025, and was not approved to self-administer medications, the provider should have been notified, the order to self-administer discontinued, and the care plan updated/revised. Staff L stated Resident 40 did not have orders for Preparation H medicated cream and it should not have been located in the resident's bathroom. During an interview on 01/07/2026 at 1:47 PM, Staff B, Director of Nursing Services (DNS), stated when the medication self-administration evaluation was completed on 12/29/2025 showing Resident 40 was not approved to self-administer medications, the provider should have been notified, the order should have been corrected for nurses to provide the ordered medications, and the care plan revised. Staff B stated Resident 40 should not have had medications at the bedside or in the bathroom to be able to self-administer. Resident 15 Review of the EHR showed Resident 15 readmitted to the facility on [DATE] with diagnoses to include diabetes (too much sugar in the blood), gastritis (inflammation/swelling of the stomach lining), and high blood pressure. Resident 15 was able to make needs known. Observation and interview on 01/07/2026 at 9:02 AM showed a container of chewable Tums (an antacid medication used to neutralize acidity in the stomach) and a container of Visine (for temporary relief of minor eye irritation, redness, dryness, and discomfort) located on the nightstand next to the bed, and a box of Visine on the overbed table. Resident 15 stated they used the Tums when they had an upset stomach, the Visine when their eyes were dry and irritated, and did not tell the nurse because they were over the counter medications. Review of the current care plan on 01/06/2026 did not show a care plan for Resident 15 to be able to self-administer medication or have medication left at the bedside. Review of the medication self-administration evaluation form dated 07/21/2025 showed Resident 15 was not approved to self-administer medications and a licensed nurse was to administer medications to the resident. Review of Resident 15's order summary report dated 01/07/2026 showed an order for, Resident MAY NOT administer own meds [medications], dated 02/24/2025. Review showed no active orders for Tums or Visine. Review of Resident 15's January 2026 MAR from 01/01/2026 - 01/07/2026 showed no active provider orders for Tums or Visine. During an interview on 01/07/2026 at 2:42 PM, Staff L, RN, stated Resident 15 should not have had medications at the bedside without an approved self-medication evaluation, provider order, and the care plan revised. Staff L stated they were still trying to complete a self-medication evaluation for Resident 15. During an interview on 01/08/2026 at 12:37 PM, Staff B, DNS, stated staff had told them yesterday (01/07/2026) evening that Resident 15 had Tums and Visine at the bedside without provider orders and an approved self-medication evaluation completed. Staff B stated this did not meet their expectations. Resident 114 Review of the EHR showed Resident 114 admitted to the facility on [DATE] with diagnoses to include cerebral infarction (a type of stroke where part of the brain dies because its blood supply gets blocked), high blood pressure, and muscle weakness. Resident 114 was able to make needs known. Observation and interview on 01/07/2025 at 9:15 AM showed Aspercreame Lidocaine roll-on medication on the overbed table. Resident 114 stated it was a gift from a friend and they would use it once or twice a day when they had pain. Resident 114 stated staff never asked or talked to them about having it and the nurses could see they had it on the overbed table. Review of the current care plan on 01/06/2026 showed no care plan for Resident 114 to be able to self-administer medication or have medication left at the bedside. Review of Resident 114's order summary report dated 01/07/2026 showed an order for, Resident MAY NOT administer own meds [medications], dated 09/17/2025. Review showed no active orders for Aspercreame Lidocaine roll-on medication. Review of the medication self-administration evaluation form dated 12/29/2025 showed Resident 114 was not approved to self-administer medications and a licensed nurse was to administer medications to the resident. During an interview and observation on 01/07/2026 at 3:03 PM, Staff L, RN, stated they could see Aspercreame lidocaine roll-on medication on Resident 114's overbed table and the resident was not in the room at the time. Staff L stated Resident 114 had a medication self-administration evaluation dated 12/29/2025 that showed the resident was not approved to self-administer medications. Staff L stated Resident 114 did not have order to have medication at the bedside prior to today (01/07/2026). During an interview on 01/08/2026 at 12:54 PM, Staff B, DNS, stated they were made aware Resident 114 had a medication self-administration evaluation dated 12/29/2025 that showed the resident was not approved to self-administer medications. Staff B stated they were told last night (01/07/2026) that Resident 114 had Aspercreame Lidocaine medication at the bedside and did not have a provider order for the medication or to have medication at the bedside and this did not meet their expectations. Reference WAC 388-97-0440, -1060(3)(I)

Based on record review and interview, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 4 of 4 sampled residents (Residents 1, 40, 7 and 8) when reviewed for hospitalization and failed to provide written notice of transfer/discharge and recapitulation of their stay for 2 of 4 sampled residents (Residents 40 and 111) when reviewed for discharge. These failures placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.Resident 1 Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses of diabetes (when the body doesn't process sugars) and respiratory failure. The resident was able to make needs known. Review of the progress notes showed Resident 1 was transferred to the hospital on [DATE]. No documentation was found that the resident was offered a bed hold. During an interview on 01/09/2026 at 12:18 PM, Staff B, Director of Nursing Services (DNS), stated bed holds should be offered to include the price per night when a resident is transferred to the hospital. This did not meet expectations for Resident 1. Resident 40 Review of the EHR showed Resident 40 readmitted to the facility on [DATE] with diagnoses to include respiratory failure, schizophrenia (mental disorder that affects how a person thinks, feels, and behaves, leading to disorganized thinking), and high blood pressure. Resident 40 was able to make needs known. Review of the discharge minimum data set assessment (MDS) dated [DATE] showed Resident 40 had an unplanned discharge to the hospital on [DATE] with return anticipated. Review of Resident 40's bed hold policy notice and authorization form dated 09/11/202 showed it was not completely filled out and was missing the year, the cost to hold the bed, and was not signed by the resident or representative. Review of Resident 40's skilled nursing facility (SNF)/ nursing facility (NF) hospital transfer form dated 09/11/2025 showed it was inaccurately filled out. It showed the date of transfer was 5/15/2025, and did not show documentation that the form was sent to the hospital with the resident at the time of transfer. Review of Resident 40's Department of Social and Health Services (DSHS) Nursing Home Transfer or Discharge Notice dated 09/11/2025 was not signed by the resident or representative. Review of Resident 40's EHR showed no documentation that the resident received in writing of the reason for the transfer to hospital on [DATE]. Review showed no documentation that the receiving hospital was conveyed required information at the time of transfer on 09/11/2025. During an interview on 01/12/2026 at 3:21 PM, Staff M, Business Office Manager (BOM), stated Resident 40's bed hold did not meet expectations because they forgot to put the rate of the bed hold, and the year/date seemed to have been cut off. Staff M stated they should have documented that Resident 40 refused to sign the bed hold instead of just documenting on the form that the resident declined the bed hold. During an interview on 01/13/2026 at 11:17 AM, Staff B, DNS, stated Resident 40's bed hold dated 09/11/202 should have had the correct year documented, the rate for the bed hold, and should have been signed by the resident or documentation to show the resident refused to sign. Staff B stated they did not know why Resident 40's SNF/NF to Hospital Transfer form dated 09/11/2025 had incorrect dates. Staff B stated this form should have been filled out correctly and sent with Resident 40's transfer to the hospital. Staff B stated they were unable to locate documentation that Resident 40 received written notice for their transfer to the hospital on [DATE] and there should have been. Resident 7 Review of the EHR showed Resident 7 admitted to the facility on [DATE] with diagnoses that included a stroke (medical emergency that occurs when blood flow to the brain is interrupted) and muscle weakness. Resident 7 was able to make needs known. Review of Resident 7's EHR showed hospitalization on 10/27/2025 and readmission to the facility on [DATE]. Review of the EHR showed an incomplete bed hold dated 10/28/2025. During an interview on 01/09/2025 at 8:50 AM, Staff M, BOM, stated they did not complete the form because long term care residents were not charged for bed holds. During an interview on 01/13/2025 at 11:40 AM, Staff A, Administrator, stated the expectation was for bed holds to be offered, completed and thoroughly documented when a resident was transferred to the hospital. Resident 8 Review of the EHR showed Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include hemorrhage in brain stem (Bleeding in brain stem), gastrostomy (surgically placed external opening into stomach), depression, anxiety and cognitive communication deficit. Resident 8 was not always able to communicate needs. During a phone interview on 01/05/2026 at 2:27 PM, Collateral Contact Z, stated Resident 8 has been discharged to the hospital multiple times, but the last time the facility did not offer a bed hold. Review of the EHR showed Resident 8 was discharged to hospital on [DATE] and returned on 12/31/2025. Review of the EHR showed Resident 8 had a Bed Hold Policy Notice and Authorization form in their record that was not signed or had verbal notification about bed hold. During an interview on 01/08/2026 at 2:16 PM, Staff J, Licensed Practical Nurse, stated the process for discharge to hospital was for the nurses to obtain the bed hold and fill out the paper form, when that was not possible there was a follow up from the office. Staff J stated the paperwork about the bed hold on Resident 8 was missing. During an interview on 01/09/2026 at 12:48 PM, Staff B, DNS, stated the bed hold documentation for Resident 8 did not meet expectations. Resident 111 Resident 111 admitted to the facility on [DATE] with diagnoses to include diabetes, chronic pain and depression (mood disorder). Resident 111 was able to make needs known. Review of the EHR showed Resident 111 discharged from the facility on 11/13/2025. The EHR did not have documentation detailing the discharge. During an interview on 01/13/2026 at 10:13 AM, Resident 111 stated they left the facility against medical advice on 11/13/2025 due to the conditions at the facility. Resident 111 stated staff were aware of the discharge which was in the afternoon. Resident 111 stated the facility did not provide them with any medications or paperwork. During an interview on 01/14/2026 at 9:54 AM, Staff V, Social Services Assistant (SSA) stated when residents discharge the Discharge Planned Documentation assessment (discharge summary) in the medical record was to be completed for all residents. Staff V stated they were unable to locate documentation of a completed assessment for Resident 111. During an interview on 01/14/2026 at 10:08 AM, Staff A, Administrator, stated the expectation was that all discharge documents to include the discharge summary were completed for all residents including self-initiated discharges. Staff A stated the document should have been provided to the resident/resident representative by mail. Reference WAC 388-97-0120(4)(b)

Based on interview and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 3 of 27 sampled residents (Residents 10, 8 and 40) reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care and a diminished quality of life. Resident 10 Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder (mental health condition with mood disorder symptoms), depression (mood disorder), and anxiety (emotion associated with worry, fear or panic). Resident 10 was able to make needs known. During an interview on 01/05/2026 at 11:36 AM, Resident 10 stated they were unable to hear anything in their left ear. Resident 10 stated they preferred for anyone speaking to them to come to their right side so they could hear clearly. Review of Resident 10's care plan dated 09/24/2022 showed the resident has impaired communication as evidenced by left ear deafness. Review of the quarterly MDS dated [DATE] showed the Hearing section marked minimal difficulty for ability to hear. During an interview on 01/09/2026 at 9:38 AM, Staff G, MDS Nurse, stated when a resident had total loss of hearing in one ear they should be assessed as moderate difficulty. Staff H stated the MDS was coded incorrectly. During an interview on 01/09/2026 at 9:47 AM, Staff H, Assistant Director of Nursing (ADON), stated the expectation was if a resident had a complete hearing deficit in one ear the MDS should have been coded as moderate. Staff H stated the expectation was for the MDS to be coded accurately. Resident 8 Review of the EHR showed Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include hemorrhage in brain stem (bleeding in brain stem), gastrostomy (surgically placed external opening into stomach), major depression, anxiety, psychotic disorder with delusions (fixed, false beliefs held with extraordinary conviction despite clear evidence of the contrary), and cognitive communication deficit. Resident 8 was not always able to communicate needs. Review of the EHR showed Resident 8 had a level 2 Pre-admission Screening and Resident Review (PASSAR, a federally mandated, in-depth evaluation for individuals with mental illness) completed on 09/12/2024. Review of the annual MDS, dated [DATE], showed Resident 8 was receiving antipsychotics and antianxiety medications (drugs that alters brain chemistry to affect mental process). Review of the annual MDS dated [DATE] showed Resident 8 was not assessed as having level 2 PASARR. During an interview on 01/09/2026 at 1:28 PM, Staff G, MDS Nurse, stated the MDS for Resident 8 was inaccurate for PASSAR, and it should be correct. During an interview on 01/14/2026 at 9:19 AM, Staff B, Director of Nursing Services, stated the expectation was for the MDS assessment to correctly reflect the residents' statuses, and Resident 8's annual MDS dated [DATE] did not meet expectations. Resident 40 Review of the EHR showed Resident 40 readmitted to the facility on [DATE] with diagnoses to include personality disorder (a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that causes problems), schizophrenia (mental disorder that affects how a person thinks, feels, and behaves, leading to disorganized thinking), and post-traumatic stress disorder (PTSD, a mental health condition where someone feels stressed and scared long after a traumatic event). Resident 40 was able to make needs known. Review of Resident 40's EHR showed a level 2 PASSAR was completed on 05/01/2020. Review of the care plan dated 10/19/2022 showed Resident 40 met PASSAR level 2 determination related to diagnoses of serious mental illness. Review of Resident 40's MDS dated [DATE] section A1500 showed Resident 40 was coded No. for having a PASSAR level 2 with serious mental illness. During an interview on 01/08/2026 at 1:06 PM, Staff G, MDS Nurse, stated Resident 40's admission MDS dated [DATE] was coded incorrectly and should have been coded yes for having a PASSAR level 2 with serious mental illness. During an interview on 01/08/2026 at 2:14 PM, Staff B, DNS, stated Resident 40's admission MDS dated [DATE] was not coded correctly for level 2 PASSAR and should have been coded Yes. Staff B stated Resident 40's admission MDS needed to be modified. Reference WAC 388-97-1000(1)(b)

Based on interview and record review the facility failed ensure care plans were reviewed and revised for 5 of 22 residents (Residents 12, 8, 2, 37 and 51) reviewed for care plan review. This failure placed the residents at risk for injuries, unmet needs, care not provided as ordered and a diminished quality of life.Resident 12 Resident 12 admitted to the facility on [DATE] with diagnoses to include diabetes (high blood glucose), high blood pressure and muscle weakness. Resident 12 was able to make needs known. Observation and interview on 01/05/2026 at 10:57 AM, showed Resident 12 with a wander guard device on their left wrist. Resident 12 stated they did not know what the device was for. Observations on 01/06/2026 at 4:08 PM, 01/08/2026 at 11:46 AM, 01/09/2026 at 8:28 AM and 2:30 PM and 01/12/2026 at 3:13 PM showed Resident 12 asleep in bed with the wander guard in place. Review of the electronic health record (EHR) showed the most recent Elopement Risk assessment was completed on 06/06/2025. During an interview on 01/09/2026 at 11:06 AM, Staff J, Licensed Practical Nurse (LPN) stated when a physical restraint was being considered for a resident, a device evaluation was to be completed and updated quarterly or as needed. Staff J stated the evaluation was not completed for Resident 12 but should have been. During an interview on 01/12/2026 at 12:36 PM, Staff B, Director of Nursing Services (DNS), stated it did not meet their expectations that a device evaluation had not been completed. Staff B stated Resident 12 had no incidents of exit seeking in over a year and should have been reassessed to make sure the wander guard was appropriate and the care plan should have been revised. Resident 8 Review of the EHR showed Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include hemorrhage in brain stem (Bleeding in brain stem), gastrostomy (surgically placed external opening into stomach) major depression, anxiety, psychotic disorder with delusions (fixed, false beliefs held with extraordinary conviction despite clear evidence of the contrary) and cognitive communication deficit. Resident 8 was not always able to communicate needs. During a phone interview on 01/05/2026 at 2:27 PM, Collateral Contact Z, stated Resident 8 was on restorative program (nursing exercise program) but was not currently. Review of the care plan initiated on 06/24/2024, showed Resident 8 was receiving Restorative program. During an interview on 01/09/2026 at 12:43 PM, Staff B, DNS, stated Resident 8 was now receiving therapy and the care plan (CP) for Restorative should have been discontinued from the CP. Resident 2 Review of the EHR showed Resident 2 was admitted to the facility on [DATE] with diagnoses to include urinary tract infection, urinary retention, diabetes (high blood sugar), anxiety, and polyneuropathy (damage to nerves that cause different symptoms of numbness, pain and weakness). Resident 2 was able to communicate needs. Review of EHR showed Resident 2 had a urinary catheter that was removed in December 2025 and there was a provider progress note dated 12/21/2025 that explained how Resident 2 was urinating fine without the catheter. Review of the care plan dated 11/07/2025 showed Resident 2 was requiring indwelling foley catheter (urinary). During an interview on 01/12/2026 at 1:08 PM, Staff B, DNS, stated the expectation was to update the care plan immediately and Resident 2's care plan did not meet expectations. Resident 37 Review of the EHR showed Resident 37 admitted to the facility on [DATE] with a diagnosis of Dementia (a set of symptoms that effects memory) and was not able to make needs known. Review of the care plan dated 11/24/2025 showed the resident had a focus area of Resident is at risk for complications related to the use of psychotropic drugs, initiated on 01/01/2024 and revised on 11/07/2025. Review of the Providers orders showed Resident 37 had discontinued all psychotropic medications on 12/12/2024 and had discontinued all behavior monitors on 10/23/2024. During an interview on 01/12/2026 at 9:22 AM, Staff V, Social Services Assistant stated care plans should be revised when orders were changed or they were given a new psychotropic medication. During an interview on 01/12/2026 at 10:13 AM, Staff B, DNS stated it was their expectation that Resident 37's care plan be revised and accurately reflect the resident's needs. Resident 51 Review of the EHR showed Resident 51 readmitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, group of conditions that cause difficulty in breathing), heart failure, and respiratory failure. Resident 51 was able to make needs known. Observation on 01/08/2026 at 3:22 PM showed Resident 51 laid in bed with oxygen infusing via nasal canula (NC, flexible tube used to deliver oxygen through the nose) connected to an oxygen concentrator (medical device used to provide oxygen) with oxygen flowing at a rate of four liters per minute. Review of the provider order dated 11/17/2025 showed Resident 51 was prescribed oxygen at four liters per minute continuously via NC. Review of Resident 51's care plan showed a focused care plan for COPD initiated on 10/04/2020 with an intervention to administer oxygen as ordered/indicated at three liters continuous to maintain saturation levels (the percentage of red blood cells carrying oxygen) greater than or equal to 90% initiated on 10/06/2020. Review showed a focused care plan for Resident 51 at risk for respiratory complications related to Covid (a highly contagious respiratory disease) initiated on 05/12/2025. Review of Resident 51's EHR on 01/08/2026 did not show the resident was actively positive for Covid. During an interview on 01/12/2026 at 1:34 PM, Staff R, Licensed Practical Nurse (LPN), stated Resident 51's care plan showed an intervention for oxygen at three liters, but the resident's current order was for four liters, and the care plan needed to be revised. Staff R stated Resident 51's focused care plan for at risk for complications related to Covid needed to be revised because Resident 51 did not have Covid. During an interview on 01/12/2026 at 2:34 PM, Staff B, DNS, stated Resident 51's current care plan did not meet their expectations because it showed the resident's oxygen liter flow was three liters and had risk for respiratory complications related to Covid; however, Resident 51's oxygen order was for four liters and the resident did not have Covid. Staff B stated that Resident 51's care plan needed to be revised. Reference WAC 388-97 -1020(3)(5)(b)

Based on observation, interview and record review the facility failed to provide the necessary care and services to maintain personal hygiene for 3 of 5 residents (Residents 117, 99 and 17) when reviewed for activities of daily living. This failure placed the residents at risk for unmet needs, decreased sense of self-worth and a diminished quality of life. Findings included.Resident 117 Review of the electronic health record (EHR) showed Resident 117 admitted to the facility on [DATE] with diagnoses to include obesity (having unhealthy amount of extra body fat), history of falling, and presence of left artificial (manmade) knee joint. Resident 117 was able to make needs known. During an interview on 01/07/2026 at 9:49 AM, Resident 117 stated they had a shower a couple of days ago; however, when they asked for one, they did not always get one. Resident 117 stated they had asked a staff member how often they could have a shower and were told they just had to ask for one but that was not true, because they have had only one shower since they had been at the facility even though they had asked. During an interview on 01/09/2026 at 11:23 AM, Resident 117 stated staff had asked them if they had a shower in December 2025 and they told them no, they had only one shower in January 2026. Resident 117 stated they did not know why they were asked about showers because they thought staff should be able to check their chart for that information. Resident 117 stated they were not offered a bed bath or another shower, but they would prefer a shower. During an interview on 01/12/2026 at 10:25 AM, Resident 117 stated they had asked yesterday (01/11/2026) for a shower and did not get one. Resident 117 stated they would ask again today because they were not able to take a shower by themselves. Review of Resident 117's Medicare 5-day minimum data set assessment (MDS) dated [DATE] showed shower/bathing Not attempted due to medical condition or safety concerns. Review of the focused care plan for ADL self-care performance deficit, initiated on 12/30/2025, showed Resident 117 required one staff assistance with bathing/showering and did not show when Resident 117 was scheduled to have a shower. Review of the shower schedule for the 100 hall on 01/12/2026, located in front of a binder at the south nurse's station showed a schedule for day shift and evening shifts. Review showed Resident 117's room/bed was scheduled to have a shower on Tuesdays on the evening shift (one day a week). Review of Resident 117's point of care bathing documentation on 01/12/2026 in the EHR showed no information available. During an interview on 01/12/2026 at 12:37 PM, Staff S, Certified Nursing Assistant (CNA) stated there was a shower schedule and was able to locate the schedule at the south nurse's station. Staff S stated they had never provided a shower to Resident 117, but they usually worked the night shift. During an interview on 01/12/2026 at 1:06 PM, Staff R, Licensed Practical Nurse (LPN), stated residents were usually scheduled at least two showers a week; however, they did not currently have a shower aid today for the South halls (100 halls) but sometimes they did. Staff R stated if there was not a shower aid scheduled then the aids on the floor were to provide showers per the shower schedule. Staff R stated they did not think every aid on the floor ended up giving showers that needed to be provided if there was no shower aid. During an interview on 01/12/2026 at 2:01 PM, Staff B, Director of Nursing Services (DNS), stated Residents were offered and/or scheduled a shower twice a week and were asked on admission if they preferred a shower once or twice a week. Staff B was provided the shower schedule obtained from the south nurse's station and asked if it was a current schedule and Staff B stated Yes. Staff B stated showers should be documented in the computer system by the aids/CNA's. Staff B stated showers should be provided as scheduled and/or requested and resident's shower preferences and schedule should be care planned. Resident 99 Review of the EHR showed Resident 99 admitted to the facility on [DATE] with diagnoses to include heart failure, diabetes (too much sugar in the blood), and muscle weakness. Resident 99 was able to make needs known. During an interview on 01/06/2026 at 10:10 AM, Resident 99 stated they had been asking for a shower since being admitted to the facility and finally got one shower about three days ago. Resident 99 stated they should be offered showers and not have to keep asking for one. During an interview on 01/07/2026 at 10:02 AM, Resident 99 stated they had been told they could have a shower once or twice a week, but they had only had one shower since they have been at the facility. During an interview on 01/08/2026 at 9:15 AM, Resident 99 stated they still had not been offered another shower but wished staff would offer them a shower. During an interview on 01/12/2026 at 10:02 AM, Resident 99 stated they still had not been provided with another shower and would ask again today because they have had only one shower since being at the facility. Review of the admission MDS dated [DATE] showed Resident 99 required substantial/maximal assistance with shower/bathes. Review of the focused care plan for ADL self-care performance deficit, initiated on 12/11/2025, showed Resident 99 required two staff assistance with bathing/showering and did not show when Resident 99 was scheduled to have a shower. Review of the shower schedule for the 100 hall on 01/12/2026 located in front of a binder at the south nurse's station showed a schedule for day shift and evening shifts. Review showed Resident 117's room/bed was scheduled to have a shower on Tuesdays on the day shift (one day a week). Review on 01/12/2026, of Resident 99's point of care documentation for bathing, showed showers were provided on 12/14/2025, 12/18/2025, 12/23/2025, 12/31/2025 and 01/06/2026 in the prior 30 days. It showed Staff S, CNA, provided Resident 99 a shower on 01/04/2026 at 4:25 PM. During a joint interview on 01/12/2026 at 12:54 PM, Resident 99 stated they knew Staff S, but Staff S had never provided them with a shower. Staff S stated they did not recall giving Resident 99 a shower or a bed bath and did not know how it got documented that they provided a shower on 01/04/2026 at 4:25 PM. During an interview on 01/12/2026 at 2:06 PM, Staff B, DNS, stated they were not aware that Staff S, CNA, had documented on 01/04/2026 at 4:24 PM that a shower was provided to Resident 99; however, both Resident 99 and Staff S stated the shower was not provided. Staff B stated showers were not consistently offered/provided or documented as required and this did not meet their expectations. Resident 17 Review of the EHR showed Resident 17 admitted to the facility on [DATE] with diagnoses of chronic pain syndrome and major depressive disorder. The resident was able to make needs known. During an interview and observation on 01/06/2026 at 10:21 AM, Resident 17 stated I have not had a shower or bed bath since May they don't help me wash my face or brush my hair or teeth, they only come in if i call them. Resident 17 had a brown and white substance on their teeth and a visible knot in their hair. Review of Resident 17s care plan dated 02/05/2025 showed the resident required one staff maximum assistance with bed baths, personal hygiene and oral care. Review on 01/06/2026 of Resident 17's point of care documentation for bathing showed four documented bed baths in the prior 30 days provided by Staff Q, Certified Nursing Assistant (CNA). Review of the shower schedule for the 100's hall on 01/12/2026 located in front of a binder at the south nurse's station showed a schedule for day shift and evening shifts. Review showed Resident 17's room/bed was scheduled to have a shower on Monday on the day shift (one day a week). During an interview on 01/12/2026 at 1:06 PM, Staff R, Licensed Practical Nurse stated the facility does not have a shower aide right now and the CNA's on the floor should provide the showers. During an interview on 01/07/2026 at 9:09 AM, Staff Q stated they did not wash their hair during a bed bath and they did not offer oral care or hair brushing to Resident 17 unless they ask. Staff Q stated they used the shower/bathing documentation to document a skin condition they had noticed but had not provided a bed bath. During an interview on 01/09/2026 at 11:22 AM, Staff C, CNA stated they only gave bed baths/showers if a resident requests, and Resident 17 would request supplies if they wanted to brush their teeth or hair. When asked if setting up Resident 17 for brushing teeth and washing face and hands was part of morning care, Staff C stated No. During an interview on 01/12/2026 at 9:12 AM, Staff B, DNS, stated it was their expectation that the assigned CNA's should provide showers/bed baths if they did not have a shower aide. Staff B stated it was their expectation that morning care for all residents includes setting the residents up to wash their face, and brush their hair and teeth. Reference WAC 388-97 -1060(2)(c)

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 3 of 3 sampled residents (Residents 40, 42 and 51) when reviewed for respiratory care. Failure to obtain and/or follow physician orders for oxygen (O2) therapy, ensure O2 saturation (Sats, the percentage of red blood cells carrying O2 in the blood) was ordered with parameters, care plan, and ensure O2 concentrators (a device used for O2 therapy) filters (used to protect the resident from particulate matter) were cleaned and maintained routinely, placed residents at risk for unmet needs and potential negative outcomes.Findings included . Resident 40 Review of the electronic health record (EHR) showed Resident 40 readmitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, group of conditions that cause difficulty in breathing), respiratory failure, and high blood pressure. Resident 40 was able to make needs known. Review of Resident 40's quarterly minimum data set assessment (MDS) dated [DATE] showed that the resident received 02 therapy. Multiple observations on 01/06/2026 at 10:22 AM, 01/07/2026 at 8:47 AM, 01/08/2026 at 8:31 AM, 01/08/2026 at 1:00 PM, and 01/09/2026 at 10:00 AM showed Resident 40 in their room and the O2 concentrator was near the bed not in use. During an interview on 01/08/2026 at 8:31 AM, Resident 40 stated that they only used O2 at night. Review of Resident 40's EHR showed a provider order dated 09/18/2025 for O2 at 3 liters per minute via nasal canula (NC, flexible tube used to deliver oxygen through the nose) continuously for pneumonia every shift and pulse oximetry (device used to measure O2 saturation) every shift to keep O2 Sats greater than or equal to 90%. Review showed no orders to clean the filter on the O2 concentrator located in Resident 40's room. Review of the EHR on 01/08/2026 did not show Resident 40 had a current diagnosis of pneumonia. Review of Resident 40's January 2026 TAR from 01/01/2026 - 01/07/2026 showed documentation that the resident received O2 per provider orders and O2 Sats were documented and were within the O2 parameters. However, there was no order or documentation to show the O2 concentrator filter was being cleaned. During an interview on 01/12/2026 at 1:15 PM, Staff R, Licensed Practical Nurse (LPN), stated O2 provider orders should be followed. Staff R stated they had not seen Resident 40 use the O2 concentrator in their room; however, they usually worked from 6:00 AM to 6:00 PM. Staff J stated that Resident 40 had an order dated 09/18/2025 for O2 at 3 liters per minute continuously for pneumonia. Staff J stated Resident 40 did not have pneumonia at that time and had not received O2 continuously and the January 2026 TAR should have shown refused if Resident 40 did not want the O2 continuously. Staff J stated that Resident 40 did not have order to change the filter on the O2 concentrator and there should have been. During an interview on 01/12/2026 at 2:20 PM Saff B, Director of Nursing Services (DNS), stated residents with orders for O2 therapy via a O2 concentrator should have O2 Sats monitored every shift with O2 Sats parameters of when to notify the provider when outside parameters, O2 liters and if O2 should be continuously or as needed, to change O2 tubing once a week, and orders to clean the O2 concentrator filter. Staff B stated Resident 40's O2 orders showed it was continuously for pneumonia but the resident did not have pneumonia, documentation should have shown refusal of O2 therapy if O2 was not utilized and the provider should have been notified. Staff B stated Resident 40 should have had an order to clean the filter on the concentrator. Staff B stated Resident 40's oxygen care and services did not meet their expectations. Resident 42Review of the EHR showed Resident 42 admitted to the facility on [DATE] with diagnoses to include COPD, heart failure, and respiratory failure. Resident 42 was sometimes able to express needs. Review of Resident 42's quarterly MDS dated [DATE] showed that the resident received O2 therapy. Observation and interview on 01/08/2026 at 3:28 PM showed Resident 42 laid in bed with O2 NC in place connected to a humidifier (used to add moisture to O2) and an O2 concentrator at 2 liters per minute. Resident 42 stated they needed the O2 due to shortness of breath. Review of Resident 42's EHR showed a provider order dated 10/09/2025 for O2 at 2 liters per minute continuously for shortness of breath. Document O2 saturations every shift. This order did not show O2 Sats were ordered with parameters of when to inform the provider. Review of Resident 42's January 2026 TAR from 01/01/2026 - 01/08/2026 showed order dated 10/09/2025 for O2 at 2 liters was provided with O2 Sats documented per provider order; however, no O2 Sats parameters were noted in the order. During an interview on 01/12/2026 at 1:29 PM, Staff R, LPN, stated Resident 42's order dated 10/09/2025 for O2 and O2 Sats should have included O2 Sats parameters of when to notify the provider and this did not meet expectations. Staff R stated the order needed to be clarified with the provider to include O2 Sats parameters. During an interview on 01/12/2026 at 2:29 PM, Staff B, DNS, stated Resident 42's O2 orders should be clarified with the provider to obtain O2 Sats parameters. Resident 51Review of the EHR showed Resident 51 readmitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease, heart failure, and respiratory failure. Resident 51 was able to make needs known. Review of Resident 51's Medicare 5-day MDS dated [DATE] showed that the resident received O2 therapy. Observation on 01/08/2026 at 3:22 PM showed Resident 51 laid in bed with O2 infusing via NC connected to an O2 concentrator with O2 flowing at a rate of 4 liters per minute. Review of the provider order dated 11/17/2025 showed Resident 51 was prescribed O2 at 4 liters per minute continuously via NC every shift related to COPD. Post treatment: evaluate heart rate, respiratory rate, pulse oximetry, skin color, and breath sound. This order did not show parameters for O2 saturation or when to notify the provider related to O2 saturations and O2 therapy. Review of Resident 51's care plan showed a focused care plan for COPD initiated on 10/04/2020 with an intervention to administer oxygen as order/indicated and to maintain saturation levels greater than or equal to 90% initiated on 10/06/2020. Review of Resident 51's January 2026 TAR from 01/01/2026 - 01/08/2026 showed an order with a start date of 11/17/2025 for O2 at 4 liters via NC every shift and documentation showed that O2 was provided per orders to include documented O2 Sats; however, the order did not include O2 Sats parameters, and post treatment to evaluate heart rate, respiratory rate, skin color, and breath sound was not documented in the TAR. During an interview on 01/12/2026 at 1:34 PM, Staff R, LPN, stated Resident 51's O2 order dated 11/17/2025 was missing O2 Sats parameters and the order needed to be clarified with the provider. Staff R stated this O2 post treatment order to evaluate heart rate, respiratory rate, skin color, and breath sounds were not documented on the TAR; however, it was documented as completed per provider order and if there was a problem then the provider would be notified. During an interview on 01/12/2026 at 2:34 PM, Staff B, DNS, stated they saw that Resident 51's O2 orders did not have O2 Sats parameters and should have. Staff B stated that Resident 51's O2 order that included post treatment to evaluate heart rate, respiratory rate, skin color, and breath sound was not documented in the TAR and/or in a progress note or EHR consistently and this did not meet their expectations. Reference WAC 388-97-1060 (3)(j)(iv)-(vi)

Based on interview and record review, the facility failed to ensure medications were administered only when necessary and in accordance with provider orders for 4 of 7 sampled residents (Residents 4, 115, 2, and 99) when reviewed for unnecessary medications/pain management. Failure to ensure non-medicated methods of pain relief were used before pain medications and ensuring blood pressure medications were provided per parameters placed residents at risk of using unnecessary medications, avoidable side effects, and a diminished quality of life. Findings included.Resident 4 Review of the electronic health record (EHR) showed Resident 4 re-admitted to the facility on [DATE] with diagnoses to include diabetes (high blood glucose), congestive heart failure (when the heart is unable to pump blood efficiently) and depression. Resident 4 was able to make needs known. Review of Resident 4's current providers orders showed the resident received Roxicodone (a narcotic pain medication) every eight hours as needed (PRN) for pain. The provider's order directed staff to document nonpharmacological interventions (NPI, nonmedicated forms of controlling pain, e.g. massage, heating, repositioning, etc.). Review of Resident 4's December 2025 Medication Administration Record (MAR) showed Roxicodone was administered 12/19/2025, 12/20/2025, 12/25/2025, and 12/30/2025. Documentation of NPI being offered/provided prior to the administration of the Roxicodone showed not applicable (N/A). Review of Resident 4's January 2026 MAR showed Roxicodone was administered 01/01/2026 and 01/03/2026. Documentation of NPI being offered/provided prior to the administration of the Roxicodone showed N/A. During an interview on 01/12/2026 at 12:18 PM, Staff DD, Licensed Practical Nurse (LPN), stated they did not offer NPI to Resident 4 prior to administering the pain medication but should have. During an interview on 01/13/2026 at 12:22 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was for staff to offer and document NPI prior to administration of PRN pain medications. Resident 115 Review of the EHR showed Resident 115 admitted to the facility on [DATE] with diagnoses to include multiple sclerosis (a chronic autoimmune disease affecting brain, spinal cord, and optic nerves), diabetes, and anxiety. The resident was able to make needs known. Review of the provider's current orders showed Resident 115 received as needed (PRN) pain medications to include: acetaminophen (an over-the-counter pain medication), ibuprofen (an over-the-counter pain medication), oxycodone (an opioid pain medication), and tizanidine (a muscle relaxant). Review showed for facility staff to provide NPI prior to their use. Review of the MAR for January 2026 showed Resident 115 received the following PRN pain medications without the use of NPI: ibuprofen two times, oxycodone 10 times, and tizanidine one time. During an interview on 01/13/2025 at 2:25 PM, Staff P, LPN, stated the facility ensured PRN pain medications were necessary by providing NPI prior to their usage. Staff P stated Resident 115 received PRN pain medications without NPI and this did not meet expectations. During an interview on 01/14/2025 at 10:40 AM, Staff B, DNS, stated nursing staff should attempt to provide NPI prior to administering PRN pain medications. Staff B stated Resident 115 received PRN pain medications without NPI and this did not meet expectations. Resident 2 Review of the EHR showed Resident 2 was admitted to the facility on [DATE] with diagnoses to include hypertensive chronic kidney disease (condition where high blood pressure and kidney damage coexist in a bidirectional relationship), diabetes, anxiety, and polyneuropathy (damage to nerves that cause different symptoms of numbness, pain and weakness). Resident 2 was able to communicate needs. Review of the January 2026 MAR showed Resident 2 had an order for amlodipine and carvedilol (medicine that controls blood pressure and heart functions) every day, and the nurse was to hold administration of the medications when the systolic (upper number) blood pressure was below 100 and heart rate was below 60. Review of the MAR showed on 01/03/2026 Resident 2 received both medications despite the heart rate being 56. Review of the January 2026 MAR showed Resident 2 was administered PRN acetaminophen on 01/01/2026, 01/03/2026, and PRN oxycodone on 01/03/2026 and 01/05/2026 without documenting NPI prior medications. Review of December 2025 MAR showed Resident 2 had as need it acetaminophen 19 times, and oxycodone three times without documenting NPI. During an interview on 01/12/2026 at 1:08 PM, Staff B, DNS, stated the expectation for the nurses was to follow orders and hold blood pressure medications per parameters. Staff B stated the nurses were expected to try and document NPI prior as need it pain medications. Staff B stated the documentation for Resident 2 did not meet expectations. Resident 99 Review of the EHR showed Resident 99 admitted to the facility on [DATE] with diagnoses to include diabetes, chronic venous hypertension of unknown cause (high pressure in leg veins due to faulty valves, causing swelling, pain, skin changes, cramps, and ulcers/open wound) with ulcer of bilateral lower extremity (both lower legs/ankles/feet), and fibromyalgia (a long-term condition causing the brain and spinal cord to become overly sensitive to pain signals, amplifying them). Resident 99 was able to make needs known. During an interview on 01/06/2026 at 10:06 AM, Resident 99 stated the staff did not always manage their pain. Review of Resident 99's focused care plan for alteration in comfort, initiated on 12/11/2025, showed interventions, initiated on 12/11/2025, to include: Monitor for non-verbal signs/symptoms of pain and medicate, as ordered, and Medicate resident, as ordered, for pain and monitor for effectiveness and side effects. Report to physician, as indicated. Review of the provider order, dated 01/02/2026, showed Resident 99 was prescribed Tylenol 1000 milligrams (mg) by mouth every six hours as needed for a pain level of 1 – 4 out of 10 (0 = no pain and 10 = worst pain imaginable) with NPI listed. Review of Resident 99's January 2026 MAR from 01/01/2026 – 01/08/2026 showed an order for Tylenol 1000 milligrams (mg) by mouth every six hours as needed for a pain level of 1 – 4 out of 10 with NPI listed, with a start date of 01/02/2026. Review showed Tylenol was provided on 01/06/2026 for a pain level of 4; however, NPI was documented NA. During an interview on 01/13/2026 at 10:53 AM, Staff B, DNS, stated Resident 99's January 2026 MAR was documented NA on 01/06/2026 and should have been marked for the NPI provided or refused and this did not meet their expectations. Reference WAC 388-97-1060(3)(k)(i)

Based on observation, interview, and record review, the facility failed to ensure resident refrigerators were maintained to ensure food was safely stored for 2 of 2 sampled refrigerators (100 and 200 Hall Refrigerators) when reviewed for kitchen. This failure placed residents at risk of foodborne illness, avoidable discomfort, and a diminished quality of life. Findings included.Review of the facility policy titled, Safe Handling of Foods from Visitor, revised 03/28/2024, showed, Label foods with resident's name, and the current date and 'use by date'. Items will be thrown out after 48 hours and Have temperature monitored daily for refrigeration < 41 F. Observation on 01/07/2026 at 11:54 PM showed the 100 Hall Resident Refrigerator contained the following items: 1) A bag teriyaki in Styrofoam packaging inside with a receipt showing the order was placed on 01/01/2026; 2) A cup of soup with no date label; 3) A plastic container teriyaki dated 12/08/2025; 4) A box of fried chicken with no date or resident name; 5) A bag with lettuce with brown spot spoilage with no date or name; 6) A half sub sandwich with receipt showing 12/23/2025 pick-up; 7) A container of nutritional formula opened with packaging showing In medical setting throw away after 24 hours with no date label and, when opened, showed dried substance in spout and floating items in formula; 8) A container of French onion dip with best by date of 11/03/2025; 9) Four strawberry banana yogurts with a best by date of 12/12/2025; 10) A Tupperware of vegetable dish with no date label; 11) Two pieces of pizza in original full pie cardboard box with no date label; 12) A plastic to go container of Chinese food with date label of 12/20/2025; 13) A bag with two pieces of cornbread in Ziplock bags and a container with a meal with no date label; 14) An opened water bottle with frozen yellow solid inside with no date label or resident name; 15) A plastic box of grapes with no date label showing grapes were wrinkled; 16) A bag with sandwich makings to include mayo, sliced meat, and lettuce and meat showed sold on 12/02/2025; 17) A plastic box with a pasta dish without date label and resident name; 18) A cardboard takeaway box with unidentifiable food with no date label; and 19) Numerous small plastic containers of condiments with illegible date or a date which was out of range. Observation on 01/08/2026 at 12:12 AM showed the 200 Hall Resident Refrigerator contained the following items: 1) A bag of fast food with a 01/02/2026 date; 2) A bag with a container of ribs and two fruit trays with no date label and the two fruit cups showed sell by date of 12/23/2025; 3) A container of tartar sauce with a 08/01/2025 use by date; 4) A plastic bag with salad dated 12/18/2025; 5) A container with a soup with no resident name or date; 6) A jar of homemade chicken broth and an orange with note showing placed on 12/20/2025; 7) A container of salad with no name or date; and 8) A paper bag with half eaten pastry with no name or date. Review of the temperature logs for the 100 and 200 Hall Refrigerators showed Refrigerator Temp 36-46 Degrees Fahrenheit. During an interview on 01/14/2026 at 9:26 AM, Staff CC, Dietary Manager, stated nursing staff was responsible for maintaining the resident refrigerators' safe food storage. Staff CC stated food should be thrown away after 48 hours and food should be stored at 41 F or below. Staff CC stated the temperature log sheets used to monitor the resident refrigerators showed an acceptable range of 34-46 F, and this was inaccurate. During an interview on 01/14/2026 at 10:26 AM, Staff A, Administrator, stated the observations of food outside of date range and temperature logs indicating inaccurate safe food temperatures did not meet expectations. Reference WAC 388-97-1100(3), -2980

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections by completing the analyzation of infection control data, identifying trends, and completing follow-up activities in response to those trends for 3 of 3 months (October, November and December 2025) when reviewed for Infection Control. The facility also failed to implement transmission-based precautions (TBP) for 2 of 4 halls when reviewed for TBP. These failures placed residents and staff at risk for communicable diseases and infections, poor clinical outcomes, and a decreased quality of life. Findings included. Review of the facility document titled Infection Prevention and Control Program dated 01/21/2025 showed they followed accepted infection prevention and control standards set by the Centers for Disease Control. <Tracking/Trending> Review of the facility provided infection control surveillance documentation for October, November and December 2025 showed infections had not been tracked to determine potential spread using a map or other tracking tool, further review showed no documented analysis of the monthly infection data to identify trends or interventions to address trends for all 3 months. During an interview on 01/12/2026 at 12:12 PM, Staff H, Licensed Practical Nurse/Assistant Director of Nursing, acting Infection Preventionist stated it was their expectation that all new infections be identified and tracked on the infection control line list and map daily and should be analyzed monthly and implement education or changes if trends were identified. <TBP> Review of the Aerosol/Contact precautions sign posted outside of room [ROOM NUMBER], undated, showed staff must perform hand hygiene and put on a gown, gloves, an N95 respirator and eye protection when entering the room. Observation on 01/05/2026 at 12:32 PM showed Staff O, Registered Nurse, entered room [ROOM NUMBER] with a surgical mask and no eye protection. Staff O Provided the resident medications and exited the room. Review of the Enhanced Barrier Precautions sign posted outside room [ROOM NUMBER], undated showed staff must perform hand hygiene and wear a gown and gloves for all high contact activities such as dressing, Bathing, transferring, or changing linens. Observation on 01/07/2026 at 9:13 AM showed Staff Q and another unidentified Staff enter room [ROOM NUMBER] and provide personal high contact care to the resident without wearing a required gown. During an interview on 01/12/2026 at 12:55 PM, Staff B, Director of Nursing Services stated it was their expectation that the infection preventionist track all facility infections and map them daily and the infection surveillance data should be analyzed monthly to identify trends. This did not happen for the months of October, November and December 2025 and should have. Staff B stated it was their expectation that staff follow the directions on the transmission-based precautions signs posted outside of the resident rooms. Reference WAC 388-97 -1320(1)(a)

Based on interview and record review, the facility failed to administer pneumococcal vaccines for 3 of 7 residents who consented to the vaccine (Residents 5,19 and 35) and failed to provide education on the risks and benefits of vaccines for 3 of 7 residents (Residents 42, 63 and 65) when reviewed for immunizations. These failures placed the residents at risk for communicable diseases and denied the residents the opportunity to make an informed decision regarding receiving immunizations. Findings included.Review of the facility policy titled Pneumococcal Vaccine dated August 2025 showed the facility would assess all residents on admission for the eligibility to receive the pneumococcal vaccine and when indicated provide the vaccine information sheet (VIS) and education on the risks and benefits and administer the vaccine within 30 days of admission if consented. Resident 5 Review of the electronic health record (EHR) on 01/11/2026 showed Resident 5 admitted to the facility on [DATE] with a diagnosis of dementia (loss of cognitive function that interferes with daily life). Resident 5's legal guardian had consented for the resident to receive the Pneumococcal vaccine on 11/21/2025. There was no documentation found that the resident had received the vaccine. Resident 19Review of the EHR on 01/11/2026 showed Resident 19 admitted to the facility on [DATE] with a diagnosis of skin infection and had consented to receive the Pneumococcal vaccine on 10/26/2025. There was no documentation found that the resident had received the vaccine. Resident 35Review of the EHR on 01/11/2026 showed Resident 35 admitted to the facility on [DATE] with a diagnosis of diabetes (when the body cannot process sugars). Resident 35's responsible family member had consented for the resident to receive the Pneumococcal vaccine on 07/16/2025. No documentation was found that the resident had received the vaccine. Resident 42Review of the EHR showed Resident 42 admitted to the facility on [DATE] and was offered the Pneumococcal vaccine and had declined. No documentation was found that the resident received the VIS or was educated on the risks and benefits of the vaccine. Resident 63Review of the EHR showed Resident 63 admitted to the facility on [DATE] and was offered the Pneumococcal vaccine and had declined. No documentation was found that the resident received the VIS or was educated on the risks and benefits of the vaccine. Resident 65Review of the EHR showed Resident 65 admitted to the facility on [DATE] and was offered the Pneumococcal vaccine and had declined. No documentation was found that the resident received the VIS or was educated on the risks and benefits of the vaccine. During an interview on 01/12/2026 at 12:06 PM, Staff H, Licensed Practical Nurse/Assistant Director of Nursing, acting infection preventionist stated it was their expectation that residents are assessed, educated and offered the pneumococcal vaccines on admission and if they consent should receive it within a week of consent. During an interview on 01/12/2026 at 12:50 PM, Staff B, Director of Nursing Services stated it was their expectation that residents receive the VIS form and were educated on the risks and benefits when they were offered the vaccines and if the resident consented to the vaccine it should have been ordered from the pharmacy and given right away. Staff B stated that the pneumococcal vaccines for Residents 5,19,35, 42,63 and 65 did not meet expectations. Reference WAC 388-97 -1340(1)(2)(3)

Based on interview and record review, the facility failed to provide necessary care and monitoring of a Foley catheter (a medical device inserted into the bladder) to prevent the occurrence of an avoidable pressure injury (PI - localized damage to skin and/or underlying soft tissue related to an inserted medical device) for 1 of 3 residents (Resident 1) reviewed for quality of care. Resident 1 experienced harm when they developed an avoidable PI to the skin around the urinary catheter insertion site, with unrelieved pain evidenced by anxiousness, rolling in bed, restlessness, verbalizing pain and discomfort that required transfer to the hospital for evaluation, treatment, and pain management. This failure placed residents at risk of infection, injury and a decreased quality of life.Findings Included.The International Wound Journal, dated 06/14/2021, defines MMPI's as a Pressure Injury [PI] located on mucous membranes with an associated history of medical device use at the site of the injury. The journal lists urinary catheters as a medical device associated with PI development and documents that these ulcers cannot be staged. (reference: Wound J. 2021 Jun 14:19(2):278-293. Doi: 10.1111/iwi.13629).Resident 1 was readmitted to the facility on [DATE] with diagnoses including Obstructive Uropathy (a condition in which the flow of urine is blocked.) The Quarterly Minimum Data Set assessment, dated 09/23/2025, documented Resident 1 as being cognitively intact.During an interview, dated 09/30/2025 at 9:40 AM, Collateral Contact (CC) 12, stated the emergency room (ER) staff said Resident 1 was having penis pain because the catheter and penis were filthy.Review of Resident 1's September 2025 physician orders showed no documented orders for Foley catheter care, monitoring, or securement of the catheter tubing.Review of Resident 1's September 2025 eTAR (electronic Treatment Administration Record) showed no orders for Foley catheter care, monitoring, or securement of the catheter tubing.Review of Resident 1's care plans (treatment plan), current for September 2025, showed no interventions placed for Foley catheter care, monitoring, or securement of the catheter tubing.Review of Resident 1's Point of Care (system used for aide documentation), current for September 2025, showed no tasks for Foley catheter care, monitoring, or securement of the catheter tubing.Review of Resident 1's Kardex (brief overview of resident needs), current for September 2025, showed no guidance for Foley catheter care, monitoring, or securement of the catheter tubing.Review of Resident 1's 09/16/2025 to 09/23/2025 progress notes showed no documentation related to Resident 1's Foley catheter care, monitoring or securement of the catheter tubing.A readmission note, dated 09/18/2025 at 3:58 PM, documented Resident 1 had a Foley catheter in place upon admission to the facility.A physician history & physical note, dated 09/23/2025 at 10:19 AM, documented Resident 1 had a Foley catheter but did not show any related assessment notes.A nursing progress note, dated 09/23/2025 at 7:06 PM, documented Resident 1 complained of severe uncontrolled pain rating it at 10/10 in the genital (penis/testicles), urethra (tube that carries urine from the bladder out of the body). Pain was not relieved by non-pharmacological (other than medication) interventions or the resident's prescribed pain medication. Documentation showed Resident 1 had, anxiousness, as evident by rolling in bed, restlessness, verbalizing [the] pain and discomfort.An SBAR (Situation Background Assessment Recommendation form used as a provider communication tool), dated 09/23/2025 at 7:17 PM, documented Resident 1 had a change in condition related to fever and pain (uncontrolled). The Pain Status Evaluation area of the SBAR documented Resident 1 had pain at the Genitourinary (includes the penis) area. Review showed there was no physical assessment documentation related to Resident 1's Foley Catheter included. Resident 1 was sent to the hospital for further evaluation.An ER triage note, dated 09/23/2025 at 5:32 PM, documented Resident 1 reported penile pain at the Foley catheter insertion site.A hospital provider note, dated 09/23/2025 at 8:55 PM, documented Resident 1 reported having pain at the Foley catheter insertion site since the insertion occurred.An Urology provider note, dated 09/24/2025 at 7:49 PM, documented the following: Upon admission [to the hospital] Resident 1's Foley catheter was exchanged. This led to resolution of the penile pain he had been dealing with. Today's examination findings show a significant meatal erosion (a breakdown of the outer layers of skin around the opening that leads to the bladder to the to the right and to the left).On 09/25/2025 at 8:00 AM, CC 13, a hospital wound nurse, documented wound care orders that included daily cleansing with normal saline, soap, water, and leaving the wound open to air due to Pressure injury stage Mucosal Membrane (MMPI).During an interview 10/09/2025 at 1:43 PM, Staff A, Registered Nurse & Director of Nursing, said she would expect Resident 1 to have provider Foley catheter care and monitoring orders on Resident 1's eTAR and a Foley catheter care plan that included care and monitoring interventions. Staff A said she would expect ensuring catheter tubing was relaxed, not pulling and as needed cleansing around the insertion site to be included in the orders and on the care plan. After reviewing Resident 1's records, Staff A said there were no Foley catheter care or monitoring care planned interventions and Foley catheter care and monitoring was not included on Resident 1's September 2025 eTAR.Reference WAC 388-97-1060-1

Based on interview and record review, the facility failed to ensure that 1 of 6 residents (Resident 1) was free from a significant medication error that resulted in opioid overdose and hospitalization in an intensive care unit, requiring administration of Narcan (a life-saving opioid-reversing medication). In addition, the facility failed to ensure correct medication administration documentation for 6 of 6 residents (Residents 1, 2, 3, 4, 5, and 6) reviewed for medication errors. On 08/14/2025 at 2:37 PM, the facility was notified of an Immediate Jeopardy at Code of Federal Regulations (CFR) 483.45(f)(2), F760, Free of any significant medication errors, related to the facility's failure to ensure that a resident (Resident 1) was not subject to significant medication errors. The significant medication error resulted in Resident 1 being found unresponsive with abnormal vital signs, requiring hospitalization and life-saving interventions to reverse the effects of medication that was given in error. The facility had removed the immediacy on 08/03/2025 by implementing a removal plan that included removal of the staff member that was identified as having a pattern of inconsistent documentation around opioid medication administration, re-educating all licensed nursing staff on the current standards of nursing practice related to safe and accurate medication administration, performing an expanded audit of other residents' medication administration records, and enlisting the assistance of the contracted pharmacy to perform an on-site medication administration audit.Findings included . Review of facility policies titled, Administering Medications, revised April 2019, and Controlled Substances, revised November 2022, showed that medication administration must be documented in the narcotic log book as well as the eMAR (electronic medication administration record). In addition, the policies showed that staff must verify the resident's identity before administering medication, and that the individual administering the medication must verify three times that they are administering to the right resident, the right medication, right dosage, right time and right method of administration before giving the medication. Review of the medical record showed that Resident 1 was admitted on [DATE] with a complex medical history and diagnoses to include chronic pain, obesity and need for assistance with personal care. Review of a facility progress note, dated 07/31/2025 at 7:19 AM, showed that Resident 1 was found unresponsive with abnormal vital signs to include low blood pressure, slow breathing, low blood oxygen saturation level, and a rapid heart rate. Staff could not wake Resident 1. The facility called 911 for emergency response, and Resident 1 was hospitalized from [DATE] to 08/08/2025. Review of hospital emergency department records, dated 07/31/2025, showed that Resident 1 tested positive for oxycodone and morphine (opioid/narcotic, Schedule II controlled substance pain medications). The hospital records further showed that Resident 1 required intensive care unit level of care, while hospitalized , a Narcan intravenous infusion, and breathing support. In addition, an emergency room progress note, dated 07/31/2025 at 9:38 AM, showed that the hospital staff spoke with the facility over the phone, and facility staff stated, the last time [Resident 1] took an opioid ‘wasn't documented' and that ‘[they] needed to ask someone else.' The progress note went on to show that the facility staff then reported that [Resident 1] took one five milligram (mg) oxycodone on 07/29/2025 and [they] ‘didn't know why that wasn't in the book.' Facility staff also reported that Resident 1 absolutely does not have access to opioids. Review of the physician's orders, dated August 2025, showed that Resident 1 had orders for oxycodone five mg every eight hours as needed for pain. Further review of the historical physician's orders, from Resident 1's facility admission [DATE] to 08-01-2025), showed that Resident 1 never had an order for morphine while in the facility. During interview on 08/01/2025 at 5:09 PM, Collateral Contact 1 stated that Resident 1 had never taken morphine, and that they had only taken oxycodone for pain. Collateral Contact 1 further stated that Resident 1 had recently had a new roommate move in, and they took morphine. Collateral Contact 1 stated that they believed the facility staff accidentally gave Resident 1 their roommate's morphine. Review of the facility incident investigation, dated 07/31/2025, showed that Resident 1's roommate, Resident 2, had orders for morphine - both scheduled and as-needed, and that there was an extra dose signed out of Resident 2's narcotic log, by Staff B, Licensed Practical Nurse (LPN), that was unaccounted for. When Staff B was questioned about the extra dose of morphine, Staff B stated they did not know why there was an extra dose signed out. When Resident 2 was interviewed, they stated that they had not missed any of their scheduled doses of morphine. The investigation showed that it was reasonable to conclude that a medication error had occurred, in which Staff B had given Resident 2's morphine to Resident 1. In an interview on 08/14/2025 at 1:23 PM, Resident 1 stated that they were given their roommate's morphine. Resident 1 stated that they remembered asking for oxycodone, and the nurse brought them a cup with two pills. Resident 1 stated they normally only took one oxycodone at a time, but they took the medication that the nurse gave them. Resident 1 stated that after that, they remembered not feeling well, and did not remember much beyond that. Resident 1 stated that they felt safe being back in the facility, because they thought staff will be more careful after making such a mistake. Resident 1 stated they would be more alert to what they were being given by the nursing staff, and if something looked unfamiliar, they would question it. Review of the facility incident investigation, dated 07/31/2025, showed that a trend of incorrect medication administration documentation was identified with Staff B, LPN, as well as with other nurses. Residents 1, 2, 3, 4, 5 and 6 had missing documentation in their electronic medication administration records (eMARs) when compared to their narcotic log pages in the narcotic log book. Review of the narcotic log showed that Resident 1 received doses of oxycodone on 07/02/2025 at 3:00 AM and 8:00 PM; 07/03/2025 at 9:00 PM; 07/07/2025 at 9:00 PM; 07/08/2025 at 9:00 PM; 07/12/2025 at an illegible time; 07/13/2025 at 8:00 PM; 07/17/2025 at 8:00 PM; 07/21/2025 at 8:00 PM; 07/22/2025 at 8:00 PM; 07/24/2025 at 8:00 PM; 07/25/2025 at 8:00 PM; 07/26/2025 at 8:00 PM; 07/27/2025 at 8:00 PM 07/29/2025 at 8:00 PM and an illegible time, none of which were documented on Resident 1's eMAR. Review of the narcotic log showed that Resident 2 received doses of morphine on 07/27/2025 at 10:00 AM; 07/28/2025 at 9:30 AM; 07/29/2025 at 2:00 AM; 07/31/2025 at 2:00 AM and 07/31/2025 at an illegible time, none of which were documented on Resident 2's eMAR. The 07/31/2025 administrations are notable because Staff B, LPN, signed out both doses of morphine on 07/31/2025: 2:00 AM and the illegible time. Resident 2 was able to have this dose of morphine every six hours, as needed, so the next dose after 2:00 AM would not have been eligible for administration until 8:00 AM. Staff B, LPN, was off shift at 6:30 AM, prior to it being time for Resident 2 to receive another dose of morphine. Review of the narcotic log showed that Resident 3 received doses of oxycodone on 07/31/2025 at 7:30 AM, 4:30 PM and 8:00 PM; 08/01/2025 at 12:01 AM, 4:00 AM, 4:30 PM and 9:00 PM; 08/03/2025 at 4:00 AM, none of which were documented in Resident 3's eMAR. Review of the narcotic log showed that Resident 4 received a dose of lorazepam (a Schedule 4 controlled narcotic medication to treat anxiety) on 08/02/2025 at 11:02 PM, which was not documented in Resident 4's eMAR. Review of the narcotic log showed that Resident 5 received doses of clonazepam (a Schedule 4 controlled narcotic medication to treat anxiety) on 07/22/2025 at 6:00 PM; 07/24/2025 at 4:00 AM and 8:00 PM; 07/26/2025 at 10:00 AM; 07/27/2025 at 9:00 PM; 07/28/2025 at 9:00 PM; 07/30/2025 at 9:00 PM; 07/31/2025 at 8:00 PM, and oxycodone on 07/26/2025 at 4:00 AM and 10:00 AM; 07/27/2025 at 4:00 AM and 7:00 PM; 07/28/2025 at 1:00 AM; 07/29/2025 at 4:00 PM and 10:00 PM; 07/30/2025 at 4:00 AM, 9:00 AM and 5:00 PM; 07/31/2025 at 6:00 PM; 08/01/2025 at 1:00 AM; 08/03/2025 at 8:43 AM, none of which were documented in Resident 5's eMAR. Review of the narcotic log showed that Resident 6 received doses of oxycodone on 07/31/2025 at 6:00 PM and 08/01/2025 at 2:00 AM, neither of which were documented in Resident 6's eMAR. In an interview on 08/14/2025 at 2:30 PM Staff A, Director of Nursing Services (DNS), stated that when Staff B, LPN, was questioned about why the extra dose of morphine was signed out of Resident 2's narcotic book, Staff B, LPN, stated I don't know. Staff A, DNS, stated that based on the facility investigation and pattern of incorrect narcotic administration documentation, Staff B, LPN's, employment was terminated. Reference WAC 388-97-1060 (3)(k)(iii).

Based on interview and record review, the facility failed to accurately assess, identify, monitor, and adequately supervise residents at risk of elopement for 1 of 3 sample resident (Resident 1) reviewed for accident hazards. Resident 1, who had a cognitive impairment and lacked safety awareness, experienced harm when they exited the facility unsupervised, was subsequently observed by a bystander to fall on a freeway ramp, hit their head, and was transported by Emergency Services (EMS) personnel to a hospital for evaluation. This failure placed residents at risk for potential injury, negative outcome, and decreased quality of life. Findings included Review of a facility's policy titled, Elopements, dated 03/22/2022, noted the facility was to utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, that included identification and assessment of risk, identification and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Resident 1 was admitted to the facility on [DATE] with multiple diagnoses, including stroke, dementia and encephalopathy (damage or disease that affects the brain that can cause confusion, memory loss, and other changes). The Minimum Data Assessment, dated 05/01/2025, noted that Resident 1 required staff assistance for activities of daily living. Review of Resident 1's care plan, dated 04/26/2025, documented the resident was at risk for falls and injury due to cognitive loss and lack of safety awareness. An addition to the care plan, dated 04/28/2025, documented Resident 1 had impairment or decline in their cognitive function or impaired thought processes related to dementia. Review of a nursing note, dated 05/01/2025 at 5:58 PM, documented Resident 1 wanted to leave and was upset that no one had checked on him. THe nursing note stated the resident started to fall, was assisted to a chair, assessed and taken to their room. A nursing note, dated 05/06/2025 at 4:57 PM, documented Resident 1 was last checked on at around 2:00 PM on 05/06/2025 and was not in the room when nursing checked on them around 4:00 PM. The nurse documented that they did not see the resident and was not aware of which resident was allowed to visit out or which one was not. The nurse noted the resident had previously attempted to leave, wanted to discharge, almost fell , and that the resident was very confused. Review of hospital documentation dated 05/06/2025, noted EMS was called at 3:41 PM after bystanders saw Resident 1 stumble while walking on a freeway ramp, fall, and hit their head. EMS arrived to find the resident sitting on the shoulder of the freeway on-ramp. EMS staff documented the resident was occasionally able to answer questions and talk in full normal sentences but then would say things that were not based in reality. The resident had abrasions and bruising on their body consistent with falls that were in different stages of healing. The resident was not able to give any medical history or say where they had come from. The resident told EMS staff that they had fallen because they had had a change in vision and their balance was off. Review of hospital notes, dated 05/06/2025, showed hospital staff contacted the facility due to the location of where Resident 1 was found. Hospital staff documented that facility staff were not aware that the resident was gone and, after several calls, it was determined the resident had not been seen at the facility since around 2:00 or 3:00 PM, when somebody had seen them walking down the hallway. Review of a nursing note, dated 05/06/2025 at 5:42 PM, showed facility staff received a call from the hospital that Resident 1 had been found on the ground outside the facility and had been taken to the hospital, and requested information regarding the resident, including their medication list. The provider was notified. Review of the facility investigation initiated on 05/06/2025, identified risks that included the accuracy of an elopement evaluation on admission; that nursing did not immediately look for the resident when they were not visualized in their room; and that staff in the Reception area did not notice the resident walk out the door. On 05/08/2025 at 1:30 PM, when asked, Staff C, a Licensed Practical Nurse and a Resident Care Manager, said if a resident was missing they would start looking, first indoors and then if not found they would look outside. When asked about Resident 1, Staff C said they had heard that the resident was missing and then they got a call from the hospital. On 05/22/2025 at 12:16 PM, Staff D, a certified nursing assistant, said when a resident is not in their room, they check the hall and the other rooms and then let the nurse know and then everyone checks and looks everywhere. On 05/22/2025 Staff D said they worked with Resident 1 on 05/06/2025, the night they left. Staff D said Resident 1 had been showered earlier and then their tray was brought in. Staff D said when they went back to get the tray, Resident 1 was not in the room and it was sometime later they figured out Resident 1 was not there. On 05/22/2025 at 3:04 PM, Staff B, the facility Director of Nursing Services, said they were shocked when the hospital called to say, we think we have one of your residents. Staff B said they had identified there was a problem with the risk assessment, and that Resident 1's assessment did not include factors from their history that would have triggered an elopement risk evaluation. Staff B also said they determined that there was a delay in beginning to look for the resident, and also that staff covering the reception area were not as familiar with the residents the day Resident 1 walked out of the facility. On 05/22/2025 at 3:50 PM, Staff A, the facility Administrator, said they have identified processes to focus on for improvement. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure two of four residents (Resident 68 and 85) reviewed for range of motion/mobility, consistently received restorative services (movement of joints to maintain range of motion) to maintain or prevent declines in mobility. This failure resulted in harm to Resident 68 who experienced a decrease in left hip extension and worsening of the left knee contracture (a permanent shortening of muscle and loss of joint mobility). This failure placed residents at risk of decreased motion, mobility and a decreased quality of life. Findings included . Review of a document titled, Restorative Nursing Services, dated July 2017, showed residents would receive restorative nursing care as needed to help promote optimal safety and independence. In addition, the following goals may include, but not limited to, supporting, and assisting the resident in adjusting or adapting to changing abilities, developing, maintaining, or strengthening his/her physiological and psychological resources, maintaining his/her dignity, independence and self-esteem and participating in the development and implementation of his/her plan of care. Resident 68 Resident 68 was admitted to the facility on [DATE] with diagnoses of absence of right leg below knee, polyneuropathy (a malfunction of many nerves throughout the body) and other reduced mobility. The Admission Minimum Data Set (MDS), a required assessment tool, dated 10/21/2022, showed Resident 68 required substantial/maximal assistance with activities of daily living. Observation on 01/21/2024 at 2:24 PM, showed Resident 68 laid flat on their back, in bed, with a pillow under a left bent knee. Resident 68 stated that they utilized the pillow to help reduce the pain in their knee. During an interview on 01/23/2024 at 11:24 AM, Resident 68 stated that they were upset they were no longer getting therapy because I never get out of bed anymore now that they have to use a lift to get me up. Resident 68 stated that it required two staff to get them out of bed but there was never enough help. Resident 68 stated that they had done restorative only a few times but not three days a week as discussed with therapy staff. Review of the provider's restorative nursing program order, dated 11/14/2023, showed Resident 68 was to have bilateral lower extremity-active assisted range of motion (BLE-AAROM) exercise to pain tolerance. Repositioning strategies to off load pressure and facilitate comfort were included. Review of a care plan, dated 11/21/2023, showed a focus area for restorative range of motion (ROM), and that Resident 68 was at risk for decrease in ROM. The goal was for the resident to maintain the current AAROM in affected joint to prevent the progression and/or development of contractures. Interventions included that the resident would work with the restorative nursing aide, (RNA), on Monday, Wednesday, and Fridays, and that the restorative nursing program meeting was to occur weekly on Fridays. RNA would assist resident with AAROM to BLE, three times a week as tolerated. During an interview on 01/23/2024 at 9:47 AM, Staff Q, RNA, stated they conducted restorative Mondays, Wednesdays and Fridays and they were the shower aide on Tuesday and Thursdays. When asked about Resident 68's participation, Staff Q stated that Resident 68 actively participated each session between 10-15 minutes. Staff Q stated that they were out sick from 01/02/2024 to 01/05/2024 and had no knowledge if restorative was covered by an alternate staff during that time. Review of the Resident 68's restorative care flow sheets for December 2023 and January 2024, showed that the resident had multiple dates they did not receive restorative care. The December 2023 dates included: 12/04/2023, 12/06/2023, 12/13/2023, 12/18/2023, 12/20/2023, 12/25/2023 and 12/27/2023. The January 2024 dates included 01/01/2024, 01/03/2024, 01/05/2024, 01/08/2024, 01/12/2024, 01/15/2024, 01/19/2024 and 01/22/2024. The restorative care flow sheets for December 2023 showed that Staff N, CNA, signed off some of the restorative tasks. During an interview on 01/23/2024 at 2:12 PM, Staff N stated although their initials were on the restorative task, they did not facilitate any ROM exercises with Resident 68. Staff N stated that only the RNA did restorative with residents. Review of the January 2023 active RNA task flow sheet, in the electronic health record (EHR), showed Not Applicable on 01/10/2024 for Resident 68's restorative task. During an interview on 01/23/2024 at 11:14 AM, Staff C, Assistant Director of Nursing (ADON), stated that they did not have any restorative progress notes in the EHR yet; however, they had just met about the resident's progress as of 01/18/2023 and Resident 68 was doing well. Staff C stated that they planned to continue with care as ordered. Staff C stated that the Not Applicable on 01/10/2024 was in error and that staff were educated to document Resident Refused instead. Staff C further stated that to their knowledge that was the only refusal by the resident. Additionally, Staff C stated that the documentation only showed participation of twice in the last 30 days. During an interview on 01/23/2024 at 11:25 AM Staff EE, Physical Therapist, stated that the only staff that facilitated restorative with residents was the RNA. Staff EE further stated CNAs should not document that the restorative task was completed. Review of the Resident 68's restorative care flow sheets for December 2023 showed that a CNA signed off restorative on 12/08/2023, 12/22/2023, and 01/10/2024. Review of the form Physical Therapy PT Discharge Summary, signed 11/02/2023, showed Resident 68 exceeded their goal of AAROM left hip extension at -18 degrees. The Patient & Response to Treatment section showed, Patient demonstrates little to no physical impairments as a result of skilled rehab. Prognosis to Maintain CLOF (current level of functioning) = Good with consistent staff follow-through. Review of form Physical Therapy PT Evaluation, dated 01/26/2024, showed current reason for referral as Physical Therapy to assess current ROM for lower extremities and determine whether pt is not appropriate for return to standard chair as they had before. The evaluation showed Resident 68 had the following decreases: AAROM left hip extension from -25 to -40, AAROM left knee extension -40 to -105 degrees and Passive ROM right hip extension -5 to -25 degrees. During an interview on 01/26/2024 at 12:25 PM, Staff G, Physical Therapist, stated that Resident 68 was discharged from Physical Therapy in November 2023 at which time they were referred to restorative. Staff G stated that based on the current evaluation Resident 68's contractures had worsened, which was a rapid decline. Staff G further stated that when restorative was being completed on a regular basis it was less likely for Resident 68 to have a rapid decline. 34567 Resident 85 Resident 85 was admitted to the facility on [DATE] with diagnoses including stroke, heart and kidney disease, seizure disorder, malnutrition, muscle weakness and anxiety disorder. Review of the Admission MDS, dated [DATE], showed Resident 85 was able to make their needs known and was dependent or required maximal substantial assistance with activities of daily living. During an interview on 01/22/2024 at 9:50 AM, Resident 85's family member stated they were unaware whether the resident received restorative care and that the resident at times had spasticity (abnormal muscle tightness due to prolonged muscle contractions) whenever the staff got the resident out of bed and into a wheelchair. Review of the provider's restorative nursing program order, dated 11/11/2023, showed that Resident 85 was to have right upper extremity (RUE) - passive range of motion (PROM) in all planes (describes all 4 movement directions; flexion and extension) wrist and digits to increase ROM, for functional use and decrease further contracture as tolerated by resident and was to be performed by the RNA every Monday, Wednesday, and Friday. Review of Resident 85's care plan, dated 11/11/2023, showed a focus area for restorative ROM, and that the resident was at risk for decrease in ROM. The goal would be for the resident to maintain the current PROM to right upper extremity to prevent the progression of contractures. Interventions included that the resident would work with the RNA on Monday, Wednesday, and Fridays, and that the restorative nursing program meeting was to occur weekly on Fridays. Review of Resident 85's flowsheet for restorative care documentation for December 2023 and January 2024, showed that the resident had multiple dates missing for restorative care. The following December 2023 dates included: 12/04/2023, 12/06/2023, 12/08/2023, 12/11/2023, 12/13/2023, 12/18/2023, 12/20/2023, 12/22/2023, 12/25/2023. The January 2024 dates included 01/03/2024, 01/05/2024, 01/08/2024 and 01/10/2024. During an interview on 01/25/2024 at 10:12 AM, Staff Q, RNA, stated that they were out sick from 01/02/2024 to 01/05/2024 and was not aware whether the restorative care occurred for Resident 85 during that time. During an interview on 01/25/2024 at 10:15 AM, Staff E, Resident Care Manager (RCM), stated that it was their expectation that the RNA would document whether the resident received their restorative care as ordered. During an interview on 01/25/2024 at 10:49 AM, Staff C, ADON, stated that it was their expectation restorative care was documented if it occurred and/or if the resident refused. Staff C, ADON, further stated that the lack of documentation appeared to show that the restorative did not happen during the December 2023 and January 2024 dates but should have occurred. Reference WAC 388-97-1060 (3)(d)

Based on observation, interview, and record review, the facility failed to address safety risk factors and provide the necessary supervision to ensure safety from avoidable accident and injuries for 1 of 3 residents (Resident 1) reviewed for accidents and supervision. This failure resulted in harm when Resident 1 was hit by a moving vehicle while in their wheelchair unsupervised out in the parking lot of the facility. Resident 1 required emergency medical services to transfer to the hospital, sustained a fracture to the left ankle, and experienced severe pain and discomfort. Findings included . Review of the admission Minimum Data Set (MDS, a required assessment tool) dated 09/06/2023, showed that Resident 1 admitted on [DATE] with diagnoses to include cerebral infarction (stroke), diabetes, generalized muscle weakness and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The MDS further showed Resident 1 had moderate cognitive impairment and exhibited inattention (easy distractibility) and episodes of disorganized thinking. According to the MDS, Resident 1 required one-person physical assistance with most activities of daily living including locomotion on and off the unit. Review of Resident 1's care plan initiated on 09/21/2023, showed that the resident required assistance with activities of daily living (ADL) care due to activity intolerance. The care plan also indicated Resident 1 was at risk for falls due to the resident's impaired mobility and chronic low back pain. Review of the facility incident log for November 2023, showed that Resident 1 had a fall incident without injury on 11/18/2023 and on 11/20/2023 had the accident in the parking lot with significant injury. Review of the fall assessment dated [DATE], showed that on 11/18/2023 Resident 1 fell while attempting to self-transfer to the wheelchair in the resident's room. The assessment identified risk safety issues that included impulsive behavior, noncompliance to safety reminders, and the resident engaging in independent activities even though they required supervision and physical assistance. Review of the facility incident investigation dated 11/20/2023, showed that on 11/20/2023 Resident 1 was in a wheelchair when they entered the parking lot to the left side of the building and was hit by a moving vehicle that was backing out from their parking spot. Further review, showed Resident 1 fell from the wheelchair and hit the ground. The facility called emergency medical services to immediately transfer the resident to the hospital. According to the incident investigation, the hospital performed x-rays of the left ankle and foot, and the results were suspicious for left ankle fracture. Review of the results of the left ankle and foot x-rays dated 11/20/2023, indicated possible minimally acute displaced fracture of the tip of the lateral malleolus (ankle bone) with overlying soft tissue swelling and adjacent ankle joint effusion (outpouring of fluid). Observation on 11/27/2023 at 2:03 PM, showed Resident 1 in bed wearing a controlled ankle movement (cam) boot to the left ankle and had bluish discolorations on the left side of the forehead. Resident 1 was awake and responsive to questions asked. In an interview on 11/27/2023 at 2:06 PM, when asked about the injuries, Resident 1 stated they were hit by a car while in the wheelchair outside the building in the parking lot. The resident further stated they did not remember what happened after falling on the ground. In the middle of the interview, Resident 1 started to get anxious and no longer wanted to be bothered with additional questions and stated, I'm in a bad mood right now. Observation on 11/27/2023 at 2:09 PM, showed Resident 1 increasingly agitated and screaming for the nurse to hurry up. The resident verbalized, this ankle is killing me. The licensed nurse went in and assessed resident's pain and said they would be back to administer the ordered pain medication. The resident kept insisting for staff to remove the cam boot. Two other nursing staff stayed to reposition the resident and readjusted the resident's cam boot. In an interview on 11/27/2023 at 2:39 PM, when asked about Resident 1's cognitive function, Staff C, Nurse Practitioner (NP), stated that Resident 1 had been diagnosed with Vascular Dementia (type of dementia caused by conditions such as stroke that disrupt blood flow to the brain and lead to problems with memory, thinking, and behavior) and Pseudobulbar Affect (a neurological condition characterized by uncontrolled crying or outbursts). When questioned about the supervision required by Resident 1 in going outside the facility, the NP stated that the resident was allowed to go out with supervision and often went out with the significant other accompanying the resident. Staff C was further interviewed regarding interventions to address the resident's severe pain. Staff C stated that the nurse administered oxycodone (a narcotic pain medication) a few minutes ago and that a nerve pain medication would be ordered for Resident 1's chronic nerve pain. According to the NP, staff repositioned the resident in bed, and did a skin check around the cam boot. Review of the orthopedic (branch of medicine concerned with bones and surrounding structures) consult note dated 11/29/2023, indicated that a three-view x-ray of the left ankle was performed, and the result showed a stable nondisplaced left ankle lateral malleolus fracture. Recommendations included for Resident 1 to wear the cam boot while ambulating and when comfortably resting the cam boot may be released. In an interview on 12/06/2023 at 12:38 PM, Staff B, Registered Nurse/ Assistant Director of Nursing (RN/ADON), stated to allow residents to go out of the facility independently, the facility assessed their cognitive status, and conducted elopement risk assessment and if a smoker then a smoking assessment will be completed. According to Staff B, Resident 1 had never previously left the facility or showed behavior that would put them at elopement risk. Staff B further stated that the facility required the residents to sign the sign-out book before leaving the facility. In an interview on 12/06/2023 at 1:30 PM, Staff A, Administrator, stated that Resident 1 never had a problem going outside of the facility and often was accompanied by the significant other. Resident 1 usually went straight to the sidewalk instead of turning left to the parking lot. According to the Administrator, what happened in the parking lot was an unfortunate accident. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to provide adequate supervision and failed to utilize prescribed mobility equipment for one of four residents (Resident 1) reviewed for falls. These failures resulted in harm when Resident 1 fell from a regular wheelchair while outdoors unattended and sustained a laceration to the forehead that required emergency transport to the hospital for treatment with stitches. Findings included . Review of the facility's policy titled, NSG215 Falls Management, revised 02/18/2020, showed that residents will be assessed for fall risk as part of the nursing assessment process and those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Review of the significant change Minimum Data Set (MDS, a required assessment tool) dated 02/17/2021, showed that Resident 1 admitted on [DATE] with diagnoses to include bilateral below the knee amputations (BKAs), diabetes, circulatory complications, high blood pressure, stroke and a history of repeated falls. The MDS further showed that Resident 1 had cognitive impairment and dependent on two-person physical assist with bed mobility and toilet use. Transfers, locomotion in and off the unit did not occur during the assessment period. Review of the admission nursing documentation dated 11/24/2020, showed that Resident 1 had a very limited sensory perception and could not feel pain over half of the body. The nursing admission documentation further showed that Resident 1 could not bear own weight and needed assistance into a chair or wheelchair. The nursing documentation also identified the potential problem for Resident 1 to slide from the wheelchair or bed and the inability to lift up self during the move. Review of Resident 1's care plan initiated 11/25/2020, showed that the resident was dependent on staff for activities of daily living (ADL) care to include bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, and toilet use due to bilateral BKAs, generalized weakness, limited mobility, cognitive impairment and stroke. The care plan further indicated that Resident 1 required two-person total assist with transfers using the hoyer lift (a mechanical lift device) and was at risk for falls due to cognitive loss, limited mobility, and poor safety awareness. The care plan did not specify the level of supervision required for Resident 1while up in the wheelchair or outdoors. Review of a physician communication form dated 03/09/2021, showed a notification to the provider that Resident 1 was uncomfortable being up in the regular wheelchair and unable to keep self upright. The provider responded by ordering physical therapy (PT) to evaluate the resident for appropriate wheelchair. Review of the physician order dated 03/15/2021, showed an order from the provider for a tilt in space wheelchair for Resident 1. Observation on 04/26/2021 at 3:01 PM showed Resident 1 in bed with eyes closed. Resident 1 had a scab on the nose about 1centimeter (cm) by 1cm in size and a round scab above the brow that measured approximately 0.5cm in length and 0.5cm in width. Resident 1 was slow to respond, appeared fatigued and slowly moved hands while trying to move the blanket. During an interview on 04/26/2021 at 3:07 PM, when asked about the scabs on the nose and forehead, Resident 1 stated I had argument with the side walk. Resident 1 had no recollection of the details of the fall. Review of the facility's incident investigation report dated 04/17/2021, showed that on 04/17/2021 at 3:00 PM, Staff, C, Nursing Assistant Certified (NAC) and Staff, D, Nursing Assistant Registered (NAR), took Resident 1 in a regular wheelchair and two other residents outdoors within the facility property to enjoy the nice weather. The report further showed that after a while, Staff C, NAC, took one of the residents back inside the facility and told Staff D, NAR, to wait until she came back. The other resident then requested to be taken back inside by Staff D, NAR, leaving Resident 1 alone outside. According to the report, Resident 1 had an unwitnessed fall and was found on the ground with a laceration on the forehead, abrasion on the nose and skin shear on the right BKA. The facility called emergency medical services (EMS) and EMS took Resident 1 to the hospital for the treatment of the laceration which required stitches. Further review of the facility incident investigation report showed that a communication was sent to physical therapy to evaluate Resident 1 for a tilt back wheelchair. During an interview on 04/30/2021 at 11:00 AM, Staff E, Licensed Practical Nurse (LPN) stated that Resident 1 required two-person assist with ADLs. According to Staff E, LPN, Resident 1 usually stayed by the door while up in the wheelchair; however, since the decline in condition, the resident wanted to stay mostly in bed. Staff E, LPN, added that Resident 1 required two-person assist during transfers using a Hoyer lift. During an interview on 04/30/2021 at 11:15 AM, Staff B, Director of Nursing Services (DNS) stated that Resident 1 did not necessarily need supervision at all times because the resident was not impulsive. According to the DNS, after the fall incident from the wheelchair on 04/17/2021, the expectation was to closely watch Resident 1 at all times during outdoor activities and stated that licensed nursing staff referred the resident to PT to evaluate for a tilt in space wheelchair. Staff B, DNS, stated that Resident 1's last fall in December 2020 was not related to fall from the wheelchair instead Resident 1 fell out of bed while attempting to get out of bed. Review of the facility's incident investigation on 12/18/2020, showed that Resident 1 attempted to get out of bed without assist and fell . Actions taken were to provide a right side fall mat and a perimeter mattress to define the edges due to poor trunk control. During an interview on 05/03/2021 at 1:39 PM, Staff F, Director of Rehabilitation (DOR), stated that PT evaluated Resident 1 after the fall from the wheelchair on 04/17/2021. Staff F, DOR, stated that the therapy department took Resident 1 off the therapy list in February 2021 because of the resident's decline in condition and a lack of progress. According to Staff F, DOR, PT had been working with Resident 1 before in using the right leg prosthesis and that Resident 1 had been using the right leg prosthesis up until recent decline in condition when the resident was placed on comfort care. Staff F, DOR, further stated that because of Resident 1's decline in condition, the resident needed more supervision especially when up in the wheelchair. When asked about the 03/15/2021 order for a tilt in space wheelchair, Staff F, DOR, stated that the order was per recommendation from Nursing. Staff F, DOR, further stated that PT did not evaluate Resident 1 for the use of a tilt in space wheelchair in March 2021 and that the referral came after the resident fell from the regular wheelchair while outdoors on 04/17/2021. During an interview on 05/17/2021 at 10:09 AM, Staff A, Administrator, stated that the expectation was for staff to follow the resident's care plan and follow the provider's orders. However, the care plan did not include interventions to prevent the resident from falling while up in the wheelchair or outdoors, or to direct the caregivers on required amount of supervision for Resident 1's safety while outdoors. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to effectively implement actions to contain the spread of COVID-19, a [MEDICAL CONDITION] causing a respiratory illness with symptoms of a cough, fever, and in severe cases, difficulty breathing and/or death. 1. The facility staff failed to follow transmission-based precautions (using personal protective equipment including gown, gloves, masks, and eye protection). The facility infection control policy for COVID-19 dated 03/27/2020 included directives for staff to wear face masks, gloves, isolation gown and eye protection. 2. The facility staff demonstrated consistent cross-contamination while using PPE (Personal Protective Equipment) making it ineffective at protecting the person wearing it. This practice created exposure to staff which then could spread [MEDICAL CONDITION] to other residents if staff became infected. 3. The staff did not demonstrate consistent hand hygiene. Hand hygiene is instrumental in preventing the spread of pathogens and infections in healthcare settings. 4. The facility failed to consistently screen all visitors, therefore increasing the risk of virus exposure to staff and residents. 5. The facility failed to report the outbreak to the state agency. 6. The facility did not keep an accurate and clear infection control line list (surveillance tool) to track the residents/employees who may have been affected by the COVID-19 outbreak. The information gathered on this worksheet is used to determine duration of the outbreak, support monitoring for and rapid identification of new cases, and assist with implementation of infection control measures. Combination of these failures created a delay in containing COVID-19 outbreak and increased exposure to residents resulting in high likelihood of serious injury, serious harm, or death and required immediate action to prevent transmission of [MEDICAL CONDITION]. This constituted an Immediate Jeopardy. Findings included: Facility line listing provided on 05/12/2020 showed that on 05/04/2020 the facility had 12 staff and two residents who tested positive for COVID-19. An interview with a Collateral Contact (CC) from the local health department was conducted on 05/18/2020 at 4:56 PM. On 5/06/20, after testing South Hall the local health department confirmed and informed the facility of 52 COVID-19. On 5/08/2020 residents who lived on the North Hall were showing symptoms of possible respiratory infections. On 5/14/2020, six days later the facility tested residents and employees on the North Unit. On 05/19/2020 nine more residents and one employee were positive for COVID-19 on the North Side. The outbreak was no longer contained on one unit. As of 5/21/2020 the facility had 71 COVID-19 cases. SURVEILLANCE Record review on 05/19/2020 at 1:37 PM of an undated facility COVID-19 outbreak check list stated that suspected residents/staff will be immediately placed on the line listing (tracking document). CROSS-CONTAMINATION AND LACK OF HAND HYGIENE According to the Center for Disease Control (CDC) and Center for Medicare and Medicaid Services (CMS), the available evidence shows that the elderly are among those most likely to be affected by severe forms of the Covid-19 disease. The elderly have the highest percent of death after contracting [MEDICAL CONDITION]. The key factors in decreasing the transmission include but are not limited to staff knowledge of proper transmission precautions, hand hygiene, and appropriate PPE usage. Record review of the facility's policy titled Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), dated 03/11/20 stated that modes of transmission include person to person spread via droplets, direct contact with infectious secretions from a patient with COVID-19, and indirect contact transmission via hand transfer of COVID-19 virus [MEDICAL CONDITION]-contaminating surfaces. The same policy identified expectations of performing hand hygiene before and after all patient contact, contact with infectious material, before and after removal of PPE. PPE USE policy provided on 05/12/2020 at 12:00 PM, included the following guidance: -Healthcare providers must take care not to touch their facemask. If they touch or adjust their facemask they must immediately perform hand hygiene. -When caring for residents suspected of having COVID-19, staff will use masks and eye protection. -Extended use of isolation gown includes wearing the same gown by a healthcare provider (HCP) when interacting with more than one patient known to be infected with the same infectious diseases when these patients are housed in the same location. Record review and interview with Staff B, DNS (Director of Nursing) on 05/12/2020 at 9:11 AM identified that as of 05/12/2020 29 residents tested positive for COVID-19 and 24 staff tested positive for COVID-19. The facility census was 100 on 05/12/20, indicating more than 25% of resident population was positive for [MEDICAL CONDITION]. Observations and interviews were completed on 05/11/2020 between 6:35 PM and 7:20 PM and 05/12/2020 between 5:12 AM and 7:10 AM with Staff A, Administrator, Staff B, Director of Nursing (DNS), Staff M, LPN, Staff J, LPN and Staff G, LPN. The facility set up a closed-off COVID-19 unit. This unit consisted of three hallways. Two of the hallways, Halls #2 and #3, housed COVID-19 positive residents. Hall #1, rooms 101-111, housed eight residents who had COVID-19 results pending and were a high exposure risk. The three hallways shared one nurses' station, a clean utility room, a staff break room, and a medication room. The signage in the COVID-19 unit instructed staff to wear N-95 masks and eye protection at all times while in direct care areas/hallways. The facility plan allowed using the same gown, mask, and eye-protection between residents' rooms and in Halls #2 and #3 (positive COVID-19 residents) to conserve PPE supply. Staff were expected to change the gowns and perform hand hygiene when going from Halls #2 and #3 to Hall #1. Observations of the COVID-19 unit on 05/11/2020 at 6:40 PM and 05/12/2020 at 5:15 AM revealed there was no clear physical and/or visual separation border between COVID-19 positive halls (#2 ) and COVID-19 hall (#1) with pending results. The physical layout of the unit did not have an identifiable or designated area for staff to safely change PPE and perform hand hygiene when going from Halls #2 and/or #3 to Hall #1. This set up allowed for ongoing cross-contamination. -Intermittent observations on 05/11/2020: On 05/11/2020 at 6:39 PM Staff F, LPN was wearing a disposable gown and assisted Staff H, NAR (Nursing Assistant Registered) helping Resident #2 in a TBP (transmission based precautions) room. Staff F, LPN and Staff H, NAR moved the resident in bed and positioned a dinner tray over the bedside table. Staff F, LPN left the room wearing contaminated gown and sat at the nurses' station. The gown came into contact with various inanimate objects at the nurses' station. At 7:00 PM Resident #1(from Hall #1) came up to the nurses' station and requested medication from Staff F, LPN. Staff F, LPN walked to the Hall #1 medication cart wearing the same contaminated gown and without performing hand hygiene started preparing medication administration for Resident #1 who did not have COVID-19 diagnosis. During the same observations the employee's contaminated gown came into contact with the medication cart and contaminated hands touched the resident's medicine cup which was lifted to the resident's mouth, where he would inhale through his mouth in order to get the pills from the cup into his mouth to swallow. During an interview with Staff G, LPN, and Staff F, LPN, on 05/11/2020 between 7:03 PM and 7:10 PM it was identified that Staff F, LPN, and Staff G, LPN floated to other units besides COVID-19 unit. Both staff also confirmed that there were only two nurses on duty on the COVID-19 unit today, but there should have been three nurses. One nurse for each hall. Staff G, LPN, and Staff F, LPN said they had 20 residents assigned each and had to cross over between Halls # 2 and #3 (COVID-19 positive unit) and Hall # 1 (pending COVID-19 results.) Both nurses verified that as of 5/11/2020 all Residents on Hall #1 are pending COVID-19 results. Both staff members explained that having 20 residents assigned to each nurse was difficult to manage due to the full PPE usage requirement. On 05/11/2020 at 6:37 PM Staff H, NAR entered Resident #2' room without performing hand hygiene. Resident #2 was on transmission-based precaution (TBP), according to the sign posted outside of the room, and based on the information on the [DIAGNOSES REDACTED]. Staff H, NAR contaminated her hands and left the room without performing hand hygiene. On 05/11/2020 at 6:41 PM Staff H, NAR entered a TBP room (Resident #3) without performing hand hygiene then touched inanimate objects in the room, and then left the room without performing hand hygiene. Staff H, NAR entered a second TBP room (Resident #4) with contaminated hands, moved items around the sink area, and left the room without performing hand hygiene. Staff H, NAR then walked over to the clean utility room and opened the door and removed clean linen with contaminated hands. This clean utility room was shared between all three halls. Staff H, NAR placed gloves onto the contaminated hands and entered the third TBP room (Resident # 5 ). Staff H, NAR walked over to the fourth TBP room, (Resident #7) and removed the gown outside of the room. Staff H, NAR grabbed the gown by the neckties and pulled it over her head contaminating herself. No hand hygiene was performed after the gown removal. With contaminated hands Staff H, NAR reached into a plastic container and removed a new gown, then walked over to the medication cart to get a pair of gloves. Staff H, NAR placed gloves over the contaminated hands. -Intermittent observations on 05/12/2020: On 05/12/2020 at 5:47 AM Staff I, NAC donned gown and gloves without performing hand hygiene first. Wearing a contaminated gown staff was observed pushing a gray bin labeled biohazard through Hall #1 and through the double doors into the facility lobby area, essentially taking contaminated material out of the designated COVID-19 wing and into the main entrance of the non COVID-19 area. On 05/12/2020 at 5:31 AM Staff I, NAC, and Staff L, NAC entered TBP room (Resident #8 and #9) to provide personal care. Both were wearing gowns and gloves. At 5:38 AM both staff members left the room after performing personal care. Both staff wore the same gowns. Both Staff I, NAC and L, NAC did not perform hand hygiene after removing contaminated gloves. At this time Staff I, NAC reached for a clean gown with contaminated hands then placed a second gown over a contaminated gown with the contaminated hands. Staff I, NAC at 5:41 AM removed the extra gown, did not perform hand hygiene and entered room [ROOM NUMBER] (Hall #1). Observation on 05/12/2020 at 6:05 AM, Staff M, LPN was at the nurses' station wearing an isolation gown. The gown came into contact with inanimate objects. At 6:07 AM Staff M, LPN walked over to Hall #1 without removing/changing the contaminated gown and without performing hand hygiene. Staff M, LPN's contaminated gown came into contact with a medication cart and the contaminated hands came into contact with inanimate items on the medication cart. Continued observations on 5/12/2020 at 6:14 AM, showed that Staff M, LPN was at the nurses' station wearing the same contaminated gown. The gown came into contact with inanimate objects again. At 6:17 AM Staff M, LPN did not remove/change the contaminated gown and did not perform hang hygiene and walked over to Hall #1 medication cart again. The contaminated gown and the contaminated hands came into contact with the medication cart on Hall #1. On 5/12/2020, Staff M, LPN at 6:32 AM was at the nurses' station wearing the same contaminated gown which came into contact with items at the nurses' station. Staff M, LPN used a computer shared between staff for documenting resident care. At approximately 6:35 AM Staff M, LPN again walked over to Hall #1 from the nurses' station wearing the same contaminated gown and with contaminated hands touched inanimate objections on the medication cart. On 5/12/2020, Staff L, NAC at 5:50 AM was within six feet of the nurses' station. The employee removed eyewear and adjusted the mask with her hands and without performing hand hygiene donned gloves onto the contaminated hands. Staff L, NAC removed gray bins labeled biohazard from Hall #2 and pushed those across Hall #1. Halfway through the hallway, Staff L, NAC returned to the nurses' station and removed the gown, and without performing hand hygiene placed another gown then returned to the bins and moved them outside of the COVID-19 unit and into the lobby area. On 5/12/2020 at 5:25 AM Staff I, NAC placed gloves on without performing hand hygiene. Staff I, NAC contaminated gloved hands by touching inanimate objects on Hall #2 and then touched her facemask and failed to perform hand hygiene. At 5:28 AM Staff I, NAC entered TBS room (Resident #8 ) then left the room without removing gloves and cleansing hands and walked into a clean utility room and removed linens with contaminated hands. On 5/12/2020 at 5:45 AM Staff J, LPN was at the nurses' station and used the shared computer and then proceeded to the med cart. Staff J, LPN donned a pair of gloves without cleansing hands first and started removing medications from the medication cart. On 5/12/2020 at 5:47 AM Staff I, NAC did not perform hand hygiene after removing a contaminated gown and then donned a clean gown and gloves using contaminated hands. On 5/12/2020, Staff N, NAC at 6:10 AM was observed touching a small cart with blood pressure cuff, thermometer and devices that is placed on residents' finger to measure the pulse and oxygen level. The cart is pushed into each room on every shift to check the status of each resident. The employee's gown came into contact with the equipment. At 6:13 AM staff entered the breakroom without removing his gown and performing hand hygiene, contaminating the area. On 5/12/2020, Staff O, NAC at 6:15 AM removed her gown and hung it outside of the break room, which was shared between the three units. Staff O, NAC entered the breakroom without performing hand hygiene, contaminating the shared breakroom. Observations conducted on 5/11/2020 and 5/12/2020 identified at least 20 missed opportunities to perform hand hygiene. FAILURE TO WEAR PROTECTIVE EYEWEAR (PPE) On 5/11/2020 at 7:03 PM Staff G, LPN said all residents on Hall 2 and 3 were positive for COVID-19, and staff wore PPE (gowns, masks, and eye-wear) inside and outside of the resident rooms to conserve supplies. On 5/11/2020 at 6:37 PM Staff F, LPN was observed without eye protection in the hallway with confirmed COVID-19 cases. At 6:39 PM Staff F, LPN was not wearing eye-protection and entered a TBP room (Resident #2). Observations on 5/12/2020 between 5:15 AM and 6:30 AM identified five nursing employees; Staff Me, NAC, Staff J, LPN, Staff K, LPN, Staff O, NAC and Staff L, NAC not wearing eye-protection (PPE) in the residents' rooms and/or care areas on the COVID-19 unit. SCREENING Review of facility policy titled Infection Control Policies and Procedures dated 3/27/2020 stated that active screening of employees, visitors, and other health care workers will be done upon entry into the center. The facility would screened for temperature, symptoms, and exposure risk, in attempt to limit the potential exposure to the COVID-19 virus. The surveyor was not immediately screened at the time of entrance to the facility on [DATE] at 6:35 PM and on 5/12/2020 at 5:10 AM. REPORTING OUTBREAK According to the facility infection control line listing, Resident #10 was tested on [DATE] with positive results for COVID-19 on 5/03/2020. Staff Q was tested on [DATE] with positive results on 4/30/2020. Record review of the agency reporting system Tracking Incidents in Vulnerable Adults on 5/19/2020 at 11:42 AM did not show that the above cases were reported to the state agency. According to the CDC the fatality rate among people age 65 and older is estimated to be between 11% - 27%. Long-Term care facilities are high risk settings for severe outcomes from COVID-19. The facility did not ensure that staff were [MEDICATION NAME] the basic infection control practices they had control over such as hand- hygiene and prevent cross-contamination. This contributed to failure to decrease the spread of the transmission, resulting in 71 COVID-19 cases. WAC Reference 388-97-1320(1)(a)(c)(2)(a)(b)(c)(5)

Based on observation, interview and record review, the facility failed to provide medically related social services to attain the highest practicable physical, mental and psychosocial well-being for three of five sampled residents (#s 111,143,160) reviewed for Social Services. Failure to ensure vision, hearing, pain, emotional and psychological adjustment needs were identified and met for two residents (Resident #'s 111 & 143), and to make arrangements for two residents (Resident #'s 111& 160) to be seen by mental health, and provide adequate emotional support, placed residents at risk for medical and mental health complications and unmet needs. This failure resulted in harm for Resident #143 who experienced persistent psychological distress due to allegations of verbal and physical abuse, inadequate assessment and staff response to behaviors. Findings included . Refer to 251 RESIDENT #143 Refer to F225 for additional information about incidents about potential abuse and neglect. Refer to F309 for additional information about pain. Record review of Admission Minimum Data Set, (MDS), a required assessment tool, dated [DATE], showed Resident #143 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident required assistance of two staff for transfers, dressing, bed mobility and toileting. Resident #143 was cognitively intact. The Admission MDS dated [DATE], assessed Resident #143 as having no concerns in pain, mood, or behaviors. It was very important to the resident to use the phone in private and participate in favorite activities. In an interview on [DATE] at 4:16 PM, Resident #143 stated recently prior to admission, she survived a house fire, had a stroke, had renal and respiratory failure, was hospitalized and almost died , relocated to a nursing facility for rehabilitation, and lost her functional independence. Her discharge plan was to return home, which was being renovated since the fire. She was not progressing as fast as she hoped. Resident #143 further stated she recently heard one son's health was deteriorating and she and her family did not know his whereabouts. The resident also said she was legally blind, hard of hearing and had difficulty communicating with staff and her family since she could not hear on the phone or see the numbers to dial. Resident #143 stated she used to be able to call someone when she needed something or to talk to someone. Here she could not. She further stated she recently heard one son's health was deteriorating and she and her family did not know his whereabouts, and had no way of trying to contact him. When asked if she had been abused while in the facility, Resident #143 said, yes. The resident stated nurse aides on night shift were rough with her, told her she had to stay in bed and sleep. Her left arm was still recovering from a large bruise that she sustained after being knocked into the bathroom doorframe, when staff transferred her in a lift, I told them it was an accident waiting to happen! I'll never use that lift again. The resident stated a nurse on night shift, Staff K, was mean to her, yelled at her and told her not to use her call light and that she was supposed to be sleeping. The resident stated she was afraid to use it for a while and didn't want to get in trouble. Resident #143 stated she had pain all the time, in her legs, lower back and left arm and left shoulder. Standing up helped relieve the pain in her legs, but the nurse did not allow it. One night I put a blanket over my face so no one would hear me cry. Resident #143 stated when she was upset about something, she will refuse meals, medication, not sleep well and isolated herself. The resident said she did this when the staff were mean to her, told her she was to stay in bed and not use her call light. Resident #143 talked about a TTY phone that she used at home because she was hard of hearing and had poor vision. I can't hear on any of these phones. I want to talk to my family. My son works during the day and not available until late evening. I was waiting to hear back from the social worker if he was allowed to visit late at night. Review of the medical record, Resident #143 did not have a psychosocial well-being care plan, initial Social Service assessment or psychosocial assessment to identify her history, triggers, coping strategies or potential risk factors that could impact her ability to reach her goals. There were no Social Service Progress notes prior to [DATE] at 4:23 PM. In a subsequent interview on [DATE] at 4:21 PM, Resident #143 said she had a bad day. She said her power of attorney (POA) visited her earlier in the day, and informed her she still did not know where her ill son was. Additionally, the resident mentioned her favorite nurse that worked the previous night shift, told her she was not allowed to get up out of bed because he didn't want to see her fall. The resident stated she wanted to get out of bed in help to relieve pain. Resident #143 became tearful and stated she was upset because she didn't know why he told her that. When asked if she had pain or discomfort, Resident #143 stated she was in pain and didn't participate in therapy that morning. She had refused her medications all day because she was upset, and didn't eat much. In an interview with Staff M, Registered Nurse (RN), and Resident #143 on [DATE] at 4:45 PM, Resident #143 stated she had been having problems with night shift. She was upset today because the nurse the night before told her she had to stay in bed. Why do I have to stay in bed? I will not attempt to get up by myself. I won't fall. Why? The resident stated staff were rough with her at night, had bruises the sizes of hands on her inner thighs. She was also was bumped into the door frame during a lift transfer, and hit her left arm. Her left arm still hurt. The resident asked why she couldn't resume on her previous pain med Resident #143 became tearful, stated she was not having a good day, raised her voice and said, I can't take it anymore! Just leave! On [DATE] at 5:25 PM, Staff M, RN, stated Resident #143 got in report that she refused all her pain meds the previous shift, and was not sure why, but thought it was related to her son's poor health. Staff M, RN, also stated she was familiar with the resident from a previous facility, and identified her as attention seeking, and a history of making false allegations. Two staff were required to be present when working with her. Staff M, RN, was not aware of the bruises on her wrist or inner thighs or the repeated problems she was having with night shift. Record review of the care plan dated [DATE], showed Resident #143 was not care planned for two staff with all cares, or updated to reflect recent allegations of rough handling, verbal abuse of night shift. Record review of the August and [DATE] Medication and Treatment Administration Records, showed no target behavior monitors were being monitored. In an interview on [DATE] at 10:42 AM, Staff T, Certified Nursing Assistant (NAC), assigned to Resident #143, stated she was not aware of allegations of rough treatment on her hall, in the last three weeks. In an interview on [DATE] at 10:48 AM, Staff L, Charge Nurse, Licensed Practical Nurse (LPN), was unaware of allegations of rough treatment or concerns with staff since admission related to Resident #143. In an interview on [DATE] at 11:29 AM, Staff F, SSA, stated she was responsible for monitoring residents for psychosocial harm, after an allegation of physical and/or verbal abuse. She indicated any follow-up would be in the Social Services progress notes. She had been working alone in the department since [DATE]. Staff F was not aware of any allegations of staff mistreatment or rough handling prior to [DATE]. When she talked to the resident about the concern voiced on [DATE], the resident didn't have any problems. Staff F, SSA, stated the most recent concern was heard on [DATE] about staff not wanting her to get out of bed and tried to talk to her about it, but Resident #143 refused. She and a nurse contacted the family, where they discovered the resident had a history of [REDACTED]. When asked why Resident #143 refused to talk to her, Staff F, SSA, said it may be there was an underlying reason, or she just didn't want to talk. I can't make her talk. Staff F, SS did not believe there were any changes in the resident's mood or psychosocial status since admission. Staff F was not aware that other residents had concerns with the treatment from same nurse, Staff K, LPN, on night shift. Staff F stated she did not have identified target behaviors to be tracked because she was not on any psychotropic medications. Staff F stated the most effective intervention for Resident #143, was to contact the family and have them come in and talk with her when needed. The family came in a couple times a week. Staff F was not aware and did not hear that Resident #143 wanted a TTY phone, and that she did not have a means to contact her family. The resident or her family never mentioned it. Social Services did not identify Resident #143's potential or actual alterations in psychosocial well-being upon admission, assess and evaluate how to comprehensively and effectively provide support to the resident, to help cope with changes, discomfort, losses, and current stressors. This failure resulted in harm to the resident. RESIDENT #111 Review of the quarterly Minimum Data Set (MDS- a required assessment tool) dated [DATE], showed that Resident #111 admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The MDS showed that Resident #111 was cognitively intact and required therapy services. Review of Resident #111's social service progress notes dated [DATE] through [DATE] showed multiple stressors that included: spouse passed away unexpectedly, financial difficulties, and family visited as often as possible. Observation and interview on [DATE] at 1:24 PM, Resident #111 was in the front lobby area with an unidentified staff member assisting her with her wheelchair. The unidentified staff member stated that I just found her outside. Resident #111 stated that she wanted to go into the street at times and have someone run her over. During an interview on [DATE] at 10:28 AM, Resident #111 stated that recently she had lost her husband unexpectedly, had to sell her house to pay for her stay and doesn't see her boys as often as she would like to. In addition the resident stated I have lost all my support systems. In addition, Resident #111 stated that she would like to have mental health services, so that she would have someone to talk to. During an interview on [DATE] at 11:01 AM, Staff F, SSA, stated that Resident #111 had seen a psychiatrist on [DATE] but, has had no further visits and has had no mental health services. Review of social service care conference documentation from date of admission [DATE] through [DATE], Resident #111 had one care conference on [DATE] to discuss her plan of care. Individuals that attended the care conference included: Social Services Assistant, a Registered Nurse, and the Unit Manager. Review of Resident #111 social services progress note dated [DATE] at 12:53 PM, showed that Resident #111 talked about the past and had a history of [REDACTED].#111 denied having suicidal thoughts or a plan to hurt herself at that time. Review of Resident #111 progress note dated [DATE] showed that Resident #111 had expressed that she was still grieving the loss of her husband and other changes in her life. During interview on [DATE] at 10:11AM, Staff O, Nursing Assistant Certified (NAC), stated that she had heard Resident #111, made comments that she wanted to go be with her deceased husband. Staff O, stated that she would report to the nurses and social services when Resident #111 made those comments. RESIDENT #160 Review of the admission MDS dated [DATE], showed that Resident #160 admitted to the facility from an acute hospital on [DATE] with multiple [DIAGNOSES REDACTED]. The MDS showed Resident #160 was cognitively intact and able to make needs known. Review of the Level II PASRR dated [DATE] showed that it was recommended that Resident #160 receive mental health services for psychiatric assessment, medication evaluation and management to ensure her needs are met. The Level II PASRR also showed that Resident #160 was interested in counseling services to help her develop coping skills to manage the sadness, guilt, and lifestyle change she experienced after her stroke. Review of Residents physician orders [REDACTED]. During an interview on [DATE] at 1:31 PM, Staff F, SSA, stated that she could not locate an order for [REDACTED].#160's medical record and that she would ask nursing to get a physician's orders [REDACTED].#160 on the list to be seen by mental health. Staff F, SSA, stated She (Resident #160) probably should have been seen sooner. During an interview on [DATE] at approximately 8:50 AM, Staff A, Administrator, stated that social services is responsible to follow up on all PASRR issues including recommendations for mental health services. Staff A, Administrator, also stated that Resident #160 should have had a doctor's order obtained for mental health as soon as the recommendation was received at the facility. WAC Reference: [DATE] (1)

Based on observation, interview and record review it was determined that the facility failed to ensure a physician was informed in a timely manner following an accident with injury for 1 of 7 Sampled Residents (#1) reviewed for physician notification. This failure caused Resident #1 to wait for two days to be seen by a practitioner. Resident #1's record indicated he was experiencing pain, yet he waited two days to receive narcotic pain medication and two days before being sent to the hospital for treatment. Findings include: Review of a facility policy dated 1/2/14 titled Guidelines for Physician/midlevel Provider Notification revealed a list of medical conditions and/or problems. For each problem/condition there were directives for staff of when to contact the physician in an urgent or routine manner. Review of the staff directive for physician notification revealed that following a fall the doctor should be notified in an urgent manner if there is an injury as a result of the fall. In an interview on 4/7/16 at 10:57 a.m., the facility's medical director reported when the staff needed to notify him regarding a resident's condition they may call him on the phone or fax an SBAR (Situation, Background. Assessment, Recommendation) form to him. The Medical Director reported he will then write down his recommendations and sign the form, then fax it back to the nursing staff so they will know he received it and know if he would like to make any changes in the resident's care. RESIDENT #1 Review of a facility incident investigation dated 2/27/16 revealed Resident #1 had fallen from his bed at 8:40 p.m. that evening. The investigation indicated the bed was at hip level height when the resident fell , landing on the floor on his right side. Further review of the investigation indicated Resident #1 had a bump to the right side of head, right shoulder pain, and a bruise on his/her right forehead as a result of the fall. Review of Resident #1's medical record revealed no documentation that a physician had been notified he had fallen and sustained injuries. Review of the facility investigation revealed a SBAR form note dated the day after the fall on 2/28/16 at 3:00 p.m. The SBAR form did not have a fax stamp on the page indicating it had been faxed to the physician. In an interview on 3/30/16 at 1:00 p.m., Staff C reported the physician did not come into the facility until approximately 7:00 p.m. on 2/28/16. Staff C confirmed there was no documentation in the resident's record or on the SBAR form to evidence the physician had been made aware of the fall with injury. During a phone interview on 4/5/16 at 3:05 p.m., Staff S confirmed that she did not notify the physician following the fall on 2/27/16. Staff S reported she had completed the SBAR form the next day on 2/28/16 and was going to give it to the physician when he came into the facility. Staff S confirmed she did not fax the form, but was waiting to see the physician. Staff S said the physician had not been into the facility by the end of her shift. Review of Resident #1's record, revealed a nursing progress note dated 2/28/16 at 11:35 p.m., which confirmed the physician did not come into the facility until evening shift that day but had missed the resident. Resident #1's record revealed a note written by the nurse practitioner dated 2/29/16 at 1:12 p.m., two days after the fall. The nurse practitioner ordered an x-ray on 2/29/16 revealing a fractured bone in Resident #1's shoulder. The note described Resident #1 as having increased pain and that he had rated his pain 8/10. In an interview on 3/30/16 at 1:00 p.m., Staff C stated there was no documentation to evidence a physician and/or practitioner had been notified during the timeframe between the time Resident #1 fell on [DATE], and the time the nurse practitioner saw the resident, two days later on 2/29/16. Review of the hospital emergency room (ER) notes revealed documentation that the resident had pain with movement. The ER physician noted that although the resident had verbally denied pain, he knew that pain was present based on grimacing and non-verbal cues. The 2/27/16 fall investigation indicated Resident #1 was having pain to his shoulder after the fall. There were two nursing progress notes in the medical record on 2/28/16; both notes indicated Resident #1 had pain in his shoulder, yet neither note indicated the physician had been notifed of pain related to the fall. Resident #1 fell on [DATE] which resulted in a bruise to his face, a bump to his head and shoulder pain. The resident's record indicated he continued to have pain and facial swelling the following day on 2/28/16. There was no documentation to support nursing staff ever attempted to call the physician to notify him of the situation. Although a SBAR note was written the next day to inform the physician of Resident #1's condition, staff failed to ensure the physician actually received the notification.

Based on observation, interview, and record review, the facility failed to identify, thoroughly investigate, and report to the state hotline, suspected abuse and/or neglect for 3 of 4 Sampled Residents (#s 1, 3 & 6) reviewed for allegations of abuse. Additionally, the facility failed to protect residents following an incident, for 1 of 7 (#1) Sampled Residents. The failure to identify, investigate, and report abuse, and the failure to protect a resident following an altercation, resulted in harm to Resident #1, and placed the residents at a potential risk of ongoing abuse. Findings include: Review of the facility's policy titled Abuse/Suspected Abuse of Vulnerable Adult Policy dated 1/20/15 revealed directives for staff suspecting abuse, neglect or financial exploitation to immediately notify the charge nurse, DNS (director of nursing services) or the administrator and the Department of Social and Health Services. The policy indicated an incident report would then be initiated. Review of the facility's abuse training titled The Path to Being the Best, Welcome to Genesis Healthcare - Linden Grove Healthcare Center that is provided on hire and annually after hire, revealed a section subtitled A Short Story. The Short Story section described a resident who reported a story about aliens visiting during the night time. The short story section is a lesson for staff that no matter how unbelievable a story may seem it should be taken seriously. RESIDENT #1 - ALLEGATION BEING BEAT WITH BASEBALL BAT Resident #1 was no longer in the facility. During an interview on 4/1/16 at 8:20 a.m., Collateral Contact (CC) #1 explained Resident #1 had told her he went to the hospital after he had been beat up with a baseball bat. CC #1 reported she was not comfortable with the resident's recall of events because although it sounded like something that would never happen, but the resident had a broken bone in his shoulder and bruises to both sides of his face, which made her suspicious. CC #1 said she had reported Resident #1's statement of being beat with a baseball bat to the facility on [DATE]. Review of the facility's February and March 2016 state reporting log revealed no entries related to abuse for Resident #1. Review of Washington State's Tracking Incidents of Vulnerable Adults (TIVA) revealed no evidence the facility had called the Department of Social and Health Services to report the alleged abuse between February 1, 2016 and March 30, 2016. During an interview on 3/30/16 at 9:57 a.m., Staff C confirmed the allegation related to Resident #1 being hit with a baseball bat was not on the state reporting log, and was not reported to the state Department of Social and Health Services. According to Staff C, prior to Resident #1's allegation, the resident was involved in an altercation with Staff E on 2/27/16. Staff E stated to Staff C that Resident #1 was reaching forward trying to grab her when he lost his balance and fell from his bed onto the floor. During an interview on 4/1/16 at 8:50 a.m., Staff F confirmed CC #1 made a report 0n 3/23/16 to Staff F that Resident #1 had stated he was beat up with a baseball bat. Staff F said she then went immediately into an office where Staff A, Staff C and Staff H were all present and Staff F reported the allegation to them, stating, We have a problem, (Resident #1) said he was hit with a baseball bat. Review of a statement written by Staff H dated 3/23/15 revealed, Staff H asked Resident #1 to tell her how he broke his shoulder and Resident #1 responded Well, I think I fell out of bed. That's all I know. There was no further investigation documentation pertaining to being beat with a baseball bat. In an interview on 3/30/16 at 12:35 p.m., Staff A stated the allegation was not entered onto the reporting log and was not called into the state because when Staff H asked the resident how he injured his shoulder, Resident #1 stated it was injured when he fell out of bed. When asked if Resident #1 had been asked if he was hit with a baseball bat, Staff A replied the resident was not asked. Staff A was asked if staff asked Resident #1 what caused him to fall out of bed, or if he had been hit or pulled out of bed, Staff A confirmed nobody had asked those questions to the resident. Staff A confirmed staff had not asked Resident #1 if he had been hit with a baseball bat. Staff A confirmed Resident #1 was not asked how he fell out of bed, or asked if he had been pushed, hit, or pulled. Staff A confirmed that Staff H had asked Resident #1 how he had injured his shoulder to which he responded he had fallen out of bed. Staff A confirmed staff had not asked Resident #1 if he was hit by a baseball bat, or if he had been hit or pushed. Staff A confirmed when Resident #1 reported he had fallen out of bed, nobody asked him how he fell out of bed to rule out the possibility the fall could have been related to being hit or pushed. Staff A then reviewed Resident #1's medical record and confirmed there was a physician's progress note dated 3/15/16 that indicated Resident #1 reported to the doctor that he went to the hospital after being beat up. The facility did not have an investigation related to Resident #1 reporting to the doctor or reporting to CC #1 that he had been beaten up. Resident #1 reported on two different occasions that he had been beat up. Neither of the allegations had been entered onto the state reporting log, reported to the Department of Social and Health Services, or investigated by the facility. Failure to investigate and rule out abuse placed the resident at a potential risk of being exposed to continued mistreatment. INCIDENT ON 2/27/16 In an interview on 4/1/16 at 8:20 a.m., CC #2 said Staff S had reported to her on 2/28/16 that there was an altercation the previous evening shift between the resident and Staff E, and that Staff E had received training related to the incident. In addition, on 2/29/16 the facility notified CC #2 that Resident #1 had a fracture and needed to go to the hospital. Review of a SBAR (Situation, Background, Assessment, Recommendation - a form used to relay resident information to the physician) form written by Staff S, dated 2/28/16, revealed a note to the doctor Resident became very agitated and disoriented during care, after waking him up that led to him falling off the bed. CC #2 said when she arrived at the facility on 2/29/16, Resident #1 had bruising to both sides of his face and Staff E was present in the room with the resident when the ambulance crew arrived. CC #2 stated the paramedics asked Staff E what happened? CC #2 stated Staff E reported to the paramedics that the resident had reached out to grab her, Staff E stated she pushed his arm back and he fell . In an interview on 4/1/16 at 3:05 p.m., Staff S confirmed the 2/28/16 phone conversation with CC #2 and that there had been an altercation. Staff S reported that Staff E, who was involved in the altercation, told Staff S, Resident #1 became physically aggressive and grabbed Staff E's arms. Staff E reported to Staff S immediately after the incident that Resident #1 had leaned forward in an attempt to grab Staff E, and lost his balance falling to the floor. Review of SBAR dated 2/28/16 written by Staff S to the physician, revealed that following the incident Resident #1 had acquired scratches on L (left) cheek, L (left) forearm, R (right) forehead, bump to R (right) forehead. During a phone interview on 4/1/16 at 3:05 p.m., Staff S confirmed Staff E reported to her that Resident #1 grabbed her arms and she was not able to get her arms free. Staff S confirmed that Resident #1 had scratches on his arms after the incident. In an interview on 4/1/16 at 3:30 p.m., Staff C stated that Staff E did not have any apparent injuries related to the altercation. Further review of the incident investigation revealed, there were no interviews with other residents to ensure there were no other residents who had concerns related to the manner in which care was provided by the staff member involved with the incident. During an interview on 4/1/16 at 12:50 p.m., Staff C confirmed that Resident #1 had a roommate and that the roommate was not interviewed following the incident to see if he had witnessed the altercation. During an interview on 4/1/16 at 12:35 p.m., Staff A confirmed that Resident #1 was not asked what happened. The facility did not thoroughly investigate to ensure the resident had not been pushed, or that there was not an action by the staff member involved, causing the resident to lose his balance and fall. During an interview on 4/1/16 at 3:05 p.m., Staff S reported she was in the hall when the incident occurred, and that she did not hear Staff E call for assistance. Staff E reported she had been grabbed, hit and squeezed real hard yet Staff E did not have injuries. Resident #1 sustained injuries including scratches to his face and arms - however, the facility did not investigate to rule out staff abuse toward the resident. PROTECTION OF RESIDENT #1 During an interview on 4/5/16 6:00 p.m., Staff F confirmed that Resident #1's family requested that the identified nursing assistant no longer work with the resident. Staff F confirmed the nursing assistant had not been suspended following the incident, and was not going to work with the resident again. During an interview on 4/7/16 at 10:30 a.m., Staff C confirmed that she had spoken to Staff E, the nursing assistant involved in the altercation, and confirmed she was in Resident #1's room on 2/29/16 when the ambulance staff arrived to pick up Resident #1 to take him to the hospital. Review of a skin assessment dated [DATE], the day Resident #1 returned to the facility, revealed that when Resident #1 returned to the facility Staff E was in the resident's room assisting the nurse complete a head to toe skin assessment. During an interview on 4/5/16 at 5:50 p.m., Staff B reviewed the 3/15/16 skin assessment and confirmed the nursing assistant had signed the skin assessment indicating she was present with the nurse doing Resident #1's assessment. Facility staff reported Staff E was not suspended following an altercation, and instead would not work with Resident #1 any further. Staff interviews confirmed Staff E continued to be involved with Resident #1's care when Staff E was in the resident's room at the time he was transported to the hospital. Staff E was in the resident's room the night the resident returned from the hospital, while the nurse conducted a full body skin assessment. RESIDENT #3 Resident #3 was no longer in the facility. Review of the facility's state reporting log revealed an entry involving Resident #3 on 3/6/16. Under the Event column was Resident handling - staff. The entry indicated the incident had not been reported to the state Department of Social and Health Services hotline. Review of the facility's investigation of the identified incident confirmed the incident had not been reported to the hotline. Further review of the incident investigation revealed Resident #3 had reported to staff that she had been hit on the head during the previous night. During an interview on 4/1/16 at 11:45 a.m., Staff N reported she had spoken with Resident #3 on the day she reported the allegation. Staff N confirmed Resident #3 stated she had been hit on the head. Staff N further reported Resident #3 did not know who hit her or what she may have been hit with. Staff N reported Resident #3 was blind, so the resident may not know who may have come in her room or what she may have been hit with. Additionally, Staff N reported that a visitor who was with Resident #3 on 3/6/16, reported that Resident #3 had alleged to her that someone was tying up her feet at night. During an interview on 4/1/16 at 10:15 a.m., Staff C confirmed that Resident #3's visitor had reported an allegation of Resident #3 being tied up and that the allegation was not listed on the state reporting log. Staff C further reported every allegation should be entered on the log separately and therefore, each allegation should have a separate investigation. Staff reported there had been two separate allegations of Resident #3 being mistreated. Review of the facility's state reporting log and incident investigation indicated neither of the two allegations had been reported to the state hotline. RESIDENT #6 - THOROUGH INVESTIGATION Resident #6 was no longer in the facility. Review of the facility's incident log revealed Resident #6 had fallen at 2:30 a.m. on 2/21/16. Review of Resident #6's medical record revealed a nursing progress note dated 2/21/16 at 9:26 p.m. that indicated the fall was at 2:30 p.m. The progress note stated Resident #6 was wearing standard socks at the time of his fall which is the root cause of his fall due to poor traction. Review of the facility incident investigation dated 2/21/16, revealed the fall was noted to have occurred at 2:30 a.m. Page 1 of the investigation titled event summary report indicated Resident #6 was standing without shoes on, the summary did not indicate if anything other than shoes were on the resident's feet. The third page of the investigation listed footwear at the time of the fall: Bare feet. The fifth page of the investigation listed root cause/conclusion: which indicated the resident was barefoot. During an interview on 4/5/16 at 5:45 p.m., Staff B and Staff C reported they were not aware of the discrepancies related to the time of the fall and what the resident's footwear at the time of the fall, until interviewed by the surveyor. Staff C then called the nurse who wrote a note to clarify when the incident occurred and the cause of the fall, on 4/5/16, more than a month after the fall. Failure to investigate all incidents thoroughly placed residents at potential risk of unidentified abuse or neglect, and not being protected from ongoing abuse or neglect. Failure to remove staff from resident care during investigations placed residents at potential risk for continued mistreatment by staff. .

Based on observation, interview and record review it was determined that the facility failed to ensure each resident was adequately monitored following an incident for 7 or 7 Sampled Residents (#s 1, 2, 3, 4, 5, 6 & 7) reviewed for incident investigations. This failure placed residents at potential risk for staff not identifying an injury and/or change in condition timely, therefore, delaying treatment. Additionally, the facility failed to ensure care was provided in an individualized manner as described in the care plan, related to the manner in which the caregiver approached the resident, for 1 of 7 Sampled Residents (#1) reviewed for care and services. This failure resulted in harm to Resident #1. Findings include: Resident #1 originally admitted to the facility in 2010. In an interview on 4/5/16 at 5:55 p.m., Staff B stated Resident #1 had no history of aggressive or combative behavior. Staff B stated the resident did not have a care plan for behavior and did not have behavior monitoring, as there had never been an indication for it. In an interview on 4/5/16 at 6:00 p.m., Staff C stated Resident #1 had only been confused and aggressive one time and the incident was over a year prior. Staff C reported staff at that time had identified the behavior was related to an underlying infection. Review of Resident #1's care plan dated 2/23/16 revealed a section alteration in cognition r/t (related to) dx (diagnosis) of dementia. Included in the interventions was explain care process step by step. Speak slowly and clearly. Allow resident ample time to process information. Facility records indicated Resident #1 fell on [DATE]. The resident was sent to the hospital on [DATE] for treatment of [REDACTED]. Resident #1 was admitted to the hospital due to an underlying infection. The resident did not return to the facility until 3/15/16, when he admitted under hospice services. PROVISION OF CARE Review of an undated statement related to Resident #1's 2/27/16 fall written by Staff E, revealed her account of what had occurred prior to the fall. The statement indicated after entering Resident #1's room Staff E turned on the light and told the resident she was going to change him. Review of a SBAR form written by Staff S, dated 2/28/16, revealed a note to the doctor Resident became very agitated and disoriented during care, after waking him up that led to him falling off the bed. During an interview on 4/1/16 at 7:40 a.m., Staff J reported nursing assistants typically do not wake residents up to provide care unless they are visibly wet. Review of the facility investigation revealed the staff statement did not indicate why the staff member was waking the resident, just that she entered the room and turned on the light. The statement indicated the staff turned on the light before she even approached the resident to see if he needed care provided. Staff E documented in her written statement she turned on the light and told Resident #1 she was going to change him. The statement did not indicate the resident was asked if she could provide care, but instead Staff E told the resident she was going to provide care. Staff E's statement indicated Resident #1 told her to let go of him and did I ask you to do that? There was no indication that Staff E was asked to clarify why she woke the resident up in the manner that she did, or why she was providing care when he was disoriented after waking him up. Staff statements indicated the resident was woken up by turning on the light in his room and staff telling him they were going to provide personal care. Statements also indicated Resident #1 was disoriented when staff started the care. Resident #1 had specific interventions based on his cognitive function to approach him and how to provide care. Staff statements indicated the resident was not approached in the identified manner and care was started even when the resident was disoriented. The staff approach to Resident #1 contributed to his confusion, which lead to his aggressive behavior. The behavior caused Resident #1 to fall and sustain injuries including a fracture. Although the fall occurred on 2/27/16, Resident #1 remained in the facility with staff until he was sent to the hospital on [DATE]. MONITORING AFTER INCIDENTS RESIDENT #1 Review of a facility incident investigation dated 2/27/16 revealed Resident #1 had fallen at 8:40 p.m. Review of Resident #1's medical record reviewed no progress notes or documentation that he had fallen. There were no nursing notes for 2/27/16, the day of the fall. Review of the fall investigation dated 2/27/16 revealed a section that was subtitled injury(ies) and had a diagram of a person. The diagram had the number 1 on the person's right forehead, a 2 on the right shoulder, and a 3 on the right cheek. Under the diagram was a list that identified 1 was a bruise and 2 indicated shoulder pain. There was no documentation to indicate what type injury 3 represented. The investigation did not document the size, color or characteristics of the injuries, or the severity of shoulder pain. Further review of Resident #1's record revealed the first progress note following the fall was dated the next day on 2/28/16. The progress note indicated Resident #1 had a bump to right side of head, facial swelling and bruising of left eye. There was no documentation of the size or color of the bruise, the amount of swelling, or the severity of the bump. Review of a SBAR (Situation, Backgrounds, Assessment, Recommendation) form dated 2/29/16 a note to the physician stating Resident #1 had fallen and acquired scratches to his left cheek, scratches to his left and right forearms, and a bump to his right forehead. There was no documentation of how many scratches, or the sizes of the scratches. There was no documentation of the size/severity of the bump. There was no ongoing monitoring of the facial swelling, bruise around eye, bump on forehead or scratches to cheek and forearms. During an interview on 4/7/16 at 8:50 a.m., Staff O reviewed Resident #1's medical record and confirmed there was not a skin assessment documented since 2/22/16, before the fall, until 2/29/16, two days after the fall. Staff O confirmed when a resident develops a skin injury such as a bruise or scratch nursing staff was expected to complete a skin assessment with measurements and descriptions of the injuries so they could be monitored. During an interview on 4/7/16 at 10:25 a.m., Staff A reported the skin assessment done prior to the fall on 2/22/16 indicated Resident #1 had no skin impairments. During an interview on 4/1/16 at 1:45 p.m., Staff C reviewed Resident #1's record and confirmed there was no documentation to support the size or severity of the bruise to the resident's face/eye, or that it was monitored after the fall. Staff C further reported there was no documentation of the size/severity of the bump to the resident's head, and no documentation that is was being monitored for changes after the fall. Staff C reported the injuries should have been documented on a skin sheet for nursing staff to monitor. During a phone interview on 4/1/16 at 3:05 p.m., Staff S confirmed she did not document the skin impairments on the skin sheet. During an interview on 4/1/16 at 4:15 p.m., Staff C review Resident #1's record and confirmed there was no nursing documentation in chart on 2/27/16, the day of the fall. Staff C reported the nurse on duty should have written a progress note related to the fall. Staff C further reported the nurse who was present at the time of the fall worked the following day on 2/28/16, however, did not document in the resident's chart that day either. RESIDENT #2 Observations on 3/30/16 at 8: 51 a.m., revealed Resident #2 sitting in her wheelchair near the nurse station. Resident #2 had a light brown colored bruise that covered most of her forehead and extended over her right eye and down onto her right cheek. Review of the facility incident investigation revealed Resident #2 had fallen on 3/5/16 at 1:59 a.m., striking her face on the floor. The investigation indicated Resident #2 was sent to the emergency room . During an interview on 4/1/16 at 10:13 a.m. Staff C reported staff may not have completed neurological checks on Resident #2 since she had been to the emergency room and had tests that were negative for bleeding in her head. Staff C confirmed facility staff should still complete alert charting for Resident #2, which would mean documenting the resident's status in the progress notes every shift for 72 hours. Review of nursing progress notes revealed a nursing progress note dated 3/5/16 at 3:17 p.m., (evening shift) indicating that Resident #2 had returned from the emergency room at 9:00 a.m. on day shift. Further review of the progress notes revealed there was not a nursing note documented for the 3/5/16 to 3/6/16 night shift. Additionally, there was no nursing progress notes documented for 3/6/16 evening shift, and no nursing progress notes documented for the night shift from 3/6/16 to 3/7/16. During an interview on 3/30/16 at 2:20 p.m., Staff C confirmed the alert charting following Resident #2's 3/5/16 fall was not complete. RESIDENT #3 Review of a facility investigation dated 3/6/16 at 1:30 p.m. revealed Resident #3 had reported to staff that she had been hit in the head. During an interview on 4/1/16 at 10:30 a.m., Staff N confirmed that Resident #3 had reported somebody had hit her on the head, however the resident was unsure of what she had been hit with. Staff N reported that Resident #3 stated she did not feel safe in the facility. Review of Resident #3's medical record revealed no documentation of the resident stating she had been hit, and no documentation related to the resident reporting she did not feel safe. Further review of the record revealed a late entry progress note dated 3/6/16 at 2:35 p.m. indicating Resident #3 had been assessed for pain. The computerized note was actually written on 3/31/16 at 2:36 p.m., after the surveyor had requested the incident investigation. Further review of the nursing progress notes revealed a late entry note dated 3/6/16 at 2:38 p.m. indicating that the DNS (Director of Nursing Services) had been in to see Resident #3. The computerized note was again written by Staff L on 3/31/16 at 2:43 p.m. During an interview on 4/1/16 at 10:15 a.m. Staff C reported that even though Staff L had written the late entry note for 3/6/16, neither Staff L or the DNS had been in the facility on 3/6/16. Additionally there were late entry progress notes dated 3/7/16 at 2:43 p.m. that were entered into the computer system on 3/31/16 at 2:45 p.m. and a late entry note dated 3/8/16 at 10:45 a.m., which was not entered into the computer system until 3/31/16 at 2:47 p.m. Following Resident #3's report of being physically hit and being fearful of being in the facility, there were not any progress notes to evidence she was being monitored for latent injury and/or psychological harm until 3/31/16, after the investigation into the matter had been requested by the state survey team. RESIDENT #4 Review of a facility incident investigation dated 3/6/16 at 9:30 p.m. revealed Resident #4 was found sitting on the floor in his room after an apparent unwitnessed fall. During an interview on 4/1/16 at 10:13 a.m. Staff C reported staff are to complete neurological assessments on residents after any unwitnessed fall in order to rule out a head injury. Review of the facility's neurological flowsheet revealed instructions to staff to complete vital signs assessments, assess pupils, eye opening, verbal response, motor response, and hand grips at the following intervals: every 15 minutes four times, then every 30 minutes four times, then every hour four times, then every 4 hours four times, making 16 total assessments. Review of Resident #4's neurological flowsheet dated 3/6/16 revealed the first four assessments had been completed. The next two assessments, scheduled at 10:30 p.m. and 11:00 p.m. had been left blank. Assessments scheduled for 3/6/16 at midnight, 3/7/16 at 1:00 a.m., 2:00 a.m., 3:00 a.m., and 4:00 a.m. all had a written noted indicating Resident #4 was asleep and there were no assessments documented in those time slots. The neurological flowsheet did not have documentation between 10:00 p.m. and 11:30 p.m. on 3/6/16 and did not have documentation between 11:30 p.m. on 3/6/16 and 8:00 a.m. on 3/7/16, more than 8 and a half hour. During the first eleven hours of monitoring, 10 hours were not documented as directed on the flow sheet. During an interview on 4/1/16 at 11:55 a.m., Staff C confirmed that Resident #4 should have been woken up by staff to ensure he had not declined during the time frame. Staff C confirmed that part of the neurological assessment includes ensuring the resident can be aroused from sleep easily and that the resident was not assessed correctly. RESIDENT #5 Review of a facility incident investigation dated 3/1/16 at 4:40 p.m., revealed Resident #5 was being assisted by staff to move up in bed. While assisting the resident staff slid him too high on the bed, bumping his head, causing an incision to open and the resident had a moderate amount of bleeding. Review of Resident #4's medical record revealed there was not documented nursing notes to evidence alert charting had been done during the 72 hours after the incident. Following the incident on 3/1/16 the evening shift nursing note dated 3/1/16 at 2:37 p.m. was entered into the computer by Staff L on 3/31/16 at 11:11 a.m.; after the state survey team had requested the investigation. Further review of the nursing progress notes revealed the next shift was for night shift and was dated 3/2/16 at 2:38 a.m. Further review of the note revealed it was not entered into the computer until 3/3/16 at 2:49 a.m. The day shift note dated 3/2/16 at 11:14 a.m. was entered into the computer on 3/31/16 at 11:15 a.m. The following note for evening shift dated 3/2/16 at 2:40 p.m. had been also been entered into the computer on 3/31/16. There was no nursing progress note for night shift on 3/2/16 to 3/3/16. The next nursing progress note was dated 3/3/16 at 4:17 p.m. had actually been entered into the computer by Staff L on 3/31/16 at 11:18 a.m. Additionally, Staff L documented a nursing progress note dated 3/4/16 at 11:19 a.m. on 3/31/16 at 11:19 a.m. During an interview on 4/1/16 at 10:15 a.m. Staff C reported alert charting should be done by nursing staff every shift for three days (three shifts document for three days). Of the nine nursing progress notes that should have been completed after Resident #5's incident, two notes were missing, and five were not entered until 3/31/16, three weeks after in the incident. During an interview on 4/1/16 at 2:45 p.m. Staff L confirmed she had written in all of the late entries because they had not been done during the 72 hours after the incident. Staff L confirmed she was not at the facility during all of the times of the late entries, but that she had gathered the documented information from other sources. RESIDENT #6 Review of facility incident investigation dated 2/21/16 at 2:30 a.m., revealed Resident #6 had fallen in his room suffering a broken hip, and broken left and right collar bones. Review of a written statement dated 2/21/16 revealed Staff T reported finding Resident #6 on the floor in his room after an unwitnessed fall. Review of Resident #6's medical record revealed no neurological flowsheet. During an interview on 4/1/16 at 10:15 a.m., Staff C reported neurological assessments were to be done after any unwitnessed fall. During an interview on 4/5/16 at 4:40 p.m. Staff C confirmed neurological assessments should have been complete following the fall on 2/21/16 and should be documented on a neurological flow sheet, however she could not locate one in Resident #6's record. RESIDENT #7 Review of facility incident investigation dated 1/2/16 at 11:05 p.m., indicated Resident #7 had an unwitnessed fall. Review of Resident #7's medical record revealed the nursing progress note dated 1/2/16 at 6:00 p.m., that documented the fall was not entered into the computer until a week later on 1/9/16 at 3:27 a.m. During an interview on 4/1/16 at 10:13 a.m., Staff C reported after a fall nursing staff should place the resident on alert charting notice meaning nursing should document the resident's condition every shift for 72 hours (three shifts for three days, making nine entries). Review of Resident #7's nursing progress notes after his fall on 1/2/16 on night shift revealed the first alert charting dated on the day shift 1/3/16 at 1:25 p.m. was not entered into the computer until 1/8/16 at 4:25 p.m., five days later. The following note for evening shift dated 1/3/16 at 5:00 p.m. was entered into the computer on 1/7/16 at 10:09 p.m. The night shift alert note dated 1/4/16 at 5:40 a.m. was entered into the computer a week later on 1/10/16 at 9:46 a.m. Review of progress notes for evening shift dated on 1/4/16 at 8:02 p.m. revealed the note was not entered until 1/9/16 at 1:14 p.m. Further review of 1/4/16 progress notes revealed no documentation by the night shift nurse from the start of shift on 1/4/16 to the end of shift on 1/5/16. Review of progress notes for the third day of alert charting revealed the day shift note dated 1/5/16 at 2:00 p.m. was not entered into the computer until 1/8/16 at 2:45 p.m. and they night shift nurse did not document from the beginning of the shift on 1/5/16 to the end of the shift on 1/6/15. Of the nine alert charting notes that should have been entered following Resident #7's fall, two were missing and five were entered later than the 72 hour window, leaving only two notes documented per the facility standard. Failure to monitor residents after an incident placed residents as risk for delay in identification of decline, latent injury and/or psychological distress. This delay placed residents at risk for delayed treatment for [REDACTED].

Based on observation, interview and record review, it was determined that the facility failed to implement interventions consistent with the resident's needs and failed to monitor and evaluate the impact of the interventions; and/or revise the interventions as appropriate for 1 of 2 Sampled Residents (#170) who were included in the Stage 2 review. This failure caused harm to Residents #170 when the Resident developed a pressure sore after admission. Findings include: Resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the facility's braden scale dated 3/29/13 and 4/7/13 documented the resident had a score of 18 which indicated the resident was at risk for pressure sores. Review of the admission nursing assessment dated [DATE] revealed the resident did not have any pressure ulcers on admit to the facility. The care plan dated 4/24/13 revealed the resident had an ADL Self Care Performance Deficit related to weakness and pain. The care plan intervention documented the resident required extensive assist with activities of daily living, including transfers, toileting, and bed mobility. Further review revealed a care plan dated 4/24/13 documented the resident had alteration in endocrine status related to diabetes. The care plan intervention directed staff to check all body areas for breaks in skin and treat promptly, and to inspect feet daily for open areas, sores, pressure areas, blisters, [MEDICAL CONDITION] or redness. Review of the record revealed weekly skin assessments were completed for all weeks except April 26, 2013, and there was no documented evidence to show that daily inspections of the feet had been completed. Record review revealed the resident was noted to have a Stage II pressure sore (Partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister) to the right heel on 4/14/13 with the following measurements: 4/14/13-Stage II, 3x2 centimeters 4/18/13-Stage II, 2.8x3.0 centimeters 4/25/13-Stage II, 4x2 centimeters 5/2/13-unable to determine (Pressure ulcer is known but not stageable due to non-removable dressing/device or due to the coverage of the wound bed by slough or eschar), 2.8x3.5 centimeters 5/9/13- unable to determine, 3.0x3.0 centimeters 5/16/13-unable to determine, 2.0x3.4 centimeters The March, 2013 and April, 2013 treatment record directed staff to float heels on pillows while in bed. A physician's orders [REDACTED]. A physician's orders [REDACTED]. During an interview on 5/21/13 at 10:33 a.m., the resident stated staff gave her the boots and told her to wear them. During the interview the resident pointed to the corner of her room, and the boots were observed to be on the floor in a corner behind a chair. The resident stated she stopped wearing the boots, and was never told to stop or to continue wearing the boots. Observations on 5/15/ at 10:57 a.m., 5/20 at 8:30 a.m., and 5/21/13 at 10:33 a.m., revealed the resident did not have her heels floated. The resident's heels were noted to rest directly on the mattress on all observations. Observation of Resident #170's right heel on 5/20/13 at 8:50 a.m., with Staff S revealed 2x3 centimeter black eschar to the right heel and heels were not floated. During observation with staff S the resident reported she was unable to keep her feet on the pillows because of how she is positioned in bed. The Resident stated she was unable to put her feet on the blue booster because her legs hurt and asked Staff S for assistance. The nurse assisted the resident to place her feet on the blue heel left, and told the resident to keep her feet on the lift to prevent further breakdown and to assist with healing. On 5/20/13 at 9:05 a.m., during an interview, Staff S stated the resident does not keep her heels floated. Staff S stated staff would assist the resident with floating her heels and if one would check 10 minutes later her heels would not be floated. When asked what is done when residents are unable to keep their heels floated, Staff S stated skin prep is applied. Review of the treatment administration record revealed skin prep was not applied until 4/16/13, two days after the resident was noted to have a stage II pressure sore to her right heel. A physician's orders [REDACTED]. On 5/20/13 at 8:30 a.m., during an interview, Resident #170 reported she has a big blue thing at the end of the bed that she is supposed to keep her feet on, but it would fall off in the middle of the night. The resident stated she told staff she was unable to keep her feet on the pillow and was told to try her best. On 5/20/13 at approximately 10:30 a.m., during an interview, the resident care manager (Staff H) confirmed that skin prep should have been initiated when the resident admitted to the facility. When asked if an assessment was done to determine why the resident was not keeping her heels floated, Staff H said no. When asked if risk and benefits were explained to the resident in regards to keeping her heels floated, Staff H said no. When asked what interventions were put in place prior to the resident sustaining a Stage II pressure ulcer, Staff H shook her head and said nothing other than to float heels. During the same interview Staff H stated when the resident first admitted she was very immobile and required extensive assist with bed mobility and transfers, and reported the resident was a little forgetful. The resident admitted to the facility on [DATE] with orders to float heels on pillows while in bed. Staff were aware the resident did not float heels on the pillow. On 4/14/13 the resident was noted to have a Stage II pressure sore to the right heel. On 4/16/13 staff began to apply skin prep, 20 days after admission. Staff confirmed skin prep should have been initiated on admit. A physician's orders [REDACTED]. On 5/2/13 documentation revealed an unstageable pressure sore to the right heel. A physician's orders [REDACTED]. The plan of care continued to direct staff to float the resident's heels as an intervention. Staff failed to reassess and revise the plan of care although they had knowledge of the resident's inability to float heels. The facility failed to provide appropriate treatment and care which caused harm to Resident #170 who developed a pressure sore.

Based on record review and interview, the facility failed to ensure drug regimens were free of unnecessary drugs for 4 of 6 residents (Residents #5, 6, 7 & Former Resident #1) reviewed for use of anti-anxiety medications. The facility failed to ensure unnecessary use of medications for Residents #1, 5, 6 & 7 related to lack of identification of non-drug interventions for staff to use before administering anti-anxiety medications and inconsistent monitoring of behaviors. The facility also failed to ensure unnecessary use of multiple medications given to Former Resident #1 who received pain medication and anti-anxiety medication together. This failure resulted in harm to former Resident #1 who had a decreased level of consciousness that required emergency treatment to counteract the sedation and hospitalization for ongoing treatment. Findings include: USE OF MULTIPLE DRUG: Review of Resident #1's hospital emergency room record dated 7/27/12 revealed ambulance staff documented a blood pressure of 100/50, pulse 110, respirations 24 upon arrival in the facility. [MEDICATION NAME] (a medication to counteract narcotic effect) was given twice in the facility. The resident required additional doses of [MEDICATION NAME] in the emergency room and subsequently received a [MEDICATION NAME] intravenous drip. The hospital report described the resident as somnolent and sedated and responsive to sternal rub. The resident admitted to the hospital with [REDACTED]. Review of Resident #1's facility record revealed admission medication orders, in part, dated 7/16/12 for [MEDICATION NAME] 0.5 milligrams (mg) every six hours as needed for anxiety and [MEDICATION NAME] 2 mg every 6 hours for pain (level 6-10). Review of a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 7/26/12, documentation on the MAR indicated resident states anxiety" and "generalized pain". Review of an interview statement (undated) written by the nurse caring for the resident during the evening on 7/26/12 (Staff B) revealed as she was going to the medication cart to get pain medication for Resident #1 another nurse told her to give the resident both [MEDICATION NAME] and [MEDICATION NAME]. Staff B indicated the resident had reported the pain to her and the resident was definitely anxious; therefore, she gave both medications. During interview on 8/15/12 at 3:20 p.m., Staff G (licensed nurse) stated in general she would not administer pain and anti-anxiety medications together because it would be difficult to monitor effectiveness of the medications. She stated she would treat the pain symptom first, because the pain might be causing anxiety; then reassess the resident and if the resident remained anxious, consider giving an anti-anxiety medication after trying non-drug interventions. Interview with Former Resident #1 on 8/3/12 revealed she did not recall much after receiving the medications about 8:00 p.m. the evening of July 26th. She recalled being sleepy after taking the medications and stated "I was out". Resident #1 did not recall why she received the medications and did not recall asking for them. During interview on 8/3/12, a resident advocate described the resident as difficult to awaken on the morning of 7/27/12 and was told by staff that there was [MEDICAL CONDITION] going around and maybe that was the cause. The advocate returned during the afternoon and found the resident still not responding and with a low blood pressure. An ambulance was subsequently called. The resident advocate stated the resident seemed her usual self, awake and alert, during the day on 7/26 and during the evening of 7/26, prior to receiving the medication. IDENTIFICATION OF NON-DRUG INTERVENTIONS/ BEHAVIOR MONITORING Review of facility policy and procedure "Psychoactive Drug Management System" dated April 2007, revealed, in part, under Practice Guidelines, nursing documentation will include the resident's specific medical condition, and/or target behaviors and interventions. The behavior monitoring flow sheet will be instituted and documented each shift. Documentation will include the number of behavior episodes, the intervention attempted, the outcome of the intervention and any side effects of the intervention. 1. For Former Resident #1 and current Residents # 5, 6 & 7, record review revealed the following: Individualized non-drug interventions were not identified for each of the above residents. Behavior monitoring for each of the above residents was inconsistently documented from day to day and shift to shift. 2. Review of a Behavior Monitor revealed staff identified Former Resident #1's target behaviors for anxiety as "anxious statements" and "agitation" Review of Resident #1's MAR indicated increased anxiety and cannot sleep". Review of the Behavior Monitor dated 7/24/12 revealed there was no evidence of behaviors identified related to how the anxiety was manifested and no evidence of interventions attempted prior to giving the medication. 3. Review of Resident #7's Behavior Monitor dated 7/2012 revealed staff identified target behaviors of "anxious statements" and "shortness of breath" as indicators of anxiety for the resident. Documentation on the MAR indicated [REDACTED]& 9:00 p.m. respectively for "increased anxiety". There were no target behaviors identified that showed how the anxiety was manifested and no evidence of interventions attempted prior to medicating the resident. Review of Resident #7's Behavior Monitor dated 8/2012 revealed there were no target behaviors identified for monitoring; however, staff documented a number of episodes of behaviors on some shifts without a corresponding identified behavior. Interview with Staff D (licensed nurse) on 8/14/12 at 1:45 p.m. revealed she did not know why there were no target behaviors identified. Staff D stated facility policy was to identify behaviors, monitor them, and try interventions before giving medications. 4. Review of Resident #5's Behavior Monitor dated August 2012 revealed target behaviors for anxiety were identified as "agitation" and "expressed worry". Review of the MAR indicated anxiety". There were no target behaviors identified that showed how the anxiety was manifested and no evidence of interventions attempted prior to medicating the resident. 5. Review of Resident #6's Behavior Monitor dated 8/2012 revealed target behaviors for anxiety documented as "restlessness" and "expressed anxiety". Review of the MAR indicated [REDACTED]. There was not a time documented for when the medication was given, no target behaviors identified that showed how the anxiety was manifested and no evidence of interventions attempted prior to medicating the resident. Interviews with Staff C (licensed nurse) and Staff E (care manager) on 8/14/12 at 1:20 p.m. and 1:45 p.m. respectively confirmed the facility's policy included identification of target behaviors and non-drug interventions and monitoring of behaviors for residents on psychoactive medications including anti-anxiety medications. Interview with Staff F (social service director) on 8/14/12 at 3:10 p.m. revealed social service staff was responsible for identifying the target behaviors, interventions, and implementing the behavior monitor flow sheet.

Based on observations, record review and interview, the facility failed to provide adequate supervision to prevent accidents and to ensure use of an assistive device during a transfer of 1 of 6 residents (#1) reviewed for falls. Harm occurred when Resident #1 fell during a transfer and sustained a fractured ankle. Therapy staff failed to use an assistive device (gait belt) during the transfer. Findings include: Observations of Resident #1 on 8/17/11 at 7:35 a.m. revealed the resident lying in bed with her lower left leg in a cast, elevated on a pillow. Resident #1 recalled falling in the bathroom when Staff B (occupational therapy assistant) was helping her learn to transfer to the toilet. Resident #1 stated her legs got weak and "just buckled" and she thought she ended up sitting down on her ankle. The resident indicated her ankle was broken in two places and she has since had surgery. She thought her legs were weak because of her increasing use of a wheel chair at home due to frequent falls and her left leg was weaker from having a recent stroke. The resident stated the staff did not have a belt on her during the transfer. During telephone interview on 8/17/11 at 2:00 p.m., Staff B confirmed she did not have a gait belt on Resident #1 at the time of the fall. Staff B stated she was aware of the therapy policy that required use of a belt whenever a resident was going to stand or transfer from one surface to another. Interview with Staff C (therapy manager) on 8/18/11 at 1:20 p.m. revealed confirmation of the policy/requirement for staff to use a gait belt as described above. Staff C confirmed the policy was in effect at the time of the incident. Review of the facility ' s investigation dated 7/28/11 confirmed the facility concluded Staff B did not follow therapy policy dated 2/2008 which resulted in the resident's fall.

Based on record review and interview, the facility failed to ensure 1 of 6 residents (#1) was allowed to exercise his right to choose health care interventions consistent with his interests and assessments. Resident #1 experienced ongoing bladder spasms and pain during a six hour time period in which the resident requested transfer to the hospital for evaluation of symptoms previously known to the resident as those of a bladder infection. Actual harm was identified for Resident #1 related to the ongoing pain and emotional distress the resident experienced while waiting in the facility for hospital evaluation which confirmed the resident had a complicated urinary tract infection. Findings include: Record review revealed Resident #1 admitted to the facility during 11/2009 with multiple medical [DIAGNOSES REDACTED]. Resident #1 had a continuous urinary catheter due to an enlarged prostate. During interview on 4/26/11 at 1:30 p.m., Resident #1 recalled the events from the night shift on 3/13/11. He stated he let staff know he was not feeling well and thought he had a bladder infection. The resident stated that was what brought him to the nursing home in the first place (referring to a bladder infection) and he knew what it felt like. He felt a lot of pain and spasms in his bladder during the night. "They kept giving me pain pills and telling me to wait and see if it would get better, but it wasn't getting any better. A night nurse told me I had to wait until the day supervisor came in to send me to the hospital. I didn't think it was right for a person to be suffering and not be allowed to go to the hospital; I knew I needed to go". Review of Resident #1's hospital record revealed [DIAGNOSES REDACTED]. The resident also received intravenous pain medication while in the emergency room . Review of a facility investigation dated 4/14/11 revealed the facility interviewed Resident #1 on 4/15/11. Resident #1 confirmed having bladder spasms and pain most of the night, asked to go to the hospital and was told by Staff A he would have to wait until the day supervisor came in. Resident #1 stated he felt Staff A should have sent him to the hospital or done more to get him there. Facility investigation included interviews with other staff working on the night shift on 3/13/11 that confirmed Resident #1 complained about pain and bladder spasms. Review of a testimonial statement by a licensed nurse also on duty that night revealed she conferred with Staff A at 3:00 a.m., assessed the resident, and told Staff A to call the physician about the resident's symptoms. The licensed nurse checked with Staff A at approximately 5:00 a.m. to see if he had called the physician; Staff A stated he was taking care of it. Investigation revealed the day supervisor arrived at the facility on 3/13/11 between 7:30 and 8:00 a.m. at which time the physician had not yet been notified and the resident's pain was not under control. The day supervisor contacted the physician and obtained orders to send the resident to the hospital for evaluation.