Every finding on record at Linden Post Acute

Based on observation, interview and record review the facility failed to ensure staff followed infection control standards of practice regarding implementation of personal protective equipment (PPE, protective equipment designed to safeguard individuals and reduce the risk of contracting or spreading infectious diseases) with residents on Transmission Base Precautions (TBP, safeguards within a room or facility that are put in place to help prevent the spread of diseases) to mitigate the spread of COVID-19 for 5 of 5 staff (Staff I, P, Q, J and K), reviewed for infection control practices. This failure placed residents, staff, and visitors at an increased risk of exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases during a COVID-19 outbreak. Findings included . Review of the Center for Disease Control and Prevention (CDC) COVID-19 guidelines titled, Infection Control Guidance: SARS-COV-2, updated 06/24/2024, showed that facilities with confirmed or suspected COVID-19 should consider implementing source control measures (a respirator/mask that covers an individual's face to prevent the spread of respiratory infections) which included the option of a NIOSH (National Institute for Occupational Safety and Health)-approved N95 (a specific fitted type of mask used against COVID-19) respirator to be worn throughout the whole facility. For staff entering a COVID-19 positive resident room, they should put on a N95 fitted respirator, a gown, gloves and eye protection (like goggles or a face shield). Review of CDC NIOSH PPE respirators guidance titled, Fit Testing, dated 02/03/2025 showed that a fit test (a testing protocol conducted to verify that a respirator provides the user with the expected protection from infectious contaminants) confirmed that a respirator formed a tight seal to an individual's face before being utilized in a workplace environment. The guidance showed that fit testing was important to ensure the expected level of protection was provided by minimizing the amount of contaminated air (like how COVID-19 can be spread) leaked into the respirator facepiece through the face seal and the specific size/model of respirator was an acceptable fit for the individual tested. Additionally, the CDC's guidance showed that facial hair could impact the N95 respirator tight facepiece seal since a proper respirator fit required an individual's face to be clean shaven at the edges of the facepiece where the seal contacted the skin. Review of the facility's policy titled, COVID-19 Using PPE, dated 01/30/2025, showed that all staff were to follow TBP when care for a resident with suspected or confirmed COVID-19 infection. The policy stated that all staff entering a COVID-19 positive room were to use an approved N95 respirator, gown, gloves and eye protection. Additionally, the policy stated that when staff were entering a COVID positive room, .a clean isolation gown is donned (to put on) upon entry into the resident room or area . During an interview on 11/17/2025 at 9:30 AM, Staff B, Director of Nursing (DON), stated the facility had multiple staff and residents that had tested positive for COVID-19 earlier on 11/17/2025. Staff B stated they had implemented facility wide N95 respirators with staff throughout the facility. Review of the facility's documented infection reporting communication, dated 11/17/2025 showed that six facility staff and eight residents were COVID-19 positive, the facility was implementing testing, and all staff were wearing N95 respirators for exposure control (a process to minimize the risk employee/resident exposure to potential infectious diseases). During an observation and interview on 11/17/2025 at 12:38 PM, showed Staff I, Nursing Assistant (NA), wearing an N95 respirator with the head straps cut and tied into a knot behind their ears. Staff I stated they had cut the straps and tied behind their ears because it made them feel better. Staff I proceeded to enter a COVID-19 resident room with signage posted for entering for staff to wear an N95 respirator, eye protection, gown and gloves. Upon entering the COVID-19 resident room, Staff I placed a second N95 respirator that was hanging on the resident's closet door, donned a yellow gown and face shield that was hanging on a used disposable biohazard container. Staff I stated they preferred to wear two N95 respirators and kept these items in the resident COVID-19 rooms. During an observation on 11/17/2025 at 12:50 PM showed Staff P, NA, was wearing a purple mask that was not an N95 respirator while working on the East/West side resident hallways and Staff Q, Licensed Practical Nurse (LPN) wearing a BYD DE2322 (a specific brand/type of N95 respirator) respirator while caring for residents on the East hallway. Review of the facility's annual staff N95 fit-testing records showed that Staff P was fit-tested on [DATE] for a 3M 1860 (a specific brand/type of N95 respirator) and the BYD DE2322 respirator. The records showed that Staff Q was fit-tested on [DATE] for the 3M 9205 (a specific brand/type of N95 respirator) respirator. During an observation on 11/19/2025 at 8:32 AM, showed Staff J, Attending Provider, enter a COVID-19 resident room while wearing an N95 respirator. Staff J had a beard that protruded two inches from the mask, not creating a seal to the face. At 9:00 AM, Staff J stated they would never shave their beard and the N95 did not form a seal around their face as it should. Staff J stated this was not the correct process for wearing an N95 respirator. During a concurrent observation and interview on 11/19/2025 at 9:03 AM, Staff F, Registered Nurse, was performing COVID-19 testing on facility residents. Staff F was observed with an N95 respirator in place over a full faced beard that was crossing under the edges of the respirators seal prior to entering a resident room, then donned a gown and gloves. Staff F stated they were going to wear an N95 respirator and full PPE (gown, gloves, mask and eye protection) because they were testing a resident who could be COVID-19 positive but would keep the same N95 respirator throughout testing. Staff F was observed entering and exiting four different resident rooms with their N95 respirator, gown, gloves but did not wear eye protection while the testing was performed. At 9:54 AM Staff F stated that one out of the four residents were positive for COVID-19. During a follow-up interview on 11/19/2025 at 10:00 AM, Staff F stated they did not have their full beard when they were originally fit-tested for the N95 respirator and that they currently did not have a tight facepiece seal with the current full faced beard they had. During an observation on 11/19/2025 at 11:47 AM, showed Staff K, LPN, obtain a face shield hanging on the back of a medication cart, put on their head and cover their face and enter a COVID-19 resident room. Staff K, then exited the room after removing their gloves and gown, carried the face shield from the room and used a sanitizer wipe and rehang on the back of the medication cart. During an observation and concurrent interview on 11/20/2025 at 12:32 PM, showed Staff K exit a COVID-19 resident room, removed gown and gloves and carried the used face shield down the hall and wiped with a sanitizer cloth and hung on the back of the medication cart. Staff K stated they had no reason why they reused the face shields. During an interview on 11/20/2025 at 3:37 PM, Staff L, Infection Control Nurse, stated when staff entered a COVID-19 resident room, staff were to be donning N95 respirator, gowns, gloves and face shields. Staff L stated staff were to place a new N95 respirator on and face shields with foam and fabric were single use and were to be disposed after use. During an interview on 10/21/2025 at 10:45 AM, Staff A, Administrator, stated the facility had enough PPE and staff were not to reuse any disposable PPE. During an interview on 11/19/2025 at 10:17 AM, Staff B, DON and Staff A, Administrator, stated the process for COVID-19 testing was the same with entering a COVID-19 positive room and staff were required to wear full PPE with a fit-tested N95 respirator, gown, gloves and eye protection. Both staff stated that Staff F had not shaved their full faced beard for religious reasons and should not have been tasked with testing residents for COVID-19 when they were unable to be correctly fit-tested for the N95 respirator. Staff B stated that they would have expected the staff member to wear eye protection when testing residents for COVID-19. Additionally, Staff B stated that facility wide implementation of N95 respirator was implemented for Staff who were entering a COVID positive room but also as exposure control, due to the number of Staff members that were becoming positive and to reduce the risk of cross contamination of the COVID-19 virus. Both staff stated the correct process for staff implementation of PPE was not followed. Reference: WAC 388-97-1320(1)(a)(2)(b)

Based on interview and record review the facility failed to ensure the notification to the resident's representative (RR) of changes in the resident's mental/psychosocial status (the impact on an individual's emotional, social and environmental factors affecting their mental health and well-being) and/or the need to alter treatment for 1 of 2 residents (Resident 61) reviewed for notification of changes. This failure placed the resident at risk of not having their RR involved in the health care decision making process and increased the risk of the RR from making an informed decision regarding the resident's care. Findings included .Resident 61Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnosis including a stroke (when blood supply to the brain is blocked or reduced), dysphagia (difficulty swallowing) following the stroke, apraxia (the inability to perform purposeful movement or gestures leading to difficulties with things such as dressing and grooming), dementia (a loss of thinking, remembering, and reasoning skills) with behavioral disturbances (a pattern of disruptive behaviors that can significantly impact an individual's daily life and social interactions), mixed receptive (difficulty understanding spoken or written language)/expressive language disorder (affects the ability to express thoughts, ideas and feeling through speech and writing) and depression. The 10/24/2025 and 10/27/2025 comprehensive assessments showed the resident had a severely impaired cognition along with being administered a psychotropic medication (medications capable of affecting the mind, emotions, and behavior). Review Resident 61's legal guardianship (a legal process that allows a designated person to make decisions for an adult that has lost the capacity to make decisions independently) document, dated 10/17/2024, showed the RR was appointed as Resident 61's guardian and would make decisions on consenting to or refusing medical treatment on the resident's behalf. Record review of Resident 61's elopement (an instance where a resident leaves a safe environment without the facility's awareness, authorization and/or necessary supervision to do so) risk assessment, dated 12/23/2024, showed the resident was a high risk for elopement from the facility due to the resident being cognitively impaired with poor decision-making skills, the risk of getting to an unsafe place, changes in behaviors/new medications, and medical diagnoses of dementia/cognitive impairments. Review of Resident 61's October 2024 through December 2024 physicians orders showed: On 10/19/2024 Seroquel (a specific type of psychotropic medication) 25 milligrams (mg, a unit of measure), administered two times a day, was started for the resident's dementia with behavioral disturbances (no documentation showing education to the RR on the risks/benefits of the medication, nor the opportunity to accept or decline the medication based off that information). On 11/27/2024 Trazadone (a specific type of psychotropic medication) 50 mg, one-time a day at bedtime, was started for .agitation/behavior/unable to sleep. On 12/20/2024 a one-time dose of Seroquel was administered to Resident 61 for behaviors, exit seeking (attempts by a confused individual to leave a safe environment or facility) and agitation. On 12/20/2024 the resident's Trazadone medication dose increased to 100 mg, one-time a day at bedtime for an altered mental state (various changes in an individual's mental functioning, including confusion, disorientation and/or changes in awareness), agitation, behaviors and unable to sleep. On 12/21/2024 Seroquel 25 mg, as needed, every 12 hours started. Review of Resident 61's progress notes showed: On 12/19/2024 at 12:05 PM, nursing staff received orders from the provider to discontinue the resident's Seroquel medication (No documentation of the RR being notified of the need to alter the resident's medication treatment). On 12/19/2024 at 9:04 PM, nursing staff reported to the provider the resident's continued behaviors of agitation, aggression and received orders to increase Trazadone medications (no documentation of the RR being notified of the need to alter the resident's medication treatment). On 12/20/2024 at 6:40 PM, Resident 61 was noted to be .very agitated, angry, exit seeking , was getting more aggressive and shaking of their body with anger. The nursing staff contacted the provider and received a one-time order to administer Seroquel 25 mg (no documentation of communication to RR on Resident 61's change in status nor the need to alter the resident's medication treatment). On 12/21/2024 at 1:29 PM, staff noted that in the morning, Resident 61 was standing at the facility's front door with their belongings, stating they were going to be leaving the facility. The note showed that when staff attempted to communicate with the resident, they became agitated, angry and staff were unable to redirect. The provider was contacted and orders received for Seroquel 25mg as needed for Residents behaviors (no documentation of communication to RR on Resident 61's behaviors nor the need to alter the resident's medication treatment). On 01/02/2025 nursing staff noted Resident 61 agitated, confused, getting upset with someone over the phone and wanted to leave the facility. Later that day nursing staff noted the provider had seen Resident 61 and orders to increase the resident's morning Seroquel medication dose (no documentation of communication to RR on medication changes). On 05/08/2025 Resident 61 was noted to be outside in the facility's parking lot with other residents from the facility and was educated on it not safe for the resident to go outside (no documentation of communication to RR). On 09/10/2025 staff noted the resident disliked the food in the facility and .prefers to eat out everyday . Review of the resident's June 2025 through October 2025, Sign in/out sheet, showed that facility staff allowed Resident 61 to sign themselves out of the facility on 17 separate occasions, without facility staff supervision and with another resident from the facility to eat at a restaurant (No documentation of the RR being notified that Resident 61 was being allowed to leave the facility without staff supervision). During an interview on 11/20/2025 at 2:05 PM, RR stated they were appointed as Resident 61's guardian since admission and had not received notification from facility staff on altering/changing medication or treatments regarding the resident's psychotropic medications, .maybe one time. The RR stated they had remembered one time that the facility staff talked with RR about Trazadone but was not aware of the multiple medication changes throughout the resident's stay at the facility. The RR stated that Resident 61 had been cognitively impaired with dementia, confusion and not able to make decision for themselves since they were admitted . The RR was concerned with Resident 61 leaving the facility without facility staff supervision and did not get any notification/communication from the facility on Resident 61 going outside the facility with other residents until 11/15/2025 when Resident 61 had an elopement from the facility. During an interview on 11/20/2025 at 3:40 PM, Staff A, Administrator, Staff B, Director of Nursing and Staff M, Social Services Director, stated that prior the Resident 61 eloping from the facility on 11/15/2025 they were leaving the facility with friends that were on the resident's contact list. During an interview on 11/21/2025 at 8:51 AM, Staff E, Licensed Practical Nurse/Resident Care Manager, stated that Resident 61 was cognitively impaired since they were admitted into the facility and not able to make their own care decisions. Staff E stated the resident had an RR who was the guardian that would make decisions for the resident. Staff E stated they did not recall the resident leaving the facility without staff supervision. Staff E stated that due to Resident 61s cognitive impairments, confusion, dementia diagnosis and behaviors the resident would need to be accompanied by staff or family for the resident to leave the facility on an outing. During an interview on 11/21/2025 at 11:31 AM, Staff A and Staff B reviewed the June 2025 through October 2025 resident sign in/out sheets with the surveyor and stated that Resident 61 would leave the facility with other facility residents prior to Resident 61 eloping. Both staff stated that Resident 61 was had severe cognitive impairments, was confusion, had a dementia diagnosis with behavioral disturbances and was on psychotropic medications. Staff A and Staff B stated the resident had incidents of escalated behaviors and when the resident would talk with one of the other residents in the facility it would calm Resident 61 down. Staff A stated that since it helped with Resident 61's de-escalation in behaviors they let Resident 61 leave the facility with another of the facility's resident/friend to eat at a restaurant. Staff A stated that no staff supervision was implemented when Resident 61 would sign themself out of the facility. Staff A stated they did not notify the RR/guardian about Resident 61's outings nor the facility's attending provider. Staff B stated that after Resident 61 eloped/contacted the RR, Resident 61 was no longer allowed to leave the facility unsupervised. Staff A and Staff B stated the correct process was not followed and the RR should have been notified of the changes in the resident's mental/psychosocial status and the need to alter Resident 61's treatment/commence a new form of treatment. Reference: WAC 388-97-0320(1)(a)(c)

Based on interview and record review the facility failed to have a system in place to ensure Residents were aware of how to file a grievance (a formal complaint by a resident or resident representative [RR]) and who the facility's Grievance officer was, these concerns were voiced in Resident Council (a formal meeting for facility residents to communicate preferences and concerns) for 3 of 5 residents (Resident 26, 39, and 75) who expressed they were unaware of how to file a grievance or who the facility Grievance Officer was. These failures placed residents at risk for overall dissatisfaction with their lives and unresolved concerns. Findings included .Record review of a facility policy titled Resident Grievance updated 08/01/2024 showed the facility supports each resident's right to voice concerns/ grievances verbally or in writing. Additionally, Social Services Director was responsible for overseeing the grievance process. On 11/19/2025 at 1:30 PM, Resident's 26, 39, 41, 54, and 75 attended Resident Council meeting. Resident 26 stated they had been in the facility for a while, and the Resident Council had a president and that the council met monthly. Resident 26 stated they did not know how to file a grievance or who the Grievance Officer was. Residents 39, and 75 stated they were also not sure how to file a grievance or who the facility Grievance Officer was. During an interview on 11/19/2025 at 2:23 PM, Staff N, Activities Director, stated they assisted the residents to organize monthly Resident Council meetings, reviewed the residents' rights and took minutes. Staff N further stated that if any concerns from the Resident Council meeting, they would document concern on the minutes, fill out a grievance form. Staff N stated they gave a copy to the Grievance officer, to the department heads to review and provide any follow-up as indicated. Staff N stated they were unaware that residents were unaware of how to file a grievance or who the grievance officer was. During an interview on 11/19/2025 at 2:35 PM, Staff M, Social Service Director, and Staff A, Administrator, stated they shared the grievances officer responsibilities. Staff A stated the resident grievance forms were located on a clip board next to the front door. An observation, accompanied by Staff A and Staff M, showed an empty clip board hanging five feet up on the wall where the Grievance forms were to be located. Staff A and Staff M stated the signs could be lowered so that residents could see and grab a Grievance form. During an interview on 11/21/2025 at 10:12 AM, Staff B, Director of Nursing, stated that she understood about Grievance forms and the process. Staff B stated they had educated staff about the Grievances process but had not educated the residents. Staff B stated education would be provided for residents to help residents understand the Grievance process and where to obtain the Grievance form. Reference WAC 388-97-0460

Based on observation, interview and record review the facility failed to develop comprehensive resident centered care plans for 2 of 6 residents (Residents 30 and 42) reviewed for care planning. This failure placed residents at risk for unmet care needs. Findings included .Resident 30 Review of the medical record showed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of a stroke (when blood supply to the brain is blocked or reduced) and obstructive sleep apnea (OSA, a condition in which an individual has repeated interruptions in breathing while sleep). The 06/07/2025 comprehensive assessment showed the resident had intact cognition, able to make their needs known and had a non-invasive mechanical ventilator (a device, like a CPAP machine, that utilizes pressure to force air/oxygen into an individual's lungs, through a mask to assist with breathing) device. A concurrent observation and interview on 11/17/2025 at 12:31 PM showed Resident 30's CPAP device on their bedside table. Resident 30 stated they were supposed to be using the CPAP device every night, but the facility staff were not filling up the canister anymore, and the resident could not remember the last time the device was cleaned. Review of Resident 30's current physician's orders showed that on 07/09/2025 an order had been started to Encourage resident to place CPAP mask every night for bedtime. No other orders were current regarding Resident 30's CPAP device. Review of Resident 30's care plan, last completed 09/09/2025, showed no resident focused goals or interventions related to their CPAP use. During an interview on 11/19/2025 at 4:09 PM, Staff L, Infection Control Nurse, stated they were also the case manager for Resident 30 and when reviewing the resident's care plan, did not see goals nor interventions that pertained to resident CPAP device use. Staff L stated that Resident 30's CPAP device should have been care planned and the correct process was not followed. During an interview on 11/21/2025 at 11:31 AM, Staff B, Director of Nursing (DON), stated the resident's care plan needed to include CPAP goals and interventions that pertained to resident specific care. Staff B stated the correct process was not followed and the care plan should have included the resident's CPAP device. Resident 42 Review of the medical record showed Resident 42 was admitted to the facility on [DATE] with diagnoses including morbid obesity (being 100 pounds or more overweight), OSA and anxiety. The 09/26/2025 comprehensive assessment showed Resident 42 required the assistance of one to two staff members for activities of daily living and had an intact cognition. Review of Resident 42's September 2025 Treatment Administration record (TAR) showed Resident 42 used a bilevel positive airway pressure [BiPAP) a device that aids breathing by delivering pressurized air through a mask or nasal plugs on the face). Review of Resident 42's care plan showed no resident focus areas, goals or interventions related to Resident 42's OSA and BiPAP use. During an observation and concurrent interview on 11/19/2025 at 4:24 PM, showed Resident 42 lying in their bed with a BiPAP on the nightstand. Resident 42 stated the BiPAP was brought from their home when they admitted to the facility. Resident 42 stated he did not know when it had last been serviced or if the settings were still correct for their use. During an interview on 11/21/2025 at 10:45 AM, Staff B, DON, stated resident care plans needed to include focus areas with goals and interventions that pertained to resident specific care. Staff B stated Resident 42's OSA and BiPAP should have been on their care plan. Reference: WAC 388-97-1020(1)(2)(a)

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure residents dependent on staff received consistent oral care and nail care for 3 of 3 residents (Residents 1, 3, and 42) reviewed for activities of daily living (ADLs) care provided for dependent residents. This failure to receive adequate, consistent grooming and oral care according to the residents' care plan placed the residents at risk for unmet care needs, impaired skin integrity, and embarrassment.Findings included .Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting revised, 03/2018, showed, residents who were unable to carry out ADLs independently would receive the services necessary to maintain grooming and personal and oral hygiene. Resident 1 Review of Resident 1's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include right leg fracture, chronic obstructive pulmonary disease (chronic lung disease that causes air to become trapped in the lungs, making it hard to breath), chronic pain, abnormal weight loss, dysphagia (difficulty swallowing), and repeated falls. Review of the comprehensive assessment showed Resident 1's cognition was moderately impaired and required substantial assistance with all care. Review of Resident 1's physician order dated 09/29/2025 showed Licensed Nurse to check fingernails and toenails once a week on bath day. Trim as needed, in the morning every Monday. During an interview and concurrent observation on 11/17/2025 at 3:03 PM, Resident 1 stated they had not had nail care done since their admission. Resident 1's fingernails were long, jagged with a yellow and dark brown substance underneath. The resident's toenails were long, jagged and curled inward towards their toes. During an interview on 11/18/2025 at 2:58 PM, Resident 1 stated their nails were long and dirty. Resident 1 stated staff had not cleaned them, nor washed their hands or face. Resident 1 stated they did not want to have long, dirty nails because they might get sick and it made them feel dirty. During an interview and concurrent observation on 11/19/2025 at 9:40 AM, Resident 1 was clean, in a blue gown leaning to their left side. Resident 1 stated they had a shower that morning. Resident 1's fingernails were long and jagged. Resident 1's toenails were long and curled inwards towards their toes. Resident 1 stated, nobody has offered to trim my nails, they are so dirty. During an interview on 11/19/2025 at 11:15 AM, Staff C, Nursing Assistant (NA), stated when they gave a shower to a resident, they were responsible to do the resident's fingernails, toenails and shave if the resident did not have a diagnosis of diabetes. Staff C stated that Resident 1 was dependent on staff for showering and did not have a diabetes diagnosis. Staff C stated Resident 1 had never refused a shower for them and received a shower that shift. Staff C stated Resident 1's nails were not done after their shower; they were busy and had not done Resident 1's nails yet. Resident 3 Review of Resident 3's medical record showed, Resident 3 was admitted to the facility on [DATE] with diagnoses to include Parkinson's disease (a progressive brain disorder that affects movement and balance), anxiety (a mental health condition characterized by persistent and excessive worry, fear or panic difficult to control and interferes with daily life), muscle weakness, dysphagia (difficulty swallowing) and falls. The comprehensive assessment dated [DATE] showed Resident 3's cognition was moderately impaired and required substantial assistance with all care. During an observation and concurrent interview on 11/18/2025 at 8:51 AM, Resident 3 was up in their wheelchair, their arms and legs twitching (involuntary jerking movements) as they were attempting to brush their hair and beard. The resident's toothbrush was lying on the ground under their bed. Resident 3 stated they were attempting to brush their teeth but could not hold on to the toothbrush. During an interview on 11/18/2025 at 1:13 PM, Resident 3 stated they had not received oral care nor had they been offered oral care. Resident 3 stated they had retrieved an old toothbrush head to their electric toothbrush from their top drawer, the used toothbrush head was sitting on the resident's bedside table. Resident 3 stated they had not tried to use the used toothbrush head, they wanted to sanitize it first. During an interview and concurrent observation on 11/19/2025 at 1:38 PM, Resident 3 was sitting up in their electric wheelchair and stated they had not received oral care for the day, the resident had white matter in between their teeth. Resident 3 stated staff do not consistently set up their oral care supplies or offer to assist them. Resident 3 stated they attempted to use their electric brush and that it fell on the ground. The resident's black electric toothbrush was under their bed. Resident 3 stated they would need a new toothbrush head for their toothbrush. Resident 3 stated they used Listerine (a type of mouthwash) to try to keep my mouth clean and sterilized. Resident 3 had a used toothbrush head sitting in a cup of Listerine. The resident stated they had found an old toothbrush head in their drawer and were sterilizing the brush to use. During an interview on 11/20/2025 at 3:04 PM, Resident 3 stated they had not received oral care for the day. Resident 3 stated they had an appointment with the doctor and was embarrassed not having their teeth brushed before their appointment. Resident 3 had white matter buildup to the bottom gums and in between their teeth. During an interview on 11/20/2025 at 1:59 PM, Staff D, NA, stated they were assigned to Resident 3 and that they had assisted them out of bed for the day. Staff D stated they had assisted the resident with their breakfast meal, incontinent care, hair combing and grooming, turned on their phone, and assisted them into their wheelchair. Staff D stated that Resident 3 did not receive oral care during cares. Staff D stated Resident 3 went to therapy, they got busy and forgot. Resident 42 Review of the medical record showed Resident 42 was admitted to the facility on [DATE] with diagnoses including morbid obesity (being 100 pounds or more overweight), diabetes (chronic condition of excess sugar in the blood) and anxiety. The 09/26/2025 comprehensive assessment showed Resident 42 required the assistance of one to two staff members for ADLs and had an intact cognition. During an observation and concurrent interview on 11/17/2025, showed Resident 42 lying in their bed and their teeth were yellow. On the nightstand was a basin with an unopened toothbrush. Resident 42 stated they had not been offered the chance to brush their teeth more than once since they arrived at the facility. Resident 42 stated they did need assistance with set-up (obtaining the basin, toothbrush, toothpaste and water) for oral care. Resident 42 stated they would like to be able brush their teeth every day. An interview on 11/19/2025 at 4:28 PM, Resident 42 stated they still had not been offered assistance to brush their teeth. During an interview on 11/20/2025 at 1:20 PM, Staff H, NA, stated Resident 42 required assistance for oral care by sitting them up in their bed, obtain a basin, toothbrush and toothpaste and then Resident 42 could brush their teeth. Staff H stated they had not offered assistance for oral care for quite some time and were unsure how long it had been. Staff H stated work had been busy and they did not have time to provide the oral care as they should have. During an interview on 11/21/2025 at 10:45 AM, Staff B, Director of Nursing stated NA's were required to offer and perform oral care, including brushing teeth every day for Residents. Reference: WAC 388-97-1060(2)(c)

Based on observation, interview and record review, the facility failed to provide respiratory care in accordance with accepted standards of practice, regarding a resident's continuous positive airway pressure (CPAP, a device that uses mild pressure to keep the airway open when asleep) machine for 1 of 2 residents (Resident 30) reviewed for respiratory care and treatment. This failure placed the resident at risk of respiratory status complications and unmet care needs.Findings included .Review of the facility's policy tiled, CPAP/Bilevel Positive Airway Pressure (BiPAP, a device that is similar to CPAP to assist with breathing while sleeping), revised March 2015, showed that resident CPAP devices need to be cleaned along with the humidifier canister at least weekly, replacing of disposable filters monthly and daily cleaning of mask/tubing. The policy showed that CPAP documentation should be complete in the resident medical record including, the time/duration of CPAP when used, the mode for the resident's CPAP and how the resident tolerated the procedure. Resident 30Review of the medical record showed the resident was admitted to the facility originally on 03/01/2023 and readmitted on [DATE] with diagnoses of a stroke (when blood supply to the brain is blocked or reduced) and obstructive sleep apnea (a condition in which an individual has repeated interruptions in breathing stops and restarts while sleep). The 06/07/2025 comprehensive assessment showed the resident had intact cognition, able to make their needs known and had a non-invasive mechanical ventilator (a device, like a CPAP machine, that utilizes pressure to force air/oxygen into an individual's lungs, through a mask to assist with breathing) device. A concurrent observation and interview on 11/17/2025 at 12:31 PM showed Resident 30's CPAP device on their bedside table. The device's canister that holds distilled water (a specific type of water for the device that adds moisture to the air, to prevent dryness /irritation when being utilized) was empty. Resident 30 stated they were supposed to be using the CPAP device every night, but the facility staff were not filling up the canister anymore, and the resident could not use the CPAP device without moisture to the air because it irritated their mouth and nose. Resident stated they have not been able to use the CPAP device for months.Review of Resident 30's active physician's orders showed that on 07/09/2025 an order was placed to Encourage resident to place CPAP mask every night for bedtime. No other orders were active regarding Resident 30's CPAP device.During an interview on 11/19/2025 at 2:02 PM, Staff F, Registered Nurse (RN), stated the process for a resident's CPAP was for the night shift nurse to set up the device, make sure it had the distilled water and the correct setting for the resident. Staff F stated that the morning shift nurse would assist the resident with getting the CPAP mask off and cleaning the device/mask. Staff F stated that order would be in place to implement a resident CPAP, and they would follow what was in the orders. During an interview on 11/19/2025 at 3:27 PM, Staff O, RN stated they were the nurse taking care of Resident 30 that day. Staff O stated that Resident 30 should have their CPAP orders in the medical records but was unable to find them. Staff O stated Resident 30's CPAP orders were discontinued, .it was because (Resident 30) might have been refusing. Staff O stated they were unable to find documentation of Resident 30 refusing their CPAP machine. During an interview on 11/19/2025 at 4:09 PM, Staff L, Infection Control Nurse, stated they were also the case manager for Resident 30 and when reviewing the resident's medical record did not see the required orders for a resident that was on a CPAP device. Staff L stated they did not find any documentation of the resident's refusal to wear their CPAP device nor that nursing staff were cleaning or refilling the resident CPAP device. Staff L stated that Resident 30 should have orders for cleaning of the CPAP device/tubing/mask, refilling the distilled water, on/off times for the CPAP and the CPAP settings, but they were not in place. Staff L stated the correct process for Resident 30 respiratory care with the CPAP device was not followed.During an interview on 11/21/2025 at 11:31 AM, Staff B, Director of Nursing, stated that Resident 30 should have had the CPAP orders in place for specific CPAP settings, monitoring the resident while on CPAP, nursing staff change out of the distilled water, cleaning of the CPAP device, and documentation of refusal, if the resident was refusing. Staff B stated the correct process for Resident 30's respiratory care with their CPAP was not followed.Reference: WAC 388-97-1060(3)(j)(vi)

Based on interview and record review, the facility failed to ensure a cognitively impaired resident representative (RR) was offered the pneumococcal immunizations (a vaccine that protects against pneumococcal infections that can lead to serious lung infections), given the opportunity with refusal or acceptance of the vaccine on behalf of the resident, nor receive education on the risk/benefits of the vaccine for 1 of 5 residents (Resident 61) reviewed for immunizations. This failure placed the resident at an increased risk for a contagious disease without the RR having the opportunity to make an informed decision in the refusal or acceptance of the pneumococcal vaccine. Findings included .Review of the facility's policy titled, Vaccination of Residents, adopted 01/30/2025, showed the facility would offer the pneumococcal vaccine to all residents within the facility, unless it was medically contraindicated or had already been vaccinated. The policy showed that residents or their legal representatives would be provided education regarding the benefits/potential side effect of the vaccinations and documented in the resident's medical record.Resident 61Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnosis including a stroke (when blood supply to the brain is blocked or reduced), dysphagia (difficulty swallowing) following the stroke, apraxia (the inability to perform purposeful movement or gestures leading to difficulties with things such as dressing and grooming), dementia (a loss of thinking, remembering, and reasoning skills) and mixed receptive (difficulty understanding spoken or written language)/expressive language disorder (affects the ability to express thoughts, ideas and feeling through speech and writing). The 10/27/2025 comprehensive assessment showed the resident had a severely impaired cognition, was not up to date on the pneumococcal vaccine and did not have a medical contraindication regarding the pneumococcal vaccine. Review Resident 61's legal guardianship (a legal process that allows a designated person to make decision for an adult that has lost the capacity to make the decisions independently) document, dated 10/17/2024, showed the RR was appointed as Resident 61's and would make decision on consenting to or refusing medical treatment on the resident's behalf. Review of Resident 61's immunization records showed no documented assessment or nursing progress note of the RR being offered the opportunity to decline or accept the pneumococcal vaccine nor that education regarding the benefits/potential side effect of the vaccination was provided to the RR. During an interview on 11/20/2025 at 11:52 AM, Staff B, Director of Nursing, stated they did not contact Resident 61's RR to offer the pneumococcal vaccine or educate the RR regarding the benefits/potential side effect of the vaccination. Staff B stated the correct process was not followed and since Resident 61 was unable to make care decisions they should have contacted the RR to offer the pneumococcal vaccine and documented their refusal or acceptance. Reference: WAC 388-97-1340(2)

Based on interview and record review, the facility failed to ensure residents and/or their representative were offered/educated on the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) immunization (the action of taking a vaccine for a particular infectious disease) for 1 of 5 sampled residents (Resident 61) reviewed for immunization status. This failure placed the resident and/or their representative at risk of making an uninformed decision and resident contracting the COVID-19 virus. Findings included .Review of the facility's policy titled, Coronavirus Disease (COVID-19) - Vaccination of residents, adopted 01/30/2025, showed the facility would offer the COVID-19 vaccine to all residents within the facility, unless it was medically contraindicated or had already been fully vaccinated. The policy showed that residents or their legal representatives would be provided education regarding the benefits/potential side effect of the vaccinations and documented in the resident's medical record. Resident 61Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnosis including a stroke (when blood supply to the brain is blocked or reduced), dysphagia (difficulty swallowing) following the stroke, apraxia (the inability to perform purposeful movement or gestures leading to difficulties with things such as dressing and grooming), dementia (a loss of thinking, remembering, and reasoning skills) and mixed receptive (difficulty understanding spoken or written language)/expressive language disorder (affects the ability to express thoughts, ideas and feeling through speech and writing). The 10/27/2025 comprehensive assessment showed the resident had a severely impaired cognition and was not up to date on the COVID-19 vaccine. Review of Resident 61's immunization records showed no documented assessment or nursing progress note of the RR being offered the opportunity to decline or accept the COVID-19 vaccine nor that education regarding the benefits/potential side effect of the vaccination was provided to the RR.During an interview on 11/20/2025 at 11:52 AM, Staff B, Director of Nursing, stated they did not contact Resident 61's RR to offer the COVID-19 vaccine or educate the RR regarding the benefits/potential side effect of the vaccination. Staff B stated the correct process was not followed and since Resident 61 was unable to make care decisions they should have contacted the RR to offer the COVID-19 vaccine. Reference: WAC 388-97-1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure that the state agency was notified about an elopement for 1 of 1 resident (Resident 1) reviewed for elopements. This failure placed the resident at risk for potential endangerment. Findings included . <Resident 1> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses including high blood pressure, Parkinson's Disease (neurodegenerative disease with brain deterioration that affects body movements by slowing movements and causes tremors and balance issues), reduced mobility and homelessness. The 05/30/2025 comprehensive assessment showed Resident 1 was alert and oriented and required partial to substantial assistance with transfers, dressing and toileting. During an interview on 06/30/2025 at 10:30 AM, Staff B, Director of Nursing Services, stated Resident 1 left the facility without notice and staff were not aware of their location. Staff B stated Resident 1 was not assessed as an elopement risk. The facility did not call the state agency to report the missing resident who left the faciity on [DATE]. Review of the May 2025 and June 2025 (reviewed through 06/30/2025) Incident Reporting Log showed no entry for Resident 1's elopement from the facility. Review of the 06/23/2025 at 12:26 PM nursing progress note showed Resident 1's breakfast tray was still on their bedside table untouched and they had served the lunch meal. Resident 1's clothing and belongings were gone. They notified Staff C, Social Services. During an interview on 06/30/2025 at 11:00 AM, Staff C stated they had tried to call Resident 1's phone number and it was a non-working phone number. Staff C then notified law enforcement on 06/24/2025. Staff C failed to log the incident and was unaware that the state agency was to be notified. Reference WAC 388-97-0640 (5)(a)

Based on observation, interview, and record review the facility failed to provide a safe, comfortable environment for 3 of 6 rooms (Rooms 27, 28 and 29) for maintenance repairs. This failure placed residents at risk of injury and a diminished quality of life by not maintaining a safe and functional environment. Findings included . Review of the undated Facility Maintenance Program policy showed the facility should have .regularly scheduled inspections .building interior inspections include checking floors, ceilings and walls weekly . Review of the April 2025 through June 2025 maintenance log did not identify Rooms 27, 28. and 29 for maintenance inspection or repair. During an observation and concurrent interview on 06/30/2025 at 11:05 AM, showed room [ROOM NUMBER] with white walls and four feet long cuts into the wall located on the right side of the room by the baseboard and the lower wall. Additionally, there were multiple gouges (indentations) brown in color where the paint was removed along the wall above the base board. On the back wall near the window of room [ROOM NUMBER] there were many patched spackled (plastic paste) areas unfinished on the back wall and a patched area above the baseboard with a five by four inches with a metal plate with sharp edges partly exposed from the wall. An observation of more peeling paint above the baseboard with exposed inside of the wall was visible. The wooden closet doors to the left of room [ROOM NUMBER] upon entering the room, had sparse old varnish in some areas on the closet doors and splintered areas along the edges of the closet doors. The back right corner on the right side of room [ROOM NUMBER] between the right side of the wall and back wall was uncleanable with yellow peeling flakes from the wall above the baseboard. Staff D, Maintenance Director, stated that it was the first time they saw these areas that needed repair. During an observation on 06/30/2025 at 11:15 AM, room [ROOM NUMBER] had white walls and on the left side of the wall above the baseboard had peeled paint and gouges observed sporadically (intermittently) along a five foot area above the baseboard. There were three inch long scratched areas into the wall. During an observation on 06/30/2025 at 11:30 AM, room [ROOM NUMBER]'s wall on the left side had significant gouges and broken sheet rock from the wall behind the bed headboard. The broken sheet rock area on the wall behind the resident's bed headboard was three by four feet. The broken pieces of sheet rock was visible from the entry way to room [ROOM NUMBER]. During an interview on 06/30/2025 at 11:45 AM, Staff D stated they made rounds in the facility daily and thorough room inspections were done monthly. Staff D was unaware that Rooms 27, 28 and 29 needed repairs. During an interview on 06/30/2025 at 11:50 AM, Staff A, Administrator, stated they should have repaired the rooms promptly. Reference WAC 388-97-3220(1)

Based on observation, interview, and record review, the facility failed to ensure residents environment remained free of accident/hazards with: A) a resident that required a smoking apron for safety when smoking for 1 of 2 residents (Resident 29) reviewed for accident/hazard of smoking, B) the securement of compressed oxygen cylinder storage for 1 of 2 storage rooms (East/West storage room) reviewed for accident/hazards of oxygen cylinder storage, and C) that toxic cleaning chemicals were safely stored away from residents for 2 of 3 hallways (East/West and Central Hall) reviewed for accidents/hazards of chemicals. This failure placed residents at an increased risk for avoidable accidents, significate injury, and unmet care needs. Findings included . Review of the facility's policy titled, Smoking Policy for Independent and Supervised, revised December 2017 showed that residents who wished to smoke would be assessed for their risks with smoking and the ability to smoke safely. Residents who did not meet the criteria to smoke independently would be provided assistance with their smoking materials and supervision when smoking. Review of an Office of Congressional Workplace Rights document titled, Compressed Gas Cylinder Storage, dated 08/2019, showed compressed gas cylinders should be treated as potential high energy projectiles and should be secured at all times to prevent tipping. All cylinders should be chained or secured to prevent them from falling. <Smoking> <Resident 29> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder [(PTSD) a mental health condition that's caused by an extremely stressful or terrifying event], depression and paralysis following a stroke that affected the residents left side of the body. The 09/12/2024 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Resident 29 need partial/moderate facility staff assistance with their oral hygiene (a resident's ability to use suitable items to clean their teeth) and substantial/maximal facility staff assistance with upper body dressing (resident ability to dress/undress themselves above the waist and use of hands/fingers to work things like buttons). Review of facility smoking observation/assessment, dated 09/06/2024, showed Resident 29 had dexterity (the ability to perform difficult actions quickly and skillfully with the hands) issues related to Resident 29's stroke, was unable to light their own cigarette, required supervision of staff when smoking and needed a smoking apron (a protective flame retardant garment that prevents burning of clothes and keeps hot cigarette ashes from burning the skin) as an adaptive equipment (any kind of tool or device that can simplify caregiving or make the resident's environment safer) when smoking. During a concurrent observation and interview on 10/23/2024 at 8:34 AM, showed Resident 29 in their room with two cigarette burn marks on the black sweater they were wearing. When inquired about the burn marks the resident stated they were a hazardous smoker before admitting into the facility. Resident 29 stated they actively went outside to smoke during the facility designated smoking times, needed to be supervised by the facility staff when smoking, but had not been required to wear a smoking apron. During a concurrent observation and interview on 10/24/2024 at 9:34 AM, showed Resident 29 being taken out to smoke during one of the designated smoking times. The resident was in/out of falling asleep in their wheelchair saying pretty dam sleepy .make sure I don't burn my clothes . when given a cigarette and helped to light it by Staff U, [NAME] Clerk/Nursing Assistant. Resident 29 was not offered nor wore a smoking apron. Staff U stated the facility had recently got smoking aprons but was unaware of residents that required a smoking apron when smoking. When asked about facility staff training on being a supervisor during resident smoking times, Staff U stated had not taken the safety training like other staff had. Observation on 10/28/2024 at 1:48 PM showed Resident 29 outside during the afternoon's staff supervised smoking time. The resident was observed smoking and was not wearing the required smoking apron. During an interview on 10/28/2024 at 1:53 PM, Staff V, Activities Director, stated they were one of the staff that supervised residents during the smoking times. Staff V stated that Resident 29 was shaky sometimes and the residents had dexterity complications, so they were required to wear a smoking apron. During an interview on 10/28/2024 at 3:02 PM, Staff D, Resident Case Manager, stated they completed the initial smoking assessment/evaluation on Resident 29. Staff D stated the resident needed staff supervision and a smoking apron due to the history of cigarette burns in their clothing/history in conjunction with the resident dexterity issues. Staff D stated the resident had never refused to wear the smoking apron. During an interview on 10/29/2024 at 9:26 AM, Staff A, Administrator and Staff B, Director of Nursing Services (DNS), stated that Resident 29 should have been wear a smoking apron with their dexterity complications and history of burns in clothing form smoking. <Oxygen Storage> An observation on 10/22/2024 at 12:16 PM, showed the Central oxygen storage closet, located in the main hall of the East/West wing of the facility, contained 24 full oxygen cylinders; four cylinders were not secured. There was a sign posted on the inside of the closet door that showed O2 (oxygen) tanks are not to be left freestanding, please put them in the holder. During a concurrent observation and interview on 10/22/2024 at 3:35 PM, Staff G, Maintenance Director, stated the process for storing oxygen cylinders included performing a weekly check of the oxygen storage rooms to ensure the cylinders were in holders or chained to the walls. Staff G opened the storage room door and observed four oxygen cylinders that were not secured. They stated all cylinders needed to be in the rack and placed one in the rack. Staff G picked up the remaining three freestanding cylinders and carried them to the North wing oxygen storage room. Staff G stated they did not know why the four cylinders were not in a rack. They stated their process was to check the storage rooms weekly for safety, and with finding the four unsecured, the process is not working. During an interview on 10/29/2024 at 2:18 PM, Staff A, Administrator, stated the process for oxygen storage was to ensure they were stored in a secure area to prevent them from falling over. They stated the oxygen delivery driver had placed the oxygen cylinders in the storage closet and left them unsecured. Staff A stated that was not the normal process and the facility needed to ensure the cylinders were safely stored. <Chemicals> Review of the 12/06/2022 Safety Data Sheet [(SDS) a document that contains information about the hazards of a chemical or product and how to handle it safely] for Medline MicroKill Two Germicidal 1 Wipes (a brand of sanitizing wipes used on hard surfaces to kill germs, bacteria, and viruses), showed the chemical could cause serious eye damage and severe skin burns. Review of the 04/05/2024 SDS for PDI Super Sani-Cloth Germicidal Wipes (a brand of disinfecting wipe used for cleaning and disinfecting) showed precautions for safe handling included avoid contact with eyes and skin. An observation on 10/23/2024 at 11:36 AM, showed a container of Super Sani-Cloth Germicidal Wipes on a side table in the puzzle room. There was one resident, unsupervised, in the puzzle room area. An observation on 10/24/2024 at 11:32 AM, showed an unattended cart containing wound care supplies in the central hallway. There was a container of MicroKill Two wipes on top of the cart within reach of residents. An observation on 10/29/2024 at 9:19 AM, showed a container of MicroKill Two germicidal wipes on the East/West nurses' station, within reach of residents. There were three residents present. During an interview on 10/29/2024 at 2:08 PM, Staff B, DNS, stated the wipes could be left out, the residents like to use them to wipe down their own wheelchairs. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to consistently provide appetizing and palatable food for 4 of 7 residents (Residents 44, 34, 21, and 57) reviewed for food quality. Additionally, observations in the kitchen showed a delay in meal service which resulted in cold food served to the residents. These failures placed residents at risk for less than adequate nutritional intake and dissatisfaction with meals. Findings included . <Resident 44> Review of the resident's record showed they were admitted to the facility with diagnoses including diabetes (high levels of sugar in the blood), and chronic obstructive pulmonary disease (COPD, a chronic lung disease). Review of the comprehensive assessment, dated 08/01/2024, showed the resident was cognitively intact with no memory impairment. Review of Resident 44's physician orders for October 2024 showed their diet was a consistent, constant, controlled, carbohydrate (CCHO) diet with regular texture, which was commonly ordered for people with diabetes. During a concurrent observation and interview on 10/23/2024 at 1:29 PM, Resident 44 was sitting up in their bed with their lunch tray on the over bed table in front of them. Their lunch consisted of mushy tortellini pasta with a red sauce and some wilted spinach on the side. The resident looked at their lunch and stated it was not very good, as they had tasted it and discovered there was something wrong with it. The resident stated the food often tasted bad and was served cold. An observation on 10/30/2024 at 8:56 AM, showed Resident 44 sitting up in their bed with their breakfast on the over bed table. The meal consisted of leathery like eggs which were hard and cold. Additionally, there was a piece of plain bread with no butter or any other topping on it. Resident 44 stated, how do you like my toast, it's just a piece of dry bread they could have at least toasted it. The resident stated they would have eaten their cereal but there was too much sugar on it as they were diabetic. <Resident 34> Review of the resident's record showed they were admitted to the facility with diagnoses including dysphagia (impaired ability to swallow) and COPD. Review of the comprehensive assessment, dated 09/22/2024, showed the resident had mild cognitive impairment however was able to make their needs known. Review of Resident 34's October 2024 physician orders showed they were on a general (regular healthy meal plan) diet with mechanical soft (foods that are easy to chew and swallow) texture cut into bite sized pieces. During an interview on 10/22/2024 at 10:41 AM Resident 34 stated, the food is terrible, I have to use barbeque sauce to cover the taste and smell. The resident stated, something needs to be done about it. During a concurrent observation and interview on 10/23/2024 at 1:23 PM, Resident 34 was sitting up in their bed with their food tray on the over the bed table in front of them. The resident's meal consisted of a brownish red sauce and bite sized pieces of a light brown meat. The resident stated, I can't eat this stuff, I don't even know what it is. The resident pointed to two cans of tuna fish and a loaf of bread and stated, people from church brought me in some food to eat because the food here is so bad. <Resident 21> Review of the resident's medical record showed they were admitted to the facility with diagnosis including diabetes. The comprehensive assessment, dated 09/01/2024, showed the resident was cognitively intact with no memory impairment. Review of Resident 21's October 2024 physician orders showed they were on a CCHO diet with regular texture. During an interview on 10/23/2024 at 2:32 PM Resident 21 stated they were not happy with the food they were being served at the facility, as it was often cold and unappetizing. The resident further stated they disliked beets, and it was on their list of food dislikes, however every time we have beets I get served them. Resident 21 stated they also had concerns about too much sugar and carbohydrates served to them related to their diabetes. I have complained many times, but nothing gets done about it. <Resident 57> Review of the resident's record showed they were admitted to the facility with diagnoses including diabetes. The resident's comprehensive assessment, dated 09/04/2024, showed they were cognitively intact and required no assistance with eating except for meal set-up. Review of the October 2024 physicians' orders showed they had orders for a CCHO diet regular texture. During an interview on 10/23/2024 at 2:24 PM Resident 57 stated they were diabetic and were often served sugar products with their meals. They do not follow my diet restrictions at all. The resident stated they went to the kitchen themselves related to their food concerns, and no matter how often they complain nothing changed. 45117 <Kitchen> An observation and interview on 10/24/2024 at 12:20 PM, showed Staff O, Cook, and Staff N, Dietary Aide, starting the lunch meal serve out, 20 minutes after the posted lunch meal start time. The first cart of lunch trays was sent out of the kitchen at 12:28 PM, the second at 12:36 PM, the third at 12:45 PM, and the fourth at 12:54 PM. At 1:01 PM, Staff O informed Staff M, Dietary Manager, that there were not enough pellet inserts (a warmed disc placed in the base of a plate holder to retain heat) for the plate warmers. There were six lunch meals that were placed in the meal tray cart that did not have pellet inserts, including the surveyor test tray. Staff M stated they frequently ran out of silverware and pellets for the warmers. They stated they go out on the meal trays but don't come back. At 1:06 PM, the final meal tray cart was sent out, one hour and six minutes after the posted mealtime. During a continued observation and interview on 10/24/2024 at 1:14 PM, showed a pureed meal, the noodles were a translucent, white, gel-like substance, with a scoop of a brown pureed substance (beef) on top. The meal included a scoop of pureed green peas on the plate. Staff M, stated the puree foods for the lunch meal was not appetizing and they would not eat it. At 1:14 PM, a surveyor test tray was removed from the last tray cart. Staff M took the temperature of the lunch meal surveyor test tray, which resulted as follows: beef stroganoff with noodles - 130.2 degrees Fahrenheit (F, a unit of measure). green peas - 106.4 F. Staff M stated those temperatures were not good and continued to take the temperature of the glass of milk, which measured 45.5 degrees F. Staff M stated the overall temperatures of the test tray were not good. Staff M stated they were aware of food temperature issues, and they needed to work on how the kitchen staff communicated with nursing staff to get trays to residents faster. Staff M stated they had extra pellet warmers and would need to get them into service. Staff M stated the posted time for the lunch meal of 12:00 PM meant the kitchen would start serve out at 12:00. They stated meal serve out was late due to kitchen staff taking their lunch breaks and cleaning the kitchen prior to the residents' meal serve out. During an interview on 10/29/2024 at 2:33 PM, Staff A, Administrator, stated the process for serving hot meals included following the times set for meal service. They stated kitchen staff needed to ensure there were enough pellets for the plate warmers to keep the food warm. Staff A stated they needed to fix the process. Reference: WAC 388-97-1100(1)(2)

Based on observation, interview, and record review, the facility failed to ensure periodic testing of sanitizing agents used for proper sanitation of food preparation surfaces in accordance with professional standards for food service safety, appropriate labeling of open foods, and that food delivery carts were clean, for 1 of 1 kitchen reviewed for safe food service. This failure placed residents, staff, and visitors that ate from the facility's kitchen at risk for food borne illnesses and the spread of infectious diseases. Findings included . Review of the policy titled, Food Preparation and Service, dated ,d+[DATE], showed food and nutrition services staff would prepare, distribute, and serve food in a manner that complied with safe food handling processes. Appropriate measures used to prevent cross contamination (the spread of chemical or disease-causing organisms transferred to food by hands, food contact surfaces, sponges, cloth towels, or utensils that were not adequately cleaned) included using sanitizing towels or cloths for wiping surfaces in a container filled with an approved sanitizing solution and at the concentration of sanitizer specified by the manufacturer of the solution. All food service equipment and utensils would be sanitized according to current guidelines and manufacturer's recommendations. Review of the policy titled, Discard Date, dated [DATE], showed foods were dated and prepared for storage to prevent deterioration, dehydration, or food borne illnesses. Leftover food that was to be served at a later date, would be wrapped, covered with plastic wrap or an approved plastic container, and stored in the appropriate manner. Leftover food would be labeled with the discard date which included the month and day. <Sanitation Buckets> During an observation and interview on [DATE] at 8:35 AM, Staff N, Dietary Aide, was observed with a red bucket at the sink. Staff N stated the bucket contained a sanitation solution that was used to wipe countertops and food service carts. The staff member stated they had just changed the solution in the bucket. Staff N obtained a container of test strips to test the solution. They opened the container, obtained a strip and placed it into the bucket of solution for 15 seconds. Staff N removed the strip from the solution and stated, it did not pass. Observation of the container of test strips showed the strip needed to turn green to pass the test; the strip remained yellow. The expiration date on the container showed the strips expired in 2023. Staff N obtained a new container of test strips with an expiration date of 2026 and retested the solution. Observation showed the strip remained yellow. Staff N stated, it did not pass either. Staff N obtained a round container of testing strips and tested the solution again (no color change on the test strip), and stated it still did not pass. Staff M, Dietary Manager, tested the solution with the round container of strips, and had failed results. At 8:37 AM, Staff O, Cook, dumped their bucket of solution, filled the bucket with the premixed sanitation solution and tested the solution with the round container of testing paper and had passing results. Staff N then dumped their bucket of solution and tested with the round container of strips with passing results. Staff N stated they were trained on changing and testing the sanitizing solution when they were hired four years ago. They stated they changed the solution every hour and retested and logged the results on the log sheet posted on the walk-in refrigerator door. During an interview at 8:56 AM, Staff M stated they personally tested the sanitation buckets once weekly. They stated the process for staff was to test the sanitation solution in the buckets after each change and log the result on the form. They stated they were unsure if staff were testing the solution properly and I believe some are not doing it correctly. Staff M stated the sanitation log was probably not accurate and did not know what the sanitation solution instructions were. Staff M stated they did not have documentation of training or return demonstration for testing the sanitation solution. They stated there was no process in place regarding the safe use of the sanitation solution. <Food Storage> During an initial kitchen tour observation and interview on [DATE] at 8:55 AM with Staff M, Dietary Manager, showed a one-gallon pitcher of pre-made health shake in the refrigerator dated [DATE]. Staff M removed the pitcher from the refrigerator and stated they could not serve it to residents as it was no longer safe for resident consumption after three days. Further review of the walk-in refrigerator with Staff M, showed a plastic bag with yellow fluid and three hard boiled eggs, a small bowl with chopped ham and cheese that was near empty, covered with no label or date. Staff M stated the eggs and bowl of ham/cheese should have been labeled with the date opened or made. Observations of the dry goods area of the kitchen showed a brownie in a plastic bag, no label or date, on the shelf with the dry cereals. Staff M stated the brownie should not have been there and threw the brownie in the trash. During an observation and interview with Staff M on [DATE] at 9:38 AM, showed the walk-in refrigerator contained a plastic bag of ham lunch meat in a bag. The bag was not sealed and was not labeled or dated. There were two half bags of lettuce mix that had been opened. One bag was dated [DATE] and the second bag was undated. There was a plastic bag of baby carrots that was previously opened, not sealed, and not labeled or dated. There was an opened plastic bag of shredded carrots that was twisted/tied in a knot with a date on the bag (under the knot). Staff M stated the date was [DATE]. There was a plastic bag of cilantro that had portions of it that were black and slimy/mushy. There was no label or date noted on the bag, and it was not sealed. Staff M stated the process for storing leftovers and/or open packages of food included placing the food in a plastic bag and label/date the package. Staff M stated the cooks were responsible for maintaining the foods in the refrigerator. Staff M stated that was not happening consistently. <Food Delivery Carts> During an observation on [DATE] at 12:20 PM through 1:09 PM, showed five food delivery carts were used for meal serve out. Each cart was made of stainless steel with two doors/four wheels and a gray rubber bumper around the base of the cart. The carts had white streaks on the outside, towards the base of the carts. The gray rubber bumpers were sticky with gray dust/debris stuck to the rubber and the wheels were rusty. At 1:09 PM, Staff M observed the carts with visible debris and rusty wheels. Staff M stated the carts looked dirty. They stated the staff were supposed to be wiping out the insides of the carts daily. Staff M stated the outside of the carts did not get wiped and needed to add the cleaning of the outside of the carts to the cleaning list. During an interview on [DATE] at 2:37 PM, Staff A, Administrator, stated there was a training issue in the kitchen for food safety. Reference: WAC [DATE](3)

Based on observation, interview, and record review, the facility failed to ensure residents that required assistance with eating received a dignified meal service, related to timely assistance with meals, for 2 of 4 residents (Residents 14 and 3) reviewed for dignity. This failure placed the residents at risk for unmet care needs and a deterioration in their quality of life. Findings included . <Resident 14> Review of the resident's medical record showed they were admitted to the facility with diagnoses including dementia (a progressive disease that destroys the memory and other important mental functions), dysphasia (impaired ability to swallow) and legal blindness. Resident 14's comprehensive assessment, dated 08/28/2024, showed the resident was severely cognitively impaired and required substantial assistance (a considerable amount) with eating. Review of Resident 14's care plan, dated 09/03/2024, showed the resident's legal blindness and cognition status was the reason they required substantial assistance from staff with their meals. During an observation on 10/22/2024 from 11:50 AM to 1:16 PM, showed Resident 14 sitting in the dining room alone at a table. At 1:00 PM, meal trays arrived, and Resident 14's meal tray was placed on the table in front of them. The three staff in the dining room were assisting other residents to eat their meals at other tables. Resident 14 waited until 1:16 PM (16 minutes after their meal arrived) for Staff T, Nursing Assistant (NA) to come from the west hall to assist the resident with their meal. During an interview on 10/22/2024 at 1:35 PM, Staff T stated they tried to come to the assisted dining room as soon as they could to help but were required to pass trays and assist other residents in the west hall first. During an observation on 10/24/2024 from 1:00 PM to 1:48 PM, showed Resident 14 sitting at a table alone. At 1:12 PM, the resident's meal tray was placed in front of them. Resident 14 stated Are you going to help me or what? The staff who had delivered the tray stated, someone will be with you soon. Resident 14 was observed leaning forward and attempting to smell their food. At 1:35 PM Staff U, NA, came into the dining room and assisted Resident 14 with their food. Resident 14 waited 17 minutes to eat after their meal tray had been served. <Resident 3> Review of the resident's medical record showed they admitted to the facility with diagnoses including deafness and dementia. The most recent comprehensive assessment, dated 08/18/2024, showed the resident was severely cognitively impaired and required substantial assistance for activities of daily living to include assistance with meals. During an observation on 10/22/2024 from 11:50 AM to 1:16 PM, showed Resident 3 was sitting in the dining room with another resident at the table. At 1:00 PM, Resident 3 had their meal placed in front of them. Staff assisted the other resident at the table to eat, however Resident 3 just sat there with untouched food. At 1:30 PM (30 minutes after their meal was served), Staff S, NA, placed the resident's hand on their cup to cue them to start eating. During an observation on 10/24/2024 from 1:00 PM to 1:48 PM, showed that Resident 3 was served their lunch tray at 1:17 PM. At 1:48 PM (31 minutes after their meal had been served), Staff S who had been assisting residents at another table, approached the resident and assisted them with their meal. During an interview on 10/30/2024 at 9:50 AM, Staff L, Licensed Practical Nurse, stated the NA working on the west hall was assigned to go to the assisted dining room to help residents with their meals after passing out the room trays. Staff L stated the reason the NA was late going to the dining room was because they also had to assist the residents who dined in their rooms and required help with their meals prior to heading to the dining room, which often put them behind. During an interview on 10/30/2024 at 12:50 PM, Staff A, Administrator, stated it was not appropriate for residents to be waiting with their meal trays in front of them for assistance while other residents were already eating. Reference: WAC 388-97-0180(1-4)

Based on interview and record review, the facility failed to identify and utilize an implanted bladder stimulator device [(InterStim) - an implantable device that treats urinary incontinence and overactive bladder by sending electrical pulses to the sacral nerves] used to treat urinary incontinence for 1 of 2 residents (Resident 5) reviewed for urinary incontinence (a loss of bladder control or involuntary urination). This failure placed the resident at risk for poor self-esteem related to dignity, skin impairments, continued urinary incontinence, and other health complications. Findings included . Review of the Medtronic InterStim guidance titled, Sacral Neuromodulation (the use of electrical or chemical stimulation to change nerve activity), dated 10/2024, showed the InterStim system was an implanted neurostimulator (a device that uses electrical stimulation to treat neurological disorders). The leads (wires) from the implanted device stimulate the sacral nerves that control normal bladder and bowel function. The InterStim device was indicated for the treatment of urinary retention and symptoms of an overactive bladder, including urinary urge incontinence. The InterStim device may be affected by or adversely affect cardiac devices, electrocautery (electric current to destroy abnormal tissue or control bleeding), defibrillators (a device that applies an electric charge or current to the heart to restore a normal heartbeat), ultrasonic equipment (a device that uses sound waves to detect and measure objects), radiation therapy, MRI [(Magnetic Resonance Imaging) - a test that produces detailed images of the internal structure of the body], and theft detectors/screening devices. <Resident 5> Review of the medical record showed Resident 5 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (a condition that causes the breakdown of cartilage in the joints of the body, leading to pain and stiffness), muscle weakness, and need for assistance with personal cares. The 09/07/2024 comprehensive assessment showed Resident 5 required substantial/maximum assistance of one staff member for activities of daily living and was dependent on two staff members for transfers. The assessment also showed Resident 5 was frequently incontinent of urine and was cognitively intact. Record review of a hospital discharge summary dated 03/01/2023, showed Resident 5 had a history of urinary incontinence after InterStim device placement. Record review of a care plan, dated 08/24/2024, showed a focus area for bladder incontinence related to impaired mobility with overactive bladder. The interventions showed Resident 5 had some bladder control and wore briefs. There was no documentation that Resident 5 had a urologist (a medical doctor specializing in condition that affect the urinary tract) or an InterStim device for urinary incontinence. During an interview on 10/22/2024 at 10:27 AM, Resident 5 stated they had an implanted device to control their bladder incontinence. They stated it was not working because they did not have the remote to control it. Resident 5 stated they had not seen a urologist since they were admitted to the facility. Resident 5 stated the staff had not asked them about their implanted device or about seeing a urologist. During an interview on 10/28/2024 at 9:21 AM, Staff P, Nursing Assistant, stated they had worked at the facility for about six years and was responsible for daily cares for Resident 5. They stated Resident 5 had always been incontinent but did know when they needed to be changed. Staff P stated there was no scheduled toileting plan in place for the resident's incontinence, except for incontinent care as needed. During an interview on 10/28/2024 at 10:03 AM, Staff K, Resident Case Manager, stated they had worked in the facility for eight years. They stated Resident 5 would sometimes ask for a bedpan for toileting. Staff K stated Resident 5 had no cognitive impairments that would limit a bladder retraining program. Staff K stated they had not done a retraining program for Resident 5. Staff K stated they were not aware that Resident 5 had an implanted device for urinary incontinence. They stated Resident 5 did not have a urologist but was taking a medication to help with the incontinence. Staff K stated they would have expected to see the implanted device identified in the medical record, specifically on the care plan. During an interview on 10/29/2024 at 1:31 PM, Staff B, Director of Nursing Services, stated the process for accuracy of medical records on admission to the facility, included reviewing the referral and hospital discharge summary. They stated they listed out the identified medical concerns to ensure they have the means to care for the resident, prior to admission. Upon arrival, they performed a physical assessment of the resident to identify additional needs. Staff B stated the implanted device was something we would catch on admit. Staff B stated they did not see any urology appointments in Resident 5's medical record and there was no care plan for the device. They stated they were unsure why this was missed. Reference: WAC 388-97-1060(3)(c)

Based on interview and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma informed care, complete with identified experiences and preferences regarding potential triggers (a stimulus that could prompt a recall of a previous traumatic event even if the stimulus itself is not traumatic or frightening) that may cause re-traumatization (a reliving of the traumatic experience) for 1 of 4 residents (Resident 29) reviewed for trauma informed care. This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included . Review of the policy titled, Trauma Informed Care, dated 08/01/2024, showed, Trauma-informed care is an approach aimed at identification of individuals with a trauma history and the development of care approaches that are sensitive to the individual needs . The policy showed identifying potential triggers and making modifications to care approaches and strategies would be a focus to order to avoid resident re-traumatization. <Resident 29> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event), traumatic brain injury (TBI, a violent blow, jolt, or external force to the head or body), partial traumatic amputation of right great toe (a partial loss of the big toe due to a severe accident or injury), nightmare disorder (a sleep disorder characterized by repeated intense nightmares that most of center on threats to physical safety and security) and depression. The 09/12/2024 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. During an interview on 10/23/2024 at 9:26 AM, Resident 29 stated they were injured overseas on a deployment in the military and there were potential triggers they knew of. They stated no staff member had talked with them about it. During a follow-up interview on 10/24/2024 at 9:59 AM, Resident 29 stated they had been blown up (involved in an explosion) overseas and was easily startled when woken from sleep/loud noises. Review of Resident 29's hospital history and physical report, dated 08/26/2024, and sent to the facility on [DATE], showed the resident was involved in multiple military war zone deployments, an explosion, and was a prisoner of war ([NAME]). Review of Resident 29's care plan, dated 09/09/2024, showed the resident was at risk for emotional trauma due to a history of .combat or exposure to a war zone . and PTSD. No care plan approaches or interventions were identified or made regarding Resident 29's combat, exposure to a war zone and/or their diagnosis of PTSD. Review of Resident 29's social history assessment (which reviewed traumatic events), dated 09/13/2024, showed the resident had a transportation accident (for example, car accident, boat accident, train wreck, plane crash) that was marked and happened to Resident 29. Other traumatic events, Combat or exposure to a war zone (in the military or as a civilian) .Fire or explosion .captivity (for example, being kidnapped, abducted, held hostage, prisoner of war) were not checked for the resident and no other traumatic events were documented. During an interview on 10/28/2024 at 9:37 AM, Staff H, Social Services Director, stated they oversaw trauma informed care assessment on residents, documented the information under the social history assessment tab in a resident's record, and developed a care plan regarding identified triggers. Staff H stated Resident 29 was at war, saw a lot of people die in combat, and was deployed to different places/war zones. Staff H stated they remembered Resident 29 informing them about having flash backs and memories of times at war. When reviewing Resident 29's trauma informed care assessment and care plan, Staff H stated no triggers were identified or care planned. During an interview on 10/28/2024 at 11:09 AM, Staff E, Registered Nurse, stated Resident 29 had PTSD from events while being deployed overseas in the military. Staff E stated Resident 29 startles awake and will talk in (Resident 29's) sleep and had some nightmare's .have to be careful on how you wake (Resident 29) up . Staff E stated the resident was injured as a [NAME], did not get a lot of sleep, and had been known to stay up in a wheelchair all night. During an interview on 10/28/2024 at 3:02 PM Staff D, Resident Case Manager (RCM), and Staff C, Infection Preventionist/RCM, stated that Resident 29 had nightmares and did not like loud noises, you have to be careful not to startle (Resident 29) or catch (Resident 29) by surprise because the resident got upset and would start yelling. Staff D stated the known potential triggers for Resident 29 should be on the resident care plan and the correct process was not followed. During an interview on 10/29/2024 at 9:26 AM, Staff A, Administrator, and Staff B, Director of Nursing Services, stated they were aware of Resident 29's history of PTSD and being in a war zone, but did not know of any triggers that were identified. Staff A and Staff B stated that Resident 29 should have been accurately assessed for potential triggers with the resident's diagnosis of PTSD/known deployments to a war zone, being easily startled when sleeping and by loud noises, and an individualized care plan should have been implemented so all staff were aware of triggers that could cause re-traumatization. Reference: WAC 388-97-1060(3)(e)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent for 2 of 5 residents (Residents 218 and 1) observed during 27 medication administration opportunities that resulted in an error rate of 7.41 percent. This failure placed the residents at risk of not receiving the full therapeutic effect of the medication and potential adverse side effects. Findings included . Review of the Basaglar KwikPen (a pre-filled disposable device containing an insulin medication) instructions for use, dated ,d+[DATE], showed the insulin pen needed to be primed (removing air from the needle and cartridge that may have collected during normal use) before each injection. If the pen was not primed before each injection, too much or too little insulin could be delivered. Review of a policy titled, Medication Administration, dated ,d+[DATE], showed check expiration date on package/container .no expired medication will be administered to a resident. <Resident 218> Review of the medical record showed Resident 218 was admitted to the facility with diagnoses including aftercare for surgery on the skin, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and type two diabetes (a group of diseases that result in too much sugar in the blood) with a foot ulcer (an open sore or wound). The [DATE] comprehensive assessment showed Resident 218 required partial/moderate assistance with activities of daily living (ADLs). The assessment also showed the resident had an intact cognition. Review of the [DATE] Medication Administration Record (MAR), showed Resident 218 was to receive 20 units (a measurement) of Basaglar insulin, injected with an insulin pen, every morning. A concurrent observation and interview on [DATE] at 8:18 AM, showed Staff E, Registered Nurse, preparing an insulin pen for Resident 218. Staff E scrubbed the hub of the pen with an alcohol swab, attached the needle, and dialed up 20 units of Basaglar insulin on the insulin pen. Staff E cleaned the resident's skin with an alcohol swab then injected the 20 units of insulin into Resident 218's lower abdomen. Staff E did not prime the pen prior to administering the insulin. Staff E stated they did not know the insulin pen needed to be primed before dialing up the correct amount of insulin. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and heart failure. The [DATE] comprehensive assessment showed Resident 1 required set-up assistance from one staff member for ADLs. The assessment also showed Resident 1 had a severely impaired cognition. A concurrent observation and interview on [DATE] at 8:51 AM, showed Staff L, Licensed Practical Nurse, preparing medications for Resident 1. Staff L obtained a package of medication from the medication cart, removed one tablet, placed it into the medication cup with other medications, and locked the medication cart. Staff L stated they were going to give the medications to Resident 1. Staff L was asked to review the expiration date on the medication prior to going into the resident room. Staff L stated the medication package showed the medication had expired on ,d+[DATE]. Staff L removed the medication from the medication cup and obtained a new package of medication with an expiration date of ,d+[DATE]. Staff L stated they were responsible for checking the expiration dates of all medications on their cart. Staff L stated they did not check the medication package because it had just arrived from the pharmacy, so they assumed it was good. During an interview on [DATE] at 1:54 PM, Staff B, Director of Nursing Services, stated the process for administering medication involved reviewing the physician order, the medication, the route of delivery, ensuring administration was to the correct resident, and checking the expiration date. Staff B stated the nurses on the medication carts were responsible for reviewing medication expiration dates. Staff B stated the process for administering insulin with a pen involved cleaning the hub of the pen, putting a needle on the pen, dialing up the correct amount of insulin, then injecting the insulin. Staff B stated they were not aware that the insulin pen needed to be primed. Reference: WAC [DATE](3)(k)(ii)

Based on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were corrected on/after residents admission to the facility and had the required Level II referral sent if residents had a positive Level I PASARR for 2 of 8 residents (Resident 29 and 56) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarification to the Pre-Admission Screening and Resident Review (PASARR or PASRR) Level I Screening Process, dated 07/06/2024, showed that nursing facilities will ensure residents with a positive Level I PASARR screen have been evaluated by the designated state-authority through the Level II PASARR process and approved for admission prior to admitting to the nursing facility. <Resident 29> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder [PTSD, a mental health condition that's caused by an extremely stressful or terrifying event) and depression. The 09/12/2024 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Review of a Level I PASARR screening form dated 08/30/2024, showed Resident 29 was pending an admitted ASAP (as soon as possible) and had anxiety disorders checked for their PTSD in the SMI indicators section. No other SMI indicators were checked, and a Level II referral evaluation was required for Residents 29's SMI indicators. During an interview on 10/28/2024 at 9:28 AM, Staff H, Social Service Director (SSD), stated they were responsible for reviewing the accuracy of the PASARR Level I screenings and Level II referral prior to the resident admitting into the facility. Staff H stated Resident 29's PASARR Level I screening was not accurate with their diagnosis of depression. Additionally, the residents PASARR was not sent for a Level II referral prior to their admission into the facility. 45117 <Resident 56> Review of the medical record showed Resident 56 was admitted to the facility on [DATE] with diagnoses including PTSD and anxiety. The 08/26/2024 comprehensive assessment showed Resident 56 required partial/moderate assistance of one staff member for activities of daily living. The assessment also showed the resident had an intact cognition. Review of a Level I PASARR screening form, dated 08/20/2024, showed Resident 56 was pending an admitted [DATE] and had no serious mental illness indicators. Review of a Level I PASARR screening form, dated 09/02/2024, showed Resident 56 was a current nursing facility resident, with an admitted [DATE]. The form showed serious mental illness indicators of an anxiety disorder and PTSD. Further review of the form showed No Level II evaluation indicated. During an interview on 10/28/2024 at 11:38 AM, Staff H, SSD, stated they were responsible for reviewing the PASARR Level I screenings prior to the resident's admission to the facility. Staff H stated Resident 56's PASARR Level I screening was incorrect and should have been referred for a Level II screening. During an interview on 10/29/2024 at 1:42 PM, Staff B, Director of Nursing Services, stated Staff H was responsible for reviewing the PASARR Level I screenings prior to admission. Staff B stated if a PASARR Level II screening was indicated, Staff H was responsible for completing the referral. Staff B stated Resident 56's PASARR Level I initial screening was incorrect. They stated Staff H completed a second PASARR Level I with the correct diagnoses and that should have been sent for a Level II referral. Reference: WAC 388-97-1915(1)(2)(a-c)

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process that addressed the resident's goals and needs, that involved the resident and the interdisciplinary team [(IDT) a group of healthcare professionals from different disciplines to help residents receive the care they need] for 1 of 3 residents (Resident 264) reviewed for discharge planning process. The failure to develop and implement a discharge plan consistent with the resident's needs and expressed discharge goals, placed the resident at risk for decreased self-worth and dissatisfaction with their living situation. Additionally, the facility failed to ensure a safe discharge when 1 of 2 residents (Resident 61) discharged against medical advice (AMA) with a peripheral inserted central catheter line [(PICC) a thin, flexible tube that is inserted into a vein in the arm and threaded into a large vein above the heart used to deliver fluids and medications]. This failure placed the resident at risk for infection and poor outcomes. Findings included . <Resident 264> Review of the medical record showed Resident 264 was admitted to the facility on [DATE] with diagnoses including fainting and collapse, heart failure, and dehydration. The 10/15/2024 comprehensive assessment showed Resident 264 required partial/moderate assistance of one staff member for activities of daily living (ADLs) and was cognitively intact. The assessment also showed Resident 264's goal for discharge was to return to the community. Record review of a care plan dated 10/01/2024, showed no documentation of discharge planning for Resident 264. Record review of a social services progress note dated 09/27/2024 at 2:38 PM, showed Resident 264 requested to discharge that day. Staff H, Social Services Director, documented they had explained the discharge process to Resident 264, who became upset and stated they wanted to return home. Staff H contacted the provider who addended their previous visit note dated 09/19/2024 that showed Resident 264 was ok to d/c from facility. Record review of a nursing progress note dated 09/24/2024 at 3:44 PM, showed Resident 264 discharged home AMA with their family. <Resident 61> Review of the medical record showed Resident 61 was admitted to the facility with diagnoses including cellulitis (a serious bacterial skin infection) of their left lower limb, osteomyelitis (a serious bone infection), and paraplegia (paralysis that makes it impossible to stand or walk). The 08/02/2024 comprehensive assessment showed Resident 61 required substantial/maximum assistance with ADLs. The assessment also showed Resident 61 had an intact cognition. Review of a Medication Administration Record (MAR) dated 08/2024, showed Resident 61 was receiving an antibiotic through their PICC line that started on 07/27/2024 and was to end on 09/02/2024. Review of a nursing progress note dated 08/29/2024, showed the licensed nurse had placed a call to Resident 61, who stated they would not be returning to the facility for their treatment cares, including their antibiotic medication through their PICC line. Review of the medical record showed no documentation that Resident 61's provider was notified of the AMA discharge with their PICC line in place. There was no documentation that showed Adult Protective Services (APS), or law enforcement had been notified. During an interview 10/29/2024 12:00 PM, Staff H stated the process for discharge planning started upon admission. They stated they reviewed the resident's goals for discharge and entered them into the care plan. Staff H stated they were required to have the initial goals documented in the care plan in the first 72 hours after admission, then re-evaluate and update the care plan within the first two weeks after admission. Staff H stated thought they had documented discharge planning in the progress notes for Resident 264. They stated their normal process was add that information to the care plan. Staff H stated, after reviewing the medical record, there was no documentation addressing Resident 264's discharge plans. During an interview on 10/29/2024 at 1:43 PM, Staff B, Director of Nursing Services, stated the process for discharge planning started on admission and was constantly reviewed. They stated Resident 61 left the facility AMA with their PICC line in place. Staff B stated it was unsafe to discharge a resident with a PICC line in place. They stated the facility should have notified the provider and other entities (law enforcement/Adult Protective Services) when Resident 61 did not return to the facility. Reference: WAC 388-97-0080(3)(a)(5)(7)(a-c)

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care of their type two diabetes mellitus (a disease that causes inadequate control of the body's blood levels of sugar, which can lead to abnormally high or low levels of the body's blood sugar) in accordance with professional standards of practice for 1 of 2 residents (Resident 218) reviewed for insulin (a medication that assists in control of blood sugar levels) therapy. This failure placed residents at an increased risk for unmet care needs, emergent situations, and poor health outcomes. Findings included . Review of a policy titled, Nursing Care of the Older Adult with Diabetes Mellitus, dated November 2020, showed blood glucose (sugar) monitoring of diabetic residents were needed to detect hyperglycemia (high levels of blood sugar in the body, greater than 150 milligrams/deciliter [mg/dL, units of measure]) and hypoglycemia (low levels of blood sugar in the body, less than 70 mg/dL) complications associated with diabetes. The policy showed that residents who were receiving sliding scale insulin ([SSI], a scale that increases the amount of pre-meal insulin that is administered to a resident based on their blood sugar level before the meal) should be monitored three to four times a day. Review of a policy titled, Obtaining a Fingerstick Glucose Level, dated September 2014, showed the fingerstick glucose device was used to determine a diabetic resident's blood sugar level. The policy showed that staff were to ensure the device was working properly as instructed by the manufacturers recommendations. <Resident 218> Review of the medical record showed Resident 218 was admitted to the facility on [DATE] with diagnoses including aftercare for surgery on their left lower leg, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and type two diabetes. The 10/17/2024 comprehensive assessment showed the resident was cognitively intact, able to make their needs known, and received daily insulin injections. During an interview on 10/23/2024 at 11:07 AM, Resident 218 stated the nursing staff utilized the residents own blood glucose monitor called FreeStyle Libre 2 (a sensor placed on the skin that continuously tracks and records blood glucose levels throughout the day and night) before administering their SSI. The resident stated their blood glucose levels had been different since they admitted to the facility and were sometimes going higher than they expected with readings at 230 mg/dL and other times going lower than they expected with readings in the 80's mg/dL. Resident 218 stated the fingerstick glucose monitoring device had not been used to check the residents blood glucose due to them having the FreeStyle Libre 2 sensor since they had admitted to the facility. Additionally, Resident 218 stated they changed out their blood glucose monitoring sensor on 10/22/2024, sometime in the morning. Review of the manufacturer's recommendations titled, FreeStyle Libre 2 Flash Glucose Monitoring System, revised August 2024, showed failure to use the System according to the instructions for use may result in you missing a severe low blood glucose or high blood glucose event and/or making a treatment decision (like administering more insulin when blood sugars values are high and/or administering sugar in the form of food or medications when values are low) that may result in injury. If your glucose reading alarms and reading from the System do not match symptoms or expectations, use a fingerstick blood glucose value from a blood glucose meter to make diabetes treatment decisions. The recommendation stated that during the first 12 hours after changing out the sensor, the sensors blood glucose values should not be used to make treatment decisions and the values needed to be confirmed with another blood glucose monitor before deciding what to do or what treatment decisions to make. Review of Resident 218's Medication Administration Record for October 2024, showed the resident's blood glucose checks were four times a day .before meals and at bedtime . The resident was administered a scheduled insulin injection in the morning and, in addition to that, a SSI based on the resident's blood glucose levels, .if 131 - 180 = 2 units (a unit of measure for insulin medication); 181 - 240 = 4 units; 241 - 300 = 6 units . On 10/22/2024 Resident 218 was administered their scheduled insulin in the morning and SSI of six units, one time in the afternoon for a 246 mg/dL blood glucose value by Staff E, Registered Nurse (RN). During an interview on 10/25/2024 at 8:18 AM, Staff E, RN, stated they had been administering Resident 218's SSI based on the FreeStyle Libre 2 sensors blood glucose readings. Staff E stated they were unaware of the FreeStyle Libre 2 sensors manufacturer's recommendations of not utilizing the blood glucose values for the first 12 hours after changing the sensor without confirming the values with another glucose monitor. Staff E stated they had never used the facility's fingerstick glucose device for reading Resident 218's blood glucose levels, nor to confirm the FreeStyle Libre 2 sensors readings. During an interview on 10/28/2024 at 3:29 PM, Staff D, Resident Case Manager, stated they did not have a policy for Resident 218's continuous blood glucose monitoring system and would refer to the FreeStyle Libre 2 sensors manufacturer's recommendations. Staff D stated Resident 218 informed them that the FreeStyle Libre 2 sensor was changed out on 10/22/2024 but was unaware of what time it was changed. Staff D stated they were unaware of the manufacturer's recommendations to not utilize the blood glucose sensors readings for the first 12 hours after it was changed out. Staff D stated that on 10/22/2024 Resident 218's blood glucose readings should have been confirmed with the facility fingerstick glucose device during the first 12 hours of changing the sensor. During an interview on 10/30/2024 at 11:13 AM, Staff A, Administrator, and Staff B, Director of Nursing Services, stated the facility did not have a process in place for confirming the FreeStyle Libre 2 sensor's blood glucose levels for Resident 218 after the sensor was changed out, per the manufacturer's recommendations. Reference: WAC 388-97-1060(1)

Based on observation, interview and record review the facility failed to ensure one of three residents (1) was assessed for and interventions developed for exit seeking behaviors and elopement (leaving the premises unaccompanied, when assessed not to be safe to do so) in a timely manner. Failure to ensure assessment for elopement risk and adequate supervision, placed residents at risk for elopement and associated injuries. This failure caused actual harm to Resident 1, who walked away from the facility and fell , resulting in injuries that required medical treatment. Findings included . Record review of the facility's policy titled, Elopement/Wandering, revised 07/18, showed that residents would be assessed for potential for elopement during admission and when a change of condition was noted, resulting in cognitive changes placing them at risk for elopement. Resident 1. Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses to include [CONDITION(S)] (damage or disease that affects the brain) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Resident 1 was assessed at low risk for elopement that included statements that the resident did not ambulate independently with or without use of assistive devices and the resident had no reported episodes of wandering in the past six months. Review of the 02/24/2022 comprehensive assessment showed the resident had severe cognitive impairment, was alert to self, could answer simple yes/no questions and required extensive assistance from staff for transfers and used a wheelchair for mobility. Review of a 05/16/2022 quarterly elopement risk evaluation showed the resident continued to be low risk for elopement/wandering and had no reported episodes of wandering in the past six months; however review of the resident's progress notes showed a change in behavior with exit attempts on 04/11/2022 and 05/04/2022. Review of a 04/11/2022 progress note at 3:23 AM, by Staff C, Registered Nurse (RN), showed res(ident) attempted to get out of facility through the west exit door, security alarm went on, immediately res(ident) returned to room, when asked, res(ident) stated (they) want to go home. Review of a 05/04/2022 progress note showed Resident at 1730 (5:30 PM) came out of room without W/C (wheelchair), LN (licensed nurse) tried to intervene and get resident to go get W/C. Resident did turn around and go back to room and sat on bed . Resident came back out into hall way without W/C again. Resident (eventually) sat in W/C and started heading towards (the) front door. LN again tried to intervene to keep resident from leaving, then resident got up and headed towards LN . Review of a 05/23/2022 incident report showed that Resident 1 was discovered missing around 2:20 AM and after extensive search inside the facility and surrounding area, the resident was found, by local police and facility staff, lying on the road near Highway 97 traffic light (approximately 720 yards from the facility). An ambulance transported Resident 1 to the local emergency department and was diagnosed with a hematoma (an abnormal collection of blood outside of a blood vessel) and abrasion to the right side of the forehead and right periorbital (around the orbit of the eye). The resident was started on preventative oral antibiotics. Resident 1 returned to the facility that morning. The incident report included the following statement: This is the resident first attempt . to exit seek, now put into the Elopement Book. During a telephone interview on 06/03/2022 at 4:30 PM, Staff C, RN, stated that he worked the evening and night shifts on the weekends. He stated Resident 1 usually slept well at night, however, there were times they would come out to the nurse's station, walking without a walker or wheelchair. He also stated that in the weeks before Resident 1 eloped, they would frequently approach the exit doors stating I don ' t live here, I want to leave. Staff C stated he was working that night (05/23/2022) and no door alarms sounded when Resident 1 left the facility. Staff C stated all of the door alarms sounded when anyone were to exit, except the front main entrance that required a code to unlock and bypass the alarm. During a telephone interview on 06/06/2022 at 1:05 PM, Staff D, Nursing Assistant (NA), worked night shift and stated that Resident 1 would get up to use the toilet or go to the nurse's station some nights. Sometimes they were in the wheelchair and lately they had been walking. Staff D stated they had found Resident 1 at the front door several nights before they eloped. When asked how they thought Resident 1 got out the door without sounding any alarms, Staff D stated, Maybe through the front door by using the code? During an interview on 06/06/2022 at 1:10 PM, Staff E, Entrance Screener, stated that Resident 1 had tried to get out the front doors several times. Each time I would tell the nurse at the nurse's station. Observation of the front facility door on 06/06/2022 at 1:15 PM showed an electronic key pad with a note CODE 1234* taped next to the pad. Observation on 06/06/2022 at 1:20 PM showed Resident 1 in a wheelchair, propelling with their feet to their room. The resident transferred self from their wheelchair to the bed in a steady manner. At this time, Resident 1 was asked if they remembered falling down outside during the night? They stated no and added I want to sleep now. During an interview on 06/06/2022 at 1:40 PM, Staff F, RN, Resident Care Manager, stated Resident 1 had been working with therapy and began walking more on their own. When asked why Resident 1 was not assessed as an elopement risk at the 05/16/2022 quarterly, Staff F stated they were not aware Resident 1 had been exit seeking. During an interview on 06/06/2022 at 2:06 PM, Staff B, Director of Nursing, stated they thought this was Resident 1's first exit attempt and was not aware of the previous attempts. Staff B stated they took Resident 1 to a door key pad to the back patio and asked them if they could open the door. Staff B stated Resident 1 read the note next to the panel and put in the correct code. Staff B stated, I think Resident 1 put in the code and walked out of the facility front doors on 05/23/2022. Reference: WAC 388-97-1060(3)(g) This is a repeat deficiency from Statement of Deficiency dated 03/10/2020.

Based on observation, interviews, and record review, the facility failed to provide adequate supervision, follow the resident's plan of care regarding sling types, and implement safety interventions during a mechanical lift transfer involving one of three residents (#1) reviewed for falls with injuries. This failed practice resulted in actual harm to Resident #1 who fell to the floor from the mechanical lift and sustained a hematoma (collection of blood outside blood vessels) and abrasion to the forehead necessitating a transfer to the emergency room . Findings included . Resident #1. Review of the resident's medical record showed [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment, dated 10/23/19, showed she required extensive assistance with two staff for dressing, toileting, turning in bed, and transfers using a mechanical lift; and extensive assistance with one staff for eating and personal hygiene. Review of the resident's plan of care, dated 07/05/18 and 07/06/2018, showed the resident had limitation in range of motion to both hands, right and left arms due to arthritis and left shoulder dislocation. Nursing orders on the plan of care, dated 07/22/18, showed staff was to use the sling that attached crossways through the resident's legs. The nursing order was revised on 12/03/2018, showing the sling was an extra large size that attached crossways through the legs. The plan of care, dated 07/22/2018, showed the resident had impaired cognition and was slow to respond at times. Review of a facility investigation report showed on 01/12/2020 at 2:20 PM the resident was transferred from the wheelchair to the bed using the mechanical lift device. The resident was leaning to the left side and fell out of the sling onto the floor landing on her left side. She sustained a hematoma and abrasion to the forehead. The investigation report showed the resident had chronic contractures that curved her upper body to the left, which prevented a barrier to proper center positioning on some of the sling types. Review of hospital records, dated 01/12/2020, showed the resident had fallen out of the mechanical lift sling striking her right upper forehead causing a hematoma. The resident had very limited range of motion and strength to all her extremities with severe contractures of her joints. Review of a written statement dated 01/12/2020, by Staff A, Nursing Assistant (NA), showed that just as she started moving the mechanical lift to the bed the resident slid out of the sling. The statement showed Staff B, NA, was moving the resident's wheelchair and was unable to help prevent the fall or guide the resident. Review of the written statement by Staff B, dated 01/12/2020, showed when Staff A was moving the sling towards the resident's bed Staff B was moving the resident's wheelchair and was not able to help prevent the fall. Review of the Operation Manual for the mechanical lift, utilized in the resident's transfer on 01/12/2020, showed the second staff member involved in the transfer was to support the resident's legs as the primary staff member moved the lift into position over either the resident's bed or wheelchair. Observation on 03/10/2020 at 2:30 PM of a reenactment of the incident by Staff A and Staff B, showed Staff B moved the resident's wheelchair, which included a headrest and two footrests, and placed it against the wall. At the time the wheelchair was being moved by Staff B, Staff A began moving the mechanical lift. Staff B had her back to the resident and the mechanical lift at the time of the fall, thus was not supporting the resident's legs to prevent injuries as recommended in the above Operation Manual. In addition, both Staff A and Staff B stated the resident's left shoulder was hanging out past the edge of the sling causing her to lean to the left prior to moving the mechanical lift. They had attempted to reposition her shoulder, however due to her contractures and weight were unable to do so. They stated the sling that was utilized during the transfer on 01/12/2020 was not the type that crossed at the legs (as ordered on the resident's plan of care), but rather did not cross at the legs, which lessened the support and security. Staff A stated during an interview on 03/10/2020 at 1:30 PM, that she had transferred the resident several times using the mechanical lift, however she utilized the cross sling (leg straps would criss cross each other and attach to adjacent sling support hooks) as that type of sling was safer to use. She stated the resident at the time of the fall on 01/12/2020 was in a full sling (legs straps did not criss cross) that had been placed under her by the day shift NA. Staff A stated most of the time the resident kept her neck on top of her left shoulder, and was very stiff. She stated both her and Staff B tried to reposition the resident in the sling, prior to the transfer, as she was leaning to the left side but were unable as the resident's weight prevented them from being able to move her. Staff A stated Staff B was trying to move the resident's wheelchair away from the lift at the time of the resident's fall from the mechanical lift. The resident was hanging in mid-air when Staff A began moving the mechanical lift. The resident immediately fell out of the sling onto the floor, hitting her head on the floor. On 03/10/2020 at 2:10 PM Staff B stated, the resident was in a wheelchair and was to be transferred into bed. Staff A was operating the mechanical lift and she was assisting with the transfer. Staff B stated both she and Staff A were trying to push the resident's body into the sling as she was leaning to the left, however they were unsuccessful. She stated she was parking the resident's wheelchair to the side and by the time she turned around (had her back to the resident and mechanical lift) the resident was already on the floor. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure 1 of 1 resident (#33), reviewed for impaired skin of the perineal area (between legs), received personal care in a manner that minimized pain while receiving that care. This failure caused actual harm as the resident experienced frequent and severe pain. Findings included: Resident #33. Per medical record review, he had [DIAGNOSES REDACTED]. Review of current medication orders showed he received a [MEDICATION NAME] (narcotic) 5 mg every evening at bedtime and a Tylenol (mild [MEDICATION NAME]) as needed, both for arthritic pain. The 06/03/18 quarterly comprehensive assessment (MDS) revealed moderately impaired cognition. It was identified the resident was always incontinent (involuntary loss of urine and feces for which incontinent briefs were used). He required extensive assistance with transfers and personal hygiene (including to cleanse the skin after each incontinent episode). Evaluation of the skin revealed Moisture Associated Skin Damage (MASD) and incontinence-associated [MEDICAL CONDITION] (skin diseases resulting in inflammation of the skin). Review of the 06/05/18 physician orders [REDACTED]. The 06/28/18 physician's evaluation noted the back surface of his scrotum had no open wounds (healed since 06/03/18). On 08/08/18 at 2:37 PM, Staff D, Licensed Practical Nurse (LPN) / Resident Care Manager (RCM), residents with a [DIAGNOSES REDACTED]. On 08/06/18 at 9:45 AM, the resident was observed scooting up and down in his wheelchair and grimacing, which continued for approximately ten minutes. When asked if he was in pain, he said he was; it was his back. When Staff H, Nursing Assistant (NA), answered the call light, she asked the resident if he wanted changed and he said yes. She left, returning with a mechanical lift and Staff M, NA, to assist transferring the resident to bed. When asked about the cause of the resident's pain, Staff H said it was not his back but his bottom. On 08/06/18 at 9:53 AM, Staff M obtained 'Prevail' disposable cleaning cloths (chemical listed on the container included alcohol and fragrance - potential skin irritants) and 'Perifresh' spray solution (chemicals listed on the bottle included fragrance and citric acid - potential skin irritants). Following the gathering of supplies, Staff H and Staff M positioned the resident on his left side. The back of his upper left thigh was observed with a small open area (less than one centimeter). The whole area, including the back of the scrotum, was reddened. Staff H confirmed the open area had been there for a while and there had been one on the upper right thigh, but it had recently healed. When the NA sprayed the Perifresh directly onto the resident's upper left thigh, he screamed loudly over and over, That hurts! The resident continued to yell out That hurts during the remainder of the cleaning process and while the barrier cream was rubbed onto the scrotal and rectal area. He was then turned onto his back. The scrotum was noted to have small reddened areas over the entire surface. The Perifresh was sprayed directly onto the scrotum by Staff M. The resident screamed louder in a long continual yell, repeating That hurts! and Stop! The NAs apologized but informed him he needed to be cleaned. When the disposable cloths were used to remove the old barrier cream, that again elicited screaming which continued until the application of the cream was completed. After applying the fresh incontinent brief, Staff H asked the resident about his pain; he said it was gone. On 08/06/18 at 10:18 AM, Staff M stated the licensed nurses were aware of the resident's pain during the cleaning process. She stated she realized it hurt the resident, but she did not know what else to do. She and Staff H reported it was like this every time he is changed. Staff H stated the resident's incontinent brief was changed after every meal or about every two hours. On 08/06/18 at 10:45 AM, the resident was questioned about the type of pain he experienced during the skin care. He stated the pain was hard to describe, maybe stinging type pain. He stated there was alway a great deal of pain every time they provided the incontinent care. On 08/06/18 at 2:30 PM, Staff I and Staff J (both NAs), provided incontinent care as the resident was laying on his back in bed. Staff I used a moist disposable cloth to gently wash off the genitalia, including the scrotum. The resident said, in a normal voice, That hurts and You're hurting me. Staff I explained what she was doing. Additonally, Staff I said she was hired in March, while Staff J identified her hire date was (MONTH) of this year. They both agreed the resident's skin on his scrotum and surrounding area was very tender and it would break down off and on since they had been here. When asked about the Perifresh spray, Staff K stated she did not use it directly on the resident; he did not like that. Actually, no resident likes to have the Perifresh sprayed directly onto them. She said because the resident did not like it, she did not do it. She said that the disposable wash cloths could be dry and cause more of a drag across the tender skin. She said the resident had always told them it hurt when care was done. She said he has such fragile skin that she suspected it did hurt him. On 08/07/18 at 9:15 AM, the resident was seated in his wheelchair in his room; he was noticed squirming in his chair. He stated he did have pain and I need changed. At 9:30 AM, Staff K and Staff L, both NAs, entered the room and transferred him via mechanical lift to his bed. The resident received incontinent care after his wet incontinent brief was removed. His scrotum was reddened and excoriated (superficial skin damage). Staff K used the disposable wash cloths to cleanse the area. The resident had asked the NAs, prior to starting the cleaning, Don't hurt me and was told by Staff K that she would try not to, but he needed the care. During the process, the resident raised his voice screaming and crying out, It hurts over and over. Staff K talked to him during the procedure, but he continued to loudly complain of pain. When Staff K was asked about the procedure for his incontinent care, she replied she usually used the Perifresh spray but Staff H had told her this morning that the resident did not like the spray used, so she was not using it, just the disposable wash clothes. At 9:40 AM, during the continued care, Staff E, LPN, entered with a medicated cream for under his arms and abdomen. Staff E stated there was MASD to that area because, immediately after the incontinent brief was changed and he was cleaned, he would wet again. Staff E stated that, during the summer, he was almost always wet from urine and sweat which caused the skin breakdown. On 08/08/18 at 11:20 AM, the resident had been positioned in bed by Staff K and Staff A, Director of Nursing (DON). The DON observed and then confirmed an open area of less than two centimeters probably on the upper back left thigh. She stated the resident had open areas in the past. The resident told the staff it hurt when the incontinent care started and continued to tell staff there was pain until the cleansing stopped. The DON observed there were reddened spots on the resident's scrotum, stating the areas looked prickly. The DON further stated the facility had disposable wash cloths and a washing spray used that had no chemicals that were irritating to the skin, but they were replaced with a different product. When it was discussed the cloths had fragrance and citric acid in them while the Perifresh spray had fragrance and alcohol, she stated she had not looked at the ingredients on the new cleansers to ensure they wer not irritating to skin. The DON was asked if it was the process to spray the Perifresh directly onto the resident's skin; she said No, it was put onto the cloths before using for cleansing. On 08/08/18 at 3:00 PM, Staff F, LPN, stated she saw the resident yesterday and there were small red areas on the scrotum which looked painful. She had heard the resident complain of pain when the area was cleaned. She stated the skin impairment on his scrotum was off and on again. He would heal from the zinc ointment and then develop more open areas later. She said his incontinent brief was usually wet from urine. On 08/09/18 at 12:32 PM, Staff D stated the physician had just assessed the resident's skin and ordered a new treatment to the scrotum, perineum, thighs, and buttock folds. Staff D stated the NAs would be changing their cleaning technique to prevent the pain the resident had with the current cleaning procedure. The 03/13/18 plan of care included a problem of pain due to arthritis of joints and chronic back and right leg pain. Approaches were for the pain medications as ordered. Alternate approaches included change position, relaxation, or diversions. However, there were no pain medications specifically for the resident's pain during personal care with excoriation and open areas on his perineal area. Further, the plan of care identified the resident at risk of developing skin breakdown due to urinary incontinence. However, there was no identification of the excoriation of the resident's scrotum and posterior perineal area; no approaches to prevent pain during care were developed. Observation of the NAs providing personal care after episodes of incontinence revealed there was nothing done in preparation for the pain the resident experienced which the NAs and licensed nurses had known was occurring. Review of the plan of care and resident record confirmed there was no pain medications or other pain relieving approaches provided immediately before the personal care for incontinence was to begin approximately every two hours. Reference WAC 388-97-1030(1)

Based on observation, record review, and interviews the facility failed to ensure adequate supervision was provided during transfers for 1 of 3 residents (#1) reviewed for accidents. This failure caused actual harm to Resident #1 due to the utilization of incorrect transfer equipment by staff, which resulted in fractures of the tibia and fibula (two bones connecting the knee to the ankle) of both legs. Findings include: Resident #1: admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Physical Therapy (PT) records revealed on 11/14/16 a referral was made to PT due to the resident's increased weakness and possible change in transfer equipment. Review of the PT evaluation, dated 11/14/16, noted the resident required maximum assistance with transfers. She was noted to be weak in her legs. The resident was unsafe with the sit to stand transfers (mechanical device that stands residents up from a sitting position) due to her lack of participation. Due to that risk the PT recommended a Hoyer lift transfer (mechanical lift device which requires no participation from the resident). Education was provided at that time by the PT to Nursing Assistants (NAs) relative to the change in transfer equipment. Review of a comprehensive nursing assessment, dated 01/19/17, revealed the resident was unable to ambulate, and required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and toilet use. Review of the plan of care, dated 07/12/10, noted she had impaired cognition and decision making ability. Nursing approaches, dated 11/14/16, were for staff to utilize a Hoyer lift for all transfers. In addition, review of the In Room Care Plan (care plan kept inside the resident's closet for staff use), last updated on 11/14/16, noted two staff was required to assist the resident with transfers utilizing a Hoyer lift system. Review of Progress Notes, dated 01/23/17 at 6:24 a.m., revealed the resident yelled out in pain as staff attempted to get her dressed. A nursing assessment noted swelling, slightly warm, and yellow bruising with areas of dark purple bruising throughout the yellow from below the knees to the lower shin areas on both legs. The resident denied falling, or other incidents that could have caused bruising. Review of hospital records noted the resident was transferred to the emergency room that morning at 7:40 a.m., where x-rays revealed tibia and fibula fractures to both legs, causing extreme pain upon any movement. Review of the facility investigation report of the above incident noted that following interviews with the resident and staff, the method utilized during transfers was the sit to stand mechanical device, rather than the Hoyer lift as care planned. Observation of the sit to stand mechanical device on 02/09/17 at 3:10 p.m. with Staff A, Director of Nursing, noted a cushioned type trough in which the resident's lower legs would be in direct contact with. Staff A stated when the sling raised the resident to a standing position there was much pressure applied against the resident's lower legs as they would lean into the cushioned area. The areas of bruising corresponded with the cushioned trough. Staff A stated that was the probable cause for the resident's fractures, and the fact she was not participating much with the transfer due to weakness. On 02/06/17 at 12:45 p.m. the resident, with splints to both lower legs, was observed screaming out in pain as she was being turned from side to side by two caregivers to change her disposable brief. The following interviews were conducted on 02/06/17: 1:50 p.m.- Staff B, NA, stated the sit to stand transfer device with two staff was always utilized for the resident. The bruising to her legs matched up with the padded areas on the transfer device. She was unaware a hoyer lift device was to have been used for transfers. Staff B stated she did not always read the care plans as they had shift report between the NAs. 1:55 p.m.- Staff C, NA, stated the hoyer lift had never been used for resident transfers, only the sit to stand device with two staff. Upon transferring the resident back to bed on the evening shift she often was very tired so staff would have to tell her to stand up straight as she would slouch. Staff C stated she was aware the resident was to have been assessed for the hoyer lift, but never heard anymore about it. 1:43 p.m.- Staff D, NA, stated all caregiver staff used the sit to stand device with the resident. She had no knowledge a hoyer lift was to have been used. 1:35 p.m.- Staff E, LN, revealed no knowledge the resident was being transferred via a sit to stand device. He stated the issue relative to the wrong type of transfer device being utilized was a break down in communication with care plans. The resident doesn't willingly bend her knees, and has many bone issues. 2:05 p.m.- Staff F, LN, revealed she had no knowledge NA staff was transferring the resident with the sit to stand device. The resident was unable to support herself, and did not like to bend her knees. She stated she was the LN that initially assessed the resident's bruises. Both legs had a yellowish color to them with the purple bruises. Staff F stated the yellow color could have even been from the lighting in the resident's room. Despite declining changes in the resident's condition necessitating a change in transfer equipment, staff did not provide the necessary supervision to ensure the resident's safety during transfers.

Based on record review and interviews the facility failed to consult with the physician in a timely manner regarding significant changes in the condition of 1 of 3 residents (#1) reviewed for injuries. Resident #1 suffered actual harm due to lack of timely consultation with the physician regarding pain medication and medical treatment. Findings include: Resident #1: review of the resident's medical record revealed [REDACTED]. Licensed staff obtained physician's orders [REDACTED]. Mobile x-ray services were then requested by staff at that time, however the x-ray was not taken until 11:45 a.m. (over 11 hours later from the time the order was received). X-rays revealed a fractured right hip. The resident was transferred to the hospital for medical treatment at 3:30 p.m. (17 hours following his fall). Despite the resident's complaints of hip pain, and staff acknowledging they only had Tylenol prescribed for the resident, the physician was not consulted for additional pain medication until 10:30 a.m. on 12/21/15 (12 hours following his fall). A telephone interview on 1/7/16 at 11:45 a.m. with the resident's primary physician revealed she had no knowledge of the resident's condition until 10:30 a.m. on 12/21/15, at which time staff was requesting pain medication for the resident. She was unaware of the difficulty staff had obtaining the mobile x-ray that had been ordered earlier by the on-call physician. She stated she takes her own calls on her residents beginning at 8:00 a.m., and residents had physician services available 24 hours per day. Staff failed to consult with the physician in a timely manner regarding pain medication and the delay in obtaining x-rays, which resulted in unnecessary suffering to the resident and delay in medical treatment. Cross-refer to F309. The facility failed to recognize, monitor, and seek immediate medical attention for signs of significant injury to the resident.

Based on record review and interviews the facility failed to recognize, monitor, and seek immediate medical attention for signs of significant injury for 1 of 3 sampled residents (#1) reviewed for injuries. Delay in obtaining the necessary medical attention resulted in pain, suffering, and untimely medical treatment to Resident #1. Findings include: Resident #1: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Progress Notes dated 12/20/15 revealed the resident had returned from the hospital that day following prostrate surgery. He was alert and oriented, and required extensive assistance with activities of daily living. Review of the resident's medical record and facility investigation report noted on 12/20/15 at 10:30 p.m. the resident was found on his knees beside his bed. He had utilized the bedside commode, then attempted to get himself back to bed. However, his knees became weak causing him to fall to the floor, primarily on his right knee. The assessment by Staff D (Licensed Nurse-LN) stated the resident was very agitated, anxious, and short of breath, thus she administered [MEDICATION NAME] prior to her assessment. No signs of injury were noted at that time. At 12:30 a.m. on 12/21/15 the resident was observed lying on his back with his right knee bent in an angle unusual position. The resident was asked by the LN to straighten his leg, and when he attempted he was unable and displayed extreme pain. Tylenol was administered as that was the only prn (as needed) pain medication resident had ever needed since admission. Staff D stated his pain was extreme at that time. Staff D then called the on-call physician at 12:30 a.m. on 12/21/15 and received orders for a right hip x-ray. She then notified the mobile x-ray service company and documented anticipating arrival shortly. Documentation by Staff D on 12/21/15 at 2:27 a.m. revealed awaiting x-rays. The resident was resting quietly with eyes closed - no outward signs of discomfort. Following the above entry the mobile x-ray company was called three separate times that morning: 6:30, 8:27, and 9:30 a.m. regarding time of arrival and staff received reports of various emergencies in other areas which delayed their arrival. There was no assessment of the resident's right hip/leg area or vital signs taken until 7:30 a.m. on 12/21/15 (seven hours following the assessment at 12:30 a.m.). At that time the resident's pain was noted to be 8 out of 10, with 10 being severe pain. Documentation by Staff E (LN) stated Tylenol was again administered to the resident which is the only prn pain med ordered for resident at that time. At approximately 10:30 a.m. a Nursing Assistant (NA) informed Staff E the resident was requesting a stronger pain medication and his pain was 9 out of 10. The resident's primary physician was then notified and ordered a narcotic pain medication. The physician was informed that an x-ray had been ordered and they were awaiting arrival. The x-ray was completed at 11:45 a.m. (approximately 11 hours following the physician's orders [REDACTED]. physician's orders [REDACTED]. The resident left the facility by ambulance at 3:30 p.m. (17 hours following his fall). An interview with the resident on 1/7/16 at 11:10 a.m. revealed he experienced pain 10 out of 10 immediately following the fall. He stated as long as I didn't move it didn't hurt. Resident #3 (resident's roommate) was interviewed on 1/7/16 at 11:15 a.m. He stated the resident fell really hard onto the floor. He stated the resident moaned a lot - anytime he tried to move - he was in a lot of pain. Resident #3 stated at least twice he went out into the hallway and informed Staff D the resident was in a lot of pain. I knew he needed something stronger than Tylenol, as they had given him Tylenol. He stated he heard staff tell the resident they did not have anything stronger to give him, as the resident had told them a couple of times during the night it was not working. Ridiculous he laid there all night in that kind of pain and only had Tylenol. Review of the resident's Medication Administration Record [REDACTED]. A telephone interview on 1/7/16 at 10:02 p.m. with Staff F (NA caring for the resident on the night shift of 12/21/15) revealed the resident was in a lot of pain. He told me he was in pain and was grimmacing. He stated he needed some pain medication as the Tylenol was not going to work. On 1/7/16 at 1:25 a.m. an interview was conducted with Staff G (NA caring for the resident on the dayshift of 12/21/15). She stated the resident was in too much pain to eat his meals. He was trying to stay in one place as when he moved his hip it would hurt. She stated he told staff he could not move at all as he was in too much pain. Despite the resident's significant pain following his fall, staff failed to obtain physician's orders [REDACTED]. In addition, staff failed to thoroughly assess the injured area and monitor for medical complications [REDACTED].

Based on observation, record review, and staff interview, the facility failed to provide sufficient supervision and a properly functioning assistive device for 1 of 3 residents (#1) sampled for falls with injuries. Resident #1 was left unattended in a dining area in a wheelchair that did not tilt properly to ensure safe positioning. The resident fell forward onto the floor resulting in facial and dental injuries. A couple days later, the resident's condition deteriorated as a result of an underlying head injury. Findings include but were not limited to: Resident #1: Review of the medical record revealed the resident had multiple medical [DIAGNOSES REDACTED]. She has a deformity to her right ankle with a limitation in ROM (range of motion). The resident was using a wheelchair that tilted. She was noted to be at risk for falls due to her poor endurance, general weakness, balance and gait deficit, short term memory deficit, forgetting her limitations, and a history of falls. Entries on her care plan on 12/23/14 and 1/11/15 documented the use of dysom (a non-skid product) to be placed on her wheelchair surface to help prevent sliding in her wheelchair. The care plan also noted the resident's cognition was impaired. She experienced confusion and disorientation. A 10/04/15 nursing entry by Staff Member A, Licensed Nurse (LN), documented at about noon Resident #1 was found on the floor in the dining room lying on her right side with her wheelchair behind her. Resident appeared to have leaned over on the right side causing her to land on her right side of her face .The right side of her face was red and the right top and bottom lip appeared cut and bloody, and the right middle tooth fell out with root attached. There appeared to be bruising to the resident's gum. The resident was transported to the hospital for further evaluation and treatment. According to the next 10/04/15 nursing entry, the resident returned to the facility at approximately 2:00 p.m. She received Tylenol at 3:00 p.m. and an ice bag to help control her facial swelling. Res. (resident) remains in bed this afternoon; taking minimal food tonight. Taking food is painful for resident due to outward signs of oral discomfort. The resident had facial bruising and swelling on the right side of her face including the right eye and brow. Nursing entries on the 10/04/15 evening shift and following night shift documented the resident experienced multiple episodes of vomiting brownish/red fluids. The Physician was contacted and directed staff to monitor the resident during the night shift. The resident had likely swallowed a large amount of blood. The resident received a Tylenol suppository for oral discomfort at 12:45 a.m. on 10/05/15. The 10/2015 Medication Administration Record (MAR) noted Tylenol was administered on 10/05/15 at 8:00 a.m. The 10/05/15 day shift nursing entry documented the resident slept most of the shift but was alert and opened her eyes when approached. She had swelling to her right lower lip and faint bruising to her lateral right eye area. Review of the 10/06/15 nursing entry revealed a report from a Nursing Assistant (NA) that the resident was unable to help with the transfer as she had before. The following 10/06/15 nursing entries noted the resident's blood pressure was rising and there was a change in her level of consciousness. There was an order to send the resident to the hospital for an evaluation. The resident was returned to the facility later that day. Diagnostic testing on 10/06/15 revealed the resident had a Large Acute Right-Sided Subdural Hematoma (a collection of blood in the brain). The following day, on 10/07/15, the resident received an order for [REDACTED]. Per 10/07/15 nursing documentation, the resident did not respond to verbal stimuli or touch. Review of the 10/04/15 facility fall investigation revealed Staff Members A and B (a NA) were on-duty at the time of the fall. On 10/19/15 at approximately 11:10 a.m. Administrative Staff Member C, a LN, identified and demonstrated the type of wheelchair Resident #1 had used. The wheelchair was thought to belong to the facility but was loaned to Resident #1. The identified wheelchair had the capacity to tilt the seat backward to allow for the resident to sit back instead of being fully upright. Staff Member C stated the whereabouts of the exact wheelchair was unknown at that time. It was possibly in use by another resident. Staff Member D, a NA, was interviewed on 10/19/15 at approximately 1:15 p.m. and stated she was the assigned NA caregiver for Resident #1 on 10/04/15, the day of the fall. She had taken the resident into the dining room in her wheelchair at about 11:35 a.m.-11:40 a.m., about 20 minutes before the lunch meal. Staff Member D recalled that Resident #1's wheelchair had not been working properly for about 1 1/2 weeks, it would not tilt back. Staff typically tilted the resident's wheelchair back. There was no dysom in the wheelchair on 10/04/15. Sometime before 10/04/15, Staff Member D had written a request for maintenance staff to repair the resident's wheelchair. She also spoke with Staff Member A on 10/05/15, the day after the fall, and she was encouraged by Staff Member A to make another request for maintenance staff to repair the wheelchair. Staff Member D further stated that on 10/04/15 she left Resident #1 in the dining room near a table. Other residents were in the dining room but no staff members were present. Staff members were in and out as they brought other residents into the dining room. When interviewed on 10/19/15 at approximately 2:00 p.m., Staff Member B recalled that on 10/04/15 at approximately 11:44 a.m. she observed feet (lying) under the table in the dining room. The resident had landed on the floor on her right side. A LN also responded to assess the resident's condition. Staff Member B stated after the assessment, staff assisted the resident into her wheelchair. She recalled there was no dysom in the wheelchair and they were unable to tilt the resident's wheelchair. Staff Member B recalled the resident tended to reach out and have balance issues. Staff Member E, a LN, was interviewed on 10/19/15 at approximately 1:30 p.m. and 2:45 p.m. The LN recalled Resident #1 hunched over in her wheelchair. If her wheelchair was left straight up, the resident was at risk for falling. Staff Member E stated she thought the wheelchair had been fixed before but it still wasn't working, it wouldn't tilt. She noted the wheelchair problem when Staff Member D had talked with her the day after the resident's fall. The LN asked the NA to write another repair request for maintenance staff. Review of the clipboard holding maintenance repair requests, at the north nurses' station, revealed a 9/14/15 entry by Staff Member F, a NA. The entry noted, wheelchair does not tilt back. Resident #1's room number was also noted. The Date Fixed was 10/5, the day following the resident's fall. On 10/19/15 at approximately 2:10 p.m., Staff Member G, the Maintenance Supervisor, was interviewed. Staff Member G stated he recalled the wheelchair cable was loose so the wheelchair was not working properly. When asked about the 9/14/15 entry and the repair date, Staff Member G stated he might have looked at/repaired the wheelchair before but he was unsure of the date. Staff Member A was interviewed by telephone on 10/20/15 at approximately 12:00 noon. The LN stated she was working the day of Resident #1's fall. All days except Sundays, the day of the fall, there was a RA (Restorative Aide, a NA doing restorative activities) present in the dining room when residents were present. Resident #1 was known to lean to the right side. Residents were not to be left without supervision in the dining room. The facility failed to provide sufficient staff supervision for Resident #1 when she was left unattended in a dining area in a wheelchair that was not functioning adequately, did not tilt properly to ensure safe positioning. The resident fell forward onto the floor resulting in substantial injuries/harm.

Based on record review and interviews the facility failed to provide the necessary care and services for 1 of 3 sampled residents (Resident #1) reviewed with a change of condition. Resident #1 experienced harm as a result of failure to adequately assess/evaluate burn areas and obtain medical treatment in a timely manner. Findings include: Resident #1: Review of a facility investigation report and resident's medical record revealed on 6/4/12 at 11:30 a.m. the resident spilled hot water on herself when she attempted to make hot chocolate in the dining room. Documentation stated there were large pink areas to the left lower thigh, just above the left knee, and left outer, lower calf. No blisters were noted. There were no measurements taken of the three involved areas. A fax (electronic message) was sent to the physician at that time stating the resident spilled hot water on her left upper thigh. The fax did not include the other two affected areas. An order was received on 6/4/12 to monitor the left upper leg redness for increased redness, swelling, or pain. Review of the resident's Treatment Record revealed only the left upper leg was being monitored by staff daily despite two additional areas burned as result of the hot water. Despite the resident's change of condition relative to the burn areas and the potential [MEDICAL CONDITION] worsen there was no further assessment of [MEDICAL CONDITION] 6/6/12 at 1:13 p.m. (approximately 50 hours later). At that time documentation stated the burn area to the left outer calf had developed a fluid filled blister. A call was placed at that time to the physician and a faxed message was sent requesting [MEDICATION NAME] cream (a topical ointment used in the treatment of [REDACTED]. There continued to be no measurements of the burn areas which would have provided the information necessary for staff to determine if the area had worsened relative to the areas of redness. Documentation on 6/7/12 at 7:21 a.m. noted the burn area on the left upper thigh remained red with no blister present (no measurements taken). The left outer calf blister was 0.45 inches with surrounding tissue that measured 0.45 by 1.36 inches. There continued to be no assessment of the area above the left knee since the initial entry on 6/4/12. Despite the burn area to the left calf was noted to worsen on 6/6/12 as evident by the blister there was no documentation any further attempts were made to notify the physician until 6/7/12 at 2:33 p.m. (approximately 25 hours later). At that time the physician ordered [MEDICATION NAME] cream to be applied to the burn areas on the left lower thigh and calf areas. Documentation stated the area above the left knee had resolved. The [MEDICATION NAME] cream treatment was not initiated until the morning of 6/8/12 (approximately 36 hours following the initial request by staff for the treatment). An interview on 6/13/12 at 2:00 p.m. with Staff Licensed Nurse B (initiated investigation on burn incident) revealed that the alert charting system (assessing resident's condition every shift for changes) should have taken place following the burn incident to the resident.

Based on observation, record review, and interviews the facility failed to provide sufficient supervision to prevent avoidable accidents for 1 of 2 sampled residents (Resident #1). Resident #1 sustained second degree burns to her left foot and thigh when she accessed hot water from the beverage cart without assistance/supervision. Findings include: Resident #1: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care noted she had upper extremity tremors, poor balance, poor safety awareness, and impaired cognition. She required extensive staff assistance with transfers, eating skills, and fluids. Review of a facility investigation report and resident's medical record revealed on 6/4/12 at 11:30 a.m. the resident was in the dining room getting herself a cup of hot water from the beverage cart to make hot chocolate. It was reported by a visitor that she spilled hot water on herself and the floor. The investigation stated the hot water at the time it was poured into the beverage container (pot) was 170 degrees. There was no facility staff in the dining room at the time of the incident. The resident sustained [REDACTED]. The investigation concluded the resident's chronic disease created challenges for her to be indepedent with self serving. She leaned to the side and her hand/wrist strength and dexterity did not allow her to be independent. An unsupervised hot beverage cart was a safety risk for her. An interview on 6/13/12 at 1:00 p.m. with the Food Service Manager revealed kitchen staff would bring the beverage cart from the kitchen to the dining room. She stated kitchen staff had never been instructed to stay with the cart until other staff arrived. Staff Resident Care Manager A stated at 1:50 p.m. on 6/13/12 that the resident used to eat in her room until two weeks ago. At that time she was moved to the dining room as she required more assistance with eating due to slowly losing her fine motor skills in her arms and hands. Observation on 6/13/12 at 12:20 p.m. noted the resident seated in her wheelchair in the dining room. She was leaning to the right and required staff supervision for cueing to hold onto her utensils. She exhibited mild tremors of both arms. She utilized curved utensils and a lip plate to increase her level of independence with eating. Two beverage pots containing hot water were observed on the beverage cart. Both were made of plastic and had handles. One pot had a twist type lid which was noted as being difficult to open by the Director of Nursing. The other pot had a push button type lid. On 6/13/12 at 11:45 a.m. Staff Nursing Assistant (NA) B stated the resident got into things..."if she wants something she will go after it." An interview on 6/13/12 at 12:15 p.m. with Staff Nursing Assistant (NA) C revealed the resident was a "difficult resident - does the opposite of what you say - does what she wants." She stated she had observed the resident at times going towards the beverage cart in the hallway (contained hot water, coffee, and several snacks). Before the resident could take anything off the cart staff would intervene and obtain what she wanted. When asked if she wanted hot chocolate she would say yes in addition to the snacks she wanted. Since the burn incident on 6/4/12 that beverage cart had been moved behind the nursing station to ensure resident safety. Approximately six years ago Staff NA C stated the resident attempted to serve herself coffee from a beverage cart utilized in an activity program. She stated she intervened before any accident occurred. Staff Restorative Aide (RA) D stated on 6/13/12 at 12:20 p.m. that she usually was the first one in the dining room to assist residents with their meals. Frequently the beverage cart would already be in the dining room when she arrived with several residents present and no staff members. She stated she had observed the resident going to the beverage cart in the hallway to retrieve food items but had never seen her attempt to get beverages by herself. The resident had only been coming to the dining room a short time and she had never observed her attempting to obtains items off that beverage cart. A telephone interview on 6/14/12 at 9:49 a.m. with Staff RA E revealed the beverage cart would be left unattended in the dining room approximately twice weekly with residents present. She stated she had observed the resident trying to grab some of the food and sugar off the beverage cart in the hallway but not any beverages. Despite the resident's cognitive deficits, upper extremity tremors, poor safety awareness, need for staff assistance with meals and liquids relative to positioning and eating skills, and history of retrieving items off a beverage cart, staff failed to identify the beverage cart containing hot liquids as a safety issue and provide staff supervision when it was brought into the dining room.

Based on record review and interviews the facility failed to ensure policies and procedures to prohibit abuse were implemented for 1 of 1 sampled residents (#1) involved in an abuse incident. Failure to follow their abuse policy and ensure policies and procedures regarding building security were in place and implemented to prevent unauthorized individuals in the facility resulted in actual harm to Resident #1. Findings include: Review of the facility policy on Abuse Prevention stated it was the policy of the facility to utilize education, supervision, symptom identification, analysis, and corrective action to prevent abuse of residents. The facility policy noted incident investigation and reporting would be completed by following the Washington State Nursing Home Guidelines manual. Review of those guidelines noted the definition of sexual abuse as being, "any form of non-consensual contact, including but not limited to, unwanted or inappropriate touching." Review of a facility investigation report revealed on 3/7/12 an unauthorized, intoxicated male was observed by a staff member "fondling" the resident's upper left arm and moving his hand towards her breast. Following the incident the resident stated the male had touched her breast and grabbed her arm hard enough to cause a bruise. She stated she did not want him touching her and was somewhat fearful he would return. Despite the above statement by the resident regarding unwanted touching, observation by a staff member of the male's hand on the resident's chest and arm area, and facility policy defining sexual abuse as unwanted or inappropriate touching; administrative staff did not recognize the incident as sexual abuse of the resident as evident by the investigation conclusionary statement. The statement noted "no sexual contact made...sexual abuse unsubstantiated". In addition, despite the male causing a bruise to the resident's left arm physical abuse was not addressed in the conclusion. Review of the resident's medical record and interviews with staff on 3/14/12 revealed the above male returned to the facility three days later on 3/10/12. Despite him sexually and physically abusing the resident just three days prior staff did not notify the police department that he was again in their facility, thus not taking all the necessary steps to prevent further abuse to residents. The unauthorized, intoxicated male visitor entered the facility on 3/7/12 through unlocked doors after visiting hours despite staff stating the doors were to be locked at 8:00 p.m. Staff did not ensure the doors were locked after the visitor was instructed and then observed to exit the facility. Later the male visitor returned to the facility and was left unsupervised in a hallway attempting to locate the resident's room. Interviews conducted on 3/14/12 with all staff working the evening of 3/7/12 revealed lack of knowledge relative to building security with the doors. Although some staff were trained on building security, training and facility expectations to ensure security did not occur until an all staff meeting was conducted a week later on 3/14/12. Cross-refer to F323. The facility failed to provide adequate supervision to ensure procedures regarding building security were in place and implemented to prevent entry of unauthorized individuals into the facility.

Based on observation, record review, and interviews the facility failed to provide adequate supervision to ensure procedures regarding building security were in place and implemented to prevent entry of unauthorized individuals into the facility. Resident #1 sustained actual harm as a result of staff not ensuring the safety of residents by securing the facility and taking immediate, appropriate measures regarding unauthorized individuals. Findings include: A. Resident #1: Review of the resident's medical record noted the young resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of a facility investigation report dated 3/8/12 revealed on 3/7/12 at 8:42 p.m. an intoxicated, male visitor was observed in the facility on the north wing by Staff Member A (Nursing Assistant) "fondling" the resident's upper left arm and moving his hand towards her breast. Staff Member A immediately intervened informing the male visitor to stop and exit the facility. The incident was then reported to the charge nurse. When Social Services (SS) interviewed the resident on 3/8/12 she stated the male visitor touched her breast and arm area stating "he grabbed her arm to the point of being painful". The resident stated she had a bruise on her arm and pointed to the area. Since the resident was wearing a long sleeved shirt at the time of the interview SS obtained verification from nursing that the resident had a new bruise to her upper left arm. review of the resident's medical record revealed [REDACTED]. When he was told by staff the uncle did not reside at the facility he then left. The incident occurred prior to 8:00 p.m. Documentation noted the Director of Nursing was notified at that time with instructions given if he were to return. Despite his abusive acts to Resident #1 just three days prior there was no directive given to call the local police department. An interview with the resident on 3/15/12 at 11:00 a.m. revealed the male visitor had caused the bruise to her left arm on 3/7/12. She was unable to answer any other questions secondary to her cognitive deficit. Observation of the bruise noted it to be purple in color. Interviews were conducted on 3/14/12 between 2-4:00 p.m. with all staff working the evening shift on 3/7/12. An absence of training on building security was apparent as many staff was unsure who was responsible to lock the doors, which doors needed to be locked, and the method for doing so. It was noted in observing all facility doors with the Administrator on 3/15/12 there were five doors that needed to be locked every evening with various locking methods. Staff was unable to determine which door the visitor entered and exited the facility on 3/7/12 as no one observed him coming in or finally leaving the facility. The following information was obtained during the interviews: Staff Member B (Nursing Assistant) stated at 3:45 p.m. she observed the male visitor after 8:00 p.m. by the front door and noted he appeared to be intoxicated. He initally asked for his uncle and when he was told his uncle no longer lived in the facility he then asked for Resident #1 by first name. She stated she referred him to Staff Member C. She stated she had not locked any of the doors that evening and sometimes the front door did not get locked. She noted everyone was responsible to ensure the doors were locked but was unaware of which doors needed to be locked. An interview at 2:20 p.m. with Staff Member C (Licensed Nurse) revealed the above male visitor was in the facility on the west wing after 8:00 p.m. on 3/7/12 and had asked where Resident #1 was. Staff Member C informed him visiting hours were over and he needed to return the next day. She stated she observed him walking out the front door; however, she did not check the door to ensure it was locked. She stated she had not locked any of the doors that night and did not think anyone specific was assigned to lock them. At 4:00 p.m. Staff Member D stated she observed an unknown male visitor walking down the hall on the north wing looking at resident names located outside each room. She stated he was mumbling Resident #1's first name as he was walking. A call light rang at that time so she left the male visitor unsupervised to answer the call light. She stated she never saw him again that night and was unaware he had entered the facility earlier that evening. The doors were to be locked at 8:00 p.m.; however, she was unsure who was responsible to lock them. She stated only the front doors needed to be locked. At 2:00 p.m. Staff Member A stated she was with the resident's roommate doing 1:1 care at 8:42 p.m. on 3/7/12 when the male visitor opened the door to the resident's room without knocking and entered the room. He then closed the door behind him (all without the consent of the residents). She stated the cubicle curtain was drawn around the roommate so the visitor was unaware she was in the room. She noted he smelled of alcohol and was speaking softly to the resident informing her he had just gotten out of jail. When she could no longer hear any conversation she pulled the cubicle curtain open to observe the visitor touching the resident's left arm and upper chest area (above the left breast). She then informed him he needed to leave the facility immediately. He left the room unsupervised and she went and informed her charge nurse of the incident. She stated the door to the facility should have been locked as staff had been told the doors needed to be locked at 8:00 p.m.; however, sometimes small rocks got stuck under the front doors causing the doors not to fully close. Staff Member E stated at 3:00 p.m. that she had only locked the front doors (not the other four doors in the building that also needed to be locked) at 8:00 p.m. on 3/7/12. She stated the male visitor had been in the facility before Christmas and was noted to be intoxicated at that time also. He had entered the facility before 8:00 p.m. and was immediately told to leave. When he exited the facility staff locked the door behind him. He then began shaking/rattling the doors in an attempt to get in and eventually did leave. She stated that in addition to being in the facility prior to Christmas and on 3/7/12 he also entered the facility on 3/10/12. He walked in through the front doors and when he saw staff coming around the hallway he immediately exited the facility. She stated that sometimes the front door did not latch when it closed so staff had to ensure the door was actually closed before locking it. An interview with Staff Member F (Licensed Nurse) at 2:40 p.m. revealed that he had not locked or checked any of the facility doors on 3/7/12; he thought Staff Member E had locked the front doors. He stated the evening of 3/7/12 was a "very busy" evening and he was orientating another staff member. He generally worked the night shift. He stated the third Licensed Nurse working the evening shift on 3/7/12 was new to the facility (his second day) and probably did not know how to lock the doors as he had come to him following the above incident with Resident #1 inquiring about the procedure on locking the front doors. Despite Staff Member G working the above evening shift on 3/7/12 she stated during a telephone interview on 3/15/12 at 1:10 p.m. that she had no awareness of any incident involving Resident #1 and the male visitor. She stated she had not locked any of the doors and there was "no set procedure" regarding the doors except they were locked by anyone that had time to do so. She stated that usually only the front doors needed to be locked. A telephone interview on 3/15/12 at 1:18 p.m. with the local police department officer revealed that despite an intoxicated visitor entering the facility prior to Christmas and rattling the doors after being asked to leave; and his return to the facility three days following his abuse to Resident #1, staff had not called the police department to report the incidents. The Director of Nursing stated education regarding securing the facility and abuse reporting and protection was not provided to staff following the incident until 3/14/12 (one week following the above incident). Review of facility policy regarding securing the facility relative to locking the doors did not address the time in which the doors were to be locked by staff, nor did it indicate which doors needed to be locked and the procedure for doing so. Residents were at risk for further potential abuse due to a delay in staff training regarding procedures relative to building security with locking doors and unauthorized individuals entering the facility including individuals who had previously abused residents.

Based on record review and interviews the facility failed to ensure care for 1 of 3 sampled residents (Resident #1) was provided care in a manner that maintained or enhanced the resident's dignity and respect. Resident #1 did not receive appropriate care by staff following a large bowel incontinency episode. As a result she was left with dried feces in her hair and on her lower back. In addition she was found lying on a bare mattress (that had some dried feces on it) with no sheets or blankets covering her and was noted to be cold. Resident #1 was unable to recall the incident due to cognitive/memory impairments. However, the incident constituted actual harm based on what a resident without cognitive deficits would have felt. Findings include: Resident #1: Review of the resident's In Room Care Plan revealed she would get confused due to her dementia. She required extensive assistance from staff for bathing/toileting and supervision with grooming and personal hygiene. Interviews conducted on 2/2/12 at 1:45 p.m. and 2/3/12 at 11:50 p.m. with Staff Member A - a Nursing Assistant (NA) revealed on 1/9/12 the resident was found at the beginning of the day shift (approximately 6:15 a.m.) lying on a bare mattress with no linens over her. She was wearing regular clothing and had placed a gown over herself in an effort to keep warm as she was noted to be cold. There was dried feces on her mattress and in her long hair. Staff Member A stated the person responsible for the resident's care on the night shift (Staff Member C) was aware there was feces in her hair. An interview on 2/3/12 at 2:10 p.m. with Staff Member B (NA) revealed she was the person who initially found the resident at approximately 6:15 a.m. on 1/9/12. She sought help from Staff Member A due to the condition the resident had been left in by the night shift NA. The resident was found as stated above. She stated the resident "smelled really bad" and when she went to give her a shower there was dried feces in her hair and over her lower back area. A telephone interview on 2/15/12 at 4:00 p.m. with Staff Member C (NA on the above night shift assigned to the resident) noted on 1/9/12 at 5:15 a.m. she found the resident incontinent of a large diarrhea type stool in bed. She stated the diarrhea was "pretty much everywhere as she (Resident #1) moves around alot in bed...had stool on the back of her hair and on her hands". She took the resident to the bathroom sink and utilizing a wet washcloth with shampoo attempted to clean the feces out of her hair. She also did the same procedure with the rest of her body. She stated she was unable to give the resident a shower at that time and she had informed her charge nurse (Staff Member D) the resident needed to be showered by the day shift. The shower was not given as the incident occurred during the "busiest time" of her shift. In addition, the facility was experiencing an infectious disease involving several residents with vomiting and diarrhea at that time which had affected her work load. She stated the last time she saw the resident that morning was when she was self propelling her wheelchair up to the nursing station (despite the lack of hygiene and being observed by other residents and staff). When questioned regarding linens not being on the resident's bed she stated clean linens were not available to make the resident's bed and staff had a "constant problem with not enough linens to do bed changes, etc." She stated the resident was able to self transfer to bed from her wheelchair. During a telephone interview on 2/15/12 at approximately 11:30 a.m. with Staff Member D (Charge Nurse on the night shift) she stated the resident propelled herself to the nursing station at 5:30 a.m. on 1/9/12. She stated she did not observe any feces in the resident's hair, however Staff Member C had informed her she was unable to get all the feces out of her hair and would need a shower. She stated at the time of the incident there were other residents on their call lights, only two NAs assigned to care for residents in that area, and it was the "busiest time" on the night shift. In addition, the laundry situation at night had been a real problem as machines would break down and frequently there was not enough linens for staff to utilize in caring for residents.

Based on observation, record review and interview, the facility failed to administer services effectively and efficiently to enable residents to meet their highest level of function. Two residents experienced harm resulting from the development of pressure sores; the activity program did not promote residents' quality of life and was directed by an individual who was not qualified; policies did not identify proper screening for newly hired staff; the temporary kitchen was not sanitary and dietary services did not follow the plan which was provided to the State Agency; and 22 residents were infected with a gastrointestinal illness due to the lack of appropriate infection control practices. Findings include: On 01/03/12 when entering the building, the survey team found that a temporary kitchen was in use during the time the kitchen floor was being replaced. The temporary kitchen was in place between 12/12/11 and 01/06/12 (25 days). The plan provided to the State Agency noted no cooking would take place in the temporary kitchen; however, food was observed being cooked on an open flame butane cook stove. Dietary staff did not follow standards for cleaning and sanitizing cooking utensils or water pitchers used by residents. In addition, the temporary kitchen was not clean. Although most food was cooked at a local hospital and returned to the facility for service to residents, temperatures were not taken to ensure holding temperatures were appropriate. Please refer to F371, dietary services. By 01/06/12 the facility advised the survey team of an outbreak in the facility of nausea and vomiting with some diarrhea. On 01/10/12 the facility advised the team that some residents tested positive for [MEDICAL CONDITION]. According to the facility's action plan, all group type activities were to be suspended during the time residents were sick. However, on 01/06/12 and again on 01/10/12, 3-5 residents were observed in the therapy area at the same time participating in exercises. By 01/08/12 22 residents and 16 staff had been or were sick. Please refer to F 441, infection control. On 01/04/12 water temperatures in resident rooms throughout the facility were noted to be between 124 and 131 degrees Fahrenheit. Residents made statements that the water was so hot "you can make coffee with it." Or "be careful, it is hot!" Interview with the Maintenance Supervisor revealed that hot water temperatures had first been noted on 12/07/11, but nothing had been done to correct the problem. The temperature log for December 2011 revealed temperatures throughout the facility between 121 and 132 degrees. The Maintenance Supervisor reported that during his absence the Administrator was taking temperatures. However, the facility did nothing to rectify the hot temperatures until 01/04/12 when the surveyors brought it to their attention (in spite of their prior knowledge of hot water temperatures). On 01/05/12 (29 days after hot water temperatures were initially discovered) a faulty mixing valve was discovered. Please refer to F323, accidents and supervision, for details. On 01/09/12 the Activity Director stated she had no prior experience in activities before becoming the interim activity director in March of 2011. The Social Service Director stated that she had been supervising the Activity Director and program prior to the Administrator coming to the facility in August 2011; however, he had told her that he would take over that responsibility after he came. On 01/09/12 during interview with the Administrator, he stated nobody had been supervising the Activity Director, in spite of her being unqualified for the position. Please refer to F248 and F 249, Quality of Life, Activities. Review of the facility's Abuse Prohibition Policy on 01/10/12 noted there was nothing regarding screening of new employees. During review of newly hired employees it was noted that one of five employees had no criminal background check. Please refer to F 226, Abuse policies.

Based on observation, record review and interview, the facility failed to prevent pressure ulcers from developing for 2 of 3 residents (#14, 85) in the sample. Both residents suffered harm from the development of pressure sores. Findings include: Resident #14. admitted in November 2011 with multiple pressure wounds - left inner foot, left heel, right knee, right buttock. The resident was seen at the wound clinic for his open wounds. He rested on an air bed which provided pressure relief. The resident's lower limbs were paralyzed and he would draw his legs up towards his chest. On 12/15/11 Physical Therapy notes documented "found a soft boot in a catalog that will be appropriate for the patient to wear to alleviate the pressure on his wounds on left, and one to hopefully prevent wounds on right foot." On 12/19/11 Physical Therapy had obtained a wedge to place under his knees. On 01/04/12 through 01/06/12 and again from 01/09/12 through 01/11/12 the resident was observed without boots on his feet to relieve pressure on the heels. The wedge was not always in place; however, when it was in place, the resident's heels rested on the mattress. Review of the plan of care did not identify the boot or the wedge as interventions for the resident. On 12/14/11 a progress note documented "Stage two (partial thickness loss of skin) to lft (left) heel." The following day "it was noted that resident's heels are becoming soft and he has severe [DIAGNOSES REDACTED] to lower extremities.... Skilled therapy requests heel protector boots and lower extremity knee separator with leg supports due to potential for contractures and skin integrity issues." Interview with Staff B on 01/06/11 at approximately 10:05 a.m. revealed the pressure sore on the left heel "was a fluid-filled blister at the onset. He is so contracted and draws his legs up. It happened before we got the air bed. We said to float the heels but you can't really do that. when we saw the blister that's when we got everything going (air bed)." Review of physician's orders [REDACTED]. However, there was no documentation of when the air bed was actually put in place. On 01/06/12 at approximately 10:05 a.m. Staff C changed the dressing on the resident's left heel. She measured the area and stated it was 0.5 centimeters (cm) by 0.75 cm (less than one inch in diameter). On 01/06/11 at approximately 9:50 a.m. Staff J, who was at the resident's bedside, stated the resident had never had any protection on his heels. "Never a boot, or nothing." In spite of the facility's knowledge of the resident's risk of developing pressure sores, the multiple pressure sores and the dry blister on the left heel when admitted , they failed to initiate prevention devices to ensure pressure was relieved on the resident's heels. He developed a fluid-filled blister on 12/14/11 even while on an alternating pressure mattress. During observations, the resident was without any pressure relieving devices on his heels. Although the fluid-filled blister on the left heel was healing, he remained without pressure relief on either heel. In addition, the plan of care did not provide direction for staff to ensure pressure was relieved from his heels. Resident #85. admitted to the facility originally on 08/02/11 with multiple [DIAGNOSES REDACTED]. He was transferred to the hospital on [DATE] and re-admitted to the facility on [DATE] with the new [DIAGNOSES REDACTED]. On re-admit to the facility on [DATE] the hospital orders were to; "apply barrier cream to the scrotum TID (three times a day) until healed". The care plan, originally dated 08/04/11, documented "Braden Scale (skin assessment risk scale) quarterly" and "currently at mild risk of skin breakdown" (despite the liver and kidney failure and pain from [MEDICAL CONDITION] throughout his entire body resulting in increased [MEDICAL CONDITION] and decreased movement). The care plan was updated on 08/22/11 with the addition of "Stage 2 to scrotum x 2, scrotal [MEDICAL CONDITION]", "is at risk for further skin breakdown related to his decreased mobility, nutrition and decreased activity". However, the "Braden Scale - currently at mild risk of skin breakdown", remained on the care plan. On 08/28/11 the physician orders [REDACTED]." No new treatment or directions for prevention of the blisters were given. The resident received a skin assessment on the admission form at each of the two admissions and no further assessments were found per the Resident Care Manager, Staff A statement on 01/12/11 at approximately 2:00 p.m. The barrier cream had been the only addition of treatment to reduce friction and/or reduce pressure between the resident's legs and swelling scrotum. Despite the resident already having skin breakdown there was no use of pressure reduction to prevent the scrotal area from breaking down further. Additionally, when the scrotum broke down further the faciltiy failed to re-assess, up date the care plan or provide pressure relief and/or new treatment.

Based on observation, record review, and interview, the facility failed to provide sufficient supervision to ensure appropriate use of assistance devices, as needed, for 1 of 3 sampled residents (#1) with falls. Resident #1 fell from a sling while suspended in a mechanical lift and sustained a fractured right shoulder. Findings include: Resident #1: Review of the medical record revealed the resident was admitted to the facility with multiple medical [DIAGNOSES REDACTED]. His In Room Care Plan documented he did not bear weight and was transferred with a Hoyer lift (a mechanical lift) with two caregivers assisting. The resident received Vicodin 5/500 milligrams, a narcotic pain medication, every six hours routinely for pain management. Additionally, he could also have Tylenol or Tylenol with Codeine as needed for additional pain control. An 11/05/11 nursing entry documented that at 11:30 a.m. the resident was found lying on the floor in his room, "had fallen out of Hoyer lift cradle during transfer". The resident complained of right elbow pain after the fall. An 11/06/11 x-ray revealed the resident had a fractured right shoulder. Review of the 11/05/11 facility investigation revealed Nursing Assistants (NA) A & B "had not attached 2 middle rings when they had lifted the resident...during the lift however when he leaned he did fall out of the right side of the sling" onto the floor. Per the investigation, the NAs stated they were "unaware that all 3 areas of the loops were required to be attached as other slings had only 2 sets of loops." Further review of the medical record revealed on 11/08/11 an Orthopedic Physician examined the resident and directed that he hold his arm against his body for another week prior to using his arm as he was able to tolerate. The nursing entries documented pain assessments and that the resident 's pain was managed by his routine narcotic pain medication. The 11/2011 medication administration record documented ongoing routine Vicodin administration every six hours and no documentation as as needed pain medication until 11/17/11. On 11/18/11 at approximately 11:05 a.m. the Director of Nursing (DNS) provided the sling for observation. There were three loops on each side of the sling that were to be attached to the mechanical lift to provide support for the resident during the transfer. The DNS stated the other facility slings had only two loops on each side. On 11/18/11 at approximately 12:05 p.m. and 12:20 p.m., Resident #1 was observed with a large purple/yellow bruise on his right bicep. He stated he had fallen on his right side (during a transfer) about four feet off the ground and did a "cartwheel". On 11/18/11 at approximately 12:20 p.m. NA C and NA D performed a mechanical lift transfer for Resident #1 from his bed to the wheelchair. During the transfer the resident called out, "Oh, Oh" when the sling touched his arm/shoulder during the transfer. As he was positioned in the wheelchair he stated to NA C, "You'd be scared if you had fallen". The resident also stated, "It's sorer than hell." After the transfer NA C stated the resident typically leaned to the right while up in the sling. When up in the sling with the three loops on each side, all three loops needed to be attached to a hook on the lift. On 11/08/11 at approximately 3:55 p.m., NA A, one of the NAs involved in the 11/05/11 transfer incident, stated there were different types of slings she had used, with two on each side or three on each side. The sling used on 11/05/11 had three loops on each side but the middle one was tucked in and she did not see it or attach it. It wasn't attached on either side. The resident typically leaned to the right but on that occasion he "really leaned over" and then fell out onto his right side. NA B was interviewed on 11/21/11 at approximately 3:10 p.m. The NA stated she had used the 3 hook/loop slings on other occasions, only attaching two loops and there had not been any problems in the past. On 11/05/11 she hooked only the two hooks (top and bottom) as she had done in the past. The resident leaned to the right side typically but when the Hoyer was moved that time the resident fell out the right side onto the floor despite attempts to break the fall. NA B further stated she did not recall any training on the Hoyer lift or slings when oriented to the facility in August 2011. The facility failed to provide sufficient supervision to ensure the sling was used in an appropriate, safe manner. NA B only attached 2 of the 3 loops on each side on multiple occasions including on 11/05/11 when the resident fell sustaining a fracture.

Based on record review and interviews the facility failed to ensure 1 of 6 sampled residents (Resident #1) was free of significant medication errors. This failed practice resulted in harm to Resident #1, who had to be transferred to the hospital for treatment of [REDACTED]. Findings include: Resident #1: admitted to the facility on [DATE] from the hospital with physician's orders [REDACTED]. Review of the facility investigation report revealed the order was transcribed incorrectly by Licensed Nurse (LN) #1 on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Despite the medication cards from the pharmacy stating the physician order [REDACTED].#2 administered 300 mgs in the morning (as stated on the MAR) on October 10,11,12,13, and 14. Licensed Nurse #3 had misread the resident's MAR indicated [REDACTED]. On 10/14/11 Licensed Nurse #3 was approached by LN #2 questioning her as to how much [MEDICATION NAME] she was administering to the resident on the evening shift as she was concerned the resident was not receiving enough [MEDICATION NAME]. Licensed Nurse #2 had observed the resident with some involuntary movements (possible [MEDICAL CONDITION] activity) [MEDICATION NAME] a few seconds. She informed LN #2 she was giving 300 mgs as stated on the MAR. At that time LN #2 stated the wrong dose of [MEDICATION NAME] was being given as he was to receive 600 mgs every evening. Thus on 10/14/11 LN #3 administered 600 mgs of [MEDICATION NAME] to the resident on the evening shift. An interview with LN #3 on 10/20/11 at 1:30 p.m. revealed that following her discussion on 10/14/11 with LN #2 she questioned the 600 mg dose in the evening as being too excessive. She stated she consulted with LN #1 who stated the 600 mgs was the correct dosage.. On 10/15/11 LN #4 administered 300 mgs of [MEDICATION NAME] to the resident in the morning prior to breakfast. At approximately 9:30 a.m. the resident was noted to have slurred speech and had vomited twice (both adverse reactions to [MEDICATION NAME]). The physician was notified and the resident was transferred to the emergency room that morning where he was diagnosed with [REDACTED]. The resident was hospitalized until 10/20/11 (5 days). Despite the pharmacy cards of [MEDICATION NAME] stating the correct dosage of [MEDICATION NAME] as ordered by the physician, and LN #3's concern regarding the dosage as being excessive staff did not consult with the pharmacy or physician to verify the dosage which resulted in a significant medication error.