Every finding on record at Marianwood Health and Rehabilitation

Based on interview and record review the facility failed to establish an infection prevention and control program that included developing an antibiotic stewardship program to promote appropriate use of antibiotics and reduce the risk of unnecessary antibiotic use for 2 (Resident 74 & 38) of 3 residents reviewed for unnecessary antibiotics and 2 (September and October 2025) of 3 months of Infection Control (IC) documents reviewed. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of antibiotics and placed residents at a greater risk of developing antibiotic resistance. Finings included .<Policy>Review of the revised 06/11/2025, Antibiotic Stewardship facility policy showed the facility would promote appropriate use of antibiotics and reduce the possible adverse side effects with antibiotic use. The policy showed the facility would review new antibiotic orders and criteria for prescribing of antibiotics daily and track measure outcome surveillance related to antibiotic use as part of Quality Assurance Performance Improvement (QAPI) meetings. The facility would consider antibiotic time-out practices that would be considered a stop order for an antibiotic when diagnostic tests or symptoms of the resident do not support the diagnosis of an infection. The Infection Preventionist (IP) would collect, track data, and review findings with the team, and feedback would be given to the physicians on their prescribing patterns.<Resident 74>Review of the 09/08/2025 quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 74 was able to make needs known, had no behaviors and had diagnoses that included loss of motor and sensory function in their lower body due to a spinal cord injury, urinary tract dysfunction that required an indwelling catheter (a tube inserted into the urinary tract to expel urine).Review of September 2025 IC documents showed Resident 74 was started on an antibiotic on 09/09/2025 and on 10/01/2025.Review of Resident 74's UA, collected on 09/01/2025 and reported to the facility on [DATE], showed two organisms present in the urine. Review of a UA collected on 09/30/2025 and reported to the facility on [DATE], showed the UA was contaminated (the sample has multiple bacteria from the skin and results were inaccurate) and would not be processed for Culture and Sensitivity (C & S, identifies the type of bacteria and the antibiotic that would be most effective).Review of physician orders showed a 09/09/2025 order to start Resident 74 on antibiotics for five days and to monitor the resident for signs and symptoms of a Urinary Tract Infection (UTI). Review of physician orders showed a 10/01/2025 order to start Resident 74 on an antibiotic for 14 days.Review of Resident 74's clinical record showed on 09/04/2025 the physician wrote a note directing staff to obtain urinalysis (UA, testing of urine to identify infection) for a one-time episode of a low-grade fever of 99.3 degrees Fahrenheit. A 09/08/2025 physician note showed Resident 74 was seen for UA results that showed organisms present in the urine. The note showed Resident 74 denied systemic symptoms (fever, chills, altered mental status) and the plan would be to wait for the C & S results before starting antibiotics. Review of Resident 74's progress notes from 09/04-09/14/2025 showed no documentation that Resident 74 had or was being monitored for signs and symptoms of a UTI or for adverse side effects related to the antibiotic. Review of Resident 74's clinical record showed a 09/29/2025 physician note that Resident 74 appeared fatigued, had confusion, painful urination, and a low-grade fever. Review of Resident 74's clinical record showed no documentation the resident 74 had or was being monitored for signs and symptoms of a UTI or for adverse side effects related to the antibiotic.In an interview on 11/21/2025 at 9:20 AM, Staff C (Infection Preventionist/Licensed Practical Nurse) stated the facility used McGeer's criteria (standardized definitions used in long term care to identify and count infections consistently) to determine when an infection met the criteria for antibiotic treatment.During an interview on 11/21/2025 at 2:40 PM with Staff B (Director of Nursing) and Staff C, Staff B stated a one-time low-grade fever would not indicate a reason to obtain a UA as one symptom does not meet McGeer's criteria for an infection or antibiotic treatment. Staff B stated a UA usually does not take up to six days to result but after six days with no symptoms Resident 74 did not require antibiotics. Staff B stated they would expect staff to contact the physician as soon as results are received and acknowledged staff waited two days after the UA results were received to notify the doctor. Staff C stated staff should document the symptoms daily, and any potential adverse side effects until the antibiotic was completed. Staff C stated that after the completion of the antibiotic the resident should be assessed to ensure the antibiotic was effective and the infection resolved. Staff B reviewed Resident 74's C & S results and stated a new UA should have been obtained and Resident 74 was sent to the hospital on [DATE], returned with the same antibiotic prescription, and was unable to locate the hospital C & S in the resident's record. Staff B stated the C & S must be obtained to ensure the antibiotic is effective against the organism and that antibiotic time outs should be done to ensure antibiotics are not prescribed unnecessarily. <Resident 38>Review of a 09/22/2025 annual MDS showed Resident 38 was able to make some needs known, had help with decisions, and had medically complex conditions including malnutrition and heart failure.Review of Resident 38's physician orders showed an 11/18/2025 antibiotic order to be given in the muscle every 24 hours for wound infection.Review of Resident 38's clinical record showed an 11/18/2025 physician note that showed the resident was seen for new lab results that showed an elevated white blood cell count, an indication of potential infection. The physician documented that given the resident's declining condition and sacral (tailbone) pressure ulcer a wound culture would be obtained before antibiotics would be started.Review of 11/19/2025 wound culture results showed, specimen requires recollection and a new order in place if results are needed.Review of Resident 38's progress notes showed a 11/20/2025 wound provider note that the wound was assessed as deteriorating. No other documentation was found in the progress notes related to signs or symptoms of the wound infection, inability to process the wound culture, or any adverse side effects to the antibiotic.In an interview on 11/21/2025 at 2:51 PM, Staff C stated they used an infection surveillance form to determine if an infection meets McGeer's criteria and Resident 38's wound infection did not meet the criteria for an antibiotic. Staff C stated there should be documentation in the resident's record monitoring any signs/symptoms of infection, monitoring of adverse side effects of the antibiotic and documentation of provider notification and discussion of Resident 38's wound infection not meeting the criteria.<September and October 2025>Review of the September 2025 IC documents showed no monthly analysis of the number of Community Acquired Infections (CAI) only Healthcare Acquired Infections (HAI), the number of the most prevalent sites or organisms of infection in the facility, no comparison on rates to previous months, trends and actions or plans to reduce IC rates within the facility.Review of the September 2025 IC rate (the percentage of infections per month, per 1000 resident days) showed Staff C documented 32 infections in the month of September at an infection rate of 39.4 %.Review of October 2025 IC documents showed similar findings with no monthly analysis of the number of Community Acquired Infections (CAI) only Healthcare Acquired Infections (HAI), the number of the most prevalent sites or organisms of infection in the facility, no comparison on rates to previous months, trends and actions or plans to reduce IC rates within the facility.Review of the October 2025 IC rate showed Staff C documented 29 infections for the month of October at an infection rate of 35.3%.Review of the total resident days for September 2025, showed a total of 2437. The rate was determined by taking the number of infections divided by the total resident days and times by 1000 to equal a September 2025 monthly IC rate of 13.3 %. Review of the total resident days for November 2025 showed 2544, for a monthly IC rate at 11.4%.During an interview on 11/21/2025 at 3:10 PM Staff C was asked how the infection control rate was determined. Staff C stated they took the number of infections for the month and divided it by the daily census and times that number by 100 to determine the rate. Staff C was shown the total number of resident days for September 2025 and acknowledged they did not use the right number for total resident days. Staff C stated they did analyze the IC documents monthly to include a narrative, will present the information at QAPI meetings, and would provide those documents. Documents provided showed Staff C completed the monthly summary to include the corrected monthly infection rate indicating the summary was completed after 11/21/2025, and not completed at the end of the month. REFERENCE: WAC 388-97-1320(2)(a)(c).

Based on interview and record review the facility failed to implement a system to ensure Advanced Directives (AD) were in place for 3 of 5 residents (Residents 18, 5 & 30) reviewed for ADs. The facility failed to provide information indicating residents were informed, educated, or offered assistance to formulate an AD. This failure placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care.Findings included.<Facility Policy>Review of the facility's Advanced Directive and Associated Documentation policy, revised 12/2023, showed the facility staff would provide the resident/family with written information regarding their right to formulate an AD and document in the resident's record, at the time of admission, that the resident/family was provided with AD information. The policy showed a copy of the resident's AD would be obtained and placed in the resident's record.<Resident 18> According to the [DATE] Annual Minimum Data Set (MDS -an assessment tool) Resident 18 admitted to the facility on [DATE] and had severe memory impairment. The MDS showed Resident 18 had diagnoses of Moyamoya disease (a rare condition where the blood vessels supplying the brain become narrowed or blocked) and aphasia (a partial or total loss of the ability to articulate ideas or comprehend spoken or written language, resulting from damage to the brain from injury or disease). Review of the [DATE] AD Care Plan (CP) Resident 18's family was legal next of kin/surrogate decision maker. The CP showed Resident 18 was unable to make decisions for themselves and their primary decision maker was a family member. Review of Resident 18's electronic health records showed a [DATE] Advanced Directive Documentation progress note stating Resident 18's family member was not prepared to take on legal guardianship and declined applying for/obtaining legal guardianship for Resident 18's health care. In an interview on [DATE] at 8:54 AM Resident 18 stated they did not have a Durable Power of Attorney or legal guardian and staff had not discussed ADs with them. In an interview on [DATE] at 1:25 PM Staff D (Social Service Director – SSD) stated Resident 18's family member was not prepared to spend the money to obtain legal guardianship for Resident 18's health care. Staff D stated they did not obtain a legal court appointed guardianship for a resident if they had a family member that could talk for them. <Resident 5> According to the [DATE] admission MDS, Resident 5 did not have cognitive impairment and had diagnoses including cancer, malnutrition, and required nutrition through a feeding tube surgically placed in the stomach. Review of an [DATE] Social Services Assessment showed Resident 5 did not have an AD. The assessment showed a checkbox resident and/or resident representative have been informed in a manner easily understood of their right to formulate advanced directives. This checkbox was left blank by facility staff. In an interview on [DATE] at 11:20 AM, Staff D stated residents were asked to provide copies of ADs upon admission and social service staff would follow up to obtain the documentation. Staff D reviewed Resident 5's records and stated the resident did not have an AD. Staff D stated they did not have documentation to show AD planning or assistance was offered, or documentation showing the resident declined. <Resident 30> According to the [DATE] Quarterly MDS, Resident 30 had some problems with thinking and memory. The MDS showed Resident 30 had diagnoses including history of a brain bleed, cancer, heart and kidney disease, and difficulty expressing speech. Review of Resident 30's record showed the resident had AD paperwork via guardianship. The guardianship paperwork showed it expired on [DATE]. Review of Resident 30's progress notes showed the social services department requested updated guardianship paperwork on [DATE]. The progress notes showed no further documentation regarding obtaining up to date guardianship paperwork. In an interview on [DATE] at 11:15 AM, Staff D stated they called the court to obtain updated guardianship paperwork, and the court was backed up. Staff D stated they were unsure if the facility followed up since [DATE]. No further documentation was provided by the facility. REFERENCE: WAC 388-97-0280(3)(a)(c).

Based on observation, interview, and record review, the facility failed to maintain a homelike environment for 4 of 4 units (Units 100, 200, 300 and 400) reviewed. The failure to provide necessary maintenance and repairs in pantry areas and resident rooms for damaged walls, carpets, and furniture left residents at risk for a diminished homelike environment.Findings included .<Facility Policy>According to the facility's October 04, 2016, Resident Rights policy, the facility would provide a safe, clean, comfortable, and homelike environment.<Units 100 and 200 Pantry/Bistro> Observations on 11/18/2025 at 10:52 AM, 11/19/2025 at 8:58 AM, and 11/20/2025 at 8:44 AM of the Bistro area (an area accessible to residents and used as a designated pantry for Units 100 and 200) showed 4 of 4 tables were soiled with dried spill marks and food debris during each observation. During each observation, residents were seen sitting in the bistro area. The refrigerator/freezer was labelled Attn: Staff Access Only and stocked with food and drinks for residents. The combination cable lock across the refrigerator door was broken and the freezer door did not have a lock. The cabinet underneath the sink showed signs of water damage with black patches of mold-like growth and odor. In an interview and observation on 11/20/2025 at 12:45 PM, Staff F (Plant Operations Manager) stated the areas needed to be repaired to prevent possible mold exposure during food and beverage preparation, and to prevent unauthorized access to the refrigerator and freezer. In an interview and observation on 11/20/2025 at 1:35 PM, Staff H (Housekeeping Supervisor) stated the bistro area was assigned to the evening staff to clean each night and needed to be disinfected to provide a safe and clean homelike environment for residents. <Unit 300 Pantry> Observations on 11/18/2025 at 10:12 AM, 11/19/2025 at 8:16 AM, and 11/20/2025 at 8:24 AM of the Unit 300 pantry (a locked room used to store and prepare food and drinks for residents) showed water damage inside the cabinet under the sink with black patches of mold-like growth and odor. In an interview and observation on 11/20/2025 at 12:45 PM, Staff F stated the areas needed to be repaired to prevent possible mold exposure during food and beverage preparation. <Unit 400 Pantry> Observations on 11/18/2025 at 10:41 AM, 11/19/2025 at 8:23 AM, and 11/20/2025 at 8:37 AM of the Unit 400 showed damage to the laminate on the cabinet making it uncleanable, and the wall beneath the hand sanitizer dispenser was damaged and unrepaired. In an interview and observation on 11/20/2025 at 12:45 PM, Staff F stated the areas needed to be repaired to allow for proper cleaning in areas of food and beverage preparation. <Wall damage/Curtain removal> Observations on 11/17/2025 at 11:34 AM, showed staff had removed window dressings from resident rooms 306, 308, 314, 316, 318, 322, 324, 326, 328, 400, 404, 406, 410, 412, 416, 418, 420, 422, and 428, leaving the walls damaged. In an interview and observation on 11/20/2025 at 12:45 PM, Staff F stated the facility removed all window curtains in September 2025 and planned to repair the wall damage when residents were on leave from the facility or the rooms became vacant. Staff F stated it was important to make timely repairs to maintain a homelike environment. Observations on 11/18/2025 at 10:03 AM showed plaster missing from the wall corner near the doorway in Resident #7's room, deep scratches beneath the television, and a carpet stain in the hallway outside the room. In an interview and observation on 11/20/2025 at 12:45 PM, Staff F stated the areas needed to be repaired to maintain a homelike environment. In an interview and observation on 11/20/2025 at 1:35 PM, Staff H stated the carpet needed to be cleaned to ensure a safe and clean homelike environment for residents. Observations on 11/18/2025 01:23 PM showed Resident 13's multiple deep scratches on the walls and their headboard was missing a large piece of laminate exposing the chipboard. In an interview and observation on 11/20/2025 at 12:45 PM, Staff F stated the areas needed to be repaired to allow for proper cleaning and to maintain a homelike environment. In an interview on 11/20/2025 at 1:10 PM, Staff F stated they conduct monthly room by room assessments and record concerns in the TELS app (a digital maintenance application) for future repair. After touring the facility, Staff F stated none of the areas of concern had been identified or entered into TELS. Staff F stated they expected staff to report problems promptly through TELS. Staff F stated no other maintenance logs or documentation besides TELS. <Personal Care Supplies> <room [ROOM NUMBER]> Observation of room [ROOM NUMBER]-1 showed the resident's nightstand was covered with personal care supplies. The nightstand contained an opened package of adult briefs with one brief lying outside the package, four packages of personal wipes, all opened, a bottle of lotion that was tipped over, two bottles of skin cleanser, and wound dressings that were not contained. In an interview on 11/20/2025 12:26 PM, Staff K (Resident Care Manager) stated personal care supplies and wound supplies should not be kept on the resident's nightstand and should be kept away in a drawer. <Wall Scrapes> <room [ROOM NUMBER]> Observation on 11/18/2025 at 8:44 AM showed the resident in room [ROOM NUMBER]-2 lying in bed. Long scrapes with the wallpaper peeling and hanging off the wall was observed behind the head of the bed, near the floor. <room [ROOM NUMBER]> Observation on 11/18/2025 at 8:48 AM showed the resident in room [ROOM NUMBER]-1 lying in bed. Long scrapes with the wallpaper peeling and hanging off the wall was observed behind the head of the bed. Reference: WAC 388-97-0880, -2040.

Based on interview and record review, the facility failed to call report to the hospital regarding the resident's status for 6 of 6 residents (Residents 38, 11, 8, 74, 9, & 22) and provide a written transfer notice to 3 of 6 residents (Residents 8, 74, & 9) reviewed for discharge process. Failure to call report to the receiving hospital placed residents at risk of a break in communication and continuity of care. Failure to ensure written notification was provided to the resident/resident representative, in a language and manner they understood, placed residents at risk for not having an opportunity to make informed decisions about their transfer/discharge rights.Findings included .<Policy>According to the facility policy titled, Transfer or Discharge Notice, dated 09/2012, the facility would provide the resident or resident representative the name, address, and telephone number of the state health department agency designated to handle appeals of transfers and discharges. According to the facility policy titled, Transfer or Discharge, Emergency, dated 09/2012, the facility would notify the receiving facility that the transfer was being made.<Resident 38> Review of the 08/20/2025 Discharge Minimum Data Set (MDS – an assessment tool), Resident 38 was discharged to the hospital with their return anticipated. Review of Resident 38's progress notes from 08/18/2025 to 08/25/2025 showed facility staff did not document a note regarding the resident's transfer to the hospital. There was no note indicating the resident's condition, who was notified of the transfer, or the reason for the transfer to the hospital. Review of an 08/20/2025 eInteract Change in Condition Evaluation assessment showed the assessment was incomplete. The Situation part of the assessment was incomplete showing only the resident seem[ed] different than usual. The second and third page of the assessment included sections for staff to document mental, functional, behavioral, respiratory, heart, abdominal, urine, skin, and pain evaluations. Both pages were blank. The assessment showed staff did not document the provider or family was notified of Resident 38's transfer to the hospital. The assessment showed staff did not document that report was called to the hospital prior to the resident's transfer. <Resident 11> Review of the 08/03/2025 Discharge MDS, Resident 11 discharged with their return anticipated. The 08/28/2025, 09/20/2025, and 10/25/2025 Discharge MDS' showed Resident 11 discharged to the hospital with their return anticipated. Review of Resident 11's progress notes from 08/03/2025 to 10/25/2025 showed staff did not document a report was called to the receiving facility regarding the resident's transfer. Review of Resident 11's eInteract assessments showed staff only completed the assessments for the resident's 08/28/2025 and 10/25/2025 hospitalizations. Staff did not document on the eInteract assessment that hospital staff were called and given report regarding Resident 11's transfers. Staff did not complete eInteract assessment forms for the 08/03/2025 or 09/20/2025 transfers. In an interview on 11/20/2025 at 12:35 PM, Staff K (Resident Care Manager - RCM) stated it was their expectation staff complete a progress note and called the hospital to give report on residents that were being transferred out emergently. <Resident 8> According to the 07/26/2025 admission MDS Resident 8 readmitted to the facility on [DATE] with no memory impairment. Resident 8 had diagnoses of anxiety disorder and depression. Review of Resident 8's health records showed they were transferred out of facility on 07/10/2025 to an acute care hospital. Resident 8's records showed no written transfer notification was provided to Resident 8 and report was not provided to the receiving acute care hospital. In an interview on 11/17/2025 at 1:20 PM Resident 8 stated they had a recent hospitalization. In an interview on 11/19/2025 at 1:39 PM Staff E (RCM) stated they did not provide Resident 8 with a written transfer notification for the 07/10/2025 transfer to the hospital. Staff E stated they did not document report called to the hospital for Resident 8's 07/10/2025 transfer but should have. Staff E stated it was important to provide written transfer notification to the residents or representatives upon transfer to ensure they understood their rights to appeal and to provide reports to receiving hospital to ensure good continuity of care. <Resident 74> According to the 04/02/2025 Annual MDS Resident 74 readmitted to the facility on [DATE] from a short stay hospital transfer. The MDS showed Resident 74 had no memory impairment. Review of Resident 74's health records showed documentation of a 12/31/2024 transfer to an acute care hospital. Resident 74's health records showed no written transfer notification was provided to Resident 74 for the 12/31/2024 transfer to the hospital and report was not provided to the receiving hospital. In an interview on 11/18/2025 at 9:11 AM Resident 74 stated they had a hospitalization at the beginning of the year. In an interview on 11/19/2025 Staff H (Director of Medical Records) reviewed Resident 74's health records stating there was no documentation of the required written transfer notification being provided to the resident. Staff H stated there was no documentation of report called to the receiving hospital for the 12/31/2024 transfer to the hospital but should be. <Resident 9> Review of the 05/18/2025 Discharge MDS, Resident 9 was discharged to the hospital with their return anticipated. Review of Resident 9's progress notes from 05/18/2025 showed they were transferred out of the facility to an acute care hospital for severe abdominal pain. Resident 9's health records showed no written transfer notification was provided, and report was not provided to the receiving acute care hospital. In an interview on 11/17/2025 at 1:43 PM Resident 9 stated they had been hospitalized this year. <Resident 22> Review of the 08/25/2025 Discharge MDS, Resident 22 was discharged to the hospital with their return anticipated. Review of a 08/25/2025 Nursing Home Transfer or Discharge Notice showed Resident 22 was being transferred to the hospital for kidney stones and was signed by Staff N (Registered Nurse) for the notice being provided to Resident 22. Review of Resident 22's progress notes from 08/25/2025 showed they were transferred out of the facility to an acute care hospital for severe abdomen and groin pain. Staff did not document they called the hospital to give report of Resident 22's status. In an interview on 11/17/2025 at 12:33 PM Resident 22 stated they had recently been hospitalized . In an interview and record review on 11/21/2025 at 12:50 PM, Staff B (Director of Nursing) stated there was no documentation of the required written transfer notification being provided to Resident 9 and no documentation of staff contacting the receiving hospitals during the transfers of Resident 9 or Resident 22. Staff B stated they expected report be given to the receiving hospital to prepare them with the resident's condition and background. Staff B stated they expected staff to document notices and reports in a resident's electronic health record. Reference: WAC 388-97-0120(1)(2)(a-d)(3)(a)(4)(b)(5), 0080, -0140(1)(a-c)(i-iii).

Based on record review and interviews, the facility failed to ensure Preadmission Screening and Resident Review level II (PASRR -federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) coordination was completed prior to admission to the facility for 1 of 5 residents (Resident 28) reviewed for PASRR. Failure to ensure PASRR II completion prior to admission placed residents at risks for unmet mental health care needs.Findings included.<Policy>POLICY?????????<Resident 28>According to the 10/28/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 28 admitted to the facility on [DATE]. The MDS showed Resident 28 had a diagnosis of Depression.Review of Resident 28's health records showed a 10/20/2025 PASRR I that indicated Resident 28 had a Serious Mental Illness (SMI). The PASRR I showed a level II evaluation was required for SMI. Resident 28's health records showed no PASRR II was completed.In an interview on 11/21/2025 at 1:22 PM Staff O (Social Service) stated the admissions department was expected to obtain the PASRR II determination or invalidation prior to admission to the facility per regulation. Staff O stated there was no documentation of a PASRR II referral being made for Resident 28. Staff O stated they did not receive a PASRR II notice of determination or invalidation prior to Resident 28's admission. Staff O stated it was important to obtain level II PASRR's prior to admission to ensure residents received specialized services that the individual required for optimal mental health needs.In an interview on 11/21/2025 at 1:35 PM Staff Q (admission Coordinator) stated when a resident was referred for a level II PASRR upon screening, they were expected to ensure the PASRR II was competed prior to admission to the facility. Staff Q stated they must have missed Resident 28's incomplete level II [NAME] before admitting them to the facility.Reference: WAC 388-97-1915(4), -1975(7)(8)(10).

Based on observation, interview, and record review, the facility failed to ensure Care Plans (CP) were updated and/or revised, as needed for 2 of 5 sample residents (Residents 22 & 75) reviewed for CPs, and conduct timely Care Conferences (CC) with the residents Interdisciplinary Team (IDT) present to ensure person-centered care for 2 of 5 sample residents (Resident 75 & 28) who were reviewed for CC's. This failure left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes.<Facility Policy>Review of the Comprehensive Person-Centered Care Planning policy, revised August 2017, showed the facility would provide advance notice for and conduct care planning conferences with each resident and/or their representative and the IDT to both create and review the residents' person-centered care needs and preferences and revise when additions were necessary.<Care Plans> <Resident 22> According to the 09/06/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 22 was admitted to the facility on [DATE] with multiple medically complex conditions including paraplegia (inability to move the lower half of the body), a blood clotting disorder and anxiety disorder. Resident 22 had no impaired memory. In an interview on 11/17/25 at 10:13 AM, Resident 22 stated frustration with their inability to attend recreation activities due to their waist-high compression hose being soiled and not available for use. Observations and interviews on 11/18/2025 2:33 PM, 11/19/2025 9:37 AM, 11/20/2025 09:41 AM and 11/21/2025 10:01 AM showed the compression hose hung at bedside and Resident 22 stated they had not been laundered. Review of a 04/24/2025 physician order showed Resident 22 was to wear waist-high compression stockings when out of bed. Review of Resident 22's comprehensive CP on 04/30/2025 showed Resident 22 had an intervention for compression hose when out of bed. Review of Resident 22's 09/02/2025 CP showed no interventions for waist-high compression stockings or task for laundering of the hose. In an interview on 11/21/2025 at 11:30 PM, Staff I (Certified Nursing Assistant) stated they were aware of Resident 22's need for daily evening handwashing of the compression hose, confirmed it was within their role, and reported completing the task on previous evening shifts. In an interview and record review on 11/21/2025 at 12:50 Staff B (Director of Nursing) stated they were aware of Resident 22's need for the compression hose. Staff B stated the facility transitioned from the old Electronic Health Record (EHR) to the current system on May 1, 2025. After reviewing Resident 22's EHR across both systems, Staff B stated the care plan was not updated accurately and left out the compression hose and their laundering care. Staff B stated they expected CNAs to handwash garments for dependent residents, as needed. <Resident 75> According to the 10/21/2025 admission MDS, Resident 75 had medically complex conditions including heart failure, kidney disease, and diabetes (inability for the body to control blood sugar levels). The MDS showed Resident 75 received a water pill and medications to treat their diabetes during the assessment period. Review of Resident 75's 11/18/2025 order summary showed a 10/17/2025 order directing staff to administer a water pill twice daily for the resident's heart failure. The order summary showed an 11/18/2025, 10/17/2025, and 10/14/2025 order directing staff to administer injectable medications to treat Resident 75's diabetes. Review of Resident 75's 10/14/2025 comprehensive CP showed staff did not initiate a focused CP to address goals and interventions regarding the resident's use of the water pill medication and heart failure. The CP did not include information regarding monitoring the resident's weight or potential adverse reactions of the water pill. The CP showed staff did not initiate a focused care plan to address goals and interventions regarding the resident's diabetes diagnosis or diabetic medication management. There were no directions to staff regarding Resident 75's usual blood sugar levels, monitoring for high or low blood sugars or adverse reactions to their diabetic medications. In an interview on 11/21/2025 at 10:50 AM, Staff K (Resident Care Manager) reviewed Resident 75's CP and confirmed the comprehensive CP did not include information regarding the resident's water pill and heart failure or the resident's diagnosis of diabetes. Staff K stated it was their expectation the CP included information regarding monitoring the water pill and diabetes management. <Care Conferences> <Resident 75> According to the 10/21/2025 admission MDS, Resident 75 admitted to the facility on [DATE] and was not cognitively impaired. In an interview on 11/18/2025 at 1:12 PM, Resident 75 stated they did not have a care conference with the therapy, nursing, or social services department. Resident 75 stated they sort of trickled in one at a time, I like to take notes, and I could not. Resident 75 stated they requested to see the social worker last week and they were still waiting for the social worker to come by their room. Review of Resident 75's comprehensive record on 11/18/2025 showed staff did not hold a CC for the resident. There was no CC assessment or progress note documenting staff offered or arranged a CC for Resident 75. In an interview on 11/19/2025 at 11:24 AM, Staff O (Social Services) stated it was their process to hold CC for newly admitted residents within 7-10 days of their admission. Staff O stated the CC would include family as applicable, social services, therapy staff, and kitchen staff. Staff O confirmed Resident 75 did not have a CC. <Resident 28> According to the 10/28/2025 admission MDS Resident 28 admitted to the facility on [DATE]. The MDS showed Resident 28 had no memory impairment. In an interview on 11/18/2025 at 9:37 AM Resident 28 stated they had not had a CC with her IDT since admission. Resident 28 stated facility staff mentioned a CC with the IDT would be scheduled but it did not happen. Review of Resident 28's health records at this time showed no CC offered or attended. In an interview on 11/20/2025 at 1:26 PM Staff O stated the facility policy was to offer CC's for newly admitted residents within 7-10 days of their admission. Staff O stated the CC would include family as applicable, social services, therapy staff, and kitchen staff. Staff O confirmed Resident 28 did not have a CC. Reference: WAC [PHONE NUMBER](2)(c)(d)(e)(f), (4)(b)(c)(i)(ii)(d-f).

Based on observation, interview, and record review the facility failed to ensure physician orders were administered as prescribed for 2 (Residents 9 & 12) of 19 sample residents, failed to obtain physician orders for treatment for 1 (Resident 74) of 19 sample residents, and failed to clarify physician orders for 1 (Resident 30) of 19 sample residents. These failures placed residents at risk for medication errors, delayed treatment, and other negative health outcomes.Findings included .<Administering Physician Orders> <Resident 9> According to the 09/02/2025 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 9 had heart and lung conditions including heart failure. Review of Resident 9's physician orders showed an 08/18/2025 order for a medication to slow their heart rate and reduce the force of their heart beat, with instructions to hold the medication if the systolic blood pressure (a measure of the pressure inside the arteries when the heart squeezes) was less than 110 mmHg (millimeters of mercury) or heart rate was less than 60 beats per minute. The physician orders showed an 11/18/2025 order directing staff to obtain orthostatic blood pressure (measuring the resident's blood pressure while lying down, sitting, and standing) once per month. Review of Resident 9's September, October, and November 2025 Medication Administration Records (MARs) showed staff failed to hold the medication on 09/03/2025, 09/04/2025, 09/07/2025, 09/21/2025, 10/05/2025, 10/14/2025, 10/16/2025, 10/30/2025, and 11/17/2025 as ordered. On 11/19/2025, Resident 9's orthostatic blood pressure was recorded as 146/73 mmHg for lying, sitting, and standing. <Resident 12> According to the 10/21/2025 Quarterly MDS, Resident 12 had impaired memory, poor nutrition, elevated blood sugar, and a risk for skin injury. Review of Resident 12's physician orders showed a 05/01/2025 order for a medication to soften stool with instructions to hold for loose stools and an 11/18/2025 order to receive orthostatic blood pressures once per month. Review of Resident 12's October and November 2025 Documentation Survey Reports and MARs showed staff documented loose stools and failed to hold the stool softening medication on 10/24/2025, 10/25/2025, 10/26/2025, 10/29/2025, 11/03/2025, 11/06/2025, 11/13/2025, 11/14/2025, 11/17/2025, 11/18/2025, and 11/19/2025. On 11/19/2025, Resident 12's orthostatic blood pressure was recorded as 96/64 mmHg for lying, sitting, and standing. In an interview on 11/20/2025 at 10:51 AM, Staff J (Certified Nursing Assistant) recalled performing one blood pressure measurement for Resident 9 and Resident 12, and both measurements were taken while they were seated. Staff J did not recall how to obtain orthostatic blood pressure measurements. Staff J stated they gave the blood pressure results to Staff G (Licensed Practical Nurse) to enter into the residents' records. In an interview on 11/21/2025 at 12:32 PM, Staff G stated they documented the blood pressure results into Resident 9 and Resident 12's medical record without questioning Staff J about the similarities between all three positions. Staff G stated orthostatic blood pressure results would not typically be identical across all three positions for both residents. Staff G stated they did not ask Staff J to clarify how the task was performed prior to documenting the results. In an interview and record review on 11/21/2025 at 1:31 PM, Staff B (Director of Nursing) stated staff failed to hold the medications per the physician orders for Resident 9 and Resident 12. Staff B stated the orthostatic blood pressure results would not typically be identical across all three positions for both residents, and they expected nurses to further assess prior to documenting them. Staff B stated it was important for staff to follow physician orders, complete ordered tasks, confirm competency prior to delegating and correctly record results in the residents' medical records. <Obtaining Physician Orders> <Resident 74> According to the 04/02/2025 Annual MDS Resident 74 had no memory impairment. The MDS showed Resident 74 had diagnoses of Paraplegia (complete paralysis of the lower body) and post-traumatic stress disorder. In an interview on 11/18/2025 at 9:17 AM Resident 74 stated they had a seatbelt in their wheelchair for a long time. Resident 74 stated staff observed them for safety related to use of the seatbelt. Review of Resident 74's health records at this time showed no physician order for the seatbelt to Resident 74's wheelchair. In an interview on 11/21/2025 at 8:55 AM Staff B stated they expected staff to obtain a physician order for restraints used for residents. Staff B reviewed Resident 74's health records and stated there was no physician order for the seatbelt to Resident 74's wheelchair but should be. Staff B stated it was important to obtain a physician order for treatments to ensure staff were aware of treatments in place for the resident and the physician was overseeing and managing care and treatments for the resident. <Clarifying Physician Orders> <Resident 30> According to the 10/27/2025 Quarterly MDS, Resident 30 had mild, cognitive impairment. The MDS showed Resident 30 was always continent of bowel and required substantial/maximal assistance from staff with toileting hygiene. In an interview on 11/17/2025 at 9:33 AM, Resident 30 stated they were constipated at times and they would take prune juice, but the juice was not enough. Resident 30 stated they were currently constipated and requested medicine from the nurse the night before but did not receive the medicine. Review of Resident 30's 10/2025 bowel documentation showed the resident did not have a bowel movement documented for 4 days, 10/07/2025 through 10/10/2025. The documentation showed Resident 30 did not have a bowel movement from 10/18/2025 through 10/21/2025 or from 10/24/2025 through 10/27/2025. Review of the 10/2025 MAR showed a 07/31/2025 order directing staff to administer an as needed medication for bowel management. The order did not specify when staff should administer the medication. The MAR showed staff did not administer the as needed bowel medication when Resident 30 was constipated. Review of Resident 30's 09/2025 bowel documentation showed the resident did not have a bowel movement documented from 09/02/2025 to 09/07/2025, from 09/18/2025 to 09/21/2025, or from 09/26/2025 to 09/30/2025. Review of the 09/2025 MAR showed a 07/31/2025 order directing staff to administer an as needed medication for bowel management. The order did not specify when staff should administer the medication. The MAR showed staff administered the as needed medication on 09/05/2025,4 days after not having a bowel movement, and on 09/07/2025, 6 days after no bowel movement. The MAR showed staff did not administer the as needed bowel medication between 09/18/2025 to 09/21/2025. The MAR showed staff did administer the bowel medication on 09/30/2025, 5 days after Resident 30 did not have a bowel movement. In an interview on 11/20/2025 at 12:20 PM, Staff K (Resident Care Manager) stated residents had standing orders for bowel protocols. Staff K stated the protocol was to administer an as needed bowel medication on the morning of the 4th day without a bowel movement, if the medication was ineffective, the evening shift was expected to administer an as needed suppository. If the suppository was ineffective, the night shift would administer an enema to the resident. Staff K stated if Resident 30 refused to take the as needed bowel medication, staff were expected to document the refusal and assess Resident 30 for bowel sounds, tenderness, distended abdomen, and notify the provider. Staff K stated staff were expected to write a progress note. Staff K reviewed Resident 30's orders and confirmed the resident did not have a complete bowel protocol ordered and that the resident's orders needed to be clarified. Reference: WAC 388-97-1620(2)(b)(i)(ii)(6)(b)(i).

Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADL) for 3 of 5 residents (Residents 22, 38, & 10) reviewed who were dependent on staff for daily cares. The failure to provide assistance with ADLs placed residents at risk for poor hygiene, diminished feeling of self-worth, and a decreased quality of life.Findings included .<Resident 22> According to the 09/06/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 22 was admitted to the facility on [DATE] with multiple medically complex conditions including paraplegia (unable to move both legs), a blood clotting disorder and anxiety disorder. Resident 22 needed staff to perform all effort required to dress their lower extremities and apply footwear. Resident 22 had no impaired memory. In an interview on 11/17/25 at 10:13 AM, Resident 22 stated frustration with their inability to attend recreation activities due to their waist-high compression hose being soiled and not available for use. Resident 22 reported asking the evening aide to handwash and hang-dry the garment and was told it was not their responsibility. Resident 22 stated the compression hose was last washed two weeks prior by a different evening aide. Resident 22 stated frustration about having to frequently negotiate their care needs with staff. Observations and interviews on 11/18/2025 at 2:33 PM, 11/19/2025 at 9:37 AM, 11/20/2025 at 09:41 AM and 11/21/2025 at 10:01 AM showed soiled compression hose hanging at bedside. Resident 22 stated the hose had not been laundered and could not be worn because they were unclean and stretched out from prior use. Review of a 04/24/2025 physician order showed Resident 22 was to wear waist-high compression stockings when out of bed. Review of Resident 22's comprehensive Care Plan (CP) on 04/30/2025 showed Resident 22 had a risk for autonomic dysflexia (a sudden, dangerous rise in blood pressure) requiring waist high compression hose when out of bed. Review of Resident 22's order summary report as of 11/20/2025 did not show an order for waist-high compression stockings. Review of Resident 22's 09/02/2025 CP showed no interventions for waist-high compression stockings or task for laundering. Review of Resident 22's 11/20/2025 Kardex (an at-a-glance snapshot of the resident's care needs available to all staff) showed no interventions for waist-high compression stockings or task for laundering. In an interview on 11/21/2025 at 11:30 PM, Staff I (Certified Nursing Assistant/CNA) stated they were aware of Resident 22's need for daily evening handwashing of the compression hose, confirmed it was within their role, and reported completing the task for Resident 22 when assigned to them on past evening shifts. In an interview and record review on 11/21/2025 at 12:50 Staff B (Director of Nursing) stated they were aware of Resident 22's need for the compression hose application prior to transferring from bed to wheelchair. Staff B stated they expected CNAs to handwash garments for dependent residents, as needed. Staff B stated the facility's failure to launder and apply the compression hose limited Resident 22's access to essential ADL support. <Resident 38> According to the 09/22/2025 Annual MDS, Resident 38 was impaired on one side of their body to their upper and lower extremity. The MDS showed Resident 38 was dependent on staff for personal hygiene. In an observation and interview on 11/18/2025 at 1:36 PM, Resident 38's fingernails to both hands extended past the tips of their fingers and there was dark debris noted underneath the nails. Resident 38's spouse was visiting and stated the resident preferred their nails short and clean. A similar observation was made on 11/19/2025 at 8:57 AM. Review of Resident 38's November 2025 bathing documentation showed staff provided a sponge bath to the resident on 11/14/2025 and 11/16/2025. <Resident 10> According to the 10/07/2025 admission MDS, Resident 10 was admitted to the facility on [DATE] with no memory impairment. The MDS showed Resident 10 was dependent on staff to perform all hygiene cares. Review of Resident 10's health records showed a 10/16/2025 ADL CP showed they required moderate assistance from staff for hygiene cares. Observations on 11/18/2025 at 12:46 PM, 11/19/2025 at 8:42 AM and 1:12 PM, 11/20/2025 at 1:40 PM, and 11/21/2025 at 9:48 AM showed Resident 10 lying in bed on their back with their hair not brushed and wearing a hospital gown. In an interview on 11/21/2025 at 8:55 AM Staff B stated they expected staff to offer and assist residents with AM. Staff B stated they expected staff to assist with brushing hair, washing face, brushing teeth, and getting residents dressed and out of bed as part of AM cares. Staff B stated, if a resident refused care, they expected staff to document all refusals and notify the residents care manager. Staff B stated, if staff were unable to complete assigned care, they expected staff to report the issue to management. In an interview on 11/21/2025 at 10:38 AM Staff P (Certified Nursing Assistant) stated they were expected to assist residents assigned to them with brushing hair, washing face, brushing teeth, getting dressed, and up for the day as part of AM cares. Staff P stated Resident 10 did not have any personal clothing except for one pink gown so they were unable to get Resident 10 dressed daily. Staff P stated they had not notified Social Services or the nurse manager that Resident 10 did not have any personal clothing but should have. Staff P stated they did not get Resident 10 out of bed on Tuesday, Thursday, or today (Friday). Staff P stated they were expected to offer AM cares before breakfast but had a lot of heavy care residents that required two-person assistance so they could not finish all tasks for each resident. Staff P stated they had not reported the incomplete tasks to management but should have. Reference: WAC 388-97-1060(2)(c).

Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional standards of practice. The facility failed to: (1) Label medications properly and dispose expired medications timely for 2 of 4 medication carts (Units 100 & 300) reviewed; (2) monitor the medication refrigerator temperature; and (3) secure medications found at the bedside for 1 (Resident 38) of 19 sample residents. These failures placed residents at risk for receiving compromised medications with decreased or no potency, the potential use of unsecured medications, and a decreased quality of life. Findings included . <Facility Policy>Review of the facility policy titled, Storage of Medications, revised April 2007, showed the facility would store all drugs and biologicals in a safe, secure, and orderly manner. The policy showed medications must be labeled accordingly and outdated drugs should be returned to the dispensing pharmacy or destroyed. The policy showed medications requiring refrigeration must be stored in a refrigerator and the nursing staff were responsible for maintaining proper medication storage. The policy showed medications should not be left unattended. <Unit 100 Medication Cart> Observation of the Unit 100 medication cart on 11/20/2025 at 11:03 AM with Staff L (Registered Nurse) showed one full bottle of Aspirin (Non-Steroidal Anti-Inflammatory Drug) expired on 10/2025, one tube of antibiotic skin wound gel expired on 05/30/2025, and one bottle of liquid disinfectant expired on 05/05/2025. In an interview on 11/20/2025 at 11:27 AM, Staff L confirmed the medications observed in the cart were expired. Staff L stated it was important to ensure expired medications were disposed of properly for resident safety. <Unit 300 Medication Cart> Observation of the Unit 300 medication cart on 11/20/2025 at 11:59 AM with Staff M (Licensed Practical Nurse) showed two opened insulin (a blood sugar medication) injection pens; one pen had a mislabeled open and discard dates, and the other pen did not have a discard date. There was one opened steroid inhaler (a respiratory medication) with no open and discard dates listed. There were four bottles of resident-owned nutritional supplements without an expiration date on the label. In an interview on 11/20/2025 at 12:23 PM, Staff B (Director of Nursing) confirmed the medication labeling issues identified in the cart. Staff B stated it was important for the nursing staff to ensure all medications were labeled appropriately with both the open and discard dates per the facility policy to ensure residents were not given expired medications. Staff B stated the resident-owned supplements observed without expiration dates should have been clarified with the provider. Staff B stated they expect the nurse who initially opened the medication to put the label properly for resident safety. < Medication Room Refrigerator> Review of the facility's Temperature Log for Refrigerator form located in the medication room showed the staff should monitor the medication refrigerator temperature and take action if the temperature was out of range (above 46F or below 36F). Observation of the medication room refrigerator on 11/20/2025 at 8:21 AM with Staff L showed there were temperature-sensitive medications located inside the refrigerator including insulin injection pens, antianxiety medication vials, suppositories, nasal inhalers, and biological vaccines. Review of the October 2025 refrigerator temperature log from 10/01/2025 until 10/31/2025 showed the temperature was not monitored for 11 days and the refrigerator was not working for two days. Review of the November 2025 refrigerator temperature log from 11/01/2025 until 11/20/2025 showed the temperature was not monitored for 14 days. In an interview on 11/20/2025 at 10:31 AM, Staff B stated the night shift nursing staff was responsible for monitoring the refrigerator temperature in the medication room. Staff B stated it was important to monitor the medication refrigerator temperature to ensure temperature-sensitive medications remained potent, .so the medication's formulation does not get ruined. Staff B reviewed the October 2025 and November 2025 temperature logs and stated the staff should have monitored the refrigerator temperature consistently as expected, but they did not. <Resident 38> Observations on 11/19/2025 at 2:10 PM showed unsecured, medicated wound treatments on Resident 38's nightstand. There were two tubes of medicated honey used to treat open wounds, and four bottles of spray wound cleanser that were accessible to Resident 38. In an interview on 11/20/2025 at 12:26 PM, Staff K (Resident Care Manager) stated the wound care supplies should not have been left on Resident 38's nightstand but should have been contained in the resident's closet. REFERENCE: WAC 388-97-1300(1)(b)(ii)

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from verbal abuse and mistreatment for 1 of 2 (Residents 1) residents reviewed for resident-to-resident incidents. Resident 1 experienced psychological harm when they had a change in their speaking pattern and tone, flat affect, crying, expressions of re-triggering of prior traumas, and feeling distressed after repeated verbal abuse by their roommate that escalated when not addressed timely by staff. This failed practice placed all residents at risk for the potential of verbal abuse, psychological harm, and diminished quality of life. Findings included . Review of the facility policy, titled, Abuse Prohibition and Prevention, dated 01/2024, showed all residents receiving care or services had the right to be free from abuse by anyone. The facility would have processes and measures in place to prevent, investigate, and act on all allegations of abuse. The policy showed the prevention of further abuse would occur by taking measures to protect the alleged victim, as well as other residents during the investigation. The alleged victim would be monitored, evaluated to determine if the resident felt safe, and if not immediate steps would be taken to alleviate fear. The policy showed residents would be protected from psychological harm during and after the investigation. <Resident 1> Review of the quarterly Minimum Data Set (MDS, an assessment tool), dated 01/13/2025, showed Resident 1 was able to make needs known, own decisions, and had no behaviors. The MDS showed Resident 1 had diagnoses including depression, inability to use legs, diabetes, and had a colostomy (an opening in the abdominal wall to divert waste from the colon). The MDS showed Resident 1 used a wheelchair, required two staff extensive assistance with transfers and lower body dressing. Review of a Nursing Progress Notes (NPN), dated 01/19/2025, showed Staff D (Resident Care Manager/Registered Nurse, RN) documented they observed Resident 1 and their roommate, Resident 2 yelling at each other, and that Resident 1 requested a room move. An additional NPN, dated 01/19/2025, showed Staff E (RN), documented the same content as Staff D's note. Both NPN's showed no documentation to support staff took any action to protect and prevent further abuse to Resident 1. Review of NPN's, dated 01/21/2025, showed Staff D documented that Resident 2 continued to yell at Resident 1, there were no options available for a room move, and the resident had a reinforced adjustment reaction and expressed response to new environment. An additional note on 01/21/2025, showed Staff E documented that Resident 1 reported that Resident 2 had used foul language at them and Staff E validated Resident 1's frustrations. Review of an electronic mail (e-mail) communication, dated Monday 01/20/2025 at 2:57 PM, showed Resident 1 emailed Staff C (Social Services (SS) Assistant) about their roommate having a fit and screaming it smells like a whore house in here. Resident 1 stated their roommate accused them constantly of smelling and when Resident 1 tried to reply to Resident 2's accusations was told to, shut up, shut, shut up. Resident 1 stated, it has been awful and I was told I will be moved rooms when a spot is available and requested a window side because of the air conditioner. Resident 1 documented they felt truly disrespected. Review of an e-mail communication, dated Tuesday 01/21/2025 at 8:42 PM, showed Resident 1 emailed Staff C again, the email showed, I am shaking as I write this email. I went to a doctor's appointment today, when I came back, my roommate started harassing me, I am unable to cope with the name calling, yelling, swearing, and telling me to go to hell. Just this evening they called me a bi**h, stupid, and I don't know anything. Telling me to go to hell and they can't wait to get my stinking a** out of here. I tried to tell them I do not appreciate them lying to others about me. Obviously, I must stay completely quiet and allow them to constantly degrade me and shout insults at me. They tell me and the staff several times a day that I stink, they have ramped up their accusations, absolutely nasty name calling, and swearing at me. I am done. I'm crying. I rarely cry, but I cannot take the verbal abuse. I am in a crisis mode emotionally. I want to call the state to report this abuse. I'm on the verge of calling 911. I was in a verbally abusive marriage, my reaction is that of PTSD (Post Traumatic Stress Disorder), and I am reliving all the physical and emotional trauma. Resident 1 emailed, If something isn't done immediately, I will be forced to find a solution myself. I am broken and need help immediately. Review of a facility investigation, completed and dated 01/25/2025, showed on 01/21/2025, Staff B (Director of Nursing Services) was informed that Resident 1 sent an email to Staff C (Social Services Assistant) and reported that Resident 2, their roommate was harassing them by stating stupid bi**h, you stink, telling anyone who entered the room that Resident 1 stunk, and reported feeling distressed. The investigation showed on 01/22/2025 Resident 1 was interviewed, expressed feeling worse than an abusive relationship, was observed with a flat face, whispering, and not speaking in a normal tone. In an observation and interview on 02/28/2025 at 1:58 PM, Resident 1 was observed in bed brushing their hair. Resident 1 stated Resident 2 would call them a bitch, liar, make statements saying you don't belong here, and if Resident 1 responded or tried to stand up for themselves Resident 2 would tell them to shut up. When asked what staff told them on 01/19/2025 after requesting a room move, Resident 1 stated Staff D told them they need to learn how to get along. Resident 1 stated they were filled with anger, it was bad how they (Resident 2) told everyone they (Resident 1) smelled, and Resident 1 started asking staff if they (Resident 1) smelled. Resident 1 stated after being called a bi**h on 01/21/2025 they were done, it was an emergency at that point because I had not felt those feelings in a long time, and referenced a history of verbal abuse in the past and feeling re-triggered by Resident 2's verbal abuse. Resident 1 stated by the time they asked about a room move they would have put up with a door bed even though they preferred a window bed just to be out of the room away from Resident 2. Resident 1 stated Resident 2 was given a behavior contract and was heard boasting to staff about it all proud. When asked if the verbal abuse stopped, Resident 1 replied it became more passive, as they could hear Resident 2 making comments but not as loudly as before. Resident 1 stated they moved rooms at the beginning of February 2025. In an interview on 02/28/2025 at 1:27 PM, Staff I (LPN) stated verbal abuse was saying anything towards a resident that made them feel uncomfortable, such as raising your voice, yelling, saying something hurtful or rude. Staff I stated it was not okay for residents to yell at each other and if they witnessed a resident yelling at another resident, the residents would need to be separated, identify the situation, and report to their supervisor. In an interview on 02/20/2025 at 1:46 PM, Staff H (Licensed Practical Nurse, LPN) stated it was not okay for a resident to yell at another resident as that would be abuse. Staff H stated if they observed two residents yelling they would separate both residents, determine what happened, start an incident report, and report to management and the state hotline. Staff H stated they have observed Resident 1 and Resident 2 yelling at each other and saw the nurse go into the room, and was not sure what happened after that. During an interview on 02/28/2025 at 2:52 PM Staff B (Director of Nursing) stated they would expect staff to separate and protect the resident from further abuse. Staff B stated they should have moved Resident 1 after staff witnessed Resident 1 and Resident 2 yelling at each other on 01/19/2025. Staff B stated a grievance was initiated after Resident 1's email was received on 01/20/2025 and Resident 2 received a behavior contract on 01/22/2025. Staff B acknowledged staff did not follow the facility abuse policy, if they would have the abuse would not have escalated, and staff did not protect Resident 1 from further verbal abuse from Resident 2 until Resident 1 had expressed emotional distress and retraumatization. REFER to F-607 REFERENCE: WAC 388-97-0640(1)(6)(b).

Based on observation, interview, and record review the facility failed to implement their abuse policies and procedures regarding identification of verbal abuse, thorough investigation, protection, preventing further abuse, and timely reporting of abuse and neglect incidents for 4 of 4 residents (Residents 1, 2, 3, & 4) reviewed for resident to resident incidents. These failures placed all residents at risk for unidentified abuse, on-going abuse, and diminished quality of life. Findings included . Review of the facility policy titled, Abuse Prohibition and Prevention, dated 01/2024, showed verbal abuse included the use of oral, written, or gestured communication or sounds, to residents within hearing distance, regardless of age, ability to comprehend or disability. The policy showed all employees received training to identify abuse and neglect, and an investigation would be conducted in response to suspected abuse, neglect, or mistreatment. The investigation would be thorough, documentation of the observed or alleged abuse in the resident's medical record, and immediate interventions would be put in place to protect the affected resident. Prevention of further abuse, neglect, and mistreatment would include monitoring the alleged victim, notification to the provider, measures taken to protect the victim when the perpetrator was a resident, such as increased monitoring and supervision or room relocation. The facility policy showed residents would be protected from physical and/or psychological harm, staff would respond immediately, room changes if necessary to protect the victim, and an examination of the alleged victim including a psychosocial assessment. All suspected and alleged violations would be reported to the administrator and required state agencies within a specified timeframe. According to the Purple Book, Nursing Home Guidelines, dated 10/2015, showed a resident to resident incident was required to be reported to the state agency when mental abuse with psychological harm was identified. When mental abuse with no psychological harm was identified, the facility was required to put the incident on their abuse/incident log. The reporting guidelines showed there was a presumption that abuse occurred whenever there was some type of offensive or unwanted contact with a resident. <Resident 1> Review of the quarterly Minimum Data Set (MDS, an assessment tool), dated 01/13/2025, showed Resident 1 was able to make needs known, own decisions, and had no behaviors. The MDS showed Resident 1 had diagnoses including depression, inability to use legs, diabetes, and had a colostomy (an opening in the abdominal wall to divert waste from the colon). The MDS showed Resident 1 used a wheelchair, required two staff extensive assistance with transfers and lower body dressing. Review of a Nursing Progress Note (NPN) on 01/19/2025, two days after moving into the room with Resident 2, Staff D (Resident Care Manager/Registered Nurse, RN) documented at 11:28 AM on 01/19/2025 they observed Resident 1 and Resident 2 yelling at each other. The NPN showed Resident 1 told Staff D they wanted to move rooms because their roommate was telling them they stink. The NPN did not indicate what Staff D did in response to Resident 1's request to move rooms, the allegation of verbal abuse, and if anyone such as the provider, administrator or DNS was notified of the incident. An additional note on 01/19/2025 at 11:26 PM by Staff E (RN), showed the exact NPN with no indication action was taken or who was notified. Review of a NPN, dated 01/21/2025 at 1:51 PM, showed Staff D documented that Resident 1's roommate continues to be disrespectful, complain about the odor, currently no options for room change, reinforced adjustment reaction and expected response to the new environment. A NPN, dated 01/21/2025 at 11:06 PM, showed Staff E documented that Resident 1 reported at 8:40 PM their roommate used foul language towards them. Staff E documented they validated Resident 1's frustrations. Both NPN's showed no indication action was taken in response to Resident 1's continued concerns of verbal abuse from Resident 2. Review of the facility census for 01/19/2025, 01/20/2025, 01/21/2025, and 01/22/2025, showed a minimum of seven female beds, two being window side as preferred by Resident 1 available. Review of a facility investigation, completed and dated 01/25/2025, showed on 01/21/2025, Staff B (Director of Nursing Services) was informed that Resident 1 sent an email to Staff C (Social Services Assistant) and reported that Resident 2, their roommate was harassing them by stating stupid bitch, you stink, telling anyone who entered the room that Resident 1 stunk, and reported feeling distressed. The investigation showed Resident 1's chart was reviewed, during initial days of being new roommates there was a verbal exchange with no distress reported, and staff acted accordingly for a new room adjustment. Staff B documented that Resident 2 continued to complain of Resident 1's odor and Resident 2 was redirected. The investigation showed on 01/22/2025 Resident 1 was interviewed, expressed feeling worse than an abusive relationship, was observed with a flat face, whispering, and not speaking in a normal tone. The investigation showed interventions put in place to prevent reoccurrence included; monitoring Resident 1 for distress, encouraged to express concerns promptly, provided with options for another room, move as soon as a preferred bed with a window is available, and reported to the state agency on 01/22/2025 for resident to resident verbal abuse, four days after the staff was aware of the verbal abuse. During an observation and interview on 02/28/2024 at 1:58 PM, Resident 1 was observed in bed, stated Resident 2 began yelling at them the first day they moved in, appeared that Resident 2 was very upset with all of my belongings, and was going to make me as miserable as possible. Resident 1 stated Resident 2 would call them a bitch, liar, and made statements that you don't belong here. Resident 1 stated they tried to talk to Resident 2 but was told shut up, shut up, shut up! Resident 1 stated they were filled with anger, it got bad, and Resident 2 constantly told everyone I stunk. I started asking staff if I smelled. When asked about their request to move rooms on 01/19/2024, Resident 1 stated Staff D told them they need to learn how to get along. Resident 1 said on 01/21/2025 after Resident 2 called her a bitch and whore, they were done, stating it was an emergency at the point, I haven't felt those feelings in a long time, and referenced a history of verbal abuse in the past and feeling re-triggered by Resident 2's verbal abuse. Resident 1 stated by the time they asked about a room move they would have put up with a door bed even though they preferred a window bed just to be out of the room away from Resident 2. Resident 1 stated Resident 2 was given a behavior contract and was heard boasting to staff about it all proud. When asked if the verbal abuse stopped, Resident 1 replied it became more passive, as they could hear Resident 2 making comments but not as loudly as before. <Resident 2> Review of the annual MDS, dated [DATE], showed Resident 2 was able to make their needs known, own decisions, and no behaviors. The MDS showed Resident 2 had diagnoses including abnormal heart rhythm, high blood pressure, and anxiety. The MDS showed Resident 2 required two staff extensive assistance with toileting, bathing, dressing, bed mobility, and transfers. Review of a NPN, dated 01/19/2025 at 11:23 AM, showed Staff D documented Resident 2 was angry and yells at the new roommate (Resident 1), when odors were present. Staff D documented there were concerns about the new environment as both Resident 1 and Resident 2 were yelling at each other. The NPN showed no indication what action Staff D took in response to Resident 1 and Resident 2 observed yelling at each other, and if anyone was notified about the incident. A NPN, dated 01/19/2025 at 11:32 PM, showed Staff E documented the exact same NPN with no indication action was taken or who was notified. Review of a NPN, dated 01/20/2025 at 1:36 PM, showed Staff F (Licensed Practical Nurse) documented Resident 2 was upset about the new roommate situation and refused to eat lunch. Review of a Social Services (SS) progress note, dated 01/20/2025, showed Staff G (SS Director) documented they were well aware of the situation with Resident 2 and Resident 1 and this was not a new behavior or reaction when Resident 2 got a new roommate. Staff G documented that Resident 2 would demand they move out of the room, reminded Resident 2 it was mean of them to tell Resident 1 they smelled due to a colostomy bag, it must be embarrassing for Resident 1, and if they were unhappy they could find them a new room. A SS progress note, dated 01/22/2025, showed Staff G documented that Resident 2's behaviors have caused difficulties for their roommate (Resident 1) and a behavior contract was presented to Resident 2. The behavior contract included all residents have equal rights, have the right to be free from belittling and bullying, and Resident 2 was verbally abusive to their roommate, and by signing the contract Resident 2 would agree to stop their behavior, move to another room, or to another facility. The note showed Resident 2 signed the contract and admitted they had done all of those things. During an observation and interview on 02/20/2025 at 2:05 PM, Resident 2 was observed in bed and stated they felt so much better after Resident 1 moved rooms. Resident 2 stated, it was my fault, it caused me to lose my temper, and I put up with so much. Resident 2 admitted to calling Resident 1 names, and making comments about the odor. In an interview on 02/20/2025 at 1:46 PM, Staff H (Licensed Practical Nurse, LPN) stated it was not okay for a resident to yell at another resident as that would be abuse. Staff H stated if they observed two residents yelling they would separate both residents, determine what happened, start an incident report, and report to management and the state hotline. Staff H stated they have observed Resident 1 and Resident 2 yelling at each other and saw the nurse go into the room, and was not sure what happened after that. In an interview on 02/28/2025 at 1:27 PM, Staff I (LPN) stated verbal abuse was saying anything towards a resident that made them feel uncomfortable, such as raising your voice, yelling, saying something hurtful or rude. Staff I stated it was not okay for residents to yell at each other and if they witnessed a resident yelling at another resident, the residents would need to be separated, identify the situation, and report to their supervisor. During an interview on 02/28/2025 at 2:52 PM, when asked what staff did when Resident 1 and Resident 2 were observed yelling at each other on 01/19/2025, Staff B replied there was an adjustment period between both residents, staff addressed the smell issue, and Staff B acknowledged the incident on 01/19/2025 should have but was not included in the investigation When asked what staff did when Resident 1 requested a room move, Staff B stated there was no documentation to show what staff did in response to the request for a room move. Staff B stated verbal abuse was yelling, shouting, or screaming at a resident, and would expect staff to separate both residents, notify management, report, and start an investigation, When asked why Resident 1 was not moved rooms and Staff D stating no rooms were available, Staff B stated they thought staff only looked at rooms on the long term care side and did not look at the short term side for room availability. When asked why the incident was reported on 01/22/2025, four days after staff observed the verbal abuse, and after Resident 1 wrote emails expressing their emergency for something to be done, Staff B replied they reported on 01/22/2025 due to Resident 1 being distressed. When asked how psychological harm was ruled out after the 01/19/2025 incident, Staff B stated there was no documentation to show Resident 1 was monitored for psychological harm and would expect staff to follow the facility policy by monitoring residents after an incident. When asked how Resident 1 was protected from further abuse by Resident 2, Staff B stated the residents should have been separated and acknowledged that Resident 2 continued to verbal abuse Resident <Resident 3> Review of the annual MDS, dated [DATE], showed Resident 3 was able to make needs known, own decisions, and had no behaviors. The MDS showed Resident 3 had diagnoses including heart failure, arthritis, and depression. The MDS showed Resident 3 used a wheelchair, required two staff extensive assistance with toileting, bathing, dressing, bed mobility, and transfers. Review of a SS progress note, dated 01/03/2025, showed Staff G documented that Resident 3 came to their office very upset due to an issue with Resident 4, who was very impulsive and volatile. Staff G documented it was Resident 4's birthday, Resident 3 had a surprise of flowers and a card for Resident 4 but they did not see the surprise, became upset, yelled, cussed, and threw an item in the dining room all directed towards Resident 3 who appeared clearly rattled by the incident. The SS progress note showed, Resident 3 thought they would change their table in the dining room to have space from Resident 4. Review of Resident 3's NPN's showed no progress notes for 01/04/2025 and 01/05/2025 and no indication Resident 3 was monitored for psychological harm related to the resident to resident incident. A late entry NPN for 01/06/2025, showed Staff B documented Resident 3 came by their office requesting to speak with them and Staff A (Administrator) about the incident that occurred on Friday with Resident 4. Staff B stated Resident 3 stated it was not urgent and they set up a meeting to talk on 01/07/2025, four days after the incident occurred. Review of a SS progress note, dated 01/07/2025, showed Staff G and Staff B met with Resident 3 who requested the meeting to discuss the events of last Friday. Resident 3 stated they planned to move tables in the dining room but changed their mind and preferred Resident 4 move. Staff G told Resident 3 that Resident 4 was adamant about not moving, reinforced that the right thing for Resident 3 would be for them to move, and Resident 3 stated they would not be moving tables. Staff G documented that Resident 3 did not seem overly distressed about the situation but did state they were scared to death of Resident 4 and it was clear Resident 3 wanted something done to prevent Resident 4's behaviors from continuing. Review of a late entry NPN, dated 01/07/2025 showed Staff J (RN), documented Resident 3 was being monitored for witnessed behavior of another resident in the dining room and Resident 3 made comments of it not being fair that they would have to move tables and not Resident 4. Review of a NPN, dated 01/11/2025, showed Staff J documented Resident 3 was on alert charting for emotional and mental distress due to reported yelling behavior by another resident in the dining room. Staff J documented they were called to the dining room to talk to Resident 4 about moving different tables away from Resident 3, Resident 4 refused, and staff moved Resident 3 to another table, and Resident 3 responded by stating Resident 4 always got their way. During an observation and interview on 02/28/2025 at 1:35 PM, Resident 3 was observed sitting in their wheelchair and stated Resident 4 had yelled, cussed, and knocked over everything on the table, including a bowl of soup because they were upset and thought Resident 3 forget their birthday. Resident 3 stated they could not take the yelling anymore and gave up their table in the dining room to Resident 4. Resident 3 stated Staff A talked with them the next day (01/04/2025) and Resident 3 told them they were shocked, the incident was terrible, and they were scared. Resident 3 stated the dining room was full of other residents during the incident and they would never talk to Resident 4 again. <Resident 4> Review of the quarterly MDS, dated [DATE], showed Resident 4 was able to make needs known, needed assistance with decisions, and had no behaviors. The MDS showed Resident 4 had medically complex conditions including a nervous system disease, insomnia, and depression. The MDS showed Resident 4 used a wheelchair, required moderate assistance from staff for toileting, dressing, bed mobility, and transfers. Review of a SS progress note, dated 01/03/2025, showed Staff G documented Resident 4 lashed out at Resident 3, yelling, cursing, and swept a cup of soup of the dining room table. Staff G documented Resident 4 was asked to move tables, refused, and stated they wanted to sit where Resident 3 was sitting. Staff G documented all residents had a right to sit where they choose, and the facility team was directed to monitor Resident 4 closely, intervene if they became volatile, and redirected if they threw any items and cued to use appropriate language. Review of Resident 4's record showed no NPN's from 01/04/2025, 01/05/2025, 01/06/2025, 01/07/2025, and 01/08/2025 to indicate Resident 4 was being monitored for behaviors or psychological harm related to the resident to resident incident. Review of the facility investigation, dated and completed 01/12/2025, nine days after the incident occurred, showed Staff B documented on 01/06/2025 Resident 3 asked to speak with management about the incident on 01/03/2025, that they were all aware of and did not appear to be urgent. Staff B documented during their conversation on 01/07/2025, Resident 3 expressed distress and scared from the incident with Resident 4, and therefore Staff B reported to the state hotline. Review of the January 2025 facility abuse/incident reporting log showed Staff B documented the incident occurred on 01/03/2025, the nature of the occurrence was behaviorand findings showed the origin was established. The incident log did not include Resident 3 and did not identify the incident as a resident to resident altercation. During an interview on 02/28/2025 at 3:15 PM, with Staff A and Staff B, Staff A stated they did not follow up with Resident 3 after the incident and was not aware they were scared from the incident with Resident 4. Staff B stated they would expect psychological harm monitoring to be completed after an incident and stated there was no psychological harm monitoring for Resident 3 in the record. When asked why the incident was not reported until Resident 3 expressed fear, Staff B stated the incident should have but was not reported timely, especially since there was no documentation to prove no psychological harm for Resident 3. REFER to F-600 REFERENCE: WAC 388-97-0640(1)(2)(a)(b)(5)(6)(a)(b)

Based on observation, interview, and record review the facility failed to ensure resident responsible parties were notified when there was a change in condition or when a resident experienced a fall for 1 (Resident 1) of 3 residents reviewed. These failures violated a resident's right to have their representative involved and informed of any changes in condition. Findings included . Review of the facility policy titled, Fall Prevention and Response, revised 08/2023, showed after a resident experienced a fall the licensed nurse was required to notify the provider and the resident's representative. <Resident 1> Review of an admission Minimum Data Set (MDS, an assessment tool), dated 06/06/2024, showed Resident 1 was not able to make their own decisions, was rarely or never understood by others, and was assessed with an altered level of consciousness ( a change in the resident's awareness of the environment with reduced alertness). The MDS showed Resident 1 had impairments to one side of their body, affecting one arm and one leg. The MDS showed Resident 1 was dependent on staff for bed mobility, toileting, and transfers. The MDS showed Resident 1 was non-verbal and had diagnoses including a history of a brain bleed (stroke), high blood pressure, and diabetes. Review of Resident 1's face sheet (a summary of the residents personal and demographic information), undated showed Resident 1 had a Collateral Contact (CC) to contact for changes in condition. Review of Resident 1's fall Care Plan (CP), revised 07/23/2024, showed Resident 1 was at risk for falls related to general weakness and current medical conditions. The CP directed staff to ensure the call light was in reach, prompt the resident to call for assistance, and ensure the resident was positioned in the center of the bed. Review of a fall investigation, dated 07/25/2024, showed Resident 1 was found on the floor by their bed lying face down on their stomach. The investigation showed Resident 1 was not able to verbalize what happened and it was believed Resident 1's fall was likely caused by the resident trying to reposition themselves in bed. The investigation showed the provider and the residents representative were informed of the fall, the documentation did not show the date or time when the notifications occurred. Review of a concern form, dated 09/04/2024, showed Resident 1's CC was very concerned they did not receive notification of Resident 1's fall. The concern form showed Resident 1's CC asked several times how this happened and was told it was the facility's policy to notify the representative of a fall. During an interview on 09/11/2024 at 2:00 PM, Staff B (Director of Nursing Services) stated licensed nurse were expected to notify the resident responsible party when a resident experienced a fall. Staff B stated Resident 1's representative notification was not documented therefore it was not done. Staff B stated Resident 1's CC called the facility social worker and was upset they did not receive notification of Resident 1's fall on 07/22/2024. Staff B stated the CC found out about Resident 1's fall during a care conference on 09/04/2024. In an observation on 09/11/2024 at 2:12 PM, Resident 1 was observed sitting in a wheelchair with their eyes closed. Resident 1 did not respond to verbal stimuli or questions about the incident. During an interview on 09/30/2024 at 1:02 PM, Resident 1's CC stated they found out about Resident 1's fall a month and a half later. The CC stated they were frustrated that they did not receive notification on the date of the fall and felt bad that Resident 1 was alone and was not able to say what happened about the fall. REFERENCE: WAC 388-97-0320(1)(a)

Based on observation, interview, and record review, the facility failed to: (1) Ensure water temperatures were maintained to remain within the safe temperature of 110 (+/- 10) degrees Fahrenheit (F) as required for 13 of 13 rooms sampled for hot water temperatures (Rooms 328, 306, 330, 324, 114, 428, 202, 124, 408, 422, 102, 228, & 404); (2) ensure hazardous chemicals were kept locked and secured at all times for 2 of 4 nursing units (Unit A & C); and (3) identify potential risks associated with a resident's care needs and environment to decrease the risk of falling for 1 of 6 residents (Resident 64) reviewed for falls. The facility's failure to complete repairs identified to be necessary to the hot water system and sample hot water temperatures in resident rooms placed residents at risk for serious burn or injury caused by scalding and constituted a Immediate Jeopardy (IJ). The facility's failure to secure hazardous chemicals placed residents at risk for accidental ingestion and/or skin impairment. The facility's failure to identify risks and implement fall interventions placed residents at risk for recurrent falls and a decreased quality of life. On 07/23/2024 at 3:30 PM, the facility was notified of an IJ in F689. The facility removed the immediacy on 07/24/2024 after they immediately contacted the outside vendor to assess and/or repair the boiler, identified other high risk residents, placed temporary caution signs in resident room sinks and shower rooms to mix cold and hot water to reduce/eliminate the risk for burns/scalding, instituted audits to monitor the boiler gauge and all resident rooms- water temperature monitoring, updated the facility's rounding log, and provided education to the Facilities (Maintenance) Manager regarding the domestic water policy, and implemented a plan of correction to sustain ongoing compliance. Findings included . <Hot Water Temperature> <Facility Policy> The facility's Domestic Water Policy, revised 01/2019, showed the facility's domestic hot water would be checked monthly to ensure a hot water temperature of 105 to 115 F was maintained. <Centers for Medicare and Medicaid Service (CMS) Hot Water Guidelines> According to revised 02/03/2023 CMS guidelines: A third-degree burn would occur after five minutes of exposure to a hot water temperature of 120 F, after three minutes of exposure to a hot water temperature of 124 F, after one minute of exposure to a hot water temperature of 127 F, and after 15 seconds of exposure to a hot water temperature of 133 F. Observation on 07/23/2024 at 10:57 AM showed room [ROOM NUMBER] had two sinks, one labeled for Resident 33, and the other for Resident 68 who shared the room. When temperatures were taken, the hot water from Resident 33's sink became hot very quickly after turning on the faucet and felt uncomfortable for hand washing. The temperature measured at that time was 127 F. At the same time, Resident 68's sink's hot water measured 125 F. The following observations of hot water were made: On 07/23/2024 at 10:59 AM, the hot water temperature in room [ROOM NUMBER] was observed at 129 F. On 07/23/2024 at 11:00 AM, the hot water temperature in room [ROOM NUMBER] was observed at 124 F. On 07/23/2024 at 11:01 AM, the hot water temperature in room [ROOM NUMBER] was observed at 126 F. On 07/23/2024 at 11:05 AM, the hot water temperature in room [ROOM NUMBER] was 130 F in one sink and 131 F in the other sink. On 07/23/2024 at 11:07 AM, the hot water temperature in room [ROOM NUMBER] was observed at 127 F. On 07/23/2024 at 11:07 AM, the hot water temperature in room [ROOM NUMBER] was 127 F in one sink and 133 F in the other sink. On 07/23/2024 at 11:10 AM, the hot water temperature in room [ROOM NUMBER] was observed at 127 F. On 07/23/2024 at 11:20 AM, the hot water temperature in room [ROOM NUMBER] was observed at 132 F. On 07/23/2024 at 11:24 AM, the hot water temperature in room [ROOM NUMBER] was observed at 132 F. On 07/23/2024 at 11:45 AM, the hot water temperature in room [ROOM NUMBER] was 133 F in one sink and 134 F in the other sink. On 07/23/2024 at 11:59 AM, the hot water temperature in room [ROOM NUMBER] was observed at 134 F. On 07/23/2024 at 12:47 PM, the hot water temperature in room [ROOM NUMBER] was observed at 130 F. In total, between 10:57 AM and 12:47 PM on 07/23/2024, surveyors observed unsafe water temperatures in multiple rooms on each of the facility's four units. None of the rooms observed had hot water at a safe temperature. In an interview on 07/23/2024 at 1:40 PM, Staff C (Facilities Manager) stated they maintained a hot water temperature log. Staff C stated hot water should be no hotter than 120 F. In an interview on 07/23/2024 at 1:47 PM, Staff C stated hot water temperatures were checked and logged monthly. Staff C stated they checked a couple rooms at the end of the building near the boiler because it serve[d] the whole building. Observation on 07/23/2024 at 2:33 PM showed the facility had two boilers located in the maintenance shop. A sign on the boilers indicated they were installed on 12/31/2020. In an interview at that time, Staff C stated if they identified any problems with excessively hot water, they called a vendor for assistance to identify and repair the problem. Review of the facility's 2024 Hot Water Temperature Log provided by Staff C on 07/23/2024 showed the hot water should be 110 DEG + or - 10 degrees which was not consistent with the facility's policy for hot water to remain in the 105-115 F range. The log showed, once a month from January through June 2024, Staff C documented two temperatures. For each month, one of those temperature measurements was taken in the maintenance room, and the second was taken in either the staff break room, the facility's main dining room, or rehabilitation gymnasium (gym). No temperatures measurements were made in resident rooms. The 2024 Hot Water Temperature Log showed on 02/27/2024 the hot water was measured at 122 F in the gym, on 05/24/2024 at 121.5 F in the gym, and on 06/24/2024 at 122 F on 06/24/2024 in the maintenance room; all three temperatures were above the maximum temperature limit for hot water as required. In an interview on 07/23/2024 at 2:51 PM, Staff C stated they contacted the vendor to fix the hot water system after identifying hot temperatures exceeded safe limits. Staff C stated they would provide documentation showing when they last contacted the vendor. On 07/23/2024, Staff C provided a 04/11/2024 estimate from the vendor for repair of a failed flow switch. This invoice was signed by Staff C on 04/15/2024. The vendor's signature was left blank. There was no indication that the work was paid for or completed. Observation on 07/23/24 at 3:46 PM with Staff's C and D (Director of Rehabilitation Services) showed the hot water temperature in room [ROOM NUMBER] was at 128 F. Both staff stated the temperature reading was high. At that time, Staff C checked the readout of a digital thermometer measuring the temperature of the pipe where hot water flowed from the hot water tanks to the rest of the facility. This thermometer showed a temperature of 123.8 F. <Resident 33> According to the 04/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 33 had impaired memory and needed substantial to maximal assistance from staff for transfers and personal hygiene. The MDS showed Resident 33 had a stroke history and hemiplegia (one-sided partial paralysis) on their right side. In an interview on 07/23/2024 at 10:42 AM, Resident 33 stated sometimes they had to wait a long time for the bathroom. Resident 33 stated if staff did not come quickly enough to assist them, they got themselves up to use the bathroom even though they knew they should wait for help as they could wait no longer. Observation at that time showed Resident 33's right hand had limited range of motion. Resident 33's fingers curled in toward the palm of the hand. Observation of the sink at 07/23/2024 at 10:57 AM showed the faucet had a left lever that controlled hot water and a right lever that controlled the cold water which could impact the ability of a person with a right-hand impairment to adjust the hot water temperature with cold water. In an interview on 07/24/2024 at 11:36 AM, Staff A (Administrator) stated it was important to ensure the hot water temperature in resident rooms were maintained within the safe temperature as required to prevent adverse outcome and resident injury including burns caused by scalding. Staff A stated Staff C knew the water flow switch needed repair last April 2024 based on the facility provided project proposal but did not address the situation appropriately. In an interview on 07/24/2024 at 11:48 AM, in the presence of Staff A, Staff C confirmed they knew about the situation and stated they should have acted upon the identified water valve repair needed but did not. 43642 <Unsecured Chemicals> <Unit A> Observations on 07/23/2024 at 1:38 PM showed the shower room door on Unit A was unlocked. Inside the unlocked room was a cabinet with a key in the keyhole. The key was attached to the cabinet by a chain. The cabinet door could be opened without having to turn the key. Inside the cabinet was a spray bottle of disinfectant with a label that stated, DANGER, keep out of reach of children, and identified first aid steps if the chemical was ingested. In an interview on 07/25/2024 at 9:47 AM, Staff C stated the shower room door and chemicals should be locked and secured. Observations at this time showed the door was unlocked and was easily opened when checked. Staff C stated the door should be locked not only to provide privacy for residents, but to assure chemicals are secured to reduce risks of accidents. 46471 <Unit C> Observation on 07/23/2024 at 10:28 AM showed the shower room door across room [ROOM NUMBER] had a sign to keep doors locked at all times but the key combination lock was broken and the door was left unlocked; inside was unsecured chemicals including a gallon of bleach cleaning solution situated next to the toilet and a spray bottle of disinfectant solution hanging from the shower grab bar. On 07/23/2024 at 10:33 AM, Staff G (Certified Nursing Assistant - Shower Aide) came and stated they were getting the shower room ready for a resident. Staff G determined the key combination lock was broken/faulty and the door was left unlocked. Staff G stated the maintenance department should be notified to have the door lock fixed right away. Staff G stated it was important to ensure the door was kept locked at all times so confused and wandering residents could not enter the room and accidentally ingest or apply any chemicals on themselves that were left unsecured inside the shower room. In an interview on 07/23/2024 at 10:43 AM, Staff C confirmed the key combination lock to the shower room in Unit C needed to be repaired and stated the shower door must be kept locked at all times (as indicated by the posted sign on the door) for resident safety. 50511 <Facility Policy> According to the Fall Prevention and Response facility policy, revised 08/2023, the facility would reduce the risk of falls and injury resulting from falls by assessing and periodically reassessing each resident's risk for falling. The policy showed the potential risks associated with increased care needs and the environment and to implement interventions to address identified risks. <Resident 64> According to the 05/15/2024 Quarterly MDS, Resident 64 needed help with functional cognition, had visual impairment, was dependent on staff in wearing their footwear, and needed moderate assistance with dressing and transferring from bed, chair and toilet. The assessment showed Resident 64 admitted to the facility on [DATE] and had two or more falls since their admission to the facility. In an interview and observation on 07/23/24 at 1:48 PM, Resident 64 stated, I have no clothes; no shoes or socks and I only have slippers and my feet hurt when I walk. Resident 64's toenails were observed long enough to curl into bottom of foot and resident had brown suede slippers and no other shoes in the room. On 07/23/2024 at 2:05 PM, Resident 64 stated, .every time I turn around, I am falling, and the toilet commode was loose, if I lean over too much, I might fall. On 07/26/2024 at 8:39 AM, Resident 64 stated, I already got myself up, the staff don't really help me, and they come in after the fact . Observation on 07/30/2024 at 8:34 AM showed Resident 64's bed was tilted downwards to the right; the bed was unbalanced when moved and Residnt 64 stated the bed was broken. On 07/31/2024 at 11:32 AM, the bed table was propped up against bathroom door, the walker was at the foot of the bed, and resident was seated at a chair in front of bed away from walker. Record reviews of the 04/25/2024 facility fall event occurrence investigation report showed Resident 64 had a fall by the room door; the 07/1/2024 investigation report showed Resident 64 sustained a fall near their bed, and the 07/07/2024 investigation report showed another fall sustained by Resident 64 near the bathroom. The fall prevention interventions listed on the investigation reports included the application of two non-slip tape strips placed on the floor by the bedside and a signage was posted to remind resident to call for assistance before attempting to transfer. In an interview on 07/30/2024 at 8:37 AM, Staff J (Licensed Nurse) stated the bed looked broken and did not look normal. Staff J stated the care staff did not get a chance to see Resident 64 yet to notice their bed, and that the resident continually refused care so we [staff] do whatever we can. In an interview on 07/30/2024 at 8:42 AM, Staff B (Director of Nursing) stated care staff still needed to encourage residents with dementia (who refused care) and must do whatever they could to help them. Staff B stated Resident 64's bed did not look normal, and the bed looked broken. Staff B observed Resident 64's long, uncut toenails and confirmed the resident needed podiatry services. Staff B stated staff should notify them when a resident had long nails and were refusing care, as foot care was important to prevent skin injury and accidents. Refer to F677- Activities of Daily Living (ADL) Care Provided for Dependent Residents. REFERENCE: WAC 388-97-1060(3)(g). 51149

Based on observations, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services for all facility residents including assistance with Activities of Daily Living (ADL) and timliness of call light response in accordance with established clinical standards, Care Plan (CP), and resident preferences. These failures placed residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident Council (RC)> Review of the 01/24/2024 RC meeting notes showed residents reported poor response times. The notes showed the administrator had coordinated with staff members who were unable to perform the needed duties and the short-term plan was for the facility to stack nursing shifts for supervision and the long-term plan was to hire staff to oversee the weekends and night shifts. During an observation on 07/23/2024 at 2:37 PM, two rooms observed to have call lights alarming. At 2:48 PM, the same two call lights were still alarming while day and evening nurses were observed to be in report during shift change. During an observation on 07/25/2024 at 10:16 AM, Staff D (Director of Rehabilitation) was observed telling the shower aide to help answer the call lights. Two rooms had call lights on and only one caregiver was seen working on the floor. <Resident 27> In an interview on 07/29/2024 at 1:17 PM, Resident 27 stated the call light response time could be 10 to 15 minutes or longer. <Resident 11> In an interview on 07/29/2024 at 1:19 PM, Resident 11 stated they waited up to two hours for care staff, especially during shift changes. Resident 11 stated the shift change between evening and night shifts was the worst, but issues would occur during any shift change. Resident 11 stated they believed it was because the facility was understaffed. <Resident 52> In an interview with Resident 52 on 07/24/2024 at 12:08 PM, Resident 52 stated residents had to wait a long time before care staff would help them during shift changes; mostly between day and evening shifts and between night and day shifts. In an interview on 07/29/2024 at 9:29 AM, Resident 52 stated there was an occurrence when they put their call light on in the bathroom because of a bladder accident. Resident 52 stated they were afraid they would slip on the wet floor and needed assistance with wiping the floor. Resident 52 stated they waited for care staff, but staff did not come right away, and they began feeling sick and they needed to go back to their bed. Resident 52 stated they could no longer wait for staff and put towels on the ground so they could walk back to their bed. <Resident 12> In an interview on 07/25/2024 at 9:13 AM, Resident 12 stated during shift change was an issue for care staff to respond to call lights. Resident 12 stated on one occurrence, care staff did not respond to their call light for a long time and the resident had to yell out for help to get care staff to answer their call light. In an interview on 07/26/2024 at 1:25 PM, Resident 12 stated they had pain in their hips, and sometimes needed help but the facility was occasionally short staffed. In an interview on 07/30/2024 at 1:08 PM, Staff GG (Staff Development) stated the facility was within required staffing ratios and adjusted schedules for call outs. Staff GG stated they used staffing ratios to ensure there are enough nurses and staff on call. Staff GG also stated the facility used agency staffing and contracted staff to support nursing shortages. In an interview on 08/01/2024 at 8:26 AM, Staff M (Registered Nurse) stated the facility may be short staffed and could use more nursing assistants and licensed practical nurses. Staff M stated staffing should not be based on how many residents the facility had but should be more about the care that residents needed. In an interview on 08/01/2024 at 9:11 AM, Staff FF (Licensed Practical Nurse) stated sometimes there is not enough staff and it gets hard to complete tasks. Staff FF stated tasks could take up to one hour, with a half hour give or take to complete. Staff FF stated,staffing should be based more about how hard a resident's care is rather than the amount of people scheduled. REFERENCE: WAC 388-97-1080(9).

Based on observation, interview, and record review, the facility failed to ensure resident meals were stored, prepared, and served in a sanitary manner for 1 of 1 kitchens and 1 of 4 unit pantries (Unit 400). These failures left residents at risk for spoiled or contaminated foods, and food-borne illness. Findings included . <Facility Policy> According to the facility's 07/2024 Food Storage policy all food items would be labeled with with a manufacturer's expiration date or the date of receipt. The policy showed refrigerated foods would be discarded using either the manufacturer's expiration date or seven days after the written date. The policy showed all refrigerators used for nutrition would be cleaned weekly by dietary staff. The policy showed food in facility refrigerators should be covered. <Dry Storage> Observation of the facility's dry food storage on 07/23/24 at 9:11 AM showed a box of thickening powder (used to alter the fluids for residents with swallowing difficulties) was left open. The plastic liner was torn open and not resealed and the cardboard flaps were wide open leaving the powder exposed. A large container of granulated garlic was observed to be open with no indication of when the container was opened or a use-by date. In an interview at that time Staff Z (Senior Cook) stated the thickening powder was not stored correctly and needed to be discarded. Staff Z stated the granulated garlic should have been labeled to indicate for how long it was safe to use. <Hair Nets> Observation on 07/23/24 01:36 PM showed Staff DD (Dietary Assistant) preparing a drink in the facility's kitchen. Staff DD's hair was long and was not secured by a hairnet or a hat. Staff DD stated they were not required to wear a hat as they were only in the kitchen briefly. At that time Staff AA (Food Service Director) was standing next to Staff DD. Staff AA interjected and stated that all staff were required to secure their hair prior to entering the kitchen to prevent hair contaminating resident meals. Staff AA stated it did not matter why staff entered the kitchen or for how long. <Unit Pantries> Observation of the 400 Unit Pantry on 07/30/2024 at 8:21 AM showed the pantry contained a refrigerator where resident snacks, leftovers, outside food, and cold beverages were stored, and a handwashing sink. This fridge contained a red plate with a half-eaten quesadilla. This quesadilla was partially covered with a paper towel matching the paper towels from the dispenser by the handwashing sink. Someone wrote 5/29 [Resident 24] 416-2 on the paper towel. The refrigerator also contained an opened bottle of lemonade that was not dated and was not labeled to indicate whom it belonged. The 400 Unit Pantry also contained a water and ice dispensing machine. This machine's clear plastic dispensing chute was observed to have a buildup of a yellow-green slime. In an interview at this time Staff B (Director of Nursing) stated the chute needed to be cleaned and the lemonade and quesadilla needed to be discarded as they were not stored appropriately. <Hand Sanitization> Observation during lunch preparation on 07/30/24 at 9:36 AM showed Staff R (Cook) wearing a surgical mask (the facility had a COVID-19 [a communicable respiratory infection] outbreak at the time) that was lowered below their chin while they spoke to another member of the dietary staff. With a gloved hand Staff R raised the surgical mask back over their mouth and nose. Without washing their hands, using the same (now soiled) gloves, Staff R then wrapped a ham with plastic. Observation on 08/01/2024 at 10:30 AM showed Staff R in the kitchen preparing lunch with their surgical mask again placed below their chin. Staff R observed a surveyor through the kitchen window and raised their mask over their mouth and nose. Without performing hand hygiene Staff R immediately continued preparing lunch In an interview on 08/01/2024 at 10:31 AM Staff N (District Dietary Manager) stated they expected all staff to use appropriate hand hygiene. Staff N stated Staff R should have washed hands and changed gloves after contaminating them by touching their surgical mask. Staff N stated Unit Pantries were the joint responsibility of the dietary and nursing departments, and stated they expected the food to be stored appropriately and the ice/water machine to be kept clean. 46471 <Uncovered Food> Observation on 07/23/2024 at 12:18 PM during meal tray service in Unit C showed the meal cart was parked between rooms [ROOM NUMBERS]. Staff O (Certified Nursing Assistant - CNA) was observed serving the meal tray for room [ROOM NUMBER], passing by an isolation room (room [ROOM NUMBER]) with the dessert left uncovered. Observation on 07/23/2024 at 12:23 PM showed Staff C serve the meal tray for room [ROOM NUMBER], again passing by the isolation room (room [ROOM NUMBER]) with the dessert left uncovered. On 07/23/2024 at 12:27, Staff P (CNA) was observed serving the meal tray for room [ROOM NUMBER] with the dessert left uncovered. Observation on 07/23/2024 at 12:29 showed Staff P serve the meal tray for room [ROOM NUMBER] which was located far and around the corner of the unit from where the meal cart was parked, passing along the isolation room (room [ROOM NUMBER]) with the dessert left uncovered. In an interview on 07/23/2024 at 12:40 PM, when Staff P was asked if it was the facility's practice to leave the desserts uncovered during meal tray service, Staff P stated, Yes, for some desserts .I don't know why .maybe because this cake has frosting and it might be a mess if covered . Staff P stated food left uncovered was at risk for contamination. In an interview on 07/30/2024 at 2:59 PM, Staff Q (Infection Preventionist) confirmed the facility was in a COVID-19 outbreak. Staff Q stated they expected food to be covered during meal service because they did not want to serve residents contaminated food, .we [staff] don't know what is present in the air . In an interview on 07/30/2024 at 3:05 PM, Staff N stated they expected the dietary staff to ensure food was covered appropriately during meal tray service. Staff N stated it was important to ensure food was covered during meal service for temperature control and to protect the safety of the food and prevent cross-contamination. Observations on 08/01/2024 at 8:17 AM showed staff passing out breakfast trays on Unit A from a meal tray cart located near the nurse's station. Staff pulled a meal tray out of the cart, with an uncovered bowl of fruit, and carried the tray past other rooms and residents in hallway to deliver it to room [ROOM NUMBER], the last room on the unit. REFERENCE: WAC 388-97-1100(3), -2980. 43642

Based on observation, interview, and record review, the facility failed to maintain a system to ensure resident grievances were identified, logged, and resolved timely for 4 of 4 residents (Residents 28, 31, 30, 6) reviewed for personal property and living environment. Facility failure to ensure missing personal items were found or replaced and resident environmental concerns were addressed placed residents at risk for missing property, an uncomfortable or less-than-homelike environment, and a decreased quality of life. Findings included . <Facility Policy> According to the 07/2024 Complaint and Grievance Policy, the facility would attempt to resolve all grievances as promptly as possible, but no longer than 10 days. The policy showed the facility would maintain grievance records for no less than three years. <Resident 28> According to the 05/20/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 28 had impaired memory and was dependent on staff for self-care and grooming. The MDS showed Resident 28 had medical conditions including partial weakness to one side of the body and memory impairment. In an interview on 07/24/2024 at 2:39 PM, Resident 28 stated they had lost items [they] didn't get back. Resident 28 identified they were missing an electric razor, nail clippers, and a $350 watch. Resident 28 stated they were told it was facility practice when a resident was missing property for the resident to replace the item and then get reimbursed by the facility. Resident 28 asked, What do you do if you don't have the money up front? I could not cover it. I never got it back. Resident 28 stated the watch went missing about a year ago. Resident 28 was not wearing a watch at the time of the interview. Review of the facility's Grievance Log did not include any grievances related to missing items for Resident 28. In an interview on 07/29/2024 at 12:29 PM, Staff E (Social Services Director) stated they recalled Resident 28 reporting a missing watch a couple years ago during the pandemic. Staff E stated Resident 28 provided them with a picture of the watch at that time. Documentation of the missing watch and picture was requested, but staff was unable to provide the requested information. Staff E stated the facility policy was that the resident was required to come up with the money in order to do the reimbursement. Staff E stated the process was that once a resident provided the receipt, the facility would then reimburse for the missing item. When asked what the plan was for the missing watch, Staff E stated, I do not know. In an interview on 08/01/2024 at 11:07 AM, Staff E stated when a resident had a concern with a missing item, they sent out an email to the appropriate staff to be on the look out for the item. Staff E stated that until survey began on 07/23/2024, they did not add missing items concerns to the Grievance Log. Staff E stated after they sent out an email, either the item was located or the resident replaced the item and was reimbursed. Staff E stated they did not recall a situation where a resident was unable to temporarily cover the cost of an item. In an interview at 08/01/24 11:48 AM, Staff E stated they just (since the prior interview) asked Resident 28 if they told anyone they did not have the means to cover the cost of the missing watch. Staff E stated they could not find evidence the watch was replaced or addressed in their emails. In an interview on 08/01/2024 at 2:03 PM, Staff A (Administrator) stated the grievance process was important so residents receive help with the concerns they had and gave the facility the opportunity to correct things. Staff A stated they considered a grievance or concern something they were unable to fix in a reasonable time, for example less than 24 hours, or on a Monday if occurred over the weekend. Staff A stated they considered a missing item a grievance and would expect staff to notify the social worker and complete a grievance form if the item was not found. Staff A stated the facility would reimburse the resident once they were able to determine an estimate, get guidance from the resident, or a receipt and expected documentation to show the outcome of the missing item. 43642 <Resident 31> According to a 07/12/2024 Admission MDS, Resident 31 admitted to the facility on [DATE], had clear speech, was understood, and able to understand others. This MDS showed staff assessed Resident 31 with no memory impairment. In an interview on 07/25/2024 at 9:14 AM, Resident 31 stated they were frustrated about missing clothes from a week ago. Resident 31 stated the clothes went to laundry, last Friday. Resident 31 stated they kept asking staff, but nobody was able to find them. Resident 31 stated they had company coming to the facility on [DATE] and they wanted their clothes back for the visit. In an interview on 07/26/2024 at 8:37 AM, Resident 31 stated their clothes were still missing, but staff had helped them find something else to wear for when their visitors arrive. Review of the grievance log on 07/26/2024 showed no grievance reports were logged for Resident 31 regarding their missing clothes. In an interview on 07/29/2024 at 11:40 AM, Staff E stated grievances were important so staff can address any issues a resident may have. Staff E stated it was their expectation staff would come let them know of any concerns/grievances, at times the issue can be resolved on the spot, and if not, Staff E stated they tell staff to fill out a grievance form. Staff E stated once they receive a grievance, their expectation was for staff to resolve and address the concern back with the resident within 10 days. Staff E stated they do not log missing items, but instead they send an email out to staff to be on the lookout for the missing items. When asked how staff track and trend missing items, Staff E stated, we just put it in emails. Review of Staff E's emails showed the email system was set to delete the emails after two years. When asked if there were currently any missing items for residents, Staff E stated, there was a missing pair of dentures, missing nightgown, and a green dress. Staff E did not have information regarding Resident 31's missing clothes. In an interview on 07/29/2024 at 12:10 PM, Resident 31 stated they finally got their clothes back a couple days ago and stated they were frustrated it took so long. <Resident 30> In an interview on 07/29/2024 at 11:40 AM, Staff E showed an email from 07/15/2024 regarding Resident 30 having a missing bag with about $100 worth of stuff inside. When asked what the outcome of that reported missing item from 14 days ago, Staff E stated, they went home, and they have not reached out to me. Review of a 07/17/2024 Discharge MDS showed Resident 30 discharged from the facility with their return not anticipated. In an interview on 07/31/2024 at 12:28 PM, Resident 30 stated they had not heard from the facility regarding the missing items until just two days prior on 07/29/2024. Resident 30 stated they found the missing bag at home, but stated they were still missing some clothes. Resident 30 stated they told the facility they did not need to replace it. In an interview on 08/01/2024 at 1:03 PM, Staff B (Director of Nursing) stated their expectation was for staff to start an investigation if a resident had a concern or missing item, by first looking for the items, and if unable to locate or resolve within 48 hours, would expect staff to address it as a grievance. Staff B stated there were, some gaps in the grievance process. 50511 <Resident 6> Review of the 06/21/2024 Admission MDS showed Resident 6 was understood and had clear comprehension. Review of care plan dated 05/07/2024 showed the resident was at risk for deterioration in ADL function and medical stability due to paraplegia (loss of function in both legs) and other medical issues, and staff were to respect the resident's preferences. On 07/25/2024 at 9:58 AM, Resident 6 stated the maintenance man took away their Air Conditioner (AC), but they needed it for their legs. Resident 6 stated it should be in their care plan that they needed an AC as their legs do not sufficiently sweat and they needed it to keep their legs cool. On 07/26/2024 at 8:55 AM, Resident 6 stated repeatedly they needed their AC, .I couldn't sleep all night. Resident 6 stated they had an AC unit in their room before the State [surveyors] got there and the facility took away the AC. Resident 6 stated they had verbalized their concern to the nursing staff. In an interview on 07/26/2024 at 10:17 AM, Staff M (Registered Nurse) stated the night shift nurse told them that the resident asked for their AC in their room last night, but it was not reported to the manager yet. However, Staff M did ask maintenance to re-install the AC, but they were waiting. Staff M stated they knew that Resident 6 needed the AC for their legs. On 07/29/2024 at 12:19 PM, Resident 6 stated, I didn't file a grievance report yet, but I asked 2 care aids and a nurse and they didn't know how to file a grievance report. In an interview on 07/29/2024 at 12:40 PM, Staff E stated they were notified by the facility's pastor on 7/25/2024 of Resident 6's concern. In an interview on 07/29/2024 at 11:37 AM, Staff L (Manger Long Term Care Registered Nurse), stated, the usual process for when a resident has an issue is, the nursing staff are notified, and we will address the issue and look further into it. In an interview on 07/30/2024 at 8:46 AM, Staff B stated the staff were to provide the resident with a grievance report if there was an issue, our social workers are then in charge of grievances and in keeping the logs. Staff B stated the nursing staff should report grievances to their nursing managers and interview the resident. REFERENCE: WAC 388-97-0460.

Based on interview and record review, the facility failed to ensure the Registered Nurse (RN) responsible for attesting to the accuracy and completeness of resident assessments was knowledgeable of the Minimum Data Set (MDS - an assessment tool) process for 3 of 3 residents (Residents 67, 20, & 45) whose Quarterly MDS assessments were reviewed for accuracy and timeliness. The facility's failure to report accurate MDS data placed residents at risk for violations of the Social Security Act. Findings included . <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual> The October 2023 RAI Manual showed signatures of persons completing the assessment would certify that the accompanying information accurately reflected resident assessment information. The RAI manual showed, by attesting and signing the MDS, the RN coordinator and its signatories understood these information were used as a basis for ensuring residents receive appropriate and quality care, a basis for payment from federal funds, and that payment of such federal funds and continued participation in the government-funded health care programs was conditioned on the accuracy and truthfulness of the MDS information provided. The RAI manual showed MDS signatories could be personally subjected to or may subject the organization to substantial criminal, civil, and/or administrative penalties for submitting false information. <Resident 67> Review of Resident 67's 06/03/2024 Quarterly MDS showed a completion date of 06/14/2024 in the resident's medical records but the assessment history report showed the RN coordinator completed the assessment on 06/17/2024. <Resident 20> Review of Resident 20's 06/03/2024 Quarterly MDS showed a completion date of 06/07/2024 in the resident's medical records but the assessment history report showed the RN coordinator completed the assessment on 06/11/2024. <Resident 45> Review of Resident 45's 04/01/2024 Quarterly MDS showed a completion date of 04/05/2024 in the resident's medical records but the assessment history report showed the RN coordinator completed the assessment on 04/09/2024. In an interview on 07/29/2024 at 12:42 PM, Staff T (MDS Coordinator) confirmed they refer to the RAI manual for assessment coding and guidance. Staff T stated MDS assessments should be completed accurately and items identified that were coded inaccurately needed to be clarified and corrected. Staff T stated MDS completion dates should not be backdated because it was unethical. Staff T confirmed the completion dates reflected in Residents 67, 20, and 45's Quarterly MDS assessments in the medical records were backdated and not the actual dates of completion and stated they needed MDS education. In an interview on 07/29/2024 at 1:14 PM, Staff A (Administrator) stated backdating MDS completion dates was an unacceptable practice and that Staff T should be educated. Staff A stated they expected the MDS coordinators to attest and document the actual MDS completion date in the resident's medical records. Refer to F638- Quarterly Assessment At Least Every 3 Months. REFERENCE: WAC 388-97-1000 (5)(a).

Based on interview and record review, the facility failed to ensure Level 1 Preadmission Screening and Resident Reviews (PASRR - a Serious Mental Illness (SMI)/Intellectual Disability (ID) screening for the need for further assessment for outside resources while in a nursing home environment) were accurate upon admission and updated as needed after a significant change as required for 3 of 5 residents (Residents 28, 45, & 32) reviewed for unnecessary medication. This failure left residents at risk for unassessed mental health needs, and other negative health outcomes. <Facility Policy> According to the PASRR facility policy, revised 01/2023, all residents would undergo a Level 1 PASRR screening prior to admission. The policy showed current residents must undergo a Level 1 PASRR if a significant change in their physical or mental condition was identified. <Resident 28> According to the 05/20/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 28 had impaired memory and medical diagnoses including dementia (a memory impairment), anxiety, and depression. The MDS showed Resident 28 received Antipsychotic (AP), Antidepressant (AD), and Antianxiety (AA) medications. Review of the 04/26/2023 Level 1 PASRR showed this PASRR did not include Resident 28's dementia diagnosis. This PASRR included a handwritten note showing reviewed but no dx (diagnosis) of dementia. In an interview on 07/31/2024 at 10:24 AM, Staff E (Social Services Director) stated it was important for PASRRs to be available in the chart and accurately reflect the resident's current condition. In an interview on 08/01/2024 at 11:55 AM Staff E stated it was important for PASRRs to be accurate and updated with changes. <Resident 45> According to the 06/17/2024 Quarterly MDS, Resident 45 admitted to the facility on [DATE] and had medical conditions including depression and anxiety. Review of Resident 45's Physician Orders (POs) showed a 01/12/2024 order for daily administration of AD and AA medications since the resident's facility admission. A 04/11/2024 social services progress note showed staff reviewed and updated Resident 45's Level 1 PASRR and referred the resident to the PASRR office for a Level 2 evaluation due to the presence of SMI. Review of Resident 45's medical records did not show the resident's Level 1 PASRR form was accessible to staff. In an interview on 07/31/2024 at 10:24 AM, Staff E indicated they found Resident 45's updated Level 1 PASRR inside a folder in their office and stated PASRRs should be accessible to staff, but Resident 45's was not. <Resident 32> According to the 05/07/2024 Significant Change MDS, Resident 32 had a severe memory impairment, difficulty focusing, and disorganized thinking. The MDS showed Resident 32 had diagnoses including Alzheimer's disease (a memory impairment) and depression. The MDS showed Resident 32 received AP and AD medications. Review of the (POs) showed a 05/15/2024 order for an AP medication prescribed for dementia, unspecified severity, with behavioral disturbance. Record review showed the facility completed a Significant Change MDS for Resident 32 on 03/07/2024 related to the resident's decision to be placed on hospice services. A second Significant Change MDS for Resident 32's health improvement was completed on 05/07/2024 following their dis-enrollment from hospice services. Record review showed the most current Level 1 PASRR in Resident 32's chart was dated 01/19/2021. This PASRR did not include Resident 32's dementia diagnosis. No Level 1 PASRR screening was completed in relation to Resident 32's 03/07/2024 and 05/07/2024 Significant Change MDSs. In an interview on 08/01/2024 at 11:55 AM, Staff E demonstrated they had a newer Level 1 PASRR dated 04/11/2024 in a file in their office that was more current. Staff E stated they did not know a Level 1 screening was required for a significant change and so did not complete a Level 1 screening after the 05/07/20234 Significant Change MDS as required. REFERENCE: WAC 388-97-1915 (1)(2)(a-c). 46471

Based on observation, interview, and record review, the facility failed to ensure Care Plans (CP) were revised and updated to reflect residents' current care needs for 6 of 21 sampled residents (Residents 28, 32, 66, 239, 64, & 189) whose CP were reviewed. This failure left residents at risk for unmet care needs, unsafe provision of care, and a decreased quality of life. Findings included . <Facility Policy> Review of the Resident Care Plan policy, revised 03/2012, showed the Resident's CP should be a communication tool for staff to provide consistency and continuity in resident care based on resident needs, values and preferences. The policy showed CPs would describe a specific plan that reflected resident preferences and care needs with measurable, specific, realistic, and achievable goals so the resident could attain or maintain their highest practicable physical, mental, and psychosocial well-being. The policy showed CPs should be revised quarterly and as needed. <Resident 28> According to the 05/20/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 28 had medical conditions including heart failure and a chronic inflammatory lung disease. The MDS showed Resident 28 experienced Shortness of Breath (SOB) with exertion, at rest, and when lying flat, and received supplemental oxygen for these conditions. According to the 05/23/2022 SOB CP, Resident 28 had a goal for clear lung sounds. This CP included an intervention for nurses to administer a nebulizer treatment (a treatment that aerosolizes an inhaled respiratory medication). Observations on 07/24/2024 at 2:51 PM and 07/30/2024 at 8:08 AM showed no nebulizer machine in Resident 28's room. In an interview on 08/01/2024 at 9:05 AM, Staff B (Director of Nursing) verified Resident 28's Physician's Orders (POs) and stated Resident 28 no longer received as needed nebulizer treatments. Staff B stated the SOB CP needed to be revised. <Resident 32> According to the 05/07/2024 Significant Change MDS, Resident 32 had a severe memory impairment and required staff assistance for mobility. The MDS showed Resident 32 had cardiorespiratory (heart/lung) diagnoses including an irregular heart rate, high blood pressure, and weakness. Review of the 06/08/2023 .on continuous oxygen therapy . CP showed Resident 32 received oxygen per the PO. The CP directed staff to monitor for SOB and changes in skin tone. Observations on 07/26/2024 at 8:50 AM, 07/26/2024 at 12:22 PM, and on 07/29/2024 at 8:35 AM and 2:10 PM showed Resident 32 breathing without supplemental oxygen. There was no oxygen therapy equipment seen in Resident 32's room. In an interview on 08/01/2024 at 8:56 AM Staff B stated Resident 32 no longer required continuous oxygen therapy. Staff B stated the CP needed to be updated to reflect Resident 32's current condition. 43642 <Resident 66> According to the 06/28/2024 Admission MDS, Resident 66 had recent surgery and required the use of Intravenous (IV - a tube placed inside a vein to deliver medications) antibiotic medications. Review of Resident 66's 06/24/2024 comprehensive CP showed staff developed a CP related to Resident 66 requiring IV antibiotic medications. This CP gave directions to staff to monitor the residents IV site for redness and swelling and to change the IV dressing as ordered. Review of Resident 66's July 2024 Medication Administration Records (MAR) showed the resident's IV antibiotics were discontinued on 07/11/2024, two weeks earlier. In an interview on 08/01/2024 at 1:03 PM, Staff B stated it was their expectation Resident 66's CP be updated and revised when the IV medication was discontinued. <Resident 189> According to a 06/12/2024 Admission MDS, Resident 189 had multiple medically complex diagnoses and required the use of a feeding tube to provide at least half of their nutritional intake. Review of a 07/21/2024 physician order showed diet orders for Resident 189 to have no food or fluids by mouth. Review of Resident 189's comprehensive CP showed the following: a 06/07/2024 constipation CP which showed directions to staff to encourage fluids; and a 06/07/2024 dehydration CP which showed directions to staff to encourage fluids. In an interview on 08/01/2024 at 1:03 PM, Staff B stated Resident 189's CP should have been updated and revised as staff should not be encouraging fluids to Resident 189. 46471 <Resident 239> According to the 07/18/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 239 had clear speech, intact memory, and had diagnoses including end stage cancer and malnutrition. The MDS showed Resident 239 did not walk and was assessed to be totally dependent on two staff for transfers and toileting. Observation and interview on 07/24/2024 at 12:09 PM showed Resident 239 was lying in bed; the bed was in low position and a fall mat was placed on the left side. Resident 239 stated they had two falls since they admitted to the facility on [DATE]. The same observations of the bed and the fall mat were noted on 07/25/2024 at 2:35 PM and on 07/26/2024 at 9:41 AM. Review of a 07/22/2025 nursing progress note showed Resident 239 had a fall in their room after attempting to go to the bathroom during breakfast. Review of a late entry progress note dated 07/24/2024 showed a Physical Therapy (PT) staff assessed Resident 239's functional mobility post-fall and implemented fall and injury prevention interventions including lowering the bed height and the use of fall mats. Review of Resident 239's Care Plan (CP) showed a 07/13/2024 Fall CP indicating the resident was at risk for falls due to generalized weakness, malnutrition, and their medical diagnoses. The CP did not show the use of a fall mat observed in place. In an interview on 07/30/2024 at 10:31 AM, Staff B (Director of Nursing) stated the CP should be complete, accurate, and revised/updated accordingly to ensure proper interventions were in place, and for Resident 239's case, to prevent recurrent falls and/or injuries. Staff B stated they expected fall interventions identified by the interdisciplinary team to be reflected in Resident 239's CP. Staff B reviewed Resident 239's CP and stated the current use of a fall mat should be listed as an intervention, but was not. 50511 <Resident 64> According to the 03/03/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 64 admitted to the facility on [DATE]. The MDS showed Resident 64 had dementia and for several days would feel down or depressed and often felt lonely or isolated. Resident also had vision impairment and may reject care for 1 to 3 days. Review of Resident 64's CP showed goals for behavior of No injuries related to dementia during facility stay and for rejection of care the goal showed the Resident would not harm self. Interventions shown in the CP were to encourage the resident to participate in daily scheduled activities, spiritual visits, provide one on one listening and to assist resident in identifying enjoyable activities. Review of Kardex (work sheet used by care staff to inform them of key patient information and instructions based on CP) on 7/26/2024 at 9:25 AM, showed no instructions provided to care staff in the following areas on the Kardex, What makes life meaningful to resident, What resident likes to do, Hearing/Vision/Dental and no specific instructions on what to do if the Resident rejected care. Observation on 07/23/2024 at 11:07 AM Resident 64 stated the staff are not doing anything for me, they treat me like I am not even here, they ignore me. Observation on 07/26/2024 at 08:39 AM, Resident 64 started crying and stated I am so lonesome. In an interview on 07/30/2024 at 08:37 AM Staff J stated Resident 64's toenails were long and not of normal length and stated for residents who refuse care, it should have been documented and put in progress notes that the resident refused care. In interviews on 07/30/2024 at 8:42 AM and 08/01/2024, Staff B (Director of Nursing) stated staff still need to encourage residents who continually refuse care, because Resident 64 has dementia, staff still need to do whatever they can. Staff B also said that don't have the time to sit with Resident 64. In an interview on 07/30/2024 at 10:31 AM, Staff B (DNS) stated the CP must be complete, accurate and updated accordingly so proper interventions would be in place to prevent injury and is used for staff to follow in providing resident care. REFERENCE: WAC 388-97-1020(2)(c)(d). 51149

Based on observation, interview, and record review, the facility failed to ensure 4 of 7 residents (Residents 45, 20, 58, & 239) reviewed for limited Range of Motion (ROM) were evaluated or provided care and services they were assessed to require, including Restorative Nursing Program (RNP). This failure placed residents at risk for decline in mobility and function, increased dependence on staff, and a decreased quality of life. Findings included . <Facility Policy> The RNP facility policy, revised 01/2022, showed the facility would provide restorative nursing services to promote a resident's ability to function at their highest level and live as independently and safely as possible. The policy showed residents who would benefit from RNPs included those who were at risk for functional decline, and residents with identified deficit(s) and had an established need. The Rigid Splint Application facility policy, revised 02/19/2024, showed splints applied incorrectly could cause unnecessary injuries such as skin or soft-tissue complications including pressure injuries and contact dermatitis beneath the splint. The policy showed prompt identification of impaired nerve or circulatory function was critical in preventing patient harm. The policy showed staff were expected to document splint care, skin assessment, and monitoring for complications. <Resident 45> According to the 06/17/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 45 had clear speech, intact memory, and with medical conditions including heart and kidney failure and a brain injury with resulting weakness on the left side of the body. The MDS showed Resident 45 was assessed to have functional limitations in their ROM. Review of Resident 45's 01/16/2024 Restorative Care Plan (CP) showed the resident was at risk for decreased upper and lower extremity mobility and had Active ROM (AROM) exercises in place. A 04/12/2024 CP intervention instructed staff to continue the application of a right ankle splint. Review of the 07/01/2024 Rehabilitation to Restorative Nursing - Nursing Recommendation Form showed Resident 45 was assessed for AROM RNP up to six days a week. The form showed rehabilitation department recommended right ankle splint application for up to 4.5 hours/day and assessed Resident 45 for splinting RNP up to six days a week. Observation and interview on 07/25/2024 at 9:49 AM showed Resident 45 was lying in bed in the room; their left foot was rotated outwards and their left arm/hand was bent inwards toward their body and was lying on top of their chest with minimal function/movement. There was no splint observed in place. Resident 45 stated they were only able to lift their left arm and leg a little bit off the pillow. When asked if they were provided exercises to help improve and/or maintain mobility and function on the left side of their body, Resident 45 stated, .once a week. Review of Resident 45's AROM RNP documentation 07/01/2024 until 07/26/2024 showed: On the week of 07/01/2024 to 07/06/2024, the RNP was provided once on 07/05/2024 and was declined by the resident twice on 07/01/2024 and 07/03/2024; on the week of 07/07/2024 to 07/13/2024, the RNP was provided once on 07/08/2024 and was declined on 07/11/2024; on the week of 07/14/2024 to 07/20/2024, the RNP was provided once on 07/15/2024 and was declined on 07/16/2024; and on the week of 07/21/2024 to 07/26/2024, the RNP was not provided and was declined by the resident on 07/22/2024 and 07/23/2024. The facility was not able to provide any documentation to support the AROM RNP was offered to Resident 45 by staff up to six days a week as assessed and planned. Review of Resident 45's Splint Training RNP documentation from 07/01/2024 until 07/26/2024 showed: On the week of 07/01/2024 to 07/06/2024, the RNP was provided three times on 07/01/2024, 07/03/2024, and 07/05/2024; on the week of 07/07/2024 to 07/13/2024, the RNP was provided three times on 07/08/2024, 07/09/2024, and 07/11/2024; on the week of 07/14/2024 to 07/20/2024, the RNP was provided two times on 07/15/2024 and 07/16/2024; and on the week of 07/21/2024 to 07/26/2024, the RNP was provided once on 07/23/2024 and was not provided on 07/25/2024 because Resident 45 was sleeping. The facility was not able to provide any documentation to support the Splint Training RNP was offered to Resident 45 by staff up to six days a week as assessed and planned. Review of Resident 45's Physician Orders (PO) showed a 04/12/2024 order for staff to conduct skin checks pre- and post-splint applications and to report any skin issues to the licensed nurse. Review of the July 2024 Treatment Administration Record (TAR) on 07/30/2024 did not show staff were conducting skin checks on Resident 45 before and after the application of their right ankle splint as ordered. There was no orders instructing staff to check Resident 45 for neurovascular (nerve and blood flow) compromise associated with splint application. In an interview on 07/26/2024 at 10:35 AM, Staff K (Licensed Practical Nurse) stated the RNP aide was responsible in applying the right ankle splint for Resident 45. In an interview on 07/26/2024 at 10:56 AM, Staff D (Director of Rehabilitation Services) stated resident RNPs was a shared responsibility between themselves, the MDS Coordinator, and the RNP aide. Staff D stated they were not providing RNP up to six days per the RNP assessment plan because their understanding was, as long as residents were provided at least 1-2 days of RNP and the residents were not declining, it was ok. Staff D stated RNPs were not offered six days in a week by the RNP aide. In an interview on 07/30/2024 at 11:53 AM, Staff B (Director of Nursing) stated skin checks should be performed on residents with splint(s) for early identification of device-related pressure injuries. Staff B stated they expected all staff involved with the facility RNPs to conduct skin checks as ordered. Staff B reviewed Resident 45's POs and stated no skin checks were being documented in Resident 45's TAR in line with the resident's current splint use. <Resident 20> According to the 06/03/2024 Quarterly MDS, Resident 20 had clear speech, intact memory, and medical conditions including a brain injury with resulting weakness on the left side of the body. The MDS showed Resident 20 was assessed to have functional limitations in their ROM. Review of Resident 20's 11/21/2023 Restorative CP showed the resident was at risk for decreased ROM to their bilateral upper and lower extremities due to generalized weakness and medical morbidities. The CP showed Resident 20 had AROM exercises and bed mobility RNPs in place. Review of the 01/15/2024 Rehabilitation to Restorative Nursing - Nursing Recommendation Form showed Resident 20 was assessed to tolerate the AROM and bed mobility RNP up to six days a week. Observation and interview on 07/25/2024 at 10:25 AM showed Resident 20's left upper and lower extremities were flaccid (limp and out of tone). Resident 20 stated they were bed bound and that staff provided them arm/leg exercises about three times a week the most. Review of Resident 20's AROM RNP documentation from 07/01/2024 until 07/26/2024 showed: On the week of 07/01/2024 to 07/06/2024, the RNP was provided once on 07/05/2024 and was declined by the resident twice on 07/03/2024; on the week of 07/07/2024 to 07/13/2024, the RNP was provided twice on 07/08/2024 and 07/11/2024; on the week of 07/14/2024 to 07/20/2024, the RNP was provided once on 07/15/2024; and on the week of 07/21/2024 to 07/26/2024, the RNP was provided once on 07/23/2024 and was declined by the resident on 07/22/2024. The facility was not able to provide any documentation to support the AROM RNP was offered to Resident 20 by the staff up to six days a week as assessed and planned. Review of Resident 20's bed mobility RNP documentation from 07/01/2024 until 07/26/2024 showed: On the week of 07/01/2024 to 07/06/2024, the RNP was provided four times on 07/03/2024, 07/04/2024, 07/05/2024, and 07/06/2024; on the week of 07/07/2024 to 07/13/2024, the RNP was provided twice on 07/07/2024 and 07/09/2024; on the week of 07/14/2024 to 07/20/2024, the RNP was provided twice on 07/18/2024 and 07/19/2024; and on the week of 07/21/2024 to 07/26/2024, the RNP was provided twice on 07/23/2024 and 07/25/2024. The facility was not able to provide any documentation to support the bed mobility RNP was offered to Resident 20 by the staff up to six days a week as assessed and planned. In an interview on 07/26/2024 at 10:56 AM, Staff D confirmed there were no documentation to show Resident 20 declined or was not able to participate in their RNPs for the days of the week not accounted for in the RNP documentation. Staff D stated RNPs were not offered to Resident 20 six days in a week as assessed and planned. <Resident 58> According to the 06/25/2024 Significant Change MDS, Resident 58 had clear speech, intact memory, with medical conditions including a brain injury with resulting weakness on the right side of the body, and was on hospice care during the assessment period. The MDS showed Resident 58 was assessed to have functional limitations in their ROM. Review of Resident 58's 04/23/2024 CP showed the resident had limited function and mobility due to their brain injury, and a CP intervention listed was to have therapy evaluation and/or treatment done per PO. Review of the July 2024 POs showed there was no order for therapy evaluation and/or treatment for Resident 58. Observation and interview on 07/24/2024 at 1:55 PM showed Resident 58 had contracted fingers on their right hand; they were stiff and had limited mobility. Resident 58 stated they were not receiving any exercises for their right hand. Resident 58 stated, I would appreciate exercises from them [staff] but they would not do it [RNP] because I am under hospice. Review of Resident 58's medical records showed the resident was not on any RNP. In an interview on 07/26/2024 at 11:08 AM, Staff D stated RNPs could be provided to hospice residents by the facility if they needed or ask for them. Staff D confirmed there was no PO in place for Resident 58. The facility was not able to provide any documentation to support the Hospice Care team was notified of the need for an RNP evaluation for Resident 58's identified limited ROM and function. In an interview on 07/26/2024 at 12:10 PM, Staff T (MDS Coordinator) reviewed the MDS coding for Resident 58 and confirmed the resident had current functional limitation in their ROM. Staff T stated they did not effectively address the identified issue under the Care Area Assessment and that was why no RNP evaluation or ROM exercises was recommended for Resident 58. <Resident 239> According to the 07/18/2024 Admission MDS, Resident 239 had clear speech, intact memory, and had medical conditions including cancer of the bladder, lungs, and liver and was on hospice care services during the assessment period. The MDS showed Resident 239 had functional limitation in ROM to one side (upper extremity) of their body. Observation and interview on 07/24/2024 at 12:14 PM showed Resident 239 was lying in bed, wearing a brace on their right hand/wrist. Resident 239 stated they sprained their wrist a while back and was unable to use it effectively, .I can move it [right wrist/hand] but it gives out once in a while. Resident 239 stated they were unsure if staff conduct skin checks underneath their splint. A 07/12/2024 Occupational Therapy (OT) note showed Resident 239 had joint contractures (deformity) on both hands from arthritis (joint inflammation). The note showed Resident 239 indicated they wore a right soft wrist support due to an old fracture they sustained in the past. Review of Resident 239's medical records did not show the resident had any current RNP in place. The facility was not able to provide any documentation to support Resident 239's functional limitation in ROM was assessed and/or evaluated for the need for RNP. Review of Resident 239's POs did not show any order for the use of a brace or skin checks. In an interview on 07/26/2024 at 11:08 AM, Staff D reviewed Resident 239's MDS with Staff T and confirmed they have identified Resident 239's functional limitation in ROM in the assessment, but did not address the situation. Staff D confirmed the presence of the 07/12/2024 OT note regarding Resident 239's wrist brace use, and stated they missed it. REFERENCE: WAC 388-97-1060(3)(d).

Based on observation, interview, and record review the facility failed to ensure 1 (Resident 8) of 3 sampled residents reviewed for Pressure Ulcers (PUs) received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure of the facility to assess skin integrity, follow Care Plan (CP) Interventions and initiate treatment orders caused harm to Resident 8 who developed an avoidable facility acquired right rib PU and a reopened a tailbone PU. Failure of the facility to complete skin assessments, prevent and treat PUs, placed Resident 8 and all other residents at risk for pressure ulcer development, increased risk for infection, and diminished quality of life. Findings included . <Facility Pressure Ulcer Policy> The facility's 01/2023 PU policy showed that the resident would not develop PU's and the facility would provide care and services consistent with professional standards of practice. A PU refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A PU would present as an open ulcer the appearance of which would vary depending on the stage and may be painful. The injury would occur as a result of intense and/or prolonged pressure. An Unstageable PU: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough (dead tissue - If the slough was removed a stage 3 or stage 4 PU would be revealed). A stage 3 PU is full thickness skin loss, and a stage 4 PU is full thickness skin and tissue loss with exposed or directly palpable fascia (a layer of connective tissue below the skin), muscle, tendon, ligament, cartilage, or bone in the ulcer. Avoidable PU: A PU that developed in the facility and the facility failed to do one or more of the following: Evaluate the resident's clinical condition risk factors: define and implement interventions that are consistent with residents needs, goals, and recognized standards of practice; or failed to monitor and evaluate the impact of the interventions or revise the interventions as appropriate. The PU policy listed expectations of staff if a PU developed after admission as follows: Obtain treatment orders, initiate an individualized CP to include new PUs with interventions for evidence of pain at site or during care, add stage, site, and treatment order to Treatment Administration Record (TAR), and document assessment of PU. <Resident 8> According to the 02/27/2023 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 8 was able to make themself understood and able to understand others, had moderate mental decline, and was totally dependent on two staff for physical assistance with moving to and from a lying position, turning side to side, and positioning the body while in bed. The MDS showed Resident 8 had diagnoses of quadriplegia (paralysis from neck down), and a disabling neuromuscular disease of the brain and spinal cord causing communication problems between the brain and the muscles. According to the MDS, Resident 8 was at high risk for developing PUs. Observation on 04/18/2023 at 10:27 AM showed Resident 8 lying on their back, and only able to move their neck and head. Resident 8's arms were bent at the elbows with their hands resting on their chest. Resident 8's elbows were pressed tightly onto their rib cage. Resident 8 was unable to shift their weight or move their body/extremities on their own. Clinical record review showed the physician ordered weekly skin assessments were not completed on 03/30/2023, 04/06/2023, and 04/13/2023. The TAR had an M in the documentation area for these dates. In an interview on 04/21/2023 at 2:11 PM Staff C Manager Long Term Care, Registered Nurse (RN), stated that an M in the documentation area on the resident's administration records meant that the staff missed doing the assigned order for those dates. In an interview on 04/21/2023 at 2:11 PM Staff M Manager Long Term Care, RN stated staff did not complete the weekly skin assessments on 03/30/2023, 04/06/2023, and 04/13/2023. Staff M stated nursing staff were expected to complete a head-to-toe skin assessment including measuring and documenting all skin issues, old and new. Review of the 04/17/2023, 04/19/2023, and 04/25/2023 Pocket Care Guide (PCG) and CPs directed staff to ensure Resident 8's elbows were cushioned with pillows and position Resident 8 either on their left or right side, not on their back to decrease pressure on buttocks. Observations on 04/18/2023 at 10:27 AM, 04/19/2023 at 8: 48 AM, 04/20/2023 8:34 AM, 4/21/2023 at 9:23 AM, 04/24/2023 at 9:38 AM, and 04/25/2023 at 10:18 AM showed Resident 8 did not have pillows under their right elbow according to the CP to prevent pressure between the elbow bone and the right rib cage. Resident 8 was observed lying on back in bed on 04/18/2023 at 10:27 AM, 04/21/2023 at 9:23 AM, 04/24/2023 at 9:38 AM, and 04/25/2023 at 10:18 AM. The 04/17/2023, 04/19/2023, and 04/25/2023 PCG instructed staff to keep Resident 8 off of their back. In an interview on 04/20/2023 at 10:07 AM Staff U Certified Nursing Assistant (CNA), stated the nursing staff use the PCG to direct them on how to care for their assigned residents. On 04/20/2023 at 10:26 AM, the wound care provider verbally gave Staff O the following wound care orders: Cleanse tailbone PU with normal saline, apply AD ointment periwound (skin surrounding wound), apply Hydraferablue (an antibacterial foam dressing), secure with silicone bordered dressing, change every other day and as needed. Cleanse rib PU with wound cleanser apply AD ointment to periwound, apply honey, secure with bordered dressing, change every other day and as needed. When interviewed on 04/20/2023 at 10:26 AM, Resident 8 denied pain when the wound care provider asked if the resident was experiencing any pain because the resident had diagnoses that prevented the resident from feeling pain. A reasonable person, that did not have Resident 8's diagnoses would experience severe pain with the development of an unstageable PU and would not be dependent on staff to prevent PUs as Resident 8 was assessed to require. Clinical record review on 04/24/2023, four days after new PUs were identified, and staff received orders for cares and treatments, showed there were no new treatment orders for the rib and tailbone PU documented in the clinical record or medication record, no nurse assessment documentation of the PUs, and the CP was not updated with new PU treatments. In an interview on 04/24/2023 01:54 PM, Staff O stated they did not document notes on newfound PUs or transfer verbal treatment orders (received on 04/20/2023) into Resident 8's medical record. Staff O stated Resident 8 went four days without wound care or wound monitoring. In an interview on 04/24/23 at 1:22 PM, Staff M stated the expectation of nurses, when they found a new PU, was to complete a head-to-toe skin assessment, measure and document all skin issues, old and new, and document findings in a nursing note in the resident's record. Staff M stated the nurse was expected to complete an incident report, notify the physician to get treatment orders, transfer the orders to the residents' records, notify the nurse manager, and the wound care provider. Staff M stated Staff O was part of the facility's wound care team so the nurses would have Staff O assess the PU and recommend treatment orders when Staff O was on duty. REFERENCE: WAC 388-97-1060(3)(b).

Based on interview and record review, the facility failed to prevent abuse or identify how Resident #2's history of loud moaning and yelling caused Resident #3 to strike out in anger and hit Resident #2 in the face with his cane to stop the noise. This failure resulted in Resident #2 being struck in the face with a cane causing bruising to his face and having unnecessary medical procedures to rule out fractures to his face. This failure constituted physical and psychological harm. Findings Included . RESIDENT #2 According to the resident face sheet, Resident #2 admitted to the facility on [DATE] with a history of a stroke and late effect [MEDICAL CONDITION] (difficulty speaking). Review of a 11/04/2020 investigation analysis showed that on 11/03/2020 a nurse observed Resident #2 to have a bruise below his left eye. The resident was unable to state what happened, so x-rays were taken to rule out a fracture. Review of a 11/04/2020 social service progress note showed, It was reported that (Resident #3) told the staff that he was waving his cane in anger and accidently hit his roommate in the eye and caused a bruising under his roommate's left eye. The writer asked him if he had time to meet to discuss the situation and he was more than willing to do so. He was asked to describe what happened and he said that he has been with this roommate for 2 years now and that he moans and makes very loud noises. Per resident, 'It drives me crazy'. He was asked if he called staff or expressed to anyone that this bothered him and he said, 'Everybody can hear him. They know that he makes noise and it bothers everyone on the entire floor.' In an interview on 12/07/2020 at 10:14 AM, Staff F, Licensed Practical Nurse (LPN) said, I think it was 12/05/2020, I went in to give him (Resident #2) his morning medications and I saw he had a bruise under his eye. That's when I asked him what happened to his eye. According to Staff F, Resident #3 said he pointed his cane or reacher at Resident #2 to tell him to be quiet and accidently struck him in the face with the object. Staff F said, He's (Resident #2) aphasic, during the evenings, he makes loud moaning or grunting noises to make his needs known. However, if he's up in his wheelchair, he frequently used yes or no phrases to communicate his needs. When asked if she had ever asked Resident #3 if the noises were bothersome to him, Staff F said, No, because he's (Resident #3) alert and oriented and capable of notifying staff if the noises were a problem. When asked if she had reported the noises, Staff F replied, As I've said before, I didn't report the noises. Besides we're all aware how loud he (Resident #2) was. In an interview on 12/07/2020 at 11:01 AM, Staff G, LPN/Nurse Manager, said that Resident #2 was aphasic and frequently moaned or grunted loudly to make his needs known. Staff G said if Resident #2 is up in his chair he occasionally used short phrases like yes or no, but most of the time if he's in bed he moans or grunts loudly. When asked if he asked Resident #3 if the noises bothered him, Staff G replied, No, he's alert and oriented and capable of letting us know if loud noises were bothersome to him. In an interview on 12/07/2020 at 11:38 AM, Staff H (Social Services Director) was asked if she was aware of any residents who made loud noises. Staff H replied, Yes, we have a few residents with those types of behaviors. There is Resident #4, she frequently makes loud disruptive noises. I have spoken to Resident #4's representative regarding a room change; however, they declined a room change. I spoke to Resident #5 (roommate of Resident #4) and attempted to ask her to be [MEDICATION NAME] as she's not elderly and not interested in a room change, and changing Resident #4's room was not an option as her representative was against a room change. Staff H continued, Also, there is another resident (Resident #2). Honestly, he's so loud you can hear him throughout the building when he's clearing his throat, sneezing, moaning or grunting. Staff H was asked if this resident had a roommate, and she replied, Yes, he does. Staff H was asked if she had ever asked Resident #2's roommate if the noises was bothersome. She replied, No, Resident #3 is alert and oriented and could notify staff if he was bothered by the noise. When asked what prevented the facility from intervening and putting measures in place to address an identified pattern of disruptive behavior that affected other residents, to include Residents #3 and #5, Staff H stated, Like I said previously, Resident #3 is alert and oriented and could make the staff aware if he was bothered by his roommate and the loud noises. The above findings were shared with with Staff A, B, and I (Therapy Director) on 12/08/2020 at 10:27 AM. Staff B acknowledged Resident #2 frequently made loud noises and attributed them to the resident's means of communicating. Staff A and B acknowledged they failed to ask Resident #3 if the noises were bothersome. Staff B said, (Resident#3) is alert and oriented and able to make his needs known. If the noise was problematic he was able to alert the staff. When asked if the resident to resident altercation, which resulted in physical abuse, could have been prevented, Staff A stated, (Resident #3) is alert and oriented and able to make his needs known. Not all interventions will fit every situation. Since the incident we've made several room changes and we think this will solve the problem. Staff I stated, (Resident #2) will often point at objects or uses eye contact to communicate. REFERENCE: WAC 388-97-0640 (1).

Based on interview and record review, the facility failed to provide supervision to prevent falls and injuries for one (#1) of one resident reviewed for falls and injuries. This failure caused Resident #1 to fall, which resulted in a hospital transfer for the treatment of [REDACTED]. Findings included . A 11/2019 facility policy titled Falls, showed that interventions to prevent falls and reduce harm when falls occurred were implemented for residents based on their falls risk assessment. This policy showed those interventions would be identified in the plan of care, to include individualized goals and interventions. RESIDENT #1 Review of a 06/12/2020 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident #1 was admitted to the facility on [DATE], and was assessed as cognitively intact, required limited assistance of one person to transfer and toilet, and had a history of [REDACTED]. Review of a 08/10/2020 Investigative Summary (IS) showed Resident #1 was last seen sitting in his recliner 15 minutes prior to the fall. Resident #1 reported that the plastic slides of his walker got caught on the threshold of the doorway which caused him to fall. This IS showed the resident routinely transfers unassisted even with multiple disciplines reinforcing the need to use the call light and wait for assistance for safety . caregivers remain vigilant to cue (Resident #1) to ask for assistance, have placed signage to call for assistance. However, despite these measures, he continues to not use call lights appropriately. The facility's interventions to prevent recurrence of a fall included, Alert charting, Neuro (neurological) checks, tennis balls on wheeled legs of (walker), therapy evaluations, pharmacy review and provider assessment. This IS included a witness report that stated, resident toilet self and that the resident sustained [REDACTED]. Review of the medical record showed staff continued to identify Resident #1 as impulsive/spontaneous, forgetful of limitations, required staff reminders to use the call light, transferred himself, required supervision and/or stand by assist while walking or transferring, and poor self-awareness (08/06/2020, 08/07/2020, 08/08/2020, 08/17/2020, 09/30/2020, and 11/04/2020). Review of the resident's current comprehensive Care Plan (CP) showed no interventions of how staff were to monitor or supervise Resident #1, even though the facility identified him as impulsive, transferred unassisted, and did not use the call light consistently since 08/05/2020. A 08/18/2020 Toileting CP showed instructions for staff to assist the resident to the bathroom before and after meals, at bedtime, upon rising in the morning and when he awakened at night. In addition, a 08/18/2020 ADLs (Activities of Daily Living) CP directed staff to refer to the Pocket Care Guide (PCG - a quick care reference tool) for assistance needs. Review of an 11/06/2020 PCG showed no direction how staff monitored or supervised the resident to prevent falls, or any indication of his toileting schedule. Review of an 11/06/2020 IS showed staff heard a loud crash coming from Resident #1's room, It was 1700 (5:00 PM) nearing dinner time, when the fall occurred. This IS showed staff found the resident sitting on the floor with his walker to his right, glasses broken on the floor next to the resident, and that the resident stated, I tripped or something. This IS showed staff assessed Resident #1 to have multiple lacerations to his head, ranging from 1 cm to 7 cm, to include a 1 cm laceration to the left eye, a 7 cm laceration to his right forehead that bled profusely, and L (left) eye appeared murky. Additionally, the IS included a witness report that stated, Time last toileted: toilets self and It is reasonable to believe the fall is related to two factors: may have tripped on something . possible he tripped on the book shelf. An additional factor that could be contributory is the common practice of (Resident #1) to not request assistance prior to transferring or ambulating. This IS showed that facility interventions to prevent recurrence of falls included to move the book shelf away from doorway area, add bright signage with large print to remind resident to call for assistance prior to transfer or ambulation, therapy consults, pharmacy and provider review, and provide emergency care and a hospital transfer. This IS showed no documentation the facility questioned why the resident was walking by himself, or why staff failed to correctly identify the resident required assistance for transfers and toileting. Review of an 11/12/2020 hospital discharge summary showed Resident #1 sustained a Ruptured globe (eye ball) of the left eye and laceration of scalp. Presents with ground level fall into cabinet corner. Review of an 11/15/2020 progress note, nine days after the fall, showed staff continued to identify Resident #1 as more forgetful . used call light sometimes but observed attempting self-transferring. Advised the pt (patient) to use call light and educated the risk of self-transferring (sic). Staff needs reminders and redirect (sic). In an interview on 11/25/2020 at 8:17 AM, Staff D, Agency Aide and staff assigned to Resident #1 when he fell on [DATE], stated she was in the hallway when, I heard something and one of the other aides seen him stand, then I went to assist. I wasn't in the room when he fell . I don't know what he was trying to do honestly. He doesn't really need assistance, he can toilet himself. Maybe every now and then, but I don't even think he needs help with the brief. No, he doesn't need to be toileted. He needs reminders to use the walker. He wasn't toileted before the fall. In an interview on 11/25/2020 at 8:24 AM, when asked what she thought Resident #1 was trying to do when he stood up, Staff E, Charge Nurse, stated, My understanding is he was walking from the bathroom to get something, and I guess he tripped from the bed side table. That's what I was thinking, and he hit his head on the book shelf. Looked like he was walking out of the bathroom. I think the (resident spouse) said he was walking out of the bathroom. Staff E confirmed, Dinner is between 5:30 PM to 5:45 PM. Staff E also stated, We have to keep checking on him 'coz he does his own thing and he doesn't wanna' call. When asked if Resident #1 was on a toileting program, Staff E stated, Umm, no, I don't think so. Probably every two hours somebody has go in to help him, nothing specific. When asked when was the last time the resident was toileted by staff, Staff E stated, Not sure exactly coz he often goes by himself. When asked if anything changed with the resident's CP after the fall, Staff E stated, Not sure. Sorry, I can't recall. Review of the IS showed Staff B, Director of Nursing (DON) completed the investigation on 11/10/2020. In an interview on 11/25/2020 at 11:07 AM, when asked if it was realistic of the staff to ask Resident #1 not to transfer himself when the facility continued to acknowledge his impulsivity and forgetfulness, Staff B stated, I would say it is realistic to always reinforce that. When asked if the CP showed interventions to compensate for Resident #1's impulsivity and forgetfulness, Staff B stated, To be fair, I don't have that in front of me. I'm not exactly sure. He would be on alert charting. He would have been on neuro checks. When asked how those measures were intended for long-term use, no answer was provided. In this continued interview, when asked if the facility interviewed the aide who stated the resident toileted himself, or verified whether or not the aide followed the CP to toilet the resident before meals, Staff B stated, I personally did not. That I cannot answer either. The resident will do it independently without our knowledge. I don't know the answer to that question. When asked if there was any follow-up with the resident to identify what prompted him to get up and walk, Staff B stated, I didn't specifically ask him what made him stand up. When asked what was the difference between the bright signage and the signage mentioned in the 08/10/2020 IS, Staff B stated, We have made it brighter to trigger the resident to call for help. When asked why that intervention was not implemented sooner when staff continued to identify safety concerns for three months after a fall, Staff B stated, I cannot answer that. I would have to double check with (Nurse Manager), and acknowledged it should have been addressed. Review of an 11/06/2020 Fall CP showed no interventions that directed staff how to supervise or monitor Resident #1 to prevent falls and their associated injuries. Review of an 11/06/2020 PCG showed no documentation the facility identified the resident was impulsive, transferred himself, or when he was supposed to be assisted to the bathroom. When asked if those interventions should be in the PCG, Staff B stated, That's why it says he is a high falls risk. When asked what that meant to staff who cared for Resident #1, Staff B stated, That he needs to be assessed as a high fall risk. When asked if the CP or the PCG addressed how staff anticipated and mitigated Resident #1's impulsive and forgetful behavior, Staff B stated, No, and acknowledged Yes, it likely should (be included). In an interview on 12/03/2020 at 8:50 AM, when asked what he was trying to do when he stood up the day of the fall, Resident #1 stated, I was coming from the bathroom trying to get a towel after washing my hands. Resident #1 confirmed he walked to the bathroom by himself. The above findings were shared in a joint interview with Staff A (Administrator), B, and C (Regional Director of Operations) on 12/02/2020 at 11:26 AM. No further information was provided. REFERENCE: WAC 388-97-1060 (3)(g).

Based on interview and record review, the facility failed to provide the required assistance to prevent falls with associated injuries for 1 (#1) of five residents reviewed for falls. This failure caused the resident to fall, and resulted in a hospital transfer for the treatment of [REDACTED]. Findings included . A facility policy, Last Revised: 11/2019 and titled Falls, showed that interventions to prevent falls and reduce harm when falls occur were implemented for residents based on their falls risk. This policy showed those interventions would be identified in the plan of care, to include individualized goals and interventions. Review of a 09/29/2020 Admission Minimum Data Set (MDS - an assessment tool) showed Resident #1 was admitted to the facility on [DATE], was assessed to require extensive assistance of two persons for toileting and transfers, used oxygen, and to have moderately impaired cognition. A 10/19/2020 fall assessment identified the resident as a high fall risk. Review of a Revised 09/23/2020 Falls care plan showed the resident was at risk for falls due to poor balance, related to excessive weight, weakness and impaired mobility. Resident needs extensive assistance with one person, two + person support for transfers. Review of progress notes from 09/27/2020 to 10/21/2020 showed staff provided 2 person extensive assist on (sic) toileting. A 10/21/2020 Physical Therapy (PT) note also showed Resident #1 required two person maximum assist, had poor safety awareness, wasn't following directions well, and that the resident's oxygen levels dropped to 74% without oxygen. Review of a 10/21/2020 24 hour Communication log showed documentation the resident was on, Precautions: 02 sats (saturation) unstable. To/From Bathroom: Extensive assist, w/c (wheel chair) Toilet Transfer: 2 person assist . Toileting: 2 person dependent . Recommend 02 for toileting. Review of a care guide dated 10/21/2020 showed, Toilet transfer: 2 person assist . Toileting: Dependent 2 person assist . **USE OXYGEN FOR TOILETING** Review of a 10/22/2020 progress note written at 4:08 AM showed, WITNESSED FALL in bathroom with head injury at 2238 (10:38 PM) hours. Upon arriving patient was on her R (right) side, head on pillow, on top of her walker. A very concerning amount of blood was present in a 12 inch puddle on the floor and disperse (sic) throughout residents (sic) gown, face, hair and bandages in which NAC (Nurse Assistant Certified - Staff D) and (Staff C) (Registered Nurse) were using to apply pressure to site of wound. This writer ensured patient LOC (level of consciousness) was intact . stated name, was able to describe that she had got up from the toilet and immediately just felt like her body was taking her forward over her walker and that she remember she hit the top of her head on the sink . At 2249 (10:49 PM) hrs. (hours) paramedics arrived, assisted with lifting resident off ground, wound was visualized by responder who stated wound was a fist sized avulsion (large amount of tissue removed, including at least three layers of skin) on the upper left aspect of the head, this nurse visualizing pulsing of blood from the inferior aspect of the wound bed, skull clearly visible. Review of a post fall assessment dated [DATE] at 4:55 AM showed, I (Staff D) assisted the patient to the toilet when she stood to pull her underwear up, she suddenly lost balance and fell forward to the floor with the walker in front of her. A resident interview in the assessment showed, (Resident #1) stated she had just stood from the toilet and fell forward over her walker, hitting the top of her head on the sink. This assessment also showed No to the question of Oxygen, Feeding Tube or Catheter present? Review of hospital discharge records dated 10/26/2020 showed, Brought in by the medics, said to have fallen getting off the toilet when her walker slipped and she lost her balance. She struck the left side of her head against the sink. She did not lose consciousness. She complains of right elbow pain. Per report, the patient had a scalp degloving (the separation of the skin and tissues under the skin from the underlying deep connective tissue, muscles and bones compromising the nearby deep connective tissue, muscles, blood vessels and nerves) with active bleeding on arrival to the ED (Emergency Department). A bleeding vessel was identified and ligated (tied) . the patient became hypotensive (low blood pressure) due to acute blood loss . The patient arrived in hypotensive (low blood pressure) shock due to acute blood loss [MEDICAL CONDITION] from scalp laceration . Closed head injury . fracture of head of right radius (a break to the radius bone in the forearm just below the elbow joint). These records showed the resident required intravenous fluids to normalize her blood pressure, and a blood transfusion. Review of an Investigative Report dated 10/26/2020 showed, Patient has also been on and off of 02. Patient does not like wearing nasal cannula. 02 sat ranges that day was 90-98% and positioning in bed attributes to low readings . lower readings require 02 via nasal cannula use. This IR also showed, It is reasonable to believe the root cause of the fall was due to sudden movement without warning or notification & (and) leaning forward. Her forward propulsion and weight cannot be adequately supported w/ (with) the assistive device. As NAC was in a kneeling position, the assistance required to maintain balance was inadequate. Blood pressure medication may have contributed to the fall. This IR did not evaluate why the resident was not provided 2 staff and oxygen at the time of toileting and transfers as she was assessed to require, in order to prevent accidents or injuries associated with poor or no safety awareness, inconsistent transfers, limited follow through of instruction, and identified significant decrease in oxygen levels during activity. In an interview on 11/09/2020 at 8:32 AM, when asked about the fall that occurred on 10/21/2020, Resident #1 stated, I stood up and the walker wobbled on me. It was so fast, (Staff D) couldn't hold me. I just stood up coz' I was done. I got 18 stitches. Resident #1 confirmed that only Staff D was present during toileting and transfers, and that Staff D was standing next to her when, I fell forward. He couldn't stop me. When asked if Staff D used a gait belt during toileting, the resident stated, No, coz' I was on the toilet. I refused the gait belt. In an interview on 11/05/2020 at 6:39 PM, when asked why he documented throughout the resident's stay and up to the day of the fall that Resident #1 required two person assist for toileting, Staff C stated, I believe two person assist because of needing help standing up and transfers is two people, because of the weight and not stable. When asked where he got the information the resident was a two person transfer, the nurse stated, The therapist evaluated them and then care plan is updated, and we have to follow the care plan. When asked if Staff D had another staff with him at the time of the fall, Staff C stated, No, I don't know. I have no idea. In an interview on 11/05/2020 at 8:27 PM, when asked how he obtained information on how to care for the residents, Staff D stated, By the pocket care guides and from the NAC on duty who gives report. When asked if he knew Resident #1 and was familiar with her care, Staff D stated, I took care of her like two times before, and clarified he worked part-time, on night shift, twice a week, and floated between units. Staff D stated that prior to Resident #1's 10/21/2020 fall, he had been assigned to the resident two weeks ago. Staff D described his first encounter with Resident #1 as, the first time I emptied her beside commode. She transferred herself to the commode and back to the bed, and that the resident required extensive assist two person. When asked if he told anyone the resident transferred herself alone, Staff D stated, I told my charge nurse she just go by herself. Staff D stated, the second time he was assigned to care for Resident #1, he did not have to transfer the resident as she declined to use the commode, and she slept most of the shift, and required extensive assist two people. Staff D stated the third time he took care of the resident was the night of the fall on 10/21/2020 and stated, It was 10:30 PM. I was a night shift aide. I was told she was cleared to go use the bathroom, not the commode, so I took her to the bathroom. What I got was she was supervised. The care guide was not updated. I couldn't find it. When asked if the fall could have been prevented, Staff D stated, More communication. This time the call lights were on like a Christmas tree. I got report from the aide. I couldn't find the care guide. When asked if he ever found the care guide, the staff stated, Later, around two hours later. I think it was misplaced, not where it used to be. When asked what the care guide said after he found it, Staff D stated, It said it has a 2 person for transfers on the care guide. If two people were there, yes, that would have been better. When asked why the resident was a two-person assist, the staff stated, Mostly what I understood is she felt weak, but I didn't get the full explanation on that one. In a follow-up interview on 11/09/2020 at 10:00 AM, Staff D stated Resident #1 did not wear any oxygen when he transferred the resident to the bathroom and stated, No, she didn't have oxygen. She had her concentrator (an appliance that delivers oxygen) before, and was not available in her room. When asked again if he saw any oxygen delivery appliances in the resident's room the night of 10/21/2020, Staff D stated, No Staff D also stated he used a gaitbelt during the transfer and toileting, contradictory to the resident's statement. The above findings were shared with Staff A, Administrator, and Staff B, Director of Nursing, on 11/06/2020 at 1:59 PM. When asked if the facility followed the instructions to provide the resident two staff during toileting and transfers, Staff B stated, No. Staff A stated, We need to make sure this thing doesn't happen again. The caregiver not following the care plan and the communication is what needs to be improved on. When asked when the facility realized the resident was not provided the amount of physical help required during toileting, Staff B stated, It was on 10/28 (a week after the fall and two days after her return from the hospital). In a follow-up joint interview with Staff A and B on 11/09/2020 at 10:16 AM, when asked if Resident #1 had been re-interviewed after re-admission, Staff B stated, Not upon arrival or through now. I personally have not (interviewed her). Staff A acknowledged, Yes, it is pertinent to interview the resident so we can ensure prevention of falls. REFERENCE: WAC 388-97-1060 (3)(g) .

Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors for one (#1) of four residents reviewed for medication administration errors. Failure to administer medications according to nursing standard of practice resulted in harm to Resident #1 who experienced discomfort and a transfer to the hospital. Findings included . Record review of the facility's undated policy titled, Medication Administration, showed that Licensed Nurses will adhere to the Six Rights of Medication Administration; right patient, right medication, right dose, right route, right time and right documentation. Prior to administration, the medication and dosage schedule on the Medication Administration Record [REDACTED]. RESIDENT #1 Resident #1 was a long term resident. Review of the 11/11/19 Quarterly Minimum Data Set (MDS - an assessment tool), showed that Resident # 1 was alert and oriented, able to make needs known, required extensive assistance of staff of ADLs, and had [DIAGNOSES REDACTED]. Record review showed Resident #1 had physician orders [REDACTED]. Review of a progress note dated 01/19/2020 showed that at 1:30 PM, Staff C, Registered Nurse, injected the medication [MEDICATION NAME], subcutaneously instead of the medication ordered, [MEDICATION NAME]. According to Drugs.com dated 01/28/20, [MEDICATION NAME] (Interferon beta - 1a) is indicated for the treatment of [REDACTED]. Side effects for which the physician should be called immediately include, but are not limited to [MEDICAL CONDITION], a light-headed feeling, shortness of breath, signs of infection, and fever. Additional side effects include muscle weakness, unsteadiness, and urinary tract infection. A Nursing Home Provider progress note dated 01/19/20 at 5:04 PM, showed that the nursing staff was directed to monitor for possible adverse side effects, and that the [MEDICATION NAME] was not expected to clear the resident's system for four days. Review of a progress note dated 01/19/20 at 10:43 PM, showed that Resident #1 complained of dizziness and weakness in legs. A progress note dated 01/20/20 at 10:33 AM, showed that Resident #1 had a fever of 102.1 degrees Fahrenheit (dF), decreased oxygen saturation level of 74% on room air (RA), and increased lethargy. 911 was called and the resident was transferred to the emergency department at 8:30 AM. A Nursing Home Provider progress note dated 01/20/20 at 8:27 AM, showed that a nurse paged to report Resident #1 was unable to open eyes or answer any questions, had a fever of 102.1 dF, down to 101.9 dF, oxygen saturation 74% on room air, with a code status of Full Code with Full Treatment interventions. The provider documented assessment, patient having possible ASE (adverse side effects) from [MEDICATION NAME] and plan, given acute symptoms of fever, [MEDICAL CONDITION] with lethargy transfer patient to ER for further evaluation and treatment. Review of the hospital discharge summary dated 01/22/20, showed that Resident #1 was admitted to the hospital on [DATE] and discharged [DATE]. Discharge [DIAGNOSES REDACTED]. Currently mental status back to baseline. On 01/29/20 at 12:33 PM, Resident #1 was observed in the facility, in bed. During an interview at that time, Resident #1 stated that she was getting better since returning from the hospital. Resident #1 stated she got someone else's medication. Resident #1 stated, It made me feel awful, Resident #1 described hearing voices, and people talking, like in a dream and stated, It was very scary. Review of the facility investigation dated 01/24/20, showed that Staff C failed to follow the basic five rights of medication administration. During an interview on 01/29/20 at 2:50 PM, Staff D, Unit Manager, stated that the medication was clearly labeled. Staff C just grabbed a vial that looked like [MEDICATION NAME] from the refrigerator, and did not check the name of the medication, or the resident's name on the label prior to administration. During an interview on 01/29/20 at 2:54 PM, Staff A, Administrator confirmed the medication error was significant and occurred when Staff C did not follow procedure. Reference WAC 388-97-1060(3)(k)(i)(iii)

Based on observation, interview and record review, the facility failed to implement interventions to prevent pressure ulcers for Resident #66. Failure to implement splinting and range of motion services resulted in the development of an avoidable Stage IV pressure ulcer on this resident's right thumb, which constituted harm. For two of four sample residents (#38 and 34) reviewed for skin conditions, the facility failed to document specific clinical information regarding the condition of pressure ulcers in weekly skin assessments. This failure placed these residents at risk for new or worsening skin conditions, including pressure ulcers. Findings included: FACILITY POLICY Review of the facility's policy titled, Skin Care, revised in April, (YEAR), showed staff were to inspect skin regularly to identify breakdown. Licensed nurses were also to assess skin on admission, weekly and more frequently as needed. The policy did not identify interventions for pressure relief related to skin areas at risk for pressure ulcers due to contractures or the use of splints, when used as part of treatment. RESIDENT #66 According to his medical history and a 12/03/18 Minimum Data Set ( MDS -an assessment tool), Resident #66 was a long-term resident of the facility with care needs related to a stroke and a [MEDICAL CONDITION]. He was dependent on staff for bed mobility, transfers and all other personal care. He had a history of [REDACTED]. Review of his care plan, last revised on 12/19/18 revealed a problem of impaired skin integrity: Right thumb wound, with a goal that the Abrasion will resolve in 30 days without complications. This problem remained current when the care plan was reviewed on 01/04/18. Further review of the record showed a care conference note, dated 06/22/18, which stated Resident #66 had been receiving skilled Occupational Therapy (OT) services since 04/23/18 which included application of Bilateral inflatable hand splints. This note also stated the Certified Nursing Assistants (NACs) had received training for putting the splints on the resident and removing them. When observed on 01/04/19 at 9:50 and 11:50 AM, on 01/08/19 at 12:30 PM, 01/09/19 at 10:52 AM and 01/11/18 at 10:15 AM, Resident #66 was observed to be seated in his wheelchair with a rolled washcloth in each hand, but no inflatable splints in place. The pressure ulcer was located on the pad of the right thumb. On 01/09/19 at 10:45 AM, Staff S, a Restorative Aide (RA) who worked with Resident #66 was asked about his restorative exercise and splinting programs. Staff S replied she had been seeing Resident #66, but getting him to participate was a hit or miss thing and that he did sometimes refuse this care. Review of Resident #66's medical record showed a progress note by his Physician (Staff U), dated 10/03/18, although the visit had occurred on 09/28/18. In this note, Staff U documented Resident #66 had a blister on his right thumb, Due to contracture related mechanical pressure. He has a blister which opened up. A progress note by Staff U, dated 10/09/18, identified the wound on Resident #66's hand was getting deeper, with mild redness, swelling, pain in thumb. On 10/16/18, Staff U stated the resident's ulcer was reviewed with a wound care consultant, and described the pressure ulcer as measuring 1.0 centimeter (cm) by 1.2 cm, with no measurable depth. The next evaluation by Staff V, a Physician's Assistant-Certified and wound consultant (PA-C), dated 11/01/18, documented Resident #66 had a Stage III pressure ruler on his right thumb (defined as a full thickness loss of skin over a joint or bony prominence), measuring 1.7 cm by 0.8 cm by .01 cm. By 11/08/18, the pressure ulcer remained a Stage III, with slightly smaller measurements. No mention was made of provision of splints to or other pressure relief measures as part of the facility's plan to promote healing of the pressure ulcer or prevent development of new pressure ulcers. According to facility documentation in the (MONTH) (YEAR) Treatment Administration Record (TAR), this pressure ulcer was healed as of 12/06/18. On 12/08/18 a physician's orders [REDACTED]. Review of this OT consultation, dated 12/11/18, directed staff to apply inflatable air splints to both of Resident #66's hands five to seven days per week, for up to four hours, as well as providing Range of Motion (ROM) three times per week with daily skin checks of both upper extremities. By 12/20/18, the pressure ulcer on Resident #66's right thumb reopened. The resident was again seen by the wound consultant (Staff V) on 12/20/18, who documented the right thumb pressure ulcer was now a Stage IV ( defined as aFull thickness loss of skin and tissue with exposed muscle, tendon or other underlying structures). Staff V described the Stage IV ulcer as measuring 0.6 cm by 0.5 cm by 1.0 cm in depth. He documented the pressure ulcer as deteriorating but without signs of infection. When Staff V examined the pressure sore on 12/27/18, he again assessed the wound to be a Stage IV pressure ulcer measuring 0.5 by 0.6 by 0.5 cm. During a On 01/03/19 assessment, Staff V documented Resident #66's right thumb to be a Stage IV pressure ulcer which measured 0.4 by 0.5 by 0.3 cm. A copy of Staff V's 01/10/18 assessment showed Resident #66's pressure ulcer was resolved by that date. LACK OF PREVENTATIVE INTERVENTIONS Review of preventative interventions identified by the facility to address Resident #66's risk for pressure sores due to contractures of both hands showed the following: According to Resident#66's current care plan, the presence of contractures of the wrist and fingers of his right hand and arm both had been present since at least July, (YEAR). Review of Minimum Data Set Assessments dated 02/06/16 and 07/21/16 both showed Resident #66 was provided Passive Range of Motion (PROM) six to seven times per week at that time. Review of subsequent MDS assessments dated 12/27/17, 03/27/18, 06/25/18 and 09/23/18 each identified Resident #66 as receiving no PROM during this time. Review of his current care plan regarding management of his right hand and shoulder contractures, with a current goal date of 03/18/19, showed a goal for Resident #66 to tolerate PROM of his right shoulder and hand, and have no worsening of the contractures. Approaches listed included assisting the resident with a Functional Maintenance Program, and monitoring his Range of Motion (ROM) as needed, but at least quarterly. Review of an 06/21/18 Occupational Therapist's assessment of Resident #66's ROM identified goals of controlling his contracture protecting his skin. The restorative program summarized by the OT directed staff to place inflatable air splints on both of Resident #66's hands six to seven mornings per week, leaving the splints in place for up to four hours. Review of the 06/25/18 and 09/23/18 MDS assessments showed no PROM or use of splints for this resident during the assessment periods. Staff also did not document any instances of care refusals on either of these (or later) MDS assessments. On 01/16/19 at 9:30 AM, the Director of Nursing (DNS) was asked for help locating records of ROM and splinting care ordered for Resident #66 as part of the OT assessment. She was unable to locate documentation for the months of (MONTH) and (MONTH) (YEAR). When asked where this information was kept, she said due to problems with staffing, restorative care and services had been on hold for a couple months. She acknowledged that Resident #66 had not received PROM or splinting as stated in his care plan during the months of (MONTH) and (MONTH) (YEAR). She also said CNAs were to provide ROM care for dependent residents during these months, but acknowledged ROM directives had not been added to where they would document care, if provided. When informed of the absence of any observations of Resident #66 wearing inflatable splints since 01/04/19, Staff B said the resident refused to wear them. No documentation by staff of these refusals was found in assessments, progress notes or in a later OT consultations dated 11/10/18 and 12/11/18, both of which specified the resident was to wear inflatable splints on both hands for up to four hours per day. She did not locate or provide evidence of recent refusals of restorative exercises or use of the splints. Without evidence the facility had consistently provided pressure relief measures for the right hand and thumb (splinting and ROM care) he had been assessed to need prior to the development of this pressure ulcer in late (MONTH) (YEAR). There was also inadequate monitoring to identify the reopening of the ulcer before it was a Stage IV ulcer in (MONTH) 2019. The lack of pressure relief to this area contributed to the development of an avoidable pressure ulcer, which constituted harm for Resident #66. RESIDENT #38 The admission MDS, dated [DATE], for Resident #38 showed the resident admitted [DATE] due to multiple medical conditions, required the assistance of staff for bed mobility and transferring, and did not walk in the room. The MDS said the resident was at risk for pressure ulcers, and did not have a pressure ulcer. Resident #38's care plan, dated last revised 12/31/18, showed the resident had interventions to prevent pressure ulcers. TARs Review of Resident #38's (MONTH) (YEAR) TAR showed a 11/12/18 order for weekly skin checks. The order instructed to document Yes/No for skin issues, a yes meaning a skin issue was present. On 11/14/18 and 11/21/18 a Y for yes was marked. Review of the resident's (MONTH) (YEAR) TAR showed weekly skin assessments for 12/05/18, 12/12/18, 12/19/18 and 12/26/18 (all skin checks for the month) were marked no. An order on the TAR dated 12/31/18 instructed staff for wound care for a Stage II on coccyx every two days on evening shift. On 12/31/18, the order was marked with an H, and did not show this order for wound care was done that day. Review of Resident #38's (MONTH) 2019 TAR showed a Y for yes for skin issues during the weekly skin check on 01/02/19. SKIN ASSESSMENTS A Braden Scale for predicting pressure sore risk for Resident #38 on 11/14/12 showed the resident was high risk for pressure sores. A Braden Scale done 12/31/18 showed the resident's score as mild risk. Review of Resident #38's (MONTH) (YEAR) skin assessments showed on 11/14/18 (a day the TAR said yes to skin issues) there was no corresponding skin assessment to explain what the skin issue was. Progress notes of that day stated, Skin is intact and likewise did not explain what skin issue prompted a yes on the TAR. For the yes marked on the TAR for 11/21/18, progress notes again stated skin was intact, and no skin assessment was noted in the resident's record that day to assess what the skin issue was. Review of the resident's (MONTH) (YEAR) skin assessments showed on 12/05/18, when the (MONTH) (YEAR) TAR noted N for no skin issues, the skin assessment form of that day was marked yes to the presence of new or ongoing skin issues, without explanation or assessment of what the skin issue was. The body diagram was unmarked on this form, and no other mention of a skin issue was in resident's record that day. PRESSURE ULCER A 12/31/18 physician order [REDACTED]. The same day, an order was marked on the (MONTH) (YEAR) TAR for every two day wound care on evening shift for a Stage II coccyx (tailbone) wound. The 12/31/18 entry for this wound care was marked H (held/not done) without explanation in the resident's record. The pressure ulcer was not otherwise documented until 01/02/19, when TAR records show the first pressure ulcer wound care was done, and physician notes and skin assessments documented the ulcer. On 01/10/19 at 10:39 AM, the resident's skin was observed in the company of Staff J, a Registered Nurse (RN) in a unit shower room. Staff J was asked to describe what she observed on the resident's coccyx. Staff J said the coccyx had, Kind of a pressure injury. The resident was observed to have a vertical, white open area on the right of the coccyx. On 01/10/19 at 9:32 AM, Resident #38 was asked if the sore (referenced above) had developed since her admission to the facility and the resident said it had. On 01/10/19 at 11:22 AM, Staff V said Resident #38 was not currently followed by his wound consulting group. On 01/15/19 at 11:16 AM, Staff K, a Registered Nurse-Clinical Manager (RN-RCM) said nurses were expected to perform weekly skin checks for residents. When asked what was expected when a Y was marked on a TAR for a skin issue, Staff K stated staff should do a skin assessment. Staff K said that, unless the skin consultant was following the resident, nurses should take measurements of the skin condition. When asked what was expected when a nurse documented the presence of a new or ongoing skin issue on skin assessment form, Staff K said the nurse should measure the skin condition and document its description in either within the skin assessment, or the progress notes. When asked if alert charting was instituted when a new pressure sore was discovered, she said this was the case, and this would continue for three days. During the same interview, Staff K stated Resident #38's pressure sore had been discovered on 12/31/18, and acknowledged it was not assessed until 01/02/19. Staff K was asked if the 11/14/18 and 11/21/18 TAR skin checks that had been marked yes should have had corresponding skin assessments and she said they should have. Staff K acknowledged the 12/05/18 skin assessment marked yes to skin issues did not have a corresponding skin assessment. Staff K also acknowledged there was no assessment of the pressure ulcer to coincide with the physician's ulcer treatment order on 12/31/18. The resident had not been placed on alert charting once the new pressure ulcer developed. The H without explanation for the 12/31/18 wound care in the (MONTH) (YEAR) TAR was discussed with Staff K. Staff K said the wound care was done on 12/31/18. When asked how it could be determined the treatment was done without documentation, Staff K said she would expect it to be documented, and if it was not, it didn't happen. In summary, as shown above, the facility failed to document identified skin issues, and failed to perform a timely assessment and document completion of ordered wound care, when a pressure ulcer was identified on 12/31/18. RESIDENT #34 According to Resident #34's most recent quarterly MDS, dated [DATE], the resident readmitted [DATE] for multiple [DIAGNOSES REDACTED]. The MDS as also assessed the resident to be dependent on staff for all care needs. Review of the resident's (MONTH) (YEAR) TAR showed an order, started 10/15/18, Wound to Left Buttock .Cleanse .cover with Allevyn. The order had been stopped on 11/04/18. Review of Resident #34's Skin Assessment Note showed on 10/20/18, the resident did not have a wound to the left buttock. A 10/25/18 skin assessment showed the resident had a pressure sore to the left buttock but the documentation did not provide further details about the wound (size, shape or appearance of the skin). The 11/01/18 skin assessment also showed a pressure sore on the buttock but provided no further details about the wound. The 11/08/18 skin assessment, again, showed a pressure sore to the buttock but also did not provide any further details about the wound. Review of the resident's progress notes found one entry related to skin on 10/10/18 by the previous Resident Care Manager, This RCM called family to obtain a consent for UWH (United Wound Healing) to follow resident for consult and treatment. There was no other documentation that pertained to the pressure sore in the resident's progress notes. On 01/11/19 1:13 PM, Staff G, a Registered Nurse-Resident Care Manager (/RN-RCM) stated that there should be more documentation for a pressure sore, including measurements and the stage of the wound. Staff G reviewed the resident's record and was unable to find further documentation. Reference :WAC 3888-97-1060(3)(b) .

Based on interview and record review the facility failed to ensure one of five residents (Resident #1) reviewed for prevention of pressure ulcers developed a pressure ulcer. This failure placed Resident #1 in a position to acquire a pressure ulcer that was not adequately treated resulting in local and systemic infection with subsequent emergent hospitalization . Findings included: Resident #1 was admitted to the facility on [DATE] for rehabilitation following surgical repair of a fractured left leg that was the result of a ground level fall at home. According to the 01/20/18 admission Minimum Data Set (MDS), an assessment, Resident #1 was able to make his own decisions, required one person supervision for bed mobility and toileting, and had no skin issues. Comorbidities were listed only as [MEDICAL CONDITION], heart failure, and pneumonia. According to the facility's 01/13/18 admission Skin Assessment Resident #1 had blisters on the left anterior shin where, there was also a dressing over the surgical site and a splint to immobilize the repaired left leg fracture. The score listed on this assessment was 15-18 and was considered to represent a Mild risk of pressure ulcer development. The facility further assessed Resident #1 by completing a Braden skin assessment on 01/13/18 supporting, Resident #1 was not at risk for development of pressure ulcers. The facility reasoned Resident #1 had no impairment, his skin was usually dry, he occasionally walked, his mobility was only slightly limited, and he ate more than half of all meals including proteins. The facility documented on this assessment Resident #1 was only at risk for developing shear related skin issues. This was defined as, Potential Problem-Moves feebly or requires minimum assistance. During move, skin probably slides to some extent against sheets, chair .Maintains relatively good positioning chair or bed most of the time but occasionally slides down. The score on this assessment was 19 indicating Resident #1 was not at risk for developing pressure ulcer. Review of the 01/08/18 hospital notes, provided to the facility at the time of discharge from the hospital and admission to the facility revealed, Resident #1 suffered from intact but decreased sensation to the lower extremities. The decreased sensation is termed [MEDICAL CONDITION] and can cause weakness, numbness and pain. The danger to a person with [MEDICAL CONDITION] is that the areas with decreased sensation can become injured without the affected person's being aware of the injury. This significant [DIAGNOSES REDACTED]. The family said, in an interview on 04/10/18 at 4:55 p.m., (Resident #1) had the [MEDICAL CONDITION] for a very long time. The facility performed an additional Skin Assessment on 01/16/18 upon which staff documented there were no new skin issues but included a typed notation that staff identified a blister to the left heel not present on previous documentation. A hand written undated note on this document subsequent to the original entry included, Nurse (Staff C) assumed it (the heel blister) was the same treatment order for the LLE (left lower extremity blister). The intact blister measured 2.5 centimeters (cm) by 2 cm. Staff C documented on 04/05/18 .a late entry note for 01/16/18, (patient) was observed to have a blister on his left heel. Followed orders to apply [MEDICATION NAME]/gauze to blister on LLE (left lower extremity) . This was the Physician Order (PO) for the blisters on the left shin. There were no specific orders for the blister on the left heel because the primary care providers were not informed and were unable to assess the wound for accurate and appropriate treatment. Staff B, interviewed on 04/10/18 at 4:10 p.m., said the nurse (Staff C) who identified the heel blister, thought the blister was the same skin issue identified on the anterior shin at the time of admission. Staff B said the heel wound was treated, immediately. Review of (MONTH) (YEAR) Physician Orders (PO) and Medication and Treatment Records (MAR/TAR) revealed, staff were instructed to, Monitor for pressure areas on Left leg during each shift .Notify provider with changes. Wound care was documented as, .keep incisions clean and dry during EACH shift . Staff documented the [MEDICATION NAME] treatment to the left heel and shin wounds despite having no specific physician orders for the treatment to the left heel. Staff C documented on the 01/23/18 weekly Skin Assessment Note, Blister (left) heel noted draining (large) Serous drainage after Ortho (orthopedic) appt (appointment), cleaned and (abdominal) dressing applied. There were no measurements on this assessment record and no other wound characteristics identified. A physician's order for referral to United Wound consultant was made at this time but was never implemented as Resident #1 was discharged to a local hospital before the wound team arrived to consult. Further 01/23/18 physician orders documented on the direct-care staff's Pocket Guide, instructed staff to apply black heel protector boot on (left lower extremity) prevent pressure on heel when in bed . The 01/23/18 Event & Occurrence Conclusion Sheet, used to summarize the facility's investigation into the cause of Resident #1's heel blister included, RCM (Residential Care Manager) reviewed (Hospital) discharge summary and orders received at the time of admission, and observed the summary and order did not specify the exact location of the blister on the left leg .(Staff C) indicated she believed the blister on the heel was not new as there was an order to treat blisters on left leg from time of admission and there were no other blisters noted on the left leg except on the heel . The facility's actual summary was, It is reasonable to believe the blister on the left heel was unavoidable, due to (Resident #1's) history of [MEDICAL CONDITION], Raynaud's and increased swelling and superficial blisters in the left lower extremity. All of those comorbidities resulted in decreased sensation, decreased perfusion, compromised skin integrity .and impaired mobility from left knee (surgery). Of note Raynaud's disease commonly affects the circulation in a person's fingers and toes and has the potential to cause tissue damage. This [DIAGNOSES REDACTED].#1 to wear, see progress note 01/18/18. The facility failed to recognize that all of the comorbidities placed Resident #1 at a much higher risk for development of pressure ulcers. Thus placing the onus on the facility to develop interventions to prevent the pressure ulcer that eventually developed. By 01/25/18 staff documented on the TAR the wound was so severe it was listed as a deep tissue injury (DTI). This means that more than one layer of skin was damaged. The only descriptive note about the wound came from the attending physician who documented on 01/29/18, Breakdown of DTI resulting in wound (with) ulceration and ulcer. Estimated 10 cm by 8 cm. Mild redness extending up from ulceration on both sides of ankle bone. The mild redness on the medial and lateral ankle could represent the infectious process. On 01/29/18 staff documented Resident #1 experienced a precipitous and debilitating deterioration that included an elevated temperature, a fall, and the left leg became warm to touch. Resident #1 was sent to a local hospital where he was diagnosed with [REDACTED]. The facility failed to accurately and comprehensively assess Resident #1 for risk of pressure ulcer development. Very specifically they did not consider any of the resident's [DIAGNOSES REDACTED].#1's risk of developing pressure ulcers. The facility did not document or transcribe the originally assessed wound to the MAR/TAR accurately so staff would known when a new wound developed or was treated. The facility did not notify the primary care provider of the left heel wound so an assessment could be performed. The facility did not clarify physician orders for wound care and implemented physician orders written for a shin wound treatment to the left heel wound. Reference: WAC 388-97-1060(3)(b)

Based on interview and record review the facility failed to ensure 1 of 3 residents (#1) reviewed for hospital discharge received necessary care and services to manage agitation behaviors related to dementia and pain by failing to clearly track, communicate and adequately respond to agitation, delusions and pain. Facility staff precipitated an assault when Staff D encroached on the resident's personal space while the resident was clearly agitated. Resident #1 was removed from the facility by 911 after assaulting Staff D. These facility failures resulted in preventable distress and harm related to undertreated pain, unmanaged psychiatric symptoms and resulted in extended unnecessary hospital stay when the facility refused to accept Resident #1 back to his home after the 12/28/16 discharge. Findings include: Record review found Resident #1 admitted to the facility 10/08/15 with medically disabling conditions and dementia with behavioral disturbance. The resident had a Foley (indwelling urinary catheter) due to a chronic medical condition. Resident #1's Minimum Data Set assessment, dated 11/20/16, identified Resident #1 had delusions and behaviors verbally directed at others and rejection of care 1-3 days out of the 7 day look back period. Behaviors were not identified as putting other residents at risk or interfering with Resident #1's care or socialization. Facility records documented on 02/10/16 Resident #1 was discharged to a Geriatric Psychiatry inpatient facility after threatening another resident. Upon return to the facility 03/14/16, Resident #1 received the mood stabilizing medication [MEDICATION NAME] 375 milligrams (mg) twice daily. In addition, other anti-depressant, anti-psychotic and anti-anxiety medications were prescribed. Resident #1 was also prescribed Tylenol 1000 mg 3 times every day and the narcotic [MEDICATION NAME] 2.5 to 5 mg every 4 hours as needed for pain. A psychiatry consultation note (PCN) dated 10/03/16 identified Resident #1's medications were adjusted in July 2016. The PCN identified Resident #1 had active delusions about murders and a gunman in the building. There were also some behaviors of tearfulness and anxiety in the previous three weeks. Throughout Resident #1's record, staff documented persistent tearfulness, yelling, swearing, agitation and confusion as to why he was at the facility. Resident #1's medication regimen as of 10/03/16 included [MEDICATION NAME] 375 mg twice daily, the anti-depressant [MEDICATION NAME] 100 mg daily, scheduled pain medication [MEDICATION NAME] 5 mg twice daily and Tylenol 1000 mg three times daily. In addition to these scheduled medications, Resident #1 was prescribed [MEDICATION NAME] 2.5 mg every 4 hours as needed for pain and the anti-anxiety medication [MEDICATION NAME] 0.5 mg every 4 hours as needed for anxiety/agitation. Medical records documented on 10/09/16 Resident #1 was admitted to the hospital for confusion, weakness and urinary tract infection. Prior to hospitalization , medication records showed Resident #1 received 1-3 doses of [MEDICATION NAME] for pain 5 of 8 days and [MEDICATION NAME] 0.5 mg 1 to 5 doses per day for agitation. These as needed medications were given in addition to routine [MEDICATION NAME] and Tylenol. On discharge back to the facility 10/21/16, the hospital discharge summary did not indicate that [MEDICATION NAME], or [MEDICATION NAME] were discontinued or changed. These medications were not listed at all. Discharge orders directed that Resident #1 was to be given the anti-psychotic medication [MEDICATION NAME] 50 mg at night, [MEDICATION NAME] 25 mg every 6 hours as needed for [MEDICAL CONDITION] (thoughts and emotions that have lost contact with reality) and Tylenol 325 mg 1-2 tablets as needed every 6 hours for pain. This medication regimen was markedly different than the pre-hospitalization medication regimen, less than two weeks earlier. Behavioral Detail Reports completed by nursing assistants documented after return from the hospital on [DATE] Resident #1 exhibited agitation, screaming, care refusal and disruptive behaviors almost daily. Medication records showed from 10/21 to 10/31 Resident #1 was given as needed [MEDICATION NAME] 25 mg 1-2 times on 7 of 10 days and Tylenol 325 mg 1-2 tabs on only 2 of 10 days. On 10/25/16 nursing communication to doctors documented Resident #1 was agitated and said yes when asked if he was in pain. The nurse documented she thought Resident #1 was in pain but unable to express this due to [MEDICAL CONDITION] (loss of ability to understand or express speech). The nurse documented as needed [MEDICATION NAME] had little effect and asked for [MEDICATION NAME] to be reinstated as needed. Records showed on 10/27/16 [MEDICATION NAME] 5 mg three times daily as needed was prescribed and the [MEDICATION NAME] dose was changed to 25 mg three times per day (total 75 mg/day). On 10/31/16 scheduled [MEDICATION NAME] 2.5 mg three time daily was added to the regimen. While this response to resident condition was appropriate, Resident #1 had no narcotic pain medication for seven days (10/21 to 10/28/16). Records revealed after scheduled [MEDICATION NAME] was reinstated, Resident #1 continued to need additional doses of as needed [MEDICATION NAME] 1 to 3 times every day except for one day (11/12/16). Records revealed Resident #1 continued to have almost daily agitation and care refusal even after these medication changes. A communication note from nursing on 11/19/16 documented Resident is being extremely agitated, verbally abuses residents, aids and nurses. He is not easily redirected as he used to be. Medical records showed that Resident #1 was hospitalized from 11/20 to 11/23/16 for a medical condition. Hospital discharge directions were to give [MEDICATION NAME] 50 mg at bedtime (not 25 mg 3 times daily). No [MEDICATION NAME] was ordered. Discharge records again did not reference or identify any changes to Resident #1's medication regimen from prior to admission. Record review revealed that for the second time in a month, on readmission to the facility, staff did not identify there was no order for [MEDICATION NAME]. [MEDICATION NAME] was re-ordered on [DATE]. Once again, Resident #1 did not receive narcotic pain medication for seven days (11/23 to 11/30/16) until [MEDICATION NAME] was reinstated. A medical provider (MP) note dated 12/02/16 documented recent readmission, discharged on ce again without [MEDICATION NAME]. Medical Notes documented after gero-psych admission He is back at SNF (skilled nursing facility) on [MEDICATION NAME], prn (as needed) [MEDICATION NAME]. While this note recognized a pattern of discharging Resident #1 without pain medication, it inaccurately identified the resident continued to receive previously ordered [MEDICATION NAME] and [MEDICATION NAME]. The MP failed to identify this [MEDICAL CONDITION] medication regimen was completely changed. A psychoactive drug assessment (PDA) dated 12/14/16 documented Resident #1 was in distress related to daily behaviors of increased agitation, swearing at staff, yelling, resistant to care, increased confusion, looked angry and upset, thought he was in jail, and fearful. Resident appears to be in distress (emotional) with episodes of delusions. Recommendations were to pursue a hospice referral. There was no record staff reached out to the consulting psychiatrist regarding Resident #1's behavior or change in [MEDICAL CONDITION] medication regimen. Nowhere in the resident record was there any mention or discussion of why or who discontinued the medication regimen established at the time of the geriatric psychiatry hospital stay. There was no notation in any medical or nursing record that staff evaluated or made specific decisions regarding Resident #1's [MEDICAL CONDITION] medication regimen in light of the resident's behavior. Records documented on 12/21/16 at 3:40 p.m. staff noted a 3.5 x 0.7 centimeter skin tear to the resident's left cheek. Facility investigation concluded the resident bent over in his wheelchair and struck his head on the footboard of his bed. Nursing notes documented Resident #1 was being monitored after an unobserved/suspected fall. This was not accurate, as Resident #1 did not fall (according to the facility investigation.) Medical records revealed on 01/21/17 Resident #1's doctor decreased the daily 50 mg [MEDICATION NAME] to 37.5 mg at bedtime. We are reducing his dose of [MEDICATION NAME] from 50 mg daily to 37.5 mg daily at Pharmacy request. The only pharmacy note in the record was from 12/07/16 focused on the medication pantoprazole (decreases stomach acid), not on pain or psychoactive medications. There was no record of pharmacy recommendation or consultation regarding changes to Resident #1's psychiatric medications. Facility records revealed after the decrease in [MEDICATION NAME] dose to 37.5 mg daily Resident #1's frequent bouts of agitation, tearfulness and yelling became daily behaviors. Records revealed on 01/27/17 Resident #1's [MEDICATION NAME] 50 mg was reinstated. Facility records documented on 12/28/16 at 8:00 a.m., Resident #1 was in an agitated state sitting in the hallway in his wheelchair outside his room. Resident #1 reportedly hit a nurse and then held both the nurse's hands and attempted to forcefully twist her arms. Staff D attempted to assist with emptying the resident's urinary drainage bag. Resident #1 grabbed Staff D by the wrist and continued to yell while twisting her wrist. Resident #1 let go when asked. Facility records documented Staff D and E then assisted Resident #1 back to his room. Resident #1 again grabbed Staff D by the wrist. Staff D bent down to adjust the resident's urinary drainage bag when Resident #1 grabbed the back of Staff D's hair. He twisted Staff D's hair and punched Staff D in the chest with his right hand, attempted to punch Staff D in the face, then grabbed Staff D's shirt and punched her in the stomach. When Resident #1 let go of Staff D, Staff D and E left the room and called 911. Resident #1 was transported to the hospital by emergency personnel. Staff D's actions were in direct violation of facility workplace violence curriculum. Facility curriculum identifies disruptive behavior as rude language, verbal threats, irrational thinking, and difficulty calming down. Disruptive behavior can escalate to violence (yelling, screaming, physical striking out, use of a weapon). Facility training states when responding to disruptive behavior NEVER touch the person. If a person becomes violent, get self and others to safety. Instead of backing away, Staff D approached Resident #1 twice to adjust his catheter bag after the resident had already become violent. There was no record that Staff D received training on workplace violence. On 12/28/16 the facility issued a discharge notice to Resident #1 referencing continued ongoing uncontrolled non-redirectable aggression and anger causing physical harm to staff and placing all other residents in danger due to extreme violence. On 01/31/17, Resident #1 was discharged to a community setting due to the facility's refusal to allow him to return to his home. In an interview on 01/27/17 at 10:43 a.m. Staff F stated Resident #1 was impulsive, confused and easily frustrated at baseline. According to Staff F, Resident #1's agitation gradually increased in August and September 2016. Staff F said at the time of the October 2016 hospitalization the hospital discontinued the [MEDICATION NAME] and all other medications. Staff F said she reviewed the change in psychiatric medications with the MP when Resident #1 returned to the facility on [DATE]. Staff F said she thought Social Services may have reached out to the consulting psychiatrist. According to Staff F, she was transitioning out of a Resident Care Manager role at the time and did not know all details of the resident's behavior. Staff F said she did know Resident #1 was more difficult to re-direct and would start yelling and swearing more. Staff F said MPs would be notified of these changes in behavior by documentation in the communication book or in progress notes. In an interview on 01/25/17 at 12:00 p.m. Staff E stated [MEDICAL CONDITION] medication dose reductions are decided by nursing (Director and Resident Care Managers) and Pharmacy, considering the reason for the medication, behavior, and how long the resident is stable on the medication dose. Staff E stated Resident #1 was having bad days and did not know why Resident #1's [MEDICAL CONDITION] medication doses were changed or decreased. In an interview on 01/25/17 at 1:30 p.m. Staff C (Director of Nursing) identified there was no record of pharmacy consultation recommendations related to reducing the dose of Resident #1's [MEDICAL CONDITION] medication(s). Staff C stated facility policy and resident care plans are to leave an agitated resident and re-approach if safe. Staff C said Resident #1 was not deemed safe on 12/28/16 because he was dragging his Foley catheter and was covered in fecal matter. In an interview on 01/25/17 at 2:30 p.m. Staff D said she knew Resident #1 smacked another nurse on the leg before Resident #1 struck out and held her wrists. Staff D said she knew Resident #1 was agitated and not in good place, I was just trying to keep him safe. In an interview on 01/25/17 at 1:35 p.m. Staff J (Medical Provider) stated it is presumed any medication adjustment done at the hospital is correct. Staff J said he ordered the [MEDICATION NAME] 50 mg decreased to 37.5 mg daily on 12/21/16 due to the resident's fall. However, as noted above, the resident did not fall but leaned forward and bumped his cheek on the end of the bed. The doctor's note said the [MEDICATION NAME] was decreased on pharmacy recommendation, which is not anywhere in the record. In an interview on 01/27/17 at 1:15 p.m. Staff J and K (both medical providers for Resident #1) discussed Resident #1's case. Staff J and K said medications are reviewed on return to the facility from the hospital. Staff K said Resident #1 may have been on a drug holiday in the hospital. Staff J said he did not know if anyone talked with the consulting psychiatrist regarding Resident #1's behaviors or medication. Both Staff J and K said they had not ever seen Behavioral Detail Reports by caregivers showing consistent frequent agitation and care refusal. Both Staff J and K said they had no knowledge of the 12/14/16 psychoactive drug assessment documenting daily agitation, swearing, yelling, resistance to care, increased confusion, looks angry and upset, thinks he is in jail, fearful and appears to be in emotional distress with episodes of delusions. Staff K said in the future she would love to see the PDA notes and said if the information was known she would have changed action based on that. Staff K said she often saw Resident #1 in the afternoons and did not see agitation behavior. Staff J said the 12/02/16 medical note referencing the resident's medications as [MEDICATION NAME] and [MEDICATION NAME] were boiler plate language and resulted when MPs cut-copy-paste in the medical record. Failure to assess and evaluate medication changes for a resident with significant agitation behaviors and the facility's lack of communication and connection regarding Resident #1's pattern of behavior in relation to medication changes, both pain and [MEDICAL CONDITION], resulted in missed opportunities to address escalating behavior and ensure Resident #1 received appropriate management and care for distressing agitation and delusions. Failure to ensure Staff D received and followed training on how to work with agitated, violent residents resulted in assault and the resident's loss of his home.

Based on observation, interview and record review the facility failed to ensure one (#1) of four sample residents reviewed for fall with injury from a census of 95 residents received adequate supervision and/or assistive devices to prevent accidents. Lack of an appropriate assistive device and supervision resulted in Resident #1 falling from her wheelchair sustaining head and significant neck injury. Findings include: RESIDENT #1: Record review revealed Resident #1 admitted to the facility in 10/09 with medically disabling conditions that affected mobility, strength and coordination. Resident record review found during 2015, Resident #1 declined in condition, becoming less able to communicate and more dependent on others for care. Facility records show Resident #1 admitted to Hospice care on 01/21/16. According to the Minimum Data Set (MDS) significant change assessment dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicative of severe cognitive impairment. Prior MDS assessments identified no or moderate cognitive impairment (BIMS 13 and 11). The 02/01/16 MDS identified Resident #1 required extensive assistance of 2 persons for bed mobility, transfer, dressing and toileting, was incontinent of bowel and bladder and was totally dependent on one person for eating. Facility records documented on 01/26/16 a Hospice occupational therapist (OT) recommended trial of a Tilt-in-Space (TIS) wheelchair. Medical supply records documented a TIS wheelchair was delivered to the facility on [DATE]. Facility records revealed on 02/11/16 the Hospice OT noted the new TIS wheelchair was in the hall, outside Resident #1's room. Nursing staff was unclear why the resident was not using the TIS chair. Facility records documented the nurse did not think it was a good day to trial the TIS chair as Resident #1 was not in a good mood. The OT planned to visit the following week with the resident's family member and explore why the TIS wheelchair was not being used. Facility records indicated Staff concerned when pt (patient) fatigued, she leans far forward in the W/C (wheelchair) and is high fall risk. Resident #1's care plan (CP) was updated 02/15/16 to identify risk for entrapment secondary to use of Tilt-in-Space wheelchair. Interventions included: Call light within reach while in chair; Resident uses call light and is able to call out if needs assistance; Continue to monitor the risk of entrapment as needed and at quarterly care plan. There was nothing on the CP about positioning the TIS wheelchair for safety. There was no indication Resident #1's ability to use the call light was re-assessed in light of the resident's change of condition and cognitive decline. Progress notes dated 02/16/16 documented Resident #1's family member (FM) expressed concern about the new TIS wheelchair due to the footrests not fitting correctly. Resident #1 was either positioning herself with her legs bunched up or letting her feet dangle unsupported. Staff B (Resident Care Manager) documented she spoke with the Hospice RN case manager and requested an OT come to the facility to fit the resident for new footrests as the current footrests could not be adjusted. This was the first notation in the record that Resident #1 was using the TIS wheelchair. Record review found no evaluation by qualified persons to ensure the TIS wheelchair fit or was safe for Resident #1 to use. When a safety concern was identified by the FM during the afternoon on 02/16/16, there was no immediate evaluation or action taken to ensure safe positioning of Resident #1 in the TIS wheelchair. A facility incident report (IR) documented on 02/16/16 at 6:20 p.m. Resident #1 was observed in the dining room sitting upright, receiving assistance eating dinner. The IR noted at 6:30-6:45 p.m. Resident #1 attended a Pampered Hands activity. At 6:40 to 6:45 p.m. Resident #1 was brought from the Pampered Hands activity to a common area nurse's station. Resident #1 insisted on returning to her room. Staff D (Activities Director) told a volunteer to take Resident #1 to her room. No adjustments were made to the wheelchair position. Resident #1 was taken to her room by a volunteer and left unattended in an upright position in a TIS wheelchair that was not fitted for her and had been identified as a safety hazard earlier in the day. The facility IR documented at 6:50 p.m. a loud noise was heard from Resident #1's room and the resident was calling out. Staff found Resident #1 lying on her right side with a moderate amount of blood under her face. The resident was noted to have a 1.5 centimeter (cm) laceration on the right side of her forehead and a bruise developing under her right eye. Resident #1 said my head hurts. The IR noted Resident #1's call light was not on and the resident did not call out for help before the fall. The facility IR documented Resident #1 was transported to the hospital by 911. Upon evaluation at the hospital, Resident #1 was found to have a cervical (neck) fracture. The facility IR identified contributing factors to Resident #1's injury: TIS wheelchair positioning not adjusted to safer reclining position after returning to her room; footrests not utilized; volunteer did not provide safe hand-off to nursing staff; resident poor safety awareness; and medical condition (involuntary movements, muscle paralysis, muscle weakness, coordination problems). On interview 02/19/16 at 1:50 p.m. Staff B stated no one in the facility knew Resident #1's TIS wheelchair was delivered and at the facility until 02/11/16 (six days later). Staff B confirmed the facts presented in facility documentation and the IR (as noted above). On interview 03/03/16 at 11:20, Resident #1's FM stated when she saw Resident #1 in the TIS wheelchair on 02/16/16 during the day she could see the wheelchair did not fit the resident. The FM said the footrests were too high causing the resident's knees to be higher than her waist which was uncomfortable. The FM stated she saw Resident #1's feet dangling in mid air, her feet not touching the floor. According to the FM, anyone unable to touch the floor when sitting in an upright position would fall out of a chair if they leaned forward. Resident #1's FM stated when she saw the problem with the chair she alerted staff. I assumed she would be reclined. The FM stated she didn't even know the TIS wheelchair could be adjusted to an upright position. On interview 03/03/16 at 12:00 p.m., the Hospice OT stated she was not able to assess Resident #1 for TIS wheelchair fit before she fell . The OT stated the foot rest position may not have been a problem if the TIS wheelchair had been tilted back. According to the OT, the TIS wheelchair was meant to prevent what happened, Resident #1 falling out of her wheelchair. Facility failure to properly evaluate equipment specifically for the resident's use, failure to immediately respond when it was evident the equipment was unsafe, failure to position the resident safely and and failure to supervise when the resident was sitting in an upright position resulted in a preventable accident with significant injury.