Every finding on record at Marysville Care Center

Based on observation, interview, and record review, the facility failed to store food in a manner that prevented contamination and foodborne illness for 1 of 1 kitchen reviewed. The facility failed to maintain required twice daily temperature logs for the refrigerator and freezer; failed to properly date and store bread products, and failed to dispose of expired food items, including moldy pita bread and expired sliced ham. This failure placed residents at risk for foodborne illness and compromised food safety.Findings included.Review of the facility policy titled, Food Safety, revised date 05/26/2026, documented temperature was recorded at least twice daily on the refrigerator and freezer temperature log; food was labeled with the date received if not already indicated on the item, and food not safe for consumption would be removed from storage. In an interview and record review on 08/12/2026 at 8:43 AM, the August temperature log binder revealed no evening (PM) temperatures were recorded from 08/01/2026 through 08/04/2026 for refrigerator and freezer. Staff W, Cook, stated the staff were required to check and record refrigerator and freezer temperatures twice daily. Two packages of pita bread observed stored in the kitchen without receiving or expiration dates. One bag was observed to have visible mold growth on the bread. Staff W confirmed the pita bread packages had no dates, and the mold package should be discarded immediately. In an observation and interview on 08/12/2026 at 9:05 AM, two containers of sliced ham was observed in the kitchen refrigerator labeled with a use by date of 08/11/2026. Staff W confirmed the ham was expired and needed to be thrown away.In an interview on 08/17/2026 at 10:24 AM, Staff X, Food Service Director/Certified Dietary Manager, stated that all food items were required to have dates marked on them. Staff X stated the pita bread should be kept in the refrigerator to prevent spoilage. Refer to WAC 388-97-1100(3)

Based on observation, interview and record review, the facility failed to ensure a safe environment on 3 of 5 resident halls. Failure to ensure resident hand rails were free from sharp elements placed residents at risk for injury. Findings included . Review of the facility policy titled, Resident Belongings and Homelike Environment, (revised date 04/01/2026), stated the resident has a right to a safe, clean, comfortable and homelike environment. In a random observation on 08/13/2026 at 4:15 PM, Resident 49 was self propelling in their wheelchair in the 100 hallway across from room [ROOM NUMBER]. Resident 49's left hand was observed moving along the wooden hand rail attached to the wall. Resident 49 stated ooh, ouch, ouch, and was observed to pick their hand up, look at it with a furrowed brow, and then touched their middle finger to their thumb several times. There was an observed raised silver colored nail head on the top surface of the wooden hand railing where Resident 49's hand had just been that was felt to be sharp to the touch. Resident 49 continued to move down the hall using their feet to self propel and their left hand moving along the hand rail. Several staff were observed in the area passing through the hall and one unknown staff was observed to walk over to the hand rail after Resident 49 passed it and moved their hand over the top of it, was observed to lean in over Resident 49 and observed their hand, before walking around the corner out of sight. In an observation on 08/14/2026 at 8:20 AM, the same protruding nail head was observed on the hand rail across from room [ROOM NUMBER]. Further observations of the hand railings identified additional exposed nail heads: one on the same section of railing several feet down the hall, one noted across from the facility business office in the center hall, one diagonally across from the Director of Nursing office, one near room [ROOM NUMBER], and one across from room [ROOM NUMBER] in the 200 hall, which were all observed on the top or side surfaces of the hand railing where residents could come in contact. In an interview and tour with Staff A, Administrator and Staff G, Maintenance Assistant, on 08/14/2026 at 9:39 AM, Staff A stated there had been no maintenance reports or notifications regarding any safety issue with the hand rails. Staff G stated the Maintenance Director was not available and was not able to speak to how the building maintenance rounds were done and safety issues identified. Staff G confirmed they had not been notified of a resident incident in the hallway yesterday or aware of any issue related to the hand rails and needed to be fixed. Refer to WAC 388-97-0880

Based on observation, interview and record review the facility failed to develop and implement comprehensive care plans for 4 of 19 residents (Resident 14, 75, 77 and 89) reviewed for comprehensive care planning. This failure placed residents at risk of not receiving needed care, a decline in their condition, and diminished quality of life.Findings included. Review of the facility policy titled, Comprehensive Care Plans and Revisions, reviewed 08/29/2025 documented the facility would ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure the comprehensive care plan was reviewed and revised.comprehensive care plans must be developed within seven days after completion of the comprehensive assessment. According to the facility policy titled Comprehensive Care Plan and Revisions with a review date of 08/29/2025 documented the facility should monitor the resident and identify changes in the resident's condition that may warrant an update to the person-centered plan of care. When these changes occur, the facility should review and update the care plan to reflect the changes to care delivery and can include additional interventions on existing problems, updating goal or problem statements and adding a short-term problem, goal and interventions to address a time-limited condition. According to the facility policy titled Cultural Awareness and Competency with a review date of 09/26/2025 documented the facility will identify areas of a resident's life that may require specific interventions or special care to take place while in the facility to ensure person-centered care, example: racial and ethnic diversity and religious preferences. The facility should use the Facility Assessment to identify populations having unique characteristics such as language, religious or cultural practices, values and preferences. Resident-specific approaches should be developed and included in the resident's care plan. <RESIDENT 75> Resident 75 was admitted to the facility on [DATE] with diagnoses that include stroke (brain bleed) diabetes, and dysphagia (difficulty swallowing). The admission Minimum Data Set (MDS – an assessment tool) dated 05/18/2026 documented the resident was dependent for bed mobility and transfers, and had difficulty, pain and discomfort from chewing. Review of Resident 75's physician orders documented the resident had a diabetic diet ordered with extra gravy and took an antidepressant for depression and to increase their appetite. Review of Resident 75's care plan dated 05/19/2026 documented the resident had an activity of daily living (ADLs) deficit related to activity intolerance. Resident 75 required staff to set them up for meals. The resident was to be up in wheelchair for all meals and could go to dining room if they chose. In an interview on 08/12/2026 at 1:41 PM, Resident 75 stated they did not get up in the wheelchair for lunch. In an observation on 08/14/2026 at 7:50 AM, Resident 75 was observed lying in bed with head of the bed slightly elevated, their breakfast tray was positioned on the table in front of the resident. In an observation on 08/14/2026 at 1:06 PM, Resident 75 was observed lying in bed with the head of bed slightly elevated, their lunch tray was positioned on the table in front of the resident. In an interview on 08/17/2026 at 9:11 AM, Resident 75 stated they were not assisted out of bed for breakfast earlier and was hoping to get up later. In an interview on 08/17/2026 at 9:41 AM, Staff Q, Nursing Assistant Certified (NAC) stated they relied on the care plan and Kardex (abbreviated version of the care plan for ADLs) to guide what level of care each resident required. Staff Q stated Resident 75 required to be set up for meals and only had to get up in their wheelchair if they wanted to. Staff Q was not aware Resident 75's care plan stated they should be up in wheelchair for all meals. In an interview on 08/17/2026 at 11:11 AM, Staff I, Registered Nurse (RN) stated it was usually the responsibility of the nurse managers to maintain and update the care plans for residents. Staff I stated Resident 75 was not eating very much, and staff had to encourage them. Staff I stated they were supposed to be up in their wheelchair for meals but often stayed in bed. In an interview on 08/17/2026 at 2:15 PM, Staff D, License Practical Nurse (LPN)/ Unit Care Coordinator (UCC) stated any nurse should be able to update a care plan; however, they were in them a lot and did the updates when needed. Staff D stated if Resident 75's care plan stated they should be up for meals, then the staff should be getting them up for meals. <RESIDENT 89> Resident 89 admitted to the facility on [DATE] with diagnoses that included visual loss, cognitive communication deficit and muscle weakness. The admission MDS dated [DATE] documented for resident preferences as very important to have reading materials at hand, keep up with the news, get fresh air often, and attend religious services. They were dependent on staff for transfers, mobility, getting dressed and toileting. Review of Resident 89's care plan, print date 08/12/2026 showed no focus, goals, or interventions related to the residents' preferences for activities. In an interview on 08/12/2026 at 10:58 AM, Resident 89 was sitting in their room and stated they were bored and had nothing to do all day long. Resident 89 stated if they were back in their apartment they would be reading, sewing, or knitting. In observations on 08/12/2026 at 1:11 PM, 2:11 PM, and 3:22 PM Resident 89 were observed parked in the hallway in their wheelchair with no activity. In observations on 08/13/2026 at 9:30 AM and 10:51 AM, Resident 89 was observed sitting in the wheelchair in their room, the TV was on a game show channel with sound barely audible. The resident was not watching the program. In an observation on 08/14/2026 at 9:48 AM, Resident 89 was observed sitting in the hallway in their wheelchair, they stated they were bored and would rather be reading a book with a nice cup of coffee. The resident remained in the hallway with no activities. In an interview on 08/14/2026 at 12:22 PM, Staff R, Activity Director stated when a new resident admitted to the facility, they had an assessment they completed, as well as they liked to bring the current month activity calendar to the resident and circled activities the resident may be interested in. Staff R stated they tried to complete those as quickly as possible, so they could update the care plans so the NACs knew what the residents may want to participate in. Staff R stated they had not completed Resident 89's care plan as of today, which was 16 days after admission. In an interview and observation on 08/17/2026 at 1:15 PM, Resident 89 was sitting in the hallway next to the nurses' station with no activity in front of them. At 2:55 PM the resident was observed sitting in hallway next to nurses' station, they were asked how they were doing, they responded they were bored. In an interview on 08/18/2026 at 9:31 AM, Staff B, Director of Nursing Services (DNS) was not aware staff had not initiated the comprehensive care plan for Resident 89's activities and were not implementing the care plan for Resident 75 for meals. <RESIDENT 77> Resident 77 was admitted to the facility on [DATE] with diagnoses to include chronic urinary tract infection (UTI), dysuria (pain, burning or discomfort were urination), macular degeneration (eye disease that causes blurriness or blank spot in your central vision), and cataract (clouding of the clear natural lens inside the eye). According to the admission MDS, dated [DATE] the resident had intact cognition, vision was adequate with eyeglasses. <VISION> In an interview on 08/12/2026 at 12:01 PM, Resident 77 stated that they had issues with their vision and they were supposed to have eye surgery but because they used a Hoyer lift (a mechanical device used by caregivers to transfer resident from one surface to the other) for transfers they were not able to do the surgery at this time. Review of Resident 77's eye exam summary dated 07/21/2026 documented early dry stage to bilateral eyes due to age-related to macular degeneration and bilateral age-related cataract with pending cataract surgery. The resident was started on two different eye drops. Review of Resident 77's care plan with a print date of 08/13/2026 did not have any documentation regarding the resident's vision. In an interview and observation on 08/18/2026 at 9:05 AM, Resident 77 stated that their eyesight was getting worse and getting blurry even with eyeglasses. The resident was unable to read regular font letters and could only read bold and bigger fonts. <CHRONIC UTI> In an interview on 08/12/2026 at 12:44 PM Resident 77 stated they had constant UTI's and it was painful when they urinated. Review of Resident 77's orders documented that the resident was taking an anti-infective medication and a hormone replacement medication for bladder health. These orders were dated 05/29/2026. There was also an order for a urology consultation due to persistent UTI symptoms dated 08/12/2026. Review of Resident 77's care plan with a print date of 08/13/2026 documented the resident's urinary incontinence, there was no documentation regarding the resident's chronic UTI and any interventions related to this. In an interview on 08/17/2026 at 1:32 PM, Staff K, NAC, stated they referred to the Kardex for information on how to care for their residents. Staff K was not aware that the resident had vision or chronic UTI issues. In an interview on 08/18/2026 at 9:25 AM, Staff J, RN/UCC stated during the admission process they developed a baseline care plan where they covered basic information on the resident's needs or care such as pain, mobility and other things. Then they added more information to the care plan as they got to know the resident. Staff J stated they were aware of the resident's vision issues and chronic UTI's and should have been included in the resident's care plan. <RESIDENT 14> Resident 14 was admitted on [DATE]. According to the admission MDS dated [DATE] the resident spoke Arabic, rarely and never understood and had severely impaired cognition. Review of the Care Area Assessment (CAA – a process that got triggered by a specific MDS response and provided the framework in building a person-centered care plan) under communication documented the resident spoke Arabic with little English. <LANGUAGE> In an interview on 08/13/2026 at 11:22 AM, using an interpreter via the language line, Resident 14 stated the staff did not understand them, and they didn't understand the staff when they tried to talk to them. The resident stated they only understood little English, just simple words. They added they communicated by pointing at things or using gestures. In an observation on 08/13/2026 at 11:30 AM Resident 14's room did not have anything that indicated their culture, there were no reading materials in Arabic and there were no communication boards or binders that the resident or staff could utilize to communicate. Review of the facility assessment with a review date of 07/27/2026 did not list Arabic under language, [NAME]/Middle Eastern was not in the list of ethnicities they currently served, and halal (diet type) was not listed in their special nutrition consideration. Review of Resident 14's care plan with a print date of 08/13/2026 documented under focus the resident's need for an interpreter however, the only thing that was under the intervention was Resident's preferred language was (blank) . The care plan did not provide the interpreter information for staff to use. There were no other interventions on different ways to communicate or understand the resident. In an interview on 08/13/2026 at 1:52 PM, Staff M, Restorative Aid stated they communicated with the resident through gestures and action and pointing at things. They added that at times the resident would answer yes and seemed to understand appropriately. In an interview on 08/17/2026 at 9:32 AM, Staff N, NAC stated they looked at the Kardex for information on how to care for a resident. Staff N stated they used gestures and pointing when they provided care for Resident 14. Staff N added they have not used the interpreter line to communicate with the resident. In a joint interview with the MDS nurses on 08/17/2026 at 10:55 AM, Staff O, RN and Staff P, RN, Staff P stated they did not use the interpreter line when they assessed Resident 14 because they (Staff P) spoke basic Arabic and was able to communicate with the resident. Staff O stated that they updated the care plan if the MDS triggered a CAA. Staff O reviewed the CAA for Resident 14 and it triggered communication, but when both the staff looked at the care plan, they could not find communication in the care plan. In a joint interview on 08/17/2026 at 2:00 PM Staff J, RN UCC and Staff B, DNS, Staff J stated they used the interpreter line to communicate with Resident 14, and the son came in the afternoon to visit and interpreted for the resident. Staff J stated they didn't have a communication board or binder that contained basic Arabic words the resident and staff could use to communicate. Staff J reviewed the care plan and stated they should have added information about the interpreter line and more interventions on how to communicate with the resident. Staff B stated that Staff J was new to their position and would need more education regarding care plans. <PREFERENCES> In an interview on 08/13/2026 at 11:22 AM, using an interpreter via the language line, Resident 14 stated they spoke Arabic, and staff did not understand them, and they didn't understand the staff. The resident also added they followed halal diet (follows Islamic dietary restrictions such as no pork and meat served were slaughtered according to specific Islamic rituals). The resident stated they only wanted female caregivers. Review of Resident 14's care plan with a print date of 08/13/2026 did not show any documentation about the resident's culture, diet preference and caregiver preference. In an interview on 08/17/2026 at 9:32 AM, Staff N, NAC stated that they looked at the Kardex for information on how to care for a resident. Staff N stated they used gestures when they communicated with Resident 14 and had never used the interpreter line. In an interview on 08/17/2026 at 1:16 PM, Staff X, Dietary Manager stated they provided halal food for Resident 14 and that they bought them at a grocery store that prepared halal meats. In a joint interview on 08/17/2026 at 11:22 AM, with Staff J and Staff B, Staff J stated they were aware that Resident 14 only wanted female caregiver and had explained to the son that they would do their best to accommodate the resident's request. Staff J reviewed the care plan and stated they should have included the resident's preferences in the care plan and made the care plan more resident-centered. Refer to WAC 388-97-1020(1)(2)(a)

Based on interview and record review, the facility failed to report to the state survey agency, allegations of resident-to-resident verbal abuse for 1 of 3 sampled residents (Resident 56) reviewed for abuse. This failure placed residents at risk of undiscovered, potential, and continued abuse. Findings included. Review of the facility policy titled, Abuse-Identification of Types, reviewed date 04/01/2026, documented the facility staff should report any suspected abuse and verbal abuse included yelling, threatening and gestured communication to residents regardless of ability to comprehend. Resident 56 was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 06/16/2026, the resident was cognitively intact and exhibited verbal behavioral symptoms directed toward others. Resident 60 was readmitted to the facility on [DATE]. According to the quarterly MDS, dated [DATE], the resident was cognitively impaired, required total assist on bed mobility and transfer, and was non-interviewable. In an interview on 08/12/2026 at 10:23 AM, Resident 56 stated they were constantly woken up at night or in the early morning by their roommate (Resident 60) making noises. Resident 56 stated they wanted to change to another room and had informed the facility multiple times. Resident 56 stated they yelled at Resident 60 to shut up a few times and told Resident 60 they would slap them. Resident 56 stated everyone knew and all heard of it. In an interview on 08/13/2026 at 11:30 AM, Staff U, Registered Nurse (RN), stated Resident 60 always made loud noises when staff changed their brief and provided care, leaving Resident 56 very frustrated and mad when woken up at night. Staff U stated that approximately one week prior, Resident 56 became very angry and threatened Resident 60.In an interview on 08/14/2026 at 3:33 PM, Staff L, RN, stated on 08/06/2026, Resident 56 became very angry, yelled f***ing word, and threatened to beat up Resident 60. Staff L stated the allegation was reported to the medical provider and Staff B, Director of Nursing, but they did not call or report to the state agency. Review of a psychiatric provider note dated 07/13/2026 at 9:00 AM, documented Resident 56 described the resident and the roommate (Resident 60) frequently told each other to shut up and engaged in repeated disputes. Review of a progress note dated 08/06/2026 at 8:46 PM, documented Resident 56 was verbally aggressive, yelled with hostile language and made threatening gestures toward Resident 60 and displayed agitation. Review of a progress note dated 08/15/2026 at 6:47 AM, documented Resident 56 yelled at Resident 60 to shut up and informed staff Resident 60 f***ing woke them up at 3:00 AM. Review of Resident 56's Electronic Health Record from July to August 2026, showed no documentation indicating the allegations were reported to the state survey agency.Review of the facility reporting log from March to August 2026, revealed no report about these allegations to the state survey agency was logged. In an interview on 08/17/2026 at 12:45 PM, Staff V, RN/Unit Care Coordinator, stated they were not sure if the allegations on 08/06/2026 and 08/15/2026 were reported to the state survey agency.In an interview on 08/17/2026 at 1:35 PM, Staff B confirmed yelling and threatening a resident was abuse and stated those allegations should have been reported to the state survey agency and investigated, but they were not reported nor investigated. Refer to F600Reference WAC 388-97-0640(5)(6)(c)

Based on observation, interview and record review the facility failed to ensure professional standards were met for 1 of 1 resident (Resident 14) reviewed for oxygen, 1 of 1 resident (Resident 75) reviewed for tube feeding and 1 of 2 residents (Resident 75) reviewed for nutrition. These failures placed residents at risk for adverse outcomes and diminished quality of life. <RESIDENT 75> Resident 75 was admitted to the facility on [DATE] with diagnoses that include depression, gastrostomy (external opening into the stomach for supplemental nutrition through a tube) and malnutrition. The admission Minimum Data Set (MDS – an assessment tool) dated 05/18/2026 documented the resident had intact cognition with moderate depression. The resident required supervision for meal intake and oral hygiene. The resident was on a feeding tube and received more than 51% of their nutritional intake through the feeding tube. Review of Resident 75's physician orders showed the following: - Mirtazapine (antidepressant) 15 milligrams (mg) once a day at bedtime for depression and poor appetite, start date 05/15/2026, - Mirtazapine 7.5 mg take once a day for depression, start date 08/03/2026, end date 08/04/2026, - tube feeding Nepro (type of formula) at 79 milliliters (ml) per hour every day, start feeding at 8:00 PM for total feeding of 630 ml., start date 08/06/2026. Review of Resident 75's psychotropic (medications that affect mood, awareness, thoughts, feelings and behaviors) consent dated 05/15/2026 documented the resident consented to Mirtazapine 15mg to increase their appetite. Review of Resident 75's care plan documentation showed the resident had nutritional problems related to the need for tube feeding and malnutrition dated 05/29/2026. Interventions included to monitor the tube feeding, monitor labs, refer to registered dietician (RD) as needed, provide diet as ordered, monitor for trouble swallowing, and monitor for malnutrition; all dated 05/29/2026. On 08/03/2026 an intervention was added, to start mirtazapine for appetite stimulation. Review of Resident 75's progress notes showed the following: - 08/03/2026 at 11:26 AM – Staff C, Registered Nurse (RN)/Assistant Director of Nursing Services (ADNS) documented the nurse practitioner (NP) would discuss mirtazapine for appetite stimulation with the resident, - 08/03/2026 at 12:37 PM – nurse note stated new medication ordered, Mirtazapine for depression at bedtime, - 08/03/2026 no time indicated – Collateral Contact 2 (CC2), NP note stated to start Mirtazapine 7.5 mg 08/04/2026. There was no documentation in the medical record that indicated why the Mirtazapine 7.5 mg was discontinued on 08/05/2026. In a review of Resident 75's electronic medication administration report (EMAR) showed Mirtazapine 15 mg and 7.5 mg both doses were administered on 08/03/2026 and 08/04/2026. In an observation on 08/12/2026 at 1:41 PM, Resident 75 had a tube feeding pole in their room. On the pole was a bottle of Nepro 1000ml formula hanging with about 400ml left in the bottle. The label on the bottle had 08/11/2026 written, the section for name, time, rate was all blank. There was a separate bag with clear liquid that was unlabeled. The syringe at the bedside had no label. In an interview on 08/13/2026 at 1:30 PM, Staff B, Director of Nursing of Services (DNS) stated the facility had not had any medication errors in the last 6 months. In observations on 08/14/2026 at 7:25 AM, and 08/17/2026 at 9:11 AM, Resident 75 had a tube feeding pole in room, the formula, clear liquid bag and syringe were all unlabeled. In an interview on 08/14/2026 at 2:10 PM, Staff S, RN stated if a resident had two separate orders for the same medication they would check with the provider to ensure accuracy of dose. Staff S confirmed they had administered both Mirtazapine doses of 15 mg and 7.5 mg to Resident 75 on 08/04/2026. Staff S stated they did not follow up with the provider on the two orders for the same medication with different doses. In an interview on 08/14/2026 at 3:06 PM, Staff D, Licensed Practical Nurse (LPN)/Unit Care Coordinator (UCC) stated the double Mirtazapine order had not been a medication error, and that the CC2 had increased the dose. Staff D stated the reason it was discontinued after two days was because CC2 did not think it was beneficial, so they canceled the order. Staff D confirmed that information was not in the medical record. Review of Resident 75's medical record on 08/17/2026, a progress note was entered on 08/14/2026 by CC2, documented they ordered an additional 7.5mg of Mirtazapine on 08/03/2026 for Resident 75. However, the resident declined the increased extra dose of 7.5 mg, and it was discontinued on 08/06/2026. In an interview on 08/17/2026 at 11:11 AM, Staff I, RN stated that all tube feeding supplies are to be labeled, with name, date, time and rate. Staff I stated that the formula and tubing was good for 24 hours. In a follow up interview on 08/17/2026 at 1:36 PM, Staff D stated CC2 was going to watch Resident 75, and see how much they were eating, then they decided the extra dose of Mirtazapine was not beneficial, so they discontinued it. Staff D was asked to review CC2 progress note from 08/14/2026, where they had documented the resident never consented to the extra dose. Staff D stated they do not know why the medication had been administered, and they did not know why a new consent was not obtained for the extra dose. Staff D stated the expectation was that all tube feeding supplies were to be labeled with the resident's name, date, time and rate. Staff D stated they were unaware Resident 75's tube feeding supplies had been left blank. In a joint interview on 08/17/2026 at 2:15 PM, with Staff B, DNS and Staff C, RN/ADNS, Staff C stated they updated Resident 75's care plan to start mirtazapine for appetite stimulation on 08/03/2026, and that was done in error. Staff C stated they were informed Resident 75 had declined the increase and were not sure why the medication had been administered for two days. Staff B was unaware the Mirtazapine was administered for two days, lacked documentation, and there had been no consent for the increased dose. In an interview on 08/18/2026 at 10:19 AM, CC2 stated they were aware Resident 75 was on a current dose of Mirtazapine 15mg for depression and appetite stimulation. CC2 stated the resident had recently had some weight loss, and they felt it was more related to their depression, so they had wanted to increase the dose of the Mirtazapine. CC2 stated they discussed the increase with Resident 75. CC2 stated they could not recall when they discussed the increased dose. CC2 stated they recalled a nurse had told them the resident was not happy about the increase, so they discontinued the increased dose. CC2 stated they did not obtain consents that was done by the nurses. <RESIDENT 12> Resident 12 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD – long-term lung disease that blocks airflow and causes trouble breathing). According to the quarterly Minimum Data Set (MDS- an assessment tool) dated 07/16/2026, the resident had moderate cognitive impairment. In an interview and observation on 08/12/2026 at 10:53 AM, Resident 12 was lying in bed wearing a nasal cannula (flexible tubing with prongs placed in the nose to receive oxygen), an oxygen concentrator (a medical device that pulls in room air and delivers oxygen for people having trouble breathing) at bedside set at 4 liters per minute (lpm). Resident 12 stated they were having shortness of breath after a shower, so the staff increased their oxygen to 4 lpm. Review of Resident 12's orders documented oxygen at 2 lpm continuously per nasal cannula, document every shift. Order was dated 05/09/2026. There was no order to increase oxygen if the resident had shortness of breath. In an observation on 08/13/2026 at 1:57 PM, Resident 12's oxygen was set at 4 lpm. In an observation on 08/14/2026 at 8:52 AM and 12:07 PM, Resident 12's oxygen was set at 4 lpm. In an interview on 08/14/2026 at 1:44 PM, Staff L, Registered Nurse, stated they checked oxygen concentrators for residents that were on oxygen at the start of their shift to make sure the residents were receiving oxygen as ordered. Staff L verified Resident 12's order and stated they were on 2 lpm continuously via nasal cannula. Staff L looked at Resident 12's concentrator and stated the oxygen concentrator was showing 4 lpm instead of 2 lpm. They were not sure why Resident 12's oxygen concentrator was set at 4 lpm. In an interview on 08/18/2026 at 8:40 AM, Staff B, Director of Nursing Services stated licensed staff were expected to check oxygen levels at the start of their shift to ensure residents were receiving the correct dosage as ordered and not to increase the oxygen if it was not ordered by the provider. Refer to WAC 388-97-1620(2)(b)(ii)

Based on observation, interview and record review, the facility failed to ensure assessment and monitoring of resident bladder programs for 1 of 3 residents (Resident 15) reviewed for bowel and bladder programs. This failure placed residents at risk for infection, bladder injury and adverse events. Findings included . Resident 15 admitted on [DATE] with diagnoses that included spinal injury with resulting bladder dysfunction. The resident was alert and oriented and able to self-advocate regarding their care. Review of Resident 15's treatment order dated 06/26/2026 documented Resident to self cath (catheterize) to drain the bladder, every hour as needed. The order lacked any specific prescription components including the catheter size (french), tip style, and accessory collection supplies (antiseptic skin wipes, lubricant, collection supplies). Review of Resident 15's treatment administration records (TAR) from 06/26/2026 to current (08/18/2026) documented zero instances of as needed self-catheterization. Review of Resident 15's admission MDS (Minimum Data Set) (a required assessment) dated 07/03/2026 showed no indwelling or intermittent catheterization captured. Further review of Resident 15's treatment orders noted a second order was added dated 07/03/2026 stating Resident may perform Self Catheterization every shift for Urine Retention. Review of Resident 15's treatment administration records (TAR) related to self catheterization from 07/03/2026 to current (08/18/2026) documented licensed nurses initials and a checkmark each shift. Review of Resident 15's record showed no bladder assessment and progress notes had only the recurrent general statement resident self caths. Review of Resident 15's care plan problem identified intermittent self-catheterization, but the goals and interventions related to indwelling catheters with interventions that did not apply to intermittent catheterization such as catheter care every shift and provide education about indwelling catheters. In an interview on 08/12/2026 at 12:21 PM, Resident 15 stated the nurses brought 3-5 catheters each day, which they felt was not enough. Resident 15 stated they had been doing self-catheterization for some time and had a history of frequent infections and catheter blockages when they used to have an indwelling catheter. Resident 15 stated they were currently self-catheterizing roughly every 8 hours, but sometimes more and had not been keeping track of output. Resident 15 stated they were not using the same style of catheter they used at home. Resident 15 denied needing assistance with the catheterization process, but verbalized frustration over lack of control over supplies. In an interview and observation on 08/14/2026 at 12:01 PM, Staff D, Licensed Practical Nurse/Unit Care Coordinator, stated Resident 15's catheters were kept in the supply room and they provided them when Resident 15 asked. Staff D did not know what size catheter was ordered for Resident 15. Staff D went into the medication supply room and brought out a single use catheter which was observed to be a regular tip style catheter labeled 14f (French) size and stated that was what they provided to resident 15. Staff D reviewed the resident record and stated they did not see specific orders for catheters, supplies and no assessment or education showing Resident 15 had the ability to safely perform self catheterization. Staff D stated (Resident 15) used to self cath at home and won't let anyone watch. Staff D stated there was no documentation of how often it was being done or the results such as urine output. In an interview on 08/14/2026 at 12:19 PM, Staff B, Director of Nursing Services, stated there should have been some type of assessment done when Resident 15 admitted but was unable to locate one. Staff B stated the orders should be complete, and documentation should indicate whether the self catheterization was being done or not and the result. Refer to WAC 388-97-1060 (3)(c)

Based on observation, interview and record review, the facility failed to ensure residents were free from significant medication errors during 1 of 1 random observation (Resident 117), and for 1 of 2 residents (Resident 121) reviewed for respiratory care. Failure to ensure supervision and accounting of resident self-administration of medications, failure to ensure accurate transcription and reconciliation of medications, and to investigate instances of medication errors, placed residents at risk for adverse events related to medication. Findings included . Review of the facility policy titled, Medication Reconciliation . (revised date 09/2025) stated medications would be reconciled by the licensed nurse. Clinically significant medication issues identified would be communicated to the physician, acted upon, and documented in the medical record. <RESIDENT 121> Resident 121 admitted on [DATE] with diagnoses which included shortness of breath related to respiratory disease and lower extremity swelling. Review of the hospital discharge summary and medication list dated 08/04/2026 included: Tiotropium (a long-acting respiratory inhaler that relaxes the muscles in the airways to ease breathing), one 18mcg (microgram) capsule inhalation daily, Furosemide 20mg (milligram) tablet (lowers fluid volume, to treat swelling), take 1/2 tablet (10mg) daily by mouth. Record review of the facility admission medication orders dated 08/04/2026 documented Staff H, Registered Nurse, Infection Preventionist, entered the admitting medication orders. Record review of a consultant pharmacist note dated 08/06/2026 identified discrepancies in the hospital discharge orders and the facility orders: The hospital discharge order for furosemide 10mg had been entered into the facility system as 20mg, The hospital order for Tiotropium once daily had been admitted for an unknown rationale, The consultant pharmacist additionally identified an eye drop that was entered in the system as routine instead of as needed, and an incomplete order for a breathing treatment that required the addition of a symptom monitor. The consultant pharmacist note included the handwritten statement corrected 08/05/2026 on the bottom with no corresponding initials. In a review of Resident 121's August medication administration record (MAR) revealed the Tiotropium order was entered into the system on 08/06/2026 and not administered until 08/07/2026. The correct 10mg furosemide order was entered into the system on 08/06/2026 (having already received 20mg on 08/06/2026) and received on 08/07/2026. In an interview and observation on 08/12/2026 at 3:04 PM, Resident 121 was observed sitting up in a chair next to their bed, with their legs propped up on the bed, both lower legs were wrapped with compression wraps and were visibly swollen. Resident 121 stated they had lung problems and had concerns about getting their respiratory medications on time. They stated they were supposed to be getting breathing treatments more often than they did and they got short of breath easily. Resident 121 did not recall the specific names of their medications but stated they did not think they had been getting all the medications they were supposed to get. Resident 121 stated they had problems with their legs and took medication that made them pee a lot so they used the bottle (urinal). In an interview on 08/13/2026 at 1:30 PM Staff B, Director of Nursing Services, (DNS) stated the facility did not have any medication errors in the last six months, so there was no report to run. In an interview on 08/17/2026 at 1:54 PM, Staff D, Licensed Practical Nurse, Unit Care Coordinator (LPN/UCC), stated the facility process included two licensed nurses to input and confirm new medication orders. One nurse would input and another went behind and checked. Staff D stated some of the orders for Resident 121 had been inputted wrong and Staff D corrected them. Staff D stated they did not know if the original orders had been double checked by a second person, there was no place to sign for so they did not know. Staff D stated it was their handwriting on the consultant pharmacist note stating the discrepancies had been corrected. Staff D noted the orders were not entered until 08/06/2026 and did not have a reason why if they had been identified on 08/05/2026. Staff D stated they had not initiated any medication error investigations, but they were medication errors so they should have. In an interview on 08/18/2026 at 10:45 AM, Staff H stated they had entered the orders for Resident 121 and recalled wanting to seek a clarification about the Tiotropium order but had no further recollection about that. Staff H stated they missed the additional instruction on the furosemide which included the half tablet. Staff B, Director of Nursing was also present and stated they believed the orders had been reviewed by a second person, who also did not recognize the errors. Staff B stated they had not previously been aware of the discrepancies or completed any investigation of the errors so was not able to speak to exactly what happened. Staff B was not aware if the resident or provider had been notified of the errors. Staff B stated the orders for Resident 121 were entered on the 6th and defaulted to the next day. <RESIDENT 117> Resident 117 admitted to the facility on [DATE] with diagnoses that included complex regional pain syndrome (CRPS - continuous burning pain, extreme touch sensitivity, swelling, and skin color or temperature changes to arm or leg), and hypomagnesemia (low magnesium level in blood). The admission Minimum Data Set (MDS – an assessment tool) dated 08/09/2026 documented the resident had intact cognition. In an interview and observation on 08/12/2026 at 1:58 PM, Resident 117 stated when they were admitted to the facility, they had brought all their home medications. At the resident's bedside, on a table was a bottle of Natures Made Magnesium Glycinate 200 milligrams (mg) capsules the bottle stated there were 60 in the bottle, the bottle was observed to be half full. Resident 117 was asked about the magnesium at the bedside, and they stated they were told by their doctor they must take the magnesium every three hours, so they kept it at their bedside and had an alarm on their cell phone to remind them to take the medication. In a review of Resident 117's physician orders, print date 08/12/2026 at 2:24 PM, the resident had orders to take 100 mg of magnesium glycinate every three hours. In a review of Resident 117's electronic medication administration record (EMAR), print date 08/12/2026 at 2:26 PM, documentation showed the resident had been administered 100mg of Magnesium glycinate by multiple nurses every three hours. The first dose was administered on 08/04/2026 at 3:00 pm, and all other doses were signed administered by multiple nurses every three hours daily, last dose documented was 08/13/2026 at 12:00 PM, when the resident discharged . In an observation and interview on 08/12/2026 at 3:45 PM, Resident 117 confirmed they took magnesium from the bottle at the bedside every three hours. The magnesium was on the bedside table next to the resident. In an interview on 08/17/2026 at 11:11 AM, Staff I, Registered Nurse (RN) stated Resident 117 did have their own magnesium, and they (the nurses) would remove the bottle, but Resident 117 would get more. Staff I stated when they worked with Resident 117, they administered the magnesium from the medication cart and would document in the EMAR system. In an interview on 08/17/2026 at 1:36 PM, Staff D, License Practical Nurse/ Unit Care Coordinator stated Resident 117 was not on a self- medication program and stated the resident refused an assessment. Staff D stated they were aware Resident 117 had medications at bedside and they did their best to remove the bottles. Staff D stated they were not aware the licensed nurses had documented they had administered the Magnesium Glycinate 100 mg every three hours, or that Resident 117 stated they were also self-administering their own Magnesium Glycinate 200 mg capsules every three hours. Staff D stated Resident 117 would do whatever they wanted. In a joint interview on 08/18/2026 at 8:20 AM, with Staff B, Director of Nursing Services (DNS) and Staff D, Staff B stated they had spoken with Resident 117 about the inventory of their belongings the resident had in their closet. Staff B stated they adamantly refused to let them inventory what was there, so there was no way to know if there were medications in the closet. Staff B stated I was aware we had removed one bottle of Magnesium from the bedside at one point. Staff D stated there was more in the room, and the licensed nurses had also administered the magnesium from the medication cart. Staff B was informed Resident 117 had stated they had an alarm on their cell phone and would take a capsule every three hours when it went off. Staff B stated they were not aware the resident had possibly received up to 300 mg of magnesium every three hours since admission. Staff B stated Resident 117 had refused a self-administration assessment. Refer WAC 388-97-1060(3)(k)(iii)

Based on observation, interview and record review, the facility failed to ensure medications were secured for 1 of 1 resident (Resident 117) observed for medications at bedside. This failure placed the residents at risk for consuming medication in excessive dosage, medical complications, and diminished quality of life. Findings included.Review of the facility policy titled, Self-Administration of Medication, reviewed 09/15/2025 documented the facility would ensure that each resident who requests to self-administer medications was assessed by the interdisciplinary team (IDT) to determine if the resident was safe to self-administer the medications. The facility will determine through an interdisciplinary assessment if the resident was able to safely store the medication in a secure area in their room and safely administer the medication as prescribed.bedside medication storage was only permitted when it does not pose a risk to confused residents who may wander.Resident 117 admitted to the facility on [DATE] with diagnoses that included complex regional pain syndrome (CRPS - continuous burning pain, extreme touch sensitivity, swelling, and skin color or temperature changes to arm or leg), and hypomagnesemia (low magnesium level in blood). The Minimum Data Set (MDS - an assessment tool) dated 08/09/2026 documented the resident had intact cognition.In an observation on 08/12/2026 at 1:58 PM, on Resident 117's bedside table was a bottle of Natures Made Magnesium Glycinate 200 milligrams (mg) capsules the bottle stated there was 60 in the bottle, observed about half full.In an observation on 08/12/2026 at 3:45 PM, Resident 117 was in their bed, the magnesium was on the bedside table next to the resident.In an observation on 08/13/2026 at 8:24 AM, Resident 117 was not in their room, the magnesium bottle with capsules in it was on their bedside table.In a review of Resident 117's medical record on 08/13/2026, there was no self-administration assessment, or a care plan for storage of medication at bedside.In an interview on 08/17/2026 at 11:11 AM, Staff I, Registered Nurse (RN) stated they were aware Resident 117 would have medications at bedside. Staff I stated management had removed a bottle of magnesium before; however, they (Resident 117) got more. Staff I stated to have medication at bedside the resident would have to be assessed for safety and have a lock box.In an interview on 08/17/2026 at 1:36 PM, Staff D, License Practical Nurse/ Unit Care Coordinator stated residents may store medications in their room if they were assessed by occupational therapy for safety and kept them locked up in a box. Staff D stated Resident 117 had refused to participate in an assessment for safety. Staff D stated they were aware Resident 117 had medications at bedside once and had removed one bottle of magnesium.In an interview on 08/18/2026 at 8:20 AM, Staff B, Director of Nursing Services stated residents were not to store medications at bedside unless they had been assessed for safety and placed the medications in a lock box. Staff B stated they were aware nurse management had removed one bottle of Magnesium from Resident 117's room and was not aware there had been more at bedside. Refer to WAC 388-97-1060(3)(k)(iii)

Based on interviews and record reviews, the facility failed to ensure residents were free from verbal abuse for 1 of 3 sampled residents (Resident 56) reviewed for allegation of abuse and neglect. The facility failed to recognize, report and investigate allegations of verbal abuse and threats of physical harm; and failed to implement interventions to protect the resident from further potential abuse. The facility failed to ensure resident protection by allowing the alleged perpetrator (Resident 56) to continue residing in the same room with the alleged victim (Resident 60) after the allegation of verbal aggression, threats and agitation. This failure placed residents at risk for potential physical and mental abuse, psychosocial harm and a diminished quality of life. Findings included.Review of facility policy titled Abuse-Prevention, reviewed date 04/01/2026, documented the facility would identify, correct and provide interventions in situations in which abuse more likely occurred, and assured residents remained free from abuse. Resident 56 was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 06/16/2026, the resident was cognitively intact and exhibited verbal behavioral symptoms directed towards others. Resident 60 was readmitted to the facility on [DATE]. According to the quarterly MDS, dated [DATE], the resident had significant cognitive impairment, required total assist on bed mobility and transfer, and was non-interviewable. In an interview on 08/12/2026 at 10:23 AM, Resident 56 stated they were very frustrated that they were constantly woken up by their roommate (Resident 60) at night or in the early morning. Resident 56 stated Resident 60 made noises at night and spoke inappropriately to staff while they received care. Resident 56 stated they wanted to change to another room and had informed the facility multiple times. Resident 56 stated they could not tolerate the situation, yelled at Resident 60 shut up multiple times and told Resident 60 they would slap them. Resident 56 stated everyone knew and all heard of it. In an interview on 08/13/2026 at 11:04 AM, Staff T, Nursing Assistant Certified, stated Resident 56 was always frustrated with Resident 60 and yelled at Resident 60 when they made noises at night. In an interview on 08/13/2026 at 11:30 AM, Staff U, Registered Nurse (RN), stated Resident 60 made loud noises when staff changed their brief and provided care, which left Resident 56 very mad when they were woken up at night. Staff U stated approximately one week prior, Resident 56 became very angry and threatened Resident 60. Staff U stated Resident 56 was also angry with staff and sometimes threw their urinal at staff.In an interview on 08/14/2026 at 3:33 PM, Staff L, RN, stated on 08/06/2026, that Resident 56 became very angry, yelled curse words and threatened to beat up Resident 60. Staff L stated Resident 56 had behavioral issues and repeatedly threw their urinal at the privacy curtain in between Resident 56 and Resident 60 or at staff multiple occurrences. Staff L stated Resident 56 was moved to a different room for one night because the resident might throw a urinal at Resident 60. Staff L stated the incident was reported to the medical provider and the Director of Nursing, but not sure if an incident report or investigation process was initiated. Review of a psychiatric provider note (Collateral Contact 1-CC1) dated 07/13/2026 at 9:00 AM, documented Resident 56's primary concern was frustration with their roommate (Resident 60), conflicts, and had requested a room change. The note documented Resident 56 described their roommate (Resident 60) as argumentative and they frequently told each other to shut up and engaged in repeated disputes. The note documented Resident 56 had already brought this matter to the attention of facility staff. The note documented Resident 56 exhibited behaviors of throwing their urinal (with urine in it) at curtains in between the two residents in their room. Review of a psychiatric provider note (CC1) dated 07/27/2026 at 9:00 AM, documented Resident 56's primary concern was ongoing irritability and incompatibility with their roommate (Resident 60) and had requested a room change, which significantly affected Resident 56's mental and emotional well-being. The note documented Resident 56 reported they could not tolerate Resident 60 makes all these crazy noises all the time and this interpersonal conflict had been on ongoing source of distress. The note documented the facility staff and administration were already aware of the situation. Review of a progress note dated 08/06/2026 at 8:46 PM, documented Resident 56 was verbally aggressive, yelled in hostile language and made threatening gestures toward Resident 60 and was agitated. The note documented that Resident 56 was moved to another room. Review of a progress note dated 08/07/2026 at 12:00 PM, documented Resident 56 was verbally aggressive to staff this am and gesturing to hit staff with his reacher, and starting to yell abusively at staff. On the same day, another progress note documented at 12:57 PM (57 minutes later), Resident 56 was moved back to their previous room with Resident 60. There was no behavior monitoring documentation on the following day (08/08/2026). Review of a progress note dated 08/15/2026 at 6:47 AM, documented Resident 56 yelled at Resident 60 shut up and informed staff Resident 60 f***ing woke them up at 3:00 AM. Review of Resident 56's comprehensive care on 08/17/2026 at 8:40 AM, revealed there were no focus areas, goals, or intervention regarding behavior toward to other residents. Review of Resident 56's census report on 08/17/2026 at 8:46 AM, revealed there was no room change after being placed with Resident 60 since 06/02/2026. Review of Resident 56's Electronic Health Record on 08/17/2026 at 9:00 AM, from 07/01/2026 to 08/17/2026 at 9:00 AM, revealed no documentation showing an investigation process for the abuse allegations was initiated or completed, nor were interventions documented to protect other residents and keep them safe from further abuse. Review of Resident 60's progress notes from 07/01/2026 to 08/17/2026 at 9:00 AM, revealed there was no documentation indicating the resident was yelled at with hostile language or threatened by their roommate (Resident 56). There was no interventions to protect the resident and keep them safe from further abuse, no documentation of monitoring for potential psychosocial harm, no documentation showing an investigation process had started, and no documentation showing any DPOA (Durable Power of Attorney-a designated person who had the legal authority to make decision for the resident) was notified of the allegations. In a phone interview on 08/17/2026 at 9:58 AM, CC1, psychiatric nurse practitioner, stated Resident 56 was aggressive and sometimes threw a urinal to the curtain in between the two residents or at staff, and the resident complained they could not reside with their roommate (Resident 60) because Resident 60 made irritating noises. CC1 stated the facility was aware of the situation but uncertain whether Resident 56 could be offered a private room given a history of incompatibility with previous roommates prior to Resident 60. In an interview on 08/17/2026 at 12:45 PM, Staff V, RN/Unit Care Coordinator, confirmed it was verbal abuse if resident threatened and yelled at another resident using hostile language. Staff V was aware Resident 56 complained about Resident 60 making noises at night and waking Resident 56 up. Staff V stated they were not sure if any investigation was completed for the allegations on 08/06/2026 and 08/15/2026, and confirmed there were no other interventions implemented for the allegations besides they separated the two residents for one night on 08/06/2026.In an interview on 08/17/2026 at 1:35 PM, Staff B, Director of Nursing, confirmed yelling and threatening to the roommate was abuse and stated an investigation should have been conducted regarding those allegations but was not done. Staff B stated the expectation was to investigate, evaluate room changes, and ensure residents were safe. Refer to F609Reference WAC 388-97-0640 (1)(6)(a)(b)

Based on interview, and record review, the facility failed to conduct a complete and thorough investigation for 1 of 1 sampled resident (Resident 1) reviewed for abuse and neglect. This failure placed residents at risk for unidentified abuse or neglect, potential ongoing abuse/neglect, and a diminished quality of life.Findings included .Review of a facility policy titled Abuse-Conducting an Investigation, reviewed 04/01/2026, documented: It is the policy of this facility that allegations of abuse are promptly and thoroughly investigated.Procedure-8. The written summary of the investigation should include, but is not limited to:h. Interviews with staff members on all shifts having contact with the resident at the time of the incidenti. Interviews with the resident's roommate, family, and/or visitors who may have information regarding the incident.j. Interviews with other residents who received care or services from the alleged perpetrator.k. A review of all circumstances surrounding the incident. According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It includes guidelines for prevention and protection, incident identification, investigation and reporting for nursing homes, the facility investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened including the probable or reasonable cause. <RESIDENT 1>Resident 1 admitted to the facility on [DATE] with diagnoses including pulmonary aspergillosis (a lung infection caused by mold), chronic pain, delirium, and disorientation. According to the admission Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], the resident was cognitively intact. Review or Resident 1's electronic medical record (EMR) documented the resident was incontinent of bowel and bladder and required 2-person assistance with toileting. Review of the facilities Reporting log, dated June 2026 showed documentation of an incident for Resident 1 of sexual abuse, on 06/01/2026.Review of the facility investigation did not show statements from licensed staff, staff that met the resident's description, interview with the resident's roommate, or interviews with other resident's. In an interview on 06/16/2026 at 3PM, Staff C, Licensed Practical Nurse, stated Staff B, Registered Nurse, Director of Nursing, completes abuse investigations. Staff C stated staff statements are obtained for incidents.In a joint interview and record review on 06/18/2026 at 2:23 PM, with Staff A and Staff B, Staff B stated they and/or Staff A complete abuse investigations. Staff B stated staff and residents are interviewed and questions are tailored to the situation. Staff B stated Resident 1 required two-person assist with incontinent care. Staff B stated they ruled out abuse based on the information they had, interviews with male staff, and other residents and Resident 1 was having a change in condition, being treated for a fungal infection, and on 05/27/2026 the resident became confused. Staff A stated male staff were interviewed but they did not document the specific questions asked during the interviews. Staff B stated interviews with female staff were conducted and stated, if the interviews were not documented on the staff interview sheet, we did not do it. Staff B reviewed the staff interview sheet and stated staff interviews listed in the investigation are all the male nursing assistants assigned to the unit, the list did not include female staff. Staff B stated resident interviews were conducted but were not documented. Staff A and Staff B stated resident 1 had a roommate. Staff B stated if Resident 1 had a roommate they were not interviewed individually. Staff A stated there was no other information whey wanted to add.Reference WAC 388-97-0640(6)(a)

Based on interview, and record review the facility failed to protect residents right to be free from neglect for 1 of 3 sampled residents (Resident 1) reviewed for falls. Facility staff failed to follow the plan of care which resulted in Resident 1 falling from their bed. This failure placed residents at risk for potential physical or mental harm, feeling safe, and a diminished quality of life.Findings included .Review of a facility policy titled Abuse-Identification of Types reviewed 04/01/2026 documented: Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Willful-is defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm Review of a facility policy titled Abuse-Prevention reviewed 04/01/2026 documented it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.Procedure- 2. Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms if any.4. Identify, assess, care plan for appropriate interventions and monitor residents with needs and behaviors which might lead to neglect such as:h. Residents that require extensive nursing care and/or are totally dependent on staff for the provision of care. Review of the Nursing Home Guidelines the purple book, dated October 2015, Appendix B, Definition Diagram-Neglect documented;b. Neglect may result from a one-time act or omission by an individual or entity with a duty of care for nursing home residents. Individual or entity with a duty of care by an action or failure to act demonstrated a serious disregard of the consequences of such magnitude that: There was a clear and present danger to the resident's health, welfare, or safety. <RESIDENT 1>Resident 1 was admitted to the facility on [DATE] with diagnoses to include polyneuropathy (damaged nerves), muscle weakness, difficulty in walking, falls, and dementia. According to the Minimum Data Set (MDS-an assessment tool) assessment dated [DATE], the resident had no cognitive impairment.Review of Resident 1's care plan dated 05/05/2026, showed the resident required extensive two-person assistance with bed mobility to turn and position in bed.Review of Resident 1's Kardex (a care guide for staff to provide resident care) dated 05/06/2026 showed Resident 1 required extensive two-person assist with bed mobility to turn and position in bed.Review of the facilities Reporting Log dated May 2026, documented Resident 1 had a fall with findings of neglect.Review of a progress note dated 05/06/2026 at 2:17 PM, documented the certified nursing assistant (CNA) reported they were providing care for Resident 1 and the resident rolled off the bed. The resident complained of pain eight out of ten to their lower back.Review of a facility investigation dated 05/06/2026 showed Staff E, CNA, was providing care for Resident 1, rolled the resident to their side and the resident rolled off of the bed. Staff E stated they knew that Resident 1 required two-person assist for care and stated therapy had told them that morning that the resident was going to be a one person assist, Staff D, Director of Rehab (DOR) stated that was not correct. The investigation concluded that Staff E by self-report was aware that the resident's plan of care showed the resident was a two-person maximum assist for bed mobility and decided to roll the resident with one person causing a fall to the ground when the resident reached for support.Review of a statement dated 05/26/2026 at 11:30 am, Staff E documented they were providing care for Resident 1, the resident was rolled away from them and rolled off of the bed onto the floor.Review of a statement dated 05/06/2026, Staff A, Administrator and Staff B, RN, Director of Nursing, documented an interview with Staff E. Staff E stated they were rolling Resident 1 away from them and the resident fell onto their right side. Staff E stated they had reviewed the resident's Kardex that morning and the resident was a two person assist. Staff E stated they talked with Staff D and told them the resident was a one person assist for bed mobility, but the care plan had not been updated.In an interview on 05/19/2026 at 1:55 PM, Staff F, CNA, stated the Kardex gives information about how to provide care such as bed mobility and how many people are required for assistance. Staff F stated the Kardex should be checked at the beginning of the shift. Staff F stated if a resident is a two person assist, they would not assist the resident by themself.In an interview on 05/19/2026 at 2:03 PM, Staff G, Licensed Practical Nurse (LPN), Nurse Manager, stated Staff E stated they had looked at Resident 1's Kardex and were aware the resident required two-person assistance. Staff E was unable to state why they had not followed the Kardex. Staff G stated staff are expected to follow the Kardex when providing resident care.In an interview on 05/19/2026 at 3:20 PM, Staff D, DOR, stated Staff E assisted them with their evaluation of Resident 1 on 05/06/2026 prior to 8:30 AM. Staff D stated they reviewed the resident's Kardex with Staff E and told Staff E the resident required two-person assistance for care and bed mobility and to always follow the resident's Kardex for care. Staff D stated they did not have a discussion with Staff E about changing the resident to one person assistance for care.In an interview on 05/19/2026 at 3:30 PM Staff C, LPN, Assistant Director of Nursing, stated staff are expected to follow the care plan and Kardex when providing care for residents.Reference WAC 388-97-0640(1)

Based on observation, interview and record review, the facility failed to ensure food items were dated and labeled and expired items were discarded in the 2 of 3 sampled facility nourishment refrigerators (Quilceda and Havenwood) reviewed for safe/sanitary food storage. This failure placed residents at risk of consuming expired food, foodborne illness, and a diminished quality of life.Findings included.Review of the facility policy titled, Food from Outside Sources, revised date 05/06/2025, documented food stored in refrigerator should be labeled with the resident's name and room number. Items should be discarded if past expiration date. Review of facility policy titled, Food Safety, reviewed date 05/01/2025, documented leftovers must be dated and labeled properly and discarded after 72 hours. In an observation on 09/23/2025 at 10:22 AM, the nourishment refrigerator in Quilceda clean utility room was observed to include: a container strawberry with brown and fuzzy covering, labeled 09/04/2025, a package of mini maple pancakes and sausage with no resident's name, best before date was 09/01/2025, a chocolate pudding with no resident's name with best before date 09/13/2025, a container cherry tomatoes were mushy with some fluid inside the container labeled 09/04/2025, a container gelatin with best before date 08/24/2025, a bottle of ranch dressing with the manufacture printed expiration date 08/09/2025, a container of two pieces of chicken meat and one bag of baby carrots in a big plastic bag with a resident's name but no date, a bag of blueberries in the freezer with the manufacture printed expiration date 06/27/2025. Review of the refrigerator cleaning log taped outside the refrigerator; the last cleaning date was 09/11/2025. In a joint observation on 09/24/2025 at 10:13 AM with Staff O, Housekeeping Assistant, the nourishment refrigerator in Quilceda clean utility room was observed to still include the expired and unlabeled items listed above. Staff O stated they cleaned the refrigerator every week and they would discard expired or bad food. Staff O stated the expired food in the refrigerator should be thrown away. In an observation and interview on 09/24/2025 at 2:40 PM, Staff P, Registered Nurse (RN)/Unit Care Coordinator, the nourishment refrigerator in Havenwood nurses' station was observed to include: frozen bread in the freezer with best before date printed 08/18/2025, a bag of honey ham slices and a bag of Swiss slices labeled 9/20 with no name, opened container of ranch dressing and a bag of bagels labeled 9/20, in the bottom drawer, there was a bag containing of cottage cheese, pecan chips, and a can of pineapple, with no name or date, in the bottom drawer, there was a to-go container with leftover food with no name or date. Staff P stated the expired and unlabeled foods should be discarded. Staff P stated leftover foods were only kept for 72 hours. In an interview on 09/24/2025 at 10:40 AM, Staff J, RN, stated they needed to label residents' outside food with their names and dates received prior to putting it in the refrigerator. In an interview on 09/24/2025 at 10:46 AM, Staff K, Licensed Practice Nurse/Unit Care Coordinator, stated residents' outside food was supposed to be kept for a couple of days. Staff K stated they needed to discard the expired and unlabeled food. In an interview on 09/24/2025 at 11:57 AM, Staff Q, Housekeeping Director, stated when the housekeeper cleaned the refrigerator, they should have discarded the expired food and checked with the nurse for unlabeled outside food. Reference WAC 388-97-1100 (2)(3)

Based on observation, interview, and record review, the facility failed to ensure a system was in place in which residents' records were complete, accurate, accessible, and systematically organized for 4 of 8 residents (Residents 3, 7, 54, and 86) reviewed for accurate and complete medical records. The facility failed to ensure the medical records reflected the behavior/psychotropic review documentation for 1 of 5 residents (Resident 3) failed to have accurate documentation for monitoring and consents for anti-anxiety medications for 1 of 5 residents (Resident 7), failed to include bed hold and discharge documentation for 1 of 2 (Resident 86) discharged residents, failed to ensure accessible documentation for hospice documentation for 1 of 1 resident (Resident 54). These failures to not maintain complete, accessible and accurate medical records placed residents at risk for medical complications, unmet care needs, and diminished quality of life. Findings included .<BEHAVIORS/PSYCHOTROPIC MANAGEMENT> <RESIDENT 7> Resident 7 admitted to the facility on [DATE] with diagnoses to include right hip fracture, anxiety and depression. Review of Resident 7's Electronic Health Record (EHR) showed a document titled 'Medication Consent (Buspirone)' an antianxiety medication, dated 08/13/2025. Review of this document showed the title was incorrect, the consent was for Bupropion (antidepressant medication), and the consent was dated 10/17/2024. The name of the medication and the date of the consent were labeled incorrectly in the EHR. Review of Resident 7's consent for Buspirone, dated 08/13/2025 showed Staff K, LPN Unit Care Coordinator, obtained and completed the consent. Review of Resident 7's Medication Administration Record (MAR) dated November 2024 showed the medication was discontinued on 11/21/2024. Review of Resident 7's MAR's dated November 2024, December 2024, January 2025, and February 2025 showed there was still an order to monitor for the side effects of Buspirone that was discontinued on 02/28/2025, which was over 3 months after the medication was discontinued. In an interview on 09/25/2025 at 10:45 AM, Staff K stated they were responsible to obtain medication consents for newly ordered psychotropic medications or when a new resident is admitted on a psychotropic medication. Staff K, LPN Unit Care Coordinator, stated that they review the consent with the resident and/or family including education regarding what type of medication was prescribed, possible side effects and what signs and symptoms were present before medication was initiated. Staff K verified they were the one who completed the Buspirone consent, dated 08/13/2025. Staff K verified that Resident 70 had stopped taking that medication in November of 2024. Staff K also verified that the document for Buspirone was not labeled correctly in the EHR and the consent was for Bupropion. Staff K stated they provide the consents to medical records, and they were responsible to name and date the uploaded documents in the EHR. In an interview on 09/29/2025 at 9:42 AM, Staff B, Director or Nursing Services, stated the expectation was that medical records and documents were labeled with the correct name and date when being uploaded or scanned into the EHR. Staff B stated consents for psychotropic medications should be accurate and monitors for the medication class should be discontinued at the same time the medication is discontinued. <RESIDENT 3> Resident 3 admitted on [DATE] with diagnoses to include recurrent major depressive disorder, anxiety disorder, and post-traumatic stress syndrome (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of the clinical record showed there was no interdisciplinary note about evaluating Resident 3's mental health diagnoses, mood and behaviors or the effectiveness of gradual dose reductions for psychotropic medications. In an interview on 09/26/2025 at 12:58 PM, Staff B, Director of Nursing Services (DNS) stated they had a monthly behavior meetings, and they evaluated for gradual dose reductions that were attended by Social Services, DNS, Pharmacist, and usually the psychiatric provider. Staff B stated they kept a binder of the reviews. Staff B stated the meeting notes should be in the medical records. Staff B provided a binder labeled, Behavioral Health Solutions that included psychotropic medication orders and handwritten notes about what was discussed at the meeting. Review of the Behavioral Health Solutions binder showed Resident 3 was discussed on 03/14/2025, 04/15/2025, 06/28/2025 and 09/18/2025. Review of the clinical record did not include documentation about the meetings on 03/14/2025, 04/15/2025, 06/28/2025 and 09/18/2025. In a joint interview on 09/29/2025 at 9:43 AM, Staff A, Administrator stated their expectation for medical records was filing, audits, and requesting medical records from other clinics and hospitals. Staff B, DNS stated they reviewed who went out to the hospital daily in stand up and they would request follow up records. Staff B stated they look for medical records when residents returned from physician appointments. In an interview on 09/29/2025 at 9:47 AM, Staff C, Regional Director of Clinical Services stated for psychotropic meetings, the resident's assessments are discussed and information discussed was documented in the binder located in the DNS office. Staff C stated the former DNS took the psychotropic assessment away. Staff C stated they now had an excel spreadsheet with the meeting details that surveyors can request. Staff C said the binder was an internal item. Staff C stated there should be a progress note detailing the meeting and gradual dose reduction discussions also included in the clinical record. <BED HOLD AND DISCHARGE> <RESIDENT 86> Resident 86 was admitted on [DATE] and hospitalized on [DATE]. In a record review on 09/25/2025 at 10:09 AM, Resident 86 did not have required discharge documentation, which would include the bed hold form and Notice of Transfer and Discharge (NOTD) form, documented in the electronic medical record (EMR) or the hard chart. In an interview on 09/25/2025, at 11:30 AM, Staff B confirmed that the bed hold form and NOTD form, for Resident 86, were not located in the resident's EMR or hard chart. Staff B stated that admissions keep all copies of the discharge paperwork. <HOSPICE> Resident 54 was admitted to the facility on [DATE] with hospice services. In an interview on 09/26/2025 at 9:20 AM Collateral Contact 1 (CC1), hospice nurse, stated there was a communication book located with the facility infection control nurse. CC1 stated the hospice staff documented in the communication book each time they came into the facility. CC1 stated if there were any changes to orders they were faxed to the facility and communicated to the nurses. On 09/26/2025 at 9:20 AM requested to review the hospice communication book from Staff H, Registered Nurse/Unit Coordinator. Staff H stated the hospice communication books were kept at the nurse's station. The hospice communication book was observed at the nurse's station and the contents were reviewed. The hospice book contained multiple handwritten notes from hospice staff for each visit since the start of Resident 54's hospice care. Review of Resident 54's EHR from 07/31/2025 through 09/26/2025 showed no notes from hospice visits. In an interview on 09/26/2025 at 9:25 AM Staff H, RN/Unit Coordinator, stated hospice communicated with the facility through fax if there are any changes of orders. Staff H stated hospice staff communicated with the facility staff after their visits. Staff H stated they didn't know how the information in the hospice binder was placed in the EHR for Resident 54. In an interview on 09/26/2025 at 9:56 AM Staff B, Director of Nursing Services stated all hospice records located in the binder should be uploaded into the resident's EHR. In an interview on 09/26/2025 at 9:58 AM Staff I, Medical Records, stated they were aware of a hospice book for Resident 54. Staff I stated the nurses reviewed the contents of the book and then provided it to them to upload into the residents EHR. In an interview on 09/29/2025 at 10:23 AM, Staff I, Medical Records Director stated they were responsible for uploading medical records into the EHR, credentialing and competency of physicians, stocking forms, and making new admission packets. Staff I stated they audited medical records on admit, quarterly, annually and on discharge to ensure the records were complete. WAC Reference 388-97-1720 (1)(a)(i)(ii)(iii), 4(a)

Based on interview, and record review, the facility failed to incorporate the recommendations from the Level II Preadmission Screening and Resident Review (PASRR a federally required screening of all individuals who has a serious mental illness (SMI) and or intellectual disability (ID) prior to admission to a Medicaid-certified nursing facility or a significant change of condition) report into the resident's assessment, and care planning for 1 of 1 resident (Resident 2) reviewed for PASRR. Facility failure to incorporate the PASRR recommendations into the residents' assessment and care plan delayed the implementation of recommendations and left the residents at risk for unmet mental health and activity needs and a diminished quality of life.Findings included . Review of the facility policy titled, Pre-admission Screening and Resident Review (PASARR) reviewed 09/26/2024, showed the facility must incorporate the recommendations from the PASARR level II determination and the evaluation report into a resident's assessment, care planning and transitions of care. Resident 2 admitted to the facility on [DATE] with diagnoses to include mood disorder, anxiety and development disorder of speech and language. Review of the clinical record showed a Level I PASRR was completed prior to admission for Resident 2 on 06/16/2025. The resident was assessed to need a Level II evaluation referral for SMI and also ID. The assessment noted the resident had a history of anxiety and depression and developmental delay. Review of the clinical record on 09/24/2025 showed there were no level II PASRR's in Resident 2's electronic health record (EHR). Review of the Level II PASRR completed 07/18/2025, provided after request on 09/24/2025 included the residents' goal to return to their apartment with their birds. The assessment documented that Resident 2 would often make threats when they were afraid. The recommendation was to ask the resident several questions about their needs or wants to get an understanding of how to proceed. The assessment documented that Resident 2 was often not listened to because they came off strong or would throw something or hit when they don't agree. The recommendation was to give Resident 2 time to express their concerns in a healthy way. Review of the follow up Level II PASRR completed 08/12/2025 included Resident 2's mental health history and approaches to be utilized by staff to identify triggers and mitigate the resident's outbursts. The PASRR included Resident 2's need for slowing down and listening when they were agitated. The evaluation noted Resident 2 needed people who would listen through the outbursts to understand what they needed. The evaluation noted that the resident wanted to go home to their birds and didn't always have the words or understanding of why they needed to follow doctor directives in order to heal correctly. The resident needed to be asked why they were doing things, so that staff could figure out how to help them. The evaluator included two examples that occurred at the facility such as they were not taking their antibiotics and it wasn't until the evaluator asked why, that they found out the antibiotics made them feel sick; at that time, the evaluator asked facility staff about an anti-nausea medication before the antibiotic to help them with feeling sick. Resident 2 understood, and the problem got resolved. Another example was that the resident took the foot board off their bed and put it under their bed. The staff were upset with them for doing this and put it back on. When Resident 2 was asked why they did that, they stated it was because it was putting pressure on their amputated foot. The staff then understood and replaced the footboard with an extended bed and mattress. These are just a few of the examples of what the resident goes through to communicate and be understood. Review of Resident 2's care plan, initiated on 06/30/2025, did not include Level II PASRR recommendations. In an observation on 09/26/2025 at 10:46 AM, Resident 2 was up in their wheelchair at the nurses' station and was frowning. Resident 2 stated everything was screwed up. The resident stated they would like a peanut butter and jelly sandwich in the middle of the night, so their blood sugar wouldn't drop. Resident 2's caregiver from their life skills group was present and stated, You look grumpy again today. Resident 2 confirmed they were grumpy. In an interview on 09/25/2025 at 10:52 AM, Staff B, Director of Nursing Services (DNS) provided the level II PASRR recommendations for Resident 2, that were not in the medical record. Staff B stated Resident 2 was about to be discharged and they were anxious, and they cried for attention. Staff B stated PASRR recommendations should be on the care plan. In an interview on 09/25/2025 at 11:42 AM, Staff D, Social Services Director stated the level II from Developmental Disability Administration (DDA) was not in the EHR. In an interview on 09/29/2025 at 10:32 AM, Staff T, Regional Director of Clinical Services stated they were unaware of any PASRR concerns. Refer to WAC 388-97-1915(1)(2)(a-c) .

Based on observation, interview and record review, the facility failed to address, respond to and/or resolve concerns and/or suggestions brought forward by the resident council (RC) for 6 of 6 months (March, April, May, June, July and August 2025) of RC minutes reviewed. Additional failed practice included the facility failure to maintain complete and accurate Resident Council meeting minutes that included details of concerns and grievances voiced during Resident Council meetings, and failures to log, report, investigate, and resolve concerns voiced by the Resident Council. These failures resulted in the same unresolved/unaddressed concerns being brought forward for consecutive months without resolution, and resulted in RC members feeling frustrated, unheard and powerless to affect the care they receive and/or their environment. Findings included .Review of the facility policy titled, Resident Council reviewed 09/26/2024, showed the Activities Director or Social Service Director will facilitate follow-up on all complaints, suggestions and ideas presented at the council meeting and will report results at the next meeting for the residents' information. This information will be included in the minutes. Each department director will be responsible for filling out a comment and concern form prior to the next meeting to provide his or her input.Review of the resident council minutes from 03/19/2025 showed old business from the prior month included out of facility activities. New business discussed was concerns over wheelchair cleaning. Review of the resident council minutes from 04/23/2025 showed old business from the prior month included the group wanting more out of facility activities, concerns over wheelchair cleaning and call lights. New business discussed was concerns over trash being left on tables and the group asked if nurses could answer call lights.Review of the resident council minutes from 05/21/2025 showed old business from the prior month included future activities and call light times. New business discussed was concerns over medications not being delivered on time and lots of employees on their cell phones. Residents requested going to a car show and other future activities.Review of the resident council minutes from 06/18/2025 showed the residents wanted to know about the bus getting fixed. The group voiced a concern about oxygen tubing not being replaced after it was left on the floor.Review of the resident council minutes from 07/23/2025 showed old business from the prior month included the juice machine getting repaired. New business discussed was they would like to go to the bowling alley. Concerns brought up were having to ask the nurses' aides for help twice, then finding the aides on their phones. Long call light times were brought up as well.Review of the resident council minutes from 08/27/2025 showed old business discussed was staff cell phone use and call light concerns. The group inquired about the status of the juice machine.The resident council meeting notes for March 2025 through August 2025 identified residents' issues and concerns were not escalated to a grievance investigation. The meeting minutes did not include written facility responses to the grievances, and often the concern(s) were not resolved and were carried over to the next month.Review of Grievance Log from March 2025 through 09/14/2025 showed grievances and recommendations from the RC were not escalated to a grievance form or the log. In the resident council meeting 9/24/2025 at 11:03 AM, Resident 58 stated the juice machine in Havenwood had been broken for 2 years. The resident stated they did not understand why the facility could not fix it. The resident stated the juice machine was brought up at every single resident council meeting. They said the van had been sitting there since 2020. They noted the license tabs were dated 2020. The resident stated they would like to go see the Lights of Christmas in [NAME], but the van was broken, and it had been for years. They stated out of facility outings were limited to where they could be pushed and they all wanted more outings. During the RC meeting, Resident 63 stated the facility should fix the juice machine and van instead of decorating. Resident 63 stated Why even come to these meetings. Nothing gets fixed.During the RC meeting, Resident 7 stated This is our home. They need to fix the van and juice machine. They get new administration all the time who say they are looking into it. There are excuses after excuses. They say we need a smaller bus that doesn't require Commercial Driver's License (CDL) or other excuses. I feel like I am wasting words, why even complain or come to these meetings. Nothing changes. During the RC meeting Staff F, Activity Director stated that they literally push five to six residents in their wheelchairs to places in the community. Staff F stated outside activities take a lot of help to push the residents in their wheelchairs. Staff F said they kept getting different answers from administration about fixing the van. The RC group was asked if the RC group made suggestions about some of the rules, did the facility act on those suggestions, and considered the views of the RC and act promptly upon grievances and recommendations. Resident's 7, 18,19,33 ,44, 58, and 63 nodded their heads indicating no and/or stated no. When asked does the grievance official respond to the resident council groups concerns and provide a rational for their response? They responded no.In an observation on 09/29/2025 at 1:47 PM, the facility van was observed in the parking lot. The passenger side window by the lift had been broken and was covered with plastic. There was mold growing on the van. The tabs on the rear license plate showed the last registration was March 2020.In an interview on 09/29/2025 at 10:16 AM, Resident 32, Resident Council President said the group frequently brings up the juice machine and it was broken and needed to be removed. The resident stated the van was another repeat concern at the meetings each month. The resident said the facility did not respond in writing or verbally about their concerns and that communication with the group could be improved. The resident stated that the group not knowing about the Ombuds program, location of survey results and how to contact the state was on her. The resident stated the RC group knew they could come to her for contact information.In an interview on 09/29/2025 at 9:49 AM, Staff A, Administrator stated the facility van had a fuel line issue and they were going to dispose of it or sell it and get a smaller van. Staff A stated the juice machine would be getting fixed. Reference: (WAC) 388-97-0920 (4) (5)

Based on interview and record review, the facility failed to ensure that current legal guardian documents were in the resident's medical record and did not provide written and verbal information related to formulating an advance directive for 1 of 5 (Resident 4) residents reviewed for advance directives. These failures placed the resident at risk of not having correct or updated legal guardian documents to verify the accurate guardian and to allow the legal guardian to formulate an advance directive to express their medical care preferences.Findings included .Resident 4 was admitted to the facility on [DATE] with diagnoses to include personal history of traumatic brain injury (occurs when an external force causes damage to the brain), aphasia (language disorder that affects ability to speak, understand, read and write), and communicating hydrocephalus (accumulation of cerebrospinal fluid in the brain's ventricles).Review of Resident 4's Electronic Health Record (EHR) showed they had a legal guardian as their responsible party. Review of the EHR showed no legal documents in their medical record.Review of Resident 4's EHR showed there was no verbal or written documentation provided for the legal guardian to formulate an advance directive.In an interview on [DATE] at 12:49 PM, Collateral Contact 2 (CC2), Resident 4's legal guardian, stated the first time they had been requested by the facility to provide legal guardianship documents was approximately the week before the interview. CC2 stated that there had been a change to the most recent legal guardianship documents as they removed a co-guardian and replaced them with another individual.Review of Resident 4's care plan conference, dated [DATE], CC2 was requested to provide a copy of their legal guardian documents. In an interview on [DATE] at 2:30 PM, Staff A, Administrator, stated the facility had documents in the resident's paper chart and provided a document of legal guardianship, with CC2 listed as a legal guardian. This document was issued on [DATE] and expired on [DATE]. Staff A stated that the legal guardian had been asked to provide the guardian documents on [DATE]. Staff A provided no further documentation related to current legal guardian documents or advance directive documents that were provided to the legal guardian. Reference WAC: 388-97-0280 (3)(c)(i-ii)

Based on interview and record review the facility failed to report an injury of unknown source with significant injury for 1 of 1 resident (Resident 5) reviewed for reporting. The facility's failure to report delayed appropriate oversight and investigation, placing residents at risk for harm and unidentified abuse and/or neglect.Findings included .The State of Washington's Nursing Home Guidelines-The Purple Book dated October 2015, Prevention and Protection, Incident Identification, Investigation, and Reporting directs what nursing home facilities report. The facility should report to the Department by telephone and via the reporting log when there was reasonable cause to believe violations have occurred involving abuse, neglect, abandonment, mistreatment and injuries of unknown sources. Facility would report to the department within two hours if there was serious bodily injury; or within 24 hours, if there was not serious bodily injury.Resident 5 re-admitted to the facility on [DATE] with diagnoses to include pneumonia, falls, and encephalopathy (brain disease that alters brain function).Review of Resident 5's care plan dated 06/16/2025 documented they were at risk for falls and to keep their bed in the lowest position.Review of the facility incident report, dated 06/17/2025, documented Resident 5 was found in their room on the floor next to their bed. Resident 5 was documented to complain of right hip pain, and x ray was done, and a hip fracture was identified. Resident 5 was sent to the emergency room. The incident report documented an unwitnessed fall and Resident 5 could not state what occurred. The incident report did not document if the state hotline had been notified of Resident 5's fracture. The incident report did not contain information about if Resident 5's care plan was being followed.In an interview on 09/25/2025 at 2:15 PM Staff B, Director of Nursing Services, stated they were unaware of the need to make a report to the state hotline and deferred to Staff C, Director of Clinical Services.In an interview on 09/25/2025 at 2:16 PM Staff C, Director of Clinical Services stated falls with serious injuries that were not witnessed, and the residents were not able to state what occurred, a report needed to be made to the state hotline. Refer to WAC 388-97-0640(5)(a)

Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were completed timely for all residents following significant change in status for 1 of 5 residents (Resident 20) reviewed for possible serious mental disorders and related conditions. This failure resulted in a potential inability to receive and benefit from Level II PASSR services for Resident 20 and placed other residents at risk for a decreased quality of life. Findings included . Review of the facility policy titled, Pre-admission Screening and Resident Review (PASRR), reviewed 09/26/2024, showed the nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review. Resident 20 was admitted to the facility on [DATE] with diagnosis of anxiety disorder. Review of the care plan developed 08/12/2024 showed the resident had a history of anxiety and depression. The care plan was revised on 04/29/2025 to include Resident 20 reporting falls that did not occur and injuries that were not substantiated. Review of Resident 20's admission Minimum Data Set (MDS) assessment dated [DATE] and Quarterly MDS dated [DATE] documented the resident was not experiencing hallucinations (perception of having seen, heard, touched, tasted or smelled something that was not actually there) or delusions (false belief that persists despite evidence proving it is false). The resident required extensive assistance to get out of bed. Review Resident 20's Level I PASRR, dated 08/07/2024, showed the resident had serious mental illness indicators including mood and anxiety disorder. The PASRR indicated a Level II PASRR referral was indicated for recurrent major depressive disorder and mixed anxiety depressive disorder. Review of Resident 20's Level II PASRR invalidation assessment, dated 08/08/2024, showed the reason for invalidation was Resident 20 did have one or more serious mental illness and did not have symptoms of serious mental illness. Review of Resident 20's psychiatric provider visit note dated 02/28/2025 at 10:30 AM, showed the resident was experiencing delusions. Review of Resident 20's psychiatric provider visit note dated 03/15/2025 at 9:30 AM, showed the resident was experiencing delusions. Review of Resident 20's psychiatric provider visit note dated 05/08/2025 at 9:30 AM, showed staff reported the resident was experiencing ongoing persecutory delusions regarding staff. Resident 20 reported they started hallucinating when they had COVID and it was all in their head. Review of Resident 20's psychiatric provider visit note dated 07/18/2025 at 9:45 AM, showed the resident was experiencing increasing delusions per chart review. Review of Resident 20's psychiatric provider visit note dated 08/21/2025 at 9:15 AM, showed delusions were evident on exam. Review of a health status note on 09/08/2025 at 2:21 PM, showed Resident 20 stated they did not need exercise and reported several delusions of walking down the hall by themselves with their walker the previous day. The provider was notified of continued delusions and inconsistencies in memory accuracy. In an interview on 09/23/2025 at 9:21 AM, Resident 20 stated that one time they snatched a cane from the physical therapy (PT) equipment room and walked out of the facility and down the block. They stated they walked down the block and called their brother to tell him they could walk. In an interview on 09/24/2025 at 1:10 PM, Resident 20 stated their family owned a castle in [NAME], a [AGE] year old brewery in Minnesota and that they had been a published author since they were sixteen. They stated their son had junk movers come, and they took their 125 books, [NAME] press badge. Resident 20 stated they had been invited to join Queen [NAME]. Review of the clinical record showed there was no significant change in PASRR referral when Resident 20 began experiencing delusions. In an interview on 09/25/2025 at 10:50 AM, Staff B, Director of Nursing Services (DNS) stated Resident 20 had delusions and at first, they thought they had borderline personality disorder. Staff B stated Resident 20 should have a PASRR revision for the delusions. In a follow up interview on 09/29/2025 at 11:24 AM, Staff B, DNS stated that Staff D, Social Services Director, confirmed they did not send off the level II PASRR for Resident 20 when they began experiencing delusions. In an interview on 09/29/2025 at 9:50 PM, Staff B, DNS stated they had been unaware of any PASRR issues in the facility. Reference (WAC): 388-97-1975 .

Based on interview and record review, the facility failed to revise care plans to accurately reflect resident conditions and needs for 2 of 4 residents (Resident 5 and 82) reviewed for falls and dental. This failed practice had the potential for unmet resident care needs.Findings Included.Review of the facility policy titled, Comprehensive Care Plans and Conferences, reviewed 08/29/2025 documented the resident's care plan must be reviewed after each assessment and revised based on changing goals, preferences and needs of the resident and in response to current interventions.<FALLS>Resident 5 re-admitted to the facility on [DATE] with diagnoses to include pneumonia, falls, and encephalopathy (brain disease that alters brain function).Review of the facility state reporting log documented Resident 5 had unwitnessed falls on 06/16/2025, 06/17/2025, 07/12/2025 and 08/24/2025.Review of the facility incident report dated 06/16/2025 documented Resident 5's bed would be placed in the lowest position as an intervention.Review of the facility incident report dated 06/17/2025 documented Resident 5 was sent to the emergency room.Review of the facility incident report dated 07/12/2025 documented Resident 5 was placed in an area where they would be seen by staff frequently and their room was within sight of the nurse's station.Review of the facility incident report dated 08/24/2025 documented Resident 5 was checked on hourly.Review of Resident 5's care plan showed they were at risk of falling with an intervention to keep their bed in the lowest position.In a joint interview on 09/25/2025 at 1:36 PM with Staff E Assistant Director of Nursing (ADNS), Staff B DNS, Staff E stated when a resident falls, an investigation is completed. Staff E stated they try to determine the cause of the fall and implement interventions. Staff E stated they discussed falls during clinical rounds and updated the care plan. Staff B stated they thought the care plan was updated with the interventions described in the incident reports for Resident 5.<ORAL CARE>Resident 82 admitted to the facility on [DATE] with diagnoses to include history of a stroke and facial weakness.Review of Resident 82's care plan dated 03/19/2025 for activities of daily living had no interventions related to oral care needs.Review of Resident 82's dental note dated 09/11/2025 documented the daily oral hygiene plan was to brush their teeth twice daily.In an interview on 09/29/2025 at 10:21 AM Staff G, Nursing Assistant Certified stated they brush resident's teeth during morning care prior to breakfast. When asked how they know how to care for a resident Staff G stated they review the Kardex ( or the care plan.In an interview on 09/29/2025 at 10:36 AM Staff H, Registered Nurse/Unit Care Coordinator stated a resident's oral care needs were documented in their electronic health record and the task was automatically placed in the charting for the nursing aides. Staff H stated Resident 82 required total assistance for oral care. Staff H stated a care plan should be in place to address Resident 5's oral care needs. Staff H stated dental hygienist notes were reviewed after their visit, and any recommendations should have been in Resident 82's care plan.WAC 388-97-1020 (1)(a)(5)(b)

Based on observation, interview and record review, the facility failed to ensure that services provided met professional standards for 2 of 3 (Resident 6 and 70) residents reviewed for professional standards. Resident 6 did not receive prescribed bowel medications when they experienced constipation and Resident 70 had a change in condition that required monitoring and new medication orders that were not documented timely. These failures placed residents at risk of not being appropriately monitored during a change in condition, effectiveness or side effects of new medications, constipation, pain, and a decreased quality of life. Findings included. Review of the facility policy titled Bowel Protocol, revised date 09/16/2024, documented the facility in coordination with the resident's attending practitioner would implement standing orders to address a lack of bowel movement. <RESIDENT 6> Resident 6 readmitted to the facility on [DATE]. Review of Resident 6's bowel elimination record from 09/09/2025 to 09/23/2025, documented the resident had no bowel movement from 09/16/2025 to 09/20/2025 (five days). Review of Resident 6's care plan, initiated date 10/22/2024, documented the goal of the focus area for constipation was to have a normal bowel movement at least every three days, and one of the interventions was to follow the facility's bowel protocol. Review of Resident 6's Medication Administration Record (MAR) dated 09/16/2025 to 09/20/2025, documented the following medications for constipation were ordered; Miralax powder daily as needed for constipation; senna oral tablet every 12 hours as needed for constipation; milk of magnesia suspension as needed for constipation for no bowel movement for three days; Bisacodyl suppository as needed for constipation if no results from milk of magnesia. The MAR showed these medications were not administered. Review of Resident 6's progress notes from 09/16/2025 to 09/20/2025, there was no documentation about the resident's bowel movement assessment or any intervention provided. In a record review and interview on 09/25/2025 at 11:42 AM, Staff B, Director of Nursing Services, stated there was no documentation that nurses provided any intervention about constipation for Resident 6 during 09/16/2025 to 09/20/2025. Staff B stated they expected nurses to follow the bowel protocol and administer medication orders when residents had no bowel movement for three days. <RESIDENT 70> Resident 70 was admitted to the facility on [DATE], with diagnoses to include intestinal adhesions with complete obstruction (bands of scar tissue that cause obstructions in the intestines), spinal stenosis (narrowing of the spine) and radiculopathy (pinched nerve in the spine). In an observation on 09/22/2025 at 9:15 AM, Resident 70 was observed sitting up in their wheelchair at the sink in their room. Resident 70 started to gag and then had emesis (vomited), staff came to assist the resident and Staff J, Registered Nurse (RN) Unit Nurse, was alerted the resident had emesis. In an observation on 09/22/2025 at 10:08 AM, Resident 70 was observed lying asleep in bed with an emesis basin positioned in their lap. In an observation on 09/23/2025 at 10:29 AM, Resident 70 was observed lying in bed, asleep with an emesis basin on the overbed table. In an observation and interview on 09/24/2025 at 9:29 AM, Resident 70 was sitting up in bed, with the emesis basin on the over bed table that was within reach. Resident 70 stated they felt nauseated again today and felt dizzy with movements. Resident 70 stated that Staff J, RN Unite Nurse had contacted the Provider related to their nausea and dizziness, but had not heard anything further. In an interview on 09/24/2025 at 2:14 PM, Resident 70 stated they no longer felt nauseated, but still felt dizzy when changing positions to lying or sitting. Resident 70 stated Staff J, RN Unit Nurse, had not returned to give an update related to contacting the Provider. Resident 70 stated they hope it would be soon and maybe they would have to wait until 09/25/2025 to hear back. Review of Resident 70's Medication Administration Record (MAR) dated September 2025, showed the resident received the medication Zofran (anti-nausea medication) which was ordered by the Provider and given as a one-time dose on 09/22/2025. An order for Meclizine (anti-vertigo/dizziness medication) was ordered by the Provider on 09/24/2025 to be given two times daily for seven days. Review of Resident 70's progress notes showed no documentation since 09/19/2025. There was no documentation related to their nausea, emesis, Provider notification, change in condition, or medications that had been ordered. In an interview on 09/25/2025 at 2:34 PM, Staff J, RN Unit Nurse, stated that they had been Resident 70's assigned nurse on 09/22/2025, 09/23/2025, 09/24/2025 and 09/25/2025. Staff J stated they would document the progress notes if a resident had a change in condition, nausea, emesis, new medication orders and if the Provider had been contacted. Staff J stated that it should be documented in an alert note. When asked about Resident 70's lack of documentation, they stated they had just done late entries related to their nausea, emesis, and medication orders and verified they had not documented in their progress notes until today. In an interview on 09/29/2025 at 9:42 AM, Staff B, Director of Nursing Services, stated their expectation was that documentation related to change in condition, new nausea or emesis, Provider contact and new medication orders would be timely. Staff B stated that the resident should have been on alert documentation, meaning every shift should document on the resident's status for at least 72 hours. Reference WAC 388-97-1620(2)(b)(i)(ii)

Based on interviews, and record review, the facility failed to ensure 1 of 4 sampled residents (Resident 1) reviewed for blood thinning medication (Warfarin) use were free from significant medication errors. Resident 1 experienced harm when they received two doses of a blood thinning medication when the medication was on hold, were hospitalized for a brain hemorrhage (bleeding within the skull), had an INR (International Normalized Ratio - a test to determine how long it takes for blood to clot) of 6.9 (normal range for resident 2.5-3.5) and required Kcentra and Vitamin K (blood clotting medications used for urgent reversal of blood thinner medications) in the emergency room. This failure placed all residents receiving blood thinning medications at risk for significant medication errors, serious complications from bleeding and a diminished quality of life. Findings included. Review of a facility policy titled Anticoagulation Management, review date 11/19/2024 documented: - Review the MAR (medication administration record) for the previous day's anticoagulant order to ensure the anticoagulant was administered or held per physician order. - Review the MAR to ensure the PT/INR (Prothrombin Time Test - a test to determine how long it takes for blood to clot) has been completed as ordered. - Review the PT/INR/Coumadin Flowsheet is current with the PT/INR results, current dose, MD notification, dose change, and the next date for the PT/INR. - Review the medical record to ensure the physician was notified of the PT/INR results and any new orders have been noted - Review the MAR to ensure any new orders have been properly transcribed <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include nontraumatic intracranial hemorrhage (bleeding within the [NAME]), atrial fibrillation (irregular heartbeat), and presence of prosthetic heart valve, and long term (current) use of anticoagulants (blood thinning medication). Review of Resident 1's medical record showed Resident 1 was sent to the ER on [DATE]. Review of Resident 1's hospital records ED (Emergency Department) COURSE dated 07/12/2025 documented: - 12:32 AM-patient has a left temporal/occipital 4.1 cm intraparenchymal hemorrhage with surrounding vasogenic edema (fluid in the brain causing swelling and pressure within the [NAME]), no midline shift (movement of brain tissue from the center of the [NAME]). - 1:06 AM-INR is 6.9. Kcentra (blood clotting medication for urgent reversal of blood thinner medication) and Vitamin K (treatment used to normalize high INR) were ordered. Review of a document titled PT/INR/Coumadin Flow Sheet, documented Resident 1's INR range should be between 2.5-3.5. On 07/09/2025 the flow sheet documented Resident 1's INR result was 3.8, the MD was notified, and the dose change column documented to Hold medication and re-check the INR on 07/10/2025. There was no documentation on the PT/INR Flow Sheet for 07/10/2025. Review of Resident 1's MAR, dated July 2025, documented Resident 1 was administered Warfarin 1.5 mg at 5:00 PM on 07/09/2025 and 07/10/2025. Review of Resident 1's progress notes did not show alert charting or guardian notification for INR results of 3.8 or an order to hold Warfarin on 07/09/2025. Review of Resident 1's progress note titled Transfer to Hospital Summary, dated 07/15/2025 at 5:16 PM, a late entry note entered by Staff B, Registered Nurse (RN), Director of Nursing, documented Review of notes from the hospital on [DATE] showed the resident had a brain bleed again and their PT/INR was higher in the ED when they returned. Staff B documented review of eMAR [electronic medical record] and provider notes showed the last PT/INR in the facility of 3.8 on 07/09/2025. Provider held coumadin at that time.In an interview on 07/17/2025 at 11:45 AM, Staff C, RN, stated the day shift nurse would obtain the INR and fill out the INR/Coumadin flow sheet to include INR result, current order, provider notification, new order and next INR date. Staff C stated that the provider makes the decision whether to change medication, hold medication and when they want the next INR done. Staff C stated that new orders would be entered into the computer and on the MAR. The nurse would make a progress note and the resident would be placed on alert charting if the INR was abnormal. In an interview and record review on 07/17/2025 at 1:26 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager, stated Resident 1's INR Flow Sheet documented an INR result of 3.8 on 07/09/2025, and orders were to hold the residents Warfarin and recheck the INR on 07/10/2025. Staff D stated Resident 1's INR would not have been checked on 07/10/2025 because that was a Thursday and INRs were only checked on Mondays, Wednesdays, and Fridays. Staff D stated the INR recheck date of 07/10/2025 was entered incorrectly because we don't check INRs on Thursday's. Staff D reviewed the July 2025 MAR and confirmed that documentation showed Resident 1 had received Warfarin 1.5 mg on 07/09/2025 and 07/10/2025. In an interview and record review on 07/22/2025 at 4:00 PM, Staff B stated Resident 1 received Warfarin 1.5 mg on 07/09/2025 and 07/10/2025 and the INR was not checked on 07/10/2025. Staff B stated the PT/INR Flow Sheet is an internal form and is not used exclusively because the provider may give an order and then later change the order. Staff B stated a verbal order could be given by the provider after the INR flow sheet had been completed and if there was not a change to the current order a new order would not be entered, and the MAR would not be changed. Staff B stated they would expect that each time a medication is held it would be discontinued on the MAR or a new order to hold the medication would be initiated. Reference WAC 388-97-1060(3)(k)(iii)

Based on interview and record review the facility failed to administer physician medication orders for 1 of 2 (Resident 1) residents reviewed for medication errors. Failure to clarify a physician's order for a diuretic (medication to reduce fluid buildup in the body) medication resulted in a significant medication error that caused harm to Resident 1 who experienced anasarca (swelling caused by excess fluid trapped in body tissues) of all extremities with a significant increase in lower extremity swelling. Resident 1 required hospitalization for shortness of breath, acute on chronic congestive heart failure (a long-term condition when the heart cannot pump blood well enough as it should) and pleural effusions (buildup of fluid between tissues that line the lungs and chest). Failure to properly administer physician medications orders placed residents at risk for complications and a potential decline in their condition. Findings included . Resident 1 readmitted to the facility on [DATE] with diagnoses that included acute duodenal ulcer (a sore that forms in the lining in the first part of the small intestine) with hemorrhage, hypertensive (elevated blood pressure) chronic kidney disease, chronic congestive heart failure, atrial fibrillation (an irregular, often rapid heart rate), and diabetes with complications. Review of a progress note, dated 05/09/2023, showed Collateral Contact 2 (CC2), physician assistant certified (PA-C) from Resident 1's physician clinic, documented the resident had venous stasis (slow blood flow in the legs that creates swelling, pressure, and skin problems) of the lower extremity and a significant increase in lower extremity swelling. CC2 ordered to increase the Torsemide (diuretic medication) to 40 milligrams (mg) twice daily for four days. Review of the May 2023 Medication Administration Record (MAR), showed Resident 1's Torsemide had been increased for four day and then dropped off the MAR from 05/14/2023 to 05/23/2023 (the resident Torsemide had dropped off the MAR and they did not receive any diuretic for nine days). Review of CC2's progress note, dated 05/29/2023, showed when Resident 1's orders were processed on 05/09/2023, they were done incorrectly [by the facility] and the Torsemide medication dropped off the clinical record completely after a temporary increase had been ordered. Resident 1 had not received Torsemide from 05/14/2023 through 05/22/2023 (for nine days). Resident 1's Primary Care Provider (CC4), came to facility on 05/23/2023 to assess the resident and found [Resident 1] short of breath and with anasarca (extreme fluid accumulation throughout entire body). During a joint interview and record review on 08/29/2023 at 11:10 AM, CC2 stated they were overseeing Resident 1's care in the facility. CC2 stated the resident was seen on 05/09/2023 and evaluated for concerns of significant increase of lower extremity edema. During the assessment CC2 documented Resident 1 had four plus (most severe type) edema and a wound noted on the right great toe. CC2 gave orders to increase Torsemide (diuretic medication to decrease fluid retention) to 40 mg twice daily for four days. CC2 documented the wound on the right great toe was likely due to increased edema. CC2 stated on 05/23/2023, CC4 to assess the resident for a change in condition, and it was determined at that time Resident 1 had not received Torsemide medication from 05/14/2023 through 05/22/2023. In an interview on 08/30/2023 at 11:40 AM, Staff E, Licensed Practical Nurse (LPN), stated they had never reviewed or noted visit notes from the outside providers which included notes from CC2 and CC4. Staff E stated when outside providers saw residents, they assumed the nurse managers reviewed the visit notes and orders and not them. Staff E stated if there was an order to temporarily increase a medication the resident already received, then after that increase the dose would automatically go back to the prior dose. In an interview on 08/30/2023 at 12:15 PM, Staff D, Registered Nurse/Nurse Manager, stated they did not think physician visit notes were reviewed by nursing staff, stating I don't usually get those in paper form, it would be really nice if every time the doctor did a visit, we got a little note like this (referring to extended care visit progress note). Staff D stated that if a provider wrote an order to increase a medication for a short period and the resident was already receiving that medication, they would clarify the order when the temporary increase was completed to continue the medication. During a joint interview and record review on 08/30/2023 at 2:00 PM, Staff A, Director of Nursing (DNS), reviewed Resident 1's physician orders and stated Resident 1 did not receive the diuretic from 05/14/2023 through 05/22/2023. Staff A stated they were unaware of this medication error and had not been notified that it happened. Staff A, stated when a provider wrote an order to temporarily increase a medication the expectation was that staff clarify the order, so they know what the physician wanted doctor wants to do after the temporary increase was completed. Reference WAC 388-97-1060 (3) (k)(iii)

Based on interview and record review, the facility failed to ensure physician orders and recommendations were followed and a change in condition was identified timely accordance with professional standards of practice for 1 of 3 residents (Resident 1) reviewed for a change in condition. Resident 1 experienced harm when they had a severe increase in edema (swelling caused by excess fluid trapped in body tissues) of all extremities, and developed complications from incorrect application of compression stockings, a lack of monitoring and treating the edema, development of a wound on the right toe related to the increased swelling that required hospitalization for shortness of breath, acute on chronic congestive heart failure (a long-term condition when the heart cannot pump blood well enough as it should), and pleural effusions (buildup of fluid between tissues that line the lungs and chest). The failure to ensure physician orders and recommendations were followed placed residents' at risk to develop medical complication. Findings included . Resident 1 readmitted to the facility on [DATE] with diagnoses that included acute duodenal ulcer (a sore that forms in the lining in the first part of the small intestine) with hemorrhage, hypertensive (elevated blood pressure) chronic kidney disease, chronic congestive heart failure, atrial fibrillation (an irregular, often rapid heart rate), and diabetes (chronic health condition characterized by elevated level of blood glucose [sugar]) with complications. Review of the Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 05/26/2023, showed Resident 1 was cognitively intact and required two-person extensive assistance with bed mobility, transfers, dressing, and toileting. Review of progress note, dated 05/09/2023, showed Collateral Contact 2 (CC2), physician assistant certified (PA-C) from Resident 1's physician clinic, documented the resident had venous stasis (inflammation of the skin of the lower legs as a result of improper functioning of the vein valves in the legs) of the lower extremities and a two centimeter (cm) sore on the right great toe likely related to the increased edema. CC2 requested the facility's contracted wound healing team to evaluate the resident on 05/11/2023 and increased Torsemide (medication to help with fluid retention) to 40 milligrams (mg) twice daily for four days. Review of CC2's progress note, dated 05/29/2023, showed follow up of orders from 05/09/2023, showed the Torsemide order was processed it was entered incorrectly [by the facility] and Torsemide medication dropped off the record completely. CC2 documented Resident 1's Primary Care Provider came to visit on 05/23/2023 and noted the resident had shortness of breath and anasarca (general swelling throughout the body). Review of CC2's physician order, dated 05/26/2023, showed Please have [contracted wound care company] see [Resident 1] as ordered on 05/09/2023. Review of CC2's physician order, dated 06/09/2023, showed If not done to date please Wound Care evaluation by [contracted wound care company] for lower extremity venous stasis/edema management as ordered on 05/09/2023 and 05/26/2023. Review of Resident 1's medical record, showed no documentation the facility requested their contracted wound care provider to evaluate the resident's venous stasis and swelling in the resident lower extremities per CC2's physician orders dated 05/09/2023, 05/26/2023 and 06/09/2023. Review of CC3, contracted wound care company PA-C, visit note, dated 06/22/2023 (the initial wound care visit by), showed Resident 1 was being seen for chronic lymphedema (swelling in an arm or leg caused by a lymphatic system blockage). Recommendations included compression bandaging system (a unique compression wrap system that is effective in management of edema in the lower extremities). Review of CC2's progress note, dated 06/26/2023, showed Resident 1 had venous stasis of lower extremity present, spoke with CC3 last week regarding possible addition of Unna wraps (a type of compression dressing) versus edema compression device (a device that treats chronic edema and venous disease with the use of forced air into a sleeve or garment). CC2 documented it is unclear if they [CC3] saw [Resident 1] or not, will await their recommendations. Review of a podiatry visit note dated 07/06/2023, showed Resident 1 was seen for long, thick toenails, and complaints of pain related to a blister on the right foot measuring approximately 2 x 2 centimeters, that started the night before. Review of CC2's progress note, dated 07/18/2023, showed they were notified today that Resident 1 had a blister on the right foot (no measurements). The nursing staff documentation on 07/10/2023 indicated the resident had been seen by a podiatrist on 07/06/2023 and orders were given to treat their right foot blister. When CC2 assessed Resident 1, the compression stockings on the resident's lower legs had not been applied correctly and the blister was likely a result of staff applying stockings ineffectively. CC2 discussed these concerns with the resident's nurse and the unit manager. CC2 documented again wrote order for resident to be evaluated by the contracted wound healing provider this week. Resident [1] was at risk for cellulitis (a common and potentially serious bacterial skin infection), if the resident's edema management and skin care not done appropriately. Review of CC2's physician orders on 07/18/2023, showed CC2 documented to please admit to [contracted wound care company] for evaluation and management of lower extremity edema and right foot blister, [CC3] Practitioner is aware of Resident 1's issue with edema and was planning to look into management options. Review of CC3's note, dated 07/20/2023, showed Resident 1 was seen for follow-up of chronic lymphedema and now had an open area on the right foot. The resident's condition had not improved. During a telephone interview on 08/22/2023 at 2:15 PM, CC1, Registered Nurse (RN)/Case Manager from Resident 1's physician clinic, stated they had multiple concerns with the facility staff's lack of assessing and monitoring the resident for changes in condition and reporting those changes in condition to the providers or the resident's primary care provider (PCP). CC1 stated there was a concern back in May 2023 when Resident 1 did not receive their diuretic medication for nine days and the error was only discovered when the physician was reviewing the resident's condition due to an increase swelling and breathing concerns. CC1 stated they were in the facility on 08/03/2023 to follow up with Resident 1 on behalf of their PCP. Resident 1 was noted to have an increase in their edema throughout their whole body and complained of experiencing shortness of breath. CC1 stated these concerns were discussed with Staff B, Licensed Practical Nurse/Nurse Manager, but no one from the facility had come in to assess Resident 1. CC1 stated on 08/04/2023, Resident 1's PCP directed them to come to the facility and assess Resident 1. CC1 stated they came into the facility, completed an assessment, found Resident 1 had increased complaints of shortness of breath, and increased edema. The PCP was notified, and orders given to send Resident 1 to the emergency room for treatment and CC1 called 9-11 for transportation. CC1 stated facility staff did not respond to their voiced concerns regarding Resident 1. In an interview on 08/28/2023 at 2:15 PM, Staff B stated CC1 was in the facility on 08/03/2023 with Resident 1's family member. Staff B stated they discussed Resident 1's condition with CC1 and the family. Staff B stated they informed CC1 Resident 1's wound on their right foot was assessed that day and it looked better than it had the week prior. Staff B stated CC1 had voiced some concerns regarding edema but they (Staff B) had not completed an assessment of the resident at that time and was unsure if the nurse on the floor had assessed the resident either. Staff B stated CC1 was in the facility on 08/04/2023 when Resident 1 was sent to the hospital, but CC1 was the one who called 911 to have the resident sent to the hospital, and facility staff didn't know what was happening until Emergency Medical Services (EMS) arrived at the facility. In an interview on 08/29/2023 at 1:40 PM, Staff A, Director of Nursing (DNS), stated the situation with Resident 1 occurred on 08/04/2023 was strange and from what they understood the provider was in the facility that day, contacted the resident's PCP, and called 911 without talking to facility staff first. Staff A stated they were unsure who the provider (CC1) even was, stating No one knew them. Staff A stated they were unaware CC1 had been in the facility the day prior and had discussed Resident 1's condition with Staff B. Staff A stated their expectation for nursing staff was a full assessment would be completed when a resident had a change in condition but was unable to confirm if the nurse assessed Resident 1 prior to the resident leaving the facility on 08/04/2023. In an interview on 08/30/2023 at 11:20 AM, Staff C, RN, stated they were the nurse assigned to Resident 1 on 08/04/2023. Staff C stated they were unaware of any issues with Resident 1 until EMS showed up in the facility to transport the resident to the hospital. Staff C stated they thought the resident's family member and someone they assumed was a physician assistant had called 911 and requested the resident to be transported. Staff C said they did not have time to complete a full assessment on the resident prior to them leaving the facility because it all happened so fast. Staff C stated after the resident left the facility, they called an on-call physician and left a voicemail informing them the resident had went to the hospital but had not actually talked to anyone directly. Reference WAC 388-97-1060 (1)(3)(b)

Based on interview and record review, the facility failed to provide necessary treatment and services for 2 of 3 residents (Residents 1, and 3) reviewed for skin and wound cares. The failure to clarify and implement wound care orders, thoroughly assess wounds, change wound dressings when ordered, and to maintain clear and accurate wound documentation placed the residents at risk for deterioration of their wounds and for diminished quality of life. Resident 1 was harmed when they experienced a worsening of their wounds when the facility failed to assess and document the status of their wounds and to implement wound care orders. Findings included . Stage of Pressure ulcers/injury were defined as: -Unstageable: Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it was obscured by slough or eschar (dead tissue that falls off from healthy skin. - Stage IV: Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament or cartilage or bone in the ulcer. RESIDENT 1 Resident 1 admitted to the facility on [DATE] with diagnoses to include diabetes, generalized muscle weakness, limitation of activities due to disability, and pressure injuries on both of their buttocks. According to the admission Minimum Data Set (MDS) assessment, dated 04/14/2023, the resident had no cognitive impairment, was frequently incontinent (lack of control over urination or defecation) of both bowel and bladder, needed extensive two-person assistance with bed mobility, transfers, dressing and toilet use. The MDS assessment indicated the resident had one unstageable (an ulcer that had full thickness tissue loss but was either covered by extensive necrotic tissue or an eschar) pressure ulcer. The resident requested to be discharged to the hospital on 04/18/2023 due to a worsening of their wounds and their dissatisfaction with the wound cares provided at the facility. In a phone interview on 05/08/2023 at 1:50 PM, Collateral Contact 3 (CC3-Resident 1's family member), stated they had to send Resident 1 to the hospital because they weren't getting the care they needed. CC3 stated staff didn't want to help them with their wounds, urine would get into the wounds, dressings would just be falling off and wet with urine, and it was painful for the resident. CC3 stated that Resident 1 would have to wait and wait for staff to come, then when they came, they wouldn't want to change the dressing and that the resident had their dressings changed a lot more in the hospital. CC3 stated they did not want the resident going back to the nursing home. Review of a Nursing Admission/Readmission assessment, dated 04/07/2023, showed on admission staff documented open areas/wounds to the right buttock that were 10 x 5 x 0.2 (no units of measurement listed), and a left buttock wound that was 17 x 3 x unable to determine depth (no units of measurement listed). Review of the Skilled Nursing Facility Transfer orders, dated 04/06/2023, showed for Wound/Skin Care: Follow current recommendations of the wound team for treatment. Review of the April 2023 Medication Administration Records/Treatment Administration Records (MARs/TARs) documentation showed: - An order dated 04/06/2023 for a left buttock wound treatment: Cleanse with normal saline, gently pat dry, and apply Xerform (dressing to promote wound healing), apply a non-adherent dressing, daily to be done in the evening. The order was implemented 04/07/2023 - 04/12/2023. - An order dated 04/06/2023 for a right buttock wound treatment: Cleanse with normal saline, gently pat dry, apply Xeroform, apply non-adherent dressing, no frequency given, apply in the evening. The order was not implemented from 04/07/2023 - 04/11/2023. Documentation showed the wound treatment was completed once, 04/12/2023. - An order dated 04/06/2023 for a coccyx (the tailbone) wound treatment: Cleanse with normal saline, gently pat dry, apply Xerform, apply a non-adherent dressing, daily in the evening for wound care. The order was implemented 04/07/2023 - 04/12/2023. In an interview on 05/08/2023 at 2:42 PM, Staff B, Registered Nurse/Director of Nursing (DON), was asked about the lack of documentation why the right buttock wound dressing change had no documentation on the MARs/TARs they were completed from 04/07/2023 - 04/11/2023.Staff B stated they thought those orders had been adjusted to be bilateral (both) buttocks. Staff B was asked about the lack of documentation about a coccyx wound dressing change for orders implemented on the April 2023 MARs/TARs from 04/07/2023-04/12/2023, they stated they thought the documentation had been changed to make three wounds be only one wound. Staff B was asked for documentation about the coccyx wound and the facility merging three wounds into one wound, they were unable to provide any documentation. Review of a wound consultant's care consultation report, dated 04/13/2023, showed: -Wound 1: Buttock, right and left buttock, size: 11.5 x 9 x 0.2 (no units of measurement listed) and signs of wound infection: Increased odor, wound breakdown, increased necrotic tissue. Plan for care and treatment: Clean with wound cleanser, apply skin prep and allow to dry, sprinkle Flagyl (antibiotic medication) on wound for odor, cover with calcium alginate, secure dressing and change every three days and as needed for accidental removal, saturation, and/or soiling. -Wound 2: Left posterior thigh, new problem, two wounds separated by intact skin, size 2.5 x 3 x 0.2 (no units of measurement listed). Plan for care and treatment: Clean with wound cleanser, apply skin prep and allow to dry, apply Medihoney (medicine that helps heal wounds) to base of wounds, secure dressing and change every three days and as needed for accidental removal, saturation and/or soiling. Review of Resident 1's April 2023 MARs/TARs, showed the wound consultant orders were neither transcribed nor implemented. Review of Resident 1's April 2023 MARs/TARs, showed these wound consultant orders did not get implemented and there was no documentation why in the clinical records. Review of Resident 1's April 2023 MARs/TARs, showed a new order as of 04/13/2023 for a hip wound treatment (no laterality or side listed) to cleanse with normal saline, pat dry, apply Medihoney, secure with foam dressing in the evening for wound care(no frequency listed). The hip wound treatment was documented as done on 04/16/2023 and 04/17/2023. In the interview on 05/08/2023 at 2:42 PM, Staff B, was asked about the new hip wound care order, dated 04/13/2023, showed no laterality (identification of left or right side) was defined or frequency listed for that treatment. Staff B stated they didn't think that was right, they thought maybe that was a thigh wound. Staff B was asked for documentation regarding the hip and/or thigh wounds and were unable to provide clarifying documents. Staff B referenced a Wound Observation Tool, dated 04/13/2023, that listed only the open areas to the right and left buttocks wounds, but had no documentation regarding a hip or posterior thigh wounds, and had no documentation how the facility had consolidated or merged Resident 1's wounds into one wound. In an interview on 05/08/2023 at 9:30 AM, Staff H, Licensed Practical Nurse (LPN), stated the resident wanted their dressing changed every time they had a bowel movement, which was often, and they tried to let them know that exposing the wound too often would increase their chance of getting an infection. Review of the medical hospitalist's History and Physical, dated 04/18/2023, showed Resident 1 had an infected sacral (lower back, near the pelvis) ulcer, Stage IV, bilateral (both sides), and the wound greatly progressed from discharge with evidence of infection. Their plan was for surgical for debridement in the operating room. RESIDENT 3 The resident admitted to the facility on [DATE] with diagnoses to include diabetes and a partial amputation of the right foot. Review of Resident 3's skilled Nursing Facility Transfer Orders, dated 04/11/2023, showed for wound/Skin Care to follow recommendations of the wound team for treatment. Review of Resident 3's hospital Discharge Summary, dated 04/11/2023, showed daily dressing changes for the vascular surgery wound. Review of Resident 3's April 2023 MARs/TARs showed no orders had been implemented for the daily dressing changes for the surgical site of their partial right foot amputation. In a phone interview on 05/03/2023 at 12:22 PM, Staff M, physician, stated they had not yet had a chance to look at Resident 3's foot, so the staff should have went with the orders that came from the hospital. Staff M stated the staff that took the orders off probably just didn't have time to review the hospital Discharge Summary. In an interview on 05/03/2023 at 1:22 PM, Staff C, Registered Nurse/Resident Care Manager, was unable to provide information as to why the admission dressing change order was not implemented. Staff C was unable to provide information about dressing changes for Resident 3's surgical wound. In an interview on 05/03/2023 at 1:22 PM, Staff B was unable to provide information why the admission dressing change order was not implemented. Reference: (WAC) 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to ensure emergency medications were readily available for residents who experienced dangerously low blood sugars, medication orders in the medication administration records (MAR) used as the source for medication dosages were accurate, and all licensed staff followed safe medication practices for 4 of 5 residents (Residents 3, 1, 2, and 10) reviewed for pharmacy practices. This placed all residents at risk for ensuring emergent medications were available when needed, ensuring the accurate acquiring, dispensing, and administering of all medications. Resident 3 was harmed when they experienced two emergent hospitalization s for hypoglycemia when the facility failed to monitor the resident's blood sugar levels as ordered, administered three times the ordered dose of metformin (a medication used to treat diabetes), and failed to have Glucagon (emergency medication used to treat severe low blood sugar) available for emergent administration. Resident 3 experienced a delay in treatment of their severely low hypoglycemia when nurses were unable to locate Glucagon for emergent use and called 911 to summon Emergency Medical Services (EMS). Findings included . RESIDENT 3 The resident admitted to the facility on [DATE] with diagnoses to include diabetes and a partial amputation of the right foot. Review of Emergency Medical Services (EMS) records, dated [DATE], showed that at 4:29 PM the medics found Resident 3 with an altered mental status, unresponsive, and a blood sugar (BS) reading of 36 (a normal BS ranges from 70 to 130). EMS administered dextrose (a sugar solution used to raise blood sugar) which raised the resident's blood sugar to 227. After the dextrose administration, the resident became responsive to pain and voice, and EMS transported them to the hospital. Review of EMS records, dated [DATE], showed the medics were called to the nursing home again and at 8:27 AM, Resident 3 was unconscious and had a BS reading of 23 (very low). EMS administered the resident dextrose which raised their blood sugar to 256, the resident was still unresponsive, and EMS had to transport them to the hospital with a primary impression of diabetic hypoglycemia (where the blood sugar was below normal range). Review of hospital records, for the admitted [DATE], showed Resident 3 was evaluated in the emergency department the day prior ([DATE]) and treated for low blood sugar, received a stroke workup, and discharged back to the nursing home. Then when the resident was brought back to the hospital on [DATE] they were admitted with diagnoses to include hypoglycemia and coma. The resident expired on [DATE]. Review of Skilled Nursing Facility Transfer Orders, dated [DATE], showed orders for Metformin (diabetes medication) 1000 mg (milligram) tablet, take ,d+[DATE] tablet in the morning and one tablet in the evening and blood glucose checks twice daily. Review of the facility's [DATE] Medication Administration Records/Treatment Administration Records (MARs/TARs) showed: -The wrong dose of metformin (1000 milligrams tablet, give 1.5 tablet(s) in the morning for 90 days). This was three times the ordered dose, and was documented as given on [DATE], [DATE], and [DATE]. The only order for checking the blood sugar was for once a month (not the twice daily blood sugar monitoring as ordered). -No documentation to support that any Glucagon or Narcan had been administered for the hypoglycemic episodes. -An order dated [DATE] to send Resident 3 to the emergency room due to a hypoglycemic episode Stat (immediately). In an interview on [DATE] at 12:01 PM, Staff B, Director of Nursing (DON), was asked about lack of implementation of the twice daily blood sugar testing order. Staff B was unable to provide any information and stated they didn't know where the Glucagon came from that was administered on [DATE], or whether it came from the e-kit, Omnicell (a type of automated medication dispensing system), or the medication carts. Staff B stated there should have been some documentation that Narcan and Glucagon were administered. In a phone interview on [DATE] at 1:10 PM, Staff K, Agency (non-permanent staff) Licensed Practical Nurse (LPN), was asked about Resident 3's hypoglycemic episode on [DATE], they stated there had been no Glucagon in the building when they needed it. Staff K stated they sought help from other nurses, checked their medication carts, the e-kit, the Omnicell and the other units, were unable to locate Glucagon and had to call 911. In a phone interview on [DATE] at 9:50 AM, Staff J, Registered Nurse (RN), was asked about Resident 3's hypoglycemic episode on [DATE], they stated they had given the resident two doses of Glucagon they got from the e-kit in the Omnicell, there was no Glucagon in the medication carts. Staff J stated Resident 3 had no orders for glucose monitoring and they had wondered why they weren't monitoring the resident's blood glucose levels as they thought they should have been. Staff J said they did give Resident 3 a dose of Narcan but the resident was not on any opioids so the Narcan didn't do anything, and they couldn't get in the Omnicell to get medications because their password didn't work and were supposed to scan medications when they took them out of the Omnicell. Staff J stated that the doctor gave them a verbal order to give Glucagon and Narcan, but they did not document the verbal orders, and they were new so they thought other staff would have backed them up with the documentation. In an interview on [DATE] at 10:25 AM, Staff L, RN/Resident Care Manager (RCM), stated they removed two doses of Glucagon out of the Omnicell on [DATE], but they didn't administer them as they gave them to Staff J, so they didn't document their administration. Staff L stated when they removed the second dose of Glucagon, they failed to scan it properly, which is why the Omnicell report still showed there was one dose still on-hand in the Omnicell as late as [DATE]. In a phone interview on [DATE] at 12:45 PM, Staff M, physician, stated the excessive metformin doses were transcription medication errors, and they directed the facility to use the discharge orders from the hospital and they would look at them when they came in. Staff M stated they didn't know why staff didn't perform blood sugar testing twice a day as ordered, as it was on the discharge orders, that they should have been transcribed and implemented as ordered. In an interview on [DATE] at 2:55 PM, Staff L, stated two nurses were supposed to be verifying all orders, but they didn't know who the second nurse was that was supposed to have verified the resident's orders. Staff L stated the metformin discrepancy was a medication error. In an interview on [DATE] at 2:57 PM, Staff B, stated there were 25 diabetic residents in the facility. RESIDENT 1 The resident admitted to the facility on [DATE] and had diagnoses to include a history of a deep vein thrombosis (a clot) in an arm, and chronic pain syndrome. Review of the Skilled Nursing Facility Transfer Orders, dated [DATE], showed orders for: - Apixaban (anticoagulant medication) 5 milligrams (mg) tablets, take two tablets by mouth, two times daily for eight doses. -Apixaban 5 mg tablet, take one tablet by mouth, two times daily for 360 doses. -Lidocaine 5% patch, place three patches onto the skin daily as needed for pain, apply for 12 hours, then remove for 12 hours. Review of the [DATE] MARs/TARs documentation showed: - Resident 1 received four doses of the two tablets of apixaban, not the eight doses that were ordered, then the order was discontinued. -Resident 1 received apixaban 5 mg, one tablet, once a day instead of the twice a day that was ordered. -Lidocaine patches, the order that was transcribed onto the MARs/TARs was a 4% patch (not the 5% as ordered), and was only for one patch, not the three that were ordered. In an interview on [DATE] at 3:57 PM, Staff B, stated the issues with the apixaban were both medication errors, and they would write the medication errors up. Staff B was unable to provide any information about the lidocaine patches except to state their medical records staff had not been keeping documentation of medication order clarifications. RESIDENT 2 The resident admitted to the facility on [DATE] with diagnoses to include insomnia and a hip fracture. Review of the Skilled Nursing Facility Transfer Orders, dated [DATE], showed orders for: -Melatonin 1 mg tablets, take one tablet by mouth nightly (the order was annotated that the amount to take had changed). - Lidocaine 5% patch, place two patches onto the skin daily, apply for 12 hours, then remove for 12 hours Review of the [DATE] MARs/TARs documentation showed: - The facility did not implement the order for melatonin 1 mg, they continued the previous order dated [DATE] to give melatonin 3 mg, 1 tablet at bedtime. -The facility did not implement the orders to apply two lidocaine 5% patches daily, they continued the previous order dated [DATE] to apply a lidocaine patch without defining the medication dose. In an interview on [DATE] at 10:30 AM, Staff I, Licensed Practical Nurse, stated the nurse that took the orders off when the resident readmitted didn't catch that there were changes to the orders and they just continued the old orders. Staff I was asked about the lack of a medication dose on the lidocaine patches on the MARs, they were unable to provide any information. Staff I and the surveyor observed lidocaine patches in the medication cart, which showed they were 4%. Staff I stated those were the house supply as they didn't have the resident's name. In an interview on [DATE] at 3:57 PM, Staff B, stated the melatonin and lidocaine patches orders did get clarified, but their medical records staff had been failing to maintain documentation of orders clarification. RESIDENT 10 Resident 10 admitted to the facility [DATE] with diagnoses to include chronic pain. Review of an incident investigation, dated [DATE], showed a nurse administered Resident 10 methadone 30 mg, instead of the ordered dose of 10 mg (three times the ordered dose). In an interview on [DATE] at 3:10 PM, Staff B, was unable to state which of the resident's medication rights the nurse had not met when they administered the excessive dose of methadone to the resident. Reference: (WAC) [DATE] (1)(a)(b)(i)(ii)(3)(a)(4)

Based on observation, interview, and record review, the facility failed to evaluate the need for additional supervision, for 1 of 3 residents (Resident 2) reviewed for accidents and supervision who experienced an injury. Resident 2 experienced multiple falls and according to more than one direct care staff needed one to one supervision; yet this was not assessed. Resident 2 was harmed when they experienced an unwitnessed hip fracture. Findings included . Review of the facility policy titled, Incident and Reportable Event Management, revised date 01/31/2023, showed: The facility to the best of its ability strives to provide an environment that was free from accident hazards over which the facility had control and provided supervision and assistive devices to each resident to prevent avoidable accidents. In response to allegations the facility must have evidence that all alleged violations were thoroughly investigated Avoidable Accident meant that an accident occurred because the facility failed to identify environmental hazards, including the need for supervision, and/or implementing interventions including adequate supervision. Resident 2 admitted to the facility from the hospital on 01/06/2023 after having a fall at home and sustained a left hip fracture and a right arm fracture. The resident had a history of frequent falls, to include a previous fracture of their right hip. The resident also had a history of alcoholism and [NAME]-Korsakoff syndrome, a neurological condition which was also referred to as alcoholic dementia which affected balance and coordination and caused confusion, as well as encephalopathy which was a disease of the brain that affects cognition. According to the quarterly Minimum Data Set (MDS) assessment (an assessment tool), dated 01/13/2023, the resident had moderate cognitive impairment, and needed one-person assist with bed mobility, transfers, toilet use and walking. The MDS also indicated the resident was not steady with balance during transitions and walking and was only able to stabilize with human assistance and had a functional limitation in range of motion on one side of their body in both upper and lower extremities. Review of a Fall Risk Evaluation, dated 03/02/2023, showed the Resident 2 scored 20 (a score of 10 or above was at risk for falls). In a phone interview on 05/01/2023 at 10:05 AM, Collateral Contact 2 (CC2), State Employee, stated they knew the facility was looking for alternative placement for the Resident 2 as they needed more supervision. CC2 stated they were concerned the resident was restrained because they had read in the resident's clinical record that staff put the resident in a chair and then placed another chair in front of them, and the resident had a fall. In an observation on 05/03/2023 at 8:40 AM, Resident 2 was observed wheeling themself down the hall in their wheelchair. The resident was not interviewable. Review of the March and April 2023 incident reporting logs showed Resident 2 had multiple fall incidents on 03/02/2023, 03/23/2023, 04/01/2023, 04/16/2023, and 04/26/2023 (injury of unknown source the resident was complaining of pain and a hip x-ray was obtained which showed the resident had re-fractured their right hip and was transferred to the hospital). Review of progress notes, dated 03/21/2023, showed Resident 2 experienced a fall after they were placed in two chairs facing each other in the hallway at 2:00 PM. The resident was restless calling out help, help . At 3:40 PM, the facility scheduler walked by and noticed the resident had kicked one chair away and slid on the floor between the two chairs with their knees on the floor. (This fall incident was not found on the March 2023 incident reporting log). In an interview on 05/10/2023 at 11:40 AM, Staff B, Director of Nursing (DON), was asked about the fall found in the progress notes dated 03/21/2023. Staff B reviewed the incident reporting log and stated that Resident 2's 03/21/2023 fall didn't get logged, but it should have been, maybe it got covered up somehow. Review of the fall incident investigation, dated 03/02/2023, showed Resident 2 was found on the floor at the foot of their bed, the resident stated they didn't know what had happened. The investigation determined the cause of the fall was the resident's confusion and poor safety awareness. The plan was to have Occupational Therapy (OT) work with the resident to improve their safety awareness. Review of the related OT evaluation notes, dated 03/06/2023, showed OT only evaluated and did not treat the resident as OT services were not indicated at that time, as the resident was already at their prior level of function. The notes documented their prior level of function was a long-term fall risk with a need for supervision. In an interview on 05/10/2023 at 11:21 AM, Staff B stated that OT services had not been provided because of their poor safety awareness and their cognition. Review of the fall incident investigation, dated 03/23/2023, showed Resident 2 was observed by a nurse walking, and was redirected to sit back in their chair. Staff heard a loud sound at 3:30 PM, and the resident was found lying on the floor at their wheelchair. The facility concluded the cause of the fall was poor safety awareness and agitation. A nursing assistant's witness statement required the nursing assistant to answer what could be done to prevent a re-occurrence of this event, the staff answered Need 1:1 which indicated the resident needed closer supervision. The provider initiated a new order to treat the resident with Seroquel, an antipsychotic medication for agitation. An attached form indicated therapy had evaluated the resident and stated the resident was not appropriate for skilled therapy interventions. Review of the fall incident investigation, dated 04/01/2023, showed the fall incident investigation was unclear as to what happened. The incident summary indicated Resident 2 was calling out help from the activity room, and staff found the resident on the floor. An attached witness statement (completed by Staff G, Registered Nurse/MDS Coordinator) stated a resident was found in the shower room bathroom with their pants down. The facility concluded the root cause of the fall was related to the resident's impulsivity and poor safety awareness, and they planned to offer the resident diversional activities and have the pharmacist complete a medication review. An attached nursing assistant witness statement showed staff were asked what could be done to prevent re-occurrence, the staff answered 1 on 1 with them, which indicated the resident had a need for more supervision. Review of a fall incident investigation, dated 04/16/2023, showed the nurse and nursing assistant heard someone yelling from the shower room, and when they went in there, they found the Resident 2 lying on the floor with their pants down. The facility concluded the cause of the fall was the resident's impulsivity and poor safety awareness. An attached nursing assistant witness statement showed staff were asked what could be done to prevent re-occurrence of this event, the staff answered, one on one. An attached Staff Training Record showed someone had left the shower room door open and the resident fell trying to toilet themselves. The plan for staff was that the shower door must be closed at all times. The fall Grand Rounds Post-Fall IDT (interdisciplinary team) Screen indicated the resident had a history of falls, a skin tear, had attempted to self-toilet in the shower room, needed more diversional activities and needed alternate placement due to a need for more oversight. Review of an incident investigation, dated 04/26/2023, showed Resident 2 had an injury of an unknown source that was discovered after the resident had complained of pain during a transfer. An Xray was obtained which indicated the resident had a new fracture of their right hip. The facility concluded the cause of the fracture was that it was related to the resident's fall on 04/16/2023. The resident was transferred to the hospital. In an interview and observation on 05/10/2023 at 10:00 AM, with Staff F, Nursing Assistant/Shower Aide, showed the Havenwood unit shower room and shower room door had a numeric code lock on the shower room doors. Staff F stated staff didn't intentionally leave the shower room door open, they tried to close it when not inside, but it does stay open if they push it all the way, then you have to grab it and manually close it. During this observation, Resident 2 was observed sitting in a wheelchair just outside of the shower room. In an interview on 05/10/2023 at 11:40 AM, Staff B, DON, was asked about care planning and interventions regarding staff supervision for this Resident 2's safety and fall prevention. Staff B stated social services was looking at putting more things in place to have more oversight for the resident. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure staff provided safe resident transfers using a Hoyer (mechanical lift used to transfer residents) ensuring equipment was safe to use and by providing training on Hoyer use, sling selection/sizing. This failed practice resulted in actual harm to Resident 1, who fell during a Hoyer lift transfer & sustained facial injuries, a laceration to their left elbow and two rib fractures necessitating a transfer to the emergency room for treatment, and placed residents who used mechanical lifts at risk for unsafe transfers. Findings included . Review of facility policy titled Mechanical Lift Use, review date 09/12/2022, showed the facility would utilize the Lippincott Procedure Transfer with a Mechanical Lift, long term care. This procedure guide stated when prepping equipment for transfer Check the size of the sling before applying it to the resident because improper sizing could result in injury. Further review of the guide showed Using a Mechanical Lift; Then attach the straps to the hooks on the sling (as shown below). Below this directive were 3 separate images of how to attach the sling to the Hoyer lift, and all 3 indicated the sling should be crisscrossed between the residents' legs, prior to attaching the sling to the lift. Resident 1 was a long-term resident of the facility. The resident's diagnoses list included [CONDITION(S)], [CONDITION(S)], abnormal posture. A review of the quarterly Minimum Data Set (MDS) assessment, dated 08/31/2022, showed the resident had moderate cognitive impairment, required extensive assistance of 2 persons for bed mobility, dressing, toileting, personal hygiene and was totally dependent on 2 persons for transfers. Review of the current care plan showed Resident 1 was at risk for falls. Following the incident on 10/03/2022, the intervention of Staff training on appropriate procedure for sling placement and fastening appropriately to the lift was added to care plan on 10/05/2022. The care plan also showed the intervention of Full body sling to be used for Hoyer transfers, was added on 10/07/2022, four days after the incident. A review of the facility investigation report dated 10/03/2022, showed a fall occurred, where the resident sustained injuries including a bruise to the left eye, a laceration to the left elbow and two rib fractures. During an interview on 10/28/2022 at 1:00 PM, Staff C, Nursing Assistant Certified (NAC), confirmed that she was one of the aides present at the time Resident 1 fell during a Hoyer lift transfer on 10/03/2022. Staff C verified using a Kardex (care plan for NAC's) for all residents when providing care, and the Kardex included resident specific information such as transfer status, assistance required for toileting, diet etc. Staff C confirmed that when the sling was attached to the lift prior to the transfer it was not crisscrossed between Resident 1's legs. They stated, At times they will cross the straps and other times not, a resident complains that its uncomfortable to crisscross, we won't do it. Staff C stated that prior to this incident, they could not recall when they last received any training/education regarding mechanical lift transfers and .a lot of the slings we use in the facility currently are very worn, making it hard to even tell what size they were. Staff C also stated that after this incident the facility educated them and placed size charts on each lift and in the laundry room to assist in selecting the proper sling for each resident, but that this was not being done prior to this incident. Staff C stated that during this investigation it was found that the facility didn't even have enough slings for all the Hoyer lift residents currently in the facility and they had to order a bunch more. During an interview on 11/03/2022 at 10:28 AM, Staff D, Anonymous stated that they assisted in the room after Resident 1 fell during a Hoyer lift transfer on 10/03/2022. Staff D confirmed that staff were using a horseshoe sling (1/2 sling) on Resident 1, during the fall. They entered the room and observed the resident on the floor in more of a prone (face down) position with an arm trapped underneath them with their head resting on the Hoyer lift machine. When nursing staff asked for assistance getting Resident 1 up from the floor, Staff D directed staff to get a full body sling, as nursing staff were proceeding to use the horseshoe sling again and they were not comfortable using the same sling the resident just fell out of. Staff D also sated Technically, I have never had any real training on mechanical lifts or sling sizing, besides a quick 10 mins during school maybe, nothing since I have been at this facility. During an interview on 11/03/2022 at 11:00 AM, Staff G, Licensed Practical Nurse (LPN), stated that she was the nurse that arrived in the room immediately after the fall and was assigned to Resident 1. Staff G stated that the resident was Laying mostly on her stomach and their head was resting on the leg of the lift. They stated that the resident was assessed as good as they could while on the floor, but that the resident had a cut above their left eye when assessed. Staff G also stated that the nursing assistants kept stating that the resident had not hit their head but stated The way the resident was positioned with their head on the lift, on their stomach I don't know how it's possible that they didn't hit their head. During a joint interview/record review on 11/03/2022 at 3:15 PM, Staff B, Director of Nursing (DNS) reviewed the investigation from Resident 1's fall on 10/03/2022. The DNS stated, I would like to say that training for using mechanical lifts is done annually, I know that it was just done with staff following this incident but prior to that they were unsure and would have to go back in the training system. Staff B was asked to provide verification of prior mechanical lift trainings for 6 random nursing staff, and they were only able to provide training, dated 2018 for Staff C, NAC. During a telephone interview on 11/03/2022 at 4:32 PM, Staff E, Staff Development Coordinator (SDC), confirmed being responsible for training/educating the staff following Resident 1's fall on 10/03/2022 and they had been SDC position since August 2022, So I am still fairly new. Staff E confirmed that the expectation for sling placement when using a Hoyer lift is that the sling is crisscrossed between the resident's legs prior to attaching to the machine, stating That is the proper way, they should be crossed and that's what staff were instructed to do during my recent training. Reference WAC- 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to ensure adequate pain management was provided for one of four residents (47) who were reviewed for pain management. Failure to ensure that Resident 47, who displayed symptoms of pain, was assessed, received care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included . The facility's policy titled, Pain Assessment and Management, with a revision date of 07/17/2021 documented: - Based on the comprehensive assessment of a resident, this facility must ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan and the resident's choices related to pain management; - All residents will be assessed for pain indicators upon admission/readmission, quarterly and with any change in condition; and - An individualized pain management care plan will be developed and initiated when pain indicators are identified. Resident 47 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician active orders as of 03/08/2022, showed the resident's pain regimen included: -[MEDICATION(S)] patch (a medication that is used to relieve severe ongoing pain,) apply 1 patch and change every 72 hours; - [MEDICATION(S)] (a medication used to relieve nerve pain) three times a day; - [MEDICATION(S)] Patch (medication used to relieve nerve pain) 5%, topically one time a day for pain; - [MEDICATION(S)] (a medication used to relieve pain) was administered as needed every four hours for moderate to severe pain; -[MEDICATION(S)] (an antianxiety medication) as needed every six hours for anxiety; - [MEDICATION(S)] (a medication used to treat muscle spasms) administered four times a day. Review of the resident's care plan with an initiation date of 02/08/2022, showed pain interventions included: to evaluate the effectiveness of the resident's pain interventions. The residents care plan did not include pain locations, pain expressions, or non-pharmacological interventions, it only listed the residents pain medications. Review of the resident's pain evaluation dated 02/18/2022, documented the resident did not have pain. Although, the resident was crying out in pain, the resident had not been re-assessed to reflect the residents current pain status. Review of a nursing note dated 02/19/2022 at 3:54PM, showed the resident yelling out frequently this shift, mama, mama crying out loudly, throwing pillows to floor, removing night gown, throwing bedding to floor will continue to observe and assess. Review of a nursing note dated 02/23/2022 at 4:36PM, showed the resident woke up throughout shift, crying and inconsolable. Resident yelling out frequently this shift, crying out loudly, throwing pillows to floor, removing night gown, throwing bedding to floor MD (medical doctor) ordered new medication of [MEDICATION(S)] for anxiety. Even though the resident exhibited indicators of pain, documented by nursing staff review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nursing note dated 03/02/2022 at 10:47AM, showed the resident was crying out in pain and had facial grimacing, indicating severe pain. The nurse administered an as needed [MEDICATION(S)] Review of a nursing note dated 03/02/2022 at 2:36PM, showed the resident continued to yell out and was not able to be redirected. The nurse administered an as needed [MEDICATION(S)]. Review of a nursing note dated 03/03/2022 at 2:57PM, showed the resident was crying and grimacing indicating severe pain. The nurse administered [MEDICATION(S)] On 03/04/2022 at 7:16 AM, the resident was observed in their bed, the resident was asleep and woke up crying out loud. On 03/04/2022 at 11:20 AM, the resident was observed in their bed, the resident was asleep and woke up crying out loud. The resident was observed to lift their body up from bed while crying out. In an interview on 03/04/2022 at 11:47 AM, Collateral Contact 3 (CC3), a family member stated the resident seemed to be in pain often. CC3 stated the resident would wake up crying and looked to be in pain. CC3 continued to state they were not sure if the facility was trying to figure out why the resident was in pain, they just give her medication but then she still wakes up crying in pain. On 03/04/2022 at 1:04 PM, the resident was observed sitting in the dining room, began crying out loud and lifted themselves off their wheelchair from their left side of their body. Review of a nursing note dated 03/07/2022 at 3:46PM, showed the resident was crying of severe pain and [MEDICATION(S)] was administered. On 03/07/2022 at 2:39 PM, the resident was observed in their bed, with no clothing on and only a sheet covering them. The resident was crying out loud, when asked if they were in pain, they replied yes. On 03/08/2022 at 9:29 AM, the resident was observed in their bed sleeping, the resident then woke up crying out. On 03/08/2022 at 9:45 AM, the resident was observed in their bed sleeping, the resident then woke up crying out. On 03/08/2022 at 11:24 AM, the resident was observed in their bed asleep, the resident then woke up crying out loud. In an interview on 03/08/2022 at 11:22 AM, Staff P, Licensed Practical Nurse (LPN), stated when they came in to work that morning the resident was restless and a bit inconsolable. Staff P did everything they could to console the resident. Staff P stated the resident sometimes was in pain on her affected arm and would administer medication to the resident to help them. In an interview on 03/08/2022 at 1:56 PM, Staff Q, Certified Occupational Assistant, stated that sometimes the resident did not participate in therapy as they had prior because of pain. In an interview 0n 03/08/2022 at 1:26 PM, Staff B, Registered Nurse/Resident Care Manager was asked about Resident 47's crying out. Staff B stated, the resident would be sleeping and suddenly would wake up crying out. Staff B stated they could rule out if the resident was in pain by asking them, because sometimes the resident could state if they were in pain. Staff B stated there had been no current pain assessment completed for the resident. Staff B acknowledged there had been no interdisciplinary team approach from the facility to discuss, assess or address the residents crying out to effectively address the resident's pain In an interview on 03/08/2022 at 2:04 PM, the Director of Nursing Services (DNS) stated understanding of the need to conduct a current pain assessment, review the Resident 47's medications, and to personalize their care plan to effectively manage their pain needs. In a review of the March 2022 Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . It was unclear how the staff assessed the resident's pain level before and after pain medication was administered to address why the resident would cry out and whether their pain management was effective or if the resident required addition interventions for pain. The facility failed to recognize and comprehensively assess when Resident 47 was experiencing unrelieved pain. Failure to recognizing the onset, presence, duration of pain, the characteristics of the pain, circumstances when pain could be anticipated and failed to evaluate the existing pain medication regimen and care plan for effectiveness. REFERENCE: WAC 388-97-1060(1)

Based on interview and record review, the facility failed to ensure residents with indwelling urinary catheters received appropriate treatment and services to prevent catheter-associated urinary tract infections (CAUTIs). Specifically, the facility failed to develop individualized plans for the prevention of CAUTIs including the failure to develop individualized and specific clinical indications for changing the catheters and/or catheter bags for three of four residents (5, 47, and 25) reviewed for indwelling urinary catheter care/management. The facility also failed to implement and document appropriate routine catheter care and services necessary to prevent CAUTIs. Resident 5 was harmed when they were hospitalized with a urinary tract infection associated with an indwelling urinary catheter use. These failures increased resident's that had indwelling urinary catheters risk for urinary tract infections and it's associated complications. Findings included . Review of the Centers for Disease Control (CDC) Guidelines for Prevention of Catheter-Associated Urinary Tract Infections, 2009 indicated the following information: Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. Review of the facility policy titled, Urinary Incontinence and indwelling Urinary Catheter (Foley) Management, dated 07/17/2021, showed: - Based on comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices; and - A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The procedure included the facility will utilize Lippincott procedures, the associated Lippincott procedure titled Indwelling Urinary Catheter (Foley) Care and Management, dated 11/19/2021, showed: - CAUTIs were the most common type of healthcare associated infection in adult patients. Researchers estimate that as many as 70% of these infections were preventable by following evidence-based practices; and - Keep in mind that the Centers for Medicare and Medicaid Services considers CAUTI a hospital-acquired condition because it can be reasonably prevented using a variety of best practices. Make sure to follow evidence-based CAUTI prevention practices - such as performing hand hygiene before and after any catheter manipulation: maintaining a sterile continuously closed drainage system: maintaining unobstructed urine flow: emptying the collection bag regularly: replacing the catheter and drainage system using sterile technique when breaks in sterile technique, disconnection, or leakage occurs; and discontinuing the catheter as soon as it's no longer clinically indicated - when caring for a patient with an indwelling urinary catheter to reduce the risk of CAUTI. RESIDENT 5 Resident 5 was recently admitted to the facility on [DATE] after a hospitalization for [CONDITION(S)] from 02/14/2022 - 02/17/2022. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Medicare 5-day Minimum Data Set (MDS) assessment, dated 02/20/2022, the resident had no cognitive impairment, had an indwelling catheter, and a [CONDITION(S)] bladder (condition in which a person lacked urinary bladder control due to brain, spinal cord, or nerve problems), had a [CONDITION(S)] in the last 30 days, and [CONDITION(S)] (also called [CONDITION(S)], blood poisoning by bacteria). Review of the resident's October 2021 Medication Administration Records (MARs)/Treatment Administration Records (TARs) showed a physician's order dated 09/29/2021, to change the foley catheter (foley was a common type of urinary bladder catheter used to drain urine) to change every month. The MARs/TARs indicated the catheter was changed 10/28/2021 on the night shift. Review of the resident's progress notes revealed no documentation there were clinical indications necessitating the foley catheter change on 10/28/2021. Review of the resident's October 2021 MARs/TARs showed a physician's order dated 01/21/2021, to change the foley catheter drainage bag every 14 days. The MARs/TARs collection bag was changed 10/14/2021 and 10/28/2021. Review of the resident's progress notes revealed no documentation there were clinical indications necessitating the urinary catheter bag changes on 10/14/2021 and 10/28/2021. The nurses should have clarified these routine orders. Review of the November 2021 MARs/TARs showed the urinary catheter bag was changed on 11/11/2021 and 11/25/2021. Review of the resident's progress notes revealed no documentation there were clinical indications necessitating the urinary catheter bag changes on 11/11/2021 and 11/25/2021. The nurses should have clarified these routine orders. Review of the December 2021 MARs/TARs showed the urinary catheter bag was changed on 12/09/2021 and 12/23/2021. Review of the resident's progress notes revealed no documentation there were clinical indications necessitating the urinary catheter bag changes on 12/09/2021 and 12/23/2021. The nurses should have clarified these routine orders. Review of the January 2022 MARs/TARs showed the urinary catheter bag was changed on 01/06/2022 and 01/20/2022. Review of the resident's progress notes revealed no documentation there were clinical indications necessitating the urinary catheter bag changes on 01/06/2022 and 01/20/2022. The nurses should have clarified these routine orders. Review of the February 2022 MARs/TARS revealed a physician's order, dated 01/21/2021 to catheter drainage bag every 14 days. The MARs/TARs indicated the catheter bag was changed 02/03/2022. Review of the resident's progress notes revealed no documentation there were clinical indications necessitating the urinary catheter bag change done 02/03/2022. The nurses should have clarified these routine orders. Review of the February 2022 MARs/TARs revealed a physician's order to change the foley catheter as needed, if indicated, order dated 09/29/2021. The February MARs/TARs indicated the catheter was changed 02/12/2022. Review of the resident's progress notes revealed no documentation there were clinical indications necessitating the catheter change done 02/12/2022. The nurses should have clarified these routine orders. Review of a hospital Discharge Summary, dated 02/17/2022, showed the resident was hospitalized from 02/14/2022 - 02/17/2022 with a Principal Problem of a [CONDITION(S)] due to an indwelling urinary catheter. Active problems to include [CONDITION(S)] due to [CONDITION(S)], [CONDITION(S)] bladder, altered mental status, and acute renal failure/chronic kidney disease. Review of the resident's care plan, print date 03/08/2022, showed the resident was care planned to have a history of recurrent (occurring often or repeatedly) [CONDITION(S)]'s and was at risk for complications. The resident had an indwelling catheter, and the goal was to have their [CONDITION(S)] resolve without complications. Other urinary focus areas included the resident had an indwelling catheter related to a [CONDITION(S)] bladder, and the goal was the resident would have no complications related to the indwelling catheter use, and the resident had penile erosion from chronic catheter use. Interventions included foley care every shift, and as needed. There was no documentation care planned for what would be appropriate indications for the catheter or catheter bag changes. In an interview on 03/07/2022 at 2:45 PM, Resident 5 was unsure how often their urinary catheter was being changed, they thought it was supposed to be changed every 30 days. In an interview on 03/08/2022 at 9:58 AM, Staff A, Licensed Practical Nurse, stated the nurses did the catheter care (wash and clean with soapy water) every shift and they documented that. When asked for that documentation, Staff A was unable to provide any information. In an interview on 03/08/2022 at 10:35 AM, Staff B, Registered Nurse/Resident Care Manager, stated the nursing assistants (NAs) documented that they did the resident's catheter care. Staff B was unable to provide documentation of when the NA performed catheter care. In an interview on 03/09/2022 at 8:37 AM, Staff A stated the nurses only did catheter cares when there were problems to be addressed or if the NAs were not available. In an interview on 03/09/2022 at 9:24 AM, Resident 5 stated before their recent hospitalization they thought their catheter care was done once a day, some days maybe twice. They stated their briefs were never wet and their catheter care was only done when staff changed their briefs. In an interview on 03/09/2022 at 9:40 AM, Staff C, Nursing Assistant (NA), stated they had done the resident's catheter cares that morning, but did not know how catheter cares were documented. Staff C stated the only documentation they did was when they documented emptying urine from the catheter bag. In an interview on 03/09/2022 at 11:44 AM, Staff J, Director of Nursing Services (DNS), stated the facility had not done an infection assessment regarding the resident's hospitalization for a [CONDITION(S)]. In an interview on 03/09/2022 at 3:20 PM, Staff J was interviewed about the facility practice of routinely changing foley catheters and bags, and stated they knew that wasn't best practice, but that was what their providers did. Staff J stated the facility had educated their medical providers about their catheter practices. Review of the bowel and bladder task worksheet (a tool used for the NA to document Foley catheter care) directed the NA to wash/clean the foley catheter with soapy water every shift, for 30 days reviewed, with a print date on 03/09/2022, showed: - On 02/10/2022 - Foley catheter care was done one time; - On 02/12/2022 - Foley catheter care was done twice; - On 02/13/2022 - Foley catheter care was done twice; and - From 02/18/2022 - 03/07/2022 - there was no documentation Foley catheter care done at all. In an interview on 03/15/2022 at 2:40 PM, Staff J stated the facility did not have a policy that incorporated best practices for indwelling urinary catheter management. In an interview on 03/15/2022 at 2:50 PM, Staff B stated the facility did not have a policy that incorporated best practices for indwelling urinary catheter management. Staff B stated the catheters were not supposed to be changed routinely. Review of urologist progress notes, dated 03/15/2021, showed the resident had consulted with a urologist to consider placing a suprapubic (an opening to the bladder from the abdomen) catheter, which the urologist did not recommend. The plan was to change the catheter monthly. There was no documented clinical rationale for the routine catheter changes. Resident 5 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation the facility had implemented a catheter care management program designed to prevent infections for this resident. The facility did not have a policy based on best practices to prevent catheter-associated [CONDITION(S)]'s, or a policy that incorporated CDC recommendations. Resident 5 was hospitalized four days for a [CONDITION(S)], on return, the facility did not do an infection assessment, the resident was again placed on the same orders for routine catheter/bag changes, not changes that were based on clinical indicators such as infection, obstruction, or when the closed system was compromised. Similar findings were found with Residents 47 and 25. RESIDENT 47 The resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 47's current Physician Orders indicated Indwelling catheter to straight drainage. Change for leakage or obstruction with a start date of 02/08/2022. Review of Resident 47's March 2022 TAR, indicated that Resident 47's catheter was changed on 03/04/2022. There was no documentation in the medical record why the catheter had been changed. RESIDENT 25 The resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 25's current Physician Orders dated 10/12/2021, indicated to change their indwelling foley catheter every 30 days (and directed to change on the 11th of every month on night shift). Review of the last three (3) months of TARs showed the catheter was changed on 12/25/2021, 01/24/2022 and 02/23/2022. There were no indication/s for when the resident's catheter should be changed, for example there was no documentation of obstruction, blockage, infection, or catheter falling out on its own or during cares or any other clinical indication for changing the catheter. The routine changing of catheters when there was no evidence of blockage or other clinical indications increases the resident's risk for urinary tract infections. In an interview on 03/15/2022 at 3:25 PM, Staff J stated they had no documentation of education of physicians regarding indwelling urinary catheter management best practices. Staff J stated their doctors argued that the residents needed routine catheter changes. In a phone interview on 03/15/2022 at 3:58 PM, Staff I, Medical Director/Physician, was asked about best practices for indwelling urinary catheter management, and stated they were not to be changed on a fixed time schedule, per CDC recommendations they would only be changed for infections, obstructions, or when the closed system was compromised, that was best practices. Staff I stated they had signed Resident 5's Order Summary Report for the admission from the hospital on 02/17/2022 that had orders for routine catheter changes, that they signed it because that's what the urologist had written for orders when the resident was seen by a urologist. In summary, the facility did not implement policies that incorporated CDC recommendations for indwelling urinary catheter management that were necessary to prevent catheter-associated urinary tract infections. Current facility practice included routine catheter/catheter bag changes that were based upon fixed time periods, not based upon clinical indications such as infection, obstruction, or when the closed systems were compromised. Related citation: See F755 - The facility failed to ensure Resident 5 received all ordered doses of antibiotics on their readmission to the nursing home after hospitalization for a catheter-associated urinary tract infection. See F841 - The facility Medical Director failed to ensure the facility implemented policies for indwelling urinary catheter care/management necessary for preventing catheter-associated urinary tract infections. Reference: (WAC) 388-97-1060 (1)(3)(c )

Based on observation, interview and record review, the facility failed to operationalize their written policy and procedures for abuse and neglect screening, training, prevention, identification, resident protection, investigation and reporting and response for 21 of 21 residents (#2, #3, #11, #10, #5, #1, #24, #15, #4, #34, #12, #16, #17, #23, #21, #25, #26, #6, #31, #32, #33) who were reviewed for incidents. There were failures in identifying and recognizing allegations of abuse, in reporting abuse and neglect, in protecting residents after incidents, not-thorough investigations, incomplete/inaccurate and/or misleading/non-factual investigation/documentation, staff unable to recognize abuse/neglect, staff did not know the facility's written abuse/neglect reporting/resident protection policy/procedures, failure to preserve/document evidence necessary for thorough investigations, facility Administrator and Director of Nursing not knowledgeable of the facility's written abuse/neglect policy and not able to demonstrate policy implementation during review of incidents, non-factual/misleading information documented in residents' incident investigation report and other non-factual and/or misleading documentation. Residents observed without call lights within reach. Residents with repeat incidents before the first incident could be investigated and reviewed, failure to protect residents between repeated incidents, falls, missed medications, repeat avoidable hospitalization s. Allegation of inadequate Personal Protective Equipment (PPE) that went uninvestigated. Unresolved family/resident concerns/grievances regarding unmet care needs, failure to implement facility concern/grievance system to ensure residents unmet care needs did not result in neglect. Abuse, neglect and harm resulted. This failed practice placed all residents' health and safety at risk. Additional failed practice included facility not in compliance with Nursing Home Guidelines AKA The Purple Book, for prevention & protection, incident identification, investigation and reporting: 1) Witness statements not signed and dated by staff providing the statements or by staff receiving statements, 2) Failures in preservation of evidence, witness lists not done, failures to document relevant evidence, 3) Failures in reporting abuse and neglect, 4) Failure to protect residents from further harm, 5) Failures to report staff found to have neglected residents, 6) Failure to conduct thorough investigations, 7) Failures in maintaining the incident reporting log, 8) Failures to complete investigations within five days, 9) Failures to make necessary changes to the provision of care and services to prevent reoccurrence, 10) Failures in completing/reporting results of investigations within five working days, 11) Failure to document date and time of collection must be included for all evidence gathered, if possible, write the date, time and name of staff person collecting the evidence, such as on the back of the picture. Immediate Jeopardy (IJ) was called on 11/13/2020 at 1:25 PM, at F607 - Develop/Implement Abuse/Neglect policies, when the facility failed to have operationalized their written policy and procedures for abuse and neglect screening, training, prevention, identification, resident protection, investigation, and reporting and response. Unidentified/unrecognized allegation of abuse, failures in reporting and protecting residents after incidents, unreported allegation of abuse, allegations not thoroughly investigated, incomplete/inaccurate investigations, staff unable to recognize abuse/neglect, and did not know facility abuse/neglect written policy, failure to preserve/document evidence necessary for thorough investigations, facility administration lacked knowledge of their own Abuse/Neglect written policies/procedures and their implementation, corporate/governing body staff putting non-factual/misleading information in resident incident investigation report. Residents with repeat incidents before facility even completed and reviewed the first incident investigation. Residents observed without call lights within reach. The IJ was removed during an on-site visit done on 12/03/2020, when the facilty showed credible evidence that investigations were reviewed, staff were in-serviced regarding the facilty's abuse and neglect policy and procedure. The IJ was removed effective 11/23/2020. Findings included . FACILITY POLICIES Review of a facility policy titled Protection of Residents: Reducing the Threat of Abuse & Neglect, dated 05/15/2020, showed excerpts to include: -Position Statement & Guidelines: Each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone; -Residents must not be subjected to abuse by anyone. This included but was not limited to: staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends or any other individuals; -It was the policy of this facility that all residents would be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation; and -The resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility must develop and implement written policies and procedures that: - Prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property; and -establish policies and procedures to investigate any such allegations, and include training as required. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: -ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures; and -Reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: -Have evidence that alleged violations were thoroughly investigated; -Prevent further abuse, neglect, exploitation or mistreatment while the investigation was in progress; -Reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken; and - The seven components of Abuse Prohibition - The facility has policies and procedures in place to provide protection for the health, welfare, and rights of each resident residing in the facility. In order to provide these protections, the facility has written policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. These policies include, but are not limited to 1) screening, 2) training, 3) prevention, 4) identification, 5) investigation, 6) protection 7) reporting and response. Review of a facility policy titled Grievance Procedures and Concern & Comment Program, reviewed date 05/19/2020, showed the purpose was when residents and families feel that staff have responded timely and with respect to reported concerns, confidence and trust were created and mutually deferential relationships follow. Use of the Concern & Comment Program in response to a reported concern: - Fostered a timely and quality response to the concern and/or comment; - Identified special needs of families and/or residents; - Ensured appropriate follow-up and systemic analysis; - Residents had a right to voice grievances to the facility, and such grievances included those with respect to care and treatment which had been furnished as well as that which had not been furnished, and other concerns regarding their facility stay; - The resident had the right to and the facility must make prompt efforts to resolve grievances the resident may have; - The social services staff and/or Executive Director (also known as the Administrator) were responsible for maintaining a record keeping system of all complaints reported via the Concern & Comment Program or any other means of reporting that included the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. And following up with the resident and family to communicate resolution or explanation and ensure that the issue was handled to the resident and family's satisfaction; - Administrative staff were responsible for ensuring the appointed manager contacted the concerned party within 24 hours to share the status of the investigation and resolution; and - The facility's response and the concerned individual's reaction to the resolution would be recorded on the Concern & Comment Form. Review of the facility Fall Management policy, dated 06/04/2020, showed the purpose was to promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators. The policy was the facility would assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. Additionally, the policy showed that the facility must ensure that the resident's environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices and interventions to prevent accidents. ADMINISTRATOR/DIRECTOR OF NURSING #4 LACK OF KNOWLEDGE OF FACILITY POLICIES In an interview on 11/13/2020 at 9:07 AM, Staff H, Director of Nursing (DON) #4, was interviewed, and Staff B, Corporate, asked to come in also, she said she came along because Staff H had only been there about two weeks and she didn't know much yet, and she was going to take some notes, Staff B ended up doing most of the talking. Staff H stated during the interview that she could not speak to the abuse/neglect policy yet, as she'd only been there two weeks, later in the interview she was unable to speak about the fall policy either. Staff B said they've been rectifying the issue (lack of staff knowledge). Staff B stated they had also self-identified that witness statements weren't being done. At 9:55 AM, Staff E, Administrator, joined the interview. This interview became very problematic, as Staff B wouldn't let the administrator or Director of Nursing speak without first coaching them what to say, Staff B wouldn't even let the Administrator answer without coaching first as to what the date by her signature meant on an incident investigation report. Staff B stated you keep asking the DON about policies, and I told you she doesn't know them yet because she's only been here two weeks. The surveyor terminated the interview and asked staff to leave the room, called the surveyors Field Manager (FM). In an in-person interview on 11/13/2020 at 10:10 AM, the Administrator interview was continued but Staff B did not return. The interview continued with the surveyor, Staff E and Staff A, Vice President Northwest Division, and the FM was on the phone. The Administrator was unable to verbalize on any incident reports reviewed about how the facility had implemented their Protection of Residents: Reducing the Threat of Abuse & Neglect written policy and procedures. Neither the Administrator nor DON #4 had working knowledge of their own abuse/neglect policy. After the interviews with the Administrator and DON #4, there was basically just lists of unanswered and/or unasked questions, as the two did not know the facility's policies or what had occurred in the incidents. RESIDENTS RESIDENT #2 The resident admitted to the facility 09/18/2019 with [DIAGNOSES REDACTED]. According to the annual Minimum Data Set (MDS) (an assessment tool) assessment, dated 09/18/2020, showed the resident had severe cognitive impairment. Review of an incident investigation report, dated 09/08/2020, showed the resident had a fall and hit her head at 10:30 PM, she stated she was trying to sit on her wheelchair to go to the bathroom, but her wheelchair moved and she fell and hit her head, a seven centimeter (cm) by four cm bump was noted on right side of head, and neuros remained within baseline. The incident investigation report said under other info Resident was found on floor with one sock and shoe on and the other sock and shoe in the bed at the end of the bed in the covers. Wheelchair breaks (sic brakes) were not on. The investigation report stated No injuries observed Post incident, but resident had hit her head. An event note was included, dated 09/09/2020 at 0018, it stated the resident denied pain except to head where bump was, neuro checks initiated, bump is speckles with purple bruises. The investigation report stated abuse/neglect not suspected. The investigation was not thorough due to it lacked a witness list and statements, the incident investigation report indicated No Witnesses Found, The facility did not follow their Protection of Resident policy, in that they did not record the results of the investigation on the Incident Investigation Questionnaire and did not include the Incident Follow-up & Recommendation form. The investigation lacked when the resident was last toileted, did not state what staff had assisted the resident to bed, if the resident's wheelchair (w/c) brakes were locked, why neuro checks were not completed per their policy, no Administrator signature that the investigation had been reviewed or documentation any family or representative was notified. In an interview on 11/13/2020 at 10:10 AM, Staff E were asked about the not thorough investigation, neuro checks not done, and no witness statements. No additional information was provided. RESIDENT #3 The resident admitted to the facility 08/19/2020, and had [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], showed she had severe cognitive impairment. Incident #1 (between Residents #2 and #3) Review of Resident #3's progress notes, dated 09/04/2020, showed Resident #3 has been fleeing her room because her roommate (Resident #2) was yelling at her. She looks for a bathroom because roommate does not want her using the shared bathroom. She is not allowed to have her TV on once Resident #2 goes to bed and wants to sleep. Review of the September 2020 incident reporting log revealed this incident did not get logged. In a phone interview on 11/06/2020 at 1:55 PM, Staff E knew nothing about the incident, she said they would look into it. Staff unable to identify verbal/mental abuse, no protection done, not logged, not reported, not investigated. - This was resident to resident verbal and mental abuse. It was also a failure of the facility to implement their Protection of Residents: Reducing the Threat of Abuse & Neglect written policy and procedures. Incident #2 (between Residents #2 & #3) Review of an incident investigation report, dated 10/17/2020, signed date 10/21/2020 by Staff B, Regional Director Clinical Services, revealed there was a resident to resident altercation between Residents #2 and #3, that occurred at approximately 8:15 PM, when Resident #3 made threats to Resident #2's health. Further review of the investigation showed the following concerns: -the residents were allowed to go to sleep in the same room after the altercation; -at 2:00 AM, Resident #2 told the night nurse Staff CC, Licensed Practical Nurse (LPN), that Resident #3 had threatened to kill her. Staff CC notified Staff G, DON #2, who directed her to separate the residents, and Resident #2 was moved to another room for the night. No mention of reporting to the state agency. Review of the complaint intake, dated 10/17/2020, revealed this allegation did not get reported within two hours as required for abuse/neglect allegations, but got reported 10/18/2020 at 8:00 PM, the next day; -the incident investigation did not indicate when this abuse allegation was reported to the facility administrator; -facility did not substantiate abuse or neglect; -it did state on 10/15/2020 Resident #3 became aggressive with staff grabbing a hold of an LN's (licensed nurse) neck when the LN attempted to redirect her from pushing another resident's w/c; -no witness list done, and no witness statement from Staff HH, Nursing Assistant (NA); -this incident investigation was not signed by either the Administrator or DON, it was only completed by Staff B; - During the conduct of their investigation, the facility documented four other residents had stated they did not feel safe in the facility, there was no documentation in the incident investigation report this was ever investigated; -did not include a review of all circumstances surrounding the incident (Per the Protection of Residents policy); and -did not include the Incident Follow-up and Recommendation Form (per the Protection of Residents policy), and did not include all additional documents, which were to be attached to the Incident Follow-up & Recommendation Form (didn't include the Staff J's written incident report she did prior to going home the night of the incident, Staff J, Registered Nurse (RN), was the nurse on duty during the incident). In a phone interview on 11/02/2020 at 10:00 AM, Staff J stated on the October 17th she was working in the memory unit, and had went to give Resident #2 her bedtime medications in which she had to turn the lights on. Resident #3 started talking why the lights were on. Staff J had to leave the room and upon re-entering the room noted Resident #3 and Resident #2 were talking angry. Staff J heard Resident #3 say she was going to kill her (Resident #2), which she always says a lot. I left the room and Resident #3 followed her out, walked down to the exit door and the NA's intervened. There were two male NA's on duty (Staff GG and Staff HH) who wanted to tag out with me regarding Resident #3's behaviors. Staff J stated she had 23-28 residents on her radar. At some point Resident #2 came out of her room, and came to me and Resident #3, and Staff J got between them. Resident #2 said she couldn't remember what had occurred and she went back to her room. In the meantime, Resident #3 was exit seeking to leave the unit, Staff J attempted to detour her but Resident #3 was verbally assaulting her (Staff J), which went on for 45 minutes. After Resident #3 went from being super manic to super high, she deescalated, she wanted to go to sleep. Resident #3 went back to their room, and went to sleep, Resident #2 was already asleep. Staff J then called the DON for assistance, and the DON directed Staff J to write an incident report (which was not provided to the surveyor with the incident investigation report) and call the doctor. Staff J continued to state that the next day I was told Resident #2 woke up and felt scared. Staff CC, LPN, had to separate them on her shift. The day shift nurse, Staff N, LPN, who was working blamed Staff J as she had to put up with what Resident #3 was doing and blamed her for not doing her job. For Sunday night they decided it was not safe for Resident #2 to sleep in the same room as Resident #3, they had Resident #2 sleep in a different unit. Staff J stated that on Monday, Resident #3 wanted to leave and was sent to the hospital that day. After Resident #3 was sent to the hospital, she was called about 7 PM by the Administrator, while working, who stated she was suspended for five days effective immediately until the investigation was completed. Staff J stated Resident #3 had actually hit her in the throat and Staff GG reported that the resident had hit him as well. Staff J stated she had spoken to someone with the state who pointed out she should report within two hours per the purple book for allegation so abuse, but her training at the facility directed her she had 24 hours, which counterdicted what they were telling me. Staff J thought the two hour reporting was only for extreme physical violence, not for verbal stuff and thought she was fine because she made the report within a 24 hour window. In a phone interview on 11/05/2020 at 3:45 PM, Staff J stated the following: -during the incident she had heard Resident #3 say I'm gonna kill you [***] to her; -she got a witness statement from Staff GG but not from Staff HH; -she had not been trained on how to conduct an investigation before that incident, since then they have given us a step by step guide on reporting and how to do all the parts of an incident report. This all happened after the incident with Resident #2 and Resident #3. I didn't know this before that; -I was upset, because I had called the DON for guidance, I was told to do the incident report and contact the doctor, which I did; -she did do the incident report ((written), the one that was not provided to surveyor when the incident investigation was requested); and -said she spoke with the doctor, I told him Resident #3 was manic and had refused her medication for that. He said to have the next shift make sure the next shift gave her a medication, I told him she was extremely manic and didn't go to her room until she was exhausted; Staff J was then asked why she didn't document she heard Resident #3 say she was going to kill Resident #2, she stated because she (Resident #3) stated it all the time. Staff J stated that Resident #3 had called her a c*** and told me to go f*** myself, which she had put this information in the comment section of the incident report. Staff J was asked if she had passed on the information of the incident to the oncoming nurse, she stated I would say Resident #2 has been doing this, and that they might not be good roommates. Review of a written incident report (this written information was not provided to surveyor when incident investigation was requested, did not find out about it until later as the LN had made an entry about the incident report in the progress notes, some of this relevant information was left out of the facility's own investigation done by Staff B), by Staff J dated 10/17/2020 at 9:30 PM, regarding the resident to resident altercation on 10/17/2020 showed: - at approximately 20:15 resident (Resident #3) started being verbally aggressive and loud with her roommate making threats to her health; -she (Resident #3) was loud and verbally abusive. She stood up to walk and took a swing at my throat hitting me in the Adam's apple area. I backed up as she connected with me to deflect the hit. She came down the hallway and attempted to go outside through the emergency exit doors several time. She had been offered and refused her HS (bedtime) medications including Quetiapine (anti-psychotic medication) for [MEDICAL CONDITION]. She pushed down a computer in the nurse's station onto the floor. She continued to be very agitated for many long minutes; -This LN wrote an abbreviated version of her actions and verbalizations of what occurred that shift. The LN documented that Resident #3 pushed down a computer onto the floor in the nurse's station, was extremely agitated, made multiple attempts to open the emergency exit, hit the LN in the throat and Staff GG on the side of his head, and was verbally assaultive calling the LN names and stating I'll kill you in the end . Review of a progress note, dated 10/20/2020 (three days after the incident) at 2:39 PM showed Resident #2 had told a registered nurse She (Resident #3) threatened to kill me. I am staying away from her. I didn't do anything. I was just lying in bed. I was afraid to go to sleep. I waited until I heard her breathing. She scared me. Review of the facility incident investigation report done by Staff B dated 10/17/2020, completed on 10/21/2020, showed the investigation was not thorough, or complete, and it contained false and/or misleading documentation. The investigation: -omitted information about the 09/04/2020 progress note where Resident #3 was fleeing her room as Resident #2 was yelling at her, it omitted the information that Resident #3 was looking for a bathroom because her roommate didn't want her using their shared bathroom, and it omitted the information that Resident #3 was not allowed to have her TV on once Resident #2 went to bed which was all relevant information that was left out of the investigation; -Stated that the progress notes reviewed to rule out any similar situations/verbal altercations with any other residents. It did not have any information at all about an incident of physical abuse between Residents #3 and Resident #10 on 10/01/2020; -It said there was intermittent 1:1 by staff, there was no documentation of any 1:1's being done at all; -It omitted the information about Resident #3 throwing a computer to the ground; -It was also misleading in that it talked about potential for delay in reporting. There was actual delay in reporting, almost 24 hours of delay; -It said unable to substantiate abuse or neglect. There was verbal and mental abuse of a resident and there was also physical abuse of staff, as two staff were physically assaulted by Resident #3 prior to her being allowed to go back to bed in same room with Resident #2, unsupervised); -It said Resident #3's medication administration records (MARS) were reviewed and there was one day she refused her [MEDICATION NAME] (Quetiapine) (antipsychotic medication). This was not accurate either, review of Resident #3's October 2020 MARS revealed three doses of [MEDICATION NAME] had been refused, 10/10/2020, 10/13/2020 and 10/17/2020; and -It said it was difficult to determine if Resident #2 suffered from some mild psychosocial distress. This was false/misleading, Resident #2 told staff she was scared, that Resident #3 had threatened to kill her, and she told Staff C that several times. Progress note review indicated resident was afraid to go to sleep. Review of the October 2020 incident reporting log, provided date 10/28/2020, the resident:resident altercation between Resident's #2 & #3 on 10/17/2020 was incorrectly listed as a 70 for Other (describe), when it should have been listed as a 35 for Resident-to-Resident altercation. The facility maintained an inaccurate incident reporting log, they put no description by the 70, but actually should have put a 35. Inaccurate incident reporting log, two errors in one incident, used the wrong code, then didn't describe the 70 -other, which was wrong anyway. In an interview on 11/13/2020 at 4:40 AM, Staff CC, LPN (this was the nurse that came on duty the next shift after the incident between Residents #2 & #3 on 10/17/2020), she stated: -she was not really told what had happened between Residents #2 & #3 when she came on shift. She said she received no details, she said Staff J, RN, told her something had happened, but it was not presented as any big deal. But then, Resident #2 told her later in the shift that Resident #3 had threatened to kill her and said it several times, she said it was plain as day to her, and she told Resident #2 she couldn't stay in there (in their shared room with Resident #3), that they had to get her some place else, some place safe, so she took her to a different room. -she said she called the DON, who didn't tell her to report it. -she said she thought Staff J, RN, had probably reported it, that maybe she should have double reported, but she called her DON for guidance, as we are supposed to do. -I know we are supposed to report abuse to both the DON and the ED (Executive Director) and to report to the 1-800# (abuse/neglect hotline). -she said there was no difference in reporting abuse between verbal or physical abuse, that abuse was abuse. -so she did tell Resident #2 they needed to find a safe place for her, she (Resident #2) was scared, she kept saying I don't want to be here in this room, I'm scared. -Resident #3 was very volatile, she had a UTi and it really messed her up. -Since then I have heard several different stories of what people said really happened. In an interview on 11/13/2020 at 5:36 AM, Staff GG was asked about Residents #2 & #3 and their incident on 10/17/2020, he stated: -Resident #3 gets real territorial, if anyone goes by her room she says get out of here or I'll knock your head in, or if you go by her she says get the hell out of my way. -Resident #3 told me I had better sleep with my eyes open because she was going to cut my throat from ear to ear, and she said some horrible things to Staff J, RN, who sat and wrote everything she said on paper, she made lots of verbal threats and nasty comments. Resident #3 swung at me to hit me and to get away. -I saw Resident #3 clean off the countertop with the computer, she wiped everything off the counter. She was out of control. -Staff GG was asked if he had done 1:1's (per Staff B's comment in the incident investigation report) with Resident #3, he said No, I was not assigned to do 1:1's. -I made the comment to Staff J, RN, I told her someone needed to be with her (Resident #3) at all times, she had a demonic look to her and she was making threats. -I left and I heard the next day that Resident #3 finally gave up and went to bed. I heard later that Staff J got ostracized for letting Resident #3 go back to bed with Resident #2. -I know Staff J, RN, called the DON, Resident #3 was still up when I went home. -I heard threats, she (Resident #3) threatened me, that was very eerie to hear someone say that. In a phone interview on 11/17/2020 at 8:52 AM, Staff G, Director of Nursing #2 (DON#2), stated she got no training at all when she started at the facility, and we were short staff, and it was unfortunate. This DON got suspended having not directed staff to report/investigate potential abuse. (incident investigation dated 10/17/2020). In an interview on 10/13/2020 at 10:10 AM, Staff E stated: -she would have to do some chart reviewing and check with social services about the four residents that stated they did not feel safe in the facility. -she said she would have to look elsewhere for when the investigation was actually completed or when she had reviewed it, or when she had been notified of the potential abuse, she was asked why this information was not in the incident investigation, no answer was provided. Review of the November 2020 incident reporting log, provided date 12/03/2020, showed that the matter of the four residents stating during the course of the 10/17/2020 incident investigation that they didn't feel safe in the facility, did get logged, for three of the residents on 11/19/2020. Summary: Failures in abuse identification, resident protection, investigating, documenting, training, prevention, reporting and response. RESID (TRUNCATED)

Based on observation, interview and record review, the facility administration and governing body failed to ensure an adequate number of adequately trained and adequately supervised caregiver staff, to include nurses for supervision and resident care management, nursing assistants and shower aides, were employed, staffed and supervised to meet residents' basic care needs; this failed practice was widespread throughout the facility on three of three units (Havenwood, Quilceda and Pilchuck) which involved 72 residents. Facility administration had a duty of care that was breached when they failed to provide structures/processes that ensured care and services that maintained residents' physical and mental health in the areas of bathing/personal hygiene care, toileting care, personal care needs/call light response, and transferring care of residents from one surface/place to another. This disregard of the consequences of facility failure to provide necessary and care planned care and services resulted in widespread neglect of residents when their care needs went unmet and the facility continued to admit additional residents, further rationing out already inadequate care and services to current residents, and subjecting newly admitted residents to unacceptable quality of care standards and conditions. Outcomes from these failures that resulted in neglect to residents were evident in: residents who experienced unmet bathing needs, avoidable skin issues to include rashes, persistent pressure injuries, malodorous skin/tissue folds, discomfort from inflamed/irritated/itchy skin, sitting in excrement (waste matter discharged from bowels, feces) for extended periods of time when there was inadequate staff to respond timely to residents' call light calls for care, residents that complained of waits for toileting for hours, residents left in bed through the morning after being in bed all night because there was not enough staff to get them up, and Resident/family/representatives with unresolved grievances concerning inadequate care. Immediate Jeopardy (IJ) was called on 11/10/2020 at 2:00 PM, when the facility's system for the provision of basic bathing care and services was inadequate to meet resident needs, placing residents in jeopardy. Failure to maintain adequate staffing and failure to have current processes/structures and nursing staff supervision/administrative oversight placed residents at risk for harm including skin breakdown and psychosocial harm due to residents being neglected and not receiving necessary care. Review of facility resident bathing documentation revealed multiple residents with no documented bathing in over 30 days. IJ Removal - In an onsite investigation on 12/03/2020, the IJ was removed, effective 11/23/2020 when the facility had evidence that all residents received a bath, resident's were interviewed regarding their bathing preferences and their care plans were updated to reflect their preferences, staff were educated on the facility's bathing protocol, and a master shower schedule was implemented. Review of facility practices found this skilled nursing facility had disregarded their grievance and concern program policy and procedures, their activities of daily living policy and procedures, resident care plans, resident rights policy and procedures. There was a lack of administrative oversight, lack of nursing supervision at all levels in the nursing home, rapid Administrator/Director of Nursing/caregiver employee turnover in the setting of unmet resident care needs and continued admissions which all resulted in widespread neglect. Findings included . Review of the facility policy titled Resident Rights, issue date 06/08/2020, showed: - The resident had a right to a dignified existence and self-determination; - A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents; and -The facility must provide equal access to quality care. Review of the facility policy titled, Activities of Daily Living (ADL's), reviewed date 05/05/2020, showed the purpose was to ensure facilities identified and provided needed care and services that were resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that would meet each resident's physical, mental, or psychosocial needs. The policy included staff to: - ADL's: the facility must provide care and services . to include hygiene - bathing, dressing, grooming, and oral care; and - A resident who was unable to carry out ADL's received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of a facility policy titled Grievance Procedures and Concern & Comment Program, reviewed date 05/19/2020, showed the purpose was when residents and families feel that staff have responded timely and with respect to reported concerns, confidence and trust were created and mutually deferential relationships follow. Use of the Concern & Comment Program in response to a reported concern: - Fostered a timely and quality response to the concern and/or comment; - Allowed for identification of possible trends and patterns; - Ensured appropriate follow-up and systemic analysis; - Residents had a right to voice grievances to the facility, and such grievances included those with respect to care and treatment which had been furnished as well as that which had not been furnished, and other concerns regarding their facility stay; - The social services staff and/or Executive Director (also known as the Administrator) were responsible for maintaining a record keeping system of all complaints reported via the Concern & Comment Program or any other means of reporting that included the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. And following up with the resident and family to communicate resolution or explanation and ensure that the issue was handled to the resident and family's satisfaction; - Administrative staff were responsible for ensuring the appointed manager contacted the concerned party within 24 hours to share the status of the investigation and resolution; and - The facility's response and the concerned individual's reaction to the resolution would be recorded on the Concern & Comment Form. RESIDENT #11 The resident, age 90+, admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident was moderately cognitively impaired, required extensive 2-person assist with the ADLs (bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing) and 1-person physical assist with walking in the room, was frequently incontinent of urine and had balance issues. Review of a Concern & Comment form, concern report date 09/11/2020, showed the residents' daughter had a concern that one shower a week was not enough for her mom, she asked for her to get at least two showers a week, please. Review of the form revealed the facility had not followed their grievance policy, as the initial contact after the concern was made, did not happen until 09/16/2020. The date/time Findings/Action Plan shared with concerned party, was blank. The investigative findings was blank. The concern/grievance was not resolved. Staff E, Administrator, wrote on the form on 10/05/2020, daughter understanding we would work toward two showers/week for her mom. Review of a progress note dated 09/11/2020, showed there was nothing documented about the resident's care concern/concern card (dated 09/11/2020) about the lack of bathing. Review of the facility bathing documentation for the resident, for 30 days print date 11/06/2020, revealed documentation the resident was bathed three times with no refusals. The bathing documentation form incorrectly stated she wanted 1-2 showers/week, but the concern/grievance dated 09/11/2020 clearly requested two showers a week. At two showers a week, the facility deprived this resident of at least 5 showers for the 30 days reviewed. In a phone interview on 11/06/2020 at 3:59 PM, the residents' daughter was asked about the 09/11/2020 concern/grievance, she stated it had not yet been resolved, she said she had complained to the new Administrator, who told her that her new policy was one shower/week. The old Director of Nurses (DON) had told the daughter that there were budget cuts and they hired new staff and it would take 6-8 weeks to train them to do work so they could have two staff to do resident showers. The daughter stated Staff R, Nursing Assistant (NA)/former shower aide, used to get the showers done, her mother loved her, and then the facility had put Staff R to work the floor because Staff R could not get all of the scheduled showers done in a day's work. The daughter stated that her mother said she was not as clean as she used to be. The daughter stated her mother was incontinent and needed to be bathed at least twice a week, and she would not take her poop medicine because she did not think staff would get her to the bathroom in time. The resident's 30 days of bathing documentation was discussed with the daughter, which showed she was bathed three times in 30 days. The daughter replied, Oh my god, how can that be right! Maybe my mother isn't going crazy. Review of a Concern & Comment form, dated 11/08/2020, showed the residents' daughter's concern was that I demand that my mom have two showers a week at the least, and that should start Now! No Excuses! The daughter further documented that the facility should be ashamed of yourselfs make this happen!!! Review of a second Concern & Comment form, dated 11/08/2020, showed the residents' daughter's concern was that her mother received her medications on time, the daughter demanded the resident received medication on her private parts when in the bathroom each time, to not leave her mother in the bathroom longer than needed, and that there were no excuses! Review of a third Concern & Comment form, dated 11/08/2020, showed the resident's daughter's concern was that she wanted her mother's bed made, wanted her table put close to her so she could answer her phone, to ensure that her heat was on, and that the daughter would take any excuses and to Take care of my mom!! In an interview on 11/09/2020 at 12:03 PM, Resident #11 stated she used to get two showers a week, on Tuesdays and Thursday, but not since the facility had changed over to the new lady in charge. She stated she needed more bathing and did not feel clean. Resident #11 stated when she was at home she bathed daily, but did not ask for more because she knew the staff were busy. The resident stated she her daughter knew what was going on. The resident stated she did not have a rash, staff were putting medication on her, but she did itch down there and pointed to her groin. The resident stated there were not enough staff to meet her needs without waiting a long time. She stated that she had waited, at times, over an hour to go to the bathroom, but that was not their (the staff's) fault because there were not enough staff. The resident declined her skin to be observed. In an interview on 11/09/2020 at 4:25 PM, Staff E was asked about the grievance dated 09/11/2020, and how the facility had resolved it, she stated it was resolved because they were working on it. Staff E was asked if the resident had ever received two showers a week as requested in the grievance, she stated she would have to look into it. In a phone interview on 11/10/2020 at 4:54 PM, Resident 11's daughter stated she had put in 3 grievances Sunday, for all kinds of things, demanded her mother to have two showers a week at the least, and the facility should be ashamed. The daughter stated she wanted to ensure her mother received her medications on time because she (Resident #11) had problems with her private parts, had a history of [REDACTED]. Review of a progress note dated 11/12/2020, Staff B, Regional Director of Clinical Services (RDCS)/Registered Nurse (RN), asked the resident if she was pleased with her shower schedule. The resident replied she was not and that it was not a schedule don't know when I have one. In a phone interview on 11/12/2020 at 11:33 AM, Resident #11's daughter stated her mother called her, which was unusual, she said staff were lying to her. She stated Resident #11 did not like her to state anything to the facility because she wanted people to like her. They did ask her yesterday when she wanted showers. I talked to her doctor about her poop medicine, he said they would look at the timing, I know she won't take it because she is afraid staff won't get to her in time, mom has told me it takes over 30 minutes when she calls for staff to come take her to the bathroom. She said they come and get her and leave her, then she has to pull the cord and they eventually come back, but she said that is too long to sit there. She can't get up on her own, so she said she's left sitting on a toilet with her pants down. That has happen many times because that is their normal practice. The daughter stated her mother had told her she had to go out into the hall to get someone to take her to the bathroom. The daughter again stated that her mother complained of pain in her vagina when she goes to the bathroom and that she was not getting cleaned up enough, either when she went to the restroom or when she was not bathed enough. The daughter stated that when she was able to go into the facility, she would talk to the aids and new what was going on. The daughter felt now, things wre not so good since the new Executive Director (ED) was hired. The daughter felt the facility was neglecting he mother with no enough bathing and with not toileting her without having to wait too long. Review of a nursing progress note dated 11/13/2020, indicated staff spoke with the residents' daughter this AM about her care concerns for her mother. The daughter stated that she wanted to make sure she had her medications on time, was cleaned appropriately and had an evaluation for proper fit of her wheelchair. Review of a progress note dated 11/14/2020, showed Resident #11's rash had worsened overnight, had no pustules, covered a large area to groin/gluteal folds and coccyx, and the resident complained of pain and burning. A new order was obtained to apply [MEDICATION NAME] cream (skin medication) to the large area of buttocks/groin reddened areas twice daily for seven days. Review of the resident's November 2020 Medication Administration Record [REDACTED]. Review of the resident's current 27 page care plan, print date 11/20/2020, showed care planning to include: - An alteration in mobility and safety and was at risk for falls related to history of falls, poor safety awareness, weakness, chronic hip pain due to history of fall, chronic back pain; - An alteration in elimination related to decreased self-mobility, weakness, history of urinary tract infection, hip and back pain; and - A potential for/actual alteration in skin integrity related to incontinence of bladder, decreased mobility, chronic skin problems to forearm, hip/back pain, chronic peri redness. In a phone interview on 11/19/2020 at 1:55 PM, the residents' daughter stated she was told over the weekend that her mother had a bad rash that exploded over the weekend and it was all over her bottom and lower back. The daughter had spoken to Staff B who didn't want to respond to me in writing, as the prior Administration did. The daughter felt Staff B was basically just trying to get her to say everything was ok now, but she was not going to state that until the issues were fixed. The daughter told Staff B that if the staff could not get her mother the bathroom within about 10 minutes, then the matter was not resolved. Review of a Concern & Comment form, dated 11/24/2020, showed the daughter had not seen a written response to her concerns, there were issues with missing clothes and a missing blanket, inquired how her mother could get her hair cut and that this information was reported to Staff B. In a phone interview on 11/24/2020 at 7:45 AM, the residents' daughter stated there were issues with her mother's medications being given on time. The daughter stated she had called Staff B, on 11/23/2020, and left a voicemail asking when she was going to get a written response to her concerns, I've still got no reply, I don't know what is going on, so now I am going to write down a concern form for a concern of not getting a written response yet to my grievances, and that on the blue card grievance form it said they have to give me a written response on what was done to resolve the issues, it says customer grievance resolution on the back of the concern card, and yet I've received no response from them at all. The daughter stated she wanted a written response from the facility regarding what they were going to do because other grievances never got replied to. The daughter mentioned the ongoing concern with no consistently putting medication her mother's private parts. The daughter stated her next step if I don't get any response to the issues, I'm going to call their corporate, I think if staff aren't addressing the issues, I will have to go up to corporate, they need to know about this. If they aren't going by their corporate rules, I think they need to look at their new executive director, I don't think she is doing her job. Since she has gotten there everything has gone downhill. I'm trying to be very patient, to just get through this, hopefully it isn't like this forever. In a phone interview on 11/25/2020 at 7:43 AM, resident's daughter called and stated that she felt the problem had a lot to do with management and corporate, she said she could not remember how many ED's there had been over the last three years and that the nurse managers would come and go just as fast. The daughter felt the corporate people were the ones that determine their budget, but corporate was looking at budget which was just looking at the bottom line, then they (the facility) would not have enough staff that stick around long enough to learn how to do a good job. Review of a progress noted dated 11/25/2020, showed a nurse had spoken to the resident's daughter on 11/20/2020 and confirmed satisfaction with shower/bath preferences. There were no further concerns at this time and made a request change to the resident's preferences. RESIDENT #1 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment, dated 10/15/2020, the resident was unable to complete the mental status assessment, had memory problems and severely impaired cognitive skills for daily decision making. The MDS indicated the resident needed 2-person assist with bed mobility, transfers, dressing and toilet use. For bathing, the MDS indicated the resident had total dependence on staff, and was incontinent of urine and bowels, and had one unhealed pressure injury that was present on admit. Review of the resident's 20 page care plan, print date 11/16/2020, showed care planning to include: - required ADL assistance and therapy services needed to maintain or attain highest level of function, related to Stage IV pressure sore on sacrum, diabetes, inadequate oral intake .; -limited physical mobility related to weakness; -at risk for falls related to current medical condition and history of falls, NIF (non-injury) falls on 09/09/2020 and 09/10/2020, and history of falls; -has break in skin integrity on sacrum (stage IV) and right heel Stage 3 (healed 10/14/2020); and -expressed generalized pain/discomfort related to stage IV pressure injury on sacrum and current medical conditions. Review of the facility's resident bathing documentation, for 30 days, print date 11/06/2020, revealed no documented bathing. The documentation indicated the resident preferred to bathe 1-2x per week. Review of the residents' Kardex (care directives for nursing assistants), print date 11/20/2020, revealed the directive was for bathing, preferred 1-2x/week, with no mention of her preference for an A.M. bed bath. Review of documents emailed from the residents' daughter, dated 07/09/2020, revealed a form Resident Preferences - Care Plan, dated 07/09/2020, revealed the daughter had annotated bed baths, 2x/week and as needed, and to be given in the AM. For 30 days at two per week, the resident wanted to have been bathed at least eight times, she was documented as receiving none. In a skin observation on 11/10/2020 at 3:17 PM, with Staff L, Licensed Practical Nurse (LPN) and Staff S, Certified Nursing Assistant (CNA), when the residents briefs were removed there was a rotten odor observed, the resident had not been incontinent, the resident's buttocks were red, and the resident had a pressure injury skin opening that was approximately three inches by two inches deep opening at the top of her sacrum. Both of the resident's calf's and both feet had very dry, thick, crusty skin, such that when the skin observation was over, the entire lower 1/3 of the bed looked to have a slight layer of snow. Both feet were observed to have red, wet looking skin between toes on both feet. In a phone interview on 11/12/2020 at 10:47 AM, the residents' daughter stated she could not come to the facility because she lived out of state. She said when her mother admitted to the facility the paperwork had bathing once a week, and she crossed that out and put in bed baths twice a week, and as needed. She stated her mother was a bather and she would want to be clean. She said she would email the surveyor the bathing paperwork. During the phone interview, the facility documentation of the residents' 30-day bathing was reviewed, the resident said no one had told her mother was not being bathed and that was probably the main reason her bedsore had not yet healed. The residents' daughter stated she couldn't really talk to her mom much because her mother forgets she was on the phone and sets it down. Resident #1 was cognitively impaired. Based on the Reasonable Person Concept, a reasonable-person in a similar position would likely have felt dehumanized after not being bathed in over 30 days. RESIDENT #2 The resident admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the annual MDS assessment dated [DATE], the resident had severe cognitive impairment, required 2-person assist with bed mobility and transfers and one person for dressing, toileting, personal hygiene and bathing. The resident was occasionally incontinent of bowel and bladder. Review of the resident's care plan, print date 10/30/2020, revealed: - ADL deficit secondary to history of fall with lumbar strain, generalized muscle weakness, impaired mobility, adult Failure to Thrive, heart failure, shortness of breath, depression, impaired cognition, impaired vision, difficulty swallowing food or fluids and incontinence; and - behavior problem of calling out when having to use the bathroom or needing help i.e. I have to use the bathroom now .Why doesn't anyone believe me. Behavior of yelling out or verbal outburst to staff and other residents. Review of the facility's resident bathing documentation, for 30 days, print date 11/06/2020, revealed she had one shower during the 30 days and no refusals. The documentation indicated she wanted to bathe 1-2x/week. Based on 1-2x/week for 30 days, the resident was care planned to have been bathed 4-8x, she was bathed once. Resident #2 was cognitively impaired. Based on the Reasonable Person Concept, a reasonable-person in a similar position would likely have felt dehumanized after having been bathed only once in 30 days. RESIDENT #3 The resident admitted to the facility 08/19/2020 - 10/19/2020, and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission MDS assessment dated [DATE], showed the resident had severe cognitive impairment, required extensive 2-person assist with the ADLs of bed mobility, transfers, walking in room, dressing and toilet use, and one person assist with personally hygiene and bathing. The resident was frequently incontinent of urine and occasionally incontinent of bowels. Review of the resident's care plan, print date 10/30/2020, showed: -No care planning at all related to the resident's bathing preferences to include type of bathing or frequency, or time of day; - Required ADL assistance and therapy services needed to maintain or attain highest level of function, related to history of diarrhea, urinary tract infection, [MEDICAL CONDITION], depression, general weakness, and dementia; and - Had urinary incontinence related to requires assistance in toileting, incontinent care related to history of urinary tract infection, dementia, depression and general weakness. Review of the Kardex, print date 10/30/2020, revealed there was no bathing frequency or type of bathing the resident wanted. Review of the facility's bathing documentation for 30 days, print date 11/06/2020, and the resident census information, showed the resident was in the facility for 22 days of the 30-day bathing review, she had no documented bathing in those 22 days. The 30-day bathing documentation had no bathing frequency documented. Though not care planned for this resident, had she been care planned for even weekly bathing, she would have been bathed three times, she got none. In an interview on 11/09/2020 at 10:39 AM, the resident did not appear unclean, she did not know when she had last bathed, and she did not know how often she wanted to bathe. In an interview/observation on 11/13/2020 at 6:11 AM, the resident was sitting in her wheelchair, she was deemed not-interviewable. The resident did not appear unclean, though her hair was a bit of a mess. Resident #3 was cognitively impaired. Based on the Reasonable Person Concept, a reasonable-person in a similar position would likely have felt dehumanized after having not been bathed at all during her 22 days in the facility for the 30-day time period reviewed. RESIDENT #4 The resident admitted to the facility on [DATE], for orthopedic after care/rehab after having a fall with fractures of the right hip and [MEDICATION NAME] vertebrae. Resident admitted to the facility with a history of falling, dementia, need for assistance with personal care, and [MEDICAL CONDITION]. Then, during the 08/03/2020 admission to the care center, the resident sustained [REDACTED]. According to the admission MDS assessment dated [DATE], showed the resident had moderate cognitive impairment, required extensive 2-person assist with bed mobility, transfers, dressing, toilet use, extensive 1-person assist with personal hygiene and was dependent on bathing needs. Review of a Documentation Survey Report, for August 2020, showed the resident had no bathing for 13 days from 08/11/2020 - 08/24/2020, and no care planned frequency listed. Review of the resident's Kardex, print date 11/05/2020, showed no documentation of resident's bathing preferences related to frequency or preferred time of day. Review of the resident's care plan, provided by facility medical records on 11/13/2020, showed care planning to include: - Required ADL assistance and therapy services needed to maintain or attain highest level of function related to a [MEDICAL CONDITION] with surgery, abscess of right elbow, aspiration pneumonia (occurs when food, saliva, liquids, or vomit is breathed into lungs or airways), breathing problems, back fracture and dementia; - At risk for falls related to generalized weakness, deconditioning, dementia, breathing problems with oxygen use, opioid's medications, recent hospitalization due to right [MEDICAL CONDITION] and surgery, and 09/29/2020 resident sent to ER related to fall with injury; - Potential for pressure ulcer development related to unstageable pressure sore on sacrum, hip incision site, requires extensive assist in bed mobility, incontinent of bowel and bladder, and dementia; and - Had bladder incontinence related to a [MEDICAL CONDITION] and surgery, an arm infection, aspiration pneumonia, breathing problems, back fracture, and dementia. In a phone interview on 11/05/2020 at 1:58 PM, the resident's family member/caregiver at home, stated she used to sit outside the window (at the facility) and no staff would come in, and she would call the facility and hear the phone ringing, and witness staff walking by but not come in (the resident's room). The family member stated the Resident #4 had no baths and was filthy dirty, and her toenails were all overgrown, and she had a pressure ulcer. At one time the family member had witness staff leave Resident #4 on the bedpan for 45 minutes. She stated she called and called and called and finally she went into the building, ended up in the kitchen, and told them she tried to get staff's attention that Resident #4 was sitting on a bedpan and hurting, but no staff would come. She said she couldn't sit there on a bedpan that long, it hurt her to have to sit on it that long, and she could see the resident was in pain. Then they put diapers on her because they said she was incontinent. The family member denied staff were turning Resident #4 in bed, she stated every time she was just laying on her back, and she was not laying on her sides at all. The family member denied staff bathed her much except for occasional sponge baths. She stated Resident #4's skin was so bad when she got home from the hospital that one toenail grew into the side of her big toe, and stated she would send pictures. The family member stated she took Resident #4 home after the 2nd hip surgery, as there was no way she was going back to the nursing home, and her sore on her bottom was awful. In a phone interview on 11/06/2020 at 11:50 AM, Resident #4 stated she received bed baths at the nursing home, but when asked if she felt clean she stated Not very. The resident was not able to recall if she had be turned onto her sides because it (her stay) was kid of murky. Resident #4 was not sure if she had been incontinent but did sta (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff were available to provide timely and necessary care and services for 72 of 72 residents (#1 - #65 & #67 - #73) reviewed. The failure to: 1) timely answer call lights, 2) to ensure residents' toileting needs met timely, 3) to ensure medications were administered as ordered, 4) to bathe residents, 5) to transfer residents in/out of bed, 6) to supervise nurses, nursing assistants and shower aides, 7) to perform neuro checks after resident hit head, 8) to obtain medication informed consent per facility policy, 9) to prevent accidents, 10) to properly transcribe medication orders, 11) to provide adequate supervision of residents, 12) to answer phones when family called, all resulted in widespread harm related to neglect due to unmet resident needs manifested by nursing supervision lacking at all levels, continuity of care lacking, rapid caregiver staff and Director of Nursing turnover, and resident complaints of rough handling. Findings included . RESIDENTS RECORD REVIEW Review of resident admitted s, and 30 days of bathing documentation, print date 11/06/2020, for 70 residents (#1-3 & #5-65 & #67 - 72 showed: -62 residents had been in the facility for the full 30 days reviewed, eight had been in less than 30 days: -24 of 62 residents had not been bathed at all in 30 days, -24 of 62 residents had been bathed once in 30 days, -6 of 62 residents had been bathed twice in 30 days, -4 of 62 residents had been bathed three times in 30 days, -4 of 62 residents had been bathed four times in 30 days, -Eight residents had been in the facility < 30 days: --These eight residents had been in the facility for 11 days, 17 days, 16 days, 11 days, 10 days, 22 days, 14 days, 21 days, -only one of these eight residents had been bathed at all, once. Review of DON#1's resignation letter, dated 08/28/2020, showed that DON#1 requested agency staff in July 202 and August 2020 and her requests were denied. DON#1 stated that the staffing crisis was reviewed with the Executive Director and that DON#1 had advised to stop admissions until the facility developed a plan to ensure staff coverage. The DON#1 stated in her resignation letter that there were not enough staff to meet the residents' care needs. However, admissions continued and the DON#1 realized the staffing crisis was not being addressed. From my clinical perspective, we do not have enough associates to meet our obligations to the residents in our care. Admissions have continued. As Director of Nursing it's important I provide a bridge between operational goals and the nursing staff: I am no longer able to be successful in this role as I am not in agreement with the current operational priorities. This conflict does not foster a healthy work environment at Marysville Care Center, nor does it support a positive professional life for myself. My last day at Marysville Care Center will be September, 11, 2020. Sincerely, Staff F, DON#1 STAFFING REVIEW 12-month Staff Turnover Rates, received 11/18/2020: Title TERM Average Turnover% last 365 days Headcount Certified Nursing Assistant 46 45 102.2 LPN Unit Nurse 10 14 71.4 RN Unit Nurse 6 6 100.0 Facility Director of Nursing 12 month history: Unknown Unknown - 02/23/2020 Staff F, DON#1 02/24/2020 - 09/25/2020 Staff G, DON#2 09/28/2020 - 10/21/2020 Staff V, DON #3 10/21/2020 - 10/28/2020 Staff H, DON#4 10/28/2020 - 11/29/2020 Staff B, RDCS/DON#5 unknown - 12/16/2020 Staff EE, DON#6 12/17/2020 - Facility Administrator 12 month history: Staff W, former administrator 11/19/2018 - 11/25/2019 Staff X, former administrator 11/26/2019 - 04/13/2020 Staff Y, former administrator 04/14/2020 - 06/07/2020 Unknown 06/08/2020 - 06/21/2020 Staff X, former administrator 06/22/2020 - 07/10/2020 Staff E, Administrator 07/13/2020 - present STAFF INTERVIEWS In an interview on 11/09/2020 at 9:45 AM, Staff E, Administrator, did not know the names of the three Resident Care Managers (RCMs) (Nurse Managers). In an interview on 11/09/2020 at 2:34 PM, Staff R, Nursing Assistant (NA)/former shower aide, stated the nursing assistants didn't do any bathing, they did wipe them down some. She stated she used to be a shower aide, but she was taken off that job because she wasn't fast enough doing showers. Interview terminated when a staff member came and said she was needed for patient care. In an interview on 11/09/2020 at 2:46 PM, Staff M, Shower Aide, but frequently pulled from her bathing duties to work as a nursing assistant when they didn't have enough nursing assistant staff to work the floor, stated they were supposed to have two shower aides every day, but they only had one shower aide on some days, and none on others because they got pulled to the floor to work as nursing assistants. Staff M said she did not know the plan to have two shower aides a day, but there the shower aides were unable to do the current shower schedule with only one shower aide a day. She said there were residents that only wanted to bathe once a week, but they haven't always been getting them. She said there was only the electronic bathing documentation which was reviewed. -In a joint review of 30 days of bathing documentation, there were lots of holes in bathing documentation, with many residents having no documentation of bathing at all in 30 days, Staff M stated there were weeks they just couldn't get to all of the residents because they were pulled to work as nursing assistants on the floor. Staff M stated that she spoke with Staff H, Director of Nursing #4, and informed DON #4 that showers weren't getting done. DON #4's reply to Staff M was to provide care instead of showers. Staff M said she was unable to provide showers as she had to work as a nursing assistant. Staff M was unable to recall all dates the shower aides were pulled, but she knew they got pulled as follows: on 11/01/2020 Staff M got pulled, 11/02/2020 the other shower aide got pulled, 10/29/2020 Staff M got pulled, 10/28/2020 both shower aides got pulled, 10/27/2020 Staff M got pulled, 10/25/2020 both shower aides got pulled. In an interview on 11/09/2020 at 3:34 PM, Staff I, LPN/RCM, stated she had been the RCM for the entire building for parts of the last month. She said they used to have three RCMs, but the other two quit, and then she was made RCM for all three units, and she was also made the Admission Nurse. Staff I denied the shower aides had reported to her they were not able to get their bathing done. Staff I was asked who was making sure bathing was getting done, she stated I don't know. Staff I did not know who did oversight of the shower aides. She stated there used to be three RCMs, but right now I am doing RCM for the entire house and the admissions. Staff I was asked how she did all of that and supervised resident care, she stated Not very well. A joint review of the residents' bathing records was done, many residents with no bathing in over 30 days, she stated she was unaware of that. In an interview on 11/09/2020 at 4:04 PM, Staff H, Director of Nursing #4, was interviewed and a joint review of 30 days of resident bathing documentation was done, there were many residents with no documented bathing in over 30 days, she said no staff had told her residents weren't being bathed. DON#4 was asked if a resident had not been bathed in 30 days would she consider that neglect, she stated Yes. A joint review of the Day Staff Sheets, from 09/01/2020 - 11/05/2020, was done, there were Shower Aides specifically scheduled only on three days, 11/03/2020, 11/04/2020, and 11/05/2020. The other days all had just CNAs documented, she said she was new so she didn't know how they tracked who worked where yet. Staff H was asked for more documentation which days shower aides worked, none was provided. Staff H was asked the names of the RCMs, but was not able to provide names yet. In an interview on 11/09/2020 at 4:25 PM, Staff E, Administrator, stated: -residents should be bathed according to their care plans, and denied that staff reported residents were not being bathed. The Administrator stated that they pulled the shower aides when needed because the floor comes first, if we need help or support on the floor it is all hands on deck, patient care comes first. When asked if bathing residents was considered patient care, the Administrator did not provide an answer. When asked if there was a staffing crisis, the Administrator said they had some staffing challenges and changes. In an interview on 11/10/2020 at 2:22 PM, Staff M, Shower Aide and an NA when pulled to the floor, stated residents had been complaining about shower hours, some of them like to be bathed before breakfast. -She was asked again about the bathing documentation, she said it's not a documentation problem, she said they know how to document bathing, the problem was they had been pulled to the floor and there was not routinely a shower aide working because they were pulled to the floor. She said we know it's not a documentation problem, that they were supposed to have two shower aides every day, but they only had one, and then not every day, because they were always getting pulled to the floor. -She said it was possible there was a documentation problem, but that was not the main problem, she said she knew of weeks they missed 30-40 residents getting bathed, and that was in the last 2-3 weeks or so, because both shower aides got pulled that week two shower aides together on the same day, and then the other shower aide got pulled a couple other days, -She said they keep telling us shower aides won't get pulled, but then they pull us anyway. -She said they were struggling with having enough aides at all, much less shower aides. -She said look at the shower schedule, does it look like one shower aide can bathe all of those residents in one shift? Joint review of the shower schedule, dated 11/02/2020, revealed Sundays had 34, Mondays had 33 #'s, etc . -She said it's not a documentation problem, it's a problem with getting pulled to work as aides, they know there's no bathing when we get pulled, they're the ones doing the pulling. In a phone interview on 11/17/2020 at 8:52 AM, Staff G, DON#2, stated: bath aides were being pulled to work as nurse aides while she was there as they were short nurse aides, and there was only one RCM while she was there, and we were short staff and it was unfortunate. In a phone interview on 11/18/2020 at 10:51 AM, Staff F, DON#1, stated the last weeks of my employment, I actually worked shifts as a nursing assistant on night shift, I still had to do my other Director of Nursing work also, they were still admitting residents. DON #1 said she told the Administrator the facility was in a crisis, and the Administrator did not agree to hire agency staff. DON#1 said the facility did not have enough staff to continue to admit residents as the facility was unable to meet the care needs of the residents. Staff were needed for Hoyer (mechanical lift ) transfers, for residents who needed two people to help transfer, which was greater than 50% of the residents on one of the floors. DON #1 said that with COVID, putting PPE (Personal Protective Equipment - gloves, gowns, masks, face shields, goggles, etc .) on/off takes time, and in meeting with corporate, DON#1 explained the facility went over budget. DON #1 stated we had 4 shower aides, and they directed me to get rid of two shower aides, they told me if I didn't do it, then I had to decrease my nursing assistants on the floor and cut their hours. So then we had to come up with a shower schedule where only two shower aides could bathe the entire building. DON#1 said the corporate staff felt too many showers were being provided and the facility needed to cut back. Corporate staff did not agree with bathing/showering the residents according to the resident preferences. The facility staff were directed to cut shower staff. DON #1 said she was aware of the risk to the resident's skin with not bathing and showering. In a phone interview on 11/19/2020 at 11:15am, with governing body staff, Staff A, Corporate Vice President Northwest Division, and Staff C, Regional Vice President, were asked about the facility's plan for maintaining their plan of correction for the neglect the facility was cited for lack of bathing in January 2020. Staff A stated the regional staff did oversight of the facility, and they used their QAPI program for maintaining the corrective action. When asked about the staffing crisis Staff A stated that there was no staffing crisis, and instead thought there was a personality conflict with the prior DON. During an interview on 12/01/2020 at 8:50 AM, Staff UU, NA, stated that staffing has been tough for a while. Staff UU stated that (today) there was supposed to be another NAC working but they called in so it is just Staff UU and the shower aide. She stated that most of the residents on this unit are 2 person assist to get up, and explained every time I need help I have to go find the shower aide to help me. During an interview on 12/01/2020 at 9:50 AM, Staff MM, LPN, stated staffing is not good around here and hasn't been for a while. Staff MM stated right now we were supposed to have 3 nursing assistants today and someone didn't show up this morning at 7am, so we have been working with 2 nursing assistants. Staff MM also stated that there is usually a nurse manager on the unit, who will help if we ask but she has been out sick too. During an interview on 12/01/2020 at 10:20 AM, Staff U, RN, when asked how she was doing stated Overwhelmed. She stated staffing has been a real challenge since I started, not too long ago. Staff U further stated I have to really fight to get 2 aides sometimes, and they are responsible for showering the residents too. She also stated that last night the night shift nurse was complaining to her because they wanted 2 nursing assistants and only had one, so the nurse that was orientating, had to work the floor as an aide. As I was leaving the unit the nurse stated 'I really hope your presence here will help us. During a telephone interview on 12/01/2020 at 11:30 AM, Staff TT, NA working on the COVID Red Zone unit during observations today, confirmed that the nursing assistants assigned to that unit are responsible for cleaning the unit. She stated We are responsible for all the personal care, all housekeeping on the unit and daily showers, it's just too much, patient care comes first. Staff TT, further stated that staffing has been a real struggle lately and more often than not, we work with two NAC's on this unit, almost everyone back here is a 2 person assist with care and I just don't know how were supposed to get all the care done, do the showers and then be a housekeeper, The cleaning gets done if we have time, which isn't often. We also have to take our garbage outside to the dumpsters as needed. RESIDENT #1 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated the resident needed 2-person assist with bed mobility, transfers, dressing and toilet use. For bathing, the MDS indicated the resident had total dependence on staff, and was incontinent of urine and bowels, and had one unhealed pressure injury that was present on admit. In a skin observation on 11/10/2020 at 3:17PM, with Staff L, LPN and Staff S, NA, when the resident's briefs were removed there was a rotten odor observed, the resident had not been incontinent, the resident's buttocks were red, and the resident had a pressure injury skin opening that was approximately 3x2x deep opening at the top of her sacrum. Both of the resident's calves and both feet had very dry, thick, crusty skin, such that when the skin observation was over, the entire lower 1/3 of the bed looked to have a slight layer of snow. Both feet were observed to have red, wet looking skin between the toes on both feet. In an observation and interview on 11/09/2020 at 12:19 PM, the resident's call light was observed to be clipped to the privacy curtain, not within the resident's reach. The resident's nurse Staff L, LPN, was notified, she stated she thought it was the students that did that. In an observation on 11/13/2020 at 6:05 AM, the resident didn't know where her call light was, she stated the nurse should know where it was. Staff J, RN, was asked if she knew where the call light was, she found it wrapped in blankets at the resident's feet hanging off right side of bed. Review of the September 2020 incident reporting log showed Resident #1 had a fall on 09/09/2020 at 2:30 AM, with a 35 coded for abrasions, and had a fall on 09/10/2020 at 2:18 AM. In an interview on 11/13/2020 at 10:10 AM, Staff E, Administrator, was unable to state how staff had protected the resident between the two falls that occurred in less than 24 hours. Staff A, Vice President Northwest Division, stated they needed to find the root cause of the fall. Staff A was asked how the facility had protected the resident while they completed the investigation from the first fall, Staff A was unable to provide any information. Review of the resident's care plan, print date 11/16/2020, showed resident had been care planned for a focus of being at risk for falls related to current medical condition and history of falls, interventions included: -entry dated 09/10/2020 to anticipate needs, provide routine checks during noc (night) for positioning as resident might get restless at noc around 2-3 AM . She cannot reliably state her needs/wants and may not call to alert staff when attempting to reposition herself, and call light within reach. Review of the facility Fall Management policy, revealed: each resident was to receive adequate supervision to prevent accidents, and -implement interventions, including adequate supervision, monitor the effectiveness of the interventions, In a phone interview on 11/12/2020 at 10:47 AM, the residents' daughter stated I got calls about bruises on her (Resident #1) face, the nurse was just letting me know. The nurse director told me the bruising was leftover from when she fell . She (Resident #1) had fallen twice within 24 hours, things like that can happen once, but then it happened again .twice in 24 hours. The resident's daughter questioned how Resident #1 who was unable to walk did not already have preventions in place. In an observation/interview on 11/13/2020 at 7:05 AM, there was a Pink Star hanging outside the door of a room across from Resident #1's room. Staff S, NA, stated the Pink Star meant that the resident in that room was a fall risk, and the Pink Star was to let staff know to keep a closer eye on that resident. Surveyor and Staff S jointly observed Resident #1's doorway, and there was no Pink Star, Staff S said she didn't know why there wasn't a Pink Star outside Resident #1's room door. In an observation/interview on 11/13/2020 at 7:18 AM, Staff L, LPN, was asked why there was no Pink Star outside Resident #1's room, since she already had two falls, Staff L stated She should have one, maybe it fell off. RESIDENT #2 The resident admitted to the facility 09/18/2019 with [DIAGNOSES REDACTED]. According to the annual MDS assessment, dated 09/18/2020, she: had severe cognitive impairment, assessed as 2-person assist with bed mobility and transfers, assessed as 1-person assist with dressing, toilet use, and personal hygiene, had balance that was not steady with moving from seated to standing position, moving on/off toilet, transfers between bed and chair or wheelchair, was occasionally incontinent of both urine and bowels, had one fall with injury since admission or prior assessment. Review of an incident investigation report, dated 09/08/2020, showed the resident had a fall and hit her head at 2230, she stated she was trying to sit on her wheelchair to go to the bathroom, but her wheelchair moved and she fell and hit her head, a 7x4 centimeter bump was noted on right side of head, and neuros remained within baseline. The incident investigation report said under other info Resident was found on floor with one sock and shoe on and the other sock and shoe in the bed at the end of the bed in the covers. Wheelchair breaks (sic brakes) were not on. The investigation report stated No injuries observed Post incident, but resident had hit her head. An event note was included, dated 09/09/2020 at 0018, it stated the resident denied pain except to head where bump was, neuro checks initiated, bump is speckles with purple bruises. The investigation report stated abuse/neglect not suspected. The investigation was not thorough, the facility failed to gather information necessary to reduce fall risk and hazards specific to this resident: investigation did not state why the wheelchair brakes were not locked, -did not state when resident was last toileted or by which staff that was done, didn't state which staff had helped the resident to bed, or when. In an interview on 11/13/2020 at 10:10 AM, Staff E, Administrator, and Staff A, Vice President Northwest Division, were asked about the not thorough investigation, no information provided. RESIDENT #4 The resident admitted to the facility on [DATE], for orthopedic after care/rehab after having a fall with fractures of the right hip and [MEDICATION NAME] vertebrae. Resident #4 admitted to the facility with a history of falling, pneumonia, cognitive communication deficit, generalized muscle weakness, dementia, need for assistance with personal care, and [MEDICAL CONDITION]. During the 08/03/2020 admission to the care center, the resident sustained [REDACTED]. According to the admission MDS, dated [DATE], the resident was moderately cognitively impaired, required extensive 2-person assist with bed mobility, transfers, dressing, toilet use, extensive 1-person assist with personal hygiene, eating, 1-person physical assist, bathing total dependence, balance, not steady: moving from seated to standing position, moving on/off toilet, surface to surface transfer between bed and chair or wheelchair, functional limitation in range of motion lower extremity, impairment on one side, frequently incontinent of urine, occasionally incontinent of bowels, dementia, did resident have any fracture related to a fall in the six months prior to admit, yes, one unstageable pressure ulcer with suspected deep tissue injury in evolution, that was present on admit. Review of a Documentation Survey Report, for August 2020, showed the resident had no bathing for 13 days from 08/11/2020 - 08/24/2020, there was no care planned frequency listed on the report for this resident. Review of the September 2020 incident reporting log showed: 1. Resident had a fall on 09/23/2020 at 1:25 AM, non-injury. 2. Resident had a fall on 09/29/2020 at 9:10 AM, with fracture. In a phone interview on 11/05/2020 @ 1:58 PM, the resident's family member/caregiver at home, stated: - she used to sit outside the window and no staff would come in, and she would call the facility and hear the phone ringing, and she saw staff walk by but not come in (the resident's room), -Resident #4 had no baths and was filthy dirty, and her toenails were all overgrown, and she had a pressure ulcer, -one time she witnessed staff to leave Resident #4 on the bedpan for 45 minutes. She stated she called and called and called and finally she went into the building, ended up in the kitchen, and told them she tried to get staff's attention that Resident #4 was sitting on a bedpan and hurting, but no staff would come. Then they put diapers on her because they said she was incontinent. The daughter denied staff were turning Resident #4 in bed, she stated every time she was just laying on her back, and she was not laying on her sides at all, she denied staff bathed her much except for occasional sponge baths,she stated Resident #4's skin was so bad when she got home from the hospital that one toenail grew into the side of her big toe and sores on her bottom. Review of two emailed pictures received 11/18/2020, showed: -the resident's left toenails, the toenail on the toe next to the big toe was grown completely over the end of the toe and curled down underneath, the left great toe had a jagged looking nail, the middle left toenail was very overgrown and rounded down over the toe end, and a small open area surrounded by a large red area in what appeared to be the resident's sacrum. In a phone interview on 11/06/2020 at 8:04 AM, Resident #4's family member/caregiver at home stated: the resident fell out of bed. After a hospital stay and a readmit to the facility, staff dropped the resident. In a phone interview on 11/06/2020 at 11:50 AM, Resident #4 was asked about her falls at the facility, she stated: -(first fall) I was told I fell out of bed by the care center, -(second fall, where she broke her other hip), one of the workers was helping me, I think it was a male, I don't know that for sure though, there was one person, I don't remember their name, they were trying to get me out of bed and they let me go and dropped me. When asked if staff had put a belt around her waist, she answered No. In a phone interview on 11/12/2020 at 11:53 AM, residents' family member/caregiver at home stated that while the resident was at the facility, the resident got another broken hip, had a lack of hygiene, toenails were overgrown, and they gave her sedating drugs without consent. The family member stated that the resident had a pressure sore on her back ½ inch deep and the size of a silver dollar. Review of neurological checklist documentation for resident's fall on 09/29/2020 showed: -the first set of neurological checks were documented as being done on 09/29/2020 at 9:00 AM (10 minutes before the fall), and they were not signed/dated by any staff (per their neurological assessment policy and the neurological check list form), 2nd set of neuro checks at 0915, not signed/dated by staff, 3rd set of neuro checks at 0930, not signed/dated by staff, 4th set of neuro checks at 0945 were annotated resident refused, vital signs were not documented, and not signed/dated by staff, 5th set of neuro checks at 1015 not signed/dated by staff, 6th set of neuro checks at 1045 not signed/dated by staff, 7th set of neuro checks at 1115 was done, and signed/dated by staff, this was the last neuro checks done, 8th set of neuro checks at 1145, not done. In an interview on 11/13/2020 at 7:32 AM, Staff K, LPN, was asked about the resident's first fall on 09/23/2020, she: -was asked when resident had last been toileted, she stated she had asked the nursing assistant, who told her about 10pm, she stated she didn't remember the nursing assistant's name. -was asked if the facility had trained her on how to do an incident investigation, she stated she had been trained on how to fill out the paperwork, she denied she had been trained on how to do a thorough incident report, to prepare witness lists, or getting witness statements, she said they did have a checklist though. In a phone interview on 11/17/2020 at 11:11 AM, resident's other son (Resident #4 lives with him and his wife who is her caregiver), stated she (Resident #4) was always sleepy and out of it, we tried to talk to her over the phone, half the time we could not get no staff to even open the window so we could talk to her. I saw my mother in the ER, they let me go in because they said one family could go in, she smelled bad like urine, she smelled really dirty, she was skinny and ghost looking, she had blood on her head and in her hair. The family member continued to state they (facility) said she had fallen and hit her head, but I wasn't expecting blood because they said they had laid her back down, so I didn't expect blood. Then they said she was asleep, that just caught me by surprise because she had hit her head, and then they let her sleep, initially they didn't know she had broken her other hip. A head injury and sleeping aren't two things that go together, in all of my experience, especially in a care facility, that just seems to me like something you just wouldn't do. The resident's son was asked if he thought there was enough staff at the facility, he stated we couldn't go in because of COVID, but when we tried to find staff there really wasn't even anyone to find. (This was in reference to trying to get through to the facility via telephone call). Review of the resident's care plan, provided by Medical Records on 11/13/2020 at 5:58 AM, showed resident was care planned for a Focus to be at risk for falls related to generalized weakness, deconditioning, dementia, breathing problems, [MEDICAL CONDITION], opioids, and a recent hospitalization due to right [MEDICAL CONDITION]. Review of the interventions showed there was no intervention or documentation how the facility was going to ensure Resident #4 received adequate supervision consistent with the resident's needs, goals, care plan, and current professional standards of practice in order to eliminate or reduce the risk of an accident. RESIDENT #5 The resident admitted to the facility 06/03/2019, and [DIAGNOSES REDACTED]. According to the quarterly MDS assessment, dated 08/26/2020, she: -had moderate cognitive impairment, was assessed as needing 2-person extensive assist with bed mobility, transfers, dressing and toilet use, was assessed as needing 1-person extensive assist with personal hygiene, was always incontinent of urine and bowels. Review of the facility Comment & Concern logs, revealed the concerns for this resident: -dated 10/13/2020, concern was long wait time, the documented resolution was DON (Director of Nursing) to F/u with resident. -dated 10/21/2020, concern was long wait time and care concerns, the resolution was left blank. Review of a Comment & Concern form, dated 10/13/2020, showed residents' daughter had a concern, Mother called and said she had been waiting a long time for call light to be answered, worried that there isn't enough help on her unit, mother stated there were times when they can't get her up because they can't find the 2nd aide to help her get up. In an interview on 11/13/2020 at 10:10 AM, Staff E, Administrator, and Staff A, Vice President Northwest Division, were interviewed regarding residents' daughters' concern dated 10/13/2020, Staff A stated they would fix it, no information provided. Review of a Concern & Comment form, dated 10/20/2020, showed the resident herself had a concern - There is not enough help to take care of patients. The wait is so long. The aides are all very nice & helpful once they are able to come, but the wait is too long. The form indicated staff member was not able to resolve the concern at the time it was shared. Review of a facility-reported complaint intake, dated 10/28/2020, revealed the resident reported to SS (social services) that on the 23rd she had to wait a long time to get up, get changed, and placed in her chair until 11:15 AM, and that this AM she waited two hours for ice water from 6 AM - 8AM. The intake follow-up indicated Staff H, DON#4, stated a staff membe (TRUNCATED)

Based on interview and record review, the facility's Governing Body failed to ensure the nursing home was resourced with a workforce that consisted of an adequate number of adequately trained and adequately supervised staff. This failure resulted in widespread failure to meet basic resident care needs to include bathing, transferring, toileting and any other needs not met when resident call lights were not answered timely due to inadequate staffing. Additional failed practice included the Governing Body's failure to ensure the nursing home administration had effectively operationalized their written abuse/neglect screening, training, prevention, identification, investigation, protection and reporting/response policies and procedures, which resulted in unidentified, unreported, uninvestigated abuse and neglect, and was evident in repeat falls, fall with fracture, persistent skin problems, unmet toileting needs, and unresolved family/resident grievances. The Governing Body's failure to suspend new admissions during a lack of adequate staffing placed all current residents and new admission residents at risk for unmet care needs and unforeseen care/safety deficits should a COVID-19 outbreak hit the facility before an adequate workforce could be obtained and stabilized. There was a lack of administrative oversight, lack of nursing supervision at all levels in the nursing home, rampant Administrator/Director of Nursing/caregiver employee turnover in the setting of unmet resident care needs, continued admissions, and COVID19 conditions, which all resulted in widespread neglect. Additional failed practice also included the Governing Body's failure to ensure sustainment of a plan of correction for a citation related to a pattern of neglect on one of three units within the nursing home in [DATE]. The nursing home was cited, they submitted a plan of correction to sustain the care deficits, then, during these investigations widespread neglect was found on all three units within the nursing home when the facility failed to provide adequate shower/bathing staff to meet even minimal bathing needs. Then, the neglect spread to all three units, and to other care areas. Many residents with unmet care needs. Governing body failed to investigate the impact of a breach in infection control when staff ran out of gowns on the first two nights facility had gone to full PPE for all residents, multiple residents tested COVID positive in the days after that, multiple residents expired after testing COVID positive, not investigated. Review of facility practices found this skilled nursing facility had disregarded their grievance and concern program policy and procedures, their activities of daily living policy and procedures, resident care plans, resident rights policy and procedures, fall management policy and procedures, and their Coronavirus (COVID 19) ([DIAGNOSES REDACTED]-CoV-2) policy and procedures. Immediate Jeopardy (IJ) x 2: -[DATE] at 2:00 PM, IJ called at F600 - Neglect, when the facility was found to be understaffed and unable to provide basic bathing care and services, multiple residents found to have no documentation of bathing over the 30 days reviewed, resident/family complaints of unmet bathing needs, unresolved grievances, lack of supervision of bathing staff, bathing staff pulled from bathing duties to work as nursing assistants because there was not enough of them. -[DATE] at 1:25 PM, IJ called at F607 - Develop/Implement Abuse/Neglect policies, when the facility failed to have operationalized their written policy (Protection of Residents: Reducing the Threat of Abuse and Neglect, dated [DATE]) and procedures for abuse and neglect screening, training, prevention, identification, resident protection, investigation, and reporting/response. Failures included: unidentified/unrecognized allegation of abuse, failures in reporting and protecting residents after incidents, unreported allegation of abuse, not thorough investigations, incomplete/inaccurate investigations, staff unable to recognize abuse/neglect, and did not know facility abuse/neglect written policy, failure to preserve/document evidence necessary for thorough investigations, facility administration lacked knowledge of their own Abuse/Neglect written policies/procedures and their implementation, corporate/governing body staff providing survey team non-factual and/or misleading documentation. Residents with repeat incidents before facility even completed and reviewed the first incident investigation. Residents observed without call lights within reach. Findings included . REGULATORY HISTORY Review of a statement of deficiencies, dated [DATE], revealed the facility was cited for a failure to have sufficient nursing staff to provide care-planned care, which resulted in a resident not receiving care-planned restorative care. Review of a statement of deficiencies, dated [DATE], revealed the facility was cited for a failure to have the necessary structures and processes in place, adequate staff, adequate staff supervision, and a responsive facility administration to ensure care-planned bathing care and services were provided on one of three units (Havenwood, a unit consisting primarily of cognitively impaired residents) reviewed for bathing care. This systemic pattern of failure on Havenwood resulted in 18 of 18 residents not receiving needed bathing care and services as frequently as care planned. Based on the Reasonable Person Concept, the Havenwood residents that were cognitively impaired, if able, would have wanted to have been bathed per their preference that had already been identified and planned in their care plans. This failure resulted in neglect to residents who experienced unmet bathing needs, avoidable skin issues to include rashes, pressure injuries, malodorous skin/tissue folds, and discomfort from inflamed skin. -Additional failed practice constituting neglect also was identified in the [DATE] statement of deficiencies when the facility failed to ensure adequate staffing/staff supervision when a resident was transferred by a solo nursing assistant when the care plan had directed a 2-person transfer, not a 1-person transfer, the resident sustained [REDACTED]. Review of a statement of deficiencies, dated [DATE], revealed the facility was cited for insufficient nursing staff. Facility had insufficient staff to ensure residents received prompt call light response and assistance to meet the needs of residents. Review of the facility policy titled Governing body, dated [DATE], showed: -Policy - the facility has an active (engaged and involved) governing body that is responsible for establishing and implementing policies regarding the management of the facility. -Governing Body refers to individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility. -Procedure: --1. The Governing body has ultimate responsibility and legal authority for the organization. The Governing Body fulfills its responsibilities as defined by the organization, law, and regulation. --2. The Governing Body has ultimate responsibility and legal authority for managing the long-term care organization and for the quality of resident care. The Governing Body may be an individual, group, or government agency, and its members fulfill their responsibilities defined by the organization and applicable law and regulation. --3. The Governing Body's authority and responsibilities are defined by state licensure or charter, articles of incorporation, constitution, by-laws, or similar documents. They are stated in writing, formally adopted, dated, and periodically reviewed and updated. --4. At least quarterly or more often if needed, the Executive Director reports to the governing body including, how the governing body responds back to the Executive Director and what types of problems and information (i.e. survey results, allegations of abuse or neglect, complaints, etc.) are reported or not reported directly to the Governing Body: --5. The Executive Director is held accountable and reports information about the facility's management and operation (i.e. audits, budgets, staffing, supplies, etc.) which is reviewed during facility visits from the regional/division team. Facility Governing Body consisted of: Staff A, Vice President Northwest Division Staff B, Regional Director Clinical Services Staff C, Regional Vice President Current surveys: See F552 Right to be informed / make treatment decisions: Staff did not follow facility written Informed Consent policy and procedures, a resident received an antidepressant medication neither she nor her representatives had any knowledge staff had been administering it to the resident, she experienced adverse side effects, and a fall with a [MEDICAL CONDITION]. See F600 Free from abuse and neglect: widespread neglect found, many residents with no bathing at all in over 30 days, many residents with complaints of inadequate staffing resulting in residents not getting toileted timely, call light response times inadequate, resident complaints of not enough staff to get them transferred in and out of bed. Facility disregarded resident care plans, resident rights policy, activities of daily living policy, grievance/concern policy, and fall management policy. See F607 Develop / implement abuse /neglect policies: facility failed to implement written abuse / neglect policy, residents with repeat incidents even before the first incident investigation could be completed. Staff lacked knowledge of the written abuse / neglect policy and there were incidents of unidentified, unreported, uninvestigated abuse and neglect. See F689 Free of accident hazards / supervision / devices: residents observed without call lights within reach, a resident had a fall, was not adequately supervised/protected then had another fall with a [MEDICAL CONDITION]. See F755 Pharmacy services / procedures: resident complaints of missed and late medication doses, resident with repeat medication errors resulting in [MEDICAL CONDITION], a fall, and repeat avoidable hospitalization s. See F758 Free from unnecessary [MEDICAL CONDITION] medications: [REDACTED]. RECORD REVIEW Review of resident admitted s, and 30 days of bathing documentation, print date [DATE], for 70 residents showed: -62 residents had been in the facility for the full 30 days reviewed, eight had been in less than 30 days: -24 of 62 residents had not been bathed at all in 30 days, -24 of 62 residents had been bathed once in 30 days, -6 of 62 residents had been bathed twice in 30 days, -4 of 62 residents had been bathed three times in 30 days, -4 of 62 residents had been bathed four times in 30 days, -Eight residents had been in the facility < 30 days: --These eight residents had been in the facility for 11 days, 17 days, 16 days, 11 days, 10 days, 22 days, 14 days, 21 days, -only one of these eight residents had been bathed at all, once. Review of DON#1's resignation letter, dated [DATE], showed: Marysville Care Center 1821 Grove Street Marysville, WA Six months ago I was excited to re-join Marysville Care Center, it is with a heavy heart that I am tendering my resignation as Director of Nursing. It's been a challenging six months - the COVID pandemic impacted our facility my first week back. I am very proud that our team has maintained a COVID free facility - I hope it continues. I verbally requested the consideration of agency in July: in early August I made a written request for agency that was denied. Many NACs had given notice, for various reasons, and the facility was not receiving applications. My many years in the industry has given me the knowledge that agency is never a quick solution, in fact, my experience is upwards of ,[DATE] weeks before an agency is able to provide assistance while a facility rebuilds its staffing pool. On [DATE] I reviewed the state of our staffing crisis with the Executive Director. Due to safety concerns (for both residents and staff), I advised we stop admissions until a plan was in place to ensure coverage. From my clinical perspective, we do not have enough associates to meet our obligations to the residents in our care. Admissions have continued. As Director of Nursing it's important I provide a bridge between operational goals and the nursing staff: I am no longer able to be successful in this role as I am not in agreement with the current operational priorities. This conflict does not foster a healthy work environment at Marysville Care Center, nor does it support a positive professional life for myself. My last day at Marysville Care Center will be September, 11, 2020. Sincerely, Staff F, DON#1 Review of an email from the administrator, dated [DATE], showed the facility COVID19 positive status was 67 total to include: -42 residents COVID19+ (13 expired), -25 staff COVID19+ (but facility did not include Staff BB, Agency Nursing Assistant, whose employment had been terminated). Title TERMs Average Turnover% last 365 days Headcount Certified Nursing Assistant 46 45 102.2 LPN Unit Nurse 10 14 71.4 RN Unit Nurse 6 6 100.0 Facility Nursing Home Administrator History: Staff W, former administrator [DATE] - [DATE] Staff X, former administrator [DATE] - [DATE] Staff Y, former administrator [DATE] - [DATE] Unknown [DATE] - [DATE] Staff X, former administrator [DATE] - [DATE] Staff E, Administrator [DATE] - present Facility Director of Nursing History: Unknown - [DATE] Staff F, DON#1 [DATE] - [DATE] Staff G, DON#2 [DATE] - [DATE] Staff V, DON#3 [DATE] - [DATE] Staff H, DON#4 [DATE] - [DATE] Staff B, RDCS/DON#5 unknown - [DATE] Staff EE, DON#6 [DATE] - STAFF INTERVIEWS In a phone interview on [DATE] at 8:52 AM, Staff G, Director of Nursing #2 (DON#2), stated: -bath aides were being pulled to work as nurse aides while she was there, as they were short nurse aides, -there was only one RCM while she was there, -we were short staff and it was unfortunate. In a phone interview on [DATE] at 10:51 AM, Staff F, DON#1, stated: -the last weeks of my employment, I actually worked shifts as a nursing assistant on night shift, I still had to do my other Director of Nursing work also, they were still admitting residents, -the final straw for me was I spoke to the administrator, I had asked for them to start working with agency to get more staff, I had been asking and asking, and people were giving notice to quit, I told them we were in a crisis. They would not allow me to do agency, they told me I was not handling the budget properly, they said if I got my budgeted hours in order, I could come back to them later and maybe they would consider agency. Then I went back to the Administrator again, and I said we did not look at agency, and we were in trouble. I asked for us to please stop admitting. I know they didn't want to hear that, I felt until we had a solid plan and more staff, it was not safe to keep admitting. Because from my perspective, when we admit residents, we are saying to residents and families that we have the staff to provide for their needs. I thought we needed to immediately stop admitting until we were confident we could meet people's needs. I asked, then I had a day off, and I asked again to please stop admitting, I was off the next day because I think I worked that night, then while I was gone for a day off, they had admitted 2 more residents. I felt like that was a big F-you to me, that they hadn't heard a word I had said, then the very next day I was not in the building to push back, they admitted two people. So I knew I had no voice in the building as the DON, and that we could not meet needs. I have done well in my career as a director and understanding the business needs as well, I don't ask for things to like pausing admissions, I was serious, it was just very disheartening. I wanted to stay, but I felt like I could not be part of that leadership team, so I had to leave. -I tried to have conversations with the new administrator, but in my opinion you can't always look at a piece of paper and tell how many staff you need, that doesn't tell the story, you have to look at acuities, staff needed for hoyer transfers, etc .I felt we needed three nursing assistants on Pilchuck because over 50% of the residents needed two staff for transfers, and I know the nurses help, but they had jobs to do too. So I started staffing three CNAs, I kept trying to staff three as much as possible, but then we didn't even have three to use, so what do you do? They only wanted two. -Then with COVID, putting PPE (Personal Protective Equipment - gloves, gowns, masks, face shields, goggles, etc .) on/off takes time, I was told by corporate staff that it didn't take any longer to care for residents when you are putting on/taking off PPE, that just didn't make sense, the corporate staff were Staff A, Vice President Northwest Division, Staff B, Regional Director Clinical Services, and Staff C, Regional Vice President. We talked because we had to meet weekly on the phone, and I had to explain where and why I was over-budget. Corporate staff said they didn't understand why we were struggling while other buildings could do it, and we couldn't. I was told no other building for Life Care in their region was struggling with that. Staff A told me to stop making excuses. It was real pleasant I can tell you that, not. I cared for my team, and it was already such a stressful time for our residents, it was not as positive as it could have been. -From my own opinion, from us being down the street from Life Care of Kirkland, the COVID epicenter, it seems like there would have been more caution about us being linked to a negative situation. From my perspective, we needed to be even more cautious about cuts in staff and money, I get it, money is tough and tight right now. -As a DON, my opinion is you do it right or you close it down. -The last couple weeks I was there, I didn't even want to look my staff in the eye, I just let them down, and I knew it. I have responsibility to everyone, staff and residents, and I had already compromised myself, I did, so I had to leave. We lost some really good people in the last couple months. Staff B and Staff C were really strong personalities, they were supposed to be providing our building oversight, I tried so hard to give them the history of the problems and the building, they were pressuring the Assistant Director of Nursing (ADON) and I to get rid of the shower aides. We had 4 shower aides, and they directed me to get rid of two shower aides, they told me if I didn't do it, then I had to decrease my nursing assistants on the floor and cut their hours. So then we had to come up with a shower schedule where only 2 shower aides could bathe the entire building. Then the ADON and I had to sit down and explain to Staff B and Staff C, and they were very condescending to us about why we couldn't bathe the entire building with just 2 shower aides. I told them we had been cited over this earlier in the year, they told me we were giving too many showers and it was unnecessary and we needed to cut the shower aides. I've been around long enough to know we were headed for citations. Here's what I told them exactly we can pay a little bit more money on the front end and do it right, or we can pay a lot of money on the back end when we are in a crisis and get cited, because then you are going to pay a lot of money on the back end. So to me, from a business perspective, that is something to seriously look at. -They never said it, but I think they were glad I was gone in the end, because I was a thorn in their side, and they were tired of listening to it. -In my [AGE] years as a DON, I've been cited on things I didn't think was fair, but this what is going on now is not the fault of the building and the people that are working there now, they are trying to meet resident needs, I believe this is a direct result of the governing body forcing an agenda on a building with a history of known negative outcomes. This is just a pattern of negative outcomes, and this is where we are headed right now with this staffing and the decrease in shower aides and nursing aides. -In all buildings you go through periods of time with inadequate staffing, but you always get through it, and it's only temporary, but not in that building. -Specifically, the corporate staff told us we were giving too many showers, and we needed to cut back, we were trying to bathe residents per their preferences, but the corporate people laughed at us because they said we were giving too many showers and they said we didn't need to. -There is such a strong history in this building of not meeting shower needs, just look at the citations we had already received. Staff A directed us to cut shower staff, and I don't understand from a business perspective why they kept focusing on us to cut shower staff. -I am still so worried about their resident's skin and everything else, my worry didn't stop when I left because I knew what was going to happen, I haven't just worried about the residents, I've felt very worried about the staff too, they were all my people. In a phone interview on [DATE] at 11:15am, with governing body staff, Staff A, Life Care Vice President Northwest Division, and Staff C, Regional Vice President: -they were asked the facility's plan for maintaining their plan of correction for the neglect the facility was cited on for lack of bathing in [DATE], Staff A stated they had the regional staff oversee the facility, and they used their QAPI program for that. -they were asked about the staffing crisis DON#1 listed in her resignation letter, Staff A stated that DON#1 became very negative in the end and she was very resistant to working with Staff E, Administrator. Staff C stated they had concluded it was a personality conflict between DON#1 and Staff E. -Staff A stated the regional staff oversee the facility, -Staff A stated the facility was financially stable, and she had never been told we cannot hire more staff if we asked, Life Care has never not once in all my years said we could not hire more staff if we need them. In an interview on [DATE] at 11:06 AM, a staff member that requested to be anonymous stated It's hard not to neglect residents when you don't have enough staff. And: -We just didn't have enough staff Friday night ([DATE]), or gowns (PPE). -Saturday night we did have enough staff, but we did not have enough gowns (PPE). -two aides were not enough to care for 28 or 29 residents, -I called Staff H, DON#4, at 4pm ([DATE]), she told me there were many allegations of neglect and she wanted me to write a statement, I told her we were supposed to have gowns and we really were provided with none, -I wrote a statement [DATE] and DON#4 got it on [DATE], it had the info about not enough PPE, I told them PPE was not sufficient, DON#4 told me her questions had nothing to do with PPE, but I told her we did not have enough PPE, and I told Staff DD, Corporate, that at some time as well. I had to call Staff DD, Corporate, at 2 AM, 4 AM, and 6 AM to tell him how call lights were going, if I had adequate staffing, and if I had adequate PPE, but I didn't call until 3 AM because I was busy. In a phone interview on [DATE] at 11:56 AM, Staff H, Director of Nursing #4, stated: -that night ([DATE]) was going to be her last shift at Marysville Care Center, -she had asked them to remove her license from that building last month, because she had serious concerns, -she put in her notice to quit [DATE], and had been working the med cart since some time in November, -there was PPE all over the building and had more delivered that weekend, and there was a storage trailer out back with PPE, -she would have thought Staff J, RN, would have made a phone call when she ran out of PPE that is a decision she made (Staff J), -her expectation was that Staff J would have called and reached out to other coworkers in the building and not wait until the next day, -Staff J had not reported the lack of PPE to her until after she had requested Staff J to write a witness statement completely unrelated to that, -there has never been a lack of PPE in that building, Staff J, RN, should have looked, as a nurse there are things you are expected to critically think through, -was asked which facility staff were responsible for ensuring staff knew where to get more PPE if they ran out on [DATE] and [DATE], she stated it was a group effort. -she stated On [DATE] as soon as I got the witness statement, I called Staff B, RDCS, Staff DD, Corporate, and Staff E, Administrator, that day, they all knew about it. -Staff DD, Corporate, was going to handle all of the reporting, -at some point in time, she also notified Staff V, Infection Preventionist/DON#3, -she denied she had input to, or ever reviewed the Summary of COVID Outbreak - Marysville Care Center [DATE] - [DATE], which was signed by Staff B, RDCS/Governing Body, -was asked if she investigated Staff J's allegation of not enough PPE and not enough staffing, and the effects on the residents, she stated you would have to speak with Staff B, RDCS, and Staff E, Administrator on that. -was asked what measures the facility had taken to ensure there was adequate PPE on all units for that first PM shift of going Red Isolation Zone in Havenwood and yellow throughout the rest of the facility, she stated I don't know entirely, it was kind of a group project, maintenance was moving the PPE into the building from the storage trailer. In an email interview dated [DATE] at 1:18 PM, Staff E, Administrator, stated There hasn't been an investigation, we have been well-stocked with PPE this entire time for the entire building and have not run out. In summary, the facility's neglectful staffing practices and continued admissions resulted in squalid nursing care standards and quality of care in the areas of basic personal care needs, bathing and hygiene, toileting care and services, and in transferring care. There was also a marked lack of caregiver continuity of care, residents/family with concerns staff didn't know how to take care of them or didn't know what they were doing. The facility Administration and Governing Body were well aware, or should have been aware, that residents were at risk of neglect as the facility was cited early in 2020 for a pattern of neglect on one of three units, but then failed to sustain their plan of correction, and then allowed the neglect to spread to all three units, and to other care areas. Then [DATE], DON#1 notified facility and the governing body they could no longer meet obligations to residents currently in their care, yet admissions continued, and neglect ensued. Neglect was widespread, it was known or should have been known by staff at all levels, it went unchecked and unreported, new admissions continued, and then only one of eight new admissions got bathed at all. COVID19: Facility was understaffed, unprepared, and staff not trained on nursing unit PPE [MEDICATION NAME] procedures for their COVID19 outbreak that started with a staff member on [DATE]. Facility ran out of gowns on the first day, PM shift [DATE], that they required full PPE for all residents/rooms, staff cared for residents without adequate gowns for at least two shifts after they had been directed to wear gowns, gloves, N95 masks and face shields. This failure presented a clear and present danger to residents' health, welfare and safety, but facility did not investigate. Facility omitted that relevant information from their Summary of COVID Outbreak - Marysville Care Center [DATE] - [DATE]. Many residents and staff tested COVID19+ in the days after that, many residents expired. Reference: (WAC) [DATE] (2)(c )

Based on interview and record review, the facility Administration failed to administer the facility in a manner that used its resources effectively to ensure residents were able to attain and/or maintain their highest practicable physical, mental, and psychosocial well-being, and to ensure the facility maintained substantial compliance with state and federal regulatory compliance. Failure to: 1) sustain plans of correction for previously identified failed practice, 2) provide sustained administrative oversight and sustained nursing supervisory oversight of facility personnel, practices, and policies, 3) to provide sufficiently trained and supervised nursing staff to meet resident needs, 4) to ensure staff were trained on facility policies and procedures, to include staff not knowing how to replenish PPE when staff ran out of gowns during the facility's COVID19 outbreak. Administration's failure to administer the facility effectively resulted in residents with unmet care needs, abuse and neglect, serial medication errors resulting in avoidable hospitalization s, repeat incidents before the first incident could be thoroughly investigated, excessive care giver turnover, failures in protecting residents after incidents, failures in timely investigating incidents, and a failure to investigate a registered nurses' allegation of inadequate Personal Protective Equipment (PPE) on the first night the facility required staff to use full PPE for all residents/rooms. Additionally, facility Administration placed residents in Immediate Jeopardy (IJ) on: -11/10/2020 at 2:00 PM, when an IJ was called at F600 - Neglect, when the facility was found to be understaffed and unable to provide basic bathing care and services, multiple residents found to have no documentation of bathing over the 30 days reviewed, resident/family complaints of unmet bathing needs, unresolved grievances, lack of supervision of bathing staff, bathing staff pulled from bathing duties to work as nursing assistants because there was not enough of them. -11/13/2020 at 1:25 PM, IJ was called at F607 - Develop/Implement Abuse/Neglect policies, when the facility failed to have operationalized their written policy (Protection of Residents: Reducing the Threat of Abuse and Neglect, dated 05/15/2020) and procedures for abuse and neglect screening, training, prevention, identification, resident protection, investigation, and reporting/response. Failures included: unidentified/unrecognized allegation of abuse, failures in reporting and protecting residents after incidents, unreported allegation of abuse, not thorough investigations, incomplete/inaccurate investigations, staff unable to recognize abuse/neglect, and did not know facility abuse/neglect written policy, failure to preserve/document evidence necessary for thorough investigations, facility administration lacked knowledge of their own Abuse/Neglect written policies/procedures and their implementation, corporate/governing body staff providing survey team non-factual and/or misleading documentation. Residents with repeat incidents before facility even completed and reviewed the first incident investigation. Residents observed without call lights within reach. Findings included . Review of the facility policy titled Administrative Responsibility Policy, dated 02/04/2020, showed: -Purpose: to define the responsibilities of the Executive Director (ED). -Policy: --ED will be responsible for supervision and overall implementation of the facility policies and with advice and counsel from the consultants, medical staff, and the departmental staff. He/she will administer and conduct all aspects of the policies and programs within the framework provided. --ED will be responsible for all implications of the facility operation as it effects the residents, staff, families, and community. --The ED is delegated by the Governing Body to have full responsibility for the daily operations of the facility. --The responsibilities and duties of the ED include, but are not limited to: ---Managing the ongoing functions of the facility, ---Identifying a registered nurse, qualified by education and experience, to direct nursing services, ---Assuring the public information describing the facilities services is accurate and fully descriptive, ---Ensuring that each resident's right to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to lodge a complaint, are strictly enforced, ---Implementing the established resident care policies, personnel policies, and other operational policies and procedures necessary to remain in compliance with required laws, regulations, and guidelines. FAILURE TO SUSTAIN PLANS OF CORRECTION F725 Sufficient nursing staff: 1. Review of a statement of deficiencies dated 02/14/2019, facility was cited because the facility failed to ensure sufficient staff were available to meet toileting needs of nine of 10 residents reviewed, residents had toileting accidents or were left sitting in urine because they did not receive timely toileting assistance. 2. Review of a statement of deficiencies, dated 04/24/2019, facility was cited for failure to have adequate staff to provide and supervise care for six of 21 residents reviewed, issues with unmet toileting needs and call light response times. 3. Review of a statement of deficiencies, dated 11/20/2019, facility was cited for insufficient staffing, residents complained of long waits, issues with call light response times, unmet needs. 4. Review of a statement of deficiencies, dated 09/22/2020, facility was cited for insufficient staffing, resident did not receive care planned restorative services. 5. Current survey: facility cited at F600 for widespread neglect due to neglectful staffing practices and continued admissions, and at F725 for insufficient nursing staffing, many residents with unmet care needs. F600 Neglect: 1. Review of a statement of deficiencies, dated 01/16/2020, facility was cited for a pattern of unmet bathing needs of 18 of 18 residents on memory care unit. 2. Current survey: Immediate jeopardy called for widespread neglect on three of three units, many residents with no documentation of bathing in 30 days, and the neglect had spread no only from the one unit, but also to other care areas. In an interview on 11/09/2020 at 4:25 PM, Staff E, Administrator, stated residents should be bathed based on what was in their care plans. Abuse and Neglect Written policy implementation: 1. Review of a statement of deficiencies, dated 04/24/2019, facility was cited at F610 for a failure to investigate incidents. 2. Review of a statement of deficiencies, dated 01/27/2020, facility was cited at F610 for a failure to thoroughly investigate a choking incident. 3. Current survey: facility cited at F607 as an immediate jeopardy for widespread failure to implement the facility written policy for abuse/neglect screening, training, prevention, identification, investigation, protection, and reporting/response. In interviews conducted on 11/13/2020, neither Staff E, Administrator, nor Staff H, Director of Nursing #4, had a working knowledge of the facility's abuse/neglect written policy. COVID19 Review of a Witness Statement form, dated 11/21/2020, showed Staff J, Registered Nurse, reported a lack of gowns on Pilchuck, PM shift 11/20/2020, and that staff had been told to gown, glove, wear N95 (respirator mask) and face shield, throughout shift for each room, and No gowns in unit, and face shields worn, gloves worn, N95 on. In a phone interview on 12/02/2020 at 11:06 AM, Anonymous Staff #1, stated we just didn't have enough staff Friday night (11/20/2020), or gowns (PPE), and Saturday night we did have enough staff, but we did not have enough gowns (PPE). In a phone interview on 12/16/2020 at 1:00 PM, Staff E, Administrator, stated they had done no investigation, that they'd had PPE in the building, and it was unsubstantiated on their end. Failure to provide residents with continuity of care givers: 12-month Staff Turnover Rates, received 11/18/2020: Title TERMs Average Turnover% last 365 days Headcount Certified Nursing Assistant 46 45 102.2 LPN Unit Nurse 10 14 71.4 RN Unit Nurse 6 6 100.0 Failure to provide continuity in the key position of Director of Nursing: Facility Director of Nursing History: Unknown - 02/23/2020 Staff F, DON#1 02/24/2020 - 09/27/2020 Staff G, DON#2 09/28/2020 - 10/21/2020 Staff V, DON#3 10/21/2020 - 10/28/2020 Staff H, DON#4 10/28/2020 - 11/29/2020 Staff B, RDCS/DON#5 unknown - 12/16/2020 Staff EE, DON#6 12/17/2020 - In an interview on 1109/2020 at 4:25 PM, Staff E, Administrator, would not say what the staffing crisis was that Staff F, Director of Nursing #1, had referenced in her resignation letter, she stated they had some staffing challenges and changes. She stated admissions continued, but were slowed, and that the DON should be providing nursing staff oversight. Facility Nursing Home Administrator History: Staff W, former administrator 11/19/2018 - 11/25/2019 Staff X, former administrator 11/26/2019 - 04/13/2020 Staff Y, former administrator 04/14/2020 - 06/07/2020 Unknown 06/08/2020 - 06/21/2020 Staff X, former administrator 06/22/2020 - 07/13/2020 Staff E, Administrator 07/13/2020 - present Reference: (WAC) 388-97-1620 (1) Related citations: F600 Free from Abuse and Neglect F607 Develop/implement Abuse/neglect Policies F689 Free of Accident Hazards/supervision/devices F755 Pharmacy Services/procedures

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and/or assistance devices, and to thoroughly investigate falls to find root cause analysis, evaluate risks and hazards specific to each resident, for five of six residents (#1, #2, #4, #15, #24) reviewed for accidents/supervision/hazards. Failure to ensure adequate supervision and to ensure the facility was free of accident hazards the facility had control over, placed residents at risk for accidents/injury. Residents #1, #15 and #24 were observed without call lights within reach. Resident #2 had a fall when her wheelchair brakes were not locked. Resident #4 was harmed when the facility failed to provide adequate supervision after a fall, and she had a repeat fall with injury, a [MEDICAL CONDITION]. Facility practices regarding fall prevention were found to be deficient when three residents observed without call lights within reach, and when the facility failed to place falling stars outside of all rooms of residents that had been identified to be a fall risk. These failures resulted in harm for three residents who experienced falls with injuries. Findings included . RESIDENTS RESIDENT #1 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment, dated 10/15/2020, the resident was unable to complete the mental status assessment, had memory problems and severely impaired cognitive skills for daily decision making. The MDS indicated the resident needed 2-person assist with bed mobility, transfers, dressing and toilet use, and she had two falls since admission or prior assessment, one non-injury and one injury. Review of the resident's care plan, print date 11/16/2020, showed care planning to include: -limited physical mobility related to weakness, -communication problem related to dementia and history of [MEDICAL CONDITION] (brain disease, damage or malfunction), -at risk for falls related to current medical condition and history of falls, NIF (non-injury fall) falls on 09/09/2020 and 09/10/2020, and history of falls. In an observation and interview on 11/09/2020 at 12:19 PM, the resident's call light was observed to be clipped to the privacy curtain, not within resident's reach, the resident's nurse Staff L, Licensed Practical Nurse (LPN), was notified, she stated she thought it was the students that did that. In an observation on 11/13/2020 at 6:05 AM, the resident didn't know where her call light was, she stated the nurse should know where it was. Staff J, Registered Nurse (RN) was asked if she knew where the call light was, she found it wrapped in blankets at the resident's feet hanging off right side of bed. Review of the September 2020 incident reporting log showed resident: -had a fall on 09/09/2020 at 2:30 AM, with a 35 coded for abrasions. -had a fall on 09/10/2020 at 2:18 AM Review of an incident investigation report, dated 09/09/2020, revealed a nursing assistant heard a bump sound at 2:30 AM and went and found the resident on the floor, the resident fell out of bed, and she had swelling to the left side of her forehead and the area was reddened, the licensed nurse documented that Resident #1 had a hematoma to her face. The investigation was not thorough and the facility failed to gather information necessary to reduce fall risks and hazards specific to this resident: -did not state position of bed, -did not state if call light was in reach, or not, -did not state if call light was on, or not, -did not state when resident had last been seen or checked on, -did not state when resident had last been toileted. Review of an incident investigation report, dated 09/10/2020, revealed at 2:18 AM, staff heard a thud sound from the resident's room, resident was found on the floor between the two beds, and she was unable to state what had happened. The investigation indicated the care plan was updated to anticipate resident needs and provide routine checks during the night as she might get restless around 2-3 AM, and resident could not reliably state her needs/wants and may not call to alert staff when attempting to reposition herself. The investigation was not thorough and the facility failed to gather information necessary to reduce fall risks and hazards specific to this resident: -did not state when staff had last checked on her or seen her, -did not state when she had last been toileted, -it did not state what protection measures had failed, since staff allowed the resident to fall again, in less than 24 hours. In an interview on 11/13/2020 at 10:10 AM, Staff E, Administrator, was unable to state how staff had protected the resident between the two falls that occurred in less than 24 hours. Staff A, Vice President Northwest Division, stated they needed to find the root cause of the fall. Staff A was asked how the facility had protected the resident while they completed the investigation from the first fall, Staff A was unable to provide any information. Review of the resident's care plan, print date 11/16/2020, showed Resident #1 had been care planned for a focus of being at risk for falls related to current medical condition and history of falls, interventions included: -entry dated 09/10/2020 to anticipate needs, provide routine checks during noc (night) for positioning as resident might get restless at noc around 2-3 AM . She cannot reliably state her needs/wants and may not call to alert staff when attempting to reposition herself, and -call light within reach. Review of the facility Fall Management policy, revealed: -each resident was to receive adequate supervision to prevent accidents, -implement interventions, including adequate supervision, monitor the effectiveness of the interventions, These were not done, Resident #1 had two falls within 24 hours, and facility had her on routine checks during the night, which was inadequate to keep resident safe - inadequate supervision. Review of an incident investigation report, incident date 09/22/2020, revealed resident had a 0.5 cm diameter purple area near her right eye right and had large (no measurements provided) yellowish bruise post fall from bed and had a recent fall. The summary of investigative facts stated Resident bed against wall resident leaned head against wall several times on 09/18/2020. The other info section of the form indicated bed placed against the wall due to falls, resident leaned head against the wall several times on 09/18/2020, In a phone interview on 11/12/2020 at 10:47 AM, the residents' daughter stated that the facility did not resond timely to her calls to discuss Resident #1's care specifically related to frequent falls, and stated that Resident #1 was unable to stand and walk. According to the resident's daughter, the director of nursing (DNS said that falls happen on a regular basis. In an observation/interview on 11/13/2020 at 7:05 AM, there was a Pink Star hanging outside the door of a room across from Resident #1's room. Staff S, Nursing Assistant (NA), stated the Pink Star meant that the resident in that room was a fall risk, and the Pink Star was to let staff know to keep a closer eye on that resident. Surveyor and Staff S jointly observed Resident #1's doorway, and there was no Pink Star, Staff S said she didn't know why there wasn't a Pink Star outside Resident #1's room door. In an observation/interview on 11/13/2020 at 7:18 AM, Staff L, LPN, was asked why there was no Pink Star outside Resident #1's room, since she already had two falls, Staff L stated She should have one, maybe it fell off. Resident #1 Summary: Facility failed to provide adequate supervision for this resident who had previously been identified as a fall risk. Resident #1 had a fall, then another fall within 24 hours, yet the facility care planned her for routine supervision. After the first fall on 09/08/2020, the facility failed to identify and document whether her assistive device, her call light, was within reach, or whether it was on. Facility failed to put a pink star outside resident's room to let staff know she was a fall risk. RESIDENT #2 The resident admitted to the facility 09/18/2019 with [DIAGNOSES REDACTED]. According to the annual Minimum Data Set (MDS) (an assessment tool) assessment, dated 09/18/2020, Resident #2: -had severe cognitive impairment, -assessed as 2-person assist with bed mobility and transfers, -assessed as 1-person assist with dressing, toilet use, and personal hygiene, -had balance that was not steady with moving from seated to standing position, moving on/off toilet, transfers between bed and chair or wheelchair, -was occasionally incontinent of both urine and bowels, -had one fall with injury since admission or prior assessment. Review of an incident investigation report, dated 09/08/2020, showed the resident had a fall and hit her head at 10:30 PM. According to the facility investigative report, Resident #2 said she was trying to sit on her wheelchair to go to the bathroom, but her wheelchair moved and she fell and hit her head. The documentation indicated the resident sustained [REDACTED]. The incident investigation report stated that Resident #2 was found on the floor with one sock and shoe on and the other sock and shoe in the bed at the end of the bed in the covers. Wheelchair breaks (sic brakes) were not on. The investigation report stated No injuries observed Post incident, but resident had hit her head. An event note was included, dated 09/09/2020 at 12:18 AM, it stated the resident denied pain except to her head where the bump was, neuro checks were initiated, bump is speckled with purple bruises. The investigation report stated abuse/neglect not suspected. The investigation was not thorough, the facility failed to gather information necessary to reduce fall risks and hazards specific to this resident: -investigation did not state why the wheelchair brakes were not locked, -did not state when the resident was last toileted or by which staff that was done, and didn't state which staff had helped the resident to bed, or when. In an interview on 11/13/2020 at 10:10 AM, Staff E, Administrator, and Staff A, Vice President Northwest Division, were asked about the not thorough investigation, no information was provided. RESIDENT #4 The resident admitted to the facility on [DATE], for orthopedic rehabilitation/after care/rehab after having a fall with fractures of the right hip and [MEDICATION NAME] vertebrae (within the last six months). Resident #4 admitted to the facility with a history of falling (within the last six months), generalized muscle weakness, dementia, need for assistance with personal care, and [MEDICAL CONDITION]. According to the admission MDS, dated [DATE], the resident was moderately cognitively impaired, required extensive 2-person assist with bed mobility, transfers, dressing, toilet use, had balance issues, not steady: moving from seated to standing position, moving on/off toilet, surface to surface transfer between bed and chair or wheelchair, had functional limitation in range of motion of the lower extremity, with impairment on one side, and required a wheeelchair for mobility. During the 08/03/2020 admission to the care center, the resident sustained [REDACTED]. Review of the resident's care plan, provided by facility medical records on 11/13/2020, showed care planning to include: ADL (activities of daily living ) assistance and therapy services were needed related to a [MEDICAL CONDITION] with surgery, back fracture and dementia, and limited physical mobility related to weakness. According to the care plan, Resident #4 was at risk for falls related to generalized weakness, deconditioning, dementia, breathing problems with oxygen use, opioids medications, recent hospitalization due to right [MEDICAL CONDITION] and surgery. On 09/29/2020 the resident was sent to the emergency room (ER) after a fall with injury, in the facility. Review of the September 2020 incident reporting log showed: 1. Resident #4 had a fall on 09/23/2020 at 1:25 AM, non-injury. 2. Resident #4 had a fall on 09/29/2020 at 9:10 AM, with fracture. Review of an incident investigation report, dated 09/23/2020, showed the resident had a fall on 09/23/2020 at 1:25 AM. According to the documentation, Resident #4's roommate called for help and staff found Resident #4 sitting on the floor. The resident stated that she was trying to go to the bathroom. The investigation was not thorough and it was incomplete as the facility failed to gather information necessary to assess/reduce fall risks and hazards specific to this resident: -no documentation to show whether the call light was on or off, or if the call light was within the resident's reach -no documentation to show when the resident was last toileted, -no documentation to show when staff last observed the resident, -no documentation to show what position the bed was in when the resident was found on the floor, -no documentation to show what footwear she was wearing when she fell , -no documentation to show what the facility was going to do to protect the resident from other falls while the facility conducted their investigation, and no documentation of increased supervision. -Staff E, Administrator, signed the form on 10/02/2020 (nine days after the incident), -Staff G, DON#2, signed the form on 10/01/2020 (eight days after the incident), both Staff E & G failed to timely evaluate the resident's first fall. Resident #4 had a second fall with a [MEDICAL CONDITION] before the facility completed the investigation for the first fall. Review of an incident investigation report, dated 09/29/2020, showed the resident had a fall on 09/29/2020 at 9:10 AM, (sent to ER - left facility at 1:45 PM), (this report was obtained by the surveyor on 10/28/2020). The investigation was not completed as of 10/28/2020, and it was not thorough as the facility did not determine the circumstances of the fall, and did not find root cause analysis to assess risks and hazards specific to this resident. the incident investigation did not state which hip was fractured, and it had no signatures from the Administrator, the Director of Nursing or the Medical Director, and no signature from staff who prepared the form, and no signature from interdisciplinary team members, though there were spaces on the form for their signatures. The witness statement from a physical therapist stated patient was on the floor near her roommate's bed, unable to state how she fell . This witness statement did not address bed position, whether call light was on/off or was/was not within resident's reach, and did not address footwear. -Review of an Occupational Therapy note, dated 09/29/2020, showed it stated Patient fell out of bed this AM. There was a typed memorandum/document in the investigation documentation, dated 09/30/2020 at 9:50 AM (day after fall w/ [MEDICAL CONDITION]), done by Staff D, Corporate, the next day when Staff D had interviewed the residents' roommate. Staff D documented an assessment of the resident's room and bed, (this was not done by facility staff when the resident was found, this was done the next day) which stated resident with scoop mattress to bed and touch pad call light with bed in lowest position. Tthis information was documented on the follow-up section of the Incident Follow-up and Recommendation Form, the facility assessed bed position and call light the day after the fall, not when the fall occurred. -Review of the resident's September 2020 Medication Administration Records, showed no adverse side effect monitoring was being done regarding the resident's treatment with [MEDICATION NAME]. This failure was not included in the facility's incident investigation for the two falls. Medications and medication-related side effects are factors that the facility should be evaluating when residents have incidents. There were no witness statements from any staff who may have interviewed the resident to try to obtain information relevant to the fall. Review of the resident's care plan, provided by medical records 11/13/2020, showed documentation done 09/30/2020 (the day after resident's 2nd fall in which the resident fractured her hip) by Staff D, Corporate, scoop mattress to bed, date initiated 09/30/2020, however, the resident was discharged to hospital on [DATE]. Touchpad call light to assist with call ease dated initiated 09/30/2020, the resident was transported to the hospital on [DATE]. Review of a progress note dated 09/29/2020 at 2:49 PM, showed the resident had an xray and the results were a fracture. The progress note did not state what bone was fractured, the resident then transferred to the hospital, left facility at 1:45 PM. In a phone interview on 11/06/2020 at 8:04 AM, Resident #4's family member stated that the facility reported Resident #4 fell out of bed. The family asked the resident what happened and the resident told the family member that staff informed the resident she fell out of bed. According to the family member, Resident #4 didn't know what had happened. According to the family member, facility staff dropped the resident and that was the second incident at the facility resulting in the other hip (left) fracture. In a phone interview on 11/06/2020 at 11:50 AM, Resident #4 was asked about her falls at the facility, she stated: (first fall) I was told I fell out of bed by the care center, (second fall, where she broke her other hip), one of the workers was helping me, I think it was a male, I don't know that for sure though, there was one person, I don't remember their name, they were trying to get me out of bed and they let me go and dropped me. When Resident #4 was asked if staff had put a belt around her waist, she answered No. The resident was unable to recall what staff were assisting her with when they dropped her. In a phone interview on 11/06/2020 at 12:07 PM, Staff D, Corporate/Clinical Quality Coordinator for Life Care Services of America, stated she helped the facility complete the resident's fall investigations for two falls, and stated I was there on 09/29/2020. Staff D stated that she entered data on both investigation Incident Follow-up and Recommendation Forms, but she signed the 09/23/2020 form only. She said she only signed the 09/23/2020 IDT section for the first fall on 09/23/2020, but she didn't sign the form for the 09/29/2020 fall because the resident went out to the hospital and had not come back yet. Staff D agreed that the 09/23/2020 progress notes did not contain all relevant information, like footwear, call light on/off, bed position, and stated that staff should have documented that. Staff D said that the responding nurse should have assessed the room and the resident, and documented all relevant facts in the progress notes, and in the incident investigation. She stated if a nursing assistant or some other staff was the one that was first on the scene at the incident, they should be required to do a witness statement and put it in the incident investigation. In a phone interview on 11/12/2020 at 11:53 AM, Resident #4's family member stated that the facility knew the resident was a falls risk. In an interview on 11/13/2020 at 7:32 AM, Staff K, LPN, was asked about the resident's first fall on 09/23/2020. According to Staff K, when asked when the resident had last been toileted, Staff K stated she asked the nursing assistant, who told her about 10:00 PM. She stated that she didn't remember the nursing assistant's name. When asked if the facility trained her on how to do an incident investigation, she stated she had been trained on how to fill out the paperwork, however, Staff K did not receive training on how to do a thorough incident report, to prepare witness lists, or getting witness statements, she said they did have a checklist though. In an interview on 11/13/2020 at 10:10 AM, Staff E, Administrator, and Staff A, Vice President Northwest Division, were interviewed: -Staff E was asked what the 10/02/2020 date by her signature on the 09/23/2020 incident investigation report meant, she stated that was the day she reviewed the incident investigation report (nine days after the incident). -Staff E was asked what date the investigation was completed, she stated 10/01/2020 (eight days after the incident). -Staff E was asked where were the witness statements for the incident, she stated there were none. -Staff E was asked who were the relevant witnesses, she was unable to provide any information. -we discussed the 09/29/2020 fall, which was not thorough, not timely, and there was no documentation it was ever reviewed by the Administrator, Staff E stated she reviewed the incident on 10/08/2020 (nine days after the incident), -Staff E was asked about the incident report stating no injuries, yet Resident #4 sustained a [MEDICAL CONDITION], she stated that was at the time of the incident, she stated she would honestly have to look. -There was nothing in the incident reports for either fall about the [MEDICATION NAME] and lack of care planning, lack of adverse side effect monitoring, lack of target behavior monitoring. Staff A stated monitoring medications was part of falls risk assessment and care planning. In a phone interview on 11/17/2020 at 11:11 AM, the resident's other family member stated that Resident #4 was sleepy and out of it, we tried to talk to her over the phone, We could not get staff to open the window so we could talk to her. This family member stated that the facility was not safe. The family member said Resident #4 hit her head and fractured her other hip with the second fall incident. According to the family member, the facility allowed the resident to lay down and go back to sleep after the second fall incident which resulted in a head injury, [MEDICAL CONDITION], and bleeding, and inquired about concussion protocols. Review of the resident's care plan, provided by Medical Records on 11/13/2020 at 5:58 AM, showed the resident was care planned for being at risk for falls related to generalized weakness, deconditioning, dementia, breathing problems, [MEDICAL CONDITION], opioids, and a recent hospitalization due to right [MEDICAL CONDITION]. The goal was she would not sustain a serious injury requiring hospitalization . Review of the interventions showed there was no intervention or documentation to show how the facility was going to ensure Resident #4 received adequate supervision consistent with the resident's needs, goals, care plan, and current professional standards of practice in order to eliminate or reduce the risk of an accident. REVIEW OF FALL RISK EVALUATIONS Review of a Fall Risk Evaluation, dated 08/03/2020, showed on the date of admission Resident #4 was assessed a fall risk of 22 (score 10 or above is a fall risk, and per the form, interventions should be initiated). Review of a Fall Risk Evaluation, dated 09/23/2020, showed after her first fall in the facility, the facility downgraded her fall risk to a 14, evaluation done by Staff K, LPN. This evaluation was not accurate, Staff K marked no falls in 90 days, yet Resident #4 had just had a fall, marked no medications taken currently or in last seven days (there was a list of different types of medications that increase fall risk, resident was taking four, two antihypertensives, a cardiovascular drug, and an antidepressant), which was inaccurate as the resident was receiving an antipsychotic medication. In an interview on 11/13/2020 at 7:32 AM, Staff K was asked about the Fall Risk Evaluation she had completed on 09/23/2020, she was unable to provide any information. Resident #4 Summary: Resident #4 admitted to nursing home with a [MEDICAL CONDITION], she had two falls while in the nursing home, incident investigations not thorough, not timely, not complete. Resident #4 had a non-injury fall, then had a second fall where she sustained a [MEDICAL CONDITION] before the facility completed the first investigation. the facility failed to protect the resident pending completion of the investigation for the first fall. Incident investigations were not complete, they were lacking relevant information necessary to assess and reduce the risks and hazards specific to this resident. Care plan lacked documentation related to how the facility was going to provide adequate supervision to eliminate or reduce the risk of an accident, and the resident had admitted to the nursing home after a fall with [MEDICAL CONDITION]. The facility failed to implement their Protection of Residents: Reducing the Threat of Abuse & Neglect written policy and they failed to implement their Fall Management policy to ensure adequate supervision of this at risk resident. Resident #4 was discharged from the nursing home to the hospital with her other [MEDICAL CONDITION], she had hip surgery. RESIDENT #15 In an observation/interview on 11/10/2020 at 10:12 AM, the resident yelled, hey you, come here. Resident #15 was observed sitting in a wheelchair beside his bed. Resident #15 said he needed Kleenex, and when the surveyor asked the resident if he had tried his call light, Resident #15 stated that staff took it away from him. The call light was observed at the head of the bed under the pillow and not within the resident's reach. Staff L, LPN, was notified, and she stated they must not have put it back when they brought him back from restorative. Review of an incident investigation, dated 10/21/2020, revealed there was a care plan included with the investigation documentation, the care plan was undated, but it did state the resident was at risk for falls, and it had an intervention Call light within reach. RESIDENT #24 In an observation/interview 11/09/2020 at 12:23 PM, the resident was observed sitting in a wheelchair beside her bed, her call light was observed to be under her pillow on the bed and not within the resident's reach. Staff L, LPN, was notified, and she stated that she thought it was the students that did that. Review of the resident's care plan, print date 11/20/2020, revealed the resident was care planned to be at risk for falls, and her care plan stated Call light within reach. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure they had effective Medication Regimen Review (MRR) processes for two residents (#4, #34) reviewed. Drug regimen review process reviewed for January to October 2020 for all residents consultant pharmacist had reviewed, inadequate facility response to irregularities, failure to act timely, or at all. The failure: 1) to conduct thorough and timely MRRs, to include failure to do an immediate MRR in a resident that had missed/omitted [MEDICAL CONDITION] medication doses due to staff medication errors that resulted in two hospitalization s, and consultant pharmacist not consulted or notified, 2) to conduct [MEDICAL CONDITION] medication adverse side effects monitoring, not identified by consultant pharmacist, 3) to monitor for target behaviors/symptoms of treatment with an antidepressant medication, not identified by consultant pharmacist, 4) failures of facility to ensure consultant pharmacist reviewed all relevant records related to medication regimens, to include informed consent records and [MEDICAL CONDITION] medication monitoring records, 5) facility failed to timely act on irregularities identified by consultant pharmacist in monthly MRRs, resulting in repeat irregularities not acted on timely the following month, 6) facility failed to notify consultant pharmacist of residents with significant changes in conditions or significant events like falls, [MEDICAL CONDITION], or hospitalization s that may have resulted from or be associated with medications. Facility system for identifying, reporting, and acting on medication-related irregularities inadequate, facility failure has placed all residents at risk for medication-related adverse consequences. Resident #4 was harmed when she had no history of depression, facility started her on an antidepressant medication she and her representatives did not know she was receiving, the facility did not monitor this medication for adverse side effects and her symptoms/behaviors were not monitored, and facility staff failed to follow facility written informed consent policy, resident had two falls in the facility, she fractured her other hip in the second fall, consultant pharmacist denied she was notified of the falls and she denied reviewing resident for medication informed consent, and she made no recommendations and identified no irregularities in her 09/26/2020 monthly MRR, even though resident was not being monitored for adverse side effects or target behaviors/symptoms of treatment with an antidepressant. Consultant pharmacist failed to complete comprehensive review of residents' medication regimen and medical record and to speak with the resident and/or resident's family or resident's representatives. Resident #34 was harmed when the facility failed to administer [MEDICAL CONDITION] medications, he had [MEDICAL CONDITION] and a hospitalization , the facility failed to do an immediate MRR to identify the medication errors and to prevent future medication errors, the resident returned from the hospital, had more missed doses of [MEDICAL CONDITION] medications due to staff transcription errors and had more [MEDICAL CONDITION] and another hospitalization , consultant pharmacist denied she was notified. Findings included . Review of an Omnicare (Pharmacy/Consultant Pharmacist) policy titled Physician/Prescriber Authorization and Communication of Orders to Pharmacy, revised date 10/31/2016, showed: 5.3 Orders that may not be accepted by pharmacy from the electronic medical record system include the following: -5.3.2 Orders with missing stop dates (i.e., antibiotics) 5.4 Orders that are not accepted by the pharmacy are rejected and order rejection was communicated to the facility customer for correction or clarification . Review of an Omnicare policy titled Medication Regimen Review, dated 11/28/2016, showed: 1. The Consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the residents' health record. 2. Facility should ensure that the Consultant Pharmacist has access to: -2.1 Complete health record/chart, -2.2 The resident and/or resident's Responsible Party: 2.4 Physician/Prescriber progress notes, nurses' notes, and other documents which may assist the Consultant Pharmacist in making a professional judgement as to whether or not irregularities exist in the medication regimen . 3. Facility should inform the Consultant Pharmacist of any physical and/or mental conditions of the resident which are likely to affect his/her medication therapy outcome. 10. If an irregularity does not require urgent action but should be addressed before the consultant pharmacist's next monthly MRR, the facility staff and the consultant pharmacist will confer on the timeliness of attending physician responses to identified irregularities based on the specific resident's clinical condition. RESIDENT #4 The resident admitted to the facility on [DATE], for orthopedic after-care/rehab after having a fall with fractures of the right hip and [MEDICATION NAME] vertebrae. Resident admitted to the facility with a history of falling, pneumonia, cognitive communication deficit, generalized muscle weakness, dementia, need for assistance with personal care, and [MEDICAL CONDITION]. During the 08/03/2020 admission to the care center, the resident had two more falls in the facility, the second fall on 09/29/2020 resulted in her fracturing her other hip, the left, necessitating transfer to the hospital. According to the admission MDS, dated [DATE], showed resident: -moderately cognitively impaired, -dementia. In a phone interview on 11/05/2020 at 1:58 PM, the residents' family member/caregiver at home, stated staff called and told her they were putting the resident on an antidepressant, and she told them no. She said she had suspected they were drugging her up with something, but not an antidepressant, after she had told them no, she said she knew what drugs Resident #4 had been on before the nursing home because she lived with her and she was Resident #4's caregiver. In a phone interview on 11/06/2020 at 8:04 AM, Resident #4's family member/caregiver at home stated that the facility called to get consent to start an anti-depressant and the family member did not give consent. According to the family member (daughter in law-DIL), the resident had already seen a neurologist who advised against any mind altering medications for Resident #4 as the resident would not tolerate the drugs. The DIL stated that Resident #4 appeard sedated and just wanted to sleep, and would be too sleepy to visit with family. Every time I went there she was sleeping, it's like they kept her sleeping, they would give her pills and just let her sleep there. The DIL stated it took two weeks at home after the 2nd [MEDICAL CONDITION] for all of the drugs to wear off and her to become herself again, now I find out they were giving her depression drugs, now it's starting to make sense. I just didn't know. The DIL stated that the facility told her the resident was not receiving anti-depressant medication. In a phone interview on 11/06/2020 at 11:50 AM, Resident #4: -was asked if staff had ever asked if they could give her a medication for depression, she stated No, they did not. -was asked if staff had given her antidepressant medications, she stated I don't know. Review of the resident's September 2020 Medication Administration Records, showed the resident had an order dated 09/03/2020 to start [MEDICATION NAME] 10 milligrams by mouth one time a day for depression. The first dose was given 09/07/2020, and resident got 21 doses before she discharged to the hospital after her second fall in the nursing home, the fall where she fractured her other hip. In a phone interview on 11/06/2020 at 12:07 PM, Staff D, Corporate/Clinical Quality Coordinator for Life Care Services of America, stated: When we get a new order for [MEDICAL CONDITION] medications we have to get a consent from the resident if they are alert and oriented, or the family or representative, we have to explain risks, benefits, and alternatives, and we have a consent form at Life Care. There should be a consent form done for [MEDICAL CONDITION] medications before we give the medications. In an interview 11/13/2020 at 5:27 AM, Staff LL, Medical Records, said she could find no permission slip (informed consent form) for any [MEDICAL CONDITION] medications, she said she just didn't even know if Resident #4 took any [MEDICAL CONDITION] medications from what she saw. In a phone interview on 11/17/2020 at 10:36 AM, residents' son/Emergency Contact #1, stated that he had power of attorney (POA) for the resident and stated that the facility did not contact him for consenting to start the resident on antidepressant drugs. In a phone interview on 11/17/2020 at 11:11 AM, resident's other son (Resident #4) lives with him and his wife who is her caregiver), stated that while the resident was at the facility, she was always sleepy and out of it. The son said the facility was told that the family did not agree or consent to starting the resident on anti-depressant medication. When asked if he felt the resident was able to give consent, the son stated No, my mom was just too confused, they asked my wife while she was on the phone, they said they were standing with my mother, and my wife said she told mom to tell them no. My wife said that my mom told them to listen to what she (my wife) said. Progress note review: -08/04/2020 at 1124: Nursing note: unspecified dementia without behavioral disturbance. 08/31/2020 at 2319: Nursing note: dementia. 09/03/2020 at 1952: Nursing note: New order [MEDICATION NAME] 10 mg by mouth daily, verbal consent taken from patient. 09/03/2020 at 2328: Nursing note: alert but confused. In an interview on 11/13/2020 at 9:07 AM, Staff H, DON#4 was interviewed with Staff B, Corporate. Staff H was asked about resident's lack of informed consent for the [MEDICATION NAME], she stated she could not speak to it. Staff B stated it was ok to obtain verbal consent. Staff B said Staff H didn't know the policies, as she hadn't been there long enough yet. In an email interview on 12/04/2020 at 5:53 PM, Staff OO, Consultant Pharmacist, stated - side effect and target behavior monitoring for compliance for [MEDICAL CONDITION] use was audited by the facility per policy, and when the resident is discussed in the monthly [MEDICAL CONDITION] meeting she reminds them to complete the evaluation of potential adverse drug events and residents' response to the medication. Staff OO also stated: - Informed consent compliance was audited by the facility, she was not notified of the resident's falls or asked to review her medication as contributing to falls,she said she had reviewed the resident's medication regimen on 09/26/2020, but no recommendations were made. (Failed to identify irregularities of adverse side effect and target behavior monitoring were not being done, and resident's 2nd fall in which she fractured her other hip was 09/29/2020), she stated side effects were not being monitored in the electronic health record, so she could not remotely audit them for compliance. (This was not accurate, the facility did document medication adverse side effects monitoring in the electronic health record, they did it in the electronic MARS/TARs, they just did not do it for this resident, at all. Lack of medication monitoring was an irregularity that needed to be identified timely. Lack of records in electronic health record does not excuse consultant pharmacist from doing thorough MRR, MRR task cannot be delegated to other staff). When asked if consultant pharmacist had ever determined if the resident who admitted without a [DIAGNOSES REDACTED].? She replied Per the electronic medical record, an order for [REDACTED]. When asked if the consultant pharmacist reviewed resident/representative informed consent forms, she stated Not any longer, as consents were not scanned into the electronic health record to access remotely. Lack of records in electronic health record does not excuse consultant pharmacist from doing thorough MRR, MRR task cannot be delegated to other staff) RESIDENT #34 The resident admitted to the facility 08/26/2019, had some missed doses of his anti-[MEDICAL CONDITION] medications in early November 2020 due to staff medication errors, had a fall/[MEDICAL CONDITION], was hospitalized [DATE] - 11/13/2020, returned to the care center, missed some more doses of anti-[MEDICAL CONDITION] medications due to staff's transcription error, had another [MEDICAL CONDITION], was hospitalized again 11/15/2020 - 11/19/2020, then after the second hospitalization , went to a different nursing home, he didn't want to return to Marysville Care Center, and his daughter agreed as she was concerned about his safety at Marysville Care Center. The resident had [DIAGNOSES REDACTED]. According to the quarterly MDS assessment, dated 10/01/2020, the resident had no cognitive impairment. In an observation on 11/13/2020 at 6:20 AM, the resident was not in his room, and his bed was made. Staff J, Registered Nurse, was asked where the resident was, she stated he'd had a fall and was still in the hospital. Incident #1 - missed medications, fall/[MEDICAL CONDITION], 1st hospitalization for [MEDICAL CONDITION] Review of an incident investigation report, dated 11/10/2020, indicated staff heard a crash, that resident sustained [REDACTED]. Resident noted to be bleeding from his right head. Resident was transferred to the hospital. Staff documented labs indicated likely urinary tract infection and a long-standing history of [MEDICAL CONDITION]. Facility did not suspect abuse or neglect, and they concluded Fall was reasonably r/t (related to) [MEDICAL CONDITION] activity. Facility plan was to educate Resident #34 on having someone with him with transferring for safety. The investigation report included a Medical Hospitalist Team Progress Note, dated 11/12/2020, which showed resident had a CT (computed tomography) done, that showed right forehead soft tissue injury. The hospital history and physical, dated 11/10/2020 indicated resident had a Large hematoma over right eye. This incident investigation report was done by Staff QQ, Registered Nurse, review of this incident investigation report revealed it was lacking: -this investigation did not mention any missed [MEDICAL CONDITION] medications as being potentially contributory to resident experiencing [MEDICAL CONDITION]. But there was a note at the bottom of the first page that on 11/17/2020 (seven days after the fall) spoke to field manager re: omitted doses, 11/02, 11/06 and 11/07, but it did not say which medications were omitted, and it did not state that the hospital was ever notified the resident had omitted doses. It did state LN (licensed nurse) provided with corrective action and all findings will be in 11/15/2020 Medication Discrepancy investigation. Review of hospital records from the second hospitalization for [MEDICAL CONDITION], dated 11/15/2020-11/19/2020, showed Daughter reports that the patient had missed at least 2 doses of medication at care center. Review of resident's November 2020 Medication Administration Records (MARs), showed resident missed doses of Levetiracetam ([MEDICAL CONDITION] medication) on 11/02/2020, 11/06/2020 and 11/07/2020. Review of resident's hospital records , showed no documentation the facility had ever notified the hospital of resident's missed Levetiracetam doses. A hospital note, dated 11/10/2020 at 6:15 AM, indicated Patient arrives from Marysville Care Center. Staff states patient was transferring himself to the toilet when he fell , hitting head. Possible [MEDICAL CONDITION] activity after hitting head per staff, lasted a few seconds. The hospital discharge summary, dated 11/15/2020 - 11/19/2020, showed records did indicate Daughter reports that the patient had missed at least 2 doses of medication at care center (it did not state if that was the first round of missed medications for the first hospitalization , or if it was the second round of missed medications that resulted in the second hospitalization ). Review of the resident's clinical record, revealed no documentation after the first hospitalization that the facility had consulted the consultant pharmacist regarding irregularities with administration of the resident's [MEDICAL CONDITION] medications. There was no documentation at all the facility had requested or done an immediate Medication Regimen Review to identify and correct the issue of missed [MEDICAL CONDITION] medications, and to prevent future medication errors. The resident returned to the care center from the hospital on [DATE]. Incident #2 - missed [MEDICAL CONDITION] medications, grand mal [MEDICAL CONDITION], 2nd hospitalization for [MEDICAL CONDITION] Review of the resident's progress notes, showed a note dated 11/15/2020 at 10:00 AM, care center staff observed resident have a grand mal [MEDICAL CONDITION], and residents' daughter wanted him sent to the ER for evaluation. Resident was sent to the hospital. Review of a Medication Error Investigation, dated 11/15/2020, showed facility identified that when the resident returned from the hospital on [DATE] that his Levetiracetam physician's orders [REDACTED]. The facility concluded the transcription error was done by Staff I, Licensed Practical Nurse, who the report stated acknowledged she had not obtained a second nurse signature, she was suspended pending investigation. Facility's investigation failed to identify that another medication, [MEDICATION NAME] (antibiotic medication), was not transcribed properly either, it was ordered for only four days, but facility staff entered it in their electronic health record as being indefinite. In an interview on 11/24/2020 at 2:59 PM, the residents' daughter stated she was his power of attorney, but I left it up to him (whether to return to Marysville Care Center after his 2nd hospitalization ), as he had been telling me for quite a while that he was not happy there. After the medication error, I left it up to him, and he chose to go to a different facility, actually in that facility it is farther away from me, but I want him to be happy with the staffing, that is important. Resident's daughter stated she saw him in the ER, she stated she did not know if he was clean, it was hard to tell, they hadn't cleaned him up and there was blood, and he did have a full-on [MEDICAL CONDITION] while I was there, it was hard to tell if he was clean with all of that blood. He just didn't want to go back there, I left it up to him, he didn't want to go back, and I didn't want him to go back either, I didn't really feel it was safe after they had messed up his medications twice causing him to have full-on [MEDICAL CONDITION], and he had to go to the hospital both times for it. In a phone interview on 12/01/2020 at 11:13 AM, Staff PP, Physician Assistant - Certified, said she did not intend for the [MEDICATION NAME] to be indefinite, she said she looked at the discharge summary, and verbally ok'd the orders, but she did not go back and check that they did them correctly, I assumed they would enter the orders the way the discharge summary said, and they must not have. The other problem with that is that the [MEDICATION NAME] (Levetiracetam) did not get entered correctly either. I signed that in a rote fashion, my bad, I assumed the staff had entered it correctly. Yes, I do think the [MEDICATION NAME] not being given properly did contribute to his rehospitalization . There were a couple issues, they didn't have the correct amount of admission staffing, I think they probably had staff that were not familiar with our routine procedures, plus that must have gone to pharmacy, you would think they might have caught that as well, honestly, I don't know what was really done, or what was done wrong or right, but I do think staffing played a part with that, I think it was probably some staff that didn't know how to do it properly. He only got his [MEDICATION NAME] once a day, not twice a day, and that is what sent him back. I saw afterwards that he did have some missed doses of [MEDICAL CONDITION] meds before his first hospitalization , I know they did an investigation of that, I didn't know about that until afterwards when I started looking into it, that [MEDICAL CONDITION] med was BID (twice a day) before he went to the hospital, but it looks like he did miss some doses then too. I never heard the results of that investigation, but I did look at that as a sentinel event (Sentinel event defined (Wikipedia) - any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness), it should not have happened, and I am not used to them doing improper entry of orders. In an email interview on 12/04/2020 at 5:53 PM, Staff OO, Consultant Pharmacist, was asked if the facility had consulted her at any time when the resident had not received his scheduled [MEDICAL CONDITION] medications, resulting in [MEDICAL CONDITION] and a fall, in his hospitalization , or when he returned to the nursing home from the hospital, then had more missed doses of [MEDICAL CONDITION] medications due to transcription errors, another round of [MEDICAL CONDITION] and another hospitalization , she replied No, I was not notified by the facility. Staff OO was asked if antibiotics were required to have an end date, like [MEDICATION NAME], She stated Yes, that she would ask the facility if she saw an antibiotic order without a stop date during her monthly review. Staff OO stated according to the pharmacy manager, the facility sent the [MEDICATION NAME] to the facility without a stop date. Resident #34 summary: facility failed to do an immediate MRR to identify medication errors and to prevent future medication errors, result - more medication errors, more [MEDICAL CONDITION] and another avoidable hospitalization . Pharmacy also failed to act on a medication irregularity when they filled an antibiotic order for [MEDICATION NAME] that was ordered for only four days, but pharmacy sent the [MEDICATION NAME] to the facility without a stop date. FACILITY FAILURE TO TIMELY ACT ON MONTHLY MEDICATION REGIMEN REVIEW IRREGULARITIES In an email interview on 12/04/2020 at 5:53 PM, Staff OO, Consultant Pharmacist, was asked: -if facility responded timely to irregularities/pharmacists' recommendations, Staff OO stated Generally, yes, she provided data: --1st quarter 2020: 30 day response 62%, 60 day response 62%, --2nd quarter 2020: 30 day response 44%, 60 day response 72%, --3rd quarter 2020: 30 day response 65%, 60 day response 75%, 09/2020 response rate 67% 10/2020 response rate 71% Was asked: if irregularities/recommendations ever had to be repeated again the next month because they were not acted on by nursing home staff, if so, what was the process, and who was contacted, she stated: Yes, the pending recommendation was repeated and was re-sent with the new recommendations each month. The letter stated repeat recommendation. In September, October and November 2020, she sent an email to leadership asking if specific recommendations had been resolved before repeating, but the email was not responded to by the facility and recommendations were repeated. She also stated she provided a medical director report that listed all resident recommendations from the previous month, and if they had been addressed. Review of facility MRRs: In an email interview on 12/02/2020 at 2:29 PM, Staff E, Administrator, provided a portion of MRRs for: -August 2020, facility provided only four of 10 residents' MRRs done by consultant pharmacist in August, -September 2020, facility provided only 14 of 26 residents' MRRs done by consultant pharmacist in September, -October 2020, facility provided only 20 of 34 residents' MRRs done by consultant pharmacist in October. In an email interview on 12/08/2020 at 1:42 PM, Staff E, Administrator, responded to an email request for missing resident MRRs for August, September, and October 2020, she stated I sent you all the ones that we have that were completed. Review of Omnicare Consultation Summary Reports for August, September and October 2020, showed the consultant pharmacist completed MRRs for: -August -10 residents, -September - 26 residents, -October - 34 residents. Reference: (WAC) 388-97-1300 (1)(b)(i)(ii)(c )(i)(ii)(iii)(3)(a)(iv)(4)(c )(d)

Based on observation, interview and record review, the facility failed to ensure accurate pharmaceutical services/procedures when administering medications for four of five residents (#34, #5, #31, #11) reviewed for pharmaceutical services. Failure to: 1) administer medications as ordered, 2) to conduct an immediate Medication Regimen Review (MRR) when a resident was hospitalized with [MEDICAL CONDITION] and had medication errors related to missed [MEDICAL CONDITION] medications/doses, and 3) to administer medications timely 4) to ensure an antibiotic order with a stop date was entered properly with a stop date, and not indefinitely, placed residents at risk for medication-related complications. Resident #34 was harmed when staff failed to administer [MEDICAL CONDITION] medications as ordered and the resident had [MEDICAL CONDITION] twice, a fall, a head injury and two avoidable hospitalization s. Findings included . Review of the facility policy titled Times of Medication Administration, dated [DATE], showed the facility had not defined what time to administer medications ordered as every evening shift. RESIDENT #34 Record review found the resident admitted to the facility [DATE], and according to the [DATE] Medication Administration Record [REDACTED]. After the second hospitalization , Resident #34 was discharged to a different nursing home. The resident had [DIAGNOSES REDACTED]. According to the quarterly MDS assessment, dated [DATE], the resident had no cognitive impairment. In an observation on [DATE] at 6:20 AM, the resident was not in his room, and his bed was made. Staff J, Registered Nurse, was asked where the resident was, she stated he'd had a fall and was still in the hospital. Incident #1 - missed medications, fall and [MEDICAL CONDITION], 1st hospitalization for [MEDICAL CONDITION] Review of an incident investigation report, dated [DATE], showed that staff heard a crash, that resident sustained [REDACTED]. When staff entered the room, Resident #34 was found sitting on the ground in his bathroom unresponsive and having a [MEDICAL CONDITION]. Staff found Resident #34 bleeding from his right head. The resident was transferred to the hospital. Staff documented labs indicated likely urinary tract infection and a long-standing history of [MEDICAL CONDITION]. the facility did not suspect abuse or neglect, and concluded Fall was reasonably r/t (related to) [MEDICAL CONDITION] activity. The facility corrective action plan was to educate Resident #34 on having someone with him when transferring for safety. The investigation report included a Medical Hospitalist Team Progress Note, dated [DATE], which showed the resident had a CT (computed tomography imaging) done, that showed a right forehead soft tissue injury. The hospital history and physical, dated [DATE] indicated the resident had a Large hematoma (ruptured blood vessels) over right eye. This incident investigation report was done by Staff QQ, Registered Nurse. Review of this incident investigation report revealed it was deficient as follows: The investigation did not mention any missed [MEDICAL CONDITION] medications as being potentially contributory to the resident experiencing [MEDICAL CONDITION]. However, there was a note at the bottom of the first page that on [DATE] (seven days after the fall) spoke to field manager re: omitted doses, ,[DATE], ,[DATE] and ,[DATE]. The noted did not state which medications were omitted, and it did not state whether the hospital was ever notified the resident had omitted doses. It did state LN (licensed nurse) provided with corrective action and all findings will be in [DATE] Medication Discrepancy investigation. Review of hospital records from the second hospitalization for [MEDICAL CONDITION], dated [DATE]-[DATE], showed that the Daughter reports that the patient had missed at least 2 doses of medication at care center. Review of the resident's [DATE] Medication Administration Records (MARs), showed the resident missed doses of Levetiracetam ([MEDICAL CONDITION] medication) on [DATE], [DATE] and [DATE]. Review of Tesident #34's hospital records (obtained by surveyor), showed no documentation the facility had ever notified the hospital of the resident's missed Levetiracetam doses. A hospital note, dated [DATE] at 6:15 AM, indicated Patient arrives from Marysville Care Center. Staff states patient was transferring himself to the toilet when he fell , hitting head. Possible [MEDICAL CONDITION] activity after hitting head per staff, lasted a few seconds. The hospital discharge summary, dated [DATE] - [DATE], showed records did indicate Daughter reports that the patient had missed at least 2 doses of medication at care center. The hospital discharge summary did not state whether that was the first round of missed medications for the first hospitalization , or if it was the second round of missed medications that resulted in the second hospitalization . Review of the resident's clinical record, showed there was no documentation after the first hospitalization that the facility consulted the pharmacist consultatn regarding irregularities with administration of the resident's [MEDICAL CONDITION] medications. There was no documentation to show the facility had requested or done an immediate Medication Regimen Review by the pharmacist, to identify and correct the issue of missed [MEDICAL CONDITION] medications, or to prevent future medication errors. The resident returned to the care center from the hospital on [DATE] (this was after the first hospitalization ). Incident #2 - missed [MEDICAL CONDITION] medications, grand mal [MEDICAL CONDITION], 2nd hospitalization for [MEDICAL CONDITION] Review of the resident's progress notes, showed a note dated [DATE] at 10:00 AM, care center staff observed resident have a grand mal [MEDICAL CONDITION], and residents' daughter wanted him sent to the ER for evaluation. Resident was sent to the hospital. Review of a Medication Error Investigation, dated [DATE], showed that the facility identified that when the resident returned from the hospital on [DATE] that his Levetiracetam ([MEDICAL CONDITION] medication), physician's order was not transcribed properly, he was ordered to get that medication twice daily to control [MEDICAL CONDITION], but staff transcribed it for only once daily, resulting in the resident missing doses on [DATE] and [DATE]. The facility concluded the transcription error was done by Staff I, LPN, who the report stated acknowledged she had not obtained a second nurse signature. During the investigation, the facility concluded there were two other residents (#5 & #31) that had one time missed documentation(s) of doses, the investigation indicated staff that missed those doses had the medication errors reviewed with nurses involved. the facility's investigation failed to identify that another medication, [MEDICATION NAME] (antibiotic medication), was not transcribed properly either, it was ordered for only four days, but facility staff entered it in their electronic health record as being indefinite, and the pharmacy sent the [MEDICATION NAME] to the facility without a stop date, when it was only ordered for four days. On [DATE] at 2:35 PM, voicemail left for Staff I, no return call ever received. In a phone interview on [DATE] at 11:13 AM, Staff PP, Physician Assistant - Certified, said she did not intend for the [MEDICATION NAME] to be indefinite, she said she looked at the discharge summary, and verbally ok'd the orders, but she did not go back and check if the orders for the antibiotic and anti-[MEDICAL CONDITION] medications were correctly transcribed. I assumed the staff had entered it correctly. Yes, I do think the [MEDICATION NAME] not being given properly did contribute to his rehospitalization . According to Staff PP, there was an issue with inadequate staffing as well as staff lacking familiarity with routing facility procedures. Staff PP said pharmacy should have caught the errors as well. Staff PP stated that Resident #34 only received [MEDICATION NAME] [MEDICATION]) once a day, not twice a day, and that is what resulted in the resident's second hospitalization . Staff PP stated that they noted Resident #34 had missed doses of [MEDICAL CONDITION] medications before his first hospitalization , and stated that the [MEDICAL CONDITION] medication was twice a day before he went to the hospital. Staff PP stated that as a sentinel event (Sentinel event defined (Wikipedia) - any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness), it should not have happened, and I am not used to them doing improper entry of orders. In an interview on [DATE] at 2:59 PM, the residents' daughter stated she saw Resident #34 in the ER, and that she observed the resident having a [MEDICAL CONDITION] while there. The resident's daughter stated that the facility missed medications causing the resident to have [MEDICAL CONDITION] and subsequent hospitalization . In an email interview on [DATE] at 5:53 PM, Staff OO, Consultant Pharmacist, was asked if the facility had consulted her at any time when the resident had not received his scheduled [MEDICAL CONDITION] medications, resulting in [MEDICAL CONDITION] and a fall, in his hospitalization , or when he returned to the nursing home from the hospital, then had more missed doses of [MEDICAL CONDITION] medications due to transcription errors, another round of [MEDICAL CONDITION] and another hospitalization , she replied No, I was not notified by the facility. Also, the consultant pharmacist stated the pharmacy sent the [MEDICATION NAME] (antibiotic) to the facility without a stop date. The facility staff failed to administer [MEDICAL CONDITION] medications as ordered, resulting in the resident having [MEDICAL CONDITION] twice, a fall, a head injury, and he had two hospitalization s, all avoidable. The facility failed to timely investigate medication errors and [MEDICAL CONDITION] which resulted in repeat medication errors and more [MEDICAL CONDITION]. While conducting their investigations, the facility concluded two other residents (#5 & #31) also had missed doses and/or documentation errors related to [MEDICAL CONDITION] medications. RESIDENT #5 The resident admitted to the facility [DATE], with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment, dated [DATE], she had moderate cognitive impairment. Review of a Medication Error Investigation (for Resident #34), dated [DATE], showed Resident #5 also had a missed dose and/or documentation error related to an [MEDICAL CONDITION] medication. Review of Resident #5's [DATE] MARs showed the following deficiencies: No documentation to show the resident received the [DATE] PM dose of Levetiracetam ([MEDICAL CONDITION] medication) (staff identified this during investigation of Resident #34's not receiving his [MEDICAL CONDITION] medication, when they investigated other residents), No documentation to show the resident received the [DATE] PM dose of Eliquis (anticoagulant medication resident took for her [MEDICAL CONDITION] to prevent a serious outcome related to clotting disorder), No documentation to show the resident received the [DATE] dose at 7:00 PM of [MEDICATION NAME] (antidepressant medication), No documentation to show the resident received the [DATE] dose at 6:00 PM of [MEDICATION NAME] (narcotic pain medication) No documentation to show the resident received the [DATE] evening shift dose of Dimethicone (skin protectant medication) to groin and buttocks for redness/skin integrity. Review of an incident investigation, dated [DATE], showed the facility had identified the residents' missing doses of [MEDICATION NAME] [MEDICATION]), Eliquis, [MEDICATION NAME] and [MEDICATION NAME]. The investigation did not have any documentation to show that staff had identified the missed dose of Dimethicone on the same date, [DATE]. RESIDENT #31 The resident admitted to the facility [DATE] and had a [DIAGNOSES REDACTED]. Review of a Medication Error Investigation (for Resident #34), dated [DATE], showed Resident #31 also had a missed dose and/or documentation error related to an [MEDICAL CONDITION] medication. RESIDENT #11 The resident, age 90+, admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. tested COVID positive on [DATE], expired from COVID complications [DATE]. According to the quarterly Minimum Data Set (MDS) (an assessment tool), dated [DATE] the resident was assessed by the facility as: -moderately cognitively impaired, -extensive 2-person assist with the ADLs bed mobility, transfers, dressing, toilet use, personal hygiene, -balance not steady with moving from seated to standing position, walking, moving on/off toilet, surface to surface transfer between bed and chair or wheelchair, -frequently incontinent of urine, -medically complex conditions, -at risk for pressure ulcers, -skin and ulcer treatments - applications of ointments/medications other than to feet. Review of a Concern & Comment form, dated [DATE], showed the residents' daughter's concern was related to the resident receiving medication on time. Review of progress notes dated [DATE], Resident's rash had worsened overnight, blanchable, no pustules, covering large area to goin (sic groin)/gluteal folds and coccyx, resident complaint of pain and burning, call placed to doctor on-call, received new order for [MEDICATION NAME] cream (skin medication), apply to large area of buttocks/groin reddened areas twice daily for seven days. Review of a Weekly Skin Integrity Data Collection, dated [DATE], showed new finding - yes, description: rash to groin, gluteal folds, buttocks and coccyx, has tripled in size from yesterday. Rash is red, no pustules or broken skin. Blanchable (blood flow is present indicating not a pressure ulcer). Review of the resident's care plan, print date [DATE], showed care planning included potential for/actual alteration in skin integrity related to incontinence of bladder, decreased mobility, chronic skin problems to forearm, hip/back pain, chronic peri redness, at risk for adverse reactions of [MEDICAL CONDITION] medication. In a phone interview on [DATE] at 4:54 PM, Resident #11's daughter stated that she had requested that the resident receive related medication when the resident was toileted. In a phone interview on [DATE] at 11:33 AM, Resident #11's daughter stated that the physician said they would look at the timeing of the medication around the resident's toileting. In a phone interview on [DATE] at 7:45 AM, the residents' daughter called the surveyor, she: -said there were issues with medications being given on time, she said the acid reflux medication had not been given prior to eating as it was supposed to be, and said that was identified as a problem when the facility switched shifts from eight hours to 12 hours. According to the daughter, Resident #11 reported she did not get the acid reflux medication before eating for a few days. The daughter stated that Staff RR, RN, explained that the facility was changing staffing shifts, and Resident #11 had a delay in her medications, and did not receive her medications until 10:30 AM and she should have received them before breakfast. In addition, the resident's daughter stated that the facility was not consistent with applying medication treatment with toileting to protect the skin and prevent a rash. Review of the resident's [DATE] MARs/TARs, revealed no documentation to show the resident received: -the bedtime dose of Quetiapine (antipsychotic medication) at bedtime on [DATE], -the bedtime dose of Pain Reliever PM Caplet on [DATE], -the evening dose of [MEDICATION NAME] (skin medication) to peri area (area between anus and scrotum or vagina) on [DATE], -the evening dose of antifungal powder under fold of right breast on [DATE], -the evening dose of zinc based barrier cream to bilateral buttocks for incontinence on [DATE]. Review of the resident's [DATE] MARs/TARs through [DATE], revealed no documentation to show the resident received: -the day, evening, and night shift doses of [MEDICATION NAME] to her peri area, on [DATE], -the night dose of [MEDICATION NAME] [DATE], -the day and evening doses of antifungal powder under fold of right breast on [DATE], -the day, evening, and night doses of zinc based barrier cream to bilateral buttocks for incontinence on [DATE], -the night dose of zinc based barrier cream to bilateral buttocks for incontinence on [DATE]. Review of a Meal Time schedule, undated, showed breakfast on Pilchuck where Resident #11 lived, was at 7:30 AM. Review of a Medication Admin Audit Report, for [DATE] - [DATE], showed the resident's [MEDICATION NAME] (acid reflux medication resident was concerned she was getting after breakfast) was scheduled for daily at 7:00 AM, resident received her [MEDICATION NAME] at: -[DATE] at 8:08 AM, -[DATE] at 8:55 AM, -[DATE] at 8:02 AM, -[DATE] at 8:19 AM, -[DATE] at 10:50 AM, -[DATE] at 8:21 AM, -[DATE] at 10:04 AM, -[DATE] at 10:13 AM. In an email interview on [DATE] at 5:53 PM, Staff OO, Consultant Pharmacist, stated [MEDICATION NAME] should be given 60 minutes before meals, and the time of administration may be modified dependent on arrival of the morning meal from the kitchen, and the medication should have been administered as directed, dependent on the morning meal time. Review of a Medication Admin Audit Report, for [DATE] - [DATE], showed the resident's [MEDICATION NAME] (heart rhythm medication) was scheduled for every evening shift at 2:00 PM, and per the audit report, resident was got it at: -[DATE] at 7:26 PM, -[DATE] at 5:46 PM, -[DATE] at 6:59 PM, -[DATE] at 6:18 PM, -[DATE] at 6:34 PM, [DATE] at 10:58 PM. In an email interview on [DATE] at 5:53 PM, Staff OO, Consultant Pharmacist, was asked if it was appropriate for a medication like [MEDICATION NAME] to be scheduled every evening shift, Staff OO stated the facility had to define what they mean by evening shift, if they intended evening shift to be at 2:00 PM and did not administer between 1:00 PM and 3:00 PM, then it should be observed as an irregularity. Reference: (WAC) [DATE] (1)(b)(i)(ii)(3)(a)(4)(d)

Based on interview and record review, the facility failed to ensure one of three residents (#4) reviewed for [MEDICAL CONDITION] medications remained free of unnecessary [MEDICAL CONDITION] drugs due to: 1) lack of target behavior monitoring, 2) lack of adverse side effect monitoring, 3) lack of informed consent for treatment with a [MEDICAL CONDITION] medication, 4) lack of a comprehensive assessment for depression prior to ordering and administering antidepressant medications, 5) failure of consultant pharmacist to identify the facility was not monitoring the resident for target behaviors and for adverse side effects of an antidepressant medication, not identified in monthly medication regimen review, 6) lack of care planning for treatment with an antidepressant medication, 7) inadequate indications for treatment with an antidepressant medication. These failures placed residents at risk for receiving unnecessary medications and for experiencing medication-related adverse side effects. Resident #4 was harmed when the resident received antidepressant medications that were not being monitored by the facility, and the resident experienced sedation, two falls, and another [MEDICAL CONDITION]. Resident #4 and the representatives did not know the resident received an antidepressant medication at the facility. The resident had no previous [DIAGNOSES REDACTED]. Findings included . Review of an Omnicare (facility's pharmacy/consultant pharmacist) written policy, titled [MEDICAL CONDITION] Medication Use, revised date 11/28/2016, showed: 1.1.4 - Facility staff should focus on an understanding of behaviors as a form of resident communication or distress. 2. Facility should involve the resident or the resident's representative(s) in the discussion of potential non-drug and medications to address the management of behaviors and the involvement should be documented in the resident's medical record. 4. [MEDICAL CONDITION] medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behaviors symptoms. 7. All medication used to treat behaviors must have a clinical indication and be used in the lowest dose to achieve the desired therapeutic effect. All medications used to treat behaviors should be monitored for: -efficacy (the ability to produce a desired or intended result), -risks, -benefits, and harm or adverse consequences. 10. Where the physician/prescriber orders a [MEDICAL CONDITION] medication for a resident, facility should ensure that physician/prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic medication is necessary. 12. Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions. 13. Facility staff should inform the resident and/or representative of the initiation, reason for use, and the risks associated with the use of [MEDICAL CONDITION] medications, per facility policy or applicable state regulations. RESIDENT #4 The resident admitted to the facility on [DATE], for orthopedic after care/rehab after having a fall with fractures of the right hip and [MEDICATION NAME] vertebrae. Resident #4 was admitted with a history of falling, cognitive communication deficit, generalized muscle weakness, dementia, need for assistance with personal care, and [MEDICAL CONDITION]. During the 08/03/2020 admission to the care center, the resident sustained [REDACTED]. According to the admission MDS, dated [DATE], the resident was moderately cognitively impaired, had balance problems and was not steady: moving from seated to standing position, moving on/off toilet, surface to surface transfer between bed and chair or wheelchair, had functional limitation in range of motion lower extremity, impairment on one side, had [MEDICAL CONDITIONS], other fracture, dementia, and was identified as having a fall with fracture in the six months prior to the admission. Review of the resident's September 2020 Medication Administration Records/Treatment Administration Records (MARs/TARs) showed an order dated 09/03/2020 for [MEDICATION NAME] (antidepressant medication) 10 mg (milligrams) to be given one time a day for depression. The resident did not receive her first dose of [MEDICATION NAME] until 09/07/2020. The resident received 21 doses of [MEDICATION NAME], and had two refusals documented. The medication entry on 09/30/2020 indicated the resident was hospitalized . Review of doctor notes, dated 09/07/2020, showed Patient appears more alert and engaging with [MEDICATION NAME]. Review of doctor notes, dated 09/07/2020, showed MAR indicated [REDACTED]. Review of doctor notes, dated 09/08/2020, showed depression - improved, MAR indicated [REDACTED]. Review of the progress notes showed a progress note dated 09/05/2020 at 11:39 PM, that the resident was on alert for [MEDICATION NAME], no adverse side effects noted. Author - Staff NN, LPN. (resident hadn't even received first dose until 09/07/2020). Review of the resident's care plan, provided by facility medical records on 11/13/2020, showed no care planning for the resident's treatment with [MEDICATION NAME] and none for depression. Review of website Rxlist.com, showed [MEDICATION NAME] side effects to include: drowsiness, dizziness, sleep problems ([MEDICAL CONDITION]), nausea, upset stomach, gas, heartburn, constipation, weight changes, dry mouth, yawning, ringing in the ears. In a phone interview on 11/05/2020 at 1:58 PM, the residents' representative/caregiver at home, stated the facility put Resident #4 on an antidepressant medication, although in a prior discussion with the facility, this resident representative requested not to start the resident on any antidepressants or any mind altering drugs. In a phone interview on 11/06/2020 at 8:04 AM, Resident #4's representative/caregiver at home stated that the facility requested a consent for antidepressant and the resident representative did not agree or provide consent. According to the resident representative, she had already worked with a neurologist related to the resident's care. The resident representative said the facility informed her that the physician would call to discuss, however, that did not occur. The resident representative stated that she had the resident evaluated by a neurologist previously, for dementia. According to the resident representative, the family were unaware the facility put Resident #4 on [MEDICATION NAME] to treat for depression. The resident representative said she was questioning the facility about Resident #4's changes in the resident's mood or behaviour and after finding out the resident was started on antidepressants, thought that was the source of the changes. The resident representative stated that after Resident #4 returned home and was off the mind altering drugs that the resident her mind was right again. Resident #4's representative stated that staff informed her that Resident #4 was refusing to participate in therapy, and that the neurologist had previously informed her that Resident #4 would not tolerate mind altering drugs. The resident representative stated that Resident #4 appeared sedated, and she didn't know hardly anything, her mind wasn't right, there were days I would come there she would say she just wanted to sleep. Every time I went there she was sleeping, it's like they kept her sleeping, they would give her pills and just let her sleep there. According to the resident representative, when she inquired what the the resident was receiving to make her sleep, the facility replied that they weren't giving the resident antidepressant, that the facility were not giving any depression drugs. In a phone interview on 11/06/2020 at 11:50 AM, Resident #4: -was asked if staff had ever asked if they could give her a medication for depression, she stated No. -was asked if staff had given her antidepressant medications, she stated I don't know. In an interview on 11/13/2020 at 5:27 AM, Staff LL, Medical Records, said she could find no target behavior monitoring sheets for Resident #4, she said she could find no permission slip (informed consent form) for any [MEDICAL CONDITION] medications either, she said she didn't know if Resident #4 took any [MEDICAL CONDITION] medications from what she saw. Staff LL provided the Resident #4's medical record. In an interview on 11/13/2020 at 4:40 A.M. Staff CC, LPN, showed the surveyor in the electronic health record/PointClickCare how another resident's (Resident #10) [MEDICAL CONDITION] medications were being monitored for adverse side effects on resident's MARs/TARs. Staff CC then pulled up Resident #4's MARs/TARs, and she could find no adverse side effect monitoring had been documented for Resident #4. Staff CC was asked how [MEDICAL CONDITION] medication target behavior monitoring was being done. Staff CC went to the nursing station and got a book, she showed the surveyor Resident #10's target behavior monitoring documentation for November 2020 which was being done on Behavior/Intervention Monthly Flow Records. In an interview on 11/13/2020 at 9:07 AM with Staff H, Director of Nursing, and Staff B, Corporate/Regional Director of Clinical Services, were interviewed. A joint review of the resident's MARs/TARs was done, and no adverse side effect monitoring was found for the resident's treatment with [MEDICATION NAME]. Staff H, DON was asked if side effect monitoring should have been done, Staff H said Yes. Joint review of the resident's care plan was done, there was no care planning done for the resident's treatment with [MEDICATION NAME], Staff B stated there should have been care planning done. Staff B and Staff H were informed medical records could find no target behavior monitoring for the resident's treatment with [MEDICATION NAME]. They were asked what target behaviors were being treated and monitored, Staff B looked in the resident's clinical record and stated she thought target behaviors were self-isolation and staying in bed, but she stated she didn't know for sure. In a phone interview on 11/17/2020 at 10:36 AM, Resident #4's son/Emergency Contact #1, stated that he had Power of Attorney POA) for Resident #4. The POA stated that the hospital's assessment of Resident #4 was that the resident was in serious cognitive decline, as if it had been a continuing decline for years. The POA said the facility did nto call to get consent for starting the residen on an anti-depressant. In a phone interview on 11/17/2020 at 11:11 AM, Resident #4's other family member, said that while Resident #4 was in the facility, the resident was always sleepy and out of it and that was a change from her normal mood and cognition. The family member said there was not an indication to start Resident #4 on anti-depressants, and the facility did not have the family's consent to start Resident #4 on anti-depressants. The family member said after the facility started Resident #4 on anti-depressants, the resident became sleepy most of the time and would be too sleepy to visit with the family. In an email interview on 12/04/2020 at 5:53 PM, Staff OO, Consultant Pharmacist, stated side effects and target behavior monitoring for compliance for [MEDICAL CONDITION] use is audited by the facility per policy, and when the resident is discussed in the monthly [MEDICAL CONDITION] meeting the pharmacist reminds the facility to complete the evaluation of potential adverse drug events and the residents' response to the medication. Staff OO stated that the facility did not notify Staff OO of the resident's falls or asked to review Resident #4's medication as contributing to falls. Staff OO said she reviewed the resident's medication regimen on 09/26/2020, but no recommendations were made. The pharmacist review failed to identify irregularities of adverse side effect and target behavior monitoring were not being done, and the resident's 2nd fall resulting in a [MEDICAL CONDITION] hip was 09/29/2020. Staff OO stated that side effects were not being monitored in the electronic health record, so she could not remotely audit them for compliance. This is not consistent with facility practice of documenting medication adverse side effects monitoring in the electronic health record. The facility enters the data in the electronic MARS/TARs, however, the facility failed to follow the practice for this resident. Lack of medication monitoring is an irregularity that was expected to be identified timely by the facility and pharmacist. When asked if a pharmacist determined whether the resident, who admitted without a [DIAGNOSES REDACTED].? Staff PP stated that per the electronic medical record, an order for [REDACTED]. Reference: (WAC) 388-97-1060 (3)(k)(i)(4)

Based on observation, interview and record review, the facility failed to provide timely emergency care for one of one resident (#1) who choked while eating in the facility. This failure resulted in a delay in treatment when facility nursing staff failed to 1) follow facility policy for using the overhead paging system to notify other staff help was needed for an emergent choking situation, 2) to immediately know where to obtain a suction machine for use in a choking emergency, 3) to not abandon a choking resident when the nurse left the unit and left the resident with a nursing assistant, 4) to follow facility policy for checking emergency equipment daily and ensuring the functionality of the equipment, 5) to provide/document ongoing assessment of the choking resident, 6) to timely call 911 to activate the emergency medical response system, 7) to support the choking resident's airway/breathing/circulation (ABCs), and 8) to initiate CPR on a choking adult who became unresponsive while choking. This pattern of failures harmed Resident #1 who, when the 911 responders arrived, found the resident to have no pulse and not receiving CPR, and the 911 responders had to immediately begin CPR, the resident died in the hospital. Additional failed practice included the facility Staff Development Program not having systems in place to monitor whether nursing staff had current CPR (cardiopulmonary resuscitation) certification, which resulted in the facility having on-hand, current CPR certification cards, for only 19 of 78 nursing staff required by their job descriptions to maintain current CPR certification. Three of the facility's healthcare responders that responded to the airway emergency did not have current CPR cards on file with the facility to include the nursing assistant that was feeding the resident in the dining room (Staff B, Nursing Assistant (NA)), the nursing assistant (Staff E, NA) that Resident #1 was left with when the nurse left the unit, and the weekend nurse supervisor (Staff C, Licensed Practical Nurse (LPN)). In addition, the Director of Nursing Services (DNS), did not have a current CPR card on-file in the facility. These failures resulted in an Immediate Jeopardy (IJ) related to multiple failures in providing emergency care to Resident #1, and when the facility placed all other residents at risk for IJ when the facility was unprepared to respond to emergencies, an IJ was called on [DATE] at 3:00 PM. The facility reviewed/revised their emergency policies and procedures, provided training to staff on emergency procedures, and revised the emergency equipment preparedness procedures, which resulted in removal of the IJ on [DATE] at 2:30 PM. Additional failed practice related to this airway emergency included a failure by facility staff to document ongoing assessment and management of Resident #1's airway, breathing, and circulation, which resulted in an incomplete clinical record, and made it impossible to determine what assessments and interventions were done, when they were done, and the resident's response to such. Furthermore, there was facility staff that did not know how to determine a resident's code/resuscitation status. Findings included . DEFINITIONS Choke - to have severe difficulty in breathing because of a constricted or obstructed throat/airway, or a lack of air. Suction Machine - an appliance used to remove substances such as blood, saliva, mucus, vomit, food and drink from a person's airway. AED - Automated External Defibrillator: a portable electronic device that automatically [DIAGNOSES REDACTED]. The AED does not and is not capable of determining whether a person has a physical pulse (a rhythmical throbbing of the arteries as blood is propelled through them, typically as felt in the wrists or neck). BLS (Basic Life Support) for Healthcare Providers, frequently used interchangeably with the term CPR certification, is training/proficiency in providing a level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital. BLS for Healthcare Providers is a training course for healthcare providers who need to know how to perform CPR and other basic life support skills in prehospital settings like nursing homes. Crash Cart - a cart, much like a tool box on wheels, that contains emergency equipment (like the suction machine) used by facility emergency responders to treat residents in distress. [MEDICAL CONDITION] - sudden, unexpected loss of heart function, breathing, and consciousness. Asystole - a [MEDICAL CONDITION] rhythm with no electrical activity in the heart at all, as displayed on the EKG monitor, it is also known as a flatline EKG, the heart is not functioning at all, it is a life-threatening condition that requires immediate action, primarily CPR, because asystole is not a shockable rhythm. FACILITY POLICY Review of the facility policy titled Removing Foreign Body Airway Obstruction - [MEDICATION NAME] Maneuver, review date [DATE], showed: -Purpose: to remove foreign body from airway to re-establish a normal breathing pattern and to prevent cardiopulmonary arrest, -Signs and symptoms of foreign body airway obstruction requiring immediate intervention include: -Cardiac: irregular pulse, rapid or slow pulse, cyanosis, absent pulse, -Respiratory: irregular breathing pattern, rapid or slow shallow breathing, apneic (absence of breathing) breathing periods, high-pitched inspiratory noises (crowing type), wheezing, inability to cough forcefully or at all, inability to speak, -Oral: vomitus in mouth or on face, partially chewed food in mouth. -Activate the emergency response system quickly if resident is having difficulty breathing, if another person is present, instruct that person to activate the emergency response system, then perform the [MEDICATION NAME] Maneuver (a first aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure is applied on the abdomen, between the navel and rib cage), -Squeeze the resident's abdomen using inward and upward thrust. Each abdominal thrust should be forceful enough to create an artificial cough that will dislodge an airway obstruction. Continue performing abdominal thrusts in rapid sequence until the airway obstruction has been relieved or the resident becomes unresponsive, -If the resident becomes unconscious, start performing CPR, -Document the procedure. Review of the facility policy titled Cardiopulmonary Resuscitation (CPR) Guidelines, revised date [DATE], showed: -staff must maintain current CPR certification for Healthcare Providers, -facility must address the provision of basic life support and CPR, including ensuring staff receive certification in performance of CPR for healthcare providers. Review of the facility policy titled Nursing Documentation, dated [DATE], showed: -Staff must document a resident's medical and non-medical status when any positive or negative condition change occurs, -The medical record must also reflect the resident's condition and the care and services provided, -The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatment and/or services, and changes in his/her condition, and/or interventions. Review of facility job descriptions for: -DON (Director of Nursing (DNS))(the nurse supervisor in charge of the facility's skilled nursing staff, and their training, supervision, oversight, and nursing administration), revised date [DATE], showed CPR certification must remain current during employment. -RN (Registered Nurse)(a nurse that has completed a nurse training program typically two - four years in length) revised date [DATE], showed CPR certification must remain current during employment. -LPN (Licensed Practical Nurse) (a nurse that has completed a nurse training program typically less than 12 months), revised date [DATE], showed CPR certification must remain current during employment. And must be able to sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours, and must be able to lift 35 lbs floor to waist, lift 35 lbs waist to shoulder, lift and carry 35 lbs, and push/pull 35 lbs. -CNA (Certified Nursing Aide) (a nurses' assistant that has completed a nursing assistant training program typically less than 120 days), revised date [DATE], showed CPR certification must remain current during employment. Review of a Facility Emergency Codes poster, undated, revealed four emergency codes: -Code Red - Fire -Code Purple - Disaster -Code Grey - Intruder/Armed [NAME]ber -Code Snow [NAME] - Unresponsive resident, Bring Crash Cart, -Resident/Patient needs medical support for cardiac and/or respiratory arrest, -Initiate life support if trained, -Call 911. RESIDENT #1 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment, dated [DATE], the resident had moderate cognitive impairment, and required extensive staff assistance with bed mobility, transfers, dressing, toilet use, personal hygiene. The MDS also indicated the resident needed 1-person assist with eating and had signs and symptoms of a possible swallowing disorder as she coughed and choked during meals or when swallowing medications. The resident's clinical record showed the resident wanted CPR/Full Treatment with the goal of prolonging life by all medically effective means. Review of the 911/EMS (Emergency Medical Services) responder's records (dated [DATE]) of the incident, obtained from the local fire department, showed: -[MEDICAL CONDITION] - Yes, prior to EMS arrival, -Staff at the nursing home reported patient began choking during lunch and stopped breathing, units dispatched to CPR in progress, however upon arrival found patient in bed with AED displaying asystole and CPR not being performed, -Patient had copious (abundant) amounts of food in and around the airway, -Several cycles of CPR were done, and the resident's heart function started again, then re-arrested (heart stopped again), got more CPR, heart started again, and resident was transported to the hospital. EMS timeline: -Call received: 1:07 PM, -Dispatched: 1:08 PM, -Enroute: 1:09 PM -On scene: 1:10 PM, -At Patient: 1:12 PM, -Depart scene: 1:58 PM Review of a Call for Service Detail Report (911 Call Transcripts), dated [DATE], revealed timeline information as follows: 1:07:37 PM: RES (resident) UNCONS (unconscious) 1:08:07 PM: Caller statement obviously NOT BREATHING & unconscious 1:08:10 PM: not breathing at all, answers arrest witnessed/just occurred 1:10:26 PM: PT (patient) IS AT THE NURSES STA (station), PT IS WAKING UP 1:12:55 PM: AID OS 1:13:48 PM CPR IN PROGRESS Review of Emergency Department records, dated [DATE] revealed: -the emergency doctor's note read I believe this patient likely suffered [MEDICAL CONDITION] from food impaction (food stuck in the esophagus) or aspiration (breathing in a foreign object (sucking food into the airway). Likely hypoxic (condition in which the body is deprived of adequate oxygen supply) etiology (cause of a disease or condition) to [MEDICAL CONDITION]. -Final impression: 1. [MEDICAL CONDITION], likely from hypoxic event, 4. Respiratory acidosis (condition in which the lungs cannot remove enough carbon [MEDICATION NAME] resulting in the body becoming acidotic). Review of hospital records, page 51 of 53, dated [DATE], revealed RCS (Residential Care Services) complaint filed to investigate events at MCC ([NAME]ville Care Center) regarding concern of negligence. Review of the resident's progress notes/fax showed: -Note dated [DATE] (day prior to the airway emergency) at 1:18 PM, Meds (medications) were attempted several times but she was unable to swallow. - Review of a fax transmission, dated [DATE] at 1:30 PM, revealed there was a fax to Resident #1's doctor that stated the resident had slept through breakfast and didn't wake up for her medications, and she drank one shake at noon, but she wouldn't swallow her meds (medications) again. -Note, written by Staff A, LPN (the nurse on duty in the resident's unit when the choking incident occurred), dated [DATE] at 1:27 PM, summarized as follows, the nursing assistant that was feeding the resident when she choked notified the nurse that the resident had eaten 50% of the meal, the nurse noted the resident was making gurgling noises, the nurse did oral care with a pink toothette swab, which did not resolve the gurgling, the nurse left the resident with a nursing assistant and went to grab a suction machine and alerted other nurse about gurgling noises and was asking for the doctor, but was told the doctor had left the building. When the nurse came back to the unit with the suction machine the Resident's face was white and was still making gurgling noises and choking. The nurse called a nursing station using phone and alerted nurses on the floor to come and help out as resident's face was white pale. The nursing assistant yelled Res (resident) is not responding . Nurse checked resident and resident appeared unconscious, so nurse called 911 immediately. Other nurses arrived, as the resident's nurse was on the phone with 911. Other nurses suctioned resident, as Staff A was still on the phone with 911. Resident was making facial expressions as she was being suctioned. Res is a full code (wants CPR/full resuscitative treatment), so she was laid in her bed and nurses were working with resident as the nurse was still on the phone with 911. Paramedics showed, and the nurse got off the phone with 911. Paramedics took over scene. Paramedics took resident out of building approximately 1:50 PM, to hospital. (This progress note, which is basically the only documentation done in the resident's clinical record by facility staff of the events/circumstances, did not contain adequate information about what/when events really happened, as determined by staff interviews, there were just too many relevant/important details and facts that were omitted, but were necessary for the clinical record to be complete and accurate). STAFF INTERVIEWS In an interview on [DATE] at 11:35 AM, Staff A, LPN, (Resident #1's assigned nurse when she choked), stated she was charting in the computer when Resident #1 was brought out of the dining room and she was told the resident was making gargling noises, and she then used a pink swab and tried to clean out her mouth, but it was not effective. She stated she left Resident #1 with Staff E, NA, to go find the doctor and to grab a suction machine. She said she told another nurse the resident was making gargling noises, and that nurse told her the doctor had left the building. She stated when she got back to Havenwood, Resident #1 was pale and appeared to be choking, so she grabbed the phone to call other nurses, and she spoke to Staff D, LPN, and she told him she needed help and that Resident #1 was pale. She stated then Staff [NAME] yelled that Resident #1 was unconscious, so she hung up the phone and immediately called 911, and that it was sometime after 1:00 PM when she called. She stated she then checked on the resident who did appear unconscious. She said she saw four nurses come to help her out. She said 911 gave her instructions on what to do, she said she delegated that to someone else, but she didn't remember who. She stated Staff D suctioned the resident, who had her eyes closed, but was making facial movements. She said they then took the resident to her room (which was at the opposite end of the hall from the nurses' station) and attached the AED. She said she stepped out of the room at that point. Staff A stated she did not know when the paramedics showed up, she thought it was around eight minutes, more or less, after she called. Staff A was asked why she didn't use the suction machine right there in Havenwood, she stated she wasn't thinking about it, and she wanted to bring the doctor back with her. She stated the suction machine she brought back from the other unit was not working, so she did end up using the suction machine that was right there in Havenwood. Staff A was asked if anyone ever checked the resident's oxygenation, she stated no, the resident was gasping for air and looked pale. Staff A stated she was unable to call for help overhead (per facility policy/procedures) because she didn't know how to page, she stated she knew the code of Snow [NAME], but didn't think she knew how to do it. Staff A stated she knew it was facility policy to page overhead for emergencies, but it didn't work for her. Staff A stated she did not know if the paramedics started CPR immediately on their arrival, because she had stepped out of the room because she needed to catch her breath, and that's why she didn't know what all was going on. She stated when she did peek in the room, she did see they were already performing CPR on the resident. Staff A stated she did not know if there were CPR backboards on the crash carts. Staff A denied she ever listened to the resident's breath sounds or assessed her airway, she stated the resident was pale and not responding, so she thought it was best to call 911. Staff A was asked if there was any concern of food obstructing the resident's airway, she stated she cleaned the resident's mouth out with a pink swab and got saliva, but no food, she did see food residue, and she said she cleaned it out, but it didn't stop the gargling noises, and that the resident wasn't really responding much by then. Staff A was asked if she knew if the resident had any recent choking incidents, which she did not know. Staff A was asked if she had any thoughts of doing a [MEDICATION NAME] Maneuver or abdominal thrusts to clear the airway, she stated she was nine months pregnant, so it would not have been safe for her to do that, she stated she wasn't talking to the other nurses, so she didn't know for sure if they had done it, she just knew the other nurses were suctioning the resident. Staff A was asked if any other nurses had assessed the resident's airway, she stated she was not hands-on, she was on the phone, so she didn't know if any other nurses had assessed the resident's airway/breathing. Staff A was asked which nurse was in charge of the resident during the emergency while she was on the phone, she stated there were four nurses working with the resident, but she did not know who was in charge of the resident because she was on the phone, she stated I knew it wasn't me, cause I was on the phone. In an interview on [DATE] at 1:14 PM, Staff H, LPN, stated Staff A had come to Quilceda (another unit down the hall) asking where she could find a suction machine, then Staff A couldn't reach it, so she got it for her. The next thing she knew the phone rang, and it was Havenwood calling saying they needed a nurse and they needed help, so Staff D, LPN, went to Havenwood to help. Then a nursing assistant from Havenwood came to Quilceda asking for the AED, and said they needed help down in Havenwood, she said she then went down there (to Havenwood). She stated when she arrived in Havenwood, Resident #1 was sitting in front of the nurses station, and she looked cyanotic (bluish discoloration of the skin and mucous membranes due to not enough oxygen in the blood). Staff H said she asked if the resident was a full code (wanted CPR/full resuscitation treatment), and was told Yes, then they rushed the resident down to her room. She stated Staff A was on the phone with 911 at that time. She stated when they got the resident to her room, they put the resident on her bed and applied the AED pads, and they were starting to get ready to put the resident on the floor when the paramedics arrived, and she then went back to her own unit. Staff H was asked who was in charge of the resident during the emergency, she stated Staff [NAME] Staff H stated the resident was breathing very minimally, and she knew what was going to happen. Staff H stated no staff ever announced the emergency via the overhead paging system, but stated That's what we are supposed to do. Staff H did not know if any staff ever performed the [MEDICATION NAME] maneuver or abdominal thrusts. In an interview on [DATE] at 9:10 AM, Staff D, LPN, stated no Snow [NAME] code was ever announced overhead. Staff D stated when he arrived at Havenwood, Resident #1 was slouched forward in her wheelchair with her head down and there was a nursing assistant trying to wake her up, but the resident was not responsive at all when he got there, and she didn't start responding until he suctioned her, then she was biting the suction device and trying to push it out of her mouth with her tongue. He said when he arrived on Havenwood, the suction machine was not there, and Staff A had told him the top of the suction canister did not fit. He said then someone brought the crash cart over as he was asking for it. He stated they then took the resident to her room and put her in bed, and his plan was to put her in bed, then on the floor. He said at that time, he was in control of the situation, and 911 was adamant about getting the AED attached, but the resident was still breathing. He stated the AED said a pulse was present (which an AED is not capable of doing) and no shock advised. Staff D denied any staff had put any supplemental oxygen on the resident. Staff D denied ever seeing CPR in progress by the medics, because he left. Staff D was asked why he had planned to put the resident on the floor, he stated because there was no CPR backboard available. Staff D was asked if any RNs were present, he stated No, because it was never paged overhead. Staff D denied any staff ever did vital signs or assessed the resident's oxygenation with a pulse oximeter (medical device used to determine a resident's blood oxygen levels). Staff D denied any staff ever did a [MEDICATION NAME] maneuver or abdominal thrusts, he said he wouldn't have done a [MEDICATION NAME], that he would have just jumped right to suctioning. Staff D stated he had looked in the resident's mouth and saw about 30 cc's (cubic centimeters) of Medpass (nutritional shake drink). Staff D was asked if he knew if there was a CPR backboard on the Quilceda unit crash cart, he looked at the crash cart and stated he did not know. In an interview on [DATE] at 10:26 AM, Staff C, LPN/Weekend Nurse Supervisor, stated she first noticed the resident was having problems about 1:00 PM, when the resident was still sitting by the nurses station, and she observed the resident to be very pale and non-responsive, and she was leaning forward. Staff C denied the resident was making any choking sounds when she first saw her. Staff C denied hearing an overhead page of the emergency, she stated they had sent a nursing assistant down to the main dining room to get her. Staff C denied seeing the resident ever stop breathing. Staff C stated she was in a supervisor role at the time. Staff C stated her concern was the resident hitting her head when they transferred her to the floor, because she may be needing CPR. Staff C was asked if there were CPR backboards on the crash carts, she stated There should be. Staff C was asked if staff should have announced the emergency using the overhead announcement system, she stated that was their policy in the past. Staff C was asked if any staff had checked the resident's vital signs or oxygen levels, she stated she thought yes, but wasn't positive. Staff C was asked if any staff had did the [MEDICATION NAME] Maneuver or abdominal thrusts, she stated she thought Staff A did, but she didn't see her do it. Staff C was asked which staff was responsible for checking crash carts for readiness, she stated night shift staff. Staff C was asked if there was supposed to be a seal on the crash cart, she stated I think so. Staff C was asked if she would have done anything differently, she stated I don't know. In an interview on [DATE] at 11:14 AM, Staff J, LPN, stated she had been working on Quilceda that day and when she came out of a room Staff D had asked her what was going on in Havenwood because somebody had fainted. She stated that her and Staff D then went down to Havenwood and she observed Resident #1 parked in her wheelchair by the nurses station, and Staff E, NA, was with her, and Staff A was behind the desk calling 911. She stated the resident was hunched over in her wheelchair and blue in the face. She stated Staff D got the suction machine and started suctioning the resident, while she herself was holding the resident's hand. She stated after being suctioned, the resident's color started getting better, and after that they wheeled the resident down to her room and put her in bed. She stated 911 told them to hook up the AED, and when they did it indicated no charge needed. She stated after that the medics arrived, but she didn't think the medics did CPR. Staff J stated the medics put the resident on the floor. Staff J stated Staff C and Staff D were in charge of the resident during the emergency. Staff J stated earlier Staff A had come down to Quilceda to get a suction machine, but had not notified anyone there was an emergency, Staff J stated Staff A had to have passed by the Havenwood suction machine when she went to Quilceda to get a suction machine. Staff J stated the suction machine Staff A had brought back to Havenwood didn't function because the lid for the suction canister wasn't the right size. Staff J was asked if there were CPR backboards on the crash carts, she stated Yes, I think so. Staff J denied there was ever an overhead announcement of the emergency. Staff J denied knowledge of any staff ever doing vital signs, she stated she didn't know, and she didn't know how long it had been going on, and that the caregivers (facility staff) were all white in color, and that she didn't know who was keeping track of what all was going on. Staff J was asked if any staff had tried the [MEDICATION NAME] Maneuver or abdominal thrusts, she stated she did not know, that the resident was blue and hunched over when she was by the nursing station, then she got better after being suctioned. Staff J was asked if the resident ever opened her eyes or responded after being suctioned, she stated she did not know, that she was basically just standing there in case anyone needed anything. Staff J was asked if an overhead announcement should have been done, she stated Yes, absolutely. Staff J stated she had been trained on how to do any overhead page. Staff J was asked if she would ever stick a toothette swab in the mouth of a resident that had signs/symptoms of choking, she stated No, I would not, and that is the right answer. In an interview on [DATE] at 11:25 AM, Staff K, NA, stated on the day of the emergency, after Staff B, NA, had fed Resident #1, she put her out in the hallway and notified the nurse of her gurgling. She stated then it kind of escalated as the resident was shaking and gurgling and it got worse and worse. Staff K stated So the nurse was calling the doctor, I think to see if she could suction her. Staff K stated we leaned the resident forward to get the strawberry fluid out, then she went and got the nurse in the Quilceda dining room, Staff C, and she explained the situation to her, and at that point, she herself went back into the dining room. She stated later, she poked her head out of the dining room, and Staff [NAME] yelled the resident was losing consciousness, and she saw Staff D and Staff H come down to Havenwood. She stated the resident was still sitting at the nurses station, and someone yelled to get the crash cart, and the staff then took the resident down to her room, and Staff K brought the crash cart down to the resident's room. She stated it looked to her that the resident had lost consciousness. Staff K was asked about Snow [NAME], she stated when a resident was losing consciousness or didn't have a pulse, that announcement was supposed to be done to let other staff know to come and help. Staff K denied ever hearing a Snow [NAME] announcement that day. In an interview on [DATE] at 10:35 AM, Staff L, LPN, was asked facility policy for announcing medical emergencies, she stated they were supposed to be announced overhead using a Snow [NAME], code. Staff L was asked which facility staff were qualified to do CPR, she stated all staff, well, clinical staff for sure, but she wasn't sure if the office or kitchen staff were CPR certified, but then stated I believe everybody is supposed to be certified. Staff L was asked about the documentation process for an emergency, she stated she was pretty sure there was a special form, almost sure anyway, but, I haven't had to do it yet. In an interview on [DATE] at 9:55 AM, Staff L, LPN, was asked if the Pilchuck (another unit in the facility) crash cart had a CPR backboard, she looked at the crash cart and said I'm going to say no. In an observation/interview on [DATE] at 2:20 PM, Staff I, LPN, was asked about the facility's process of ensuring crash cart equipment was ready, she stated night shift staff were supposed to be doing the crash cart inventory every night. During the interview we observed the Havenwood crash cart, and it was observed to not be sealed with a serial numbered seal like the other two units' crash carts. In an interview on [DATE] at 10:44 AM, Staff M, LPN/Resident Care Manager (RCM), stated staff could verify a resident's code/resuscitation status by looking at the green POLST (Physician's Orders for Life-Sustaining Treatment) in the resident's clinical records, and that it was also in PCC (PointClickCare (electronic health record)). Staff L stated emergency codes were supposed to be announced overhead by dialing *72. Staff M stated she would call 911 if a resident stopped breathing or had no pulse, and also for any residents that were turning blue and didn't have vital signs, and she stated I would personally call 911 if they are choking. Staff M stated she thought nurses and nursing assistants could do CPR, and that she believed all staff were to have BLS (CPR training). Staff M stated she thought there was a special form to be used to document medical emergencies/codes, but she stated she didn't know as she'd never been in a code at the facility. Staff M stated if a resident was choking, she would stay with the resident, call for help, try to get help from other staff, and see if there was anything obstructing the airway. In an interview on [DATE] at 10:55 AM, Staff N, NA, did not know how to verify a resident's code/resuscitation status. Staff N stated the code status should be in P[NAME] (POINTOFCARE (electronic health record for nursing assistants)), then she looked in P[NAME] for two other residents, couldn't find it, then stated This is our information, we should have it handy, I don't know. Staff N stated she thought all staff were CPR qualified. Staff N stated 911 should be called in an emergencies like fire, choking resident, and a robbery. In an interview on [DATE] at 11:05 AM, Staff O, Director of Rehabilitation/Physical Therapist, stated a resident's code/resuscitation status could be verified by looking in the medical chart and in PCC. Staff O was asked when she would call 911, she stated she always calls the nurse first, and then runs and calls 911. Staff O stated all staff were CPR certified. Staff O said she knew there was an AED in the facility, but I don't know where it's at. Staff O was asked about the documentation process for a code/medical emergency, she stated there was a sheet the nurse gave them to fill out for what they did. Staff O stated if she came across a choking resident, she would first chec

Based on observation, interview and record review, the facility failed to have the necessary structures and processes in place, adequate staff, adequate staff supervision, and a responsive facility administration to ensure care-planned bathing care and services were provided on one of three units (Havenwood, a unit consisting primarily of cognitively impaired residents) reviewed for bathing care. This systemic failure on Havenwood resulted in 18 of 18 residents (#21, #29, #20, #18, #15, #16, #17, #1, #19, #22, #23, #24, #25, #26, #27, #7, #28, #2) not receiving needed bathing care and services as frequently as care planned. Based on the Reasonable Person Concept, the Havenwood residents that were cognitively impaired, if able, would have wanted to have been bathed per their preferences that had already been identified and planned in their care plans. This failure resulted in neglect to residents who experienced unmet bathing needs, avoidable skin issues to include rashes, pressure injuries, malodorous skin/tissue folds, and discomfort from inflamed skin. Additionally, the facility failed to ensure a safe transfer was done for one of three residents (#3) reviewed for accidents and supervision. Resident #3 was harmed when she sustained a leg fracture after being transferred by a Nursing Assistant (NA) when the resident's care plan directed the staff to transfer the person with two people assistance. Findings included. DEFINITIONS Per the Revised Code of [STATE] (RCW): Neglect under Chapter 18.51 RCW, neglect meant: - A pattern of conduct or inaction by a person or entity with a duty of care that failed to provide the goods and services that maintained physical or mental health of a vulnerable adult, or that failed to avoid or prevent physical or mental harm or pain to a vulnerable adult; or - An act or omission by a person or entity with a duty of care that demonstrated a serious disregard of consequences of such a magnitude as to constitute a clear and present danger to the vulnerable adult's health, welfare, or safety, including but not limited to conduct prohibited under RCW 9A.42.100. - In a skilled nursing facility or nursing facility, neglect also meant a failure to provide a resident with the goods and services necessary to avoid physical harm, mental anguish, or mental illness. Moisture-Associated Skin Damage (MASD) (definition from woundsource.com) was defined as inflammation and erosion of the skin caused by prolonged exposure to moisture and its contents, including urine, stool, perspiration, wound exudate, mucus or saliva. Dementia - an overall term for diseases and conditions characterized by a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities. Review of the facility policy titled, Resident Rights, revised date 11/09/16, showed: - The resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; - The resident had the right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the care plan; - The resident had the right to receive the services and/or items included in the plan of care; - The resident had the right to be treated with respect and dignity; - The resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation; - The resident had the right to reside and receive services in the facility with reasonable accommodation of resident and preferences except when to do so would endanger the health or safety of the resident or other residents; and - The resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident. Review of the facility policy titled, Activities of Daily Living (ADLs), reviewed date 04/22/19, showed: it's purpose was to ensure facility's identified and provided needed care and services that were resident-centered, in accordance with the resident's preferences, goals for care, and professional standards of practice that would meet each resident's physical, mental, and psychosocial needs. Review of a complaint intake dated 12/24/19, revealed an anonymous concern that [AGE]% of the residents in one particular unit were being neglected. Review of a complaint intake dated 12/26/19, revealed an anonymous concern the facility was not providing adequate staffing in Havenwood for the past three months resulting in residents not being bathed and [AGE]% of residents had skin breakdown. The concern stated residents who resided in this unit were being abused and neglected. The report identified the other two units in the facility had a shower aide and were providing showers due to the resident in these units could verbalize their needs. On [DATE], Anonymous Staff #1 identified four Havenwood residents with skin issues/concerns and wanted these issues to be investigated. RESIDENT #21 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident's cognitive status interview was not able to be completed. The MDS indicated Resident #21 required extensive 1-2 person assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. For bathing, the resident required 1 person total assistance. The MDS indicated the resident was always incontinent (loss of control) of urine, and always incontinent of bowels. Review of bathing documentation for a 30 day look back period from [DATE], revealed Resident #21 had been bathed once in 30 days, and had been care planned to receive one shower a week. The resident had no documented refusals. For 30 days, at one per week, the resident had been care-planned to have received at least four showers, she received one. Review of the Weekly Skin Integrity Data Collection dated 12/25/19, showed that both forearms had bruising, her left hand had a scab and her coccyx had intact, pink, slow blanching skin. Review of the resident's care plan, print date 12/30/19, revealed a problem/focus area to include: - ADL self-care performance deficit related to (r/t) dementia and a history of a stroke; - Limited physical mobility r/t Alzheimer's and weakness; - Communication problem r/t a hearing deficit and impaired cognition due to dementia; - At risk for falls, confusion, gait/balance problems, incontinence, poor communication/comprehension, unaware of safety needs and vision/hearing problems; - Chronic [DIAGNOSES REDACTED]icile (a bacterial infection); - Potential for pressure ulcer development r/t decreased self-mobility and bedfast almost daily; and - Urinary incontinence. Review of the Kardex, print date 12/30/19, revealed Resident #21 preferred a shower once a week, and required 2-person extensive assistance with bathing/showering. In an interview on 01/02/20 at 12:49 PM, the resident was deemed not interviewable. Resident #21 was cognitively impaired. Based on the Reasonable Person Concept, a reasonable-person in a similar position would likely have felt dehumanized after being bathed only once in 30 days. RESIDENT #29 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly MDS assessment dated [DATE], she had moderate cognitive impairment, and required extensive 1-2 person assist with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. The MDS indicated that bathing did not occur during the entire 7-day look back period. The MDS showed the resident was always incontinent of urine and frequently incontinent of bowels. Review of the resident's care plan revealed she was care planned for problem/focus areas to include: - ADL self-care performance deficit related to [MEDICAL CONDITION], generalized muscle weakness, impaired functional mobility, confusion, impaired cognition, urinary problems, and bowel incontinence; - Limited physical mobility related to weakness; - Incontinent of bowel and bladder; and - At risk for impaired skin integrity and history of pressure ulcers (PUs). Review of the bathing documentation for a 30 day look back period from [DATE], revealed Resident #29 had been bathed on three days, but had been care-planned for two showers weekly. There was a lack of documented bathing from 11/28/19 - 12/11/19 (14 days), and from 12/21/19 - [DATE]. The resident had documented refusals on seven days (12/03/19, 12/13/19, 12/14/19, [DATE], [DATE], 12/24/19, and 12/26/19). For 30 days at two per week, the resident was care planned to have received at least eight showers, she received three. Review of the progress notes for 12/03/19, 12/13/19, 12/14/19, [DATE], [DATE], 12/24/19, and 12/26/19 revealed no documentation why the resident may have refused to bathe, and there was no documentation how the resident expressed her refusal to bathe. Review of the Weekly Skin Integrity Data Collection dated [DATE], showed the resident had an open area on the right buttock that measured 0.7 cm x 1 cm and on the left buttock that was described as a 1.5 x 1 (no units given) open area. In an interview on [DATE] at 2:15 PM, the resident did not respond at all when spoken to; she was deemed not-interviewable. Review of the resident's Kardex (a care guide to Nursing Assistants), print date 12/30/19, revealed her preference was to have showers twice week. In an interview on 12/30/19 at 3:40 PM, Staff C, Licensed Practical Nurse (LPN), was not aware of any refusals to bathe, or any other refusals at all. Staff C did not think the resident had any open areas on her skin. In an observation on 12/30/19 at 3:45 PM, the resident's skin was observed with Staff C. There were two open areas on the resident's coccyx area, the open area on the right side was approximately one centimeter (cm) by one cm and had a whitish covering over the area. The open area on the left side was approximately one cm by two cm and had a whitish covering over the area. Review of an incident investigation report dated [DATE], revealed an investigation was done because the resident was found to have superficial open areas to her left and right buttocks areas. The report indicated the resident had a history of [REDACTED]. The report indicated the resident was at an increased risk for PUs and alteration to her skin integrity due to her diagnoses. The facility did not substantiate abuse or neglect. The investigation showed that the wound would be treated with a barrier ([MED]) cream due to the resident was incontinent and moisture is an ongoing issue. Analysis of the incident investigation report dated [DATE], revealed no documentation the facility had assessed whether the plan of care was being followed. The report also had no documentation the facility had considered whether a lack of bathing had contributed to her developing these skin injuries (the resident had not been bathed since [DATE], she was care planned to be bathed twice weekly). In an interview on 01/02/20 at 4:04 PM, Staff E, Acting Director of Nursing Services/Assistant Director of Nursing Services (ADNS), was asked where the facility documented why residents refused to bathe, she stated they (the facility) did not push the resident for that information, if they refuse they refuse. The ADNS stated that this information of why a resident refused a bath would not be documented. Resident #29 was cognitively impaired, and also had communication problems. Based on the Reasonable Person Concept would likely have felt dehumanized after experiencing this pattern of unmet care needs. RESIDENT #20 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], Resident #20 did not have any cognitive impairment, required 1-2 person assist with bed mobility, transfers, locomotion, dressing and toilet use. The MDS indicated the resident required one-person assist with bathing. The MDS indicated the resident was occasionally incontinent of urine. Review of the bathing documentation for a 30 day look back period from [DATE], revealed she had been bathed on four days, but she had been care planned to receive two showers weekly. She had one documented refusal on 12/04/19. For 30 days, at two per week, the resident was care planned to have received at least eight showers/baths, she received them on four days. Review of the resident's progress notes dated 12/04/19, revealed no documentation why the resident refused to bathe that day. Review of a Quarterly Nutrition Documentation form dated 12/04/19, revealed documentation under skin, that read MASD of lower abdomen. Review of a Weekly Skin Integrity Data Collection form dated [DATE], revealed two skin issue which included a bruise to the resident's right hand and a bruise to the left elbow. There was no documentation identifying the groin rash or abdominal rash. Review of a progress note dated [DATE], revealed the resident had an uncomfortable red rash in her groin. Review of the December 2019 Medication Administration Records (MARs)/Treatment Administration Records (TARs), revealed an order for [REDACTED]. Review of a Weekly Skin Integrity Data Collection dated 12/25/19, revealed there was an old left elbow bruise. There was no documentation identifying the groin rash or abdominal rash. In an interview on [DATE] at 2:07 PM, the resident stated she wanted to shower today, but was informed they (facility staff) were too busy. She said she wasn't sure when she last got to bathe, but knew she hadn't been bathed yet this week. Review of the resident's care plan, print date 12/30/19, revealed Resident #20 was care-planned for problem/focus areas to include: - ADL & mobility self-care deficit due to history of fractures and a stroke; - At risk for impaired skin integrity/PUs related to impaired mobility,[MEDICAL CONDITION](stroke) and weakness, occasionally incontinent of bladder; and - Potential/actual impairment to skin integrity Review of the Kardex (care directives for nursing assistants), print date 12/30/19, revealed the resident's preference was to have showers 2x/week. Review of a Weekly Skin Integrity Data Collection form, dated 01/01/20, revealed documentation about the left elbow bruise and redness to groin. There was no documentation at all about the abdominal rash, the foul odor, or that the groin rash was painful to the resident. In an observation on 01/02/20 at 10:25 AM, the resident's skin was observed with Staff A, Registered Nurse (RN) and Staff B, Nursing Assistant (NA), the abdominal folds had a red rash from one side to the other. The resident's groin folds on both sides were very red, the left side was particularly red, inflamed and angry looking, and the resident grimaced when Staff A opened it up to visualize it and there was a foul odor when exposed. Staff B asked the resident if her groin hurt her, the resident nodded her head up and down and was observed to put her hand on Staff As hand when she opened the left groin area up for visualization. In an interview on 01/02/20 at 10:35 AM, Staff A stated the resident has had skin issues for the past few weeks. Staff A stated she had not seen the resident's left groin that bad before. Staff A was asked about the resident grimacing when her groin folds were assessed and cleaned, Staff A stated she did not feel this was hurting the resident. In an interview on 01/02/20 at 10:52 AM, Staff J, Regional Clinical Services, said he had looked at the wounds and the skin assessment, and he thought the documentation looked appropriate to him. Staff J stated this was a new skin issue/concern for the resident. Staff J was asked about the foul odor coming from the resident's groin folds; he didn't say anything. In an interview on 01/02/20 at 12:58 PM, Staff B stated the resident groin had been inflamed for about three months. Staff B stated the inflammation would come and go. RESIDENT #18 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], the resident was unable to complete the mental status interview, and required extensive assist of 1-2 persons with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. The MDS indicated she was total dependent with two people for bathing, was always incontinent of bowel and bladder. In an interview on [DATE] at 2:31 PM, the resident was non-verbal and was deemed to be not-interviewable. Review of the bathing documentation for a 30 day look back period from [DATE], revealed she had been bathed on six days, but she had been care planned to receive three showers weekly. There were no documented refusals. For 30 days, at three per week, the resident was care planned to have received at least 12 showers, she received them on six days. Review of the resident's care plan, print date 12/30/19, revealed she was care planned for the following problem/focus areas and interventions to include: - The resident was totally dependent on staff to provide two showers a week as necessary; - Communication problem related to dementia, impaired hearing, and history of stroke. The resident sometimes was able to express her needs and understand others - intervention was to anticipate and meet her needs; - At risk for potential PU development and other skin breakdown secondary to decreased self-mobility, dementia, impaired cognition, diabetes, incontinent of bowel and bladder, obesity, excessive moisture/perspiration, and history of refusal of care; - Redness under abdominal folds and right breast; and - Incontinent of bowel and bladder and at risk for urinary tract infection [MEDICAL CONDITION] secondary to brief use, incontinence, and history of UTI, intervention is check and change program. Review of the Kardex with a print date 12/30/19, revealed the resident preferred to shower three times a week, was totally dependent on staff to provide showers twice weekly as necessary. Review of the Weekly Skin Integrity Data Collection dated 12/31/19, revealed three sites with skin issues: - Right iliac crest, no description was given besides the location and to continue with the treatment; - Left iliac crest, no description given besides the location and to continue with the treatment; and - Redness under the right breast. In an observation on 01/02/20 at 10:16 AM, there was a red rash under the resident's right breast, and the right and left groin areas. There was a foul odor when the skin the groin skin areas were exposed. Resident #18 was cognitively impaired. Based on the Reasonable Person Concept, a reasonable-person would likely have felt dehumanized after experiencing this pattern of unmet care needs. RESIDENT #15 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly MDS assessment dated [DATE], the resident was rarely/never understood, and required extensive 1-2 person assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated the resident required 1-person physical help with bathing and was frequently incontinent of his bowel and bladder. In an interview on [DATE] at 2:33 PM, the resident was not sure how often he bathed, and he didn't know when he had last bathed. Review of the bathing documentation for a 30 day look back period from [DATE], revealed he had been bathed four times, but had been care planned to receive three showers weekly. As of [DATE], his last documented bathing was 1[DATE], which was 10 days prior. There were no documented refusals. For 30 days, at three per week, the resident was care planned to have received at least 12 showers; he received four. Review of the care plan, with a print date of 12/30/19, revealed the resident required assistance with his ADLs, which included bathing, to maintain his highest level of function. Review of the Kardex, with a print date of 12/30/19, revealed he preferred to be showered three times a week. Resident #15 was cognitively impaired. Based on the Reasonable Person Concept, a reasonable-person in a similar position like Resident #15 would likely have felt dehumanized after experiencing this pattern of unmet care needs. RESIDENT #16 Resident #16 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Admission MDS assessment dated [DATE], he had severe cognitive impairment, required extensive 1-2 person assist with bed mobility, transfers, and locomotion. The resident required one person physical assistance for bathing. Review of the bathing documentation from admit on [DATE] to [DATE], revealed he had been bathed twice. The last documented bathing was on 12/09/19. There was no documented bathing from [DATE] - [DATE], which was 18 days. His bathing documentation indicated he wanted to be bathed weekly. He had no documented refusals. For 28 days, at one bath per week, the resident was care planned to have been bathed four times, he was bathed twice. Review of the resident's care plan, print date 12/30/19, revealed the resident required ADL assistance to maintain his highest level of function, he had limited physical mobility due to weakness and was at risk for a break in his skin integrity related being incontinent of bowels and a decrease in self-mobility. Review of the Kardex, print date 12/30/19, revealed he wanted to bathe once weekly on Mondays. In an interview on 01/02/20 at 3:05 PM, the resident didn't think he had bathed for about a month and he didn't know if he was bathed often enough or not. Resident #16 was cognitively impaired. Based on the Reasonable Person Concept, a reasonable-person would have likely felt dehumanized after experiencing this pattern of unmet care needs. RESIDENT #17 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 12/13/19, revealed she had severe cognitive impairment, required extensive 1-2 person assist with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. The MDS indicated she required 1-person physical help in part of bathing activity. The MDS indicated she was frequently incontinent of urine and bowels. In an interview on 01/02/20 at 10:38 AM, the resident was deemed not-interviewable. Review of the bathing documentation from admit on 12/06/19 to [DATE], revealed she had been bathed three times, with no refusals. The documentation indicated she wanted to be bathed three times weekly. For 22 days, at three baths weekly, the resident was care planned to have been bathed at least nine times, she was bathed three times. Review of the Weekly Skin Integrity Data Collection dated 12/30/19, revealed the resident had redness under her breast and in her groin. This documentation did not contain any information about which breast, or which side of the groin were affected. Review of the resident's care plan, print date 12/30/19, revealed she had problem/focus areas to include: - ADL deficit r/t a fracture, dementia and weakness; - Potential for PU development r/t an actual stage 2 PU on her coccyx (present on admission), immobility, dementia and a history of a stroke; and - Bladder incontinence r/t dementia and impaired mobility. Review of the Kardex, print date 12/30/19, revealed she wanted to bathe three times a week in the morning (all three of her showers were documented as done in the afternoon). Resident #17 was unable to speak or write. Based on the Reasonable Person Concept, a reasonable-person in a similar position would likely have felt dehumanized after experiencing this pattern of unmet care needs. RESIDENT #1 The resident re-admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. According to the Significant Change MDS assessment dated [DATE], she had severe cognitive impairment, and was totally dependent on two persons for bathing. The MDS indicated she was frequently incontinent of urine and occasionally incontinent of bowels. Review of bathing documentation for 30 days, back from [DATE], revealed she had been bathed on three days, but had been care planned to receive two showers weekly. She had no documented refusals. On 12/30/19 at 3:35 PM, the resident declined to have her skin observed. Review of the Weekly Skin Integrity Data Collection, dated 12/30/19, revealed her skin was not intact. Resident #1 had bruising on her groin and left lower arm/wrist, MASD on her right lower abdomen, and chronic redness on top of her feet. Review of the care plan, print date 12/30/19, revealed problem/focus areas to include: - A new skin issues noted to right heel that measured approximately 1.5 cm by 1.5 cm; - A deficit in her self-care ADL performance due to her condition; - Required 1 person extensive assistance with showering; and - was incontinent of bowel and bladder. Review of the Kardex, print date 12/30/19, revealed the resident preferred two showers/week. In an interview on 01/02/20 at 3:12 PM, the resident was asked if she was able to bathe as often as she wanted, she stated not always, but most of the time. She provided no other information. Resident #1 was cognitively impaired. Based on the Reasonable Person Concept, a reasonable-person would likely have felt dehumanized after experiencing this pattern of unmet care needs. RESIDENT #19 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly MDS assessment dated [DATE], he had severe cognitive impairment, and required extensive 1-person assist with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated the resident required two person physical assist with bathing and was frequently incontinent of bowel and bladder. Review of the bathing documentation for a 30 day look back period from [DATE], revealed he had been bathed on 12/09/19 (this documentation indicated he was bathed at 1:57 PM and also at 3:46 PM, which was twice in the same afternoon) and [DATE], but had been care planned to receive two showers weekly. It had been seven days since the resident was bathed. Further review showed the resident had gone 11 days without being bathed (from 11/28/19 - 12/09/19). There were no documented refusals. In an interview on [DATE] at 2:08 PM, the resident did not know when he had last bathed, and he did not know if he was able to bathe as often as he wanted, he was not interviewable. Review of the resident's care plan, with a print date of 12/30/19, revealed he was care planned for problem/focus areas to include: - Memory loss r/t dementia; - ADL self-care performance deficit r/t dementia and muscle weakness. The resident was to be bathed twice weekly in the morning; - Potential for pressure ulcer development r/t incontinence, dementia/cognitive loss, impaired mobility, and need for assistance with ADLs; and - Urinary incontinence. Review of the Kardex, print date 12/30/19, revealed he preferred showers 2x/week. Review of the Weekly Skin Integrity Data Collection, dated 01/01/20, revealed the skin was documented as intact, but on the assessment stated that the resident had a treatment to the lower extremity (did not state which lower leg). There was not enough detail in the documentation to indicate what was being treated on the resident's lower extremity. Resident #19 was cognitively impaired. Based on the Reasonable Person Concept, a reasonable-person in a similar position like Resident #19's position would likely have felt dehumanized after experiencing this pattern of unmet care needs. RESIDENT #22 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Annual MDS assessment, dated 11/13/19, the facility was unable to assess the resident's cognitive status because she was rarely/never understood, and required extensive 1-2 person assist with bed mobility, locomotion, dressing, eating, and personal hygiene. The MDS indicated she had total dependence of two persons for physical assist with bathing, transfers and toilet use. The MDS indicated the resident was always incontinent of urine and bowels. \Review of the Weekly Skin Integrity Data Collection, dated 12/25/19, revealed the resident had an old bruise on her right arm, and dry skin around her mouth and side of nose. In an interview on [DATE] at 2:27 PM, the resident was deemed not-interviewable. Review of the bathing documentation for a 30 day look back period from [DATE], revealed she had been bathed three times, but she wanted to be bathed twice weekly. She had one documented refusal on 12/14/19. There was one documented shower on 12/12/19, and went nine days before she was showered again on 12/21/19. For 30 days, at twice weekly, the resident was care planned to have been bathed at least eight times; she was bathed three times. Review of the resident's care plan, print date 12/30/19, revealed she was care planned for problem/focus areas to include: - Alteration in elimination, total bowel and bladder incontinence; - ADL and mobility self-care deficit and dementia with behaviors; and - A communication problem r/t dementia. Review of the Kardex, print date 12/30/19, revealed she preferred to be showered twice weekly. Resident #22 was cognitively impaired. Based on the Reasonable Person Concept, a reasonable-person in a similar position like Resident #22's position would likely have felt dehumanized after experiencing this pattern of unmet care needs. RESIDENT #23 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly MDS assessment dated [DATE], he had seve

Based on observation, interview and record review, the facility failed to provide a living environment that enhanced and promoted a dignified existence in the facility for 1 of 1 residents (15) reviewed who stated her life was disrupted due to the noise disturbances of another resident/next-door neighbor with long-term, calling out behaviors. The facility's failure to maintain comfortable sound levels caused harm to Resident 15 when: she experienced exhaustion due to lack of sleep, she had to listen to another resident yell shut up, shut up, shut up at nighttime, and when she herself deemed it necessary to act out physically by banging on the wall between the two resident's rooms. Findings included: Review of the facility Resident Admission Agreement indicated at Section 11: Resident Rights: 1. The resident has a right to a dignified existence . 41. The resident has a right to prompt efforts by the facility to resolve grievances, including those with respect to the behavior of other residents. RESIDENT 15 The resident originally admitted to the facility in April 2016. Review of her MDS assessment, dated 10/09/17, revealed she did not have any cognitive impairment. In an interview on 01/08/18 at 1:28 PM, Resident 15 stated Resident 9's nightly calling-out behaviors were causing her nightly sleep problems, sometimes sleep problems during the evening, and that she felt sleep-deprived. In an interview on 01/09/18 at 9:50 AM, the resident stated her next door neighbor (Resident 9) was difficult to be around because she screamed a lot from her room and she calls out loud all night long, especially from 2:00 - 6:00 AM, and this has been going on for months. She stated the Administrator accused her of mocking Resident 9 and he told her Resident 9 had a right to scream and make as much noise as she wanted. She said she wasn't mocking Resident 9, she said she just had asked her why she was screaming all of the time and not using her call light to ask for help. Review of Daily Bed Census Reports revealed Resident 15 had resided in her room since 09/30/16, and Resident 9 had resided in her room since 09/22/16. In an interview on 01/09/18 at 1:21 PM, the Administrator stated he had offered Resident 15 a room change to another unit due to Resident 15's complaints of her neighbor calling-out. The room change offer was declined. In an interview on 01/11/18 at 8:57 AM, Staff K, Registered Nurse/Resident Care Manager, was asked how the facility monitored other residents for harm related to Resident 9' care plan problem: Behavior problem, socially inappropriate, as evidenced by hollering/calling out when needing something, and the goal of Resident will not harm themselves or others secondary to their behaviors. Staff K stated I don't make these care plans (behavior care plans), social services does that. I'm not sure they would want to make a goal of no calling out because that is not a feasible goal for her because it is more related to how her needs are being met. Staff K was asked if the facility was aware of noise or calling out complaints by either resident, Staff K stated Yes, . that came to light just since you guys have come to the survey, we have added that to Resident 15's care plan. Staff K was asked if any other residents had complained of Resident 9's calling out, Staff K stated There have been a couple of incidents where other residents were near her and we ended up moving them so they would not have to listen to her . We jointly reviewed Resident 9's care plan and behavior monitoring forms that indicated a long-term problem, Staff K stated Maybe with all of this going on, maybe Resident 15 will come to the realization she needs to move if it's too loud for her . At 10:04 AM, Staff L, Social Services Director, was asked if she knew about the noise issue between the two residents, she stated Yes, Resident 15 is upset about all of the calling out. Staff L was asked if the noise issue was ever resolved, she stated I think it still occasionally occurs, but I don't think it is as frequent as it used to (be). Even now if you sat here and listened, you would hear her calling out a half a dozen times a day. Staff L stated they had offered Resident 15 a room change on 10/02/17 because of all of the calling out, they had offered her to go back to another shared room which she had declined. Staff L added there would not have been enough room for her because she needs a lift to get her in and out of bed and the private rooms they had, other than where she was currently at, were too small. Staff L was asked if the facility had ever considered how all of this calling out had affected other residents in the nearby rooms, Staff L stated I would like to think we would. Staff L was asked if she thought it was a dignified existence if a resident was unable to sleep due to the noise and calling out of another resident, Staff L stated Is it perfect, No, do we try to figure out what is going on, Yes, I'm going to look into this, I just wrote it down, obviously it is still going on. At 1:28 PM, Resident 15 stated staff had been talking to her all day about her problems, then at night it is scream, scream scream. She said she wished she could just get some sleep. She said last night it was so loud she decided to hit the wall between the rooms with her reacher, she said after she would hit the wall, her neighbor would wait for awhile and then start screaming some more. Resident 15 stated I am feeling tired right now, I'm not worried about safety, I am exhausted, I can't get any sleep. I feel like I am stirring up a pot. The resident stated she was offered a room change, but other than the room she was in, there wasn't a room big enough here (at the facility) for me, so I don't have any options. Resident 15 stated she (Resident 9) is disrupting my life, so it's hard to be around her . In an observation on 01/11/18 at 1:28 PM, during a resident interview in Resident 15's room, the television from her neighbor could be heard through the wall. In an interview on 01/12/18 at 8:49 AM, Resident 15 indicated the noise issues had been going on since she and Resident 9 had become next-door neighbors (09/30/16). She said she had previously been in a different room in the facility but it did not meet her needs, which is why she was moved to her current room. She said she was trying to settle into her room long-term because she did not have any options to go to a lesser care facility due to her care needs. She said the calling-out by her neighbor had continued last night. She said it had gotten so bad that she heard a male resident yell out Shut up, shut up, shut up whenever Resident 9 started calling out. She said she did not feel it was right to ask her to move because her neighbor had bad behaviors of calling out at all hours. She said I know I have a quite a bit of personal belongings, but this is my home as I recently was forced to sell my mobile home. I don't intend to infringe upon my neighbor's rights, but my rights are important to me too. I've been very upset . In summary, the facility failed to provide an environment that promoted and enhanced resident well-being and provided residents with a dignified existence. A reasonable person would not want to live in an environment where they were subject to long-term noise disturbances that negatively affected their sleep and their psychosocial well-being. Reference: (WAC) 388-97-0180 Refer to: CFR 483.10(i), F-584 - Safe, clean, comfortable, homelike environment CFR 483.10(j) , F-585 - Grievances CFR 483.35(a), F-725 - Sufficient nursing staff CFR 483.40 (d), F745 - Medically-related Social Services

Based on interview and record review, the facility failed to promptly and thoroughly resolve and document resident and/or family grievances for 3 of 3 residents/grievances (15, 75, family member) reviewed for grievance resolution. The facility failed to implement the facility Concern & Comment Program to: identify and thoroughly document the specific issues, to timely resolve the grievances, to ensure all grievances were properly logged and investigated and not documented as Completed until actually resolved, to prevent further potential violation of resident rights related to grievances, and to perform ongoing monitoring and to obtain feedback whether the grievances were resolved after initial attempts to resolve them. These failures caused harm to Resident 15 when the facility failed to resolve a grievance and the resident began to self-isolate from group activities, was subjected to lack of sleep due to ongoing noise disturbances, when she deemed it necessary to confront her next-door neighbor about her calling-out, and when she reported feeling intimidated by the Administrator after he confronted her about a grievance as she felt he had discouraged her from attending activities and made her feel not welcome at the facility. Facility also failed to investigate and document a verbal and/or written resident grievance/allegation about the Administrator. Findings included: Review of the facility Resident Admission Agreement indicated at Section 11: Resident Rights: 1. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 2. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights . 40. The resident has the right to voice grievances to the facility or other agency or entity that bears grievances without discrimination or reprisal and without fear of discrimination or reprisal. 41. The resident has a right to prompt efforts by the facility to resolve grievances, including those with respect to the behavior of other residents. Review of the Concern & Comment (facility grievance) Program, dated ,[DATE], revealed: Purpose: To encourage a timely and quality response to the concern and/or comment. Procedure: 2. Persons completing the form will take adequate time to record the concern comprehensively or allow the concerned individual to record their comments. Complete information will help to facilitate a comprehensive and prompt follow-up. 3. When completing the form, include observations concerning the emotional intensity of the individual such as calm, understanding, upset, angry, or hostile. This information will offer insight to staff involved in the follow-up. 7. The appointed manager will be in contact with the concerned individual within 24 hours or as soon as possible to share the status of the investigation and any results. 8. If the problem is one that may take an extended period of time to resolve, or it cannot be remedied , the responding manager and administrator will discuss an appropriate response and possible alternatives that may meet the concerned person's needs. 9. The facility's response as well as the concerned individual's reaction to the remedy will be recorded on the Concern & Comment Form. 10. The administrator or designee will assure that all Concern & Comment Reports have been reviewed and followed up on timely and appropriately and that concerned individuals feel that some type of resolution has been achieved and maintained. 11. For families who have repeated or endless concerns, the administrator will involve social services and other appropriate staff in creating a plan of care to adequately respond to those individuals. RESIDENT 15 The resident originally admitted to the facility in [DATE]. Review of her Minimum Data Set assessment, dated [DATE], revealed she did not have any cognitive impairment. Review of the Comment & Concern Log revealed an entry dated [DATE] related to a Neighbor, the log indicated the issue was completed (resolved) on [DATE]. Review of the Blue Concern & Comment Form, revealed the person reporting the concern was the Administrator. The form asked the concerned individual to Please describe in detail your Concern, Comment, or Commendation. The Administrator wrote Staff member (no name listed) reported that Resident 15 made a comment about her neighbor using her call light instead of calling out. The form question Was a staff member able to resolve the concern at the time it was shared? was left blank, there was no documentation the concern was resolved. On page 2 of the Concern & Comment Form, the Administrator's name was written on the form for the staff member designated to investigate and follow-up with Concern. The investigation findings indicated Spoke with Resident 9 who said she was doing well. Call light was in reach and educated use of it. Spoke with Resident 15 to let her know that a comment like that could offend the resident, if heard. The documented actions taken to Resolve/Respond to concern were Offered room move away from (Resident 9's room) and Resident 15 declined. The question Concerned party's response to the Action Plan/Outcome was left blank, the form had other questions to ask/document as follows: -Pleased that an appropriate plan has been identified and implemented (left blank). -Sense of relief that staff have attempted to resolve the concern (left blank). -Cautious but optimistic (left blank). -Hesitant and concerned (left blank). -Doubtful that plan or resolution will meet expectations (left blank). -Resolution has been incorporated into this resident's plan of care (left blank). In an interview on [DATE] at 2:15 PM, regarding the Comment & Concern Form, the Administrator was asked who the staff member was that reported the comment, he could not recall. The Administrator was asked what the comment was and if it was derogatory or demeaning, he could not recall. The Administrator was asked why Resident 9 was calling out, he stated he did not know, he stated she would sit and call out while watching tv. The Administrator stated he was the grievance official at the facility, and that he just didn't remember there was ever a grievance form filled out regarding an issue between those two residents. Review of Resident 15's clinical record revealed no documentation the Administrator had documented any issues related to the Concern & Comment Form concerns, and there was no documentation the Administrator had made a referral to/or notified social services or nursing to assist with resolving the issue. Review of a facility incident investigation report, dated [DATE], revealed It appears that she (Resident 15) has had life events in which has made her emotionally fragile to which she will cry easily or anger. This is demonstrated by interactions with people regarding situations she is uncomfortable with and she will demonstrate avoidance. Review of the [DATE] Comment & Concern Log, revealed an entry dated [DATE], resident was Resident 15, reporter was the Administrator, concern was neighbor, given to was the Administrator, completed on was [DATE]. In an interview on [DATE] at 1:24 PM, Resident 15 stated the Administrator had discouraged her from going to activities because he told her she was mocking another resident (Resident 9) that made a lot of noise. She stated the Administrator had suggested to her that she would be happier at another facility, the resident was observed tearing up, she said she used to like to go to group activities and she had went a lot. In an interview on [DATE] at 9:11 AM, Resident 15 stated that after the Administrator had talked to her she filled out one of the blue Comment & Concern cards and gave it to the previous Director of Nursing Services (DNS). She stated she felt the Administrator had been verbally abusive to her and she felt unsafe. She stated she felt intimidated by him and that she was made to feel like she didn't belong at the facility anymore, and she thought by going to the DNS something would be done about it. The resident stated that Bingo had been her favorite activity in the past and he had taken that away from her. The resident also stated that the incident made her feel like a tattle-tail and that wasn't the way she wanted to be perceived by the staff. The resident stated after submitting the Comment & Concern card no staff ever got back to her and she was worried she had gotten the DNS in trouble and that was why she no longer worked at the facility. Review of a facility investigation report, dated [DATE], revealed there was a witness (Staff W) to the conversation between Resident 15 and the Administrator. Staff W's Witness Statement Form, dated [DATE], revealed Resident 15 made some unkind statements to another resident .She felt that yelling at the other resident was not a problem. This yelling incident was not logged, reported or investigated. In an interview on [DATE] at 2:00 PM, Staff N, Regional Vice President, and Staff O were asked if the [DATE] Blue Concern and Comment form that had been done by the Administrator was completed in accordance with corporate documentation standards, they did not provide any information. They were also asked if the Concern & Comment card had enough information to determine what was the issue and how it was resolved, they did not provide any information. They were also asked if there was enough information on the Concern & Comment card to determine how Resident 15 felt about resolution of the issue, they did not provide an answer. They were also asked if the Administrator should have documented any information in resident clinical records regarding the issue/resolution, they did not provide any information. The only information they provided was to state it all depended on the situation for what should have been documented. Review of the Comment and Concern log revealed no entry regarding Resident 15's Comment & Concern card issue with the Administrator. The current DNS and Staff O, Regional Director of Clinical Services, were asked to provide the Blue Concern & Comment card, they were unable to locate it. Review of a facility investigation report, dated [DATE], revealed the Staff O, Regional Director of Clinical Services contacted Staff X, the prior DNS, who remembered a staff member (not identified) telling her that Resident 15 wanted to talk to her about the Administrator. Staff X's statement indicated she instructed that nurse to go see what the resident wanted to make sure it was not an allegation of abuse or neglect. Staff X's statement indicated she never received any comment card from Resident 15 about abuse or neglect. The statement continued Staff X stated she talked with Resident 15 and she stated that the Administrator had come to her room because she had said something that she shouldn't have regarding another resident. Resident 15 denied abuse and neglect and she said she just did not care for the Administrator because he was too young to be a boss. There was no reason or issue listed why she thought he was too young. The statement/report continued Staff X stated that she told Resident 15 that from now on she would address her concerns so the Administrator did not have to interact with her. Resident 15 agreed and liked the resolution. Staff X stated she then called Staff Y, DDCS (corporate), and Staff N, Regional Vice President, to notify them. She stated at no time did it appear to be an issue of abuse or neglect. This nurse (Staff O) cannot remember any details regarding this incident or resident. Staff Y, DDCS, stated he could not recall this particular phone conversation or resident. The facility did not thoroughly investigate this grievance, nor did they identify and document the actual concern or issue voiced by the resident. The change to facility practice of the Administrator no longer interacting with Resident 15 was not documented in the resident's care plan. Review of this incident investigation report revealed there was a grievance/allegation about an Administrator. The Director of Nursing Services, the Regional Vice President, the Regional Director of Clinical Services, and Staff Y, DDCS, were all involved, but there was no documentation to explain the incident. Review of the Administrator's personnel file revealed no documentation regarding the issue In summary, facility staff knew of a long-term (>1 year) problem regarding calling-out/noise issues. When the facility did not resolve the issue, Resident 15 indicated she tried to figure it out on her own and confronted the other resident, and I got in trouble. The Administrator intervened, and when the resident didn't accept his offer of a room-change, there was nothing else done and nothing else documented. There was a grievance form done by the Administrator, but it did not state the issues, it did not state how the residents felt about the resolution, it did not state that the issue was resolved. The Administrator did not follow facility policy for documenting and resolving resident concerns. Resident 15 suffered sleep problems. She also had psychosocial harm after the incident because she felt she was no longer welcome at the facility after the incident and she self-isolated in her room, with knowledge of staff, but even then, staff did not attempt to resolve the issues. The calling-out noise issues continued. The Comment & Concern Log indicated the issue was resolved on [DATE], the same day it was reported, but the issue continued into 2018. There was also an issue of a missing Blue Concern & Comment card, to which the resident indicated she felt she was verbally abused and she felt unsafe, this card was never located. Additionally, facility leadership failed to intervene, investigate, and document a grievance/allegation about the Administrator. RESIDENT 75 In a family interview on [DATE] at 10:52 AM, the resident's family member stated the resident was missing her upper dentures and that there was a very slow response from the administrator and the business office staff to work on getting a replacement. Review of the Comment and Concern Log revealed an entry regarding missing upper dentures that was logged on [DATE]. The entry was documented on the log as being Completed (resolved) on [DATE]. Review of the associated Concern and Comment Form, revealed there was not enough information to determine if/how the issue was ever resolved. The form indicated it was updated (the updated information was not dated or signed) and there was an appointment (dental, to get new dentures) scheduled for [DATE]. Facility submitted additional information to the surveyors on [DATE] that indicated the issue had not yet been resolved. The additional information stated Timeline is an estimation. PUBLIC BATHROOMS A review of a grievance card dated [DATE] written by a familly member revealed the family member had a concern regarding the public restrooms near the dining room having mold problems which the family member claimed made her sick. The grievance card stated the concern was reported to the front desk. A review of the facility investigation of the grievance revealed the Executive Director (ED) was assigned to investigate and follow up. The investigation findings stated only that the ED attempted to contact the family member and left a message indicating the public restrooms were scheduled to be renovated and offered the family member the use of a staff restroom. Observations of the public restrooms on [DATE] revealed: The Right public restroom had cracked flooring in the corner behind the toilet exposing subfloor with blackened matter visible behind the flooring. The mirror was damaged at the edges. There was an approximately 12 inch area of detached wallpaper beneath the paper towel dispenser which had been secured back down with staples. The flooring was stained throughout. The Left public restroom had a cracked damaged counter near the sink. The mirror was damaged in the corner near the wall. The wall below the paper towel had a rust colored water stained streaked appearance. The flooring is stained throughout. In an interview on [DATE] at 11:10 AM, The ED stated that no investigation of the complaint had occurred and that the public restrooms had not been assessed or tested for mold or evaluated related to the complaint. The ED stated only that the public restrooms were going to renovated sometime in the next year and that this was the only time anyone had complained that the restrooms made them sick. Reference: (WAC) [DATE] (1)(2) Refer to: CFR 483.10, F-550 - Resident rights/exercise of rights CFR 483.10(i), F-584 - Safe, clean, comfortable, homelike environment CFR 483.35(a), F-725 - Sufficient nursing staff CFR 483.40 (d), F-745 - Medically-related Social Services CFR 483.45(c), F-758 - Free from unnecessary [MEDICAL CONDITION] Meds/PRN use CFR 483.90(i), F -921 Other Environmental Conditions

Based on observation, interview and record review, the facility failed to ensure necessary care and services were provided to prevent the occurance of avoidable pressure ulcers for 2 of 4 residents (76 and 48) and the deterioration of an existing pressure ulcer in 1 of 4 (76) residents reviewed for pressure ulcers. The facility failed to comprehensively evaluate the residents' clinical conditions, identify the residents' increased pressure ulcer risk factors, and aggressively provide care and treatment. These failures caused harm to the residents when Resident 76 developed one new Stage II pressure ulcer, had one Stage I pressure ulcer deteriorate to a Stage III and Resident 48 developed a new Stage III pressure ulcer. Findings included: The facility's Pressure Ulcer/Injury Prevention policy dated 11/2017 identified a resident's risk may increase due to an acute illness, or condition change. The frequency of assessment should be based upon each resident's specific needs. Measures to protect the patient against the adverse effects of external mechanical forces such as pressure, friction and shear are implemented in the plan of care and included to reposition at least every 2-4 hours as consistent with overall patient goal and medical condition, utilizing positioning devices to keep bony prominences from direct contact and heel protection/suspension should be implemented while the patient is in bed. Risk factors identified that increased a patient's susceptibility to develop or impair healing of pressure ulcers included: impaired/decreased mobility and decreased functional ability; drugs that may affect wound healing, [MEDICAL CONDITION], co-morbid conditions, such as end stage [MEDICAL CONDITION] or diabetes mellitus; or history of a healed ulcer. The facility's Evaluations, Screenings, and Assessments policy dated 11/2017, stated the patient is evaluated on admission for special needs related to skin care and additionally, all patients received a weekly skin integrity check performed by licensed personnel. Pressure ulcer (PU)staging definitions as defined by the Resident Assessment Manual and the National Pressure Ulcer advisory panel are as follows: Stage I is intact skin with non-blanchable redness of a localized area; Stage III PU is a full thickness tissue loss. Slough may be present. An unstageable PU is a full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (dead tissue). Further noted in the definitions, a scab and eschar are different both physically and chemically. A scab sits on top of the skin, and forms over exposed wounds. It is a sign of wound healing but does not change the staging of a PU. RESIDENT 76 Resident 76 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented the resident was at risk to develop PUs and she had no unhealed pressure ulcers at Stage I or higher on admission. It further documented that she needed extensive assistance of 2 people for bed mobility and transfers. The MDS assessment dated [DATE] documented the resident was still at risk to develop PUs and now had 1 stage 2 ulcer. The MDS assessment documented the resident had mild cognitive impairment. Review of the initial Data Collection Tool/Nursing Service revealed documentation the resident had a scab over sacral area and a right hip incision, required 2 person assistance to reposition self in bed and experienced numbness and tingling in bilateral feet at night. In the review of the Braden Scale for predicting Pressure Sore Risk dated 11/16/17, she was scored at 14 or moderate risk for developing a PU. It documented the resident had no sensory impairment in contrast to the nursing assessment. The Pressure Ulcer Risk Assessment Tool dated 11/16/17 documented the resident had a predisposing medical condition of chronic renal (kidney) and [MEDICAL CONDITION], with risk factors to include recent surgery, decreased bed/chair mobility, urinary or bowel incontinence, and pain affecting movement or mood. Review of the clinical record revealed 1 blank weekly skin integrity data collection sheet, and one dated for December, 2017 with assessments performed on 12/08/17, 12/13/17, 12/15/17, and 12/29/17. The 12/08/17 assessment documented the right hip incision and right heel wound; 12/13/17 assessment documented Stage I redness to coccyx and right hip incision; 12/15/17 and 12/29/17 assessments documented coccyx, right heel, and right hip incision. The resident Pressure Ulcer Status Record for December, 2017 showed the coccyx ulcer was first observed on 12/15/17, was a stage II with [MEDICATION NAME] tissue bed (pink tissue) measuring 1.75 x1.75 centimeters (cm). On 12/22/17 the wound had increased to 2 x 2 cm with pink tissue bed. On 12/28/17 the wound remained unchanged. On 01/05/18 the wound had deteriorated to a Stage III measuring 2.0 x 2.25 x 0.1 cm with pink tissue and yellow slough in the wound bed. The wound care was changed to clean ulcer and apply [MEDICATION NAME] and cover with [MEDICATION NAME] bordered dressing. The Resident Pressure Ulcer Status Record for December 2017 for the right heel ulcer showed the heel ulcer was first observed on 12/07/17, was a stage II measuring 2.5 x 2.5 cm with a pink wound bed; 12/13/17, 12/22/17 and 12/29/17 showed the wound continued to heal with no deterioration. In the review of the clinical record it showed physician's orders [REDACTED]. Review of the nursing progress notes revealed the following: 11/16/17: reddness on coccyx documented 11/17/17: resident with some confusion 12/07/17: right heel ulcer noted 12/20/17: order for blue boot to right foot 12/21/17: calmo to coccyx, resident complaining of pain at coccyx, encouraged to turn from side to side 12/29/17: got order for ETAFC (extra thick anti-fungal cream) 2 x day for open area on coccyx 12/30/17: some confusion, at baseline 01/02/18: open area on coccyx increased in size, air mattress ordered 01/05/18: coccyx, stage III, slough, dressing procedure changed. Review of the therapy Daily Notes Report dated 12/21/17 documented the resident had a new Roho cushion (for wheelchair) due to posterior skin wound. Review of the Treatment Administration Records (TARS) for November, 2017-December, 2017 showed: 11/22/17: Calmo (cream) to coccyx 2 x day and monitor 12/01/17: monitor scab to coccyx daily until resolved, this is dated 11/16/17 on the December TAR however, this treatment was not found on the November TAR. 12/07/17: heel bridge on bed while in bed to elevate heels 12/13/17: monitor open area on coccyx and surrounding red area, encourage side lying, continue calmo 2 x day 12/20/17: blue boot on right foot and tennis shoe on left foot when out of bed. 12/21/17: apply [MEDICATION NAME] to right heel ulcer and cover, heel cup daily 12/21/17: apply extra thick antifungal cream to coccyx 3 x day until resolved 12/27/17: clean, skin prep, [MEDICATION NAME] to right heel daily and cover with heel cup. The review of the care plan dated 11/16/17 showed an identified problem of PotentialActual alteration in skin integrity relating to right femur (leg/hip) fracture, incontinency, and decreased self-mobility The goals were the resident to have intact skin and surgical wound would heal without complications. Approaches (interventions) included to assist as needed to reposition/shift weight to relieve pressure, complete weekly skin assessments, provide pressure relieving or reduction device (standard mattress and chair cushions used for all residents). On 12/07/17 heel cup was hand written in. The care plan did not identify the coccyx scab vs redness on admit, nor the heel ulcer that developed. No specific interventions related to these skin wounds were documented in the care plan. Additionally, there was no clear directive for frequency of turning or repositioning the resident who required extensive assist to reposition herself. The review of the nurse's assistant (NA) Care Directive with the date of 01/04/18 documented the resident directed to heel bridge on bed/float heels in bed, blue boot to right foot at all times when out of bed, scheduled supine or left side lying and in between meals and elevate legs, use pillows for positioning. Turn every 2 hours was hand written in with no date. There was no date as to when the directives were added. Observations were as follows: 01/08/18 at 09:00 AM: up in WC, boot on 01/08/18 at 10:44 AM: up in WC, boot on 01/08/18 at 2:30 PM: up in WC, boot on 01/09/18 at 08:20 AM: up in WC, boot on 01/09/18 at 10:25 AM: up WC, boot on 01/09/18 at 2:45 PM: up in WC, boot on 01/10/18 at 08:35 AM: up in wheelchair, boot on 01/10/18 at 11:45 AM: up in wheelchair, boot on 01/11/18 at 08:07 AM: up in wheelchair, boot on 01/11/18 at 09:59 AM: up in wheelchair dressed, boot on Multiple observations of the resident sitting up in wheelchair during the day for long periods. There were no observations of staff reminding resident to reposition self in the wheelchair as she sat. On 01/11/18 at 11:40 AM, wound care to the resident's coccyx PU was observed. The wound was approximately 2-3 cm diameter in diameter with yellow slough, loosening some at edges, some pink tissue visible, surrounding skin with some redness. The dressing change was done appropriately except, the nurse did not wash her hands after removing the old dressing and gloves and donning new gloves to put on the new dressing. The right heel ulcer is healed and the resident continues to wear blue boot when up in wheelchair and bridge heels in bed (observed in early morning prior to getting up). In an interview on 01/10/18 at 1:59 PM the resident stated she was doing really good in therapy. The wound on my foot doesn't hurt, but my backside does. Not sure when I got them .few weeks ago? They keep this special boot on my foot now to help. It's getting better, but it still hurts on my tailbone. In an interview on 01/11/18 at 11:15 AM, Staff BB, Nursing Assistant (NA), stated she knew the resident from when she first got to the facility. She didn't have any open areas that I know of. She had just a regular gel cushion in her wheelchair, but I don't think it was enough. She sat up a lot in her wheelchair and she didn't move enough to make a difference. We were floating her heels at first with a pillow but it would flatten and her heels would be on the bed. After she got the ulcer we started using a foam wedge that worked really well. I think she was put on a turn schedule, not sure. In an interview on 01/11/18 at 11:15 AM during the coccyx wound care, Staff AA, Licensed Practical Nurse (LPN) stated she is now on this special air mattress, but she was on the regular mattress like all the residents are on when they admit. They are suppose to be pressure relieving, I don't know. No mattress alone is enough to prevent breakdown though. The residents get put on these special air mattresses after they get a stage 2 or 3 ulcer I think. The wound care was just changed to [MEDICATION NAME] for the sacral ulcer to see if they could get better debridement. The heel ulcer is healed now. In an interview on 01/11/18 at 2:10 PM, Staff K, Registered Nurse/Resident Care Manager (RN/RCM), stated I think everyone is at risk for PUs, but I don't think she was anymore at risk than other residents. She was rated moderate risk on the Braden scale. We use our regular mattress, lotion, skin checks weekly and the braden assessment as prevention for residents at risk. I can't remember if we had added any additional measures in place for her. The calmo (skin barrier cream) lotion was started in November after admit to her coccyx, for a reddened area. I don't remember if it had scab at first or was just reddened. I see that the documentation isn't consistent. We started bridging her heels when she developed the open area. She needed assistance to turn and we tried to turn her few hours, but she didn't always like to turn. When she was asked when residents were switched to a specialty mattress, she stated if resident doesn't like to turn, is having pain, or has more than one pressure area or open area I bring in the Assistant Director of Nursing Services (ADNS) who assesses the resident and decides if a mattress is needed. We used have a skin team, but now I have to ask the ADNS if I have concerns. I am getting better at skin and wound assessment now though. When questioned about the care plan not being comprehensive and addressing the coccyx PU, she replied I thought I had done the one for her hip infection, I can't find it though. I guess I didn't do it. She acknowledged that the care plan had not been updated with the pressure ulcers either. I see that, that should be on the care plan. She was not certain when the turn every 2 hours was added to the care directive. The other directives would have been added when the order was written. The turn every 2 hours must of been written in to clarify (positioning), but I don't know when. We normally don't put residents on a written every 2 hour turn schedule because it is too hard to track. The NAs just know to do it. I will see if I can find it in the computer. (Turn every 2 hours was hand written in.) Also requested weekly skin assessment for November, 2017. No further information was provided to clarify documentation or additional skin assessments given. RESIDENT 48 Resident 48 admitted to the facility on [DATE] with a readmission on 08/06/17 with [DIAGNOSES REDACTED]. The review of the quarterly MDS assessment dated [DATE] documented the resident was limited assist in bed mobility and extensive assist with transfers and dressing. It further documented the resident was at risk for developing pressure ulcers and there were no pressure ulcers present at the time of the assessment. The resident was cognitively intact. The Braden Scale for Predicting Pressure Sore Risk dated 04/17/17 documented the resident scored 20, or at no risk. The scale dated 08/20/17 showed the resident's score had dropped to 15, placing him at risk. The scale documented that he had slightly limited sensory perception, mobility, and decrease in nutritional status (dietary following). The Pressure Ulcer Risk Assessment Tool dated 08/20/17 documented the resident was at increased risk due to chronic renal and [MEDICAL CONDITION], lower extremity [MEDICAL CONDITION], and diabetes. Also, the resident had recent surgery, decreased or impaired bed/chair mobility, and pain that affects movement or mood. The assessment tool dated 04/17/17 documented the only risk factors the resident had were chronic renal and [MEDICAL CONDITIONS], and diabetes, thus showing a decline from April, 2017 to August, 2017. The Initial data Collection Tool/Nursing Service dated 08/06/17 showed no pressure ulcers present on readmission. Resident was alert and oriented x 4, had 1+ lower extremity (LE) [MEDICAL CONDITION] (mild), and required 1 person assist to reposition self in bed. The review of the Weekly Skin Integrity Data collection sheets for September, 2017 showed a pacemaker incision; October documented chronic LE [MEDICAL CONDITION] with a new skin tear and [MEDICAL CONDITION] dated 10/29/17; November had documentation on 11/05, 11/19 and 11/26 which showed no new wounds, and treatment was in progress; December documented the resident now had an open area to right heel and skin was dry with redness. There was no wound description or measurements. The resident continued to have LE [MEDICAL CONDITION]. The review of the Pressure Ulcer Status Record for November, 2017 documented the resident had a new left heel pressure ulcer first observed on 11/21/17 measuring 2 x 2 cm with black base. (The weekly skin assessment documented the ulcer was on the right heel and not assessed on sheet until 12/03/17.) There was no documentation of pain at site until 01/05/18. There was no documentation of the PU stage. The review of the clinical record revealed a podiatry consult note dated 12/04/17 which documented the bilateral feet had absence of hair, skin was thin, shiny, hyperpigmented and cold. Ankle [MEDICAL CONDITION] was noted. Additional review of the clinical record showed a fax cover sheet dated 11/21/17 which documented a 2 m black area on the left inner heel/ankle area had been found. Will apply skin prep BID (2x day), allevyn heel cup at all times and float heels. Further review of record showed nursing progress notes dated 11/21/17 and 11/22/17 which documented there was reported decreased sensitivity of bilateral LEs. The review of the physician's orders [REDACTED]. Review of the TAR's from September, 2017 -December, 2017 revealed wound care for heel, heel cup and to float heels while bed was added on 11/21/17. On 11/30/17 remedy repair cream to LEs, [MEDICATION NAME] to right LE over dressings and TED hose (compression socks) to left LE added on 11/30/17 for [MEDICAL CONDITION]. The review of the care plan revealed the following problems: Potential for alteration in skin integrity: risk for PU due to diabetes, [MEDICAL CONDITION], and kidney disease: initiated 02/13/17. The care plan was updated 11/30/17 with an actual left medial heel ulcer with the goal that the non-stageable pressure ulcer would resolve without complication in 30 days. Approaches (interventions) included to assist to reposition/shift weight to relieve pressure as needed, discuss non-compliance issues with resident and educate about risk factors, pressure relieving mattress (standard), treatments as ordered. The review of the Care Directive to the NAs documented the resident was independent in bed mobility and transfers, needed reminders to turn, to notify nurse of any new areas of skin breakdown noted during bathing or daily care, and TED hose on in AM off at HS. The directive for the black heel bridge to be on the bed to float heels was hand written in on 12/27/17. There was no guidance on how often to remind the resident to turn. Additionally, there was no directive to float heels while in bed added until 12/27/17, five weeks after the PU was first discovered. Further review of the Routine Resident Care and the Care Directive showed no specific instructions to the NAs to apply lotions or creams to help prevent skin breakdown as a routine part of care. On multiple observations of the resident throughout survey, the resident spent most of his day up in his wheelchair, going to meals in the dining room, and in his room on his computer. The special pressure relieving boot was on while resident was up. The resident was not observed while in bed during his midday nap as the resident kept his door closed. On 01/10/18 at 2:16 PM Staff CC, RN, was observed performing wound care. The wound appeared to be about 1.5-2.cm in diameter with about 90% tannish slough at wound base with some pink tissue visible with no surrounding redness. The wound was cleansed and [MEDICATION NAME] applied per the physcian's order. The dressing was applied correctly. There were no breaks in infection control practices observed during the wound care procedure. The resident did not express any pain during the procedure. In an interview on 01/03/18 at 11:00 AM the resident stated I got this pressure ulcer from this facility about 2 months ago. I am suppose to go to the wound clinic to find out what happened. They are using a wedge now. The resident said that he came to this facility from another facility and about 8 months after he admitted he developed this pressure sore on his right heel. He went on to state that it takes a long wait to have someone answer his light. He said he encountered the problem mostly at night when he was in bed. He explained that when he calls for help it takes a long while to get someone to come in. In an interview on 01/10/17 at 10:50 AM Staff AA, LPN, stated that every mattress in the facility is a standard pressure reducing mattress. She was not sure what type it was. In an interview on 01/10/17 at 10:55 Staff F, LPN/RCM stated the resident had the standard pressure reducing mattress but no other pressure relieving measures had been started as he was independent in bed mobility. We did weekly skin checks and quarterly the Bradens. He does have diabetes, [MEDICAL CONDITION] and [MEDICAL CONDITION] that increase his risk, but he has no loss of sensation in his LEs. He loves to lie on his side and was resistant to turn. He was not on a turn schedule as he is independent in bed. He now has a heel cup, wedge, bilateral boots while in bed, and a transfer boot with tread for when he is up in the wheelchair to keep the pressure of that heel. In an interview on 01/11/18 at 1:30 PM Staff DD (NA), stated she had worked with the resident quite a bit. She stated that he was independent in bed mobility, he can move pretty well around in bed on his own. He didn't have anything special like boots or anything before he got the ulcer that I know of. Now he does. I think he can feel his feet but not sure how much. In an interview on 01/11/18 at 1:35 PM the resident stated I don't know how I got this wound. They found it in the shower and the aide let the nurse know. I didn't know it was there. I have diabetes, my feet are numb so I really can't feel anything. Maybe a little bit, not much. I don't really feel much when they change the dressing. I hope it is healing. I have a special wedge now to keep the pressure off that heel, didn't have anything done before. In an interview on 01/11/18 at 2:30 PM Staff F replied when told the resident had stated he had numbness in his feet, well he does have sensation when we assess, he feels it when we change the dressing. We found it while he was in the shower, but he was saying it was sore when we found it. I don't know why it's documented in the progress notes he has decreased sensation. His sensation may vary, go up and down or change a bit, but he can feel. In an interview on 01/12/18 at 8:30 AM Staff F also acknowledged the documentation of the staging and location of the PU was not complete and not accurate (the weekly skin assessment documented the PU on the right heel and the pressure ulcer status record documented it on the left heel). The review of the clinical record revealed no education done with the resident concerning the risks of not turning off his side. Requested additional information if available. No further information provided. In summary the facility failed to accurately assess, identify risk factors and aggressively implement pressure relieving measures when increased risk factors were identified. The facility additionally failed to provide aggressive treatment to prevent the deterioration of an existing pressure ulcer. Reference: WAC 388-97-1060(3)(b)

Based on interview and record review, the facility failed to actively and consistently provide medically-related social services to attain the highest level of mental and psychosocial well-being for 2 of 2 residents (15 & 9) reviewed for behavioral impact/incompatibility issues that affected their relationship, living conditions and activity participation. Failure: to assess documented behavioral issues to determine impact on other residents, to consistently advocate for the residents, and to consider/attempt a multidisciplinary approach to ongoing behavioral issues caused harm to Resident 15 when she suffered disrupted sleep patterns, emotional distress and decreased activity participation due to Resident 9's long-term (> 1 year) behavioral problems. Resident 9 was harmed when the facility failed to consistently and accurately monitor and document her behaviors, and to try to find an effective resolution to her care needs, resulting in ongoing crying-out and calling-out. Findings included: RESIDENT 9 The resident admitted to the facility in 2016. Review of her Minimum Data Set (MDS) assessment, dated 12/27/17, revealed she did not have any cognitive impairment. The MDS indicated the resident had behaviors, but the facility coded that her behaviors did not significantly intrude on the privacy or activity of others, and that the behaviors did not significantly disrupt care or living environment. The MDS also indicated she required extensive assist with bed mobility, transfers, locomotion on/off unit, dressing, toilet use and personal hygiene. Review of Resident 9's Care Plan revealed a problem Behavior problem, socially inappropriate, as evidenced by hollering/calling out when needing something . The associated Goal was Resident will not harm themselves or others secondary to their behaviors . One of the care planned Approaches to this problem was Resident yells out when she needs something and has not been responded to in a timely manner. The onset date for the problem was 07/05/16. Review of Resident 9's behavior monitoring forms from 09/01/17 - 01/11/18, revealed 69 shifts (either day/evening/night) where there were documented behaviors of calling-out. The facility was not following the instructions on the form which stated to enter # of behavior episodes, and the facility was mostly putting + and not a number. There were 15 shifts with no documentation at all. Of the 69 shifts with documented behaviors, there were 32 times where the behavior was unchanged after an intervention. There were 14 times documented where the behavior was worsened after the intervention. Due to the lack of consistency in documentation, it was impossible to determine the extent or number of times calling-out had happened during the time period reviewed. Review of a quarterly social services progress note for Resident 9, dated 10/04/17, revealed She continues to call out multiple times often for her call light or to use the bathroom. There was no documentation social services assessed the impact the resident's behaviors had on other residents, even though that was a care plan goal of not harming others due to her behaviors. Review of a quarterly social services progress note for Resident 9, dated 01/03/18, revealed Resident most often calling out when she has a need that she perceives is immediate and she does not get a quick enough response from staff, but behavior/anxiety is reduced when need is met. There was no documentation social services assessed the impact the resident's behaviors had on other residents, even though that was a care plan goal of not harming others due to her behaviors. Review of Resident 9's Behavior/Intervention Monthly Flow Records from 09/22/16 - 01/11/18 (excluding August 2017) for all shifts (day/evening/nights) revealed: 286 shifts (shifts, not #'s) with documented behaviors of crying out or calling out related to her anxiety and depression. 30 shifts with no documentation at all. Due to staff not following instructions on the forms (to document # of Behavior Episodes) and putting a + instead of a #, unable to accurately determine the number of episodes of crying out or calling out. RESIDENT 15 The resident originally admitted to the facility in 2016. Review of her MDS assessment, dated 10/09/17, revealed she did not have any cognitive impairment. In an interview on 01/03/18 at 1:24 PM, Resident 15 stated the Administrator had discouraged her from going to activities because he told her she was mocking another resident (Resident 9) that made a lot of noise. She stated the Administrator had suggested to her that she would be happier at another facility, the resident was observed tearing up, she said she used to like to go to group activities and she had went a lot. In an interview on 01/08/18 at 1:28 PM, Resident 15 stated Resident 9's behaviors of calling-out caused her sleep problems every night and sometimes in the evenings and she felt sleep-deprived. In an interview on 01/10/18 at 8:21 AM Resident 9 stated I get anxious at night sometimes, I put my call light on, but it takes a long time for them to come, so I call out for help. I'm afraid the call light won't work so I call for help. In an interview on 01/09/18 at 9:50 AM, Resident 15 stated she didn't go to a lot of activities because she didn't like her neighbor (Resident 9). She didn't behave well, so she was difficult to be around. She said her neighbor screamed a lot from her room and she called out loudly all night long. She was especially loud from 2:00 AM - 6:00 AM and this had been going on for months. She started crying and said she did not think there was a solution. She said her solution was to not go to activities and to try to keep her mouth shut. In an interview on 01/09/18 at 10:05 AM, Staff M, Activities Director, stated Resident 15 didn't come to Cribbage anymore, Resident 15 has a conflict with another resident (Resident 9) and if she is there, she will not attend. She stated that it was nothing that is a problem, it is just a preference. She stated I know they have talked to social services and they are both adults, It is just personalities, there was not an incident, it is just a personality conflict. Staff M was asked for documentation how the facility had attempted to resolve the problem, she stated she talked to social services about it, but they didn't take it to nursing because she said Resident 15 didn't want it to go to nursing. Staff M did not know if the Administrator was aware of the problem, then she added she didn't remember if social services was involved or not. In an interview on 01/09/18 at 10:31 AM, Staff L, Social Services Director, stated she thought the conflict might be because of Resident 9's behavior and them being neighbors. She stated they had offered Resident 15 mental health services, but she declined. Staff L stated She (Resident 15) has become more self-isolating lately, so she doesn't do as many activities as she used to. Resident 9 is a tough one . It sounds like she (Resident 9) has changed in the last year, I think I'm going to have to look at this, I put this on my list to do. Staff L stated Resident 9 has some calling out issues when she has urgency with needs and she is fearful that people aren't going to come, and this at times has irritated Resident 15, I don't get why she (Resident 15) isn't going to things (activities) because of Resident 9. In an interview on 01/09/18 at 10:49 AM, the Administrator stated the activities department had given Resident 15 some in-room things to do, and that his understanding was that Resident 15 didn't want to go to activities because she didn't get along with Resident 9. The Administrator stated it's mostly been handled from an activities standpoint, and they've given her things to do in her room. He stated Resident 9 doesn't know Resident 15 doesn't like her, and we didn't want to cause Resident 9 any psychosocial harm by bringing it up. The Administrator was asked what the issue was between the two residents, he stated I'm not sure. The Administrator was asked if he knew about a noise issue between the two residents, he stated he now remembered the issue which he thought was about a month ago. In a joint review, a blue Concern & Comment Form (facility grievance form), dated 10/02/17, was reviewed with the Administrator. Review of the Blue Concern & Comment Form, revealed the person reporting the concern was the Administrator. The form asked the concerned individual to Please describe in detail your Concern, Comment, or Commendation. The Administrator wrote Staff member (no name listed) reported that Resident 15 made a comment about her neighbor using her call light instead of calling out. The form question Was a staff member able to resolve the concern at the time it was shared? was left blank, there was no documentation the concern was resolved. The documented actions taken to Resolve/Respond to concern were Offered room move away from (Resident 9's room) and Resident 15 declined. Review of Resident 15's clinical record revealed no documentation the Administrator had documented any issues related to the Concern & Comment Form concerns, and there was no documentation the Administrator had made a referral to social services or nursing to assist with resolving the issue. Review of a facility incident investigation report, dated 01/09/18, revealed It appears that she (Resident 15) has had life events in which has made her emotionally fragile to which she will cry easily or anger. This is demonstrated by interactions with people regarding situations she is uncomfortable with and she will demonstrate avoidance. Review of Resident 15's Individual Resident Daily Participation Records revealed Bingo and/or PoKeeNo attendance as follows: March 2017 - Attended 12 times, 1 refusal April 2017 - Attended 12 times, 0 refusals May 2017 - Attended 8 times, 1 refusal June 2017 - Attended 3 times, 0 refusals July 2017 - Attended 3 times, 3 refusals August 2017 - Attended 10 times, 0 refusals September 2017 - Attended 8 times, 1 refusal October 2017 - Attended 1 time, 1 refusal November 2017 - Attended 0 times, 2 refusals December 2017 - Attended 0 times, 1 refusal 01/01/18 - 01/08/18 - Attended 0 times, 1 refusal Review of Resident 15's progress notes revealed a social services entry, dated 10/11/17, she does however get upset at times with other residents who do call out as she finds it disruptive. Review of Resident 15's progress notes revealed an activities entry, dated 10/12/17, Resident still becomes tearful at times and gets frustrated with other residents calling out. Review of Resident 15's progress notes revealed an activity entry, dated 01/09/18, Res (resident) has had a decline in bingo/game participation in the last quarter. When AD (Activity Director) asked resident about this on 01/09/18 resident stated it was because there are some people she does not want to be around .I know enough about myself that I just shouldn't be around her .Resident stated that this is her issue, that she has been offered a room move, to which she declined .Res did become tearful, stating she is ashamed of her own behavior. In an interview on 01/11/18 at 8:57 AM, Staff K, Registered Nurse/Resident Care Manager, was asked how the facility monitored other residents for harm related to Resident 9' care plan problem: Behavior problem, socially inappropriate, as evidenced by hollering/calling out when needing something, and the goal of Resident will not harm themselves or others secondary to their behaviors. Staff K stated I don't make these care plans (behavior care plans), social services does that. I'm not sure they would want to make a goal of no calling out because that is not a feasible goal for her because it is more related to how her needs are being met. Staff K was asked if the facility was aware of noise or calling out complaints by either resident, Staff K stated Yes, .that came to light just since you guys have come to the survey, we have added that to Resident 15's care plan. Staff K stated There have been a couple of incidents where other residents were near her (Resident 9) and we ended up moving them so they would not have to listen to her . We jointly reviewed Resident 9's care plan and behavior monitoring forms that indicated a long-term problem, Staff K stated Maybe with all of this going on, maybe Resident 15 will come to the realization she needs to move . In an interview on 01/11/18 at 10:04 AM, Staff L, Social Services Director, stated Resident 15 is upset about all of the calling out. Staff L was asked if the noise issue was ever resolved, she stated I think it still occasionally occurs, but I don't think it is as frequent as it used to (be). Even now if you sat here and listened, you would hear her calling out a half a dozen times a day. Staff L stated Resident 15 was offered a room change on 10/02/17 because of all of the calling out, they had offered her to go back to another shared room which she had declined because she liked a private room and she liked to have her things out. Staff L added there would not have been enough room for her because she needs a lift to get her in and out of bed and the private rooms they had, other than where she was currently at, were too small. She said Resident 15 had previously been in a shared room, but that didn't work out because Resident 15 felt people were traipsing through her space, and that they had even put a sign on the door to knock before entering because her roommates' family members would just walk in the room without knocking. Staff L was asked if the facility had ever considered how all of this calling out had affected other residents in the nearby rooms, Staff L stated I would like to think we would. Staff L reviewed the care plan and behavior monitoring forms for Resident 9 and was unable to provide any information about the missing/inaccurate documentation. Staff L was asked if she thought it was a dignified existence if a resident was unable to sleep due to the noise and calling out of another resident, Staff L stated Is it perfect, No, do we try to figure out what is going on, Yes, I'm going to look into this, I just wrote it down, obviously it is still going on. In an interview on 01/11/18 at 1:28 PM, Resident 15 stated staff had been talking to her all day about her problems, then at night it is scream, scream scream. She said she wished she could just get some sleep. She said last night it had got so loud, she decided to hit the wall between the rooms with her reacher, she said after she would hit the wall, her neighbor would wait for a while and then start screaming some more. She said the noise had been better since the surveyors were there but it is still not right. Resident 15 stated I am feeling tired right now, I'm not worried about safety, I am exhausted, I can't get any sleep. I feel like I am stirring up a pot. The resident stated she was offered a room change, but other than the room she was in, there wasn't a room big enough here (at the facility) for me, so I don't have any options. She was asked about her relationship with Resident 9, to which she stated It's not that I don't like her, I'm sure she's a good person (resident was observed tearing up), but she is disrupting my life, so it's hard to be around her, I was just trying to ask her why she couldn't use her call light like everyone else, then it wouldn't be so disruptive and I could sleep, I couldn't get anyone that works here to help me, then I got in trouble. The resident then stated she didn't think she should have to move out of her room because her neighbor had bad behaviors. In an interview on 01/12/18 at 8:49 AM, Resident 15 indicated the noise issues had been going on since she and Resident 9 had become next-door neighbors. She said she had previously been in a different room in the facility but it did not meet her needs, which is why she was moved to her current room. She said she was trying to settle into her room long-term because she did not have any options to go to a lesser care facility due to her care needs. She said the calling-out by her neighbor had continued last night. She said it had gotten so bad that she heard a male resident yell out Shut up, shut up, shut up whenever Resident 9 started calling out. She said she did not feel it was right to ask her to move because her neighbor had bad behaviors of calling out at all hours. She said I know I have a quite a bit of personal belongings, but this is my home as I recently was forced to sell my mobile home. I don't intend to infringe upon my neighbor's rights, but my rights are important to me too. I've been very upset .I like the staff, but the people in charge don't know how to solve our problems. Review of Daily Bed Census Reports revealed Resident 9 and Resident 15 became next-door neighbors in September 2016. Facility staff failed to advocate for either Resident 9 or 15. They did not advocate for Resident 9 when they failed to accurately and consistently monitor and document her behaviors and they did not assess and analyze her behaviors for the impact they had on other residents, even though this had been identified as a care-planned problem. Facility staff also failed Resident 9 when they did not continue to find alternative, effective resolutions to her long-term and ongoing behavioral problems. A reasonable person would want to know if their behaviors were negatively affecting their relationship with their neighbor. A reasonable person also would not want to have to cry out or call out at all hours to try to get help getting their needs met. Facility staff failed to advocate for Resident 15 by not assessing her for the impact her neighbor's behaviors were having on her life. Resident 15 described a situation where she was unable to have a dignified existence in the facility, she confronted another resident when she could not obtain staff assistance, then after that incident and an interaction with the Administrator, she self-isolated to her room with staff knowledge and a staff failure to try to resolve her issues. Resident 15 then found it necessary to physically act out by banging on the wall between the resident's rooms with her reacher. There were also at least two other residents that facility staff reported had to be moved due to the noise disturbances of Resident 9 Reference: (WAC) 388-97-0960 (1) Refer to: CFR 483.10, F-550 - Resident rights/exercise of rights CFR 483.10(i), F-584 - Safe, clean, comfortable, homelike environment CFR 483.10(j), F-585 - Grievances CFR 483.35(a), F-725 - Sufficient nursing staff CFR 483.45(c), F-758 - Free from unnecessary [MEDICAL CONDITION] Meds/PRN use

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 3 residents (1 & 2) reviewed for falls. Failure to implement adequate supervision, consistent with residents' needs & care plan, and monitor the effectiveness of the interventions and modify the interventions to the residents' individualized needs resulted in harm for Resident 1 & 2 having falls with fractures. Findings included: RESIDENT 1 Resident 1 admitted to the facility in October 2017 with [DIAGNOSES REDACTED]. An admission note indicated the resident had, severe STML and was transiently alert & oriented x 1-2 (person-place); often forgetting what has just been said or what she has just said in preceding moment. An admission fall risk evaluation identified the resident as being at risk for falls. An initial interim written plan of care (P(NAME)) for falls, dated 10/16/17, listed interventions of 1 person assist with transfers and ambulation, encourage use of proper footwear, and low bed. The written care plan for mobility & safety included fall risk assessment, safety measures to reduce fall risk, remind resident & reinforce safety awareness-lock brakes on bed/wheelchair before transferring, educate/remind resident to request assistance prior to ambulation, appropriate footwear. Review of progress notes from 10/21/17 - 10/23/17 showed the resident was confused, and needed redirection & frequent reminders not to ambulate or get up by self. On 10/23/17 at 5:24 pm, the resident had an unwitnessed fall and was found sitting on the floor by her bed in her room. Staff assessed her as being without injury. Facility documentation indicated the resident had been last seen lying in bed. The care plan was revised to include bed in low position, bilateral floor mats next to the bed, and to educate as needed/remind the resident to request assistance prior to ambulation. Progress notes from 10/25/17 - 10/27/17 showed the resident needed frequent reminders not to get up by self and required close supervision when in wheelchair. On 10/28/17 at 4:30 pm, a nursing assistant (NA) placed Resident 1, sitting in her wheelchair, in the hall just outside her room. The NA left to answer call lights. Shortly afterwards, another NA passed by & found the Resident 1 sitting on the floor between the medicine cart & wheelchair. The resident was assessed as having no injuries. Another fall risk evaluation was done on 10/28/17 and listed the following interventions: nonskid socks, call light in reach, low bed, floor mats, & added, Do not leave (resident) alone while in wheelchair. Facility documentation indicated the wheelchair brakes were not locked. The P(NAME) was revised to include instructions for staff: Do not leave (Resident 1) unattended/alone in room while up in wheelchair, park in populated area; and to have therapy assess the resident for an anti-rollback braking system for her wheelchair (ordered on 10/30). The P(NAME) did not indicate whether staff were to ensure wheelchair brakes were locked when parking the resident in a populated area. During an interview on 12/19/17 at 11:20 AM with Staff A, resident care nurse manager, stated that she wouldn't expect staff to lock wheelchair brakes when parking a resident in the hall because that would be a restraint and that Resident 1 was able to self-propel some. Review of progress notes for 10/29/17 day shift indicated, Safety plan appropriate as resident sits in common area when not resting .& reminders to stay in chair. On 10/30/17 on day shift , it was noted the resident did not consistently call for assistance and that the resident did not complain of pain, but was observed to wince in pain when being raised up in bed, had a hard time rolling over, and initially refused to get out of bed. Later that day after dinner, a restorative aide placed the resident, sitting in her wheelchair, in the hall next to a nurse's medication cart & the doorway of an empty resident room. At 5:40 pm, another staff answered a call-lite & found the resident in the empty room on the floor lying on her left side, complaining of L leg & hip pain. X-ray results revealed a left [MEDICAL CONDITION]. Although Resident 1 was parked in the hall as per the P(NAME), there was no indication there were staff consistently present to adequately/visually supervise the resident (who was known to have severe STML) to prevent another unwitnessed fall from her wheelchair. After this third fall, another fall risk evaluation was done and the following intervention were added to the P(NAME): Educate restorative staff to not leave resident alone when in wheelchair after resident eats meals, education to staff, frequent checks. During an interview on 12/19/17 at 11:20 AM, Staff A, said that Resident 1 did not seem to know that it was not safe to get up, The resident needed reminders, but didn't seem to remember things, more so in the evening. Staff A stated that they were fully staffed on the evening shift of 10/30/17, and that the resident was unsupervised in the hallway for only a brief amount of time, The NACs were in with a resident requiring 2-person assist and the nurse had walked away from her cart to do something. In that short time, the resident must have wheeled herself from the hall into the room, must have got up, and fell . When asked about the facility's post incident investigative process, Staff A stated that their process was to gather information after a fall so as to figure out what happened and what other interventions might help to prevent it from happening again, I don't know if one on one (staff supervision of Resident 1) would have been an (intervention) option. RESIDENT 2 Resident 2 admitted to the facility in October 2017 with [DIAGNOSES REDACTED]. According to hospital discharge documentation, Resident 2 had been on a fall prevention plan while at the hospital that included interventions of safety checks, nonskid shoes & personal alarm. Resident 2's admission fall risk evaluation identified her as being at risk for falls. The admission interim care plan dated 10/15/17 identified Resident 2 as being at risk for falls due to unsteady ambulation & recent falls, and initiated interventions to: ensure proper footwear, 1-2 person assist with transfers and ambulating, & orient resident to use of call light use/room. It did not include visual safety checks. A care directive for dated 10/16/17, containing Resident 2's individual care information for use by staff, indicated the resident had very dramatic mood swings with highs & lows in her energy level. The care directive did not inform staff that the resident was a fall risk. A physical therapy evaluation dated 10/16/17 showed the resident was oriented to place only, anxious, able to follow one-step directions some of the time, was at high risk for falling, had poor standing balance with inability to stand without support, and significantly impaired memory & safety awareness. Progress notes from 10/16/17 -10/19/17 showed Resident 2 was alert & confused, could not consistently demonstrate use of the call light, had periods of anxiety, required one-person assist with transfers, and was working with therapy for strengthening. On 10/20/17, a progress note indicated that the resident got anxious when in her room & therefore staff placed the resident in a common area. On 10/22/17, the resident was on alert related to a new skin tear (ST) on her left (L) elbow. The progress note revealed, She is anxious & that is the reason she got injury on L elbow. A Physician Assistant then wrote an order for [REDACTED]. During an interview on 12/19/17 at 12:30 PM with Staff B, a resident care manager, Staff B stated that the resident did not sustain a new L elbow ST on 12/22/17 as the resident admitted with the ST on the L elbow. The RCM stated the resident's cognition varied a lot in that the resident seemed quite alert at times, and then not. Staff B could not recall how the resident's anxiety specifically exhibited, as in whether it manifested as frequent standing up without assist, calling out, etc., but acknowledged that the intervention of engaging Resident 1 with an activity to keep her occupied/distracted/less anxious was found to be not very effective. On 10/23/17, the resident was confused, got up & ambulated without assist several times, & staff redirected her to either sit in wheelchair or go back to bed. On 10/23/17 at 5:13 PM, the resident was again confused and got up several times without assist. Staff redirected Resident 2 back to wheelchair or bed, and staff tried to engage her in activities. Staff also discovered a dark purple hematoma, 5 centimeter (cm) x 5 cm x 1.5 cm, on the back of Resident 2's right leg that staff surmised was related to bumping her leg on edge of bed or wheelchair. There was a written P(NAME) related to antianxiety medication with interventions listed to give as ordered, monitor behavior every shift. The 10/23/17 P(NAME) for mood included report changes in mood & behavior to social service (SS) prn (as needed); SS to provide 1:1 for support prn; offer/encourage activities to distract resident when noted to get anxious. On 10/24/17 at 4:22 PM, a progress note indicated Resident 1 had anxiety, and engaged in activities, but still tried to get up by self & walk. Then on 10/24/17, documentation showed that Resident 2 had an unwitnessed fall at 9:00 PM while getting out of the wheelchair. The resident was found alert, confused, sitting on floor against the bed in her room with a large skin tear on her left upper arm (15 cm) and a lump (6 cm x 6 cm x 1 cm) at the posterior rib area. There was no pain upon palpation of the area & ice applied, within 2 minutes of leaving room after getting resident comfortable in bed, patient found trying to get out of bed. A Physician Assistant note dated 10/24/17 noted the resident required close supervision because staff had seen the resident ambulating independently in room. The resident's fall P(NAME) interventions included: remind resident and reinforce safety awareness to request assist prior to ambulation, nonskid socks, call light in reach, & on 10/24/17 added: low bed. It did not include closer supervision and/or frequent visual checks. On 10/25/17, a medical provider wrote orders for a chest & left rib x-ray to rule out fracture from fall, and that the patient (Resident 2) needs to be on fall precautions. On 10/25/17 night shift, it was noted that Resident 2 did not complain of pain, made no attempts to get of bed, and that the head of bed was raised up slightly for comfort. On 10/25/17 day shift, staff monitored the resident's oxygen saturation (O2Sat) level and noted the O2 Sat was 88% on room air. The resident was encouraged to cough .O2 Sat remained below 88%, and licensed staff applied 2 Liters of oxygen. Later, the O2Sat improved to 93% on room air. The note also indicated, Safety plan appropriate & in place. It did not indicate the specific safety plan interventions. A handwritten progress note on 10/25/17 also noted the O2Sat level of 88% that did not improve with deep breathing exercises, and that Resident 2 had a pain rating of 7 out of 10 in the L lateral posterior lower rib cage. On 10/26/17, progress notes showed that Resident 2 was slightly restless, complaining of back pain, and noted the facility had an appropriate safety plan for Resident 2 with reminders to wait for help before getting up and low bed. Her O2Sat improved. A Physician assistant note dated 10/26/17 noted the resident was a high fall risk given underlying dementia & impulsivity. On 10/27/17 at 12:14 AM, a progress note indicated the resident had rib pain, and that the x-ray showed two left lateral (side) rib fractures (#5 & 6). Staff medicated the resident for anxiety & noted Resident 2 attempted multiple times to get out of low bed. A later note at 4:55 PM showed that the resident was, on alert for fall, she had fall, no new problem noted. During an interview on 12/20/17 at 1:00 PM with Staff C, Assistant Director of Nursing, stated that the (4:55 PM) note was not clear, as the resident did not have a fall on 10/27/17. Staff revised the written P(NAME) on 10/27/17 for increased fall risk to include a lipped mattress (then discontinued), soft touch call light, and fall mats. The P(NAME) indicated that staff should provide the amount of supervision that was needed, but did not specify the amount necessary to meet Resident 2's individual needs, such as closer supervision and/or frequent visual checks. A physician's note of 10/27/17 noted staff report the resident was forgetful with poor concentration, and her attention wanders too much. On 10/28/17 at 3:49 PM, a Left hip x-ray was done (negative for fracture). The day shift note indicated the resident denied having pain, had no anxiety or attempts to get out of bed/wheelchair and the bed was in low position. Then at 4:00 PM, Resident 2 had another fall. An NA heard the resident calling out, and found Resident 2 sitting with her back next to bed. Bed was in low position. Nursing noted the resident did not have any skin integrity issues related to the fall, but did complain of pain off & on throughout the evening. The resident had no SOB or no increased anxiety. During an interview on 12/19/17 at 12:30 PM with Staff B, Staff B stated that keeping the resident out in the hall did not work because she would just wheel herself back in the room. (Resident 2) would frequently try to get up at times .mostly on evening shift. We were doing more than what was written in the nurses' notes. The nurses not only reminded the resident to not stand up, but the nurses would often park their medicine cart by her door to keep a better eye on her. Further progress note review for 10/29/17 at 7:08 AM, showed the resident did not attempt to self-transfer. Bruising was noted to the L side rib cage & the physician assistant updated. Later on 10/29/17, a progress note indicated Resident 2 was weak in arms & legs, and slept the whole shift except for meals. At 1:30 pm, the resident's O2 Saturation level dropped to 84% on room air, placed on oxygen, and then staff sent Resident 2 to hospital emergency room . Hospital records dated 10/29/17 showed Resident 2 was found to have multiple lateral rib fractures L ribs #6,7,8, and posterior L rib fractures #7,8,9,10. The resident was diagnosed with [REDACTED]. The resident also had a large Left pleural effusion (excess fluid around lungs) with a collapse of the majority of Left lung, and a Left pelvic fracture. The facility failed to provided enough supervision for two residents who had cognitive deficits to prevent avoidable accidents that resulted in harm for both residents.

Based on interview and record review, the facility failed to perform the necessary assessments, thoroughly communicate with the physician and provide care or treatments in response to changes in the condition for 1 of 7 sampled residents (1). Failure to consistently and thoroughly identify, assess, communicate information regarding the resident's condition, and/or act timely on condition changes for a resident with known [MEDICAL CONDITION] contributed to Resident 1 having further deterioration in his physical condition, hospitalization , and death. Findings include: Resident 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The physician admission visit note dated [DATE] documented the resident also had a history of [REDACTED]. The clinical record showed that from [DATE] to [DATE], the resident had frequent complaints of indigestion, with no evidence that staff thoroughly assessed the resident to determine the nature or cause of the pain. Review of a progress note dated [DATE] indicated the resident had a pain. The note did not specify the location of the pain. The note also indicated the resident had an episode of chest pain (CP), but did not describe the CP location, whether the CP was throughout the chest area or localized. It did not include CP duration (length of time) or include a description of the CP (sharp, dull, etc.) There was no documented evidence that the information regarding the chest pain episode was communicated to the physician for consultation or the family. A evening shift progress note for [DATE] documented Resident 1 complained of severe GI (gastro-intestinal) upset including burning in his chest. The note indicated his vital signs were stable. The note did not document that the resident had nausea nor did it document further in-depth assessment of the GI upset/burning in chest to include: the specific time(s) when the resident had symptoms, duration, location, and any precipitating factors for both the GI upset & burning chest discomfort. A fax dated [DATE] was sent to the physician and read the resident complained of nausea and decreased appetite. The Licensed Nurse requested the MD to please advise. The fax did not communicate all possibly relevant information to the physician, particularly regarding Resident 1's cardiac history, severe GI upset, burning in chest, or vital signs. There was no documented evidence a licensed nurse attempted to first call the physician for timely communication of a thorough assessment, with an in-depth description of the resident's symptoms or what the and overall condition was at that time. Progress notes showed there was no documented evidence of ongoing monitoring of the resident's condition during the night shift between ,[DATE] - ,[DATE] even though the physician had been contacted. A progress note dated [DATE], indicated Resident 1 had frequent indigestion, the note did not reveal when the indigestion occurred or whether the indigestion was associated with eating food and/or medications. In addition there was no analysis that since the indigestion had occurred so frequently that staff had assessed if there was another cause for the pain which presented as indigestion. A nurse's note dated [DATE] noted the resident, continued to have frequent indigestion, despite receiving TUMS for acid reflux. The resident reported belching relieved the discomfort along with positioning in upright position. The note indicated the resident had bowel sounds and no abdominal tenderness, and that the resident denied being short of breath, dizzy, having nausea/vomiting, but did report the pain as sharp. The note did not indicate the location or duration of the sharp pain. Even though the facility staff had knowledge of Resident 1's prior episodes of chest pain ([DATE]) and complaint of burning in his chest ([DATE]) along with a known history of [MEDICAL CONDITION] & cardiac procedures, there was no documented evidence in the chart that the licensed nurse(s) communicated with the physician regarding the resident's condition change with sharp pain on [DATE]. A nursing note dated [DATE] indicated Resident 1 did not complain of GI distress during day shift but on the evening shift a nursing note indicated the resident had a blood pressure of ,[DATE]. There was no indication or assessment if the blood pressure was low for the resident compared to other blood pressures. A daily physical therapy assistant (PTA) note dated [DATE] indicated the resident had increased lethargy and initially declined therapy due to fatigue. His blood pressure was ,[DATE]. During a second PT session, it was documented the resident's physician was notified the low BP reading and the resident's complaints of stomach pains yesterday and today. The resident's medical record showed a physician ' s note for the same day. The note did not list pain, indigestion, nausea, and/or burning in chest in the current problems or staff concerns, exam, or assessment/plan sections, and indicated the resident's BP was ,[DATE]. A nurse progress note on [DATE] at 11:25 am revealed the resident complained of general, all over pain that morning. The physician was notified and orders were received for a chest x-ray (for increased pain), as soon as possible along with blood and urine tests, and a new prn narcotic pain medication was added. The [DATE] pain flow sheet showed the resident received a dose of the pain medication for all over general pain with a pain intensity level of ,[DATE]. (Zero being no pain and 10 being the worst pain.) He reported his pain level 15 minutes after the pain medication remained at ,[DATE], and then was ,[DATE] after 30 minutes, ,[DATE] after 1 hour, and ,[DATE] after 3 hours. A PTA note on [DATE] indicated the resident declined therapy in afternoon due to c/o nausea & fatigue. A evening shift progress note for the same day indicated Resident 1 reported his pain level as, ,[DATE] with anxiety and he was becoming restless. The pain flow sheet revealed on [DATE] at 4 pm a dose of the narcotic pain medication was administered for general pain with a pain intensity level of ,[DATE], decreasing to ,[DATE] after 15 minutes, ,[DATE] after 30 minutes, and ,[DATE] after 1 hour. A pain assessment form was completed at 6 pm which revealed the resident was currently in pain, as related to noted changes in body language, facial expression and behavior. There was no documented evidence that the resident's physician was informed of the evening nurse's assessment(s) related to the new observed changes in behavior, body language or anxiety with restlessness associated with an increase in his pain intensity of ,[DATE]. There was no nurse documentation for the Night shift of [DATE] to indicate continued monitoring of Resident 1 related to the earlier significant change in condition, new physician orders, initiation of a new narcotic medication, and new onset behavioral symptoms. The next nursing progress note was on [DATE] at 2:57 pm which noted a family member wanted Resident 1 to be sent to a hospital for evaluation. It noted when the transport arrived, the resident had a very low BP reading of ,[DATE] whereby 911 transported the resident to the emergency room . Review of the hospital documentation for [DATE] indicated Resident 1 presented with chest pain. It noted the resident had been experiencing constant sharp chest pain for the last 3 days that radiated to his back. The hospital physician note described the resident as appearing ill & BP remained significantly decreased at ,[DATE]. The resident was described as being in an unstable condition with test results indicative of cardiogenic shock, [MEDICAL CONDITION], and blood clots in the lungs. The resident's condition deteriorated and then later the documentation noted the resident as deceased . During an interview with licensed staff on [DATE] at approximately 3:20 pm, LN1 was asked about the procedure for notifying a physician of any changes in a resident's condition. LN1 said it would depend on the physician. For (Resident 1's) physician, she said the procedure would be to call, We call the answering service, and then he calls back. LN1 indicated faxing the physician was an option, but said she would call the physician rather than sending a fax when there was a real change in a resident's condition. The staff indicated the physician came to the facility several days a week to see residents, but did not have a specific onsite visit schedule. During an interview on [DATE], with the facility administrator, Director of Nursing, and Assistant Director of Nursing, they did not provide any additional information in regards to timeliness & completeness of communication to include thorough assessment information the resident's significant changes (eg. chest pain) in condition to Resident 1's physician and family.

Based on observation, interview and record review the facility failed to prevent an accident for 1 of 3 residents (1). Failure to prevent accidents for Resident 1 resulted in harm of a fracture. These failures placed the resident at risk for injury, increased discomfort, and/or potential health complications. Findings Include: Resident 1 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) an assessment, dated 09/04/15, indicated the resident had severe impaired cognition and he was assessed as needing two plus persons to physically assist the resident for bed mobility. The MDS is part of the Resident Assessment Instrument (RAI), a tool used to identify the resident's funtional capacity and health status. In addition the results of the RAI are used to develop the plan of care. The MDS assessment, describes Bed Mobility as how a resident moves to and from lying position, turns side to side, and positions the body while in bed or alternate sleep furniture. The MDS dated [DATE]/04/15 had also assessed Resident 1's bed mobility as a two plus persons physical assist. The Care Area Assessment (CAA is part of the RAI process) dated 06/04/15 stated the resident required extensive to total assist with ADL and mobility tasks with the exception of eating skills, because he had joint limitations in both lower extremities. A review of the Nursing Assistant charting on bed mobility from July to September 2015 revealed the staff was providing 2 person extensive assist or total dependent assist the majority of the time. In a document dated 10/06/15 provided from the facility they estimated the resident was receiving one person assist for cares 15% of the time over a three month period. Therefore, 85% of the time the resident required 2 plus person assist. In an incident investigation, dated 09/20/15 at 3:30 A.M., Staff A, Nursing Assistant Certified (NAC), yelled out for help. The resident was found by the Licensed Nurse (LN) on the floor in a seated position with his right leg underneath him and left leg out in front. His right arm was lodged in the bed frame and the resident was crying out in pain. The resident complained of 10 out of 10 pain in his right knee and the LN noted swelling to the area. Three staff members assisted the resident back to bed with a Hoyer lift. The conclusion to the investigation was Staff believes that resident was being assisted by the NAC to roll onto side and accidently rolled out of the bed onto the floor. Plan of Care was being followed at the time of the incident. The Resident was sent to the hospital where he stayed for 5 days and returned to the facility on [DATE]. Per the hospital discharge summary, dated 09/25/15, the resident was found to have a distal right closed femur fracture. The resident returned from the hospital with a soft cast from hip to toe on his right leg to immobilize his leg. A review of the care plan noted there was no specific information for care of the resident with ADL's. On the Falls care plan two person cares for bed mobility was added on 09/25/15 after the fall and return from the hospital. On 10/05/15 at 11:00 A.M., the resident was observed in his tilt a space wheelchair with his legs elevated. The resident's bed had a large speciality mattress. The resident stated that he remembers falling out of bed and reported it was an accident but it shouldn't have happened. They usually have two girls to help me and that night there was only one. So she turned me over and there was no one on the other side and I fell out of this bed. It hurt real bad and my leg still hurts and I banged my arm up too. I can't move my leg now with this thing on it. In an interview at 11:30 A.M. the resident's roommate reported they always used two staff to care for Resident 1. He hardly moves for them, he can't. He's a big guy. That night all the noise woke me up because he had to be changed and an aide came in and she was alone and then he fell out of bed and started yelling real loud cause he was hurt. In an interview at 12:20 P.M., with Staff B, Physical Therapist (PT), stated the residents last evaluation from PT was 02/16/15. February was the last time we worked with him. We are involved again since the fracture. He has a soft cast to immobilize the leg from toe to hip and we are working on pain management, positioning training for the staff for wheelchair, Hoyer lift, rolling and positioning for this resident. Staff B could not answer how many people it would take to turn the resident since he had not been evaluated since February. At 1:30 P.M., in an interview with Staff C, the MDS assessment nurse, verified the resident had consistently scored a two person assist for bed mobility and there had not been a change. We review the NAC documentation for bed mobility and the majority of the time the resident was requiring a two person assist. When asked why it was on the care guide as a one person assist for bed mobility she could not provide an answer. It probably should have been re-assessed. During an interview at 1:45 P.M., with the resident's spouse stated, they always use two staff when they do care for him. I know that the aid was alone the night he fell . He can't move by himself he has little strength to do much and now with this fracture it will be harder for him. He can't turn over by himself he needs the girls to help him. The resident interjected and reported that it could be a staffing issue and that is why she was alone changing him. The spouse agreed. In an interview at 2:03 P.M., with Staff D, NAC, reported they recently changed the amount of people to provide care, it was one, now it's two people because of the fall. We used two for him because he is big and doesn't move well. In an interview with Staff E, LN, at 2:15 P.M., stated they always use two people with care for this resident, he is large man. We can't get him to lie on his side he prefers to be on his back all the time. He cannot roll over without help. During an interview with the Assistant Director of Nursing (ADON) at 3:00 P.M., she stated the decision to have the care guide stated one person for bed mobility is based on the therapy evaluation. The ADON stated bed mobility had to do with pulling the resident up in bed and therapies felt one person could do that task. The MDS had been coded for two person assist with bed mobility. The four months of the staff charting providing 2 person care was not a consideration for the plan of care. The ADON could not provide an answer but would follow up. On 10/06/15 the facility provided an additional document the Rehabilitation Services Multidisciplinary Screening Tool dated 09/08/15. Bed mobility was moderate assistance of 1-2 people. Moderate assistance means 50-75% physical assistance is needed to care for the resident. In an interview on 10/07/15 at 8:30 A.M., Staff A, NAC who was involved in the incident with Resident 1, stated she went in to help the resident after a bowel movement. I cleaned him up and had him lying on his left side, I had tucked fresh linen on the right side at the resident's back. I went back to the left side of the bed and rolled the resident to the right over the fresh linen and he kept rolling and fell out of the bed. He cannot turn himself I had to assist him and my hands were on the resident and then he kept going and fell out of the bed. I tried to grab him but I was on the left side of the bed and he fell out the right side between the bed and his bookshelf. That's when I went for the nurse and she came to help. Most of the time I can care for him by myself but I don't do that anymore since the fall. The facility did not provide adequate supervision for the resident. One NAC providing care to the resident resulted in the resident falling out of bed and receiving a fracture.

Based on observation, interview and record review, the facility failed to ensure acceptable pain management for 1 of 3 sample residents (2). This failed practice resulted in harm to Resident 2 as evidenced by her complaints of uncontrolled pain, suicidal thoughts, decreased functional status, and diminished quality of life. Findings include: Resident 2 was admitted to the facility in December 2014 with [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) assessment, dated 12/29/14, indicated she was cognitively intact. A review of the resident's Pain Assessment form admission entry on 12/22/14 revealed no pain history assessment or past pain intervention effectiveness assessment had been completed on admission. A review of the resident's hospital Discharge Summary dated 12/22/14 revealed the resident had previously had a narcotic pain regimen that included [MEDICATION NAME] 60 milligrams (mg) twice daily and [MEDICATION NAME] 30 mg every 12 hours as needed. The Discharge Summary also listed an additional order for [MEDICATION NAME] 5 mg 1-2 tablets every 6 hours as needed for pain. A review of the resident's Physician admission orders [REDACTED]. In an interview on 2/24/15 at 9:30 a.m., Resident 2 stated her pain was currently at a 10/10 (on a scale of 1-10, with 0 being no pain and 10 the worst pain you can imagine), uncontrolled, and she hurt all over. The resident stated she felt suicidal because she could not get any pain relief, was unable to get enough sleep, and her pain medications were ineffective. The resident stated she had previously been treated by a pain clinic and had better pain control, but since admission to the facility her pain management had been inadequate. A review of the resident's nurse progress notes revealed a note on 2/24/15 at 12:57 a.m. by Staff A, Licensed Nurse (LN), which stated resident was tearful this afternoon and c/o (complained of) pain 10/10 that is unrelieved with PRN (as needed) and routine medications. She states that she had a busy day working with therapy, and that makes for her evenings to have an increase in pain. She states that she was tearful because she is really trying her best to work with PT (physical therapy), and be able to move in bed, but it is just unbearable. [MEDICATION NAME] 30 mg and Visteril 50 mg was given prn at 1730 and 2130. Left note in ARNP (Nurse Practitioner) folder. A review of the ARNP folder on 2/24/15 at 12:15 p.m., revealed no note to the Nurse Practitioner was available. In an interview at 12:15 p.m., the Assistant Director of Nursing Services (ADNS) was asked about the communication to the Nurse Practitioner. She looked into it and determined no communication had been made. In an interview at 12:20 p.m., the ADNS stated she had contacted the Nurse Practitioner and received orders for a Pain Clinic consult and a muscle relaxant. In an interview at 12:30 p.m, the resident stated her pain was currently a 9/10. Resident stated she was very tired because she only ever got 3-4 hours of sleep per 24 hours. Resident was observed to grimace whenever she attempted to reposition herself in bed and she stated she got shooting pain in her back and hips whenever she moved. A review of the resident's Pain Flow Sheets from admission on 12/22/14 - 2/24/15 revealed 214 resident complaints of pain of 8 or above. A review of the resident's Care Plan Conference Record dated 12/29/14 stated the resident's pain impacted her functional status and was a barrier to her advancing.

Based on observation, interview and record review, the facility failed to prevent Resident 3, one of 4 sampled residents, from sustaining an avoidable second degree burn. This constituted harm to the resident as defined in the regulations at 483.25(h). Findings include: Resident 3 had dementia with behavioral disturbance, weakness, and a fracture wound for which she required narcotic pain medication. The MDS (Minimum Data Set) assessment dated [DATE] included that the resident required extensive assistance by a staff person to eat. On 10/04/14, according to facility records, a physical therapy assistant gave Resident 3 a cup of hot coffee from an urn in the facility lobby. The coffee was 140F when put out in the lobby some time after 11:30 p.m. Staff F gave the cup of coffee to the resident, and the resident spilled it on her lap at approximately 11:45 a.m. This resulted in what the facility determined to be a second degree burn to the left upper inner thigh. According to 483.25(h), liquid of 140 F takes 5 seconds of contact to cause a 3rd degree burn to skin. Record review revealed a new order for a routine narcotic pain medication on 10/06/2014, in addition to current pain medication orders, and an order to apply antibiotic ointment to the burn and cover it. On 10/23/14 at 11:15 a.m., Resident 3 was observed being transferred by Staff D and an unidentified nursing assistant to the toilet using a mechanical full-body lift. The healing burn wound to the upper left inner thigh was visible and uncovered, the surrounding area reddened. In an interview on 10/24/14 at 9:50 a.m., Staff G from rehabilitation said that after Resident 3 was burned, he recommended a 'sippy cup' for her. He said the weight of the regular coffee cup had caused her to spill it. When the resident's orders and care plan were checked after this interview, there was no documentation the sippy cup had been implemented. Staff G said that the coffee in the lobby was "universal" and therefore could be served to residents. During an exit interview on 10/24/14 at 10:10 a.m. Staff A and B were notified that the burn incident had been reviewed and staff had been interviewed. They were asked to provide any information on staff education or inservicing after the burn, and said they would forward that information later.

Based on interview and record review, the facility failed to consistently address known mentally and verbally abusive behaviors as evidenced by ridiculing, willful disparaging and derogatory verbalizations towards other residents by Residents 5, 6, and 7. This failure resulted in a loss of dignity and harm for Resident 3 and placed all other residents who ate in the dining room at risk of possible repeated negative comments. Findings include: The Washington State "Nursing Home Guidelines", dated February 2012, defines verbal abuse as "any use of oral, written or gestured language that willfully includes threats, and/or disparaging and derogatory terms to or about residents or their families, within hearing distance of any resident regardless of their age, ability to comprehend or disability." On 04/09/13, Residents 5, 6, and 7 separately signed a behavior contract with the facility. The contract read "I understand that my fell ow residents have the right to be spoken to and treated with respect, including speaking at an appropriate volume, not singling out other residents and not interrupting other residents' meal time." Resident 5 was admitted in March 2012 with [DIAGNOSES REDACTED]. His most recent minimum Data Set (MDS) assessment, dated 03/11/13, identified his memory and recall as intact - 15/15 points on the memory assessment tool. On 06/03/13 at 1:30 p.m., Resident 5 reported he ate his meals with Residents 6 and 7 in the dining room at the same table for the past year. Although there was no assigned seating in the dining room, the three of them sat together at the same table in the same chair at each meal. He reported they have been asked to lower their voices, including him. He stated he had "lots going on in his life" and it made him feel "intolerant" of others. He stated he and Residents 6 and 7 did talk of other residents in the dining room. He did not think they were "really loud". However, he and Residents 6 and 7 were told residents complained about the comments. For example, they referred to one resident as "the history channel" as he voiced opinions as "an expert." Whenever he spoke, they would comment, "Here we go again." They referred to another resident as the "discovery channel - he was continuously talking and it weighed on our brains." Residents 5, 6 and 7 made comments about residents who were heavy and/or overweight. He stated they spoke of Resident 3 and her weight status. He did not recall saying anything directly to her. Additionally, the three residents talked about residents who needed assistance with meals. He did not recall whether they made negative comments regarding residents who needed help with meals. Resident 5 stated he signed the behavior contract, dated 04/09/13, because he had "no choice." The contract originated because there were "difficulties with some residents." He reported he did not know any other details of his behavior(s) that contributed to the contract. Resident 5 reported these inappropriate behaviors were "fading." Resident 6 was admitted in August 2012 with [DIAGNOSES REDACTED]. His most recent MDS assessment, dated 05/07/13, identified his memory and recall as intact - 15/15/ points on the memory assessment tool. On 06/03/13 at 09:12 a.m., Resident 6 reported the Administrator told him other residents overheard what they (Residents 5, 6, and 7) were saying about them in the dining room during meals and "it was rude." Resident 6 stated he did not think these comments "were that rude." They were talking about other residents "in a joking manner." He did not know whether the other residents heard what they were saying about them. He did not recall whether anything happened or was said about Resident 3. Resident 6 could not "figure out" why he had to sign the behavior contract. He reported no staff had asked him to lower his voice since he signed the contract on 04/09/13. Resident 7 was admitted in March 2011with [DIAGNOSES REDACTED]. On 06/03/13 at 09:12 a.m., Resident 7 reported he and Residents 5 and 6 always sat together for their meals in the dining room. They liked to "horse around and talk about anything and everything." He continued, " We cut up and laugh. We got loud a couple of times. We were joking and clowning. They thought we were loud." He also signed a behavior contract on 04/09/13. Resident 7 did not recall what the contract was about. The resident reported he had not been asked to lower his voice or leave the dining room since he signed the contract. At 12:15 p.m., Staff 2 reported Residents 5 and 7 had been "belligerent" in her view. Resident 7 sat in a seat that gave him a full view of the other residents in the dining room. Resident 7 often "instigated" the comments. Staff 2 explained Resident 5 used to turn in his chair and face all the other residents in the dining room, and make comments about the other residents in the dining room. These verbal comments were overheard by residents and staff. She described their tone of voice as "disgusted, almost as if they were better than others." She compared the situation "like dealing with 2 year olds." The two main topics were residents who were overweight and residents with physical impairment who needed assistance with meal set-up. For example, they commented on overweight residents, "She doesn't need to eat that, she is too fat." They often spoke of Resident 3 and her weight, "being too fat - a lot." Resident 3 told Staff 2 about these comments, stating Residents 5, 6, and 7 "were mean and hurt her feelings" frequently before Residents 5, 6, and 7 signed their behavior contracts. Residents 5, 6, and 7 commented when Staff 2 assisted physically impaired residents with their meal set-up. They would comment, "He is lazy." Staff 2 recalled Residents 5, 6, and 7 made comments multiple times about a former resident whose name she did not recall. Comments such as, "get him out of here" that were loud enough to be overheard by other residents. Some of those other residents, who have also discharged , made complaints to her about the inappropriate comments. Staff 2 reported these complaints in the daily morning meeting. Staff 2 thought Residents 5, 6, and 7 continued with these same behaviors since signing the behavior contract on 04/09/13 - "disagreeable". They speak "more under their breath." Staff 2 continued to hear the comments at the table and when she went to the buffet line, a few feet from the table where they habitually sat. Whenever she thought they were too loud, she asked them to lower their voices. She continued to ask them to lower their voices "a lot" since they signed the contract. Resident 5 sometimes still turned around to see the other residents and make comments. She had asked Resident 7 to leave the dining room once since the contract, and he did eventually leave the room. Other times she offered to send a meal tray to their room rather than directly ask them to leave the dining room. Staff 2 reported the behaviors of Residents 5, 6, and 7 still "comes up often" in the daily morning staff meeting. On 05/23/13 at 2:50 p.m., Staff 3 reported Residents 5, 6, and 7 were "lots of work". They always sit together and "make comments a lot." For example, if someone has a loud voice (person might be hard of hearing), they will say (loudly), "Wish that person would not talk so loud." Additionally, if a resident has some physical impairment, such as the inability to use both arms and hands when eating, they make comments if that person spills food on the floor, how they "don't like it." Usually their voice is a normal volume. But, Staff 3 heard the comments whenever she passed by their table. She continued to remind them to lower their voices and she reported the behaviors in the daily morning meeting. In an interview on 05/23/13 at 2:05 p.m., the Administrator, Staff 1, Staff 4, and the Director of Nursing Services, reported they were aware of the behaviors of Residents 5, 6, and 7 and their comments regarding other residents. The behavior contracts were the results of complaints from multiple other residents who ate in the dining room - talking too loudly, commenting on other tables, such as other residents are too talkative. Residents 5, 6, and 7 did not seem to want noise from other residents in the dining room. Residents 5, 6, and 7 would behave for 3-5 days; then they started making comments again. The leadership thought Residents 5, 6, and 7 were currently making comments 1-2 times/week, but had no evidence of documentation of these occurrences. They discussed these comments and behaviors in the daily meetings. The staff were not documenting any monitoring of these behaviors in the clinical records. Review of the clinical records of Residents 5, 6. And 7 revealed they each signed a behavior contract on 04/09/13. The contract noted the signee would not disturb the dining room and would show respect to fell ow diners. If the signee did not comply, he may be asked to leave the dining room. Additional review of their clinical records revealed only Resident 7 had any documentation to monitor for behavior issues. There was no evidence of specific monitoring of dining room behaviors in his record. There were no behavior(s) issues documented for May 2013 in his record. The clinical records of Residents 5 and 6 had no evidence of documentation of monitoring for dining room or any other behaviors.

Based on observation, interview and record review, the facility failed to provide 1 of 3 sample resident (1) with needed equipment for skin care due to [MEDICAL CONDITION] treatment. Failure to provide sitz baths for Resident 1 resulted harm of skin sloughing and a need to hold [MEDICAL CONDITION] treatment. Findings include: Resident 1 was admitted to the facility on [DATE] from the hospital. The hospital's Patient Transfer summary documented the resident had a "red coccyx" area which needed "cleanse/rinse". The facility's nursing admit assessment documented the resident's coccyx area was excoriated and showed signs of redness/inflammation. The Minimum Data Set (MDS) assessment, dated 4/3/12, documented the resident received [MEDICAL CONDITION] treatment for [REDACTED]. The MDS revealed that the resident had moisture associated skin damage (MASD) and was at risk for skin breakdown due to incontinence and her medical condition. On 4/23/12, at 9:40 a.m., the resident's skin was observed with a Licensed Nurse (LN T). LN T stated that the resident's buttock had been red, but today the buttock was "more red" with peeling. After the skin was observed, the LN T documented on the facility's "Weekly Skin Integrity Collection" sheet that the resident's skin had redness and circled the buttocks/coccyx area on the diagramed. On 4/23/12 at 10:15 a.m., the resident stated the [MEDICAL CONDITION] oncologist had ordered sitz baths twice a day. She stated the facility had "not given" her a sitz bath and that her diarrhea and loose stool was acidic to her skin". When the LN T was asked about the sitz bath, she was unable to verify whether the resident had received a sitz bath twice a day. Resident 1 stated "this is really bad as the skin can get worse, I can see it going to a decubitus" due to the irritation and not getting my sitz baths. The resident stated she had purchased the equipment for the sitz bath herself as the facility had not provided the equipment. Interview with the shower aide (NAC H) stated Resident 1 had been getting showers, usually every other day, but was "not aware of Sitz Bath" order and had not offered the resident a tub bath. On 4/23/12 at 10:45 a.m., LN S stated that the resident had bloody stools which irritated the skin. The clinical record review with the nurse manage (LN S) revealed the sitz bath was ordered twice a day. A nursing note on 3/29/12 read: "TO (telephone order) sitz bath BID (twice a day)". The note indicated that the facility was "unable to provide sitz bath at this time and left a message at physician's office". There was no further documentation regarding the sitz bath until 4/3/12, when the resident's primary physician confirmed that it was OK to give a sitz bath. Review of the Treatment Administration Record (TAR) for March and April 2012 indicated no sitz bath had been given. The Plan of Care for the skin excoriation to the buttocks and nursing assistant (NAC) worksheet did not include sitz baths for management of skin integrity. The April TAR revealed that the sitz bath to peri area BID PRN, if available, and for comfort. There was no documented evidence that sitz bath was provided. The Director of Nursing (DNS) stated the nursing note on 3/29/12 which read "Sitz bath BID" was not written as a telephone order as we "did not have a sitz bath, and we were going to do alternatives". She stated the facility was not going to change anything (Sitz bath) without a physician's orders [REDACTED]. When asked how the facility provided the sitz bath for the resident, the DNS stated she would "request the sitz prn (as needed) just like pain medication". The DNS stated that "alternatives" to the sitz bath was considered. When asked what the alternatives to the sitz bath were, she stated that the facility had "talked about alternatives". Review of the Plan of Care revealed no documented alternatives to the sitz baths or further communication with the [MEDICAL CONDITION] oncology physician regarding the sitz bath not being available. Even after the physician's orders [REDACTED]. There was no indication the facility had communicated with the [MEDICAL CONDITION] oncology clinic regarding what skin care alternative options could be offered Resident 1 who had skin irritation from bloody loose stool and received [MEDICAL CONDITION] to the rectal area 5 times a week. Interview on 4/23/12 with the clinic nurse (CN D) who managed Resident 1's [MEDICAL CONDITION] treatments stated that the resident was seen today in the clinic. CN D stated that the sitz bath should have been provided a "minimum twice a day". She stated that the resident's skin had "gotten worse" and the skin was sloughing off, peeling". She stated the facility was notified that the resident needed a sitz bath for skin care and revealed that on 4/12/12, the facility still had not provided the sitz bath for the resident. On 4/24/12 the nurse at the [MEDICAL CONDITION] oncologist's office responsible for Resident 1's skin assessments and ordering skin care stated that on 4/12/12 the resident still had not received her sitz baths as ordered. The nurse (LN L) stated that the facility had been notified on 4/12/12 and informed the facility about the need for the sitz bath. LN L stated the facility would deliver a sitz bath on 4/13/12. LN L stated that when she called to verify if the resident was getting the sitz baths on 4/16/12, the facility stated that "they do not do sitz bath". LN L stated that due to her concern regarding Resident 1's skin care needs, she had left a message with the facility Director of Nursing as the resident had not yet received a sitz bath as ordered by the radiologist on 3/29/12 (19 days). LN L stated that Resident 1 had diarrhea that was "like battery acid" on her buttock and needed the sitz baths to prevent skin irritation and breakdown. LN L stated due to lack of skin care and the resident not receiving sitz bath as ordered, the skin on the buttock was "sloughing" with "popped blisters", a moist desquamation of the skin. Due to lack of skin care the resident's [MEDICAL CONDITION] would be on hold. There was no documented evidence that the facility had accommodated the resident with skin care need of sitz bath or alternatives which resulted in moist desquamation of the resident's buttocks and delay in completing her [MEDICAL CONDITION] for [MEDICAL CONDITION].

Based on interview and record review, the facility failed to maintain physical well-being for a resident. Failure to assess and care plan Resident 1's surgical incision prior to discharge resulted in harm of skin growth over some of the incisional staples. Resident 1 suffered discomfort and pain during staple removal and received treatment to the incision site. Findings include: Resident 1 was admitted [DATE] with multiple [DIAGNOSES REDACTED]. He had a surgical incision 8 centimeters in length that was secured with staples. Review of his "Treatment Administration Record" (TAR) form revealed staff were to "monitor left inguinal surgical wound and dry dressing daily". There was documentation of performance of this task for all days in the facility except 02/28/2011. On 03/03/11 Resident 1's physician ordered him discharged with current medications. There was no mention of the staples or care for the incision. Review of the discharge plan revealed no evidence of documentation of the presence of staples. There was no plan for monitoring, or scheduled time/date for their removal of the staples. There was no care plan for monitoring and assessing the healing of the surgical incision. On 03/22 at 12:42 p.m., Resident 1's family member reported on 03/16/11 the Home Health Nurse (HHN) assessed the surgical incision and discovered the presence of staples. Skin had grown over a couple of the staples. The HHN notified Resident 1's physician who ordered her to remove the staples. Resident 1's family member reported he complained of pain during the removal of the staples that had skin covering them. There was a yellow discharge from the center area of the incision for a couple of days after the staples were removed. Antibiotic ointment and a dressing were applied. On 03/22/11 at 3:07 p.m., Licensed Nurse 1 reported she performed the discharge for Resident 1. She did not recall the condition of his surgical wound at discharge. She failed to address the dressing change and include incision care in the discharge plan. She had no knowledge of the presence of staples. LN 1 stated both the dressing and the staples should have been included in the discharge care plan for Resident 1. On 04/01/11 at 09:00 a.m., a family member of Resident 1 reported she was present for the discharge from the facility. No staff told her Resident 1 had surgical staples and/or a dressing at the incision site. She had no knowledge of the staples until the HHN pulled the old dressing off the surgical site.

Based on interview and record review, the facility failed to consistently implement their policy for monitoring and treating constipation. Affected were three of four residents reviewed for bowel status. Failure to address constipation as ordered resulted in harm of fecal impaction for Resident 1 who required manual removal of stool and placed residents at risk of fecal impaction and discomfort. Findings include: Resident 1 was admitted in April 2010 for rehabilitation after a fall with traumatic injury to her spine. The physician ordered pain relief medications. These medications had potential side effects of constipation. Review of Resident 1's clinical record revealed on 04/19/10 her physician ordered nursing to document the size of bowel movement (BM). If Resident 1 had no BM for 3 days, nursing should assess for constipation and administer the ordered necessary medications - tablets, milk of magnesia and/or a suppository - to resolve the constipation. If the treatment was not successful, nursing should notify the physician. Resident 1's most recent Minimum Data Set (MDS) assessment, dated 09/21/10, identified her short-term and long-term memory and recall ability were intact. On 11/01/10 at 09:10 a.m., Resident 1 reported she experienced two instances in previous months when the nurse had to "put on gloves and dig" to remove stool from her bowel. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The result was a large BM. Review of the MAR for June 2010 revealed nursing documented Resident 1 had no BM for 5 days - three times during the month - June 10 - 15, 17 - 22, and 23 - 29. No evidence of administration of the ordered medications for 3 days without a BM was found. The physician was not notified until 5 days without a BM. On 06/22/10 the physician ordered manual disimpaction. Nursing documented the result was a large BM and noted Resident 1 stated she felt "a lot better" after the disimpaction procedure. At 10:40 a.m., Licensed Nurse (LN) 1 reported the Nursing Assistants (NA) were supposed to tell the LN when a resident had a BM. Not all the NAs did this. NAs also documented BM occurrence in an electronic application, but the LNs did not access that data. Review of the October 2010 MAR for Resident 1 revealed documentation of BM at least every 3 days. Review of the electronic data entered by the NAs revealed differences for dates and size. For example, the MAR indicated [REDACTED]. The NA electronic entries were 10/01/10 large BM, 10/02/10 medium BM and 10/03/10 medium BM. The NA electronic data report had a 9 day span of no BM. Similar charting differences were present for August and September 2010 for Resident 1. At 3:01 p.m., the Director of Nursing Services (DNS) reported the communication between the NAs and the LNs was not always strong or consistent. She had no additional information. 2. Resident 3 was most recently admitted in August 2010 with [DIAGNOSES REDACTED]. His most recent MDS assessment, dated 08/28/10, identified his cognitive skills for daily decision-making were severely impaired. Review of clinical record revealed physician orders [REDACTED]. The orders were the same as those for Resident 1. Review of the MAR for October 2010 revealed no evidence of documentation of BM for 5 days twice - October 3 - 7 and 8 - 12. No BM was documented for 10 days between 19 - 29. No administration of the tablets or suppository for constipation was found. Milk of magnesia was documented only on 10/26/10 and 10/27/10. On 10/29/10 the healthcare provider noted Resident 3 was impacted and ordered an enema which resulted in a large BM. At 11:42 a.m., LN 2, who was caring for Resident 3, reported many of the residents on that unit received laxatives routinely. She stated the unit kept a list and LNs were supposed to administer laxatives when needed following the physician orders. To her knowledge, the MAR indicated [REDACTED]. 3. Resident 4 was admitted in February 2010 with [DIAGNOSES REDACTED]. Her most recent MDS assessment, dated 08/02/10, identified a problem with her short-term and long-term memory. Her speech was unclear. Review of Resident 4's clinical record revealed the same physician orders, dated 05/06/10, to administer medications for complaints of constipation or no BM in 3 days as Resident 1. Review of the MAR for August 2010 revealed documentation of no BM for 5 days - August 14 - 19. On 08/18/10, nursing documented Resident 4 was "hollering, grunting and moaning very loudly." Nursing noted "helped by stimulating anus externally and the BM came out." No BM was documented for 6 days between August 22 - 28. Only one dose of milk of magnesia was documented during this time frame. No documentation of a suppository was found.

Based on interview and record review, the facility failed to provide care that addressed Resident 4's dignity and recognized her individual elimination and toileting needs. Failure to develop and provide care services for voiding resulted in harm as evidenced by repeated periods of wetness, discomfort, and feelings of humiliation and embarrassment. Affected was 1 of 7 sample residents. Findings include: Resident 4 was admitted in April 2010 after fracturing her spine in two places. Resident 4 had multiple diagnoses, including charcot, a condition of weakness and numbness, in both feet. She used braces on both lower legs and ankles when walking. Her Minimum Data Set (MDS) assessment, dated 09/21/10, identified her short-term and long-term memory and recall ability were intact. She required a two plus staff assistance for toileting. On 10/22/10 at 09:15 a.m., Resident 4 reported she did sense when she needed to void. She knew staff were busy in the mornings. Sometimes staff took a long time to answer her call light. She could not always get to the toilet in time to prevent an accident. When she was in bed, staff needed to place her leg braces, get her up from the bed or wheelchair and then into the bathroom to void. When seated in her wheelchair, she was not to get up alone. She recalled sitting in her wheelchair, next to the transfer pole, waiting for assistance. She soaked her brief, her clothes, and into the seat of the wheelchair while waiting for assistance. Resident 4 had to change her clothes and felt humiliated. She tried to remain positive, but had lost patience and thought the situation was ridiculous. Each morning she attempted to really empty her bladder to keep dry as long as possible. During the day, she repeated the attempt to empty her bladder as much as possible at least two more times to make herself feel "better and cleaner" as a woman, more confident. Resident 4 did not expect special treatment, but the morning was demanding and stressful for her. She needed time to empty her bladder and did not always get the time she needed before therapy sessions. She had told the staff, but they did not change her schedule to the afternoons. She thought she would try to speak up again; but it was difficult for her. Resident 4 stated sometimes she had to wait in the bed and continued to wet her brief up to 3 more times. She felt embarrassed. It was "really demeaning." The resident had apologized to the staff because "it smells so much." When she was so wet, she asked to be changed in the bed. The resident reported staff preferred to change her in the bathroom. Review of Resident 4's care plan revealed a problem with altered elimination. Interventions listed "routine toileting". The Director of Nursing Services said routine toileting was before/after meals and at bedtime.

Based on interview and record review, the facility failed to assess continence for one of two sampled residents (4) reviewed for continence management. Failure to assess Resident 4's bladder and bowel changing continence level and implement an individualized and updated care plan resulted in harm as evidenced by unaddressed urinary discomfort and placed the resident at risk of unaddressed bladder and bowel needs. Findings include: Resident 4 was admitted in April 2010 for rehabilitation after a fall that fractured two bones in her back. Her [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) assessment, dated 09/21/10, identified her short and long-term memory and recall ability as intact. Her bladder and bowel continence status were identified as frequently incontinent. Her used briefs and pads for her bladder and bowel needs. On 10/22/10 at 9:15 a.m., Resident 4 reported she did sense when she needed to void or have a bowel movement. She was continent of bladder and bowel prior to her fall at home. She had some incontinence of bladder and bowel during her hospital stay and when she initially arrived at the facility. Currently, she required a 2 person assist to get to the bathroom. The staff could not always response in time to get her up from the bed, apply her leg supports, and get her to the bathroom before she needed to void. She tried to fully empty her bladder each morning so that she could remain dry as long as possible. She had trained herself to have a bowel movement each morning since her stay in the facility. She did not recall any staff inquiring about her current abilities to sense when she needed to void or offering to schedule times for toileting needs. A "Urinary incontinence Questionnaire" form, dated 04/1/9/10, documented Resident 4 had incontinence of bladder and bowel for the past 2 weeks. She had no urine leakage and was currently using pads/briefs for her incontinence. The "Urinary Incontinence Assessment" form, dated 04/19/10, identified incontinence of urine. The type of incontinence was blank. The assessment documented Resident 4 was able to follow directions, sense urgency, learn to control the urge to void and able to contract the pelvic muscles. The section on program for toileting training needs was blank. The "assessment for bowel and bladder training" form, dated 09/26/10, identified Resident 4 as a candidate for timed or scheduled voiding. Review of Resident 4's care plan revealed a problem of alteration in elimination, dated 04/29/10. The interventions listed incontinence products to protect skin and offer to assist with routine toileting. The goals, dated 10/01/10, included return to continence of bowel and less than 2 incontinence episodes per day. Resident to be free of signs/symptoms of urinary tract infection [MEDICAL CONDITION]. Review of Resident 4's clinical record revealed she was diagnosed with [REDACTED]. She most recent "Weekly skin integrity data collection" form noted the skin of both buttocks was excoriated and reddened on 10/19/10. At 11:05 a.m., LN 2 reported Resident 4's skin was still excoriated and reddened from top to base on both buttocks when he examined it earlier that morning. At 9:43 a.m., Licensed Nurse (LN) 1 reported any LN or other staff could review a resident care plan and update or add to it at any time. Neither LN 1 nor the Director of Nursing Services had any additional information for Resident 4's elimination assessment and care plan discrepancies or why a toileting program was not initiated.