Every finding on record at Mckay Healthcare & Rehab CTR

Based on observation, interview and record review, the facility failed to ensure residents consistently received restorative therapy services (movement of joints to maintain range of motion) to maintain range of motion (ROM) for 3 of 12 residents (Residents 24, 1 and 6) reviewed for ROM/mobility. This failure placed residents at risk of decreased joint motion, progressive contractures and a diminished quality of life. Findings include . Resident 24 Review of the medical record showed the resident admitted to the facility with diagnoses including stroke (when blood stops flowing to part of your brain), dementia (a decline in mental abilities severe enough to interfere with daily life) and a left sided hemiplegia ( a neurological condition causing severe or complete paralysis on one side of the body). The 03/01/2026 comprehensive assessment showed Resident 24's cognition was severely impaired and required the assistance of one staff member with activities of daily living and had a contracture to the left hand. Review of Resident 24's care plan dated 01/23/2026 showed the resident was scheduled to receive a restorative nursing program for passive range of motion (PROM- moving a person's joints for them when they cannot move then on their own) to their upper extremities. The care plan specified that the resident was to receive left hand upper extremity exercises that directed staff to place objects in a tub, fill it with water, instruct the resident to retrieve the objects from the water, and thoroughly dry the resident's hands upon completion of the activity with a goal to compete the program three of seven days a week. Review of the resident's electronic medical record within the tasks section (the facility's digital flow sheet used by staff to document the actual delivery of scheduled care) for May 2026 showed the scheduled restorative program was documented as completed on only three out of 31 days (05/04 2026 documented as completed, 05/05/2026 documented as not applicable and 05/06/2026 documented as a resident refusal). The electronic record contained no documentation, shift entries, or clinical justifications for the remaining 28 days of omissions. During an observation and concurrent interview on 05/31/2026 at 1:42 PM, showed Resident 24 sitting in their wheelchair with their left arm laying flaccid in their lap. Resident 24's left hand had severe contractures, tightly closed in a fist with the thumb positioned over the fingers, and a foul odor was emitting from the hand. Resident 24 stated they could not open their hand, stating it would break. Resident 24 further stated they did not receive any exercises for that hand. During an observation of hand hygiene on 06/04/2026 at 9:57 AM, Staff H, Nursing Assistant (NA), performed hand hygiene on Resident 24's contracted left hand using a warm washcloth. Immediately following this intervention, the washcloth was observed covered in a brown substance extracted from the resident's palm. Staff H stated the palm was very dirty and red. Observation of the resident's palm directly under the thumb showed a red area emitting a strong, foul odor. During an interview on 06/02/2026 at 2:23 PM, Staff P, Restorative Assistant, stated Resident 24 was on an active restorative nursing program for ROM but services were disrupted due to facility staffing difficulties. Staff P stated they were consistently pulled to the floor the entire month of May 2026, and no restorative programs were completed except for those 3 days that were charted for Resident 24. Staff P further stated they did not have a nurse providing oversight and administrative monitoring. Staff P further stated, we have not been having any meetings or anything for restorative in a long time. During an interview on 06/03/2026 at 4:38 PM Staff A, Administrator, stated they did not have any therapy in the building during most of May 2026 and were aware of the restorative issues. Staff A stated that the facility failed to maintain the required restorative services during this time and they were currently working on fixing the issue.' Review of the facility's policy, titled, Restorative Program, dated 10/24/2024, showed Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include; passive or active range of motion. Resident 1 Review of Resident 1's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include quadriplegia (partial or total paralysis of all four extremities and torso), depression (a serious mood disorder characterized by persistent sadness and loss of interest in daily activities) and need for assistance with personal care. During an observation and concurrent interview on 05/31/2026 at 2:01 PM, Resident 1 had limited movement to their left hand. Resident 1 stated that they were not receiving any therapy right at that time. Review of Resident 1's daily Kardex (a task sheet with a resident's daily care needs, used for easy reference by the nursing staff) showed Resident 1 had an active range of motion (AROM) and a passive range of motion (PROM) program for their upper and lower extremities. During an observation and concurrent interview on 06/02/2026 at 4:08 PM, Resident 1 was observed with contracted ring and pinky fingers on their left hand. The resident stated they did not wear a brace on their hand at night. Resident 1 stated, I do need one to hold these fingers straight . If they had something that would hold my fingers straight, I'd wear it. Resident 6 Resident 6 was admitted to the facility on [DATE] with diagnoses to include persistent vegetative state (a condition where a person with severe brain damage appears awake but has no conscious awareness of themselves or their surroundings) and contractures (the permanent tightening and shortening of muscles, tendons, ligaments, or skin) of both arms and both hands. The comprehensive assessment dated [DATE] showed the resident's cognition was severely impaired and was dependent on staff for all mobility and cares. Review of Resident 6's daily Kardex showed Resident 6 was to have a PROM program for their upper and lower extremities daily. In an observation and concurrent interview on 06/01/2026 at 10:10 AM, Resident 6 was observed sitting in a tilt-in-space wheelchair with visible bilateral upper arm contractures. The Resident Representative (RR) stated the facility's therapy was not enough. The RR stated, If they don't get therapy, they will get really stiff. Therapy needs to be done every day .so, I come in to do their range of motion every day. In an interview on 06/02/2026 at 11:00 AM, Staff P, Restorative Assistant, stated that during the month of May 2026, residents did not receive a consistent restorative program. Staff P stated that Resident 1 and Resident 6 were on active programs, but because restorative aides were routinely pulled to work as floor Nursing Assistant (NA), the restorative programs could not be completed. During an interview on 06/03/2026 at 9:33 AM, Staff M, NA, stated that floor NAs did not perform restorative programs because the facility has designated restorative aides. Staff M verified that the restorative aides work the floor a lot due to staffing needs and added that the facility had been without therapy services for a few weeks. Reference: WAC 388-97-1060 (3)(d)

Based on interview and record review, the facility failed to ensure that specific facility primary provider dialysis (a medical treatment that acts as an artificial kidney, it filters waste, toxins, and extra fluid out of the blood) monitoring orders were implemented and followed for 1 of 1 residents (Resident 18) reviewed for dialysis care. This failure placed the residents at risk for fluid overload, electrolyte imbalances, cardiovascular instability, and missed identification of life-threatening post-dialysis complications. Findings included. Review of the medical record showed the resident admitted to the facility with diagnoses end stage renal disease (when your kidneys have lost their function, leaving them unable to adequately filter waste and excess fluid from the blood to support daily life). The 03/01/2026 comprehensive assessment showed Resident 18's cognition was intact and required the assistance of one- two staff members with activities of daily living and was receiving dialysis treatments. Record review of a provider encounter dated 05/11/2026, showed orders as follows: Obtain daily weights and notify the provider for a weight gain of 2 pounds (lbs.) in 24 hours, or 5 lbs. in 7 days. If a weight gain of 2 lbs. in 24 hours is accompanied by dyspnea (shortness of breath) or edema (swelling), obtain a STAT (immediate) Basic Metabolic Panel (BMP-a blood test that measures your body's chemistry) and arrange an urgent dialysis adjustment. Monitor blood pressure (BP) each shift. Hold carvedilol (a medication used to treat high BP and heart failure) if systolic blood pressure (the top number of blood pressure reading) is less than 95, or if the heart rate is less than 55 beats per minute. Limit fluid intake to 1.5 liters (L) per day. Record review of Resident 18's physician orders and Medication/Treatment Administration Records (MAR/TAR) for May 2026 showed that none of the provider monitoring orders had been transcribed or implemented by the facility. Review of Resident 18's weight records from 05/13/2026 to 05/18/2026 showed a 13-lb. weight gain within five days. Furthermore, a review of weight records from 05/29/2026 to 06/01/2026 showed a 25.5-lb. weight gain within three days. A review of the medical record showed no evidence that the primary provider was notified of either of these significant weight gains, as required by the 05/11/2026 provider orders. Review of Resident 18's active dietary orders and kitchen diet slips for May 2026 showed no evidence that the ordered 1.5-liter per day fluid restriction had been implemented or communicated to the dietary staff. During observations on the following dates and times, Resident 18 was observed with unmonitored fluids at their bedside: On 06/02/2026 at 3:59 PM: A 32-ounce water cup was observed on the resident's bedside table, filled with approximately 300 cubic centimeters (cc) of water. An additional cup containing approximately 180 cc of juice was also sitting on the bedside table. On 06/03/2026 at 10:19 AM: The resident was observed with a 32-ounce water cup at their bedside containing approximately 600 cc of fluid. During an interview on 06/01/2026 at 4:17 PM, Resident 18 stated the facility did not weigh them consistently, stating, Maybe twice since I have been here. The resident further stated, I have been feeling a little more short of breath these last few days and some swelling in my hands and leg, but I have not told anyone because I'm just used to it, I guess, when I get too much fluid. During an interview on 06/02/2026 at 4:15 PM, Staff I, Licensed Practical Nurse, stated that if a resident was on a fluid restriction, it would appear on the MAR, and Resident 18 did not have a restriction listed on the MAR. Staff I further stated they were not aware of the resident's recent increase in shortness of breath or edema. Additionally, Staff I stated that the facility did not have a policy to weigh residents daily, nor did they have specific daily weight orders for dialysis patients; it was their understanding that dialysis patients were only to be weighed at the dialysis clinic. During an interview on 06/03/2026 at 4:26 PM, Staff A, Administrator, stated that the expectation for inputting provider visit orders was for the resident case managers (RCMs) to review the providers visits to ensure all orders were completed and placed in the resident's electronic record. Staff A stated they had no idea this was happening; otherwise, they would have had a check system in place. Staff A further stated that there was a failure in the process. During an interview on 06/03/2026 at 4:38 PM, Staff B, Director of Nursing Services, stated that for the fluid restriction, the dietician and the provider did not pass the orders on, and that was where the process broke down. Staff B stated that the process was for the RCMs to read the provider's dictation and placed the orders into the system. Reference: WAC 388-97-1900 (1)

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for 1 of 3 residents (Resident 48) reviewed for Beneficiary Notices. This failure placed residents and/or their representatives at risk of not having adequate information to make financial decisions related to the residents' stay within the facility. Findings included . Review of a Notice of Medicare Non-Coverage, dated 02/08/2026, showed Resident 48 had not been provided with a SNF ABN prior to their discharge from the facility. In an interview on 06/01/2026 at 2:05 PM, Staff K, Business Office Manager (BOM), stated they were responsible for notifying residents of changes in their Medicare coverage. Staff K stated they had not provided Resident 48 with the SNF ABN form, they were unaware they were to provide the form. In an interview on 06/01/2026 at 2:18 PM, Staff A acknowledged that Resident 48 had not been provided with the SNF ABN form and stated they should have been. Staff A stated they had educated the BOM of the process. Reference (WAC) 388-97-0300 (4) (a-c)

Based on interview, record review, and observation, the facility failed to ensure information regarding the grievance process was readily available for residents or resident representatives [RR]) and failed to ensure residents were aware of their right to file grievances anonymously. These concerns were voiced in Resident Council (a formal meeting for facility residents to communicate preferences and concerns) for 3 of 5 residents (Resident 26, 39, and 75) reviewed for grievances. This failure placed residents at risk for overall dissatisfaction with their care and unresolved concerns. Findings included . Review of the facility policy, titled, Resident and Family Grievances, revised date 10/28/2019 showed how to file a grievance or complaint would be available to residents. During an observation on 06/02/2026 at 9:28 AM, throughout the facility there were no physical grievance forms available for resident or RR access. In an interview on 06/02/2026 at 10:19 AM, Residents 26, 39, and 75 stated they did not know where grievance forms were located were unaware, they could submit forms anonymously, and that they believed staff members had to fill out the forms on their behalf. In an interview on 06/03/2026 at 4:21 PM, Staff L, Activities Director, stated grievance forms were kept on the wall near the nursing assistant charting area and the Director of Nursing Services office. They acknowledged that if residents did not know what the forms looked like or where they were located, the facility needed to re-educate them and improve their process. In an interview on 06/03/2026 at 4:42 PM, Staff A, Administrator, acknowledged a gap in resident awareness regarding the grievance process. Staff A confirmed that some residents could be unfamiliar with their right to file anonymously and where to locate physical grievance forms. Reference: WAC 388-97-0460

Based on observation, interview, and record review, the facility failed to ensure that residents, dependent on staff, received necessary care and services. The facility failed to provide consistent, oral care and personal grooming (nail care) for 2 of 2 residents (Resident 1 and 24) reviewed for Activities of Daily Living (ADLs). This failure placed residents at risk for impaired skin integrity, oral infections, unmet care needs and embarrassment.Findings include. Review of the facility policy titled, Activities of Daily living (ADLs) dated 10/24/2024, showed based on the resident's comprehensive assessment and consistent with the resident's needs, care and services would be provided that included grooming and oral care. Resident 1 Review of the resident record showed the resident admitted to the facility on [DATE] with diagnoses to include quadriplegia (the partial or total paralysis of all four extremities (both arms and both legs) and the torso) and need assistance with personal care. The comprehensive assessment dated [DATE] showed the resident was dependent on staff for ADLs. Review of Resident 1's undated Kardex directed nursing assistants to provide mouth care and personal hygiene. In an interview on 05/31/2026 at 2:11 PM, Resident 1 stated they were unable to access supplies independently and had not brushed their teeth that day. Resident 1 stated staff do not offer a setup to brush their teeth. During an observation 06/01/2026 at 8:08 AM, Resident 1 laying in their bed with the head of the bed elevated for their breakfast, with disheveled, oily hair. The resident's toothbrush was observed dry and stored in a crayon caddy on the bedside table. In an interview on 06/01/2026 at 8:53 AM, Staff M, Nursing Assistant (NA), stated Resident 1 had been cooperative with care but verified they had not offered oral care that morning. During an observation on 06/01/2026 at 4:10 PM, Resident 1 with brown teeth and a thick, white film along the gumline. The resident stated that staff did not offer oral care, stating, They don't offer supplies and I can't get it myself. During an observation and concurrent interview on 06/02/2026 at 9:17 AM, Resident 1's toothbrush was observed dry with visible dirt and fuzz embedded in the bristles. The resident stated the staff had not offered oral care that morning. During an observation on 06/03/2026 at 11:06 AM, Staff N, NA and Staff J, NA were observed providing a bed bath for Resident 1. The resident's toothbrush remained dry with dark specks of dirt and fuzz. The resident's teeth exhibited a brown color and a white film along the gumline. The CNAs completed the bed bath and changed the resident's gown and bed linen but failed to offer or provide oral care. In an interview on 06/03/2026 at 10:20 AM, Staff E, Resident Care Manager (RCM) and Staff G, RCM acknowledged that while the resident occasionally refuses other care (such as therapies or braces), facility staff had completely failed to offer oral care to the resident. Resident 24 Review of the medical record showed the resident admitted to the facility with diagnoses including stroke (when blood stops flowing to part of your brain), dementia (a decline in mental abilities severe enough to interfere with daily life). The 03/01/2026 comprehensive assessment showed Resident 24's cognition was severely impaired and required the assistance of one staff member with personal hygiene. Review of Resident 24's care plan, dated 04/13/2022, showed that the resident had an activity of daily living self-care performance deficit and required assistance of one staff member with all personal hygiene. During an observation and concurrent interview on 05/31/2026 at 1:42 PM, Resident 24 was observed sitting in their wheelchair. Residet 24's left hand presented with severe contractures and emitted a very foul odor. Resident 24's left thumb was tightly positioned on top of their first finger. Resident 24 stated that their left hand cannot open, it will break and stated no one opens that hand. Further observation showed Resident 24's fingernails were long and jagged, with chipped nail polish and a brown substance accumulated underneath the nails. During an observation on 06/01/2026 at 2:16 PM showed Resident 24 had long, jagged fingernails with old, chipped green nail polish and a brown substance remaining underneath the nails. Resident 24's left hand fingernails were observed digging into their palm, and a strong, foul odor was emitting from the hand. During an observation on 06/02/2026 at 2:15 PM, Resident 24 was ambulating in the hallway. Observation of both hands revealed the identical unkempt appearance from previous days. Resident 24's fingernails remained long, jagged, covered in old, chipped green nail polish, with a brown substance visible underneath the nails. During an observation and concurrent interview on 06/04/2026 at 9:57 AM, Staff H, Nursing Assistant (NA), stated they had tried to cut Residents 24's nails and they had pulled away and they had not attempted since. Staff H then performed hand hygiene on Resident 24's contracted left hand using a warm washcloth. Immediately following this, the washcloth was observed covered in a brown substance extracted from the resident's palm. Staff H stated the palm was very dirty and red. Observation of the resident's palm directly under the thumb showed a red area emitting a strong, foul odor. During an interview on 06/03/2026 at 4:39 PM, Staff A, Administrator stated the NA's were responsible for nail care which was to be done daily with care and as needed. Staff A stated they were aware of the nail care issue and that it was very disappointing. Staff A further stated more training needed to be done with the NA's. Reference: WAC 388-97-1060 (2)(c)

Based on observation and interview, the facility failed to provide a safe and sanitary (relating to the conditions that affect hygiene and health) environment for 1 of 1 Laundry room, reviewed for a functional environment. This failure placed residents and staff at an increased risk of cross-contamination (the harmful spread of diseases). Findings included.During an environmental tour of the facility's laundry room on 06/03/2026 at 12:00 PM, showed: An active water leak originated from the commercial washing machine. This ongoing leak resulted in a significant accumulation of standing, pooling water directly behind and underneath the washing machine unit. The floor surface directly beneath and surrounding the commercial washing machines and chemical dispensing units showed extensive, visible water damage, pitting, and structural deterioration. The floor area beneath the liquid laundry chemical drums and intake lines showed significant discoloration and physical pitting. The flooring was unable to be properly cleaned or sanitized. Observation of the laundry room ceiling showed water damage. The affected ceiling area showed paint blistering and bubbling, with sections of the paint completely failing and peeled away, leaving the underlying drywall fully exposed. The wall surface located to the left side of the washing machine showed water damage and dark staining. Multiple areas of bubbling, peeling paint were observed, along with physical holes in the wall structure that left the interior wall components exposed, the surface was unable to be properly cleaned or sanitized. The wall surface located behind the washing machines, positioned to the right side of the window, showed a large area of water damage and structural deterioration. This affected section of the wall measured approximately 2 feet (ft- a unit of measure) by 1 1/2 ft in size. Further observation of the same wall, located to the left side of the window, showed an additional area of water damage and structural deterioration. This affected section measured approximately 3 ft by 9 inches (in- a unit of measure) in size, leaving the wall material exposed and uncleanable. Observation of the laundry room hopper showed extensive water damage to the wall directly behind the unit, rust and metal were visible through the broken drywall. The wall trim surrounding the hopper was warped and actively pulling away from the wall structure, creating surfaces that were not cleanable. Multiple areas of heavily chipped peeling paint were observed directly in front of and to the left of the hopper unit, leaving the underlying drywall fully exposed to moisture and unable to be properly cleaned or sanitized. During an interview and concurrent observation on 06/03/2026 at 12:20 PM, Staff A, Administrator, stated the facility process required the maintenance department to perform routine rounds, and all facility staff were expected to use the TELS system (an electronic communication system designed for maintenance requests) to report any environmental issues that needed to be addressed. Staff A reviewed the laundry room conditions and stated that the damage was way worse than the last time they were in the room. Staff A further stated they would expect the laundry supervisor to have reported the damage to maintenance via the electronic system and acknowledged that the facility's process was not followed. During an interview and concurrent observation on 06/03/2026 at 12:34 PM, Staff F, Maintenance Director, stated they perform environmental rounds daily but had not been in the laundry room frequently and were not aware of any of the damage on or by the windows, hopper, ceilings or floors. Staff F stated they were aware of the leak from the washing machine and were waiting on parts that were about six to eight weeks out. Staff F stated all staff communicated any repair needed verbally and utilized the TELS system. Staff F acknowledged the deficient environmental conditions. Reference: WAC 388-97-3220 (1)

Based on observation, interview and record review, the facility failed to implement the resident elopement protocol for 1 of 3 residents (Resident 1) reviewed for accidents. This failure placed the resident at risk for possible serious injury related to an elopement (the potential danger when a resident, often deemed impaired to make sound decisions, leaves the facility premises or safe area unauthorized, posing immediate threats to their health or safety). Findings included .Review of the facility policy dated 08/16/2023 titled, Elopement and Wandering Residents, showed the definition of Suspected Elopement occurs when there is reasonable evidence that a resident has eloped or a resident's whereabouts are not immediately known. Further review showed that any staff member becoming aware of or suspecting a missing resident will alert personnel using facility approved protocol (internal alert code). Resident 1 Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), depression (a mental health condition characterized by persistent sadness and a loss of interest in activities for long periods of time) and chronic pain. The comprehensive assessment dated [DATE], showed the resident required supervision or touching assistance with walking and that their cognition was intact. Review of a history and physical, dated 10/20/2025, showed Resident 1 had a polysubstance abuse disorder (a condition where a person compulsively uses three or more different classes of drugs or substances over a 12-month period, often without a primary preference for one specific substance). Review of an elopement risk assessment for Resident 1, dated 10/22/2025, showed an elopement risk score of five (moderate risk) of leaving the facility. Review of the care plan dated 12/19/2025 did not show an elopement care plan for Resident 1. Review of the facility's visitor sign-in sheet dated 03/07/2026 showed Resident 1 had a family member visit at 11:30 AM on that day. There was no sign-out time from the family member or Resident 1. Review of the facility's incident logs dated January 2026 through 03/18/2026, showed Resident 1 was a missing resident/elopement on 03/08/2026 at 8:00 AM. In an interview on 03/18/2026 at 12:30 PM, Staff D, Licensed Practical Nurse, stated they were assigned to Resident 1 on 03/07/2026 and administered their morning medications between 6:00AM to 7:00 AM. Staff D stated they went into Resident 1's room to administer their 1:00 PM medications and the resident was not there. Staff D stated the roommate said Resident 1 had gone to lunch with their family member. Staff D stated they did not call the family to verify the resident was with them. Staff D stated they were not aware of a time frame to call a resident or family member of when they would return to the facility. Staff D stated that Resident 1 did not come back on their shift (6:00 PM was the end of their shift, five hours after Resident 1 was missing from the facility). Staff D stated they did not implement the missing resident/elopement protocol. Review of Resident 1's progress notes, dated 03/08/2026, showed documentation of the resident missing at 8:30 AM on that day, when the dayshift nurse noticed Resident 1 was not in bed for their scheduled morning medications. The nurse had called the family and found the resident had been dropped off at the facility on 03/07/2026 (the previous day) at 2:00 PM in the parking lot. The progress notes further showed the nurse implemented the missing resident/ elopement protocol at that time (18 hours after Resident 1 was missing from the facility). During an interview on 03/18/2026 at 1:35 PM, Staff A, Administrator, stated the facility had an agency nurse working at the time of the incident and nothing had been done when Resident 1 was missing until the next day. Staff A stated Resident 1 was found by the water (about half of a mile from the facility) and was sent to the local hospital for evaluation. Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to provide care and services in a manner that promoted resident respect and dignity for 3 of 4 residents (Residents 14, 27, and 29) reviewed for resident rights. This failure placed the residents at risk for distress, embarrassment, and an undignified existence. Findings included . Review of a policy titled, Resident Rights, edited 10/28/2024, showed the resident had the right to self-determination and a dignified existence. <Resident 14> Review of the medical record showed Resident 14 was admitted to the facility with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), difficulty speaking, and difficulty swallowing. The 02/06/2025 comprehensive assessment showed Resident 14 was dependent on one to two staff members for activities of daily living (ADLs). The assessment also showed Resident 14 was able to make their needs known. An observation on 03/17/2025 at 10:09 AM, showed Resident 14 sitting in their wheelchair in the hallway outside of restroom [ROOM NUMBER], waiting to use the restroom. Restroom [ROOM NUMBER] had a door that opened into the restroom and a privacy curtain hanging across the doorway. Resident 14 was assisted into the restroom by Staff F, Nursing Assistant (NA), and Staff H, NA. Staff H exited the restroom and closed the privacy curtain. Staff F was overheard talking to Resident 14 about their toileting needs. An observation on 03/18/2025 at 9:36 AM, showed Resident 14 sitting in their wheelchair in the hallway outside of restroom [ROOM NUMBER]. There were two additional residents in the hallway waiting in line to use the restroom. Resident 14 was transferred into the restroom and on to the toilet by Staff D, NA, and Staff E, NA, using a mechanical lift (a device to safely lift and move people who can not stand or walk on their own). The curtain was pulled closed, leaving a three-inch gap between the wall and the curtain. Staff D told Staff E they needed to get a brief for Resident 14. Staff E exited the restroom and stated to Staff F, NA, the resident was on the toilet and walked down the hall towards Resident 14's room. At 9:42 AM, Staff E returned to the restroom, opened the curtain, and entered the restroom with Resident 14 ' s brief. The toilet was flushed, and Resident 14 was brought out of the restroom on the mechanical lift. A strong odor of feces was noted in the hallway. During an interview on 03/20/2025 at 11:04 AM, Resident 14's representative (RR) stated the restroom in the hallway (#104) was ridiculous (small and not private). They stated there was another restroom (#110) just down the hall that was larger, and the door could be shut. The RR stated they had always had an issue with privacy in the small restroom (#104) and stated the lack of privacy would be an issue for Resident 14 as well. <Resident 27> Review of the medical record showed Resident 27 was admitted to the facility with diagnoses including a stroke, kidney disease, and dementia (a progressive disease that destroys memory and other important mental functions). The 01/31/2025 comprehensive assessment showed Resident 27 was dependent on one to two staff for ADLs and had a severely impaired cognition. During an observation on 03/18/2025 at 9:48 AM, Staff D and Staff F transferred Resident 27 to restroom [ROOM NUMBER] using a mechanical lift. The privacy curtain was pulled, and the door was not shut. Toileting cares could be overheard from the hallway. During an interview on 03/18/2025 at 9:57 AM, Staff G, NA, stated they used restroom [ROOM NUMBER] for toileting residents because it was larger and safer area for toileting the residents that used a mechanical lift. They stated they were able to provide privacy by shutting the door. Staff G stated staff preferred to use the smaller restroom (#104) for convenience. During an interview on 03/18/2025 at 10:05 AM, Staff D stated they used the smaller restroom (#104) because it was quicker to toilet the residents that used a mechanical lift. Staff D stated they should always close the door for privacy. During a concurrent observation and interview on 03/20/2025 at 10:27 AM, showed Staff E and Staff I, NA, exiting the small restroom (#104) after assisting a resident with toileting. Staff E stated they preferred to use the smaller restroom for residents on a mechanical lift because it was quicker. Staff I stated they would not be comfortable going to the bathroom with just this curtain for privacy. Staff E stated they were able to close the door, when the lift was not in the bathroom. They stated they would have to take the lift out if they wanted to close the door. Staff E stated they closed the curtain for privacy. <Resident 29> Review of the medical record showed Resident 29 was admitted to the facility with diagnoses including neurocognitive disorder with Lewy bodies (a progressive disease that causes memory loss, tremors, stiffness, anxiety, depression, and sleep disorders), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and presbyopia (gradual loss of the eye's ability to focus on nearby objects). The 02/13/2025 comprehensive assessment showed Resident 29 was dependent on one to two staff for ADLs. The assessment also showed Resident 29 had a severely impaired cognition and wore corrective lenses. Resident 29 was receiving palliative care (patient centered care that optimizes the quality of life by addressing physical, emotional, and social needs, and facilitates access to information and patient choice) during the assessment period. During a concurrent observation and interview on 03/17/2025 at 1:04 PM, showed Resident 29 sitting in their wheelchair in a private dining area with their representative, eating their meal. Resident 29 was wearing their glasses that had visible deterioration to both lenses. Resident 29's Representative (RR) stated the resident wore glasses but needed to have them replaced due to wear on the lenses. The RR stated they spoke with Staff J, Social Services Director (SSD), and was told they would look into what needed to be done to replace the glasses. An observation on 03/18/2025 at 10:02 AM, showed Resident 29 resting in bed. Their glasses were lying on the bedside table next to the resident's bed. Observation of the lenses of the glasses showed the protective film on each lens had deteriorated and was peeling, obstructing the clarity of the lenses. Review of a progress note dated 03/17/2025, showed Staff J had met with Resident 29's representative and informed them that Resident 29 was receiving palliative care and did not qualify for vision appointments. During an interview on 03/19/2025 at 8:41 AM, Staff J stated the family had brought concerns related to Resident 29's glasses to them on 03/17/2025. Staff J stated they had told Resident 29's RR since Resident 29 was on palliative care, they did not typically send residents out for appointments for things like that. Staff J stated palliative and hospice care (specialized care that focuses on comfort and quality of life for individuals with a terminal illness) were the same type of care. During an interview on 03/20/2025 at 2:29 PM, Staff B, Director of Nursing, stated the process for ensuring respect and dignity during toileting included assisting the resident to the restroom and ensuring privacy by closing the door to the restroom. Staff B stated they were unsure why the NAs were using the small restroom (# 104) for residents that required a mechanical lift for transfers. On the same day, during a follow-up interview at 3:20 PM, Staff B stated their expectation was for staff to close the restroom door when toileting residents. Staff B stated the process for obtaining necessary items for residents on palliative care included reviewing the need with the resident and/or their RR and proceed with obtaining the items that the resident needed. Reference: WAC 388-97-0180(1)(2)(4)(a)

Based on interview and record review, the facility failed to ensure residents retained the right to exercise self-determination regarding their dining experience for 1 of 2 residents (Resident 14) reviewed for choices. This failure placed the residents at risk for dissatisfaction in their dining experience and decreased self-worth. Findings included . Review of a policy titled, Resident Rights, last edited 10/28/2024, showed the resident had the right to and the facility must promote resident self-determination through the support of resident choice, including the right to make choices about aspects of their life that were significant to the resident. <Resident 14> Review of the medical record showed Resident 14 was admitted to the facility with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), difficulty speaking, and difficulty swallowing. The 02/06/2025 comprehensive assessment showed Resident 14 was dependent on one to two staff members for activities of daily living. The assessment also showed Resident 14 was able to make their needs known. During a concurrent interview on 03/20/2025 at 11:04 AM, Resident 14's Representative stated the resident did not want to eat their meals in the dining room. Resident 14 stated they wanted to eat in their room because the dining room was too noisy. Resident 14 stated they had told staff they did not want to eat in the dining room but was told they had to because of their choking issues. During an interview on 03/20/2025 at 4:23 PM, Staff B, Director of Nursing, stated the residents had the right to choose where they have their meals, either the dining room or their own room. They stated when a resident required assistance with meals and chose to eat in their room, the facility would provide staff to assist. Staff B stated they were unsure why Resident 14's choices were not honored. Reference: WAC 388-97-0900(1)(3)

Based on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were corrected on admission and had the required Level 2 referral sent for a positive Level 1 PASARR for 2 of 3 residents (Residents 31 and 26) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarification to the Pre-Admission Screening and Resident Review (PASARR or PASRR) Level 1 Screening Process, dated 07/06/2024, showed a positive level one PASARR screen (that would then require a referral for a level two PASARR) was Any of the questions in Section 1A (1, 2, and/or 3) are marked Yes: or sufficient evidence of SMI is not available, but there is a credible suspicion that a SMI may exist; and the requirements for exempted hospital discharge do not apply . Additionally, nursing facilities will ensure residents with a positive level one PASARR screen have been evaluated by the designated state-authority through the level two PASARR process and approved for admission prior to admitting to the nursing facility. <Resident 31> Review of Resident 31's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), restlessness, agitation, and insomnia (trouble sleeping). Review of the quarterly comprehensive assessment, dated 01/25/2025, showed the resident's cognition was moderately impaired and required minimal assistance of one staff member for activities of daily living (ADLs). Review of Resident 31's PASARR dated 09/27/2024, showed Resident 31 had a SMI of both depression and anxiety. Review of Resident 13's medical record showed no level 2 referral had been sent for review. <Resident 26> Review of Resident 26's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including depression, anxiety, and insomnia. Review of the quarterly assessment dated [DATE] showed the resident was cognitively intact and required substantial assistance of one to two staff members for ADLs. Review of Resident 26's PASARR dated 09/27/2024, showed Resident 26 had SMI's including an adjustment disorder, depression and anxiety. Review of Resident 26's medical record showed no Level 2 referral had been sent for review. During an interview on 03/20/2025 at 4:22 PM with Staff J, Social Services Director, they stated they had become aware of the requirement to send out a referral for a PASARR Level 2 if section 1A listed a SMI/ID diagnosis. Staff J stated they had been going through all the resident's records to assure they were correct but had not reviewed all of the resident's records yet. Reference: WAC 388-97-1975 (1)(2)(3)(4), -1915 (1)(2)(a-c)

Based on observation, interview, and record review, the facility failed to ensure a resident that experienced past trauma received care and services directed at avoiding re-traumatization and promoting healing and recovery, in accordance with professional standards of practice for 1 of 3 residents (Resident 29), reviewed for trauma informed care. This failure placed the resident at risk for unidentified trauma triggers and re-traumatization. Findings included . Review of a policy titled, Trauma Informed Care, last edited 10/28/2024, showed the facility would collaborate with the resident and/or their family and provider to develop and implement individualized care plan interventions. Additionally, the facility would identify triggers which may re-traumatize residents with a history of trauma. Those identified triggers would be added to the resident's care plan. <Resident 29> Review of the medical record showed Resident 29 was admitted to the facility with diagnoses including parkinsonism (a progressive disease that causes rigidity, tremors, and unstable posture), aphasia (a disorder that affects the ability to communicate), vision and hearing loss. The 02/13/2025 comprehensive assessment showed Resident 29 was dependent on one to two staff for activities of daily living, including eating. The assessment also showed Resident 29 had a severely impaired cognition. During an interview on 03/17/2025 at 12:59 PM, Resident 29's representative (RR) stated the resident was severely physically and mentally abused by their spouse, and their mother growing up. The RR stated Resident 29 had triggers (a stimulus, situation, or memory that causes a strong emotional or physical reaction to past trauma or negative experiences), specifically with any fast movements and/or movement towards their face. The RR stated Resident 29 needed to be fed slow because they were scared due to the trauma and their limited vision. Review of a Social Service Assessment form, completed on admission, dated 06/06/2024, showed Staff J, Social Services Director, had completed the assessment and had noted Resident 29 had a prior history of abuse. The documentation showed the resident had repeated, disturbing memories, thoughts, or images of a stressful experiences from the past that were triggered by loud noises and was jumpy. Review of the care plan dated 03/17/2025, showed no documentation related to Resident 29's history of trauma or identified triggers. During an interview on 03/19/2025 at 8:29 AM, Staff J stated the process for screening for trauma included completing the Social Service Assessment. Staff J stated if the resident had a history of trauma, they would update the care plan with identified triggers and interventions. Staff J stated they were not aware of any concerns related to a history of trauma and/or abuse for Resident 29. During an interview on 03/20/2025 at 2:20 PM, Staff B, Director of Nursing, stated the Social Services Director was responsible for completing the trauma screen on admission. Staff B stated the identified trauma, and triggers should have been addressed and entered onto Resident 29's care plan. Reference: WAC 388-97-1060(1)(3)(e)

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents (Resident 2) reviewed for unnecessary medications. The failure to administer an anti-depressant medication as ordered placed the resident at risk for less than an optimal therapeutic effect and/or a potential negative health outcome. Findings included . Review of a policy titled, Medication Errors, dated 04/03/2024, showed the facility would ensure medications would be administered according to physician's orders. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including major depressive disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that interfere with daily life), and anxiety. The 12/27/2024 comprehensive assessment showed Resident 2 was dependent on one to two staff members for activities of daily living. Further review showed Resident 2 was taking an anti-depressant (type of medication used to treat clinical depression) medication and had an intact cognition during the assessment period. Review of a physician order dated 11/05/2024, showed an order for paroxetine (a brand of anti-depressant medication) to be given daily for Resident 2's diagnosis of depression and anxiety. Further review showed the medication was to be given for 90 days, with a stop date of 02/03/2025. Prior to the stop date, the Primary Care Provider (PCP) was to reassess the medication for necessity. Review of a provider visit note dated 01/28/2025, showed Resident 2's medication was reviewed by the PCP with an order to continue the anti-depressant medication daily ongoing indefinitely. Review of the February 2025 medication administration record (MAR) showed the antidepressant medication was discontinued on 02/03/2025. Additionally, the record showed an order on 02/21/2025 for the anti -depressant medication once daily to be restarted (18 days after the original order was discontinued even though the PCP gave an order to continue the anti-depressant medication on 01/28/2025). During an interview on 03/20/2025 at 1:14 PM, Staff B, Director of Nursing, stated the order for the anti-depressant medication for Resident 2 did not get continued after the original order, written for 90 days, had been discontinued. Staff B stated they did not see that anyone had caught that medication error. Staff B further stated the process for receiving orders for any medication change was to review the current order to ensure no changes needed to be made. Staff B stated the process was not followed for Resident 2, and it was just missed. During an interview on 03/20/2025 at 4:36 PM, the PCP stated they were not notified of the medication error and had discovered the error while they were doing a review of Resident 2's medications. The primary care provider further stated they would expect to be notified on any medication errors. Reference: WAC 388-97-1060(3)(k)(iii)

Based on observation, interview, and record review, the facility failed to obtain a current hospice written agreement and develop and implement a process that ensured effective communication, collaboration, and coordination of care between the facility and hospice provider for 1 of 2 residents (Resident 14) reviewed for hospice services. This failure placed the resident at risk for not receiving necessary care and services at end-of-life. Findings included . Review of a policy titled, Hospice Services Coordination, dated 01/22/2024, showed the facility would maintain a written agreement with the hospice provider that specified the care and services to be provided and the process for hospice and nursing home communication. The facility would communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility. <Resident 14> Review of the medical record showed Resident 14 was admitted to the facility with diagnoses including Parkinson ' s disease without dyskinesia (a progressive disease that destroys memory and other important mental functions, and causes tremors, rigidity, and slowness of movement, but without involuntary movements), and heart failure. The 02/06/2025 comprehensive assessment showed Resident 14 was dependent on one to two staff for activities of daily living and was able to make their needs known. Review of the written hospice agreement titled Nursing Facilities Services Agreement, dated 08/01/2019, showed the agreement would be reviewed no less than annually. There was no documentation that the document was reviewed since the initial agreement dated 08/01/2019 and was not signed by an authorized representative of the facility. Review of a document titled Medicare Election Form- [NAME], dated 03/12/2025 showed the Resident 14 ' s Representative enrolled Resident 14 into Hospice services with a Start of Care Date of 03/12/2025. Review of Resident 14 ' s care plan, showed no focus area, goals, or interventions related to hospice services until 03/18/2025. During an interview on 03/17/2025 at 10:13 AM, Collateral Contact 1 (CC1), Hospice Registered Nurse, stated Resident 14 was brand new to hospice services and they were performing their initial assessment. They stated there should be a care plan in place for Resident 14. CC1 stated they gave a verbal report to the facility nursing staff before and after each visit. During an interview on 03/19/2025 at 1:29 PM, Staff M, Licensed Practical Nurse, stated there was a binder for staff to leave notes for Hospice, but generally they would do a phone call or fax with the Hospice staff if there was a need. They stated Resident 14 was new to Hospice and did not have anything in the binder yet and the binder was mostly used for the nursing assistants to communicate things like showers. Review of the Hospice Communication Log showed no entries for Resident 14. During an interview on 03/20/2025 at 2:49 PM, Staff B, Director of Nursing, stated the process for ensuring the facility had a current agreement was the responsibility of the Administrator and the facility was working on an updated agreement. They stated the process for communication, collaboration, and coordination of care between the facility and the Hospice provider included the Hospice providers receiving the referral for services, meeting with the resident and/or their representative, and formulating care plan. They stated once the services were initiated, the Hospice staff would inform the nursing staff when they entered the building to perform services, sign in/out of the Hospice logbook, and report findings of their visit to both the nurse and the family. Staff B stated they expected facility nursing staff to document visits/conversations with the Hospice staff in the nursing progress notes. Reference: WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure 4 of 5 (Staff C, D, E and F) sampled agency (contracted) staff whose personnel files were reviewed, showed established proficiency with the operation of mechanical lift transfers prior to or at the time of assignment to the facility. This failure placed the residents at risk for falls and their associated injuries. Findings included . Review of an undated and modified facility policy titled Safe Resident Handling/Transfers showed, two staff members must transfer residents with a mechanical lift. The policy directed the staff to position the resident in preparation for the transfer and apply, adjust, and secure the lift sling according to the manufacturer's guidelines. The policy instructed the staff that if a sit-to-stand lift [a lift that required the resident to bear some of their own weight and participate actively in the transfer] was used, to additionally secure the resident by buckling up the lift sling around the resident's waist prior to the transfer. Review of a 02/06/2024 care plan intervention showed Resident 1 was not able to pull [themselves] up to a standing position with one person assist. This intervention instructed the staff to transfer the resident with the use of a sit to stand lift with 2 person assist. Review of a 12/31/2024 facility investigation showed Resident 1 experienced a fall from the sit-to-stand lift the morning of 12/31/2024 and required a hospital transfer for further evaluation. The investigation showed Staff C, Agency Nursing Assistant (NA), and Staff D (Agency NA) were involved in Resident 1's transfer from the bed to the wheelchair the morning of the fall. In an interview on 01/07/2024 at 1:41 PM, Staff C stated, It hasn't even been a month, a couple of weeks [working with the staffing agency]. Staff C shared they recently completed their NA training then went to work directly with the staffing agency. Staff C recalled being exposed once to the use of a Hoyer lift (a lift that allows a resident to be fully lifted and transferred with no physical effort, unlike a sit-to-stand) at a different facility. Staff C was asked if they knew what the facility policy was regarding the use of a mechanical lift transfer and stated, No, not really. I don't know. When asked if they received any training on the use of mechanical lifts at the facility, Staff C stated, The first time I arrived [at the facility] another aide gave me a packet that had all that resident information, like a rundown of my residents and the assistance they needed, and what time I get my breaks and that's everything. Staff C stated that Staff D left them alone in the room with Resident 1 in a standing position in the sit-to-stand. Staff C described Resident 1 then leaned forward and slowly slid off the foot plate of the sit-to-stand and, I was in shock, confused, and didn't know what to do so, I laid [the resident] on the floor. Staff C stated that they did not remember seeing the lift sling buckle secured around the resident's torso. Staff C stated, I didn't put the sling on [the resident], it was the other aide. In an interview on 01/03/2024 at 2:37 PM, Staff D stated that when they were returning to Resident 1's room, they saw Staff C, ran out into the hall and said [Resident 1] fell . Staff D stated that when they entered the room, Resident 1's face was down and arms were up and, did not have the buckle on, just the sling around [their] back. Staff D stated, The buckle is for safety so they can't slip or fall. In an interview on 01/03/2025 at 11:11 AM, Staff B, Director of Nursing, was asked if the facility verified Staff C and Staff D were proficient in the use of mechanical lift transfers prior to their assignment or upon their arrival to the facility. Staff B stated that they received no records from the staffing agency and that, We get their basics [information] to verify their licenses and No, we didn't do our competencies or orientation [with Staff C and Staff D]. In an interview on 01/07/2025 at 9:32 AM, Staff G, Staffing Coordinator, stated that once they confirmed an agency aide was available for open shifts, they requested a Caregiver Profile (CP) from the staffing agency. The CP included, background checks, licenses, immunizations, work history, and references. Staff G stated that a proficiency skills checklist was automatically included with the CP and if it wasn't, they would request it. Staff G stated that once they received the CP, they reviewed it, forwarded it to the Human Resources Department, then scheduled the aide to work. Staff G stated that orientation of agency staff in the facility included providing knowledge of assignment and supply's locations, a little bit on the residents, and was not based on the proficiency skills checklist received from the staffing agency. In the continued interview of 01/07/2025 at 9:32 AM, Staff G stated Staff C, was super new to our facility, and worked two shifts, on 12/20/2024 and 12/31/2024 (the day of the fall). Staff G requested Staff C's proficiency skills checklist from the staffing agency on 01/03/2024, three days after the fall and 15 days after the initial day of work. In the continued interview of 01/07/2025 at 9:32 AM, Staff G confirmed Staff D worked in the facility on 12/02/2024, 12/03/2024, 12/05/2024, 12/09/2024, 12/11/2024 12/14/2024, 12/15/2024, 12/21/2024, 12/22/2024, 12/24/2024, 12/25/2024, 12/28/2024, 12/30/2024, and 12/31/2024. Review of the CP with Staff G showed no documentation the facility established Staff D's skills proficiency. In the continued interview of 01/07/2025 at 9:32 AM, Staff G stated that the facility employed a total of 21 agency NA. Staff E worked on 12/13/2024 and accepted assignments in the facility since 04/26/2024. Staff F worked on 12/14/2024 and accepted assignments in the facility since 04/07/2024. Review of the CP with Staff G showed no documentation the facility established Staff E's or Staff F's proficiencies. In an interview on 01/03/2025 at 11:35 AM, Staff A, Administrator, stated that agency staff proficiency, should be obtained and confirmed prior to their coming to work or at the time of their shift. Absolutely, like ASAP [as soon as possible]. No further information was provided. Refer to F689. Reference WAC 388-97-1080 (1), -1090 (1), -1680 (2)(a)(b)(i-ii)(c).

Based on observation, interview, and record review, the facility failed to ensure the staff implemented safe transfer technique during the operation of a mechanical lift for 1 of 3 (Resident 1) sampled residents reviewed for accidents. This resulted in Resident 1 experiencing a fall from a mechanical lift and a transfer to the hospital for further evaluation. Findings included . An undated and modified facility policy titled Safe Resident Handling/Transfers showed, two staff members must transfer residents with a mechanical lift. The policy directed the staff to position the resident in preparation for the transfer and apply, adjust, and secure the lift sling according to the manufacturer's guidelines. The policy instructed the staff that if a sit-to-stand lift [a lift that required the resident to bear some of their own weight and participate actively in the transfer] was used, to additionally secure the resident by buckling up the lift sling around the resident's waist prior to the transfer. Review of an 11/08/2024 comprehensive assessment showed Resident 1 admitted to the facility on [DATE] with a progressive neurological condition. The assessment showed the staff assessed Resident 1's cognition was severely impaired and dependent on the staff for transfers. Review of a 02/06/2024 care plan intervention showed Resident 1 was not able to pull [themselves] up to a standing position with one person assist. This intervention instructed the staff to transfer the resident with the use of a sit to stand lift with 2 person assist. An observation on 01/03/2025 at 10:17 AM showed two staff transferred Resident 1 from their wheelchair to the restroom in a sit-to-stand lift. Closer observation showed a dark purple bruise extending from the side of Resident 1's left elbow to the middle of the forearm, approximately 6 inches by 3 inches in size. Review of a 12/31/2024 progress note showed a nurse was called to Resident 1's room. The note showed that the nurse found Resident 1 face down on the floor and fell in mid-transfer from bed to wheelchair via sit to stand. The note showed the staff had Resident 1 transferred to the hospital for further evaluation. Review of a 12/31/2024 emergency room Summary showed Resident 1 presented to the emergency room with face and arm pain. The summary showed Resident 1 experienced a fall with a resulting cut inside the mouth and bruising to the upper gums and left upper arm. The notes showed there was no serious traumatic injury. Resident 1 was discharged back to the facility in stable condition that same day. Review of a 12/31/2024 facility investigation showed Resident 1 experienced a fall from the sit-to-stand lift the morning of 12/31/2024. The investigation showed Staff C, Agency Nursing Assistant (NA), and Staff D (Agency NA) were involved in Resident 1's transfer from the bed to the wheelchair the morning of the fall. In an interview on 01/07/2024 at 1:41 PM, Staff C stated that after providing personal cares to Resident 1 with the help of Staff D, they assisted the resident to sit at the edge of the bed, then stood the resident up with the sit-to-stand lift. Staff C stated that after the resident was assisted to a standing position, [Staff D] left me to go get other residents up. Staff C described Resident 1 then leaned forward and slowly slid off the foot plate of the sit-to-stand and, I was in shock, confused, and didn't know what to do so, I laid [the resident] on the floor. Staff C stated that they did not remember seeing the lift sling buckle secured around the resident's torso. Staff C stated, I didn't put the sling on [the resident], it was the other aide. Staff C stated that it was required to have two people present during a mechanical lift transfer, To keep an eye out for the resident in case like accidents like this, for safety reasons. Staff C stated that some of the things they would do to prevent a fall from a mechanical lift included, Double check everything. Like for future reference, make sure, be cautious. After this incident I would never be too sure, and double check. In an interview on 01/03/2024 at 2:37 PM, Staff D stated that when they were returning to Resident 1's room, they saw Staff C, ran out into the hall and said [Resident 1] fell . Staff D stated that when they entered the room, Resident 1's face was down and arms were up and, did not have the buckle on, just the sling around [their] back. Staff D stated, The buckle is for safety so they can't slip or fall. In an interview on 01/03/2025 at 11:11 AM, Staff B, Director of Nursing, stated that the investigation deducted, The lower waist belt was not buckled. Staff B acknowledged Staff C and Staff D did not follow the intervention that instructed the staff to transfer the resident with 2 person assist during the use of a sit-to-stand lift. The above findings were shared with Staff A, Administrator, on 01/07/2025 at 10:14 AM. Staff A stated the staff, did not follow the care plan. If [they] did what was supposed to be done, that could have prevented it [the fall]. Refer to F726. Reference WAC 388-97-1060 (3)(g).

Based on interview and record review, the facility failed to provide care in a dignified manner related to bathing frequency for 2 of 3 residents (Resident 1 and 2) reviewed for dignity. This deficient practice placed the residents at risk for distress, embarrassment, and an undignified existence. Findings included . <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dysarthria (where you have difficulty speaking because the muscles you use for speech are weak), and history of small strokes. Review of the comprehensive assessment, dated 05/17/2024, showed Resident 1 had moderate cognitive impairment and required the assistance of two people for toileting and transfers, and the assistance of one person for dressing and personal hygiene. During an interview, on 08/19/2024 at 10:30 AM, a Resident Representative (RR) stated they had visited Resident 1 on 08/11/2024 and was unable to give Resident 1 a hug at the end of the visit due to Resident 1's pungent (a strong, sharp, and unpleasant smell) odor. RR stated Resident 1 had a strong smell of body odor and sweat, and .they (Resident 1) would be so embarrassed if they realized how they smelled. Review of the medical record showed Resident 1's bathing schedule was to be assisted with showers two times per week on Mondays and Thursdays. Review of the bathing record for dates 07/23/2024 to 08/22/2024 (the last 30 days), Resident 1 was scheduled for assistance with nine showers. The bathing record showed the following documentation: 07/25/2024-Not Applicable 07/29/2024-Shower 08/07/2024-Not Applicable 08/08/2024-Not Available 08/12/2024-Refused 08/15/2024-Not Applicable 08/19/2024-Not Applicable 08/20/2024-Not Applicable 08/22/2024-Shower Resident 1's bathing record showed they received assistance with a shower two out of nine times in a 30-day period. <Resident 2> Review of the medical record showed Resident 2 admitted to the facility on [DATE] with diagnoses of dementia, heart failure, and generalized weakness. Review of the comprehensive assessment, dated 07/12/2024, showed Resident 2 had moderate cognitive impairment and required the assistance of two people for transfers and toileting, and the assistance of one person for dressing and personal hygiene. Review of the medical record showed Resident 2's bathing schedule was to be assisted with showers two times per week on Sundays and Wednesdays. Review of the bathing record for dates 07/23/2024 to 08/22/2024 (the last 30 days), Resident 2 was scheduled for assistance with nine showers. The bathing record showed the following documentation: 07/24/2024-Not Applicable 08/04/2024-Not Applicable 08/07/2024-Not Applicable 08/11/2024-Not Applicable 08/14/2024-Shower 08/18/2024-Shower 08/20/2024-Not Applicable 08/21/2024-Shower Resident 2's bathing record showed they received assistance with a shower three out of nine times in a 30-day period. During an interview, on 08/22/2024 at 2:23 PM, Staff D, Nursing Assistant (NA), stated the daily shower schedule was posted on the whiteboard in the charting area, and there was a master schedule in the bathing book. Staff D stated there were typically two showers scheduled per hallway (total of four hallways) and when they were fully staffed with four or more NAs, there was no problem getting showers completed. Staff D stated showers that were documented as Not Applicable were showers that did not get done, .likely due to being short staffed. During an interview, on 08/22/2024 at 2:30 PM, Staff E, NA, stated each hall assignment usually had two scheduled showers on Day Shift and Evening Shift, and if showers were not completed, the assigned NA would either document Not Applicable or leave it blank. Staff E stated they did not feel two or three showers in a 30-day period was hygienically enough for the residents. During an interview, on 08/22/2024 at 2:48 PM, Staff F, NA, stated the showers were completed more consistently when there was a bath aide (an NA dedicated to bathing residents for the shift), but .being short staffed makes it hard . to get the showers done. Staff F stated when they were unable to complete a shower, they leave the documentation blank and pass it on to the next shift. During an interview, on 08/22/2024 at 4:25 PM, Staff B, Director of Nursing, acknowledged the shower assistance documentation and stated they did not realize it was an issue. During an interview, on 08/22/2024 at 4:30 PM, Staff A stated .the staff do the best they can. That's all they can do. Reference: WAC 388-97-0180 (1-4)

Based on interview and record review, the facility failed to monitor the effectiveness of medications that affect blood pressure (BP [the force of blood against the walls of the arteries]) for 2 of 3 residents (Resident 1 and 3) reviewed for unnecessary medications. This deficient practice placed the resident at risk of developing abnormal vital signs (body temperature, heart rate, respiration rate, and BP), experiencing adverse side effects, and the potential of receiving medications unnecessarily. Findings included . <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dysarthria (where you have difficulty speaking because the muscles you use for speech are weak), and high Blood Pressure (BP). Review of the comprehensive assessment, dated 05/17/2024, showed Resident 1 had moderate cognitive impairment and required the assistance of one person for eating, dressing and personal hygiene. Review of the August 2024 Physician's Orders (POs) showed Resident 1 was prescribed three medications (Lasix, Lisinopril, and Atenolol) for the diagnosis of hypertension (high blood pressure). Further review of the POs showed the medication Lisinopril had additional instructions-hold administration if Resident 1's Systolic Blood Pressure (SBP [top blood pressure value]) reading was less than 90. Review of the Medication Administration Records (MARs) for June 2024, July 2024, and August 2024 showed no documentation for routine BP monitoring with the administration of the high blood pressure medication Lisinopril. <Resident 3> Review of the medical record showed Resident 3 admitted to the facility on [DATE] with diagnoses of left above the knee amputation, heart disease including high BP, and severe obesity. Review of the comprehensive assessment, dated 07/26/2024, showed Resident 3 was cognitively intact, required the assistance of two people for personal cares. Review of the August 2024 POs showed Resident 3 was prescribed three medications (Bumex, Lisinopril, and Spironolactone) that affect and/or treat high BP. Further review of the POs showed the medication Spironolactone had additional instructions-hold administration if Resident 3's SBP reading was less than 100. Review of the MARs for June 2024, July 2024, and August 2024 showed no documentation for routine BP monitoring with the administration of the Spironolactone. During an interview, on 08/19/2024 at 3:10 PM, Staff C, Registered Nurse (RN), stated they obtained a BP reading prior to administering a high BP medication only when the order prompted them to. Staff C stated Resident 1's and Resident 3's orders for high BP medications did not have a prompt to check their BP before administration. Staff C stated administering medications without monitoring and/or considering the parameters was not safe. During an interview, on 08/22/2024 at 12:15 PM, Staff B, Director of Nursing, stated they were aware some medication orders had parameters and they felt it was a system that was not working. Reference: WAC 388-97-1060 (3)(k)(i)

Based on observation, interview, and record review the facility failed to ensure a severely cognitively impaired resident was free from non-consensual sexual abuse for 1 of 4 residents (Resident 2) reviewed for sexual abuse. Resident 1 was observed interacting with Resident 2 in a nonconsensual sexually inappropriate manner.The failure to adequately supervise Resident 1 with their known pattern of inappropriate sexual behaviors toward female residents placed Resident 2 at risk for continued sexual abuse. Findings included . Review of the facility' policy titled Abuse, Neglect, and Exploitation Policy, dated 09/10/2023, showed the definition of sexual abuse was nonconsensual sexual contact of any type with a resident. Review of the State Operations Manual, dated 03/06/2019, defined Sexual abuse at Code of Federal Regulation (CFR) 483.5 as nonconsensual sexual contact of any type with a resident. Generally sexual contact is nonconsensual if the resident lacks the cognitive ability to consent. <Resident 2> Review of the electronic medical record showed Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and the ability to carry out simple tasks), anxiety (a feeling of worry, nervousness, or unease), and insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep). Further record review showed Resident 2's cognition was severely impaired. Review of Resident 2's most current comprehensive assessment dated [DATE], showed the resident was dependent (a person that relies on staff do all the work due to the resident's inability to put forth effort or complete the activity at hand) on staff for their personal hygiene, dressing, toileting, transfers, and bed mobility. The resident required supervision or touching assistance with eating. Review of the care plan dated 05/23/2024 showed Resident 2 was not capable of making their own healthcare decisions and/or giving informed consent (the ability to understand/comprehend important information about their health/wellness and the possible risk/benefits of medical treatment in order to make an informed decision). During a concurrent observation and interview on 06/26/2024 at 3:44 PM Resident 2 was in the dining room participating in bingo activities, when bingo numbers were called out the resident had trouble identifying the correct number. When greeted Resident 2, responded to their name, was unable to comprehend questions being asked or respond/hold a meaningful conversation. <Resident 1> Review of the electronic medical record showed Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included a compression fracture (collapsing the bone in the front of the spine and leaving the back of the same bone unchanged), bipolar disorder (a brain disorder that causes changes in a person's mood, energy, or ability to function). Review of Resident 1's most current comprehensive assessment dated [DATE], showed the resident was cognitively intact, able to make their needs known, was easily understood by staff, and had the ability to express their ideas/wants with clear comprehension. Once Resident 1 was assisted into their wheelchair they were able to self-propel throughout the facility and no functional limitation of their upper and lower body. Review of an incident investigation report dated 06/10/2024 showed Resident 1 (a male resident 12 inches taller in stature to Resident 2) was in the dining room sitting in their wheelchair next to Resident 2 (a smaller female resident) who was also in their wheelchair. Resident 1 was being very friendly (towards Resident 2). Staff D, Registered Nurse (RN), after administering another residents medication, returned to the dining room to observe Resident 1 (a male who was 12 inches taller in stature than Resident 2) had proceeded to maneuver their wheelchair into a position that had blocked Resident 2 (so that Resident 2's back was up against a table. Resident 1 was facing Resident 2 with their legs together .(Resident 1's) legs touching (Resident 2's) legs and had (Resident 2's) hand in (Resident 1's) lap, and (Resident 1) was giggling. Staff C, Social Services Director, conducted an interview with Resident 1 on 06/13/2024 where the resident stated they did not remember the incident or the other resident involved, .but I must have liked it. Further review of incident investigation report showed on 06/15/2024, Staff C was stopped by Resident 1 to discuss the incident further. Staff C stated that Resident 1 was defensively stating that the incident was by both consenting adults .I got a raging erection, I provoked it, but (Resident 2) seemed fine .it was uncomfortable and I put the tip out of my waistband . Staff C stated that Resident 1 was aware that the other resident involved in the incident was Resident 2 and Staff C informed Resident 1 they should not be exposing themselves to other residents. Additionally, Staff C stated that Resident 2 was not cognitively able to make those kinds of decisions. Record review of Resident 1's progress notes from February 2024 through June 2024, showed that Resident 1 had multiple episodes of sexual inappropriate behaviors as follows: On 02/10/2024 at 12:45 PM, Staff H, RN, documented that (Resident 1) asked another resident if (Resident 1) could touch (unidentified female residents) b**bs in the dining hall and that Resident 1 was educated on sexually inappropriate behaviors. On 05/13/2024 at 1:06 AM, showed Staff D, RN observed Resident 1 came out into the hallway after dinner and sat next to an unidentified female in their wheelchair. Resident 1 was observed reaching towards the unidentified female's lap. On 06/10/2024 at 7:47 PM, showed Staff D, observed Resident 1 in the dining room with Resident 2 being very friendly. Staff D documented (Resident 1) had maneuvered their wheelchair to block (Resident 2's) wheelchair so (Resident 2's) back was to table. During an interview on 06/26/2024 at 1:04 PM, Resident 1 stated they remembered the incident with Resident 2 on 06/10/2024. Resident 1 stated they were sitting in the dining room with Resident 2. Resident 1 claimed Resident 2 had lifted their shirt and exposed their breast to Resident 1, What is a man to do? Resident 1 stated, one thing led to another and that Resident 2 had consented but, nothing really happened. Further, as far as I'm concerned the incident has been blown out of proportion. During an interview on 06/26/2024 at 1:07 PM, Staff E, Nursing Assistant, NA, stated they were aware of Resident 1's inappropriate behaviors back when they were first admitted . During an interview on 06/26/2024 at 1:41 PM, Staff C, stated they had spoke with Resident 1 about the incident on 06/10/2024 and initially Resident 1 stated they were unable to remember anything about the incident. Staff C stated then three days later, Resident 1 communicated they had gotten an erection and let the tip out of their waist band and that Resident 2 had given consent. Staff C then stated they had informed Resident 1 that Resident 2 was unable to give consent due to their dementia. During an interview on 06/26/2024 at 2:34 PM, Staff G, Licensed Practical Nurse (LPN), stated Resident 2 had a hard time focusing and staying on task due to their dementia, (Resident 2) is not real with it (meaning they were cognitively impaired). Staff G stated that Resident 2 could not hold a meaningful conversation for any length of time. Staff G further explained that Resident 2 would not be able to give an informed consent such as if the resident were to get a new medication, they would not be able to understand why or what the medication was for. Staff G stated that Resident 1 had no impulse control and that they themselves have been subjected to Resident 1's inappropriate behaviors before, when Resident 1 inquired about the staff members tattoos which led to Resident 1 stating do you have tattoos on your b**bs too? Additionally, Staff G stated they kept an eye on (Resident 1), but there had been no implementation of one-on-one supervision (a method where an individual staff member stays close to a resident to ensure constant supervision and immediate intervention for safety reasons) for Resident 1. During an interview on 06/27/2024 at 9:36 AM, Staff D, RN, stated, I feel like Resident 1 is a predator (a person who hurts or takes advantage of others for personal gain) .their behavior usually happens after dinner, when the (Nursing Assistants, NA) are busy, and nurses are passing their medications. Staff D stated, on 06/10/2024 they peeked into the dining room, observed Resident 1 entering/self-propelling their wheelchair. Staff D stated that Resident 1 did not usually socialize after dinner. Then Staff D stated, they felt an urgency, to quickly finish administering some medications that were in their hands since they had concerns about Resident 1's intentions and being alone in the dining room with a female resident. When Staff D returned to the dining room, they observed Resident 1 had maneuvered Resident 2's wheelchair so Resident 2's back was against the table, (Resident 1's) knees against (Resident 2's) knees .(Resident 2) couldn't go forward or back, (Resident 2) couldn't get away. Staff D stated that Resident 2 was totally unaware of the situation and (Resident 1) had no shame (meaning that Resident 1 remorseful about their sexually inappropriate actions). Staff D stated .I did not call the police, or the power of attorney. I wrote my progress note. During an interview on 06/26/2024 at 4:49 PM, Staff A, Administrator, and Staff B, Director of Nursing Services, both stated that Resident 2 was not cognitively aware enough to make decisions. Both staff stated they had not implemented one-on-one supervision for Resident 1, but that Resident 1 was being watch more closely so they are not alone with the opposite sex. Additionally, Staff A and Staff B stated that Resident 1 did have a history of sexually inappropriate behaviors towards females. Reference: WAC 388-97-0640 (1)

Based on interview, and record review, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency, as required, for one of three sampled residents (Resident 1), reviewed for abuse. Failure to report alleged neglect placed Resident 1 and additional residents in the facility at risk for continued neglect and poor quality of life. Findings included . Review of the facility's policy titled Abuse, Neglect and Misappropriation Policy, dated 09/10/2023, showed the facility was to report all alleged violations to the Administrator, State Agency, and all other required agencies in specified time frame. Review of the facility assessment, dated 12/15/2023, showed Resident 1 had diagnoses which included a neurological disorder. The resident was able to make their needs known. Per a facility investigation, initiated on 04/17/2024, Resident 1's representative reported to the facility they felt Resident 1 was being neglected and denied liquids. The allegation had not been reported to the State Agency, as required. During an interview on 04/25/2024 at 2:17 PM, Staff A, Director of Nursing (DNS), stated they had received the phone call from Resident 1's representative who alleged Resident 1 had been neglected. Staff A stated an investigation was done and neglect had not been suspected, so didn't think it met the criteria to call it to the State Agency. F-609 Reporting of Alleged Violations is a repeat deficiency; See Statement of Deficiencies dated 02/09/2024. Reference: WAC 388-97-0640 (5) (a)

Based on observation, interview, and record review, the facility failed to identify the risk of hot liquids, adequately supervise, and initiate interventions for the safe use of hot liquids for a resident who required staff assistance with drinking fluids for 1 of 3 residents (Resident 6), reviewed for accidents. Resident 6 experienced harm as they sustained a second degree burn to their right thigh. Additionally, the facility failed to safeguard the residents' environment by securing cleaning chemicals for 2 of 3 common resident bathrooms (bathrooms [ROOM NUMBERS] on hall D ) and 2 of 2 shower rooms (shower rooms [ROOM NUMBERS] on hall D), reviewed for environment. These failures placed the residents at risk for injury and/or medical complications secondary to hot liquid spills and the ingestion of harmful chemicals. Findings included . Review of the State Operations Manual, Appendix PP, last revised February 2023, Code of Federal Regulation 483.25 (d) F-689 Accident hazards, showed second-degree burns involve the first two layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin. <Hot Liquids> <Resident 6> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include intracerebral hemorrhage (a condition in which a ruptured blood vessel causes bleeding inside the brain), macular degeneration (an eye disease that causes vision loss), and muscle weakness. Resident 6's comprehensive assessment, dated 01/12/2024, showed the resident's cognition was moderately impaired. Further review of the assessment showed the resident required one staff member supervision or touching assistance with eating and drinking. Review of Resident 6's medical record showed the resident had a hot liquid evaluation on 07/25/2021 which showed the resident was not at risk for injury from hot liquids. Further review showed no further evaluations had been completed until after the resident sustained an injury from hot liquids on 01/21/2024. Review of Resident 6's care plan, dated 10/24/2023, showed the resident was to use a lipped plate for meals, receive thin liquids, and showed no documented risks regarding hot liquids. A dining observation on 02/04/2024 at 9:06 AM, showed Resident 6 in shorts with a large wound dressing to their right inner thigh, and were feeding themself without supervision or assistance. Further observations on 02/05/2024 at 11:32 AM, 02/06/2024 at 11:52 AM, 02/07/2024 at 12:32 PM, and 02/08/2024 at 11:22 AM, showed Resident 6 feeding themself and drinking a beverage without supervision or assistance. Review of a nursing progress note, dated 01/21/2024, showed Resident 6 spilled hot liquid down their front side and had reddened areas to their stomach and right thigh. During the nursing assessment, Resident 6 stated it felt like hell. Review of Resident 6's skin assessment, dated 01/21/2024, showed the resident had three blisters to their right thigh from the hot liquid spill. The three blisters measured one centimeter (cm, a unit of measure) by four cm; one cm by one cm; and one cm by four cm. Review of a 01/28/2024 skin assessment showed no documented measurements of the blisters. Review of a skin assessment, dated 01/30/2024, showed Resident 6 had two blisters to their right thigh with measurements of 14 cm by three cm, and six cm by 1.5 cm with yellow eschar (dead tissue that sheds or falls off from the skin) in the wounds. During an interview on 02/08/2024 at 10:11 AM, Staff L, Charge Nurse (CN), stated Resident 6 had a right thigh burn and had a daily wound care. Staff L explained that there were three areas that were cleaned with wound spray, then a pure gel (a water-soluble agent that reduces pain, protects the wound area from contamination and further injury) was applied to the wound, a collagen strip (a biomaterial that encourages wound healing) was applied to the wound, and then it was covered with two large gauze pads. During an interview on 02/08/2024 at 10:55 AM, Staff M, Restorative Aide (RA), stated Resident 6 had a morning restorative program but due to the burn on their leg, they were currently unable to complete their walking in the restorative program. During an interview on 02/08/2024 at 11:22 AM, Resident 6 stated they had burned their leg with coffee and now the staff had them using a lid on their cup any time they were drinking hot liquids. Resident 6 stated on the day of the 01/21/2024 incident, they had lost their grip of the cup and the hot coffee fell in their lap causing the burn. An observation of Staff L, CN, performing wound care on 02/08/2024 at 2:00 PM, showed Resident 6's right thigh had three large areas that were open. The wound beds had yellow eschar with redness around the wound edges. During an interview on 02/08/2024 at 4:18 PM, Staff B, Director of Nursing Services, stated the kitchen staff were not checking temperatures of the hot liquids and the coffee was delivered from the kitchen in a carafe (a container with a flared lip for serving liquids) for staff to serve to the residents. During an interview on 02/08/2024 at 4:26 PM, Staff G, Dietary Manager (DM), stated on 02/05/2024, they had their food vendor come out to lower the temperature on their coffee machine. During an interview on 02/09/2024 at 8:16 AM, Staff I, Cook, stated they did not check the temperatures of coffee served to residents, nor was it checked prior to Resident 6's hot coffee spill incident. During an interview on 02/09/2024 at 8:49 AM, Staff L (CN), stated Resident 6 had a second-degree partial thickness burn to their right thigh. Additionally, Staff L stated the measurements documented on the 01/30/2024 skin assessment only showed two of the areas on the thigh due to the third open area being difficult to measure. <Environment> Record review of the undated Material Safety Data Sheet for Micro-kill disposable disinfectant wipes (a pre-moistened towelette that contains a sanitizing disinfecting formula that kill or reduce germs on surfaces) showed, .Emergency overview: Do not get into eyes .wash thoroughly with soap and water after handling and before eating or drinking .if ingested rinse mouth, do not induce vomiting and obtain emergency medical attention . Observations on 02/04/2024 at 8:41 AM and 2/08/2024 at 1:13 PM, showed two bathrooms and two shower rooms located on the D hall with unsecured chemicals: Shower room [ROOM NUMBER]. One opened Micro-kill tub of disinfectant wipes observed in an unsecured cabinet. Shower room [ROOM NUMBER]. One opened Micro-kill tub of disinfectant wipes observed in an unsecured cabinet. Bathroom [ROOM NUMBER]. One opened Micro-kill tub of disinfectant wipes observed unsecured, on top of a cabinet in front of the toilet, and in an unsecured cabinet. Bathroom [ROOM NUMBER]. One opened Micro-kill tub of disinfectant wipes observed in an unsecured cabinet. During an interview on 02/08/2024 at 1:21 PM, Staff A, Administrator, stated that the cabinets in the shower rooms and bathrooms were closed, but they should have locks on them. Staff A stated the staff know better and should not have left the chemicals in the shower/bathrooms unsecured. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to implement key interventions to safeguard, protect and prevent a resident from eloping outside of the facility (an instance where a resident leaves the facility without authorization and/or any necessary supervision to do so) for one of three residents (1), reviewed for accidents/hazards; by the resident having access to an unsecured/unsupervised egress (an exit from the facility) door. This failure resulted in an Immediate Jeopardy (IJ), on 10/21/2022, for Resident 1 who had been unsupervised for six minutes and in that time had eloped from the facility at without a door alarm sounding or staff's knowledge. Review of local weather temperatures (at the time of Resident 1's elopement) showed that it had reached 43 degrees Fahrenheit and after 48 minutes the resident had traveled one quarter of a mile away from the facility, sustained multiple lacerations (a deep cut in the skin) and abrasions (a scrape of skin taken off) to the head, face, hands/shoulder which required Resident 1 to be transferred by emergency services to the hospital. Furthermore, the facility failed to identify all hazards/risks and implement adequate alternative supervision/alarm interventions for 155 days after their Wander Guard (WG, a system that safeguards high risk residents by alarming staff of possible resident elopement) had stopped functioning. These failures resulted in serious injuries to Resident 1 and increased the likelihood/risk of serious imminent harm for all 17 residents that the facility had identified as a moderate to high risk for elopement, which constituted an Immediate Jeopardy (IJ). On 10/21/2022 at 2:10 PM, the facility was notified of an IJ at CFR 483.25 (d)(1)(2) F689, Free of Accident/Hazards/Supervision/Devices, related to the facility's failure to implement key interventions to safeguard, protect and prevent a resident from an elopement. The facility removed the immediacy on 10/24/2022 with an onsite verification from investigators by, implementing a continuous sounding alarm on all facility egress doors (and main hallway door to the resident care areas) that were activated at all times, re-education of all staff (prior to working their next scheduled shift) regarding elopement policies/procedures and new measures implemented, which ensured an effective system was in place to safeguard, protect and prevent residents that were at risk for elopement. Findings included . Record review of the facility's policy titled, Elopement, dated 10/18/2016, showed that upon return of a resident (after an elopement event) the Social Service Director (SSD) shall complete an elopement risk assessment. Resident 1. Review of the resident's medical records showed they were admitted on [DATE] with a diagnosis of Dementia (an impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Furthermore, the resident had a severe cognitive impairment, was able to ambulate independently and, until the recent cease (come to an end) in function of the WG system, had worn the device that would have set off the WG system. Review of the elopement risk assessment dated [DATE] showed that the resident was a moderate risk and had a history of wandering (a resident that strays beyond the view or control of staff and aimlessly moves about within a building or grounds without appreciation of their personal safety). Review of the Resident 1's elopement investigation, dated 10/19/2022, showed that on 10/18/2022 between 12:15 AM and 12:22 AM Resident 1 eloped from the facility. Review showed the resident varies on their instances of wandering or exit seeking, and that during the elopement incident the gray doors separating the resident care area and administration offices leading to the front exit was not closed at this time (it was propped open). Furthermore, the records showed it was tracked that Resident 1 may have exited through the front door . Additionally, the records did not show implementation of adequate interventions to safeguard, protect and prevent Resident 1 from eloping again. Review of Resident 1's updated elopement care plan, dated 10/18/2022, showed that 15 minutes checks were implemented after the resident had eloped from the facility (although on the night of the incident the facility determined that Resident 1 eloped from the facility after six minutes without supervision). Review of the elopement risk assessment after Resident 1 successful elopement on 10/18/2022 showed that it had not been completed. Observation on 10/20/2022 at 1:14 PM showed that when the front door was opened that a quick two sound, quiet low volume, no continuous audible notification (a chime) was heard. A concurrent observation and interview on 10/20/2022 at 1:34 PM showed that the main double doors (gray double doors) that separated the resident care area from the administration offices was propped in the open position. When inquired about the gray double doors, Staff E, Licensed Nurse, stated that they were to remain closed only during mealtimes. Review of multiple/local weather resources for 10/18/2022 at 12:00 AM showed that the temperature was at 43 degrees Fahrenheit. Observations on 10/20/2022 at 11:00 PM showed that when the front door was opened the same two sound audible notifier was heard. Furthermore, the same gray double doors that separated the resident care area from the administration offices were propped in the open position. Additionally, no staff were observed in the administration office section of the building and staff were mainly in the resident care section of the building during the nighttime hours. During an interview on 10/20/2022 at 11:00 PM, Staff D, Resident Care Manager (RCM), stated that the old WG system had been in place right after the gray double doors so that an alarm would notify staff if a resident had passed through the double doors and into the administration offices during the nighttime hours. When asked what was currently in place instead of the WG system by the gray double doors, Staff D stated, We don't have anything, and something should be there. During an interview on 10/20/2022 at 11:26 PM, Staff G, Nursing Assistant (NA), stated that if they were in a resident's room during the nighttime hours, they would not have been able to hear any alarm/audible notifier sounding off past the gray double doors. During an interview on 10/21/2022 at 12:08 AM, Staff H, NA, stated that they had seen Resident 1 pass through the gray double doors and make their way to the front door of the facility on a couple of different occasions. During an interview on 10/21/2022 at 9:40 AM, Staff F, Maintenance Director (MD), stated that the front door to the facility was a chime and was not set for a continuous alarm, In my opinion it should be alarmed (the front door), but it is not, and continuous alarms have not been placed on the front door or the gray double doors because they were opened continuously throughout the day. Staff F further stated that it was previously discussed/determined during the facility's team meeting's that Resident 1's elopement route had taken them through the gray double doors and out of the facility via the front door, and no alarm had sounded or had been heard by staff because the front door was set to chime as the audible notifier. Record review of Staff F's sequence of events regarding the WG system, showed that on 05/05/2022 the WG system had begun malfunctioning and then on 05/19/2022 stopped working altogether. During an interview on 10/21/2022 at 10:00 AM, Staff C, SSD, who conducted the elopement investigation on Resident 1, stated that the resident had sustained multiple wounds/injuries to the forehead/face and was found one quarter mile away from the facility with no alarm having been set off, I really think (Resident 1) came through the front door. Staff C stated (after Resident 1 had eloped) that even though they implemented 15-minute checks along with closure of the gray double doors after six o'clock at night after Resident 1 eloped, it was still not adequate. Staff C further stated that staff working the resident care area beyond the gray double doors would not be able to hear the front door chime and that Resident 1 could still get through the gray double doors on their own. Additionally, Staff C stated, I think someone can still elope .someone can get through the double doors and elope right now at night, and that the facility did not have an adequate process in place to safeguard residents at risk for elopement. During an interview on 10/21/2022 at 10:38 AM, Staff I, NA, who had been working the night that Resident 1 eloped, stated that during the nighttime hours staff get busy with other residents and were not always able to watch/conduct 15-minute checks on Resident 1 and that is why they had the old WG system that would alarm them. Staff I further stated, I think (Resident 1) needs to be one on one (one person in charge/designated to watch over one resident), also that the current process/interventions that were in place were not sufficient and that it was possible for Resident 1 to elope again. Observation on 10/21/2022 at 11:02 AM showed Resident 1 had a laceration of the left eyebrow/forehead, along with an abrasion to the left cheek and a slight purple/brown tinted bruise to the left eye socket. Further observations showed multiple abrasions and bruising to Resident 1's hands and left shoulder areas. During an interview on 10/24/2022 at 1:20 PM, Staff J, Registered Nurse (RN), who was working the night that Resident 1 eloped, stated that the resident had to have gone out the front door, and that they did not/would have not heard an alarm or chime by the front door. Staff J further stated that if the old WG system (or something similar) was still in place they would have been alerted to Resident 1's elopement. During an interview on 10/26/2022 at 12:22 PM, Staff A, Administrator, and Staff B, Director of Nursing Services, stated that they both agreed that they could have implemented different interventions after the WG system had stopped functioning. Further, that they should have gotten together with their team to come up with different ideas regarding safeguards/protection and prevention of resident elopements, along with placing continuous nonstop alarms on the gray double doors and the front door of the facility. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility's Administration failed to effectively utilize its multidisciplinary resources to maintain the facility's compliance with federal regulatory requirements related to not implementing key interventions to safeguard, protect and prevent one of three residents (1), reviewed for accidents/hazards who was cognitively impaired and lacked safety awareness. The facility's Administration failed to ensure a functioning wanderguard (WG, a system that safeguards high risk residents by alarming staff of possible resident elopement) system or other effective preventative interventions were in place to prevent residents at risk for elopement (an instance where a resident leaves the facility without authorization and/or any necessary supervision to do so) from unsafe elopements. This failure resulted in harm to Resident 1 and/or increased the likelihood/risk of serious harm to all residents that had been identified by the facility to be at risk for elopement. In addition, the Administration failed to sustain substantial compliance at F-689 Free of Accident Hazards/Supervision/Devices, identified as failures in three continued out of compliance surveys in a two-month timeframe, of which two resulted in harm. Findings included . Review of the Maintenance Director's timeline statement (describing the sequence of events regarding the functionality of the WG system), dated 10/21/2022, showed that on 05/19/2022 the WG system had stopped working altogether. The record further showed that door alarms were implemented around the facility as a temporary solution to prevent a resident from eloping. Review of the Resident 1's elopement investigation summary, dated 10/19/2022, showed that Resident 1 successfully eloped from the facility on 10/18/2022 between the hours of 0015 and 0022 (12:15 AM and 12:22 AM) .may have exited through the front door . and no alarms were set off during the resident's elopement from the facility. Additionally, the records showed no adequate interventions were implemented to safeguard, protect, and prevent Resident 1 from eloping again. Observations on 10/20/2022, 10/21/2022 and 10/24/2022 showed that the facility's interventions in place were not adequate to prevent residents (at risk for elopement) from access to an unsecured/unsupervised area/egress door of the facility. Furthermore, observations showed that not all the facility's doors had continuous alarms that would sound and that some had only a two-chime (audile notifier) sound when opened. During an interview on 10/21/2022 at 10:00 AM, Staff C, Social Services Director (SSD), who conducted the elopement investigation on Resident 1, stated they identified the current system in place for elopement was not adequate. I think someone can still elope .someone can get through the double doors and elope right now at night. During an interview on 10/26/2022 at 12:22 PM, Staff A, Administrator, and Staff B, Director of Nursing Services, stated that they should have met as a team to discuss different ideas in regard to safeguarding/protecting and preventing residents at risk for elopements. Additional failures of the facility Administration were identified as the following: 1) F-865 CFR 483.75 (a)(1)-(4)(b)(1)-(4)(f)(1)-(6)(h)(i), QAPI Program/Plan, Disclosure/Good Faith Attempt; the facility's Administration failed to implement, effectively monitor, and maintain a Quality Assurance and Performance Improvement (QAPI) plan process. 2) F-837 CFR 483.70(d)(1)(2), Governing Body; the facility's Administration/Governing Body's lack of engagement/involvement in the management of the Quality Assurance Performance Improvement (QAPI) process along with the Facility Assessment in addition to, the timeline of actions taken by the Governing Body (when the WG systems stopped functioning) increased the likelihood/risk of injury/harm regarding resident elopements. 3) F-838 CFR 483.70(e)(1)-(3), Facility Assessment; the facility's Administration failed to sustain compliance with federal regulatory requirements related to conducting/documenting a Facility Assessment annually, for the years 2021 and 2022. During an interview on 10/24/2022 at 1:55 PM, Staff A, Administrator, stated that they first informed/notified (through their monthly administrator reports) the Governing Body of the WG system needing to be replaced in April 2022. Staff A stated that around June/July 2022 the governing body denied the funding for a new WG system. Staff A further stated that on 08/25/2022 they had the DNS and the Social Service Director (SSD) talk with the Governing Body about the WG system needing to be replaced, and in August 2022 the Governing Body approved the funding for the new WG system. During a continued interview on 10/24/2022 at 1:55 PM, Staff A stated that after the approval of the new WG system, it took time to get the supplies shipped and that the bulk of the supplies needed for the new WG system had come in around two weeks ago. Record review of the Governing Body's meeting minutes showed that on 08/31/2022 the Governing Body approved the funding for the new WG system (almost four months after being informed that the old WG system needed to be replaced). The WG invoice (receipt of the facility ordering the new WG system) showed that on 09/27/2022 the order for the new WG system was made (27 days after the approval of the funding for the new WG system). During an interview on 10/25/2022 at 4:21 PM, Staff O, Member of the Governing Body, stated that they knew the WG system had stopped working, but that they did not always, hear about when things happen, and wish there was more transparency (clear communications from the facility, on what had been happening). Staff O further stated that the Governing Body was not involved in the QAPI process of the facility.we need more transparency related to that (QAPI). Additionally, Staff O stated they were not aware of the requirement for the Facility Assessment, but were updated on facility staffing requirements and when equipment was needed. During an interview on 10/25/2022 at 4:42 PM, Staff A, Administrator, stated that Staff E was now the QAPI coordinator since January/February of 2022. Staff A further stated that the governing body had never been informed of QAPI and/or been involved in the construction of the Facility Assessment. Additionally, Staff A stated, It's been about a year since the Medical Director or pharmacy have been on the QAPI meetings. During a continued interview on 10/25/2022 at 4:42 PM, Staff A stated that the QAPI process was divided up between key staff/managers in the facility and each manager was to perform their own Performance Improvement Project's (PIPs, were concentrated efforts made/implemented by the facility on a particular problem in one area of the facility or facility wide that were formed from data identified through QAPI) but did not know of any other PIPs that the facility was working on since December of 2021. Don't know if we have reached that goal quite yet (regarding implementation of PIPs through key staff/managers in the facility). Review of the Facility Assessment, dated February 2022, showed that it was not completed, and did not involve the Medical Director, DNS, or a representative from the Governing Body. During an interview on 10/26/2022 at 9:27 AM, Staff A, Administrator, stated that the Facility Assessment was partially filled out in February of 2022 but that it was not completed and only had input from Staff A. Staff A further stated that the Medical Director, DNS, nor a member of the Governing Body were involved in the Facility Assessment for 2021 or 2022. Record review of the QAPI meeting minutes for July, August, September, and October 2022 showed that data collection from various sources was inadequate and did not include high risk, problem-prone adverse events that had happened recently within the facility. Records further showed that no PIP's were constructed and/or implemented around adverse events within the facility related to accident prevention/supervision. During an interview on 10/26/2022 at 10:27 AM, Staff E, QAPI coordinator, stated it was planned that Medical Director and pharmacy were going to attend a quarterly QAPI committee meeting, but that it was not happening. When asked if there were any PIPs for August/September 2022 that were currently being implemented, Staff E stated that they did not have any PIPs for August or September related accident prevention/supervision and that the last PIP was in December of 2021. Staff E stated that they had not added high risk/problematic areas into their monthly data collection and had not identified elopement or the WG system functionality as areas of concerns. The process is just not working properly right now. 4) F-726 CFR 483.35(a)(3)(4)(c), Competent Nursing Staff; the facility's Administration failed to ensure nursing staff had documented competencies and skill sets in accordance with professional standards of practice. Review of personnel files/annual evaluations for Staff J, Registered Nurse, Staff K, Nursing Assistant (NA) and Staff L, NA, showed that none of the staff had completed the required annual skills/competencies since the year 2020. During an interview on 10/26/2022 at 11:20 AM, Staff B, DNS, stated that they did not have the documented competencies and skill sets in accordance with professional standards of practice for Staff J, Staff K and Staff L since the year 2020. Staff B stated that they were aware of the competency requirement but had not found a consistent process to get them accomplished. Refer to F-689, F-726, F-838, and F-865 Reference: WAC 388-97-1620(1)

Based on observation, interview, and record review, the facility failed to ensure one of one resident (1) reviewed for accidents received adequate interventions and supervision to prevent wandering and falls. The failure to evaluate and analyze the risks of multiple unwitnessed falls and wandering, and to ensure interventions were provided, resulted in harm when the resident exited the building (from an area not intended for resident access) and fell from their wheelchair onto the concrete. Findings included . Resident 1. Review of the medical record showed the resident was admitted to the facility on [DATE]. Diagnoses included advanced dementia with disorientation. Review of Resident 1's admission assessment, dated 08/09/2022, showed they had severe cognitive impairment and required extensive assistance of one caregiver for all care provided. Review of Resident 1's 08/09/2022 care plan showed the resident had advanced disease process (Alzheimer's Disease/dementia) and impaired balance, physical mobility, and poor communication/comprehension. The resident was at risk for falls due to confusion, deconditioning, gait/balance problems, and being unaware of their safety needs. Review of an 08/02/2022 at 1:28 PM progress note showed the resident was found on the floor, in another resident's room yelling out to put me to bed. The medical record showed no incident investigation was completed nor were interventions identified to mitigate the risk of the resident's wandering and accidental falls. Review of an 08/04/2022 progress note showed an elopement risk assessment was completed and the resident was at risk for elopement due to current diagnoses and their ability to be self-propel independently in their wheelchair. There were no interventions added to their care plan. Review of an 08/06/2022 incident investigation showed the resident was found on the floor in front of their wheelchair in Hallway A and was heard to yell that they want to go back to bed. The incident report showed the resident resided on D Hallway. No new interventions were added, and the investigation conclusion showed that the resident was confused and impulsive and staff were not able to educate the resident to ask for help as [Resident 1] is not able to retain information .staff have been trying to anticipate resident needs . No additional interventions to reduce wandering/accident hazards were added. Review of an 08/07/2022 progress note showed at 12:15 PM, Resident 1 was found in Room 4 (not their room) on the floor next to the bed. The resident had attempted to self-transfer from their wheelchair to go to bed. No interventions were added to their care plan. Later, on that same day, 08/07/2022 a progress note showed the resident was found at 6:30 PM on the floor near the doorway to their room. The record showed no interventions or increased supervision was added to the resident's care plan. Review of an 08/14/2022 incident investigation showed the resident was found at 9:25 PM outside the kitchen exit lying on the ground, with their wheelchair beside them. The resident's glasses were broken, the resident had skin tears on the right eyebrow and knuckles, and an abrasion to the right knee. Review of an 08/15/2022 nurse's progress note showed the resident was able to respond to commands however was very irritated at being woken. The note showed the resident's right eye had blood drained down, the resident had a blackeye,and the right eyelid was swollen, discolored, and painful to touch. During an observation on 08/22/2022 at 11:40 AM the area where the resident eloped from the building and fell from the wheelchair was observed. To access the kitchen from the main hallway, one would have had to push open an unalarmed set of swinging double doors, then proceed approximately 10 feet to the exterior door. The exit door had a small white box (alarm) which sounded one chime when opened (audible only at the box). The exterior, just off the exit door, showed a 10-foot sloped concrete ramp which had a drop off of 8 inches onto the concrete below. During an interview on 08/22/2022 at 12:20 PM Staff B, Nursing Assistant (NA), stated they had worked the night of the resident's elopement. Staff B stated that they were assigned to the resident's care and usually laid them down after the 5:00 P.M. meal service. Staff B stated they were short staffed that evening and only two NAs were working. There were only two of us and it was very busy, and that Resident 1 goes all over the building. Staff B stated they looked for the resident for about 20 minutes throughout the facility and then notified the nurse. Within five minutes the resident was located outside the kitchen exit. During an interview on 08/22/2022 at 12:30 PM Staff C, Licensed Nurse, stated that on the evening of 08/14/2022 the residents were being cared for and put into bed. Staff C was notified by Staff B that Resident 1 was missing. A full search of the facility was conducted, which ultimately showed the resident had exited the kitchen door and had fallen out of their wheelchair onto the blacktop. Staff C stated that she recalled prior to the fall, the resident had been looking for their room and said they wanted to go to bed. Staff C stated that it is the busiest time (evening after meals) and that usually three aides were on duty and there were only two on duty that evening. During an interview on 08/22/2022 at 12:58 PM the Resident's Representative (RR) stated that on 08/14/2022, the facility called them between 10:15 PM and 10:30 PM and informed them that Resident 1 had a fall onto cement and had cuts over their right eye, their fingers were swollen, and the fingernail was bent back. The RR stated that the next day they went to the facility and noted the resident's eye was swollen shut and thumb was swollen and bruised. The RR stated that I gently pressed it (resident's thumb) and [Resident 1] flinched back. The RR stated there had been a couple occasions when they went to visit Resident 1 where facility staff could not find them. The RR stated that on 07/16/2022 at 2:00 PM when at the facility for a visit they couldn't find [Resident 1] about five minutes went by and they found them in a bedroom at the other end of the hall . it's frustrating because they're not doing what they told me they told me they would do. They said there would be someone there to help. During an interview on 08/22/2022 at 1:40 PM Staff A, Administrator, provided copies of two incident reports showing the resident experienced falls on 08/06/2022 and 08/14/2022. No incident reports were completed for the fall which occurred on 08/02/2022 and the two separate falls which occurred on 08/07/2022. Review of the care plan showed no interventions until 08/18/2022 (four days after the fall with injuries) which showed the resident was to be helped to bed, per their request, following meals. During an interview on 08/22/2022 at 1:55 PM Staff A acknowledged that interventions to reduce the risk of accidents and wandering were not included in the resident's care plan in a timely manner. Staff A stated that the Wander Guard system (a safety device that alerts when resident is out of facility) had not been working for more than a month and that Resident 1 was undetected moving through the double door and out the exit. Staff A stated that they recognized the failure to adequately supervise the resident and to complete thorough investigations with interventions. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to secure 26 oxygen cylinder tanks located in room [ROOM NUMBER] and the central supply room. This failed practice placed 36 of 36 residents residing in the facility at high likelihood of serious injury from the unsecured oxygen tanks. On 03/26/18 an Immediate Jeopardy (IJ) was identified. On 03/27/18 the IJ was removed. Additionally, the facility failed to ensure comprehensive preventive measures/corrective actions had been developed and implemented to attempt to prevent future falls for one of two residents (#37) reviewed for falls. Findings included: OXYGEN STORAGE Per the Office of Compliance Fast Facts (MONTH) 2006 Volume 1 Number 8, .Potential Dangers of a Pressurized Cylinder: pressurized cylinders, used to store various flammable and nonflammable gases, are likely to fall over if left unsecured. Such a fall could cause damage to the cylinder's valve or the cylinder itself, resulting in a gas leak. A rapid loss of pressure can turn a cylinder into an unguided missile powerful enough to break through a concrete wall . On 03/26/18 at 9:35 AM, an unsecured, full (pressurized) oxygen tank was observed in room [ROOM NUMBER], upright against the wall and next to a chair directly across from the resident's bed in room [ROOM NUMBER], bed 1 (by the door). Staff I, Nursing Assistant (NA), was observed picking up the oxygen tank, walked out of the room and down the hall to the central supply room. The NA stated she was directed by the Director of Nursing Services (DNS) to remove the tank from room [ROOM NUMBER]. On 03/26/18 at 9:49 AM, eleven wheeled, individual tank carriers were observed in the Oxygen Room located next to room [ROOM NUMBER], which were not in use at the time to secure the oxygen tanks in the facility. On 03/26/18 at 10:10 AM, eighteen larger tanks (including the oxygen tank removed from room [ROOM NUMBER]) and eight smaller tanks were free-standing within a make-shift wooden enclosure of three panels attached to a wall in the central supply room. The oxygen tanks occupied approximately 40% of the space, while the remaining 60% of the space was empty. The three wooden panels that formed the three sides of the enclosure were observed to be unstable and shifted easily with minimal movement by the surveyor to check for stability. During an interview on 03/26/18 at 10:10 AM, while observing the oxygen tanks in the central supply room, Staff I stated the Maintenance Director built the wooden enclosure because the facility needed to store more oxygen tanks and the enclosure allowed more storage. During an interview on 03/26/18 at 10:19 AM, Staff B, DNS, stated she was the person responsible to call the oxygen company in when the facility needed a supply of oxygen tanks. Staff B stated the oxygen company last delivered the oxygen tanks Last Wednesday (five days prior) . She stated the oxygen company usually supplied full tanks to replace the empty ones, but was aware they did not have enough supply on the last delivery to replace all of the empty tanks in central supply. The DNS was aware of the oxygen storage situation and the amount of free space within the enclosure. On 03/26/18 at 11:29 AM, the DNS further explained she was aware of the unsecured oxygen tank in room [ROOM NUMBER]. She observed the oxygen tank against the wall as she was answering Resident #7's (room [ROOM NUMBER], bed 2) call light. The DNS stated she did not know why the oxygen tank was in room [ROOM NUMBER] because neither resident in the room required oxygen. During an interview on 03/27/18 at 2:48 PM, Staff I recalled why she removed the oxygen tank from room [ROOM NUMBER] on 03/26/18. Prior to removing the tank, she stated the DNS called Staff I to her office and directed her to remove the tank. Review of the facility policy titled Oxygen Storage Policy showed it was last edited 03/09/18 and documented .Cylinders not in use are to be stored only in provided rack in oxygen storage room located in Central Supply . During an interview on 03/27/18 at 3:22 PM, Staff B, DNS, when asked what the provided rack was as documented in the facility policy and procedure, the DNS stated the referenced rack was a wooden box with a top on it that had holes for secured storage of the oxygen tanks. The DNS stated when she last revised the policy (03/09/18), she did not look over the part about the provided rack as stated in the policy. Staff B further explained that facility was not following the current oxygen storage policy and procedure. FALLS Resident #37. Review of medical records revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] showed he was cognitively impaired, required extensive assist for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the resident's plan of care dated 12/01/17 identified the fall risk. The interventions included bed at the lowest position, non-skid soles on when out of bed, scoop mattress, fall mat at bedside. No mention of the helmet he was to wear to protect his head. The plan of care dated 12/13/17 identified his impaired physical mobility and self-care related to his stroke and the interventions documented Transfer: supervision, limited assist of 1, resident is impulsive and will self-transfer. Yet (six days prior) the comprehensive assessment dated [DATE] showed he was extensive assist for transfers. Review of the investigations showed: 1. 12/01/17 at 2:00 PM approximately two hours after being admitted the resident had been found on the floor in front of a toilet in the hallway. The resident had removed his helmet. The resident was observed to have socks without any grips .The resident was very agitated and could not communicate . The resident was toileted and became calm and not acting stressed. 2. 12/05/17 at 2:10 PM the resident was found on the floor by the doorway in his room. The resident had attempted to self-transfer . using the tray table to try and stand up and spilled water in the process and crawled to the doorway. There was no documented evidence as to the type of footwear the resident had at the time of the fall. Additionally, there was no evidence of what new interventions were to be put in place to prevent future falls. 3. 12/25/18 at 4:45 PM the resident went to his room after eating his evening meal. He was found sitting on the floor in front of the wheelchair, brakes locked, with his leg underneath the bed. The conclusion of the fall showed the resident is impatient and will forget to wait for supervision with his transfers. No documented evidence of type of footwear the resident had at the time of the fall. On 03/25/18 at 2:45 PM the resident was observed sitting in his wheelchair. He wore a splint on his right forearm, he was able to self-propel using his left foot. His speech was unintelligible. He used his left hand to make gestures. He kept pointing to his right arm and leg as to indicate he was not able to use his right upper and lower extremity. On 03/29/18 at 9:35 AM Staff D, Resident Care Manager, stated she had completed the first two fall investigations in (MONTH) of (YEAR). She added, at the time of the investigations she had not thought of asking facility staff of when the resident was last seen prior to the fall, hence she had not obtained any staff interviews. She added she not not been consistent in implementing the three day specific alert charting after the resident's falls. Review of the Accident and Incident-Investigating and Reporting Policy with an effective date of 03/27/18 (three months after Resident #37's falls), the facility Admininstrator reported no additional Accident/Incident policy had been in place. Review of fall investigations showed a lack of comprehensive preventive measures/corrective actions. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview and record review the facility failed to ensure residents received the necessary services to promote healing, prevent infection, and prevent new pressure injuries from developing for two of two resident's (#'s 188, 7) reviewed for pressure injuries. Failure to ensure the residents received the treatment and services consistent with professional standards of practice caused the residents unnecessary pain and discomfort and placed them at an increased risk of harm. Findings included: Resident #188. Per the medical record the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further [DIAGNOSES REDACTED]. Resident #188's most recent comprehensive assessment dated [DATE] showed she had moderately impaired cognition and required extensive assistance of two caregivers for bed mobility, transfers and positioning. Her wound was described on the assessment as a Stage 4 pressure wound that was 27.2 cm (centimeters) (10.7 inches) in length, 6.6 cm (2.59 inches) in width and 4.8 cm (1.88 inches) in depth by Staff C, RN/ Care Coordinator. Review of Resident #188's facility skin assessments since admission showed multiple discrepencies with the wound measurements by Staff C and Staff D, Registered Nurses (RN). On the 03/21/18 assessment, the wound was measured at 10.7 inches in length, 2.59 inches in width and 1.88 inches in depth. On the 03/24/18 assessment, the wound was measured as 1.81 inches in length, 2.32 inches in width and no depth. Additionally, none of the assessments included a description of the wound bed, color, odor, drainage, undermining, tunneling, surrounding tissue appearance, wound pain, current treatment, effectiveness of treatment or any additional care needed. Review of Resident #188's nursing progress notes from admitted [DATE] through 03/26/18 had no documentation of the condition of the wound or why there was a discrepancy of the wound sizes listed in the assessments. On 03/26/18 at 10:30 am, the resident was observed lying in her bed and propped up with pillows on her right side. She stated she was in the facility because My bottom has a sore on it that is very painful and it is infected. Resident #188 was fully clothed and had on white thin socks with her heels pressed against the mattress and both of her feet and ankles had [MEDICAL CONDITION] (fluid filled swelling) present. The bed and wheelchair did not show a specialized pressure relieving mattress or chair cushion. On 03/26/18 at 2:06 PM, the resident was observed in her wheelchair with her feet dangling as Staff K, RN, administered her intravenous (IV) antibiotic medication. When asked why the resident's lower extremities were edemetous, Staff K stated, I don't really know, probably because she has been sitting up in her chair more today than previously. Staff K stated that the resident should have heel protectors on as her heels were mushy (soft tissue when pressed, often a precursor to skin breakdown). Staff K further explained the reason for the resident being in her chair for an extended period was to administer an IV medication at 1:30 PM and allow therapy to work with the resident during the infusion over the next hour. An hour later, at 2:30 PM on the same day, the resident was sitting in her wheelchair in her socks talking with a therapist. She stated her bottom was aching badly and asked if she could be layed down. Review of Resident #188's care plan dated 03/16/18 showed interventions for her pressure injury was to avoid positioning resident on her back, to turn and position approximately every two hours, to keep heel boots on to protect heels from pressure, and the resident required pressure relieving devices on her bed and chair. Review of nursing progress notes dated 03/15/18 through 03/26/18 showed no evidence of documentation of pressure relieving devices or of the resident's edemetous lower extremities. Review of Resident #188's (MONTH) (YEAR) treatment sheets showed she was admitted with orders for wet to dry dressing changes twice a day. The order was changed on the treatment sheet on 03/27/18 to an opticell AG dressing (keeps moisture in the wound and prevents infections) with a foam border dressing directly on top and to be changed every three days. On 03/28/18 at 1:35 PM, Staff D, RN, and Staff J, Licensed Practical Nurse (LPN) were observed performing a dressing change for Resident #188. Staff D had already prepared her dressing change items in a plastic bag at the treatment cart and carried them into the room and placed them on the bedside table without a barrier. She washed her hands, put on clean gloves and removed the soiled gauze from the wound. She then cleansed the wound with normal saline and patted it dry with gauze. When asked about measuring the wound, the RN stated she did not bring anything to measure the wound with. On 03/28/18 at 1:35 PM the surveyor observed the wound to be approximately 4 inches in length, 5 inches in width and 1 inch in depth. The wound bed was clean with a pink semi shiny surface. Areas of tunneling (sinus tracts under the skin) were approximately 0.5 inches in various areas within the wound bed. There was minimal browinsh drainage on the gauze removed and no odor was detected. There was approximately one inch of undermining at the top of the wound with a scattered amount of yellow colored tissue present. The surrounding outer tissue was red and irritated in appearance. During the same observation, Staff D, RN, then proceeded to pull out a long strip of presoaked gauze from the plastic bag on the bedside table, she began squeezing and preparing to place the gauze into the wound with the same soiled gloves that she had removed the soiled dressing with. The surveyor had to intervene as Staff D was attempting to place the contaminated gauze into the wound. Staff D stated Oh, you're right, I don't know what I was thinking. Staff D left the room, went and obtained new sterile supplies. In an interview with Staff D on 03/29/18 at 10:33 AM, when asked why she did not complete the dressing change with the new order, she stated I didn't read the new orders and just followed what the nurse dressed it with the previous evening. Review of Resident #188's admission orders [REDACTED]. During an interview on 03/29/18 at 1:25 PM Staff B, the Director of Nursing Services (DNS), stated she had no idea how the order got missed on admission that Resident #188 was to be on an airbed at all times. She stated she was sending out Staff C, RN/MDS Coordinator, to pick up an overlay mattress for the resident's bed. In an interview on 03/29/18 at 2:59 PM with Resident #188's surgeon, she stated when she ordered the airbed, her intention was for the resident to have an airflow bed that kept the pressure off the resident's wound at all times. She stated she did not want an overlay mattress on the bed as the resident's wound had a poor chance of healing with all of her comorbidities without strict interventions. During the same interview, the surgeon stated the resident was beyond a high risk for further breakdown and had no idea the resident was not placed on the airbed as ordered and no one from the facility had notified her of this. In addition, when the physician was asked if she had knowledge of the resident's [MEDICAL CONDITION] to her bilateral lower extremities, she stated she was not, but hoped the facility was assessing for [MEDICAL CONDITION] (blood clots) as the resident was at a very high risk to develop them especially if she had been up in a chair at the facility. During an interview on 03/29/18 at 6:30 PM with the Administrator, the DNS, and the MDS Coordinator following a report of the surveyor's findings on Resident #188, they agreed that the facility had failed to provide the resident with the treatments and services needed to promote the resident's highest level of well being. Resident #7. Review of the medical record showed the resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive assessment dated [DATE] documented the resident with intact cognition and at risk for developing a pressure injury. Review of the facility matrix showed documentation of the resident with a facility-acquired pressure injury. During an interview on 03/27/18 at 10:52 AM, Staff K, Registered Nurse (RN)/Charge Nurse, stated the resident had a Stage 2 pressure injury on the left heel. The RN stated the resident used to choose to stay in bed most of the time and would only get out of bed when she had to leave the facility for [MEDICAL TREATMENT] treatment. Staff K stated the resident had recently started getting out of bed more often. The RN stated, .We tried to float her heels because she did not like anything on her feet . after explaining the facility attempted to implement heel protectors before the Stage 2 developed. We knew it (resident's heel) was going to be an issue because of the redness and it feeling boggy. Then it (resident's heel) broke down . On 03/28/18 at 12:47 PM, Staff D, RN/Resident Care Manager, was providing wound care for the resident. The pressure injury on the resident's left heel was observed with a wound bed approximately 0.5 inches in width. The surrounding tissue of the wound was observed as dry/flaky. Staff D stated the wound was slowly healing. Review of the 09/06/16 comprehensive care plan showed documentation about the resident at risk for pressure injuries. The facility revised the care plan on 12/07/17 with interventions to float heels when in bed and the use of bilateral heel protectors. In an interview on 03/29/18 at 1:07 PM, Staff H, Nursing Assistant (NA), stated the resident had the smaller heel protectors and they were instructed to use for the resident. She (Resident #7) stopped using them because they would not stay on very well .they were not good for much. The NA further explained the smaller heel protectors had a strap, but did not stay on the resident feel. Staff H stated the resident had foam boots while in bed, implemented a few weeks ago. They (larger foam boots) stay on (the resident). Review of the medical record showed a 03/15/18 physician order [REDACTED]. Review of physician protocol orders dated 06/14/16 showed .Nutritional Wound Intervention: Initiate when wound is (greater) than Stage I .Vitamin C .Zinc .[MEDICATION NAME] . Review of the resident's medical record did not show evidence the nutritional supplements were added per physician protocol. On 03/28/18 at 5:29 PM, Staff B, DNS, stated the resident's pressure injury probably could have been avoided. She explained the resident was non-compliant at times when it came to the implementation of the floating of her heels or the use of the heel protectors. She further explained the nutritional supplements were not added for the resident after the identification of the Stage 2 pressure injury to the heel. Reference: WAC 388-97-1060(3)(b)

Based on observation, interview and record review the facility failed to recognize and manage pain for 1 of 2 residents (#58) reviewed for pain management. Failure to assess and treat the resident for consistent complaints of severe pain caused the resident undo pain and suffering. Findings include: Resident #58. Per the medical record, the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation and interview of Resident #58 on 06/06/17 at 11:00 a.m. revealed her sitting at a dining room table in her wheelchair with both legs elevated on foot pedals and pillows. She had facial grimacing and was rubbing her right leg. She reported she was having pain at a level 9, (on a scale of 1 to 10. 10 being the most severe pain), in her right leg, back and chest. She stated she had been in constant pain since she fell in another facility especially when she is moved during cares and doing physical therapy. She reported the only time she gets relief is when she is lying still in bed. Observation and interview of Resident #58 on 06/07/17 at 2:55 p.m. revealed her lying on her back in bed. She stated that currently her back and left side of her chest were hurting where her ribs were broken at a pain level 6 out of 10. She stated she only received Tylenol for the pain and it doesn't help. She stated she had asked for stronger pain medication and to see a physician but to her knowledge that has not happened and the nurses do not offer her medication or other forms of pain relief. She stated repositioning helps relieve the pain at times and she used to get a topical pain medication rub at another facility which also helped. In an interview with Staff Member C, a Licensed Nurse, she stated that Resident #58 does complain of pain a lot of the time though she is not sure how much is real as she will begin saying ow ow ow before the staff even touch her and she often reported that the staff were being too rough with her even when they were gently providing cares. In an interview with Staff Member D, a Nursing Assistant who had provided care to Resident #58 since admission, stated that the resident always yells out in pain when care is provided and anticipated the pain before it even happened by stating ow ow before she had even been touched. In an interview with Staff Member B, the Therapy Director, he stated he had been working with Resident #58 since she admitted to the facility for both physical and occupational therapy. He stated that the resident consistently complains of back and rib pain and he asked the nurses to give her pain medication prior to therapy which seemed to help. He stated he did not know which pain medication the resident received prior to therapy. He stated she will say ow ow a lot just because she is used to saying it though he knows she is in real pain due to both acute and chronic injuries and he had to go slow with her therapy to make even minimal improvement. Review of her most recent comprehensive assessment dated [DATE] revealed her cognition was intact and she required extensive assist of two people for her activities of daily living and a hoyer lift for transfers from bed to chair. Pain assessments completed on her comprehensive 5 day assessment on 05/24/17 and her 14 day comprehensive assessment on 05/30/17 indicated the resident reported that she had almost constant pain of a level 9 that made it hard to sleep at night and limited her day to day activities. Review of Resident #58's physician orders [REDACTED]. A review of the medication sheets revealed that the Tylenol was only given 6 times from 05/17/17 to 06/05/17 for pain levels ranging from a 6 to 10 on a pain scale of 1-10. Review of Resident #58's nurse progress notes from admission through 06/06/17 revealed that the staff noted on several occasions that the resident reported the staff are hurting her and claimed any care hurt her. Resident #58 was reported in the progress notes as sharp tongued and demanding of staff. Further review of the residents medical record does not indicate that the physician was notified of the residents complaints of severe pain at any time after admission to the facility. In an interview with the Director of Nursing on 06/08/17 at approximately 3:00 p.m., she stated that a thorough assessment and plan of care to manage the residents pain as she would expect was not completed during her stay at the facility. Reference WAC 388-97-1060(1)

Based on interview and record review, the facility failed to assess and provide care to assure the highest practicable level of psychosocial well being for 1 of 2 residents (#10) reviewed for end of life. Failure assess the resident's fear of dying and being alone, and to develop and implement care for her fears caused the resident to have continued anxiety and fearfulness until the time of her death. Findings include: Resident #40. admitted on [DATE] with [DIAGNOSES REDACTED]. The physician ordered numerous medications to treat the resident's multiple health issues, including oxygen therapy. After admission the physician also ordered treatment by a Speech Language Pathologist for the resident's trouble swallowing and the risk of inhaling food and/or fluid into her lungs. On [DATE] at 2:00 p.m., Staff Member G, a Nursing Assistant (NA), reported the resident had a cell phone and called family and friends to come and stay with her. Staff Member G stated, She called all the time. Staff Member H, a NA, also present during the interview, said during the day shift, family and friends stayed in the resident's room almost all of the time. Staff Member G, who worked all three shifts, stated, She'd even call her friends to come stay with her on the night shift and they would. On [DATE] at 2:30 p.m., Staff Member C, a Licensed Nurse (LN), reported the resident was very afraid of dying and she was great if you could be in the room with her. The LN added that the resident was admitted on 'comfort care/end of life' and at one point the LN had asked if the resident wanted to go to the hospital because she was having trouble breathing. The LN said the resident told the LN, No. I'm dying. The comprehensive care plan included a problem for Mood State related to depression .Monitor behaviors such as statements of despair/dying .Staff to redirect conversations from a negative to a positive when resident begins to speak of health ailments and disabilities .attempt to redirect to positive conversation. At the top of the comprehensive care plan was the directive to Call niece or daughter!!!! Progress notes dated from [DATE] through [DATE] report the resident's statements that she believed she was dying and wanted someone to be with her all the time. On [DATE], a LN documented, Has been awake most of the night. Has repeatedly asked if one of us can stay in the room at all times and has been told .we cannot stay in one room all night. Resident states she is frightened. On [DATE] a LN wrote, Has been very challenging this night shift. She has been awake all night and yelling out loudly. When asked what she needs, she replies that she wants someone to stay in the room with her at all times. I have explained that we cannot stay in the room with her .resident continues to yell out loudly, 'Please help me, please help me.' Resident always states she knows we will be back in one hour but begins yelling as soon as we leave the room. On [DATE], a LN documented at 2:25 a.m., that the resident awoke a little after midnight. Started yelling for the nurse to help her die .Started yelling, 'Help .' .Help me die bravely. The LN wrote the resident yelled for about an hour. Nothing we did satisfied her. The Death Certificate revealed the resident died in the facility at 5:55 a.m.

Based on observation, interview and record review, it was determined the facility failed to provide necessary monitoring or services to ensure that 1 of 2 sampled residents (#11) who entered the facility without a pressure ulcer did not develop a pressure ulcer while in the facility. The facility failed to prevent the formation of the pressure ulcers, and failed to establish and document a treatment for [REDACTED]. This placed the resident at risk of infection, further skin breakdown, continued pain and a decreased quality of life. This failure resulted in the development of 2 painful pressure ulcers causing harm to resident #11. Findings include: Resident #11. admitted [DATE] with multiple [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment dated [DATE] revealed the residents cognitive status as severly impaired and he required extensive assistance of 2 caregivers for bed mobility, transfers, dressing and toileting, and total assistance with personal hygeine and bathing. Review of the resident's assessments and progress notes revealed that on admission the resident's bottom was noted to be excoriated. The next skin assessment recorded was on 03/07/16 stating the resident had a stage II pressure area (partial thickness skin loss involving epidermis, dermis or both) on his coccyx, measuring 9 cm (centimeters, approximately 3.5 inches) x 10 cm (3.9 inches) x .1 cm. A progress note on 03/10/16 also noted that the resident has a stage II pressure ulcer to his coccyx and a duoderm was applied. There were no further skin assessments or progress notes until 03/28/16 where a nurses note states, changed dressing to coccyx, original wound is improving at 0.4 inches x 0.4 inches at the top of the gluteal fold. Purulent malodorous drainage noted from wound. New breakdown was identified on left buttock at 0.6 inches x 0.4 inches. Review of the resident's care plan and Treatment Administration Records (TAR) revealed there was no plan in place to treat the pressure areas and no documentation was present indicating the physician was aware of the wounds or that a treatment had ever been initiated. On 03/30/16 at 11:00 a.m., in an interview with the Director of Nursing, she stated that she was unaware that the resident had open wounds to his bottom and agreed that there was no documentation on the TAR to indicate the wound was being treated. She also stated that the facility did not have a written policy or protocols in place for treating pressure ulcers. On 03/30/16 at 2:45 p.m., the resident was noted to be yelling out loudly from his bed, when asked what was wrong, he stated my butt feels like it's on fire. On 04/04/16 the wounds were observed with the Director of Nursing and the Resident Care Manager in attendance. The first wound was measured as 0.8 x 0.5 x 0.3 cm at the gluteal fold at a stage III (full thickness skin loss involving damage to or necrosis of subcutaneous tissue). It appeared to contain a hard yellow wound bed with purple red skin around the wound. There was a moderate amount of yellowish drainage on the dressing when it was removed. The second wound was measured at 1.0 x 0.8 cm without depth on the left buttock at a stage II.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable level for 2 of 6 residents (#3, 46) related to pain and bowel management. This resulted in harm for Resident #46. Findings include: Pain management: 1. Resident #46, per record review, admitted to the facility for rehabilitation (rehab) after having a knee replacement. The resident had no memory problems or difficulty making daily decisions. The resident initially required extensive assistance with activities of daily living (ADL's), but progressed with her rehab and required limited assistance with ADL's. The facility completed a pain assessment on admission and noted she had pain and rated the pain "8" out of 10 (the pain scale is from 0-10. 0 is no pain and 10 is severe pain) to her right knee, hips, and lower back. The pain impacted her sleep, appetite, and physical activity. The assessment documented cold packs, repositioning, and medications helped relieve the pain. The resident's goal was "3" out of 10. The facility initiated pain management flow sheets so they could track her pain. The resident had an order for [REDACTED]. On 6/8/11 at 2:09 p.m. during an interview, the resident had a pained look on her face, grimaced, and rubbed her right leg. The resident reported her pain was "10" out of 10. She put her call light on to request pain medication. The call light remained on until 2:26 p.m. (17 minutes after she put the light on). Staff #C answered the light and reported she would let the nurse know she needed pain medications. Staff #C went into other rooms and assisted residents. The resident was increasingly more uncomfortable. On 6/8/11 at 2:42 p.m., the surveyor asked Staff #D and #E if Staff #C told them the resident was in pain. They reported Staff #C never told them about the pain. At 2:45 p.m., Staff #D medicated the resident with 1 narcotic pain medication ([MEDICATION NAME] 5 mg/Tylenol 325 mg). He stated he gave the resident 1 pain pill because she had another therapy session this afternoon. He told the resident to ask for pain medication before her pain was severe. On 6/8/11 at 3:40 p.m., the resident reported she still had severe pain and rated the pain "10" out of 10. At 3:48 p.m., Staff #D gave the resident another narcotic pain medication ([MEDICATION NAME] with Tylenol). At 4:20 p.m., the resident stated she had no pain and the medication was effective. On 6/10/11 at 11:15 a.m., the resident reported her pain was "10" out of 10 to her right knee. She put the light on and requested pain medication. On 6/10/11 at 12:00 p.m., Staff #E gave the resident 2 narcotic pain medications ([MEDICATION NAME] with Tylenol). (This was 45 minutes after she requested pain medication). On 6/13/11 at 11:20 a.m., the resident reported her pain was good. She reported she got pain medication this morning and ice. She stated, "The ice is sometimes just as good as the pain pill." Per record review, the facility staff did not medicate the resident with narcotic pain medications until her pain was rated between 8 to 10. The medication could be given every 4 hours as needed, but facility staff did not give the narcotic pain medications until the pain was severe. There was 1 instance documented where ice was given to help alleviate the pain. The facility staff did not attempt to give the resident the stronger narcotic when she did not get good pain relief. The facility failed to give as needed narcotic pain medications until the resident was in significant pain or try non medication interventions identified by the resident that helped with the pain. This resulted in harm to Resident #46. Bowel Management: 2. Resident #3, per record review, had [DIAGNOSES REDACTED]. The resident had memory problems and difficulty with daily decision-making. The resident required extensive to total assist with all activities of daily living. Per record review, the resident took a stool softener twice a day and a fiber laxative once a day. Per review of the resident's plan of care, the resident needed approximately 1260cc of fluids per day. The resident had difficulty with bowel elimination due to constipation and the goal was for the resident to have a BM every 3 days. The staff was directed to follow the facility BM plan. Per record review, the facility's bowel plan was as follows: if no bowel movement (BM) on day 2 give prune juice, no BM on day 3 give milk of magnesia, if on BM on day 4 night shift give a suppository at the end of the shift. If no BM on the day shift of day 4 then re-evaluate, give an enema and if no results notify the physician. In April 2011, the resident went 6 days without having a BM. The resident was given milk of magnesia (MOM) on day 2, prune juice and MOM on day 5 and on day 7 had MOM resulting in a large BM that evening. The physician was not notified and the facility bowel plan had not been followed. In May 2011, the resident went 5 days without a BM. The resident received a dose of MOM on day 5, had a medium BM on day 6 and went another 5 days with no BM. The physician had not been notified and the facility bowel plan had not been followed. Per record review, the progress notes dated 5/1/11 stated, "performed external assistance for resident to pass extremely large, hardened, formed stool. Resident heard crying out in pain, as stool passed anal opening...resident had only 1 stool of large size and hardened consistency since 4/13/11. With appearance of stool today, likely severe constipation has been present since that time". There was no documentation found that indicated the physician had been notified. On 5/18/11 the physician made rounds in the facility. The resident's fiber laxative was increased to twice a day. Per record review, the progress notes dated 5/22/11 stated, "assisted resident to pass large, hard, clay consistency BM...enough to cause severe pain per resident. External pressure and digital stimulation needed to help resident pass stool. Several small clay-like pellets passed afterwards". No documentation was found that indicated the physician had been notified. Per interview on 6/14/11, Staff #A confirmed the physician should have been notified and the bowel plan did not appear to have been followed. .

Based on record review and interview the facility failed to notify 1 of 3 sampled resident's (#1) physician in a timely manner regarding the resident's constipation. The resident had three episodes of severe constipation before her physician was notified and/or interventions were implemented. Findings include: Resident # 1 had [DIAGNOSES REDACTED]. Per her record she required total assistance of two persons for most activities of daily living. She was incontinent of bladder and usually continent of bowel. Per the facility Problem Oriented Progress Notes the following was noted: On 11/1/10 the resident "was unable to have a bowel movement, the stool consistency was clay like and the resident complained of some pain and discomfort and was unable to withstand the process to have a complete bowel movement". On 12/5/10 per the notes, "the resident was having difficulty during a bowel movement. The licensed nurse used manipulation to aid the resident in passing stool. The resident complained of pain during the process". On 12/19/10, the resident was having "a difficult time during a bowel movement. The licensed nurse used digital manipulation to assist the resident. The resident had some pain during the process and trace blood was noted upon clean up". On 12/22/10, (over 45 days after the resident's first episode of constipation an order was obtained to increase the stool softener medication for the resident. Per an interview with 2 licensed nurses, Staff A and Staff B, they did not know why the resident's physician was not notified after the first and/or future episodes of constipation. Per the Director of Nurses, the physician should have been notified after the first episode and an order obtained to increase the resident's stool softener medication. The facility did not notify the resident's physician in a timely manner to address the resident's constipation which resulted in pain and bleeding and harm to resident # 1.