Every finding on record at Mt Baker Care Center

Based on interview and record review the facility failed to ensure their abuse and neglect policy was followed for an allegation of abuse for 1 of 1 resident (Resident 1). This failed practice placed Resident 1 and all other residents at risk of abuse and neglect. Findings included.Review of the facility's policy titled, Abuse and Neglect Policy, with a review date of 11/11/2025, showed it was the policy of the facility to follow effective procedures to protect and prevent abuse of residents which included to report allegations of abuse and neglect to the appropriate authorities and investigate allegations of abuse and neglect. Resident 1 was admitted to the facility on [DATE]. The resident's Minimum Data Assessment (MDS- an assessment tool) dated 04/16/2026 showed the resident was assessed as cognitively intact, with no mood or behavior symptoms. Review of the facility's April and May 2026 grievance and incident logs showed no grievance or incident involving Resident 1. Review of Resident 1's Clinical Census report showed Resident 1 was moved from the South hallway to the Medicare Hallway on 04/10/2026 until 04/20/2026. In a phone interview on 05/11/2026 at 8:17 AM, Resident 1's, Family Member/Collateral Contact (CC) 1, stated the prior week Resident 1 normally had a roommate but due to COVID, the resident had been isolated for 10 days in a private room. CC 1 stated the resident reported there were three men in their room groping them when they woke up naked. CC 1 stated Resident 1 reported they felt like they had been drugged, their room was dark, and the individuals in their room did not want to be seen. CC 1 stated Resident 1 identified one of the men in their room but could not identify the other two men. CC 1 stated the resident reported the incident to Staff B, Nursing Assistant Certified (NAC) and as Resident 1 indicated Staff B seemed to know this was occurring. CC 1 stated the resident had been very happy in the facility, and this was all quite a shock. CC 1 stated they were worried about reprisal of staff wanting to cover their behinds. CC 1 stated Resident 1 was very vulnerable. CC 1 stated they had reported the incident to the state's advocacy volunteer who indicated they would look into the matter. CC 1 stated they felt powerless. CC 1 stated the resident reported they had discussed the incident with other residents who reported this type of thing occurs. In an interview on 05/11/2026 at 12:41 PM, Resident 1 stated they had a COVID infection and were moved to a room by themselves. Resident 1 stated one night there was a loud crash and they woke up with no clothes or covers on with three males standing around groping them. Resident 1 stated they felt like they must have been drugged as they are usually a light sleeper. Resident 1 stated they reported the incident to Nursing Assistant Certified (NAC) Staff B, noting that residents frequently reported issues to this specific staff member. Resident 1 stated Staff B had said it was difficult to know how these things got started. Resident 1 stated they reported there were three guys in their room, two on the side of their bed and one at the foot of their bed. Resident 1 stated they felt frozen in emotion and could not speak. Resident 1 stated they reported the incident to Staff B a couple of days after they moved back to the room they are in now. In an interview on 05/11/2026 at 1:21 PM, the surveyor asked Staff B if Resident 1 had shared any information with them. Staff B stated they remember what the surveyor was asking about. Staff B stated they shared the information with one of the nurses but could not recall exactly which nurse. Staff B stated Resident 1 reported a man was standing over them while they were on the Medicare Hall. Staff B stated they did not fill out a grievance report but had wanted to give information to the facility's administration. Staff B stated they believed they had said something to Staff C, RN/Case Manager, or one of the care managers. Staff B stated they reported the information verbally, it was a serious matter, and they always tell a care manager. Staff B stated Resident 1 had told them they did not want to get anyone else involved. Staff B stated Resident 1 had reported to them it was scary as there was a dark figure of a man standing over them. Staff B stated they did not believe they had filled out a statement. In an interview on 05/11/2025 at 1:38 PM, Staff C stated they vaguely recalled something involving Resident 1. Staff C stated the resident had COVID and they had woken up in the night scared. Staff C stated they would have to look into it as they could not recall the circumstances exactly. In an interview on 05/11/2026 at 2:30 PM, Staff D, NAC stated they had training in abuse and neglect and if a resident reported an incident of abuse or neglect they would tell someone like a nurse. Staff D stated they would fill out a form about what the residents reported and would tell a nurse. Staff D stated the forms were at the nurses' station in a binder. Staff D stated they had abuse and neglect training about a month ago. Staff D was asked several times if they would report an allegation to anyone else and Staff D did not indicate they would report the allegation to the State Agency. In an interview on 05/11/2026 at 2:55 PM, Staff A, NAC stated they always worked on the evening shift and had worked toward the end of the COVID outbreak. Staff A stated they had provided care for Resident 1 one time when the resident was in their usual hallway but had not provided care for Resident 1 during the outbreak. In an interview on 05.11.2026 at 4:15 PM, Staff E, NAC requested Staff F, Director of Nursing Services, to sit in on the interview. Staff E stated they had received training on abuse and neglect. Staff E was asked what they would do if a resident reported an allegation of abuse. Staff E stated they would talk it through with the resident and take the allegation to the nurse. Staff E confirmed they would not need to report the allegation to anyone else. After the interview Staff F stated they were glad they were able to observe the interview and could see where the facility needed to do some training. Reference WAC 388-97-0640 (2)(b)(5)(a)(6)(a)(b)(c)

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) received the necessary care and services to attain or maintain the highest practicable physical level of well-being. Failure to ensure Resident 1 received care in accordance with a physician order and their care plan when they received a bath and not a shower. This failure potentially placed the resident at risk of medical complications and a decreased or diminished quality of life. Findings included .Resident 1 was admitted to the facility on [DATE] with diagnoses to include vesicointestinal fistula (abnormal opening between the bladder and the intestines) and colovaginal fistula (abnormal opening between the colon and the vagina).Review of Resident 1's admission Minimum Data Set assessment (a resident assessment tool), dated 7/27/2025, showed the resident had a Brief Interview for Mental Status (BIMS - a structured cognitive interview) score of 09 which indicated the resident had moderate cognitive impairment.Review of Resident 1's Activities of Daily Living (ADL) care plan, date initiated 07/21/2025, showed they were to have only a shower related to their urinary and gastrointestinal fistulas.Review of Resident 1's Kardex (a guide the care staff use to help direct the resident care), dated 07/21/2025, showed they were to have only a shower related to their urinary and gastrointestinal fistulas.Review of Resident 1's documentation survey report (Nursing Assistant Certified (NAC) documentation in the electronic health record) dated August 2025 showed the resident received a bath on 08/21/2025 by Staff B, NAC.In an interview on 01/07/2025 at 1:46 PM, Staff B, NAC, stated they reviewed a resident's care plan and Kardex to know what kind of assistance and care they need. Staff C stated that the documentation code for shower was different from a bath. Staff C confirmed they documented Resident 1 received a bath on 08/21/2025.In an interview on 01/07/2025 at 2:09 PM, Staff A, Registered Nurse (RN)/Director of Nursing Services (DNS), stated care plans were used to make sure staff knew how to provide a residents personal care. Staff A stated they would expect staff to follow the care plan and not give baths when they were to only receive showers. Reference WAC: 388-97-1060(1)(2)(c)

Based on observation, interview and record review, the facility failed to develop comprehensive care plans to reflect the resident's current medical status and/or to include all provided nursing services for 1 of 1 resident (Resident 54) reviewed for edema management, 1 of 2 residents (Resident 5) reviewed for discharge planning, and 1 of 2 residents (Resident 15) reviewed for dementia care. This failure placed residents at risk of not receiving needed care, decline in condition, and diminished quality of life. Findings included . <RESIDENT 54> EDEMA MANAGEMENT Resident 54 was admitted to the facility on [DATE], with diagnoses which included gastrointestinal issues, and vascular (veins) wounds with cellulitis (infection of the tissue) to both lower legs. Record Review on 06/30/2025 showed Resident 54 had orders for knee high elastic stockings ordered for lower extremity edema management on 06/18/2025, and orders for Lasix (a diuretic-removes excess water from the body) for edema on 06/26/2025. In an observation and interview on 06/26/2025 at 2:00 PM, Resident 54 was sitting up in their wheelchair in their room with elastic stockings visible on both feet. Resident 54 stated they have been having a lot of issues with their swelling in their feet. Resident 54 stated they have had swelling and issues with sores on their legs before. Review of Resident 54's care plan dated 06/30/2025 showed no care plan had been developed related to elastic stockings, edema or diuretic use. In an interview on 07/01/2025 at 2:12 PM, Staff F, Registered Nurse/RCM (Resident Case Manager), stated residents with edema should have edema monitoring and there should be side effect monitoring for diuretic therapy. Staff F stated they needed to update Resident 54's care plan to include those items. <RESIDENT 5> DISCHARGE PLANNING Resident 5 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (nervous system disorder), epilepsy (seizure disorder), left lower leg fracture and right leg fracture. Review of Resident 5's Care Area Assessment (CAA- a focused assessment to determine if a triggered area should be care planned), dated June 2025 showed they expressed interest in moving to an independent living facility. The CAA further documented that social services had assisted the resident with the process, but they had been denied at independent living facilities. A review of Resident 5's care plan dated 12/23/2023 and 06/10/2025, showed a resolved focus for discharge planning. There was no current discharge care plan found for Resident 5. In an interview on 07/02/2025 at 8:54 AM, Staff G, Licensed Practical Nurse (LPN), RCM stated they were unable to find a current/active discharge care plan for Resident 5. Staff G stated Resident 5 did have a discharge care plan in the past. Staff G stated Resident 5 had expressed a desire to be discharged from the facility within the month, social services was involved, and they wanted to move to an independent living facility after healing from their recent fractures. In an interview on 07/02/2025 at 9:20 AM Staff J, Social Services, stated they were unable to locate a current and active discharge plan for Resident 5. Staff J stated they had met with Resident 5 multiple times about discharge planning and provided corresponding progress notes of the interactions. Staff J stated Resident 5 expressed wanting to discharge to an independent living facility once healed from their recent fractures. <RESIDENT 15> DEMENTIA CARE Resident 15 admitted to the facility on [DATE], with diagnoses that included dementia, high blood pressure, and peripheral vascular disease (circulatory condition that affects blood flow to limbs). Review of Resident 15's cognitive CAA dated 10/22/2024, showed no analysis of findings for cognitive loss/dementia and referred to the psychosocial CAA. In an interview on 07/01/2025 at 1:19 PM Staff K, NAC (Nursing Assistant, Certified), stated they work with residents with dementia, gently. Staff K stated they knew Resident 15 liked English tea and does not like to take showers. Staff K stated they did not work with Resident 15 often and deferred to the care plan, stating it would have more details about Resident 15's dementia-related care. In an interview on 07/01/2025 at 2:07 PM Staff G, NAC stated Resident 15 was female care only. When asked how Resident 15's dementia manifested, they stated Resident 15 could be different from day to day, but was oriented to place and day, and used the newspaper to help with orientation. Staff G stated Resident 15 could become confused. Staff G described altered perceptions that Resident 15 had voiced in the past, specifically concerns about a scar (cesarean scar) being open and being concerned about it. Staff G stated they tried and reassured Resident 15 to make them comfortable and redirect their attention to a cup of tea or talk with them about their daughter. When asked how they knew how to care for residents and their dementia, Staff G stated they had worked as an aide for seven years, been through a lot of training related to dementia care and started their career by working in a dementia unit. Review of Resident 15's care plan dated 12/18/2019 showed they had a focus related to cognitive function due to impairment related to dementia. The goal was Resident 15 would be able to communicate basic needs daily. Interventions included asking close-ended questions, presentation of ideas, thoughts, directions to them one at a time and to use task segmentation. The care plan did not include all stated known behaviors and approaches for Resident 15. In an interview on 07/02/2025 at 1:05 PM, Staff B, Director of Nursing, stated care plans should be updated right away, and the expectation is that care plans are done on admission, with comprehensive assessments, and with changes in condition. Staff B stated care plans are necessary to provide communication to provide care. Reference WAC 388-97-1020(1),(2)(a)

Based on observation, interview and record review, the facility failed to ensure 1 of 5 residents (Resident 45) reviewed for unnecessary medications, were free from unnecessary psychotropic medication (a drug that affects brain activities associated with mental processes and behavior). Failure to provide a valid diagnosis for the use of psychotropic medications placed residents at risk for receiving unnecessary psychotropic medications, for adverse events and diminished quality of life. Findings included . According to the facility policy titled Unnecessary Medication Policy (undated) showed: All medications must be supported by a documented diagnosis or clinical rationale. The Federal Drug Administration Black Box Warning for Risperidone (an antipsychotic medication) stated that elderly patients with dementia-related psychosis (mental disorder characterized by a disconnection from reality) who are treated with this medication are at a significantly higher risk of death. Risperidone is not approved for use in patients with dementia-related psychosis and included a black box warning related to an increased risk of death or stroke in dementia patients. Resident 45 was admitted to the facility on [DATE] with diagnoses to include dementia. According to the Significant Change Minimum Data Set (MDS - an assessment tool) assessment dated [DATE], Resident 45 had severe cognitive impairment. In an observation on 06/27/2025 at 12:49 PM, Resident 45 was propelling self in their wheelchair using their legs and arms, not exhibiting any signs of psychosis, and was easily redirectable. In an observation on 06/30/2025 at 9:48 AM, Resident 45 was in their room with a family member visiting, with no behaviors observed. Record review of Resident 45's physician's orders on 06/30/2025 documented an order dated 03/21/2025 for Risperidone 0.25 milligram (mg) by mouth in the morning and 0.5 mg by mouth at bedtime, related to dementia with behavioral disturbances. In an interview on 07/01/2025 at 9:09 AM, Staff D, Nursing Assistant Certified (NAC), stated that Resident 45 liked to wander in the hallways by self-propelling in their wheelchair. In an interview on 07/01/2025 at 9:15 AM, Staff E, Licensed Practical Nurse (LPN) stated that Resident 45 was receiving Risperidone, and they monitored their behavior and documented them in their Behavior Administration Record (BAR). The behaviors listed were, anger/agitation, withdrawn, restlessness/exploring, despondence and shortness of breath. In an interview on 07/01/2025 at 9:45 AM, Staff F, Registered Nurse/Resident Case Manager, stated that prior to starting a resident on a psychotropic medication, they first obtained consent from the resident or family member, then set up a care plan and ensure monitoring for side effects and behaviors were in place. Staff F added that they ensured that the appropriate diagnosis was in place and if they didn't think the diagnosis was appropriate, they notified the provider. Staff F stated the provider would then do their research and ensure an appropriate diagnosis would be in place for the medication. Staff F reviewed the diagnosis for Resident 45's Risperidone and stated that dementia was not an appropriate diagnosis for Risperidone and they would review Resident 45's chart to find out why they were started on that medication. In an interview on 07/01/2025 at 2:00 PM, Staff B, Director of Nursing, stated that they talked to the provider and were informed that Resident 45 was started on Risperidone when they were still at their assisted living facility due to behaviors. Staff B handed me a copy of the provider progress note dated 05/29/2024 that showed Risperidone was started at 0.25 mg every afternoon for dementia with behavioral features. In the note, it was documented that Resident 45 was not taking medications and that the nurse reported increased confusion, especially in the afternoon and increased behaviors which were not easily redirected. There was no mention of attempts to use other interventions. In a telephone interview on 07/01/2025 at 3:30 PM, Collateral Contact 1 (CC1), Pharmacist, stated that they participated in the facility monthly psychotropic medication review and they reviewed residents' psychotropic medications. CC1 stated that a dementia diagnosis was not an appropriate indication for Risperidone use. CC1 reviewed Resident 45's Risperidone order and stated that the diagnosis was not appropriate and there should be a specific behavior added to the diagnosis for it to be appropriate. In an interview on 07/02/2025 at 1:00 PM, Staff B, Director of Nursing, stated the expectation is to review psychotropic medications when they are ordered, during the facility psychotropic meeting, and they audited the process monthly. The process was to audit the medication consents and diagnoses during the monthly meetings and stated they failed to identify the incorrect diagnosis for Resident 45. Refer to WAC 388-97-0620(1)(a)

Based on observation, interview, and record review the facility failed to ensure 1 of 3 residents (Resident 15) reviewed for Pressure Ulcers (PU), were provided care planned interventions they required for the prevention of a PU. This failure to implement pressure reducing interventions in accordance with physician's orders placed residents at risk for PU development, pain and a diminished quality of life. Findings included . Resident 15 admitted to the facility on [DATE] with diagnoses that included dementia, high blood pressure, and peripheral vascular disease (circulatory condition that affects blood flow to limbs). Review of Resident 15's care plan, dated 12/03/2019 and revised on 03/15/2023, showed they had a focus area of skin at risk due to failure to thrive, advanced age and fragile/thin skin. The goal was Resident 15 would have no skin breakdown daily. Interventions included encouraging and assisting Resident 15 to reposition every two to three hours and as needed for comfort and to float heels (elevation of legs, typically with pillows, to prevent heels from touching the surface) when in bed for skin integrity to heels. Resident 15 was documented as having no PUs at the time of the 10/08/2024 significant change minimum data set (MDS- a required assessment tool) assessment. In a review of Resident 15's Care Area Assessment (CAA- a systematic process to determine if a triggered care area should be care planned), dated 10/22/2024, showed they were at risk for pressure areas and skin breakdown related to impaired mobility, incontinence of bowel and bladder, and advanced age with fragile skin. A review of Resident 15's Braden Scale (a risk assessment tool used to identify patients at risk of developing pressure ulcers), dated 06/03/2025, showed Resident 15 had no skin breakdown and were low risk for the development of a pressure ulcer. Review of Resident 15's Kardex (a nursing worksheet that includes daily care schedules/patient specific care needs) directed nursing assistants to float (elevate) both heels when in bed for skin integrity for heels. Review of Resident 15's Treatment Administration Record (TAR) for June 2025 showed a physician order for both their heels to be floated while in bed to maintain skin integrity. In observations on 06/26/2025 at 10:20 AM, 06/27/2025 at 1:01 PM, and 06/30/2025 at 10:04 AM, Resident 15 was in their bed and their heels resting flat on the mattress (not floated). In an observation and interview on 07/01/2025 at 3:37 PM, Staff H entered Resident 15's room and requested to readjust their pillows under their legs. Resident 15's heels were observed resting on the mattress with a single pillow located under their knees. Staff H was observed to readjust the pillow to float Resident 15's heels. Staff H stated Resident 15 often slid down in bed and needed repositioning and they tried to check on them frequently to make sure their heels were floated. Staff H stated Resident 15 would, at times, request to have the pillow used to float their heels removed. In an interview on 07/02/2025 at 9:11 AM Staff I, Registered Nurse (RN), stated Resident 15 had an order to float both their heels when in bed. Staff I entered Resident 15's room and requested to adjust the pillow under their legs. Resident 15's heels were observed touching their mattress with a single pillow under their knees. Staff I readjusted the pillow to ensure Resident 15's heels were floated. Staff I stated they checked Resident 15's positioning before checking off that their heels are floated in the TAR. Staff I stated if Resident 15's heels are not floated when checked, they readjust the resident to ensure their heels are floated before checking off on the TAR. In an interview on 07/02/2025 at 9:42 AM Staff G, Licensed Practical Nurse (LPN)/Case Manager, stated they were not aware Resident 15 was sliding down in their bed causing their heels not to be floated. Staff G stated a pillow should be folding when floating Resident 15's heels. In an interview on 07/02/2025 at 1:00 PM, Staff B, Director of Nursing, stated all elderly residents are at risk for PUs. Staff B stated they provided specialty mattresses, wheelchair cushions, and float their heels. Staff B stated Resident 15 was very particular and the staff needed to document their refusals and get creative on preventative measures, and document. Refer to WAC 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to ensure 3 of 3 residents (Residents 17, 54 and 160) were free of unnecessary drugs due to lack of monitoring and care planning of high-risk medications, including lack of assessment for anti-coagulant (blood thinning medication) use and edema (accumulation of fluid in the body) monitoring. These failures could result in unrecognized change in condition for Resident 54 related to lack of edema monitoring and Resident's 17 and 160 experiencing unrecognized signs and symptoms of bleeding while receiving an anti-coagulant medication and placed all residents at risk for adverse effects of high-risk medications. Findings included . Manufacturer recommendations regarding the use of Eliquis/Apixaban (anti-coagulant) stated the most common side effects were bleeding and bruising more easily. Indications for the use of the drug were that it was typically used to reduce the risk of stroke, prevent the formation of blood clots. <RESIDENT 17> Resident 17 was admitted to the facility on [DATE] with diagnoses to include aortic valve stenosis with insufficiency (heart condition where the aortic (heart) valve narrows) and atrial fibrillation (irregular heartbeat). Review of the Significant Change Minimum Data Set (MDS) assessment, dated 04/18/2025, identified the resident was taking an anti-coagulant. Review of the physician's orders dated 12/16/2022 showed Resident 17 was to receive Eliquis medication two times daily related to aortic valve stenosis. Review of Resident 17's care plan printed 06/27/2025 showed there was no care plan addressing the atrial fibrillation or goals for the use of the Eliquis medication; interventions to include monitoring, safety precautions and reporting were not developed. An anti-coagulation care plan would have included goals and interventions for the medication and would have directed staff on what kind of monitoring was needed and what to do in the event of an adverse reaction. Review of the April, May and June 2025 Medication Administration Records (MARs) showed Resident 17 was administered Eliquis twice a day. There was no monitor in place to monitor for signs and symptoms of bleeding events or bruising. <RESIDENT 160> Resident 160 admitted on [DATE] with diagnoses which included recent cardiac surgery. Review of Resident 160's physician's orders dated 06/25/2025 showed Apixaban twice per day related to heart disease. Review of the June 2025 MAR showed the resident was administered the apixaban twice per day as ordered. There was no monitor in place to observe for signs and symptoms of bleeding events or increased bruising. Review of Resident 160's baseline care plan on 06/27/2025 showed there was no care plan addressing the use of Apixaban, or side effect monitoring for its use. In an interview and observation on 06/27/2025, Resident 160 was in bed with eyes closed, the resident's spouse was at the bedside stating that they were waiting to see the doctor and they had to place a catheter last night because (Resident 160) could not urinate, and now the resident had blood in the (catheter) bag. Resident 160's catheter collection bag was observed to be hanging on the lower bed frame and was full of bright red bloody urine. Resident 160's spouse stated Resident 160 had issues with bleeding in the hospital and had to have transfusions. Review of Resident 160's MAR on 06/30/2025 at 10:00 AM, showed the resident's Apixaban was placed on hold on 06/27/2025 related to blood in the urine. Resident 160 was transferred to the emergency department on 06/30/2025 related to continued bleeding and decreased blood pressures and was admitted to the hospital. In an interview on 07/01/2025 at 2:12 PM, Staff F, Registered Nurse, Resident Case Manager, stated care plans for new admissions have options for standard choices such as ADL (activities of daily living) ability, pain, nutrition and the admitting nurse reviewed the resident record and can add other appropriate problems. There was noted to be a standardized choice for psychotropic medications, but not for other medications such as blood thinners or diuretics. Staff F stated if someone was admitted on a blood thinner it should be on the baseline care plan. Staff F stated when the orders for blood thinners were entered, there was a space for additional documentation which was supposed to include the side effect monitoring, and Staff F reviewed Resident 160's orders and stated the order template for Apixaban was lacking that information, so it would have needed to be manually entered, and it was not for Resident 160. In an interview on 07/02/2025 at 1:05 PM, Staff B, Director of Nursing stated there had not been monitoring in place for Resident 17 and 160's anti-coagulants. Staff B stated they had just completed an audit of residents' anti-coagulant orders for any additional concerns. Staff B stated they would change the electronic medical record to auto-populate monitoring when anti-coagulant orders were received. <RESIDENT 54> Resident 54 admitted on [DATE] with diagnoses which included gastrointestinal issues, and vascular (veins) wounds with cellulitis (infection of the tissue) to both lower legs. Record Review on 06/30/2025 showed Resident 54 had orders for knee high elastic stocking ordered for lower extremity edema management on 06/18/2025 and orders for Lasix (a diuretic) for edema on 06/26/2025. Review of the Resident's MAR for the month of June 2025 showed no edema monitoring or side effect monitoring for the use of Lasix. In an observation and interview on 06/26/2025 at 2:00 PM, Resident 54 was sitting up in their wheelchair in their room with elastic stockings visible on both feet. Resident 54 stated they have been having a lot of issues with swelling in their feet. Resident 54 stated they have had swelling and issues with sores on their legs before. In an interview on 07/01/2025 at 2:12 PM, Staff F stated that resident's with edema should have edema monitoring and there should be side effect monitoring for diuretic therapy. Staff F stated they needed to update Resident 54's care plan. Reference WAC 388-97-1060(4)

Based on observation, interview and record review, the facility failed to ensure staff were following established guidelines related to Enhanced Barrier Precautions (EBP), which are infection control interventions designed to reduce the transmission of multi-drug-resistant organisms in healthcare settings, for 1 of 3 residents (Resident 19) reviewed for pressure ulcers. These failures placed residents and staff at risk for potential infection from cross contamination of infectious organisms. Findings included . EBP focuses on the use of gowns and gloves during specific high risk resident care activities and is implemented for residents known to be infected, colonized, or at increased risk for acquiring a multi-drug-resistant organism, including residents with chronic wounds or indwelling devices. Record Review on 06/30/2025 at 12:22 PM documented Resident 19 developed a pressure ulcer to the right heel related to a hard cast. The ulcer onset date was documented as 12/04/2024, when the hard cast was removed and the ulcer was discovered. The record documented the wound remained open requiring dressing changes. In an observation on 06/30/2025 at 12:22 PM, there were no EBP in place for Resident 19. In an interview on 06/30/2025 at 2:29 PM, Staff C, Infection Preventionist, stated EBP should be in place for residents with chronic or stagnant wounds. Staff C was not able to recall the current precautions for Resident 19. In an interview on 07/01/2025 at 1:06 PM, Staff G, Licensed Practical Nurse, Resident Case Manager, stated Resident 19's right heel wound was observed following removal of the hard cast in December, and stated it had not fully healed. Staff G confirmed the right heel wound was chronic and required EBP. In an interview on 07/02/2025 at 1:00 PM, Staff B, Director of Nursing stated Resident 19 should have been on EBP for the chronic wound. Reference WAC 388-97-1320(2)(b)

Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living to include personal hygiene and bathing for 5 of 5 sampled dependent residents (Residents 7, 9, 11, 49 and 10) reviewed for activities of daily living (ADL's). Facility failure to provide resident's, who were dependent on staff for assistance with hygiene including oral care, and showers placed residents and others at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy, Bathing/Showers, revised 06/23/2023, showed the policy was to ensure residents are receiving proper personal hygiene regarding bathing and the facility is meeting their needs and bathing preferences. If a shower /bath cannot be physically tolerated by the resident a bed bath would be offered. Refusals would be documented, and staff would reapproach. If multiple refusals occur, the LN to be informed. Showers/baths are also given as needed based on resident preference. Review of the facility's policy, Oral Care Policy, revised 06/27/2023, showed all residents oral health will be maintained at their highest practicable level. Each resident shall receive oral care every AM, PM, and as needed (PRN). Residents who need assistance with oral care will receive it and those residents who can perform the oral care themselves will be set up for oral care if needed. <RESIDENT 7> Resident 7 admitted on [DATE] with diagnoses to include respiratory disease requiring a tracheostomy, muscle weakness and need for assistance with ADL care. Review of the Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 03/13/2024, showed Resident 7 did not reject care. Review of Resident 7's the care plan, revised on 02/27/2024, directed one staff to assist with oral care to gently brush their gums and lower teeth twice daily, bathing, and grooming. The care plan showed the resident required special care of their tracheostomy (a surgically created hole, a stoma, in the windpipe, the trachea, that provided an alternative airway for breathing) to protect their airway during showers twice weekly. In an interview on 04/08/2024 at 2:16 PM, Resident 7 stated they had upper dentures in the cupboard that did not fit really good. Resident 7 stated they did not receive oral care. In an interview on 04/12/2024 at 9:36 AM, Staff L, Nursing Assistant Certified (NAC), said Resident 7 needed set up for personal hygiene. Staff L said they did not remember if the resident had teeth. Resident 7 received bed baths and did not refuse personal hygiene care. In an interview on 04/11/2024 at 9:22 AM, Resident 7 said they do not receive oral care in the facility. The resident said the staff do nothing in my mouth and they don't have time, so I don't force the issue. They denied mouthwash, swabbing or oral care of any kind since admitted to the facility. They said they have not refused. The resident said they could do it themself if the staff got them the stuff to do it or got them out of bed and up to the sink. There were no oral care items were visible in the room or at the sink. In an interview on 04/12/2024 at 9:18 AM, Resident 7 was in bed reading the activity paper and said they still had not been offered oral care. Resident 7 said they preferred bed baths. Review of Resident 7's 01/01/2024 through 04/12/2024, shower records showed the resident did not receive bathing twice a week. The bathing records showed the resident did not receive consistent bathing. In January, on 01/01/2024 the documentation showed the shower was not applicable, the resident refused on 01/11/2024, and received one shower on 01/22/2024. In February, they received bathing on 02/05/2024, refused on 02/19/2024, and received a bed bath on 02/24/2024. In March, bathing was documented refused on 03/01/24, and was bathed on 03/15/2024. As of 04/12/2024 at 11:00 AM, Resident 7 received a bed bath on 04/04/2024. In an interview on 04/12/2024 at 10:22 AM, Staff G, Registered Nurse (RN)/Case Manager (CM), stated they had not heard Resident 7 had not been getting oral care or bathed per their preference. Staff G said the resident preferred bed baths. Staff G said they were not aware of the resident's missed bathing or showers. Staff G said the expectation was for showers at least weekly and per the resident desire and oral care was to be completed a minimum of morning and at bedtime. Staff G said Resident 7 could do their own oral care with set up. <RESIDENT 9> Resident 9 admitted on [DATE] with multiple cardiac diagnoses, major depressive disorder, and anxiety. Review of the Quarterly MDS assessment, stated 03/05/2024, showed Resident 9 did not reject care. Review of Resident 9's care plan, revised on 04/26/2022, directed staff to set up the resident at the sink to complete their oral care twice a day. The resident received moderate assistance for upper body dressing. The care plan showed the resident was to have one shower a week. Review of Resident 9's shower records, dated 02/01/2024 through 03/27/20024, showed the resident did not receive a shower weekly. The resident did not receive bathing in February on 02/04/2024, 02/16/2024, 02/22/2024 and 02/28/2024. The resident refused showers on 02/12/2024, 02/13/2024, 02/15/2024 and 02/25/2024. The resident received bathing on 03/03/2024, 03/06/2024, 03/10/2024, 03/20/2024 and 03/27/2024. The resident refused bathing on 03/13/2024. In an interview and observation on 04/08/2024, Resident 9 was observed in their recliner wearing a lavender and white polka dot night gown. In an interview and observation on 04/09/2024 at 3:14 PM, Resident 9 was up in her wheelchair wearing a lavender and white polka dot nightgown. In an interview and observation on 04/10/2024 at 9:11 AM, Resident 9 was up in their recliner asleep wearing a lavender and white polka dot nightgown. In an interview and observation on 04/11/2024 at 9:33 AM, Resident 9 was sitting in their recliner with the same lavender and white polka dot nightgown on since 04/08/2024, with dried yellow food on their left chest area. Resident 9 said they never got me dressed but today, they had to I am seeing the knitting group. Resident 9 said the staff should change their gown as they had been in the same nightgown over a week. The resident said they felt dirty. The resident had heavy plaque in their bottom teeth. The resident stated they had been here three years and they have never brushed my teeth. I want to brush them before my appointment Monday. I want to brush my teeth. I would need to get in front of the sink and there is a wheelchair there. I have 2 teeth on top and my bottom. There were no oral care items observed in the room. On 04/12/24 09:25 AM, Resident 9 was observed sitting up in their recliner wearing a white and blue flowered nightgown. The resident does not recall when the last time they received oral care. The resident stated you have to ask for it. They do not offer anything here. There were no oral care items observed at the sink or nearby. In an interview on 04/12/2024 at 9:48 AM, Staff G stated oral care needed to be looked at. Staff G said there was a time when the staff monitored Resident 9's mouth related to dental pain. <RESIDENT 11> Resident 11 admitted on [DATE] with diagnoses to include multiple sclerosis, chronic pain, multiple cardiac diagnoses, and major depressive disorder. Review of the Quarterly MDS assessment, dated 02/14/2024, showed Resident 11 rejected care on one to two days during the seven-day lookback (the MDS assessment time) period. Review of Resident 11's care plan, revised on 08/22/2022, showed the resident required physical assistance with most ADL's, except for oral care the resident required set up assistance. The resident tracked their showers in their closet. They wanted one to two showers a week preferably on Mondays and Thursdays. In an interview on 04/08/2024 at 3:33 PM, Collateral Contact 1 (CC1), Resident 11's family member, said their loved one would like more showers. In an interview on 04/09/2024 at 12:46 PM, Resident 11 stated they took showers but not often enough. The resident stated their last shower was a week and a day late, two weeks ago. They said they had waited three weeks for a shower even though they told the staff to put them on the list (a list to be showered). The resident commented my hair gets greasy fast. Review of the 01/01/2024 through 04/11/2024 bathing records, showed Resident 11 received bed baths five times in January (on 01/02/2024, 01/10/2024, 01/20/2024, 1/22/2024 and 01/31/2024), three times in February (on 02/03/2024, 02/17/2024, 02/19/2024, and refused on 02/20/2024, and 02/27/2024). In March the resident received bed baths three times (on 03/03/2024, 03/09/2024, 03/12/2024), refused three times (on 03/13/2024, 03/19/2024, 03/25/2024), and on 03/26/2024 and 03/30/2024 the bathing was documented as not applicable. As of 04/12/2024 at 12:03 PM, Resident 11 received a bath on 04/05/2024 and refused on 04/03/2024. In an interview on 04/10/2024 at 1:01 PM, Resident 11 stated they were upset it had been two weeks since their last shower and staff was able to assist them into the shower today. Resident 11 commented it was not right that if you don't feel like getting your shower that day, you get lost in the shuffle and they do not offer you another shower the following day. The resident said it had been several months since the facility had a shower aide. In an interview on 04/11/2024 at 9:00 AM, Resident 11 resident stated they had only refused two showers in the two years they had been there. They questioned why they would refuse something they loved. The resident said their showers were missed and they have asked them and asked them to put their name on a routine schedule. The resident said they would love to have two showers a week but that would never happen. The resident said they at least need one a week as their hair gets very greasy. They commented otherwise they must put baby powder in their hair to absorb the grease and luckily the baby powder was the same color as their hair. <RESIDENT 49> Resident 49 admitted on [DATE] with diagnoses to include major depressive disorder and gait and mobility abnormalities. Review of the Admission MDS assessment, dated 02/07/2024, showed Resident 49 rejected care on one to three days during the seven-day look back period. Review of Resident 49's care plan, revised on 03/28/2024, directed staff to provide set up assistance for oral care at the sink. The care plan showed the resident preferred showers in the afternoon or evening two to three times a week. In an observation on 04/08/2024 at 10:28 AM, Resident 49 was sitting up in bed and had greasy hair. In an observation and interview on 04/09/2024 at 11:28 AM, Resident 49 was sitting up in bed with brown liquid on their right chest area of their gown. The resident's hair remained greasy. Resident 49 said the staff do not set them up to have oral care, but they needed it. The resident said they were not supposed to get out of bed by themself, so they needed help getting their toothbrush and toothpaste to be able to brush their teeth in bed. There was an electric toothbrush and kidney basin observed out of the resident's reach and located behind them on their nightstand. Review of Resident 49's 02/01/2024 through 04/09/2024 shower records, showed the resident received four showers in February (on 02/04/2024, 02/09/2024, 02/20/2024, and 02/27/2024), and refused three times (on 02/18/2024, 02/19/2024 and 02/25/2024). In March, the resident received one shower on 03/03/2024, and refused four times (on 03/07/2024, 03/11/2024, 03/21/2024, 03/28/2024). In April, there was no documentation the resident received a shower, but did refused to be showered on 04/02/2024 and 04/09/2024. 43954 <RESIDENT 10> Resident 10 was admitted to the facility on [DATE] with diagnoses to include fracture of left shoulder, depression, cellulitis (bacterial skin infection) of limb, and coronary artery disease (plaque buildup in the wall of the arteries that supply blood to the heart). Review of Resident 10's Admission MDS assessment, dated 03/18/2024, showed the resident was cognitively intact and had no refusals of care. Review of Resident 10's current care plan showed they preferred two showers per week in the mornings and required assistance with their ADL's. Review of Resident 10's March 2024 documentation survey report (NAC documentation) showed the resident refused a shower on 3/12/2024 and received showers on 03/13/2024, 03/17/2024, 03/25/2024 and 03/31/2024. Review of Resident 10's 04/01/2024 through 04/11/2024 documentation survey report, showed they refused a shower on 04/06/2023 and received showers on 04/07/2024 and 04/11/2024. In an interview on 04/08/2024 at 3:03 PM, Resident 10 stated they were supposed to receive showers on Sundays and Wednesdays but does not happen on all scheduled Sundays and/or Wednesdays. Resident 10 stated they thought there was a scheduling issue, and the facility staff could do better to follow the schedule. In an interview on 04/12/2024 at 10:15 AM, Staff I, NAC/Restorative Aide, stated the facility had dedicated shower aide's and floor staff do not regularly have to shower/bathe their assigned residents. Staff I stated the facility NACs would help if showers needed to be done. In an interview on 04/12/2024 at 10:35 AM, Staff H, NAC, stated the facility had shower aide's dedicated to complete showers in the mornings and evenings. Staff H stated if NAC's were required to do showers, they could manage their time to give a resident a shower. In a joint interview on 04/12/2024 at 12:00 PM, Staff A, Administrator, and Staff B, RN/Director of Nursing Services, were asked about Resident's 7, 9, 10, 11 and 49 ADL concerns. Staff A and Staff B stated the facility had a shower aide that was out with an injury for over two months and they identified residents showers were inconsistent. Refer to WAC 388-97-1060 (2)(a)(i)

Based on interview, and record review, the facility failed to identify a significant change in status for 1 of 1 sampled resident (Resident 22), reviewed for Hospice services. Failure to identify and complete a Significant Change in Status assessment, according to the Resident Assessment Instrument (RAI - consists of three basic components: The Minimum Data Set, the Care Area Assessment process, and the RAI Utilization Guidelines. The utilization of the three components of the RAI yields information about a resident's functional status, strengths, weaknesses, and preferences, as well as offering guidance on further assessment once problems have been identified). manual, placed residents at risk for inadequate care planning and a diminished quality of life. Findings included . Record review of the Long-Term Care Facility Resident Assessment Instrument, User's Manual, Version 3.0, dated October 2019, showed that a Significant Change in Status assessment must be conducted within two weeks of the resident's election of their Hospice benefit. Review of Resident 22's medical record showed they admitted on [DATE] and were not receiving Hospice services. The record showed the resident was transferred to an acute care hospital on 03/19/2024, readmitted to the facility on [DATE] and had elected their Hospice benefit during their hospitalization . The RAI manual required the facility to conduct a significant change in status assessment within 14 days. Review of Resident 22's Minimum Data Set (MDS) assessments, showed an assessment was created on 04/01/2024 which was incorrectly coded as an Admission assessment rather than the required Significant Change in Status assessment. In an interview on 04/09/2024 at 10:00 AM, Staff C, Registered Nurse, MDS Coordinator, stated they were still learning the role and were not aware that the Significant Change Assessment was not an option in this case or that the Admission assessment was not a correct MDS selection. Staff C stated they would do a modification of the assessment. Refer to WAC 388-97-1000(3)(b)

Based on observation, interview, and record review the facility failed to implement comprehensive person-centered care plans for 1 of 2 sampled residents (Resident 42) reviewed for urinary catheters (tube inserted into the bladder to remove urine), 1 of 4 sampled residents (Resident 22) reviewed for non-pressure skin alterations, and 1 of 5 sampled residents (Resident 49) reviewed for unnecessary medications. This failure to ensure the comprehensive care plan was implemented placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, Comprehensive Care Plans, dated 07/01/2017 stated that all residents will have a comprehensive care plan developed within seven days of the comprehensive assessment. Care plans will be reviewed annually, quarterly, if there was a change in condition or as needed. All care plans will be revised based on changing goals, preferences, and needs of the resident. <URINARY CATHETER> Resident 42 admitted to the facility on [DATE] with diagnoses including urinary retention, and bladder obstruction. The Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 02/21/2024, showed the resident had severe cognition impairment, was dependent on staff for their toileting and personal hygiene needs, and had a urinary catheter. Review of Resident 42's physician orders showed the following: dated 08/11/2023 catheter care performed every shift, dated 10/25/2023 staff may change the catheter as needed and, dated 04/06/2024 staff to flush the catheter with normal saline every evening shift and eight hours as needed. Review Resident 42's care plan showed a focus problem, dated 05/15/2023, the resident had an alteration in bladder and bowel elimination related to urinary retention with a goal to maintain continence (ability to control) their bladder and bowels. Interventions included, dated 06/01/2023, the resident had a urinary catheter and was okay to wear adult pull-up briefs as staff should anticipate the residents care needs. Observation on 04/08/2024 at 3:12 PM, Resident 42 had a urinary catheter privacy bag attached to their wheelchair (w/c), there was no urinary bag present. The resident appeared to have a urinary leg bag, as the tubing and edges of the leg bag were visible under the resident's pants. Observations on 04/09/2024 at 9:00 AM, 11:00 AM, 1:03 PM, and 2:03 PM, Resident 42 had a urinary catheter privacy bag attached to their w/c, there was no urinary bag present. Resident 42 appeared to have a urinary leg bag, as the tubing and edges of the leg bag were visible under the resident's pants. In an observation and interview on 04/10/2024 at 9:18 AM, Resident 42 had a urinary catheter privacy bag attached to their w/c, there was no urinary bag present. Resident 42 appeared to have a urinary leg bag, as the tubing and edges of the leg bag were visible under the resident's pants. Resident 42 was asked if they had a urinary catheter, the resident pointed to their leg with the tubing and stated, I don't know what I have, but its here. In an interview on 04/10/2024 at 9:48 AM, Staff D, Nursing Assistant Certified (NAC), stated Resident 42 wore a urinary leg bag during the day, and staff switched the resident from an overnight bag every morning. In an interview on 04/11/2024 at 10:29 AM, Staff E, NAC, stated Resident 42 wore a urinary leg bag during the day. Staff E stated every morning they would switch out the urinary bag from an overnight bag to the leg bag for the resident. Staff E was asked where they get that direction of care, and they stated they followed the care plan. In an interview on 04/11/2024 at 11:17 AM, Staff F, Licensed Practical Nurse (LPN), stated Resident 42 preferred to wear a urinary leg bag during the day, so the NACs would switch the resident from an overnight urinary bag to a urinary leg bag every morning. Staff F was asked where that direction of care was located, Staff F reviewed the physician orders and did not see an order and stated it was probably on the care plan as that was the resident's preference. Review of Resident 42's physician orders and care plan on 04/11/2024 showed no order or direction of care that the resident preferred to have the overnight urinary bag switched to a urinary leg bag every day. In an interview on 04/11/2024 at 12:07 PM, Staff G, Registered Nurse (RN)/Case Manager (CM), stated Resident 42 preferred to have the overnight urinary bag switched to a urinary leg bag every day. Staff G was asked to show where in the resident's medical record that information was located, and Staff G stated they would have to investigate that. In a follow-up interview on 04/11/2024 at 1:45 PM, Staff G stated when they reviewed Resident 42's care plan and physician orders, they did not find any order or direct of care for a urinary leg bag. Staff G stated they went to discuss with the NAC's who worked with the resident, and they stated the resident preferred a urinary leg bag every day, so they just did it. Staff G stated the information should have been on the care plan. 37890 <NON-PRESSURE SKIN> Resident 22 readmitted to the facility on [DATE] with diagnosis of end stage kidney disease which the resident declined aggressive treatment for, selecting Hospice services. The resident's untreated medical condition resulted in a symptom of significant itching to the skin. In an observation and interview on 04/10/2024 at 10:17 AM, Resident 22 received dressing changes to their lower legs. On the resident's upper thighs were large, scratched areas and blood. Hospice staff were present and talking to the resident about the itching and the medication that was currently ordered to treat it. Resident 22 stated the medicine helped only a little. They stated they try not to scratch but they can't help it, it just itches all the time. The resident stated they had nail clippers and tried to remember to clip their own fingernails. Staff J, RN/CM, stated the itching was the resident's main issue and the medication ordered helped some but not enough. Staff J stated there should be other interventions they could do such as lotion and monitoring of any scratches. Review of Resident 22's current care plan, showed there was no problem or interventions related to the resident's itching or self-injury from scratching. 36787 <UNECESSARY MEDICATIONS> Resident 49 admitted on [DATE] with diagnosis to include major depressive disorder. The resident was receiving fluoxetine (Prozac), an anti-depressant medication. In an interview on 04/08/2024 at 10:52 AM, Resident 49 said they had been on Prozac most of their adult life. Review of the care plan showed there was no care plan addressing the diagnosis of major depressive disorder or anti-depressant use. In an interview on 04/12/2024 at 12:47 PM, Staff C, RN/Minimum Data Set Coordinator, said they had missed addressing Resident 49's depression and use of Prozac on their care plan. In an interview on 04/12/2024 at 12:06 PM, Staff B, RN/Director of Nursing Services, stated they were aware there was some concerns with the comprehensive care plans for the residents. Staff B stated they were in the process of changing how the review and update the care plans, and moving forward the Care Managers would be taking over that roll. Staff B stated Resident 42 should of have the urinary leg bag on the physician orders as well as care planned for how staff should manage the urinary bag. Refer to WAC 388-97-1020(1)(2)(a)

Based on observation, interview, and record review, the facility failed to comprehensively assess, monitor, and implement dietary interventions as needed to prevent weight loss for 1 of 2 residents (Resident 49) reviewed for nutritional status. This failure placed residents at risk for continued weight loss, dehydration, and a decline in their nutritional status. Findings included . Review of the facility policy titled, Nutrition Review Committee, revised 06/02/2023, showed the facility was to assure that residents have adequate nutritional intake to maintain healthy weights, to maintain current health status/healing .The policy showed the facility would monitor all residents with weight loss more than (>) 5% in 30 days, >7.5% in 90 days or >10% in 180 days (as pulled with weight triggers). Resident care managers will make sure that care plans include a plan to meet nutritional needs of residents at risk for nutritional deficiencies with measurable goals. Residents with above mentioned needs to be reviewed at meetings. Resident 49 admitted [DATE] with diagnoses which included syncope (fainting), major depressive disorder, cardiac disease, and history of stroke. They were able to make their needs known. Review of the facility nursing admission assessment, dated 01/31/2024, showed Resident 49's admission weight was documented at 202.8 pounds (lbs.) and the facility used a chair lift scale to obtain the admission weight. The admission assessment noted the resident had two plus pitting edema (excess fluid built up in the body, causing swelling and when pressure is applied to swollen areas, a pit or indentation remains for more than two seconds) to both lower extremities. Review of the Admission Minimum Data Set (MDS - an assessment tool) assessment, dated 02/07/2024, showed Resident 49 required set up or clean up (staff only assist prior to or following the activity) assistance with eating. The history of weight loss or weight gain was marked as no or unknown and the weight obtained on 02/12/2024 of 193 lbs. was utilized in the MDS. Review of the dietary profile assessment, dated 02/02/2024, showed Resident 49 reported their appetite was good and their usual weight was 200 lbs. Review of Resident 49's Registered Dieticians (RD) nutritional assessment, dated 02/08/2024, showed the resident's food and beverage preferences were reviewed with dietary. Resident 49's appetite was good, and they reported their usual weight was 200 lbs. The RD documented their weight was stable at 196.4 lbs. A review of the facility's weight exception report summary for Resident 49 showed on the resident weighed 202.8 lbs. on admission (01/31/2024). On 03/07/2024, the resident weighed 184.0 lbs, an 18.8 lb or 9.3% weight loss in two months. On 04/11/2024 the resident weighed 177.8 lbs, a weight loss of 12.3 % or 25.0 lbs. weight loss since admit on 01/31/2024. Review of Resident 49's progress note, dated 03/07/2024 at 7:37 AM, showed the resident had vomited daily, they were declining Zofran (anti-nausea medication) related to a bad prior experience. In an interview on 04/08/2024 at 10:40 AM, Resident 49 said they felt pukey and had been experiencing uncontrolled nausea and vomiting and did not know why. The resident reported they had lost 20 lbs. since they admitted to the facility. In an interview on 04/09/2024 at 11:28 AM, Resident 49 was sitting up in bed with a pained expression. They had brown vomit on the right chest area of their gown. They said they were still pukey. The resident commented they were not sure if staff were even looking into their nausea and vomiting. At 12:55 PM, the resident said they could not eat lunch. At 3:12 PM, the resident had a pained expression and reported they had nausea and vomiting after eating and no foods seemed to trigger it. In a review of Resident 49's clinical record on 04/10/2024, showed the provider and/or staff had not documented any edema concerns in the resident's progress notes. Edema was only documented on the resident's admission assessment. The medical record showed the attending physician was notified of nausea and vomiting, there was no documentation they were notified of the residents trending weight loss and decreased meal intake. In an interview on 04/10/2024 at 9:09 AM, Resident 49 was resting in bed with a pained expression. There was a full breakfast tray with waffle sticks and bacon untouched on the overbed table. The resident stated they threw up this morning and were too scared to eat. The resident said they were supposed to be seen by the doctor today. In an interview on 04/10/2024 at 2:56 PM, Staff B, Registered Nurse/Director of Nursing Services (DNS), said they have nutrition at risk (NAR) meetings on Thursdays. Staff B said they were not sure if Resident 49 had been on their radar for weight loss. The weight history was shown to Staff B that showed progressive weight loss according to the clinical record. The weight loss was calculated at 11.98% or a 24.3 lbs. in two months. In an interview on 04/11/2024 at 8:28 AM, Staff B said the nurses had been doing things for Resident 49. Staff B said they thought the nausea and vomiting was a postural blood pressure (a form of low blood pressure that happens when standing after sitting or lying down) issue and the doctor and RD would see them today. In an interview on 04/11/2024 at 9:05 AM, Resident 49 was in bed in their new room. The resident stated they had been vomiting since 3:00 AM. When asked about vomiting triggers, the resident stated they did not necessarily need to be standing to throw up, as they would throw up while in bed also. The resident said that it was just guaranteed they would throw up if they stood up. In an interview on 04/11/2024 at 10:09 AM, Staff O, RD, said they saw Resident 49 on admission and in February when they triggered for weight loss. Staff O said some of the initial weight loss was thought to be fluid related. Staff O said they checked the resident's meal monitor and there were good meals, bad meals, and their intake had decreased in the past two weeks. Staff O said there were more meals where they ate less than 50%. Staff O said they would talk with the resident about their nausea and vomiting. Staff O said Staff B did review the weight loss as a fluid shift (a change in location or position of body fluids from one compartment to another) mid-February and now with the nausea there were significant weight variances. Staff O said they were going to address the weight loss today and confirm their weight. They said staff had consistently obtained all weights with the same chair scale so weights would be accurate. Staff O said Staff B had a nutrition binder with some information in it that was not always in the resident's clinical record. Staff O stated they do not revise the care plans but believed the Case Managers (CM) did. Staff O commented until Resident 49's nausea was under control; weight loss was expected. Staff O said they had not been aware of the resident's nausea until this morning. Review of an RD assessment, dated 04/11/2024, showed Resident 49 was discussed in NAR meeting. The RD confirmed the resident had not been eating much due to nausea. The RD reviewed the importance of nutrition and suggested to help with nausea to include ginger ale or ginger candy, small frequent meals, snacks, and cold food options. The RD noted the resident was on a general, regular diet with thin liquids and extra sauce. The RD noted the resident's meal intake was 0-75%. The RD recorded the resident's weight was documented as 198.8 on 02/04/2024, 188 lbs. on 03/04/2024, 183 lbs. on 03/28/2024 and 177.8 lbs. on 04/11/2024. The RD documented the resident was seen in their room after lunch for issues around nausea, decreased intake and weight loss trend. The RD documented the resident's weight was down 5.5% in 1 month, and down 10.6% in 2 months. The RD included a review of anti-nausea medication and mood-altering medication could affect their appetite, and diuretics with potassium could cause weight fluctuation. Nursing and Advanced Registered Nurse Practitioner (ARNP) were addressing the possibility of the resident's vertigo (dizziness) caused their nausea. The dietary recommendations implemented included increasing fluids on meal trays and adding a nutritional supplement twice daily when the resident received medications. Review of Resident 49 meal monitors since admission, showed the resident's intake was variable and inconsistent ranging from 0-75% and the resident did not receive any nutritional supplements or snacks. In an interview on 04/12/2024 at 9:41 AM, Staff L, Nursing Assistant Certified (NAC), said Resident 49 had vomited a lot and they reported this to the nurse. Staff L said they had cared for the resident since admit and they did not refuse meals, they just could not eat related to the nausea. Staff L said they brought the resident mint tea to help them. In a joint interview and record review on 04/12/2024 at 10:26 AM, Staff G, RN/CM, said Resident 49 was not wanting to eat and was a bit dry, so they were giving them intravenous solution (IV) fluids now. Staff G said the residents family member had called with concerns. Staff G said they had only been the residents care manager for about two weeks and was trying to piece their clinical history together. Staff G said they knew the resident was losing weight but thought the weight loss was recent and just triggering now. The weight history was reviewed with Staff G who said they were unaware the resident had experienced a significant weight loss of 25 lbs. since admit on 01/31/2024. In an interview on 04/12/2024 at 12:39 PM, Resident 49 was in bed smiling and eating their lunch. The resident stated they were feeling so much better, and they were not sure if it was the new medication or the IV fluids. They said their nurse practitioner was in yesterday and told them they were dehydrated. The resident stated they were down to 177 lbs. yesterday and had lost 34 lbs. The resident stated they did not want to lose the weight the way they did as that had been miserable. In a joint interview on 04/12/2024 at 1:21 PM, Staff P, Advanced Registered Nurse Practitioner (ARNP), and Staff B, Staff P said they thought Resident 49's weight loss was related to fluid shifts. Staff P stated the resident admitted with pedal edema and had been admitted with a recent order for two diuretics that would lead to weight loss. Staff P said the nausea had been getting worse the past week and had been unaware of the resident's nausea until 03/23/2024. Staff B said they attributed the weight loss to edema. Staff B said they had been doing interventions but could have documented everything better in the resident's clinical record. Staff B provided a spreadsheet from 02/15/2024 that showed the resident's weight was down to 194.6 lbs. from 202.8 lbs. and weight loss was expected related to fluid issues. No recommendations were made. Staff B said they would make sure documentation from their nutrition binder made it into the resident's chart. Staff B and Staff P were not aware of the resident's weigh loss until it was brought to their attention on 04/10/2024 during the facility's annual survey. Refer to WAC 388-97-1060 (3)(h)

Based on observation, interview, and record review, the facility failed to ensure residents who were trauma survivors and diagnosed with Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed) received culturally competent, trauma-informed care and services in accordance with professional standards of practice for 2 of 2 sampled residents (Resident 9 and 15) reviewed for Trauma informed care. The facility's failure to develop and implement resident centered interventions placed residents at risk for unidentified triggers, re-traumatization, and a decreased quality of life. Findings included . <RESIDENT 15> Resident 15 admitted [DATE] with diagnoses which included Alzheimer's dementia and PTSD. Review of the Annual Minimum Data Set (MDS - an assessment tool) assessment, dated 02/24/2024, showed severe cognitive impairment, total dependence on staff for all activities of daily living including transfers, toileting, eating and participation in activities. Review of Resident 15's record on 04/10/2024, showed no person-centered trauma assessment in the record. Review of Resident 15's care plan on 04/10/2024, showed a care plan problem for PTSD related to history of childhood sexual abuse. The intervention listed showed care in pairs for safety related to the resident becoming agitated during cares. The care plan had no further person centered interventions related to the resident's abuse history. In an observation on 04/10/24 at 10:05 AM, Resident 15 and another resident were sitting in the common room and the television (TV) program on was Law and Order- Special Victims Unit which was a graphic crime drama that focuses on sexual crimes. The resident's eyes were open and they were looking at the TV. When asked if the resident liked the program that was on, the resident made eye contact and smiled but did not verbally respond. Applying the reasonable person concept, a resident with a diagnosis of dementia and a history of childhood sexual abuse, would not desire to watch a violent sexual crime drama. Resident 15 was chair bound and would be unable to remove themselves from the situation. Staff Q, Licensed Practical Nurse (LPN), was observed at their cart next to the common room, in view and earshot of the TV, but did not appear to notice the programming choice or the possibility of it being a triggering program for Resident 15. The other resident present commented the TV program was gruesome. In an observation on 04/10/2024 at 10:07 AM, Staff K, Registered Nurse (RN)/Staff Development Coordinator, was observed to walk down the hall and passed the common room stating oh, a little Law and Order, huh? as they walked by. In an interview on 04/10/24 at 10:15 AM, Staff Q stated they couldn't think of anything specific they would do or avoid for Resident 15, and when asked about activities or programming choices, Staff Q stated they were supposed to watch family friendly shows. Staff Q stated they thought the TV was on the Price is Right. Staff Q was asked about the observed TV program, and they stated that would not be a good one for the resident to watch. In an interview on 04/10/2024 at 11:30 AM, Staff R, Social Services, stated they attempted to interview residents (or the representatives) about trauma history and then placed the information on the care plan. Staff R stated they did not see a trauma assessment for Resident 15 and were not aware of any specific triggers for the resident other than cares being provided. 36787 <RESIDENT 9> Resident 9 admitted on [DATE] with diagnoses to include chronic PTSD, major depressive disorder. Review of a social history and discharge plan assessment, dated 06/17/2021, showed Resident 9 had no history of a traumatic event and no negative triggers. Review of the annual Psychosocial well-being care area assessment, dated 06/09/2023, showed Resident 9 could get frustrated at facility policies that could possibly escalate to verbal outbursts. There was no mention of the resident's diagnoses of PTSD. Review of the Quarterly MDS assessment, dated 03/05/2024, showed no cognitive impairment, and the resident felt lonely or isolated from those around them sometimes. In an interview on 04/08/2024 at 1:53 PM, Resident 9 stated they were born in another country during World War II and had been hit with shrapnel. The resident stated the shrapnel was sharp and hit them in their head, neck, and arms. In an interview on 04/10/2024 at 11:05 AM, Resident 9 was asked how their day was and responded they were a survivor and had been through a lot in their life. Review of the resident record on 04/10/2024 showed a trauma care plan was revised on 03/15/2024. The care plan focus was about one of the resident's children passing away in November of 2020 which had been an extreme loss for them. One of their children was experiencing health issues that distressed the resident. The care plan interventions included active listening, reporting odd behavior or expressions of fear, anxiety, continual refusing of services, or crying to social services or nursing. Social services were to check in with the resident daily and they were to make a referral to mental health as necessary. In an interview on 04/11/2024 at 9:33 AM, Resident 9 was sitting in their recliner and stated they were okay but had been through a lot. The resident stated they were born in another country during WW II when the Germans occupied it. The resident talked about their hatred for a dictator of another country and how this dictator treated other people of a certain ethno-religious group and nation. Resident 9 said their family hid radios in the floor because the Germans came into their home and took it over. They described when they were [AGE] years old, they recalled how difficult their life was when growing up in this type of environment, and how they had to live a day at a time. The resident again discussed how they got hit with shrapnel on the street from a German soldier, and they still had a piece in their back and arm and still had the scars. Resident 9 said they did not like to watch anything war related or with guns, criminals, or violence. They said they turn it off. Resident 9 said Staff G, RN/Case Manager knew all about their history. The resident stated they would like to talk to their minister as they were their supporter who comes into see them. The resident said they received counseling often. Resident 9 stated they lost all but one family member from smoking and they could not get over it. In an interview on 04/12/2024 at 9:39 AM, Staff L, Nursing Assistant Certified (NAC), said Resident 9 was to be cared for by female staff only but they were unsure why. Staff L said they did help the resident get their clothes out, with meal orders and ice water delivery. Staff L said they were unsure if the resident had PTSD. In an interview on 04/12/2024 at 9:48 AM, Staff G said Resident 9 had experienced lots of loss. Staff G said they believed the PTSD was from the deaths in their family, they kept reliving. Staff G said they had forgotten about the residents past experiences in the country they were born and being hit by shrapnel. Staff G said some things may trigger them, but they could not tell what they were. Staff G acknowledged they were unaware of them not wanting war related, gun, criminal, or violent programs. Staff G said they would revise the care plan and they only wanted female caregivers. In an interview on 04/12/2024 at 1:07 PM, Staff S, Social Services, stated when a resident had a diagnosis of PTSD, the care plan would be developed to include triggers and how to avoid them. Review of Resident 9's care plan had no further person centered interventions related to the resident's history during World War II, their physical and mental war related injuries, the resident's triggers, or intervention to mitigated signs of PTSD. The care plan did not include the resident's counselor visit frequency or contact information. Refer to WAC 388-97-1060(3)(e)

Based on observation, interview and record review, the facility failed to ensure infection control standards were followed during 1 of 2 residents (Resident 45) wound care observations when hand hygiene was not completed between glove changes and when items were touched in a drawer and gloves were not changed. This failure placed residents at risk for an infection of their wound. Findings included . Review of the facility provided policy titled, Hand Hygiene, undated, showed hand hygiene was to be performed after gloves were removed. Resident 45 was admitted to the facility on [DATE], with the most recent admission on 03/28/2024, and had diagnoses to include open wound to left thigh, malnutrition, cancer of left leg and an infection following a procedure of a surgical site. Review of Resident 45's provider orders, initiated 03/28/2024, showed there was an order for daily wound care and dressing change to their left thigh wound. In an observation on 04/08/2024 at 1:24 PM, Staff J, Registered Nurse (RN)/Case Manager, performed wound care for Resident 45. Staff J donned (put gloves on) and doffed (took gloves off) gloves four times during wound care and did not perform hand hygiene in between any set of glove changes. Staff J, with gloved hands and went to the resident's dresser top drawer, pulled it open, rummaged through the dressing supplies in the drawer, closed drawer, opened the gauze packaging, and with the contaminated gloves applied the gauze to the resident's wound. In an interview on 04/11/2024 at 1:54 PM, Staff K, RN/Infection Preventionist/Staff Development Coordinator, stated they do competency observations of nurse's wound care related to infection control that included hand hygiene. In an interview on 04/11/2024 at 3:30PM, Staff B, RN/Director of Nursing Services, stated it was their expectation hand hygiene be done appropriately during wound care, after removal of gloves, and gloves should have been changed after opening Resident 45's drawer and touching other supplies. Refer to WAC 388-97-1320 (1)(c)

Based on interview, and record review, the facility failed to ensure they were free of significant medication errors for 1 of 3 sampled residents (Resident 1). The facility administered two doses of an antibiotic listed on Resident 1's allergy list. This failure placed Resident 1 at an increased risk of an allergic reaction to the medication, potential complications, and placed other residents at risk of medication errors. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include heart failure. Review of Resident 1's clinical record showed allergies listed as nitrofurantoin (antibiotic) and sulfa (antibiotic). Review of Resident 1's hospital discharge record, dated 09/07/2024, showed the resident had a history of urinary tract infections (UTIs) and had allergy to nitrofurantoin and sulfa antibiotics. Review of urine culture results, dated 09/28/2023, showed Resident 1 had an UTI. There was a handwritten order on the urine culture result form for Septra DS (sulfa antibiotic) twice daily for seven days was signed by the resident's provider. Review of Resident 1's Medication Administration Record (MAR) for September 2023, showed the resident received Bactrim DS (same medication as Septra DS) on the evening of 09/28/2023 and the morning of 09/29/2023. The MAR showed the resident had an allergy to nitrofurantoin and sulfa antibiotics. Review of nursing progress note dated 09/28/2023 showed Resident 1 received their first dose of Bactrim DS. Review of Advanced Registered Nurse Practitioner (ARNP) note, dated 09/29/2023, showed they received notification from a nurse, that the pharmacy had contacted the facility and informed them Resident 1 was allergic to sulfa antibiotics. The ARNP discontinued the Septra DS and started a different antibiotic. Review of progress note showed Resident 1 had a light rash on arms and oral discomfort; unknown if related to one of the antibiotics. Review of electronic-mail communication from the pharmacy, showed Resident 1's allergy to sulfa medications was listed and it flagged when the order for the sulfa antibiotic was processed on 09/28/2023. The pharmacy reported they faxed the facility about the allergy. Due to lack of documentation and the length of time since the event, the pharmacy staff were unsure what happened; however, the medication was sent to the facility that evening. In an interview on 04/01/2024 at 4:10 PM, Staff A, Registered Nurse (RN)/Director of Nursing Services, stated nurses were to follow the eight rights when administering medications and were not to administer medications on the resident's allergy list without special consent. On 04/02/2024 at 10:35 AM, Staff B, RN, stated when orders were received for a resident, they routinely checked for allergies. Staff B stated the nurses completed the final check for allergies to medications prior to administration. On 04/02/2024 at 1:15 PM, Staff C, RN/Resident Care Manager, stated they recalled Resident 1 had an allergy to sulfa antibiotics. Staff D stated the resident received two doses and then the pharmacy informed the facility of the allergy. Staff C stated the resident's allergy to sulfa medications was listed in the resident's clinical record. On 04/03/2024 at 2:30 PM, Staff A stated it was their expectation nurses would check for allergies when orders were processed and administered. They stated they did not have a specific policy, but it was a standard of practice. Staff A stated they did not have additional information providing a justified reason the sulfa medication was administered to Resident 1 in spite of their allergy. Refer to WAC: 388-97-1060(3)(k)(iii)

Based on interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 sampled residents (Resident 1) reviewed for quality of care. The facility failed to ensure Resident 1's oxygen (O2) was replaced on the resident after completion of cares. This failure resulted in Resident 1 becoming hypoxic (absence of enough air in the tissues to sustain bodily functions) and placed other residents with orders for O2 at risk for hypoxia, medical complications, and a diminished quality of life. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include heart failure and chronic respiratory failure (condition that occurs when the lungs cannot get enough O2 into the blood). Review of Resident 1's Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 01/21/2024, showed the resident was cognitively intact. Section J (health conditions) of the MDS assessment, showed the resident had shortness of breath with exertion and when lying flat. Review of Resident 1's physician orders, showed order dated 12/17/2023 for O2 at three to four liters per minute continuous, via nasal cannula (device that gives O2 through the nose via thin flexible tube that goes around the head and into the nose. There are two prongs that go inside the nostrils that deliver the O2). Review of a nursing progress note, dated 02/10/2024, revealed Staff B, Registered Nurse (RN), approached Resident 1 on 02/09/2024 at 7:50 PM, and observed the resident did not have their supplemental O2 on. Resident 1's face and hands were a greyish color and they stated they were not feeling well. Staff B immediately placed the O2 on Resident 1. Resident 1 informed Staff B their O2 had been removed during care and had not been replaced. Resident 1's pulse oximeter (electronic device that measures the saturation of O2 carried in the red blood cells) readings were 77-83% on various fingers. Normal pulse oximeter readings are between 95% and 100%. Review of Resident 1's current Kardex (care plan for Nursing Assistants directing residents care) located in the medical record, showed no approaches for O2 use. Review of facility investigation, dated 02/09/2024, showed Staff B found Resident 1 without their O2 on and observed the resident's face and hands were gray in color and O2 saturations were initially 77-78%. Resident 1 reported Staff A, Nursing Assistant-Registered (NAR), had assisted them to change clothing and forgot to replace their O2 when finished. Resident 1 stated they started to feel unwell. Resident 1 had severely compromised cardiopulmonary (heart and lungs) status and was dependent on O2. The facility concluded that due to the serious risk for adverse effects from the situation, unintentional neglect had occurred. Review of an undated Standards of Care for Nursing Assistants (NA's) form, showed approaches for NA's to include mobility, activities of daily living, social services, activities, and nursing standards. There were no approaches for respiratory care to include O2. Review of electronic mail (e-mail), dated 02/29/2024, from Staff D, Director of Nursing Services, showed the facility did not have respiratory standards of care for NA's. Staff D stated going forward the facility planned to add something about O2 to the form. In an interview on 02/26/2024, Resident 1 stated they recalled the incident on 02/09/2024 when their O2 was not put back on before Staff A left their room. Resident 1 said they started to feel woozy with the O2 off and they either called for the nurse with their call light, or the nurse happened to come in their room at the right time to check on them. Resident 1 said the nurse put the O2 back on and it took just a short time to get back to normal. Resident 1 stated they always wore O2, other than taking it off for a few seconds to change their shirt. In an interview on 02/26/2024 at 3:25 PM, Staff A stated they were assigned to provide care for Resident 1 on the evening shift on 02/09/2024. Staff A stated Resident 1 requested assistance with changing into their gown, and said they usually took their O2 off while changing tops. Staff A stated on prior occasions, they always ensured they put the O2 back on right away, however on 02/09/2024, they did not do so. Staff A stated the nurse found the resident a short time later with their O2 off, and stated the resident was hypoxic. Staff A stated each resident had a care plan that showed what care was to be provided and they followed Standards of Care. In an interview on 02/27/2024 at 4:35 PM, Staff C, Licensed Practical Nurse (LPN), stated they were currently assigned to provide care for Resident 1. Staff C stated they were not at work when Resident 1's incident occurred on 02/09/2024 but was aware of the resident had a hypoxic episode related to O2 not being replaced after cares. Staff C stated they were aware of the severity of Resident 1's diagnoses and serious need for O2. Staff C stated they always monitored O2 regularly on rounds and during medication pass for residents who had orders for O2. In a telephone interview on 02/28/2024 at 1:15 PM, Staff B stated they were Resident 1's nurse on 02/09/2024 when Staff A forgot to replace the resident's O2 after cares. Staff B stated when they entered Resident 1's room to bring medications, they immediately observed the resident's face and hands were grey, and then noted the resident did not have their O2 on. Staff B reported Resident 1's O2 saturations were in the 70's, however quickly returned to the 90's once their O2 was replaced. Staff B stated by the second 15-minute check after replacing Resident 1's O2, their color had improved to baseline. On 03/04/2024 at 6:15 PM, Staff D stated Staff A should have ensured Resident 1's nasal cannula for O2 administration was in place before leaving their room on 02/09/2024. The DNS stated they attributed Staff A's failure to ensure the O2 was in place was related to their newness to their job and checking that O2 was in place was not routine to them yet. The DNS stated they plan to make some changes, to include increasing NA education about O2 use and adding O2-related standards to their NA standards of care to ensure a similar event would not occur. The DNS acknowledged the failed practice had a potential for serious consequences. Reference (WAC): 388-97-1060(1)

Based on interviews, personnel record review, and facility job description review, the facility failed to ensure Staff C, Dietary Manager (DM), was qualified with the appropriate competencies and skill sets to serve as the Director of Food and Nutrition Services. This had the potential to affect all 57 residents who consumed food from the kitchen. Findings included . Review of the facility's Job Description and Qualifications provided by the facility for the Dining Services Director, undated, indicated Prefer dietary manager certification. Review of the personnel records provided by the facility revealed Staff C and Staff E, Assistant Dietary Manager, had completed the Washington State Food Worker Card. There was no evidence of any other trainings or certifications being completed. During an interview on 01/06/2023 at 1:01 PM, Staff A, Administrator, stated Staff C was not certified, but she thought they were in the course. During an interview on 01/06/2023 at 2:01 PM, Staff C stated she started as the Dietary Manager during the start of COVID in 2020. She stated she was a cook prior. She stated she had been piecing together knowledge. She stated she was not currently enrolled in the course for her certification. She stated she had timed out and needed to restart the program. During an interview on 01/06/2023 at 2:30 PM, Staff A stated she was not aware Staff C was not currently enrolled in the certification program. She stated she was aware there was a regulatory requirement for a qualified Dietary Manager. WAC reference: 388-97-1160(1)(3)(a-b)(i)

Based on observations, interviews, and facility policy review, the facility failed to ensure cold food was stored at the proper temperature; cold food was covered during storage; cold food was held at proper temperature for meal service; and the stove hood was cleaned in accordance with professional standards for food service safety. This had the potential to affect all 57 residents who consumed food from the kitchen. Findings included . Review of the facility's policy titled Cooking Food dated 05/04/2017, indicated Effective methods for cooling foods include: 1. Foods should be loosely covered to facilitate heat transfer while also protecting from contamination. Review of the facility's policy titled Refrigerated Storage Standards dated 05/04/2017, indicated Refrigerated temperature will be cold enough to hold food items at 41 degrees F [Fahrenheit] or less. Review of the facility's policy titled Service dated 05/04/2017, indicated The hot food must be equal to or higher than 135 degrees F and cold food equal to or lower than 41 degrees F. During an observation in the kitchen on 01/04/2023 at 9:00 AM, the tall refrigerator revealed an internal temperature of 50 degrees F. Several containers of yogurt, pudding, and cottage cheese were in the refrigerator. During an interview on 01/04/2023 at 9:03 AM, Staff E stated he was the Assistant Dietary Manager in the kitchen. He stated the door was open during meal service and so the temperature was warm. He took the temperature of a container of cottage cheese from the refrigerator and the temperature was 50.5 degrees F. Staff E confirmed the temperature should have been 41 degrees F or below. He stated he had no documentation of the temperature of the refrigerator that morning before meal service. He stated he did not know how long the refrigerator had registered a warm temperature. During an observation in the kitchen on 01/04/2023 at 9:08 AM, the walk-in refrigerator revealed several containers of food uncovered and open to air. There was a large pan of brown gravy, open to air with small particles along the surface. There was a small metal container of white gravy and another container of boiled eggs, uncovered and open to air. There was a small cart with a container of two pieces of cooked chicken, and a small container of brown gravy, uncovered and open to air. During an interview on 01/04/2023 at 9:12 AM, Staff E stated he did not cover some of the items because he did not cover the food while it was hot. He stated he did know about the other food items and stated he was going to throw them out. Staff E confirmed the food should have been covered during storage. During another interview on 01/04/2023 at 10:12 AM, Staff E stated he talked to Staff C, Dietary Manager (DM), regarding the temperature of the food items, and they decided to throw the food out since they did not know how long the food had been out of proper temperature. During an observation and interview Staff F, cook, on 01/05/2023 at 1:19 PM, revealed the stove hood was dirty with grease and built-up lint. Staff F stated someone had cleaned the hood about two months ago. During an interview on 01/05/2023 at 2:35 PM, Staff E stated the stove hood was on the cleaning schedule to be cleaned monthly. He stated he thought it was last cleaned in October and was unable to find the documentation from November. He confirmed the hood should have been cleaned monthly and as needed. During an observation of the main kitchen on 01/06/2023 at 10:32 AM Staff F placed several food items on the counter near the tall refrigerator. Small metal pans of cheese slices, hard boiled eggs, tuna salad, mayonnaise, egg salad, sliced turkey lunch meat, sliced ham lunch meat, and sliced roast beef lunch meat were all set out on the counter. At 10:58 AM, Staff F took the food temperatures prior to meal service. The coleslaw located in the tall refrigerator registered a temperature of 45 degrees F. The temperature of the coleslaw located near the back was 43 degrees F. At 11:04 AM, Staff F acknowledged the refrigerator temperature was 45 degrees F. She left the coleslaw in the warm refrigerator. The egg salad was 49 degrees F. Staff F stated she usually only tested the temperature of one of the food items, on the counter. During an observation of food preparation on 01/06/2023 at 11:20 AM, Staff F was making salad using the items out at room temperature. She added the sliced meat, shredded cheese, and boiled egg to the salad. Staff F was observed throughout meal service making sandwiches and salads using the food out at room temperature. During an interview on 01/06/2023 at 11:45 AM, Staff E stated they needed to contact maintenance regarding the temperature of the refrigerator. At 11:58 AM, after the staff served residents in the dining room, Staff E took the temperatures of the food items out at room temperature. The boiled eggs were 55 degrees F, the shredded cheese was 54 degrees F, the mayonnaise was 53 degrees F, the sliced turkey was 47 degrees F, the sliced ham was 48 degrees F, the sliced roast beef was 49 degrees F, and the tuna fish was 64 degrees F. Staff E confirmed the food items were warm and all of the food needed to be replaced. During an interview on 01/06/2023 at 1:01 PM, Staff A, Administrator, stated she knew about the refrigerator running warm. She confirmed cold food needed to be 40 degrees F. She stated she would have maintenance look at the refrigerator. During an interview on 01/06/2023 at 2:16 PM, Staff D, Registered Dietitian RD), stated she completed kitchen sanitation audits quarterly. She confirmed the temperature for cold food should have been 41 degrees F or below. Staff D stated it was ok to bring the food out of refrigeration about 30 minutes before meal service and sit out at room temperature for up to four hours. She stated it was ok for the food to be 40-70 degrees F during meal service. She stated the food should have been brought back into refrigeration after meal service as long as registering less than 70 degrees F. Staff D stated they used the Washington food handlers guidelines. She stated the food was not covered in cold storage until it was cooled down to proper temperature. She stated the food should not have been left uncovered. Reference WAC: 388-97-1100(2)(3)

Based on observation, interview, and record review, the facility failed to accurately assess one of five residents (9) whose Minimum Data Sets (MDS) Assessment (a tool used to identify a resident's care needs) was reviewed. Failure to ensure accurate assessments regarding dental/oral status placed residents at risk for unidentified and/or unmet care needs. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, (a guide to accurately complete the Minimum Data Set (MDS) assessment). Steps for Assessment of Oral/Dental Status include: . Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining RESIDENT 9 Resident 9 admitted to the facility on [DATE] with diagnoses to include COPD (Chronic Obstructive Pulmonary Disease) and tracheostomy (tube placed into windpipe to help a person breath). Review of the Annual MDS assessment dated [DATE], showed no Obvious or likely cavity or broken natural teeth. In an interview and observation on 01/04/2023 at 2:25 PM, the resident was observed to have missing lower teeth with areas of observable broken teeth along lower front gum line. Resident 9 stated their teeth were broken during a fall prior to admission to this facility. The resident stated that this area Gets a little tender at times and they had not seen a dentist about it. Record review showed a dental hygienist consultation report dated 12/17/2021 that indicated the resident had fractured teeth with 6 lower teeth root tips observed. Review of progress notes from January 2022 through December 2022 and the current care plan showed no dental concerns, interventions or services provided. In a joint interview/record review on 01/06/2023 at 1:50 PM, Staff J, Registered Nurse (RN)/ Nurse Manager, confirmed that the quarterly nursing assessment dated [DATE] was marked No obvious problems regarding teeth and indicated they were unaware of Resident 9 having any dental issues or dental consultations. In a joint interview/record review on 01/06/2023 at 2:15 PM with Staff K, RN/MDS Coordinator, stated that when they complete scheduled MDS assessments, they review care plans, progress notes, and quarterly assessments completed by licensed nurses as their source of information. Staff K also confirmed there was no documentation in the resident's record indicating any dental issues and that they had not observed or interviewed the resident regarding their dental status and were unaware of the dental hygienist consultation. Reference: (WAC) 388-97-1000(1)(a)

Based on observation, interview, and review of the manufacturer's instructions for prefilled insulin syringes, the facility failed to ensure the correct procedure was followed as directed prior to administering insulin via a prefilled syringe for one of two residents (314) observed during medication pass who received insulin. This had the potential for the resident not to receive the correct amount of insulin needed in order to control blood sugars. Findings included . Review of the Electronic Medical Record (EMR) for Resident 314 under the Census tab reviewed an admitted [DATE]. In the EMR under the Diagnosis tab revealed that the resident had diabetes. Review of the EMR for Resident 314 under the Orders tab revealed an Order for Lispro (a short acting insulin) 5 units subcutaneously, per sliding scale, three times a day, as needed (PRN). Review of the Manufacturer's Instructions provided by the facility for the prefilled insulin syringe directed the needle unit to be attached to the prefilled syringe. The needle unit is then to be primed with 2 units of insulin to clear air from the needle and then administer the dose as ordered. Observation and interview of Staff H, Licensed Practical Nurse (LPN), on 01/06/2023 at 11:25 AM revealed Staff H attached the needle to the prefilled syringe. Staff H dialed the pen to 5 units and administered the insulin dose to Resident 314 without priming the needle unit. Staff H confirmed she did not prime the insulin pen before dialing the pen to 5 units and administering the insulin to the resident. Interview with the Staff B, Director of Nursing Services (DNS), on 01/06/23 at 11:27 AM confirmed the needle unit, which is attached to the prefilled insulin syringe, is to be primed with 2 units of insulin prior to the dose to be administered as ordered by the physician. Staff B confirmed the correct amount of insulin may not be accurately administered without priming the needle unit first. WAC reference: 388-97-1060 (3)(k)(iii)

F791 Based on interview, observation, and record review, the facility failed to ensure timely dental services were provided for one of one resident (9) reviewed for dental care and services. This failure placed the resident at risk for pain and a diminished quality of life. RESIDENT 9 Resident 9 admitted to the facility on [DATE] with diagnoses to include COPD (Chronic Obstructive Pulmonary Disease) and tracheostomy (tube placed into windpipe to help a person breath). Review of the Annual MDS Assessment (a tool used to identify a resident's care needs) dated 09/29/2022, showed no Obvious or likely cavity or broken natural teeth. In an interview and observation on 01/04/2023 at 2:25 PM, the resident was observed to have missing lower teeth with areas of observable broken teeth along lower front gum line. Resident 9 stated their teeth were broken during a fall prior to admission to this facility. The resident stated that this area Gets a little tender at times and they had not seen a dentist about it. Record review showed a dental hygienist consultation report dated 12/17/2021, that showed: - Fractured teeth - 6 lower teeth root tips -Patient wants cleaning - We will schedule the patient for a follow-up appointment in ASAP months Review of progress notes for January 2022 through December 2022 and the current care plan showed no dental concerns, interventions or services provided. In an interview/record review on 01/06/2023 at 1:50 PM, Staff J, Registered Nurse (RN)/Resident Care Manager (RCM), stated they were unaware of Resident 9 having any dental issues, dental consultations or need for a dental referral. In an interview on 01/06/2023 at 2:50 PM, Staff B, the Director of Nursing Services (DNS) stated that previously social services had coordinated dental services but recently the RCMs were responsible. The DNS also stated they were unaware of Resident 9 needing any dental services. In a follow-up interview at 01/06/2023 at 3:20 PM, the DNS confirmed they had reviewed the dental hygienist consultation report dated 12/17/2021 and were unable to find documentation in the clinical record that it was followed up on. Reference: (WAC) 388-97-1060 (3)(vii)

Based on interview and record review, the facility failed to ensure 3 of 5 residents (3, 21 and 11) received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain the residents highest practicable level of well-being. This failed practice caused harm for Resident 3 when he slid sideways off his bed, with his head hanging off the bed for four hours resulting in severe pain, anxiety, fear and psychosocial harm under the reasonable person concept. Additionally, the facility failed to effectively address and manage high blood glucose levels placing the resident at risk for possible complications including eye, kidney, nerve disease and diabetic coma from unmanaged diabetes. Findings included: RESIDENT 3 Review of the facility's undated policy titled, Standards of Care for Nursing Assistants, showed all Standards of Care were provided for each resident every day unless otherwise indicated, to keep call light within easy reach and to reposition the residents every two hours. Resident 3 was a long term resident of the facility with a [DIAGNOSES REDACTED].) Review of the resident's quarterly Minimum Data Set assessment dated [DATE], showed the resident was cognitively intact, and required extensive two person assist with bed mobility. Review of the resident's initial Care Plan dated [DATE] and revised on [DATE], showed the following: · The resident needed assistance with his activities of daily living related to his ALS resulting in weakness and loss of mobility in all extremities, and used a cervical collar when up; · There was a soft touch call light, which was to be placed next to his left lower leg due to loss of his upper extremity mobility and was to be kept in reach at all times; · The resident had a communication problem and had adaptive equipment to facilitate his communication needs; · The resident was at risk of falls and was to be placed in the center of the bed for safety; · Staff were to follow the Facility Standard Fall Care plan; and · The resident was at risk of respiratory complications related to ALS and had a Trilogy ventilator machine he used at night when he slept. Review of Staff G's, Nursing Assistant (NA), statement dated [DATE] at 6:30 AM, showed Staff G had gone into the resident's room at 6:30 AM on [DATE] and found Resident 3 in bad shape in his bed with his feet out of the bed and his head out off the pillow. The resident said he could not use the call light. The resident had said this happened at 2:30 AM, his call light was on the night stand. The resident complained of major neck pain. Review of Staff H, NA, statement dated [DATE] at 6:30 AM, showed the resident had been sideways in his bed, feet hanging off one side and his head sloped off the other. The call light was on the desk. After the resident was assisted upright in bed he said he had major pain to his neck and requested [MEDICATION NAME]. The resident also stated he wanted to see Staff I's, NA, documentation after 2:30 AM. The resident had said he hit his sound alarm five times until he fell out of range to use with his eyes. The resident still needed to be suctioned and then got [MEDICATION NAME]. The resident was very distressed and requested assistance to fill out a grievance form. The resident had said he had been sideways since 2:30 AM. Review of Staff J, Registered Nurse (RN)/Case Manager, statement dated [DATE], showed she had gone to check in with the resident with Staff K, RN, and interviewed the resident. The resident stated Staff I had left his room without placing the call light in reach. The resident had tried to use his Eye Gaze machine (A device which the resident used his eyes to communicate with accessing computer) to call for help but no one heard it. The resident then slid to the side and was no longer able to communicate in any way. The resident stated he had laid there for four hours and was unable to call for help. The resident was asked if he felt neglected and he said yes. The resident said if he had a coughing attack or needed suctioning he could have died . The resident stated he had been very scared. Review of Staff K's statement dated [DATE] at 8:30 AM, showed the resident had stated that at 2:30 AM he had fell sideways on his bed. The resident had wanted to press his call light for cough assist. His call light was not on his bed within reach. The resident had then used his eye gaze pad to sound the alarm and tried that five times before he fell over. The resident stated nobody came in until 6:30 AM to check on him. The resident was asked if he felt neglected and scared and Resident 3 stated yeah because his options were so limited. The resident was nonverbal and had no muscle control related to his ALS. Review of the progress note for [DATE] at 4:48 PM, showed Staff J had responded to the concern regarding the resident's positioning over the night shift. The resident had initially had some discomfort in his neck, but mostly was anxious. Review of the facility's Event and Occurrence Conclusion Sheet dated [DATE], and signed off by Staff J, the Director of Nursing Services (DNS) and the Administrator showed reasonable cause to believe based on investigation that abuse and neglect was ruled out. Additionally, the report stated the resident's Eye Gaze Talk machine had been installed but had not been fully set up or staff instructed on its use. This feature was planned to be set up and staff trained for the following week from the incident. In an interview on [DATE] at 10:15 AM, Staff J stated that the NA (Staff J did not identify the staff member involved) on duty had found the resident at 6:30 AM on [DATE] hanging across the bed sideways with face up off the bed and his bed down on the other side of the bed. The call light was on the bedside table and the assigned NA had not alerted her coworkers she was having difficulty completing her rounds. Staff J stated the nurses were to supervise the NAs. Staff J continued to state, We ruled there was neglect by the NA. In an interview at 3:41 PM, Staff L, RN, was asked how she supervised the care of the residents she was assigned. Staff L stated, You are constantly watching the call lights and are in and out of the resident's rooms. If a concern is noted you follow up to ensure care is completed and assist the staff with the resident's needs. It requires constant monitoring and prioritizing. In an interview at 3:43 PM, Staff M, RN, was asked how she supervised the care of the residents she was assigned. Staff M stated that she checked to see who was on and had a direct care huddle to review which resident went to the dining room, who was a check and change, had a dressing change and set up the day as much as possible. She continued to state she checked to see who was on break and tried to not overlap staff breaks. She further stated she walked through with her medication pass and would make sure the resident call lights were in place. In an interview at 3:47 PM, Staff N, Licensed Practical Nurse, was asked how she supervised her resident's care. Staff N stated that usually they had really good communication with the NAs and management would let the nurses know if the NAs. Staff N stated she would assist the Nursing Assistants, the Nursing Assistants are always asking us to check on items. We keep our line of communication open and available. Every shift in the resident's room, it would be impossible to go behind the Nursing Assistants. Staff N stated that there were times she had double checked on NA's and offered suggestions or constructive criticism. The Nursing Assistants all had to be signed off on skills competencies and new staff would have a trainer they followed for some time until they felt ready or the staff felt they were ready to work on their own. If the NA is new she stated she would talk with them more frequently to ensure they were doing what they needed to do. The facility failed to ensure the staff provided the necessary care and services to Resident 3 which was essential to provide care to the resident and avoid severe pain and distressing psychosocial harm while he laid face up with his head hanging off one side of his bed and his feet hanging off the other side of the bed for four hours due to not having his call light within reach or being checked on for four hours. ELEVATED BLOOD GLUCOSE LEVELS According to the American Diabetic Association (ADA), hemoglobin A1C (HbA1c) is a lab test that measured how well a residents blood glucose levels were controlled over a 3 month period. Older adults with multiple coexisting chronic illnesses, cognitive impairment, or functional dependence should have a goal of hemoglobin A1C <8XXX,[DATE].5%. The ADA stated skilled nursing facilities should call the provider as soon as possible for glucose values greater than 250 mg/dL within a 24-hour period and glucose values greater than 300 mg/dL over 2 consecutive days. RESIDENT 21 Resident 21 admitted [DATE] with [DIAGNOSES REDACTED]. Resident 21 required diabetic management to be managed by staff related to his cognition. Review of the physician orders [REDACTED]. The resident also received an oral hyperglycemic agent twice daily. HbA1c results reflecting < 7 % is indicative of well-controlled diabetes. HbA1c lab value > 7% indicates suboptimal control. Review of Resident 21's HbA1c lab results since admission were consistently elevated: - On [DATE], the lab result was 9.8%; - On [DATE], the lab result was 10.30%; - On [DATE], the lab result was 10.6 %; and - On [DATE], the lab result was 9.2%. Review of the (MONTH) (YEAR) eMAR (electronic medication administration record) showed blood glucose (BG) readings were obtained 4 times per day. The BG levels were between ,[DATE] mg/dl on 19 checks, between ,[DATE] mg/dl on 18 checks, between ,[DATE] mg/dl on 33 checks and over 500 mg/dl on 13 checks. Review of the (MONTH) (YEAR) eMAR showed BG readings were obtained 4 times per day. The BG levels were between ,[DATE] mg/dl on 18 checks, between ,[DATE] mg/dl on 14 checks, between ,[DATE] mg/dl on 22 checks, over 500 mg/dl on 12 checks and over 600 mg/dl on 2 checks. Review of the (MONTH) (YEAR) eMAR showed BG readings were obtained 4 times per day. The BG levels were between ,[DATE] mg/dl on 14 checks, between ,[DATE] mg/dl on 16 checks, between ,[DATE] mg/dl on 8 checks, over 500 mg/dl on 12 checks. Review of the (MONTH) (YEAR) eMAR showed BG readings were obtained 4 times per day. The BG levels were between ,[DATE] mg/dl on 14 checks, between ,[DATE] mg/dl on 30 checks, between ,[DATE] mg/dl on 22 checks, over 500 mg/dl on 15 checks . Review of the (MONTH) (YEAR) eMAR showed BG readings were obtained 4 times per day. The BG levels were between ,[DATE] mg/dl on 14 checks, between ,[DATE] mg/dl on 23 checks, between ,[DATE] mg/dl on 18 checks, over 500 mg/dl on 7 checks. The eMAR's directed staff to notify MD if BG was less than 60 or greater than 500 (after recheck 2 hours later). Review of the clinical record showed there was no evidence this was occurring as ordered. In an interview on [DATE] at 11:10 AM, Staff E, Registered Nurse/ Resident Care Manager, confirmed Resident 21's blood sugars were not well-controlled. Staff E was asked for the documentation of the blood glucose rechecks for the checks over 500. After reviewing the eMar and clinical records, Staff E indicated he would set up a system to record the rechecks. Staff E stated the Advanced Registered Nurse Practitioner (ARNP) was updated weekly on the blood glucose checks. In an interview on [DATE] at 12:23 PM, Resident 21's ARNP was asked about Resident 21's chronic elevated BGs. The ARNP stated, I follow the pharmacy recommendations and did exactly what they said and it was too much (insulin). He is impossible to control he goes to Summit Place (Assisted Living adjacent to facility) and he eats 20 cookies and if we correct too much, he bottoms out. I try really hard . I like him to be between 200 and 500. It is difficult to control him. I check him every week. I look at his blood sugars I may not document to it. I rely on the pharmacist to assist me. I know 500 is not ideal. The ARNP confirmed she was aware of the uncontrolled [MEDICAL CONDITION] and she was not informed of all BG rechecks when the BG was over 500. She stated That is not on me. In an interview on [DATE] at 3:29 PM, Staff D, Licensed Practical Nurse, stated He does go over the 500 (BG) for me. There are parameters to check. He goes to Summit Place and gets snacks .Periodically he has outbursts. It could be something to do with his blood sugars being off. There were no interventions to redirect Resident 21 from Summit Place nor to offer him better dietary snacks in an effort to decrease [MEDICAL CONDITION]. RESIDENT 11 Resident 11 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of MARS/TARS, dated (MONTH) (YEAR), revealed an order to draw the HbA1C on [DATE]. Review of a Medication Regimen Review report, dated [DATE], revealed the Pharmacist was unable to locate the results for HbA1c that was ordered in (MONTH) (YEAR). The pharmacist requested that staff update the chart. Review of progress notes, dated [DATE], revealed the order requesting HbA1c test on [DATE] was not drawn and lab was not completed until [DATE]. Review of a lab report, dated [DATE], for HbA1c, revealed the lab was collected [DATE] and the results were abnormal. In an interview on [DATE] at 10:43 AM, Staff K, Registered Nurse/Resident Care Manager, stated the facility was unable to locate the lab results that was ordered for HbA1C test on [DATE]. Staff K was unable to locate or confirm that HbA1C lab from (MONTH) (YEAR) was completed. Reference: (WAC) [DATE] (1)

Based on observation, interview and record review the facility failed to provide adequate supervision to prevent an accident for 1 of 4 residents (1) reviewed for accidents. This failure resulted in harm of a bruised knee and three fractured toes for resident 1. Findings Include: Resident 1 was admitted with [DIAGNOSES REDACTED]. The resident was deaf, but was able to read lips or speak through an interpreter in the facility. The resident also had a weakness to her left side for which she required extensive assistance from staff for activities of daily living including wheel chair mobility. On 10/24/17 at 1:00 P.M., a sign was observed on the door where residents are picked up by the transit bus which read, Please do not assist residents out of the building without first checking with their nurse. The small hallway where residents meet the transit bus was an L shaped blind spot, staff working in the hall were unable to see the residents unless they walked to the end of their hallway. A review of the resident's care plan revealed the resident was to go by bus to attend church, and a friend would meet her at the church to assist the resident when she got to the church. Documented on a facility investigation dated 10/15/17, Staff A, Certified Nursing Assistant (CNA), assisted the resident to the door at 2:30 P.M., left her alone, to wait for the bus to go to church. At 2:45 P.M., an unidentified person heard the resident yelling help, help and brought her into the facility and told Staff B, Licensed Nurse (LN), the resident was wedged between two parked cars. According to the resident, an unknown person opened the door and pushed the resident out onto the sidewalk and did not lock her brakes. The resident was unable to control her wheelchair as it coasted down the sidewalk and hit a parked car. Nursing staff assessed the resident and noted a bruise below her left knee. The resident still wanted to go to church. When the resident returned she was re-evaluated and a 5 cm (centimeter) x 3.5 cm bruise was noted on her left knee. The next day the resident complained of pain in her right knee and foot. An x-ray revealed a fracture to the 1st, 2nd, and 3rd toes on the right foot. On 10/24/17, at 1:40 P.M., the resident spoke through an interpreter and stated her right knee and foot were still sore. The resident reported she felt somewhat safe, but she doesn't want people to hurt her by pushing her outside. She reported she was unable to identify the man who pushed her. She reported he pushed her outside and disappeared. At 2:30 P.M. in an interview with the Director of Nursing Services (DNS), who verified that despite multiple attempts the resident had been unable to identify who pushed her wheelchair. The DNS verified why the resident left the facility after the incident, the resident was yelling at staff to be able to go to church, the staff assessed her before she left and again on her return. The DNS also verified the resident could in no way assist in controlling her wheelchair. The DNS also confirmed neither the person who pushed the resident out onto the sidewalk nor the person who brought her to the nurse were ever identified. The lack of supervision, allowed a stranger to move the resident's wheel chair outside of the facility, where the resident rolled into a parked car and received injuries. Neither stranger who had contact with the resident were ever identified. Refer to WAC 388-97-1060(3)(g)

F 323, Phillips, Connie S. Based on observation, interview and record review, the facility failed to assess a restraint for 1 of 5 sample residents (6) reviewed for accidents. The facility also failed to maintain the courtyard environment free of accident hazards. These failures caused harm to Resident 6 when she was ejected from her electric wheelchair outside after hitting a divot in the grass while her legs were restrained to the wheelchair, which caused 2 broken legs, increased pain, health complications and isolation. Findings include: Definition of Restraint per the Resident Assessment Instrument (RAI) manual A ''physical restraint is defined as any manual method of physical or mechanical device, material, or equipment attached or adjacent to the residents body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body''. Facility Investigative Report Review of the facility's investigative report, dated 07/25/16, indicated Resident 6 had an unwitnessed fall on 07/20/16 at 7:10 PM while she was outside in the courtyard. The report revealed the resident was self-propelling her electric wheelchair outside when she left the sidewalk and went on the grass. The chair hit a divot in the ground and the resident was ejected out of the wheelchair. She landed on her right side with her lower legs still strapped into her wheelchair. The resident denied hitting her head, so 3 staff persons lifted the resident back into her chair. The resident was taken inside and placed in bed. The next day the resident complained of increased pain, so x-rays were taken and the resident ' s upper legs were fractured. Chart Review Resident 6 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 04/06/16, revealed the resident required extensive assist of 1 or 2 staff members with bed mobility and transfers, and was independent after set up with locomotion off unit. The record also showed the resident enjoyed self-propelling her electric wheel chair to participate in outside activities including gardening. Review of a physician's order [REDACTED]. There was no documentation the velcro strap was assessed for necessity or safety reasons. Review of the Resident Care Guide dated 04/18/16, revealed staff were to apply a padded velcro strap to the resident's shins when she was in the wheelchair. Review of the wheelchair assessment completed by Staff H, Licensed Nurse (LN) on 07/04/16. The assessment did not include or reveal an assessment for the velcro strap or that it was necessary to restrain or prevent the resident's lower legs from falling off the wheelchair. In a nursing progress note, dated 07/20/16, after the incident, Resident 6 reported she felt she would have been better off without the velcro leg strap on. Review of the care plan, dated 07/20/16, revealed that staff were to use a padded velcro strap over the resident's shins to keep her knees at a 90 degree angle and ensure proper foot placement when the resident was up in the wheelchair. Review of the x-ray report dated 07/21/16 showed Resident 6 had sustained two broken bones in her upper legs. Interviews In an interview on 07/22/16 at 10:15 AM, Resident 6 stated her feet would dangle off her footrests and they would get injured, that is why the facility tied them down. Resident 6 also stated that when she lived at home, she used to use an ace wrap to secure her legs to each other but not to the chair. In an interview on 07/26/16 at 7:26 AM, Staff E, the Resident Care Manager, stated, ''I'm not sure we did an assessment on the strap that holds her legs together because she was able to take it off and put it on herself. Staff E was unable to produce an assessment on the velcro strap. In an interview on 07/26/16 at 12:47 PM, Staff F, Nurse Aide-Certified (NAC) stated she was familiar with the resident's care and would place the velcro strap around her shins after she was up in her wheelchair to keep her feet on the padded footrest. She further stated that she had never seen the resident put on or take off the strap. In an interview on 7/27/16 at 1:06 PM, the Director of Nursing Services (DNS), stated that the velcro strap was not a restraint for the resident because she was able to release it; therefore an assessment did not need to be completed. She was unsure of exactly how long the velcro strap had been used. She indicated the velcro strap was used to keep her feet on the footrest to prevent injury. In an observation on 07/28/16 at 8:20 AM, there was about a 2 foot by 2 foot area of fresh dirt outside where Resident 6 was found injured. Review of the medical record showed that prior to the accident, the resident was taking pain medications due to knee and shoulder pain. After the accident her pain medications were changed to a stronger dosage and an additional medication was added to prevent blood clotting, because she was then put on bed rest. There was no documented assessment to establish how she managed her legs falling off the chair prior to admit, to determine whether the strap was safe if she became sick, what the impact of her taking her pain medications would have on her to get the strap off in emergencies, or if her chair was to tip. There also was no consent or physicians order in the clinical record for the use of the velcro strap attached to Resident 6's wheelchair which restricted leg movement.

Based on observation, interview and record review the facility failed to prevent an accident for 1 of 3 residents reviewed for accidents (Resident 2). Failure to consistently follow facility policy for serving hot beverages resulted in harm of a second degree burn for Resident 2 and placed other residents at risk for injury. Findings Include: The Mt. Baker Policy and Procedure for Serving Hot Beverages stated All residents desiring beverages hotter than 140 degrees will have a hot Beverage Evaluation done on admit, updated quarterly or change of condition. Temperatures will not exceed 140 degrees. Lids are provided for hot beverages. RESIDENT 2 Resident 2 was admitted in November 2015 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] stated the resident required 2 person physical assist for cares but, was independent and set up only with eating. The MDS also stated the resident was severely cognitively impaired. An investigation dated 12/16/15 stated Resident 2 was eating in the social dining room and sustained a burn from a coffee spill on her lap. Staff D Nursing Assistant Certified (NAC) provided Resident 2 with a cup of coffee, turned her back and heard the resident scream. The NAC noted the cup of coffee had spilled on the resident's shirt and lap. Staff E Licensed Nurse (LN) was called for assistance. Resident 2 was brought back to her room where the LN performed a skin assessment and applied cold wet wash cloths to the area. The coffee temperatures were checked and found to be at 140 degrees. By the end of the shift the resident's skin was free of redness. On 12/17/15 burn marks were noted with blisters on her left thigh and the MD and family were notified. In a statment from Staff D, NAC, dated 12/16/15, it stated I was the only person in the social dining room when Resident 2 asked for coffee. I filled her cup from the pre-filled carafe from the kitchen. I did not put a lid on it but set it down in front of her. I turned around with my back to Resident 2, when I heard a slight shriek and I spun around to see the coffee spilled all down her front. In a Fax sent to the physician, dated 12/16/15, it stated the resident spilled coffee down her torso. Resident has a 19 cm x 0.5 cm red mark with 3 small blisters on left upper thigh with skin intact. Will monitor for pain. Will provide lids for hot liquids. A skin assessment dated [DATE] noted the date of report and observation was 12/17/15. It stated the upper left thigh near groin as the area, the length was 19 cm and the width was 0.5 cm. A summary stated the area of burn from hot coffee on 12/16/15. Area appeared to have resolved then blisters appeared on 12/17/15. Area of measurement red with 3 small blisters. 2 blisters about 0.3cm with one large blister 1.5cm x 0.5cm. It also stated the physician was notified on 12/17/15. A progress note dated 12/17/15 at 2:29 was noted as a Late Entry for the Incident note. It reiterated the incident and added on evening shift of the 17th the redness and blisters were noted, physician and family notified. On 12/22/15 at 8:30 A.M., in an interview with Resident 2, she stated she had coffee with lunch with no lid and it spilled on her thigh and now she has scars. The resident reported she asked for a dressing, otherwise it hurts because it rubs on her clothes. The resident reported this to the nurses. On 12/22/15 at 9:05 A.M., in an interview with Staff A, LN, reported the resident just had a shower and now the dressing can be applied. A reddened area runs along the resident's left groin area approximately 19 cm in length, with a 1 inch intact blister in the center of burn. No other intact blisters noted. Staff A placed a guaze 4 x 4 with paper tape to burn. The LN reported the facility was out of the dressing ordered so she used the guaze instead. When asked if the resident received any pain medication for the burn she stated the resident has refused when she has asked about pain. She also verified Staff E, LN who originally assessed the resident, was not in the facility. Temperatures in the coffee and hot water carafes in the dining room were checked at 9:33 A.M., after breakfast was over and temperatures for water were 139.5 and 135.7 for coffee. There was a sign on the wall above the hot beverages, to please ask for assistance before serving yourself or others any Hot Liquids. In an interview on 12/22/15 at 10:30 A.M., Staff F, the Dietary Manager explained the kitchen staff filled the coffee and hot water carafes, checks the temperatures and adds ice if over 140 then re-checks. Lids for the coffee cups are the NAC's responsibility they know who needs lids. An interview at 10:40 A.M., with Staff G, Dietary Assistant, she verified the process of pouring hot liquids and checking temperatures. If they are above 140 degrees we add ice and re check the temperature. A three month review of the Hot Beverage Temperature Log from the Kitchen revealed; in October the coffee exceeded 140 degrees 43 times with a high of 145. In November the coffee exceeded 140 degrees 46 times with a high of 144. In December which was only temped until 12/22, the coffee exceeded 140 degrees 46 times with a high of 149 degrees. There is not a space on the form to verify ice was added to the out of range temperatures before being served to residents. In an observation of Resident 2 at lunch at 1:15 P.M., with Staff H, NAC, in the dining room, Resident 2 was the only resident in the dining room and was talking with the NAC. The resident was eating with her fingers, she motioned her fingers to her mouth but had no food in her hand. The NAC had to remind her she had dropped her bread and it was not in her hand. The resident then looked at her hand and said I guess I did. The resident was physically able to lift her drinks to her mouth but had to be reminded to eat her food. In an interview at 1:30 P.M., with the Director of Nursing Services (DNS) she verified there was no safety assessment for Hot Beverages for this resident. The policy stated we do an assessment if the resident wanted the beverages hotter than 140 degrees. The DNS and the Administrator stated they were under the assumption that 140 degrees was safe for the residents. Using lids for all residents was the facility's safety measure. The DNS also verified Resident 2 did not have a lid on the coffee which caused the burn.

Based on interview and record review, the facility failed to provide adequate supervision for 1 of 4 residents (Resident 1) reviewed for falls. Leaving the resident, a known fall risk, unattended in the bathroom, resulted in harm for the resident, who fell and fractured her wrist. Findings include: Resident 1 admitted to the facility in December of 2013 after falling at home and fracturing a hip. The Minimum Data Set ((MDS) dated [DATE], an assessment tool used by the facility, indicated the resident had severe memory impairment, was dependant upon two staff members for dressing and transferring, and was at high danger of repeated falls. A review of the resident's closed record on 1/16/14 revealed the resident had a non-injury fall from bed on 12/14/13 while at the nursing facility. The resident's care plan was changed to include placement of an alarm system on the resident when in bed to alert staff if the resident tried to get out of the bed and a directive to not leave the resident unattended in the bathroom . According to the nursing notes in the resident's record, the resident was unable to use the call light system to summon assistance when she needed help and made numerous attempts to climb out of her bed. The resident fell again when left unattended in the bathroom on 12/20/13. According to the facility investigation, the resident was being toileted by Staff A, a physical therapist. Staff A left the resident and returned "a minute later" to find the resident had fallen while getting up from the toilet. The resident was sent to the hospital via 911. The resident returned to the facility later that day with a new [DIAGNOSES REDACTED]. On 1/16/14 at 11:05 a.m., Staff A was interviewed by the surveyor. She informed the surveyor she had left the resident unattended while she went to the therapy gym, located several hundred feet away. The staff member acknowledged she did not follow the resident's care plan by leaving her unattended. The Director of nursing was interviewed on the same day at 11:45 a.m. When asked, she stated the resident should not have been left alone.

Based on interview and record review, a facility staff member failed to meet professional standards for nursing care services. Failure to identify, assess, notify, plan and implement individualized care management interventions for Resident 1 resulted in harm of unaddressed increase in pain without adequate relief. Findings include: Resident 1 was admitted in May 2013 after recent [MEDICAL CONDITION] intervention [MEDICAL CONDITION] of the colon and bowel obstruction. She changed to hospice services on 07/05/13. All current medications and laboratory orders were discontinued on that date. Her new orders, started on 07/05/13, included pain relief and nausea/vomiting medications only. The goal of these medications was effective management and control of pain and nausea/vomiting. Because Resident 1 was identified as high risk of death in the next few days, hospice services focused on comfort for Resident 1. Hospice records noted Resident 1 stated she was satisfied with her level of comfort on 07/05/13. On 09/04/13 at 3:08 p.m., a family member reported she stayed in Resident 1's room during the night of 07/07/13. She stayed in the room because she thought if she exited, Resident 1 would not receive care. Resident 1 was unable to swallow and keep anything down. The family member stated she spent most of the time wiping fluids from the mouth and chin where she held a small basin to catch the fluids that leaked from her mouth and filled the basin every 4-5 minutes almost all night long. The family member told Staff A, who was assigned to care for Resident 1 that night. Staff A failed to assess Resident 1. Staff A failed to notify hospice services or the physician of Resident 1 of the changes in her condition. A family member telephoned hospice services about 5 a.m. On 09/16/13 at 1:30 p.m., Staff B reported all nursing staff were oriented when hired to notify physicians and/or hospice services whenever a resident had an acute change in condition. Staff B explained hospice services can often obtain medications faster than notifying a physician and then ordering medications from the pharmacy. Staff B stated all residents who have hospice services have a sticker attached to their clinical record as an alert for staff. The kardex at the nursing station also has the contact details for hospice services. On 09/12/13 at 1:15 p.m., the Director of Nursing Services (DNS) and the Administrator reported staff are trained to notify hospice services or physicians whenever a resident has a change in condition. Staff A failed to follow this policy. Staff A failed to assess for pain and pain relief with the current intervention(s) during that night of 07/07/13. Such an assessment and evaluation are part of pain management for residents. The DNS stated Staff A should have contacted hospice services for a change in the route of administration of the pain relief medications for Resident 1. Review of the hospice clinical record revealed no evidence of documentation that any staff from the building telephoned hospice services during the night of 07/07/13. Review of the facility clinical record revealed similar findings. Staff A noted Resident 1 had "multiple complaints and requests" during the night, including pain, difficulty sleeping, anxiety, sore throat and frequent regurgitation of thin brown fluid." Staff A documented the family contacted hospice services, who telephoned Staff A at 5:30 a.m. and stated a hospice nurse would come in to assess Resident 1. Review of the facility investigation revealed they concluded Staff A should have notified hospice services or the physician of Resident1 for proactive orders. This procedure is part of the plan of care for a hospice resident in the building. Additionally, the investigation noted this expectation was appropriate for any licensed nurse [MEDICATION NAME] in the building.

Based on interview and record review, the facility failed to manage pain for Resident 1. Failure to assess, notify, and implement interventions for Resident 1 resulted in harm of inadequate pain relief. Findings include: Resident 1 was admitted in May 2013 with multiple [DIAGNOSES REDACTED]. Her Minimum Data Set assessment, dated 05/28/13, identified her memory and recall abilities as 13/15 possible points on the memory assessment tool. The facility used a verbal report pain scale of 0-10, with 10 being the highest level for pain. Her nursing admission assessment, dated 05/21/13, identified Resident 1 reported she "always had pain in my belly, 8/10." Her physician initially ordered Tylenol for pain and changed that to [MEDICATION NAME], a pain relief medication, a few days after admission. On 09/26/13 at 08:46 a.m., a hospice nurse reported he conducted the initial assessment and opened hospice services for Resident 1 on 07/05/13. He reviewed those services with the family. These services focused on pain management with a goal to keep a person comfortable. Review of the hospice record, dated 07/05/13, revealed documentation Resident 1 experienced increased nausea, pain and weakness. She experienced pain daily. It was chronic in duration and frequently interrupted her sleep. It was controlled with medication intervention. She stated no pain was acceptable for her. Resident 1 also had moderate nausea and/or vomiting. The record noted Resident 1 had bowel obstruction and she was at risk of death in the coming days. All previous medication and laboratory orders were stopped. New orders for pain relief medications included: ? [MEDICATION NAME] by mouth every hour as needed for mild to severe pain - titrate to effective dose. ? Oxyocodone, a narcotic pain relief medication, by mouth every 4 hours as needed for pain relief. ? [MEDICATION NAME], a narcotic pain relief medication, by mouth every 4 hours as needed for pain relief. On 09/04/13 at 3:08 p.m., a family member reported she visited Resident 1 on 07/07/13. She stated Resident 1 did not drink as she had great difficulty swallowing - fluids dribbled from her mouth. Between 10 and 11 p.m. that night, the family member reported she held a small kidney-shaped basin under Resident 1's chin. The basin filled between ? and ? full approximately every 5 minutes throughout the remainder of the night. Resident 1 could not hold the [MEDICATION NAME] under her tongue. Brown matter leaked from her mouth. The family member told Staff A what was occurring. The family member did not recall Staff A either touching or assessing Resident 1 for pain/comfort. Rather, Staff A suggested a sedative for Resident 1. The family member asked whether a sedative might result in aspiration for Resident 1. Staff A did not reply to the question. The family member stated Staff A did not notify hospice services during the night of the changes for Resident 1. Staff A entered Resident 1's room every 1-2 hours throughout the night and told the family member Resident 1 "was sick." The family member did not leave Resident 1's room during the night because she thought Resident 1 "would be covered in brown matter." On 09/11/13 at 5:34 p.m., Staff C reported he cared for Resident 1 the night of 07/06/13 and 07/07/13. He stated she had a problem keeping food down both dates. He notified Staff A of the situation. On 07/07/13, any medication Staff A administered, Resident 1 vomited. Staff C brought "stacks of towels and washcloths" throughout the night for the family to use on Resident 1. Staff C observed Resident 1 had pain and distress throughout the night. Staff C recalled the family asked where was Staff A throughout the night. He reported the family concerns to Staff A. On 09/16/13 at 1:30 p.m., Staff B reported she received report from Staff A the morning of 07/08/13. Based on that report, Staff B thought Staff A should have telephoned hospice services during the night. Staff B showed Staff A the "neon yellow" sticker on Resident 1's chart. The sticker listed the telephone number of hospice services and indicated they were available 24 hours/day. Staff B stated she observed fluids dribbling from Resident 1's mouth that morning. She described the fluids as "alternating poop brown to dark chocolate color." Sometimes the fluids were thin; sometimes particles were present. Resident 1 was retching about every 20-30 minutes. Whenever Resident 1 attempted to swallow water, it came back up immediately. Resident 1's tongue was reddened and cracked. When Staff B went to telephone hospice services, she saw the hospice nurse entering the building. She explained Resident 1's condition and requested pain relief and nausea medications for the resident. On 09/04/13 at 3:08 p.m., a family member stated she returned to visit Resident 1 about 8 p.m. on 07/08/13. Another family member told her at that time, Resident 1 had not vomited in the past 2 hours. Resident 1 was quiet and smiled at the family member. The family member thought the [MEDICATION NAME] was finally working for Resident 1. Review of the hospice record revealed documentation, dated 07/08/13 at 1:10 p.m, Resident 1 continued to have nausea and vomiting throughout the hospice nurse visit. The hospice nurse noted that Resident 1 showed no non verbal signs of pain following administration of 3 milligrams of [MEDICATION NAME] subcutaneously (an injection under the skin). The hospice nurse discontinued all medications by mouth for Resident 1. See F281 - lack of professional standards for additional details.

Based on observation, interview and record review, the facility failed to provide necessary supervision to prevent a burn from hot liquids for 1 of 6 sample residents (1). Failure to ensure the resident recieved and facility staff served hot liquids in accordance with facility policy resulted in harm for the resident who was burned after spillage of a hot beverage. Findings include: All interviews took place on 11/9/12 unless otherwise indicated. Resident 1 stated she had sustained a burn from hot water. On 10/25/12 the resident requested a cup of tea. Resident 1 stated she was served hot beverages in a cup with a lid at her request. After she was served the tea, she tried to get the lid off without staff assistance but her "fingers don't work." The hot water spilled on her. "It really hurt, it was very painful and my skin came off". She stated the water was hotter than normal. "It was so boiling hot". Resident 1 was admitted to the facility in 2009 with [DIAGNOSES REDACTED]. Staff caring for the resident stated she would occasionally have "jerking movement of her hands." The resident's Hot Beverage Safety Evaluation Plan, dated 8/11/2011 indicated she could have hot beverages without assistance as long as she wore a clothing protector, was sitting at a table and the liquids were "served at no more than 140 degrees". Review of the facility's investigative report, dated 10/30/12, verified that Resident 1 was wearing a clothing protector, was seated at a table and the hot water served to Resident 1 was more that 140 degrees. The report documented that the staff member serving the hot water had gotten the water from the "red hot water lever in the kitchen", and not from a pump pot containing hot beverage prepared by the kitchen staff. The report documented that the burn was 5 centimeter (cm) by 5 cm in size. The facility investigative report includesa statement from the Dietary Manager (DM), dated 10/25/12, indicating "coffee temperature is at 140 degrees. Temp is recorded (but hot water is not). Hot water temp is at 180 degrees. Ice is available to cool hot beverages..." Following the incident with Resident 1, the facility changed their policy for hot beverage service. The DM stated during interview that staff members were not allowed to get hot water from the dispenser in the kitchen. If staff needed to get a cup of hot water, the kitchen staff dispenses the hot water and ensured that hot water was cooled prior to leaving the kitchen. The DM stated that when Resident 1 sustained the burn from the hot water obtained from the hot water dispenser in the kitchen, The hot water had not been cooled per facility procedure and poured into a carfate or pump pot. Review of the facility's undated policy, "Serving Hot Beverages" read: " Hot beverages are served to residents at a temperature that is comfortable for drinking and cool enough not to cause harm. All hot beverages will be provided by the kitchen, a carafe of hot water will be provided for making tea and a container of ice will be provided for cooling coffee and tea to appropriate temperatures. Review of the clinical record revealed that the resident sustained [REDACTED]. of an ointment and dressing. A nursing note, dated 10/26/12 and 10/27/12 documented that the burn was painful and required medications to help alleviate the resident's pain. The ARNP saw the resident on 10/31/12 and documented "area of burn on abdomen remains [DIAGNOSES REDACTED]tous with granulation tissue present". The LNs were to continue the application of ointment with dressing change twice a day. The facility failed to ensure staff provided the necessary supervison to prevent accidental injury to Resident 1. The failure of staff to supervise and monitor the hot beverage service for the resident resulted in a painful, preventable burn.

Based on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 1)reviewed, was free from physical restraint imposed for the purpose of staff convenience. Resident 1 was physically restrained against his will during a non-emergency medical procedure which resulted in him becoming extremely physically and mentally agitated as well as frightened. Findings include: "Physical Restraints" are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to ones body. "Convenience" is defined as any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest. Restraints may not be used for staff convenience. However, if the resident needs emergency care, restraints may be used for brief periods to permit medical treatment to proceed unless the facility has a notice indicating that the resident has previously made a valid refusal of the treatment in question. Resident 1 was admitted on [DATE] to recover after a car accident which led to [MEDICAL CONDITION] and two broken lower legs. Resident 1 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment, dated 9/13/11, indicated Resident 1 had memory problems with no recall, was severely impaired in his decision making abilities and had periods of inattention, disorganized thinking with altered level of consciousness during the day. Resident 1 required extensive assistance with all of his daily care needs and was resistant to care at times. Multiple progress notes in Resident 1's clinical record indicated he was consistently confused, agitated, aggressive and not easily redirected until his discharge to the hospital on [DATE]. Resident 1 had multiple falls out of bed and/or his wheelchair and one to one care was frequently required to support his needs. On 11/03/11 at 10:15 a.m., the Director of Nursing services (DNS) reported the facility did not have a written policy on restraints but that the facility did have a "No Restraints" policy in effect. On 10/18/11 at a care conference in the facility for Resident 1, a representative for Resident 1 reported concern about Resident 1 being held down during the insertion of a urinary catheter. Resident 1 had a urinary catheter which he had removed himself on 10/12/11. The Physician (a urologist) for Resident 1 had written an order to notify her if Resident 1 "Was unable to urinate", had residual urine (urine staying in his bladder) of 300 milliliters (mls) or more and to do a straight catherter if he has not urinated. The facility did not have a bladder scan to determine the amount of residual urine Resident 1 had. Resident 1 was treated for [REDACTED]. Progress notes indicated Resident 1 had urinated on his own after the catheter was removed and he had a straight catheter (a temporary in and out catheter) placed as well with 250 mls. of urine present in his bladder on 10/12/11. Resident 1 was incontinent of urine on 10/13/11, twice on 10/14/11 and had a straight catheter twice on 10/15/11 for 200 mls. of urine both times. There was no documentation to indicate how the straight catheterization procedure went with Resident 1. A progress note in Resident 1's clinical record, dated 10/16/11 night shift, read: "Resident was restless with agitated behaviors at 11:00 p.m.. Resident required one to one care from staff. Attempting repeatedly to self transfer. Resident alert with confusion. Straight catheter done with no urinary output to rule out agitation from a full bladder. Resident showed signs of pain, facial grimacing, restlessness, refusal of care. Assisted resident to bed, repositioned and resident repeatedly attempted to roll out of bed. Gave a pain (relief) medication at 12:30 a.m. and at 1:00 a.m., resident became aggressive with staff and was unable to provide care and gave [MEDICATION NAME] (an anti-psychotic medication) at 1:15 a.m. and behaviors increased. Notified family and they came to stay with the resident one to one. At 2:00 a.m., resident was resting in bed." An "Event and Occurrence Report", dated 10/31/11, indicated the facility had investigated the concern voiced from the resident representative and had concluded "The Licensed Nurse had questioned if his increase in agitation was due to [MEDICAL CONDITION]. He did have an order for [REDACTED]. Resident 1 during the time of the straight catheterization kept moving his legs off of the bed. The two Nursing Assistants were trying to redirect Resident 1 while the Licensed Nurse tried to do the straight catheter, which was unsuccessful." A "Witness Statement", dated 10/18/11, from a resident representative, read "On Sunday, October 16, 2011, at 12:40 a.m., I came into Resident 1's room. I came because I was called at home that he was highly agitated at about 12:10 a.m.. When I came into the room, a nurse and two Nursing Assistants were with him. The male Nursing Assistant was sitting on the bed holding his legs down with his hands. The female Nursing Assistant was on the floor near his head controlling his arm movements. The nurse was on the floor inserting a tube into his penis. I was told they were trying to relieve his bladder. I asked everyone to leave the room. I knew I could calm him down. He appeared very frustrated and said he did not like the "Big Guy". I told him (Resident 1) it was OK and that no one would come back. I told the nurse to leave and to not come back, that I would calm him down. After they left, he (Resident 1) said "They were trying to have sex with me." I tried to explain what they were doing but he (Resident 1) was not accepting my explanation. At that time, he got on the mattress on the floor and I was able to change the subject. We sat on the floor talking and he said he was tired. At about 3:10 a.m....covered him and about 3:30 a.m. he fell asleep." A "Witness Statement", dated 10/29/11, from the Licensed Nurse doing the catheterization, read: "...He (Resident 1) had not urinated late evening shift or on nights yet...with the assistance of the two Nursing Assistants we explained what I was going to do and why. As I attempted to do the straight catheter, he (Resident 1) was still concerned with the heater being on and moving his legs off the bed. The Nursing Assistants were comforting him and redirecting his attention. We were unsuccessful with the procedure. Due to his high level of confusion and agitation and ruling out bladder needs and pain, I called the family earlier and asked to come and provide comfort, they agreed and arrived when we were finishing up..." Resident 1 urinated twice on his own later that day.

Based on interview and record review, the facility failed to provide appropriate staff to assist a resident. Affected was Resident 6, who suffered two fractures during a transfer when untrained staff assisted her. Findings include: Resident 6 was admitted in October 2010 with [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) assessment, dated 01/27/11, identified her recall abilities, short-term and long-term memory as intact. She required a two person physical assistance for transfer. On 01/18/11 at 1:00 p.m., Resident 6 fell and fractured the upper and lower leg bones of her left leg. On 03/08/11 at xx:30 p.m., Resident 6 reported the Nursing Assistant (NA 1) who was assisting her during the transfer that day had not cared for her in the past. NA 1 had not been trained how to place the leg brace and assist her with transfer. On 01/15/11 the Physical Therapist (PT) 1 determined Resident 6 could transfer with one person extensive assistance and use of a knee immobilizer provided the staff were "familiar" with Resident 6 and her needs for transfer. On 03/08/11 at 2:30 p.m., the Director of Nursing Services (DNS) reported she thought NA 1 had cared for Resident 6 about 20-30 tines before the incident of the fractures. She stated NA 1 was assigned to that hallway. At 2:35 p.m., the Staff Development Coordinator (SDC) reported NA 1 worked part-time and had not worked with Resident 6 on a regular basis prior to the incident. The SDC stated there had not yet been any in-service or training for staff regarding how to use the knee immobilizer and one person extensive assist transfer when Physical Therapy made the determination in January 2011.

Based on observation, interview and record review, the facility did not provide supervision and ensure the safe use of assistive devices for 3 of 5 residents (Resident 1, 2, 3). Failure to use an appropriate transport device for Resident 1 resulted in harm for the resident who sustained a closed head injury with loss of consciousness. Not following facility policy for a van transport for Resident 3 resulted in harm for the resident who experienced pain and required medical intervention due to a fall when being transported in the facility's van. In addition, failure to provide adequate supervision and an updated plan of care for using an assistive device with a transfer resulted in bruising for Resident 2. Findings include: RESIDENT 1: Review of the facility's investigative report, dated 11/1/10, documented that Resident 1 was going for a home visit to the Boarding Home (BH) next door to the Nursing Home (NH) and was accompanied by a private duty caregiver and facility occupational therapy staff. This report documented that the resident was transferred using her 4WW. The resident was seated on the seat of the 4WW and the private duty caregiver was pushing Resident 1. The report revealed that the sidewalk had a slight decline and the private duty caregiver who was pushing the 4WW, stated "wee" and her "speed picked up". "At that point the walker hit a crack in the sidewalk and tipped over backwards", and the back of the resident's head hit "the cement-her eyes were open but she was non responsive for several minutes". The emergency system 911 was activated and the resident was sent to the hospital for further evaluation. On 11/4/10 at 9:45 a.m., Resident 1 was interviewed and stated she was at the facility because she had fallen in her apartment . She stated on the day she went for a home visit, it was raining. The resident stated she was told "to sit" on the seat of her walker during the trip from the NH to the BH. The clinical record review revealed that the resident used a 4 wheel walker with a seat (4WW). The seat of the walker was to be used for convenient resting for the resident. During an interview on 11/4/10 at 11:00am, the Skilled Therapy Rehabilitation Director stated that a four wheeled walker (4WW) is only to be used as a walking device. The 4WW is provided for "balance support", and the seated portion is to be used only for the a resident "to rest" when tired. The Director stated that the 4WW is not identified as a transportation device and should not be used to push or transport a resident. She stated that if a skilled therapists (OT, PT) would observe improper use of a 4WW, it would be their responsibility to "point out safety risk, ...intervene, and "provide a safe manner and appropriate transfer method". During an interview with the OT who accompanied the private duty caregiver and resident on the home visit, and witnessed the Resident 1's fall was interviewed at 11:50 a.m. She stated the private duty caregiver had the resident seated in her 4WW walker and pushed the resident in the 4WW down the cement sidewalk/pathway. She stated the side walk was wet and as the sidewalk sloped down, the caregiver "said wee when gaining speed". The OT stated that the resident should have been transported in a wheelchair instead of the 4 WW. The therapist stated that 4WW should not be used to push or transport residents. She stated when the private duty caregiver arrived at the nursing station with the resident seated in her 4WW, she knew a wheelchair was the appropriate equipment to safely transport the resident, however she she did not transfer Resident 1 to the wheelchair. The hospital's emergency note, dated 11/1/10, documented that the resident had an " altered mental status " and required workup for her head injury. The resident returned to the facility with [DIAGNOSES REDACTED]. RESIDENT 3: Resident 3 was admitted to the facility on [DATE] for rehabilitation. The resident had a stroke with right sided weakness, dementia and a history of cervical spine pain and seizures. The clinical record revealed that the resident was at high risk for falls and was on a blood thinning medication. The Minimum Data Set (MDS) assessment, dated 7/28/10, revealed that the resident was dependent on staff for transfers and weighed 260 pounds. Review of the clinical record revealed that the resident's level of consiousness fluctuated with activities, and was limited as to the amount of time in his wheelchair due to "significant blood pressure fluctuations" "hypotension" (low pressure). The nursing notes, dated 8/9/10, documented "incident in facility van,...patient slipped out of w/c (wheelchair) to floor of van, repositioned and transported" to hospital campus. Review of the facility's incident report, dated 8/9/10, documented that Resident 3 was being transported to a rehabilitation center in the facility's van. Only one facility staff was in the van and that member was driving. The report indicated that a " 5 pt (point) restraint-4 on base of w/c, 1 fastening to previous for shoulder,... not properly engaged as it became disengaged en route". The "Resident slipped out to floor of bus. Bus parked as soon as able". "Repositioned resident on floor". This report indicated that when the staff member was able to pull the van over to reposition Resident 3, the spouse who had been following the van in her car, got into the van and stayed in the van until arriving at the rehabilitation center. This report indicated that the facility's plan to prevent reoccurrance would be for "all further transports will have 2nd person present". The report documented that the resident required medical evaluation after the fall, as Resident 3 had complaints of right lower leg pain and "whiplash to neck" to rule out any fractures. On 11/16/10, during an interview with the facility's administrator, she stated that the facility's policy was to have 2 people in the facility's van when transporting residents. She stated that there should have been a nursing staff and a driver in the van when Resident 3 was being transported in the facility's van. She stated that Resident 3 was "medically complicated" and needed to have a nursing staff in the van and the resident's "injury was our (facility's) fault". The administrator stated that the maintainence department is responsible for training staff who transport residents in the facility van regarding the proper operation of the van equipment. On 11/16/10 at 3:00p.m., the facility's van used to transport residents to outside activitis/appointments was observed with facility staff. The van had spaces for wheelchairs. Each space had 4 floor/tie-down straps to secure each wheelchair plus a shoulder/lap seat belt for each resident in the wheelchair. The staff member stated prior to transporting a resident in a wheelchair, the following safety devices/belts are to be strapped and secured. These included the 4 floor straps/tie downs that are attached to the wheelchair frame and the shoulder/lap seat belt, which would support the resident's upper body. The staff member stated a pre-trip checklist is completed prior to transporting residents. The facility's "Drivers checklist" forms were reviewed. There was no documented evidence that a pre-trip or post-trip checklist had been completed on 8/9/10 regarding the tie downs and belts used to safely secure residents when Resident 3 slipped out of his wheelchair. When asked about what training the staff member receives, the administrator stated that the maintainence department is responsible for training staff regarding the operation of the faciltiy transport van. When the maintainence department was interviewed regarding inservicing staff who transported residents in the facility's van, the department stated they had not been involved with the operations of the van since 2003. One of the facility's van drivers was also interviewed and stated he had not been inserviced on the application of the van's tie-down straps or shoulder/lap straps since hire. A faxed copy, dated 11/16/10, of the facility's undated Van Use Policy read: "when transporting any resident for any purpose,...staff will always travel with another staff, one friving and one assuring to the comfort and cares of the passengers. Non-activity staff will only operate the vehicle with a resident if a member of the nursing staff is on-board. Passengers in wheelchairs must be properly restrained by first securing the chair to the floor then the passenger to the chair with a lap/shoulder restraint per manufacturer's instructions". A copy of the faciltiy's staff who operated the van were reviewed and revealed there was no consistent staff member who ensured training for safe transport of resident was completed. RESIDENT 2: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan indicated that the resident was receiving skilled therapy (OT, PT) due to her generalized weakness and skilled therapy would provide staff/caregiver training as needed. The Resident Care Guide under transfers revealed that a mechanical lift (Vander) was to be used. The nursing progress notes indicated that skilled therapy was working with the resident's transfer techniques. The notes revealed that the resident required assistance of 2 persons for transfers. On 11/16/10 at 11:38 a.m., the resident stated that her bruises on her right upper arm were from the gait belt. She stated the gait belt "pinched and grasped a hold of her skin like a claw and staff were not aware". She stated the staff member who was assisting with the transfer "did not pay attention and the clasp of the belt" was not centered in the front during her transfer. The facility's investigation report, dated 10/26/10, documented that the "gait belt used to transfer, caused bruising and teeth of gait belt caused scratches". The report revealed one bruise measured 3 centimeters (cm) by 3 cm in size and another bruise measured 4cm by 2 cm and were purple in color and located on the right "upper arm on underside". The report indicated that "gaitbelt c (with) teeth to adjust". In addition, the preventive plan was to consult with skilled therapy regarding gait belt placement due to the resident's body size. The Care plan for skin integrity documented that Resident 1 had "bruising r (right) upper arm related to gait belt " and the intervention, dated 10/29/10 read "use extreme caution when applying gait belt to upper body vs (versus) waist,.. use extreme caution not to pinch loose skin, do not pull up on gait belt-use only as a guide in a transfer". On 11/4/10, the Nursing Manager (NM) was interviewed regarding the resident's plan of care. She stated that "after the incident" the skilled therapist was asked about the appropriate method to transfer the resident using the gait belt to avoid bruising. The NM stated that not until after the resident had sustained the bruises was the care plan updated to prevent any further harm to the resident and ensure the correct placement of the gait belt during transfers.