Every finding on record at North Bend Post Acute

Based on interview and record review the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS- a federal agency managing healthcare programs and health insurance standards) for Quarter 4 (Q4, October 2025, November 2025, December 2025) reviewed for Payroll Based Journal (PBJ-mandatory reporting of staffing information based on payroll data) submission. This failure affected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact provisions of resident care and services. Findings included . Findings included .<CMS-Electronic Staffing Data Submission PBJ>Review of the June 2022, CMS Long-Term Care Facility PBJ Policy Manual, showed long term care facilities were required to electronically submit direct care staffing information based on payroll and auditable data. The data, when combined with the census information can be used to not only report on the level of staff in each nursing home, but reports staff turnover and tenure, that can impact the quality of care delivered at the facility. The policy manual showed the facility must electronically submit complete and accurate information by the required deadline to include; direct care staff, the category of work for each direct care staff member, resident census data, and direct care staff turnover and tenure. Review of the PBJ data submitted by the facility for Q4, dated October 01, 2025 through December 31, 2025 showed a reported census total of 5133, a difference of two days from the correct census of 5135. Review of the facility monthly census for October 1, 2025 through December 31, 2025 showed multiple days to include 11/04/2025, 11/16/2025, 11/17/2025, 11/25/2025, 11/26/2025 and 12/12/2025 with an inaccurate reported census.During an interview on 06/05/2026 at 10:04 am Staff A (Administrator) stated an issue was identified with the facility payroll software that did not correctly carry over certain job codes affecting the licensed nurse and certified nursing assistant total hours. Staff A stated if the codes were carried over correctly the facility would have met the 3.4 HPRD and they would expect correct and accurate census and staffing hours to be reported. REFERENCE: WAC 388-97-1090(1)(2)(3)

Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were comprehensive, resident-specific and/or implemented for 4 of 17 residents (Residents 3, 54, 6, & 58) whose CPs were reviewed. This failure placed residents at risk for unmet care needs and frustration. Findings included . <Facility Policy>According to the facility's 2025 Care Planning - Resident Participation policy, the care planning process would include assessment of the resident's strengths and needs. The policy showed the CP would incorporate the resident's personal and cultural preferences, and be person-centered.<Resident 3>According to the 05/08/2026 Significant Change Minimum Data Set, Resident 3 was cognitively intact and independent with mobility and personal care. The MDS showed Resident 3 had diagnoses including a viral blood borne disease, an ileostomy (a surgical hole to allow the passing of digestive waste bypassing the large intestine), and puncture wounds on their lower back and pelvis. The MDS showed Resident 3 was not considered by the Preadmission Screening and Resident Review (PASRR - a mental health screening process) process to have a serious mental illness.In an interview on 06/01/2026 9:10 AM Resident 3 stated they had an ileostomy. Resident 3 stated they did a lot of the care and maintenance of the ileostomy themself. Observation at this time showed Resident 3 had an ileostomy pouch extending from their abdomen. Resident 3 stated they hoped to discharge from the facility but first needed a surgery in August 2026.Review of Resident 3's comprehensive CP showed a 04/19/2026 alteration in bowel elimination [related] to ileostomy . Care Plan (CP). This CP included a revised 05/21/2026 goal showing ostomy care will be done by nursing. The Comprehensive CP included 04/07/2026 Discharge Potential CP included an intervention showing discharge potential to lesser care discussed with resident/family/responsible other is ___________. This CP intervention was incomplete and did not indicate what Resident 3's potential for discharge was.The Comprehensive CP included a 04/07/2026 PASRR Recommendations CP that included an intervention showing PASSAR is (negative/positive) and did not indicate whether the PASRR identified Resident 3 with serious mental illness.In an interview on 06/05/2026 at 9:05 AM Staff B (Director of Nursing) stated the purpose of the CP was to identify the individual resident's needs and guide the staff in the care and treatment of the resident. Staff B stated all CPs should be comprehensive, accurate, and resident-specific, and CPs should be updated periodically with reassessment, and as needed. In an interview on 06/05/2026 10:30 AM, Staff B stated the Ileostomy CP should reflect Resident 3's current care needs. <Resident 54>According to the 02/18/2026 Quarterly MDS, Resident 54 required partial/moderate assistance with rolling from their back to their side in bed. The MDS showed Resident 54 had medically complex diagnoses including a progressive blood circulation disorder that narrows the blood vessels outside the heart and brain, often affecting the legs and feet, malnutrition, and a condition making controlling blood sugar more difficult. The MDS showed Resident 54 was at risk for developing pressure injuries (bed sores - open wounds caused by pressure over bony prominences).Record review showed a 05/19/2026 order for an air mattress to manage Resident 54's risk for pressure injuries. This order directed staff to keep the mattress on the soft setting.Review of the at a high risk for pressure injury . CP showed the instruction to keep the mattress on the softest from the 05/19/2026 air mattress order was not reflected on the CP. In an interview on 06/05/2026 at 9:05 AM, Staff B stated Resident 54's CP should be comprehensive and address all their identified care needs.In an interview on 06/05/2026 at 9:18 AM, Staff B stated Resident 54's mattress should be on the soft setting. <Resident 6>According to the 04/06/2026 Quarterly MDS, Resident 6 had diagnoses including lower body paralysis. The MDS showed Resident 6 had two pressure wounds with full thickness skin and tissue loss and exposure of bone or tendon.Review of the actual skin breakdown . CP, Resident 6's air mattress should be set at on the soft setting. The CP showed the mattress setting should be checked each shift.In an interview on 05/31/2026 at 10:43 AM Resident 6 stated they had pressure wounds and needed the air mattress because being turned too often was too much. Observation at the time showed the air mattress set three quarters of the way from the soft setting, one quarter from the firmest setting. The same air mattress setting of three quarters firm was observed on 05/31/2026 at 11:00 AM, on 06/04/2026 at 7:33 AM, and on 06/04/2026 at 8:49 AM. In an interview on 06/05/2026 9:18 AM, Staff B stated nurses should check the air mattress setting each shift. Staff B stated the mattress should be on the softest setting and that the CP should be followed. <Resident 58>According to the 03/13/2026 admission MDS, Resident 58 admitted to the facility on [DATE] and had intact cognition. The MDS showed Resident 58 was not actively planning to discharge from the facility at the time of the assessment. Review of Resident 58's comprehensive CP showed a 03/06/2026 Discharge Potential CP. This CP included an intervention showing Discharge potential to lesser care discussed with resident/family/responsible other is ___________. This CP intervention was incomplete and did not indicate what Resident 3's potential for discharge was.In an interview on 06/05/2026 at 9:05 AM Staff B stated all CPs should be comprehensive and accurate. REFERENCE: WAC [PHONE NUMBER](1)(2)(a)(b).

Based on interview and record review, the facility failed to complete the appropriate transfer notifications for 1 of 4 residents (Residents 48) reviewed for hospitalization, and 1 supplemental resident (Resident 61). Failure to ensure a written notification was provided to the resident and/or representative in a language and manner the resident and/or representative understood and give a report to the receiving hospital on resident's condition placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care/preferences, and a break in communication and continuity of care.Findings included .<Facility Policy>Review of a 2025 Transfer and Discharge policy showed when the facility transferred or discharged a resident, they would document the transfer or discharge in the medical record and appropriate information would be communicated to the receiving care institution or provider. This policy showed when the transfer or discharge was initiated, the resident would receive written notice using the Resident Notice of Transfer or Discharge form.<Resident 48> According to the 01/16/2026, 02/21/2026, and 02/27/2026 Discharge Return Anticipated Minimum Data Sets (MDS - an assessment tool) Resident 48 discharged to the hospital on the corresponding dates related to a change in the resident's condition. The MDSs showed Resident 48 had medical conditions including respiratory disease and anxiety. Review of Resident 48's health records for transfers on 01/16/2026, 02/21/2026, and 02/27/2026 showed no report was communicated to the receiving hospital and no written transfer notifications were provided to Resident 48. In an interview and record review on 06/04/2026 at 10:00 AM, Staff B (Director of Nursing) stated the facility should have provided Resident 48 with written discharge notices and provided a report to the receiving hospital for each hospital transfer, but they did not. Staff B stated transfer/discharge notices were important to ensure continuity of care and inform Resident 48 of their right to appeal transfer decisions. <Resident 61> According to the 05/05/2026 Discharge Return Anticipated MDSs, Resident 61 discharged to the hospital on [DATE] related to a change in the resident's condition. The MDS showed Resident 61 had medical conditions including failure to thrive and narrowing of the spine. Record reviews showed no documentation facility staff provided Resident 61 or their representative with a written notification of the reason for transfer to the hospital as required. In an interview and record review on 06/04/2026 at 7:55 AM, Staff B stated the facility did not provide written notices for hospitalizations and they were only aware this was the requirement for planned discharges. Staff B stated the facility should have provided the written discharge notice to Resident 61, but they did not. REFERENCE: WAC 388-97-0120(1)(2)(a)-(d)(3)(a)(4)(b)(5) -0080 -0140(1)(a)-(c)(i)-(iii).

Based on observation, interview, and record review, the facility failed to ensure Level I Preadmission Screening and Resident Reviews (PASRR - a mental health screening required prior to most nursing home admissions) screenings were accurate for 3 of 6 (Residents 48, 3, & 29) residents reviewed for PASRR. This failure placed residents at risk for inappropriate placement, unmet health needs, and other health concerns. Findings included . <Facility Policy>According to the facility's undated Resident Assessment - Coordination with PASRR Program policy, the facility would coordinate resident assessments with the PASRR program to ensure individuals with mental disorders or related conditions received services in the most integrated setting appropriate to their needs. The policy required a Level I screening prior to admission and Level II evaluation for positive screens to determine appropriate placement and specialized services.<Resident 48> According to the 10/24/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 48 admitted on [DATE] with a diagnosis of anxiety disorder (a mental disorder causing a person to overly worry or fear). The MDS showed Resident 48 took antidepressant medications. Record review showed a Level I screening was completed for Resident 48 on 01/26/2026. This screening did not indicate Resident 48's diagnosis of anxiety and did not refer the resident for a Level II evaluation. In an observation and interview on 06/05/2026 7:33 AM, Resident 48 expressed constant concern related to not being stable enough to safely return home in the future. Resident 48 stated they were unsure where they would live after leaving the facility and stated, I can't get it off my mind. In an interview and record review on 06/05/2026 at 10:30 AM, Staff H (Admissions Coordinator) stated Resident 48's Level I screening should have included their diagnosis of anxiety and indicated the need for a Level II evaluation, but it did not. Staff H stated a corrected Level I screening should have been resubmitted prior to Resident 48's admission, but it was not. Staff H stated it was important to ensure an accurate and timely Level I screening to ensure Resident 48 received any recommended mental health care and services, as needed. In an interview and record review on 06/05/2026 at 11:02 AM, Staff B (Director of Nursing Services) stated Resident 48's Level I screening should have been completed accurately and corrected prior to admission, but it was not. Staff B stated it was important to accurately assess the need for Level II evaluations to better support residents with serious mental illnesses. <Resident 3> According to the 05/08/2026 Significant Change MDS, Resident 3 had diagnoses including anxiety, depression, and Post Traumatic Stress Disorder. The MDS showed Resident 3 used an antidepressant medication. The MDS showed Resident 3 admitted to the facility on [DATE]. Observation on 06/02/2026 at 7:00 AM showed Resident 3 lying in bed awake. The light was off and the shades were drawn. Review of Resident 3's orders showed a 04/20/2026 order for an antidepressant medication, used to treat Resident 3's depression. Record review showed no Level I screening available in Resident 3's chart. Review of a 03/25/2026 Level II PASRR Invalidation showed Resident 3 had PTSD and anxiety diagnoses but did not capture their depression diagnosis. In an interview on 06/04/2026 10:04 AM with Staff H and Staff I (Social Services), Staff I stated it was important for Level I screenings to be accurate. Staff H provided a copy of a 03/25/2026 Level I PASRR screening. Staff I reviewed the PASRR and confirmed it did not but should have captured Resident 3's depression diagnosis. <Resident 29> According to the 03/27/2026 Quarterly MDS, Resident 29 had diagnoses including anxiety, depression, and an intellectual disability. The MDS showed Resident 29 admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 3's 10/10/2023 Level I PASSR screening showed this PASRR identified Resident 29's depression diagnosis, but not their anxiety diagnosis. In an interview on 06/04/2026 10:04 AM, Staff I stated the 10/10/2023 Level I Screening did not capture Resident 29's anxiety diagnosis. Staff I stated the Level I screening should be accurate but was not. REFERENCE: WAC 388-97-1915(1)(2)(a)-(c).

Based on observation, interview, and record review the facility failed to ensure controlled medications were accurately reconciled for 2 of 2 (South Medication and Central Medication) carts reviewed for medication storage and reconciliation. Failure to ensure an accurate account of resident narcotic medications placed the residents at risk for uncontrolled pain, decreased quality of life, and possible diversion of controlled substances.Findings included.<Facility Policy>According to the facility's undated Medication Storage policy the facility would maintain controlled substance accounting in an accurate, legible, and traceable manner at all times.<Central Medication Cart>In an observation and interview on 05/31/2026 at 11:35 AM, the Central medication Cart narcotic ledger showed the following discrepancies: Resident 6 had prescriptions for two controlled substances, an antiseizure drug and a narcotic pain medication. The narcotic ledger showed there were 20 antiseizure capsules left but the pack showed 19 capsules were available. The narcotic ledger showed there were three narcotic pain pills left but the pack showed two pills were available. The narcotic ledger showed Resident 34 had four narcotic pain pills, but the pack showed only 3 pills were available. The narcotic ledger showed Resident 2 had 11 antiseizure capsules left but the pack showed only 10 capsules were available. In an interview at this time, Staff G (Licensed Practical Nurse - LPN) stated they administered the controlled medications earlier that morning to the residents. Staff G stated the morning medication pass was busy and they would sign the medications out later in the day. Staff G confirmed they should sign the narcotic medications out at the time of administration.<South Medication Cart>In an observation and interview on 05/31/2026 at 12:32 PM, the South Medication Cart narcotic ledger showed Resident 51 had four bottles of a liquid narcotic left but there were only three bottles available in the cart. The narcotic ledger showed Resident 52 had four bottles of a liquid narcotic available but there were only three bottles available in the cart. In an interview at this time, Staff E (LPN) stated the morning medication pass was very busy. Staff E confirmed they should sign the narcotics out at the time of administration.In an interview on 06/04/2026 at 7:45 AM, Staff B (Director of Nursing) stated staff not signing out narcotics at the time of administration was a safety concern. Staff B stated they expected staff to sign out narcotics at the time the narcotic was given.REFERENCE: WAC 388-97-1300(1)(b)(i-ii).

Based on observation, interview, and record review the facility failed to ensure the facility environment was free of accident hazards. The failure to: ensure residents who smoked complied with facilities policies for 3 of 3 residents reviewed for smoking (Residents 6, 41 & 58), ensure safe hot water temperatures were maintained for 2 of 2 units (North and South Units), ensure fire exits were free of obstructions for 1 of 2 units (South Unit), and failure to ensure shower rooms did not contain unsecured hazards for 1 of 2 shower rooms (South Shower room) placed residents at risk for smoking hazards, burns, cuts, and other negative health outcomes. Findings included .<Smoking> <Facility Policy> According to the facility's revised 01/28/2025 Smoking Policy, the facility was a no-smoking facility. The policy showed effective 07/09/2024, newly admitted residents would not be permitted to smoke independently outside the facility. The policy showed residents and their representatives would be informed of the policy, and residents with a history of smoking would be assessed to see if they needed pharmacological or behavior interventions to assist them to not smoke while a resident. <Resident 6> According to the 04/06/2026 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 6 had no vision or hearing impairments, was cognitively intact, and used their wheelchair independently. The MDS showed Resident 6 had a nicotine dependence diagnosis. In an interview on 05/31/2026 at 11:02 AM, Resident 6 stated they smoked outside the facility. Resident 6 stated they kept their cigarettes on their person during the day but you can turn them into the nurse at night. Resident 6 was sitting up in bed at the time. Resident 6 stated they had cigarettes on their person but declined to show them. According to the 10/08/2024 Smoking Care Plan (CP), Resident 6's goals were to sustain no injuries from smoking and follow facility smoking rules. This CP showed all Resident 6's smoking paraphernalia would be stocked in an individualized box in the nurse's cart or nurse's med room for safety. Resident 6 would ask staff for their smoking items and must sign out when going out to smoke. The CP showed upon return to the facility, Resident 6 would sign in, immediately return smoking supplies to the staff and if Resident 6 was noncompliant with the smoking policy other steps would occur. According to the 04/23/2026 Smoking Assessment, Resident 6 had decreased sensation in arms, legs or trunk that would impair their ability to detect pain from burning embers and took a medication that could affect cognition or judgment. This assessment determined Resident 6 was safe to smoke independently. In an interview on 06/04/2026 9:04 AM, Staff B (Director of Nursing) stated Resident 6 flagged twice on their Smoking Assessment, but a threshold of three or more flags was required to determine that a resident was unsafe. Staff B stated they expected Resident 6 to be compliant with facility policies on smoking and to keep their cigarettes locked with the nurse when not smoking. <Resident 58> According to the 03/13/2026 admission MDS, Resident 58 admitted to the facility on [DATE], had no vision or hearing impairments, and had intact cognition. The MDS showed Resident 58 was independent with most mobility and cares. The MDS showed Resident 58 had diagnoses including tobacco use but was not currently smoking. In an interview on 06/01/2026 at 10:01 AM, Resident 58 stated they still smoked and kept their own cigarettes but smoked away from the facility. Resident 58 appeared comfortable sharing their smoking status. According to 02/25/2026 Hospital History and Physical (H & P) Resident 58 smoked approximately 2 cigarettes daily. Review of the facility's list of residents who smoked on 06/02/2026 showed Resident 58 was not identified as an active smoker. Record review showed a copy of the facility's revised 05/27/2025 smoking policy, signed by Resident 58 in their chart. This copy of the policy had language showing smoking, including the use of electronic cigarettes, is prohibited in all areas ., new admission[s] wishing to smoke will initiate immediate discharge planning from the facility. Only grandfathered residents will be allowed to smoke ., and residents with a history of smoking will be further assessed to determine whether or not. Record review showed no smoking assessment in Resident 58's chart. In an interview on 06/04/2026 8:54 AM, Staff B stated when a resident admitted who wished to smoke, the facility completed a smoking assessment. Staff B stated they discussed the expectations with the resident. Staff B stated if a resident wished to stay and was an active smoker there were tools to help them stop but they needed to go through the doctor. Staff B stated facility staff monitored residents as they came and went from the facility for compliance with the facility's smoking rules. Staff B reviewed Resident 58's record and could not find a smoking assessment. Staff B looked frustrated and stated Resident 58 was dishonest with the facility about their desire to smoke. Staff B stated they did not see anything in Resident 58's chart to indicate the facility attempted to determine if Resident 58 needed assistance with smoking cessation. <Resident 41> According to the 05/04/2026 Quarterly MDS, Resident 41 admitted to the facility on [DATE] with Chronic Obstructive Pulmonary Disease (COPD - breathing difficulty), respiratory failure, and nicotine dependence. Review of the 04/28/2026 Risk for Relapsing on Smoking CP showed Resident 41 was at risk for a smoking relapse due to an extensive history of smoking and had a goal of smoking cessation. In an interview on 05/31/2026 at 10:51 AM, Resident 41 stated they smoked cigarettes and they hid their cigarettes from staff. In an interview on 06/06/2026 at 08:39 AM, Staff L (Registered Nurse) stated that Resident 41 smoked cigarettes and observed smoking outside the facility. In an interview on 06/04/2026 at 08:41 AM, Staff M (Certified Nurse Assistant - CNA) stated Resident 41 was a smoker. In an interview and record review on 06/04/2026 at 11:06 AM, Staff B stated residents who smoked were assessed upon admission, the facility followed up on the resident's smoking history, physician's orders relating to smoking were obtained, and CPs were developed and implemented by staff. Staff B stated the facility also documented the resident's name on to the active smokers list for monitoring safety. Staff B reviewed Resident 41's record and stated, we do not have record on that, confirming there was no documented smoking assessment, physician's order, or smoking-related CP interventions related to the resident's ongoing smoking. <Hot Water> According to the facility's 2026 Safe Water Temperatures policy, the facility would maintain hot water temperatures between 100 Degrees Fahrenheit (F) and 120 F. The policy showed hot water tanks/boilers/thermostats would be adjusted as needed to maintain safe temperatures and water temperature logs would be kept for three years Observation on 06/05/2026 at 7:33 AM showed the water temperature in room S3 was 124.2 F. Resident 3 stated the water in the room was hot but not hot-hot. On 06/05/2026 at 7:38 AM the water temperature in room N1 was measured at 127.4 F. In an interview at that time, Staff A (Administrator) observed the reading on the thermometer and stated he would instruct the maintenance department to adjust the thermostat. Staff A stated the temperature of 127.4 F was not within the acceptable range. Observation on 06/05/2026 at 7:42 AM showed the temperature in room N6 was 126.5 F. In an interview at that time Resident 21 stated the water gets hot. Observation on 06/05/2026 at 7:48 AM showed the hot water temperature in room N 11, at the far north end of the building was 126.4 F. Observation on 06/05/2026 at 7:53 AM showed the hot water in room S12, at the far south end of the building was 115.9 F. In an interview on 06/05/2026 at 10:40 AM, Staff A stated facility staff tested water temperatures throughout the facility and identified hot water exceeding 120 F in the majority of resident rooms. Staff A stated it was important to maintain hot water temperatures under 120 F for safety and the facility was monitoring water temperatures until all rooms had hot water within. the safe range. <Blocked Fire Exit> Observation on 06/04/2026 at 4:18 AM showed the fire exit located next to the conference room was blocked by a mechanical lift and a large wheelchair. A sign on the wall next to the lift showed THIS CORRIDOR TO BE KEPT CLEAR AT ALL TIMES. In an interview on 06/04/2026 at 6:55 AM Staff B looked at the blocked fire exit and stated it was not appropriate to leave the equipment in a hallway that needed to remain clear and they would provide education to staff. In an interview on 06/04/2026 at 7:03 AM Staff A stated it was important to keep fire exits clear for safety in the event of an emergency. <South Unit Shower Room> Observations on 05/31/2026 at 9:38 AM and on 06/01/2026 at 10:45 AM and 1:35 PM showed the South Unit shower room door was unlocked with no staff present. Hair and body cleaning products, and disposable razors were stored in unlocked cabinets. In an observation and interview on 06/01/2026 at 1:36 PM, Staff B entered the unlocked South Unit shower room and stated it should be always locked but was not. Staff B noted that razors and cleaning products were accessible in the unlocked cabinet. Staff B stated the unlocked shower room posed a safety hazard for residents with mental illness or an altered mental status, as staff would not know if a resident entered the room and experienced a fall or injury. REFERENCE: WAC 388-97-1060(3)(g).

Based on observation, interview, and record review the facility failed to conduct care conferences to ensure person-centered care for 8 of 18 residents (Residents 7, 10, 41, 43, 48, 54, 32, & 29) sample residents. These failures placed residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . <Facility Policy>According to the facility's 2025 Care Planning-Resident Participation policy, the facility would support the resident's right to be informed of and participate in care planning and treatment. The policy showed the facility would honor residents requests for care plan meetings, encourage resident and/or resident representatives participation in choosing care and treatment options at regular scheduled care plan conferences, upon admission, at routine intervals, and after a significant change occurred.<Resident 7> According to the 04/07/2026 Annual Minimum Data Set (MDS - an assessment tool) Resident 7 had severely impaired memory, was unable to make their own decisions, and depended on staff for mobility, hygiene, and transfers. Review of Resident 10's record showed a care conference last occurred on 09/24/2025. There was no documentation showing a care conference was conducted or offered since that time. Record review showed Resident 7 had a medical Power of Attorney (POA) who participated in previous care conferences. <Resident 10> According to the 04/03/2026 Quarterly MDS, Resident 10 admitted to the facility on [DATE] with no memory impairment. Review of Resident 10's record showed the last documented care conference occurred on 07/16/2025, with no other care conference provided or offered since. In an interview on 05/31/2026 at 1:37 PM Resident 10 stated they could not remember having a care conference or being offered one for a long time but would like to participate in one. <Resident 41> According to the 05/04/2026 Quarterly MDS, Resident 41 admitted to the facility on [DATE], had clear speech, could be understood and was able to understand others in conversation. Review of Resident 41's record showed no documentation that a care conference was conducted or offered since admission. In an interview on 06/01/2026 at 12:27 PM Resident 41 stated the facility had not conducted or offered a care conference to them since their admission. <Resident 43> According to the 05/01/2026 Quarterly MDS, Resident 43 was admitted to the facility on [DATE]. The MDS showed Resident 43 had no memory impairment. Record review showed the last documented care conference for Resident 43 occurred on 10/23/2025 with no evidence that a care conference was conducted or offered since. In an interview on 06/01/2026 at 08:23 AM Resident 43 stated they did not participate in a care conference for almost a year, was not contacted regarding one, and would like the opportunity to discuss concerns with the Interdisciplinary Team (IDT – a multidiscipline committee of department heads overseeing resident care). In an interview and record review on 06/04/2026 at 9:26 AM, Staff N (Social Services) stated care conferences should be conducted upon admission, quarterly, with a significant change in residents care, and as needed if requested by residents or their representatives. Staff N reviewed the records for Residents 7, 10, 41 and 43 and confirmed care conferences did not occur and were not offered for the residents or their representatives since the documented care conferences in their records. <Resident 48> According to a 10/24/2025 admission MDS, Resident 48 admitted to the facility on [DATE] with clear speech, could be understood, and was able to understand others in conversation. In an interview on 06/02/2026 at 1:32 PM, Resident 48 expressed concern about not knowing the plans for their future care and did not recall having a care conference. Review of Resident 48's record showed no documentation of any care conferences since admission. In an interview and record review on 06/04/2026 at 10:00 AM, Staff B (Director of Nursing) stated care conferences should occur quarterly and be documented in a progress note in the resident's record. Staff B reported they did not see documentation showing care conferences were completed for Resident 48. Staff B stated care conferences were important so all departments and the resident were informed and could follow up on any identified concerns. <Similar Findings> <Resident 54> According to the 02/18/2025 Quarterly MDS, Resident 54 admitted to the facility on [DATE]. The MDS showed Resident 54 had intact cognition and did not refuse any care during the assessment's lookback period. Record review showed Resident 54's most recent quarterly care conference was on 08/22/2025. There were no progress notes indicating Resident 54 refused to participate in a care conference since that date. <Resident 32> According to the 04/06/2026 Quarterly MDS, Resident 32 had intact cognition and did not refuse any care during the assessment's lookback period. The MDS showed Resident 32 admitted to the facility on [DATE]. Record review showed Resident 32's most recent quarterly care conference was on 08/29/2025. There were no progress notes indicating Resident 32 refused to participate in a care conference since that date. <Resident 29> According to the 03/27/2026 Quarterly MDS, Resident 29 admitted to the facility on [DATE]. The MDS showed Resident 29 had intact cognition and did not refuse any care during the assessment's lookback period. Record review showed Resident 29's most recent quarterly care conference was on 07/15/2025. There were no progress notes indicating Resident 29 refused to participate in a care conference since that date. In an interview and record review on 06/04/2026 at 9:26 AM, Staff N stated care conferences should be conducted upon admission, quarterly, with a significant change in residents care, and as needed if requested by residents or their representatives. In an interview and record review on 06/04/2026 at 10:00 AM, Staff B stated care conferences should occur quarterly and be documented in a progress note in the resident's record. REFERENCE: WAC 388-97-1020(2)(e)(f)(4)(b)(d)-(f).

Based on observation, interview, and record review, the facility failed to ensure resident medical records were complete and accurate for 3 of 17 (Residents 29, 7, & 3) whose records were reviewed. The failure to ensure admission documents were added to the chart timely and ensure device assessments were documented placed residents at risk for incomplete records and undocumented care. Findings included . <Facility Policy>According to the facility's 2025 Maintenance of Electronic Clinical Records policy, electronic clinical records should contain physician orders, required assessments, and care provided. The policy showed records would be maintained in accordance with acceptable standards of practice.<Resident 29> According to the 03/27/2026 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 29 used a wheelchair and a had a history of falling since the last assessment. The MDS showed Resident 29 had diagnoses including a history of stroke, dementia, one-sided paralysis, and a developmental disorder. Observation on 06/01/2026 at 10:25 AM showed Resident 29 in a wheelchair with a buckled lap belt around their waist. Resident 29 demonstrated they could unbuckle the lap belt. Review of Resident 29's record showed the last documented safety assessment for the lap belt was completed on 09/12/2024. In an interview on 06/04/2026 9:08 AM, Staff B (Director of Nursing) stated it was important to assess devices like lap belts periodically for safety and to ensure they were still of benefit to the resident. Staff B stated they completed assessments of various safety devices for Resident 29 quarterly and completed one recently. Staff B reviewed the most recent safety device assessment for Resident 29 and noted it did not include an area to document assessment of Resident 29's lap belt. Staff B stated they could not demonstrate Resident 29's lap belt was assessed after 09/12/2024 as the form used since did not have a space to capture that assessment. <Resident 3> According to the 05/08/2026 Significant Change in Status MDS, Resident 3 had diagnoses including anxiety and depression. The MDS showed Resident 3 admitted to the facility on [DATE]. Record review showed a 03/25/2026 Level II Preadmission Screening and Resident Review (PASRR) Invalidation Assessment (a determination the resident did not require specialized mental health services while in the home) indicating a prior Level I PASRR Screening showed Resident 3 had potential serious mental illness indicators requiring further assessment. This Level I PASRR screening was not found in Resident 3's record. In an interview on 06/04/2026 10:04 AM, Staff H (Admissions Coordinator) stated they had Resident 3's Level I PASRR screening that was not available in the resident's record and stated it should have been uploaded to the chart by now but was not. In an interview on 06/05/2026 at 9:05 A, Staff B stated they expected Resident 3's Level I PASRR to be uploaded into their record in a timely fashion. <Missing Documentation> <Resident 7> According to the 04/07/2026 annual MDS assessment, Resident 7 had severely impaired memory, was unable to make own decisions, and was dependent on staff for mobility, hygiene, and transfers. Review of the 04/26/2026 Risk for Falls related to arthritis, seizure disorder, unsteady gait, impulsiveness, syncope, and history of falls Care Plan (CP) showed staff were to identify and address fall risks and educate Resident 7 and their family regarding safety risks and interventions. Observation on 06/02/2026 8:12 AM showed Resident 7 lying in bed on a scoop mattress (a mattress with raised, curved sides intended to prevent falls). In an interview and record review on 06/04/2026 at 1:06 PM, Staff B stated the facility should obtain informed consent from the resident or (resident's representative), a physician's order, and complete an assessment prior to use of a scoop mattress. Staff B stated it was important to complete and document due to potential safety risks for Resident 7. Staff B reviewed Resident's 7's record and stated there was no documented informed consent, physician's order, or assessment completed by the facility related to the scoop mattress. REFERENCE: WAC 388-97 -1720(1)(a)(i)-(iv)(b).

Based on observation, interview, and record review, the facility failed to ensure physician orders, assessment and care planning were in place for 1of 1 resident (Resident 41) reviewed for respiratory care. These failures placed the resident at risk for potential negative outcomes such as poor/under oxygenation and a decreased quality of life. <Policy>According to the facility's 2026 Oxygen Administration policy, staff were to administered oxygen to residents according to professional standards of practice, physician orders, comprehensive person-centered care plans, and resident goals and preferences. According to the 05/04/2026 Quarterly Minimum Data Set (MDS-an assessment tool), Resident 41 admitted to the facility on [DATE] with severe impaired memory, chronic obstructive pulmonary disease (COPD-breathing difficulty) and respiratory failure. Review of the 02/07/2026 COPD risk for ineffective breathing pattern care plan (CP) showed staff would administer oxygen as ordered. Review of physician progress note on 04/01/2026, 05/02/2026, and 05/19/2026 instructed staff to use supplemental oxygen as needed to maintain Resident 41's oxygen saturation at greater than 90%. Review of Resident 41's order summary on 04/2026, and 05/2026 showed there was no physician order for supplemental oxygen use. In an observation and interview on 06/02/2026 at 07:13 AM, Resident 41 was lying in bed, and a portable oxygen tank positioned beside the bed. A nasal cannula (a tubing to deliver oxygen therapy) was attached to the oxygen tank. Resident 41 appeared to be alert and oriented and stated they independently used the portable oxygen tank for oxygen therapy. Resident 41 stated, I usually use it before going for my walk outside. I get my oxygen up and then go for my walk. Resident 41 stated, I turn it on up to two for 15 minutes, and after my oxygen is up, I turn it off and go for my walk. In an interview on 06/02/2026 at 11:10 AM, Staff J (Certified Nurse Assistant), stated Resident 41 independently operated the portable oxygen tank in their room. In an interview on 06/02/2026 at 11:15 AM, Staff K (Licensed Practical Nurse) stated Resident 41 knew how to independently operate the portable oxygen tank and had used it when their oxygen was low. In an observation, interview, and record review on 06/02/2026 at 11:44 AM, Staff B (Director of Nursing), observed the portable oxygen tank in Resident 41's room. Staff B stated residents with respiratory problems were assessed upon admission, physician orders were obtained, and care plans were developed and implemented by nursing staff. Staff B stated Resident 41's record had no physician order for supplemental oxygen use, no assessment, and no care plan related to supplemental oxygen therapy but should have. Reference: WAC 388-97-1060 (3)(iv).

Based on observation, interview, and record review the facility failed to ensure appropriate ileostomy (a surgically created hole allowing waste to void into a bag, bypassing the large intestine) care was provided for 1 of 1 residents (Resident 3) reviewed for ileostomy. This failure placed residents at risk for unmet care needs and infection control concerns. Findings included . <Facility Policy>According to the facility's 2025 Ostomy (surgical hole) Policy, ostomy care would be provided by licensed nurses under the orders of the attending physician.<Resident 3>According to the 05/08/2026 Significant Change Minimum Data Set, Resident 3 was cognitively intact and independent with mobility and personal care. The MDS showed Resident 3 had diagnoses including a viral blood borne disease, an ileostomy, and puncture wounds on their low back and pelvis. In an interview on 06/01/2026 9:10 AM Resident 3 stated they had an ileostomy. Resident 3 stated they stated did a lot of the care and maintenance of the ostomy themself. Observation at this time showed Resident 3 had an ileostomy pouch extending from their abdomen. Record review showed a 04/19/2026 alteration in bowel elimination [related] to ileostomy . Care Plan (CP). This CP included a revised 05/21/2026 goal showing ostomy care will be done by nursing. The CP showed ileostomy care would be completed as ordered. Record review showed a 04/22/2026 order to place Resident 3 on Enhanced Barrier Precautions (an infection control measure requiring nursing staff to use gowns and gloves for certain types of care) related to their ileostomy. There were no other orders in Resident 3's record describing how to care for and/or monitor Resident 3, including monitoring. In an interview on 06/05/2026 at 10:30 AM, Staff B (Director of Nursing) stated both the nurses and Resident 3 were responsible for the care of Resident 3's ileostomy. Staff B stated the site of the ileostomy needed to be checked and the wafer (a small, disc-shaped barrier placed between the ileostomy pouch and the skin for skin protection) changed as needed. Staff B reviewed Resident 3's record and confirmed the were no orders related to acre and maintenance of the ileostomy in Resident 3's record. Staff B stated there should orders and the absence of ileostomy orders was a failure on the part of the facility. REFERENCE: WAC 388-97-1060(1)-(3).

Based on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADL - grooming, bathing, personal hygiene etc.) to dependent residents for 1 of 3 residents (Resident 54) reviewed for ADL. Findings included . <Facility Policies>According to the facility's 2025 ADL Policy, the facility would provide assistance with ADL including bathing consistent with the resident's assessed needs. According to the facility's 2025 Nail Care Policy, the resident's Care Plan (CP) would identify the frequency and type of nail care the resident needed. This policy showed residents' nails should be kept smooth to avoid skin injury.<Resident 54>According to the 02/18/2026 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 54 required substantial/maximum assistance with bathing and was totally dependent on staff for personal hygiene. The MDS showed Resident 54 was always incontinent of bladder and bowel.Observation on 06/01/2026 at 10:56 AM showed Resident 54 in bed. Resident 54's fingernails were observed to extend past the tips of their fingers, and were uneven/jagged with soiling visible under the nails. Observation on 06/04/2026 at 8:27 AM and 06/05/2026 at 8:59 AM again showed Resident 54 with fingernails extending past the tips of their fingers, and were uneven/jagged with soiling visible under the nails.Review of the Resident 54's bathing documentation showed no documentation of any showers or baths in May 2026. Resident 54 was documented to refuse their shower on 05/01/2026 and 05/08/2026 and was marked as inapplicable on 05/28/2026. The April 2026 bathing records showed Resident 54 received a shower on 04/03/2026 and 04/10/2026, refused on 04/17/2026, and was marked as not applicable on 04/24/2026. Review of the progress notes showed no refusals of bathing over that time period.According to the 05/26/2024 ADL CP, nursing staff should provide Resident 54 ADL care as needed. This CP showed Resident 54 should be provided bathing/showering at least two times per week . This CP showed nailcare should be offered during Resident 54's shower.In an interview on 06/05/2026 9:27 AM, Staff B (Director of Nursing) stated Resident 54 should be provided bathing per the schedule. Staff B stated Resident 54 was scheduled for bathing twice weekly, and if the resident refused a shower one day, there was still an opportunity for a second shower that week. Staff B stated there could be additional shower documentation in a shower book that was not yet added to Resident 54's record. Staff B stated Resident 54 now refused nail care from nursing staff and would only allow a family member to trim their nailsOn 06/05/2026 at 9:40 AM, Staff B reviewed the shower book and located a documentation of a shower provided on 05/29/2026 and a refusal of bathing on 05/22/2026. Staff B was not able to provide documentation showing Resident 54 was offered a shower twice weekly as per the ADL CP, or received at least one shower per week. REFERENCE: WAC 388-97-1060(2)(c).

Based on observation, interview, and record review the facility failed to ensure nursing services were provided within professional standards of nursing. The failure to: clarify physician's orders when required for 2 of 4 residents (Residents 32 & 6) reviewed for pain management, follow physician's orders for 3 of 18 sample residents (Residents 6, 54, & 10), and discontinue obsolete orders for 1 of 18 sample residents (Resident 29), placed residents at risk for unmet care needs, unneeded care, and other negative health outcomes. <Facility Policy>According to the facility's 2025 Weight Monitoring policy, the facility would ensure residents maintain acceptable nutritional status and body weight parameters. The facility would develop and consistently implement individualized interventions, monitor effectiveness, and revise them as necessary. The policy showed that staff would implement ongoing monitoring and document residents' weight to ensure residents maintain acceptable nutritional status.Findings included .<Clarifying Orders> <Resident 32> According to the 04/06/2026 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 32 had diagnoses including a chronic autoimmune disease of the central nervous system, disc degeneration, and migraines. The MDS showed Resident 32 had mild pain that occasionally had an effect on their sleep and day-to-day activities. Review of the physician's orders showed Resident 32 had two as-needed pain medications they could take for pain management: a 10/20/2022 order for an over-the counter pain medication to be given every four hours as needed for pain management; an 04/02/2026 order for an opioid pain medication to be given as needed for chronic pain okay to take additional 1 tab if waken due to pain at night. The as-needed opioid order did not show how long to wait between doses. Neither as-needed pain medication order included parameters to direct nurses to know which medication to be given for what level of pain. In an interview on 06/05/2026 at 9:05 AM, Staff B (Director of Nursing) stated Resident 32's as-needed opioid pain medication should indicate how frequently the medication could be given but did not. Staff B stated if a resident had more than one as-needed pain medication, the orders should include parameters for when to give which medication such as use of a zero-to-ten pain scale, but did not, so it was unclear when to give each medication. Staff B stated the orders needed clarification. <Resident 6> According to the 04/06/2026 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 6 had diagnoses including traumatic spinal cord dysfunction and received both scheduled and as needed pain medications. The MDS showed Resident 6 was assessed with frequent, severe pain that frequently affected their sleep and occasionally interfered with their day-to-day activities. The MDS showed Resident 6 had two pressure wounds (bed sores - open wounds caused by pressure over bony prominences) with full thickness skin and tissue loss and exposure of bone or tendon. Review of the physician's orders showed two as needed pain medications: a 10/01/2024 over-the-counter pain medication, give two 325 Milligram (MG) tablets every 4 hours for pain; a 05/21/2026 order for a narcotic pain medication, give one 15 MG tablet every three hours as needed for pain. Neither as-needed pain medication order included parameters to direct nurses to know which medication to be given for what level of pain. In an interview on 06/05/2026 at 9:05 AM, Staff B stated the orders should include parameters for when to give which medication but did not. Staff B stated the orders needed clarification. Staff B stated nurses were responsible for clarifying unclear or incomplete with the physician. <Following Orders> <Resident 6> Record review showed a 02/07/2025 order for an air mattress for treatment of pressure wounds. The order showed Resident 6's mattress should be kept on the soft setting. In an interview on 05/31/2026 at 10:43 AM, Resident 6 stated when they were in the hospital, staff there would turn them at regular intervals, which they found to be too much. Resident 6 stated the air mattress helped as an alternative. Observation at the time showed the air mattress set three quarters of the way from the soft setting, one quarter from the firmest setting. Observation at the time showed the air mattress set three quarters of the way from the soft setting, one quarter from the firmest setting. The same air mattress setting of three quarters firm was observed on 05/31/2026 at 11:00 AM, on 06/04/2026 at 7:33 AM, and on 06/04/2026 at 8:49 AM. In an interview on 06/02/2026 at 9:01 AM, Resident 6 expressed concern that their air mattress was not set at the right firmness level. Observation showed the air mattress set at three quarters firm In an interview on 06/05/2026 at 9:18 AM, Staff B stated Resident 6's mattress should be kept at the setting identified in the 02/07/2025 order but was not. <Resident 54> According to the 02/18/2026 Quarterly MDS, Resident 54 required partial/moderate assistance with rolling from their back to their side in bed. The MDS showed Resident 54 had medically complex diagnoses including a progressive blood circulation disorder that narrows the blood vessels outside the heart and brain, often affecting the legs and feet, malnutrition, and a condition making controlling blood sugar more difficult. The MDS showed Resident 54 was at risk for developing pressure wounds. Record review showed a 05/19/2026 order for an air mattress needed due to Resident 54's history of wounds on their tailbone area. The order showed the air mattress should be set on the soft setting each shift. Observation on 06/01/2026 at 10:36 AM showed mattress on the firmest setting. Resident 6's mattress was again observed on the firmest setting on 06/03/2026 at 11:56 AM and 06/05/2026 at 7:13 AM. In an interview on 06/05/2026 at 9:18 AM, Staff B stated Resident 54's mattress should be kept at the setting identified in the 02/07/2025 order but was not. <Resident 10> Review of the revised 07/13/2025 Nutritional Risk CP showed Resident 10 had the potential for an altered nutrition status related to alcoholic liver cirrhosis, hypertension, and diuretic (water pill) use and instructed staff to monitor, record, and report to the physician any weight loss greater than five % (Percent) in one month, 7.5 % in three months, and 10 % in six months. Review of Resident 10's Order Summary showed a 04/04/2024 physician's order directing staff to obtain and document the resident's weight weekly every Wednesday. Record review showed that the last documented weight for Resident 10 was obtained on 05/13/2026. Review of April 2026 and May 2026 MARs showed weights documented on 04/22/2026, 04/13/2026 and 05/13/2026. In an interview and record review on 06/05/2026 at 10:17 AM, Staff O (Dietitian) stated the last nutritional assessment completed for Resident 10 was the quarterly assessment dated [DATE]. Staff O stated they expected nursing staff to follow physician's orders for weekly weights. Staff O reviewed Resident 10's health record and confirmed Resident 10's weights were not obtained as ordered. In an interview and record review on 06/05/2026 at 10:53 AM, Staff B stated staff were expected to follow and implement the physician's orders. Staff B reviewed Resident 10's health record and confirmed the order for weekly weights was not followed. <Obsolete Orders> <Resident 29> According to the 03/27/2026 Quarterly MDS, Resident 29 had diagnoses including high blood pressure, a history of stroke, and an enlarged heart. The MDS showed Resident 29 took an antiplatelet medication but no anticoagulant medication during the assessment period. Review of the order summary showed Resident had a 1/12/2024 order for an antiplatelet medication, and a no anticoagulant orders. The orders included a 11/04/2024 order to monitor for adverse side effects of an anticoagulant medication. In an interview on 06/05/2026 at 9:33 AM, Staff B stated Resident 29 switched from an anticoagulant medication to an antiplatelet medication. Staff B stated when the anticoagulant medication was discontinued, the anticoagulant medication adverse side effect monitoring should have been but was not discontinued. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii)(6)(b)(i).

Based on interview and record review, the facility failed to ensure and designate a qualified staff person to serve as the Infection Preventionist (IP) and that the IP physically worked onsite in the facility at least part time hours as determined by the Facility Assessment. This failure placed residents at risk for unmet infection control issues and prevented a lack of over site of the facility staff's infection control practices. Findings included . Upon entrance to the facility on [DATE] Staff B (Director of Nursing) stated Staff D (Registered Nurse) was the facility's IP. Staff B provided Staff D's Certificate of Training from the Centers for Disease Control Nursing Home Infection Preventionist Training Course of 19.3 hours completed on 12/14/2020. In an interview on 03/04/2025 at 9:00 AM, Staff B stated Staff D was working as an IP offsite. Staff B stated Staff D did not work physically in the facility at least 20 hours a week according to the facility census, they came to the facility sometimes and reviewed infection control issues. Review of the facility's 08/28/2024 Facility Assessment showed the facility did not assess or determine the amount of time the facility required an IP to fulfill their roll based on resident census and need. The Facility Assessment showed services the facility offered related to infection control included identification of infection, standard/transmission based precautions, and prevention of infection but did not determine the amount of time the IP required in order to ensure residents received these services as offered by the facility. In an interview on 03/04/2025 at 9:07 AM, Staff A (Administrator) stated Staff D worked as an IP offsite and came to the facility on ce a month. Staff A stated the last time Staff D was in the facility was 02/17/2025 for eight hours to review infection control issues. Staff A stated they were aware of the requirement of a qualified staff person to serve as an IP must physically work onsite in the facility at least for 20 hours a week according to the facility census, but they did not have one. Refer to F881, Antibiotic Stewardship. REFERENCE: WAC 388-97-1320(1)(a).

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) provided at least eight hours of direct care supervision per day for 5 of 31 days reviewed. This failure placed residents at risk for delay in resident assessments, identification of changes in condition, provision of care and services outside the scope of practice of the Licensed Practical Nurse (LPN), and unmet care needs. Findings included . Review of the facility's Daily Nurse Staff Documentation showed on five days (02/02/2025, 02/08/2025, 02/09/2025, 02/15/2025, and 02/16/2025 - on Saturdays and Sundays) from 01/27/2025 through 02/26/2025 there was no RN on site for eight hours as required by federal regulations. In an interview on 03/04/2025 at 11:21 AM, Staff I (Staffing Coordinator) stated they were responsible for scheduling daily nursing staff. Staff I stated when staff called out, they were responsible for finding a substitute. Staff I stated they started with in-house staffing resources who were off on that day. Staff I stated call outs were most common on the weekends. In an interview of 03/05/2025 at 2:08 PM, Staff H (LPN) stated the facility had RNs and LPNs to work on the floor daily all three shifts and over the weekends. Sometimes, there were call outs and the staffing coordinator was responsible to find another RN or LPN to fill in. Staff H stated their Director of Nursing worked on the floor to cover the shift for any call outs at times. Staff H stated on the weekend, the facility depended on the on-call nurse. If the on-call nurse for that weekend did not hold an RN license, there was no opportunity to fulfill the eight-hour RN requirement. In an interview on 03/05/2025 at 2:35 PM, Staff B (Director of Nursing) stated they were aware the facility did not have RN coverage over the weekend at times. Staff B stated it was hard to fulfill the RN requirement and acknowledged the weekends when the facility failed to meet the eight-hour requirement. REFERENCE: WAC 388-97-1080 (3)(a).

Based on interview and record review, the facility failed to thoroughly investigate and resolve grievances identified through a resident council meeting or provide a grievance log entry for 3 (Residents 14, 39, & 24) of 4 sample residents reviewed and 1 (Resident 35) supplemental resident, reviewed for grievances. The failure to thoroughly investigate a grievance and either resolve the resident grievance timely or provide an explanation the grievance could not be resolved placed residents at risk for frustration and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 2025 Resident and Family Grievances policy, the facility would make prompt efforts to resolve resident or family grievances. The facility would acknowledge a complaint or grievance and actively work towards a resolution. <Resident Council Minutes> The 12/30/2024 Resident Council Minutes included an Old Business section that included a resident concern regarding the ceiling in room North 3. A resident asked when it would be fixed. These Minutes' New Business section showed residents asked about the possibility of better bed mattresses during the meeting. The 01/22/2025 Resident Council Minutes showed Resident 35 attended the meeting. These Minutes showed Resident 35 asked about the possibility of implementing an air mattress during the meeting. The Minute's New Business section also showed residents brought up concerns with aides turning off call lights without providing care, residents requesting water be offered every shift, coffee with every meal, and Resident 24 asked about their incontinence pads. Review of the 02/18/2025 Resident Council Minutes under New Business showed Resident 35 still had questions about getting a better mattress. The Minutes showed Resident 39 was missing a pair of black leggings In an interview on 03/05/2025 at 1:00 PM Staff R (Activities Supervisor) stated they facilitated the monthly Resident Council meetings. Staff R stated after each meeting, they reviewed the Minutes, divvied up the concerns that came up by facility department, and presented the concerns to the appropriate department. Staff R stated they reviewed the Old Business at the beginning of each meeting and if residents remained dissatisfied, they moved the item down to New Business. In an interview on 03/05/2025 at 11:40 AM, Resident 35 stated they had a concern related to their mattress. Resident 35 stated they asked repeatedly for an air mattress since admission but did not know if they would be able to get one and were not informed if there was a reason they could not have one. In an interview on 03/05/2025 at 1:25 PM Staff B (Director of Nursing) stated because Resident 35 did not have an appropriate condition such as a risk for skin breakdown, the resident was not eligible for an air mattress. Staff B stated they discussed the matter with Resident 35 when they admitted but did not discuss it further. Staff B stated they were not informed of Resident 35's repeated requests at Resident Council meetings. Staff B stated they, Staff A (Administrator), and Staff R all played a role in notifying residents on the outcome of grievances. <Grievance Log> Review of the facility's Grievance Log from 09/01/2024 through 02/28/2024 showed nothing logged related to Resident 35's repeated concern with an air mattress. The logs showed a 10/21/2024 entry for Resident 14 related to environmental services. The November 2024 Grievance Log listed 13 individual grievances. Of these 13 grievances, there were five grievances logged on 11/26/2024 or later, and none were assigned to a staff member to investigate and none of the five were concluded. The December 2024 Grievance Log listed 11 individual grievances. Of these 11 grievances only one was assigned to a staff member to investigate. For the 11 grievances on the log, none were concluded. The January 2025 Grievance Log listed 11 grievances. Of these 11 grievances, none were assigned to a staff member to investigate. For the 11 grievances on the log, none were concluded. The February 2025 Grievance Log listed five grievances. These grievances did not include Resident 39's concern regarding their missing black leggings. <January 2025 Grievance Forms> Review of the nine available individual grievance forms related to the 11 logged January 2024 grievances showed on each form: no investigator was assigned, no follow up was documented, no resolution date was added, no department assigned, no grievance official's signature was added, no indication was present showing the resident's representative was notified as necessary. Only four forms had an investigator assigned, and only three forms included a follow-up. These three form were signed by their investigators but did not show the date the grievance was resolved. <Resident 14> Review of the 10/21/2024 grievance form showed Resident 14 complained a housekeeper bumped a drawer in their room causing damage to a charging station, two laptop computers, and a tablet computer. The form showed the charging station was replaced, one laptop was easily fixed once it could be charged, and the other laptop and the tablet would be repaired even though unable to substantiate . The grievance form included an attestation for the replacement charger signed by Resident 14 on 11/25/2024. In an interview on 03/05/2025 at 11:20 AM Resident 14 stated their laptop and tablets were not fixed. Resident 14 stated they did not receive much feedback on the status of their broken electronic items, and added they felt the facility kept them out of the loop. Resident 14 stated it was over a month since the facility provided an update. <Resident 39> In an interview on 03/05/2025 at 10:35 AM Resident 39 stated there was no resolution to their missing black leggings. Resident 39 stated they are in process, I guess. In an interview on 03/05/2025 at 2:05 PM Staff A stated the outcomes of grievance investigations should be documented on the grievance form. Staff A stated any explanation to a resident relating to the resolution of, or the facility's inability to resolve a grievance would be documented on the grievance form. Related to the incomplete Grievance Logs from 11/26/2024 through 01/31/2025 and incomplete grievance forms from January 2025, Staff A stated the facility identified at the end of January 2025 that there was a breakdown in the grievance process following a change in staff responsibilities. Staff A stated both the logs, and the forms should be complete. Staff A stated the facility needed to do a better job of explaining to residents why they could not resolve a grievance to the residents' satisfaction once it was concluded that was the case. REFERENCE: WAC 388-97-0460.

Based on observation, interview, and record review the facility failed to ensure planned breakout menus were followed during meal service and 5 (Resident 53, 25, 30, 40, & 20) residents with specialized diets were provided meals that were in alignment with their prescribed diets. These failures placed residents at risk for less than adequate nutritional intake, consuming meal portion sizes and calories other than as planned by a Registered Dietician (RD), and unmet nutritional needs. Findings included . <Facility Policy> Review of the facility's 2023 Menus and Adequate Nutrition policy showed menus were developed and prepared to meet residents choices including their nutritional, religious, cultural, and ethnic needs. This policy showed menus would be followed as posted and the facility would ensure the menus met the nutritional needs of residents. Review of the facility's 02/28/2025 Week 3 breakout menu showed the facility was serving Panko crusted fish with zucchini and tomatoes for lunch. This menu showed residents on large portion diets would receive 1 and 1/2 pieces of the fish. Review of the facility's 03/03/2025 Week 3 breakout menu showed the facility was serving sausage patties for breakfast. This menu showed residents on large portion diets would receive 2 sausage patties. <Resident 53> According to a 01/31/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 53 had multiple medically complex diagnoses including anemia (condition of not having enough protein in the cells to carry oxygen through the body), heart failure, and a progressive movement disorder disease. This MDS showed Resident 53 was on a therapeutic diet. Review of an 08/10/2024 nutritional status Care Area Assessment showed Resident 53 was at risk for weight fluctuations and staff would proceed to the Care Plan (CP) to assure the facility meets the resident's nutritional needs while preventing dehydration and reducing risk of weight loss. Review of Resident 53's nutritional risk CP showed the resident had the potential for altered nutrition and/or hydration status related to their diagnoses and gave directions to staff to provide and serve the diet as ordered. According to a 01/31/2025 quarterly nutrition assessment progress note completed by the RD, Resident 53 was to continue receiving large protein portions as an intervention for resident's recent weight loss. Review of Resident 53's tray card showed they were on a regular diet with large protein portions and cut up meats. Observations on 02/28/2025 at 12:20 PM showed Resident 53 received their lunch tray. On the tray was a tray card that said the resident was to receive large portions of proteins. On Resident 53's tray was one piece of plain fish, not Panko crusted fish or large portions as directed on the menu. Observations on 03/03/2025 at 8:11 AM showed staff delivering a breakfast tray to Resident 53. This tray included only one cut up sausage patty, instead of large portions as directed. Observations on 03/03/2025 at 12:19 PM showed staff delivering a lunch tray to Resident 53. This tray only had one whole piece of meatloaf, rather than the large portions cut up as directed on the breakout menu. <Resident 25> According to an 11/27/2024 Admission MDS, Resident 25 had multiple medically complex diagnoses including heart failure, pressure wounds, and obesity. This MDS showed Resident 25 had clear speech with no memory impairment and was on a therapeutic diet. Review of Resident 25's tray card showed the resident was on a regular diet, no added salt, and was to receive double protein portions. This tray card listed Resident 25's dislikes which included bacon and tomato. In an interview on 02/26/2025 at 1:25 PM, Resident 25 stated they were frustrated with the kitchen service. Resident 25 stated they do not eat pork and reported they kept getting pork as well as other things they disliked from the kitchen. Resident stated, it just happened a couple days ago, I was served pizza with bacon on it. Observations on 02/28/2025 at 11:28 AM showed Resident 25 received their lunch tray. On the tray was one piece of plain fish, not Panko crusted fish or double portions as directed on the tray card. Resident 25 was also served zucchini with tomatoes when their dislikes listed tomato. The tray also included a packet of salt and pepper, rather than the no added salt directions on Resident 25's meal tray card. Observation of the meal service tray line on 03/04/2025 at 12:07 PM showed kitchen staff placed a salt packet on Resident 25's tray. Review of the tray card showed the resident was not to receive added salt on their meals. In an interview on 03/05/2025 at 2:56 PM, Staff B (Director of Nursing) stated it was their expectation the menu was followed by staff to keep a resident's nutritional status stable. 46479 Review of the facility's 03/04/2025 Week 4 breakout menu showed the facility was serving meatloaf and mashed potatoes with gravy for lunch. This menu specified that a large portion of meat loaf was 4 ounces (oz) and large portion mashed potatoes was equal to a size #16 scoop. Observation of the lunch service tray line on 03/04/2025 at 12:07 PM showed kitchen staff preparing to plate the lunch meal for residents. The mashed potatoes on the steam table had a gray handled scoop staff used to put the potatoes on the resident's plates. The meatloaf was sliced in a variety of sizes and thickness and contained a spatula for serving. <Resident 30> Observation on 03/04/2025 at 12:07 PM showed kitchen staff prepping Resident 30's lunch tray. Review of Resident 30's tray card showed a diet order of no added salt. Staff placed a salt packet on Resident 30's tray. <Resident 40> Observation on 03/04/2025 at 12:12 PM, Staff O (Kitchen Cook) was plating Resident 40's lunch. Resident 40's tray card showed the resident was on a regular diet with large portions. Staff O placed one slice of meatloaf and one scoop of mashed potatoes using the gray handled scoop. A different scoop was not used for large portions as directed by the breakout menu. <Resident 20> Observation on 03/04/2025 at 12:29 PM showed Staff O preparing Resident 20's lunch plate. Staff O placed one slice of meatloaf on Resident 20's plate. Review of Resident 20's tray card showed the resident was to receive large protein portions. In an interview on 03/04/2025 at 1:36 PM, Staff N (Dietary Supervisor) stated it was very important for kitchen staff to follow the menu. Staff N stated residents had expectations of what they were receiving for meals and it was important they received diets as ordered with the right portion sizes for proper nutrition. Staff N confirmed Resident 30 and Resident 25 should not receive salt packets on their trays. Staff N stated large portions meant residents were supposed to get double the amount of food. Staff N was unaware about the scoop sizes and what size kitchen staff should use based on diet orders. In an interview on 03/05/2025 at 1:05 PM, Staff P (RD) stated not following the menu could impact resident nutrition calculations if residents received too much or too little food. Staff P stated they expected kitchen staff to follow menus and use stated scoop sizes as identified in the breakout menu. REFERENCE: WAC 388-97-1160(1)(a)(b).

Based on observation, interview, and record review the facility failed to ensure residents received and/or participated in care conferences for 3 (Residents 23, 58, & 20) of 17 residents reviewed and failed to ensure Care Plans (CP) were updated and/or revised to reflect person-centered care for 5 (Residents 7, 25, 53, 8, & 58) of 17 sample residents. These failures left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 2024 Care Planning - Resident Participation policy, the facility would discuss the resident's plan of care with the resident and/or representative at regularly scheduled care conferences. The facility would obtain a signature from the resident and/or representative after discussion or viewing the CP. According to the facility's 2025 Comprehensive Care Plans policy, the facility would develop and implement a comprehensive, person-centered CP for each resident that included measurable objectives and timeframes. The comprehensive CP would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS - an assessment tool) assessment. <Care Conference> <Resident 23> According to a 12/06/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 23 admitted to the facility on [DATE], had clear speech, made self-understood, and understood others. In an interview on 02/27/2025 at 11:23 PM, Resident 23 stated they felt staff did not communicate with them about their care or goals. Resident 23 stated they did not have any care conferences since their admission. Review of Resident 23's records showed the only documented care conference was on 09/05/2024, six months previously. <Resident 58> According to a 02/06/2025 Admission MDS, Resident 58 was admitted to the facility on [DATE] with multiple medically complex diagnoses including stroke, heart failure, and end stage kidney disease. Review of Resident 58's records showed no documentation a care conference was completed since admission on 01/30/2025, almost two months previously. In an interview on 03/05/2025 at 1:37 PM, Staff C (Social Services Director) stated care conferences were important to establish care, make discharge plans, and resolve any frustrations and/or barriers to care a resident was experiencing. Staff C stated care conferences should be completed within 72 hours of admission, quarterly, and as needed with any significant changes. Staff C stated if a care conference was completed, it would be documented in the resident's records. Staff C reviewed Resident 23 and Resident 58's records and was unable to find the residents had documentation showing a care conference was completed since their admission to the facility. <Resident 20> According to the 01/03/2025 Annual MDS, Resident 20 was understood and could understand others and had minimal cognitive impairment. This MDS showed Resident 20 had diagnoses including high blood pressure, kidney disease, diabetes, and depression. In an interview on 02/27/2025 at 11:26 AM, Resident 20 stated they only had one care conference. Record review showed Resident 20 had a quarterly care conference on 07/15/2024. Resident 20 did not have another care conference until 01/14/2025. In an interview on 03/05/2025 at 1:43 PM, Staff B (Director of Nursing) stated care conferences included the social worker, nursing staff, activities, dietary, and therapy. Staff B stated they expected care conferences to be held quarterly for the residents. <Care Plan Revision> <Resident 7> According to a 02/05/2025 Admission MDS Resident 7 had multiple medically complex diagnoses including a traumatic spinal cord injury with paralysis (inability to move some or all of your body), and pressure ulcers. This MDS showed Resident 7 did not walk or transfer out of bed during the assessment period. Review of a revised 02/07/2025 Activities of Daily Living (ADL) CP showed Resident 7 was at risk for altered ADLs and required, from weight bearing to non-weight bearing assistance. Varies from independent to supervised level and partial to substantial assistance on ADL. The interventions for this CP were for mobility devices as applicable for transfers, gait and locomotion in facility, and to provide assistance with ADLs as indicated. There were no directions to care staff to identify what those mobility devices were or what the level of assistance was required for Resident 7's ADLs. In an interview on 03/05/2025 at 1:19 PM, Staff Q (Certified Nursing Assistant) stated they utilized a resident's CP to determine what care a resident required. Staff Q stated Resident 7 required a two person assist and used a mechanical lift for transfers. Staff Q reviewed Resident 7's CP and stated they were unable to find directions to staff on the resident's care needs. In an interview on 03/05/2025 at 2:56 PM, Staff B stated it was their expectation CPs be updated and revised to reflect a resident's current conditions. Staff B stated Resident 7's CP should indicate the level of care for staff to provide for transfers. <Resident 25> According to an 11/27/2025 Admission MDS, Resident 25 had no broken natural teeth. In an observation on 02/26/2025 at 1:37 PM Resident 25 showed they had broken front upper and lower teeth since and stated they have been broken since before their admission. In an interview on 02/28/2025 at 11:20 AM, Staff E (Licensed Practical Nurse) stated they were aware that Resident 25's teeth were broken since admission. Review of an 11/20/2024 ADL CP showed interventions for: Oral Care: The resident has own teeth, upper/lower dentures, broken teeth, decayed teeth, sore gums, bridgework. This intervention was not revised or individualized to identify which concerns were applicable for Resident 25. In an interview on 03/05/2025 at 2:56 PM, Staff B stated Resident 25's CP should have been updated and individualized to reflect the resident's broken teeth identified by staff. <Resident 53> According to a 01/31/2025 Quarterly MDS, Resident 53 had a progressive neurological condition and heart failure. This MDS showed Resident 53 required set up assistance from staff for eating and was on a therapeutic diet. Review of an 08/25/2024 allergy CP showed Resident 53 was at risk for allergic reaction due to drug allergy to (enter/specify allergy) and medication allergy to (enter/specify allergy). This CP was not revised to reflect the individualized allergies for Resident 53. In an interview on 03/05/2025 at 2:56 PM, Staff B stated Resident 53's CP should be revised to specify what allergies the resident had. <Resident 58> According to a 02/06/2025 Admission MDS, Resident 58 was admitted to the facility on [DATE] with multiple medically complex diagnoses including stroke, heart failure, and end stage kidney disease and required a feeding tube for nutritional support. Review of Resident 58's physician orders showed a 02/21/2025 diet order for the resident to receive Nothing By Mouth (NPO). Review of a 01/30/2025 dehydration CP showed interventions directing staff to offer fluids as tolerated or as indicated per diet order. In an interview on 03/05/2025 at 2:56 PM, Staff B stated the intervention indicated on Resident 58's dehydration CP needed to be updated and revised to reflect the resident's NPO status. 45941 <Resident 8> According to the 12/25/2024 Annual MDS, Resident 8 admitted to the facility on [DATE], was assessed as cognitively impaired, and required one person assistance with personal hygiene. The MDS showed Resident 8 had indwelling catheter (a thin tube inserted into the bladder to drain urine) and was always incontinent of bowel. Review of a 12/13/2023 ADL self-care deficit CP showed Resident 8 was incontinent of both bowel and bladder; wore incontinent briefs and needed one-to-two-person assistance with care. Review of Resident 8's March 2025 physician orders showed Resident 8 had an indwelling catheter and staff were directed to provide catheter care every shift. Observations on 02/26/2025 at 9:08 AM, on 02/28/2025 at 12:35 PM, and on 03/03/2025 at 11:02 AM showed Resident 8 had an indwelling catheter for bladder needs. In an interview on 03/03/2025 at 9:37 AM, Staff H (Licensed Practical Nurse) stated Resident 8 had indwelling catheter and was incontinent of bowel. In an interview on 03/05/2025 at 10:45 AM, Staff B stated Resident 8 had an indwelling catheter. Staff B reviewed Resident 8's CP and stated the CP was not updated to show Resident 8's status. Staff B stated the CP should be updated but it was not. 46479 REFERENCE: WAC 388-97-1020(2)(c)(d), (2)(f), (4)(b).

Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL) related to cleanliness and grooming for 6 (Residents 8, 22, 41, 37, 27, & 55) of 17 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving, bathing, and nail care placed the residents at risk for poor hygiene, unwanted long facial hair, embarrassment, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's 08/2024 ADLs policy, a resident who was unable to carry out ADLs would receive the necessary services to maintain good grooming, personal and oral hygiene. <Resident 8> According to the 12/25/2024 Annual Minimum Data Set (MDS - an assessment tool), Resident 8 had impairment to their right arm and both legs, was assessed as cognitively impaired, and required one person assistance with personal hygiene. The MDS showed Resident 8 had no behavior of rejecting care during the assessment period. Observations on 02/26/2025 at 10:48 AM and on 02/27/2025 at 9:55 AM, showed Resident 8 was in their wheelchair in the dining area. Resident 8 was not shaved and had long fingernails. Observation on 03/03/2025 at 10:09 AM showed Resident 8 was in their wheelchair in the dining room watching television. Resident 8 had long fingernails. According to the 11/03/2020 ADL self-care performance deficit Care Plan (CP), Resident 8 required one-person extensive assistance with personal hygiene and Resident 8 was dependent on staff for bathing. In an interview on 03/05/2025 at 10:42 AM, Staff B (Director of Nursing) stated they expected staff to check the resident's CPs related to ADLs and provide assistance as needed. If the resident refused, staff should document the refusals. Staff B stated staff should follow the CP and provide assistance to Resident 8 with shaving and clip their fingernails on shower days, but they did not. <Resident 22> According to the 02/05/2025 Quarterly MDS, Resident 22 had right sided weakness, was assessed as cognitively intact, and required one person assistance with personal hygiene. The MDS showed Resident 22 had no behavior of rejecting care during assessment period. Observations on 02/27/2025 at 10:04 AM, on 02/28/2025 at 9:13 AM, and on 03/03/2025 at 8:30 AM showed Resident 22 was lying in bed, was not shaved, had long fingernails, and long toenails. Observation and interview on 03/03/2025 at 10:23 AM showed Resident 22 was not shaved and had long fingernails. Resident 22 stated they could not shave themselves or clip their own nails. Resident 22 stated staff should help them with shaving and nail care during showers, but they did not. According to the 05/31/2023 ADL self-care performance deficit CP, Resident 22 required one-person extensive assistance with personal hygiene and bathing. In an interview on 03/05/2025 at 10:42 AM, Staff B stated they expected staff to check the resident's CPs related to ADLs and provide assistance as needed. Staff B stated Resident 22 had weakness to the right side of their body and required assistance from staff with shaving and nail care. Staff B stated staff should follow the CP and provide assistance to Resident 22 with shaving, trimming fingernails, and toenails on shower days, but they did not. <Resident 41> According to the 01/29/2025 Annual MDS, Resident 41 had medical conditions including a stroke (brain injury) resulting in paralysis (loss of function) to one half of their body and required one person extensive assistance with personal hygiene. The MDS showed Resident 41 was assessed as cognitively impaired and did not reject care during the assessment period. Observation on 02/27/2025 at 9:36 AM showed Resident 41 lying in bed, was not shaved, and had long fingernails. Observation on 02/28/2025 at 9:11 AM showed Resident 41 had long fingernails. According to the 05/31/2023 ADL self-care performance deficit revised CP, Resident 41 required one-person extensive assistance with personal hygiene. The CP instructed staff to offer shaving and nail care to Resident 41 during showers or per Resident 41's preferences. In an interview on 03/05/2025 at 10:42 AM, Staff B stated they expected staff to check the resident's CPs related to ADLs and provide assistance as needed. Staff B stated staff should follow the CP and provide assistance to Resident 41 with shaving and trimming fingernails on shower days, but they did not. 46479 <Resident 27> According to the 02/24/2025 Annual MDS, Resident 27 had severe cognitive impairment and had diagnoses including a progressive memory loss disorder, depression, and anxiety. The MDS showed Resident 27 did not have behaviors or reject care during the assessment period. Review of Resident 27's 09/14/2024 revised ADL self-care performance deficit CP showed the resident often refused bathing/showering assistance. This CP showed Resident 27 preferred showers twice weekly and required assistance from one staff member for showering. Observation on 02/26/2025 at 10:03 AM showed Resident 27 lying in bed. Resident 27 had several long gray and black hairs on their upper lip and chin. Similar observations were made on 02/28/2025 at 1:05 PM and 03/04/2025 at 2:24 PM. Review of Resident 27's shower task documentation and shower skin sheets on 03/04/2025 showed Resident 27 did not have a shower since 02/19/2025. This task documentation showed staff only documented two instances of Resident 27 refusing care on 02/14/2025 and 02/21/2025. In an observation and interview on 03/04/2025 at 2:38 PM, Staff B confirmed Resident 27 had long hairs to their upper lip and chin. <Resident 55> According to the 02/12/2025 Admission MDS, Resident 55 was moderately impaired for daily decision making and required supervision. This MDS showed Resident 55 had weakness/paralysis to one side of their body and required assistance for personal care. Review of Resident 55's 02/05/2025 ADL CP directed staff to provide bathing assistance to the resident twice weekly. This CP directed staff to offer nail care during showers. Review of Resident 55's February 2025 treatment administration record showed a 02/05/2025 order directing licensed nurses to perform/offer nail care to Resident 55 each week. This record showed staff documented on 02/26/2025 Resident 55 did not need nail care. Observation on 02/28/2025 showed Resident 55 with long, broken, and dirty fingernails on their right hand. Review of Resident 55's 03/02/2025 skin monitoring shower review form showed the resident received a shower that day. The form included an area for the shower aid to document whether the resident needed nail care and if the resident required a nurse to perform nail care. Staff left this portion of the form blank. Observations on 03/05/2025 showed Resident 55's left hand with long, dirty fingernails. <Resident 37> According to the 02/14/2025 Annual MDS, Resident 37 had no cognitive impairment and had diagnoses including a stroke, end stage kidney disease, and a limb amputation. The MDS showed Resident 37 did not reject care during the look back period. Review of Resident 37's 01/08/2024 revised ADL self-care performance deficit CP showed the resident preferred two showers per week and was totally dependent on staff for bathing assistance. Review of Resident 37's January 2025 tasks report showed the resident preferred one shower per week. This report showed no showers were documented for the resident for the month of January. This report showed staff documented Resident 37 did not have any refusals of care during the month. Review of Resident 37's skin monitoring shower review form showed the resident received one shower for the month of January, on 01/19/2025. There were no shower refusal forms for the month of January. Review of Resident 37's February 2025 tasks report showed the resident preferred one shower per week. The report showed no showers were documented for the resident for the month of February. This report showed staff documented Resident 37 did not have any refusals of care during the month. Review of Resident 37's February skin monitoring shower review form showed the resident received two showers in February, one on 02/26/2025 and on 02/23/2025. There were no shower refusal forms for the month of February. In an interview on 03/05/2025 at 1:49 PM, Staff B stated shower documentation was an issue. Staff B stated it was their expectation shower staff offered to shave and provide nail care to all resident on their shower days. Staff B stated they expected staff to document in the record if a resident refused to be showered/bathed or refused nail care and shaving. Staff B stated if a resident refused, the facility process was to have another staff person approach the resident later. If the resident continued to refuse, Staff B would check in with the resident to see if there was an issue that needed resolving. REFERENCE: WAC 388-97-1060(2)(c).

Based on observation, interview, and record review the facility failed to ensure 4 of 9 (Residents 49, 14, 7, & 25) residents reviewed for Pressure Ulcers (PU - injury to the skin and underlying tissue due to prolonged pressure), received necessary care and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure to timely monitor, assess, implement wound provider recommendations, and preventative skin measures placed all resident's at risk for deterioration in skin condition(s), pain, and diminished quality of life. Findings included . Review of the 2024 facility Pressure Injury Prevention and Management policy, showed the facility would use a systematic approach for PU prevention and management. This included prompt assessment and treatment of the PU, interventions to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as necessary. The policy showed the Registered Nurse (RN) or designee would review all relevant documentation regarding skin assessments, PU risks, progression towards healing, and compliance at least once weekly, and document a summary of findings in the resident's medical record. The attending physician would be notified of a new PU and any complications with the wound. The policy showed a Care Plan (CP) would be developed that included relevant goals for prevention and management of PU's with appropriate interventions. <Resident 49> Review of a 12/10/2024 Admission Minimum Data Set (MDS - an assessment tool), showed Resident 49 was able to make needs known and required assistance with decision making. The MDS showed Resident 49 was frequently incontinent of bowel and bladder, and had no behaviors of rejecting care. The MDS showed Resident 49 was at risk for PU development, had no PU's, and was dependent on staff for toileting, bathing, and required moderate assistance with bed mobility. The MDS showed Resident 49 had an infectious lung disease, chronic lung disease, memory loss disorder, chronic pain, muscle weakness, malnutrition, and reduced mobility. Review of a 12/03/2024 Braden Scale (a risk assessment tool used to identify risk of developing a PU), showed Resident 49 was assessed to be at risk for developing a PU. Review of Resident 49's CP, initiated 12/03/2024, showed no CP in place with interventions for the resident's high risk of PU development or actual PU that developed on 02/10/2025. Review of 02/10/2025 progress note showed Staff J (RN) documented Resident 49 was assessed with a red area to the upper left buttocks. Staff J documented that Staff B (Director of Nursing) was notified and prophylactic (preventative) treatment orders were placed. Review of Resident 49's 02/10/2025 physician's orders showed no orders placed for prophylactic treatment for Resident 49's new wound. Review of a 02/10/2025 skin evaluation showed Staff B documented Resident 49 had a Stage 1 PU (intact skin with redness usually over a bony prominence) in the middle of their buttocks (near tailbone) on the right side that was newly acquired at the facility. The PU measured 3.2 centimeters (cm) in length and 2.3 cm in width, with no drainage or pain noted. The skin evaluation showed Staff B documented a treatment dressing was ordered, turning and repositioning schedule initiated, and nutritional supplements added. Review of a skin evaluation, dated 02/17/2025, and signed off on 02/18/2025, showed Staff H (Licensed Practical Nurse - LPN) documented Resident 49 had a pressure sore to the right buttocks. The evaluation did not include measurements of the size of the PU or pain level related to the PU. Review of the February 2025 treatment administration record showed no documentation of treatment orders placed or implemented by facility staff. In an interview on 02/27/2025 at 12:00 PM, Staff B stated Resident 49 had a Stage 1 PU on their sacrum (tailbone) that was not open. Staff B stated the facility was applying a prophylactic wound dressing and cream to the area, Resident 49 had discharged the facility to another facility. In an interview on 03/12/2025 at 2:03 PM, Resident 49's Collateral Contact (CC), stated the resident arrived to the new facility on 02/18/2025, with redness and rash in their groin area, and an open area on their tailbone. In an interview on 03/13/2025 at 11:38 PM, Staff B stated they expected staff to document wound measurements and pain on the weekly wound evaluation and stated they did not include that information on the 02/17/2025 evaluation. Staff B stated Resident 49's PU was closer to the right and not on the left buttocks near the tailbone as Staff J documented. Staff B stated they did not see physicians orders placed in Resident 49's medical record for monitoring and treatment of the PU and would expect staff to put in orders as received by the physician. Staff B stated the wound and wound treatment orders should be but were not included on the transfer discharge summary. <Resident 14> Review of a 01/28/2025 Quarterly MDS showed Resident 14 was able to make needs known, was independent for decision making, and had no memory issues. The MDS showed Resident 14 had no behaviors of rejecting care, had an indwelling catheter (drains urine from the bladder into a bag), and was frequently incontinent of bowel. The MDS showed Resident 14 was at risk for PUs, had three PUs, and a diabetic foot ulcer (open area on the foot related to a blood sugar disorder). The MDS showed Resident 14 did not have a pressure relieving device for the wheelchair and the bed, and did receive PU care and applications of dressings. Resident 14 was dependent on staff for toileting, bathing, dressing, and transfers. The MDS showed Resident 14 had medically complex conditions including diabetes, heart failure, muscle weakness, and muscle wasting, Review of a 02/12/2025 Braden score showed Resident 14 was assessed to be at risk for PUs due to moist skin, inadequate nutrition, and the inability to walk. Review of a wound CP, revised 02/19/2025, showed Resident 14 had five wounds including a diabetic foot ulcer to the right foot, a Stage 4 PU (extends to muscle, tendon, or bone) to the right ankle, a surgical open area to the tailbone, a Stage 3 PU (full thickness tissue loss with no muscle, tendon, or bone exposed) to the back of the left thigh, and a Stage 3 PU to the right buttocks. The CP directed staff to assess, record, and document wound healing by measuring the length, width, and depth of the wound weekly. The CP directed staff to float the right foot off the bed surface to provide pressure relief on the wound by using off loading boots or pillows. Review of Resident 14's medical record, showed Resident 14 was last seen by a wound specialist at the facility on 10/24/2024. Review of weekly skin and wound evaluation documentation showed Resident 49's multiple wounds were not measured on 10/31/2024, 11/08/2024, 11/23/2024, 11/30/2024, 12/07/2024, 12/11/2024, 12/18/2024, 12/25/2024, 01/01/2025, 01/08/2025, 01/22/2025, 02/05/2025, 02/12/2025, 02/19/2025, 02/26/2025, and 03/05/2025. Review of wound clinic documents, dated 11/19/2024, showed Resident 14 was seen by a wound provider for a diabetic foot ulcer on the right foot, a diabetic ulcer of the right ankle, a stage 4 PU to the sacrum, a Stage 3 PU to the left buttocks, and a Stage 3 PU to the right buttocks. The documentation included measurements for 3 out of 5 wounds. Review of wound clinic documents, dated 12/17/2024, and faxed to the facility on [DATE], showed pictures of wounds with a measuring tape against the wound. The pictures were not clear, and wound measurements were unable to be determined by the quality of the faxed pictures. The wound clinic documents showed, the provider recommended staff should check Resident 14's feet daily, off load pressure by elevating their feet when at rest, appropriate footwear to be worn if resident worked with therapy, such as diabetic shoes, frequent repositioning/turning when in bed, elevate heels, avoid prolonged time in the wheelchair, and appropriate low airloss mattress (distributes body weight over a broad surface area to help prevent skin breakdown). Review of a 01/17/2025 wound clinic documentation showed similar findings with blurry wound images, wound measurements not visible, and the same provider recommendations. During an observation and interview on 02/27/2025 at 2:37 PM, Resident 14 was observed in their wheelchair, on their computer. Resident 14 was wearing gym shoes and observations of their bed showed no air loss mattress was in place. Resident 14 stated they had multiple open wounds on their bottom, two wounds on their right foot, and stated their wounds were becoming progressively worse. Resident 14 stated they were wearing diabetic gym shoes that they purchased. In an interview on 03/13/2025 at 9:52 AM, Resident 14's CC stated Resident 14's wound dressings were saturated upon arrival to the clinic. The CC stated three of the four wounds worsened by measuring bigger in size. The CC stated one of the wounds fluctuated in size but was to be expected due to the location of the wound and contributing factors of moisture. During an interview on 03/13/2025 at 11:08 AM, Staff B stated when a resident was found with a wound, they expected staff to notify them, the provider, and responsible party. The staff should complete an incident report, measure and assess the wound weekly, obtain and implement treatment orders, and notify the provider of any wound changes. Staff B stated they would expect Resident 14's wounds to be assessed and measured weekly. Staff B stated when a resident was not seen by the wound provider at the facility, nursing staff were responsible for measuring and documenting the wounds weekly. Staff B stated they did not see documentation that the wounds were measured weekly as expected. Staff B stated they were not aware of the wound providers recommendations as they were faxed to the facility after the appointment and scanned in the medical record. Staff B stated wound provider recommendations were not carried out as they would expect, and stated Resident 14 did not have an air mattress but the facility did encourage off loading of the right foot, frequent repositioning and limited time in the wheelchair. 43642 <Resident 7> According to a 02/05/2025 Admission MDS, Resident 7 admitted to the facility on [DATE] with multiple medically complex diagnoses including PUs and a spinal cord injury resulting in loss of movement to their lower extremities. Review of a 02/24/2025 progress note by a contracted wound clinic showed Resident 7 had a left buttock PU with significant improvement and a wound VAC (a medical device that used negative pressure to promote wound healing) would be resumed. This progress note gave recommendations and instructions to adjust the wound VAC settings to 120/125 millimeters of mercury (mmHg) intermittent suction and gave additional recommendations for wound treatment until the wound VAC supplies were delivered. Review of Resident 7's physician orders showed a 02/24/2025 order for wound treatment orders to left buttock until wound VAC supplies were delivered. There were no current physician orders for the use of the wound VAC or what the settings should be once initiated. Observations on 03/04/2025 at 10:11 AM showed Resident 7 with a wound VAC machine at the bedside. This wound VAC was set to 125 mmHg. Review of Resident 7's progress notes showed no indication when the wound VAC supplies were received. In an interview on 03/05/2025 at 2:56 PM, Staff B stated nursing staff should have obtained physician orders for the wound VAC once the supplies were received prior to implementing the device. <Resident 25> According to an 11/27/2025 Admission MDS, Resident 25 was assessed by staff to be at risk for developing PUs/injuries, had PUs on admission and received PU/injury care during the assessment period. Review of Resident 25's physician orders showed the following orders from 02/28/2025 for both the upper and lower buttock wounds: staff were to cleanse the areas with saline, apply a skin prep to the surrounding area around the wound, apply a collagen sheet (a sheet of protein designed to promote wound healing), and cover with a dressing. Observations of wound care on 03/03/2025 at 11:25 AM showed Staff K (LPN) perform wound care to the upper and lower PUs of Resident 25's buttocks. Staff K did not apply the skin prep to the surrounding areas of the PUs for either wound as directed in the physician orders. Staff K used a cotton swab on a stick to insert a strip of an antiseptic dressing into the upper PU, instead of using a collagen sheet to the PU as ordered. Review of Resident 25's records showed the resident's PUs were measured by a contracted wound clinic on 01/31/2025, with no further wound measurements documented until 02/24/2025, over three weeks later. In an interview on 03/05/2025 at 2:56 PM, Staff B stated it was their expectation staff follow the physician orders for wound treatments and wounds be measured and documented weekly by staff in order to determine the progress of a wound's status. REFERENCE: WAC 388-97-1080(1)(3)(b).

Based on interview and record review, the facility failed to provide baseline Care Plans (CP) to 6 (Residents 23, 25, 7, 58, 40 & 55) of 17 residents reviewed. The failure to provide the resident and/or their representative with a summary of their baseline CP placed residents and/or their representatives at risk for not being informed of their initial plan for delivery of care and services, and placed residents at risk for unmet care needs. Findings included . <Facility Policy> Review of the facility's 2024 Baseline Care Plan policy showed the baseline CP would be developed within 48 hours of the resident's admission and include the minimum healthcare information necessary to properly care for a resident. The policy showed a written summary of the baseline CP would be provided to the resident and/or their representative in a manner and language they could understand. <Resident 23> According to a 09/10/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 23 admitted to the facility on [DATE] after a recent surgery which required skilled nursing care. In an interview on 02/27/2025 at 11:23 AM, Resident 23 stated they felt staff were not communicating with them about their care or goals. Review of Resident 23's records showed no documentation a baseline CP was provided to the resident and/or their representative as required. <Resident 25> According to an 11/27/2025 Admission MDS, Resident 25 admitted to the facility on [DATE] with multiple medically complex diagnoses including heart failure, a wound infection, and respiratory failure. Review of Resident 25's records showed no documentation a baseline CP was provided to the resident and/or their representative as required. <Resident 7> According to a 02/05/2025 Admission MDS, Resident 7 admitted to the facility on [DATE] with multiple medically complex diagnoses including pressure ulcers and a spinal cord injury resulting in loss of movement to their lower extremities. Review of Resident 7's records showed no documentation a baseline CP was provided to the resident and/or their representative as required. <Resident 58> According to a 02/06/2025 Admission MDS, Resident 58 admitted to the facility on [DATE] with multiple medically complex diagnoses including heart failure, end-stage kidney disease, and stroke. Review of Resident 58's records showed no documentation a baseline CP was provided to the resident and/or their representative as required. 46479 <Resident 40> Review of Resident 40's 01/07/2025 Quarterly MDS showed the resident admitted to the facility on [DATE] with diagnoses including paraplegia, a neurogenic bladder (impaired bladder control caused by nerve dysfunction), pressure ulcers, and a seizure disorder. Review of Resident 40's record showed no documentation that a baseline CP was initiated or provided to Resident 40 for their review. <Resident 55> Review of Resident 55's 02/12/2025 Admission MDS showed the resident admitted to the facility on [DATE] with diagnoses including an amputation, high blood pressure, inability to control their blood sugars, malnutrition, and a stroke. Review of Resident 55's record showed no documentation that a baseline CP was initiated or provided to the resident or their representative for their review. In an interview on 03/05/2025 at 2:11 PM, Staff B (Director of Nursing) stated it was not the facility's current practice to complete baseline CPs. Staff B stated they did not provide baseline CP documentation to the residents or their representatives. REFERENCE: WAC 388-97-1020(3).

Based on observation, interview, and record review the facility failed to ensure 1 of 1 resident (Resident 43) reviewed for bowel management, 1 of 1 resident (Resident 4) reviewed for Diabetes (unstable blood sugar levels) management, and 1 of 4 residents (Residents 41) reviewed for non-pressure skin management received necessary care and services in accordance with professional standards of practice for quality of care. Resident 43 experienced harm when they were administered a daily laxative incongruent with prescribing provider order, did not receive antidiarrheal medications for prolonged diarrhea, did not have a stool sample obtained for laboratory evaluation or specialized diet initiated per standing orders which resulted in daily watery stools with increased, persistent discomfort and abdominal pain that required the use of a narcotic pain medication. The failure to recognize, accurately assess, provide ongoing monitoring for prolonged diarrhea with abdominal pain, unstable blood sugar levels, and appropriately treat non-pressure skin wounds placed residents at risk for acute distress due to mismanagement of critical diagnoses, rehospitalization , infection, decreased quality of life, and potential death. Findings included . <Bowel Management> <Facility Policy> Review of the facility policy titled Standing Orders, dated 05/01/2023, showed for residents with loose watery diarrhea, the facility would obtain a stool sample and send it to the laboratory for evaluation, the resident would be placed on a BRAT (bananas, rice, applesauce, and toast) diet, and nursing staff would administer an antidiarrheal medication for persistent diarrhea. The facility's policy titled Ostomy Care, dated 2022, showed the frequency of the ostomy pouch change and the products required would be noted on the resident's Care Plan (CP). <Resident 43> According to the 10/22/2023 Admission Minimum Data Set (MDS - an assessment tool) Resident 43 showed no memory/cognitive impairment and was assessed to require extensive physical assistance from staff for bed mobility, transfers, dressing, and personal hygiene. This MDS showed Resident 43 did not exhibit rejection of care during the assessment period. This assessment showed Resident 43 had an ileostomy (an opening in the abdomen where fecal matter drained into a bag from the small intestines). Review of Resident 43's 10/09/2023 CP showed Resident 43 would have a soft formed stool every one to three days. This CP showed staff would administer and evaluate the effects of the ordered bowel medications and update Resident 43's provider with any complications or side effects. In an interview on 12/05/2023 at 10:50 AM, Resident 43 stated they had diarrhea with abdominal pain and cramping since their admission to the facility in October 2023. Resident 43 stated prior to admission, they always had soft stools in their ileostomy but never watery liquid stool like it was since staying at the facility. Resident 43 stated they reported the diarrhea and abdominal pain to nurses every day and the nurses would give them a narcotic pain medication which helped for a little bit. Resident 43 stated they required the pain medication several times a day because it would only help for a short time and then it would wear off and the abdominal pain would come back intensified. Observations and interviews on 12/07/2023 at 9:01 AM, 12/08/2023 at 8:32 AM, 12/11/2023 at 10:03 AM, and 12/12/2023 at 9:59 AM showed large amounts of watery liquid stool in Resident 43's ileostomy bag. On these same dates and times, Resident 43 stated they were having abdominal pain and intestinal cramping, so the nurse gave them the narcotic pain medication. Resident 43 stated they reported the watery stools and abdominal pain to their assigned nurse on each of these days. Resident 43 stated the nurse would bring them their medications and they would take whatever the nurse brought, including the laxative. Resident 43 stated they took whatever the nurse would bring because the nurse knew best. Review of a provider progress note dated 11/16/2023 showed Resident 43 preferred firmer stools rather than the watery stools they were experiencing. This provider note showed an order for a laxative to be given as needed, not daily as transcribed on the Physician Orders (PO). Review of a provider progress note, dated 12/07/2023, stated .last visit [the resident] expressed having diarrhea and a preference for firmer stool rather than watery in the colostomy bag. The note showed the provider instructed staff to continue holding Resident 43's stool softener, and that Resident 43's stool consistency did not change with continued complaints from Resident 43 stating they were still having watery stools and abdominal pain. The provider notes did not show any changes to Resident 43's bowel medications. The stool softener continued to be prescribed on hold, and the provider stated in the note hoping to see improvement on the next provider visit. Review of Resident 43's October 2023, November 2023, and December 2023 Medication Administration Records (MAR) showed a laxative was administered daily since the resident's admission to the facility 10/09/2023. The provider notes showed the laxative was ordered to be given as needed, (not scheduled to be given daily.) The MARs showed an order for a narcotic pain medication to be given every two hours as needed for pain. Review of the MARs showed the narcotic pain medication was administered five to seven times per day 10/09/2023 through 12/07/2023. The November 2023 MAR showed a stool softener was placed on hold on 11/22/2023 for Resident 43 and the daily laxative order remained active. Review of Resident 43's October 2023 through December 2023 PO's, the facility did not send a stool sample for Resident 43 to the laboratory for testing or place the resident on a BRAT diet as the facility policy showed they would. In an interview on 12/08/2023 at 8:46 AM Staff O (Licensed Practical Nurse - LPN) stated they should hold all laxatives and stool softeners when Resident 43 complained of diarrhea with abdominal pain and cramping, but they did not, and confirmed Resident 43 received 30ml's of the laxative daily since admission. In an interview on 12/11/2023 at 11:02 AM Staff B stated they expected staff to hold bowel medications when Resident 43 complained of loose stools and notify the provider. Staff B stated they expected staff to thoroughly assess residents and their orders, evaluate any possible cause of the pain, and report the findings with the abdominal pain to the provider. 46471 <Diabetes Management> <Resident 4> According to the facility's 11/21/2023 reporting laboratory results guidelines, the reference range for glucose (Blood Sugar - BS) level was 74-109 milligrams per deciliter (mg/dL - a unit of measurement that showed the concentration of a substance in a specific amount of fluid in the body). The 10/07/2023 Annual MDS showed Resident 4 had clear speech, was cognitively intact, and had multiple complex medical diagnoses including diabetes and respiratory failure. The MDS showed Resident 4 was on daily supplemental oxygen and was administered an injectable medication used to treat high BS level in the body six days during the assessment period. In an interview on 12/05/2023 at 9:54 AM, Resident 4 stated their BS was sometimes very high and sometimes very low. Resident 4 stated they suffered a diabetic coma (a medical emergency that required prompt medical treatment and could result in death) in the past. The revised 10/22/2023 diabetes CP showed an 11/26/2021 intervention instructing the nursing staff to monitor, document, and report any signs and symptoms of hyperglycemia (elevated BS level) and hypoglycemia (low/deficient BS levels). Review of the facility policy titled Standing Orders, dated 05/01/2023, under the hypoglycemia protocol, if a resident had a BS that was less than or equal to 40mg/dL, staff were to administer one ampoule of an injectable medication to restore the low BS level and to notify the physician immediately. Review of Resident 4's October 2023 MAR showed on 10/04/2023, Resident 4's BS was 25 mg/dL. The MAR did not show staff administered the injectable medication on 10/04/2023 and the facility did not provide any documentation to support nurses notified the physician immediately as outlined in the facility's hypoglycemia protocol. The October 2023 MAR showed an 08/15/2023 PO instructing nursing staff to notify the physician when Resident 4's BS level was above 450 mg/dL. The MAR showed that on 10/09/2023 at 12:00 PM, Resident 4's BS was 469 mg/dL and on 10/10/2023 at 12:00 PM the BS level was 528 mg/dL. Review of Resident 4's progress notes from 10/09/2023 to 10/10/2023 did not show the physician was notified regarding Resident 4's elevated BS as ordered. The facility did not provide any documentation to support nurses notified the physician as ordered. A 10/10/2023 progress note showed Resident 4 was having difficulty breathing and their oxygen level readings were low. The note showed staff called the physician, reported Resident 4's low oxygen level, and was given an order for an oral steroid (a medication used to decrease swelling and inflammation) to manage Resident 4's respiratory failure. The progress note did not show the nurse notified the physician of Resident 4's high BS reading of 528 mg/dL at the time. The October 2023 MAR showed the first dose of the steroid was administered to Resident 4 on 10/10/2023 at 4:00 PM. A 10/10/2023 nursing alert progress note showed Resident 4 was sent to the hospital at 4:47 PM due to continued low oxygen reading levels and the emergence of congestion and labored breathing. In an interview on 12/12/2023 at 10:34 AM, Staff N (Registered Nurse) stated nurses were expected to notify the physician when Resident 4's BS was outside of the reference range per order and in accordance with the facility's protocol. Staff N stated the physician notification done on 10/10/2023 should include both the high BS and the difficulty of breathing so the physician could get the total picture of Resident 4's condition. In an interview on 12/12/2023 at 11:37 AM, Staff P (Medical Director) stated older residents with diabetes had frail blood sugar control and their BS levels were usually unstable and could be difficult to manage. Staff P stated oral steroid administration was prone to increase hyperglycemia further and should be a clinical consideration. Staff P stated there was no documentation found in Resident 4's medical records that a notification to the provider was made on 10/04/2023 when Resident 4's BS was 25 mg/dL (critically low) or on 10/10/2023 when Resident 4's BS was 528 mg/dL (critically high). Staff P stated the nurses should have but did not perform the appropriate physician notification per the facility protocol and as ordered. 48010 <Non-Pressure Skin> <Facility Policy> Review of the facility policy titled, Wound Treatment Management, dated 05/01/2023, showed wound treatments would be provided in accordance with POs, including the cleansing method, type of dressing, and frequency of dressing change. <Resident 41> According to the 11/02/2023 Quarterly MDS, Resident 41 admitted to the facility on [DATE]. Resident 41 made their own decisions. Resident 41 had medically complex conditions including skin cancer behind their left ear. Review of the 07/13/2023 CP showed Resident 41 had a cancerous lesion to the left ear. Staff were to apply a medication and cover the area with a dressing on odd days and as needed. A 07/13/2023 PO instructed staff to cleanse the left ear, apply a white gauze impregnated with medication, and cover with a dressing. In an interview and observation on 12/05/2023 at 10:06 AM, Resident 41 stated they were unhappy with the wound care they were receiving. Resident 41 stated staff changed the dressing to their ear daily due to the wound bleeding onto their pillowcases. It was observed that the white gauze medicated treatment was not present and the lesion was covered in a Band-Aid, not the prescribed treatment. In an interview on 12/07/2023 at 1:00 PM, Staff M (Licensed Practical Nurse) confirmed Band-Aids were not the ordered dressings. Staff M was aware of the prescribed medication that should be applied to Resident 41's ear but could not confirm Resident 41 had the medication applied to the wound. Staff M stated PO's should be followed to ensure proper healing of wounds. Refer to F726- Competent Nursing Staff. Refer to F759 Free of Medication Errors. REFERENCE: WAC 388-97-1060(1).

Based on interview and record review, the facility failed to consistently implement care planned safety interventions for 2 of 3 residents (Residents 1 & 9) who exhibited aggressive behaviors to ensure the care planned behaviors did not escalate to verbal, physical or psychological abuse for 4 of 4 residents (Resident 7, 12, 2, 10), and the facility failed to protect 3 of 3 residents (Resident 6, 7, & 8) from potential abuse when they did not immediately remove (Staff E) from providing care to all residents after allegations of abuse and neglected were reported. These failures resulted in harm for Resident 8 who sustained an acute knee injury that required hospitalization and an increase in pain medications after being roughly handled by Staff E and harm to Resident 2 after being slapped by Resident 1. These failures placed all residents at risk for verbal, physical, and psychological abuse. Findings included . Review of the facility Abuse, Neglect and Exploitation policy, dated 04/27/2023, showed the facility would make all efforts to ensure all residents were protected from physical and psychological harm by responding immediately to protect the alleged victim, examining the alleged victim for injury or psychosocial abuse, increase supervision of the alleged victim, room or staffing changes to protect the victim from the alleged perpetrator, protection from retaliation, and provide emotional support and counseling to residents during and after the investigation. <Resident 1> Review of a 06/10/2023 Quarterly Minimum Data Set (MDS an assessment tool) showed Resident 1 was not able to make their own decisions, had adequate hearing, clear speech, and spoke a different language that required an interpreter. Resident 1 had diagnoses to include dementia and history of a brain bleed. The MDS showed Resident 1 had worsened behaviors that included verbal behaviors directed towards others, no physical behaviors towards others, and these behaviors did not put others at risk, significantly disrupt care, or intrude on the privacy or activity of other residents. Review of a psychotropic (affects behavior, mood, thoughts, and perception) medication care plan (CP), dated 05/10/2023, directed staff to monitor and document when Resident 1 had verbal and physical behaviors, with interventions to re-direct the resident, distract the resident, reduce stimulation in the environment, one on one conversation, or call family. <Resident 1 & Unidentified Residents> Review of a Nursing Progress Note (NPN), dated 07/11/2023, showed Resident 1 stood up and began yelling at a female resident in Resident 1's native language. Review of a NPN, dated 07/12/2023, showed Resident 1 was aggressive towards other females at the nurses station. The resident walked over and attempted to strike two other females residents while yelling in Resident 1's native language. Review of a 08/02/2023 NPN at 7:41 PM showed Resident 1 was observed spitting on staff and two other residents. That same night on 08/02/2023 at 7:53 PM staff reported that Resident 1 spit on them when they tried to re-direct Resident 1 who was being verbally mean to another resident. The NPN showed Resident 1 had ongoing behaviors directed towards other residents. Review of a 08/06/2023 NPN showed Resident 1 was very aggressive towards multiple residents by charging at residents with their walker while screaming at them. Staff stood in between residents but Resident 1 continued to yell at the other residents. <Resident 1 & Resident 2> Review of a 08/08/2023 NPN showed Resident 1 charged at another resident [Resident 2] who entered the lobby and Resident 1 slapped Resident 2's right arm before staff could intervene. Review of July 2023 behavior monitoring showed facility staff signed off that behaviors were monitored but the documentation did not include what behaviors were observed, how often, what interventions were used and if those interventions were effective. Similar findings were observed for August 2023 behavior monitoring, the documentation did not show what interventions were used and if those interventions were effective. <Resident 9> Review of a 08/04/2023 Quarterly MDS showed Resident 9 was able to make their own decisions, had adequate hearing, clear speech, and made themselves understood and could understand others. Resident 9 had diagnoses including depression and adrenal disease. The MDS assessed Resident 9 with no physical or verbal behaviors directed towards others. Review of a 08/28/2023 behavior CP showed Resident 9 used psychotropic medications for behaviors of verbally abusing other residents, throwing items at residents, picking out leftover food from the food carts, barking or chirping like an animal, and difficulties re-directing. The CP directed staff to monitor Resident 9 for these behaviors and evaluate the effectiveness of interventions weekly, bi-weekly, monthly, quarterly, and as needed. The CP showed when Resident 9 became agitated, staff should intervene before agitation escalates, guide resident away from the source of distress, engage calmly in conversation, and if Resident 9 was aggressive towards the staff, staff were instructed to calmly walk away, inform another caregiver of the resident's behavior, and if needed re-approach at a later time. <Resident 9 & Resident 7> Review of a 09/05/2023 activities progress note showed Resident 9 tried entering the kitchen and another resident [Resident 7] told them they could not enter that area. Resident 9 turned around and told the resident to shut up b****! and stuck their tongue out and made barking noises at Resident 7. Review of a 09/07/2023 activities progress note showed Resident 9 was heard having verbal altercations with residents at the round table (a group of residents who sit at a round table for dining and activities, Resident 7 being one of them) when the other residents told Resident 9 to shut the door, Resident 9 yelled back profanities at the residents. Review of a 09/19/2023 NPN showed Resident 9 had a verbal altercation with Resident 7, who was exiting the dining room and Resident 7 accidentally ran over Resident 9's ankle when both wheelchairs got tangled together. Review of a 09/23/2023 NPN showed Resident 9 was bothering Resident 7 in the dining room, attempted to follow Resident 7 out of the dining room, and made barking noises at the resident. Both residents ended up cursing and yelling at each other. In an interview on 09/27/2023 at 3:10 PM Resident 7 stated Resident 9 was poorly supervised by the facility staff, they wandered up and down the halls, and Resident 9 made animal noises of oinking like a pig or barking like a dog at Resident 7. Resident 7 stated Resident 9 would go after Resident 11 and it concerned Resident 7 because Resident 11 had developmental delays and did not have the mental capacity to understand. <Resident 9 & Resident 10> Review of a 09/12/2023 NPN showed Resident 9 had a verbal altercation with Resident 10 that resulted in Resident 9 throwing a cup of lukewarm coffee at and hitting Resident 10 with coffee on the chest and side of the face. In an interview on 09/27/2023 at 2:48 PM Resident 10 stated they had issues with Resident 9, was concerned that Resident 9 was seeking out Resident 1, and Resident 10 and other residents watched out for Resident 11. Resident 9 stated that while in the dining room, Resident 9 tried to give Resident 11 a sandwich, and I told Resident 11 to not take the sandwich because they were on a special diet. Resident 9 proceed to get coffee from the coffee cart when Resident 10 stated they should not get coffee without staff assistance, and Resident 9 threw the coffee in my face. <Resident 9 & Resident 12> Review of a 09/23/2023 NPN showed Resident 9 had a verbal altercation with their neighbor [Resident 12] when Resident 9 would not move out of Resident 12's doorway after being asked by Resident 12. Both residents yelled and cursed at each other. Review of September 2023 behavior monitoring showed staff were monitoring for behaviors related to depression. Staff signed off that behaviors were monitored but the documentation did not show what behavior was observed, how often the behavior occurred, what interventions were used, or if those interventions were effective. Additional behavior monitoring and interventions were started on 09/13/2023. Review of the behavior monitoring showed staff documented the number of behaviors, but the documentation did not identify what behaviors occurred. Review of the interventions showed staff documented what intervention were used but the documentation did not include if the intervention was effective. In an interview on 10/04/2023 at 6:30 PM Staff B (Director of Nursing) stated Resident 1 was a handful and was not appropriate for the facility due to their aggressive behaviors towards other residents. Staff B stated Resident 9 was seen by a mental health provider and had medications changes to help decrease behaviors. Staff B stated that Resident 9 was not appropriate for the facility with their behaviors directed towards others. <Resident 6> Review of the 06/09/2023 Quarterly MDS showed Resident 6 was able to make their needs known, had adequate hearing, clear speech, made themselves understood and could understand others. Resident 6 had diagnoses including diabetes, depression, and aftercare following an amputation. Resident 6 required two person extensive assistance with bed mobility and transfers. Review of a 03/03/2023 Activities of Daily Living (ADL) CP showed Resident 6 had self-care deficits related to both legs with below the knee amputations. Review of a 08/04/2023 grievance form showed Resident 6 documented concerns that Staff E (Certified Nurse Assistant), was great until something went wrong or supplies were missing, then Staff E slams all the drawers and is then rough with me. Resident 6 was not available for an interview and was discharged from the facility. There was no documentation to support the facility investigated Resident 6's grievance. Staff E continued to work with residents after Resident 6's allegation of rough care. <Resident 7> Review of the 08/01/2023 Quarterly MDS showed Resident 7 was able to make their needs known, had adequate hearing, clear speech, made themselves understood and could understand others. Resident 7 had diagnoses including depression, diabetes, muscle weakness, and arthritis. The staff assessed Resident 7 to require two person extensive assistance with bed mobility, transfers, and toileting. Review of a 03/20/2022 ADL CP showed Resident 7 had self-care deficits related to limited physical mobility. Review of a 08/08/2023 grievance form showed Resident 7 documented concerns with Staff E, when Staff E was taking me off the commode they were very rough wiping me and I was wondering if I would have any skin left. It was really hurting in the vaginal area. The next morning the aide was concerned because I was bleeding in the vagina. Besides being very harsh, Staff E was extremely rude in their comments, like you guys are killing me having to answer the light so often, or I've overheard the arguing with my roommate [Resident 8]. Because of these continued issues I am asking they not be assigned to our room again. The grievance form was signed by Staff B on 08/11/2023 and the action plan showed see incident report. In an interview on 09/12/2023 at 12:40 PM Resident 7 stated Staff E was rough with handling me, it felt like they were ripping the skin off. This made me angry and feel dehumanized. <Resident 8> Review of a 07/15/2023 Quarterly MDS showed Resident 8 was able to make their own decisions, had adequate hearing, clear speech, made themselves understood and could understand others. Resident 8 had diagnoses including traumatic spinal cord dysfunction, neurogenic bladder (lack of bladder control due to spinal cord injury), and osteoporosis (weak and brittle bones). The staff assessed Resident 8 to require two person extensive assistance with bed mobility and transfers. Review of a 10/23/2020 ADL CP showed Resident 8 had self-care deficits related to paraplegia (inability to move lower parts of the body) and multiple locations of pain. The CP directed staff to have two staff members with all care for frequent allegations and to maintain consistency of events. Review of a grievance form, dated 08/08/2023 at 2:00 AM showed Resident 8 documented that Staff E answered the call light by stating, Now what do you want? when Resident 8 requested assistance with re-positioning of their left leg. Staff E roughly grabbed my left foot and forced my lower left leg to bend sideways and the upper leg did not move, I yelled, what are you doing? During this time I heard and felt a pop. Instantly there was pain in my knee that radiated up my leg. I was in shock and realize now when I initially reported the incident I forgot some details. I wrote a note to the nurse asking for pain medications and handed it to Staff E to deliver and they responded, What? Another note? I was being questioned and basically judged for needing to communicate with my nurse. I did not need to answer to Staff E. It was clear they were upset that I had put my light on, and no matter what, they were upset. My injury was clearly from Staff E not listening to my request for them to tilt my left foot. I feel that Staff E physically took their anger out on me. Grievances from Resident 7 and Resident 8 were both received by facility staff on 08/08/2023 at 2:00 AM. The facility failed to intervene and protect resident's by allowing Staff E to continue working with residents until the end of their shift. During an interview on 08/30/2023 at 12:45 PM when asked if they received any complaints or concerns for staff verbal abuse against residents, Staff B stated only with Staff E who was terminated due to their yelling, unwillingness to help the residents, and rough handling that resulted in an injury to Resident 8. In an interview on 09/12/2023 at 12:00 PM Resident 8 stated on 08/08/2023 Staff E responded to their call light, was snippy and down right rude, did not want Staff E to continue to provide care due to their attitude. Resident 8 stated when they reported their concerns, facility staff responded and stated that three other residents had completed grievances about Staff E. Resident 8 stated they felt and heard a pop with instant pain in their knee and it started swelling. Resident 8 stated the physician ordered x-rays of the knee that revealed an acute fracture that was ruled out by a CT scan at the hospital. Resident 8 stated they had increased pain that required new pain medication prescriptions. In an interview on 09/12/2023 at 11:15 AM with Staff C (Operations Manager) and Staff B, Staff C stated Resident 7 reported their allegations of rough handling on 08/08/2023 and Staff E was not suspended that night but kept on the same set of residents except for Resident 7 and Resident 8. When asked how the facility protected the other residents from abuse by allowing Staff E to continue to work on the floor, Staff B replied that their understanding was the nurse talked with Staff E, maybe counseled or gave education. I am not sure. Refer to F725 Sufficient Staffing, F607 Failure to Implement Abuse Policies, F610-Prevent/Correct/Investigate Abuse/Neglect, F689 Free of Accident Hazards/Supervision/Devices REFERENCE: WAC 388-97-0640(1)

Based on observation, interview and record review, the facility failed to ensure that resident's who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice by not identifying, monitoring, or treating past experiences of Post-Traumatic Stress Disorder (PTSD - a disorder that develop when a person had experienced or witnessed a scary, shocking, terrifying, or dangerous event) for 3 of 3 residents (Residents 13, 12, & 14) reviewed for mood and behavior. These failures caused psychological harm to Resident 13 who was re-triggered and traumatized by facility staff and placed other residents with a trauma history at risk for unidentified triggers, re-traumatization, and a decreased quality of life. Findings included . According to the undated facility Trauma Informed Care policy, the facility would provide care and services using approaches that were culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and re-traumatization. The facility would collaborate with the resident, their representatives, and staff involved in the residents care to develop a Care Plan (CP) with individualized interventions. The facility would identify triggers, trigger specific interventions to decrease the resident's response to triggers, and would evaluate whether the interventions were effective or need to be re-evaluated. <Resident 13> Review of a [DATE] Admission Minimum Data Set (MDS - an assessment tool) showed Resident 13 was able to make their own decisions, had no hallucinations, delusions and no verbal or physical behaviors directed at others. Resident 13 had diagnoses including anxiety, depression, and PTSD. Review of Resident 13's medical record showed no indication the facility developed an individualized CP related to their PTSD diagnoses and trauma history. Review of a [DATE] admission Nursing Progress Note (NPN) showed Resident 13 informed staff they had a history of PTSD. Review of a [DATE] facility Trauma Informed Care- Life Event checklist showed Staff P (Social Services Director) marked no traumatic experiences or life events, documented none for all other questions, and patient report didn't think about or no trauma at this time. Review of a [DATE] physician encounter note showed Resident 13 reported to the physician that, they always talked in their sleep or had nightmares due to their PTSD. Resident 13 became tearful, stated wants to go home to family, and the physician referred Resident 13 for a behavioral health evaluation due to increased behaviors, major depressive disorder, and PTSD. The physician documented Resident 13 remained very emotional, frequently tearful, talking, crying, and yelling in their sleep. Review of a [DATE] psychiatrist note showed Resident 13 had a chronic history of complex PTSD, depression, and anxiety. The Psychiatrist recommended a medication increase to decrease intrusive thoughts secondary to PTSD. Review of an [DATE] facility investigation showed Resident 13 had an incident when Staff O (Certified Nurses Assistant - CNA) insisted they take a bath, took their clothes off, and started cleaning the resident before consent was given. Resident 13 started screaming sexual assault, asked the CNA to not touch them, and leave the room. In an observation and interview on [DATE] at 11:53 AM Resident 13 was observed in bed and stated they had a history of PTSD and this incident with Staff O re-triggered their PTSD. Resident 13 stated Staff O must have told others because other staff were not talking with them and when Staff O came back into their room a few days after the incident, they were terrified and felt like Staff O could do anything they wanted. Resident 13 was observed drifting out during the interview and had to be re-oriented. Resident 13 apologized, and stated, it was part of their PTSD, I drift out or have a hard time answering questions. Resident 13 stated sometimes they will scream if they don't have a call light or yell in their sleep, which is why they couldn't have a roommate because they would scare someone. Review of a [DATE] NPN showed staff documented Resident 13 reported a resurgence of PTSD. A [DATE] NPN showed Resident 13 had two episodes of calling out and emotional trauma, the nurse found Resident 13 crying both times and stated, it is just my PTSD. In an interview on [DATE] at 3:08 PM Staff M (Registered Nurse) stated Resident 13 was obtunded (out of it, lethargic) and had increased anxiety after the incident with Staff O. Staff M stated it was traumatizing for Resident 13 who continued to have PTSD stuff going on. During an interview on [DATE] at 3:50 PM with Staff B (Director of Nursing Services) and Staff P, Staff P stated they were not sure why Resident 13 had PTSD but stated they had nightmares. Staff B would prevent re-triggering by removing triggers, although no triggers were identified. When asked what Resident 13's triggers were, Staff P could not identify and stated triggers and interventions should be identified, included in the CP, and on the kardex (a quick reference guide derived from the CP) so facility staff were aware and the trauma assessment should have reflected the resident's history. <Resident 12> Review of a [DATE] Quarterly MDS showed Resident 12 was able to make their own decisions, had no physical behaviors directed towards others, and had verbal behaviors directed towards others. Resident 12 had diagnoses including right femur fracture, anxiety, depression, and PTSD. Review of Resident 12's medical record showed no indication the facility developed an individualized CP related to their PTSD diagnoses and trauma history. Review of a [DATE] facility Trauma Informed Care- Life-Events Checklist showed Staff P marked n/a or non-applicable for all sections of the assessment. Review of a [DATE] physician encounter note showed a request for psychiatrist evaluation for possible medications to assist with Resident 12's anxiety related to vivid dreams. A [DATE] physician encounter note showed that Resident 12 was still struggling with nightmares related to their PTSD and was on the list to be seen by behavioral health. Additional physician encounter notes on [DATE] showed Resident 12 continued with insomnia. A [DATE] physician encounter note showed Resident 12 was seen for insomnia and stated they experienced vivid dreams that are very realistic like going to another city with their deceased family member. The physician documented Resident 12 had a long-standing issues with insomnia and PTSD. In an interview on [DATE] at 3:53 PM, Staff B stated Resident 12 get's jumpy if you knock too hard on the door, and had PTSD due to their military experience in the Vietnam war. Staff B stated Resident 12 took medications nightly related to insomnia and off label use to treat nightmares associated with PTSD. Staff B would expect Resident 12's trauma assessment to reflect their history of trauma, identify triggers, individualized interventions, and incorporate in the resident's CP to prevent re-traumatization. <Resident 14> Review of a [DATE] Quarterly MDS showed Resident 14 could not make their own decisions and had diagnoses including a brain bleed and schizophrenia. Resident 14 had no verbal or physical behaviors directed towards others. Review of a [DATE] potential for alteration in mood or behavior related to depression and PTSD CP directed staff to monitor physical behaviors of paranoia, social isolation, nightmares, sadness and depressed statements. The CP showed specify for interventions staff should use to relieve behaviors. Review of a [DATE] facility Trauma Informed Care-Life Events Checklist showed Staff P documented all answers as none. Review of a [DATE] PASRR (Pre-Admission Screening and Resident Review) Level II (confirms that an individual had a mental illness and assess need for specialized services) showed Resident 14's reason for referral was schizophrenia, PTSD, and paranoia. The PASRR showed Resident 14 had a PTSD history due to significant sexual, physical, and mental abuse. In an interview on [DATE] at 3:55 PM, Staff P stated they were not sure why Resident 14 had PTSD and although Staff P reviewed Level II PASRRs, they were not aware of Resident 14's history and would expect the trauma assessment to reflect Resident 14's trauma history, identify triggers, and individualized interventions incorporated in the CP to prevent re-traumatization. Staff P was asked if a resident admitted with a diagnosis of PTSD and/or took medications for PTSD related symptoms, how did the facility staff identify triggers and individualize interventions to reduce re-traumatization, and Staff P replied, one-on-one conversations, sit with them [residents] if having behaviors, bring concerns to the Director of Nursing. Staff P stated they had not received Trauma Informed Care training before. REFERENCE: WAC [DATE](e).

Based on interview and record review, the facility failed to provide the level of supervision necessary to prevent accidents for resident-to-resident altercations and falls for 4 of 4 (Residents 1, 3, 9, 15) residents reviewed for accidents, hazards, and supervision. The lack of supervision and implementation of safety measures to prevent resident-to-resident altercations allowed Resident 1 and Resident 9 to initiate verbal and physical altercations with multiple residents and caused physical harm to one resident (Resident 2) when they were slapped in the forearm. The facility failed to provide supervision and implement interventions for Resident 3, identified as a high fall risk, who experienced multiple potentially avoidable falls with harm when they sustained injuries to include a nasal bone fracture, an eyebrow laceration, and a hospital evaluation for head injury, and placed other residents at risk for potential verbal and physical abuse, serious injury, pain, and diminished quality of life. Findings included . Review of the facility Accidents and Supervision policy, dated 04/27/2023, showed supervision was an intervention and a means of mitigating accident risks. The facility would provide each resident with adequate supervision to prevent accidents. The type and frequency of supervision would be based on the individual's assessed needs and identified hazards in the resident environment. <Resident 1> Review of a 06/10/2023 Quarterly Minimum Data Set (MDS an assessment tool) showed Resident 1 was not able to make their own decisions, had adequate hearing, clear speech, and spoke a different language that required an interpreter. Resident 1 had diagnoses to include, dementia and history of a brain bleed. Resident 1 was assessed with worsened behaviors that included, verbal behaviors directed towards others, no physical behaviors directed towards others, and these behaviors did not put others at risk, significantly disrupter care, or intrude on the privacy or activity of other residents. Review of a 12/01/2022 CP showed Resident 1 had the potential to be intrusive and attempted to hug others, thinking they were their children. The CP directed staff to attempt to re-direct Resident 1 with pleasant diversions, such as activities and food. Review of a 07/11/2023 physicians order (PO) directed staff to provide one-on-one (direct supervision of one staff member to one resident) care for Resident 1 being combative with other residents at all times. Review of a 07/12/2023 Nursing Progress Notes (NPN) showed Resident 1 became aggressive towards other female residents sitting at the nurses station, started yelling in their native language, and attempted to strike two female residents for getting too close to them. The NPN showed a one on one was immediately put in place per the PO and send Resident 1 to the hospital for further evaluation as they were a threat to themselves and others in the facility. Resident 1 refused to go to the hospital to be evaluated. Review of a 07/27/2023 NPN showed Resident 1 had a PO for a one on one, was not receiving the one-on-one at the time, and Staff B (Director of Nursing) would discontinue the PO for a one-on-one caregiver and follow up with the mental health provider on how to manage Resident 1's behaviors. Review of Resident 1's clinical record showed no documentation that Staff B followed up with the mental health provider. Review of the July 2023 and August 2023 Medication Administration Record (MAR) showed the PO for one on one was active and staff documented on 08/01/2023 no one on one care at this time and on 08/02/2023 do not have the staff for a one on one. Review of a NPN, dated 08/02/2023, showed staff documented that Resident 1 spit on staff and two other residents, and was being verbally mean to another female resident sitting in a wheelchair. The NPN indicated the physician was notified and PO's were received for a medication to decrease behaviors but did not mention if Resident 1 should have a one on one at this time. Review of a NPN, dated 08/06/2023, showed Resident 1 was very aggressive towards multiple residents, using their walker to charge other residents while screaming. Resident 1 continued to yell at residents and charge with their walker continuously throughout the shift. Review of a NPN, dated 08/08/2023, showed Resident 1 continued with aggressive behaviors and required direct supervision from staff. An additional note from 08/08/2023 showed later in the day Resident 1 charged Resident 2 and slapped their right arm. The note indicated that Resident 1 was put on a one on one for their own safety, as well as for the safety of other residents at the facility. Resident 1 was sent to the hospital for further evaluation. Review of the August 2023 MAR showed for Resident 1's one on one staff documented a 5 on the MAR, indicating to hold or see progress notes for 08/02/2023 and 08/06/2023. Review of MAR progress notes showed on 08/02/2023, staff documented do not have the staff for a one-on-one. In an interview on 08/30/2023 at 12:42 PM, Staff B stated Resident 1 had patterns of behaviors that increased in the evening shift. On 08/08/2023, Resident 1 slapped Resident 2 on the right forearm unprovoked. Resident 1 was sent out to be evaluated at the hospital, did not have any acute medical problem, and would not be returning to the facility, rather a dementia unit at another facility. <Resident 3> Review of a 08/14/2023 Admission MDS showed Resident 3 was not able to make their own decisions, had adequate hearing, clear speech, made themselves understood and could understand others. Resident 3 had diagnoses including traumatic brain injury, renal disease, and muscle weakness. The MDS showed Resident 3 with no behaviors and required one person staff assistance with transfers, dressing, and toileting. Review of a 08/09/2023 Fall CP showed Resident 3 was at risk for falls and directed staff to do not leave the resident alone when up in the wheelchair. A 08/23/2023 Actual Fall CP showed Resident 3 had a fall with a nasal bone fracture. The CP directed staff to continue interventions on the at risk for falls CP. Review of a 08/10/2023 fall risk assessment showed Resident 3 was assessed at high risk for falls. Review of 08/19/2023 hospital documents showed Resident 3 arrived at the emergency room at 9:25 PM on 08/19/2023 for a right eyebrow laceration after falling out of bed. Review of a 08/20/2023 NPN showed staff documented Resident 3 returned from the hospital where they were sent for a fall with head injury. Review of Resident 3's medical record showed no indication the facility put fall prevention interventions in place after Resident 3 suffered a fall with eyebrow laceration on 08/19/2023. Review of a 08/22/2023 physician encounter note showed Resident 3 was seen by the physician for another unwitnessed fall on 08/22/2023 and was noted with swelling and minor bleeding to the right forehead/eyebrow area. The assessment showed the plan was to transport Resident 3 to the hospital for a fall with head injury. Additional NPN dated 08/22/2023 showed Resident readmitted back to the facility after a fall and sustained a nasal bone fracture. Observations on 08/30/2023 at 2:15 PM showed Resident 3 sitting alone in the dining room eating their lunch. Resident 3 was observed with dark black and blue discoloration around the right eye, with steri-strips (small bandages) to the right eyebrow. In an interview on 08/30/2023 at 2:19 PM Staff S (Interim Resident Care Manager) entered the dining room and stated they would sit with Resident 3 while Resident 3 finished eating their lunch. Observations on 09/12/2023 at 2:15 PM showed Resident 3 sitting alone in the dining room with no staff present, purple and green discoloration was observed by Resident 3's right eye. In an interview on 09/12/2023 at 2:20 PM Staff B was brought to the dining room and observed Resident 3 sitting alone with no staff supervision and stated this is a problem, Resident 3 should not be left alone. <Resident 9> Review of a 08/04/2023 Quarterly MDS showed Resident 9 was able to make their own decisions, had adequate hearing, clear speech, able to understand and be understood by others. The MDS showed Resident 9 with no verbal or physical behaviors directed towards others, and had diagnoses including cancer and depression. Review of a 08/28/2023 Behavior CP showed an intervention that directed staff to provide supervision in the dining room during meals by a nurse and during activities the dining room would be supervised by the activity's director. Review of a 08/08/2023 NPN, showed at 9:34 PM staff documented they found Resident 9 opening the top drawer of the treatment cart taking a band-aid. A similar NPN on 08/21/2023 showed Resident 9 was witnessed trying to open drawers of the treatment cart to get a band-aid for their bleeding ear. Review of a Resident 9's medical record showed multiple notes with Resident 9 involved in resident-to-resident altercations. A 09/05/2023 activities progress note showed Resident 9 had verbal altercation and cussed at Resident 7 outside the dining room near the kitchen door. A 09/07/2023 activities progress note showed Resident 9 had verbal altercations with profanity at the round table players [Resident 7, Resident 10] in the dining room. Five days later on 09/12/2023 Resident 9 had a verbal altercation with Resident 10 in the dining room resulting in Resident 9 throwing a cup of coffee at Resident 10. A week later on 09/19/2023 Resident 9 had their third verbal altercation with Resident 7 as Resident 7 was exiting the dining room and ran over Resident 9's ankle. Four days later on 09/23/2023 at 11:50 PM Resident 9 had a verbal altercation with their next door neighbor, Resident 12. Resident 9 was not able to be re-directed from the area and eventually wheeled themselves down the hall. An hour and a half later at 1:30 PM Resident 9 was involved in another verbal altercation with Resident 7 in the dining room, where Resident 7 left the dining room crying and not able to enjoy their meal in Resident 9's presence. During an interview on 10/04/2023 at 6:00 PM Staff B was asked how Resident 9 was supervised in the dining room where five out of six incidents occurred, Staff B replied that there should be staff present in the dining room to supervise residents. Due to low staffing issues, Staff B stated there were no staff present as they would expect in the dining room during resident meals. Staff B would expect residents to be immediately separated for safety, notifications made, and an incident report completed. When asked how the facility planned to prevent reoccurrence, Staff B stated Resident 9 was assessed by the mental health provider and started on an antipsychotic medication to manage behaviors. The facility did not have a plan to prevent reoccurrence of Resident 9's verbal altercations with other residents. <Resident 15> Review of a 09/19/2023 Quarterly MDS showed Resident 15 was not able to make their own decisions, was rarely able to understand and rarely understood by others. Resident 15 was assessed with verbal and physical behaviors directed towards others that significantly put the resident at risk, interfered with the resident's care, and interfered with the resident's participation in activities or social interaction. Resident 15 had wandering behaviors daily that put the resident at significant risk of getting to a potentially dangerous place and significantly intruded on the privacy or activities of others. These behaviors were assessed to be worse. Review of a 12/01/2022 Wander Risk Care Plan (CP) showed Resident 15 wandered aimlessly, had poor safety awareness, and significantly intruded on the privacy and activities of others. The CP directed staff to distract the resident from wandering by offering pleasant diversions like structured activities, food, conversation, television, and books. The CP showed under resident preferred was left as specify and did not show what distractions the resident preferred. Review of the 07/29/2022 Activity CP showed Resident 15 had little or no activity involvement related to disinterest. Review of Resident 15's medical record showed multiple progress notes of Resident 15 wandering into other resident rooms. A 08/11/2023 NPN showed Resident 15 was restless, going to other resident rooms, was not easily redirected, paranoid about everything, and refused to leave the managers office's. A 08/12/2023 NPN showed Resident 15 followed staff to other resident rooms and was not able to be redirected by staff. A 08/14/2023 NPN showed similar findings of Resident 15 following staff to other resident rooms and not able to be redirected by staff. A 08/17/2023 NPN showed Resident 15 was wandering into other resident rooms and trying to open medication carts, grabbing at items and was angry when staff tried to retrieve the items from the resident, and a one-on-one with a CNA was used as needed for the resident's safety. A 08/21/2023 NPN showed Resident 15 was found sleeping in an empty bed this morning in another resident's room. A 09/01/2023 NPN showed staff were now providing one-on-one caregiver to supervise Resident 15 for safety and for a quick redirection. Review of a 09/01/2023 facility investigation showed a grievance was received from Resident 19, that showed on 08/17/2023 at approximately 9:30 PM Resident 19 heard their roommate [Resident 20] moaning and struggling and found Resident 15 attempting to smother Resident 20 with a blanket. A CNA was called to the room by Resident 19 and the CNA helped get Resident 15 away from Resident 20 but Resident 15 would not let go of Resident 20's blanket. Eventually Resident 15 was escorted back to their room and Resident 19 stated they couldn't sleep that night or the next due to being afraid Resident 15 would hurt their roommate. The Grievance form showed Resident 19 documented on 08/30/2023 when they returned from the store Resident 15 was found sleeping in their bed. Resident 19 stated their roommate was very upset to hear Resident 15 was in the room without their knowledge. Resident 19 documented they reported the incident to Staff B, who told them that is impossible the resident was in their office., after leaving Staff B's office Resident 19 observed Resident 15 wandering in the hallway. The grievance form showed Resident 19 informed Staff B that another male resident told them Resident 15 had wandered into their room and got into their bed too. The facility investigation determined through interview with Resident 20 that Resident 15 did not smother them with a blanket, but was trying to take the blanket away from Resident 20. Review of a 09/10/2023 NPN showed Resident 15 was wandering throughout the halls and locked themselves in a weight room and attempted to go into many rooms, including Resident 19 and resident 20's room. Staff documented there was no one-on one caregiver available due to lack of staff. Observations on 09/27/2023 at 5:00 PM showed Resident 15 with a one-on-one caregiver walking down the hall. Staff R (CNA) stated Resident 15 was very active in the evening with their sundowning (symptoms of restlessness, agitation, irritability or confusion that begin or worsen when the sun goes down) and want to walk up and down the halls. In an interview on 10/04/2023 at 6:20 PM Staff B stated Resident 15 was not on a one-on-one caregiver at that time of the incident on 08/17/2023. Nurses and CNA's were responsible for supervising residents, and Staff B would expect residents to be supervised. Staff B was not sure how Resident 15 locked themselves in the weight room, and expected the one-on-one caregiver to be with the resident when Resident 15 was awake. REFERENCE: WAC 388-97-1060(3)(g) Refer to F725 Sufficient Staffing, F600 Free from Abuse, F607 Failure to Implement Abuse Policies, F610-Prevent/Correct/Investigate Abuse/Neglect

Based on observation, interview, and record review the facility failed to obtain Physician Orders (PO) for wound care to include assessment, monitoring, and treatment, and to notify the physician timely of changes in wound condition for 3 of 3 residents (Resident 1, 2, and 3) reviewed for surgical incision wounds. This failure resulted in harm to Resident 1 who experienced bleeding and a surgical incision dehiscence (a separation of the wound edges) and to clarify conflicting wound care POs for Resident 3 related to removal of sutures which resulted in a delay of treatment for 7 days, and placed all other residents at risk of delayed wound care, increased pain, and diminished quality of life. Findings included . <Facility Policy> Review of the 05/01/2023 facility Wound Treatment policy and procedure showed wound treatments would be provided in accordance with PO's, including the cleansing method, type of dressing, and frequency of the dressing change. In the absence of a treatment order, the licensed nurse (LN) would notify the physician to obtain treatment orders. <Resident 1> According to the 04/11/2023 Admission Minimum Data Set (MDS - an assessment tool) Resident 1 admitted to the facility on [DATE], was able to make their own decisions, able to communicate, and had a surgical incision that required treatment and application of a non-surgical dressing. Resident 1 had medically complex diagnoses that included atrial fibrillation (abnormal heart rhythm) that required blood thinners, and a recent surgical procedure to reroute the blood supply around a blocked artery in the right leg that was complicated by excessive bleeding near the surgical incisions. A 04/07/2023 hospital discharge summary showed staff were directed to monitor Resident 1's incisions for unexpected bleeding. The summary directed staff to report to the physician any increase in redness, drainage, swelling, warmth, or odor from the surgical incision site. Review of Resident 1's 04/07/2023 Care Plan (CP) showed it did not address the surgical wound and showed no goals or interventions for the post surgical wound care to the right leg. Review of Resident 1's PO's showed there were no POs to assess, monitor, and treat the surgical incisions to the right leg. A 04/07/2023 Nursing Progress Note (NPN) showed Resident 1 was admitted to the facility at 1:05 PM on 04/07/2023, had three incisions to the right inner thigh and groin, sutures were intact, and the right leg was wrapped in two elastic bandages. Review of a NPN, dated 04/07/2023 at 11:50 PM, showed Resident 1 identified the dressing became loose and started to slide down their leg. Resident 1 requested help from staff and requested the bandage to the right leg be wrapped higher up the thigh. The note showed Staff C, Licensed Practical Nurse (LPN), had no PO for the dressing change to the surgical incisions on the right leg. Staff C documented they would notify the provider through a Physician Communication. The physician communication was a paper form filled out by facility staff communicating concerns to the physician and left in the physician's mailbox until the physician arrived at the facility to review. Review of a Physician Communication form showed Staff C did not communicate with the physician until 04/08/2023 and that Resident 1 did not have PO's for wound care. Review of the 04/08/2023 NPN showed at 9:40 AM Staff D LPN, documented they observed swelling and redness near the groin incision. Staff D documented they cleansed the wound and applied a dressing to the right leg despite having no PO. There was no documentation by facility staff to support Staff D notified the physician of these observed changes. Review of a NPN dated 04/08/2023 at 7:34 PM, showed Resident 1 reported to Staff D the dressing had blood on it and the middle wound was open. Staff D documented they observed the incision, blood was observed between the first and second sutures, and the wound was open. The note showed Staff D documented they cleaned the incisions, changed the dressing, and notified the physician. Review of a 04/08/2023 Physician Communication form showed Staff D requested wound care orders for Resident 1's surgical incision and a referral to a wound specialist. There was no documentation to support a phone call or fax was sent to the physician. During an interview on 04/28/2023 at 11:15 AM Staff B, Director of Nursing, stated the Physician Communication forms were placed in the physician's mailbox and they would review the physician communication form on their next scheduled day in the facility which would be 04/11/2023. A 04/10/2023 NPN showed unidentified staff documented the upper surgical site was bleeding. The NPN indicated that the physician did not need to be contacted. Review of NPN's dated 04/10/2023 showed no documentation staff informed the physician of the bleeding from Resident 1's surgical incision. A 04/11/2023 NPN showed Resident 1's wound was bleeding after participating in physical therapy. The NPN showed staff called Resident 1's surgeon who ordered staff to send Resident 1 to the emergency room (ER) for evaluation, three days after the surgical incisions started bleeding. The note showed Resident 1 told staff they did not want to come back to the facility due to the poor care. A 04/11/2023 physician's encounter note showed the physician identified the wound opened up approximately three days ago, is now gaping open with a hematoma (collected blood) and increased bloody drainage with movement and standing. The physician ordered staff to send Resident 1 to the ER. During an interview on 04/24/2023 at 2:35 PM, Resident 1 stated at the time of the initial admission to the facility, the surgeon stated the dressings needed to be changed frequently. Resident 1 could not recall how often the dressing should be changed. Resident 1 stated I had to lie in a bloody bed for 10 hours. I requested the night nurse to change the dressing to my right leg, but it did not get done until the next day around 11:00 AM. Resident 1 stated the delay in care resulted in them having to endure extensive testing and prolonged hospitalization from [DATE]-[DATE] to rule out an active bleed in their leg and administration of antibiotics because of the facility's mismanagement of the wound care. In an interview on 04/28/2023 at 11:00 AM Staff B stated facility staff should obtain surgical wound orders upon admission. Staff B stated, we don't wait hours. Staff B stated the nurse should call the physician or surgeon to obtain orders before changing the dressing. Staff B stated they would absolutely expect the staff to inform the physician of any bleeding or changes in the surgical incision. Staff B acknowledged the provider did not see Resident 1 until 04/11/2023, the day they were sent to the ER, and four days after bleeding and changes in Resident 1's condition were initially identified. <Resident 2> According to the 04/28/2023 Admission MDS Resident 2 admitted to the facility on [DATE], was able to make their own decisions, and had a primary diagnosis of postsurgical care following a below the knee amputation (BKA- a surgical procedure to remove the lower leg) of the left leg. A 04/22/2023 Hospital After Visit Summary for Resident 2 showed instructions to apply ice to the affected area, leave dressing on but keep it clean, dry, and intact until the clinic visit scheduled for 04/26/2023. Review of a 04/22/2023 CP showed no wound care instructions were provided to staff related to care of the surgical incisions on the left leg. The 04/25/2023 a amputation of the LLE (left lower extremity) CP directed staff to check and document the wound condition daily for signs and symptoms of infection, drainage, bleeding, any skin breakdown, or impaired circulation. A 04/23/2023 NPN showed Resident 2 had a brace over the left BKA. Review of Resident 2's record showed no PO or CP directions to staff to monitor or manage the brace. Review of a 04/23/2023 NPN showed Staff C identified, the day after admission, Resident 2 had no wound care or brace care orders for monitoring or treatments and notified the on-call provider. The NPN showed the provider would review Resident 2's paperwork and call back with orders. Review of NPN and PO's showed no indication the physician provided wound care orders until 04/26/2023, four days after admission. Review of the 04/25/2023 CP related to amputation of the LLE (left lower extremity) directed staff to check and document the wound condition daily for signs and symptoms of infection, drainage, bleeding, and skin breakdown, or impaired circulation. In an interview on 04/28/2023 at 11:00 AM Staff B stated they expected staff to obtain PO's to assess, monitor, and treatment upon admission or when no orders were found. <Resident 3> According to the 03/29/2023 Admission MDS Resident 3 admitted to the facility on [DATE], was able to make their own decisions, and able to communicate. Resident 3 had diagnoses to include a surgical repair of a fracture of the left femur and a terminal condition. The MDS incorrectly assessed and showed that Resident 3 had no surgical incision. Review of the 03/21/2023 fracture of the left femur CP showed the goal for Resident 3 was to return to their prior level of functioning after wound healing. The interventions included treatments per physician orders but no treatments were listed. A 03/22/2023 Nursing Admission Assessment (NAA) showed Resident 3 had three surgical incisions to the left femur. Dressings were not to be removed until the resident was seen by the bone doctor. Staff documented on the NAA unable to observe incisions. Review of a 03/22/2023 PO directed staff to monitor the incision to the left upper thigh every shift for signs/symptoms of infection, three sutures in place and to be removed at bone doctor appointment. A second 03/22/2023 PO directed staff to not remove the three silver dressings until bone doctor appointment. A third 03/22/2023 PO directed staff to monitor incisions to the left knee, three sutures in place, and monitor for signs/symptoms of infection. The 03/22/2023 NAA showed staff documented and observed the surgical incision to the front of the left thigh, a surgical incision to the front of the left knee, and a surgical incision to the left outer thigh. Despite the PO's to keep the dressings intact, staff included surgical incision measurements. The assessment was signed on 03/29/2023, seven days after Resident 3 admitted to the facility. A 04/05/2023 NPN showed Resident 3 had a bone doctor appointment on 04/06/2023 via zoom and requested that the facility staff remove the sutures when the surgeon gave the okay to do so. Review of a 04/07/2023 PO directed staff to remove the sutures from the left thigh, left outer knee, left outer thigh, and front of left thigh. A 04/09/2023 NPN showed facility staff were confused with two separate orders and documented, the Medication Administration Record showed to remove the sutures and the Treatment Administration Records showed the sutures to be removed at the bone doctor appointment. This NPN included no documentation or support that the facility staff called the physician to clarify the orders for wound treatments. Review of a 04/14/2023 NPN showed Resident 3's sutures were removed on 04/14/2023, seven days after the PO was received. Review of Resident 3's record showed no documentation the resident was seen by the bone surgeon, documents were requested, but none were provided. In an interview on 04/28/2023 at 11:00 AM, Staff B stated they expected staff to clarify a PO if there were multiple or confusing orders and to obtain a PO to monitor, assess, and provide wound treatments. REFERENCE: WAC 388-97-1060(1).

Based on observation, interview and record review, the facility failed to identify 34 baseboard heaters to be a hazard to residents identified as unable to move themselves out of harm's way of an electrical baseboard heater, that could result in extensive [CONDITION(S)]. This failure resulted in harm to 1 of 1 resident (Resident 1), related to multiple second degree [CONDITION(S)] on the back, and a laceration on the right middle finger, and placed 22 other residents, in beds near the baseboard heaters, at risk of [CONDITION(S)]. Resident 1 According to the 11/10/2021 Quarterly Minimum Data Set, Resident 1 diagnoses included Alzheimer's Dementia. Resident 1 was assessed with cognitive impairment (Brief Interview for Mental Status score of 3) of severe cognitive impact and required substantial/maximal assistance with transfers and positioning in bed. A Care Plan dated 11/09/2021 showed the resident required total assistance by one staff for repositioning, two staff for transfers, and a perimeter mattress was used to ensure safety. Resident 1 was able to roll to their side into a fetal position. Review of the facility Incident Report dated 01/01/2022 showed that Resident 1 appeared to have rolled out of bed. Review of the facility investigation dated 01/05/2022 showed the air mattress was inspected after the incident and was found to have a small air leak causing deflation when pressure was applied. Review of the facility Incident Report dated 01/01/2022 at 12:30 AM showed Resident 1 was found on the floor, next to her bed, with her back against the baseboard heater, a hematoma above the left ear, a laceration of the right middle finger that appeared to need sutures, and redness on the back where contact was made with the heater. The facility investigation concluded the cause of fall with injury, as the resident was positioned too far on right side and too close to the edge of bed. Observation of Resident 1's back on 01/13/2022 at 10:55 AM, with the wound care team, showed extensive back [CONDITION(S)], and a laceration on the right middle finger with 11 sutures (stitches) in place. During an interview on 01/13/2022 at 10:55 AM, Staff C, Contracted Wound Care, stated, some of the [CONDITION(S)] have a greenish drainage and a white colored slough covering them. Staff C stated that, the overall measurement on Residnet 1's back measured a surface area of 30 centimeters x 22 centimeters. The [CONDITION(S)] covered Resident 1 from the shoulder blades to the lower back. Staff D stated that all the wounds were counted as one area. Review of facility Progress Notes dated 01/01/2022 at 01:26 AM showed, Resident 1 was on their left side of the bed on the floor with their back against the radiator, bleeding profusely from a laceration on their R (right) middle finger. Resident 1 was moved away from the radiator but had redness on their back. During an interview on 01/13/2022 at 1:22 PM, Staff B, Director of Nursing, stated that they were notified at the end of the shift, of the incident involving the burn. Staff B was unable to determine, based on the burn, a definite time of how long the resident was against the heater, but was most likely about 10-15 minutes. Review of the facility Incident Report dated 01/01/2022 showed Resident 1 was found on the floor with their back against the base board heater. Staff responded to a loud noise and knocking on the wall. The resident was sent out to the ER (emergency room ) immediately. Hospital MD (physician) note dated 01/02/2022 at 6:33 AM showed, several [CONDITION(S)] on patient's back, pink, red, 2 blisters present as well. R middle finger is bandaged and has stitches. Hospital MD note dated 01/02/2022 at 5:04 PM showed, extensive [CONDITION(S)]/second-degree (first and second layer of skin) and possibly third-degree (entire layer of skin) on back. During an interview on 01/13/2022 at 10:55 AM, Staff D stated, I was not aware of any issues with the heaters since I have been here. During an interview on 01/13/2022 at 1:00 PM, Staff A (Administrator) stated I was unaware of any issues with the baseboard heaters when I started here. Following the incident, we implemented preventative measures including checking the heaters for temperature and applying tape to the floor in front of the heaters. We checked the temperatures of all the heaters. We had an inadequate temperature gauge, so we bought an infrared one. We used a temperature of 120 degrees Fahrenheit (dF), on the top or front of the heaters as a gauge to which ones should be replaced. We are replacing 14 of the heaters in the North Hall. The undated Baseboard Heater Temperatures spreadsheet showed 14 heaters testing over 120 dF. Ten tested over 140 dF, with the highest readings 154 dF, and 155 dF. During an interview on 01/13/2022 at 12:35 PM, Staff E stated that the heater in the room where Resident 1 fell , Room N4, tested over 150 degrees Fahrenheit (dF) on the outside, it was the hottest. Staff E stated that the heater was replaced a few days ago. During an interview on 01/13/2022 at 12:35 PM Staff E stated that a facility wide audit showed the North Hall heaters all tested hotter than the South Hall rooms. Some of the thermostats were broken and will be replaced. Staff E was observed on 01/13/2022 at 12:50 PM, to test the temperatures on the baseboard heater in room N3 with an infrared thermometer: inside heater 240 dF, top of heater 158 dF, baffle 233 dF. The heater was hot to touch. Staff E then tested the new heater in room N4 on 01/13/2022 at 12:53 PM: inside 134 dF, top of heater 94 dF. The new heaters did not have baffles (a flow-directing panel). On 01/13/2022 at 12:35 PM, Staff E was observed in room N17 to tape off the floor area around the baseboard heater 6 inches on the left and right ends and 18 inches to the outside of the tape. During an interview, Staff E stated that we have taped off all the floors and explained to the alert residents why the tape was there. We are doing audit checks every week and I am checking twice a day to see if things are in the taped off area. During an interview on 01/13/2022 at 1:22 PM, Staff B stated, we have audited the rooms, taped the floors, made sure nightstands were placed on the window side of the bed to keep the beds away from the heaters. I am doing walking rounds twice a day and we have a huddle every day at 2 PM. A tour of resident rooms on 01/13/2022, 12 days after the incident, showed the facility did not have a system in place to monitor, assess and supervise the risk factors for residents who resided in beds that were located next to the baseboard heaters as evidenced by the following observations: S1 (south hall) no tape on the floor, fall mat underneath the heater, heater warm to the touch, thermostat turned all the way up. During an interview at that time, Resident 4 stated that they had previously fallen out of bed, to the window side. S2 yellow tape on floor heater warm to touch, thermostat set to 80 dF, air mattress and tubing inside the taped zone. S3 no tape in room, heater hot to touch, thermostat at 85 dF, wheelchair in taped off area. S5 Resident 2 stated that they placed the observed tape down a couple days ago. S6 yellow tape on floor, heater warm to touch, thermostat at 65 dF. Nightstand was not on window side of the bed. S7 yellow tape, heater, and wall above heater warm to touch, thermostat at 80 dF. S8 yellow tape in front of heater, nightstand on door side of bed, bed closer to heater than tape line. S9 short piece of yellow tape, no tape in front of heater. S13 tape on floor, heater hot to touch, thermostat at 85 dF. S14 yellow tape, heater hot to touch. S17 no tape on floor, heater cool to touch, thermostat off, nightstand on door side of bed, not window side. N1 (North Hall) yellow tape on floor, heater cool, linen on floor next to heater, unable to read thermostat. N3 yellow tape with fall mat halfway in safety zone and nightstand on door side, not window side. N5 yellow tape, heater cold, 4 wheeled walker and bed side table in taped off area. N7 yellow tape, heater cold to touch, thermostat in lowest setting, nightstand on door side of bed. N8 yellow tape, heater warm to touch, thermostat at 50 dF. N9 tape on floor, heater warm to touch, garbage can in taped off area. N10 Resident 3 stated they just placed the tape yesterday. N11 yellow tape, nightstand on door side, not window side of bed. Resident 5 stated that the tape was applied, I think it was yesterday because stuff was on the floor and moved out of the way. Resident 5 stated they were told not to put anything on the other side of the tape. N16 taped off, Resident 6 stated, they did that so I wouldn't put clothes down there. N20 taped off area with fast food paper bag, trash, activity calendar, and four wheeled- walker. During an interview on 01/13/2022 at 12:35 PM, Staff E stated that they had one last room to tape off. Staff E stated that they ran out of tape. Staff E taped the area off with painter's tape. Staff E stated, I will change the tape to outdoor weather tape that will last longer, I will get started tomorrow. REFERENCE: WAC 388-97-1060 (3)(g).

Based on observation, interview and record review the facility failed to provide necessary care and services to maintain the highest practicable mental and psychosocial well-being for all residents. This failure resulted in the cumulative effect of psychological harm for three (#s 24, 14 & 27) of eight residents reviewed for room changes who subsequently suffered loss of control, and ongoing distress as evidenced by feelings of extreme sadness, agitation and anxiety which required medical intervention. Findings included . Refer to CFR 483.10(e)(7)(i)-(iii)(8), F-560, Right to Refuse Room /Roommate Change CFR 483.40(d), F-745, Medically Related Social Services RESIDENT #27 According to the 09/03/19 Quarterly Minimum Data Set (MDS - an assessment tool), Resident #27 was assessed as cognitively intact, able to understand and be understood in conversation. Record review revealed Resident #27 received a 07/05/19 written notice from the facility which read, Due to low census and limited staffing (due to low census) for safety concerns, we are asking several of our residents to move rooms so that our residents are grouped closer together to make it easier and quicker to get call lights answered and so that staff is available to hear our residents easily for any emergencies. Please understand that it is for benefit of all of our residents that we ask you to do this. You will be moving to room N7A on 7/9/19. Thank you for your understanding of this situation. Progress notes dated 07/05/19 showed, Letter to notify resident of pending room move on 7/9/19 to N7A given today. Resident states she does not want to move rooms. DNS (Director of Nursing Services) verbalized understanding and attempted to explained (sic) the reasoning for the move. resident states she doesn't care. Ombudsman notified on Wednesday 7/3/19. A progress note dated 07/07/19 showed, Resident also expressed concern and is angry over room change. Resident requested to speak with Corporate regarding the change. Corporate Number given to resident. Ombudsman' phone number given to resident on Friday as well. WCTM (Will Continue To Monitor). On 07/08/19 staff documented, Resident very upset and anxious that her room will be changed tomorrow. Calling on phone. Progress notes dated 07/09/19 showed, Resident very unhappy with room change, pacing in hallway in her scooter, crying and state feeling very upset . An additional note on evening shift 07/09/19 showed, Resident (complained of) not happy with the new room. According to staff documentation on 07/10/19, Resident very upset, crying, screaming, shouting, not happy with room change, DNS (Director of Nursing), Social Service aware. On 07/11/19, staff documented, Resident quiet though still upset with room change but adjusting well. However, five days later, on 07/17/19, staff noted, Resident very upset, screaming, seems frustrated, state(s) she is very depressed because of this room and is unable to get out of bed and so wetting herself all time. Called Social Services and (staff) went to talk to her. Despite continued objections to the room change and repeated demonstrations of distress and anxiety, the facility failed to enhance or support the resident's sense of well-being. Facility staff disregarded the resident's blatant dissatisfaction with the environment and control over her life. Record review showed Resident #27 was not transferred back to her original room until 09/20/19. In an interview on 10/14/19 at 11:29 PM, when asked about the room change, Resident #27 was observed to scowl and replied angrily, Don't get me started, I called the Ombudsman. Tell me about it! Someone complained of call lights not being answered on 07/05/19 and the next thing we know, our stuff was moved. We were out of our rooms for almost three months! Staff K (Regional Corporate Staff) and Staff L (Regional Corporate Staff) didn't know. They finally let us go back. When asked how the room change made her feel, the resident replied, It was horrible and uncalled for, I am still mad. Observations on 10/14/19 at 11:15 AM revealed there were 15 steps from the resident's original room to the room she was transferred to (room [ROOM NUMBER]). The facility had a call light system that was visible and audible from the centralized nurses station. In an interview on 10/14/19 at 12:04 PM, Staff C, Corporate Nurse, and Staff E, Regional Nurse, were asked what the safety issue was which catalyzed the room changes. Staff [NAME] replied, Staff did the room changes for the residents. We moved the residents closer to the nurses' station to attempt to consolidate care, so staff are in one hallway .They thought it would be beneficial .there were call light issues . Staff C and [NAME] were asked for any audits or documents to support how the the room change was for resident safety rather than staff convenience. No information was provided. When asked at what time the facility re-evaluated to reconsider the room changes as a good idea, Staff [NAME] replied, Hopefully, less than two months, if that's what it took. Staff C elaborated that the DNS at the time thought the room change was a good idea and, We evaluated and moved them back; because they were requesting to move back. Upon review of Resident #27's progress notes which showed the resident was angry, anxious, and distressed upon being informed of the impending room change, Staff [NAME] stated, If the residents showed signs of distress prior to room move, the team ideally would have come together and reevaluated the room changes . When asked what staff should do it was identified the room change caused the resident to cry, Staff [NAME] stated, Move them back. When asked why this didn't happen, Staff C replied, We did move them back . When informed the residents weren't moved back until 9/20/19, Staff [NAME] stated I don't think it was that recent. When asked how the resident's demonstrated behavioral distress and extreme sadness impacted the decision to make the room change, Staff [NAME] stated, Ideally it would have been stopped. RESIDENT #24 A 08/22/19 Annual MDS showed Resident #24 was assessed as cognitively intact, able to understand and be understood in conversation. Review of Resident #24's medical record showed the facility gave the resident a letter, dated 07/05/19, informing Resident #24, You will be moving to room N6A on 07/09/19. Review of progress notes showed that when the facility gave the resident the room move notice on 07/05/19, Resident #24 stated she does not want to move rooms. A 07/07/19 progress note showed the resident expressed extreme anxiety regarding room change. Resident began to cry and requested to call MD for [MEDICATION NAME] (anxiety medication). This LN (licensed nurse) notified MD (physician) who ordered a one time does of [MEDICATION NAME] . The following day on 07/08/19, a progress note showed, Resident still unhappy about room change, she likes to watch the trains .vss (vital signs stable), except (sic) pulse 102. An additional 07/08/19 note described this resident as, very anxious and tearful, does not want to change her room, was explained, very tearful this shift. An afternoon progress note showed, Resident states she is glad room change will be temporary (if possible). She was tearful and verbalized she desires to take [MEDICATION NAME] (an antipsychotic) again, since it helped her with helplessness and sadness. On 07/09/19 staff documented, Had a room change to N6A bed, not happy at all, crying, state (sic) room is small and her stuff is not fitting well, vss stable but resident very anxious, and Resident states she is not happy with the room but is happy her call light will be attended to timely. A 07/10/19 progress note showed, resident upset with her room change, still crying on and off but is better than yesterday. A 07/11/19 note showed, . still anxious and upset for room move but is trying to adjust well. On 07/12/19 a progress note showed, The resident does not like her new room but she is going to give it time to adjust. Review of progress notes between 07/05/19 and 07/12/19 showed the facility failed to helped Resident #24 in maintaining a sense of control or supported the resident in making her own choices, despite continued objections to a room move or persistent signs of psychological harm before, during and after a room move. In an interview about the room move on 10/14/19 at 11:53 AM, Resident #24 stated, I really loved it here (current room) because it's a great room. My youngest daughter arranged for things here so I could see the mountains and trains. When asked how she felt when asked to move to another room, Resident #24 said, Oh, yes, it upset me. They gave me a calming medication. I had a panic attack because of the notice to move. I had to keep pestering them to move me back here . I feel great now, I have a choice now. I didn't have any choice about the room move. Record review showed Resident #24 was not transferred back to her original room until 09/20/19. RESIDENT #14 According to the 08/06/19 Annual MDS assessment, staff determined Resident #14 was cognitively intact, was understood and able to understand conversation. Progress notes dated 07/05/19 showed, Letter to notify resident of pending room move on 7/9/19 to N7A (Per Census records, Resident #14 was actually transferred to room N7B) given today. Resident states she does not want to move rooms. DNS (Director of Nursing Services) verbalized understanding and attempted to explain the reasoning for the move. Ombudsman notified on Wednesday 7/3/19. Progress notes dated 07/08/19 indicated, Spoke with resident's son regarding upcoming room move. Explained the moves are for all resident's safety and that resident would be moved back to current room if possible in the future. and Spoke with resident regarding her upcoming room move and that I spoke with her son earlier. Explained that the plan is to move her and her roommate back to current room when census is better. She states that this makes her happy. On 07/09/19, Resident was moved to (new room), not happy, screaming, shouting, state (sic) feeling very upset . and tolerating new room well. But then on 07/10/19 staff documented, Resident still not coping with new room, was screaming, shouting, crying all shift, took medications but was denying first to take it . Progress notes dated 07/11/19, resident still upset with room change and agitated on and off but is much better than yesterday and stated she is trying . On 07/13/19, She is not happy with her new room. chat with her and asked her to give it a time. On 07/30/19, over three weeks after the room change, staff documented the resident was, not happy with her new room assignment. On 07/31/19 staff noted the resident was, .very anxious and was angry today, screaming at staff that she does not understand why she is in this room .Resident was explained few times that why she was moved but state it does not make any sense to her. Social service staff also talked with her. In an interview on 10/14/19 at 12:01 PM, when asked about the room move, Resident #14 stated, We were there (room [ROOM NUMBER]) for quite a while. This was our original room. When asked if she knew why she was moved from her original room, Resident #14 stated, I don't think they told us .I enjoy being back here. On 10/14/19 at 12:15 PM, the above findings were discussed in an interview with Staff C, Regional Corporate Nurse, and Staff E, Vice President of Nursing Services, who acknowledged the facility's repeated disregard of Residents' ability to make choices and have control caused psychological harm. REFERENCE: WAC 388-97-1060(1). .

Based on interview, and record review, the facility failed to provide adequate supervision, ensure falls were thoroughly investigated, and/or fall prevention interventions specific to residents' needs were consistently implemented, for one (#1) of three sample residents reviewed for accidents. Failure to comprehensively evaluate possible root causes, and revise and implement interventions to meet the resident's needs, contributed to repeated falls by Resident #1 resulting in fractures. Findings included: RESIDENT #1 Resident #1 admitted to the facility on [DATE]. The 03/09/18 Admission Bladder Incontinence Evaluation revealed the Resident is continent of urine with occasional incontinent episodes (wears pull ups). She uses toilet with SBA (Stand By Assist), usually uses call light for help. The listed plan was to provide, Bladder Retraining. The 03/08/18 Stress, overflow bladder incontinence Care Plan (CP) listed a goal of The resident will decrease frequency of urinary incontinence through the next review date (12/05/18). According to the 03/15/18 Admission Minimum Data Set (MDS - an assessment tool) the resident had moderately impaired cognition, required one person extensive assistance with transfers, walking and toileting. The resident was assessed as occasionally incontinent of urine with no trial toileting program attempted since admission. According to this MDS the resident had falls prior to, but none following admission. On 04/13/18 at 1:39 p.m., according to investigative documents, the resident was found on the floor next to her bed. The facility investigation determined the root cause to be worn out, non-skid socks and provided the resident with new socks. The 03/08/18 Risk for Falls CP was updated to include, Frequent visual checks on resident when she is in her room. Ask resident if she needs or wants anything when she is trying to transfer or walk, and Identify and address any underline cause of fall risk as appropriate. According to the 06/14/18 Quarterly MDS the resident was assessed with [REDACTED]. The resident was noted to have had two or more non injury falls since the prior MDS, was occasionally incontinent of urine and no trial toileting program had been attempted. According to facility investigative documents, Resident #1 fell out of bed on 06/26/18. Interventions listed to prevent reoccurrence included Resident, to have non-skid socks when in bed and shoes or non-skid socks when up. Review of the CP revealed the care plan was not revised. According to facility investigative documents, Resident #1 was found on the floor of her room on 07/29/18 at 6:32 a.m. The resident stated she was going to the bathroom, did not make it, and she was sorry she kept forgetting to call. The resident was not wearing foot wear. The resident was sent to the hospital, was diagnosed with [REDACTED]. The Risk for Falls CP listed the 03/08/18 intervention of Ensure resident is wearing appropriate non-skid socks or footwear when ambulating, which on 08/09/18 was revised to add And non-skid socks when sleeping in bed. In an interview on 11/08/18 at 1:15 p.m. when asked if the care plan was followed when the resident fell on [DATE], Staff D (Corporate Nurse) replied, It wasn't because we said we'd have non skid socks on after the (June) fall. Staff C indicated at that time Resident #1 was capable of removing the socks. Review of the investigative documents revealed no information regarding if the resident had non skid sock and took them off or not. According to MDS documents, the resident was discharged [DATE] to the hospital and was readmitted on [DATE] with a [MEDICAL CONDITION]. According to the 5 day MDS dated [DATE] the resident was assessed with [REDACTED]. According to the MDS the resident was now always incontinent, and no toileting program had been attempted since incontinence was first identified. According to the 09/13/18 Quarterly MDS the resident was assessed with [REDACTED]. The resident had no falls since the prior MDS and was frequently incontinent, with no toileting program. The 09/13/18 Bladder Incontinence Evaluation noted the resident was frequently incontinent and Resident is aware of urge to void but doesn't remember to use call lights. Check on resident frequently and offering toileting, also check and change if needed. The listed plan was Prompted voiding, and check and change. The 03/08/18 Stress, overflow bladder incontinence CP was revised 09/13/18 to include the intervention of Check and change. Offer toileting resident at around 10:00 a.m., 1:00 p.m. and 8:00 p.m. as needed. In an interview on 11/08/18 at 1:15 p.m. Staff C said I put her on scheduled toileting. When asked how the times of toileting were determined, Staff C said By observation, when trying to go and use the bathroom. When asked to provide an assessment of the void pattern, Staff C indicated there was no documentation as we observed her needing to go at those time. According to facility investigative documents, on 09/30/18 at 6:40 a.m. Resident #1 fell while self ambulating to the bathroom, again without socks or shoes. The resident sustained [REDACTED]. The listed interventions to prevent further falls included, Resident was placed on toileting program prior to meals and at bedtime as well as 15 minute checks. The resident had previously fallen on 07/29/18 at 6:32 a.m. and again on 09/30/18 at 6:40 a.m. going to the bathroom. The investigation documents did not include statements from the caregivers to determine when last toileted, if the resident had been offered non-skid socks, or when the resident was last observed. The Risk for Falls CP was revised 10/01/18 to include the intervention of Offer to toilet resident every AM before and after meals and at HS (hour of sleep). Resident can walk to bathroom with CNA (Certified Nursing Assistant). CNA using FWW (Front Wheeled Walker) with CGA (Contact Guard Assist). The 10/01/18 [MEDICAL CONDITION] Medication Review revealed, Resident has recently had frequent falls with acute problems that have contributed to weight loss. Resident has lost about 7 lbs (pounds) in a month after recent hospitalization r/t (related to) [MEDICAL CONDITION] and surgical repair. Resident is pleasant and confused, staff to anticipate resident needs, dementia is progressing and resident is not able to always follow precautions. Staff to provide frequent checks and toileting program . According to the 10/04/18 60-day MDS the resident was assessed with [REDACTED]. According to this MDS the resident had one non-injury fall since the prior assessment, was frequently incontinent and no scheduled toileting, prompted voiding or bladder training had been attempted. According to facility investigative documents on 10/31/18 at 12:40 a.m. Resident #1 was found lying on the floor to her right side calling for help. The resident sustained [REDACTED]. The resident returned to the facility 11/01/18 with non-weight bearing status, and an orthopedic referral to be done in two weeks. The physician ordered strict bed rest until orthopedic appointment. The Risk for Falls CP was revised on 11/01/18 to include, Floor mats on both sides of bed, Air flow mattress with bolsters. On 11/08/18 at 11:13 a.m. Resident #1 was observed in a low bed with bilateral fall mats in place. Resident #1 was unable to answer specific questions regarding the previous falls. In an interview on 11/08/18 at 1:15 p.m. when asked according to the CP the resident was on frequent checks, prior to the fall when was the resident last seen, and what was she doing and when was the resident last toileted, Staff D reviewed the incident investigation and unable to respond said, I'm thinking there's more. Staff D referred the investigator to the Director of Nursing, Staff B who was expected to return to the facility 11/12/18. In an interview on 11/13/18 at 10:27 a.m. Staff B confirmed the resident was not placed on Bladder Retraining as planned, and said I did education with (Staff C) on how to put on a toileting program. In regards to frequent checks, Staff B said, We don't necessarily document that and indicated the resident was not on 15 minute checks which would have been documented. When asked for staff interviews for the 09/30/18 and 10/31/18 investigations, Staff B replied, We don't have that. Reference WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to implement written polices and procedure components of thorough investigation, protection, and reporting of allegations of abuse, for six (#s 27, 59, 50, 48, 18 & 53) of 12 residents with grievances reviewed, one (#56) of three residents with abuse investigations reviewed, two (#51 & 34) of two residents reviewed for accidents and supplemental residents in attendance at a food committee meeting and in Resident Council. Failure to thoroughly investigate allegations of neglect/mistreatment resulted in abuse/neglect going undiscovered which precluded the facility from taking timely, necessary corrective actions and resulted in patterned feelings of anger, frustration, and despondency/resignation by residents. Findings include: Refer to CFR 483.13(b)&(c), F-223, Free from Abuse According to a 11/2016 facility policy regarding Abuse/Neglect/Misappropriation/Exploitation, Prevention: Facility residents and families may report concerns, incidents and grievances without fear of reprisal to any staff member or through the Grievance process. Identification: Facility supervisors and direct care staff monitor for .occurrences, patterns and trends that may constitute abuse. Investigation: All alleged incidents of abuse, neglect .are thoroughly investigated in order to determine what occurred and make necessary changes to the provision of care and services to prevent reoccurrences. The investigator is objective and looks at the incident without bias. Protection: Protecting the resident from further harm means keeping the resident safe by: Immediately suspend the alleged perpetrator., Allowing the resident to stay in an area where he/she feels safe. RESIDENT #27 According to a concern/comment form dated 08/25/17, Resident #27 did not receive her bowel program early as planned and as she requested by her nurse. According to this document staff determined, Upon spot checks/clinical review it was noted that assigned LN (Licensed Nurse) failed to administer bowel program to resident early per resident and staff request. The action taken included, DNS (Director of Nursing Services) asked RCM (Resident Care Manager) to take over resident care and obtained LN on shift's statement and sent her home. While the concern/grievance indicated no negative outcome for the resident in an attached email to the staffing agency who supplied the nurse, Staff B (Director of Nursing) documented, Unfortunately I have to send (staff member) home now. She failed to follow the plan of care for a resident who is scheduled for an appointment today. She was told 3 times to do the bowel program for the resident and assist with her AM care per MD orders, but she refused and stated she does not have time. The resident has a scheduled appointment at 10:00 am and had to cancel her appointment regarding the delayed care/not received care by (agency staff). Please note we will not be paying for the remainder of this shift or any scheduled shifts today 08/25/17 . Staff concluded, LN failed to administer bowel program early per resident's request no negative outcome for the resident .LN will not return to (facility), Res appt (appointment) rescheduled 10/05/17. Staff indicated no negative outcome when clearly there was a delay in services. There was no way to tell, through review of the grievance, if the resident received any part of the bowel program. In an interview on 10/09/17 at 10:30 a.m., when asked why this allegation of not receiving required services was not investigated as an allegation of neglect, Staff B replied, I remember that one (incident) I sent her (LN in question) home immediately. Upon review of the concern/comment form, there was no information regarding what bowel program was withheld, if it was necessary for the appointment that had to be canceled or if the LN refused care to any other residents. When asked, Staff B was able to state that it was a regularly scheduled [MEDICATION NAME] suppository that was delayed and the appointment that had to be postponed was for an injection, maybe for the knee? Facility staff failed to thoroughly investigate this incident and failed to consider/investigate if the six week delay in the appointment caused the resident to experience a delay in treatment of [REDACTED]. According to an additional grievance form dated 08/17/17, Res(ident) reported to RCM that staff are not (changing) her suprapubic cath(eter). According to the grievance, an LN was identified as documenting that the suprapubic catheter was changed, when it was not. The grievance form indicated Treatment error started to (follow up) on possible omission. The grievance indicated LN was educated and LN inserviced on proper documentation/notification. The grievance summary indicated, .called and spoke with (Staff PP, Registered Nurse) in regards to changing suprapubic catheter for (Resident #27) on scheduled shifts that were signed off by (Staff PP). (Staff PP) stated that the first time she attempted to change catheter resident had told her that it was already completed on a shift prior to (Staff PP's) and that she forgot to strike out her signature and prog(ress) note it properly. When asked in an interview on 10/09/17 at 11:15 a.m., Staff B was unable to state when and by whom the catheter had been changed on a shift prior to Staff PP's or if Staff PP confirmed the care was actually provided. The grievance also indicated, On another scheduled shift for (Staff PP) when she had signed off changing catheter (Staff PP) had stated that when she went to change the catheter the resident had stated, why are you changing it? it has been less than 30 days since the last time it was changed. Staff PP had stated that she forgot to document refusal and notify proper personal. When asked in an interview on 10/09/17 at 11:15 a.m., Staff B was unable to state which of the two described incidents related to the date in question (08/17/17), and what exactly was the date of the other instance of Staff PP falsely documenting the catheter was changed. Staff B indicated Resident #27 declined to have Staff PP change the catheter because, (Staff PP) isn't liked by the resident. Staff B was unable to explain what supported this conclusion or why it was not documented. When asked how one could conclude the failure to provide goods and services the resident was assessed to require was not neglect, Staff B stated, Neglect? I guess yeah, I see where you are heading with that question .I see what you mean . The grievance clearly indicated there were repeated, trendable episodes of failure to change resident's catheter after Staff PP falsely documented provision of necessary care the resident was assessed to require. RESIDENT #59 According to a grievance dated 05/30/17 the resident stated he, . had to wait 3 hours for help when in the conference room on 05/22/17. When he got moved to a different room the call light was not working so he had to wait again for over an hour . Staff documented under action taken that Resident requested to go to a quiet room, EVE (evening shift) LN offered him to sit in conference room, he agreed, NACs (Nursing Aide Certified) were checking on him every 15 min(utes). LN checked call light when res(ident) complained that call light not working and found it was in good working condition . This document did not indicate if the call light in question was the call light in the conference room or the call light in the room the resident was moved to later that evening. There were four staff listed under staff interviewed but there were no interviews with any of the NACs who purportedly did 15 minute checks nor were there any documents to support 15 minute checks were done. The document indicated, Also, at about 10:35 (p.m.) the resident used his phone to call the facility so it was not like he couldn't reach the staff . but did not reflect what the resident said or needed when he called the staff. There was no attempt at any timeline to establish how long the resident was in the conference room. Progress notes by Staff KK, Licensed Practical Nurse dated 05/30/17 at 12:11 a.m. revealed, heard someone yelling help during dinner time, went in to see what resident wanted, res wanted to get up and walk in hallway-explained that it was still dinner and staff were unavailable at this time, started swearing. Later in the evening heard res yelling help again. Res started yelling how this (explicative ) place is a[***]hole you are all idiots. Told res since he is safe sitting in his chair I will leave room until he could talk in a civil manner and left the room . Res continued yelling and some young men outside the facility jumped the fence to see if he needed help. LNs informed men who they were and that res was ok. Res told the men to call the cops. Res wanted to go to bathroom . In an interview with Staff B on the morning of 10/09/17,when asked how long the resident was in the conference room, Staff B stated, I was there that night .A couple of hours I don't know .I don't know if I checked .now that I am talking to you I remember . When asked why people from outside the building, across the yard, on the other side of the fence heard the resident yelling for help and attempted to intervene prior to staff intervening to assist the resident with his elimination needs, Staff B did not answer. Staff B later stated, I should have done an investigation. When asked, in an interview on 10/09/17 at 10:47 a.m., details regarding the grievances in question which might confirm or refute neglect/abuse, Staff C stated, there are a lot of unanswered questions. RESIDENT #56 A facility abuse investigation dated 06/09/17 indicated Resident #56 alleged that (Staff R, Licensed Practical Nurse) is aggressive with her approach and intimidates him. He also stated that he asked for his pain medication and she wouldn't give it to him on time . Despite the resident's intact cognition, facility staff disregarded progress notes by Staff R that Resident #56 demonstrated fear in her presence, and concluded the resident's allegations were unsubstantiated and his statements were paranoia related to a recent medication change. Record review revealed Resident #56 reported intimidation from and demonstrated fear of only Staff R, which was not identified in the investigation. In an interview on 10/11/17 at 11:53 a.m., four months after the reported incident, when asked if he had any issues with any staff members being aggressive back in June the resident stated, Oh yeah, that'd be Staff R. It was a constant problem with her. She was horrible. That'd been going on for a while. She made my life hell, she doesn't work here no more .yep her name was (Staff R). Failure to thoroughly investigate allegations of abuse caused Resident #56, and other residents, to have continued exposure to Staff R, resulting in residents experiencing feelings of fear and intimidation. RESIDENT #50 According to a concern/comment form Resident #50 on 09/09/17 stated, (Staff Q, Licensed Practical Nurse) told her she was too busy to come find out why I was losing oxygen .and said she did not have a crystal ball to know what was going on even after she was told. According to this grievance the resident called the main phone line and informed the BOM (Business Office Manager) with the issue . The resident's oxygen tank was at functioning status. The resident's oxygen level .was found to be at 93%. Staff Q stated that she sent (an NAC) to check on the resident's oxygen tank and measure the resident's O2 (Oxygen) status. Staff listed the action taken to resolve was (Staff Q) was educated to customer service, best practice, bedside manners. The follow up included the statement, Resident is at baseline findings. Employee educated, she verbalized understanding. Staff Q subsequently received a list of definitions of bedside manners, [MEDICATION NAME], honesty, respect, communication and the importance of pay full attention. The concern/comment did not confirm or refute the original allegation, if Staff Q told the resident she didn't have a crystal ball, or how the alleged statement impacted the resident. In an interview on 10/09/17 at 1:40 p.m. regarding the 09/09/17 incident, Resident #50 stated, My fingers were blue, I called and (a NAC and BOM) came down, when she (Staff Q) said she was too busy to come down it made me feel[***]y. She's always behind with meds, has a[***]y attitude. There is always miscommunication with staff. RESIDENT #48 A similar concern/comment form was completed for Resident #48 who alleged on 08/15/17 that her medications were received two hours late. According to the Grievance form, I am suppose to get meds between 4:00 and 4:30 a.m. and she (nurse) brought them at 6:00 a.m. I said she was late and she said she had been on break. (Staff) is agency and I hope she is not sent out again. The department manager review indicated, Review of MAR (Medication Administration Records) indicates meds were given 23 minutes outside of allowed window. Will discuss med timeliness with LNs. Will ask nsg (nursing) be invited to next res council meeting to discuss agency use. The Findings column was left blank. Staff documented action recommendations including LN was educated on timely med pass. She verbalized understanding. DNS attended res council, res verbalizing (decrease) concerns r/t nursing care in general. The outcome was Resident is at baseline, no change in condition. Staff failed to indicate what education the LN received regarding timely medication pass and failed to determine if other residents were impacted by this identified failed practice. Failure to thoroughly investigate this allegation of not receiving timely pain medication detracted from staff's ability to rule out late medications for any other resident. A similar grievance dated 09/10/17 indicated that, At 4 pm resident stated that she had asked for Tylenol from the NAC at around 3 (p.m.) and hasn't received it until 4 pm when she complained again. While the concern was, received from Staff Q, the document did not specify if Staff Q was the LN who didn't administer the medication timely. According to the concern form, Upon review of the facts and LN interview it was noted when the NAC told LN there was a miscommunication and LN thought that NAC meant the resident in room N11 wanted Tylenol. The resident alleged a delay in receipt of pain medication. Facility staff failed to thoroughly investigate as evidenced by no documented interviews with any staff involved and no additional interview with the resident. Staff documented resident remained comfortable until the end of the shift and at baseline findings per pain assessment. Staff also documented, Resident is at an increase pain level. Staff did not reference when the pain assessment was completed, or what the resident's reported pain was at the time of the original request and receipt of the medication an hour later. There was no consideration of if the LN in question was Staff Q, or if it was potentially a trendable issue with provision of care. Failure to thoroughly investigate resident allegations, despite facility staff confirmation of resident's repeated reports of not receiving pain medications timely, prevented staff from identifying a systems problem which resulted in residents experiencing pain, frustration and anger due to lack of care. In an interview on 10/09/17 at 2:00 p.m., Resident #48 stated the complaint of medications being late on 08/15/17, is still happening a lot . When asked, in an interview on on 10/09/17 at 11:15 a.m., if not getting medications as ordered by the physician would potentially be considered neglect, Staff B stated, I wouldn't .yeah I know we have some of those on the grievances, yeah, no that wouldn't be . I don't see those as allegations (of neglect). After further questioning, Staff B stated, Neglect? I guess yeah, I see where you are heading with that question .I see what you mean . Failure of the person responsible for abuse investigations (Director of Nursing) to identify and investigate issues of potential abuse/neglect resulted in residents experiencing continued fear, anger, and frustration. According to a grievance form dated 05/12/17, Resident state that she requested a shower from (Staff S, NAC) on 05/05/17, but (Staff S) told her that she's not doing showers and that the resident was on a different set. While the grievance identified Staff S was not the aide assigned to Resident #48, it failed to identify the resident was scheduled for, but did not receive, bathing on 05/05/17. Failure to thoroughly investigate the resident's allegation resulted in staff's inability to identify Resident #48 did not get the goods and services she was assessed to require. In an interview on 10/09/17 at 2:00 p.m., regarding the grievance dated 05/12/17 Resident #48 stated, It certainly didn't feel good. The resident indicated she felt,blown off stating, I am due on Fridays and Mondays, that was a shower day for me and I didn't get one . RESIDENT #18 Resident #18 lodged a grievance on 07/30/17 which indicated, Resident informed SW that an aide by the name of (Staff QQ) is constantly walking around at night with a hat and headphones in .very distracted, not able to do tasks, forgetful. Answers call light but always makes her wait so he can get help. She states she is only a one person assist. According to this grievance, there were no interviews with other residents or staff members in an attempt to confirm or refute the allegation of Staff QQ not providing timely services as required. Staff documented on the grievance on 07/31/17 that the action taken was, agency notified and requested NAC (Staff QQ) no longer assigned to facility. However review of the communication to the staffing agency, this request was not made until 08/09/17, more than a week after staff documented it was done. According to this 08/09/17 document, Let's replace (Staff QQ) please for all shifts. He did his double, but on top of the poor caregiving and disappearing, based on a nurse recheck of all his oxygen sats (saturations) which were recorded as being in the mid 80s for all his patients. On room air, still in bed, they all registered mid 90's as they should. Despite facility staff identifying the nursing agency requested NAC no longer assigned to facility, the facility continued to schedule Staff QQ, who continued to be exposed to residents for another week until the agency was contacted on 08/09/17. Failure to protect residents from inadequate care resulted in continued poor caregiving. There were no efforts to determine if a delay in care provision was an issue for any other resident or how this may have impacted the residents. Additionally, the DNS signed the grievance as both the person completing the form and as the Administrator. When asked, in the morning of 10/09/17, Staff B was unable to explain the disparity between the time the grievance indicated the agency was called, and documentation which supported it was done. Staff B stated, You have a valid, point, it should have been thoroughly investigated. In an interview on the afternoon of 10/10/17 at 2:19 p.m., Staff C confirmed Staff QQ continued to work with residents after 07/31/17 and did not document in the computer that care was provided. RESIDENT #53 According to a grievance dated 04/10/17, (Resident #53) reports for the past 5 days her meds have been late. Specifically in the a.m. She reports she didn't get a.m. meds until 10 a.m. Per investigation: res is asleep at med times. The Department Manager review indicated the resident, stated she wants to be woken up for meds. Staff attached a concern/comment dated 11/22/16 which reflected the resident doesn't get to choose when she gets up. Would prefer to sleep in until 10:00 a.m. In an interview on 10/09/17 at 10:18 a.m., Staff B was asked which nurse(s), over the course of five days, administered the resident's medications late, what time the medications were ordered, what time they were actually administered. Staff B was asked if any other residents received medications late during that time period or if there were any negative outcomes based on the type of medications (for example pain medications.) Staff B stated, this is confusing and was unable to answer the questions. Failure to thoroughly investigate allegations of neglect (not receiving medications timely) detracted from staff's ability to confirm/refute the allegation. Additionally, in an interview on 10/09/17 at 2:27 p.m., Resident #53 stated, Yes I am still having issues with the meds being late .it's aggravating and there isn't anything you can do about it; they have one hour before and one hour after and they're still doing it late; they say it's because it's someone new and that's the excuse; it's been going on how long? .since April . RESIDENT #51 In an interview on 10/04/17 at 8:25 a.m. when asked if Resident #51 had fallen in the past 30 days, Staff G, (Licensed Practical Nurse, Resident Care Manager) said that on 09/13/17 Resident #51, reported to staff that he slipped and fell in the bathroom, roommate put the call light on, non injury. The last fall prior to that was on 08/17/17. In an interview on 10/03/17 at 8:44 a.m. Resident #55 referred to his roommate, Resident #51 and said, He has a hard time, when he falls I have to call for help .I tell them to leave the curtain open so if anything happens I can call for him. In an interview on 10/04/17 at 1:17 p.m. Resident #51's representative recalled, 1-2 weeks ago, Resident #51's roommate said, Did you know your dad fell today at 2:00 p.m.? The representative said Resident #51 falls getting out of bed, in the bathroom, the neighbor hit the call light. They don't answer right away so he started yelling. According to the 07/06/17 Quarterly Minimum Data Set (MDS - an assessment tool) Resident #51 required one person physical assistance with bed mobility, transfers, toileting, and one person supervision with ambulation. The resident's balance was assessed as not steady, but able to stabilize without staff assistance. The resident was frequently incontinent of urine, not on a toileting program and had sustained falls since the prior MDS, one non injury and two with injury. According to the 11/02/17 Limited Physical Mobility Care Plan (CP), the resident requires supervision at minimum with ambulation and reminders to use FWW (Front Wheeled Walker). Interventions listed on the 11/02/16 Risk for Falls CP included, but were not limited to: be sure the resident's call light is within reach, ensure resident is wearing appropriate footware when ambulating with therapy or up in w/c (wheelchair), identify & address any underline cause of fall risk as appropriate. On 10/05/17 at 9:23 a.m. Resident #51 was observed sitting on the bedside eating breakfast. The call light was on the bed, behind the resident and not easily within reach. Review of progress notes revealed documentation of nursing staff ensuring the resident was provided supervision while walking; 10/01/17 at 9:45 p.m., Independent with transfers and uses his walker to ambulate to BR (bathroom) to void, continent of urine . 10/03/17 at 1:29 p.m., Transfers himself & uses his walker to ambulate to BR to void, continent . 10/03/17 at 5:57 p.m., Able to ambulate self with walker to the bathroom, (resident) is continent of bowel and bladder ., Review of falls revealed Resident #51 reported he fell while in or going to the bathroom on 06/19/17, 06/29/17 (twice), 08/17/17, 09/13/17, and 10/07/17. Review of the 09/13/17 incident investigation revealed the assigned nursing assistant stated the resident was in his room with the NACs regular rounds doing his usual ADL (Activities of Daily Living) and within usual needs. The investigator did not ascertain what the nursing assistant understood those needs to be, what was provided or when the resident had last been toileted. In an interview on 10/11/17 at 10:50 a.m., when asked if the resident had been placed on a toileting program in an attempt to prevent reoccurrence, Staff C said in 2016, staff initiated a toileting schedule upon rising, before meals and PRN (as needed). The 11/02/16 Incontinence CP listed intervention of Prompted voiding: in AM upon rising, before meals and PRN. A 9/22/16 intervention listed voiding trial to determine schedule for toileting program. monitor for any s/s (sign/symptom) retention post Foley catheter removal. An 09/29/16 intervention listed trial scheduling toileting upon arising in AM, before meals and PRN successful. Staff C acknowledged the investigation did not determine if the staff were following the plan, nor was another toileting plan implemented. Review of the progress notes revealed on 06/29/17, I was called to residents room at around (5:00 p.m.), resident was lying on his right side on the floor .he had just come from the bathroom, he reported he slid and fell while trying to get in bed, he had on non skid socks, the floor was dry, his walker was by the foot of the bed ., Resident also had another fall at around (9:00 p.m.), this time he was found lying supine, his head was against the commode in the bathroom, he was bleeding from his rt (right) elbow, resident was assisted to bed, his gait was very unsteady, he had tremors and I was unable to get his BP (Blood Pressure) standing up. BP sitting was 158/53, p (pulse) 65, lying 96/41, p 66. Neuro checks were intact, he was wearing non skid socks, floor in the bathroom was dry, resident advised to use call light if he needed to use call light, bedside urinal offered, skin tear 1.5 x 5 cleaned and dressed. In an interview on 10/11/17 at 10:50 a.m. Staff C said after a resident falls, staff are to complete an incident report, conduct an investigation and implement interventions on the care plan. According to Staff C we log all incidents/falls on the incident report log. Neither of the 06/29/17 falls were listed on the log. Requests for investigative documents were requested. On 10/11/17 at 10:55 a.m. Staff C said They are not in our system. RESIDENT #34 In an interview on 10/04/17 at 8:32 a.m. Staff G said Resident #34 had a witnessed fall on 10/01/17. The resident got up from the table, grabbed walker, tripped and fell . The NAC was unable to get to the resident in time to prevent the fall. Review of the incident log on 10/11/17 revealed the incident was not listed on the log for investigation. In an interview on 10/11/17 at 1:17 p.m. Staff F, Registered Nurse - Resident Care Manager, said the incident report is in the computer, it needs a signature of Administrator, I'm guessing, it's all filled out. Staff concluded, This is the resident's first fall since she admitted , considered an isolated incident. Review of the investigation revealed no indication facility staff assessed any potential contributing factors to the fall including: appropriateness of footwear, environment, or medications. In an interview on 10/09/17 at 11:15 a.m., Staff B (Director of Nursing) and C indicated there were grievances that should have been investigated as neglect, and that investigations were not thorough. When asked, in an interview on 10/09/17 at 10:47 a.m., for details regarding the grievances in question which might confirm or refute neglect/abuse, Staff C stated, There are a lot of unanswered questions. Failure to investigate allegations prevented staff from identifying abuse and neglect and implementing timely interventions. In an interview on the morning of 10/12/17, Staff D confirmed there were investigations that were not reviewed or approved by an Administrator or Administrator designee. FOOD COMMITTEE According to Food Committee Meeting notes dated 06/13/17, topics discussed included, There were many comments/complaints made about CNA (Staff S-see above resident complaints), ignoring residents, saying she will do something and not return. (Resident #50) stated feels like she ignores her on purpose. One incident, served everyone but her a drink at table. Explained to the residents that these grievances should be filled out and filed with appropriate people. Facility staff failed to identify these allegations as potential neglect and/or retaliation, failed to protect the residents from further exposure to these behaviors, and failed to report or investigate these resident stated allegations. RESIDENT COUNCIL According to resident council minutes from 04/11/17, Between 9 and 10 pm it is difficult to get call light answered because some staff are ready to leave at 9:00 pm and Staff who work doubles sometimes complain about having to work a double. While facility staff were aware of this issue, there was no indication facility staff investigated to ensure resident's care needs were being met and that residents experienced no negative outcomes. Record review revealed the nursing staff monthly schedules and daily nursing assignment sheets did not match. The daily nursing assignment sheets did not list all the staff who actually worked, and did not indicate which section of the building the staff covered. In an interview on 10/11/17 at 8:32 a.m. Staff E said, generally it's an incomplete filling out of the form. Staff E noted that frequently the regular staff were listed on the daily nursing assignment sheets, but the agency staff were not. Failure to identify which staff were assigned to which residents, placed the facility at a disadvantage when investigating allegations. Reference: (WAC) 388-97-0640(2)(a)(6)(a)(b)(c)

Based on observation, interview and record review, the facility failed to ensure residents were free from a culture of abuse and neglect. Facility staff demonstrated continued and patterned behaviors of insensitive blaming of residents, dismissive responses to allegations of verbal abuse and neglect which resulted in residents feeling disregarded by staff and fearful of retaliation. These failures perpetuated emotional/psychosocial abuse as evidenced by a pattern of feelings of fear, frustration, anger, and concerns of retaliation, by multiple residents (Resident #s 53, 48, 59, 18, 28, 55, 50, 63, 75, 41, 14, 32, 56, 27, 44, 11 & 7) which constituted harm. Findings include: Refer to: CFR 483.10(f)(2), F-166, Facility Resolve Grievances CFR 483.13(b)&(c)(2)(3), F-226, Abuse Policies/Procedures CFR 483.15(a), F-241, Dignity CFR 483.15(c), F-243, Staff may Attend Groups CFR 483.25, F-309, Care and Services CFR 453.30(a)(1)&(2), F-353, Sufficient Staff POLICY/DEFINITIONS According to a ,[DATE] facility policy regarding Abuse/Neglect/Misappropriation/Exploitation, Abuse is defined as, the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Mental abuse was defined as coercions, harassment, inappropriately isolating a vulnerable adult from family, friends or regular activity and verbal assault that includes ridiculing, intimidating, yelling or swearing. Neglect was defined as The failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. FACILITY CULTURE According to facility investigative documents dated [DATE], corporate staff identified, The residents feel frustrated and do not feel that management has addressed their concerns or issues .One of the issues identified is the culture that has been created in the building, that complaining residents are related to behaviors and not addressing their issue(s). RESIDENT # 53 According to the [DATE] and [DATE] Minimum Data Sets (MDS-an assessment tool), Resident #53 had no cognitive impairment, demonstrated clear comprehension and was able to be understood in conversation and had no behaviors. In an interview on [DATE] at 1:12 p.m. Resident #53 stated she was fearful of Staff B (Director of Nursing Services-DNS). Resident #53 stated, She caught me outside my room, I didn't even know her, I knew her by sight and she started talking to me about my condition of depression that I had been seeing Navos (Mental Health Providers) for. They were recommending a plan of medication to help me with my depression and my daughter and I had thought the plan was good and I should try that (a planned medication change) because I had been suffering from anxiety and depression. The resident further elaborated, I didn't know she was going to evaluate me for the medication, she told me over and over and over when she caught me outside in the hall, I was in my pajamas and slippers. She kept telling me I didn't need medication and I didn't have depression and, 'Why do you think you have depression!' and 'You can't have it that badly!' and she kept going on and on and on and on The resident tearfully stated, I told her, 'You don't know me, you look at a piece of paper and you think you know me?' When asked how long ago this took place, the resident stated, It's been quite some time, seven months maybe; I've been here a year; I am not completely sure but it's been some time. She kept going on and on and I told her, 'What do you want from me?' When I said I had anxiety she said I didn't have that. I wanted to try to help myself be better and she finally went so long and so right in my face, inside my comfort zone; she said, 'You don't have depression do you?' and I eventually said no. She was able to stop my medication because she said I said I didn't have depression to get her to go away. After that it took even longer to get the medication. Resident #53 indicated she could not be alone with Staff B, stating that if Staff B was present, .I should be with either my daughter or (Staff RR-previous Social Worker). But she came back once after that and said, 'This will be different you can talk and I will ask questions', but I told her to leave and then I had to say 'Now!' because she kept talking; Staff RR talked to the administrator (Staff LL) to let him know how I feel; between the three of us he made it possible that she wouldn't be near me without someone present. When asked if she was fearful of retaliation Resident #53 stated, Oh yes, it's happened. The resident went on to describe medication changes and not always receiving the medications she should. When asked how she felt about Staff B, Resident #53 replied, I shouldn't have to fight for my medications. I don't even want to see her. I won't be around her; I am trying to get out of here so I can get every thing even keel. The resident was asked if she was afraid of anyone else and she stated, Yes we are afraid, we've had our rooms searched. They had someone in here saying that the state mandated that they could only have certain things in my room, and put plastic bags on things No they didn't ask, she just started going through my drawers .and my daughter got angry and they stopped. But they did it to (Resident #48) and I don't know who else. When asked if she would attend Resident Council if Staff B attended, Resident #53 stated, (Staff B) came to one of the meetings without being asked and I left. I can't be around her; even with my medications, it doesn't work when she comes around. I don't like to be angry I just can't stand the biting tone . In an interview on [DATE] at 2:30 p.m., Resident #53's daughter stated, When she first entered she was intimidating mom in her room. Mom feels uncomfortable, they decided from then on, I would have to be present or Staff RR when she was there would need to be present. When asked if there were any subsequent issues with Staff B, the family member stated, (Staff B) at one time called me um .about mom's (psychiatrist) we discussed everything and decided to put mom on a medication and Staff B called me and argued with me about the medication. I flat out told her she didn't know what she was talking about .I can't remember the exact date; it took a while probably about a month before they would let her take the medication. The family member further elaborated, There have been times when mom says she hasn't been given her medication or on time or it hasn't been ordered, it hasn't happened in the last month; but there for a while she was getting mix ups with her medications. I came in one afternoon and I couldn't rouse my mother. I talked to the nurse three times saying something is seriously wrong with her and the nurse told me to go get her a cup of coffee. I think they were giving her medications too close to one another. In fact she couldn't get a pulse; I made them call 911, and the ambulance driver said, You did the right thing . According to investigative documents dated [DATE], investigated after the above report, facility staff concluded Per investigation, resident/staff interviews, chart review, it is substantiated that DNS does not listen, respond to staff/resident concerns, and that the DNS (Staff B) has communication and interpersonal issues with peers and subordinates alike. (Resident # 53) reports she felt intimidated by the DNS when asked about her depressive state and in order to have her leave and terminate the conversation, agreed that she was not depressed, causing a delay in starting antidepressant medication. Abuse substantiated. RESIDENT #59 During initial Stage one interviews on [DATE] at 10:09 A.M., Resident #59 stated he did not feel that staff treated him with dignity and respect. Resident #59 stated, I've had some instances where I've been disappointed by staff and administration's response. It still sticks in my craw. The first week I arrived here I was in a room with a television blaring, blaring, all night long. I wanted to be someplace quiet so they put me in a conference room for five hours. I had no means of contacting anyone. I expressed my concern the second day I got here. They left me in my room with no call light. The resident gave another example of, Maybe a week or two weeks after that, one of the people (Staff R - Licensed Practical Nurse) involved in that .it was a Saturday .I waited for three hours and no one answered the light. So, I got up and went to the nurses station and, not aggressively, just flippantly said, 'What's today? Self-service?' and the nurse said, 'In your case, you're not gonna get any service.' She was totally disrespectful. And of course I got angry and shouted at her. The resident elaborated that he became even more annoyed when after he demonstrated behaviors as a result of how he was treated by staff, The doctor recommended I should see a counselor about my anger issues .that boggled my mind. I had another staff member who lied to me, most of the majority of people here don't care about me. The resident indicated that he understood that no one had to care about him, he was just interested in getting the help he was supposed to receive. Resident #59 cited an example of, There was an aide who said I wasn't on her set. It was (Staff S, Nursing Assistant). When I called her out on it she said 'Sorry I am having a bad day.' Ironically, she was the employee of the month . When asked if he reported to any of the administrative staff about the incident, Resident #59 stated, Yes, nothing happened except they put me in my room and left me alone. It got to the point that I was at the window hollering and a neighbor came over to see if they could help (when resident was left in his room). It was a staffing issue, it was a holiday weekend. It is pretty frustrating. RESIDENT #18 During initial Stage one interviews on [DATE] at 1:29 p.m., Resident #18 stated she did not feel that staff treated her with dignity and respect. Resident #18 stated, .Not so much, any more we have agency staff, we have very little original staff anymore, they don't listen, when you ask them something they say 'ok I'll get to you later' and dismiss you and never come back. I don't feel like that's right . RESIDENT #28 On [DATE] at 8:48 a.m. Resident #28 was observed in bed. In an interview at that time, Resident #28 said she was waiting for an aide to get cleaned up, I had an accident. When informed the call light was not on, Resident #28 indicated she knew, and said the aide had come and told her most of the staff were passing trays and asked if she could give him some time. Resident #28 said that had been about six minutes ago. At 8:55 a.m. Staff U, Nursing Assistant was observed in the hallway passing room trays. At 9:02 a.m. Staff U served Resident #28 in bed. After Staff U left, when asked if she was okay to eat breakfast while wet, Resident #28 replied Ya, you have to take advantage of the situation. At 9:39 a.m. Resident #28 acknowledged no one had come to assist her yet and commented, It's one of the busiest times of the day. At 9:58 a.m. the resident was cued by State Survey staff to put the call light back on. At 10:03 a.m. Staff U answered the light, asked if she needed something, Resident #28 said the commode would be handy. Staff U asked dissmissively, you good? as the resident attempted to sit up. Staff U said Did you know you have an appointment at 11 o 'clock, so in a few minutes I have to get you ready .not now. Staff U, noting the resident was still trying to get up, asked You want to use this? pointing to the commode and the resident replied Yes. As Staff U began to assist the resident he asked, Do you want to get dressed right now or wait a little bit, its 10 o 'clock and the resident responded, I better get dressed. The resident's bed was observed to be wet through the soaked attends she was wearing. When informed of the delayed response, Staff U said Nobody told me. Resident #28 said I don't understand these folks. I just want to go home. RESIDENT #55 In an interview on [DATE] at 1:57 p.m. as Resident #55 put on the call light for assistance to get into bed, he said Yesterday it took me three hours to get back into bed. At 2:01 p.m. Staff T, Nursing Assistant was observed to enter the resident's room, turn off the light, and leave the room without asking the resident what, if anything the resident needed. RESIDENT #50 In an interview on [DATE] at 1:29 p.m. when asked if she was treated with dignity and respect, Resident #50 stated,I have had issues with (Staff Q - Licensed Practical Nurse) the nurse. I had a couple of run ins with her. When asked to describe a specific incident Resident #50 responded, Here's an example, my concentrator quit working and I could tell my oxygen level was low .I have [MEDICAL CONDITIONS] and I know when it (oxygen level) is low .my fingers were turning blue they don't answer the call light down here .I used my cellphone to call the front desk Staff G (Residential Care Manager) came running and took care of it. The concentrator was replaced. I told Staff G I was angry that Staff Q was not around to help me .about 15 minutes later Staff Q came down, she knew I was mad, she said, 'I don't have a crystal ball, I was busy with other people.' What kind of response is that? I was pissed off, and I mean really pissed off, I felt like she was talking down to me, like I didn't matter to her, I was pissed . I then filled out a (grievance) form. RESIDENT #63 Resident #63 admitted to the facility on [DATE] with care needs related liver disease and ascites. According to the [DATE] Quarterly MDS the resident had a BIMS (Brief Interview for Mental Status) score of ,[DATE], indicating the resident was cognitively intact. On [DATE] at 10:10 a.m. Resident #63 complained of staff not bringing his pain medications on time. When asked for specifics, Resident #63 stated, Last night for example, I requested my pain medication at around 10:30 p.m., I asked before that, but they said I could not have it until 10:30 p.m My pain was a 2 (out of 10) when I was lying in bed. It's tolerable if I am lying in bed. Finally at 11:00 p.m. I walked down to the nurses station to see what the hell was going on with my pain pill and cussed her (nurse) out. My pain was an 8 walking down the hall. My pain pill was right on the counter next to them, they had already got it ready, but she said she would not give it to me until I ate my blood pressure pills .I still had two blood pressure pills in my cup, they were from earlier in the day like 8:00 p.m so I had to walk back to my room. I got it (pain pill) at almost exactly 11:30 p.m She brought it to me and I took it with my blood pressure medications. Resident #63 then verbalized, She (nurse) was just mad at me 'cause I cussed her out. A nurses note written on [DATE] at 2:00 a.m. by Staff TT, Licensed Practical Nurse (LPN) stated, Res(ident) is alert and responsive, with server (sic) confusion and forgetfulness .Res(ident) came to the nurses station wanting his pain medication. Resident was explained that it was change of shift and this nurse would be down with them. Res(ident) went back to the room and could be heard yelling at the aid (sic) about having to go back down to the nurses station again, Staff asked about his medication that he still did not take from evening shift .I put the pain pill in the medication cup with his other medications and watched him swallow .Res(ident) then began to yell about his pain pill that he just got done taking in front of me. Res(ident) was reminded(sic) of chain of events and was still not able to remember .Res(ident) behavior seems to fall in line with not taking his [MEDICATION NAME] as ordered. Res(ident) has a hx (history) of these behaviors when medication is not taken as ordered. Res(ident) has HX of throwing out [MEDICATION NAME] when left on table . The nurses note portrayed the resident as severely confused, yelling and having, behaviors that fall in line with not taking his [MEDICATION NAME]. There is no mention of the underlying cause of the resident's behaviors, which was staff's failure to provide the resident with his pain medication in a timely manner, exacerbated by the increased pain caused by being required to walk to the nurses station to inquire about the delayed pain medication. Instead, the note implied that the staff were being treated unfairly, effectively dismissing the resident's expressed concerns. According to an interview on [DATE] at 11:06 a.m., Staff D (Corporate Nurse) confirmed there was a delay in administration of pain medication. RESIDENT #75 On [DATE] at 1:16 p.m., Resident #75 overheard his roommate speaking with a surveyor about not receiving pain medications timely. Resident #75 stated, That is why I keep this. Resident #75 held up a handwritten log of the dates and times he had received his pain medication. Resident #75 stated he had to start writing it down because staff were not bringing his pain medications when he requested them. When asked if he had told anyone about his late pain medications, Resident #75 laughed and stated, Ya, everyday .I don't remember who, the first few days I had a different person every time .after a day or two I realized it doesn't do any good, they (staff) would just say 'ok, I will tell someone' but nothing happened .One day I tried not to take any (pain medication) because I was so pissed off that they didn't bring them (when requested), but that was a bad idea .I had hip surgery .I got to where I could not tolerate it, so I had to request them again .I am a pretty laid back guy, I am known for my patience with people who know me, but one day I was just pissed off, I don't understand why (they can't bring pain medication when requested), it is easier to do things right then to lie about it . It is just too bad we have to suffer. I am not a complainer but my roommate is going to be here after I leave and I want this taken care of. When asked if anyone from the facility had followed up with him about the late pain medications Resident #75 stated, no. RESIDENT #41 In an interview on [DATE] at 9:32 a.m., Resident #41 stated he did not feel like staff treated him with dignity and respect stating, Sometimes yes, sometimes not .I will keep it to myself. While the resident declined to elaborate on dignity issues, he commented on some of his issues with staff stating, Some guy tried to wake me up by tickling my feet, what do they (the facility) do, hire 'em out of King County Jail? The resident also indicated he had an issue with staff going into his personal areas stating, There was somebody rifling around in my closet, I had to tell 'em to get out. Just the two black guys I set 'em straight and they went to squeal to the nurse. They squealed like babies. The resident indicated he was scolded by staff for protecting his property and trying to direct his own care. On [DATE] at 1:34 p.m., Resident #41 requested to speak to a surveyor. Resident #41 reported, (Staff KK, LPN) is a nurse that used to work here but she left. Now she just comes here and there. I turned her in once for not helping (a resident) who was on the floor. After that she wouldn't bring me my pain medications on time. She would tell me I had to wait because she was busy .later she told me 'It doesn't pay to smart off to us nurses.' Resident #41 indicated that he felt Staff KK was retaliating against him for turning her in. When asked if he had reported this to the facility, Resident #41 sated, It doesn't do any good they will make ya pay for it but I think it is time to stand up for my dignity and make a stand . She (Staff KK) was here the last couple of days, I told her let's start over but she just stared at me .as soon as you leave they are gonna (expletive) me over .most of the nurses here care a lot, just not (Staff KK). RESIDENT #14 In an interview on [DATE] at 1:35 p.m., Resident #14 said, The house is always right and the things the patients come up with are their own fault. When asked about his experience with Staff B, Resident #14 said She and I have had words in the past. I'm not confident that she understands what the problems are in regards to patient relationships. When asked how he felt about Staff B, Resident #14 replied, Since I try to avoid her I don't really know how well she performs on her job, I'm assuming she performs according to the standards of this place, so I tend to accept what this place lays down as their rules and I stay away from her. RESIDENT #32 In an interview on [DATE] at 1:17 p.m., when asked if she had experienced any medication errors, Resident #32 replied, I don't ask anymore. I just say a prayer and take them. When asked about her experience with Staff B, Resident #32 said All I know is what I've heard .from what I've heard she's not very well liked. Resident #32 said she had heard this from the other staff members. When asked specifically what she had heard, Resident #32 said she's not approachable, she has certain people who are pets, and that creates unrest when you have that situation . GRIEVANCES/INVESTIGATIONS RESIDENT #59 Resident #59 was admitted to the facility on [DATE] and according to the [DATE] Admission MDS had no cognitive impairment and had [DIAGNOSES REDACTED]. The resident was assessed to require two person extensive assist for bed mobility and transfers and one person limited physical assistance for locomotion on and off the unit. This MDS indicated the resident was unsteady moving from a seated to standing position, only able to stabilize with human assistance. The resident was determined to have bilateral upper extremity functional limitations in range of motion. According to a grievance dated [DATE] the resident reported, he had to wait three hours for help when in the conference room on [DATE]. When he got moved to a different room the call light was not working so he had to wait again for over an hour . Staff documented under action taken that Resident (#59) requested to go to a quiet room, EVE(ening shift) LN (Licensed Nurse) offered him to sit in conference room, he agreed, NACs (Nursing Aide Certified) were checking on him every 15 mins. LN checked call light when res(ident) complained that call light not working and found it was in good working condition . Progress notes dated [DATE] at 12:58 a.m. indicated, Res(ident) yelled at staff because electric chair needed to be recharged . According to this note the resident remained in the conference room at 10:30 p.m. and the evening shift nurse (Staff KK- see above resident complaints) Informed (night) staff where resident was. This note also indicated the resident refused to stay in room and wanted to go and sit somewhere quiet and when later asked if he wanted to go back to his room the resident stated, when the room is quiet. Facility staff labeled the resident as refusing when he only wanted a quiet environment. According to the grievance form, facility staff concluded, at about 10:35 (p.m.) the resident used his phone to call the facility (from the conference room) so it was not like he couldn't reach the staff or the staff were not regularly checking on him as he was in the conference room. Rather than question why the resident had to resort to using his phone to contact staff or detail what the phone call entailed, facility staff rationalized this as having a means to contact staff. Findings were listed as, Resident was anxious on his (first) day of admission . Facility staff labeled the resident as anxious, rather than consider his frustrations at being secluded in a conference room for a prolonged period of time after attempting to avoid placement in a noisy room. A progress note later in the morning identified the resident was verbally aggressive toward staff .stated, I want to leave this room. Facility staff documented,Resident has complained multiple times about his roommate bothering him . Resident temporarily moved to room across the hallway to a room by himself. Resident satisfied at this time with room . Facility staff blamed the resident for being angry and verbally aggressive towards staff rather than initially identifying and attempting to resolve the resident's concerns. This document did not indicate if the call light in question was the call light in the conference room or the call light in the room the resident was moved to later that evening. There were no interviews with any of the NACs who purportedly did 15 minute checks, nor were there any documents to support 15 min checks were done. [DATE] According to investigative documents dated [DATE], On [DATE] (Resident #59) filed a grievance against LPN (Staff R) regarding an incident that occurred on Saturday [DATE] in the afternoon. He alleges that he needed his urinal emptied and had his call light on for about an hour, and when no one came to help, he walked down to the nurses station and jokingly said, What is this, self-service day? He alleges that the nurse (Staff R) asked him to be more respectful if he wanted someone to help. He then alleged that she said something about his mother at which time he went back to his room . Facility staff failed to identify that this allegation was equivalent to a threat of withholding services unless behaviors complied with staff expectation. According to this document, .he claims that she (Staff R) said, Your momma at which time he said, yes my momma was fat too and died . Facility staff completing this investigation documented the resident indicated .he was not harmed and not afraid that he was just angry that she was so rude to him. According to this document, Staff KK (a nurse who witnessed the incident) heard Staff R say Your mama. Staff KK said, (Staff R) looked surprised that he heard her. Facility staff failed to identify this statement was disparaging, derogatory and clearly within Resident #59's hearing distance which constituted verbal abuse. This document indicated, there is evidence that this nurse tried to handle the situation professionally but also that the resident's behavior did get to her eventually. Facility staff justified Staff R's actions as related to Resident #59's behavior and failed to consider the resident's self admitted aggressive behaviors were a result of not getting his initial needs met. Facility staff failed to consider Staff R's witnessed rude behavior towards Resident #59 caused the resident to experience anger and, per his report during initial rounds, frustration. This investigation indicated Staff R had No prior write ups for similar incidents. Was educated previously regarding a similar incident . [DATE] Investigative documents dated [DATE] indicated, Resident is stating that he needed assistance but he didn't get it and he had to self transfer. According to this document, The resident put his call light on at 10:30 a.m. At 10:40 a.m., (Staff S) and (Staff SS, NAC) went to answer his call light, but the resident cussed them out and said: Get the (explicative) out of here, this place is (explicative). Staff concluded, Abuse or neglect ruled out, incident reasonably related to resident's anger about his own condition. Staff documented, He has been offered mental health and 1:1 (one to one contact) but declined both. Staff failed to identify how it was concluded the call light was on for only 10 minutes before assistance was offered, and failed to consider the resident's demonstrated anger was consistently related to stated delays in receipt of care. Additionally, facility staff failed to identify the resident's indignation at being offered mental health services related to anger about not receiving the care he believed he required in a timely manner. RESIDENT #56 Resident #56 was admitted to the facility on [DATE] and according to the [DATE] Admission and [DATE] Quarterly MDSs, was assessed with [REDACTED]. According to investigative documents dated [DATE], Resident #56, alleged that LN (Staff R) is aggressive with her approach and intimidates him. He also stated that he asked for his pain medicine and she wouldn't give it to him on time. According to the investigative documents, It was noted that the resident had an increase in [MEDICATION NAME] from 10 mg to 60 mg and it may be causing the agitation. Staff concluded, The change and irritability was noted in the resident's behavior after the start of the [MEDICATION NAME] 60 mg . Staff subsequently concluded the [MEDICATION NAME] caused side effects of agitation, anxiety and paranoia, contacted the physician and had the [MEDICATION NAME] decreased. Staff offered a room move to be on the other wing away from the LN he dislikes, he refused. Staff failed to identify how [MEDICATION NAME] would cause the resident to dislike only Staff R, or why the resident should have to move to avoid the LN. Staff failed to identify how [MEDICATION NAME] would cause the resident to identify that only Staff R intimidated him. Progress notes by Staff R dated [DATE] indicated, Res(ident) nervous, panicky and shaking during initial interaction. When approached resident jumps behind another staff member. Res asked if he needed any assistance or was there an issue. Res asked to be left alone by this nurse. Res request respected and another nurse pulled and gave him his medication. Staff R wrote on [DATE] Res(ident) demonstrates aggressive behavior upon this nurse arriving on shift. Res panicky and nervous about this nurse giving his care. Res was assured that there is no need to be scared and care will be given as he requests. Res balls up fists and tightens body. Res states he will not accept care from this nurse. Res proceeds to threaten this nurse, watch yourself with balled fists . Review of progress notes during this period revealed the resident did not demonstrate this fearful/aggressive behavior with any other staff member. There was no indication why, after identifying the resident wanted nothing to do with her, Staff R continued to approach the resident on [DATE]. Facility staff failed to identify the resident's aggressive behavior was related to Staff R disregarding his repeated requests to be left alone by her. In an interview on [DATE] at 11:53 a.m., when asked if he had any issues with any staff members being aggressive back in June Resident #56 stated, Oh yeah, that'd be (Staff R) . It was a constant problem with her; She was horrible. That'd been going on for a while . it (was) a battle between her and me, she made my life hell, she doesn't work here no more . The resident was observed at this time to retrieve a card from his glass case, on which Staff R's name was written. Yep, her name was (Staff R). (Staff LL) was the (administrator) here and there was a problem over like, the Fourth of July .he said he would take care of this but he ended up leaving shortly there after. I said I was going to call the police but he didn't want me to, he said he'd take care of it. I went to nursing staff but they didn't do anything .I kept saying what is up with her (Staff R), is she related to somebody in the company? The resident indicated at this time he was frustrated that his concerns, including those regarding Staff R, were dismissed. RESIDENT #27 According to a concern/comment form dated [DATE], Resident #27 was concerned she did not receive her bowel program early from the LN as planned and as requested. According to this document, the agency staff member was told 3 times to do the bowel program for the resident and assist with her AM care per MD's orders but she refused and

Based on observation, interview and record review, the facility failed to ensure 14 (#s 40, 74, 28, 63, 59, 18, 12, 57, 22, 31, 51, 26, 29 & 55) of the 22 sample residents and two (#s 75 &11) two supplemental residents reviewed, received the necessary care and services to attain or maintain their highest practicable level of well-being. Failure to ensure three (#s 74, 28 & 63) of three and five (#s 40, 75, 59, 18 & 12) supplemental residents reviewed for pain, received timely and effective pain management; two (#s 74 & 57) of three and one (#59) supplemental residents reviewed for non-pressure skin received services related to skin issues; consistent bowel care was provided for four (#s 40, 31, 22 and 12) of five residents reviewed; TED Hose (compression stockings) were applied as ordered for five (#s 51, 26, 11, 12 & 29) of six residents reviewed; one (#55) of two residents reviewed for positioning was positioned appropriately, one of one (# 22) residents reviewed for needs related to sleep apnea, and Intake & Output monitoring was provided as ordered for Resident #63, placed residents at risk of decreased quality of life and resulted in harm to seven of seven residents related to not applying interventions to manage pain in a time consistent with the residents' needs. Findings include: Refer to: CFR 483.20(k)(3)(i), F-281, Services meet Professional Standards CFR 453.30(a)(1)&(2), F-353, Sufficient Staff PAIN After the State Agency informed the facility of multiple resident complaints about late pain medications, the facility initiated an investigation. According to the 10/16/17 investigation documents: There have been multiple allegations of late medications, specifically pain medications on multiple shifts, by numerous residents .Multiple staff, residents' interviews and chart reviews were completed .Per investigation, resident and staff interviews and chart reviews, it is substantiated that there is a trend with residents not receiving pain med(ications) timely, whether routine or as needed. The residents feel frustrated and do not feel that management has addressed their concerns or issues .Root cause: One of the issues identified is the culture that has been created in the building, that complaining residents are related to behaviors and not addressing their issues; Lack of oversight, supervision, auditing, and management of pain management process; agency staffing; Resident assignments (staffing). RESIDENT #40 Resident #40 admitted to the facility on [DATE] with care needs related to dementia, impaired functional mobility, anxiety and depression. According to a 07/25/17 Quarterly Minimum Data Set (MDS - an assessment tool), the resident required two person extensive assistance with most Activities of Daily Living (ADL), had moderate cognitive impairment and experienced pain occasionally. Observations on 10/10/17 revealed; at 6:07 a.m. Resident #40 could be heard calling out help me, help me from the nurses station, two nurses aides and one nurse were present but did not go investigate; At 6:13 a.m. Resident #40 was still calling out Help me, help me when asked what was wrong Resident #40 stated, My butt hurts. The head of the bed was noted to be at approximately 30 degrees, resident was supine with heels floated on pillows and the knee of the bed elevated.; At 6:50 a.m. the resident was observed to be in the same position calling out Please help me .my butt .my legs hurt, my right one.; At 6:55 a.m. the resident was again observed in the same position calling out help me; At 7:35 a.m. Resident #40 was still calling out help me my butt, observed in the same position, supine in bed with head of bed at approximately 30 degrees, bed elevated at knee and heels floated on pillows. On 10/10/17 at 8:09 a.m. Staff CC, Licensed Practical Nurse (assigned to resident #40) was observed passing medications. Resident #40 was heard calling out help me. Staff CC stated, she wants her PRN (as needed) pain pill. Staff CC prepared [MEDICATION NAME] 2.5 mg for pain. Per the narcotic ledger the last time it was used was 10/09/17 at 1:10 p.m.(which was a scheduled dose). Upon entering Resident #40's room she was heard calling out Lord help me, oh Lord help me. Staff CC stated, I am sorry you are hurting, to which Resident #40 responded, I'm sorry I'm hurting too .my butt . Staff C responded, We can reposition you and attempted to find a nurses aide but was unable to locate one. Resident #40 expressed that her pain was a 10. After administering the [MEDICATION NAME], Staff CC exited the room without repositioning the resident. On 10/10/17 at 8:18 a.m. Resident #40 was still heard calling out help me, help me Staff CC was passing medications and no nurses' aides were seen in the area. Resident #40 had not yet been repositioned. On 10/10/17 at 8:21 a.m. Staff CC saw a nurses aide and requested that Resident #40 be repositioned. On 10/10/17 at 8:31 a.m. Resident #40 was no longer heard calling out. Review of the October 2017 physician's orders [REDACTED].#40 had orders for [MEDICATION NAME] three times a day, [MEDICATION NAME] 2.5 mg once per day and every four hours as needed and for a [MEDICATION NAME] to be applied every three days with direction to check placement every shift. Review of the October 2017 Medication Administration Record [REDACTED]. Staff documented + on 10/08/17 evening and night shift indicating the patch remained in place. On 10/09/17 day shift, the nurse documented - indicating the [MEDICATION NAME] was not in place. Evening and night shift on 10/09/17 and day shift on 10/10/17 also documented - indicating the patch was not observed to be in place. A 10/10/17 at 8:27 a.m. nurse's note stated, Res(ident's) assigned LN (Licensed Nurse, Staff CC) reported that the res(idents) [MEDICATION NAME], that was applied on 10/08/17 fell off .and (Staff CC) was unable to find it on her skin. Assessed the res(ident's) body and was unable to find patch. Pt (patient) c/o (complains of) 'all over' pain, MD notified, ok to put on new patch . A 10/10/17 at 8:47 a.m. progress note stated, [MEDICATION NAME] that fell off was found in res(ident's) bed. In an interview on 10/12/17 at 7:56 a.m. When asked what action should be taken if a [MEDICATION NAME] is noted not to be in place, Staff G, Resident Care Manager stated, Try to find it, call the doctor and get an order to replace it earlier. When asked why the nurses who documented on 10/09/17 day, evening and night shift did not notify the MD that the patch was missing, Staff G indicated she did not know and stated, I wish I was aware .I did not know. When asked what the resident's primary source of pain control was, Staff G stated, I would say it is her [MEDICATION NAME] because she does not refuse it, indicating that Resident #40 did refuse her oral medications at times. Review of Resident #40's every shift pain monitor from 09/01/17 to 10/10/17 revealed that, over the past 120 shifts on three prior occasions the resident report pain greater than 7. Facility Staff' failed to respond to Resident #40's calling out in pain for over two (observed) hours. Staff failed to: assess the source of pain, provide non pharmacological interventions such as repositioning, failed to offer the resident her as needed pain medication (until 8:09 a.m.), and failed to notify the doctor that the resident's [MEDICATION NAME] was not in place until greater than 24 hours after it had been identified. These failures resulted in harm to the resident who experienced increased and prolonged pain secondary to staffs' inaction. RESIDENT #74 Resident #74 was admitted to the facility on [DATE] and according to the 09/28/17 Admission MDS had [DIAGNOSES REDACTED]. This MDS indicated the resident required daily and as needed pain medication and was to receive end of life care. Observation on 10/04/17 at 8:28 a.m. revealed the resident lying in bed. The resident was able to participate in conversation, but frequently vocalized pain, grimacing as he moaned oh, it hurts rubbing his knees and back of neck/shoulder area. In an interview at that time Resident #74 stated he had, pain between shoulder blades and knees. The resident indicated he often had to wait for his pain medications stating, You'd be surprised at what a difference you guys coming in can make, she (nurse) usually says she's too busy or doesn't have enough time (to get medications); it takes 45 minutes (to get pain medication). They promised me at (the hospital) that I was here for pain control; you wait that long and the pain really sets in. When asked how long he had to wait for pain medication the resident stated, The longest time? I'd say over an hour. The resident indicated that dayshift is wonderful but he had issues with evening and night shift staff providing timely pain medication stating, I am in a tough spot, I don't want to say anything or I won't see them (staff) at all .I think at night it's pretty chronic, I don't see much enthusiasm at night, since you came in somebody's watching. In an interview on 10/06/17 at 7:50 a.m., the resident stated he had pain in both knees and a pain level of 7 to his right shoulder and upper right back, between my shoulder blades. The resident indicated his pain needs to be addressed more and indicated he wanted, to be woke up for scheduled meds. The resident expressed frustration that when he pushes the call button he gets the help that are not nurses and he has to wait for pain medication. In an interview on 10/12/17 at 9:31 a.m., the resident complained of pain in his back. Review of MARs from 10/01 through 10/06/17 revealed the resident was correct, and on evening shift of 10/02/17, the resident received [MEDICATION NAME] that was scheduled for administration at 4:00 p.m., six hours later at 10:22 p.m. Nursing staff also administered the regularly scheduled 10:00 p.m. dose of [MEDICATION NAME] at 10:22 p.m., essentially doubling the dose. Similar findings were identified on evening shift on 10/04 and 5/17 and night shift on 10/02/17, when the resident's [MEDICATION NAME] was administered over an hour outside the prescribed window. Failure to administer regularly scheduled pain medication timely as directed caused the resident to experience unrelieved pain, and constituted harm. Review of September 2017 MARs revealed direction to staff to apply a [MEDICATION NAME] Patch 5% apply to affected area topically one time a day for pain. Apply two patches [MEDICATION NAME]. The order was changed on 10/06/17 to read [MEDICATION NAME] Patch 4% apply to bilat (eral ) knees topically one time a day for knee pain. A 10/06/17 PO directed staff to apply, [MEDICATION NAME] 4% apply to center of shoulder blades topically one time a day for back pain. Despite clear instructions, nursing staff on 10/08/17 documented, [MEDICATION NAME] to knees and lower back. Failure to apply the patch to the correct affected location (between shoulder blades) detracted from the intended efficacy of the medication. In an interview on 10/12/17 at 8:36 a.m. when asked about the application location for the original [MEDICATION NAME] order, Staff H, Licensed Practical Nurse (LPN) stated, When it says affected area I asked the patient, when I went in there he (Resident #74) said, The knees is where I get the patches, he was getting 1/2 a patch to each knee .and then the order changed .then it was a patch to his back and the same as always, his knees; Hospice changed the percent to 4%. When asked how she knew the resident wasn't to receive the pain patch to the back/shoulder area as that was affected with pain, Staff H repeated the resident indicated he got patches to the knees but was unable to confirm the resident should not have received a patch to the back. Staff H confirmed, the order itself wasn't clear, it didn't specify what area was affected. In a secondary interview on 10/12/17 at 10:18 a.m., Staff H indicated they were cutting the pain patch in half when applying the knee patches back when it was a 5% order. Halving the dose of the pain patch by cutting it in half reduced the efficacy of the [MEDICATION NAME]. RESIDENT #28 Resident #28 admitted to the facility on [DATE]. The 09/18/17 30-day MDS indicated the resident had [DIAGNOSES REDACTED]. In an interview the resident indicated she had pain, occasionally, which did not make it difficult to sleep or limit day to day activities. The resident's worse reported pain was at a level six. In an interview on 10/05/17 at 9:28 a.m. Resident #28 said her current pain was as usual, between six and seven. An 08/21/17 Pain Assessment revealed the resident indicated she had frequently experienced pain in the prior five days, in the lower back, which did not make it hard to sleep at night and did not limit day to day activities. The resident's acceptable level of pain was identified as 4 out of ten. The 09/19/17 Pain Care Plan (CP) indicated the Resident reports increased spasms to back and legs following chemo treatment. The listed goal was The resident will not have an interruption in normal activities due to pain through the review date (10/31/17). The CP did not include a measurable pain level goal. In an interview on 10/11/17 at 12:48 p.m. Staff F, Resident Care Manager acknowledged the listed goal did not meet the resident's reported pain level goal. The 09/19/17 Pain CP interventions included, Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor pain, pain med administration, and pain medication effectiveness per facility protocol, Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain, provide non-drug interventions PRN for pain including repositioning, elevating legs, laying on her side. Review of the MARs revealed no non drug interventions were documented as provided in July, August, September and October 2017. In an interview on 10/11/17 at 12:48 p.m. Staff F said Yes I know, that was an issue we had last year, we will need to educate them again. On 10/03/17 at 11:02 a.m. Resident #28 was observed rubbing her left knee. Resident #28 was also observed trying to free her feet from sheets at the foot of the bed, which caused pain to her left knee. Resident #28 put on the call light and Staff B promptly responded and freed the resident's feet. Staff B asked the resident, You need pain medication?, and the resident responded, Ya. In an interview at that time, when asked about the left leg pain, Resident #28 said, It is really new. I've had a knee replacement and I swear if I had to do it again I wouldn't. It aggravated this leg (pointing to the right leg), now I have a [MEDICAL CONDITION] (blood clot) in that leg and anticoagulant to keep it out of the lungs, and the doctor thinks I'm in full blown invasion .I have two types [MEDICAL CONDITION] .At 11:05 a.m. a nursing assistant entered the room and told the resident, Nurse said you are due within the hour. She will bring it to you. At 11:21 a.m. the nurse brought the resident an Iron pill and a pain pill. In an interview on 10/03/17 at 11:07 a.m. when asked if she had any discomfort or pain, heaviness, burning, or hurting with no relief?, Resident #28 replied, Yes and explained, still hurts 45 minutes after pain medication, then it starts to go down to where I can stand it. When asked if she received pain medications timely, Resident #28 said most of the time, unless we're super busy then I get left on the back burner, but I'm from a family of nurses, it doesn't get bad until I start yelling. When asked why she yells, Resident #28 said Because the pain has gone up higher than my max I scoot myself around, move my legs because that is what hurts, if they're still not here when they reach 7 then I yell until I get my meds. Review of the September 2017 MAR indicated [REDACTED].every shift for pain management. Staff documented the resident had a pain level of 9 on night shift of 9/28/17. The resident was given [MEDICATION NAME] 5 mg at 2:34 a.m. The resident had not received a PRN pain pill since 11:36 p.m. on 9/26/17, despite a pain level of 5 on day and evening shifts on 09/27/17. On 09/20/17 at 2:42 a.m. Resident #28's pain was assessed at level 9 and the resident was given [MEDICATION NAME] 5 mg and Tylenol 650 mg. The resident had not received a PRN pain pill since 09/19/17 at 4:38 a.m. despite pain levels of 5. Similar findings were noted on 09/22/17 when the resident was assessed with [REDACTED]. In an interview on 10/11/17 at 12:48 p.m. Staff F was unable to explain why staff were administering both medications at the same time, I don't know. Staff F indicated the expectation would be to give one and if not effective then administer the other, and if needed to administer together to notify the physician. Review of MARs for July 2017 revealed the resident did not have routine pain medication ordered, and experienced pain levels of 7 and above on 11 occasions. In August 2017 the resident had pain levels of 7 and above on 26 occasions, and on 08/14/17 was started on routine [MEDICATION NAME] 5 mg three times a day. In September 2017 the resident's pain was above 7 on 18 occasions. Further review of the 08/21/17 Pain Assessment revealed staff documented the resident received 0 PRN pain medications since last review and answered No to the question, Has there been a change in pain management since last review. The prior review, dated 07/24/17 noted the resident received PRN pain medications on 11 occasions. Review of the July and August 2017 MARS revealed the resident received PRN pain medications on 45 occasions. On 10/06/17 at 10:01 a.m. Resident #28 said her pain level was about a seven. Resident #28 said she had received a routine pain pill, I got one this morning, but had not received a PRN pain pill, I'm only supposed to get them every four to six hours. I'm probably due for another one, but they're very very late. In an interview on 10/06/17 at 10:15 a.m. Staff BB, Licensed Practical Nurse, confirmed the resident received her morning pain pill, Yes, I already did, she has blood sugar before eating, so I start with my blood sugar residents. Review of the October 2017 MAR indicated [REDACTED] RESIDENT #63 Resident #63 admitted to the facility on [DATE] with care needs related to liver disease and ascites. According to the 07/18/17 Quarterly MDS, the resident was cognitively intact, required only supervision for activities of daily living, and did not have pain. Record review revealed, a 09/26/17 nurse's note that stated the resident c/o (complained of) pain 9/10 to L(eft) hip, denies falling, hurting his hip, stated it just started hurting when he was walking to the bathroom. Called (provider), ordered X-ray to rule out fracture or dislocation. The X-ray results were received on 09/27/17 and concluded there was no fracture or dislocation, revealed only [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of the October 2017 PO's revealed, a 10/02/17 order for [MEDICATION NAME] 50 mg every 12 hours as needed for Sciatica (describes leg pain, numbness or weakness that starts in the low back and travels down the sciatic nerve in the leg causing sciatica pain). On 10/10/17 at 10:10 a.m. Resident #63 complained of staff not bringing his pain medications on time. When asked for specifics, Resident #63 stated, Last night for example, I requested my pain medication at around 10:30 p.m., I asked before that, but they said I could not have it until 10:30 p.m My pain was a 2 (out of 10) when I was lying in bed. It's tolerable if I am lying in bed. Finally at 11:00 p.m. I walked down to the nurses station to see what the hell was going on with my pain pill and cussed her (nurse) out. My pain was an 8 walking down the hall. My pain pill was right on the counter next to them, they had already got it ready, but she said she would not give it to me until I ate my blood pressure pills .I still had two blood pressure pills in my cup, they were from earlier in the day like 8:00 p.m so I had to walk back to my room. I got it (pain pill) at almost exactly 11:30 p.m She brought it to me and I took it with my blood pressure medications. Resident #63 then verbalized, She (nurse) was just mad at me 'cause I cussed her out. On 10/10/17 at 10:13 when asked if his pain got worse while waiting for the pain medication, Resident #63 stated, well it was a two when I am just lying in bed .it got worse an 8/10 because I had to walk down there .it is tolerable if I am lying in bed, it hurts when I have to get up .like going to the bathroom . According to investigation documents, in a statement obtained on 10/12/17 at 9:10 a.m., Staff KK (evening shift LPN) stated, Prior to the start of night shift (Resident #63) had asked for his [MEDICATION NAME] but I told him it wasn't due until 10:30 p.m. (Per Staff D, Corporate nurse, night shift starts at 10:00 p.m.). During report at 10:15 to 10:25 (Resident #63) came back to the nurses station again very angry telling us we were supposed to give him his pain pills. I reminded him they were not due until 10:30 p.m., he walked away cussing .when count was over Staff TT began getting his medications ready and he walked back to the nurses' station .Staff TT said she would bring them to him but he said he wanted them right there .Staff TT told him to take a seat but again he got angry and I couldn't tell what happened but he went back to his room. Per a statement obtained by telephone on 10/11/17 at 5:30 p.m., Staff TT (oncoming night LPN) stated, While LN's were doing report/count a NAC (Nursing Assistant Certified) told her Resident #63 had requested pain medications. She asked the NAC to remind Resident #63 to take his meds that were there (blood pressure meds at bedside from 8:00 p.m.) and she would get his pain meds as soon as she was done with report. At approximately 11:00 p.m. (Resident #63) came back to the nurses' station and Staff TT was in the process of getting him his meds, when she then tried to give him his meds but he wouldn't take the [MEDICATION NAME] without cranberry juice. So Staff TT told him to go back to his room and she would bring cranberry juice. The investigation does not determine why Staff TT was attempting to give the Resident his [MEDICATION NAME] when he had requested his [MEDICATION NAME] for pain or why the resident was instructed to go back to his room while she obtained cranberry juice to go with the [MEDICATION NAME] instead of providing the [MEDICATION NAME] as requested. Further, by all accounts the resident initially requested his pain medication prior to night shift (10:00 p.m.) and was told it was not due until 10:30 p.m. Per the nursing statements the resident came back out at 10:15 to 10:25 p.m. and was again told to wait until 10:30. At 11:00 p.m. the resident still had not received the requested pain medication even though staff were aware that he needed it and could have it at 10:30 p.m. per their own statements. The investigation concluded, .That medication administration procedures were not followed. There was a delay in administration of requested PRN [MEDICATION NAME] as the resident could have received it at 10:30 (p.m.) and did not receive it until 11:02 (p.m.) in spite of multiple requests. On 10/16/17 at 11:06 a.m. via telephone Staff C (Corporate nurse who completed the investigation) acknowledged that facility staff should have stopped report and attended to the resident care needs. Facility Staff were aware that Resident #63 was experiencing pain and had requested his pain medication prior to 10:00 p.m., but informed him it was not due until 10:30 p.m. Instead of preparing and administering the pain medication as requested at 10:30 p.m., staff chose to finish report resulting in an additional 30 minute delay. This caused increased pain to the resident when he walked down to the nurses' station in an attempt to get his prescribed medication as well as undue stress and frustration as evidenced by the resident's anger and cussing out of the nurse. Additionally, on 10/06/17 at 9:04 a.m. while discussing poor pain control, Resident #63's stated, A nurse finally found that I had an order for [REDACTED]. Record review revealed a 10/02/17 order for [MEDICATION NAME] 50 mg (milligrams) every 12 hours as needed for sciatica. Review of the Bingo card of [MEDICATION NAME] revealed that it had been filled by the pharmacy on 09/28/17. On 10/24/17 at 12:48 p.m. in a telephone interview, Staff D (corporate nurse) stated that the Nurse Practitioner (NP) had seen Resident #63 on 09/27/17 and assessed the resident to require [MEDICATION NAME] for pain control. Per Staff D the NP called the script to the pharmacy but did not inform facility staff, thus there was a four day delay in Resident #63 receiving the pain medication he was assessed to require. RESIDENT #75 On 10/11/17 at 1:16 p.m., Resident #75 overheard his roommate speaking with a surveyor about not receiving pain medications timely. Resident #75 stated, That is why I keep this. Resident #75 held up a handwritten log of the dates and times he had received his pain medication. Resident #75 stated he had to start writing it down because staff were not bringing his pain medications when he requested them. Per Resident #75 he was requesting his [MEDICATION NAME] every three hours but would consistently have to wait an hour and a half for it to come, the worst time was more than three hours. When asked if he had told anyone about his late pain medications, Resident #75 laughed and stated, Ya, everyday .I don't remember who, the first few days I had a different person every time .after a day or two I realized it doesn't do any good, they (staff) would just say 'ok, I will tell someone' but nothing happened .One day I tried not to take any (pain medication) because I was so pissed off that they didn't bring them (when requested), but that was a bad idea .I had hip surgery .I got to where I could not tolerate it, so I had to request them again .I am a pretty laid back guy, I am known for my patience with people who know me, but one day I was just pissed off, I don't understand why (they can't bring pain medication when requested), it is easier to do things right then to lie about it . It is just to bad we have to suffer. I am not a complainer but my roommate is going to be here after I leave and I want this taken care of. When asked if anyone from the facility had followed up with him about the late pain medications Resident #75 stated, no. When asked what day he attempted to go without pain medications due to being .so pissed off . Resident #75 stated, Not sure, a few days back. According to the October 2017 PO's Resident #75 had an order for [REDACTED]. Review of the Narcotic ledger revealed Resident #75 received [MEDICATION NAME] six times on 10/06/17 at 12:00 a.m., 4:00 a.m., 7:25 a.m., 1:50 p.m., and 7:20 p.m.; on 10/07/17 the resident received [MEDICATION NAME] five times, at 12:00 a.m., 6:00 a.m., 4:45 p.m., 8:15 p.m. and 10:11 p.m.; On 10/08/17 [MEDICATION NAME] was administered six times, at 2:30 a.m., 5:50 a.m., 8:45 a.m., 1:15 p.m., 4:30 p.m. and 8:00 p.m. Resident #75 then received no further pain medication until 2:00 p.m. on 10/09/17, 18 hours later. The 18 hour gap is consistent with the residents claim that he was so pissed off due to excessive wait times that he stopped requesting pain pills until .I got to where I could not tolerate it, so I had to request them again It's just too bad we have to suffer . Resident #75 then returned to receiving pain medication six times a day on 10/10/17. Additionally, an entry on the narcotic ledger shows that one 5 mg [MEDICATION NAME] was signed out on 10/09/17 at 12:00 p.m. Under nurses signature it stated, waste-dropped on floor with two sets of initials. The nurse did not sign out another [MEDICATION NAME] (to replace the one that was wasted) until two hours later at 2:00 p.m. Since the [MEDICATION NAME] is only administered at resident request this confirms a minimum of a two hour delay in administration of Resident #75's pain medication. Failure of facility staff to timely provide pain medications when requested, resulted in Resident #75 experiencing uncontrolled pain, frustration, and anger to the point that he attempted to stop requesting pain medications at all. RESIDENT #59 Resident #59 admitted to the facility on [DATE] and according to the 06/02/17 Admission and 08/24/17 MDSs, was assessed with [REDACTED]. According to these assessments the resident had care needs related to a spinal injury which impacted mobility and the resident required regularly scheduled and as needed pain medications. In an interview on 10/09/17 at 8:45 a.m. the resident stated he was waiting for his 8:00 a.m. medications and they are often late. Resident #59 stated he received his 8:00 a.m. medications at 10:00 a.m. over the weekend, Only after I called for it twice The resident indicated his 4:00 p.m. medications were also late and he got them only after calling (for them) and he questioned if he didn't call he might not ever get them. Review of MARs revealed the resident was correct and did not get his 8:00 a.m. medication on 10/07/17 until after 10:00 a.m., including medications for muscle spasms, pain, and antibiotics. Similar findings were identified on 10/06/17 and 10/07/17 for 4:00 p.m. medications, and on 10/08/17 for the resident's 12:00 a.m. pain medication. Failure to ensure residents received timely medication had the potential to contribute to increased muscle spasms and decreased effectiveness of regularly scheduled pain medications. RESIDENT #18 In an interview on 10/05/17 at 10:17 a.m., Resident #18 stated they (nurses) often bring my morning medications late between 10:30 and 11:00 a.m. Heck, by then its time for my afternoon medication and that really fouls up my schedule. Resident #18 said when she asked the nurses why they're always late bring her medications they say, I'm sorry but I was busy. According to the resident she's attempted to resolve the issue with Staff B (Director of Nursing). However, Resident #18 indicated, All she( Staff B) said was you're incorrect she very dismissive of my concerns. She never listens to me. If I send a nursing aide to tell the nurse I need something for pain the nurse will usually wait until its time for my regularly scheduled medication which could be any where between 1-2 hours. Resident #18 said, That's not right, if I'm in pain I shouldn't have to wait for an hour of two for pain medication. RESIDENT #12 A review of the Annual MDS dated [DATE] revealed Resident #12 required extensive assistance with ambulation both in her room and in the corridor. According to Staff S, in a interview on 10/11/17 at 10:08 a.m., Resident #12 refused to ambulate five to six times each month. Staff S said, You know she has a lot of pain in her hip. When asked if she informed the nurse when the resident refused to walk, Staff S said, No, because sometimes she doesn't want to walk because she said she's having pain. During an interview on 10/11/17 at 11:21 a.m.,when asked to whom and when

Based on observation, interview and record review, the Administration failed to effectively and efficiently manage facility compliance with federal regulatory requirements. The administrator failed to ensure compliance related to the prevention of abuse and neglect which resulted in psychological harm, as evidenced by patterned feelings of fear, anger, and frustration, to multiple residents. Additionally, the administrator failed to ensure thorough investigations to rule out abuse/neglect and ensure residents received timely pain medication which resulted in harm. Findings include: Failed practice found during the standard, abbreviated and extended survey ending on 10/12/17 was as follows: F 157 - 483.10(b)(11)(i)(C) Notify of Change The administration failed to consult with a resident's physician concerning a change in medication. F 166 - 483.10(f)(2) The facility failed to ensure a system to resolve resident grievances. F 176 - 483.10(n) Resident self-administer drugs if deemed safe The administration failed to assess the safety of a resident to administer his own medication. F 223 - 483.13(b)&(c) Free from Abuse The administration failed to ensure each resident was free from abuse/neglect. F 226 - 483.13(c)(3) Develop/implement abuse/neglect, etc policies The administration failed to thoroughly investigate allegations of abuse and neglect. F 241 - 483.15(a) Dignity The administration failed to promote care for residents in a manner and in an environment that maintained or enhanced dignity and respect in full recognition of individuality. F 242 - 483.15(b) Right to make choices The administration failed to ensure residents had the right to make choices in their daily lives which were important to them. F 243 - 483.15 (c)(4) Listen/act on group grievances/recommendation The administration failed to allow only those staff invited, to attend Resident Council. F 248 - 483.15(f)(1) Activities program The administration failed to ensure residents were provided meaningful activities. F 250 - 483.15(g)(1) Medically related social services The administration failed to ensure residents with refusal behaviors had appropriate interventions and failed to ensure timely discharge for one resident. F 272 - 483.20(b)(1) Comprehensive assessments The administration failed to ensure accurate and comprehensive assessments were completed on all residents. F 279 - 483.20(k)(1) Comprehensive care plan development The administration failed to ensure care plans were developed and revised as necessary to meet the needs of residents. F 281 - 483.20(k)(3)(i) - Services provided meet professional standards The administration failed to ensure facility staff provided care and services according to professional standards of practice. F 309 - 483.25 Provide care/services for highest well being The administration failed to ensure facility staff provided care and services which assured resident's positioning, skin issues, pain, bowels and TED hose. F 318 - 483.25(e)(2) Prevent decrease in range of motion The administration failed to ensure residents with decreased range of motion received treatment to prevent or further decrease range of motion. F 329 - 483.25(l)(1) - Drug regimen is free from unnecessary drugs The administration failed to adequately monitor, ensure adequate indication for medication use, implement non-drug interventions and prevent concomitant medication use. F 332 - 483.25(m)(1) Free of medication error rates of 5% or more The administration was not aware of licensed nurses experiencing a medication administration error rate of 28%. F 353 - 483.30(a) Sufficient 24-hour nursing staff per care plans The administration failed to ensure the facility had adequate staff to provide basic care and services. F 363 - 483.35(c)(1)-(3) Menus and nutritional adequacy, Menu followed The administration failed to ensure the facility followed menus. F 364 - 483.35(d)(2) Food flavor, appearance, palatable The administration failed to ensure the facility provided food that was appetizing and palatable. F 368 - 483.35(f)(1)-(4) Frequency of Meals The administration failed to ensure less than 15 hours between meals unless a substantial snack is served. F 412 - 483.55(b)(1)(2) Routine and emergency dental services in nursing facilities The administration failed to ensure dental services were provided to residents including any necessary dentures. F 431 - 483.45(b)(2)(3)(g)(h) Drug records, label/store drugs and biological's The administration did not ensure drugs were stored in accordance with currently accepted principles. F 498 - 483.75(f) Nurse aide performance review and in-service training The administration failed to have in place a system by which nursing assistants received a minimum of 12 hours of in-service education. F 514 - 483.75(l)(1) Resident records-complete/accurate/accessible The administration failed to ensure facility records were complete and accurate in accordance with accepted professional standards and practices. F 520 - 483.75(o)(1)(i)-(iii)(2)(i)(ii) Quality assessment and assurance committee The administration failed to develop and implement effective and appropriate plans of action to correct identified quality deficiencies. In an interview on 10/11/17 at 12:58 p.m., Staff A indicated the lack of consistent administrators contributed to the facility's failed practice. Reference: (WAC) 388-97-1620(1)

Based on interview and record review the facility failed for one of two residents (#1) reviewed for discharge, to thoroughly assess the resident for discharge, plan for or consider the effects of extended travel on pain, the potential for exacerbation of pain, or potential pain relief during and after travel. Failure to identify the potential for an increase in pain related to a lengthy cabulance ride and provide associated medical and non-medical interventions caused Resident #1 to experience pain. Findings included: Refer to CFR 483.15(c)(2)(ii) Documentation for Transfer According to the annual 02/27/2017 Minimum Data Set Resident #1 resided in the facility since March of 2016, had [DIAGNOSES REDACTED]. Staff assessed Resident #1 to be able to make his own decisions, had trouble speaking and required extensive assistance of one to two staff for activities of daily living. Resident #1 described pain, on this assessment, as occasional and four out of ten on a numeric scale where ten is the worst pain. Review of physician orders revealed Resident #1 received, Voltaren Gel 1% Apply 1 application transdermally two times daily for chronic pain to the left shoulder, Hydrocodone-Acetaminophen Tablet 5-325 mg (milligrams) four times a day for pain, and Hydrocodone-Acetaminophen Tablet 5-325 mg every 12 hours as needed for pain. Medication Administration Records from September of 2016 through March of 2017 revealed staff administered medications for relief of pain daily. According to pain assessments performed by staff quarterly or at the time pain medication was requested and/or administered Resident#1's pain level was as high as ten, during this same time period. Review of the facility's November 2016 Admission/Transfer/discharge policy, provided 04/03/2017 by Staff C the Social Service Director, revealed there were no instructions to staff on what documents should be sent with a resident when transferring or discharging. The facility's undated Discharge Instructions, included, 1. Coordinate D/C (discharge) with the IDT (interdisciplinary team) including the physician/ARNP for any required signatures .2. Complete Discharge Summary .by nursing, activities, social service and the physician .3. Review the Discharge Summary with the resident .sign the Discharge Summary acknowledging .understanding .6. Nursing to complete a discharge progress note that included's: .Resident status (pain .). 7. The following items are to be sent with the resident on discharge .Medications - ensure an adequate supply . On 04/03/2017 at 4:00 p.m. the facility was asked to provide all documentation to support the facility assessed and planned Resident #1's discharge, in light of his complex medical [DIAGNOSES REDACTED]. Review of March 2017 Social Service notes and other clinical records revealed no documentation to support other facility departments were involved in assessing Resident #1 for discharge. The last physician's note was dated 03/09/2017 and did not discuss Resident #1's discharge or potential issues with pain or a cabulanace ride almost two hours long. There was no physician's order for discharge in the record until the day after Resident #1 was discharged on [DATE] to an eastern Washington facility. No signed physician orders were found in the packet of documents sent with Resident #1 to the new facility. The Discharge Summary was signed by a nurse but included only a hand written note, See Phys. (physician's) orders. There was no documentation to suggest any of the information on the incomplete summary was discussed with Resident #1. And no staff documented Resident #1's status including the level of pain at the time of discharge. The facility provided a 03/27/2017 Medications/Products Returned for Credit and Medications Destroyed forms that listed Resident #1's medications as being returned to the pharmacy and/or destroyed. The list included medications to treat Resident #1's pain, neuromuscular disease, depression, high blood pressure and more. According to Discharge Instruction policy enough of these medications was to be provided to discharging resident, .until confirmed MD (medical doctor) appointment. None of Resident #1's medications were sent on the one hour and forty-five minute drive from western Washington to eastern Washington with the resident. According to Staff B, interviewed on 04/03/2017 at 5:00 p.m., the trip from the facility in western Washington to the eastern Washington facility would take one hour and fifteen minutes. According to the Washington State Department of Transportation's website the road conditions on 03/27/2017 were 3.5 inches of new snow and road construction that decreased a multi-lane highway to one lane in both the east and west directions. Such conditions would delay Resident #1's arrival by an extra 30 minutes. According to the 03/27/2017 eastern Washington facility admission records Resident #1 arrived at 11:45 a.m. on 03/27/2017 with a pain level of eight out of ten and no physician's orders or medication to alleviate the pain. Since Resident #1 received his last pain medication according to physician orders at 8:00 a.m. on 03/27/2017 the next dose was due at 12:00 p.m. No medication was available. The facility did not follow it's own polices and procedures for discharging a resident, adequately assess Resident #1 for discharge, or develop and implement care planned interventions to ensure a smooth transition between facilities. The facility did not anticipate the length of the trip or unplanned impediments along the way and clearly did not consider the physical and emotional well-being of Resident #1 as it related to acute upon chronic pain exacerbated by an eventful and unusual day for the resident. Reference: (WAC) 388-97-0960(1)

Based on interview and record review the facility failed, for one of two residents reviewed for pain and discharge, to ensure pain and discharge assessments were comprehensive and accurate and care planned measures were accurate and/or implemented. This failure caused Resident #1 to experience pain. Findings included: Refer to CFR 483.15(c)(2)(ii) Documentation for Transfer Refer to CFR 483.40(d) Provision of Medically Related Social Services The facility's 11/2015 Pain Management Overview policy included; Purpose: To define how pain will be managed for residents in (the facility) .Procedure: 1 .a. assessment of the resident .b. addressing and treating the underlying causes of pain c. Development and implementation of interventions to manage pain .g. revision of approaches as indicated .4. Resident needs and goals, as well as factors precipitating and alleviating pain are considered . Resident #1 experienced frequent pain that prevented Resident #1 from sleeping according to the 09/06/2016 Pain Evaluation form. Just prior to this assessment, 08/22/2016, Resident #1's physician increased the pain medication [MEDICATION NAME] 5-325 mg (milligrams) from twice daily to four times daily. Staff documented on the 12/06/2016 Pain Evaluation form, frequent pain that made it hard to sleep at night. Review of Medication Administration Records, where staff documented Resident #1's pain levels, September 2016 through March 2017 revealed Resident #1 described daily pain as high as ten out of ten on the numeric scale where ten is the worst pain in September, October and November of 2016. In December of 2016 Resident #1 described pain as nine out of ten on three occasions. The highest level of pain experienced by Resident #1 in January, February and March was and eight out of ten. According to the annual 02/27/2017 Minimum Data Set Resident #1 resided in the facility since March of 2016, had [DIAGNOSES REDACTED]. Staff assessed Resident #1 to be able to make his own decisions, had trouble speaking and required extensive assistance of one to two staff for activities of daily living. The facility developed a 03/28/2016 pain care plan that included: The resident has chronic pain r/t (related to) Depression, daily moderate to severe pain, neck contracture, R (right) shoulder pain, R hip pain. The facility established a goal of: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. (06/03/2017). Staff documented pain relieving interventions as: 1. Acceptable pain level 5. 2. Anticipate the resident's need for pain relief and respond immediately. 3. Medications/Labs (laboratory) per MD (medical doctor). 4. Monitor pain, pain med (medication) administration, and pain medication effectiveness per facility protocol. 5. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. 6. Provide Repositioning as non-drug interventions PRN (as needed) for pain. 7. The resident's pain is aggravated by: lying in bed, being up in a chair for too long. 8. The resident's pain is alleviated/relieved by: getting out of bed to W/C (wheelchair) going back to bed, working with therapy, repositioning. 9. Therapy (PT/OT/ST) as ordered. Staff documented the only change to Resident #1's pain care plan was on 09/20/2016 when routine therapy services were altered. Review of March 2017 physician orders [REDACTED]. Tablet 5-325 mg every 12 hours as needed for pain. Review of Medication Administration Records from September of 2016 through March of 2017 revealed Resident #1 required the as needed [MEDICATION NAME] each month with the exception of December 2016 for pain not alleviated by the routine [MEDICATION NAME] administered four times a day supporting the routine medication was not consistently effective in managing Resident #1's pain. According to 03/17/2017 Social Services progress notes, .resident will likely be transferring to another SNF (skilled nursing facility) in Ellensburg to be closer to his son . The 03/17/2016 discharge care plan included, assist with financial planning, encourage family to call, encourage (resident) to come out of his room, offer extra support, offer (mental health) support, and If discharge plans change notify (social service director). According to the facility's March 2017 discharge log and progress notes Resident #1 discharged to an eastern Washington facility on 03/27/2017 by cabulanace on a ride that took almost two hours. According to 03/27/2017 admission documentation from the eastern Washington facility Resident #1 was assessed with [REDACTED]. On 04/03/2017 at 4:00 p.m. the facility was asked to provide all documentation to support the facility assessed and planned Resident #1's discharge. The facility did not provide updated care plans for discharge or pain reflective of Resident #1's changing needs as instructed in the available care plans. The facility did provide a 03/27/2017 Medications/Products Returned for Credit and Medications Destroyed forms that listed all of Resident #1's medications as being returned to the pharmacy and/or destroyed. This supported none of Resident #1's medications were sent on the trip from the facility in western Washington to the facility in eastern Washington. Social Service Director Staff C, interviewed on 04/03/2017 at 4:00 p.m., said about signed physician orders, .they (the receiving facility) did not ask for them. We never send signed orders. Without physician orders [REDACTED].#1's pain medication orders, send them to a local pharmacy and obtain medication timely delaying pain medication administration to Resident #1. Despite the facility's identifying Resident #1 had pain as high as ten out of ten and was imminently discharging from the facility as major changes in Resident #1's plan, the facility failed to anticipate Resident #1's changing needs, thoroughly assess Resident #1 for discharge or for potential/actual pain associated with the discharge conditions. Knowing Resident #1's pain was aggravated by being in one position too long the facility did not consider the long drive as being out of Resident #1's routine, and that lack of repositioning would be inadequate if not impossible on the drive to eastern Washington. The facility did not consider Resident #1 required pain medication to be available to staff in the receiving facility so they could immediately administered required pain medication and provide relief for Resident #1 who experienced harm as a result of the facility's failure. Reference: (WAC) 388-97-1060(1)

Based on observation, interview and record review the facility failed to ensure 1 of 3 residents (#1) reviewed for incidents received adequate supervision and assistive devices during showering. This resulted in the resident sustaining a comminuted leg fracture (bone broken into several pieces) when she slid down in the upright shower chair. Findings include: Record review found Resident #1 admitted to the facility in 05/06 with severe brain damage resulting in a state of partial arousal rather than true awareness. The resident's Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 did not exhibit cognition, mood or behavior. The assessment identified Resident #1 was totally dependent on two persons for Activities of Daily Living including bed mobility, transfers, toileting, and bathing. Resident #1's care plan identified the resident was to be up in a Tilt-in-Space wheelchair (w/c) daily for at least 2 hours as able. Tilt-in-Space wheelchairs provide position change and support for persons who cannot maintain trunk or head position and/or balance against gravity for prolonged periods of time. The care plan directed Keep w/c tilted back at all times. Resident #1's care plan identified the resident was totally dependent on one staff to provide a shower three times per week and required two staff to transfer with a Hoyer (mechanical hydraulic) lift. Resident #1's Kardex (directive to caregivers) identified the resident used a Tilt-in-Space w/c, noting use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. There was no directive on the Kardex to use a specific shower chair (Tilt back versus upright). There was no directive on the Kardex about supporting Resident #1 with pillows or bolsters when seated in an upright chair. An incident report (IR) dated 08/11/16 at 11:46 a.m. noted an NAC (nursing assistant certified) informed the Licensed Nurse that Resident #1's right knee was out of alignment and had swelling. The IR documented the resident's knee was contracted and had a dimple type area on the side of the leg above the knee cap. Resident #1 moaned with movement and touching area and quieted when left alone. The facility IR documented staff notified the doctor and the resident was sent to the emergency room . An x-ray found a comminuted impact fracture of the shaft of the thigh bone in the area closest to the knee. Surgery was not an option. Resident #1 was prescribed a knee immobilizer and returned to the facility. The facility IR documented an interview with Staff C (agency NAC). On initial interview, Staff C stated she transferred Resident #1 to the blue (upright) shower chair as instructed by Staff D. Staff C did not indicate anything happened during the shower. On second interview, Staff C stated Resident #1 kept going to the left and she used a pillow to prop her up. She kept hitting the side of the chair. I put the chair against the wall. (Staff B) came in and we lifted her up in the shower chair. Staff C could not say for sure if Resident #1 bumped her legs. In a written statement, Staff B said at approximately 10:15 a.m. an NAC called from the shower room doorway asking for help to pull Resident #1 up in the shower chair because the resident was sliding down. Staff B documented she found Resident #1 slid down in the chair. A drawing contained in the written statement showed a body slumped down with her back on the seat of the chair. Staff B stated she grabbed behind the resident's back and under her legs where the sling was and lifted the resident up in the chair. Staff B said she then exited the room to finish passing medications. Observation on 09/01/16 at 2:40 p.m. noted two kinds of shower chairs available in the common shower room. The blue upright shower chair had no foot rest or support for a person with poor trunk control. A yellow shower chair had a tilt back feature with padded leg support. Observation on 09/01/16 at 4:20 p.m. revealed Resident #1 sitting up in a padded Tilt-in-Space wheelchair. Two bolsters were located on each side of the wheelchair back, supporting the resident as she reclined. Resident #1 was alert and awake but unresponsive to conversation or greeting. At 4:25 p.m. two staff (G and H) transferred Resident #1 into bed using a Hoyer lift. The resident's right leg was bent and encased in a splint. The right knee was visibly larger than the left. In an interview on 09/01/16 at 4:30 p.m. both Staff G and H stated before the accident, Resident #1's right leg was as straight as the left. Both staff stated they would use the tilt-back shower chair for Resident #1 because it was safer as sometimes Resident #1 moved around. In an interview on 09/01/16 at 4:35 p.m. Staff I stated she would use the yellow tilt option shower chair because it mimics the resident's current chair and staff can control how far the resident tilts back. The straight (shower) chair is not good because she does wiggle. In an interview on 09/01/16 at 2:00 p.m. Staff F stated he assisted transferring Resident #1 to the upright shower chair before the shower. According to Staff F, this chair was used in order to weigh the resident. Staff F said if he was going to shower Resident #1 he would use the tilt back shower chair. In an interview on 09/01/16 at 2:50 p.m. Staff B stated a caregiver beckoned her from the shower room saying I need you. Staff B stated on entering the shower room she saw Resident #1 positioned low in the shower chair with her buttocks on the rim. Staff B stated she thought this was dangerous as the resident could fall. Staff B said she asked the caregiver Who told you to use that chair? and told the caregiver it was not safe. According to Staff B, she and the caregiver scooped the resident up and repositioned her on the chair. In an interview on 09/01/16 at 5:00 p.m. the Director of Nursing Services (DNS) stated it would be acceptable for Resident #1 to be showered using the unsupported upright shower chair. The facility Administrator stated Resident #1's Tilt-in-Space wheelchair was used when Resident #1 sat up for long periods of time. The Administrator stated Resident #1 could be showered safely in the upright unsupported shower chair. In a telephone interview on 09/02/16 at 2:45 p.m. Staff D stated she was the regular shower aide working at the facility. Staff D stated she typically showered Resident #1 in the upright chair supported with pillows. The facility failed to ensure staff used appropriate shower assistive equipment to prevent an accident for a resident with poor trunk control and behaviors that made use of an upright shower chair hazardous. This failure resulted in a preventable injury to the resident.

Based on observation, interview and record review, the facility failed to provide adequate nursing assessment and pain management for 2 of 2 sample residents (#1, #2) reviewed for pain management from a census of 57 residents. Failure to adequately assess and manage pain resulted in harm to both Residents #1 and #2 who experienced unnecessary pain and diminished quality of life. Findings include: RESIDENT #1: Records show Resident #1 was admitted to the facility 09/11/15 with multiple medically disabling conditions including [MEDICAL TREATMENT] for kidney failure. Resident #1's minimum data set (MDS) admission assessment dated [DATE] identified the resident had no cognitive impairment and required extensive assistance of 1-2 persons for activities of daily living. The admission MDS identified Resident #1 received as needed pain medication but had no pain at the time of the assessment. Facility records documented on 10/04/15 at 3:05 p.m. Resident #1 was found on the floor. Resident #1 told facility staff she had been putting clothes in the closet and stood up and lost her balance, falling to the floor. The resident complained of hip pain and was transported to the hospital where left [MEDICAL CONDITION] was diagnosed . A medical decision was made to not repair the [MEDICAL CONDITION]. Progress notes documented Resident #1 was readmitted to the facility on [DATE] with un-repaired displaced left [MEDICAL CONDITION]. This meant that every time the resident moved the unrepaired hip, there would be pain when the bones rubbed against one another. The resident had an indwelling Foley catheter (tube inserted into the bladder to drain urine). On return to the facility 10/07/15 the narcotic medication [MEDICATION NAME] 2.5 milligrams (mg) to 5 mg was prescribed every 4 hours as needed for moderate to severe pain. Pain medication [MEDICATION NAME] 25 mg every 6 hours as needed for moderate to severe pain was also prescribed. This meant that nurses had to evaluate pain and give medication if pain was present. Nursing pain assessment every shift from 10/7/15 evening until 10/09/15 morning documented Resident #1 experienced pain levels of 8 (on a scale of 1-10 with 10 being the worst pain possible). This is moderate to severe pain. Medication administration records (MAR) documented Resident #1 received [MEDICATION NAME] 4 times and [MEDICATION NAME] 3 times from 10/07 to 10/09. Even when nurses noted the pain medication was effective, Resident #1 continued to report pain level 8 when assessed. This indicates the resident experienced highs and lows and her pain was not well controlled. Progress notes documented on 10/09/15 Resident #1 exhibited signs of acute illness. On medical evaluation 10/09/15, Resident #1's doctor documented uncontrolled pain in addition to low blood pressure and low grade fever. Resident #1 was sent to the hospital for medical evaluation, returning to the facility on [DATE] with no change to prescribed pain medication regimen. A pain assessment done 10/14/15 on re-admission to the facility identified pain had made it difficult for Resident #1 to sleep at night and limited her day-to-day activities. According to the 10/14/15 pain assessment, even though it was difficult to sleep at night and day-to-day activities were limited due to pain, Resident #1 indicated her pain medication regimen effectively controlled her pain. Ongoing nursing pain assessments did not support the 10/14/15 conclusion that Resident #1's pain medication regimen controlled her pain. From 10/14 to 10/19/15 Nursing pain assessments each shift documented Resident #1's pain level of 8 for 3 of 4 day shifts and pain level 5 to 8 for evening shifts. From 10/14 to 10/17/15 narcotic pain medication [MEDICATION NAME] was given 1-2 times daily for pain levels of 7 to 8. On 10/18/15 Resident #1 received [MEDICATION NAME] 4 times and [MEDICATION NAME] once when the [MEDICATION NAME] was deemed ineffective. On 10/19/15 MAR indicated [REDACTED] This pattern indicated Resident #1's pain was not well controlled. There was no nursing assessment documenting evaluation of when or what caused Resident #1 to experience severe pain. Therapy notes documented Resident #1's high level of pain interfered with her ability to participate in therapy. Medical record review found no communication with the doctor about Resident #1's ongoing high level of pain. Observation 10/19/15 at 11:00 a.m. found Resident #1 lying in bed. The resident stated she broke her hip 2 weeks ago at the facility. Resident #1 said she was given medication for pain but it makes me sick - dizzy and nauseous. The resident stated pain ran down her leg at a level of 7, 8, or 9. Resident #1 stated It's terrible . they try to adjust me, it just about kills me. Resident #1's non-verbal cues supported her verbal report of pain: lying in darkened room, furrowed brow, non-smiling flat affect, lying quietly without moving. According to Resident #1 the doctor at the hospital told her she just have to live with it (the pain) until it heals over. Resident #1 said nurses at the facility told her I have to heal up and live with it. Resident #1 stated she used to get up in her wheelchair but I would like to stay in bed because it hurts. On interview 10/19/15 at 11:40 a.m. Staff D stated he was the nursing assistant caring for Resident #1. Staff D stated Resident #1 had really a lot of pain. Staff D said Resident #1 did not want to turn because of the pain. Staff D and the state surveyor entered Resident #1's room together. Staff D asked the resident if he could clean her up. Resident #1 said no, she was having pain. On interview 10/19/15 at 11:50 a.m. Staff C stated she was planning to go ask the resident if her pain was relieved by the 09:30 a.m. pain medication but had not had time to do so yet. Staff C stated she was not aware the resident was experiencing pain level 7 after being given both [MEDICATION NAME] and [MEDICATION NAME]. On interview 10/23/15 therapy Staff I (1:05 p.m.) and K (12:55 p.m.) identified Resident had pain of 7 or 8 frequently and they worked with positioning but this did not help. Staff K stated she told nursing staff about Resident #1's pain and the nurse said s/he would look into it. Staff I and K both said Resident #1 had 7 or 8 pain even after pain medication. According to Staff I, Resident #1's pain definitely limited her functional mobility which placed the resident at risk for deconditioning, pressure ulcer, skin breakdown, and decreased strength. Facility pain evaluation policy identified if pain was an identified problem, staff would anticipate need for pain relief and respond immediately to any complaint of pain. Staff was to evaluate the effectiveness of pain interventions and impact on functional ability. This was not done. RESIDENT #2: Records show Resident #2 was admitted to the facility 10/09/15 with multiple medically disabling conditions including left [MEDICAL CONDITION] and unrepaired right [MEDICAL CONDITION]. Resident #2's admission MDS assessment dated [DATE] identified the resident was not able to complete a brief interview for mental status (BIMS) due to inattention and disorganized thinking. The resident required extensive assistance of two persons for activities of daily living (ADL) and one person supervision and set up for eating. The assessment indicated the resident had a Foley catheter for urine. The MDS assessment indicated frequent pain at a level 8 limiting day-to-day activities. Progress notes dated 10/10/15 (one day after re-admission) documented Resident #2 started to evidence significant pain. Notes documented notification of the doctor and adjustments made to pain medication resulting in better pain control (per narrative notes). Progress notes documented yelling out behavior and some nonsensical statements (related to cognitive status.) Progress notes documented Resident #2 had a Foley catheter which was removed on 10/12/15. Nursing staff documented that after catheter removal, Resident #2 was incontinent of urine. The last documentation of bladder status was 10/16/15 at 3:40 p.m. Starting 10/14/15 Resident #2 had both scheduled [MEDICATION NAME] 5 mg every 6 hours and as needed [MEDICATION NAME] 2.5 to 5 mg every 4 hours for pain. Nursing staff continued to document giving as needed [MEDICATION NAME] for pain levels of 5 to 10 one to two times per day. This indicates Resident #2's pain was not well controlled. Medication administration review found that on 10/19/15 at 7:46 a.m. Staff B (nurse caring for Resident #2) documented he gave Resident #2 [MEDICATION NAME] for a pain level 7. Staff B stated he checked back with Resident #2 at 9:00 a.m. and could tell she was feeling better as she was less confused and had less calling out behavior. On 10/19/15 at 12:35 p.m. Staff B and the state surveyor went to Resident #2's room. Observation found Resident #2 in bed, moaning. The resident had furrowed brows, tense body and closed eyes. She was picking at a reddened area on her left hip. The resident said she hurt all over . I'm sick - my stomach flutters like butterflies, Oh God please help me!- It will be on hold for a while. Staff B stated Resident #2 was definitely in pain. Staff B proceeded to prepare and give Resident #2's scheduled dose of [MEDICATION NAME]. On 10/19/15 at 12:40 p.m. Staff E (caregiver assigned to Resident #2) and the state surveyor went to Resident #2's room. Observation found Resident #2 with the same appearance of pain and pain behavior. Staff E stated she encourages Resident #2 to use the toilet but Resident #2 says she is having pain. Staff E said the resident's pain was not bad this morning, not as bad as the previous Saturday (10/17/15). According to Staff E she did not know if Resident #2's current behavior indicated pain. This is how she is. On 10/19/15 at 1:35 p.m. Staff J (occupational therapy assistant) and the state surveyor went to Resident #2's room. Observation found Resident #2 sitting up in bed with an uneaten tray of food on her overbed table. Resident #2 was moaning with eyes closed. I hurt all over. I can't pee, I tried to pee . I can't. The resident's brows were furrowed. Staff J said she was not sure if Resident #2's behavior indicated pain. On 10/19/15 at 2:30 p.m. Staff A (charge nurse) and the state surveyor went to Resident #2's room. Observation found Resident #2 lying in bed, partially disrobed, crying, lunch tray untouched. I hurt all over. Firebolt. Resident #2 motioned to her chest and lower belly. Staff A stated This appears to be pain or [MEDICAL CONDITION] or pain and [MEDICAL CONDITION] together. At 3:00 p.m. Staff A reported that on catheterization, 700 cubic centimeters of urine were returned from Resident #2's bladder. According to the National Institutes of Health, a normal bladder can contain 1 1/2 to 2 cups of urine (360-500 cc). http://www.niddk.nih.gov/health-information/health-topics/Anatomy/urinary-tract-how-it-works/Pages/anatomy.aspx On 10/19/15 at 3:00 p.m. Resident #2 was observed to be awake, alert and visibly more comfortable and relaxed without calling out behavior. Staff F (evening assigned caregiver) was at the resident's bedside. Staff F stated Resident #2 was dry as a bone the previous evening when he worked (10/18/15). Staff F said we should let (the nurse) know but some resident's don't do much, don't really know what's going on. The facility failed to adequately recognize and assess the nature and cause of Resident #2's pain in particular related to bladder function.