Every finding on record at North Cascades Health and Rehabilitation

Based on observation, interview and record review, the facility failed to follow infection prevention and hand hygiene practices consistent with facility policy and accepted standards of practice for 1 of 1 resident (Resident 1) during wound care observation. This failure placed residents at risk for wound complications including infection and pain. Findings included . Review of the facility policy titled Handwashing/Hand Hygiene, dated August 2025 stated hand hygiene with ABHR (Alcohol Based Hand Rub) or soap and water would be performed before and after wound care, after contact with blood or body fluids, when moving between contaminated to clean sites, after removing gloves and after contact with potentially contaminated surfaces or items in the resident's environment. In an observation of wound care on 08/06/2026 at 10:29 AM, Staff C, Assistant Director of Nursing, and Staff D, Registered Nurse (RN)/Unit Manager, were observed to don gowns and gloves prior to entering Resident 1' room. Consultant Wound Care provider (CC1) was present and conducting weekly wound assessments. Resident 1 was in bed and Staff C and D were observed to approach the bed, touching the resident and the resident's bedding while physically assisting the resident to position on their side for access to the first of several wounds. CC1 removed a soiled dressing and conduced wound measurements. Staff D was observed to pick up a wound cleanser spray bottle while wearing the same gloves worn while positioning the resident, picked up clean gauze and conducted wound cleansing with the same gloves. Staff C was observed to use bandage scissors to cut open dressing supply packages and then placed the scissors directly onto the resident's bed. Staff C was observed to apply the ordered wound dressing to the wound without changing gloves or performing hand hygiene. Staff D was observed to pick up the bandage scissors from the bed and use them to cut open other clean dressing packages without disinfecting them and then placed the scissors on a shelf in the resident room that included other clean dressing supplies without disinfecting them. Staff D removed gloves and applied new gloves without performing hand hygiene. The resident was repositioned onto their other side which provided a view of two large wounds on the resident's buttock and tailbone areas. Both wounds were observed to be open and uncovered. There was red and yellowish drainage on the bed pad which had been in direct contact with the resident's wounds. CC1 asked about the lack of dressings over the wounds and Staff D stated they may have come off in the bed, yet none were observed in the bed, bedding or the nearby trash can. Staff F, Certified Nursing Assistant, happened to enter the room and stated they had notified Resident 1's nurse (Staff E) that Resident 1's bandages were not in place this morning sometime around breakfast. In a continued observation, Staff D changed gloves again without performing hand hygiene, picked up the bottle of wound cleanser, and performed wound cleansing with the same gloves. Staff C did not change gloves and assisted with applying clean wound dressing supplies to the resident's wounds.In an interview on 08/06/2026 at 11:02 AM, CC1 stated they were in the facility once a week and this had not been the first instance of finding wound dressings not being in place for Resident 1. CC1 stated the type of wound dressing and the size and location of the wounds made it difficult to get good adherence but it was strange for them not to be there at all, and the expectation was that if a dressing became displaced it would be communicated and re-applied.In an interview on 08/06/2026 at 11:15 AM, Staff D nodded and said they had not done enough glove changes or hand hygiene during the wound treatment and could have been more organized. Staff C acknowledged the observations during the wound treatment.In an interview on 08/06/2026 at 12:06 PM, Staff E, RN, denied they had been made aware of Resident 1's wound dressings being off. Staff E stated if they had been made aware, they would have re-applied them. Staff E stated they typically did not do anything with Resident 1's wounds on the day the wound consultant rounds were done so they had not observed Resident 1's wounds or dressings yet that day.In an interview on 08/011/2026 at 12:11 PM, Staff B, Director of Nursing, stated they were currently conducting monthly audits related to infection prevention which included the proper use of personal protective equipment (PPE) such as gowns, gloves, and hand hygiene. Staff B stated all nursing staff had been in-serviced again specifically regarding PPE and hand hygiene as part of the facility plan of correction for annual survey. Staff B stated the expectation was the nurses would be checking the resident and if a dressing was found to be missing it needed to be replaced.This is a repeat citation from annual survey dated 04/13/2026.Refer to WAC 388-97-1320 (1)(c),(2)(b)

Based on interview and record review the facility failed to identify and report a potential allegation of abuse and/or neglect for 1 of 3 residents (Resident 1) and failed to report results of abuse and/or neglect investigations within 5 days for 3 of 3 resident investigations (Residents 1, 2, and 3) reviewed for abuse. The facility failed to report unexplained bruises found on Resident 1's arms, legs and torso and failed to report the results of a resident to resident (Residents 2 and 3) abuse allegation. This failure placed the residents at risk of further abuse, psychological distress, and diminished quality of life. Findings included .Review of the facility policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated March 2025, documented the facility will report immediately all suspected and/or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source in accordance with state and federal law. <RESIDENT 1>Resident 1 admitted to the facility 06/10/2026 with diagnoses that include developmental delay since childhood, depression, and pain. The admission Minimum Data Set (MDS - an assessment tool) dated 06/16/2026 showed the resident had an intellectual disability, with severe impaired cognition. Review of the facilities investigation dated 06/16/2026 for Resident 1's skin concern documented that during a care conference the facility was alerted to a bruise on the resident's arm. The investigation note stated the resident was found to have bruising on left upper arm, abdomen, and both legs. In a phone interview on 06/22/2026 at 12:50 PM, Collateral Contact (CC) 1 stated that during a visit with Resident 1 on 06/16/2026 several bruises were observed on Resident 1's upper arms, upper leg area and several across the lower abdomen area. CC1 stated these were brought to the attention of the facility during a care conference on 06/16/2026 with a nurse manager present. Review of facility state reporting log provided on 06/22/2026, showed no logged results report for Resident 1's unexplained bruises to upper arms, torso or legs. <RESIDENT TO RESIDENT>Resident 2 was admitted to facility on 03/28/2025 with diagnoses that included bipolar disorder (mental health condition that causes extreme, uncontrollable shifts in mood, energy, and activity levels), anxiety and depression. The quarterly MDS dated [DATE] documented the resident had intact cognition. Resident 3 was admitted to the facility on [DATE] with diagnoses that included depression and anxiety. The quarterly MDS dated [DATE] documented they had intact cognition with physical behaviors towards others for 1 to 3 days of the look back period. Review of a facility investigation dated 05/29/2026 at 3:30 pm documented that staff found Resident 2 crying in their room and reported to staff that Resident 3 had verbally abused them outside at the smoking area. The investigation documented that Resident 3 was aggressive towards Resident 2, after they refused to give them a cigarette. Resident 2 stated they felt Resident 3 was invasive and followed them into the facility making comments. Review of facility state reporting log provided on 06/22/2026, showed no logged results report for Resident 2 and Resident 3's verbal abuse allegation. In an interview on 06/23/2026 at 3:08 PM, Staff B, Licensed Practical Nurse (LPN) stated any unknown bruising found on a resident, especially any that are on torso or upper legs should be reported to the state and investigated. Staff B stated the facility was made aware of the bruises on Resident 1 during a care conference with the care manager on 06/16/2026. In an interview on 06/23/2026 at 3:37 PM, Staff A, Director of Nursing Services (DNS) stated all potential allegations of abuse and/or neglect should be reported immediately and reported on the state reporting log within five days. Staff A stated they were not in the building and had been unable to report and investigate the bruises on Resident 1 till Monday June 22nd, 7 days after they had been discovered. Staff A was asked who at the facility was responsible for reporting allegations of abuse and neglect, and Staff A stated everyone in the facility was. Staff A confirmed the bruises for Resident 1 should have been reported, and confirmed the investigations for Resident 1, and the resident to resident involving Resident 2 and 3 should have been logged as well. Reference WAC 388-97-0640(5)(a)(6)(a)

Based on interviews, and record reviews, the facility failed to conduct thorough investigations for 1 of 3 resident investigations (Resident 1) reviewed for abuse, and/or neglect. The failure to conduct thorough investigation into unexplained bruises to a resident placed all residents at risk for repeat incidents, potential injury, and unmet care needs. Findings included.Findings included. Review of the facility policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated March 2025, documented the facility will conduct a thorough investigation of potential, suspected and/or allegations of abuse and neglect and injuries of unknown source in accordance with federal and state regulations. Resident 1 admitted to the facility 06/10/2026 with diagnoses that include developmental delay since childhood, depression, and pain. The admission Minimum Data Set (MDS - an assessment tool) dated 06/16/2026 showed the resident had an intellectual disability, with severe impaired cognition. Review of Resident 1's admission assessment dated [DATE] skin documentation showed the resident had a surgical wound site, no documentation of bruising to the resident's body. Review of Resident 1's medical record a progress note dated 06/16/2026 at 3:09 PM, documented by Staff A, Director of Nursing Services (DNS), documented during care conference caregiver noted that the resident had large bruise to upper left arm that measured 2 inches (in) by 2 in. The note did not mention any other bruises to the resident's body. Review of Resident 1's medical record a progress note dated 06/16/2026 at 9:22 PM, documented by Staff B, Licensed Practical Nurse (LPN) documented the resident was on alert for multiple bruises in front of the abdomen, back of right thigh of unknown origin. Review of the facilities investigation dated 06/16/2026, during Resident 1's care conference a Collateral Contact (CC) notified the facility that they had a bruise to their left upper arm that measured 2 centimeters (cm) by 5 cm, dark in color. In the investigation report it was documented that the residents were found to have bruises in their abdomen area and both of their legs. The conclusion of the investigation only addressed the bruise to the upper arm, there was no description (size, color, exact location) of the bruises found on the resident's abdomen region, or legs. There was no documentation provided in the investigation that abuse and neglect had been ruled out related to the unexplained bruises found on Resident 1. In an interview on 06/23/2026 at 11:40 AM, Staff A stated, I forgot to tell you about the other bruises for Resident 1. Staff A stated they were not aware Resident 1 had bruises in their abdomen and thighs till Friday morning on the 19th, and that they had not been in the facility, they did not investigate them till Monday morning on the 22nd. In an interview on 06/23/2026 at 3:08 PM, Staff B stated they were notified that Resident 1 had been found with unexplained bruises to their arms, abdomen and upper thigh area when they came on shift 06/16/2026. Staff B stated they were told that the nurse manager was notified of the bruises during Resident 1's care conference earlier in the day. Staff B stated they were told that they nurse manager was investigating the bruises. In an interview on 06/23/2026 at 3:37 PM, Staff A stated it was the expectation that all unexplained bruises were thoroughly investigated to rule out any potential abuse and/or neglect. Staff A stated they were alerted to a bruise on Resident 1's upper arm during the resident's care conference on 06/16/2026 towards the end of the day. Staff A was asked if a skin check was completed for Resident 1 after they found the bruise, as there was none provided in the investigation nor in Resident 1's medical record. Staff A stated yes, and provided a piece of paper from their desk, it was a drawing of the front of a person's body and backside of body, there were multiple x's marked on the abdomen, leg and arms and it was dated 6/16/2026 with a note that read multiple bruises there were no measurements or descriptions of the bruises. Staff A stated they thought the skin check was completed on the 17th and added they had not been in the facility. Staff A was asked about the progress note that was made in Resident 1's medical record on the evening of the 16th that documented the resident was on alert for unexplained bruises to arms, abdomen and upper thighs. Staff A added that they were not in the facility and were not notified of the other bruises till the morning of the 19th and did not start an investigation till the 22nd. Staff A confirmed all unexplained bruises should be investigated thoroughly to rule out abuse and neglect. Refer to WAC 388-97-0640(6)(a)

Based on interview and record review, the facility failed to provide a written notice of bed hold at the time of transfer to the hospital for 4 of 4 residents (Residents 10, 14, 33 and 52) reviewed for hospitalizations and bed holds. This failure placed the residents and/or representatives at risk of not having the necessary information to make an informed decision regarding their ability to return to the facility, Findings included .Review of facility policy titled Bed hold policy, dated April 2025, documented in section 5.2: Bed Holds. The Community will provide a bed hold notice in accordance with applicable regulations and discuss the bed hold note (if applicable) with the resident and responsible party of the time of transfer to an acute hospital. <RESIDENT 14>Resident 14 admitted to the facility on [DATE], with diagnoses to include anoxic brain damage (a severe, often permanent, acquired brain injury), diabetes, and pain. Review of Resident 14's Electronic Health Record (EHR) documented the resident discharged to the hospital return anticipated on:- 01/31/2026,- 02/16/2026,- 03/23/2026,- 04/05/2026. Further review of Resident 14's EHR for 01/30/2026 through 04/09/2026 showed there was no documentation of written bed hold information being provided to the resident at time of discharges to the hospital on [DATE], 02/16/2026, 03/23/2026, or 04/05/2026. <RESIDENT 33>Resident 33 was admitted to the facility on [DATE]. Review of Resident 33's EHR documented the resident discharged to the hospital return anticipated on:- 01/16/2026, - 02/15/2026, - 03/07/2026. Further review of Resident 33's EHR for 01/15/2026 through 04/09/2026 showed there was no documentation of written bed hold information being provided to the resident at time of discharges to the hospital on [DATE], 02/15/2026, or 03/07/2026. <RESIDENT 52>Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's EHR documented the resident discharged to the hospital return anticipated on 03/10/2026. There was no documentation in the EHR that a written bed hold notice had been provided to the resident at time of discharge to the hospital. <RESIDENT 10> Resident 10 initially admitted to the facility on [DATE] with a readmission date of 11/26/2025 with diagnoses to include a pressure wound of the sacral region, stage three (deep, crater-like wound resulting from prolonged pressure), lumbar spina bifida (a birth defect where the lower spine doesn't close properly, leaving nerves exposed), paraplegia (paralysis of the lower half of the body), and diabetes type two (chronic health condition when blood sugar levels are too high because the body cannot properly produce or use insulin). Review of Resident 10's progress notes, on 11/16/2025 at 5:24 PM Staff R, Licensed Practical Nurse (LPN), documented that Resident 10 was transferred to the emergency room per physician orders. Review of Resident 10's EHR from 11/16/2026 through 11/26/2026 had no documentation of written bed hold information being provided to the resident at time of discharge to the hospital. In an interview on 04/10/2026, Staff H, LPN/Resident Care Manager, stated that the cart nurse on the floor should be doing the bed hold when sending a resident out to the hospital. Staff H stated that it would be documented in the progress notes if the resident accepted the bed hold but did not think it would be documented if it was offered and declined. Staff H stated there would not be scanned documents that the only documentation would be in progress notes. In an interview on 04/13/2026, at 1:30 PM, Staff A, Administrator stated that they were unaware of the correct bed hold process. Reference WAC 388-97-0120 (4)

Based on observation, interview and record review, the facility failed to ensure the facility assessment addressed the physical environment, equipment, services, and other physical plant considerations that are necessary to care for its identified resident smoking population. Failure to thoroughly assess all factors associated with resident smoking placed residents at risk for adverse events related to smoking safety. Findings included . Review of the facility policy titled, Resident Smoking Safety ., updated January 2025 stated no smoking was allowed on the facility grounds, including parking lots, except in designated areas smoking areas were provided with metal cannisters for the disposal of smoking materials .smoking areas were provided with a portable properly rated fire extinguisher and a suitable number of code compliant smoking aprons. Resident who was assessed were required to safely store their smoking materials in a locked box in their room or lockable mailbox type container outside. In an observation on 04/07/2026 at 11:30 AM, there was a resident smoking area in the front facility parking lot which included a canopy style pop up tent, a fire extinguisher, metal smoking receptacles and smoking aprons. The smoking tent was observed blocking one of two accessible handicapped parking spaces. In an observation on 04/08/2026 at 2:00 PM the smoking area and items were observed to have been relocated to another area of the parking lot which was out of compliance with state and local requirements that prohibit smoking within 25 feet of entrances or windows that open. During a resident group interview on 04/08/2026 at 2:53 PM, Residents 30, 59 and 79 stated they kept their own smoking materials and had lock boxes in their rooms but said they did not have keys for their lock boxes. Review of the Facility assessment dated [DATE] documented the resident population included 8 residents identified with tobacco use. Further review of the Facility Assessment revealed no further documentation regarding physical environment, equipment or services necessary related to the identified resident smoking population. In an interview on 04/13/2026 Staff A, Administrator stated they were aware of issues regarding the location of the facility smoking area. Staff A was not aware of residents not having locking boxes with keys to keep smoking materials. Staff A did not have further information related to the Facility Assessment's lack of addressing the facility needs related to resident smoking. No associated WAC reference

Based on observation, interview and record review, the facility failed to ensure smoking policies were implemented in accordance with applicable Federal, state and local laws and regulations regarding smoking, smoking areas, and smoking safety. Failure to ensure smoking areas were in compliance with the Americans with Disabilities Act which prohibits blocking handicapped parking spaces, and Revised Codes of the State of [NAME] which prohibits smoking within 25 feet of facility entrances or windows that open, impacted parking accessibility and created the potential for smoke intrusion into the facility. Findings included . Review of the facility policy titled, Resident Smoking Safety . updated January 2025 stated no smoking was allowed on the facility grounds, including parking lots, except in designated areas. In an observation on 04/07/2026 at 11:00 AM, the facility had two handicapped accessible parking spaces in the front parking lot to the left of main entrance to the building. A pop up canopy style tent was observed set up over one of the two handicapped parking spaces. A wooden post had been placed in the ground next to the canopy with a fire extinguisher. Smoking aprons and smoking receptables were observed placed in the area. There were two residents observed sitting under the canopy smoking. In an interview on 04/07/2026 at 1:30 PM, Resident 83 stated they were a smoker and had been in the facility since January 2026. Resident 83 stated the smoking tent had been in the same place since before they admitted . Resident 83 stated they had been concerned about the smoking area being in the parking lot and blocking one of the handicapped parking spaces. In an observation on 04/08/2026 at 2:00 PM, the smoking area was observed to have been relocated. The smoking canopy and related fire extinguisher, smoking aprons and receptables were now observed to the right of the facility entrance. The observed relocated placement of the smoking area was within 25 feet of the facility entrance and nearby windows that could open. In an interview on 04/13/2026 at 2:00 PM, Staff A, Administrator, stated they were aware there were issues with the location of the smoking area and stated that currently there was not a definitive plan regarding the smoking area or placement. Refer to the Americans with Disabilities Act Refer to RCWs 46.19, 46.61 and 70.160Refer to WAC 388-97-1780(1)(2)(a)(i)(d)

Based on interview and record review, the facility failed to ensure grievances were reviewed promptly and thoroughly resolved with supporting documentation to prevent reoccurrences for 9 of 15 Residents (Residents 30, 47, 57, 65, 79, 95, 105, 122 and 124) reviewed for grievance process. The failure to resolve grievance concerns caused the uncertainty of the resident and/or resident representative receiving necessary care and services, having a diminished quality of life, and not being able to voice concerns with some type of resolution.Findings included . Review of the facility policy titled Grievance Procedure Policy, updated March 2025, documented the administrator was the designated grievance official and oversees the procedures. grievances were resolved immediately when possible and when not possible routed to the grievance official promptly. If the grievance involved abuse, neglect, exploitation, or misappropriation of resident property the Administrator was notified immediately and an investigation would begin. <RESIDENT 105> Resident 105 was admitted to the facility on [DATE] with diagnoses to include major depressive disorder and anxiety. In an interview on 04/07/2026 at 12:55 PM, Resident 105 stated the facility lost their blankets and clothes. The resident said they were upset they lost their black [NAME] blanket that had been given to them from their son who had since passed away. The resident stated they had reported this to the laundry department and had not received follow up and the facility had not offered to reimburse them. Review of Resident 105's personal belongings inventory dated 12/15/2025, showed the resident admitted with a blue and black electric blanket, a black and red blanket and another blue blanket. In a follow up interview on 04/10/2026 at 9:27 AM, Resident 105 stated the facility had not located their blanket or missing clothes yet. The resident stated they talked to someone in laundry and they told them that since they did not have the items written down on their inventory sheet, it was too bad and they probably would not get reimbursed for them. The resident stated the blanket they were missing was the red and black one. Resident 105 said it was not about the money. They stated although the [NAME] blanket was expensive, it was that their son had given it to them before they passed away. In an interview on 04/10/2026 at 10:20 AM, Resident 105 stated they needed assistance to get a new blanket and stated they were missing a tribal hoodie sweatshirt also. In an interview on 04/10/2026 at 1:40 PM, Staff G, Social Services Assistant stated Resident 105 mentioned they were missing their [NAME] blanket. Staff G stated the resident talked with Staff I, housekeeping supervisor, but they (Staff G) had not looked in the laundry room. Staff G stated the resident had been missing the blanket from their deceased son for several months. Staff G stated since the blanket was not on their initial inventory list, they were told from administration the facility would not reimburse the resident for it. In an interview on 04/13/2026 at 11:22 AM, Staff B, Director of Nursing stated the process for missing items was to search for the item or replace or reimburse if the item was determined to be missing while the resident was in the facility. Staff B was unaware of Resident 105's missing items. In an interview on 04/13/2026 at 12:22 PM, Staff F, Social Services Director (SSD) stated they met with Resident 105 and identified the missing [NAME] blanket was not the earlier grievance filed regarding a different geometric blanket. They said they completed a new grievance for the missing [NAME] blanket with black crabs on it. <RESIDENT 122> Review of the grievance dated 01/26/2026 at 1:56 PM, Resident 122, documented they last had a shower on 01/19/2026. The resident documented they had mentioned to staff they had been waiting for a shower for a couple of days; their hair was greasy and had buildup of dandruff flakes in their hair. Resident 122 wrote they were not offered a shower or bed bath on 01/23/2026. The investigation/findings documented Resident 122 had refused a shower on 01/23/2026 and a shower was given on the day the grievance was written on 01/26/2026. The grievance contained no supporting documentation of Resident 122's refusal of a shower or discussion with them about their grievance. The grievance was not signed by Resident 122. <RESIDENT 124> Review of the grievance dated 02/03/2026, Resident 124 documented they were showered in the shower room with a resident of the opposite sex in the stall next to them and they had experienced a two-hour call light response. The investigation/findings documented Resident 124 was brought into the shower room which was occupied by another resident of the opposite sex. The grievance showed Resident 124 denied feeling abused or neglected and the two hour wait time was not a problem as they did not time it. The investigation/findings failed to address the circumstances and details around the call light wait time and the grievance was considered resolved as it was isolated. Resident 124 did not want the aide to get in trouble and denied abuse/neglect. No other residents were interviewed, and no call light audits were completed to determine whether the grievance was isolated and rule out abuse/neglect. There was no mention of staff education or in servicing about call light expectations or avoiding showering of male and female residents in the shower room at the same time. <RESIDENT 47> Review of the grievance dated 03/06/2026 showed Resident 47 documented there were unclear communications from nurses. They had wanted pain medication and the nurse threatened them. Review of the investigations/findings showed Resident 47 stated the nurse told them to go back to their room because they were fighting with them and it was not time for their medication. The resolution was that nurses would give medications as ordered and Resident 47 denied feeling neglected or abused. No further interviews with residents/staff or information were documented to rule out abuse/neglect. <RESIDENT 95> Review of the grievance dated 03/05/2026 and documented received on 03/17/2026 (12 days after the date of the grievance) revealed Resident 95 documented that staff were not great at communication and follow through and call light response had taken longer than 30 minutes. Review of the investigation/finding showed Resident 95 was interviewed, and they reported call light wait time longer than 30 minutes was rare and primarily involved agency staff. There was no documentation which determined the nature of the grievance, when or what shift the call light wait time was longer than 30 minutes, or a description of the nature of the communication issue and lack of follow through entailed. A call light audit was conducted during day shift only on 03/19/2026 and 03/20/2026 with no findings. There were no other call light audits completed to determine if a trend existed. An in-service education was conducted on 03/26/2026 (21 days after the date of the grievance) with the topic described as all staff and the content of the in-service was customer service and survey preparation. Review of the in-service documented attendees, none of which were agency staff. The grievance was not signed by the administrator and reviewed on date was blank. <RESIDENT 57> Review of the grievance dated 03/17/2026 at 7:30 PM, Resident 57 documented Staff W, Nursing Assistant Certified (NAC), had an attitude. Resident 57 documented they had been having difficulty keeping food down for the last week and when they informed the staff they had a bowel movement and needed to be changed they were told there was nothing in their brief. Resident 57 documented I don't need to be treated cruelly. The investigation/findings documented Resident 57 stated Staff W was rude to them when they asked them to reheat their soup. Education was provided to the resident on the facility policy of reheating food and Staff W was in-serviced on respect. The grievance was not escalated to an investigation. Findings failed to address the documented allegations of potential verbal/mental abuse and neglect or to address their concerns for not being able to keep food down. <RESIDENT 30> Review of the grievance dated 03/14/2026 and documented as received on 03/20/2026 showed Resident 30 documented their call light wait time was long. Resident 30 documented they were waiting to have their urinal emptied so they could use it. Resident 30 documented their urinal was full and because of not having them emptied, they had wet their pants. Review of the investigation/findings documented Staff FF, NAC, did not empty the urinal and one on one education was provided to them on 03/24/2026 by phone. The grievance was not escalated to an investigation and failed to identify and rule out potential neglect of Resident 30. The grievance was logged and reviewed by Staff A, Administrator on 03/24/2026. Review of the grievance dated 03/15/2026 and received on 03/20/2026 revealed Resident 30 documented they and another resident waited over 40 minutes for their call light to be answered. Resident 30 documented when Staff EE, NAC, arrived, they explained they had been on their break. Resident 30 documented they asked Staff EE about having their hall covered while on break and Staff EE, an agency NAC, provided a sarcastic response. The investigation/findings documented Staff EE did not provide care to the resident, passed off the care to another aide, and Staff EE would be blocked from picking up shifts at the facility. The investigation failed to identify what care had not provided and rule out neglect. The grievance was logged and reviewed by Staff A, Administrator, on 03/25/2026 (10 days after the grievance was dated). <RESIDENT 79> Review of the grievance dated 03/26/2026 revealed Resident 79 documented staff were telling them they could not help them with something due to not having additional help. Review of the investigation/findings documented Resident 79 stated staff came in their room and told them they don't have time or help to do things for them. Resident 79 was unable to describe the nursing assistant that said they could not help them. An in-service education was provided to all staff, dated 04/01/2026, for the topic of call lights, a total of six NAC's signed the in-service roster, none of which were agency staff. The grievance contained no information or details about what care or services were not provided to Resident 79 or if there was a pattern of multiple residents making the same statement. No other residents were interviewed to determine if other residents were affected. Review of the incident reporting log dated 01/26/2026 through 03/31/2026 showed no logged entries to indicate any of the grievances reviewed were escalated to allegations of abuse/neglect. In an interview on 04/10/2026 at 11:23 AM, Staff N, NAC, stated there were red grievance forms that residents completed and signed. Staff N stated the resident, or they would put the completed grievance forms in the drop box close to the nurse's station. Staff N stated if they were given a grievance by a resident, they would put it in the grievance box. When asked if they would read the grievance, they stated they would not they would just place it in the box. In an interview on 04/13/2026 at 9:07 AM Staff G, Social Services Assistant, stated the grievance process for the facility included filling out a grievance form, which could be completed by either the staff or the resident. Staff G stated a grievance could be anything from missing items, to a roommate issue and when a grievance form would be filled out, a copy was made and provided to the department that needed to investigate. Staff G stated the grievances were read in the morning meetings with Staff A, Administrator. Staff G stated grievances should be resolved within 48 hours. When asked about the difference between a grievance and an allegation, Staff G stated an allegation was an incident that could cause harm such as a staff member being rude to a resident or physical with them. Staff G stated all allegations must be reported to Staff A within two hours. In an interview on 04/13/2026 at 9:43 AM Staff D, Licensed Practical Nurse/Resident Care Manager, stated there were several spots in which the grievances forms, pink in color, were posted. Staff D stated social services had educated residents and family members of where the grievance forms were located. Staff D stated the grievance box on the first floor was located on the wall in a black mailbox and the box was checked every morning by social services. Staff D stated they don't always read the grievances given to them by residents and would place them in the social services or Staff B's, Director of Nursing Services (DNS) box. When asked about the difference between a grievance and an allegation, Staff D stated a grievance was a concern like loud noise or a dietary preference, a situation in which there would be no harm or intent of harm, and an allegation would be about harm or unintentional harm. In an interview on 04/13/2026 at 11:45 AM, Staff B, DNS, stated the process for grievances included reading them immediately to determine if there was an allegation of abuse/neglect and if a report was required. If the grievance was determined to require a report, Staff A, Administrator, would be notified right away and then the facility would complete an investigation within five days. Staff B stated they thought the grievance boxes were located at the nurse's station and they were checked twice a day by social services. Staff B stated staff were educated to read the grievances, if they were provided to them, to ensure there was not an allegation of abuse or neglect. Staff B stated an allegation was an incident/situation that alleged abuse, neglect or misappropriation and a grievance was something a resident didn't like that doesn't cause harm. Reference WAC 388-97-0460

Based on interview and record review, the facility failed to ensure 5 of 7 sampled residents (Residents 4, 6, 13, 18 and 104) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to monitor and document behaviors and symptoms, and failed to document non-pharmacological interventions, and effective use of medication. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication. Findings included .Review of the facility policy titled, Psychoactive Medication, dated June 2025 documented behavior monitoring is initiated to identify problem behaviors and specific behavior interventions are placed on the behavioral monitor for documentation by staff prior to initiation of psychoactive medications.if there are behavioral changes an evaluation is completed and documented as to cause of behaviors, alert charting, notification to all parties, behavioral monitoring is established, non-pharmacological interventions attempted. <RESIDENT 4> Resident 4 readmitted to the facility on [DATE], with diagnoses that included anxiety and depression. The Quarterly Minimum Data Set (MDS- an assessment tool) dated 02/10/2026 documented the resident had intact cognition, minimal depression, and displayed verbal behaviors towards other 1 – 3 days of the look back period. Review of Resident 4's care plan, print date 04/08/2026 documented the resident had impaired psychosocial wellbeing as evidence by behaviors requiring interventions and psychotropic drug utilization related to their anxiety, and resistant to care with refusal to take anxiety medication. Review of Resident 4's physician orders on 04/08/2026, documented the resident was prescribed buspirone (medication used to treat anxiety), duloxetine (medication used to treat depression) and hydroxyzine (medication used to treat anxiety). The three psychotropic medications were administered and received by the residents daily. There were no physician orders to monitor behavioral symptoms, no orders for non-pharmacological interventions, or if they were effective or not. <RESIDENT 6> Resident 6 admitted to the facility on [DATE] with diagnoses that included anxiety, depression, posttraumatic stress disorder (PTSD), and disorganized schizophrenia (severe disrupted thought processes, speech, and behavior). Review of Resident 6's care plan, print date 04/08/2026 documented the resident had impaired psychosocial wellbeing as evidence by behaviors requiring intervention and psychotropic drug utilization related to diagnosis of schizophrenia, PTSD, depression and anxiety. The goal was to have reduced and manageable behaviors through review date. Review of Resident 6's physician orders on 0408/2026, documented the resident was prescribed buspirone, duloxetine, quetiapine (medication used to treat schizophrenia symptoms), and trazadone (medication used to treat depression). The four psychotropic medications were administered and received by the resident daily. There were no physician orders to monitor behavioral symptoms, no orders for non-pharmacological interventions, or if they were effective or not. In an interview on 04/10/2026 at 10:42 AM, Staff J, Registered Nurse (RN) stated that the nurses only document in the progress notes if a resident has behaviors, if they continue, they will place the resident on alert for three days to monitor those behaviors. Staff J stated they do not complete daily behavior monitoring for residents that were prescribe and took routine or as needed psychotropic medications. Staff J stated only the nursing assistant certified (NAC) document if they observe behaviors. In an interview on 04/10/2026 at 12:04 PM, Staff H, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), stated when a resident first admits they will monitor for behaviors for the first two weeks. Staff H stated that the social services department will update the care plan to the specific behaviors for that resident. Staff H stated social services department will also have the NACs document any observed behaviors. Staff H stated the licensed staff were not completing daily behavior monitoring for residents that were prescribed and took routine or as needed psychotropic medications, only NACs. Staff H was unable to provide any documentation for licensed nurses monitoring Resident 4 or Resident 6's behaviors. In a joint interview on 04/10/2026 at 1:37 PM, Staff F, Social Service Director and Staff K, Regional Social Service Director, Staff F stated they review resident's psychotropic medications on admission, quarterly and as needed. Staff F stated they discuss residents weekly in a clinical meeting, they review the behaviors that are documented, and progress notes. Staff F was asked if the behavior documentation was from licensed staff or the NACs. Staff K stated the documentation should only be by the licensed nursing staff, as they were to monitor behaviors, document appropriate non-pharmacological interventions that were used and if effective. Staff F and Staff K were unaware the licensed nurses were not monitoring behaviors, and which non-pharmacological interventions were used. Staff K was unable to locate any documentation by licensed nurses for monitoring of behaviors for Resident 4 and Resident 6. <RESIDENT 104> Resident 104 admitted to the facility on [DATE], with diagnoses that included dementia, anxiety and depression. The admission MDS dated [DATE] documented the resident had impaired cognition, minimal depression, and delusions with no displayed behaviors towards others in the look back period. Review of Resident 104's care plan, initiated 11/07/2025 documented the resident had impaired psychosocial wellbeing as evidence by behaviors requiring interventions and psychotropic drug utilization related to their anxiety, dementia without behavioral, psychotic or mood disturbance. Review of Resident 104's physician orders showed the resident was prescribed Quetiapine (anti-psychotic medication) twice a day beginning 12/31/2025. There were no physician orders to monitor behavioral symptoms, no orders for non-pharmacological interventions, or if they were effective or not. <RESIDENT 13> Resident 13 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, anxiety, depression and delirium due to physiological condition. According to the Significant Change Minimum Data Set (MDS- and assessment tool), dated 01/09/2026, the resident had memory problems and had severely impaired cognition. Review of Resident 13's care plan with the print date of 04/08/2026 documented the resident had impaired psychosocial well-being as evidenced by behaviors requiring intervention and psychotropic drug utilization related to a diagnosis of delirium, anxiety and depression. A list of target behaviors included: anxious, crying, exiting/wandering, removal/attempted removal of Wander Guard Band, insomnia/not sleeping, panic, withdrawal, self-isolating. Review of Resident 13's physician orders on 04/09/2026, documented the resident was prescribed three psychotropic medications. Escitalopram (medication to treat depression) daily, Quetiapine (medication to treat delirium) daily and Lorazepam (medication to treat anxiety) as needed. The resident received Escitalopram and Quetiapine daily and the resident received Lorazepam twice in March 2026. There were no orders to monitor behavioral symptoms and no orders for non-pharmacological interventions. In an interview on 04/10/2026 at 8:15 AM, Staff P, LPN stated that if a resident had specific behaviors they need to monitor, the behaviors will be listed in the Treatment Administration Record for the nurses to document. If a resident does not have specific behaviors, then they don't document unless the resident had behaviors during their shift. They will document the behaviors in the progress note and place them on alert charting. Staff P stated that not all residents who were taking psychotropic medications had behavior monitoring. In an interview on 04/10/2026 at 12:04 PM, Staff H, LPN/RCM stated, for newly admitted residents that were on psychotropic medication, they put them on alert charting for behavior monitoring for two weeks. The social services department (SSD) then will review the behaviors and place them in the care plan. This will then be transcribed for the nursing assistants to monitor and document. Staff H could not provide documents to show that the nursing assistants were monitoring and documenting Resident 13's behaviors. In an interview on 04/10/2026 at 1:07 PM, Staff H stated that it's an expectation for the nurses to offer non-pharmacological interventions prior to giving any as needed medications. The non-pharmacological interventions will come out as a question for the nurse to answer prior to giving the as needed medication. Staff H could not provide documents that nurses provided non-pharmacological interventions prior to administering the Lorazepam to Resident 13. <RESIDENT 18> Resident 18 admitted on [DATE] with diagnoses which included frequent falls, Parkinson's disease (progressive disorder causing tremors, rigidity and affecting movement) and anxiety. Review of Resident 18's physician's orders on 04/08/2026, documented an order for Alprazolam (an antianxiety medication) ordered every 12 hours as needed for anxiety. Review of the Medication Administration Records for March 23-31, 2026 and April 1-7, 2026 showed the resident received as needed Alprazolam 6 doses in March and 8 doses in April. The administration records revealed each as needed dose was administered without documentation of any non-pharmacological interventions that had been attempted prior to administration, and no identified target behaviors exhibited which would necessitate medication being needed at the time. The follow-up documentations stated effective with no further documentation. Review of routine behavior monitoring documentation in the record revealed that the only behavior documentation was completed by certified nursing assistants and did not correspond or relate to medication administrations. In an interview on 04/10/2026 at 9:23 AM, Staff P, LPN, reviewed the Alprazolam order for Resident 18 and stated they did not see anywhere in the Medication Administration fields to document if target behaviors or non-pharmacologic interventions had been attempted. Staff P was not aware of what behaviors Resident 18 had been exhibiting which had necessitated administering the antianxiety medication and stated, I don't know, it doesn't say. In an interview on 04/10/2026 at 9:28 AM, Staff H, stated the nursing assistants charted behaviors for their shift and nurses should be charting and establishing behaviors, and acknowledged there were no non-pharmacologic interventions or target behaviors associated with the as needed antianxiety medication for Resident 18. In a joint interview on 04/13/2026 at 1:01 PM, Staff A, Administrator and Staff B, Director of Nursing Services, Staff B stated they were unaware that the behavior monitor reports reflected only NAC documentation, and there was nowhere for licensed nurses to monitor residents behaviors, nowhere for them to document which non-pharmacological interventions were used and if they were effective or not. Staff A agreed that the licensed nursing staff should be the ones responsible for that documentation. Reference WAC 388-97-1060(3)(k)(i), - 0620(1)(a)

Based on interview and record review, the facility failed to ensure the level one Pre-admission Screening and Resident Review (PASRR- assessment/a federal requirement for Medicaid-certified nursing facilities to ensure individuals, especially those with mental illness, seeking admission are appropriately placed and receive necessary services) were referred and followed up on for 5 of 6 residents (Residents 11, 13, 73, 82 and 104) reviewed for PASRR. This failure placed residents at risk of unmet mental health services and a diminished quality of life. Findings included .<RESIDENT 82> Resident 82 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, schizophrenia, and unspecified psychosis. Review of Resident 82's Level 1 PASRR dated 02/22/2026 showed the resident was positive for a serious mental illness with indicators marked for mood disorders (depression), schizophrenia, and anxiety disorder. The service needs section documented there was no need for a Level 2 evaluation at this time due to an exempted hospital discharge, however if the resident stayed in the nursing home longer than 30 days, the Level 2 evaluation must be completed. Review of Resident 82's medical record on 04/07/2026 (16 days after the 30-day deadline) lacked any documentation that there had been a Level 2 request for evaluation completed, or that any communication with the PASRR coordinator had been completed. In an interview on 04/10/2026 at 1:37 PM, Staff K, Regional Social Services Director (RSSD) stated the PASRR were reviewed upon admission, and if there were any discrepancies they would follow up with the PASRR coordinator. Staff K stated that it was the expectation for all positive Level 1's to have a Level 2 evaluation or a Notice of Determination letter on file prior to admission of a resident. Staff K was asked what the process was for positive Level 1's with a 30-day exemption, and they stated they make a notification in their outlook calendar to send a request for Level 2 on day 24-25. Staff K stated they communicate with the PASRR coordinator monthly for follow up. Staff K was asked if there had been any communication with PASRR coordinator for Resident 82. Staff K stated they could provide that information. Staff K was asked where that information would be in the resident's medical record, and Staff K stated they would make a progress note, and/or it would be scanned in. In a follow up interview on 04/10/2026 at 2:35 PM, Staff K provided a copy of an email sent to the PASRR coordinator for Resident 82, it was dated 04/07/2026. Staff K could not provide any other documentation that they had submitted for the Level 2 to the PASRR coordinator for the 30-day exemption prior to the deadline. <RESIDENT 11> Resident 11 was admitted to the facility on [DATE] with diagnoses to include Post-Traumatic Stress Disorder (PTSD) (mental health condition triggered by experiencing or witnessing a traumatic event), depression, anxiety and psychosis (mental condition in which thought and emotions are so affected that contact is lost with external reality). Review of Resident 11's most recent Level 1 PASRR, dated 11/24/25, completed by Staff K, RSSD, documented they required a Level 2 PASRR referral. Review of Resident 11's progress note dated 11/26/2025 at 8:09 AM, Staff K, documented they referred to and sent the Level 1 PASRR to the Level 2 PASRR evaluator. In an interview on 04/13/2026 at 11:00 AM, Staff K stated they had completed a progress note in April of 2026 related to follow up with the Level 2 PASRR evaluator. Requested Staff K, if there was documentation related to monthly follow up with the Level 2 PASRR evaluator and they stated they did not reach out monthly for follow up. <RESIDENT 73> Resident 73 was admitted to the facility on [DATE] with diagnoses to include dementia (decline in cognitive function, affecting memory, thinking, and behavior), depression, anxiety and psychosis (mental condition in which thought and emotions are so affected that contact is lost with external reality). Review of Resident 73's most recent Level 1 PASRR, dated 11/24/2025, completed by Staff K, RSSD, documented they required a Level 2 PASRR referral. Review of Resident 73's progress note dated 11/26/2025 at 8:06 AM, documented the Level 1 PASRR had been referred to and sent to the Level 2 PASRR evaluator. In an interview on 04/13/2026 at 12:01 PM, Staff K, stated Resident 73 had an invalidation from their previous PASRR, dated 04/03/2025. Staff K stated they were unsure if there was documentation of contact or monthly follow up with the Level 2 PASRR evaluator between 11/26/2025 and 04/07/2026. <RESIDENT 13> Resident 13 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, Anxiety, Depression and delirium due to physiological condition. In a record review, Resident 13 had PASRR's dated 08/14/2026 and 11/24/2025 with Level 2 evaluation referral required for serious mental illness (SMI). Review of Resident 13's electronic chart did not show Level 2 evaluation documents. Record review of Resident 13's progress note dated 10/09/2025, Social Services documented that they notified PASRR Coordinator that resident remained at the facility as a long-term care resident. No mention regarding the follow up for the Level 2 evaluation. Record review of Resident 13's progress note dated 11/26/2025, Social Services documented that they reviewed Resident 13's PASRR and that Level 2 referral for evaluation was sent to the PASRR assessor. There were no other notes regarding the PASRR and follow ups on the Level 2 referral in Resident 13's progress notes until 04/08/2026. Social Services documented that they talked to the PASRR coordinator to follow up on the Level 2 referral on 11/25/2025 and was informed that the PASRR will be invalidated and documents will be sent. Resident 13 had been at the facility for 7 months. In an interview on 04/10/2026 at 1:36 PM, Staff K, stated that it was an expectation for newly admitted residents' PASRR's that require a Level 2 evaluation should have the notice of determination and/or invalidation upon admission. If it was not available, then they would reach out to the PASRR Coordinator to see the status of the Level 2 evaluation. Staff K could not provide documentation that they had followed up regularly with the PASRR coordinator regarding Level 2 evaluation for Resident 13. <RESIDENT 104> Resident 104 admitted to the facility on [DATE] with diagnoses to include dementia (a general term for problems with reasoning, planning, memory, and other thought processes) without behavioral, mood or psychotic disturbance (characterized by a loss of touch with reality characterized by altered thinking, perceptions, and behavior). Review Resident 104's Level I PASRR, dated 10/06/2025, a month prior to admission showed the resident had a serious mental illness (MI) indicator however psychotic disorder was not marked. The PASRR indicated a Level II PASRR was indicated. Comments added were Resident 104 takes anti-psychotic medication for dementia and had a history of depression with anxiety for which they were not currently medicated. Psychosis was not selected and there were no comments of such. Review of Resident 104's level II PASRR invalidation dated 11/01/2025 showed the resident had depression and anxiety and did not meet the criteria for a level II evaluation and recommendations for specialized services. Review of provider visits dated 11/11/2025, 12/31/2025, 01/08/2026 and 02/07/2026 showed the same assessment/plan for unspecified psychosis not due to a substance or known physiological condition. The notes documented repeated history of active auditory and visual hallucinations, a history of calling 911 frequently and wander and elopement risk. Review of a physician order showed Resident 104's anti-psychotic medication had to be increased on 12/31/2025. In an interview on 04/10/2026 1:52 PM, Staff G, Social Services Director, reviewed Resident 104's medical record and stated they could not locate a PASRR revision. Staff G stated they would talk to their team about it. They stated they were unaware of any PASRR issues. The PASRR was not revised when the Level 1 PASRR did not accurately identify the resident's psychosis and need for a Level 2 evaluation. Reference WAC 388-97-1915(2)(4)

Based on observation, interview and record review the facility failed to ensure care plans were revised as needed for 5 of 9 sampled residents, 2 of 6 (Resident 56 and 105) reviewed for accidents, 2 of 3 (Resident 41 and 84) reviewed for skin issues, and 1 of 6 (Resident 46) reviewed for activities of daily living. This failure placed residents at risk of unmet needs, decreased quality of care related to outdated or inaccurate care plans, and a diminished quality of life.<ACCIDENTS> <RESIDENT 56> Resident 56 was admitted to the facility on [DATE] with diagnoses to include convulsions (episodes of uncontrollable shaking, jerking, or stiffening of the muscles), Parkinson's disease (a slow, progressive brain disorder that impacts movement), polyneuropathy (dysfunction of multiple nerves often causing numbness, tingling, or weakness, typically starting in the hands and feet) and anxiety. Review of Resident 56's admission minimum data set (MDS - as assessment tool), dated 02/18/2026, documented severe cognitive impairment. The MDS documented seizure disorder as an active diagnosis and no history of falls. Resident 56's end of Medicare Part A MDS, dated [DATE], documented one non-injury fall and one injury fall since admission. Review of Resident 56's order summary, print date 04/08/2026, documented seizure precautions every shift with an order date of 02/19/2026. Review of Resident 56's fall assessment dated [DATE], documented the resident was a high fall risk. In a record review of Resident 56's electronic health record (EHR), they had falls on 03/01/2026, 03/09/2026, 04/09/2026 and 04/10/2026. In a progress note for Resident 56 dated 02/18/2026, at 1:36 PM, Staff H, Licensed Practical Nurse (LPN)/ Resident Care Manager (RCM) documented Resident 56 had seizure activity and was transported to the emergency room. Review of Resident 56's hospital admission records from 02/11/2026, documented Resident 56 was a high fall risk and interventions in place at the hospital included safety checks and bed alarm. The hospital admission records also documented new onset seizures as an active issue. Review of Resident 56's after visit summary dated 02/18/2026, documented seizure disorder under diagnoses. Review of Resident 56's care plan, dated 02/12/2026, documented Resident 56 was at risk for falls related to deconditioning, gait/balance problems and interventions included to ensure the call light was within reach and to encourage the resident to use it, ensure the resident was wearing appropriate footwear, to use wheelchair when returning to facility with family, to keep the room free of clutter, and have a safe environment. The care plan did not have documentation of seizure precautions. In a joint interview on 04/10/2026 at 2:23 PM, Collateral Contact (CC) 5, and CC 6, stated that Resident 56 was a known high fall risk. They stated the facility wanted to put Resident 56's bed against the wall upon admission due to being a fall risk, but family declined. CC 5 and CC 6 stated that after Resident 56's first fall, on 03/01/2026, that Resident 56 was supposed to get fall mats and only got fall mats after the third fall on 04/09/2026. CC 5 and CC 6 stated that they didn't think Resident 56 was checked on frequently enough and were concerned with the interventions in place. CC 5 and CC 6 also requested other interventions to further prevent falls and injury, and no other interventions were provided by the facility. In an interview on 04/13/2026, at 9:23 AM, Staff BB, Nursing Assistant Certified (NAC), stated that Resident 56 did suffer from seizures and tremors. Staff BB stated that for seizure precautions they monitored and notified the nurse of any seizure activity and made sure that they didn't hurt themselves. Staff BB also stated Resident 56 was a high fall risk, that they tried to get up on their own and that was when they fell so they kept Resident 56 in the hallway to monitor them closely. In an interview on 04/13/2026, at 10:56 AM, Staff C, Assistant Director of Nursing Services (ADNS), confirmed seizure precautions were on Resident 56's physician orders but not on the care plan. Staff C stated that they were unaware of what seizure precautions were. Staff C also stated that for a resident who is a high fall risk the facility would typically do fall mats for prevention of injury and bed positioning could be another intervention. In an interview on 04/13/2026, at 1230:PM, Staff B, Director of Nursing Services (DNS), stated they are not sure what seizures precautions were but they should be care planned along with the high fall risk. <SKIN ISSUES> <RESIDENT 84>Resident 84 was admitted to the facility on [DATE] with diagnoses that included diabetes, peripheral vascular disease (circulation disorder involving narrowing, blockage, or spasms in blood vessels), and venous insufficiency (circulation disorder involving narrowing, blockage, or spasms in blood vessels). The quarterly MDS dated [DATE] documented the resident had an infected diabetic foot ulcer with dressing orders. Review of Resident 84's wound documentation on 11/30/2025 documented the resident had developed a diabetic ulcer to their right heel. In an observation and interview on 04/07/2026 at 1:44 PM, Resident 84 was observed sitting upright on their bed, with their right heel lying flat on bed with an ice pack on top of the foot. The resident stated that the ice helped with the pain in between their pain medication. The resident stated the wound started a few months ago, they were applying lotion and a piece of skin just fell off. The resident stated they were going to an infectious disease doctor and have now been referred to see a podiatrist. The resident stated they were independent with their activities of daily living (ADLs) but would ring for help if needed. The resident stated they did wound care every day and once a week the wound specialist came to look at it. Review of Resident 84's care plan, print date 04/08/2026, documented the resident had a focus area they were at risk for pressure ulcer related to limited mobility, and on 12/02/2025 developed a right heel diabetic ulcer. Interventions listed education to the resident on skin breakdown, follow facility protocols for skin breakdown, inform if there was new skin breakdown, inspect skin while providing care, manage incontinence, and frequent turning and repositioning. The care plan lacked any individualized goals, or interventions for prevention and treatment of the resident's right heel wound. In an observation on 04/08/2026 at 1:53 PM, Resident 84 was observed returning to the facility with a shoe and sock on their right heel. In an interview on 04/10/2026 at 8:50 AM, Staff X, NAC stated that they used the Kardex (condensed version of the care plan) and the whole care plan to guide what type of care they delivered to residents. In an interview on 04/10/2026 at 10:42 AM, Staff J, Registered Nurse (RN) stated it was the Resident Care Managers (RCM) who updated the care plans, and if there was an inaccuracy they will report to them. In an interview on 04/10/2026 at 12:04 PM, Staff H, Licensed Practical Nurse (LPN)/RCM stated care plans were updated by all the interdisciplinary team (IDT), nursing section would usually be done by the MDS nurse or the RCMs. Staff H stated that the expectation was if there was a change needed the cart nurse should be able to make those changes and not wait for management to complete. Staff H stated that Resident 84 was supposed to be non-weight bearing to their right foot, however the resident continued to be independent with all ADL's and was struggling to keep control of their autonomy and was not following the guidance. Staff H was not aware there was no individualized goals, or interventions for prevention and treatment of the resident's right heel wound. <RESIDENT 41> Resident 41 was admitted to the facility on [DATE] with diagnoses including intracerebral hemorrhage (ruptured blood vessel bleeding into the brain tissue), generalized anxiety disorder and aphasia (difficulty talking). A review of Resident 41's admission MDS assessment, dated 01/06/2026, showed the resident did not have moisture associated skin damage (MASD, inflammation and erosion of the skin caused by prolonged exposure to moisture, such as sweat, urine, stool). Review of a progress note on 03/27/2026 at 11:00 AM, showed the resident had developed MASD. A review Resident 41's quarterly MDS assessment, dated 04/06/2026, showed the resident had MASD. Review of Resident 41's care plan, initiated on 12/29/2025, showed the resident was at risk for impaired skin integrity related to limited mobility. There was no care plan revision when the resident developed MASD. In an interview on 04/10/2026 at 1:21 PM, Staff C, Assistant Director of Nursing Services (ADNS) was asked about the MASD not care planned for Resident 41. Staff C stated Staff D, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) would follow that type of skin issue. In an interview on 04/13/2026 at 10:04 AM, Staff D stated a few of the staff revised care plans. They stated medical records reviewed them and RCMs reviewed them at care conferences. Staff D stated they did their own section. Staff D stated the MDS nurses revised them. They stated they thought they should do an audit of the care plans. <ACTIVITIES OF DAILY LIVING> <RESIDENT 46> Resident 46 was admitted to the facility on [DATE] with diagnoses to include congestive heart failure (long term condition in which the heart can't pump blood well enough to meet the body's need), depression, anxiety, and peripheral vascular disease (disorder of blood vessels outside the heart that can cause pain, and numbness in the limbs). Review of Resident 46's quarterly Minimum Data Set (MDS - resident assessment tool) dated 01/07/2026 documented they were independent with toilet hygiene, upper and lower body dressing, shoes and socks, bed mobility, transfers, ambulation and was always continent of bowel and bladder. Review of Resident 46's Activities of Daily Living (ADL) care plan documented they required supervision for ambulation with their walker, 1 person assist with transfers, showers and dressing, occasional incontinence of bowel and bladder, and required 2-person assist for bed mobility and was dependent for assistance with shoe or sock needs. In an observation on 04/07/2026 at 10:13 AM, Resident 46 was observed to exit their room into the hallway ambulating with their walker independently. Resident 46 spoke to staff in the hallway and alerted them they were going to obtain their weight and then report to the nurse. Resident 46 was observed to ambulate to the scale independently, obtain weight independently and give their weight to the nurse. In an interview on 04/10/2026 at 9:22 AM, Staff S, Nursing Assistant Certified (NAC), stated they reviewed the resident's care plan or Kardex to know what care a resident required. Staff S stated Resident 46 was independent with their ADL's. In an interview on 04/10/2026 at 2:53 PM, Staff D, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), stated staff obtained information of resident care needs by review of their Kardex, and information from verbal pass down of previous shift during hand off/shift change. Staff D stated the care plan should be updated after a care conference, quarterly, when new orders were obtained, or if there was a change in resident needs. Staff D stated Resident 46 was independent with ADL's and was unaware what their care plan or Kardex directed related to ADL's. In an interview on 04/13/2026 at 09:38 AM, Staff B, Director of Nursing Services (DNS) stated their expectation was staff were to review the resident's care plan and Kardex to guide the care provided. Staff B stated their expectation was a resident's care plan and Kardex reflected the current needs of the residents. Staff B stated their expectation was care plans are updated at least quarterly and for any change of condition. Reference: (WAC) 388-97-1020(5)(b)

Based on interview, and record review, the facility failed to provide sufficient qualified staff to provide care and services for 18 of 23 sampled residents (Residents 1,6, 9, 19, 28, 30, 35, 50, 58, 60, 65, 79, 83, 95, 105, 115, 121, 124) and 3 of 5 family members that had concerns related to staffing. The facility had insufficient staff to ensure residents received prompt call light response, medications delivered timely, assistance with activities of daily living including nail care, restorative care and to ensure care was completed in accordance with established clinical standards, the facility assessment, and resident's needs and preferences. These failures placed residents at risk of experiencing feelings of frustration, vulnerability, diminished quality of life, and unmet care needs. Findings included . <FACILITY ASSESSMENT>Review of the facility's assessment, reviewed 04/01/2026, showed the overall full-time employees needed for adequate staffing was 5 Registered Nurses, 5 Licensed Practical Nurses, 5 Nurses' Aides (NAC's) and 2 restorative aides. The facility assessment did not include shower aides.<STAFFING PATTERN>Review of the facility provided staffing pattern for the last 31 days, dated 03/08/2026 through 04/07/2026, showed a wide variance of 7 to 10 NACs on 31 shifts of 31 days. There were only 4 or 5 NAC's on for 6 of 31 days. <RESIDENT INTERVIEWS><RESIDENT 19>In an interview on 04/07/2026 at 10:27 AM, Resident 19 stated at shift change they wait over 30 minutes for their call light to be answered. They stated the facility used a lot of agency staff because a lot of the staff had quit.<RESIDENT 35>In an interview on 04/07/2026 at 1:01 PM, Resident 35 stated there were not enough staff at the facility, and the call light wait time was excessive, at times more than an hour to get help.<RESIDENT 1>In an interview on 04/07/2026 at 2:21 PM, Resident 1 stated that at shift change they don't dare ask for anything or they would be out of luck especially if they had to go to the bathroom. Resident 1 stated they lost their patience a few weeks ago while waiting and went to the bathroom and they slipped and their foot hit the wall. The resident stated their foot hurt and they were worried about their foot, so they called their surgeon and requested an x-ray.<RESIDENT 115>In an interview on 04/07/2026 at 2:53 PM, Resident 115 stated they had experienced some falls. They reported call light wait times are long during staff breaks and there were no other staff to cover for staff while on break resulting in call light times longer than 30 minutes. The resident stated they were going to have an incontinent episode, and they get really embarrassed if that happened. <RESIDENT 121>In an interview on 04/07/2026 at 3:05 PM, Resident 121 stated they have had to wait a long time for their call light to be answered. The resident stated when they first got there it was really rough and they waited hours and hours to get help.<RESIDENT 6>In an interview on 04/08/2026 at 8:38 AM, Resident 6 stated that usually around shift change, call lights take an hour or longer. They stated if they were having a heart attack that would not be good. <RESIDENT 60>In an interview on 04/08/2026 at 10:11 AM, Resident 60 stated there was a lot of staff turnover and they frequently had agency staff. Resident 60 stated call light response times were 20-30 minutes now. The resident stated call light response time had gotten slower over the last few months <RESIDENT 28>In an interview on 04/08/2026 at 9:07 AM, Resident 28 stated they experienced long call light wait times. The resident stated that by the afternoon, call lights start to get a little slacked and by the evening including last night they waited 30 minutes to get their call light answered after dinner. The resident stated it took until 11 PM to get shaved and washed up. They stated some days the facility was understaffed and there were call outs. The residents stated they waited to get pain medications, and for someone to respond to their IV pump including last night. They stated if they needed to get repositioned it took a while to get help. They stated they were not sure if the facility was truly understaffed or staff just had too many people to take care of. Resident 28 stated their medications were late too and they got it around shift change instead of 4:00 AM when it was ordered to be given. <RESIDENT 58>In an interview on 04/08/2026 at 9:48 AM, Resident 58 stated some call lights were answered in 5 minutes and with some it seemed like 5 hours before they were answered. Resident 58 stated that when they had a bowel movement, they would call and wait for a long time. The resident stated the facility did not have enough staff to get to the needs of the residents. Resident 58's family member, Collateral Contact 7 (CC7) was present and stated the facility did not have enough staff and they had observed an hour wait time for the staff to check in about pain medication. <RESIDENT 65>In an interview on 04/08/2026 at 11:04 AM, Resident 65 stated the facility did not have enough staff. They stated they did not get training and didn't know what they were doing.In an observation on 04/10/2026 at 9:50 AM, the call light for room [ROOM NUMBER] came on. Multiple staff members walked past the call light. At 10:10 AM, the call light turned to a flashing light. At 10:12 AM, Staff SDC got up, looked at the call light board and went to the room. The call light was turned off at 10:14 AM. <FAMILY INTERVIEWS>In a joint interview on 04/10/2026 at 12:45 PM, CC 5 and CC 6 stated that they had a family member downstairs that comes up and checks on Resident 56 because they don't get enough help. CC 6 stated there was so much staff here because the state was here. CC 6 stated there was never this many staff at the facility. They stated that after the surveyors left yesterday, the facility was a ghost town with barely any staff. CC6 stated that when they call the nurses' station on the 2nd floor of the facility that they called multiple times and no one answered. CC 6 stated they would call Resident 56's cell phone and have them put it on speaker phone to call for help. In an interview on 04/13/2026 at 10:20 AM, CC 1, Resident 41's family member, stated care had been good and bad. CC 1 stated that at times they come in to find their spouse covered in bowel movement (BM). They stated they put the call light on and wait and wait, and it could be 40 minutes to get help. CC 1 stated they noticed when (state surveyors) were there, there was more staff here. They stated it was not usually like this and there were so many staff out there now.<GRIEVANCES>Review of a grievance dated 02/03/2026 from Resident 124 documented they waited two hours for their call light to be answered.Review of a grievance dated 03/05/2026 and documented as received 03/17/2026 from Resident 95 documented call lights take longer than 30 minutes for someone to respond.Review of a grievance dated 03/15/2026 and documented as received on 03/20/2026, documented Resident 30 and their roommate waited over 40 minutes to get help. Resident 30 documented they were told by their NAC they had been on their break. Resident 30 asked them if they had another NAC to cover their break and they received a flippant answer.Review of a grievance dated 03/14/2026 and documented as received 03/20/2026 from Resident 30 showed they pushed their call light and waited a long time, so they left their room and asked an NAC to empty their urinals. Resident 30 documented the staff did not empty the full urinals which resulted in them wetting their pants. <RESTORATIVE CARE>In an interview on 04/10/2026 at 11:36 AM, Staff KK, Restorative Aide (RA) stated there were quite a few more RA programs now. Staff KK stated Staff LL, the RA was pulled from their RA duties once this week and tonight they were also pulled to work the floor rather than their duties. Staff KK stated last month was bad and they were pulled frequently to work on the floor rather than complete residents RA programs. <RESIDENT COUNCIL MINUTES>-Review of the resident council minutes, dated 02/18/2026, residents voiced call lights were not being answered timely. <RESIDENT COUNCIL MEETING>During a resident council meeting with the surveyor on 04/08/2026 at 2:26 PM;- Resident 50 stated Resident 105 pulled their call light out of the wall on several occasions after pushing the button so many times to get help to come. Resident 50 stated Resident 105 walked down the hall to the nurse's station with their diaper and pants to their knees to get help. Resident 50 stated they were left on the floor for long periods after they fell without receiving help. -Resident 79 stated they heard Resident 9 yelling help, help and they found then hanging off their bed with their head almost to the floor. Resident 9 stated they could not get anyone to help them, so they held Resident 90's head so it didn't hit the floor. Resident 79 stated when staff arrived, they stated they were not their resident. Resident 79 stated when staff pass the meal trays they don't respond to call lights and staff tell them they cannot provide care until everyone is done eating, which was a long time.-Resident 65 stated the facility was short staffed, residents fall, and showers were missed. Resident 65 stated they wrote letters to the staff about their care issues. They said at 4:00-5:00 AM, almost every call light was on. They look up and down the halls but cannot find a staff member.-Resident 30 stated they fell and laid on the floor for 45 minutes.-Resident 79 stated that two days prior, they asked staff why their roommate (Resident 106) was not getting their showers. The resident said staff told them it was because someone fell. Resident 79 stated Resident 106 was given their dinner tray at 6:00 PM and no one came to change them until 9:00 PM. Resident 79 stated their roommate was soiled and up in their wheelchair from 6:00 PM to 9:00 PM. Resident 79 stated no one should be wet for 3 hours.<MEDICATION ADMINISTRATION>-Resident 83 stated nurses give them their dinner and bedtime medications together and they tell the nurses they are not to be given together.-Residents 30, 37, 50, 61, and 79 stated both agency and facility nurses leave their medications at bedside without observing if they take them.<STAFF INTERVIEWS>In an interview on 04/10/2026 at 9:41 AM Staff MM, NAC stated they were scheduled to give showers for the first time today. Staff MM stated the facility did not have shower aids scheduled and floor staff were responsible for doing their own showers. At that time Staff B, DNS told Staff MM there were shower makeups to give and to help pass meals at lunch. In an interview on 04/13/2026 at 10:06 AM, Staff D, RCM stated the facility was still short staffed. They stated there were call outs and something needed to be done about the call outs. Staff D stated it was very rough for staff to have their schedules changed to a 5-day schedule and they lost staff and morale was down as the staff who stayed were unhappy. Staff D stated that Staff MM helping out giving showers today was amazing. Staff D stated they went to above management even and voiced their concerns with staffing. They stated showers were missed since they had no shower aide. They said some NAC's have 3 to 4 showers to do besides being responsible to care for 10-11 residents. Staff D stated if they had 6 NAC's they had 10-11 residents and more if they only had 5 NACs. They stated they should have 6 NACs on downstairs but usually had 5. In an interview on 04/13/2026 at 1:01 PM, Staff A, Administrator, was asked if the Quality Assurance and Performance Improvement committee was aware of staffing issues. Staff A stated Really? then stated, Let's move on.No additional information was provided. Reference WAC 388-97-1080 (1)

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals were labeled and dated, expired medications were removed in the medication cart and medications were not left at bedside unattended. Failure to label and date 2 of 2 intravenous (IV) medications, not dating insulin vials after opened, keeping expired medications in 2 of 4 medication carts and 3 random observations of medications at bedside unattended, placed residents at risk for adverse effects for receiving expired medications, taking the wrong medications and a diminished quality of life. Findings included .According to the facility policy titled Medication Storage, review date 01/2025 documented, note the date on the label for insulin vials and pens when first used. Outdated .are immediately removed from stock, disposed of according to procedures for medication disposals. <MEDICATION CARTS> In an observation on 04/08/2026 at 11:22 AM, inside Medication Cart B on the second floor, was an insulin pen with an expired date of 04/03/2026. According to Staff P, Licensed Practical Nurse (LPN) they were not aware that the insulin expired because they don't administer that during day shift. Staff P took the insulin out and disposed of it. In an observation on 04/08/2026 at 12:33 PM, inside the Medication Cart C on the first floor, two vials of insulin were observed opened. Both vials did not have a date when they were opened. In an interview on 04/08/2026 at 12:33 PM, Staff Q, Registered Nurse (RN) stated, upon opening an insulin vial, the staff should write the date it was opened on the vial. Staff P added, the insulin vials were only good for 28 days after they are opened. In an observation and interviews on 04/08/2025 at 12:50 PM, inside the Treatment Cart on the first floor, there were 11 packets of lubricating jelly with expired date of 11/30/2025 and 2 boxes of Saline Fleets Enema with expired dates of 06/2025 and 03/2026. Staff Q stated that all nurses are responsible for checking to make sure medications were not expired in the Medication or Treatment Carts. In an interview on 04/10/2026 at 3:00 PM, Staff B, Director of Nursing Services (DNS) stated they were not aware that there were expired medications and unlabeled insulin vials in the medication carts. They will look at the other carts to ensure there were no expired medications in them. <INTRAVENOUS MEDICATION> In an observation on 04/07/2026, at 2:32 PM, Resident 89 had an IV pole in their room, a bag half full of 0.9% sodium chloride with tubing attached including the IV catheter. No resident identifier label or date was observed on the IV pole, medication bag or tubing. The same observation was made on 04/08/2026, 04/09/2026, 04/10/2026 and 04/13/2026. In a review of Resident 89's, April 2026, medication administration record (MAR), documented that Sodium Chloride 0.9% was ordered 1000 milliliter (mL) to be administered one time a day for hydration and run over five hours with a start date of 04/01/2026 and discontinue date of 04/04/2026. In an observation on 04/10/2026, at 12:41 PM, Resident 56 had an IV pole in their room, a bag of 0.9% sodium chloride hanging from it, tubing and IV catheter (small, flexible, plastic tube inserted into a vein to deliver fluids or medications into the bloodstream) attached, without resident identifier label or date observed on it. In an interview on 04/13/2026, at 10:52 AM, Staff C, Registered Nurse/Assistant Director of Nursing, confirmed the IV medications for Resident 89 were not labeled or dated for the medication or IV tubing. Staff C stated that IV tubing expires after 24 hours and was unsure of Resident 89's IV medication order. <MEDICATION AT BEDSIDE> In an observation on 04/07/2026 at 11:49 AM, a blue bottle of liquid gas relief and white bottle of probiotic and daily fiber capsules were on the window ledge of Resident 64's room. Resident 64's overbed table had a bottle of TUMS (an antacid). In an observation on 04/07/2026 at 2:33 PM, a bottle of Advil was on the window ledge of Resident 121 room. Observed multiple prescription medications, unable to identify, located in a bag sitting on a chair across from Resident 121's bed. In an observation on 04/08/2026 at 10:25 AM Resident 3's bedside table had a liquid flu medicine and package of topical pain medication. In an interview on 04/13/2026 at 10:04 AM Staff D, Licensed Practical Nurse/Resident Care Manager, stated over the counter medications, supplements, and any prescribed medications were not to be kept at the resident's bedside. Staff D stated they were not aware Resident 3 and 64 had any medications at their room/bedside. In an interview on 04/13/2026 at 11:45 AM Staff B, Director of Nursing Services, stated residents should not have medications at their bedside. In the resident council meeting on 04/08/2026 at 2:42 PM, Resident 65 stated that on Easter (04/05/2026) night they came back to the facility at 9:30 PM and there was medicine on their roommate 72's overbed table. Resident 65 stated they asked Resident 72 why they hadn't taken their medicine that was sitting on their table. Resident 72 told them it was not time to take their medicine and they were told to take them in 2 hours. Resident 72 stated they had told Staff GG, agency LPN those were not their medications. At 2:57 PM, Residents 30, 37, 50, 61 and 79 stated both agency and facility nurses left medications at bedside for them to take independently. Reference WAC 388-97-1300(4)(a)(ii)(iii)

Based on observation and interview the facility failed to provide a nourishing, palatable, well-balanced diet that met residents' daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 4 of 14 residents (Resident 19, 35, 119, and 121) reviewed for the facility meeting the dietary needs of each resident. This failure placed all residents at risk of unintended weight loss, malnutrition, depression, feelings of helplessness, and a diminished quality of life.Findings included . In an interview and observation on 04/07/2026 at 2:39 PM, Resident 121 stated the facility food does not look or taste good. The lunch tray was uncovered, on Resident 121's overbed table, pushed to the side of them, with three pieces of uneaten fish and a scoop of brown rice and carrots. In an interview on 04/07/2026 at 12:29 PM, Resident 119 stated their fish was cold and dried out. Resident 119 stated their coffee was warm for the first time ever. In an interview on 04/07/2026 at 1:01 PM, Resident 35 stated the food was terrible and they would not feed it to their dog. In an interview on 04/07/2026 at 10:29 AM, Resident 19 stated the facility food tasted terrible and was not appealing. Resident 19 stated the meals looked like canned food. In an observation of a two test trays on 04/10/2026 at 1:18PM showed the following: Temperature: Gluten Meal Temperature: 142.3 degrees main dish casserole, Pepper Casserole, mixed vegetables 117.8 degrees Regular Meal Temperature: 148.5 degrees for the main dish, Pepper Casserole, mixed vegetables 127.8 degrees Presentation: Gluten free meal diet had no roll and the regular diet meal had a roll. There were no condiments other than salt and pepper. There were no drinks as those are resident specific and poured by the staff prior to providing trays to residents. The casserole was molded into the scoop that was used to serve the food creating the presentation of institutional food/meals and not homelike. The vegetables were overcooked, very soft, and lacked color, translucent. Taste: The meat in the casserole was ground beef, quality was poor, meat did not have a consistency of typical ground beef, almost too lean, thinned. The dish lacked any spices or flavor and tasted like nothing. The dessert was a brownie with a dab of whipped topping. Reference WAC 388-97-1100 (1)(2)

Based on observation, interview, and record review, the facility failed to ensure food was stored under sanitary conditions in 2 of 4 snack/nourishment refrigerators. The failure to monitor and document refrigerator temperatures, label opened food/beverage items, discard expired food items in the unit refrigerators placed all residents at risk for their food to be contaminated, development of food borne illnesses, and consuming spoiled food.Findings included .In an observation on 04/10/2026 at 3:25 PM, the second-floor nourishment refrigerator contained 12 small bottles of drinkable yogurt, with an expiration date of 03/31/2026, dairy creamer with an expiration date of 2/2026, a plastic bag contained an undated to go box, and opened, undated, salad dressing in the door. During the observation, no temperature logs were observed. In an observation and interview on 04/10/2026 at 09:37 AM, the nutrition fridge on the first floor, showed there was a temperature log to be documented and signed daily. The temperature and signature boxes were blank for 04/08/2026 and 04/09/2026 and there was expired resident yogurt in the fridge, dated with an expiration date of 12/2025. Staff S, Nursing Assistant Certified (NAC), stated they were unaware of who was supposed to monitor the fridge temperature and food items inside. In an interview on 04/10/2026 at 1:13 PM, Staff U, Senior Regional Registered Dietitian, stated they threw out the expired yogurt and documented on the temperature log for today's date. Staff U stated they were unsure of who was responsible for monitoring the fridge's temperature and contents and confirmed the temperature log had no documentation for 04/08/2026 or 04/09/2026. Reference WAC 388-97-1100 (3)

Based on interview and record review, the facility failed to document and address issues raised by the Resident Council group for seven of seven months (September, October, November, December of 2025 and January, February and March 2026) meeting minutes reviewed. Failure of activity staff to document concerns and grievances filed by the resident council in the meeting minutes and failure to report back to the council group in writing with a response, rationale and action taken placed the residents at risk for having unresolved, ongoing care concerns. Findings included . Review of the facility policy, titled Resident Council updated January 2017, documented resident council members have the right to gather and discuss thoughts, ideas, or issues related to their care and treatment. The meeting begins by reading minutes from the previous meeting, then reviewing new and old business with an opportunity for members to express concerns. Concerns brought forth by the Council are resolved via the Center grievance policy. The center communicates a response and/or decisions to the Resident Council by the next meeting. Review of the resident council minutes for 09/17/2025 showed there were no issues or concerns with administration, nursing, maintenance, social services and activities. Review of the resident council minutes for 10/22/2025 showed there were no issues or concerns with administration, nursing, maintenance, social services and activities. The minutes showed there was no old business to discuss. Review of the resident council minutes for 11/19/2025 showed there were no issues or concerns with administration, nursing, maintenance, social services and activities. The minutes showed there was no old business to discuss. Review of the resident council minutes for 12/17/2025 showed there were no issues or concerns with administration, nursing, maintenance, social services and activities. The minutes showed there was no discussion of old business. Review of the resident council minutes for 01/21/2026 showed there were no issues or concerns with administration. The minutes showed an unidentified grievance was made by an unidentified resident. A maintenance concern related to heat in an unknown location was expressed and placed in the maintenance binder. A dietary concern regarding weekend meals was included in the minutes. The minutes showed there was no discussion of old business. Review of the resident council minutes for 02/18/2026 showed there were concerns discussed with the Director of Nursing Services, their concerns and issues which were unidentified in the meeting minutes. A concern about call lights being answered in a timely manner was documented. The minutes showed there was no old business to discuss. Review of a grievance dated 02/18/2026 showed resident council members reported slow call light response, call lights not being answered by nurses or during meals. Review of the resident council minutes for 03/18/2026 showed there were no issues or concerns with administration, nursing, maintenance, social services and activities. The minutes showed there was no old business to discuss. Review of the grievance log showed resident council concerns including rude staff and a dirty ice scoop were escalated to a grievance report and investigation on 03/18/2026. In a resident council group interview on 04/08/2026 at 2:12 PM, Resident 50 and Resident 79 stated grievances from the meeting were not followed up on. Resident 50 stated Staff E, Activity Director (AD) would provide them with the completed resident council meeting minutes. Resident 50 stated Staff E thinks they write there were no complaints voiced in the minutes because they heard the grievances and concerns and would pass the information on. Resident 65 stated the minutes were not accurate and the group had complaints for months and months that were not resolved. Resident 79 stated there were serious facility concerns and problems were not resolved. Resident 65 stated residents were scared to write a grievance. In an interview on 04/13/2026 at 1:11 PM, Staff E, was informed of concerns voiced in resident council that the minutes did not reflect that concerns were voiced during the meeting. The resident group reported that the minutes showed no concerns were documented, when they knew they had voiced them. Resident 50 stated that the resident council group did not know resolutions were in place the next month when old business was discussed. Staff E stated they escalated concerns to grievance forms from the resident council meeting. They acknowledged they wrote no concerns were voiced on the resident council minutes. Staff E stated that it would be a good idea to document the concerns on the resident council meeting minute form. In an interview on 04/13/2026 at 11:22 AM, Staff B, Director of Nursing stated no issues or concerns being identified on the resident council meeting forms was not accurate and needed to change. Reference WAC 388-97-0920 (4)(5)

Based on observation, interview, and record review, the facility failed to comprehensively assess and monitor the need for physical restraints for 2 of 2 residents (Residents 41 and 55) reviewed for physical restraints. The facility failed to assess, obtain consent and physician order, care plan and document ongoing evaluation of the need for the restraint. These failures placed residents at risk for harm and diminished quality of life. Findings included . The Centers for Medicare and Medicaid Services (CMS) defined Physical Restraints as Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body (State Operations Manual Appendix PP). A review of the facility policy titled, Physical Restraints and Enablers/Devices, updated in January showed the residents have the right to be free from any physical restraints imposed for purposes of discipline or convenience. A physical restraint is defined as any manual method, physical device, equipment attached or adjacent to the resident that meets the following criteria: 1). Is attached or adjacent to the resident's body, 2). Cannot be removed easily by the resident: and, 3). Restricts the resident's freedom of movement or normal access to his or her body The policy directed the facility staff if it is determined the device is restraining, the physician is contacted for orders for the specific type of device, the reason for use, and duration. Some physical or mechanical devices used as restraints may include directions such as release at least every 2 hours for exercise, position change, toileting, and/or to offer fluids. The resident is evaluated by the device evaluation on admission, readmission, annually and change in the resident's condition. Review of the manufacturer's website for the green position perfect wedge guidelines that clinical indications were to aid in providing and maintaining the turn angle of 30 degrees for people at risk for pressure injuries. For safety, the wedge should not be placed beyond the residents midline. <RESIDENT 41> Resident 41 was admitted to the facility on [DATE] with diagnoses including intracerebral hemorrhage (ruptured blood vessel bleeding into the brain tissue), generalized anxiety disorder and aphasia (difficulty talking). Review of Resident 41's quarterly minimum data set (MDS - an assessment tool) assessment dated [DATE], showed the resident had severe cognitive impairment, was not understood and needed two-person assistance with bed mobility and with transfers. The MDS also showed the resident was not currently using any form of physical restraints. In an observation on 04/07/2026 at 9:19 AM, Resident 41 was in bed sitting up, appeared to be attempting to climb over two green triangular 18.5-inch shaped wedges that were tucked under their fitted bed sheet, not removable by the resident. The right side of their bed was against the wall, and a grey fall mat was on the floor to the left of their bed. In an observation on 04/07/2026 at 2:39 PM Resident 41 was crying and trying to get over the wedges. An unidentified staff member went into the room and said, Do you feel stuck? In an observation on 4/08/2026 at 8:51 AM, Resident 41 was in bed, the bed was in high position. The resident was staring at their breakfast with no attempts to eat it while voicing unintelligible words. Two green wedges were placed under their fitted sheet. The resident was positioned in the middle of the bed, about 14 inches from the devices. In observations on 4/09/2026 at 8:37 AM, 11:37 AM and 1:50 PM, Resident 41 was in bed with three green wedges tucked under the fitted sheet lining the edge of their bed. In an observation on 04/09/2026 at 3:25 PM, Resident 41 was in bed with the privacy curtain pulled around them, their overbed table was up high and in the middle of the room , out of the residents reach. The three green wedges remained tucked under their fitted sheet. In a progress note dated 04/09/2026 at 4:19 PM, Resident 41 was found by housekeeping sitting on the floor with their buttocks on their fall mat, positioned parallel to their bed. The resident was assisted into their wheelchair and brought to the activity room for increased supervision. In an observation on 04/10/2026 at 9:25 AM, Resident 41 was in bed asleep, three green wedges were under their fitted sheet. In an observation and interview on 04/10/2026 at 10:15 AM, Staff T, Nurse's Aide Certified (NAC) was providing care to Resident 41. Staff T stated the green wedges were in place, so the resident stayed in bed and did not fall. In an interview on 04/10/2026 at 1:21 PM, Staff C, Assistant Director of Nursing (ADON) stated Resident 41 can get restless and tearful. Staff C stated they were not aware of green wedges lining the edge of the resident's bed. Staff C stated the green wedges should be used for positioning only and for no other reason. Informed Staff C of multiple observations and interview that NACs were using green wedges to line the side of the resident's bed. In an observation on 04/13/2026 at 10:07 AM, Resident 41 was in bed with one green wedge under their fitted sheet. At 11:49 AM, the resident was in bed, restless and there was one green wedge under their fitted sheet. At 12:52 PM the resident was in bed eating lunch; there were two green wedges under their fitted sheet. In an interview on 04/13/2026 at 10:20 AM, Collateral Contact 1 (CC 1), Resident 41's spouse was at bedside. CC 1 stated the green wedges were used to keep their loved one in bed. CC 1 stated they did not sign consents for them to be used to keep them in bed. Review of the resident's clinical records (Physician order sheets, Assessments and Evaluations, care plan and clinical progress notes), showed no evidence that the facility had comprehensively and accurately assessed the resident's condition that would warrant use of restraints. <RESIDENT 55> Resident 55 admitted on [DATE] with diagnoses to include profound developmental delay, autism (condition characterized by challenges in social communication, restricted activities and repetitive behaviors) depression, anxiety disorder and history of falling with recent neck fracture. A review of Resident 55's admission MDS assessment dated [DATE], showed the resident had impaired cognition and needed one person assistance with bed mobility and transfers. The MDS also showed that the resident was not currently using any form of physical restraints. In an observation on 04/07/2026 at 9:29 AM, Resident 55 was restless in bed with a neck collar on. The resident's bed was against the wall (left side of the resident), and they were positioned in the middle of the bed with two green wedges positioned under their fitted sheet and a mat on the floor. The wedges would not be removable by the resident. In subsequent observations on 04/07/2026 at 9:35 AM, 12:44 PM and 2:34 PM, as well as 04/08/2026 at 9:02 AM, and 04/09/2026 at 8:50 AM, Resident 55 was in the middle of their bed with two green wedges under the fitted sheet, lining the edge of their bed. Review of the resident's clinical records (Physician order sheets, Assessments and Evaluations, care plan and clinical progress notes), showed no evidence that the facility had comprehensively and accurately assessed the resident's condition that would warrant use of restraints. In an interview on 04/13/2026 at 10:13 AM, Staff D, Licensed Practical Nurse/ Resident Care Manager stated they had not observed the wedges in residents' beds. Staff D stated the green wedges were supposed to be for positioning only and only with documented consent, and stated they had not seen any other use for them. Staff D acknowledged wedges used to line the bed would be a restraint. In an interview on 4/13/2026 at 11:22 AM, Staff B, Director of Nursing Services was informed of wedges used to keep residents in bed. Staff B stated they would fix that immediately as they should be used for positioning only. Reference: WAC 388-97-0620-1(a)(b) 2(d) 4(a)(b)(c)

Based on observation, interview and record review, the facility failed to provide assistance with grooming, including shaving and nail care for 3 of 4 residents (Residents 89, 104 and 121) reviewed who were unable to carry out their ADL's (activities of daily living) independently. The failure to provide residents, who were dependent on staff for assistance with grooming, placed the residents and others at risk for poor hygiene, injury, unmet care needs and a diminished quality of life. Findings included . <RESIDENT 89> Resident 89 was admitted to the facility on [DATE] with diagnoses to include traumatic brain bleed, multiple sclerosis (chronic disease where the body's immune system mistakenly attacks the protective covering of the nerves in the brain and spinal cord), and chronic obstructive pulmonary disease (COPD - progressive, long-term lung disease that makes it hard to breathe). Review of Resident 89's admission minimum data set (MDS - an assessment tool), dated 01/05/2026, documented they were dependent for personal hygiene. Review of Resident 89's care plan, dated 12/30/2025, documented they were dependent on staff for grooming. In an observation on 04/07/2026, at 1:40 PM, Resident 89 was resting in their bed with prominent chin hairs and hair was unkempt. In an observation on 04/09/2026, at 9:33 AM, Resident 89 was resting in bed with several prominent chin hairs. In an interview on 04/10/2026, at 1:17 PM, Staff AA, Nursing Assistant Certified (NAC), stated that Resident 89 was dependent for all of their cares and that aides are responsible for shaving, and that shaving and nail care was typically done on shower days. In an interview on 04/13/2026, at 12:30 PM, Resident 89 stated they would like their chin hairs shaved off. In an observation on 04/13/2026, at 1:41 PM, Resident 89 was in bed with unbrushed wet hair, nails not trimmed and chin hairs not shaved. It was documented, in the shower binder, that Resident 89 had a bed bath on the day shift that day. In an interview on 04/13/2026, at 9:23 AM, Staff BB, NAC stated that Resident 89 was fully dependent on cares and that they have shaved their chin hairs in the past. Staff BB stated during showers was when they offered shaving and nail care. In an interview on 04/13/2026, at 12:30 PM, Staff B, Director of Nursing (DNS) stated that their expectation was residents activities of daily living were completed everyday including hair, shaving, and nail care. <RESIDENT 121> Resident 121 was admitted to the facility on [DATE] with diagnoses to include type two diabetes (chronic condition where the body does not properly use or make enough insulin), bladder infection, and heart failure. Review of Resident 121's Care Area Assessment (care planning tool) dated 04/08/2026 documented they required assistance with all of their ADL's. Review of Resident 121's care plan dated 03/30/2026 documented they were dependent on staff for grooming, preferred showers twice a week on Sunday and Wednesday. Review of Resident 121's electronic health record dated 03/30/2026 through 04/09/2026 showed they had a bed bath on 04/01/2026, 04/05/2026, and 04/08/2026 and refused bathing on 03/30/2026. There was no documentation why a bed bath was provided, instead of Resident 121's preference for a shower. In an interview on 04/07/2026 at 2:33 PM Resident 121 stated they had not had a shower since their admission, only bed baths, and they were not adequate. Resident was observed to have facial hair, approximately a quarter to a half inch long. When asked about their facial hair, Resident 121 began to cry and stated they needed some help with things, and they were not getting the help. Resident 121 stated they required the use of a hair removal product rather than a razor because the razor left bumps on their face. On 04/09/2026 at 3:15 PM, observed Resident 121 lying in their bed, sleeping. Resident 121 was observed to have the same facial hair on their chin and neck area. In an interview on 04/10/2026 at 11:23 AM Staff N, NAC stated they knew how to care for residents through review of their Kardex (resident specific guide to care for a resident), from other staff and alert bulletins in the electronic medical record. Staff N stated they were responsible for the scheduled showers during their shift, which were preassigned. In an interview on 04/13/2026 at 10:04 AM Staff D, Licensed Practical Nurse/Resident Care Manager, stated the only reason a bed bath would have been given to Resident 121 was if they refused a shower. Staff D stated they were not aware of Resident 121's preference and concern regarding use of a product rather than a razor to remove their facial hair. Staff D stated Resident 121's facial hair should have been addressed during their bed bath. On 04/13/2026 at 1:15 PM, observed Resident 121 in the hallway in their wheelchair. Resident 121 was observed wearing a hospital gown, engaged in conversation with the social worker, and had visible white course chin/neck hairs present. <RESIDENT 104> Resident 104 was admitted to the facility on [DATE] with diagnoses to include dementia, anxiety and depression. Review of the quarterly MDS dated [DATE] showed the resident had cognitive impairment and did not refuse care. Review of a provider note on 04/05/2026 at 9:44 AM, the note showed Resident 104's skin was very dry and scaly on the lower limbs and feet related to deficient hygiene care. In an observation on 04/07/2026 at 11:53 AM, Resident 104 was observed in their room. They had 1/2 inch long white chin hairs. Their fingernails were long and jagged. In an observation on 04/08/2026 at 12:11 PM, Resident 104 was in the dining room. There was no evidence of grooming to their facial hair or fingernails. Review of a provider note on 04/08/2026 at 12:22 PM, the note showed toenails thickened, discolored and brittle in keeping with onychomycosis. Skin very dry and scaly on the lower limbs and feet related to deficient hygiene care. In a provider note on 04/09/2026 at 12:00 AM, provider documented Resident 104 received help with nail trimming and showering, enjoyed the process, and had good care on the left side nails but some nails on the right side remain unsafe and need trimming. Patient's skin on legs is very dry and requires regular showering to hydrate skin and remove accumulated debris. In an observation on 04/09/2026 at 10:30 AM, Resident 104 was walking to the nurse's station. Their chin hairs and fingernails on their right hand remained long. At 2:14 PM, Resident 104 was in bed. The chin hairs remained and left hand fingernails had been trimmed. The right hand fingernails remained long and jagged. In an observation on 04/10/2026 at 12:11 PM, Resident 104 was in the dining room. The resident was in need of shaving to their chin and right hand nailcare. Review of the behavior monitors documented by nurses' aides showed Resident 104 refused care 02/12/2026. On 03/16/2026 the resident was neglecting self-care. There were no behaviors documented in April as of 04/13/2026. In an interview on 04/13/2026 at 11:22 AM, Staff B, DNS stated the NACs were responsible to shave men and women. Staff B stated the facility did not have an ADL policy. Reference WAC 388-97-1060(2)(c)

Based on observation, interview and record review, the facility failed to ensure 4 of 5 residents (Residents 28, 72, 104, and 106) reviewed received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. The facility failed to assess and document Resident's 72 and 106's for possible injury after abuse allegations. The facility failed to order mental health services as ordered for Resident 104. Additionally, the facility failed to ensure Resident 28 received care and treatment for their catheter. This placed the residents at increased risk for decline in conditions, unmet care needs, increased discomfort, psychosocial distress and less than optimal quality of care and life. Findings included . <RESIDENT 72> In an interview on 04/10/2026 at 11:51 AM, Resident 72 stated this week Staff GG, Licensed Practical Nurse (LPN) left pills for them to take when they wanted to. Staff GG then brought Resident 72 a narcotic and they did not want it. Staff GG told them they had to because they already popped it out from the narcotic card. Resident 72 stated they felt they could not refuse the pain pill and reluctantly took it. Resident 72 stated they had another concern that occurred two or three nights ago on night shift. The resident stated they had asked a female aide to go to the bathroom, but their roommate was in there. Resident 72 said the aide told them to put on a diaper and go in it and they would come back and clean them up. Resident 72 said they were shocked and thought that was gross that it was even brought up, that they couldn't believe that was even suggested to poop in a diaper then they would have stool on their skin. Resident 72 stated they had reported this to Staff C, Assistant Director of Nursing Services (ADNS). In an interview on 04/10/2026 at 1:14 PM, Staff C stated they had not heard these concerns from Resident 72. Review of the documentation for 04/10/2026 to 04/13/2026 showed there was no mention of allegations or monitoring for psychological distress. <RESIDENT 106> Resident 106 admitted on [DATE] with diagnoses to include cerebral palsy, seizure disorder, bipolar disorder and pain. During Resident Council meeting on 04/08/2026 at 2:38 PM, Resident 79 stated that on 04/06/2026, their roommate Resident 106 was given their dinner tray at 6:00 PM and no one came into change them or remove the dinner tray until 9:00 PM. Resident 79 stated Resident 106 was up soiled in their wheelchair from 6:00 PM to 9:00 PM with their dinner tray in front of them. Resident 79 stated, No one should be wet for 3 hours. Resident 79 stated they reported this to Staff G, who said they would look into it. In an interview on 04/10/2026 at 1:57 PM, Staff G stated they did not know about the allegation and if that was the case they would tell the DNS or Executive Director and they would tell them if they could call the hotline. The allegations regarding Residents 72 and 106 were reported to Staff B, Director of Nursing on 04/10/2026 at 2:40 PM. Review of the documentation for 04/10/2026 to 04/13/2026 showed there was no assessment for skin injury, mention of allegations or monitoring for psychological distress. In an interview on 04/13/2026 at 11:22 AM, Staff B, DNS stated they were responsible to set up alert charting after the allegations regarding Resident 72 and 106. Staff B was not aware there had been no alert documentation for both residents. No additional information provided. <RESIDENT 28> Resident 28 admitted to the facility on [DATE] with diagnoses to include hereditary spastic paraplegia (rare genetic disorder characterized by stiffness and weakness in the legs) and neuromuscular dysfunction of the bladder (loss of bladder control). In an interview on 04/08/2026 at 9:07 AM, Resident 28 stated they were concerned about their suprapubic catheter (a thin tube inserted into the bladder through a small incision in the lower abdomen) because it needed to be changed every month and it had not been changed since they admitted to the facility. In a review of Resident 28's discharge orders from the hospital, dated 03/14/2026, timestamped 03/16/2026, documented they were to follow up with urology as scheduled on 04/05/2026 for their routine suprapubic catheter change. In a review of Resident 28's care plan dated 04/08/2026 documented they had an indwelling catheter (a tube inserted into the bladder) and to anchor their catheter to prevent urethral tears. In a review of Resident 28's Care Area Assessment (tool used to create care plan) for Urinary Incontinence and Indwelling Catheter dated 03/23/2026 documented they had an indwelling catheter. There was no documentation regarding Resident 28's type of catheter used or need for it to be changed monthly. In a review of Resident 28's Medication and Treatment Administration Record from 4/01/2026 to 04/08/2026 contained no documentation/order for a catheter change or for the scheduled urology appointment scheduled on 04/05/2026. In an interview on 04/08/2026 at 9:24 AM, Staff D, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), stated they would need to check if Resident 28 required or had an order to change their suprapubic catheter. In a follow up interview on 04/09/2026 at 9:26 AM, Staff D, stated they had contacted the urologist to obtain an order to change Resident 28's suprapubic catheter. Staff D stated they had reviewed the hospital discharge records which showed Resident 28 should have attended a urology appointment on 04/05/2026. Staff D, when asked about the process of ensuring discharge orders from the hospital were followed, stated there was a three-step process in place. Staff D stated the nurse who completed the admission would be the first to identify and implement the orders, resident care managers would then review and finally the Director of Nursing Services (DNS). Staff D stated Resident 28's scheduled appointment and catheter had been missed during the admission process. In an interview on 04/13/2026 at 11:45 AM Staff B, DNS, stated the facility expectation was that all orders received would be put into the resident's medical record right away. <RESIDENT 104> Resident 104 admitted to the facility on [DATE], with diagnoses that included dementia, anxiety and depression. The admission Minimum Data Set assessment dated [DATE] documented the resident had impaired cognition, minimal depression, and delusions. Review of a progress note dated 12/30/2025 at 8:42 AM, documented Resident 104 was displaying paranoid behavior and delusions that shift and they placed the resident on alert, notified the doctor via fax and the resident care manager (RCM) was aware. Review of a fax from the nurse to the provider on 12/30/2025 documented Resident 104 was displaying increased paranoid behavior and delusions. On 12/31/2025, the provider responded and ordered to increase Quetiapine (anti-psychotic medication) from 25 mg twice a day to 50 mg twice a day and to please arrange for behavioral health consult. Review of Resident 104's clinical record showed there was no record of a behavioral health consult having occurred. In an interview on 04/09/2026 at 2:09 PM, Staff D, confirmed there was no documentation or consultation from a behavioral health provider. Staff D stated social services were working on getting residents seen by behavioral health. Staff D stated they would make sure the resident was seen by behavioral health. In an interview 04/10/2026 1:52 PM, Staff G, Social Services Assistant could not locate any documentation resident was seen by behavioral health since admit. In an interview on 04/13/2026 at 11:14 AM, Staff F, Social Services Director stated they discussed the order for behavioral health in their care conference in January and they did not want it. Staff F stated they were not sure they had documented that. Review of care conference notes on 04/13/2026, did not include discussion of behavioral health consult. Reference WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to comprehensively assess and ensure timely and appropriate services/interventions were provided to maintain, increase and/or prevent a decrease in range of motion (ROM - was the extent that a joint can move within the expected [normal] range of values) for 1 of 4 sampled residents (Resident 3) reviewed for ROM and restorative nursing services. This placed residents at risk for developing new contractures (permanent, abnormal shortening of muscles, tendons, or skin) and/or worsening of existing contractures.Findings Included .Resident 3 was admitted to the facility on [DATE] with diagnoses to include history of stroke, which affected their dominant right side. On 04/08/2026 at 10:16 AM Resident 3 was observed in their bed. Resident 3 right hand was observed balled into a fist the with the exception of their ring finger and middle finger. No splints, hand rolls, or other devices were observed on or near them. Review of Resident 3' care plan, last revised 02/11/2026 documented they were not on any restorative programs. In an interview on 04/09/2026 at 11:40 AM, Staff HH, Director of Rehabilitation, stated Resident 3 had received an evaluation after returning from the hospital to make sure there was no decline or need for additional therapy. Staff HH stated they typically screened residents every quarter for changes/decline in their function. When asked about a tool used to screen residents for decline/change, Staff HH stated there was no tool used and they had worked with Resident 3 for a long time and knew their baseline, so if there was a change it would be communicated. Staff HH stated Resident 3 currently received physical therapy. In an interview on 04/09/2026 at 11:48 AM, Staff CC, Physical Therapist (PT) stated Resident 3 did not have any contractures with major joints, although they had limited range of motion to their right side due to their stroke. Staff CC stated Resident 3 was receiving physical therapy only and they used their right hand to hold on to the bar while standing with some assistance to open their right hand, citing their hand had spasticity (tightness of muscles). Staff CC stated Resident 3 did not have any known splinting device or interventions in place for their right hand and deferred to occupational therapy (OT). In an interview and observation on 04/09/2026 at 12:29 PM, Staff II, OT manually opened Resident 3's right hand, and thickened yellow matter was visualized on the palm of their right hand. Staff II stated Resident 3 had spasticity and had been treated with medication; however, Staff II did not know if they were still taking the medication. Staff II attempted to conduct a series of movements with Resident 3, but Resident 3 was unable to follow several prompts and directions due to their cognitive status. Staff II stated an OT evaluation would need to be completed. Staff II stated the condition of Resident 3's hand could develop a contracture if not addressed and left for several months. Staff II stated they would follow up with the provider and obtain an order for an OT evaluation. In an interview on 04/09/2026 at 12:44 PM, Staff JJ, Registered Nurse, stated Resident 3 was not on a restorative program. Staff JJ stated Resident 3 had been on a restorative program, but therapy had started working with them again and restorative ended. Staff JJ stated Resident 3's prior restorative program included bilateral upper extremity range of motion and transfers with the use of parallel bars, until they were hospitalized . Staff JJ stated Resident 3 started with therapy services when they returned to the facility from the hospital. Staff JJ stated Resident 3 was at risk for contractures to their right upper and lower extremities including their shoulder and wrist. In an interview on 04/10/2026 at 10:51 AM, Staff KK, Restorative Aide, stated Resident 3 had been on restorative, but was no longer on the program. Staff KK stated Resident 3's restorative program focused on their right upper and lower extremities, not their right hand. Staff KK stated they had not worked with Resident 3 in a while, and they currently received physical therapy. Review of Resident 3's OT discharge note dated 08/14/2025 documented their right wrist's range of motion was within normal limits and flexion (joint action that reduces the angle between two bones) of 21 degrees. Review of Resident 3's OT evaluation dated 12/24/2025 documented they were not appropriate for OT services as they were at their baseline. Review of Resident 3's OT evaluation dated 04/10/2025 documented that they did not have any flexion in their right wrist, a 21-degree loss in flexion since at least 12/24/2025. Goals included Resident 3 would demonstrate ability to tolerate resting hand roll splint on right hand/wrist for one hour. In an interview on 04/13/2026 at 11:45 AM, Staff B, Director of Nursing Services, stated the facility expectation was that residents were evaluated by PT and OT as changes/decline were identified. Reference WAC 388-97-1060 (3)(d)

Based on observation, interview and record review, the facility failed to ensure residents were free from accidents for 2 of 3 residents (Resident's 18 and 56) sampled for accidents and for 4 of 6 sampled residents (Resident 30, 50, 79, and 105) reviewed for smoking. Failure to ensure smoking materials (cigarettes and lighters) were secured for a safe environment to protect other residents from potential fire hazard and failed to ensure residents did not experience falls placed residents at risk for avoidable injuries and diminished quality of life. Findings included . Review of the facility policy titled: Fall Management and Neurological Check, updated January 2025 stated a fall assessment was completed on admission and interventions were implemented based on the assessment. The care plan was reviewed quarterly and after a fall to determine effectiveness of current interventions and Licensed Nurses updated care plans to reduce or prevent falls. A systemic review of current interventions was completed post fall and root cause identified. <ACCIDENTS> <RESIDENT 56> Resident 56 was admitted to the facility on [DATE] with diagnoses to include convulsions (episodes of uncontrollable shaking, jerking, or stiffening of the muscles), Parkinson's disease (a slow, progressive brain disorder that impacts movement), polyneuropathy (dysfunction of multiple nerves often causing numbness, tingling, or weakness, typically starting in the hands and feet), depression, and anxiety. Review of Resident 56's admission minimum data set (MDS - as assessment tool), dated 02/18/2026, documented severe cognitive impairment. The MDS documented seizure disorder as an active diagnosis and no history of falls. Review of Resident 56's end of Medicare Part A MDS, dated [DATE], documented one non-injury fall and one injury fall since admission. Review of Resident 56's care area assessment (CAAs - specific health concerns triggered from the MDS), dated [DATE], documented falls as a triggered care area. The CAAs documented Resident 56 was taking high-risk medications, which included antianxiety and antidepressants, that could contribute to falls. The CAAs documented internal risk factors for falls included incontinence, Parkinson's disease, seizure disorder, cognitive impairment, anxiety, and depression. No environmental factors, such as poor lighting, obstructed walkway, slippery floors were documented as a contributing factor. No input from the resident or family was documented for falls. Review of Resident 56's fall assessment dated [DATE], documented they were a high fall risk. Review of Resident 56's order summary, as of 04/08/2026, documented seizure precautions every shift with an order date of 02/19/2026. In a record review of Resident 56's electronic health record (EHR), they had falls on 03/01/2026, 03/09/2026, 04/09/2026 and 04/10/2026. In a record review of Resident 56's progress note on 02/18/2026, at 1:36 PM, Staff H, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) documented Resident 56 had seizure activity and was transported to the emergency room. Review of Resident 56's hospital admission records from 02/11/2026, documented Resident 56 was a high fall risk with interventions in place at the hospital that included safety checks and a bed alarm. The hospital admission records also documented new onset seizures. Review of Resident 56's after visit summary, dated 02/18/2026, documented seizure disorder under diagnoses. Review of Resident 56's care plan, dated 02/12/2026, documented Resident 56 was at risk for falls related to deconditioning, gait/balance problems. Interventions included to ensure the call light was within reach and encourage resident to use it, ensure resident was wearing appropriate footwear. Care plan did not contain interventions related to seizure precautions. In a joint interview on 04/10/2026, at 2:23 PM, Collateral Contact (CC) 5, and CC 6, stated Resident 56 was known to be a high fall risk. They stated the facility wanted to put Resident 56's bed against the wall upon admit due to being a fall risk, the family declined. CC 5 and CC 6 stated after Resident 56's first fall, on 03/01/2026, Resident 56 was supposed to have fall mats and only received fall mats after the third fall on 04/09/2026. CC 5 and CC 6 stated they did not think Resident 56 was checked on frequently enough and were concerned with lack of the interventions in place. CC 5 and CC 6 also requested other interventions such as bed alarm and bed rails for further fall prevention and injury prevention and was declined by the facility. In an interview on 04/13/2026, at 9:23 AM, Staff BB, Nursing Assistant Certified (NAC), stated Resident 56 suffered from seizures and tremors. Staff BB stated for seizure precautions they monitored and notified the nurse of any seizure activity and made sure they did not hurt themselves during a seizure. Staff BB also stated Resident 56 was a high fall risk, they try to get up on their own and that was when they fall so they keep Resident 56 in the hallway to monitor them closely. In an interview on 04/13/2026, at 10:56 AM, Staff C, Registered Nurse (RN)/Assistant Director of Nursing Services (ADNS), confirmed seizure precautions were on Resident 56's physician orders but not on the care plan. Staff C stated that they were unaware of what seizure precautions were. Staff C stated for a resident who was a high fall risk the facility would typically do fall mats and bed positioning for prevention of injury. <RESIDENT 18> Resident 18 admitted on [DATE] with diagnoses which included frequent falls, Parkinson's disease and anxiety. Review of the Fall assessment dated [DATE] documented the resident was a high fall risk. Review of Resident 18's baseline care plan for mobility dated 03/23/2026 showed they required two-person assistance for transfers and walking was with therapy only. The initial care plan for falls dated 03/23/2026 showed the following fall prevention interventions: call light within reach, ensure proper footwear when in wheelchair or when ambulating and keep room free of clutter. Review of a progress note dated 03/26/2026 at 11:44 AM, documented Resident 18 was able to verbalize their needs when asked but was not initiating or using the call light for assistance and staff needed to anticipate their needs. Review of Resident 18's progress notes documented a fall, dated 03/26/2026 at 11:43 PM. Resident 18 was found sitting near the foot of the bed and a head laceration was observed. The resident was sent to the emergency room and returned within 24 hours with staples to their head laceration. The progress note stated at the time of the fall the bed was in a low position and there was a fall mat next to the right side of the bed. Review of the facility incident investigation dated 03/26/2026 stated Resident 18 had an extensive history of falls and this is the reason (they) are in the facility. Fall witness statement forms did not include care planned fall interventions such as the call light, footwear, or clutter. The summary of the fall was written on 03/30/2026 and stated planned interventions were to place their bed in low position and fall mat at bedside. Review of Resident 18's record documented a second fall on 03/28/2026 at 6:40 PM. The progress note stated Resident 18 sustained a non-injury fall in their room. Per staff statements, the resident's assigned nurse and nursing assistant were both off the floor at the time of the fall and completed the fall investigation fields stating N/A (not applicable). There was no nursing staff documentation of the details of the fall. Nursing assistant statements vaguely stated the resident was found on the floor, vital signs were taken and the resident brought to the nurse's station in a wheelchair. The record did not address care planned interventions. The post fall summary was completed on 04/01/2026 by Staff B, Director of Nursing Services, and stated interventions were implemented at the time of the incident. An additional intervention was planned to keep the resident in public areas after meals and encourage the resident to eat in the dining room. Review of Resident 18's care plan showed there were no updates made to the care plan following the fall on 03/26/2026. The additional fall interventions did not occur until after the resident experienced the second fall on 03/28/2026 and included: Bed in low position (added 03/29/2026) Fall mat next to the bed (added 03/29/2026) (does not specify right or left side) Frequent Safety checks (added 03/30/2026) Keep bed at appropriate height: low bed (added 03/30/2026 and updated 04/01/2026) Keep in public areas as resident allows, Encourage eating in dining room (added 04/01/2026) Wear non-skid socks (added 03/30/2026) Toileting program in morning, after meals and bedtime (added 03/30/2026) In observations on 04/07/2026, 04/08/2026, and 04/09/2026, Resident 18 was observed to have a fall mat in the room which was sometimes placed on the right side of the bed, the left side of the bed, or leaned against the wall in the room. In an observation on 04/08/2026 at 2:32 PM, Resident 18 was sitting up in their room sitting on the left side of their bed with a lunch tray in front of them. Resident 18 was observed to begin leaning to the right and precariously reaching forward toward the floor toward an object on the ground near the bottom corner of the bed. There was no fall mat in place, as the overbed table was placed with the meal tray. Staff Y, NAC was nearby and was alerted. Staff Y stated, oh my gosh! and intervened to assist Resident 18. The fall mat was now observed on the right side of the bed. In an interview on 04/13/2026 at 9:44 AM, Staff C, stated they use the Morse Fall scale assessment on admission and then complete the baseline care plan. There was a care plan problem for falls that was done. If someone fell or there was a change in condition, then something needs to be done. If they fell, then they could fall again if we don't implement something. There should be an immediate intervention and investigation, and we review falls in our interdisciplinary team and find a root cause. If someone had a fall mat the care plan should say what side it should be on. In an interview on 04/13/2026 at 11:22 AM, Staff B, Director of Nursing Services, stated interventions should be reviewed and revised post fall under the fall risk care plan. The interventions should be based on the root cause of the fall. Regarding Resident 18, Staff B stated they were not sure why the care plan was not updated until after the second fall. Staff B stated they had noted that the staff witness statements for the 03/28/2026 fall had stated N/A and when asked if the post fall documentation included enough information to determine a root cause or if the care planned interventions were being followed, Staff B stated they were not sure, but that was information that should be on the form. <SMOKING SAFETY> Policy updated January 2025, Resident smoking safety independent and unsupervised. The policy revealed that all smoking materials, including cigarettes, electronic cigarettes and lighters are locked up including smoking materials for residents who are assessed to be supervised smokers. In an observation and interview on 04/07/2026 at 12:55 PM, Resident 105 was sitting in their recliner. The top dresser drawer contained three hard packs of cigarettes present. A whiteboard on their wall included a handwritten message that documented lighter and smokes should be locked in the lock box. There was an open orange lock box present with no cigarettes in it. In an observation on 04/08/2026 at 8:50 AM, Resident 105 was sitting in their recliner in their room, there were three packs of cigarettes in their top dresser drawer. In an interview and observation on 04/08/2026 at 2:00 PM, Resident 105 was sitting at a table in the dining room awaiting the resident council meeting with their pack of cigarettes and butane lighter on the table. During resident council meeting on 04/08/2026 at 2:53 PM; - Resident 50 stated they kept their cigarettes and lighter in a lock box, but they had no key for it. Resident 50 stated when the facility secured them, they were missing 4 lighters and 2 packs of cigarettes. -Resident 79 stated they kept their smoking materials in their room otherwise it took 20 minutes to get a nurse to get them. The resident stated they had a lock box but, no key to it. - Resident 30 stated they kept their cigarettes and lighters in their room in a lock box. They stated they just didn't have a key to it. In an observation on 04/09/2026 at 8:50 AM, Resident 105 wheeled into the nurse's station with a gold refillable lighter in hand. Staff C, RN filled their lighter with lighter fluid stored in first floor medication room. In an interview on 04/13/2026 at 11:22 AM, Staff B stated the Administrator was responsible for the smoking safety of residents and nursing completed the smoking evaluations. Staff B was unaware Resident 105 had their cigarettes in an open dresser drawer and that some residents did not use their lock box or have keys to secure them. Staff B confirmed that the location of smoking materials should be included on the care plan. Staff B stated the cigarettes and lighters needed to be secured in their room or locked in the medication cart. In a joint interview on 04/13/2026 at 1:01 PM, Staff A, Administrator and Staff B, stated they were unaware smoking materials were not consistently secured. Smoking policy was reviewed with Staff A and B who acknowledged that the policy stated that the facility would ensure the residents had lock boxes and would secure materials in them. Staff A stated the residents had the right to refuse to lock up their smoking materials. Staff A was not aware there were concerns with the lock boxes and some did not have keys. This is a repeat deficiency from SOD's dated 01/24/2025, 03/28/2025 and 01/28/2026. Refer to WAC 388-97-1060(1)(3)(g)

Based on interview and record review, the facility failed to ensure a resident was free from sexual abuse by a staff member for 1 of 1 resident (Resident 1) reviewed for abuse. The facility failed to recognize and report the allegation immediately to protect the resident from the potential further abuse. This failure allowed the alleged perpetrator to continue to work with other residents and allowed them to still have access to Resident 1. Resident 1 who had a known history of domestic violence, was a victim of a home robbery by a past caregiver, experienced psychosocial harm when they experienced increased panic attacks, a change in their sleeping pattern and increased anxiety related to fear of the staff member. This failure placed residents at risk for potential sexual abuse, psychological harm, and a diminished quality of life.Finding included.Review of the facility policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated March 2025, stated sexual abuse was non-consensual contact of any type with a resident.includes but not limited to unwanted intimate touching of any kind.a mandated reporter is any employee of the facility.defined immediately as means as soon as possible, but not later than two hours after an allegation has been made.Resident 1 admitted to the facility on [DATE] with diagnoses that included bipolar disorder (chronic mental health condition characterized by intense mood swings), agoraphobia (fear of not being able to escape or get help), and anxiety disorder. The admission Minimum Data Set (MDS - an assessment tool) dated 11/10/2025 documented the resident had no refusal of care, no behaviors, and was dependent on staff for toileting and personal care.Review of Resident 1's care plan had a focus revised date of 12/26/2025, documented the resident had impaired psychosocial well-being with goals of care that included the resident will feel safe in this facility to process trauma. Interventions included but not limited to; cares in pairs, trigger behavior can come from a history of domestic violence and ensure the residents' safety.Review of the facility investigation dated 02/23/2026 at 6:57 PM, documented Resident 1 informed a staff member of a sexual assault allegation. Resident 1 identified Staff H, Nursing Assistant Certified (NAC) as the alleged perpetrator and stated Staff H stroked the inside of the resident's thigh and made inappropriate comments. Resident 1's description of the events showed Staff H had entered their room to change their brief, during the process Staff H stroked the resident's leg and told the resident they were hot. While Staff H was cleaning the residents' genitals, Resident 1 stated they made the area very wet [with the peri cleaning wipes] and the resident reported to Staff H that they did not need to be that wet. The resident's statement documented that Staff H replied, that's how it's supposed to be. The statement documented that Staff H asked Resident 1 whether they were single or married, and that Resident 1 stated they felt unsafe. The investigation conclusion documented the allegations made by Resident 1 had not changed or waivered, and they had clearly recalled the events multiple times, down to what color of clothes they were wearing. The conclusion also documented that Resident 1 stated they would not feel comfortable if Staff H was allowed to work at the facility.Review of Resident 1's nurse progress notes, dated 02/23/2026 at 5:44 PM, Staff C, Licensed Practical Nurse/Resident Care Manager, documented the allegation occurred on 02/22/2026 and the resident reported Staff H took an extended time while cleaning the residents genital area, touched their thigh and made comments that their skin was soft and that they were hot. The note documented that Resident 1 reported they were uncomfortable and requested to have the brief placed on them three times, but they kept cleaning and stated they needed to be wet.In an interview on 02/25/2026 at 1:30 PM, Resident 1 was able to recall the allegation. Resident 1 stated they placed their call light on for a brief change and Staff H entered their room. Resident 1 stated Staff H rolled the resident onto their back, and told them to lift their legs, the resident stated they told Staff H they could not. Resident 1 was tearful during the interview and continued to recall the allegation. Resident 1 stated that Staff H cleaned their thighs very slowly while telling them their skin was soft, and that they were pretty and hot. Resident 1 stated while Staff H was cleaning their genital area, they asked them to stop, and Staff H replied to them they were not wet enough. Resident 1 stated they asked Staff H to stop several times at which they then applied the brief roughly. They stated Staff H returned to their room later that day to answer their call light. Resident 1 stated the incident occurred on a Sunday, and they had not been able to sleep since the incident.Review of Resident 1's nurse progress note dated 02/25/2026 at 3:43 PM, the resident stated they have had trouble sleeping related to the allegation of sexual abuse.Review of Resident 1's nurse progress note dated 02/25/2026 at 8:46 PM, the resident stated they were anxious and felt like they were having a panic attack and had abnormally high blood pressure.Review of Resident 1's medical record on 02/25/2026, showed one documented panic attack prior to the allegation and trouble sleeping had not been reported until after the allegation.Review of Resident 1's medical record documented a behavioral health note dated 02/26/2026 at 8:30 AM. The note documented the visit was prompted by the allegation of sexual abuse, and ongoing distress that the alleged perpetrator would contact the resident through social media. Resident 1 reported that they were experiencing panic attacks related to the allegation. The note documented Resident 1's thought process was linear, able to provide coherent narrative of the events, their affect was distressed and anxious when discussing the allegation, the resident showed no evidence of delusion and expressed concern about their safety. The note documented that Resident 1 had experienced an increase in panic attacks triggered by the recent sexual allegation and the resident's fearfulness the perpetrator will contact them on social media.Review of Resident 1's nurse progress note dated 02/26/2026 at 10:47 PM, showed Resident 1 became anxious and experienced a panic attack.In an interview on 03/02/2026 at 2:10 PM, Staff E, NAC, stated that around 2:00 PM on 02/22/2026 when they started their shift at the facility they were told by another staff member [Staff D, NAC] that they had switched rooms with Staff H due to the resident in room [ROOM NUMBER] [Resident 1], told them that Staff H had made them feel uncomfortable. Staff E was asked if Staff D stated exactly what had occurred and replied Staff H had made some comments to Resident 1, and that made them feel uncomfortable. Staff E recalled, later in the shift on 02/22/2026 and the next day, they had heard more of the story. Staff E stated they never reported the inappropriate behavior Staff D had told them about to anyone as they had not heard it first-hand. Staff E was able to confirm that they wrote the statement that was included in the investigation, that documented immediately heard from Staff D that Staff H was being inappropriate to Resident 1, as they had made them feel uncomfortable.In an interview on 03/02/2026 at 2:38 PM, Staff F, NAC, stated they worked evening shift (2:00 PM - 10:00 PM) on 02/22/2026. They and another caregiver were in room [ROOM NUMBER] assisting Resident 1's roommate with evening care, when Resident 1 stated to them that on day shift, Staff H sexually assaulted them while they were providing peri-care (cleaning of the genital and anal areas) and made weird comments. Staff F stated Resident 1 told them that they had kicked Staff H out of their room, but Staff H returned to the room to bring them ice water. Staff F stated they did not inform or report this information.In an interview on 03/02/2026 at 2:49 PM, Staff G, Registered Nurse, stated they were the assigned nurse for Resident 1 for the evening shift of 02/22/2026. Staff G stated they had no knowledge of the allegation until 02/23/2026 when Resident 1 informed them that Staff H had been inappropriate with them the prior day. Staff G stated they recalled that the caregivers had informed them at the beginning of shift on 02/22/2026 that Staff H and another caregiver switched assigned rooms between room [ROOM NUMBER] and another room. Staff G stated they did not ask why they switched rooms, as staff did that all the time, so they did not think anything about it.In an interview on 03/03/2026 at 9:25 AM, Staff D stated during their shift (6:00 AM - 2:00 PM) on 02/22/2026 Resident 1 informed them that Staff H had made them feel very uncomfortable and said things to them which were inappropriate. Staff D stated that they went into Resident 1's room to answer the call light. Staff D stated Resident 1 told them that Staff H told the resident they were skinny and beautiful. Staff D stated Resident 1 said when Staff H was providing peri-care to them, they would wipe them different than all the other staff, they would take longer and it was gentle. Staff D was asked if they reported any of what Resident 1 told them to anyone, Staff D stated they told the nurse they were switching rooms but did not tell them why, Staff D stated they wanted Resident 1 to feel safe in their own home.In a phone interview on 03/03/2026 at 10:20 AM, Staff H stated they were contracted staff that worked at the facility. Staff H stated they worked a double (6:00 AM - 10:00 PM - two shifts in a row) on 02/22/2026. Staff H stated they were assigned to care for Resident 1. Staff H stated they entered Resident 1's room to provide peri-care to them, provided the care, and afterwards Resident 1 informed them they did not want a male caregiver. Staff H stated they provided care to Resident 1 one more time that day. Staff H stated they performed care alone; they did not know the resident was cares in pairs. In an interview on 03/04/2026 at 11:20 AM, Staff C stated they were informed of the allegation on Monday 02/23/2026 at the end of the day. Resident 1 informed them that on 02/22/2026, Staff H touched them and demonstrated by pointing to their leg and inner thigh, and that Staff H made inappropriate comments. Staff C stated Resident 1 said they told Staff H to put their brief back on three times and they kept delaying and going slow while providing peri-care. Staff C stated Resident 1 had informed another caregiver so they switched rooms so Staff H would not care for them anymore that day. Staff C stated they had placed Resident 1 on alert monitoring after the allegation as they were having an increase in panic attacks. Staff C stated Resident 1 was having trouble sleeping and very anxious at night after the allegation.In an interview on 03/04/2026 at 12:06 PM, Staff B, Director of Nursing Services, stated that they were informed of the sexual allegation on 02/23/2026 around 5:15 PM via a phone call. Staff B stated they returned to the facility within an hour to start an investigation and report the allegation. Staff B stated Resident 1 had an increase in their panic attacks after the allegation and was fearful the alleged staff (Staff H) was going to contact them and their friends through social media.Cross reference: F609 and F610.Reference: (WAC) 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to ensure staff immediately performed Cardio-Pulmonary Resuscitation (CPR) to 2 of 2 residents (Residents 1 & 2) who were found unresponsive (not breathing and without a pulse) and had a physician order to initiate CPR. Resident 1 had a signed POLST (Physician Order for Life Sustaining Treatment- a form indicating the resident's wishes to have or not have CPR) for life-sustaining care and services, facility staff were unable to locate Resident 2's POLST after they became unresponsive. The failure to train staff on the facility's expectation how to respond to a resident who required CPR, locate for immediate reference a resident's POLST/Advanced Directives, and accurately assess signs of irreversible death, resulted in staff not performing CPR for both residents, and placed other current residents who may need CPR at risk of not receiving life sustaining treatment and/or full medical interventions in an emergency, constituted in an Immediate Jeopardy (IJ-noncompliance that has caused or is likely to cause, serious injury, harm, impairment, or death to a resident). On [DATE] at 4:10 PM, the facility was notified of an IJ in F678. The IJ was determined to have begun on [DATE] when the facility failed to perform CPR immediately when a resident was found unresponsive without a pulse, was not breathing, and had a physician order to initiate CPR. The facility removed the immediacy on [DATE] at 3:04 PM, after educating staff in emergency response, reviewing their CPR policy, all residents' POLST forms for accuracy, CPR training for completion, and implemented a plan of correction to sustain ongoing compliance. Findings included . Review of the facility policy titled, Cardiopulmonary Resuscitation (CPR), updated [DATE] stated licensed nurses employed by the facility will have current CPR certification from American Heart Association or American Red Cross.CPR certification is reviewed routinely to validate current CPR certification for licensed nurses was maintained.CPR would be initiated for residents who have requested through advanced directives or POLST form to have CPR, and for residents that have not formulated an advanced directive &/or POLST form was in their medical record.POLST binder will be centrally located in a accessible location in an the event of an emergency the form would be utilized to direct the plan of care.in the event of a code blue event a staff member identifies a resident that was absence of pulse or breath, a staff member immediately seeks assistance from a licensed nurse and ask another staff member to announce a code blue, a staff member will be assigned to obtain the residents code status via POLST binder, and a licensed nurse will validate the residents code status and follow directions. Review of American Heart Association's guidelines for 2025, reviewed on [DATE] CPR should be initiated immediately when an individual has been found without a pulse or breathing. <RESIDENT 1> Resident 1 was admitted to the facility on [DATE] with diagnoses including endocarditis (infection of heart tissue), and sepsis (infection in the blood).Review of Resident 1's POLST form sign by a physician on [DATE], documented the resident selected attempt resuscitation/CPR in the even they had no pulse and were not breathing. Review of Resident 1's progress note dated [DATE] at 11:15 AM, the nurse documented they were informed the resident was unresponsive, they entered the resident's room, resident was not breathing and had no pulse. The nurse called for help, called 911, and notified the nurse practitioner who was at bedside. Review of Resident 1's progress note dated [DATE] at 1:02 PM, the nurse manager documented they notified the county coroner's office related to unexpected passing of the resident. There was no further documentation in Resident 1's medical record. Review of the POLST binders on the 1st and 2nd floors on [DATE] from 12:12 - 1:15 PM, the 1st floor binder listed only 1st floor residents by room, and the 2nd floor binder listed only 2nd floor residents by room. Three residents POLST forms were not located in the correct room per the electronic medical records, and one POLST form was for a 2nd floor resident whose POLST form was still physically located in the 1st floor binder, on the 1st floor. Several residents on both floors had duplicate POLST forms that showed conflicting results, i.e. one form would elect to have CPR, and the other did not. In an interview on [DATE] at 1:20 PM, Staff M, Nursing Assistant Certified (NAC) was asked how to tell if a resident elected CPR if they were found unresponsive without a heart rate or breathing. Staff M stated they thought that information was in the resident's electronic individual service plan. Staff M stated if they found a resident that was unresponsive, they would check their vitals then get a nurse.In an interview on [DATE] at 1:25 PM, Staff D, Registered Nurse (RN) stated that in the event a resident was found to be unresponsive (no pulse and not breathing) they are to call for help, check the code status and initiate CPR if necessary. Staff D stated if they were unable to find the code status they are to provide CPR. Staff D stated they were told Resident 1 was found unresponsive and went to the resident's room on [DATE]. Staff D stated they had no pulse, and they were not breathing. Staff D stated they called for help, and went to the nurse's station, Staff D stated Staff C, RN/Assistant Director of Nursing (ADNS), and Collateral Contact (CC) 1, Nurse Practitioner (NP) came back to Resident 1's room with them, Staff F, RN, called 911. Staff D stated that Staff C, and CC1 assessed Resident 1 and found they were absent from pulse and breath. Staff D stated, no one started CPR. Staff D stated everyone was frazzled. Staff D stated emergency services arrived and they started CPR.In an interview on [DATE] at 1:33 PM, CC1 stated they were in another room when they heard that Resident 1 was unresponsive. CC1 stated they entered the resident's room and saw Staff C in the room assessing the resident with a pulse oximeter (finger device that measures heart rate and oxygen saturation) and there were no results on the meter. CC1 stated they then listened to Resident 1's heart and heard nothing. CC1 stated Staff D, and Staff F entered the room, and someone stated the resident was a full code. CC1 stated they remember stating we need to be sure and if they are we should start compressions, and then they walked out of the room to verify. CC1 stated to their knowledge no facility staff, or themselves started CPR on Resident 1. In an interview on [DATE] at 2:29 PM, Staff C, stated when a resident was found unresponsive, without a pulse or breathing, they should alert someone there was a code blue and start CPR. Staff C stated usually someone would be checking the residents' code status and if they were a full code you would continue with life saving measures until emergency services arrived. If the residents had not elected to not have CPR on their POLST or advanced directive they should stop CPR. Staff C stated they were notified by a therapist that Resident 1 had been unresponsive. Staff C stated they went to the room with Staff D, RN and found Resident 1 was not breathing and had no pulse. Staff C stated they thought Staff F was checking to see if the resident wanted CPR and was going to call 911. Staff C stated that shortly after they arrived in the room CC1 entered the room and wanted to assess the resident as well. Staff C stated CC1 said something along the lines of they had passed away,, just as Staff F had come back into the room and stated the resident was a full code and required CPR. Staff C stated no one at the facility started CPR during that time, and that CPR was started when the emergency services personnel arrived. Staff C stated CPR should have started on Resident 1. In an interview on [DATE] at 2:42 PM, CC 2, Occupational therapist (OT) stated on [DATE] around 11:00 AM to 11:15 AM they went to Resident 1's room to conduct a therapy session with the resident. CC 2 stated the resident was observed in bed, with oxygen tubing to their nasal passageway via a concentrator that was running. CC 2 stated the residents did not wake up or respond. CC 2 stated they performed a sternal rub (applying a fist totheir chest and rub to arouse) with no response so they quickly left the room and grabbed Staff D, then quickly told Staff C and CC 1 as well, then they left the room. Review of an Emergency Medical Services (EMS) report printed [DATE] at 9:23 AM, for the EMS 911 call for Resident 1 on [DATE], documented the resident appeared unresponsive, skin, head and face appeared normal. The report showed the 911 call came in at 11:10 AM, EMS unit was notified at 11:13 AM, EMS unit was at bedside with Resident 1 at 11:24 AM, (14 minutes total time from call to bedside to start CPR). In a phone interview on [DATE] at 11:56 AM, Staff F, stated they overheard a therapy staff tell Staff D that Resident 1 was unresponsive. Staff F stated they saw Staff C, and Staff D enter Resident 1's room, then about a minute or so later they followed into the resident's room. Staff F stated they went to call 911 and exited the room. Staff F stated after they got off the phone with the 911 operator, they went back to Resident 1's room where Staff C, Staff D, and CC1 were present. Staff F stated CC1 was assessing Resident 1, no one had started CPR. Staff F stated they left the room since there were three licensed staff in the room. Staff F stated they were never asked by anyone to confirm Resident 1's code status, and that they never went to check their code status. Staff F stated the POLST binder was on the nurse's station counter open when they were calling 911. Staff F stated they did not remember when this occurred other than it was between 10:00 AM - and 12:00 PM. Staff F stated prior to this event? they remembered one of the NACs reported to them that Resident 1 had some trouble breathing., Staff F said the NAC told them they had helped the resident to breathe, the resident was ok now, and did not go re-check on the resident. In an interview on [DATE] at 2:25 PM, Staff G, NAC, stated they heard Resident 1 calling for help between 10:45 AM and 10:50 AM on the morning of [DATE]. Staff G stated Resident 1 appeared to be having difficulty breathing and talked them through some breathing exercises through their nose, while wearing oxygen supplementation via nasal tube. Staff G stated they assisted Resident 1 to get back into their bed, and informed Staff F, since Resident 1's nurse (Staff D) was on lunch that the resident had a few episodes of breathing concerns. Staff G stated when they left the resident, they were breathing fine, lying in bed with oxygen supplementation via a nasal tube, and appeared comfortable. In an interview on [DATE] at 3:11 PM, CC 3 stated they had held a therapy session with Resident 1 on [DATE] sometime after 9:00 AM that morning. CC 3 stated that the residents presented short of breath during their workout but did not seem out of the ordinary. Review of the preliminary facility investigation on [DATE], undated showed an audit was completed on [DATE] for the POLST binders located on the 1st and 2nd floor of the facility were up to date. Review of the completed facility investigation dated [DATE], documented a witness statement by a NAC that sometime around 10:50 AM they heard someone yelling Help, Help from room [ROOM NUMBER]. They entered the room to find Resident 1 in their wheelchair flailing their arms and yelling. The residents stated they could not breathe. The staff stated Resident 1 had oxygen on and they encouraged them to breathe. The resident calmed down and asked to be assisted to bed. When they were assisting Resident 1 with positioning in bed they began flailing around again and saying they couldn't breathe. The NAC stated in the statement they went to notify the nurse. The nurse (Staff D) was on break, so they left them a note on their med cart and informed the other nurse (Staff F). The investigation documented Resident 1 was found unresponsive by a therapy staff (CC 2) around 11:00 AM - 11:15 AM, they notified a nurse. The investigation documented that three licensed nurses were all in Resident 1's room and found them without a pulse and were not breathing. A fourth licensed nurse called emergency services (911). The investigation documented that no licensed staff started CPR on Resident 1. Emergency services personnel initiated CPR to Resident 1 when they arrived, the resident was pronounced dead by emergency services. The facility substantiated that the licensed staff failed to provide CPR services to a resident that had requested and needed life saving measures. In an interview on [DATE] at 12:19 PM, CC 4, Medical Director, stated their expectation was for anyone in the facility that was certified to perform CPR, would be following that protocol. CC 4 stated that CPR should be initiated while someone verified the residents' code status. CC 4 confirmed it was their expectation that the nurse practitioner should have given guidance to start CPR on Resident 1. In an interview on [DATE] at 1:09 PM, Staff B stated that it was the facility policy that facility staff are initiating CPR on any resident that was found not breathing or without a heartbeat. Staff B stated that while one staff member performs CPR, someone else can alert emergency services and verify code status on the resident. Staff B stated in the event the resident did elect CPR, staff are to continue CPR until emergency personnel arrive and take over, if they did not want CPR the staff can stop life saving measures. Staff B stated that Resident 1 should have had CPR. <RESIDENT 2> Resident 2 was admitted to the facility on [DATE] with diagnoses to include bladder tumor, kidney disease and vasovagal response (fainting spell caused by a sudden, temporary drop in blood pressure). Review of the facilities incident report, dated [DATE], showed Resident 2 experienced a fall without fracture and an unanticipated death both with the same time of 5:30 AM. The incident report contained a nursing description, witness statement forms for three staff members, written statement from a visitor and fall investigation checklist. The incident report documented the fall, and the unanticipated death were not witnessed. The investigation report showed a statement by staff with no associated signed statement, which documented the police and 911 were called after Resident 2 was found on the floor, moved to their bed, provided oxygen, and subsequently stopped breathing, at which time they obtained the crash cart to start CPR. The incident report did not contain a timeline of events, who performed CPR, how long CPR was performed or names of the staff involved. Review of EMS report, dated [DATE], showed EMS was notified at 5:01 AM of Resident 2's condition. EMS arrived at Resident 2's bedside at 5:13 AM and the narrative documented Resident 2 as unresponsive, CPR was initiated but stopped, and it was unclear why CPR was not in progress at EMS arrival. In an interview on [DATE] at 3:02 PM Staff J, Licensed Practical Nurse (LPN), stated they did not perform any CPR on Resident 2. Staff J stated they had assisted another nurse get Resident 2 back to bed and placed oxygen on them after finding a pulse. Staff J stated they went to the nurse's station and attempted to find Resident 2's code status but were unable to locate it. Staff J stated Resident 2 was found about 4:30 AM and EMS arrived within five to six minutes.In an interview on [DATE] at 9:38 AM Staff E, LPN/Staff Development stated licensed nurses were required to have up to date and current CPR certification, however the nursing assistants were not. When asked if Staff I, Nursing Assistant Certified (NAC) and Staff H, NAC had current CPR certification, Staff E stated there were no current CPR certifications on file for either NAC. In an interview on [DATE] at 10:47 AM Staff I, NAC stated they did not provide CPR to Resident 2 on [DATE]. Staff I stated Staff H, NAC, motioned to them to come and help with Resident 2. Staff I stated Resident 2 was in bed and they assisted Staff H with placement of a rescue board under Resident 2 in bed. Staff I stated they counted respirations while Staff H completed chest compressions. Staff I stated they counted to about 25 and then Staff H stopped compressions. Staff I stated they did not have a current CPR certification. Staff I stated they did not witness any other staff member provide CPR to Resident 2. In an interview on [DATE] at 12:53 PM, Staff H stated they provided 30 - 50 chest compressions to Resident 2 on [DATE]. Staff H stated they were directed by Staff L, Registered Nurse (RN) to go to Resident 2's room and start CPR. Staff H stated they started last rounds with Staff I about 3:30 AM and decided to leave Resident 2's hall for last to allow them to sleep. Staff H stated they were almost done with rounds in the longest hall, which usually took about an hour, when they were directed to go to Resident 2's room. Staff H stated Staff J and Staff L along with the downstairs nurse, Staff K were all at the nurse's station about 10-15 minutes prior to being told to start CPR on Resident 2. Staff H stated they did not take over CPR for any of the nurses and as far as they knew were the only one who provided CPR to Resident 2. Staff H stated they stopped providing chest compressions when Staff L and Staff K, RN came to Resident 2's room. Staff H stated they asked the nurses for the AMBU (manual bag to provide respirations) and if they needed to continue CPR. Staff H stated Staff K and Staff L just stood there and said nothing and provided no direction. Staff H stated they told Staff K and Staff L they were tired and unable to continue CPR. Staff H stated they had been certified for CPR in the past, did not know if they were current on their certification as they had lost their certification card.In an interview on [DATE] at 2:27 PM Staff K, RN stated they were called by Staff L, RN to assist with finding Resident 2's code status. Staff K stated they received the call after 4:00 AM. Staff K stated they did not provide any CPR to Resident 2 and did not go to their room or assess them in any way. Staff K stated they brought the crash cart upstairs and Staff J and Staff L were both at the nurse's station looking for Resident 2's code status.In an interview on [DATE] at 12:50 PM Staff B stated CPR must be provided to residents if their code status was not known. Refer WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to provide an environment that was free from accident hazards over which the facility has control for 1 of 3 residents (Resident 1) reviewed for falls. Resident 1, who had a known history of falls experienced harm when the facility failed to safely administer medications which resulted in cumulative adverse effects contributing to a fall with a significant injury. Findings included .Review of the facility policy titled: Fall Management and Neurological Check, with a revised date of January 2025, stated care plans were updated to reflect individualized interventions to reduce falls and a systematic review of current interventions was completed post fall and root causes identified. Resident 1 admitted on [DATE] with diagnoses which included hypertension (high blood pressure, chronic kidney disease, heart failure) and vision deficit. Review of the fall risk assessment dated [DATE] showed the resident was assessed as at high risk for falls.Review of the admission Minimum Data Set (MDS- a required assessment tool) dated 08/26/2025 showed the resident had no history of falls reported in the 6 months prior to admission. Review of the associated Care Area Assessment (CAA) related to falls dated 08/26/2025 stated Resident 1 did not have a history of falls in the look back period. The CAA identified medications as risk factor and stated to proceed to the care plan related to risk for falls.Review of the care plan dated 08/20/2025 documented a care plan problem related to mood and behavior which identified the resident as taking several medications for mood and included side effects such as dizziness, drowsiness, unsteadiness and blurred vision and the potential for a drop in blood pressure when moving quickly from sitting to standing (orthostatic hypotension.) A care plan problem related to falls stated Resident 1 was at risk for falls related to deconditioning. The goals dated 08/20/2025 and revised 11/24/2025 stated the Resident 1 would remain free from injury related to falls. Care plan interventions included having the call light in reach, wearing proper footwear, keeping the room free of clutter, and reminding the resident to sit at the edge of the bed prior to standing to prevent orthostatic hypotension. The care plan did not include a focus area related to cardiac related blood pressure medications. Review of Resident 1's medical record on 01/28/2026 showed the resident began experiencing falls: On 12/06/2025, Resident 1 was documented as having a fall and hitting their head, a neurological assessment was done, a CT of the head showing no acute injury and laboratory tests were completed. One blood pressure medication was discontinued. There were no new interventions or updates made to the care planned fall interventions. On 12/11/2025, Resident 1 had a fall with no stated injury. There were no new orders and no changes to the care planned fall interventions. Further falls were documented on 01/08/2026 (the provider assessed the resident and noted orthostatic hypotension with significant drop in blood pressure upon standing and Positive for signs and symptoms of dehydration the resident received an intravenous fluid bolus), 01/09/2026 (Resident 1 slid out of their wheelchair in another resident room) and 01/10/2026, with no new orders, interventions or updates to the care plan. 01/12/2026 a pharmacist review noted frequent falls. There were frequent medication order changes due to dizziness, weakness and frequent falls. On 01/14/2026 at 11:30 AM, the resident had a fall in their room, striking their face and complaining of back pain. The resident was sent to the emergency department where they were assessed to have a right forehead hemotoma (a solid swelling of clotted blood in tissue) and an acute L2 (low back) vertebral compression fracture. The emergency department report stated the resident arrived stating I fell because of my blood pressure. Review of the facility medication administration records for the month of January 2026, documented the resident had received three blood pressure medications prior to the fall on 01/14/2026 which had parameters included in their orders to hold those medications when the resident's diastolic blood pressure (bottom number) was below 60. The blood pressure documented on 01/14/2026 was 112/58. The MAR also documented administrations when the residents blood pressure was below the ordered parameters on 01/01/2026, 01/04/2026 and twice since the fall on 01/26/2026 and 01/27/2027. Review of the facility incident investigation dated 01/14/2026 did not identify Resident 1 as having suffered injury from the fall. The incident investigation stated no injuries apparent at time of incident, despite the resident having obvious facial trauma, and the post incident section stated no injuries observed post incident. The level of pain and level of consciousness sections of the investigation were blank. The entire section of predisposing factors such as clutter in the environment, physical factors, or mental factors was blank. Staff statements stated the resident had been seen 30 minutes prior to the fall lying in bed and their blood sugar had been checked. Resident 1 was stated to have been wearing proper footwear and had last eaten at 9:00 AM. The investigation stated neurological checks were done but there was no documentation of them included in the report or in the resident record. The medication errors related to the blood pressure medications were not identified and medication risk factors previously identified in the CAA were not reviewed as part of the post fall investigation. The resident returned from the emergency department at 8:00 PM on 01/14/2025 with new orders for a pain management patch to their low back, and a new medication order related to additional findings of decreased liver function. There were no updates made to the care plan related to actual falls, fracture/pain management or medication side effect monitoring. In an interview on 01/28/2026 at 9:00 AM, CC1, resident representative, reported there were problems and overdosing with blood pressure medications since admission, the resident has had falls and needed fluids at one time related to dehydration. CC1 stated the resident has fallen several times, and was weaker, due to mismanagement by the facility. CC1 stated this has also impacted Resident 1 being able to do therapy stating, (Resident 1) used to be able to walk; Now she is weak and in pain. In an interview and observation on 01/28/2026 at 10:30 AM, Staff E, Registered Nurse, RN, was administering medications, Staff E showed the medication screen view and the orders and stated when a medication was selected that included a requirement to check a blood pressure or pulse, a box would appear to enter the value. Staff E stated Resident 1 had a parameter for the blood pressure medications. Staff E stated if the blood pressure or pulse was too low they should not administer the medication. Staff E stated Resident 1 had declined lately, was sleeping and staying in bed more and stated they were going to offer them a nutrition shake, because they did not eat breakfast today. In an interview on 01/28/2026 at 10:40 AM, Staff K, Nursing Assistant Certified, stated Resident 1 had been sleeping a lot lately, did not eat breakfast and used to be more independent. Staff K picked up Resident 1's uneaten breakfast tray and had notified Staff E that Resident 1 had not eaten and said they were not hungry. Staff K stated Resident 1 had a low bed because they had fallen and was not aware of any other fall interventions. Staff K stated Resident 1 used the call light, and could tell you what they needed. In an interview and observation on 01/28/2026 at 11:16 PM, Resident 1 was sitting up in their wheelchair and was observed with yellow and purple resolving bruising around their right eye. Resident 1 stated they have had a lot problems with their blood pressure and blood pressure medications. Resident 1 stated their memory was a bit fuzzy from the day of that specific fall, but they remembered standing at the sink and feeling dizzy, turning around to trying and sit on their bed and they fell. Resident 1 stated they told me I I broke my back and it still hurts. Resident 1 says they are using a pain patch on their back and it only helps a little. Resident 1 stated they had been having ongoing episodes of dizziness but never used to. and said their head sometimes just feels numb. Resident 1 stated they use the call light like they tell her to, but it usually takes at least a half an hour for someone to come. In an interview on 01/28/2026 at 1:12 PM, Staff C, LPN, Resident Care Manager, stated the medication parameters were included with the orders in the administration screens but the system would not stop you if you administered a medication outside of a parameter. It was up to the nurse to view the entire order and to hold the medication based on the order. Staff C reviewed the administration orders for Resident 1 and the administration record and stated those were all errors, the medication should not have been given and the provider should have been notified. Staff C stated medication side effects would be on the care plans and should be updated when there were changes and reviewed after falls and the team reviewed falls during the daily stand up meetings. In an interview on 01/28/2028 at 2:28 PM, Staff B, Director of Nursing, stated administration of the blood pressure medication outside the parameter constituted an error and would need an investigation. Staff B stated they had not identified the medication errors while conducting the 01/14/2026 fall investigation for Resident 1 and had not identified medication as a contributing factor in that fall.Refer to F 760 - 483.45 (f)(2) - Residents Are Free of Significant Med ErrorsRefer to WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for falls were free from significant medication errors. Failure to follow physician ordered medication parameters for antihypertensive (blood pressure lowering) medications resulted in harm when Resident 1 experienced dizziness and a fall resulting in significant injury. Findings included .Review of the facility policy titled, Medication Administration Guidelines, dated 01/23 stated prior to administration of medication, review and confirm the orders for each individual medication. Resident 1 admitted [DATE] with diagnoses which included hypertension (high blood pressure) chronic kidney disease and congestive heart failure. Resident 1 had a history of falls. Review of Resident 1's physician's orders showed the resident had orders for:A diuretic (furosemide) (medication that lowers blood pressure by removing fluid from the body) once per day at 11:00 AM. The order instructed the nursing staff to hold the medication if the resident's systolic (top number) blood pressure was less than 100mm/Hg (millimeters of mercury), and/or the diastolic (bottom number) was less than 60mm/Hg. An antihypertensive medication (hydralazine)(lowers blood pressure by relaxing the smooth muscle in blood vessels) once per day at 11:00 AM. The order instructed the nursing staff to hold the medication if the resident's systolic (top number) blood pressure was less than 110mm/Hg (millimeters of mercury), and/or the diastolic (bottom number) was less than 60mm/Hg.An antihypertensive medication (lisinopril)(lowers blood pressure by relaxing the smooth muscle in blood vessels) once per day at 11:00 AM. The order instructed the nursing staff to hold the medication if the resident's systolic (top number) blood pressure was less than 100mm/Hg (millimeters of mercury), and/or the diastolic (bottom number) was less than 60mm/Hg. Review of Resident 1's Medication Administration Record (MAR) for 01/01/2026- 01/27/2026 documented: On 01/01/2026, blood pressure was documented as 132/54 (diastolic BP was below 60). The MAR documented that the resident was administered furosemide, hydralazine and lisinopril. On 01/04/2026, blood pressure was documented as 106/71 (systolic BP was below 110). The MAR documented the resident was administered hydralazine. On 01/14/2026, blood pressure was documented as 112/58 (diastolic BP was below 60). The MAR documented the resident was administered furosemide, hydralazine and lisinopril. Review of Resident 1's medical record, documented Resident 1 fell in their room on 01/14/2026 at 11:30 AM, striking their face during the fall and complaining of back pain. Resident 1 was transported to the emergency department where review of an emergency department summary report revealed the resident had a hematoma on the right forehead and an acute L2 (low back) compression fracture. Review of Resident 1's MAR for days following the fall, showed two additional days (01/26/2026 and 01/27/2026) that the blood pressure medications were administered when the resident's diastolic blood pressure was below 60. In an interview on 01/28/2026 at 9:00 AM, CC1, resident representative, reported there were problems and overdosing with blood pressure medications since admission, the resident has had falls and needed fluids at one time related to dehydration. CC1 stated the resident has fallen several times, and was weaker, due to mismanagement by the facility. In an interview and observation on 01/28/2026 at 10:30 AM, Staff E, Registered Nurse, RN, was administering medications, Staff E showed the medication screen view and the orders and stated when a medication was selected that included a requirement to check a blood pressure or pulse, a box would appear to enter the value. Staff E stated Resident 1 had a parameter for the blood pressure medications. Staff E stated if the blood pressure or pulse was too low, they would hold the medication and there would be a code entered that indicated the medication was not administered due to vital signs being outside the ordered parameter. In an interview and observation on 01/28/2026 at 11:16 PM, Resident 1 was sitting up in their wheelchair and was observed with yellow and purple resolving bruising around their right eye. Resident 1 stated they have had a lot problems with their blood pressure and blood pressure medications. Resident 1 stated their memory was a bit fuzzy from the day of that specific fall, but they remembered standing at the sink and feeling dizzy, turning around to try and sit on their bed and they fell. Resident 1 stated they told me I I broke my back and it still hurts. In an interview on 01/28/2026 at 1:12 PM, Staff C, LPN, Resident Care Manager, stated the medication parameters were included with the orders in the administration screens but the system would not stop you if you administered a medication outside of a parameter. It was up to the nurse to view the entire order and to hold the medication based on the order. Staff C reviewed the administration orders for Resident 1 and the administration record and stated those were all errors, the medication should not have been given and the provider should have been notified. In an interview on 01/28/2028 at 2:28 PM, Staff B, Director of Nursing, stated administration of the blood pressure medication outside the parameter constituted an error and would need an investigation. Staff B stated they had not identified the medication errors while conducting the 01/14/2026 fall investigation for Resident 1 and had not identified medication as a contributing factor in that fall. Refer to F 689 - 483.25 (d)(1)(2)- Free of Accident Hazards/supervision/devices Refer to WAC 388-97-1060(3)(k)(iii)

Based on observation, interview and record review, the facility failed to ensure residents who engaged in smoking were assessed for adequate supervision to prevent injury from burns, provided a safe environment, necessary devices, and supplies to safely smoke, and to protect other residents from potential fire hazard for 2 of 2 residents (Residents 66 and 78) reviewed for smoking. These failures potentially placed all residents at risk for injury related to unsafe smoking practices and constituted an Immediate Jeopardy (IJ). The failed practice resulted in an IJ on 01/16/2025 when the facility failed to ensure residents, and the resident environment were safe from injury from burns and fire. The IJ was removed on 01/17/2025 after the facility-initiated safe smoking evaluations, skin assessments for burns and room inspections to ensure cigarette butts had been properly disposed of for Residents 66 and 78. A safe smoking location was provided with a safe disposal receptacle. Residents 66 and 78 were educated on the safe smoking location, safe disposal of cigarette butts in the smoking receptacle, and turning in their smoking paraphernalia when they return to the building. Staff were educated prior to their next scheduled shift to ensure awareness of the new smoking safety plan. Staff were directed to ask residents to show that they do not have any cigarette butts on their persons when they returned from smoking. Findings included . In an entrance conference interview on 01/16/2025 at 9:04 AM, Staff A, Administrator stated the facility was a non-smoking facility, and there were no residents in the facility who smoked. Record review of the facility policy titled, Smoke-Free Center, revised date of April 2014, showed smoking was prohibited for everyone on the property owned and operated by the center, including residents, employees, visitors, volunteers, consultants, contractors and government representatives. The policy included an italicized line that showed Center does not own the sidewalks and streets that border the grounds. Employees who see individuals smoking on the Center's grounds are encouraged to inform these individuals with courtesy, that the Center's policy prohibits smoking anywhere on the Center ' s grounds. Review of the Smoke Free Center Policy Acknowledgement form, updated November 2016 showed By signing this form, I acknowledge that I have been informed of and agree to follow the Smoke-Free Center Policy. If I am found in violation of this policy, I understand that I may be discharged from the Center according to applicable state and federal laws. <RESIDENT 66> Resident 66 admitted to the facility on [DATE] with diagnoses to include left and right below the knee amputations and nicotine/cigarette dependence. According to their Admission Minimum Data Set (MDS- an assessment tool) assessment dated [DATE], Resident 66 had no cognitive impairment and no current tobacco use. Review of Resident 66's admission orders from the hospital dated 08/06/2024 showed staff were directed to place a nicotine patch 21 MG (milligrams) in 24 hours onto the skin daily, removing the old patch before applying a new patch. Review of the practitioner visit note dated 08/07/2024 showed Resident 66 had been smoking since age 10, three quarters of a pack (15 cigarettes) per day and had three cigarettes since admission. The resident reported they used cigarettes to cope with stress. Review of a note labeled Psych follow up dated 12/03/2024 at 7:15 AM, showed diagnosis of nicotine dependence and to encourage smoking cessation. Review of a note labeled Psych follow up dated 12/31/2024 at 10:15 AM, documented nicotine dependence and a behavioral intervention to encourage smoking cessation, provide reorientation and avoid overstimulation to prevent agitation. In an interview and observation on 01/15/2025 at 9:31 AM, Resident 66 was in their room which smelled heavily of cigarettes. Resident 66 appeared agitated and stated that they received a letter stating they would have to discharge from the facility. Resident 66 showed this surveyor their discharge notice that showed they no longer needed skilled nursing, had refused therapies and had been verbally abusive with staff. In an observation on 01/16/2025 at 7:50 AM, Resident 66 was observed smoking on the sidewalk outside of the facility. In an observation on 01/16/2025 at 8:44 AM, Resident 66 was in their wheelchair in their room. The hallway and room smelled heavily of cigarette odor. In an observation on 01/16/2025 at 10:40 AM, Resident 66 was in the hall being pushed in their wheelchair by a visitor. Resident 66 stated they were going outside for some fresh air. They stated As long as I have a pusher. I will get fresh air. In a joint interview on 01/16/2025 at 10:44 AM, Staff E, Licensed Practical Nurse (LPN) stated Resident 66 goes outside to smoke but they weren't supposed to. Staff D, Registered Nurse (RN) stated Resident 78 also goes out to smoke. Staff E stated both residents had been educated about smoking, many times by Staff C, Staff A, Administrator and Staff B, Director of Nursing Services (DNS). Staff E stated they did not have or keep the resident's cigarettes or lighter. Staff E stated they assumed the cigarettes and lighter are with the residents. Staff D said Resident 66's room always smells like cigarette smoke, but they didn't believe the resident had smoked in their room as they see them smoking outside. Staff D said Resident 66 refused their nicotine patches. Review of the clinical record 01/16/2025 at 12:28 PM showed there was no smoking safety evaluation or care plan about nicotine dependence or smoking for Resident 66. In an observation and interview on 01/16/2025 at 1:04 PM, the hallway outside room [ROOM NUMBER] smelled heavily of cigarette odor. Resident 66 was in their room and stated staff Get after them for smoking, especially (Staff C, Social Services). Resident 66 stated Staff C told them the state would not like them smoking and would make them quit. The resident stated Staff C told them they would probably have to have a staff member hold the cigarette for them. Resident 66 stated they started smoking at ten years old and staff knew they smoked when they admitted . The resident stated they smoke off the property and extinguished the cigarettes in their hands by twisting until the tobacco falls out. Resident 66 stated sometimes they will try to run over the cherry (lit portion of cigarette) with their wheelchair. Resident 66 had both hands in their sweatshirt pockets and shook them while stating they kept their cigarette butts in their sweatshirt pockets because there was no place to discard the cigarette butts outside. Resident 66 stated they cannot extinguish the cigarettes because they have no feet. Resident 66 stated they get mad at other people who smoke here and leave their cigarette butts on the ground. The resident stated they kept their cigarettes and lighter in their coat pocket in their room. There was an outline of a cigarette pack observed in their left inner coat pocket. Resident 66 stated they had tried Zyban (medication to aid smoking cessation) in the past and broke out in hives. Review of Resident 66's clinical record on 01/16/2025 at 12:28 PM, showed the facility had not assessed the resident for smoking safety and there was no care plan in place despite the resident's longstanding smoking history and nicotine replacement therapy in place from admission. The resident was at high risk to smoke given their current stressors of recent loss of both lower extremities and their sudden impaired mobility. In an observation on 01/16/2025 at 1:18 PM, Resident 66 was observed on the sidewalk smoking a cigarette with no staff present. Smoke was visible. There was no cigarette disposal receptacle present. The nearest garbage can was located right inside the door of the facility. The garbage can was plastic with a clear plastic liner in it. In an observation on 01/17/2025 at 7:55 AM, Resident 66 was observed sitting outside in their wheelchair on the sidewalk on the property next to a trash can. The resident was observed to roll the end of the lit cigarette with their finger and then place their hands in their pocket. No cigarette butts were located on the ground where they were seated. Review of Resident 66's facility smoking evaluation dated 01/16/2025 at 4:35 PM, was completed after the IJ was called. The assessment summarized the resident was on medications with the side effect of drowsiness. <RESIDENT 78> Resident 78 admitted on [DATE] with diagnoses to include left leg fracture, multiple heart conditions and nicotine dependence. According to the resident's Admission MDS assessment dated [DATE], showed the resident had no cognitive impairment and no current tobacco use. Review of the hospital discharge summary/orders dated 12/13/2024 showed Resident 78 was a patient that smoked. The orders directed staff to place a nicotine patch 21 MG (milligrams) in 24 hours onto the skin daily, removing old patch before applying a new patch. Review of a facility provider note dated 12/16/2024, showed Resident 78 was a current smoker of one to two packs a day and current user of smokeless tobacco/chew. Review of a weekly skilled Interdisciplinary (IDT) Meeting note dated 01/02/2025 at 12:34 PM, written by Staff B, Director of Nursing noted Resident 78 was smoking. Review of a progress note dated 01/13/2025 at 11:44 PM, showed Resident 78 arrived via taxi from the hospital emergency department around 11:30 PM, Alert and Oriented to person, place, time and event, appeared to be at baseline, and right away they wheeled themselves outside for a smoke, returned and asked for their pain pill. Review of Resident 78's clinical record 01/16/2025 at 12:21 PM showed there was no smoking safety evaluation or care plan about nicotine dependence, or smoking completed for the resident. In an interview and observation on 01/16/2025 at 1:40 PM, a black lighter was observed on Resident 78's overbed table. The resident stated they had a lot of stress over discharging, and they were only able to see half of their visual field in their right eye for the past 5 days. Resident 78 stated they chewed tobacco normally and they did not like smoking but could not chew in a place like this, related to their rules. The resident stated they go outside to smoke two to three times a day and the nurses remove their nicotine patch before they go out to smoke. Resident 78 stated they were not wearing their patch that day because they planned to go out and smoke a lot. The resident stated they go off property 30 or 40 feet to smoke. The resident stated to put their cigarette out, they knock the cherry off and twist the cigarette with their fingers. The resident stated they roll the cigarette paper into a small bit and put the cigarette filter in their pocket until they find a garbage can, The resident stated there were no ash trays or garbage cans outside so they come into the facility where there is a garbage can right inside the door and then they dispose of the filter there. In an interview and observation on 01/16/2025 at 2:29 PM, the black lighter was still present on Resident 78's overbed table. The resident stated they only had half a cigarette left and it is in their cigarette box in their coat pocket (pointing to their coat on the neighboring bed. The resident became irritated and asked, why, is it against the law? In an observation on 01/16/2025 at 2:45 PM, Resident 78 was observed to smoke unsupervised on the sidewalk outside the facility, they were observed to cross a high traffic parking lot to access the sidewalk. Resident 78 was observed to twist the end of cigarette to put it out, and then placed the cigarette butt in their pocket and self-propelled back across the high traffic parking lot into the facility. Review of Resident 78's clinical record showed the facility smoking evaluation dated 01/16/2025 at 4:38 PM was completed by the facility after the IJ was called. The assessment summarized the resident had no visual limitations and they were on medications with the side effect of drowsiness. In an interview on 01/24/2024 at 9:07 AM, Staff A, stated there would be more emphasis on screening new admissions and smoking safety. Reference: WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure staff monitored, assessed, and implemented interventions to prevent the occurrence of avoidable pressure ulcer/pressure injuries (PI) for 1 sampled resident (Resident 1) reviewed for PI. Resident 1 experienced harm when they developed an avoidable Stage 3 pressure PI to their rib area and two avoidable unstageable PI's to their sacrum. This failed practice placed all other residents at risk of the development of a PI. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) PI definition and stages of PI's include: -A PI is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as the result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate (the skin temperature, humidity, and airflow next to the skin's surface), nutrition, perfusion (measures how well the circulatory system is working), co-morbidities, and condition of the soft tissue. Stage 3 PI is a Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) and tunneling (when a wound progresses to form passageways underneath the surface) may occur. Unstageable PI is an obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Resident 1 was admitted to the facility on [DATE], with diagnoses to include type 2 diabetes mellitus (medical condition in which the body doesn't use insulin properly), peripheral vascular disease (PVD - is a slow and progressive circulation disorder), and major depressive disorder. Review of the care plan focus problem, revised on 02/29/2024, showed Resident 1 was at risk for PI development, had admitted with a Stage 3 PI to their sacrum (a large bone at the base of the spine), had an electrical burn to their back, a laceration to the right side of their back and to the back of their head. The interventions included to follow facility policies/protocols for the prevention/treatment of skin breakdown, administer treatments as ordered and monitor for effectiveness, and administer medications as ordered. Staff were to monitor/document any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. Review of the consulting wound care note, dated 04/03/2024, showed Resident 1 was being discharged from the consulting wound care services. The note showed Resident 1's chronic sacrum PI was closed and in the final remodeling phase (the final phase of the wound healing process) of wound healing. Staff were to continue offloading (a way to redistribute pressure) as much as possible with frequent position changes was recommended. Review of Resident 1's April 2024 Treatment Administration Record, showed the following information: -Sacrum wound care one time a day every Monday, Wednesday and Friday, cleanse with wound cleanser, apply skin prep to peri wound and allow to dry and apply bordered dressing, initiated on 03/29/2024 and discontinued on 04/17/2024. -Sacrum wound monitor every dayshift and evening shift for signs and symptoms of infection, initiated on 03/28/2024 and discontinued on 04/17/2024. -Weekly Skin Observation Tool evaluation every Tuesday, completed on 04/02/2024, 04/09/2024 04/16/2024 and 04/23/2024. -Monitor blister wound to the back right side daily, cleanse and leave open to air, monitor for infection on dayshift, evening shift and night shift initiated on 02/28/2024 through night shift on 04/30/2024. Review of the Discharge Minimum Data Set (MDS-an assessment tool) assessment, dated 04/30/2024, showed Resident 1 had no PI's or a non-removable dressing. Review of the hospital's scanned photo, scanned date 04/30/2024, showed Resident 1 had PI's to their right rib area and on their buttocks. Review of the hospital wound care progress note, dated 04/30/2024, showed Resident 1 had the following wounds: - A stage 3 PI measuring 2.5 cm (centimeters) x 1.6 cm x 0.4 cm to the right ribs. - An unstageable PI measuring 0.5 cm x 0.5 cm x 0.3 cm to their left sacrum. - An unstageable PI measuring 0.6 cm x 0.6 cm x 0.4 cm to their right sacrum. In a co-interview on 05/29/2024 at 2:45 PM, Staff A, Registered Nurse (RN)/Director of Nursing Services, and Staff B, RN. Staff B stated Resident 1 was seen by the consulting wound care provider and remember they resolved Resident 1's wounds. Staff B stated the resident's pressure injuries were resolved on 04/23/2024 and if they reopened the staff should have let them know and they should have obtained a treatment order for a wound care. In an interview on 05/30/2024 at 2:43 PM, Staff C, RN/MDS Nurse, stated they looked at the skin evaluation sheets, or the consulting wound clinic care notes when they coded PI on the MDS assessment. Staff C stated they had assigned skin nurses now to verify what was on the skin sheet was accurate. Staff C stated if there were any discrepancy they would talk to the nurses and verify with the skin nurse prior to coding the MDS. Staff C stated if they were in doubt about the documentation they would conduct an observation of the resident's skin. Staff C stated as of 04/10/2024, Resident 1's PI had resolved, but did know they had a skin tear. Staff C stated on 04/29/2024 Resident 1 had no current PI's. In an interview on 06/03/2024 at 2:30 PM, Staff D, Licensed Practical Nurse (LPN), stated the Nursing Assistant Certified (NAC) would inform the nurse if a resident had skin break down. Staff D stated, they would evaluate the resident, obtain a treatment order, and notify the RN. Staff D stated that if you place a checkmark on the skin check as yes, for a new skin issue, the electronic medical records system auto populated a skin evaluation to be completed. Staff D stated the + sign on the skin checks only means the skin check was completed. Staff D stated you would have to look in the evaluations section of the medical records to see the documentation if there was a new skin issue. In an interview on 06/03/2024 at 2:36 PM, Staff E, NAC, stated if they noted changes in a resident's skin they would tell the charge nurse, In an interview on 06/03/2024 at 2:56 PM, Staff F, NAC/ Staffing Coordinator, stated the NACs should let the nurse know if a resident had a new PI. In an interview on 06/18/2024 at 12:19 PM, Staff B stated they had completed Resident 1's skin check to their bottom on 04/12/2024, with another nurse, and the resident had no open areas. Staff B stated they had completed skin check on 04/24/2024, with another nurse, and did not note any skin breakdown for Resident 1 at that time. Staff B stated Resident 1 was sent to the hospital emergency roiagnom on [DATE]. In an interview on 06/18/2024 at 2:45 PM, Staff G, NAC, stated they believed they had provided a shower on 04/26/2024 for Resident 1 and did not see any skin break down during the shower. Staff G stated they did not usually provide direct care for Resident 1. Staff G stated they were aware Resident 1 had skin breakdown in the past but on 04/26/2024 they did not note any skin breakdown. Refer to WAC 388-97-1060(3)(b) F686 repeate in last 15 mon: 06/09/2023 S/S G

Based on observation, interview, and record review, the facility failed to consistently monitor a resident for significant weight loss, notify the physician/responsible party, provide nutritional supplements timely, assistance with meals, and meal alternatives when the meals were consumed at less than 50% for 1 of 6 sampled residents (Resident 39) reviewed for weight loss. The facility failed to recognize Resident 39 experienced harm when they had significant weight loss of 12.3% in 4 months (calculated from their weight on 11/05/2023 to their 03/07/2024 weight). These failures placed all other residents at risk for unrecognized weight loss and decline in their nutritional status. Findings included . Review of the facility policy titled, Weights, revised 06/10/2021, showed the facility used weights as a component to evaluate the resident's nutritional status . Any weight of a 5-pound (lb.) variant the resident must be re-weighed within 24 hours .if there was a significant variance they would document in the resident's medical record, revise the care plan, referral to Nutrition Hydration Skin Committee, and notify the provider and resident/resident's authorized representative. All notifications should be documented in the progress notes of the medical record. Review of the facility policy titled, Nutrition Risk Monitoring and Evaluation Guidelines, updated October 2017, showed residents nutritional risk factors were evaluated by the Interdisciplinary Team (IDT) ongoing .factors to consider were significant weight loss of 5 lbs. or more, repeated diarrhea or constipation . IDT will initiate interventions such as updated care plan, referral to Nutritional Hydration Skin Committee, document in the medical record . the IDT will continue to monitor and evaluate the interventions. Resident 39 admitted to the facility on [DATE] with diagnoses including history of stroke with loss of strength to left side of body, dementia, and depression. The Quarterly Minimum Date Set (MDS - an assessment tool) assessment, dated 02/02/2024, showed the resident had intact cognition, impairment to one side of the upper and lower body, was independent with set up for meals, and was not on a weight loss program. Review of a physician order, dated 11/05/2023, showed Resident 39 was to be weighed on the fifth of every month. Review of Resident 39's medical record, showed the following documented weights: - On 11/05/2023, they weighed 191.4 pounds (lbs.), (admission weight was 189 lbs.), - The resident was not weighed in December 2023, - On 01/21/2024, they weighed 177.2 lbs., a 7.4% or a 14.2 lb. weight loss in 11 weeks. There was no reweigh documented, - On 02/05/2024, they weighed 175.6 lbs., an 8.3% or a 15.8 lb. weight loss in 13 weeks, - On 03/07/2024, they weighed 167.8 lbs., an 12.3% or a 23.6 lb. weight loss in 17 1/2 weeks. Review of Resident 39's care plan showed a focused problem, dated 11/01/2022, showed the resident was at nutritional risk related to their cognition, constipation, mechanically altered diet texture, and no lower teeth. Interventions, dated 11/01/2022, included choking precautions, provide them assistance as needed, diet as ordered, to honor food preferences, to offer a substitute or alternative if the resident ate less than 50% of their meal, and encourage fluid intake. Review of all Resident 39's progress notes on 01/21/2024 showed no documentation for the resident's significant weight loss of 7.4%. The progress notes showed no documentation that the care plan had been updated, a referral made to the Nutritional Hydration Skin Committee, or notification to the provider and the resident/resident's representative were done. Review of Resident 39's Nutrition Note Assessment, dated 02/02/2024, stated the reason for the evaluation was it was a quarterly review. The assessment showed no identification of the resident's 7.4% weight loss in three months. The assessment had a recommendation of four-ounce house supplement (nutritional caloric drink) daily. Review of Resident 39's Nutritional Hydration Skin Committee Assessment, dated 02/07/2024, showed the resident had weight loss. The assessment stated the resident had inconsistent intake of food, refused supplements, was sleeping more during the day, and was self-isolating themselves. The resident required set up and cueing with meals. No nutritional concerns at this time and recommended a four-ounce house supplement daily. Review of Resident 39's physician orders showed the resident was on a no added salt diet with regular texture and soft-and-bite size meats. A four-ounce house supplement was ordered for one time a day for decreased appetite and weight loss, dated 02/16/2024 (14 days from first recommendation from Registered Dietician). Review of all Resident 39's progress notes on 02/05/2024, showed no documentation for the resident's significant weight loss of 8.3%. The progress notes showed no documentation that the care plan had been updated, or notification to the provider and the resident/residents representative. Review of all Resident 39's progress notes, from 11/05/2023 - 03/06/2024, showed no documentation the resident had experienced significant weight loss. In an observation and interview on 03/03/2024 at 3:01 PM, Resident 39 was observed lying in bed on their back, the lunch tray was visible in front of the resident on the over the bed table (lunch trays were served at 1:15 PM). The resident had eaten 25% of the food from the lunch tray. The resident stated they did not like the food served and had not been offered alternative that was to their preferences. In a continuous observation on 03/04/2024 starting at 1:10 PM, Resident 39 was observed in their room lying in bed, a staff member delivered the resident's lunch tray, and left the room. At 1:15 PM, an unidentified staff member entered the resident's room, repositioned resident for their meal, set up their lunch tray on the over bed table, then exited the room. At 1:58 PM, the resident was observed to try and pick up a utensil and attempted to feed themselves. The resident had taken one bite of food and finished half of their glass of milk. The resident's breakfast tray was observed on the resident's recliner. In an observation and interview at 03/04/2024 at 3:45 PM, Resident 39 was observed lying in the bed flat, the over the bed table was positioned across their body, and their lunch tray was still present. The resident had eaten less than 25% of the meal. The resident was asked if staff assisted them with their lunch, they replied no. The breakfast tray was observed sitting in the resident's recliner (breakfast was served at 8:45 AM). In a continuous observation on 03/05/2024 starting at 9:00 AM, Resident 39 was observed lying in bed, and they were leaning to the left side. The resident had the over the bed table in front of them, the breakfast tray was on top of the table and was full of food. The resident was observed to try and feed themselves with their left hand, a bite of food fell into the resident's lap. At 9:55 AM, the resident was lying in the bed leaning to the side. The resident had not taken any more bites, and the bite of food that fell into their lap was still present. At no time was a staff member observed to enter Resident 39's room to offer any assistance. In an observation on 03/05/2024 at 11:35 AM, Resident 39's untouched breakfast tray was observed in front of them while they were lying in the bed asleep. In an interview on 03/05/2024 at 11:48 AM, Staff G, Nursing Assistant Certified (NAC), stated they had worked at the facility for about three months. Staff G was asked if Resident 39 was ever assisted to get out of bed for meals, they replied they had only seen them up once. Staff G was asked what type of assistance the resident received for meals, and they replied they ate their meals independently. In a continuous observation on 03/05/2024 at 1:35 PM, Resident 39 was observed with their lunch tray in front of them while they were in bed. At 2:27 PM, the resident had consumed 25% of their lunch, no staff had entered the room. At 2:30 PM, staff entered the resident's room and removed the lunch tray and did not offer the resident a meal replacement. In an interview on 03/06/2024 at 1:30 PM, Staff N, Registered Dietician (RD), stated the Nutrition Hydration Skin Committee met weekly to discuss residents. Staff N stated if there was a resident who had a significant weight change (gain or a loss) they would address it in the meeting. Staff N stated if there was no weight entered into the medical record, then they would not be able address the resident's weight, they relied on the nursing staff to obtain the weights. Staff N stated they recommended a four-ounce house supplement for Resident 39 on 02/02/2024 and was unaware the recommendation was not initiated until 02/16/2024. Staff N did not provide any further information when asked about the 02/07/2024 Nutrition Hydration Skin meeting, and why the resident did not trigger for the 8.3% weight loss. Review of Resident 39's care plan on 03/07/2024, showed there had been no update to the plan of care to address the resident's significant weight loss. The care plan did not address any interventions, monitoring or further assessments related to the residents significant weight loss. In an interview on 03/07/2024 at 11:35 AM, Staff O, NAC, stated Resident 39's care plan was their guide for direction of care for each resident. Staff O stated if a resident refused care, or their meal, they were to offer alternatives, notify the nurse and document the refusals in the electronic medical record. Staff O stated Resident 39 needed 1:1 assistance with their breakfast today. Staff O stated they were not aware they had weight loss. In an interview on 03/07/2024 at 11:44 AM, Staff P, Licensed Practical Nurse (LPN), stated if a resident had refused care or meals, they would redirect them, notify the provider, and place the resident on alert monitoring (each shift the nurse would need to assess and document to the alert). Staff P was asked if Resident 39 needed assistance with meals, and they stated today they did not think the resident was positioned well in bed and would benefit from getting up for meals. Staff P stated they were not sure whether the resident has had weight loss and asked to review the resident's weights. Staff P then stated Resident 39 has had significant weight loss over the last few months. Staff P stated residents with weight loss should get a referral to the RD, placed on alert monitoring, and notification to the provider and representative. In an interview on 03/08/2024 at 9:29 AM, Staff Q, Registered Nurse (RN)/Resident Care Manager (RCM), stated they monitor for weight loss by the triggers that were alerted in the electronic medical record. Staff Q stated if there was no weight entered then they would not know if there was weight loss. Staff Q stated if there was a resident with weight loss, they would notify the provider, the resident representative, and the RD. Staff Q stated the Nutrition, Hydration, and Skin meeting met weekly to discuss residents with weight loss. Staff Q was asked what type of interventions would be put into place if a resident had weight loss, and they stated they default to the RD recommendations for their interventions. Staff Q was asked who was notified of Resident 39's weight loss in January and February of 2024, Staff Q was not aware and stated they would follow up. Staff Q reviewed the weights for Resident 39 and stated the resident had significant weight loss. In an interview on 03/08/2024 at 9:50 AM, Collateral Contact (CC) 2, a nurse practitioner, stated the facility would usually provide a printout of an abnormal vital signs, such as a weight and they would review. CC2 stated they did not remember whether the facility had provided the documentation to them for Resident 39's weight loss. In an interview on 03/08/2024 at 10:23 AM, Staff B, RN/Director of Nursing Services, stated the process when a resident had weight loss was to notify the provider, the resident representative, and the RD. Staff B was unable to locate any documentation that was completed for Resident 39's significant weight loss. Staff B stated they should have been monitoring Resident 39's weights more often than they were; should have been weekly. Staff B stated the facility had not monitored or placed appropriate interventions in the plan of care to address Resident 39's significant weight loss. Reference: (WAC) 388-97-1060(3)(h)

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 4 sampled residents (Resident 6) reviewed for abuse and/or neglect. The failure to provide incontinence care to a resident who was identified to be incontinent of bowel and bladder and required staff assistance for toileting assistance from the day shift staff (approximately for six hours and 23 minutes) prior to being discharged from the facility. This resulted in psychological harm for Resident 6 in the form of mental anguish and embarrassment, (applying the reasonable person approach), when they experienced urine incontinence on a paratransit bus and when they arrived home and placed other residents at risk for experiencing embarrassment and a diminished quality of life. Findings included . Review of the facility's policy, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated October 2022, included the following: -The definition of neglect described as Failure of the Center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), resulting in physical harm, pain, mental anguish, or emotional distress. - A reasonable person approach is used when there is difficulty in determining psychological outcome/ impact to a resident. Resident 6 admitted to the facility on [DATE] with diagnoses including chronic pulmonary obstructive disease (COPD-chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic kidney disease, and fracture of the left leg. Review of Resident 6's care plan, dated 08/19/2023, showed the resident experienced delirium/acute confusional episode with a noted score of 5/15 on the Brief Interview for Mental Status (BIMS - a structured cognitive interview) that identified the resident was severely cognitively impaired. The care plan showed Resident 6 had occasional incontinent episodes related to cognitive loss. Interventions for incontinence included use of briefs, direction to staff to clean (wash, rinse, dry and change clothing as needed) the resident's peri-area with each incontinence episode and to check Resident 6 frequently. Review of Resident 6 Minimum Data Set (MDS-an assessment tool) assessment, dated 10/09/2023, showed the resident was not cognitively impaired, required maximum assistance from staff with toileting, and was frequently incontinent of their bowel and bladder. Review of a progress note, dated 11/22/2023 at 1:10 PM, showed Resident 6 had discharged home this shift. Review of Resident 6's 11/21/2023 through 11/22/2023 Documentation Survey Report v2 (daily documentation of cares by nursing assistants), showed no documented care by staff provided to Resident 6 on 11/21/2023 night shift and 11/22/2023 day shift. Review of an incident report, dated 11/27/2023, showed the facility was contacted by Resident 6's family and informed when the resident returned home, they were not wearing a brief, and had been incontinent on the paratransit bus. The incident report showed this incident was a very unpleasant experience for Resident 6. The incident report contained interviews and statements from all the Nursing Assistant Certified (NAC's) who worked during the day, none of which provided any direct care to Resident 6 on the day of discharge from the facility. Resident 6 was described as needing one person assistance with toileting, transfers and bed mobility and did not walk without assistance. Review of an undated and timed interview with Staff Z, Nursing Assistant Registered, Staff A, Administrator, documented Staff Z helped prepare the resident for discharge. When Staff Z went to assist Resident 1, they were already dressed and in their w/c. Staff Z assisted the resident with their belongings. The incident report did not show when the resident was last toileted or provided personal care. In an interview on 12/12/2023 at 2:44 PM with Collateral Contact 3 (CC3), Resident 6's family member, stated Resident 6 discharged from the facility back to their residence on the paratransit bus on 11/22/2023 and had been incontinent. CC3 stated the hired a caregiver who gave Resident 6 a shower after they arrived back home. CC3 stated Resident 6's sweatpants were soaked with urine and the amount of urine on the seat and back of the wheelchair (w/c) indicated to them Resident 6 was not wearing a brief. CC3 stated they cleaned the wheelchair of the urine, and it looked like Resident 6 had been without a brief for several hours because of the quantity of urine. CC3 stated due to Resident 6's cognitive status they preferred the resident not be interviewed. In an interview on 12/13/2023 at 9:56 AM Staff O, Licensed Practical Nurse (LPN), stated they recalled Resident 6 and worked the day they discharged (11/22/2023) from the facility. Staff O stated they did not provide any personal care to Resident 6. Staff O stated they were not involved in Resident 6's discharge and the only contact with Resident 6 was to provide them with their morning medications while at the facility. Staff O stated the nursing assistant assigned to Resident 6 would have been responsible for any personal care the resident would have needed. Staff O stated Resident 6 frequently fell and needed to be checked on frequently. In an interview on 12/13/2023 at 3:05 PM Staff P, Nursing Assistant Certified, stated they did not provide any personal care to Resident 6 prior to them discharging from the facility on 11/22/2023. Staff P stated they only knew Resident 6 had discharged because they had taken the meal tray to their room, they were not there, and when they asked another staff member, they were told Resident 6 had discharged . In an interview on 12/14/2023 at 1:26 PM Staff E, Registered Nurse (RN)/Assistant Director of Nursing Services, stated they completed the skin check for Resident 6 prior to them discharging from the facility. Staff E stated they did not provide any cares to Resident 6 and only conducted a skin check. Staff E stated they recalled Resident 6 wearing a brief, which they stated was not soiled, at the time of the skin check which was around 11:00 AM. In an interview on 12/14/2023 at 3:10 PM, CC 4, Paratransit Manager, stated the paratransit bus arrived at the facility at 12:18 PM and left the facility at 12:23 PM after loading Resident 6 onto the bus. Resident 6 arrived at their residence at 1:31 PM. In a joint interview on 12/15/2023 at 1:37 PM Staff A, Administrator, and Staff B, Director of Nursing Services, Staff A stated the process for investigating abuse and/or neglect was to suspend the staff that was involved, interview the staff that worked including the nurse, review the medical records, and interview other residents. When asked who was responsible for interviewing staff and residents, Staff A stated it was a shared responsibility between Staff B, Staff E, and social services. Staff A stated interview questions used were standard questions about care and if residents felt safe at the facility. Staff A directed staff which interview questions were to be used. Staff B stated interview questions were developed as a team and based on the allegation. When asked what information was gathered to rule out abuse and/or neglect involving Resident 6 and the condition in which they arrived at home, Staff A stated they try to get all sides of the story. When asked Staff A and Staff B to review the nursing aide charting for the day of discharge, they both agreed there was no documentation that care was provided to Resident 6 on the day of discharge. Refer to 42 CFR 483.12(b)(1)(4), 483.12(b)(5) F-607 - Develop/implement Abuse/neglect Policies. Reference (WAC) 388-97-0640(1)

Based on interview and record review, the facility failed to provide care and services according to professional nursing standards for 1 of 3 residents (Resident 1) reviewed for unwitnessed falls. The facility failed to identify a possible neurological injury (injury to that effects the head, brain, and spine) when the resident presented with multiple episodes of elevated blood pressures beyond their base line, after an unwitnessed fall where the resident had head trauma. The facility failed to appropriately notify the provider after the resident had an unwitnessed fall that caused head trauma, and failed to notify the provider that there was a delay in treatment of a physician's order to obtain x-rays for the resident after they had three consecutive unwitnessed falls that resulted in head trauma, increased neck pain and a decline in the resident's condition. Resident 1 experienced harm when they were found to have a Type three cervical (C) fracture [(Dens Fracture) an unstable fracture of the second cervical (upper portion) vertebra (spine)]. The resident had significant decline when they were placed in a C-spine collar (hard neck collar that stabilized the spine) indefinitely, they were found to be a poor surgical candidate. The resident was unable to swallow and unable to remove the C-collar, without choking and was deemed unsafe to have anything by mouth by the speech therapist. This failure placed all residents at risk for unmet care needs, and a diminished quality of life. Findings included . Review of the facility polity titled, Fall Evaluation and Management, updated March 2018 stated the licensed nurse will evaluate the residents neurological assessments for 72 hours after a resident has an unwitnessed fall or that involve a resident hitting their head. The nurse will follow up with physician to provide updates. Resident 1 admitted to the facility on [DATE] with diagnoses including fracture of right ribs and thoracic vertebra (middle bones in spine) related to multiple falls, osteoporosis (weak bones), and seizures. The Admission Minimum Date Set (MDS- and assessment tool) assessment, dated 11/22/2023, showed the resident had no behaviors, no rejection of care, and had intact cognition. The resident required substantial to maximum assistance for toileting, bed mobility, and transfers. The Care Area Assessment (CAA) showed the resident was a high risk for falls due to poor mobility, transfers, safety awareness, and their needs to be addressed on the care plan. Review of Resident 1's physician orders for their diet showed on 11/21/2023 it was for soft and bite size. Review of Resident 1's care plan showed a problem, dated 11/15/2023, the resident was at risk for falls related to deconditioning, gait/balance problems and history of falling. Interventions to prevent falls were to anticipate the resident's needs, keep their call light within reach, educate the resident and their family on safety reminders, follow the facility fall protocol, and physical therapy as ordered. The resident's plan of care showed an intervention, dated 11/15/2023, the resident ate in their room with set up assistance. Review of Resident 1's electronic medical record showed they were admitted to room [ROOM NUMBER], was not visible from the nurse's station, or in an area of high traffic for frequent visibility. Review of Resident 1's fall assessment evaluations, completed on 11/16/2023, 11/23/2023, 11/25/2023, 11/27/2023, and 12/04/2023, showed the resident was deemed a high fall risk. Review of the facility fall investigation, dated 11/23/2023 at 9:30 PM, showed Resident 1 was found lying on the floor on their back, was perpendicular to the bed, and their legs were still on the bed. The resident stated to the nurse they fell and hit their head on the ground. The nurse documented they provided a written communication to the provider of the unwitnessed fall where the resident hit their head on the floor. Review of Resident 1's neurological assessment monitoring form, dated 11/23/2023 at 9:30AM - 11/24/2023 at 5:15 AM, directed staff to monitor the resident neurological status that included their vital signs (measurement of the body's basic functions) every 15 minutes for two hours, then every 30 minutes for two hours, then every one hour for four hours, and then every eight hours for the remaining 64 hours after a fall. The form showed 15 of the 16 entries for the resident's blood pressure (BP) was elevated ranging from 162/70 to 179/88 above their baseline. Review of Resident 1's progress notes, dated 11/23/2023 and 11/24/2023, showed the provider was notified of two abnormal B/P readings. There was no documentation the provider was notified of the 15 abnormal readings found on the neurological assessment monitoring form. Review of Resident 1's second facility fall investigation, dated 11/25/2023 at 4:00 AM, showed Resident 1 was found on the floor in the hallway scooting on their bottom. The investigation showed the resident was last checked around 11:15 PM, five hours after they were found on the floor. Review of Resident 1's neurological assessment monitoring form, dated 11/25/2023, showed the resident had two abnormal B/P readings (172/80 and 170/80) above their baseline (ranged from 125/77 to 135/84). The resident refused their B/P to be assessed nine times. Review of the facility fall investigation, dated 11/25/2023 at 6:00 PM, showed Resident 1, the resident's third fall within 48 hours, was found lying on the floor on their right side with their legs under the bed. The resident stated to the nurse they had fallen. Review of Resident 1's progress notes, dated 11/25/2023 at 9:56 PM, showed the resident had sustained an injury from a fall, unknown date and time when the resident had fallen, and a mat had been placed next their bed to prevent further injury. Review of Resident 1's progress notes on 11/25/2023, showed no record of the resident's second unwitnessed fall at 4:00 AM or their third fall at 6:00PM. There was no documentation the provider was notified of the abnormal B/P found on the neurological assessment monitoring form. Review of a written communication form to the provider, dated 11/25/2023 at 9:30 PM, showed a written notification that Resident 1 had an unwitnessed fall on 11/25/2023 at 6:00 PM. The provider reviewed the communication form regarding the second fall two days later 11/27/2023. Review of Resident 1's nursing progress note, dated 11/26/2023 at 2:28 AM, showed the nurse documented the resident had been restless and confused. Review of Resident 1's nursing progress note, dated 11/26/2023 at 10:46 AM, showed the nurse documented the resident had been restless, new facial bruising, and their neck was tilted forward and pointed down. Review of Resident 1's progress note, dated 11/26/2023 at 4:49 PM, showed the nurse documented they called the on-call provider due to the resident's multiple falls, new facial bruising, and neck pain. The progress note stated the on-call provider ordered a head and neck x-ray to rule out any fractures. The nurse documented the in-house x-ray service was unable to provide that type of x-ray service. The nurse documented they would notify the Resident Care Manager (RCM) in the morning, the provider was not notified there would be a delay in the x-ray order. Review of Resident 1's nursing progress note, dated 11/27/2023 at 4:33 PM, showed the resident was sent to an outside x-ray provider, 23 hours since the x-ray was ordered by the provider. The outside x-ray provider noted they had difficulty obtaining good x-rays due to the resident had dizziness, recommended the resident be sent to the hospital, and would send results of the x-rays they were able to obtain. The note stated the provider was notified on a written communication form. Review of Resident 1's progress note, dated 11/27/2023 at 7:48 PM, showed the nurse documented the outside x-ray provider sent over results of the visit earlier at 4:33 PM. The x-ray showed the resident had a new fracture of the cervical vertebra. The resident was sent to the hospital. Review of Resident 1's 11/23/2023 - 11/27/2023 Medication Administration Record, showed the resident had orders, dated 11/16/2023 and discontinued on 11/24/2023, for oxycodone (a narcotic pain medication) 2.5 milligrams (mg) as needed (PRN) every four hours for a pain rating of four to six, and 5 mg PRN every four hours for a pain rating of seven to ten. On 11/24/2023, the order was changed to oxycodone 2.5 mg PRN for pain twice daily. On 11/25/2023, an order for Buprenorphine (a controlled substance pain medication to help relive severe ongoing pain) transdermal patch 20 micrograms/hour and to change the patch every Saturday. Review of Resident 1's pain monitoring dated 11/23/2023 - 11/27/2023, showed the resident had increased pain on a 0 - 10 pain scale (0 - 10 where 0 means no pain, and 10 would be extreme pain). The resident reported pain on the following days prior to being sent to the hospital: - On 11/23/2023 at 9:25 AM and 7:21 PM, pain score was a 7, oxycodone 5 mg was administered. - On 11/24/2023 at 7:04 AM, pain score was a 5, oxycodone 5 mg was administered. - On 11/26/2023 at 8:01 PM, their pain was a 9, oxycodone 2.5 mg administered, and the medication was ineffective. - On 11/27 at 12:07 AM, their pain was a 10, oxycodone 2.5 mg administered, the outcome of the medication was marked U (unknown). Review of Resident 1's medical record, dated 12/04/2023, showed the resident had readmitted to the facility following a hospital stay. The resident had new diagnoses including the type three C2 fracture, and new fractures to the 7 - 9th, and 12th ribs, and dysphagia (swallowing disorder). Review of Resident 1's hospital discharge summary, dated 12/04/2023, showed the resident would need to be on a puree diet, aspiration (choking) precautions, required one-to-one assistance with eating, and Speech Therapy (ST). Review of Resident 1's ST evaluation, dated 12/05/2023, showed a decreased tolerance to complete the meal, lack of ability to chew the food, and a significant delay in their swallow. Review of Resident 1's ST progress note, dated 12/07/2023, showed the ST had recommended the resident not have anything by mouth due to safety concerns. Review of Resident 1's December 2023 nutritional meal monitors showed the resident consumed less than 25% of the meal for 12/04/2023, 12/05/2023, and 12/06/2023. The documentation then showed that the resident had nothing by mouth from 12/07/2023 - 12/09/2023. Review of Resident 1's progress note dated 12/09/2023 at 12:06, stated that the resident was transferred to an end-of-life care center. In an interview on 12/12/2023 at 2:14 PM, Staff I, Registered Nurse (RN), stated they were on duty when Resident 1 had their first fall on 11/23/2023. Staff I they could not recall the events, had started neurological checks, but it was at the end of their shift. Staff I stated the resident was very restless all the time. Staff I stated if a resident had a B/P that was out of their baseline, they would use clinical judgement if they needed to notify the provider. Staff I did not remember why they did not notify the provider about the abnormal B/P readings. In an interview on 12/14/2023 at 10:43 AM, Staff J, Licensed Practical Nurse (LPN), stated if a resident had an unwitnessed fall and possibly hit their head, they would call the on-call provider or speak to one if they were in the building. Staff J stated if a resident had an elevated abnormal B/P, they would recheck the resident's B/P, and if still high call the on-call provider or see if one was in the building to assess the resident. In an interview on 12/14/2023 at 1:43 PM, Staff K, LPN, stated if a resident had an elevated abnormal B/P, they would recheck the B/P, and if still high call the on-call provider or see if one was in the building to assess the resident. Staff K stated they worked with Resident 1 on 11/26/2023 after they had their falls, and the resident was confused and restless. Staff K stated the resident had new facial bruising all over their face and was behaving different, something was just off. Staff K stated they called the on-call provider and got orders for x-rays. Staff K stated they had to wait to get x-rays in the morning as in-house x-ray technician stated they were unable to perform that type of x-ray. Staff K stated since the order was not STAT (complete immediately) they placed in RCM box for morning. In an interview on 12/14/2023 at 2:18 PM, Staff L, LPN, stated if a resident had an unwitnessed fall, they would only call the on-call provider if there were injuries. Staff L stated the incident should be documented in the progress notes and the resident would be placed on alert monitoring. Staff L stated they were on duty for Resident 1's second fall on 11/25/2023 at 4:00 AM. Staff L stated they were unaware the resident had abnormal elevated B/P's. Anonymous staff 1 (AS1), date and time omitted to protect their anonymity, stated Resident 1 had a fall, was confused, hit their head, but was never sent out to the hospital to be evaluated. AS1 stated the resident continued to fall over the weekend, and it appeared they had broken their neck by the resident's appearance but was not sent to the hospital till days later. AS1 stated over the weekend they were not aware if anyone ever notified the on-call doctor of all the unwitnessed falls, change in condition or increased pain for Resident 1. In an interview on 12/15/2023 at 12:53 PM, Collateral Contact 1 (CC1), Nurse Practitioner, stated the facility would document on a communication form and place the form in a binder if there were non-urgent concerns the nurse would like addressed for a resident. CC1 stated on urgent matters should be directed to the on-call pager system if the provider was not already in the facility. CC1 stated Resident 1 was a high fall risk who admitted with multiple fractures prior to the falls at the facility. CC1 stated the resident was always leaning forward, however after the falls they were way worse, they could not support their head at all. CC1 stated they were unaware the resident had abnormal elevated B/P's following the unwitnessed fall where they had possible head trauma. CC1 stated their expectation would be the facility either called the on-call provider or they had sent the resident to the hospital for further evaluation. CC1 stated knowing all Resident 1's information, their expectation for the facility would have been to send Resident 1 to the hospital for further evaluation because they could not obtain an x-ray, they had change in condition, new bruising, and increased pain. CC1 stated the fact that they could not support their head at all they should have sent them sooner. In an interview on 12/15/2023 at 1:20 PM, CC2, Director of Rehabilitation/ST, stated the C-spine collar Resident 1 had to wear indefinitely had an impact on the resident's swallowing and their ability to eat. CC2 stated the collar could not be removed due to the type three C2 fracture the resident had suffered from the falls. CC2 stated the resident was unable to swallow safely, been in a lot of pain, and had lost a lot of weight. CC2 stated the resident was choking on their own saliva they recommended nothing by mouth and nursing should have a conversation with the family about end of life if the resident did not want artificial nutrition. In an interview on 12/20/2023 at 12:13 PM, Staff D, LPN/RCM, stated the expectation for the facility and the nurses was if a resident had an unwitnessed fall and stated they hit their head, the on-call provider would be called. Staff D stated their expectation for elevated abnormal B/P's, was the nurses contacted the on-call provider versus report abnormal B/P's in a book for the provider to review. Staff D stated the provider did not usually look at the neurological assessment monitor unless the nurse reported to them the assessments were abnormal. Staff D stated if a resident had an unwitnessed fall, hit their head, and had elevated abnormal B/P's that could indicate a head injury and they would expect the nurse to call the on-call provider immediately and more than likely send the resident to the hospital for further evaluation. Staff D stated Resident 1 should have been sent to the hospital after the first fall due to the history of their fractures, they had hit their head, and the elevated B/P's could indicate a head injury. Staff D was not sure why that was not done. Staff D stated Resident 1 should have been sent to the hospital on 11/26/2023 when they were unable to get the x-ray. Staff D stated the provider should have been advised of the delay in the order to get the x-ray, as they would have told the facility to send the resident to the hospital. In a phone interview on 12/20/2023 at 2:32 PM, Staff M, LPN/weekend RCM, stated they were working the weekend of 11/25/2023 and 11/26/2023. Staff M stated they were on the medication cart, so they were unable to work as an RCM. Staff M stated they were not assigned to care for Resident 1, however overheard what was going on with their change in condition, increased pain, and they could not hold their head up. Staff M stated they were not sure if the provider was notified that the order to get an x-ray would be delayed. Staff M stated the resident was a huge clinical concern for the nurses that weekend due to their increased restlessness and poor body mechanics. In a joint interview on 12/21/2023 at 10:04 AM, Staff A, Administrator, and Staff B, Director of Nursing Services, Staff B stated residents who admit as a high fall risk, their expectation would be there were interventions implemented to prevent falls, such as placing the resident in a room close to the nurse's station, or in a room that was on a highly visible hallway. Staff B stated if a resident had a change in condition their expectation would be the on-call provider would be notified, the communication form was used for non-urgent issues, the nurse would conduct a thorough assessment, document in the progress notes and place them on alert monitoring for 72 hours. Staff B stated in the clinical meeting they would address any falls that had occurred and ensure the resident's care plan was updated accordingly. Staff B stated after Resident 1 had an unwitnessed fall on 11/23/2023, the staff were to follow the fall protocol, which was to start a neurological assessment monitor. Staff A and Staff B were asked if the neurological assessment monitors were reviewed in the clinical meeting, Staff A stated no, Staff B stated the nurse should be monitoring that. Reviewed Resident 1's fall on 11/23/2023 with Staff A and Staff B, staff B stated staff should have notified the on-call provider on the phone when the resident had fallen and hit their head, as well as when the resident had so many abnormal and elevated B/P's. Reviewed the residents fall on 11/25/2023 at 6:00 PM with Staff A and Staff B, Staff B stated the provider should have been notified the x-ray was unable to be completed. Staff B was not sure why there was a delay in care to Resident 1. Staff A and Staff B confirmed the resident had a significant decline in their condition after the three unwitnessed falls, was placed on end-of-life care and then passed away. Staff A and Staff B were asked to provide policies and procedures for a change in a resident's condition, notification to a provider, and their abnormal vital signs procedure. Staff A stated they did not have policies or procedures for those concerns. Refer to WAC 388-97-1620(1)(2)(b)(i)(ii)

Based on observation, interview, and record review, the facility failed to ensure safety and mobility interventions were provided as directed in the care plan for 2 of 3 residents (Resident 1 and 2) reviewed for falls. This failure caused harm to Resident 1, who experienced a fall when assisted with a one-person transfer that resulted in a fracture, Resident 2 at risk for injury when a fall occurred during ambulation with a nursing assistant, and placed residents at risk for a fall with potential injury. Findings included . <RESIDENT 1> Resident 1 admitted to the facility 12/22/2022 with diagnoses which included heart failure, diabetes, and cognitive impairment. Review of Resident 1's care plan, revised 02/17/2023, showed they were at risk for falls and required extensive assistance of two staff for transfers. Review of progress note, dated 08/22/2023, showed Resident 1 was being transferred in their room by Staff C, Certified Nursing Assistant (CNA), and the resident was not moving their feet, then the resident stated, I'm falling. Staff C lowered the resident to the ground. There was a small abrasion noted to their right knee. Review of a progress noted, dated 08/23/2023, showed Resident 1 complained of right ankle pain. An x-ray was obtained that showed two non-displaced (when the bone cracks or breaks but retains its proper alignment) fractures to the right ankle. Review of the medical record showed, dated 08/25/2023, showed Resident 1 had an orthopedic (a bone specialist) consultation and a cast was placed on the resident's right lower leg and an order that the resident was non-weight bearing to this extremity. In an observation on 09/19/2023 at 1:15 PM, Resident 1 was in their room sitting in their wheelchair (w/c) with their casted right leg elevated on the w/c footrest. The resident was noted to yell out help several times but could not state a need when asked. The resident was not able to provide information about the fall and did not respond to any other questions. Staff C was no longer employed at the facility. Review of a written statement, dated 08/25/2023, by staff C stated they were aware that Resident 1 was care planned for two-person assistance and it was wrong not to have another employee help with transfer. Review of the facility investigation, dated 08/25/2023, showed the root cause of the fall was related to the CNA not following the care plan for transfers and the facility had conducted an in-service education for nursing assistants. <RESIDENT 2> Resident 2 admitted to the facility 09/01/2023 with diagnoses with included diabetes and foot ulcers. Review of Resident 2's care plan, dated 09/01/2023, showed the resident was at risk for falls and required two-person assistance with transfers and walking. Review of Resident 2's record showed on 09/10/2023, Staff D, CNA, attempted to assist the resident to walk to the bathroom and the resident fell . The resident suffered skin tears to their arm. Review of the facility incident investigation, dated 09/10/2023, showed staff D stated they had received report that Resident 2 required one person assistance had not reviewed the resident's care plan. In an interview and observation on 09/19/2023 at 1:00 PM, Resident 2 stated they usually used the bedside commode but this time they were walking to the bathroom instead, stating they were not sure why. They had bandages noted on both feet and they stated this made it hard for them to walk and their feet hurt when they put weight on them. Resident 2 stated they remember there was one aid helping them and then someone else came in after they fell . The resident stated they got a gash on their arm from their bracelet. Resident 2's forearm was observed to have a healing scabbed area. In an interview on 09/19/2023 at 12:45 PM, Staff G, CNA, stated they get report verbally, aid (CNA) to aid and nurses also give them report. Staff G stated they knew what the resident's needs were by looking at the Individualized Service Plan (ISP - a care plan for CNAs) and showed a handheld tablet used to access documentation and for charting. Staff G stated the ISP was in place almost immediately for new admits and updated right away for changes. It always included the resident's mobility and fall information. Staff G stated if a resident was a two person assist, they never had an issue trying to find anyone to help, stating the nurses would always help if the other aids were busy. In an interview on 09/19/2023 at 2:00 PM, Staff B, Director of Nursing Services, stated the staff received report verbally at their change of shift. Nurses and CNA's gave report to each other. The staff were also expected to review their residents' care plans. For CNAs the care plan was known as the ISP which included all resident's mobility interventions, any restrictions and fall prevention. Staff B stated Resident 1 and Resident 2 had clear mobility interventions on their ISP, which was available for staff to review at any computer station, as well as handheld tablets the CNAs carry. Staff C and Staff D had not followed either resident's care plan. In an interview on 09/19/2023 at 2:30 PM, Staff A, Administrator, stated the facility had put a plan to provide education for all the nursing staff related to accessing and following the care plan after Resident 1's fall. This included an additional copy of the care plan (ISP) being placed inside the residents' closets. When reviewing Resident 2's subsequent fall, it was discovered Staff D had not received the education and they had done a new audit to ensure no other staff had missed the education. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to prevent the occurrence of an avoidable pressure ulcer/pressure injury (PU/PI) of an avoidable Pressure Ulcer/Pressure Injury (PU/PI) for 1 of 5 residents (Resident 383) who was admitted without a PU/PI and had multiple co-morbidities with an increased risk for PU/PI development. The facility failed to adjust and implement new interventions to Resident 383's plan of care when a PU was identified on the resident's right buttock on 03/20/2023, and to timely refer the resident to a specific wound care company. These failed practices caused harm to Resident 383 who developed an avoidable Stage III (defined as full thickness loss of tissue) to their right buttock and paced the resident at risk for deterioration of their wound, and a diminished quality of life. Findings included . Review of the Minimum Data Set (MDS), an assessment tool, 3.0 Resident Assessment Instrument manual, showed a PU defined as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, because of intense and/or prolonged pressure or pressure in combination with shear. The PU/PI can present as intact skin or an open ulcer and may be painful. A stage III PU was defined as full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle was not exposed. Slough (non-viable [dead] tissue) may be present but does not obscure the depth of tissue loss. Review of the facility policy titled, Skin Integrity, updated October 2022, stated that if a resident developed a PU, care was provided to treat, heal and prevent further PU development. Staff were to conduct a full evaluation that included a comprehensive review of the resident's medical record to identify interventions, implement the interventions to the care plan, assess the interventions implemented for effectiveness, notify the Registered Dietician (RD), notify the Director of Nursing Services (DNS), and the resident's provider (medical doctor). Resident 383 was admitted to the facility on [DATE] with diagnoses including fracture of spine affecting the neck and lower back, resulting in quadriplegia (paralyzed both arms and legs). Review of the Quarterly MDS Assessment, dated 06/02/2023, showed Resident 383 had severe cognitive impairment, required extensive assistance with two staff members for bed mobility and personal hygiene. The resident was incontinent (no voluntary control) of their bowels. Review of Resident 383's care plan, dated 03/09/2023, showed a baseline plan of care that included interventions for skin at risk and instructed staff to use a pressure reducing air mattress and reposition routinely. Resident 383's had a focused care plan, dated 03/09/2023, for potential PU development that instructed staff to administer medications and treatments as ordered, educate on skin breakdown, follow facility policies, inform resident and family of any new skin areas, monitor, document, report as needed for any changes in skin, and weekly treatment documentation. There were no updates to the care plan related to Resident 383's active Stage III PU to their right buttock which had developed on 03/20/2023. Review of Resident 383's weekly skin evaluation, dated 03/20/2023, showed the resident had a new skin impairment to their right buttock fold that measured 1.5 centimeters (cm) in length by 0.5 cm in width. Review of Resident 383's progress note, dated 03/20/2023, showed the resident developed a new open area to their right buttock. Review of Resident 383's progress notes from 03/20/2023 (after the open area was identified) through 04/03/2023, showed no documentation that the resident's wound had been assessed, or an evaluation to see whether new interventions were needed. Review of a physician order, dated 03/20/2023, directed staff to apply Optifoam (an adhesive type of dressing) every day to Resident 383's wound for skin protection. Review of a physician note for Resident 383, dated 04/07/2023, stated the wound had been classified as a PU by the provider, the provider documented the wound had not been visualized. Review of Resident 383's weekly skin evaluation, dated 04/25/2023, showed the wound was classified as a PU that had increased to 4.5 cm in length by 3 cm in width by 0.2 cm in depth and the PU had worsened. Review of Resident 383's physician note, dated 04/26/2023, showed that nursing staff had reported the resident's PU to their right buttock had dead tissue in the wound bed that was yellow and black. The treatment order for the resident's PU was updated to use Santyl (topical medication that would remove dead tissue from a wound). Review of Resident 383's nursing progress note, dated 05/06/2023, showed the resident was on alert charting due to the buttock wound had worsened, there was an unpleasant odor, had purulent (sign of infection) drainage, and dead tissue. Review of a physician order, dated 05/06/2023, directed staff Resident 383's PU be referred to a specified wound care company. Review of Resident 383's weekly skin evaluation, completed on 05/09/2023, showed the PU measured 7.5 cm in length by 3.8 cm in width by 0.2 cm in depth that had worsened, and the wound bed was covered with black and yellow tissue (there was no documentation identifying the stage of the PU). Review of Resident 383's skin evaluation, dated 05/30/2023, showed the facility identified the PU located on the resident's right buttock was a stage three PU. In an observation and interview on 06/07/2023 at 9:35 AM, Staff T, Licensed Practical Nurse (LPN), provided wound treatment to Resident 383's PU to their right buttock. The wound bed was observed to be 50% red and 50% yellowish brown. Staff T stated the wound bed was 50% slough (dead skin). Staff T was asked to describe the wound edges, they stated the top of the wound showed signs of tunneling (opening underneath the surface of the skin). In an interview on 06/08/2023 at 1:01 PM, Staff H, Registered Nurse (RN)/Resident Care Manager (RCM), stated the staff were to notify the nurse immediately if a resident had a new skin issue. The nurse was to then assess the resident, measure the wound, implement an intervention, and notify the provider and family/representative. In a joint interview on 06/09/2023 at 11:18 AM, with Staff I, Assistant DNS (ADNS) and Staff A, DNS, Staff I stated they were measuring Resident 383's wound weekly, and the resident had not been seen by wound care provider (even though this was ordered by the resident's provider on 05/06/2023). Staff I stated the facility was repositioning the resident, but the wound just continued to get worse. Staff I stated that Resident 383's PU had been assessed by the facility provider twice since the PU developed on 03/20/2023. Staff A agreed with the information provided by Staff I. In a joint interview on 06/09/2023 at 1:35 PM, with Staff A and Staff B, Divisional Director of Clinical Operations, Staff A stated they were unaware there had been a lack of assessment, monitoring, and effective interventions put into place for Resident 383's PU. Staff B agreed there was a lack of wound care oversight in the facility. When asked about the order dated 05/06/2023 to refer Resident 383 to the specified wound care company, Staff B stated the facility currently did not use the that wound care company, but was going to get the wound care company back into the facility. Reference: (WAC) 388-97-1060(3)(b)

Based on observation, interview, and record review, the facility failed to monitor residents for significant weight loss, notify physician/responsible parties, and to implement preventative measures for 3 of 3 residents (Resident 16, 86, and 89) reviewed for significant weight loss. These failures caused harm to Resident 16 who had a 10.8% significant weight loss in 43 days (calculated from baseline weight on 04/16/2023 weight to 05/28/2023 weight), Resident 86 who had a 10% significant weight loss in two weeks, and Resident 89 had a 11. 6% significant weight loss in one month and placed other residents at risk for additional unrecognized weight loss and for declines in their nutritional status. Findings included . Review of the facility policy titled, Weights, revised 06/10/2023, showed: -A significant weight loss includes loss greater than 5% in 30 days. -Any weight with a five-pound (lb.) variance is re-weighed within 24 hours, and the weight obtained after the re-weigh will be recorded in the resident's permanent record. -If a significant variance is actual after a re-weigh, the nurse documents in the medical record, revises the care plan, refers to Nutritional Hydration Skin Committee and notifies the physician and resident/resident's representative. The notifications are recorded in the nursing progress notes of the medical record. <RESIDENT 16> Resident 16 admitted to the facility on [DATE] with diagnoses including dementia, and bipolar disorder. According to the Admission Minimum Data Set (MDS) assessment (an assessment tool), dated 04/16/2023, showed the resident had severe impaired cognition and required supervision with one staff member for eating. Resident 16 was not-interviewable. Review of Residents 16's electronic medical record (EMR), showed the following documented weights: - 04/16/2023 157.0 pounds (lbs.). There was no evidence the resident was weighed between their admission on 04/09/2023 and the first weight documented in the medical record on 04/16/2023 (this weight was used as the resident's baseline weight). - 04/30/2023 147.5 lbs, a six percent significant weight loss from their baseline. - 05/02/2023 142.4 lbs, a 9.3% significant weight loss from their baseline. - 05/28/2023 139.9 lbs, a 10.8% significant weight loss from their baseline. Review of Resident 16's facility EMR evaluation titled, Nutritional Hydration Skin Committee Review Form, locked on 05/04/2023, showed Resident 16 was referred to the progressive self-feeding program (PSFP, a specialized program where a small group of residents, under supervision from staff, work toward relearning to feed themselves) as the resident was staring at their food unless they were cued to eat. Review of Resident 16's restorative program, dated 05/02/2023, showed the resident was to attend PSFP to assist the resident to eat at least 75% of their lunch for three to six day a week. Review of Resident 16's documentation for PSFP, initiated on 05/03/2023, showed the resident was assisted in PSFP only eight out of 29 days in May and there was no documentation for June 2023. Review of Resident 16's facility EMR evaluation titled, Nutritional Hydration Skin Committee Review Form, locked on 06/01/2023, showed Resident 16 continued to have weight loss, the facility would offer a calorie dense supplement and for the resident to eat at the nurse's station. Review of Resident 16's progress notes, dated 04/06/2023 to 06/05/2023, showed there was no notification to the registered dietician (RD) or to the provider regarding the resident's significant weight loss. The progress notes had no documentation the resident had been monitored or interventions were initiated for their weight loss. Review of Resident 16's care plan showed a focus for nutrition, hydration, and cognitive issues. The care plan did not reflect any updates after the resident's documented weight loss on 04/30/2023 and 05/28/2023. There was no documentation that directed staff to have the resident eat their meals at the nurse's station to promote weight gain. In an interview on 06/05/2023 at 1:52 PM, Collateral Contact 1 (CC1), Resident 16's Power of Attorney, stated that they were concerned about Resident 16's weight loss, and they had brought this to the facility's attention during a recent care conference. Staff O, Social Service Director, stated that the weight loss was of concern. Observations on 06/05/2023 - 06/09/2023, showed that of the ten opportunities for the resident to be observed at the nurse's station for meals, they were observed at the nurse's station for only one meal. In an interview on 06/08/2023 at 9:29 AM, Staff E, agency Nursing Assistant Certified (NAC), stated Resident 16 ate in their room and required set up assistance with their meals. Staff E was unaware the resident should be eating their meals at the nurse station, or that the resident required cueing for assistance with their meals due to weight loss. Staff E stated they were only given a list of residents that they were required to weigh that shift. Staff E stated they were unaware of the resident's previous weights. In an interview on 06/08/2023 at 11:56 AM, Staff F, Restorative Assistant (RA), stated they were instructed by management the PSFP program would be completed by the NACs on the floor during the communicable disease outbreak. Staff F stated when Resident 16 did attend PSFP they would eat almost a 100% of their meal. In an interview on 06/08/2023 at 1:01 PM, Staff H, Registered Nurse (RN) /Resident Care Manager (RCM), stated they had just moved into the RCM role one week ago and were limited on their knowledge of what was required of an RCM. Staff H stated they were aware that Resident 16 would eat well when they were at the nurse's station and were unaware of their weight loss. Staff H stated they provided a list of weights required for the shift to the NACs. If a resident were to have significant weight loss, they were to place the resident on alert charting to be monitored every shift and notify their provider. In an interview on 06/09/2023 at 11:24 AM, Staff I, Assistant Director of Nursing Services (ADNS) and Staff A, Director of Nursing Services (DNS); Staff I stated when a resident had significant weight loss the expectation would be the resident was reweighed, the provider was notified right away, the family and resident were notified right away, the resident was placed on alert monitoring (charting) every shift, and the RD was notified right away. Staff A stated they agreed with that statement and when there were any gaps in resident weights there would be corrective action and we would follow our policies. Staff A stated it was up to the RCMs to monitor those weights weekly. Staff A agreed there had been no documentation in Resident 16's medical record that the provider, family, or the RD was notified, and there was no documentation that Resident 16 had been monitored every shift for their weight loss per facility policy. 33954 <RESIDENT 86> The resident admitted to the facility on [DATE] with diagnoses to include a skin abscess (a collection of pus that had built up within the tissue of the body), anemia (a blood disorder), diabetes (a chronic health condition that affected how the body turns food into energy), and constipation. According to the admission MDS assessment, dated 05/30/2023, the resident needed supervision with eating and had no cognitive impairment. The resident's weight in the hospital prior to admission to the nursing home was 169 lbs. Review of Resident 86's weight history showed: - On 05/23/2023: 167.2 lbs. - On 05/26/2023: 167.8 lbs. - On 05/30/2023: 152.0 lbs (9% significant weight loss from admission on 05/23/2023). - On 06/01/2023: 153.8 lbs. - On 06/06/2023: 150.6 lbs (10% significant weight loss from admission on 05/23/2023). Review of Resident 86's progress notes for 05/03/2023 and 05/31/2023, showed there was no documentation of the resident's significant weight loss identified on 05/30/2023, or that the physician had been notified. Review of Resident 86's progress notes for 06/01/2023 through 06/06/2023, showed there was no documentation the facility was aware of and monitoring the resident for their significant weight loss. In an interview on 06/07/2023 at 2:59 PM, Staff U, RN/RCM, was unable to state whether Resident 86's physician or the RD had been notified of the resident's significant weight loss, or whether the resident had been placed on alert charting for their significant weight loss. Staff U stated they thought the previous weights in the 160s were erroneous. Review of a facsimile (fax), dated 06/08/2023, showed the physician was faxed on 06/08/2023 to notify them of Resident 86's significant weight loss from admit. The physician ordered a lab test, a liberalized diet, and to encourage oral fluids. <RESIDENT 89> Resident 89 admitted to the facility 03/30/2023 with diagnoses to include Parkinson's (a brain disorder that cased unintended or uncontrollable movements) disease, dementia, and shoulder and hip fractures. According to the admission MDS assessment, dated 04/04/2023, the resident had severe cognitive impairment and needed supervision with eating. The resident was not-interviewable. Review of Resident 89's weight history showed: -03/30/2023: 185 lbs. -04/06/2023: 182.4 lbs. -04/06/2023: 180 lbs. -04/13/2023: 178 lbs. -04/20/2023: 178 lbs. -05/12/2023: 157.4 lbs (this was a significant weight loss of 11.6% in one month). -05/18/2023: 155.7 lbs. -05/25/2023: 152.4 lbs. -06/02/2023: 155.6 lbs. -06/08/2023: 160.2 lbs (this was a significant weight loss of 13.4% in ten weeks). Review of Resident 89's treatment administration records for April and May 2023 showed an order for weekly weights, dated 04/06/2023, and there were no documented weekly weights between 04/20/2023 and 05/12/2023 when the resident was found to have a significant weight loss of 11.6%. Review of a physician assistant's progress note, dated 05/14/2023, showed Resident 89 was seen for a significant weight loss indicating a total loss of 10%, or almost 30 lbs. compared to admission. The note indicated Resident 89 should be reweighed as the weight appeared to be slowly decreasing but was stable up until 04/13/2023 when their weight was 178.0 lbs. If the resident's weight was determined to be accurate, a RD evaluation should be done and evaluated for dietary deficits initiated. Review of Resident 89's weight history and the progress notes showed the resident had not been re-weighed until 05/18/2023, four days after the physician assistant requested it to be done. Review of physician assistant's progress note, dated 05/17/2023, showed Resident 86's documented weight in the progress note was still the weight from 05/12/2023 of 157.4 lbs. There was no documentation of a re-weigh that had been requested in the 05/14/2023 progress note. Review of a physician assistant's progress note, dated 05/20/2023, showed Resident 89 weighed 155.7 lbs on 05/18/2023, an additional two lbs. of weight loss, and indicated the resident should have a RD evaluation. Review of Resident 89's clinical record showed the dietitian did not evaluate the resident's weight loss until 06/08/2023, and when they did, they recommended nutrition enhanced meals related to the resident's dementia and potential to lose weight. In an interview on 06/09/2023 at 11:26 AM, Staff H was unable to provide any information about Resident 89's significant weight loss, or why their weights weren't monitored weekly as ordered. Reference: (WAC) 388-97-1060(3)(h)

Based on interview and record review the facility failed to ensure one of one residents (Resident 1) reviewed for supervision, who was experiencing changes in behavior and was found sitting on the floor at 1:00 am, received timely assessment, identification, treatment and monitoring for a hematoma (a pool of broken blood vessels that were damaged from trauma) for a potential latent head injury. This failure caused harm to the resident when there was a delay in potential treatment and services for the resident who then experienced a significant change in condition after they suffered a head injury. Findings include . Review of the facility policy titled, Neurological Evaluation, updated September 2014, stated that any resident that was suspected to have had an unwitnessed fall and/or injured their head would have neurological evaluations initiated and continued for 72 hours and the resident would be placed on alert charting .If any evaluation is not within the normal limits notify the physician immediately as this is an emergency situation, the nurse will begin to prepare the resident for transfer to the hospital for further assessment. Resident 1 admitted to the facility on [DATE] with diagnoses including dementia and a history of falls. The Admission Minimum Date Set (MDS) assessment, dated 02/20/2023, showed the resident had severe impaired cognition. Review of the resident's medical record showed on 02/26/2023 that the resident was walking in their room with supervision assistance of one care giver, they were continent of bowel and bladder, able to eat their meals independently with set up assistance and had no swallowing issues. Review of the facility's state reporting log showed that on 02/27/2023 at 11:45 AM, Resident 1 had a bruise to the forehead that was documented as a substantial bruise of deep color, and depth. The reporting log showed on 02/27/2023 at 1:00 AM (10 hours and 45 minutes prior), Resident 1 had a fall with substantial injury. Review of the facility incident report dated 02/27/2023 at 1:00 AM showed that Resident 1 could not recall how they had got on to the floor. Review of the facility incident report, dated 02/27/2023 at 11:45 AM, showed there was no history of an injury or event that could have caused the bruise. Review of a progress note dated 02/27/2023 at 11:58 AM, Staff D, Licensed Practical Nurse (LPN), documented Resident 1 had a round bruise to their forehead. Staff D documented they were unable to locate any information in the medical record of any injury or fall. Review of a progress note, dated 02/27/2023 at 1:13 PM Staff D, documented Resident 1 had been confused, had made unusual statements to the nurse such as were getting on a boat, that the resident had slept most of the shift, and only eaten 15% of their breakfast and no lunch. Review of a progress note, dated 02/28/2023 at 2:41 PM, showed Staff E, LPN, documented they had previously worked with Resident 1 five days ago. Staff E stated in the note that five days ago the resident had been alert, able to take their medications, hold a conversation with the staff, walk with the assistance of their walker, and had no skin concerns. The nurse documented the resident had a bump to the forehead, and the resident's right eye was black, and they were unable to determine how the injuries had occurred. Staff E documented the resident was having difficulty with swallowing, and unable to drink or use a straw. Staff E documented they were concerned about sudden decline in the resident's condition. Review of a progress note, dated 02/28/2023 at 3:23 PM, showed Resident 1 had been placed on comfort care due to further decline of the resident's condition (38 hours and 20 minutes after the resident was located on the floor). The resident was no longer taking any medications and had not been able to eat any food. Review of the resident's medical record showed on 03/01/2023 the resident was totally dependent for all activities of daily living by the staff, they were not able to swallow, eat or walk. Review of the progress note, dated 03/01/2023 at 7:10 PM, showed Resident 1 had passed away and at 8:00 PM the body was released to the funeral home. In a phone interview on 03/06/2023 at 10:31 AM with Collateral Contact (CC) 1, family member, and CC 2, family member, CC 1 stated when they went to see Resident 1 on 02/27/2023 the resident had a bump on their forehead, it was purple, and the resident had a black eye. CC 1 stated they asked the staff at the facility what had happened, no one was able to tell them. The next day the bruising had increased, and the resident had two black eyes. In a phone interview on 03/06/2023 at 12:41 PM, CC 3, stated on Sunday 02/26/2023, they had visited the resident; the resident had no injuries when they left that evening. CC 3 stated on the morning of 02/27/2023 another family member had been at the facility and contacted them to inform them the resident had a large bump on the forehead and bruising to their face. CC 3 stated after the injury the resident declined, they stopped taking their medication, they were sleeping a lot and well we just wanted the resident to be comfortable and they declined so much afterwards we did not want to send them back to the hospital, she passed away two days later. In a phone interview on 03/09/2023 at 2:32 PM, Staff D stated they observed a bump on the resident's forehead, the bump had a dark purple bruise around it. Staff D stated they reviewed the medical record, asked other staff, and the family if they were aware how the resident obtained the injury to their head, there was no record of any injury. Staff D stated the next day the resident was not able to walk or talk to the staff, the bump and the bruising on the resident's face had increased and the resident had two black eyes. Staff D stated they found out in the afternoon on 02/28/2023 (over 24 hours after the incident) that the resident had been found on the floor on 02/27/2023 at 1:00 AM. In an interview on 03/14/2023 at 10:52 AM, Staff B Director of Nursing Services (DNS) confirmed the facility had not monitored the resident's neurological function after the resident was found on the floor or after the bruise was discovered on the resident's forehead on 02/27/2023. Staff B confirmed there was no documentation that the resident received any treatment or care after they were found on the floor on 02/27/2023 at 1:00 AM. In a phone interview on 03/20/2023 at 12:59 PM, Staff C LPN, stated while conducting rounds they had found Resident 1 sitting on the floor next to their bed on 02/27/2023 at 1:00 AM. Staff C was asked if they assessed the resident for injuries, and Staff C stated, I looked at their arms and legs, and well they were talking to me, so I assumed they were ok. Staff C stated they did not conduct a neurological exam on the resident, complete an assessment of the resident for injury, and did not place the resident on alert monitoring for any latent injuries. Review of Resident 1's medical record on 03/20/2023, showed there was no documentation on 02/27/2023 that the resident had been found on the floor, had been assessed for any injuries, that the resident's neurological function was assessed and monitored, nor that the resident might require monitoring to assess for latent injuries or harm. There was no documentation on 02/27/2023 or 02/28/2023 that showed the resident had received any treatment/care for the unknown head injury. There was no documentation that the resident received any treatment or care for increased confusion, drowsiness, or the decreased nutritional intake on 02/27/2023 or 02/28/2023. In an interview on 03/21/2023 at 2:41 PM, CC 4, County Medical Examiner, stated Resident 1 had large hematoma on their forehead and dark circles of pooled blood around the eyes. Through an autopsy CC 4 stated the resident had a subgaleal (space on the head below the skin and above the skull) hematoma. In an interview on 03/22/2023 at 11:09 AM, Staff A, Administrator was not able to offer any further information as to why Resident 1 did not receive immediate treatment and services when they were found on the floor, or after the latent injury to the head was observed. Staff A confirmed the facility had not followed their policy. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to provide prompt and timely emergency care and services for 1 of 1 resident (Resident 1) who seized for an hour prior to the facility activating the Emergency Medical Services (EMS). This failed practice caused the resident undue harm from seizing for an hour and placed other residents at increased risk of lack of timely and prompt emergent care and services. Findings included . Review of the POLST dated [DATE], showed the resident's elected level of medical intervention was Do Not Attempt Resuscitation (DNAR/DNR) with Selective Treatment - Primary goal was to treat medical conditions while avoiding invasive measures whenever possible and transfer to hospital if indicated. Resident 1 was admitted to the facility on [DATE] with diagnoses to include hypoxic ischemic encephalopathy (brain injury from decrease of oxygen or blood flow) and anxiety disorder. Review of the resident's medical record on [DATE] showed Resident 1 had no history of seizures. In a phone interview on [DATE] at 2:02 PM, Staff D, Nursing Assistance Certified (NAC), stated that they had walked into the resident's room, and Resident 1 was having tremors, responding a little, and sweaty, and they notified the nurse on duty. Staff D stated that the nurse had said they would go check on the resident when they had a minute as they were passing medications. Staff D stated that they later noticed that the therapist was in the resident's room. Staff D stated that they stayed near the resident's room checking in on them and then they had to take a resident for a shower. Staff D stated that the next time they saw the resident, EMS was in the resident's room. Staff D stated that the nurse did not come as quickly as they thought they would and was surprised it did not seem as urgent to the nurse even though they had tried to express urgency. Staff D stated that it was pretty much the nurse and themselves on the hallway that day. In an interview on [DATE] at 12:34 PM, Staff H, Physical Therapist, stated that they had walked by the resident's room and noted that Resident 1 was in distress. Staff H stated that they had told the resident's nurse, Staff A, that Resident 1 was in bad shape. Staff H stated that the resident's seizure was more like a Grand Mal Seizure, they were grinding their teeth, having the type of shakes like a Grand Mal Seizure. Staff H stated that you could tell from the hallway that the resident was having a seizure. Review of a progress note dated [DATE], documented by Staff A, LPN showed that at approximately 9:00 AM, the NAC and Therapist called the nurse as the resident was diaphoretic (excessive sweating) and seizing in bed. The resident's vital signs were the following: temperature was 100.5 Fahrenheit, a blood pressure was unable to be obtained, a pulse was 96 beats per minute, and respirations were labored and uneven at 20 breaths per minute. The resident's oxygen saturation was 96 percent on room air. The resident's medications were administered as well as flushed via PEG tube (a tube inserted through the wall of the abdomen directly into the stomach). The Resident Care Manager (RCM) was called and came to assess. The resident's DNR with comfort care orders was in place. Unable to contact family to see if they wished to send the resident to the Emergency Department (ED) since there was no history of seizures in the resident's chart. The note indicated that they were unable to contact the provider initially, then contacted the Health Provider Clinic and received orders from the on-call physician to send the resident to the ED for further assessment. At approximately 10:10 AM, EMS arrived in the building. Assessment of the resident was still having repeat seizure activity. FSBS (finger stick blood sugar) was obtained with a [high] blood glucose of 333 mg/dl (milligrams per deciliter) at that time. EMS administered an IM (intramuscular) injection, which immediately calmed the symptom of seizure. Review of a progress note dated [DATE], documented by Staff B, LPN/RCM, showed that they had been called to the first floor to evaluate the resident in seizure activity. The resident was red, diaphoretic and was having moderate seizure activity. The resident was noted to be a DNR with limited interventions. In a phone interview on [DATE] at 8:43 AM, the Collateral Contact (CC) 2, County EMS Staff, stated that the EMS log showed that the facility called EMS on [DATE] at 10:07 AM, and EMS was dispatched to the facility at 10:08 AM. Review of the EMS Report dated [DATE] showed the EMS arrived at the scene at 10:16 AM. The EMS Assessment Summary showed that the resident was unresponsive, the resident's skin was hot, temperature was 98.5 Fahrenheit, heart rate was rapid at 124 beats per minute, respirations were labored at 30 breaths per minute. The EMS Narrative showed that the nurse reported that a tech had made rounds about an hour ago and found the resident having a seizure and the resident had been seizing since. The report noted that the estimated time of the seizure prior to EMS activation was one hour. The report continued that the resident had no history of seizures. The EMS report noted that the resident's seizure activity reduced quickly and ceased after an IM medication (Versed 4 milligram, an anticonvulsant to stop the seizure) was administered. In a phone interview on [DATE] at 10:30 AM, CC1, Family Member, stated that they noted that they had missed a call at 12:46 PM Eastern Time (9:46 AM Pacific Time) and called the facility back at 1:36 PM Eastern Time (10:36 AM Pacific Time) and was told that Resident 1 was on their way to the hospital. CC1 stated that the resident was a DNR, but Resident 1 had a seizure that took 45 minutes for the facility to contact the doctor as the main doctor was not working that day and they had to wait to get a doctor. CC1 stated that they asked the facility staff what they would do if a dog was seizing for an hour. CC1 stated that they had spoken with Staff F, RN, who had double checked the resident's DNR and had said that they did not know why EMS was not called, and the resident was allowed to seize for an hour due to their DNR status. CC1 stated they were told that the resident's seizure was considered a Grand Mal Seizure (causes a loss of consciousness and violent muscle contractions) due to the length of time of the seizure. In a phone interview on [DATE] at 11:33 AM, CC3, Family Member, stated that the day before the resident had the seizure, the resident seemed fine, responsive, and communicating. CC3 stated that they received a call from the facility that Resident 1 was on their way to the hospital. CC3 stated that they were told that it had been an hour before the facility called EMS and it had something to do with the resident's DNR. CC3 stated that before the resident and family had elected a DNR, they were ensured that it was only if the resident's heart stopped that CPR (Cardiopulmonary Resuscitation) would not be provided. CC3 stated that Staff A had told them that they had sat with Resident 1 while they seized for an hour. CC3 stated that the facility had call them once and they missed the call. CC3 stated that when they returned the call the facility said that they could not call EMS until they had spoken to a family member and then they retracted that statement, but it was more like they omitted it. CC3 stated that when they arrived at the hospital, Resident 1 was unresponsive and looking to the left. CC3 stated that they hoped that the facility would be more prompt and would immediately call for help for a resident having a seizure ASAP (As Soon As Possible). In a phone interview on [DATE] at 11:57 AM, CC4, Family Member, stated that the facility should have policies and procedures. CC4 stated that they were unaware that Resident 1 had a prior history of seizures but had been told that with a brain injury the resident could have a seizure. CC4 stated that the seizure Resident 1 had was very long, an hour and a quarter long seizure, which was a drastic seizure. CC4 stated that was not the norm and the facility should have called 911. CC4 stated that whoever was on duty that day watched Resident 1 for an hour and 15 minutes seize, which distressed the resident's body. In an interview on [DATE] at 4:26 PM, Staff A, stated that the therapy staff had let them know that something was going on with the resident. Staff A stated that when they had gone into the resident's room the resident was saturated with sweat. Staff A stated that the resident had these diaphoretic episodes and jerking as well sometimes when they were upset, they would get rigid. Staff A stated that it was undeniable that day that Resident 1 was having a seizure. Staff A stated that they were unable to get a blood pressure as the resident was having rhythmic jerking. Staff A stated that they had called down the hall and therapy staff sat with the resident as they pulled up the resident's chart. Staff A stated that they called upstairs as they did not have a case manager that day. Staff A stated that it was probably ,d+[DATE] minutes that Staff B was trying to get through to the physician and family before the Health Care Provider Center said to send the resident into the ED. Staff A stated that the EMS arrived relatively quickly and gave the resident an injection of something that stopped the seizure completely. Staff A stated that the resident had comfort measures in place as Staff A knew that because Resident 1 had an order for morphine (a narcotic pain medication). Staff A stated that they did not know the resident's code status. Staff A stated that there was usually a plan in place on the resident's POLST and there may be another medical directive. Staff A stated that Staff B had decided that they needed to contact the family as the resident's directive was unclear and the family had not answered their call. In an interview on [DATE] at 1:58 PM, Staff B, stated that they recalled that Staff A had called and reported to them that Resident 1 was having clonic-tonic seizure activity (also known as grand mal seizures) and the staff was having difficulty obtaining the resident's vital signs. Staff B stated that they got the resident's POLST form and attempted to contact the resident's family. Staff B stated that the resident was a DNR with limited interventions, which could be many things but that they would want to go to the hospital. Staff B stated that they were unable to contact the family, that they were on hold for 10 minutes with the Health Provider Clinic and started printing out information to send the resident to the hospital. Staff B stated that the Health Clinic ordered the resident to go to the hospital. Staff B stated that they called 911, completed the paperwork and the paramedics came in approximately 20 minutes from the time they had called EMS. In an interview on [DATE] at 12:53 PM, Staff G, Registered Nurse (RN), stated that basically if a resident chose Selective Treatment on the POLST (Portable Orders for Life-Sustaining Treatment) and they were having a newly onset seizure they would assess the resident and would call 911. In an interview on [DATE] at 4:45 PM, Staff C, Advanced Registered Nurse Practitioner, stated that if a resident had a new onset seizure their expectations were for the nursing staff to call for medication or call 911 and send the resident out. In an interview on [DATE] at 4:07 PM, the Director of Nursing Services (DNS), stated that the facility did not have a policy or procedure for activating emergency response services. The DNS stated that when a resident had a DNR with limited services they wanted the staff to call the resident's family. The DNS stated that the staff had to wait five to ten minutes and at 9:30 AM, they got the orders to send the resident out. The DNS stated that the nursing staff performed their assessment, they were unable to get a blood pressure, but the resident's oxygen saturations were good. The DNS reiterated that the nursing staff had called the Health Care Clinic and was waiting on hold to get the order to send the resident out. The DNS stated that by the time 911 was called and the transfer paperwork was completed from start to finish was around 45 minutes. The DNS stated that it was probably uncomfortable to have a seizure, but the resident went to the hospital. Reference: (WAC) [DATE] (1)

Based on observation, interview, and record review the facility failed to prevent abuse/mistreatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure caused harm to Resident 2 who voiced complaints of emotional distress from endured abuse/mistreatment from a Nursing Assistant Certified (NAC). The facility staff failed to protect residents from a staff member with an identified pattern of allegations, which allowed potential abuse to continue. The failure of facility staff to protect residents from a staff member with a pattern of alleged mistreatment and abuse, willful disregard of safety, left all residents vulnerable to continued abuse. The failed practice placed all residents at risk for abuse and placed them at risk for physical injury, fear, mental anguish, intimidation, and feelings of victimization. Findings included . Review of the facility policy titled, Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, neglect, Misappropriation of Resident Property, and Exploitation, dated September 2017, showed that each resident had the right to be free from abuse, including verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion, mistreatment, neglect. The center implements policies and processes so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members, and others who may have unsupervised access to residents. The facility policy stated neglect was the failure of the Center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Mistreatment was defined as inappropriate treatment or exploitation of a resident. Review of the facility's Pride and Abuse training, dated March 2020, showed; - Safety is a fundamental basic need that must be met. A resident should never feel unsafe; - Abuse allegations must include interviewing and recording statements from the alleged abuser, witnesses, other residents, employees and family members; - Employees who have multiple allegations are a concern; and - At least two reference checks from employers must not be negative references. RESIDENT 2 Resident 2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident used a wheelchair (w/c) for mobility. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], assessed the resident as cognitively intact and she required extensive assistance for transfers. Review of the resident's care plan revised 03/25/2021, directed staff to perform a two-person extensive assistance low pivot (transfer while squatting) transfer from the bed to the wheelchair (w/c). Review of a handwritten undated statement from Staff M, NAC, showed on Friday, 05/28/2021, the resident in room [ROOM NUMBER] had a red mark on their right wrist. Staff M stated the resident stated they had hit it on the railing on the window. Review of the facility assignment sheet showed Staff D worked as a NAC on 05/30/2021 from 6:00 PM to 8:00 PM and on 05/31/2021 from 6:00 PM to 9:00 PM. Review of Staff D's time sheets showed he did work on Sunday 05/30/2021 from 5:01 AM until 8:09 PM and worked as a NAC from 5:38 AM to 8:58 PM as a NAC. Staff D worked on 06/01/2021 from 5:33 AM to 10:14 AM as a NAC. A facility investigation dated 06/01/2021, showed that Staff A, Social Services Director, received a call from Resident 2's daughter stating her mother had reported to her on Sunday morning 05/31/2021 (date was a Monday) that the resident was treated roughly by Staff D, NAC. The resident reported they were being transferred off the toilet, became unsteady and Staff D gripped their wrist tightly and roughly and placed them in their w/c. Review of a skin check showed the resident had a bruise to their right wrist that was brownish/red in color. The resident indicated Staff D had transferred them alone and the resident felt herself slipping. Staff D grabbed the resident's wrist and roughly placed them in a chair. The resident stated they did not say anything at the time because they did not want to get Staff D in trouble. The Director of Nursing Services (DNS) interviewed Resident 2 on 06/02/2021, which showed Staff D transferred them off the toilet alone, the resident started to slip, and Staff D grabbed their wrist tightly and roughly and placed them in their w/c. Included in the facility investigation dated 06/01/2021, showed Resident 17 was asked about Staff D. The resident stated, We get along just fine however he can be a bit rough as he halfway does things. I try not to complain as I know he feels rushed. Resident 35 stated, Staff D had been rough in the past but had gotten softer with time. Review of the May and June 2021 progress notes, revealed no mention of the resident having a red mark, a licensed nurse notification or being assessed for an injury. Review of the clinical record did not show the bruise until 06/01/2021. In the investigation, Staff J, Regional Director of Clinical Services (RDCS), documented Resident 2 had given conflicting stories, and interviews of other residents' concerns about rushed approach were identified and addressed. The wrist bruise was circular measuring 3 centimeter (cm) by 4 cm. The NAC in question was removed from the floor and would undergo additional training. Staff J noted the bruise appeared to be reasonably related to self-inflicted trauma. The investigation did not show staff interviews about any potential concerns with Staff D. The investigation did not address Staff D not providing a two-person transfer for the resident. A progress note written by the Administrator dated 06/02/2021 at 12:44 PM, showed that Staff K, Business Office Manager, received a phone message from Resident 2's friend on 06/01/2021 at 9:30 (did not specify AM or PM). Staff K listened to the message that stated a male was transferring them off the toilet and they both had fallen and the resident had hurt their wrist. There was no mention of the resident's status at that time. Review of Resident 2's progress notes did not include a consistent assessment for psychosocial harm. Beginning 06/01/2021 at 11:16 AM, Staff L, Social Services Assistant, documented they had received a call from the resident's daughter on Sunday morning (05/30/21) that their mother was handled roughly by Staff D. The daughter reported bruising to the resident's right wrist. The resident reported feeling unsteady and the NAC gripped their wrist too tightly and roughly put her in her w/c. Review of the progress notes from 06/01/2021 to 06/03/2021, showed there was no assessment of the resident for physical or psychosocial harm every shift. Review of a progress note dated 06/03/2021, showed the resident's cognitive orientation as alert to self, remembers people's names and events. In an interview and observation on 06/11/2021 at 10:34 AM, Resident 2 stated there was a prior incident with Staff D. The resident stated, (Staff D) told me I was not the professional and not to be a sissy. We both fell . (Staff D) was not kind and was abrupt. I wasn't going to tell anybody, but the nurse told me then he (Staff D) could hurt someone else. Resident 2 showed this surveyor a fading one-inch circular purple bruise to their right anterior wrist. The resident stated, It happened so quick he (Staff D) picked me up and moved me. He (Staff D) was behind me and landed on top of me. I told him we are going to fall, and he (Staff D) said, no we are not. He had no (gait) belt on me and I didn't have my walker. I wanted to transfer using the (Slide) board. He (Staff D) lifted me with his arms from around me (the resident gestured to be a bear hug). He wouldn't let me do the slide board. I told him I need to try and I am getting lessons on it but he wouldn't let me do it. He was by my wheelchair. I told him to lower me, he was behind me, he told me to turn around, and he sat me in the chair hard. Resident 2 than stated Staff D had grabbed her wrist, which resulted in the bruise. The resident stated this was her first transfer interaction with Staff D. We both fell to the floor and he got me right back up and put me into bed. He was forceful to get me into bed again. It was not easy. He did not get a nurse to check me over. I was hurt. My hipbone hurt. Generally, I hurt all over. I was scared. Now I am afraid. I am cautious. I am still afraid. I am fearful when I am working with staff. I even told the staff. I am still scared and fearful. I asked when will I get over it? PT (Physical Therapist) said I will get over it (the fear) but it will take some time. In an interview on 06/21/2021 at 2:09 PM, Staff D said they no longer wanted to work as a NAC. Staff D stated there had been many resident allegations against them because they tried to finish his job fast. Staff D stated, There are not enough CNA's so you rush more. You see the call lights and you rush because you are so short on the floor. Staff D stated he did not work at all on 05/30/2021 but worked with Resident 2 on 05/31/2021, Memorial Day. Staff D said they transferred the resident to the chair from their bed and that was that. Staff D stated they completed the transfer independently because the resident was a one-person assist. Staff D could not explain why the resident's account of the transfer was different. Staff D stated these allegations were just due to their hurrying and lack of staffing. Staff D said, There are just so many call lights going off all the time. Staff D stated they were suspended this time and sent home but the prior allegations they just kept him in an office and investigated quickly then he went back to work. In an interview on 06/22/2021 at 1:52 PM, the Administrator stated they had identified a trend with Staff D and they did an action plan to correct it and they took aggressive measures. The Administrator said they tracked the abuse back from when she got here (10/28/2018) when we started seeing the trend, they took aggressive action. The Administrator stated Staff D currently worked in the kitchen as there was a huge language barrier and he was perceived by the residents as rushed or not communicating. Staff J, RDCS stated, There is a perception with him that we recognized and he was taken off the floor. He needs to slow down. He does not understand what it is that he is doing. I do not think he presents as a safety issue or we would not have kept him. On 06/23/2021 at 9:50 AM a group interview was held with DNS, Administrator and Staff J. Staff J, reported, We came to the conclusion he (Staff D) is safe to work in the kitchen, 40 hours a week. He was just trying to juggle too much. Staff J acknowledged after they interviewed residents that there were two other residents who complained Staff D was rough. Staff J stated she could work with Staff D on approach and communication to make him successful. She stated, Staff D tends to hurry and that can come across as being rough to residents. Staff J stated, Staff D can be hard to follow in multiple occasions. She said when there is a language barrier there is a perception that ESL (English second language) staff are in a hurry. The Administrator acknowledged they had identified a pattern of allegations involving Staff D. They were asked how this most recent allegation could be unsubstantiated as the resident is alert and oriented and her consistent perception and account of the events was Staff D was rough. No additional information was provided. In an interview on 06/23/2021 at 10:55 AM, Resident 2 showed me her right wrist bruise is resolving. A 1 inch by 1-inch red area remained to her right wrist in a location inconsistent with self infliction. She commented, This is where (Staff D) grabbed my wrist. He transferred me so quickly. I said slow down, I want to use the board but he didn't. We fell . I was so scared. I am still bothered about him. I try to get it out of my head as soon as it comes to mind. In an interview on 06/24/2021 at 2:35 PM, Resident 2's friend stated, (Resident 2) told me a male aide let her fall. She said he picked her up and she was unsteady and she said you are going to drop me but he said he could do it and kept going. She told him he needed to get someone else too, another person to help but he didn't. She said they both fell and she said, Get off me, get off me. I don't think it was sexual. He told her not to tell anybody. He said Do not report it. I told her, you have to report this. This is Elder abuse. He cannot tell you this. I am in Canada and they tried to tell me she hit her wrist on the windowsill. She clearly told me, the aide hurt her wrist during the fall. (Resident 2) never said that. I reported to Staff L (Social Services) right after she told me. (Resident 2) forgets what day it is but never forgets anything else. When you are in the hospital or a facility, you can miss dates that is why they write the date in your room on a board. She does not make stories up. Shouldn't he (Staff D) have reported that this happened? In an interview on 06/24/2021 at 2:44 PM, Resident 2's daughter stated, Mom said (Staff D) picked her up and she told him, you need to get another person. I am falling. He told her he knew what he was doing and could handle her by himself. She kept sliding and he fell on top of her hurting her wrist and her back. He grabbed her wrist. He hurt her. Then he said do not tell anyone. Do not report this. It will not be good for you. She was afraid to tell anyone. She took what he said as a threat. She was scared to report it so I did, right after. At her age, a threat is scary. She is still upset. He scared the bejesus out of her. My mom and I have always promised to tell each other if we fall. I called and reported this to Staff L, the care manager but she said she only had five minutes to complete the report. She told me mom got the bruise herself, it was self-inflicted from hitting the windowsill, but she couldn't have flipped her arm upside down and made that bruise. I didn't even get to tell the whole story. I have called there and called there and no one answers the phone or returns calls. No one has followed up with me on this. I can't let her be scared or afraid to talk to anybody. Included in the facility investigation for Resident 2 dated 06/01/2021,were two other residents (17 and 35) with allegations about Staff D. RESIDENT 17 Resident 17 admitted on [DATE]. Review of the Admission MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident 17's incident investigation dated 06/01/2021 showed, Staff D could be a bit rough, took short cuts to get done quickly and instead of using a gait belt Staff D would grab the resident and swing them over onto the chair and it was rough. Review of a second interview (undated and unsigned) showed Resident 17 stated, When it comes to transferring instead of using a gait belt Staff D would grab my buttocks and swing me over onto my chair and it was rough. I would prefer he use a gait belt. The interview stated the resident would prefer Staff D used a gait belt and a less rushed approach. Staff J documented concerns regarding Staff D's rushed approach and transfer technique that was identified and addressed. Unable to substantiate abuse or neglect. Staff D was removed from floor and will undergo additional training. In an interview on 06/10/2021 at 1:30 PM, Resident 17 was asked about the incident with Staff D. Resident 17 stated, Some of the people are a little rough. RESIDENT 35 Resident 35 admitted on [DATE]. Review of a progress note dated 06/20/2021, showed the resident was alert and oriented to person, place, and time with no cognitive impairment. Review of Resident 35's incident investigation dated 06/01/2021 showed, Staff D was rough in the past but had gotten softer with time. Resident 35 stated that Staff D would pull them out of bed in a hurry; they felt they were being jerked around which made them feel uncomfortable. In an interview on 06/11/2021 at 9:17 AM, Resident 35 stated they had one staff member (Staff D) who did not treat them right and made them feel uncomfortable. Resident 35 stated Staff D had been fired because they hurt Resident 2's arm and caused a bruise. In an interview on 06/17/2021 at 2:55 PM, the DNS stated they were doing interviews related to another allegation regarding Staff D. Resident 35 was asked how the care was and asked about Staff D. The resident stated, He is very gotta get it done, gotta get it done. He has to slow down. The DNS reported Resident 35 stated they were agreeable to the plan of the employee (Staff D) no longer caring for them. In an interview on 06/18/2021 at 10:12 AM, Staff D stated they never had any issues when caring for Resident 35, that the resident had complained about being rushed or feeling uncomfortable. Staff D stated they have been re-instructed to slow down. Staff D stated they are working in the kitchen at this time and the plan was to re-evaluate and re-train prior to potentially returning to the floor. Review of the abuse allegation investigations for Resident 2, 17 and 35 showed concerns regarding rushed approach and transfer technique by Staff D. While the facility documented they ruled abuse and neglect were not substantiated, they did not include how the determination was made. A review of Staff D's employee file revealed date of hire was 10/22/2012. Staff D had two reference checks upon hire. A reference check from another Skilled Nursing Facility dated 10/26/2012 showed Staff D would not be re-hired. Staff D received abuse education from the facility on 03/09/2021, 04/23/2021, 05/05/2021 and 06/01/2021. In-service education was provided to Staff D on 05/05/2021 to follow the ISP/Plan of Care and Staff D was instructed to familiarize himself with the plan of care prior to taking care of a resident. Both the facility and Staff D acknowledged Staff D rushed residents with care which can lead to the perception of rough handling. The facility management had knowledge of a history of multiple allegations and residents had perceived Staff D as rough and how this could affect the residents' wellbeing. Review of Staff D's disciplinary action dated 06/04/2021, showed they were suspended pending investigation of abuse on 03/09/2021, 04/23/2021, 05/05/2021 and 06/01/2021. The facility documented, while the above allegations were not able to be substantiated, a trend over a limited 3-month time frame had been identified. As such, a trend had been identified and these corrective actions were intended to implement measures that would reduce the risk of future care issues. Effective 06/04/2021, Staff D was placed on a 90-day probationary period and would be utilized for his primary position as a cook until such time as deemed appropriate by the Executive Director (Administrator). Review of Staff D's undated education lesson, showed performance standards were to demonstrate understanding that slowing down, and a gentle approach reduce the risk for perception of rough handling. Reference: (WAC) 388-97-0640 (1)

Based on observation, interview and record review, the facility failed to provide care and services to prevent pressure ulcers for two of two residents (79 and 8) reviewed for pressure ulcers. The facility failed to implement a turning/repositioning program for a resident with decreased mobility caused harm to Resident 79 who admitted with a stage II pressure ulcer to the sacrum (area at bottom of spine) which deteriorated to a stage III pressure ulcer. Resident 79 did not receive a thorough and ongoing skin assessment that included observing for change in risk factors, pressure points, and evaluating effectiveness of interventions. Facility failure placed other residents at risk for the development of a pressure ulcer. Findings included . The National Pressure Ulcer (also known as a pressure injury) Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages included: - A pressure injury (PI) was a localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurred as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue; - A Stage 2 PI was partial-thickness skin loss with exposed dermis. The wound bed was viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel; and - An unstageable PI was obscured full-thickness skin and tissue loss, full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it was obscured by slough or eschar (non-viable tissue covering the wound bed) (the eschar was dry, adherent, and intact without redness). The NPUAP (2017), Educational and Clinical Resources and PI Prevention Points, advises to inspect the skin at least daily for signs of pressure injury, assess pressure points, reposition all individuals at risk for pressure injury based on support surfaces and individual preference. The Resident Assessment Instrument (RAI) Manual defined the stage of a pressure ulcer (PU) as followed: - A stage II PI (ulcer) was described as a partial thickness loss of the skin; - A stage III PI (ulcer) was described as a full thickness loss of the skin; - An unstageable PI (ulcer) was a full thickness skin and tissue loss was obscured by slough (non-viable tissue) or eschar (dead or devitalized tissue); and - A Deep Tissue Injury (DTI) was described as intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration. RESIDENT 79 Resident 79 readmitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission-readmission nursing evaluation on 02/03/2021 showed a sacrum scar and redness to their left and right buttock and groin. No pressure ulcers (PU's) or open areas were identified on the admit assessment. Review of the Braden Scale for Predicting Pressure Sore Risk (an assessment tool to determine a resident's risk for developing PU's), dated 02/03/2021, revealed the resident was at risk for pressure sores. Review of the Admission Minimum Data Set (MDS) assessment on 02/10/2021 showed the resident was at risk for developing pressure ulcers (PU's)/injuries and he had one or more unhealed pressure ulcers/injuries. The MDS assessment showed the resident had one stage II PU. The resident was not on a turning/repositioning program or nutrition intervention to manage skin problems. The Care Area Assessment (CAA) revealed the resident had no PU's at present with risk factors to include required assist with bed mobility, [CONDITION(S)], and episodes of incontinence. The CAA showed to continue plan of care with preventing the development of pressure ulcers. According to their Quarterly MDS, dated [DATE], they had no cognitive impairment, was frequently incontinent of bladder and always incontinent of bowel. Resident 79 required extensive two-person assist with bed mobility, transfers, dressing, toilet use and personal hygiene, was at risk for developing PU's, and did not have a turning/repositioning program in place. The resident did not reject care. The assessment showed the PU had deteriorated to a Stage III, which was not present on admission. Review of the Braden Scale for Predicting Pressure Sore Risk, dated 05/06/2021, showed the resident was assessed to be high risk for PU's. Review of the Individual Service Plan Report (directives for nursing assistants), print date 06/12/2021, revealed the resident's skin was at risk and he was on a pressure reducing mattress, he required two-person extensive assistance with clothing management, hygiene and transfers required a mechanical lift. Staff were directed to turn/reposition routinely and encourage the resident to position side to side as tolerated. Review of the resident's care plan, print date 06/10/2021, revealed the following: - the resident had an Activities of Daily Living (ADL) problem of self-care performance deficit related to impaired balance; - had a problem of limited physical mobility; - had a potential for alteration in nutrition related to [CONDITION(S)], congestive heart disease and decrease chewing abilities; - had a risk for pain related to [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]; and - had the potential for PU development and an actual stage 3 pressure ulcer (dated 5/6) related to immobility, incontinence and care refusal, and an intervention included to turn/reposition routinely. Staff were to monitor low air loss mattress function every shift beginning 05/10/21. There were no directives to staff on the desired pump settings. Review of the handwritten notes showed stage II healing pressure ulcer left sacrum: - On 02/03/2021, a 1.5 centimeter (cm) X 2 cm X 0.1 cm wound with well-defined edges, the wound bed had fully granulated tissue and there was no pain present; - On 02/10/2021, a 1.2 cm X 1.5 cm X 0.1 cm wound with increase in epithelial tissue and the wound bed had fully granulated tissue, there was no pain present; and - On 02/17/2021, a 1 cm X 1.2 cm X 0.1 cm wound with moisture damage and the wound bed had fully granulated tissue present. Review of the weekly skin evaluation documentation showed assessments on 03/03/2021, 03/10/2021, 03/17/2021 and 03/24/2021 for a left elbow skin tear only. Review of the weekly skin evaluation dated 05/06/2021, a stage III PU was identified, the site (location) was left blank, the wound measured 1.2 centimeter (cm) by 1.5 cm and depth was left blank. The wound had 100% slough and surrounding edges were macerated. Review of the handwritten notes showed stage III pressure ulcer with no location indicated: - On 05/06/2021, a wound measured 1.2 cm x 1.5 cm x 0.1 cm with adherent slough noted in the wound bed, there was no foul odor; - On 05/06/2021, a wound measured a 1.2 cm x 1.5 cm x 1.0 cm with adherent yellow slough in the wound bed, there was no foul odor or drainage; - On 05/13/2021, a wound measured 1.1 cm x 1.5 cm x 0.1 cm with adherent slough in the wound bed, no signs of infection identified; - On 05/14/2021, a wound measured 1.0 cm x 1.3 cm x 0.2 cm with beefy red tissue present in the wound bed; - On 05/21/2021, a wound measured 1.1 cm x 1.4 cm x 0.1 cm, there was no change in wound the bed and the slough appeared to be loosening with no signs of infection present; - On 05/27/21, a wound measured 1.0 cm x 1.2 cm x 0.2 cm with half of the wound bed had adherent slough and the other half of the wound bed had was red; - On 06/04/21, a wound measured 1.0 cm x 1.0 cm x 0.2 cm with a beefy red wound bed; and - On 06/10/21, a wound measured 1 cm x 0.8 cm x 0.2 cm with the wound bed described as red with no signs of infection and no drainage. Review of the February, March, April, May and June 2021 Treatment Administration Record (TAR), showed no documentation regarding the desired settings for the low air loss mattress for optimal pressure relief. Review of the April 2021 and May 2021 Nursing Assistant (NA) documentation showed no documentation the resident refused any repositioning or the adherence or tolerance to position changes. Review of a progress note on 05/19/2021, showed Staff F, Licensed Practical Nurse (LPN), told the resident they could not add a pillow or pad to their wheelchair (w/c) and that they could ask Physical Therapy (PT) to check on the resident's w/c and cushion. Staff F documented the resident stated that the w/c was too short, not comfortable, so they refused to get up. In an observation on 06/09/2021 at 3:44 PM, the resident was lying in bed on their back. In an observation on 06/10/2021 at 8:56 AM, the resident was lying in bed on their back In and observation on 06/10/2021 at 11:02 AM, the resident was lying in bed on their back. In an observation on 06/11/2021 at 2:31 PM, the resident was lying in bed on their back. In observations on 06/14/2021 at 1:46 PM, the resident was lying in bed on their back. In an observation on 06/14/2021 at 3:00 PM, the resident was lying in bed on their back. In observations on 06/15/2021 at 10:09 AM, 11:18 AM, 1:32 PM, and 3:05 PM, the resident was lying in bed on their back. In observations on 06/16/2021 at 09:11 AM, 10:43 AM, 1:41 PM and 2:54 PM, the resident was lying in bed on their back. In observations on 06/17/2021 at 09:33 AM and 10:38 AM, the resident was lying in bed on their back. In an observation/interview on 06/17/2021 at 11:05 PM, during wound care, the resident required extensive assistance for bed mobility by Staff B, Registered Nurse (RN) and Staff C, LPN. Staff C stated the PU had resolved and then came back. The sacral wound did not have a dressing in place when the resident was turned on their side. The wound bed was red. Staff C stated it was a stage II PU and the wound current measurement was a 1.9 cm by 1.0 cm with a depth of 0.3 cm. The skin around the open area was purple and red. There was a 2 cm by 2 cm red area on his right buttock. After the staff provided care to the resident, they were positioned back onto their back. In an observation on 06/17/2021 at 1:41 PM, the resident was lying in bed on their back. In observations on 06/18/2021 at 05:31 AM, 6:59 AM, 8:02 AM, 10:17 AM, and 12:01 PM the resident was lying in bed on their back. In an interview on 06/18/2021 at 6:59 AM, Staff P, LPN, stated she does not see Resident 79's skin a lot on night shift. Staff P stated if they repositioned the resident, the resident would go back onto their back. In an interview on 06/18/2021 at 10:17 AM, the resident was in bed on their back with his head off the mattress and no pillow present. The resident stated they did not get off their back and was unable to turn side to side because of their shoulder pain. The resident stated they needed help from the staff and could not have his hips propped on pillows because of his arthritis. The resident was transferred to the hospital on 06/20/2021, for shortness of breath. Review of the hospital Emergency Medicine physician note dated 06/20/2021, showed the resident admitted with a chronic ulcer on his back with a deep open wound. The resident was noted to have redness over his left scapula and skin breakdown of the buttocks with a deep circular ulcer over the coccyx region. In an interview on 06/22/2021 at 10:14 AM, the Director of Nursing Services (DNS) stated the wound was a stage III and it was getting better every time she looked. The DNS acknowledged the wound had deteriorated from a stage II to III. In an interview on 06/23/2021 at 10:02 AM with the DNS and Staff J, Regional Director of Clinical Services (RDCS) was held. The DNS stated Resident 79 refused care including incontinent care. The DNS stated the resident's care plan did not necessarily reflect care being given. The DNS stated to check the progress notes for nurse's documentation of refusals. Staff J stated the resident admitted with a stage II PU and then it healed and reopened to a stage III PU. Both staff acknowledged the CAA (care area assessment) showed the resident had no PU's identified. Review of the resident's clinical records showed he refused PT and a bed bath on 04/19/2021. On 04/26/2021 and 04/27/2021, he declined to be changed. On 05/19/2021 the resident declined to get into the w/c. There were no care plan interventions to address care refusals. Nursing documentation did not contain evidence of ongoing assessment, implementation of interventions and re-evaluation of interventions consistent with professional standards. The nursing documentation also did not reflect a proactive approach to skin management. The resident readmitted [DATE] with a stage II pressure ulcer. The facility's failure to provide pressure-relieving interventions for Resident 79 resulted in wound deterioration for Resident 79 who was dependent on staff for all care and positioning. RESIDENT 8 Resident 8 admitted on [DATE] with Alzheimer's, diabetes, heart failure and pain. Review of the Quarterly MDS assessment dated [DATE], showed the resident required extensive assistance for transfers and was always incontinent of bowel and bladder. The resident did not reject care. Review of the Braden Scale for Predicting Pressure Sore Risk, dated 04/16/2021, revealed the resident was at risk for pressure sores. Review of their care plan showed they had a baseline care plan problem for skin at risk. Interventions included routine toileting before and after meals and before bedtime per family request beginning 07/05/2019. The care plan stated they were incontinent. They were extensive two person assistance for toileting, repositioning and was to be turned and repositioned routinely with a pressure reducing mattress. Barrier cream was to be applied. In multiple observations, all days of survey. Resident 8 was observed out of bed, in their wheelchair in the hallway. The resident was observed in bed upon request to observe care. In observations on 06/09/2021 at 10:45 AM and 1:01 PM they were observed in their wheelchair in the hall in the same position and location. In observations on 06/10/2021 at 9:33 AM and 10:52 AM they were observed in their wheelchair in the hall in the same position and location. In observations on 06/11/2021 at 9:22 AM and 2:31 PM, they were observed in their wheelchair in the hall in the same position and location. In observations on 06/14/2021 at 1:33 PM and 3:02 PM, they were observed in their wheelchair in the hall in the same position and location. In observations on 06/15/2021 at 8:52 AM, 10:08 AM, 11:17 AM, 1:36 PM, and 2:49 PM they were observed in their wheelchair in the hall in the same position and location. In observations on 06/16/2021 at 9:08 AM, 10:42 AM, 1:48 PM, 2:00 PM, 2:52 PM they were observed in their wheelchair in the hall in the same position and location. In a resident interview on 06/16/2021 at 11:22 AM, Resident 14 stated (Resident 8) stinks all the time. There are bathrooms all over. Why do they not take care of them three to four times a day? They are in the hall all the time. They never put them inside her room. Why do they not lay them down? In an interview on 06/16/2021 at 11:24 AM, Resident #3 commented (Resident 8) is always on the hall and they wondered why they do not lay them down. In observations on 06/17/2021 at 9:00 AM, 9:32 AM, 10:44 AM, 1:47 PM, 2:06 PM, the resident was observed in their wheelchair in the hall in the same position and location. At 2:09 PM, peri care observation was requested. In an interview and observation on 06/17/2021 at 2:56 PM, Staff Q, NAC stated the resident sits in their chair a lot because it is the safest place for them, or they will try to get out of bed. Staff Q said the resident had a red groin they apply cream to.The resident had been incontinent of urine and stool. The resident's buttocks were red/purple. There was blanching (localized reaction to pressing on the skin) around Staff E's glove but a 1.5 cm by 1.5 cm area that did not blanch (indicator of pressure ulcer development) when the Staff E, NAC touched it. There was a red linear open area to their left groin. In subsequent observations on 06/18/2021 at 8:03 AM, 10:16 AM, and 12:00 PM they were observed in their wheelchair in the hall in the same position and location. In observations on 06/21/2021 at 9:00 AM, 9:57 AM, 11:30 AM, 12:40 PM, and 1:57 PM they were observed in their wheelchair in the hall in the same position and location. In observations on 06/22/2021 at 8:40 AM, 9:35 AM, 9:59 AM, 10:57 AM, 12:11 PM, 12:32 PM the resident was restless and 2:53 PM they were observed in their wheelchair in the hall in the same position and location. In an interview on 06/22/2021 at 1:58 PM, Staff S, RN stated when Resident 8 was restless they put them in bed so they could take a nap, or they may need changed. She stated she was unsure of the resident's pressure relief interventions and Resident 8 was not diabetic. In an interview on 06/22/2021 at 3:11 PM, Staff T, hospitality aide stated Resident 8 was total care and was in the hall always until 8:30 at night. She stated the resident's bottom was a little red today. In an interview on 06/22/2021 at 3:55 PM, Staff F, LPN stated Resident 8 was in the hall because the resident crawled out of bed a lot. When asked about their skin condition, she stated the NAC's use barrier cream on the resident. In an observation on 06/23/2021 at 9:51 AM, they were observed in their observed in their wheelchair in the hall in the same position and location as prior hall observations. In a group interview on 06/23/2021 at 10:13 AM, The Administrator, Director of Nursing Services and Staff J, RDCS were informed Resident 8 was observed in their wheelchair in the hall except one observation in bed after a request to observe peri care. Further, two residents voiced concerns about the resident being up in their wheelchair for extended periods. Staff J stated they did reposition Resident 8 frequently. Reference: (WAC) 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to ensure two of two sample residents (20 and 30) reviewed for bladder and bowel functions received appropriate care and services necessary to maintain and avoid loss of bowel and bladder function. This failed practice caused harm to Resident 20 who felt the lack of care was demeaning as they had control of their bowels but had to defecate in an incontinent brief due to not having a toilet seat in which they could use. This failed practice placed the residents at risk of diminished quality of life and risk for skin impairment. Findings included . Review of the facility's policy titled, Bladder and/or Bowel Incontinence, updated September 2017, showed if a bowel and/or bladder toileting/retraining program is indicated, create an individualized toileting program for the resident to assist in keeping the resident optimally continent. Appropriate and individualized Care Plan interventions are implemented when the evaluation was completed. Review of the facility's completed Centers for Medicare & Medicaid Services 672 form dated 06/09/2021, showed the facility identified 53 residents who were occasionally or frequently incontinent of bladder and 51 residents who were occasionally or frequently incontinent of bowel. The facility had identified nine residents on a urinary toileting program and zero residents on a bowel toileting program. RESIDENT 20 Resident 20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Bowel Evaluation report dated 07/24/2020, showed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no apparent pattern of incontinence and would be managed with adult incontinence products. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] showed the resident was cognitively intact, was always continent of urine but frequently incontinent of bowel. The resident was not on a bowel toileting program. Review of the baseline care plan dated 07/24/2020, identified the resident was incontinent. Review of the care plan dated 10/19/2020, showed the resident had bladder incontinence related to activity intolerance, impaired mobility and diabetes. The interventions showed the staff were to check the resident at least every two hours and as needed for incontinence. In an interview on 06/10/2021 at 2:12 PM, the resident stated they would prefer an oblong toilet seat. The resident stated that guys do not like a round toilet seat. The resident stated transferring from the bed to the wheelchair (w/c) was scary when they could not see but transferring from the w/c without an oblong toilet seat and being blind, you hang up your junk. Review of the Visual/Bedside Individual Service Plan (ISP) Report printed on 06/14/2021, showed the staff were to check the resident at least every two hours and as needed for incontinence. Toileting was extensive assistance of two people with a Hoyer lift (a type of mechanical lifting device) to use the bed pan, and maximum assistance/dependent for clothing management and hygiene. Toileting was noted as incontinent. In an observation on 06/16/2021 at 2:06 PM, the resident's bathroom had an over the toilet riser seat with a white round toilet seat. In an interview on 06/18/2021 at 10:55 AM, the resident stated that he had tried to use the toilet in their bathroom, but they kept from going to the toilet because it squished their scrotum. The resident stated because the toilet seat squished his scrotum, they had their bowel movement in their incontinent brief versus using the toilet in the bathroom. In an interview on 06/18/2021 at 11:46 AM, Staff I, Nursing Assistant Certified (NAC)/ Restorative Aide, stated that Resident 20 was continent of urine and they would call with the call light after having a bowel movement in their brief. Staff I stated they were unsure if the resident was continent of bowels, but they know when they have had a bowel movement. In an interview on 06/18/2021 at 12:16 PM, Resident 20 stated that they knew when they were going to have a bowel movement and that they were not incontinent. In an interview on 06/21/2021 at 11:22 PM, Staff O, NAC, stated that Resident 20 knew when they had to have a bowel movement. In an interview on 06/21/2021 at 2:03 PM, Staff C, Licensed Practical Nurse/ Resident Care Manager, stated that most residents were incontinent but would have to check on their facility process for bowel and bladder retraining. Staff C was asked how the facility assessed residents for a potential candidate for a bowel or bladder retraining program. Staff C was not able to state how a resident was assessed to be a potential candidate for a bowel or bladder retraining program. No further information was provided. In an interview on 06/21/2021 at 2:47 PM, the Director of Nursing Services (DNS) stated that Resident 20 had always said they would rather go in their incontinent brief. The DNS stated that the resident did not want to get onto the toilet, they did not want to pinch themselves as the toilet seat was round. The DNS was asked what assessment was completed to determine if a resident was a candidate for bowel retraining and what accommodations were made for the resident to not pinch themselves on the toilet seat. The DNS stated that there was concern with dignity for the resident who had control of their bowels, but what was done as of now was the resident was incontinent of bowel related to the toilet seat. In an interview on 06/22/2021 at 9:22 AM, the resident stated that having their bowel movements in a brief was demeaning. RESIDENT 30 Resident 30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Bladder Evaluation report dated 04/09/2021, showed the resident had CHF ([CONDITION(S)]). The category of incontinence was noted as urge incontinence - involuntary loss of urine associated with strong sensation of urgency, often on the way to the bathroom. The assessment showed the resident was able and willing to follow instructions and the treatment option selected was to manage with adult incontinence products and routine toileting. The facility did not attempt a 3-Day bladder screen, bladder retraining or prompted voiding program although the resident was determined to be able to follow directions. Review of the Admission MDS assessment dated [DATE] showed the resident with moderate cognitive impairment was occasionally incontinent of urine and bowel and was not on a urinary or bowel toileting program. The urinary CAA (Care Area Assessment) dated 04/15/2021, showed urinary incontinence would be addressed in the care plan. The CAA showed the resident had episodes of urinary incontinence and required assistance with toileting. The resident was assisted with toileting as needed and had prompt peri care after each incontinent episode and for the plan of care to continue. Review of the care plan showed the resident had no urinary focus problem. The baseline care plan goal, dated 04/08/2021, showed the resident was continent and would have their toileting needs met. Review of the ISP printed on 06/14/2021, showed the resident was continent. The resident required extensive one person assistance with toileting and maximum assistance with clothing management and hygiene. In an interview on 06/16/2021 at 10:29 AM, Resident 12 (roommate of Resident 30) stated their roommate had to go to the bathroom often and a staff member commented, I can't be in here all night. Resident 12 said he had heard staff tell their roommate to go to the bathroom in their brief instead of taking them to the bathroom. In an interview on 06/18/2021 at 6:48 AM, Staff P, LPN, stated Resident 30 was on the (call light) light quite a bit during the night. Staff P stated they felt they had to urinate and literally goes this much (motioned to 1 inch). Staff P stated they had not heard staff telling the resident to go in their brief but could see them saying it, especially to (Resident 30) because he goes so little on the toilet. In an interview on 06/21/2021 at 2:24 PM, Staff R, NAC, stated Resident 30 goes to the bathroom a lot so they used the urinal. Staff R said the resident urinated often but was just a little bit. Staff R stated they told the nurses about the resident's urinary frequency and he had no toileting program. Staff R stated, The nurses were aware. In an interview on 06/22/2021 at 3:41 PM, Staff F, LPN, stated Resident 30 would try to get in the bathroom independently. Staff F stated the resident used the urinal but would spill at times. Reference WAC: 388-97-1060(3)(c)

Based on observation, interview and record review the facility failed to ensure proper daily oral hygiene and failed to assist the resident with replacement of a missing upper dental partial for the past two years for one of one resident (45) reviewed for dental care. This failed practice caused harm for Resident 45 related to the severe nature of dental disease and the likelihood of eventual loss of all teeth given the lack of proper hygiene. Additionally, the lack of the facility's follow-up on the resident's missing dental partial placed the resident at risk of diminished quality of life. Findings included . Review of the facility's policy on dental/oral care showed a Certified Nursing Assistant's (NAC) Oral Hygiene Competency monitor, with a revised date of July 2014, which directed the steps to provide oral care for a resident. Review of the facility's policy titled, Dental Services - Dentures, dated October 2017, showed the Policy Statement: The Center assists the resident with dental services when loss or damage to dentures occurs. The Center assists residents as necessary or requested upon notification and confirmation of lost or damaged dentures by arranging for transportation to and from dental services location and within three days of notification and confirmation, refers residents with lost or damaged dentures for dental services and documents the referral in the medical record. Resident 45 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], showed the resident had no rejection of care and required extensive assistance with personal hygiene which was how the resident maintained personal hygiene including oral care. Review of the Care Area assessment dated [DATE], showed the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . ADL performance was monitored and documented daily. The plan was to continue to meet the resident's ADL needs. Review of the care planned problem dated 03/08/2018, showed the resident had a self-care performance deficit related to physical limitations related to [CONDITION(S)] and [CONDITION(S)] (weakness or the inability to move on one side of the body, making it hard to perform everyday activities). The intervention for personal hygiene/oral care showed the caregivers were to provide set up, the resident could manage their oral care and the resident had a partial upper plate that was loose. Review of focused care plan problem, initiated on 05/17/2019 and a resolve date of 02/01/2021, showed the resident had a potential for oral and dental health issues due to a poorly fitting upper partial plate. The interventions included to coordinate arrangements for dental care and transportation as needed. Review of the Clinical Functional Abilities Evaluation dated 05/03/2021, showed the resident required set up or clean up assistance with oral hygiene. Review of the MDS assessment dated [DATE], showed no rejection of care and they required extensive assistance with personal hygiene. Review of the dental clinic progress note dated 05/13/2021 (which was not in the facility's resident's medical record and was requested from the dental clinic during survey) showed the resident had caries (decay and crumbling) with rampant decay with caries present in all remaining teeth, oral hygiene was poor/nonexistent. The resident had heavy plaque, light calculus (calcium [MEDICATION(S)] mineral salts deposited between and within remnants of formerly viable microorganisms) with heavy stain detected. The resident's behavior was noted to be cooperative. The resident reported that they rarely were assisted to brush their teeth at the facility. A note was written to the facility to please attempt to help the resident clean their teeth twice daily and to get an automatic toothbrush if possible. Review of the Visual/Bedside Individual Service Plan (a guide for direct caregivers to care for the resident) printed on 06/14/2021, showed the resident was independent with oral/teeth care after set up assistance. Review of the NAC documentation from 01/01/2021 through 06/14/2021, showed personal hygiene level of care varied from independent with set up to one-person total assistance. There was no documented refusals of personal hygiene. In an interview on 06/11/2021 at 10:53 AM, the resident was asked if they had any problems with their teeth or gums. The resident nodded yes and stated that was a, hard subject. The resident continued to state that they went in to see the dentist and after over a year and a half of not seeing the dentist their teeth went from a repairable issue to now only extractions (tooth removal) and dentures. Resident 45 stated that the issue was the staff had not brought the resident their toothbrush and toothpaste. Review of a Progress Note dated 06/11/2021 at 5:59 PM, 30 days after the resident had seen the dentist, showed the resident's family was notified that the dentist had recommended the resident use an electric toothbrush. In a follow up interview on 06/15/2021 at 8:51 AM, Resident 45 stated that it had been two months since they had been set up to brush their teeth. The resident stated that they brushed their teeth when they were showered which was twice a week. The resident stated that no nurses looked into their mouth or at their teeth. The resident was observed to have missing front teeth and lower back teeth. In an interview on 06/16/2021 at 9:42 AM, Staff N, NAC, stated that the ISP (Individual Service Plan) was in the computer and showed the level of care the residents need. Staff N stated that personal hygiene included brushing the residents' teeth. Staff N stated that Resident 45 does their own personal care. In an interview on 06/16/2021 at 10:43 AM, Staff O, NAC, stated that Resident 45 does not do well with oral care and the resident does not seem to care. Staff O stated that they ask the resident if they want to do oral care, but they do not make them do what they do not want to do. In an interview on 06/18/2021 at 12:12 PM, the resident stated that they had been without their upper partial plate for the last two years. The resident stated that their partial was sent for realignment. The resident stated that there had never been follow up to get the upper partial plate back and the nursing staff had not offered to help with obtaining the partial. Review of a Progress Note dated 6/21/2021 at 10:18 AM, showed that a dental clinic was called regarding the resident's upper partial plate that was dropped off in 2019. The dental clinic returned the call and said impressions were done in 2019 for the partial to have new clasps placed on partial plate. Review of a Progress Note dated 6/21/2021 at 10:43 AM, showed that the dental clinic had called and reported that the resident's partial plate was found. An appointment was scheduled for 06/29/2021 to pick up the partial plate. In an interview on 06/21/2021 at 2:00 PM, Staff C, Licensed Practical Nurse/Resident Care Manager, stated that a different dental clinic had found the resident's partial plate, and the resident had an appointment scheduled for the following week. In an observation and follow up interview on 06/22/2021 at 11:01 AM, Resident 45 stated that the staff rarely encouraged them to brush their teeth. The resident was observed to have missing upper teeth and a black discolored tooth on their middle lower row. The resident stated that they noted it was discolored and out of alignment. Reference: (WAC) 388-97-1060(2)(c), (3)(j)(vii)

Based on observation, interview and record review, the facility failed to ensure 9 of 27 residents (29, 50, 52, 58, 59, 64, 73, 87, and 89) reviewed received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. These failures resulted in harm for Resident 64 and Resident 52. Resident 64 did not receive adequate care and services for scrotal [MEDICAL CONDITION] and Resident 52 did not receive bowel medications when required. All other residents are at increased risk of unmet care needs. Findings included: RESIDENT 64 Resident 64 was admitted to the facility in (MONTH) of (YEAR) with [DIAGNOSES REDACTED]. In an interview on 01/31/18 at 10:45 AM, the resident stated, The nurses here did not think I needed to go to the hospital but when I went to the wound clinic for my foot, I told them about my scrotum. The doctor took one look and called 911. I went to the ER and was in the hospital for four days. Review of the medical record revealed an order dated 09/17/17 showed an order for [REDACTED]. Review of the resident's daily weights for the month of (MONTH) (YEAR) showed the resident had a five pound weight gain from 09/21/17 to 09/22/17 with no documented indication the ARNP was notified. Review of a progress note dated 09/23/17 revealed the Resident has a moderately swollen scrotum . Resident complains of some mild pain to touch . The progress note dated 09/24/17 revealed, Res (resident) on alert for scrotal [MEDICAL CONDITION], Res noted to be quite swollen this AM . Review of the ARNP progress note dated 09/25/17, revealed the resident was evaluated per nursing request due to noted increased global [MEDICAL CONDITION]. A progress note dated 09/25/17 at 12:49 PM, showed the resident was experiencing increased global [MEDICAL CONDITION]. His lung sounds has crackles throughout. The [MEDICATION NAME] (respiratory medication) was minimally effective. The ARNP was in and assessed the resident. Ordered chest x-ray related to increased [MEDICAL CONDITION] and crackles. An intermuscular antibiotic was ordered with a [DIAGNOSES REDACTED]. A progress note at 5:23 PM showed the chest x-ray results had no evidence of pneumonia, pneumothorax or pleural effusion with mild [MEDICAL CONDITIONS]/[MEDICAL CONDITION]. The resident continued to complain of discomfort and being swollen up. The progress note dated 09/26/17 at 5:08 PM showed the Resident scrotum is swollen and firm but better than yesterday per resident. He has global [MEDICAL CONDITION] in face, hands, legs, and feet at this time. A progress note dated 09/27/17 at 1:30 PM revealed, He had pain in his scrotum and back. [MEDICATION NAME] long action and short acting with little effect . Scrotum is swollen twice it's size, tender to touch with peeling skin. Review of the progress notes revealed the facility had not notified the resident's physician or ARNP of the resident's increased scrotal discomfort or swelling. Review of the facility's copy of the wound clinic visit note on 09/27/17 showed the resident was at the clinic for a follow up on a prior wound to the resident's foot. The resident appeared acutely uncomfortable. The resident requested to be transported to the hospital. Further review of the full wound clinic note dated 09/27/17 obtained from the wound clinic revealed, the clinic had received a call from a nurse at Evergreen North Cascade prior to seeing the resident in the clinic as the resident was complaining there that he needed to go to the ER. He came to us complaining of excruciating lower back pain, unable to keep still in the chair while his (foot) wound was assessed. He had a temperature of 100.4 degrees, which is normally around 97 degrees. A call was placed to 911. Review of the hospital history and physical dated 09/27/17 showed the resident presented to the hospital after being seen in the wound care center with severe scrotal [DIAGNOSES REDACTED]/[MEDICAL CONDITION] (redness/swelling) and ongoing pain. He reported the pain had been escalating but particularly bad in the last few days. The resident was noted to have markedly swollen testicles to the size of a grapefruit, easily 10 cm (centimeters) in diameter, [DIAGNOSES REDACTED]tous, firm and tender. The resident was diagnosed with [REDACTED]. Review of the hospital discharge summary dated 10/02/17 showed the resident had surgery on the day of admission. The resident was noted to have a scrotal abscess with severe bilateral scrotal wall [MEDICAL CONDITION] and [MEDICAL CONDITION], which was infected with Staphylococcus and Group G Streptococcus (both bacterias). Further review of the resident's medical record revealed [REDACTED]. In an interview on 02/07/18 at 1:46 PM, Staff R, Resident Care Manager (RCM), Licensed Practical Nurse (LPN) reviewed the resident's medical record and confirmed that the physician nor the ARNP had not been notified of the resident's five pound weight gain on 9/22/18 or the increase in scrotal swelling on 09/27/17. On 02/08/17 at 3:08 PM, Staff L, Assistant Director of Nursing (ADON) presented a packet of progress notes to the survey team and stated the ARNP was willing to discuss concerns regarding the potential harm from the resident's scrotal issues. In an interview on 02/09/18 at 11:03 AM, Staff P, Registered Nurse (RN) stated she only worked down stairs occasionally. She probably worked a double on the day of 09/26/17 and had not worked with the resident the previous day. Staff P did not recall if the resident asked to go to the hospital. In an interview on 02/12/18 at 12:54 PM, the ARNP stated, I believe there were some orders to elevate the resident's scrotum but honestly, it has been so long ago I do not remember. The ARNP stated, Oh yeah, yes, when asked if the resident's treatment would have been different if staff had notified her of his weight increase. She later clarified that this was a generalized statement regarding care of any patient in the same situation and that she was aware of the patients weight. Resident 64 had requested to be sent to the hospital while residing in the facility, which the facility failed to accommodate the resident's request. The facility failed to notify or follow the ARNP orders subsequently the resident suffered increased discomfort, pain, and a potential delay in treatment. VITAL SIGN MONITORING The facility's in-service regarding hold parameters and notifying the physician read: Follow directions as specified by PCP (primary care physician). If unspecified follow house parameters. House parameters: 1. Blood pressure, Hold medication if systolic blood pressure (SBP) less than 100. (The first number, called systolic blood pressure, measures the pressure in your blood vessels when your heart beats) 2. Cardiac, Hold if <(less than) 60 3. Blood sugar: <(less than )80, hold, notify MD >(greater than) 350, notify MD If in doubt Google, call pharmacy, or use drug manual Notify (fax unless symptomatic) the MD if medications are held. Chart the holding of medications and MD response or others. Report to next shift. The American Heart Association (AHA) considers blood pressure to be within the normal range when both systolic and diastolic numbers are in these ranges. Blood pressure readings are expressed in millimeters of mercury . A normal reading would be any blood pressure below 120/80 mm Hg and above 90/60 mm Hg. ([DATE], (YEAR)) [MEDICAL CONDITION] is the medical term for low blood pressure (less than 90/60). RESIDENT 58 Resident 58 admitted (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The resident received 2 cardiac medications ([MEDICATION NAME] and Losartan) known to lower blood pressure. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]<100/60. The medication was administered outside the parameters on the following dates: 01/12/18 blood pressure of 95/61 01/24/18 blood pressure of 99/59 01/26/18 blood pressure of 96/54 RESIDENT 73 Resident 73 admitted (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The Resident received 4 cardiac medications ([MEDICATION NAME] and [MEDICATION NAME]) known to decrease blood pressures. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Doses were documented as given on 01/22/18 and 01/23/18 MAR but charted as held in the progress notes. The [MEDICATION NAME] order did not contain parameters of when to hold the medication. The medication was administered on the following dates: 01/12/18 blood pressure of 75/40 01/13/18 blood pressure of 63/44 01/17/18 blood pressure of 97/56 01/22/18 blood pressure of 89/51 01/28/18 blood pressure of 90/50 On 01/16/18, the PCP provided parameters for [MEDICATION NAME] to be held of HR< 60 or BP<100/60. The resident received the medication when it should have been held on 01/17/18 and 01/28/18. RESIDENT 64 Review of the resident's medical record showed an order for [REDACTED]. Further review of the medical record revealed the following: · 09/01/17 B/P was 94/61 and [MEDICATION NAME] and Carvedilol was given, · 10/06/17 B/P was 100/64 [MEDICATION NAME] order changed to hold for SBP less than 110, [MEDICATION NAME] was not held as ordered, · 10/14/17 B/P was 102/60 [MEDICATION NAME] was not held per orders, · 11/03/17 B/P was 107/52, 11/05/17 B/P was 102/72, 11/18/17 B/P was 104/66 [MEDICATION NAME] was not held as ordered, · 12/11/17 B/P was 100/74 [MEDICATION NAME] was not held as ordered. RESIDENT 89 Resident 89 was a long term resident with [DIAGNOSES REDACTED]. The Resident received [MEDICATION NAME] known to decrease blood pressure. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]<110, HR <60 or dizziness. The medication was inappropriately administered on the following dates: 12/14/17 blood pressure 107/49 12/16/17 blood pressure 102/54 12/18/17 blood pressure 101/51 12/29/17 blood pressure 108/62 01/01/18 blood pressure 103/60 01/17/18 blood pressure 104/69 01/18/18 blood pressure 97/63 01/25/18 blood pressure 109/65 02/01/18 blood pressure 108/74 02/02/18 blood pressure 102/68 02/05/18 blood pressure 107/42 RESIDENT 52 Resident 52 readmitted to the facility (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Orthostatic blood pressure's were not assessed as ordered for the resident on 01/08/18 or 01/21/18. Review of the Medication Administration Record [REDACTED]. The medication was not held on these dates. Review of the medical record showed no additional documentation or notification of the physician. RESIDENT 50 Resident 50 was a long term resident with [DIAGNOSES REDACTED]. Review of the vital sign record in Point Click Care (electronic charting) showed the resident's respirations were documented only 3 times instead of weekly from (MONTH) (YEAR) through (MONTH) (YEAR). The last documentation of respirations was on 01/18/2018. On 02/07/18 at approximately 10:00 AM, Staff R Resident Care Manager double-checked the residents documentation and confirmed respirations had only been recorded 3 times since (MONTH) (YEAR). She stated respirations is part of the vital signs and should be monitored when vital signs are checked and when oxygen saturation levels are checked. In an interview on 02/06/18 at 1:20 PM, Staff L, Assistant Director of Nursing, stated I just found out this was a problem. DAILY WEIGHTS RESIDENT 64 Review of the resident's medical record showed an order for [REDACTED]. Review of the resident's daily weights and [MEDICATION NAME] administration revealed the following: · 11/03/17 the resident was not weighed per physician orders, · 11/05/17 [MEDICATION NAME] was administered without a weight increase in 24 hours, · 11/02/17, 11/25/17 the resident had a greater than 3 lb weight gain. [MEDICATION NAME] was not administered per physican order, · 12/02/17, 12/14/17, 12/26/17 the resident was not weighed per physician orders, · 12/7/17, 12/08/17, and 12/15/17 [MEDICATION NAME] was administered without a 3 lb weight increase in 24 hours, · 01/23/18 the resident was not weighed with no documented reason, · 01/12/18, 01/20/18, 01/24/18, 01/26/18, 01/30/18 [MEDICATION NAME] was administered without a 3 lb weight increase in 24 hours, RESIDENT 58 Resident 58 admitted (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Additionally, Resident 58 had an order for [REDACTED]. RESIDENT 59 Resident 59 admitted (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The resident was alert and oriented, able to make her needs known and did not refuse care. On 12/30/17 daily weights were ordered and staff were directed to notify the physician of weight gain greater than 3 pounds in 24 hours. Review of the clinical record revealed missing daily weights for 6 of 43 days. Additionally, the physician or ARNP were not notified of blood sugar's less than 80 or over 400 mg/dl on 11 blood sugar checks. BOWEL MONITORING/CONSTIPATION According to the facility's Bowel Protocol (MONTH) (YEAR), Residents are treated for [REDACTED]. The licensed nurse reviews the bowel monitor (BM) daily. If a resident does not have a bowel movement for 3 days, administer milk of magnesia per physician order [REDACTED].) per physician order [REDACTED]. If resident continues to have no results from suppository, administer an enema on the next shift, during waking hours. If no results from enema, notify physician. RESIDENT 52 Resident 52 readmitted to the facility (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The resident was able to make his needs known. Review of the admission assessment on 01/20/18 revealed the residents last BM was 01/18/18. In an interview on 01/30/18 at 1:42 PM, Resident 52 stated I talked to (the physician) twice and we disagreed on some things. I was getting too many medications. All told, I was taking 15-16 pills a day then I couldn't eat and I had no BM for a week. Further review of the BM record revealed the resident did not have a BM for over seven days (24 shifts) from 01/22/18 through 01/28/18. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of a MD note dated 01/25/18 revealed Nurses ask that I review (Resident 52) due to complaints of abdominal pain . He has not really been eating or drinking much and they are worried that he is losing weight .He doesn't have an appetite and really has not eaten or drunk anything for the last week. He hasn't had a bowel movement for the last week either. He has had persistent nausea for a week and has vomited a few times .He stated several times that he wishes he could be dead especially since nobody is doing anything about his pain .Does not feel that [MEDICATION NAME] (stomach medication) is helping with his nausea or pain. For Resident 52 who was at increased risk for constipation due to multiple gastrointestinal [DIAGNOSES REDACTED]. In an interview on 02/07/18 at 1:48 PM, Staff L, Assistant Director of Nursing stated He had pain .abdominal pain and we addressed it with [MEDICATION NAME] and [MEDICATION NAME] (medications for stomach). We set up a GI (gastrointestinal) consult. The pain was all his stomach issues. RESIDENT 64 Review of the resident's medical record showed an order for [REDACTED]. Review of the resident's bowel monitor revealed the resident did not have a bowel movement for four days, from 01/28/18 until 02/01/18 with no MOM administered to the resident. In an interview on 02/12/18 at 12:54 PM, the ARNP was asked about the ARNP's expectations related to the resident's blood pressure medication administered outside the blood pressure parameters and bowel medication orders. The ARNP stated, That is a silly question, I would expect they (the residents) would receive what was ordered. RESIDENT 87 Resident 87 admitted (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of bowel monitor records revealed the resident did not have a bowel movement 01/11/18 through 01/14/18 and 01/29/18 through 02/02/18 nor received bowel medication to treat the constipation per facility protocol. RESIDENT 58 Review of the BM record revealed the resident did not have a BM on 01/16/18 through 01/19/18 and 01/28/18 until 02/02/18. Review of the (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]. BOWEL PROGRAM RESIDENT 29 Resident 29 admitted to the facility in (MONTH) (YEAR). Review of Resident 29's physician orders [REDACTED]. Review of the bowel monitor records for (MONTH) and (MONTH) (YEAR) showed Resident 29 did not have a bowel movement on 01/19/18, 01/20/18, and 01/21/18. The next documented BM was at 1:59 PM on 01/22/18. Additionally, documentation showed he had no BM on 01/31/18, 02/01/18, and 02/02/18. The next documented BM was at 1:59 PM on 02/03/18. Review of the (MONTH) and (MONTH) MARS showed no documentation of MOM being given on 01/22/18 and 02/03/18 as ordered. WAC: 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to provided necessary care and services for 2 of 5 residents (118 & 49) reviewed for pain management and non-pressure related skin conditions. Failure to adequately assess Resident 118 and 29, notify the attending physician and implement interventions resulted in harm to resident 118 due to inadequate pain relief and placed Resident 29 at increased risk for worsening skin conditions. Findings include: RESIDENT 118 Resident 118 was admitted to the facility in August 2016 with [DIAGNOSES REDACTED]. Review of the resident's current Minimum Data Set assessment revealed the resident was cognitively intact. Review of the resident's medication administration assessment (MAR) revealed the resident had been on the following pain management regime since the resident's admission: -Pramipexole (to treat restless leg syndrome) routinely -[MEDICATION NAME] (nonsteroidal anti-[MEDICAL CONDITION]) 3 times daily as needed -[MEDICATION NAME]-[MEDICATION NAME] (narcotic pain-reliever) every 6 hours as needed Review of a progress note dated 09/29/16 revealed the resident was making slow progress. Pain and muscle spasms were limiting the resident's participation and the physician was notified. In an interview on 11/14/16 at 2:03 PM, Resident 118 stated, I have chronic arthritis pain and do not have pain relief with my current medication. The physician will not change my medication. I was told I would have to see my personal physician to receive a change in my pain medication. Occupational Therapy had used a machine with electric currents which helped but I have not had that recently, the last time was in October, I only had it done twice. In an interview on 11/17/16 at 9:18 AM, Resident 118 stated, I had a bad night, my pain is a 9 out of 10 in the morning when getting up. My back hurts due to my [MEDICAL CONDITION] disc disease, I have constant throbbing in my hips due to my [MEDICAL CONDITION]. Review of the shift pain monitor on the MAR indicated [REDACTED]. In an interview on 11/17/16 at 1:36 PM, Staff M, LN stated, We had a new training regarding how to document pain several months ago. The training was provided by Staff D, LPN/Assistant Director of Nursing Services (ADNS), and we are to rate the resident's pain based on how the resident outwardly exhibits pain. In an interview on 11/17/16 at 4:12 PM, Staff A, LN stated, I worked with the resident for the past 2 to 3 days and did not complete a pain scale with the resident. If I do not hear anything regarding the resident, I document 0 in the pain assessment on the MAR. In an interview on 11/17/16 at 4:19 PM, Staff N, LN stated, Pain is assessed according to the residents activities, received training to assess pain related to what the resident was doing. In an interview on 11/17/16 at 4:32 PM, Staff P, Physician stated, Had not focused on any chronic pain issues with the resident, X-ray's showed the resident had [MEDICAL CONDITION] and was referred to PT to help manage the resident's pain. In an interview on 11/17/16 at 4:47 PM, the Director of Nursing Services stated, Patients are trained to rate pain at a 9 out of 10 so they can get 2 pain pills as opposed to 1 pain pill. Instead of focusing on the resident's pain rating we focus on the resident's activity. In an interview on 11/17/16 at 4:52 PM, Staff D, LPN/ADNS stated, The staff was trained to assess the resident's pain based on the resident's activity .If the resident is having chronic pain the physician would be informed .Pain is so subjective it is not merely a number. Review of the resident's shift pain monitor on the MAR from admit to 11/17/16 revealed the documentation of the resident's pain was documented 0 to 4, minimal pain based on the LN's assessment. Review of the resident's care plan revealed Resident 118 had chronic pain and the resident was to be asked to describe pain and location. Review of the PT pain assessment ratings from 08/18/16 through 11/15/16 revealed the resident verbalized pain ranging from 5 out of 10 to 10 out of 10 often times. The resident often described the pain as horrible, sharp or deep pain predominately to the resident's left hip. Review of the resident's progress notes revealed no further communication after 09/29/16 with the physician regarding the resident's continued complaints of pain. The facility failed to ensure evidence based standard pain assessments were completed and subsequently failed to provide effective routine pain management resulting in harm for Resident 118. RESIDENT 49 Resident 49 was admitted to the facility in January 2016. In an observation and interview on 11/14/16 at 11:38 AM, Resident 49 was observed repeatedly scratching his right forearm. His right forearm had abrasions with surrounding redness. The resident stated he picked at his arm. The resident's fingernails were long. Review of progress notes for the previous 2 months revealed no documentation about the right arm itching or rash. Review of the Treatment Administration Record (TAR) revealed no entry for monitoring or treating the rash. In an interview on 11/17/16 at 8:49 AM, Staff L, Licensed Nurse (LN) stated the process the nurses are to follow for skin alterations is to put the resident on alert charting, notify the responsible party and physician, and make an entry on the residents' TAR to monitor (and add treatment if ordered). In an observation and interview on 11/17/16 at 9:14 AM with Staff U, Nursing Assistant, Resident 49 was scratching his right forearm. He had a scabby red rash on his forearm. Staff U stated the rash and itching had been present for about 3 months. She stated the nurses had tried to put Band-Aids on the but he picked at his arm so they did not stay on. In an interview on 11/17/16 at 9:26 AM Staff V, LN stated she was aware of the rash on the resident's right forearm. She stated it had been going on awhile and she had tried applying Band-Aids but he pulled them off. She stated he picked at his arm but that it looked a lot better than it had in the past. She stated there were no treatment orders for the rash. In an interview on 11/17/16 at 11:00 AM, Staff D, Assistant Director of Nursing stated Resident 49 previously had an order for [REDACTED].

Based on observation, interview, and record review the facility failed recognize actual verbal abuse, the potential for verbal abuse and to keep residents protected from inappropriate verbal behaviors exhibited by Resident 2 when the facility staff had knowledge of the history of inappropriate behaviors by Resident 2. The facility did not implemented interventions to protect other residents from verbal incidents which lead to actual harm for Resident 1 who was yelled at and displayed psychologic distress. Findings include: The facility policy for Abuse, Neglect, and Misappropriation of Resident Property Prohibition stated: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Center implements policies and processes so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members and others who may have unsupervised access to residents. Mental Abuse: Includes but is not limited to, coercion, harassment, inappropriately isolating a vulnerable adult from family, friends, or regular activity, and verbal assault that includes ridiculing, intimidating, yelling or swearing. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medical record showed the resident was cognitively intact but had a hard time communicating and would mumble. Resident 1 moved in to a double room with Resident 2 on her day of admit. Resident 2 was admitted to the facility on [DATE] and per the resident care plan, exhibited behaviors that included ripping the call light out of the wall, physical and verbal aggression towards staff, angry outbursts, repetitive anxious complaints, poor insight (threw a footrest at a staff member), and inappropriate interactions with other residents per her behavioral monitoring sheets. Review of the record showed that Resident 2 had a long history of being verbally abusiveness to other residents and staff dating back as far as December of 2015. On 12/7/15, documentation showed that Resident 2 was witnessed displaying rude tones towards other residents. On 12/8/15, Social Services Director (SSD) documented the resident was observed by the SSD raising her voice and saying Get the hell out of the way to another resident in the hallway who had dementia. At that time Resident 2 indicated that she had difficulty dealing with residents of lower cognition. Review of Resident 2's behavioral monitoring sheets revealed she was being monitored for behaviors of inappropriate interactions with residents. Documentation showed Resident 2 exhibited this behavior on 09/23/16, but there was no documentation that showed who the other resident was, if an assessment done on either resident, or that it was reported to the Resident Care Manager or Social Services per the care plan. In an interview on 10/27/16, the Administrator stated that the above documentation was incorrect and that was not what the nurse intended. Review of Resident 2's care plan, dated 08/03/16, revealed problems that included: -Seeking attention as exhibited by ripping a call light out of the wall. -History of physical aggression towards staff. -Verbally aggressive toward staff. -Angry outbursts. -Repetitive anxious complaints/concerns. -Cognitive deficit related to poor insight into consequences of own behaviors, i.e. throwing footrest at staff member. -Inappropriate interactions with other residents (One of the interventions was to alert the Resident Care Manager or Social Services if there was a change in Mood or Behaviors). Resident 1 Progress notes for Resident 1, included an entry dated Saturday, 08/06/16, 51 days prior to the incident. Resident 1 reported to Staff C, Licensed Nurse (LN) that Resident 2 is always yelling at me. The LN documented that she encouraged Resident 1 to talk with Social Services (SS) on Monday (2 days later). There was no documentation that the LN took any actions, such as: reporting Resident 1's concerns to SS, or protecting her from being yelled at further, or had assessed the resident for psychological harm, or had placed her on alert charting to determine outcome. Instead, she left it to the resident to report, which there was no documentation she had done so. Review of an incident report dated 9/27/16 indicated that the LPN/Assistant Director of Nursing Services (LPN/ADNS) documented that on 9/28/16, Resident 1 reported that Resident 2 was often rude and made her not want to get help because of how her roommate responds. In addition, Resident 2 has a history of challenging behaviors including angry outburst, verbal aggression and inappropriate interaction with staff and other residents. The LPN/ADNS indicated that even though this incident took place there would be no care plan changes. The LPN/ADNS also documented that Resident 1 confirmed that she was hesitant to request appropriate assistance as she did not want Resident 2 to yell or be rude to her. Resident 2's behavior was noted to be verbally abusive and Resident 1 demonstrated signs of distress. Review of the incident investigation revealed staff witnessed the verbal abuse and crying on the evening of 09/27/16. However, it was not reported until 09/28/16 when staff reported A health and safety concern for Resident 1. Even though staff witnessed verbal abuse and crying on 09/27/16, staff didn't implement any protective measures until the next day. Failure to immediately protect Resident 1 and to timely report the verbal abuse contributed to her psychosocial harm, crying and signs of distress. The investigation included a section titled Investigator's Interview, which stated that after the altercation, Resident 1 reported to the interviewer, that her roommate, Resident 2, was rude and made her not want to get help because Resident 2 gets mad. The interviewer concluded Resident 1 was participating in unsafe behaviors and had two falls. She was scared to call staff and ask for assistance because Resident 2 didn't want her to turn on her call light or have the NAs come into the room to help her. Resident 1 reported that she spent time out of her room even when she was tired because of Resident 2's treatment. Staff B, NA, documented on a note, attached to the Event Investigation, which showed Resident 2's tone of voice was belittling and rude. Staff B's witness statement stated We tried calming Resident 2 down, but she kept yelling at Resident 1. Staff B's witness statement revealed after the altercation, Staff B asked Resident 1 what she could do to help, Resident 1 said nothing, and that she would be quiet. Staff B also documented when she checked on Resident 1 later that evening, Resident 1 was crying. During a record review on 10/28/16 showed that the facility moved Resident 2 to another room on 9/28/16, which was down the same hall from Resident 1. Both residents were independent in their wheel chairs and Resident 2 would still have access to Resident 1 being in the same hall. The record also showed the after the resident was moved in with Resident 3. On 10/14/16 Resident 2 got into another verbal altercation with Resident 3 over lights. Resident 3 was temporarily moved into another room until the morning when Management was able to handle the situation. Social Services had both of the residents sign a roommate agreement on how to get along. In an interview on 10/14/16 at 9:45 AM, Resident 1 stated she remembered the incident with Resident 2 and she was glad she was not her roommate any longer, but did not want to talk about it or offer any further details. In an interview on 10/14/16 at 1:30 PM, Staff E, LPN/ADNS, stated that the NAs did not report the incident until the next morning. Staff E stated the NAs said that Resident 1 had been spending more time out of the room and had experienced 2 falls. The facility concluded Resident 1 had behaviors of unsafe self-transferring. Resident 1 did not want to turn on her light and ask for help for fear that her roommate, Resident 2, would get mad. Even though the NAs were aware of the Resident spending time out of her room, no actions were taken. In an interview on 10/14/16 at 1:30 PM, Staff E LPN/Assistant Director of Nursing Services stated that Staff B reported the 9/27/16 incident to Staff C, LN, but Staff C was not concerned, because Resident 2 got upset with the aides a lot. Staff B also reported that she had went back into Resident 1's room later that night after the verbal abuse incident, and Resident 1 was crying. Staff E stated the NAs said that Resident 1 was using her call light less and was out of her room more and Resident 2 had a history of [REDACTED]. In an interview on 10/12/16 at 2:11 PM, Staff A stated that he and Staff B, the lead NAC, were helping Resident 2 and she was very angry. Resident 2 asked Staff A for help and Resident 2 freaked out. Resident 2 had stated she was Totally tired of her and said to Resident 1 I'm sick of you. Staff A stated that he did not report the incident to anyone because, Staff B was the lead NA and she had told him she was going to report it. In addition, Staff A stated that he did not know what being a mandated reporter meant. In an interview on 10/28/16 at 5:20 pm, Staff C stated that Resident 1 told her about Resident 2 verbally yelling at her on 08/06/16, when she was giving her night time medications. She stated that Resident 1 did not act scared and her demeanor was the same. She said she was aware she was a mandatory reporter, but honestly didn ' t feel the resident's safety was at risk. Staff were aware Resident 2 had aggressive behaviors and of the relationship between Resident 1 & 2 as evidenced by documentation in a progress note dated on 08/06/16 and care planning for Resident 2. The facility was also aware that Resident 2 had behaviors of verbal and physical aggression. Yet, the facility failed to recognize Resident 2's behaviors as abuse. There were no interventions, or assessments of Resident 1, or monitoring put into place to ensure Resident 1 was in a safe environment.

Based on observation, interview, and record review, the facility failed to ensure care and services were provided in a manner which enhanced and maintained resident dignity and feelings of self-worth by ensuring four residents (#1, 2, 4 and 8) were spoken to in a kind and respectful manner which resulted in residents feeling disrespected. Findings include: Resident # 4 Review of a facility investigation, dated 7/8/13 revealed that Resident 4's daughter reported that NA 1 was "rude" to resident when she was assisting the resident with a shower and putting on on Resident 4's ted hose. The daughter requested that NA 1 no longer care for her mother. Resident 4 stated that NA 1 had always been "rude, condescending and had an attitude". She stated that NA 1 did not treat her the way she felt she should have been treated. Resident 4 stated that she would not ask NA 1 to help her put on her socks because NA 1 "gets mad". The resident stated that she was hard of hearing and would have to repeat a question more than once. When she did NA 1 would yell at her. "She doesn't have to yell at me, just speak louder." The resident had expressed that she no longer wanted NA 1 to provide care because of her "attitude". The investigation showed that NA 1 was educated on "poor customer service" and was placed on probation. She was also directed to read and follow each resident's care directive and provide the listed cares including applying specialty items such as ted hose as directed by the LNs. Another facility investigation dated 7/29/13 revealed that Resident 4's daughter reported that NA 1 was "rude and sarcastic" to her mother and ignored her requests. Resident 1 Review of a facility investigation dated 11/15/12, revealed that Resident 1 reported that NA 1 was very rude to her and spoke down at her "as if I was a child". Resident 8 Resident 8, reported that NA 1 was "rude", spoke down to residents, rolled her eyes and did not knock on doors before entering resident rooms. Resident 2 Review of a facility investigation, dated 11/19/12, revealed Resident 2 stated NA 1 was "abrupt" when providing care. When NA 1 left his room she did not give him his call bell, which left him feeling vulnerable. The facility continued to utilize NA 1 as a caregiver despite multiple residents voicing their concerns about the manner in which she delivered the care and communicated with them.

Based on interviews and record reviews the appointed administrator of this facility failed to ensure the highest psychosocial well-being of each resident was maintained when multiple residents (# 1, 2, 4 and 8) complained of rude and disrespectful treatment by a nursing assistant (NA 1) over several months. The facility had knowledge that NA 1 was "rude", "condescending", "abrupt" and had an "attitude" with residents beginning on 11/15/12. The investigations related to the allegations about NA 1's the behaviors toward residents began on 11/15/12 and continued through July 2013. Findings include: Resident 4 Review of a facility investigation, dated 7/8/13 revealed that Resident 4's daughter reported that NA 1 was rude to resident while in the shower putting on Resident 4's ted hose. The daughter requested that NA 1 no longer care for her mother. The Social Services Director documented in the progress notes on 7/29/13 that Resident 4 had agreed to allow NA 1 to care for her as long as there were two caregivers in the room even though both the resident and her family member requested on 7/8/13 to not have NA 1 provide care any longer. On 7/29/13, NA 1 signed a statement that stated "I understand that I am not to care for Resident 4, alone. I will have another staff member present with me if I answer a call light and provide cares including in the dining room." Resident 4 requested on 7/8/13 that she did not want NA 1 to care for her. The facility continued to allow NA 1 to provide care for the resident because Resident 4 had agreed after, staff spoke to the resident, that NA 1 may care for her if there was an additional staff member present. After multiple resident complaints about NA 1, the administrator continued to allow NA 1 to care for one of the same Residents who had asked very specifically not to receive care from this NA and had voiced her concerns over the interactions that she and NA 1 had had. Resident 1 Review of a facility investigation dated 11/15/12, revealed that Resident 1 reported NA 1 was very rude to her and spoke down at her "as if I was a child". Resident 8 Resident 8, reported that NA 1 was "rude", spoke down to residents, rolled her eyes and did not knock on doors before entering resident rooms. Resident 2 Review of a facility investigation, dated 11/19/12, revealed Resident 2 stated NA 1 was "abrupt" when providing care. When NA 1 left his room she did not give him his call bell. On the date of the onsite visit (9/26/13), NA 1 was still employed by the facility although she was not currently working with residents. Prior to her suspension on 9/8/13, the facility had continued to give NA 1 resident assignments even to residents who had requested no contact with NA 1. The administrator of the facility did not ensure that Residents 1, 2, 4 and 8 were treated in a dignified and respectful manner.

Based on interview and record review, the facility failed to ensure 1 of 5 sample residents (Resident 1) was free from significant medication errors. Administering medications a resident was allergic to resulted in two medication errors for the resident in a period of less than ten days, made by two different nurses. The second medication error resulted in harm, as the resident, who was sent by 911 to the emergency room , developed anaphylactic shock (a life-threatening allergic reaction) after the error was made. Findings include: Resident 1 admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. The admission paperwork from the hospital indicated the resident was allergic [MEDICATION NAME] antibiotic. A review of the resident's closed record on [DATE] revealed an alert sticker on the cover indicating an allergy to Cipro. Additionally, the resident's admission face sheet and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE], the resident contracted a urinary tract infection. Staff B, a nurse, contacted the physician to ask for an antibiotic. The order [MEDICATION NAME] received and one dose was given to the resident before the error was discovered. The resident was placed on alert status to observe for any allergic reactions to the antibiotic. None were noted. During an investigation by the facility, the nurse admitted s/he did not review the resident's record for any allergies [REDACTED]. On [DATE], the resident's medication was reviewed by her Nephrologist (kidney doctor). The medication [MEDICATION NAME], a drug used to treat certain conditions related to heart failure, was discontinued. The reason given was "Patient has allergic reactions". A new face sheet was printed and placed in the resident's chart along with each monthly MAR, indicating the resident was allergic to the drug. A sticker was placed on the front of the resident's chart stating "Allergic to [MEDICATION NAME]". The medication was shown to be discontinued in the resident's MAR indicated [REDACTED] However, the facility failed to remove the medication from the medication cart once it was discontinued. A review of the facility policy for discontinued medications on [DATE], revealed the medication should have been removed immediately and sent back to the pharmacy or destroyed. In [DATE], the resident was transferred to another floor and all of her medications were sent with her, including the discontinued [MEDICATION NAME]. During a medication administration on [DATE], Staff A, an LPN, retrieved [MEDICATION NAME] from the discontinued package, even though the MAR indicated [REDACTED]. The LPN gave the medication to the resident who developed breathing problems shortly after. Upon realizing her mistake, the nurse activated the 911 emergency response and sent the resident to the emergency department, where the resident required intubation (placement of a breathing tube) due to a severe allergic reaction. The resident remained in the Intensive Care Unit for three days. The facility conducted an investigation starting on [DATE]. Staff A admitted she did not give medication per the policy of the facility, which was to review the MAR. Instead, the nurse retrieved all of the resident's medications from the medication cart and started to dispense them, without knowing what was current or had been discontinued. During an interview with the investigator on [DATE] at 11:10 a.m., Resident 1 became tearful and stated she was scared to take any medications because she didn't trust any nurse. "I almost died when I couldn't breathe". "They had to shove tubes down my throat to keep it from swelling shut". .

Based on observation, interview and record review the facility failed to identify and recognize abusive behaviors and provide interventions to protect other residents from physical attack from 2 of 2 residents (1 & 5) who were displaying disruptive behaviors that created an intimidating environment for other residents. The facility's failure to recognize and take immediate action resulted in immediate jeopardy and resulted in psychological or physical harm for 7 identified residents (2, 3, 4, 5, 6, 7, & 8). In addition, other facility residents who observed the incidents were placed at risk for psychological harm. Findings include: The facility's "Abuse, Neglect and Misappropriation of Resident Property Prohibition" indicated that each resident had the right to be free from abuse. The facility was to implement policies and processes so that residents were not subjected to abuse by other residents. The facility was to "screen" for potentially abusive residents. Residents identified by staff as being self injurious or exhibiting abusive behaviorwere to be reviewed by the Interdisciplinary Team and/or physician; referrals made and treatment plans modified as appropriate. 1.) Resident 1 Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1 and Resident 2 (roommates) Documentation on an "Event Investigation Report" dated 9/5/11 at 1:35 am, indicated that Resident 1 physically attacked Resident 2, who was bed bound. Resident 1 climbed on top of Resident 2 in bed, and proceeded to choke and scratch Resident 2's neck. The facility's intervention was to move Resident 1 into a private room and update her care plan for "[MEDICAL CONDITION]". Documentation in the progress notes by the facility's "Event Committee" dated 9/6/11 indicated the incident was reviewed and determined the investigation was in process. There was no further follow up by the Event Committee. A licensed nursed documented on 9/6/11 that Resident 2 asked to have her door shut to keep everyone "out" of her room. The facility Social Worker documented in the progress notes on 9/7/11 that Resident 2 was interviewed. Resident 2 stated that she did not feel safe related to the incident. In an interview on 12/15/11 at 12:10 pm, Resident 2 described the incident. She stated that she woke up with Resident 1 on top of her. She said the incident took away "my ability to feel safe." She stated she felt "anger and embarrassment" and was "still irritated" over the incident (occurred over 3 months prior). Resident 1 and Resident 3 (roommates) On 9/26/11, the SW documented that Resident 1 was moved from the private room to a semi-private room with Resident 3. No interventions were put into place to prevent Resident 1 from repeating the same behavior with her new roommate, except to place the resident on alert charting for one week to evaluate adjustment to the room move. Documentation in the progress notes on 9/26/11 showed that Resident 3 began to complain about Resident 1 sharing her room. On 9/27/11 Resident 3 complained and asked staff if she was "being punished? Do you guys hate me?" Resident 3 had many outbursts of frustration related to Resident 1 being her roommate. Staff responded by telling Resident 3, "It will be this roommate for now". In an interview on 12/9/11 at 11:00 am, Resident 3 stated that on 11/11/11, she called for staff to come to her room. Resident 1 had urinated and defecated on the floor. Resident 3 described where Resident 1 had urinated on the floor, and where she had been walking around the room. Resident 3 stated that Resident 1 became "violent" when staff arrived to intervene. Documentation in the progress notes by Staff B dated 11/11/11 at 8:00 am, indicated Resident 1 was aggressive, pushed staff away and bolted toward Resident 3. Resident 1 kicked Staff B in the face two times and Resident 1 was trying to bite staff. It was recorded this "[MEDICAL CONDITION]" activity lasted 32 minutes. Documentation in the progress notes by Staff A dated 12/1/11, indicated that on 11/11/11, Resident 1 was having a "violet [MEDICAL CONDITION]". Staff A and Staff B were trying to keep Resident 1 away from Resident 3, who was lying in bed. Resident 1 was trying to climb on the bed of where Resident 3 was lying. Resident 1 was flailing her arms and legs, kicked Staff B in the face two times and was attempting to bite staff. Staff A was trying to keep Resident 1 "on the floor, without injuring her, by surrounding her with my arms." We struggled continually for 30 minutes or more." The resident was attempting to crawl across the floor to get to the bathroom. She was yelling "help me, let me in the bathroom". Staff A documented on a witness statement dated 11/12/11, "We were trying to keep her (Resident 1) safe and keep her from injuring her roommate (Resident 3)." In an interview on 11/30/11 at 9:30 am, Staff B stated that Resident 1 became aggressive, slapped and kicked her in the side of her face. Resident 1 tried to grab something off of the wall and then "lunged" toward Resident 3. There was no Event Investigation Report filled out and an investigation was not completed because staff felt the resident was having a [MEDICAL CONDITION]. The resident was moved back to a private room to prevent further incidents. In an interview on 12/9/11 at 10:10 am, Staff A stated that a nursing assistant (NA) told Staff A that Resident 1 was acting different. When Staff A responded, the resident was flailing her arms trying to climb on a stool and grab items off of the wall. Staff A stated that she got behind Resident 1, wrapped her arms around Resident 1's upper torso to hold her arms down. Staff A used her knees to bump the back of Resident 1's knees causing Resident 1's knees to buckle so she could get her to the floor. Staff A stated she was trying to keep both residents safe. Staff A stated she was unaware of what Resident 1's care plan interventions for behaviors were and she was unable to find the care plan. Social Services had not "trained" staff on how to handle Resident 1's behaviors, but Staff A realized she should have just called 911. A LN documented in the progress notes on 11/12/11 that Resident 3 was a witness to her roommate having a [MEDICAL CONDITION]. Resident 3 stated "Does this happen often, I want a new roommate. I'll be fine as long as that crazy lady stays.....away from me!" Resident 1 and Resident 4 Documentation on an Event Investigation Report dated 12/10/11 at 7:45 am, indicated that Resident 1 entered bedbound Resident 4's room and got into Resident 4's bed. Resident 1 began hitting, kicking, and attempting to choke Resident 4. In an interview on 12/15/11 at 1:00 pm, Resident 4 stated "She kicked the hell out of me and hurt me." Resident 4 also stated that he was aware that Resident 1 had "attacked people before." Records showed that Resident 4 was a hoyer lift transfer and was unable to exit the bed without assistance. Resident 4's bed was observed to be up against the wall preventing exit from that side of the bed. In an interview on 12/15/11 LN B stated that Resident 1 had her hands up and around Resident 4's neck attempting to choke him. 2.) Resident 5 Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. His MDS dated [DATE], indicated the resident's cognition was severely impaired and English was not the resident's primary language. Resident 5 and Resident 6 Resident 6, who was the wife of Resident 5, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation on an "Event Investigation" form dated 11/13/11 at 8:10 pm, revealed Resident 6 was sleeping on Resident 5's bed. Resident 5 became upset when staff tried to take Resident 6 back to her own room. Resident 5 grabbed Resident 6 by her arms, was shaking her, which resulted in pain and bruising on her arms. An LN documented that Resident 6 was "wincing and crying out" when staff attempted to remove her clothing. The resident was taken to the nurse's station and her daughter, who spoke the resident's primary language, was called. The daughter stated that her mother was in "excruciating" pain in her right shoulder and the resident wanted to die because no cared. The daughter asked the facility to get an x-ray of her mother's shoulder, which revealed arthritis. There was no documentation on how this event impacted Resident 5's roommate, Resident 7. The "Event Committee" documented on 11/21/11, that the incident was reviewed and they recorded that an investigation was in progress. There was no further documentation from the Event Committee. In an interview on 12/15/11 at 12:45 pm, the RCM stated that the facility was unsure of what triggered Resident 5's behaviors toward his wife; because neither resident spoke English, as their primary language. Staff were unaware of what they were saying to each other. In an interview on 12/15/11, Staff A stated that in order to communicate with both Resident 5 and Resident 6, staff would call the family for interpretation. Licensed Staff documented in the progress notes on 3 occasions, dated 11/7/11, 11/14/11 and 11/22/11, they were unable to reach the residents' daughter by phone and staff had to leave messages for family. There was no other documented plan on how to communicate with the resident if the facility was unable to reach the family. Resident 5 and Resident 7 Documentation in the progress notes dated 11/13/11 at 1:00 am, revealed Resident 5 went to Resident 6's room, woke her up and led her to his room. Resident 5's roommate was out of the facility at the time. When the roommate returned, he found that Resident 5 and Resident 6 had moved all of his belongings to the other side of the room. Resident 7 was upset by this. In addition, Resident 5 had taken and was wearing Resident 7's jacket and would not return it. Documentation showed that Resident 5 became agitated and would not give the jacket back to staff or Resident 7. Resident 5 was moved to a private room on a different hallway. Documentation in the progress notes dated 11/15/11 at 11:30 pm, indicated Resident 5 went into his old room where Resident 7 remained. The resident was trying to remove Resident 7's clothing from the room. This caused Resident 7 to become "over stimulated" and voices were raised. Multiple staff members tried to intervene which caused an increase in agitation for Resident 5. "All other residents present around the commotion were asked to go back to their rooms and the doors were closed." There was no investigation completed to determine how or if the incident had a negative impact on the residents who were told to go back to their rooms. Documentation on an "Event Investigation" form dated 11/18/11 at 12:00 pm, revealed that Resident 7 was yelling at Resident 5 and 6, telling them to stay out of his room. Resident 7 pushed Resident 5 to the floor. Resident 6 was holding hands with Resident 5 and she fell also. Resident 5 hit his head on the floor and received a lump and an abrasion and was sent to the emergency room resulting in a [DIAGNOSES REDACTED]. Resident 7 stated that Residents 5 and 6 were in his room and Resident 5 hit him in the face and took his clothes. The "Event Committee" documented on 11/21/11, that the incident was reviewed and the determination was that Resident 7 was moved to a different floor until a long term solution could be made. There was no further documentation by the Event Committee. Resident 5 and Resident 8 Documentation on an "Event Investigation" form dated 11/22/11, revealed that Resident 5 would not let Resident 8 exit his room and closed the door on his hand. Resident 8 would open his door and Resident 5 would pull the door shut. The LN documented that Resident 8 was attempting to exit his room when Resident 5 kept pulling the door shut. Resident 8 substained a painful bruise on his hand from the door. Resident 8 reported to an LN, "I was trying to get out of my room and someone kept sutting the door". Resident 8 reported that his thumb on his right hand hurt. The "Event Committee" reviewed the incident on 11/23/11 and documented Resident 8 had a large bruise on his right hand. The event committee determined the investigation was still in progress. There was no further documentation from the Event Committee. In an interview on 12/15/11 at 1:00 pm Staff C stated that other residents had stated that Resident 5 scared them. If Resident 5 began to act out, he would march down the hall and everyone knew to get out of his way. Staff would move other residents out of the area to protect them if they were able, but Resident 5 would go into other resident's rooms and rummage through their belongings and take want he liked.

Based on observation, interview and record review, the facility failed to administer services effectively and efficiently in order to attain, and/or maintain, each resident's optimal physical, mental and psychosocial well-being. Failure to recognize specific resident to resident incidents as potential abuse also resulted in the facility not implementing effective protective interventions to prevent recurrence. This failure resulted in harm for at least 7 identified residents (2, 3, 4, 5, 6, 7 & 8) and created an unsafe and intimidating environment for all residents living on the first floor of the facility. In addition, it placed residents at imminent risk for experiencing harm from Resident's 1 & 5's behavioral outbursts. Findings include: 1. Administration failed to ensure the facility implemented written abuse prevention policies and procedures and failed to take immediate action to protect residents during and after investigation of allegations of abuse and neglect. This failure demonstrated that the facility's abuse prevention program was ineffective and represented an immediate jeopardy, impacting at least 7 residents and potentially placing all residents on the first floor at risk for abuse and neglect. Refer CFR 483.13 (c) F 226 - Develop/Implement Abuse/Neglect, ETC Policies 2. Administration failed to ensure necessary medically related Social Services were provided. Social Services failed to develop interventions, monitor those interventions or train staff to manage aggressive and disruptive behaviors from Residents 1 & 5. This failure resulted in physical or psychological harm for at least 7 identified residents (2, 3, 4, 5, 6, 7 & 8) and created an intimidating environment for other residents living on the first floor of the facility. Refer to CFR 483.15(g)(1) Provision of Medically Related Social Services

Based on interview and record review the facility failed to provide medically related Social Services by failing to aggressively assess, develop interventions or to evaluate existing interventions and revise those interventions for 2 of 2 residents (1 & 5) who had aggressive and disruptive behaviors that were impacting other residents. This failure resulted in physical or psychological harm for at least 7 identified residents (2, 3, 4, 5, 6, 7 & 8). Findings include: 1.) Resident 1 Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation in the Medical Record showed a Neurologist from the hospital dictated on 4/2/11 that Resident 1 had behavioral problems that were described as "Temper Tantrums". Documentation in the progress notes showed the resident began to have behavioral problems on 4/26/11 that were exhibited by: -being aggressive, combative, demanding and verbally abusive to staff on 12 different days. -wandering into other residents rooms on 2 different days. -trying to climb onto the nursing station counter on 6/24/11. -making inappropriate comments to other residents on 9/2/11. -had self injurious behaviors by wiping herself so hard until she bled on 9/26/11. Documentation on Resident 1's "Behavior Monitoring Flow Records", that were completed by the nursing assistants, for October of 2011. The flow records showed that for the first week of October there was no documentation of behaviors. From October 8 through October 31, 2011 the resident had 13 days that behaviors were documented. The behaviors documented indicated the resident was "easily frustrated as exhibited by anger over simple things" and "continuously going to the bathroom for extended amounts of time." The behaviors were described as being triggered by depression and psychosis. The interventions that were attempted by the Nursing Assistants (NAs) were "approach the resident in a calm manner and explain cares prior to giving them." The outcome for all 13 days was there was "no change" in the behavior. On all days of these behaviors, Licensed Nurses documented once in the progress notes. Licensed Nurses or Social Services of assessments did not document any assessments depression or psychosis that the Nursing Assistants were documenting as triggers to the behaviors. There were no adjustments to the interventions even though documentation showed that the planned interventions were not effective. There was no available care plan for the behaviors. Social Services documented in the progress notes on 10/19/11 that Resident 1's behaviors were discussed in an Interdisciplinary Team (IDT) meeting. Documentation indicated that Resident 1 had no issues at the time and had stabilized. "No changes necessary at this time." However, behavior monitoring flow sheets showed the resident had been having behaviors almost daily prior to the IDT meeting. In an interview on 12/12/11 at 12:55 pm the SW stated there was no progress notes written by the SW from the time of admit on 4/5/11 to 9/26/11. The SW stated that she had documented Care Conferences but none contained behavioral assessments or planned interventions. Documentation in the progress notes showed there were no progress notes written about Resident 1's behavior until 9/26/11, 5 months after the resident was admitted . The SW documented a late entry progress note on 9/26/11; 21 days after Resident 1 had physically attacked Resident 2. The SW documented that the physical attack on Resident 2 had been "an isolated incident" and Resident 1 could not remember what happened, so Resident 2 was spoken to. In an interview on 11/30/11 at 9:45 am, the SW stated she had created a behavioral care plan for Resident 1, but was unable to find it. She stated the care plan would have been a duplicate of the behavior flow sheets. 2.) Resident 5 Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. His MDS dated [DATE], indicated the resident's cognition was severely impaired and English was not the resident's primary language. Documentation in the progress notes showed the resident began to have behavioral problems that were exhibited by: -Anxiety / Agitation were displayed on 13 days. -being aggressive, combative, and yelling, at staff on 7 days -Eloped from facility on 8/13 and was found 1 ? blocks away -Took other resident's belongings: 10/2, 10/23, 10/24, 11/13, 11/15 -Physically abusive / Aggressive with wife: 9/12, 11/13 - Wandering Halls: 8/11, 8/13, 8/15, 8/31, 9/15, 10/9, 10/11, 10/12 -wandered into other residents rooms: 10/2, 10/24, 11/15, 11/23, 11/24, 12/8 -Physical Altercations with other residents: 11/18, 11/22 "Behavior Monitoring Flow Sheets" were reviewed from August 2011 to November 2011 and showed there was consistent Nursing Assistant documentation of behaviors that resulted in "no change" or "worsened" when established interventions were attempted. Social Services did not make any adjustments to the interventions, even though they were not working. Refer CFR 483.13 (c) F 226 - Develop/Implement Abuse/Neglect, ETC Policies

Based on interview, and record review, the facility failed to provide adequate supervision and ensure the use of assistive devices for 2 of 4 residents (Resident 1, 2) who were at high risk for falls. Lack of supervision and incorrect use of an assistive device resulted in harm for Resident 1 who experienced a fall with injury and placed Resident 2 at risk for possible additional falls. Findings include: RESIDENT 1: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was identified to be at high fall risk. The fall risk evaluation, dated 9/10/10, documented the resident was " unable to reposition " herself due to left sided [DIAGNOSES REDACTED]. The facility ' s investigation report, dated 9/24/10, indicated the resident had a fall from the tilt in space wheelchair (w/c) when "she was leaning forward and unable to lean back once she started tipping forward". The report documented that the skilled therapist (PT) left the resident unsupervised in the wheelchair that was not tilted back to prevent the Resident 1 from falling out of the chair. In addition, the PT had not communicated with the nursing staff regarding the use of the tilt in space wheelchair. On 11/9/10, during an interview with the facility ' s administrator, she stated that on 9/23/10, the resident was evaluated by PT for a seating device that would enable better sitting balance, positioning and decrease the risk of falling due to Resident 1' s inability to maintain position in a standard wheelchair. She stated on 9/23/10, PT placed the resident in a seating device that tilted back (tilt in space wheelchair) to provide trunk support and to prevent falls. The PT, who had placed the resident in the tilt back wheelchair, left the resident unattended in the chair, which was not in a tilted position. In addition, the PT did not update the plan of care to have the chair " tilted back" when stationary. The nursing progress notes, dated 9/23/10, revealed that the resident complained of left shoulder pain after the fall. The X-Ray report, dated 9/23/10, revealed that the resident had a fracture of the distal left clavicle. The resident required the use of a sling to immobilize her arm and narcotic pain medications for her shoulder pain. The PT's summary notes, dated 9/21 to 10/1/10, documented that after Resident 1 fell and fractured her left shoulder, the resident's participation in therapy decreased due to pain, which resulted in a delay in Resident 1's rehabilitation. RESIDENT 2: Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 9/26/10, revealed the resident was cognitively impaired and dependent on staff for care. The Resident Assessment Protocol (RAP) for Activities of Daily Living and Falls indicated that the resident was able to self propel her wheelchair short distances, and due to her high risk for falls, alarm devices were placed in her bed and in her wheelchair. The Nursing Care Directive used by staff indicated that the resident was to have an alarm device in her wheelchair and bed due to her high fall risk assessment. On 10/19/10, the resident had a fall. The facility ' s investigation report, dated 10/19/10 documented the resident stated she " bumped her head". The report documented that the resident's wheelchair alarm device " was not on her chair " when she fell out of the chair. On 11/9/10, the administrator stated that at the time of Resident 2' s fall, the resident ' s plan of care was not followed, as no alarm was in the wheelchair to alert staff of her attempts to get up from the chair.