Every finding on record at Olympic View Post Acute

Based on interview and record review the facility failed to ensure the safety of 1 of 3 residents (Resident 2) reviewed for preventable accidents. This failure placed the residents at risk for injury, pain, and a diminished quality of life.Findings included.Resident 2 admitted to the facility on [DATE] with a diagnoses of stroke and dementia. The quarterly Minimum Data Set, an assessment tool, dated 07/08/2026, showed Resident 2 was severely cognitively impaired and was independently mobile with their wheelchair.Review of Resident 2's care plan, revised on 03/28/2026, showed Resident 2 had impaired cognitive function/dementia and impaired though processes related to diagnosis of dementia with behavioral disturbances. Cognitive status fluctuates and confusion at times.Review of an Incident Report, dated 08/12/2026 at 1:30PM, showed Resident 2 was found on the ground, at that date and time, at the front parking lot by a passerby who immediately notified facility staff. Resident 2 was assessed by Staff D, Assistant DNS (Director of Nursing Services), who documented Resident 2 had a laceration to the left forehead and called emergency services.Review of hospital records, dated 08/13/2026, showed Resident 2 had suffered a cervical fracture and a laceration to the left side of their face due to the fall on 08/12/2026. Findings included a possible urinary tract infection for which antibiotics were started as a treatment before discharge back to the facility.On 08/20/2026 at 3:20PM, Staff A said it was possible a visitor had taken Resident 2 outside to the front of the facility for a visit and then didn't bring Resident 2 back inside when they left. Staff A said they completed an investigation but could not determine how Resident 2 came to be outside alone.Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review the facility failed to provide toenail care services for 1 of 4 residents (Resident 1) reviewed for foot care. This failure placed residents at risk for pain, decreased mobility, and a diminished quality of life.Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses of Diabetes and Dementia. The quarterly Minimum Data Set, an assessment tool, dated 07/23/2026, showed Resident 1 was severely cognitively impaired and needed moderate assistance for transfers and ambulating.Review of Resident 1's orders, dated 07/30/2024, showed diabetic foot checks were to be completed every week on Fridays, and that if there was an issue, the provider was to be notified. The Treatment Administration Record (TAR) for July 2026 documented nurses completed foot checks on the 3rd, the 17th, the 24th, and the 31st. The TAR for August 2026 documented nurses completed foot checks on the 7th and the 14th. There was no documentation on those dates about concerns regarding Resident 1's toenails or notification of the provider.On 08/20/2026 at 11:12AM, Collateral Contact 1 (CC1), dialysis center nurse, said Resident 1 complained of foot pain at their 08/10/2026 appointment. CC1 said they removed Resident 1's footwear and saw their toenails were very overgrown and ragged. CC1 said they called the facility and spoke to Staff A, Director of Nursing, who said Resident 1 had not been seen by a podiatrist because of their dialysis schedule.On 08/20/2026 at 2:10PM, Resident 1 was observed in their room sitting in their wheelchair with their socks and shoes off. The big toe on both feet had long, thickened, yellow and purplish colored nails. The second toe on the left foot was thickened, yellow, and had grown about 3 centimeters upwards from the toe. All other toenails were in the process of curling over the toes and close to cutting into the pad of the foot. Resident 1 complained of pain when the left second toe was touched. When asked if it hurt to stand, Resident 1 said it did.Review of a provider notification form, dated 08/10/2026, showed Staff C, Licensed Practical Nurse, informed Staff B, facility Medical Doctor, about the condition of Resident 1's toenails. Review of Staff B's order, dated 08/10/2026 showed they ordered a podiatry consult to evaluate and treat bilateral thickened/dystrophic (abnormal changes in shape, texture, color, or thickness) toenails with suspected onychomycosis (fungal infection of the fingernails or toenails that causes them to become discolored, thick, and brittle); nailcare/debridement as indicated.On 08/20/2026 at 3:15PM, Staff B, facility Medical Doctor, and Staff A, Director of Nursing Services, observed Resident 1's toenails. Staff B said they thought Resident 1 had already been seen by a podiatrist. Staff A told Staff B the podiatrist that was scheduled to come to the facility the prior week had not come due to illness. When asked if pain should have been addressed in an urgent manner, Staff B said it should have been.On 08/20/2026 at 3:20PM, Staff A, Director of Nursing, said they did not know how the condition of Resident 1's toenails was not addressed sooner if nurses were completing weekly foot checks. When asked if the condition of Resident 1's toenails and the pain associated with it would affect mobility and quality of life, Staff A said it would.Reference WAC 388-97-1040(1)

Based on interview and record review, the facility failed to ensure specialized rehabilitative services were provided as ordered for 1 of 4 residents (Resident 24) reviewed for rehabilitation services. This failure delayed residents from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psycho-social well-being. Findings included .Resident 24Resident 24 was admitted to the facility on [DATE]. The hospital transfer orders, dated 07/01/2026, showed the resident had orders for Physical therapy (PT) and Occupational therapy (OT). Review of the facility's grievance log showed Resident 24 filed a grievance on 07/07/2026. The grievance documented Resident 24 was very frustrated he had been in the facility for a week (07/01/2026- 07/07/2026) and not received any therapy services. Under findings staff documented the reason Resident 24's PT and OT evaluations had not yet been completed was because Resident 24 had refused therapy several times. Review of the electronic health record showed there was no documentation in Resident 24's record about refusing therapy services until after Resident 24 filed the grievance on 07/07/2026. A nurses note dated 07/07/2026 at 4:32 PM, documented [Resident 24] expressed frustration about being in a rehabilitation center and not receiving therapy. Spoke to therapy department who reported res[ident] refused therapy. Therapy to reapproach tomorrow, resident aware and agreeable. On 07/23/2026 at 2:27 PM, copies of Resident 24's initial PT and OT evaluations, daily treatment notes were requested, including documentation of the dates/times when the facility attempted to complete Resident 24's PT/OT evaluations but were unable to secondary to Resident 24's refusals. On 07/23/2026 at 4:34 PM Resident 24's therapy documentation was provided via email. Review of the documents showed there was no documentation prior to 07/08/2026. On 07/24/2026 at 1:18 PM, Staff A was asked what documentation he relied upon to determine Resident 24's PT/OT evaluations were not completed from 07/01/2026- 07/07/2026 due to the resident's multiple refusals Staff A, Administrator, said he was informed by Staff GG, Director of Rehabilitation (DOR), that Resident 24 was refusing all his therapy. When asked for documentation of the date(s)/time(s) PT/OT evaluations were attempted and Resident 24 refused Staff A, Administrator, requested a telephone interview be conducted with Staff GG, DOR. In a telephone interview on 07/24/2026 at 1:21 PM, Staff GG, DOR, indicated Resident 24's evaluations were not completed during the first week due to his refusals. Staff GG reported the refusals were not documented because the therapists cannot enter any information into the therapy program until an evaluation is opened but therapy staff could not open the evaluations because Resident 24 had refused them. A copy of the therapy schedule from 07/01/2026-07/07/2026 and a punch detail report for all therapist for the same time period, was requested at that time. In a telephone interview 07/24/2026 at 1:32 PM, Staff GG, DOR, said Resident 24 was scheduled for PT/OT evaluations on 07/02/2026. The PT and OT approached Resident 24 together as they planned to perform a joint evaluation, but the resident refused. The PT and OT reapproached Resident 24 later in the day but again refused. When asked why Resident 24 was put on the schedule to be evaluated by PT and OT on 07/03/2026, (Friday) 07/04/2026 (Saturday), 07/05/2026 (Sunday), 07/06/2026 (Monday), or 07/07/2026 (Tuesday) Staff GG, DOR said the facility did not provide therapy on the weekends at that time. When asked why the resident was not scheduled for Friday or the following Monday or Tuesday Staff GG acknowledged the facility did not have many PTs or OTs available to perform the evaluations. Review of the punch detail report for the facility's OT's showed the facility had an OT on duty on 07/02/2026, 07/03/2026, and two OTs on duty on 07/06/2026 and 07/07/2026. Review of the punch detail report for PT staff showed the only day from 07/01/2026- 07/07/2026 that the facility had a PT on duty was Saturday 07/04/2026. The documentation provided showed the facility did not have a PT on duty on 07/02/2026. Reference WAC 388-97-1280(1)(a)(b)(4)

Based on observation, interview, and record review, the facility failed to prevent 3 of 3 residents (Resident 1, Resident 2, and Resident 3) from experiencing neglect from nursing staff. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life.Findings included.An Abuse, Neglect and Exploitation Policy, dated 08/29/2026, defined neglect as failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Resident 1Resident 1 admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 01/02/2026, showed Resident 1 was cognitively intact.Review of the Activities of Daily Living Self Care Performance care plan, dated 03/26/2026, showed Resident 1 required two persons utilizing a sit to stand lift (a mobility aid designed to help individuals transition safely from seated position to a standing position) for transfers.On 07/08/2026 at 3:30PM, Resident 1 said they were dropped from the sit to stand lift about 10 days prior. Resident 1 said Staff C, Certified Nursing Assistant (CNA) was the only one working with the lift. Resident 1 said Staff C repositioned the straps several times and then attempted to have them stand. Resident 1 said they slid down to the ground and bruised both their knees and pulled their shoulder and neck. They said Staff C then left the room to get help.On 07/08/2026 at 3:40PM, Staff A, Director of Nursing (DNS) said Staff C, CNA, did not report the incident and that they only became aware when Resident 1 told them about it a few days later. Staff A said Staff C did not follow the care plan and should not have used the lift without another staff member.Resident 2Resident 2 admitted to the facility on [DATE]. The 5-day admission MDS showed Resident 2 was moderately cognitively impaired.Review of the care plan, dated 06/24/2026, showed Resident 2 was at risk for falls related to not being aware of safety needs. It showed Resident 2 was at risk for injury and or bleeding related to being on an anticoagulant (prevents blood clots) therapy for a history of pulmonary emboli (blood clots in the lungs).On 07/08/2026 at 4:33PM, Resident 2 said they had a fall from the bed to the floor a few weeks prior. They said they had hurt their right hip and leg and had hit their face. Resident 2 said the aides helped them back to bed but that they were never seen by the nurse.On 07/08/2026 at 4:45PM, Staff A, DNS, said Staff D, Registered Nurse (RN) did not complete an incident report until two days after the incident. Staff A said when they came to work on Monday, June 22, they had several grievances and complaints about Staff D regarding neglect of residents as Staff D had worked the weekend prior. Staff A said an incident report and a nursing assessment should be completed at the time of the incident.Resident 3Resident 3 admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 3 was cognitively intact.Review of a nurse's note, dated 05/28/2026, showed Resident 3 had a witnessed fall and was sent to the hospital. Resident 3 was found to have fractures to their right foot which required a cast.On 07/08/2026 at 2:15PM, Resident 3 said they had completed a grievance on 06/21/2026 about Staff D, RN. Resident 3 said Staff D was walking down the hall talking on their cell phone and accidentally hit Resident 3's right foot. Resident 3 said they cried out as it was painful and that Staff D said sorry but did not stop to assess the situation. Resident 3 said Staff D was often rude and dismissive.On 07/08/2026 at 2:45PM, Staff B, Assistant Director of Nursing, said they had investigated the grievance from Resident 3 and had completed a formal reprimand. Staff B said Staff D, RN, was not acceptive of the reprimand and refused to sign the document. Reference WAC 388-97-0640(1)

Based on interview and record review, the facility failed to make a reasonable effort to uncover information about prospective employees by not completing reference checks for 3 of 3 employees (Staff D, Staff E, and Staff F) reviewed for implementation of abuse and neglect policies. This failure placed residents at risk for unmet care needs and services and a diminished quality of life. Findings included .Staff D was hired by the facility on 05/06/2026 as a Registered Nurse. Staff E was hired on 07/01/2024 as a Student Nurse. Staff F was hired on 07/16/2016 as a Certified Nursing Assistant. Review of the facility's personnel files showed neither Staff D, Staff E, nor Staff F had reference checks completed before they were hired or during their employment. On 07/08/2026 at 4:35PM, Staff A, Director of Nursing Services, said reference checks should be completed for all employees as part of the hiring process. Reference WAC 388-97-0640(2)(a)(b) Reference F600

Based on observation, interview, and record review the facility failed to prevent 4 of 4 residents (Resident 1, Resident 2, Resident 3, and Resident 4) from experiencing sexual abuse and or neglect at the hands of staff and or of other residents. This failure placed residents at risk of injury, psychosocial harm, and a diminished quality of life.Findings included.An Abuse, Neglect and Exploitation Policy, dated 08/29/2026, defined Sexual Abuse as non-consensual sexual contact of any type with a resident. It defined Neglect as failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.Sexual AbuseResident 1 admitted to the facility on [DATE]. The quarterly Minimum Data Set, (MDS, an assessment tool) showed Resident 1 was severely cognitively impaired. Resident 1 had a history of trauma, neglect, and dementia.Resident 2 admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 2 was cognitively intact. Resident 2 had a history of a significant stroke that caused aphasia (inability to speak) and poor impulse control.On 05/20/2026 at 1:20PM, Staff E, Certified Nursing Assistant, said on one of the days earlier in the week, they had observed Resident 2 bringing a dish of ice cream into Resident 1's room. Staff E said when they passed by the room a few minutes later, they observed Resident 2 had their hand placed on the inside of Resident 1's thigh. Staff E said they did not report the observation to anyone. Staff E said a few days later on 05/19/2026 at approximately 10:30AM, they went into Resident 1's room and observed Resident 1 and Resident 2 involved in mouth to mouth kissing. Staff E said they observed both residents had their hands in each other's genital area. Staff E said they stopped the interaction when they saw Staff E enter the room. Staff E reported the interaction to the nurse.On 05/20/2026 at 12:15PM, Staff A, Administrator, said Resident 2 did not have a history of any sexual aggression. Staff A said Resident 2 was very friendly and liked to give hugs to staff and other residents.Resident 2's care plan, dated 01/20/2025, documented Resident 2 showed sexually disinhibited behaviors, including kissing, hugging, and boundary violations. It said Resident 2 may have difficulty regulating emotions which could place others at risk.On 05/20/2026 at 12:30PM, Staff B, Director of Nursing Services (DNS), said Staff E should have reported the first observation so that interventions could have been immediately put into place. Staff B said Resident 1 did not have the mental capability to consent to sexual interactions. Staff B said Resident 2 should have had closer monitoring and interventions for their hugging and touching behaviors.NeglectResident 3 admitted to the facility on [DATE] with a diagnosis of a heart attack requiring open heart surgery. The admission 5 day MDS, dated [DATE], showed Resident 3 was cognitively intact.On 05/19/2026 at 10:12AM, Resident 3 said they were in a lot of pain on the night of 05/01/2026 and had asked for the 11:00PM dose of Tramadol (opioid pain killer used to treat moderate to severe pain). Resident 3 said Staff F, Registered Nurse, took their blood pressure and then told them the dose could not be administered due to the pressure being too low. Resident 3 asked for a dose of Tylenol at around 3:00AM but did not receive it until 6:10AM. Resident 3 said they were in tears at that point.Review of the pain care plan, dated 05/04/2026, showed Resident 3 had the potential for pain. Interventions included, Administer analgesia as per orders and discuss concerns regarding pain management with the provider and consulting pharmacist as needed.Review of the May Medication Administration Record showed Resident 3's blood pressure at 11:00PM was 107/63. The parameters for administration of Tramadol read to hold the medication if blood pressure was under 100.On 05/20/2026 at 4:30PM, Staff B, DNS, said their investigation showed Staff E was neglectful due to not administering the medication as ordered. Staff B said if Staff E was concerned about the blood pressure, they should have called the on-call provider to see if there was something else that could be given.Staff E was no longer employed with the facility and unavailable for interview.Resident 4 was admitted to the facility on [DATE]. The annual MDS, dated [DATE], showed Resident 4 was cognitively intact and needed moderate assistance for activities of daily living.Review of the self-performance care plan, dated 03/31/2025, showed Resident 4 needed 1 person to assist them with transfers including using the bathroom.On 05/21/2026 at 11:10PM, Resident 4 said Staff C, Certified Nursing Aide, had left them in the bathroom a few weeks ago. Resident 4 said they had gone into the bathroom themselves and transferred to the toilet. Resident 4 said they called for help to get off the toilet from Staff C who was in the room assisting their roommate. Staff C helped them stand then walked away. Resident 4 said they fell and bruised their chest. Resident 4 said the toilet was too low and that they had expressed this frustration to several staff members.On 05/21/2026 at 11:20PM, Staff D, Director of Rehabilitation, said falls were discussed at stand ups every day. If it was deemed necessary, the rehab department would do an assessment and come up with interventions to prevent further falls. Staff D said this fall should have been evaluated by their department but that they had not been informed of the fall.On 05/21/2026 at 11:25PM, Staff B, DNS, said Staff C did not report the fall. Staff B said they found out from Resident 4 about a week later. Staff B did not ask for an evaluation from the rehabilitation department. Staff B said Resident 4 should not have been left alone in the bathroom.Staff C was no longer employed with the facility and was unavailable for interview.Reference WAC 388-97-0620(1)

Based on observation, interview, and record review, the facility failed to honor food preferences for 2 of 3 residents (Resident 2 and Resident 3) reviewed for dietary services. The facility also failed to provide alternative foods and failed to provide foods that were on the menu. These failures placed residents at risk for an unsatisfactory meal experience and a diminished quality of life.Findings included .Resident 2 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS, an assessment tool), dated 01/26/2026 was cognitively intact and was able to make their own choices regarding meals. On 04/01/2026 at 1:44 PM, Resident 2 was observed in their room with a lunch tray. The plate had a large helping of cut up red beets. Resident 2 pointed at their meal slip which had beets typed under the dislikes section. Resident 2 said they would often receive foods they did not like and would have to ask for a peanut butter and jelly sandwich instead. Resident 2 said they had repeatedly talked to Staff A about the problems regarding food service.Resident 3 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 3 was cognitively intact and was able to make their own choices regarding meals. On 04/01/2026 at 1:10 PM, Resident 3 was observed with a lunch tray that had mashed potatoes on it. Resident 3 said that was surprising because, usually, if rice was on the menu, that is what they would receive. Resident 3 pointed to the meal slip on the tray that had rice typed under the dislikes section. Resident 3 said they would often order off the bistro menu but would still receive the main meal. Resident 3 said the menu was incorrect for four of seven days of the previous week. On 04/01/2026 at 5:30 PM, the menu of the day was observed outside of the dining room. Residents were supposed to have spiced pears but bowls on the trays contained orange colored fruit and whipped topping. On 04/01/2026 at 5:33 PM, Staff F, Dietary Aide, said the fruit was mangos. When asked why mangos were served instead of spiced pears, Staff F said that happened frequently. Staff F said the day shift would just make what they had on hand for the dinner staff to serve and, oftentimes, it was not what was on the menu. On 04/02/2026 at 2:38 PM, Staff A, Administrator, said they had to let the dietary manager go a couple of weeks prior. Staff A said another kitchen staff member was filling in but said there were starting to be some issues. Staff A said residents should not be receiving foods that are on their dislikes/allergy's lists. Staff A said residents should be able to order and receive food off of the alternate menus. Staff A said the food served should be on the menu, and if changes needed to be made, that residents should be notified beforehand. Reference WAC 388-97-1120(3)(a)

Based on interview and record review, the facility failed to prevent, and appropriately intervene for, verbal abuse and neglect received from a staff member for 1 of 3 residents (Resident 1) reviewed for abuse. This failure placed residents at risk for emotional distress, fear, and a diminished quality of life.Findings included.An Abuse, Neglect, and Exploitation Policy, dated 08/29/2026, stated, neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. It also said that a report would be made to the appropriate agencies within two hours and an immediate and thorough investigation would be completed for any suspicion of abuse.Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 was cognitively intact and dependent on staff for most of their care.On 4/17/2026 at 3:15 PM, Resident 1 said on February 2 of 2026, Staff E, Certified Nursing Assistant, came into the room to provide care. Resident 1 said they were completely dependent on staff for changing and repositioning. Resident 1 said Staff E began rummaging around in their personal drawer which did not contain hygiene products. When Resident 1 asked why Staff E was looking through the drawer, Staff E became irate and started cussing at Resident 1. Staff E told Resident 1 to change themselves and left Resident 1 exposed as they walked out the door. Resident 1 said they felt threatened when Staff E said Resident 1 should be careful about how they talk to staff that serve them food. Resident 1 said they could hear Staff E telling other aides in the hall not to provide care for them.On 04/17/2026 at 3:15 PM, CC1, Family, said on 02/02/2026 around 10:00 AM, they received a phone call from Resident 1. CC1 said the resident was very upset and tearful due to being left exposed by a care giver. CC1 said they arrived at the facility ten minutes later and found Resident 1 naked on the bed. There were no blankets on or around the bed. The call light was not within reach. CC1 requested a grievance form and gave it to Staff D, Social Service Assistant, within the hour and was told there would be an investigation. CC1 said they had to request another grievance form on 02/25/2026 as they did not believe an investigation had been completed. CC1 said Staff E would mean mug them and Resident 1 whenever they passed each other.On 04/02/2026 at 2:15 PM, Staff D said they did not remember receiving a grievance form from CC1 on 02/02/2026.On 04/02/2026 at 2:30 PM, Staff C, Social Services Director, said they received a grievance form from CC1 on 02/25/2026 and began an investigation. It was completed by 03/12/2026. Staff C said during the investigation, Staff E was found to be neglectful, unprofessional, and rude to other staff and to some residents.On 04/02/2026 at 2:38 PM, Staff A, Administrator, said they were not aware of the abuse allegation until it was reported to them on 03/13/2026 by Staff C. Staff A said Staff E was suspended on 03/11/2026 and was terminated due to the investigation results on 03/19/2026. Staff A said Staff E worked 5 shifts from 02/25/2026 to 03/11/2026.On 04/02/2026 at 3:11 PM, Staff B, Regional Registered Nurse, said the incident should have been reported within two hours, an investigation should have been started on 02/02/2026, and Staff E should have been immediately suspended.Reference WAC 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to ensure the hot water used for beverage(s) were at a safe temperature for 1 of 3 residents (Resident 1) reviewed for accidents hazards. Resident 1 experienced harm when staff served them hot water directly from the dispensing machine without checking the temperature; the hot water spilled on the resident that resulted in a burn with blistering to the midline of their abdomen with reported pain and required wound care. This failure placed residents at risk for serious injury related to scalding and burns. Findings included . Consumer product safety commission publication 5098, undated, documented, Most adults will suffer third-degree burns if exposed to 150-degree [Fahrenheit F] water for two seconds. Burns will also occur with a six-second exposure to 140-degree water or with a thirty second exposure to 130-degree water.Resident 1 admitted to the facility on [DATE].The quarterly Minimum Data Set, dated [DATE], an assessment tool, showed Resident 1 was cognitively intact.Resident was not available for interview during course of investigation. Review of an investigative report, dated 02/18/2026, showed on that day around 6PM, Resident 1 rode their motorized wheelchair to the kitchen and asked for a cup of hot chocolate. Staff E, Dietary Aide, filled a cup directly from the hot water dispensing machine, added hot chocolate mix, secured a plastic lid on top, and handed it to Resident 1. Staff E did not test the temperature of the water first. Resident 1 placed the cup in their lap and rode outside. The report documented Resident 1 had said the water spilled through the straw hole of the lid. A nursing note, dated 02/18/2026 at 7:44 PM, documented Resident 1 reported to Staff D, Wound Care Nurse, two other nurses, and a provider that they had been burnt by the hot chocolate. Resident 1 was assessed by the nurses and the provider and was found to have a 10 centimeter (cm) long and 2.5 cm wide burn with blistering to the midline of their abdomen. When asked if the resident was in pain from the burn, she said, 'a little.'On 03/11/2026 at 12:51 PM, Staff C was observed filling a cup with water directly from the dispensing machine. The temperature was immediately taken and read 180.1 degrees F.On 03/11/2026 at 12:31 PM, Staff C, Dietary Director, said the temperature of hot water directly from the machine had always been 180-degrees F. Staff C said their process was to fill several carafes with hot water and then let them sit for about an hour until the temperature dropped to 140-degrees F. Staff C said if there weren't any carafes of 140-degree F water available, staff would use water directly from the machine and add ice cubes.On 03/11/2026 at 4:15 PM, Staff D, Wound Care nurse, acknowledged that burn included blistering and that classifying it as a Stage 2 burn (partial thickness - damage to the outer and middle layers of skin) would be accurate. On 03/16/2026 at 2:50 PM, Staff E, Dietary Aide, said they just got busy and forgot to check the temperature of hot cocoa before handing it to the resident. Staff E said the cups get warped in the dishwasher and the lids don't always fit correctly.On 03/16/2026 at 4:30 PM, Staff A, Administrator, said the burn was avoidable and should not have happened. Staff A said there needed to be some changes in operations in the kitchen.Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review the facility failed to provide necessary assistance with personal hygiene in a timely manner and in accordance with resident preferences for 2 of 3 residents (Residents 2 and Resident 3) reviewed for quality of care. This failure placed residents at risk for un-met care needs, feelings of neglect, and discomfort.Findings included .Resident 2Resident 2 was admitted to the facility on [DATE] due to a fall at home and subsequent lower back fractures. The re-admission Minimum Data Set (MDS, an assessment tool), dated 02/25/2026, showed Resident 1 was cognitively intact. Resident 1 needed extensive assistance for their activities of daily living (ADLs).Review of the care plan, dated 02/15/2026, showed the resident would receive a bed bath when a shower couldn't be tolerated. It did not specify how many per week or on what days.Review of the Bathing/Shower task form showed Resident 1 had not received a shower from 02/12/2026 to 03/08/2026. They had received a bed bath on 02/13/2026, 02/15/2026, 02/21/2026, 02/26/2026, and 03/08/2026.During an interview on 03/11/2026 at 2:18 PM, Resident 1 said they had not received showers or adequate bed baths since they admitted . They said the bed baths were only completed with some wet wipes and were not thorough. Resident 1 said they didn't know why they weren't getting showers but thought maybe it was due to the back fractures. Resident 1 said there hadn't been any communication from the staff. Resident 1 stated, I just feel so unclean and uncomfortable.Resident 3Resident 3 admitted to the facility on [DATE] due to a recent left lower leg amputation. The re-admission 5-day MDS, dated [DATE], showed Resident 3 was moderately cognitively impaired and needed extensive assistance with their ADLs.Review of the care plan, dated 02/05/2026, showed Resident 2 required one to two staff members for transfers and that their nails were to be cleaned and trimmed on bath day as necessary. It did not specify how Resident 3 needed to be showered or bathed, nor did it specify the number of days per week.Review of the Bathing/Shower task form showed Resident 1 had not received a shower from 02/14/2026 to 03/07/2026. They had received a bed bath on 02/21/2026 and on 03/07/2026.During an interview on 03/11/2026 at 3:32 PM, Staff B, Unit Manager, Licensed Practical Nurse, said the task forms were accurate and there was no additional documentation. Staff B said they had noticed over the previous few weeks that residents were not receiving their showers and or baths. Staff B said the floor aides were too busy.During an interview on 03/11/2026 at 4:30PM, Staff A, Administrator, said residents should be receiving bathing services at least twice per week and preferences should be reflected on the care plan.Reference WAC 388-97-1060(1)-(3)

.Based on interview and record review, the facility failed to ensure there was a designated and qualified Infection Preventionist (IP) responsible for the facility's Infection Control Program. This failure placed residents at risk for unmet infection control issues or care needs.Finings included .On 02/04/2026 at 3:15PM, Staff B, Director of Nursing Services, DNS, said Staff C, Registered Nurse (RN), had been assigned the role of IP since December of 2025. Staff B was unable to provide any information on the facility's Infection Prevention and Control Program. On 02/04/2026 at 3:37PM, Staff C, RN, said they were assigned two roles, Wound Care Nurse and IP. Staff C said they had graduated from nursing school just a few months prior and did not have any infection control experience other than nursing school. Staff C said they were working over 40 hours a week performing wound care and were unable to dedicate the requisite 20 hours per week for the IP role. Staff C said they had not begun the IP certification program. Refer to F880, Infection ControlWAC reference 388-97-1620(2)(b)(i)(ii)

.Based on interview and record review, the facility failed to establish an Infection and Control Program (IPCP) that included: developing an antibiotic stewardship program, to promote appropriate use of antibiotics and reduce the risk of unnecessary antibiotic use, including the development of antibiotic resistance. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of antibiotics.Findings included. On 02/04/2026 at 3:15PM, Staff B, Director of Nursing Services, was asked for the facility's IPCP which would include an antibiotic stewardship portion. Staff B said they did not know where any of the information for the facility's IPCP was. Staff B said they were unaware of any system being used to track antibiotic usage in the facility. Reference WAC 388-97-1620(2)(b)(i)(ii)

.Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive Infection Prevention and Control Program (IPCP) based on facility specific and community-based risk assessment. The facility failed to timely prevent, identify, and respond when Resident 1 exhibited respiratory symptoms, which significantly contributed to the spread of illness as Residents 2, 3, 4, & 5 subsequently tested positive. This deficient practice placed residents at risk for illness and outbreak transmission.Findings included.Resident 1 admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS, an assessment tool), showed Resident 1 was moderately cognitively impaired.A nursing note, dated 02/01/2026 at 1:34 PM, documented Resident 1 was complaining of breathing discomfort and chest pain. Resident 1 was transported to the hospital and was returned to the facility on the same day with a diagnosis of Respiratory Syncytial Virus (RSV, a highly contagious virus, often causing severe lung issues and or worsening chronic conditions).On 02/05/2026 at 10:20 AM, CC1 (Collateral Contact 1), Emergency Medical Technician, said Resident 1 was picked up from the facility on 02/01/2026 around 2:00 PM in a very disheveled state. CC1 said Resident 1 had yellowish liquid that smelled like vomit all over their body, impeding the placement of heart monitoring equipment. CC1 said Resident 1's bed, floor, and the bedside wall were covered in dry yellow liquid. They said none of the staff, including nurses and aides, who were going in and out of the room, were wearing Protective Personal Equipment (PPE) or were utilizing any sort of precautions. CC1 said Resident 1 was returned to the facility about 4 hours later. CC1 said the room looked the same and they had to clean it with disinfecting wipes they found outside of the room. Resident 1's roommate was still in the shared room and there were no infection precautions in place.On 02/04/2026 at 1:30 PM, a Contact Precautions (key measures include hand hygiene, gloves and a gown) sign was observed on the door to room [ROOM NUMBER]. At 1:32 PM, Staff E, Registered Nurse (RN), was observed coming out of the room without gloves or a gown. Staff E went directly to their medication cart without performing hand hygiene. Staff F, Certified Nursing Assistant (CNA), also came out of the room without gloves or a gown and went directly across the hall to another room without performing hand hygiene.On 02/04/2026 at 1:35 PM, Staff E was asked why there was a Contact Precautions sign on the door to room [ROOM NUMBER]. They said they thought it was due to one of the residents having a foley catheter (a tube in the ureter to drain urine) in place. When asked if Contact Precautions should be in place for a resident that has a foley catheter, Staff E said they did not know. They said there were never the right signs on the doors, and they didn't know who to talk to. Staff E said they had been a nurse for a long time and knew that the facility did not have a good infection control program.On 02/04/2026 at 3:15PM, Staff B, Director of Nursing Services (DNS), said Resident 1 should have been placed on a combination of Droplet Precautions and Contact Precautions (key measures include wearing masks, gloves, gown, eye protection, frequent hand hygiene, isolation of the resident) when they returned from the hospital. They said the room should have been thoroughly cleaned and disinfected. Staff B said Staff C, RN, became the Infection Preventionist (IP) in December of 2025 when the last IP left. Staff B said they did not know where any of the IPCP information was.On 02/04/2026 at 3:37PM, Staff C, RN, said they had not been trained, nor did they have time to perform the duties of an IP. Staff A, Administrator, was not in the building the week of February 2, 2026, through February 6, 2026, and was unavailable for interview.On 02/11/2026 at 10:37PM, Staff D, Regional Nurse Consultant (RNC), said they would immediately go to the facility and begin the process of creating an IPCP which would include the RSV infection.On 02/12/2026 at 11:52PM, Staff D, RNC, reported four new cases of RSV, including Resident 3. At 6:16 PM, three more cases were reported, including Resident 2, Resident 4, and Resident 5.Resident 2 admitted to the facility on [DATE]. The annual MDS, dated [DATE], documented Resident 2 was severely cognitively impaired.A nursing note on 02/08/2026 at 8:50PM documented Resident 1 had a low heart rate and was having difficulty breathing. The next morning on 02/09/2026 at 6:28 AM, the same nurse documented Resident 1 had passed away. At 10:02 AM, positive RSV lab results were received and documented. Resident 3 admitted to the facility on [DATE]. The annual MDS, dated [DATE], documented Resident 3 was severely cognitively impaired. A Health Status note, dated 02/09/2026 at 10:00 AM, documented a positive RSV lab had been received. On 02/11/2026 at 7:26 PM, Resident 3 was sent to the hospital for increased temperature and decreased oxygen saturation. Resident 4 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE] documented Resident 4 was severely cognitively impaired. A nurse's note, dated 02/13/2026 at 3:37 AM, documented Resident 4 was sent to the hospital for respiratory distress and increased temperature. Resident 5 was admitted to the facility on [DATE]. The annual MDS, dated [DATE], documented Resident 5 was severely cognitively impaired. A nurse's note, dated 02/13/2026 at 3:39 AM, documented Resident 5 was sent to the hospital for labored breathing and gurgling chest sounds. On 02/18/2026 at 10:09 AM, Staff D, RNC, said the lack of a comprehensive IPCP, the lack of a credentialed and trained IP, and the lack of infection control training and education for staff all contributed to the outbreak and severity of the RSV infection.Reference WAC 388-97-1320(1)(a)(2)(a)(2)(b)

.Based on observation and interview, the facility failed to ensure a resident's room was clean, free of potentially infectious bodily fluids, and free of a potential fire hazard for 1 of 3 residents (Resident 1) reviewed for a safe, sanitary, and homelike environment. This failure placed residents at risk for illness, fire and or burns, and a decreased quality of life. Findings included . Resident 1 admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS, an assessment tool), showed Resident 1 was moderately cognitively impaired.On 02/04/2026 at 2:55PM, Resident 1's room, 50 bed 2, was observed. The floor by the window was littered with debris, including ear cleaners, wrappers, and pill containers. The window seal, blinds, and along the edge of the floor trim had dark yellow brown substances. The sheet on the bed had food particles and stains of varying shapes and colors. A large disc heater was positioned on the dresser which was located below a large cork board. The heater was on and was producing a bright orange glow. The plug in was only halfway into the outlet. There were piles of clothes, bedding, and personal items all crowded around the heater.On 02/04/2025 at 11:03PM, Staff G, Maintenance Manager, observed the heater. Staff G said the fire marshal said the heaters were okay in facilities but needed at least 3 feet of clearance from any object. Staff G said there were too many items close to heater, including the corkboard, which would create a fire hazard. When asked how staff would know what the regulations were regarding space heaters in resident's rooms, he stated, They should just know.On 02/05/2026 at 11:45, Staff H, Housekeeping Manager, observed Resident 1's room. Staff H moved Resident 1's bed with their foot. Brownish yellow liquid could be seen oozing from under the bed frame legs. Staff H said the room was very dirty and that it was evident the room had not been deep cleaned for a long time. When asked how important cleaning rooms with potential pathogens (bacteria, virus, or microorganism) was, Staff H said it was very important to decrease the risk of spreading infection. On 02/23/2026 at 1:17PM, Staff A, Administrator, said they had determined Resident 1 would often refuse to have their room cleaned, but that staff should have reported the condition of the room and the refusals to management, especially when there was concern for infectious diseases. Staff A said the facility would no longer be allowing space heaters due to the risk of fires and burns. See F880, Infection ControlReference WAC 388-97-0880

Based on observation, interview, and record review the facility failed to ensure residents received necessary nursing assessment, monitoring, and/or care when licensed nursing staff were not actively involved in the assessment or management of residents' wounds and a change in condition and unlicensed medication or nurse technicians performed wound care and assessments without nursing oversight, resulting in complications and hospitalizations for 2 of 2 residents (Resident 1 and Resident 2) reviewed for care and services. Resident 1 experienced harm when their bilateral lower extremity wounds became infected, the resident had a change in consciousness and required transfer to the hospital where they were diagnosed with severe sepsis with organ disfunction (life-threatening whole-body response to infection). Additionally, the facility failed to ensure orders and care plan were in place regarding a peripherally inserted central line for 1 of 1 resident reviewed for central lines. These failures placed residents at risk for additional delayed treatments, diminished quality of life and medical complications and death.Findings included .RCW 18.88A.082 (4) A medication assistant may not: (a) Accept telephone or verbal orders from a prescriber; (b) Calculate medication dosages; (c) Inject any medications; (d) Perform any sterile task; (e) Administer medications through a tube; (f) Administer any Schedule I, II, or III controlled substance; or (g) Perform any task that requires nursing judgment.Resident 1Resident 1 was re-admitted to the facility on [DATE]. The 5-day admission MDS (Minimum Data Set, an assessment tool), dated 11/11/2025, showed Resident 1 had four bilateral lower extremity venous and or arterial ulcers and was cognitively intact. Resident 1 needed substantial assistance with activities of daily living (ADLs).Review of the December 2025 Treatment Administration Record (TAR) showed lower extremity edema (fluid build-up and swelling, can stretch the skin to the point of blistering and breakdown) monitoring was completed daily. Staff C and Staff D, Medication Technicians, signed off they had assessed and determined the amount of edema present for 13 days of the month (12/01/2025, 12/03/2025, 12/09/2025, 12/10/2025, 12/11/2025, 12/14/2025 -12/17/2025, 12/19/2025, 12/22/2025-12/24/2025).Resident 1's care plan, dated 11/28/2025, did not show documentation of edema or interventions, wounds, wound interventions and treatments, or signs and symptoms of infection. The care plan did not document which staff would be responsible for wound care management.A nursing progress note, dated 12/07/2025, documented bilateral lower extremities had multiple blisters, open wounds, and drainage to the lower extremities. Wound cultures were not ordered until 12/23/2025 when the out of facility wound care team saw the resident.Orders, dated 12/12/2025, showed advanced wound care including cleansing the wounds, application of special sterile dressings (calcium alginate with silver and collagen) was to be provided to the left anterior lower leg, left lateral lower leg, left medial lower leg, and right lateral lower leg in the AM and PM. On 12/14/2025 AM, 12/17/2025 AM, and 12/19/2025 AM, wound care was signed off by Staff C, Medication Technician.A provider note, dated 12/15/2025, documented Resident 1 was somnolent (abnormally drowsy) and was mumbling incoherently. Resident 1 had a lunch tray in front of him but was not eating. The note speculated that over sedation with oxycodone (a narcotic) was to blame for the drowsiness.Review of the December 2025 Medication Administration Record (MAR) showed Resident 1 had orders for oxycodone HCI, 2.5mg [milligrams] every four hours as needed for moderate to severe pain, and oxycodone HCI, 5mg every four hours as needed for severe pain. Resident 1 received 2.5mg at 4:30AM and 5mg at 11:10AM on 12/15/2025, for a total of two doses. The 5mg dose was discontinued at 2:01PM on 12/15/2025.Review of the Electronic Health Record (EHR) showed no nursing notes from 12/15/2024 through 12/25/2025 when the resident was transferred to the hospital.In an interview on 01/20/2026 at 3:46PM, Staff F, Certified Nursing Aid, said they had been caring for Resident 1 for the night shift, 6:00PM to 6:00AM on 12/24/2025. Staff F said they had been concerned about Resident 1 due to lack of responsiveness. Staff F said they informed the nurse around 9:00PM on 12/24/2025 and again at 4:00AM on 12/25/2025 about their concern. Staff F said the nurse took Resident 1's pulse both times but did not call Emergency Medical Services (EMS). On 12/25/2025 at 6:00AM, Staff G, Licensed Practical Nurse, documented Resident 1 was found unresponsive, with a fixed gaze, and hypothermic (body temperature dropping below 95 degrees Fahrenheit [F]) with a temperature of 90.3 degrees F. Resident 1 was sent to the hospital. Staff G was unreachable for interview.emergency room notes, dated 12/25/2025, documented Resident 1's rectal temperature was between 83-84 degrees F. Cultures from the lower extremity wounds showed gram positive cocci (a type of bacteria), Staphylococcus aureus (a type of bacteria), and Pseudomonas (rod shaped bacteria). Resident 1 also had Staphylococcus epidermidis bacteremia (a blood stream infection). Resident 1 also had thrombocytopenia (low platelets) and the physician documented, severe thrombocytopenia and a positive wound culture for pseudomonas support the diagnosis of sepsis and possible disseminated intravascular coagulation [life threatening condition where blood-clotting mechanisms malfunction]). Resident 1 passed away at the hospital on [DATE].On 01/20/2026 at 4:00 PM, Staff B, Director of Nursing Services (DNS), said assessing for and monitoring of edema was out of the scope of practice for a Medical Technician. Staff B said assessing and treatment of wounds was also out of the scope of practice for a Medical Technician. Staff B said Resident 1 should have been placed on alert charting for the increase in wound drainage, medication changes, and for clinical deterioration. Staff B said Licensed Nurses (LN) should have been performing all wound care for Resident 1 and should have been documenting a detailed recording of the wounds.Resident 2Resident 2 was admitted to the facility on [DATE] with a diagnosis of severe esophageal stenosis (narrowing of the esophagus making it difficult to swallow). The 5-day admission MDS, dated [DATE], showed Resident 2 was moderately cognitively impaired and needed partial assistance with ADLs.Resident 2's care plan, dated 10/27/2025, showed Resident 2 was on a full liquid diet consisting of supplements. Resident 2's liquids could be thin in consistency. A Daily Skilled Evaluation Form, dated 12/17/2025 AM shift, documented Resident 2 had normal breathing patterns, did not have shortness of breath, and had clear lung sounds. No nursing evaluations were completed for 12/18/2025 or 12/19/2025.A provider note, dated 12/18/2025, documented Resident 2 was short of breath, had audible wheezing, and had a non-productive cough. A chest x-ray was ordered but was not completed.A nursing note created by Staff E, Nursing Tech, dated 12/20/2025 at 6:53 PM, documented Resident 2 was struggling to breathe, had audible wheezing, and was coughing up blood. Staff E called EMS. Resident 2 was taken to the hospital and admitted for aspiration pneumonia (lung infection caused by inhaling substances such as liquid).On 12/29/2025 at 5:20 PM, Staff E, Nurse Technician, said Resident 2 had been coughing up blood for two days. When asked if a Registered Nurse (RN) had assessed the resident in the previous two days, they said they did not know. When asked if a Registered Nurse had assessed the resident before EMS was called, Staff E stated, No. When asked why, they said there was only one RN in the building for 83 residents. Staff E said they felt overwhelmed at the time.On 12/29/2025 at 5:30 PM, Staff B, DNS, said due to Resident 2's symptoms, the chest x-ray should have been obtained as soon as possible. Staff B said Resident 2 should have been placed on alert and closely monitored by an LN. Staff B said it was out of Staff E's scope of practice to make the judgment call to send a resident to the emergency room. On 12/29/2025 at 5:45 PM, Staff A, Administrator, said the facility would no longer be employing Nurse Technicians or Medication Technicians. Staff A said LN's should have completed and documented assessments of all residents.Resident 3Resident 3 was admitted to the facility on [DATE] for intravenous (via the vein) antibiotic therapy for pneumonia (lung infection). The 5-day admission MDS, dated [DATE], showed Resident 3 was cognitively intact and needed substantial assistance with ADLs. Resident 3 had a Peripherally Inserted Central Catheter (PICC -thin, flexible tube inserted into an arm vein and guided to a large vein near the heart), in their right arm.A provider note, dated 12/18/2025, documented Resident 3 had concerns about the PICC dressing as it was falling off and was at risk for infection. The note said nursing would be notified so that it could be changed.Review of the December 2025 TAR showed two orders for PICC dressing changes. The first order read to change weekly and was completed on 12/14/2025. The second order read to change as needed every 24 hours. There was no documentation the dressing had been changed on 12/18/2025. Both orders read, Measure upper arm circumference and external catheter length on admission and with each dressing change. There was no documentation providing this information.Resident 3's care plan, dated 12/15/2025, acknowledged the presence of a PICC in the right arm but there were no interventions or what to monitor for. There were no directions on blood draws. There were no instructions about not taking blood pressures on the right arm. There were no instructions on the sterile technique process required for dressing changes.On 12/29/2025 at 4:15PM, Staff B, DNS, said the PICC should have been changed as ordered and detailed instructions/interventions should have been added to the care plan.Reference WAC 388-97-1060(1-3)Reference RCW 18.88A.082

Based on interview and record review, the facility failed to ensure timely pharmacy services by not having a system in place to obtain ordered antibiotics in a timely manner, resulting in a delay in administration of prescribed antibiotics for 1 of 3 residents (Resident 1) reviewed for care and services. This placed resident at risk of prolonged infection, delay in care and a decreased quality of life. Findings include:Resident 3 was admitted to the facility on [DATE] for intravenous (via the vein) antibiotic therapy for pneumonia (lung infection). The 5-day admission MDS, dated [DATE], showed Resident 3 was cognitively intact and needed substantial assistance with ADLs. Resident 3 had a Peripherally Inserted Central Catheter (thin, flexible tube inserted into an arm vein and guided to a large vein near the heart), PICC, in their right arm. Review of the December 2025 Medication Administration Record showed Meropenem-Sodium Chloride 1 gram IV every 8 hours was ordered on 12/13/2025 and the first dose was due at 11:00PM that night. The medication was not given until 7:00AM on 12/15/2025 due to unavailability. Resident 3 had missed four doses by that time. A provider note, dated 12/19/2025, documented labs showed an increase in white blood cells (possible indication of infection) and Resident 3 reported not feeling well. Resident 3 was sent to the hospital. On 01/20/2026 at 2:00PM, Collateral Contact 1 (CC1), Social Worker at the hospital, said Resident 3 expressed frustrations with the facility due to not receiving medications and treatments as ordered. CC1 said Resident 3 feared for their well-being at the facility and had no intention of returning. On 12/29/2025 at 4:15PM, Staff B, DNS, said the PICC should have been changed as ordered and detailed instructions/interventions should have been added to the care plan. Reference WAC 388-97-1300(1)(b)(i)(ii)

Based on interview and record review, the facility failed to notify the Power of Attorney and or Legal Guardian of significant changes for 1 of 3 residents (Resident 1) reviewed for significant changes. This failure placed responsible parties at risk for not being able to make informed decisions. Findings included.Resident 1 admitted to the facility on [DATE] and had a diagnosis of Dementia. The significant change Minimum Data Set (an assessment tool), dated 09/29/2025, showed Resident 1 was severely cognitively impaired. Review of Resident 1's profile/demographics showed they had a legal guardian in place who was the first contact for any changes.Review of hospital records, dated 10/05/2025, showed Resident 1 was seen in the emergency room due to an assault by a roommate. Resident 1 had suffered skin impairments to the left elbow and left pointer finger lower knuckle. Resident 1 was returned to the facility later that same day and was moved to a different room. On 11/18/2025 at 2:51PM, Collateral Contact 1 (CC1), Legal Guardian, reported they had not been informed of the altercation and subsequent injury, the emergency room visit, or the room change.On 11/25/2025 at 4:15PM, Staff A, Administrator, said staff should have contacted the legal guardian as soon as the incident occurred and informed them of the room change.Reference WAC 388-97-0320(1)(a)(d)(2)(a)(b)

Based on observation, interview and record review the facility failed to provide ordered pain-relieving interventions in a timely manner for 1 of 3 residents (Resident 1) reviewed for pain management. This failure placed residents at risk for unmet needs, anxiety, and a diminished quality of life.Finding included.Resident 1 admitted to the facility on [DATE] at 2PM from the hospital after having a left ureteral stint placement (a procedure where a thin, flexible tube is inserted into the ureter to ensure urine flows from the kidney to the bladder). The admission 5-day Minimum Data Set (an assessment tool), dated 11/12/2025, showed Resident 1 was cognitively intact and had pain that interfered with activities of daily living. During an interview and observation on 11/25/2025 at 2:35 PM, Resident 1 said they had severe pain to the left flank, 7 out of 10 on the pain scale. Resident 1 said they had not received the noon dose of Tylenol and had been waiting for over two hours for as needed (PRN) medication. Resident 1 said they had asked several staff members. Resident 1 said the nurses had not been adequately managing the pain since admission to the facility. Resident 1 stated they did not have any patches on their body. No patches were observed on Resident 1. Review of Resident 1's orders and Medication Administration Record (MAR) for November 2025 reviewed on 11/25/2025 at 2:40PM, showed Resident 1 had the following pain medications ordered and received:Order dated 11/19/2025, tramadol HCI oral tablet every eight hours PRN for groin pain. The most recent dose was documented as given on 11/21/2025 at 6:35PM. Order dated 11/07/2025, lidocaine patches applied topically at 8AM and removed after 12 hours. The most recent application was documented by a medication technician at 8AM on 11/25/2025. Order dated 11/06/2025, oxycodone10 milligrams (m)g every six hours PRN for severe pain. The most recent dose had been documented as given received on 11/25/2025 at 6AM for an undocumented pain level. Order dated 11/06/2025, Tylenol oral tablet 325mg, 3 tablets every 6 hours for pain. The 6AM and 6PM doses were not given on 11/19/2025. The 6AM dose was not given on 11/20/2025 and 11/25/2025. The November 2025 MAR showed Resident 1 did not receive scheduled Tylenol until 12AM on 11/07/2025 and did not receive PRN oxycodone until 8:04AM on 11/08/2025.On 11/25/2025 at 3:30PM, Staff A, Medical Technician, was asked if they were aware Resident 1 was in pain and had requested PRN pain medication. Staff A said they were not aware. When asked if they had applied the Lidocaine patches that morning, Staff A said they had. When informed that Resident 1 did not have any patches on, Staff A said they must have forgotten.On 11/25/2025 at 3:45PM, Staff B, Director of Nursing, said they had completed training with staff about signing for medications before giving them. Staff B did not know why it took 10 hours on the day of admission for Resident 1 to receive Tylenol or why it took 42 hours to receive PRN oxycodone. Staff B said Resident 1 should be receiving scheduled and PRN pain medications in a consistent and timely manner. Reference WAC 388-97-1060(1)

Based on interview and record review, the facility failed to involve the resident's representative in the development of the resident's plan of care, inform the representative of changes in the plan of care and review the plan of care for 1 of 3 (Resident 1) residents reviewed. This failure placed residents at risk of lack of advocacy for their healthcare needs, preferences and medical history. Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia, bipolar disorder (a chronic mental health condition characterized by extreme mood swings) and diabetes (a condition where the body does not produce or use insulin effectively, leading to high blood sugar levels).Resident 1's Clinical admission Assessment, dated 08/05/2025, showed Resident 1 was chronically confused and had moderate cognitive impairment.Resident 1's Durable Power of Attorney for Health Care (DPOA-HC) dated 10/02/2023 and uploaded to Resident 1's electronic medical record (EMR) on 08/05/2025, showed Collateral Contact 1 (CC1) was Resident 1's chosen agent and was effective on the date the DPOA-HC was signed.On 09/09/2025 at 1:10 PM, CC1, said Resident 1 had been a diabetic for years and had been on insulin to manage their diabetes. CC1 said when Resident 1 was admitted to the facility Resident 1 had not been admitted with insulin orders but CC1 was not informed of that. CC1 said the facility discontinued many of Resident 1's medications for their bipolar disorder that had kept their condition stable without notifying CC1. CC1 said staff informed them the medications were discontinued due to Resident 1 having nausea and vomiting. CC1 said they had not been informed that any medications had been discontinued and were very concerned because CC1's diabetes and bipolar disorder had been stabilized with those medications. CC1 said they were working with an assisted living facility for Resident 1 to move to after their stay at the facility. CC1 said the assisted living facility could not accept Resident 1 due to unstable blood sugar levels. CC1 said they had never seen Resident 1's care plan and had requested to view it, a list of Resident 1's medications, including when medications had been started and stopped and the blood sugar readings. CC1 said they were not contacted until the end of August by the medical provider but had still not received the plan of care and/or the answers to the specific questions regarding the medications even after repeated requests. CC1 said the staff had not made an effort to collaborate with CC1 regarding the plan of care.Resident 1's progress notes, dated 08/06/2025, showed Resident 1 continued with nausea and vomiting, up throughout the night with emesis (vomit) brown liquid and the medical provider notified.Resident 1's progress note, dated 08/07/2025, showed an IV (a catheter used to administer medications and/or liquids into a vein) was inserted and Sodium Chloride (solution used to rehydrate) was running per the orders.Resident 1's medical provider notes, dated 08/07/2025, showed Resident 1's dementia was advanced, and they were oriented to self and place but had marked short term memory loss. The note showed since arrival at the facility, Resident 1 had nausea and vomiting, somnolence (sleepiness), and poor intake. The note showed the nausea, vomiting, and somnolence was possible due to medication or metabolic cause and the plan was to order labs and start IV fluids for 48 hours for hydration. The noted showed staff were to discontinue medications to include medications for diabetes and bipolar disorder.Resident 1's EMR (electronic medical record) showed no notification to CC 1 regarding the medications being discontinued, lab orders and/or the IV hydration.Resident 1's medical provider notes, dated 08-29-2025, showed a care conference was held with the resident and CC1. The note showed the staff discussed multiple issues regarding Resident 1's admission, medication management and progress.On 09/17/2025 at 1:12 PM, CC2, resident advocate, said they had attended Resident 1's care conference on 08/29/2025 and the facility staff were unable to answer all CC1's questions. CC2 said it was very frustrating.Review of an email from CC1 to facility staff, dated 09/04/2025, showed CC1 addressed concerns to the team that was taking care of Resident 1 to include: the plan for Resident 1 due to their insurance ending, an assessment of Resident 1's current condition, Resident 1's medication list, a final report from PT [physical therapy], OT [occupational therapy] and ST [speech therapy]. The email showed that CC1 did not know Resident 1's plan of care and it was not discussed in the care meeting.Review of an email from facility staff, dated 09/04/2025, showed facility staff responded to CC1's questions but wrote that CC1 should let them know if they still had concerns.Review of an email from CC1 to facility staff, dated 09/05/2025, showed CC1 had questions that were not addressed in the 09/04/2025 email from facility staff and had asked for a care plan and had not received it. CC1 wrote it was a deep concern to them. CC1 requested information about a swallowing issue from the evening prior. Facility staff responded to the email on 09/05/2025 and said they would schedule a care conference to address the rest of the questions.Review of an email from CC1 to facility staff, dated 09/10/2025, showed CC1 was following up regarding the care conference, they had not heard from the staff.Review of an email from CC1 to facility staff, dated 09/11/2025, showed CC1 had asked for a care meeting to answer CC1's questions and had not heard back. The email showed CC1 had questions regarding medication status, therapy and discharge, and the email showed CC1 was upset at the lack of response to their questions and requests.On 09/17/2025 at 2:33 PM, Staff A, Resident Care Manager and licensed practical nurse, said they had been Resident 1's care manager since admission on [DATE]. Staff A said they had a care conference on 09/16/2025 with CC1 and that was the first time they had spoken to them. Staff A said it was the responsibility of the license nurses on the floor to notify residents' representatives of changes in a resident's care.On 09/17/2025 at 4:00 PM, Staff B, Director of Nursing, said they expected when residents had a change in condition and/or changes to the plan of care the DPOA-HC should be notified. Staff B said CC1 should have been notified of Resident 1's clinical change of condition, medications changes and plan of care. When asked if CC1 should have been sent Resident 1's plan of care, Staff B said yes, they should have had that information. On 09/17/2025 at 5:33 PM, Staff C, Administrator, said they understood why CC1 was frustrated, and they should have been involved in Resident 1's care since admission to include the plan of care and changes to their medications.WAC Reference 388-97-1000(1)(a),1020 (2)(f)

Based on interview and record review the facility failed to obtain and monitor laboratory tests timely per physician orders for 1 of 3 residents (Resident 1) reviewed. This failure placed residents at risk of clinical complications, unstable medical conditions and delayed recovery. Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia, bipolar disorder (a chronic mental health condition characterized by extreme mood swings) and diabetes (a condition where the body does not produce or use insulin effectively, leading to high blood sugar levels).Resident 1's medical provider notes, dated 08/07/2025, showed since arrival at the facility, Resident 1 had nausea and vomiting, somnolence (sleepiness), and poor intake. The note showed the nausea, vomiting, and somnolence was possible due to medication or metabolic cause and the plan was to order labs and start IV fluids (liquids administered through a catheter in the vein) for 48 hours for hydration. The note showed the plan was to order laboratory tests. Resident 1's physician orders, dated 08/07/2025, showed an order to draw a CMP (test to monitor electrolyte balance), CBC (blood test that measures the number and types of cells in the blood), TSH (blood test to monitor thyroid function), Hgb A1C (lab related to diabetes) and a valproic acid level (anti-seizure medication - checking for level of medication in blood).Resident 1's provider notes, dated 08/19/2025, showed labs still pending and Depakote was held pending labs.Review of Resident 1's laboratory results, dated 08/25/2025, showed results for CMP, CBC, and TSH.Review of Resident 1's laboratory results, dated 09/04/2025, showed results for a valproic level.Review of Resident 1's electronic medical record (EMR) showed no result for the Hgb A1C.On 09/17/2025 at 2:33 PM, Staff A, Resident Care Manager and Licensed Practical Nurse, reviewed Resident 1's EMAR and contacted the facility laboratory to obtain all lab results from Resident 1. Staff A could not locate a Hgb A1C lab result and verified the CMP, CBC and TSH were not collected until 08/25/25 and the valproic acid level was completed on 09/04/2025.On 09/17/2025 at 4:00 PM, Staff B, Director of Nursing, said when medical providers order labs to be drawn they expect them to be completed timely.WAC Reference 388-97-1620(2)(b)(i)

.Based on observation, interview, and record review, the facility failed to provide the appropriate care and services for 2 of 3 residents (Resident 1 and Resident 2) reviewed for indwelling catheter (a flexible tube inserted into the bladder to drain urine) care and maintenance. Resident 1 experienced harm when their indwelling suprapubic urinary catheter was not changed monthly as ordered and required hospitalization due to catheter related complications. This failure placed residents with indwelling catheters at risk of medical complications. Findings included.An Indwelling Catheter Policy, revised 12/2024, stated indwelling catheters need, Orders to include type of catheter (size and balloon size), diagnosis, and catheter change orders to include change complete catheter system prn, blockage, leakage, encrustation, catheter care every shift and change catheter bag as needed.<Resident 1>Resident 1 admitted to the facility on [DATE] with a diagnosis of obstructive uropathy (a urinary tract disorder that occurs when the urine flow is blocked) and had an indwelling urethral catheter. The quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 was cognitively intact and needed minimal assistance with activities of daily living (ADL's). Review of the electronic medical record (EMR) showed Resident 1 had the indwelling urethral catheter removed and a suprapubic (small opening in the lower abdomen through which a catheter is inserted directly into the bladder) catheter placed on 07/25/2024. Orders documented to follow up in four to six weeks for catheter change. Resident 1 was seen at a clinic on 08/24/2025 where the suprapubic catheter was changed and was sent with orders following that visit said to change out the catheter monthly. Review of the care plan, dated 07/26/2024, showed to document the size and type of catheter to change the catheter per physician order. Review of the Treatment Administration Record (TAR) from July of 2024 to June of 2025 did not have an order to change the catheter.Review of the EMR showed the suprapubic catheter was changed out by the facility Physician Assistant-Certified (PA-C) on 10/02/2024 and 11/12/2024. Review of a Resident Choice of Medication, Treatment and/or Dietary Restriction form, dated 11/12/2024, was signed by the PA-C and Resident 1. The form addressed the following risks of not changing the catheter out monthly: urinary tract infection, catheter blockage, bladder spasms, skin breakdown, bladder stones, and/or kidney failure. o Review of progress notes, dated 12/19/2024, 02/01/2025, and 03/10/2025, showed Resident 1 refused the catheter change. No further documentation was provided regarding possible alternatives or the increase in risks. There was no documentation about catheter changes or refusals for January 2024, April 2024, May 2024, or June of 2024. Facility records showed the catheter had not been changed since 11/12/2024 through 06/24/2025 (224 days) when the resident was sent to the hospital. Review of progress notes showed Resident 1 was sent to the hospital on [DATE] due to not having urine output in the collection bag attached to the suprapubic catheter. Review of hospital documentation, showed Resident 1 had significant cellulitis (infection of the skin) along the inside of both legs and groin area from leaking urine. The emergency department attempted to remove the suprapubic catheter, but it was too painful due to calcifications (buildup of calcium salts which harden) that were formed inside the bladder. Resident 1 was admitted to the hospital for surgical removal of the suprapubic catheter and intravenous (in the vein) medications for cellulitis and a urinary tract infection. On 07/29/2025 at 3:40PM, Staff C, Registered Nurse (RN), said they were aware of Resident 1's skin issues but didn't realize how bad they were until the wound nurse notified them on 05/16/2025 and they went to assess. Staff C said there was a strong urine odor. Resident 1 was sent to the hospital and was diagnosed with dermatitis (skin inflammation), was prescribed cream, and was sent back the same day. Staff C said they thought the dermatitis was caused by Resident 1 emptying his urine bag and having some dribble down the legs. When asked if the nursing team had discussed the catheter being changed out, Staff C said they did not. When asked if the skin conditions could have been caused by the catheter becoming obstructed and leaking, they said yes. Staff C said they thought the PA-C was changing it. When asked if changing a suprapubic catheter was within the scope of an RN, they said yes. On 07/29/2025 at 4:25PM, Staff B, Director of Nursing (DNS), said they were not aware that the catheter had not been replaced for several months. Staff B said they thought the PA-C was completing that task. When asked if the facility had a policy for suprapubic catheters, Staff B said they did not. When asked if changing a suprapubic catheter was within the scope of an RN, they responded, yes. On 07/29/2025 at 5:06PM, Resident 1 had returned from the clinic after having their catheter changed. Resident 1 said they had been under the impression that the catheter needed to be changed every 6 months or so. When asked if they had understood the severe complications that could happen if the catheter was not changed out monthly, Resident 1 said they did not. They said if they had, they would never have refused. <Resident 2>Resident 2 admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 2 had severe cognitive impairment and was dependent on staff for all ADLs. Review of the care plan, dated 05/16/2025, showed Resident 2 had a urethral foley catheter in place. The care plan interventions and tasks did not include when the catheter needed to be replaced. Review of the TAR showed an order for the catheter to be changed every month with a start date of 02/06/2024. The TAR showed the catheter was not changed for the month of May 2025. On 07/29/2025 at 4:40PM, Staff B, DNS, said all catheter care and maintenance should be on the care plan. They said orders should be obtained for changing out a catheter on admit or as soon as a catheter is placed. Reference WAC 388-97-1060(3)(c) .

Based on interview and record review the facility failed to intervene timely and/or provide necessary supervision during a resident-to-resident altercation for 2 of 3 residents (Resident 1 & 2) reviewed for accidents and supervision with known histories of agitation and inappropriate behaviors. Resident 1 experienced harm when they developed a subdural hematoma (blood pooling on surface of the brain) during the altercation. The failure to provide adequate interventions and supervision during resident altercations placed all resident at risk for potential injuries or harm. Findings included . Review of the facility policy titled, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Injuries of Unknown Source, and Misappropriation of Resident Property, dated ,d+[DATE], documented that staff were trained in the utilization of appropriate interventions to deal with aggressive and detrimental reactions of residents, they were trained how to provide protection for the residents. Staff were to prevent adverse events by ongoing supervision of residents and recognitions of signs of resident-to-resident frustration or stress and to identify, intervene, and correct situations where residents with needs and behaviors might lead to abuse. When staff identified events such as resident to resident altercations, they were to provide for the residents' immediate safety by moving the resident to another room or unit. Review of the facility's incident reporting log, for [DATE], showed a resident-to-resident altercation between Resident 1 and Resident 2 occurred on [DATE] at 9:15 PM in a common area of the facility and Resident 1 sustained injuries. <Resident 1> Resident 1 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS), an assessment tool, dated [DATE], documented they had moderate cognitive impairment, sometimes could make themselves understood and/or understand others. The MDS also documented Resident 1 displayed verbal and physical behaviors that significantly interfered with the resident's care and placed others at significant risk of physical injury and was dependent on two staff members for bed mobility, transfers, toileting, and dressing. Resident 1 was dependent on a wheelchair for mobility. The care plan for behavioral problems related to anxiety and agitation, initiated on [DATE], documented Resident 1 could be verbally and physically abusive at times. Goals included to have no injury to self or others and interventions included to intervene as necessary to protect the rights and safety of others, approach in a calm manner, divert attention, and remove the situation and to take resident to an alternate location as needed. An incident note, dated [DATE] at 10:45 PM, documented Resident 1 was dragged out of the wheelchair to the floor by another resident [Resident 2] who was showing signs of aggression and incapacitation including speech and odor of alcohol. An alert note, dated [DATE] at 4:37 PM, documented Resident 1 was pronounced deceased at 3:35 PM. <Resident 2> Resident 2 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented the resident was cognitively intact, displayed verbal behaviors that significantly interfered with residents' care/put others at risk for injury, was intrusive to others and significantly disrupted the living environment. Resident 2 was independent for all activities of daily living and used no assistive devices. The care plan focus for behavioral problems related to alcohol abuse, insomnia, anxiety, and auditory hallucinations, initiated on [DATE], documented interventions included the resident would report they was drinking alcohol at times, mostly in the evening and the resident may experience elevated mood/behaviors towards others, and staff were to intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, and remove from the situation and take to alternate location as needed. A mood and behavior note, dated [DATE] at 9:11 PM, documented Resident 2 was noted to be drunk and belligerent during and after medication administration. <Incident> The facility investigation report showed on [DATE] at 9:15 PM, that Resident 1 was sitting in their wheelchair near the nurses' station when Resident 2, who appeared to be intoxicated, approached Resident 1 and attempted to pull up Resident 1's pants. Staff intervened and asked for Resident 2 to move back and away from Resident 1. Resident 2 became verbally aggressive to staff. The staff stayed at the nurse's station to observe, Resident 2 then re-approached Resident 1 and after Resident 1 grabbed Resident 1's arm, Resident 2 aggressively pulled back which caused Resident 1's wheelchair to tip over. Resident 1 was assessed for injury and a 5-centimeter (cm) x (by) 2 cm bruise was noted over Resident 1's left eye. Resident 1 was transferred back to their wheelchair. An incident note, dated [DATE] at 12:03 PM, by Staff B, Registered Nurse/Director of Nursing, documented events from the previous evening, [DATE], including that Resident 2 appeared, per staff, to be intoxicated, was being verbally abusive to staff, ignoring staff directions and persisted in initiating contact with Resident 1, Staff B documented Resident 2 was observed instructing Resident 1 to grab on this, bite on this while holding their arm out to them. Resident 1 grabbed onto Resident 2's arm and when Resident 2 was unsuccessful in pulling their arm away, Resident 2 pulled aggressively, causing Resident 1's wheelchair to topple over on its side where Resident 1's head struck the floor. All staff witness statements were reviewed and were similar and consistent with the facility investigation and incident notes as documented above. Review of facility incident log showed Resident 1 had no documented falls since admission. The Coroner's Report for the death of Resident 1, dated [DATE] 09:00 AM, as time of examination, documented Resident 1's cause of death was an accident and the manner of death to be a subarachnoid hemorrhage (bleeding in the space that surrounds the brain) as a consequence of blunt force trauma to the head. <Staff Interviews> On [DATE] at 4:26 PM, Staff F, Nursing Assistant (NA) said Resident 1's usual behaviors were to yell, grab and swear, but once they were in bed for the night, they were usually good until early morning. Staff F said Resident 2's usual behaviors were dependent on if they seemed under the influence of something, and if so, they would be loud with the other residents and be more involved than was necessary. Regarding the incident on [DATE], Staff F recalled Resident 2 had returned to the facility at approximately 8:30 PM that night and initially went to their room. Staff F said Resident 2 came back out some minutes later and told staff that Resident 1 needed help getting their pants pulled up. Staff F accompanied by Staff I (NA) went to another room to attend to another resident and Staff G (NA) and Staff H (NA) were at the nurses' station. When Staff F and Staff I came out of the other resident's room, approximately 5 minutes later, Staff G and H were assisting Resident 1, while Resident 2 was interfering with the process and sticking their arm out and was not responding to direction to leave the area. Staff F said they were able to get Resident 2 to move back from Resident 1. When they finished providing care to Resident 1, Staff F, G, and H went behind the nurses' station and Staff I remained in front of the station to observe. Staff F said after a few minutes, Staff I entered the nurses' station and that was when Resident 2 approached Resident 1 again and Resident 1 grabbed Resident 2's arm and yanked [their] arm and [Resident 1] fell to [their] left side. Staff F said Resident 1 was not removed from the area because they needed the resident to settle down before they would be able to provide care. On [DATE] at 4:02 PM, Staff H, said the usual behaviors for Resident 1 were to yell, use vulgar language and grab onto people. Staff H said usual behaviors for Resident 2 depended on if Resident 2 seemed under the influence of alcohol, they would not listen to staff, would be loud and mean. Staff H said Resident 2 continued interfering with care they were providing Resident 1, and did not respond to verbal direction from staff. Resident 2 kept saying things to Resident 1 on the night of the incident and Resident 1 was swearing back. Staff H said they were charting at the nurses' station when the accident occurred. Staff H said the time frame of the interaction was approximately 15 minutes. Staff H said Resident 1 was not removed from the area because they were a fall risk. On [DATE] at 4:29 PM, Staff G, said usual behaviors for Resident 1 would fluctuate depending on the day, some days Resident 1 would grab your hand and kiss it and other days Resident 1 would grab you and try to bite you, and the day of the incident, [DATE], Resident 1 was being aggressive. Staff G said Resident 2 could be aggressive towards staff. Staff G said Resident 2 returned to the facility after 8:00 PM that evening and told them Resident 1 needed help with their pants, Staff G and H were behind the nurses' station charting at the time, they instructed Resident 2 to leave the area, but Resident 2 did not listen, staff assisted Resident 1 with pulling up his pants and then returned to charting. Staff H stated, [Staff F] and I came to the area and all four nursing assistants were behind the nurses' station at the time of the accident. When asked how long the whole interaction took place, Staff G replied, Maybe ,d+[DATE] minutes. Staff G said Resident 1 was not moved from the area because they were a fall risk. On [DATE] at 5:00 PM, Staff J, Licensed Practical Nurse, (LPN) said Resident 1's usual behavior would be to grab onto people if they were close. Resident 2's behaviors were usually dependent on whether they were intoxicated, and Resident 2would yell and be confrontational. Staff J said he was not in the immediate area at the time of the altercation. Staff J said the staff's first response in a resident-to-resident altercation would be to get the residents out of immediate danger. Staff J said Resident 1 was not moved because they were a fall risk. On [DATE] at 7:01 PM, Staff I, said usual behaviors for Resident 1 were agitation and yelling. Staff I said usual behaviors for Resident 2 appeared when they seemed to be under the influence and Resident 2 would then argue with people, have slurred speech and impaired walking. Staff I said Resident 2 was physically and verbally interfering with them while they were trying to provide care to Resident 1 and Resident 2 did not respond to verbal direction of staff. Staff I said the interaction lasted not more than ,d+[DATE] minutes. When asked why Resident 1 was not moved from the area, Staff I said it was their first day assigned to this resident and the other staff said it was better to let Resident 1 calm down before trying to lay the resident down. On [DATE] at 1:38 PM, Staff E, Social Services Director (SSD), said the usual behaviors for Resident 1 was attempting to grab onto staff and cussing. Staff E said the usual behaviors for Resident 2 were aggressiveness towards staff and alcohol related behaviors. Staff E said during a resident-to-resident altercation staff should remove the threat and make sure everyone was safe. On [DATE] at 9:20 AM, Staff C, LPN, Unit Manager, said during a resident-to-resident altercation she would expect staff to separate the residents and make sure everyone was safe. She did not know why staff did not remove Resident 1 from the area at the time of the altercation. On [DATE] at 12:13 PM, Staff B, Registered Nurse (RN), Director of Nursing (DNS) said Resident 1's usual behavior could fluctuate, but Resident 1 would try to hold onto staff and could get agitated and verbally cuss. Staff B said Resident 2's behaviors would be verbal aggression and frequent intoxication. Staff B said these behaviors had been Resident 2's baseline behaviors as long as they had been at the facility. Staff B said during a resident-to-resident altercation the first action would be resident safety and separating the two residents to make sure they were safe. When asked why staff had not removed Resident 1 from the area Staff B stated, I cannot say for sure, but two of them [staff] said they felt they needed to keep [Resident 1] in an open space to watch [them]. When asked if they would have expected staff to remove Resident 1 from the area, Staff B said if it was safe to do so it was expected that staff would remove residents from the setting. On [DATE] at 11:31 AM, Staff A, Executive Director said during a resident-to-resident altercation they would expect staff to separate the residents and keep them both safe. Staff A did not know why staff did not separate Resident 1 and Resident 2. Staff A said they would have expected them to do so, But that did not happen. Reference WAC: [DATE](3)(g)

Based on interview and record review, the facility failed to identify, assess, and monitor a pressure ulcer (PU - an injury to skin and underlying tissue resulting from prolonged pressure on the skin) and to implement orders timely to prevent the PU from deterioration and infection for 1 of 3 sampled residents (1), reviewed for PUs. Resident 1 experienced harm when the facility did not identify, monitor, or implement orders to care for a PU resulting in the resident developing septic shock (a potentially fatal condition when organs fail as a result of an infection) and a Stage 3 PU (full thickness loss of skin exposing subcutaneous tissue). This failure placed residents at risk for wound infection, delayed healing, increased pain, and a decreased quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including a stroke and heart failure. The Minimum Data Set (MDS ), an assessment tool, dated 10/12/2023, documented Resident 1 had severe cognitive impairment and was dependent on staff for activities of daily living . The hospital wound notes for Resident 1, dated 09/25/2023, (prior to admission to the facility), documented Resident 1 had impaired skin on the buttocks due to friction and incontinence associated dermatitis and there was scattered breakdown of the skin but that it was in a stage of healing and there were no signs of infection. Resident 1's Admission Evaluation - Skin Integrity notes, dated 10/06/2023, documented Resident 1 had a small skin tear on their buttocks with a dressing that was clean, dry, and intact. Resident 1's Total Body Skin Evaluation, dated 10/06/2023, documented Resident 1's right buttock had a small skin tear and the dressing was clean, dry, and intact. Resident 1's nursing progress notes, dated 10/06/2023, documented Resident 1 had a small skin tear to the buttock with the dressing clean, dry, and intact. Resident 1's provider visit notes, dated 10/09/2023, documented Resident 1's skin was intact with no lesions. No orders were provided for skin integrity concerns. The facility admission History and Physical, dated 10/13/2023, documented Resident 1's skin had no rashes or lesions and Resident 1's skin was warm and dry. The Wound Clinic notes, dated 10/12/2023, documented Resident 1 had an unstageable PU to the buttock. The wound measured 10 centimeters (cm) x 9 cm x 0.2 cm. The wound had heavy, bright red drainage. A picture of the wound showed black tissue covering Resident 1's buttock with some of the underlying tissue visible. The tissue appeared bright red and raw with some additional black tissue. The notes document the resident was receiving daily dressing changes and the wound clinic provided the following orders: - Cleanse the wound with cleanser and pat dry with gauze. Apply oil emulsion gauze to the wound bed, followed by alginate (used for wounds with heavy drainage). - Cover with foam with silicone bordered dressing, change three times weekly and as needed. Use bordered gauze between scheduled dressing changes and PRN (as needed) for soiled or loose dressing. - Note: The wound clinic will change dressings once weekly and the facility staff nurse is to change twice weekly. These wound care orders recommended by the Wound Clinic on 10/12/2023 were never transcribed onto the treatment record or implemented . Resident 1's care plan, dated 10/16/2023, documented Resident 1 was admitted with an unstageable pressure ulcer. This timeline of being admitted with an unstageable pressure ulcer was inconsistent with Resident 1's Admission Evaluation, Total Body Skin Evaluation, initial progress notes, and initial Provider Visit notes as referenced above. It was not clear upon record review if the resident had no skin impairment, a small skin tear to the right buttock, or an unstageable pressure ulcer. Resident 1's care plan, dated 10/16/2023, documented interventions for staff to assess, monitor, and document on the status of the PU, including for nursing to monitor the dressing daily and turn, reposition, and support the resident's heels with pillows. Interventions also included family would be informed of any new areas of skin breakdown. Physician orders for Resident 1, dated 10/16/2023, documented staff would cleanse the wound with wound cleanser, pat dry, apply impregnated gauze (gauze with the oil in it) to the wound bed, followed by alginate and to cover with silicone-bordered dressing. The order was transcribed and initiated on 10/17/2023. This was the only dressing change documented during the resident's stay. Provider notes for Resident 1, dated 10/19/2023, documented Resident 1 developed a fever, high pulse, and low blood pressure. Resident 1's skin was documented as having no visible lesions, no rash and the resident required transportation to the hospital for further evaluation. Progress notes for Resident 1, dated 10/19/2023, documented Resident 1 was found unresponsive with fast, shallow breathing and staff were unable to arouse the resident. The resident was sent to the hospital. A Change in Condition Evaluation for Resident 1, dated 10/19/2023, documented Resident 1 would be transporting to the hospital for a change in vital signs and altered mental status. The document had no notations regarding Resident 1's PU. On 11/17/2023 at 3:26 PM, Resident 1's family member and Collateral Contact 1 (CC1) said they had concerns with the care of the resident's skin. CC1 said Resident 1 had some skin concerns in the past but understood the skin had improved prior to admission to the hospital. During the resident's stay at the facility, CC1 said they had noted concerns with repositioning and bathing. CC1 said they had voiced their concerns and had not noted any changes in care. CC1 said facility staff had not reported concerns about Resident 1's skin during this time. CC1 said on 10/19/2023, they went to visit Resident 1 and found them lethargic and ill appearing. CC1 said they were very concerned about what was going on because they had not been notified. CC1 said they were Resident 1's Power of Attorney (POA). CC1 said Resident 1 was sent to the hospital and as they rolled the resident off the stretcher, they saw a large wound on the resident's buttock. CC1 said Resident 1's buttock wound was black. CC1 said they did not feel the wound was cared for properly and Resident 1 required immediate surgery to address the infection in the wound. CC cried as they described the pain and procedures Resident 1 required. CC1 said Resident 1 eventually passed away from the infection in the PU. The hospital History and Physical, dated 10/19/2023, documented Resident 1 had been found by CC1 appearing ill when she saw him at the facility. Upon arrival to the hospital, the resident was found to be in severe septic shock due to the large PU on their buttock and documented, this appears to be the source of infection and shock. The surgical notes, dated 10/25/2023, documented Resident 1 required surgical interventions to remove necrotic skin on the wound. On 12/04/2023 at 2:40 PM, Staff E, Certified Nursing Assistant, said residents at risk for PUs should be turned frequently and provided good hygiene. Staff E said they usually could get residents turned as they needed to, unless they were short staffed. Staff E said this happened more than it should. Staff E said if she found a wound on a resident, she would report it to the nurse in charge. Staff E said she had gone above the nurse's head on some occasions because the nurse did not respond to the reported skin concerns. At 2:48 PM, Staff D, Resident Care Manager and Licensed Practical Nurse (LPN), said staff should assess a resident's skin upon admission and document any concerns. Any concerns should be reported to Staff B, Director of Nursing Services and Registered Nurse. The nurse should obtain orders to care for the resident's wound and develop care plan interventions. Wounds should be monitored weekly by nursing and the wound clinic. If a resident developed a wound after admission, the staff should follow the same process. Staff B said the electronic medical record cued the nursing staff to do each of the tasks. At 3:03 PM, Staff B said staff should assess a resident's skin upon admission or when there was a change in the condition of the skin. The staff should document the wound characteristics and monitor weekly. The wound clinic assessed wounds weekly. The care plan should reflect the interventions needed to treat the PU. Staff B said she recalled Resident 1 had a PU prior to admission and was not aware of concerns. Upon review of Resident 1's record, Staff B said nursing staff did not identify or documented the presence of a PU on Resident 1's buttock. Staff B said nursing staff were required to assess the wound. Staff B said the record did not include measurements or characteristics of Resident 1's PU. Staff B said the wound clinic gave orders for caring for Resident 1's PU, which were not implemented until 10/16/2023. Staff B said the record did not show documentation the POA was notified of the status of the resident's skin or of the change in the resident's condition. The record did not show the transporting hospital was notified of the presence of a PU on 10/19/2023. At 3:29 PM, Staff A, Administrator, said she was not aware of concerns with Resident 1's care and would need to review the record. Reivew of an email communication on 12/06/2023 at 11:56 AM, Staff A documented Resident 1 was sent to the facility without wound care orders. Staff A documented, the facility did fail in classifying the wound the same as the hospital and was not seen by wound care until six days after admission. Staff A documented, the nursing unit was slow in delivery of care. Reference WAC 388-97-1060 (3)(b)

Based on observation, record review and interview, the facility failed to comprehensively assess and evaluate treatment related to bowel interventions for residents receiving medications that increase the risk of constipation for one of three sampled residents (1)reviewed for bowel care and management. This failure placed residents at risk for pain, constipation and a diminished quality of life. This caused harm to Resident #1 when the facility did not effectively assess, monitor and develop and implement interventions for constipation resulting in being sent to the hospital for the development of a fecal impaction (severe form of constipation). Findings included . The facility's policy, Bowel and Bladder Program, undated, documented staff will monitor for changes in bowel habits and consider factors related to bowel changes such as medications that slows bowel mobility, decreased physical activity, immobility, central nervous system disease, and inactivity. The facility will assess factors related to bowel changes and review quarterly and with a significant change in condition. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS), an assessment tool, dated 03/03/2021, documented Resident #1 had no cognitive impairment and required extensive assistance from two staff for toileting. The MDS documented the resident was always incontinent of bowel, was not on a toileting program, and had no constipation during the assessment period. The Bowel Data Collection and Evaluation, dated 02/10/2021, documented Resident #1 was always incontinent of stool due to factors impacting bowel function such as a history of a stroke, contractures, profound immobility and medications including antipsychotic/antidepressant and aspirin. The evaluation documentation showed there was no physical exam of Resident #1, the resident did not recognize the sensation for a bowel movement, and was unable to participate in a bowel management program due to immobility - bed-bound. The evaluation did not address the resident's ongoing opioid use as it contributed to bowel function. There was no evaluation related to the resident's history of noninfectious [CONDITION(S)] and bowel impaction in the medical record. The February 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] --[MEDICATION(S)] (a medication used to treat muscle pain and spasms) 20 mg three times daily --[MEDICATION(S)] (a opioid pain medication) ER (extended release) 10 mg twice daily --Oxycodone HCI (a opioid pain medication) 5 mg three times a day for pain. --Trazadone (antidepressant) HCL 75 mg at bedtime --[MEDICATION(S)] (antidepressant) 20 mg daily --[MEDICATION(S)] (nerve pain medication) 75 mg three times daily --[MEDICATION(S)] (treats stomach issues) 20 mg daily routinely --Senna (laxative) 8.6 mg 2 tablets once daily, the only medication to address constipation According to the Davis's Drug Guide for Nurses, 17th edition, dated 2021, [MEDICATION(S)], oxycodone, trazadone, [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] cause side effects of constipation. Progress notes, dated 02/21/2021, documented Resident #1 was experiencing nausea and projectile vomiting. The resident had some mild abdominal tenderness, diarrhea, and black coffee grounds vomitus. The resident was transported to the hospital for evaluation. The Hospital Admission Note, dated 02/22/2021, documented Resident #1 was hospitalized with altered mental status and hematemesis (vomiting of blood). The resident had multiple liquid bowel movements while in the emergency room and an abdominal CT Scan showed the resident had signs of [CONDITION(S)]. The resident had tinkling on auscultation, a possible sign of bowel obstruction, heard when listening to abdominal sounds with a stethoscope. The resident was admitted to the intensive care unit. The Discharge Summary, dated 02/26/2021, documented the resident experienced possible infectious [CONDITION(S)] with thickened colon and rectal walls, was treated with antibiotics, and returned to the facility with improved condition. Resident #1's medical record did not show evidence of assessment and monitoring of Resident #1's bowel status upon readmission to the facility on [DATE]. The care plan, dated 03/01/2021, documented Resident #1 had an alteration in bowel elimination due to decreased mobility. The care plan documented staff would follow the facility protocol for bowel management, monitor for side effects of medications, and monitor for signs and symptoms of constipation. The March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional constipation medications were ordered. No additional monitoring of the resident's bowel status was noted. Provider Note, dated 03/10/2021, documented Resident #1 complained of chronic pain and pain in the left arm and shoulder. Staff G, Nurse Practitioner (NP), increased [MEDICATION(S)] to 15 mg twice daily from 10 mg twice daily and noted to continue [MEDICATION(S)], [MEDICATION(S)], and oxycodone as ordered. The notes did not address the resident's risk for constipation or bowel status. The medical record did not show documentation of monitoring for side effects related to the increased dose of [MEDICATION(S)] on 03/10/2021, such as constipation. A provider note, dated 03/17/2021, documented Resident #1 reported constipation to Staff G. The NP noted to encourage fluid intake and continue the facility bowel protocol. The medical record did not show the staff addressed the resident's concern for constipation. No additional bowel medications were administered. No additional documentation showed the facility encouraged fluid intake. No additional medications were implemented related to the bowel protocol. The progress notes, dated 03/18/2021, documented Resident #1 vomited, appearing coffee ground in appearance. The notes documented the resident continued to vomit and had copious amounts of black diarrhea. The resident was transported to the hospital. The hospital history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had coffee ground appearance to his vomit (possible indication of blood in vomit). An abdominal CT scan showed the resident had severe obstipation (severe constipation) with proctitis (inflammation of the rectum) caused by stool compression against the bowel. The hospital Progress Notes, dated 03/19/2021, documented Resident #1's bowel impaction with obstipation was likely secondary to opioid induced constipation. The resident required aggressive disimpaction bowel regiment with [MEDICATION(S)] (a solution used to clean out the bowel), magnesium [MEDICATION(S)], mineral oil enema, and manual disimpaction. The hospital Nursing Progress Notes, dated 03/20/2021, documented staff tried to digitally disimpact patient . was not successful. Stool was just out of reach but did feel soft. Patient has had about 5 episodes of extensive loose stool[s]. The hospital Progress Notes, dated 03/21/2021, documented the resident continued to have stool in the rectal vault and would require a water soluble enema with fluoroscopy (imaging used to visualized internal body structures). The hospital Discharge Summary, dated 03/22/2021, documented Resident #1 found to be severely constipated with fecal impaction, opiate-induced, please review hospitalization , follow-up constipation and titrate opioids down if possible. Please make sure patient has been compliant with his stool softeners and laxatives and remains to have regular steady bowel movements. Additional bowel medications and [MEDICATION(S)] dose reduction were ordered by the discharging provider. The Provider Notes, dated 03/22/2021, documented the hospital reported an update to the resident's provider. Resident #1 was admitted to the hospital coming from this facility complaining of vomiting and diarrhea. CT abdomen was obtained revealing severe constipation with some rectal proctitis from the stools more likely due to chronic use of opiate use with no bowel regiment. Patient also had electrolyte imbalances notably potassium however all patient electrolytes where corrected during his hospitalization . In the ED, patient was manually disimpacted. This provider also believes that the patient might still have small to moderate stools and mostly patent. In addition, this provider also reported the patient developed asymptomatic [CONDITION(S)] [slow heart rate] during hospitalization likely due to constipation. On 04/01/2021 at 11:50 AM, Resident #1 was observed in bed. Resident #1 said he did not have complaints or concerns with care. On 04/18/2021 at 7:10 PM, Resident #1 was observed in his bed and watching TV. Resident #1 said he did not have concerns with care. On 04/19/2021 at 11:40 AM, Resident #1 was observed in his bed. Resident #1 said he did not have complaints or concerns with care. On 04/26/2021 at 2:33 PM, Staff C, Registered Nurse (RN), said she had not worked with the resident for very long but she did complete readmissions and assessments after hospitalization s. While discussing the resident's risk for constipation, Staff C said Resident #1 was on opioid narcotics, had [CONDITION(S)], ate in him room, did not move independently, and relied on staff for mobility. Staff C said Resident #1 was stable now and denied any ongoing issue with constipation. At 2:40 PM, Staff B, Director of Nursing Service and RN, said she would expect monitoring or routine bowel medication with medications, such as narcotics that increased the risk of constipation. Staff B said residents should be reassessed when they have a change in condition, but she was not familiar with Resident #1 and his hospitalization . Staff B said she would review the record and provide an update. No further information and/or update was provided. At 3:31 PM, Staff D, Nurse Practitioner, said she was not aware of the history of constipation concerns with Resident #1. Staff D said when a resident is taking opioids and pain medications, they should be assessed for constipation. Staff D said she was unaware of Resident #1 complaining about constipation on 03/10/2021. Staff D said she would have written an order to increase bowel medication and monitoring at that time. On 04/29/2021 at 11:00 AM, Staff A, Executive Director, said residents should be assessed when they have a change in status. Reference WAC 388-97-1060(1)

Based on observation, interviews, and record review the facility failed to identify and evaluate safety risks and provide adequate supervision and interventions to ensure resident safety for 4 of 5 residents (#1, 6, 8, & 10) reviewed for supervision. This resulted in actual harm to Resident #1, who left the facility without staff intervening, resulting in the death of the resident. Findings included . 1) Resident #1 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] (a stroke) with [CONDITION(S)] (weakness on one side of the body), major depressive disorder, craniotomy (removal of a portion of the skull) with post-surgical complications, and history of substance abuse. The Minimum Data Set (MDS), dated [DATE], documented Resident #1 had no cognitive impairment, required assistance with activities of daily living (ADLs), and did not have a history of wandering. Resident #1 was his own decision maker and his Power of Attorney (POA) designation was not active. Progress notes from Resident #1's prior facility, dated ,d+[DATE] to ,d+[DATE], documented Resident #1 had a history of risk for elopement and required a Wanderguard (a device alerting staff when a resident is near an exit). An Elopement Risk Evaluation, dated [DATE], documented the resident was not exit seeking and was alert and oriented. The resident's risk factors of elopement history, expressed desire to leave, was mobile with a wheelchair or ambulatory (walking without assistive device), adjustment difficulties, alcohol or drug abuse, psychiatric history, wandering, restless, and/or irritable were blank. No care plan interventions were recommended on the assessment. Progress notes, dated [DATE], documented Resident #1's family member (FM) told staff of Resident #1's plan is to get out of the facility, live in the community, and raise his child. The FM said she was concerned for the resident since moving to the facility as the resident would have the pressures of past drug use and had a recent history of overdosing on drugs in the past. Progress notes, dated [DATE], documented Resident #1's FM told staff Resident #1 was liable to bolt if we discourage his idea of leaving facility and raising his son independently. Resident #1's FM had concerns the resident would meet up with old friends and feel the pressure to start doing drugs again. Discharge plans discussed at this time with a tentative plan to return to the community. The care plan, dated [DATE], documented Resident #1 required staff supervision for walking and wheelchair mobility, required monitoring and documentation for signs of depression, and allow Resident #1 to express his feelings. The care plan documented Resident #1 had impaired psychosocial well-being problems related to depression, anxiety, inability to concentrate and problem solve, ineffective coping, and lack of acceptance of current condition requiring monitoring. The care plan noted staff would document signs of depression, assist with identifying stressors and solutions, and move the resident to a calm, safe environment when conflicts arose. A revision of the care plan, dated [DATE], documented Resident #1 would like the opportunity to go outside and get fresh air when the weather was good. The care plan did not identify individualized target behaviors, past and recent drug use, or potential life stressors such as separation from his child. Provider Notification, dated [DATE], documented Resident #1 exhibited odd behaviors, goes in and out of his room continuously, and keeps roommate up at night. The Medical Provider's (MP) ordered psychiatric evaluation, which occurred on [DATE], had no care plan recommendations. Psychiatric follow-ups, dated [DATE] and [DATE], documented no concerns with Resident #1's mental status and did not make any new recommendations. Provider notes, dated [DATE], documented Resident #1 was very mad because he had not been able to find community housing. The MP documented Social Services (SS) would help the resident with completing housing applications. Provider notes, dated [DATE], documented Resident #1 should see psychiatric services for his anxiety, and the resident agreed. No recommendations were made to the resident's plan of care. Progress notes, dated [DATE], documented Resident #1 wanted to be closer to family, especially his child. Resident #1 was having difficulty handling his emotions, getting very angry and frustrated. Resident #1 wanted to find a place to live in the community, but could not remember how to use the phone. SS was working on how to use the phone, and noted concerns with feeding and dressing self. No recommendations were made to the resident's plan of care. Progress notes, dated [DATE], documented staff observed Resident #1 with his blankets pulled over his head, subdued, and seemed to want time alone. No follow up to Resident #1 mood status was noted in the medical record. Progress notes, dated [DATE], documented Resident #1 voiced concerns about his roommate and wanted the roommate to move. The resident reported his roommate took all of his belongings out of his drawers and threw it all over the place. Staff spoke with the roommate. No follow up to Resident #1 mood status was noted in the medical record. Progress notes, dated [DATE], documented Resident #1 was heard yelling at staff and roommate accusing his roommate of stealing his belongings. Resident #1 was increasingly agitated through the day and complained about his roommate. No interventions or room changes noted. Progress notes, dated [DATE], documented Resident #1 asked for assistance with contacting a law firm regarding filing an abuse claim against the Boy Scouts of America. SS assisted with this paperwork. No revisions or follow up was noted in the resident's medical record. Progress notes, dated [DATE], documented Resident #1 said he packed his bags and was going to leave as he was upset about his roommate yelling all day. Resident #1 said his was going to a friend's house but could not give any contact name or number of the location. SS asked Resident #1 to find a quiet place. When reproached, the resident decided to stay at the facility. Resident #1 declined a room change. Progress notes, dated [DATE], documented SS assisted Resident #1 with follow up on community living. A phone interview was set up for [DATE] related to his application for housing. Progress notes, dated [DATE], documented Resident #1 spoke with SS about visiting his child. The note showed this was referred to the Administrator. No follow up was noted in the medical record. Provider notes, dated [DATE], documented Resident #1 interrupted the Medical Provider (MP) while visiting with another resident, was angry about his medication changes and demanded the MP see him regarding his concerns. Medications were adjusted per resident's wishes. Progress notes, dated [DATE], documented Resident #1 was very agitated due to roommate yelling out and screaming. SS told Resident #1 the roommate could not help himself. Resident #1 verbalized understanding, but seemed very sad, and said he would try harder to be kind to his roommate. No recommendations or follow up were noted in the residents medical record. A progress note, struck out by staff, dated [DATE], documented the details of when staff discovered Resident #1 was missing. The strike out indicated the note was incorrect documentation. No additional notes were in the medical record documenting the series of events occurring when the resident was discovered missing. Progress notes, dated [DATE], documented Resident #1 appears to have left AMA (against medical advice). Resident #1 left his belongings at the facility. Attempts to contact the resident had been unsuccessful. Progress notes, dated [DATE], documented Resident #1 continues elopement . and to be discharged at 24 hour mark. Progress notes, dated [DATE], documented Resident #1 decided to leave the facility, had no cognitive impairment, POA was not active, and the resident was his own decision maker. Notified Resident #1's FM, a friend, and contact in his chart. This contact was a person who knew the resident at his prior facility and stated she thought he would leave sooner now that he was back in town with his friends. Resident #1's friend said he had communicated with him the night he went missing and asked for money for rent. The note documented when Resident #1's friend responded, Resident #1 did not answer. Discharge/Discharge Planning Note, dated [DATE], documented Resident #1 left the faciity on [DATE] at approximately 4:30 PM and did not return to the facility. Resident #1 was his own decision maker and had no cognitive impairment. On [DATE], staff performed a perimeter check, notified the police, and contacted family and friends. SS was notified Resident #1 left AMA. Discharge/Discharge Planning Note, dated [DATE], documented police notified the facility that Resident #1 was found deceased . Family notified. Progress notes, dated [DATE], documented summary of events for [DATE]. A licensed nurse (LN) on duty went to give Resident #1 his medications and could not find him. The notes documented initially, the LNs in the facility initiated the elopement protocol by conducting a facility search, then perimeter search, then driving around the community attempting to locate the resident . police department was notified as well as friends and family. Resident #1 was his own decision maker, had no cognitive impairment and did not demonstrate any exit seeking behaviors. The notes documented therefore, elopement is not suspected but rather resident left the facility Against Medical Advice. A nursing assistant witnessed Resident #1 leave the facility at approximately [4:30 PM-4:45 PM] and did not question the resident as he frequently went outside to sit at the front of the building. Adult protective services notified of the incident. The County Case Supplement Report, dated [DATE], documented Resident #1 died due to exposure to the environmental elements. No belongings were with Resident #1 when he was found deceased . On [DATE] at 4:03 PM, Resident #1's family member (FM) said upon Resident #1's admission to the facility, the FM reported concerns with Resident #1 leaving the facility independently and told the facility the resident needed a bracelet (Wanderguard) in the past due to his risk for elopement (leaving the facility unattended or unknown by staff). Resident #1's FM said staff contacted the FM to report Resident #1 was packing his belongings the Thursday before Resident #1 left the faciity on [DATE]. The FM said she reported her concerns to staff about Resident #1 leaving the building and became aware at this time the resident did not have a Wanderguard in place. Resident #1's FM said they felt the facility was responsible for the resident leaving the facility since they did not intervene or prevent the resident from leaving. On [DATE] at 2:30 PM, Staff I, Nursing Assistant (NA), said she would routinely walk with Resident #1 during the day. Staff I said Resident #1 had improved with his mobility and would talk about looking forward to moving into the community. Staff I said Resident #1 was pleasant and cooperative but would have angry outbursts. Staff would attempt to redirect Resident #1. Staff I said Resident #1 did not leave the building unattended or go sit outside to her knowledge. Staff I said she was very surprised Resident #1 left. Staff I said she would have intervened if she saw Resident #1 leave the building. At 2:45 PM, Staff G, RN, said Resident #1 exhibited verbally aggressive and frustrated responses to other residents and staff. Staff would remove Resident #1 from situations and would need redirection. Staff G was not sure if Resident #1 would go outside, but did not think the resident was an elopement risk. On [DATE] at 3:00 PM, the facility grounds were observed with Staff G, Registered Nurse (RN). An unidentified resident was observed outside. Staff G said the resident should not be outside without supervision of staff. Staff G said it was difficult to monitor residents who go outside without staff knowing. On [DATE] at 2:08 PM, Staff P, NA, said she cared for Resident #1 and would often walk with him in the evenings. Staff P said Resident #1 had a short fuse and would get mad easily but would often calm down then apologize when redirected. Staff P said Resident #1 did not go outside to her knowledge. Staff P said Resident #1 expressed how excited he was to discharge into the community. Staff P said on [DATE], around supper, she was in the dining room getting residents ready for supper when she saw Resident #1 at the door. Staff P noted it was weird because Resident #1 was wearing a sweatshirt as he usually wore a short-sleeved shirt and shorts. Resident #1 waved at her and smiled. Staff P said she waved back and told him it was suppertime. Resident #1 then went out the front door. Staff P said she did not tell anyone Resident #1 had left and she did not go to check on him at that time. Staff P assisted with looking for the resident when it was discovered he was gone. Staff P did not hear or see anything to indicate Resident #1 would leave the facility. Staff P said she did not give a statement for the investigation to the DNS or Administrator, and there was no education on resident supervision after the incident. Staff P said it was difficult to monitor the whereabouts of mobile residents during her shift because there was no system for tracking their whereabouts. On [DATE] at 11:36 AM, Staff E, NA, said Resident #1 was mostly independent with ADLs and did very well with mobility. Staff E said the resident did not have any behavioral concerns but would start yelling and become upset related to laundry and food. Staff E said Resident #1 did not go outside, to her knowledge, and never saw the resident pack or attempts to leave the facility. Staff E said she did hear Resident #1 was upset the day he left, but did not see any red flags in his behaviors. Resident #1 was very excited about his future with his child so she was surprise Resident #1 left. On [DATE] at 04:01 PM, Staff O, Licensed Practice Nurse (LPN), said she was working on [DATE] when Resident #1 left the building. Staff O said it was near supper and Resident #1 was typically in the dining room watching television at this time. Staff O went to look for Resident #1 to administer his evening medications. Staff O said she could not find him and asked other staff if anyone had seen him. Staff O asked other residents and checked the outside smoking area without seeing the resident. Staff O said an NA told her at that time she had saw Resident #1 leave out the front door. The NA responded by saying sorry I didn't say anything and I thought he could go out. Staff O said she would have stopped the resident to ask where he was going, as this was out of character for Resident #1 to leave. Staff O said she initiated the Elopement Protocol and made all the appropriate notifications, including the local Police Department. Staff O utilized the checklist, which was part of the Elopement Protocol to search for the resident, but they were unable to find him. Staff O said she was flabbergasted Resident #1 left. She said it was dark and rainy at the time and staff should have intervened when they saw him leave the building. Staff O said it was unlike Resident #1 to leave like this. Staff O said in the following days, the Director of Nursing Services (DNS) told her it was determined Resident #1 left AMA. Staff O said she felt the resident eloped, which was why she initiated the protocol. On [DATE] at 10:00 AM, Staff H, Social Services Director, said Resident #1 would come visit her often. Staff H said she was surprised Resident #1 left and was working with Resident #1 to find community housing. Staff H said Resident #1 did not have behaviors. Staff H said Resident #1 would get upset, but would easily calm down when redirected. Afterwards, Resident #1 would come to her and apologize. Staff H said Resident #1 would pack his belongings and talk about leaving, but once staff spoke with the resident and redirected him he would stay and unpack his belongings. Staff H said she was unaware of any attempts to leave the building unattended prior to [DATE]. Staff H said she was unsure if Resident #1 went outside much but did not have concerns with the resident going outside independently. Staff H said Resident #1 was his own decision maker and she would not have thought anything of the resident going outside. On [DATE] at 1:51 PM, Staff F, RN, said Resident #1 had poor safety decision-making and would become frustrated when he could not express himself as he wanted. Staff would intervene and deescalate Resident #1's behavior. Staff F said the resident was upset due to the length of time it was taking to find community housing. Staff F said Resident #1 was talking about winning money on a lottery ticket prior to [DATE], but never made any comment about leaving the facility due to his winnings. Staff F said he never saw a winning lottery ticket. Staff F said he was surprised Resident #1 left, as he never attempted to leave or go outside. Staff F said he would have intervened if he had saw Resident #1 at the door. Staff F said if a resident was to go outside, he would then check on them in ,d+[DATE] minutes. Staff F said he still does not understand how this happened. On [DATE] at 11:11 AM, Staff B, DNS, said the investigation details concluded Resident #1 left AMA. Staff B said Resident #1 would go independently outside and get fresh air and was able to make his own decisions. Staff B said they attempted to contact him by phone and he did not return the call or answer. Staff B said Resident #1 told some staff and residents he won money, so it was determined he left the facility and got a ride from someone. Staff B said Resident #1 left his belongings at the facility. Staff B was unaware of any history of attempts to leave the facility or prior facilities. Staff B said he did not have evidence of staff statements related to the series of events on [DATE], when Resident #1 left. Staff B said they reported the incident to the State Agency, but could not remember the date. Staff B said he was not aware of the history of elopement risk, staff reporting the resident did not typically go outside or Resident #1 being observed leaving by staff, who did not intervene. Staff B said he would have expected staff to intervene. Staff B said it was not a good idea for the resident to leave, and the resident had a poor lack of judgement. On [DATE] at 12:17 PM, Staff A, Administrator, said she spoke with Resident #1 daily and he was looking forward to discharging into the community. Resident #1 would argue with staff but was easily redirected. Staff A said she had no idea why Resident #1 left. Staff A said she was not told of the history of elopement risk, concerns voiced to staff by Resident #1's FM, or staff observed the resident leave with lack of intervention. Staff A said a thorough investigation should include interviews with staff present at the time of the incident. Staff A said the incident should be called to the State Agency according to the policy. 2) Resident #8 was admitted to facility on [DATE] with diagnoses including a [CONDITION(S)] with bleeding, [CONDITION(S)] disorder, post traumatic stress disorder, and brief psychotic disorder. The admission MDS, dated [DATE], documented the resident was moderately cognitively impaired, required extensive assistance with ADLs, and limited assistance with walking in room and corridor and locomotion on and off unit. Care plan for Resident #8, updated [DATE], documented to monitor for sexually inappropriate behavior and to notify the nurse immediately. The Care Plan was updated on [DATE] to notify the nurse, MD, and MP of inappropriate behavior and/or attempts to demonstrate behaviors towards other residents. 3) Resident #9 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, arthritis, and depression. The quarterly MDS, dated [DATE], documented the resident was severely cognitively impaired; required extensive assistance with ADLs including bed mobility, walk in room and corridor, and transfers; and required supervision with eating and locomotion on and off unit. The facility's investigation, dated [DATE], documented Resident #8 was found giving Resident #9 a kiss. The investigation documented Resident #9 was removed from the area and Resident #8 was told his behavior was inappropriate. The investigation noted the Care Plan was updated. Progress Note, dated [DATE] at 6:19 AM, documented Resident #8 as having predatory behaviors approaching staff and residents with a cane and making comments about beating them with it. The note showed Resident #8 was also approaching female residents and staff, saying he wanted to marry them and do other things to them. The note documented Resident #8 required 1:1 supervision to ensure the safety of other residents. No care plan updates or documentation of 1:1 supervision were noted in the medical record. When requested, no additional information was provided regarding 1:1 supervision. Progress Note, dated [DATE] at 7:00 PM, documented Resident #8 locked another resident in the linen closet and threw a wooden chair across the room. Resident #8 said he wanted to murder people. Staff called 911 and Resident #8 was transferred to the ER for evaluation. No documentation of 1:1 supervision, initiated on [DATE], was noted in the medical record. On [DATE] at 9:34 AM, Staff L, Registered Nurse, said Resident #8 was not sleeping and was having sundowning behaviors. Staff L said Resident #8 threw a chair and was not appropriate for this facility due to his behaviors. When asked about interventions, Staff L indicated she was concerned about the safety of other residents and transferred Resident #8 to the ER for evaluation. Staff L was not able to provide information about interventions implemented prior to the incident. On [DATE] at 10:01 AM, Staff B, DNS, was aware Resident #8 had a sexually inappropriate encounter with Resident #9. When asked if there were interventions in place for Resident #8, Staff B said he did not remember 1:1 supervision being implemented. Staff B said the priority was to ensure residents were safe. On [DATE] at 11:30 AM, Staff A, Administrator, said she was unaware of Resident #8's behaviors on [DATE]. Staff A said it should have been reported to her and she would have responded. Staff A said the expectation was to figure out target behaviors, monitor, and maintain all residents' safety. 4) Resident #6 was admitted to the facility on [DATE] with diagnoses including pleural effusion (fluid buildup on the lungs), [CONDITION(S)] (nerve pain), chronic [CONDITION(S)] lung disease, anxiety, and depression. The MDS, an assessment tool, dated [DATE], showed Resident #6 was cognitively intact and required supervision with ADLs. The resident's care plan, updated [DATE], documented history of substance abuse of alcohol and cannabis, and to notify MP if the resident appeared impaired prior to administering medications. A care plan goal was for the resident to not use cannabis due to general health concerns and mixing with medications for health concerns. The Care plan did not address behaviors such as leaving the facility and interventions for monitoring resident safety. No Elopement Risk Assessment was documented in the medical record for Resident #6. Progress Notes, dated [DATE] at 7:14 PM, documented the facility received a call from the police asking if a resident was missing. Head count showed Resident #6 was not in the facility. When found, the facility attempted to give Resident #6 a ride back to the facility, but the resident refused a ride and wanted to return on his own. The facility did not document when the resident returned or a follow-up after the incident. On [DATE], Resident #6 declined to be interviewed. On [DATE] at 4:01 PM, Staff O, LPN, said Resident #6 takes off a lot. Staff O said Resident #6 goes and gets [NAME], and they have no way of tracking where or when he goes. Staff O said Resident #6 has not taken off as much due to COVID restrictions, but has still left. Staff O said she believed [DATE] was the last time Resident #6 took off, but was unsure. Staff O said the resident would come back, but would be under the influence when he returned. Staff O said at this time, there was not a system in place to track when residents come and go from the facility. On [DATE] at 1:51 PM, Staff F, RN, said it was difficult to track when residents left the building. There was no system in place at this point. The facility has had the residents sign in and out in the past, but that stopped when COVID restrictions were implemented. Staff F said the courtyard door and front door are difficult to monitor from the building. Staff F said Resident #6 was a resident who was difficult to keep track of because he did not notify the staff when he leaves the building. Staff F said they are not sure what to do to ensure/improve supervision of residents with more mobility and who do not follow the rules. On [DATE] at 10:01 AM, when asked about monitoring Resident #6 for elopement, Staff B, DNS, said because he has a BIMS of 15, Resident #6 can make decisions on his own. Staff B said the facility should complete an elopement risk assessment on all residents and reassess when there are changes in the resident's condition. Staff B said the facility was unable to provide documentation of an Elopement Risk Assessment for Resident #6. Staff B said there was a sign out log, but they were currently not using it because of COVID precautions. Staff B said residents can leave for up to 4 hours and sign out in the log book. Staff B said he did not know of any residents leaving into the community. Staff B said there was no other system in place at this time. On [DATE] at 11:30 AM, Staff A, Administrator, said her expectation was that Resident #6 should let staff know when he left the facility. Staff A said there was no follow-up documentation on the incident on [DATE], and there should have been. Staff A said there should have been an Elopement Risk Assessment, and care plan interventions should be updated as necessary. Reference WAC [DATE] (3)(g)

Based on interview and record review, the facility failed to ensure necessary care and services were provided to prevent development and deterioration of pressure injuries when the resident's clinical condition was not comprehensively assessed to identify risk factors and develop and implement a plan of care to manage the risk factors for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. This failure placed residents at risk for unmet care needs, pressure injuries developing and/or worsening, and a diminished quality of life. This caused harm to Resident #1 when he developed facility acquired pressure injuries to his heels that worsened over time. Findings included . National Pressure Ulcer Advisory Panel (NPUAP, (YEAR)) Educational and Clinical Resources and Pressure Injury Prevention Points, documented any pressure injury should be treated in accordance with current evidence-based practices and monitored closely for changes that require re-evaluation of treatment strategies. The NPUAP advised a pressure injury risk assessment should include impairments in blood flow to the extremities from vascular disease, diabetes, or tobacco use. The Panel documented the care plan should be based on areas of risk and interventions should be developed to mitigate the risk factors. The facility's policy, Wound Prevention and Management, undated, documented the pressure injury must be monitored weekly using the Skin Grid until the wound heals and the care plan should be revised quarterly and with a significant change of condition. The policy documented intensive efforts would be directed at managing risk factors, providing preventive interventions, and providing treatment. The facility's policy, Refusal of Medication, Treatment and/or Dietary Restriction, undated, documented alternative interventions should be offered if a resident refuses medication, treatment or dietary restrictions. The policy documented staff should complete the Resident Choice of Medication, Treatment and/or Dietary Restriction Evaluation if the resident remains consistent with their refusal and the form should be signed by resident and/or family and maintained in the medical record. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 06/14/19, documented Resident #1 was alert and oriented, required extensive assistance with activities of daily living, and had an existing pressure injury (wound) on his tail bone. Resident #1's care plan, dated 06/25/19, did not identify Resident #1's risk factors (immobility, diabetes, substance abuse, impaired blood flow) for development of pressure injuries and did not include interventions to prevent pressure injuries or their deterioration. The care plan, updated 07/31/19 (15 days after the right heel wound was discovered and 12 days after the left heel wound was discovered), documented status of wound healing should be assessed weekly with progress and declines reported to the physician. <RIGHT HEEL> A progress note, dated 07/15/19, documented Resident #1 had a new open area on his right heel, 6 centimeters (cm) in width and 2.5 cm in length, and the wound bed contained dead tissue. The Weekly Skin Grid was completed 5 of 14 weeks (08/06/19, 08/27/19, 09/24/19, 10/10/19, and 10/16/19). The Weekly Skin Grid, dated 10/16/19, documented the wound deteriorated and was 17 cm in length and 9 cm in width, and the wound bed contained dead tissue. <LEFT HEEL> Resident #1's pressure injury care plan, dated 06/25/19, did not include the change in status of the wound. A progress note, dated 07/19/19, documented Resident #1 had a new open area on his left heel, 6 cm in length and 4 cm in width, and the wound bed contained dead tissue. The Weekly Skin Grid was completed 4 of 14 weeks (08/06/19, 08/27/19, 10/10/19, and 10/16/19). The Weekly Skin Grid, dated 10/16/19, documented the wound deteriorated and was 13.6 cm in length and 4.5 cm in width, and the wound bed contained dead tissue. <MAGGOTS> Resident #1's care plan, dated 07/31/19, was not include the care, treatment, or prevention of maggots in wounds. A progress note, dated 09/22/19, documented maggots were found in Resident #1's left and right foot wounds. A progress note, dated 09/30/19, documented Resident #1's left heel wound was filled with maggot therapy, and the maggots were maintained and then covered with a dressing. The resident's medical record did not document physicians orders for maggot therapy or management of maggots in wounds. On 10/25/19 at 1:40 PM, Staff D, Nurse Practitioner, indicated maggots in Resident #1's wound were not ordered as therapy. Staff D stated Resident #1 often refused care, spent many hours outdoors without dressings and his wounds may have drawn flies, resulting in the development of maggots. <REFUSALS OF CARE> Resident #1's progress notes, dated 06/08/19 through 10/22/19, documented the resident refused care 90 times. Resident #1's care plan for Non-Compliance with Care, dated 07/16/19, was not revised and did not identify alternative interventions when patterns of refusals continued and new wounds developed and deteriorated. Resident #1's medical record did not contain the Refusal of Medication, Treatment and/or Dietary Restriction form signed by the resident and/or family representative. A podiatrist's evaluation, dated 10/10/19, documented an order for [REDACTED]. A progress note, dated 10/10/19, documented Resident #1 refused to go to the hospital as the podiatrist recommended. Progress notes; dated 10/10/19, 10/11/19, 10/13/19, 10/14/9, 10/5/19, 10/16/19, and 10/17/19; documented Resident #1's refusals to transfer to the hospital for care and the staff's efforts to advise him of the risks and benefits of his decision to refuse treatment. A physician's progress note, dated 10/18/19, documented Resident #1 was evaluated by the psychologist as competent to make his own decisions. The progress note documented Resident #1 was given the option by his medical team of a surgical consult for his chronic infected lower leg wounds or comfort care, and the resident stated, Don't let the door hit you in the ass on the way out. On 11/15/19 at 2:45 PM, Staff C, Licensed Practical Nurse (LPN) and Resident Care Manager, indicated Resident #1's wound condition deteriorated as a result of his pervasive refusals of care, and stated, It all comes down to non-compliance. Staff C said Resident #1 frequently refused care and recommendations. Staff C said Resident #1 refused dressing changes to his wounds, turning and repositioning to prevent pressure ulcers; and refused to stop smoking and using [MEDICATION NAME]. Staff C indicated Resident #1 refused to sleep in his bed to relieve pressure from his heels. Staff C said attempts to help the resident make a decision in the interest of his health and well-being were rejected. Staff C indicated care plans should be revised when interventions were not effective, and the medical provider should be consulted to develop alternative interventions. At 5:15 PM, Staff E, LPN, said on 10/22/19, Resident #1 was finally transferred to the hospital for care of his non-healing wounds and infection. At 5:30 PM, Staff D said attempts were made to transfer Resident #1 to the hospital for care of his wounds and infection since 10/10/19. Staff D said he refused until 10/22/19 when his family, nurses, and paramedics convinced him he could lose his life if he did not accept a transfer to the hospital. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to provide necessary care, services, treatment and assessment, in accordance with professional standards of practice, for 1 of 14 sampled residents (#11) reviewed for a change in condition. This failure placed residents at risk for medical complications, injury, and a diminished quality of life. This caused harm to Resident #11 when the resident was moved after a fall before being adequately assessed. Findings included . Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 03/20/19, documented Resident #11 was cognitively intact, required extensive assistance of two staff with transferring, and extensive assistance of one staff with toileting and personal hygiene. The care plan, dated 05/01/19, documented Resident #11 required one staff to assist with pivot transfers (a transfer in which the resident can physically assist with the movement). The progress notes, dated 06/05/19 at 12:48 PM, documented the resident had a possible change in condition due to difficulty with transfers. The note documented the resident was usually a one staff pivot assist with transferring, but kept straightening left leg out under the bed and could not get her foot under her to stand. A therapy referral was made. The emergency room notes, dated 06/05/19 at 5:16 PM, documented Resident #11's foot got caught in her bed railing while staff were transferring her and then felt a pop in her knee. The notes documented Resident #11 was in almost constant pain, rating a 9 out 10 (indicating severe pain). The emergency room notes documented the resident was found to have a left tibial plateau fracture (a break in the lower leg bone near the knee). Orders by the emergency room provider included non-weight bearing on her left leg, pain medication ([MEDICATION NAME]) 1 tablet every 6 hours for 3 days, stool softener 1-2 tabs daily, knee immobilizer, and ice packs every 1 to 2 hours for the first 24 to 48 hours to ease pain and swelling. Record review showed there was no facility documentation of the specifics of the incident, including when the incident occurred. The progress notes, dated 06/06/19, documented Resident #11 was seen in the emergency room and was found to have a left tibial plateau fracture and required an immobilizer on left knee. The notes documented the resident was non-weight bearing to left lower leg. Therapy to nursing communication, dated 06/07/19, documented the resident required non-weight bearing to left lower leg and should be transferred by two staff, using a sliding board (equipment used when a resident cannot bear weight on their legs) to assist in transfers. A review of the medical record showed the medication and treatment record were not updated with the emergency room provider orders and the care plan was not revised to reflect the change in the resident's status or therapy's recommendation for transferring with a sliding board. On 06/13/19 at 1:15 PM, Resident #11 said two staff, Staff S, Licensed Practical Nurse (LPN) and an unknown staff member, were transferring her from her wheelchair to her bed when her left foot got caught on something under her bed. Resident #11 said during the transfer, she told the staff she was had a grinding in her leg and then heard an audible pop. Resident #11 said the staff did not respond to her concerns about her leg. The resident said once in bed, she voiced concerns about her leg and requested an x-ray. Resident #11 said the staff did not respond to her request. The resident said after hours of waiting for staff to address her concerns, she called 911 and was transferred to the emergency room , and the emergency room provider diagnosed a fracture in her left leg. The resident said staff were still transferring her the same way they transferred her at the time of her injury. Resident #11 was observed crying and said she experienced a lot of pain since her fracture. Resident #11 said she felt this fracture was a double whammy because she was still recovering from the fracture of her other leg. At 2:15 PM, Staff P, Nursing Assistant (NA), said Resident #11 was a 1-2 person pivot transfer. Staff P said Resident #11 did not move her legs much so staff needed to make sure her legs don't get stuck. When asked about weight bearing on the resident's left leg, Staff P said Resident #11 was light enough, Resident #11 hugs staff and staff can pick the resident up while transferring her. At 3:30 PM, Staff K, Occupational Therapist, said she assessed Resident #11 and the resident should be non-weight bearing on her left leg. Staff K said it was determined a slider board was the safest way to transfer the resident. Staff K said she was going to start training staff tomorrow. When discussing the use of a hug to transfer, Staff K said this was an unsafe way to transfer a resident. On 06/21/19 at 9:05 AM, Resident #11 said staff were continuing to transfer her using the same method used when she sustained her fracture. At 9:25 AM, Staff Q, NA, and Staff L, LPN, were observed transferring the resident from her bed to the wheelchair. Staff Q was observed to transfer the resident by grabbing the resident's pants using a pivot transfer while Staff L assisted guiding Resident #11 into her wheelchair. Resident #11 was observed to put weight on both legs. The staff did not use a gait belt or the slider board for transferring. At 10:00 AM, Staff R, Physical Therapy Assistant, said only staff who were educated on how to use the slider board with Resident #11 should transfer her. Staff R said not using a gait belt or the slider board was an unsafe transfer for Resident #11. At 1:10 PM, Staff C, RN and Assistant DNS, said Resident #11's care plan had not been updated with the change in status, and none of the emergency room provider orders were implemented. Staff C said staff should be using a gait belt when transferring the resident. Staff C said he was unaware therapy put in a nursing communication note regarding the need for a slider board on 06/07/19. At 2:30, Staff B said Resident #11's emergency room orders were not followed and her care plan was not updated. Reference WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure a resident's oxygen supply was available when oxygen saturation levels fell dangerously low for 1 of 1 residents (Resident #2) reviewed for respiratory care. This failure resulted in harm to Resident #2 when tubing was not connected to an oxygen source and her oxygen level fell to 59%, causing her to suffer shortness of breath and fear that she was dying, constituting psychological harm. Findings include . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented Resident #2 was alert and oriented without mood problems and required extensive assistance with activities of daily living. An undated and unsigned physician's orders [REDACTED]. On 10/03/18 at 3:12 PM Resident #2 was observed in her room, visiting with her son and receiving oxygen via a nasal cannula. Resident #2 said on 09/30/18, an occupational therapist brought her to her room from therapy with oxygen tubing attached to a portable oxygen canister on the back of her wheelchair. Resident #2 said some hours later she checked her oxygen saturation level using her own equipment (pulse oximeter used to measure the percentage of oxygen in her blood through attachment to a fingertip) and it registered 79%. She said she put her call light on and when the staff did not respond, her roommate (Resident #1) went to the hallway to find a nurse. Resident #2 said Staff D, an LPS, came to her room and indicated she wanted to use the facility's pulse oximeter and left the room. Resident #2 said, She returned 3-4 minutes later and it was still low and she went to call 911 .I was alone .I was so scared, I thought I was going on life support. At 3:15 PM, Resident #2's son stated he came to visit his mother on 09/30/18 and as he passed the nursing station he overheard Staff D calling 911 for his mother so he went to her room where he found her crying, telling him she was dying. He said he saw that the pulse oximeter read 59%. Resident #2 said, We were saying our goodbyes, telling each other we loved each other. I was so scared, and then I asked him to check the oxygen. He did and he said the tubing was connected to an empty oxygen tank .he reconnected me to the concentrator and it started to go up. On 09/30/18 a nursing note documented Resident #2 left at 2:55 PM via ambulance to the hospital for symptoms that included complaints of shortness of breath. On 10/06/18 at 3:17 PM, Staff D said that on 09/30/18 she found the resident's oxygen saturation level at 77%. Staff D said a family member was upset that resident #1 was hooked up to an empty oxygen tank. Staff D indicated resident #1 was connected to an empty oxygen tank. On 10/03/18 at 4:30 PM, when asked about licensed nurse staffing on the facility's clinically complex unit, Staff C, the Acting Director of Nursing stated, We've got to have an RN .it's wrong to schedule an LPN on that unit without the clinical supervision and support of an RN. WAC Reference 388-97-1060 (3)(vi)

Based on observation, interview, and record review, the facility failed to ensure sufficient staffing levels in order to provide care and services and maintain the highest practicable physical, mental and psychosocial well-being. This failure placed Resident #'s 1, 2, 4, 10 16, 13 &17 at risk for harm and neglect and resulted in actual harm to Resident # 3, 5 and 6. Findings include . Interviewes conducted with nine facility nursing staff revealed that facility had unsafe staffing levels and as a result there were multiple omitted care tasks. RESIDENT #3 Interventions for Resident #3 on the Care Delivery Guide for (communicates to certified nursing assistants necessary interventions for resident care), dated 05/16/18, stated, bridge feet off mattress and elevate legs on pillow while in bed. On 10/12/18 at 3:12 PM and on 10/17/18 at 3:15 PM, Resident #3 was observed in bed with her right heel directly on the bed without positioning to offload pressure. The heel had a raised, black, intact blister. On 10/06/18 at 12:05 PM, Staff J, a Registered Nurse (RN), stated Resident #3 developed a new blister on her right heel when the unit was short-staffed. Staff J said, We were so short they didn't have time to position her. On 10/06/18 at 3:10 PM, Staff O, a Certified Nursing Assistant (NAC), stated, We are consistently and continuously understaffed .there is no time to turn them. F686-for additional information related to Resident #3 developing pressure injury. RESIDENT #5 Physician orders [REDACTED]. Resident #5's (YEAR) Medication Administration Record [REDACTED]. On 10/12/18, at 3:41 PM, Resident #5's physician stated she discontinued the anticoagulant medication because Resident #5 had persistent nose bleeds that could have continued with anticoagulant medication. On 10/17/18 at 2:10 PM, Staff A said, When I was the RCM, I followed up on orders quickly, checking the fax every 15-30 minutes but now I pass meds, I work the floor. We have a system but we can't follow it because we are short of licensed nurses so we are on carts passing meds instead of being resident care managers. F760-for additional information related to medication error involving Resident #4 RESIDENT #4 A faxed physician's orders [REDACTED].#4, starting 09/29/18, was to receive a diuretic medication ([MEDICATION NAME] 2.5 mg) every morning. The Medication Administration Records (MAR) for (MONTH) and (MONTH) (YEAR) did not show Resident #4 received [MEDICATION NAME] as ordered through 10/02/18. Late entry nursing notes dated 10/04/18 showed Resident #4 was transferred to the hospital on [DATE] with a change in her condition, including shortness of breath. On 10/17/18 at 2:00 PM, Staff A, an RN, stated the order was not transcribed because as written, it needed clarification. Staff A said she did not transcribe it and passed the information about the order to the night shift nurse. Resident indicated that physician order [REDACTED]. On 10/17/18, the evening medication pass for East Station was observed for 10 minutes between 5:30 PM and 5:40 PM. The medication nurse was interrupted 4 times in 10 minutes by staff approaching her cart. F760-for additional information related to medication error involving Resident #4 RESIDENT #6 On 10/05/18 at 9:35 AM, Resident #6 was observed lying on the edge of his bed with bluish black discoloration under his left eye and he stated, It still hurts .I fell out of bed, rolled over and just fell waited about ten minutes for staff. I fell today, too. Resident #6's roommate, Resident #11, stated, It was last night, it woke me up, it was a loud thud. I put my call light on and called out for help was 20 to 40 minutes .I was dozing on and off. F689-for additional information related to Resident #6 related to accident prevention and supervision. RESIDENT #10 On 10/11/18 at 4:20 PM, Resident #10 said he waited 30-40 minutes for a response to a call light before his fall. He said, I am not supposed to get up but I wanted to see why I wasn't getting help. Resident #10 stated, They are very short-handed here. Just two aides. The resident did not receive restorative nursing care because facility pulled restorative aids to provide direct care. F689-for additional information related to Resident #10 related to accident prevention and supervision. RESIDENT #17 On 10/05/18, a call light was observed on and unanswered from 9:28 am through 9:57 am. On 10/06/18 from 11:55 AM through 12:25 PM, Resident #17 was observed sitting in his wheel chair while other residents were being assisted with eating. His pureed meal sat beside him, uncovered for 29 minutes before a staff member sat down to feed him. RESIDENT # 16 On 10/06/18 at 2:05 PM, Resident #16 was observed ambulating from bathroom to bed by hanging onto bed and over bed table, moving slowly with pained expression. Her call light was on. Resident #16 said, she was not supposed to do this and stated she had an infection in her leg and a problem with a painful shoulder. Staff K, a CNA walked in room to answer call light and said he was sorry. Outside, in the hall, he said, We are a little bit short Resident #16 did not receive necessary supervision. RESIDENT #1 On 10/03/18 at 2:30 PM, Resident #1 said, they are understaffed here, running around like crazy .30 patients to one CNA. Nurses have cried, they are trying to do a good job. On 10/10/18 at 4:55 PM, during an interview a collateral contact (CC) reported, I feel the nurses there are running around manic and in a frenzy, they are trying their hardest, unable to do it. On 10/10/18 at 4:45 PM, a CC said, I came in and the nurse had been crying. I went to the desk and I told her she was not a bad nurse .I think the administration is expecting too much of them. You can't expect them to work short and say it's fine and hope people don't get neglected. RESIDENT #10 On 10/11/18 at 4:20 PM, Resident #10 said he waited 30-40 minutes for a response to a call light before his fall. He said, I am not supposed to get up but I wanted to see why I wasn't getting help. Resident #10 stated, They are very short-handed here. Just two aides. RESIDENT #2 On 10/06/18 at 2:15 PM, Resident #2 stated breakfast was an hour and a half late and the pancakes were cold. Who eats cold pancakes? On 10/09/18 at 6:55 AM, Resident #2 stated, I complained the second day I was here that I had to wait 30 minutes to get someone to help me wipe when I was on the toilet. I can't reach my vagina at all .Now I just try to do it the best I can. I still have to wait but it's my fault because I don't want to wait longer than ten minutes. RESIDENT #13 On 10/10/18 at 11:20 AM, Resident #13 stated, I always had to wait an hour to get them to get me to the toilet so finally I just stopped drinking during the day so I wouldn't have to go. That is not good for healing. A CNA told me I could go in my Attends but I didn't want to do that. On 10/10/18 at 11:21 AM, Resident #13 stated, It was so awful. All week, it always took an hour to get help. Maybe because my roommate used her call light a lot they didn't come. I don't remember which night it was that I was on toilet 20 minutes. I think between Thursday and Sunday .I had to leave because of non-attention STAFF INTERVIEWS On 10/06/18 at 11:50 AM, Staff J, an RN, stated the facility started the day shift that day with two aides and for 3 hours and 50 minutes there was no aide on the East End. On 10/06/18, the facility's day schedule for nursing staff for 10/06/18 showed one nursing assistant assigned to the East Station but a handwritten note said, not here 0730. The schedule showed a handwritten note indicating another aide arrived to work the East End at 9:50 AM. On 10/03/18 at 4:30 PM, Staff C, an RN and the acting director of nursing services said, Care planning is done by resident care managers (RCMs) but there are no RCMS to do it .They've stepped down. We don't have enough staff. On 10/03/18 at 4:30 PM, when asked about licensed nurse staffing on the facility's clinically complex unit, Staff C stated, We've got to have an RN .it's wrong to schedule an LPN on that unit. On 10/04/18 at 2:10 PM Staff F, a certified nursing assistant (NAC) was observed crying and stated, We have 3 aides on evening shift - it's not safe for me or my residents - I had 22 residents on PM shift Tuesday (09/25/18) or Thursday (09/27/18). West side normally has 5 aides. Sometimes residents don't get changed once a shift. On 10/06/18 at 12:05 PM, Staff J, an RN, stated, When we first came we had a two man floor with one on light duty and one hospitality aide. We have a three man shift - one aide was told to stay home because she has too many hours .For 3 hours and 50 minutes there was no aide on the East End. An aide came at 9:50. So we had 3 CNAs for 87 residents. Now we have 4 .we need 8-10 CNAs on day shift .we've been running 4 aides for 80-90 patients for a long time. On 10/06/18 at 12:05 PM, Staff J, an RN, stated Resident #3 developed a new blister on her right heel when the unit was short-staffed. Staff J said, We were so short they didn't have time to position her. On 10/06/18 at 3:00 PM, Staff O, an NAC, stated, We are consistently and continuously understaffed .there is no time to turn them. On 10/06/18 at 3:10 PM, Staff N, an NAC, stated Resident #7 fell . Staff N said, I feel horrible because I can't take care of them properly. I feel bad, really bad. I had too many residents to keep an eye on. For two years we've been short. On 10/06/18 at 3:10 PM, Staff N, said, We are short all the time. We have 2 meals, showers, ADLS, we can't do everything. I did one quick bed bath today, I don't know how many I was assigned, I didn't have a chance to look - we were three. We had 23 patients each - there were only three of us for three hours. I feel horrible because I can't take care of them properly, I feel like a crappy person. On 10/06/18 at 3:10 PM, Staff N stated that she was unable to do her resident baths and said, I was assigned 4 baths (today). I couldn't do 34-2, 46-1 or 47-2. On 10/06/18 at 4:30 PM, Staff G, an LPN stated, No showers were done on my unit. I take that back, there was one. On 10/09/18 at 4:40 AM, Staff P, an NAC, stated, Three aides are not enough staff for proper watching of residents who have fall risk. On 10/09/18 at 5:40 AM, Staff C stated the fall risk management program was not fully in place and was compromised by staffing shortages. On 10/09/18 at 5:01 AM, Staff M, an NAC, said, When we are lucky we have 3 or 4 of us CNAs - mostly we run 3. I am not able to give the care I know I am able to give. It affects the residents mentally and physically. It takes me 20 minutes to answer a call light. It's like a full moon, all the lights going off and I can't get to them all, I can't check and change everyone. On 10/09/18 at 5:40 AM, Staff C stated fall risk management program was not fully in place and was compromised by staffing shortages. On 10/9/18 at 4:30 PM, PM Staff T, an NAC stated, About a month ago I couldn't get to my baths because we were short . Staff T said she was called at home by management and asked to come to the facility and document the showers were done. Staff T stated, I went and documented showers I didn't do. On 10/12/18 at 3:30 PM, when asked if wounds are assessed every 7 days, Staff J said, We used to have a weekly skin day but since the RCMs haven't been here things have fallen through the cracks. On 10/12/18 at 3:50 PM, Staff C said the restorative nursing program was not in place as the restorative nursing aides were pulled to the floor to work as CNAs. On 10/17/18 at 2:00 PM, Staff A, an RN stated distractions may have prevented follow-up on an order for [REDACTED]. Rehab staff need to do a lot of face-to-face communication with nursing. Staff A indicated she was available for such communication when she was recently a Resident Care Manager (RCM) but since there were not enough nurses, she was functioning in a staff nurse role. On 10/17/18 at 2:10 PM, Staff A said, When I was the RCM, I followed up on orders quickly, checking the fax every 15-30 minutes but now I pass meds, I work the floor. We have a system but we can't follow it because we are short of licensed nurses so we are on carts passing meds instead of being resident care managers. On 10/06/18 at 11:45 AM, Staff B, the administrator stated, I've stopped admissions as of yesterday afternoon until further notice because weekend came and I was worried about staffing. I've called my team to help. We are working on the problem and have interviews and new CNA graduates coming. We have ongoing recruitment efforts including advertisements all over town, on sandwich boards, which was an idea from the staff. Reference (WAC) 388-97-1080

Based on observation, interview, and record review, the facility failed to ensure 1 of 1 sampled residents (Resident #3) reviewed for pressure ulcers received preventive care consistent with professional standards when she was not turned and repositioned to offload pressure on her heels. This failure resulted in the development of a pressure ulcer on Resident #3's right heel. Findings include . Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment, dated 07/19/18, documented Resident #3 was alert with some memory problems and required extensive assistance moving and repositioning in bed. The pressure ulcer prevention care plan for Resident #3, dated 05/01/18, stated interventions included the facility's Yellow Dot Program. The facility's policy for turning and repositioning instructed staff to place a yellow dot on the nameplate of the resident's door whenever a resident is unable to turn herself so that staff would readily identify residents who are at risk and need frequent turning and repositioning. Interventions for Resident #3 on the Care Delivery Guide for (communicates to certified nursing assistants necessary interventions for resident care), dated 05/16/18, stated, bridge feet off mattress and elevate legs on pillow while in bed. On 10/12/18 at 3:12 PM, Resident #3 was observed in bed with her right heel directly on the bed without positioning to offload pressure. The heel had a raised, black, intact blister. On 10/17/18 at 3:15 PM, Resident #3 was in bed and her right heel was pressing directly on the mattress. Resident #3's feet were not bridged, her legs were not elevated, and there was no yellow dot on the door. On 10/06/18 at 12:05 PM, Staff J, a Registered Nurse (RN), stated Resident #3 developed a new blister on her right heel when the unit was short-staffed. Staff J said, We were so short they didn't have time to position her. On 10/06/18 at 3:10 PM, Staff O, a Certified Nursing Assistant (NAC), stated, We are consistently and continuously understaffed .there is no time to turn them. The facility's Skin Grid for Pressure Ulcers showed on 09/30/18 Resident #3 had a new pressure ulcer on her right heel that measured 6 by 5 centimeters and was black. On 10/11/18, the Skin Grid documented the pressure area was a deep tissue injury (pressure related injury to tissues under intact skin). The pressure ulcer prevention care plan for Resident #3, dated 05/01/18, stated interventions included the facility's Yellow Dot Program. The facility's policy for turning and repositioning instructed staff to place a yellow dot on the nameplate of the resident's door whenever a resident is unable to turn herself so that staff would readily identify residents who are at risk and need frequent turning and repositioning. Interventions on the Care Delivery Guide (communicates to certified nursing assistants necessary interventions for resident care), dated 05/16/18, stated, bridge feet off mattress and elevate legs on pillow while in bed. On 10/17/18 at 3:15 PM, Resident #3 was in bed and her right heel was pressing directly on the mattress. Resident #3's feet were not bridged, her legs were not elevated, and there was no yellow dot on the door. On 10/17/18 at 3:30 PM, Staff C, an RN and Acting Director of Nursing, said, We do not currently have the Yellow Dot Program in place for turning and repositioning residents. At 3:38 PM, Staff H, an RN from the facility's corporate office, stated the Yellow Dot Program includes preventive interventions for any resident with a Braden Scale score of 15 or less. Staff H said the expectation is that the facility will implement the Yellow Dot Program. Reference: WAC 388-97-1060 (3) (b)

Based on observation, interview, and record review, the facility failed to identify fall risk, develop and revise fall risk care plans, implement fall prevention interventions, and supervise residents to prevent falls for 2 of 8 residents (Resident #6, 10).This failure resulted in harm for Resident #6 when he sustained an injury and placed Resident #10 at risk for repeat injuries. Findings include . The facility policy, Fall/Injury Management-Post Fall or Injury, dated (MONTH) (YEAR), stated after a resident falls, staff were to complete a fall risk assessment, revise the resident's care plan, and communicate interventions to staff using the care delivery guide. The facility's policy for the Prevention and Management Care Plan, dated (MONTH) (YEAR), stated care planned interventions should include the initiation of restorative nursing or rehabilitative programs to enhance the resident's strength, balance, gait and transfers. RESIDENT #6 Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, an assessment, dated 10/01/18, documented Resident #6 was alert with memory difficulties and required extensive assistance moving around in bed and transferring in and out of bed. On 10/05/18 at 9:35 AM, Resident #6 was observed lying on the edge of his bed with bluish black discoloration under his left eye and he stated, It still hurts .I fell out of bed, rolled over and just fell waited about ten minutes for staff. I fell today, too. Resident #6's roommate, Resident #11, stated, It was last night, it woke me up, it was a loud thud. I put my call light on and called out for help was 20 to 40 minutes .I was dozing on and off. A nursing note, dated 09/22/18, documented Resident #6 was found face down on the floor with a moderate amount of blood from a head wound around the left eyebrow. A fall risk assessment, dated 09/17/18, was incomplete. The medical record did not contain a fall prevention care plan. A care delivery guide was updated 09/18/18 and stated Resident #6 was at risk for falls but it contained no updated guidance for fall prevention after Resident #6 fell [DATE]. Nursing notes review did not find evidence that facility staff knew of the fall, conducted assessments, notified the physician and family, or developed a care plan. On 10/5/18 At 9:55 AM, Staff C, an RN and Acting Director of Nursing Services, was not aware the fall reported by Resident #6 occurred and said, This is the first I've heard of it. It did not come through to us, it was not on report. Following a fall with significant injury on 10/5/18 observations revealed the facility did not ensure the resident was supervised and the interventions to prevent additional accidents were in place. A fall risk care plan, initiated 10/05/18, documented interventions including: mat to floor, bed next to wall, and bed in lowest position. On 10/06/18 at 11:40 AM, Resident #6 was observed in bed. His bed was in a high position and there was no mat on the floor. On 10/09/18 at 5:01 AM, Resident #6 was observed in bed. The bed was in a high position and there was no mat on the floor. On 10/09/18 at 5:03 AM, when asked what interventions should be in place to prevent falls for Resident #6, Staff M, an NAC, said, I don't actually know, I just try to watch him closely and check on him frequently. Staff M said she could check the care directive but stated, There is not always time to check it. I usually have to hit the floor running and even if there is time, the care directive is not always done or updated. When we are lucky we have 3 or 4 of us CNAs - mostly we run 3. I am not able to give the care I know I am able to give. On 10/09/18 at 5:40 AM, Staff C, the Acting Director of Nursing Services, stated fall risk management program was not fully in place and was compromised by staffing shortages. RESIDENT #10 Resident #10 was admitted to the facility 12/31/11 with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented Resident #10 was alert, oriented, and required extensive assistance with activities of daily living including transfers and toileting. Resident #10's quarterly fall risk assessment for (MONTH) (YEAR) was not completed. Resident #10's fall risk care plan, dated 06/14/18, stated he should be encouraged to participate in activities that promote exercise for strengthening and improved mobility. Resident #10's care plan for activities of daily living documented his restorative nursing program interventions for strengthening were to focus on transfers 3 to 6 days per week. No restorative nursing documentation was found. Nursing notes dated 10/06/18 documented Resident #10 fell without injury in his room. At 4:20 PM, Resident #10 stated, I was not hurt at all. On 10/12/18 at 3:50 PM, Staff C said the restorative nursing program was not in place as the restorative nursing aides were pulled to the floor to work as CNAs. On 10/11/18 at 4:20 PM, Resident #10 said he waited 30-40 minutes for a response to a call light before his fall. He said, I am not supposed to get up but I wanted to see why I wasn't getting help. Resident #10 stated, They are very short-handed here. Just two aides. On 10/09/18 at 5:01 AM, Staff M, an NAC, said, When we are lucky we have 3 or 4 of us CNAs - mostly we run 3 .it takes me 20 minutes to answer a call light. It's like a full moon, all the lights going off and I can't get to them all. On 10/09/18 at 5:40 AM, Staff C, the Acting Director of Nursing Services, stated fall risk management program was not fully in place and was compromised by staffing shortages. On 10/12/18 at 3:50 PM, Staff C said the restorative nursing program was not in place as the restorative nursing aides were pulled to the floor to work as CNAs. On 10/17/18 at 5:02 PM, Staff B, the Administrator, stated he was concerned about the falls and that the fall risk management program was undergoing performance improvement and the system for fall management was being revitalized by the new director of nursing services. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure that 2 of 2 sampled residents' (Resident #4, #5) medication orders were followed. This failure had potential for harm for Resident #4 when she did not receive medication to prevent complications of [MEDICAL CONDITION] and kidney failure, and actual harm for Resident #5 when she continued to receive medication for blood thinning for 7 days after the physician discontinued the order when Resident #5 had nose bleeds. Findings include . RESIDENT #5 Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented Resident #5 was alert and confused and dependent on staff for activities of daily living including bed mobility, transfers, and personal hygiene. Physician orders [REDACTED]. Resident #5's (YEAR) Medication Administration Record [REDACTED]. On 10/12/18, at 3:41 PM, Resident #5's physician stated she discontinued the anticoagulant medication because Resident #5 had persistent nose bleeds that could have continued with anticoagulant medication. On 10/17/18 at 2:10 PM, Staff A said, When I was the RCM, I followed up on orders quickly, checking the fax every 15-30 minutes but now I pass meds, I work the floor. We have a system but we can't follow it because we are short of licensed nurses so we are on carts passing meds instead of being resident care managers. RESIDENT #4 Resident #4 was admitted to the facility 09/20/18 with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented Resident #4 was alert and oriented and required extensive assistance with most activities of daily living. A faxed physician's orders [REDACTED].#4, starting 09/29/18, was to receive a diuretic medication ([MEDICATION NAME] 2.5 mg) every morning. The Medication Administration Records (MAR) for (MONTH) and (MONTH) (YEAR) did not show Resident #4 received [MEDICATION NAME] as ordered through 10/02/18. Late entry nursing notes dated 10/04/18 showed Resident #4 was transferred to the hospital on [DATE] with a change in her condition, including shortness of breath. On 10/12/18 at 3:30 PM, Resident #4's physician said the resident received acute [MEDICAL TREATMENT] and was on the intensive care unit. When asked if the medication error resulted in hospitalization for Resident #4, the physician said, I can't be 100% sure but I know that if she had a chance to avoid hospitalization , getting that medication was possibly her only chance. On 10/17/18 at 2:00 PM, Staff A, an RN, stated the order was not transcribed because as written, it needed clarification. Staff A said she did not transcribe it and passed the information about the order to the night shift nurse. Staff A said she should have clarified the order when it was received. Staff A stated distractions may have prevented follow-up on the order for Resident #4: Being on the cart I am constantly interrupted by others, for example, therapy staff and aides. The aides need help. Rehab staff need to do a lot of face-to-face communication with nursing. Staff A indicated she was available for such communication when she was recently an RCM but since there were not enough nurses, she was functioning in a staff nurse role. On 10/17/18, the evening medication pass for East Station was observed for 10 minutes between 5:30 PM and 5:40 PM. The medication nurse was interrupted 4 times in 10 minutes by staff approaching her cart. Reference (WAC) 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to ensure residents were free of verbal, physical and/or mental abuse and intimidation from other residents when the facility failed to take protective action in response to increasing aggressive behaviors by another resident for 2 of 5 sampled residents (#2 & 3) reviewed for physical abuse. This failure placed residents at risk for abuse and not reaching their highest level of well-being. This caused harm to Resident #2 and Resident #3. Findings include . 1) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 02/28/18, indicated the resident was severely cognitively impaired, and required minimal assistance with activities of daily living including locomotion on and off the unit and in facility corridors. The MDS showed Resident #2 had no functional limitations in range of motion and used a walker for mobility. The facilities incident report, dated 03/13/18, documented, on 03/11/18 at approximately 6:45 PM, staff entered the dining room and noted Resident #2 lying on the floor, on his left side. Resident #2 was unable to recount the events of the fall and verbalized wanting to get up. The Registered Nurse (RN) made the decision to have the resident evaluated at the local hospital emergency room due to his acute change in speech pattern, left sided facial droop, and new onset of left hip pain. Approximately 1 hour after the fall, a Nursing Assistant (NA) from another unit reported to the RN that one of the female residents (Resident #11) had been in the dining room and was a witness to Resident #2's fall. The female resident told the RN (Resident #1)beckoned to the old man, then (Resident #1) knocked (Resident #2) down. (Resident #2) fell hard. On 03/22/18 at 12:35 PM, Resident #11, who witnessed the fall of Resident #2, stated, Resident #1 motioned for the older man (Resident #2) to come over and pushed him down. (Resident #2) hit his head real hard. At 4:05 PM, RN 1 stated she was responsible for providing care for Resident #2 on 03/11/18. RN 1 said she was notified Resident #2 had a fall in the dining room. RN 1 said when she entered the dining room Nursing Assistant (NA) H was assisting the resident. RN 1 stated Resident #2 was initially fine, speech was normal, no facial droop, he just wanted to get up. RN 1 stated Resident #2 quickly developed a facial droop and left sided weakness. RN 1 said she quickly prepared for and sent Resident #2 to the ER for treatment. RN 1 stated later in her shift she was notified by an aide that Resident #11 had witnessed the fall and conducted an interview. RN 1 stated during the interview, Resident #11 said she witnessed Resident #1 call Resident #2 over to him and then push Resident #2 over. RN 1 stated, I believe (Resident #11) even though she has a cognitive impairment. The local hospital ER records documented Resident #2 arrived in theER on [DATE] at 7:37 PM, after an apparent fall. The record documented Resident #2 does not move left leg well, and a left facial droop is mild but present. This is a terminal event. (Resident #2) is resting, but BP (blood pressure) going up and pulse dropping, suspect herniation (deadly side effect of very high pressure within the skull that occurs when a part of the brain is squeezed across structures within the skull). The record showed Resident #2 passed away at 11:39 PM, 4 hours after arriving at the ER. 2) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated the resident was cognitively intact, required minimal assistance with activities of daily living, and used a walker for mobility. The facilities incident report, dated 03/14/18, documented on 03/14/18, at approximately 6:15 PM, Resident #3 entered the dining room where Resident #1 was watching television. Resident #3 approached NA E and started a conversation. Resident #1 yelled at Resident #3 to shut up. Resident #3 continued to talk with NA E and Resident #1 grabbed her arm and pulled her to the ground, injuring her left ankle, left hip and right wrist. In a witness statement, dated 03/14/18, NA E documented, (Resident #3) comes in and started to talk to me and (Resident #1) looks at (Resident #3) and tells her to shut up and grabs her right arm and pulls her to and ends up pulling (Resident #3) to the ground and (Resident #3) lands on her bottom and (NA A) came in and intervened while I made sure (Resident #3) was ok. On 3/19/18 at 4:00 PM, NA A stated he heard Resident #1 yelling so he entered the dining room. NA A said he observed Resident #3 on the ground, Resident #1 attempting to hit Resident #3, and NA E was sitting in a chair. NA A said NA E stood up and assisted Resident #3 while he redirected Resident #1. On 03/21/18 at 10:40 AM, Resident #3 said she entered the dining room and started talking with an aide (NA E). Resident #3 stated, (Resident #1) started yelling at me but I just kept talking with the aide. The next thing I know (Resident #1) grabbed me and threw me and my walker down. Resident #3 said she had pain to her ankle, hip and wrist where Resident #1 grabbed her. On 03/22/18 at 2:28 PM, the Director of Nursing Services (DNS) stated, NA E was assigned to Resident #1 as a 1:1. The DNS said NA E was on light duty. NA E was providing 1:1 care to protect other residents from Resident #1 following a physical abuse allegation. DNS said NA E did not perform the duties of a 1:1 as expected. NA E should have acted to prevent Resident #1 from grabbing Resident #3. The facility failed to evaluate the effectiveness of current interventions for identified behaviors, and did not provide interventions to assure the safety of residents to prevent resident to resident abuse. Staff failed to adequately monitor for verbally and physically aggressive behavior. These failures caused harm to Resident #2 and Resident #3. Reference WAC 388-97-0640(1)

Based on interview and record review, the facility failed to adequately assess for change in condition and seek immediate help for signs and symptoms of distress for 1 of 3 sampled residents (#4) reviewed quality of care. This failure placed residents at risk for a delay in recognition, assessment and timely treatment and a diminished quality of life. This caused harm to Resident #4. Findings included . Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 01/04/18, indicated the resident was severely cognitively impaired, and required assistance with activities of daily living. The MDS documented did not show Resident #4 had a condition and/or disease that would result in a life expectancy of less than 6 months. Record review showed no documentation Resident #4 was on hospice and/or comfort care, and no documentation of advance directions. The resident's care plan, initiated on 01/25/18, showed an intervention of companion staffing (1:1) for safety. Resident #4's care delivery guide (instruction for caregivers) documented resident is to be turned and 'check and change' every 2 hours. On 03/21/18 at 3:30 PM, Hospitality Aide (HA) 1 stated she was assigned to Resident #4 as a 1:1 for approximately 8 hours a day for approximately 2 weeks. HA 1 said when she started her shift on 03/13/18, at approximately 2:45 PM, she immediately noticed Resident #4 was significantly different than she was the prior day. HA 1 said Resident #4 was not responding correctly and was not verbal. Resident #4's lips were dry, cracked, and she appeared pale. HA 1 stated she reported her concern to Licensed Nurse (LN) 1. HA 1 said LN 1 entered the room approximately 1 hour later and assessed Resident #4. HA 1 said LN 1 told her she is fine, she is just tired. Later in the Shift, HA 1 noticed Resident #4 was unable to eat her dinner and was unable to hold a spoon in her hand. HA 1 requested assistance from Nursing Assistant (NA) B to help Resident #4 eat. NA B attempted to assist Resident #4 with eating and was unable to get the resident to eat. At 5:11 PM, LN 1 stated she was the nurse responsible for the care of Resident #4 on 03/12/18 from 2:00 PM, through 10:30 PM. LN 1 said she was not contacted by any aide regarding any concerns related to Resident #4. LN 1 said the only thing abnormal during the shift was Resident #4 did not eat her dinner. LN 1 said she faxed the doctor regarding Resident #4 not eating or drinking. At 5:49 PM, NA B stated she was approached by HA 1 and asked to help her with Resident #4. NA B said she was unable to wake up Resident #4. NA B said it is not unusual for Resident #4 to not complete her meal, but she always at least wakes up. NA B said she noticed Resident #4's skin was dry and would not return to normal when lightly pinched. NA B stated she reported her findings to LN 1 and was told there is nothing wrong with Resident #4. At 6:30 PM, LN 2 stated she was not made aware of any concerns regarding Resident #4 during shift report. LN 2 said the first time she was made aware that there was a concern regarding Resident #4 was when NA C approached her around midnight. LN 2 stated when she entered Resident #4's room she was soaking wet with sweat. LN 2 said she attempted to wake Resident #4 and was unable. LN 2 stated she attempted a sternal rub and got no response. LN 2 said she was unable to get a blood pressure and could only feel a faint pulse. LN 2 said she initiated a transfer to the local hospital emergency room (ER). A review of ER records, dated 03/13/18, documented Resident #4's pre-hospital blood pressure was 60 systolic (abnormally low blood pressure) and heart rate was 140bpm (abnormally high pulse rate). Resident #4 presented with obtundation (altered level of consciousness) and [MEDICAL CONDITION] (abnormally low blood pressure). The hospital's Hospitalist Death Summary, documented Resident #4 was admitted to the hospital on [DATE] with [MEDICAL CONDITION] (presence of harmful bacteria and their toxins) with septic shock (organ injury or damage in response to infection), acute metabolic [MEDICAL CONDITION] (abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function) due [MEDICAL CONDITION], healthcare associated pneumonia, lactic acidosis (excessive acid accumulates due to a problem with the body's metabolism of lactic acid), and urinary tract infection. Resident #4 passed away on 03/13/18 at 3:55 PM. On 03/21/18 at 3:30 PM HA 1 said she had been the companion for Resident #4 for the 2 weeks prior to her death. HA 1 said she is not a licensed NA and is unable to provide direct care. HA 1 said during her shifts not at any time did I see (Resident #4) receive 2 hour check and changes. At 5:49 PM, NA B said HA 1 was assigned to provide care for Resident #4 but she was in training and could not provide the care. NA B said no one was providing care for Resident #4 during HA 1's shifts. The facility failed to provide necessary care and services and take appropriate actions when staff recognized a significant change in condition for Resident #4. This failure delayed needed care/treatment that resulted in harm to Resident #4. Reference WAC 388-97-1060(1)

Based on interview and record review, the facility's administration failed to effectively and/or efficiently use its resources to prevent physical abuse for 2 of 5 sampled residents (#2 & 3) and to ensure necessary care and services were provided in a timely manner for 1 of 3 sampled residents (#4). Failure to assess and address staff knowledge to meet resident needs resulted in harm to Resident #2, 3, & 4, and placed the individualized and specific needs of residents at risk for failure to reach their highest level of function and a decrease in quality of care and quality of life. Findings include . The facility administrator failed to ensure the facility resources were sufficient to ensure allegations of abuse and neglect to residents and residents with change of condition were provided the care and services needed to meet their highest practicable physical, mental, and psychosocial well being. 1) Refer to 42 CFR 483.12 F-600, Free From Abuse and Neglect for facility failure to ensure 2 of 5 sampled residents (#2 & 3) were free from physical abuse and to communicate, document, and collaborate pertinent information regarding an increase in severity and frequency of aggressive resident behaviors and resulted in harm to these residents. 2) Refer to 42 CFR 483.25 F-684, Quality of Care for facility failed to ensure staff provided care and services for 1 of 3 sampled residents (#4) who experience an acute change in condition to help them attain and/or maintain their highest practicable level of function and impacted their well being, quality of life and quality of care, and resulted in harm to this resident. Reference WAC 388-97-1620 (1)

Based on interview and record review, the facility failed to provide the care and services to ensure pressure ulcers did not develop for 1 of 3 sampled residents (#1) reviewed for skin injuries. This failure placed residents at risk for delay in identification and treatment of [REDACTED]. This caused harm to Resident #1. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a comprehensive assessment tool, dated [DATE], documented the resident required extensive assistance with transfers and activities of daily living, was continent of bowel and occasionally incontinent of bladder. No pressure ulcers were identified in the MDS assessment. Resident #1 expired at the facility on [DATE]. A nursing admission note, dated [DATE] at 4:40 p.m., documented moderate [MEDICAL CONDITION] (swelling) to both of Resident #1's lower legs due to poor blood flow. Nursing documented several open areas with weeping on the lower legs and referred to the skin assessment. The Admission Skin Assessment, dated [DATE], charted the weeping and open areas on Resident #1's lower legs. The Skin Assessment noted an area on Resident #1's left heel with redness and weeping. A physician note, dated [DATE], documented Resident #1 had ,[DATE]+ ankle [MEDICAL CONDITION] (mild to moderate swelling), and a couple of very small open areas on (both) shins that should resolve quickly in the NH (nursing home) with leg elevation. Review of the [DATE] Treatment Record documented Resident #1 was scheduled to have weekly skin assessments on Tuesdays. The [DATE] and [DATE] dates documented skin assessments were completed. Documentation did not show the skin assessment scheduled for [DATE] was completed. A nursing note, dated [DATE] pm, documented, Open area on R (right) heel .5 cm L x 2.5 w. Area cleaned and Allevyn heel dressing applied, pillows put under legs to keep heels off the bed. MD faxed. The record documented the response from the physician on [DATE] at 10:30 a.m., Observe for worsening sx's (symptoms). Culture area with C&S (culture & sensitivity lab test to determine type of infection and most effective medication) if indicated. Update prn (as needed). On [DATE] at 2:15 p.m., nursing notified Resident #1's physician, Assessed R heel pressure ulcer. Now noted to be a St II (Stage II) collapsed blister that is open measuring 4 x 4.5 cm - superficial wound depth. Minimal serous (clear/light yellow) drainage . On [DATE] at 12:30 p.m., a request to place a foam heel dressing for added absorption and protection, and to change the dressing every 3 days and as needed, was signed by the physician. Review of the [DATE] Treatment Record included an entry to clean and dress the Stage II wound on Resident #1's right heel every three days and as needed. Documentation showed the treatment was completed on [DATE]. Review of Resident #1's Actual/Potential for Infection Care Plan, updated [DATE], documented, Wound: LE's (lower extremities) related to swelling and poor circulation, weeping [MEDICAL CONDITION]. There was no documentation on the care plan regarding the pressure ulcer on Resident #1's right heel. The conclusion of the Occurrence Report, dated [DATE], documented, Resident was not identified as a high risk for pressures . On [DATE] at 1:50 p.m., when asked how the facility became aware of the pressure ulcer to Resident #1's right heel, LN A stated an aide found it and reported it to the nurse. When asked if that was after the resident had been in the facility for awhile, LN A stated, It was acquired in-house. It was a good size, it covered his whole heel. It was a 2 (Stage II) wet blister. We used an Allevyn (dressing) on the heel for serous drainage. It was clean, no slough. Failure to identify a potential skin concern to the heel and put preventative measures in place for a resident with multiple skin concerns, resulted in the resident developing a Stage 2 pressure injury. This caused harm to Resident #1. Reference WAC [DATE](3)(b)

Based on observation, interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs), cleanliness and grooming for 14 of 14 sampled residents (1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, & 15) reviewed for ADLs. The facility's failure to promptly respond to resident's request for assistance and failure to assist dependent residents with ADLs caused psychological harm to 7 residents (2, 4, 5, 7, 8, 12, and 15) and placed all residents at risk of falls, health complications, injury to skin, discomfort, embarrassment, decreased quality of life and dehumanization. Findings include: 1) Resident #5 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #5's Minimum Data Set (MDS), a comprehensive assessment tool, dated 7/21/17, documented Resident #5 was cognitively intact and required extensive assistance with toileting and dressing. Resident #5's care delivery guide, updated 7/11/17, documented she required 1 person assistance for transfers, positioning, bathing, dressing, and grooming. A Resident grievance report, dated 7/14/17, documented Resident #5 reported to Staff H she waited while seated on the toilet for 30 minutes on 7/13/17 for assistance. Resident #5 called out to her roommate to get help. Her roommate said she was unable to find a staff member to help, there were lots of lights on. Resident #5 reported I'm sore (buttock area) today because I didn't get cleaned up. On 7/27/17 at 1:00 p.m., Resident #5 was observed waiting on the toilet for assistance for 33 minutes after the emergency bathroom call light was activated. Resident #5 was calling out I need some help in here for approximately 14 minutes before her roommate wheeled into the hall and shouted for help. Licensed Nurse (LN) A responded to calls for help and assisted Resident #5, 33 minutes after the emergency call light was activated. On 7/27/17 at 1:10 p.m., Resident #5 stated call lights were not answered promptly. The resident said it took at a minimum 30 minutes and routinely 45-60 minutes for a call light to be answered. Resident #5 became tearful when describing how this made her feel. Resident #5 stated, I feel like a piece of meat and not a person. 2) Resident #7 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #7's MDS, dated [DATE], documented Resident #7 was moderately cognitively impaired and required extensive assistance with toileting and dressing. Resident #7's care delivery guide, updated 8/10/17, documented she required 1 person assistance for transfers, positioning, and locomotion. On 07/27/17 at 1:38 p.m., Resident #7 indicated call lights are not answered timely and residents have to wait up to an hour for assistance. Resident #7 stated, This is what I'm talking about referring to her roommate who was currently calling out and waiting for assistance on the toilet. Resident #7 stated, I need to go get someone because no one will come if I don't. Resident #7 wheeled into the hall and called out for assistance. On 08/20/2017 at 10:52 a.m., Resident #7 indicated the call response time had not improved significantly since 07/27/17. Resident #7 said, The staff do not have time to help us. Resident #7 stated on 8/17/17 she had a bloody nose which soiled her bedding. Resident #7 requested assistance changing the sheets on the morning of 8/17/17 and again on the afternoon of 8/18/17. At approximately 6:00 p.m., on 8/18/17, Resident #7 demanded a new set of sheets and a pillow case and changed the sheets herself from her wheelchair. Resident #7 stated, I feel there is a safety factor, when they don't come. It makes me feel like a second rate citizen. I feel like a number and am only here for revenue. I feel anxious. I can't sleep well feeling that if I have an emergency I will not get help. I have had nightmares about losing my foot and not being able to walk due to no body being able to help me when I need it. 3) Resident #2 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #2's MDS, dated [DATE], documented Resident #2 was cognitively intact and required assistance for transfers, toileting and dressing. Resident #2's care delivery guide, updated 7/21/17, documented he required 1 person assistance for transfers, positioning every 2 hours, and locomotion. On 7/28/17 at 12:52 p.m., Resident #2 stated, I have to wait for 30-40 minutes for anything. I sit in my soiled depends (adult incontinent brief) waiting for help. Resident #2 indicated he does not get regular showers. Resident #2 stated, I feel like a helpless child. 4) Resident #13 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #13's MDS, dated [DATE], documented Resident #13 was cognitively intact and required 1 person assistance for transfers, toilet use, and dressing. Resident #13's care delivery guide, updated 6/22/17, documented she required 1 person assistance for transfers with a gait belt, showers, and dressing. On 7/28/17 at 12:58 p.m., Resident #13 stated, I have to wait quite a while for help. Resident #13 indicated she had missed multiple showers. They need more staff, everything is in a tailspin around here. 5) Resident #6 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #6's MDS, dated [DATE], documented Resident #6 was cognitively intact and required 2 persons physical assistance for bed mobility, and toileting. Resident #6's care delivery guide, updated 7/6/17, documented she required 1 person assistance for transfers, showers, and dressing. She required 2 persons assistance for bed mobility. Resident #6 was on an every 1 hour check and change schedule for incontinence. On 7/28/17 at 12:58 p.m., Resident #6 stated, I have to wait up to an hour for someone to help me. 6) Resident #12 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #12's MDS, dated [DATE], documented Resident #12 was cognitively intact and required 2 person assistance for bed mobility, toileting, and dressing. Resident #12's care delivery guide, updated 7/19/17, documented he required 1 person assistance for transfers, showers, and dressing. Resident #12 required 2 persons assistance every 2 hours for turning. On 7/28/2017 at 1:01 p.m., Resident #12 stated, I have to wait 20-30 min for my call light to be answered. I used to take a shower every day. I'm supposed to get 2 showers a week, I'm lucky if I get 1 shower every other week. I don't get turned like I'm supposed to. I feel like a farm animal. 7) Resident #11 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #11's MDS, dated [DATE], documented Resident #11 was cognitively intact and required 2 person assistance for transfers, toileting, and dressing. Resident #11's care delivery guide, updated 5/10/17, documented she required 2 person assistance for transfers, positioning every 2 hours, showers, and dressing. On 7/28/17 at 1:10 p.m., Resident #11 stated, It takes at least 30 minutes, but consistently 45-60 minutes to get help. On 8/20/17 at 12:34 p.m., Resident #11 stated on Friday 8/19/17 she was told don't even bother asking for a bed bath, there is no way it will be done today. The following day Resident #11 asked for a bed bath and was told there was only enough time to clean around her wounds. Resident #11 stated, I feel like the people that run this place don't care. I do not get help unless I ask. I am having anxiety over my wounds getting infected and not getting proper care. I don't want another infection. 8) Resident #1 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #1's MDS, dated [DATE], documented Resident #1 was mildly cognitively impaired and required 1 person assistance for transfers, toilet use, and dressing. Resident #1's care delivery guide, updated 4/12/17, documented she required 1 person assistance for showers. On 7/28/17 at 1:15 p.m., Resident #1 stated, It takes 20-30 minutes to get a call light answered. There is not enough staff. People are always screaming for help. On 8/20/17 at 12:17 p.m., Resident #1 said her bed does not getting made regularly. Resident #1 stated she was told she could not have a shower today. Resident #1 said, I feel dirty and angry. At 12:17 p.m., Resident #1 was observed in bed wearing a hospital gown. Resident #1's hair was uncombed and greasy. At 12:30 p.m., Nursing Assistant (NA) I stated, I have not had a chance to get into Resident #1's room. This is the craziest place I have ever worked. I have 20 residents and no help. I cannot provide the care I want to. 9) Resident #10 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #10's MDS, dated [DATE], documented Resident #10 was severely cognitively impaired and required 1 person assistance for transfers, toilet use and dressing. Resident #10's care delivery guide, updated 8/8/17, documented he required 1 person assistance for transfers, positioning every 2 hours, showers and dressing. On 7/28/17 at 1:23 p.m., Resident #10 stated it took 30-60 minutes to get a call light answered. I'm not getting my showers. There is not enough staff. It bothers me that I have not gotten a shower. I need one now. 10) Resident #3 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #3's MDS, dated [DATE], documented Resident #3 was mildly cognitively impaired and required 1 person assistance for transfers, and dressing. Resident #3 required 2 persons assistance with toilet use. Resident #3's care delivery guide, updated 8/14/17, documented he required 2 person assistance for positioning every 2 hours. On 7/28/17 at 1:26 p.m., Resident #3 stated it took between 15-60 minutes to get assistance. Resident #3 stated, We do not get our showers consistently. 11) Resident #4 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #4's MDS, dated [DATE], documented Resident #4 was severely cognitively impaired and required 1 person assistance for personal hygiene, and dressing. Resident #4 required 2 persons assistance with transfers. Resident #4's care delivery guide, updated 6/14/17, documented she required 2 person assistance for transfers, and positioning every 2 hours. Special instructions included max care with all activities of daily living. On 7/28/17 at 1:30 p.m., Resident #4 stated, Call lights take forever. I do not get the help I need. I do not get showered very often. 08/20/2017 at 1:21 p.m., Resident #4 was observed parked in the hall calling out for help. Resident #4 stated she needed to go to bed, her tailbone hurt sitting in the chair. Multiple staff (NA F, NA G, NA H, Licensed Nurse (LN) D) were observed walking by resident without acknowledging her requests for help. At 1:42, NA F and NA H acknowledged Resident #4's request and transferred Resident #4 into bed. At 1:45 p.m., NA F stated, There are too many resident needs to get it all done. (Resident #4) had to wait 20 minutes for assistance because we had other residents to care for. At 2:02 p.m., Resident #4 said she felt angry that she had to wait every day for help. At 2:02 p.m., Resident #4 was observed with thick black 1 inch long chin hair and upper lip hair that was visible from across the room. Resident #4 stated it was embarrassing when asked if she preferred to be shaved. At 2:09 p.m., when asked about Resident #4's chin hair, LN J stated, That should not have happened. LN J said her chin hair should have been taken care of during showers. 12) Resident #8 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #8's MDS, dated [DATE], documented Resident #8 was moderately cognitively impaired and required 2 person assistance for toilet use, transfers, and bed mobility. Resident #8's care delivery guide, updated 7/6/17, documented she required 2 person assistance for transfers, and positioning every 2 hours. On 7/28/17 at 1:34 p.m., Resident #8 said call lights took about 45 minutes to be answered, There is no staff. I'm supposed to get 2 showers a week. I don't get them. Resident #8 said, It makes me feel dirty. I urinated in my pants due to the wait times. I was crying and mortified. I get anxious about body odor. On 08/20/17 at 12:07 p.m., Resident #8's family member said, Mom took a shower daily prior to moving into this facility. Mom has cried due to not getting showers. Mom's bed was not being made. I had to change linens myself because there was no staff to help. 13) Resident #14 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #14's MDS, dated [DATE], documented Resident #14 was moderately cognitively impaired and required 2 person assistance for toileting, transfers, and bed mobility. Resident #14's care delivery guide, updated 7/6/17, documented she required 2 person assistance for transfers, and positioning every 2 hours. On 08/20/17 at 2:16 p.m., Resident #14's call light was on for 35 minutes. Resident #14 said, My bottom is tired and painful, I have skin breakdown. I'm anxious about the pain, and not getting help when I need it. At 2:30 p.m., NA K said, Resident #14's call light was on for over 30 minutes because she is a 2 person transfer and the other NA's were helping other residents. 14) Resident #15 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #15's care delivery guide, updated 8/14/17, documented she required 2 person assistance for positioning. 08/20/2017 2:20 p.m., Resident #15's call light was activated. Resident #15 stated, I have been waiting for 30 min to get into bed. Resident #15 said she has to wait up to an hour regularly. The first night she was in the facility, 8/14/17, Resident #15 was told that she needed to urinate in an adult diaper because she could not be transferred out of bed. Resident #15 said, I had to go along with them. I did not have a choice. Resident #15 stated, I was humiliated, I never felt like that. I felt like I was a child, a piece of meat. It's insulting. Even this morning I was asked where my brief was. I felt embarrassed and harassed. It's disgusting. A review of Resident #15's bladder assessment, dated 8/15/17, documented, Resident is continent of bladder. A review of Resident #15's bowel assessment, dated 8/15/17, documented, Resident is continent of stool. On 08/20/17 at 4:48 p.m., the Director of Nursing (DON) said, A continent resident should not be placed in a brief and told to urinate. On 7/28/17 at at 1:21 p.m., LN D stated there was not enough staff to care for the residents. There is only enough staff to fight fires. We cannot set up any kind of systematic care. Daily care like tooth brushing and general cleanliness was not being done, It's disgusting. We are not able to complete the 2 hour checks on residents due to staffing. At 1:37 p.m., when asked if there was enough staff to meet the needs of the residents LN C said, Absolutely not. LN C indicated showers were not being completed, and weekends were the worst. LN C stated multiple care needs are not being met such as fingernail care, shaving, and tooth brushing. At 1:40 p.m., Nursing Assistant (NA) E stated, We need more people to do a better job. At 1:44 p.m., NA F indicated there was not enough staff to properly care for the current residents. Due to the lack of staffing, showers, tooth brushing, and combing hair are not getting done. At 1:50 p.m., NA G indicated there had not been enough staff to meet the needs of the residents for the past year. We do not have time to soak dentures, clean teeth, clean rooms, make beds, and we do not provide any 1:1 interactions with the residents. At 2:05 p.m., LN A said given the number of residents on the hall and the number of residents who require extensive assistance, there was not enough staff to uphold the plans of care. At 2:10 p.m., LN B said the facility did not have enough staff to meet the needs of the residents. LN B stated, Call lights are answered in 30-60 minutes. A review of the facilities staffing pattern for 8/6/17 through 8/20/17 documented a daily average of 5.3 NA's (17.6 residents per NA) for dayshift, 5.5 NA's (17.6 residents per NA) for evening shift, and 4 NA's (22 residents per NA) for night shift. The average daily census for the same time period was 88.6 residents. On 7/28/17 at 2:20 p.m., review of the facilities Care Delivery Guides, for all current residents, documented 39 residents required 1 person assistance, 40 residents required 2 person assistance, 62 residents required 2 hour changing and/or turning, and 72 residents were assessed as a fall risk. A review of the facilities shower logs for all residents, from 7/20/17 through 7/26/17, documented 21 residents did not receive a shower during the 7 day review period. During the same period 94 scheduled showers were missed. The facility failed to provide timely assistance to residents when assistance was requested. The facility also failed to provide services to maintain personal hygiene, grooming and oral hygiene. At 3:08 p.m., when asked if there was enough staff to meet the needs of the current residents in the facility, the administrator answered No. On 8/20/2017 at 5:05 p.m., when asked if there was enough staff to meet the needs of the current residents in the facility, the DON stated, No, we are staffing challenged. Reference WAC 388-97-1060(1)

Based on observation, interview and record review it was determined the facility failed to evaluate and monitor the pain level for 1 of 2 sample residents (#1) reviewed for pain. This failure placed the resident at harm for inadequate pain control, and narcotic pain medication withdrawal. Findings Include: Resident #1 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1 had a history of [REDACTED]. On 05/15/16 at approximately 11:30 p.m.; Resident #1 was observed to be yelling out, Ey yi yi. The resident was observed to have a facial grimace with evidence of pain on her face as well as tightened up and closed eyes. On 05/16/16 at 1:09 a.m.; Nursing Assistant (NA) A indicated the resident had been there since 05/14/16 and during that time she had been showing signs of pain stating, she has been in a lot of pain. NA A indicated the resident's daughter had been with her the quite often due to the resident's level of pain. On 05/16/16 at approximately 12:00 p.m.; Resident #1 was observed to again be yelling out, Ey yi yi. The resident was observed again to have a facial grimace of pain on her face. Resident #1 was observed to have a slight jerking motion of her right arm that happened intermittently and was observed to be sweating. On 05/16/16 Resident #1 was observed through the day to be in pain and yelling out in pain. Resident #1 was observed to be sweating, and be in a obvious state of discomfort. On 05/16/16 at 3:00 p.m.; Resident #1's daughter indicated that she had been trying to contact the resident's doctor's office to see about something more for the resident's pain. The resident's daughter was worried as to the level of pain her mother was experiencing. The daughter indicated that the facility nursing staff had indicated to her that they had faxed the on-call Physician; however, the nursing staff was unsure when the doctor would be in to assess the resident. The daughter indicated the resident was being followed by a pain management clinic prior to surgery; however, once the surgery was done the pain medication was turned over to the surgeon and facility physician. The resident's daughter indicated she was open to all possibilities of pain control including but not limited to non-narcotic interventions. Record review of Resident #1's Medication Administration Record [REDACTED]. Review of the resident's pain data collection and assessment dated [DATE] indicated the resident's history of pain medication use included [MEDICATION NAME], and [MEDICATION NAME]; this indicated all of these medications were effective for pain control. Record review of Resident #1's pain management care plan indicated the resident's goal was to, decrease persistent pain to a tolerated level so resident can function in daily life. Also indicated, Will not have signs and symptoms of unrelieved pain; verbalization of pain relief, no vocalization related to pain. Interventions listed as part of this care plan included, Assess for verbal and not-verbal signs and symptoms of distress or pain unrelieved by ordered treatments/medications. Record review of the facility's clinical programs manual for pain management indicated, Assessment also evaluates alleviating and/or exacerbating factors, reviewing effectiveness of past and current treatment. On 5/16/16 at 4:46 p.m.; the Licensed Nurse (LN) A indicated that she had not yet heard from the physician. LN A indicated that prior to the resident's admission she was on high doses of narcotic pain medication; including [MEDICATION NAME] twice a day. LN A indicated that on the first day she admitted (05/14/16) LN A asked the resident if she would like anything stronger for pain, but has since not reassessed the resident for anything stronger or more effective. LN A indicated she had not since spoken to family about their wishes for pain treatment beyond what was already prescribed. LN A indicated the resident was receiving [MEDICATION NAME] 5mg every 4 hours; however, it was only effective for 2 maybe 3 hours, then the resident was left in pain for at least another 1-2 hours until the next dose was able to be given. On 05/16/16 at 5:10 p.m.; Resident #1's daughter stopped the State Surveyor and asked if the facility could maybe even prescribe her mom [MEDICATION NAME] indicated she was highly concerned her mother was in a state of withdrawal from being on pain medication, further indicating she was terribly concerned about the level of her mom's pain. LN B joined the conversation and indicated that she had not yet heard back from the Physician; however, if by 6:00 p.m. if no contact was made by the doctor Resident #1 would be sent out the emergency room . On 05/17/16 Record review indicated the resident was sent to Olympic Medical Center and returned with new prescriptions for pain medications including [MEDICATION NAME] 10mg twice a day (every 12 hours). The resident had a returned [DIAGNOSES REDACTED].

Based on observation, interview and record review, it was determined the facility failed to aggressively advocate for 1 of 1 sampled resident (#87) with agitation and increased behaviors. This failure resulted in the [AGE] year old resident lying on the floor being handcuffed by the police and taken to the ER. Findings include: Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/16/16 at 4:00 p.m., the Surveyor heard noise in the hallway and observed Resident #87 was seen lying on the floor with hand cuffs on and a police officer kneeling at her side. Other staff members were standing around. The resident was calm and complained of the handcuffs hurting her wrists. There was blood on her wrist and a staff member went and got a dressing as the resident had obtained a skin tear from the handcuffs. Between 4:00 p.m., when this was observed, until EMS arrived around 4:45 p.m., the resident was on the floor lying on a pillow and remained handcuffed. Per the progress notes at 16:30 p.m., paramedics arrived. The paramedic talked with resident. The paramedic asked if she would help him sit her on the stretcher. The resident stated, Get her away from me and pointed at the police officer. The paramedic assisted the resident to the stretcher and took resident out of the facility. At 5:00 p.m., the Clinical Educator (CE) stated, I don't know much about her as a patient. This morning there were some issues of her trying to get out the door, ramming people with her walker. This is abnormal for her. We all had to stand guard to keep her in the facility. When asked about dementia training the CE responded, We educate on deescalating techniques on residents with dementia and we address in general orientation and approach. At 5:18 p.m., Licensed Nurse (LN) F stated, The DNS (Director of Nursing Services) asked me to call the police. The resident was yelling at the DNS as we entered the door and she was ramming the walker at staff. LN F stated, I called 911 and the dispatcher asked if we needed paramedics. I told them no, just the police to show an act of force to get her to calm down. This behavior comes and goes. We can deescalate her and calm her down. I know she has had some med changes the last couple of weeks. Not sure if it was related to a urinary tract infection (UTI) or related to med changes. On 2/16/16 at 5:27 p.m., the Director of Nursing (DNS) stated, She has been having up and downs with behaviors. The interdisciplinary team met and came up with a plan of care for her and asked pharmacy to review medications. The DNS stated, This afternoon, staff have been trying to redirect her. She has been verbally abusive. We have walked with her. She became physically abusive and was not easily directed. We call 911 and asked for police to see if they could redirect. It looked like she was physically aggressive toward a police office. It was heart wrenching to see her in hand cuffs. Social Service records from 12/11/15 made no mention of resident's aggressive behavior. The Med review/psychotropic meeting notes, dated 1/21/1016, indicated the resident had been more agitated and recommended to increase the Buspar (an antianxiety medication) if the agitation continued. There was no noted increase documented in the medical record regarding behaviors. On 1/31/16 the resident's urine was tested and it was positive for infection. Resident #87 was started on Cipro for 3 days. There was no follow-up urinary test conducted after the resident finished the 3 days of antibiotics, despite the increase in the resident's behaviors. The resident was sent to the hospital on [DATE]. A urine test was completed at the hospital and the resident was sent back to the facility the same day with a different antibiotic, bactrim, scheduled for 10 days. Additionally, the resident's ativan (an antianxiety medication) was increased. On 2/19/16 at 12:06 p.m., the SSD stated, When this all started I was told it was a UTI and that is what they were looking into it. She was put on an antibiotic for 3 days and it didn't seem to make a difference. That is when she went to the hospital and they increased her Ativan and then sent her back. We discussed the resident and it looks like it is more than a UTI. We talked to psychologist yesterday and she said it looks like she needs an antipsychotic (a medication used to decrease agitated behaviors.) The SSD stated, She has had the behaviors in the past with increased agitation, but this time it is obvious it is continuing. I know the RCM (resident care manager) has asked the doctor for a plan. We do 1:1, take for her for walks, coloring, music, and talk about her family. The resident's Mood and Behavior Symptom Assessment care plan, dated 7/31/15, 12/11/15, and 2/3/16, revealed generic behavioral approaches. There was no information about what approaches seemed to be the most effective, what worked or what didn't work, or if there were staff members that worked better with the resident than others. The care plan gave no direction to staff on what behaviors might trigger escalation of anxiety or how to handle the behaviors when they occured. On 2/19/16 at 12:12 p.m., the DNS stated, We have been trying to see the escalation and do something before having to send her to the ER. Once she is escalated it is hard on her and everyone else. The MD would not give orders for other medications. We sent her out last night I am going to go to the medical director. At 12:15 p.m., the Medical Director (MD) stated, We are changing medications, I talked with her son, and the local psychiatrist is assisting with her being geriatric. We are going to try Seroquel (an antipsychotic medication), I wrote the order already. In summary, the facility failed to aggressively advocate for the resident to determine why the behaviors were escalating. Failure to determine and provide interventions to mitigate possible causitive factors resulted in the police being called and the resident hand cuffed in front of other residents, families, and staff. At no time did the facility advocate to move the resident out of the line of sight, nor ask if the handcuffs were necessary even at the point of the resident remaining calm for almost an hour. The facility did not rule out if the behavior was a continuance of a UTI, or other medical issues. It was not until the resident was sent to the ER that any testing was done to rule out a medical issue. There was no monitoring of the behaviors or direction on the care plan specific for this resident's behaviors. The care plan was generic and had nothing specific or individualized for this resident. The social service assessment, dated 12/11/15, had no behaviors listed in the behavioral symptoms section; therefore, it was difficult to determine where the information on the care plan came from regarding behaviors. There was no documentation from social services on what interventions they had initiated to assist this resident with her behavior and left it up to the physician to develop the plan of care. This resulted in potential psychosocial harm and embarrassment to the resident as any reasonable person in the same situation would feel.

Based on observation, interview and record review, it was determined the facility failed to ensure qualified Professional staff ( licensed, certified, or registered in accordance with applicable State laws) provided care to 1 of 4 sampled residents (#1) during transfer assist. This failure placed all residents at risk for injuries when services were provided by unqualified staff and caused harm to Resident # 1 when an unqualified staff member assisted the resident to transfer and shortly after, the resident was found to have a fractured right arm and dislocation of the resident's right shoulder. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Department of Social and Health Services assessment dated [DATE] documented the resident had a history of [REDACTED]. The resident's initial assessment dated [DATE] documented the resident had memory problems, impaired decision making-ability and had pain in shoulders with limited range of motion. The resident was dependent on staff for assistance with activities of daily living, bed mobility and transfers. On 8/11/15 the resident was observed sitting in her wheelchair, in her room. The resident's right arm was in a sling. The resident was not able to provide additional information related to the incident. Review of an event report revealed on 8/1/15 an unqualified staff member helped the resident up from the wheelchair by pulling resident up by (resident's) hands, (without a gait belt) and transferred the resident to the wheelchair and taken to lunch. After lunch, the resident complained of pain to her right arm and cried out in pain when staff attempted to move the resident's elbow. The resident was transported to the hospital for evaluation and was diagnosed with [REDACTED]. According to the physical therapy treatment note dated 7/30/15, the resident was trained to perform sit to stand and stand-pivot transfer with standby assist. The resident was able to perform the transfer with no upper extremity support. On 8/11/15 the Activity Director (AD) stated she assisted the resident to transfer from the resident's bed to the resident's wheelchair on 8/1/15. The AD said she held the resident's hands and the resident stood up and pivoted to the wheelchair. The facility could not provide evidence the AD was registered, certified, licensed or had training to perform transfers of residents with limited mobility. Resident Care Manager (RCM) A said the AD was not a a qualified professional who could assist residents with transfers. The Director of Nursing Services (DNS) said the resident could stand independently and required one staff standby assist to provide verbal guidance during a transfer.

Based on observation, interview and record review, the facility failed to provide medically related social services to maintain the highest practicable mental and psychosocial well-being for 1 of 35 current sampled residents (#187) reviewed. This failure to respond resulted in on-going psychological distress and harm for Resident #187 and placed other residents at risk for a diminished quality of life. Findings include: Facility policy entitled "Concerns-Resident/Family" indicated "All staff are responsible for documenting resident/family concerns. The social worker will keep the resident concern log. The social worker will bring the log to the Daily Stand-Up Meeting and inform the facility team of pending unresolved concerns. Resident #187 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set, an assessment tool, dated 10/21/13, the resident was alert and oriented with occasional problems remembering dates and times. The resident required extensive staff assistance for activities of daily living. On 11/18/13 at 3:49 p.m., resident #187 reported, "A resident (male) with dementia came into my room and hid behind the curtain. He exposed himself as a nurse was bending down trying to tie his shoes. I was upset for weeks because I saw his genitals. I have been unable to sleep. I don't feel safe. This happened approximately two weeks ago. I have felt afraid for two weeks since this happened. I reported it to the facility social worker. She never came back to report on the progress of the report. I also told Licensed Nurse (LN) E who told me that the resident was kicked out of the facility, but I am worried that he will come back. I am scared of this resident. There is no security in this building and the doors are open 24 hours a day." On 11/21/13 at 3:42 p.m., the Social Services Director (SSD) stated, "I don't remember the resident or anyone reporting this incident. This is the first time I have heard of this incident." No evidence was found regarding this incident or documentation in the facility's concern log. On 11/21/13 at 5:13 p.m., LN E stated, "I knew the male resident was wandering throughout the building. With husband present, (Resident #187), told me about the incident and both husband and resident told me it was no big deal. I even offered a concern form to her husband, but he said not to worry since the male resident was gone." On 11/27/13 at 10:32 a.m., Resident #187's husband stated he was not present when LN E interviewed his wife, and does not recall being offered a concern form. The husband did not recall stating it was not worrisome, because his wife had experienced past life circumstances which left her afraid of not being able to protect herself. The resident's husband stated, "This incident with the resident entering her (Resident #187) room has left her fearful because she could not move or walk or get out of bed to get away from an intruder, leaving her vulnerable and unable to protect herself." On 11/27/13 at 12:07 p.m., Resident #187's daughter-in-law confirmed she had called the facility regarding the male resident entering Resident #187's room. Her phone call was transferred to the SSD. Resident #187's daughter-in-law stated, "I proceeded to tell the social worker about my concerns about my mother-in-law being very upset and feeling unsafe at the facility." The facility's failure to respond to Resident #187's allegations, left the resident scared, concerned and worried the wandering resident would return. This failure resulted in Resident #187 having reoccuring feelings of fear and had been unable to sleep. The resident stated she was "scared the man would come back." This caused psychosocial harm to Resident #187. .