Every finding on record at Providence Mount St Vincent

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from abuse for 1 of 4 residents (Resident 1) reviewed for exploitation and the right to be free from neglect for 1 of 1 resident (Resident 2) reviewed for elopement (leaving a safe area). The failure to protect residents from abuse by staff, and the failure to have structure, processes, and staff training in place to prevent elopement, placed the residents at risk for injury, accidents, fear, intimidation, mental anguish, emotional distress, and diminished quality of life.Findings included.Abuse - ExploitationReview of the 06/2025 facility policy titled Abuse Prohibition and Prevention showed all residents had the right to be free from abuse including financial exploitation. The policy showed the facility had implemented processes to prevent, investigate and act on all allegations of abuse. The policy defined exploitation as taking advantage of a resident for personal gain, thru the use of manipulation, intimidation, threats, or coercion.Review of the 07/02/2026 quarterly Minimum Data Set (MDS, an assessment tool) Resident 1 was cognitively intact with diagnoses including anxiety, depression and post-traumatic stress disorder. The MDS showed Resident 1 required staff assistance with personal care and assistance with discharge back to the community.Review of the 07/23/2026 facility investigation showed Resident 1 was buying food and coffee and had given $60 cash to Staff D between the months of April 2026 and July 2026. The investigation showed multiple text communications with requests for coffee drinks on Resident 1's cell phone. The investigation showed financial transactions for purchases made at the facility cafe which Resident 1 stated were for Staff D. The investigation showed a cash withdrawal from the facility cash machine which Resident 1 stated they gave $60 to Staff D. The investigation showed an interview with Resident 1 in which they stated Staff D's multiple requests for food and drinks had become burdensome and Resident 1 expressed concern of retaliation from Staff D since the incidents were reported. The investigation summary showed Staff D engaged in inappropriate financial interactions and solicitation of goods from Resident 1.In an interview, on 08/06/2026 at 3:20 PM, Resident 1 stated they bought coffee and food items for Staff D multiple times over the past few months because they were friends. Resident 1 stated they initially offered Staff D a coffee from the cafe as a thank you, but the one gift escalated into Staff D frequently asking for coffee and food from the cafe on multiple occasions. Resident 1 stated Staff D told them they did not have any food at home so Resident 1 gave them $60. Resident 1 stated Staff D shared personal problems, looked for advice, demonstrated a range of strange behaviors and emotions, which made Resident 1 feel sorry for them and wanted to help Staff D. Resident 1 stated Staff D once told them a violent story that happened outside of work, then Resident 1 stated they were concerned what Staff D would do if Resident 1 stopped providing gifts of coffee and food, or asked for the loan of cash to be repaid. Resident 1 stated one day they told Staff D that was the last time they were going to buy coffee and Staff D started crying and said to Resident 1 that they only asked for coffee when they had a bad day, Resident 1 stated they felt bad, went to the facility thrift store, and bought Staff D a teddy bear to make them feel better. Resident 1 stated I am a patient here because I have a lot of medical things going on and I am vulnerable. I have been a caregiver, and [Staff D] should not have taken advantage of me like that. I feel like an idiot for letting this happen, I should have known better. Resident 1 was tearful and stated the investigation was very upsetting, and they felt manipulated and ashamed of themself. Resident 1 stated people like [Staff D] seek out people like me, that made me feel unsafe, and this was not ok. Resident 1 stated between cash, food and coffee that Staff D took about $100 for their own personal gain. Resident 1 stated they did not want to get anyone in trouble and was afraid that Staff D would retaliate. Resident 1 stated the facility staff were very supportive once the incident was reported and Resident 1 stated they felt safe and cared for by the facility staff.In a phone interview, on 08/07/2026 at 2:25 PM, with Staff A (Administrator), Staff B (Director of Nursing) and Staff C (Director of Clinical Operations) Staff B stated employees are expected to follow the policies of the facility, they are trained at new employee orientation and annually on resident abuse and prevention, and additional abuse training is provided to staff anytime an allegation comes up. Staff B stated caregivers should not share personal information with residents; it can make the residents feel bad for them and want to do things for them. Staff A stated staff must maintain professionalism when working and are expected to follow the facility no soliciting policy and were not allowed to accept gifts from residents. Staff A stated Staff D did not follow facility policy and was terminated for violating the facility no soliciting policy and standards of conduct policy.Neglect - ElopementReview of the July 2026 Missing Resident policy showed when a resident was assessed as an elopement risk, the staff would initiate a Roam Alert device to alert staff when the resident attempted to leave the facility through an exit enabled with the Roam Alert detectors. When a resident could not be located after an initial search, a code green announcement would be initiated by the switchboard operator / receptionist, the incident command center would be activated for an organized search for the resident outside the facility, required notifications, and accurate documentation of the incident until the missing resident was located.Review of the 7/02/2026 quarterly Minimum Data Set (MDS, an assessment tool) Resident 2 was cognitively impaired and had diagnoses including non-traumatic brain dysfunction and dementia. The MDS showed Resident 2 was able to move and walk independently without any assistance or devices.Review of the 04/16/2026 Care Plan (CP) showed Resident 2 had a diagnosis of wandering, was at risk for elopement related to their dementia diagnosis and had past incidents of elopement. The CP showed Resident 2 wore a Roam Alert bracelet and should not go outside independently. The CP showed Resident 2's Representative (RR) installed a locating device in Resident 2's shoes in the event they did go outside independently, they could be easily located.Review of the July 2026 Treatment Administration Record (TAR) showed Resident 2 had a Roam Alert bracelet which staff were required to check placement on Resident 2's right wrist twice daily and check the battery weekly on Mondays with a tag reader. The TAR showed staff completed both tasks as directed.Review of the 07/27/2026 facility incident investigation showed Resident 2 had an elopement event from the facility on 07/27/2026. Resident 2 was last seen by the night shift nursing staff at 4:45 AM sleeping in their bed during care rounds. At 7:15 AM (2 hours 30 minutes later) Resident 2 could not be located and the facility staff initiated their missing resident policy. At 7:20 AM, the RR was notified of the elopement and facility staff asked about the locating device in the shoes. The RR stated they had not kept up with the locating device and were not sure the device was still active. At 8:00 AM the RR stated they were able to locate Resident 2 using the locating device. At 8:25 AM, (3 hours and 40 minutes later) Resident 2 was located over two miles away from the facility and was returned to the facility. Resident 2 told staff that they were tired and hungry and grateful for the ride back to the facility. In an interview, on 08/07/2026 at 1:30 PM, Staff E (Director of Operations) stated the Roam Alert system is enabled on multiple exit doors of the facility including the main entrance. Staff E stated they tested Resident 2's device and reviewed the system logs. Staff E stated the Roam Alert did not function as designed, the system should have detected the bracelet and if the door was closed the door would be disabled from opening, and if the door was open, the system would have sent out the Roam Alert signal to staff radios. Staff E stated there was no Roam Alert signal sent to the radios and the door opened for Resident 2 to exit. Staff E stated the facility investigation concluded the bracelet tag failed and did not alert the system as expected and Resident 2 was able to bypass the Roam Alert detector at the main entrance. Staff E explained the investigation debrief found that Staff F (Receptionist) saw Resident 2 outside the main exit at 5:30 AM on the day of elopement but did not know Resident 2 was at risk for wandering, risk of elopement, or wore a Roam Alert bracelet. Staff E stated Staff F was filling in as the receptionist for the first time and had not been trained in the elopement policies of the facility. Staff E stated the position of receptionist initiates the Resident Watch part of the missing resident policy which directs the staff to search for the missing resident. Staff E stated Staff F should have been trained on the missing resident policy and should have recognized Resident 2 should not have been outside the facility independently. Staff E stated if the Roam Alert system would have sounded or if Staff F was trained in the elopement policies it would have possibly prevented Resident 2 from leaving the facility independently.REFERENCE: WAC 388-97-0640(1)(2)(a)(3)(c).

Based on observation, interview, and record review, the facility failed to: ensure Transmission Based Precautions (TBP - a set of infection control practices used to prevent the spread of infectious agents in addition to standard precautions) were implemented or followed for 2 of 2 residents (Resident 212 & 33) and 3 supplemental residents (Residents 12, 156, & 157) reviewed for TBP and/or exposed to respiratory symptoms; failed to ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves and gowns used to prevent exposure to infectious materials) for 1 of 2 residents (Residents 201) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug resistant organisms); ensure staff used appropriate Hand Hygiene (HH) during resident care for 1 resident (Resident 93) who was observed for care; and failed to ensure proper storage of resident hygiene items for 2 of 14 resident rooms (Rooms 220 & 221) on the 2 North unit reviewed for infection control. These failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases. Findings included.<Facility Policy>According to the facility policy titled, Transmission Based Precautions, dated April 2025, the facility would implement TBP for residents with documented or suspected to have infections that could be transmitted by airborne or droplet transmission. The policy showed droplets could be generated by the residents coughing, sneezing, talking or during the performance of procedures. The policy showed the facility used different types of precautions to protect residents and staff from different kinds of communicable diseases. The facility would place appropriate signage at the entrance door of resident rooms to alert staff and visitors of necessary measures. The policy showed staff would use PPE as indicated by the identified precaution. <TBP/PPE> <Resident 12> According to the 03/04/2026 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 12 admitted to the facility on [DATE]. The MDS showed Resident 12 had no memory impairment and was able to make themselves understood and understand others. Observation on 04/06/2026 at 1:03 PM showed Resident 12 lying in their bed, eyes closed, and their door was open. There were two signs; a contact precaution sign and a droplet precaution sign were posted on Resident 12's door. A third EBP sign was posted on the wall outside Resident 12's door. In an interview on 04/06/2026 at 1:25 PM, Staff R (Certified Nursing Assistant - CNA) stated Resident 12 was on droplet precautions because they had respiratory infection. Observation on 04/07/2026 at 11:54 AM showed Resident 12 lying in their bed coughing. Resident 12 was receiving oxygen via a nasal tube. Resident 12 had a contact precaution sign posted outside their room. The contact precaution sign directed staff to clean their hands before entering and exiting the room; put on gloves and a gown before entering the room; and directed staff to use dedicated or disposable equipment. In an interview on 04/07/2026 at 11:57 AM, Staff V (Licensed Practical Nurse) stated Resident 12 was on droplet precautions and staff must wear masks and a gown before going into their room. Observation on 04/07/2026 at 12:02 PM showed Staff V enter Resident 12's room without putting on PPE. Staff V exited the room and started talking to another staff member in the hallway. Staff V did not wear PPE and did not sanitize their hands. Review of the April 2026 physician orders showed no order directing staff to implement contact/droplet precautions for Resident 12. In an interview on 04/07/2026 at 12:05 PM, Staff V stated they went to see Resident 12 in their room. Staff V was asked if they should follow the sign posted on the door, Staff V read the sign and stated they should follow the directions on the sign to wear PPE, but they did not. <Resident 157> Observation on 04/06/2026 at 11:31 AM showed Resident 157 lying in their bed with their eyes closed, coughing, and gurgling. Gurgling sounds could be heard outside Resident 157's room in hallway. In an interview on 04/06/2026 at 11:35 AM, Staff R stated Resident 157 was receiving end-of-life care and had a respiratory infection. Review of Resident 157's nursing progress notes showed a 04/06/2026 note documented at 12:27 PM that Resident 157 was placed on droplet precautions related to a fever and a cough. Observation on 04/07/2026 at 10:02 AM showed a droplet precaution sign posted on Resident 157's door and an isolation cart was placed outside the room. A droplet precautions sign gave directions for staff to follow: Prior to entering: Visitors check in with nursing; wash/gel hands; wear mask; wear eye protection; and wear gown and gloves if contact with secretions. Review of Resident 157's April 2026 physician orders showed no orders directing staff to implement droplet precautions for Resident 157. Observation on 04/07/2026 at 11:32 AM showed a contract staff member entering Resident 157's room without putting on a mask, eye wear, or gown. The contracted staff talked to Resident 157's representative at Resident 157's bedside and exited the room. In an interview on 04/07/2026 at 11:40 AM, the contract staff stated they should have worn PPE and followed the droplet sign posted on Resident 157's door, but they did not. In an interview on 04/13/2026 at 9:59 AM, Staff B (Director of Nursing) stated the facility staff followed the Centers for Disease Control and Prevention guidelines for TBP. Staff B stated staff should follow the signs posted on residents' doors, but they did not. Staff B stated there should be physician orders for isolation precautions in resident's records according to the diagnoses. Staff B stated the facility staff should wear mask with other PPE when they enter a TBP room with droplet precautions, but they did not. <Resident 33> According to the 03/24/2026 Quarterly MDS, Resident 33 admitted to the facility on [DATE] with a diagnosis of heart disease and diabetes (inability to control blood sugars). The MDS showed Resident 33 had pressure wounds requiring treatment. In an observation and interview on 04/06/2026 at 12:29 PM Staff AA (CNA) was observed entering Resident 33's room without wearing PPE. Resident 33's room had a sign taped to the door for contact precautions, indicating that staff must wear a gown and gloves prior to entering the room. Staff AA stated they should have worn a gown and gloves, because the resident could be contagious and they could spread infections to others. In an interview on 04/09/2026 at 10:59 AM Staff P (Infection Preventionist) stated that staff should have worn PPE prior to entering Resident 33's room. Staff P stated that it was important to wear PPE to care for those with contact precautions to avoid spreading infections. <Resident 212> According to the 03/30/2026 admission MDS, Resident 212 had multiple medically complex diagnoses including a multidrug-resistant organism (a germ which antibiotics could not easily treat), wounds, and required intravenous (through the blood) antibiotics. In an observation and interview on 04/06/2026 at 10:08 AM, two precaution signs (EBP and contact) were posted outside Resident 212's room. The contact sign instructed staff to wear an isolation gown and gloves before entering the room. Staff Y (Long Term Care Registered Nurse - LTC RN) entered Resident 212's room without a gown or gloves. Staff Y stated they were expected to wear a gown and gloves prior to entering the room, but they did not. In an interview on 04/10/2026 at 11:54 AM, Staff P stated each room labelled with isolation precautions should have only one sign to communicate the highest level of measures to prevent the spread of infectious organisms. Staff P stated Resident 212's room should have only a contact precaution sign and staff were expected to wear a gown and gloves prior to entering the room. <Resident 156> According to the 03/20/2026 admission MDS, Resident 156 admitted to the facility on [DATE]. The MDS showed Resident 156 had no memory impairment and was able to make themselves understood and understood others. In an observation and interview on 04/08/2026 at 8:13 AM, Resident 156 stated they had developed a cough and runny nose. Resident 156 stated they were tested for a respiratory infection and were waiting to hear the results. Resident 156 stated they felt miserable. There was no TBP signage posted outside of Resident 156's room. In an interview on 04/08/2026 at 11:35 AM Staff P stated they expected staff to initiate TBP as soon as a resident presented with respiratory symptoms. In an interview on 04/09/2026 at 12:21 PM Staff P stated Resident 156 had a pending chest x-ray and was tested for Respiratory Syncytial Virus (RSV – a respiratory infection that could worsen underlying lung conditions and present increased risk in older adults) but those results were also still pending. Staff P stated for suspected respiratory infections, they placed Resident 156 on droplet precautions on 04/09/2026. Staff P stated they expected staff to place Resident 156 on droplet precautions at the time of RSV testing and development of the respiratory symptoms, but staff did not. Staff P stated this was important to prevent the spread of infection. In an interview on 04/13/2026 at 1:55 PM Staff B stated they expected staff to implement TBP for residents with respiratory symptoms and for residents being tested for RSV. Staff B stated it was important to place residents on TBP with respiratory symptoms to prevent spread of infections. <EBP> <Resident 201> According to the 04/02/2026 admission MDS, Resident 201 admitted to the facility with diagnosis of end stage kidney disease and gangrene (death of tissue) to their left foot. Review of a 04/03/2026 infection prevention and control progress note showed Resident 93 was placed on EBP for the gangrene to their foot. Observation on 04/09/2026 at 9:38 AM showed an EBP sign posted at the resident's door. The signage was to be posted for high contact resident care including changing linens, bathing and dressing. Interventions showed staff were to wear a gown and gloves during high contact care for residents. In an observation on 04/09/2026 at 9:38 AM, Staff EE (Environmental Services Technician) removed the dirty bedding from Resident 201's bed without a gown. Staff EE pulled the dirty bedding into a pile, pulled them close to their body, and placed the dirty linens into a trash bag. Staff EE did not change their gloves or perform HH. Staff EE grabbed a spray bottle and a towel, sprayed the bed and wiped it. Staff EE wiped the bedside table and sink with the same gloved hand. While wearing the same gloves, Staff EE grabbed the vacuum and vacuumed the floor. Staff EE went into Resident 201's bathroom and grabbed a towel and wiped and cleaned the bathroom. Staff EE removed their gloves and did not perform HH. Staff EE grabbed new bedding and made up the resident's bed. Staff EE removed their gloves and performed HH. In an interview on 04/09/2026 9:58 AM, Staff G (Director LTC RN) stated they expected all staff to follow the EBP required guidelines. Staff G stated it kept residents safe and allowed additional monitoring to prevent the spread of infection. In an interview 04/09/2026 10:23 AM, Staff P stated they expected staff to wear a gown when changing linens and cleaning beds of residents on EBP. Staff P stated it was important to prevent infection and protect residents and staff who provide care. <Hand Hygiene> <Resident 93>Observation on 04/08/2026 at 9:44 AM showed Staff H (LTC RN) providing colostomy care (a surgical opening in the abdomen allowing stool to pass through to an external pouch) for Resident 93. Staff H wore two pairs of gloves on each hand. Staff H removed the old pouch from the abdominal opening and removed the first layer of gloves leaving the second layer of gloves on. Staff H took a towel and cleansed the skin around the opening of Resident 93's stomach. Staff H removed the second layer gloves. and did not perform HH. Staff H put on two new pairs of gloves, used scissors to cut a hole in the new wafer and placed the wafer over Resident 93's abdominal opening. Staff H removed the first layer of gloves. While wearing the second layer of gloves, Staff H grabbed the wafer pouch and secured it to the wafer. Staff H removed their second layer of gloves and performed HH. In an interview on 04/08/2026 at 9:44 AM, Staff H stated they double gloved because of the resident's diagnosis of a communicable disease. In an interview on 04/09/2026 at 10:23 AM, Staff P stated they expected staff to perform HH and wash their hands if they were visibly soiled to reduce the risk of spreading infections. In an interview on 04/13/2026 at 11:41 AM, Staff B stated double gloving should not occur. Staff B stated they expected staff to perform HH during and after care as double gloving prevented staff from performing HH. <Personal Hygiene Items> <room [ROOM NUMBER]> Observation on 04/06/2026 at 9:58 AM and on 04/08/2026 at 9:25 AM showed a bin full of personal hygiene items stored next to the sink in room [ROOM NUMBER]. The bin contained an uncovered, used toothbrush stored on top of other items, with a hairbrush containing strands of hair stored on top of the toothbrush. <room [ROOM NUMBER]> Observation on 04/06/2026 at 9:37 AM showed two residents shared room [ROOM NUMBER]. An emesis basin (a small kidney-shaped basin often used for oral hygiene) next to the sink contained a used toothbrush, with a second used toothbrush laid across the top of the basin, with nothing to indicate which resident they belonged to. A third used toothbrush was stored vertically in a labeled bin, with the toothbrush bristles touching the wall. In an observation and interview on 04/08/2026 at 9:55 AM, Staff E (LTC RN) and Staff S (CNA) confirmed the toothbrush and hairbrush in room [ROOM NUMBER] were stored together in the same bin. Staff E stated toothbrushes and hairbrushes should be stored separately, and they needed to have a better system to store personal hygiene items, for infection control. In an interview on 04/08/2026 at 12:55 PM, Staff P stated that all personal hygiene equipment and products should be stored separately in separate containers. Staff P stated it was important to keep residents' hygiene products separated for infection control. REFERENCE: WAC 388-97-1320(1)(c),(3),(5)(a)(b).

Based on observation, interview, and record review, the facility failed to ensure food was stored and served under sanitary conditions for 1 of 1 main kitchen and ensure food was prepared and served in a sanitary manner and following residents' dietary needs in 1 of 6 neighborhood kitchens (Saint [NAME] Residence/SJR). The failure to cover refrigerated and frozen food, ensure staff secured their hair and performed hand hygiene, placed residents at risk for cross-contamination, foodborne illness and the spread of infection. Findings included .<Facility Policy>According to the facility's revised 11/2023 Food Storage policy, staff would ensure all containers had tight fitting covers and were clearly labeled and dated to prevent contamination.According to the facility's revised 04/2024 Hand Hygiene policy, staff would perform hand hygiene to prevent the spread of infection in all areas of the facility including during meals. <Main Kitchen> <Food Storage> During an observation of the main kitchen refrigerator on 04/06/2026 at 08:35 AM, a large sheet pan containing white sauce and two large sheet pans containing tomato soup were dated 04/05/2026 and not covered. A plastic container with cooked pieces of bacon was undated and not covered. In the main freezer, two muffin pans containing 12 servings of pureed cauliflower in each pan were observed to be undated and not covered. In an observation and interview on 04/06/2026 at 9:05 AM, Staff CC (Interim Dining Services Manager) stated the white sauce and tomato soup should have been covered, but they were not. Staff CC stated the bacon pieces and cauliflower cups should have been dated and covered, but they were not. In an interview on 04/10/2026 at 11:42 AM Staff FF (District Manager) stated hot foods placed in the refrigerator for quick cooling should be labeled and stored in uncovered shallow pans until cool. Staff FF stated this process typically occurs within six hours and, once cool, they expect pans to be covered and stored according to the facility's policy. <SJR Kitchen & Dining Room> <Hand Hygiene & Unsecured Hair) In an observation on 04/06/2026 at 11:40 AM, Staff U (Nutrition Attendant) was plating food and delivering meals to residents seated in the SJR dining room. Staff U returned to the steam table to continue plating food without performing hand hygiene or putting on gloves. Three other dining assistants were observed plating food at the steam table with hair loosely pulled back and not fully secured in a hairnet while serving food. In an observation on 04/06/2026 at 12:10 PM, a volunteer touched residents' clothing to make adjustments and then entered the kitchen area without performing hand hygiene and without wearing a hairnet. The volunteer was observed serving water to a visitor and going through the kitchen to the refrigerator. In an observation on 04/06/2026 at 12:15 PM Staff D (Licensed Practical Nurse) adjusted one resident's clothing while feeding them and used the same hand to feed another resident without performing hand hygiene between residents. In an interview on 04/06/2026 at 12:19 PM, Staff U stated volunteers were available to assist in feeding residents but were not allowed to plate food or enter the kitchen area. In an interview on 04/06/2026 at 12:29 PM Staff D stated volunteers helped with visits and feeding and was not sure if volunteers had food safety cards. Staff D stated they were not aware whether feeding two residents with the same hand required hand hygiene between residents but should be followed for infection control. In an interview on 04/13/2026 at 1:16 PM Staff B (Director of Nursing) stated volunteers should not have been in the kitchen area around food and should not have been serving up water or going through the refrigerator. Staff B stated staff should perform hand hygiene between feeding two residents if they were also touching residents with the same hand as they fed residents for infection control. REFERENCE: WAC 388-97-1100(3).

Based on observation, interview, and record review, the facility failed to ensure expired medications and expired medical supplies were discarded timely for 2 of 5 medication storage rooms (Saint [NAME] Residence -SJR Medication Storage Room & 2 North Medication Storage Room) and 2 of 6 medication carts (4 South Medication Cart & 5 North Medication Cart B) reviewed for medication storage, and failed to ensure medications were properly secured in 4 of 10 units (4 South, 3 South, 5 Central, and 2 North) reviewed for medications at the bedside. This failure placed residents at risk for receiving incorrect or expired medications, ineffective treatment, and diminished quality of life.<Facility Policy>According to the facility's Medication Administration and Storage policy revised 04/2025, medications must be stored, secured, and managed in a manner that ensure residents safety and decreases the risk of medication error; medication practices must maintain medication integrity and prevent unsafe practices. For residents approved for Self-Administration of Medications (SAM), medications must be stored in a locked container with the resident's room or another approved secure location.<EXPIRED MEDICATIONS AND SUPPLIES> <SJR Medication Storage Room> An observation and interview on 04/08/2026 at 10:52 AM in the SJR Medication Storage Room showed 100 sterile cotton tipped applicators expired on 04/22/2025 and one COVID test expired on 10/04/2025. Staff BB (Licensed Practice Nurse) confirmed the expiration dates and stated the items should have been discarded prior to the expiration dates but were not. <2 North Medication Storage Room> An observation and interview on 04/08/2026 at 11:20 AM in the 2 North Medication Storage Room showed expired medical supplies with expiration dates ranging from 04/2020 to 03/13/2026, including 27 sterile wound dressings, 22 blood collection tubes, 10 specimen collection kits, six colostomy dressings, five sterile intravenous (in the vein) supplies, two tube feeding kits, and two sterile specimen collection kits. Staff E (Long Term Care Registered Nurse) confirmed the expiration dates and stated the items should have been discarded prior to the expiration dates but were not. In an interview on 04/10/2026 at 1:05 PM, Staff B (Director of Nursing) stated they expected staff to discard all medical supplies prior to the expiration date on the packaging. <4 South Medication Cart> Observation on 04/07/2026 at 9:42 AM showed the 4 South medication cart contained two insulin pens (used to control blood sugars), with labeling showing they were opened on 02/2026 with no specific open day specified. In an interview on 04/07/2026 at 9:56 AM, Staff N (Licensed Practical Nurse) stated the insulin pens expired 28 days after opening. Staff N stated the pens should be labeled with the specific date opened, and they were expired and should have been discarded. In an interview on 04/13/2026 at 11:58 AM, Staff B stated expired medications should be disposed of prior to the expiration date. <5 North Medication Cart B> Observation on 04/07/2026 at 09:36 AM, medication cart on 5 North Medication Cart B contained three packages of pain-relieving suppositories (medication inserted rectally) with an expiration date of 11/2025, and eight packages of laxative suppositories with an expiration date of 03/2026. In an interview on 04/07/2026 at 09:51 AM, Staff H (Registered Nurse) stated expired medications should not be present in the medication cart. Staff H stated administering expired medications could lead to potential adverse reactions and compromise resident safety. <MEDICATIONS AT BEDSIDE> <4 South Unit> <Resident 188> According to the 02/23/2026 admission 5-Day Minimum Data Set (MDS - an assessment tool), Resident 188 had intact memory, clear speech, and was able to understand others. Observations on 04/06/2026 at 10:02 AM, 04/07/2026 at 1:22 PM, and on 04/09/2026 at 10:47 AM showed a bottle of topical powder and a bottle of antiseptic skin cleanser solution on Resident 188's bedside table. In an interview on 04/06/2026 at 10:05 AM, Resident 188 stated these medications were left in their room at bedside table for more than a week. Review of Resident 188's April 2026 Physician Orders showed no order for Resident 188 to keep medications at their bedside. In an interview on 04/09/2026 at 10:56 AM, Staff V (Licensed Practical Nurse) confirmed the medication was unsecured in Resident 188's room and should be secured in the medication cart. <3 South Unit> <Resident 99> Observation on 04/07/2026 at 10:32 AM showed Resident 99 asleep in their bed. A medication cup containing a large, round pink tablet was placed in front of them on the overbed table. Resident 99 did not wake up upon knocking and entering the room. Review of Resident 99's physician orders on 04/07/2026 showed no orders directing staff to leave medications at the resident's bedside. Review of Resident 99's comprehensive care plan at this time showed no interventions that Resident 99 could have their medications left at the bedside, unsupervised. In an observation and interview at 04/07/2026 at 10:37 AM, Staff T (Long Term Care Registered Nurse) confirmed the medication placed in the cup on the overbed table. Staff T stated they did not leave medications at the bedside and Resident 99 must have spit the medication out. Staff T stated they should remain with the resident and ensure the resident took their medications entirely before exiting the room. <5 Central Unit> <Resident 212> According to the 03/30/2026 admission MDS, Resident 212 had decreased memory, clear speech, and an ability to understand others. An observation and interview, on 04/06/2026 at 10:08 AM, showed a sealed package of stool softener powder and a half empty bottle of medicated cream on Resident 212's bedside table. Resident 212 stated they had brought the medications to the facility on admission. Resident 212 stated they had self-administered the medicated cream daily while at the facility. Staff Y (Long Term Care Registered Nurse) stated the medications should have been stored in a secured medication cart but were not. Review of Resident 212's health record on 04/07/2026 showed no physician orders or care plan interventions directing staff to leave medications at the resident's bedside, unsupervised. <2 North Unit> <Resident 66> Observations on 04/06/2026 at 10:41 AM and 04/08/2026 at 9:32 AM showed Resident 66 was not present in their room. Observation showed the overbed table contained a medicated oral spray and a box of medicated vaginal cream pre-filled applicators. Observation showed a container of medicated hemorrhoidal cooling pads stored in Resident 66's bathroom. Review of active physician's orders from 04/01/2026 through 04/30/2026 showed Resident 66 was on the SAM program and was allowed to keep selected medications at their bedside, including the vaginal cream, oral spray, and hemorrhoidal medication. Review of a Care Plan entry, dated 02/05/2026, showed Resident 66 was allowed to keep certain medications at their bedside, utilizing a lock box. In an observation and interview on 04/08/2026 at 9:58 AM, Staff E confirmed the vaginal cream, oral spray, and hemorrhoidal medications were unsecured in Resident 66's room. Observation showed a lock box on Resident 66's nightstand, and Resident 66 was not present in their room. Staff E stated Resident 66 was the SAM program and was supposed to secure their medications in their lock box. Staff E stated they needed to re-assess Resident 66 for appropriateness of the SAM program. <Resident 81> Observations on 04/06/2026 at 9:52 AM and 04/08/2026 at 9:25 AM showed a bin labeled with Resident 81's name near the sink in Resident 81's room, containing a medicated shampoo. Review of Resident 81's active physician's orders from 04/01/2026 through 04/30/2026 showed no order that allowed Resident 81 to keep the medicated shampoo in their room. Review of a Care Plan, dated 04/14/2026, showed no evidence that Resident 81 was allowed to store medications in their room. In an observation and interview on 04/08/2026 at 9:50 AM, Staff E confirmed the medicated shampoo was unsecured in Resident 81's room and should have been stored in the nurse's medication cart for safety. <Resident 115> Observations on 04/06/2026 at 10:32 AM and 04/08/2026 at 9:31 AM showed a tube of medicated topical paste on the counter near Resident 115's sink. Review of Resident 115's active physician's orders from 04/01/2026 through 04/30/2026 showed no order that allowed Resident 115 to keep the medicated paste in their room. Review of a Care Plan, dated 04/14/2026, showed no evidence that Resident 115 was allowed to store medications in their room. In an observation and interview on 04/08/2026 at 10:00 AM, Staff E confirmed the medicated paste was unsecured in Resident 115's room and should have been stored in the nurse's medication cart for safety. <Resident 160> Observations on 04/06/226 at 9:25 AM and 04/08/2026 at 9:22 AM showed a tube of medicated topical ointment on Resident 160's bedside table. Review of Resident 160's active physician's orders from 04/01/2026 through 04/30/2026 showed no order that allowed Resident 160 to keep the medicated ointment in their room. Review of a Care Plan, dated 04/14/2026, showed no evidence that Resident 160 was allowed to store medications in their room. In an observation and interview on 04/08/2026 at 9:48 AM, Staff E confirmed the medicated ointment was unsecured in Resident 160's room and should have been stored in the nurse's medication cart for safety. In an interview on 04/13/2026 at 9:55 AM, Staff B stated their expectation was for staff not to leave any medications in resident rooms unless they had physician orders for self-medication program. Staff B stated they expected the medications to be secured in medication cart or in a lock box. REFERENCE: WAC 388-97-1300(2)

Based on observation, record review and interview, the facility failed to ensure 3 of 10 residents (Residents 94, 24 & 3) and 1 supplemental resident (Resident 47) reviewed for accidents were assessed for the ability to smoke safely and to address storage of smoking materials (Residents 94 & 24), were provided an assistive device to prevent accidents (Resident 3), and were provided an environment free of unsecured chemicals (Resident 47). Additionally, the facility failed to ensure the environment was free of unsecured chemicals and sharps in shower rooms for 2 of 10 units (4 South & 5 North) reviewed. These failures placed residents at risk for burns, accidental removal of implanted devices, exposure to chemicals and sharps, and other negative health outcomes.Findings included .<Facility Policy>Review of the facility's Resident Safety, Accident Prevention, and Supervision policy, revised 04/2025, showed the facility was committed to providing a resident environment that was as free from accident hazards as possible, and to ensure each resident received adequate supervision and assistive support to prevent avoidable accidents.Review of the facility's Non-Smoking Policy, revised 03/2026, showed smoking posed a serious health and safety risk and was prohibited on facility property. Residents were informed of the non-smoking policy and agreed not to smoke or possess smoking material (cigarettes, lighters, matches, etc.) while residing at the facility. Smoking materials were prohibited from being stored in a resident's room. If a resident persisted in smoking, the facility would complete a smoking assessment, a safety plan, and update the Care Plan (CP). Every staff member was responsible for enforcing the non-smoking policy by reporting violations immediately to the Resident's care team or management for follow-up. <SMOKING> <RESIDENT 94> According to a 01/20/2026 Comprehensive Minimum Data Set (MDS – an assessment tool), Resident 94 admitted to the facility on [DATE] with multiple diagnoses including a recent leg amputation and respiratory issues. Resident 94 was able to understand and be understood and had no current tobacco use. Review of a Non-Smoking Policy Acknowledgement, dated 12/22/2025, showed Resident 94 indicated they were a smoker or had a history of smoking, and agreed not to possess cigarettes or smoking materials or to smoke any tobacco products while residing at the facility. The space on the form to write their last day of smoking was left blank. Review of a Care Plan (CP), dated 04/07/2026, showed Resident 94 preferred independence and had reduced supervision during extended outings away from the facility. The CP showed no documentation regarding smoking or smoking materials. In an observation and interview on 04/07/2026 at 10:33 AM, Resident 94 stated they were currently a smoker, arranged their own transportation to go out of the facility, and smoked when they got to their destination. Resident 94 declined to say where they kept their smoking materials and said they were not going to let anyone see them. Observation showed Resident 94 laid in their bed wearing a hospital gown, and no smoking materials were within view in their room. Review of a 03/23/2026 provider progress note showed Resident 94 currently smoked cigarettes when they left the facility via wheelchair, with their last cigarette being the previous Friday. In an interview on 04/09/2026 at 12:52 PM, Staff M (Social Worker) stated they were working with Resident 94 on a discharge plan and had suggested a facility that allowed smoking. Staff M stated Resident 94 was extremely independent, arranged their own transportation, and currently smoked when they went out of the facility. Staff M stated they did not know where Resident 94 kept their smoking materials. In an interview on 04/08/2026 at 1:18 PM, Staff E (Long Term Care Registered Nurse - RN) stated there were currently no smokers on their unit (2 North). Staff E stated Resident 94 often made their own arrangements and went out of the facility, but Staff E was not aware they smoked. Staff E stated Resident 94 was not allowed to keep smoking materials there, and Staff E needed to talk to their manager about it. In an interview on 04/09/2026 at 3:00 PM, Staff A (Administrator) stated they were not aware Resident 94 was a current smoker. Staff A stated they needed to talk to Resident 94, complete a smoking assessment, and secure their smoking materials for safety. In an interview on 04/13/2026 at 11:06 AM, Staff B (Director of Nursing) stated staff should have asked Resident 94 upon admission about their smoking materials and date last smoked when Resident 94 indicated they were a smoker. Staff B stated Resident 94 was not on the facility's smoking list, and they expected staff to inform management when they became aware Resident 94 continued to smoke. <Resident 24> According to a 03/23/2026 Quarterly MDS, Resident 24 admitted to the facility on [DATE] with diagnoses including heart conditions and nicotine dependence. The MDS showed that Resident 24 was independent with Activities of Daily Living and was a current tobacco user. Review of a 09/16/2025 smoking assessment showed staff verbally assessed Resident 24, while in their room, for their ability to smoke, with no direct observation of Resident 24's ability to use a lighter or handle lit smoking materials. The assessment showed Resident 24 was no longer planning to smoke. Review of a 04/06/2026 smoking CP showed Resident 24 smoked one cigarette per day after lunch, and smoking materials were not to be kept in Resident 24's room. Review of Resident 24's records showed no further smoking assessment was completed after 09/16/2025, until a 04/06/2026 smoking assessment for Resident 24 showed they could smoke safely. In an interview on 04/10/2026 at 10:43 AM, Staff B stated Resident 24 was assessed for smoking on 04/06/2026. Staff B stated Resident 24 should have been assessed for the ability to smoke safely when it was seen they were continuing to smoke, but that did not happen. Staff B stated it was important to accurately assess the ability to smoke safely due to the risk of fires or burns. <Assistive devices> <Resident 3> According to the 12/07/2025 admission MDS, Resident 3 admitted to the facility on [DATE] with diagnoses including heart conditions and recent stroke. The MDS showed Resident 3 had severely impaired cognition and was dependent on a feeding tube (a tube implanted into the stomach through the abdominal wall for nutrition). Review of a 03/27/2026 tube feeding CP showed Resident 3 had a history of pulling out their feeding tube, and staff were to keep an abdominal binder (an assistive device that could be used to prevent accidental removal of feeding tubes) in place as in intervention to prevent re-occurrence. Review of physician progress notes dated 12/02/25, 12/05/2025, 12/10/2025, 12/17/2025, 12/23/2025, 01/02/2026, 01/13/2026, 01/27/2026, 02/06/2026, 03/03/2026, 03/12/2026, 03/27/2026, and 04/01/2026 showed Resident 3 was dependent on tube feeding to meet nutritional goals and was to wear an abdominal binder to prevent accidental pulling of feeding tube. In an interview on 04/07/2026 at 12:10 PM, Resident 3's responsible party stated Resident 3 was supposed to wear an abdominal binder and received one while in the hospital. Resident 3's responsible party stated Resident 3 recently had to go to the hospital because their feeding tube accidentally came out when they were not wearing the abdominal binder. In an interview on 04/10/2026 at 10:52 AM, Staff B stated there was no physician's order or CP for Resident 3 to wear an abdominal binder at the time the feeding tube was accidentally removed. Staff B stated it was not known by staff that the abdominal binder should have been in place for Resident 3. Staff B stated the facility did not have a process for reviewing physician notes to ensure recommendations were being followed. <Chemicals and Sharps> <Resident 47> Observations on 04/06/2026 at 10:04 AM and 04/08/2026 at 9:25 AM showed a large bottle of 70% isopropyl alcohol (a colorless, flammable chemical commonly used as a solvent, antiseptic, and cleaner) was stored in Resident 47's room on a shelf underneath the sink. The label on the bottle showed it was for external use only, and fumes may be harmful. In an observation and interview on 04/08/2026 at 9:53 AM, Staff E confirmed the bottle of isopropyl alcohol was underneath Resident 47's sink. Staff E stated it was a hazard, especially if someone drank it, and should not be stored in a resident's room. <4 South Shower Room> Observation on 04/09/2026 at 9:56 AM showed a shower room on the 4 South unit with the door open and cleaning chemicals and a used razor accessible, with no staff members present in the area. In an interview on 04/09/2026 at 9:58 AM, Staff X (Certified Nursing Assistant) stated the door should have been shut and locked for resident safety and the razor should have been disposed of after use. In an interview on 04/09/2026 at 11:23 AM, Staff B stated that the shower room door should have been shut and the razor was a safety concern. <5 North> Observation on 04/07/2026 at 8:52 AM and 04/09/2026 at 11:58 AM showed the 5 North unit spa door open and unlocked. The spa had an unsecured bottle of a chemical disinfectant and some razors. In an interview on 04/07/2026 at 8:54 AM Staff II (RN) stated the spa door should be locked and closed. Staff II stated it was important to keep the door locked for residents' safety since there were chemicals and razors in there. In an interview on 04/09/2026/ at 11:58 AM Staff G (Director Long Term Care RN) stated it was important to keep the door closed and locked because there were multiple chemicals and razors stored in there. Staff G stated it was important to ensure the chemicals and razors were secure for resident safety. Reference: WAC 388-97-1060(3)(g).

Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and/or revised as needed for 2 of 35 sample residents (Residents 82 & 18) reviewed, and failed to conduct care conferences for residents with their resident representative and the applicable Interdisciplinary Team (IDT) members for 2 of 7 residents (Resident 58 and 214) reviewed for care planning. Failure to ensure CPs were updated and to offer care conferences to reflect current care needs left residents at risk for unmet care needs, delay in treatments, and a diminished quality of life.Findings included .<Facility Policy>According to the facility's Resident Care Plan Reviews and Care Conferences policy, revised 01/2025, the facility conducted regular CP reviews and care conferences to ensure each resident's needs were met in a timely and effective manner, and were held according to regulatory requirements and as needed, such as with changes of condition or when significant changes to care goals and approaches occurred.<Resident 82> According to the 11/10/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 82 had muscle weakness and a urinary tract infection. The MDS showed Resident 82 was assessed as needing pain management. Review of the 08/20/2024 At risk for pain related to decreased physical mobility CP, staff were to provide nonpharmacological approaches to pain, such as repositioning the resident, and assess the effectiveness of pain medications. The CP did not show Resident 82 had a history of urinary tract infections, what nonpharmacological interventions to do to relieve pain, or when to notify the provider of ongoing pain needs. Review of Resident 82's April 2026 Medication Administration Record (MAR) showed a 12/31/2025 as needed pain medication. The MAR showed the pain medication was administered on 04/04/2026 and 04/05/2026 for pain, on 04/07/2026 for flank pain and on 04/08/2026 for groin pain. No documentation was found in this MAR to show staff assessed Resident 82 for pain medication effectiveness or that nonpharmacological interventions were provided. Review of Resident 82's April 2026 MAR showed an order dated 04/08/2026 for a pain medication to treat pain from a urinary tract infection. Review of the April 2026 MAR showed the medication was administered on 04/08/2026 with no documentation to show the pain medication was effective or what nonpharmacological interventions were provided. Observations and interviews included the following: On 04/07/2026 at 10:02 AM, Resident 82 stated they had pain in their back. On 4/8/2026 at 12:14 PM, Resident 82 yelled from their room that they were in pain. On 4/10/2026 at 10:14 AM, Resident 82 stated they had pain in their stomach. On 4/13/2026 at 9:57 AM, Resident 82 stated they had pain in their head and hurt badly. In an interview on 04/13/2026 at 10:40 AM, Staff F (Long Term Care RN) stated they could not find in Resident 82's medical record that staff assessed resident recently for urinary or general pain or assessed pain medication effectiveness. Staff F stated nursing staff should assess Resident 82's pain to determine the source of pain and notify the provider so necessary pain management could be ordered and added to the CP, but they did not. In an interview on 04/13/2026 at 12:53 PM, Staff B (Director of Nursing) stated nursing staff should check resident's pain every shift and use a pain scale to determine effectiveness of pain management. Staff B stated the source of pain and daily pain monitoring should be stated on the CP to manage Resident 82's pain effectively, but it was not. <Resident 18> According to the 03/15/2026 Annual MDS, Resident 18 received end of life care, had a physical impairment to one side of their body and was dependent on staff for their mobility. Review of the 8/19/2024 Potential for Compromised Psychosocial Wellbeing CP showed staff were to check with Resident 18 and involve them in activities of interest as they were willing and able. Review of the 04/10/2026 Kardex (staff task list), staff were to assist Resident 18 out of bed at least once daily mid-morning and report to the nurse if Resident 18 refused. Observations on 04/06/2026 at 12:49 PM, 4/8/2026 at 12:11 pm, 4/8/2026 at 9:31 AM and 4/9/2026 at 9:11 AM, showed Resident 18 in their room lying in bed. In an interview on 04/07/2026 at 11:22 AM, Resident 18's representative stated Resident 18 was often left in their room instead of being assisted to the dining room for meals or activities. The representative stated it would be good for Resident 18 to be around others at least two to three times per week as the representative was not always available to visit and take Resident 18 out for activities. In an interview on 4/10/2026 at 9:47 AM, Staff Q (Long Term Care RN) stated Resident 18's representative usually took the resident out of their room, and staff waited for the representative because Resident 18 often refused services if the representative was not at the facility. Staff Q stated they were not notified of Resident 18's refusals to leave their room and Resident 18's CP did not include instructions for what to do for refusals. In an interview on 04/13/2026 at 10:32 AM, Staff F (Long term care RN) stated staff waited for the representative to take Resident 18 out because Resident 18 refused to leave their room. Staff F stated staff should document refusals and let the nurses know when residents refused services so adjustments to Resident 18's CP could be made. Staff F stated the CP should be updated to include instructions to staff about resident refusals and interventions on what to do when the representative was not there. In an interview on 04/13/2026 at 12:35 PM, Staff B stated they expected staff to follow what was on the Kardex and the CP and help Resident 18 up in their specialized chair to get out of the room, and to document refusals. Staff B stated they were not aware of refusals documented in Resident 18's record. <Care Conferences> <Resident 58> According to the 01/09/2026 Quarterly MDS, Resident 58 did not speak and rarely/never understood others. The MDS showed Resident 58 had diagnoses including a progressive, incurable brain disorder that caused severe memory loss, cognitive decline, and changes in behavior. The MDS showed Resident 58 was dependent on staff for eating, personal hygiene, toileting, and dressing. In a telephone interview on 04/07/2026 at 12:34 PM, Resident 58's Power of Attorney (POA) stated the facility used to arrange a care conference once a year. Resident 58's POA stated the last time they were included in a care conference was two years ago. Review of a 03/20/2025 progress note showed the social worker left a voicemail for Resident 58's POA, inviting them to a quarterly care conference. Review of progress notes from 04/2025 to 04/2026 showed no documentation of staff inviting to or providing Resident 58 and their POA with a care conference. Review of a 01/22/2026 Care Plan Conference Interdisciplinary Team (IDT) document showed the facility's IDT met and reviewed Resident 58's plan of care. The document included a section listing Resident 58's POA with checkboxes showing invited, attended, or did not attend. All check boxes were left blank by staff. In a joint interview on 04/10/2026 at 9:22 AM, Staff L (Social Services Manager) and Staff O (Social Worker) stated the facility's process for care conferences was to meet as an IDT and review the resident's record prior to the care conference. Staff L and Staff O stated care conferences were offered quarterly and with significant changes. Staff L and Staff O stated they worked around the resident and/or family's schedule. Staff O reviewed Resident 58's records and confirmed the last documentation regarding a care conference was 03/20/2025. Staff L stated families should be offered care conferences and staff should document whether the resident/family accepted or declined to participate in the care conference. <Resident 214> According to the 04/09/2026 admission MDS, Resident 214 admitted to the facility on [DATE] and had no memory impairment. In an interview on 04/07/2026 at 11:10 AM, Resident 214 stated staff had not offered or discussed a care conference with them. In an interview on 04/10/2026 at 9:28 AM, Resident 214 stated they asked staff about discharge plans on 04/09/2026 but did not get an answer. Resident 214 stated staff did not discuss or offer a care conference to discuss goals and discharge plans. In an interview and record review on 04/10/2026 at 10:32 AM, Staff L (Social Services Manager) reviewed Resident 214's records and stated they had not been offered a care conference and must have been missed because the primary social worker was on leave. Staff L stated they expected staff to offer and provide a care conference within five days of admission to the facility. REFER TO: F697-Pain Management Reference: WAC 388-97-1020 (1), (2)(a-d)(f), (4)(b)(c)(i-ii), (5)(b).

Based on interview and record review, the facility failed to ensure residents' medication regimens were free of chemical restraints for 1 of 6 residents (Resident 3) reviewed for unnecessary medications. Staff failure to ensure appropriate indication for use, monitor residents for target behaviors, provide nonpharmacological interventions, and obtain consent for psychotropic medications placed residents at risk for receiving unnecessary medications and other negative health outcomes.Findings included .<Policy>According to the facility's 01/2025 Psychotropic Medication (a medication that affects mental processes and behavior) Management policy the facility would utilize behavioral and non-pharmacological approaches to minimize the need for psychotropic medications. This policy showed psychotropic medications would be considered when non-pharmacological approaches were attempted but did not relieve the resident of their medical symptoms. The policy showed prior to initiating the use of psychotropic medication, the staff and the physician would review non-pharmacological alternatives, rationale for the recommendation, potential risks and benefits, and the resident/representative's right to accept or decline the treatment. The policy showed that as needed antipsychotic medications should only be used for 14 days unless the resident is evaluated by a physician for continued use.<Resident 3>According to the 12/07/2025 admission Minimum Data Set (MDS - An assessment tool) Resident 3 admitted the facility on 12/01/2025 with diagnoses of high blood pressure, kidney disease, and a history of a recent stroke. The MDS showed Resident 3 had severely impaired cognition, showed no indicators of psychosis, and had no behaviors in the look back period.Record review of a 12/22/2025 4:00 AM nursing progress note showed Resident 3 had an unwitnessed fall and the physician called a message was left for the on-call provider. There is no documentation in the note regarding predisposing circumstances of Resident 3's fall or behaviors being reported to the on-call provider.Record review of a 12/23/2025 physician progress note showed the physician evaluated Resident 3 and stated more restless with frequent falls. Vitals are stable. Doubt acute illness or other etiology. Suspect this is because (Resident 3) is more alert and strong now. Will start (Resident 3) on (antipsychotic medication) in the evenings routine. Will also have as needed dose available. The physicians note did not specify a medical diagnosis for use of antipsychotics.Record review of a 01/02/2026 physician progress note showed the physician evaluated Resident 3 and did not update the indication for use for the routine use of antipsychotic medication. The physician did not evaluate the use of as needed antipsychotic medication for Resident 3. Resident 3 would not have another physician visit until 01/13/2026.Review of Resident 3's physicians' orders for December 2025 and January 2026 showed a 12/22/2025 order for an anti-psychotic medication to be given once a day in the evening for restlessness. The same anti-psychotic medication was discontinued and restarted for Resident 3 on 01/03/2026 with the same schedule and indication for use and was then discontinued on 01/09/2026. There was no medical diagnosis documented for Resident 3's use of routine antipsychotic medication.Review of Resident 3's physicians' orders for December 2025 and January 2026 showed an antipsychotic medication was ordered on 12/22/2025 to be given as needed for restlessness. Resident 3's as needed antipsychotic medication was discontinued and restarted on 01/09/2026, 18 days later, with the same as needed indication. Resident 3's as needed anti-psychotic medication was discontinued on 01/22/2026. The antipsychotic medication orders do not include a medical diagnosis for use. There was no physician order to monitor adverse side effects or target behaviors.Record review of a 01/08/2026 pharmacy consultation report showed that a consultant pharmacist reviewed Resident 3's medication regimen and recommended the anti-psychotic medication be discontinued. Rationale for the recommendation for Resident 3 stated, CMS requires that (as needed) orders for antipsychotic medications be limited to 14 days. A new order should not be written without the prescriber directly examining the resident and assessing the resident's condition and progress to determine if the (as needed) antipsychotic medications are still needed. Report of the resident's condition from facility staff to the prescriber does not meet criteria for an evaluation. There was no signature or note to indicate the recommendation was seen by the physician for Resident 3.Review of Resident 3's medical records on 04/13/2026 showed no documented abnormal involuntary movement scale assessment. Resident 3's medical records showed no signed or verbal consent for anti-psychotic medications. Resident 3's medical records showed no non-pharmacological interventions used prior to prescribing an anti-psychotic medication.In an interview on 04/10/2026 at 11:07 AM with Staff G, Director of Long-Term Care Registered Nurse, and Staff B, Director of Nursing, Staff B stated that there was no appropriate indication of use for the anti-psychotic medication ordered for Resident 3. Staff G was unable to locate consent for the anti-psychotic medication for Resident 3. Staff G was unable to find documentation of adverse side effect monitoring or behavior monitoring for Resident 3. Staff B stated that a consent should have been in place for Resident 3, and monitoring should have been completed.In an interview on 04/13/2026 at 09:46 AM Staff L, Social Services Manager, stated that there was no appropriate indication of use for the anti-psychotic medication for Resident 3 and that the medication was used as needed for longer than 14 days without a physician evaluation.Refer to F610: Prevent/Investigate/Correct alleged violationREFERENCE: WAC388-97-1060(3)(k)(i), -0620(1)(a)

Based on interview and record review, the facility failed to ensure nurses aides completed required annual training for 2 of 5 nurses aides (Staff J, Certified Nursing Assistant - CNA, and Staff K, CNA) reviewed for annual training. The failure to ensure CNAs completed 12 hours of annual training placed residents at risk for care deficits and other negative health outcomes. Findings included . <Facility Policy>According the facility's 06/2025 Mandatory Education/Training Requirements policy, the facility would establish a system to ensure all caregivers completed mandatory education and training in accordance with certification and regulatory requirements. The policy showed CNAs must complete a minimum of 12 hours training annually. Review of Staff J's annual training documentation from their last full year of employment from 9/9/2024 through 09/09/2025 showed Staff J completed 4.3 hours of education/training. Staff J did not meet the 12 hour requirement. In an interview on 04/13/2026 at 11:47 AM, Staff B (Director of Nursing) stated the facility had difficulty encouraging CNAs to complete the required training that required creativity because of the size of the facility and the format of the education modules provided by ownership/foundation. Staff B stated Staff J and K did not but should have completed a minimum of 12 hours of annual training. REFERENCE: WAC 388-97-1680(2)(a-c).

Based on observation, interview, and record review the facility: Failed to ensure residents' skin was assessed, documented, monitored, and treated as required for 2 of 4 residents (Residents 188 & 214) reviewed for non-pressure skin. These failures placed all residents at risk for delay in treatment, worsening of condition, and decreased quality of life. Findings included .<Facility Policy>According to the facility policy titled, Skin Integrity Monitoring- Non-Pressure Related Conditions, dated 04/2024, the facility would ensure skin conditions would be assessed and issues would be documented in the resident's records to include location, description, and interventions. The policy showed follow up monitoring would occur to evaluate progression or resolution of the skin condition.<Resident 188> According to the 02/23/2026 5 Day Medicare Minimum Data Set (MDS - an assessment tool), Resident 188 did not have cognitive impairment, was understood, and able to understand others in conversation. This assessment showed Resident 188 did not have any wounds or skin problems and Resident 188 did not receive blood thinner medication during assessment period. Review of Resident 188's record showed Resident 188 was readmitted to the facility from the hospital on [DATE] after a scheduled procedure was performed. Review of a 03/27/2026 Comprehensive Skin Inspection showed staff performed a head-to-toe skin assessment on Resident 188 upon their readmission to the facility. This assessment showed staff did not document bruises on the skin map. Observation on 04/07/2026 at 9:14 AM showed Resident 188 had multiple open scabs on their face, arms, and lower legs, and dark purple bruises on both arms. Resident 188 stated the bruises occurred in the hospital during blood draws and intravenous medication administration during the procedure. Review of Resident 188's April 2026 Physician Orders showed no orders directing staff to monitor the bruising on Resident 188's arms. Review of a 04/06/2026 Weekly Skin Assessment showed no documentation on the skin map that Resident 188 had bruising on both arms. In an interview on 04/09/2026 at 11:01 AM, Staff V (Licensed Practical Nurse) stated they were not a regular staff on this unit, they worked on this unit three days ago (04/06/2026) and noticed bruises on Resident 188's both arms. Staff V stated they did not notify the provider because the bruises were not new and they thought the regular staff on this unit knew about these bruises. In an interview on 04/10/2026 at 9:13 AM, Staff R (Certified Nursing Assistant) stated they did not notice the bruises on Resident 188's arms because Resident 188 was able take care of their upper body independently. In an interview on 04/13/2026 at 9:39 AM Staff B (Director of Nursing) stated it was their expectation staff assessed resident's skin weekly and as needed, document all the issues in the resident's record, notify the clinical manager of any new skin issues, notify the provider, and obtain orders to monitor and/or treat the skin issues. <Resident 214> According to the 04/09/2026 admission MDS, Resident 214 admitted to the facility on [DATE] and had no memory impairment. The MDS showed Resident 214 did not have any wounds or skin problems and Resident 214 received blood thinner medication during the assessment period. Observation and interview on 04/07/2026 at 11:25 AM showed Resident 214 had an 8 X 4.5-centimeter dark purple raised bruise to their right arm. Resident 214 stated they received a blood transfusion in the hospital, but it was looking larger and more swollen. Resident 214 stated they took blood thinner medication. In an interview and record review on 04/10/2026 at 9:45 AM Staff G (Director of Long-Term Care Registered Nurse) reviewed Resident 214's skin assessments since admission and stated staff only documented bruise and did not document an assessment of the bruise. Staff G stated they expected staff to do an accurate and thorough skin assessment documenting the appearance to include the size in measurements, color, and any swelling. Staff G stated it was important to document the appearance to have a baseline observation and ensure the skin issue was improving and not worsening. Reference: WAC 388-97-1060(1).

Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs), related to cleanliness and grooming for 3 of 7 sample residents (Residents 39, 189, & 156) reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with nail care (Resident 39 and 189), and bathing (Resident 156) placed the residents at risk for poor hygiene, embarrassment and diminished quality of life.Findings included .<Facility Policy>According to the facility's Activities of Daily Living (ADLs) policy, revised 01/2025, the facility provided residents with care and services for ADLs, including bathing and grooming. <Resident 39> According to a 01/29/2026 admission Minimum Data Set (MDS – an assessment tool), Resident 39 had no memory impairment, had clear speech, and was able to make independent daily decisions. This MDS showed Resident 39 required maximal assistance from staff for transfers, personal hygiene, and bathing, and had no rejection of care during the assessment period. Review of the 12/08/2025 ADL Self-care deficit related to decreased mobility Care Plan (CP) showed a goal for Resident 39 to receive an appropriate level of assistance from staff during ADL care to improve their current level of ADL function. Review of Resident 39's Resident Preference Checklist, signed on 01/21/2026, showed Resident 39 preferred nail care to be provided by staff. Observations on 04/06/2026 at 1:12 PM, on 04/07/2026 at 8:41 AM, on 04/08/2026 at 12:52 PM, and on 04/10/2026 at 12:15 PM showed Resident 39 had long fingernails with black debris underneath. In an interview on 04/07/2026 at 8:42 AM, Resident 39 stated they needed assistance to clip their fingernails. In an interview on 04/10/2026 at 12:19 PM, Staff R (Certified Nursing Assistant) confirmed Resident 39 had long fingernails with black debris underneath. Staff R stated they should clip Resident 39's fingernails on their shower day, but they did not. In an interview on 04/13/2026 at 9:39 AM, Staff B (Director of Nursing) stated their expectation was for staff to perform ADL care daily during morning care. Staff B stated staff should provide nail care to all residents on their shower days and as needed, but they did not. <Resident 189> According to the 01/23/2026 Quarterly MDS, Resident 189 was cognitively intact. The MDS showed Resident 189 had impairment on one of their arms and one of their legs and was dependent on staff for assistance with personal hygiene. The MDS showed Resident 189 had a blood sugar control disorder. In an observation and interview on 04/07/2026 at 8:58 AM, Resident 189 stated they could not use their right hand from the elbow down. Resident 189 used their left hand to open their contracted (rigid or deformed joint) fingers on their right hand. Their fingernails on their right and left hands were long, extending past the nail bed. Review of a 04/08/2026 weekly skin check assessment showed the licensed nurse assessed Resident 189's fingernails and documented fingernail length is [within normal limits] per resident preference. Observation on 04/09/2026 at 10:01 AM showed Resident 189's contracted right pinky nail and ring fingernail were over a half inch long. Resident 189 stated they had to ask staff to get their nails clipped, and staff did not offer to clip their fingernails. Resident 189 stated they would like their fingernails to be shorter. In an observation and interview on 04/10/2026 at 11:45 AM, Staff HH (Long Term Care Registered Nurse) stated the facility had a designated nurse who performed nail care. Staff HH stated the nurse aides reported to the nurse anytime a resident needed nail care done. In an observation at this time, Staff HH assessed Resident 189's fingernails and confirmed they needed to be trimmed. Resident 189 stated, Oh, that would be great. In an interview on 04/13/2026 at 10:01 AM, Staff B stated nail care should be offered each week on the resident's shower day and included clipping and cleaning the nails. Staff B stated if the resident had a blood sugar control disorder, the nurse was responsible for checking and trimming their nails. Staff B stated if a resident refused nail care, they expected staff to document the refusal. <Resident 156> According to the 03/20/2026 admission MDS, Resident 156 admitted to the facility on [DATE] with no memory impairment. The MDS showed it was very important for Resident 156 to choose between a tub bath, shower, bed bath, or sponge bath. The MDS showed Resident 156 did not reject care during the assessment period. The MDS showed Resident 156 was occasionally incontinent of urine. Record review of Resident 156's nursing bathing documentation for 03/14/2026 to 04/09/2026 showed no showers were offered or provided. In an interview on 04/06/2026 at 9:21 AM, Resident 156 stated staff told them only Occupational Therapy (OT) could give them showers. Resident 156 stated they preferred showers at least three times a week. Resident 156 stated OT had only assisted them with one or two showers since admission to the facility. In an interview and record review on 04/09/2026 at 1:19 PM, Staff GG (Rehab Director) reviewed Resident 156's OT treatment notes since admission and stated Resident 156 only had showers on 03/18/2026 and 04/08/2026 with OT. Staff GG stated they expected nursing staff to provide bathing per Resident 156's bathing schedule as OT may not always work on bathing with each treatment. Staff GG stated nursing staff were trained to safely transfer residents so there should not be an issue for them to transfer Resident 156 and provide bathing. In an interview and record review on 04/09/2026 at 2:14 PM, Staff G (Director Long Term Care Registered Nurse) reviewed Resident 156's bathing schedule and stated they were scheduled to receive showers every Monday evening. Staff G reviewed nursing bathing documentation and stated there was no documentation to support Resident 156 was offered or provided a shower. Staff G stated they expected nursing to offer and provide residents bathing even when OT was working with the residents on bathing. Staff G stated it was important to offer and provide showers for residents' hygiene. REFERENCE: WAC 388-97-1060(2)(c)

Based on observation, interview, and record review the facility failed to ensure pain management was provided to residents consistent with professional standards of practice including the failure to assess pain medication effectiveness for as needed (PRN) pain medications and failure to assess residents pain utilizing pain assessments and pain scales for 2 of 6 residents (Resident 82 & 52 ) reviewed for pain management. These failures placed residents at risk for experiencing untreated pain, possible side effects, and a decreased quality of life. Findings included <Facility Policy>According to the facility's Pain Management policy, revised 02/2026, the facility assessed residents who had pain using pain assessment tools, including a numeric pain rating scale (a pain severity scale from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable) or a Wong-Baker FACES Pain Rating Scale (a pain assessment tool using six faces ranging from smiling to crying), to ensure consistent and accurate evaluation of resident pain severity and to guide clinical decision-making.<Resident 82> According to the 02/02/2026 Significant Change Minimum Data Set (MDS – an assessment tool), Resident 82 had multiple medically complex conditions, including a bladder infection, cognitive impairment, and muscle weakness. This MDS showed Resident 82 had generalized pain and received pain medications. Review of the 8/20/2024 At risk for pain related to decreased physical mobility Care Plan (CP) showed staff were to assess effectiveness of Resident 82's pain medications, use a pain scale to assess for pain and monitor side effects of pain medications. Review of Resident 82's medical record did not show a recent pain assessment had been completed for Resident 82 and did not show the provider was notified of resident's ongoing pain needs. Review of Resident 82's April 2026 Medication Administration Record (MAR) showed a 12/31/2025 as needed pain medication. The MAR showed the pain medication was administered on 4/4/2026, 4/5/2026, 4/7/2026 and 4/8/2026, no documentation was found in the MAR to show staff reassessed Resident 82's pain medication for effectiveness or used a pain scale to monitor Resident 82's pain. Review of Resident 82's April 2026 MAR showed an order dated 04/08/2026 for a pain medication for a urinary tract infection. Review of the April 2026 MAR showed the medication was administered on 4/8/2026. The MAR did not show documentation the nurses reassess if Resident 82's pain medication was effective and did not show nurses used a pain scale to assess Resident 82's pain level. Observation and interview on 04/07/2026 at 10:02 AM, Resident 82 stated they had pain in their back and always had pain. Observation on 4/8/2026 at 12:14 PM, Resident 82 was observed yelling from their room they were in pain. Observation and interview on 4/10/2026 at 10:14 AM, Resident 82 stated they had pain in their stomach. Observation and interview on 4/13/2026 at 9:57 AM Resident 82 stated they had pain in their head, and it hurt badly. In an interview on 04/13/2026 at 10:40 AM Staff F (Long Term Care RN) stated they could not find a current pain assessment in Resident 82's record. Staff F reviewed the April 2026 MAR and stated nursing staff should re-assess pain medication for effectiveness every time they administer an as needed pain medication, to provide necessary pain management, but did not. In an interview on 04/13/2026 at 12:53 PM, Staff B (Director of Nursing) stated nursing staff should have assessed Resident 82 for pain on every shift and used a pain scale to determine effectiveness of pain medications but did not. Staff B stated staff should have notified Resident 82's provider to obtain orders for routine pain medications instead of using as needed pain medications. Staff B stated it was important to assess residents for pain so adjustments could be made to manage residents' pain effectively. <Resident 52> According to a 04/09/2026 Comprehensive MDS, Resident 52 re-admitted to the facility on [DATE] after a hospitalization, with diagnoses including heart issues, cancer, wounds, and chronic pain syndrome. The MDS showed Resident 52 reported they frequently had pain, and they rated their worst pain during the last five days at a 5 out of 10 on the numeric pain scale. Resident 52 was able to understand and be understood. Review of a care plan entry, dated 02/26/2026, showed Resident 52 had chronic pain to their lower extremities. Staff were to monitor pain and report to the physician if pain was unresolved after medication administration or if pain worsened. Staff were to utilize the pain scale and follow up assessments per facility protocol. In an observation and interview on 04/07/2026 at 9:18 AM, Resident 52 laid in their hospital bed with the head of bed raised. Resident 52 stated their pain was always an 8 or 9 out of 10, the doctor had not discussed pain management with them, and they were frustrated when nurses told them it was not yet time for their pain medication. Resident 52 stated they had pain in their neck, shoulders, back and leg, and they should be able to get additional medication for breakthrough pain. Review of 03/27/2026 hospital Skilled Nursing Facility Transfer Orders showed Resident 52's principal problem at the hospital was chronic pain syndrome. Physician orders included suboxone (used to treat chronic pain, especially for residents with opioid use disorder) every eight hours routinely, and acetaminophen (an over-the-counter pain reliever) every four hours as needed for pain. Review of Resident 52's MAR dated 04/01/2026 through 04/30/2026, showed a 03/27/2026 physician order for suboxone every eight hours as needed for opioid dependance. Documentation showed suboxone was administered 10 times from 04/01/2026 through 04/07/2026. No pain scale rating was documented for eight of 10 administrations, and no pain scale rating was documented for the results of any of the 10 administrations. Review of interdisciplinary progress notes showed no documentation of Resident 52's pain levels on 03/27/2026, 03/28/2026, or from 03/30/2026 through 04/08/2026 (10 days). Review of a Clients by Vital Parameter report, dated 04/10/2026, showed Resident 52's pain level was 0 out of 10 on 03/27/2026, no pain level entries from 03/28/2026 through 04/08/2026 (12 days), pain level was 8 out of 10 on 04/09/2026 and 9 out of 10 on 04/10/2026. Review of physician visit notes dated 03/30/2026, 04/03/2026, and 04/08/2026, showed no documentation of Resident 52's pain level using the numeric pain scale. In an interview on 04/09/2026 at 9:10 AM, Staff DD (Long Term Care RN) stated whenever they went into Resident 52's room, they asked Resident 52 if they were doing well. Staff DD stated if Resident 52 wanted pain medication, they asked for it. When asked, Staff DD stated they typically documented the pain level in progress notes. In an interview on 04/09/2026 at 12:34 PM, Resident 52 stated she just asked Staff DD for a pain pill and was told it was too soon. Resident 52 stated their pain level was currently an 81/2 or 9 out of 10. In an interview on 04/09/2026 at 12:37 PM, Staff DD stated Resident 52 was sleeping and woke up when they went in their room. Staff DD stated Resident 52 told them they were starting to hurt and requested pain medication, but it was too soon, according to physician's orders. Staff DD stated Resident 52 did not say what their pain level was. In an interview on 04/10/2026 at 9:55 AM, Resident 52 stated their pain level was currently an 8 out of 10, down from 91/2 out of 10. Resident 52 stated with good pain control, their pain went down to as low as 6 out of 10. Resident 52 stated Staff DD and some of the other nurses rarely asked what their pain level was, and they had never told anyone their pain was less than 6 out of 10. In an interview on 04/13/2026 at 11:06 AM, Staff B stated because Resident 52 had chronic pain issues, the nurses should provide ongoing pain assessments, including documentation of the location of pain, severity of pain, and the effectiveness of pain medications and other interventions using the numerical pain scale, but they did not. REFER to: F657 Care Planning Timing and Revision Reference WAC 388-97-1060(1).

Based on observation, interview, and record review the facility failed to: Ensure Physician's Orders (POs) were clarified and followed, to have parameters for pain medications, and medications given within ordered parameters for 2 of 6 sample residents (Residents 7 & 17), Staff failed to sign for narcotics from the narcotic ledger when given, and count the narcotics effectively each shift for 1 of 5 medication carts reviewed (Four south unit). These failures placed residents at risk for medication errors, unmet care needs, narcotic diversion, and other negative health outcomes.Findings included .<Policy>According to the facility's 02/2026 Pain Management policy the facility would use adequate doses of as needed medications to achieve the residents desired level of pain relief.According to the facility's 02/2025 Bowel Care policy the facility would monitor resident bowel movements and if no bowel movement after 6 shifts staff were to follow the physician ordered bowel care protocol and administer stool softeners and/or laxatives as needed.According to the facility's 02/2026 Controlled Substances Management policy the facility would document in the controlled substance log the date and time a controlled substance was removed and administered to a resident. The policy stated facility staff would count controlled substances at each shift change every day. The policy states staff would count controlled substances by reviewing the controlled substance logbook page by page comparing the documented amount of medication available against the actual amount of medication available in the cart.<Resident 7> According to a 01/29/2026 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 7 had multiple medically complex conditions including chronic kidney disease, arthritis, and high blood pressure. The MDS showed Resident 7 frequently experienced pain, and the resident's pain almost constantly interrupted their sleep and frequently affected their daily activities. This assessment showed Resident 7 required the use of narcotic pain medication during the assessment period. Review of the April 2026 Medication Administration Record (MAR) showed Resident 7 had the following physician orders: A 10/28/2025 order for a narcotic pain medication with directions to staff to administer one tablet two times daily as needed for pain; another 11/17/2025 order for a non-narcotic pain medication with directions to staff to administer one tablet every eight hours as needed for pain. There were no directions to staff to indicate what parameters should be used to identify which pain medication should be administered by staff. In an interview on 04/13/2026 at 9:50 AM, Staff B (Director of Nursing) stated pain medication orders should include parameters according to pain intensity on pain scale for residents. Staff B stated staff should clarify Resident 7's pain medication orders with provider, but they did not. <Resident 17> <Pain medication> According to a 03/05/2026 Quarterly MDS, Resident 17 admitted to the facility on [DATE] with diagnoses of cancer, an anxiety disorder, and constipation. The MDS showed that Resident 17 had occasional pain that limited activities of daily living and made it difficult to sleep at night. Record review of Resident 17's February MAR showed that they had orders for an as needed narcotic pain medication with staff to give one tablet for pain levels four to six out of ten and two tablets for pain levels seven to ten out of ten. Review of the February MAR showed that Resident 17 was administered one tablet of as needed narcotic pain medication for a pain level of seven on 02/23/2026 at 10:35 PM, 02/25/2026 at 10:29 PM, 02/26/2026 at 11:12 PM, and 02/27/2026 at 11:21 PM. In an interview on 04/10/2026 at 11:17 AM Staff B stated Resident 17's pain medication parameters were not being followed but should have been, as the error could have led to under treated pain. <Bowel Care> According to a 03/05/2026 Quarterly MDS Resident 17 admitted to the facility on [DATE] with diagnoses on cancer, an anxiety disorder, and constipation. The MDS showed that Resident 17 was cognitively intact and continent of bowel and bladder with the ability to use the bathroom independently. Record review of February Activity of Daily Living documentation for Resident 17 showed no documented bowel movements from 02/15/2026 through 02/19/2026. Record review of Resident 17's February MAR showed no documentation of the bowel protocol being initiated or as needed stool softeners and/or laxatives being given. In an interview on 04/10/2026 at 11:20 AM Staff B stated that staff caring for Resident 17 should have initiated the bowel protocol and given as needed medications as ordered but did not. <Signing for Narcotics> In an observation on 04/07/2026 at 9:42 AM in the fourth-floor south medication cart showed a narcotic ledger showing one narcotic medication available on page 37, this narcotic medication was not available in the cart. In an interview and observation on 04/07/2026 at 10:02 AM Staff N (Licensed Practical Nurse) stated they reviewed the ledger and the medication administration record for the resident who the medication belonged to and was able to show the medication was given on 04/01/2026 but not signed out of the ledger. Documents seen show the medication was given as ordered, though not signed for in the narcotic ledger. In an interview on 04/13/2026 at 11:56 AM Staff B stated the staff working the fourth-floor medication cart should have signed for the medication when given and counted the cart correctly to identify that the count was not correct but did not. REFRENCE: WAC 388-97-1620(1)(2)(b)(i)(ii). .

Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) level 2 referrals were followed up on timely for 1 of 6 residents (Resident 16) whose PASRRs were reviewed. This failure placed residents at risk of not receiving timely and necessary services to meet their mental health needs.Findings included.<Facility Policy>According to the facility's Mood and Behavior Program policy, revised 03/2026, the facility would follow guidance as issued by the State-designated PASRR authority.<Resident 16>According to the 12/05/2025 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 16 had diagnoses including a progressive, irreversible brain disorder that slowly destroyed memory, thinking skills, and the ability to perform simple tasks, anxiety, and depression. The MDS showed Resident 16 received an antipsychotic, antianxiety, and antidepressant medication during the assessment period.Review of a 12/03/2025 social services care conference progress note showed Resident 16's family and facility staff had concerns regarding worsening behaviors of the resident. The note showed Resident 16 was displaying aggressive behavior, was paranoid about their money being stolen, and paranoid about food and drinks. The progress note showed the physician was present, a psychiatric consult was completed, and medication changes were made.Review of Resident 16's physician orders showed a 12/06/2025 physician order directing staff to administer an antipsychotic medication to Resident 16 every day at bedtime.Review of a 01/23/2026 PASRR level 1 showed Resident 16 had serious mental health indicators including mood and anxiety disorders. The PASRR showed staff assessed that a PASRR level 2 evaluation referral was required for Resident 16's identified serious mental illness.Review of Resident 16's comprehensive record and social services progress notes from 01/2026 to 04/10/2026 did not show documentation that a PASRR level 2 determination was received or follow up on the referral by staff was completed.In an interview on 04/10/2026 at 9:38 AM, Staff O (Social Worker) stated their process was to follow up on referrals quarterly. Staff O reviewed Resident 16's records and confirmed the determination was not received and follow-up by staff was not completed but should have been.REFERENCE: WAC 388-97-1975 (2)(3).

Based on interview and record review, the facility failed to thoroughly investigate, notify provider of changes in condition, implement appropriate fall interventions, and rule out abuse/neglect for 2 of 11 sampled residents (Resident 3 & 27) reviewed for investigations. The failure to conduct thorough investigations left residents at risk for unidentified abuse and/or neglect, recurrence of events, and a decreased quality of life.<Policy>According to the facility's 10/2025 Fall Prevention and Response policy the facility would investigate falls, including interviewing residents, staff, and others about the nature of the falls, and assess the resident for injuries sustained in the event. The policy stated the facility would initiate neurological assessments for residents who sustain an unwitnessed fall to check for potential injury and report to the physician for further assessment and treatment as needed.<Resident 3>According to the 12/07/2025 admission Minimum Data Set (MDS- an assessment tool) Resident 3 admitted to the facility on [DATE] with diagnoses including kidney disease, stroke, and high blood pressure. The MDS showed Resident 3 had recent brain surgery, no history of falls and was dependent on staff for Activities of Daily Living (ADL)Review of a 12/19/2025 Falls Care Plan (CP) showed Resident 3 was at risk for falls. Resident 3's CP showed fall interventions of room close to nursing station and anticipate all needs prior to leaving room. Resident 3's CP did not include when to notify provider of change in condition post fall or fall monitoring interventions.Review of the facility's fall investigation summary for Resident 3's fall on 12/20/2025 showed ADL care was provided an hour and a half prior to the fall and nursing staff had provided care 15 minutes prior to the fall. Documents attached to the summary of Resident 3's fall investigation did not include witness statements or other documented evidence to support when care was provided. Review of a 12/20/2025 nursing progress note showed the fall was unwitnessed and circumstances leading up the fall were unknown. Review of the Neurological Assessment record for Resident 3 following the 12/20/2025 fall showed missing vital signs, observation of signs of neurological changes, and nurses initials on 12/21/2025 at 3:15 PM.Review of the facility's fall investigation summary for Resident 3's fall on 12/22/2025 showed ADL care was provided two hours prior to the fall, and Resident 3 was seen one hour prior to the fall in bed asleep. The facility failed to provide documentation in the fall summary for Resident 3 to support when care was provided or circumstances leading to the fall. A 12/23/2025 physician's note showed Resident 3 was prescribed an anti-psychotic medication (a medication that effects mood and brain processes) as an intervention for falls due to their restlessness.Review of facility's fall investigation for Resident 3's fall on 12/30/2025 showed neurological assessments following the unwitnessed fall were completed at 6:30 AM, 7:30 AM, 9:30 AM, and 11:30 AM, staff had marked yes to indicate new onset of seizures, headaches, vomiting, or paralysis and required physician notification. There was no documentation found in the investigation to show Resident 3's condition was reported to the provider.In an interview on 04/10/2026 at 10:58 AM Staff B (Director of Nursing- DNS) stated a complete and thorough fall investigation would include staff witness statements and accurately completed neurological assessments. Staff B stated there was not an appropriate indication of use for Resident 3's anti-psychotic medication. Staff B stated Resident 3's neurological assessments were inaccurate, and investigations into Resident 3's falls should have included witness statements but did not. <Resident 27> According to the 03/19/2026 Quarterly MDS Resident 27 admitted to the facility on [DATE] with diagnoses of heart failure, an abnormal heart rhythm, and a urinary tract infection. The MDS showed Resident 27 required supervision with ADLs.Review of the facility's fall investigation for Resident 27's fall on 11/12/2025 showed Resident 27 had a fall at home when out of the facility and staff initiated neurological assessments. The neurological assessment within the fall investigation showed staff had marked yes to indicate a new onset of seizures, headache, nausea, or paralysis and required physician notification 11 times between 11/13/2025 and 11/15/2025. There was no documented evidence of physician notification of Resident 27's condition.Review of the facility's fall investigation for Resident 27's fall on 01/21/2026 showed Resident 27 had an unwitnessed fall in their room at 12:01 AM. Staff witness statements for Resident 27's fall showed staff marked NA when asked if the CP was being followed and the last time Resident 27 was toileted. Witness statements for Resident 27's fall were left blank when asked if there was anything different about (Resident 27) during the shift and what the potential cause of the fall was. Neurological assessments attached to the fall investigation showed staff documented in Resident 27's neurological assessments were missed on 01/21/2026 at 8:00 AM and 12:00 PM.In an interview on 04/20/2026 at 11:14 AM Staff B (DNS) stated Resident 27's neurological assessments were inaccurate and not completed. Staff B stated the witness statements should have been further investigated but were not.Refer to F605: Right to be Free from Chemical RestraintsREFERENCE: WAC 388-97-0640(6)(a)(b)

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5 percent (%). Failure of 1 of 5 nurses (Staff W - Long Term Care Registered Nurse) to properly administer 2 of 29 medications for 1 (Resident 56) of 6 residents observed during medication pass, resulted in a medication error rate of 6.9%. This failure placed residents at risk for adverse side effects and/or not receiving prescribed medications as ordered.Findings included .<Facility Policy>Review of the facility's Medication Administration policy, revised 04/2025, showed the facility staff administering the medication should be sure to review elements of the medication order including verifying the resident name, name of medication, strength, dosage, time, and route.<Staff W>Observation on 04/08/2026 at 9:04 AM showed Staff W preparing to administer morning medications to Resident 56. Staff W measured 25 milliliters (ml) of a liquid supplement medication into a medication cup and prepared prescription eye drops for Resident 56. Staff W was ready to administer the medication to Resident 56 in their room. Staff W administered 1 drop of the prescribed eye drop to each eye for Resident 56. Resident 56 told Staff W they received two drops in each eye every day from other nurses. Staff W stated Resident 56's physician order directed staff to administer one drop of the eye drops in each eye.On 04/08/2026 at 9:17 AM, Staff W reviewed Resident 56's physician orders, and stated the resident was right. Resident 56's physician orders directed staff to administer two eye drops in each eye and instructed staff to administer 30 ml of the liquid supplement, not 25 ml as Staff W was going to administer. Staff W stated they should check the orders for all residents before they administer medications to the residents.In an interview on 04/13/2026 at 9:44 AM, Staff B (Director of Nursing) stated their expectation was for staff to check the physician orders before they administered medications to residents, but they did not.REFERENCE: WAC 388-97-1060(3)(k)(ii).

Based on observation, interview, and record review, the facility failed to ensure residents were provided care and services in a dignified manner for 2 (Residents 202 & 3) of 36 sample residents and 2 supplemental residents. The failure to: ensure catheter bags (bags that collect urine from tubing placed in the body to assist with urinary drainage) were covered to obscure their contents (Resident 202 & 3) and ensure 1 staff (Staff D - Licensed Practical Nurse) sat when providing feeding assistance to residents, placed residents at risk for undignified care and a diminished sense of self-worth.<Facility Policy>According to the facility's revised April 2025 Standards of Care policy, staff would ensure urinary catheters were covered to promote residents' privacy and dignity.According to the facility's revised January 2026 Resident Rights policy, staff would promote dignity, individuality, independence, and quality of life by minimizing institutional characteristics.<Resident 202> According to the 04/10/2026 admission Minimum Data Set (MDS - an assessment tool), Resident 202 admitted to the facility on [DATE] with diagnosis of urinary infection, enlarged prostate, and obstructive uropathy (a blockage in the urinary tract). Record review showed a 03/29/2026 physician order instructing staff to cover Resident 202's catheter bag to ensure dignity. In an observation on 04/06/2026 at 9:08 AM, Resident 202 was sitting in their wheelchair with the catheter bag hanging from it without a cover. In an observation on 04/07/2026 at 9:19 AM, Resident 202 was sitting in bed with the drainage bag hanging on the bedrail without a cover. In an interview on 04/08/2026 at 9:50 AM, Staff H (Long Term Care Registered Nurse) stated Resident 202's catheter bag should have been covered to maintain dignity, but it was not. In an interview on 04/10/2026 at 9:24 AM, Staff B (Director of Nursing) stated they expected staff to use dignity covers for drainage bags to obscure their contents and preserve the resident's dignity and respect. <Resident 3> According to the 12/07/2025 admission MDS, Resident 3 admitted to the facility on [DATE] with diagnoses of stroke, high blood pressure, and kidney disease. The MDS showed Resident 3 had an indwelling urinary catheter. Review of Resident 3's 03/31/2026 care plan showed staff were to keep the urinary catheter drainage bag covered to promote dignity. In observations on 04/06/2026 at 1:01 PM, 04/07/2026 at 8:41 AM, and 04/08/2026 at 9:09 AM showed that Resident 3's catheter bag was not covered and was visible to others in the dining room and from the hallway looking into their room. In an interview on 04/08/2026 at 9:19 AM Staff N (Licensed Practical Nurse) stated Resident 3's catheter drainage bag should be covered but was not. In an interview on 04/10/2026 at 11:22 AM with Staff B stated that catheter drainage bags should be covered for residents to provide dignity. <Saint [NAME] Residence (SJR) Dining Room> During an observation on 04/06/2026 at 11:52 AM in the SJR dining room, two female residents were seated at the same table and required assistance with eating. Staff D was observed standing next to the table and feeding both residents by alternating between them. In an interview on 04/06/2026 at 12:29 PM Staff D stated, the facility used teamwork to feed residents and the nurses often interchanged with the nursing assistants to help feed residents. Staff D stated they were not aware that dignity was an issue when standing to feed residents. Staff D stated they were not aware of a policy that staff should sit when assisting residents to eat. In an interview on 04/13/2026 at 10:55 AM, Staff F (Long Term Care Registered Nurse) stated staff should sit down while feeding residents. Staff F stated a resident would have to look up to be fed and that would be demeaning. In an interview on 04/13/2026 at 1:16 PM Staff B stated they expected staff to sit down while assisting residents with feeding for residents' dignity. REFERENCE: WAC 388-97-0180 (1-4).

Based on interview and record review, the facility failed to implement a system to ensure Advanced Directives (AD) were in place for 3 (Residents 188, 189, & 7) of 8 residents reviewed for ADs. This failure placed residents at risk of losing their right to have their stated preferences/decisions honored regarding medical treatment and end-of-life care.Findings included.<Facility Policy>Review of the facility's 04/2025 revised Advanced Directives policy showed facility staff would determine on admission whether the resident had an AD and if not, determine if the resident wished to formulate an AD. The policy showed staff would obtain a copy of the resident's AD and maintain the copy for all staff members to access in the resident's record.<Resident 189> According to the 01/23/2026 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 189 had intact cognition and diagnoses including heart failure, difficulty speaking following a brain bleed, and weakness to one side of their body. In an interview on 04/07/2026 at 8:58 AM, Resident 189 stated their sister used to be their Power of Attorney (POA) but was not any longer. Review of an 11/12/2025 Care Plan Conference form showed the resident did not have a POA under the ADs section of the form. Review of an 11/13/2025 social services progress note showed the social work staff contacted Resident 189's POA regarding setting up a care plan conference. Review of Resident 189's comprehensive records on 04/09/2026 at 1:38 PM showed no POA paperwork was available in the record. In a joint interview on 04/10/2026 at 9:13 AM with Staff L (Social Services Manager) and Staff O (Social Worker), Staff O stated the facility process was to ask residents/family on admission if they had a POA and request copies of the paperwork. Staff O reviewed Resident 189's records and confirmed they could not find a copy of the resident's POA paperwork. Staff L stated it was their expectation POA paperwork was available in resident's records. <Resident 7> According to the 01/29/2026 Quarterly MDS, Resident 7 had no impaired memory and no rejection of care during the assessment period. Record review of Resident 7's face sheet showed Resident 7 was their own responsible party. There was no copy of an AD for Resident 7 in their record. There was no documentation showing the facility attempted to offer/assist to complete AD for Resident 7. In an interview on 04/09/2026 at 8:53 AM Staff L reviewed Resident 7's record and stated there was no AD or POA papers in Resident 7's record at that time. Staff L stated they thought the facility was talking to Resident 7's family member for POA paperwork but were unable to provide documentation. In an interview on 04/13/2026 at 9:23 AM, Staff B (Director of Nursing) stated they expected all residents AD/POA paperwork to be available for staff all the time in resident's record. <Resident 188> According to the 02/23/2026 admission 5 Day MDS, Resident 188 had intact memory, clear speech, and was able to understand others. The assessment showed Resident 188 had no rejection of care during the assessment period. Record review of Resident 188's face sheet showed Resident 188 was their own responsible party. There was no copy of an AD for Resident 188 in their record. There was no documentation showing the facility offered or/and assisted Resident 188 to complete their AD papers. In an interview on 04/13/2026 at 8:42 AM Staff L reviewed Resident 188's record and stated they did not obtain a copy of Resident 188's ADs. Staff L stated they should have Resident 188's AD copy in the resident's record, but they did not have one. In an interview on 04/13/2026 at 9:23 AM, Staff B stated they expected all residents AD/POA paperwork to be available for staff to access in resident's records. REFERENCE: WAC 388-97-0280(3)(c)(i-ii).

Based on observation, interview, and record review the facility failed to ensure specialized rehabilitative services were provided as assessed to be required for 3 of 5 sample residents (Residents 188, 189, & 156) reviewed for rehabilitation with skilled therapy services. This failure prevented residents from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psycho-social well-being.Findings included . <Resident 188> According to the 02/23/2026 5 Day Medicare Minimum Data Set (MDS - an assessment tool), Resident 188 did not have cognitive impairment, was understood, and able to understand others in conversation. The assessment showed Resident 188 had diagnoses of kidney stones and bladder infection and required assistance from staff with daily needs including personal hygiene. Review of the facility Census record showed Resident 188 was hospitalized on [DATE] for scheduled procedure to remove kidney stones and came back to the facility on [DATE]. Review of the 03/27/2026 hospital Physician transfer orders showed Resident 188 required Physical Therapy (PT) and Occupational Therapy (OT) evaluation and management to resume previous level of activity. Review of Resident 188's March and April 2026 Physician Orders showed no orders for PT and OT evaluation and treatment. Observations on 04/06/2026 at 10:21 AM and on 04/07/2026 at 9:13 AM showed Resident 188 was lying in bed in their hospital gown. In an interview on 04/06/2026 at 10:25 AM, Resident 188 stated they were in the hospital for more than a week for kidney stone removal procedure and were told therapy staff would work with them to get stronger when they come back to the facility, but no one had worked with them. Resident 188 stated they felt weak and wished they received therapy to help them to sit them on the edge of their bed. In an interview on 04/09/2026 at 12:26 PM, Staff GG (Rehab Director) stated therapy staff was expected to receive hospital transfer orders for new admissions and readmissions, to complete PT/OT evaluations and treatment as required. Staff GG reviewed Resident 188's hospital transfer orders and stated they missed the therapy orders to evaluate Resident 188 for therapy needs. Staff GG stated they should have evaluated Resident 188 for PT and OT services and treated them to resume their previous level of functions, but they did not. <Resident 189> According to the 01/23/2026 Quarterly MDS, Resident 189 was cognitively intact and had diagnoses including weakness to one side of their body. The MDS showed Resident 189 was dependent on staff for oral hygiene, toileting, getting dressed, and personal hygiene. The MDS showed Resident 189 required substantial/maximal assistance from staff to roll left and right in bed and was dependent on staff for getting up in their wheelchair. This assessment showed Resident 189 did not receive OT, PT, restorative therapy, or splint/brace assistance during the assessment period. Review of Resident 189's 02/07/2026 [activities of daily living] self-care deficit related to decreased mobility. care plan showed an intervention of therapy as ordered/needed to increase the resident's strength and independence. Review of Resident 189's OT certification notes showed the last time OT assessed and provided therapy services to Resident 189 for their hand contracture was from 02/16/2024 to 04/24/2024, nearly two years prior. The OT discharge summary showed the therapist discharged Resident 189 due to the resident declining to wear the recommended hand splint. There was no documentation showing why the resident declined the splint, if alternate therapies were offered, or if a restorative nursing program was offered/recommended. In an interview and observation on 04/07/2026 at 8:58 AM, Resident 189 was lying in bed. Resident 189 stated they could not use their right hand due to having a stroke (brain bleed). Observation at this time showed their right hand was contracted, with their fingers forming a fist; there was no brace or splint in place. Resident 189 used their left hand to pry open their fingers on their right hand. Observation at this time showed Resident 189's left leg was amputated above their knee. Resident 189 stated [the staff] have been talking about therapy recently but no one has started therapy with them. Observation on 04/08/2026 at 9:47 AM and 1:40 PM showed Resident 189 in bed, no brace was present on their right hand. In an interview on 04/09/2026 at 9:58 AM, Resident 189 stated they wanted to use their hand and staff were not working with them to stretch or provide range of motion. In a joint interview on 04/13/2026 at 1:23 PM with Staff GG and Staff A (Administrator), Staff GG stated their process for refusals during therapy was to find out the reason for refusal and attempt to address barriers to promote compliance with therapy services. Staff GG stated it was the therapy department's process to screen residents for restorative nursing programs every six months to a year if the resident was not evaluated in that time. Staff GG stated therapy also performed quarterly therapy screenings on residents and confirmed there was no quarterly screenings for Resident 189, but there should be. Staff A stated the importance of the quarterly screenings was to determine if there were any changes in the resident's functional abilities and to prevent functional decline if able. Staff GG stated they spoke to Resident 189 in 2025 regarding their hand contracture and confirmed they did not have documentation regarding the conversation with Resident 189. Staff GG and Staff A confirmed there should be documentation to show what was offered and discussed with Resident 189 but there was not. <Resident 156> According to the 03/20/2026 admission MDS Resident 156 admitted to the facility on [DATE] with no memory impairment. The MDS showed Resident 156 worked with OT services. The MDS showed Resident 156 did not reject care during the assessment period. Record review of Resident 156's 03/16/2026 OT evaluation showed OT would work with Resident 156 three to six times a week for four weeks. Review of the OT treatment sessions only showed two OT sessions for the week of 03/16/2026 to 03/21/2026. In an interview and record review on 04/09/2026 at 1:19 PM Staff GG reviewed Resident 156's OT treatment sessions and stated they only received OT service twice the first week (03/16/2026 to 03/21/2026) they were admitted to the facility. Staff GG stated they used a Sunday to Saturday week when scheduling rehab treatment sessions. Staff GG stated Resident 156 only received OT on 03/16/2026 and 03/18/2026 but should have received at least three sessions that week per the OT evaluation and plan. Staff GG stated rehab services were important to get residents stronger, independent, and back home. Reference: WAC 388-97-1280(1)(a).

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases. The facility failed to implement and/or follow Transmission Based Precaution (TBP) protocol for 4 of 16 residents (Residents 1, 2, 3, & 4) reviewed for infection control related to COVID-19 (Coronavirus Disease of 2019, an infectious respiratory disease caused by a virus). This failure placed residents at risk of infection and related complications.<Facility Policy>The facility's 08/2024 Transmission-Based Precautions (TBP) policy showed the facility would implement Aerosol Contact Precautions (ACP) for residents with confirmed or suspected infections from COVID-19, which spreads through airborne and droplet routes through coughing, sneezing, talking, and through the provision of care. The TBP policy showed the facility would place a sign on the resident's door to inform staff and visitors of the appropriate Personal Protective Equipment (PPE) to put on and actions to take before entering the resident's room.In an interview on 07/30/2025 at 2:55 PM, Staff C (Infection Control Preventionist) stated a COVID-19 outbreak started in the facility on 07/26/2025 with 10 residents on the third floor south (3-S) testing positive for COVID-19. Staff C stated the residents who tested positive had ACP signage placed on their doors to notify visitors of PPE requirements. Staff C stated on 07/28/2025 five additional residents tested positive, and on 07/30/2025 one more resident tested positive for a total of 16 residents with confirmed COVID-19 infections.In an interview on 07/30/2025 at 4:27 PM, Staff D (Licensed Practical Nurse) provided a 3-S resident census for 07/30/2025 which showed 16 residents, including Resident 1, Resident 2, Resident 3, and Resident 4, had the COVID-19 infection. Staff D stated the 16 residents were isolated to their rooms, staff were required to wear PPE before entering and when providing care to the 16 residents. Staff D stated the nurse on duty was responsible to ensure staff wore the correct PPE when entering the isolated resident's room for care. Staff D stated there were carts with PPE outside the residents' rooms and there were ACP signs on the doors of residents that were in isolation.Observations on 07/30/2025 at 4:35 PM showed rooms 314 (Resident 1), 316 (Resident 2), 315 (Resident 3), and 319 (Resident 4) did not have ACP signage on the door to notify visitors and staff of COVID-19 positive residents.In an interview on 07/30/2025 at 5:43 PM, Staff B (Director of Nursing) stated residents with COVID-19 infections should be on ACP precautions and each door should have signage to notify staff and visitors of PPE use and actions to take before entering the room. Staff B stated no specific staff person routinely monitored for ACP signage or staff use of PPE. Staff B stated all managers and the Infection Control Preventionist oversee the ACP signage and staff use of PPE.REFERENCE: WAC 388-97-1320(1)(a), (2)(a-c).

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 8 of 12 residents (Residents 1, 2, 3, 4, 5, 6, 7, & 8) reviewed for abuse. Resident 1 experienced physical harm when Staff D (Certified Nursing Assistant - CNA) grabbed the resident's arms which left fingerprint bruises and a nail inflicted skin tear;after the incident as demonstrated by mood changes including frequent crying, increased behaviors of distress, multiple days of refused care and medications, and repetitive verbalized statements of fear of being physically hurt. These failures placed residents at risk of verbal, physical, mental, psychological abuse, and diminished quality of life. Findings included . Review of the facility's Abuse Prohibition and Prevention policy revised on 01/2024 showed all residents had the right to be free from mistreatment including physical, mental, and verbal abuse. The facility had processes and measures in place to prevent, investigate, and act on all allegations of abuse. The facility provided training to staff to prevent, identify, and report resident abuse. The facility established practices, evaluated regularly, and ensured on-going effectiveness of the abuse prevention policy. Staff received on-going training to identify types of abuse, recognize indicators of abuse (such as injuries and behavior changes), and how to respond to suspected abuse. The policy showed staff were expected to investigate allegations, prevent further abuse during an investigation, protect/monitor and provide emotional support to residents during investigations, report allegations immediately to the Administrator, State Agency (SA) and all other required agencies as mandated reporters. <Resident 1> Review of the 05/15/2025 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 had a diagnosis of depression, anxiety and dementia. The MDS showed Resident 1 was severely cognitively impaired, did not have any physical or verbal behaviors, no hallucinations, delusions, or delirium. Resident 1 was administered medications for anxiety and depression, but no medications that would cause bruising. Resident 1 was assessed as dependent on staff for all care, hygiene, and mobility. The MDS showed Resident 1 required a mechanical lift for transfers and a wheelchair for ambulation. Review of the 05/30/2024 Care Plan (CP) showed Resident 1 had episodes of mood disturbances related to paranoia, anxiety and fear of falling. The CP showed Resident 1 had behaviors including negative statements about self, declined use of the call light, declined help from staff, and aggressive verbal behaviors to staff. The CP directed staff to use a calm approach, reassurance to prevent anxiety and reapproach later when Resident 1 denied care. The CP did not show Resident 1 had physical behaviors towards staff and did not show interventions for physical behaviors. Review of the weekly skin assessment completed on 05/09/2025 showed Resident 1 had a bruise on their right forearm. The skin assessment did show measurements of the bruise and no indication of any other skin injury. Review of the 05/2025 behavior monitor document by Staff D showed Resident 1 had combative behaviors on 05/09/2025. Staff D also documented on 05/09/2025 the nurse was notified of the behaviors. Review of the nursing progress notes between 05/01/2025 and 05/19/2025 showed no information regarding the injuries on Resident 1's forearm. The progress notes showed no behavior notes for 05/09/2025. Review of the 05/2025 nurse behavior monitor showed no resident behaviors or behavior interventions from 05/01/2025 through 05/08/2025. The behavior monitor showed starting on 05/10/2025 through 05/31/2025 Resident 1 required behavior interventions for documented behaviors of excessive worrying, fear and repetitive statements Don't hurt me, please don't hurt me while crying. Review of the 05/2025 Medication Administration Record (MAR) showed Resident 1 refused their medication one time between 05/01/2025 and 05/08/2025. The MAR showed Resident 1 refused their medication on seven days between 05/09/2025 and 05/30/2025. The medications refused included medications for pain, bowels, dementia, anxiety, and depression. A review of the 05/2025 facility incident and accident log provided by Staff B (Director of Nursing) on 05/19/2025 showed no reporting of injuries to Resident 1. In an email from Staff B on 05/23/2025 at 7:14 PM, Staff B stated during an investigation of Staff D, Resident 1 was found to have a skin tear and bruising on their forearm. Staff B stated Staff D was responsible for physical abuse of Resident 1. Review of social work note dated 05/23/2025 showed Resident 1's Representative (RR) was notified of the incident causing bruises and injury to Resident 1 resulting in anxiety and fearfulness. The note showed the RR reported Resident 1 said for some time now that people were not being nice to them. The note showed the RR was tearful and upset to receive the notification that Resident 1 was injured by Staff D. Review of chaplain progress notes dated 05/23/2025 and 05/24/2025 showed Resident 1 was tearful with repetitive statements of Please help me; Don't let him hurt me; I am afraid; I cannot do anything for myself; Don't let me get hurt; Don't let me fall. The note showed Resident 1 stated a fear of death. The chaplain notes do not show the nurse, or management was informed of the behaviors and statements of Resident 1. Review of the 05/23/2025 facility abuse investigation report showed Staff G (Social Services Manager) visited Resident 1 on 05/23/2025 and observed the right arm with a thumbprint size skin tear with surrounding skin bruising. Resident 1 was crying out statements don't let him hurt me, don't let him touch me. The report showed Staff E (CNA), and Staff F (CNA) arrived during the visit and reported to Staff G the skin tear and bruises were caused by Staff D grabbing Resident 1's arms on 05/09/2025. The report showed Staff E and Staff F stated they reported the injuries to Staff C (Resident Care Manager) on 05/09/2025. The report showed the facility removed Staff D from resident care on 05/20/2025, 11 days after the physical injuries to Resident 1. The report showed the facility initiated the investigation and reported to the SA the abuse of Resident 1 on 05/23/2025, 14 days after the incident which caused physical injuries. In an interview on 05/27/2025 at 10:25 AM, Staff A (Administrator) stated the facility investigation showed Staff D caused physical, mental and continued psychological harm to Resident 1. Staff A stated the investigation showed Staff C was aware of the injuries to Resident 1 caused by Staff D; Staff C did not suspend Staff D; Staff C did not investigate the allegation of abuse; Staff C did not report the suspected abuse to the Administrator, the Director of Nursing, or the SA as expected by the facility policy. Review of a 05/27/2025 dietician progress note showed Resident 1 was referred to the dietician for poor meal intake. The note showed the dietician attributed Resident 1's decreased eating to the incident (with Staff D) being investigated by management. The dietician attempted to interview Resident 1 twice, but they would not participate in the discussion. Review of the 05/28/2025 Physician visit note showed Resident 1 was assessed in response to the abuse investigation of 05/23/2025. The Physician documented Resident 1 demonstrated more combativeness and resistance to care in the past few weeks. The Physician's physical exam showed irregular shaped blueish bruising, measuring 1.5 centimeters by 4.0 centimeters, on the left forearm and the nail inflicted skin tear observed on 05/23/2025 had resolved on the 05/29/2025 exam. In an interview on 05/29/2025 at 11:05 AM, Resident 9 (Resident 1's roommate) stated Resident 1 slept a lot, did not eat much, and cried more often in the recent couple weeks. Resident 9 stated Resident 1 did not talk much, and they did not know why Resident 1 was crying more often. Resident 9 stated they did not know of any incidents between Resident 1 and Staff D. In an interview on 05/29/2025 at 11:57 AM, Staff E stated that on 05/09/2025 Staff D was at the nurse's desk and reported to Staff H (Licensed Practical Nurse) that Resident 1 was combative with care and pinched Staff D. Staff E stated on 05/15/2025 Staff E was assigned to care for Resident 1 and observed bruises in the shape of fingers on both Resident 1's arms and a big skin tear on Resident 1's left arm. Staff E asked Staff D about the bruises and skin tear. Staff D stated to Staff E they grabbed Resident 1's arms when they were combative the prior week and that is how the bruises and skin tear happened. Staff E reported the injuries and Staff D's statement on 05/15/2025 to Staff I (Agency Nurse) and Staff C. In an interview on 05/29/2025 at 12:27 PM, Staff I stated Staff E reported the arm injuries to them on 05/15/2025. Staff I stated they were not able to find any assessment or details about the injuries in Resident 1's record, so they asked Staff C for instructions. Staff C told Staff I the assessment and incident report were done and nothing further was required. Staff I stated on 05/15/2025 Resident 1 was not on alert monitoring for the injuries and there were no treatment orders for the skin tear. <Resident 2> Review of the 04/21/2025 Quarterly MDS showed Resident 2 was cognitively intact. The MDS showed Resident 2 was admitted for a spinal cord injury and was assessed to require maximum assistance with their care and mobility. In an observation and interview on 05/19/2025 at 2:39 PM, Resident 2 was lying in bed, trying to sit up independently with a lot of difficulty, then used the call light to call staff for help. Resident 2 stated they knew Staff D who was very rude and was rough when providing care to Resident 2. Resident 2 stated they told another staff person they never wanted [Staff D] to take care of them ever again. Resident 2 stated they were afraid of Staff D because when Staff D rolled them in bed it caused pain in their back and neck, and they were so close to the edge of the bed they felt like they were going to fall on the floor. Resident 2 stated Staff D cleaned them very roughly with the towel during incontinence care and it hurt their skin and private areas. Resident 2 stated Staff D worked the night shift and on the nights Staff D worked they could not sleep because they did not know when Staff D would come in and what Staff D would do to them. Resident 2 stated Staff D still worked at the facility and was in their room that morning (05/19/2025) to provide morning care. Resident 2 stated they could not talk with Staff D about being too rough because they were afraid of what Staff D would do to them. Resident 2 stated they just did what Staff D told them to do, so Staff D would leave the room faster. Resident 2 stated they did not want to see Staff D ever again. <Resident 3> Review of the 02/16/2025 Quarterly MDS showed Resident 3 was cognitively intact. The MDS showed Resident 3 was assessed to require set-up assistance with their personal care and was independent with their mobility. The MDS showed Resident 3 had a catheter for their bladder and needed staff assistance with catheter care. Review of the 05/20/2025 abuse investigation showed Resident 3 was interviewed by facility staff. The investigation document showed Resident 3 stated Staff D loses their temper and raised their voice at Resident 3. Resident 3 stated they felt like they were walking on their [NAME] toes to see what kind of day it would be with Staff D. Resident 3 stated Staff D called them stupid. In an interview on 05/29/2025 at 12:45 PM, Resident 3 stated Staff D talked to them like I was stupid, I have two master's degrees, and I am not stupid. Resident 3 stated Staff D was intimidating, because when Staff D helped their roommate, Resident 3 would ask for help when Staff D was done, Resident 3 said Staff D would say You have to use your call light for help, Resident 3 stated '[Staff D] would not help me without my call light on. Resident 3 stated, I just learned to do what [Staff D] told me to do, I did not argue because I did not know what [Staff D] would do to me in retaliation. Resident 3 stated they lost sleep at night and did not leave their room when Staff D was working to avoid Staff D in the common areas. <Resident 4> Review of the 03/04/2025 Quarterly MDS showed Resident 4 was cognitively intact with some forgetfulness. The MDS showed Resident 4 had a prior stroke with residual mobility and cognition deficits. Resident 4 was assessed to require set up and cues for personal care and was independent with mobility. Review of the 05/20/2025 abuse investigation showed Resident 4 was interviewed by facility staff. The investigation document described Resident 4 began to openly cry when asked if they knew Staff D. Resident 4 stated they knew Staff D and Staff D was mean to them. The investigation notes showed it was clear by [Resident 4's] emotional reaction they were upset by the care received from [Staff D]. In an interview and observation on 05/29/2025 at 11:42 AM, Resident 4 was observed to have difficulty with speech and only able to provide short answers to questions. Resident 4 took a deep breath, began to moan, tears in eyes, short fast breaths with crying and stated Staff D was mean. Resident 4 stated while crying that Staff D talked mean to them, was not nice, and Resident 4 did not like Staff D. <Resident 5> Review of the 02/14/2025 Quarterly MDS showed Resident 5 was cognitively intact. The MDS showed Resident 5 had a prior stroke with residual mobility and cognition deficits. Resident 5 was assessed to be dependent on staff for all care and mobility. Review of the 05/20/2025 abuse investigation showed Resident 5 was interviewed by facility staff. The investigation document showed Resident 5 knew Staff D. Resident 5 stated Staff D was rude and would not answer Resident 5's questions. In an interview on 05/29/2025 at 11:12 AM, Resident 5 stated Staff D was kind of rough when providing care. Resident 5 stated Staff D would come into their room and throw things, slam the door and get mad at Resident 10 (Resident 5's roommate). Resident 5 stated Staff D would throw Resident 10's walker out of the way. Resident 10 stated they did not know Staff D and did not remember anyone throwing their walker. <Resident 6> Review of the 05/12/2025 Quarterly MDS showed Resident 6 was cognitively intact. The MDS showed Resident 6 was assessed with inability to move both legs, required a mechanical lift for transfers, and was dependent on staff for mobility in bed and all personal care. Review of the 05/20/2025 abuse investigation showed Resident 6 was interviewed by facility staff. The investigation document showed Resident 6 knew Staff D. Resident 6 stated care provided by Staff D was difficult; Staff D was not forthcoming, was dismissive, and Staff D yelled at Resident 6. In an interview on 05/29/2025 at 12:39 PM, Resident 6 stated Staff D provided care too fast, was rough when turning them in bed, and Resident 6 felt like they were going to fall off the bed. Resident 6 stated they did not like Staff D and told someone they did not want Staff D to be assigned to them. Resident 6 stated they did not remember who they told but Staff D continued to come into their room to provide care. <Resident 7> Review of the 05/15/2025 Annual MDS showed Resident 7 was cognitively intact. Resident 7 had a diagnosis of stroke with the inability to use their arm and leg on one side of their body. Resident 7 was assessed to be dependent on staff for all bed mobility, transfers in and out of bed, and personal care. Review of the 05/20/2025 abuse investigation interview with Resident 7 showed Resident 7 stated Staff D was hurried and rough when providing incontinence care or moving them in bed. In an interview on 05/29/2025 at 11:57 AM, Staff E stated they observed Staff D trying to lift Resident 7 up in bed. Resident 7 said Ow, ow, ow. Staff E stated they went in the room to help Staff D when Staff D yelled at them Why did you not sit [Resident 7] up in bed for breakfast? Staff E stated they informed their supervisor, Staff C, of what happened but did not think Staff C did anything about it. In an interview on 05/29/2025 at 12:59 PM, Resident 7 stated Staff D was rough when [Staff D] was assisting me to sit up in bed for lunch and my back was hurting and [Staff D] kept moving me. I told [Staff D] to stop because they were hurting me. Resident 7 stated they had not seen Staff D in a while and was glad because Resident 7 did not like Staff D. <Resident 8> Review of the 04/14/2025 Annual MDS showed Resident 8 had forgetfulness from a brain injury. Resident 8 was assessed to require assistance with mobility and personal care. Review of the 05/20/2025 abuse investigation showed Resident 8 was interviewed by facility staff. The investigation document showed Resident 8 knew Staff D. Resident 8 stated Staff D must have an underlying anger issue because they tell me what to do and told me three other staff did not like me. In an interview on 06/10/2025 at 9:10 AM, Staff A stated Staff D should have been suspended when Staff C was informed of the allegation of physical abuse of Resident 1. Staff A stated Staff C did not follow the facility's abuse and neglect policy. Staff A stated Staff C did not identify suspected abuse of Resident 1, did not assess or monitor Resident 1 for abuse, did not protect other residents on the fourth floor, did not investigate the incident, did not report the incident to the administrator, and did not report abuse to the State Agency (SA), as required. Staff A stated Staff D was terminated. Refer to F607 Develop/Implement Abuse/Neglect Policies F610 Investigate/Prevent/Correct Alleged Violations REFERENCE: WAC 388-97-0640(1)(3)(6)(b).

Based on interview and record review, the facility failed to permit 1 of 3 residents (Resident 1) reviewed for hospitalization to return to the facility after a facility-initiated transfer to the emergency room (ER). Resident 1 experienced psychological harm when they experienced a two-week long hospitalization delay while another nursing facility could be arranged for discharge, anxiety related to being placed in an unfamiliar environment, expressions of fear of homelessness and hopelessness when the facility failed to permit the Resident 1 to return to the facility and resume residency when they were medically cleared by the hospital to discharge. Findings included . Review of the 10/22/2024 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 had a chronic, progressive neurological disease, was cognitively intact, had a feeding tube in their abdomen for nutrition, required assistance from staff for all personal care and mobility. Review of a facility nurse progress note, dated 01/15/2025 8:40 PM, showed the emergency room (ER) nurse called the facility nurse to give a status report on Resident 1 who was ready for discharge from the ER. The note showed the ER was ready to send Resident 1 back to the facility by ambulance. The progress note showed the facility nurse notified the ER nurse that Resident 1's room was cleared of all their belongings and the room was no longer available as directed by the facility management. The progress note showed the ER charge nurse confirmed Resident 1 would then be admitted to the hospital instead of returning to the facility. Review of a facility physician progress note, dated 01/20/2025 for an assessment completed on 01/15/2025, showed Resident 1 required a higher level of medical treatment that could not be provided at the facility. The note showed the physician directed the facility staff to send Resident 1 to the ER for evaluation of a possible abdominal infection and a required replacement of the feeding tube. In an interview on 01/24/2025 at 4:15 PM, Staff A (Administrator) stated Resident 1 went to the ER for a blockage in their feeding tube and there was concern by the facility physician about an infection. Staff A stated Resident 1's representative declined a bed hold due to the cost, but the facility would readmit Resident 1 to an available long-term bed when Resident 1 was medically stable to return. Staff A stated they had received messages from and made calls to the hospital and was told Resident 1 was admitted . Staff A stated they were not aware if the hospital sent a referral to the facility to arrange Resident 1's return home. Staff A stated the facility admissions team usually follows up with the hospital to have residents return when they were ready for discharge from the hospital. In an interview on 01/28/2025 at 4:40 PM, Staff D (Admissions Assistant) stated on 01/15/2025 an internal communication directive was sent that Resident 1 would not be readmitted from the hospital. Staff D stated they received and reviewed the hospital referral on 01/16/2025 for Resident 1 to return to the facility. Staff D stated they informed the hospital discharge coordinator on 01/16/2025 that the admissions staff was not allowed to bring Resident 1 back to the facility. In an interview on 01/29/2025 at 3:51 PM, Collateral Contact 1 (CC1, Hospital Discharge Coordinator) stated Resident 1 arrived at theER on [DATE] for a dislodged feeding tube, the tube was replaced on that day and Resident 1 was supposed to return to the facility on [DATE]. CC1 stated Resident 1 did not need to be admitted to the hospital but remained in the hospital from 01/15/2025 until 01/29/2025. CC1 stated they had a phone call on 01/16/2025 with the facility admissions assistant who stated the facility would not accept Resident 1 back. In an interview on 01/30/2025 at 12:38 PM, Resident 1's Representative (RR) stated they received a phone call and voice mail from Resident 1 on 01/15/2025 at 8:33 PM. RR1 stated Resident 1 was crying and stated in their message I am at the end of my rope .I am at the hospital . I had my tube replaced . I have been dumped . I no longer have a place to live . as soon as I left, they were packing up my stuff .the reason they were pushing me out the door today was so they could pack me up and now I am homeless .I don't know .I'm flat out giving up . I do not care whether I live . I can't live anymore . I am staying overnight; they lied to me about getting an ambulance to go home. The RR stated they spoke with Resident 1 on the phone on 01/16/2025 and described Resident 1 as very discouraged, talking about suicide, resenting all the mistreatment she had received. The RR stated Resident 1 explained they did not want to go to the ER and wanted to schedule an appointment to have the tube replaced but their request was refused and Resident 1 was sent to the ER against their will. The RR stated they only heard from the facility social worker on 01/15/2025 to ask about a bed hold but there was no other contact made to have Resident 1 return to their home. The RR stated Resident 1 left the hospital and went to a different nursing facility on 01/29/2025 and they did not have a phone. In an interview on 01/30/2025 at 1:17 PM, Collateral Contact 2 (CC2, Hospital Physician) stated they had a conversation with Resident 1 on 01/15/2025 after Resident 1 was informed they would not be returning to the facility. CC2 stated Resident 1 explained they were upset and not given any notice of going to the ER, Resident 1 stated they were frustrated and felt like the facility was planning to move them without talking to them about it. CC2 stated Resident 1 was tearful and said they were dumped at the hospital and did not know what to do now. CC2 stated they called the facility twice, left one voicemail to ask for a call back, and did not receive any calls from the facility. In an interview on 02/07/2025 at 11:45AM, Staff E (Resident Care Manager) stated they could not find any discharge transfer sheets or progress notes in Resident 1's record. Staff E stated they worked on the transfer of Resident 1 to the ER with another nurse. Resident 1 was transferred about 8:00 AM. Staff E stated they called the hospital ER nurse to provide information about the feeding tube and relay concerns of infection. Staff E stated they do not make any decisions about when or if residents return from the hospital. Staff E stated Staff B (Director of Nursing) and Staff C (Director of Clinical Operations) made all the decisions for resident readmission from the hospital. Staff E stated Resident 1's belongings were packed and remained in their room for about four or five days after they left. Staff E was told Resident 1 would not be returning and their belongings were moved to another location so another resident could move into Resident 1's old room. Staff E stated Resident 1's room was not occupied by another resident until 01/27/2025, 12 days after Resident 1 went to the ER. In an interview on 02/07/2025 at 4:17 PM with Staff A, Staff B, and Staff C, Staff A stated the facility was committed to providing continued care to the residents they serve as part of their mission. Staff A stated the facility should ensure when a resident was sent to the hospital the resident would be allowed to return, either through a bed hold to the same room or return to another available bed, for continued care. Staff A stated Resident 1 should have returned to the facility when they were medically cleared by the hospital for discharge. REFERENCE: WAC 388-97-0120(4)(b).

Based on interview and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 5 sample residents (Residents 110) reviewed for abuse. Resident 110 experienced psychological harm when they were touched inappropriately without consent by a staff member and continued to ruminate on the incident. This failure placed other residents at risk of sexual, verbal, and mental abuse, psychological harm, and diminished quality of life. Findings included . <Facility Policy> The facility's Abuse Prohibition and Prevention policy dated 01/2024, all residents receiving care and services at the facility had the right to be free from mistreatment including sexual, physical, mental, and verbal abuse. The policy defined sexual abuse as non-consensual sexual contact of any kind. The policy showed when a resident made an abuse allegation against a caregiver, that caregiver would be placed on administrative leave until the conclusion of the investigation. The policy showed if the allegation was substantiated appropriate corrective action would be taken. <Resident 110> According to the Admission Minimum Data Set (MDS - an assessment tool) dated 11/14/2024, Resident 110 had intact memory and experienced social isolation on rare occasions. The assessment showed Resident 110 required partial to moderate assistance with transferring from a chair to a bed and supervision/touching assistance for moving in bed. The MDS showed Resident 110 had a fractured right hip. The MDS showed Resident 110 was over [AGE] years old, and of petite stature. Review of the facility's investigation dated 12/27/2024, showed the incident was reported to the facility on [DATE] and took place on 12/24/2024. The investigation showed the facility was notified by Resident 110's collateral contact that when they visited Resident 110 on Christmas Day 2024, the resident informed them that a male caregiver entered their room, kissed them, and attempted to climb into the bed . The investigation showed Resident 110 could demonstrate they knew the nationality of the caregiver, but they did not recognize them from any prior assignments on the unit. The investigation showed there was nothing in Resident 110's medication regimen contributing to the incident and noted Resident 110 journaled daily. The facility's investigation did not include Resident 110's journal entries but assessed that the habit of daily journaling made Resident 110 a reliable reporter. The investigation showed Staff D (Social Services Director) presented Resident 110 with a photo array of all staff working the third floor the morning of 12/24/2024 and the resident without hesitation identified Staff I (Certified Nursing Assistant - CNA) as the person who kissed them and tried to get into their bed, and Staff I was immediately removed from the schedule. The 12/27/2024 investigation showed Staff B (Director of Nursing) and Staff F (Director of Clinical Operations) interviewed Staff I via telephone and informed Staff I they were not permitted to return to the facility. Staff I had a vague recollection of working with Resident 110. The 12/27/2024 investigation concluded the incident occurred in the early morning of 12/24/2024. The 12/27/2024 investigation concluded that due to Resident 110's alert and oriented status, intact memory, daily journaling, and ability to without hesitation identify Staff I, it was reasonable to believe the resident's account was accurate and Staff I likely acted in an inappropriate manner toward the resident. In an interview on 01/02/2025 at 9:41 AM, Resident 110 was asked if they had any concerns with their care at the facility. Without hesitation, Resident 110 immediately directed the conversation to a specific incident that occurred before Christmas the prior month (10 days prior). Resident 110 stated a facility caregiver kissed them and tried to climb into their bed. Resident 110 stated nothing further happened, and they later told a family member who notified the facility. Resident 110 stated they knew the staff member was dismissed by the facility because of their behavior after Resident 110 made the allegation. In interviews on 01/08/2025 at 10:01 AM and 01/09/2025 11:22 AM, Resident 110 on both occasions recalled the incident unprompted. Resident 110 stated they were not fearful, but when asked how they felt, the resident consistently brought up the inappropriate touching/kissing incident. In an Interview with Staff B and Staff F on 01/08/2025 at 3:12 PM Staff B stated the facility used Washington State's Purple Book (nursing home guidelines for prevention of, protection from, and identification, investigation, and reporting of abuse.) Staff B stated the facility concluded Resident 110's claim was substantiated by the facility's investigation and Staff I was dismissed. Refer to: F607, F609, and F610. REFERENCE: WAC 388-97-0640 (1).

Based on observation, interview, and record review the facility failed to ensure an environment free of avoidable accidents/injuries for 1 of 7 residents (Resident 1) reviewed for accidents. The failure to ensure nursing staff followed the resident care plan (CP) and facility policy while transferring Resident 1 using a mechanical lift resulted in harm when the resident was transferred by one staff person instead of two staff persons, obtained a laceration on the right leg, and was hospitalized for five days. This failure placed residents requiring a mechanical lift transfer at risk for injury, hospitalization , and diminished quality of life. Findings included . The facility policy Mechanical Lift Use reviewed 04/2023 showed residents transferred using a mechanical lift required two staff to operate the lift to ensure resident safety and prevent injuries. One staff will stabilize the resident while a second staff guides the resident to the transfer destination, gently lowering the resident into a resting position. Review of the 12/15/2023 nursing staff training document showed the facility provided mechanical lift training to staff. The training document showed the facility required two staff to operate the mechanical lift when transferring residents. The staff sign in sheet showed Staff D (CNA, Certified Nursing Assistant) attended the training. The 03/29/2024 Admission Minimum Data Set (MDS, an assessment tool) showed Resident 1 was cognitively intact, able to make themselves understood, had clear speech and was able to understand others. The MDS showed Resident 1 was assessed to have limited range of motion in both legs, unable to stand or walk, and was dependent on staff for all transfers from the bed to a wheelchair. Resident 1 had a skin condition that caused blisters and open wounds to their skin requiring wound care. The 04/09/2024 Comprehensive CP showed Resident 1 had a self-care deficit related to decreased mobility, would receive the assessed level of assistance during care, and directed staff to use Resident 1's Kardex (instructions to staff how to provide care) when providing care. The CP showed therapy and nursing updated the Kardex to show Resident 1's required care. The CP showed Resident 1 was at increased risk of skin impairment and referred to the Kardex for interventions for prevention of impaired skin integrity. Resident 1' Kardex, printed on 05/06/2024, showed Resident 1 was dependent on staff for transfers from bed to the tilt-in-space wheelchair and required two staff to use a mechanical lift to move the resident. The Kardex showed Resident 1 had very fragile skin and asked staff to be careful in skin care. The Kardex instructed staff to place a pad under Resident 1's knees when using the mechanical lift to prevent injury to the skin. Review of the 04/25/2024 facility incident investigation report showed at 1:45 PM, Resident 1 was transferred from the bed to the wheelchair using the mechanical lift by Staff D without assistance from a second staff person. The report showed Resident 1's right lower leg was cut by the footrest resulting in a laceration (deep cut) measuring 11-12 centimeters (cm) in length by 8-9 cm in width and the connective tissue (layer of tissue between the outer skin and inner muscle) exposed. The report showed a large amount of blood was on the floor, the nurse was notified, and Staff D transferred Resident 1 back into bed using the mechanical lift and there was no second person to assist. Resident 1 was transferred to the emergency room for medical treatment that was not able to be provided at the facility. Review of the 04/25/2024 hospital records showed Resident 1 arrived at the emergency room at 10:29 PM, with a 11 centimeter (cm) long, 8 cm wide and very deep laceration on the right leg with visible connective tissue of the leg muscle. The hospital records showed Resident 1 complained of pain and discomfort at the site of the wound. The records showed Resident 1 required blood draws by the lab, intravenous (IV) fluids, blood thinning medication injections, and narcotic pain medication injections. A surgical consult was required for the deep wound that required an operation for repair, Resident 1 was admitted to the hospital for further evaluations due to required evaluations in preparation for surgery since Resident 1 had multiple complicating medical conditions. Resident 1 remained in the hospital for five days before surgical treatment was completed and then returned to the facility. In an interview on 05/06/2024 at 1:46 PM, Staff B (Director of Clinical Operations) stated Staff D stated in an interview they completed the mechanical lift transfer independently and did not have a second person to assist them. Staff B stated the facility expectation was that two staff were required to be present and assist in a mechanical lift transfer. Staff B stated Staff D was terminated from employment for not following the CP and not following facility policy. In an interview on 05/14/2024 at 12:55 PM, Resident 1 stated Staff D was using the mechanical lift to move Resident 1 from the bed to the wheelchair. Staff D did not have a second person to assist and Resident 1's right leg was injured by a metal piece of the wheelchair. Resident 1 stated it hurt badly, they yelled out Ow and saw that their leg was bleeding all over the floor. Resident 1 stated Staff D used the mechanical lift to put them back in bed, again without a second person to assist. Resident 1 stated Staff D put towels on their leg for the bleeding and it took a long time for the nurse to come and look at their leg and then Resident 1 had to go to the hospital because the cut was deep and would not stop bleeding. Resident 1 stated Staff D had used the mechanical lift by themselves multiple times in the past without a second person to assist. In an interview on 05/14/2024 at 1:22 PM, Staff C (Resident Care Manager) stated there was staff training how to use a mechanical lift at the end of 2023. Staff were expected to have two persons to transfer a resident with a mechanical lift for the resident's safety. Staff C stated Staff D attended the training and was expected to have two staff assist with a mechanical lift transfer. In an interview on 05/14/2024 at 1:58 PM Staff A (Director of Nursing) stated Staff D attended recent facility training in December 20203 which reviewed the facility policy on mechanical lift transfers which required two staff to operate the lift. Staff D was required to follow the facility policy. REFERENCE: WAC 388-97-1060(3)(g).

Based on observation, interview, and record review the facility failed to provide supervision for 1 of 6 (Resident 1) residents reviewed for wandering and elopement and failed to ensure all exits were secured. These failures allowed Resident 1 to exit the facility, onto a parking lot adjacent to the facility, resulting in a fall with a significant head injury, that required continued hospitalization and placed all residents who wandered at risk for elopement and suffering significant injury. Findings included . Review of a 03/04/2022 Admission note showed Resident 1 had a black Global Positioning Device (GPS) on the left wrist, memory impairment, behaviors, and due to dementia required closer supervision to prevent falls. Review of a Client Diagnosis Report, an assessment, dated 03/14/2022 showed Resident 1 had diagnoses of unspecified dementia without behavioral disturbances, anxiety disorder, history of [CONDITION(S)] (temporary period of symptoms similar to those of a stroke, TIA), and cerebral infarction (disrupted blood flow to the brain, a stroke). Review of Resident 1's 03/04/2022 Care Plan (CP) showed Resident 1 was independent with transfers, able to walk independently with a walker, able to toilet themselves, and required limited assistance with dressing if the resident was tired. Review of 03/09/2022 Physician Progress Note showed Resident 1 had a progressive cognitive decline, stopped being able to carry on conversations, and experienced recurrent falls requiring transfer from an Assisted Living facility associated and in the same building with the Long Term Care facility to which the resident was transferred. Review of 03/10/2022 Nurses Notes showed Resident 1 demonstrated aggressive behavior and twice tried to run off the unit where Resident #1 lived. Review of 03/11/2022 Physician's Orders (PO) showed a referral for a Mental Health Consult related to anxiety and agitation, urine laboratory analysis, new medications started for paranoia, anxiety, and depression, physical and occupational therapy for recurrent falls, and a wander guard (electronic device that would alert staff that resident was trying to exit the facility). Review of the 03/11/2022 Nursing Alert Charting at 6:32 PM showed Resident 1 was restless throughout the night and tried to leave the building, so many times and (was) found near the elevator a few times. Review of Nursing Alert Charting dated 03/11/2022 at 9:38 PM showed Resident 1 was wandering around the unit hallway and other resident rooms. Staff redirected Resident 1 multiple times but the resident was not redirectable. Review of Nursing Alert Charting dated 03/11/2022 at 1:04 PM showed Resident 1 went downstairs trying to get out of the building. Staff were able to redirect but Resident 1 had couple more attempts at leaving facility. Review of Nursing Alert Charting dated 03/12/2022 at 8:12 PM showed Resident 1 was wandering around the unit hallway and going into other resident's rooms. Review of Nursing Alert Charting dated 03/13/2022 at 9:45 PM showed Resident 1 was observed leaving the building headed to the temple (church sanctuary associated with the facility and in the same building) trying to get out of the building. Staff were able to redirect the resident. Review of a Physician Consult note dated 03/14/2022 at 10:42 AM showed Resident 1 was, more confused, agitated, and trying to leave the facility over the last 1-2 days. Review of Nursing Alert Charting dated 03/14/2022 at 8:24 PM showed, In the morning and evening shift Resident 1 left the unit several times and was found downstairs. Resident 1 is unaware of self-safety and walks fast with their walker. Resident 1 found multiple times in elevator. Staff assigned almost 1 on 1 care during both shifts. Review of Nursing Alert Behavior note dated 03/14/2022 at 3:54 PM showed Resident 1's family voiced concern that the facility was not able to handle Resident 1. During an interview on 03/16/2022 at 9:45 AM a Collateral Contact (CC) stated, They (the CC) were headed to work at 4:00 AM when they noticed Resident 1 sitting on the curb near the South parking lot (of the facility). The CC noted Resident 1 with a huge head injury, described as 1/2 the size of a baseball on the right eyebrow with blood down their face and on their hands from a laceration (cut) above the right eyebrow. Resident 1 was also noted to be violently shivering. The CC called 911 who responded immediately and transported Resident 1 to the hospital (where Resident 1 was) admitted . During observation on 03/16/2022 at 3:20 PM Staff F Certified Nursing Assistant was unaware of, and unable to locate the device used to check the functionality of the wander guard device, used to ensure Resident 1 remained in the facility, in their nurse's cart. During an observation on 03/16/2022 at 4:10 PM one of three exit doors, in the Providence Eldercare Program Services (PEPS, on the second floor the same floor on which the resident resided) room, had a sign that showed Door Alarm is Off. When the door was pushed open no alarm sounded. During an interview on 03/16/2022 at 2:30 PM Staff C Plant Operations Director stated, I believe Resident 1 went out the doors in the PEPS room. The door was supposed to be locked to get into that area. There are three doors in that room that do not have video cameras attached to them, and they are not connected to the wander guard system. During an interview on 03/16/2022 at 3:15 PM Staff E Licensed Practical Nurse attempted to demonstrate the device used to check the functionality of the wander guards, it would not turn on. They stated they would notify Staff C immediately. During an interview on 03/16/2022 at 3:20 PM Staff F stated, We check the wander guards once a week, I check them by taking them down to the front door to see if they alarm When asked about the wander guard device they stated, I don't know about a device. Staff F was unable to locate on the Treatment Administered Records (TAR) that the four residents on the staff's hall had the resident's wander guard devices checked weekly. During an interview on 03/16/2022 at 4:10 PM Staff K Personal Care Aide stated, Two of the doors in here always have the alarm on. Because of COVID-19 we use the third door to go outside with the clients. This door is unlocked during business hours. During an interview on 03/16/2022 at 4:20 PM Staff J PEPS Manager stated, I found out today the alarm wasn't working on this door when Staff C came up to check our doors. I don't know how long it hasn't been working. I program it every night. We flip the sign on the door to read, This Door is Alarmed, every night when we leave. During an interview on 03/17/2022 at 9:05 AM Staff B Director of Nursing stated that Staff C noted the alarm on the exit door in the PEPS area was broken when they checked it on 03/16/2022. Staff B stated, We think Resident 1 left the facility through one of the doors not connected to the SARA system (Security doors designed to automatically lock when a resident wearing a security device approaches the door to prevent them from leaving a secure area). Resident 1 remained in the hospital as a result of their injuries as of 03/24/2022. Refer to: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to provide effective supervision and assistance for two of four residents (Resident #1 & #2) reviewed for falls. This failure did not protect the residents from additional falls, and resulted in harm to both residents when they sustained fractures from falls. Findings included . A 10/2019 facility policy titled Falls, showed the facility sought to reduce resident falls and adverse outcomes of falls, with processes aimed at identifying residents with a fall risk, and putting plans in place to prevent falls and sequelae. RESIDENT #1 Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with a left [MEDICAL CONDITION], and had a previous right [MEDICAL CONDITION] in 2018. Review of a 01/04/2021 Admission Minimum Data Set (MDS, an assessment tool) showed Resident #1 had [MEDICAL CONDITION], required assistance with transfers and toileting, and was, Not steady; only able to stabilize with human assistance, when moving from seated to standing position. A 01/04/2021 Resident Information Sheet (RIS) identified Resident #1 had poor safety awareness, was a very high risk for falls, and had an unsteady gait. This RIS instructed staff to anticipate needs, closely monitor the resident due to high risk for falls, and not leave unsupervised in the bathroom due to orthostatic [MEDICAL CONDITION] (drop in blood pressure when rising). This RIS showed no instruction how staff was to closely monitor the resident. FIRST FALL A 01/05/2021 progress note showed Resident #1 was discovered kneeling at the bedside at 9:15 AM by a Social Worker walking by. This progress note showed staff determined the resident's impulsivity, poor safety awareness, general weakness, and wanting to be independent as some of the root causes of the fall. Interventions again included to closely monitor the resident, anticipate needs, and encourage fluids. SECOND FALL A 01/07/2021 progress note showed Resident #1 had an unwitnessed fall at 8:40 AM, when the resident had gotten up to go to the bathroom. The root cause was determined to be, poor safety awareness, not using call light. A 01/07/2021 therapy note showed, NIF (Non-injury fall) this morning. (Resident #1) was seen by nsg (nursing) staff multiple times during the morning attempting to take (self) to the bathroom without using call light, sometimes not use FWW (walker) and sometimes attempting to use BSC (bed side commode) as walker. A 01/08/2021 medical provider note showed, Nursing reports pt (patient) uses her wc (wheel chair) and self transferred herself and walked to the bathroom on her own today, they also report that she sometimes uses the call light . sometimes she appears very forgetful and confused. A 01/08/2021 Investigative Document (ID) showed, This fall appeared to occur while she was using a BSC to walk from the BR (bathroom) . Patient is very impulsive and had been caught up moving in room several minutes since first fall. Staff attributed root causes of the fall to Resident #1 wanting to be independent, and having impulsive behavior and poor safety awareness. A 01/04/2021 RIS included with the ID showed, Anticipate needs. Closely monitor due to high risk for falls. This RIS showed no instruction how staff was to closely monitor the resident. In an interview on 02/23/2021 at 11:29 AM, when asked how the Care Plan (CP) changed after the second fall to compensate for Resident #1's memory loss, impulsivity, and inconsistent use of the call light, Staff D, Neighborhood Coordinator (NC), stated, We moved her to a room where staff could actually see her. THIRD FALL A 01/09/2021 progress note showed that, At about 1930 (7:30 PM) on 1/08/2021, the RA (Resident Assistant) noticed (Resident #1) on the floor in the resident's room . Patient replied she wanted to use the bathroom so she got out of bed, however she did not make it to the BR and fell . A 01/12/2021 ID included, Toileting is offered every 2 hours with (Resident #1) sometimes declining, as an action to prevent re-occurrence. A 01/04/2021 RIS included with the 01/12/2021 ID showed no changes to instruct the staff to offer toileting every two hours. This RIS showed no additional changes to address how staff was to closely monitor the resident and anticipate needs. In an interview on 02/23/2021 at 11:29 AM, when asked if the CP changed to address Resident #1's toileting needs, Staff I stated, Not done. I'd have to look at hers. A 01/09/2021 progress note showed, Staff caught patient attempting to get out of her bed without asking for help multiple times, staff frequently reminds patient to press call light when needing assistance, however, most of the time she fails to do so. A 01/13/2021 progress note showed, Patient confused and impulsive this shift. Staff monitored closely and caught patient a few times trying to get up . assisted to toilet after 9pm after being caught trying to get up. Very unsteady and would have fallen if not for staff assistance stabilizing. A 01/15/2021 progress note showed, Pt continues to be impulsive, attempted to get out of bed x4 (four times), hard to redirect. A 01/16/2021 progress note showed the facility Fall Team reviewed Resident #1's falls and identified impulsivity and lack of awareness as potential causes for falls, and the interventions included, Staff walking with (Resident #1), Staff taking turns to provide more frequent visual checks. The Fall Team identified Resident #1, needs a frequent reminder to go to bathroom. In an interview on 02/23/2021 at 11:29 AM, when asked how interventions changed after the third fall to compensate for Resident #1's memory loss, forgetfulness, and inconsistent use of the call light, Staff D stated, I will check for some more information. When asked how staff frequently checked Resident #1 to prevent falls and anticipate needs, Staff I stated, We rotated care every 15 to 20 minutes, somebody had an eye on her. FOURTH FALL A 01/16/2021 therapy note showed, Pt noted to not sleep well last night and was highly impulsive when mobilizing in the morning often without walker . continue to require constant CGA (Contact Guard Assist) and 24 hour SUP (supervision) due to impaired safety awareness, impulsivity . Progress notes dated 01/17/2021 showed the resident was found crawling under the table by a Dining Host. Staff L, RN, identified root causes of the fall included poor safety awareness, generalized weakness, restless, Pt needs continues (sic) monitoring, and Pt continuously trying to get out of chair and bed without calling assistance (sic), gait unstable. Pt needs continuous one on one monitoring to ensure safety, discussed issue with supervisor, to continue monitor for now and one on one care to be reviewed per supervisor. A 01/20/2021 ID showed, CNA had toileted resident and brought resident to the common area to watch TV and to be observed by several staff members. Staff last saw resident at about 4:25 PM she was seen 5 minutes prior by the dining host watching TV, with his back to her for just a few minutes fixing the salads for the meal and the nurse was at the computer in the general area. In an interview on 02/24/2021 at 4:00 PM, Staff L stated that he had discussed the need for one on one (1:1) with Staff D. Staff L stated, After (Resident #1) fell , I recommended she be a one on one, and described 1:1 care as, We were switching staff to be with her, she was with me while I was charting. A Post Fall Assessment, dated 01/17/2020 and included with the 01/20/2021 ID, showed that staff continued to attribute impulsiveness and poor safety awareness as possible causes for Resident #1's fall and that, based on the root cause of the fall, Resident #1, needs continuous monitoring and safety checks. A 01/17/2021 RIS attached to the 01/20/2021 ID showed, Frequent safety monitoring/checking due to high risk for fall 01/17/20 (sic). This RIS showed no instruction how staff provided frequent safety monitoring/checks to prevent falls. In an interview on 02/23/2021 at 3:27 PM, Staff J, the RA assigned to Resident #1 on 01/17/2021, stated the resident required, One to one needed at all times, and described 1:1 as the staff sits with resident the whole shift, when they go on break then someone else covers and sits with her. Staff J described continuous supervision and constant supervision as has a caregiver all the time. In an interview on 02/23/2021 at 11:29 AM, when asked what the difference was between continuous monitoring and frequent checks, Staff D stated, It's just a change in terminology. We are doing the same thing. When asked how supervision for Resident #1 changed after the fourth fall, Staff D stated, The only thing I can recall is we had no extra staff to do it at the time. FIFTH FALL A 01/18/2021 progress note showed, Pt continues to have poor safety awareness, staff keeps patient within view at all times. A later note showed, Pt. continuously try to get out of chair and bed without calling assistance (sic), gait unstable. A 01/19/2021 progress note showed, Impulsive and poor safety awareness. Frequent visual check maintained d/t (due to) high fall risk. A 01/20/2021 progress note showed Resident #1 fell at 2:55 AM at the nurse's station. Staff I (RN) stated she was sitting next to the patient, and had to answer a call light. (Resident #1) had just dozed off. Went to bring snacks to a patient and walked out and found (Resident #1) getting up from the chair and took a few steps and watched her lose (sic) her balance and fall, landing on her knees and hands. Staff I identified the root cause of the fall was, She's impulsive, doesn't follow directions. Difficult to redirect. Poor balance and gait. SIXTH FALL Another 01/20/2021 progress note showed Resident #1 fell again at 3:30 AM. This note showed Resident #1 had dozed off, suddenly jerked awake, bumped her head on the ledge of the desk, and fell forward off her chair. This note showed that, despite a RA stated they were sitting next to the resident, they were not able to catch her on time. Staff identified once more that the root cause of the fall was, She's impulsive, doesn't follow directions. Difficult to redirect. Poor balance and gait. Review of a 01/20/2021 facility internal e-mail from Staff I to Staff D showed, Resident needs someone to sit with her one to one at this point because it is even impossible to turn to chart while she's next to you . I understand staffing concerns but if you can't even turn to chart without her falling, it's ridiculous . I had to bring her outside to patient's rooms while (the RA) was busy answering lights and I had to pass meds (medications). In an interview on 02/24/2021 at 3:51 PM, Staff I stated, (Resident #1) needed to be in a common area for supervision. I have had cases when someone stays with the resident at all times and only assigned to that resident. I was by myself at the nurse's station with her and she was dozing off, somebody called, I grabbed something they asked for and when I came back she was standing up. I ran as fast as I could, and just could not turn the corner fast enough and she fell . On night shift, there is one nurse and one aide. The aide was on break and I cover while on break. There is about 16 to 20 residents. A 01/24/2021 ID showed, Since these falls, she would continue to be found by staff on multiple occasions attempting to get up on her own . Discussion with (Collateral Contact 1) describing patient's condition and need for 1:1 care. Progress notes dated 01/20/2021 showed the facility contacted Collateral Contact 1 (CC1) to, discuss the resident's care and the request for 1:1 care . reviewed falls and the need for staff to constantly have the resident within their sight and provide constant supervision secondary to patient's fall risk and impulsive behavior . request for 1:1 care was not heard, and (CC1) was not able to address or hear (Resident #1) needs 1:1 care and will ask (Managed Care) team for assistance on Thursday to address this. A 01/20/2021 provider note showed, Nursing staff are currently needing to provide 1:1 care due to safety risk. A 01/21/2021 progress note showed, Pt continuously try to get out of chair and bed without calling for assistance, gait unstable . frequent safety checks and one on one visit. A 01/22/2021 progress note showed, Frequent visual checks and 1:1 as needed. In an interview on 02/23/2021 at 11:29 AM, Staff D stated, (RA) was right at the computer with (Resident #1) next to her. I don't think she was that far away. When asked what was the difference between one on one visit, 1:1, and frequent safety checks, Staff D stated, I know all of the staff there was 1:1 during that 15 minutes rotation, and defined 1:1 care as, It really depends on what the resident needs are. Staff D stated the Managed Care team, Wouldn't provide that (1:1), and confirmed the facility asked CC1 to provide 1:1 care for Resident #1. A 01/22/2021 x-ray result showed Resident #1 sustained an acute right [MEDICAL CONDITION]. SEVENTH FALL A 01/24/2021 late entry note for 01/23/2021 06:30 (6:30 AM) showed, 1:1 assistance from staff as warranted as (Resident #1) is impulsive, has poor safety judgment and is definitely a high fall risk . Patient cannot stay still in bed and frequently attempts to get out of bed . she exhibited episodes of just wanting to stand up and get out of the wheel chair . Endorsed to Day Shift nurse that patient did not have any sleep at all for night shift and that same patient requires 1:1 supervision to prevent patient from falling. A 01/23/2021 progress note showed Resident #1 fell at 3:20 PM in her room, and was found at her bedside. This note showed Staff K (RN) had been in the resident's room, couple minutes earlier and was currently at the med cart near the patient's room. At last glance patient appeared to be asleep with eyes closed and deep/even breaths. Looked into patient's room to check on her a minute later and found her on her knees. Did not hear any sounds indicating patient was moving . Patient crawled back into bed while talking to RN. Staff identified the root cause of the fall and care plan changes indicated were, Impulsive w/ (with) very poor safety awareness and impaired balance/strength/coordination, needs constant supervision. An Event Report associated with the 01/26/2021 ID showed, What do you think caused this event?, to which staff stated, Impulsivity and poor safety awareness. Likely needs constant 1:1 supervision. In an interview on 02/24/2021 at 10:00 AM, Staff K stated Resident #1 required, One to one was needed, and described 1:1 as, In constant eyesight, sometimes at the nursing station, or in bed when tired. Staff L stated that continuous supervision and constant supervision, They are synonyms and mean always. Staff K stated the resident, needed constant 1:1 care and staffing was not enough to give 1:1 and still provide care to the rest of the residents. Another progress note on 01/23/2021 showed, Frequently attempts to get OOB (out of bed) or stand up from WC. Frequent visual checks before fall and 1:1 supervision post fall. A 01/24/2021 progress note showed, Frequent visual checks and 1:1 when possible. A 01/26/2021 progress note showed, Caught multiple times walking around in room or attempting to self-transfer. Constantly had to be reminded that staff needs to be there to assist in order to prevent falls . Stayed in room most of the shift under close supervision. A 01/29/2021 progress note showed, Pt continues to be impulsive w/ (with) poor gait/balance and safety awareness. 1:1 as able d/t (due to) high fall risk. A 01/27/2021 Falls CP continued to instruct staff to remind Resident #1 to use the call light, despite the facility identified the resident was inconsistent with its use. Also, the CP failed to show the increased supervision the staff identified Resident #1 required to prevent falls. In an interview on 02/23/2021 at 11:29 AM, Staff D acknowledged Resident #1's use of the call light was, Not consistent. When asked if 1:1 supervision was provided for Resident #1 at the time of the fall on 01/23/2021, Staff D stated, I'll look into that. When asked if walking away from the resident provided constant or 1:1 supervision, Staff I did not answer. When asked what kind of supervision was required to compensate for Resident #1's impulsivity and poor safety awareness and prevent falls, Staff D stated, Honestly, if I had my druthers and if we had enough staff, we would have had somebody constantly with her. The above findings were shared with Staff A (Administrator) and Staff B (Director of Nursing) on 02/25/2021 at 3:04 PM. When asked who was responsible for facilitating or providing an increased level of care, Staff B stated, Usually we are, but in this situation there was a family conference where we discussed the pattern of falls and so forth and a private care giver at one point for that resident, and that family declined that option. When asked if the facility provided 1:1 supervision for Resident #1, Staff B stated she would look for that information. Review of Staff Schedule Sheets provided by Staff B on 01/25/2021 at 4:37 PM showed that, between 01/17/2021 and 02/03/2021, the facility provided 1:1 supervision for three out of 33 shifts (01/30/2021 on Day Shift, 02/01/2021 for Evening Shift, and 02/03/2021 for Day Shift), even though staff continued to identify Resident #1's impulsivity and poor safety awareness, and a fracture. In an interview on 02/23/2021 at 4:15 PM, CC1 stated, They never talked to me about a 1:1. They never mentioned additional expenses for 1:1 care. They would not need to talk to me, the health care system should be sophisticated enough to manage her care. I would not expect them to call for my permission, they should do what the patient needs. Overall, I expect that they are the expert professionals and understand how to take care of someone after hip surgery with [MEDICAL CONDITION], and that they have the manpower to provide the care that is needed. I do not understand how it works, but they are the professionals. I only thought she had three falls. Seven falls is incomprehensible. RESIDENT #2 A 01/13/2021 Admission MDS showed Resident #2 was admitted on [DATE], assessed with [REDACTED]. The MDS showed the resident required assistance of one person for bed mobility, transfers, walking in the room, toileting and dressing, and experienced frequent bladder incontinence. Additionally, the MDS stated Resident #2 was, Not steady; only able to stabilize with human assistance, when moving from seated to standing position. A 01/13/2021 Care Area Assessment (CAA, a care summary) showed Resident #2 had dementia. The CAA stated that the Plan of Care included interventions to compensate for the resident's cognitive losses, ensure needs were met, and decrease the risk for injuries. A 01/19/2021 Falls CP instructed staff to, Anticipate ADLS (Activities of Daily Living) and other needs if appropriate before leaving patient's room, especially toileting needs, Encourage wear of nonskid footwear, Left knee immobilizer at all times, and Remind (the resident) to use the call light to get assistance with ambulation. Keep call light within reach and answer promptly. A 01/10/2021 Resident Information Sheet (RIS) showed Resident #2 was confused and a very high risk for falls. This RIS showed the resident was able to walk to the bathroom with the help of one person and a walker, was incontinent of bladder, and to Offer toileting upon waking up in the AM (morning), in between meals and HS (bedtime). Frequent visual check. Reorient pt (patient) to call light all throughout your shift. Progress notes dated 01/06/2021, the day of admission, showed Resident #1, attempted to get out of bed this evening shift . found resident in hallways and walking in to nursing station with walker and was (sic) only brief on . Resident can't wait for us and she said yes to wait for us then next found resident in bathroom, Up to bathroom at (4:30 AM). Did not use call light but staff heard motion, and (7:49PM) she has been getting up to the bathroom or walking out in the hallway independently for the most part. She is probably using the call light about 50% of the time . Resident up and walking around as usual . Resident time to time walk out of her room and walking in hallways and one time found walking with no walker . Medical provider notes dated 01/08/2021 showed Resident #2 was admitted to the facility for left hip prosthetic dislocation after a fall. The provider also noted the resident was an ongoing very high fall risk, had advanced dementia with very poor memory and insight, and at very high risk of recurrent left hip dislocation. Progress notes dated 01/08/2021 showed, Could be seen walking around in her room. Oriented to herself, slightly confused and needs frequent re-direction and re-assurance, . forgetful easily. Walking around in her room without walker or walk out to hallways without walker and or with walker. Restless noted. Resident redirected 1:1 (one on one) multiple times. Progress notes dated 01/09/2021 showed, Walked into hallway to ask staff for assistance, stating to LN (Licensed Nurse) that 'I was told to call if I needed assistance' and Resident made frequent trips from her room to the RN (Registered Nurse) seeking assistance instead of using the call light. Progress notes dated 01/10/2021 showed, Goes to the bathroom on her own . sign placed next to bed to remind resident to use call light when needing assistance. The medical record showed no progress notes between 01/16/2021 and 01/23/2021. FIRST FALL Progress notes dated 01/24/2021 showed Resident #2 was found on the floor in her room at 4:00 PM, Turning around to get into bed and the walker slipped away. Unwitnessed. Left elbow on the ground, her right hand on the bed. Root cause of this fall and care plan changes as indicated: was wearing a pair of sandals that prevent her from wearing nonskid socks and when she took the sandals off to get into bed she stumbled on them. Care plan was amended to place the blue sandals out of site (sic) and to ensure she is wearing her non-skid socks while out of bed, and Resident is not able to use call light effectively and benefits from frequent safety checks to ensure needs are being met. An Event Report, associated with a facility ID dated 01/26/2021, showed Staff E (RA) stated, At (3:30 PM), when (Resident #2) was walking in the hall, I approached her to get her order for dinner. In an interview on 01/29/2021 at 10:33 AM, Staff E stated, She walked out of her room and back in the room, and then tripped. She was wearing more of the flip flop (sandals). She had her own pair. I know she liked them. (Wore them) 25 to 50 percent of the time. Staff E stated that the sandals, may have contributed to it (the fall) along with the stiff leg and a leg brace. Another Event Report included with the 01/26/2021 ID showed Staff F (RA) observed Resident #2 walking in the hallway two hours before the fall, and then 15 minutes before the fall. In response to the question asked in the Event Report, Describe all care you provided to the resident in the 2 hours prior to the event, Staff F stated, My shift started at 2PM. I saw her walking around the hallway. My coworker saw her prior to her fall and asked her what she wanted for dinner, and Last time that she was checked around 1:00 PM by Day Shift. This staff stated in the Event Report, I saw a pair of blue sleepers (sic) and do not look very safe for her, the sleepers were by her side when she was found on the floor. I think that maybe was a huge factor. In an interview on 02/18/2021 at 6:30 AM, Staff F confirmed she was familiar with and assigned to Resident #2 on 01/24/2021. Staff F stated that the resident tended to gaze down often, was hard of hearing, did not follow directions, and was forgetful. Staff F identified the resident used the call light, here and there. When asked if Resident #2 wore a leg brace before the fall, Staff F stated, Good question, then stated the resident did wear a leg brace between 2:00 PM and 3:45 PM. When asked what cares she provided for the resident between 2:00 PM to 3:45 PM, Staff F stated, I was taking her vitals and put her back to bed at 2:00 PM. Staff F stated that Resident #2 walked mostly independent, except when she is sleepy, and that the resident took herself to the bathroom, and required help when her pants would get stuck in the leg brace. Staff F stated that the resident used sandals since she was admitted to the facility, primarily in the afternoon hours and that, We all knew, Resident #2 wore sandals. In an interview on 02/18/2021 at 7:15 AM, Staff G (RA) stated that he was familiar with Resident #2, and that the resident walked to the bathroom, and got in and out of bed by herself, contrary to the type of assistance the resident was assessed to require. Another Event Report included with the 01/26/2021 ID showed, Staff H (RN), stated he, heard something hit the wall or bump against something from the med cart and found (Resident #2) on the floor, that he last saw Resident #2 15 minutes before the fall walking in the hallway and then returned to her room, and did not provide any cares to the resident two hours prior to the incident. Staff H stated Resident #2 was wearing shoes that prevented her from putting on non-skid socks. This staff answered the care plan was not followed as, Resident was not wearing her leg brace when she got out of bed. In an interview on 01/19/2021 at 11:05 AM, Staff H identified Resident #2 was able to get up and out of bed, chair or toilet without assistance, contrary to the type of assistance the resident was assed to require. Staff H stated Resident #2 wore sandals since admission to the facility. Staff H stated that prior to the fall at 3:45 PM, he saw Resident #2 walking out of her room without the leg brace on, headed back to her room, wearing sandals, and no non-skid socks on, and that the leg brace was found on the resident's bed at the time of the fall. When asked what kind of foot wear Resident #2 should have been wearing, Staff H stated, To be honest, to my knowledge, I'm not sure anything specific. I don't remember any specifics in the Care Plan. After the fall we were more attentive to her wearing non-skid socks and avoiding the flip flop sandals. Staff H stated staff should have intervened, When we had seen her in the hallway walking. Escort her to the room to get her brace on. Staff H stated it was the nurse's responsibility to ensure the resident was wearing appropriate footwear. A 01/26/2021 ID showed actions to prevent reoccurrence included, Resident is not able to use the call light effectively and benefits from frequent safety checks to ensure that she is safe and her needs are being met. Review of the ID showed no documentation the facility addressed the staff's failure to provide the resident assistance when walking independently prior to the fall, or why the staff identified the resident as independent with transfers, toileting, and able to put on non-skid socks, contrary to being assessed to require assistance for all tasks. A CP attached to the 01/26/2021 ID continued to instruct staff to remind Resident #2 to use the call light to get assistance with ambulation, even though the staff identified the resident had impaired cognition, and did not use the call light consistently. Review of the CP and the RIS attached to the ID showed no documentation how staff provided frequent checks in order to anticipate the resident's needs. Review of a 01/10/2021 RIS showed the added instruction of, 1/29 Up with leg brace to be worn when out of bed, three weeks after admission, and 13 days after the fall. Review of a Fall Risk Factor Assessment with multiple dates, showed the facility did not include the risk factors of incorrect use of assistive device (leg brace) and poor footwear - barefoot until 02/08/2021. This failure placed Resident #2 at risk of not being assessed for additional interventions to prevent falls, like Frequent checks to identify patterns in resident movement or therapy services. In an interview on 02/19/2021 at 3:22 PM, Staff C (NC) stated, (Resident #2) should be wearing the non-skid socks not the flip flops, and acknowledged the sandals did not meet the definition of nonskid footwear. Staff C stated her expectation was for staff to identify the use of the sandals isn't right and keep the non-skid socks on. SECOND FALL Progress notes between 01/25/2021 and 01/29/2021 showed, staff identified Resident #2 continued to, Needs frequent reminders to use (walker). Will forget and walk into hall or room without (walker), ambulate herself around in her room and out to the hallways with walker or without walker, has been up walking around without issue, and does not use the call light appropriately and benefits from frequent reminders to wear leg braces and socks The medical records showed no progress notes between 02/01/2021 and 02/07/2021. A 02/08/2021 progress note showed Resident #2 was found lying on her back in her room at 07:35 AM, and that the resident stated she fell because of, Walking to the bathroom, and stated trip (sic) on leg brace. Review of a 02/10/2021 ID showed Resident #2 had a fall with injury on 02/08/2021 at 7:35 AM. This document showed, Two nurses were just outside her room and heard a 'cluck' sound. They went immediately to the room and found the resident laying on her back, just outside the bathroom door. The resident said, 'I tripped'. This document showed the root cause of the event was,as resident stated, 'I tripped on the carpet coming out of the bathroom.' Review of a Point of Care History Report showed no toileting assistance was offered to Resident #2 between 6:00 AM and 7:30 AM on 02/08/2021. In an interview on 02/18/2021 at 6:30 AM, Staff F stated she did not ask or offer Resident #2 assistance with toileting when she took the resident's vital signs at 7:30 AM because, if the resident needed to use the bathroom, She would have said something. If (Resident #2) really needs help, she would yell. Review of hospital notes dated 02/08/2021 showed Resident #2 sustained a fracture and traumatic hematoma (bleeding outside of the blood vessels) of the left elbow, laceration of the left upper extremity, and neck muscle strain. A 02/11/2021 RIS showed, Encourage resident to call for assist using bathroom call light, when finished using the bathroom. The comprehensive CP continued to show the instruction to remind Resident #2 to use the call light, despite the resident's impaired cognition and inconsistent use of the call light. In an interview on 02/19/201 at 3:22 PM, when asked if it was a realistic or appropriate intervention for staff to remind Resident #2, who was cognitively impaired and lacked safety awareness, to use the call light to get assistance with ambulation, Staff C stated, Probably not. When asked if the facility determined how frequently Resident #2 was to be checked by staff, Staff C stated, I don't think they ever found a pattern. We knew she was a fall risk coming out of Assisted Living. Staff's sustained perception that Resident #2 was able to walk and toilet herself independently, and failure to intervene when the resident walked without assistance, appropriate footwear or the leg brace, placed the resident at risk for falls, with an eventual traumatic fall on 02/08/2021. The above findings were shared with Staff A, Administrator, and Staff B, Director of Nursing, on 02/24/2021 at 3:00 PM. No further information was provided. REFERENCE: WAC 388-97-1060(3)(g). <b (TRUNCATED)

Based on observation, interview and record review, the facility failed to prevent a pattern of resident to resident altercations for two (#3 and #4) of ten sample residents, which included Resident #1 slapping and grabbing Resident #2's arm causing a skin tear, yelling at Resident #3 and #4, and shoving a walker toward Resident #4, a resident who was seated, and Resident #3, an ambulatory resident. In addition, the facility failed to identify, protect, assess, report, and prevent a pattern of aggressive acts toward fell ow residents on seven occasions, 04/06/2020, 04/07/2020, 04/11/2020, 05/04/2020, 05/10/2020, 05/22/2020, and 06/07/2020. The facility failed to recognize these incidents as abuse, analyze the circumstances of these abusive behaviors, or implement plans for prevention or recurrence. Failure to recognize and analyze multiple incidents of resident to resident altercations and provide adequate supervision and care planning with interventions, placed residents who lived in the area at risk of serious injury or harm, including continued abuse. This failure resulted in an Immediate Jeopardy (IJ) related to abuse on 06/23/2020. The facility reassessed Resident #1, provided a 1:1 care giver and trained staff regarding recognizing and reporting resident to resident altercations and abuse, which led to the removal of the IJ on 07/13/2020. Refer to CFR 483.21, F 657; Care Plan Timing and Revision 483.12, F 609; Reporting of Alleged Violations 483.25, F 689; Free of Accidents Hazards/Supervision 483.75, F 867; QAPI/QAA Improvement Activities Findings included . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including a stroke and depression. A 07/09/2018 Pre-admission Screening and Resident Review (PASRR - a mental health assessment) showed Resident #1 did not speak English and had limited communication, and impaired cognition. A 05/25/2020 Care Area Assessment (CAA - an assessment summary) showed, . dementia is a contributing factor. Per note review, impaired recent memory, impaired recall judgment. This summary also showed, Resident is ambulatory with FWW (front-wheeled walker) from room to dining room with staff supervision. In an interview on 06/18/2020 at 11:47 AM, when asked about Resident #1's mood and behavior, Staff M, Resident Assistant (RA) stated, (Resident #1) has a specific chair which is meant for him and he wants no one, and if he finds someone sitting on it he fight. I heard he was fighting one of the residents because of the chair in the dining room. Staff M identified Resident #4 as a resident who sat in Resident #1's preferred chair and, (Resident #4) goes to his chair often. She always because she doesn't know, but we redirect her. (Resident #1) tries to talk to them in his language. His voice is loud. When asked how other residents reacted to Resident #1's loud voice, Staff M stated, They are scared. When asked how often Resident #1 became loud, Staff M stated the incidents occurred when other residents sat in Resident #1's preferred chair. Review of a 01/26/2019 progress note showed, (Resident #1) was witnessed slapping at (Resident #2) when she was sitting in what (Resident #1) believed to be his usual chair . sitting on his walker and would not back away. Attempted to move his walker with him out of the way of (Resident #2). (Resident #1) would not budge, reached around me and grabbed (Resident #2's) upper R (right) arm tightly with one hand. I grabbed his hand to try to remove it and he released it and grabbed (Resident #2) R (right) forearm with both hands, I had to pry his hands from her arm, loudly yelling for him to stop and let go. (Resident #2) cried out, 'That really hurts; you'll break my arm!' Was able to pry arm away and assisted (Resident #2) out of seat to a seat on the other side of DR (Dining Room). Law enforcement contacted and spoke with (Resident #1). He denied harm to other resident and said (through translation) that he didn't want anyone to sit in his chair and become sick like him. He stated he had asked (Resident #2) to move and she had not. Agreed not to harm others. Review of a 01/30/2019 Investigative Report (IR) showed, due to dialect and dementia issues staff have found the on-line 'In-Demand' translator service of minimal value with (Resident #1) as translators rarely understand him .he tried to get (Resident #2) out of his chair and being unable to communicate resorted to trying to physically pull her up. This caused minor arm injury to (Resident #2) . Even though police were involved, staff do not believe given (Resident #1's) level of dementia, we do not think their presence or reminders about this would serve as any deterrent for him . Family explained there may be a cultural component in addition to obvious communication problem. (Resident #1's) family says he considers the chair contaminated with his 'germs' and not safe for other people to sit in. This sounds like a rationalization to us but we do lack familiarity with his culture . All 3 North staff including support staff, have been advised of the situation and are attempting to discourage any other residents from sitting in 'his chair'. We are also keeping (Resident #2) away from him.I have asked staff to obtain an order for [REDACTED]. This IR showed Resident #2 sustained a 1.5 inch skin tear to the right forearm. Review of a 10/24/18 Baseline CP included with the 01/30/2019 IR showed Resident #1, Does not follow directions .Disoriented to situation and time, confused and forgetful and He would get upset with someone sitting in recliner chair. Make sure no other resident will sit there to prevent altercation 01/26/19. Review of a comprehensive CP plan showed a Behavior CP, original date of 01/23/19, and no interventions that directed staff on how to monitor Resident #1 to prevent another resident to resident altercation. In an interview on 06/23/2020 at 8:42 AM, when asked if the CP showed how staff would make sure other residents would not sit in Resident #1's preferred chair, Staff D, Neighborhood Coordinator (NC), stated, Well it should say 'Redirect them away.' Everyone knows his routine. It would be mainly redirecting other residents and looking for obstacles in his pathway. When asked if the investigation showed the facility followed up to ensure staff familiarity with (Resident #1's) culture, Staff D stated, I'm afraid not. Included in the 01/30/2019 IR was a form titled, Event Report and dated [DATE]. This form asked for a brief description of the event, and event-specific questions like what was seen or heard prior to the event, what the resident was doing prior to the event, if anyone else was present, what the resident said about the event, what the staff thinks caused the event, and if the staff had any important information to tell about the event. This form showed a housekeeper and a Primary Nurse (PN) for 3 North were present during the resident to resident altercation. In addition, this form showed the staff's answer to, What do you think caused this event? was, Staff can't communicate with (Resident #1). Don't speak (unintelligible writing followed). The IR did not show documentation the facility interviewed the second eye witness identified, the 3 North PN, beyond the progress note written on 01/26/2019. In this continued interview, when asked when the Event Report was used, Staff D stated, I often edit them myself. It's a general (facility) form when an incident occurs. It's the standard form used to collect staff statements and information which can sometimes collect data or context we didn't know about. When asked if the investigation included all possible witness statements that could provide information to help prevent recurrence of altercations, Staff D acknowledged the investigation did not include the second eye witness' Event Report and stated, Yes, it should be included and a good attempt to get as many as possible. Review of a 05/20/2019 progress note showed, As told to me by RA (Resident Assistant) who was there: This resident (Resident #1) was walking towards his room in the hallway. Another resident (Resident #3) was also walking with a RA from the opposite direction. (Resident #1) was heard by (Resident #3) to be muttering something in his own language as they came close to each other. (Resident #3) came forward to inquire what the other had said. Instead of replying, (Resident #1) shoved his walker towards (Resident #2), who didn't get hit by the walker because RA stopped it in time. (Resident #3) immediately extended her hand/fist up, about to slap/punch (Resident #1) and this again was stopped by the RA with her arm. Both were separated and instructed to go and stay in their rooms. A 05/22/2019 IR showed, Staff are now aware that when they are present with (Resident #3) it is important to make sure she is not crowded by other residents. The same will be added for (Resident #1). He cannot use speech to express frustrations and when he is moving he is impulsive. He should be monitored to assure a clear pathway. He does however move independently and staff may not be present. The care plans for both residents have been edited to add this approach. This IR did not show the facility included witness statements or Event Reports. No updated CPs for Resident #1 were included with the 05/22/2019 IR. Review of Resident #1's comprehensive Behavior CP, while it showed an effective date of 05/23/19, did not show additional interventions between 02/01/19 and 06/14/2020, including when and how to provide supervision or monitoring to prevent further resident to resident altercations. In this continued interview on 06/23/2020, when asked if the record showed if and how staff supervised Resident #1, Staff D stated, Frequent visual checks. The staff know they required supervision. When asked if the record showed the facility reviewed, developed and implemented interventions to prevent future altercations or abuse between Resident #1 and other residents after the 05/20/2019 resident to resident altercation, Staff D stated, The staff were all made aware we all need to keep an eye on him. Educating the staff and everyone being aware of the conflict that occurred and making sure they keep visual contact with him. No further information was provided. When asked what became of the Mental Health referral mentioned in the 01/26/2019 IR, Staff D stated, I don't honestly remember. When asked if this IR ruled out if abusive behavior occurred, Staff D stated, I don't think it ruled it out. I think the behavior was abusive. Review of Resident #3's 05/23/2019 CP included with the IR showed, Redirect other residents if she or they block each other's pathway to reduce conflict, Walks with either supervision, or independently, and Monitor to avoid personal space violations. In this continued interview, when asked if the record showed how staff monitored Resident #3 in order to prevent another resident to resident altercation, Staff D stated, I am sure of that. No further information was provided. Review of a progress note dated 09/12/2019 and timed at 6:38 AM showed, (Resident #1) placed on alert for altercation with another resident, (Resident #3). (Resident #3) was in recliner chair in DR that resident has identified as belonging to him; this is the regular chair that he sits in when in DR. Both residents with dementia and difficulty communicating needs. (Resident #1) is Cantonese speaking. He approached chair with (Resident #3) in it during report. Staff heard yelling and were able to intervene prior to physical contact. Removed (Resident #3) to another chair. An IR dated 09/20/2019, eight days after the resident to resident altercation occurred, showed (Resident #1) reacts with hostility if other residents block his pathway and he also believes the black leather easy chair, which he loves, actually belongs to him. He gets in it very early in the morning and prefers to rest there most of the day, frequently walking independently to his room to use the toilet or lay down for a while, and while (Resident #3) strongly prefers using the brown leather easy chair, on occasion she uses the black one. This had occurred resulting in conflict with (Resident #1) several months ago. Review of the IR showed no witness statements or Event Reports were included. In this continued interview, when asked if the 09/20/2019 IR showed the facility re-evaluated the effectiveness of how staff monitored or supervised Resident #1, Staff D stated Well, obviously it happened again. I would think so. I can't say that's the case. I don't think we are there yet. I don't know if there was an assessment of the problem other than what is in the nursing notes for behaviors. When asked if the CP or the IR included interventions that showed how staff supervised Resident #1 differently after the third resident to resident altercation, Staff D stated, I think I am still working on that one. I don't think that is closed yet. When asked if the IR ruled out abuse, Staff D stated, No. When asked if the 09/20/2019 IR showed a root-cause-analysis, to include review of witness statements, Event Reports, and trending of incidents, Staff D stated, I don't know. When asked if the facility followed-up or reconsidered mental health services for Resident #1, Staff D stated, We did just reconsider. I will talk to the nurse practitioner again. It's not that it's not a problem. He didn't harm anybody. We are still working on that one. When asked if waiting 18 months was an acceptable timeframe for follow-up on mental health services after repeated resident to resident altercations, Staff D stated, Maybe not. Review of Resident #1's April 2020 Medication Administration Record [REDACTED]. Aggressive acts towards fell ow residents, and instructed staff that if these (behaviors) occur, notify PN (Primary Nurse) or NC at or before shift exchange. Notification = Intervention: Y or NA (Not Applicable). Review of this MAR indicated [REDACTED]. An I was marked as the intervention on 04/07/2020. Review of 04/06/2020, 04/07/2020 and 04/11/2020 progress notes did not show documentation of the identified aggressive acts towards fell ow residents, any indication who Resident #1 was aggressive towards, what staff did to protect the resident(s), or how interventions changed to prevent recurrence of aggression. Review of the facility incident log showed no documentation the 04/06/2020, 04/07/2020 and 04/11/2020 incidents of resident to resident aggression were investigated by the facility to rule out abuse and prevent recurrence of aggressive acts towards fell ow residents, or reported to the State Agency (SA). In this continued interview on 06/23/2020, when asked if aggressive acts towards fell ow residents is considered a resident to resident altercation and reportable to the SA, Staff D stated, Three episodes . I was not the one informed in any of those. When asked if aggressive acts towards fell ow residents warranted an assessment or follow-up of the identified behavior, Staff D stated, I would have hoped. There's no notes. They didn't back it up. I don't think they told me about it. When asked if he expected follow-up notes to clarify the aggressive acts, Staff D stated, There should have been some explanation. I don't remember hearing about it. When asked if the progress notes between 04/06/2020 and 05/11/2020 showed how interventions changed to prevent recurrences of resident to resident altercations or aggression between Resident #1 and other residents, Staff D stated, I don't think so because if I didn't hear about it there wouldn't be a change. When asked if the record showed staff supervised or monitored Resident #1 to prevent resident to resident altercations, Staff D stated, These three incidents, I have to definitely say no. Review of a progress note dated 05/10/2020 and timed at 9:37 PM showed, (Resident #1) showed hostile reaction when the dining chair where he usually sat on was taken. He mumbled something in a loud demanding voice and was pointing simultaneously at the resident sitting nearby. RN was immediately alerted that he might be referring to the chair, so another chair was promptly pulled up for him to sit. This was resolved without any incident. Review of the facility reporting log did not show the 05/10/2020 incident was followed-up by the facility to rule out abuse, evaluated to prevent recurrence of resident to resident altercations or abusive behaviors, or reported to the SA. In this continued interview on 06/23/2020, when asked if the 05/10/2020 progress note showed who Resident #1 was hostile towards, or if staff assessed the other resident to rule out abuse, Staff D stated the progress notes did not identify who the other resident was and, I don't think a Datix (incident report) report was filed. No further information was provided. A May 2020 MAR indicated [REDACTED]. aggressive acts towards fell ow residents, and instructed staff that if these occur, notify PN or NC at or before shift exchange. Notification = Intervention: Y or NA. In addition, this MAR indicated [REDACTED]. Review of 05/04/2020 progress notes did not show documentation of the identified aggressive acts towards fell ow residents, what staff did to protect the resident(s) involved at the time of the incident, or how interventions changed to prevent recurrence of aggression. Review of the 05/22/2020 progress notes showed, However, prior to dinner, (Resident #1) had one brief episode of aggressive behavior concerning the chair placed at his usual spot but occupied by a female resident. He was demanding for dinner, speaking in his native Chinese language. All 3 staff were able to alleviate his anger. Review of 05/22/2020 progress notes did not show the facility followed-up to evaluate Resident #1's aggressive behavior, what staff did to protect the female resident involved at the time of the incident, or how interventions changed to prevent recurrence of aggression. Review of the facility incident log showed no documentation the 05/04/2020 and 05/22/2020 incidents of resident to resident aggression were investigated by the facility to rule out abuse and prevent recurrence of aggressive acts towards fell ow residents, or reported to the State Agency (SA). In this continued interview on 06/23/2020, when asked if he was aware of the aggressive acts towards other residents identified by staff in the May 2020 MAR, Staff D stated, Evening shift has more of a problem. Why I don't recall any of these two . When asked if he expected an investigation of aggressive acts, Staff D acknowledged they should be investigated and stated, You do a Datix (incident report), and I would have asked for more specifics (like) who was involved and what exactly happened in detail, and make a decision as to if we need to do an incident report or not. This not that thorough, and I wish she had given more detail in the progress note. It would have been nice. Review of progress notes and the comprehensive CP between 05/22/2020 and 06/07/2020 did not show documentation staff evaluated or modified interventions to prevent recurrences of resident to resident altercations or abusive behaviors between Resident #1 and other residents. A progress note dated 06/07/2020 and timed at 9:25 PM showed, Had been contended (sic) sitting on his usual seat but his behavior changed today when he thought someone would be sitting next to him. He uttered in a loud angry voice, shoved his 4-wheeled walker towards the seat, and jerked it away from him. The other resident was moved away from him. Review of the facility incident log showed no documentation the 06/07/2020 incident was investigated by the facility to rule out abuse and prevent recurrence of resident to resident altercation, or reported to the SA. In this continued interview on 06/23/2020, when asked if the facility evaluated what uttered in a loud angry voice, shoved, or jerked away from him mean, Staff D stated, I can't tell you. Not a lot of detail here. I don't know if the other resident was aware or upset by it. Not enough detail, no. It is pretty bad English. It's not a wildly clear progress note of the incident. I don't know what they meant by that. Review of Resident #1's 05/23/19 CP and progress notes between 06/07/2020 and 06/14/2020 did not show documentation staff evaluated or modified interventions to prevent recurrences of resident to resident altercation between Resident #1 and other residents. Review of 06/15/2020 progress notes showed, (Resident #1) is placed on alert charting for recent resident to resident altercation that happened earlier today at 2:10 PM; while this LN was carrying out doctor's orders in the nurses station, this LN heard a loud noise in the dining room area and saw (Resident #1) yelling at another resident (Resident #4) who was sitting in his chair (FYI: (Resident #1) does (sic) like anybody else sitting in his chair); (Resident #1) was also pushing the chair where (Resident #4) was sitting with his FWW; (Resident #4) was not hit physically but she was upset; this LN ran to the incident area right away, separated (Resident #1) and (Resident #4) right away, and made sure they were both safe, and provided emotional support; this LN called provider for above both residents and notified with above info; NC was also notified, SW (Social Worker) was attending the 3N shift change meeting on this date when there was a commotion from the dining area. (Resident #1) came out of his room and went to the chair/table where he always sits. He became upset when he found another resident in his chair. He began yelling in Cantonese and pushing his walker into the chair. He never removed his hands from the walker handles, but continued to shout and push the chair until the other resident removed herself. (Resident #4) became upset, crying and unsure of what she did wrong, I have spoken to (POA) to report the emotional upset suffered by (Resident #4), after being yelled at by another resident . She was not harmed physically at all but was emotionally upset so I directed the (SW) to file an online mandated reporter report to (the SA), and (Resident #4) continued to be in tears and stated that she didn't want to be near the guy and didn't do anything wrong. She was in this condition for approximately 2 hours until she was taken for a walk by the activity coordinator. Review of the 06/19/2020 IR showed, Activity Director had made laminated signs with their (Resident #1 and #4) names on it for their chairs. It is too early to tell if either resident is aware or cares, but it is helping remind staff. Care plans for both residents updated. An observation on 06/18/2020 at 11:46 AM showed Resident #1 in the DR seated in a stationery chair against the wall. Above the chair was an 8 ½ by 11 inches laminated sign with the words, (Resident #1's name) chair. In an interview on 06/18/2020 at 12:00 PM, when asked about the presence of the laminated sign above Resident #1's preferred chair, Staff O, Licensed Practical Nurse (LPN), stated, I'm not really sure how long it's really been there. When asked what interventions were in place to prevent resident to resident altercations, Staff O stated, New intervention is to redirect residents. Staff O did not indicate the laminated sign was a new intervention to deter resident to resident altercations. In an interview on 06/18/2020 at 12:15 PM, when asked if Resident #1 had any behavior issues, Staff R (RA) stated, Yes if he doesn't like it he doesn't like it, because he doesn't understand most English, so I use phone to translate. One time I noticed agitated but when it happened I am not here it was with (Resident #4), and this is now his second time. The same thing, it's the chair. We tried to write (Resident #4's) chair but it don't work, she sits everywhere. But that only chair is (Resident #1's) chair. He is very particular. When asked about the laminated sign above Resident #1's preferred chair, Staff R stated, It doesn't make sense because (Resident #4) doesn't know. (Resident #1) only wants that chair. It's not going to be effective. Staff R did not show an understanding of the laminated sign's purpose, which was to remind staff to redirect residents away from Resident #1's preferred chair. In an interview on 06/18/2020 at 12:15 PM, when asked about the laminated sign above Resident #1's preferred chair and how long the laminated sign had been in use, Staff N (RA) stated, I did not notice he has a sign posted on wall. Staff N stated the intent of the laminated sign was, For staff to know it is the (Resident #1's) chair. In an interview on 06/22/2020 at 10:38 AM, when asked about the laminated sign above Resident #1's preferred chair, Staff P, Registered Nurse (RN), stated, Oh, is it behind? I didn't even see that. When asked what the purpose of the laminated sign was, Staff P stated, To help (Resident #1) feel comfortable. When asked if this was the first time she recognized the laminated sign, Staff R stated, Yes. The above findings were discussed with Staff D in the continued interview of 06/23/2020. When asked what the purpose of the laminated sign was, Staff D stated, How they could not see it (the sign)? It's been there for a week. Slightly a little more than a week. Most people know. It's to communicate mainly to staff to remind them this is (Resident #1's) chair and not to have anyone siting on it. It's for the staff. Staff D acknowledged the staff's knowledge deficit of the laminated sign above Resident #1's preferred chair detracted from effective and consistent implementation to redirect residents away from Resident #1's chair. Review of the 06/19/2020 IR showed, We considered a (local hospital) Mental Health Team referral but decided not to pursue this as [MEDICAL CONDITION] medications are not appropriate for this level of behavior. I did ask one of my Evening shift nurses to speak to him regularly. This is to encourage him to tell us when he is upset or frustrated, help his mood and ask him not to yell at other residents. In this continued interview, when asked if the intervention to request from Resident #1 not to yell at other residents was a realistic expectation for a cognitively impaired and impulsive resident, Staff D stated, Well not completely. When asked if mental health team recommendations were limited to the use of [MEDICAL CONDITION] medications, Staff D stated, They do provide practical care approaches. When asked if the facility re-addressed a mental health team referral after the 05/20/2019 and 09/12/2019 resident to resident altercations, which by then the facility had identified instances of slapping, grabbing/pulling residents by their arm, shoving walker at seated or ambulatory residents and yelling, Staff D stated, Will get notes. No further information was provided. Review of Resident #1's June 2020 MAR indicated [REDACTED]. In this continued interview with Staff D, when asked why non-pharmacological approaches were developed in June 2020, instead of May 2019 when the second resident to resident altercation occurred, Staff D stated, In hindsight, sure. Why didn't we do this six or nine months ago? We are trying to come up with new and different things. We just didn't make that one. It's a good one to make. Review of a 06/19/2020 IR showed, Resident #4 sat in (Resident #1's) chair while he was briefly away. He returned, saw (Resident #4) in his chair, got upset and yelled at her . This IR did not show documentation the facility evaluated how long Resident #4 had been sitting in Resident #1's preferred chair, how briefly Resident #1 had been away from his preferred chair, or accounted for Resident #1's or staff's whereabouts prior to the altercation. In addition, this IR did not include a statement of the assigned primary aide for Resident #1, or analyzed how Resident #1 walked into the DR towards his chair when he was supposed to be supervised. In this continued interview, when asked when the last time Resident #1 was seen prior to the altercation of 06/15/2020, Staff D stated, We don't show that in the record. We don't track people's physical whereabouts throughout the day. We just know he is either in his room or in his chair. We don't track where he spends his time. When asked if the IR showed where staff were when the resident to resident altercation occurred, Staff D stated, (The SW and Nurse) were both in the dining room. I asked them both (the nurse and SW) to write progress notes to which they did, so that is their witness statement. When asked if obtaining a statement from Resident #1's assigned aide, and establishing the aide's whereabouts prior to the altercation, would help determine how the interventions to supervise or monitor Resident #1 failed, Staff D answered, It would play an important role. In this continued interview, when asked if the 06/19/2020 IR showed the staff supervised Resident #1, Staff D stated, They were nearby. When asked how did nearby staff supervise Resident #1, when the resident managed to enter the DR, walk towards his preferred chair, and engage in an altercation with Resident #4, Staff D stated, No, he was not directly eyeballed or supervised when he came out of his room. When asked if the staff present in the DR intervened to prevent the resident to resident altercation, Staff D stated, No. She (SW) was talking to someone else, and (Nurse) was at the med (medication) cart. Staff D acknowledged staff did not supervise Resident #1, which allowed the resident to be unaccounted for an undetermined period of time prior and leading up to the resident to resident altercation. When asked how did interventions change after the 06/15/2020 altercation, Staff D stated, Get more family visits. More phone visits. More positive impact on mood. When asked how those interventions provided supervision for Resident #1, Staff D stated, The nurse reminds the aides to keep an eye aware of his presence. When asked if that was any different from monitoring or supervising the resident for the past 18 months, Staff D stated, Well, no, not necessarily. Everybody keeps an eye on him. When asked if the facility evaluated why the supervision or monitoring failed after repeated acts of aggression or resident to resident altercations, Staff D stated, No. When asked if the facility analyzed when the altercations occurred, adjusted interventions accordingly, and implemented those interventions to prevent additional altercations including abuse, Staff D stated, One hole in the program is we have the behavior monitor but we don't print them out to analyze them, which might be a good idea before you find it. Documentation was present but not analyzed. The above findings were shared with Staff A (Administrator) and Staff C (Risk Management) on 06/23/2020 at 12:04 PM in a joint interview. Staff A identified Staff C as the Abuse Coordinator and the staff responsible for incident management in the facility. When asked how recurrence of resident to resident altercations were addressed by the facility, Staff C stated, You're gonna' look at what was your interventions. When the second episode happens (TRUNCATED)

Based on interview and record review, the facility failed to ensure an environment that was free from accidents for four (#5, #8, #9 and #38) of seven sample residents reviewed for accidents. The facility failed to implement preventative interventions to prevent further falls for Resident#5, #8, #9 and #38. This failure resulted in harm when Resident #8, #9 and #38, fell and sustained [MEDICAL CONDITION] requiring surgical procedures to repair [MEDICAL CONDITION], resulting in death. Additionally, this failure placed Resident #5 at risk for recurrent falls and serious harm. Findings include: FACILITY'S FALL POLICY Review of the facility's policy for fall prevention, revised on ,[DATE], read in part: Interventions after fall 4. Residents are re-assessed quarterly, with a change in condition that affects fall risk factors or when the root cause of a new fall is due to a previously unidentified risk factors for that resident. Care plan revisions are added or discontinued in response to changes in risk factor. Post fall care planning 2. Care plan changes are made in accordance with the findings of the root cause analysis. RESIDENT #8 According to the annual Minimum Data Set (MDS) assessment, dated [DATE], Resident #8 was initially admitted to the facility on [DATE] with medically disabling conditions including altered mental status, history of falls and vision impairment. This MDS identified the resident had severely impaired cognition and required physical assistance of staff for all Activities of Daily Living (ADLs), including mobility and transfers. Review of MDS assessments since Resident #8 admitted to the facility dated [DATE], [DATE], [DATE] and [DATE], consistently showed the resident required extensive physical assistance of staff for transfers and toileting. Review of Resident #8's comprehensive Care Plan (CP) and the resident information sheet dated [DATE], which was printed on [DATE] showed transfers: (Independent to extensive assistance with Front Wheeled walker (FWW)), inconsistent with MDS assessments which identified Resident #8 as requiring one person physical assistance with transfers and toileting. The CP did not reflect the actual care level the resident required based on assessed care needs. FALL #1 Review of progress notes dated [DATE], showed Resident #8 had an unwitnessed fall in her room at 8:00 AM. According to the progress notes, when asked, the resident stated, she stood up after using the bedside commode, lost balance and fell . Further review of the progress notes showed, the cause of the fall was due to the resident forgot to use the call light for assistance before transfer to the commode. The plan to prevent further accidents included to remind the resident to use the call light for assistance with transfers. Review of Resident #8's medical record did not show the facility completed a thorough investigation to determine the root cause of the fall and implement revised preventative measures to prevent further falls. On [DATE] at 12:30 in interview, when Staff S, a licensed nurse was asked, who determined the level of assistance the resident required for transfer and toileting? Staff S said It was the direct care givers, Resident Aides (RA). Staff S was then asked if the RA had expertise and were expected to make clinical judgements related to level of care required to transfer or toilet a resident. Staff S did not answer. On [DATE] at 12:30 PM Staff S, was asked, if she coordinated with the nurse who completed MDS assessments before developing a CP for Resident #8 in order to implement an interdisciplinary resident centered care plan, Staff S said No. when Staff S was asked what resources she utilized to develop the resident's care plan for toileting and transfers in order to prevent accidents for Resident #8 who admitted with a history of falls, Staff S said she consulted with the nurse's aides who provided direct care for the resident and understood the level of care the resident required, inconsistent with the facility's CP policy and procedure and professional standards of practice which required a licensed nurse to conduct assessments. Review of progress notes dated [DATE] showed the resident forgot to use the call light to ask for assistance when she attempted to self-transfer after using the bedside commode, lost balance and fell . The fall was unwitnessed, and the resident did not sustain any injuries. In a joint interview on [DATE] at 12:00 PM, with Staff A, the administrator and Staff B, the Director of Nursing Services (DNS), and Staff L, the Neighborhood coordinator was asked to provide a completed investigation for the fall incident dated [DATE], Staff L was unable to provide. Additionally Staff L was asked, what interventions were put in place to prevent further falls, Staff L did not respond. FALL #2 According to progress notes dated [DATE], Resident #8 was transferred to a different unit as a precaution to prevent the spread of COVID-19, as her roommate tested positive for COVID-19. Review of progress notes dated [DATE], showed Resident #8 had an unwitnessed fall in her room at 11:10 AM (2 days after moving to a different room). When the resident was asked, she said she attempted to get a bowl of water to brush her teeth, lost balance and fell . According to progress notes dated [DATE], the cause of the fall was due to the resident's impaired cognition, impatience, impulsivity and new care givers still learning the resident's routine. Review of the facility's Incident Log (IL) for [DATE], found the facility did not log Resident #8's fall incident on [DATE], and the facility could not provide evidence of investigation of incident. On [DATE] at 11:30 AM, when Staff L was asked if the fall incident dated [DATE] was investigated in order to prevent further accidents for Resident #8, Staff L, said No and did not provide the incident investigation, but later provided written notes of the incident. The written notes were dated [DATE] (the date of the interview [DATE]). Review of the Care Area Assessments (CAA's) dated [DATE], with a look back period of seven days, showed Resident #8 had a significant decline in cognition from moderate impaired cognition to severely impaired cognition, declining Brief Interview for Mental Status (BIMs) score, from 12 out of fifteen (,[DATE]) to six out of fifteen (,[DATE]), indicating a significant decline in mental cognition. Review of the CP, did not show the staff revised Resident #8's plan of care to compensate for the resident's impulsivity and severely impaired cognition to prevent further falls for the resident. Additionally, this care plan did not include specific revised interventions to instruct staff, how often staff were to check on the resident and ensure the resident's toileting needs were met based on the resident's assessed care needs, which included the resident's poor safety awareness, impulsivity and inability to use the call light for assistance. FALL #3 Review of the Incident Investigation Report (IIR) dated [DATE], showed Resident #8 again, experienced a fall in her room as she attempted to self-transfer to use the bedside commode for toileting. According to progress notes dated [DATE], the resident sustained [REDACTED]. Review of progress notes dated [DATE] showed, the resident was transferred to the hospital for further evaluation. Review of the facility's IIR summary dated [DATE], showed Resident #8 sustained a left [MEDICAL CONDITION] and underwent a failed surgical procedure to fix the left hip, and later passed away on [DATE]. Review of Resident #8's death certificate dated [DATE], indicated the resident's immediate cause of death was the left femur fracture as a consequence of [MEDICATION NAME] force injury to the left hip related to the fall incident on [DATE]. In spite of staff's awareness of Resident #8's decline in cognition, and forgetfulness to use call light for assistance, unsteady gait and a history of falls, there were no specific preventative measures to address the resident's toileting care needs to prevent further falls. Further review of the IIR showed the root cause of the fall was due to the resident's poor self-awareness, not using the call light for assistance. In interview, on [DATE] at 12 pm, Staff L and Staff B the Director of Nursing Services (DNS) acknowledged and stated,staff should have revised the care plan with interventions to prevent further falls. The failure to revise preventative measures to address the resident's toileting/transfer care needs based on identified assessed needs, precluded the staff from ensuring the resident's care needs were met, resulting in the resident's subsequent fall and [MEDICAL CONDITION] hip while attempting multiple times to self-transfer to use a bedside commode. RESIDENT #9 According to the annual MDS, dated [DATE], Resident #9 admitted to the facility on [DATE] with medically disabling conditions that including altered mental status and Dementia complicated by depression with behavioral disturbance. This MDS identified the resident had severely impaired cognition and required physical assistance of staff for all Activities of Daily Living (ADLs), including mobility, transfers and toileting. FALL #1 Review of the Incident Investigation Report (IIR) dated [DATE] showed Resident #9 had a witnessed fall near the breakfast bar at 4:15 AM. According to the IIR, the resident was observed parking her Front Wheeled Walker (FWW) at the phone column across from the breakfast bar, and ambulated without a walker to the breakfast bar when she lost balance and fell . The resident did not sustain any injuries. Further review of the IIR dated [DATE] showed the root cause of the resident's fall, was due to walking without a walker, cognitive deficits leading to poor safety judgement by underestimating where she leaves the walker and to the chair. Review of Resident #9's care plan did not show staff revised Resident #9's CP at the end of the two shifts following the resident's fall as stated in the facility's fall policy for accident prevention to address a new fall's unidentified risk factor. On [DATE] at 11:30 AM, Staff F, the unit neighborhood Co-coordinator, was asked how staff insured the resident's safety after the Resident #9's fall incident on [DATE]. Staff L said staff were instructed to check on the resident frequently to ensure she does not fall. Review of Resident #9's CP did not include care instructions for staff to check on the resident frequently, as stated in the IIR Action /Plan for prevention of Recurrence. When asked, Staff L was unable to explain how frequently staff were to check on the resident. Staff L acknowledged there were no revised implemented preventative interventions to prevent fall recurrences for Resident #9, and stated the CP should have been revised to reflect accident preventative measures to prevent further falls. FALL #2 Review of the IIR dated [DATE] at 4:00 AM, showed Resident #9 had an unwitnessed fall in her room at 4:00 AM, and was found sitting on the floor by Staff J. Further review of the IIR showed that Resident #9 was last seen at 2:30 AM, when she was observed continuously/repeatedly changing her socks. When the resident was asked, she was unable to state what caused her to fall. Review of the IIR root cause analysis showed, the cause of the fall was due to Resident #9's attempt to sit on her recliner but was too far forward on the seat, and as she sat, she slid right off in front of recliner. The resident underestimated the distance of her standing and her recliner due to cognitive impairment. Review of the IIR preventative plan dated [DATE] indicated no revised fall preventative interventions to prevent falls. The action/plan prevention recurrence of falls showed staff were to continue to perform more visual checks and keep the FWW at the resident's side. Despite the staff's awareness of the resident's cognitive impairment, forgetfulness to use the walker for ambulation and poor safety awareness due to dementia, there were no revised implemented interventions to address how staff were to ensure the resident's safety, as previously implemented interventions were not effective, as evidenced by the resident's repeated falls. FALL #3 Review of nurse's progress notes and IIR dated [DATE] at 4:05 AM, showed Staff J, a Certified Nurse's Aide (CNA) heard a loud noise. When Staff J, walked into the hallway, she heard Resident #9 calling out for help. When Staff J walked in Resident #9's room, she found the resident had fallen, and was sitting in the floor with one hand on the walker. Review of nurse's progress notes dated [DATE], Staff H, a licensed nurse, assessed the resident and noted, the resident had increased pain to left hip. Resident #9's doctor was notified of the resident's fall incident and post fall assessment results. The doctor issued a new order to X-ray the resident's left hip. According to progress notes dated [DATE], X-ray results showed a left [MEDICAL CONDITION]. The resident was transferred to the hospital per doctor's order for further evaluation of the fractured left hip. Resident #9 underwent a surgical procedure to repair a fractured left hip for which she could not recover, and later died on [DATE]. Review of Resident #9's death certificate showed the resident deceased on [DATE]. Review of the IIR root cause analysis dated [DATE], showed the cause of the Resident #9's fall was due to the resident's self-induced tiredness and was worn out due to being awake the whole night, and wandering back and forth without sleep, causing the resident to loose balance and fall. Review of the CP dated [DATE], showed Resident #9 was identified as a fall risk related to history of falls in the past 6 months, bilateral lower extremity weakness, history of shortness of breath and increased confusion and wandering. This CP did not include fall interventions, but instructed staff to refer to the resident's information sheet for interventions to prevent falls. Review of Resident #9's information sheet printed on dated [DATE] and on [DATE], did not show specific care interventions to prevent further falls for Resident #9 as instructed in the comprehensive care plan. On [DATE] at 2:30 PM in interview, Staff J, a regularly assigned night shift care giver to Resident #9 explained that the resident had experienced difficulty sleeping in past few months prior to the fall incident on [DATE]. Staff J Further stated that the resident spent most nights pacing back and forth in the hall and did not even try to sleep. On [DATE] at 10:30 PM, in an interview, Staff J was asked how she ensured Resident #9's safety and was free from accidents, as the resident spent sleepless nights wandering in the unit hallways. Staff J stated I offered her whatever I could offer her. Staff J did not state specific fall precautions that she implemented in order to prevent the resident from falling. On [DATE] at 10:45 PM , in an interview, Staff H, the regularly assigned night shift licensed nurse acknowledged Resident #9 had experienced difficulty sleeping, since acute hospitalization for mental evaluation at the Geri-psychiatry unit three months prior to the fall on [DATE]. The failure to implement accident preventative measures to prevent residents from falling caused harm to Resident #8 and #9 leading to death. Additionally, the facility's failure to investigate and identify accident hazards and implement interventions to prevent further falls, placed Resident #9 and #8 and all residents at risk for recurrent falls resulting in serious harm. RESIDENT #38 According to the admission progress notes of [DATE], Resident #38 was admitted to the facility on [DATE] with medically disabling conditions that included vision impairment due to [MEDICATION NAME] degeneration, tremors and a left [MEDICAL CONDITION]. Review of a hospital discharge summary dated [DATE] showed, Resident #38 sustained a left [MEDICAL CONDITION] after a traumatic fall at home on [DATE], and underwent a surgical procedure to fix the [MEDICAL CONDITION] (two days prior to admission to the facility). Review of a Physical/Occupational Therapy (PT/OT) notes dated [DATE] showed Resident #38 was assessed upon admission to the facility, was identified to be at high risk for falls, and required Contact Guard Assistance (CGA) from staff for transfers. These notes showed the resident used a wheel chair for mobility. Review of Resident #38's Incident Investigation Report (IIR) dated [DATE] showed Resident #38 was found on the floor close to the sink in her room at 5:06 PM (four days after admission to the facility). According to IIR, the resident stated that after washing her hands at the sink, she attempted to turn to the right side to grab her walker, tripped and fell on her left side. Further review of the above IIR showed, Staff FF and Staff GG assessed Resident #38 after the fall. Upon assessment, the resident had complaints of increased pain to the left hip. Staff FF notified the doctor with the assessment results. The doctor issued a new order to X-ray the resident's left hip. Review of the X-ray results showed a new fracture to the left hip, and the resident was transferred back to the hospital for further treatment to fix the fracture. Review of Resident #38's Care Plan (CP) dated [DATE], identified the resident as being at high risk for falls, and showed the resident required Contact Guard Assistance (CGA) from staff with a Front Wheeled Walker (FFW) for transfers. This CP further showed the resident required to be set-up for grooming. Review of the PT/OT notes dated [DATE] showed the resident had Poor, unable to correct balance standing dynamic. Further review of PT/OT notes showed, the resident presented with impaired endurance and unable to walk to the length of the bathroom. These PT/OT notes instructed staff to set up the resident for grooming seated at the Edge of the Bed (EOB) with grooming supplies. In an interview on [DATE] at at 4:46 PM, Staff EE said he assisted Resident #38 to walk to the the sink to wash her hands using a FWW at around 5:00 PM during dinner time. Staff EE then left the resident standing at the sink washing her hands, to pass dinner trays to other residents. A few minutes later, Staff EE heard Resident #38 calling out for help. Staff FF and Staff GG entered the resident's room and found the resident on the floor laying on the left side. On [DATE] at 4:50 PM, when Staff EE was asked, he said he did not check the resident's CP for interventions to prevent the resident from falling, but instead asked the resident if she was, ok standing at the sink, and the resident seemed to be ok but lost balance and fell . Staff EE's action was inconsistent with the resident's care interventions based on the PT/OT assessments which instructed staff to use a wheel chair for mobility/and or set up the resident for grooming with grooming supplies at the edge of the bed. Staff EE also said that during the investigation of Resident #38's fall, Staff EE was counseled by the Staff G, a Neighborhood Coordinator, that he should not have left the resident by herself at the sink, as instructed in the resident's plan of care due to the resident's poor standing balance. Review of the IIR conclusion dated [DATE], completed by Staff G showed Staff EE, felt the resident was stable at the sink and he left for few minutes as noted by the care plan, an action inconsistent with care instructions for the resident's fall prevention interventions assessed to require by PT/OT disciplines, and as indicated on the Resident Information Sheet dated [DATE]. Review of the above IIR showed Staff G concluded that The careplan was followed (by Staff EE), contradicting Staff EE's acknowledgment that he shouldn't have left the resident alone by the sink. This IIR conclusion dated [DATE] written by staff G was inconsistent with the interview statement provided by staff EE during his counseling session with Staff G, who reprimanded staff EE for leaving Resident #38 un-attended at the sink. The facility's failure to implement appropriate fall preventative measures for Resident #38, based on assessed care needs, caused harm to Resident #38 when she fell and sustained a second fracture to the left hip, four days after admission to the facility. SIMILAR FINDINGS RESIDENT #5 Review of the medical record showed Resident #5 readmitted to the facility on [DATE] for multiple care needs, including dementia, and had a history of [REDACTED].#5 was assessed to require limited assistance of one staff member for walking in her room and in the corridor. Review of the resident's Fall Risk CP included the intervention, dated [DATE], Provide supervision with ambulation out of room but allow her to wander at will. Do not startle her when bringing her FWW to her. Tends to lose balance when she stops walking and when she turns while walking. Reveiw of the resident's record showed the resident had a witnessed fall on [DATE] at 4:00 PM. A progress note dated [DATE] at 9:24 PM showed, the Res (resident) was walking to the dining room from her room lost balance and fall (sic). The root cause of the fall was stated as Res (Resident) was using the walker but when she lost balance she tried to grape (sic) the sit to stand machine but the machine moved and res end up of the floor. This fall resulted in a large bruise to the left hip. An Investigation Summary (IS), dated [DATE], stated the resident is very high risk for fall related to h/o (history of) . poor safety awareness, does not always use FWW (front wheeled walker). Walks independently to supervision with FWW (needs cues to use FWW and watch path) per care plan. The IS did not address that the resident ambulated independently at the time of the fall, even though staff identified she was assessed to need supervision with ambulation. Further review of the resident's record showed Resident #5 had a second witnessed fall on [DATE] at 6:00 AM that resulted in a bruise over her right eye. According to the undated IS the resident was ambulating in the hallway without her FWW and tripped over a parked walker in the hallway. The root cause of the fall was identified as, Bathroom seeking without her FWW. Further review of the IS showed, Fall Assessment: very high risk for falls related to h/o (second fall this year), poor safety awareness .Walks supervised, as tolerated with FWW, needs cues to use FWW and watch path . Under the Action Taken section of the IS it showed .staff assist her when she is walking and transferring as tolerated however she still gets up on own per care plan and resident rights. The IS did not address the resident's need for supervision when ambulating to ensure the use of her walker and prevent falls. On [DATE] at 7:30 AM Staff T stated, (the resident) has the right to be free of movement. We do not provide 1:1 supervision . REFERENCE: WAC [DATE] (3)(g).

Based on interview and record review, the facility failed to recognize, comprehensively assess, monitor, or treat disturbed sleep patterns for one (#9) of one resident reviewed for disturbed sleep pattern. These failures caused harm to Resident #9, who experienced continuous pacing and lack of sleep, resulting in a diminished quality of life and sustaining a fall with substantial injury to the left hip, and requiring hospitalization for a surgical procedure to fix the [MEDICAL CONDITION]. Findings included . PROMOTING SLEEP POLICY AND PROCEDURE Review of the sleep policy and procedure dated 01/2015 and last revised on 07/2017 read in part: .PMSV nursing staff assess and intervene to promote optimum sleep quality in short and long -stay residents. POLICY INTERPRETATION AND IMPLEMENTATION ASSESSMENT 2. If the screening assessment suggests unsatisfactory sleep quality, factors contributing to sleep disturbance are identified. Information from this assessment is used to identify specific sleep problems that direct development of an individualized care plan. RESIDENT #9 Resident #9 was a long term resident of the facility who was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had impaired cognition and needed queuing from staff to complete most activities of daily living including sleep promotion. Review of Incident witness statement dated 06/16/2020, showed Resident #9 had been up the whole night, was pacing back and forth on the unit hall way, when she experienced a fall and sustained a left [MEDICAL CONDITION]. Review of the Incident Investigation Report (IIR) root cause analysis dated 06/16/2020, showed, the cause of Resident #9's fall was due to, self-induced tiredness as the resident spent whole night pacing back and forth, causing her to loose balance and fall. Review of nurse's progress notes dated 04/22/2020, showed, Resident #9 experienced significant difficulty sleeping in the recent past, being up wandering and restlessness during the middle of the night. Review of the May 2020, Medication Administration Record [REDACTED]. Further review of the listed interventions for target behaviors related to difficulty sleeping instructed staff to provide sleep. In interview on 06/23/2020 at 11:45 AM, when Staff F, the Neighborhood Coordinator (NC) was asked how staff promoted sleep quality as instructed in the MAR for the resident, Staff F did not respond. Staff F then continued and stated, Initially, the resident slept well and did not need any sleep interventions based on admission sleep assessment. Staff F, further said that Resident #9 had developed sleep disturbances in the past few months. In an interview on 06/23/2020 at 11:45 AM, when Staff F was asked if the resident was re-assed after a change in sleep pattern? Staff F, said No. In interview on 06/23/2020 at 11:45 AM, when staff F was asked if Resident #9's doctor was notified of the resident's change in sleep pattern. Staff F, said, the doctor was aware of the resident's change in sleep pattern, but he did not issue any new orders such as, sleep medication, to aid the resident to sleep. Review of Resident #9's Care Plan (CP) and Information Sheet did not include interventions, on how staff were to care for the resident in order to promote sleep. In interview on 06/28/2020 at 10:45 PM, Staff J, a regularly assigned night care giver, was asked, how she promoted sleep for Resident #9, Staff J was unable to state specific interventions on how she was to promote sleep for the resident, then later stated I provided her whatever I could. Review of the resident's medical record did not show the staff assessed the resident's sleep quality, to identity factors or circumstances causing the resident's sleep disturbance. Nor did the facility develop a care plan to promote sleep, based on the assessed sleep needs, as stated in the facility's sleep promotion policy and procedure. The failure to assess Resident #9's sleep disturbances, identify factors causing the resident's sleep disturbances or develop and implement interventions to promote resident's sleep resulted in harm, when Resident #9 spent sleepless nights and experienced fatigue, resulting in the resident falling and sustaining a fractured Left hip. REFERENCE: WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to ensure that services provided met professional standards of practice with regard to pressure ulcer prevention in 1 (Resident #57) of 3 sampled residents with facility acquired pressure ulcers. The Facility failed to ensure the residents extremity was checked for circulation, sensation and movement and skin breakdown on a routine basis. The facility failed to ensure the treatment of [REDACTED]. Failure to meet professional standards of practice placed the Resident at risk for increased pressure ulcer formation, increased chance of infection, delayed healing and decreased quality of life. Findings include: Resident #57 was assessed to be at risk for pressure ulcers secondary to [MEDICAL CONDITION], obesity, limited range of motion, and diabetes. The resident sustained [REDACTED]. The resident returned to the facility with a cast. The cast was replaced with a CAM walker boot (a removable, ridgid, plastic splint device with a foam lining and velcro straps that stabilizes the extremity) by the orthopedic surgeon 12/21/2011. The resident was seen again by the orthopedic surgeon on 01/03/2012 and there was no skin breakdown found during either visit. A review of LN (licensed nurse) and CNA (certified nursing assistant) documentation from 01/03/12 through 01/13/12, a 10 day period, revealed no assessment of the left lower extremity. There was no documentation of splint removal, skin assessment, surgical wound check or washing of the boot lining. There was no documentation of the Residents refusal of care. There was no evidence nursing staff called the physician to obtain orders on how to use the boot or wound care of the surgical site. There was no evidence of any other type of research related to use of the boot. There was no indication that the facility had assessed or identified the risk of skin breakdown associated with the boot use and there was no care plan in place for use of the boot, cleaning of the boot, or surgical wound care. On 1/14/12 nursing documentation revealed a "sticky, moisture and foul odor was found between the botton of the toe and a plastic cushion inside the cast." On 1/15/12 after a full skin check, documentation revealed that "two new wounds found on the left foot. Stage II pressure ulcer on the dorsal (back) of left toe, unstageable pressure wound on left heel." In an interview on 4/12/12 at 2:30 PM with Staff Q, RN, Staff R, LPN, and Staff S, CNA, they stated that the resident had refused to allow staff to remove her splint. Staff Q stated the residents leg was wrapped with Coban (an elastic, adhesive dressing) under the splint. Staff Q also stated the extremity had been checked on a regular basis. In an interview on 04/05/12 at 11:25 AM with Staff O RN, Neighborhood Coordinator she was unable to find evidence that staff had checked the left foot daily for signs of skin breakdown. She stated she would expect the nurses to check the whole foot with complaints of pain. She stated the resident was complaining daily of foot and ankle pain. On 04/04/12 at 12:30 PM the resident stated that she got the ulcer after her surgery. She stated she has a lot of care needs and that staff helped her for a little while but then said they didn't have time. She stated that some of the staff are "very lax" and they are often "in a hurry". A review of Medical Surgical Nursing Care, third edition by Burke, Mohn-Brown, and Eby, 2011 revealed when a patient has a splint in place, care requires "frequent neurovascular checks, wound assessment and splint care. Change dressing as ordered". Instruction for the CAM walking boot obtained from ZipHeal.com dated 02/02/2012 recommended " Place a sock between your skin and the boot. Check your skin from time to time to ensure that there is no redness due to contact with the liners. In case there is persistent redness, do contact your physician." Washing of the splint liner was recommended every 4-7 days. A review of Gerontological Nursing, Competencies for Care, by Mauk, 2010 revealed "due to the increased risk of infection and slow healing that results from diabetes, foot care is an essential component." .

Based on observation, interview and record review the facility failed to properly assess, monitor and develop a plan of care for 2 (Residents # 57, 304) of 4 residents with a facility acquired pressure ulcer. The facility failed to put in place preventive measures to decrease the likelihood of ulcer development. Failure to assess, monitor and establish a plan of care placed the residents at risk for skin breakdown, ulcer formation, infection, and decreased quality of life. Findings include: Resident #57 was admitted to the facility on [DATE] with [MEDICAL CONDITION], decreased mobility, diabetes, hypertension, chronic indwelling foley catheter and repeat urinary tract infections. The Resident was identified to be at risk for skin breakdown related to limited mobility, obesity, and diabetes. The resident was also being treated for [REDACTED]. One pressure ulcer on her buttock and one on her coccyx. On 12/08/11, the resident sustained [REDACTED]. The resident was readmitted on [DATE] with a cast on her left ankle. On 12/21/11 the orthopedic surgeon changed the resident's cast to a CAM walking boot (a removable, ridgid splint device with a foam liner and velcro straps used to stabilize the ankle and foot). There was no skin breakdown on the left foot at that time. The resident was seen again by the orthopedic surgeon on 1/03/12 and there were no signs of skin breakdown. A review of the nursing record for 1/14/12 revealed the Resident had a "sticky, moisture and foul odor was found between the bottom of the toe and a plastic cushion inside the cast." On 1/15/12 on the resident's bath day, nursing documentation revealed "two new wounds found on the left foot. Stage II pressure ulcer on the dorsal of left toe, unstageable pressure wound on left heel." A review of the facility incident report dated 1/14/12 noted "Pressure ulcer, substantial, from CAM walker boot." A review of the care plan, after the placement of the CAM walker boot on 12/21/11, revealed the resident was at risk for skin breakdown. A care plan was in place for the treatment and monitoring of the Stage II pressure ulcer on her buttocks and coccyx. However, there was no plan of care for skin and surgical wound checks of the left foot and no plan for use and cleaning of the CAM boot. There was no plan of care to address the Residents' refusal of care.The care plan was not updated until 4/12/12. A review of LN (licensed nurse) and CNA (certified nursing assistant) documentation for a 10 day period from 1/03/12 through 1/13/12 revealed no assessment of the left lower extremity. There was no documentation of splint removal, skin assessment, surgical wound check or washing of the boot lining. There was no documentation of the Residents refusal of care. A review of the medical record revealed that no attempts had been made to obtain a physician order [REDACTED]. In an interview on 4/12/12 at 2:30 pm with Staff Q, RN, Staff R, LPN, and Staff S, CNA they stated the resident had refused to have her splint removed and did not want her leg to be moved. Staff Q stated the leg was checked daily. There was no record of the extremity checks or the Residents refusal of care. When asked about bathing the resident, Staff Q stated she was getting bed baths. Total skin checks are to performed at the facility on the residents bath days. On 4/05/12 at 11:25 AM in an interview with Staff O, RN, the Neighborhood Coordinator, she verified there was no evidence that staff had assessed the left lower extremity for signs of a pressure ulcer between 1/03/12 and 1/13/12. She verified the resident was having ongoing pain in the left foot and ankle. She stated she would expect the nurses to check the whole foot with complaints of pain. "I don't think she had any stocking or padding between the CAM boot and the skin." She stated the Resident was to have the air cast (CAM boot) "checked by staff, remove and look at the skin but the resident would refuse at times." She stated no skin issues were noted when the resident had on the splint. She stated the air splint was padded with nothing between the splint and the skin. In an interview with Staff P, Physical Therapy on 4/09/12 at 4:30 pm, he stated the CAM splint is not used very often and the facility does not have a policy for it's use. He stated they get direction from the doctor on how long to wear the splint. He stated skin checks should be done once a shift. On 4/04/12 at 12:30 pm, the resident stated that she got the ulcer after her surgery. She stated she had a lot of care needs and that staff helped her for a little while but then said they didn't have time. She stated that some of the staff were "very lax" and they were often "in a hurry". RESIDENT #304: This resident was admitted on [DATE] with care needs related to a stroke with right-sided impairment, nutritional and hydration deficits, and low [MEDICATION NAME] (protein required for healing), among other conditions. His right arm and leg were flaccid and he had difficulty making his needs known, as he was non-verbal. He was totally dependent for care. The Admission Nursing Assessment recorded the resident as having a reddened coccyx but no other skin conditions. The Admission Minimum Data Set (MDS) on 2/24/12 documented the resident as having no skin breakdown. His Braden score (a skin risk assessment) on 2/26/12 gave him a score which indicated he was at High Risk for developing a pressure ulcer or other loss of skin integrity. The 14-day MDS on 3/4/12 indicated there was an unstagable deep tissue injury in evolution. The Progress Notes refered to 'mushy heels', but no open areas. Interventions listed a pressure relief mattress, and a turn and repostion schedule. On 3/11/12, another MDS recorded the presence of a Stage II ulcer of 3.5 cm by 3.5 cm dimensions and added an intervention for a wheelchair pad. The progress notes of 3/9/12 indicate this was on his dependent side, the right heel. The 30-day MDS on 3/18/12 added another unstageable skin area on the coccyx due to sheering, and included a dressing for interventions. The initial Care Plan of 3/2/12 identified impaired functional mobility related to a flaccid right side due to a [MEDICAL CONDITION]. Interventions related to skin included a turn and repostion schedule of every 2-3 hours, despite being identified as having High Risk skin. Only after the discovery of a Stage II ulcer was the intervention of a egg crate cradle on the bed under heels, and a pillow on the wheelchair footrests, added on 3/9/12. On 3/13/12, foam boots while in bed was implemented. After the discovery of the coccyx sheering, an intermittant-pressure air mattress was obtained for this residen on 3/23/12. Observation of Resident #304 on 4/12/12, revealed that the right heel ulcer had healed as of 3/22/12. However, the coccyx shear discovered on 3/18/12 was slightly larger than previously described and a [MEDICATION NAME] dressing was being used. During an interview with the Neighborhood Coordinator Staff L, on 4/112/12 at 1:00pm, she acknowledged the lack of skin integrity for this resident probably was avoidable, and interventions were not implemented in a timely and consistent manner. The facility policy dated 10/14/10, Skin Assessment and Interventions to Maintain and Restore Skin Integrity described the Standard of Care Interventions for all residents. Relevant interventions would be "(5) Pressure relief is provided for heels, elbows, hips, coccyx and all bony prominences as needs" and "(6) When assisting residents to change position or relieve pressure, lifts or assistive devices are used to avoid sheering or friction.". Other relevant High Risk Interventions included, among others, the use of specialty pressure relieving mattresses, more frequent turning or positioning, specialty wheelchair cushions, and special heel protection. The facility failed to provide appropriate interventions in a proactive manner, which did not protect the resident from developing a pressure ulcer.

Based on observations, interviews, and record reviews, the facility failed to ensure 1 of 5 sampled residents (Resident #145) was transferred from bed to recliner with a sit to stand transfer device instead of a mechanical lift device according to the resident ' s care plan directives. Failure of the facility to implement care plan directives and interventions during a transfer resulted in a fall for Resident #145 and sustained a right femur (thigh) fracture, left knee abrasion, and psychological harm due to severe pain and discomfort. Findings include: RESIDENT #145 Resident #145 was admitted to the facility with multiple medical [DIAGNOSES REDACTED]. Resident #145 was assessed as a risk for falls due to history of falls. Due to declining medical condition, resident was receiving Hospice (end of life)services. Review of Nursing Care Plan, At Risk For Falls, for Resident #145 dated 4/2010 showed " refer to the resident's RAI " (Resident Assistant Information Sheet). The RAI constituted the care directions for Nursing Assistants. The RAI dated 7/10/2010 showed the use of a maxi- lift transfer device with total assist for mobility transfers. Review of resident progress notes dated 8/7/2010 at 2:03 p.m. showed Resident # 145 had a fall that resulted in a fractured right leg and abrasion to the left knee. Staff A and Staff B, NACs (Nursing Assistant Certified), transferred Resident #145 from bed to recliner. The resident ' s RAI directed caregivers to use mechanical lift transfer device (a mechanical lift device used when a resident is completely dependent and unable to participate in the transfer). However, Staff A and B transferred the resident using a sit to stand lift device (a mobile lift that allows for patient transfers from a seated position with participation from the resident). During the transfer, the resident's knee buckled from a standing position; she hit the footrest of the sit to stand lift device. Both staff failed to verify resident ' s transfer status before transferring her. Review of resident progress notes dated 8/8/2010 at 9: p.m. showed Resident # 145 yelled when touched on her right hip. Progress notes dated 8/9/2010 at 1:12 p.m. showed resident yelled when she was repositioned every two hours. Progress notes dated 8/10/2010 showed at: ? 11:26 a.m. the resident screamed with pain, was combative and resident stated, " Pain is all over. " The notes indicated the resident received pain medicine hourly, but it afforded little relief. She continued to state she was in pain. Non-verbal signs of pain were also present as furrowed brows, grimaced when lying still, and had pain when her right thigh was lightly touched. ? 7:28 p.m. Resident #145 was anxious whenever touched and would shout, " No leave me alone. " Resident screamed more with attempts to flex her right knee. The right knee was bruised. ? 9:27 p.m. Resident #145 general body ache and right knee swelling. Review of resident progress notes dated 8/11/2010 at 7:20 a.m. showed resident ' s right knee swollen, tender, and painful with care. The resident received pain medication. She experienced some relief, but not completely effective. Review of x- ray results on the resident ' s right knee dated 8/11/2010 showed " acute fracture in the distal right femur (thigh). " The facility sent the resident to the hospital at 7:00 p.m. for further evaluation and treatment. When asked on 8/27/2010 at 12:50 p.m. how she was trained to do resident transfers Staff A said, " I unfortunately did not read the care plan. I transferred her with the sit to stand lift instead of the mechanical lift. I assumed it was the sit to stand because that ' s what written in the care plan three weeks ago. " When asked on 8/27/2010 at 12:50 p.m. how the facility trained her to do resident transfers, Staff A said, " I unfortunately did not read the care plan. I transferred her with the sit to stand lift instead of the mechanical lift. I assumed it was the sit to stand because that's what was written in the care plan three weeks ago. " On 8/27/2010 at 1:10 p.m., Staff C, a NAC, was asked how caregivers were made aware of residents ' transfer methods to prevent falls on residents. Staff C said, " I look at the care plan located behind the bathroom door for the transfer technique before I transfer a resident because changes may take place. I keep in touch with the nurse with the previous shift. " On 8/27/2010 at 1:25 p.m., Staff C was observed with a resident transfer from a wheelchair to bed with a sit to stand lift device. When asked when she would use a sit to stand lift for a resident, she stated, " We use it and look at the resident's ability to grasp the handles of the device, it is usually in the care plan." On 8/27/2010 at 1:35 p.m. interview with Staff D, a NAC, as to what they were instructed to do before assisting with a resident transfer and she stated, " I have learned my lessons I look in the care plan. "