Every finding on record at Puget Sound Transitional Care

Based on observation, interview and record review the facility failed to initiate and investigate an allegation of resident-to-resident abuse for 2 of 4 (Resident 1 & 2) residents reviewed for resident-to-resident incidents. The failure to initiate an investigation, document the incident and thoroughly investigate put all residents at risk for unidentified abuse or neglect, lack of protection, continued abuse, and decreased quality of life.Findings included. <Facility Policy>Review of the facility's revised 04/2025 Abuse Prevention of and Prohibition Against policy, showed the facility would protect and prevent abuse from occurring in the facility by identifying, correcting and intervening in situations where abuse is more likely to occur. The policy showed for resident-to-resident allegations the facility would assess, monitor and intervene as necessary to maximize resident health and safety. According to the policy, the facility would investigate and conduct interviews with the residents involved, witnesses, staff members and other residents, and a licensed nurse would immediately examine the resident upon receiving reports of alleged physical abuse and record the examination in the resident's medical record.<Resident 1>According to the 04/21/2026 annual Minimum Data Set (MDS- an assessment tool), Resident 1 had depression (sadness), pain, anxiety, and used a wheelchair. The MDS showed Resident 1 had no memory issues and communication could be understood and was understood by others. According to the revised 03/06/2026 Depression care plan, staff were to monitor, document and report to the provider signs of sadness, negative mood comments and fear of others. Review of the care plan did not show updated documentation of a resident-to-resident incident occurring. In an observation and interview on 07/30/2026 at 2:09 PM, Resident 1 was observed sitting in their wheelchair and stated, approximately two weeks ago Resident 2 intentionally bumped into their wheelchair with their wheelchair while they were near the activity room. Resident 1 stated Resident 2 would get mad at times when they saw Resident 1 talking to another resident or staff member. Resident 1 believed the intentional wheelchair bumping was because of this. Resident 1 stated they told Staff C (Resident Care Manager) about the incident after the event occurred and reported the incident to both Staff A (Administrator) and Staff B (Director of Nursing). Resident 1 stated they had heard back from the facility about interventions the facility had done to prevent this type of event from happening again and was not aware if the facility was monitoring their condition. Resident 1 stated after the bumping event happened, they called their surgeon and case manager to notify them of the bumping incident because they noticed their neck was stiffer after the incident and the additional neck stiffness could delay their upcoming neck surgery. Resident 1 stated after talking with surgeon, there was no delay in surgery plans because of the neck being stiffer.Review of Resident 1's medical record showed no indication that staff documented the resident-to-resident incident, did not monitor Resident 1's condition after the incident, and did not show interventions were put into place to address Resident 1's concerns. The facility was unable to provide documentation to show staff documented and investigated the resident-to-resident incident into Resident 1's medical records. Review of the facility's July 2026 incident and grievance logs showed no resident-to-resident incident documented for Resident 1 and Resident 2.<Resident 2>According to the 06/09/2026 quarterly MDS, Resident 2 had memory impairment, altered mental status, a mood disorder, and used a wheelchair for mobility. According to the 11/11/2024 Potential for Psychosocial Wellbeing care plan, staff were to observe Resident 2 for mood changes, and aggressive or impulsive behaviors. Review of Resident 2's medical records showed no documentation of the resident-to-resident incident that occurred between Resident 2 and Resident 1. In an interview on 07/30/2026 at 3:40 PM, Resident 2 stated they sometimes had issues with others but did not have any issues right now and did not recall the event of bumping another resident. In an interview on 07/30/2026 at 2:41 PM Staff C (Resident Care Manager) stated they were made aware of the resident-to-resident incident by Resident 1, however Resident 1 did not appear distressed and Staff C stated they appeared jolly about the event. Staff C stated they reported the incident to the Interdisciplinary Team (IDT) but did not investigate the incident further and did not document the event in the resident's record. Staff C stated if there were incidents of potential abuse, the facility staff should investigate, report, document and notify the Director of Nursing right away for resident safety but did not for the resident-to-resident incident involving Resident 1 and Resident 2.In an interview on 07/30/2026 at 3:30 PM Staff D (Licensed Practical Nurse) stated Resident 2 could become aggressive at times towards others if they were angry. Staff D was not made aware of a resident-to-resident incident between Resident 1 and Resident 2. In an interview on 07/30/2026 at 4:22 PM Staff A stated they were aware of the resident-to-resident incident and thought the incident was accidental and not intentional. Staff A stated no further interventions were put into place to monitor both Resident 1 and Resident 2 for aggressiveness because the residents remained in contact with one another. Staff A stated they kept a file of the occurrence but did not document the conversation with Resident 1 in the medical record and did not conduct a full investigation because they believed the incident to be an accident. Staff A stated all incidents of potential abuse should be investigated and documented in the medical record and updates should have been made to the care plan but were not. REFERENCE: WAC 399-97-0640(6)(a

Based on observation, interview and record review, the facility failed to protect 1 of 1 sampled resident (Resident 1) reviewed for abuse and the right to be free from physical abuse by (Resident 2). The facility failed to assess, monitor and implement safety interventions to protect residents from residents with known behaviors. These failures placed residents at risk of physical and psychosocial harm, mental anguish, and a diminished quality of life. Findings included. Review of the facility's policy titled Freedom from Abuse, Neglect and Exploitation, revised 04/2025, documented each resident had the right to be free from abuse, and mistreatment. The policy documented the facility would identify, assess, and implement a care plan for appropriate interventions, and monitor residents with behaviors that might lead to conflict.<Resident 1>Review of the annual Minimum Data Set Assessment (MDS-an assessment tool) dated 03/22/2026, showed Resident 1 had Dementia (memory impairment), depression, pain and used a wheelchair for mobility. Review of Resident 1's At Risk for Depression related to Dementia Care Plan (CP) dated 05/03/2025, documented staff were to monitor Resident 1 for being at risk for increased anger, or agitation and feelings of being threatened by others.<Resident 2>Review of Resident 2's admission MDS dated [DATE], documented the resident admitted to the facility on [DATE]. The MDS showed Resident 2 had post-traumatic stress disorder (PTSD), psychoactive substance abuse and major depression.Review of Resident 2's Behavior CP, dated 04/20/2026, documented the resident had the potential to demonstrate physical behaviors, physical and verbal aggression towards others related to anger, poor impulse control, history of PTSD and drug abuse. The CP showed staff interventions were to monitor Resident 2 for signs and symptoms of psychological harm.Review of facility's Investigation Report dated 04/20/2026, documented staff heard residents yelling in a room shared by Resident 1 and 2. Staff observed Resident 1 was on the floor on their back with their wheelchair tipped over backwards. Resident 2 was sitting on the side of their bed yelling at Resident 1. The facility investigation showed Resident 1 stated Resident 2 started screaming at them and grabbed their neck and tipped them over backwards. Upon assessment staff observed Resident 1 had redness and scratches on their neck. The investigation report showed Resident 2 was removed by law enforcement from the facility.In an interview on 04/30/2026 at 1:45 PM, Staff B, Director of Nursing (DNS) stated the facility usually did not admit potential residents if they had uncontrolled behaviors. Staff B stated they were not aware Resident 2 had behaviors prior to being admitted to the facility and did not provide one on one monitoring until after the incident occurred on 4/20/2026. Staff B stated if there were behaviors after admission, the facility should have documented and monitored the residents for safety.In an interview on 04/30/2026 at 1:50 PM, Staff A, Administrator, stated the facility was not aware Resident 2 had behavior issues. Staff A stated the facility does not have a way to screen residents for behaviors if it was not listed on the discharging hospital paperwork prior to admission. Staff A stated they were not aware of the reason why Resident 2 had PTSD and what triggers were to be monitored. Reference WAC 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to ensure residents with a Percutaneous Endoscopic Gastrostomy (PEG) tube (a soft, flexible plastic feeding tube inserted directly into the stomach through the abdominal wall) received the appropriate treatment and services according to professional standards of practice for 2 of 3 residents (Residents 1 & 2) reviewed for tube feeding management. The facility failed to follow and implement the physician's orders pertaining to tube feeding volume delivery to meet the resident's assessed nutritional requirements (Resident 1) and failed to ensure ongoing review and evaluation regarding the discontinuation of the PEG site after adequate oral nutrition was established and achieved by the resident (Resident 2). These failures placed residents at risk for inadequate nutrition/hydration, PEG site complications including infection, unnecessary pain/discomfort, and a decreased quality of life. Findings included. <Facility Policy>The facility policy titled, Gastrostomy Tube Care and Management, revised 04/2025, showed the facility must follow physician orders and provide proper care and maintenance of gastrostomy tubes. The policy showed the facility should determine if the resident felt any pain or discomfort around the tube insertion site by questioning the resident and evaluating any changes in the resident's gastrointestinal system. The undated facility policy for nursing clinical procedures titled, Physician Order- Transcribing, showed all treatment orders were to be transcribed into the electronic health record and all new orders, including family/representative notification, were to be documented in the nursing notes.<Resident 1>According to the 11/03/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 1 had impaired memory, did not have the ability to communicate verbally, and had medical conditions including a brain injury with resulting swallowing difficulty. The MDS showed Resident 1 had a PEG tube in place and was administered tube feeding during the assessment period. Review of Resident 1's revised 09/28/2025 nutrition Care Plan (CP) showed the resident had a nutritional problem due to their medical condition and required tube feeding via their PEG tube to meet their nutritional requirements. A 09/28/2025 CP intervention instructed the nursing staff to administer tube feeding as ordered by the physician. Review of Resident 1's January 2026 Medication Administration Record (MAR) showed a 11/02/2025 physician's order to administer a total of 1700 milliliters (ml) of tube feeding to the resident over a span of 20 hours during the day. The MAR showed on 28 out of 30 days, Resident 1 was administered less than what was prescribed: 1660ml on 01/14/2026; 1640ml on 01/29/2026-01/30/2026; 1637ml on 01/27/2026; 1630ml on 01/22/2026-01/26/2026; 1600ml on 01/08/2026-01/12/2026 and 01/20/2026-01/21/2026; 1560ml on 01/15/2026-01/19/2026; 1558ml on 01/01/2026-01/03/2026; 1550ml on 01/13/2026 and 01/28/2026; 1300ml on 01/04/2026; and 450ml on 01/07/2026. In a joint interview with Staff A (Administrator) and Staff E (Infection Preventionist/Staff Development) on 03/05/2026 at 12:13 PM, Staff E stated it was important to ensure residents received the prescribed tube feeding volume for nutritional health and safety. Staff E reviewed Resident 1's MAR and stated the resident should have but was not administered the tube feeding amount the resident was assessed to require as ordered. In a phone interview on 03/09/2026 at 2:34 PM, Staff B (Director of Nursing) stated they expected the nursing staff to follow and implement physician's orders for tube feeding as indicated in the MAR. <Resident 2> According to the 11/07/2025 Quarterly MDS, Resident 2 had clear speech, memory deficits, and had medical conditions including cardiac arrest (a sudden cessation of heart function), respiratory failure, and swallowing difficulty. The MDS showed Resident 2 was provided a mechanically altered texture diet and did not receive any tube feeding during the assessment period. Review of Resident 2's revised 11/01/2025 nutrition CP showed the resident had a PEG tube in place and was able to take food by mouth. A 07/10/2025 nutritional evaluation showed Resident 2's tube feeding was discontinued because the resident established good appetite and oral intake of food. A 11/25/2025 nursing note showed Resident 2's representative notified the facility of the need for a referral from the physician to coordinate the resident's PEG tube removal. A 01/10/2026 progress note by the Physician's Assistant (PA) showed Resident 2 alerted them about the status of their PEG tube removal and expressed discomfort from it. The note showed an order to have the PEG tube removed was pending per the nursing staff. In an observation and interview on 02/11/2026 at 1:56 PM, Resident 2 was observed sitting up in bed; their PEG site had a dressing on. Resident 2 stated they could now manage their nutrition needs by eating and no longer needed tube feeding. Resident 2 stated they did not understand why the facility did not order their PEG tube be removed and wanted their PEG site closed, .I want this [PEG tube] thing out of me. Review of Resident 2's medical records and progress notes from 01/11/2026 until 03/05/2026 did not show the facility followed up regarding the status of Resident 2's PEG tube removal. Documentation was requested from the facility but no additional information regarding a follow-up was provided. In a joint interview with Staff A and Staff E on 03/05/2026 at 12:13 PM, Staff E stated it was important to ensure a PEG tube was removed if it was no longer needed for nutritional support because it was considered a foreign object in the body and could cause infections. Staff E added there was a risk of accidentally pulling the PEG tube out if left in place unnecessarily. Staff E reviewed Resident 2's medical records and stated there was no documentation in the resident's medical records to show follow-up was made by the facility to have Resident 2's PEG tube removed after the PA's visit on 01/10/2026. In a phone interview on 03/09/2026 at 2:34 PM, Staff B stated care coordination regarding the removal of Resident 2's PEG tube was overlooked, .unfortunately, the communication fell through the cracks. REFERENCE: WAC 388-97-1060(3)(f)

Based on observation, interview, and record review, the facility failed to ensure the resident's medical records were complete, accurate, and reflected the actual care provided for 1 of 7 sample residents (Resident 7) reviewed for resident records. The failure to ensure wound care completion was documented accurately in the Treatment Administration Record (TAR) placed residents at risk for inaccurate representation of wound condition and care, unnecessary repetition of dressing changes, and a decreased quality of life. Findings included. <Facility Policy>The facility policy titled, Skin and Wound Monitoring and Management, revised 04/2025, showed the facility would implement wound care approaches that were consistent with the resident's Care Plan (CP) including monitoring the impact of interventions and modifying them as appropriate based on any identified wound change(s) via documentation in the TAR. The policy showed the facility would confirm all treatment orders were implemented as ordered.<Resident 7>According to the 11/25/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 7 was cognitively intact and had medical conditions including heart and respiratory failure, unstable blood sugar levels, and needed assistance with daily cares. The MDS showed Resident 7 had a venous ulcer (a slow-healing, chronic, open wound usually occurring on the lower leg near the ankle due to poor circulation) to their right lower leg and was provided skin/wound treatment during the assessment period. Review of Resident 7's revised 06/03/2025 skin CP showed the resident had altered skin integrity from the venous ulcer in their right leg. A 08/23/2024 CP intervention instructed the nursing staff to perform treatments as ordered and to assess, record, and monitor wound healing. Observation on 02/25/2026 at 1:04 PM showed Resident 7 was lying in bed with their right leg elevated on a pillow; a white, mesh dressing was wrapped around their lower leg that extended up to the ankle and was secured with silk tape. The dressing had scant drainage along the side of their leg and was observed unlabeled (no date/staff initial). In an observation and interview on 03/05/2026 at 11:04 AM, Resident 7's right leg dressing was observed in place and was unlabeled. Resident 7 stated they could not recall exactly when the dressing change was done, .for sure not today. In an interview on 03/05/2026 at 11:43 AM, Staff F (Registered Nurse) stated they changed Resident 7's right leg dressing every other day as ordered. Staff F stated they did not put a date or initial on the dressing after changing it. Review of Resident 7's February 2025 TAR showed, on 02/02/2026, 02/06/2026, and 02/16/2026, the treatment order for Resident 7's right leg wound dressing change was not signed off as completed by the nursing staff and was left blank. In a joint interview with Staff A (Administrator) and Staff E (Infection Preventionist/Staff Development) on 03/05/2026 at 12:13 PM, Staff E stated they expected the nurses to put the date and their initial on the dressing after changing it because it was important for auditing purposes. Staff A reviewed Resident 7's February 2026 TAR and stated they expected the nursing staff to follow wound treatments as ordered by the physician and to document the care that was provided in the resident's medical records. REFERENCE: WAC 388-97-1720(1)(a)(i)-(iv)(b)

Based on interview and record review, the facility failed to ensure the Dietary Manager met the minimum qualifications required in the absence of a full-time Registered Dietician for 1 of 1 facility kitchens. This failure placed residents at risk for unmet nutritional needs and other negative health outcomes. Findings included.Review of the facility's Key Personnel list showed Staff D was the facility's Dietary Manager for the facility. The list did not identify who worked as the facility's Registered Dietician.In an interview on 08/22/2025 at 9:33 AM Staff A (Interim Administrator) stated they would provide contact information for Staff C (Dietary Manager). Staff A wrote Staff C's phone number and email address on a sticky note and added on the note that Staff C worked three times a week and as needed at the facility, and that Staff D was currently enrolled in a dietary manager certification class.In an interview on 08/26/2025 at 9:42 AM, Staff D stated they worked as dietary manager for thirteen months. Staff D stated Staff C was on site at the facility on Thursdays.In an interview on 08/27/2025 9:41 AM, Staff A stated they did not know if Staff D's experience or qualifications were sufficient to meet the regulatory requirements for a dietary manager as they did not complete their certification. Staff A stated they were unsure if Staff C also worked elsewhere. Staff A stated they would provide any documentation that demonstrated Staff D's experience or qualifications were sufficient. No further information was provided.In an interview on 08/27/2025 at 10:21 AM, Staff C confirmed they were only on site at the facility on Thursdays and remotely two other days. Staff C stated they also provided dietician services at another facility. REFERENCE: WAC 388-97 -1160 (1).

Based on observation, interview, and record review the facility failed to ensure food was stored under sanitary conditions for 2 of 2 unit refrigerators (200 & 300 unit refrigerators), and meal trays were distributed in a way that promoted food safety for 1 of 2 units (300 unit). These failures placed residents at risk for spoiled food, foodborne illness, injury, and infections. Findings included .<Policy>According to the facility's revised July 2014 Food Receiving and Storage Statement, food service or other designated staff would ensure food storage areas were always clean. The policy showed all food items stored in refrigerators on the unit would be kept below 41 degrees Fahrenheit (F) and must be labeled with a use-by date, and all food belonging to residents must be labeled with the resident's name, the name of the item, and a use-by date. The policy did not identify a temperature below which frozen food must be stored.<Unit Snack Fridges> Observation of the 200 Unit snack refrigerator on 08/25/2025 at 8:59 AM showed no temperature log was maintained for the freezer party of the combination refrigerator/freezer. The freezer contained a frozen meal that did not identify to which resident it belonged, a frozen bottle of iced tea that did not identify to whom it belonged, and an open water bottle half full of a brown frozen liquid. There were large orange liquid stains, now dry, splattered inside the refrigerator. A sign posted on the refrigerator door showed no non-resident food should be stored in the refrigerator and all food must have a resident name, room, and date. The sign showed all perishable food could be stored for a maximum of three days. Observation of the 300 Unit snack refrigerator on 08/25/2025 at 9:06 AM showed the refrigerator contained outside food for rooms [ROOM NUMBERS] that were not dated. The log for the freezer dates showed no temperatures documented from 08/01/2025 through 08/14/2025. There was an unopened bottle of a blue fruit beverage that did identify to whom it belonged and an open, half-consumed bottle of green soda. There was a container that once contained store-bought macaroni salad that now contained a brown substance with a texture consistent with cooked ground beef. This container had a label that read “1-31st-2025”. In the bottom right drawer of the refrigerator was a disposable soup bowl container with a lid. This bowl contained a moldy substance and the liquid inside was now spilled over the bottom of the drawer. The container did not indicate when it was brought in, when it should be discarded, to whom it belonged, or what it contained. In an interview at this time Staff JJ (Corporate Resource Nurse) observed the state of the refrigerator and its contents and declined to comment on whether the food inside was stored appropriately. Staff E (Dietary Aide) appeared and stated the nurse’s aides were responsible for maintaining the cleanliness of the snack fridges and the labeling of food brought in for residents. Staff E stated the freezer temperature should be monitored, and the refrigerator was not but should be clean. In an interview on 08/26/2025 at 9:42 AM, Staff D (Dietary Manager) stated the nursing department was responsible for the upkeep of the snack fridges. Staff D stated they expected the unit fridges to be kept clean, and all food stored to be labeled with a name and a use-by date. <300 Unit> Observation on 08/20/2025 at 1:09 PM showed Staff AA (Certified Nursing Assistant) carrying two lunch trays to room [ROOM NUMBER]. Staff AA set a tray in front of the resident in bed A and the other tray in front of the resident in bed B. At this time, both residents in room [ROOM NUMBER] started calling for Staff AA to come back because their lunch trays were swapped. In an interview at this time Staff AA stated they were expected to bring residents their meal trays one at a time. Staff AA stated it was important to bring meal trays one at a time so they wouldn’t give a resident the wrong meal which could present a risk of injury, or incorrect diet. In an interview on 08/27/2025 at 10:47 AM Staff B (Director of Nursing) stated they expected staff to deliver one tray at time to residents to ensure they did not give a resident an incorrect meal. Staff B stated it was important for residents’ safety and infection prevention. REFERENCE: WAC 388-97 -1100 (3), -2980.

Based on interview and record review, the facility failed to ensure a system by which residents received required written notices and Long Term Care Ombudsman (LTCO) notifications at the time of transfer/discharge for 6 of 7 residents (Residents 1, 7, 9, 3, 11, & 53) and report to receiving hospital for 2 of 7 residents (Residents 3 & 11) reviewed for hospitalization. Failure to ensure a written notification was provided to the resident and/or representative in a language and manner the resident and/or representative understood, notify the LTCO as required of the reasons for the discharge, and give a report to the receiving hospital on resident's condition placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care/preferences, and a break in communication and continuity of care. Findings included . <Facility Policy>According to the facility's revised 04/2025 Criteria for Discharge policy, the facility would provide the resident or their representative with the reason for the discharge in writing and send a copy to the State LTCO office within 30 days. The policy showed this should happen prior to transfer or as soon as practicable and should include the reason for transfer.<Resident 1> According to the 06/17/2025 and 08/10/2025 Discharge Return Anticipated Minimum Data (MDS - an assessment tool) Resident 1 discharged to the hospital on [DATE] and again on 08/10/2025 related to a change in the resident's condition. The MDS showed Resident 1 had medical conditions including stroke (a medical condition prevents the brain from getting enough blood supply) and kidney failure. Record review of Resident 1's clinical record showed no copy of any written transfer notice provided to the resident or their representative describing the reason for transfer for either hospitalization as required scanned into the record. for either hospitalization. <Resident 7> According to the 06/17/2025 and 08/15/2025 Discharge Return Anticipated MDS, Resident 7 discharged to the hospital on [DATE] and again on 08/15/2025 related to a change in the resident's condition. The MDS showed Resident 7 had medical conditions including kidney failure and high blood sugars. Record review of Resident 7’s clinical record showed no copy of any written transfer notice provided to the resident or their representative describing the reason for transfer for either hospitalization as required scanned into the record. <Resident 9> According to the 07/15/2025 Discharge Return Anticipated MDS, Resident 9 discharged to the hospital on [DATE] related to abdominal pain. The MDS showed Resident 9 had medical conditions including high blood sugars and inflammation of the pancreas. Record review of Resident 9’s clinical record showed no copy of any written transfer notice provided to the resident or their representative describing the reason for transfer for either hospitalization as required scanned into the record for either hospitalization as required. In an interview on 08/26/2025 at 10:45 AM, Staff F (Resident Care Manager - RCM) stated they notified residents families by phone about residents’ hospital transfers and sent an “e-interact” (emergency transfer) form to the hospital with residents. Staff F stated they were not aware of the requirement to provide written notifications to residents and/or their representatives for discharge and hospitalizations. In an interview on 08/26/2025 at 10:50 AM, Staff L (Admissions Director) stated they were not responsible for the written notice providing to residents or their representatives during discharge or hospitalizations. In an interview on 08/26/2025 at 12:50 PM, Staff M (Corporate Clinical Consultant) stated they only sent the e-interact form with residents to the hospital. Staff M stated the facility should have, but did not provide Resident 1, Resident 7, and Resident 9 the required written transfer/discharge notice during hospitalizations. <Resident 3> According to the 02/13/2025 Discharge Return Not Anticipated MDS Resident 3 discharged to the hospital on [DATE]. The MDS showed Resident 3 had medical conditions including a terminal illness. Review of Resident 3’s records showed no written transfer notification was provided to Resident 3 for the 02/13/2025 hospitalization. Resident 3’s records showed they stayed in the hospital from [DATE] and returned to the facility on [DATE]. Review of Resident 3’s “Nursing Home to Hospital Transfer Form” showed the report was not communicated to the receiving hospital. In an interview on 08/21/2025 at 9:30 AM Resident 3 stated they “threw up blood and were sent to the hospital on their birthday,” on 02/13/2025. In an interview on 08/26/2025 at 11:51 AM Staff H (Social Services) stated the LTCO was not notified of Resident 3's transfer to the hospital on [DATE]. <Resident 11> According to the 04/01/2025 Discharge Return Anticipated MDS Resident 11 was transferred to an acute care hospital on [DATE]. The MDS showed Resident 11 had medical conditions including a stroke (a medical emergency occurring when blood flow to the brain is interrupted or reduced causing brain cell loss). According to the 04/24/2025 Discharge Return Anticipated MDS Resident 11 was transferred to an acute care hospital on [DATE]. The MDS showed Resident 11 had medical conditions including a stroke. Review of Resident 11’s records showed no written transfer notification was provided to Resident 11 or their representative for the 04/01/2025 or 04/24/2025 hospitalizations. Resident 11’s records showed they stayed at the hospital from [DATE] and returned to the facility on [DATE] and were transferred to the hospital again on 04/24/2025 and returned to the facility on [DATE]. Review of Resident 11’s “Nursing Home to Hospital Transfer Form” showed report was not communicated to the receiving hospital for either transfer. In an interview on 08/26/2025 at 9:21 AM Staff J (RCM) stated they did not provide written transfer notifications to Resident 3 or Resident 11 at the time of the transfers. Staff J stated they were never instructed that nursing was to provide written transfer notifications to residents at time of transfers. Staff J reviewed Resident 3 and Resident 11’s records and stated report was not called to the receiving hospital for Resident 3’s 02/13/2025 transfer or for Resident s 11’s 04/01/2025 and 04/24/2025 transfers. Staff J stated it was important to provide residents with a written transfer notification, so they understood their rights regarding the transfer and report to the receiving facilities for continuity of care. In an interview on 08/26/2025 at 11:51 AM Staff H (Social Services) stated the LTCO was not notified of Resident 11's transfers to the hospital on [DATE] or 04/24/2025. <Resident 53> According to the 08/09/2025 Discharge Return Anticipated MDS, Resident 53 discharged to the hospital on that date. Record review showed no written transfer notification was provided to Resident 53 explaining the reason for their 08/09/2025 hospitalization as required. According to the 07/12/2025 Discharge Return Anticipated MDS, Resident 53 discharged to the hospital on that date. Record review showed no written transfer notification was provided to Resident 53 explaining the reason for their 07/12/2025 hospitalization as required. In an interview on 08/26/2025 at 12:52 PM Staff J stated they did not see in Resident 53’s chart that the resident was provided written notification for the basis of their transfer to the hospital on [DATE] or 07/12/2025. REFERENCE: WAC 388-97-0120 (2)(a-d), -0140 (1)(a)(b)(c)(i-iii).

Based on interview and record review the facility failed to educate and offer staff the Covid 19 (C19) vaccination for all staff when reviewed for vaccinations. This failure placed staff and residents at a higher risk of contracting C19 infections.Findings included .<Policy>According to the facility policy titled, Infection Prevention and Control Program - C19 vaccine for staff, dated 01/12/20222, the facility would educate staff on the risks and benefits of the C19 vaccines and offer to administer the vaccine to staff.In an interview on 08/25/2025 at 10:00 AM with Staff BB (Resource Infection Preventionist) and HH (Human Resource), Staff HH stated they do not keep records of staff C19 vaccinations or education of the vaccinations. Staff HH stated they understood that the Infection Preventionist (Staff BB) would keep employee records of the C19 vaccinations. Staff BB reviewed the infection preventionist records and stated they did not educate or offer any staff the C19 vaccine. Staff BB was unable to provide any staff C19 vaccination education or documentation staff were offered the C19 vaccination. Reference: WAC 388-97-1320

Based on observation, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and revised periodically and as needed for 5 of 19 sample residents whose CPs were reviewed (Residents 57, 28, 2, & 11). This failure placed residents at risk for unmet care needs, unnecessary care, and frustration.Findings included.<Facility Policy>According to the facility's revised 04/2025 Comprehensive Care Planning policy, the facility's Interdisciplinary Team (IDT) would develop a comprehensive, person-centered CP including measurable goals and timeframes. The policy showed CPs would be reviewed and revised quarterly, and as needed to meet the resident's ongoing needs. <Resident 57> According to the 07/18/2025 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 57 used hearing aids. Review of the revised 07/30/2023 “impaired communication…” CP showed Resident 57 required hearing aids. Resident 57’s “alteration in sensory…” CP showed staff should provide Resident 57 with hearing aids daily. Observation on 08/25/2025 at 8:18 AM, 08/22/2025 at 7:52 AM, 08/22/2025 at 7:57 AM, 08/26/2025 at 10:36 AM, and 08/26/2025 on 11:52 AM showed Resident 57 in bed with no hearing aids. In an interview on 08/26/2025 at 1:16 PM Staff J (Resident Care Manager - RCM) stated Resident 57 did not wear the hearing aids for a long time. Staff J stated the CP should be updated to reflect the resident’s preference. <Resident 28> Review of the 06/11/2025 Quarterly MDS showed Resident 28 had a mental health diagnosis. The MDS showed Resident 28 received an antipsychotic medication to treat this condition. Review of the physician’s orders showed a 05/07/2025 order for an antipsychotic medication to treat Resident 28’s mental health condition. Review of Resident 28’s comprehensive CP showed a revised 07/09/2024 psychotropic medication CP was developed. There was no CP developed to address Resident 28’s mental health diagnosis. In an interview on 08/26/2025 at 10:39 AM Staff J reviewed Resident 28’s CP and stated no CP was developed to address Resident 28’s mental health diagnosis, only their medication. Staff J stated a CP should have been developed to address the diagnosis but was not. <Resident 2> According to the 08/14/2025 Quarterly MDS, Resident 2 had multiple medical complex conditions including kidney failure and heart failure. The MDS showed Resident 2 had no impairment in functional range of motion on both arms and legs. The MDS showed Resident 2 had no swallowing issues and had an order for soft food. The MDS showed Resident 2 did not use a feeding tube during the assessment period. Review of the August 2025 Physician Order showed a 03/05/2025 order directed staff to provide regular diet, soft texture with thin liquid to Resident 2 each meal. Observations on 08/20/2025 at 12:02 PM, 08/21/2025 at 8:06 AM, and 08/25/2025 at 12:13 PM showed Resident 2 was eating breakfast and lunch meals with staff assistance without any swallowing problem. In an interview on 08/20/2025 at 3:31 PM, Resident 2’s representative stated Resident 2 had not used a feeding tube for food since May 2025 because they were eating soft food with no difficulty. Review of Resident 2’s 02/07/2025 Nutritional Care Plan showed Resident 2 required a tube feeding and the interventions directed staff to keep Resident 2’s head of bed up. The CP showed Resident 2 was dependent on the feeding tube for nutrition and staff to obtain and monitor labs as ordered. In an interview on 08/26/2025 at 11:52 AM, Staff F (RCM) stated Resident 2 was not using the feeding tube anymore. Staff F stated staff should update the CPs, but they did not. <Resident 11> According to the 08/07/2025 Quarterly MDS Resident 11 had diagnoses of a Stroke (poor blood flow to the brain causing cell death) and non- Alzheimer’s Dementia. The MDS showed Resident 11 was dependent on staff for bathing, dressing, toileting, and all hygiene needs. Review of Resident 11’s health records showed an ADL Self-Performance Deficit CP with an intervention of shower/bathe self twice weekly and as needed, two days a week not specified on the CP. Observation on 08/21/2025 at 11:50 AM showed Resident 11 dependent on staff for all mobility and care. Resident 11 was lying in bed wearing a gown. In an interview on 08/26/2025 at 9:21 AM Staff J stated the CP should show bed baths twice a week on Mondays and Fridays and as needed. Staff J stated it was important to update the CP, so staff knew how to care for and assist Resident 11. Staff J stated physical therapy completed an assessment on Resident 11 and recommended getting them up in their wheelchair daily for mobility purposes with pillows to prop them from falling toward their weak side, but the CP did not reflect positioning or instruct staff to get Resident 11 up daily in their wheelchair. Refer to F677 - ADL Care for Dependent Residents. Reference: WAC 388-97-1020(2)(c)(d).

Based on observation, interview, and record review the facility failed to ensure residents admitted with Indwelling Catheters (I/C - a flexible tube inserted into the bladder) were assessed for the continued need for a I/C, attempted to remove the I/C as soon as possible for 1 (Resident 9) of 3 residents reviewed for the I/C. These failures placed residents at risk for urinary tract infections, decreased bladder tone (muscle strength), urethral erosion (gradual destruction of the tissues), and dignity issues. Findings included .According to the facility's 01/2025 Indwelling Catheter Care policy, Staff would provide catheter care to each resident with an I/C every day and as needed to promote hygiene, comfort and decrease the risk of infection.<Resident 9>According to the 07/27/2025 admission 5-day Minimum Data Set (MDS - an assessment tool), Resident 9 admitted to the facility on [DATE] and was assessed as cognitively impaired and had the indwelling catheter during the assessment period. In an interview on 08/20/2025 at 1:23 PM, Resident 9's representative stated Resident 9 went to the hospital in June 2025 and they inserted this catheter in her bladder. Resident 9 came to this facility on 06/23/2025 from the hospital and no one talk to them about the catheter. Review of the 08/18/2025 bowl and bladder assessment in Resident 9's record showed Resident 9 was incontinent of bowel and bladder. Resident 9's record showed no I/C assessment showing the reason Resident 9 had a catheter in their bladder. Observations on 08/20/2025 at 11:21 AM and 08/22/2025 at 9:02 AM showed Resident was lying in bed and an I/C was hanging on the bed frame. Observation on 08/25/2025 at 10:39 AM showed Resident 9 was up in a wheelchair in their room and I/C bag was resting on the floor under their wheelchair in their room. Review of the 06/24/2025 Physician Order showed Resident 9 had an I/C, and staff were to provide catheter care every shift. Review of the 06/24/2025 Indwelling Catheter Care Plan showed interventions instructing staff to provide I/C care every shift for Resident 9. In an interview on 08/26/2025 at 10:44 AM, Staff F (Resident Care Manager) stated the facility process for I/C care was ; when a resident got admitted to the facility from the hospital with an I/C, staff would complete bowel and bladder assessment, why a resident needed I/C, would consult with a provider and attempt a trial to remove a catheter and would complete post void residual (PVR - amount of urine remaining in bladder after a voluntary urination). If a resident had difficulty voiding independently and had PVR more than 200 milli liters, staff would consult with the provider. Staff F reviewed Resident 9's record and said they did not assess Resident 9 for an I/C. Staff F did not provide documentation about why Resident 9 needed an I/C in bladder. Staff F stated the facility did not attempt a trial to remove the catheter. Staff F stated staff should assess the resident for need of I/C, attempt a trial to remove the catheter and complete PVR, but they did not. REFERENCE: WAC 388-97-1060 (2)(a)(iii).

Based on observation, interview, and record review the facility failed to offer and provide individualized activities plans and to document the refusals for 2 of 3 residents (Resident 11 & 2) reviewed for activities. Failure to consistently offer and provide meaningful individual activity plans left residents at risk of boredom, frustration, isolation, and a diminished quality of life.Findings included. According to the facility's 04/2025 Activities Programming policy, the facility would ensure activities were available for all residents to meet resident's needs and interest that would support the physical, mental, and psychosocial well being of the resident. The policy showed the facility would conduct an activity evaluation at admission time to determine resident's preferences and interests including cultural preferences and spiritual preferences. The facility staff would make efforts to accommodate resident's preferences according to activity calendar. The policy showed the facility would provide assistance to transfer residents in wheelchair for activities, provide proper seating and positioning and placements of supplies for residents with physical limitations.<Resident 11> According to the 08/07/2025 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 11 was readmitted to the facility on [DATE]. The MDS showed Resident 11’s activity preferences for customary routine were not assessed. Review of the 08/08/2025 Dependent on Staff for Activities Care Plan (CP) showed activities staff would provide 1:1 room visits for music, hand massage, and hair care. The CP showed Resident 11 required escort by staff to group activities and staff would provide assistance during group activities. Observations on 08/21/2025 at 9:58 AM, 11:50 AM, and 12:58 PM, 08/22/2025 at 7:55 AM, 9:38 AM, 11:11 AM, and 1:21 PM, and 08/25/2025 at 8:35 AM, 12:01 PM until 1:12PM, 08/26/2025 at 8:20 AM until 9:16 AM showed Resident 11 lying in bed in a gown. These observations showed no music was playing and Resident 11’s television was turned off. These observations showed Resident 11 was dependent on staff for all mobility and care. During the 08/25/2025 at 8:35 AM Resident 11 was restless, sweaty, and agitated, and unable to verbally express discomfort or utilize call light. In an interview on 08/26/2025 at 9:21 AM Staff J (Resident Care Manager -RCM) stated Resident 11 was dependent on staff for all mobility and care. Staff J stated Resident 11 “really lit up when staff would play music for them and they could tell the resident really enjoyed music.” Staff J stated staff should turn music or the TV on for Resident 11 during the day when they’re in their room. Staff J stated Resident 11 was nonverbal, so staff had to anticipate all the residents’ needs. Staff J stated they expected staff to get Resident out of bed daily per their CP. In an interview on 08/26/2025 at 10:27 Staff Y (Activities Director) stated they have requested staff to get Resident 11 out of bed so they could attend group activities, but it hasn’t happened. Staff Y stated when Resident 11 was sleeping they would document “Not Applicable” in their records for activities offered. Staff Y stated they expected activities offered and refused to be documented in the residents’ records, but they were not. Staff Y was unable to provide documentation for activities offered for Resident 11. Staff Y stated it was important to offer and provide activities to residents for quality of life and because they looked forward to socialization and entertainment. <Resident 2> According to the 05/14/2025 Quarterly MDS, Resident 2 was assessed with medically complex conditions including depression. The MDS showed activity preferences including listening to music, participating in favorite activities, and in religious services were very important to Resident 2. The MDS showed Resident 2 was dependent on staff to get out of bed and had no rejection of care during the assessment period. Record review showed the 02/19/2025 revised Activities CP showed Resident 2 had impaired vision and could not see TV images or read the captions. The CP included goals for Resident 2 to participate in one-to-one visits as much as possible from staff and attend activities of choice. The CP showed Resident 2 required escort by staff to group activities and staff would provide assistance during activities such as; religious services, music/entertainment, exercise, and basic word games. Observations on 08/20/2025 at 10:33 AM and 1:57 PM, on 08/21/2025 at 8:02 AM, 10:45 AM, and 2:32 PM, on 08/22/2025 at 9:20 AM and 2:43 PM, and on 08/25/2025 at 7:53 AM, 9:46 AM, and 1:32 PM showed Resident 2 lying in their bed awake, in hospital gown. These observations showed no music was playing in Resident 2’s room and television was turned off. In an interview on 08/25/2025 at 11:02 AM, Resident 2 stated they could not see the television because their one eye was bad. Resident 2 stated they would like to attend activities such as listening to music and going outside for fresh air and church services but needed assistance from staff for all mobility and care. In an interview on 08/25/2025 at 11:02 AM, Staff F (RCM) stated Resident 2 required assistance from staff with transferring from bed to wheelchair and Resident 2 refused care at times. When asked about activities for Resident 2, Staff F stated Resident 2 would like to stay in their room most of the time. Staff F stated staff should check with the resident and get them up in a wheelchair for activities per Resident 2’s preferences. In an interview on 08/27/2025 at 9:00 AM, Staff Y stated activities were important to help take people's minds off problems, as it gives residents meaning for life, and to give them something to look forward to. Staff Y stated Resident 2 was sleeping in their room most of the time and activity staff would not bother them. Staff Y stated Resident 2 could not see but staff turned the television on at times. When asked Staff Y about Resident’s preferences according to assessment and CP, Staff Y stated they did not have a radio to play music in Resident 2’s room and they would ask Resident 2’s daughter to bring a radio or music player to play music in Resident 2’s room. Staff Y did not provide documentation for activities offered or refusals for Resident 2 including religious services and fresh air outside. Staff Y stated staff should get Resident 2 up in a wheelchair for activities as CP, but they did not. REFERENCE: WAC 388-97- 0940(1).

Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs - bathing, grooming, getting up, oral hygiene etc.) to residents dependent on staff assistance for ADL for 4 of 6 (Residents 10, 2, 11, & 13) residents reviewed for ADLs and 1 supplemental resident (Resident 53). The failure to provide assistance with showers, dressing, oral hygiene, and getting out of bed left residents at risk for frustration, poor hygiene, embarrassment, and diminished quality of life. Findings included. <Facility Policy>According to the facility's revised 07/2015 ADL policy, Certified Nursing Assistants (CNAs) would provide ADL assistance to residents according to their individualized Care Plans (CPs). The policy showed CNAs would document the ADL assistance provided in the residents' medical records<Resident 10> According to the 07/22/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 10 admitted to the facility on [DATE] with medically complex conditions including respiratory failure and kidney issues. The MDS showed Resident 10 had no functional limitations in their arms or legs. The MDS showed Resident 10 was dependent on staff for lower body dressing and toileting needs and required one-person assistance from staff with personal hygiene, transfers, and showers. The MDS showed Resident 10 had no behavior of refusing care during the assessment period. According to the revised 08/19/2025 ADL Self-Care Performance Deficit Care CP, Resident 10 required one-to-two-person assistance from staff with toileting, transferring, and personal hygiene including showering and oral care, and dressing. Observations on 08/20/2025 at 10:47 AM, on 08/21/2025 at 11:22 AM, and on 08/22/2025 at 10:34 AM showed Resident 10 lying in bed in a hospital gown, not shaved, with greasy hair, and their teeth not brushed. On each occasion Resident 10’s toothbrush was noted to be dry and placed in a wash basin near their closet In an interview on 08/22/2025 at 12:53 PM, Resident 10 stated no one helped them to brush their teeth. Resident 10 was seated in their wheelchair wearing a hospital gown, with greasy, uncombed hair and unbrushed teeth. In an interview on 08/22/2025 at 1:03 PM, Staff S (Certified Nursing Assistant - CNA) stated Resident 10 was asleep this morning so they only assisted to change them. Staff S stated they did not help the resident to brush their teeth. Staff S looked for Resident 10’s toothbrush in their room and it took a while for the staff to find the toothbrush. Staff S stated they should provide oral care to assigned residents in the morning, dress them, and brush their hair before helping them into their wheelchair, but they did not. In an interview on 08/26/2025 at 10:18 AM, Staff F (Resident Care Manager - RCM) stated they expected staff to check all assigned resident’s preferences related to ADLs and provide the assistance they needed every morning. Staff F stated staff should provide morning care including oral care, hair care, dressing, and assistance to get up per the residents’ preferences. Staff F stated if the resident refused care, staff should document the refusals. Staff F stated staff should provide oral care, hair care, shaving, dressing, and assistance to get up for meals to Resident 10, but they did not. <Resident 2> According to the 05/14/2025 Quarterly MDS, Resident 2 admitted to the facility on [DATE], had impaired memory, and required maximal assistance with personal hygiene, toileting, and transferring. The MDS showed Resident 2 had no behavior of refusing care during the assessment period. According to the 02/07/2025 revised ADL Self-Care Performance Deficit CP, Resident 2 required two-person assistance with a mechanical lift (a machine to assist with transferring) to transfer from their bed to their wheelchair. Review of Resident 2’s Kardex (care instructions for CNAs) on 08/22/2025 showed CNAs should offer and assist the resident to get out of bed every day before lunch and help them back to bed after lunch. Observations on 08/20/2025 at 10:22 AM, on 08/21/2025 at 1:39 PM, and on 08/22/2025 at 12:20 PM showed Resident 2 lying in bed in a hospital gown. Staff were observed assisting the resident with lunch while the resident remained in their bed. In an interview on 08/26/2025 at 11:52 AM, Staff F stated they expected staff to follow the CP and Kardex regarding Resident 2’s daily routine and preferences. Staff F stated if the resident refused, staff should document the refusals. Staff F stated staff should dress the resident per their preferences and get them up for lunch and activities as needed, but they did not. <Resident 11> According to the 08/07/2025 Quarterly MDS Resident 11 was dependent for all cares. The MDS showed Resident 11 had medical conditions including stroke and non-Alzheimer’s Dementia. Review of a 06/08/2025 ADL Self Care Performance Deficit related to impaired functional mobilities CP showed an intervention to get Resident 11 out of bed from 11:00 AM until 3:00 PM. The CP showed Resident 11 required assistance from staff for transfers, bed mobility, and dressing. Review of Resident 11’s health records showed no bathing was offered or provided for June, July, or August of 2025. Observations on 08/21/2025 at 9:58 AM, 11:50 AM, and 12:58 PM, 08/22/2025 at 7:55 AM, 9:38 AM, 11:11 AM, and 1:21 PM, and 08/25/2025 at 8:35 AM, 12:01 PM until 1:12PM, 08/26/2025 at 8:20 AM until 9:16 AM showed Resident 11 lying in bed in a gown. In an interview on 08/26/2025 at 9:21 AM Staff J (RCM) stated Resident 11 was dependent on staff for all mobility and cares. Staff J stated Resident 11 should be offered bed baths every Monday, Friday, and as needed. Staff J was unable to provide documentation that bathing was offered for June, July, or August 2025. Staff J stated bathing was important for good hygiene and good health. Staff J stated the last time Resident 11 was assisted out of bed was for an eye examination in June 2025. Staff J stated Resident 11 should be getting up, dressed, and out of bed daily for quality of life. Staff J stated Resident 11 was nonverbal, so staff had to anticipate all the residents’ needs. <Resident 13> According to the 06/04/2025 Quarterly MDS Resident 13 was dependent on staff for toileting hygiene and bathing. The MDS showed Resident 13 required substantial assistance from staff for dressing. The MDS showed Resident 13 had medical conditions including stroke and non-Alzheimer’s Dementia. Review of Resident 13’s health records showed a 07/29/2023 ADL Self Care Performance Deficit related to weakness and decreased mobility CP with bathing twice weekly, per the resident’s preference, and as needed. The CP showed Resident 13 required staff assistance with bathing and dressing. In an interview on 08/20/2025 at 10:09 AM Resident 13 stated staff always left them in bed and never got them dressed. Resident 13 stated they were incontinent of bowel and bladder, and staff cleaned them up once a day. Observation on 08/22/2025 at 9:31 AM showed Resident 13 received a shower, was placed back into a hospital gown, and returned to bed. In an interview on 08/26/2025 at 8:58 AM Staff W (CNA) stated they were expected to check on Resident 13 at least every two hours and provide incontinent care when needed. Staff W stated they were expected to offer and provide assistance with morning ADL cares to all residents needing help which included washing up, incontinence or toileting assistance, dressing, and oral hygiene. In an interview on 08/26/2025 at 9:21 AM Staff J stated they expected staff to offer Resident 13 bathing twice weekly on Sundays and Fridays per the schedule, and as needed. Staff J reviewed Resident 13’s records and stated Resident 13 was not offered bathing twice weekly for June, July, or August 2025. Staff J stated they expected staff to assist Resident 13 with dressing and getting out of bed daily, but Resident 13 would refuse sometimes. Staff J reviewed Resident 13’s records and was unable to provide documentation of refusals. Staff J stated they expected staff to document refusals to show they were offering the resident cares per CP. <Resident 53> According to the 05/08/2025 Quarterly MDS, Resident 53 had diagnoses including a spinal cord injury, lower body paralysis, and muscle weakness. The MDS showed Resident 53 was dependent on staff for transferring from their bed to a chair and required partial/moderate assistance with bathing themselves. The MDS showed Resident 53 had intact memory. In an interview on 08/20/2025 at 2:05 PM Resident 53 stated they were frustrated because they were supposed to get two showers a week on Mondays and Fridays, but they did not receive showers per the schedule in their CP. Resident 53 stated they felt “cheated.” Resident 53 was in bed at the time. According to the 12/16/2024 ADL CP, Resident 53 required 1-person assistance with showering. This CP showed Resident 53 should receive bathing/showering twice a week and as needed. Review of the CNA shower documentation showed from 07/25/2025 through 08/22/25 Resident 53 showered on only three occasions out of eight scheduled shower days (Resident 53 was out of the facility from 08/09/2025 to 08/13/2025): 07/28/2025, 08/04/2025, and 08/18/2025. There were no documented refusals of bathing assistance. In an interview on 08/26/2025 at 1:05 PM, Staff J (Resident Care Manager) stated they knew showers were important to Resident 53 and felt the resident was provided showers as care planned. Staff J reviewed the CNA shower documentation and stated there could also be showers documented in the unit shower book. Review of the 300 Unit shower book showed documentation Resident 53 was also provided with a shower on 08/22/2025. This meant Resident 53 received a total of four showers out of eight scheduled shower days. In an interview on 08/26/2025 at 1:02 PM, Staff J stated they would provide any additional documentation showing Resident 53 received showering assistance as required. No additional documentation was provided. REFERENCE: WAC 388-97-1060 (2)(c).

Based on observation, interview, and record review the facility failed to ensure 1 (Resident 1) of 1 sample residents reviewed for communication was provided with a functional communication system. Failure to identify and provide services to maintain effective communication placed residents at risk for unmet care needs, social isolation, and a diminished sense of well-being. Findings included . <Facility Policy>On 08/25/2025 at 1:13 PM, Staff A (Executive Director) stated they did not have language and communication policy for residents with English as a second language. <Resident 1>According to the 06/25/2025 admission Minimum Data Set (MDS - an assessment tool), Resident 1 admitted to the facility on [DATE] with multiple medical conditions and had no memory issues. The MDS showed Resident 1 was Asian, had clear speech and made self-understood and able to understand others. The MDS showed Resident 1's preferred language was not English and needed interpreter to speak with health care staff. Observations on 08/20/2025 at 2:27 PM, and 08/22/2025 at 9:19 AM showed Resident 1 lying in their bed in their room and mumbling in their language. A note was posted on a wall for a language line phone number in Resident 1's room. In an interview on 08/22/2025 at 9:20 AM, Resident 1 opened their eyes, mumbled, and was unable to make themselves understood to the surveyor. Resident 1 was observed tapping on their right leg multiple times.Observations on 08/22/2025 at 10:33 AM and on 08/25/2025 at 11:23 AM showed staff F (Resident Care Manager) assisting with Resident's feeding tube (a soft, flexible tube inserted in stomach for individual unable to swallow to meet their nutritional needs) and oxygen (the process of adding oxygen to body's tissues to maintain cellular function and life, involving the lungs for gas exchange and circulation). Resident 1 mumbled but Staff F could not understand the resident. Staff F was not observed to use the language line phone number to assist with communication to provide better care to Resident 1.Review of the revised 10/28/2024 Communication Care Plan (CP) showed Resident 1 had a communication problem related to a language barrier. The CP had nursing interventions instructing staff to anticipate and meet Resident 1's needs. The CP showed Resident 1 only understood and spoke preferred language and instructed staff to call the resident's family or to use the language line whenever needed to communicate with the resident. In an interview on 08/25/2025 at 10:52 AM, Resident 1's representative at bed side in Resident 1's room stated Resident 1 did not speak English at all. Resident 1's representative stated they visited the resident this morning and noticed the resident with shortness of breath but the resident was not able to explain that to staff. Resident 1 was observed with oxygen in their nose and lying in their bed comfortably at that time. In an interview on 08/26/2025 at 11:26 AM, Staff F stated Resident 1 could not speak English and communicated with staff by facial expressions. Staff F stated they posted the language line phone number in Resident 1's room for when staff needed an interpreter to communicate with the resident. When asked how facility staff communicated with the resident while providing care during day and night shifts, Staff F stated they should have a communication binder with everyday words and pictures in Resident 1's room for better communication with the resident, but they did not have one. REFERENCE: WAC 388-97-1620 (2)(a)(v).

Based on observation, interview, and record review the facility: failed to ensure physician's orders were followed for 3 of 19 (Residents 11, 62, & 5) sampled residents; failed to ensure nurses only signed for treatment once provided for 1 of 19 (Resident 1) sampled residents; failed to ensure physician's orders were clarified as needed for 1 of 19 (Resident 1) sampled residents; ensure physician's orders were in place prior to care for 2 of 19 (Residents 1 & 53) sampled residents. These failures placed residents at risk for unmet needs, and ineffective and/or delayed treatments. Findings included.<Following Orders> <Resident 11> According to the 08/07/2025 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 11 was at risk of pressure ulcers. The MDS showed Resident 11 had a pressure reducing device for their bed. Review of Resident 11’s 08/19/2025 Pressure Ulcer Development related to Impaired Functional Abilities Care Plan (CP) showed an intervention of a pressure relieving/reducing device for the resident’s bed. The CP also included an intervention of an air mattress with a weight setting of 170-180 pounds for Resident 11. Review of Resident 11’s physician’s orders showed an order for air mattress with a weight setting 160-180 pounds, check function and inflation every shift. Observations on 08/21/2025 at 9:58 AM, 08/22/2025 at 7:55 AM, and 08/25/2025 at 8:35 AM showed Resident 11’s air mattress setting was 300 pounds. Observation on 08/25/2025 at 8:35 AM showed Resident 11 restless, sweaty, agitated, and unable to verbally express discomfort. In an interview on 08/25/2025 at 8:35 AM Staff J (Resident Care Manager - RCM) stated Resident 11’s air mattress settings should not be at 300 pounds. Staff J reviewed Resident 11’s physician orders and stated the air mattress should be set at 160-180 pounds but the air mattress Resident 11 had was unable to accommodate those settings. Staff J stated Resident 11’s air mattress could only be set at 50-pound increments, so the order needed to be clarified with the physician to allow a setting of 150 pounds since Resident 11 weighed 168 pounds. Staff J stated it was important to follow physician’s orders and set the air mattress at an appropriate weight for the residents to relieve pressure and reduce the risk of pressure ulcer development. <Resident 62> According to the 08/1/2025 Quarterly MDS, Resident 62 had multiple medically complex diagnoses including heart failure, high blood pressure (BP), atrial fibrillation (irregular electrical signals of the heart) and used blood thinning medications. Review of Resident 62's physician’s orders showed the resident received a medication to lower their BP with instructions to hold the medication if the resident’s Systolic BP (the pressure in your arteries when your heart beats, the larger BP value) was less than 100. Review of the August 2024 MAR showed this medication was administered on two occasions when Resident 62's SBP was less than 100: on 08/03/2025 at 10:48 AM for a value of 99 and on 08/10/2025 at 9:21 AM for a value of 98. Review of Resident 62's physician’s orders showed the resident received a diuretic medication (used to increase urinary output) with instructions to hold the dose when the resident’s SBP was less than 100 or their pulse less than 60. Review of the August 2024 MAR showed medication was administered on one occasion when Resident 62's SBP was less than 100 on 08/10/2025. In an interview on 08/22/2025 at 1:30 PM, Staff J reviewed Resident 62’s August 2025 MAR and confirmed the blood pressure and diuretic medications were administered outside parameters on 3 occasions. Staff J stated they expected staff to hold medications as ordered. <Resident 5> According to the 06/20/2025 Quarterly MDS Resident 5 had two stage 2 pressure ulcers at the time of their 06/17/2023 admission and was at risk of developing additional pressure ulcers. The MDS showed Resident 5 had a pressure-reducing device for their bed. Review of Resident 5’s record showed a physician’s order for an air mattress to be set to 100-110 lbs. The order showed staff should monitor the mattress for functionality every shift. Review of Resident 5’s August 2025 MAR showed staff documented the air mattress was monitored every shift. Observations on 08/20/2025 at 8:47 AM, 08/21/2025 at 9:32 AM, and 08/22/2025 at 7:55 AM showed Resident 5’s air mattress weight indicator was set at 200 pounds. In an interview on 08/21/2025 at 09:38 AM, Resident 5 stated the bed was not particularly comfortable and explained that was why they asked for so many pillows. In an interview on 08/22/2025 at 8:16 AM Staff Q (Licensed Practical Nurse) confirmed Resident 5’s air mattress was set at 200 pounds and should have been set at 100 pounds per the physician’s orders. Staff Q stated it is important to follow the physician’s orders to provide therapeutic benefit and comfort for the residents. <Signing for Medications Administered> According to the 06/25/2025 admission MDS, Resident 1 had medically complex conditions including a stroke with left arm weakness and difficulty swallowing. The MDS showed Resident 1 received nutrition via a feeding tube during assessment period. In an interview on 08/22/2025 at 9:13 AM, Staff K (Registered Nurse) stated they administered all morning medications to Resident 1 that morning. Staff K opened Resident 1’s August 2024 Medication Administration Record (MAR) and showed none of the morning medications were signed for that day to indicate staff administered morning medications to Resident 1. In an interview on 08/22/2025 at 9:25 AM, Staff K stated they were supposed to sign the MAR as soon as the morning medications were administered to Resident 1, but they did not. <Clarifying Orders> <Resident 1> Observations on 08/20/2025 at 11:50 AM, on 08/21/2025 at 2:01 PM, and on 08/22/2025 at 10:18 AM showed Resident 1 lying in bed with a feeding tube providing artificial nutrition at 45 Milliliter per Hour (ML/hour). Review of Resident 1’s physician’s orders showed a 08/14/2025 order directing staff to administer artificial nutrition at 45 ML/hour via a feeding tube. There was no order showing what type of artificial nutrition to administer for Resident 1. In an interview on 08/22/2025 at 11:10 AM, Staff F (RCM) stated their expectation was for staff to administer medications and artificial nutrition to residents as ordered. Staff F reviewed Resident 1’s physician orders and stated there was no order showing what artificial nutrition to administer for Resident 1. Staff F stated staff should have clarified the orders with a provider but did not. <Obtaining Orders Prior to Care> <Resident 1> Observations on 08/21/2025 at 11:52 AM and on 08/22/2025 at 10:18 AM showed Resident 1 was lying in their bed receiving oxygen on at 2 liter per minute via nasal cannula (tubing providing supplemental oxygen directly to the nostrils). Resident 1 was observed removing the cannula from their nose and throwing it on the floor. Review of Resident 1’s physician’s orders showed no order for oxygen for Resident 1. In an interview on 08/22/2025 at 11:06 AM, Staff F reviewed Resident 1’s physician’s orders and confirmed there was no oxygen order. Staff F stated it was important to have physician’s orders in place prior to providing the resident care. Staff F stated the facility should have obtained an order from the provider to administer Oxygen for Resident 1 but did not. <Resident 53>According to the 05/08/2025 Quarterly MDS, Resident 53 had diagnoses including lower body paralysis, a spinal cord injury, and deep tissue damage at the base of spine caused by pressure. The MDS showed Resident 53 was at risk for pressure injuries and had moisture associated skin damage. The MDS did not show Resident 53 had a pressure-reducing device for their bed. Observation on 08/20/2025 at 2:09 PM showed Resident 53 lying in bed. The mattress on the bed was a low air loss mattress used to reduce pressure when there is a risk of pressure injury. According to a 08/13/2025 physician’s orders, Resident 53 “may have pressure relieving/reducing device on bed.” There were no more specific orders directing staff to use a low-air-loss mattress. In an interview on 08/26/2025 at 12:57 PM, Staff J stated they did not see an order for a low air loss mattress in Resident 53’s record. Staff J stated there should be an order. Staff J stated there was a low air loss mattress order in place prior to Resident 53’s recent hospitalization. In an interview on 08/27/2025 at 9:52 AM, Staff B (Director of Nursing) stated it was important for physician's orders to be clarified when they were not specific. REFERENCE: WAC 388-97-1000 (1)(b).

Based on observation, interview, and record review the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) level 2 comprehensive evaluation (a process to determine what mental health services residents required after a level 1 PASRR identified potential indicators of Serious Mental Illness - SMI) were obtained for 2 of 5 residents (Residents 1 & 3) whose PASRRs were reviewed. This failure placed residents at risk for not receiving the necessary mental health care and services they needed, frustration, and unmet mental health needs. Findings included. <Policy>According to the facility's revised 09/2018 PASRR policy, a PASRR would be completed upon admission rather than prior to admission as required. The policy showed based on assessment, residents would be referred to the state PASRR office for evaluation for specialized mental health services. The policy showed the facility's social services office was responsible for communication with the PASRR office.<Resident 1> According to the 06/25/2025 Admission/5-Day Minimum Data Set (MDS – an assessment tool) Resident 1 originally admitted to the facility on [DATE] with a diagnosis of depression. The MDS showed Resident 1 received an antidepressant medication every day of the assessment period. Review of Resident 1’s record showed the facility started a course of antidepressant medication for Resident 1 on 12/31/2024 to treat the resident’s depression. Review of Resident record showed a 04/01/2025 PASRR level 1 with “level 2 evaluation required for serious mental illness” and was completed four months after Resident 1 was diagnosed with depression. Review of Resident 1’s record on 08/26/2025 showed no follow up on the level 2 PASRR. In an interview on 08/26/2025 at 12:07 PM, Staff G (Corporate Social Service Resource) stated they were aware Resident 1 started antidepressant treatment on 12/31/2024 and the facility did not update the level 1 PASRR until 04/01/2025, four months late. Staff G stated the facility needed to update the level 1 PASRR as soon as the resident started the treatment for depression and the facility should request the State PASRR office complete a level 2 PASRR evaluation. Staff G stated the facility’s Social Services Director worked by themselves in the facility and could not follow up on all the PASRRs. <Resident 3> According to the 05/22/2025 Quarterly MDS, Resident 3 had a diagnosis of a psychiatric mood disorder. The MDS showed Resident 3 had no rejection of care. Review of Resident 3’s health records showed a 05/06/2024 PASSR level 1 with “level 2 evaluation required for serious mental illness. Resident 3’s records did not include a level 2 PASRR. In an interview on 08/26/2025 at 9:21 AM Staff J (Resident Care Manager) stated Resident 3 had behaviors often. In an interview on 08/26/2025 at 11:51 AM Staff G stated they sent the referral for a level 2 evaluation on 05/06/2024 and followed up on 08/11/2025, over one year and three months after the referral was initially made. Staff G stated it was the state PASRR office’s fault for not doing the evaluation. When Staff G was asked if the facility should follow up to ensure their residents are receiving necessary mental health services, Staff G stated the regulation only said “timely” and declined to provide a timeframe for what timely meant or say whether a delay of over a year and three months was timely or not. In an interview on 08/27/2025 at 8:44 AM Staff A (Administrator) stated they expected staff to follow up on PASRR level II reviews timely. Staff A stated follow up one year and three months later was not timely. REFERENCE: WAC 388-97 -1915 (4).

Based on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS - an assessment tool) accurately reflected the status of the resident for 2 of 19 sampled residents (Residents 53 and 71). This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included .<Resident 53>According to the 05/08/2025 Quarterly MDS Resident 53 had a condition where the bladder muscles and nerves did not function properly due to damage to the nervous system. The MDS showed Resident 53 used an indwelling catheter (tubing to assist with bladder drainage). The MDS showed Resident 53 was always incontinent of bladder.Observation on 08/20/2025 at 9:28 AM showed Resident 53 lying in bed. Resident 53's catheter was attached to the bed frame below the resident.In an interview on 08/27/2025 Staff I (MDS Coordinator) stated it was important for MDS assessments to be accurate as they were the basis for care planning for residents. Staff I stated because Resident 53 used an indwelling catheter, his incontinence status should have been coded as not rated rather than always incontinent.<Resident 71>According to the 07/17/2025 Quarterly MDS, Resident 71 was assessed with a mood score of 16 out of a possible 27 (with higher numbers indicating a worsening mood.) This assessment showed Resident 71 had a poor appetite, felt bad about themselves, and had difficulty concentrating nearly every day of the assessment's two-week lookback period. The MDS showed Resident 71 took an antidepressant medication but showed Resident 71 did not have a diagnosis of depression.Review of the physician's orders showed Resident 71 had a 10/16/2024 order of an antidepressant. The order showed to give 300 milligrams in the morning for depression.In an interview on 08/27/2025 Staff I stated as Resident 71 was actively treated for depression during the MDS assessment, Resident 71 should have been identified with a depression diagnosis on the MDS assessment.REFERENCE: WAC 388-97-1000 (1)(b).

Based on interview and record review, the facility failed to complete the comprehensive assessments within the regulatory timeframes for 1 of 2 (Residents 64) supplemental residents, and 2 of 3 resident (Resident 18 & 93) reviewed as closed records for assessments and timing. The failure to ensure comprehensive admission Minimum Data Set (MDS - an assessment tool) assessments were completed timely hindered the care planning process necessary to provide the appropriate resident care and services, and placed residents at risk for unidentified care needs, delayed services, and a decreased quality of life. Findings included. <Resident Assessment Instrument (RAI - instructional guidelines for MDS completion) Manual>The October 2019 RAI Manual outlined an admission MDS was a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1. The manual outlined an Annual MDS was a comprehensive assessment for a resident that must be completed on an annual basis and the completion date must be no later than 14 days after the Assessment Reference Date (ARD).<Resident 64>According to the 07/16/2025 admission 5 Day Minimum Data Set (MDS- an assessment tool), Resident 64 was admitted to the facility on [DATE] with multiple medical conditions including heart failure. Review of the MDS with ARD date 07/16/2025 and the completion date by the MDS Coordinator showed 07/31/2025, 15 days past the regulatory time frame as required. <Resident 18>According to the 07/15/2025 admission MDS, Resident 18 was admitted to the facility on [DATE]. Review of the date of MDS completion by the RN Coordinator showed 07/31/2025, five days past the regulatory timeframe as required. <Resident 93>According to the 07/16/2025 admission MDS, Resident 93 was admitted to the facility on [DATE]. Review of the MDS completion date by the RN Coordinator showed 07/31/2025, 15 days past the regulatory timeframe as required. In an interview on 08/26/2025 at 2:20 PM, Staff I (MDS Coordinator) stated it was important for comprehensive assessments to be completed timely for resident care and for the purposes of facility reimbursement. Staff I stated if the MDS was not completed timely, then the residents care plans will not be initiated to provide appropriate care. Staff I stated they started working in this facility for a month and when they started working here, facility had no MDS Coordinator. Staff I stated they were aware the facility was behind with the completion of their residents' MDS assessments. REFERENCE: WAC 388-97-1000(b)(c)(ii), (3)(a)

Based on observation, interview, and record review the facility failed to provide information and assistance to formulate an Advance Directive (a document describing a resident's wishes for care if they became incapacitated) for 2 of 4 residents (Resident 11 & 8) reviewed for advanced directives. This failure left residents at risk for losing the right to have their preferences and choices honored during emergent and end of life care. Findings included .<Policy>According to a facility policy titled, Advanced Directives and Associated Documentation, date 04/2025, showed the facility would provide written information to formulate an advance directive prior to, upon, or immediately after admission to all residents or their representative. The policy showed staff would document in the resident's record at the time of admission, the resident or representative had been provided written information regarding advance directives. The policy showed if a resident already had an advance directive staff would obtain a copy and place in the resident's records. <Resident 11>According to 08/07/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 11 readmitted to the facility on [DATE] and was rarely/never understood and their memory was severely impaired. The MDS showed Resident 11 was dependent on staff for all care. The MDS showed Resident 11 had dementia related to a stroke, altered mental status, and other disorders of the brain. Review of Resident 11's health records showed a 03/13/2025 I am interested in formulating an Advance Directive Care Plan (CP). Resident 11's records showed a 05/01/2025 Advanced Directives information form documenting Resident 11 did not have an advanced directive formulated but was interested in receiving information and assistance to formulate one. The form showed no information was provided to Resident 11. Observations on 08/22/2025 7:55 AM and 08/25/2025 8:35 AM showed Resident 11 did not verbally respond. In an interview on 08/26/2025 9:21 AM Staff J (Resident Care Manager) stated Resident 11 had a stroke and was unable to verbally communicate or make needs known. Staff J stated Resident 11's needs were anticipated by staff. Staff J stated Resident 11 did not have an advanced directive. <Resident 8>According to 07/22/2025 Quarterly MDS Resident 8 readmitted to the facility on [DATE]. The MDS showed Resident 8 would understand others and make self-understood. The MDS showed Resident 8 had severe memory impairment. The MDS showed Resident 8 had diagnoses of, but not limited to, non-Alzheimer's dementia and a progress neurological condition. Review of Resident 8's health records showed a I have an advance directive: I have a Guardian who is my decision maker CP. Resident 8's records showed an undated advance directive information form uploaded to their records on 04/16/2025 showing Resident 8 reported they had advance directive paperwork completed but also showed Resident 8 requested information on how to formulate an advance directive. In an interview on 08/26/2025 at 11:51 AM Staff H (Social Service) reviewed Resident 11s health records and was unable to provide documentation that Advanced Directive information or assistance was provided to Resident 11 or their family at the time of the 05/01/2025 request. Staff H reviewed Resident 8's records and was unable to provide documentation of an advance directive or that information and/or assistance was provided to Resident 8 to formulate an advance directive if they did not have one. In an interview on 08/27/2025 at 10:48 AM Staff B (Director of Nursing) stated they expected staff to provide information and assistance with formulating advanced directives at the time of the resident's request. Staff B stated if a resident had an advance directive, they expected staff to attempt to obtain a copy and document attempts. Reference: WAC 388-97-0280(3) (c) (i-ii), -0300 (1) (b. (3) (a-c)

Based on interview and record review, the facility failed to ensure one (Resident 9) of five sampled residents reviewed for unnecessary medications had completed consents for psychoactive medications. Additionally, the facility failed to obtain consents for safety devices including bed against the wall and floor mats both sides of bed for 2 (Resident 2 & 3) of 7 residents reviewed for safety devices. These failures did not ensure residents were notified about their medications, safety devices, and facility policies. Findings included <Resident 9> According to the 07/27/2025 admission Medicare 5 Day Minimum Data Set (MDS- an assessment tool) Resident 9 had clear speech and was able to make themselves understood. The MDS showed Resident 9 had memory issues and demonstrated no behavior of rejection of care during the assessment period. Review of August 2025 Medication Administration Record on 08/26/2025 showed Resident 9 received an antianxiety medication on 08/22/2025, 08/23/2025, 08/24/2025, and on 08/26/2025. Review of Resident 9’s record showed no resident/representative approval for the medication. In an interview on 08/26/2025 at 11:00 AM, Staff F (Resident Care Manager - RCM) reviewed Resident 9’s record and stated the facility did not receive a consent for an administration of an antianxiety medication. Staff F stated they expected staff to obtain consent from the residents/representatives before starting any medications, but they did not. <Resident 2> According to the 05/14/2025 Quarterly MDS Resident 2 had a history of falls with fractures. The MDS showed Resident 2 had memory issues and no rejection of care during the assessment period. Observations on 08/20/2025 at 3:27 PM, on 08/21/2025 at 10:49 AM, and 08/25/2025 at 12:21 PM showed Resident 2 was lying in their bed and had fall mats on the floor both sides of the bed. Review of Resident 2’s record showed no resident/representative approval for the fall mats on the floor as a safety device. In an interview on 08/26/2025 at 11:01 AM, Staff F stated they expected staff to assess the resident for any safety devices, receive a Physician order and obtain a consent from the resident/representative prior to implementing the interventions. Staff F reviewed Resident 2’s record and stated they did not have a consent for the fall mats on the floor for Resident 2. <Resident 3> According to a 05/22/2025 Quarterly MDS Resident 3 had no memory impairment. The MDS showed Resident 3 had no restraints in place. Review of Resident 3’s health records showed a 03/22/2025 Activities of Daily Living Performance Deficit Care Plan with an intervention to have the bed against the wall. Observation on 08/21/2025 at 9:36 AM showed Resident 3’s right side of bed against the wall. In an interview on 08/26/2025 at 9:21 AM Staff J (RCM) stated they did not obtain a signed consent from Resident 3 for the bed against the wall. Staff J stated they were expected to obtain a consent for the bed against the wall because it would be a form of a restraint, and the facility should ensure the resident consented to it. Reference: WAC 388-97-0300(3)(a), -0260, -1020(4) (a-b). .

Based on observation, interview, and record review the facility: Failed to ensure residents' skin was assessed weekly as ordered, monitored, and treated as required for 2 (Residents 9 & 10) of 4 residents reviewed for non-pressure skin. These failures placed all residents at risk for delay in treatment, worsening condition, unmet care needs, and a decreased quality of life. Findings included . <Facility Policy>Review of the facility's 04/2025 Skin and Wound Monitoring and Management revised policy showed the facility would provide care and services to prevent the development of new skin issues. The policy showed staff would perform weekly head-to-toe checks for all residents, document the findings in resident's record, and notify the provider to obtain treatment orders as needed. The policy showed nursing staff would implement the ordered interventions and develop a Care Plan (CP) for staff to consistently implement the care.<Resident 9> According to the 07/27/2025 admission Minimum Data Set (MDS - an assessment tool) Resident 9 had memory impairment, was understood, and able to understand others in conversation. This assessment showed Resident 9 did not have any wounds or skin problems. Observations on 08/20/2025 at 11:45 AM, 08/21/2025 at 9:21 AM, on 08/22/2025 at 2:12 PM, and on 08/26/2025 at 9:00 AM showed Resident 9 had multiple bruises on both their arms. Review of Resident 9’s August 2025 physician’s orders showed no orders directing staff to monitor the bruising on Resident 9’s arms. Review of the 06/23/2025 Skin CP showed instructions to staff to perform weekly head-to-toe skin assessments and notify the nurse supervisor immediately of any skin breakdown including redness, blisters, and bruises. Review of Resident 9’s weekly skin assessments on 08/26/2025 showed staff performed head-to-toe skin assessment for Resident 9 on 08/04/2025 and 08/25/2025. These assessments showed staff did not identify any skin impairments for Resident 9. In an interview on 08/26/2025 at 9:05 AM, Staff F (Resident Care Manager) stated the facility’s process for monitoring skin issues was for staff to perform head-to-toe skin assessments for residents upon admission, weekly, and as needed, and to document any new issues in the resident’s record. Staff F stated if staff noticed any new skin issues for any resident, they should notify the nursing supervisor, to provider and resident’s families. Staff F reviewed Resident 9’s weekly skin assessments and stated staff did not complete weekly skin checks as ordered and did not document any skin problems. On 08/26/2025 at 9:15 AM, Staff F assessed Resident 9’s skin with this surveyor and stated Resident 9 had multiple bruises on both arms that staff did not report to them. Staff F stated the 08/25/2025 weekly skin assessment was not accurate. Staff F stated staff should document all skin issues in the resident’s record and notify the provider, but they did not. <Resident 10> According to the 07/22/2025 admission MDS, Resident 10 had memory impairment, was understood, and able to understand others in conversation. This assessment showed Resident 10 did not have any wounds or skin problems. The MDS showed Resident 10 had no behavior of refusing care during the assessment period. Observations on 08/20/2025 at 10:00 AM, on 08/21/2025 at 11:21 AM, and on 08/22/2025 at 2:12 PM showed Resident 10 had a one-centimeter by one-centimeter scab with light, bloody drainage on their left cheek. Review of Resident 10’s physician’s orders showed a 07/18/2025 order directing staff to perform weekly skin checks. There was no order for treatment of Resident 10’s left cheek scab in the record. Review of Resident 10’s weekly skin assessments on 08/26/2025 showed staff last performed and documented a head-to-toe assessment for Resident 10 on 08/09/2025 and did not identify any skin impairments for Resident 10. There were no weekly skin assessments completed after 08/09/2025. In an interview on 08/26/2025 at 9:45 AM, Staff F reviewed Resident 10’s record and stated the facility staff did not perform weekly skin assessments as ordered and there was no documentation showing Resident 10 had a scab on their left cheek. Staff F stated staff should perform weekly skin assessment as ordered, document any skin impairments in Resident 10’s record, and notify the physician to obtain treatment orders, but did not. In an interview on 08/26/2025 at 9:39 AM, Staff B (Director of Nursing) stated it was their expectation staff follow the facility policy and the physician’s order to complete weekly skin assessments, notify the RCM of any new skin issues, evaluate and document the newly identified skin issue, and notify and obtain orders from the physician. REFERENCE: WAC 388-97-1060(1).

Based on interview and record review, the facility failed to ensure Basic Life Support (BLS) was initiated immediately, as directed in the facility policy, including Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air) for 1 of 1 resident (Resident 1) reviewed for unexpected death in the facility. This failed practice placed 48 additional residents (Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50 & 51), who had current physician orders to receive CPR, at serious risk for adverse outcome including death and constituted an Immediate Jeopardy (IJ). On [DATE] at 2:05 PM, the facility was notified of an IJ in F678. The facility removed the immediacy on [DATE] after they audited the records of all residents, audited the Physician Order for Life Sustaining Treatment (POLST - a form indicating the resident's wishes to have or not have CPR) binders, educated staff on the facility's Medical Emergency Response Policy for CPR, performed CPR drills and staff competency training, and implemented a plan of correction to sustain ongoing compliance. Findings included . <Facility Policy> Review of the facility policy, Cardiopulmonary Resuscitation, revised 04/2025, showed the facility would provide basic life support, including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel. The policy showed when a resident was found unresponsive, not breathing, and no pulse, the staff must activate the Emergency Medical Services (EMS) system, start CPR, and to not stop providing CPR until another trained responder or EMS personnel takes over. The policy showed the facility referred to the American Heart Association for guidelines. Review of the 2020 American Heart Association Advanced Cardiovascular Life Support Provider Manual showed the passage of time drove all aspects of emergency cardiovascular care. The guidance showed the final outcomes were determined by the intervals between collapse or onset of the emergency and the delivery of basic and advanced interventions, and that the probability of survival declined sharply with each passing minute of cardiopulmonary compromise. Review of the facility policy titled, Emergency Procedure - CPR, revised [DATE], showed key clinical staff members, who would direct resuscitative efforts, must obtain and/or maintain their American Red Cross or American Heart Association certification in BLS/CPR, and had completed training on the initiation of BLS/CPR, including the use of an Automated External Defibrillator (AED - a device that analyzes the heart's rhythm and can deliver an electric shock in cases of sudden cardiac arrest). The policy showed the licensed staff member, who was certified in CPR, should initiate CPR unless a Do Not Resuscitate order was in place or there were obvious signs of irreversible death such as rigor mortis (the stiffening of muscles that occurs after death due to chemical changes in the muscle tissue). <Resident 1> According to the [DATE] admission Minimum Data Set (MDS - an assessment tool), Resident 1 admitted to the facility on [DATE] and had medical conditions including heart disease. A [DATE] Death in Facility entry in the MDS showed Resident 1 had expired. Review of Resident 1's POLST showed it was signed by the resident on [DATE] and signed by the Physician's Assistant on [DATE]. The form showed Resident 1 wanted CPR if they were not breathing and had no pulse. The form showed Resident 1 wanted full treatment to prolong life by all medically effective means including transfer to the hospital and intensive care (Full Code). Review of Resident 1's electronic medical record showed Resident 1 was designated as a Full Code under their physician's orders. Review of a [DATE] nursing progress note showed, at 3:20 PM, Staff C (Registered Nurse) found Resident 1 sitting on the wheelchair with their head down, unresponsive without a pulse and was not breathing. The note showed Staff C performed a sternal rub (a technique to test an unconscious person's responsiveness) and when Resident 1 did not respond, Staff C left the resident to call and notify the Director of Nursing (DON). Review of the undated incident timeline provided by Staff B (DON) showed on [DATE] at 3:20 PM, Staff C found Resident 1 unresponsive, without a pulse, and was not breathing. At 3:23 PM, Staff B came to Resident 1's room with the physician assistant and asked Staff C why CPR was not being performed for Resident 1. At 3:25 PM, Resident 1 was pronounced deceased by the physician assistant. Review of Resident 1's medical records showed CPR was not performed and 911/EMS was not called to respond. In an interview on [DATE] at 2:10 PM, Staff B stated Resident 1 elected a Full Code status. Staff B stated CPR should have been initiated for Resident 1 after they were found unresponsive, without a pulse and not breathing by Staff C, who was first on the scene, but did not. In an interview on [DATE] at 2:37 PM, Staff C stated they were the first licensed staff on the scene to find Resident 1 unresponsive, without a pulse, and was not breathing. Staff C stated they did not activate the EMS or assess Resident 1 for obvious signs of irreversible death because they panicked, .I [nurse] got nervous, so I called the DON instead. Staff C stated they should have initiated CPR on Resident 1 when they initially found the resident but did not. Staff C stated Staff's D & E (Certified Nursing Assistants) were with them in Resident 1's room while waiting for the DON to arrive. Review of Staff C's CPR card showed it was renewed on [DATE]. Review of Staff D's CPR card showed it expired last [DATE] and was not current at the time of the incident on [DATE]. Review of Staff E's CPR card showed it expired [DATE] and was not current at the time of the incident on [DATE]. In an interview on [DATE] at 2:27 PM, Staff A (Administrator) stated the facility did not have a process in place that ensured the staff's CPR cards were current or reviewed before they expired. In a joint interview with Staff A and Staff B on [DATE] at 4:57 PM, Staff A stated they expected all licensed staff who were trained in CPR to perform CPR on Full Code residents. Staff A stated performing CPR was a critical element in saving a resident's life during an emergency. A review of the electronic medical records showed 48 residents (Residents 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50 & 51) had current physician orders to receive CPR according to the facility policy. These 48 residents all resided in the facility on [DATE]. Refer to F609 - Reporting of Alleged Violations. Refer to F610 - Investigate/Prevent/Correct Alleged Violation. Refer to F726 - Competent Nursing Staff. REFERENCE: WAC 388-97-1060(1). .

Based on interview and record review, the facility failed to provide effective supervision for 1 (Resident 1) of 3 residents reviewed for falls. This failure did not protect Resident 1 from additional falls, and resulted in harm when Resident 1 sustained a pelvic fracture. Findings included . Review of a 07/01/2021 Significant Change Minimum Data Set (MDS, an assessment tool) showed Resident 1 was admitted to the facility on [DATE], with multiple diagnoses to include [CONDITION(S)], a stroke, and weakness or paralysis to one side of the body. This MDS showed staff assessed Resident 1 required extensive assist from staff for bed mobility, transfers, and toileting, and had severe cognitive impairment. In addition, this MDS showed Resident 1 had a history of falls since admission. Review of a 10/20/2019 facility policy titled Fall Risk Assessment showed the facility would ensure it provided an environment free from accident hazards and provide supervision and assistive devices to each resident to prevent avoidable accidents. This policy showed a Fall Risk Assessment (FRA) would be completed upon admission or when a significant change was identified, and that a Care Plan (CP) would be completed for each resident to address each item identified in the risk assessment, and include interventions, including adequate supervision. The policy showed the CP interventions would be monitored for their effectiveness and modified as necessary. Review of a 10/20/2019 facility policy titled Fall Reduction Program showed the facility would assess each resident for the risk of falling and provide the resident with care and services according to the level of risk to minimize the likelihood of falls. This policy showed staff was instructed to refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. Interventions for the Low/Moderate Risk Protocols included, Implement routine rounding schedule. Interventions in the High Risk protocol instructed staff to provide additional interventions like increased frequency of rounds, a sitter if indicated, scheduled walking or toileting assistance. This policy showed that interventions to prevent falls would be identified in the resident's CP. Review of a 12/08/2020 Fall Risk Assessment (FRA) showed staff identified Resident 1 was a Low Risk for falls with a score of 4. A 03/05/2021 FRA showed Resident 1's fall risk increased to a High Risk, with a score of 16, and the staff assesed a decline in memory and recall ability, vision pattern changed from adequate to inadequate, continence changed from continent to frequently incontinent, and a worsening gait. In an interview on 08/09/2021 at 9:07 AM, Staff B, Licensed Practical Nurse (LPN), stated that Resident 1 was previously independent with walking, became progressively weaker, transferred on their own, and that staff reminded the resident to use the call light. Staff B stated that staff would bring Resident 1 to the hallway for better surveillance as the resident was impulsive and kind of confused and would just stand up and go or tried to walk out of the bed. In an interview on 08/16/2021 at 12:11 PM, Staff C, Certified Nursing Assistant (CNA), stated that he provided care to Resident 1 when the regular aide was off. Staff C described Resident 1 as very restless and transferred in and out of the bed or chair without asking or waiting for staff assistance. Staff C stated that Resident 1 did not use the call light even though it was within reach and did not ask for help. Staff C stated that before 08/02/2021, Resident 1 needed supervision at Any time. Always watching the resident whenever I go there. Not 1 on 1 but just we have to put the resident in front of the nurse's station in the hallway. Review of a 05/13/2021 progress note showed staff found Resident 1 sitting on the floor by the restroom door in front of the wheelchair, and that the resident stated that they slipped from the wheelchair when they tried to stand up and walk to the restroom. Review of a 05/18/2021 Investigative Report (IR) showed that the resident attempted to transfer independently from the wheelchair to the toilet, the wheelchair brakes were not locked, and the call light was in reach but not used. This IR showed the facility updated the CP to include assistance with toileting in the morning, after each meal, and at bedtime. Review of Resident 1's CP showed no documentation the facility considered routine rounding schedule, or an increased frequency of rounds after staff identified the resident's fall risk had worsened and attempted to transfer on their own. Review of Resident 1's 05/18/2021 Kardex (Care Instructions) showed staff were to remind Resident 1 to use the wheelchair for long distance mobility, even though staff identified the resident was forgetful and impulsive. The Kardex showed no interventions that addressed how staff compensated for Resident 1's impulsivity, restlessness, poor safety awareness, and unsupervised transfers. Review of a 06/07/2021 FRA showed Resident 1's fall risk score worsened from a 16 to a 22. This assessment showed the risk score increased due to Resident 1's previous fall and worsened incontinence from frequent to total. Review of a 06/27/2021 progress note showed staff found Resident 1 sitting on the floor mat next to the wheelchair in their room. Review of a 07/04/2021 progress note showed staff found Resident 1 sitting on the floor in the Activity Room next to the wheelchair. Review of the medical record showed no documentation the facility investigated how or why the falls occurred. Review of Resident 1's CP showed no documentation the facility considered routine rounding schedule, or an increased frequency of rounds to address Resident 1's worsened High Risk for falls, as directed in the Fall Reduction Program. A Safety at Risk CP initiated on 10/12/2019 showed Resident 1 fell on [DATE], 06/27/2021, 07/04/2021, and 08/02/2021. The comprehensive CP showed no interventions from the High Falls Risk Protocols that addressed Resident 1's impulsivity and unsafe transfers identified by staff until 08/02/2021, where staff was instructed to check on the resident every 15 minutes. The CP also instructed staff to reinforce the need to call for assistance, even though the resident was assessed to have memory problems. Review of an 08/03/2021 progress note showed that a nurse heard a loud bang when standing by the medication cart and found Resident 1 lying on their left side in their room. An 08/03/2021 Restorative Note showed Resident 1 fell attempting to retrieve some crackers. Another 08/03/2021 progress note showed Resident 1 sustained the pelvic fracture from the recent fall on 8/2/21. Review of witness statements corresponding to the 08/02/2021 IR showed that Staff C, Certified Nursing Assistant (CNA), answered he did not know when he last saw Resident 1 prior to the fall. Staff C answered the resident was in the chair and had No idea of any other concerns regarding the incident. Staff D, CNA, witness statement showed she last saw Resident 1 17 minutes prior to the fall sitting in bed, gave the resident crackers, and when they encountered the resident after the fall that the resident said they did not know what they were trying to do. In an interview on 08/16/2021 at 11:15 AM, Staff D stated that she was assigned to Resident 1 on 08/02/2021. Staff D stated that Resident 1 was very forgetful and kept wanting to get up and is very unsteady. Staff D stated Resident 1 had been very forgetful for several months and imagines things that are not there and thinks [they] need to get up and do them. We'd put [the resident] in bed and [the resident] would want to get out. Before the 08/02/2021 fall, Staff D stated that staff supervised Resident 1 by walking by the resident frequently and peeked in at the resident, and other times the resident would be brought in the hallway by the medication cart and the nurse. When asked how staff was now preventing Resident 1 from falling, Staff D stated, We are just monitoring her the best we can. We walk by her room frequently and check on her. I'd say every 20 minutes or half an hour. In an interview on 08/16/2021 at 12:11 PM, Staff C stated, I cannot tell you what the fall prevention measures are right now, but every resident's care plan is in the closet. They have to see it before they take care of the resident. The above findings were shared with Staff A, Administrator, on 08/16/2021. Staff A stated she could not locate the investigations for the 06/27/2021 and 07/04/2021 falls. No further information was provided to show the facility followed their Falls Reduction Program when staff assessed Resident 1's fall risk worsened on two occasions, and the resident fell three times. The facility failed to provide consistent and effective supervision to Resident 1 to prevent unsafe and unsupervised transfers, which consequently led to another unsupervised and unsafe transfer on 08/02/2021, and a pelvic fracture. Reference WAC 388-97-1060 (3)(g).

Based on interview and record review, the facility failed to provide advanced written notice for room changes, to include the reason for the move, for 2 (Residents 2 and 3) of 3 residents reviewed for room changes. These failures placed the residents at risk for feelings of powerlessness and decreased quality of life. In addition, failure to properly conduct and address continued complaints of a room move, caused Resident 2 psychological harm the night of the room move, and continued physical and mood stressors. Findings included . Review of a 10/20/2017 policy titled Change of Room or Roommate showed the facility would conduct room changes or roommate assignments when considered to be necessary by the facility and/or when requested by the resident or their representative. This policy showed the reason for a roommate change or room move included incompatibility of residents in a shared room, provision of a more accommodating environment to help the resident reach their therapy goals, a request by the resident, a temporary transfer for repairs or renovations, or medical conditions which prohibited room sharing. This policy showed that requests for changes in room or roommate should be communicated to the Social Services Designee, the facility would give the resident and their representative advance notice of such a change, and the notice would be provided in writing and include the reasons why the move or change was required. This policy showed the Social Service staff would assist the resident to adjust to the new room or roommate by involving the resident in the decision and selection of a room or roommate when possible, allowing the resident to ask questions about the move, showing the resident where the room is located, introducing the resident to their new roommate and to employees who will be providing care, and explaining to the resident why the change is necessary. RESIDENT 2 Review of a 06/29/2021 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 2 was admitted to the facility on [DATE] with complex medical conditions. This MDS showed that staff assessed Resident 2's hearing was adequate, that the resident understood others and others were able to clearly understand the resident, and vision was adequate. In addition, staff assessed Resident 2 had no cognitive impairments. In an interview on 08/09/2021 at 9:10 AM, Resident 2 stated, I am very miserable. Downstairs I had my own room for 10 months. Then suddenly out of nowhere they came in on a Monday and said We're gonna move you upstairs. And I told them, I've been here with no issues. When I came back from [CONDITION(S)] on Tuesday night my belongings were moved up here. They told me it's a shared room and I never shared a room with anyone, not even with my common-law husband. They just moved me up here. I was so sick with the space I vomited three times over this move. I had a stomachache for 12 hours because of the move. Resident 2 stated the reason for the room move was, They said they want to close the ground floor. Resident 2 stated they were currently having privacy and noise issues with the shared room and stated, My roommate has care needs where staff come in the room at night, and because [the roommate] is hard of hearing the staff have to speak loudly. [The roommate] is nice but she can't hear, and I can't sleep. Review of a 07/27/2021 Social Service note showed, SSD [Social Services Director] reminded the resident that [they] would be moving to the 3rd floor after [their] [CONDITION(S)] appointment today. Review of the medical record showed no documentation the facility provided Resident 2 a notice in writing and informed the resident of the reason for the room move, that the resident was going to occupy a room with another resident, or the opportunity to meet the roommate and staff and become acquainted with the new surroundings. Review of a 07/28/2021 progress note showed that when Resident 2 returned from [CONDITION(S)] the evening of 07/27/2021, the resident was moved to room [ROOM NUMBER]B. This progress note described how Resident 2 became upset, did not like the room, complained of the roommate snoring loud, and declined the offer of ear plugs. The staff described how Resident 2 vomited twice due to the situation in [the] room and requested oxygen. This note showed staff notified the Social Worker of the situation by leaving a message. Review of a 07/29/2021 progress note showed Resident 2 doesn't want [the] room and social worker is already aware. Another 07/29/2021 progress note showed Resident 2 insisted they wanted to go back to their former room and that staff notified the SW. Review of 07/30/2021 progress notes showed twice that Resident 2 was unhappy with the new room and stated they wanted to return to their former room. These notes showed staff made the SW aware. Review of a 07/30/2021 Social Services note showed the SSD met with Resident 2 to follow up on only the resident's food choices. Review of the record showed no documentation the SSD addressed Resident 2's reaction to the room move. Review of a 07/31/2021 progress note showed Resident 2 was still complaining of her room and stating that they did not like it. This note showed that the staff made the SW aware. No documentation was found to show the facility followed up with the multiple daily complaints of the resident's dissatisfaction with the room move, and how it affected the resident's mood, sleep disturbance and overall well-being. In an interview on 08/17/2021 at 4:41 PM, Staff E (SSD) stated that the room move came about because the facility was short staffed and attempted to consolidate care on two instead of three floors. Staff E stated that when she notified Resident 2 of the room move, that Resident 2 wanted to call the State before the move and refused to sign the Room Change Notification form because the resident did not understand why they were moving. Staff E stated that the day before the move she reminded Resident 2 that the room move would occur upon their return from [CONDITION(S)]. Staff E stated that she had no awareness of Resident 2's daily complaints from the onset of the room move, how Resident 2 reacted the night of the room move, and the sustained complaint of lack of sleep and privacy. Staff E stated that when she went to see Resident 2 three days after the move, the resident complained the room was dark, and refused to speak any further to Staff E as the resident blamed Staff E for the room move. Staff E stated she forwarded Resident 2's complaint of the dark room to the Administrator and stated, So she's still on the third floor. When asked if Resident 2 had the opportunity to choose a room or who their roommate would be, Staff E stated, We [the facility] just look at the rooms and who the residents are compatible with. RESIDENT 3 Review of a 07/29/2021 Quarterly MDS showed Resident 3 was admitted to the facility on [DATE] with complex care needs. This MDS showed that staff assessed Resident 3's hearing was adequate, that the resident understood others and others were able to clearly understand the resident, and vision was adequate. In addition, staff assessed Resident 3 was cognitively intact. In an interview on 08/09/2021 at 3:17 PM, Resident 3 stated, Been moved four times, last room move was four or five weeks ago. I moved within ten minutes of notice. I was on the first floor for two weeks, then they sent me to the 2nd floor for three to four weeks. Then another room on the 2nd floor, there for 4 to 5 weeks then came up here. And reason was they were understaffed and didn't have enough people to run all the floors. Review of Resident 3's medical record showed they were admitted to the facility on [DATE] to room [ROOM NUMBER]A. Review of the census showed Resident 3 moved on 05/06/2021 to room [ROOM NUMBER]B, on 05/27/2021 to room [ROOM NUMBER]A, and on 07/26/2021 to room [ROOM NUMBER]B. Review of the medical records showed that the facility provided Resident 3 written notification of the room moves only once, on 07/26/2021. Review of a 07/26/2021 progress note showed Resident 3 was moved from the second floor to room [ROOM NUMBER]B. Review of the Notification of Room or Roommate Change form showed the facility notified Resident 3 of the room move the same day the resident was moved on 07/26/2021. This form showed no documentation Resident 3 waived the three days advance notice of the move, which would allow the resident time to adjust to the room move and instead moved on 07/29/2021. Review of the 04/28/2021 Admission MDS showed staff conducted a PHQ9 (a depression scale questionnaire) on Resident 3, which resulted in a score of 9, or mild depression. Review of a 07/28/2021 Quarterly MDS showed Resident 3's depression worsened to a moderate depression, with a score of 13. In addition, the 07/28/2021 MDS showed staff identified Resident 3 expressed thoughts of being better off dead, or hurting themselves in some way, and had these thoughts two to six days over a two week period. While a 07/29/2021 Social Service note showed the facility offered Resident 3 mental health services for suicidal thoughts, the progress notes failed to show the facility considered the toll of abrupt room moves Resident 3 suffered. RESIDENT 4 Review of the medical records showed that Resident 4 admitted to the facility on [DATE]. Review of the medical record showed four room moves happened 24 hours after the Notification of Room or Roommate Change was issued by the facility and consented to by Resident 4, and that Resident 4 waived the three days advance notice (10/15/2020 - moved from 226 to 318B, 12/10/2020 - moved to 124B from 318B, 12/28/2020 - moved to 300B from 318B, and 04/26/2021- moved from 300 to 312B). In an interview on 08/09/2021 at 10:16 AM, Resident 4 stated, I've been all over. The turnaround time for the room move was the next day. This last move I didn't bother to unpack, what's the use. I feel like a yoyo. It's hard to be uprooted all the time. After I moved here, they asked me what was different and [resident paused] the staff is different. You get used to the staff here and they're all wonderful but still you miss them [former staff on the other floor]. The above findings were shared with Staff A, Administrator, on 08/16/2021 at 2:23 PM. Staff A stated, We move the residents after proper notification has been done. Staff A stated staff should have addressed Resident 2's complaints about the room move, The day [Resident 2] was unhappy about it. Reference WAC 388-97-0580(1)(b)(i)(ii).

Based on observation, interview and record review, the facility failed to ensure a system by which resident weights were evaluated, meal intake assessed, significant weight loss identified, and interventions were developed and implemented for 6 (Residents 34, 56, 63, 43, 35 & 64) of 9 residents reviewed for weight loss/ nutrition. Facility staffs' failure to: review and evaluate weights and meal intake; offer replacement meals to residents who required them; conduct weekly nutrition at risk interdisciplinary meetings (IDT), precluded staff from identifying and implementing interventions to provide additional nutritional support to residents experiencing unplanned weight. loss. These failures resulted in harm to Resident 34, who triggered for significant weight loss (had lost 5% of body mass in 30 days) on 06/11/2021. On 07 /21/2021 (6 weeks later) the facility still had not identified or addressed the weight loss, which continued. Findings included . According to the facility's 04/13/2021 Weight Monitoring policy, the facility will ensure that all residents maintain acceptable parameters of nutritional status such as usual body weight or desirable body weight range. A weight monitoring schedule would be developed upon admission for all residents. Weights should be recorded at the time obtained and compared with the previous recorded weights. If there is a three pound difference from the previous weight, the resident would be reweighed. If there continues to be a discrepancy, the nurse will perform a weight assessment, including but not limited to reviewing medications, diagnoses, checking for [CONDITION(S)], lung sounds, and labs. If a resident has a significant weight loss or gain, defined as: a 5% weight change in a month (30 days); 7.5% change in three months (90 days); a 10% change in six months (180 days), the Physician, Registered Dietician (RD), and Power of Attorney (POA) should be informed of the significant change in weight. The Physician, RD and Dietary Manager should be consulted to assist with interventions, meal consumption information should be documented, and observations pertinent to the resident's nutritional status should be recorded in the medical record. A policy for the facility's weekly IDT Nutrition at Risk (NAR) meeting was requested but was not provided. In an interview on 07/16/2021 at 01:03 PM, Staff B, Director of Nursing (DON), explained that resident weights were reviewed weekly, and if a resident was identified with trending or significant weight loss, they would be added to the weekly NAR meeting. The resident would be reviewed at the weekly NAR meeting until stable. Staff B explained the IDT for the NAR meeting included the RD, DON, and Resident Care Managers (RCMs). Resident 34 Resident 34 admitted to the facility 05/19/2021. According to the 05/25/2021 Admission Minimum Data Set (MDS, an assessment tool), the resident had severe cognitive impairment, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 34 required a therapeutic, mechanically altered diet, Speech Therapy (ST) services, and extensive assistance with eating. A 06/01/2021 Nutritional Status Care Area Assessment (CAA), indicated Resident 34's intake was affected by swallowing problems, vision problems, difficulty communicating (non-English speaking), cognitive impairment, altered textured diet, and an inability to feed self independently. The CAA directed the reader to the Registered Dietician's (RD) 05/24/2021 nutrition assessment. Review of the 05/24/2021 Nutrition at Risk (NAR) assessment, showed Staff Y, RD, assessed Resident 34 consumed greater than 50% of most meals, accepted 120 milliliters (ml) of glucerna (diabetic nutritional supplement) daily, and was on a controlled carbohydrate, no added salt diet. Staff Y calculated Resident 34's Body Mass Index (BMI) to be 22.2 and determined it was a .a healthy range for age. Staff Y made recommendations to liberalize Resident 34's diet to regular, discontinue the Glucerna, and offer a snack at HS (bedtime). Staff Y established a nutritional goal of .no sig(nificant) weight changes, as able. Review of the weight flowsheets showed Resident 34 weighed 126.4 lbs on 5/19/2021, and 120 lbs on 06/11/2021. This demonstrated a significant weight loss of 5.1% in 23 days. Review of the May 2021 meal monitor showed out of 32 documented meals, Resident 34 ate 50-100% of the meal 26 times, and ate 50% or less on only 6 occasions. The meal monitor directed staff to offer a meal replacement if a resident consumed less than 50% of a meal and document whether it was accepted or refused. Facility staff failed to offer a meal replacement all six times the resident ate less than 50%. Review of Resident 34's June 2021 meal monitor showed staff failed to document meal intake from 06/01/2021 to 06/12/2021, the period of time where Resident 34 experienced the significant weight loss. Record review showed no indication facility staff reviewed Resident 34's weights, identified the significant weight loss, referred the resident to the RD, or took any action to address the resident's nutritional status. On 07/06/2021 Resident 34's weight was recorded as 117.6 lbs (-2.4 lbs, -7% body mass). Review of the June 2021 meal monitor from 06/13/2021 - 06/30/2021 showed, Resident 34 had a marked decline in oral intake. Of the 54 meals recorded, the resident ate only 0-25% 44 times. Additionally, staff failed to offer a meal replacement 41 of the 44 times it was required. Resident 34's weight loss continued with a 07/14/2021 weight of 116.2 lbs (-8.1%), and a 07/21/2021 weight of 114.6 lbs (-9.3%). Record review still showed no indication staff reported the resident's pronounced decline in intake, identified the failure to provide replacement meals, or identified Resident 34's ongoing significant weight loss. During an interview on 07/21/2021 at 12:00 PM, Staff C, Registered Nurse (RN) acknowledged the facility should have, but did not, identify Resident 34's significant weight loss on 06/11/2021, resulting in a lack of intervention and continued weight loss for an additional six weeks. Additionally, Staff C also acknowledged facility staff routinely failed to offer a replacement meal to Resident 34 when she ate less than 50% of her meal. In an interview on 07/22/2021 at 6:48 AM, Staff B shared that the facility was not currently having a weekly NAR meeting, and that RCMs would be responsible for reviewing and evaluating the weights on their individual units. Staff B then explained that the facility currently had no RCMs. Resident 56 Resident 56 admitted to the facility on [DATE], and according to the 06/20/2021 Admission MDS weighed 151 lbs. According to weight records, the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . According to RD notes dated 07/12/2021, the RD resident is not worried about her weight .noted with history of congestive heart failure and diuretic use which may be causing some weight loss. admitted to the facility with right hip swelling which has likely resolved. In an interview on 07/13/21 at 8:35 AM, Resident 56 stated they'd lost eight pounds in the last two weeks. The resident was observed at this time up in a wheelchair, self propelling to the hallway. Review of July 2021 meal monitors showed staff failed to offer meal supplements for four of six opportunities from 07/01/2021 through 07/12/2021. In an interview on 07/19/21 at 4:35 PM Staff C, Registered Nurse, indicated direct care staff should offer a meal replacement when less than 50% of a meal is consumed. Resident 63 Resident 63 admitted to the facility on [DATE] and according to the 06/20/2021 Admission MDS, the resident weighed 157 lbs and had no chewing problems. The resident discharged to the hospital on 06/21/2021 and returned to the facility on [DATE]. In an interview on 07/14/21 at 12:11 PM Resident 63 stated they lost weight since admission to the facility. Observation at this time showed the resident lying in bed, multiple containers of fluids were noted at the bedside. According to weight records, staff documented the following: 157 lbs (06/18/2021), 151.2 lbs (06/29/2021), 148.4 lbs (07/05/2021) and 144.4 lbs (07/15/2021). According to the RD evaluation dated 7/12/2021 Resident 63 was identified with a weight loss in one month and consumed an average of 50% of meals. RD recommendations included adding a nutritional supplement, Ensure Plus 120 mL (milliliters), twice a day, and for staff to document the amount accepted in the MAR (Medication Administration Record). Review of July 2021 MARs showed staff transcribed the recommendations as Ensure, not Ensure Plus, and staff failed to document any consumption of the ordered supplements. In an interview on 07/19/2021 at 4:35 PM Staff C, confirmed nursing staff did not, but should have implemented the RD recommendations as directed. Additionally, review of July 2021 meal monitors showed direct care staff failed to offer meal replacement on 38 of 49 instances where the resident consumed less than 50% of meals from 07/01/2021 through 07/19/2021. Resident 43 Resident 43 was originally admitted to the facility on [DATE], discharged and readmitted to the facility on [DATE]. According to the 06/05/2021 Admission MDS, was admitted with medically complex conditions, including malnutrition and diabetes and weighed 241 lbs. According to the 04/05/2021 CP documents, Resident 43 was identified with an alteration in nutrition with risk for sig. wt. (significant weight) changes. The goal was to deter significant weight changes with interventions which included weight monitoring as ordered. 05/30/2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of records showed no weights until 06/03/2021, four days after readmission, when staff assessed Resident 43 to weigh 240.6 lbs. Review of the 06/07/2021 NAR assessment, showed Staff Y documented sig[nificant] weight loss, may have been r/t [related to] period of NPO [nothing by mouth] in the hospital as well as diuresis [increased production of urine]. Staff failed to obtain additional weights until a 07/05/2021 weight of 232.6 lbs, a month after readmission, which showed an additional eight-pound weight loss. Review of July 2021 meal monitors showed staff failed to document meal intake seven times from 07/01/2021 to 07/16/2021 and failed to offer a meal replacement when the resident consumed less than 50% of meal on nine of the 11 times it was required. Observations on 07/12/2021 at 10:00 AM showed the resident's breakfast tray still untouched on table and resident indicated they did not want to eat anything. In an interview on 07/12/2021 at 1:18 PM, Resident 43 stated, I'm diabetic, I have lost 49 pounds. I just don't have an appetite anymore. According to a 07/12/2021 RD note, .change diet to general r/t poor intake with significant weight loss . and to, .start Ensure Plus [a nutritional drink] 120 mls BID [twice daily], doc[ument] mL consumed in MAR . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of July 2021 MARs revealed facility staff failed to document the amount of Ensure Plus consumed by the resident as recommended by the RD which prevented staff's ability to accurately assess the resident's nutritional intake. Further observations on 07/15/2021 at 8:55 AM showed Resident 43's breakfast tray was left untouched. Resident 43's lunch tray was observed on 07/15/2021 at 1:50 PM with no food consumed. Review of meal monitor on 07/16/2021 at 3:34 PM showed no documentation of the resident's meal consumed for breakfast or lunch on 07/15/2021. Observations on 07/16/2021 of Resident 43's lunch meal tray card showed a diet of NAS (No Added Salt), Low Fat/Chol(esterol), small portions. Facility staff failed to change to the new general diet per POs and RD recommendations. Further observations of the dinner meal tray card on 07/21/2021, a full seven days later, showed facility staff still had not implemented the RD recommendations and Resident 43 was still being served the previously restricted diet. During an interview on 07/16/2021 at 12:55 PM, Staff S, RN, verified the current diet was inaccurate on the meal tray card and indicated that staff should have, but did not update it as ordered. In an interview on 07/16/2021 at 1:03 PM, Staff B, DNS, stated that staff should re-weigh as soon as potential discrepancy is identified. Staff B also stated that RD recommendations should be implemented the next meal after receiving the order. Resident 35 Resident 35 was admitted to the facility on [DATE], and according to the 12/02/2020 Admission MDS, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the resident weighed 249 lbs. and received a mechanically altered and therapeutic diet with a mechanically altered texture and no added salt. Review of Resident 35's PO's showed a 05/07/2021 PO for weights to be checked monthly. Review of the NAR assessment dated [DATE], showed Resident 35's weight status was marked as a weight loss trend of 1.9% in 2 days (11/27/20: 249 lbs., 11/26/20: 254.1 lbs., and 11/25/20: 253.8 lbs) and was assessed to consume an average of 75% of most meals, with recommendations to continue the plan of care; diet as ordered, intake and output as clinically indicated, tray monitor as clinically indicated, medications as ordered, supplements as ordered, offer fluids with medication pass and weights as ordered. According to the NAR the Dietitian wrote may see weight fluctuation related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident 35's 11/25/2020 CP revealed an Alteration in nutrition with risk for significant weight changes CP related to [CONDITION(S)] (low [CONDITION(S)] functioning), [CONDITION(S)] (High cholesterol) and Heart Failure with a goal to maintain unbroken oral mucous membranes. The CP did not include the resident's preference for mealtimes, the resident's identified significant weight loss, any pertinent related goals and did not include interventions to prevent weight loss. Resident 35's Vital Signs chart documented the following weights: 11/25/2020 - 253.8 lbs; 01/14/2021 - 249.7 lbs; 05/05/2021 - 241.8 lbs; 06/07/2021 - 226.4 lbs (a weight loss of 15.4 lbs. or 6.4% in 33 days); 07/07/2021 - 224 lbs (a weight loss of 25.7 lbs. or 10.3% weight change in 6 months). Review of Resident 35's clinical record revealed Resident 35 was not seen by the RD after 06/07/2021 when a weight loss of 15.4 lbs. occurred, and no POs were observed for interventions to prevent weight loss. The facility did not assess or identify the cause of Resident 35's weight loss. Review of the 05/12/2021 Dietary Profile showed Resident 35 was documented to have a good appetite, to eat independently and that their favorite meal was breakfast. Resident 35 was observed to be sleeping during the Breakfast meal time on the following occasions: on 07/13/2021 at 11:37 AM (3 hours after meal being served); on 07/14/2021 at 09:19 AM and at 12:17 PM (4 hours after meal served); on 07/15/2021 at 09:44 AM and 12:45 PM (4 hours and 45 minutes after meal served) with no observation of breakfast being consumed. At 2:15 PM on 07/13/2021, the resident's lunch tray was observed on the bedside table untouched, with lids still on drinks and the cover on the plate. Review of Resident 35's Meal Monitoring on 07/13/2021 at 2:30 PM showed Staff U, Certified Nurse Assistant (CNA), documented the resident consumed 76-100% of their lunch, which did not reflect the observed untouched plate and drinks. On 07/15/2021 at 9:44 AM, Staff T stated that Resident 35 likes to sleep in, usually until 12 PM. Staff T added the resident will get mad if staff try to wake them up, so staff leave a meal tray in case the resident wants to eat later. In an interview on 07/15/2021 at 12:45 PM, Resident 35 when stated they didn't eat breakfast because I like to sleep in. It's okay, lunch will be coming soon. On 07/15/2021 at 1:20 PM Resident 35's breakfast tray was removed from the room and observed to be untouched on the meal cart. At 1:20 PM on 07/15/2021, Staff U confirmed that no drinks or food were consumed from the breakfast tray. Staff U stated that they offer Resident 35 breakfast, but the resident doesn't get up and doesn't eat. They usually eat a good amount of lunch. We leave the meal tray in there and keep it covered in the event they want to eat later. According to Meal Monitoring on 07/15/2021, Resident 35 was documented to have consumed: 76-100% of their breakfast when none was consumed. Additional observations were made on 07/16/2021 at 9:52 AM and 07/21/2021 at 9:16 AM, of the resident sleeping with their breakfast meal tray, served at 8 AM, remaining untouched on the bed side table In an interview on 07/21/2021 at 09:18 AM, Staff V, CNA, stated the resident is awake all night and sleeps all day. I only know the resident is up all night because I worked night shift the other day. This information was not included in the resident's assessment or care plan. In an interview on 07/16/2021 at 01:04 PM, Staff B stated for a resident who had experienced a significant weight loss, weights should be monitored weekly until stable. If we remove from weekly monitoring, we will make a progress note. Staff B stated the expectation for a significant weight loss would be to notify the RD after the weight loss is identified (typically within 24-48 hrs). Review of Resident 35's clinical record showed no indication the facility acted on or notified the physician of the significant weight loss of 6.4% on 06/07/2021 or 10.3% on 07/07/2021. The resident was not referred to the RD or the Physician as the facility had not identified the weight loss. Resident 64 According to a 06/02/2020 MDS, Resident 64 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2021 POs showed Resident 64 was restricted to no more than 1.5 - 2.0 Liters of fluid intake per day. Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Oral intake records were requested for the month of July for Resident 64 but no intake data was provided. In an interview on 07/21/2021 at 11:15 AM, Resident 64 stated I know I have a fluid restriction; I can only have a certain amount of fluid per day; I do not know how much though. I had two episodes in the past, drinking too much and they had to put a needle in my back to drain me. If I drink too much fluid, it will lead to pneumonia or fluid around my heart, and I can die. Resident 64 further stated, They do not measure or keep track of what I drink because I do not tell them what I am drinking. An observation of Resident 64's room on 07/14/2021 at 12:27 PM showed a breakfast tray on the bedside table with breakfast uneaten, with 6 oz. of juice and 6 oz. of milk on the tray. Four unopened cans of juice and an empty 20 oz. personal water cup with a lid on the nightstand. On 07/20/2021 at 4:15 PM, two 16 oz. cans of sparkling water and two 16 oz. bottles of sports drinks were observed on Resident 64's bedside table One sparkling water can was open with a straw inserted. Resident 64 stated the drinks were purchased while out at [CONDITION(S)] on 7/19/2021. An observation of Resident 64's room on 07/21/2021 08:58 AM showed one can of ICE drink spilled on the floor, five sealed cans of juice, and one opened 16 oz. sports drink on the bedside table. In interview on 07/19/2021 at 12:13 PM, Staff X, LPN, stated nurses have to document on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff X stated that dining has a specified amount of fluids allowed per meal that is printed on the tray ticket. When asked about the process for intake monitoring and daily summary, Staff X stated they did not know who did the 24-hour summary. When asked how the CNA knows who is on a fluid restriction, Staff X referred to a paper on the inside of the closet door dated 02/22/2021 for Resident 64's care directions. Upon inspection, Staff X was not able to find any instructions to the CNA showing Resident 64 required measuring and recording of all fluid intake. Staff X stated, the information for the fluid restriction should be on the care directive. In interview on 07/21/2021 at 09:05 AM, Staff T, CNA, confirmed they were aware Resident 64 was on a fluid restriction. When asked how the fluids were measured and recorded, Staff T stated they asked the resident at the end of the shift how much fluid was taken and then the amount is recorded on the I/O (Input/Output) sheet. Staff T looked in the yellow I/O binder and was not able to locate a documentation sheet for Resident 64. In interview 07/22/2021 at 9:12 AM, Staff B stated the expectation for nurse management of a resident on a fluid restriction would include documentation of all fluid intake and a daily summary total. Staff B confirmed the documentation and daily summary was necessary to accurately assess whether Resident 64 was adherent to the fluid restriction while on [CONDITION(S)] and at risk for fluid overload and serious health outcomes. REFERENCE: WAC 388-97-1060 (3)(h)(i).

Based on observation, interview and record review, the facility failed to accurately assess and identify a decline in urinary incontinence, ensure a plan for treatment and services to restore as much normal bladder and/or bowel function as possible for 3 (Residents 45, 31, & 69) of 4 residents reviewed for indwelling catheters. Failure to identify and assess/determine causative factors requiring catheter use for Residents 69, provide treatment to promote restoration of bladder function, and interventions to prevent injury for Residents 45 & 31, placed residents at risk for continued urinary decline, and decreased quality of life and caused harm to Resident 45 who experienced untreated urinary retention and subsequent infection which required hospitalization . Findings Included . According to the undated Appropriate Use of Indwelling Catheters Policy, residents who are admitted to the facility with an indwelling catheter, will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary. Resident 45 Resident 45 admitted to the facility on [DATE], was discharged to the hospital on 05/29/2021 and readmitted to the facility on [DATE] According to the 06/04/2021 5-day Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation/ interview on 07/12/21 at 12:57 PM , Resident 45 was observed with a urinary collection bag hanging from the right side of the bed frame. Resident 45 stated, I have a suprapubic catheter [a hollow flexible tube that is inserted through the abdomen into the bladder to drain urine] and I want it out . [urine] has been leaking from my penis the last two weeks .yeah it's new [urine is draining from his penis, instead of through the supra-pubic catheter] it's clogged up or something .I need to talk to the urologist about getting it out. When queried whether he had informed his nurse Resident 45 stated, Yes .all of them know, the aides too, because they have to clean it up. Review of Resident 45's July 2021 intake and output (I&O) flowsheet showed from 07/01/2021 to 07/07/2021 facility staff were documenting Resident 45's urine output in milliliters (ml) and were documenting f/c [Foley catheter] next to the output value, indicating the urine was obtained from the catheter collection bag. From 07/08/2021- 07/19/2021 staff documented that Resident 45 was incontinent and with no urine output documented from the catheter, indicating the catheter clogged. A review of the July 2021 progress notes showed a 07/10/2021 7:43 AM note written by Staff AA, Licensed Practical Nurse (LPN), that stated, [Resident 45's] suprapubic catheter not working, it has a blockage, offered a cath[eter] change but [resident] refused as well. MD notified. Will continue to monitor. No further nurses notes were found addressing the clogged catheter between 07/08/2021 (when the catheter became clogged and/or non-functional) and 07/19/2021, when the resident was hospitalized . Review of the July 2021 Treatment Administration Record (TAR) showed a 01/26/2021 order directing nurses to verify suprapubic catheter placement every shift, and notify the provider if decreased urine output, bladder distension, or swelling around the insertion site. This order was signed off by facility nurses three times daily from 07/08/2021 - 07/19/2021, despite a nurse assessing the catheter was clogged on 07/10/2021 and nurses aides continuing to document that there was no urine output from the catheter from 07/08/2021 through 07/22/2021. Additionally, Resident 45 had an order to irrigate the catheter with 60 ml normal saline for signs and symptoms of a blockage as needed. If unable to clear, notify MD and change the catheter. However, review of the TAR showed no nurse attempted to flush the blocked catheter as directed. Nor was there any indication facility nurses notified the MD about the catheter blockage and lack of urine output in the catheter. In an interview on 07/22/2021 at 5:39 AM, Staff BB, Certified Nursing Assistant (CNA), stated,[Resident 45's] catheter stopped draining a couple weeks ago and then he was incontinent, we told the nurses. When asked what nurse she told Staff BB stated, Whoever was on. Staff BB indicated one nurse was Staff AA, LPN. In an interview on 07/22/2021 at 6:08 AM, Staff CC, CNA, also confirmed Resident 45's catheter had not been draining urine for a couple weeks and that the nurses on duty were notified. In an interview on 07/22/2021 at 5:55 AM, Staff AA, LPN, confirmed CNAs had informed her Resident 45's catheter wasn't draining. Staff AA, indicated she had offered to change the resident's catheter but he refused. According to Staff AA she faxed the MD and made a progress note (referring to the 07/10/2021 nurses note referenced above). When asked if the MD ever responded Staff SS stated she did not know. When asked if she took any other action between 07/10/2021 and 07/19/2021 as she was aware the problem had not been resolved (when Resident 45 was hospitalized on [DATE]) Staff AA indicated she had not, but stated she heard Resident 45 refused to go to his urology appointment. Record review showed Resident 45 had routine monthly urology appointments for catheter changes. The resident was seen on 05/19/2021, 06/4/2021, had a 07/07/2021 urology appointment which he declined to go to and was rescheduled for 07/21/2021. This occurred prior to his supra-pubic catheter becoming clogged. Despite multiple staff members being aware of Resident 45's catheter malfunction, the resident was not placed on alert. Physicians orders to report to the MD if decreased urine output, direction to irrigate the catheter if occluded, and then to notify the Physician if unable to clear the blockage, and an order to change the catheter if irrigation failed, were not followed. A 07/19/2021 10:50 PM nurses note stated that Resident 45 was complaining of urgency to void but he could not, the supra-pubic catheter had malfunctioned and was not draining into the bag. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the hospital 07/20/2021 History and Physical,[ Resident 45's ] suprapubic catheter was replaced. At the time suprapubic catheter was replaced it was noticed there was a discharge of pus. Following placement of a new suprapubic catheter, patient voided 1200 ml of urine which was pinkish in color .The patient says he is feeling much better now. Resident 45 was subsequently diagnosed with a urinary tract infection and started on antibiotic therapy. Resident 31 Resident 31 admitted to the facility on [DATE], and according to the 05/23/2021 Admission MDS was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the associated Care Area Assessment (CAA) staff should utilize, Leg strap and dignity bag in place every shift. Replace leg strap as needed. According to the 05/27/2021 Urinary Catheter Care Plan (CP), staff were to prevent tension on urinary meatus from catheter and secure catheter with cath strap - check Q [shift]. Catheter straps keep the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter; and securing the catheter to facilitate flow of urine, preventing kinking of the tubing. Observations on 07/12/21 at 1:10 PM showed Resident 31 had a urine drainage bag attached to the side of the bed. At this time the resident indicated there was no catheter strap to reduce pressure on the urinary meatus (the head of the penis). Observations on 07/14/2021 at 12:27 PM showed the resident did not have a catheter strap in place. At this time, the urinary drainage bag was noted on the floor next to the bed. In an interview on 07/15/21 at 8:50 AM and 9:55 AM and on 07/16/2021 at 9:20 AM and 10:38 AM showed the resident reported there was no catheter strap present. Observations at these time showed the drainage bag was attached to the bed frame. Observations on 07/19/21 at 9:53 AM showed the resident had no catheter strap in place to decrease the pressure on the urinary meatus. Observation with Staff B on 07/19/21 at 9:53 AM showed the resident had no catheter strap and the urinary drainage bag was on the floor. In an interview on 07/19/21 at 9:53 AM, Staff B, Director of Nursing, confirmed staff should have, but did not implement the catheter strap and that the urinary drainage bag should not be on the floor. Resident 69 Resident 69 admitted to the facility on [DATE] and according to the 06/23/2021 Admission MDS had multiple medically complex diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 07/13/2021 at 8:52 AM, Resident 69 was observed lying in bed, a urinary catheter bag was noted hanging from the bed frame. The resident stated at this time, they didn't use a catheter prior to January 2021. According to CP documents dated 06/18/2021, Resident 69 was identified with Untreatable blockage and [CONDITION(S)] bladder which required the use of the indwelling catheter and had a failed removal. Interventions included review for possible removal of catheter. In an interview on 07/21/21 at 11:45 AM, Staff C, Registered Nurse, was asked to provide any indication Resident 69 was evaluated by a urologist, any history of failed catheter removal, any documentation to support the resident had an untreatable blockage or evidence facility staff reviewed for possible removal of the catheter as indicated in the care plan. Staff C stated there was no indication staff followed the intervention of, review for possible removal of catheter. Staff C indicated staff should have, but did not, attempt a void trial with post void residual (a test to determine if the resident can urinate effectively without an indwelling catheter) and assess for retention. Staff C stated that while the CP indicated the resident had a failed removal review of the current and historical records did not reveal any failed removal. Staff C confirmed there should be, but was no, indication of a failed attempt to remove the catheter or any referral to urology to consult for continued need of the indwelling catheter. REFERENCE: WAC 388-97-1060(3)(c).

Based on observation, interview and record review, the facility failed to ensure professional standards were met for 9 of 22 (Residents 34, 16, 63, 43, 64, 45, 74, 31, & 137) sampled residents. Facility failure to timely and accurately assess an acute condition (Resident 43); follow and /or clarify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Failure to timely and adequately assess Resident 43's urinary status caused a delay in treatment and required transfer to emergency room for treatment, which constituted harm. Findings included . FAILURE TO ASSESS Resident 43 Resident 43 admitted to the facility on [DATE]. According to the 06/05/2021 Admission Minimum Data Set (MDS - an assessment tool) the resident was admitted with multiple medically complex diagnoses, was assessed as cognitively intact, and occasionally incontinent of urine. In an interview on 07/12/21 at 1:24 PM the resident stated, It's been over a month since I've had a bladder infection. I have burning so bad when I urinate. I can't get the doctor to do anything. Observations were made at this time of Resident 43 grimacing while describing the burning and discomfort. Progress notes dated 6/21/2021 showed, Res(ident) also noted to have bloody urine, MD (Medical Doctor/Physician) informed, per MD monitor and if res c/o (complains of) any UTI (Urinary Tract Infection) symptoms to collect UA (Urinalysis) With C and S (Culture and Sensitivity, a test to determine the most effective antibiotic to treat infection). A second progress note dated 6/22/2021 showed, Res(ident) c/o burning and dysuria (painful urination), MD informed, got verbal order to collect UA with C & S if indicated. Res informed. According to laboratory (lab) test results, a urine specimen was obtained on 06/23/2021. Results from this test were reported on 06/24/2021 and included abnormal results of turbid urine, protein and 3+ White Blood Cell (WBC) Esterase (indicative of infection), greater than 30 WBCs and greater than 30 Red Blood Cells and Many Abnormal Bacteria in the urine. This indicated Resident 43 had a UTI. According to lab documents dated 06/24/2021, this specimen warranted a Urine Culture. According to a late entry Provider note dated 6/27/2021, for 06/25/2021, the provider identified, Chief Complaint: Seen for complaints of dysuria-c/o burning & pain on urination x 5 days, follow up of labs . The note addressed the resident's complaints of difficulty with urination, symptoms of UTI, and burning pain on urination, no chills/fever, no gross hematuria . The practitioner documented Discussed [MEDICATION(S)] x dysuria while awaiting U/C/S (urine culture and sensitivity) - says its okay can wait till final C/S comes back tomorrow? A culture result dated 06/28/2021 showed the culture was abnormal and positive for [CONDITION(S)] pneumoniae greater than 100,000, indicative of infection, with a list of antibiotics that would be effective against the identified microorganism. This document also identified the specimen was submitted in a sterile cup which required refrigerated temperatures to maintain the organisms without excessive growth in transport. The lab recommended the use of the urine culture transport device for urine specimens. Record review showed no indication nursing staff notified the physician of the 06/28/2021 culture results. In an interview on 07/21/2021 at 11:20 AM, Staff C, Registered Nurse, confirmed nursing staff should have, but did not, notify the physician of the culture and sensitivity results, which indicated the resident required treatment. Staff C indicated nursing staff should have, but did not utilize the urine culture transport device required for urine specimens. Staff C elaborated that based on this identified discrepancy, nursing staff should have notified the doctor and requested to repeat the test using required urine testing supplies. Record review showed no further assessment of the resident's urinary status until a progress note dated 07/08/2021 where staff documented, .contact to doctor .and talk about her UTI symptoms and resend results to doctor and waiting for orders of medication and received orders for cranberry juice (an approach to acidify the urine). Despite staff documenting waiting for orders of medication, record review showed no further contact with the physician regarding the resident's urinary symptoms, and no evidence nursing staff placed the resident on alert charting to monitor the resident's condition. Review of vital signs dated 07/21/2021 at 9:48 AM showed Resident 43's blood pressure had dropped to 95/58 with an irregular -new onset pulse of 116. No further assessment of vital signs or physician notification was documented until a progress note dated 07/21/2021 at 8:20 PM, that showed the resident was lethargic, with no response to gentle touch or verbal stimulation and had an irregular elevated heart rate of 120-135. The resident was sent to the emergency room via 911. According to hospital records dated 07/21/2021, the resident reported, .lower abdominal discomfort which has been ongoing for some time, is constant, but worse with palpation . Hospital records show the resident was identified with a urinary tract infection which required Intravenous antibiotic treatment. In an interview on 07/21/2021 at 11:20 AM, Staff C, Registered Nurse, confirmed nursing staff should have, but did not, monitor the resident's urinary status after receipt of the 06/28/2021 C & S and after resending the lab results to the physician on 07/08/2021. FAILURE TO FOLLOW / CLARIFY PHYSICIAN ORDERS Resident 31 Review of July 2021 Medication Administration Records (MARs) showed staff were to administer multiple medications via a PEG tube (a tube inserted into the stomach through the abdomen). Observations on 07/12/21 at 1:10 PM showed Resident 31 had a PEG tube in place. In an interview at that time, the resident reported taking medications orally and that medications were no longer administered through the tube. In an interview on 07/19/2021 at 11:44 AM, Staff B (Director of Nursing) confirmed nursing staff should have clarified the orders that administration through the PEG tube was no longer required. Review of July 2021 MARs showed nursing staff were directed to hold the blood pressure (BP) medication [MEDICATION(S)] (a medication to treat low blood pressure) if the systolic BP was greater than 120. Record review showed that staff administered the medication when the BP was greater than 120 on five of five occasions (07/06/2021 x 2, 07/08/2021, 07/10/2021 and 07/12/2021). In an interview on 07/19/2021 at 11:44 AM, Staff B confirmed nursing staff should have, but did not hold the medication as ordered. July 2021 MARs showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review showed the resident had a regularly scheduled order for Senna twice a day which would call for the suppository any time the resident went 8 hours without a bowel movement. In an interview on 07/19/2021 at 11:44 AM, Staff B indicated the [MEDICATION(S)] order should be clarified. Resident 63 Review of July 2021 MARs showed staff were directed to hold [MEDICATION(S)] (a blood pressure medication) for BP less than 100. In an interview on 07/20/2021 at 7:57 AM, Staff E (Registered Nurse) indicated the order should be clarified to determine if the parameter referred to systolic or diastolic levels. According to July 2021 MARs, Resident 63 received antibiotics through a specialized intravenous device inserted in the arm to instill medications close to the heart. According to the MAR, staff were instructed to flush this device before and after each antibiotic administration. A separate order directed staff to flush the device at least every week in addition to the flushes after medications. When asked why it was necessary to access the device excessively as it was already flushed multiple times daily, Staff E stated the nurses should have clarified the order. According to July 2021 MARs, nursing staff were directed to administer Tylenol for pain on a scale of 1-4. On 07/10/2021 nursing staff administered the Tylenol for a pain level of 6. In an interview on 07/20/2021 at 7:57 AM, Staff E confirmed staff did not follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 16 Resident 16 admitted to the facility on [DATE]. According to the 04/21/2021 Admission MDS the resident had medically complex conditions including hypertension (HTN) and renal (kidney) insufficiency which required the use of medications to keep heart rate and blood pressure within a specified range. Review of May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff were directed to hold the medication for a heart rate less than 60 beats per minute (bpm). According to the May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Similar findings were noted on the June and July 2021 MARs on 06/04/2021, 06/09/2012, 06/19/2021, 06/27/2021 and on 07/11/2021. Further record review of May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff were directed to hold the medication for a heart rate less than 60 bpm. According to the May 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Similar findings were noted on the June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The order directed nursing staff to hold the medication for a heart rate less than 60 bpm. Review of June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 07/19/2021 at 11:44 AM, Staff B indicated nursing staff should follow physician orders. Resident 74 Record review showed 05/10/2021 orders for: Senna (a vegetable laxative) two tabs as needed for constipation. No direction was instructing staff when the medication should be utilized, or how frequently it could be administered. During an interview on 07/21/2021 at 12:20 PM, Staff C stated the order was unclear and should be clarified. Resident 45 Record review showed 07/14/2020 orders for: [MEDICATION(S)] every 48 hours as needed for constipation; and a 07/14/2020 order for [MEDICATION(S)] every 24 as needed for constipation. There was no instruction indicating when the medications should be used, in what order, or if they could be given together. During an interview on 07/21/2021 at 12:20 PM, Staff C indicated the orders were unclear, and needed to be clarified. SIGNING FOR TASKS NOT COMPLETED Resident 31 Resident 31 admitted to the facility on [DATE] and according to the 05/23/2021 Admission MDS was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . This MDS showed the resident was understood and able to understand conversation, required extensive two person assistance with bed mobility and was totally dependent on staff for transfers and had multiple pressure ulcers. According to a nursing admission assessment dated [DATE] the resident was assessed to require bilateral lower extremity brace until follow-up with Orthopedic. Observations on 07/12/21 at 1:10 PM showed the resident lying in bed. Lower extremity hinged leg braces were noted on a wheelchair at the bedside. In an interview at this time, the resident stated they wore the leg braces at the time of admission, but stopped wearing them, a while ago related to a pressure ulcer that developed on the left foot. Multiple observations on each day of the survey (07/13/2021, 07/14/2021, 07/15/21, 07/16/2021) showed the resident lying in bed, the leg braces either at the bedside or on the wheelchair in the room. Observations with Staff B on 07/19/21 at 9:53 AM showed the resident did not utilize the leg braces. In an interview at this time Staff B was unsure if the resident should be wearing the braces and confirmed with the resident that the braces had not been applied in some time. According to July 2021 Treatment Administration Records (TARs), nursing staff documented on each shift on 07/13/2021, 07/14/2021, 07/15/2021, 07/16/2021, 07/17/2021, and 07/18/2021 that Bilateral Lower Extremity Brace was monitored and skin integrity checked. Professional standards of practice indicated that nursing staff should only sign for those tasks completed. Resident 137 Resident 137 was admitted to the facility on [DATE]. According to the Admission MDS dated [DATE], had medically complex conditions including diabetes and was assessed to require limited assistance from staff for personal hygiene. According to a 07/01/2021 Care Plan (CP), Resident 137 was identified with a self-care deficit with interventions identified for nail care by LN. In an interview on 07/13/2021 at 9:10 AM Resident 137 stated that he had wanted his nails trimmed. He reported that he had signed up for the manicure group scheduled for 07/12/2021 but states that staff never came to get him. Observations at the time showed the resident's fingernails were long on both hands. Resident 137 declined observations of toenails. Review of the July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff documented that nail care was performed on 07/02/2021 and 07/10/2021. During further observations on 07/14/2021 at 8:45 AM, Staff D, RN, verified that Resident 137's fingernails were long and were untrimmed. In an interview on 07/16/2021 at 9:42 AM Staff B confirmed the resident's nails were not trimmed and nursing staff should not document for tasks that were not completed. Resident 43 Resident 43 was originally admitted to the facility on [DATE], discharged and readmitted on [DATE]. According to the 06/05/2021 Admission MDS, the resident had medically complex conditions including diabetes, and was assessed to require extensive assistance by staff for personal hygiene. According to CP documents dated 04/05/2021 Resident 43 was identified with a Risk for complications related to diabetes which included interventions that required nail care by LN (Licensed Nurse). During an interview on 07/12/2021 at 1:21 PM Resident 43 stated their toenails hadn't been clipped since admit and that they had been hoping to see the podiatrist. Observations at time of interview showed both feet with long and jagged toenails. Review of July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff documented that nail care had been performed on 07/02/2021 and 07/09/2021. During observations on 07/16/2021 at 9:40 AM, Staff B verified that the toenails were not trimmed. Resident 43 stated they are obnoxious, I have a big crack down the middle on the right big toe. In an interview on 07/16/2021 at 9:42 AM Staff B stated nursing staff should not sign for tasks that were not performed. Resident 45 Resident 45 admitted to the facility on [DATE]. According to the 06/04/2021 5-day MDS, the resident was cognitively intact, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 07/12/21 at 12:57 PM , Resident 45 complained that his suprapubic catheter (a hollow flexible tube that is inserted through the abdomen into the bladder to drain urine) was clogged up or something, and indicated urine was not draining into the catheter bag, instead, urine was leaking from his urethra. Resident 45 indicated facility nurse's and nurse's aides were aware of the malfunction. Review of Resident 45's July 2021 intake and output (I&O) record, showed from 07/01/2021 to 07/07/2021 facility staff documented the resident had between 550- and 1150 ml of urine output via the catheter daily. From 07/08/2021- 07/19/2021 the resident had no further urine output from the catheter. Staff just documented the resident was incontinent for 12 consecutive days. A 07/10/2021 7:43 AM nurses note stated, .[Resident 45's] suprapubic catheter not working, it has a blockage. Offered to change cath[eter] but refused as well. MD notified . Review of the July 2021 TAR showed for 32 of 33 shifts between 07/08/2021 and 07/19/2021 facility nurses signed that they checked the suprapubic catheter placement, and notified the provider if decreased urine output, bladder distention, purulent drainage or swelling around the insertion was noted. During that time frame only one nurse identified that the catheter was clogged and notified the MD. Facility nurses also signed on 32 of 33 shifts they provided catheter care and checked function. Despite the suprapubic being non-functional for all 33 shifts, only one nurse identified it. Lastly, for 33 consecutive shifts, facility nurses failed to follow the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . If unable to clear (blockage), notify the doctor and change the catheter. Record review shows Resident 45 had no recorded urine output from the catheter for 33 shifts. In an interview 07/22/2021 at 06:38 AM, Staff B acknowledged that 9 different nurses, for 33 consecutive shifts signed for tasks they did not complete, and also failed to irrigate Resident 45's catheter with NS as ordered, for s/sx of blockage. The resident was subsequently transferred to the hospital where they were diagnosed and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 34 Review of Resident 34's July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility nurses signed that this was completed daily, but there was no place provided to document whether the resident accepted/consumed the snack. During an interview on 07/21/2021 at 12:08 PM, Staff C, Registered Nurse, acknowledged there should be a place provided to document whether the resident accepted/consumed the snack, and stated that the order needed to be clarified. Resident 64 Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2021 MARs showed Resident 64 refused Senna for 14 out of 18 daily administrations in July. Resident 64 refused [MEDICATION(S)] for 14 out of 18 daily administrations in July. Resident 64 refused [MEDICATION(S)] for 18 out of 42 administrations between July 1st and July 14th. Observation of medication administration on 07/21/2021 at 10:50 AM showed that, Resident 64 refused the [MEDICATION(S)] nasal spray and asked the nurse to verify that Senna was not in the cup of medications. Resident 64 stated they did not want the Senna or the nasal spray. Staff X, LPN did not ask the resident why the medications were being refused. Staff X returned to the medication cart and documented resident refused in the MAR. In an interview on 07/21/2021 at 11:15 AM Resident 64 stated, They were sneaking stool softeners into my pills. I do not want a stool softener unless I ask for it. When the resident was asked why the nasal spray was refused that morning, the resident replied that it makes their throat dry and difficult to swallow the pills. In an interview on 07/21/2021 at 10:53 AM, Staff X reviewed the progress notes and confirmed that the physician was not notified of any medication refusals for Resident 64 in the month of July. In an interview on 07/22/2021 at 09:12 AM, Staff B stated the expectation was to report medication refusals to the physician and obtain further instructions. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii).

Based on interview and record review, the facility failed to ensure three (#s 1, 2, & 3) of three residents reviewed for accidents were adequately re-assessed after accidents and provided supervision to prevent further accidents and associated injuries. For Resident #1, the facility failed to implement safety measures to protect Resident #1 from sustaining injury, while using an electric wheelchair. Resident #1 sustained injuries that included abrasion, laceration, and limb wedged between the motorized wheel chair and the sink, hitting of lower extremities on beds, doors, and elevator, fractures, and subsequent pain from injuries. For Residents #2 and #3, the facility failed to develop and/or implement preventative measures after falls, which resulted in repeated falls with a fracture (Resident #2) and surgical wound dehiscence (Resident #3). These failures resulted in harm related to serious injuries to the resident. Refer to CFR 483.21(b)(2)(i)-(iii), F-657, Care Plan Timing and Revision Findings included . A facility policy dated March 2020 and titled Electric Wheelchair/Scooter showed the Administrator and Director of Nursing would establish rules for the use of electric wheel chair in the facility. This policy showed the facility would inform the resident of the rules, teach safe driving practice and suspend driving privileges of those residents deemed unable to safely drive. This policy also showed the facility would discuss the risks and benefits with the resident or responsible party if the resident was deemed unsafe to use the electric wheel chair and, if the resident operated the wheel chair in an unsafe manner, caused injury to self or others or created excessive damage to facility property, the facility would request the resident to use an alternative means of transportation in the facility. RESIDENT #1 A 08/07/2020 Quarterly Minimum Data Set (MDS - an assessment tool) showed RESIDENT #1 was admitted to the facility on [DATE] with complex care needs, and had moderately impaired cognition. Resident #1 used a motorized wheel chair for mobility. INCIDENT #1 Review of a 03/30/2020 progress note showed, This LN (Licensed Nurse) was called into Resident room on around (sic) 2000 (8:00 PM) that Resident right shin is bleeding. This LN asked resident what happened to her right shin, per Resident, 'I was trying to get the call light by the commode and bump my leg to the commode'. This progress note showed the resident sustained [REDACTED]. Review of a 04/06/2020 progress note showed, This resident was assessed by OT (Occupational Therapy) for power wheel chair safety. Resident was noted to be safe and independent with power wheel chair mobility per therapist for use in the facility. Review of the progress notes between 03/30/2020 and 04/27/2020 showed no documentation of what measures staff used to prevent injuries associated with the use of a motorized wheel chair. INCIDENT #2 Review of a 04/27/2020 progress note showed, Resident is having hard time to operate her power chair. Resident stated she is still learning. Today around 1930 (7:30 PM) resident got in an accident driving her power chair. She bumped her chair with her roommate bed and spilled coffee on her thighs. Review of the medical record between 04/28/2020 and 05/04/2020 showed no documentation of what measures staff used to prevent injuries associated with the continued use of a motorized wheel chair. INCIDENT #3 Review of a 05/04/2020 progress note showed, This writer noticed an abrasion about 3.8 cm (centimeters) x 0.5 cm on resident left shin. Res (Resident) stated she tried to avoid hitting her roommate while she was in her electric wheel chair which caused her to hit her left shin on her bed. Review of the medical records between 05/04/2020 and 06/11/2020 showed no documentation of what measures staff used to prevent injuries associated with the continued use of a motorized wheel chair. INCIDENT #4 Review of a 06/11/2020 progress note showed, Resident called from her room and she stated that she was stuck in her wheel chair and her RFA (right forearm) was caught in the corner of her sink. Saw that her RFA was wedged at the sink. She stated she was afraid to move herself with the motor of her wheel chair (sic). Changed wheel chair from motor mode to manual mode and moved her arm away from the corner of the sink. Nsg (Nursing) will continue to monitor RFA discoloration at this time . corners of sink were padded down until maintenance can come and put soft corners at the sink. A 06/11/2020 progress note showed, Resident is on alert charting related to the bruise on Rt. (right) forearm. The bruise is intact . Resident was educated related to the safe power w/c (wheel chair) use. Review of the medical records between 06/11/2020 and 06/30/2020 showed no documentation of what measures staff used to prevent injuries associated with the continued use of a motorized wheel chair. INCIDENT #5 Review of a 06/30/2020 progress note showed, Resident accidentally hit her right leg on her bed edge. Mild bleeding noted . she has laceration on right front lower leg . tissue is tear with the skin. White matter appears like a tendon on the right leg. Resident has the blue bruise near to the skin laceration . resident complained of 7/10 (severe pain) pain on her right lower leg. A 07/20/2020 progress note showed, Seen by (Wound Consultant), laceration required debridement of which resident complained of pain afterwards and narcotic [MEDICATION NAME] was given . and complained of pain 8/10 (severe pain) to right lower leg, narcotic [MEDICATION NAME] given. Review of the medical records between 06/30/2020 and 07/28/2020 showed no documentation of what measures staff used to prevent injuries associated with the continued use of motorized wheel chair. INCIDENT #6 Review of a 07/28/2020 progress note showed, Resident told she hit her left foot on the elevator, complained of mild pain and a 07/29/2020 progress note showed, Assigned LN notified that resident complained of pain on her left ankle/foot. Assessed resident, resident notified that while maneuvering electric wheel chair resident hit left foot on the elevator last evening. Resident stated that yesterday was not too bad but today I feel more pain. Noted left foot/ankle area redness, warm, to touch, mild swelling, resident complained of pain while moving legs up and down. Review of a 07/29/2020 nurse practitioner telephone note showed, PT (Physical Therapy) has been working with her since last injury on arm and leg from bumping herself on furniture, has cautioned to go slow . Use manual wheel chair as she has injured herself multiple times now on motor w/c in LTC (Long Term Care). Review of progress notes between 07/28/2020 and 09/27/2020 showed the resident continued to use a motorized wheel chair despite the practitioner's request to use a manual wheel chair, and a 08/12/2020 progress note showed, She is using electric wc for locomotion and at times required assistance with w/c mobility to move around obstacles. Review of the medical records between 07/28/2020 and 09/27/2020 showed the facility failed to reassess the resident regarding the use of the motorized wheelchair, failed to provide the resident a manual wheelchair, and failed to implement measures to prevent injuries associated with the continued use of a motorized wheel chair. INCIDENT #7 A progress note of 09/27/2020 showed, Patient reported as she was entering vending machine room on second floor she bumped into the door at the entrance. Her right foot was bent back and she experienced pain. Further review of the medical record showed the resident sustained [REDACTED]. Review of a 09/28/2020 practitioner telephone note showed, has been working with therapy on electric scooter as multiple incidences in facility running into furniture causing skin breakdown nursing to follow up with PT on getting a manual wc. Review of the medical record between 09/28/2020 and 10/05/2020 showed no documentation of what measures staff used to prevent injuries associated with the continued use of a motorized wheel chair, despite a second request by the practitioner for the resident to use a manual wheel chair. Review of a 10/05/2020 practitioner telephone note showed, Recommend not using motorized wc as there has been multiple injuries with leg wounds and now fracture, resulting from improper use of electric wc and From my understanding there has also been complaints from last month from other residents who state patient wheels past on electric w/c fast, almost hitting them. Start use of manual w/c. A progress note dated 10/05/2020, eight days after the fracture and the third practitioner's request for a manual wheel chair, showed, RCM (Resident Care Manager) and SW (Social Worker) met with resident today and discussed about the option of using a manual w/c for her safety and other residents safety and resident without hesitation agreed to using a manual w/c . stated she will use this w/c as the ortho MD also suggested that the risks of using the power w/c out way (sic) the benefits and SW called and talked to resident's son/POA (Power of Attorney) following concerns about resident continuing to use electric w/c despite therapy and nursing recommendations to use manual w/c for resident safety and safety of others. Review of the comprehensive care plan showed no documentation staff developed and implemented interventions to prevent additional injuries between 03/05/2020 and 10/05/2020 except on 06/11/2020, corner of sink reinforced by soft padding to prevent future injury. In an interview with Staff D, Director of Physical Therapy/Occupational Therapy (PT/OT) on 10/15/2020 at 1:20 PM confirmed that the resident was assessed and cleared to use either manual or electric wheelchair. When asked what that was supposed to mean to the caregiver? Staff D said that the resident would choose on the type of wheelchair she would use. When asked if the recommendation of the physician to use manual wheelchair was followed, staff D stated that the use of the DMEs (Durable Medical Equipment) were at the discretion of PT/OT assessment. When asked if the therapist was aware of the resident's accidents and injuries, staff D said yes, but not hitting other residents. when asked at what point the recommendation would be made to cease the use of the power wheelchair, Staff D replied, When it is not safe to the resident and others. In an interview on 10/15/2020 at 1:40 PM, Staff B, Director of Nursing (DNS) confirmed that Resident #1 used the motorized wheelchair since admission until 10/05/2020. Staff B stated that the resident was recommended to therapy and was cleared to use a motorized wheelchair. Staff B stated that there were no additional interventions implemented after Resident #1 sustained injuries and the resident continued using the power wheelchair. When asked if the primary physician was aware of the resident's choice to continue to use a power wheel chair, Staff B stated, not sure. When asked what her expectation was, staff B stated I cannot answer that. RESIDENT #2 A 10/01/2020 Admission MDS showed the resident was admitted to the facility on [DATE], had moderately impaired cognition, and abnormal gait and mobility. Review of a 09/25/2020 Falls Assessment showed staff assessed the resident to be at moderate risk for falls. A 09/25/2020 progress note showed, Call light/facility (sic) explained with minimal understanding. A 09/27/2020 progress note showed, Resident self-transferred from bed x 2 (two times) , came out from her room using fww (front wheeled walker) and looking for bathroom. Reminded her to use the call light for assistance. Closely monitoring the patient. A 09/28/2020 provider note showed resident was assessed to have, PMH (Past medical History) significant for memory loss, balance difficulty . low vision . had decline in her cognitive function for over a year . frequent falls . [MEDICAL CONDITION] with current pathological fracture . increased confusion at ALF (Assisted Living Facility), SLP (Speech Therapist) in hospital noted deficits in recall, organization, judgment, impulse control. Review of a 09/30/2020 progress note showed, At 2300 (11:00 PM) as this LN was walking by Resident's room noted Resident was sitting on the floor between her bed and chair facing the door when asked Resident stated she just wanted to sit on the floor it feels good per Resident she didn't fall she wanted to sit on the floor and her Nightgown was off she only had Brief on . Call light was within reach but not in use . Reminded her to use the call light if help needed . Resident on alert to monitor and staff closely monitoring the patient. Review of a progress note on 10/01/2020 showed, Encouraged to use the call light for assistance. Review of a progress note on 10/02/2020 showed, Resident alert with some confusion . was trying to get up from the bed and walk. Resident was reminded to use wheel chair for mobility. Review of progress notes between 09/25/2020 to 10/03/2020 showed no documentation how staff closely monitored the resident, or how interventions changed to compensate for cognitive impairment, to include memory recall, and prevent falls or falls associated trauma. An interview on 10/15/2020 at 12:00 PM, with Staff B confirmed that resident #2 had cognitive impairment. When asked how the resident was monitored closely, Staff B stated that staff were checking on the resident. Review of a 10/03/2020 progress note showed, Around 0440 (4:40 AM) the nursing aide was rounding and found the resident sitting on the floor . she said I was trying to get out of bed and I slide off the bed . call light was within reach but not in use. Five hours later, another 10/03/2020 progress note showed, at 0930 (9:30 AM), Patient was found by assigned NAC (Nursing Assistant Certified) sitting on floor next to bed . When patient was asked how fall occurred; she reports, 'I was trying to sit on the wheel chair.' Review of the medical record showed no documentation how staff closely monitored the resident, or how interventions changed to compensate for cognitive impairment, to include memory recall, and prevent falls or falls associated trauma. Thirteen hours later, another 10/03/2020 progress note showed, This LN called to resident's room and found resident sitting on the floor . Complained of left shoulder pain . they found the resident sitting on the floor, lying on her left side at the foot of the bed. According to the resident, 'I got out of bed to find the TV remote control' and when asked if she forgot to use the call light she answered 'no, I did not'. The call light is off at the time of the incident . Assessed resident for injury, cut on upper lip noted and on the left side of the bridge of the nose, skin tear on left knee. Review of the progress notes showed the resident was transferred to the hospital, and a 10/04/2020 progress note showed, Call received from (local hospital) that the pt. (patient) would be discharged and sent back to the facility . Resident diagnosed with [REDACTED]. Review of the care plan showed a falls care plan dated 09/25/2020 to include non- skid socks, reinforce call for assistance, call light within reach, bed in low positon, and assist with transfers and ambulation. This care plan showed no documentation staff re-evaluated interventions when they identified the resident transferred herself, did not use the call light, or after each fall occurred until 10/04/2020, after the fall. Staff failure to develop and implement fall interventions resulted in a fourth fall wherein the resident sustained [REDACTED]. During an interview on 10/15/2020 at 12:00 PM, with Staff B confirmed that Resident #2 had an unwitnessed fall on 09/30/2020 with no injuries, three additional falls on 10/03/2020 and consequently sustained a shoulder fracture. When asked if the record showed how interventions changed to compensate for cognitive impairment, to include memory recall, and prevent falls or falls associated trauma. Staff B stated that Resident #2 looked fine, BIM Score was 13 and was encouraged to use a call light. When asked if reminding the resident to use a call light or the wheel chair was a realistic intervention for a cognitively impaired resident, staff B stated, no. When asked if the record showed how the resident was being closely monitored to prevent falls, Staff B stated I can't answer that. RESIDENT #3. Review of a 08/31/2020 Admission MDS showed the resident was admitted on [DATE], assessed to be cognitively intact, required extensive assistance of two people for transfers and toileting. This MDS also showed both staff and the resident believed the resident is capable of increased independence in at least some ADLs (Activities of Daily Living). Review of a 08/25/2020 Falls Risk Assessment showed the staff assessed the resident to be at moderate risk for falls. Review of a 08/25/2020 care plan showed the resident was a safety risk due to impaired balance, poor coordination and weakness and would have no unavoidable falls or injury as a goal. Interventions also dated 08/25/2020 included to provide assistance for transfers and ambulation until resident safe without assist, nonskid socks shoes or slippers, call light in reach at all times, and reinforce need to call for assistance. On 09/04/2020, the intervention to keep bed in lowest position was added. Review of the progress notes showed that on 09/10/2020, Around 1800 (6:00 PM), Resident #3 was assisted to the bathroom to void, per resident statement 'I tried to get up on my own to pull my depends (brief) on since I am going home soon then I fall on the floor. This note also showed, noted on the floor on her left side, and some blood noted on the floor . she was evaluated at this time and her surgical incision on her lumbar region was noted to be dehiscence (a wound splitting open) . Review of the medical record showed no documentation staff reviewed current interventions after the 09/10/2020 fall to prevent recurrence of falls or falls-associated injury, to include mitigating the resident's perception that she could do more for herself than care planned for. Five days later, a progress note dated 09/15/2020 showed, Around 0325 (3:25 AM) this LN was doing round check and found resident was on the floor of bedside lying down on her back. She said, 'I was trying to go to the bathroom for by myself. I felt I can make it on my own without asking help.' Review of the care plan or progress notes showed no documentation staff reviewed current interventions after the 09/15/2020 fall to prevent recurrence of falls or falls-associated trauma, to include mitigating the resident's perception that she could do more for herself than care planned. During an interview on 10/15/2020 at 1300 (1:00 PM) Staff B stated that Resident #2 had an unwitnessed fall on 09/10/2020 in her bathroom when the assigned nursing assistant had left her in the bathroom to answer another resident's call light, but when she returned she found Resident #2 on the floor. Resident #2 sustained dehiscence measuring 2cm on her surgical area. Staff B stated that Resident #2 required two staff assist with toileting. When asked if the staff followed the Resident's care plan for toileting, staff B stated, no, resident was reminded to use the call light and the care plan was not updated. Staff B further confirmed that Resident #2 had another (unwitnessed fall) on 09/15/2020 at 03:25 AM and sustained no injuries. When asked if the record showed the facility identified interventions to prevent falls recurrence and/or associated trauma on 09/10/2020 and again on 09/15/2020. Staff B said I can't answer that. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to identify and prevent a pattern of abuse for two (#s 1 & 2) of four sample residents. The facility failed to identify abuse, and implement preventative measures to protect the residents. Failure to recognize and analyze a pattern of incidents of resident to resident altercations, provide adequate supervision and care planning with interventions, placed residents at risk of continued abuse and resulted in Resident #2 hitting Resident #1's face, causing redness and swelling which constitutes harm. Findings Included . Resident #1 was admitted to the facility on [DATE] and according to the 05/08/2020 Annual Minimum Data Set (MDS- an assessment tool), had multiple diagnoses, including Alzheimer's, and [MEDICAL CONDITION] with behavior disturbance. Review of the 02/02/2020 Care Plan (CP) showed Resident #1 will often yell, call people names, swear or tell people what to do. Interventions to prevent abusive behavior included: Re-direct, if needed suggest pleasant actions from resident, if she yells/swears/calls names/tells peers what to do during groups. Offer resident to sit out in the hallway with a word puzzle or book by nurses' cart when not watching television in her room or participating activities. Review of a facility Incident investigation dated 06/29/2020 showed, on 06/22/2020 at about 3:35 PM, Staff C Licensed Practical Nurse (LPN), and Staff D, LPN heard Resident #1 yelling, she hit me, she hit me from the hallway. The two nurses went out to the hallway and found Resident #1 seated in her wheelchair covering her right eye and saying she hit me, she hit me. Upon assessment, Resident #1 was noted with swelling and a red mark on her face over her right eye down to the right inner eye measuring 3.5 cm x 2.0 cm (centimeter). Resident#1 further stated that she thought that it was funny because she saw stars when hit. On 07/27/2020 at 12:05 PM, Resident #1 was observed seated in a wheelchair, in her room. Resident #1 was observed with no redness or swelling to the right area eye. During an interview at this time, when asked how the other residents treated her, Resident #1 stated that she had a problem with one lady who no longer lived on the floor. Resident #1 stated, I said some(thing) to her which she didn't like and she hit me on the face but now it's healed, as she pointed to her right eye. In an interview on 07/22/2020 at 3:12 PM, Staff D revealed that she heard a resident saying She hit me, she hit me. When she went out and found Resident #1 covering her face and Resident #2 had wheeled herself to her room. When asked what happened, Staff D stated that Resident #1 had called Resident #2 Black[***] , big[***] . When Staff D asked Resident #2 what happed, she revealed that she was tired of being verbally insulted by Resident #1 and being called names. The investigation conclusion dated 06/29/2020 revealed, Resident #2 admitted to hitting Resident #1 in the face as she stated 'I'm sick of her calling me an[***] . I wasn't even talking to her, I was just trying to get by.' On 07/27/2020 at 11:45 PM, Resident #2 was observed seated in a wheelchair, in the second floor hallway. During an interview at this time, when asked if staff treated her well, Resident #2 stated, Yes. When asked about other residents, Resident #2 stated, I had a problem with one lady upstairs calling me names and I got tired and reacted, I hit her and feel sorry and that is not right. Review of the investigation conclusion dated 06/29/2020, showed facility staff concluded no abuse or neglect occurred. During an interview on 07/27/2020 at 12:20 PM Staff B, Director of Nursing (DNS) confirmed Resident #2 hit Resident #1. Further review of the incident investigation dated 06/29/2020 showed a witness statement by Staff E, Registered Nurse (RN), who documented that earlier in the morning of 06/22/2020 Staff E, heard Resident #1 cursing/calling out names while passing morning medication in the hallways. Resident's #1's needs were attended to but the resident continued to be loud. Resident #2 was pissed off and said to her shut up which other resident didn't like to hear and started cursing her answering back. Immediately both residents were separated to avoid further altercation. Both residents were in the hallway before lunch and both appeared to be calm and quiet. In an interview on 07/22/2020 at 2:42 PM, when asked about Resident #1 and Resident #2's morning altercation, Staff E revealed that Resident #1 was calling for help and being loud, then Residen t#2 said to Resident #1 Shut up. Resident #1 responded with a vulgar word back to Resident #2. Staff E intervened and separated the two residents without further abuse until later that afternoon. When asked if he reported the abuse to anyone, Staff E said No, that's her normal behavior and nothing really happened. Staff E further indicated that Residen t#1 had a behavior of cursing at anyone around her when she needed help. Review of the facility incident log showed no documentation the 06/22/2020 morning shift resident to resident verbal altercation. In an interview on 07/22/2020 at 8:12 AM, when asked if the altercation in the morning shift 06/22/2020 incident was reported on incident/accident log, Staff B said No. When asked if it was investigated, Staff B stated no. The facility failed to investigate a resident to resident verbal altercation to rule out abuse and prevent recurrence of further altercations. Further review of the 06/29/2020 incident investigation revealed that Resident #1 had a known history of being directly and indirectly vulgar when she perceived that her needs were not met. Resident #1 had a previous history of verbal altercation with another resident in 02/02/2020 when she had a shouting match with another resident who is no longer a resident at the facility. In an interview on 07/22/2020 at 3:25 PM, Staff F, Nursing Assistant (NA), revealed that Resident #1 had behaviors of calling for help and cursing at anyone around her. When asked how often the resident called and cursed, Staff F stated, daily. When asked if she had reported these behaviors to anyone including the Administrator or the State Abuse Hotline, Staff F, said everyone know that's her behavior. During an interview on 07/22/2020 at 3:40 PM, Staff G, NA, confirmed that Resident #1 had behaviors of cursing and insulting other residents. When asked what happened when other residents got offended, Staff G said Resident #1 is re-directed with activities. In an interview on 07/22/2020 at 8:12 AM, Staff B stated Resident #1 was re-directed to her room or to activities whenever she started cursing. During an interview on 07/22/2020 at 3:50 PM, Staff H, NA revealed that Resident #1 had a pattern of calling for help and cursing at residents and staff. When asked how other residents reacted to Resident #1's abusive behavior, Staff H stated that they were, mad, but staff redirect (Resident #1) with activities. Further review of the 02/02/2020 CP showed there were no interventions that directed staff on how to intervene or prevent resident to resident altercations. Review of the March, April, and May 2020 Treatment Administration Records (TARs) showed no direction to staff to monitor cursing or verbally abusive behaviors by Resident #1 or to document interventions. Review of written statements dated 06/23/2020 by Staff F, Staff G, and Staff H all showed they had, witnessed Resident #1 verbally cursing at residents and staff on 3rd floor. In an interview on 07/22/2020 at 8:12 AM, regarding preventing mental and verbal abuse by Resident #1 to other residents, Staff B stated that Resident #1 sat at the nurse station so staff could keep an eye on her. When asked if there was staff witness to the physical abuse on the afternoon of 06/22/2020, staff B said No. REFERENCE: WAC 388-97-0640 (1)

Based on observation, interview and record review, the Administration failed to effectively and efficiently manage facility compliance with federal regulatory requirements. The Administrator failed to prevent Immediate Jeopardy from occurring as referenced F 257 for failure to ensure timely reaction to a failed heating system and keep minimum temperatures at a sufficient level which adversely affected resident health and safety, causing residents to experience discomfort and created the risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and colds. Findings include: Failed practice found during the standard, abbreviated and extended survey ending on 11/08/17 was as follows: F 156 - 483.10(b)(11), Notice of rights, rules, services changes The administration failed to provide residents notice of their eligibility for additional services. F 176 - 483.10(n) Resident self-administer drugs if deemed safe The administration failed to assess the safety of residents to administer his/her own medication. F 241 - 483.15(a) Dignity The administration failed to promote care for residents in a manner and in an environment that maintained or enhanced dignity and respect in full recognition of individuality. F 242 - 483.15(b) Right to make choices The administration failed to ensure residents had the right to make choices in their daily lives which were important to them. F 250 - 483.40(d) Medically related social services The administration failed to provide medically related social services as required for one resident. F 253 - 483.10(i)(2) Housekeeping and maintenance services The administration failed to ensure an environment which was clean and in good repair on the third floor. F 257 - 483.15(h)(6) Comfortable temperatures The administration failed to ensure comfortable and safe temperature levels to minimize residents' susceptibility to loss of body heat and risk of hypothermia or, susceptibility to respiratory ailments and colds, when the heat went out in the resident rooms. Although Administration was notified the same day the heat went out, the Administration did not [MEDICATION(S)] until the next day. The outside temperatures reached below freezing temperatures overnight, and before the heating outage was corrected, resident room temperatures reached 53 degrees Fahrenheit. This resulted in an immediate jeopardy situation. F 281 - 483.20(k)(3)(i) - Services provided meet professional standards The administration failed to ensure facility staff provided care and services according to professional standards of practice. F 309 - 483.25 Provide care/services for highest well being The administration failed to ensure facility staff provided care and services which assured resident's skin issues, pain, positioning and bowels. F 312 - 483.25(a)(3) - Dependent resident receives Care The administration failed to ensure a system by which assistance with Activities of Daily Living (ADL's) related to bathing for two of three dependant residents reviewed for ADL's was provided. F 314 - 483.25(c) - Pressure Sore Development/Treatment The administration failed to ensure preventative measures for one of four residents reviewed for Pressure Ulcers. F 323 - 483.25(d)(1)(2)(n)(1)-(3) Free from accident hazards The administration failed to provide adequate supervision to ensure hazardous chemicals and potentially harmful equipment were inaccessible to residents. F 327 - 483.25(j) - Hydration The administration failed to ensure sufficient fluids were provided to prevent signs and symptoms of dehydration for one resident. F 328 - 483.25(k)(6) - Special Needs-Intravenous Services The administration failed to ensure a system which provided appropriate care, treatment, and monitoring for Peripherally Inserted Central Catheters (PICC) for six of six residents reviewed with PICC lines. F 329 - 483.25(l)(1) - Drug regimen is free from unnecessary drugs The administration failed to ensure adequate indications for medication use, adequately monitor, implement non-drug interventions and attempt a gradual dose reduction. F 332 - 483.25(m)(1) Free of medication error rates of 5% or more The administration was not aware of licensed nurses experiencing a medication administration error rate of 12%. F 353 - 483.30(a) Sufficient 24-hour nursing staff per care plans The administration failed to ensure the facility had adequate staff to provide basic care and services. F 363 - 483.35(c)(1-3) Menus followed The administration failed to ensure the facility followed the menu for pureed diets. F 371 - 483.60(i)(1)-(3) Procure, store, prepare food in sanitary conditions The administration failed to ensure a sanitary kitchen, consistent hand washing during meal preparation and thermometer were available to monitor food temperatures. F 514 - 483.75(l)(1) Resident records-complete/accurate/accessible The administration failed to ensure facility records were complete and accurate in accordance with accepted professional standards and practices. Reference: WAC 388-97-1620(1)

Based on observation, interview and record review, the facility failed to ensure comfortable and safe temperatures for residents. Failure to ensure timely reaction to a failed heating system and keep minimum temperatures at a sufficient level, adversely affected resident health and safety, causing residents to experience discomfort and created the risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and colds. Findings include: Upon entrance to the facility on [DATE] at approximately 6:45 a.m., survey staff observed the second floor of the facility was noted to be significantly colder than on previous days of the survey (11/01, 02, & 03/17). According to Staff B, Director of Nursing (DNS), in an interview at that time, he was aware the building was a little cold and would have someone from the maintenance department adjust the heat in the conference room to make the room more comfortable. Staff B, at this time, did not voice awareness that there was a facility wide systemic issue with the heat supply. On 11/06/17 at 9:13 a.m. the second floor conference room was noted to be 61.3 degrees Fahrenheit (dF). At 9:16 a.m. the hall outside the DNS office it was 61.3 dF. The central stairwell on the second floor was 63.8 dF. All the following temperatures were taken on 11/06/17 unless otherwise stated. FIRST FLOOR In an interview on 11/06/17 at 9:59 a.m., Resident #264 said, I'm all skin and bones. This cold (temperature) may be ok for others, but I'm freezing. The furnace stopped working around 3:00 p.m. yesterday, even the people who work here started wearing their coats. If they don't get this problem fixed I'm leaving as soon as my infusion is done. I'll call my son-in law and have him come get me and take me to their house where it's warm. In an interview on 11/06/17 at 10:01 a.m., Resident #170 stated It's been freezing in here since sometime last night. I think the furnace/heaters may have gone out, I had to ask for another blanket for my shoulders. On 11/06/17 at 9:30 a.m., it was 67.6 dF in the hall by room 126. The nurses station (nss) on the first floor was 68.6 dF. Resident #293, who was in a wheelchair in front of the nss at this time, was not interviewable, but staff were noted to be tucking a blanket around her. The first floor dining room was 65.5 dF. Resident #163 stated, I am really cold. I have an under shirt and a sweater here and then this (a layered overshirt), and then the blankets of course. Its better now, it was worse this morning. In the hall outside room 123, proximal to the nss it was 69.6 dF, however, in Room 123 at 9:43 a.m., it was 62.7 dF. The temperatures proximal to the nss were noted to be higher than those further away. At 11/06/17 at 9:45 a.m. the Rose Room (dining room) was 64.6 dF. In an interview on 11/06/17 at 9:56 a.m. the resident in room 120 stated she had only been in the facility for a few days, however she complained the cold temperature affected the arthritis and caused her to feel achy. In an interview on 11/06/17 at 9:52 a.m., Resident #64 was observed watching television in the first floor common area. The resident said whew its cold. Resident #64 shook his body and began vigorously rubbing his arms to emphasize he was cold. SECOND FLOOR In Room 216 on 11/06/17 at 9:50 a.m. the room temperature was 58.5 dF. Resident #293 was observed in a gray hooded sweatshirt with her hood over her head and stated, It is cold but better than last night .I have one, two, three, four blankets on my bed because I was freezing .they (staff) said it was in the 60's last night, but I don't know . Resident #176 (roommate in Room 216) called out it felt like it was in the 50's to me, I am lucky my son brought this blanket in (blanket draped over shoulders) .but my neck is freezing .I will have my son bring in some thermal T-shirts. Room 217 on 11/06/17 at 9:53 a.m. had a temperature of 57.9 dF. Resident #275 was observed sitting in her wheel chair in the room with a blue blanket wrapped around her shoulders and neck. Resident #275 stated, It is cold, it was really cold last night. In Room 228 on 11/06/17 at 10:05 a.m. the temperature was 61.1 dF. Resident #294 stated, It is awful .it is cold, I have a flannel jacket and another jacket on under this and I have two blankets .I wasn't real warm yesterday either but nothing like this. When asked if she was comfortable now Resident #294 stated, No! Good grief! Not at all, my nose is cold, and I know if my nose is cold the air is cold. The second floor dining room at 10:08 a.m. was 64.3 dF. The second floor nss was 67.3 dF. In Room 203 Resident #292 stated, Yes, I am cold I do have this fuzzy blanket. It was 63.4 dF in the hall by room 201. The therapy room on the second floor was 65.3 dF. Progress notes for Resident #139 on 11/06/17 at 9:28 p.m. by Staff N, Registered Nurse (RN) indicated, Due to low temperature in room, offered to move to warmer area, she declined, alert charting imitated to monitor for any s/sx (signs/symptoms) of infection such as fever, chills or coughing THIRD FLOOR On 11/06/17 at approximately 9:22 a.m. it was 55.6 dF in room 318. In room 316 at approximately 9:24 a.m. it was 57.8 dF. Resident #58 at that time stated, I am cold, I am not gonna get dressed 'til it warms up. The cold is sure hard on my arthritis. The vent above the resident's bed didn't present with any air exchange and the room presented as cold. It was 59.3 dF in the hallway immediately outside room 316. Resident #171, in room 322 stated she was cold. It was 58.6 dF by the window. In the hallway by room 306 across from the nss was 66.4 dF. Room 310 was 56.6 dF and felt cold. Resident #27 had a fan and denied problems with the temperature, but Resident #251, in bed 310 A stated, It might not bother him, but I am cold, I can't handle it! The hallway by room 310 was 68.1 dF. In room 328 on 11/06/17 at 9:34 a.m., the temperature was 59.0 dF, Resident #15 stated, It's cold in here I was freezing all night. It was 61.4 dF in room 300 by the bay window. Resident #122 stated at that time, I am cold and indicated the need for a blanket which staff provided. It was 64.6 dF in the hallway near room 301. It was 54.4 dF in room 301 and 69.7 dF proximal to the nss in the hall. The Sound View Dining Room was 66.4 dF near the windows. The hallway outside the dining room was 63.3 dF. Hallway temperatures appeared consistently colder as the distance from the nurses station increased. On 11/06/17 at 9:25 a.m., Resident #146 was observed sitting in the hall on the third floor near the Sound View dining room wearing a sweat shirt and pants Resident #146 stated its so cold in here my back is cold. On 11/06/17 at 9:50 a.m., Resident #148 was seated in a wheelchair in the hallway, when asked about the temperature she stated it is cold and commented it has been that way for a couple of days. On 11/06/17, at 10:00 a.m. Resident #137 was observed wearing a outdoor winter jacket. When asked about the temperature, the resident stated, it has been cold for two days, I did not sleep. When I came down to get extra blanket there were none. On 11/06/17 at 10:02 a.m., Resident #58 said it was cold last night. The resident said, I have extra blankets in room and used them. On 11/06/17 at 10:04 a.m. Resident #6 was in bed wearing a bathrobe. Resident #6 stated, It is cold in here, last night too, I did not sleep well because it was cold. Resident #112 was observed seated in the doorway her room at 10:05 a.m. The resident, who was non English speaking, appeared to be cold as evidenced by rubbing her arms and legs. Resident #82 said, I usually don't like to have a lot of blankets but I got extra blankets last night because it was cold. They need to warm up the air temperature some. On 11/06/17 at 10:07 a.m. Resident #130 was observed wearing a thick one piece pajama suit with feet. The resident stated It was really cold last night .that is why I am wearing this. On 11/06/17 at 10:50 a.m., Staff GG, a nursing assistant who worked in the facility the previous day was interviewed. When asked about the temperature the previous day (11/05/17), she stated the temperature was kinda cold and said some residents complained about the temperature the previous day. Staff GG commented, It was really cold this morning. FACILITY TIMELINE In an interview on 11/06/17 at 11:42 a.m. Staff B indicated he did not have, but was asked to provide a timeline of when and which staff first identified the issue with cold temperatures and what interventions were initiated. According to a written statement by Staff L (first floor evening shift RN), provided on 11/07/17, On November 5th during my evening shift time at 100 South around 7 p.m. we noted cold at North side wall (sic) way. And we check thermostat by the nurses station. It was 72 F. Immediately we start checking each room and pass extra blankets. Soon I called weekend supervisor (Staff BB - Nurse Manager) , but suddenly the call is disconnected before I end my conversation. And I tried to call again but with out point, so I left voice message about the situation. At that time there is no complain in South site except room 124 and 108. And I checked their temperature. Their temperature were around 97F. And they are good with 3 blankets. As usual we offer room 124 with hot drink water .(no residents) complaining of the cold except 104 and 108 for whom we added blankets. Around 8:40 (p.m.), DNS called me and I explained him the situation. After two hours, at 10:30 (p.m.) the night nurse and she is supervisory nurse came and I reported (to) her. Immediately she start contacting (administrative staff) . Facility staff did not objectively assess the temperatures of the resident's rooms. There was no data to support facility staff assessed, or conveyed the extent of the low temperatures in the facility, and their impact on the residents, to administrative staff. A statement by Staff CC (RN working the third floor from 10:30 p.m. to 4:00 a.m. on 11/05-06/17) documented, It was cold on that night and a few residents complained about the temperature. I explained to them that I can't change the temperature of the building but I can give them extra blankets. Some of them accepted and some refused. According to a timeline provided by the facility, Staff BB (Weekend Nurse Manager On Call) texted Staff B (Director of Nursing-RN) at 8:38 p.m., .I just got a call from the 100 hall nurse and reporting that the patients rooms are very cold. I think this has to be taken care of before the state back to the building tomorrow. Before patients complain about it . An additional statement by Staff JJ, Licensed Practical Nurse (LPN) indicated, Last Sunday night 317 A complain, he said it is cold - saw thermostat 70-71 (F) crank up the thermostat and cover the resident with blanket - he has about 2 blankets - 313 A husband called also (checked) thermostat about 72 (degrees) - put additional blanket to the resident. I give extra blanket to all other residents. Facility staff did not indicate at what point in time these concerns were identified on 11/05/17. A text dated 11/05/17 at 10:44 p.m. from Staff F (night shift Charge Nurse-RN) to Staff A (Administrator), reflected, Did you get a message from (Staff B) about the heat? Apparently from report it has been cold in all the rooms tonight and also in the hallway. All residents with double blankets. This text was received by Staff A two hours after the original concern was voiced by staff with no subsequent intervention. Staff A replied, Yes, (Staff R - Maintenance Director) will be there early in the morning to address it. Despite repeated concerns voiced by staff about the low temperatures, there was no additional assessment of the heat loss nor was there immediate intervention to correct the problem. Administrative staff demonstrated no sense of urgency for this problem, as evidenced by the plan to wait until the following day to determine the extent and provide a solution to repeated expressed concerns of heat loss. ADMINISTRATIVE INTERVIEWS/COMMUNICATIONS In an interview on 11/06/17 at 10:25 a.m. when asked at what time he became aware of the temperature issue, Staff B stated, I came in at 6:30 a.m. (on 11/06/17) .it was very cold here, my office is never cold. At this time, Staff B did not indicate he was aware of the heating issue prior to arriving at 6:30 a.m. At this time Staff B stated, I think this morning (Staff F- RN who worked night shift) said she talked to (Staff R) who was already here; he got here earlier than me to check in on the heating; he was already here. (Staff F) said the building was too cold. (Staff F) is the night nurse, she works on the first floor. The staff were complaining (of cold temperatures) when I got here. Almost everyone I saw complained that it was cold. When asked, would you expect staff to notify you (of the cold temperatures)? Staff B replied, I suppose that's true. If it is that cold they should say something. In an interview on 11/06/17 at 9:51 a.m. Staff A stated, (Staff R) was working on it, but then the Fire Marshal showed up .(Staff R) seemed to think the chiller was the issue. At this time Staff A conferred with maintenance staff, and stated, (Staff T - Maintenance Assistant) is still trying to trouble shoot. He is thinking that he needs to restart the computer for the fan on top of the roof. I need to get a hold of (Staff R). I sent him a text to get (a repair company) in here to get it fixed as soon as possible. At this time, more than 13 hours after the original complaints of cold temperatures, Staff A was still not aware of the etiology of the heating problem and staff were still troubleshooting the issue. During this interview, Staff A was asked when he first became aware of the cold temperature issue and replied, I was informed this morning, (Staff B) sent me a text this morning (11/06/17). At about 7:31 a.m. It said, It appears our building is unusually cold today. Staff A stated, (Staff R) was (at the facility), I texted (Staff R) as I was coming in. Staff A elaborated, I asked (Staff R) to make the patient care areas warm if possible, this I said to (Staff R) at like 7:30 a.m., he turned the room fans off so cool air isn't blowing into the rooms. These statements conflict with the timeline of administration's awareness of the heat loss which was documented in text form as 8:36 p.m. on 11/05/17. When it was mentioned that this was not a timely response to the complaints of cold voiced the previous day, Staff A stated, I wouldn't argue with you on that. In an interview on 11/06/17 at 12:31 p.m., the Maintenance Direcotor, Staff R indicated he came in to the facility at 4:00 a.m. or 4:15 a.m. that day. He indicated he had received a call from Staff B prior to that and that is why he came in. It was not until probed further that Staff R stated, He (Staff B) texted me at 9:00 p.m. (on 11/05/17, the previous day) and he was talking about the nurses saying that the 100 floor was too cold. I took that to mean the nurses station. The last time I checked, they (thermostats) were set at 70 degrees. I didn't realize he was talking about the entire floor. When asked who informed him of the cold temperatures, Staff B stated, I am not sure .(Staff BB) one of the nurse managers. At this time, Staff B stated he knew about the cold temperatures the previous day (11/05/17) stating, (Staff BB) texted me around 9:00 p.m. Staff B reviewed the time stamps on his texts and stated he received the first text about cold temperatures at 8:56 p.m. on 11/05/17 (sent at 8:38 p.m.), and immediately sent a text to Staff R (Director of Maintenance) of, I just got a text from (Staff BB) that a nurse called her saying that the 100 floor is too cold. Can you guys please check to make sure the temp is within appropriate setting before state shows up tomorrow morning? . The maintenance director replied, Last I checked all temp controls are set to 70 degrees. I'll be in early tomorrow and check them out. While administration was aware of the very cold temperatures, they failed to contemplate the negative ramifications to residents, as evidenced by the accepted delay in maintenance intervention. Staff R confirmed, I got a text (around 9:00 p.m.) from Staff B that the 100 unit was too cold, so I replied that it's set at 70. According to Staff R, The heating system runs all of the floors; when they said one hundred is cold I took that as it was just there (not the whole building). Staff R indicated he did not realize the extent of the heating issue until he came into the facility and received further report from nursing staff. Failure of administrative staff (Staff A, B & R) to assess these repeated complaints in a timely manner, prevented staff from identifying the facility wide implications for residents. According to texts at 7:33 a.m. on 11/06/17, Staff A who was CC'd on previous text messages, texted (Staff R) I am on my way in. But can you please take a look at making the patient care areas warmer if possible before it becomes an issue with the state? If we need to get a vendor in to fix the central heat let's do it ASAP. Apparently surveyors have noticed it (cold temperatures) too. If they start asking patients and patients complain we could be looking at a not so good citation. If we can resolve it quick though, we'll be fine. Staff R replied, Okay, I have been turning the room fans OFF so cool air isn't blowing into the rooms. Temporary at best, but it'll help. Staff's focus on the potential citation outcomes, rather than considering the comfort and quality of life of residents, created a negative impact on the residents who experienced prolonged exposure to cold temperatures. According to texts dated 11/06/17 at 11:44 p.m., from Staff R to Staff A, the heating system was now functioning, at least 15 hours after cold temperatures were reported. There was no data to support when the heating system actually failed, as an unknown period of time elapsed before temperatures were significantly low enough to be noticed and reported by staff. Review of work order documents from the company contacted to assess and repair the heating issue revealed, Boiler Partially Down, State Inspector is on site and needs someone ASAP Of the two boilers assessed, boiler-1 was determined to be non-operational. The second boiler was also assessed as not functioning correctly as the document read, Also found on boiler-2 that flame rectification wasn't consistent and the maint guy mentioned it would fail to ignite on some tries and would eventually work .told maint director they need a new flame sensor and cable for boiler-2 for a permanent fix. They will be picking up the part and installing it on this boiler. They are content now with the primary boiler-1 at least working accordingly. According to an interview on the morning of 11/08/17, Staff R explained boiler-1 was responsible for heating resident rooms, and boiler-2 kicked in if the outside temperature drops or to prevent over working of the first boiler. Staff R elaborated that heating units located on the roof continued to function and heated some areas of the building, including the nurses stations. Staff R indicated that each time the nurses checked the thermostats, these temperatures were not reflective of the temperatures in the halls or resident rooms as the boiler-1 was responsible for heating the resident rooms and was not functioning. In an interview on 11/07/17 at 11:22 a.m., Staff A acknowledged, .someone could have done an assessment earlier and be more accurate (regarding the extent of the issue). Staff A explained at this time that attempts to get a contracted vendor to address the failed heating system were unsuccessful until his supervisor became involved and only then were they able to get a vendor to come to the facility. According to Staff A, this was sometime after 7:30 a.m. on 11/06/17. Additionally, in an interview on 11/09/17 at 7:25 a.m., when asked if the facility had a loss of heat policy, Staff A replied, We have one related to power outage, but none directly related to loss of heat. EMERGENCY GENERATOR Observation on 11/06/17 at 10:58 a.m. revealed Staff T in the basement attempting to start the emergency generator, but the auxiliary fault light was red and the generator was not starting despite repeated attempts by Staff T who indicated it was the battery (that was the problem). In an interview on 11/06/17 at 11:16 a.m., Staff A stated, I was not aware of that (generator not working). Staff A stated he should have been, but was not informed, that the emergency generator did not function. In an interview on 11/07/17 at 11:26 a.m., Staff A indicated that when he originally texted maintenance staff, he did not know the extent of the failed heating issue. Facility failure to timely identify the extent of cold temperatures, determine the origin of the problem and fix it, caused the residents to experience heat loss, cold, discomfort and placed them at risk for extended exposure to cold and hypothermia. Reference: WAC 388-97-0880(3)