Every finding on record at Queen Anne Healthcare

Based on interview and record review, the facility failed to follow the elopement protocols for 1 of 3 residents (Resident 1), reviewed for accident hazards. This failure placed residents at risks for additional elopements, injury, and diminished quality of life.Findings included.Review of the facility's policy titled, Avamere Living-Code Pink Guidelines, revised on December 2020, showed, When a door alarm sounds. Check the door and the immediate area near the exit outside and inside to determine that no resident has exited or attempted to exit the facility unaccompanied.Review of the admission elopement risk evaluation on 06/25/2026 showed that Resident 1 was at risk for elopement.Review of Resident 1's care plan initiated on 06/25/2026 showed that they were at risk for elopement related to new admission to facility and cognitive impairment.In an interview on 07/09/2026 at 1:00 PM, Resident 1 stated that they did not remember the incident and/or they left the faciity on [DATE].Review of the facility investigation report dated 07/04/2026, showed that Resident 1 was at the nurses' station trying to talk to the nurse and when the nurse went to look for a staff who could translate for the resident, Resident 1 walked away from the nurses' station down the hall. The nurse heard the stairwell door alarm and went there to see who set off the alarm and did not see Resident 1. The investigation report further showed that the nurse stated that they did not check inside the stairwell or open the door of the stairwell when they checked the alarm.In an interview on 08/03/2026 at 3:27 PM, Staff B, Assistant Director of Nursing, stated that they expected staff to follow their code pink protocol for if staff could not find a resident. Staff B stated that when they looked at the camera, Resident 1 exited out the door around 4:00 AM on 07/04/2026. Staff B stated that Resident 1 was high risk for elopement and that it was care planned and they placed Resident 1's photo and information in the code pink book at the nurses' station and the front desk on admission dated 06/25/2026. Staff B stated that they expected staff to look in the stairwell when the alarm went off. Staff B further stated that Resident 1 was not safe to have left the facility unsupervised.In an interview on 08/03/2026 at 4:50 PM, Staff A, Director of Nursing, stated that they expected staff to follow their code pink protocol and when the stairwell alarm goes off to go into the stairwell and make sure no one was in the stairwell.Reference: (WAC) 388-97-1060 (3)(g).

Based on interview and record review, the facility failed to initiate and resolve a grievance for 1 of 2 residents (Resident 68), reviewed for grievances. The failure to initiate, investigate, and resolve grievances for missing personal item placed the resident at risk for feelings of frustration, unmet care needs, and a diminished quality of life.Findings included.Review of the facility's policy titled, Resident Grievance/Complaint Policy and Procedure, updated on 03/20/2026, showed, Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, loss of property, or any other concerns that can not be immediately resolved regarding his or her stay at this facility.In an interview on 05/04/2026 at 8:31 AM, Resident 68 stated that they were missing a blue sweater in January 2026 and that staff did not put their name on it when they took it to laundry. Resident 68 further stated that they did not remember if they spoke to the Social Worker (SW) about it and that their sweater had not been found and/or replaced. Review of Staff L, Nurse Practitioner, progress note dated 01/27/2026 showed that Resident 68 was requesting to speak with the SW to discuss missing items in the laundry.Review of the facility's January 2026 grievance log did not show that a grievance was logged for Resident 68's missing items.In an interview on 05/04/2026 at 11:21 AM, Staff L stated that they could not remember if they told the SW about Resident 68 wanting to speak to them about their missing items in the laundry. When asked if they knew the facility's grievance policy, Staff L stated that they did not know. When Staff L was asked what they would do if a resident informed them of missing personal property, Staff L stated that they would let the SW know and that it was standard practice.In an interview and joint record review on 05/04/2026 at 11:27 AM, Staff I, Social Services Director, stated that they had a new grievance form and that they could be submitted anonymously. Staff I stated that residents could complete it themselves or that staff could help residents complete the grievance form for them. Staff I stated that the grievance box was checked daily and that they had five days to resolve the grievance. A joint record review of Staff L's progress note dated 01/27/2026 showed that Resident 68 was requesting to speak with the SW to discuss missing items in the laundry. Staff I stated that they were not notified in January 2026 that Resident 68 wanted to speak to them regarding their missing item in the laundry. Staff I reviewed Resident 68's progress notes and stated that a SW had met with Resident 68 on 01/30/2026 and that there was no mention of any missing items. When asked if a grievance form was completed for Resident 68, Staff I stated that they could look for it. Staff I further stated that if they were aware of Resident 68's missing items, they would have met with them and if they could not find the missing items, they would complete a grievance form.In a follow up interview on 05/05/2026 at 10:59 AM, Staff I stated that a grievance form had not been completed for Resident 68 in January 2026 and that they were not notified of Resident 68's missing items. In an interview on 05/05/2026 at 11:02 AM, Staff A, Administrator, stated that they would have expected grievances to have been completed if a resident reported to staff that they were missing personal items that staff could not find right away. Staff A stated that they were not aware of Staff L's progress note on 01/27/2026. Staff A stated that they if they knew about it, they would have expected staff to complete a grievance, look for the items and if not found, they would replace them. When asked if they would have expected a grievance to be filed for Resident 68 in January 2026, Staff A stated, If my staff knew about it, yes, but it sounds like they didn't [did not] know about it. When asked if they would have expected Staff L to notify the SW about Resident 68's missing items, Staff A stated that Staff L did not work for them and that logically if a patient [resident] had a concern, I would expect they would tell us.Reference: (WAC) 388-97-0460 (1)(2).

Based on observation, interview, and record review, the facility failed to ensure a self-administration of medication evaluation and a physician order were obtained for 1 of 1 resident (Resident 103), reviewed for self-administration of medication. This failure placed the resident at risk for inaccurate and unsafe medication administration, adverse side effects, and a diminished quality of life.Findings included.Review of the facility's policy titled, Self-Administration of Medications, dated November 2025, showed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan.Review of the medical diagnoses sheet printed on 04/30/2026 showed Resident 103 had diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - an ongoing lung condition caused by damage to lungs), dyspnea (shortness of breath/not being able to get enough air into the lungs), and obstructive sleep apnea (sleep disorder caused by repeated interruptions in breathing during sleep).Review of Resident 103's Electronic Health Records (EHR) under evaluations tab printed on 04/30/2026 (from 04/22/2026 to 04/29/2026) showed no evaluation or assessment for self-administration of medication for Resident 103.Review of the physician orders printed on 04/30/2026 showed no documentation to indicate that Resident 103 had an order to keep the albuterol sulfate inhaler (medication used to open the airways to increase air flow to the lungs) at bedside.Review of the April 2026 Treatment Administration Record (TAR) showed Resident 103 had an order for SMP [Self-Medication Program] for Albuterol Sulfate and to document the following: can patient [resident] administer [medication] on her own? . does patient ask for inhaler at the right time. does patient know the right dosage. does patient know what medication is for? scheduled for 00:00 AM (midnight), 4:00 AM, 8:00 AM, 12:00 PM (noon), 4:00 PM and 8:00 PM, dated 04/28/2026.Observation on 04/30/2026 at 9:51 AM showed a red canister inhaler on Resident 103's bedside table that was visible and within Resident 103's reach.Observation on 04/30/2026 at 10:26 AM, showed Resident 103 had an albuterol sulfate inhaler that had 160 puffs left in it from 200 total puffs. Resident 103 stated that they brought their albuterol inhaler from home and that they had been using their inhaler since they were admitted to the facility. Resident 103 further stated that they self-administered their home albuterol inhaler two puffs three to four times a day depending on how I'm [I am] feeling.In an interview and joint record review on 04/30/2026 at 10:48 PM, Staff E, Registered Nurse, stated that if residents were on self-medication program, the facility would assess the residents to see if they could take their medications, an evaluation would be completed and get a physician order. A joint record review of Resident 103's April 2026 TAR showed Resident had orders for SMP for albuterol inhaler every four hours. Staff E stated that Resident 103 had an order for self-administration program for albuterol sulfate. When asked where Resident 103 kept their albuterol inhaler, Staff E stated they kept it in the medication cart, and that they did not know if Resident 103 kept their own albuterol inhaler in their room.A joint observation and interview on 04/30/2026 at 10:59 AM with Staff E, showed that Resident 103 had an albuterol sulfate inhaler on top of their bedside table that was within their reach. Staff E took the albuterol inhaler and informed Resident 103 that they could not keep the inhaler in their room. Staff E further stated that Resident 103 was not supposed to keep the albuterol inhaler with them.In an interview and joint record review on 05/05/2026 at 10:21 AM, Staff H, Resident Care Manager (RCM), and Staff D, RCM, stated that residents who wanted to self-administer medications would have a self-administration evaluation completed prior to starting the self-administration of medication program, have an order, and a care plan. Staff H and Staff D stated that residents who could safely self-administer their medications would be allowed to keep their medications in their room in a lockbox. A joint record review of the evaluations tab did not show Resident 103 had a self-administration evaluation prior to 04/30/2026. Staff H and Staff D stated that Resident 103 should not have had an albuterol inhaler at their bedside without having a self-administration of medication evaluation. Staff D further stated that Resident 103 was not safe to keep their albuterol inhaler at bedside.In an interview on 05/05/2026 at 11:27 AM, Staff B, Director of Nursing, stated that residents who wanted to self-administer their medications would have had an evaluation, an order, and a lockbox to keep their medications at bedside. Staff B stated that Resident 103 should have had a self-administration of medication evaluation completed before they could keep their medication at bedside and be able to self-administer their inhaler. Staff B further stated that Resident 103 should not have had their albuterol inhaler in their room.Reference: (WAC) 388-97-0440,1060 (3)(I).

Based on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP- precaution to protect residents from Multidrug-Resistant Organism [MDRO-a germ that is resistant to medications that treat infections]) for 1 of 7 Staff (Staff E), reviewed for infection control. This failure placed the residents, visitors, and staff at an increased risk for infection and related complications.Findings included .Review of the facility's policy titled, Enhanced Barrier Precautions, dated 03/21/2024, showed, .the facility will implement Enhanced Barrier Precautions (EBP mask, Gown, gloves) for residents with colonization of an MDRO during high-contact care activities and for resident with wounds requiring dressing changes or indwelling [residing within or being permanently placed inside the body] medical devices for the duration of the stay or when the wound is resolved and/or the indwelling device is discontinued.Review of the Centers for Disease Control and Prevention (CDC) online document titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2026, showed, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. The document further showed, Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include:.Device care or use:.feeding tube [a flexible tube that is inserted into the stomach to deliver nutrition, fluids, and medications when a person cannot eat or swallow safely] .Review of Resident 43's physician orders showed an order for Enhanced Barrier Precautions until resolved dated 04/15/2026.Review of Resident 43' comprehensive care plan printed on 04/30/2026 showed, The resident is on enhanced barrier precautions (EBP) r/t [related to] tube feeding. Further review of the care plan showed interventions for Direct care staff and visitors to follow EBP and Direct care staff to utilize gowns and gloves for all personal care. Observation on 05/01/2026 at 8:23 AM, showed Staff E, Registered Nurse, entered Resident 1's room wearing gloves. Staff E turned off Resident 43's feeding pump and disconnected their feeding tube. Staff E then placed Resident 43's feeding tube inside their shirt and covered their chest with a towel. Staff E removed their gloves and performed hand hygiene. Staff E was not wearing a gown when they provided feeding tube care for Resident 43.In an interview on 05/01/2026 at 8:36 AM, Staff E stated that when caring for residents with a feeding tube, they would wear a mask, gloves and gown. Staff E stated that Resident 43 was on EBP for their feeding tube. Staff E further stated that they should have worn a gown when they provided tube feeding care for Resident 43.In an interview on 05/04/2026 at 3:16 PM, Staff H, Resident Care Manager, stated that staff would wear gown and gloves when providing incontinent care, repositioning, tube feeding care and when changing the residents linens. Staff H further stated that they would have expected staff to wear gown and gloves when providing tube feeding care to Resident 43.In an interview on 05/05/2026 at 10:25 AM, Staff B, Director of Nursing, stated that they followed CDC guidelines for infection prevention. Staff B stated that they expected residents on EBP to have a signage outside their door and for staff to follow recommendations for treatment while trying to keep a home-like environment. Staff B stated that they expected staff to apply PPE when transferring a resident, if they were changing linens in an occupied bed, providing wound care, personal care, and if they were at risk of coming in close contact with the resident. When asked if they would have expected staff to wear PPE when providing feeding tube care, Staff B stated, yes. Staff B stated that if Staff E was not flushing or administering medication via the feeding tube, they would not have expected them to wear a gown. Staff B stated that if they were administering medication via the feeding tube, they would have expected them to wear one. Staff B further stated that this question had not come up before and would have to take a look.Reference: (WAC) 388-97-1320(1)(a).

Based on observation, interview, and record review, the facility failed to follow and maintain food safety and services in accordance with professional standards for 2 of 11 staff (Staff O & Staff K), reviewed for food safety. The failure to perform hand hygiene before and after serving food and not covering food items during meal delivery placed the residents at risk for food-borne illness (caused by ingestion of contaminated food or beverages), food contamination and a diminished quality of life.Findings included . Review of the facility's policy titled, Hand washing/ hand hygiene, dated October 2025, showed, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Review of the facility's policy titled, Infection Control for In-Room Dining Meal Service, revised in December 2023, showed, .hand wash prior to distributing meals .if you physically touch .their [residents'] belongings .and/or are assisting with a meal tray set-up . Review of the facility's policy titled, Food Preparation and Service, revised in November 2022, showed, When actively serving residents in a dining room or outside a resident's room where trained staff are serving food/beverage choices directly from a mobile food cart or steam table, there is no need for food to be covered. However, food should be covered when traveling a distance (i.e. [for example], down a hallway, to a different unit or floor). HAND HYGIENESTAFF OObservation on 04/29/2026 at 11:40 AM, showed Staff O, Certified Nursing Assistant (CNA), took a meal tray from the cart and set it up on the table for Resident 66 in the Dynasty Dining Room. Staff O took another meal tray and set it up for Resident 85 at the other table. Staff O then adjusted Resident 85's wheelchair to keep them in an upright position and proceeded to assist Resident 85 with their meal. Staff O did not perform hand hygiene before and after setting up the meals for Resident 66 and Resident 85 and after adjusting Resident 85's wheelchair. In an interview on 04/29/2026 at 12:19 PM, Staff O stated that they were expected to perform hand hygiene before and after setting up the residents' meals and after adjusting their wheelchair/equipment. Staff O stated that they did not perform hand hygiene before and after they set up meals for Resident 66 and Resident 85 and after they adjusted Resident 85's wheelchair and prior to assisting them with their meal. In an interview on 04/29/2026 at 12:24 PM, Staff P, Registered Nurse, stated that staff were expected to perform hand hygiene before and after setting up residents' meals and after touching residents' equipment. In an interview on 05/05/2026 at 10:45 AM, Staff B, Director of Nursing, stated that they expected Staff O to have performed hand hygiene before and after setting up residents' meals and after touching residents' equipment. MEAL TRAY DELIVERYSTAFF KObservation and interview on 05/04/2026 at 12:11 PM, showed Staff J, CNA, took a meal tray with an uncovered fruit crisp from the meal cart labeled Cart # [number] 6 that was parked in front of room [ROOM NUMBER]. Staff J walked down the hallway and stopped in front of room [ROOM NUMBER] and handed the tray to Staff K, CNA. Staff K took the meal tray and walked to the Gardenview Dining Room and delivered the meal tray to Resident 64. A joint observation of Resident 64's meal tray showed that the fruit crisp was uncovered. Staff K stated that the fruit crisp was not covered. In an interview on 05/04/2026 at 1:09 PM, Staff K stated that they were trained not to walk down the hallway to deliver meal trays, perform hand hygiene before/after delivering meal trays and that they had to sit down with the resident when assisting them with their meals. When asked if food items on the meal tray were covered, Staff K stated, sometimes they are, sometimes they aren't [are not] and that it depended on who was working in the kitchen. Staff K stated that the meal tray they delivered in the Gardenview Dining Room was misplaced and that they were trying to give it to them [Resident 64]. When asked if the fruit crisp was covered, Staff K stated that it was not covered and that none of those things were covered in the trays. Staff K stated that they did not realize that it was uncovered until they got to the resident. In an interview on 05/04/2026 at 3:12 PM, Staff H, Resident Care Manager, stated that food items on the meal trays should be covered when walking a distance. In an interview 05/04/2026 at 3:21 PM, Staff N, Kitchen Manager, stated that they expected staff to take the meal cart room to room to deliver the meal trays. Staff N stated that food on the meal trays did not have to be covered if they delivered the meal trays from room to room and that if they carried the meal trays down the hallway, the food had to be covered. When Staff N was informed of observation of a meal tray taken from a meal cart that was parked in front of room [ROOM NUMBER] and delivered to the Gardenview Dining Room, Staff N stated that they would have expected staff to find something to cover it if they were going to walk down the hallway. Staff N further stated, a couple room should be fine, but the Gardenview Dining Room would be a little too far. In an interview on 05/05/2026 at 11:01 AM, Staff A, Administrator, stated that staff should probably cover it [food items] when they delivered the meal tray to the Gardenview Dining Room. Reference: (WAC) 388-97-1100 (3)

Based on observation, interview, and record review, the facility failed to ensure medication was discarded upon reaching its discard date and to properly label and store medications in accordance with current accepted professional standards for 2 of 3 medication carts (Second Floor Medication Cart 1 & First Floor Medication Cart 2), reviewed for medication labeling and storage. These failures placed the residents at risk of receiving compromised and ineffective medications.Findings included .Review of the undated facility's policy titled, Medication Labeling and Storage, showed, Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical [medicine] practices .Multi-dose vials that have been opened or accessed (e.g.[example], needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.SECOND FLOOR MEDICATION CART 1 A joint observation and interview on 05/01/2026 at 1:25 PM, with Staff F, Licensed Practical Nurse, showed Resident 26's Ozempic pen (a drug used to treat diabetes [disease where the body cannot properly regulate blood sugar levels]) was labeled as first used on 02/14/2026 and stored in the medication cart. Further observation of the pen's instruction showed, Discard 56 days after first use. Staff F stated that the Ozempic pen's first day of use was 02/14/2026 and it should have been discarded after 56 days [on 04/11/2026].FIRST FLOOR MEDICATION CART 2A joint observation and interview on 05/01/2026 at 1:59 PM, with Staff E, Registered Nurse, showed the following medications stored in the First Floor Medication Cart 2:- One opened liquid Ferrous sulfate (iron supplement) date opened sticker field was blank and unlabeled.- Two opened amantadine hydrochloride (used to treat movement disorders) oral solution bottles were not labeled with open date.Staff E stated that these medications should have been labeled with open date.In an interview on 05/04/2026 at 1:10 PM, Staff C, Resident Care Manager, stated that liquid medications would be labeled when opened and medications would be discarded based on the pharmacy's instruction.In an interview on 05/05/2026 at 9:24 AM, Staff B, Director of Nursing, stated that staff were expected to label medications with an open date. Staff B stated that any medication that had a sticker and required an open date must be labeled at the time it was opened. Staff B further stated that they expected the Ozempic pen to have been discarded 56 days after first use.Reference: (WAC) 388-97-1300 (2).

Based on interview and record review, the facility failed to develop a care plan for 1 of 1 resident (Resident 2), reviewed for comprehensive care plan. The failure to develop a care plan for diabetes mellitus (a disease where the body cannot properly regulate blood sugar levels) placed the resident at risk for unmet care needs and a diminished quality of life.Findings included.Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, reviewed in June 2025, showed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Minimum Data Set -an assessment tool] assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.Review of the admission record printed on 05/05/2026 showed Resident 2 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus.Review of the admission MDS dated [DATE] showed Resident 2 had a diagnosis of diabetes mellitus and was receiving insulin (drug that lowers the level of sugar in the blood) during the assessment period.Review of Resident 2's comprehensive care plan printed on 05/01/2026 showed that there was no care plan developed for Resident 2's diagnosis of diabetes or insulin use.In an interview and joint record review on 05/04/2026 at 11:39 AM, Staff D, Resident Care Manager, stated that if a resident had a diagnosis of diabetes mellitus and receiving insulin, a comprehensive care plan would be developed. A joint record review of Resident 2's comprehensive care plan printed on 05/01/2026 showed that there was no care plan developed for Resident 2's diagnosis of diabetes or insulin use. Staff D stated that there was no care plan initiated for Resident 2's diabetes or insulin use, and it should have been initiated.In an interview on 05/05/2026 at 9:21 AM, Staff B, Director of Nursing, stated that they expected that care plan to be initiated for diagnosis of diabetes mellitus and insulin use.Reference: (WAC) 388-97-1020(1).

Based on interview and record review, the facility failed to ensure resident assessments were completed accurately for 1 of 1 resident (Resident 1), reviewed for pressure ulcers (bedsore). The failure to ensure accurate assessments for turning/repositioning program placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included.According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS [Minimum Data Set- an assessment tool] items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. Further review of the RAI manual showed, The turning/repositioning program is specific as to the approaches for changing the resident's position and realigning the body. The program should specify the intervention (e.g. [for example], reposition on side, pillows between knees) and frequency (e.g., every 2 [two] hours). Progress notes, assessments, and other documentation (as dictated by facility policy) should support that the turning/repositioning program is monitored and reassessed to determine the effectiveness of the intervention.Review of the facility's policy titled, Certifying Accuracy of the Resident Assessment, dated in November 2019, showed, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. The policy further showed, The information captured on the assessment reflects the status of the resident during the observation ( look-back) period for that assessment.Review of the admission MDS dated [DATE] showed that Resident 1 readmitted to the facility on [DATE]. Further review showed that Section M1200C (Skin and Ulcer/Injury Treatments) was marked for Turning/repositioning program.Review of Resident 1's Actual skin impairment care plan intervention initiated on 03/12/2026 showed, Turn and position resident REPOSITIONING/ OFF-LOADING PROGRAM: Res. [Resident] to be repositioned Q2 [every two hours] when in bed. When laying supine [flat on their back]- place pillows under the knees for comfort ensuring heels are floated and blanket tented at toes. Turn to right side- placing pillow between the legs (avoiding bone on bone contact and ensuring hips are aligned. Place additional pillow behind the back for support/ avoiding pressure to coccyx [tailbone] area. Turn to left side, same as right side position. Staff to ensure proper alignment.Review of Resident 1's electronic health record (physician orders, progress notes, tasks) did not show documentation that Resident 1 was repositioned every two hours and/or that their turning/repositioning program was monitored/reassessed to determine the effectiveness of the program.In an interview on 05/04/2026 at 1:16 PM, Staff K, Certified Nursing Assistant, was asked if Resident 1 was on a turning/repositioning program, Staff K stated, No, not to my knowledge. In an interview on 05/04/2026 at 1:56 PM, Staff E, Registered Nurse, stated that they were not sure if Resident 1 was on a turning/repositioning program. Staff E stated that Resident 1 had a wound on their back, that they did not move much and that they had to keep repositioning Resident 1 back and forth [from side to side].In an interview and joint record review on 05/04/2026 at 2:03 PM, Staff G, MDS Coordinator, stated that they followed the RAI manual for MDS completion. Staff G stated that to code turning/repositioning program in the MDS, the program had to be followed by a nurse, have specific times, instructions on how to do the program and that it had to be evaluated. When asked if Resident 1 was on a turning/repositioning program, Staff G stated, Looks like [Resident 1] was. It didn't [did not] get restarted and was discontinued on 4/3 [04/03/2026]. A joint record review of Resident 1's admission MDS dated [DATE] showed that Section M1200C was marked for Turning/repositioning program. Staff G stated, it [turning/repositioning program] was coded. Staff G reviewed Resident 1's physician orders and stated that it was discontinued on 4/3. Staff G further stated that Resident 1's admission MDS was inaccurate. In an interview on 05/05/2026 at 10:34 AM, Staff B, Director of Nursing Services, stated that they expected the MDS to be completed accurately.Reference: (WAC) 388-97-1000(1)(b).

Based on interview and record review, the facility failed to ensure clinical records were accurate for 1 of 5 residents (Resident 103), reviewed for unnecessary medications. This failure placed the resident at risk for medical complications and unmet care needs.Findings included.Review of the April 2026 Medication Administration Record (MAR) showed Resident 103 had an order for Albuterol sulfate inhaler (an inhaler used to open the airways to increase air flow to the lungs) three times a day at 8:00 AM, at 2:00 PM and at 9:00 PM that was documented as administered daily from 04/28/2026 to 04/30/2026.Review of the April 2026 Treatment Administration Record (TAR) showed Resident 103 had an order for SMP [Self-Medication Program] for Albuterol Sulfate and to document the following: can patient [resident] administer on her own? . does patient ask for inhaler at the right time. does patient know the right dosage. does patient know what medication is for? The TAR showed that the SMP for the Albuterol was signed as administered for 00:00 AM (midnight), 4:00 AM, 8:00 AM, 12:00 PM (noon), 4:00 PM, and 8:00 PM from 04/28/2026 to 04/30/2026.Review of the May 2026 MAR showed Resident 103 had an order for Albuterol sulfate inhaler three times a day and was documented as administered daily from 05/01/2026 to 05/05/2026.Review of the May 2026 TAR showed Resident 103 had an order for SMP for Albuterol Sulfate to document the following: can patient administer on her own? . does patient ask for inhaler at the right time. does patient know the right dosage. does patient know what medication is for? The TAR was signed as administered for 00:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM from 05/01/2026 to 05/05/2026. Further review of the May 2026 TAR for SMP showed it was marked 6 [six-hospitalized ] on 05/03/2026 at 8:00 PM.A joint record review and interview on 05/05/2026 at 10:45 AM with Staff E, Registered Nurse, showed Resident 103 had orders for albuterol sulfate inhaler three times a day. Staff E stated that they provided Resident 103's albuterol inhaler at 8:00 AM and at 2:00 PM during their shift. Further joint record review showed Resident 103's May 2026 TAR had an order for SMP for albuterol inhaler every 4 hours that was signed daily from 05/01/2026 to 05/05/2026. Staff E stated that they documented in Resident 103's TAR for albuterol sulfate inhaler SMP at 8:00 AM and 12:00 PM. Staff E stated that they provided Resident 103 albuterol twice during their shift and that the 12:00 PM was the only second time where they could document that they did Resident 103's SMP daily during their morning shift. Staff E stated that the order was confusing and that the SMP for albuterol sulfate should have been updated to match Resident 103's albuterol inhaler order scheduled for 8:00 AM, 2:00 PM and 9:00 PM.A joint record review and interview on 05/05/2026 at 11:03 AM with Staff D, Resident Care Manager, showed Resident 103's April 2026 MAR and May 2026 MAR had orders for albuterol sulfate inhaler three times a day at 8:00 AM, at 2:00 PM, and at 9:00 PM. Further joint record review showed Resident 103's April 2026 TAR and May 2026 TAR had order for SMP for Albuterol Sulfate every four hours that was signed daily from 04/28/2026 to 05/05/2026. Staff D stated that Resident 103's SMP order should have been updated to reflect the times that Resident 103 was provided their albuterol inhaler for 8:00 AM, 2:00 PM, and 9:00 PM.In an interview and joint record review on 05/05/2026 at 11:39 AM, Staff B, Director of Nursing, stated that Resident 103's SMP for albuterol inhaler should have been updated to reflect Resident 103's albuterol inhaler order for 8:00 AM, 2:00 PM, and 9:00 PM. A joint record review of the May 2026 TAR showed that Resident 103's SMP for albuterol inhaler was marked 6 [six-hospitalized ] on 05/03/2026 at 8:00 PM. Staff B stated that Resident 103 was not in the hospital on [DATE] at 8:00 PM, and that they would educate the staff about appropriate documentation.Reference: (WAC) 388-97-1720 (1)(a)(i)(ii).

Based on interview and record review, the facility failed to accurately assess 1 of 3 residents (Resident 1), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to accurately assess a surgical wound placed the resident at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources . include the resident's medical record . The RAI manual further showed, if a pressure ulcer [or pressure injury-wounds that occur from prolonged pressure on the skin] is surgically closed with a flap or graft [a body tissue used to cover another body area], it should be coded as a surgical wound and not as a pressure ulcer. If the flap or graft fails, continue to code it as a surgical wound until [it is] healed. Review of a physician progress note dated 02/04/2025, showed Resident 1 had a pressure ulcer on their sacrum (tail bone) that had undergone a failed flap surgery in 2023. Further review of the physician progress note showed Resident 1 had one unstageable (loss of the deepest layers of the skin extending into the muscle in which the base of the ulcer is covered by slough [yellowish layer of dead tissue] or eschar [dead tissue that appears hard, dry, dark covering]) pressure ulcer on their left ischium (hip bone). Review of the hospital wound note dated 02/10/2025, showed Resident 1 had history of stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer on their sacrum. Further review of the hospital wound note showed that Resident 1 had failed flap surgery on their sacral pressure ulcer. Review of Resident 1's significant change MDS dated [DATE], showed Section M0300D (Number of Stage 4 Pressure Ulcer) was coded 1. Review of Resident 1's physician progress note dated 04/15/2025, showed that Resident 1 had a flap surgical wound on their sacrum and unstageable pressure ulcer to their left ischium that was debrided (the process of removing dead skin from a wound to promote healing) and was evaluated as a stage 4 pressure ulcer. Review of the discharge MDS dated [DATE], showed Resident 1 was discharged to the hospital. Further review of the discharge MDS showed Section M0300D was coded 2. In an interview and joint record review on 04/22/2025 at 11:12 AM, Staff B, MDS Nurse, stated that they followed the RAI manual in coding the MDS. A joint record review of Resident 1's significant change MDS dated [DATE] showed that Section M0300D was coded 1. Joint review of Resident 1's discharge MDS dated [DATE] showed Section M0300D was coded 2. Staff B stated that they coded Resident 1's sacral wound as a stage 4 pressure ulcer on Resident 1's significant change MDS and on their discharge MDS. Joint review of the RAI manual dated October 2024 showed that a pressure ulcer should be coded as a surgical wound and not as a pressure ulcer when it was surgically closed with a flap and would continue to code it as a surgical wound even if the flap failed. Staff B stated that they did not code Resident 1's MDS accurately and will correct them. In an interview on 04/22/2025 at 1:54 PM, Staff A, Director of Nursing, stated that Resident 1's sacral pressure ulcer was not coded correctly and that they expected Resident 1's MDS to be coded accurately. Reference: (WAC) 388-97-1000 (1)(b)

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP- precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) practices were followed for 1 of 9 residents (Resident 72), reviewed for infection control. In addition, the facility failed to ensure hand hygiene and proper glove use were followed for 1 of 3 residents (Resident 12), reviewed for wound care, and failed to ensure clean linens were carried appropriately for 1 of 1 resident (Resident 6), reviewed for laundry services. These failures placed the residents, staff, and visitors at an increased risk for infection and related complications. Findings included . Review of the facility's policy titled, Enhanced Barrier Precautions, dated 03/21/2024, showed, PPE [Personal Protective Equipment-equipment [gown, gloves, mask] worn to minimize exposure to hazards that cause illness] for enhanced barrier precautions is only necessary when performing high-contact care activities. It showed that that high contact activities included, providing hygiene. Review of the facility's policy titled, Handwashing/Hand Hygiene, revised in August 2019, showed to use an alcohol-based hand rub .or, alternatively, soap (antimicrobial or non-antimicrobial) and water .after removing gloves. ENHANCED BARRIER PRECAUTIONS RESIDENT 72 Review of Resident 72's admission minimum data set (an assessment tool), dated 01/29/2025, showed Resident 72 required substantial/maximal assistance (helper does more than half the effort) for oral hygiene. Review of Resident 72's infection care plan, revised on 11/15/2024, showed Resident 72 was on EBP. Observation and interview on 01/29/2025 at 10:33 AM, showed Staff O, Speech Therapist, enter Resident 72's room (EBP room) wearing gloves, and no other PPE. It showed Staff O using an oral swab and providing oral care for Resident 72. Staff O stated, if I need to give oral care, I just need gloves. Joint observation of the EBP signage outside Resident 72's room showed to wear gown and gloves when providing personal hygiene. Staff O stated that oral care was considered personal hygiene and I should wear a gown. In an interview on 02/03/2025 at 11:26 AM, Staff D, Infection Preventionist, stated that they expected staff to follow the protocol for residents on EBP. Staff D stated that staff should wear PPE (gown and gloves) when they have high contact with residents, which included providing hygiene. Staff D further stated that oral care was considered personal hygiene and staff should wear gown, gloves and a mask. In an interview on 02/03/2025 at 11:56 AM, Staff B, Director of Nursing, stated that all staff, including therapy staff, should wear PPE when providing personal hygiene care to residents on EBP. Staff B stated that oral care was considered personal hygiene and staff should wear gloves, mask and gown. HAND HYGIENE/GLOVE USE RESIDENT 12 Review of Resident 12's comprehensive care plan, revised on 12/08/2024, showed Resident 12 had a pressure wound. Review of Resident 12's January 2025 Medication Administration Record, showed an order for daily dressing changes for wound care, started on 01/14/2025. Observation on 01/30/2025 at 11:14 AM, showed Staff H, Licensed Practical Nurse, was assisting to change Resident 12's briefs. Staff H used wipes to clean Resident 12, then took off their soiled gloves, put on clean gloves, and helped to put clean linens on the bed. No hand hygiene was done between glove changes. Observation on 01/30/2025 at 11:43 AM, showed Staff H perform hand hygiene, put on clean gloves and cleaned around the wound with gauze and wound cleanser. Staff H removed their soiled gloves and put on new gloves, and did not perform hand hygiene between glove changes. Staff H then applied the skin prep (used to protect the skin) around the wound, took off their soiled gloves, put on new gloves and applied the dressing. No hand hygiene was done between glove changes. In an interview on 01/30/2025 at 11:56 AM, Staff H stated that hand hygiene should be done between glove use and that they did not do this when performing Resident 12's dressing change. In an interview on 02/03/2025 at 11:26 AM, Staff D stated that they expected staff to perform hand hygiene before and after changing gloves, and we should be doing [hand hygiene] between glove use. In an interview on 02/03/2025 at 11:56 AM, Staff B stated that they expected staff to follow our policy for handwashing. Staff B further stated that hand hygiene should be done between glove use. 47218 TRANSPORTING CLEAN LINEN Review of the facility's policy titled, Infection Prevention and Control Program, revised in October 2018, showed that An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. RESIDENT 6 Review of the physician orders printed on 01/27/2025 showed Resident 6 had an order for EBP. Further review of the physician orders showed Resident 6 had wounds on their right and left legs and was receiving wound care treatments. Observation and interview on 01/29/2025 at 9:34 AM, showed Staff I, Certified Nursing Assistants, carrying clean linens that included one white blanket, one blue blanket, one fitted sheet, and one flat sheet against Staff I's chest touching their clothes. Staff I stated that they were going to change Resident 6's bed linens. Staff I further stated that they carried the clean linens against their chest because [it] is hard to manage when we need to use Purell [brand name-hand sanitizer], we have to do it all the time, gel in and gel out. On 02/03/2025 at 11:59 AM, Staff K, Registered Nurse, stated that clean linens should be carried away from the body and not against the body. On 02/03/2025 at 12:01 PM, Staff L, Resident Care Manager, stated they expected that clean linens were carried away from staff's body or uniform. Staff L further stated that staff should not have had the clean linens touch their body when entering Resident 6's room. On 02/03/2025 at 12:07 PM, Staff D stated they did not expect staff to carry clean linens against their body. On 02/03/2025 at 12:24 PM, Staff B stated they expected staff to carry clean linens away from their body and that staff should not have carried the clean linens against their body to change Resident 6's linens. Reference: (WAC) 388-97-1320 (1)(a)(c)(3)

Based on interview and record review, the facility failed to notify the State Pre-Admission Screening and Resident Review (PASARR or PASRR-an assessment used to identify people [residents] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities, or related conditions are not inappropriately placed in nursing facilities for long term care) Coordinator after a significant change in status occurred for 1 of 7 residents (Resident 7), reviewed for PASARR. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, PASRR Policy, revised on 03/22/2024, showed, The PASRR determines that individuals are admitted appropriately to the nursing facility. It identifies people who have an intellectual disability or related concern, or a serious mental health illness, ensuring they receive the services needed. Resident 7 admitted to the facility on [DATE] with diagnoses that included depression (a mental health condition that involves intense feeling of sadness), paranoid personality disorder (a mental health condition characterized by a long-term pattern of extreme distrust and suspicion of others), and unspecified psychosis (a disorder where the individual experiences symptoms such as delusions, hallucinations, disorganized thinking and speech and emotional withdrawal). Review of the Level I PASARR updated on 09/10/2024, showed Resident 7 had SMI and required a Level II PASARR evaluation (a comprehensive evaluation for a positive Level I screening) referral. Review of the Certification of Terminal Illness dated 10/30/2024, showed Resident 7 had a terminal illness with a life expectancy of six months or less. It further showed that Resident 7 enrolled in hospice services on 10/29/2024. A review of Resident 7's Electronic Health Record (EHR) showed Resident 7 had a significant change in status Minimum Data Set (an assessment tool) dated on 11/04/2024. In an interview on 01/31/2025 at 12:55 PM, Staff Q, Social Services Director, stated that their process was to complete a new Level I PASARR and refer for Level II PASARR evaluation if a resident had a significant change in status. Staff Q stated that enrolling in hospice was considered a significant change in status. Staff Q stated that Resident 7 admitted to hospice on 10/29/2024 and there should have been a new Level I PASARR done for her change in condition. Staff Q further stated that they did not notify the PASARR coordinator about Resident 7's significant change in status. In an interview and joint record review on 02/03/2025 at 12:14 PM, Staff A, Administrator, stated that their expectation for a resident who had a significant change in status, was that they would do a new one [Level I PASARR] or update the PASARR coordinator. Staff A stated that when a resident enrolled in hospice services it was considered a significant change in status, and they expected a new referral for Level II evaluation to be sent. Joint record review of Resident 7's EHR showed Resident 7 had a Level I PASARR updated on 09/10/2024, and that Resident 7 required a Level II PASARR evaluation referral. Further review of the EHR showed no documentation that a new Level I PASARR was sent for Level II PASARR evaluation after Resident 7 enrolled in hospice services. Staff A stated, I would say she would need to have a new one [Level I PASARR] after hospice enrollment. Reference: (WAC) 388-97-1975 (7)

Based on observation, interview, and record review, the facility failed to ensure physician's orders for oxygen were in place and/or followed according to professional standards of practice for 2 of 3 residents (Residents 85 & 12), reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, and related respiratory complications. Findings included . Review of the facility's policy titled, Oxygen Administration, revised in October 2010, showed The purpose of this procedure is to provide guidelines for safe oxygen administration . Oxygen therapy is administered by way of an oxygen mask, nasal cannula [flexible tubing that sits inside the nostrils and delivers oxygen], and/or nasal catheter [flexible rubber or plastic tube with several holes near the tip inserted in the nostril] . Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. RESIDENT 85 Resident 85 admitted to the facility on [DATE] with diagnoses that included sarcoidosis of the lungs (a condition that causes inflammation and lumps in the lungs that can cause shortness of breath, cough, and fatigue) and chronic respiratory failure with hypoxia (insufficient oxygen in the blood). Observation on 01/27/2025 at 2:47 PM, showed Resident 85 was receiving oxygen from an oxygen concentrator via a nasal cannula at a rate of two and a half liters (unit of measurement) per minute. Resident 85 stated that they have used oxygen for a long time due to their sarcoidosis and that they use their oxygen continuously from an oxygen concentrator when in their room and from an oxygen tank when out of their room. Review of the physician's orders printed on 01/27/2025 did not show Resident 85 had orders for oxygen. Review of the hospital discharge summary dated 01/09/2025 showed Resident 85 received oxygen at two to three liters per minute via nasal cannula. Further review of the discharge summary showed continues on 3L NC [three liters per minute via nasal cannula]. Review of the physician's progress note dated 01/10/2025 showed, Plan: continuous oxygen at 2 L [two liters per minute] at rest and 4 L [four liters per minute] with activities per pulmonary [lung doctor] recommendations. On 01/29/2025 at 1:55 PM, Staff L, Certified Nursing Assistant, stated that Resident 85 used their oxygen all the time. In an interview and joint record review on 01/29/2025 at 2:12 PM with Staff N, Registered Nurse (RN), stated that Resident 85 was on continuous oxygen at a rate of two liters per minute. Joint record review of the physician's orders showed Resident 85 did not have orders for continuous oxygen. Staff N stated that there was an order to check oxygen saturation (percentage amount of oxygen in the blood - specifically in the red blood cells) as needed and that there should have been an order for how much oxygen Resident 85 was getting per minute. In an interview and joint record review on 01/29/2025 at 2:21 PM with Staff E, Resident Care Manager (RCM), stated they expected residents admitting with oxygen had an oxygen order in place. Staff E stated that oxygen orders would have information if the oxygen was as needed or continuously, and the amount of oxygen liters per minute. Joint record review of the physician's order dated 01/29/2025, showed Resident 85 had an order to increase the oxygen up to four liters per minute as needed. Staff E stated that Resident 85's order to increase oxygen was started on 01/29/2025. Joint record review of the hospital discharge summary indicated that Resident 85 was on two to three liters per minute of oxygen via nasal cannula. Staff E stated that Resident 85 should have had orders for oxygen since their admission [01/09/2025]. On 02/03/2025 at 12:34 PM, Staff B, Director of Nursing, stated they expected oxygen administration orders were in place for residents who admitted with supplemental oxygen. Staff B further stated that Resident 85 should have had an order for oxygen upon admission. 46912 RESIDENT 12 Resident 12 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe) and chronic respiratory failure. Review of Resident 12's January 2025 Medication Administration Record (MAR), showed an order for O2 [oxygen] @ [at] 2L/min [minute] via NC [nasal cannula] PRN [as needed] for SOB [shortness of breath]/cyanosis [when the skin, lips or nails turn blue due to a lack of oxygen in the blood], as needed for decreasing O2 sat [oxygen saturation] < [less than] 90% [percent], started on 12/02/2024. Observations on 01/27/2025 at 10:35 AM, on 01/28/2025 at 9:19 AM, on 01/29/2025 at 8:32 AM, and on 01/29/2025 at 12:05 PM, showed Resident 12 receiving oxygen from an oxygen concentrator via a nasal cannula at two and a half liters. In an interview on 01/28/2025 at 10:15 AM, Resident 12 stated they had been using oxygen continuously probably for a year at a low dose. In an interview and joint observation on 01/29/2025 at 1:28 PM, Staff P, RN, stated that they would expect an order if a resident was using oxygen continuously. Staff P stated that Resident 12 was receiving continuous oxygen. Joint observation showed Resident 12 was receiving oxygen from an oxygen concentrator via a nasal cannula at two and a half liters. Staff P stated they were responsible for checking the oxygen whenever I go in [resident rooms]. Joint record review of Resident 12's January 2025 MAR showed an order for O2 @ 2 L/min via NC PRN for SOB/cyanosis, as needed for decreasing O2 sat < 90%. Staff P stated the order should be for continuous oxygen at two liters per minute and I'm going to adjust it [Resident 12's oxygen concentrator settings] to two liters. In an interview and joint record review on 01/29/2025 at 2:40 PM, Staff G, RCM, stated they would expect an order if a resident was receiving continuous oxygen therapy. Staff G stated, she's [Resident 12] on PRN oxygen and we are monitoring her oxygen sats [saturation] and if it goes below 90 percent. Joint record review of the vitals tab in Resident 12's electronic health record showed no documentation that Resident 12's oxygen saturation went below 90 percent. Staff G stated the documentation did not show that Resident 12's oxygen saturations dropped below 90 percent. Joint record review of Resident 12's January 2025 MAR showed no documentation that Resident 12 was using oxygen, Staff G stated, it should be documented. Staff G stated that Resident 12 should be on two liters of oxygen and not two and a half liters. Staff G further stated, I checked with the provider, and we are changing it [Resident 12's oxygen order] to continuous. In an interview on 02/03/2025 at 11:56 AM, Staff B stated that if a resident had been on PRN oxygen for a while, I would expect a new order for continuous oxygen. Staff B further stated that if a resident had an order to receive two liters of oxygen, I would not expect the oxygen settings to be at two and a half liters. Reference: (WAC) 388-97-1060 (3)(j)(vi)

Based on observation, interview, and record review, the facility failed to ensure a physician order was followed and/or clarified for 1 of 4 residents (Resident 194), reviewed for medication administration. This failure placed the resident at risk for receiving incorrect medication dosage and formula, adverse side effects, and a diminished quality of life. Findings included . Review of the facility's policy titled, Administering Medications, revised in April 2019, showed medications should be administered in accordance with the prescriber's orders. The policy further showed that the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of Resident 194's physician orders showed an order for Ferrous Sulfate (iron supplement) oral tablet delayed release 324 milligrams (mg-unit of measurement) initiated on 01/18/2025 to be given one time a day every other day. Observation on 01/30/2025 at 8:39 AM, showed Staff H, Licensed Practical Nurse, administered Ferrous Sulfate 325 mg to Resident 194 instead of the prescribed order above. In an interview on 01/30/2025 at 8:51 AM, Staff H stated that they administered the iron supplement (325 mg) they had in supply to Resident 194 and that they were not sure if it was delayed release as it was not labeled on the bottle. Staff H stated that they should confirm the order, read the order, then look for the medication and administer it. Staff H further stated that if the order did not match the medication, then they had to clarify the order with the provider and that they did not do that with Resident 194's iron supplement. Joint record review and interview on 01/30/2025 at 2:10 PM with Staff G, Resident Care Manager, showed a nursing progress note dated 01/30/2025 that Staff H had documented they had given iron 325 mg in error instead of iron 324 mg delayed release and they had notified the provider. Staff G stated that the staff should check the resident name, medication, dose, and route prior to administration. Staff G stated Staff H should have done this prior to administering the incorrect iron supplement to Resident 194. Staff G stated that Staff H should have clarified the order with the provider. Staff G further stated that the provider changed Resident 194's order to iron 325 mg (the facility's house stock). On 01/31/2025 at 1:22 PM, Staff B, Director of Nursing, stated their expectation was for nursing staff to check for the correct medication order, patient, dose, route, and strength. Staff B further stated that Staff H should have clarified the order with the provider. Reference: (WAC) 388-97-1300 (3)(a)

Based on interview and record review, the facility failed to accurately assess 2 of 25 residents (Residents 89 & 190), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding discharge status and insulin (medication/hormone that regulates blood sugar levels) injections placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. The MDS manual further showed to mark/code medications given to the resident by any route. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). RESIDENT 89 Review of Resident 89's face sheet showed they admitted to the facility on [DATE] and discharged from the facility on 12/24/2024. Review of Resident 89's progress note dated 12/24/2024 showed they discharged to the community. Review of the discharge MDS dated [DATE] showed Resident 89 was coded for discharge status to acute hospital. In an interview and joint record review on 01/31/2025 at 11:42 AM with Staff M, MDS Coordinator, they stated that they followed the RAI manual for completion of MDSs. Joint record review of Resident 89's discharge MDS, showed that it was coded/marked for discharge to acute hospital. Staff M stated Resident 89's MDS showed they discharged to the hospital. Another joint record review and interview with Staff M, showed Resident 89's progress notes indicated that they discharged against medical advice to the community. Staff M stated Resident 89's discharge MDS was inaccurate and that it should have been coded as discharged to the community. RESIDENT 190 Review of the January 2025 Medication Administration Record showed Resident 190 was administered insulin on 01/17/2025, 01/18/2025, 01/20/2025, 01/21/2025, and 01/22/2025, for a total of five-days during the look back period. Review of the admission MDS dated [DATE] showed Resident 190 was marked that they received 6 injections and 6 insulin injections in Section N (Medications). Joint record review and interview on 01/31/2025 at 11:26 AM with Staff M, showed Resident 190's MDS was coded for 6 injections and 6 insulin injections, indicating that Resident 190 received insulin injections for six days. Staff M stated that Resident 190 received 6 insulin injections from 01/17/2025 through 01/22/2025. Another joint record review and interview with Staff M showed Resident 190's progress notes indicated that insulin was held and not given on 01/19/2025. Staff M stated that Resident 190's MDS was coded incorrectly and that they would modify it to show 5 injections and 5 insulin injections in Section N. On 02/03/2025 at 12:25 PM, Staff B, Director of Nursing, stated they expected MDSs were completed accurately. Staff B stated that Resident 89's discharge MDS was coded incorrectly. Staff B further stated they expected Resident 190's admission MDS to be coded accurately. Reference: (WAC) 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to ensure the influenza vaccine (used to prevent influenza [an infection of the nose, throat, and lungs]), was provided for 1 of 5 residents (Resident 10), reviewed for immunizations. This failure placed the resident at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from influenza disease. Findings included . Review of the facility's policy titled, Influenza Vaccine, revised in March 2022, showed, Between October 1st [first] and March 31st [thirty first] each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized. Resident 10 admitted to the facility on [DATE]. Review of the facility's document titled, Vaccination History and Consent, dated 01/09/2025, showed that Resident 10's representative consented to receive the influenza vaccine on 01/12/2025. It further showed that a nurse signed the form on 01/21/2025. Review of the electronic health record showed no documentation that Resident 10 was provided an influenza vaccination. In an interview and joint record review on 02/03/2025 at 11:00 AM, Staff D, Infection Preventionist, stated that they offered the influenza vaccine to residents on admission. Staff D stated that if a resident and/or their representative signed that they wanted to receive the influenza vaccine, they would order it and send out to the pharmacy. Joint record review of the Vaccination History and Consent, dated 01/09/2025, showed that Resident 10's representative consented to receive the influenza vaccine on 01/12/2025. Joint record review of Resident 10's January 2025 medication administration record showed that there was no documentation that Resident 10 received the influenza vaccine. Staff D stated, I don't see an order, I need to follow up and I don't know what happened. I think I missed this one. Staff C, Assistant Director of Nursing, stated that the influenza vaccine would be given to the resident usually within the week of signing that they wanted to receive the vaccine. In an interview on 02/03/2025 at 11:56 AM, Staff B, Director of Nursing, stated that they offered the influenza vaccine to every new admission, and once they accept it, the vaccine is ordered and administered. Staff B stated they expected the influenza vaccine to be ordered right after getting consent and would get the vaccine from the pharmacy in around three to four days. Reference: (WAC) 388-97-1340 (1)(2)

Based on interview and record review, the facility failed to ensure the COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) vaccine was provided for 1 of 5 residents (Resident 10), reviewed for immunizations. The failure to provide the COVID-19 vaccination placed the resident at risk for contracting the COVID-19 virus and related complications. Findings included . Review of the Centers for Disease Control and Prevention online document titled, Staying Up to Date with COVID-19 Vaccines, dated 10/03/2024, showed that everyone ages 6 months and older should get a 2024-2025 COVID-19 vaccine. It showed that people ages 12-[AGE] years are up to date when they have received one dose of the 2024-2025 COVID-19 vaccine. It further showed that people ages [AGE] years and older are up to date when they have received two doses of any 2024-2025 COVID-19 vaccine 6 months apart. Review of the facility's policy titled, COVID-19 Vaccine, dated 08/11/2023, showed All residents and employees who have no medical contraindications to the vaccine will be offered the COVID-19 Vaccine. It further showed, The resident's medical record will include .each dose of COVID-19 vaccine administered. Resident 10 admitted to the facility on [DATE]. Review of the facility's document titled, Vaccination History and Consent, dated 01/09/2025, showed that Resident 10's representative consented to receive the COVID-19 vaccine on 01/12/2025. It further showed that a nurse signed the form on 01/21/2025. Review of Resident 10's electronic health record showed no documentation that Resident 10 was provided a COVID-19 vaccination. In an interview and joint record review on 02/03/2025 at 11:00 AM, Staff D, Infection Preventionist, stated that they offered the COVID-19 vaccine to residents on admission. Staff D stated that if a resident and/or their representative signed that they wanted to receive the COVID-19 vaccine, they would order it and send out to the pharmacy. Joint record review of the Vaccination History and Consent, dated 01/09/2025, showed that Resident 10's representative consented to receive the COVID-19 vaccine on 01/12/2025. Joint record review of Resident 10's January 2025 Medication Administration Record showed no documentation that Resident 10 received the COVID-19 vaccine. Staff D stated, I don't see an order, I need to follow up and I don't know what happened. I think I missed this one. Staff C, Assistant Director of Nursing, stated that they received the completed consent form from Resident 10's representative on 01/21/2025. Staff C further stated that the COVID-19 vaccine would be given to the resident usually within the week of signing that they wanted to receive the vaccine. In an interview on 02/03/2025 at 11:56 AM, Staff B, Director of Nursing, stated that they offer the COVID-19 vaccine to every new admission, and once they accept it, the vaccine is ordered and administered. Staff B stated they expected the COVID-19 vaccine to be ordered right after getting [the] consent and the vaccine would be ordered from the pharmacy and be available in the facility in around 3-4 days. No reference WAC

Based on observation, interview, and record review, the facility failed to ensure residents were evaluated, assessed, and obtained a physician order for safe administration of medications for 2 of 2 residents (Residents 30 & 48), reviewed for self-medication administration. The failure to complete a self-administration of medication assessment and obtain a physician's order placed the residents at risk for medication errors, adverse medication interactions, and complications. Findings included . Review of the facility's policy titled, Self-Administration of Medications, revised in February 2001, showed, Residents have the right to self-administer medications. It showed, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The policy further showed, Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. RESIDENT 30 Review of the admission Minimum Data Set (MDS-an assessment tool) dated 12/13/2024 showed Resident 30 admitted to the facility on [DATE] and that they were cognitively intact. In an interview and observation on 01/29/2025 at 2:16 PM, Resident 30 stated that they take Vitamin D (supplement) because they did not get any sun. Resident 30 then took a bottle of Vitamin A & D [supplement] from their bedside table. Another observation and interview on 01/30/2025 at 2:47 PM, showed Resident 30 had one opened bottle of Turmeric (supplement) and one opened bottle of Vitamin A & D on their bedside table. Resident 30 stated that they administer it themselves. When asked if staff were aware of the medications they were taking, Resident 30 stated, I would imagine, I leave them out. In a follow up interview at 4:10 PM, Resident 30 stated that they had been taking it for three days and took the recommended dose on the bottle. Review of Resident 30's January 2025 Medication Administration Record (MAR) did not show an order for Vitamin A & D and Turmeric. Further review showed that Resident 30 had an order for Cholecalciferol (Vitamin D3-supplement) once a day for bone health with a start date of 01/26/2025. Review of Resident 30's assessment tab in their Electronic Health Record (EHR) printed on 01/30/2025 did not show that a self-medication program was completed. RESIDENT 48 Review of the quarterly MDS dated [DATE] showed Resident 48 readmitted to the facility on [DATE]. Observation and interview on 01/29/2025 at 12:04 PM, showed Resident 48 took an opened tube of Terbinafine (an antifungal cream) from their bedside table and stated that their podiatrist (foot doctor) gave it to them for their foot. Resident 48 further stated that an unidentified nurse told them that they had to keep it [medication] over the counter [medication cart] and that they told the nurse no. Observation and interview on 01/30/2025 at 9:51 AM, showed one opened tube of Terbinafine on Resident 48's bedside table. Resident 48 stated that the nurse applied it on them two times a day, that sometimes they used it more than twice and sometimes not at all. Resident 48 further stated they had been using it before they came to the facility. Review of Resident 48's January 2025 MAR showed an order for Terbinafine Cream. Apply to feet topically two times a day for debrided nails with a start date of 01/18/2025. Review of Resident 48's assessment tab in the EHR printed on 01/30/2025 did not show that a self-medication program was completed. In an interview and joint observation on 01/30/2025 at 3:11 PM, Staff F, Licensed Practical Nurse, stated that they did not allow residents to keep their medications at the beside unless there was an order from the provider. Staff F stated that if it was an over the counter medication and the resident wanted to keep it with them, they would have to check with the provider and store the medication in the medication cart. When asked if residents were allowed to self-administer medications and keep it at the bedside, Staff F stated, No, unless there's an order. Joint observation showed that Resident 48 had one tube of Terbinafine on their bedside table. When asked if Resident 48 should have it at the bedside, Staff F stated, No and that they had to apply it for them. Joint record review of Resident 48's physician orders showed an order for Terbinafine. Staff F stated that it should not have been on their bedside table. Another joint observation showed Resident 30 had one bottle of Turmeric and one bottle of Vitamin A & D on their bedside table. Staff F stated that it should not have been on their bedside table and that Resident 30 should have had an order for the medications. Joint record review of Resident 30's physician orders showed that they did not have an order for Turmeric and Vitamin A & D. Staff F stated that they did not see an order for the medications. In an interview on 01/30/2025 at 3:47 PM, Staff E, Registered Nurse, stated that residents should not have had medications at bedside unless they had an order and that a self-medication program had to be completed. Staff E stated that Resident 48 did not have a self-medication program completed and that they should have had one. Staff E stated that Resident 30 did not have a self-medication program completed and that to their knowledge they did not know that Resident 30 was keeping the medications at bedside because they did not have an order for them. Staff E further stated that they always encourage residents/family to let the staff know before bringing medications/supplements in the facility. In a follow up interview at 4:04 PM, Staff E stated that if they were aware of the medications at resident's bedside and if resident request to self-administer the medications and want to keep it at the bedside, they would notify the provider and complete a self-medication program. Staff E further stated that their process was to lock up the medications until the provider gave an order, complete a self-medication program, assess the resident for safe medication administration, and safely store the medication at bedside. In an interview on 01/31/2025 at 1:38 PM, Staff B, Director of Nursing, stated that if a resident wanted to self-administer and keep their medications at bedside, they expected the resident to have a self-medication program and a physician's order that they can keep it at the bedside. Staff B stated that they would expect staff to ensure the resident's environment was safe by looking for medications at the bedside, or anything that they would need to secure. Staff B further stated that if Resident 30 and Resident 48 were observed with medications at the bedside, they would have expected staff to pick up the medications and complete a self-medication program if it was their wish to do it. Reference: (WAC) 388-97-1060(3)(l), 0440

Based on observation, interview, and record review, the facility failed to ensure foods stored in residents' personal refrigerators were labeled with use by date, discarded after use by date, and refrigerators had internal thermometer for 2 of 3 residents (Residents 1 & 2) and for 1 of 2 resident refrigeration units (First Floor Resident Refrigeration Unit), reviewed for personal food safety. In addition, the facility failed to ensure refrigerator temperatures were monitored and maintained for 2 of 3 refrigerators (Resident 2's Personal Refrigerator & First Floor Resident Refrigeration Unit). These failures placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life. Findings included . Review of the facility's policy titled, Personal Food Storage, revised in [DATE], showed that food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal room refrigeration units will be monitored by designated facility staff for food safety. It further showed that perishable foods items without a manufacturer's expiration date should be dated upon arrival in the facility and thrown away three days after the date marked. Items in unmarked or in unlabeled containers should be marked with the current date the food items were stored. Food or beverages past the manufacturer's expiration date will be thrown away immediately. All refrigeration units will have internal thermometers to monitor for safe food storage temperatures. Units must maintain safe internal temperatures in accordance with state and federal standards for safety storage temperatures. Staff will monitor and document unit refrigerator temperature. RESIDENT 1'S PERSONAL ROOM REFRIGERATOR During an interview on [DATE] at 4:19 PM with Collateral Contact 1, stated that the resident received food from the facility that tasted bad. During a joint observation and interview on [DATE] at 11:10 AM with Staff G, Certified Nursing Assistant, showed Resident 1's personal refrigerator had the following food items: - One clear zip top plastic bag of sliced pastrami meat, with a use by date of [DATE] - One clear zip top plastic bag of sliced beef roast meat, with a use by date of [DATE]. Staff G stated that the deli meats (pastrami and beef roast) were not good to consume and should have been discarded after the use by date of [DATE]. A joint observation and interview on [DATE] at 11:25 AM with Staff D, Resident Care Manager, showed Resident 1's refrigerator had food items inside, and it did not have an internal thermometer. Staff D stated that Resident 1's refrigerator should have had a thermometer inside. Staff D further stated that the dietary staff was responsible to check the food items in residents' personal refrigerators and monitor the temperature. On [DATE] at 12:48 PM, Staff I, Dietary Aide, stated they logged Resident 1's personal refrigerator's temperature and they must have missed to inspect the food items and their use by date. Staff I further stated the expired food items should have been thrown out after their use by date. RESIDENT 2'S PERSONAL ROOM REFRIGERATOR During a joint observation and interview on [DATE] at 12:22 PM with Staff H, Nursing Assistant Registered, showed Resident 2's personal refrigerator had three clear zip top plastic bags of half sized sandwiches [chicken sandwiches] without label and date. Further observation showed there was no internal thermometer inside Resident 2's refrigerator. Staff H stated that these were chicken salad sandwiches from the kitchen, which had no written label of resident's name and their use by date. Staff H further stated that they would not be able to know when to discard them. On [DATE] at 12:23 PM, Staff E, Registered Dietician, stated that the dietary staff were responsible to check the residents personal room refrigerators daily, which also included temperature checking, cleaning and/or discarding expired food items beyond use by date. Staff E further stated that the kitchen delivered the chicken salad sandwiches to the residents in zip top plastic bag and were not labeled with what type of food, residents' name, and use by date. A joint record review and interview on [DATE] at 12:44 PM with Staff E, showed three residents (Resident 1, 2 & 3) were entered on the [DATE] Resident Room Fridge Temperature Log. The temperature log record showed Resident 2 had no refrigerator temperature recorded for the month of [DATE]. Staff E stated that they would have placed a thermometer in Resident 2's new refrigerator if they had known it had arrived. An interview and observation on [DATE] at 1:21 PM, Resident 2 was asked if he remembered when their refrigerator was delivered, Resident 2 was observed checking their personal computer [laptop] and stated that their personal refrigerator arrived on [DATE]. On [DATE] at 1:35 PM, Staff C, Assistant Director of Nursing, was asked when they would expect internal thermometer be placed for new refrigerators, Staff C stated when refrigerators were [first plugged in and] functioning. FIRST FLOOR RESIDENT'S REFRIGERATOR UNIT During a joint observation and interview on [DATE] at 12:50 PM with Staff E, showed a resident refrigerator unit located on the First Floor (physician charting room) had posted a note that read, This fridge is for resident supplements/snacks. Pls [please] bring personal food in the pantry. Inside the refrigerator showed it had no internal thermometer/no temperature log monitoring, and had the following food items: - One round clear food storage container with an unknown food, labeled room [ROOM NUMBER]B, the food item was not labeled with resident's name and/or what date it was received. - One clear plastic container labeled orzo (small pasta cut in the shape of short-grain rice) salad with use by date of [DATE]. Staff E stated that dietary staff were not responsible for checking the food items and monitoring temperatures for the this [First Floor Resident's refrigerator Unit] refrigerator. On [DATE] at 1:02 PM, Staff F, Charge Nurse, stated that food items received from residents and/or their representatives should have been labeled with the resident's name and the date it was received. Staff F stated that the leftover food items in the first-floor residents' refrigerator and the orzo salad that was beyond its use by date should have been thrown out. Staff F further stated that the unlabeled food container should have had the resident's name and the date it was received. On [DATE] at 1:35 PM, Staff C stated they expected each refrigeration units to have an internal thermometer and that food items received from residents and/or their representatives should be labeled with resident's name and the date it was received. Staff C further stated that any food items beyond the use by date should have been discarded by dietary staff and/or nursing staff. On [DATE] at 11:00 AM, Staff B, Director of Nursing, stated that each resident's personal room refrigeration unit should have had a thermometer in it, and that food items should be labeled with resident's name, and the date the food item was received. Staff B further stated that food items in Resident 1's refrigerator should have been discarded after their use by date and that Resident 2's refrigeration unit should have had a thermometer in it and daily temperature checks. On [DATE] at 11:30 AM, Staff A, Administrator, stated they expected staff to follow the facility policy on personal food storage. Staff A further stated that staff were expected to discard food items that were beyond use by date and that that each refrigeration unit should have had a thermometer and a temperature log. Reference: (WAC) [DATE] (3)

Based on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 1) was free from a significant medication error. The failure to clarify a physician's order for an anticoagulant (blood thinner) medication placed the resident at risk for excessive bleeding, a decline in medical condition, and a diminished quality of life. Findings included . Review of an entry tracking Minimum Data Set assessment (MDS-an assessment tool) dated 12/29/2023 showed Resident 1 was readmitted to the facility from the hospital on 12/29/2023. Review of the hospital discharge summary dated 12/29/2023, under medications showed, you may resume Apixaban 5 [five] mg [milligram] on post op [post operative] day #5 (1/2/2024). The discharge summary showed to continue these medications which have not changed Apixaban 5 mg take 1 tablet (5 mg) every 12 hours. Review of the December 2023 Medication Administration Record (MAR) showed Resident 1 received Apixaban 5 mg at 8:00 PM on 12/29/2023, and from 12/30/2023 to 12/31/2023 every 12 hours at 8:00 AM and at 8:00 PM. Review of the January 2024 MAR showed Resident 1 received Apixaban 5 mg on 01/01/2024 every 12 hours at 8:00 AM and 8:00 PM. Review of the facility's medication incident summary form dated 01/17/2024, showed Resident 1 was restarted on Apixaban 5 mg every 12 hours when they returned from the hospital [on 12/29/2023], rather than resuming on post op day 5 (01/02/2024) as mentioned on the discharge summary under therapeutic recommendations. The hospital discharge summary [under continue] current medications showed, continue Apixaban 5 mg every 12 hours. The facility medication incident summary form dated 01/17/2024 also showed the discrepancy should have been clarified by the nurse that readmitted Resident 1 to the facility. On 02/20/2024 at 1:21 PM, Staff C, Registered Nurse/Resident Care Manager, stated if there was a discrepancy in a medication order, the order would have to be clarified with the physician to know the correct medication to give to the resident. Staff C further stated that the medication should not be given to the resident until the order was clarified by the physician. On 02/20/2024 at 12:47 PM, Staff B, Assistant Director Nursing Services, stated the Apixaban was a medication error, the nurse should have clarified the order for Resident 1 until the order was clarified by the physician. Reference: (WAC) 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to prevent physical abuse to 1 of 3 residents (Resident 1), reviewed for abuse investigations. Resident 1, who had known behaviors of lack of boundary control and encroaching in other residents' space, was harmed when they initiated an aggressive incident with another resident, without staff present, Resident 1 was struck in the left eye resulting in a black eye. This failure placed other residents at risk for potential physical abuse, injuries, and a diminished quality of life. Findings included . Review of the admission Minimum Data Set (MDS - an assessment tool) dated 11/16/2023, showed Resident 1 was admitted to the facility on [DATE]. The MDS dated [DATE], showed the resident had impaired thinking, and had a diagnosis of schizophrenia (a serious mental condition that involved a break down between thought, emotion and behavior leading to inappropriate actions and feelings). Review of the December 2023 Medication Administration Record (MAR) showed Resident 1 was prescribed on Haldol (a medication used to treat schizophrenia behaviors) 5 milligrams (mg, a unit of measurement) at bedtime since 11/18/2023, and 2 mg at 8:00 AM since 12/06/2023 for schizophrenia. The MAR showed Resident 1 had documented behaviors of combativeness, calling out and refusal of care. Interventions included redirection, leave room and return, validate feelings and/or offer snack. Review of the interventions in the MAR showed they were used, and at times were ineffective. Further review of the MAR showed no additional information when the interventions were ineffective. Review of an incident investigation report dated 12/31/2023, showed Resident 1 self-propelled themselves in a wheelchair in the hallway when they reached over to grab a mask (surgical face mask) off Resident 2's face. Resident 2 then struck Resident 1 in the left eye. Review of the January 2024 Treatment Administration Record showed Resident 1 had a bruise to the left eye. In an interview on 02/05/2024 at 5:27 PM with Resident 1's Representative, they stated it bothered him to see Resident 1 that way and for having a black eye. An interview on 02/09/2024 at 1:57 PM with Staff D, Resident Care Manager, stated Resident 1 had a lot of aggressive behaviors, agitation, and combative behaviors when the resident first came to the facility. Staff D stated Resident 1 would strike out at times, yell, call out, curse, had no boundaries, and would get into other residents' space. When asked about Resident 1's supervision, Staff D stated Resident 1 was not put on 1:1 (one on one) until after the abuse incident. An interview on 02/09/2024 at 2:49 PM with Staff C, Assistant Director of Nursing Services, stated the incident was substantiated as abuse when Resident 1 was struck in the left eye by Resident 2 and that Resident 1 sustained an injury to the left eye. Reference: (WAC) 388-97-0640 (1)

Based on interview and record review, the facility failed to ensure supervision was provided to prevent an avoidable injury for 1 of 3 residents (Resident 1), reviewed for abuse investigations. Resident 1, who had known behaviors of striking, calling out, lack of boundary control and encroaching in other residents' space, experienced harm when another resident struck them in the left eye resulting in a black eye. This failure placed other residents at risk for potential physical injuries and a diminished quality of life. Findings included . Review of the admission Minimum Data Set (MDS - an assessment tool) dated 11/16/2023, showed Resident 1 was admitted to the facility on [DATE]. The MDS dated [DATE], showed the resident had impaired thinking, and had a diagnosis of schizophrenia (a serious mental condition that involved a break down between thought, emotion and behavior leading to inappropriate actions and feelings). Review of the December 2023 Medication Administration Record (MAR) showed Resident 1 was prescribed on Haldol (a medication used to treat schizophrenia behaviors) 5 milligrams (mg, a unit of measurement) at bedtime since 11/18/2023, and 2 mg at 8:00 AM since 12/06/2023 for schizophrenia. The MAR showed Resident 1 had documented behaviors of combativeness, calling out and refusal of care. Interventions included redirection, leave room and return, validate feelings and/or offer snack. Review of the interventions in the MAR showed they were used, and at times were ineffective. Further review of the MAR showed no additional information when the interventions were ineffective. Review of an incident investigation report dated 12/31/2023, showed Resident 1 self-propelled themselves in a wheelchair in the hallway when they reached over to grab a mask (surgical face mask) off Resident 2's face. Resident 2 then struck Resident 1 in the left eye. Review of the January 2024 Treatment Administration Record showed Resident 1 had a bruise to the left eye. In an interview on 01/26/2024 at 12:13 PM with Resident 2, stated they felt bad after hitting Resident 1 in the eye. Resident 2 stated that Resident 1 pulled their mask down and it hurt and that was when they punched Resident 1. In an an interview on 02/09/2024 at 1:57 PM with Staff D, Resident Care Manager, stated Resident 1 had a lot of aggressive behaviors, agitation, and combative behaviors when the resident first came to the facility. Staff D stated Resident 1 would strike out at times, yell, call out, curse, had no boundaries, and would get into other residents' space. When asked about Resident 1's supervision, Staff D stated Resident 1 was not put on 1:1 (one on one) until after the abuse incident. An interview on 02/09/2024 at 2:49 PM with Staff C, Assistant Director of Nursing Services, stated the incident was substantiated as abuse when Resident 1 was struck in the left eye by Resident 2. Staff C stated Resident 1 sustained an injury to the left eye. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation record review and interview, the facility failed to ensure the resident environment was safe and free from hazards when a resident received a significant burn from a hot beverage for one of three sampled residents (Resident #1) reviewed for accident hazards. Staff did not ensure hot beverages were served at a safe temperature. Resident #1 spilled a hot beverage in her lap and sustained a second-degree burn which constitutes harm. Findings included . Record review of the facility's undated policy titled, Hot Beverage Safety, showed that liquids served at temperatures greater than 160 degrees Fahrenheit can cause third [MEDICAL CONDITION] contact with human skin. The following steps must be taken to reduce the potential [MEDICAL CONDITION] serving hot beverages: Regulate the temperature of hot beverages and monitor brewing and holding temperatures . the policy also indicated when drinking or serving a hot beverage, the hot beverage should be between 155-165 degrees Fahrenheit. Review of Resident #1's medical record showed the resident had lived in the facility since (MONTH) 2019 with [DIAGNOSES REDACTED]. Review of progress notes showed Resident #1 was alert, oriented, and was able to make her needs known. Resident #1's most recent care plan, dated 11/24/19, showed that she was able to feed herself independently. Review of a facility investigative report, dated 01/05/2020, showed that hot beverages were being served to residents by Staff A during a planned activity in the dining room. Further review showed Resident #1 was served hot chocolate by Staff A, Activity Director. Resident #1 then picked up the cup from the table and the hot beverage spilled in her lap. The report showed that Resident #1 sustained a second degree burn (fluid-filled blisters), 2 centimeter (cm) x(by) 1 cm, on both her right and left thigh, and a 1 cm x 1 cm reddened area on her abdomen. The facility's investigative report, dated 01/05/2020, showed that the hot water temperature should have been between 155-160 degrees Fahrenheit. During an interview on 01/28/2020 at 12 PM, Resident #1 was asked about the incident. Resident #1 stated that she dropped the cup and it (hot chocolate) spilled on her, she added that it really hurt. During an interview on 01/28/2020 at 11 AM, Staff A stated that she removed a carafe of hot water from the kitchen and did not check the water temperature before she served it to the residents. Staff A stated that she served hot beverages, made using the hot water, to Resident #1 and three other residents seated at the tablet. Staff A also stated that the hot water temperature should have been between 155-160 degrees Fahrenheit, and that she usually checked the temperatures, but she just did not do it this time. Staff A did not monitor the temperature of the hot beverage before she served it to the resident(s). During an interview on 01/28/2020 at 12:15 PM, the Director of Nursing (DON) stated that the staff should have checked the temperature before serving the hot beverage. The DON also stated that all staff have been in-serviced on hot beverage safety. WAC REFERENCE: 388-97-1060 (3)(g)

Based on observation, interview and record review the facility failed to ensure staff followed and implemented abuse and neglect policies and procedures for reporting, investigation and protection for 1 of 1 resident (1) reviewed for abuse and neglect. The facility's failure to immediately report an allegation of physical abuse to law enforcement and state agency as required, failure to initiate immediate investigation and failure to protect the resident after an allegation of physical abuse was made constituted a situation of immediate jeopardy (IJ) on 10/02/18. Findings Included: According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated (MONTH) (YEAR), stated, PROTECTION: Implement facility administrative decisions to ensure the suspected or accused staff person does not have unsupervised access to any resident; INVESTIGATION: Protect the resident and other residents during the course of the investigation. The Elder Justice Act of 2009 added the requirement for the reporting of possible crimes to law enforcement. A review of the facility policy titled Abuse Prevention Policy and Procedure dated 08/11/17, stated, It is the policy of this facility that all suspected, alleged, or actual cases of resident abuse, including injuries of unknown origin, shall be thoroughly and completely investigated and reported according to State and Federal regulations. The Policy directed facility staff to: 1. Investigation: The facility would investigate as soon as a report of alleged or suspected abuse was received. 2. Protection: The facility would provide immediate protection to all residents who have had incidents, accidents and injuries of unknown origin. This may include immediate suspension of the employee or contractor. 3. Reporting: The facility would immediately report to their onsite supervisor and the State Hotline. The facility would immediately report to Law enforcement when and if a reasonable cause to believe that abuse, neglect, involuntary seclusion, abandonment or financial exploitation has occurred, or when a reason to suspect an incident is sexual or physical assault. The Director of Nursing and Administrator shall be immediately notified of all allegations of abuse and neglect. Resident 1 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the resident's Annual Minimum Data Set (MDS) assessment dated [DATE], showed the resident had impaired cognition and needed 1 person extensive assistance with activities of daily living. Review of the State Hotline report dated 09/30/18, showed an allegation of physical abuse involving Resident 1. The report also documented that the reporter was told by his supervisors not to report the incident to the state agency as required. Review of the facility's incident and grievance log from 04/01/18 to 10/02/18, showed no evidence of incident documentation for Resident 1. During an interview and observation on 10/02/18 at 9:55 AM, the resident was observed in bed. The resident complained to the state investigator about a staff member who punched and hurt her. In an interview on 10/02/18 at 10:18 AM, Resident 1's roommate stated, Resident 1 told her she was hurting and somebody had punched her in the back. According to the roommate, Resident 1 had reported it to her more than once. I did not report it at first. But when Resident 1 reported it again, I started saying something. Resident 1's roommate stated, early Sunday morning, 09/30/18, Staff B, Nursing Assistant, (NA), came to change Resident 1. She overheard the conversation between the two. According to the Resident 1's roommate, Resident 1 stated, see, you did not hurt me. Staff B responded to Resident 1, who hurt you? This was when Resident 1 told Staff B what may have happened. The roommate stated, Staff B found a bruise on Resident 1's back and acted immediately and reported the concern to Staff C, Registered Nurse, (RN) and Staff D, Licensed Practical Nurse, (LPN). Resident 1's roommate stated, she told Staff B that on either Thursday or Friday night last week, she heard Resident 1 screaming during care. The roommate stated, I asked Resident 1 if she was ok. That was when Staff A, NAC, answered for Resident 1 and stated, she's fine. That was when I knew it was Staff A who may have hurt Resident 1. The roommate added, Staff A usually had a different approach compared to other NAC's. She's rushed to get work done. She is very straight forward. The roommate further stated, Resident 1 told her, Staff A, pulled her clothes either last night or Monday morning (10/01/18). In an interview on 10/02/18 at 10:55 AM, Staff D, LPN, stated, the incident was reported to her on 09/30/18 at about 6:00 AM. Staff D stated, she was notified of the allegation of physical abuse and bruising by Staff C, RN, on Resident 1's back. Staff D added, We checked Resident 1's back and we did not see anything. According to Staff D, she also notified the weekend supervisor, Staff E, RN, of the situation and they all rechecked Resident 1's skin and found no bruising. Staff D further stated, they (Staff C and Staff E) were all aware of the allegation against Staff A, NAC, and she assumed that Staff C, had already reported the allegation of physical abuse to the police and state agency. We knew about Staff A since Sunday morning (9/30/18). Staff A worked for few hours yesterday (10/1/18) with the same resident. Yes, this incident should have been reported immediately to the police and state agency as required and Staff A should have been suspended. During an observation and interview on 10/02/18 at 11:14 AM, with Staff D, LPN, the resident's skin was observed. The resident reported pain and stated, she was punched in the back at her kidney area. The skin inspection revealed a light yellowish discoloration to the resident's mid lower back area that measured approximately 5 centimeter (cm) in length and 5 cm wide with intact skin. The resident reiterated that someone had hurt her but she was not sure who and when it happened. In an interview on 10/02/18 at 11:54 AM, Staff F, Staff Development Coordinator, stated, the expectation for staff was to immediately report any allegation of abuse or neglect to the state agency and law enforcement if a potential crime was suspected. Staff F stated, she was not notified of the allegation until 10/01/18 at around 10:00 AM. Staff F added, she received the written incident report from Staff C, RN, that showed Resident 1 reported somebody had hurt her and the NAC on duty, Staff B, noticed a bruise. The state and the police should have been notified immediately because the nature of allegation was physical abuse. Staff F further stated, the alleged perpetrator, Staff A, NAC, wasn't suspended until 10/01/18 and had worked unsupervised with Resident 1 and other residents of the facility after the allegation was made. During a phone interview on 10/02/18 at 12:44 PM, Staff B, NA, stated, on 09/30/18 at approximately 5:30 AM, he was notified of the potential assault involving Resident 1 and Staff A. Staff B stated, Resident 1's roommate first told him of the incident. I talked to Resident 1 about the incident and confirmed she was hit. Staff B added, he noticed a huge bruise to the resident's back and immediately reported the incident to his supervisor, Staff C, RN. Staff B stated, Staff C, told him to wait for Staff D, RN, so they could inspect and follow-up with Resident 1 together. Staff B further stated, after showing Staff C and Staff D the bruise, Staff D told him, I will take care of it. Staff B stated, shortly after Staff D told him she would take care of the situation, Staff E, Resident Care Manager/LPN, came and also inspected Resident 1. Staff B added, after Staff E left the room, he was told by Staff C, they said you don't have to report the incident to the state because they have to do an internal investigation first. Staff E stated he felt that the licensed nurses were not going to do the right thing. Staff B was asked why he would feel the facility would not do the right thing for Resident 1. Staff B stated, the following day, 10/01/18 at the beginning of his shift, he received a letter from a manager that stated, After assessment of Resident 1, there is no need to call the state d/t (due to) no bruise being noted. Staff B also stated, that Staff C sent him a text message stating, That's why I told you not to make a move first because usually the facility have to investigate first then the supervisors are the one who will report it to the state if real. Review of the documents provided by Staff B showed a written note from Staff E, Resident Care Manager/RN directing Staff B not to call the state regarding the allegation of physical abuse. A copy of the text message was also reviewed and showed the conversation between Staff C and Staff B. During a joint record review with Staff G, Staffing coordinator, confirmed Staff A, NA, continued to work on 10/01/18 from 6:03 AM to 11:12 AM and from 11:42 AM to 12:23 PM. The facility had knowledge of the allegation of physical abuse against Staff A since 09/30/18 at 5:30 AM. The facility failed to immediately call and notify law enforcement and state agency as required, and failed to protect Resident 1 and other residents of the facility from potential abuse. These failures placed Resident 1 and other residents of the facility in serious harm and jeopardy related to abuse. During a meeting on 10/02/18 at 2:47 PM with the Administrator, Director of Nursing, (DNS), Assistant Director of Nursing and Staff F, Staff Development Coordinator, each staff member stated, the facility had failed to implement their abuse and neglect policy. The DNS stated, the incident could have been handled better and Staff A should have been immediately suspended to protect the resident against further potential abuse. The DNS further stated, this allegation of physical abuse should have been reported immediately to law enforcement and the state agency as required. Both the Administrator and the DNS stated, they were not immediately notified of the allegation as directed by the facility policy. Each staff member stated the facility would immediately conduct an audit of accidents and incidents, staff re-education regarding abuse and neglect/reporting guidelines and would follow up with Resident 1 and other residents to ensure no other resident was abused. Reference: (WAC) 388-97-0640 (2)(b), (6)(a-c)

Based on observation, interview and record review, the facility failed to comprehensively assess, initiate appropriate and timely fall interventions, failed to provide adequate supervision and followed the plan of care for 1 of 1 resident (2) reviewed for accidents hazards and fall. The facility's failure to provide adequate supervision, failure to initiate timely and appropriate fall interventions and the failure to follow written plan of care for Resident 2 constituted an Immediate Jeopardy (IJ) on 10/03/18. Resident 2 suffered falls with major injuries including multiple rib fractures, back and scalp abrasions, pain and [MEDICAL CONDITION] that required hospitalization and surgical interventions. Findings included: According to the Center for Disease Control, (CDC), a fall can cause an injury such as a broken bone or a head injury. These can be very serious, especially if the person is taking certain medicines like blood thinners. Such injuries can make it hard for a person to get around and do everyday activities. Resident 2 was a long term resident of the facility with recent re-admission on 08/16/18. The resident [DIAGNOSES REDACTED]. A review of the resident's significant change Minimum Data Set (MDS) assessment dated [DATE], showed the resident had severe cognitive impairment and needed a 2 person extensive assistance with ambulation and locomotion in the unit. The MDS also showed the resident had history of falls with fractures in the past with a prior admission to the facility. Review of the resident's clinical records showed, the resident had 2 recent emergency room visits related to falls dated 09/01/18 and 09/30/18. Review of the facility's incident reporting log from 04/01/18 to 10/02/18, showed the resident had a fall with an injury on 09/01/18. Review of the incident investigation report dated 09/01/18 documented, the Resident was sitting on his wheelchair next to the nursing station reading a book when suddenly he moved to the edge of his w/c (wheelchair), and slid off before staff could catch him. The resident fell on his right side but did not hit his head. Small abrasions noted on the mid back and redness of the skin about 6cm long. Interventions on how to prevent reoccurrence: closely monitor the resident and offer assistance. The interventions were not specific and did not address the root cause of the problem. Review of the incident investigation summary report dated 09/06/18, showed the resident was sent to the emergency room for a further evaluation related to uncontrolled pain. The hospital report dated 09/02/18, showed the resident suffered multiple rib fractures and abrasions related to the fall. The report also indicated, the incident was not reported to the state agency, as required. During an observation on 10/02/18 at 9:45 AM, Resident 2 was observed sitting next to the nurses' station. The resident was restless and was observed attempting to stand up from a tilted wheelchair. The resident was noted with a dark purple bruised face surrounding the right eye with a closed laceration above the right eye. In an interview on 10/02/18 at 9:55 AM, with Staff D, Licensed Practical Nurse, (LPN), stated, the resident's injury was from a fall on 09/30/18. It was an unwitnessed fall. He was sent to the emergency room for evaluation and came back the same day. Review of the resident's fall care plan dated 05/20/16, with recent revisions made on 09/12/18 and 10/02/18, showed the resident was at high risk for falls related to the resident's cognitive problems and poor safety awareness. The focus, care plan goals and interventions were not person centered and missing clear and specific directions to staff on how to minimize the risk of falls/injuries for Resident 2. The resident's fall care plan showed no evidence that it was reviewed and/or revised based on the resident's risks related to recent hospitalization on [DATE] and 09/30/18. During an observation on 10/02/18 at 10:30 AM, the resident was observed at the same location next to the nurses' station hallway. The resident was restless and was observed attempting to stand up from a tilted wheelchair. There was no staff around to supervise the resident. Similar findings were applicable during a separate observation on the same day at 11:58 AM and 2:40 PM, the resident was left unsupervised, restless and attempting to stand up from a tilted wheelchair. During an observation on 10/03/18 at 11:10 AM, the resident was observed sitting across the second floor nurses' station in the hallway. There was no staff around to supervise the resident. The resident was restless and attempting to stand up from the tilted wheelchair. In an interview at the time of the observation, the resident was not able to respond to the surveyors' questions, was confused, restless and was unable to follow simple directions. Review of the incident summary report dated 09/30/18, showed the resident fell at 3:20 AM, and the fall was not witnessed by any staff member. The incident report documented, Resident was found lying on the floor in front of the bathroom door with his head profusely bleeding. He is naked with shoes and socks on. Area is clutter free with blood scattered on the floor. The report indicated, the last time the resident was seen and cared for was at 1:00 AM. Interventions on how to prevent reoccurrence was to educate the resident with the use of call light when the resident wants to get up and provide 1 on 1 staff supervision. In an interview on 10/03/18 at 1:10 PM, Staff F, Staff Development Coordinator/Registered Nurse, (SDC/RN), stated, she was responsible for completing and closing incident reports in the facility. However, for Resident 2's incident on 09/30/18, I haven't looked at the incident report and I am not aware of the details of the incident at this time. In an interview on 10/03/18 at 1:20 PM, the Assistant Director of Nursing/Registered Nurse, (ADNS/RN) stated, she was not aware of the circumstances of the fall and I just looked at it today. The ADNS further stated, she hasn't looked at the incident and was not aware of the details of the incident. During a meeting on 10/03/18 at 1:25 PM with the Administrator, Director of Nursing (DNS), ADNS, SDC, Regional Director of Operations, and two corporate nurses, the DNS stated, she was only notified of the incident this morning and it was the first time the facility had looked at the incident. The DNS added, the current intervention for the resident was not appropriate because the resident cannot use the call light and was not on a one on one supervision. The DNS further stated, the incident was not reported to the state agency, as required. During the same meeting, the Administrator, DNS, ADNS and SDC stated, the incident report hasn't been looked at by the interdisciplinary team. Each staff member stated, there were no care plan revisions and interventions made to prevent and minimize the risk of future falls and injury to Resident 2. This increased the likelihood of having another fall with serious injury/harm. The interventions at this time wasn't appropriate to the resident. The Administrator stated, he wasn't aware of the incident and he wasn't notified until this morning. During several interviews on 10/03/18 at 2:12 PM with Staff H, LPN, Staff I, Nursing Assistant, Staff J, Resident Care Manager, (RCM/LPN), Staff K, RN/RCM, and Staff L, RN, each staff member stated, the interventions for Resident 2 needed to be more specific to effectively follow the plan of care. Each staff member stated, Resident 2 was not on a 1 on 1 staff supervision as directed by the plan of care. The facility's failure to provide adequate supervision, failure to ensure incident investigations were accurate and followed-up on, failure to initiate timely and appropriate interventions to minimize risk of avoidable accidents, and failure to update and follow the plan of care caused serious harm and bodily injury to Resident 2, and placed the resident in the likelihood of having serious injuries/death from avoidable accidents and falls. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview and record review, the Administration failed to effectively manage the facility in compliance with state and federal regulatory requirements. The administrator failed to ensure compliance related to the implementation of abuse and neglect policy for reporting, investigation and resident protection for Resident 1. Additionally, the administrator failed to ensure staff provided adequate supervision, and ensure timely/appropriate fall interventions and the written plan of care for Resident 2 were followed. These failures caused serious harm and resulted in an Immediate Jeopardy (IJ) situation on 10/02/18 and 10/03/18. Findings included: 1. The Administration failed to provide adequate supervision, failed to ensure incident investigations were accurate and followed-up on, failed to initiate timely and appropriate interventions to minimize risk of avoidable accidents, and failure to update and follow the plan of care caused serious harm and bodily injury to Resident 2. During a meeting on 10/03/18 at 1:25 PM, the Administrator, DNS, ADNS and SDC concurred and stated, the incident report hasn't been looked at by the Interdisciplinary team. Each staff member stated, there were no care plan revisions and interventions made to prevent and minimize the risk of future falls and injury to Resident 2 increasing the likelihood of having another fall with serious injury/harm. The Administrator and the DNS stated, they have no excuse for not reviewing the investigation to ensure timely and appropriate interventions were put in place to prevent avoidable accidents for Resident 2. Refer to F689 - Free of Accident Hazards/supervision/devices for more information. 2. The Administration failed to immediately call and notify law enforcement and the state agency as required for an allegation of physical abuse, failed to immediately suspend Staff A and failed to protect Resident 1 and other residents of the facility for potential abuse. These failures placed Resident 1 and other residents of the facility in serious harm and jeopardy related to abuse. During a meeting on 10/02/18 at 2:47 PM with the Administrator, Director of Nursing, (DNS), Assistant Director of Nursing and Staff F, Staff Development Coordinator, each staff member stated, the facility had failed to implement their abuse and neglect policy. The Administrator and the DNS stated, they were not immediately notified of the allegation of physical abuse for Resident 1. Both staff members stated, they would re-educate staff regarding the facility's abuse and neglect policy to prevent reoccurrence of the incident. During a meeting on 10/02/18 at 2:47 PM with the Administrator, Director of Nursing, (DNS), Assistant Director of Nursing and Staff F, Staff Development Coordinator, each staff member stated, the facility had failed to implement their abuse and neglect policy. Refer to F607- Develop/Implement Abuse/Neglect Policies for more information. Reference: (WAC) 388-97-1620 (1)

Based on observation, interview and record review the facility failed to ensure 3 of 3 residents (55, 33, 58) were provided adequate and necessary supervision and monitoring related to smoking. This failure placed residents at risk for significant harm, injury and unmet care needs. In addition, the facility failed to ensure that the residents' environment was free from hazards when using wall heaters (also known as Cadet Heaters). This failure placed residents at significant risk for harm and injury related to burns. Findings included . ENVIRONMENT HAZARDS During the initial tour of the facility on 03/08/18 at approximately 10:00 AM, multiple rooms on the first floor were noted using wall heaters in the room. The heaters in the room showed the following sticker posted, Please do not place items near heater. Thank you. The heaters had the following sticker warning that stated, FIRE HAZARD! CAUTION - High temperature, risk of fire, keep electrical cords, drapery, and other furnishings at least 3 feet (0.9m) from the front of the heater and away from the side and rear. During the initial tour, the following were observed; a. room [ROOM NUMBER] - Resident personal items, sleepers, food items, and drawer were noted within 3 feet distance to the heater. b. room [ROOM NUMBER] - Resident personal items, chair, and jacket were noted within 3 feet distance to the heater. c. room [ROOM NUMBER] - Resident personal items, clothing's, a bag of clothes and other personal items were noted right next to the heater. Similar findings were noted to rooms, 104, 106, 107, 112 and 113 were residents personal items, other furnishings and other flammable material were placed/located within 3 feet distance to the heater. During a seperate observation on 03/09/18 at 08:30 AM, similar findings were noted to the above rooms, were residents personal items, other furnishings and other flammable material were placed/located within 3 feet distance to the heater. In an interview and observation with Staff L, Maintenance Director at 11:32 AM, was made aware of the above findings. Staff L stated, Yes, all these items should be at least 3 feet away from the heater. Staff L further stated, that the facility staff should make sure to keep an eye on this because some residents were not aware of the potential fire hazards. SMOKING In a review of the facility Smoking Policy dated 11/21/2016, Smoking article for residents with independent smoking privileges: a) Residents who have independent smoking privileges shall not be permitted to keep cigarettes, pipes, tobacco, or other smoking articles in their possession. b) At no time may the resident possess ignition sources such as lighters or matches or tobacco or other smoking materials on their person, inside the facility or inside their room. RESIDENT 55 Resident 55 admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. In a review of Resident's current care plan showed, Resident is able to smoke safely with independent privileges. The interventions stated, (MONTH) keep cigarettes and smoking materials in a secured location in room. In an observation on 03/08/18 at 3:12 PM, revealed smoking pipes filled with tobacco products on the bedside table. In an observation on 03/16/18 at 10:32 AM, smoking pipes filled with tobacco products and a lighter on the bedside table were observed. In an interview on 03/09/18 at 3:12 PM resident stated, I always keep my tobacco products on my bedside table, and I keep the lighter on me at all times. In an interview on 03/16/18 at 11:32 AM with the Assistant Director of Nursing; when asked about Resident 55 keeping his tobacco products and lighter on his bedside table, she stated yes, he should not have those items there. Yes, we are not following the smoking policy. Resident 33 and Resident 58 Similar Findings were noted for Resident 33 and Resident 58 (identified as independent smokers), were smoking paraphernalia's and materials such as liquid lighters, tobacco products and cigarettes were stored, and left at the bedside unsecured, not monitored, and/or supervised by facility staff. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to comprehensively assess and ensure 1 of 5 residents (103) received appropriate care and services necessary to maintain and avoid loss of bowel and bladder functions. These failed practices caused harm to Resident 103. Resident 103's bowel function declined from always continent to incontinent and had contributed to the development of severe bladder and urinary tract infection,[MEDICAL CONDITION] (severe blood infection), self humiliation, and diminished quality of life. Findings included . RESIDENT 103 Resident 103 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. In a review of the resident's admission Bowel and Bladder Evaluation dated 12/30/17, the facility identified the resident as voids appropriately without incontinence, yes, but less than daily. The resident was identified as a candidate for scheduled toileting during this time, and was identified as continent of bowel. In a review of the Minimum Data Set (MDS) assessment dated [DATE], showed the resident's urinary continence as occasionally incontinent and bowel continence was continent. The resident was identified as needing a 1 person assistance from staff for bed mobility, transfers and toileting. The MDS also showed the resident was not on a toileting program, and no trial of a toileting program had been attempted since admission or since urinary incontinence was noted in the facility. In a review of the Care Area Assessment Worksheet (CAA) dated 01/06/18, showed the resident had both Urge (overactive or spastic bladder) and Functional (can't get to toilet in time) incontinence. In a review of the Bowel and Bladder Evaluation dated 01/12/18, the facility identified the resident as incontinent of both bowel and bladder. The resident was identified as a candidate for scheduled toileting, but no documentation was found in the clinical records that the facility had implemented and/or initiated a trial for a toileting program. In a review of the Urinary and Bladder documentations from 02/12/18 to 03/13/18 showed the resident was documented to be incontinent of urine for at least 18 days during the time frame. In a review of the Bowel and Continence documentations from 02/12/18 to 03/13/18 showed the resident was documented to be incontinent of bowel for at least 16 days during the time frame. In a review of the Bowel Care Plan initiated on 12/30/17, with revisions made on 01/01/18 and 01/15/18, showed no toileting plan and no person centered goals that identified the resident strengths, and/or reflect the resident bowel and bladder incontinent episodes. There was no documentation of any interventions or plan to either help the resident improve, prevent any decline and or any trial of toileting program attempted since bowel incontinence was noted/identified. During an observation on 03/08/18 at 12:15 PM, the resident was observed eating in his room. A strong body odor and urine odor were present. The resident's finger nails were also observed to be long with dark brown matter underneath each finger nail. During an observation on 03/09/18 at 9:45 AM, the resident was observed in bed asleep, covered with a blanket. A body odor with urine smell was present. During an observation at 1:45 PM, the resident was served lunch in his room by a staff member. There was dark brown matter observed under the resident's fingernails. There was a strong odor of bowel movement/stool present. During an observation on 03/12/18 at 12:01 PM, the resident was observed in his room. There was a strong odor of urine present. In an interview with the resident at 1:08 PM, a bowel/stool odor was present. The resident was asked if he needed to be changed, and the resident nodded, yes. When asked how he feels about having incontinent episodes, the resident stated, I feel bad about myself. In an interview with Staff N, Nursing Assistant Certified (NAC), on 03/16/18 at 10:49 AM, Staff N was asked regarding the resident's bowel and bladder patterns. Staff N stated, the resident was incontinent of bowel and bladder. According to Staff N, the resident was able to take himself to the bathroom but sometimes will have accidents. Staff N further stated, the resident was more incontinent after meals, and when she toileted the resident, he was already wet. Staff N stated, Resident 103 was not on a toileting plan/program. In an interview with Staff A, Registered Nurse (RN), at 10:57 AM, Staff A was asked regarding the resident's bowel and bladder patterns. Staff A stated, the resident needed reminder when to use the bathroom, Resident 103 is incontinent of bowel and bladder. According to Staff A, the resident can use the toilet himself but needed more help. Staff A further stated, Resident 103 was not on a toileting plan/program. Further review of the resident's clinical records showed the resident was hospitalized from [DATE] to 02/10/18. Hospital discharge [DIAGNOSES REDACTED]. Review of the hospital's Urine Culture and Sensitivity result dated 02/09/18, showed the bacteria present in the urine was positive for Escherichia Coli (E.coli), a bacteria commonly seen/present in the large intestine and the rectum. The hospital course summary documented the resident was treated for [REDACTED]. The resident received Intravenous antibiotic therapy, and later transitioned to oral antibiotics and was discharged back to the facility on [DATE]. In a joint interview with Staff G, Director of Nursing and Staff I, Resident Care Manager on 03/16/18 at 11:42 AM, Staff I stated, the resident was incontinent of bowel and bladder, and the resident was not on a toileting program. According to Staff I, the resident needed 1 person assistance in toileting and personal hygiene tasks, and the staff should be assisting the resident with toileting at least every 2 hours. Staff I was asked, if this expectation was documented in the resident's clinical record or care plan, Staff I stated, No. It is not on the care plan. In summary, there was no documentation the facility had identified, comprehensively and accurately assessed, or treated/addressed Resident 103's bladder and bowel incontinence. Resident 103's bowel and bladder incontinence issues were not accurately care planned, not person centered to identify the resident's strengths, goals and were missing interventions to address the root cause of the incontinent problem. There was no documentation in the medical record that the facility had attempted, initiated or considered a trial for bowel and bladder retraining to further improve or restore continence. There was no documentation in Resident 103's medical record from admission to 03/16/18 that a facility physician, or a specialist had identified, assessed, or provided any treatment or services to either achieve or maintain as much normal bowel and bladder function as possible for Resident 103. Reference (WAC) 388-97-1060 (3)(c)

Based on observation, record review and interviews, the facility staff failed to ensure the safety of 1 (Resident #1) of 3 residents in wheelchairs. The staff left Resident #1 in a wheelchair device, which he had not been assessed as safe to maneuver, in an unsupervised environment. The resident fell and sustained a fractured hip. This practice did not ensure each resident received adequate supervision to prevent injury, and this constituted harm. The resident was admitted to the facility on [DATE] with multiple complex [DIAGNOSES REDACTED]. According to progress notes and interview with Assistant Director of Nursing (DON), the resident had multiple falls at home and was assessed as being high risk for falls. Resident #1 spoke no English, and facility used an interpreter in attempt to communicate. The resident was noted to only mumble and could not communicate appropriately. According to the most recent care plan, the resident was high risk for falls, related to history of falls, incontinence, poor balance, poor safety awareness and impaired cognition. According to the facility's incident report dated 10/7/2017, Resident #1 was found in the room at 10 am on the floor. The wheel chair was against the wall. According to the incident report the wheels on the wheel chair were unlocked and movable. In interview with the ADON when asked if the facility considered individualized risk related to hazards in the environment, she stated, we never lock wheels on wheelchairs here, it is considered restraining the resident. There was no documented evidence that the facility had implemented individualized interventions which included adequate supervision and devices that were consistent with each resident's mobility and safety needs to reduce the risk of accidents. The facility did not evaluate and analyze the unlocked wheelchair of Resident #1 which could be considered a potential hazard for the resident. The wheel chair was observed in the room, it was a narrow device and the chair easily glided across the room when softly touched. Resident #1 was observed in bed after his hip repair and unable to respond to questions due to his cognitive ability and language barrier. When asked about the safety of the resident while in an unsupervised space, The Director of Nursing and the ADON stated resident propels himself in the wheel chair and went to his room to watch TV. Interview with the physical therapist about Resident's #1's ability to self-propel in the wheelchair, she replied, oh no, he cannot self-propel that wheelchair, he would need a lot, a lot of cueing from staff to do that. When asked for documented evidence that Resident #1 had been assessed to safely maneuver and propel the wheelchair independently; two physical therapy documents were provided. The documents did not indicate that Resident #1 could safely and independently maneuver a wheelchair. The resident was left in the room unsupervised in a wheelchair that he had not been safe to propel or maneuver independently. The progress noted stated that the resident required 1-2 person assist with transfers, toileting, and bed mobility. The progress notes were reviewed for dates of service of 6/8/17 through 10/12/2017, the notes did not indicate that the resident self-propelled himself in the wheelchair while in the facility. Resident #1 was left unsupervised in a device that placed him at risk for falls and/or injuries. The facility staff did not take into account the resident's safety when they left the resident in an unsupervised area in a wheelchair with movable wheels which he had not been assessed as safe to maneuver himself. Resident #1 fell and sustained an impacted fracture, and this constituted harm. WAC reference -1060 (3) (g)

F-323-G Based on observations, interviews and record reviews the facility failed to ensure the safety of one of ten sampled residents (Resident #15). Resident #15 was assessed as at risk for wandering, exited the back door in his wheelchair to the parking lot and had a fall with injuries requiring hospitalization . Failure to provide a departure alert alarm sensor device near the back exit door placed Resident #15 and other exit seeking residents at risk for avoidable accidents and injuries. RESIDENT #15 Resident # 15 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #15 had a history of [REDACTED]. On 5/11/2012 at 10:10 a.m. on observation, Resident #15 was asleep in bed. Interview with Staff A CNA (Certified Nurses ' Assistant) stated, " We had been watching him because he fell outside of the facility. He went through the back door. " Review of Nurses ' Progress Notes on admitted d 4/26/2012 found, " Resident #15 was alert and oriented x 2 and was able to verbalize needs most of the time. " Further review of Nurses ' Progress Notes dated 4/28/2012 found, " The resident was wandering around the unit in his wheelchair at the front door, a code alert bracelet was placed on the resident secondary to wandering and exit seeking behavior. " Evening shift documentation showed, " Alert and confused at times, exit seeking behavior noted, wander guard in place, will continue to monitor. " Review of notes dated 4/29/2012 at 2:15 p.m. showed, " Resident removed Wander Guard (sensor device) from wrist, refused replacement , Wander Guard placed on wheelchair. " At 3:00 p.m., " Resident found lying face down in facility driveway with injury to head. " Review of Physical and Occupational Therapy Evaluation Notes dated 4/27/2012 showed, " Resident was a high fall risk , had decreased safety awareness and judgment, impulsive, stand without breaks, responded no when asked if he needed someone with him to stand up. " Review of Wander/Elopement Risk Evaluation on Resident #15 dated 4/26/28/29/2012 showed, " Resident was cognitively impaired and had impaired decision making skills that decrease his awareness of safety, currently wanders or has a history of wandering, automatically a high risk for wandering. " Review of Facility Investigation documentation regarding the elopement incident dated 4/29/2012 found, " Resident was last seen by staff at approximately 2:45 p.m. attempting to go up to the second floor in the elevator because he thought his room was upstairs, (Resident ' s room was on first floor Room 118) resident was redirected several times and to stay in front of the nursing station. Resident noted a facility vendor enter the facility through the back door. Resident at this time noted exit door and exited the facility by pushing on the door handle and caused the door guard to release and the resident attempted to self propel his wheelchair down and sustained a fall with injuries. At 3:00 p.m. resident was found lying face down on the ground in the back parking lot with his wheelchair tipped over and wheelchair lying on resident with facial injuries, with bleeding from laceration to upper lip. This is resident ' s second admission, has a history of wandering on unit, a Wander Guard was placed on the resident secondary to wandering toward lobby. Resident was sent to the hospital and returned with minimally displaced fracture of the right eye orbit, maxillary sinus and right facial bruising and soft tissue swelling, laceration to upper lip with tract that communicates with the inside of the mouth, abrasion to bridge of nose and right side of face and right cheek. Resident was not able to recall fall and attempting to leave the facility. " Review of 5/1/12 documentation of an interview with a Facility Vendor found, " On Sunday 4/29/2012 I came to pick up rental equipment. I did not see him outside the facility when I arrived or entered the building, I do recall seeing him in the back hallway as I passed him entering the facility. " On 5/11/2012 at 12:00 p.m. on observation, Resident#15 propelled his own powered wheelchair through the back hallway independently with supervision, this surveyor asked the resident to open the back door, he grabbed the bar and struggled to open with his right hand and right foot and the door alarm sounded. The Wander Guard alarm on his wheelchair failed to alarm. No Wander Guard sensor was found at the exit door. When asked as to why did he try to exit the facility some weeks ago he stated, " I don ' t remember. " On 5/11/2012 at 12:05 p.m. on observation of the rear facility parking lot, found the driveway steep and curved towards downhill to the outside of the premises. On 5/11/2012 at 12:10 p.m. interview with Staff B (Receptionist) when asked regarding the elopement incident she stated, " It was a Sunday when the resident went outside through the back door, nobody was at the front desk. I was upstairs by the kitchen. I did not hear the alarm. The laundry people usually respond because their office is by the back door but their office was closed on weekends. " On 5/11/2012 at 2:00 p.m. interview with Staff C (Administrator) when asked how they protect residents at risk for wandering and elopement she stated, " This incident has never happened to us before, this is the first time. Alarms sound at the nurses ' station, the back door and local areas. The laundry close to the back door was closed because it was a weekend. The receptionist was upstairs. We do not admit residents here that exit seek. We allowed the resident to stay with us because he was a wanderer but never eloped. We are not a secured unit. The alarm at the backdoor was not meant for elopement but for security for vendors who come in and out and at night time. The door automatically opens after 13 seconds. " On 5/15/2012 at 8:45 a.m. interview with Staff D (Licensed Nurse) she stated, " Before this incident we did not have a camera for the back door. We couldn ' t see residents when they tried to exit though the back door. " When asked what were they trained to do when they hear exit alarms she stated, " Respond as soon as we can but I doubt that we will hear it because if we are in a remote resident room I don ' t believe that we will hear it. " On 5/15/2012 at 9:15 a.m. interview with Staff E (CNA) when asked as to what was their responsibility when they hear an exit alarm she stated, " We are to go there right away but when it is on the far end of the other side of the resident rooms we can ' t hear it. I have not heard an alarm yet. " On 5/15/2012 at 9:30 a.m. interview with Staff F (CNA) he stated, " We are to respond right away but if we are at the North end side of the hall and we are in a resident room with the door closed we can ' t hear it. " On 5/15/2012 at 10:15 a.m. interview with Staff G (CNA) he stated, " We are to respond right away to an alarm, but if I am in room 104, 108, 110 at the north end I can ' t hear it and if I am in the middle of a resident care I have to finish helping the resident first. " On 5/15/2012 at 3:44 p.m. on a telephone interview with Staff H (Licensed Nurse) regarding the incident she stated, " I came at 2:30 p.m. after I got report I went out to the desk after I helped a resident in the bathroom, someone came and said a resident had fallen outside so I called 911. I did not really hear the alarm. " On 5/15/2012 at 3:58 p.m. on a telephone interview with Staff I (Licensed Nurse) regarding the incident she stated, " It was at the change of shift after doing my rounds, the back door alarm went off when I was in the shower room looking for the resident, it took me about two minutes before I could get to back door. Then I saw the resident outside about 30 feet from the door with his face down and his wheelchair on top of him. His face was bleeding. He was not exit seeking but the day before he wandered more. He removed his Wander Guard from his wrist so we put it on his wheel chair. " When asked if she heard the alarm trigger from his wheelchair prior to the resident exiting she stated, " No, the Wander Guard alarm does not trigger at the backdoor, only the front and side doors have Wander Guard alert systems. " On 5/24/2012 at 9:22 a.m. observation of the alarm box at the nurses' station showed a flashing light and a sound emission when the back door exit alarm sounded. On observation of the shower room with the door closed the alarm could not be heard. The sound of alarms in the hallways was faint. Facility staff could not respond in a timely manner to an alarm triggered by a wandering resident because the alarm could not be heard in all areas of the first floor. The lack of a Wander Guard alarm sensor near the facility backdoor to alert staff of a wandering resident (Resident #15) caused the resident actual harm with injuries and required a hospital visit.