Every finding on record at Regency at the Park

Based on interview and record review, the facility failed to consistently document post dialysis (a treatment to filter wastes and water from the blood) assessments for 1 of 2 resident (Resident 6 and 22) reviewed for dialysis. This failure placed the resident at risk for unmet care needs and a potential for medical complications. Findings included .Review of the facility's policy titled, Dialysis Policy revised March 2024, showed a licensed nurse to complete the pre- and post-dialysis assessments with each dialysis visit. Review of the medical record showed Resident 6 had been admitted to the facility on [DATE], with diagnosis to include kidney failure, heart disease, depression and dementia. The comprehensive assessment dated [DATE] showed Resident 6's cognition was intact, and dependent on two staff members for care and transfers. Review of Resident 6's physician orders showed the resident required dialysis every Tuesday, Thursday and Saturday. Further review showed staff were to follow dialysis flow sheet protocol for pre and post dialysis and to check pressure dressing post dialysis and remove after two to three hours. During an interview on 01/05/2026 at 3:27 PM, Resident 6 stated they were unaware of the communication between the dialysis when being sent or when coming back to the facility after the dialysis visit. Resident 6 stated the staff were not consistently checking on them when they returned from dialysis. Review of Resident 6's December 2025 Licensed Nurse administration record showed the resident did not have post dialysis vitals on 12/16/2025and 12/23/2025. Review of Resident 6's November 2025 Licensed Nurse administration record showed the resident did not have post dialysis vitals on 11/04/2025, 11/11/2025, and 11/22/2025. During an interview on 01/06/2026 at 3:43 PM, Staff J, Nursing Assistant (NA), stated their process after dialysis was to get the resident in bed, get them a meal and a quick change. Staff J stated they do not always get the vitals, if the nurse is too busy then they will ask us to do the vitals. During an interview on 01/08/2026 at 8:45 AM, Staff K, Resident Care Manger, (RCM), stated a Dialysis communication form was sent with the resident with each visit and the dialysis center would fill it out when the resident session was done and send it back with the resident. The facility then checked for new orders on the form. Staff K stated the communication forms were not always completed by the dialysis center. The dialysis center would call if the resident had trouble with their treatment or if they had to send them to the local emergency to be evaluated. During the same interview Staff L, Registered Nurse, (RN), stated dialysis would send a monthly report, although the dialysis center had been inconsistent lately, nursing had been having to call them for the information. During an interview on 01/09/2026 at 9:42 AM, Staff K, RCM reviewed the licensed nurse administration record for Resident 6's post dialysis care with the missing documentation. Staff K stated their expectation of their staff were for them to follow the dialysis protocol for the residents' post dialysis care. Reference: WAC 388-97-1900 (1), (6)(a-c)

Based on interview and record review, the facility failed to develop and maintain a current hospice (a type of care that focuses on comfort and quality of life for people who were terminally ill or near the end of their life) care plan in collaboration with contracted hospice services, that identified what provider was responsible for performing specific services/functions for 1 of 2 sampled residents (Resident 24 ) reviewed for hospice services. This failure placed residents at risk for not receiving necessary care and services. Findings included . Review of the Hospice Contract, dated 01/05/2026, showed the facility and hospice provider must maintain a coordinated Care Plan that is responsive to the unique needs of the patient and their representative while remaining consistent with hospice philosophy. This unified care plan must identify specific hospice services, including interventions for pain management and symptom relief, and provide a detailed statement of the scope and frequency of these services along with measurable anticipated outcomes. Furthermore, the plan must delineate the specific provider responsible for performing each function, including the administration of drugs, treatments, medical supplies, and appliances necessary to meet the patient's needs. Review of the medical record showed the resident admitted to the facility with diagnoses including chronic congestive heart failure ( heart is not pumping blood as strongly as it should) chronic kidney disease (your kidneys are not working well enough to filter waste and extra fluid from your blood). The 12/03/2025 comprehensive assessment showed Resident 24's cognition was moderately impaired and required assistance of one staff member for activities of daily living (ADLs). Further review showed Resident 24 was receiving hospice services. Review of Resident 24's electronic health record (EHR) on 01/06/2026 showed Resident 21 had no hospice care plan. During an interview on 01/08/2026 at 10:20 AM, Staff G, Resident Case Manager, stated they did not integrate the hospice care plan with the facility's care plan when a resident was admitted to hospice services, 'I just use our care plan. Staff G further stated they were unsure of the process for integrating the hospice care plan with the facility's care plan. During an interview on 01/08/2025 at 11:41 AM, Collateral Contact 1 (CC1) associated with Hospice, stated the process for the hospice care plan was for it to be fully integrated with the facility's comprehensive care plan. To ensure continuity of care and professional standards, CC1 stated that all disciplines must maintain a unified approach, ensuring that patient-centered goals and clinical interventions are consistent across both providers. During an interview on 01/09/2026 at 9:25 AM, Staff B, Director of Nursing, stated that the expectation for nursing staff was that they must incorporate the hospice care plan into the facility's comprehensive care plan. The integration ensures all interventions coincide and all components are clearly documented for continuity of care. Staff B stated this process was not followed for Resident 24. Reference WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP, [a type of isolation used to prevent spread of infections]) for three of five residents (Resident 6, 31, and 76) reviewed for infection control. Ensure hand hygiene was performed and ensure proper use of Personal Protective Equipment (PPE) during daily resident cares and wound care treatment. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included .Resident 76 Review of the medical record showed the resident admitted to the facility with diagnoses including stroke (when blood flow to part of the brain is suddenly cut off, either by a blockage or a burst blood vessel, causing brain cells to die from lack of oxygen, leading to sudden impairment or loss of function like weakness, numbness, or trouble speaking). The 11/18/2025 comprehensive assessment showed Resident 76's cognition was moderately impaired and required assistance of one-two staff member for activities of daily living (ADLs). Wound Care During a concurrent observation and interview on 01/05/2026 at 10:28 AM, Staff U, Registered Nurse, was observed entering Resident 76's room to perform wound care without a gown or gloves. Staff U failed to place a barrier on the bedside table prior to placing wound supplies. Staff U , after leaving and re-entering the room, donned (put on) gloves without performing hand hygiene. Staff U removed the soiled dressing from the resident's left lower leg wound. After removing the contaminated dressing, Staff U continued to use the same gloves to clean the wound with saline, handle clean gauze, and apply Iodosorb (a gel that cleans and treats wet, infected wounds like ulcers) medication with a tongue depressor. Staff U further used the contaminated gloves to apply the new dressing, replace the resident's sock, and adjust the bed linens. When interviewed during the observation, Staff U stated the correct process was to remove the old dressing, perform hand hygiene, and don new gloves before cleaning the wound and placing a new dressing. Staff U stated they only use gloves for PPE; further stating I am not required to wear any other PPE; there is nothing on the wound orders. Enhanced Barrier Precautions During a concurrent observation and interview on 01/08/2026 at 3:17 PM, Staff V and Staff W, Nursing Assistants, entered Resident 76's room to assist the resident into bed. Both Staff V and Staff W applied the Hoyer sling and assisted Resident 76 to their bed, they wore only gloves and failed to don required gowns. Staff V stated, Yes, we would normally use EBP including a gown, but I just forgot; I have been here since 6:00 AM. Staff W stated, I just forgot as well. Both staff members stated they were aware of the requirement, stating the signage on the door indicates when gowns are necessary. Staff W continued to provide care without donning the proper PPE. While repositioning the resident, their clothing came into direct contact with the resident's surfaces, including the bed and the resident's own clothing. A review of the signage outside room [ROOM NUMBER] confirmed that Bed A and Bed B were on EBP's, requiring staff to wear gloves and gowns for high-contact care activities, including transferring and repositioning. Review of the facility's policy titled, Hand Hygiene Policy, dated 01/2026, showed to prevent the spread of infection by implementing appropriate precautions when a resident is identified with a communicable disease and requiring staff to use proper hand hygiene during resident cares. Enhanced Barrier Precautions Resident 31Review of the medical record showed Resident 31 admitted to the facility on [DATE] with diagnoses to include kidney disease, diabetes (a disease in which the body does not control glucose (a type of sugar) in the blood), weakness and their cognition was intact. During an observation and concurrent interview on 01/05/2026 at 11:40 AM, Staff Q, Registered Nurse, (RN), entered a room with an EBP sign and stated they would be doing a dressing change. Staff Q had placed gloves on and proceeded to remove Resident 31's sock, no other Personal Protective Equipment (PPE). Staff Q removed their gloves, sanitized their hands, and placed a barrier on the table for their wound supplies. Staff Q used a pillow from Resident 31's chair to elevate the resident's wound on the left heel. Staff Q changed their gloves and washed their hands, replaced gloves and then set a barrier underneath the resident's heel. Staff Q cleansed resident's heel with a gauze with normal saline (a sterile solution) and used a Q-Tip to remove any film from the left heel wound. Staff Q removed their soiled gloves, sanitized their hands and reapplied clean gloves. Staff Q applied Santyl (a medicated ointment) on the wound and placed a bordered gauze over the left heel. Staff Q stated they should have been wearing a gown during the wound care for Resident 31. Staff Q stated they had got nervous and forgot. Resident 6Review of the medical record showed Resident 6 had been admitted to the facility on [DATE], with diagnosis to include kidney failure, heart disease, and depression. The comprehensive assessment dated [DATE] showed Resident 6's cognition was intact, and dependent on two staff members for care and transfers. During an observation and interview on 01/05/2026 at 3:01 PM, Staff R, NA were in Resident 6's room (an EBP room) they repositioned the resident and cleaned up spilt water off the floor, Staff R was wearing gloves and had no other PPE. Staff R was unable to state what the EBP sign had directed them to do, after reviewing the EBP signage, Staff R stated they should have been wearing a gown in Resident 6's room while doing their care. During an interview on 01/09/2026 at 8:43 AM, Staff S, Infection Preventionist (IP) stated they were aware of the staff's failure to use proper PPE while delivering care to residents who were in EBP rooms. Staff S stated there is no exception, the staff need to follow the signs that are placed for the protection of everyone. Reference: WAC 388-97-1320 (1)(c), (2)(b)

Based on observation, interview and record review, the facility failed to ensure residents were evaluated, assessed, and physician orders were obtained for safe self-administration of medication for 1 of 3 residents (Resident 10), reviewed for self-medication administration. This failure placed residents at risk for inaccurate and unsafe medication administration, adverse side effects, and medical complications. Findings included . Review of the policy titled, Storage and Expiration Dating of Medications and Biologicals, revised date 06/30/2025, showed the facility should not provide bedside medications without a physician order and approval by the Interdisciplinary Care Team and facility administration. Review of policy titled, General Dose Preparation and Medication Administration, revised date 11/15/2024, showed the facility staff would not leave mediations unattended and observe the resident's consumption of the medication. Review of the medical record showed Resident 10 was admitted to the facility with diagnoses including diabetes (a condition that causes high blood sugar in the blood), heart failure and glaucoma (a progressive vision condition that can lead to blindness). The 11/02/2025 comprehensive assessment showed Resident 10 was independent with Activities of Daily Living (ADLs), with exception of supervision with bathing. The assessment also showed Resident 10's cognition was intact. During an observation and interview on 01/05/2026 at 3:24 PM, showed Resident 10 in their room with two medications in a small unlabeled clear cup and a bottle of eye drops on top of a bedside table. Resident 10 stated they had returned from an outing and the nurses placed their medications on their beside table when they returned. Resident 10 stated one of medications was for their joints and the other was for their blood pressure. Resident 10 stated they would give the eye drops back to the nurse when they were done using the eye drops. During an observation and interview on 01/06/2026 at 8:49 AM, showed Resident 10 in their room eating breakfast. On their bedside table was an unlabeled clear cup with two large white medication tablets Resident 10 stated they had taken some of their morning medications and had left these two large white tablets to take after their breakfast and did not know what the medications were. During an observation and interview on 01/08/2026 at 9:25 AM, showed Staff E, Registered Nurse, entered Resident 10's room and obtained two bottles of eye drops used for the treatment of glaucoma, and then returned to the medication cart. Staff E stated they left the medications with Resident 10 as they had requested to take their medication by themself. Record review of Resident 10's medical record showed that there was no self-medication assessment or a physician's order in place for the safe self-administration of medications. During a concurrent interview on 01/08/2026 at 4:19 PM, Staff B, Director of Nursing, stated staff should be observing residents take their medications and not leave them at the resident's bedside. Staff B stated if a resident wanted to self-administer their medications, the process would be to perform a cognitive assessment and obtain a provider order. Staff B stated that would be done to ensure a resident was safe to be able to self-administer medications. During the same interview at 4:30 PM, Staff C, Regional Director of Clinical Operations, stated that for a resident that wanted to self-administer their medications, the facility would ensure the facility provider visited the resident and ordered a self-medications assessment to verify appropriateness for the resident to self-administer their medications. Staff C stated Resident 10 did not have that process completed and their medications should not be left at their bedside. Reference WAC: 388-97-0440

Based on observation, interview, and record review, the facility failed to develop comprehensive person-centered care plans to address vision impairments for 2 of 3 Residents (Resident 42 and 76 ) reviewed for care plan development. This failure placed the residents at risk for unmet care and/or safety needs related to inaccurate or inadequate direction to staff. Findings included.Resident 42 Review of the medical record showed the resident admitted to the facility with diagnoses including chronic congestive heart failure ( heart is not pumping blood as strongly as it should), dementia (a significant decline in thinking, memory, and reasoning skills that's bad enough to interfere with daily life) and visual disturbance. The 11/27/2025 comprehensive assessment showed Resident 42s cognition was moderately impaired and required assistance of one staff member for activities of daily living (ADLs). Further review showed Resident 42's vision was severely impaired. A concurrent observation and interview on 01/06/2026 at 11:05 AM, showed Resident 42 lying in bed with their water cup located on the bedside table. The bedside table was positioned out of the resident's reach. Resident 42 stated, I cannot see well; all I see is black. It's scary when I try to get up and go somewhere. If I bump into people, they get mad; they don't understand that I am blind. Resident 42 further stated that their water cup was out of reach on the end table, stating, I don't know where my water cup is; I can't see it. I sometimes put my water on the floor so I can find it. I could reach it if they put the table right by me. During an observation on 01/06/2026 at 2:54 PM, Resident 42 was observed lying in bed; the water cup was located on an end table positioned out of the resident's reach. During an observation on 01/07/2026 at 9:17 AM, Staff O, Nursing Assistant, was observed assisting Resident 42 to bed. Afterwards, Staff O failed to position the bedside table or water cup within the resident's reach. The table was located to the left of the nightstand, inaccessible to the resident. Record review of the Electronic Health Record (EHR) on 01/09/2026, showed no care plan was in place to address Resident 42's vision impairment, nor were there documented interventions to guide staff on environmental safety or accessibility related to the resident's severely impaired vision. Resident 76Review of the medical record showed the resident admitted to the facility with diagnoses including stroke (when blood flow to part of the brain is suddenly cut off, either by a blockage or a burst blood vessel, causing brain cells to die from lack of oxygen, leading to sudden impairment or loss of function like weakness, numbness, or trouble speaking). The 11/18/2025 comprehensive assessment showed Resident 76's cognition was moderately impaired and required assistance of one-two staff member for ADL's. A concurrent observation and interview on 01/07/2026 at 4:06 PM, showed Resident 76's bedside table was positioned out of the resident's reach. Resident 76 was observed attempting to reach their water but was unable to do so. The resident stated they could not see the table or the water because they were positioned out of their visual field. Resident 76 further stated that they could not see anything to the side unless they turn their head significantly. When asked to use the call light to request assistance, the resident stated they could not find the button. The call light was observed clipped to the upper right-hand corner of the bed, out of the resident's visual field and reach. During an observation on 01/08/2026 at 11:45 AM, Resident 76 was observed lying in bed with their water cup out of reach. The resident attempted to obtain the water cup but tipped it over while searching for it. Resident 76 stated, I cannot see it. The water cup was located to their right on the bedside table, positioned in the middle of the table rather than being pushed to the edge for accessibility. Record review of the EHR on 01/09/2026, showed no care plan was in place to address Resident 76's vision impairment, nor were there documented interventions to guide staff on environmental safety or accessibility related to the resident's vision. During an interview on 01/08/2026 at 10:26 AM, Staff G, Resident Case Manager, stated they were aware of the vision deficits for Resident 42 and Resident 76. Staff G stated the facility's process was to have a vision care plan in place for these residents. Staff G further stated, I did not do either one of them. I just overlooked it. During an interview on 01/09/2026 at 9:37 AM, Staff B, Director of Nursing Services, stated they expected vision-specific care plans to be implemented for residents with visual impairments to ensure staff are provided with the necessary direction to provide care. Reference WAC 388-97-1020 (1), (2)(a)(b)

Based on interview and record review, the facility failed to provide copies personal medical records, as required, to 1 of 2 resident (Resident 27), reviewed for resident rights. This failed practice placed residents at risk of not having access to their complete medical history, potential emotional stress affecting their ability to make informed decisions about their care, and a violation of their resident's rights. Findings included . Review of the facility's November 2025 policy titled Resident Rights showed upon request, the resident has the right to receive records, in a language he or she can understand, pertaining to his or her care within 24 hours of request. Further review did not show residents were required to give a written request for their medical records. Resident 27 Review of the medical record showed Resident 27 admitted to the facility on [DATE] with diagnoses to include diabetes (a disease in which the body does not control sugar in the blood), muscular dystrophy (genetic disorders causing progressive weakness and loss of muscle mass), heart and kidney disease. Review of the comprehensive assessment dated [DATE] showed Resident 27's cognition was intact and independent with personal cares. During the Resident Council meeting conducted by the State Agency on 01/07/2026 at 9:47 AM, Resident 27 stated they were unable to have a copy of their medical records. Resident 27 stated they were only offered to view their records on the computer. During an interview on 01/07/2026 at 3:57 PM, Resident 27 stated that they had some blood drawn in December and wanted to know their lab results. Resident 27 stated their doctor had ordered the labs and had stated they could have a copy of their results. Staff I looked them up on the computer and stated they could write down their results. Resident 27 stated they asked Staff I for a copy of their records and were told they could not have a copy. Resident 27 stated Staff I had asked if they had My chart (online system that contained Resident medical history) Resident 27 stated they said no, they did not have a computer. Resident 27 stated they had a genetic disorder and a heart condition. Resident 27 stated they were thinking the nurse had seen something wrong and did not want them to see it. During an interview on 01/08/2026 at 9:16 AM, Staff I, Resident Care Manager (RCM), stated they had explained to Resident 27 once medical records were in the chart they may need a written request for their medical records. Staff I stated they had offered to sit and view lab results from the computer with Resident 27. Staff I stated they wanted to check the facility's policy about giving out medical records once records were in the facility's system. Staff I stated they had gone over the lab results with the resident in office and offered for Resident 27 to write it down while they double checked the policy. Staff I stated that occurred on Monday 01/05/2026 and then got distracted. During an interview on 01/08/2026 at 10:21 AM, Resident 27 stated their family had history of severe illness and kept close record of their results. Resident 27 stated they did not want to write results down, they just wanted a paper copy to review on their own. During an interview on 01/09/2026 at 10:53 AM, Staff A, Administrator, and Staff B, Director of Nursing, stated there had been some miscommunication between Staff I, RCM and Resident 27. Reference: WAC 388-97-0300 (2)(a)(b)

Based on observation, interview, and record review the facility failed to promote resident dignity during mealtime in the dining room for 3 of 8 residents (Resident 70. 28 and 74) reviewed for dignity. Resident 70 had their medical information discussed while eating their meal and Resident's 28 and 74 were referred to by pet names. This failure placed residents at risk for embarrassment and a poor quality of life. Findings included . Record review of an undated facility policy titled The Dining Experience; Staff Responsibilities showed, the dining experience will enhance each individual's quality of life through person centered dining. Staff will treat each individual with dignity and respect. Staff will respect the confidentiality of any individuals. Resident 70 Review of the resident's medical record showed the resident was admitted with diagnoses which included history of a stroke (blood supply is cut-off from the brain) with right hemiplegia (paralysis of one side of the body usually following a stroke) and dementia. Review of the comprehensive assessment dated [DATE] showed they had cognitive impairment and were dependent on staff for dressing grooming, transfers and mobility needs. During an observation on 01/05/2026 at 12:51 PM, in the large dining room Staff N, Nursing Assistant, (NA) stated to Staff I, Resident Care Manager (RCM), that Resident 70 was not eating very well. Staff N continued to discuss their concerns about Resident 70's nutritional status and stated they were trying to get Resident 70 to drink health shakes to replace their refused meals. Staff I questioned Staff N about Resident 70 having a possible urinary tract infection (UTI) which may be causing their poor appetite. Staff I further stated they were going to get a urine sample from Resident 70 to rule out a UTI. The confidential health conversation between Staff N and Staff I about Resident 70 occurred in front of eight other residents who were sitting in the dining room eating their meals. Resident 28 Review of the resident's medical record showed the resident admitted with diagnoses which included dementia, and chronic kidney disease. Review of the comprehensive assessment dated [DATE] showed the resident had mild cognitive impairment and required extensive assistance from staff for dressing and mobility. During an observation on 01/05/2026 at 12:56 PM, showed Staff M, NA, conversing at the dining room table with Resident 28. During the conversation Staff M referred to Resident 28 as honey several times as they were talking. Resident 74 Review of the resident's medical record showed they were admitted with diagnoses which included dementia and hypertension. Review of the comprehensive assessment dated [DATE] showed the resident had cognitive impairment and required moderate assistance from staff for dressing and mobility. During an observation on 01/07/2026 at 8:40 AM, Staff P, Director of Therapy, came into the dining room and approached Resident 74 who was sitting at their dining room table with two other residents. Staff P stated Hello Sweetheart to Resident 74 and reminded them that they were going to work with them later that day. During an interview on 01/09/2026 at 12:40 PM Staff B, Director of Nursing, stated they expected staff to not discuss medical information in the dining rooms or refer to residents by nick names such as honey or sweetie unless the resident preferences were known. Reference WAC 388-97-0180(1-4)

Based on observation, interview, and record review, the facility failed to provide necessary adaptive equipment for residents with highly impaired vision to maintain the highest practicable level of independence for 1 of 4 residents (Resident 42) reviewed for Activities of Daily Living (ADL's). This failure placed residents at risk for decreased nutritional intake, weight loss and a diminished quality of life. Findings included.Review of the medical record showed the resident admitted to the facility with diagnoses including chronic congestive heart failure (heart is not pumping blood as strongly as it should), dementia (a significant decline in thinking, memory, and reasoning skills that's bad enough to interfere with daily life) and visual disturbance. The 11/27/2025 comprehensive assessment showed Resident 42s cognition was moderately impaired and required assistance of one staff member for ADLs and set-up assistance for eating. Further review showed Resident 42's vision was severely impaired, and they were not receiving any specialized care with eating. During an interview on 01/06/2026 at 11:01 AM, Resident 42 stated they had a hard time eating and would like to have better forks and spoons to help them eat, it's hard to get my food onto theses ones. Resident 42 was referring to he plastic utensils they were currently using. During an observation on 01/07/2026 at 8:59 AM Resident 42 was observed using their hands to feel for their food, had plastic utensils, regular plate and no adaptive equipment. Resident 42 ate with their hands the entire meal. Food was observed on the resident's shirt and spilled from the plate onto the table. During an observation on 01/07/2026 at12:39 PM Resident 42 was served a lunch tray consisting of chopped ham, mashed potatoes, green beans and cake. Resident 42 was observed using a standard spoon to eat mashed potatoes. Food was observed falling off the spoon onto the resident's shirt. Resident 42 used their hands to scoop their food from the plate onto the spoon, food was spilling off the side of the plate. No adaptive equipment was utilized. During an interview on 01/08/2026 at 12:16 PM, Staff T, Registered Dietician, stated they had observed Resident 42 eating and was aware of their poor vision. Staff T stated the facility's process was for Occupational Therapy (OT) to assess residents to determine if they would benefit from adaptive equipment. Staff T stated they could not verify if OT had assessed Resident 42 because nursing was responsible for obtaining OT orders for adaptive equipment needs. Staff T confirmed Resident 42 did not have any active orders for adaptive equipment related to eating. During an interview on 01/08/2026 at 1:22 PM, Staff P, Director of Rehab, stated Resident 42 had not been evaluated by OT for their eating or for any adaptive equipment needs. Staff P stated they were aware of the need for Resident 42 to have an assessment. During an interview on 01/09/2026 at 9:37 AM, Staff B, Director of Nursing, stated they expected Resident 42 would have received a nursing evaluation and a referral to OT to address eating deficits related to his severely impaired vision. Reference WAC 388-97-1660 1(b)

Based on observation, interview, and record review, the facility failed to implement care plan interventions and provide adequate supervision to prevent avoidable accidents during mechanical lift transfers for 2 of 2 residents (Residents 30 and 7) reviewed for falls. Resident 30 experienced harm when they fell from a mechanical lift while being transferred without the two-caregiver assistance as care planned onto their surgical incision site from their recent right below the knee amputation (BKA) requiring a transfer to the emergency room , surgical repair, and a five-day hospital stay. Resident 7 experienced an avoidable fall when left alone in their wheelchair after staff applied a mechanical lift sling under the resident and attached the sling to the mechanical lift. This failure placed the residents at risk for injury, pain, and recurrent falls. Findings included . <Resident 30> Review of the medical record showed Resident 30 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD), diabetes and a complete BKA of the right lower leg. Review of the most recent comprehensive assessment dated [DATE] showed Resident 30 was cognitively intact and required assistance of one to two caregivers for bed mobility, transfers, toileting and dressing. Review of Resident 30's care plan dated 12/27/2024 and revised on 01/15/2025 showed the resident required assistance of two caregivers with a Sara Steady lift (a manual lift that helps patients stand up from a seated position) for transfers. During an observation and interview with Resident 30 on 02/24/2025 at 12:56 PM showed them sitting in an electric wheelchair eating lunch independently. Resident 30 stated they had an amputation of their right lower leg on 12/26/2024 that was healing well until they had a fall from a Sara Steady lift on 01/31/2025, landing on the stump of their right leg causing the surgical incision to open again. Resident 30 stated they had been doing well working with the facility therapists and was hoping to get a lower leg prosthesis (an artificial device that replaces a missing body part) soon and get back home as soon as possible. Resident 30 stated they felt the fall had set them back considerably from all the progress they had made towards their goal of being discharged home soon. In a follow up interview with Resident 30 on 02/28/2025 at 12:18 PM, they explained how the fall on 01/31/2025 happened. They stated they wanted to move from one chair in their room to their electric wheelchair and asked for assistance from Staff P, Nursing Assistant (NA). Staff P came into the room with a Sara Steady lift (where a resident is able to stand on the lift to transfer from one place to another). Resident 30 stated they told Staff P they needed to get another person to help with the transfer because they could not stand safely on just one leg, but Staff P told them it was okay and they could do it by themselves. The resident let Staff P do the transfer alone. Resident 30 stated as soon as they grabbed the bar on the lift and was assisted to a standing position by Staff P, they could not hold on tightly enough and their one leg gave out and they fell directly down to the floor with their stump taking the full weight of their body. Resident 30 stated the pain was excruciating and the leg wound began bleeding heavily immediately. Resident 30 stated other staff immediately came into their room and got them back onto their bed and attempted to stop the bleeding. Resident 30 stated 911 was called and they were transferred back to the hospital where they had to have surgery again to repair the damage to their stump the fall caused. During the same interview, Resident 30 stated multiple staff members came in and asked questions about how the fall occurred and was told that Staff P should not have been transferring them by themselves and would be reprimanded for not getting assistance. Resident 30 stated after they returned from the hospital on 02/05/2025, their transfer status had been changed to using a Hoyer lift (an electric mechanical lift completely transfers a dependent resident) only with a two person assist. Review of a nursing progress note dated 01/31/2025 at 1:35 PM stated This RN (Registered Nurse) called to residents' room by CNA (Certified Nursing Assistant). When arrived therapy was assisting resident in wheelchair. It was reported to me that the resident was being transferred from wheelchair to a Sara Steady. Resident fell during transfer onto right stump of BKA. Stump was bleeding from site through dressing onto floor. Resident denied hitting head or feeling any other injuries. Resident was assisted by therapy team and CNA from wheelchair using a gait belt for adjustment and then transferred to bed with Hoyer lift (a mechanical lift). During transfer, this RN applied pressure to wound. Once resident was in bed, stump was elevated and dressing removed to assess surgical site. Noted that surgical site had opened and abd (a thick absorbent pad) was saturated with blood. Resident bled through second abd pad. Pressure applied. New abd pad and ace wrap applied. Resident transferred to hospital via EMS (an ambulance service). Review of the facility incident report and an interview Staff B, Director of Nursing Services (DNS) on 02/28/2025 at 12:39 PM, they stated Staff P was a newer NA that worked for the facility on a as needed basis. Staff B stated they investigated the cause of Resident 30's fall immediately on 01/31/2025 and had interviewed Resident 30, Staff P and any witnesses of the event that day. Staff B stated in the interview with Staff P they stated they knew mechanical lifts always required assistance of two caregivers and that Resident 30 should have had two persons assisting with the transfer. Staff P stated the resident was in a hurry to get transferred so they just attempted to do it themselves. Staff P stated Resident 30 did not hold on correctly when they lifted them to standing and their good leg buckled causing them to fall onto their right stump. Review of Staff P's personnel file showed they had transfer training on mechanical lifts during NA training orientation on 10/28/2024 and individual training on 01/31/2025. During an interview with Staff A, Administrator, on 02/28/2025 at 1:45 PM, they stated they were aware of the fall with injury to Resident 30 and knew trainings had been completed as the plan of care was not followed for two person transfers for Resident 30, nor was the facility policy followed to have two person transfers with all mechanical lifts. 45117 Review of a document titled, Mechanical Lift Competency - Bed to Wheelchair, dated 12/2023, showed always use two person assists for all lifts, and ensure bed/wheelchair brakes are locked and secure. <Resident 7> Review of the medical record showed Resident 7 was readmitted to the facility on [DATE] with diagnoses including a stroke with hemiplegia/hemiparesis (a medical condition that causes weakness or paralysis on one side of the body) affecting the left side, heart failure, and anxiety. The record showed. The 01/25/2025 comprehensive assessment showed Resident 7 had an impairment on their upper left extremity and both lower extremities and was dependent on two staff members for assistance with transfers. The assessment also showed Resident 7 had a moderately impaired cognition. Review of a facility investigation dated 02/26/2025 at 7:11 PM, showed Resident 7 was in their room behind a closed door, yelling out for help. The resident was observed sitting on the floor with the back of their shoulders leaning against the wheelchair legs and the mechanical lift sling partially in the wheelchair. The mechanical lift was positioned in front of the resident with the legs of the lift open and the brakes not engaged. Resident 7 appeared to have slid out of their wheelchair to the floor. The wheelchair brakes were not engaged. During an interview on 02/27/2025 at 12:20 PM, Staff L, Nursing Assistant (NA), stated they were walking past Resident 7's room and saw them trying to hook their sling to the mechanical lift. Staff L stated they attached the sling to the mechanical lift and left the room to get a second NA to help with the transfer. Staff L stated the second NA needed assistance with their resident and they went to help that NA. Staff L stated they went to lunch after helping the NA with their resident and had forgotten they had left Resident 7 attached to the mechanical lift. During a follow-up interview at 12:52 PM, Staff L stated they had been trained on the safe use of mechanical lifts and had not been trained to hook up a resident to a mechanical lift and leave them alone while still attached to the mechanical lift. Staff L stated, I just forgot, it was a mistake. During an interview on 03/03/2025 at 2:26 PM, Staff D, Regional Director of Clinical Services, stated the process for safe transfers was not followed for Resident 7. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview and record review the facility failed to allow 6 of 6 residents (Residents 20, 12, 8, 56, 35, and 40) reviewed for resident rights, the right to self-determination to hold resident council meetings at the times of their choice and to discuss topics that were important to them such as dining and food choice issues. The failure to accommodate and address their right to make choices about important issues in their lives, placed the residents at risk for a diminished quality of life. Findings included . During a resident council meeting on 02/25/2025 from 10:00 AM to 11:15 AM, six residents (Residents 20, 12, 8, 56, 35, and 40) voiced the following concerns about how they felt they were not given either the time or the choice to share issues that were important to them in the monthly resident council meetings. All resident interviews were completed during the resident council meeting. <Resident 20> Review of the medical record showed the resident was admitted to the facility on [DATE] with a primary diagnosis of Multiple Sclerosis ( a long-term neurological disorder where the body attacks itself and can lead to muscle stiffness and involuntary muscle spasms). Resident 20's most recent comprehensive assessment dated [DATE] showed the resident was cognitively intact and required assistance of one to two caregivers for all activities of daily living (ADLs). In the 02/25/2025 interview between 10:00 AM and 11:15 AM, Resident 20 stated this was their first month as President of the Resident Council Committee and they had attended most of the monthly resident council meetings for the past three years. Their main concern was not having enough time in the council meetings to express concerns that were important to the residents living in the facility. In the same interview, Resident 20 stated the meetings were scheduled once a month by the activities department at 11:30 AM and then were over at 12:00 PM so the residents in attendance could go to lunch. Resident 20 stated the Resident Council meetings were 30 minutes long and was not enough time to discuss their concerns. Review of the previous Resident Council meeting from January 2025 showed notes/minutes where the same questions were asked every month for issues in each department. Due to lack of time most residents said there were no problems and then the meeting ended. During the same 02/25/2025 interview, Resident 20 stated committee members have repeatedly reported the quality of the food was poor in taste, presentation and service. They stated the residents rarely received what was on the menu or what it listed on their tray carts they were supposed to get. During the same interview, Resident 20 stated call light response times was another issue that was always brought up in the council meetings. They stated they knew it was a constant common problem and wished administration would explain to them what the problem was and offered choices on a reasonable way to fix the issue. <Resident 12> Review of the medical record showed the resident was readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that cause airflow obstruction and breathing difficulties) and Congestive Heart Failure (CHF, a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs). In the interview on 02/25/2025 between 10:00 AM and 11:15 AM, Resident 12 stated they had been in the facility for over two years and usually attended the resident council meetings for something to do. Resident 12 stated their call lights were not being answered timely and was a big concern they had repeatedly shared. In the same 02/25/2025 interview between 10:00 AM and 11:15 AM, Resident 12 stated their constant concern was with the food. They stated it was of poor quality and the residents were rarely served what the menu listed. <Resident 8> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including diabetes (a chronic, metabolic disease characterized by elevated levels of blood sugar, which leads over time to serious damage to the heart, kidneys, blood vessels and other organs) and CHF. During an interview on 02/25/2025 between 10:00 AM and 11:15 AM, Resident 8 stated they had been in the facility for six months and had the most concern about getting the call lights answered timely. Resident 8 stated they had waited for more than an hour on more than one occasion. Resident 8 stated their concern, was that no one checked to see why the light was even on and staff did not attempt to check the status of the resident. In the same interview, Resident 8 also stated the food was not appealing and they did not look forward to eating it. They stated the food was often served cold and the posted weekly menus and the individual tray cards were not followed. <Resident 56> Review of the medical record showed the resident was admitted on [DATE] with diagnoses including diabetes and kidney disease. During an interview on 02/25/2025 between 10:00 AM and 11:15 AM, Resident 56 stated they had been in the facility over one year and had attended several of the Resident Council meetings and felt they were useless as far as being listened to about their concerns. Resident 56 stated they shared the concern of not getting their call light answered in a timely manner, waiting over an hour at times. Resident 56 also stated they had a diagnosis of diabetes and received the same diet as everyone else. Resident 56 stated the meals were often not what was listed on the posted menus. <Resident 35> Review of the medical record showed the resident admitted to the facility on [DATE] with a diagnosis of kidney disease. During an interview on 02/25/2025 between 10:00 AM and 11:15 AM, Resident 35 stated the slow call light response time was their main concern. In the same interview, Resident 35 stated they agreed if someone from the facility administration would talk with the members of the resident council about the problem and together come up with possible solutions, they would at least feel heard and possibly come up with a solution on how to make a better system. <Resident 40> Review of the medical record showed the resident was admitted to the facility on [DATE] with a diagnosis of diabetes. During an interview on 02/25/2025 between 10:00 AM and 11:15 AM, Resident 40 stated it was their first resident council meeting they attended and hoped that something could be done about the quality of the food and the food service. During an interview with Staff T, Activities Director, on 02/26/2025 at 2:35 PM, they stated the Resident Council meeting times could be changed to which ever date and times the residents felt would be the most beneficial to them and would discuss the issue with them and decide. During an interview with Staff A, Administrator, on 03/03/2025, at 11:05 AM, they stated they would follow up with the activities and dietary departments to work out the best times to have monthly meetings where the Resident Council could share their concerns. Reference: WAC 388-97-0900(1)

Based on observation, interview and record review, the facility failed to provide a comfortable and homelike environment when residents were served and ate off the plate still on the delivery tray in 2 of 2 dining rooms (900-unit and subacute dining rooms), reviewed for dining services. This failure placed the residents at risk for a non-homelike environment. Findings included . Observation on 02/24/2025 at 12:15 PM, in the subacute dining room, showed Resident 2, Resident 7, Resident 18, Resident 22, and Resident 36 were eating their lunch meals with the plates still on the delivery trays. Staff N, Nursing Assistant (NA), assisted Resident 36 with their lunch meal, from the plate which was still on the delivery tray. Observation on 02/24/2025 at 12:27 PM, in the 900-unit dining room, showed Staff J, Nursing Assistant (NA) had served Resident 58 their lunch meal and left the resident's meal on their tray. Staff J then served Resident 63's lunch meal and left the resident's meal on their tray. Staff J then removed a tray from the meal cart, placed a clothing protector on Resident 62, performed set up for the resident, and left the lunch meal on the delivery tray and began to assist the resident. Observation and concurrent interview on 02/25/2025 at 8:36 AM, Staff M, NA, delivered the resident's meal on a tray and sat it down on their table. Staff M stated Resident 6 enjoyed fruit with their meal and required assistance during mealtime. Resident 6's breakfast meal was sitting on a tray while being assisted by Staff M. During an interview on 02/28/2025 at 8:32 AM, Staff M, NA, recalled assisting Resident 6 with their breakfast while the plate remained on the delivery tray. Staff M stated they were feeling anxious, moving too quickly, and forgetting the sequence of actions they were supposed to take at that moment. During an interview on 03/04/2025 at 8:16 AM, Staff J, NA, stated their process involved taking the plate off the tray and arranging it as if they were in their own home. Staff J stated they were feeling nervous being observed, which led to forgetting to take away the trays, to take the plate off of the tray and set it up like if they were at home. Staff J stated they were nervous being watched and forgot to remove the trays. During an interview on 03/04/2025 at 8:38 AM, Staff K, Registered Nurse, stated expectation was for staff to provide the residents a clean, comfortable and homelike environment. Reference: WAC 388-97-0880(1)

Based on observation, interview, and record review, the facility failed to provide treatment and services to maintain and/or prevent a further decrease in range of motion [(ROM) - how far and in what direction you can move a joint or muscle] for a hand contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to rigidity of joints) for 1 of 3 residents (Resident 7) reviewed for restorative services. This failure placed the residents at increased risk for a worsening contracture, potential decrease in range of motion, and skin integrity issues. Findings included . Review of a document titled, Restorative Program, revised 04/2018, showed the facility would promote resident independence and quality of life by maintaining functional ROM. All residents would be assessed for functional limitations in ROM during their admission assessment period and quarterly. <Resident 7> Review of the medical record showed Resident 7 was readmitted to the facility on [DATE] with diagnoses including a stroke with hemiplegia/hemiparesis (a medical condition that causes weakness or paralysis on one side of the body) affecting the left side, heart failure, and anxiety. The record showed Resident 7 was discharged to the hospital on 01/27/2025 and returned to the facility on [DATE]. The 01/27/2025 comprehensive assessment showed Resident 7 had an impairment on their upper left extremity and required substantial/maximum assistance of one staff member for upper body dressing. The assessment also showed Resident 7 had a moderately impaired cognition. Review of the quarterly comprehensive assessment dated [DATE], showed Resident 7 received six days of active ROM from a restorative nursing program in the previous seven days. A concurrent observation and interview on 02/24/2025 at 3:12 PM, showed Resident 7 lying in bed with the fingers of their left-hand curled inwards toward the palm of their left hand. Resident 7 stated they were unable to move their left hand. They stated they used to have something for their hand (splint or brace) and they try to stretch it. During an interview on 02/26/2025 at 3:26 PM, Staff E, Registered Nurse, stated Resident 7 was not currently on a restorative program. Staff E stated Resident 7 used to do finger and elbow extensions with the restorative aide. During an interview on 02/27/2025 at 2:49 PM, Staff F, Director of Rehab, stated when a resident discharged to the hospital, the facility discontinued all therapy/restorative programs. They stated the process when a resident was readmitted to the facility included receiving physical therapy (PT)/occupational therapy (OT)/speech therapy (ST) to evaluate and treat. OT did not enroll Resident 7 into an OT program. Staff F stated when a resident was not enrolled into an OT program, there was a form that should have been completed and given to the restorative aide to restart their previous restorative services. Staff F stated that step was missed due to the transition of the therapy department from contracted services to facility staff. Reference: WAC 388-97-1060(3)(d)

Based on interview and record review, the facility failed to ensure the accuracy of the residents' comprehensive assessment [(MDS) minimum data set, a standardized assessment tool that measures health status in nursing home residents)] regarding injectable anti-diabetic medications for 2 of 5 residents (Resident 32 and 49) reviewed for injectable medication. This failure placed the residents at risk for ineffective, inaccurate care plan interventions, and unmet care needs. Findings included . Review of the Centers for Medicare and Medicaid Services guidance titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User 's Manual, dated 10/2024, showed: review the resident ' s medication administration record for the seven days prior to the assessment date for use of insulin (an injectable hormone that helps your body use blood sugar for energy and manage blood sugar levels) injections. Count the number of days insulin injections were received; enter that number of injections onto the MDS. <Resident 32> Review of the medical record showed Resident 32 was admitted to the facility with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and depression. The 12/20/2024 comprehensive assessment showed Resident 32 was cognitively intact and received insulin injections. During an interview on 02/24/2025 at 3:48 PM, Resident 32 stated they did not use insulin. During an interview on 03/03/2025 at 12:32 PM, Staff C, Registered Nurse/MDS Coordinator, stated they had entered the code for insulin use on the MDS for the resident's use of Trulicity (a non-insulin medication used to treat diabetes) based on guidelines that showed it was being used to manage the resident's insulin levels. During a follow up interview at 1:05 PM, Staff C stated Trulicity was not insulin, and they had coded it wrong on the MDS. <Resident 49> Review of the medical record showed Resident 49 was admitted to the facility with diagnoses including diabetes, current use of injectable non-insulin drugs, and depression. The 12/31/2024 comprehensive assessment showed Resident 49 was cognitively intact and received insulin injections. During an interview on 03/04/2025 at 9:15 AM, Staff C stated Resident 49 had been incorrectly coded on their MDS as using insulin. They stated Resident 49 received Trulicity and they would make the corrections to the MDS. During an interview on 03/03/2025 at 2:44 PM, Staff D, Regional Director of Clinical Services, stated there was a process in place to ensure accuracy of the MDS for skilled nursing (treatments for complex medical care, not day-to-day needs) only. Reference: WAC 388-97-1000(1)(b)

Based on observation and interview the facility failed to provide a safe, functional, and sanitary (the conditions that affect hygiene and health) environment for residents and staff for 1 of 1 Laundry room (LR 1), reviewed for a comfortable environment. This failure placed residents and staff at risk for not feeling safe/secure with their environment and an increased risk of the cross contamination of diseases. Findings included . During a concurrent observation and interview on 02/27/2025 at 9:55 AM, showed the LR 1's washing machine number five had an area of previous water damage (an accidental leakage or discharge of water that caused possible losses or value of materials) to the linoleum (a common floor covering) floor beneath it and an area that was currently leaking water out from the washing machine. The water had seeped (a slow flow of a liquid through a material's small holes) under the linoleum and had spread through a four foot (ft, a unit of measure) by three ft section under washing machine number five. Staff R, Housekeeping/Laundry Director, stated they knew that washing machine number five had been leaking and was in the process of ordering a new washing machine. When surveyor walked over between washing machines number four and five, the linoleum floor squished down, and a grayish sludge (a thick, soft, wet mixture of liquid) oozed out from in-between the laminate flooring. Observations of puddle of water under washing machine number four noted, which was separated from the other washing machine leak that covered a three ft by three ft section and had also seeped under the flooring. During an interview on 02/27/2025 at 10:10 AM, Staff R stated the leak from washing machine number four/five had seeped underneath the linoleum and the grayish sludge, that had oozed out underneath the linoleum flooring, had the potential to grow bacteria. Staff R stated the floor could not be disinfected because the water had already seeped underneath the flooring. During a concurrent interview and observation on 02/27/2025 at 12:06 PM, Staff Q, Infection Preventionist, stated they were informed that two washing machines in the laundry room, had a water leak, that had seeped underneath the linoleum flooring. Staff Q, with the surveyor, observed the water leak and sludge that was oozing through the linoleum flooring. Staff Q stated, could be growing something, which was not sanitary. Staff Q was joined by Staff S, Maintenance Director, and both staff members stated the floor under the washing machines was not a safe/cleanable surface and needed to be fixed. Reference: WAC 388-97-3220(1)

Based on interview and record review, the facility failed to ensure residents and/or their representative were offered/educated on the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) immunization (the action of taking a vaccine for a particular infectious disease) for 2 of 5 sampled residents (Residents 26 and 42) reviewed for immunization status. This failure placed the residents at risk of making an uninformed decision and contracting the COVID-19 virus. Findings included . Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, COVID-19 Vaccine Immunization Requirements for Residents and Staff, dated 05/20/2021, showed for COVID-19 resident vaccinations the facility was required to: Educate residents or their representatives on the benefits and potential side effects associated with the COVID-19 vaccine in a manner they can understand, Offer residents the COVID-19 vaccine, Document that a resident was educated, their decision to accept or decline the vaccine, contraindications to the resident receiving the vaccine, and administration of the vaccine, if applicable. Review of the facility's policy titled, Resident Immunizations Policy, revised November 2024, showed the facility would offer residents the COVID-19 vaccine and .will have a consent completed, including education . on the risk/benefits of the immunization. <Resident 26> Review of the resident's medical record showed they were admitted to the facility on [DATE], with diagnosis including fracture left leg, dementia (a progressive disease that destroys the memory and other important mental functions), and anxiety. The comprehensive assessment dated [DATE] showed the resident had a severely impaired cognition. Review of Resident 26's immunization notes, dated 02/06/2025 showed the resident themselves refused the COVID-19 vaccination and was educated on the risk/benefits. There was no documentation of a COVID-19 immunization assessment, education or a signed consent/declination form completed for the resident. During a concurrent observation and interview on 02/27/2025 at 8:34 AM, Resident 26 was unable to have a conversation with the surveyor and was confused when asked about their immunization status/education. During an interview on 02/27/2025 at 8:53 AM, Staff O, Registered Nurse for Resident 26, stated the resident was unable to understand or make medical decisions and that all medical decisions had to go through the resident's representative. During an interview on 02/27/2025 at 9:16 AM, Resident 26's Representative stated the facility staff had never offered nor educated them on the risk versus benefits and potential side effects associated with the COVID-19 vaccine. <Resident 42> Review of the resident's medical record showed they were admitted to the facility on [DATE], with diagnosis including heart failure, dementia), and lung complications. The comprehensive assessment dated [DATE] showed the resident had a moderately impaired cognition and was able to make their needs known. Review of Resident 42's immunization notes, showed the resident had received the COVID-19 vaccine in 2023, but refused the COVID-19 vaccination on 01/02/2025 and was educated on the risk/benefits. No documentation of a COVID-19 immunization assessment, education or a signed consent/declination form was completed for the resident. During an interview on 02/27/2025 at 8:44 AM, Resident 42 stated that staff had never offered nor educated them on the risk versus benefits of the COVID-19 vaccine, but they would have wanted the current COVID-19 vaccine. Resident 42 stated their Resident Representative had usually taken care of making the medical decision like accepting or refusing vaccines. During an interview on 02/27/2025 at 9:10 AM, Resident 42's Representative stated that no staff member from the facility had offered or educated them on the risk versus benefits and potential side effects associated with the COVID-19 vaccine. They stated that Resident 42 had received the previous COVID-19 vaccination and would have wanted the current COVID-19 vaccine. During an interview on 02/27/2025 at 9:29 AM, Staff Q, Infection Preventionist, stated when a resident was admitted they offered residents all the required immunizations and obtained consent for them, including the COVID-19 vaccine. Staff Q stated when a resident was unable to make their own medical decisions due to impaired cognition, the Resident Representative (RR) would be offered/educated on the risk versus benefits and potential side effects associated with the COVID-19 vaccine. When conveyed information on Resident 26, Resident 42 and their RR interviews regarding the COVID-19 vaccine, Staff Q stated that the correct process was not followed. During an interview on 02/27/2025 at 3:38 PM, Staff B, Director of Nursing Services, stated that residents with impaired cognition who were unable to make health care decision or have a legal RR that make health care decisions for them, should have been offering/educated on the risk versus benefits and potential side effects associated with the COVID-19 vaccine. Staff B stated Resident 26, Resident 42 and their representatives were not given the chance to make an informed decision, and the correct process was not followed. Reference: WAC 388-97-1320(2)(a)

Based on interview and record review, the facility failed to ensure the medical record related to dental services was accurate for 1 of 2 residents (Resident 18) reviewed for complete medical records. This failure had the potential risk for healthcare providers to rely on inadequate information when making treatment decisions for residents and a potential risk for not receiving quality care. Findings included . Review of the policy titled, Record Review, revised 07/2018, showed the facility shall maintain complete clinical records for each resident. <Resident 18> Review of the medical record showed Resident 18 was admitted to facility with diagnoses including a stroke, vascular dementia with psychotic disturbance (a brain disorder caused by poor blood flow that includes delusions and hallucinations) and agitation, and depression. Record review of a nursing progress note (PN) dated 12/06/2024, showed Resident 18 did not like to wear their dentures because they had a sore spot in their mouth along the upper left gumline. The PN showed the resident had been assessed for pain with no lesion noted but had requested to see their denturist. Record review of the medical record showed Resident 18 had last seen the dentist on 10/03/2024. During an interview on 02/28/2025 at 9:32 AM, Staff G, Patient Care Coordinator/RN, stated they had informed Staff H, Social Services Director, on 12/06/2024 that Resident 18 was having pain and needed a dental appointment. Staff G stated once that information was given to Staff H, if they did not receive any follow up from Staff H, that would mean Staff H had done their piece of either scheduling the appointment or moving it on to the scheduler to schedule the appointment. Staff G stated they did not follow up on scheduling concerns related to dental issues after they had reported them to Staff H. During an interview on 02/28/2025 at 10:21 AM, Staff H stated when they received a request for dental services, especially if the resident was having pain, they completed the appointment request form and forwarded that form to Staff I, Activities Driver, to schedule an urgent appointment. During a concurrent observation and interview on 02/28/2025 at 10:29 AM, Staff I stated they recalled taking Resident 18 to dental appointments for denture adjustments. Staff I removed a file folder from their file cabinet that contained scheduling forms. They reviewed a completed form that showed Resident 18 had been taken to a dental appointment on 12/12/2024. There was no documentation in the resident's medical record that they had attended the 12/12/2024 appointment. During an interview on 02/28/2025 at 12:11 PM, Staff D, Regional Director of Clinical Services, stated they would have expected to find a nursing progress note in the resident's record if they had been seen by the denturist. During an interview on 02/28/2025 at 2:25 PM, Staff B, Director of Nursing Services, stated they had placed a call to Resident 18's son to confirm that they had accompanied Resident 18 to their denturist appointment on 12/12/2024. Staff B stated the process should have been for the nurse to call the provider, receive a verbal report of the visit, and document that information in the resident's medical record. Reference: WAC 388-97-1720(1)(a)(i-iii)(2)(d-f)

Based on interview and record review the facility failed to ensure allegations of potential abuse and/or neglect of a fall with significant injury for 1 of 1 resident (Resident 30), was reported to the State Survey Agency. The failure to report as required resulted in the inability to recognize patterns of potential abuse and/or neglect with incidents of significant injury. Findings included . Review of the Washington State Department of Social and Health Services (DSHS) October 2015 Nursing Home Guidelines: The Purple Book, showed any incident investigated for potential abuse/neglect or mistreatment causing a significant injury must be reported to the DSHS Hotline within 24 hours of the incident. <Resident 30> Review of the medical record showed Resident 30 was admitted to the facility on [DATE] with a diagnosis of a below the knee amputation (BKA) of the right leg. Review of Resident 30's care plan dated 12/27/2024 and revised on 01/15/2025 showed the resident required assistance of two caregivers and a manual mechanical lift for transfers. Review of the 01/31/2025 facility incident report showed Resident 30 had a fall with significant injury on 01/31/2025 when the surgical incision of the recent BKA caused a deep dehiscence (when the surgical incision reopens exposing the underlying tissue and requiring immediate surgical intervention). The incident report further showed the facility investigated the fall as a potential abuse and/or neglect as a nursing assistant helping the resident transfer did so without following Resident 30's care plan for a two person assist with transfers. Review of the October 2024 through March 2025 facility incident and reporting logbook showed Resident 30's fall with significant injury was not reported to the State Agency as required per the Nursing Home Guidelines. During an interview with Staff B, Director of Nursing Services (DNS) on 02/28/2025 at 12:39 PM, they stated the incident was not reported to the State Agency because they thought since the cause of the injury was known, the incident only needed to be logged into the incident and reporting logbook within five days of their investigation. Reference: WAC 388-97-0640(6)(c)

Based on observation, interview, and record review, the facility failed to coordinate a referral for denture services for 1 of 2 residents (Resident 7) reviewed for dental services. This failure placed the residents at risk for altered self-image, difficulty eating, and weight loss. Findings included . <Resident 7> Review of the medical record showed Resident 7 was admitted to the facility with diagnoses including heart failure, gastro-esophageal reflux disease without esophagitis [a disease where the stomach contents flow back into the esophagus (the tube that connects the mouth to the stomach) but do not cause inflammation or damage to the esophageal lining], and Barrett's Esophagus (damage to the lower portion of the esophagus). The 01/25/2025 comprehensive assessment showed Resident 7 required assistance of one to two staff members for activities of daily living. The assessment also showed Resident 7 had a moderately impaired cognition and was able to make their needs known. Record review of Resident 7's care plan dated 02/26/2025, showed Resident 7 had full upper dentures and partial lower dentures. An observation and interview on 02/24/2025 at 3:02 PM, showed Resident 7 resting in bed. They were not wearing dentures. Resident 7 stated they were supposed to get new dentures maybe in March (2025). Record review of a dental visit document titled, Preventative Report, dated 10/03/2024, showed Resident 7 was interested in new dentures and a referral to a denturist was ordered. There was no documentation in the medical record that the referral had been completed. During an interview on 02/27/2025 at 8:51 AM, Staff G, Patient Care Coordinator/RN, stated the process for dental referrals included forwarding those referrals to Staff H, Social Services Director, to schedule the denture care appointments. Staff G stated they did not see the referral form from Resident 7's dental appointment. During an interview on 02/28/2025 at 10:21 AM, Staff H stated their process for scheduling a denturist appointment included completing a scheduling form and giving it to Staff I, Activities Driver, to schedule the appointment and transport the resident to the appointment. During an interview on 02/28/2025 at 10:29 AM, Staff I stated they scheduled outside appointments. They stated they received the referral scheduling form from the nursing staff. Staff I stated they did not recall receiving a referral form for Resident 7. During an interview on 02/28/2025 at 12:05 PM, Staff D, Regional Director of Clinical Services, stated they were aware of the concerns and there was not a good system in place related to the process for completing dental referrals. Reference: WAC 388-97-1060(1)(3)(vii)

Based on interviews and record review the facility failed to complete a performance review at least once every 12 months as required, for 4 of 4 Nursing Assistants (NAs) (Staff B, C, D, E) reviewed for performance reviews. The failure to complete annual performance reviews placed residents at risk for unmet care needs from potentially unqualified staff. Findings included . On 05/22/2024 at 3:00 PM a list of NA personnel records that included the dates of hire and annual performance reviews were requested from Staff A, Administrator. The records showed the following: Staff B - date of hire was 09/28/2016; last performance review was on 09/28/2020 Staff C - date of hire was 04/15/2020; last performance review was on 07/16/2022 Staff D - date of hire was 10/29/2021; last performance review was on 07/19/2022 Staff E - date of hire was 02/27/2023; no performance review completed On 05/22/2024 at 3:00 PM Staff A, stated they were aware there were performance reviews that had not yet been completed on staff. The facility had recently implemented a new system to track performance reviews to ensure they were completed in a timely manner. Reference (WAC) 388-97-1680(2)(b)

Based on observation, interview, and record review, the facility failed to Identify and prevent potentially dangerous accidents and hazards when portable oxygen (02) tanks were unsecured for 2 of 2 residents (Resident 58 and 17) reviewed for O2 use, and implement interventions that addressed the cause of the falls for 1 of 2 residents (Resident 29) reviewed for falls. This placed Resident 29 at risk for future falls, injury and unmet care needs. The failure to secure portable O2 tanks which could explode if dropped placed Resident 58, Resident 17, and residents and anyone else in the facility at risk for serious injury, harm or death. On 01/10/2024 at 1:35 PM, the facility was notified of an Immediate Jeopardy at CFR 483.25 (d)(1)(2) F689, Free of Accident/Hazards/Supervision/Devices, related to the facility's failure to safely secure three portable oxygen tanks while they were being utilized/transported by residents. The facility removed the immediacy on 01/10/2024 with an onsite verification from investigators by implementing a process to properly secure portable oxygen tanks to resident wheelchairs (w/c) and front wheeled walkers (FWW, a four-legged frame that allows a person to lean on it for balance, support, and rest) while in use and/or transported. The immediacy removal included re-education of all staff (prior to working their next scheduled shift) regarding securing portable oxygen tanks policies/procedures and the new measures implemented, which ensured an effective system was in place to safeguard, protect, and prevent residents from accident hazards, risk of injury, and/or harm. Findings included . <Oxygen Tanks> <Resident 58> Review of Resident 58's medical records showed the resident was admitted to the facility on [DATE] with diagnoses to include a lung disease that caused obstructed airflow from the lungs and was dependent on O2 use. The comprehensive assessment, dated 11/24/2023, showed Resident 58 was cognitively intact and required supervision or touch assistance from staff with transfers from their bed to the w/c. During a concurrent observation and interview, on 01/10/2024 at 11:05 AM, showed Resident 58 sitting on the edge of their bed with their FWW in front of them. In the FWW's storage compartment, there were two portable oxygen tanks, unsecured in their bags, one full and one partially full, with greater than half of the tanks sticking up out of the storage compartment. Resident 58 had their oxygen tubing secured to their face and connected to the partially full O2 tank. Resident 58 stated they had two portable O2 tanks for an appointment they had outside of the facility, the day prior (on 01/09/2024), but the appointment had been cancelled and the tanks were never removed. An observation on 01/10/2024 at 11:30 AM, showed Resident 58 ambulating out of their room with their FWW and Staff E, Physical Therapist Assistant, following behind the resident, with the two portable O2 tanks still unsecured in the storage compartment of the walker. <Resident 17> Review of Resident 17's medical records showed the resident was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a disease that blocks air flow and makes it difficult to breathe). Review of Resident 17's January 2024 physician orders showed the resident required oxygen to maintain appropriate oxygen levels in the blood. During an observation on 01/10/2023 at 11:23 AM, Resident 17 was observed ambulating down the hall with their FWW. The resident had oxygen tubing in their nose connected to a portable tank lying in a wire basket attached to the front of their FWW. The tank was lying on its side, to the right side of the basket, with the top sticking out. Further observation showed a loose bungy cord, crisscrossed on the tank. The Surveyor requested permission from the resident and pulled on the portable O2 tank to check the security of the tank and the tank was not secured and easily pulled forward. During an interview on 01/10/2024, at 11:29 AM, Staff F, Resident Care Manager (RCM), stated portable oxygen tanks should be secured within a fitted bag and to the back of a resident's w/c or if using a FWW, they should be placed in an oxygen trolly cart (a small wheeled O2 holder used to transport highly flammable oxygen canisters and cylinders safely from one place to another), and rolled alongside the resident with the help of staff. <Falls> Review of the facility's policy titled Fall Risk Overview, revised February 2020, showed fall risk assessments were to be completed after each fall to identify specific conditions placing the resident at risk for fall. The policy further showed interventions would be developed and implemented according to the fall risk factors identified in the assessment. <Resident 29> Review of Resident 29's medical records showed the resident admitted to the facility on [DATE] with diagnoses to include depression, anxiety (a mental illness that causes constant fear and worry, characterized by a sudden feeling of worry, fear, and restlessness), and a lung disease that caused obstructed airflow from the lungs. The comprehensive assessment on 12/31/2023 showed Resident 29's cognition was intact, had limited range of motion to their lower extremities, required staff assistance with setting up/cleaning up after toileting, and supervision or touching assistance with transfers, and had frequent incontinence of their bladder. A concurrent observation and interview, on 01/09/2024 at 9:26 AM, showed Resident 29 sleeping diagonally, partially on/off their bed, with their upper torso and partial buttocks on the bed, and the remaining buttocks and lower extremities hanging off the bed. Resident 29 had a two-seated couch, towards the center, right side of their shared room, that had personal belongings piled up to the back of the couch (clothes, computer monitor, and other items underneath that could not be seen). To the right of the couch there was a book shelf, filled with books and food items, to the right of the book shelf there was a computer stand with a printer, to the right of the computer stand was a table top with a TV monitor on it and two medium sized boxes stacked underneath it, in front of that table top there was a two-drawer night stand with wound dressings on the top, and a smaller, moveable table stand with computer equipment. The room area also had a small refrigerator with clothes and miscellaneous on top of it and a bedside table. Review of the facility's Incident Log dated 10/02/2023 through 01/10/2024, showed Resident 29 fell on [DATE], 12/03/2023, 12/12/2023, 12/15/2023, and 01/03/2024. Review of the facility's fall incident investigations showed, On 10/15/2023 at 6:36 PM, Resident 29 had an unwitnessed fall while attempting to self-transfer from their bed to their w/c to use the restroom. The investigation showed a fall risk assessment (an evaluation of a resident's risk for having a fall) had not been completed on 10/15/2023 and had not been completed until 10/24/2023 (nine days after the fall, scored 11= high risk, previous assessment 09/27/2023 showed a score of 9= moderate risk). The investigation further showed an intervention to encourage the resident to use their call light and wait for staff to come and assist/supervise them. On 12/03/2023 at 5:21 AM, Resident 29 had an unwitnessed fall while attempting to self-transfer from their bed to their w/c to use the restroom and had increased weakness. The investigation showed on 12/04/2023 a fall risk assessment had been completed on 12/04/2023 (score of 15=high risk) and an intervention for prompted, routine toileting every 2-3 hours for fall prevention. Staff S, Licensed Practical Nurse and Staff T, Nursing Assistant (NA) witness statements showed the resident toilets self when previous interventions showed resident was to have staff assistance/supervision to the toilet. On 12/12/2023 at 9:58 AM, Resident 29 had an unwitnessed fall while attempting to self-transfer from their bed to their w/c. Fall risk assessment had not been completed on 12/12/2023 and had not been completed until 12/28/2023 (14 days after fall, scored14=high risk) and there was no evaluation to determine whether new interventions were needed. The investigation showed the resident had predisposing factors of clutter and furniture and shortly after the fall complained of pain to their hip and back (did not identify the pain location). Staff W, NA, documented on their witness statement Resident 29 was independent for transfers. On 12/15/2023 at 2:17 PM, Resident 29 had an unwitnessed fall after self-transferring to their bed and slid to the floor. The investigation showed the resident's floor was cluttered with the computer near the bed and Resident 29 had increased confusion, there was no evaluation to determine whether new interventions were needed. On 01/03/2024 at 6:00 PM, Resident 29 had an unwitnessed fall and was found on the floor by the head of their bed. Resident 29 stated when they reached for their phone, the phone line, bed control, and call light cords were tangled up in the bed frame, causing Resident 29 to fall and break their bedside table in half. Predisposing factors were furniture, clutter, and crowding. No fall risk assessment had been completed, there was no evaluation to determine whether new interventions were needed. Review of Resident 29's care plan, dated 12/31/2023, showed an intervention initiated on 12/05/2023 for a routine toileting plan to reduce risk of falls, check and change per facility protocol (not a prompted toileting program every two to three hours) and an intervention initiated on 03/22/2022 to provide a safe resident environment (clutter free) with a revision on 12/13/2023 for bed in lowest position but did not specify what would be done to address the clutter being identified, and for toileting assistance on 10/12/2023, the resident required supervision assistance by one staff using a gait belt (a safety device used to help someone move or walk) and a FWW, to move between surfaces using a stand and pivot. During an interview, on 01/12/2024 at 11:01 AM, Staff Y, NA, stated Resident 29's room was cluttered and felt like the clutter was a factor to the resident's falls. Staff Y stated they would inform the Social Services department to assist with the clutter in the room but did not know if that had been done by anyone. During an interview, on 01/12/2024 at 11:25 AM, Staff D, Social Services Director, stated they had not been notified of Resident 29's room needing to be de-cluttered. Staff D further stated that would be a maintenance issue. Additional observations on 01/10/2024 at 9:46 AM, 01/12/2024 at 11:09 AM, and 01/16/2024 at 1:52 PM, showed the resident's two-seated couch, and furniture were in the same position as observed on 01/09/2024 at 9:26 AM and the bed control, call light, and phone cords on the floor, unraveled, next to the bed. During an observation on 01/16/2024 at 1:16 PM, Staff W, assisted the resident up off the bed, assisted them with pulling their pants up, which were down to above the knees, and then to their w/c. During an interview, on 01/17/2024 at 10:52 AM, Staff EE, RCM, stated fall risk assessments should be completed within 24 hours of the fall and the nurse who initiated the incident report should have completed the assessment. Staff EE further stated if the nurse did not complete a fall risk assessment it should have been done by the RCM the next day. During an interview, on 01/17/2024 at 11:44 AM, Staff B, Director of Nursing Services, stated fall risk assessments were to be completed by the RCM's within 24 hours of the fall. Staff B further stated they were aware they were not being completed. Staff B further stated they were informed Resident 29's room had been cleaned up and decluttered but had not seen it for themselves. Further, Staff B stated they would have expected staff followed through with the new interventions put into place and would need to provide additional education. Reference: WAC 388-97-1060 (3)(g) 39652

Based on interview and record review, the facility failed to provide dietary services that met individualized dietary needs for 1 of 1 resident (Resident 64), reviewed for specialized diets. Resident 64 was on a physician ordered, gluten-free diet (no wheat, barley, or rye) related to a diagnosis of celiac disease (a disease that causes inflammation of the intestines if gluten is ingested). Resident 64 was served gluten in the form of a Salisbury steak on 12/24/2023. This failure caused harm to Resident 64 who experienced dizziness, nausea, and shortness of breath after consuming the gluten. Resident 64's change in condition resulted in physician notification and enhanced monitoring of their condition to ensure their safety. Findings included . Review of Disease Management and Monitoring dated 2024 through Beyond Celiac. org (a professional organization that provides education and guidance for people who suffer from celiac disease), showed the following: .currently the only treatment for celiac disease is a strict lifelong gluten free diet. Eating gluten even in small amounts can cause damage to the intestines . <Resident 64> Review of Resident 64's medical record showed they admitted to the facility on [DATE] with diagnoses including left ankle fracture and celiac disease. Review of the most current comprehensive assessment, dated 12/23/2023, showed the resident was cognitively intact and required minimal assistance for transfers and mobility. Review of Resident 64's physician orders, dated 12/19/2023, showed the resident was ordered a gluten free diet related to their allergies and celiac disease. During an interview, on 01/09/2024 at 10:14 AM, Resident 64 stated they had been served a Salisbury steak for a meal and had a severe reaction as the steak had a wheat binder (a substance that is added to food to bind together ingredients that would otherwise not stick together) in it. Resident 64 stated after eating the Salisbury steak they experienced dizziness, nausea, and shortness of breath. Review of the progress notes from 12/23/2023 thru 1/16/2024 showed there were no nursing assessments or monitoring completed related to Resident 64's statement of shortness of breath after eating a meal with gluten in it. The neurological flow sheet dated 12/24/2023 was reviewed and was incomplete. Record review of a facility incident report, dated 12/24/2023, showed Resident 64 was served a Salisbury steak from the kitchen during the supper meal on 12/24/2023. The kitchen staff were unaware that there was a wheat binder in the product and had not checked the label for listed ingredients, which showed wheat and barley as ingredients in the steak. The report further showed the physician was notified and ordered every 15-minute checks and neurological assessments (an assessment to monitor nervous system functioning) to ensure safety. During an interview, on 01/11/2024 at 11:10 AM, Staff CC, Dietary Manager, stated they were aware of the incident in which Resident 64 had been served Salisbury steak with a wheat binder in it. Staff CC stated the dietary staff had assumed the Salisbury steak did not have gluten in it and had not checked the label for listed ingredients prior to serving it to Resident 64. During an additional interview, on 01/12/2024 at 11:13 AM, Resident 64 stated they had been served other food items after the Salisbury steak incident on 12/24/2023 that contained gluten in them. Most recently they had been served a canned chili con carne with beans. Resident 64 stated they requested to see the label which showed wheat as an ingredient in the chili, therefore they refused to eat it. Before I eat the food here, I ask to see the label so I can check for myself if there is any gluten in it. I have been served gluten more than a few times and am very afraid of eating it again. Record review of the nutrition label for Salisbury steak showed in the list of ingredients, two types of flour used: wheat and barley flour. Record review of the nutrition label for chili con carne showed it also contained gluten in the form of wheat flour. During a follow up interview, on 01/14/2024 at 1:40 PM, Staff CC stated they were not aware that Resident 64 had been served chili with gluten in it. Staff CC reviewed menus and verified that the chili containing gluten had been served as a meal on 01/04/2024. During an interview, on 01/18/2024 at 12:10 PM, Staff B, Director of Nursing Services, stated they were aware of Resident 64 having an allergic reaction after eating Salisbury steak with gluten in it. Staff B stated the incident had resulted in physician notification and enhanced monitoring for further safety concerns. Staff B stated their expectation would be that residents received appropriate diets as ordered. Reference WAC 388-97-1100(1)

Based on observation, interview, and record review, the facility failed to ensure visitation rights were protected when they did not allow or advocate for the resident's choice in their decision making when the Resident's Representative (RR) denied them access for eight days, to their significant other (SO) and their SO's family member, for 1 of 3 residents (Resident 32), reviewed for choices. Resident 32 experienced psychological harm when they became angry, had a decreased appetite, and refused care when they were denied visitation with their SO. Findings included . <Resident 32> Review of Resident 32's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include recovery from COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) with required therapy and muscle weakness. The comprehensive assessment, dated 12/16/2023, showed Resident 32 had moderately impaired cognition, required partial to moderate staff assistance with transfers, toileting, and showering, had no issues with behaviors or refusals of care, and showed no depression. A concurrent observation and interview on 01/08/2024 at 10:12 AM, showed Resident 32 was sitting in a chair in the sitting area at the back exit of the 900 unit, alone. The resident had a frown on their face and was gazing out the window. The resident stated, I think I am doing okay but I have no energy. Resident 32 further stated they were sitting there waiting for the love of my life to come and visit. Resident 32 continued to talk about not being married but had lived with their SO for the past four and a half years. Resident 32's plans were to discharge home with their SO, as they were prior to admission to the facility, after they regained their strength. During an interview on 01/08/2024 at 3:39 PM, Staff K, Licensed Practical Nurse, stated Resident 32 had been down because the RR stopped visitations from the SO and the SO's family member. Staff K further stated the RR told Staff A, Administrator, that when the SO visited it would upset Resident 32, which Staff K stated they had not observed Resident 32 upset with the SO visitied. Staff K further stated the SO would come to the facility to visit Resident 32 nearly daily, but they had never seen the RR visit the resident since the resident admitted . Staff K stated they were informed by the Administrator on 01/04/2024 to no longer allow the visits from the SO and their family member. A concurrent observation and interview on 01/09/2024 at 9:16 AM, showed Resident 32 was lying in bed with the blankets pulled up to their neck. Resident 32 had their breakfast sitting on the bedside table, untouched. Resident 32 stated they were not hungry and felt sad and confused about what their RR was doing to Resident 32 and their SO. Resident 32 further stated they needed to go home and be with their SO but their RR was trying to keep Resident 32 from doing that. Review of a progress note, dated 01/04/2024 at 3:54 PM, showed Staff A documented the RR contacted them and stated that Resident 32's SO and the SO's family member got Resident 32 flustered (agitated or confused) when they visited. The RR made accusations that Resident 32's SO and the SO's family member ordered the staff around and would convince the resident they were cold and in pain so the resident wanted to go home with them. The RR further stated they felt Resident 32's SO was a pill popper and would keep the resident drugged up and in bed. Staff A documented the RR was the Power of Attorney (POA, a legal document that gives one person the power to act for another person in property, financial, or medical matters) and Resident 32 had a diagnosis of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) so the RR wanted to block any further visits with the SO and the SO's family member. The note further showed [RR] feels that [Resident 32] will be much calmer and happier w/o [without] visits from [SO] and their [family member]. A concurrent observation and interview on 01/10/2024 at 10:32 AM, showed Resident 32 was sitting at the edge of their bed with their front wheeled walker in front of them. Resident 32 was talking with Staff K and refusing their shower. Staff K was encouraging Resident 32 to take a shower and be shaved, and Resident 32 continued to refuse. Staff K stated Resident 32 had been sad because they were not able to visit their SO and had only been allowed to talk to them on the phone. During an interview on 01/10/2024 at 3:01 PM, Staff D, Social Services Director, stated the RR was not following the wishes and the best interests of Resident 32 when they made the decision to stop visits from the SO. Staff D further stated [Resident 32] is able to express their wishes and I didn't agree with their decision. In a concurrent observation and interview on 01/10/2024 at 3:17 PM, Resident 32 stated they had made a huge mistake and screwed up big time by trusting their RR. Resident 32's lunch tray was sitting on the bedside table with 25% of the meal eaten and Resident 32 stated they could not eat because I am too upset to eat. Resident 32 stated they felt like their RR had become jealous of the relationship they had with their SO and did not like it because it might have jeopardized their inheritance or my assets. Resident 32 became shaky, teary eyed, and stated they were terribly angry and wanted to go home with the love of their life and now that was not going to happen. Review of nursing notes showed as follows: 1) on 01/11/2024 at 7:25 AM, showed Resident 32 had expressed their feelings to a NA and stated they were not happy about not seeing their SO and that Resident 32 was depressed. The note further showed, Resident 32 had poor appetite, barely ate dinner. 2) On 01/07/2024 at 3:06 PM, Resident 32 told staff they had once been close to their RR but now the RR had become jealous of the SO and was keeping them apart, and was only after [Resident 32's] money. 3) On 01/05/2024 at 12:20 PM, denying visition was causing Resident 32 emotional harm. Review of the NA tasks record for showers, showed showers were consistently received from 12/13/2023 through 01/03/2024, and from 01/04/2024 (the day visitations were stopped) through 01/13/2024, no shower had been received. A concurrent observation and interview on 01/11/2024 at 11:02 AM, showed Resident 32 was in bed sleeping. Resident 32 did not arouse with a knock at the door or when calling out their name. At the same time, Staff Q, Nursing Assistant (NA), entered the room and stated the resident never accepted a shower on 01/10/2024 so they offered to shower Resident 32 today. Resident 32 replied with later. Staff Q, with Staff U, NA, stated Resident 32 used to come out of their room and visit with other residents all the time and was pleasant, but since visits with their SO stopped, they did not see Resident 32 doing that anymore. An observation on 01/11/2024 at 1:12 PM, showed Resident 32 sitting up at their bedside, lunch still sitting in front of them untouched. Resident 32's hair was disheveled, and face was ungroomed. During an interview on 01/12/2024 at 10:32 AM, Staff A stated Resident 32's RR called and stated when the SO visited, it caused the resident to get ramped up and caused the resident to never get better, so the RR put a stop to their visits. Staff A further stated they did not feel the RR had acted in the best interest of the resident. Staff A stated they did not think the RR had discussed the decision to stop the SO from visiting with Resident 32 and the resident expressed they were not happy about the decision. Staff A further stated they did not know if the RR was right or wrong and the facility should have possibly sought legal counsel or did some further research on the subject matter and had concern the RR would sue us. Staff A further stated the resident had not been deemed incapacitated by a court. During an interview on 01/12/2024 at 10:59 AM, the Surveyor was approached by Staff A and stated they had communicated to Resident 32 that they had called their SO and informed them they could come and visit Resident 32. Staff A stated I am calling the [RR] and setting up a care conference so we can all discuss [Resident 32's] wishes. Reference: WAC 388-97-0520 (1)(h), (2)

Based on observation, interview, and record review the facility failed to identify hazards and risks to ensure the resident's environment remained free of accident hazards and the resident received adequate supervision of one person staff assistance for wheelchair (w/c) mobility off the unit for one of three residents (1) reviewed for falls. These failures caused harm to the resident when they fell and sustained an injury to their right eye. Findings included . Resident 1. Review of the resident's medical record showed the resident readmitted to the facility on [DATE] with diagnosis of [CONDITION(S)] ([CONDITION(S)], a disease characterized by persistent respiratory symptoms like progressive breathlessness and cough) and required a blood thinner medication. Further review of the resident's 06/10/2022 comprehensive assessment showed the resident was cognitively intact and required one person staff assistance and supervision with wheelchair (w/c) mobility when using the w/c off the unit. The 06/10/2022 care plan showed the resident was at risk for falls related to deconditioning (cause to lose fitness or muscle tone, especially through lack of exercise) and falling asleep in their w/c due to late night activities which included interventions to monitor the resident for sleepiness and to closely monitor the resident while up late in their w/c (last revised date of interventions showed 03/16/2022). During a concurrent observation and interview on 08/24/2022 at 2:30 PM, Resident 1 was smoking in the corner of the facility's back parking lot. The resident stated they smoked in that area because they had been told by one of the nurses (unknown) that they needed to stay up here. The resident also stated they smoked by the sewer grate and threw their cigarette butts down the sewer because they didn't have anywhere else to dispose of them. Resident 1 further stated they had a previous fall (07/28/2022) while outside smoking when they were outside smoking late at night, they dropped an item on the ground, and when they bent over to retrieve the item, they fell out of the w/c onto their face on the pavement. Another resident outside smoking with Resident 1 at the same time had to alert staff to the fall in order to get the resident help. The resident additionally stated they had to go to the hospital to be evaluated because they had pain to their hip and bruising to their face. Review of the facility's 07/05/2022 through 08/23/2022 Incident Log, showed on 07/28/2022 at 12:45 AM the resident had a fall with substantial injury. Review of the facility's 07/28/2022 investigation of Resident 1's fall, showed Staff F, Registered Nurse (RN), found Resident 1 outside of the facility by the kitchen entry/exit area, lying on their right side on the asphalt next to a sewer grate. The resident complained of pain to their right hip and had hit their head on the asphalt, just above their right eye. Staff F assessed the resident to have bruising, swelling, and a small cut with scant bleeding above the resident's right eye. Staff F's assessment further showed the ground was at a slight decline due to being next to a sewer grate. Staff F documented they had previously observed Resident 1 smoking cigarettes in the same spot and would dispose of the used cigarettes down the sewer grate. Additionally, the investigation showed the resident had slipped out of their wheelchair and onto the pavement. The resident had been transported to the hospital for evaluation. During an interview on 08/24/2022 at 1:36 P.M., Staff A, Interim Administrator (IA), stated the facility was a non-smoking facility and the residents who chose to smoke would go off the facility grounds to smoke. Staff A was not aware there were residents who smoked on the facility property. During an interview on 08/25/2022 at 11:04 A.M., Staff C, Social Services (SS), stated the residents who chose to smoke would sign in and out when leaving the facility to smoke. The residents were not required to inform staff when they left or returned from smoking. Staff C stated Resident 1 had been assessed to safely smoke independently. Review of the facility's Smoking Safety Evaluation, dated 07/15/2022, showed no assessment of w/c use on or off the unit or on un-even surfaces. The assessment further showed the resident had been assessed to smoke outside and [Resident 1] is able to safely smoke cigarettes. During an interview on 08/25/2022 at 11:31 A.M., Staff H, Resident Care Manager (RCM), stated they were on vacation when the 07/28/2022 fall had occurred and had not had time to review Resident 1's fall for additional interventions and that the resident had been assessed to safely smoke independently. When asked if w/c mobility was a part of that assessment, Staff H stated they were not aware of the resident being assessed for safe mobility use of their w/c outside or on uneven surfaces. Staff H further stated they were not aware of any supervision being provided for the resident while using their w/c off the unit or during w/c use late at night. During an interview and observation on 08/25/2022 at 12:30 P.M., Staff E, Maintenance Director (Maint), showed the Surveyor the area where the residents exited and entered the facility for smoking. Staff E stated the area was utilized for delivery and emergent medical services and was not a designated entrance or exit for the residents. Staff E further stated there was a code to exit the building that the residents used, and showed a green button that was within reach, that the residents could push for re-entry. An observation of the blacktop showed a 1 1/2 inch () lip from the concrete entrance to the blacktop. The length of surface that had a lip was 2 1/2 feet in length. Staff E stated the lip could cause an accident and stated he would begin repairs to ensure a smooth transition from blacktop to concrete. The surrounding area had several cigarette butts (approximately 7 -10) and Staff E stated that when the residents went out that door, they were not observable from the interior of the building and threw the butts into the sewer grate (showed a metal grate near the curb) and on the concrete. Staff E stated it was difficult to ensure compliance with smoking off campus, especially after daylight. During an interview on 8/25/2022 at 1:00 P.M., Staff B, Director of Nursing (DNS), with Staff D, Regional Nurse Consultant (RNC) present, stated the residents were to smoke off the property and sign themselves in and out when they left the building. Staff B stated Resident 1 had been assessed to safely smoke independently outside and they thought the resident had been previously assessed by therapy for w/c mobility off the unit and on uneven surfaces. Staff B stated the resident had not been provided staff supervision assistance with their w/c mobility or during late night use of their w/c. Staff B additionally stated they had not provided or assessed for additional interventions for Resident 1 after their fall on 07/28/2022 other than education for smoking. During a follow-up interview at 1:12 PM, Staff B confirmed that therapy had not assessed Resident 1 for w/c mobility off the unit or on un-even surfaces as they previously thought. WAC Reference: 388-97-1060 (3)(g)

Based on observation, interview and record review the facility failed to ensure infection control interventions intended to mitigate the risk for transmission of COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) and other contagious bacteria, were consistently implemented, resulting in the decline and subsequent hospitalization for symptomatic, positive COVID-19 infection for four residents (1, 4, 5 ,6). The COVID-19 outbreak resulted in a total of 49 positive residents and 30 positive staff in a 28 day period. The identified system failure in infection control included in the areas of: A) Screening - failed to complete the COVID-19 screening process for 14 of 40 sampled staff (C, D, F, G, H, I, J, K, L, M, O, P, Q, R), that was comprised of administrative, nursing, therapy, and housekeeping staff, to determine if they were eligible to work; failed to exclude four staff (C, E, L, N) from working with a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2 (COVID-19), symptoms of COVID-19, or those that had a higher-risk exposure (exposure of eyes, nose, or mouth to material potentially containing [CONDITION(S)]-CoV-2) to individuals with confirmed [CONDITION(S)]-CoV-2 (COVID-19) infection; B) Personal Protective Equipment (PPE) - failed to use appropriate PPE per Centers for Disease Control and Prevention (CDC) guidelines for face shields/eye protection; failed to ensure current N95 (respirator/mask) fit testing for five of five sampled staff (B, C, E, N, AA) and a total of 95/137 staff; failed to don appropriate PPE required for Aerosol Generating Procedures (AGP) rooms for three of three sampled staff (DD, EE, FF); C) Disinfection - failed to use the appropriate product for cleaning/disinfection following the manufacturer's instructions for disinfection contact time (the length of time required for a disinfectant to stay wet on a surface to be effective). On 06/02/2022 at 7:35 PM the facility was notified of an Immediate Jeopardy at Code of Federal Regulations (CFR) 483.80(a)(1) for F880-Infection Prevention and Control, related to the facility's failure to ensure and properly prevent and/or contain COVID-19 from further spread in the facility. This failure led to the decline and subsequent hospitalization for symptomatic positive COVID-19 infection for four residents (1, 4, 5, 6). The facility removed the immediacy on 06/07/2022, as confirmed by an onsite verification by investigators. The immediacy was removed by implementing a removal plan that included limiting the entrance to the facility to two entrances, eliminating the use of the electronic kiosk for screening upon entrance to the facility, resuming the process of a paper form for screening, education/training for all staff on the new screening process, and education/training for all Licensed Nurses on the need to evaluate screening forms and testing for COVID-19. Education/training was provided to all staff for required PPE when entering an AGP resident room. All staff, including the Medical Director, were provided education/training on the use of face shields/eye protection in the facility when community COVID-19 transmission levels were substantial or high. Additionally, the facility performed N95 mask fit testing for staff that did not have an initial and/or current mask fit test. Findings included . During an interview on 06/01/2022 at 4:10 PM, Staff C, Infection Preventionist (IP), stated that Resident 6 was sent out today; there are three total residents in the hospital now. Review of the facility records showed Resident 1 was admitted to the hospital on 05/13/2022 and returned to the facility on [DATE]. Resident 1. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 04/29/2022 comprehensive assessment showed the resident required extensive of one or more staff for all activities of daily living (ADL's). The assessment also showed the resident had an intact cognition. Further review of the medical record progress notes on 05/14/2022 at 1:20 AM, showed on 05/13/2022, the resident had a temperature of 104 degrees Fahrenheit, a wet, non-productive cough, and respiratory rate of 24 breaths per minute. The resident tested positive for COVID-19 and was transferred to the local emergency room at 10:22 PM, where he was subsequently admitted for treatment. Resident 4. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 04/05/2022 comprehensive assessment showed the resident required extensive assistance of one staff for all ADL's. The comprehensive assessment also showed the resident had an intact cognition. Further review of the medical record showed that on 05/17/2022, the resident had a fever and cold like symptoms. The resident was tested for COVID-19 with positive results. On 05/24/2022 at 7:00 PM, the resident was found curled into a ball on the floor of their room. The resident was unable to speak clearly and was transferred to the local emergency room for evaluation. Review of hospital records dated 05/31/2022 showed acute worsening of respiratory distress and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 5. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 03/11/2022 comprehensive assessment showed the resident required extensive assist of two staff for all ADL's; extensive assistance of one staff for eating. The comprehensive assessment also showed the resident had a severely impaired cognition. Further review of the medical record showed the resident tested positive for COVID-19 on 05/23/2022. Progress notes dated 05/24/2022 by Staff B, Director of Nursing (DON) showed the resident had an oxygen saturation reading of 84% (individuals with lung disease can have normal oxygen levels around 90%) on 5 liters of oxygen. The resident was transferred to the local hospital for evaluation and returned later that evening with instructions to monitor the resident for respiratory changes and fever. Review of the hospital medical record from 06/03/2022 showed the resident presented from the facility on 05/25/2022, with [CONDITION(S)] (not enough oxygen in the tissues to sustain bodily functions) and acute metabolic syndrome (a problem in the brain caused by a chemical imbalance in the blood that makes it harder to think clearly and remember things). Further review showed they were diagnosed with acute hypoxic respiratory failure due to COVID-19 pneumonia and acute metabolic [CONDITION(S)] due to COVID-19 infection. Resident 6. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 05/15/2022 comprehensive assessment showed the resident required extensive assistance of two staff for all ADL's; extensive assistance of one staff for eating. The comprehensive assessment also showed the resident was cognitively intact. Further review of the medical record showed the resident tested positive for COVID-19 on 05/26/2022, during outbreak testing. On 05/26/2022, the resident was confused and sleepy and had a temperature of 99.1 degrees Fahrenheit. The resident was transferred to the local hospital on 06/01/2022 for worsening symptoms. The hospital medical records, dated 06/02/2022, showed the resident was diagnosed with acute hypoxic respiratory failure (lack of oxygen in the blood), COVID-19 pneumonia, and acute metabolic [CONDITION(S)] (brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body). In addition, the resident was diagnosed with an acute right-sided pulmonary [CONDITION(S)] (a blood clot in the lung). The hospital record showed that it was a possibility that breakthrough pulmonary embolism occurred because the patient had COVID-19. A) Screening. Review of the 02/02/2022 CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, showed recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic included an established process to identify anyone entering the facility, regardless of their vaccination status, who had any of the following three criteria so that they were properly managed: a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2 (COVID-19), symptoms of COVID-19 or close contact with someone with [CONDITION(S)]-CoV-2 (COVID-19) infection (for patients and visitors) or a higher-risk exposure for healthcare personnel (HCP). Review of the 01/21/2022 CDC's Interim Guidance for Managing Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection or Exposure to [CONDITION(S)]-CoV-2, showed up to date (those who have received all vaccine doses in the primary series and all recommended boosters) and not up to date HCP with [CONDITION(S)]-CoV-2 infection should be restricted from work for 10 days, or seven days with a negative test, if asymptomatic or mild to moderate illness with improving symptoms. Work restrictions for HCP with [CONDITION(S)]-CoV-2 exposure for HCP that are asymptomatic and up to date with vaccinations have no work restrictions if they have a negative test result on day one and again on day five - seven after exposure. HCP that are not up to date with vaccinations should be excluded from work for 10 days or seven days with a negative test and if they do not develop symptoms. Asymptomatic HCP should continue to monitor for symptoms, those that develop symptoms should immediately self-isolate and contact their established point of contact to arrange for medical evaluation and testing. During an observation on 06/01/2022 at 4:53 PM, showed the staff entrance to the COVID-19 unit on the 300 hall had a plastic zippered wall separating the entrance from the COVID-19 unit. The entrance area contained PPE (N95 masks, gowns, gloves, and eye protection), a table with hand sanitizer and blank paper screening forms. There was no information guiding staff on the procedure for completing the screening form or who they contact if they were symptomatic or had an exposure to COVID-19. During an interview on 06/01/2022 at 4:10 PM Staff C, IP, stated that staff screening in the COVID-19 unit were writing on paper screening forms but they (Staff C) needed to put them out. During an interview the next day, 06/02/2022 at 9:26 AM, Staff C stated that the electronic (kiosk) screening sent a message if someone screened out (answered yes having symptoms/exposure to COVID-19), then they do a paper form, and a nurse would review the form to determine if the employee was eligible to work. In addition, Staff C stated, there is no screening process for the COVID-19 unit. Later that same day at 12:05 PM, Staff C stated if staff screened with symptoms, the system (electronic kiosk) throws them out. I would expect a paper form and nursing would need to review the form before clearing staff for work. Staff C stated that the screening process for both the COVID-19 unit (300 hall) and the long hall (extended COVID-19 unit) was at the entrance to the COVID-19 unit, by the 300 hall. When asked how staff scheduled to work in the COVID-19 unit were screened prior to Staff C putting out the screening forms the day before, Staff C stated, staff would not have screened, the screening process was a failure. During a telephone interview on 06/03/2022 at 12:11 PM, Staff G, Nursing Assistant (NA), stated I have to screen with the machine, if I have symptoms, I need to fill out physical papers. When asked if they screened on their shifts 05/11/2022, 05/12/2022, 05/13/2022, 05/14/2022, and 05/15/2022, Staff replied, I did not. During a telephone interview on 06/03/2022 at 2:41 PM, Staff D, NA, stated in the COVID-19 unit, the 300 unit, there was no kiosk or any COVID-19 screening form to fill out. During an interview on 06/06/2022 at 9:09 AM, Staff C stated they receive visitor comments by email from the electronic kiosk about visitors leaving the building, nothing regarding staff alerts, no notifications for staff that do not screen in or staff that don't pass the kiosk screening. When asked how symptomatic staff are screened, Staff C stated that symptomatic staff would have to enter the building to get the nurse to screen and test. In addition, Staff C stated, the only way to solve this would be to have someone sit there (at the screening area) from 6:00 AM to 10:00 PM, staff with signs and symptoms of COVID-19 should not come to work. During an interview on 06/02/2022 at 4:08 PM, Staff C stated that prior to testing positive, they were tired and had a cold. Additionally, on 06/06/2022 at 9:09 AM, Staff C stated that during the time they tested positive, a lot of people had coughs, including me. Staff C further stated that they worked in the COVID-19 unit, despite having symptoms and a positive test on 05/20/2022. Staff C did not have current N95 fit test. During an interview on 06/02/2022 at 8:34 PM, Staff E, Registered Nurse (RN), stated that they had contacted Staff C on the morning of 05/10/2022 to report symptoms and an exposure to COVID-19 two days prior to testing positive for COVID-19 (05/10/2022). Staff E stated that they were told to come to the facility at 3:00 PM that day for a COVID-19 test since they were scheduled to work that evening at 7:00 PM. Staff E stated that they reported to the facility at 3:00 PM for testing and had negative results. Staff E stated they were told to report to work that evening, despite being unvaccinated, symptomatic, and having a recent exposure. Staff E stated that they were instructed by Staff C to perform test for COVID-19 prior to the start of each shift due to their exposure and symptoms. Upon arrival to the facility at 6:41 PM, Staff E repeated the COVID-19 test in the medication room and had positive results, indicative of active COVID-19 infection. Staff E stated that they reported the positive results to both Staff B, DON, and Staff C. Staff C came into the facility and performed a third COVID-19 test, which was positive. Staff E stated that they were told to go home, and Staff B and Staff C would take over their duties. Review of the staff electronic screening log for Staff E verified that they screened into the facility at 6:41 PM and left at 8:41 PM and had denied any exposure and/or symptoms consistent with COVID-19. Staff E was unvaccinated with an approved exemption and was not fit tested for their N95 mask. During an interview on 06/06/2022 at 9:09 AM, Staff C stated they received a text message the morning of 05/10/2022 from Staff E, that showed Staff E had a sore throat and cough. Staff C stated they had advised Staff E to come to the facility at 2:00 PM for COVID-19 testing. Staff E arrived at 2:00 PM and was tested at the back door of the facility and had negative results. Staff C stated that later that day Staff E arrived at work and retested for COVID-19 with positive results. Staff C stated that they arrived at the facility at 7:00 PM and performed an additional COVID-19 test, which showed positive results. Staff C stated Staff B arrived shortly after that and instructed Staff E to home. Staff C stated that Staff E had no contact with residents and had been in the staff breakroom since their arrival to the facility. Despite staff C stating that Staff E had no contact with residents, record review of the facility's Medication Administration Report on 06/06/2022 at 11:12 AM showed Staff E had administered evening medications to two residents (1, 2) on 05/10/2022, prior to leaving the facility. Resident 1 tested positive for COVID-19 on 05/13/2022 and admitted to the local hospital with symptoms of 104 degree temperature, oxygen saturation of 91%, coarse lung sounds, and a wet, productive cough. Resident 2 tested positive for COVID-19 on 05/15/2022. During an interview on 06/07/2022 at 9:30 AM, Staff D, NA, stated that on 05/13/2022, Staff N, Licensed Practical Nurse (LPN), was coughing bad, it sounded like they had a cold. Staff D stated that they asked Staff N why are you working when you are sick? You don't sound good. Staff D stated that Staff N told them they were fine, had been checked, and did not have COVID-19. During a telephone interview on 06/07/2022 at 12:26 PM, Staff N stated they were tested for COVID-19 on 05/14/2022 due to exposure to Resident 1 on 05/14/2022 and had negative results. They tested again on 05/18/2022 and had positive results. Staff N stated they had a few days off and returned to work on 05/18/2022 with a change in their cold symptoms, their chest felt tighter. Staff N stated that they asked Staff CC, RN, when they should be tested (due to the exposure to Resident 1). Staff N stated that they were tested on [DATE] and immediately reported to work on the 900 unit while results of the test were pending. Despite having a positive COVID-19 test result and being symptomatic, Staff CC instructed Staff N to start working in the COVID-19 unit rather than being sent home. Staff N stated that they wore an N95 while in the facility, however they were not fit tested . Review of the staff electronic screening kiosk log showed Staff N did not screen on 05/14/2022, had a negative screening (no symptoms or exposure) on 05/15/2022, and 05/18/2022 despite having signs and symptoms. During an interview on 06/07/2022 at 10:30 AM, Staff L, RN, stated that on 05/23/2022 they were working on the 900 unit. Towards the end of their shift, they became symptomatic with a runny nose, body aches, and fatigue. Staff N was tested for COVID-19 had positive results. Staff N stated they took a few days off until they felt better. Upon returning to work, they were assigned to the COVID-19 unit, despite being unvaccinated and not having a fit test for their N95. Record review of the staff electronic screening kiosk log for 05/11/2022, 05/12/2022, 05/13/2022, 05/14/2022, 05/15/2022, 05/18/2022, 05/19/2022, 05/21/2022, 05/22/2022, and 05/23/2022 showed 14 of 40 staff (C, D, F, G, H, I, J, K, L, M, O, P, Q, R) reviewed for screening, did not perform the electronic screening, and/or did not complete a paper screening form. B) Personal Protective Equipment (PPE). Review of the 04/22/2022 Washington State Department of Health (DOH) Interim Recommendations for [CONDITION(S)]-CoV-2 Infection Prevention and Control in Healthcare Settings 2022 showed that when caring for patients in transmission based precautions (TBP) for confirmed or suspected COVID-19, HCP must wear appropriate PPE including an National Institute of Occupational Health and Safety (NIOSH) approved respirator (N95), gloves, gown, eye protection (goggles or a face shield that covered the front and sides of the face) and up to three hours after an AGP. Further review showed the NIOSH approved respirator must be a fit tested (process used to verify that a respirator/N95 mask had a seal against the face and provided protection from infectious airborne particles) N95 mask and was required for HCP that had close contact with patients presumed or confirmed COVID-19 positive, in observation/quarantine, and up to three hours after completion of an AGP. Further review showed physical distancing (at least six feet away from others) is recommended for everyone in a healthcare setting .particularly for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission. Review of the 02/16/2022 DOH guidance Recommendations for Cohorting in Long-Term Care Facilities During a COVID-19 Outbreak showed if active outbreak in the facility, all HCP should wear fit-tested , NIOSH-approved N95. During an observation of staff COVID-19 testing on 06/01/2022 at 10:44 AM Staff T, Hospitality Aide (HA), and Staff U, Maintenance Assistant (MA), were sitting face to face at a small, round table, with their knees less than one foot apart, despite guidance to be at least six feet away from each other (current county transmission level was high). Both Staff T and Staff U placed their eye protection on top of their head, pulled down their N95 masks, and swabbed their nares, while still facing each other. Both Staff T and Staff U remained seated at the table, less than one foot between them, for the 15-minute test result time, facing each other without eye protection. Staff T's N95 was lowered to chin level, leaving their nose and mouth exposed. Staff T gathered all testing waste without wearing gloves, N95 lowered, eye protection on top of their head, and placed the waste into the trash can. During a concurrent observation and interview on 06/01/2022 at 2:46 PM, Staff W, NA, and Staff Y, NA, were seated at the sub-acute hall nurse's station. Staff W was wearing eye protection on top of their head and a surgical mask. Staff Y was wearing a black KN95 mask (a respirator/mask not approved by NIOSH), not the required NIOSH N95 mask. When asked what the required PPE was for the facility in outbreak, Staff W stated that we are supposed to wear N95's but there aren't any, they always run out of masks (N95), and they had to use surgical masks. Staff W stated that they were never fit tested for an N95. During the same interview at 2:49 PM, Staff Y stated they bought their own N95 masks as they can never find an N95 mask in the facility Despite the above statements by Staff W and Staff Y, observations were made on 06/01/2022 at 10:35 AM and 06/02/2022 at 9:20 AM that showed an ample supply of N95 masks located at the staff screening stations. During an observation on 06/01/2022 at 4:19 PM, Staff N was at the medication cart in the COVID-19 unit wearing a pink camouflage respirator. When asked if they were fit tested for that respirator, Staff N stated that they had not been fit tested . Staff C, who was seated at the nurse's station across from the medication cart, stated that they had fit tested Staff N for the blue BYD N95 mask and not the pink camouflage mask. Review of the facility's fit test records showed Staff N had not been fit tested for any NIOSH N95. During an observation on 06/01/2022 at 4:49 PM, Staff S, Medical Director, was seen in the COVID-19 unit with their eye protection resting on top of their head. During an observation on 06/02/2022 at 9:28 AM, Staff Z, Maintenance Director, was wearing their eye protection on top of their head while standing at the end of the long hall unit. On 06/02/2022 at 9:30 AM, Staff U, MA, was observed wearing an N95 mask over their full-face beard, facial hair extended one to two inches past the edges of the N95 mask. Review of the facility's N95 mask fit test training records, signed on 01/31/2022 by Staff U, showed that they had received training for N95 mask use that included DO NOT use the respirator with beards or other facial hair, which may interfere with the direct contact between your face and the sealing surface of the respirator. During an interview on 06/02/2022 at 11:52 AM, Staff U stated that they were fit tested for the N95 mask that they were currently wearing. They stated that they go into the COVID-19 unit as needed, anytime there is a need for maintenance. Staff U stated that they were not aware that facial hair would prevent a seal for the N95 mask. During an interview on 06/06/2022 at 12:05 PM, Staff C stated Staff U was informed that they could not have facial hair when wearing an N95 mask. During an interview the following day on 06/07/2022 at 9:58 AM, Staff C stated Staff U had been fit tested that morning and passed with his facial hair under the seal of the N95. When asked if that followed the instructions for use, Staff C stated, they said they couldn't taste the bitter (indicative of a seal between the face and the N95). Despite the above training for N95 mask use, Staff C cleared Staff U to wear the N95 mask with facial hair. An observation on 06/02/2022 at 10:32 AM showed Resident 3 did not have AGP precautions signage on their door, nor did they have PPE located within vicinity of their room. During a concurrent observation and interview on 06/02/2022 at 10:35 AM, showed Staff DD, LPN, had exited Resident 3's room without PPE. Staff DD stated that Resident 3 is very independent with Continuous Positive Airway Pressure ([CONDITION(S)] - an aerosol generating procedure that provides pressurized air to prevent airway collapse while sleeping), they use it whenever they want. Staff DD further stated that they would always need to wear PPE because we never know the resident is using it. Review of the facility's N95 mask fit test log showed Staff DD was not fit tested for an N95. During an observation and interview on 06/02/2022 at 12:26 PM, Staff EE, NA, responded to Resident 3's call light and entered their room without appropriate PPE for AGP's. Upon exit of the resident's room, Staff EE stated that they change all PPE when coming out of an AGP room, including their N95. When asked if they had worn all PPE when they entered the resident's room, Staff EE stated they were not aware that the resident was on AGP precautions. During an observation on 06/02/2022 at 1:12 PM, Staff FF, NA, was seen entering Resident 3's room without appropriate PPE. In a telephone interview on 06/07/2022 at 11:27 AM, the LHJ Public Health Nurse stated that they were unaware that there were unvaccinated staff working in the COVID-19 unit that were not fit tested for an N95 mask. Additionally, unvaccinated staff should not have been working in the COVID-19 unit if they were not fit tested . The LHJ also stated that a KN95 was not appropriate and not equivalent to the required NIOSH N95. During an observation on 06/07/2022 at 12:48 PM, Staff A, Administrator (AD), was wearing an unapproved black KN95 mask, despite their recent fit test on 06/06/2022 using a NIOSH approved BYD N95 mask. Review of facility records on 06/06/2022, showed 95 facility staff, including administrative staff (Staff A, Staff B, and Staff C) were not current with N95 fit testing. In addition, facility record review on 06/07/2022 showed Staff AA, Agency Nursing Assistant, had not been fit tested for an N95 mask. Staff AA was unvaccinated, had worked during the facility outbreak in the COVID-19 unit and tested positive for COVID-19 on 05/18/2022. C) Disinfection. Review of the 04/22/2022 DOH Interim Recommendations for [CONDITION(S)]-CoV-2 Infection Prevention and Control in Healthcare Settings showed all non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer's instructions and facility policies before use on another patient. Routine cleaning and disinfection procedures (using an Environmental Protection Agency (EPA)-registered, hospital-grade disinfectant .for appropriate contact times as indicated on the product's label) are appropriate for [CONDITION(S)]-CoV-2 in healthcare settings .refer to the United States Environmental Protection Agency for EPA-registered disinfectants that kill [CONDITION(S)]-CoV-2. During a concurrent observation and interview on 06/01/2022 at 10:34 AM, Staff BB, Housekeeper, stated that they deep clean with a premixed 14 Plus Antibacterial All-Purpose Cleaner. When asked if they waited the appropriate wet time for disinfection, Staff BB stated they did not know. Review of the instructions for use showed treated surfaces must remain wet for three minutes. During an observation on 06/01/2022 at 4:38 PM, Staff N, LPN, used MicroKill+ disinfectant wipes to clean a non-dedicated glucometer (a device used to measure blood sugar) after obtaining a blood sample from a resident. Staff N wiped the meter with one disinfectant wipe and placed the meter on top of another disinfectant wipe on the top of their medication cart. Review of the manufacturer's instructions for use for MicroKill+ disinfectant wipes (EPA Registration Number -10- ) showed that MicroKill + was not appropriate for disinfection of [CONDITION(S)]-CoV-2. Additionally, the instructions for use required a two-step process for cleaning and disinfection, including a wet time (the amount of time the item needs to stay wet for complete disinfection). Staff N did not use the appropriate disinfectant and did not ensure the glucometer stayed wet for the recommended wet time. During an interview on 06/02/2022 at 2:20 PM, Staff A stated, the screening process is a total failure, we are going back to paper (screening forms). During an interview that same day at 7:35 PM, Staff A stated that they had no questions regarding the Immediate Jeopardy allegations of screening and PPE failures, and that they own this (the failures). Reference: WAC 388-97-1320(1)(b)(2)(a)(c)(5)(c)(e)

Based on interviews and record review, the facility failed to perform thorough assessments and monitoring of three of four residents (Resident 1, 4, 5) reviewed who were experiencing changes in condition resulting in hospitalization . This resulted in actual harm to Resident 1 due to a delay in obtaining emergent medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1. Review of the resident's medical record showed they had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's comprehensive assessment, dated 02/03/2022, showed they had severe cognitive deficits; required extensive assistance by two staff for turning in bed, transfers, and toilet use; extensive assistance by one staff for dressing and personal hygiene; and supervision by one staff for eating. Review of hospital records, dated 01/12/2022, showed they were transferred from the facility to the emergency room (ER) due to having difficulty breathing, elevated heart rate, respiratory rate, and body temperature of 100.4 degrees Fahrenheit (F). The resident was being cared for in the hospital Intensive Care Unit (ICU) for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical record showed Progress Notes (PNs), dated 01/17/2022 at 7:21 AM by Staff I, Licensed Practical Nurse (LPN), showed Staff I had received a report (on 01/16/2022 at 7:00 PM) that the resident had been doing well and was up and walking with oxygen. The resident's oxygen saturation levels (percentage of oxygen in the blood with normal levels being above 95%) were remaining in the 90's. Staff I was called to the resident's room at approximately 8:00 PM where they were told the resident was having a panic attack. Their vital signs were all over the place with blood pressures (B/Ps) in excess of 102/158 and heart rate from 45 to 145 beats per minute. The resident was sweating, which was a symptom they had leading up to their last hospitalization (01/12/2022-01/15/2022). Staff I documented they called the resident's representative and their spouse regarding the resident's condition. They decided they would come and check on the resident and take them to the ER if needed. The resident was taken by wheelchair at 9:04 PM on 01/16/2022 to the representative's vehicle and was able to transfer in the car with stand by assistance. Later the resident's representative reported the resident required intubation (placement of a plastic tube into the trachea to maintain an open airway so air can get to the lungs) upon arrival to the hospital. Review of the hospital History and Physical, dated 01/16/2022, showed the resident arrived to the ER in respiratory distress and was emergently intubated. The resident's heart rate was in the 150's (normal adult heart rate was between 60 to 100) which required shocking the resident twice (procedure sending electric shock to the heart to restore a normal heart rhythm). The resident was admitted to the ICU for acute hypoxic respiratory failure (inadequate oxygen exchange in the lungs), [CONDITION(S)] (irregular heart rate that can lead to blood clots and stroke), and asthma. The resident remained in the hospital until 01/28/2022 (12 days), at which time they were readmitted to the facility. The resident's representative stated during telephone interviews on 03/01/2022 at 10:53 AM and 03/02/2022 at 6:10 PM, that on 01/16/2022 a male Licensed Nurse (LN) called between 8:00 PM to 9:00 PM stating the resident was not doing very well, oxygen saturation levels were in the 80's and B/P all over the place. The representative asked the LN so if you feel [Resident 1] is not doing well maybe you should call the ambulance. The LN responded by stating, We called and they said it would be best for you [representative], would be quicker to take to the hospital. The representative and their spouse immediately left for the facility which was located approximately 10-15 minutes away, and found the resident seated in a wheelchair upon their arrival. The representative stated, the resident's eyes are almost rolling back, she is saying help me . face pale, worse experience, I'm still traumatized by it. Staff had to lift the resident into the car as they were unable to stand up on their own. The representative stated they had to drive 70 miles per hour to the ER. If they [staff] had acted faster the resident would never have been on a ventilator (machine that blows air with extra oxygen into airways and lungs). The resident was terrified as they couldn't breathe. The resident remained on a ventilator for six days. During a telephone interview on 03/02/2022 at 5:59 PM with the spouse of the resident's representative, they stated a facility staff member called their home the evening of 01/16/2022 stating the resident was having an anxiety attack and it might be a good idea to come down and take [the resident] to the ER. The spouse stated the representative questioned the staff member if the resident's condition was bad why were they not calling an ambulance. Upon arrival to the facility the resident was in pretty bad condition, eyes kinda rolling back, breathing shallow and hard. The spouse stated, it wasn't an anxiety issue, it was a critical issue, I was scared, worried wouldn't make it to the hospital on time. The resident was saying, help me, help me. Upon arrival to the ER the resident was not able to move their legs or arms, couldn't breathe, and was making sounds but unable to answer any questions. Staff I stated during a telephone interview on 03/02/2022 at 9:32 AM, that when they received report at 7:00 PM on 01/16/2022 from Staff N, Registered Nurse (RN), the resident was in no distress. Later Staff I was called into the resident's room where they found Staff N in the room. The resident was breathing different, was havng signs and symptoms of a panic attack, breathing was somewhat labored. The B/P of 102/158 was actually not a B/P but rather a range of the systolic number (top number of a B/P which measures the force the heart exerts on the walls of the arteries each time it beats) they observed on the B/P machine. Staff I then left the resident's room to notify the physician, and called the wrong provider. Following that Staff I stated they returned to the resident's room where Staff N was still with the resident, who was stable. Staff I then called the physician's clinic and was informed by the operator there was no physician by that name at the clinic. Staff I stated they then called the resident's representative to inquire who the resident's physician was. The representative asked Staff I what was going on, [they] wanted to come in and check on the resident. Staff I stated while the representative was enroute to the facility they called the facility and stated they would take the resident to the ER. Staff I denied telling the representative they needed to take the resident to the ER. Staff I stated they were unaware of any staff member checking the resident's oxygen saturation levels as they were busy trying to determine whether to transfer the resident or not. They stated the resident transferred without assistance into the representative's car. Staff I stated Staff N left the facility at approximately 9:00 PM on 01/16/2022 after spending time with the resident. Staff I stated, I had a stable resident that I was working on moving forward. Staff N stated during a telephone interview on 03/02/2022 at 10:10 AM, that throughout the day (01/16/2022) the resident was doing fine with no signs or symptoms of respiratory distress. Staff N had left the facility following shift report at 7:00 PM on 01/16/2022 and returned between 7:15 PM to 7:20 PM due to forgetting something they had left at the facility. Staff O, Nursing Assistant (NA), upon seeing Staff N, requested they assess the resident as they seemed to be in respiratory distress. Upon entering the resident's room they were anxious, vital signs were stable with oxygen saturation levels between 93% to 96%. Staff N stated Staff I then entered the resident's room, however was not certain what they were doing. Staff N stated they were only in the resident's room for about four to five minutes prior to leaving the facility. Staff N stated Staff I was aware of when they left the facility. Staff O stated during telephone interviews on 03/02/2022 at 11:01 AM and 03/01/2022 at 10:10 AM, that when caring for the resident the evening of 01/16/2022 the resident did well until right after dinner when putting them to bed, which occurred between 7:00 to 8:00 PM. They began hyperventilating which resulted in difficulty in breathing and complained they could not breathe. When Staff I came to the resident's room they stated they wanted to call the family and let them decide what to do regarding the resident. Later Staff O was given instructions to get the resident up in a wheelchair as their family was taking them to the hospital. The resident's representative arrived at the facility at approximately 8:15 PM. The resident was weak and short of breath during the transfer to the representative's car, thus had to be assisted by Staff O and Staff I. Staff O stated they questioned (in their head) why the resident was not being transported by ambulance to the hospital due to the distress they were having. Resident 5. Review of the resident's medical record showed they had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's comprehensive assessment, dated 02/18/2022, showed they had moderate impairment in cognition; required extensive assistance with one staff for turning in bed, transfers, dressing, toilet use, personal hygiene; and supervision with set-up assistance for eating. Review of PNs, dated 02/04/2022 at 12:53 PM, documented by Staff K, RN, showed the resident was complaining of pain (eight on a scale of zero to ten, with zero being no pain and ten being unspeakable pain) to their penis. Bright red blood with no clots was observed in their [CONDITION(S)] catheter bag and catheter tubing. The catheter tubing was readjusted and clear urine was then observed in the tubing. Vital signs were taken and were within normal limits. The resident was given pain medication and the physician was notified. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's Weights and Vitals Summary form, dated 02/05/2022, showed the resident had a fever with a documented body temperature at 9:20 AM of 101.8 degrees F and 101.8 degrees F at 10:31 AM. Review of the resident's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital History and Physical, dated 02/05/2022, showed the resident was evaluated in the ER and was found to be septic (potentially life threatening condition that occurs when the body's response to an infection damages its own tissue) with a urinary tract infection. The resident remained in the hospital until 02/12/2022, at which time they were readmitted to the facility. Staff L, Medical Records, stated on 03/01/2022 at 2:15 PM, that the resident was transferred to the ER at 1:22 PM on 02/05/2022. Despite the resident's significant change in condition necessitating transfer to the ER, and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff K stated during a telephone interview on 03/01/2022 at 12:25 PM, that they observed blood in the resident's urinary catheter bag and tubing. The catheter was readjusted and clear urine was then observed in the tubing. The physician was notified with orders to monitor the resident. During an interview on 03/02/2022 at 9:32 AM with Staff I, responsible for the care of the resident between 7:00 PM on 02/04/2022 to 7:00 AM on 02/05/2022, they stated that they did not document on the resident if they were not on alert charting, and was unable to recall if the resident was on alert charting. Staff M, LPN, nurse in charge of the resident on the day shift of 02/05/2022, stated on 02/28/2022 at 4:00 PM, that they did not document any assessment of the resident as gets so busy. At the beginning of the shift the resident stated they were very tired and did not want to get out of bed. The resident then became febrile, sweating so bad it soaked their clothes. Staff M stated Staff J, Director of Nursing, had directed them to send the resident to the ER as they had observed the resident. The resident was transferred to the ER between 12:30 PM to 1:30 PM on 02/05/2022. Resident 4. Review of the resident's medical record showed they had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's comprehensive assessment, dated 01/30/2022, showed the resident was without cognitive deficits; required extensive assistance by one staff for turning in bed, dressing; extensive assistance with two staff for transfers; and limited assistance by one staff for toilet use and personal hygiene. Review of PNs, dated 02/23/2022 at 11:55 AM, showed that blood was observed coming from the resident's penis. The resident denied pain with urination, however complained of pain when perineal care was performed by staff. There was no evidence of trauma. At 2:08 PM on 02/23/2022 PNs showed the physician was notified regarding the blood and staff was to monitor for bleeding or bruising, bloody urine or stool. Review of the resident's body temperature taken on 02/24/2022 at 12:36 AM, 10:26 AM, and 12:49 PM showed the resident did not have a fever. Despite the significant change in the resident's condition, and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a lack of documentation in assessments showing the cause necessitating the transfer to the hospital. Review of the hospital History and Physical, dated 02/24/2022, showed the resident was shaking, had chills, dizzy with nausea, and was having difficulty expressing their thoughts. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Staff M on 02/28/2022 at 9:45 AM, they stated a NA had reported to them that the resident did not feel well. The resident came out of their room and requested Tylenol. The resident's legs and arms were shaking and they stated they were having a cold. The resident's B/P and body temperature were then checked and found to be within normal limits. The Nurse Practitioner, who was in the facility at that time, assessed the resident and determined they needed to be sent to the ER. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the Statement of Deficiencies dated 11/09/2021

Based on observation, interview and record review the facility failed to ensure one of one resident (#46), reviewed for falls with injuries was provided the necessary evaluation to determine the resident's environment was free of accident hazards, and to ensure adequate supervision was provided to prevent repeated falls. This failed practice resulted in harm to Resident #46 due to four of the seven falls resulted in injuries. Additionally, the facility failed to ensure resident equipment was appropriately working for two of two residents (#12,10) reviewed for equipment related accidents and hazards. 1) Resident #12's transfer pole was not secured and became loose during a transfer which posed a risk for a fall. 2) Resident #10's right wheelchair leg rest/foot pedal was not replaced leaving her right leg unsupported or protected. This failure resulted in harm as the resident injured her right leg. Findings included . The 02/2019 facility Incident Documentation and Investigation Policy showed the investigation should include who, what, when, where, why and how the incident occurred. The data collection and analysis was to be completed and then the Director of Nursing was to complete a narrative summary describing the incident and determining a cause of the incident. Abuse and neglect was to be determined. Interventions were to be developed to prevent further incidents. Resident #46. Review of the resident's medical record showed the resident was admitted to the facility on [DATE] with multiple medical conditions including an infection with drug resistant bacteria of lower legs, falls with rhabdomyolysis (breakdown tissues that caused damaging protein into the blood causing kidney damage/muscle breakdown and pain), history of urinary tract infections, and significant back pain. The 12/31/19 Fall Risk Evaluation showed the resident was at moderate risk for falls, and had experienced one to two falls previously. The resident was alert and oriented to time, place and person. She had a balance problem with decreased muscular coordination and unsafe ambulation and transfers. Review of the 01/07/2020 comprehensive nursing assessment showed the resident was alert, oriented, and able to make needs known but required extensive assistance with two staff to transfer the resident. The 12/31/19 Fall Care Plan showed resident fall goals A) the resident will free from serious injury related to falls, B) the resident will resume normal activities without further falls through the next review. Fall Interventions included : -Anticipate needs of the resident -Be sure the resident's call light is within reach; the resident needs prompt response to all requests -Ensure resident is wearing non-skid footwear -Provide safe resident environment, clutter free, bed in low position with bedside fall mat. (However, these interventions were not resident centered and were basic nursing standards of practice.) During an observation and interview on 02/11/2020 at 11:08 AM, the resident was sitting on the side of the bed her feet flat on the floor. The bed was a plastic piped frame and approximately six inches from the floor. She complained of back pain that went all the way down to her buttocks and was rocking herself back and forth on the bed. The resident stated the nursing staff do not answer the call light and she had fallen to the floor a few times. The resident had bruises on upper and lower arms. During an interview on 02/13/2020 at 9:30 AM, the resident stated staff did not always respond to her call light, I have been left in bed for a long time. She stated she had experienced an episode of [MEDICAL CONDITION] and required assistance for personal care. She stated the watery stool had gone through her brief, down her wheelchair and onto the floor. She stated it took a long time for them to answer the call light and she could not get anyone to come and help her. During an observation and interview on 02/18/2020 at approximately 12:30 PM, the resident had a large purple/black bruise to her right eye and right arm with ecchymosis (bruises) and a large skin tear to her lower right forearm. Her bed was against the wall and a bed mattress was on the side of the bed. She stated it took a long time for the night shift to answer lights. She stated she had laid on the floor for over an hour before they came and she had been yelling for help. The resident stated she fell several times last night and waited a longtime for them to come help her. She stated the last time she fell this morning it took about an hour for staff to come early this morning. Review of the (MONTH) and (MONTH) 202 Fall Incident Reports showed the resident had experienced six unwitnessed falls. During four of the six falls the resident sustained [REDACTED]. On 01/12/2020 at 4:15 PM the resident was found on the floor in her room and sustained a one by one inch bruise to the left side of her forehead. The cause was determined to probably be from the resident sleeping in her wheelchair. On 01/21/2020 at 3:45 AM the resident slipped out of her chair and sustained a bruise to the right side of her face and skin abrasion to her right hip. The cause was determined to be from falling out of her wheelchair. On 02/13/2020 at 9:45 PM the resident was found on the floor with a skin tear to her right arm. There was no determination as to the cause because the resident did not know how she fell . No further investigation was conducted. On 02/18/2020 at 12:50 AM the resident was found on the floor with a hematoma (swelling with bleeding under the skin) to the right side of the face and eyebrow. The incident report showed the resident had been in bed, reached for water, attempted to sit up in bed, and fell out of the bed. Additionally, two non-injury falls were on 01/07/2020 at 3:00 AM and 01/13/2020 on 7:45 PM. During both falls, the resident had fallen out of her wheelchair or recliner. These fall incident reports did not show a thorough collection, evaluation, and analysis of data to identify specific hazards and risks in order to develop targeted interventions to reduce the repeated falls during the approximately seven weeks since her admit. Therefore, without these interventions, there were no plans to ensure the safety of the resident while in her wheelchair, recliner and/or bed (furniture needed by the resident). During an interview on 02/19/2020 at 10:42 AM, Staff C, Director of Nursing Services, stated she was aware of the issues in the facility and agreed that there were many unwitnessed falls on the resident. She stated that she had started as interim in (MONTH) 2019 and found many concerns to work on and training issues. She stated she would map out the resident's falls and review them. Review of the facility's policy and procedure titled, Incident Documentation and Investigation, revised 02/2019, showed it included, .define how .nursing facilities will document and investigate incidents .in order to protect residents from further incidents .11. The investigation should end with the identification of who was involved in the incident and what, when, where, why and how the incident happened, including the probable or reasonable cause . Resident #12. Review of the resident's record showed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's record showed a 07/29/19 order for, Transfer pole at bedside and a 09/03/19 physician order [REDACTED]. Review of the resident's 08/24/19 and 11/21/19 quarterly comprehensive assessments showed the resident needed extensive help from one staff to transfer. Review of the resident's comprehensive care plan, updated 02/18/2020, included, Transfers: transfer pole at bedside to aid with transfers in and out of bed, and .has .impaired thought processes . A 02/11/2020 observation and interview with the resident at 1:15 PM showed the resident seated in a wheelchair in her room. A transfer pole was in place about two feet away from the resident's bed. The bed was in a low position and against the wall. The resident stated her transfer pole fell over a few days before. She stated, It barely missed me. The resident stated that she told an unnamed staff person the pole was loose at the ceiling. The resident stated she used the transfer pole to help her get in and out of bed. During a 02/11/2020 interview at 2:00 PM with Staff HH, Maintenance Director, when asked if he placed or replaced a transfer pole recently, he stated, Apparently over the weekend, (resident's) transfer pole fell over. He stated that he put it back up on Monday, (02/10/2020). Staff HH stated that he saw the request in his work orders to replace the pole. He stated that he did not receive a call from the facility over the weekend about the fallen transfer pole. During a 02/13/2020 observation and interview at 12:03 PM with Staff O, Nursing Assistant (NA), she stated that she knew about the fallen transfer pole. She showed where she saw the transfer pole laying on the floor, out of the way, after it came down on Saturday, 02/07/2020. During a 02/13/2020 interview at 2:50 PM with Staff B, Corporate Registered Nurse, he stated he was shocked when he saw the surveyor's request for the incident investigation about the fallen transfer pole because he was not aware this occurred. He stated no investigation was started as yet, but it was important because it was an equipment failure. Review of the facility's incident/accident log showed the incident was not logged into the incident/accident log until 02/13/2020, after the incident was brought to the attention of Staff B. Review of the resident's record did not show documentation about the incident, how it occurred, the resident's response, or what measures were taken to ensure the resident's safety once the pole was down. During a 02/19/2020 interview at 12:18 PM with Staff B, he stated Staff HH was now going to start checking all transfer poles in use in the facility on a monthly basis to ensure all were stable and not loose. During an interview with Staff B later that same day at 1:39 PM, he stated Staff HH had not been directed to check the condition and stability of the transfer pole for Resident #12 or for any other resident that used a transfer pole. During a 02/19/2020 interview at 1:03 PM with Staff M, Registered Nurse/Resident Care Manager, she stated that she knew about the transfer pole incident. She stated she did not start an incident/accident report because since the resident wasn't involved, I didn't think to do an incident report/investigation. During a 02/24/2020 interview at approximately 2:00 PM with Staff GG, Licensed Practical Nurse, she stated when Staff N, NA, told Staff GG about the loose transfer pole, she went to the resident's room and took the pole down, setting it on the floor under the sink, out of the way. When asked, Staff GG stated she did not think of starting an incident/accident report. During a 02/24/2020 interview at 2:15 PM with Staff N, NA, she stated at about 4:00 PM on 02/07/2020, she was in the resident's room, helping her get up from the bed. The NA stated she helped the resident sit at the side of the bed. When the resident reached for the transfer pole, the pole, at the ceiling, started moving around in a circle. The NA stated she helped the resident sit back down on the bed and told Staff GG what happened. Review of a maintenance log (undated) listed the types of devices used by residents throughout the facility. The log showed there were four residents who used transfer poles. Review of a typed maintenance document that listed devices and other things maintenance personnel audited on a monthly basis did not include transfer poles. Resident #10. Review of the record showed the resident admitted on [DATE] with [DIAGNOSES REDACTED]. The 02/15/2020 comprehensive assessment showed the resident was cognitively intact. On 02/18/2020 at 2:35 PM, the resident was observed in her room in her power wheel chair (w/c). Staff OO, NA was observed to wrap blankets around the resident's lower legs, which were both positioned on the left leg pad and foot rest. The right side of the foot and leg rest were not on the chair. The resident stated that the leg and foot rest broke sometime in (MONTH) 2019 and had been removed. She instructed the NA to carefully wrap the blankets around her legs (on the one leg rest) and not to allow any of the blankets to drag. She stated that on a previous occasion, because the leg rest was missing, one of the blankets was dragging off the w/c and got caught in the wheel of the chair which then caused her leg to fall resulting in an injury to her foot. Review of nurse progress notes showed: *10/09/19 showed patient broke her R (right) foot peg on her power chair, she states she was outside and the peg got caught in the grass and just broke off. * 10/23/19 w/c repair company, had been at the facility to conduct repairs of the chair and ordering her R foot and mechanical breaks. * 11/23/19 Resident was outside in w/c her blanket became caught in wheel and the w/c almost tipped over. In the process she injured her LT(left) great toe. (The record showed no investigation was completed) *02/23/2020 indicated the resident was returning from outdoors and the wind slammed the door shut on my leg. The note showed the injury was observed as a large raised purple bruise 3 inches long by 0.5 inches wide on the right lower extremity (RLE). During an observation on 02/24/2020 at 2:39 PM, the resident was accompanied by Staff PP, Physical Therapist, just outside of the Director of Nursing's office. The resident informed Staff C, Director of Nursing Services (DNS) that over the weekend, the wind caught the exterior door, which slammed into her leg causing an injury. The leg was observed to have purplish bruising to the exterior portion of the calf. There was no leg or foot rest on the right side of the w/c. Both of the resident's legs and feet and legs were propped onto the left leg of the w/c. The resident stated that the bruised area was painful and she was concerned as to whether Staff PP should apply compression wraps (to treat on-going swelling issues of her lower legs). Review of a 02/25/2020 Incident Report showed that the Resident did not have the right foot and leg rest on when the injury occurred to the RLE. During a joint interview on 02/25/2020 at 9:51 AM, Staff C DNS, stated that the resident resided in the rehabilitation unit when the w/c repair company came to the facility for an evaluation of the broken leg rest. She stated that the resident was later transferred to the extended care unit and that there was a failure to communicate, from one Resident Care Manger (RCM) to the other regarding the needed repairs to the wheelchair. Staff A, Administrator, stated that somehow it was not addressed in October, when it should have been. She acknowledged the facility did not act timely to facilitate the repairs to the wheelchair. Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure the residents' need for incontinent care was met in a timely manner for one of two residents (#76) reviewed for incontinent care. This failure caused psychological harm and resulted in, for Resident #76, stool/bowel movement remaining on the resident's skin for four hours until her representative brought the issue to the attention of care staff. The facility also failed to ensure one of one resident (#46) reviewed for rough handling and bruising, that staff cared for the resident without physical aggression. This failure caused harm and resulted in the resident experiencing rough handling during transfers and personal care that caused pain and bruising to both upper arms. Findings included . Review of the facility's 05/2019 policy titled, Abuse/Neglect/Misappropriation/Exploitation included, It is the policy of this facility to protect residents from mistreatment, neglect, abuse .by implementing procedures designed to prevent, identify, report and investigate potential instances of abuse, neglect and exploitation. Abuse was defined in the policy as .unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .also includes the deprivation .of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . Neglect was defined in the policy as The failure of the facility, its employees or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Resident #76. Review of the resident's medical record showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive assessment, dated 01/26/2020, showed the resident had severe cognitive impairment; was unable to walk; limited assistance of one staff for locomotion; extensive assistance of one staff for turning in bed and personal hygiene; extensive assistance of two staff for toileting and transfers; able to feed herself with set up help from staff; and was frequently incontinent of urine and stool. Review of the resident's plan of care, dated 02/01/2019, showed the resident had bladder incontinence related to dementia and used disposable briefs; staff was to check and change her. An interview with Staff B, Registered Nurse/Interim Director of Nursing (RN/DON), on 02/14/2020 at 11:00 AM, showed the facility policy for check and change was every two to three hours, or as needed. The resident's representative stated during telephone interviews on 02/12/2020 at 12:16 PM and at 4:41 PM that the resident was seated in the dining room for the evening meal when she went to visit the resident on 01/16/2020 at approximately 5:00 PM. The resident informed her representative that her pants were wet. The resident's representative then noticed the resident's pants were visibly wet. She stated there were not many staff present at the time and the resident got missed for toileting before the dinner meal. The resident's representative placed the resident on the toilet with the assistance of Staff E, Nursing Assistant (NA). The resident had dried stool over her buttocks and up onto her lower back. She stated it took 10-15 disposable wipes to remove all the feces from the resident's skin. There was a lot of stool .it was all the way across her .urine in her briefs. Staff G, NA, told her they were short-handed and she meant to provide care to the resident but never did. The resident's representative stated she was very angry regarding the incident, especially the amount of dried stool that was found on the resident's bottom. Staff [NAME] stated during an interview on 02/13/2020 at 2:55 PM, that he did not provide any care to the resident on 01/16/2020 until the resident's representative approached him to assist her with cleaning the resident. When the resident's representative arrived at the facility on 01/16/2020 the resident was already in the dining room awaiting dinner. Staff [NAME] stated he arrived at the facility at approximately 3:30 PM and was working extra as the facility was short-handed. The resident was placed on the toilet and he was holding her up as the resident's representative was wiping her bottom, which was covered in dried stool. Staff [NAME] stated it looked like the stool had been on the resident's bottom for a few hours. He stated it took more than 20 disposable wipes to clean the resident's bottom. The resident's representative was very upset about the situation and he had stated to her he completely agreed. Staff G stated on 02/13/2020 at 3:10 PM, that when she arrived to work on the subacute/advanced recovery units on 01/16/2020 at 2:00 PM she was the only one there until Staff F, NA, arrived at 2:30 PM. She stated she just started answering call lights, and did not provide any care to the resident prior to the incident. Staff J, Administrative Coordinator, stated during a telephone interview on 02/27/2020 at 4:15 PM, that there was a total of 29 residents on the subacute/advanced recovery units of the facility on 01/16/2020. A telephone interview with Staff F on 02/13/2020 at 4:02 PM, showed that when he reported to work in the subacute/advanced recovery units the afternoon of 01/16/2020 he never provided care to the resident that day. He stated that when he arrived to work on the units at 2:30 PM he observed the resident in her wheelchair in the hallway. He stated sometimes the resident would get out of bed independently if her wheelchair was next to her bed. Review of the facility investigation report showed on 01/16/20 Staff NN, NA, had performed perineal care on the resident at 1:00 PM, thus no further care was provided to the resident for four hours. Resident #46. Review of the medical record showed the resident was admitted to the facility on [DATE] with a history of falls and urinary tract infections. Review of the 01/07/2020 comprehensive nursing assessment showed the resident was alert, oriented, and able to make needs known but required extensive assistance with two people to transfer the resident. Review of the current 02/18/2020 care plan (also in the Kardex directing the nursing assistants) showed the resident required extensive assistance of two persons for transfers and assisting the resident with toileting. During a 02/11/2020 interview at 10:40 AM, the resident stated she had bruises (blood vessels near the surface of the skin burst open, usually caused by impact trauma) from staff transferring her by her upper arms. She stated the staff caused pain and they were too rough with her. During an observation and interview on 02/11/2020 at approximately 10:50 AM, the resident showed she had several areas of red and greenish bruises the resident had on the right upper arm above the elbow. The bruising to the right upper arm were approximately two inch long lines (similar to finger marks) across, and horizontally stacked three inches above the right elbow. Additionally, there was bruising, approximately one inch in diameter, above the left elbow. The resident stated she bruised easily but the staff were usually man handling and rushing her during her cares and transfers. During an interview in the resident's room on 02/11/2020 at approximately 11:00 AM, Staff CC and Staff H, both Registered Nurses (RN), were providing a treatment. Staff CC stated the bruises on the resident's upper left arm were from the resident scratching herself, but Staff CC did not know why the resident's upper right arm was bruised as well. During Staff CC's and Staff H's interaction with the resident, she complained of rough handling during cares and transfers by nursing staff. Staff CC stated the resident was confused and that she hallucinated, thus minimizing the allegation of rough handling. During an interview related to possible abuse or neglect on 02/11/2020 at approximately 11:30 AM, the Administrator and Staff B, RN, Interim Director of Nursing Services (DNS), stated they would look into the resident's bruises and complaints of staff handling the resident roughly during transfers. During a 02/13/2020 observation and interview at 9:43 AM, the resident was wearing short sleeves the right upper arm had less bruising as evidenced by light color yellow and green of the skin. The resident stated she was lifted by staff moving her around; they hurt her and she had pain. The resident stated she was thrown around like a sack of spuds. During an interview on 02/13/2020 at 10:42 AM, Staff C, Director of Nursing, stated she had arrived in (MONTH) and that the facility was short in staffing .we need to get a class going as soon as we can. I'm going to be honest, I saw in (MONTH) (2019) what (the surveyor) are seeing now. During an interview on 02/13/2020 at approximately 11:00 AM, Staff MM, Physical Therapy Assistant, (PTA), stated she had much concern about how the nursing staff transfer residents. She stated she had observed incorrect transfers with Hoyer lifts (mechanical lift) and basic techniques of nursing staff not using two persons to transfer resident when indicated on their care plan. Staff MM stated she had previously reported to her supervisor her concerns and had recommended they provide training to nursing staff. During a 02/20/2020 observation at 1:30 PM the resident was transferred from the toilet by Staff DD, Nursing Assistant (NA), and provided perineal/rectal cleansing prior to transferring the resident to her wheelchair. The NA was observed to rush with the cleansing and the transfer. Further, Staff DD failed to use two staff while transferring the resident as directed by the care plan. During an interview with the resident on 02/20/2020 at 1:40 PM, the resident stated that Staff DD was rough with her and she doesn't think the staff know how rough they could be with sick fragile people. Review of the progress note dated 02/20/2020 showed the Social Service Director had followed up with the resident regarding her concerns about nursing assistants' treatment of [REDACTED]. During a 02/24/2020 interview at approximately 2:00 PM with Staff R, Social Services Director, she stated the resident told her that she was handled roughly during transfers. The resident asked if the nursing staff could be trained better to be careful with people that have pain and illness. During an interview on 02/20/2020 at 1:45 PM, with Staff EE and the DNS stated they acted upon the resident's complaint by placing the resident on alert monitoring, calling the complaint resolution unit and interviewing staff and residents (nine days past the first resident complaint on 02/11/2020). Reference: WAC 388-97-0640 (1)

Based on observation, interviews, and record review the facility failed to assess risk factors and develop and/or initiate planned interventions to address resident falls for one of four residents (#1) reviewed for accidents. This failed practice resulted in harm to Resident #1 who sustained a C-1 vertebrae fracture (cervical neck fracture - is life threatening, potentially fatal injury sometimes associated with injury to the spinal cord and resulting paralysis) following a third fall to the floor in a seven day period of time. Findings included . Resident #1. Review of the resident's medical record showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's comprehensive nursing assessment, dated 8/21/19, showed the resident had no cognitive impairments, required one staff to assist with turning side to side in bed, transfers, dressing, and toileting. The resident was receiving a diuretic (water pill) and a blood thinner medication twice daily. Review of the resident's plan of care, dated 10/27/17, showed the resident was at risk for falls due to gait/balance problems, history of falls, and weakness. Interventions included bed in the low position. In addition, the plan of care revised on 05/31/18, showed the resident was independent with turning in bed, ambulation using a front wheeled walker, and transfers. On 08/06/18 the plan of care was revised showing the resident was independent with toileting, however she required staff to check and change her on the night shift due to incontinence problems. Review of a facility investigation report showed on 10/18/19 at 3:30 AM the resident was found on the floor by her bed. She stated she was getting up to use the bathroom and fell sustaining a large skin tear to the right forearm, abrasion to the right knee, and a hematoma (collection of blood outside of blood vessels) to the back of her head. The resident was sent to the emergency room (ER) where imaging tests revealed no further injuries. Following the fall on 10/18/19 there were no new interventions developed to prevent further falls, and there was no determination as to how the resident fell . Review of a facility investigation report showed on 10/19/19 at 9:00 PM the resident was found lying on the floor by her bed. The resident was unable to give a description of how she fell . Predisposing factors included improper bed height, call light not utilized by resident, impaired memory, used walker to ambulate, and incontinence. Despite the predisposing factors the only new intervention to prevent falls was to have therapy evaluate for safe transfers and ambulation. In addition, there was no determination made as to how the resident fell . Staff A, Administrator, stated during an interview on 11/07/19 at 9:30 AM, that therapy had not evaluated the resident following her fall on 10/19/19. Review of a facility investigation report showed on 10/24/19 the resident had fallen during the morning medication administration pass. She was alert and confused as to how she fell . A hematoma was present to her right forehead and skin tears to the right arm. The report stated it was reasonable to assume the resident self transferred from her walker to the bed per her usual routine, and used the bedside table for balance. The table moved which resulted in the resident losing her balance and falling. The resident was transferred to the ER for evaluation. Review of hospital records, dated 10/24/19, showed the resident had a [MEDICAL CONDITION] cervical vertebra with developing hematoma. The resident remained hospitalized until 11/05/19 (12 days) at which time she was readmitted to the facility. Observation and interview with the resident on 11/05/19 at 2:50 PM, showed she was lying in bed wearing a cervical collar. She had bruising under her right eye and swelling to the right side of her forehead. The resident was asking where her television had gone as it was missing, however the television was directly in front of her against the wall. Staff B, Licensed Practical Nurse, stated on 11/05/19 at 1:50 PM, that the resident was found lying on her side the morning of 10/24/19 with a golf ball size hematoma to her right forehead. Initially, the resident was unable to open her right eye. The resident was confused as she was unable to state how she fell . The resident complained of her head and neck hurting which worsened when she was transferred by staff to a chair. Staff B stated the resident utilized the bedside table to steady herself, and kept her bed in a high position at all times. The physician was called and ambulance personnel was alerted for transport. A cervical collar was placed around the resident's neck by ambulance personnel upon their arrival to the facility. Staff C, Nursing Assistant (NA), stated on 11/05/19 at 12:20 PM, that she had seen the resident 30 minutes prior to the fall on 10/24/19 coming out of the bathroom. The resident had her bed height higher than what Staff C was comfortable with. Staff C stated at the time of the fall the resident had been trying to get up. The resident initially complained of head pain but when she was transferred to a chair by three staff she then complained of neck pain. Staff K, NA, caregiver who found the resident on the floor on 10/19/19, stated during a telephone interview on 11/13/19 at 12:00 PM, that it appeared the resident had slid to the floor. The resident was unable to state how she fell . He stated the resident kept the bed height as high as it could go. In addition, the resident did not position her feet correctly on the floor when she attempted to ambulate, but rather she would walk on the tips of her toes with her heels up. Staff K stated he had informed Licensed Nurses and the Resident Care Manager (RCM) that staff needed to figure out how to make it safer for the resident like lowering her bed, to which they responded they were unable to change her bed. During an interview on 11/05/19 at 2:04 PM with Staff D, Registered Nurse/RCM, he stated prior to the resident's fall on 10/18/19 the resident had not fallen since 07/18/19. At that time therapy worked with her on ambulation and transfers. He stated the resident always keeps bed at high position. Reference (WAC) 388-97-1060(3)(g) This is a repeat deficiency from the Statement of Deficiencies dated 02/21/19.

Based on interviews and record review the facility failed to timely evaluate and monitor one of three residents (#2) reviewed for change of condition. This failed practice resulted in actual harm to Resident #2 due to a delay in obtaining medical treatment in response to the resident's change of condition. In addition, based on interviews and record review the facility failed to ensure care and services met professional standards following falls with injury for one of four residents (#1) reviewed for accidents. This failed practice placed Resident #1 at risk for worsening of her cervical spinal fracture. Findings included . Resident #2. Review of the resident's medical record showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's comprehensive nursing assessment, dated 09/26/19, showed the resident had no cognitive impairments, and required one staff to assist with transfers, dressing, toileting, turning in bed, and personal hygiene. Review of a facility investigation report showed on 10/17/19 at 10:00 PM the resident was found on the floor next to her bed. The walker was to the right of the resident. She sustained a skin tear to the left elbow amd a bruise to the right elbow. Review of a statement by Staff L, Nursing Assistant (NA), showed when he arrived on shift just after 10:00 PM on 10/17/19 the resident was restless, scooting on her bed, and seemed to be confused. Staff L found the resident's oxygen saturation level (amount of oxygen in the blood - normal is 95-100%) to be in the 80's. Staff M, Registered Nurse (RN), was informed by Staff L that he was obtaining oxygen for the resident. When the oxygen was administered at two liters per minute the resident's oxygen saturation level increased to the 90's. The statement showed since the resident was restless Staff L lowered her bed to the floor, placed it against the wall, and put a fall mat down. Further review of the investigation report showed when Staff N, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), arrived at 6:00 AM on 10/18/19 she was given report by Staff L of the resident's condition. The resident was immediately assessed by Staff N and was found to be restless with oxygen being administered at two liters per minute. She called the Nurse Practitioner (NP) to assess the resident and also the primary care physician. physician's orders [REDACTED]. Review of the Acute Visit form, dated 10/18/19 and documented by the above NP, showed it had been reported the resident had a fall the evening before and was agitated and anxious,not like herself. The NA reported staff found the resident with an oxygen saturation level of 70% so they placed oxygen on her. The resident was anxious, restless, and her heart rate was high at 114 beats per minute. The resident was not answering questions or cooperating, but knew the year and her location. There was concern for possible pneumonia, thus the resident was transported to the ER. Review of hospital records showed on 10/18/19 the resident had a low saturation level of 82% on room air. She was diagnosed with [REDACTED]. She remained in the hospital until 10/25/19 (seven days). Despite the above significant changes in the resident's condition review of Progress Notes showed no documentation of assessments/monitoring of the resident until 6:00 AM on 10/18/19 by Staff N, at which time the resident was assessed by medical staff with orders given to transport her to the ER. Staff L stated during a telephone interview on 11/08/19 at 10:26 AM, that he arrived to the resident's room shortly after 10:00 PM on 10/17/19, and found the resident to be very confused, wiggling all over the bed, and breathing rapidly. He stated normally the resident was calm and oriented. Staff L stated, I saw changes right away, this is not her. The resident had fallen just prior to his arrival to work. Due to the changes in the resident Staff L checked her oxygen saturation level and found it to be low at 80%, thus he informed Staff M that he was going to put oxygen on her at two liters per minute. When he applied oxygen the resident's saturation level increased to 94% to 95%. Staff L stated that controlled the resident's anxious behavior for about two hours. Following that the resident again became anxious, very confused, started moving around again, and attempting to get out of bed. The resident would not leave her oxygen on, thus her saturation levels decreased to 84%. Staff L stated he told Staff M twice that we need to get her out of here to the hospital. Finally, after the second time he voiced his concern to Staff M, she came and looked at the resident, which was approximately 3:00 to 4:00 AM on 10/18/19. Staff L stated to Staff M, you have to do something with this lady .she (Staff M) was busy and seemed overwhelmed. Staff L stated the changes in the resident's condition started at the beginning of his shift. He stated he discussed with Staff N and Staff D, RN/RCM issues regarding waiting too long to send the resident to the hospital. Staff M stated during a telephone interview on 11/10/19 at 5:33 PM, that when she observed the resident at 3:00 AM she did not want to stay in bed. She stated she gave permission to Staff L to administer oxygen to the resident. She stated she thought the resident had a urinary tract infection. Staff M stated she did not document in the resident's medical record that shift as she had just started employment at the facility approximately two weeks prior to that time, and did not know how to document in the Progress Notes (PNs). She stated it was a horrible night as Resident #1 had also fallen that night (review of Resident # 1's PNs, documented by Staff M, showed she had fallen at 3:30 AM on 10/18/19 and was sent to the ER). During a telephone interview on 11/08/19 at 10:45 AM with Staff N, she stated that sometime shortly after she arrived to work (approximately 5:30 to 5:45 AM on 10/18/19) she was approached by Staff L regarding changes in the resident's condition. Staff L informed her the resident looked different all shift, oxygen saturation levels were low so he had applied oxygen, and she was attempting to get out of bed so he had put the bed in the low position. Staff N stated she immediately went to assess the resident and had the NP (who was in the facility at the time) come to the resident's room with her. She stated the resident's primary care physician came to the resident's room approximately five minutes later. The paramedics were notified at 6:25 AM to transport the resident to the ER. Resident #1. Review of the resident's comprehensive nursing assessment, dated 8/21/19, showed the resident had no cognitive impairments. Review of PNs, dated 10/24/19 and documented by Staff B, LPN, showed the resident fell in her room that morning. She hit her head and sustained a large hematoma (collection of blood outside blood vessels) to the right forehead. Neurological signs were not within normal limits. It was difficult to assess the reaction of the resident's right eye as she was not opening her eye upon initial assessment. The resident had severe pain to her head and neck, and was confused. The physician was notified and the resident was transported to the ER. Hospital staff reported the resident was life flighted to another hospital with a C-1 fracture (cervical neck fracture - life threatening, potentially fatal injury sometimes associated with injury to the spinal cord and resulting paralysis). Staff B stated during an interview on 11/05/19 at 1:50 PM, that when she found the resident on the floor the morning of 10/24/19 she was lying on her side with a golf ball size hematoma to the right forehead. Initially, she was unable to open her right eye. Staff placed a pillow under her head. Three staff then transferred her to a chair where she complained of her head and neck hurting horribly. Her neck pain was worsening. Emergency personnel were called and they placed a cervical collar around her neck when they arrived to the facility. Staff O, NA, stated on 11/05/19 at 12:10 PM, that when she arrived to the resident's room on 10/24/19 the resident was on the floor and Staff B was present. Staff O stated the resident complained of neck pain on the floor. The resident was lifted off the floor to a chair by three staff. The resident continued to complain of neck pain. Staff did not stabilize her neck. Staff C, NA, stated on 11/05/19 at 12:20 PM, that on 10/24/19 she observed the resident on the floor lying on her front and to the right side. A baseball size bump was present to the right forehead, and she could not open her right eye. Staff C stated the resident complained of head pain. Initially the resident was transferred off the floor to the edge of her bed by three staff, and then transferred to a chair. At that time she complained of neck pain. The resident was very confused. The resident's neck was not stabilized by staff, however when emergency personnel arrived they placed a cervical collar around her neck. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the Statement of Deficiencies dated 07/24/19, and 11/14/18.

Based on interviews and record review the facility failed to ensure one of three residents (#1), reviewed for falls, was provided adequate supervision and that care plan interventions were followed to prevent falls. This failed practice resulted in actual harm to Resident #1 who fell forward from her wheelchair and sustained a fractured right hip and contusion (bruise) on her forehead. Findings included . Resident #1. Review of the resident's medical record showed the resident was admitted to the facility 06/28/16 with [DIAGNOSES REDACTED]. Review of the Restorative Evaluation and Summary, dated 12/28/18, showed the resident was on a range of motion program using the Omnicycle (motorized arm and leg pedal exerciser), and continued to self propel via the wheelchair in hallways short distances. The resident was unable to ambulate, and required two staff to assist with transfers. The resident's plan of care, dated 12/05/17 (but reviewed periodically), showed the resident was at risk for falls due to a history of falls, impaired cognition, weakness, and incontinence. Nursing orders included to put the resident to bed after meals as the resident allowed. Review of a facility investigation report showed on 02/11/19 at 8:30 PM Staff A, Registered Nurse, observed Staff B, Nursing Assistant (NA), guide the resident in her wheelchair down the hallway to her room to put her to bed. A few moments later the resident fell head first onto the floor from the wheelchair. There was a loud bang when the resident hit the floor. The resident was lying on her right side in the fetal position with the wheelchair behind her, and her feet underneath the chair. A large, circular bruise with swelling was observed on the resident's forehead, and the knuckles on her right hand were reddened. The resident was yelling, crying, and had cringing facial expressions. The resident was guarding her right leg and expressed pain during range of motion to the right leg. She was transferred to the emergency room . Hospital records, dated 02/11/19, showed the resident sustained [REDACTED]. Per telephone interview on 02/20/19 at 12:54 PM with Staff A, she stated Staff B was really behind in getting residents back to bed. Resident #1 was a priority lay down and she was one of the residents that needed to be put to bed first. Staff B stated during a telephone interview on 02/20/19 at 10:15 AM, she had transferred the resident from her bed to the wheelchair for dinner at approximately 4:30 PM on 02/11/19. She stated the resident was a priority lay down after the dinner meal. The resident finished her dinner meal between 6:00 to 6:30 PM, however Staff B did not put her to bed after dinner due to attending other residents' call lights. Upon pushing the resident's wheelchair down the hallway later at 8:30 PM she was not able to pick up her feet. She was sitting straight up in her wheelchair (with no footrests) and then leaned forward. Staff B was unable to hold onto her, thus the resident fell to the floor. A telephone interview with Staff C, NA, on 02/20/19 at 2:45 PM, stated the last time she observed the resident prior to her fall was approximately 8:15 PM on 02/11/19. She was seated in her wheelchair with her head slightly down, and leaning slightly forward. Staff C stated, She was getting pretty tired, as she was opening and closing her eyes. She stated when she was assigned to care for the resident she would put her to bed right after supper as she was a mandatory lay down after meals for safety reasons. Staff D, NA, stated during an interview on 02/20/19 at 9:15 AM, the resident would lean forward slightly if she became tired when seated in her wheelchair. When self propelling her wheelchair the resident would shuffle her feet. She would instruct the resident to pick up her feet, which she did, when Staff D pushed her wheelchair. If the resident was really tired she sometimes would not put her feet up, thus Staff D would return to assist her. Staff E, NA, stated during a telephone interview on 02/20/19 at 10:29 AM, the resident was a priority lay down after meals due to a history of falls, thus she would put the resident to bed right after dinner. At times she would not lift her feet high enough when being pushed in her wheelchair. Per telephone interview with Staff F, NA, on 02/20/19 at 10:24 AM, he stated the resident was seated in her wheelchair at the nursing station prior to the fall. He stated when caring for the resident he usually tried to put her to bed between 6:00 to 7:00 PM as she was a mandatory lay down due to being a fall risk. The night of the fall (02/11/19) the resident was up later than normal. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interviews, and record reviews, the facility failed to prevent physical and psychological abuse to 1 of 10 residents (#2) reviewed for abuse. The facility failed to provide adequate supervision, effective interventions to assure the safety of residents, and evaluate the effectiveness of current interventions to prevent abuse. In addition, staff failed to adequately monitor Resident #1 for physical aggressive behavior and wandering which created an environment of fear for 7 of 9 residents (#'s 3, 4, 5 6, 7, 8, 9). Failure of the facility caused residents to be subjected to emotional and physical abuse, and placed all residents at risk of abuse. Findings included: Resident #1. Review of the resident's medical record showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care, dated 05/11/18, showed he exhibited behaviors of wandering into other residents' rooms and aggression. Review of nursing approaches was to monitor for physical behaviors and wandering, keep resident at a distance from a male resident in room [ROOM NUMBER], approach resident in a calm manner - reapproach at a later time if agitated or uncooperative, and redirect resident as needed when he wanders into other resident rooms. Per review of the plan of care, dated 05/16/18, showed the resident was able to self propel his wheelchair, required one staff member to assist with activities of daily living, and had impaired cognition. Observation of the resident on 01/11/19 at 10:28 AM showed he was seated in his wheelchair by the nursing station sleeping with his arms folded. An interview was attempted at 11:13 AM with no answers to questions asked. At 1:00 PM the resident was self propelling his wheelchair in the short hall of the extended unit. A staff member was directly supervising the resident. Per interview on 01/11/19 at 3:30 PM with Staff F, Administrator, she stated after the state investigator disclosed the interview with Resident #4 (see below) regarding Resident #1 grabbing Resident #4's arm, it was decided to have Resident #1 supervised by staff on a one to one basis. Review of the following Progress Notes (PNs) showed Resident #1's history of behavioral problems: 09/29/18 at 8:00 PM - Staff A (Licensed Practical Nurse) documented the resident wandered into residents' rooms on all halls throughout the facility upsetting numerous residents, and getting into their things. He was removed from Resident #5's room at least three times, Rooms 179 and Resident #8's room two times, room [ROOM NUMBER] three times, and room [ROOM NUMBER] one time. A stop sign banner was placed over the door threshold of Resident #5's room, however the banner did not stop him, thus Resident #5 had to keep her door closed. 10/06/18 at 6:03 PM - Staff A documented the resident continued to wander into other residents' rooms on all the halls throughout the facility, and getting into their things. Numerous residents were upset. The resident was removed from Resident #5's room at least three times this shift. A stop sign banner over the door entrance did not stop him. In addition, he was removed twice from Resident #8's room, three times from room [ROOM NUMBER], and once from room [ROOM NUMBER], and several residents on the long hall of the extended unit. One resident was upset and complained she had tried three times before removing the resident from her room. Received numerous complaints the resident kept going into other resident rooms located on the other halls, and upsetting the residents and their families. 10/11/18 at 7:49 PM - The resident continued to wander into other residents' rooms. When staff attempted to remove him from the rooms the resident would become resistant and hold onto something in order to stop from being moved. This shift the resident repeatedly entered other female residents' rooms and was asked not to go in, explaining they wanted their privacy. The resident grabbed ahold of the Licensed Nurse's (LNs) arm and squeezed tightly. It was very difficult to break away from his grip as he was surprisingly strong. The resident attempted to grab another resident near him as he was being moved in his wheelchair. 11/03/18 at 7:01 PM - Staff A documented she had numerous complaints about the resident going into other resident rooms and through their belongings. Resident #8, completely bedridden, and terrified of Resident #1, stated he knocked things over and got into her things. He would then stand up from his wheelchair and come toward her when she said something to him. Resident #8 was afraid he might do something violent and did not feel safe when he came into her room. Resident #5 stated the resident continued to come into her room and did not leave, thus she had to shut her door to keep him out as he would run through the stop sign banner across her doorway. 11/15/18 at 10:58 AM - Social Services documented the resident was unable to answer or understand questions presented to him due to his dementia. The resident was alert to self only and not able to make his own decisions. Staff had reported six incidents of wandering and two incidents of grabbing, which were both common for the resident and not an escalation in behaviors. 12/29/19 at 8:23 PM - Staff A was at the nursing station when she heard loud screaming down the hall saying get out, get out. Nursing Assistants (NAs) found Resident #1 in Resident #2's room and Resident #1 had his hands on Resident #2's arm twisting and pulling. Resident #2 was calling out in pain. Resident #2 was bedridden and could not get away as she was unable to get out of bed without staff assistance. 01/02/19 at 8:51 PM - Resident #1 was involved in an altercation with Resident #3. Resident #3 was examined for injuries and none were found. Resident rooms were equipped with stop sign banners over the doorways to keep Resident #1 out of their rooms. 01/04/19 at 2:18 AM - Resident #1 continued to be aggressive with staff when he was being removed from another resident room and did not want to be removed. The resident continued to go into other residents' rooms and try to stand up. Resident #2. Review of Progress Notes in the medical record, dated 01/10/19, showed the resident was able to make her needs known, required staff to propel her wheelchair, and two staff to assist with transfers utilzing a mechanical lift device. Review of a facility investigation report showed on 12/29/18 at 6:15 PM Resident #1 entered Resident #2's room and grabbed her arm, twisting and pulling on it. Resident #2 stated he hurt her arm and bruising was evident to the wrist area. Review of witness statements by two NAs showed Resident #2 was crying and screaming at the time of the above incident. The preventative measure was to place a stop sign banner over Resident #2's doorway to keep Resident #1 from entering her room. Per interview on 01/11/19 at 2:30 PM with Staff B, NA, witness to the above incident on 12/29/18, she stated Resident #1 grabs, twists arms and hands, gets aggressive, and behavior unpredictable. On 12/29/18 she heard Resident #2 yelling, get out of here, you've got my arm. Resident #1 had one hand and two fingers with the other hand grabbing Resident #2's wrist. Staff B was able to remove Resident #1's hand off Resident #2's wrist. Staff B stated some residents were scared of Resident #1 as they do not know what he is going to do when he is in their room. Staff B stated many of the door banners were placed on residents' doors approximately two weeks ago, however Resident #5 has had her door banner up since May, (YEAR). Staff B stated Resident #1 was constantly moving. Staff C, Registered Nurse, stated on 01/11/19 at 10:45 AM, there were times when Resident #1 would pull down the banners across the doorways and enter resident rooms. Staff C stated he would not stay in one place at any time. She stated since the incident on 12/29/18 when Resident #1 would pass Resident #2 in his wheelchair, Resident #2 would say, get away, get away. She did not want Resident #2 anywhere near her. Per interview on 01/11/19 at 10:35 AM with Resident #2, regarding the above incident on 12/29/18, she stated It hurt, I screamed and cried. I told him (Resident #1) to get out, get out, and leave me alone. The resident stated she was scared of Resident #1. As she was talking she kept pointing to her wrist where the bruise had been. Resident #3. Review of the resident's medical record showed she was admitted with [DIAGNOSES REDACTED]. Review of a facility investigation report showed she required extensive assistance with all activities of daily living. On 01/02/19 at 5:55 PM Staff B heard the resident yelling out, ouch that hurts. When Staff B entered the resident's room she observed Resident #1 grabbing Resident #3's arm. Staff immediately removed Resident #1 from Resident #3's room. Resident #3 denied being scared of Resident #1, but did not want him in her room. The intervention was all the residents' doors on the extended unit had stop sign banners placed on their doors, and a urinalysis was to be performed on Resident #1. Per interview on 01/14/19 at 7:35 PM with Staff A, she stated Resident #1 had Resident #3's arm with both of his hands. Staff A stated the facility had several residents fearful of Resident #1. Resident #1 would be dozing in his wheelchair, and within minutes would be gone. Staff B stated usually Resident #1 would grab staffs' wrists. There were times he grabbed so hard and would not let go. Sometimes the door banners were effective, and sometimes they were not. Resident #3 stated on 01/11/19 at 10:15 AM, Resident #1 would take down the door banner and come into her room approximately one time per week. She stated she would tell staff to get Resident #1 out of her room and they would. Resident #4. Per interview on 01/11/19 at 10:25 AM, she stated approximately two weeks ago Resident #1 came into her room and grabbed her arm and it really hurt. She denied informing staff relative to the incident and denied being fearful of Resident #1. She stated the door banner across her door had only been in place for a few days, and Resident #1 just takes it down and enters her room. Per interview on 01/11/19 at 3:30 PM with Staff F, Administrator, she stated after the state investigator disclosed the above interview with Resident #4 regarding Resident #1 grabbing her arm, it was decided to have Resident #1 supervised by staff on a one to one basis, which was done. Resident #5. A mental status assessment in the resident's medical record, dated 12/27/18, showed the resident was cognitively intact. Per interview on 01/11/19 at 11:50 AM, she stated Resident #1 would take down the door banner and come into her room, despite her telling him no. She stated approximately a week ago he grabbed her left wrist, however she did not report the incident to staff. He comes into her room everyday, touches everything, and bangs on her table. She stated she was scared of him. Resident #6. The resident stated during an interview on 01/11/19 at 1:00 PM a banner had been placed across her doorway a couple of weeks ago. She stated she felt Resident #1 was harmless but it's still scary. If I'm laying down I feel vulnerable, but if I'm in my chair (electric wheelchair) and I meet him, and I tell him to go away. Resident #7. Per interview with the resident on 01/11/19 at 1:10 PM, she stated Resident #1 had been in her room approximately one time per week, until the time of her move three weeks ago. She stated she would be scared of him if she were lying in bed. The nurses had told her Resident #1 would not let go if he got ahold of her. Resident #8. On 01/11/19 at 1:26 PM she stated Resident #1 came into her room all the time, at least three times daily. She stated she was scared of him, has a mean look, don't trust him. She stated he could go straight through the banner. She stated she had spoken with the Administrator approximately two to three weeks ago regarding Resident #1 and was told, there isn't much she can do. She stated she pretends to call the police when he enters her room. Resident #9. Per interview on 01/11/19 at 1:15 PM, she stated when Resident #1 entered her room he starts touching stuff and I tell him no, no. She stated because staff had told her the resident was mean she was not terrified but am cautious, he pinches and hits. Staff D, Nursing Assistant, stated on 01/11/19 at 12:55 PM, Resident #1 would get around the entire facility in his wheelchair and goes into other resident rooms. He would grab onto things, very aggressive, I'm pretty sure he can take down banners .hard to get away from him once he clamps onto you. Staff E, Social Services, stated on 01/11/19 at 12:20 PM, staff had just started looking into discharging the resident to a more suitable facility. She had just started that day (01/11/19) to interview residents in the facility relative to Resident #1 coming into their rooms, and if they felt frightened. She stated Resident #1 could go right through the door banners. Besides the door banner to protect residents staff was to redirect him. Reference (WAC) 388-97-0640(1)

Based on interviews, and record review, the facility failed to ensure staff provided adequate pain management in a timely manner for 1 of 4 residents (#1) receiving as needed narcotic medication for pain. This failed practice resulted in actual harm to Resident #1, who was admitted to the facility following recent back surgery, and despite several requests for pain medication waited a total of approximately nine hours between doses of narcotic pain medication. Findings include: Resident #1. review of the resident's medical record revealed [REDACTED]. [MEDICATION NAME] (narcotic pain medication) five milligrams (mgs), one to four tablets, was ordered by the physician on 10/23/17 to be administered every four hours as needed for pain. Review of hospital records revealed [MEDICATION NAME] 20 mgs was administered at 10:12 AM and 5:50 AM on 10/23/17, prior to the resident's admission to the facility. Review of Progress Notes, dated 10/23/17 at 12:18 PM, showed the resident was accompanied by a family member to the facility. The resident was alert and oriented. Four surgical incisions were noted to the resident's back area, and were covered with dressings. A pain assessment, dated 10/23/17 at 1:02 PM, revealed the resident's pain level on a scale of 0 (no pain) to 10 (severe pain) was noted as a 3. The resident's physician stated during a telephone interview on 12/11/17 at 1:10 PM, that he saw the resident right after lunch on 10/23/17, and she did not seem to be in pain at that time. He recalled telling the resident she was going to have much pain following her back surgery. He stated the first week following back surgery was horrible for pain issues. A telephone interview on 12/11/17 at 1:30 PM with Staff A, Nursing Assistant (NA), who cared for the resident between 2:00 - 10:00 PM on 10/23/17, noted the resident was having a difficult time with pain, and was requesting pain medication. He stated he had alerted a nurse of the resident's request for pain medication. The NA was unable to recall, when he spoke to the nurse, if the pain medication had not yet arrived at the facility from the pharmacy, or if the resident was not allowed any due to the last time she had received it at the hospital. He stated he had alerted a nurse of the resident's request for pain medication. When he assisted the resident with transferring to the bathroom, she could hardly get out of bed to get to the bathroom due to back pain. She was able to tell Staff A she was in pain, but also she grimmaced in pain with movement. Staff A stated he turned the resident frequently as she became uncomfortable. Staff A stated the first day was a rough one for her. A telephone interview with the clinical manager from the consulting pharmacist, showed they received the signed prescription order for the resident's [MEDICATION NAME] at 2:31 PM on 10/23/17. At 6:40 PM on 10/23/17 a facility staff member had called to receive authorization to pull a dose of [MEDICATION NAME] from the facility emergency kit. The clinical manager stated that once the pharmacy received the signed prescription facility staff could then call and receive authorization to use the emergency kit supply, until the delivery was made. The resident's family member was interviewed by telephone on 12/14/17 at 11:15 AM, and stated he really got angry with staff, due to the resident's pain, approximately four hours following the resident's admission to the facility. The resident at that time was lying in a fetal position moaning in pain. He stated he went to the nursing station to address the resident's pain and was informed staff was waiting on physician's orders [REDACTED]. She did not eat anything for dinner that evening (10/23/17) due to the pain, however had taken fluids. The family member went down to the nursing station a second time, and was told by a male licensed nurse (LN), that he (male LN), needed to check with the other nurses to see if the order had come in for the pain medication. Review of the resident's Medication Administration Record [REDACTED]. Tylenol was administered on 10/23/17 at 2:59 PM for a pain level of 4, however it was not given with the [MEDICATION NAME] as ordered. Documentation noted the Tylenol was effective, however it was unknown when that assessment was made. Despite [MEDICATION NAME] being ordered every four hours as needed for pain, requests by the resident and family member for pain medication, it was not administered to the resident until 7:12 PM on 10/23/17 (nine hours following the last dose). At that time the resident's pain level was noted as a 9. There was no evidence of a nursing assessment relative to the resident's pain following the administration of Tylenol at 2:59 PM. Reference (WAC) 388-97-1060(1)

Based on observation, record review, and interview, the facility failed to provide necessary care in an appropriate and timely manner to address wound complications for 2 of 3 sampled residents (#1 & #2). Resident #1 experienced serious wound infections with observed tissue changes. Despite directives for the facility staff to arrange an appointment with the resident's Surgeon ASAP (as soon as possible) due to the deterioration of the resident's wounds, the facility sent a fax and failed to call to ensure timely follow-up was facilitated. Resident #1 was sent five days later to a routine follow-up appointment. At that time, the resident's condition necessitated hospitalization for intravenous antibiotic therapy and additional surgery. Resident #2 developed a wound infection and the facility failed to complete the necessary follow-up to ensure the prescribed treatment was initiated in a timely manner. Additionally, the resident received an additional dose of antibiotic beyond what was prescribed. Findings include but were not limited to: Resident #1: Review of the medical record revealed the resident was re-admitted to the facility on [DATE] following an amputation on the resident's second leg. The resident had multiple medical [DIAGNOSES REDACTED]. Nurse Practitioner (ARNP), Wound Care Consultant, services were ordered by the Primary Care Physician (PCP) to provide wound care services for the resident, to monitor the condition of the incisional wounds on both legs and to order necessary treatments and follow-up. The 7/27/16 PCP documentation noted the resident had a Healing wound on bilateral stumps. According to the 8/02/16 nursing entry, Resident #1's surgical sites had no drainage or odor. The Surgeon examined the resident that day. A 8/05/16 nursing entry noted a call from the Surgeon's office directing the ARNP, Wound Consultant, to follow-up with scab trimming. New orders also included a directive to soak wounds in water for 2 minutes, pat dry with gauze then wrap in clean dry gauze. The ARNP was notified of the new orders. On 8/08/16 the ARNP completed a debridement (trimming/removal) of the incisions (scabs), 100% on the right and 20% on the left. The ARNP wound note, dated 8/16/16, noted both incisions needed more [MEDICATION NAME]. New treatments were ordered. More swelling was noted on both leg wounds. An 8/24/16 nursing entry identified there was yellow slough on the wound bed on the right leg and a foul odor was present. There was a little yellow drainage to left leg. The 8/26/16 ARNP wound note documented the right incision had mixed yellow slough and red, non-granulating tissue. The incision was open with fried edges and had more swelling. The left incision was also open and swollen. A new daily treatment was ordered, Santyl (a wound care ointment to debride dead tissue in wounds), to the right wound to aid in [MEDICATION NAME] the unhealthy tissue. A nursing entry, dated 8/29/16, noted the resident continued to have a foul odor to the right stump when the daily dressing was changed. On 9/01/16 the ARNP documented, Staff called (with) concern that there were sutures visible in the right stump incision. The left wound had a red and brown wound bed with evidence of swelling present around the wound. The right wound had a 90% yellow/brown non-viable wound bed with mushy tissue. After [MEDICATION NAME] the non-viable tissue, was able to probe bone. Thick brown exudate (drainage) was present and the stump was swollen. There was a marked change in wound. A wound culture was obtained. The ARNP wrote an order on 9/01/16, and documented in the wound note, to Schedule a f/u (follow-up) appt. (appointment) with his surgeon ASAP. The Santyl treatment was ordered for both incisions on 9/01/16. According to a 9/01/16 morning fax transmission, the facility faxed the ARNP's 9/01/16 wound note to the Surgeon's clinic. However, there was no documentation that any facility staff member had called the Surgeon's clinic to attempt to schedule a timely appointment despite the noted wound changes/deterioration and ARNP's directive for an ASAP appointment. In the afternoon on 9/01/16, the day the ARNP noted the significant wound changes/deterioration and ordered the appointment ASAP with the Surgeon, Staff Member B, a Licensed Nurse (LN)/Resident Care Manager, documented in a Weight Change Note, Surgical sites continue to heal slowly. Another 9/01/16 afternoon nursing entry revealed that the resident's Family Member was in the facility that day. The Family Member reported that the resident had a scheduled appointment with the Surgeon on 9/06/16, five days later. There was no documentation in the medical record that the ARNP was notified of the facility's plan to send the resident to the Surgeon five days later, to a previously scheduled follow-up appointment, instead of promptly facilitating an opportunity for the Surgeon to evaluate the resident's significant wound changes identified by the ARNP. A nursing entry, dated 9/06/16, documented the resident left the facility for a follow-up appointment with the Surgeon. The facility then received a call from the Surgeon's office notifying them that the resident was admitted to the hospital and surgery was planned two days later. The Surgeon's office was contacted on 10/21/16 at approximately 10:45 a.m. to inquire about communication from the facility. The Office Staff Person stated they had received the 9/01/16 faxed copy of the ARNP's wound care notes but they had no record of any telephone contact from the facility to attempt to have the resident seen/evaluated. If a telephone call was received from a facility, the office staff contacted the Surgeon for directives even when the Surgeon was not at the office. Faxed documents were reviewed later when the Surgeon returned to the office, often days later. Review of the 9/06/16 hospital Admission History & Physical by the Hospitalist revealed the resident was seen in the Surgeon's clinic that day and was admitted for possible wound debridement and wound VAC placement in two days. In the meantime, the resident was receiving intravenous antibiotic treatment. Gentle hydration was also provided. The 9/08/16 Surgeon's Vascular Surgery Procedure Note documented the resident had bilateral [MEDICAL CONDITION] (right on 5/18/16, left 7/12/16). His bilateral wounds were almost healed with only a dry scab over his incisions one month earlier. The resident had returned to the clinic for follow-up on 9/06/16 with the plan for possible initiation of the prosthesis fitting. However, the resident had developed significant necrotic (dead tissue) wound of his bilateral below knee amputation wound (sic), worst in the right, consistent with wound infection. Excisional debridement of the skin, subcutaneous tissue, fascia (fibrous tissue connecting other structures) and muscle was performed to remove all the infected and necrotic tissue. A wound VAC was placed due to the size of the remaining cavity, to promote healing. On 10/24/16 at approximately 9:35 a.m., the Surgeon was interviewed via the telephone. The Surgeon recalled examining the resident in the clinic on 8/02/16. The wound(s) were approximately 95% healed. Complete healing was anticipated in 2-3 weeks. A follow-up appointment was scheduled on 9/06/16, about a month later, to initiate a fitting for a prosthesis. When the resident returned on 9/06/16 the resident's wounds were grossly infected. The resident was very lucky he was not septic (had an infection involving his entire body). The resident required IV (intravenous) antibiotics to address the severity of the infection (not oral antibiotics). The resident was sent to the hospital for antibiotic treatment and surgical debridement a couple days later. No further vascular compromise was identified. The Surgeon also stated that if the facility staff had called the clinic to report a change or discuss a concern about the condition of the wound(s), she would have made a plan to have the resident evaluated the same day, either in the clinic or the hospital. The Surgeon or her colleague were also available on-call after regular office hours. Resident #2: Review of the medical record revealed the resident was re-admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The resident was seen by the ARNP/Wound Care Consultant at the facility for wound management. According to a 9/27/16 nursing entry, a telephone call was received from the PCP's office. The resident had been seen by the PCP in his office on 9/26/16. The physician reported that the resident's coccyx (same site as previously identified) might have a fistula (an abnormal tract). A culture was done in the office. A 9/29/16 physician's orders [REDACTED]. [MEDICATION NAME] 1 Gram, an antibiotic, was to be injected into the muscle every 12 hours for 5 days, for a total of 10 doses. The injectable antibiotic was to be mixed with 0.9 milliliters of [MEDICATION NAME] (to decrease the pain from the injection). A nursing entry, during the evening shift of 9/29/16, documented the resident had an allergy to [MEDICATION NAME] and the plan was to fax the PCP requesting a review of the order and consideration of another medication. ([MEDICATION NAME] was to be used cautiously in patients with [MEDICATION NAME] allergies [REDACTED]. On 9/30/16 the LN called the PCP's office to report that the resident had refused the [MEDICATION NAME] that morning due to her [MEDICATION NAME] allergy. No further follow-up with the PCP was noted for three more days, until 10/03/16. On 10/03/16 the PCP directed the staff to administer the [MEDICATION NAME]. According to the October 2016 Medication Administration Record [REDACTED]. Following the second administered [MEDICATION NAME] dose, the order was re-written for the [MEDICATION NAME] with more [MEDICATION NAME] added. However, a tally revealed that 11 total doses were administered instead of the ordered 10 doses. On 10/19/16 at approximately 12:30 p.m., Staff Member A, a LN, was observed during a dressing change on Resident #2's right inner ankle wound. Resident #2 was observed to have yellowish drainage that had seeped through the dressing and through her sock. The drainage area of the sock was approximately 3/4 of an inch in diameter. Staff Member A stated that was a usual amount of drainage/presentation. (The damp drainage created a potential point of entry for organisms, an identified risk for the the resident). In preparation for the dressing change, Staff Member A completed a hand wash and then placed gloves. Next, Staff Member A moved a walker out of the area with gloved hands. Without another hand wash and glove change, Staff Member A proceeded to remove the soiled dressings, cleanse the wound with normal saline (a solution compatible with body fluids), place the new foam wound covering, and then place the wrap. No hand wash/glove change was completed between the soiled and clean phases of the wound care. On 10/20/16 at approximately 11:30 a.m., an interview was conducted with Staff Member B, a LN/Resident Care Manager. Staff Member B noted there was no documented follow-up with the PCP between the 9/30/16 call and 10/03/15 when the PCP gave directives to administer the medication.

Based on observation, interview, and record review, the facility failed to consistently evaluate the resident's clinical condition, define and re-evaluate the impact of the interventions and/or revise interventions to ensure that a resident without a pressure ulcer did not develop one for 1 of 3 sampled residents (#58) who acquired pressure ulcers in the facility. This failure resulted in the development of a painful unstageable pressure ulcer causing physical harm. Additionally, the facility failed to consistently monitor skin status, identify a pressure ulcer, assess and implement necessary care and services in a timely manner for 1 of 1 sampled residents (#86) reviewed with an unidentified pressure ulcer. This delay in assessment caused a delay in treatment of [REDACTED]. Further, the facility failed to consistently, accurately, and appropriately assess pressure ulcers for 1 of 1 resident (#19) reviewed who had pressure ulcers upon admit. Without the correct and informative assessments, this failure caused a potential for inappropriate and/or timely treatments which could effect the healing process. Findings include but are not limited to: The Facility Policy and procedure for Skin at Risk Program Overview dated 11/2015 identified the procedure that nurses would use in prevention and assessment, as follows: 1. The Skin at Risk Program is based on the nursing process and includes: a. Identification of residents at risk for skin breakdown b. Care plan development to prevent skin breakdown c. implementation of care plan interventions consistent with current standards of nursing practice d. Evaluate and monitor interventions consistent with current standards of nursing practice. 3. Development of Stage 1 or greater pressure ulcer will be documented on an Incident report and investigate per protocol. An avoidable pressure ulcer means the resident developed a pressure ulcer and the facility likely failed to do one or more of the following--evaluate the resident's clinical condition and pressure ulcer risk factors define and implement interventions that are consistent with resident needs, goals, and recognized standard of practice, monitored and evaluated the impact of the interventions and revised the approaches as appropriate. Resident #58. Per medical record review, she was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. According to the 02/12/16 comprehensive admission assessment, she had cognitive impairment and required extensive assistance by two nursing staff for bed mobility (turning in bed), transfers, toilet use, and personal hygiene. The assessment included a skin assessment, dated 02/05/2016, which documented that there were no skin issues or pressure ulcers present. Review of the resident's 02/17/16 care plan identified a rash on the resident's bottom with interventions of re-positioning with goals for the resident not to develop skin problems. There was no identification of a pressure ulcer on the care plan. On 08/04/16 at 8:40 a.m., Staff Member E, a Registered Nurse (a RN), stated when the resident came into the facility on [DATE] she did not have a pressure ulcer. The resident was confused and did not want to move and was incontinent of bowel and bladder. The resident developed an excoriated red area on her bottom from incontinence. Staff Member E also stated the resident had a fall on 02/20/16; it was noticed there was a dark area on sacrum so it was staged as unstageable it was dark purple and boggy. We wanted to get get her up and work with therapy but sometimes she did not want to get up. Staff Member E stated the staff did not investigate to learn how she developed a pressure ulcer. Review of the Initial Ulcer Assessment, dated 02/21/16, revealed the resident had acquired an unstageable pressure ulcer on her coccyx (tail bone) and it was described as boggy, purple hue, warm, and clear blood-tinged drainage (drainage would indicate the skin was no longer intact). On 02/29/16 (8 days later) a wound evaluation documented in the medical record revealed dark black eschar (dead tissue-scab) on the coccyx and was described as much worse, since she has fallen this week (02/24/16) opening the skin on her bottom. A physician progress notes [REDACTED]. The physician note also noted a facility acquired large stage 4 sacral (tail bone) pressure sore The physician diagnosed low blood pressure, dehydration, failure to thrive, Stage 4 pressure ulcer, poor prognosis, grave condition (all would be considered an increased risk for skin breakdown). On 08/04/16 at 9:40 a.m., the family representative stated the resident had acquired the pressure ulcer in the facility and had cried in pain. On 08/05/16 at 10:15 a.m., Staff Member F, the Director of Nursing Services, stated she had been told when the resident had been admitted to the facility she had been placed on a standard facility mattress. During interview on 08/05/16 at 11:30 a.m. with Staff Member A, the Administrator, she stated only after the resident developed the open pressure ulcer was she changed to a pressure relieving matress. Interview on 08/05/16 at 10:30 a.m. with Staff Member G, the Rehabilitation Manager, stated she became aware of the resident's unstageable pressure ulcer on 02/22/16 and changed her basic cushion for comfort to a pressure relieving cushion in the resident's wheel chair. Interview on 08/05/16 at 10:40 a.m., Staff Member H, a Registered Nurse, she stated the ulcer is still open and there is some tunneling but it is much smaller. The ulcer was observed as a hole on her coccyx. On 08/04/2016 11:00 a.m., Staff Member Q, a Rehabilitation Program Assistant, was interviewed, and she stated she helped in rehab therapy interpret for Spanish speaking residents. The stated the resident complained she was in pain, sick, and had a wound on her bottom. The resident would often cry causing stress for her family. Resident #86. Per record review the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/02/16 at 1:20 p.m., Resident #86's skin was observed during incontinent care provided by Staff Members J and K, both Nursing Assistants (NAs). In addition to a dressing on the resident's left foot, there was a preventative foam adhesive pad ([MEDICATION NAME]) on the left hip and no pad on the right hip. The right hip had a solid dark red spot approximately 2 centimeters in diameter. On 08/02/16 at 2:00 p.m. Staff Member N, a Resident Care Manager (RCM), stated the resident currently had one pressure injury on her left foot near the small toe. (Staff Member M did not identify that she was aware of the reddened area on the resident's right hip.) Review of a 08/02/16 progress note referred to monitoring and elevating the resident's left foot. However, there was no mention of the red right hip. A skin/wound note dated 08/03/16 written by Staff Member O, a Licensed Nurse (LN) addressed the status of the left foot wound and included [MEDICATION NAME] placed bilateral hips for preventative purposed (sic). Resident turned q (every) 1 hour. Review of physician orders [REDACTED]. Review of the nursing assistant task for skin observations from 07/22/16 to 08/04/16 documented none of the above observed (scratched, red area, discoloration, skin tear, and open areas). On 08/04/16 at 9:30 a.m. Staff Member O stated she had changed the resident's protective hip pads earlier that morning. The resident was noted in bed on her back and off loaded to her right side. When asked about the red spot on the resident's right hip, the LN stated she was not aware of any current red areas. With the help of Staff Member L, a NA, the LN removed the right hip protective pad; the adhesive of the pad was observed stuck to the reddened area of skin as the pad was not centered over the red area. The LN stated she did not know it was there and could now see that the skin was not intact with a small break in the skin. The same day at 9:50 a.m., Staff Member L stated the red area on the resident's right hip had been there a couple of days and she had reported it to Staff Member M, a LN, on 08/01/16. On 08/05/16 at 10:40 a.m. Staff Member N stated the nursing assistants were to report skin injuries to the licensed nurse who then should assess, start an incident report and notify the physician for orders. Resident #19. The medical record review noted he was admitted [DATE] with [DIAGNOSES REDACTED]. The complicated wound included surgical amputations of toes and tendons with removal of infected tissue on the forward/front part of the foot. Review of the 05/03/16 'Admission Profile' assessment documented the left heel had two pressure ulcers with 100% hard eschar tissue (dark, thick dead tissue) adhered to the wound bed. Review of the 05/04/16 'Initial Ulcer Assessment' documented left heel pressure ulcer, present on admit, was 1.0 by 1.0 centimeters (cm) in length and width. The wound was described as containing slough (light colored, soft, moist, dead tissue in the process of separating from the viable portions of the body). But later in this same assessment, the 'wound bed' was then described as 100% eschar, and not slough. Review of the 'Weekly Ulcer Measurement Wound Evaluation' assessments on 05/11/16, 05/18/16, 05/25/16, and 06/01/16 combined the evaluation of the two pressure ulcers. Each evaluation documented the size as 1.0 cm by 1.0 cm. However, on thewound evaluation sheets dated 06/22/16, 06/26/16, 07/13/16, 07/20/16, and 07/27/16 , the assessments were further combined for the two pressure ulcers along with the surgical wound of the front part of the foot. On each of these dates, the size of the wounds were also combined without a definite description of where the pressure ulcers were located and the appearance of each separate ulcer. Further, the pressure ulcers were increasing in size to 1.2 by 1.2 cm without an assessment as to the cause. During an interview on 08/08/16 at 4:00 p.m., the Director of Nursing reviewed the resident's ulcer/wound assessments and stated each of the two pressure ulcers should have had individual assessment sheets; not the two ulcers together on one assessment. An interiew on 08/09/16 at 10:00 a.m. with Staff Member E, a licensed nurse, revealed the resident had been admitted on to her unit. She demonstrated the location on her foot where the two pressure ulcers were located underneath and close to the back of the mid-heel area. (The exact location had not been described on any of the ulcer assessments.) When interviewed on 08/09/16 at 1:00 p.m., Staff Member H, a LN, stated the resident had a large major wound on the toe area of his left foot which had a dressing that he had changed. He did not remember the heel ulcers; they got lost in the larger wound. He stated the last skin assessment sheet he saw described only the wound on the toes. He reviewed the skin ulcer sheets and the physician treatments and evaluation documentation and then stated the progression of the heel ulcers were not clearly described in the assessments. The documentation led him to believe there was only the massive wound on the front part of the foot/toes.

Based on record review and interviews the facility failed to provide the necessary care and services to maintain the highest practicable level for 2 of 5 sampled residents (#'s 1, 2) relative to pain management. This deficient practice resulted in harm to Resident #1 as her pain worsened due to the delay in receiving her pain medication by Staff A (Licensed Nurse). Findings include: Resident #1: admitted to the facility on [DATE] from the hospital following abdominal surgery. Review of a nursing assessment dated [DATE] revealed the resident was alert and oriented, and had a large, midline abdominal incision measuring 7.5 by 3 inches with a depth of 5 inches. Review of a facility Resident/Visitor Concern Form revealed pain medications were not given on the night shift when the resident requested them. Further documentation stated the resident had requested pain medication due to a tooth problem at 4:45 a.m. on 12/26/14, but she never received them from Staff A. The resident had asked Staff E (Nursing Assistant on the day shift) for pain medication at 6:00 a.m., and stated she had previously made this request at 4:45 a.m. Review of the facility Narcotic Log revealed Staff A had signed out pain medication (ordered every six hours) at 11:05 p.m. on 12/25/14, and the next dose was not obtained until 6:45 a.m. on 12/26/14. Review of Progress Notes dated 12/30/14 revealed an x-ray of the resident's tooth noted it was infected and had decayed into the nerve. An interview with Staff E at 1:20 p.m. on 1/9/15 noted when she came to work at 6:00 a.m. on 12/26/14 the resident requested pain medication, and had stated she had asked for pain medication earlier at 4:45 a.m. and had never received it. Staff E stated the resident was very upset and stated she had previous issues with Staff A relative to not receiving her pain medication. Interviews with the resident on 1/8,9/15 revealed she had been in much pain the morning of 12/26/14 and did not receive any pain medication until 1-2 hours after she had requested it. She stated the problem with pain medication had been going on for 1-1.5 months, but had not been a problem in the past 4 days. Her pain level was between 6-7 (on a scale of 0-10 with 0 being no pain, and 10 being severe pain) when she initially requested medication, and would increase to 8-9 with the delay in receiving it. She also stated she had issues with Staff A on 10/19/14 when she requested pain medication at 2:40 a.m. (it was due to be given at 2:45 a.m.), 3:15 a.m., 4:00 a.m, and finally received it at 6:00 a.m. by Staff A. She stated Staff F (Nursing Assistant) had answered her call light three different times on 10/19/14 regarding her request for pain medication. The resident stated a third time occurred on 1/5/15 when she put on her call light on at 4:25 a.m. and asked Staff G (Nursing Assistant) for pain medication. At 5:43 a.m. she again put her call light on and Staff G answered it stating, "you never got it?" She stated she finally received her pain medication from Staff D at 6:10 a.m. Review of the facility Narcotic Log in October 2014 and January 2015 revealed the resident had pain medication ordered to be given every 4 hours as needed. On 10/18/14 Staff A had obtained pain medication at 10:45 p.m. on 10/18/14 and the next dose she obtained was at 6:00 a.m. on 10/19/14 (7 hours and 15 minutes later). On 1/5/15 Staff D obtained pain medication at 6:00 a.m. for the resident. Review of the facility Call Light Response report revealed on 10/19/14 the resident had put her call light on at 2:48 a.m., 3:35 a.m., and 5:39 a.m. On 1/5/15 the resident had put her call light on at 4:27 a.m., and 5:54 a.m. A telephone interview on 1/13/15 at 7:43 a.m. with Staff G noted he recalled the resident requesting pain medication on the night shift and had informed Staff A of her request. He stated the resident called again for pain medication and he again informed Staff A. Resident #2: An interview with the resident on 1/9/15 at 3:12 p.m. noted she would have to wait 1.5 hours at times to receive pain medication when Staff A worked the night shift, and it was ordered every four hours as needed. She stated one night the previous week she had to use her call light three times to request pain medication and each time a Nursing Assistant (NA) would answer her light. The NA stated Staff A was working her way down the hall. She stated she needed pain medication to help her walk as she just had hip surgery on 12/16/14. review of the resident's medical record revealed [REDACTED]. Her Medication Administration Record [REDACTED]. A telephone interview on 1/13/15 at 7:43 a.m. with Staff G noted he recalled the resident requesting pain medication on the night shift and had informed Staff A of her request. He stated the resident called again for pain medication and he again informed Staff A.

Based on record review and interviews the facility failed to promptly address grievances for 1 of 7 sampled residents (#1). Failure of the facility to communicate, update and resolve Resident #1's grievances resulted in psychological harm to the resident. Findings include: Resident #1: admitted to the facility on [DATE] from the hospital following abdominal surgery, which resulted in a [MEDICAL CONDITION] (a surgical procedure that brings the large intestine out through an opening (stoma) made in the abdominal wall. Stools moving through the intestine drain through the stoma into a bag attached to the abdomen). Review of a nursing assessment dated [DATE] revealed the resident was alert and oriented with some anxiety; required assistance with toileting, transfers, and bed mobility; and in addition to the [MEDICAL CONDITION] had a large, midline, abdominal wound measuring 7.5 by 3 inches with a depth of 5 inches. Review of a facility Resident/Visitor Concern Form dated 9/20/14 revealed the resident stated to Staff B (Social Service Director) that Staff A was rude to her. Staff A had stated to the resident that she had tried to change the [MEDICAL CONDITION] bag, but it was "too hard" and she was "too busy, so you'll have to wait until the morning." Staff A then left the resident with rags and a pad. The resident's [MEDICAL CONDITION] bag was loose and needed to be changed. The resident stated to Staff A that she did not want stool everywhere to which Staff A stated "either way there's going to be BM (bowel movement) everywhere." The Concern Form stated the resident did not sleep from 1-5:00 a.m. because she was worried her stool would "migrate" into her incision. Documentation stated Staff B changed the staffing so Staff A would no longer work with the resident. During interviews conducted with the resident on 1/8/15 at 8:15 p.m. and 1/9/15 at 1:50 p.m., she stated Staff A had changed her [MEDICAL CONDITION] bag on 9/19/14 between 10:00 p.m. and midnight, however it had come off again and needed to be changed as it was leaking stool around the sides. Staff A had gotten frustrated and stated to the resident she was "not working with that (referring to [MEDICAL CONDITION] bag) again." She stated towels were placed on her left side due to stool leaking, however Staff A never returned to her room to check the [MEDICAL CONDITION] bag. She stated she had to lie in "feces" that night with it coming close to her incision, and in the morning Staff C (Nursing Assistant on the night shift) assisted in cleaning the stool off of her. The resident stated she was very upset and hurt to know someone would not help her. Following the incident she had asked that Staff A not care for her any longer as she was not a "friendly person," and was told by Staff B she would not be. However, the resident stated Staff A continued to work with her. She stated she would would keep track of the nights she worked as she would "look forward to her days off." A telephone interview on 1/9/15 at 1:35 p.m. with Staff B revealed she thought "it had been handled (referring to Staff A no longer working with the resident)," but was made aware around Christmas time Staff A had continued to work with the resident. Review of a written statement by Staff D (Licensed Nurse on the day shift) and an interview on 1/9/15 at 11:55 a.m. revealed the resident had told him Staff A did not have time to change her [MEDICAL CONDITION] bag during her shift. Staff D stated the resident was concerned it would get into her surgical incision. A washcloth with brown fecal material was noted around the [MEDICAL CONDITION] bag when Staff D went to change the bag the morning of 9/20/14. Staff C stated during a telephone interview on 1/12/15 at 6:56 p.m. the [MEDICAL CONDITION] bag and wafer around it were coming off and the resident was having loose stools. Staff C stated she was told by Staff A that she wasn't going to change it ([MEDICAL CONDITION] bag/wafer) again and the resident would have to wait until the next shift. The incident occurred between approximately 1-1:30 a.m. The resident was very upset and told her she was going to talk to someone in the morning about it. Staff C stated she felt bad for the resident as she needed help. She did assist the resident in the morning by cleaning her up from the stool. Review of a second facility Resident/Visitor Concern form dated 12/26/14 regarding the resident noted medications were not given on the night shift when she requested them. Further documentation revealed Staff A had not administered the resident's pain medication when she requested it at 4:45 a.m. on 12/26/14. This allegation was addressed to Staff A on a piece of paper and also stated to please ensure she was no longer working with the resident. The piece of paper was noted to be left for Staff A at the time clock on 12/26/14 by Staff H (Social Services Assistant). Staff H documented on 12/26/14 that she had attempted to see the resident four times that day (12/26/14), but she was either unavailable or out of the facility. Documentation between 12/29-31/14 revealed several attempts were made to see the resident, but again she was unavailable or out of the facility. Staff H interviewed the resident on 1/2/15 and documented Staff A was "doing better, has had no further issues." A documented interview with the resident on 1/2/15 (7 days following her allegation) revealed that she had waited an hour for pain medication and no one came until the day shift. She stated she had been informed when she first was admitted by Staff B that she would not have to "deal" with Staff A again due to an incident that had occurred (referred to the incident on 9/20/14). An interview with Staff H on 1/9/15 at 1:25 p.m. revealed that she left a copy for Staff A of the resident's allegations regarding pain medication at the time clock. The Administrator stated on 1/13/15 at approximately 3:00 p.m. that a decision was made on 1/9/15 (following the state investigation that day) by administration to remove Staff A from caring for the resident. Despite the resident's grievances relative to the care given to her by Staff A, staff failed to take appropriate measures to resolve those grievances in a timely manner. Cross-refer to F309. The facility failed to provide the necessary care and services to maintain the highest practicable level regarding pain medication.

Based on record review and interviews the facility failed to perform the necessary assessments, care, and treatment in response to changes in the condition of 1 of 3 residents (#1) reviewed for changes in condition. This failure to timely and accurately assess the resident's change of condition and administer pain medication caused harm to Resident #1 and placed all residents at risk for inadequate care and treatment. Findings include: Resident #1: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care revealed she had impaired cognition with memory impairments, and required staff assistance with transfers. Review of the resident's medical record noted on 10/11/14 at 3:45 p.m. and on 10/13/14 at 2:30 p.m. the resident was found on her back on the floor of the bathroom. The resident stated she did not know how it happened. Documentation stated there were no obvious injuries with either fall. at the time they occurred. On 10/14/14 at 1:53 p.m. documentation stated the resident complained of some left hip pain that morning. The resident was able to stand and when she was assisted in the bathroom at lunch she did not appear in pain as she had that morning. The alert status was updated at that time to monitor the resident for left hip pain. That evening (10/14/14) at 7:25 p.m. documentation by Staff A (Licensed Nurse - LN) stated the resident "grimmacing and sucking air through her teeth" when transferring to the toilet. The resident was unable to tell the LN where the pain was located or how severe it was. Later at 9:48 p.m. the resident grimmaced when assisted to stand to use the bathroom and sucked air through her teeth. She denied pain when asked if she was hurting. Despite the resident's expression of pain with transfers, and knowledge of two recent falls, there was no evidence a thorough assessment of the resident was performed to determine if any injuries existed Despite changes in the resident's condition and need for monitoring (recent fall and onset of grimmacing with transfers) there was no further assessment of the resident until 10/15/14 at 9:05 a.m. (11 hours and 17 minutes later). Documentation at that time stated the resident continued to grimmace and groan with transfers with pain to left hip. The physician was faxed at that time and caregivers were made aware of the resident's pain. Upon consultation on 10/15/14 at 10:30 a.m. with the resident's guardian relative to the left hip pain following the fall on 10/13/14, she agreed to have x-rays performed on the resident if the physician felt it was appropriate. The physician was faxed at that time for x-ray orders. On 10/16/14 at 12:32 a.m. documentation stated a narcotic medication was administered to the resident for "severe pain on the left side" with noted effectiveness documented at 6:38 a.m. Review of the resident's Medication Administration Record [REDACTED]. X-rays of the left hip were obtained on 10/17/14 and results obtained on 10/20/14 revealed a left [MEDICAL CONDITION]. A telephone interview with Staff A on 11/18/14 at 1:35 p.m. noted that when she transferred the resident to the toilet and later to bed on 10/14/14 she grimmaced like she was in pain, however the resident denied it. Despite the resident's falls and expressions of pain during transfers in conjunction with her dementia, staff failed to thoroughly assess the resident for possible injuries and provide pain management in a timely manner.

Based on interviews and record reviews the facility failed to thoroughly investigate incidents of sexual abuse, protect residents, prevent further incidents, and report to appropriate agencies in accordance with 42 CFR 483.13(c)(3)(4) for three of six female residents (#'s 2,3,4) involving one male resident (#5). This failure placed residents at risk for abuse due to lack of thorough investigations and prevention. This resulted in actual harm to Resident #4. Findings include: Resident #5: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care revealed he was able to propel his wheelchair, had a language barrier, and transferred with staff assistance. Review of a facility investigation report revealed on 9/28/14 at 1:58 p.m. the resident reached over to Resident #2, removed her blanket from her chest, and repeatedly squeezed her breast. The incident occurred at the nursing station. The resident was immediately removed from the area. Resident #2 had stated to the resident during the incident, "Stop that, don't do that." Following the incident Resident #2 had no recollection of what had occurred and stated no one had been bothering her. Medication changes were made and a urinalyis was done, which was negative. Despite the resident's ability to self propel the preventation plan established following the incident was to keep the resident at least an arm's length from female residents and frequent visual checks. An interview on 11/14/14 at 4:15 p.m. with Staff B (Director of Nursing) revealed frequent visual checks were every hour as standard checks were every two hours. On 10/23/14 at 7:50 a.m. the resident was observed grasping Resident #3's breast with his left hand and was squeezing aggressively. The resident was immediately removed from the area. The investigation noted the resident was initially placed in the dining room by staff, however he propelled himself out of the dining room and approached Resident #3, who was seated right outside the dining room and squeezed her breast. In addition to medication changes and discharge planning, the preventative plan following the incident was to keep the resident in line of sight at all times when he was out of his room and every 15 minute checks. The investigation did not determine the pace at which the resident was able to self propel prior to the development of a preventative plan. Following the incident Resident #3 displayed no changes in behavior. Review of a facility investigation report revealed on 10/26/14 at 12:50 p.m. Resident #4 was screaming at the nursing station area and pointing to her right breast. The investigation revealed the resident's caregiver had placed him to the right of the couch at the nursing station (his usual place). She then informed the LN that she had to go into another resident's room to perform care. The LN had her back turned to Resident #1 when he propelled his wheelchair over to Resident #4 and grabbed her breast. Review of Resident #4's medical record and facility investigation report revealed she was aphasic but could communicate her needs, alert and oriented, and aware of her surroundings. Following the incident she was upset from being grabbed inappropriately. An interview on 11/14/14 at 1:50 p.m. with Staff C (LN) noted the resident propelled himself using his left leg. The LN stated the resident was "quicker than you think...if resident was in need of something he can propel himself." The above sexual abuse incidents on 9/28/14 and 10/23/14 were not reported to local law enforcement or the State agency as required.

Based on observation, record review, and interviews the facility failed to provide interventions for 1 of 3 residents (#16) reviewed for weight loss. Resident #16 was identified by the facility to have a posture that limited her ability to eat properly. The facility did not take any action to to further assess or implement further interventions to support a position that would allow her to properly eat and drink her meals. This failure resulted in a significant weight loss for this resident. Resident #16. [DIAGNOSES REDACTED]. Review of the resident's weight and vitals summary documented the resident's weight of 105 pounds (lbs) on 01/07/14 and a weight of 94 lbs on 06/10/14 a weight loss of 11 lbs. or 10.5% in the past 6 months (severe). On 06/03/14 at approximately 7:25 a.m., the resident was observed sitting in her wheelchair next to the nurses' station. She was hunched over, chin to her chest, and her eyes closed. She sat hunched over for approximately 40 minute while waiting for her breakfast. At approximately 8:00 a.m. the resident was placed next to the dining table; Staff Member B, a Nursing Assistant (NA), placed the meal tray on an over bed table and proceeded to feed the resident. During the entire meal the resident's posture was in a hunched over position with her head to her chin and periodically opening her eyes and mouth when spoken to by Staff Member B. Within 15 minutes of starting the meal, the resident refused to eat any further and requested to be taken to her bed. The resident consumed 2 bites of a banana and several sips out of a liquid supplement. The resident was observed to cough twice after drinking the supplement and once after swallowing one bite of banana. On 06/03/14 at approximately 8:30 a.m., Staff Member B stated she had been caring for the resident and feeding her breakfast and lunch on a one to one basis "for about 3 to 4 weeks she has trouble eating she bends down and can't feed herself. I think she gets tired sitting that way." (referring to the hunched over position) She added the resident seemed to like to eat in her room in bed, "she likes the quiet of the room and tends to eat better." On 06/03/14 at approximately 9:13 p.m., the resident's representative stated "she (the resident) had lost weight and seemed to have lost interest in eating. I visit about once or twice a month, so I do not really get a chance to see her during meals. I know she has a problem with eating." On 06/05/14 at approximately 9:15 a.m., Staff Member A, a Resident Care Manager (RCM), stated she was in charge of the 900 unit. "We moved Resident #16 on 05/08/14 to the 900 unit eating area because it was a quieter area and she could get one to one support with meals." She added prior to the moving her to the 900 unit eating area "the resident was being distracted by another resident who kept telling her to straighten herself up, so the resident started to refuse to go to the small dining room." She added "I have been concerned that the resident's hunched over posture while sitting in her wheelchair put her at risk for falling out of her chair as she had a history of [REDACTED]." On 06/05/14 at approximately 12 noon, Staff Member B was observed feeding the resident in her bed. The resident was in a semi-reclined position. The NA stated "she seems to eat better when she is in bed and is not hunched over. I have told the nurses about her liking to eat while she is in bed." The resident was alert, asking for food and fluids, consumed 90% of her 8 oz. supplement, 4 small bites of a meat ball, noodles, and cake. Approximately 20 minutes into the meal the resident stated "I am full" and refused to eat any further. On 06/05/14 at approximately 2:00 p.m., Staff Member C, the Registered Dietician (RD), stated she had completed an annual assessment on Resident #16 on 01/17/14 and felt the resident's weight was stable at 105 pounds. "From her history she has been a thin person. I was told by nursing staff the resident was feeling embarrassed about eating in the small dining room, you know she has kyphosis." The RD added she had seen the resident in April and May and had noted a weight loss. She had not observed the resident in her new setting nor had she taken into consideration the resident's poor posture and its impact on her eating. In addition the RD stated she was not aware of any reports that the resident was experiencing coughing spells during meals. On 06/05/14 at approximately 3:45 p.m., Staff Member A stated "in December (12/04/13) of last year I requested an occupational evaluation of her wheelchair and an under arm self-releasing seat belt. The physician ordered the self-releasing belt to help keep her in an upright position, but I did not follow through and never got the belt. (The physician consultation dated 12/18/13 documented extreme lumbar flexion and the needed bracing or harness to maintain upright posture.") I should have also requested a physical therapy evaluation, but I did not." On 06/06/14 Staff Member A also stated she had made a referral for speech evaluation for the resident's coughing. She added she had interviewed the NAs in the 900 unit regarding the resident's coughing during meals and "yes, she has been coughing for a long time, they were unable to tell me exactly for how long and they had not notified me." Record review revealed an occupational therapy evaluation dated 12/17/13 identified her static sitting as fair with a kyphosis posture. The speech evaluation, dated 06/05/14, documented the resident had some difficulty with swallowing. Recommendations included upright posture during meals. On 06/06/14 at approximately 12 noon Staff Member D, the Physical Therapist (PT), stated the resident's "evaluation was done today the hunched over position put the resident at risk for aspiration as the food might not go down the right passage. I am recommending a chest harness and requesting from the State a tilt in space wheelchair." She added "I was not aware the resident was experiencing posture problems." On 06/11/14 at approximately 12:15 p.m. Staff Member A, a RCM, stated the resident received her tilt in space wheelchair and she was able to be placed next to the dining table and was able to feed herself and view the other residents at the table. Only after the issue of the resident's posture was brought to the facility's attention by the surveyor did they obtain a tilt in space chair to improve her posture for meals. Failure to identify the resident's posture as a contributing factor in her severe weight loss placed the resident at risk for complications related to her nutritional status.

Based on observation, record review, and interview, the facility engaged in mistreatment and financial exploitation of 1 of 3 sampled residents (#5) when: a) the facility attempted to obtain Social Security payee status as a means of securing payment of the resident's monthly financial obligation and/or past due balance owed to the facility; and b) the facility's corporate office served documents on the resident which purported to sue the resident for the balance she owed to the facility. Securing the right to receive a cognitively alert resident's social security payments without her permission was a violation of her rights. Serving legal documents, of unknown authenticity on the resident constituted resident mistreatment/harassment. Instead of taking allowable actions in response to the resident's non-payment, the facility took steps that intimidated the resident, even though the facility was obligated to advocate for and protect her. Findings include but were not limited to: A.) Payee Issue: Resident #5: Review of the medical record revealed the resident had a chronic condition that resulted in dependence on staff for assistance with many activities of daily living such as bed mobility, transferring, and dressing. The resident participated in decision making regarding community access and the associated risks. A 5/06/13 social service entry documented a discussion about the resident's choice to leave the facility in her wheelchair to access the community. The 5/31/13 quarterly assessment revealed the resident scored 15 out of 15 on the cognitive assessment, indicating the resident was cognitively alert. A social service entry on 8/26/13 noted the resident was "currently experiencing financial difficulties and is at risk of diminished psychosocial well-being" related to these issues and a care plan was initiated. Resident #5 was interviewed on 3/21/14 at approximately 11:20 a.m. about her care, treatment, and financial issues. The resident offered specific details and dates without difficulty. Although seated in a wheelchair, she accessed and operated her computer to provide supporting documentation. The resident stated she had managed her own finances without difficulty since admission (1/17/05). Unexpectedly, she had received a (6/28/13) letter from the Social Security Administration notifying her that the facility had been granted protective payee status due to her inability to manage her money. The resident stated the facility had initiated the action to obtain representative payee status in order to obtain her social security funds directly, without her having to pay the facility. When asked about the balance owed the facility, the resident reported she had paid approximately 85% of her bill but she had some concerns about the facility environment and its billing practices that she wanted addressed (prior to fully paying the facility). According to 6/28/13 documentation from the Social Security Administration Resident #5 was notified, "that we have information that shows you need help managing your money and meeting your needs. Because of this information we plan to send your Social Security benefits to ADM REGENCY CARE CNTR. We will call this organization your representative payee...." Resident #5 provided a copy of a 7/11/13 letter written to the Social Security Administration requesting reconsideration of the decision to make the facility protective payee. Resident #5 further stated the payment of the Social Security funds was paid directly to the facility. The resident subsequently contacted the local police department to report the theft of her funds by the facility. Following that action, the resident was notified that the Social Security Administration had reversed the action and the resident would receive her funds again. The resident stated the facility had engaged in harassment toward her. Review of 8/02/13 police report revealed a contact with the resident on that date due to a report of theft of $1000 dollars. The report noted that an administrative contact had stated the facility was made representative payee because the resident was not paying her bill. It was further reported by the administrative contact that the resident had a chance to dispute the decision but had chosen not to. When interviewed on 3/21/14 at approximately 3:00 p.m., the facility Administrator stated she recalled a conversation between herself, the business office manager, and corporate individuals discussing suggestions for how to obtain payment from Resident #5 for the unpaid balance. The idea that was suggested/proposed was to have the facility contact the Social Security Administration and obtain representative payee status. The action was not something the resident had requested. As a result the resident experienced mistreatment and financial exploitation when the facility and corporate representatives launched a plan to represent the resident as unable to manage her financial affairs, and in need of the facility assistance, in order to capture more of her funds to apply to her bill. B.) Summons/Law Suit: According to a 3/02/14 nursing entry, there was a man at the facility who stated he had legal papers "to serve" on Resident #5. The nurse on-duty pointed to the location of the resident's room (and allowed him to enter the room). On 3/21/14 at approximately 1:00 p.m. Resident #5 described a 3/02/14 incident when a man entered her room after calling out her name. He did not knock or request permission to enter the room. When the resident heard her name, she thought it was a caregiver's voice. The resident was eating her meal with her back to the door and never saw the man's face. "The server" reportedly dropped the envelope on the resident's tray table stating, 'Read it' and exited the room. Resident #5 stated it felt like "the server" was "trespassing." The resident expressed concern that the individual could have been anyone, even someone who could have physically hurt her. Resident #5 opened the envelope and identified a "Summons," dated 12/19/13, stating, "A lawsuit has been filed against you..." by the facility (related to non-payment). The document referenced the Walla Walla Superior Court as the jurisdiction where the lawsuit had been filed against the resident. Thereafter, two nurses entered the resident's room to check on her well-being. From that time on two person care was initiated for all resident contact, not just the care requiring two persons for safety. The resident stated that having two persons in her room for all facility staff contacts (even bringing her a hot beverage) made her "uncomfortable." The resident stated she requested a conference to discuss the issues. Resident #5 further stated she experienced increased physical symptoms such as fatigue, increased breathing difficulties, and sleep issues. Although a part of her disease, the symptoms worsen with stress. During the resident interview, the resident stated she had come to question the authenticity of the document(s) received. The actions taken by the facility established "a pattern of harassment." A follow-up telephone contact on 3/24/14 at approximately 1:20 p.m. with the Walla Walla County Clerk's office revealed the lawsuit had not been filed with that jurisdiction. Instead of the facility/corporation taking the actions legally allowed for non-payment, it engaged in resident mistreatment and financial exploitation, in an attempt to coerce the resident into paying her bill.

Based on observation, record review, and interviews the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 3 sampled residents (#2) reviewed for accidents. In addition, staff failed to ensure preventative measures were followed to prevent further injuries. Resident #2 sustained second degree burns to her chest from hot coffee. Findings include: Resident #2: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In addition, the resident suffered a stroke in September 2013. Review of the resident's plan of care revealed she had impaired memory and decision making ability, was short tempered with aggressive/disruptive behaviors. Review of the Resident Status Sheet dated 12/17/13 noted the resident fed herself in her room following set-up, and had abnormal movements to all extremities, Review of an Occupational Therapy (OT) Evaluation form dated 12/18/13 noted the resident had impaired gross and fine motor skills relative to coordination and manipulation with poor sitting balance and safety awareness. The evaluation also stated the resident's mood fluctuated between calm to rage. Review of Progress Notes dated 12/5/13 noted the resident threw her entire 240 milliliters of tea on a staff member's shirt. Review of a facility investigation report revealed on 12/22/13 at 7:00 p.m. the resident had spilled coffee onto her chest. Staff Member D (Nursing Assistant - NA) had given her thickened coffee like she did every night. The resident sustained [REDACTED]. By 8:45 p.m. that evening the areas to her chest were noted to be fluid filled blisters (second degree burns). The facility investigation concluded the resident had "abnormal involuntary movements to all extremities." Staff Member D had obtained hot water from the staff breakroom coffee maker and used a nectar thick coffee packet to make the resident's coffee which she gave to her. The resident jerked and spilled coffee causing the burn. The water temperature from the coffee maker in the staff break room was eight degrees higher at 173 degrees than it should have been (no more than 165 degrees). Preventative measures established following the above incident included placing lids on all coffee drinks, clothing protector on resident when given coffee, and staff obtaining hot water from the coffee maker in the activities room rather than the staff break room. A telephone interview on 1/2/14 at 2:40 p.m. with Staff Member D revealed hot water for the resident's coffee in the evening was obtained from the staff break room as the kitchen was closed. She stated that five minutes after she had given the resident her coffee she had spilled it onto herself causing the burns. There was no clothing protector on the resident, nor were any lids used on the coffee cup. Staff Member D stated the resident displayed jerking movements of her arms and head. She "spills her tea alot," but had never seen her spill coffee before. Staff Member E (NA) stated on 1/2/14 at 11:20 a.m. resident would get upset and start flailing her arms if her schedule was not the same. She stated since the burn incident on 12/22/13 the resident had thrown her entire meal tray onto the floor. Paper plates were utilized during meals due to her behaviors of throwing plates. An interview on 12/31/13 at 3:20 p.m. with Staff Member F (OT) revealed the resident "spills all the time, often see signs of spillage on clothes, she grabs drinks no matter how far away they are placed." She stated the coffee drink was new for the resident as usually she only drank cold tea. Since her hip fracture in September her trunk control had worsened and had more delay in her response time. Despite the resident's involuntary, jerking type movements; poor decision making, safety awareness, and sitting balance; impaired cognition with behavioral problems; and recent decline secondary to a hip fracture; the facility failed to adequately supervise staff to ensure the safety of the resident while taking hot beverages relative to assistive devices and hot water temperatures. On 12/31/13 at 12:00 noon a meal tray was served by a NA to the resident in bed. A cup containing thickened coffee was on the tray without a lid. The pureed food was served on paper plates. The NA then exited the room without recognizing the need for a coffee lid. The resident's head was in constant motion with jerking type movements during the observation. She kept her head down while eating. The state investigator made staff aware of the situation prior to the resident drinking from the cup. Despite preventative measures to place lids on all coffee drinks staff did not supervise to ensure measures were implemented.

Based on record review and interviews the facility failed to ensure 1 of 5 sampled residents (#1) were free from significant medication errors. This failed practice resulted in harm to Resident #1 as she was transferred to the emergency room (ER) to treat symptoms of lethargy secondary to an overdose of [MEDICATION NAME] (narcotic medication). Findings include: Resident #1: Review of physician's orders [REDACTED]. Standards of nursing practice require that the old patch be removed prior to a new patch being applied to ensure the correct dosage of medication ordered by the physician. Review of Progress Notes dated 3/18/13 at 6:30 p.m. noted the resident had a decline in her level of consciousness during the shift and had interrnittent "blowing respirations". She was responsive but sluggish and her eyes were "glazed over." She exhibited a poor appetite at supper. The physician was notified and orders were received to transfer her to the ER. Review of hospital records dated 3/18/13 revealed the resident received [MEDICATION NAME] (medication used to counter the effects of narcotic overdose). Documentation stated she was much more awake after removing the two [MEDICATION NAME]es and administering [MEDICATION NAME]. Review of the facility investigation report revealed on 3/16/13 Staff Licensed Nurse (LN) A placed a new [MEDICATION NAME] on the resident; however, the old patch was not removed. The investigation stated no "impact noted." A telephone interview on 4/4/13 at 4:00 p.m. with Staff LN B revealed when the ER called the facility on 3/18/13 with an update on the resident's condition prior to sending her back to the facility they stated she had two Fentanly patches on at the same time. They administered [MEDICATION NAME] (medication used to counter the effects of a narcotic overdose) to the resident. An interview on 4/4/13 at 3:00 p.m. with Staff A revealed she placed a new [MEDICATION NAME] on the resident on 3/16/13. She stated she did not remove the old patch as she was unable to find it. The resident was very difficult to turn due to her size thus she only looked at her upper back area in an attempt to locate the old patch. During a telephone interview on 4/4/13 at 3:25 p.m. with the resident's family member she stated she was with the resident in theER on [DATE]. She stated when she arrived to the ER the resident was not moving or talking, her face was swollen and she was drooling. Staff was reversing the effects of the narcotic patches by administering a medication intravenously. After the medication was completed the resident started to talk and seemed "more like normal". Despite standards of practice to remove the old [MEDICATION NAME] prior to placing a new one staff did not thoroughly visualize the resident's body thus the resident received an overdose of the narcotic medication necessitating a transfer to the ER for treatment.

Based on observation, record review, and interviews the facility failed to ensure the medication regime for 1 of 3 residents reviewed (#1) was free from unnecessary drugs. The facility failed to ensure on-going evaluation and monitoring of a medication given for short term treatment of [REDACTED]. Findings include: Resident #1: admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. On 6/4/12 [MEDICATION NAME] (used for short term relief of anxiety) was ordered by the physician to be given twice daily as needed for anxiety. Adverse effects of the medication included confusion, dizziness, [MEDICAL CONDITION], sleep disturbance, slurred speech, irritability, muscle weakness and tremors, blurred vision, and somnolence. Review of the resident's June 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the June 2012 Behavior Monitor form noted the targeted behaviors for the [MEDICATION NAME] were exit seeking, verbally aggression towards staff or residents, and verbalization of suicide. Due to the frequency of behaviors the medication was changed on 6/27/12 to twice daily rather than as needed. On 7/12/12 at 7:40 p.m. the resident was found on the floor with bleeding from her nose and mouth. She was transferred to the emergency room . Review of hospital records noted she had displayed "excess sedation and weakness in her legs" since being on routine [MEDICATION NAME]. Despite frequent episodes of exit seeking and verbal aggression in June 2012 review of the Behavior Monitor form for July noted only a minimal number of episodes occurred. However, there was no assessment noting the change in frequency of targeted behaviors and possible need to reduce/discontinue the [MEDICATION NAME] until the fall on 7/12/12 resulting in a fractured nose. At that time the [MEDICATION NAME] was discontinued. Review of a Nutrition Committee Review report dated 7/20/12 noted the resident had a five pound weight loss in a two week period of time between 6/21 (125 pounds) to 7/5/12 (120 pounds). On 7/23/12 at 2:15 p.m. Staff Member C (Licensed Nurse) stated the resident was sleeping alot after the [MEDICATION NAME] was changed to twice daily. We "probably should have adjusted it." An interview on 7/23/12 at 2:50 p.m. with Staff Member K (Nursing Assistant) revealed at the time of the resident's fall on 7/12/12 she no longer could bear weight with standing due to weakness in her legs or transfer herself. She stated she would fall asleep in her wheelchair and at her best was only eating 20% of her meal. Despite the change in the resident's condition exhibited by a decrease in targeted behaviors, weight loss, increased sleeping, and change in functional status; staff did not evaluate the changes and take appropriate measures in a timely manner. Cross-refer to F323. The facility failaed to provide sufficient supervision to prevent accidents.

Based on observation, record review, and interview, the facility failed to provide sufficient supervision to prevent accidents for 1 of 3 sampled residents (#1) reviewed with identified behaviors. Failure to sufficiently supervise the cognitively impaired resident resulted in actual harm due to falls resulting in substantial injury. Findings include: Resident #1: Review of the medical record revealed the resident had multiple medical [DIAGNOSES REDACTED]. She independently mobilized her wheelchair. She was at high risk for falls due to her unsteadiness. According to a 5/28/12 9:00 p.m. nursing entry, the resident went out the front door and was looking for her car. A follow-up elopement assessment was conducted. The resident's picture was added to the Resident of the Month Club to alert visitors not to aid the resident in exiting the building. Review of the 6/13/12 nursing entry noted that a facility Licensed Nurse (LN) found Resident #1 outside the back door (at 6:45 p.m.) wheeling herself on the sidewalk. The resident was placed on an every hour staff check to establish her whereabouts. A nursing entry on 6/15/12 documented the resident left the building via the front door during the evening shift. The plan of care was amended to include every 15 minute staff checks on the resident. The 6/21/12 nursing entry stated visitors found the resident walking outside in the parking lot. The 6/21/12 facility investigation noted the resident was walking in her stocking feet. The resident was trying to access her car and stated she wanted to go home. The resident was returned to the building without injury. Although there was no change in the supervision plan, there was a plan to escort the resident every shift she was awake to see her vehicle. A 6/22/12 facility investigation documented the resident was found outside the main entrance at 3:20 p.m. The resident's plan of care was changed to one-on-one supervision. Review of the facility monitor checks revealed no documentation for 6/15/12 or 6/16/12 after a transition to the every 15 minute checks. The documentation contained no recorded checks for the 6/22/12 elopement interval. When interviewed on 7/12/12 at approximately 5:35 p.m., Staff Member E (LN), stated the facility was missing the observational sheets for 6/15/12, 6/16/12, and for the elopement interval on 6/22/12. On 6/27/12 the resident's physician changed the Clonazepam (used to treat anxiety) medication order from as needed (ordered on [DATE]) to twice daily. Adverse effects included confusion, muscle weakness, somnolence, and dizziness. Although the resident was currently on one-to-one staff observation, per the plan of care, there were multiple observations on 7/11/12 at approximately 12:46 p.m., 1:55 p.m. 2:55 p.m., and at 3:55 p.m. when the resident had no staff members in close proximity. The resident was observed attempting to eat a lunch tray that was observed at her bedside for approximately two hours. Later she appeared to be drowsy in her wheelchair with her eyes closed and her head extended backwards. On 7/12/12 at approximately 9:15 a.m. the resident was in her room without any staff members present. On 7/12/12 at approximately 2:30 p.m., Staff Member D was asked about the whereabouts of Resident #1. She stated, "We need to keep an eye on her." The Staff Member searched for the resident and located her in a room adjacent to the nurses' station. On 7/12/12 at approximately 2:35 p.m., Staff Member F (Nursing Assistant), stated the resident's supervision plan was "rocky" as it took an aide off the floor to sit with Resident #1 so they tried to switch off the duty to supervise her. Staff Member F (Nursing Assistant) stated the resident had eloped multiple times on the evening shift in the past but they were typically able to hear the front door alarm when it sounded. (The resident had exited the back door as well.) Review of the resident's medical record and facility investigation report noted documentation on 7/12/12 at 7:40 p.m. stating the resident was found in her room beside the bed laying on her right side in an eight inch pool of blood. She had a laceration under her chin and was bleeding from her nose and mouth. Bruising was noted around both eyes and her cheeks. The resident complained of severe pain in her right hip and both arms. The resident was transported to the emergency room where she was diagnosed with [REDACTED]. Despite the plan for the resident to be on one-to-one staff observation there was no staff members present at the time of the fall. Review of the plan of care following the fall noted interventions which included one-to-one "continual monitor." Despite the planned intervention of one-to-one continual monitor by staff review of the medical record noted on 7/14/12 at 12:30 a.m. the resident was heard calling for help. She was found on the floor and had sustained a quarter size bump to the back of her head. Despite the above intervention of one-to-one continual monitor an interview with Staff Member D (LN) on 7/23/12 at 2:40 p.m. revealed the facility did not have the staff to sit by her. She stated when the resident was in bed sleeping staff would check on her every 5-10 minutes and when she was up it was one-to-one staffing. Staff Member D also stated the resident would often try to get up when she was in bed. Staff Member A (LN) stated on 7/23/12 at 2:45 p.m. that the resident was to be a one-to-one but it was "hard to do secondary to staffing issues." She stated the resident moved alot and quickly. She stated at night the resident was on 15 minute checks. Despite the resident's elopements, impulsive behavior, high risk of falls due to an unsteady gait, history of falls, and use of an antianxiety medication; the facility failed to provide consistent staff supervision to protect the resident from accidents.

Based on observation, record review, and interviews the facility failed to allow 1 of 6 sampled residents (Resident #1) to make choices relative to bathing. Resident #1 suffered psychological harm due to failure by staff to provide showers in the evening on a routine basis. Findings include: Resident #1: During an interview with the resident on 4/18/11 at 3:00 p.m. she stated staff was not offering to give her a shower in the evening and often it was a month before she received a shower. She stated she liked her showers in the evening before bed and had told staff that when she was first admitted . "They are not asking me - its just like I don't exist...its the only thing they do for me". "They tell me they will see how the evening goes and if they have time they will squeeze me in...they have time to care for other residents but not for me". She stated 8:00 p.m. was the latest time she wanted to be showered as she was tired by then but often it was after 8:00 p.m. when staff finally got time to care for her. Prior to her last shower on 4/15/11 a family member of her roommate had gone and asked staff if she could get a shower and was initially told staff had to get everyone ready for bed first. During the above statements the resident was very upset as noted by the loud tone of her voice and the angry expression on her face. An interview on 4/15/11 at 3:20 p.m. with the above family member revealed that she "had to go to bat" for the resident twice, once on 4/15 and then on 4/4/11. Both times she asked staff to give the resident a shower as the resident was upset about the lack of showers she was receiving. She stated the last time was on 4/15/11 as she was going to take the resident out of the facility for a birthday party on the weekend and knew the resident wanted to be showered before she left. She stated she was told the staff never know how the shift was going to go and would try to get to her, however they had to put other residents to bed first. She stated that often the resident would try and make arrangements for a shower and then staff would come in at 9:00 p.m. and the resident was too tired, thus she would not get her shower. She stated in March her hair was so matted as she had not had her hair washed for a month. An interview on 4/18/11 at 3:00 p.m. with Licensed Nurse #1 revealed the above family member had approached him on 4/15 and 4/4/11 regarding the resident wanting a shower. He stated that prior to that time he did not realize how "adament" the resident was about getting her showers in the evening and had assumed she was getting them during the day. He stated she was the only resident in the facility who was requesting an evening shower. An interview with Nursing Assistant #1 on 4/18/11 at 2:00 p.m. revealed the resident would want her shower at 7:00 p.m. however staff was busy with other residents at that time. "We would try and tell her (the resident) can't predict how the evening shift would go and would try and get to her as soon as we could." Review of the resident's bathing records revealed the resident had not had a shower between 2/8 - 3/4/11 (24 days), 3/4 - 4/4/11 (31 days), and 4/4 - 15/11 (11 days). Despite the resident wanting her showers in the evening she was scheduled for showers during the day on Mondays and Fridays.

Based on record review and interviews the facility failed to immediately consult with the physician for an acute change of condition for 1 of 3 sampled residents (Resident #1) reviewed for notification. Failure to immediately consult with the resident's physician resulted in harm to the resident due to a delay in receiving medical treatment. Findings include: Resident #1: Readmitted to the facility on [DATE] from the hospital following surgery for [REDACTED]. Review of documentation dated 12/15/10 by the hospital PT stated the resident had ambulated 20 feet using a walker with two staff members assisting. Review of Progress Notes dated 12/16/10 at 11:59 p.m. noted the resident refused some of her evening medications and was removing her nasal cannula. At 1:00 a.m. on 12/17/10 the resident was noted to be "minimally responsive to name" with irregular respirations. Later that same day at 1:00 p.m. the resident was "very lethargic" and was not able to take her medications. On 12/18/10 documentation throughout the day noted she continued to be very lethargic and was unable to eat breakfast or lunch or take medications. Documentation at 4:10 a.m. on 12/19/10 noted the resident's body temperature had increased to 100.7 degrees with an increased respiratory rate of 40 breaths per minute. Tylenol was administered for her temperature. Her oxygen saturation levels had decreased to 88% so the oxygen level was increased to 2 liters per minute. Twenty minutes later at 4:30 p.m. the resident continued to be febrile with a temperature of 100.4 degrees and rapid respirations. The physician was notified at 4:50 a.m. on 12/19/10 and ordered to send the resident to the emergency room (ER). Review of the ER report noted the resident had aspiration pneumonia and severe kidney disease. The treatment plan was for intravenous antibiotics. Review of the PT Evaluation form dated 12/17/10 noted an assessment of the resident was unable to be performed by the PT due to the resident's lethargy. An interview with the PT at 1:00 p.m. on 12/20/10 revealed the resident's lethargy had worsened on 12/18/10 from her initial assessment on 12/17/10. An interview with the Resident Care Manager (RCM) on 12/20/10 at 1:15 and 3:40 p.m. noted the resident was "very different" on 12/17/10 thus she had typed out a faxed message to the physician asking for an order for [REDACTED]. Despite the change in the resident's condition the faxed message was never sent to the physician as a few hours later on 12/17/10 the resident was observed by the RCM sitting in a chair for a short period of time taking a small amount of fluids and eating pudding. An interview with Nursing Assistant (NA) #1 on 12/20/10 at 1:25 p.m. noted on 12/17/10 the resident slept most of the dayshift and did not eat any breakfast or lunch. She had transferred the resident into a wheelchair for lunch however the resident just sat in the chair sleeping. The next day on 12/18/10 she was very sleepy and not responding. The NA stated the resident was unable to eat or drink anything during the dayshift. Nursing Assistant #2 stated on 12/20/10 at 1:20 p.m. that the resident was "doing pretty bad" on 12/18/10. She was unable to awaken the resident at 7:30 a.m. and she had no oral intake during breakfast and lunch due to her lethargy. A telephone interview with a family member on 12/21/10 at 3:30 p.m. revealed that after the resident was readmitted to the facility her condition had "gotten worse". The resident was "completely out of it" in the facility. Despite the signficant changes in the resident's condition following her readmission to the facility staff did not consult with the physician in a timely manner, thus not allowing the physician an opportunity to initiate medical treatment.