Every finding on record at Regency Care Center at Monroe

Based on record review and interview, the facility failed to ensure a pharmacy recommendation for a gradual dose reduction (GDR) was implemented as ordered by the provider for 1 of 5 residents (Resident 49) reviewed for unnecessary medications. This failure placed the resident at risk for receiving unnecessary psychotropic medications and potential adverse drug effects.Finding included.Review of the facility policy titled, Medication Regimen Review, revised date 06/01/2024, documented nursing staff should act upon the recommendations contained within the Medication Regimen Review. Resident 49 readmitted to the facility on [DATE] with diagnoses to include depression.Review of Resident 49's July 2026 Medication Administration Record, documented the resident was receiving Trazodone (an antidepressant) 50 milligrams (mg) orally once daily at bedtime, active since 12/29/2025.Review of Resident 49's comprehensive care plan, initiated 09/30/2024, documented an intervention to evaluate psychotropic medication therapy for potential gradual dose reduction per regulatory guidelines and when clinically necessary. Review of Resident 49's pharmacy consultation report, dated 01/15/2026 at 2:27 PM, revealed a pharmacist recommendation to initiate a gradual dose reduction of Trazodone to 25 mg orally once daily at bedtime. Under the physician's response section, the box stating I accept the recommendation(s) above, please implement as written was checked, signed, and dated by the provider on 01/16/2026.Review of Resident 49's Electronic Health Record from 01/15/2026 to 07/29/2026, revealed no documentation indicating the physician-approved pharmacy recommendation was implemented, nor was there documentation of any discussion with the provider or resident to hold or cancel the dose reduction.In an interview and record review on 07/30/2026 at 10AM, Staff H, Registered Nurse/Resident Care Manager, stated Resident 49 had attempted a dosage reduction in December, but not in January. Staff H verified there was no documentation or follow-up regarding the physician's order to decrease the dose in January.In an interview on 07/30/2026 at 12:35 PM, Staff B, Director of Nursing, stated that the facility missed the pharmacy recommendation and the corresponding physician order to decrease the medication dosage. Staff B stated the expectation was for staff to follow provider's orders and pharmacy recommendations in accordance with facility policy and regulatory guidelines. Refer to WAC 388-97-1300(4)(c)

Based on observation, interview and record review, the facility failed to promote dignity and privacy, and to develop a comprehensive care plan regarding indwelling catheter (a flexible tube placed in the bladder to drain urine continuously) care for 1 of 2 residents (Resident 6) reviewed for catheter care. The facility left the resident's catheter drainage bag uncovered and failed to initiate a care plan addressing the resident's indwelling catheter. This failure placed the resident at risk for compromised privacy, loss of dignity, unmet catheter care and diminished quality of life. Findings included. Review of the facility policy titled, Indwelling Urinary Catheters, revised date 04/2018, documented resident with indwelling catheter care would have care plan interventions developed to prevent complications, and residents with catheter bags would have them covered or use of bags that provided dignity while in bed with visibility from hallway, out of their room or in community. Resident 6 admitted to the facility on [DATE] with diagnoses to include urinary retention. According to the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 07/20/2026, the resident was cognitively intact and utilized an indwelling catheter. <DIGNITY> In an observation on 07/28/2026 at 10:56 AM and 1:29 PM, Resident 6's catheter drainage bag was observed hanging uncovered on the side of their wheelchair, clearly visible from the hallway. In an observation on 07/29/2026 at 8:47 AM, Resident 6 was observed sitting in a wheelchair in the main hallway while being pushed to the shower room by Staff G, Certified Nursing Assistant. The catheter drainage bag was hanging on the side of the wheelchair without a privacy cover, exposing urine to full view. In an interview on 07/29/2026 at 12:31PM, Staff G stated Resident 6 did not have a privacy cover on the catheter drainage bag until after completing their shower. In an interview on 07/29/2026 at 1:51PM, Staff H, Registered Nurse/Resident Care Manager, stated that catheter drainage bags should be covered to maintain the resident's privacy and dignity. <CARE PLAN>Review of Resident 6's comprehensive care plan, printed on 07/28/2026 at 4:02 PM, revealed no focus area, goals, or interventions regarding indwelling urinary catheter care. In an interview and record review on 07/29/2026 at 1:51PM, Staff H stated that Resident 6 had utilized an indwelling catheter since 07/06/2026. Staff H confirmed that a catheter care plan should have been initiated and verified that none was present in the record. In an interview on 07/30/2026 at 12:35 PM, Staff B, Director of Nursing, stated that staff were expected to always cover catheter drainage bags to preserve resident dignity and privacy. Staff B confirmed catheter care instructions and interventions must be properly documented in the resident's comprehensive care plan. Refer to WAC 388-97-1060(1)(3)(c )

Based on interview and record review, the facility failed to ensure that unless the facility had a full-time Registered Dietician, that the Dietary Manager (Staff D) had completed an academic program in nutrition or dietetics accredited by an appropriate national accreditation organization. This failure placed residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.Findings include .In an interview on 07/28/2026 at 9:30 AM, Staff D, Dietary Manager stated that they have worked as Dietary Manager for a year and a half. They had completed the Dietary Manager Certification course and needed to complete the testing to obtain their certification. Staff D provided a certificate that showed ServSafe Food Protection Manager Certification. Online research showed that this was not the required credential as a Dietary Manager.In an interview on 07/30/2026 at 3:18 PM, Staff C, Regional [NAME] President, stated Staff D had completed the Dietary Manager Certification course and needed to complete testing. Staff A stated they have a Registered Dietitian that spent 16 hours a week at their facility and 16 hours a week at their other facility and were available anytime they needed them. They also have a full- time corporate dietitian that is available as needed.This was a repeat citation.Reference WAC 388-97-1160(3)(a)(b)(i)

Based on interview and record review, the facility failed to prevent physical abuse for 1 of 2 residents (Resident 1) reviewed for abuse. This failure placed residents at risk of injury and emotional distress.Findings included.Review of a facility policy, titled, Abuse/Neglect/Misappropriation/Exploitation, revised date 10/2022, documented physical abuse included hitting and slapping.Resident 1 had moderately impaired cognition according to the Minimum Data Set (MDS, an assessment tool) dated 03/04/2026.Resident 2 had severely impaired cognition and rarely understood others according to the MDS dated [DATE].Review of a progress note, dated 05/21/2026, documented Resident 1 had been hit on the side of the head by another resident.Review of a progress note, dated 05/21/2026, documented Resident 2 had struck another resident on the head. The note documented Resident 2 was attempting to push another resident in their wheelchair. Other residents that were present told Resident 2 to stop pushing the wheelchair which caused Resident 2 to become agitated and struck the other resident in the head.During an observation and interview on 06/03/2026 at 8:44 AM, Resident 2 was ambulating in the hallway. Resident 2 did not respond verbally to questions.During an interview on 06/03/2026 at 11:49 AM, Staff A, Registered Nurse (RN)/Resident Care Manager (RCM), reported they had not witnessed the interaction between Resident 1 and Resident 2 but had spoken with the other residents that were in the day room when it occurred. Staff A reported the residents had relayed that Resident 2 came up behind Resident 1 and started to push their wheelchair. Resident 1 told Resident 2 to stop, and the other residents present also told Resident 2 to stop. Resident 2 then struck Resident 1 on the side of the head. Staff B stated the residents that witnessed the incident were cognitively intact.During a phone interview on 06/03/2026 at 12:04 PM, Staff B, RN/RCM, stated they heard loud voices coming from the day room and entered as Resident 2 was leaving the room. Staff B reported the other residents in the room reported Resident 2 hit Resident 1. Staff B stated they observed Resident 1 sitting in the wheelchair with their hands folded in their lap and stated, I don't know why that just happened. Staff B stated Resident 1 did not report pain at that time.During an interview on 06/03/2026 at 12:20 PM, Resident 3 reported they were a witness to the interaction between Resident 1 and Resident 2. Resident 3 stated Resident 2 started to push the wheelchair of Resident 1 who told them to stop. Resident 3 reported they told Resident 2 to stop as well. Resident 3 reported Resident 2 hit Resident 1 with a flat hand on their head.During an interview on 06/03/2026 at 12:29 PM, Resident 4 reported they were a witness to the interaction between Resident 1 and Resident 2. Resident 4 reported Resident 2 came up behind Resident 1and hit them on the head.During an interview on 06/03/2026 at 12:50 PM, Resident 5 reported they were in the day room when there was an interaction between Resident 1 and Resident 2. Resident 5 reported they were in their wheelchair and had their back to the incident but could hear Resident 1 telling Resident 2 to stop and then Resident 3 also told Resident 2 to stop. Resident 5 stated they heard a slap but not able to see Resident 1's reaction, but then Resident 2 left the day room.During an interview on 06/03/2026 at 12:40 PM, Resident 1 stated they had not had any issues with any of the other residents on the unit. Refer to WAC 388-97-0640(1)

Based on interview and record review, the facility failed to ensure that unless the facility had a full-time Registered Dietician, that the Dietary Manager (Staff E) had completed an academic program in nutrition or dietetics accredited by an appropriate national accreditation organization. This failure placed residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services. Findings include . In an interview on 05/02/2025 at 10:13 AM, Staff E, Dietary Manager stated that they have worked as Dietary Manager for almost a year. They were currently enrolled for the dietary manager certification and will be done in December 2025. Staff E provided a certificate that showed ServSafe Food Protection Manager Certification. Online research showed that this was not the required credential as a Dietary Manager. In an interview on 05/06/2025 at 10:10 AM, Staff D, Registered Dietitian stated that they work 32 hours a week. They work 2 days in the facility and 2 days at the other facility in Coupeville. They visit the facility one day a week and work from home the second day. In an interview on 05/06/2025 at 10:45 AM, Staff A, Administrator, stated that their Dietary Manager was still working on getting their certification. Staff A stated they have a Registered Dietitian that was hired full time by their corporate office. They spent 2 days at their facility and 2 days at their other facility and were available anytime they needed them. They also have a full- time corporate dietitian that oversees things. This was a repeat citation. Reference WAC 388-97-1160(3)(a)(b)(i)

<EQUIPMENT SANITATION> During an observation on the Cascade unit on 05/07/2025 at 2:25 PM, Staff S, NAC, was observed pushing the mechanical lift from inside room [ROOM NUMBER] and placed it along the wall in the hallway. Staff S did not disinfect the mechanical lift. One minute later, observed Staff K, exit room [ROOM NUMBER]. Staff K reported that they had used the lift with Staff S in room [ROOM NUMBER]. Staff K walked down the hallway and into another room and did not disinfect the mechanical lift. During an interview on 05/07/2025 at 2:50 PM, Staff K stated they had not disinfected the lift because Staff S had pushed it into the hallway. Staff K stated that the mechanical lift should have been wiped with disinfection wipes after use. During an interview on 05/07/2025 at 2:52 PM, Staff S stated that they had not disinfected the mechanical lift after using it in room [ROOM NUMBER]. In an observation on 05/01/2025 at 9:27 AM observed Staff U, NAC, left room [ROOM NUMBER], a room with an EBP sign on the door, with a mechanical lift. Staff U parked the mechanical lift against a wall that had wipes mounted to it. Staff U left the mechanical lift and returned to room [ROOM NUMBER] without cleaning the lift. In an interview on 05/01/2025 at 2:50 PM, Staff U stated the mechanical lifts were to be cleaned both before and after use. Staff U stated there were specific cleansing cloths mounted to the wall where the lifts were parked to wipe them down. Staff U stated they did not wipe the lift down after the use in room [ROOM NUMBER]. <GARBAGE HANDLING> On 05/07/2025 at 9:31 AM observed Staff Y, NAC using their bare hands to push garbage down in the garbage can located in room [ROOM NUMBER], then removed the bag from the garbage can and exited the room. room [ROOM NUMBER] had an EBP sign pinned to their door. In an interview on 05/07/2025 at 9:32 AM, Staff Y acknowledged they were not wearing gloves when pushing the garbage down in room [ROOM NUMBER] with bare hands. Staff Y stated they were told not to wear gloves in the hallway. No other information was provided. Refer to WAC 388-97-1320 (1)(2)(b) <ENHANCED BARRIER PRECAUTIONS> Resident 40 was admitted on [DATE] with wounds in the right knee and right calf. In an observation on 05/05/2025 at 12:17 PM, Resident 40's door showed a sign that resident had EBP in place. The sign documented staff were to wear a gown when providing high contact care, such as dressing, transferring, providing hygiene or changing briefs. In an observation on 05/05/2025 at 12:17 PM, Staff K, NAC and Staff J, NAC were both wearing gloves prior to going to Resident 40's bedside. Neither staff were wearing gowns during pericare, dressing and transferring resident to their wheelchair. In a joint interview on 05/05/2025 at 12:33 PM, with Staff J and Staff K, Staff J stated that the EBP sign was for Resident 40. Staff K stated that the EBP sign meant that staff should wear gowns and gloves during wound care. Staff K stated the resident had wounds on their legs and that's why resident had the EBP sign. Both staff read the sign and Staff K stated that they should have worn gowns, and they forgot to wear them. Based on observation, interview and record review, the facility failed to ensure that staff were compliant with Infection Prevention and Control Guidelines (IPCP) and standards of practice for 1 of 3 units (Cascade Unit) reviewed for infection control practices and 1 of 2 residents (Resident 4) observed with personal care. The facility failed to follow IPCP standards during resident care activities and when handling garbage. The facility failed to ensure that staff used Personal Protective Equipment ([PPE] - specialized clothing worn to protect from infection or illness) during personal care, high contact resident care activities and handling garbage and failed to sanitize equipment after use. These failures placed all residents and staff at an increased risk for the potential transmission of infections. Findings included . Review of a facility policy titled, Transmission-Based Precaution, Revised date 11/2024, documented Enhanced Barrier Precaution (EBP) are indicated for residents with chronic wounds. Review of a facility policy titled, Resident Equipment Sanitation, Revised date 10/2017, documented staff will use a disinfectant spray or wipe to cleanse non-critical items (mechanical lift) between uses by different residents. <RESIDENT 4> Resident 4 admitted to the facility on [DATE]. Review of the Minimum Data Set Assessment (assessment of care needs), dated 03/26/2025, documented Resident 4 was dependent on personal care. In an observation on 05/05/2025 at 11:44 AM, Staff Q, Nursing Assistant Certified (NAC) and Staff R, NAC, provided peri-care (the practice of washing the genital and anal area) to Resident 4 after putting on gloves. Staff Q and Staff R removed Resident 4's brief and wiped the perineal area and buttocks. Without performing hand hygiene or changing gloves, Staff Q and Staff R applied a clean brief and pants for Resident 4. Staff Q and Staff R placed a mechanical lift sling, (material that lifts person in the air with a machine to move to another surface) under Resident 4's body, and moved Resident 4 to a wheelchair. Staff R's touched and opened the privacy curtain with the same contaminated glove. With the contaminated gloves on, Staff Q picked a comb from Resident 4's nightstand and combed their hair. In an interview on 05/05/2025 at 11:57 PM, Staff R stated they should perform hand hygiene and change their gloves after cleaning Resident 4's perineal area and before applying the clean brief, but they had not done that. In an interview on 05/06/2025 at 12:32 PM, Staff O, Registered Nurse/Infection Preventionist, stated staff needed to perform hand hygiene and change gloves after cleaning the perineal area and bottom before applying a clean new brief. Staff O stated staff needed to change gloves and perform hand hygiene when providing care from dirty to clean.

Based on interview and record review the facility failed to have a system in place that ensured grievances were addressed and resolved in response to residents' verbal conveyance of concerns for 6 of 6 resident council's (October 2024, December 2024, January 2025, March 2025 and April 2025), who verbalized complaints during Resident Council (RC) meeting and failed to follow the grievance process for 1 of 1 residents (Resident 47) who voiced grievances of missing pants. These failures led to residents repeatedly reporting the same issues without resolution and placed them at risk of feeling frustrated, unimportant, with diminished self-worth and decreased quality of life. Findings included . In a review of the facility policy titled, Grievance Procedure showed the facility would have a process in place for notification, identification, and follow up of resident/resident representative grievances in a timely manner. The facility would utilize their grievance form and ensure that all written grievances decisions included the date the grievance was received, summary of the grievance, steps taken to investigate the grievance, the findings of the grievance and the date of the written decision related to the grievance. Review of RC minutes for the previous six months showed: October 2024 Minutes showed the attending residents voiced the evening trash containers becoming too full. November 2024 Minutes showed the attending residents voiced they would like more shower aides, the nursing staff needed to be more mindful of noise at night when providing care to their roommates, and beds needed to be made timelier. December 2024 Minutes showed the attending residents voiced the nursing assistants were not getting messages to the nurses when they needed their care. January 2025 Minutes showed the attending residents voiced they were itching as result of the laundry detergent. April 2025 Minutes showed the attending residents voiced the staff at night were loud. In a group interview on 05/02/2025 at 2:30 PM with residents that attended RC (Resident 1, 3, 8, 10, 13, 14, 35, 36, 38, 39, 41, 47, 51, 55, 57, and 63) stated review of the prior RC's meeting minutes occurred, however there was not follow up on the grievances brought up during the council meeting. In review of the noted grievances from RC minutes October 2024-April 2025, the residents stated they had not received notification or status of the resolution to the grievances from the prior month. In a review of the facility's grievance log from November 2024 through May 5, 2025 there were no documented grievances from resident council or Resident 47. On 05/02/2025 at 2:43 PM Resident 47 stated they had lost all of their pants while at the facility, with no resolution. Resident 47 stated they had told their aides and laundry staff. In an interview on 05/05/2025 at 3:08 PM Staff V, Activities Director, stated they attended all of the RC meetings for the last six months. When asked about how the grievance process was explained in RC, Staff V stated they explain to the residents there are yellow forms (grievance forms) that can be filled out and if they can't fill them out then staff can assist them. Staff V stated if a laundry item is said to be missing, they will try to find it and if they are unable to locate it then they will complete a grievance form. Staff V stated they fill out grievance forms from grievances brought up in RC sometimes, but it had been a while. Staff V stated they review the resident council minutes with Staff A, Administrator, within 48 hours and will communicate with department heads as needed. Staff V stated the most recent grievance voiced at RC was related to noise level in the hallways at night and they reviewed the concern in the morning meeting. Staff V stated they followed up with the RC president but had not filled out a grievance form. In an interview on 05/07/2025 at 9:19 AM Staff L, Nursing Assistant Certified (NAC), stated Resident 47 had told them about missing their pants and they went to the laundry and found them. Staff L stated they had not filled out a grievance form for Resident 47 and had not offered them a grievance form to fill out. When asked when a grievance form would be filled out Staff L stated when a resident becomes really mad about something or if there are resident concerns about staff. Staff L stated the social worker follows up on missing items. In a follow up interview on 05/07/2025 at 9:40 AM Staff L provided additional information, stating the grievance forms are used primarily for the family of the residents. In an interview on 05/07/2025 at 10:02 AM Staff W, Housekeeping Supervisor stated if there was missing resident clothing, they checked the resident's inventory sheet to see if the item was listed. If they are unable to find the item, they report it to the social services director and they fill out a grievance form. In an interview on 05/07/2025 at 10:13 AM Staff X, Social Services Director, stated they were the designated grievance official of the facility. Staff X stated the grievance process included, someone reported something missing, a grievance form is filled out, a room search is completed and report to laundry and housekeeping is done. Staff X stated they would also check laundry to see if they were able to find the missing item. Staff X stated the missing item could not be found, then contact would be made with the residents' family and see if they could purchase the item, or the facility could purchase the item for them. Staff X stated they don't attend the resident council meetings. Staff X stated if a grievance form was given to them, they would follow up on it right away. Staff X stated they were not provided with a grievance form for Resident 47's missing pants. Reference WAC 388-97-0460

<RESIDENT 273> Resident 273 admitted to the facility on [DATE]. In an interview on 05/01/2025 at 10:25 AM, Resident 273 stated they fell the day after the admission and they hurt their hip. In an interview on 05/05/2025 at 9:27 AM, Resident 273 stated they fell three months ago. Review of the electronic health record (EHR) showed Resident 273 had a fall in their room on 04/25/2025 and complained increased pain in the right hip on the next day. Review of Resident 273's fall risk evaluation on admission, dated 04/24/2025 at 1:45 PM, showed Resident 273 had one to two falls in the past three months. Review of Resident 273's admission MDS, dated [DATE], documented Resident 273 did not have a fall in the last month prior to admission, in the last two to six months prior to admission, or no fall since admission. The care area assessment (CAA) related to fall was not triggered as no fall indicated in the MDS. In an interview on 05/05/2025 at 10:58 AM, Staff H stated they did not review Resident 273's EHR. Staff H reviewed the fall risk assessment and progress notes, stated the MDS was not accurate and needed to be modified. <RESIDENT 275> Resident 275 admitted to the facility on [DATE]. In an interview on 05/01/2025 at 12:50 PM, Resident 275 stated they had two to three falls during the last six months prior to admission. Resident 275 stated they fell in the facility the day after admission. Review of the EHR showed Resident 275 had a fall in the facility on 04/25/2025 at 10:20 PM. Review of Resident 275's fall risk evaluation, dated 04/25/2025 at 1:20 PM, showed Resident 275 had one to two falls in the past three months. Review of Resident 275's admission MDS, dated [DATE], documented Resident 275 did not have a fall in the last month prior to admission, in the last two to six months prior to admission, or no fall since admission. The care area assessment (CAA) related to fall was not triggered as no fall indicated in the MDS. In an interview on 05/05/2025 at 10:58 AM, Staff H stated they did not review Resident 275's EHR. Staff H reviewed the fall risk assessment and progress notes, stated the MDS was not accurate and needed to be modified. In an interview on 05/06/2025 at 11:51 AM, Staff B, Director of Nursing Service, stated they expected the MDS to be completed accurately. Reference WAC 388-97-1000 (1)(b) Based on interview and record review, the facility failed to ensure that the Minimum Data Set (MDS - an assessment tool) assessments were accurate for 3 of 18 residents reviewed for assessments. Failure to ensure accurate assessments regarding the active diagnosis (Resident 38) and fall history and fall incident in the facility (Residents 273 and 275) placed residents at risk for not receiving appropriate interventions and care and diminished quality of life. Findings included . <RESIDENT 38> Resident 38 was admitted to the facility on [DATE]. According to the quarterly MDS assessment, dated 04/08/2025, the resident had a diagnosis of Schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly) and did not receive any antipsychotic medication (medication to help reduce psychotic symptoms like hallucinations, delusions, and disordered thinking.) In a review of diagnoses list on 05/02/2025, Resident 38 had a schizoaffective disorder - Bipolar type (mental health condition characterized by the combined presence of symptoms of both Schizophrenia and mood disorder) was added to their diagnosis on 08/25/2022. In a joint interview on 05/05/2025 at 9:25 AM, Staff F, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) and Staff G, LPN/RCM stated they were both familiar with Resident 38. They were not aware how the schizoaffective disorder was added to residents' diagnoses. They were not able to provide documentation on how the resident was diagnosed with schizoaffective disorder. In an interview on 05/05/2025 at 9:38 AM, Staff H, Registered Nurse (RN)/MDS Coordinator, stated that they were not sure how the schizoaffective disorder was added to Resident 38's diagnosis list. They will review the residents' chart and will get back with me. In an interview on 05/05/2025 at 2:17 PM, Staff H stated that after reviewing Resident 38's chart, they thought it was a transcription issue that the schizoaffective disorder -bipolar type was added to residents' diagnoses. They stated that the former MDS Coordinator was trying to add Bipolar Type diagnosis, and they clicked on the schizoaffective disorder -bipolar type code by mistake.

Based on interview and record review, the facility failed to provide the necessary care and services to ensure residents' abilities in activities of daily living (ADLs) did not diminish. The facility failed to provide showers/bathing to 1 of 3 residents (Resident 63) reviewed for ADLs. This failure placed residents at risk for avoidable decline, unmet needs and a diminished quality of life. Findings Included . Resident 63 admitted to the facility on [DATE] with diagnoses to include fracture of the pelvis, chronic pain, and spinal stenosis (narrowing I the spinal canal which leads to compression on the spinal cord). In an interview on 05/01/2025 at 10:32 AM Resident 63 stated they would like more than one shower a week. Resident 63 stated they were admitted to the facility around Thanksgiving time and there was a time when they did not get a shower for almost two full weeks. Review of Resident 63's care plan dated 11/18/2024, documented that they had a deficit in performing their bathing/showering due to a recent fall with rib and pelvis fracture and generalized weakness. As of 12/12/2024 Resident 63 required supervision/touch of one person to assist with their shower/bathing. Review of the Document Survey report v2 (charting of the NAC) for showers for November 2024 showed Resident 63 had a total of two showers, but no showers from admission, 11/18/2024 through 11/28/2025, a total of 10 days without a shower. In an interview on 05/06/2025 at 1:13 PM Staff U, Nursing Assistant Certified/Shower Aide, stated when a new admission comes to the facility, the nurse managers coordinate with them and where to put them on the shower schedule. Staff U stated the main reason showers were not completed was related to resident refusals. Staff U stated they attempt to encourage the residents to complete their showers and reapproach them at least three times. Staff U stated residents are scheduled for showers at the minimum of once a week. Staff U stated showers are documented in the electronic health record system. Staff U stated they believed Resident 63 to get a shower once to twice weekly. In an interview on 05/06/2025 at 1:25 PM Staff B, Director of Nursing Services, stated residents are placed on a shower schedule based on their room. Staff B stated if a resident had a preference or special request for showers they would adjust the schedule. Staff B stated the expectation of the staff was they were offered and given a shower. Staff B stated they review a weekly report on showers. Staff B stated they would review Resident 63 for documentation to show showers were provided after they admitted for the month of November 2024. No other information was provided. Reference WAC 388-97-1060(2)(a)(i)

Based on observation, interview and record review, the facility failed to provide proper treatment to maintain vision for 1 of 1 resident (Resident 7) reviewed for vision. This failure placed residents at risk for decline in the ability to see and diminish quality of life. Findings include . Resident 7 was admitted to the facility on [DATE] with admitting diagnoses to include Cataract (clouding of the lens of the eye), Diabetes Mellitus Type 2 (persistently high blood sugar levels). According to the quarterly Minimum Data Set (MDS - an assessment tool) assessment dated [DATE], the resident was cognitively intact, wears glasses and had adequate vision. In an interview on 05/01/2025 at 10:45 AM, Resident 7 stated that they wanted to get their eyes checked and that they might need new glasses. They don't remember the last time they had an eye exam. In a record review on 05/05/2025, it was documented that Resident 7 received new prescription eyeglasses in September 2021. In an interview on 05/05/2025 at 2:23 PM, Staff G, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) stated that on admit, they assess residents for vision and for long term care residents, they ask about vision during care conferences. Staff G stated that they have an optometrist that comes to their facility to do eye exams and that the Medical Records staff was the one that arranges it. When asked how residents get on the list to be seen by optometrist and Staff G stated when a resident or family requests or when they mention it in care conferences. In an interview on 05/05/2025 at 2:30 PM Staff I, Medical Records, stated they have a binder for the optometrist to look at and the optometrist only comes when there's 6 residents or more on the list. Staff I stated that the optometrist came to the facility last April and they think they will be back in June. Staff I stated that the optometrist keeps a list of residents that they need to see the next year. Staff I stated that Resident 7 was last seen by optometrist in 2021, and they would add them to the list to be seen. In a record review on 05/05/2025 Resident 7's Optometry note dated 07/20/2021 documented that they recommend resident to see an optometrist in 1 year. No further optometry notes seen in the chart or provided. In an interview on 05/06/2025 at 1:25 PM, Resident 7 stated that they were having a hard time reading the letterings on their TV even when they wear their eyeglasses. They think they informed a staff member about their vision issues a few weeks ago but were unsure who the staff was. In an interview on 05/07/20250 at 8:57 AM, Staff L, Nursing Assistant Certified (NAC) stated that when a resident complains of their eyeglasses not helping with their blurry vision, they will make sure the eyeglasses were clean first and ask if it helped and if the resident still complains of blurry vision, then they notify the nurse. Staff L stated they were unaware Resident 7 was having vision issues. In an interview on 05/07/2025 at 9:12 AM Staff M, LPN stated that if a resident complains of blurry vision or eyeglasses not working, they add the resident to the list to be seen by optometrist that comes to the facility. Staff M stated they were unaware Resident 7 was having vision issues. In an interview on 05/07/2025 at 9:21 AM, Staff H, Registered Nurse (RN)/MDS Coordinator stated that when they assess for vision for MDS on residents that were alert, they have residents read some papers in their room and ask things in their surroundings to check if they can see them. When asked if they remember if Resident 7 mentioned any issues with their vision and Staff H stated they don't remember the resident mentioning they had any issues. In an interview on 05/07/2025 at 10:00 AM, Staff H, RN/MDS Coordinator stated that they went and talked to Resident 7 and had the resident read their tablet and was able to do that, but resident was having issues reading letters on the TV with their eyeglasses. Staff H stated they will add the resident to the list of residents to be seen by the optometrist. In a joint interview on 05/07/2025 at 10:22 AM with Staff B, Director of Nursing Services and Staff C, Regional Nurse, Staff B stated that when a resident or family member report concerns of their vision they would add the resident to the list of residents to be seen by optometrists. Their MDS Coordinator assesses residents' vision during their MDS window and will add residents on the list if they identified vision issues. Staff C stated that they also ask about residents' vision during care conferences. Record review of Resident 7's care conference dated 04/17/2025 showed under accommodation of needs and under letter b for eyeglasses and other visual appliances were left blank and at the bottom the not applicable was checked. Reference WAC 388-97-1060(3)(a)

Based on observation, interview, and record review, the facility failed to ensure effective interventions were implemented to maintain adequate nutrition for 1 of 2 sampled residents (Resident 275) reviewed for nutrition. This failure placed the residents at risk for ongoing poor oral intake, weight loss, poor nutrition and potential harm. Findings included . Review of the facility's policy titled, Nutrition and Hydration Maintenance, revised date 06/2024, showed the nutrition assessment would include: - History of food and fluid intake - Refusal of meals and poor intake - Resident preferences - If a resident refuses a meal or consumes less than 50%, a meal substitute will be offered. Resident 275 was admitted to the facility on [DATE]. According to the admission Minimum Data Set (MDS-an assessment tool) assessment, dated 04/28/2025, Resident 275 was cognitively intact and complained about difficulty or pain when swallowing. In an observation and interview on 05/01/2025 at 12:32 PM, observed Resident 275 consumed 25% of the meal. Resident 275 stated they only ate a bit of meatloaf which was too salty, and a few bites of mashed potatoes, veggies and roll, and ate a tiny bit of the fruit cup which tasted very fishy. Resident 275 stated they had lost their sense of smell and taste, so they did not have appetite. Resident 275 stated the nurse had not asked them if they would like any substitute. In an interview on 05/01/2025 at 12:37 PM, Collateral Contact (CC1) stated Resident 275 only ate one quarter of the lunch and always had very poor intake.'' CC1 stated Resident 275 consumed less than 50% of the meals more than half of the times. CC1 stated they brought home cooked food, but Resident 275 still did not eat much. In an observation on 05/01/2025 at 12:37 PM, Staff Z, Nursing Assistant Certified (NAC), came into Resident 275's room and collected the lunch plate and was not observed to encourage Resident 275 to eat or ask if resident wanted any substitute. In an observation and interview on 05/02/2025 at 12:32 PM, observed Resident 275 consumed less than 25% of the lunch. Resident 275 stated they ate a couple of bites of everything and they did not like the lunch.'' In an observation on 05/02/2025 at 12:36 PM, observed Staff AA, NAC, came in the room and collected the lunch tray and was not observed to encourage Resident 275 to eat or offer any substitute. In an observation and interview on 05/05/2025 at 12:22 PM, observed Resident 275 had consumed less than half of the lunch. Resident 275 stated they preferred the food to have more colors to make it more appetizing. CC1 stated Resident 275 only ate one quarter to one third of the meal, which was the usual intake amount. CC1 stated no staff had offered any substitute. CC1 stated they brought in protein drinks, and nobody had been offering them to the resident. Resident 275 stated they asked one nurse for the protein drink this morning but they did not get it. CC1 stated they were very worried about Resident 275's meal intake and weight stability. In an observation, interview and record review on 05/05/2025 at 12:43 PM, Staff Z collected the lunch tray from Resident 275's room and was not observed to encourage the resident to eat or offer any substitute. Staff Z stated Resident 275 ate about 40% of the lunch. Review of Resident 275's [NAME] (an instruction for NAC's care provided) documented to offer meal substitute if resident eats less than 50%. Staff Z stated they did not offer any meal substitute to Resident 275. Review of Resident 275's meal monitor record dated 04/24/2025 to 05/05/2025, documented Resident 275 only had three meals consumed less than 50% which were lunch and dinner on 04/28/2025 and lunch on 05/05/2025. The two lunches observed when Resident 275 ate less than 50% on 05/01/2025 and 05/02/2025 were documented 51-75% on 05/01/2025 and 76-100% on 05/02/2025. Review of Resident 275's care plan, print date 05/02/2025, showed Resident 275 was at risk for nutritional problems. One intervention was to offer a meal substitute for less than 50% meal consumption or refusal. Review of provider progress notes dated 04/29/2025 at 10:33 AM and 05/02/2025 at 12:31 PM, documented Resident 275 had diagnosis of malnutrition (a condition due to poor food intake). Review of Resident 275's electronic health record (EHR) from 04/24/2025 until 05/05/2025 at 12:00 PM, there was no documentation about food preferences. There was no documentation until the surveyor brought it to their attention. Review of a hospital nutrition therapy note, dated 04/19/2025, documented Resident 275 needed a lot of encouragement to eat, and their spouse made them protein shakes every morning. The hospital dietitian recommended to give protein shake three times a day. In an interview on 05/06/2025 at 9:49 AM, Staff BB, Licensed Practice Nurse/Resident Care Manager, stated they were not aware why the aides documented inaccurately on the two lunches when surveyor observed documentation to be inaccurate on 05/01/2025 and 05/02/2025. In an interview on 05/06/2025 at 11:53 AM, Staff B, Director of Nursing services, stated they expected nurses to document accurately on meal intake and offer meal substitute or supplement accordingly. In an interview and record review on 05/06/2025 at 1:31 PM, Staff CC, Registered Dietician, stated in Resident 275's nutrition assessment, they documented Resident 275's meal intake Good, generally 51-75% x 5d per documentation according to the aides documented meal intake record. Staff CC stated they did not interview Resident 275 and/or the family about the history and overall meal intake. Staff CC stated they were not aware that the aide documented inaccurately, and Staff CC thought Resident 275 had good meal intake based on the documentation. Reference WAC 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 11) reviewed for hemodialysis (medical procedure that uses a machine to filter and clean the blood when the kidneys are failing) had consistent, completed and accurate assessments on the dialysis communication form (a form containing vital information about the resident which is sent to dialysis center for coordination of care and services) and failed to have a care plan that provided an accurate description of where their access site (a location on the resident's body in which the dialysis process is done) was located. These failures placed the resident at risk for medical complications, confusion among their medical providers, and unmet care needs. Findings Included . Resident 11 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease and was receiving hemodialysis. In an interview on 05/05/2025 at 11:31 AM, Staff F, Licensed Practical Nurse (LPN)/ Resident Care Manager (RCM) stated that Resident 11's dialysis access site was in the femoral (groin) and it was a port (a surgically implanted device), and the dialysis center were the ones that accesses the site. In an interview on 05/06/2025 at 9:50AM, Staff M, LPN stated that Resident 11 goes to the dialysis center every Tuesdays, Thursdays and Saturdays, they leave at around 5:30 AM and the NOC shift nurse was the one that fills out the dialysis communication form. Staff M stated that Resident 11 has a port in his groin for the dialysis access site and has a dressing. When the resident comes back from dialysis, the NAC will get residents' weight and vital signs. If there's changes or follow ups, the dialysis center will call the facility and if they have questions they call the dialysis center. Record review of the dialysis communication forms on 05/06/2025 showed that on dates: 03/16/25, 03/22/25, 03/25/25, 03/27/25, 04/01/25, 04/03/25, 04/05/25, 04/08/25, 04/15/25, 04/19/25, 04/26/25, 05/01/25, 05/03/25 the licensed nurse documented + bruit (swishing and whooshing sound using a stethoscope over a fistula [a surgically created connection between an artery an a vein usually used as an access site for hemodialysis] indicating turbulent flow) and thrill (palpable vibratory sensation felt over the fistula, signifying turbulent flow). In a joint interview on 05/06/2025 at 1:25 PM with Staff F, LPN/RCM and Staff G, LPN/RCM, Staff G stated that Resident 11 has a right femoral tunneled catheter line (a flexible tube known as a central venous catheter, that is inserted into a large vein and tunneled under the skin before entering the vein). Per Staff G, staff at the facility were not supposed to do anything with the site, they just need to reinforce the dressing, the dialysis center cared for their access site. When asked how the nurses knew what kind of dialysis access site the resident has, they stated it's in their communication board in resident's chart and in the provider's order. Staff F stated that they were mistaken when they told me the dialysis access site was a port. Staff G reviewed Resident 11's care plan, the dialysis access site was upper chest central line which was not accurate. Staff G stated they will update the care plan right away. Staff F reviewed the dialysis communication forms and saw the documentation of + bruit and thrill and Staff G stated that it was not accurate as Resident 11 does not have a fistula and the nurse should not have been documenting + bruit and thrill. In a joint interview on 05/07/2025 at 10:25 AM, Staff B, Director of Nursing Services and Staff C, Regional Nurse, Staff B stated that it was an expectation that the nurse's document what they have actually done. Staff C confirmed that Resident 11 does not have a shunt/fistula and will educate the nurse on what a bruit and thrill was. Staff B stated that RCM updates and reviews the care plans, and they usually review it quarterly or when there are changes in the residents. They were expected to update the care plan as soon as possible. Staff B also stated that any licensed nurse can update the care plan as well. Reference WAC 388-97-1900(1)

Based on interview and record review, the facility failed to ensure behavioral health care and services were provided for 1 of 1 sampled resident (Resident 63) reviewed for behavioral health services. This failure placed residents at risk for increased behaviors, not receiving necessary services to meet their mental health needs and a diminished quality of life. Findings Included . Resident 63 admitted to the facility on [DATE] with diagnoses to include attention-deficit hyperactivity disorder (a condition that occurs during the development of the nervous system which affect attention and impulsivity) and bipolar disorder (a mental illness characterized by extreme shift in mood, energy and activity levels). In a review of Resident 63's monthly medication review for 02/10/2025 showed a recommendation for a psychiatric evaluation of their medications as a contributing factor to falls. The medication review was not signed by the physician or noted by any of the facility staff. In a review of Resident 63's progress notes, showed on 2/03/2025 they were given contact information for a local mental health organization to start services. There was no other information about mental health services until 04/18/2025 where a referral to a different mental health organization for Resident 63. In an interview on 05/06/2025 at 11:41 AM Staff T, Social Services Assistant stated there had not been a lot of resources for mental health for residents and the facility had just obtained a contract with a mental health organization to provide virtual visits to start in May. Staff T stated there were four other residents waiting to start mental health services with the new provider. Staff T stated the local mental health organization was not user friendly in it required a phone call to set up services on a specific date and time with an excessive waiting time. Staff T stated they had not discussed setting up mental health services with Resident 63. In an interview on 05/06/2025 at 12:58 AM Staff G, Licensed Practical Nurse/Resident Care Manager stated they had not seen the monthly medication review dated 02/10/2025 and did not know why it had been scanned into Resident 63's medical record without being noted by the physician or themselves. Staff G stated there was a new contract with a mental health organization to provide virtual appointments to residents who need mental health services due to start next week. In an interview on 05/06/2025 at 12:21 PM Staff A, Administrator, stated the social workers at the facility provid some of the psychological therapy. Staff A stated there is a recently obtained contract with a mental health organization. Staff A stated prior to the contract if a resident required/wanted counseling or psychiatry they would send them to an outside agency or use telehealth. Staff A stated the Director of Social Services would discuss and offer residents counseling or psychiatrist services. Staff A stated if a resident had behaviors, they would consider using the state offered behavioral health services program. Staff A stated the medical director was involved in any review of psychoactive medication and their use and if a resident had been seeing a psychiatrist they would consult with them as well for any adjustments in medications. Reference WAC 388-97-1060(3)(e)

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 sampled residents (Resident 54) reviewed for unnecessary medications. Failure to evaluate the need for continued use of an antifungal medication placed residents at risk for use of unnecessary medications and/or have adverse side effects. Findings include . Resident 54 was admitted to the facility on [DATE] with admitting diagnoses to include chronic abdominal wall abscess. In a record review on 05/05/2025 at 8:50 AM, Resident 5's orders showed Fluconazole 200 mg tablet one time a day every Thursday for infection. The order was dated 06/27/2024. Record review of the May 2025 Medication Administration Record (MAR) showed that Resident 54 received a dose of Fluconazole on 05/01/2025. Record review of monthly Medication Regimen Review Reports from Pharmacy since December 2024 did not show any notes regarding Fluconazole use of Resident 54. In an interview on 05/07/2025 at 8:53 AM, Staff F, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) stated that Resident 54's Fluconazole order was for infection. Staff F reviewed the order and the date the order started, which was 06/2024, they stated that they think that it's a prophylactic medication but will put a call to the provider to clarify what the Fluconazole was for. In an interview on 05/07/2025 at 10:18 AM, Staff G, LPN/RCM stated they would look for documentation about why Resident 54 continued to be on fluconazole. In a joint interview on 05/07/2025 at 10:22 AM with Staff B, Director of Nursing Services and Staff C, Regional Nurse, Staff B stated that medical records print out the resident's medications monthly and the RCM's review the medications for accuracy and update them as needed. When asked if infection was the proper indication for the Fluconazole order for Resident 54 that they have been taking since 06/2024, Staff C stated that infection should not be the indication. Requested documentation to show that they have discussed the Fluconazole order with the provider, pharmacist and or Infection Control nurse. Record review of Resident 54's provider progress notes for 03/03/2025 did not show any documentation about why the Fluconazole needed to be continued, it was listed as one of the residents' medications. In an interview on 05/07/2025 at 12:03 PM, Staff G stated that they spoke to the provider and the Fluconazole will be discontinued as of today. Reference WAC 388-97-1060(3)(k)(i)

Based on interview, and record review, the facility failed to ensure a system in which residents' records were complete, accurate, and accessible, for 1 of 1 resident (Resident 4) reviewed for hospice (end of life) services. The facility failed to ensure the residents' medical records contained hospice provider's notes which placed residents at risk for medical complications, unmet care needs, and for diminished quality of life. Finding included . <RESIDENT 4> Resident 4 was admitted to the facility on [DATE] and enrolled in hospice services starting on 12/13/2024. Review of Resident 4's electronic health record (EHR) showed no hospice visit nurse documentation since 12/26/2024. Review of a form titled, Interdisciplinary Team of Care SNF (Skilled Nurse Facility)/ALF (Assisted Living Facility) and Hospice Plan of care dated 12/13/2024, indicated the hospice skilled nurse to visit twice a week and the home health aide to visit twice a week. In an interview on 05/05/2025 at 9:07AM, Staff H, Registered Nurse (RN), stated they were not sure how often the hospice nurse and the home health aide visited Resident 4 and they communicated with the hospice nurse verbally in person or via phone call. Staff H stated the hospice nurse talked to the facility nurses to get updates or to inform them of changes on orders, but there was no report or notes. In an interview and record review on 05/05/2025 at 9:14 AM, Staff O, RN/Infection Preventionist, stated they had a binder to keep Resident 4's hospice documentation. Review of Resident 4's binder showed no documentation of the hospice nurse and the home health aide visit. In an interview on 05/05/2025 at 9:43 AM, Staff P, RN/Resident Care Manager, stated the hospice nurse visited Resident 4 once a week and the home health aide came in twice a week. Staff P stated the hospice staff documented their clinical notes in their own system and the facility nurse had no access to the hospice system. Staff P stated the hospice nurse could fax their notes to the facility and the facility could request the document as well. Staff P stated they were not able to locate any hospice nurse visit record, but the notes should be in the facility's system for nurses to review. Staff P stated they would request the hospice agency to fax their documentation to the facility immediately. In an interview on 05/05/2025 at 10:24 AM, Collateral Contact (CC2), stated they came in to see Resident 4 every Tuesday. CC2 stated they usually speak with the facility nurse during visits and documented in their own hospice agency system, but the facility had no access to the hospice software system. CC2 stated their clinical visit notes including Resident 4's physical assessments, skin assessment, vital signs, care plans, any medication change, etc. CC2 stated the home health aide visited Resident 4 twice a week and provided services including oral care, nail care, shower or bathing, changing linen, dressing, companionship, etc., and the home health aide also documented in their own system which the facility had no access to it. CC2 stated they were not sure if the notes were faxed to the facility, but the facility could request any note. In an interview on 05/06/2025 at 11:37AM, Staff B, Director of Nursing Services, stated they had no access to the hospice provider's documentation system. Staff B stated the hospice staff communicated any change through talking to the facility nurse or the RCM. Staff B stated they expected the hospice visit note to be faxed to the facility and to be uploaded into the facility's EHR to make accessible for the facility staff. Reference WAC 388-97-1720(1)(a)(i)(iii)(2)(f)

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment in 1 of 2 emergency carts (carts that contain needed medical equipment during an emergency) when an unlocked sharps container (a specialized, puncture-resistant, and leak-proof container designed for the safe disposal of sharp medical instruments, like needles, syringes, and scalpels, to prevent accidental injuries and ensure proper waste handling) was found to be soiled and contained five syringes. This failure placed residents and staff at risk for injury, potential exposure to diseases and lack of necessary medical equipment during an emergency. Findings Included . In an observation on 05/01/2025 at 8:53 AM observed an emergency cart located outside of the Cascade Residential Unit Nurses station, near the entrance of the shower room, with an unlocked sharps container on the lower shelf. In an observation of the sharp's container, the top cover to the sharp's container was soiled with unidentifiable brown matter and five syringes inside of the container. In an interview on 05/01/2025 at 8:53 AM Staff M, Licensed Practical Nurse, stated the cart was their emergency kit and suctioning cart. When Staff M was asked what the purpose of a sharp's container on the cart they stated it was a good question and stated they did not believe it should be there. When asked about the five syringes found in the container, Staff M stated they thought they might be syringes for insulin or tuberculosis testing. Staff M stated the process of disposing of sharps consisted of placing them in the disposable box in the biohazard room. In an interview on 05/06/2025 at 1:35 PM Staff B, Director of Nurses Services, stated there are locked sharp containers on each of the nurse's carts for sharp disposal. Reference WAC 388-97-3220(1)

Based on interview, and record review, the facility failed to ensure the person designated to serve as the Director of Food and Nutrition Services (Staff P) had the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services. Findings included . On 02/20/2023 at 9:16 AM, Staff P, Dietary Manager (DM), stated they were not a certified DM. Staff P stated they had only experienced survey twice and were in the process of obtaining their certification. In an interview on 02/23/2024 at 1:08 PM, Staff P stated the facility had a contracted Registered Dietician that comes to the facility weekly. On 02/20/2024 at 9:16 AM, the posted food handler cards and certificates located on a corkboard in a hallway section of the kitchen were reviewed, showed no certifications for Staff P other than their food handler's card. In a review of the staff roster, undated, showed that Staff P had been employed at the facility since 09/19/2018. Refer to WAC 388-97-1160 (2)(3)(a)(b)(i)

Based on observation, interview, and record review, the facility failed to ensure 4 of 5 residents (Resident 3, 6, 21, and 7) reviewed for range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM. This failure placed the residents already identified with decreased ROM risk for further decline in ROM. Findings included . Review of a facility policy titled, Restorative Program, dated April 2018, showed, The goal of the Restorative Program was to promote and maintain the highest practicable level of physical, mental and psychosocial functioning and thereby improve self-esteem and quality of life. The restorative program was a philosophy of care with a specific approach that was organized, planned, documented, monitored, must evaluated to improve or maintain function and/or prevent a slow decline. The restorative program much include the following: - An assessment completed by a licensed nurse, which demonstrated the need for the Restorative Program (RNP). - The RNP was individualized, had measurable objectives with specific interventions, was documented in the care plan and in the clinical record. The RNP assisted or promoted the residents ability to achieve and maintain an optimal level of wellness, safety, self-care, and independence. - Was integrated into the resident's daily care, provided consistently one-on-one or in a group, as needed, twenty-four (24 hours per day), seven (7) days per week, dependent upon the resident's needs. Review of the resident council meeting minutes for 12/12/2023, showed the restorative schedule had been better but was still not consistent. Review of the resident council meeting minutes for 01/08/2024 and 02/13/2024, showed the residents said the restorative schedule was hit and miss. <RESIDENT 3> Resident 3 admitted on [DATE] with diagnoses to include cerebral palsy, right hand and finger contractures (fixed tightening of muscles and tendons), physical debility, muscle weakness, and a need for assistance with ADL (activities of daily living) care. The resident did not reject care. Review of the care plan initiated 03/29/2018 showed the resident was to perform active range of motion (AROM - is the range of flexibility in a joint reached by voluntary movement) using the using OmniCycle (a therapeutic powered exercise system) at a level 2 (a type of resistance level), alternating upper extremity (UE) and lower extremity (LE) three times a week for 15 minutes. Review of the quarterly restorative evaluation and summary, dated 06/20/2023, showed Resident 3 received a ROM program due to weakness, osteoarthritis, and Cerebral palsy (CP- a disorder that affects movement, muscle tone, balance, and posture). The goal for the resident to maintain flexibility to their upper and lower extremities, maintain strength, endurance, and maintain highest level of function. The intervention was for the resident to participate in AROM using the OmniCycle at level two, alternating UE and LE up to three times a week for 15 minutes. Review of the medical record showed no recent quarterly restorative evaluation and summary done after 06/20/2023. Review of the 12/21/2023 to 02/21/2024 RNP documentation, showed Resident 3 did not receive the RNP as indicated. In December 2023, they received the RNP eight times, on 12/05/2023, 12/07/2023, 12/12/2023, 12/13/2023, 12/14/2023, 12/20/2023, 12/21/2023 and 12/27/2023. In January 2024, the resident received RNP four times, on 01/02/2024, 01/03/2024, 01/09/2024, and 01/10/2024. In February 2024, the resident received their RNP twice on 02/16/2024 and 02/21/2024. In an interview on 02/21/2024 at 2:51 PM, Resident 3 said they rarely get restorative. The resident said If they don't have enough aides, I don't get it. <RESIDENT 6> Resident 6 admitted [DATE] with diagnoses to include cerebral infarction (disrupted blood flow to the brain), left and right leg stiffness, muscle weakness, and difficulty walking. According to the Annual Minimum Data Set (MDS - an assessment tool) assessment, dated 02/11/2024, the resident did not reject care. Review of Resident 6's clinical record, showed the most recent restorative evaluation and summary was dated 08/20/2019. Review of the RNP care plan, revised 11/02/2023, the goal was to maintain Resident 6's flexibility to their UE's and LE's. The program included ambulation up to 200 feet with stand by assist and to turn twice, and NuStep (a type of recumbent exercise machine) for AROM up to three times a week for 15 minutes. Review of the 12/01/2023 to 02/23/2024 RNP documentation, showed Resident 6 did not receive the RNP as indicated. In December 2023, they received their RNP four times, on 12/02/2023, 12/05/2023, 12/14/2023, and 12/31/2023. In January 2024, the resident received their RNP three times, on 01/01/2024, 01/02/2024, and 01/10/2024. In February2024, the resident received their RNP nine times, on 02/03/2024, 02/09/2024, 02/10/2024, 02/14/2024, 02/15/2024, 02/17/2024, 02/19/2024, 02/21/2024 and 02/23/2024. In an interview on 02/21/2024 at 2:49 PM, Resident 6 said restorative needs some attention. They get pulled to work the floor. I don't get it like I am supposed to. That I get it three to five time a week is a joke. In an interview on 02/22/2024 at 1:45 PM, Staff A, Administrator, said they were aware of the missed RNP's. In an interview on 02/23/2024 at 2:27 PM, Staff B, Director of Nursing Services (DNS), was aware of the concerns of RNP's not being completed as ordered. The DNS stated the missed RNP's, and the Restorative aides were being pulled to work the floor as a Nursing Assistants when there were call-in's. 42927 <RESIDENT 21> Resident 21 admitted to the facility on [DATE]. Review of the MDS assessment, dated 12/14/2023, showed Resident 21 had functional limitation of ROM on both UE's and LE's. Review of Resident 21's restorative care plan, revised date 04/17/2023, showed the resident was to have passive range of motion (PROM - when someone physically moves or stretches a part of your body) to both legs and have a splint on both hands, one at a time for four hours. The program was to be done three times a week. Review of restorative participation documentation, showed Resident 21 did not receive their RNP as indicated. In January 2024, they received restorative on 01/02/2024, 01/03/2024, 01/04/2024, 01/05/2024, 01/09/2024, 01/10/2024, 01/11/2024, 01/12/2024, 01/22/2024, 01/30/2024, and 01/31/2024. In February 2024, from 02/01/2024 - 02/22/2024, Resident 21 received their RNP on 02/03/2024, 02/05/2024, 02/09/2024, 02/13/2024, 02/15/2024 and 02/16/2024. On 02/21/2024 and 02/22/2024, the RNP documentation showed Resident 21 had their splints applied, but did not have ROM. Review of a contracture screening assessment, dated 12/10/2023, showed Resident 21 had contractures to both UE and LE. The assessment did not show if the contractures were better or worse. The assessment did not show if the program was effective or if it needed to be modified. During an observation on 02/21/2024 at 9:16 AM, Resident 21 did not have any splints to either UE's. During an observation on 02/21/2024 at 1:43 PM, Resident 21 had a splint on their left hand, but their fingers were not in the splint, and they were in a closed fist. The straps of the splint were not in contact with the resident's left hand. There was no splint on resident's right hand. During observations on 02/22/2024 at 8:43 AM, 9:07 AM, 10:12 AM and 12:34 PM, Resident 21 did not have any splints on either of their UE's. During an interview on 02/21/2024 at 9:16 AM, Staff E, Nursing Assistant Certified (NAC), stated the RNP tasks have been intermittent since the last restorative aide resigned. Staff E stated they had not had formal training in applying the splints for Resident 21, so they were not able do that part of the restorative program. During an interview on 02/23/2024 at 12:36 PM, Staff B stated the facility had not been doing recent restorative assessments to determine if programs were effective or needed to be modified. <RESIDENT 7> Resident 7 admitted to the facility on [DATE]. During an interview on 02/20/2024 at 1:48 PM, Resident 7 stated they were to have RNP on Mondays, Wednesdays, and Fridays but they had not been getting it that often. Review of the restorative care plan, initiated on 06/19/2023, showed Resident 7 was to perform following RNP's three times a week: - AROM with dumbbells to UE using one-pound weights. -Omni-cycle level 4 alternating UE and LE. -Wheelchair mobility (resident propelling their wheelchair themselves)150 feet. Review of restorative participation documentation, showed Resident 21 did not receive their RNP as indicated. In January 2024, they received restorative on 01/02/2024, 01/03/2024, 01/04/2024, 01/05/2024, 01/09/2024, 01/11/2024, 01/12/2024, and 01/30/2024. In February 2024, from 02/01/2024 - 02/22/2024, the resident received their RNP on 02/09/2024, 02/15/2024, 02/16/2024, and 02/22/2024. During an interview on 02/22/2024 at 6:58 AM, Staff D, NAC, stated they did restorative some days, but they also worked as a floor aide or a shower aide. Staff D stated Resident 7 had their RNP done when there was coverage, but there was not always coverage. Refer to WAC 388-97-1060 (3)(d), (j)(ix)

Based on interview and record review, the facility failed to ensure annual Nurse Aide Certified (NAC) performance reviews were completed for 3 of 5 employee (NAC's Q, R and T) files reviewed who had been employed longer than 1 year. This failed practice had the potential to negatively affect the competency of these NAC's and the quality of care provided to residents. Findings included . Review of the facility's policy, Training Requirements, revised 10/2022 showed facilities will conduct annual performance reviews to identify any areas of weakness that require further education. Staff Q, NAC, was hired on 03/09/2022. Review of Staff Q's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff Q. Staff R, NAC, was hired on 04/26/2022. Review of Staff R's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff R. Staff T, NAC, was hired on 08/30/2022. Review of Staff T's employee file showed there was no current employee evaluation done. There was no evidence the evaluator completed this evaluation nor if it was reviewed/discussed with Staff T. In a joint interview on 02/21/2024 at 11:23 AM, Staff B, Director of Nursing Services, said there were a few performance evaluations for NAC's were missed when they were on leave. In an interview on 02/21/2024 at 11:30 AM, Staff A, Administrator, said they had tried to keep up on the performance evaluations when Staff B was on leave, but some were missed. Refer to WAC 388-97-1680 (2)(a-c)

Based on interview, and record review, the facility failed to ensure a system in which resident's records were complete, accurate, accessible, and systematically organized for 6 of 6 residents (Residents 6, 22, 35, 17, 50, and 61) reviewed for accurate and complete medical records. Failure to ensure that clinical records were complete and accurate placed residents at risk for medical complications, unmet care needs, and for diminished quality of life. Findings included . <RESIDENT 6> Review of the December 2023 documentation survey report (v2 - where the Nursing Assistant Certified documents when resident care was performed), showed no documentation of Activities of Daily Living (ADL - dressing, transfers, bed mobility, walking/locomotion, bathing personal hygiene, toileting and eating) care was provided to Resident 6 once on the day shift (12/24/2023), twice on the evening shift (12/25/2023 and 12/26/2023), and six times on the NOC (night) shift (12/01/2023, 12/08/2023, 12/16/2023, 12/21/2023, 12/26/2023, and 12/31/2023). Review of the January 2024 documentation survey report (v2), showed no documentation of ADL care was provided to Resident 6 once the evening shift (01/19/2024) and five times on the NOC shift (01/04/2024, 01/05/2024, 01/15/2024, 01/20/2024, and 01/27/2024). Review of the 02/01/2024 to 02/22/2024 documentation survey report (v2), showed no documentation of ADL care was provided to Resident 6 once on the day shift (02/18/2024, three times on the evening shift (02/09/2024, 02/18/2024, and 02/22/2024), and twice on the NOC shift (02/10/2024 and 02/22/2024). <RESIDENT 22> Review of December 2023 documentation survey report (v2), showed no documentation of ADL care was provided to Resident 22 once on the evening shift (12/26/2023) and six times on the NOC shift (12/01/2023, 12/08/2023, 12/16/2023, 12/21/2023, 12/26/2023, and 12/31/2023). Review of the January 2024 documentation survey report (v2), showed no documentation of ADL care was provided to Resident 22 once on day shift (01/04/2024), once on the evening sift (01/19/2024), and three times on the NOC shift (01/04/2024, 01/05/2024, and 01/08/2024). Review of the 02/01/2024 to 02/19/2024 documentation survey report (v2), showed no documentation of ADL care was provided to Resident 22 once on the day shift (02/18/2024), three times on the evening shift (02/09/2024, 02/10/2024, and 02/18/2024) and once on the NOC shift (02/10/2024). <RESIDENT 35> Review of the December 2023 documentation survey report (v2), showed no documentation of ADL care was provided to Resident 35 five times on the NOC shift (12/02/2023, 12/09/2023, 12/16/2023, 12/21/2023, and 12/31/2023). Review of the January 2024 documentation survey report (v2), showed no documentation of ADL care was provided to Resident 35 once on the day shift (01/17/2024), twice on the evening shift (01/11/2024 and 01/28/2024), and twice on the NOC shift (01/25/2024 and 01/28/2024). Review of the 02/01/2024 to 02/12/2024 documentation survey report (v2), showed no documentation of ADL care was provided to Resident 35 once on the day shift (02/07/2024) and twice on the NOC shift (02/04/2024 and 02/07/2024). 47047 <RESIDENT 17> Resident 17 admitted to the facility on [DATE] with diagnoses including stroke, dysphagia (difficulty swallowing food or liquid), and received enteral (an opening where a flexible tube is inserted into the stomach) feedings. Review of Resident 17's February 2024 Medication Administration Record (MAR), showed no documentation for: - There was no documentation on 02/17/2024 evening shift, and on 02/18/2024 the day/evening shift regarding the nurse assessing the residents enteral feeding site for irritation, redness, or drainage and notify the physician of an signs and symptoms of infection. - On 02/17/2024, the day shift, and on 02/18/2024 the day and evening shift, showed no documentation of the actual amount of enteral feeding formula administered to the resident in cubic centimeters. <RESIDENT 50> Resident 50 admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), and Alzheimer's Disease (a progressive brain disorder which affects memory, thinking and behavior). Review of 02/01/2024 to 02/22/2024 documentation survey report (v2), showed no documentation for activities was provided to Resident 50 the evening shift from 02/01/2024 through 02/04/2024, 02/06/2024 through 02/10/2024, 02/12/2024 through 02/14/2024, and from 02/16/2024 through 02/21/2024. <RESIDENT 61> Review of Resident 61's 02/01/2024 to 02/22/2024 MAR and Treatment Administration Record (TAR) for February 2024 showed no documentation for: -Obtaining the resident's weight every day on 02/02/2024, 02/06/2024, 02/07/2024, 02/13/2024, 02/18/2024 and 02/19/2024. - The Licensed nurse to ensure catheter (thin tube that is inserted into the body) system was secured, catheter strap in place, covered appropriately with a privacy bad and catheter care provided every shift showed no documentation for day shift on 02/02/2024, 02/06/2024, 02/07/2024, 02/18/2024 and 02/19/2024, and for NOC shift on 02/08/2024, 02/09/2024, and 2/16/2024. Review of the 02/01/2024 to 02/22/2024 documentation survey report (v2), showed no documentation for Resident 61's urine output in cubic centimeters twice on the day shift (02/10/2024 and 02/16/2024), twice on the evening shift (02/03/2024 and 02/06/2024), and three times on the NOC shift (02/06/2024, 02/19/2024, and 02/21/2024). In an interview on 02/23/2024 at 11:05 AM, Staff U, Licensed Practical Nurse/Resident Care Manager, stated the expectations for documentation/charting on the MAR/TAR and NAC tasks were to be completed daily. Staff U was unaware there were any charting issues. In an interview on 02/22/2023 at 3:24 PM, Staff A, Administrator, stated documentation/charting was monitored daily and they had not noticed a big concern. Refer to WAC 388-97-1720 (1)(a)(i)(ii)

Based on observation, interview and record review, the facility failed to comprehensively assess and initiate interventions as needed to prevent significant weight loss for 1 of 5 residents (60) reviewed for nutritional status and weight loss. This resulted in actual harm to Resident 60, who experienced severe weight loss of 17 pounds or 10% in approximately one month. Findings include: Record review of the facility's policy titled, Nutrition and Hydration, revised 07/18 included: -Residents who showed an unexpected significant weight change were assessed by the facility dietician and Resident Care Manager (RCM); -The resident's weight would be monitored weekly until stable for 4 weeks following admission and monthly thereafter if stable; -The RCM would monitor weights and request a reweigh if the resident's weight varied by 5 pounds (lbs) or more (plus or minus) from the previous weight; -Resident's showing a significant weight variance (5% in 30 days ) would be referred to the Registered Dietician (RD) and Nutrition Risk Committee for assessment, care plan review and implementation of additional interventions; and -Resident's with significant weight changes would be reviewed by the Nutrition Risk Committee until stable. Resident 60 was admitted [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set assessment, Resident 60 was alert and oriented, did not refuse care and required supervision with one person assistance for eating. Review of Resident 60's care plan dated 08/31/18, showed the resident was at risk for nutritional problems related to advanced age and mechanically altered textured diet. The resident's goals were to maintain body weight without significant weight changes of her usual body weight of 180 lbs. Resident 60's approaches were to monitor weight per facility policy, report significant losses/gains to physician and RD, the RD to evaluate and make recommendations and report coughing, choking and pocketing of food to the nurse. Review of the Resident 60's weight summary showed: - On 08/27/18, the resident weighed 177.4 pounds; - On 08/28/18, the resident weighed 168.4 pounds (the resident was not re-weighed due to 9 pound weight discrepancy); - On 09/04/18, the resident weighed 161.1 pounds, the resident lost 7.3 pounds in one week; - On 09/06/18, the resident weighed 161.8 pounds; - On 09/12/18, the resident weighed 162.8 pounds; and - On 09/25/18, the resident weighed 160.4 pounds. The resident lost 17 pounds or 10% in approximately one month. Review of the admission cardiovascular assessment dated [DATE], showed no [MEDICAL CONDITION] present. Review of the resident's medical record showed no orders for a nutritional supplement. Review of the Nutrition Risk Assessment summary and recommendations dated 08/31/18, showed the resident did not follow a diabetic diet at home, received a liberalized diet per the hospital notes and the diabetic diet was discontinued. The note stated the resident denied any recent weight changes from her usual body weight of 180 pounds. Recommendations included to liberalize to a regular diet to promote intake and requested a Speech Therapy (ST) evaluation because the resident was on a mechanical soft diet. The resident was at nutritional risk related to advanced age and the mechanically altered textured diet. The goal was for no significant weight change from usual body weight of 180 lbs. RD will follow up as needed per protocol. Review of a nursing progress note dated 09/06/18, showed the Resident is a recent admission with a weight decline likely related to fluid shifts, as well as difference in weighing with or without brace in place. Resident in facility for rehab related to back surgery which could cause this shift related to the extra fluids given during her hospitalization . Resident appetite is fair and she has recently been evaluated by RD with some recommendation for supplementation, will continue to assess for any further needed changes. Review of the nutrition referral book from (MONTH) (YEAR) to (MONTH) (YEAR) did not show a nutritional referral for weight loss for Resident 60. In an observation and interview on 09/25/18 at 12:40 PM, the resident was sitting up in her chair and stated, I have lost weight, I am nauseated because of the antibiotics I have taken. In an interview on 09/26/18 at 11:02 AM, Staff W, RCM, stated all residents were weighed on admission and then weekly when they had a shower. Staff W stated if there was a 2-3 lb weight loss the shower aid would notify the RCM. Staff W stated if weight loss was identified, the resident would be reweighed and if there was further weight loss the resident would be referred to the RD. In an interview on 09/26/18 at 1:34 PM Staff X, shower aide, stated all residents were usually weighed with their weekly shower and if there was a weight discrepancy of 3 lbs up or down the RCM was notified and they would assess the weight and let her know if the resident needed to be reweighed. Staff X stated Resident 60 was weighted with her brace on because she needed it on when she was out of bed and the brace weighed 1.4 lbs for Resident 60. In an interview on 09/26/18 at 2:43 PM, Staff R, Consulting RD, stated she saw all new admits within 14 days and completed a dietary profile and a nutrition at risk assessment. Staff R stated the staff would notify her of a resident's weight loss by placing the resident in the referral book or verbally telling her. Staff R stated she would run a report to identify new residents and residents with weight loss. Staff R stated she initially saw Resident 60 because she was a new admission to the facility, but did not see her for weight loss. Staff R stated she probably should have reassessed Resident 60 after being asked to look at her trending weight loss. In an interview on 09/27/18 at 10:17 AM, the Director of Nursing Services (DNS) stated residents were weighed on admission and then weekly by the shower aid, if there was a weight discrepancy the resident was reweighed the next day. The DNS stated the electronic medical record would give notifications of weight loss. The DNS stated the family and medical provider would be notified of the weight loss. The DNS stated the intervention for Resident 60 was to get ST involved to see if a diet upgrade would slow the progression of weight loss. In an interview on 10/02/18 at 10:33 AM Staff Y, Speech Pathologist, stated she began working with Resident 60 on 09/11/18 (10 days after RD had recommended ST) for reports of coughing and a possible swallowing problem. Staff Y stated the resident was tiring easily while eating a mechanical soft diet because she was constantly chewing her food before she would swallow. Staff Y stated she worked on strategies for increasing the resident's chewing efficiency and Resident 60 was able to transition to a regular diet with thin liquids. Reference (WAC) 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to follow their abuse and neglect policy for 2 of 3 residents (3,4). Failure to identify abuse and protect Resident 4 resulted in distress for Resident 4 and placed Resident 3 and other residents at risk for possible abuse. Findings include: The facility's Abuse/Neglect/Misappropriation policy/procedure read: it is the policy of this facility to protect residents from, .abuse, by implementing procedures designed to prevent, identify, report and investigated potential instances of abuse, . Verbal abuse definition was described as the use of oral, written or gesture language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability. A Licensed Nurse's (LN) note documented on 2/12/16 at 4:07 p.m., Resident 3 had been verbally aggressive and yelling at her roommate (Resident 4). The LN documented she had asked Resident 3 to be kind and not yell at Resident 4. Another LN entry for 10:33 p.m., documented Resident 3 was very rude and verbally abusive to Resident 4. Resident 3 told Resident 4 that she was not allowed to use the bathroom (BR) because the BR was only for Resident 3. The note indicated Resident 3's statement upset Resident 4. A LN note dated 2/13/16 documented Resident 3 was still yelling at Resident 4, or complaining about her with an attitude. The LN documented she encouraged Resident 3 to refrain from getting angry. During an interview with the Resident Care Manager (RCM) at 10:48 a.m., he stated Resident 3 tries to get rid of roommate(s) because she believes that staff time and attention is not directed to her when she has a roommate. The RCM stated Resident 3 complained about her roommate (Resident 4) in February 2016. The RCM stated Resident 3 has has a history of delusional behaviors which is managed with medications. Review of Resident 4's clinical record revealed she was admitted to the facility on [DATE] with pneumonia. The resident was alert and oriented. A LN note dated 2/16/16 revealed that Resident 4 still was requesting a room change due to roommate's behaviors (Resident 3). The facility documented there was no available bed. Clinical record revealed that on 2/16/16, Resident 4 was very upset over roommate's behavior. Resident 4 was crying and called her daughter who had provided her reassurance. On 2/17/16, she continued to be upset over events that occurred and stated I just wanted to slap her (Resident 3) when verbalizing anger. Resident 4 stated she called her daughter and told daughter that she wanted out of here. The LN indicated she allowed Resident 4 to verbalize her frustration until she calmed down enough to fall asleep. Even though the LNs documented Resident 3 was rude and verbally abusive toward Resident 4 there was no documented evidence as to how they protected the resident from unwanted verbal behaviors until 2/17/16 (6 days later) when Resident 4 moved to another room. During an interview at 11:40 a.m., SS stated verbal abuse is someone being rude and indicated it was the facility policy to initiate an investigation if/when an allegation of abuse is made by any resident. During a review of Resident 3's clinical record with the Director of Nursing (DNS) and the Administrator at 12:05 p.m., they stated the documentation regarding possible verbal abused should have alerted LNs to initiate an investigation to ensure Residents were protected from further incidence of abuse. Review of the facility's census from 2/12/16 to 2/18/16 identified the facility's bed capacity was 92 and the daily census ranged from 86 to 88. Refer to CFR 483.15 (g) (1) Provision Of Medically Related social Service.

Based on interview and record review, the facility failed to provide medically related social service needs for 1 of 3 residents (4). Failure to evaluate options to assist the emotional needs of Resident 4 resulted in unnecessary distress exhibited by crying and seeking support from family. Findings include: Resident 4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 4 was placed in a semi-private room with Resident 3. The Licensed Nurse (LN) notes for Resident 4, dated 2/12/16, indicated they had notified Social Service (SS) that she requested a room move. Resident 4 told SS that her roommate, Resident 3, was somewhat rude to her and makes comments about her being in her room which is making her feel unwelcomed. The 2/12/16 nursing note, also indicated nursing had notified Social Service (SS) that Resident 4 had requested a room move. Resident 4 informed SS that Resident 3 is somewhat rude to her and makes comments about her being in her room which is making her feel unwelcomed. A Social Service note, dated 2/17/16, documented that her roommate was causing her distress which resulted in her moving to another room after numerous days of tolerating her roommate's behaviors towards her. The note revealed Resident 4's family member called the facility and demanded a room change as her mother had called her the night prior very upset and distraught regarding her roommate. Even though LNs documented Resident 4 had requested a room change due to Resident 3 being rude and verbally abusive toward her, there was no documented evidence that all possible options were evaluated to ensure each resident's individualized needs were being met. Refer to CFR 483.13 (c) Develop/Implement Abuse/Neglect, Etc Policies.

Based on observation, interview and record review, the facility failed to consistently provide adequate supervision for 1 sample resident (#1) who was known to be impulsive with a history of falls from his wheelchair. Failure to follow the plan of care, to keep the resident in area to be supervised, to prevent falls resulted in harm for Resident 1 who sustained a fracture. Findings include: Resident 1 had [DIAGNOSES REDACTED]. The fall risk assessments, dated 9/17/15 and 10/23/15 revealed he was a fall risk due to his impulsivenes, confusion and balance issues. The Minimum Data Set (MDS) assessment, dated 9/24/15, documented Resident 1 had severe cognitive impairment and required one person assist for wheelchair mobiltiy. Review Resident 1's prior falls revealed they had occurred when he attempted to self transfer himself from his wheelchair. At the time of his 9/17/15 fall, the skilled therapist recommended to have the resident continue to use a regular wheelchair as it would allow him to self-propel. On 1/5/16 at 12:10 p.m., the nursing assistant (NAC A) stated Resident 1 needed to be pushed in his wheelchair, however, on rare occassions he was able on his good days to self propel on his own. On 1/5/16 at 1:05 p.m., the resident was observed seated in his wheelchair at the dining room table with his feet positioned on the foot rests. The brakes of the chair were not locked. NAC B stated Resident 1's brakes should not be locked as he sometimes self-propels in his wheelchair. The current plan of care for fall prevention directed staff to place the resident in a supervised area when he was out of bed. The Kardex used by nursing assistants (NACs) revealed that the resident required supervision/assistance with all decision making. The facility's investigative report, dated 12/9/15, revealed Resident 1 had a fall at 11:35 a.m. The report indicated staff had heard a call for help and discovered Resident 1 laying on the floor in front of his room, across from the day room. The report indicated at the time of his fall, his wheelchair was discovered in the day room with the brakes locked. The report also indicated he had refused toileting prior to his fall at 11:00 a.m. and he was asleep in his wheelchair and no one was with the resident. The facility's investigative report concluded that due to the resident's impulsivity he got up from his wheelchair and ambulated unassisted and sustained fall resulting in fracture. In an interview on 1/5/16 the DNS could not provide any further information as to why the resident was left alone and in an area unsupervised.

Based on observation, interview and record review, the facility failed to evaluate and monitor 1 of 2 sample (4) resident's care needs with a medical condition change. Failure to evaluate transfer needs resulted in a fall with harm for Resident 4. Findings include: RESIDENT 4: Resident 1 had [DIAGNOSES REDACTED]. The Minimum Data Assessment, dated 12/29/14, indicated the resident required supervision with transfers and extensive assistance with toileting, was unsteady with her balance, had limited range of motion in her lower extremities and weighed 220 pounds. The care plan informed staff that Resident 4's cognitive function may be affected by pain, infection, acute illness or medication changes. Review of the progress notes, dated 2/9/15, documented the resident had been assessed to be safe to be alone while on the commode, was able to independently transfer to and from commode. The Consideration Sheet (CON) used by nursing assistance, dated 1/15/25, revealed Resident could transfer independently and may need SBA (standby assistance) "if requested". The CON sheet indicated she used a BSC (bedside commode) and was incontinent of urine. The care plan, dated 3/16/15, read: toilet use: The resident can be left alone on commode and transfer on/off ad lib (as tolerated) and able to stand and bear weight with transfers. The care plan, dated 3/16/15, revealed she required "decreased weight bearing activities until wound (foot) resolved". The progress note, dated 3/15/15, revealed the resident's left foot had redness, swelling and warmth and her ulcer on the bottom of the foot had drainage. She was started on an antibiotic. On 3/16/15, the Licensed Nurses (LNs) documented Resident 4 was experiencing foot pain, rate 7 (0 being no pain, 10 being worse pain) and required more assistance with her ADL's (activities of daily living). On 3/19/14 the LN documented "PT will continue to work with her on transfers and strengthening". The skilled therapy note dated 3/19/15 documented skilled PT (physical therapy) would be on hold due to her non-healing ulcer on the ball of left foot and indicated her physician had recommended OT (occupational therapy) to start for upper body strengthening and conditioning. On 3/19/15, the resident was seen at the wound clinic due to the [MEDICAL CONDITION] of her foot. The wound clinic note documented pressure relief strategies were needed to avoid pressure on the ulcer on the bottom of her foot. The note documented a wedge-type trauma shoe (protective) was to be tried. The progress note, dated 3/22/15, documented the resident had a fall and at the time of the fall had a protective boot on her left foot. The resident complained of extreme pain and was transferred to the hospital. The facility ' s investigative report, dated 3/22/15, documented "heard resident scream, upon getting to room, resident was lying on her left side next to her commode". Emergency system (911) activated due to resident ' s complaint of neck, back, and hip pain. There was no documentation regarding the resident s foot wear. The hospital admission note, dated 3/22/15, revealed Resident 4 had a fracture of her hip and questionable fracture of her spine. On 3/31/15 at 4:25 p.m., during an interview with the Director of Nursing (DNS), she verified Resident 4's legs gave out when the resident attempted to get off the bedside commode. The DNS was unable to verify as to whether the resident's transfer status had been monitored and evaluated after a protective boot was provided on 3/19/15. There was no documented evidence the facility had monitored or revised the plan of care for Resident 4 who had a foot infection with pain, required decreased weight bearing to the foot and used a protective boot for pressure relief for the bottom of her foot.

Based on observation, interview and record review, the facility failed to provide adequate supervision for 3 of 4 sample residents (#1, 2, 3). Failure to provide supervision during a mechanical transfer resulted in harm for Resident 1 who sustained a fracture, failure to provide supervision for Resident 2 who had cognitive impairment during toileting resulted in a head and neck injury and failure to recognize use of emergency egress exits by staff and/or visitor may have resulted in the elopement of Resident 3, placing other residents residing in the memory unit at risk. Findings include: RESIDENT 1: The facility's mechanical lift procedure undated instructed staff that when they "begin to lift the resident and back the lift or wheelchair away while monitoring the shift in the resident's center of gravity and preventing the sling from swinging, and when the resident is clear from the area, slowly turn the lift and move the resident to the desired location". Resident 1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 12/21/14, indicated she required two people for bed mobility and transfers. She used a wheelchair for mobility. She was 170 pounds and 5 feet 6 inches in height. The fall evaluation, dated 12/20/14, documented she had no history of falls, was orientated and had gait/balance difficulty with limited physical mobility. The "Resident Con Sheet" (form used by nursing assistance) revealed the resident was able to make needs known and had intermittent confusion. The Physician visited the resident due to her flu like illness. The physician's visit note for 1/13/15 revealed the resident's feet are externally rotated, legs won't support her. The note indicated she had chronic pain and was on 2 narcotic medications to manage her chronic pain. Nursing notes from 1/5/15 to 1/28/15 revealed the resident had flu-like symptoms, confusion, lethargy, a cough and was experiencing pain. During this time, she was treated with intravenous fluids, flu medication, and antibiotic and medication changes. The nursing notes, dated 1/29/15, at 3:25 p.m., documented Resident 1 sustained fall from a mechanical lift during a transfer, "3 staff members were present during the fall". "Resident slid out of sling feet first falling onto buttocks and back", Resident c/o (complained) acute pain LLE (left lower extremity). The resident was transferred to the hospital. On 2/7/15 at 12:07 p.m., the Director of Nursing (DNS) stated Resident 1 was non-weight bearing due to history of knee replacement/removal. She stated when the resident sat in her wheelchair; her legs would be in the extended position. On 2/9/15 at 2:00 p.m., a mechanical lift (Hoyer) was observed. Two Nursing Assistance (NACs) performed the lift. The NACs initially held legs of the resident and the sling formed and wrapped around the torso of the resident (upright position). One NAC held the residen'ts legs, and the other NAC held back (torso) of resident's back and sling, a cocoon appearance of the lift. One NAC stated "the sling is raised up and the resident's back is supported and hugs the resident, we "always have 2 staff." On 2/9/15 at 9:18 a.m., the resident was observed in bed with head of bed elevated. She appeared dozing and did not respond. On 2/9/15 at 9:33 a.m., the Licensed Nurse (LN l)stated Hoyer lifts are done with 2 people; she stated Resident 1 was currently confused and lucid at times. On 2/9/15 at 10:50 a.m., during an interview with the DNS, she stated Resident 1 had "slipped out of sling, feet first." She stated when rising up the lift, Resident 1's sweater got caught and jolted her forward and slid out of sling". The DNS stated Resident 1 had periods of anxiety especially with transfers, she would " yell and scream". The DNS stated the incident was "an accident and not avoidable". On 2/9/15 at 9:00 a.m., the administrator verified when Resident 1 was being transferred using a mechanical lift, the resident's sweater got stuck as the sling was being lifted. She confirmed there was 3 staff present during the transfer. In the investigative report, dated 1/29/15, the LN statement revealed 3 staff assisted in the transfer. "There were three staff in the room; all three were in close proximity to resident in correct position to provide a safe transfer. When the mechanical lift was elevated approximately 6 inches from the surface of the resident's wheelchair, "she slid feet first, and subsequently fell out of sling, onto floor, landing on her back and buttocks". The investigative report concluded Resident 1 had lack of core musculature, involuntary movements due to her disease process, and hip tightness due to her inability to bear weight on her legs. The report documented Resident 1 had "slid forward out of the sling landing on her feet, which could not support her body weight causing them to buckle". Even though 3 staff were present during Resident 1's transfer using a mechanical lift, appropriate assistance and supervision was not provided. RESIDENT 2: Resident 2 had [DIAGNOSES REDACTED]. The MDS indicated she was unable to balance without staff assistance. The fall assessment, dated 11/29/14, indicated Resident 2 was at risk for falls due to disorientation, and the need for safety reminders due to her balance problem. The Nursing Assistant (NAC) flow sheet indicated she required extensive assistance-staff provide weight-bearing support. On 2/9/15 at 9:40 a.m., the resident was observed seated in a recliner. She had a bruise on her forehead above her left eye. The resident was confused and when asked about her bruise, she stated she "had no idea, probably hit door or something". On 2/9/15 at 9:30 a.m., the LN1 was asked about Resident 2's mental status. She stated the resident was "confused" and after her naps, she is really confused, and it takes some time for her to get bearings as to where she is. LN 1 stated Resident 2 was dependent on staff for wheelchair mobility. The Care Plan for activities of daily living (ADLs) revealed the resident's participation in toileting was dependent on her strength and endurance; her ability to stand and bear weight may fluctuate and staff needed to anticipate the need for assistance. The Care plan for impaired cognitive function/dementia or impaired thought processes informed staff to cue, re-orient and supervise as needed. An investigative report, dated 1/23/15, revealed Resident 2 was found in the bathroom on her back on the floor between the toilet and the sink with her head under the sink. The report documented she complained of pain, "hurts really bad" in her head. A written statement by the nursing assistant (NAC) documented she had assisted Resident 2 to the toilet and left her unattended. The report indicated she had "discoloration" on forehead dated 1/24/15. The progress notes for 1/23/15 documented the resident sustained [REDACTED]. Another note revealed that after the fall, she experienced neck pain with swelling and was transferred to the hospital for evaluation. A nursing note entry for 1/24/15 documented the resident "developing bruising on her forehead dark purple colored" and that she was experiencing a headache. On 2/9/15, the Director of Nursing (DNS) verified that after the fall, Resident 2's pain level changed from her baseline, and she complained of neck pain, and had edema (swelling) around her neck. On 2/25/15 at 4:00 p.m., the DNS verified Resident 2's care plan did not specify the necessary interventions to reduce the risks of falls for a cognitively impaired resident. RESIDENT #3: Resident 3 was admitted to the facility on [DATE] from home due to a decline in his health. The admit Elopement Evaluation revealed he was at risk for elopement due to cognitive impairment, and wanting to go back home as he was unhappy about being admitted to the facility. The Progress Notes revealed that on 1/14/15, Resident 3 had eloped. He was found in the parking lot. At this time, the Licensed Nurse (LN) documented he was confused and was impulsive. After Resident 3's initial elopement on 1/14/15, the plan of care to minimize further elopements was to place the resident in the memory care unit (MCU) due to his "poor safety awareness . The MCU's exit doors require a code to be inputted in order to exit, and the doors leading out to the courtyard are alarmed doors which alert staff if residents would attempt to exit the MCU. The progress notes from 1/15/15 to 2/3/15 while in the MCU, revealed Resident 3 frequently attempted to elope, would exit the alarmed door to the courtyard, was fixated on "getting out of here", and was very confused. A note for 1/31/15 documented he exited out of one of the key padded doors by putting in the code. On 2/9/15, the secured unit's key pad doors, alarmed doors and egress system were observed with the Director of Nursing. The back doors which lead to the courtyard were both alarmed. The courtyard was enclosed by a fence with a gate. In order to enter or exit through the gate, a code was needed. The gate had a magnetic strip which would ensure the gate closed after it was opened. A second elopement occurred on 2/4/15. The investigative report documented the facility was notified by the school which was across the street from the facility. The report revealed the resident frequently opened the doors to the courtyard. Prior to Resident 3's elopement, the facility staff had noticed that some visitors had been using the secured courtyard to enter the memory care unit. Another staff member had also noticed more vehicles parked in the stall closest to the gated entrance of the courtyard. On 2/9/15, the DNS confirmed staff had not heard the door alarm when Resident 3 eloped. He was discovered across the street from the facility. Even though, Resident 3 was placed in the MCU, staff failed to alert administration regarding visitors entrance through the secured doors and gate. On 2/25/15 at 4:00 p.m., Resident 3 was observed seated in chair in his room. He stated he "walked down the highway", wants to go home but now happy walking independently with a cane.

2 Based on observation, interview and record review, the facility failed to evaluate and monitor 1 of 2 sample (4) resident's care needs with a medical condition change. Failure to evaluate transfer needs resulted in a fall with harm for Resident 4. Findings include: RESIDENT 4: Resident 1 had [DIAGNOSES REDACTED]. The Minimum Data Assessment, dated 12/29/14, indicated the resident required supervision with transfers and extensive assistance with toileting, was unsteady with her balance, had limited range of motion in her lower extremities and weighed 220 pounds. The care plan informed staff that Resident 4's cognitive function may be affected by pain, infection, acute illness or medication changes. Review of the progress notes, dated 2/9/15, documented the resident had been assessed to be safe to be alone while on the commode, was able to independently transfer to and from commode. The Consideration Sheet (CON) used by nursing assistance, dated 1/15/25, revealed Resident could transfer independently and may need SBA (standby assistance) if requested. The CON sheet indicated she used a BSC (bedside commode) and was incontinent of urine. The care plan, dated 3/16/15, read: toilet use: The resident can be left alone on commode and transfer on/off ad lib (as tolerated) and able to stand and bear weight with transfers. The care plan, dated 3/16/15, revealed she required decreased weight bearing activities until wound (foot) resolved. The progress note, dated 3/15/15, revealed the resident's left foot had redness, swelling and warmth and her ulcer on the bottom of the foot had drainage. She was started on an antibiotic. On 3/16/15, the Licensed Nurses (LNs) documented Resident 4 was experiencing foot pain, rate 7 (0 being no pain, 10 being worse pain) and required more assistance with her ADL's (activities of daily living). On 3/19/14 the LN documented PT will continue to work with her on transfers and strengthening. The skilled therapy note dated 3/19/15 documented skilled PT (physical therapy) would be on hold due to her non-healing ulcer on the ball of left foot and indicated her physician had recommended OT (occupational therapy) to start for upper body strengthening and conditioning. On 3/19/15, the resident was seen at the wound clinic due to the [MEDICAL CONDITION] of her foot. The wound clinic note documented pressure relief strategies were needed to avoid pressure on the ulcer on the bottom of her foot. The note documented a wedge-type trauma shoe (protective) was to be tried. The progress note, dated 3/22/15, documented the resident had a fall and at the time of the fall had a protective boot on her left foot. The resident complained of extreme pain and was transferred to the hospital. The facility ' s investigative report, dated 3/22/15, documented heard resident scream, upon getting to room, resident was lying on her left side next to her commode. Emergency system (911) activated due to resident ' s complaint of neck, back, and hip pain. There was no documentation regarding the resident s foot wear. The hospital admission note, dated 3/22/15, revealed Resident 4 had a fracture of her hip and questionable fracture of her spine. On 3/31/15 at 4:25 p.m., during an interview with the Director of Nursing (DNS), she verified Resident 4's legs gave out when the resident attempted to get off the bedside commode. The DNS was unable to verify as to whether the resident's transfer status had been monitored and evaluated after a protective boot was provided on 3/19/15. There was no documented evidence the facility had monitored or revised the plan of care for Resident 4 who had a foot infection with pain, required decreased weight bearing to the foot and used a protective boot for pressure relief for the bottom of her foot.

Based on observation, interview and record review, the facility failed to provide adequate supervision for 1 of 3 sampled residents (Resident 24) reviewed for accidents. Failure to remain with Resident 24 while the resident was on the commode resulted in harm for Resident 24 who experienced a fall with injury. Findings include: Resident 24 was admitted to the facility on [DATE]. The resident was alert and oriented and required extensive assistance of 2 staff for toilet use. The resident was considered at risk for falls due to a medical condition that impaired her balance. The resident's CON sheet (the plan of care the Nursing Assistants use.) located inside the residents closet door, directed the Nursing Assistants (NA's) to not leave the resident unattended while she was on the commode. An event and occurrence report dated 12/2/11, revealed the resident was found on the floor in front of the commode. The resident stated she leaned forward while on the commode and fell . The facility investigation revealed that the NA assigned to the resident the day of the incident (NA 1), failed to follow the resident ' s plan of care. NA 1 transferred the resident onto the commode by himself and then left her unattended on the commode, while he went to take care of another resident in a different room . Upon returning to Resident 24 ' s room, he found the resident on the floor. Resident 24 told the NA she hit her head when she fell from the commode. The resident sustained [REDACTED]. She was transported to the Emergency Department where she was evaluated for further injuries. Two days later, nursing recorded the bruising had progressed to purple discoloration around the resident's eyes ("raccoon eyes"). According to a statement from NA 1 dated 12/6/11, he did not look to see what was updated on the resident's CON sheet and was not aware the resident was a 2 person transfer or that the resident was not to be left alone. In an interview with the resident on 12/22/11 at 10:35 a.m., she stated she remembered the fall, she was repositioning herself and fell forward. She further stated, "luckily I didn't break something." The resident was observed to have fading discoloration around the eyes. In an interview with the Director of Nursing Services (DNS) on 12/22/11 at 11:00 a.m., she stated the aid received disciplinary action for not following the resident's plan of care and the "whole house has been in-serviced on reading the resident's CON sheets."