Every finding on record at Regency Coupeville Rehab and Nursing Center

Based on observation, interview, and record review the facility failed to protect residents right to be free from physical abuse for 2 of 3 sampled residents (Residents 4 and 5) reviewed for resident-to-resident altercations. Additionally, the facility failed to consistently supervise, accurately assess, and care plan 1 of 1 sampled resident (Resident 5) who had a known history of verbal and physical outbursts towards others, reviewed for 1:1 monitoring. Resident 5 caused an unsafe environment for Resident 6 when they blocked them from leaving a public area. This failure placed residents at risk for potential physical or mental abuse, feeling safe, experiencing fear, intimidation, and a decreased quality of life. Findings included. Review of the facility policy titled, Abuse/Neglect/Misappropriation/Exploitation, revised on 10/2022, documented it is the policy of the facility to protect residents from mistreatment, neglect, and abuse. The facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish. Physical abuse included, but not limited to hitting, slapping, pinching, choking, striking with an object, kicking, shoving, and prodding. <RESIDENT TO RESIDENT PHYSICAL ALTERCATION>RESIDENT 4Resident 4 admitted to the facility in May 2024 with diagnoses to include a stroke, bipolar (a serious mental illness characterized by extreme mood swings) disorder, post-traumatic stress disorder (PTSD - a psychiatric disorder that may occur in people who have experienced or witness a traumatic event) and had a developmental disability. Review of a quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 02/13/2026, documented the resident was cognitively intact and independent with their wheelchair (w/c) mobility. Review of Resident 4's impaired cognitive function care and/or impaired thought process care plan, revised on 04/02/2026, documented the resident's goal was to communicate their daily basic needs. The care plan documented Resident 4 received services through the Developmental Disability Association. Interventions included keeping their routine as consistent as possible. Review of a progress note, dated 03/16/2026 at 5:10 PM, documented Resident 4 observed Resident 5 in their w/c pointing and coming towards Staff J, Registered Nurse (RN), and punched Staff J with a closed fist in their right arm and flank. Staff J stepped away from Resident 5, observed Resident 4 coming towards them, pushed a tray off the table, grabbed Resident 5's sweatshirt and began yelling at Resident 5. Staff J then observed Resident 5 yelling at Resident 4 and they began hitting one another with closed fists. The residents were separated and Resident 4 was having a hard time calming down and was taken to their room. In an interview and observation on 04/14/2026 at 11:55 AM, Resident 4 was in their w/c sitting in their room with a visitor. Resident 4 stated yes when asked if they had any concerns with any other residents in the facility. Resident 4 stated one evening in the dining room they observed Resident 5 running their w/c into a nurse. Resident 4 stated I guess my protective instincts kicked in and went over to Resident 5 and grabbed their sweatshirt to pull them away from the nurse. When asked if they had struck Resident 5, they stated no. The resident stated, I just avoid [Resident 5], when asked if they have had any further interaction with Resident 5. RESIDENT 5Resident 5 admitted to the facility 02/09/2026 with diagnoses to include disorder of psychological development and intellectual disability. Review of the admission MDS assessment, dated 02/13/2026, documented Resident 5 had severe cognitive impairment, required setup assistance with w/c mobility, speech clarity was unclear, and sometimes understands what was being communicated to them. Review of Resident 5's risk for decrease in activity involvement, dated 02/25/2026, documented the resident was at risk related to their acute condition, limited attention span, communication deficit, history of self-injurious behaviors, and history of resident-to-resident conflicts. The staff were directed to provide activities that empowered the resident to make choices, encourage self-expression, and responsibility. Review of Resident 5's impaired cognitive function and/or impaired thought process care plan, created on 02/09/2026, documented the resident was developmentally delayed and had a diagnosis of Autism (a neurodevelopmental condition affecting how individuals communicate, interact, and perceive the world). The care plan directed staff to keep Resident 5's caregivers consistent as much as possible to help decrease their confusion and required assistance with decision making. Review of Resident 5's progress note, dated 03/26/2026 at 7:49 PM, Staff J documented upon entering the East dining room the resident was observed in their w/c, yelling, putting their arms up, and stated something about the television remote control. Staff J approached Resident 5 to calm them down, when Resident 4 was observed to propel their w/c over to them, yelled and grabbed Resident 5's sweater. Resident 4 and Resident 5 were observed hitting each other with closed fists. The residents were separated, and staff stayed with Resident 5 in the dining room and distracted them as much as possible until a 1:1 caregiver could arrive at the facility. In an observation and interview on 04/20/206 at 11:05 AM, Resident 5 was observed in the hallway in their w/c with their 1:1 caregiver. The resident was smiling and said hello to this surveyor. Resident 5 stated they were doing fine today. When asked if they were on their way for lunch, the resident made a sound and wanted to go into the East dining room. No further questions were asked. RESIDENT TO RESIDENT INCIDENT INVESTIGATIONReview of a facility incident investigation, dated 03/26/2026 at 5:10 PM, documented a physical altercation was observed between Resident 4 and Resident 5. In the East dining room, Resident 4 was observed in their w/c to rush past the licensed nurse (LN), moved a table out of the way, knocked a leftover dinner tray from the table onto the floor, and grabbed Resident 5's sweater. The LN intervened immediately and thought the situation between the two residents had de-escalated, when Resident 4 wheeled past the LN towards Resident 5 and began to strike Resident 5. Resident 5 struck Resident 4 back and they began to exchange closed-fist strikes. Resident 5 was escorted to the LN station and placed on 1:1 observation until they calmed down. The investigation documented Resident 4's response was triggered by Resident 5's behaviors related to their history of PTSD which had contributed to their emotional reaction when Resident 4 perceived the LN was at risk. The investigator documented Resident 4's actions were impulsive, were intended to assist the staff, and resulted in a brief physical altercation. Abuse and neglect were ruled out related to this physical altercation had occurred during an acute resident behavioral issue. Staff were attempting to de-escalate Resident 4 and Resident 5's behaviors and their care plans were followed. The investigation documented Resident 4's actions were reactive and not premeditated or malicious in intent. During an interview on 04/20/2026 at 2:45 PM, Staff D, RN/Regional Director of Clinical Services, was asked the rational how physical abuse was ruled out regarding the resident-to-resident physical altercation between Resident 4 and Resident 5. Staff D stated Resident 4 was protecting Staff J from Resident 5. Staff D stated Resident 4 was not acting malicious and was sorry for what occurred. <ONE TO ONE MONITORING>Review of a facility undated form titled, the facility's 1:1 Monitor, documented the purpose of the monitor was to validate the safety residents and to prevention behaviors from negatively affecting others. Staff were directed to document every hour on the form describing the residents' activities and what interventions were provided for the resident. Staff were directed when the resident was found awake and wandering staff must designate an individual to support the resident, and if the resident was sleeping the staff would document this on the form. This form would help create a resident's care plan and the potential removal of the 1:1 monitoring. Review of Resident 5's progress note, dated 03/26/2026 at 7:49 PM, documented the resident was observed in a physical altercation with another resident (Resident 4). The resident was placed on 1:1 staffing after the altercation. Review of a progress note dated 03/29/2026 at 1:18 PM, the LN documented Resident 5 continued to reach out towards peers and staff, and hits themselves, walls and staff when frustrated. Review of a progress note dated 03/31/2026 at 9:44 AM, the LN documented Resident 5 does raise their fist towards other people and hits themselves at times per [their] baseline behaviors. Review of an Interdisciplinary Team (IDT) progress note dated 04/02/2026 at 9:20 AM, documented Resident 5's 1:1 monitoring had been gradually increasing distance between the resident and the staff member to allow Resident 5 space, staff were to observe their behaviors and be able to intervene when necessary. The IDT note documented a trial of decreasing the 1:1 monitoring during the day shift starting 04/02/2026, and the resident will remain on 1:1 monitoring on the night shift. The IDT would reevaluate the need for 1:1 monitoring on Monday 04/06/2026. Review of a progress note dated 04/02/2026 at 10:28 AM, Staff E, RN/Patient Care Coordinator, documented they discussed the 1:1 monitoring with Resident 5 who expressed frustration with the 1:1 monitoring. Staff E documented trial discontinuation of 1:1 staring now. Review of Resident 5's progress notes, dated 04/02/2026 to 04/07/2026, documented the following:- On 04/03/2026 at 1:13 PM, documented the resident continued to yell out at staff, not easily redirected, and hits themselves. There was no documentation if the resident was on any 1:1 monitoring.- On 04/04/2026 at 1:36 PM, there was no documentation regarding the decrease in 1:1 monitoring.- There was no documentation regarding Resident 5's behaviors or 1:1 monitoring on 04/05/2026 or 04/06/2026.- There was no IDT note reevaluating the resident's need for 1:1 monitoring on 04/06/2026 per the IDT note on 04/02/2026.- On 04/07/2026 at 1:58 PM, Staff K, Licensed Practical Nurse (LPN)/Resident Care Coordinator, documented Resident 5 was now on 1:1 monitoring and required staff redirection due to their behaviors towards others. There was no further documentation indicating why this decision was made. Review of Resident 5's 1:1 Monitoring forms, dated 04/02/2026 to 04/07/2026 at noon, documented the following:- On 04/02/2026, 1:1 documentation stopped at 11:00 AM.- On 04/03/2026, 1:1 documentation was completed at 10:00 PM and 11:00 PM, there was no other 1:1 documentation on the form.- On 04/04/2026 and 04/05/2026, 1:1 documentation was completed from midnight to 6:00 AM, at 10:00 PM, and at 11:00 PM. The staff documented at 1:00 AM and at 2:00 AM the resident was upset at the nurse's station related to not being able to log into a television network. There was no documentation on the form between the hours of 7:00 AM to 9:00 PM.- On 04/06/2026, 1:1 documentation was completed from midnight to 6:00 AM. There was no further 1:1 documentation on the form.- On 04/07/2026, 1:1 documentation was completed from noon to midnight. Review of a grievance form dated 04/06/2026 at 6:00 PM, Resident 6's family member documented Resident 4 came into the lobby area where Resident 6 and their family member were visiting. Resident 4 propelled their w/c up to Resident 6 and blocked them and their daughter from exiting the room. When Resident 6 and their family member attempted again to leave the lobby area, Resident 4 came straight towards Resident 6 in their w/c. It was not safe. Staff A, Administer in Training, interviewed Resident 6's family member who stated they felt Resident 6 was being targeted by Resident 4 and this was not a safe situation. Staff A documented Resident 5's 1:1 monitoring was reinstated after the facility had received the grievance. Review of Resident 5's impaired cognitive function and/or impaired thought process care plan, revised on 04/15/2026, documented an intervention was created and implemented on 04/13/2026 that the resident had a history of sudden outbursts and was currently on 1:1 supervision related to this behavior. There was no other documentation on the resident's care plan indicating the resident had been on 1:1 monitoring prior to 4/13/2026. On 04/14/2026 at 9:41 AM, Resident 5 was observed in the main dining room doing an activity. There was an unidentified staff member next to the resident. In an interview and observation on 04/14/2026 at 9:47 AM, Staff F, Nursing Assistant Certified (NAC), was observed in the main dining area with Resident 5 who was doing an activity. Staff F stated they were Resident 5's assigned 1:1 staff member. Staff F stated the resident was on 1:1 monitoring related to their behaviors. Staff F stated they were the resident's caregiver when they were on shift. When they went on a break, they obtained another staff member to monitor Resident 5. During the interview, Resident 5 was observed to look back at Staff F and call out to them (Resident 5's speech was not clear). Staff F would reassure the resident they would be right there. In an interview on 04/14/2026 at 10:12 AM, Staff L, NAC, stated Resident 5 was on 1:1 monitoring related to their behavior towards others. In an interview on 04/14/2026 at 10:22 AM, Staff F, NAC, stated Resident 5 was on 1:1 monitoring related to their behaviors. Staff F stated the resident would get fixate on some of the staff and would target them (seek them out when they were working). In an interview on 04/14/2026 at 11:55 AM, Staff G, Licensed Practical Nurse (LPN), stated Resident 5 currently received 1:1 staffing. When asked why they were on 1:1 staffing, Staff G stated the resident had outbursts, yelled, and would hit the staff. Staff G stated there was a special binder located at the nurse's station that directed staff on how to interact and handle Resident 5's behaviors. On 04/14/2026 at 12:43 PM, Resident 5 was observed in their w/c on the phone at the East nurse's station. Resident 5 handed the phone to Staff F who spoke to the person on the phone. Resident 5 was observed to become agitated, was motioning for the phone back, was pointing at Staff F, and repeated it is mine repeatedly. Staff F handed the phone back to Resident 5 who then calmed down. On 04/14/2026 at 12:59 PM, Resident 5 was observed in their room sitting with the 1:1 caregiver and watching television. On 04/16/2026 at 9:22 AM, Resident 5 was observed sitting in their w/c in their room, watching television and continuously moving their w/c back and forth. In an interview on 04/16/2026 at 3:02 PM, Staff M, NAC, stated Resident 5 was on 1:1 monitoring related to their behaviors. Staff M stated the 1:1 caregiver care for all of Resident 5's needs and they only cover the assigned staff member when they go on a break. In an interview on 04/16/2026 at 3:30 PM, Staff H, Social Service Director, was interviewed at the East nurse's station. Staff H was asked who was in the room with Resident 5. Staff H stated this was a person provided by an outside agency to visit with the resident two days a week for a couple of hours. At that time, Resident 5 was observed to call out (unintelligibly) to Staff H, raising their fists. Staff H stated to Resident 5 they would come and visit them in a minute. Staff H stepped back out of Resident 5's direct line of sight and Resident 5 was observed to calm down. Staff H stated the resident fixated on them at times. On 04/20/2026 at 11:05 AM, Resident 5 was observed in their w/c on the East hallway with a 1:1 caregiver. In an interview on 04/20/2026 at 2:09 PM, Staff E stated staff were to document on Resident 5's 1:1 monitors every hour what the resident was doing, the resident's behaviors, and what they did to de-escalate the resident. Staff E stated on 04/02/2026 the resident's 1:1 monitoring was decreased related to Resident 5 was exhibiting signs of frustration due to the 1:1 monitoring. Staff E was asked if there was any further information directing the staff what decreased 1:1 monitoring meant, what staff expectations were, if this had been assessed, documented, and care planned. Staff E could not provide any additional information. On 04/20/2026 at 3:15 PM, an interview with Staff B, RN/Interim Director of Nursing Services, Staff C LPN/Assistant Director of Nursing, and Staff D was conducted. The staff were asked regarding Resident 5's decreased 1:1 monitoring. Staff C reviewed the resident's record and stated Resident 5 was placed on decreased 1:1 monitoring on 04/02/2026 related to Resident 5 was becoming agitated and the facility was honoring their rights. Staff C stated the IDT was to reassess Resident 5's decreased 1:1 monitoring on 04/06/2026. Staff C could not locate an IDT note reassessing Resident 5's decreased 1:1 monitoring. The staff were asked for documentation in Resident 5's medical record assessing what decrease monitoring meant, what were the expectations of the staff, were the staff directed to document to the resident's behaviors and whereabouts during this trial period, and if the 1:1 was care planned. Staff C and Staff D could not locate any additional information in Resident 5's chart. The staff were asked regarding the grievance dated 04/06/2026 filled out by Resident 6's family member and how Resident 5 made them feel unsafe in the lobby area, the staff confirmed the 1:1 monitoring was reinstated after this incident had occurred. Reference WAC 388-97-0640(1)

Based on interview, and record review the facility failed to ensure resident choices/preferences regarding their bathing schedule were honored for 2 of 3 sampled residents (Residents 1 and 3) reviewed for choices. These failures placed the residents at risk for decreased cleanliness, increased risk of infection and diminished quality of life. Findings included .<RESIDENT 1>Resident 1 was admitted to the facility on [DATE] with a diagnosis to include dementia with anxiety. Review of Resident 1's Minimum Data Set (MDS - an assessment tool) assessment, dated 12/30/2025, documented the resident had severe cognitive impairment. Review of Resident 1's bathing/shower care plan, dated 07/08/2025, documented the resident frequently declined showers and required maximal assistance of one person for showering. There was no information directing staff on what to do when the resident refused a shower. Review of Resident 1's December 2025 Documentation Survey Report v2 (a report that showed the Nursing Assistant Certified documentation to specific tasks performed with a resident), documented the resident received three showers (on 12/04/2025, 12/08/2025 and 12/11/2025). Resident 1 refused a shower on 12/18/2025, 12/25/2025, 12/29/2025, and the Nursing Assistant Certified (NAC) documented NA (not applicable) on 12/20/2025 and 12/22/2025. Review of Resident 1's January 2026 Documentation Survey Report v2, documented Resident 1 was showered on 01/15/2026 (36 days after their last shower) and 01/29/2026. Resident 1 refused on 01/01/2026, 01/08/2026, and 01/22/2026. Review of Resident 1's February 1 through 25, 2026 Documentation Survey Report v2, documented Resident 1 was showered on 02/17/2026 (19 days after their last shower). The resident refused a shower for six days (on 02/02/2026, 02/05/2026, 02/12/2026, 02/16/2026, 02/19/2026, and 02/23/2026). Review of Resident 1's progress notes dated 12/01/2025 to 02/26/2026, documented the resident refused a shower on 12/29/2025 and the staff reapproached offered the resident a shower and they refused. The staff documented the resident stated she bathed in the sink with soap and water each morning and did not want a shower with someone else present. There was no other documentation regarding Resident 1's refusals of showers. Review of Resident 1's electronic medical record showed no documentation of the resident's preference of how they wished to be showered/bathed. In an interview on 02/26/2026 at 1:36 PM, Staff D, NAC, stated Resident 1 does refuse care at times. Staff D stated the resident told them they have been doing it for years and is capable to care for themselves. Staff D stated when a resident refused care, they attempted to reapproach the resident and obtain a different staff member. If the resident continued to refuse, they reported the refusal to the nurse, and the refusal was documented in Point Click Care (PCC - the facility's electronic medical record). In an interview on 02/26/2026 at 1:58 PM, Staff H, NAC/Shower NAC, stated residents were showered twice a week. Staff H stated Resident 1 did refuse showers, but when they were able to shower the resident, they communicated to them step by step what they were doing. Staff H stated when a resident refused a shower they attempted to reapproach, offer them a shower on a different day, documented the refusal and informed the nurse on shift. <RESIDENT 3>Resident 3 was admitted to the facility 10/22/2025 with diagnosis to include a stroke with left-sided hemiplegia (complete loss to control one side of the body). Review of Resident 3's Quarterly MDS assessment, dated 01/26/2026, showed the resident's Brief Interview for Mental Status (BIMS - a structured cognitive interview) score was 13 out of 15. The resident was cognitively intact. Review of Resident 3's bathing/showering care plan, revised on 11/06/2025, documented Resident 3 preferred two showers a week per the facility shower schedule and required maximal assistance of one person. Review of Resident 3's December 2025 Documentation Survey Report v2, documented the resident was showered once on 12/24/2025, refused twice (on 12/03/2025 and 12/10/2025), documented NA three times (on 12/06/2025, 12/08/2025, and 12/10/2025), and was not available for a shower on 12/31/2025. Review of Resident 3's January 2026 Documentation Survey Report v2, documented Resident 3 was showered/bathed on 01/10/2026 (16 days since their last shower), and 01/28/2026. The resident refused showers twice (on 01/14/2026 and 01/21/2026). Review of Resident 3's February 1 through 25, 2026 Documentation Survey Report v2, documented the resident was showered/bathed once 02/04/2026, and refused twice on 02/14/2026, and 02/18/2026. The NAC documented NA. Review of Resident 3's nursing progress notes, dated 12/01/2025 to 02/26/2026, showed no documentation of the resident's refusal to be showered. In an interview on 02/26/2026 at 1:47 PM, Staff F, NAC, stated residents were showered twice a week. When a resident refused their shower, they would attempt to offer it again before their next scheduled shower day. Staff F stated they document in PCC when they gave a resident a shower. Staff F stated if a resident refused a shower they would inform the nurse on duty. In an interview on 02/26/2026 at 1:58 PM, Staff H, NAC, stated the residents were scheduled to receive two showers a week. If a resident refused a shower, they would reapproach two times, and if they continued to refuse would document the refusal in PCC and notify the nurse. Staff H stated they would try to offer the resident a shower later in the week. Review of an email communication on 02/26/2026 at 3:59 PM, Staff C, Registered Nurse (RN)/Regional Director of Clinical Operations, documented the facility does not have a resident shower policy. Reference WAC 388-97-0180(2)

Based on interview and record review, the facility failed to maintain complete, accurate, and accessible clinical records for 5 of 8 sampled residents (Residents 1, 2, 3, 10 and 11) reviewed for complete and accurate medical records. The failure to maintain clinical records in accordance with professional standards of practice placed residents at risk for unmet care needs and diminished quality of life. Findings included . <RESIDENT 1>Review of Resident 1 December 2025 Documentation Survey Report v2 (a report that showed the Nursing Assistant Certified documentation to specific tasks performed with a resident), showed several missing entries of Nursing Assistant Certified (NAC) documentation. Review of the intervention/tasks showed: - The task of ALL CARE PROVIDED, there was no documentation on 12/02/2025, 12/11/2025, 12/13/2025, 12/14/2025, 12/17/2025 – 12/19/2025, 12/26/2025, and 12/28/2025 (day shift), once on evening shift (12/02/2025), and three days on night shift (12/16/2025, 12/22/2025, and 12/31/2025).- The task Skin Observation, there was no documentation on 12/02/2025, 12/10/2025, 12/11/2025, 12/13/2025, 12/14/2025, 12/17/2025 – 12/19/2025, 12/26/2025, and 12/28/2025 (day shift), and three days on night shift (12/16/2025, 12/22/2025, and 12/31/2025).- Further review of the report showed missing documentation on all shift under the intervention/task section of behavioral symptoms, bowel monitoring, activities of daily living (ADL's – dressing, transfers, upper body and lower body dressing, oral hygiene, personal hygiene, toileting, bathing, bed mobility, bowel and bladder continence, walking, and eating), and food and fluid intake. Review of Resident 1's January 2026 Documentation Survey Report v2, showed no intervention/tasks documentation on ten days. No day shift documentation on 01/01/2026, 01/02/2026, 01/05/2026, 01/12/2026, 01/19/2026 and 01/26/2026), and three days on night shift (on 01/04/2026, 01/10/2026, and 01/11/2026). Review of Resident 1's February 1 through 25, 2026 Documentation Survey Report v2, showed no intervention/tasks documentation on three days on day shift (on 02/04/2026, 02/09/2026, and 02/12/2026), once on the evening shift (02/03/2026), and once on the night shift (on 02/07/2026). Review of Resident 1's Fall risk assessment, dated 02/18/2026, documented it was not locked/completed until 02/24/2026. <RESIDENT 3>Review of Resident 3 December 2025 Documentation Survey Report v2, showed no intervention/tasks documentation eight days on the day shift (on 12/05/2025, 12/12/2025, 12/13/2025, 12/14/2025, 12/17/2025, 12/19/20025, 12/20/2025, and 12/27/2025), two days on the evening shift (on 12/08/2025, 12/17/2025), and three days on the night shift (on 12/14/2025, 12/16/2025, and 12/31/2025). Review of Resident 3's January 2026 Documentation Survey Report v2, showed no intervention/tasks documentation six days on the day shift (on 01/03/2026, 01/07/2026, 01/08/2026, 01/17/2026, 01/19/2026, 01/24/2026 and 01/31/2026), two days on the evening shift (on 01/04/2026 and 01/13/2026), and two days the night shift (on 01/06/2026 and 01/31/2026 In an interview on 02/26/2026 at 1:36 PM, Staff D, NAC, and Staff E, NAC, stated all NAC documentation was documented in Point Click Care (PCC - the facility's electronic medical record). <RESIDENT 2>Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Electronic Medical Record (EMR) documented they had an interdisciplinary care conference on 02/17/2026, and the documentation was not completed by Staff J, Social Services Director (SSD), as of 02/26/2026. <RESIDENT 10>Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's EMR documented they had an interdisciplinary care conference on 2/17/2026, and the documentation was not completed by Staff J, SSD, until 02/22/2026. <RESIDENT 11>Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's EMR documented that they had an interdisciplinary care conference on 12/17/2025, and the documentation was not completed by Staff J, SSD, until 12/26/2025. On 02/26/2026 at 4:52 PM, an interview was conducted with Staff B, Chief Operating Officer, Staff C, Registered Nurse (RN)/Regional Director of Clinical Operations, and Staff K, RN/Corporate Nurse. Staff B stated a Care Plan Conference User-Defined Assessment (UDA) form may be initiated prior to the scheduled CPC. On the day the CPC was held the expectation was it was completed/locked within a day. When asked when the NAC should complete their documentation in PCC stated by the end of their shift. The staff were made aware of the incomplete NAC documentation found in PCC. Reference WAC 388-97-1720 (a)(i)(ii),(4)(a)

Based on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences (a collaborative care plan meeting where a resident's care was discussed and coordinated by a team of health care providers, family members and residents) for 1 of 3 sampled residents (Resident 1) reviewed for participation in care planning. This failure placed residents at risk of not being allowed to be involved and informed about care and services and a diminished quality of life. Findings included.Review of the facility's policy, titled, Interdisciplinary Care Conference, dated 3/2024 and revised on 12/16, documented an interdisciplinary care conference is completed upon the resident's admission to the facility, quarterly, and following a change in condition. The resident and/or the resident representative will be invited to the care conference. Resident 1 was admitted to the facility on [DATE] with a diagnosis to include dementia with anxiety. Review of Resident 1's electronic medical record (EMR) documented a care plan conference (CPC), dated 07/14/2025, was held. There were no other CPCs found in Resident 1's EMR. During a telephone interview on 02/12/2026 at 11:00 AM, Collateral Contact 1 (CC 1) stated they have only attended one CPC since Resident 1 was admitted to the facility. CC 1 stated there had been a CPC set up within the past month, and something had come up at the last minute and was not able to attend and requested for the meeting to be rescheduled. CC 1 stated they would like to be involved in Resident 1's care. In an interview on 02/26/2026 at 2:34 PM, Staff J, Social Services, stated CPCs were completed within the residents first week of admission, and quarterly CPCs were set up in accordance with the residents scheduled Minimum Data Set (MDS - an assessment tool) assessment. Staff J was asked about Resident 1 CPCs. There was one documented CPC held on 07/14/2025 at 2:00 PM located in Resident 1's medical record. Staff J searched through Resident 1's EMR and did not find any additional CPCs. Staff J stated the facility was working on scheduling a CPC with Resident 1 and CC 1. Reference WAC 388-97-0200(3)

Based on interview and record review the facility failed to notify the resident's responsible party of orders for a new medication for 1 of 3 sample residents (Resident 1) reviewed for notification of changes. This failure prevented the person responsible for making healthcare decisions from being part of the care planning process and being knowledgeable about medications the resident was taking. Findings included.Resident 1 was admitted to the facility on [DATE] with a diagnosis to include dementia with anxiety. Review of Resident 1's Minimum Data Set (MDS - an assessment tool) assessment, dated 12/30/2025, documented the resident had severe cognitive impairment.During a telephone interview on 02/12/2026 at 11:00 AM, Collateral Contact 1 (CC 1), Resident 1's responsible party, stated they were not kept informed of when Resident 1 had any changes in their medications. Review of a physician order, dated 01/21/2026, documented to increase Resident 1's acetaminophen (a pain reliver) to two tablets every 12 hours and start a lidocaine external patch to their lower back daily and removed per schedule for back pain. Review of Resident 1's electronic medical record showed CC1 had not been notified of the resident's back pain or the medication change.On 02/26/2026 at 4:52 PM, Staff B, Chief Operating Officer, Staff C, Registered Nurse (RN)/Regional Director of Clinical Operations, and Staff K, RN/Corporate nurse, were asked if residents responsible party were notified when there were medication changes. Staff C stated yes. The staff were notified that CC 1 had not been notified of Resident 1's 01/21/2026 medication changes. Reference WAC 388-97-0320(1)(c)

Based on interview and record review, the facility failed to ensure 1 of 4 residents (Resident 2) reviewed for the Pre-admission Screening and Resident Review (PASSR) process received the required follow up from the Regional Developmental Disabilities Act (DDA) Intellectual Disability (ID) or Related Condition (RC) PASRR team before admission to the facility and failed to ensure they were referred for a PASRR Level 2. These failures placed Resident 2 at risk for unmet care needs and a diminished quality of life. Findings included .Review of the Level 1 PASRR document, revised 06/2025, documented if the resident had an ID or RC, the form was to be forwarded to the Regional DDA ID/RC PASRR team, and follow up by the DDA Administration was required before the resident could be admitted to a nursing facility.Resident 2 was admitted to the facility on [DATE] with diagnoses to include intellectual disabilities, and disorders of psychological development.Review of Resident 2's Level 1 PASRR, dated 02/09/2026, documented they had an ID and were required to forward the form to the Regional DDA ID/RC PASRR team before the resident could be admitted to a nursing facility.Review of Resident 2's Electronic Medical Record (EMR) showed no documentation the Regional DDA ID/RC PASRR team had been contacted prior to their admission to the facility.In an interview on 02/26/2026 at 2:33 PM, Staff J, Social Services Director (SSD) stated they were unaware the Level I PASRR was required to be forwarded to the Regional DDA ID/RC PASRR team prior to admission to the facility. Staff J stated Staff I, Admissions, were the ones who reviewed PASRR information before a resident was admitted . Staff J stated they did not see a resident's PASRR until after they had been admitted to the facility, after it was scanned into the EMR by medical records.In an interview on 02/26/2026 at 3:07 PM, Staff I, Admissions, stated they were responsible to review the Level 1 PASRR forms prior to admission to the facility and were unaware that Resident 2's PASRR was required to be forwarded to the Regional DDA ID/RC PASRR team for review and determination for admission to the facility related to their diagnosis of an intellectual disability. Reference WAC: 388-97-1915(1)(2)(a-c)

Based on interview and record review, the facility failed to ensure required notices were provided to 3 of 4 residents (Residents 11, 23 and 43) reviewed for hospitalizations. Failure to provide and follow-up to ensure communication of the required notices, placed residents and their representatives at risk of being uninformed of their legal rights related to bed hold and transfer/discharge status. Findings included .<RESIDENT 23> Resident 23 admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (alteration in consciousness that is induced by brain dysfunction), Parkinson’s disease (progressive movement disorder of the nervous system) and clostridium difficile (bacterium that causes an infection of the colon). Review of Resident 23’s progress note dated 07/23/2025 at 12:15 PM, Staff N documented the resident was hard to arouse throughout the morning and that the provider was notified and the resident was sent to the hospital. Review of Resident 23’s progress notes dated 07/23/2025 showed no documentation that the resident had been transferred to the hospital or given a facility bed hold or notice of transfer/discharge. In an interview on 07/29/2025 at 1:22 PM, Staff C, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) stated that when a resident required transfer out of the facility, that staff were to print off a transfer packet which included the bed hold. Staff C stated the transfer packet for Resident 23 did not have any documentation related to a bed hold and was unaware of any facility document related to notice of transfer/discharge. <RESIDENT 43> Resident 43 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD) (lung disease that restricts breathing), and Chronic Heart Failure (CHF) (condition that occurs when the heart is unable to pump blood effectively) and right pelvis fracture. Review of Resident 43’s progress note dated 06/23/2025 at 8:16 PM, Staff M, LPN, documented the resident was found on the floor and expressed pain in their left hip, Provider was notified and gave an order to send the resident to the hospital. Review of progress notes dated 06/23/2025 showed no documentation related to a bed hold or a notice of transfer/discharge had been provided. In an interview on 07/29/2025 at 1:22 PM, Staff C stated there was no documentation of a transfer assessment, bed hold or notice of transfer/discharge documentation for Resident 43. <RESIDENT 11> Resident 11 admitted [DATE] with diagnoses which included a history of falls and a fracture. According to the 12/03/2024 comprehensive MDS assessment, Resident 11 was alert and oriented. Review of Resident 11's medical record dated 01/08/2025, documented Resident 11 was transferred to the emergency department following a fall and was admitted to the hospital. Review of an assessment titled transfer to hospital evaluation dated 01/08/2025, documented by check box that bed hold notice/transfer notices were sent to the hospital with the resident. Further review of the record found no copies of the stated forms or documentation of follow-up to ensure the resident or their representatives were informed of their rights regarding bed hold or their transfer/discharge rights. In an interview on 07/28/2025 at 11:30 AM, Staff G, LPN, RCM, provided a blank copy of the form titled bed hold/transfer notice which Staff G stated was automatically sent with residents when they go out to the hospital. Staff G stated they do not keep any copy of the form. In an interview on 07/30/2025 at 11:18 AM, Staff B, Director of Nursing Services, stated the bed hold notice and transfer notice are a combined form and it is sent with the resident when they are transferred. Staff B stated that a copy should go to medical records and there should be follow up done immediately and a note made in the chart. Reference WAC 388-97-0120

Based on interview and record review, the facility failed to ensure a system in which resident records were complete, accurate, accessible, and that documentation was in accordance with state law for 6 residents (Residents 3,8,10,30,32,and 43), and on one of two resident units. Failure to ensure records included accurate and timely entries and prohibit the use of stamped signatures on medical records, placed residents at risk for records that did not accurately reflect their care, and placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility policy titled, General Documentation Guidelines, dated 3/2013, showed the procedure for completing and correcting clinical records was:- Every entry shall be recorded promptly as the events or observations occur. - All entries should be complete, concise, descriptive and accurate- Record pertinent observations, psychosocial and physical manifestations, incidents, unusual occurrences and abnormal behavior. -All entries shall reflect the actual date and time.-When entering late entries, document as soon as possible. The more time passes the less reliable the entry. <RESIDENT 3>Review of the Psychosocial History and Discharge Plan documented an effective date of 05/08/2025 at 8:44 AM. Included on the plan was the admission date of 05/28/2025. The assessment was documented as being completed on 07/06/2025. Review of the Interdisciplinary Care Conference documented an effective date of 06/03/2025 at 12:55 PM. The meeting time and date was recorded as 06/03/2025 at 2:00 PM. The Care Conference was documented as being completed on 07/13/2025. <RESIDENT 8>Review of the Interdisciplinary Care Conference documented an effective date of 07/09/2025 at 3:53 PM. The meeting time and date was recorded as 07/14/2025 at 2:00 PM. The Care Conference was documented as being completed on 07/20/2025. <RESIDENT 10>Review of June 2025 MAR showed weekly weights were not documented on 06/04/2025 and 06/25/2025. Review of the July 2025 MAR showed weights were not documented on 07/02/2025, 07/15/2025, 07/16/2025, 07/24/2025 and 07/29/2025. In a joint interview on 07/30/2025 at 10:54 AM, Staff A, Administrator and Staff B, Director of Nursing Services stated they were unaware of late or missed documentation concern. Staff B stated there was no current auditing in place to ensure accurate and complete medical records. Staff J, Regional Director of Clinical Services stated it was not good practice to document late. In an interview on 07/30/2025 at 12:29 PM, Staff K, Social Services Director, stated they write assessments and care plans on paper. Staff K stated they tried to use the computers for documentation but had internet issues, dead computer batteries, and could not directly focus on the tasks at hand so they documented them on paper then put care conferences and assessments into the medical record later. <RESIDENT 30>Review of Resident 30’s clinical record showed the resident had an interdisciplinary team care conference on 07/18/2025 which was not signed or documented until 07/24/2025 by Staff K. <RESIDENT 32>Review of Resident 32’s clinical record showed the resident had an interdisciplinary team care conference on 06/27/2025 which was not signed or documented until 07/07/2025 by Staff K. <RESIDENT 43>Review of Resident 43’s clinical record showed the resident had an interdisciplinary team care conference on 07/18/2025 which was not signed or documented until 07/24/2025 by Staff K. <Resident 12>Review of Resident 12's immunization tab for their required two-step Tuberculosis (TB - a potentially serious bacterial infections that mainly affects the lungs) testing failed to document the lot number (unique identifier assigned to specific batches of product which is necessary in the event of product recalls) and the expiration date of the product for both steps. <Resident 13>Review of Resident 13's immunization tab for their required two-step TB testing failed to document the lot number and the expiration date of the product for both steps (07/08/2025 and 07/19/2025). <Resident 11>Review of Resident 11's immunization tab for their required two-step TB testing failed to document the lot number and the expiration date of the product for step one (11/01/2024). <Resident 43>Review of Resident 43's immunization tab for their required two-step TB testing failed to document the lot number and the expiration date of the product for both steps (06/04/2025 and 06/14/2025). <Resident 32>Review of Resident 32's immunization tab for their required two-step TB testing failed to document the lot number and the expiration date of the product for step one (06/18/2025). During an interview on 07/30/2025, at 8:59 AM, Staff B, Director of Nursing Services, DNS, stated that the lot number and expiration date of the tuberculosis solution should be documented under the immunization in the clinical record for each resident. They stated if it was not documented under the immunization tab then it would not be found elsewhere. Review of Resident 32’s pharmacist consultant reviews on 07/28/2025 showed six pharmacist recommendations signed by the facility provider on 07/11/2025 that included a stamp in the lower right corner. The stamp had the word “noted” and a blank line that was filled in with the date “07/22/2025” and below the line the stamped writing included the first name of Staff G, RCM and the words “LPN/RCM.” Further review of Resident 32’s medical records showed Staff G used this stamp to indicate they had “noted” physician’s orders and other documents. In an interview on 07/28/2025 at 11:10 AM, Staff G stated they assisted with the processing of the pharmacy reviews sometimes. Staff G stated they received the pharmacy reviews or other orders and “noted” them, which indicated that the orders or recommendations had been implemented. Staff G was asked about the “noted” stamp and staff G stated that was their signature. In an interview on 07/30/2025 at 11:45 AM, Staff A, Administrator, stated stamped signatures were not allowed and they were not aware anyone was using one. Staff A stated stamped signatures were not legal in the State of [NAME]. Reference WAC 388-97-1720

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and discarded when expired on 2 of 2 medication carts and 1 of 1 medication storage room reviewed. This failure placed residents at risk for not receiving the full benefits of the medications. Findings include .The facility provided policy was titled Storage and Expiration Dating of Medications and Biologicals, last revised 08/01/2024 showed that the facility should ensure medications or biologicals that have an expired date on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier.In an observation and interview on 07/28/2025 at 9:29 AM of the facility East medication room with Staff C showed that there were 3 sets of medical supplies with expiration dates of 12/31/2024 and one box of medical supplies with an expiration date of 04/13/2025. Staff C verified that the medical supplies were expired and should be removed.In an observation and interview on 07/28/2025 at 10:27 AM of facility medication cart #3 with Staff D showed there was over the counter bottles of cholecalciferol (Vitamin D) D3 1250 micrograms (mcg) and folic acid (supplement) 400mcg with expiration dates of 06/2025. Staff D verified the medications were expired and stated that the pharmacy staff goes through the medication carts and was unsure of the facility policy or procedure or how often this occurred.In an observation and interview on 07/28/2025 at 10:54 AM of facility medication cart #4 with Staff L, RN, showed there was an over the counter box of Nicorette gum 4mg that had an expiration date of 01/2025. Staff L verified that the gum was expired. In an interview on 07/30/2025 at 11:00 AM, Staff B stated that charge nurse does medication cart audits to make sure that expired medications are pulled out of the carts, nurses should check and the pharmacy should also review. Reference WAC: 388-97-1300 (2)

Based on interview and record review, the facility failed to ensure laboratory (labs) tests were completed as ordered and to provide timely laboratory results to meet the needs of six of eight residents (Residents 4, 8, 10, 21, 70 and 72) reviewed for laboratory services. These failed practices had the potential for negative complications related to delay of obtaining and follow up of laboratory results along with a risk for medical complications, related to a lack of monitoring chronic medical conditions and delayed identification and treatment of underlying health conditions.Findings included.<RESIDENT 70> Resident 70 admitted on [DATE] with diagnoses which included sepsis (serious complication of infection causing inflammatory response throughout the entire body and can potentially lead to organ failure). Review of Resident 70’s admission orders showed several labs to be done twice weekly to monitor the status of the resident’s sepsis: CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), ESR, CRP, CK, (monitors of inflammation and infection) and Magnesium (an electrolyte). Review of the resident record showed blank entries in the resident MAR (Medication Administration record) for three of the ordered laboratory dates (05/09, 05/12 and 05/16). During this time period, Resident 70 was documented as being on alert for a critical Magnesium level dated 05/05/2025 and Magnesium was the only lab which was documented as having been repeated. Review of a progress note dated 05/08/2025 documented the lab had not called the facility regarding the continued critical Magnesium level. Labs were collected on 05/19/2025, Resident 70 was assessed by their infectious disease specialist and returned to the hospital on [DATE] related to continued fragile status and abnormal labs. <Resident 21> Resident 21 admitted on [DATE] with diagnosis to include urinary incontinence. Review of the July MAR showed a lab order dated 07/11/2025 for nursing staff to obtain a UA (urinalysis) and culture if indicated one time for 5 days. The MAR had open spots for nurses to document if they obtained the UA from 07/11/2025 to 07/16/2025. There were no entries documented. Review of a progress note dated 07/16/2025 at 7:37 AM documented Resident 21 was reminded they needed to obtain a urine sample but declined as they needed to rest. The progress note showed the resident complained in the morning it had not been obtained and the nurse assured them it would be obtained later that day. At 1:46 PM, nursing documented UA attempts were unsuccessful. Review of a progress note on 07/18/2025 at 12:58 AM showed obtaining a UA was attempted but the nurse had been unsuccessful. Review of the progress notes 07/19/2025 to 07/24/2025 did not mention the UA order or attempts to collect it. In an interview on 07/23/2025 at 10:23 AM, Resident 21 stated that nine days ago the doctor ordered a urine test, and it was still not done. The resident stated the nurses needed to do a urine sample and they had not been able to successfully obtain the urine, and they tried several times. In an interview on 07/24/2025 at 8:57 AM, Resident 21 stated the nurses had still not gotten their urine sample, and they asked the nurse what the procedure was when they do not follow a doctor’s order. The resident stated they were upset about this and were not sure when their doctor was getting back from vacation. The resident stated their doctor wanted their urine tested since they were having an increase in hallucinations. <RESIDENT 4> Resident 4 was a long-term care resident who had recently completed antibiotics for a urinary tract infection and had a diagnosis related to electrolyte imbalances. Review of the Resident 4’s orders showed laboratory testing for CBC and CMP were ordered to be collected with a date range of 07/18/2025 and 07/25/2025. Review of the resident record on 07/29/2025 showed the labs were documented as drawn on 07/20/2025, with no further information or laboratory results found in the record. <RESIDENT 72> Resident 72 admitted on [DATE] and discharged on 05/23/2025. Review of Resident 72’s orders showed CMP, CBC, Free T4, TSH (thyroid tests), HgbA1c (blood sugar monitor) to be drawn on 05/21 or 05/22/2025. The labs were not drawn as ordered with no explanation in the record. In an interview on 07/28/2025 at 10:20 AM, Staff M, Licensed Practical Nurse (LPN), stated the nurses drew their own labs and someone from the facility delivered them to the lab. Staff M stated the providers entered the lab orders in the system and then they showed up on the Medication Administration Record (MAR) to complete. Results came over the fax machine and then were given to the provider directly if they were here, or by phone. Staff M stated they would call the provider or on-call provider if the results needed to be addressed right away. Staff M was asked how they knew which labs were pending and Staff M stated they would expect that to be in their shift report. Once labs were completed and reviewed, they were scanned into the record in the documents section. In an interview on 07/28/2025 at 10:37 AM, Staff G, LPN, Resident Care Manager (RCM), stated the orders entered by the providers go to a “pending confirmation” status, and a nurse had to go in and check to make sure all the correct boxes were checked, and then the order would appear on the MAR. Staff G stated labs were usually received later the same day they were sent, or the next day, and stated they called the lab if they hadn’t received them by the next day. Staff G stated they were having trouble with the fax communication between the facility and the lab. Staff G reviewed lab orders for Resident 4 and stated it looked like it had been drawn on the 20th, and they could not locate results, stating they should have had those by now, and would have to call the lab. Staff G stated they did not know why there was no documentation of the labs ordered for Resident’s 70 and 72. Staff G stated Resident 70 had labs done and contact with the provider and stated the record likely was not accurate or lab results were not scanned in. Staff G stated resident 72's labs may have been “routine labs” that the provider orders on everyone but had no information about why they had not been drawn, and why there were no notes explaining why not. <RESIDENT 8> Resident 8 was re-admitted on [DATE] with diagnoses to include lung disease and vitamin B deficiency. Review of a physician progress note dated 07/25/2025 at 12:00 AM, documented a BMP and CBC were ordered for Resident 8. Review of the clinical record showed no indication that the BMP or CBC had been obtained or processed. <RESIDENT 10> Resident 10 admitted on [DATE] with diagnoses to include a history of prostate cancer. Review of the July Medication Administration Record (MAR) showed a lab order dated 07/17/2025 for nursing staff to obtain a UA (urinalysis) with a culture if indicated one time for 7 days. The MAR had open spots for nurses to document when they obtained the UA from 07/17/2025 to 07/24/2025. There was one entry made on 07/20/2025 at 5:10 PM that indicated “9-other/see nurses notes,”. Review of Resident 10’s progress notes showed there was no progress note completed for 07/20/2025. Review of a progress note dated 07/19/2025 at 2:30 AM documented the UA was ordered but Resident 10 was too aggressive to obtain. Review of a progress note on 07/21/2025 at 7:06 PM, documented that they were unable to get the urine sample, and Resident 10 was agreeable to provide it tomorrow. Review of a progress note on 07/22/2025 at 5:33 PM showed the Resident 10 stated they didn’t think they could provide a sample. The writer reported they would alert the oncoming nurse. Review of a progress note on 07/25/2025 at 2:44 PM showed the physician was notified they had been unsuccessful at obtaining the UA from Resident 10. Review of the physician note on 07/25/2025 at 12:00 AM, revealed the UA ordered last week was not successful for Resident 10. In an interview on 07/29/2025 at 3:49 PM, Staff I, LPN stated the lab process was that they block off the lab on the treatment administration record (TAR) so that other nurses can see if the lab had been obtained. Staff I stated that management could print a report and see if the labs had been obtained. Staff I stated if they do not obtain the ordered lab, they need to notify the doctor the lab was not obtained. In an interview on 07/30/2025 at 10:52 AM, Staff B, Director of Nursing stated the facility was working on the lab process. Staff B stated the current process is the doctor puts in the order or gives it to the nurse, a lab slip is filled out, the blood is drawn, and the lab sample is driven to the local hospital lab. Staff B stated that the nurses need to follow up if there were no results. Staff B stated they could run a report to see if there were missing labs and then follow up. Staff B stated the facility had no lab policy. There should be documentation in the notes when abnormal labs are received and communication to the providers, as well as the lab noted and scanned into the record under the laboratory section. Reference WAC 388-97-1620 (2)(b)(i)

Based on interview and record review, the facility failed to ensure a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were reviewed and acted upon for five of six months reviewed. This failure placed residents at risk for delays in necessary medication changes, risk for adverse side effects, and receiving medications without required pharmacist oversight. Findings included .Review of the (undated) facility policy titled Timeliness of Medication Regimen Review (MRR) Reports documented that the facility would receive MRR reports within 3 days of the pharmacist review, and the provider would review and respond to reports within 14 days. The policy did not address the timeliness of the facility to note and implement the recommendations after the provider reviewed them. The policy also stated if the pharmacist identified an irregularity that needed urgent attention, they would notify the facility to ensure prompt attention from the physician. It is noted that recommendations that were labeled as urgent were, in fact, addressed. The following applied to the remainder of the monthly MRR reports and recommendations that were not identified as urgent. Review of the January 2025 MRR reports showed the pharmacist review dates varied from 01/13-01/16/2025 and were not reviewed by the provider until 02/10/2025. Review of the February 2025 MRR reports showed the pharmacist review dates varied from 02/07, 02/09, and 02/29/2025 and were not reviewed by the provider until 03/26/2025. After review by the provider, the reviewed recommendations were not noted and implemented by the facility until 04/14/2025. Review of the March 2025 MRR reports showed the pharmacist review dates varied from 03/11-03/13/2025 and were not reviewed by the provider until 04/10/2025. After review by the provider, the reviewed recommendations were not noted and implemented by the facility until 04/14/2025. Review of the May 2025 MRR reports showed the pharmacist review dates varied from 05/07-05/14 and were not reviewed and signed by the provider until 06/02/2025. After review by the provider, the reviewed recommendations were not noted and implemented by the facility staff until 06/19/2025. Review of the June 2025 MRR reports showed the pharmacist review dates varied from 06/15-06/24/2025 and were not reviewed and signed by the provider until 07/11/2025. After review by the provider, the recommendations reviewed were not noted and implemented by the facility staff until several days later, on 07/15/2025. Six reviews were not noted or implemented until 07/22/2025. In an interview on 07/30/2025 at 11:27 AM, Staff B, Director of Nursing Services, stated the facility had switched pharmacies in February and the MRR reports are sent by email to them (Staff B). Staff B stated they are printed as they arrive and given to the provider. Staff B stated they used to come at the end of the month and now they are at all different dates and stated they should be reviewed timely and implemented and the facility needed to work on the process as they have still not adjusted to the new pharmacy process and acknowledged that not all the reviews are being reviewed or addressed timely. Reference WAC 388-97-13300 (4)(c)

Based on interview and record review the facility failed to ensure residents were free from significant medication errors for five of eight residents (3, 10, 12, 13, and 21) reviewed for medications. Failure to follow physician's orders related to medication parameters placed residents at risk for adverse outcomes including low blood pressure which can result in dizziness and fainting from receiving medications which were outside of the ordered parameters for administration.Findings included .<RESIDENT 3> Resident 3 admitted on [DATE] with diagnoses to include respiratory disease, heart failure and high blood pressure. Review of the physician medication orders showed the resident received Metoprolol (a hypertension medication) twice daily and Digoxin (a heart medication) daily. The Licensed Nurse (LN) was to hold the medications if the systolic blood pressure (SBP) was below 110, or the heart rate was below 60. Review of the July Medication Administration Record (MAR) showed Resident 3 received the 07/13/2025 PM dose of Metoprolol even though the SBP was 90. <RESIDENT 10> Resident 10 admitted on [DATE] with diagnosis to include high blood pressure. Review of the physician medication orders showed the resident received Metoprolol twice daily and Lisinopril (a hypertension medication) once daily. The Licensed Nurse (LN) was to hold the Metoprolol medication if the SBP was below 100, or the heart rate was below 60. The Lisinopril was to be held if the SBP was less than 110. Review of the May MAR showed documentation that Resident 10’s PM dose of Metoprolol was held on 05/31/2025 even though the SBP was 100. The chart code entered into the MAR was a “5” indicative of hold/see progress notes. Review of the progress notes for May did not include an entry as to why the Medication was held. Review of the June MAR showed documentation Resident 10 received the Lisinopril on 06/01/2025 when the SBP was 107 and on 06/06/2025 when the SBP was 109. Review of the July MAR showed documentation Resident 10 received the AM dose of Lisinopril on 07/04/2024 when the SBP was 104 and on 07/12/2025 when the SBP was 106. <RESIDENT 21> Resident 21 admitted on [DATE] with a diagnosis of high blood pressure. Review of the physician medication orders showed the resident received Metoprolol twice daily. The LN was to hold the Metoprolol medication if the SBP was below 110, or the heart rate was below 60. Review of the May MAR showed Resident 10 received the PM dose of Metoprolol on 05/31/2025 when the SBP was 108. Review of the June MAR showed Resident 10 received the PM dose of Metoprolol on 06/02/2025 when the SBP was 104. Review of the July MAR showed Resident 10 received the PM dose of Metoprolol on 07/21/2025 when the SBP was 108 and on 07/22/2025 when the SBP was 98. Review of the facility's state reporting log did not show these medication errors had been identified. In an interview on 07/30/2025 at 10:48 AM, Staff B, Director of Nursing Services stated their expectation was for the nurses to take the vital signs and hold the medication if the blood pressure was lower than the parameters ordered. <RESIDENT 13> Resident 13 was admitted to the facility on [DATE] with diagnoses of high blood pressure. Record review of Resident 13’s physician’s order showed, Amlodipine, give 1 tablet by mouth daily for HTN and hold if SBP is less than 110, or HR of less than 60. The resident also had orders for Losartan Potassium 1 tablet by mouth twice a day for HTN, hold if SBP less than 110. Record review of Resident 13’s MAR for July 2025, with a print date of 07/24/2025, showed a documentation that on 07/22/2025 the medications Amlodipine and Losartan Potassium were administered outside the ordered parameters. <RESIDENT 12> Resident 12 was admitted to the facility with diagnoses to include HTN, autonomic nervous system disorder (dysfunction of the nerves that regulate the non-voluntary body functions such as HR, blood pressure [BP] and sweating), panic disorder and seizures. Review of Resident 12’s physician orders showed: -Propranolol, give 1 tablet by mouth twice a day for HTN, hold if SBP is less than 110 or HR less than 60. -Amlodipine Besylate,1 tablet mouth daily, hold if SBP less than 110 or HR less than 60. - Propranolol HCl, give 1 tablet every 24 hours as needed (PRN) for when severe overstimulation is anticipated and signs of Autonomic storm – atypical seizure like movements/posturing, elevated BP, HR, respirations, sweating, or hyperthermia. Check vital signs (measurement of body’s most basic functions, it includes temperature, pulse/HR, respiration rate, and blood pressure) before administration and immediately after the episode. In a record review of Resident 12’s July 2025 MAR with a print date of 07/24/2025, it was documented that the resident received Propranolol on 07/07/2025 and 07/11/2025. There was a set of vital signs documented on 07/07/2025 and another set of vital signs on 07/11/2025. It was not clear whether the vital signs were taken prior to giving the medication or after. Further review of the resident’s electronic chart did not show another set of vital signs on 07/07/2025 and 07/11/2025. In a record review of Resident 12’s MAR for May and June 2025 with a print date of 07/24/2025, it was documented that the resident received Propranolol outside the BP parameters on 05/27/2025, 05/30/2025 and 06/12/2025. In a record review of Resident 12’s May 2025 MAR with a print date of 07/24/2025, it was documented that resident received the medication Amlodipine was administered outside the BP parameters on 05/27/2025. In an interview on 07/28/2025 at 2:14 PM, Staff D, Licensed Practical Nurse (LPN) stated that a check mark on top of a nurse’s initial in the MAR meant the medication was given. They stated that with BP parameters, they should get the resident’s BP and HR prior to giving the medication and then document it in the MAR or under the vital signs tab in the resident’s electronic chart. If a medication was not given, they usually document reason in the resident’s progress note. Staff D reviewed the vital signs for the PRN propranolol, and they stated that they can’t find the other set of vital signs. They added per the provider’s order, they should take the vital signs before and then after the medication was given. In a record review on 07/28/2025 at 3:10 PM, Resident 13’s progress notes did not include any documentation regarding medications given outside the parameters and vital signs taken after the PRN propranolol was given. In an interview on 07/29/2025 at 1:28 PM, Staff C, Resident Care Manager/LPN, stated that the nursing assistant usually takes vital signs at the start of their shift and if it’s within the hour prior to giving a medication with a BP/HR parameter and they were within the parameters, the nurse usually uses that to give the medication. If it’s outside the hour and/or not within the parameters, the nurse retakes the BP/HR prior to giving the medication and if it’s outside the parameters, they expect the nurse to hold the medication. Staff C stated they don’t audit medications with parameters. Staff C reviewed Resident 12’s MAR for the PRN Propranolol and stated that the nurses seemed to not have taken the resident’s vital signs after they gave the medication as ordered. Staff C added the nurses should have taken the vital signs when they assessed the resident for the effectiveness of the medication given. In an interview on 07/30/2025 at 10:19 AM, Staff B, Director of Nursing Services stated that they expect the nurses to follow the parameters the doctors ordered and that they should not give medications outside the ordered parameters. They added that they expect the nurses to follow providers orders and if it’s stated to take vital signs after medication was given that the nurses should be taking the vital signs as ordered. Reference WAC: 388-97-1060 (3)(k)(iii)

Based on interview and record review the facility failed to ensure pharmacy services were provided to meet the needs of 2 of 3 residents (Resident 70 and 72) reviewed for Admission/Discharge planning. Failure to ensure medications were acquired and administered as ordered, and to follow facility processes for medications not available, placed residents at risk for adverse events related to missing medications. Findings included .<Resident 70>Resident 70 admitted to the facility on [DATE] with diagnoses to include hypomagnesemia (low magnesium levels in the body). Review of Resident 70’s physician orders showed an order for Magnesium with calcium (a supplement for magnesium and calcium), three times a day for a daily supplement with a start date of 05/01/2025 at 6:00 PM. Resident 70’s physician orders showed an order for Magnesium Oxide three times a day for Hypomagnesemia with a start date of 05/06/2025 at 12:00 PM. Review of Resident 70’s electronic medication administration record (EMAR) for May 2025 documented on 05/01/2025, 05/02/2025, 05/03/2025, 05/04/2025, 05/05/2025, 05/06/2025, and 05/07/2025 a “9” coded which indicated the medication was not given as ordered and to see progress notes. Review of Resident 70’s progress notes showed licensed staff documented the following:• 05/01/2025 at 9:42 PM - “Medication ordered; MD notified.”• 05/02/2025 at 8:57 AM – “Unavailable. Will reorder.”• 05/03/2025 at 8:19 AM – “On order.”• 05/03/2025 at 4:49 PM – “On order.”• 05/04/2025 at 1:50 PM - On order.• 05/05/2025 at 9:12 AM – “Not given, on order pharmacy unable to deliver.”• 05/05/2025 at 9:02 PM – “Call from WMHC lab to report critical low magnesium level of 0.9. Normal range is 1.2-2.3. Call placed to on-call provider. Theorder received was to administer a one time dose of 400 mg magnesium oxide from house supply and redraw BMP tomorrow 5/6. House MDalerted via note in provider notebook.”• 05/06/2025 at 7:40 AM – “not sent by pharmacy, called for update. Not in Omnicell to pull.”• 05/06/2025 at 11:53 AM – “Pharmacy has on order, awaiting shipment. Notified PCP of need for update in order or order for facility supply. Awaiting response.”• 05/07/2025 at 8:27 AM – “On hold awaiting clarification from provider, pharmacy does not carry.” There was no documentation that the resident had been notified of the omission of magnesium supplement and no documentation that the resident had been assessed for signs of hypomagnesemia related to lack of medication being administered as ordered. In an interview on 07/30/2025 at 10:34 AM, Staff C, Licensed Practical Nurse(LPN)/Resident Care Manager(RCM), stated as an RCM they confirm medications are at the facility when they admit a resident. Staff C acknowledged the EMAR was coded 9 on those dates for magnesium supplements and acknowledged the progress notes stating that the medication was not given for multiple shifts. Staff C stated they have options and there should not be a reason a resident does not get a medication. <Resident 72>Resident 72 admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD – a disease that effects the lungs causing breathing problems) and depression. Review of Resident 72’s physician orders showed an order for Pramipexole Dihydrochloride (depression medication) at bedtime related to depression with a start date of 05/18/2025 at 9:00 PM. Resident 72’s physician orders showed an order for Trelegy Elipta Inhalation, to give one inhalation orally one time a day related to COPD with a start date of 05/19/2025 at 8:00 AM. Review of Resident 72’s EMAR for May 2025 documented on 05/18/2025 and 05/19/2025 a “9” coded which indicated the medications were not given as ordered and to see progress notes. Review of Resident 72’s progress notes showed licensed staff documented the following:• 05/18/2025 at 9:01 PM – “not in Omnicell – on order”• 05/19/2025 at 8:10 AM – “has not arrived from pharmacy. calling today.” There was no documentation that the resident had been notified of the omission of medications or assessed for adverse outcomes. In an interview on 07/30/2025 at 11:26 AM, Staff B, Director of Nursing Services, stated if a medication was not available and was not in the emergency kit there should be follow-up with the pharmacy about when they would get the medications, and if not available, the provider must be notified that there is a delay and to get direction. Reference WAC 388-97-1300 (1) (a) (b) (i) (ii)

Based on interview and record review the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were completed timely following a significant change in status for 2 of 5 residents (Residents 10 and 21) reviewed for possible serious mental disorders and related conditions. This failure resulted in a potential inability to receive and benefit from Level II PASRR services for Residents 10 and 21, and placed other residents at risk for unmet mental health needs and a decreased quality of life. Findings included .Review of the facility policy titled, Pre-admission Screening and Resident Review (PASRR), dated 11/2016, showed the PASRR would be reviewed and updated as indicated with significant changes in residents' physical or mental condition. The state mental health authority would be notified of the changes affecting the residents' physical or mental condition. <RESIDENT 10>Resident 10 admitted to the facility on [DATE] with diagnoses to include post-traumatic stress disorder (PTSD, a mental health condition caused by an extremely stressful or terrifying event). Review of Resident 10's admission Minimum Data Set (MDS) assessment dated [DATE] and quarterly MDS dated [DATE] documented the resident was not experiencing hallucinations (perception of having seen, heard, touched , tasted or smelled something that was not actually there) or delusions (false belief that persists despite evidence proving it is false). Review of Resident 10's quarterly MDS assessments on [DATE], [DATE] and the annual MDS on [DATE] indicated the resident was experiencing a new onset of hallucinations and delusions. Review of Resident 10's Behavior Care Area Assessment, dated [DATE], showed the resident had PTSD with behaviors, a history of night terrors and hallucinations. Review of Resident 10's Level I PASRR, dated [DATE], showed the resident had a serious mental illness indicator, however delusional disorder and psychotic disorder were not marked. The PASRR responses showed a Level II PASRR referral was indicated. The PASRR did not reflect the new onset of hallucinations and delusions, so the PASRR evaluator could properly assess the resident. Review of Resident 10's Level II PASRR, dated [DATE], showed the reason for the referral was a new anti-depressant order for nightmares and restlessness with presumed association with PTSD. The evaluation did not address the delusions or hallucinations. Review of Resident 10's physician visit note dated [DATE] at 12:00 AM, showed the chief complaint was increased hallucinations and confusion. <RESIDENT 21>Resident 21 admitted on [DATE] with diagnoses to include depression, dementia and mood disturbance. Review of Resident 21's admission MDS assessment dated [DATE] documented the resident was not experiencing hallucinations. Review of Resident 10's quarterly MDS assessment on [DATE] indicated the resident began experiencing hallucinations. Review of the clinical record showed there was no significant change PASRR referral when Resident 21 began experiencing hallucinations. Review of Resident 21's care plan initiated on [DATE] showed the resident had verbalized having very vivid hallucinations about aliens, visitors taking pictures in her room for a newspaper, little blue boys by the fire alarm, very descriptive information of people outside the window, and bubbles on their feet. In an interview on [DATE] at 10:20 AM, Resident 21 stated they had been experiencing delusions. The resident stated the facility had turned the parking lot into Sea World and there were boats and sea [NAME] there. In an interview and observation on [DATE] at 2:10 PM, Resident 21 stated a couple was in a fight and slamming doors the other night. The resident said the man in the fight had been upset because one of the baby seals that live outside on the blue awning had died. The resident pointed out the window and said the other two seals were still there and this was not a hallucination. In an interview on [DATE] at 10:48 AM, Staff B, Director of Nursing Services, was informed of the PASRR issues for Residents 10 and 21. Staff B stated their expectation was to notify the PASRR evaluator of significant changes and the PASSR information needed to go to the care plan. In an interview on [DATE] at 12:27 PM, Staff K, Social Services Director stated they did not know about referring anything other than depression or anxiety to the PASRR evaluator. Staff K stated they knew about significant changes with anxiety and depression, but they were not aware of the need to notify the PASRR evaluator about delusions or hallucinations. Reference (WAC): 388-97-1975(7) .

Based on observation, interview and record review, the facility failed to ensure professional standards of practice were implemented for 1 of 5 residents (Resident 13) reviewed for medication management. Failure to obtain a doctor's order and failure to monitor residents use of their own medical equipment, placed residents at risk for injuries and potential adverse outcomes.Findings include.Resident 13 was admitted to the facility on [DATE] with diagnoses to include lower extremity cellulitis (bacterial infection of the deeper layers of the skin) and polyneuropathy (nerve damage in multiple areas of the body). According to the admission Minimum Data Set (MDS - an assessment tool) dated 07/15/2025, the resident was cognitively intact.In an observation and interview on 07/25/2025 at 9:58 AM, Resident 13 stated that the rectangular white machine that was on their table and was plugged in the electrical socket in the wall was a machine called Therma Zone (pain management device that provides heating and cooling therapy without the use of ice). Resident 13 explained that it was a hot or cold compress that they used for their shoulder, lower back or knee pain. The machine had two tubes attached and on the other end of the tubes was a fabric that had Velcro that you wrap on your back, shoulder or knee. Resident 13 demonstrated how the machine worked by showing what buttons to push, to turn on and which buttons to press for hot or cold temperature. They stated that they add distilled water in the machine and the water is what makes the compress hot or cold. Resident 13 further explained that it helped with their joint pain.In an observation on 07/28/2025 at 10:03 AM, the Therma Zone machine was on Resident 13's overbed table and was plugged into the wall. The resident was not in their room.In a record review on 07/28/2025 at 10:13 AM, there were no physician orders about the use of the Therma Zone in Resident 13's electronic chart. There was no monitoring regarding the Therma Zone in Resident 13's Treatment Administration Record (TAR). The Therma Zone was not mentioned in resident's care plan.In an interview on 07/28/2025 at 10:14 AM, Staff E, Nursing Assistant Certified, stated that on admission anything that a resident brings to the facility was listed in the resident's personal inventory list and if it's medical equipment they also inform the nurse. Staff E was not aware of the Therma Zone equipment in Resident 13's room and had not seen the resident use the device.In an interview on 07/28/2025 at 10:45 AM, Staff D, Licensed Practical Nurse (LPN), stated they were not aware of Resident 13 having medical equipment in their room aside from the CPAP machine. Staff D looked at the machine on the resident's bedside table and stated it's a hot/cold compress machine. They stated they don't have a doctor's order for the resident to use it and it's not in the resident's TAR. Staff D stated they have not seen Resident 13 use the machine.In an interview on 07/28/2025 at 11:03 AM, Staff F, Occupational Therapist, stated that they have worked with Resident 13. They stated that they had not done a hot or cold compress therapy with the resident and was not aware that resident had a Therma Zone machine in their room.In an interview on 07/28/2025 at 11:19 AM, Staff C, Resident Care Manager stated that according to their policy, aside from CPAP and pacemaker monitor machine, the facility does not allow residents to bring and use any electrical medical equipment in the facility. Staff C stated they were not aware that Resident 13 had a Therma Zone machine in their room.In an interview on 07/30/2025 at 10:19 AM, Staff B, Director of Nursing Services, stated that if a resident brings in a medical device, they will need to get an order from the doctor first, assess the resident if they were able to safely use the machine and then the maintenance department will need to inspect the device prior to the resident using it. Staff B expected the staff to check residents' rooms to ensure that if there's some equipment they don't recognize that they report it to the nurse so the nurse on the floor can verify the equipment was ordered for the resident to use. Refer to WAC 388-97-1620(2)(b)(ii)

Based on interview and record review, the facility failed to incorporate the recommendations from the Level II Preadmission Screening and Resident Review (PASRR, a federally required screening of all individuals who have a serious mental illness (SMI) report into the resident's assessment, and care planning for 1 of 1 resident (Resident 8) reviewed for PASRR. Facility failure to incorporate the PASRR recommendations into the residents' assessment and care plan delayed the implementation of recommendations and left the residents at risk for unmet mental health and activity needs and a diminished quality of life. Findings included . Review of the facility policy titled, Pre-admission Screening and Resident Review (PASRR) dated 11/2016 directed the interdisciplinary team to incorporate level II recommendations into the resident's care plan. Resident 8 was re-admitted to the facility on [DATE] with diagnoses to include a history of depression and moderate dementia with anxiety. Review of the clinical record showed a Level II PASRR was completed for Resident 8 on 03/05/2025. The PASRR recommendations included environment, staff approach and training, behavioral support and activity recommendations. The activity recommendation was for staff to encourage daily activities for structure and mental stimulation and for staff to ask Resident 8's family what activities they had previously enjoyed. Review of the Level II PASRR included Resident 8's mental health history and approaches to be utilized by staff to identify triggers and mitigate the resident's extreme/rapid mood swings and many incidences of uncontrollable crying. The PASRR included Resident 8's need for a consistent routine with consistent staff who speak in gentle tones and redirect or distract them with happier thoughts. The evaluation noted Resident 8 may not do well with a roommate and monitoring was necessary if a roommate was unavoidable. Review of Resident 8's care plan, initiated on 06/24/2025, did not include the Level II PASRR recommendations. In an interview and observation on 07/25/2025 at 9:58 AM, Resident 8 was sitting in their chair positioned up against the wall of their shared room. The resident was coloring on their overbed table. Resident 8 stated someone gave them the paper to color and they felt like they were back in school, but it passed the time. In observations on 07/25/2025 at 11:40 AM and 1:38 PM, Resident 8 was in their room with no activity items present. In observations on 07/28/2025 at 10:09 AM and 11:01 AM, Resident 8 was in their room with no activity items present. In observations on 07/29/2025 at 8:30 AM, 9:50 AM, 11:40 AM and 2:20 PM, Resident 8 was in their room with no activity items present. In an interview on 07/30/2025 at 10:47 AM, Staff J, Regional Director of Clinical Services, stated the PASRR evaluations included good information that needed to go onto the care plan. Staff B, Director of Nursing Services, was informed of the PASRR issues for Resident 8. Staff B stated their expectation was the PASSR information needed to go into the care plan. In an interview on 07/30/2025 at 12:24 PM, Staff K, Social Services Director, stated that once the Level II PASRR was received, they reviewed the PASRR evaluation and send it to medical records to be scanned into the medical record. Staff K stated they had not been putting the PASRR recommendations or interventions on the care plan as they were not aware they needed to. Refer to WAC 388-97-1915 (1)(2) (a-c) .

Based on observation, interview, and record review the facility failed to ensure staff performed Cardio-Pulmonary Resuscitation (CPR) to 1 of 1 resident (Resident 1) who was found unresponsive and had a physician order to initiate CPR and signed POLST (Physician Order for Life Sustaining Treatment- a form indicating the resident's wishes to have or not have CPR) for life-sustaining care and services. The failure to train staff on the facility's expectation how to respond to a resident requiring CPR, locate, for immediate reference, resident POLST/Advanced Directives, and accurately assess signs of irreversible death, resulted in staff not following Resident 1's CPR directives, and placed other current residents with CPR directives at risk of not receiving CPR and/or full medical interventions in an emergency which constituted an Immediate Jeopardy (IJ-noncompliance that has caused or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility corrected the above deficient practice prior to the initiation of the abbreviated survey on [DATE]. This failure was a past noncompliance IJ (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified) situation and was no longer outstanding. The facility removed the immediacy by educating staff on emergency response, reviewing their CPR policy, conducting mock code [NAME], reviewing all residents' POLST forms for accuracy, reviewing the crash cart and CPR training for completion. of death, performed CPR drills on the day, evening and night shifts, and implemented a plan of correction to sustain ongoing compliance. Findings included . Review of facility policy titled CPR dated 05/2019, documented the facility was to provide guidance in CPR to ensure every effort to honor residents documented wishes as related to end-of-life decisions. The policy states the facility shall be able to and does provide emergency basic life support immediately when needed, including CPR, to residents requiring such care prior to the arrival of emergency medical personnel in accordance with the related physician's orders and the residents' advance directives. Facilities will initiate CPR for full code residents immediately unless obvious signs of irreversible death as defined per regulatory guidelines (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present or initiating CPR could cause injury or peril to the rescuer. Resident 1 was admitted to the facility on [DATE] with diagnoses to include left femur fracture, malnutrition (lack of sufficient nutrients in the body) and dysphagia (difficulty or inability to swallow). Review of the Quarterly Minimum Data Set (MDS- an assessment tool) assessment dated [DATE] documented the resident was cognitively intact. Review of Resident 1's POLST form sign by a physician on [DATE], documented the resident wished to be a full code status, attempt CPR and the primary goal is prolonging life by all medically effective means. Review of Resident 1's provider's (MD, ARNP, PA-C) orders documented the resident was full treatment, attempt resuscitation/CPR, order initiated on [DATE]. Review of Resident 1's nursing progress created on [DATE] at 7:40 PM, showed Staff D, Licensed Practical Nurse (LPN) documented that around 1:06 PM, they were on their break and were notified by another Licensed Nurse (LN) at 1:04 PM that Resident 1 was no longer here. Staff D documented they went into the resident's room with another nurse to assess the resident. Resident 1 was not breathing, no pulse (heartbeat) was felt to the left wrist, and their bilateral fingers and hands were turning purple. Staff D documented they called Staff F, Nurse Manager, to inform them of the situation. Staff F asked them if they had called anyone else, and Staff D stated No. Staff F instructed them to call the family. While Staff D was calling the family, Staff F called back and asked if 9-11 had been called and Staff D stated No. Staff F made another call and then called back and instructed Staff D to call 9-11 and the coroner's office. 9-11 was called at 1:45 PM (approximately 40 mins after discovering Resident 1 unresponsive) and Emergency Medical Services (EMS) arrived five minutes later. Staff D documented going into the resident's room with EMS to inform them of the situation. One of the Emergency Medical Technicians (EMT) felt the resident's arm and stated that it was still warm. The EMT's placed the resident on the floor to initiate CPR. Information given to police officer and they stated they were going to their car to call the coroner. The police officer returned to inform this LN that corner was going to call with their estimated time of arrival. Staff D documented that they did not see the EMT's leave. Staff D documented they went into the resident's room around 2:40 PM and saw the resident laying on the floor with a blanket covering them. At 4:53 PM the on-call provider service was called, and a message was sent to the Physician Assistant (PA). At 5:45 PM, the PA called back, and they were informed of what occurred with Resident 1. Review of a witness statement dated [DATE], showed Staff E documented at approximately 1:02 - 1:03 PM on [DATE] they were called to Resident 1's room. Staff E stated they entered the room to find the resident unresponsive, no heartbeat or breathing, I called it at 1:04 PM. There was no documentation or assessment from a Registered Nurse or medical staff related to the pronouncement of Resident 1's death. Review of a witness statement dated [DATE], showed Staff F documented on [DATE] at 1:30 PM they received a call from Staff D to notify them that Resident 1 was found unresponsive at 1:03 PM. Staff F asked, You coded the resident because they were a Full code right? Staff D stated they were on a break and another LN did. Staff F stated they would notify Staff C Registered Nurse (RN)/Assistant Director of Nursing (ADNS) for further instructions and call back. Staff F documented that Staff C asked if staff had called 911 and Staff F stated, they didn't say. Staff F then called the Administrator, and they stated to have Staff D call 911 and the coroner. Staff F called Staff D back and told them to call 911 and the coroner. Staff F stated at approx. 2:39 PM they received a call from Staff D to tell them what happened when EMTs and police arrived. On [DATE], Staff F was in the facility and was informed by Staff C that they had not initiated CPR on Resident 1 on [DATE], as they were under the impression the resident was on hospice (form of medical care for people near end of life). Review of an EMS report incident #25-W03792, dated [DATE], documented EMS arrived at the facility and assessed Resident 1 at 1:52 PM. EMS report stated The general impression of the resident was they were unresponsive, pulse less and apneic (not breathing). The resident was warm to the touch and did not have any rigor mortis, dependent lividity (purplish-blue discoloration of the skin that occurs on dependent parts of the body after death), or any other obvious signs of death present. EMS documented they moved the resident to the floor and initiated CPR. CPR continued until 2:23 PM, when time of death was called by a physician. In an interview on [DATE] at 10:43 AM, Staff E, LPN stated they were the first nurse to assess Resident 1 when they were found unresponsive on [DATE] at 1:03PM. Staff E stated they attempted to find a pulse and could not and did not see the resident breathing. Staff E stated they thought Resident 1 was on hospice services, so they did not check the resident's POLST form. Staff E stated they knew they should have checked it but did not. Staff E stated they left the room and went to alert Staff D, LPN, the residents assigned nurse who was on a lunch break that the resident was found unresponsive, with no pulse and was not breathing. Staff E stated Staff D said they were not expecting Resident 1 to pass away. Staff E asked Staff D if Resident 1 was on hospice and they did not reply. Staff D went with Staff E to assess Resident 1 and Staff D was unable to find a pulse. Staff E stated they did not initiate CPR, or call EMS. Staff E stated they learned Resident 1 was a full code when EMS asked Staff D, who replied they were a full code. Staff E stated that no one in the facility initiated or performed CPR, EMS initiated CPR when they arrived at the facility. Staff D stated they should have checked Resident 1's POLST form when they were found unresponsive and initiated CPR. In an interview on [DATE] at 12:02 PM, Staff F stated they were on call when Resident 1 was found unresponsive on [DATE] and received a phone call from Staff D around 1:30 PM telling them that Resident 1 had passed away. Staff F asked Staff D if they coded the resident, meaning did they give the resident CPR and Staff D replied Staff E had done it. Staff F stated they did not know what Staff D thought they meant when that question was asked, but stated they did not specifically ask if they had initiated CPR. Staff F stated they would call Staff C and call back with further instructions. Staff C asked Staff F if EMS had been called, and that was when Staff F found out Staff D had not yet called EMS. Staff F stated they asked Staff D what Resident 1's code status was, and they were informed the resident was a full code. Staff F stated they found out on [DATE] that Resident 1 had not received CPR from any facility staff. Staff F stated Resident 1's POLST should have been assessed first and foremost, and CPR should have been initiated immediately upon finding the resident unresponsive. In an interview on [DATE] at 12:29 PM Staff D stated that they were the assigned nurse for Resident 1 on [DATE]. Staff D stated that they were on lunch in the break room when notified by Staff E, LPN that Resident 1 was nonresponsive. Staff D went to Resident 1's room and stated when they entered the room The resident was already gone. Staff D stated the resident's hands were turning purple, and the resident had no pulse or breath sounds, but stated they had not auscultated the lungs or heart (examine resident by listening to sounds from heart, lungs, or other organs). Staff D stated that if a resident was full code, then we should initiate CPR if they found them unresponsive. Staff D stated that Resident 1 was a full code status, but they did not check their code status at the time they found them unresponsive as they were in shock or a panic mode. Staff D stated that the POLST forms are located in the computer system and in binders at both nurses' stations. Staff D stated that they called the nurse manager, and the nurse manager instructed them to call 9-11 and the coroner's office. Staff D stated that when EMS arrived at Resident 1's room, they stated that the resident was still warm. They proceeded to pull Resident 1 to the floor and initiated CPR. Staff D stated they left the room at that time. In a joint interview on [DATE] at 4:24 PM, with Staff B, Registered Nurse/Interim Director of Nursing Services (RN/IDNS) and Staff C, stated the expectations for an unresponsive resident would be to check the resident for a pulse, call for a licensed nurse if one is not in the room, check the POLST form, grab the crash cart and initiate code blue, initiate CPR if indicated. Staff C stated they were notified by Staff F that Resident 1 was found unresponsive and facility staff-initiated CPR. Staff C stated they found out later that neither Staff D nor Staff E initiated CPR. Staff C asked Staff F if EMS had been called and found out that had not been completed, and they instructed staff to call EMS, the coroner and Resident 1's family. Staff C stated the expectation was CPR would be initiated for a resident who was full code. Staff C stated CPR should have been initiated for Resident 1. In an interview on [DATE] at 4:48 PM, Staff A, Administrator, stated it was their expectation that staff follow the facility CPR policy and initiate CPR in accordance with the residents' POLST form. Staff A stated they were under the impression staff had initiated CPR, but upon reviewing documentation, they found it was not supportive of that claim. Staff A stated Resident 1 was a full code and facility staff had not initiated or performed CPR, which was determined the following day after the resident had passed away. Staff A stated that the amount of time it took Staff D to call EMS was too long but was unsure of how long. Staff A confirmed that EMS did initiate CPR upon arrival at the facility and it should have been initiated by facility staff prior to EMS arrival. Cross reference F60 (neglect) Reference WAC 388-97-1060(1)

Based on interview and record review the facility failed to protect the resident's right to be free from neglect when they failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) timely to respond correctly to a medical emergency for 1 of 2 residents (Resident 1) reviewed for abuse and neglect. Resident 1 experienced harm when the resident was found unresponsive, required CPR that was not initiated by facility staff and an unexpected death occurred. The facility staff were aware of the CPR protocol but failed to follow directives that resulted in a delay in 911 EMS call, and the initiation of CPR was delayed by 45 minutes. These failures placed all residents at risk of unmet care needs and potential neglect. The facility corrected the above deficient practice prior to the initiation of the abbreviated survey on [DATE]. This failure was a past noncompliance G (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified) situation and was no longer outstanding. The facility removed the neglect by educating staff on emergency response, reviewing their CPR policy, conducting mock code [NAME], reviewing all residents' POLST forms for accuracy, reviewing the crash cart and CPR training for completion. of death, performed CPR drills on the day, evening and night shifts, and implemented a plan of correction to sustain ongoing compliance. Findings included . Review of the facility policy titled, Abuse/Neglect/Misappropriation/Exploitation, last revised 10/2022, reviewed on [DATE] documented the facility would protect residents from mistreatment, neglect, abuse by implementing procedures designed to prevent, identify, report and investigate potential instances of abuse, neglect and exploitation. Neglect was described as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of facility policy titled CPR dated 05/2019, documented the facility was to provide guidance in CPR to ensure every effort to honor residents documented wishes as related to end-of-life decisions. The policy states the facility shall be able to and does provide emergency basic life support immediately when needed, including CPR, to residents requiring such care prior to the arrival of emergency medical personnel in accordance with the related physician's orders and the residents' advance directives. Facilities will initiate CPR for full code residents immediately unless obvious signs of irreversible death as defined per regulatory guidelines (e.g. rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present or initiating CPR could cause injury or peril to the rescuer. Resident 1 was admitted to the facility on [DATE] with diagnoses to include left femur fracture, malnutrition (lack of sufficient nutrients in the body) and dysphagia (difficulty or inability to swallow). Review of Resident 1's Quarterly Minimum Data Set (MDS-an assessment tool) assessment dated [DATE] showed the resident was cognitively intact. Review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST) form, signed on [DATE], documented the resident wished to have CPR initiated if they were found without a pulse and apneic (not breathing). Review of Resident 1's physician's orders on [DATE] documented an order to attempt resuscitation/CPR and full treatment, order initiated on [DATE]. Review of Resident 1's progress note dated [DATE] at 12:15PM, which was a late entry and was documented on [DATE] at 12:16 PM, Staff E, Licensed Practical Nurse (LPN) documented the resident was found unresponsive with no heart rate or breathing noted. Staff E documented they called the residents time of death as 1:04 PM. Review of an EMS incident report #25-W03792 dated [DATE], documented EMS arrive at the facility and assessed Resident 1 at 1:52 PM. EMS report stated The general impression of the resident was they were unresponsive, pulse less and apneic (not breathing). The resident was warm to the touch and did not have any rigor mortis, dependent lividity (purplish-blue discoloration of the skin that occurs on dependent parts of the body after death), or any other obvious signs of death present. EMS documented they moved the resident to the floor and initiated CPR. CPR continued until 2:23 PM, when time of death was called by a physician. In an interview on [DATE] at 10:43 AM, Staff E stated they were the first nurse to assess Resident 1 when they were found unresponsive on [DATE] at 1:03PM. Staff E stated they attempted to find a pulse and could not and did not see the resident breathing. Staff E stated they thought Resident 1 was on hospice services, so they did not check the resident's POLST form. Staff E stated they knew they should have checked it but did not. Staff E stated they left the room and went to alert Staff D, LPN, the residents assigned nurse who was on a lunch break that the resident was found unresponsive, with no pulse and was not breathing. Staff E stated Staff D said they were not expecting Resident 1 to pass away. Staff E asked Staff D if Resident 1 was on hospice (form of medical care for people near end of life) and they did not reply. Staff D went with Staff E to assess Resident 1 and Staff D was unable to find a pulse. Staff E stated they did not initiate CPR, or call EMS. Staff E stated they learned Resident 1 was a full code when EMS asked Staff D, who replied they were a full code. Staff E stated that no one in the facility initiated or performed CPR, EMS initiated CPR when they arrived at the facility. Staff D stated they should have checked Resident 1's POLST form when they were found unresponsive and initiated CPR. In an interview on [DATE] at 12:29 PM, Staff D stated they gave Resident 1 medications in the morning of [DATE] around 9:50 AM and the resident was alert, talking, and at their baseline. Staff D stated they were on their lunch break when Staff E had notified them that Resident 1 had passed away. Staff D stated they went with Staff E to assess Resident 1 and they were already gone, and their hands had turned purple, they could not find a pulse or breaths and admitted they had not used their stethoscope to listen to their heart or lungs. Staff D stated they were in shock or panic mode and did not check Resident 1's POLST form. Staff D stated they did not initiate CPR, or call EMS services when they found Resident 1 unresponsive. Staff D stated they called Staff F, LPN, In-service director, since they were on-call, they asked the residents code status, and I told them the resident was a full code. Staff F stated they would call Staff C, Registered Nurse, Assistant Director of Nursing Services (RN/ADNS) to notify them. Staff F called back and told me to call EMS and the coroner. Staff D stated no facility staff-initiated CPR, and the EMS staff-initiated CPR after stating Resident 1 was still warm. Staff D stated a full code meant they needed to initiate CPR. In an interview on [DATE] at 12:02 PM, Staff F, LPN/Inservice Director stated they were on call when Resident 1 was found unresponsive on [DATE] and received a phone call from Staff D around 1:30 PM telling them the resident had passed away. Staff F asked Staff D if they coded the resident, meaning did they give the resident CPR and Staff D replied Staff E had done it. Staff F stated they did not know what Staff D thought they meant when that question was asked, but stated they did not specifically ask if they had initiated CPR. Staff F stated they would call Staff C and call back with further instructions. Staff C asked Staff F if EMS had been called, and that was when Staff F found out Staff D had not yet called EMS. Staff F stated they asked Staff D what Resident 1's code status was, and they were informed the resident was a full code. Staff F stated they found out on [DATE] that Resident 1 had not received CPR from any facility staff. Staff F stated Resident 1's POLST should have been assessed first and foremost, and CPR should have been initiated immediately upon finding the resident unresponsive. In a joint interview on [DATE] at 4:24 PM, with Staff B, Registered Nurse/Interim Director of Nursing Services (RN/IDNS) and Staff C, Registered Nurse (RN)/Assistant Director of Nursing (ADNS) stated the expectations for an unresponsive resident would be to check the resident for a pulse, call for a licensed nurse if one is not in the room, check the POLST form, grab the crash cart and initiate code blue, initiate CPR if indicated. Staff C stated they were notified by Staff F that Resident 1 was found unresponsive and facility staff-initiated CPR. Staff C stated they found out later that neither Staff D nor Staff E initiated CPR. Staff C asked Staff F if EMS had been called and found out that had not been completed, and they instructed staff to call EMS, the coroner and Resident 1's family. Staff C stated the expectation was CPR would be initiated for a resident who was full code. Staff C stated CPR should have been initiated for Resident 1. In an interview on [DATE] at 4:48 PM, Staff A, Administrator stated it was their expectation that staff follow the facility CPR policy and initiate CPR in accordance with the residents' POLST form. Staff A stated they were under the impression staff had initiated CPR, but upon reviewing documentation, they found it was not supportive of that claim. Staff A stated Resident 1 was a full code and facility staff had not initiated or performed CPR, which was determined the following day after the resident had passed away. Staff A stated that the amount of time it took Staff D to call EMS was too long but was unsure of how long. Staff A confirmed that EMS did initiate CPR upon arrival at the facility and it should have been initiated by facility staff prior to EMS arrival. Cross reference F678 Reference WAC 388-97-0640(1)(3)(c)

Based on interviews and record review, the facility failed to ensure staff recognize and report timely allegations of abuse/neglect for 2 of 2 residents (Resident 1 and 2) reviewed for allegations of abuse/neglect. These failures to timely report and investigate allegations of abuse/neglect and unexpected death placed residents at risk for potential abuse/neglect. Findings included . According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated [DATE], showed Unexpected Death, possibly related to abuse or neglect, Not related to abuse/neglect but suspicious needed to be reported to the State Hotline, Law enforcement agency as needed if a crime was suspected, Coroner or Medical Examiner and must be logged within 5 days of the event/incident. <RESIDENT 1> Resident 1 was admitted to the facility on [DATE] with diagnoses to include left femur fracture, malnutrition (lack of sufficient nutrients in the body) and dysphagia (difficulty or inability to swallow). Review of the facility provided state reporting log, dated [DATE], showed Resident 1 had an incident on [DATE], coded as a 70, which was 'other' with no description next to it. Resident 1 was not coded as an unexpected death on the reporting log and was not reported or investigated as an unexpected death. Review of Resident 1's progress note dated [DATE] at 1:15 PM as a late entry documented on [DATE] at 12:16 PM, documented Staff D, Licensed Practical Nurse (LPN) was called to Resident 1's room where the resident was found unresponsive with no heart rate and was not breathing. Review of Resident 1's electronic medical record (EMR) showed the resident was not on hospice services or receiving end-of-life care prior to their death on [DATE]. In an interview on [DATE] at 12:29 PM, Staff D stated Resident 1 was alert and oriented on the morning of [DATE] and not on hospice services or receiving end-of-life care. In an interview on [DATE] at 12:02 PM, Staff F, LPN/Inservice Director stated Resident 1 was an unexpected death as they seemed at their baseline and the resident was not on hospice services or receiving end-of-life care prior to their death on [DATE]. In an interview on [DATE] at 4:24PM, Staff C, Registered Nurse (RN)/Assistant Director of Nursing (ADNS) stated they were unaware than an unexpected death had to be added to the facility incident log or reported to the state agency. In an interview on [DATE] at 4:48 PM, Staff A, Administrator stated their expectation was that the policy and procedure should be followed for an unexpected death, and they considered an unexpected death to be any resident who was not on hospice or has had a significant decline. In an interview on [DATE] at 1:25 PM, Staff A stated they were unaware Resident 1 should have been reported as an unexpected death. <RESIDENT 2> Resident 2 was admitted to the facility on [DATE] with diagnoses to include sarcopenia (condition characterized by loss of muscle mass, strength and function), chronic pain syndrome, dementia (decline in mental ability, affecting memory, thinking, language and judgement) and was legally blind. Review of Resident 2's Annual Minimum Data Set (MDS-an assessment tool) assessment dated [DATE] documented they required substantial/maximal assistance (staff do more than 50% of the work to complete tasks) or were dependent on staff in their activities of daily living, and care needs. Review of Resident 2's Kardex (staff instructions for resident care needs) dated [DATE] showed staff were to be sure the resident's call light was within reach and they needed a prompt response to all requests for assistance. In an interview on [DATE] at 11:00 AM, Staff E, Nursing Assistant Certified (NAC), stated staff reported Resident 2's call light appeared to be deliberately moved out of reach of the resident during night shifts on [DATE] and was unable to recall the date of the second report. Staff E stated they reported the first incident to Staff B, Registered Nurse (RN)/ Interim DNS on [DATE] and the second incident to Staff C on [DATE]. Staff E stated they were unsure if they told Staff B or Staff C that it had been reported that the call light appeared, it was intentionally positioned away from the resident or if they only reported the call light was out of reach from the resident. Staff E stated they were a mandated reporter, and this should have been reported to the state agency, especially for Resident 2, as they can't see, and are dependent on the call light for staff assistance. In a joint interview on [DATE] at 4:24 PM, Staff B and Staff C stated they were both informed of a concern about Resident 2's call light being out of reach but were unaware of the report that it could have been intentionally moved out of Resident 2's reach. In an interview on [DATE] at 4:48 PM, Staff A stated they were aware of a report that Resident 2's call light had not been within reach but was not made aware the report included it could have been intentional. In an interview on [DATE] at 1:25 PM, Staff A stated they were unaware of the concern with facility staff not reporting allegations of abuse and neglect. Staff A stated their expectations are that staff follow the abuse and neglect reporting policy and to complete reporting timely. Reference WAC 388-97-0640(5)(a)

Based on interview and record review, the facility failed to ensure thorough investigations were completed for 3 of 3 residents (Residents 1, 2, and 3) reviewed for allegations of abuse and/or neglect. Failure to conduct thorough investigations to identify root cause(s) and all contributing factors related to allegations of abuse and/or neglect placed all residents at risk for unidentified abuse or neglect, unidentified corrective actions, potential harm and decreased quality of life. Findings included . Review of the facility provided policy titled, Abuse/Neglect/Misappropriation/Exploitation, revised 10/2022 documented during the investigation, the data collection involved interview of the alleged resident victim, interview caregivers, family, visitors, roommates and the alleged perpetrator. The policy also documented that after an investigation was complete, action to correct the reasonable cause of the incident and prevent further recurrences must be taken. According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated October 2015, stated, A thorough investigation is a systemic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences. <RESIDENT 1> Resident 1 was admitted to the facility on [DATE] with diagnoses to include Chronic Heart Failure (chronic condition in which the heart doesn't pump blood as well as it should), malnutrition, depression, anxiety and muscle weakness. Resident 1 was discharged from the facility on 01/03/2025. Review of the facility Incident Report Log dated January 2025 documented there was an allegation of neglect for Resident 1 on 01/06/2025. Review of Resident 1's progress note dated 01/06/2025 at 9:47 AM showed Staff A, Administrator documented Resident 1's family member had care concerns related to Resident 1's stay at the facility. Review of Resident 1's facility investigation, dated 01/08/2025 showed the facility unsubstantiated the allegation related to potential neglect based on review of Resident 1's medical record documentation. The investigation was not thorough and missed information such as statements from all staff that were working with the resident, other residents, potential witnesses and was unable to determine how the facility ruled out abuse and/or neglect. During an interview on 05/22/2025 at 11:55 AM, Staff A stated there were no statements related to Resident 1's 01/06/2025 investigation. <Resident 2> Resident 2 was most recently admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease (final stage of chronic kidney disease), muscle weakness, recurrent clostridium difficile (bacteria that can cause a serious intestinal infection), pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacrum (tailbone) and anxiety disorder. Review of the facility incident reporting log dated April 2025 documented Resident 2 had an allegation of staff to resident abuse on 04/15/2025 and 04/19/2025. Review of Resident 2's progress note dated as a late entry for 04/15/2025 documented the resident had an incident with two Nursing Assistants Certified (NAC). No other documentation was completed on 04/15/2025 or 04/16/2025 to monitor for psychosocial harm after the allegation of abuse. Review of Resident 2's care plan showed no updated interventions related to the allegation of abuse on 04/15/2025. Review of Resident 2's facility investigation dated 04/15/2025 showed the facility unsubstantiated the allegation related to potential abuse based on staff interviews. The investigation was not thorough, the facility did not monitor for potential psychosocial harm after the allegation and did not implement any interventions to prevent recurrence. Review of Resident 2's progress note dated 04/19/2025 at 10:10 AM Staff D, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), documented Resident 2 reported an allegation of staff to resident abuse that occurred on 04/18/2025 during the evening. Review of Resident 2's care plan showed no updated interventions related to the reported allegation of abuse on 04/19/2025. Review of Resident 2's facility investigation dated 04/21/2025 showed the facility unsubstantiated the allegation related to potential abuse/neglect based on there being no physical injury and it was an isolated event. The investigation was not thorough and missed information such as statements from all staff that were working with the resident, potential witnesses and was unable to determine how the facility ruled out abuse and/or neglect. During an interview on 05/22/2025 at 11:55 AM with Staff A stated there were no statements related to Resident 2's 04/19/2025 investigation. In an interview on 05/22/2025 at 1:38 PM, Resident 2 stated the facility had not put any interventions into place to avoid recurrence from the 04/15/2025 allegation of abuse that included staff waking them too early for care, medications and/or to obtain vital signs. Resident 2 stated it made them mad to be woken so early and it had continued repeatedly. In an interview on 05/22/2025 at 2:18 PM, Staff D stated after an allegation of abuse, they would get statements from the Resident involved in the allegation and sometimes will get a staff statement and stated facility management takes over and obtains the rest of the needed statements. Staff D stated there should be witness statements in every investigation. Staff D stated alert documentation was to be completed for at least 72 hours after an allegation to monitor residents for psychosocial harm. Staff D acknowledged and confirmed the care plan interventions had not been updated for Resident 2, and it should have been. <RESIDENT 3> Resident 3 was admitted to the facility on [DATE] with diagnoses to include cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), expressive language disorder (lifelong condition that affects a person's ability to use language), and cognitive communication deficit (difficulty communicating due to problems with cognitive functions). Review of the facility incident reporting log dated April 2025 documented there was an allegation of abuse related to Resident 3 on 04/18/2025. Review of Resident 3's progress note dated 04/18/2025 at 10:36 AM, Staff D documented Resident 3's roommate reported an allegation of staff to resident abuse. Review of Resident 3's facility investigation dated 04/22/2025 showed the investigation was not thorough and missed information such as statements from the resident that reported the allegation, witness and/or staff statements. Unable to determine how the facility ruled out abuse and/or neglect when a thorough investigation was not completed. Review of Resident 3's care plan documented no updated interventions after the allegation of abuse was reported on 04/18/2025. During an interview on 05/22/2025 at 11:55 AM with Staff A stated there were no statements related to Resident 3's investigation dated 04/18/2025. In an interview on 05/22/2025 at 2:43 PM, Staff E, LPN/RCM, stated allegations and alert documentation to monitor for psychosocial harm should be completed to monitor residents after an allegation of abuse. Staff E stated resident care plans should be updated based on the allegation. Staff E stated staff and witness statements should be obtained and in the investigation. In an joint interview on 05/22/2025 at 3:46 PM, with Staff B, Registered Nurse (RN), Interim Director of Nursing Services (DNS) and Staff C, RN, Assistant Director of Nursing Services (ADNS), Staff B and Staff C stated the expectations for a thorough investigation would be to interview staff, have staff write statements, and obtain witness statements. Staff B and Staff C agreed there should be documentation related to the allegation in the resident medical record, in a progress note, and alert documentation for a minimum of 72 hours to monitor for psychosocial harm. Staff B stated investigations are completed to rule out abuse/neglect, and a thorough investigation needed to be completed. Reference WAC 388-97-0640 (6)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure 3 of 4 sampled residents (Residents 169, 13, and 37) reviewed for accidents, were free of accident hazards, individualized care plan approaches were followed, effectiveness of current care plan interventions were evaluated, addition preventative measures to prevent falls were implemented, and assistance with meals was provided. Resident 169 was harmed when the identified care plan interventions to assist the resident with one-person maximal assistance with walking were not followed and the resident experienced a fall with fracture injury to their left greater trochanter (upper part of the thigh bone). These failures placed residents at risk for further accidents, falls, and a decreased quality of life. Findings included . <FALLS> RESIDENT 169 Resident 169 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis on one side of the body) affecting the resident's left side, dementia, depression, lack of coordination, and muscle weakness. Review of the Physical Therapy plan, start of care dated 11/09/2023, showed that Resident 169 was a fall risk related to left sided hemiplegia, dyscoordination (lack of coordination), and mild impulsiveness. Review of Resident 169's at risk for falls care plan, showed Resident 169 required maximal assistance of one-person maximal assistance for transfers, dated initiated 11/09/2023, and was a high risk for falls related to hemiplegia, date initiated 11/10/2023. The resident required one-person maximal (staff does more than half of the effort to complete task) assist for walking, date initiated 11/12/2023. Review of emergency room (ER) documentation, dated 11/12/2023, showed Resident 169 had a displaced left greater trochanter (upper part of the thigh bone) fracture. Review of a progress note, dated 11/12/2023 at 2:22 PM, showed Resident 169 returned from the hospital. There was no mention in the progress note what the resident was seen for in the ER. Review of Resident 169's Kardex (guide for an NAC to care for resident), dated 11/12/2023, showed the resident was continent of bowel and blader, required one maximal assistance of one person with waking, toileting, and transfers. Review of the facility fall investigation, completed on 11/16/2023, showed on 11/12/2023 at 4:02 AM, Staff UU, Nursing Assistant Certified (NAC), had answered Resident 169's call light, noted the resident was sitting at the edge of the bed, and needed to use the bathroom. Staff UU assisted the resident with minimal stand by assistance and a walker, as Staff UU turned to open the bathroom door, and saw the resident fall to the left side, Resident 169 stated her left leg was weak and fell . Staff VV, Registered Nurse (RN), assessed the resident, who denied pain, and the resident was assisted with two people to the toilet. Upon transferring the resident off the toilet, the resident complained of left hip pain. The facility concluded per the therapy notes the resident was able to walk with minimal assistance from staff. (There was conflicting information between the PT notes and the residents care plan and Kardex, which showed the resident required one-person maximal assistance with walking and transfers). In an interview on 11/21/2023 at 10:00 AM, Resident 169 stated they were unsure about the fall on 11/12/2023 and could not recall details. In an interview on 11/21/2023 at 10:40 AM, Staff V, NAC, stated they review the care plan or Kardex when they need to obtain information related to a resident's status. Staff V stated they also use pass down (verbal report at shift change) as a source of information about residents or can ask a licensed nurse. In an interview on 11/21/2023 at 12:33 PM, Staff WW, NAC, stated Resident 169 was a one person assist before and after the fall on 11/12/2023. Staff WW stated they do not review the care plan or Kardex and rely on pass down from last shift. In an interview on 11/22/2023 at 8:34 AM, Staff VV stated they did not witness the fall, but was the nurse on duty and assessed resident when they fell on [DATE]. Staff VV stated reported they were told Resident 169 was a standby assist for walking and transfers. Staff VV stated the resident initially denied pain, assisted Staff UU transfer the resident to the toilet, and then the resident complained of pain after standing up from the toilet after their fall. Staff VV stated they had noted swelling and bruising to the resident's left hip area. In an interview on 11/22/2023 at 9:20 AM, Staff B, RN/Director of Nursing Services, stated Resident 169 fell because of their left sided weakness as their leg went out. Staff B stated Resident 169's care plan and Kardex both showed they were to have one-person maximal assist for transfers and walking. Staff B did not provide any information regarding the staff not following the resident's care plan and Kardex which indicated the resident did require one-person maximal assistance with walking and transfers. 47047 RESIDENT 13 Resident 13 was admitted to the facility on [DATE] with diagnoses to include heart failure, unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and a left leg above the knee amputation. Review of Resident 13's care plan, focus for falls, revised 03/31/2023, showed Resident 13 was at risk for falls related to their confusion, decreased safety awareness, gait/balance problems, use of psychotropic medications and history of falls. The care plan showed Resident 13's Morse Fall Scale (MFS- a rapid and simple method of assessing a patient's likelihood of falling) showed a score of 75, indicating the resident was at a high risk for falling. In a review of the care plan interventions, show no revisions or additions since 07/11/2022. There was no indication that Resident 13's care plan had been updated to reflect interventions that were resident specific. Review of facility incident reports showed Resident 13 had fell on [DATE], 06/27/2023, 07/31/2023, and 10/16/2023. Review of these incident reports showed no details regarding the effectiveness of current interventions in place and no additional interventions were put into place to help reduce/prevent falls other than Resident 13 was placed on alert charting and neurological checks (an assessment of a resident's level of consciousness, pupil response, strength coordination, muscle tone and vital signs to monitor for deterioration) being completed. Review of the incident report, dated 06/27/2023, showed Resident 13 voiced not being able to locate their call light when attempting to get a soda from their refrigerator. Review of the incident report summary, dated 07/31/2023, showed Resident 13 was upset their favorite soda was not available, and they fell trying to locate their soda. Review of the incident report, dated 10/16/2023, showed resident had dropped a water cup on the floor, fell , was wedged under the tray table, and laying on top of the trapeze bar leg (positioning device that is designed to provide support to move into different positions or to transfer themselves in and out of bed.) In a review of Resident 13's type Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 10/03/2023, showed the Brief Interview for Mental Status (BIMS - a structured cognitive interview), score was six out of 15, indicating severe cognitive impact. During observations on 11/15/2023 at 8:56 AM, 12:57 PM and 3:06 PM, Resident 13 was observed in bed, the bed was in the lowest position, and a fall mat (a specifically designed floor mat to cushion a fall and reducing the impact when a resident falls) was located under the bed and not safely placed to be of any benefit as it was out of the area where the resident might fall. Observations on 11/17/2023 at 9:23 AM and 11:21 AM, Resident 13 was observed in bed, the bed was in the lowest position, and a fall mat was located under the bed and not safely placed to be of any benefit as it was out of the area where the resident might fall. On 11/20/2023 at 9:17 AM, Resident 13's bed was observed raised up approximately three feet from the ground. In an interview and observation on 11/20/2023 at 9:32 AM Staff L, NAC, stated they were familiar with Resident 13's care. Staff L stated the resident was a fall risk, had not fallen on their shift, and did not know the details of the resident's prior falls. When asked about fall interventions for Resident 13, Staff L stated they lowered the bed, then they distracted/occupied the resident with baby dolls, placed a pillow under their legs, and positioned them in the middle of the bed. Staff L stated Resident 13 hallucinated, and they attempted to get up from bed and tried walk. Staff L stated they obtained information on how to care for a resident at shift change, the nurses, and review of the resident's care plan. Staff L went to Resident 13's room and stated the bed was not in the lowest position and it should not be like that. In an interview on 11/20/2023 at 10:49 AM, Staff D, Licensed Practical Nurse (LPN)/Patient Care Coordinator, stated Resident 13 was a fall risk and could be impulsive. Staff D stated Resident 13 wanted to do everything themselves and would say they could walk. Staff D stated Resident 13's interventions included frequent rounding every two hours, repositioning, get them up when they wanted, and the bed locked in the lowest position. 36787 <SUPERVISION WITH MEALS> RESIDENT 37 Resident 37 admitted on [DATE] with diagnoses to include dementia, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing problems), osteoarthritis, absence of their right fingers. Review of the Quarterly MDS assessment, dated 09/12/2023, showed Resident 37 had moderate cognitive impairment and required supervision with eating. Review of the nutrition care plan, intervention dated 05/02/2022, directed staff to supervise the resident when eating. Review of the respiratory status care plan, dated 05/03/2023, directed staff to monitor for any signs or symptoms of respiratory distress and report to the nurse and/or the provider as needed. In an observation on 11/14/2023 at 12:28 PM, Resident 37 was in the East dining room for lunch and was coughing after each bite. There were no staff present or within the line of sight of the resident. At 12:38 PM, Staff U, NAC, came into the dining room and encouraged the resident to breathe. In a continuous observation on 11/15/2023 starting at 8:26 AM, Resident 37 was in the East dining room on supplemental oxygen delivered through a nasal canula (tube from an O2 machine to nose), using their accessory muscles (muscles used to that assist with breathing when breathing is labored or impaired) to breathe with an occasional course cough. At 8:52 AM, the resident had eaten all their breakfast quickly, with occasional coughing, and was noted to be drowsy. At 9:03 AM, the resident fell asleep with a lidded coffee cup in their left hand, and the cup was observed to tip while they slept. There were no staff present in dining room other than to deliver trays. The nurses were outside of the dining room with no direct visualization of the resident. In a continuous observation on 11/16/2023 at 1:05 PM, Resident 37 was asleep in the East dining room, holding a lidded coffee cup, was drowsy, then would startle, open their eyes, and doze off again. At 1:15 PM, Resident 37 spilled coffee on themselves and five coffee spots on their white tee shirt from the spill. The resident was asked if they were ok and replied yes, the coffee hurt their lips more than their stomach. Staff H, LPN, was immediately notified, came into the dining room, and encouraged Resident 37 to go with them to their room to look at their stomach. At 1:23 PM, Staff H said the resident denied any pain, there was no redness present, and wanted their coffee back. Staff H assisted the resident back to the main dining room and placed the resident on 15-minute checks. Staff C, Regional Director of Clinical Services, stated they just temped the coffee and it was at 116 degrees. In an observation on 11/19/2023 at 12:39 PM, Resident 37 was in the East dining room eating lunch, an occasional cough was heard, and there were no staff present in the dining room. Staff AA, RN, and Staff GG, LPN, were outside of the dining room. From 12:56 PM to 1:04 PM, Resident 37 had an observed prolonged, persistent coughing episode, their face was red, and they were using their accessory muscles to breath. Staff AA told Staff GG they would administer the rescue inhaler (dispenses medication into the lungs to make it easier to breathe), and if that didn't help, they would go further. Staff J, LPN was at the nurses station and commented it must have been the rice or peas. The resident had consumed 95% of their lunch consisting of chopped ham, rice, and green beans. At 1:15 PM, the resident remained seated in the East dining room and when they attempted to talk, they went into a continuous cough, a long thick clear secretion was observed coming out of their mouth, their face was red, and Staff AA attended to Resident 37. Staff AA said they were sending the resident to the emergency room . In an interview on 11/19/2023 at 1:24 PM, Staff J stated maybe Resident 37 was choking, because they told them to slow down eating but they wouldn't. Staff J said the resident did not need supervised eating and they tried to let the resident be as independent as they could be. In an interview on 11/19/2023 at 1:25 PM, Staff AA stated the resident does not need supervision for eating. In an interview and observation on 11/20/2023 at 9:11 AM, Resident 37 was seated in the East dining wearing a white t-shirt that had a two two-inch circular brown spots on it. The resident stated the spots were from coffee. The resident stated they had coughed during breakfast. At 9:27 AM, the resident was coughing. Staff HH, Nursing Assistant Registration, came into the dining room to check on Resident 37, Staff W, NAC, informed Staff HH Resident 37 could not have straws, and would spill all over themselves if there was no lid on their cup. At 9:45 AM, Staff II, RN, entered the dining room, and offered to assist the resident to lay down. The resident declined and fell back asleep. In an observation on 11/20/2023 at 12:30 PM, Resident 37 was in the main dining room. Staff U said the resident had coughed some while drinking coffee and needed frequent reminders to slow down. In an observation on 11/21/2023 at 10:06 AM, Resident 37 was in the East dining room drinking coffee and dozing off. In an interview on 11/22/2023 at 9:28 AM, Staff W, NAC, said they followed the care plan or Kardex (a care guide to NAC's) and when they received report at shift change. In an observation on 11/22/2023 at 9:40 AM, Resident 37 was in the East dining room holding their coffee cup with two hands. They had a three-inch clear brown area on their white t-shirt, and stated, I probably spilled my coffee again. In an observation on 11/22/2023 at 9:55 AM, Staff E RN/Patient Care Coordinator, said the staff were to follow the Kardex on how much supervision residents needed. Staff E stated Resident 37 spilled their coffee most days and they had ordered a non-spill mug. Staff E could not state what interventions were in place since the non-spill mug had not arrived, and stated they would have to check with Staff A, Administrator. Refer to WAC: 388-97-1060(3)(g)

Based on observation, interview and record review the facility failed to provide pain management for two of three residents (Resident 15 and 49) reviewed for pain control, and to ensure medication to manage pain was administered timely. This failure caused harm to Resident 15 and 49 who experienced unrelieved pain. Findings included . Review of the Facility's policy titled, Pain Management, revised 04/2018, showed it was the policy of the facility to provide care and services to effectively manage resident pain by addressing and treating the underlying causes of pain. The staff were directed to assess for possible indicators of pain such as facial expressions-grimacing and protective body movement or postures such as rubbing or massaging a body part or holding a body part during movement. RESIDENT COUNCIL Review of the resident council minutes for 01/31/2022, showed the residents would like walkie talkies to help communicate with med [medication] nurses about pain since it takes them a long time to respond to call lights. They said communication between the aides and nurses was very poor. RESIDENT 15 Resident 15 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a pain evaluation on 03/22/2022, showed the resident received [MEDICATION(S)] in the morning, [MEDICATION(S)]-Acetaminophen every six hours and Acetaminophen every six hours as needed and [MEDICATION(S)] Gel (a pain medication) topically every six hours as needed. The assessment showed the resident received 26 PRN medications in the last 30 days (was this the Acetaminophen?). Non-drug approaches that made pain better were distraction, repositioning, and rest with a desire to sleep comfortably and have total pain relief. Pain levels varied from none to seven in the past 14 days. According to the 04/01/2022 Annual Minimum Data Set (MDS) assessment, Resident 15, required assistance with activities of daily living. They were on a scheduled pain medication regimen, received PRN pain medications and received non-medication intervention for pain. The resident indicated they had frequent pain or were hurting in the last five days. The assessment showed the resident had pain over the past five days that made it hard for them to sleep at night and the pain limited their day-to-day activities. The resident indicated their worst pain was a six on the 0-10 pain scale. Review of the Care Area Assessment (CAA) dated 04/01/2022, showed the resident had pain and was being medicated for their left leg amputation pain, phantom limb pain and occasional headaches. The CAA showed the pain was managed with routine and as needed medications currently. Resident 15's pain medications were listed as [MEDICATION(S)], [MEDICATION(S)] (an anti-depressant), [MEDICATION(S)]-Acetaminophen, and as needed Acetaminophen and [MEDICATION(S)] gel. The care plan goal was for the resident to verbalize pain relief and pain would be evaluated every shift by the nurse. The doctor would be notified if the pain medication regime was ineffective. Review of the resident's care plan showed they had acute and/or chronic pain related to phantom pain from left BKA, [CONDITION(S)], chronic kidney disease and chronic pain syndrome. The staff were directed to: o Allow resident to verbalize feelings, validate feelings and give emotional support; o Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Observe and report to LN (License Nurse) signs/symptoms of pain-crying, resistance in moving during care, agitation or worsening of pain; o Coordinate with Palliative Care nurse (medical professional who provides healthcare to terminal patients after recovery is no longer feasible) to optimize care for resident; o Encourage resident to be out of bed for meals; o Identify & address underlying causes of pain as appropriate; o Medications/Labs per MD (Medical Doctor) orders; o Monitor pain, pain med administration, and pain medication effectiveness per facility protocol; o Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain; o Offer non-pharmalogical interventions such as drawing and/or activities that offer diversion from pain, warm blanket, repositioning, massage, ice on leg or back and conversation; o [MEDICATION(S)] (a narcotic pain medication) discontinued per resident request by provider. Nursing pursuing nonpharmacological interventions of distraction with conversation, TV, activities of choice, repositioning, massage, warm blankets; o Provide the resident and family education about pain and options available for pain management. Discuss and record preferences; and o Refer to Physical Therapy/ Occupational Therapy/Mental health as needed. In an interview and continuous observation on 06/27/2022 starting at 11:05 AM, Resident 15 was in bed closing their eyes with a pained facial expression as evidenced by grimacing. They stated they were in pain and the nurse was supposed to have brought them a pain pill a while ago. At 11:08 AM, Resident 15 told Staff G, Nurse's Aide Certified (NAC), to go ask Staff K, (Licensed Practical Nurse [LPN]) for that pain pill. The resident's eyes were closed, and they were grimacing. This surveyor offered to come back later for the interview. The resident responded they would rather you (surveyor) stay. At 11:32 AM, the resident put their call light on, Staff G and Staff U, Registered Nurse (RN), were in the room assisting the roommate (Resident 30). Resident 15 stated, please get (Staff K). I have been waiting for a pain pill for 40 minutes now. Staff G stated they would go tell the nurse again and offered to grab the resident another heated blanket. The resident stated their pain was at a nine on the 0-10 scale and never completely goes away. Their eyes remained closed, grimacing continued, and the resident began to rock back and forth while holding their left stump. They said they were tired as they did not sleep well and when they did get to sleep, the pain woke them up. At 11:36 AM, Staff G arrived with the second warm blanket and placed it per their request on their left stump. At 11:50 AM, the resident stated pain pills, warm blankets, and ice help to alleviate the pain. The resident stated, I think they could manage my pain better. I was told people can live all right with pain now a days but not me. I have never had pain like this before. At 12:05 PM, the nurse had not arrived yet. The resident stated It takes an hour to get my pain medicine, as you can tell, sometimes longer. Certain nurses do everything on time unless there was an emergency. It takes a while with (Staff K). The resident was sitting up, with their eyes closed, a pained expression, rocking back and forth in bed and stated, They tell me my pain will get better but it hasn't. At 12:13 PM, the resident stated, I am still awaiting pain pills. It has been 6 hours since my last one. Staff G and Staff U were still in the room assisting with a dressing change on their roommate. At 12:17 PM, the resident put their call light on again to request the pain pill. Staff U peeked around the privacy curtain at 12:19 PM, and said I overheard you, the nurse will be in as soon as they can. At 12:22 PM, Staff K brought the (routine?) pain pill in, an hour and 17 minutes after Resident 15's first observed request for a pain pill. The resident had stated they first requested the pain pill at 10:52 AM. Staff K did not ask the resident about their pain, nor offer additional pain pills or interventions. Staff G and U were present in the room throughout the interview except when quickly stepping out to grab supplies. Review of the narcotic ledger showed that the [MEDICATION(S)]-Acetaminophen was to be given every six hours, was administered to the resident on 06/27/2022 at 12:19 PM. I think this is pretty picky they were off by three minutes it doesn't really add any strength to this. The resident's prior dose was signed out as administered at 5:26 AM, which would have made it approximately one hour late. In an interview and observation on 06/28/2022 at 8:44 AM, Resident 15 was in bed trying to locate their call light which was on the floor. The resident stated they were in pain but not like yesterday. In an interview and observation on 06/30/2022 at 8:31 AM, Resident 15 was in bed and stated they had a pain pill not long ago and still had some pain at a six on a 0-10 pain scale. In an interview on 06/30/2022 at 8:31 AM, Resident 15's roommate, Resident 30 stated sometimes their roommate Waits a while for pain meds, depends on what nurse is on, if (Resident 15) will get them on time. In an interview on 06/30/2022 at 11:24 AM, Staff W, NAC, stated Resident 15 had pain in their leg sometimes and they would tell the nurse. In an interview on 06/30/2022 at 1:03 PM, Staff V, LPN, stated Resident 15 complained of pain a lot, phantom pain from their old amputation. Staff V stated the resident still complained about the pain and they treated it as if they were having pain. Staff V stated the nurses give the resident [MEDICATION(S)], Tylenol and [MEDICATION(S)] ([MEDICATION(S)]-Acetaminophen) and the resident did not feel the Tylenol and [MEDICATION(S)] were as effective as the [MEDICATION(S)]. Staff V stated the nurses should give pain meds as quickly as possible. Staff V stated, Sometimes (Resident 15) tells me I am in pain, and I have to remind our med nurse to give pain pills. I reminded (Staff H, LPN) yesterday. Staff V was informed there was an observation of Resident 15 in pain awaiting pain pills for at least 1 hour and 17 minutes on 06/27/2022. Staff V responded, Too long. I tell the med nurses to come get me and I can help them. They may have the keys but if residents complain, I remind them I can give meds. I tell the nurses, the most important medications are insulin, narcotics and antibiotics. They need to give them as close to the time they are to be given. Pain should be addressed right away. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 06/30/2022 at 1:22 PM, Staff EE, LPN, stated if they received a report a resident was in severe pain, they would usually address their pain right away. In an interview and observation on 07/01/2022 at 10:19 AM, Resident 15 was in bed, with facial grimacing and said they were in pain. They stated they were irritated at people who kept asking them to describe their pain. They stated I can't. I just hurt. At that time, they grabbed their left stump and rubbed it. In an interview on 07/01/2022 at 10:25 AM, Staff T, Advanced Registered Nurse Practitioner/Staff Development Coordinator stated the facility had clinical meetings every morning to discuss pain and anything out of the normal range. Staff T stated Resident 15 had chronic pain along with phantom pain and was able to communicate their needs and ask for pain medication. They stated the resident had a referral to go to the pain clinic and they were not sure when the appointment was. Review of the clinical record showed no pain clinic referral, order or pending appointment. RESIDENT 49 Per the Admission Record, Resident 49 was admitted on [DATE]with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 49's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/02/2022, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated Resident 49 was cognitively intact. Review of Resident 49's Pain Care Plan, dated 05/13/2022 indicated Resident 49 was experiencing pain related to an open area and [CONDITION(S)] (bacterial infection) to their left leg. Interventions included: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Medicate resident with pain medication ordered and repositioning done for comfort with one person assist. Review of Resident 49's Pain Evaluation, dated 06/02/2022 showed Resident 49's pain was managed with their current pain medication regimen and indicated as needed pain medication had been administered only one time in the 30 days prior to the assessment date. Review of Resident 49's Order Summary Report, dated 06/01/2022 through 06/30/2022 and found in the EMR under the Orders Tab, indicated orders for Acetaminophen (Tylenol) two tablets three times a day (8:00 AM, 2:00 PM, and 8:00 PM) for leg pain, and [MEDICATION(S)] 0.5 tablet (a pain medication that effects mood or behavior or a narcotic pain medication - is what we used above) by mouth one time a day for pain, and [MEDICATION(S)] one tablet by mouth every 12 hours PRN for pain. Review of Resident 49's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no indication the PRN dose of [MEDICATION(S)] was administered to Resident 49 on the morning of 06/28/2022. During an interview on 06/28/2022 at 11:24 AM, Resident 49 stated their left leg was causing them a lot of pain. Resident 49 stated, It hurts so bad and has been so painful all last night and today. I would like to have my pain medicine. I told the nurses about 20 or 30 minutes ago and I still haven't had anything [pain medication]. I want to get walking, but I am not going anywhere until I can get this pain managed. My leg was really swollen and last night I touched it and it started to bleed. Resident 49's leg was observed to be wrapped in a bandage and appeared to be swollen. Resident 49 stated, My pain is up all the way to 10 [on a scale of one to 10] now. It is really doing a number on me today. It makes it uncomfortable and then I can't even eat. I told the nurse on duty. (did the resident say when they told the nurse on duty?) I have told a lot of people in the last hour, and nothing is happening and that makes me upset. I'm upset because it hurts, and I am not one to call [the nursing staff] unless it hurts. During an interview on 06/28/22 at 11:31 AM, with Staff L, Certified Medication Assistant (CMA), on 06/28/22 at 11:31 AM, Staff L was informed of Resident 49's complaint of pain. Staff L stated they gave Resident 49 their scheduled Tylenol at 7:54 AM that morning. Staff L stated, [Resident 49] didn't get any other pain medication from me. [Staff C, Patient Care Coordinator/Registered Nurse (RN)] may have given them narcotics. I don't give narcotics. [Staff C] gives [Resident 49] [MEDICATION(S)] sometime between 6:00 AM and 10:00 AM. During an interview on 06/28/22 at 12:40 PM, Resident 49 she stated they had still not received medication for their reported pain. Resident 49 stated, This is not funny. This happens all the time. Resident 49 asked the surveyor to report their pain to nursing staff again and stated, I need something for pain to this left leg. Resident 49 reported a pain level of 10 out of 10 to this surveyor. During an interview on 06/28/22 at 12:44 PM, Staff C was notified by this surveyor of Resident 49's pain. Staff C stated, OK. During an interview on 06/28/22 at 12:56 PM, Resident 49 indicated no one had been in to assess their pain or give them pain medication. Resident 49 was sitting on their bed, rocking back and forth, crying, and holding their head. Resident 49 stated, This happens all the time. In an observation on 06/28/22 at 12:57 PM, Staff C was entered Resident 49's room and administered a dose of Tylenol. Staff C stated they were administering Tylenol and wanted to give that a chance to work. Staff C stated they would administer the PRN [MEDICATION(S)] dose in a while if it was needed. Review of the pain monitoring log on TAR (Treatment Administration Record) indicated a pain level of 10/10 as reported on 06/28/2022 at 1:06 PM. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 06/28/2022 at 1:45 PM, Resident 49 stated their pain was better. Resident 49 stated they were given Tylenol and were trying to rest while the medication worked. Resident 49 stated, It is a little better. In an observation on 06/28/2022 at 3:25 PM, Resident 49 was in their room, moving about from their bed to their chair using their walker. Resident 49 appeared to be relaxed and comfortable. During an interview on 06/30/2022 at 8:56 AM, Staff C indicated Resident 49 had vascular wounds that caused them pain and stated Resident 49 was receiving scheduled Tylenol and scheduled and PRN [MEDICATION(S)]. Staff C stated, I'm aware [Resident 49] has the prn order for [MEDICATION(S)] and I would have given it if I had known they were in pain. If they were hurting the staff should have told me because on that day, I was the one who would have given [Resident 49] the narcotics [[MEDICATION(S)]]. Staff C stated, If [Resident 49] was rating their pain as not being relieved earlier I would have given the oxy[[MEDICATION(S)]]. [Staff L] should have notified me of what the resident's pain was reported as [10/10] and should have gone in to assess the resident for pain. Obviously [reported] pain of 10/10 [requires] oxy [[MEDICATION(S)]]. During an interview on 06/30/2022 at 10:30 AM, Staff L acknowledged this surveyor reported to her Resident 49's pain level of 10/10 on 06/28/2022 at 11:31AM but failed to notify Staff C. Staff L stated, The licensed nurse gives the oxy [[MEDICATION(S)]] and I give the Tylenol [acetaminophen]. I try to get in there [early] because I know [Resident 49] is in a lot of pain, so I try to get in there to give their medication first. I always ask them if they are ready for their medication, and they always are so I pull it out and give it to them. If they are still in pain and I [gave] them the scheduled medication [acetaminophen] I tell the licensed nurse and then the licensed nurse takes it from there. Staff L further stated, I'm sure [Resident 49] is in pain. [Resident 49] has that open wound, and it has been painful for them. During an interview on 06/30/2022 at 11:16 AM, the Director of Nursing (Staff B) stated, A CMA [Certified Medication Assistant] cannot assess [a resident's pain] so if it [pain] was reported to a CMA and Tylenol ineffective, then the CMA should let the charge nurse know about it and the licensed nurse should go observe [the resident) and assess [the resident] and follow through with what needs to be done to assess and treat the pain. WAC 388-97-1060(3)(k)(iii)

Based on observation, interview and record review, the facility failed to provide care in a manner that promoted resident respect and dignity for one of three residents (1) reviewed for dignity. Staff directing the resident to urinate in their brief instead of assisting the resident with toileting, which resulted in embarrassment, anxiety, humiliation, and diminished self-worth. Findings included . Review of the facility Dignity Policy titled Resident Rights, revised 11/2016 showed Resident has a right to a dignified existence, self-determination . and Resident has the right to receive treatment and care with respect and dignity in a manner . that promotes maintenance or enhancement of his or her quality of life and individuality . Resident 1 admitted to the facility on [DATE] on hospice services for end of life care, with diagnoses to include lung cancer which had spread to bones and liver. In a telephone interview on 05/05/2022 at 9:45 AM, the Director of Nursing Services (DNS) stated they had admitted a hospice resident who was mostly bedbound but also used a bedside commode. The DNS stated on 05/04/2022, the resident asked to use the commode and the Nursing Assistant (NA) told the resident to just go in their brief. The DNS stated Resident 1 already had anxiety issues and this caused them anguish. Review of the facility investigation dated 05/04/2022, showed on 05/05/2022, the resident reported that sometime after supper on 05/04/2022 they requested to use the bedside commode. Two NA's were present, and Staff A, NA directed Resident 1 to urinate in their brief. Resident 1 stated they feared the NA's and did not want them back in their room until speaking with the DNS. Upon interview, Resident 1 confirmed to the DNS that Staff A, NA had told them to urinate in their brief and they felt offended by this statement. The DNS acknowledged the need for staff education on resident dignity. Review of the attached witness statement showed Staff A acknowledged they told Resident 1 to urinate in their brief. In an interview on 05/10/2022 at 10:55 AM, the DNS stated their expectation of staff related to toileting requests, was to honor the wishes of the resident based on care plan and resident ability. The expectation was for staff not to tell residents to urinate in their briefs. In an interview on 05/10/2022 at 11:45 AM, Staff A stated on 05/04/2022, Resident 1 initially asked to use a bedpan. Staff A stated there was not a bedpan in the room, so the resident asked to go into the bathroom. Staff A stated they told the resident to urinate in their brief and they would change it afterwards. In an observation and interview on 05/10/2022 at 11:20 AM, Resident 1 stated Staff A had told them to urinate in their brief. Resident 1 stated it wasn't just what they said; it was how they said it. Resident 1 stated this caused them great anxiety and extreme embarrassment. Resident 1 stated they were still very much upset about what happened. As the resident spoke about the event, their eyes were observed to become teary. In a telephone interview on 05/11/2022 at 9:30 AM, Resident 1's spouse stated Resident 1 had told them they were told by a NA to urinate in their brief and then they would change the resident. Resident 1's spouse stated when they told them about it, the resident cried and said they were very embarrassed. Resident 1's spouse stated they felt bad the resident had to go through that situation with everything else they were going through. The spouse stated they were never contacted by facility staff about the incident. In an email communication on 05/11/2022 at 11:13 AM, when the DNS was informed the resident's spouse stated they had not been informed of the incident by facility staff, they stated the resident had told their spouse about the incident. Review of the resident's admission nursing assessment dated [DATE], showed they were alert and oriented and without communication problems. Resident 1 required assistance of two staff for toileting. The resident was incontinent of bladder and also used the bedside commode. Review of the resident's care plan dated 05/04/2022, showed the resident had no cognitive or communication impairment. The resident was incontinent and was to be checked and have brief changed or provision of bedpan or bedside commode. Review of the resident's progress notes dated 05/04/2022 through 05/10/2022, showed no documentation of the incident or any documentation the resident had been monitored for psychosocial harm. Review of the resident's care plan 05/04/2022 through 05/10/2022, showed no entries regarding the incident or monitoring for signs of psychosocial harm Reference (WAC): 380-97-0180(1) and (2)

Based on interview and record review the facility failed to ensure one of two residents (2) reviewed for verbal abuse were free from verbal abuse. This failure resulted in psychosocial distress to Resident 2 who was verbally abused by a staff member and placed other residents at risk for staff to resident or resident to resident abuse. Findings included . Review of the facility policy titled Abuse/Neglect/Misappropriation/Exploitation, revised 01/22 revealed It is the policy of this facility to protect residents from mistreatment, neglect, abuse, exploitation, involuntary seclusion and misappropriation of property by implementing procedures designed to prevent, identify, report and investigate potential instances of abuse, neglect, and exploitation. Additionally, verbal abuse was defined as The use of oral, written or gestured 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. Resident 2 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly Minimum Data Set assessment dated [DATE], showed the resident had moderate cognitive impairment. The resident required two-person extensive assistance for transfers and due to impaired balance, they required staff assistance to stabilize them during transition from a seated to standing position. Review of Resident 2's care plan showed a focus for risk for behavior symptoms related to tearfulness when speaking with daughter on the phone, accusatory behavior related to care, and poor insight. Interventions included: allow the resident to make choices about daily routine and care when possible (updated 01/28/2022) and to approach the resident in a calm manner, re-approach at a later time if agitated or if uncooperative (updated 01/28/2022). Additionally, under focus for psychosocial well-being related to physical limitations imposed by recent health issues, and interventions dated 12/01/2021, directed staff to allow the resident the opportunity to identify their own self care needs and provide the resident with as many situations as possible which gave the resident control over their environment and care. Review of progress note dated 03/30/2022, two days prior to the verbal abuse, showed Resident 2 had stated they did not want to receive care from a specific aide moving forward. Review of the facility investigation for alleged abuse of Staff B, an agency Nursing Assistant (NA), by Resident 2, dated 04/01/2022, showed the Director of Nursing Services (DNS) interviewed Resident 2 who reported an argument with Staff B and stated Staff B told them to shut-up. The DNS substantiated verbal abuse. The DNS interview of the witness, Staff C, NA, revealed Staff C heard Resident 2 saying get out, get out! Upon investigation, Staff C witnessed Resident 2 and Staff B arguing and heard Staff B tell Resident 2 shut up, you're not going to talk to me like that! Staff C reported they intervened and took the resident for a walk. In an interview on 04/22/2022 at 1:05 PM, Resident 2 stated their left knee was very weak and felt very uncomfortable when transferred with only one staff member. Resident 2 stated they were unsure of the date, but approximately a few weeks ago Staff B insisted they could transfer the resident alone and tried to pick the resident up; the resident was swaying, and it was a very uncomfortable situation. Resident 2 stated at that time they told staff they did not want Staff B to provide care anymore. Resident 2 stated then on the night Staff B 2 yelled at them, Staff B came in to transfer them and Resident 2 said that they had not intended to be rude but told Staff B that they needed to go work out and build more muscle because their arms were so thin. Resident 2 stated When (Staff B) picks me up I worry about falling and landing on top of him, I get so off balance. I told others to watch out for (Staff B). Resident 2 stated they could not recall exactly what Staff B said but it was very loud and spontaneous. Resident 2 said they told Staff B to go and find someone else to help but Staff B refused. The resident stated they told Staff B they felt very unsure; said Staff B said they could do it but Resident 2 was so fearful and unsure. Resident 2 stated Staff B would not listen to them and yelled at them. Resident 2 stated he said, Please get a second person to help, and Staff B yelled at them and then Resident 2 yelled back, and then Staff B yelled Shut up! Resident 2 stated It was very upsetting to me and I don't want to see (Staff B) again, (Staff B) scares me that they won't listen and yells at me. Resident 2 stated luckily someone else heard them and came in and helped. In a telephone interview on 04/25/2022 at 2:17 PM, Staff C stated on 04/01/2022 at approximately 4:30 AM they heard scuffling and elevated voices coming from Resident 2's room. Staff C reported hearing Staff B's voice and went to find out what was going on. Staff C stated when they entered the room, Staff B said, He wants to treat me like a slave. and then Staff B said to Resident 2 I am not your slave, and pointed his finger at Resident 2's face. Staff C stated Staff B told them to leave the room, but they refused. Staff C stated they asked Resident 2 what was wrong, and they stated (Staff B) is not strong, he is weak, he almost dropped me. Then Staff B told Resident 2 to Shut up, and Staff C told Staff B to leave the room. Staff C stated she told Staff B to take a nap because they were so overwhelmed and angry. Staff C stated Staff D, LPN was present after the incident and thought Staff D was aware of the verbal abuse. Staff C stated they stayed with Resident 2 until Staff B left the area. Staff C stated they could not locate the hotline number to report the incident but had contacted Adult Protective Services later. In an interview on 04/22/2022 at 3:40 PM Staff D, LPN stated their concern about Staff B was the way they talked to residents and stated the tone they used was inappropriate. Review of interview form dated 04/01/2022 and signed by Staff F, Social Services Director, revealed the resident's responses to the following questions: Has any care staff caused you anguish? Resident 2 response: Yes, the large person who is very thin and very black. Do you feel safe here? Resident response: No. Because of that . Resident states came in the room this morning and started yelling at me. In an e-mail communication dated 04/26/2022, the DNS stated they were not informed of Resident 2 verbal abuse incident by Staff C, NA on 04/01/2022 until 10:00 AM. The DNS stated Staff B was immediately interviewed and suspended and a hotline report was filed. In an interview on 05/03/2022 at 10:45 AM, the DNS was informed that when they did investigation regarding verbal abuse to Resident 2, the residents they interviewed were not the same residents as listed that Staff B assigned on that night. The DNS stated the scheduler made NA assignments, but then they found out that on night shift staff often trades with each other so does not necessarily know which residents which staff had. The DNS stated they interviewed a sample of residents after the verbal abuse incident, but since it was verbal abuse, they did not do physical assessments of the non-verbal residents. The DNS stated on 04/01/2022 when Resident 2 was verbally abused by Staff B, Staff B had been aware they were not supposed to provide care to Resident 2 but did so anyway. The DNS was unclear as to why but referred to Resident B's progress note dated 03/30/2022 which indicated Resident 2 had indicated a staff member he did not want to care for them. The DNS stated Staff B was not suspended and removed from the facility until she was notified of the incident at approximately 10:00 AM and stated the incident occurred at 3:30 or 4:00 AM. The DNS stated Staff B continued to provide care to residents until that time because Staff D, Licensed Nurse who was on duty at the time of the abuse stated they were not informed of the verbal abuse incident when it occurred. The DNS stated they did a corrective action with Staff C, NA because of not clearly reporting the incident to Staff D and because of not timely reporting to the hotline. Reference WAC: 388-97-0640 (1)

Based on observation, interview and record review, the facility failed to provide adequate supervision and ensure appropriate care was provided in accordance with the resident's assessment and plan of care for one of three residents (1) reviewed for accidents/incidents. This failure resulted in harm to Resident 1 who sustained a broken right upper arm and placed other residents at risk for serious harm and injury. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include right sided [CONDITION(S)] (paralysis of one side of the body) resulting from a stroke, and incomplete [CONDITION(S)] (paralysis of lower part of the body). Review of Resident 1's quarterly Minimum Data Set assessment dated [DATE], showed they had moderate cognitive impairment. Resident 1 required two-person extensive assist with transfers and most other activities of daily living (ADL's). Review of Resident 1's care plan for ADL's dated 12/14/2020, showed the resident required extensive assist of two for transfers using a mechanical lift. Review of a progress note dated 07/07/2021 at 6:21 PM, showed the resident complained of pain in the right arm which required ice and pain medication. Review of facility investigation dated 07/08/2021, showed that Resident 1 required maximum assist of two staff using a mechanical lift, however was transferred from their wheelchair to bed by Staff A, Nursing Assistant (NA), with a one person assist. During rounds the following morning the resident could not move their right arm and expressed severe pain. X-rays were completed which revealed a right humerus fracture. The investigation showed neglect was substantiated. Review of Staff A's statement dated 07/08/2021, showed on the evening of 07/07/2021, Resident 1 asked to be transferred to bed and they tried to find someone to help with the transfer but were unable. Staff A reported the resident normally transferred with two NA's lifting under the resident's arms and they thought they could lift the resident without assist. Staff A stated they transferred Resident A to their bed and the resident reported pain after the transfer. Review of Resident 1's right shoulder x-ray report dated 07/08/2021, showed an acute fracture through the right humeral neck which was mildly displaced. Review of Provider note dated 07/08/2021, showed Resident 1 was in acute distress with pain in their right arm due to being transferred by only one person. In an interview on 07/21/2021 at 3:00 PM, the Director of Nursing Services (DNS) stated Resident 1's arm was fractured when Staff A transferred the resident to bed without assist or use of a mechanical lift. The DNS stated Resident 1 was a two-person transfer with a mechanical lift. In an interview and observation on 07/21/2021 at 1:00 PM, Resident 1 was observed with a right shoulder immobilizer in place. The resident stated their arm was broke when a NA transferred them to bed without assistance. The resident said two staff were supposed to help transfer, and there had usually been two, but not always. Resident 1 stated the injury hurt a lot at first. In an interview on 07/21/2021 at 4:20 PM, Staff D, NA, stated they always verified a resident's transfer status before transferring the resident. Staff D said it was an easy process; they just needed to look at the resident's care plan. Staff D stated it was difficult to find someone to assist with 2 person transfers at times, but it was not safe to do it alone. Staff D stated if they found a staff member who had not followed the care plan for transfers, they would report it to the nurse. In a telephone interview on 07/27/2021 at 9:00 AM, Staff B, Registered Nurse (RN), stated they were the charge nurse on 07/08/2021 when Resident 1 was noted to have severe right arm pain during wound rounds. In a telephone interview on 07/28/2021 at 2:20 PM, Staff C, RN, stated they recalled the evening of 07/07/2021 when Resident 1 complained of right arm pain. Staff C stated it was so unusual for Resident 1 to complain of pain, and with such a specific location of pain. Staff C stated at the time they attributed the pain to the resident having just been transferred. Staff C stated later they discovered Resident 1's arm was fractured that evening related to Staff A transferring the resident alone and without the mechanical lift. Staff C stated they had to just trust that the NA's were doing their job correctly. Staff C stated they had no recollection of Staff A requesting assistance with Resident 1's transfer that evening. Staff A was not available for an interview due to being terminated. Reference: (WAC) 388-97-1060(3)g

Based on observation, interview, and record review, the facility failed to ensure safety measures were followed to prevent potential complications associated with artificial nutrition delivery through tube feeding devices for two of four residents (#3 and #31) reviewed for maintaining proper positioning during administration, and the time period following administration of tube feeding, as well as staff competency for providing care to residents receiving tube feeding. This failure placed residents at the likelihood for risk for aspiration (inhaling of food/fluid contents into the lungs) and development of lung infection. These failures resulted in an Immediate Jeopardy (IJ) related to inadequate care and services on 01/30/19. The facility DNS and Administrator reviewed/revised their policies and procedures and provided training to licensed nurses and nursing assistants, which led to the removal of the IJ on 01/31/19. Findings included . According to the facility policy Enteral Feedings- Safety Precautions, last revised (MONTH) 2014, showed to always elevate the head of bed at least 30 degrees-45 degrees during tube feeding and at least one hour after. RESIDENT #3 Resident #3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician note, dated 07/19/18, showed the resident had a history of [REDACTED]. The resident had increased dysphagia and a feeding tube was placed in (MONTH) (YEAR). The resident's major risks were of worsening [MEDICAL CONDITION] and aspiration pneumonia. The resident would be unable to manage her secretions with the progression of her diagnoses. Review of the (MONTH) 2019 Medication Administration Records (MARs) revealed facility staff were directed to keep the head of the bed elevated at 45 degrees while in bed every shift to prevent aspiration. Review of the Kardex (individualized instructions for resident care) dated 01/30/19, instructed the staff that the resident was NPO (no food/fluids by mouth) and was to have the head of bed elevated to 45 degrees during and for 30 minutes after administration of tube feeding. The Kardex also showed under hospice instructions, the resident was to have the head of bed up to 30 degrees and she was to be pulled up in bed. Review of a hospice progress note, dated 01/28/19, showed the resident was having auscultated lung sounds with crackles (abnormal lung sounds) noted in her right lower lobe. There was a sign posted on the head of the resident's bed that read, Elevate head of bed at 45 degrees. The resident was observed on 01/29/19 at 9:02 AM, in a queen size memory foam style bed on an adjustable base without foot or head boards, with the head of bed up at less than a 30 degree angle. The tube feeding was disconnected. Further observations of the resident on 01/30/19 at 8:53 AM, in bed with the head of the bed up at less than 30 degrees. The tube feeding was turned off. The resident was observed on 01/30/19 at 3:40 PM, in bed with the tube feeding on. The resident's head of the bed was at less than a 30 degree angle and the resident appeared to be sunken into the mattress. The resident was observed on 01/30/19 at 3:45 PM, with the tube feeding running at 60 milliliters per hour with the head of the bed elevated at 10 degrees. Staff B, Nursing Assistant (NA), came into the room and was asked about the resident's positioning. Staff B stated the resident slides all over and then Staff B pulled the resident up in the bed using a sheet. Staff B was unable to identify what height the mattress was at. The resident was moved up in bed, but the head of the bed was still not at 30-45 degrees. In an interview on 01/30/19 at 4:02 PM, Staff C, Physical Therapist, was requested to come check the head of the bed measurement with a goniometer (a tool to measure the angle of the bed). The resident was on a bed frame that was at 36 degrees, and mattress was at 30 degrees. Staff C stated it was difficult to determine the elevation of the head of the bed due to the resident sinking into the mattress. Staff C reported the bed was not a standard healthcare grade bed. In an observation and interview on 01/30/19 at 4:06 PM, the head of the bed appeared to be elevated less than 45 degrees. Staff HH, Medical Director, estimated the head of the bed was elevated approximately 15 to 20 degrees and was unsure what the proper head of the bed elevation should be for patients receiving tube feeding. In an interview on 01/30/19 at 4:48 PM, Staff D, hospice Registered Nurse (RN), stated that the tube feeding had been turned off. Staff D reported the resident was difficult to properly position due to the bed being a challenge. She stated the resident was at an incredibly high risk of aspiration and that the resident aspirated during oral care. RESIDENT #31 Resident #31 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. In an observation on 01/30/19 at 4:45 PM, the resident was lying in bed with no tube feeding being administered and the head of the bed was elevated at approximately 35 degrees. A sign posted on the wall behind the resident's bed instructed staff the head of bed was to be at 45 degrees at all times. In an interview on 01/30/19 at 4:49 PM, Staff E, Physical Therapist Assistant, stated that she believed the bed to be at about 40 degrees angle. In an interview on 01/30/19 at 4:51 PM, the Director of Nursing Services stated that the head of the bed looked to be between 25 -30 degrees and the expectation was to keep residents with tube feeding at 45 degrees. In an interview on 01/30/19 at 5:04 PM, Staff F, NA, stated that she thought the proper angle for a resident receiving tube feeding was 25-30 degrees. Staff F stated that she was unaware of any residents receiving tube feeding and that no training was provided regarding caring for residents receiving tube feeding. In an observation on 02/05/19 at 8:55 AM, the resident was laying almost completely flat in bed. Requested for Staff G, RN, walking by to come and check resident positioning, and Staff G acknowledged that the resident had slid down in bed and was not at the proper angle/positioning. Review of tube feeding care plan, dated 12/22/16, showed that staff were to ensure the resident head of bed was elevated 45 degrees at all times and to monitor for signs or symptoms of aspiration such as shortness of breath, choking, labored respirations, and lung congestion. The ADL (Activities of Daily Living) care plan showed a safety interventions to ensure the resident's bed was in the low position, and the head of bed up at 45 degrees at all times. Review of the (MONTH) 2019 Medication Administration Records (MARs) showed an order for [REDACTED]. The MARs showed that the resident had congestion, phlegm, and monitor cold symptoms starting 01/14/19. Upon comprehensive review of the facility's tube-feeding care and services practices, as well as the associated risks, it was concluded the facility skilled nursing staff were not properly trained/supervised and/or responsive to the high aspiration risks associated with caring for a resident receiving tube-feedings. This is a repeat citation from survey dated 01/17/18. Reference: (WAC) 388-97-1060 (3)(f)

Based on observation, interview and record review, the facility failed to secure one small oxygen tank located in room [ROOM NUMBER] and two small oxygen tanks in the East storage room. This failed practice placed one of one residents (#33) living in room [ROOM NUMBER] at significant risk of injury and serious harm and placed all other residents residing in the facility at a high likelihood of injury and harm from the unsecured oxygen cylinders. Additionally, the facility failed to ensure adequate supervision was provided to prevent future falls and resident to resident altercations for two of two residents (#6 and #18) reviewed. The facility failed to assess and provide an appropriate mattress and frame to prevent the risk of injury for one of one residents (#3) reviewed. This failure to provide an appropriate and secured bed placed the resident at risk for falls and injuries. An Immediate Jeopardy was called on 01/29/19 at 2:10 PM, the Administrator was notified. The Immediate Jeopardy was removed on 01/30/19 at 2:23 PM, when the facility secured and stored the oxygen tanks safely and provided in-service training for the staff. Findings included . OXYGEN STORAGE Record review of the facility's policy titled, Oxygen Storage Safety, dated 02/06/18 showed the following: · Oxygen cylinders will be stored in the soiled utility rooms, in their designated holding containers properly secured; · Oxygen cylinders should not be stored in any other location in the building; · Cylinders should be stored upright in the holding containers properly secured; · Residents who utilize oxygen when ambulating outside of their room should be switched from a portable oxygen tank to a concentrator when they return to their room and the portable oxygen cylinder should be stored appropriated; · It is the responsibility of staff accompanying the resident back to their room to ensure the oxygen cylinder is removed and put in storage. According to the Office of Compliance Fast Facts (MONTH) 2006 Volume 1 Number 8, .Potential Dangers of a Pressurized Cylinder: pressurized cylinders, used to store various flammable and nonflammable gases, are likely to fall over if left unsecured. Such a fall could cause damage to the cylinder's valve or the cylinder itself, resulting in a gas leak. A rapid loss of pressure can turn a cylinder into an unguided missile powerful enough to break through a concrete wall . Resident 33 was admitted [DATE] with [DIAGNOSES REDACTED]. Record review showed Resident #33 had an order for [REDACTED]. In an observation on 01/29/19 at 11:26 AM, Staff S, Nursing Assistant Certified (NAC) was getting Resident #33 ready for a shower. This surveyor scheduled an interview with Resident #33 and noticed sitting on the window sill in his room approximately one inch from the ledge was an unsecured small oxygen cylinder. The window sill was very cluttered with various items to include a glass of juice, a pillow, a pink wash basin, two plants, a gait belt, a whole carton of juice, towels and 3 books right next to the oxygen cylinder. Resident #33 was receiving oxygen sitting in his chair via an oxygen concentrator. In an observation and interview on 01/29/19 at 11:40 AM, in the east oxygen supply room were 2 unsecured small oxygen cylinders, one was sitting upright in front of the other secured oxygen cylinders and one cylinder was laying sideways on top of the other secured cylinders. Staff EE, Maintenance Assistant stated any oxygen cylinders should not be unsecured on the ground nor should they be laying across other oxygen containers. Staff EE stated that was dangerous and the cylinders are not stable when they are not secured. In an observation and interview on 01/29/19 at 12:22 PM, Resident #33 was sitting in his wheelchair and he had a portable oxygen cylinder attached and secured to the back of his wheelchair. Resident #33's wife stated the oxygen was a new treatment for [REDACTED]. She pointed at the unsecured oxygen tank sitting on the window sill and stated that the portable ones are used so he can go out of his room and still have oxygen on. In an observation at 01/29/19 at 12:48 PM Staff AA, Medical Records walked by room. At 12:51 PM, Staff V, NAC, walked by room. At 12:54 PM, Staff V, NAC, walked back by room. At 12:55 PM, Staff FF, Dietary Aide, walked by room. At 12:56 PM, Staff S, NAC walked by room looking for a chair. At 12:59 PM, Staff GG, Licensed Practical Nurse (LPN), walked by and looked in the room but did not go in the room. At 1:02 PM, Staff Q, Registered Nurse, (RN) walked into the room and came back out of the room empty handed, leaving the unsecured oxygen cylinder still sitting on the window sill. At 1:42 PM, the unsecured small oxygen tank was still on the window sill. Record review of the 67 current residents showed 17 residents with routine oxygen or as needed oxygen orders. In an interview on 01/29/19 at 12:17 PM, Staff X, RN stated the portable oxygen cylinders are secured in a dolly if used by the resident and if they not secured they are dangerous. At 12:17 PM, Staff S, NAC, stated if a resident uses oxygen in their room they will have a concentrator in their room. If they are working with therapy or going out of there room they can have a portable oxygen cylinder but it should be placed in a bag and attached behind the resident's wheelchair. Staff S continued to state that when the portable oxygen cylinder is not use it should be stored in the oxygen room in a container secured; not in the resident's room. At 12:23 PM, Staff C, Physical Therapist, stated portable oxygen tanks are stored upright in the utility room in plastic crates to keep them off the floor. Staff C continued to state that If a resident has an oxygen cylinder in their room it should be placed in a 'pack' upright. At 12:24 PM. Staff II, LPN stated only concentrators are allow in a residents room. At 12:25 PM, Staff JJ, NAC stated when a resident has a 'travel tank' it must be placed in a bag attached to the back of the wheelchair so that it is kept off the floor. Staff JJ stated when residents are not using the oxygen tank it is kept on the ledge of the window sill. At 12:29 PM, Staff GG, LPN stated when the residents are not using the portable oxygen cylinders they are to be taken out of the room and placed in the utility room and the resident should go back on the concentrator. They should never be stored on the window sill. At 12:38 PM, Staff KK, NAC stated when a resident returns to their room, they are to be taken off their portable oxygen and placed on their concentrator, and the portable tank can be placed on the window sill or left on the back of the wheelchair. At 1:42 PM, Staff LL, NAC stated the portable oxygen tanks should never be placed on their side and they should not be placed on the window sill for fear they may fall off and that would be dangerous. In an observation and interview on 01/29/19 at 1:50 PM the Administrator walked into Resident #33's room where he immediately saw the small unsecured oxygen cylinder sitting on the window sill. He stated they should never be stored on the window sill, they should be stored and secured in the oxygen room at all times. He stated when the portable tanks are not in use they are to be taken out of the resident's room. He acknowledged the danger of having the unsecured oxygen cylinder sitting on the window sill. Review of the Falls-Clinical Protocol dated (MONTH) 2012, showed, Those individuals with falls may have a treatable medical disorder or functional disturbance as the underlying cause. Falls should be categorized as .rolling from a low bed to the floor. Falls should also be identified as witnessed or unwitnessed events. After more than one fall, the physician should review the residents gait, balance and current medication that may be associated with dizziness or falling .many categories of medications, and especially combinations of medications in several categories , increase the risk of falling. According to the facility's undated Fall policy and procedure, directs staff to take care of the resident first; assess for injury, pain and ROM (range of motion) do a complete assessment including VS (vital signs), ROM (range of motion), Blood sugar if diabetic document your findings and action. Fill out an incident report completely. All falls should have an immediate intervention put in place and documented on the fall report and in the progress note Falls from bed: Address immediate need: food, fluid, toileting needs. Unwitnessed falls trigger neuro checks. RESIDENT #6 Resident #6 admitted on [DATE] with [DIAGNOSES REDACTED]. She had severe cognitive impairment and required two-person extensive assist with transfers. According to her Kardex (a guide for care), If .yelling, agitated behaviors try the following interventions in place that are intermittently effective but have not been 100% are staff within her view, having tactile touch with staff (holding on to staff's uniform or hand) , staff sitting and talking to her, being wheeled around facility, listening to music in the activity room, sitting outside for short periods of time, offering food, ensuring toileting needs met, naps to maximize her sleep hygiene, and pet therapy, as well as son visiting with their dogs. When she becomes agitated; Intervene before agitation escalated; Guide away from source of distress; Engage calmly in conversation. Assist her to group activities of potential interest where some outbursts can be more easily tolerated. FALL PREVENTION Review of a progress note dated 11/27/18 at 9:00 PM, showed, Was informed by other nurse that when aid was trying to transfer resident in RM 37 by herself without any assistance. She was trying to instruct her/helping her to stand up using the bar resident started lowering herself and staff safely lowered her to the floor and called for assistance. Resident was quickly assess for any discoloration on her knees and if she has any pain .Counseled staff about the care plan and if not sure to always asked other staff for safety. VERBAL RESIDENT-TO-RESIDENT ALTERCATIONS Review of a progress note dated 08/08/18 at 10:43 PM, showed, will yell Come back don't you f . leave me. Overheard other resident talking in room [ROOM NUMBER] and said Maybe if we all complaint they will get rid of her maybe then we will get relief from annoying yelling looks like they are not doing anything. In a progress note on 08/08/18 at 11:42 PM, showed Resident continued to call out. Resident stating you stupid old b . The other LN moved her chair closer to the med cart and resident stated If you touch me like that again I will beat the s . out of you.Other residents yelling back shut up or go home then. Review of a 08/09/18 at 6:01 PM progress notes showed, Review of yelling out behaviors. This has an impact on others on the unit by disrupting living environment .MD gave orders to increase [MEDICATION NAME] (anti-psychotic medication) from 1 MG BID (two times a day ) to TID (3 times a day) with continued 0.5 ml (0.5 mg) PRN. Review of a physician progress notes [REDACTED]. Review of a progress note on 08/10/19 at 10:29 PM, showed Resident's calling out becomes louder and more verbally aggressive when not attended 1:1. Review of a progress note dated 08/11/18 at 1:55 PM, showed, behavior issue .11 am Resident is dozing off. 11:15 (AM) resident is now yelling 'help me help me. Resident toileted after yelling out numerous times I need to piss and poop .placed on toilet and within 3 minutes she is yelling out I need help Help meeeeeeee I'm done. Suggested that she sit a little longer, and was told you're such a b you don't know anything. You are so stupid. Resident was assisted off toilet .Continues to verbalize profanity stating, You're such a stupid b , you don't know anything. Taken out to hall to sit near nurse. Began yelling in the dining room I wanna go home I wanna go home. Other resident started yelling, go home, and go home. She responded, Shut the f . up. Resident taken back to hall . Review of a progress note dated 08/12/18 at 5:11 PM, showed, behavior issue: She continues to disrupt the unit with very loud yelling that can be heard at the ends of each hallway. Residents on the unit are often yelling back at her to be quiet . Review of a progress noted dated 08/12/18 at 11:22 PM, showed behavior issue: Resident grabs onto walker of other resident as she walks by. Other resident just stood there until I removed her hand. Resident would not remove her hand when asked. Resident also goes to grab at other residents as they pass by. This LN asks her to please respect other people space. Resident said nothing, Resident screams I need help, help .Resident continues to yell out. Other resident yell Shut up or go home. She tells them to shut the hell up you sons of b Review of a physician progress notes [REDACTED]. Plan: over the weekend we went ahead with scheduled [MEDICATION NAME] doses tid (three times daily) because they have seemed to have some efficacy in the past. Recent initiation of [MEDICATION NAME], and she is due once again for an increase to 4 mg qhs this evening . Review of a progress note dated 08/13/18 at 3:35 PM, showed, behavior issue .Sitting in hall near nurses station afterwards and continued yelling I want to go home, help me, help me, told another resident to shut the f up, All of you know nothing, nothing but stupid b . Review of a physician progress notes [REDACTED].Continued very problematic behaviors for her own health and safety as well as fell ow residents as well as facility employees. Recent work identified available beds at an inpatient geropsychiatric unit. Review of a progress note dated 08/29/18 at 9:51 PM showed,Resident calling out come on you idiots get me up. Resident offered snacks and would eat 1-2 bites then spit it on the floor. NAC is sitting with her so she doesn't continue to yell as other residents are yelling back shut up or then go home until she is ready for bed as she refused to get to bed. In an interview on 01/29/19 at 11:23 AM, Resident #6's daughter was asked if her mother had any issues with other residents. She stated, Yes, she is not a social person and she has issues with other residents. She tells residents to shut the hell up. That is her normal self. In an interview on 02/05/19 at 2:04 PM, Staff Z, LPN was asked about Resident #6. She stated, She usually sits here. She screams for help so we try to get her drink or something. Sometimes resident walking by will yell back to her shut up. I then report it to the other nurses and I tell the other residents she doesn't mean to scream. They say I know. Review of a social service progress note in Resident #36's medical record on 8/10/18 met with (Resident #36), President of the special resident council to discuss the impact of another resident , (Resident #6) vocalizations throughout the day and night on the other residents. Resident #36 reported that she felt sorry for Resident #6, and that she quiets down if she has another person close or holding her hand. Resident 36 did point out the she believes that other residents would benefit from a briefing and problem solving conversation about (Resident #6) and her effect on the other residents. It was decided that this would be a topic of conversation at the nest Resident Mtg. helped on 08/29/18 at 2:00 PM. This social worker will attend the meeting to help lead discussion. Review of the resident council minutes showed there was a 08/29/19 discussion at resident council about being kind to others. Review of Resident #42's progress note dated 08/04/18 at 1:13 PM, showed Very verbally aggressive towards another resident. Would separate them, but then resident would come back out of room to speak/read in hall and it would start up again. Encouraged resident not to respond to everything being said. Back to room [ROOM NUMBER]. In an interview on 02/05/19 at 2:15 PM, The Administrator was asked what measures were in place at the time of her verbal aggression to prevent verbal resident-to-resident altercations with other residents. He stated, She been seen by mental health . maybe we didn't document all that we have done but we had her seen by RCS, the pharmacist and doctor. Maybe, we just don't have it charted. Can I now discharge her since she is abusing my residents? That is what you are saying isn't it. The Administrator was asked if someone was reviewing progress notes in Point Click Care. He stated Every morning in stand up. I guess the (MONTH) incidents got past me. In a joint interview on 02/05/19 at 2:57 PM, Staff H, Medical Director stated, It is better now than before in terms of frequency of things. We all wish here was a better-staffed facility for her. The Administrator stated, If you are saying to me that she is truly a threat to other residents. We could do two to three resident to resident incidents a day to investigate on her. In a follow up interview on 02/05/19 at 4:36 PM, Staff H, Medical Director stated, I wonder if she would do better at a dementia unit where they are trained to deal with these behaviors . We certainly need to follow our regulations and we would love any insight you can give us. I will try to talk (Administrator) into one on ones. I know it isn't perfect. She will still call out but maybe it will help. In an interview on 02/05/19 at 5:13 PM., Staff L, Social Services stated, Nobody has come to me directly about a resident yelling but I read in the notes about things occurring. Usually at stand up I will bring up what is the plan what can we do after reading notes .for the resident with the behavior or other residents involved. I will bring this up at stand up with the DNS, Administrator, RCM's (Resident Care Managers), Staff BB is sometimes there. In an interview on 02/05/19 at 5:43 PM, Resident #2 was asked about noise. He stated, There is a lady that calls out all the time. I have to close my door. When asked if he ever heard, other residents yell back at her he responded Yes In an interview on 02/06/19 at 10:29 AM, The Director of Nursing services stated, We interviewed at least six residents that were near where she shouts out. Two of the six complained the noise is bothering them. None of them felt personally attacked but they were just tired of the constant yelling out. She (Resident #6) does not appear concerned that residents shout back at her .I am still trying to identify who it is that shouts back at her. Residents voiced that the calling out is wearing on them. This is a pattern of behavior and has apparently been going on since at least (MONTH) and possibly longer than that. We have her on one on ones now to help with the calling out. I notified the hotline and am in the process of notifying all the families and doctor. All staff are being educated on verbal abuse and to intervene right away. The facility failed to provide adequate supervision after distressed behaviors of verbal aggression resulting in verbal resident-to-resident altercations. Further, the facility did not provide immediate interventions to assure the safety of residents, and to assess the root cause to prevent further resident-to-resident altercations. The facility lacked assessment and monitoring of the residents for psychosocial harm. The facility had an abuse policy in place but failed to implement the measures. RESIDENT #18 Resident #18 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He had severe cognitive impairment. He required extensive assistance for mobility. Review on his medical record revealed he was not currently on restorative or therapy. He was seen by Physical Therapy from 05/03/18 to 05/28/18 due to documented physical impairments and associated functional deficits. Resident 18 was at risk for decrease in level of mobility; falls, further decline in function and increase dependency on caregivers. At that time, he ambulated 10 to 49 feet with Contact Guard Assist. Review of the care plan problem focus of high fall risk related to decreased mobility, poor memory and insight regarding current functional status and poor safety judgement directed staff to: · Assist him to the bathroom after dinner to decrease attempts at trying to get up without assist, have him in common area (near nursing station or in west lounge) if he is not in bed for more frequent eyes on by staff for attempts at standing without assist; · If resident is restless, rule out need to go to BR, having increased pain and need for repositioning, and that comfort needs are met (cold, warm, hunger, thirst). Resident is not able to ambulate well as his legs give out or lock up. He frequently rolls out or makes attempt to get out of bed onto fall mats. This is a behavioral pattern for him; · If he is found on the floor next to his bed, with his upper body resting on the bed (he is sitting on the floor) indicating a controlled attempt at getting onto the floor, then proceed with the following; LN to assess to determine no injury and then no incident. The following progress notes included unwitnessed falls with no incident report or log: Review on a progress note dated 05/04/18 at 12:41 AM, showed Resident's whole body was laying on his bed on his left side perpendicular. His head was somewhat dangling resting on the sheets .he was also very diaphoretic, lethargic, but abele to open his eyes when his name was called, stated, I am hungry. Blood glucose was 50 (low). Review of a progress note dated 05/05/18 at 11:24 PM, showed, Was found standing in his room at 1930 by CNA, claiming that he had fallen and that he had bumped his head When asked how he had bumped his head, he would continue to change his story each time he is asked . Review on a progress note dated 07/04/18 at 12:06 AM, showed Seen holding the rails close to the West dining room while getting out of the room .tried to run to help resident but before I even got there he started to sit down and help him lower to the floor. Review on a progress note dated 07/23/18 at 12:04 AM, showed , At 2100, Resident was found sitting on the floor mat of his room .with three quarters of his body on the floor and his head and arm resting on the bed .he was complaining of dizziness . Review on a progress note dated 07/25/18 at 10:45 PM, showed Caregiver reported that resident was sitting on the floor next to bed leaning against his bed with his brief removed . Review on a progress note dated 07/27/18 at 4:00 PM, showed, Found resident with his L (eft) side of body still in bed leaning on to it. His bottom hanging on due to resident having bowel movement extra-large . Review on a progress note dated 07/31/18 at 3:41 PM, showed Resident attempted to stand up in room and sat down on foot pedals of wheelchair .obtained an abrasion to right elbow and right knee .redness to right knee . Review of a progress note dated 07/31/18 at 10:07 PM, showed Found resident sitting on the floor in the bathroom close to toilet bowl and said I did not make it on time. Resident was trying to use the bathroom for a bowel movement. Noticed that this 3 falls is because he was trying to do bowel movement. We will try to assist resident to bathroom after dinner and will do close monitoring at least every 30 minutes or 1 hour. (New interventions were not added to care plan for other staff to view) Review on a progress note dated 08/03/18 at 5:10 PM, showed Resident sitting at edge of bed. Told him to move to middle but he was slowly sliding and let him sat on the floor mat and while on the mat he started to lying down. Review on a progress note dated 08/07/18 at 11:26 PM, showed, Resident seen sliding and sat himself with his back resting to bed frame. Review on a progress note dated 08/16/18 at 9:51 PM, showed unwitnessed fall-Found resident on the floor away from the mat lying position with BM close by. When asked why he is on the floor he said he heard something like the sound of plastic bag that made me upset and that's why I'm trying to find out. Neuro check started . Review on a progress note dated 08/18/18 at 2:39 PM showed, I seen resident was trying to get out from the bed almost on floor mat. Before I could help him, he already lower him on the floor and sit next to his bed. I call for help. Review of a progress note dated 08/18/18 at 9:44 PM, showed Seen resident climb out of bed despite bridging with pillows .he had no idea why he was on the mat. Review on a progress note dated 08/25/18 at 10:05 PM, showed Resident still in bed around 2145. Found resident in side lying position in a mat close to his room mated bed. Knows how to climb out of bed and seen him doing it a couple times. Review on a progress note dated 08/30/18 at 10:58 PM, showed Found resident lying flat in the mattress and resident claimed I slipped and when asked why he said I wanna see my wife. Is she here? Neuro started since it was unwitnessed fall. Review on a progress note dated 09/05/18 at 4:05 PM showed, Resident found on mat next to bed with head, shoulder and arms on bed .Neuros started . Review on a progress note dated 09/06/18 at 10:32 PM, showed Resident tried to get out of bed looking for bathroom. No apparent injuries from fall. Review on a progress note dated 09/25/18 at 10:56 PM, showed Visitor reported resident found on the floor with upper body leaned against the side of the bed .resident stated I need to go to the bathroom. Review on a progress note dated 09/26/18 at 6:59 PM, showed,Resident was sitting on the mat next to his bed leaning against his bed Review of a monthly summary dated 10/09/18 at 1:53 PM showed, Resident had no fall in 30 days, but pulled himself out of bed and onto mat on floor. Review on a progress note dated 10/21/18 at 4:15 PM showed, Resident was found by writer crawling to his door in his room. Review on a progress note dated 10/26/18 at 8:35 AM, showed Resident found on the floor by his bathroom. He stated that he got out of bed and crawled to the bathroom. Review of a progress note dated 10/26/18 at 4:30 PM, showed Resident got himself out of bed in a controlled fashion and was sitting in between his bed and his roommate's bed . Review on a progress note dated 10/27/18 at 11:47 AM, showed Resident crawled out of bed and into the bathroom. Resident turned on the call light in the bathroom Resident has had a large bowel movement in his brief. Review on a progress note dated, 11/07/18 at 10:24 PM,showed, Did try to crawl out of bed. Review on a progress note dated 11/14/18 at 9:14 PM, showed, Resident was found lowering himself from the bed to the mat by his bed. Before this LN (licensed nurse) could get him he started scooting across the floor on his bottom stating where my wife is. Review on a progress note dated 11/24/18 at 6:19 AM,showed, Resident was found sitting on his bottom on his safety mat upper body leaning on his mattress around 0200. Review on a progress note dated 11/26/18 at 11:15 PM, Showed Resident was anxious this shift and crawled from bed to mat by bed with no injuries. Review of a progress note dated 12/02/18 at 12:57 PM, showed Resident was sitting on the floor looking for his wife . Review of a progress noted sate 12/02/18 at 10:27 PM, showed Found resident sitting on the floor and starts to crawl looking for his wife. Review on a progress note dated 12/04/18 at 10:54 PM, showed Resident attempted to climb out of chair 3 X (times), ambulated by himself in short distance X 2 and crawled out of bed 2 X all due to looking for his wife . Review on a progress note dated 12/05/18 at 11:40 PM, showed Attempted to climb out of wheelchair and was seen sitting on the floor looking for his wife. Incontinent care provided. Review on a progress note dated 12/12/18 at 10:07 PM, showed Found him sitting on the floor and was assisted to his wheelchair with no apparent injury. Review of a progress note dated 12/17/18 at 10:48 PM,showed Resident crawled out of the bed early part of shift looking for his wife Refused to go to dining room for dinner .wanted to go back to bed Started crawling back to bed. Review of a progress note dated 12/18/18 at 10:47 PM, showed, Resident climb out of bed looking for his wife . Review on a progress note dated 12/22/18 at 10:04 PM, showed Middle of shift resident seen crawling wanting to talk to his wife. Review on a progress note dated 01/19/19 at 11:17 AM, showed Resident rolled to the floor from his bed . Review on a progress note dated 01/29/19 at 10:56 PM, showed Resident found crawling out of bed onto mat once this shift . Review on a progress note dated 02/01/19 at 11:37 PM, showed Resident found sitting in the floor fooling for his wife. Review on a progress note dated 02/10/19 at 9:38 PM, showed Crawled out of bed this afternoon . Review of the Treatment Administration Record (TAR) entry beginning 10/14/18 showed, Information regarding found on floor in room every shift has capability to get out of bed in a controlled fashion, If found on the floor in his room with an obvious controlled attempt (buttocks on floor and UB on bed or found crawling in the room) LN to assess for injury and if none, no incident report needed In an observation on 02/06/19 at 12:02 PM, Resident #18 was by the nurse's station attempting to stand up. Staff X, RN was at the cart unaware. An unknown visitor alerted Staff X and began helping by sitting with him to distract him. Staff X stated, Your wife will not be happy if you fall. In an observation on 02/06/19 at 12:18 PM, Resident #18 was again attempting to stand. Staff X stated, (Resident #18) No no don't stand up. We will go to the dining room in just a bit. There was no inquiry to see if his needs were met. In an interview on 02/11/19 at 11:18 AM, Staff DD, LPN was asked about falls. She stated, A fall is a change in elevation and requires an assessment unless there is a care plan that states different. Like with (Resident 18). She confirmed he has severe cognitive impairment and can not say exactly what happened. In an interview on 02/11/19 at 1:55 PM, Staff Y, LPN was asked about the falls located in the progress note with no corresponding investigations. She stated,We try not to bother him in bed. He usually climb out of the bed. Sometimes we observe him slide out of the bed, he scoot on his butt. Sometimes to bathroom, I am not sure. We pick him up then ask him if he needs to use the bathroom and he asks have you seen my wife. Sometimes if he is anxious, we call the wife and he will be fine . When he crawls out of bed, we call wife to tell him to calm him down. A fall is considered from bed to floor . low bed too but with him, he is not really fall. When asked how she knows if he fell during transfer or while ambulating if not witnessed with his severe cognitive impairment. She got quiet and said, Well it is care planned not to investigate. I did see him one time slide. We check vitals and skin when we find him. We usually toilet him after dinner and he does some

Based on observation, interview, and record review, the facility failed to ensure the residents were free from abuse for vulnerable residents with dementia or protect residents from abusive behaviors from Resident 16. Resident 16 would shove her walker into other residents when they wandered into her room or that she disliked which impacted 14 of 15 residents reviewed for abuse (#2, #6, #14, #16, #24, #26, #36, #42, #44, #66, #101, and three unidentified residents). The facility failed to recognize, by monitoring, that Resident #6's behaviors might provoke a reaction by other residents, which could provoke other residents to have aggressive behaviors escalating into abuse. This created harm for all of the residents impacted by Resident #16 and Resident #6's behaviors and had the potential to place all residents at risk for physical and or verbal abuse. Findings included . Refer to F607 for additional information on facility failure to operationalize abuse/neglect policy and procedures and repeatedly demonstrated inability to identify neglect/abuse; failure to protect the residents and thoroughly investigate allegations of neglect/abuse, and implement interventions based on root cause analysis to prevent reoccurrence for residents. Review of the facility policy for Abuse and Neglect dated (MONTH) (YEAR) indicated: Every resident has the right to be free from abuse in all forms. Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents, physicians, consultants, volunteers, family members, legal guardians, friends, or other individuals. Every resident has the right to be free from mistreatment, neglect, and misappropriation of property. This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, development of strategies to prevent occurrences by monitoring for changes that would trigger abusive behavior, and reassessment on a regular basis Abuse, is defined at §483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as defined at §483.5 and as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. RESIDENT #6 Resident #6 admitted on [DATE] with [DIAGNOSES REDACTED]. Her Quarterly Minimum Data Set (MDS) assessment, dated 10/19/18, showed she had a Brief Interview of Mental Status (BIMs) score of 3, which indicated, severe cognitive impairment. The MDS also indicated the resident displayed verbal behavioral symptoms directed towards others (e.g. threatening, screaming, and cussing at others) this behavior happened daily, during the look back period. Resident #26 On 02/12/19 at 4:48 PM, the record showed that Resident #26 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The MDS also indicated the resident displayed verbal behavioral symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing) 1-3 times during the look back period. In an attempted interview on 02/13/19 at 2:08 PM, Resident #26, due to his poor cognitive status, stated he did not have any recall of either of the incidents that happened with Resident #16. Resident #14 On 02/12/19 at 04:48 PM, the record showed that Resident #14 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The MDS also indicated the resident had no behaviors during the look back period except for wandering. RESIDENT #24 In an interview on 01/30/19 at 11:31 AM, Resident #24 was asked if she had any confrontations with other residents. She said, this One lady (referring to Resident #16) used to come in the dining room and she would bang me with her walker into my wheelchair. This used to happen almost every day it seems. Resident #101 Record review showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #101's Initial MDS dated [DATE] indicated his BIMs score was a 9 showing that he had moderately impaired cognition and did not have any behaviors. Resident #16 On 02/12/19 at 3:26 PM, the record showed that Resident #16, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's quarterly MDS assessment dated [DATE] indicated Resident 16 had a BIMs score of 2 which indicated severe cognitive impairment. The MDS also indicated the resident displayed verbal behavioral symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing) 1-3 times during the look back period. The record also included that staff anticipate the resident's needs due to baseline confusion. A review of the incident log from 12/01/18 to 01/29/19 showed that on 3 occasions (12/31/18, 01/01/19, & 01/05/19) Resident #16 became physically aggressive with other residents by using her walker and ramming it into the other residents. The facility on all three occasions did not recognize that these actions were a form of abuse. They documented their findings, were that the incidents were reasonably related because of her dementia. A review of Resident #16's record progress notes from 03/23/18 to 02/12/19 showed Resident #16 was independent to ambulate throughout the facility with her front wheeled walker. She had multiple entries of being agitated and had several encounters of pushing her walker into other residents on: 07/24/18; 09/16/18; 12/10/18; 12/31/18; 01/01/19 and 01/05/19. On 7/24/18, documentation in the progress notes indicated that Resident #16 motioned her walker into Resident #6, Hard enough to hear the sound of metal against metal. As Resident #16 moved away Resident #6 attempted to grab Resident #16, but Resident #16 was able to move away. Resident 16 then remarked you ought to do something about her, some of us got to work in the morning. The Licensed Nurse (LN) asked Resident 16 why she did that, Resident #16 replied, Why? Should I just let her scream like that all night, it's not fair. Documentation also showed that Resident #16 was put on close monitoring and placed on alert charting for psychological harm. The record did not indicate what close monitoring was and the care plan did not reflect close monitoring. On 7/26/18, in a follow up progress note indicated Resident #16 was heard complaining about Resident #6 and her constant yelling as Resident #16 was walking past Resident #6. The LN documented that she stood between the two residents. On 9/16/18, documentation showed that Resident #16 was blocking the hall, and Resident #101 accidently bumped Resident #16's walker, as he was passing. Resident #16 stood up and slammed her walker into the other resident's wheel chair. On 12/10/18, documentation showed that Resident #16, was sitting in the dining room and had a verbal altercation that included gesturing rudely (middle finger) with two other residents (#24 & #36). On 12/31/18, documentation indicated Resident #26 wandered into Resident #16's room, and was lying on the bed. Resident #16 reported the incident, so the Nursing Assistant (NA) who then attempted to remove Resident #26 from the room. Resident #16 ran her walker into the back of his wheel chair. The NA asked Resident #16 not to do that and Resident #16 proceeded to hit Resident 26's wheel chair again. The next day on 01/01/19, Resident #16 saw Resident #26, while they were going to the dining room. Resident #16 intentionally rammed her walker into the back of Resident #26's wheel chair. On 01/01/19, documentation in the Progress notes indicated that Resident #14 was in Resident #16's room and Resident #16 was yelling at her (Resident #14) to get out of her room. Resident #16 proceeded to ram her walker into her (Resident #14) knees / upper shins. In an observation and interview on 02/13/19 at 2:19 PM, Resident #16 was observed walking fast throughout the facility. When asked about the past altercations, stated that she remembered Resident #26 coming into her room and she got mad at him, but denied recalling the other incidents. In an interview on 02/13/19 at 2:54 PM, the Administrator stated that if a resident did not show signs of physical or mental harm, then it is not abuse. When asked about Resident #16, he said that she was bumping her walker into other's wheel chairs. When she rammed the resident's legs, there was no visible harm, so it was not abuse. The Administrator was asked about resident / resident abuse. He stated that the facility defers to the purple book reporting guidelines. The Abuse definition was reviewed in the purple book identified and the Administrator stated the nurse would have to assess the resident if they had physical injury. There was no documentation that showed the facility recognized the behaviors of resident 16 could be abusive even, if there was no physical injuries. The facility failed to take into consideration that residents with dementia or cognitive impairments may not display the same type of symptom of psychological harm as someone with intact cognition. RESIDENT # 6 Resident # 6 admitted on [DATE] with [DIAGNOSES REDACTED]. Her Quarterly MDS assessment, dated 10/19/18, showed she had a Brief Interview of Mental Status (BIMs) score of 3, which indicated, severe cognitive impairment. The MDS also indicated the resident displayed verbal behavioral symptoms directed towards others (e.g. threatening, screaming, and cussing at others, ) this behavior happened daily, during the look back period. In a telephonic interview on 01/29/19 at 11:23 AM, Resident # 6's daughter was asked if her mother had any issues with other residents. She stated, Yes, she is not a social person and she has issues with other residents. She tells residents to shut the hell up. That is her normal self. Review of her care plan showed, When she becomes agitated; Intervene before agitation escalated; Guide away from source of distress; Engage calmly in conversation. Review of a progress note dated 08/08/18 at 10:43 PM, showed will yell Come back don't you (cuss word) leave me. Overheard other resident talking in room [ROOM NUMBER] and said Maybe if we all complain they will get rid of her maybe then we will get relief from annoying yelling looks like they are not doing anything. Review of a progress note dated 08/08/18 at 11:42 PM showed, Resident continued to call out. Resident stating You stupid old b h. The other LN moved her chair closer to the med cart and Resident #6 stated, If you touch me like that again I will beat the sh out of you .Other (unidentified) residents yelling back shut up or go home then. Review of a progress note dated 08/12/18 at 5:11 PM, showed,Behavior issue She continues to disrupt the unit with very loud yelling that can be heard at the ends of each hallway. Residents on the unit are often yelling back at her to be quiet. Review of a Resident # 6's progress note dated 08/11/18 at 1:55 PM, showed a Behavior issue . 11:15 resident is now yelling 'help me help me. Resident toileted after yelling out numerous times I need to piss and poop .placed on toilet and within 3 minutes she is yelling out I need help Help meeeeeeee I'm done. Suggested that she sit a little longer, and was told you're such a b .you don't know anything. You are so stupid. Resident was assisted off toilet .Continues to verbalize profanity stating, You're such a stupid b ., you don't know anything. Taken out to hall to sit near nurse. Began yelling in the dining room I wanna go home I wanna go home. Other resident started yelling, go home, go home. She responded, Shut the f up. Resident taken back to hall. Review of Resident #6's progress note dated 08/12/18 at 11:22 PM, showed, Behavior issue: Resident grabs onto walker of other (unidentified) resident as she walks by. Other resident just stood there until I removed her hand. Resident would not remove her hand when asked. Resident also goes to grab at other residents as they pass by. This LN asks her to please respect other people space. Resident said nothing, Resident screams I need help, help .Resident continues to yell out. Other resident yell shut up or go home. She tells them to Shut the hell up you sons of b . Review of a progress note dated 08/13/18 at 3:35 PM, showed, Behavior issue .Sitting in hall near nurses station afterwards and continued yelling I want to go home, help me, help me, told another resident to shut the f up, All of you know nothing, nothing but stupid b . Review of a progress note dated 08/29/18 at 9:51 PM, showed, .Resident calling out come on you idiots get me up. Resident offered snacks and would eat 1-2 bites then spit it on the floor. NAC is sitting with her so she doesn't continue to yell as other residents are yelling back shut up or then go home until she is ready for bed as she refused to get to bed. Review of the incident log did not reveal any incident reports for the above progress notes. There was no identification of verbal abuse, protection, investigation, or reporting. The involved resident's were not assessed for psychosocial harm at the time of the verbalizations. In an interview on 02/05/19 at 10:16 AM, Resident #42 was asked if she had issues with noise. She stated, There is a lady here (Resident #6) she yells and no one does anything. If I acted like that for 2 hours, they would get rid of me . but she gets away with it. She calls me names that get me mad. I can't even tell you what she says since they don't bear repeating. They are terrible. I wish someone would do something. She confirmed that Resident #6 calls her names. In an interview on 02/05/19 at 10:23 AM, Staff R, NAC was asked what the process is for witnessing or being informed of abuse or neglect. She stated she would fill out a grievance form and tell the nurses, Administrator, RCM and DNS and then it would be in their hands. In an interview on 02/05/19 at 10:25 AM, Resident #36 stated, (Resident #6) screams out help me she grates on my nerves. I spoke softly to her and she speaks softly to me. Some people yell at her. They yell back at her. I hear it a lot shut up back to her .No you can't have any help. The staff know. She just bothers me and once my sister had to leave because she couldn't handle her screaming. She caused my visitor to leave. In an interview on 02/05/19 at 10:30 AM, Resident #66 stated, There is a lady who screams I want to go home. She is looking for her mom and dad. She is not very happy. Other residents tell her to shut up because she does it (yelling) late at night .very late at night when they are trying to sleep. Everybody hears her. At times, she is sitting up by the nurse's station. She is usually asleep. I would be too if I were up yelling all night. In an interview on 02/05/19 at 12:50 PM, The Administrator confirmed the identified progress notes would require an investigation and would not be a grievance as reported by several staff. He stated he was not aware of these progress notes. In an interview on 02/05/19 at 2:04 PM, Staff Z, LPN was asked about Resident #6. She stated, She usually sits here. She screams for help so we try to get her drink or something. Sometimes residents walking by her will yell back to her shut up. I asked what her process is when she observes this and she stated, I then report it to the other nurses. In an interview on 02/05/19 at 2:15 PM, the Administrator She (Resident #6) has been seen by mental health. I told her maybe we didn't document all that we have done but we had her seen by RCS (Residential Care Services behavioral health), the pharmacist and doctor. Maybe, we just don't have it charted. The Administrator was asked what measures were in place to identify verbal abuse, prevent, protect, investigate, correct, report and log for multiple resident-to-resident interactions involving Resident #6 and others. He confirmed the process was not followed. The Administrator was asked what process the facility had to review progress notes and clinical concerns. He stated, Every morning in stand up. I guess the (MONTH) incidents got past me. In an interview on 02/05/19 at 5:13 PM, Staff L, Social Services was asked if any residents had voiced a concern involving noise or interactions with other residents. She stated, Nobody has come to me directly about a resident yelling but I read in the notes about things occurring. Usually at stand up, I will bring up what is the plan. What can we do after reading notes .for the resident with the behavior or other residents involved? I will bring this up at stand up with the Director of Nursing, Administrator, Resident Care Managers, Staff BB, Registerd Nurse is sometimes there. In an interview on 02/05/19 at 5:43 PM, Resident #2 was asked about any noise concerns, He stated, There is a lady that calls out all the time. I have to close my door. Asked if he ever heard, other residents yell back at her and he stated Yes In an interview on 02/06/19 at 11:10 AM, The Administrator stated, I do not disagree at all with F-600 citation-there were no investigations, protection . staff not recognizing potential abuse. In an observation on 02/06/19 at 2:15 PM, Staff U, NAC Scheduler asked Staff Y, LPN if a resident to resident altercation was abuse. Staff Y responded No. At that time Staff U, said Come with me I am going to in-service you on abuse RESDIENT #42 Review of Resident #42's progress notes dated 08/04/18 at 1:13 PM, showed, Very verbally aggressive towards another resident. Would separate them, but then resident would come back out of room to speak/read in hall and it would start up again. Encouraged resident not to respond to everything being said. Back to room [ROOM NUMBER]:15 PM. There was no incident report or further details for the 08/04/18 incident. The facility failed provide evidence that it completed a resident assessment, provided care-planning interventions to address the resident's distressed behaviors of physical or verbal aggression. Based on the presence of the resident-to-resident altercations, the facility did not assess the involved residents, evaluate the effectiveness of the interventions. Further, staff did not provide immediate interventions to assure the safety of residents nor provide protection to prevent resident-to-resident abuse. The facility neglected to investigate, and complete a root cause analysis to prevent reoccurrence. The facility had an abuse policy in place but failed to implement the procedures as outlined. RESIDENT #44 Resident #44 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the state reporting log showed Resident #44 had made an allegation of neglect on 01/16/19. The incident was logged on 01/18/19. Review of the incident report dated 01/17/19 showed Resident #44 stated to Staff QQ, NAC on 01/16/19 at 2:30 PM that she had not been changed since the AM (an allegation of neglect). Review of the incident report showed an entry from Staff Q, RN stating, At 1400, on 01/17/19 Staff RR, RN notified this RN (Staff Q) that a caregiver not under her supervision at the time, reported to her the alleged neglect of a resident. This RN (Staff Q) immediately told the Director of Nursing Services. Staff QQ, NAC reported the allegation of neglect to Staff RR, RN on 01/16/19 in the afternoon. The investigation was not started until 01/17/19, 24 hours after the allegation was reported. Reference: (WAC) 388-97-0640(1)

Based on observation, interview, and record review, the Administration failed to manage the facility in a way to ensure the facility was in substantial compliance with federal regulatory requirements. The Administration failed to ensure there was monitoring of systems related to Abuse/Neglect, Accidents, Tube Feedings, Pain Management, Social Services, Staffing, QAPI, and Range of Motion programs. This failure placed residents at risk for injury, abuse, incomplete or outdated care directives, declines in physical function, and diminished quality of life. Failure to provide oversight resulted in an Immediate Jeopardy (IJ) on 01/29/19 under F689, Accidents Hazards/Supervision/devices due to unsecured oxygen tanks left on windowsills and under F693, Management of Tube Feeding due to staff failure to follow physician orders [REDACTED]. The Administration failed to ensure the facility was in compliance with regulatory requirements (see below). This failure represented a pattern of widespread deficiencies, in the following requirements which placed all residents at risk for a diminished quality of life. Findings included . During a review of past statements of deficiencies issued on 05/17/18, 03/08/18 and 01/17/18 showed that during this current survey: There were 2 repeated citations from 05/17/18 at F657 (Care Planning) and F686 (Treatment and Svcs to prevent pressure ulcers.) F835, CFR 483.70, Administration, is a repeat citation from the 03/08/18 post revisit survey, in which the Administration did not correct citations from the full survey dated 01/17/19. The current full survey showed there are 24 repeated citations from the 01/17/18 full survey. See below for repeat and harm citations. Refer to: F558, CFR 483.10(e)(3) - Reasonable Accommodations Needs / preferences The Administration failed to ensure call light accessibility for a resident who needed help. This is a repeat citation from 01/17/18 Refer to: F561, CFR 483.10(f)(1)-(3)(8) - Self-Determination The Administration failed to ensure personal preferences were honored for rising times, bathing preferences, and grooming frequency of choices. This is a repeat citation from 01/17/18 Refer to: F582, CFR 483.10(g)(17)(i-ii)(18)(i)-(v) Medicaid / Medicare Coverage/liability Notices The Administration failed to ensure staff provided a required liability notice for 2 residents. This is a repeat citation from 01/17/18 Refer to: F584, CFR 483.10(i)(1)-(7) Safe/Clean/Comfortable/homelike Environment The Administration failed to identify and provide necessary maintenance and housekeeping services in the facility. This is a repeat citation from 01/17/18 Refer to: F585, CFR 483.10(j)(1)-(4) - Grievances The Administration failed to ensure all staff are oriented and implemented the grievance policy, which included missing items and that the residents are informed of how to file a grievance. This is a repeat citation from 01/17/18 Refer to F600, CFR 483.12(a)(1) Free From Abuse and Neglect The Administration failed to ensure that all staff were able recognize / analyze / abuse and neglect that involved resident-to-resident altercations, and verbal abuse. This caused harm to residents who were submitted to Resident 16 running her walker into them and Resident 6 yelling, cussing and calling residents foul names. Refer to: F605, CFR 483.10(e)(1) 483.12(a)(2) Right to be free from Chemical Restraints The Administrator failed to ensure staff keep residents free from Chemical Restraints. This resulted in harm for Resident 6 who was overly sedated. Refer to: F609, CFR 483.12(c)(1)(4) - Reporting Of Alleged Violations The Administration failed to report to the local law enforcement or the department of a drug diversion of missing narcotics. This is a repeat citation from 01/17/18 Refer to: F610, CFR 483.12(c)(2)-(4) - Investigate/prevent/correct Alleged Violation The Administration failed to ensure staff thoroughly and accurately investigated allegations of abuse/neglect or incidents or accidents. This placed residents at a high risk for abuse or continued abuse. This is a repeat citation from 01/17/18 Refer to: F625, CFR 483.15(d)(1)(2) Notice of Bed Hold Policy Before/upon Transfer The Administration failed to ensure staff provided bed hold notices at the time of transfer to the hospital or within 24 hours of transfer to the hospital for 3 residents. This is a repeat citation from 01/17/18 Refer to: F656, CFR 483.21(b)(1) - Develop/implement Comprehensive Care Plan The Administration failed to ensure staff developed and implemented a comprehensive person-centered care plans for 2 residents. This is a repeat citation from 01/17/18 Refer to: F657, CFR 483.21(b)(2)(i)-(iii) - Care Plan Timing And Revision The Administration failed to ensure staff reviewed and revised care plans for two residents. This is a repeat citation from 01/17/18 This is also a repeat citation from 05/17/18 Refer to F684, CFR 483.25 - Quality Of Care The Administration failed to provide the necessary care and services reviewed for unnecessary medications with a [DIAGNOSES REDACTED]. This is a repeat citation from 1/17/18 Refer to F686, CFR 483.25(b)(1)(i)(ii) - Treatment/svcs To Prevent/heal Pressure The Administration failed to ensure staff prevented one resident from developing a deep tissue injury (DTI) This is a repeat citation from 1/17/18 and 05/17/18. Refer to F688, CFR 483.25(c)(1)-(3) Increase / prevent decrease in ROM / mobility The Administration failed to ensure restorative service were consistently provided for residents. This caused harm for 2 residents 6 & 18 Refer to F 689, CFR 483.25 (d)(1)(2), Free Of Accident Hazards/supervision/devices; The Administration failed to provide oversight, which resulted in an Immediate Jeopardy (IJ) due to unsecured oxygen tanks being left on windowsills on 1/29/19. The Administration also failed to ensure there was adequate numbers of staff to provide supervision to prevent accidents. The created an atmosphere of placing residents at high risk of injuries. During a review of the incident log, it showed that in: August (YEAR), there were: 28 falls, 4 self-inflicted injuries, 2 skin tears September (YEAR), there were: 31 falls, 1 self-inflicted injuries, & 1 injury during handling October (YEAR), there were: 13 falls, 1 self-inflicted injury November (YEAR), there were 11 falls December (YEAR), 18 falls, 2 alleged abuse, 2 resident to resident altercations involving 5 people This is a repeat citation from 1/17/18 Refer to F693, CFR 483.25(g)(4)(5) - Tube Feeding Mgmt/restore Eating Skills The Administration failed to ensure safety measures were followed to prevent potential complications through tube feeding devices for two residents. On 01/30/19 an immediate jeopardy was called because, the Administration failed to ensure staff followed physician orders [REDACTED]. This is a repeat citation from 01/17/18 Refer to F697, CFR 483.25(k) - Pain Management The Administration failed to provide adequate pain control for 1 of 4 residents (15) This resulted in harm for Resident 15 This is a repeat citation from 01/17/18 Refer to F725, CFR 483.35(a)(1)(2), Sufficient Nursing Staff; The Administration failed to provide and retain adequate staff, including a Director of Nursing (DNS), to meet and provide the basic needs of the residents or ensure services were provided and clinical system were put in place. The facility currently has no DNS. This is a repeat citation from 01/17/18 Refer to F756, CFR 483.45(c)(1)(2)(4)(5) - Drug Regimen Review, Report Irregular The Administration failed to ensure staff followed up on all pharmacy recommendations. This is a repeat citation from 01/17/18 Refer to F758, CFR 483.45(c)(3)(e)(1)-(5) - Free From Unnec [MEDICAL CONDITION] Meds/prn Use The Administration failed to ensure all residents were free from unnecessary [MEDICAL CONDITION] medications (drugs that affect brain activities associated with mental processes and behavior). This is a repeat citation from 01/17/18 Refer to F812, CFR 483.60(i)(1)(2) - Food Procurement, store/prepare/serve-Sanitary The Administrator failed to ensure staff maintained a sanitary kitchen environment. In addition, the Administration failed to maintain dry food goods that were free from contamination by storing potatoes on the floor. This is a repeat citation from 1/17/18 Refer to F842, CFR Resident Records The Administration failed to ensure the facility medical records were accurate, and complete. This is a repeat citation from 1/17/18 Refer to F880, CFR 483.80(g)(1)(i)-(iv)(2)(i) Infection Prevention & Control The Administration failed to ensure staff developed or implemented policies and procedures to ensure the reduction of potential growth and spread of opportunistic pathogens in the facility's water system. This is a repeat citation from 1/17/18 In an interview on 02/08/19 at 12:48 PM, the Director of Nursing (DNS) stated, she felt that she could no longer continue her employment in the building, because every system in the building is broken. When she was hired she not aware that the building had 7 Directors of Nursing in a year. The DNS also stated the facility does not have it's own facility specific policies. The Administrator bought Med Pass policies and that is what the facility is using. They are not facility specific and almost every one of them needs to be updated to current standards, some dating as far back as 2008. They need to reflect what is going on in the facility. The DNS said she has tried to put systems in place. The DNS said that the Administrator will go to Staff BB before he comes to the DNS, because he says that she knows how to do something, even if it is the wrong way. The Administrator, wants to have meetings, but the problem is, the meetings take so long, and there are not enough hours in the day for her to do her job that he wants done, so nothing gets resolved. The DNS resigned from her position on 02/08/19. In an interview on 02/13/19 at 2:54 PM, the administrator stated that if a resident did not show signs of physical or mental harm, then it is not abuse. When asked about Resident 16, he said that she was bumping her walker into other's wheel chairs. When she rammed the resident's legs because there was no harm, then it is not abuse. The Administrator was asked if missing narcotics was, a crime and he stated, It potentially could be a crime, if a resident wanted they would want to contact law enforcement. In addition, because the missing narcotic medications were all discharged residents, there was no misappropration, so law enforcement was not contacted. Administration had not ensured there were procedures and systems in place to sustain compliance with federal regulatory requirements creating wide spread system breakdown causing harm and placing residents at high risk of further harm. Reference WAC 388-97-1620(1),(2)(ii)

Based on interview and record review, the governing body acted with disregard to the well-being of the residents of the facility, by not providing adequate oversight and monitoring of the appointed Administrator. The governing body failed to recognize a pattern of widespread neglect by staff, which resulted in harm to residents. The governing body failed to ensure clinical systems were in place and followed to prevent harm to residents from pressure ulcers, the tube feedings, and that residents consistently received a Restorative Nursing Program. The governing body failed to ensure the Administrator had sufficient staff to meet the needs of the residents, i.e. showers, restorative programs, and that call lights were answered timely. The governing body failed to have a separate governing body (that did not include the Administrator) to provide oversight of the Administrator. These failures also resulted in harm to residents and had the potential to place residents at risk of negative outcomes. Findings Included . The facility Governance Policy dated 01/05/17 and 05/11/18, which had outdated information by referencing an old citation number F493 section 483.70(d) instead of the new F837, 483.70(d)(1)-(3) The policy indicated the: Purpose: in accordance with F 493 section 483.70(d), Careage of Whidbey's governing body oversees the development and implementation of policies and procedures regarding the operation of the nursing home. The governing bodies role is to oversee and establish quality initiative carried out by the QAPI Committee. Also, the Governing Body is directly responsible for appointing a qualified administrator of the operation. Members: (Staff HHH, owner, Staff JJJ, owners, the Staff III, President and the Administrator. Agenda: The Governing Body is to meet on a quarterly basis to review the current standing of the operation. Areas for review include quality, compliance, satisfaction, financial's, and risk. Areas of deficiency will be identified and passed through to the QAPI committee. New policies and procedures will be reviewed and accepted for implementation. The Policy was signed by the Administrator. Refer to F835, CFR 483.70, Administration (this is a repeat citation from 3/8/18) The governing body failed to ensure the administrator managed the facility efficiently enough to be in substantial compliance with federal regulatory requirements, nor did they ensure the Administrator corrected citations and they remained corrected and not repeated. The governing body failed in its duties to recognize repeat citations and to maintain correction so citations were not repeated. There were 2 repeated citations from 05/17/18 at F657 (Care Planning) and F686 (Treatment and Svcs to prevent pressure ulcers.) F835, CFR 483.70, Administration was a repeat citation from 03/08/18 post resurvey, because the Administration was not correcting citations from the full annual survey dated 01/17/19, in which the current full survey found 24 repeated citations from 01/17/18 Harm level citations from the current full survey are as follows below: Refer to F600, CFR 483.12(a)(1) Free From Abuse and Neglect The Governing body failed to ensure that the Administrator ensured that all staff were able recognize / analyze abuse / neglect that involved resident-to-resident altercations, and how verbal altercations could be abusive and impact other residents. Refer to: F609, CFR 483.12(c)(1)(4) - Reporting Of Alleged Violations The Administration failed to report to the local law enforcement or the department of a drug diversion or allegations of Abuse/Neglect This is a repeat citation from 01/17/18 Refer to: F605, CFR 483.10(e)(1) 483.12(a)(2) Right to be free from Chemical Restraints The governing body failed to ensure Administration keep residents free from Chemical Restraints. This resulted from harm for Resident 6 who was overly sedated. Refer to F688, CFR 483.25(c)(1)-(3) Caused Harm for 2 residents 6 & 18 Refer to F689, CFR 483.25 (d)(1)(2), Free Of Accident Hazards/supervision/devices; The Administration failed to provide oversight, which resulted in an Immediate Jeopardy (IJ) on 1/29/19 due to unsecured oxygen tanks lying on their side on windowsills. This is a repeat citation from 01/17/18 and 10/21/16, for keeping residents free from hazards. Refer to F693, CFR 483.25(g)(4)(5) - Tube Feeding Mgmt/restore Eating Skills The Administration failed to ensure staff followed physician orders. This affected residents' safety. This resulted in an immediate jeopardy on 01/30/19. This is a repeat citation from 01/17/18 Refer to F697, CFR 483.25(k) - Pain Management The Administration failed to provide adequate pain control for 1 of 4 residents (15) This resulted in harm for Resident 15 This is a repeat citation from 01/17/18 Refer to F725, CFR 483.35(a)(1)(2), Sufficient Nursing Staff; The Administration failed to provide adequate staff to meet and provide the basic needs of the residents. This is a repeat citation from 01/17/18 Refer to F865, CFR 483.75(a)(b)(f)(h)(i) QAPI prgm/plan/disclosure/good faith attempt. The Governing body failed to ensure the facility had or maintained an effective Quality Assessment and Assurance Program (QAPI) that identified deficiencies, and implemented appropriate preventative or corrective actions. The facility's QAPI program failed to timely recognize already compromised care and services that resulted in the severity of harm, immediate Jeopardy (IJ), as well as a potential for widespread scope of resident harm. The Governing body failed to ensure repeat citations were corrected. While reviewing the Facility Assessment, there was no evidence that other members of the governing body besides the Administrator worked on the assessment. In an interview on 02/08/19 at 12:48 PM, the Director of Nursing (DNS) stated, she felt that she could no longer continue her employment in the building, because every system in the building is broken. In an interview on 02/13/19 at 2:37 PM, the Administrator stated that the governing body consisted of Staff HHH, owner, Staff JJJ, owner, Staff III, president, and himself. He stated the goal of the governing body was to review policies and procedures, facility performance, and quality improvement of the organization. The Administrator stated the governing body last met about 6 months ago. The Administrator stated they review compliance by looking at statements of deficiencies, and complaint investigations. The last time they met, they identified skin at risk and developed a better tracking system. The Administrator also stated they train staff to the new regulations by supplying them with the survey pathways, rules of participation and the Manual. The other members of the governing body were not available during the survey. Reference: WAC 388-97-1620 (2)(c)

Based on observation, interview and record review, the facility failed to comprehensively assess, care plan, and document chemical restraint use for one of one resident (# 6) reviewed for restraints. Failure to: 1) comprehensively assess the risks and benefits and parameters of use of a chemical restraint, 2) to follow care plan interventions to ensure the least restrictive alternatives were attempted and were ineffective prior to chemical restraint use and 3) to monitor for sedation and adverse side effects including AIMS (Abnormal Involuntary Movement Scale) testing and to ensure she was not sedated resulted in harm related to a decline in her ability to complete her activities of daily living, poor quality of life, somnolence and the residents inability to open her eyes. Findings included . Review of the facility's policy titled, Medication Utilization and Prescribing-Clinical Protocol, dated (MONTH) 2012, revealed: The physician will provide and/or document a rationale when the dose, duration, or frequency of a prescribed medication is greater than commonly accepted practice or the manufacturer's recommendations or the medication is considered high risk compared to other available, relevant alternatives. The staff and physician will identify and address the unexpected, unintended, undesirable or excessive responses to a medication based on the severity of underlying conditions, the seriousness of any adverse drug reactions, risks of worsening of medical condition and other factors .for example a necessary medication that is causing daytime sedation could instead be administered in the evening for that peak side effects occur during sleep. According to the American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults are widely used by clinicians, educators, researchers, healthcare administrators, and regulators. The 2019 Beers Criteria included both [MEDICATION NAME] and [MEDICATION NAME] as PIM. [MEDICATION NAME] had an increased risk of [MEDICAL CONDITION] (stroke) and greater rate of cognitive decline and mortality in persons with dementia. The rationale included, Avoid antipsychotic's for behavioral problems of dementia or [MEDICAL CONDITION] unless non-pharmacological options have failed or are not possible and the older adult is threatening substantial harm to self or others. [MEDICATION NAME] had a high risk for orthostatic [MEDICAL CONDITION] and associated harm, especially in older adults. Resident # 6 admitted on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Annual Minimum Data Set (MDS) assessment dated [DATE], showed she had severe cognitive impairment, had no hallucinations or delusions and did not reject care. Resident # 6 was admitted on [MEDICATION NAME] (anti-psychotic mediation) 0.5 MG (milligrams) once a day at bedtime. The current [MEDICATION NAME] dose was 2 MG three times a day, eight times the amount of last year's dose and 16 times the admission dose. The [DIAGNOSES REDACTED]. Additionally, the resident was on [MEDICATION NAME] (a blood pressure medication) for the off label use of [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. The physician declined a GDR 07/17/17 based on ongoing behaviors. The [MEDICATION NAME] dose at that time was 2 MG (BID) twice a day. On 08/27/18, the physician increased to [MEDICATION NAME] to 4 MG (TID) three times a day. In a joint telephonic interview with the resident's daughter and son on 01/29/19 at 11:24 AM, The daughter stated,They have her on a lot of medications and she is sedated. They say it is because she yells out. It was almost like we had to agree to the medications to calm her down and since those medications have started she is way more out of it. We were between a rock and a hard spot. They (Administration) talked about sending her to [NAME]ingham if we didn't get the medications and her behaviors under control. It was like they had us over a barrel. No one wants her to go to [NAME]ingham so far away. The doctor called me and they were trying to give her meds not even approved for dementia. He said they are not approved but places do it all the time. She was on [MEDICATION NAME] while living at home a very low dose. It did help her. She absolutely needs it so she doesn't think people are breaking into her house or following her. I am not sure she needs to be on such a high dose. She was on a really really low dose and once she was on it she did not think people were following her. She used to get [MEDICATION NAME] 0.5 MG once in the evening. We picked her up for Christmas and she was out of it the whole time. She couldn't walk and slept the whole time. She didn't have the strength to even feed herself. She is gorked out it. It's like night and day from last year. I am afraid if you look into the [MEDICATION NAME] they will make her go to a facility far away because she will be calling out more. the daughter voiced a concern with the amount of [MEDICATION NAME] her mother was on. They (facility) tell us she yells. I am not sure why they do not understand that she has dementia and she will (yell) until she gets help. She does not remember how to use the call bell. They should know that people with dementia cannot remember 10 minutes ago. They act like she yells on purpose as a behavior .she can't remember she can't retain. She needs help. They do not get dementia there. At 11:45 AM, her daughter stated, She could walk when she first came in. Her son said, She can barely take a sip of Pepsi. Her daughter interjected, Then they wanted her to do PT (Physical Therapy) because she declined it from the [MEDICATION NAME]. She did it at first but she is not receptive to therapy. She is just not going there but with the [MEDICATION NAME] on board, I don't think she can do anything. Maybe they can have her do things in her room. She was also aggressive with staff. One girl got kicked and one girl got scratched. It was a while ago .maybe 8 months ago. I am not sure if that is why they monkeyed with her medication. Review of her care plan directed staff as follows: · Complete an AIMS every 6 months (03/01/18 was the only AIMS located in the medical record); · If . yelling, agitated behaviors try the following interventions in place that are intermittently effective but have not been 100% are staff within her view, having tactile touch with staff (holding on to staff's uniform or hand) , staff sitting and talking to her, being wheeled around facility, listening to music in the activity room, sitting outside for short periods of time, offering food, ensuring toileting needs met, naps to maximize her sleep hygiene, and pet therapy, as well as son visiting with their dogs; · Place pillows on both sides (bilaterally) . She can remove pillows on her own. The pillows help support and comfort her; · Psychologist consult per order; · Staff to offer Interactive Stuffed Puppy to her when she starts to cry out about going home/finding her son and to provide comfort and re-direction during sun downing periods; · Take for a walk in wheelchair around the facility or outside. Likes to smell the [MEDICATION NAME] and [MEDICATION NAME] plants; · Talk to her about her son's dogs with her; · When she becomes agitated; Intervene before agitation escalated; Guide away from source of distress; engage calmly in conversation; · Meds per order; · Assist her to group of potential interest where some outbursts can be more easily tolerated; outdoor gardening programs and small group sensory programs . needs assistance/escort to activity functions; · She prefers activities, which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as simple exercises and ball toss, folding towels, matching and sorting tasks .and prefers the following TV channels; 934 Classic Country, QVC channel. When she chooses not to participate in organized activities, she prefers to fold towels or match baby socks, listen to country music, sit in the hallway and watch others, listen to QVC TV channel for social and sensory stimulation. The only observed care plan interventions during multiple observations all days of survey were wheeling her around the facility and medications. Review of a progress note dated 08/09/18 at 6:01 PM, showed, Review of yelling out behaviors. This has an impact on others on the unit by disrupting living environment .MD gave orders to increase [MEDICATION NAME] from 1 MG BID (two times a day ) to TID (3 times a day) with continued 0.5 mL (0.5 mg) PRN. Review of the progress note dated 08/11/18 at 1:55 PM, Behavior issue .11 am Resident is dozing off. 11:15 resident is now yelling help me help me. Resident toileted after yelling out numerous times I need to piss and poop . placed on toilet and within 3 minutes she is yelling out I need help Help meeeeeeee I'm done. Suggested that she sit a little longer, and was told you're such a b h .you don't know anything. You are so stupid. Resident was assisted off toilet .Continues to verbalize profanity stating, You're such a stupid b , you don't know anything. Taken out to hall to sit near nurse. Began yelling in the dining room I wanna go home I wanna go home. Other resident started yelling, go home, go home. She responded, Shut the f . up. Resident taken back to hall . Review of a progress note dated 08/12/18 at 5:11 PM, showed behavior issue, She continues to disrupt the unit with very loud yelling that can be heard at the ends of each hallway. Residents on the unit are often yelling back at her to be quiet. Slept through breakfast .Afternoon [MEDICATION NAME] given at 1:15 PM with drowsy effect noted approx. (approximately) 2 PM. Review of a physician progress notes [REDACTED].medications: [REDACTED].Continued very problematic behaviors for her own health and safety as well as fell ow residents as well as facility. Review of a physician's progress note dated 08/20/18 at 1:35 PM, showed Exam: somnolent .Assessment: Dementia, [MEDICAL CONDITION] with delusions. The resident does seem to be getting more sleep since initiation of the [MEDICATION NAME] and upwards titration .Plan: Increase to the target of 6 mg . [MEDICATION NAME] tonight, and then continue as long as benefit is perceived. Review of a physician progress notes [REDACTED]. Report over the weekend of significant episodes of calling out, very loud, to the point of becoming distressing to multiple other long-term care residents. On-call RN was building working with her, found that some recent distracting techniques which have proven effective were lately ineffective the last couple of days, such as redirection with music and aromatherapy .She appeared to have numbness and sedation. Today she is asleep and early afternoon redirection techniques seem to be having some beneficial effect. Plan: Will increase her [MEDICATION NAME] to 4 MG TID scheduled and continue to monitor . Review of a progress note dated 08/30/18 at 11:21 PM, showed, Resident sleeping on and off early part of the shift. Started to yell, cursed and calling name to staff taking care of her via 1:1. Kept yelling and hitting her despite helping her to wheeled around area .Very demanding and telling sitter to you should be staying here with me all the time that's what you're supposed to do. Review of a progress note on 09/01/18 at 2:49 PM, She was dozing more than usual but she does sometimes have days she does do that. However the [MEDICATION NAME] was increased on 8/27/18 and so need to monitor for ADR . At 11:39 PM, a progress note showed, Still yelling and screaming when awake despite having sitter. Review of a physician's progress noted dated 09/12/18 at 12:36 PM, showed, [MEDICATION NAME] 4 MG TID scheduled .dementia with agitation and delusions: overall behaviors have been less frequent, although not completely eliminated. Concern regarding decreasing blood sugars and decreasing weight concomitant with last increase in [MEDICATION NAME] that she is over sedated to the extent that her caloric intake is decreased. Review of a progress note dated 09/15/18 at 2:05 PM, After dinner resident was drowsy but responding when prompted. Went to bed early without any yelling. Review of a progress note on 10/05/18 at 2:44 PM, showed, Sleeping soundly all AM-allowed this restful sleep until nearly noon at which time we did purposefully awaken her to prevent noc (night) time awakefullness. She continued to be sleepy but arousable to voice. Tried to get her more fully awake with talking and touch with no success. Did not give any medications including neither dose of routine [MEDICATION NAME] this shift. Review of a progress note dated 10/08/18 at 9:41 PM, showed, Resident was yelling most of the time especially when sitter was out of the site and once she sees staff sitting close to her she will be ok. Interventions like talking and wheeling her around helps . Review of a progress note dated 10/13/18 at 5:50 AM, showed, Resident did not rest on noc (night) shift. Resident would yell, Someone come sit with me over and over. Staff would go into her room to see what resident needed and resident would say nothing then yell out again as soon as staff left her room .Resident calmed after staff helped her to w/c (wheelchair) and resident sat at nurses station with this LN but as soon as I had to leave the desk for even a min. resident started to yell out again. Review of a progress note dated 10/17/18 at 3:52 PM, showed Demanding, calling out, difficult to distract. In a quarterly review progress note dated 11/02/18 at 11:51 AM, [MEDICATION NAME] to help with behaviors as well. The dose of medication has been changed several times to attempt to get to a therapeutic level .continues with daily behaviors. Review of the resident's weight history showed a significant weight loss of 11.7% or 19.8 pounds on 11/08/18 compared to her 06/05/18 weight of 168.6 pounds. Review of a progress note dated 12/02/18 at 9:42 PM, showed, Taking [MEDICATION NAME] for difficult behavior and agitation. Easily redirected and needed staff around the area to calm her down. Review of the 01/02/19 monthly summary showed,She is disoriented and expresses herself by yelling and constantly expressing she needs help. She uses [MEDICATION NAME] though out the day. Periodically she needs her [MEDICATION NAME] held due to her sedated state. On multiple observations all days of survey, Resident #6 was observed with her eyes closed. Inability to open your eyes is a known adverse side effect of [MEDICATION NAME]. She was observed with her eyes open on only three observations (02/05/19 at 9:03 AM, 02/15/19 at 9:33 AM and 12:40 PM) all days of survey. In a co-interview on 02/05/19 at 12:50 PM, The Administrator and Director of Nursing were informed of the concern the [MEDICATION NAME] was being used as a chemical restraint for Resident #6. They were informed of the lack of observed interventions and activities for her as well as the excessive dose with multiple nursing staff entries of somnolence, sleeping all day and staff waking her up. Further, there were no delusions or hallucinations, only calling out, an inappropriate indication for [MEDICATION NAME]. The DNS confirmed the [MEDICATION NAME] was a high dose. In a co-interview on 02/05/19 at 2:57 PM, Staff HH, Medical Director/ Resident #6's Physician and the Administrator. Staff HH said the resident's daughter was resistant to allowing other medications with less known side effects. He said she was only agreeable to medications FDA approved for dementia and [MEDICATION NAME] was approved for dementia. He said, I have had concerns she is over sedated .then the next day she would be alert. I would have liked to try Quetiapine but the daughter would not allow it. We all wish here (the facility) was a better-staffed facility for her. I realize she is not on the most optimal agent. The physician was asked about the frequent increases in the dosage. He stated, You can go up 100's of milligrams . I sure wish Geropsych would come in here and tell me what to prescribe. On 02/05/19 at 3:20 PM, The Field Manager received an email with an attached assessment completed by Behavioral Health Quality Improvement Consultant (BHQIC) with Residential Care Services (RCS) on 09/11/18 . The BHQIC had just received a phone call from the Administrator requesting another copy of the assessment completed on 09/11/18. The assessment had been provided to the facility on [DATE] and a digital copy was emailed to the facility on [DATE]. The assessment by RCS but was not in Resident # 6's medical record or care plan and only requested it after chemical restraint concerns were voiced to the Administrator at 2:57 PM. The report detailed suggestions to assist the facility in caring for Resident # 6 and contained medication monitoring, learning more about her mental health, considering visions as a issue, tracking behavior and sleep patterns, ideas for redirection. The assessment included contact information and resources for additional mental health services, volunteers, library services as well as videos links to educate staff on how to deal with frustration. Further, associated WAC's and Federal Regulations including chemical restraints were detailed in the assessment. In a follow up interview with Staff HH on 02/05/19 at 4:36 PM, he said he had just contacted the county designated mental health professional about solutions for her and could not assess her as a danger to others. When asked if she could be experiencing pain that she was unable to verbalize, he stated, I haven't really assessed her to be in pain but we can look at that. He said he had also just had a phone conversation with the daughter and she was concerned with the [MEDICATION NAME] dose. She said her mother had slept all through Christmas. He commented that staff were more focused on her before and she does better with someone by her. I know once I ramped up the [MEDICATION NAME] dose she is snowed (motioned air quotes) .well they (staff) get a three day break from her so they think of that as a positive treatment for [REDACTED]. I wonder if she would do better at a dementia unit where they are trained to deal with these behaviors. I will try to talk to (the administrator) into one on ones. I know it isn't perfect. She will still call out but maybe it will help. In an interview on 02/07/19 at 7:08 AM, Staff N, LPN, stated, She calls out a lot and there is nothing that consoles her. We all try. I am not sure how much she sleeps. Review of a palliative care consult on 02/07/19 from Staff DDD, ARNP recommended Staff HH, reinitiate a anti-depressant , begin a slow dose reduction of [MEDICATION NAME], possible introduce an atypical antipsychotic, Quietiapine with least amount of EPS (uncontrolled involuntary movements), increase Tylenol to three times a day dosing with known [MEDICAL CONDITION]. Staff DDD noted on exam she did exhibit pain behaviors with ROM (range of motion) to extremities .Worth trying this for increase comfort to see if this adds to decrease distress. In an interview on 02/08/19 at 9:38 am, Staff O, RN stated, She has these days when she sleeps and sleeps and then like last week she is calling out. That is how her pattern has been for the past two months. She will sleep for days then if you hold her [MEDICATION NAME] she hollers out. Last weekend she really had other residents worked up. I had to call her doctor and get a 2 MG (as needed) [MEDICATION NAME] dose. In an interview on 02/13/19 at 11:07 AM, Staff G, Staff Development Coordinator was asked about Resident #6 and [MEDICAL CONDITION] monitoring. She said AIMS was to be assessed on admission if the resident was an anti-psychotic, quarterly and as needed. She confirmed AIMS was not completed as indicated and there was no sleep monitor set up or monitoring of orthostatic blood pressures. She stated, Her behavior is greatly improved on the [MEDICATION NAME]. She used to yell so much you couldn't even get her to eat. It must be frightening to her. She needs to be calmed down to have a normal life. In an interview on 02/13/19 at 2:34 PM, Staff W, RCM, said, AIMS is to be done on admit if they are on a antipsychotic and then quarterly. If there are any changes then we would notify the doctor. We are not monitoring orthostatics. In a joint interview on 02/14/19 at 11:02 AM, the restorative aides were asked about Resident 6. Staff T, NAC stated, She sleeps too much. Staff S, NAC said, She is so out of it sometimes it would not be safe to do her program. Review of the (MONTH) (YEAR) through (MONTH) 2019 MAR's revealed only four of 318 routine doses of the [MEDICATION NAME] were not administered despite reports of resident sleeping for days. Review of the behavior monitors from (MONTH) (YEAR) through (MONTH) 2019 showed six of 318 shifts with delusions documented. There were multiple behavior monitoring omissions as well. A sleep monitor was initiated on 02/14/19 after brought to the facility's attention staff were documenting to too little/too much sleep which was not an effective monitor to ascertain if the resident was experiencing [MEDICAL CONDITION] or sedation. Review of the medical record showed no documentation that medications with less side effects were attempted. Gradual dose reductions were not attempted per regulatory guidelines. The medication continued to be administered despite sedation. There was no appropriate indication for the [MEDICATION NAME] or [MEDICATION NAME]. No additional information was provided. Reference: (WAC) 388-97-0620 (1)(a)

Based on observation, interview and record review the facility failed to provide the necessary care and services related to restorative nursing programs to ensure residents achieved and/or maintained their optimal functional level for four of five residents (#2, #6, #18 and #24) reviewed for positioning, mobility and range of motion which caused harm for Resident #6 and #18 and placed all other residents at risk for complications of immobility, functional decline and a decline in condition. Findings included . Review of the facility's policy titled, Guide to Successful Restorative Programs, dated (YEAR), stated the purpose was to promote the resident's ability to adapt and adjust to living as independently and safely as possible. A Restorative program is initiated when the resident is admitted to the facility with restorative needs but is not a candidate for formalized speech-language, occupational, and or physical rehabilitation therapies, when restorative needs arise during the course of a long-term stay, and/or when a resident is discharged from formalized physical, occupational , or speech therapy. According to the Resident Assessment Instrument Manual (provides guidance for completion of the Minimum Data Set - MDS), the following criteria must be met for Restorative Nursing Programs: - The program must have measurable objective goals and interventions must be documented in the care plan and in the medical record; - There needs to be evidence of periodic evaluation by the licensed nurse and must be present in the resident's medical record; - Nursing Assistants (NAs) must be trained in the techniques that promoted resident involvement in the activity; and - A Registered Nurse (RN) or a Licensed Practical Nurse (LPN) must supervise the activities in a restorative nursing program. RESIDENT # 6 Resident # 6 admitted on [DATE] with dementia with behavioral disturbance and history of a stroke. She required on person assistance with her activities of daily living (ADL's) and only set up for eating. According to her quarterly Minimum Data Set (MDS) assessment dated [DATE], she did not receive skilled therapy nor restorative services and she had no refusals of care. She was assessed to have a decline in her ability to transfer, locomotion on and off the unit, dressing, eating and personal hygiene since admission. Review of the care area assessment dated [DATE] showed, Needs help for the completion of her ADL's. She needs assist with dressing, hygiene and grooming, transfers and bed mobility. Having poor vision does not help her either. She is able to feed herself with supervision. With her dementia, it is difficult for her to initiate her ADL's as functional decline as is proportionate to cognitive decline. In an interview on 01/29/19 at 11:34 AM, The residents daughter stated, She has definitely declined. They have her on a lot of medications and she is sedated. She continue to state, They never have gotten her a wheelchair to make her more comfortable. When we come over to see her, she is slumped over. It isn't just her though, there are a lot of other residents that look like that too. She sits with her back straight up too. Review of Resident #6's care plan directed staff to assist the resident with a daily walking program and also included a transfer program. Review of the Restorative Administration Record for the months of October, November, (MONTH) (2018) and (MONTH) and (MONTH) (2019), showed the resident participated six times in October, seven times in November, twenty one times in December, twelve times in (MONTH) and 2 times in (MONTH) (through 02/12/19) in the RNP (Restorative Nursing Program). Review of a therapy restorative referral dated 09/21/18, showed reason for referral Functional decline and included goals to maintain and improve her ambulation ability/distance and her transfer ability. The approaches were to ambulate 30 feet times 2 with FWW (front wheeled walker) or to tolerance. Assist required to steer the FWW and sit to stand times 5 with cues for technique in the room three times per week. Review of a restorative assessment dated [DATE], showed functional decline The assessment showed, ROM (range of motion) not tried, bed mobility not tried, bed to chair transfers not tried. This was not a thorough assessment, as assessor circled not tried on ROM, bed mobility and bed to chair transfers. Review of the care area assessment dated [DATE], showed 1-2 (person) extensive assist for transferring, toileting and bed mobility. She is able to bear weight at times but is unsteady. Often she does not attempt to do so and requires more assistance. In an joint interview on 01/29/19 at 11:45 AM, Resident #6's daughter stated, She could walk when she first came in. Then they wanted her to do PT (physical therapy) because she declined from the [MEDICATION NAME]. She did at first but she is not receptive to therapy. She is just not going there. But with the [MEDICATION NAME] on board I don't think she can do anything. Maybe they can have her do things in her room. The resident's son interjected, She can barely take a sip of Pepsi. Resident #6 was observed in a standard sling type wheelchair leaning to her left on multiple observations all days of survey. There was only one observation of her positioned with pillows in her wheelchair. She was not observed to walk at any time. She was not observed receiving restorative services. Review of a palliative care consultation from Staff DDD, ARNP on 02/07/19 showed, Patient does drift to the left in sitting both in wheelchair and recliner; patient with stiffness when examined, denies pain though presents with upper extremity stiffness and grimacing with movement on exam .Patient has had a functional decline over the last several weeks, less able to pivot and transfer, follow directions. Are using sit to stand (mechanical lift device) because of fluctuating awareness and participation and difficult with cueing. Patient does spend most of her time in the wheelchair and or her recliner. In an interview on 02/08/19 at 8:20 AM, Staff S, NAC/RA (Nursing Assistant Certified/ Restorative Aide), stated, Yes, she can ambulate with a FWW (front wheeled walker) about 15 feet. I try to get to her five to seven times a week. We used to have three restorative aides. We try to coordinate who has been seen and not seen. We have 23 people (residents) on RA but not all are seen daily. She (Resident #6) does refuse once in a while and we re-approach. It is easier for her to walk in non- skid socks instead of slippers and she does better. She doesn't have contractures she just needs extensive assist to boost up. In an interview on 02/08/19 at 9:39 AM, the Director of Nursing Services confirmed she had a recent decline in transfers, ambulation, dressing, eating and grooming and was not receiving restorative services as care planned. In an observation and interview on 02/12/19 at 11:08 AM, Resident #6 was sitting in her wheelchair leaning to her left repeatedly stating, Can somebody help me? My side hurts. Staff CC, LPN (Licensed Practical Nurse)was asked about her positioning and if she had ever had a wheelchair evaluation. Staff CC stated, Not that I heard . she hasn't always leaned. I can ask the doctor to see if we can get a wheelchair eval. Staff CC then went to the resident's room and got bed pillows which she tuck to between the left side the resident and the side of the wheelchair. In an interview on 02/12/19 at 2:41 PM, Staff C, PT (Physical Therapy), was asked about the resident's observed poor positioning in the standard sling back wheelchair. Staff C stated, I have not done a wheelchair eval on her and there is not one in her record. I did talk to (Staff CC) earlier and she is getting an order for [REDACTED].>In a joint interview on 02/14/19 at 11:02 AM, Staff T, NAC/RA, was asked about Resident #6's RA program. She stated, It is supposed to be done daily. She does refuse sometimes and she sleeps too much. Staff S, NAC/RA interjected, She is so out of it sometimes it would not be safe to do her program. RESIDENT #18 Resident #18 admitted on [DATE] with [MEDICAL CONDITION] and a tremor with increasing level of assistance needed at home, multiple falls and increased burden of care. On admission, the resident required one person assistance to complete his Activities of Daily Living (ADL). Review of the physical therapy note dated 05/04/18 showed, Required min a (minimal assist, 10% hands on assist required) and hands on assist for transfers and gait. He ambulated 10 feet with a walker. Review of a restorative program note dated 05/23/18, showed, He used to be an athlete .agreeable and somewhat motivated to participate in RNP (restorative nursing program)/FMP (functional maintenance program). Will place on RNP/FMP for transfers and amb(ambulate) to promote and maintain current functional ability. According to the 11/09/18 quarterly MDS, Resident #18 had declined in transfers, ambulation, dressing, eating, toilet use, personal hygiene and bathing. He was not on skilled therapy, restorative services and had not rejected care. Review of the clinical record showed the resident received Physical Therapy from 05/03/18 to 05/28/18. Review of the care plan titled high fall risk due to decreased mobility, poor memory and insight regarding functional status did not include any intervention or approached to maintain the resident's ability to complete ADL's. Review of the resident's progress notes showed he had over 40 falls from 05/04/18 to 02/12/19. He was not referred to physical or occupational therapy to improve his functional mobility or to decrease additional falls. In an interview on 02/08/19 at 8:20 AM, Staff S, NAC/RA, stated, I do not have him on my list. I have been doing this over a year. In an interview on 02/08/19 at 9:47 AM, the Director of Nursing Services confirmed Resident #18 had a decline and was not on therapy or restorative services. She stated, I looked in the RA book and there is nothing. I talked to (Staff C) in therapy and he thinks he was seen at one time. We are sending (Staff XX) to restorative training in the next month. I know that does not help for him (Resident #18). After notifying the facility of the lack of therapy or restorative program for Resident #18, a progress note titled, Restorative Nursing Review dated 02/13/19, showed the resident had no RNP program currently. The RA program was dc'd (discontinued) in (MONTH) due to increasingly difficult to transfer due to posterior lean, cognitive status of [MEDICAL CONDITION] unable to follow direction and decreased safety awareness .He has very unsteady gait. Unable to assess ambulation at this time as resident in bed and unwilling to walk. In an interview on 02/14/19 at 11:04 AM, Staff T, NAC/RA stated that the resident was not receiving any restorative services. The resident was observed in bed or in his wheelchair during multiple observations all days of survey. He was not observed to ambulate. Review of the Restorative Administration Record for the months of October, November, (MONTH) (2018) and (MONTH) and (MONTH) (2019), showed the resident participated twenty one times in October, nine times in November, fifteen times in December, thirteen times in (MONTH) and 7 times in (MONTH) through 02/12/19 in the RNP. In an interview on 02/08/19 at 8:25 AM, Staff S, NAC/ RA was asked about Resident #18's daily restorative program. She said that there was currently only her and another restorative aide. She stated, (Staff T) does him. In an interview on 02/14/19 at 11:04 AM, Staff T was asked about Resident #2's restorative program. She stated that he was seen by her on Mondays and Fridays. She continued to state that he doesn't refuse, as he likes his exercise. The facility failed to provide services to maintain the resident's status and resulted in a decline to his ability to assist with his activities of daily living and frequent falls. RESIDENT #2 Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. According to his quarterly MDS assessment dated [DATE] showed the resident received active and passive range of motion on four days in the look back period. He had no refusals of care. During an interview on 02/14/19 at 12:50 PM, Resident # 2 was asked how many times a week he received his restorative program. He said, Only get once or twice. Not enough. Review of Resident #2's care plan directed staff to perform daily ROM exercises, both active and passive as tolerated to his left and right upper and lower extremities then apply a right wrist splint for six hours and then remove. RESIDENT #24 Resident #24 admitted on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly MDS assessment dated [DATE] showed, she received active range of motion on two days in the look back period. She had no refusals of care. Review of Resident #24's care plan directed staff to assist her with active ROM exercises using the Nustep for 15 minutes and work on transfer training at the parallel bars three times a week. During an interview on 01/30/19 at 11:27 AM, Resident #24 stated, They want me to go to the gym and exercise .use the bike but I don't so I don't walk. Review of the restorative program evaluation dated 01/30/19 showed, Assessed and program remains appropriate. (MONTH) decline without restorative due to dementia. Interview of res(resident) she enjoys the program. Review of the Restorative Administration Record for the months of October, November, (MONTH) (2018) and (MONTH) and (MONTH) (2019), showed the resident participated 11 times in October, nine times in November, seven times in December, six times in (MONTH) and 1 time in (MONTH) through 02/12/19 in the RNP. Resident #24 did not receive restorative services as care planned. In an interview on 02/08/18 at 9:47 AM, the DNS was informed of the concerns of restorative programs not being completed as care planned for residents #2, #6, #18 and #24. She acknowledged the missed restorative care and lack of periodic assessments of the programs. She stated that Staff XX was in the process of evaluating every resident for a possible program. No additional information was provided. Reference: (WAC) 388-97-1060 (3)(d)

Based on observation, interview, record review the facility failed to provide adequate pain control for one of four sampled residents (#15) reviewed for pain management. This failed practiced caused harm related to undue severe pain daily for Resident #15. Findings included . Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 Day PPS (Prospective Payment System) Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact and had a frequent pain rated at an eight (on a zero to 10 pain scale), which made it hard to sleep at night. Review of the resident's care plan showed the resident had a problem of chronic pain related to her [MEDICAL CONDITIONS] arthritis and neuropathies (a result of damage to the nerves in the hands/feet which caused numbness and pain). The resident's goal was to have minimal pain daily. The interventions included the resident's ability to state her pain verbally and to obtain prescriptions to increase or decrease [MEDICATION NAME] doses when indicated based on the resident's pain severity. Review of the physician orders [REDACTED]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED] · The resident was assessed to have had severe pain at 8:00 AM on 17 days; · Received as needed [MEDICATION NAME] four times for severe pain; · Received as needed [MEDICATION NAME] 30 times for severe pain; · Started routine [MEDICATION NAME] on 01/07/19 at 10:00 AM and 10:00 PM with assessed serve pain on 37 times; · Had pain assessed three times daily with severe pain on 62 out of 93 times; and · The resident did not use the as needed Solanpas patch. Review of the (MONTH) 1st through 13th MAR indicated [REDACTED] · The resident was assessed to have had severe pain at 8:00 AM on eight days; · Received prn [MEDICATION NAME] for severe pain 20 times; · Received routine [MEDICATION NAME] at 10:00 AM and 10:00 PM, for assessed severe pain 19 times; · Had a pain assessed three times daily with severe pain on 27 out of 40 times; and · Received no as needed [MEDICATION NAME] or the Salonpas patch. During an interview on 01/29/19 at 11:26 AM, the resident stated, Right now my lower back is killing me, I have arthritis I am never really comfortable. The resident was observed sitting up on the edge of the bed then laid back across the bed sideways. During an interview on 02/01/19 at 10:18 AM, the resident stated she felt listless and achy to all her joints and back. The resident stated she did not sleep well last night due to being achy throughout the night. During an interview on 02/06/19 at 2:44 PM, the resident stated she was aching all over, weak, nervous and could not rest. In an observation and interview on 02/08/19 at 8:44 AM, Resident #15 was sitting up on the edge of the bed and bent over to her knees. The resident stated she was having a hard morning. My hands hurt, my back hurts at a seven to eight (pain scale of zero to ten). Mostly I wake up like this every morning. On 02/11/19 at 9:44 AM, the resident stated feeling better than before, My pain was at an eight to nine, now at a seven to eight and feeling shaky inside. In an observation and interview on 02/12/19 at 9:13 AM, the resident was observed sitting on the edge of the bed with her head down resting on the bedside table. The resident was asked how she felt and she replied, Don't ask, bad. At 9:48 AM, the resident continued to sit on the edge of bed leaning over with her head resting on the bedside table. At 9:55 AM, Staff X, Registered Nurse (RN), stated the resident had [MEDICAL CONDITION] and she had been getting infusions that were stopped in December. Staff X stated the resident's pain had increased which had been going on for a couple of weeks and the pain had become intolerable. Staff X stated that once Resident #15 received two as needed pain medications, her pain would become tolerable. At 10:43 AM, the resident was lying sideways on the bed with her eyes closed. At 11:00 AM, Staff HH, Medical Director, stated the resident had been receiving remicade treatments and was not in the loop as to why the treatments had been stopped. Staff HH stated that when the resident would take her medication, it was effective to treat her pain. Staff HH stated that it was his perception the resident did not like to take medications so much. During an interview on 02/13/19 at 8:42 AM, the resident stated that her pain was at an eight. The resident identified her pain was in her shoulders, arms, hands and in all of her joints. At 9:43 AM, Staff CC, Licensed Practical Nurse, (LPN), stated the process when a resident had pain daily between a seven to a ten daily for three to four days would be to inform the physician, request a routine pain medication and utilize all treatment options. At 3:34 PM, Staff BB, RN, stated her expectations for residents with severe pain would be to follow up with the physician. Staff BB stated the facility did not have a formal pain assessment but interviewed residents for pain when their MDS assessment was done (which was upon admission, quarterly and with a change of assessment). Review of the medical record showed no evidence the physician was notified regarding the resident had experienced consistent severe pain. The facility failed to adequately assess the resident's pain utilizing a resident specific assessment. Additionally, the facility failed to timely notify the physician of the resident's frequent daily severe pain thus failed to manage the resident's pain which caused the resident undue severe pain. This is a repeat citation from survey dated 01/17/18. Reference: (WAC) 388-97-1060(1)

Based on observation, interview and record review the facility failed to ensure necessary care and services were provided to prevent the occurrences of avoidable pressure ulcers for 3 of 4 residents (22, 37 and 118) reviewed for pressure ulcers. These failures caused harm to Resident 22 by the formation of 5 pressure ulcers, 3 of which were stage II, to Resident 37 by the development of an infection and un-stageable deep tissue injury and 118 by not providing care and treatment of [REDACTED]. Findings Included: Review of the facility's undated policy titled, Skin Assessment Policy and Procedures revealed: · Nurses will perform weekly skin assessments on all residents and document their findings in the progress notes as part of the weekly summary; · All pressure related skin conditions will be documented on the pressure wound weekly assessment sheets at the time of discovery and kept in the wound book; · All pressure related skin conditions will be measured weekly and treatment orders will be evaluated for effectiveness and documented on the pressure wound weekly assessment sheets; · MD (medical doctor, power of attorney, nurses manager and Director of Nursing (DNS) to be notified of all new pressure areas; · Care plans will be updated to include goals and interventions for wound healing. The Resident Assessment Instrument (RAI) Manual defined the stage of a pressure ulcer (PU) as followed: · Stage I is intact skin with non-blanchable redness of a localized area; · Stage II PU is a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. This may also present as an intact or open/ruptured blister; · An unstageable PU is full thickness skin and tissue loss is obscured by slough or eschar; · Deep Tissue Injury (DTI) is described as intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discolorations. RESIDENT 22 Resident 22 admitted to the facility under hospice services on 10/23/17 with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], showed: · Resident 22 was not admitted with pressure ulcers (PU); · The resident required extensive assistance of two people for bed mobility, toilet use and transfers; · Had an indwelling catheter · He sometimes was able to respond to simple, direct communication. Review of the PU Care Area Assessment (CAA) summary, dated 11/03/17 revealed Resident 22 was at risk for the development of a pressure ulcer due to decreased mobility and incontinence of bowel. The CAA further documented that he was repositioned for comfort and currently his heels and buttocks are intact. Review of the admission nursing assessment dated [DATE] documented a 0.5 by 0.5 centimeter (cm) red area to the right outer ankle and a 4 cm by 5 cm grayish discoloration' on the right inner ankle. A Braden Scale assessment (an assessment for predicting pressure sore risk), dated 10/23/17 was completed but did not identify Resident 22's assessed risk level. Review of the care plan revealed a potential for skin integrity impairment (not an actual skin impairment problem) due to risk factors of decreased mobility and incontinence with a goal of skin will be intact x 90 days and interventions to include: · Float heels by elevating legs on pillows- check pillows frequently to be sure heels remain floating; · Reposition every 2-3 hours and as needed. Review of the care plan for nursing assistants (NA) revealed the NA was to apply wool heel protectors in bed only without socks. Review of the only pressure wound weekly assessment dated [DATE] revealed Resident 22 had an in house acquired, Stage I pressure ulcer on his right lower extremity and Hospice was following wounds and providing routine wound care, refer to Hospice notes in chart. Review of the nursing progress notes from 10/23/17 through 01/09/18 revealed one weekly summary note (documentation of skin assessments) dated 01/04/18 documenting, R foot has 1 x 1 cm, R big toe 0.5 x 0.3, R lower leg has 1 x 0.5 cm, 1 x 0.5 cm and 1 x 3 cm scabbed and healing slowly, R outer ankle has 1 x 0.5 cm excoriation that are healing. Review of the Hospice progress notes from 10/28/17 through 01/09/18 documented the following: · 11/27/17- new non-blanching pressure area to right lower extremity, applied [MEDICATION NAME] foam dressing will obtain new orders and have faxed · 11/30/17- stage 1 wound dressing to be changed tomorrow · 12/01/17- right lower leg stage 1 intact dressings changed, intact redness, dressings changed to outer aspect of shin, outer ankle and top of right foot, all remain intact without signs and symptoms of infection · 12/07/17- all dressings changed · 12/14/17- all dressings changed · 12/17/17- all dressings (5) changed · 12/17/17- right ankle pressure wound are improving, other pressure areas remain stable · 12/28/17- 3 stage 1's and 2 stage 2's all stable · 01/02/18- right heel [MEDICATION NAME] applied (dressing), right outer shin cleansed and [MEDICATION NAME] with border applied (dressing), [MEDICATION NAME] along lower shin, right great toe wound foam applied and secured with [MEDICATION NAME], right inner ankle malleolus (ankle) wound cleansed and covered with foam · 01/05/18- wounds measured, redressed and stable, and given to facility wound staff representative · 01/09/18- right lower extremity pressure ulcers x 3 (all stage 2) cleaned, covered and barrier film applied and [MEDICATION NAME] dressings applied Review of the December 2017 and January 2018 Treatment Administration Record showed only one treatment order for the resident's wounds, Wound dressings pad apply to right calf topically every 72 hours for wound healing , [MEDICATION NAME] foam dressings changed twice weekly. In multiple observations throughout the day on 01/03/18, 01/04/18, 01/08/18, 01/09/18, and 01/10/18 showed Resident 22's heels were not floated and his right leg was externally rotated. In an interview on 01/08/18 at 10:05 AM, Staff M, Licensed Practical Nurse (LPN) stated Resident 22 had three pressure sores. She further stated skin checks are done during showers; documentation and progression of the wounds are located in the hospice notes. In an interview on 01/09/18 at 9:15 AM Staff SS, Hospice Nurse stated he developed the pressure ulcers since admission. Staff SS stated the resident was at risk related to his poor nutrition and his diagnosis. Staff SS further commented that his ulcers are all on his left side because he has paralysis from a stroke. Staff SS continued to say hospice changes the dressings twice a week with the visit and charts accordingly, she stated she gave measurements to Staff A (LPN) the last time she saw the resident. In an observation during a dressing change by the Hospice Nurse on 01/09/18 at 9:15 AM, the resident was noted to have a open wound approximately the size of a quarter with pink tissue to his right medial ankle. He was noted to have a discolored shiny mis-shaped area to his right lateral shin and had a dark colored pea sized spot to his right lateral foot. In an interview on 01/10/18 at 2:00 PM, the Director of Nursing (DNS) stated skin checks are done weekly by the nurses and if a pressure ulcer is identified, the wound would be assessed and measure. The physician would be notified for appropriate treatment, the care plan would be implemented, and a wound sheet would be started. The DNS further stated a weekly assessment would be complete to include measurements and on-going progress. When asked if she was aware of Resident 22's wound she stated she was aware of the heel ulcer. (He currently did not have a heel ulcer). When asked for weekly documentation of Resident 22's wounds, no information was provided. The DNS acknowledged the lack of assessment, on-going evaluation, and care planning involving all of Resident 22's wounds. In an observation on 01/10/18 at 3:22 PM, an overlay pressure mattress was delivered and placed on Resident 22's bed after the surveyor identified a concern, 44 days after a pressure ulcer was identified. The facility failed to assess identifiable risk factors, implement preventative interventions that were consistent with the resident's needs, goals, and professional standards of care all of which caused harm to Resident 22 in the development of multiple pressure ulcers. RESIDENT 37 Resident 37 was admitted to the facility in October 2017 with [DIAGNOSES REDACTED]. Review of the hospital documentation dated 10/18/17, Discharge-Hand Off of Care (discharge summary) showed the resident's coccyx area had intact skin with [DIAGNOSES REDACTED] (superficial reddening of the skin). Review of a Progress Note dated 10/18/17 at 1:18 PM, titled Health Status Note, by former Staff P, Registered Nurse (RN), Resident Care Manager (RCM) documented, Skin-some MASD (Moisture Associated Skin Damage) on buttocks. Asks to be repositioned frequently. Review of a Progress Note titled Admission Summary documented at 6:21 PM, by Staff Q, RN, showed, Skin assessment .has a stage I to buttocks including coccyx, with [DIAGNOSES REDACTED] and maceration at middle site of coccyx, with 1 cm of hard skin, (will inform MD and request an order for [REDACTED]. Review of the Admit Nursing Assessment showed the resident was assessed with [REDACTED]. Review of the paper chart as well as the electronic chart showed no evidence the MD was notified of the skin impairment on the resident's buttocks, coccyx or sacral areas on admission. Additionally, there was no evidence that indicated the facility requested, obtained or implemented an order for [REDACTED]. On 10/21/17 at 8:01 PM, Staff P documented the resident's sacrum wound was worsening . two areas that are deep tissue injury bilaterally . Review of the admission MDS assessment dated [DATE] revealed the resident was assessed to need extensive assist to reposition with the aid of two staff members. Additionally, the resident was documented to have admitted to the facility without a deep tissue injury. Review of the resident's active care plan revealed the facility had initiated a plan on admission identifying the resident had a potential for skin integrity impairment. The facility's interventions included: · Check and change the resident every 2-3 hours and as needed; · Monitor for skin integrity problems during care; · Position for comfort with pillows; · Preventative moisture barrier per orders; and · Reposition every 2-3 hours and as needed. The facility failed to initiate a pressure reducing device while the resident was in in bed, or obtain orders for preventative treatment. Additionally, repositioning the resident every 2-3 hours exceeded the current standard of practice for resident's identified to be at risk of skin impairment. On 10/27/17, the facility added a care plan for the actual pressure ulcer-sacral-DTI, seven days after the sacral ulcer was identified to be a deep tissue injury. The interventions included: · Check and change pad with peri-care every 2-3 hours and as needed, · Pressure reduction intervention in bed with an APP mattress (alternating pressure mattress); and · Pressure reduction interventions in wheelchair with a ROHO (interconnected air cushion). Review of the Nursing Assistant Plan of Care revealed no interventions directing the staff on the need to assist the resident with bed mobility or repositioning. Review of the Occupational Therapy Notes reviewed the resident had a tilt in space wheelchair up until 10/31/17, after which a standard wheelchair with a ROHO cushion was documented as implemented. Review of the resident's clinical record revealed no physician orders to initiate the ROHO wheelchair cushion or the APP mattress. Review of a Skin/Wound Progress Note dated 11/07/17, showed the resident requested to have the APP mattress removed due to affecting the resident's ability to move in bed. The record showed no evidence the resident's mattress was assessed for proper inflation. Review of a Skin/Wound Progress Note dated 11/20/17, showed the resident's, Sacral/right buttock wound worse . (Resident 37) insisted on using a foam eggcrate mattress . faxed MD an update .wound culture?? Referral to wound clinic . (Resident 37 is not up for prolonged periods). Review of an Progress Note dated 11/30/17, revealed Received order for wound clinic wound care for sacral pressure ulcer. Review of a Skin/Wound Progress Note dated 12/04/17 showed, Greenish tinged to the proximal wound - faxed to provider today to request culture test. Review of Progress Notes dated 12/07/17 revealed, Wound culture taken from coccyx . preliminary report showed gram positive rods to site, culture pending. Review of the final wound culture results dated 12/11/17, revealed the wound culture was positive for Staphylococcus Aureus. On 12/14/17 the clinical recorded showed, Received response fax from MD r/t (related to) wound cx (culture) results. MD gave an order for [REDACTED].>Review of the facility's ROHO manufacture information sheet revised on 12/13 revealed an exclamation symbol, NOTE: DO NOT sit on an improperly inflated cushion. Under-inflation and over-inflation of the cushion sections reduce or eliminate the cushion's benefits and could increase risk to the skin and other soft tissue. In an interview on 01/09/18 at 3:22 PM, the resident stated he used to have a wheelchair cushion with little areas of air but the therapist indicated one day the cushion was broke and the air mattress on the bed would go flat as well. In an interview on 01/11/18 at 10:09 AM, Staff R, RN/RCM stated, To my knowledge a ROHO cushion should be used when a resident has breakdown . we should be obtaining orders and discussing with the physician. We have pumps on east wing, but not aware of a process for proper inflation or to check the cushion's inflation. In a follow up interview at 12:40 PM, Staff R confirmed the resident did not have orders for the use of the care planned ROHO cushion or the APP mattress. When asked why the devices were still care planned and not in use, Staff R stated that is a good question. Staff R confirmed the lack of evidence the resident received treatment initially for the identified Stage I ulcer on admission until the wound deteriorated to an unstageable deep tissue injury. In an interview on 01/12/18 at 11:53 PM, Staff S, Physical Therapist stated, the ROHO cushion is a better cushion if there is a current or potential risk of skin breakdown. The nursing staff would get physician orders for the use of the ROHO and the therapy notes should indicate the ROHO cushion was assessed. Staff S confirmed the lack of documentation the cushion had been assessed. The facility failed to inform the physician on admission of the resident's assessed skin impairment, to obtain treatment and to initiate an active care plan with current standards of preventative interventions. The facility failed to obtain physician orders for the use of the APP bed mattress or the ROHO wheelchair cushion along with failure to implement a process of assessing the devices were properly inflated. Additionally the facility failed to update the resident's care plan upon the removal of the devices. The resident developed an unstageable deep tissue injury, suffered an infection to the wound and had a delay in treatment of [REDACTED]. home. RESIDENT 118 Resident 118 admitted to the facility in December 2017 with [DIAGNOSES REDACTED]. Review of the admission MDS assessment revealed Resident 118 required extensive assist of 2 staff for bed mobility, dressing, and toileting. Review of the Care Area Assessment review note dated 01/08/18, revealed the resident was admitted with a pressure ulcer to her right great toe and was at risk for further pressure ulcers due to mobiity deficit, underweight, and, inadequate circulation and urinary incontinence. Review of the admission careplan dated 12/26/17, showed the resident was at high risk to develop pressure ulcers. Approaches included to turn and reposition the resident every 2 hours. Review of the resident's record revealed the resident had one Braden Scale for Predicting Pressure Sore Risk assessment, dated 12/26/17, the date of admission. No further skin risk assessments were completed through 01/17/18. Review of the resident's Point of Care (NA electronic documentation) Turn and Reposition documentation for 01/03/18 through 01/15/18 revealed turning was not consistently done every 2 hours. Daily, there were time gaps of up to 10 hours between documentation of turning. Examples to include: On 01/04/18 the resident was turned at 8:00 PM, the next documentation of turning was at 5:44 AM (almost 10 hours). On 01/13/18, turning documentation was at 5:36 AM and then not again until 12:00 PM (over 6 hours). Not one day during this time interval was the resident documented as being turned every 2 hours. Observations throughout the survey dates revealed the resident had a standard mattress in place until 01/16/18 when a low air loss mattress was placed. During numerous observations on 1/10/18 from 12:43 PM through 3:27 PM, Resident 118 was lying on her back with the head of the bed up approximately 45 degrees with no change in position. Numerous observations on 01/12/18 between 9:39 AM and 2:57 PM, revealed the resident was lying on her back with the head of the bed partially up. No position changes observed. On 01/12/18 at 12:59 PM, the Director of Nursing Services stated residents who cannot reposition independently should be turned every 2 hours. She was informed of Resident 118 being observed greater than 2 hours on her back. On 01/16/18, Staff U, NA stated Resident 118 should be turned every 2 hours. Staff U stated the resident had a new pressure area on her coccyx, so definitely needed to be turned every 2 hours. In an observation and interview on 01/16/18 at 2:00 PM, with Staff M, Charge Nurse, Resident 19 had an angry red area on her coccyx and surrounding area. The tissue appeared swollen, rough and fragile. Staff was able to show the area slowly blanched. Staff M stated the skin concern was related to pressure. She stated the resident was to continue to be turned every 2 hours with the goal of keeping pressure off her coccyx. Reference: (WAC) 387-97-1060 (3)(b)

Based on observation, interview and record review the facility failed to prevent an accident and provide immediate medical treatment for 1 of 4 residents reviewed for accidents (22). This failure resulted in harm of a second degree burn to Resident 22's left hip and had the potential to place other residents at risk for injury and a diminished quality of life. Findings Included: Record review of the facility's undated policy titled Hot Beverage Policy revealed, when a resident is given a hot beverage, the person giving the beverage will place ice or cold water in the beverage to cool the temperature as the resident allows. Lids will be placed on all mugs or cups of hot beverages. Residents will be assisted per their need and desire. Resident 22 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required two person physical assist for care but was independent requiring set up only with eating. The MDS also identified Resident 22 was cognitively impaired. Review of an investigation dated 10/29/17, revealed the resident received a cup of coffee around 5:00 PM from a former staff member and the resident spilled a little on his left hip. The former employee soaked it up right away and then noticed a tiny pinkish spot on his skin. At around 9:00 PM, the former employee assisted the resident to bed and noticed a big red area and informed the nurse approximately 4 hours after the initial spill. Staff G., Licenced Practical Nurse (LPN) assessed the area measuring 11 cm (centimeters) by 4 cm, cleaned the area with normal saline and left the wound open to air. The resident denied pain at the time. The summary concluded the resident had spilled just brewed' coffee which had been served in a cup with a lid. The investigation further stated the resident was able to drink by himself but had some poor coordination at times due to prior [MEDICAL CONDITION]. The plan was for the dietary staff to check the temperatures of coffee to ensure that they are in compliance with temperatures and no change in the way he is offered coffee. A fax was sent to the physician on 10/29/17 around 10:00 PM stating the resident had spilled coffee on his left hip and had redness measuring 11 cm x 4 cm (burnt like) and requested treatment. The fax was received and processed by a nurse on 10/30/17 and a treatment of [REDACTED]. Review of the October 2017 and November 2017 Treatment Administration Records showed treatment for [REDACTED]. In an interview on 01/09/18 at 2:27 PM, the Director of Nursing Services (DNS) stated the treatment to Resident 22's burn should have been started right away but the facility was just switching from paper charting to electronic medical charting and she would look for further documentation. No further information was provided. In an interview on 01/09/18 at 2:27 PM, Staff G, Licensed Practical Nurse (LPN) stated she gave the resident a cup of coffee during the game but he gave it back to her because it was warmso she brewed a new pot of coffee, placed it in the airpot and put it in the hallway. She continued to state she was not sure what time the former employee gave the resident a cup of coffee, but it was sometime during the game. She further stated the former employee did not tell her about the burn until she had assisted Resident 22 to bed and noticed a large red spot to his left hip/thigh area. She stated she faxed the doctor and called the resident's wife. She stated she applied ice to the wound and left it open to air. In an interview on 01/09/18 at 10:38 AM Staff U, Nursing Assistant (NA) stated she would report any change of condition with a resident or any incident to her charge nurse immediately. She further stated that hot liquids are served with a lid on them or with assistance by staff. In an interview on 01/09/18 at 12:33 PM, Staff CC, Dietary Manager, stated coffee was brewed per manufactures recommendations between 155 - 165 degrees and temperatures of the coffee was not taken prior to being served. He stated he had not been informed to take the coffee temperature after Resident 22 was burned. In an interview on 01/09/18 at 12:46 PM, Staff A, Resident Care Manager (RCM) stated there is no formal resident assessment for hot beverages but we are supposed to put ice cubes in hot beverages and serve with a lid. In an observation on 01/09/18 at 2:14 PM, Staff CC took the temperature of hot water from an air pot the facility used to serve coffee. The hot water temperature was 161 degrees Fahrenheit In an interview on 01/10/18 at 3:28 PM, Staff G stated Resident 22 had blisters to his left hip/thigh area when she worked with him three days later. Review of the user guide and additional information from Farmers Brothers showed coffee is brewed by Café Series Airpot/ Thermal Decanter Pourover Coffee Brewing System showed: Temperature in the hot holding tank = 175 degrees Fahrenheit (F); · Temperature in airpot after brewing should be between 155-165 degrees F; · Thermostat cannot be set below 165 degree F, will not turn on. In an observation on 01/10/18 at 12:37, PM Staff QQ, NA delivered a lidded cup of hot tea without ice placed, to a resident in room [ROOM NUMBER]. An observation at 12:41 PM Staff RR, NA delivered a cup of hot cocoa to a resident in room [ROOM NUMBER] with the lid on. The resident then requested ice and Staff RR placed a glass of ice on her bedside table. In an observation and interview on 01/09/18 at 9:15 AM, Staff SS, (Hospice Nurse) removed a dressing from the resident's left thigh/hip area and noted a large reddish/ purple closed area with noted scant grayish drainage on the dressing. Staff SS stated the resident had a second degree burn to the left hip/thigh area, that had looked awful, and the wound got infected. She further stated it was a large blister and it was quite painful for the resident. Review of a physician's progress note dated 11/07/17 documented, fairly large second-degree burn to left thigh that has developed some purulent drainage and he is now on Bactrim (an antibiotic). In an interview on 01/09/18 at 1:47 PM, the Director of Nursing Services (DNS) stated she expected the staff to put ice in all hot beverages and serve them covered with a lid. She further stated if a resident was burned her expectation was for the staff to assess the burn immediately, fill out an incident report and call the physician and family as soon as possible. She stated she did not look at Resident 22's incident report regarding the burn and she is now responsible for incidents reports. In summary, the facility failed to ensure the residents were safely served hot beverages, failed to report, assess and seek medical treatment for [REDACTED]. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review the facility failed to provide necessary care and services to support a resident who had a potentially a life threatening lab result, hold medications necessary to lower the critical lab value, immediately consult with the correct physician, timely follow orders or to relieve the resident's pain. The abnormal lab had a potential to result in symptoms causing a fall with a subsequent fracture, and placed the resident at risk for adverse cardiac arrhythmias, compromised treatment plan, other complications including death and resulted harm to the resident who experienced pain after a fall. Findings include: RESIDENT 1 Resident 1 was a long term resident with [DIAGNOSES REDACTED]. She required close monitoring of her labs for recurrent high potassium levels. Review of her clinical record on 09/01/17 included an order from the Nephrologist (doctor specializing in kidneys) to check BMP (basic metabolic panel lab) on 09/05/17. Review of the progress note dated 09/06/17 at 9:46 PM, indicated the lab had been drawn and sent off. The laboratory called Staff A and reported a critical lab result (Potassium 6.0) Staff A, a Registered Nurse at 11:06 PM. The critical lab result was faxed to Nephrologist even though the office was closed on 09/07/17 at 3:02 AM, almost 4 hours later. Per a statement received on 10/19/17 the nurse had notified the wrong physician, the primary care physician, of the critical lab even though the Nephrologist was the physician who ordered the blood draw and was addressing her lab results. There was no telephone order or progress note ascertaining this. Review of the residents Medication Administration Record [REDACTED]. Review of the clinical record showed, the resident was not placed on alert charting status for close monitoring of cardiac irregularities, weakness, paralysis or nausea from the critical lab value. There was no evidence the fell ow nurses caring for Resident 1 were aware of the high potassium. Review of the clinical record revealed a faxed letter from the Nephrologist dated 09/12/17 at 08:07 AM, Attention Nursing Director of the Careage SNF. I am concerned about a missed opportunity of patient care improvement. I made change on this patient's medications and ordered the BMP test for 09/06/17. The result showed a potassium level of 6.0, as I discovered this on 9/11 when I had staff contact the lab. Your staff never notified me the result, and still has not responded to my inquiry about this sent on last Friday (3 days prior). This situation could create a care challenge for the primary care physician and his team, because they may not have all the background information to take the best possible intervention. This patient is now facing the possibility of recurrent [MEDICAL CONDITION] again .Now please fax me the following info immediately; the patient's current med list and her next scheduled lab draw. At 3:04 PM, the Nephrologist faxed over new medication and lab orders and requested Resident 1 be seen in his office in early October. In review of progress note dated 09/15/17 at 6:55 PM, resident was on the floor on her bottom and slightly to the right. Stated she got some paper to sort out, as she turned back to sit down she felt dizzy and fell on her bottom .c/o (complaint of) pain with tough to left lateral thigh, c/o burning to her right inner groin .MD was notified via fax. A progress note dated 2 days after the fall on 09/17/17 at 12:58 PM, included Resident still having some pain impacting her mobility of her right hip/thigh-assessed leg-able to flex in supine position only with effort and discomfort. PROM (Passive Range of Motion) had some discomfort but able to do. The pain with movement is lateral/posterior mid-thigh and medial mid-thigh .She is ambulating with some antalgia (indication of pain while weight bearing) walking to and from the bathroom with assist. Though there is low suspicion for fracture, do feel prudent to check. Resident does not want to go to the hospital for it-she wants to wait for when the portable x-ray can come in .Primary Care Physician was called and agreed to a portable x-ray at 1:15 PM. The Schryver Medical imaging report showed the right hip x-ray was not obtained until 09/18/17 at 3:35 PM (over 24 hours after the order was received). The results revealed no fracture or other bony pathology. On 09/21/17 at 10:28 AM, staff faxed the primary care physician Resident has been requiring extensive assist /max (maximum) with bed mobility and transfers. She also has had recent multiple falls. Recommend evaluate for treatment and for use of wheelchair related to pain after fall and weakness. The Primary Care Physician did not respond to the fax until 09/26/17 at 6:44 PM, 5 days after the request for therapies. On 09/26/17 at 7:01 PM, Staff A, Registered Nurse faxed the Covering Physician requesting follow up x-rays to find out the reason for her pain and discomfort. The Covering Physician responded 2 days later on 09/28/17 May repeat right hip x-ray. In a progress note dated 10/01/17 at 9:24 PM, Resident c/o pain to right hip. Stated she felt therapy was making pain worse and standing too long made pain unbearable.X-Ray to be done this week. There was no physician notification of this. Resident 1 did not receive the follow up x-ray until 10/02/17 at 3:17 PM, 4 days after the MD ordered it and 6 days after the initial request. The referral was faxed to the hospital on [DATE] at 12:22 PM. The imaging results revealed minimally displaced fractures throughout the right inferior pubic ramus. The results were called to the Primary Care Physician at 3:35 PM from the medical center. Further, on 10/03/17 then nurse requested the Nephrologist increase her as needed pain medication to be scheduled routinely. The Nephrologist did not send an order until 10/08/17. Additionally, the facility nursing staff did not process the order until 2 days later on 10/10/17. There was no documentation of attempts to contact the physician about the response delay. In an observation on 10/18/17 at 12:00 PM, the resident was observed sitting in a wheelchair in her room. She stated I broke my hip. I have had both my hips replaced before but the pain was real bad this time. The groin pain is just unbearable. The pain medicine helps some. I was in bed for a long time. I would color to try to keep myself busy. I felt so lazy. The pain was too great to put my foot down. Maybe they should get another company to do their x-rays. In an interview on 10/19/17 at 9:15 AM, the Nephrologist confirmed the critical lab results were not communicated to him. He stated the high potassium could lead to arrhythmias and weakness. The Nephrologist stated Obviously they should have held the potassium when the lab was high. I heard she fell . I am not sure high potassium caused fall, I cannot draw line in the sand if the high potassium caused her fall. He stated he had not seen her this month per his prior order and since she lost mobility. In an interview with the Director of Nursing on 10/18/17 at 1:00 PM, she confirmed she had been aware of the delay in obtaining the x-ray and the lack of critical lab follow-up. At 1:48 PM, She indicated pain, falls with suspected fractures and critical labs warrant calls to the physician not faxes. She stated I was unaware they kept giving her potassium. The other nurses weren't aware of the high lab or would've held it and no . no alert. There was no investigation of the physician concern, instances of delayed orders or medication error provided. Reference: WAC 388-97-1060 (1)

Based on observation, interview and record review the facility failed to ensure 1 of 4 (1) residents were free from emotional abuse related to a staff to resident allegation of verbal abuse. This failed practice caused psychological harm and decreased quality of life for Resident 1. Findings include: Washington state Nursing Home Guidelines AKA The Purple Book, Sixth Edition, October 2015, defines verbal abuse: Any use of oral, written or gestured language that willfully includes threats and/or disparaging and derogatory terms to or about residents or their families, within hearing distance of any resident regardless of their age, ability to comprehend, or disability; threats of harm; saying things to frighten a resident. Mental Abuse: humiliation, harassment, threats of punishment or deprivation. Review of the Abuse and Neglect Policy stated every resident has the right to be free from abuse in all forms by anyone including employees, other resident, consults, volunteers, family members, friends or other individuals. Resident 1 was admitted in February 2017 with a diagnose to include Depression. She was cognitively intact. Review of the investigation summary incident report dated 03/07/17 complete by the Director of Nursing (DNS) documented 'Resident was admitted from home and is currently coping with emotional turmoil and still transitioning from a traumatic event with the death of her husband. Resident also experiencing anxiety related to her future, feeling overwhelmed about making decisions for herself.' Further findings documented, Staff C, Licensed Nurse (LN) was accused of being rude by Resident 1, 'by a controversial conversation and shutting the door of the resident's room.' The incident report action noted Staff C was removed from the floor and Abuse and Neglect were ruled out and, 'Resident 1 was emotionally unstable and subject to sudden onsets of sadness. A witness statement from Staff A dated 03/07/17 revealed Staff A and Staff B, Nursing Assistants (NA) walked into the residents room to answer call light and the resident stated, Staff C, LN answered her call light on 03/06/17, closed her door and rudely said to her that staff were sick and tired of her, being rude to her employees. Staff A, NA revealed Resident 1 was 'crying pretty hard' over what was said. Staff A informed Director of Nursing (DNS) of the incident. A witness statement from Staff D, LN dated 03/07/17 documented the Resident stated Staff C entered Resident 1's room, closed the door and Resident 1 said to her not to talk to her or the NA so rudely. The Resident stated she was shocked that a nurse would treat her like that and further stated that Staff C pointed her finger at her and said rudely, Don't talk to my staff like that, you don't get to do that, you need to be quiet. The resident said it was rude and mean. Resident 1 further stated Staff C even talks that way to this old lady (her roommate). She is old and she shouldn't do that to her and she hurts her (Resident 7). I saw her but I'm going to keep my mouth shut about that. A witness statement dated 03/06/17 at 8:30 PM from Staff E, (Nursing Student) revealed she left Resident 1's room and went to Staff C to give report to her. Staff C asked Staff E if she was rude to her. Staff C stated to Staff E, Well she must like you because she is always rude to me! I had to tell her today to stop being rude to me and all the staff and I don't talk to her like that so she shouldn't talk to me and others like that. Staff E did not report this. In an interview on 03/23/17 at 10:43 AM Resident 1 stated Staff C, LN came in her room to get a urine sample, Staff C then closed the door and started 'baby talking the resident. Resident #1 told Staff C she's not one of her old people and don't talk to her like that. Resident 1 was wringing a piece of Kleenex that was in her hand while talking. Staff C, LN then told Resident 1, I'm sick and tired of you abusing my staff an I'm done with it. Resident 1 further stated, You know how people go postal, she may come back here to do something to me. I don't know if I should move out or not, but I am under a lot of stress right now, you know with my husband's death and all. Resident 1 is now crying and picking at her blanket. Resident 1 further stated Staff C, LN unnecessarily hurt resident 7 when she was cleaning her feet. The resident heard 2 slaps and then resident 7 screaming like a banchie. The privacy curtain was closed. Resident 1 had never heard resident 7 scream like that before. Resident 1 stated, I didn't feel safe after that. Resident 1 did not report the incident regarding resident 7. She stated, I have been crying since I got here, I don't know who I can trust here anymore and that scares me. In an interview on 03/23/17 at 1:40 PM, Staff A, NA, stated on 03/06/17, Resident 1 had her call light on. As Staff A and Staff B, NAs, answered the call light, the resident told them the night before Staff C, LN, had yelled at her and pointed her finger telling the resident to stop being rude to the staff. Staff C stated she was sick and tired how she (the resident) was treating her staff. The resident stated Staff C told her that she would not stand for it and then turned, walked out of the room and shut the door. Resident 1 began to cry and asked Staff A and B if she was too demanding. Both staff members reassured the resident. Staff A stated the resident was visibly upset and crying. Staff A and B immediately left the room and reported it to Staff D, LN, and Staff E, student nurse. Staff A stated Staff E then stated she worked with Staff C the night prior and Staff C told Staff E she put (Resident 1) in her place, Staff E then stated she had witnessed Staff C being rough and mean to Resident 7. Staff D directed Staff A and B to report the allegation immediately to the DNS. When asked if Staff A felt Staff C was mentally abusive to Resident 1, Staff A stated yes. Staff A stated she did not call the state hotline number because she had reported it to her supervisor and was worried about the resident. Staff A stated she should have called the state hotline number. At 1:59 PM, Staff B stated on 03/07/17, she answered Resident 1's call light with Staff A. Staff B described and confirmed what occurred the night prior. Staff B reported it to Staff D who was with Staff E. Staff B stated when this was being reported to Staff D, Staff E stated Staff C had been rough and mean to Resident 7 when they were putting the resident to bed. Staff B thought she had filled out a witness statement regarding the above events. Staff B stated she felt Staff C had mentally abused Resident 1. Staff B did not call the state hotline, and was aware she should have regarding the allegation of abuse. At 2:30 PM, the Administrator and DNS were interviewed. The DNS stated the facility had ruled out abuse and neglect due to Resident 1 had not changed from her behavioral/mood baseline. The Administrator and DNS were made aware Resident 1 recalled the event, was still visibly upset and was worried Staff C would come back and do something to her. The Administrator and DNS were not able to provide any addition information why the allegation of potential abuse written in Staff D's witness statement regarding Staff C and Resident 7 was not investigated. The facility failed to investigate all allegations involving Staff C. The administrator and DNS were made aware staff did not call the state hotline regarding the allegation of abuse nor did the facility call the hotline within a timely manner. Please see F 225 for further information Reference: (WAC) 388-97-0640 (1)

Based on observation, interview and record review the facility failed to identify skin at risk, put interventions in place to prevent pressure injuries for 4 of 4 residents (4, 5, 41 & 106). If a resident developed a skin injury they failed to contact the physician for orders on how to treat wounds. This failure led to harm by residents developing pressure ulcers, causing pain and had the potential of staff not using appropriate interventions. Findings included: RESIDENT 106 Resident 106 was a former resident who admitted to the facility May 24, 2016 with [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE] indicated the resident required extensive assist of two people for bed mobility, transfers and toileting. The resident was continent of urine and frequently incontinent of bowel. The resident had no cognitive impairment. Review of the pressure ulcer care plan directed staff to reposition the resident every 2-3 hours, treatment per orders, encourage toileting to decrease moisture, pressure reduction mattress and wheelchair cushion. Review of the admit assessment dated [DATE] revealed the resident had a stage I pressure ulcer to his sacrum. The pressure ulcer was not measured. The resident's left heel was intact. Review of the sacrum pressure ulcer assessment sheet revealed the following: -on 05/31/16, the resident developed three stage II pressure ulcers to the sacrum that measured 2.0 cm by 1.2 cm, 0.7 cm by 0.6 cm and 0.3 cm by 0.3 cm. The treatment was to apply an Allyven (a foam dressing), change the dressing as needed and to turn the resident side to side. - on 06/14/16 the previously three pressure ulcers on the resident's sacrum where now documented as a 1.8 cm by 0.8 cm stage II pressure ulcer on the right buttock and a 1.0 cm by 0.4 cm stage II pressure ulcer on the gluteal cleft. The treatment changed to apply moisture barrier to area twice daily. - on 06/26/16 the right buttock stage II pressure ulcer measured 1.0 cm by 0.5 cm and the gluteal cleft stage II pressure ulcer measured 0.1 cm. The LN documented the pressure ulcers had decreased in size and were improving. Review of the left heel pressure ulcer assessment sheet revealed the following: -on 05/31/16 the resident developed a 2.0 cm by 1.5 cm Suspected Deep Tissue Injury (SDTI) to the left heel. The treatment was to apply Allevyn padding and to float the heel. -on 06/04/16, the left heel SDTI was now a stage II 2.0 cm by 2.0 cm intact blister. The surrounding tissue was very red and measured 6 cm by 6 cm. The treatment was to apply a [MEDICATION NAME] (a type of dressing). -on 06/14/16 the stage II pressure ulcer measured 2.2 cm by 1.7 cm. The treatment changed to cleaning the wound with normal saline, apply a type of foam dressing ([MEDICATION NAME] or allevyn) and wrap with kerlix. The dressing was changed daily. On 06/26/16, the stage II pressure ulcer measured 1.6 cm by 1.2 cm. There was no change in the treatment. Review of the physician orders revealed, there were no physician orders to treat the residents various pressure ulcers. Review of the medical record revealed one weekly skin assessment done on 05/31/16. There was no weekly skin assessment documented in June. In an interview on 10/19/16 at 4:15 PM, Staff S, LN stated when the resident was admitted he was medically complex. The resident did develop pressure ulcers but were getting better. Staff S stated the facility practice was if it was a simple dressing change, the LN did not obtain a physician order. Staff S was not able to state if the resident's physician was notified when the resident developed the pressure ulcers. The resident was discharged on [DATE]. The resident had a stage II pressure ulcer on his left heel, a stage II pressure ulcer on the sacrum and gluteal cleft. Resident 106 was admitted to the facility with a stage I pressure ulcer on his sacrum. The resident was identified at high risk and developed four pressure ulcers after a week of being admitted to the facility. The facility had been identified as staffed challenged which placed the resident at risk for developing pressure ulcers. There was no evidence the LN involved the physician when a treatment was implemented nor did the LN obtain a physician order for [REDACTED].>RESIDENT 5 Resident 5 was admitted to the facility in February 2016 without a pressure injury. In an interview on 10/13/16 at 1:35 PM, Staff S, Licensed Nurse, stated the resident had a stage II pressure injury (open area to skin resulting from pressure exerted over a bony prominence) to the resident's coccyx. Review of the resident's care plan revealed there was no care plan for the resident's current pressure injury. Review of the resident's weekly skin assessments revealed there were 8 out of 14 documented skin checks from 07/15/16 through 10/18/16 with the last skin check completed on 10/03/16. Review of the 10/03/16 skin check revealed a 0.6 centimeter (cm) x 0.4 cm pressure ulcer with 2.7 cm x 1.8 cm indurated area surrounding the open area and an Allevyn dressing was applied along with an entry of dry skin (cocoa butter applied) no other skin issues. Review of the resident's treatment record revealed on 10/03/16 a treatment to cleanse the stage II pressure wound with soap and water then apply an Allevyn dressing every 2-3 days and as needed. On 10/05/16, the treatment was changed to a Duoderm with an Opsite change every 2 days. On 10/11/16 the wound was documented to be an unstageable pressure injury, the treatment was changed to cleanse and apply Santyl, cover with a normal saline saturated gauze and cover with a dry gauze secured with an Opsite changed every other day and as needed. In an interview on 10/19/16 at 1:30 PM, Staff G, Licensed Nurse stated, the physician had not been notified of the original wound noted on 10/03/16. In an interview on 10/18/16 at 4:25 PM, the resident stated, my bottom hurts, that's why I get out of my wheelchair. RESIDENT 41 Resident 41 was admitted to the facility in July 2016 with multiple pressure injuries. In an observation on 10/19/16 at 2:14 PM, Staff BB, Licensed Nurse, performed wound care to resident's right hip and flank wounds. Staff BB cleansed the wounds starting with the surrounding tissues, cleansing inwards to the open wound. Staff BB was stopped prior to cleansing further wounds. According to the nursing standards of nursing practice the procedure was to cleanse a wound is starting from the wound site to the surrounding tissues to prevent the spread of potential infectious organisms into the wound bed. In an interview on 10/19/16 at 3:13 PM, Staff BB stated she felt the wound care for Resident 41 was a disaster, Staff BB did not provide any further comment. In an interview on 10/19/16 at 12:54 PM, the Director of Nursing Services stated, Staff BB completed the residents' weekly wound assessments, and has recently completed a wound care class. RESIDENT 4 Resident 4 was a long term care resident with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], the resident required extensive assist of two people for bed mobility, transfers and toileting. Resident 4 was continent of her bowel and bladder. Review of the care plan revealed the resident was at risk for a pressure ulcer. The goal was for the resident would not develop a pressure ulcer. Interventions included: encourage and provide repositioning, a pressure relieving mattress in place and to complete weekly skin assessments. On 09/25/16, the resident had an assisted fall. A progress noted dated 09/26/16, revealed Resident 4 had a possible hairline [MEDICAL CONDITION] lower leg (fibula). The Licensed Nurse (LN) documented the resident was non-weight bearing to the left lower extremity and was a mechanical lift until further notice. On 09/28/16, the LN documented in the progress notes the resident had an open area on the left glute (buttocks). Review of a pressure ulcer assessment dated [DATE], the LN documented the resident had a 1.0 centimeter (cm) by 0.7 cm stage II pressure ulcer on the left buttock. The surrounding tissue was red, moist and semi-blanchable. The LN documented the resident had contributing factors which caused the pressure ulcer. These factors included: the resident had a recent injury causing a decrease in mobility, the use of a bed pain and mostly bed bound. Review of a pressure ulcer assessment dated [DATE], indicated the stage II pressure ulcer measured 0.8 cm x 0.5 cm. On 10/17/16, 10/18/16 and 10/19/16, there was no cushion (of any type) observed in the resident's wheelchair. On 10/19/16 at 8:30 AM, Staff G, LN, stated the resident was compliant with care. Staff G stated the resident stage II pressure ulcer on the left buttock was healing. At 11:00 AM, the resident's left buttock was observed with Staff G. The skin was fragile and intact. Review of the Treatment Administration Record (TAR) directed the LN to apply A&D ointment to the left buttock and bridge (a type of positioning to relieve pressure to the resident's buttocks) every shift. Review of the physician orders revealed no order for the A&D ointment to the resident's stage II pressure ulcer. In an interview on 10/19/16 at 1:40, Staff CC, Nursing Assistant Registered, stated Resident 4 had never refused care from her. At 1:55 PM, Staff BB, LN, stated the facility's practice for pressure ulcers was the LN, using their judgment, assessed the resident's skin and updated the TAR with a new treatment. The LN did not obtain a physician order for [REDACTED]. At 2:30 PM, the Director of Nursing Services was not able to provide any additional information regarding why the resident developed a stage II pressure ulcer. The facility failed to implement interventions when Resident 4 had a decline in her condition on 09/26/16. The resident had a change in her ability to bear weight and her transfer status was changed form a two person extensive assist to a mechanical lift. The resident developed a stage II pressure ulcer within three days of the change of condition or contact the physician. The facility failed to change her care plan and implement interventions to prevent the stage II pressure ulcer from developing. The facility failed to have systems in place to identify or treat pressure injuries, including contacting the physician for guidance and directions.

Based on observation, interview, and record review, the facility failed to communicate with the [MEDICAL TREATMENT] center, for 1 of 2 (48) residents and failed to ensure fluid restriction were followed for 2 of 2 residents (48 & 104). These failures caused harm of prolonged bleeding / pain for Resident 48 and placed all other residents at risk for fluid overload for both Resident 48 & 104 and / or other complications and any other residents who were on fluid restrictions. Findings include: The facility agreement with the [MEDICAL TREATMENT] center showed that under: Communication: The facility is to notify of emergency and non-emergency change in resident's medical condition, will be immediately communicated by the party having primary knowledge of the change to the other party regardless of the location of the patient at the time of the change. RESIDENT 48 Resident 48 was a long term resident, who had kidney disease requiring [MEDICAL TREATMENT] (a process to filter blood for removal of waste and extra fluid). The resident had very limited english skills which made it hard to communicate. The record showed that the resident was hosptalized on [DATE] returning to the facility on [DATE]. Review of her hospital discharge orders on 10/13/16 included a [MEDICATION NAME] injection (potent blood thinner) 5000 units to be given three times daily for [MEDICAL CONDITION] (prevention of blood clots). Review of a [MEDICAL TREATMENT] communication form between the kidney center and facility did not notify the center of the new order for [MEDICATION NAME]. The care plan did not have any directive for the nurses or nursing assistants on how to provide care for a resident on [MEDICATION NAME]. There were no interventions for possible bleeding or directives to staff for careful handling of resident. Review of the progress note dated 10/17/16 at 12:30 PM, stated Resident has been bleeding from inside of her mouth for several hours this morning. Large dark clot noted on the inside of her left cheek which is oozing blood. Cheek packed with gauze. Bleeding less but still present. MD faxed. At 9:05 PM the progress note stated, received fax reply 1. D/C [MEDICATION NAME] for 2 days. 2. Apply pressure, if can't get it to stop then may need to go to ER .upon assessment this evening, it was noted a large protruding ecchymotic mass to the right side of inner cheek. Review of the progress note dated 10/18/16 at 2:19 PM Received order from the nephrologist to stop the Aspirin due to the fact she had prolonged bleeding from [MEDICAL TREATMENT] access yesterday unsure if he was aware she had been put on [MEDICATION NAME] at the hospital. Assessed the clot area in her mouth and one of the blebs came off. The progress note dated 10/18/16 11:47 PM, stated received fax from primary care physician: Did she stop bleeding from gums. Contact her nephrologist (kidney doctor) about shunt issue bleeding post [MEDICAL TREATMENT]. In an observation on 10/19/16 at 9:31 AM, the resident was observed with a resolving hematoma on her left cheek. In an interview with the charge nurse at the Kidney Center on 10/20/16 at 10:20 AM, she stated I notified (the physician) of the prolonged bleeding. We were unaware she was receiving [MEDICATION NAME] at the facility too. He will be following up with the facility. In an interview with the Director of Nursing on 10/20/16 at 3:30 PM, she was unable to provide additional information. The facility failed to notify the kidney center of the new order for [MEDICATION NAME] which caused double dosing of [MEDICATION NAME] resulting in an unnecessary hematoma and bleeding in her mouth and at the infusion site. FLUID RESTRICTIONS Review of the physician's orders [REDACTED]. The resident's fluid restriction were not on the care plan to alert nurses or nurse's aide or on the meal tray card. There was no intake or output documentation in the clinical record or evidence or monitoring. Observations on 10/18/16, 10/19/16,10/20/16 and 10/21/16 revealed the resident had fluids at bedside. RESIDENT 104 Resident 104 was a long term care resident. On 10/06/16 the resident's physician ordered to restrict her free water intake to 1 liter a day. The resident's fluid restriction was not on the care plan to alert her nurses or nurses' aides or on her meal tray card. The treatment sheet stated Restrict water to 1 liter day, please write the amount every shift beginning 10/07/16. There were only 4 of the 36 shifts documented an amount. There were 25 entries of initials only. 7 shifts were blank. In multiple observations all days of survey resident had a 500 milliliter water pitcher within her reach. In an observation and interview with the resident on 10/19/16 at 9:26 AM, Staff U delivered a 240 milliliter cup of coffee to the resident. The resident was asked about her fluid restriction. She stated If they take anything else away from me I don't know what I would do. I have waited over an hour for this coffee. In an interview with the Registered Dietician on 10/18/16 at 10:00 AM, she indicated there were no current residents on a fluid restriction, even though two were identified. In an interview with Staff H on 10/18/16 at 12:21 PM, she stated The only resident on a fluid restriction right now is (resident 48) In an interview on 10/18/16 at 1:20 PM with Staff O, NA Only (resident 48) is on a fluid restriction. In an interview with the Director of Nursing on 10/19/16 at 12:51 PM, she indicated there was a communication issue with the fluid restrictions. She stated the licensed Nurse (LN) should monitor fluid restrictions ordered by the physician. No additional information was provided.

Based on interview and record review, the facility failed to ensure a quality assessment and assurance (QAA) committee was active and meeting to identify quality assurance issues and/or implement plans of action to correct the quality issues related to the following areas: screening and training of new employees, abuse/prohibition, activity program, housekeeping and maintenance services, staff competency to provide resident care, assessment, care and treatment of [REDACTED]. The failed practice affected the quality of life and quality of care for 85 facility residents. Findings include: On 11/30/15, 12/01/15, 12/02/15 and 12/03/15 the administrator was not present in the facility. Staff CCC, an AIT (administrator-in-training) had been covering the duties of the administrator for the past 3 weeks. On 12/02/15 the owner stated the administrator had been on leave and out of the facility for the last 3 weeks and was available by telephone for consult with the AIT. Staff CCC was interviewed on 12/03/15 regarding actions of the QAA committee. He stated he had been to one meeting in the past 2-3 months. Staff BB was designated by the owner as the contact person for QAA. Staff BB, listed on the employee list as Resident Care Manager, acting Director of Nursing Service and infection control nurse was interviewed 12/04/15. She had recently returned to work at the facility October of 2015. She stated she had not been to any QAA meetings. She was not able to locate any information regarding any QAA meetings for 2014 or 2015. Staff V, the MDS (Minimum Data Set assessment) coordinator was interviewed 12/04/15, and stated she had worked at the facility since March 2015. She had been to one meeting. Additionally, in interview with a variety of staff it was determined there had not been an active Quality Assurance Committee over the past year. The Director of Nursing Service was interviewed 12/07/15 and stated there had not been any QAA meetings since she was hired in March 2015.

Based on interview and record review, the facility failed to ensure the Medical Director provided the leadership role per agreement to actively assist the facility in providing quality care to residents. The failed practice affected the quality of care delivered to all residents and placed them at risk for decline in condition, injury and psychosocial harm. Findings include: Review of the Medical Director's Agreement, signed and effective as of 12/01/2010 included the following: 1. The Medical Director agrees to provide administrative medical services to the facility in the areas of: a. Medical Care b. Written Policies Review c. Staff Meetings d. Employee Health e. In-Service Training During an interview with Staff BB on 12/17/15 it was revealed that earlier in the year the medical director had reportedly been in the facility almost daily and was working with the Director of Nursing Services (DNS) on review and revision of some of the policies. She was not able to provide any documentation of the work on revision of policies but stated there may be something on the computer of the DNS. She also stated that since she was rehired in October the Medical Director had pretty much only been in the facility on Fridays seeing his patients. Whenever needed he did cover for other physicians in providing medical care to residents. ADMINISTRATOR INTERVIEW In an interview on 12/17/2015 at 10:45 AM, the Administrator was asked about the Medical Director Agreement and how involved the Medical Director was in relation to various facets of the facility's operations: A. Medical Care - the administrator stated He comes most Fridays for 1/2 day, he sees residents and consults with the nurses. B Written Policies Review - the Administrator stated He normally did that with the DNS (Director of Nursing Services), I can't give specifics on that .the DNS recently left. When asked for documentation of any Written Policy Review the Medical Director had performed, the Administrator said he didn't have specific information about this and he stated I don't want to speak without specific knowledge. C. Staff Meetings - the Administrator stated he used to come to our weekly staff meetings, but he hasn't done that in awhile. He stated I'm not sure when asked when he had last attended. D. Employee Health - the Administrator stated the only thing he has done with that is to encourage staff to get the flu shots. He (the medical director) wants to make it a policy as a condition of employment that all staff working here are required to get the flu shot, but he hasn't done that yet. E. Inservice Training - The Administrator stated he once did a diabetes inservice, but I don't know when that was. The Administrator was asked for written documentation of the Medical Directors involvement with the items listed in A - E, The Administrator said he would have to look into it and would fax the documentation to the surveyor. As of 12/30/15, the Administrator had not faxed any of the requested information to the survey team. .

Based on interview and record review, the facility's administration, through its supervisory staff, failed to ensure the facility effectively and efficiently attained and/or maintained each resident's optimal physical, mental and psychosocial well-being in the areas of abuse/neglect/staff training, nursing assistant evaluation and training, supervision for accident prevention, providing sufficient staff to maintain needed care and services, housekeeping, maintenance and infection control. These failures resulted in actual harm to Residents 5, 11, 13, 25, 26, 33, 34, 51, 56, 57, 85, 92, 99, 105, 118, 145, 147 and 165 and placed all residents at risk for unmet needs and decreased quality of life. Findings include: 1. The Administration failed to appropriately screen and train new employees, identify occurrences requiring action, protect residents, investigate and report as necessary placing all residents at risk for repeat occurrences of abuse and neglect. The failure to identify potential abuse and/or neglect caused psychological harm for Resident 145 with disregard by staff in their duty to appropriately provide care and services. Refer to CFR 483.13(c), F-226 for failure to implement policy and procedure for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. 2. The Administration failed to provide sufficient qualified staff to ensure residents were cared for with respect and dignity, supervised to prevent accidents, received services to improve/maintain activities of daily living, answered call lights in a timely manner and received care in an appropriate manner to prevent the spread of infection. Refer to CFR 483.30, F-353 for failure to provide sufficient qualified staff. Refer to CFR 483.25, F-315 for failure to provide appropriate treatment and services to prevent urinary tract infections and restore as much bladder function as possible. Refer to CFR 483.65, F-441 for failure to maintain an effective infection control program. 3. The Administration failed to ensure nursing assistants were competent, received registry verification, received performance evaluations and the required 12 hours of continuing education annually. Refer to CFR 483.75(e)(2), F-494, (e)(4)F-495, (e)(5)F-496, (e)(8)F-497 and (f)F-498. 4. The Administration failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable interior. Refer to CFR 483.15(h)(2), F-253 for failure to maintain resident environment.

Based on observation, interview, and record review, the facility failed to develop and implement an effective infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Failure to: monitor and analyze urinary tract infection (UTI) prevalence rates, initiate/complete staff education in response to increasing prevalence of UTI's, to develop and implement a laundry procedures policy, and to have a trained facility infection control nurse placed all residents at risk for infectious disease and illness. Additionally, based on interview and record review the facility failed to assess 3 of 5 residents (43, 60, 94) experiencing symptoms of potential infection. This failure placed other residents at risk for infection. Findings include: URINARY TRACT INFECTIONS Review of the facility Infection Control Book revealed the facility had 78 documented facility-acquired UTI's from January - November 2015. Review of the June 2015 Infection Control mapping data, revealed 12 residents had developed facility-acquired urinary tract infections (UTI). The mapping data revealed 6 facility-acquired UTI's were on the West wing of the facility, and 6 facility-acquired UTI's on the East wing. In an interview on 12/09/15 at 11:28 AM, Staff BB, Infection Control Nurse, did not know if the June 2015 UTI prevalence data had ever been analyzed or assessed for causative factors, or if the prevalence had been reported to the facility medical director or the Quality Assessment and Assurance (QAA) Committee. Review of the November 2015 Infection Control Mapping data revealed 10 residents had developed facility-acquired UTI's, 8 of which were clustered on the East unit. In an interview on 12/09/15 at 11:28 AM, Staff BB said the November 2015 facility-acquired UTI prevalence on the East unit was due to maybe handwashing and peri (perineal) care. Staff BB said no formal analysis had yet to be done on the November facility-acquired UTI prevalence. Staff BB said no staff training had yet to be performed related to the November facility-acquired UTI prevalence. Staff BB said she didn't think the November 2015 facility-acquired UTI prevalence rates had been reported to the facility QAA committee for follow up. PERINEAL CARE OBSERVATION In a perineal care observation on 12/09/15 at 12:04 PM until 12:25 PM, Staff MM, Nursing Assistant Certified (NAC), and Staff NN, Nursing Assistant Registered (NAR), performed perineal care on Resident 116, an East Wing resident who had been incontinent of stool. Staff MM and Staff NN did not use proper procedures that met current standards of practice which included: Staff MM's used gloves that were visibly contaminated with feces. Staff MM used her feces contaminated glove to push the soap dispenser that was on the wall behind the resident's head. She repeated this process several times. Staff MM, while still wearing the feces contaminated gloves, covered up the resident with her sheets. Staff MM with the feces contaminated gloves, and Staff NN with clean gloves, repositioned the resident. Staff MM while wearing feces contaminated gloves, helped the resident lift her head while Staff NN put the clean pillow under her head. At the conclusion of the procedure, the wall soap dispenser, the new brief, the bed linen, and the pillowcase were all contaminated. In an interview at 12:25 PM, Staff C, Licensed Nurse, was briefed about the perineal care observation. Staff C stated there were quite a few problems with it when asked about the observed infection control lapses. CATHETER CARE OBSERVATION In a observation of catheter care on 12/17/15 at 11:02 AM, Staff OO, NAC, and Staff PP, NAR, performed on Resident 13 who had an indwelling Foley catheter. Staff OO and Staff PP did not use proper procedures that met current standards of practice, which included: Staff PP held the resident while Staff OO cleaned the resident's groin. In between washcloth changes, Staff OO would use her contaminated left hand to obtain soap from the wall mounted soap dispenser. Staff OO cleaned the resident's buttocks, rolled up the soiled brief under the resident. A new brief was placed and was secured with contaminated gloves. The resident was then lifted up higher in bed and the linen placed up on the resident while still wearing the contaminated gloves. The 2 staff removed the bags of soiled washcloths, removed their gloves and washed their hands. At the conclusion of the procedure, the wall soap dispenser, the new brief, and the bed linen were all contaminated. The procedure lasted from 11:02 AM until 11:25 AM. LAUNDRY In an observation on 12/09/15 at 10:31 AM, there was a rack of clean resident clothes being stored directly in front of the washing machine. Staff DD, Laundry Aide, said they were extra clothes for residents and they were always stored there. When asked about the practice of storing clean clothes by the washing machines, Staff DD was unable to provide any information. In an observation on 12/09/15 at 10:31 AM, Staff DD was observed processing a load of soiled linen. She loaded the dirty linen in the washing machine and shut the washing machine door without disinfecting the contaminated rim. The rim to the washing machine had accumulated white colored debris. In an interview at 10:31 AM, Staff DD said she cleaned the washing machine rim once a day. When asked about the laundry policy for cleaning the washing machine, Staff DD referred the surveyor to her supervisor. In an observation at 10:41 AM, 10 minutes after a load of soiled linen was started on the washing cycle, Staff DD was asked to check the temperature on the currently washing load of soiled linen. Staff DD pressed a button on the machine and the temperature was observed to be 119 degrees Fahrenheit (F). In an interview at 10:41 AM, Staff DD said No when asked if the washing machine water temperature was going to get hotter. Staff DD was unable to provide any information when asked how she knew the washing machine water temperature had reached an acceptable level. Staff DD was also unable to provide any information when asked if the laundry detergent/bleach concentration was effective at destroying microorganisms in the laundry items. Staff DD said she thought there was a policy regarding water temperatures and detergent concentrations, but was unable to provide a copy. Staff DD referred the surveyors to her supervisor. Staff DD was unable to provide the package insert for the Tide Professional detergent. In an interview at 10:51 AM, Staff EE, Maintenance/Housekeeping Supervisor, said there was no facility laundry policy. Staff EE said that the laundry water temperature was set at 140F, but was unable to state whether that was an adequate temperature or whether the Tide/Bleach/Downy concentrations were sufficient to destroy microorganisms in laundry items. INFECTION CONTROL NURSE In an interview on 12/09/15 at 11:28 AM, Staff BB, Infection Control Nurse, said she did not have any formal training or experience to qualify her to be an Infection Control Nurse. POTENTIAL INFECTIONS On 12/16/15 at 8:22 AM, the Administrator said some residents had loose stools without fever. This was being called in to the State hotline and the Health Department. The facility policy entitled Assessment of Change of Health Status included the following: -The most common occurrence to consider in this population would be: GI (gastrointestinal issues) -The focus of the assessment will be determined by presentation of signs and symptoms and follow standard nursing assessment skills. -All assessments will include vital signs. -Other possibilities exist and need to be kept in mind during assessment. RESIDENT 43 Review of the clinical record revealed no assessment of Resident 43 since the onset of the loose stools. A 12/16/15 fax to the physician noted the resident had loose stools for 2 days. During a 12/16/15 at 1:45 PM interview with Staff KK, a Licensed Practical Nurse (LPN), she said the resident had been sick for two days. RESIDENT 60 Review of the clinical record on 12/16/15 revealed no nursing notes since 11/13/15. There was no assessment of Resident 60 since the onset of loose stools. A 12/16/15 fax to the physician noted the resident had 24 hours of loose stools. During a 12/16/15 1:50 PM interview with Staff KK, LPN, she said the resident has had one day of loose stools. RESIDENT 94 Review of the clinical record revealed no assessment of Resident 94 since the onset of the loose stools. During a 12/16/15 1:50 PM interview with Staff KK, LPN, she said the resident has had one day of feeling poorly and had loose stools. Please refer to Federal Regulations F226, F253, F315, F334, F431, and F507 for additional details related to the facility's failure to implement appropriate infection control policies and procedures.

Based on observation, interview and record review, the facility failed to provide sufficient qualified staffing to treat residents with respect and dignity, prevent accidents, receive services to improve/maintain Activities of Daily Living, answer call lights in a timely manner, provide timely assistance with toileting, prevent urinary incontinence, and prevent spread of infections for 18 of 27 sampled residents (5, 11, 13, 25, 26, 33, 34, 51, 56, 57, 85, 92, 99, 105, 118, 145, 147 and 165). This failure resulted in actual harm, feelings of frustration and humiliation, diminished quality of life and unmet care needs of the residents. Findings include: RESIDENT OBSERVATIONS, INTERVIEWS AND RECORD REVIEWS During interviews with residents and a family member, residents complained of problems with receiving care or assistance from staff due to a lack of sufficient staffing. On 12/08/15 at 12:45 PM, Resident 56 stated, she cannot always get out of bed in the mornings because she needs two staff to use the hoyer lift and there were not enough staff. Call light wait time is 35 to 45 minutes. There are a lot of staff that don't show up to work so the staff are short. The staff do not care or have any work ethic. The left hand does not know what the right hand is doing. I hear staff say I don't want to go in there, she's too picky, I only ask for a little bit of comfort. I hear them say she wants her bedding without wrinkles. I haven't had a bed bath for several weeks now. The last bed bath I had was 11-16-15, (written on napkin), My arm pits or feet have not been washed in weeks because I am picky and they don't want to help me. I didn't envision this for me. I do not ever ask for things I don't need. I cannot reach items on my window sill and need help. The shower aide came in around the 25th (November) and told me she would come back in 2 days to give me a bed bath and then every Wednesday from here on out. She still has not come back. On 11/30/15 at 2:55 PM, Resident 118's family member stated there is not enough staff. Most of the waits are about 40 minutes. The longest time waiting was 55 minutes. At 2:58 PM, Resident 105 stated Around dinner time I can't get staff. They have a bad habit of leaving me in the hallway waiting for hours sometimes. On 12/01/15 at 9:50 AM, Resident 11 stated Usually around 3:00 or 4:00 PM and it is time to use the bathroom and there is no help available. The other day I waited so long I became irritated. I began to clap my hand and could not get anyone's attention. I tried to get up and I fell . I had yelled and done everything. Please, please help me I was crying and yelling I just need some help here. I felt terrible. They deserted me. I was shook up. It was a bad experience. This happened two days ago. At 10:41 AM, Resident 34 stated, There is never enough staff to take care of us. Sometimes it takes way too long for them to come help when I call them. At 2:17 PM, Resident 26 stated, weekends are bad and it's all shifts. Call light response is slow. At 2:55 PM, Resident 33 stated, my roommate needs help with toileting and everything and often has to wait a half hour or more. On 12/02/15 at 9:14 AM, Resident 165 stated One day I waited an hour to get a breathing treatment that I needed. On 12/03/15 at 1:45 PM, Resident 99 stated When I do not get a shower they tell me it is because no staff came to help and taking care of people in bed is more important than taking a shower. It is a bummer. In the morning, I have waited 30 minutes for my light to get answered. I mostly have to wait in the mornings. I need help pulling my pants up. I feel belittled and insignificant when I wait. At 1:55 PM, Resident 85 stated, I don't think there is enough staff. You just wait. If you sit on the commode long enough your legs get numb. This happens in the morning when staff are busy getting other residents up. It makes me feel irritable. At 2:08 PM, Resident 25 stated At night there are not enough staff. Sometimes I have to wait hours. I am supposed to have 2 showers each week. Last week I only got one shower. This makes me feel very disappointed. There should be some kind of back up for the shower person. Sometimes they cut staff when the census is low and we have to wait a long time. On 12/07/15 at 11:15 AM, Resident 92 was observed repeatedly calling out I have to go to the bathroom, while his call light was on. Staff LL was observed at 11:20 AM outside of Resident 92's room. During this time Resident 92 was still calling out. At 11:25 AM, Staff LL walked away and did not tell anyone about the resident calling out for assistance. The call light was not answered until 11:37 AM. On 12/08/15 at 9:00 AM, Resident 92 stated no, there absolutely is not enough staff. They are pretty much understaffed. I wait a long time to go to the bathroom. Sometimes 45 minutes. My whole bottom hurts. It's embarrassing. You get no relief. There is an open sore there now. Tell these people to help me or get out. It is this way all the time. At 9:30 AM, Resident 5 stated we never have enough staff. Staffing is lousy. I wait an hour sometimes to find an aide so I use this (backscratcher) to tap to get a hold of them. They don't like it but I need to do it to get their attention. Yesterday I missed getting to the bathroom on time twice. It makes me feel miserable. This morning before breakfast I heard a woman screaming help, help, somebody help. This has gone on for days. At 10:00 AM, Resident 57 stated They don't have enough staff. I wait longer than I need to wait and that is just because they are busy. I need help going to the bathroom at night and sometimes they forget to come back for me. At 12:55 PM, Resident 145 was observed crying during this interview. The resident stated I have terrible pain. I have to wait. On last Friday, after you guys left, Staff Y, (nursing scheduler) totally cut all caregivers to one. I wait easily 30 minutes to as much as an hour and a half to 2 hours when I pressed my button. I don't feel dignified. Sometimes I lay in a pool of feces and urine. Another resident told me we should buy 8 hour briefs for us since we don't get changed often. There is lots of gossip and if you complain you get the cold shoulder. They allow people to come and clean me and they are just starting. They don't have any training. They talk over me in the middle of the night. I called my husband in the middle of the night and he came in to see me. My husband told the charge nurse they didn't change me for hours and hours. The caregiver told my husband with the nurse standing there that she changed me at 4:00 AM, but I was awake then and she didn't change me. I was on the phone talking with my husband. I have had 2 urinary tract infections since I got here. I have not had one since I was in my 20's. I have to wait and wait and wait because there are so many people here to care for. Last night they changed my brief but never washed me. I knew I wasn't clean. I never wore briefs before. It is embarrassing. I can hear staff gossiping and laughing when my door is open. Review of Resident 145's progress notes showed a Social Service note, dated 10/29/15 at 9:46 AM, which stated (Resident's 1st name) stated she is often left sitting in her own feces because there isn't enough staff to treat her in a reasonable time and that staff on the noc (night) shift largely ignores her or comes into her room, half awake. (Resident's 1st name) stated that last night, 10/27/15, she sat in her feces for hours before anyone came to help her, and that when the aide did arrive, she barely wiped/cleaned up (Resident's 1st name) vaginal and rectal area. In an interview on 12/08/15 at 3:35 PM, Staff W, Social Services Director stated she has a complaint from every single resident in the facility every day that they wait too long to get cleaned up and to go to the bathroom. She added she listens to a certain resident near her office that calls out all day long that he needs to go to the bathroom. STAFF INTERVIEWS On 12/03/15 at 11:39 AM, Staff FF, NAC, stated there is not enough staff to provide the necessary care. At 1:31 PM, Staff GG, NAC, stated I am overwhelmed by my position. I get pulled from my work to provide care to the residents. The management wants me to stay late. The residents get very upset. On 12/07/15 at 10:56 AM, Staff HH, NAC, stated I get pulled from my work to provide care for the resident's. I have too much work to do. At 2:15 PM, Staff II, NAR, stated No, there is not enough staff, not at all. We are spread pretty thin. On 12/08/15 at 9:49 AM Staff JJ, NAC, stated No, there is not enough staff. I get pulled to provide resident care. This happens too many times to count. I am not able to provide the care I am supposed to. SHOWER SCHEDULES Resident 25, 26, 33, 51 and 147 lack of consistent showering. On 12/07/15 the shower records were reviewed. Resident 33 had not been bathed since 11/26/15, eleven days. Resident 51 was bathed once in October. In November the resident received a shower on 11/05/15 and not another until 11/19/15, 14 days. Resident 147's last October bath was on 10/23/15 and did not receive another bath until 11/18, 26 days. This resident had not been bathed since 11/18/15, 15 days. Resident 25 had not been bathed since 11/25/15, twelve days. Resident 26 was to be showered two times per week. There were 6 days between showers 10/08/15 - 10/14/15, 2 weeks between showers 10/14/15 - 10/29/15 and 10 days between showers 11/15/15 - 11/26/15. RESTORATIVE NURSING SCHEDULE In review of provision of Restorative Nursing Programs (RNP) 2 of 3 sample residents reviewed were not consistently being provided the planned services, placing them at risk for decline. Resident 13 was scheduled to receive a Restorative Nursing Program (RNP) 6 days per week. In review of the Restorative Aide's (RA) documentation records for the time period 09/01/15 - 12/07/15 it was revealed Resident 13 received her program 4 times 09/15/15 - 09/21/15, 3 times 09/22 - 09/28, 5 times 09/29 - 10/06, 4 times 10/13 - 10/19, 4 times 10/20 - 10/26, 2 times 10/27 - 11/02, 3 times 11/03 - 11/09, 1 time 11/10 - 11/16 and 3 times 11/17 - 11/23. Resident 118 was scheduled to receive 2 RNP's, transfer training and walking, 6 days per week. In review of the RA documentation records 10/01/15 - 12/07/15 it was revealed Resident 118 received his program 5 times 10/20 - 10/26, 1 time 10/27 - 11/02, 1 time 11/03 - 11/09, not at all for the 3 weeks from 11/10 - 11/30 and 3 times 12/01 - 12/07. Resident Council October 2015 meeting minutes, 3 residents complained about lack of staffing, resulting in residents having to wait an hour for bathroom assistance, turning down the heat, lack of staff in the evenings and nights, and having to holler for assistance dressing. Refer also to other examples of lack of qualified staffing and harm/potential harm to residents at: 42CFR 483.13(c), F226, Staff treatment of [REDACTED]. 42CFR 483.15(a), F241, Dignity (resident harm) 42CFR 483.25(a)(2), F311 Treatment/Services to Improve/Maintain ADL's 42CFR 483.25(d), F315 Urinary Incontinence (resident harm) 42CFR 483.25(h), F323 Accidents Hazards/Supervision/Devices 42CFR 483.65, F441 Infection Control, Prevent Spread (resident harm)

Based on observation, interview and record review, the facility failed to assess and promote an improved level of urinary continence, and to provide the appropriate care and services to prevent urinary tract infections [MEDICAL CONDITION] for 1 of 2 residents (145) reviewed for urinary function. These failures resulted in harm to Resident 145 when her previously normal urinary function was not improved or restored and she experienced a urinary tract infection [MEDICAL CONDITION]. Findings include: RESIDENT 145 Resident 145 was readmitted to the facility in September 2015. Review of the Minimum Data Set (MDS) assessment, dated 11/06/15, revealed she had no cognitive impairment, required extensive assist of 2 staff for toileting, was frequently incontinent of urine, was not catheterized, and no trial of toileting, prompted voiding, or bladder training had been attempted on admission/reentry or since urinary incontinence was noted in the facility. Review of Resident 145's care plan, printed 12/09/15, revealed no trial of a toileting program such as scheduled toileting, prompted voiding, or bladder training had been care planned to restore her urinary continence. Review of Resident 145's Urinary Incontinence Care Area Assessment, dated 09/24/15, revealed resident is aware of need to void but due to functional incontinence and need for assistance with toileting, transfers and mobility, has difficulty making it to the bathroom or onto bed pan quickly enough. Review of the facility infection control log revealed Resident 145 had a facility-acquired UTI with an onset date of 11/19/15. Review of the resident's November 2015 Medication Administration Records revealed she was started on an antibiotic on 11/19/15 for a UTI. Review of a Nursing progress note, dated 11/22/15 at 1:32 PM, that read Resident continues on ABX (antibiotics) with no ASE (adverse side effects) noted at this time. Fax received from MD (medical doctor) asking about response to ABX, faxed back letting MD know that resident is still complaining of burning during urination. Review of the resident's progress notes revealed a Social Services note, dated 10/26/15 at 12:00 PM, that indicated the resident has concerns regarding hygiene and care from staff, stating she is not cleaned properly Review of the resident's progress notes revealed a Social Services note, dated 10/29/15 at 9:26 AM, that read resident stated she is often left sitting in her own feces because there isn't enough staff to treat her in a reasonable time, and that staff on the noc (night) shift largely ignores her or comes into her room half awake. (resident name) stated that last night, 10/27/15, she sat in her feces for hours before anyone came to help her, and that when the aide did arrive, she barely wiped/cleaned up (resident name) vaginal and rectum area. (Resident name) further stated that the aide wiped her vaginal area from back to front, and that she had to stop the aide from wiping incorrectly. Review of the resident's progress notes revealed a Social Services note, dated 10/29/15 at 3:00 PM, that read I spoke with the DNS (Director of Nursing Services) .regarding (resident's name) concerns of sitting in feces for hours, incorrect wiping, random following of care plans, and poor customer service. (DNS name) stated she was aware of the issues and would be scheduling training with staff to address them. In an interview on 12/08/15 at 3:15 PM, the DNS reviewed the above-mentioned progress notes and agreed there was neglect. The DNS said she was not aware of these notes and to her knowledge nothing had been done to address Resident 145's concerns noted to the Social Services Director. Review of the resident's progress notes revealed a nursing note, dated 12/08/15 on night shift that read c/o (complaint of) px (pain) with urination - burning sensation .fax to MD re: symptoms she's had and to advise. Review of the resident's progress notes revealed a nursing note, dated 12/08/15 at 11:48 AM, which read Rcvd (received) MD order for U/A (urine analysis). Review of the resident's medical record on 12/17/15 revealed no urine analysis report was available for review. Review of the progress notes, dated 12/13/15 at 3:40 PM, revealed a nurse had attempted to catheterize the resident to obtain a urine sample, but the procedure was aborted prior to completion. The progress notes revealed the resident wanted a different nurse to do the procedure. In an interview on 12/17/15 at 8:59 AM, Staff C, Licensed Nurse (LN), said the U/A still had not been done. She said she would try herself later in the day. Staff C said she didn't know if the resident's physician had been notified the facility had not yet completed the UA ordered on [DATE]. In an interview on 12/09/15 at 9:07 AM, Resident 145 said she was continent of urine prior to her admit to the facility, but was incontinent when admitted because she was sedated from all of her pain medications. The resident said she had been wearing briefs since she was admitted to the facility. She stated she had not had a UTI since she was a teenager, but she said she was having burning pain when she urinated right now. The resident said it was challenging being a resident at the facility because staff were not happy if she asked them to clean her better after going to the bathroom and sometimes staff come in and change her wet brief, and put on a clean brief without wiping her down and doing any peri care. Resident stated she did feel the urge to urinate, and might be able to urinate in a commode if there were enough staff to get her to the commode in a timely manner. She said she had waited up to 2 hours for staff to help her when she used her call light. In an interview on 12/09/15 at 9:33 AM, Staff C was unable to provide a urinary assessment for Resident 145. Staff C was unable to provide any information when asked if the facility had attempted any urinary training program or prompted voiding program for Resident 145. Please refer to Federal Regulations F226 and F441 for additional details related to the facility's failure to provide necessary care and services to prevent and treat urinary tract infections.

Based on interview and record review, the facility staff failed to provide disease management for three of 13 insulin dependent diabetic residents (1, 4, and 5). Failure to perform and document nursing assessments for diabetic symptoms and obtain and implement physician guidelines for blood sugar management (symptoms of [DIAGNOSES REDACTED]) resulted in harm for Residents 4 and 5 including lack of timely nursing assessments, lack of physician notification of changes in condition for insulin dependent diabetic residents, lack of clarification of physician orders, administration of inaccurate doses of insulin as ordered, and lack of implementation of appropriate individualized treatment for [REDACTED]. Findings include: Per insulin manufacturer guidelines, to control diabetes, physicians order insulin products to keep blood glucose at near-normal levels (per the American diabetes Associate, a level less than 130mg/dL prior to meals). The time course of action of any insulin may vary considerably in different individuals or at different times in the same individual. 1. Resident 5 was admitted [DATE] with [DIAGNOSES REDACTED]. His physician ordered [MEDICATION NAME] 70/30 insulin for each morning at breakfast and each evening at dinner. The physician ordered blood sugar checks before each meal and at bedtime. There were no parameters included with the insulin order to guide staff when to notify the physician of blood sugar results or guidelines of when to "hold" (not administer) the medication. On 02/21/13 Resident 5 complained of feeling "nauseous" all day and did not eat his meals. His blood sugar was 103 mg/dL prior to dinner. Licensed nurse (LN) 2 documented administration of the dinner meal insulin at 4:30 p.m. on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no evidence he was offered or ate a snack at bedtime documented for 02/21/13 on the MAR. At 11:45 p.m. on 02/21/13 a nursing assistant (NA) told LN 3 Resident 5 was "acting funny". LN 3 assessed Resident 5 and wrote he was "cool, clammy, and mumbly". She checked Resident 5's blood sugar; it was 29 mg/dL (severely low). She phoned the physician service and waited for a call back as there was no physician order already in place for treatment of [REDACTED]. On 02/22/13 LN 4 documented she administered only 20 units of the morning dose of 40 units of [MEDICATION NAME] 70/30. There was no evidence of physician order for [REDACTED]. There was no physician order or physician notification documented for this change of order. LN 5 documented she held the morning dose of insulin on 02/26/13 without any additional details. On 02/28/13, review of the MAR indicated [REDACTED]. On 02/28/13 at 11:30 a.m., LN 6 reported although interim care plans for residents should be started on the day of admission, she had not yet written an interim care plan for Resident 5. Additional review of the clinical record revealed that even though Resident 5 had experienced severe low blood sugar on 02/22/13, no interim individualized care plan for management of diabetes or nutrition was created by nursing. 2. Resident 4 was readmitted after hospitalization in April 2012. His [DIAGNOSES REDACTED]. In August 2012, his physician ordered 3 units of insulin before each meal and at bedtime. The order read "inject 3 units subcutaneously before meals pre sliding slide ...and ...at bedtime pre sliding scale." Additionally, the physician ordered sliding scale insulin coverage dependent upon the blood sugar level measured for Resident 4 before meals and at bedtime. Review of the MAR for January 2013 and February 2013 revealed some LNs interpreted the above order either as 3 units scheduled plus sliding scale coverage while others interpreted the order as not scheduled and give only if the blood sugar was elevated prior to meals and at bedtime. On 02/28/13 at 1:20 p.m., LN 1 reported she contacted the physician for clarification of the order on 02/25/13. She updated the order as 3 units of insulin before each meal and at bedtime plus sliding scale coverage for elevated blood sugar. She acknowledged multiple medication administration errors of omission occurred in January and February 2013. She had no information why none of the staff nurses contacted the physician sooner for clarification of the order. Review of the MAR, dated January 2013, revealed 21 errors of omission (failure to administer insulin as ordered). The MAR, dated February 2013, had 13 errors of omission for the scheduled insulin. 3. Resident 6 was admitted in April 2012 with multiple [DIAGNOSES REDACTED]. Review of her MAR, dated February 2013, revealed parameters to notify the physician if her blood sugar was less than 40 mg/dL (severe low) or greater than 700 mg/dL (severe high). On 03/01/13 at 10:25 a.m., the Director of Nursing Services (DNS) reported the glucometer, a device for measuring blood sugar levels, used in the facility could only read blood sugar values to a maximum high of 500 mg/dL. Consequently, staff could not monitor any blood sugar values above 500 mg/dL and would not know when to call the physician for [MEDICAL CONDITION]. The DNS had no additional information why nursing did not notify the physician of this situation.

Based on observation, interview and record review, the facility failed to protect residents appropriately during an outbreak of infection. Affected were 73 of 91 current residents and 30 staff members who acquired a contagious infection and experienced nausea/vomiting, fever, and/or diarrhea. Potentially affected were all residents, staff and visitors to the facility. This was determined to be Immediate Jeopardy on 12/31/12. Findings include: On 12/31/12 at 09:30 a.m., the Administrator reported the initial case of infection symptoms of nausea, vomiting, diarrhea and fever was on 12/11/12. He was aware that large numbers of both residents and staff experienced symptoms in the past 20 days. He did not notify the County Health Department or the State hotline of the outbreak. All group activities, except one Christmas party, for residents continued and all residents without active symptoms ate in the group dining rooms. The Administrator noted there was no infection control program in the facility; no dedicated staff member(s) met and reviewed infection control data, trends, or preventive/control measures. He stated he had notified the facility Medical Director (MD) on 12/27/12 that a number of residents were experiencing symptoms but had not communicated the scope of the outbreak to the MD until 12/31/12. Facility administration failed to develop and implement the state and federally mandated infection control policy and program to identify and trend residents with contagious infection. There was no monitoring, trending, identifying of the spread of the infection throughout the facility. Facility administration failed to isolate infected residents during the outbreak and failed to educate residents on how to prevent cross contamination. Facility administration failed to alert all visitors in a timely manner of the risk of exposure to possible infection and failed to voluntarily restrict admissions during the outbreak. Facility administration failed to implement additional procedures to prevent cross contamination in the building, and failed to report the outbreak to local and State agencies in accordance with federal regulation and state code. These failures resulted in an environment of unnecessary and avoidable exposure to contagious infection for all residents and placed them at risk of on-going repeated exposure to illness symptoms. See F441 - failure to develop and implement a facility infection control written policy and program for prevention, monitoring, trending, intervening and reporting of infection(s) in the building for additional details.

Based on observation, interview and record review, the facility failed to intervene for residents with a contagious infection. Failure to develop and implement infection control measures to isolate infected residents, monitor and contain locations of infection, intervene to prevent spread and contamination resulted in 73 of 91 current residents and 30 staff members acquiring a contagious infection and experiencing nausea/vomiting, fever, and/or diarrhea. This was determined to be Immediate Jeopardy on 12/31/2012. Findings include: On 12/31/12 at 08:30 a.m., the investigator entered the facility. There was no signage currently posted at the entrance to the facility to alert visitors of the presence of a contagious infection in the building. At 08:45 a.m., Staff 1 told the investigator that residents and staff were experiencing "the flu" and "just getting over it". She was not certain when it started. She stated 30 staff had reported they experienced symptoms including nausea, vomiting and diarrhea. She did not know how many residents had the infection. At 09:02 a.m., the Director of Nursing Services (DNS) reported symptoms including the above plus "low-grade fever" for some residents. Most residents were symptomatic for about 24 hours, but a few were "a little longer". The facility had not sent any samples to the laboratory for analysis. She noted it started on 12/14/12 and thought about "two-thirds" of all residents had experienced the infection. She did not know whether the Administrator notified the County Health Department or the State Hotline regarding the outbreak of the infection. The facility had not alerted visitors on entry doors to the facility over the holidays of the outbreak of intestinal illness. The DNS stated no residents had been admitted ,[DATE] - 12/26/12. She stated the facility had not voluntarily stopped admissions - none were scheduled. The DNS reported the next admission after the holiday developed symptoms. At the time of this interview, the DNS reported no new cases since 12/29/12. Later in the morning on 12/31/12, she learned that another resident experienced new symptoms of the infection. The facility isolated residents in their rooms only when they developed active symptoms. Any residents who were not experiencing symptoms were permitted to eat in the central dining room and participate in group activities. Although the facility identified and recorded which residents in which rooms were ill by date, there was no attempt on the facility ' s part to look at cross contamination of residents, care givers, housekeeping staff or other staff who would typically have access/interaction to various parts of the building going from infected resident rooms to rooms where residents were not infected. No additional cleaning measures/techniques were initiated since the outbreak began on 12/11/12 to prevent cross contamination or spread of the infection. Residents were not advised or educated on hand washing or cross contamination prevention. Staff were not re-educated or prepared to cope with the increased needs of residents during the outbreak of infection, and the reduced availability of additional staff resources. Visitors were not alerted to the outbreak in the building until 12/22/12. On that date a sign was posted at the entrance to only one unit alerting visitors of the symptoms on that unit with a recommendation not to visit. At 09:30 a.m., the Administrator reported he had not notified the County Health Department or State Hotline of the outbreak of infection in the building. Although staff were assigned to specific resident rooms, they often helped in other areas of the building during their work. He explained the facility did cancel one Christmas Party scheduled for 12/21/12. All other group activities were continuing. Residents without active symptoms were allowed to eat in the group dining rooms, which were using the facility routine non-disposable dishes and silverware. The Administrator stated he had notified the faciltiy Medical Director (MD) on 12/27/12 that a number of residents were experiencing symptom on nausea, vomiting and diarrhea but had not communicated the scope of the outbreak to the MD. The DNS was unable to locate a written policy for facility infection control related to infection outbreak. Review of documentation revealed 73 of 91 residents experienced symptoms of nausea/vomiting, diarrhea and/or fever. The outbreak of infection began on 12/11/12 in one unit of the building. On 12/14/12 it began on a second unit. The third unit of the facility had its first case on 12/20/12. Although the facility identified the residents and spread of the infection through the building, the facility did not assess for cross contamination, observe hand washing techniques of staff and residents, alert visitors to the risk of entering the building, develop interventions to prevent additional outbreak of infection among residents and staff, such as stopping group activities or implementing additional cleaning procedures, or report the outbreak to County Health Department officials and the State hotline. Thirty staff members, including one nurse, 15 nursing assistants, one housekeeper, one laundry worker, two business office workers, one medical records worker, five rehabilitation workers, and one activities worker, experienced symptoms between 12/13/12 and 12/29/12. Additionally, two children in the day care extension of the building also developed symptoms on 12/13/12 and 12/20/12, respectively. There was no evidence of documentation of monitoring of the spread of the infection within rooms, such as when first one resident developed symptoms followed by the roommate, or among the resident care units. No timeline of when residents in an adjacent room that shared a bathroom likewise developed symptoms. Staff were not restricted to working within a unit or educated on potential cross contamination during the outbreak. There was no tracking of which staff assisted which residents when to correlate development of symptoms and spread of the infection. No analysis of the development and spread of the infection throughout the facility was performed. No interventions to restrict staff assignment/movement or instructions to remain at home until after all symptoms were gone or if symptoms developed at work to alert their supervisor immediately and cease all care activities with residents were documented. There was no evidence of documentation for the isolation and monitoring of residents beyond active symptoms. No consideration of possible benefit of isolation of residents beyond the active symptom phase was documented or implemented. No documentation of additional cleaning/disinfection procedures for infectious outbreak was found. The undated documentation titled addition to standard precautions pending confirmation of [DIAGNOSES REDACTED]. There was no evidence of guidance for continent residents who developed diarrhea. Additionally, there was no documentation of guidance for outbreaks of symptoms of infectious vomiting or fever among the resident population. On 01/04/13 at 11:50 a.m., the DNS reported she served as the Infection Control Nurse (ICN) for the facility from early December 2012 through the end of the year. The DNS described the role of ICN as the person who kept track of infections in the building and recorded trends of infections. The ICN would in-service staff to abate those trends of infection. There was no infection control program when she assumed the role. No facility team existed for infection control routine monitoring or reporting of outbreaks. The facility implemented appropriate linen procedures to prevent the spread of infection, but lacked a written infection control policy or program for illness/outbreak. This prevented the facility staff from knowing what additional interventions to implement and when, as well as how long to isolate residents to prevent spread of the infection.

Based on interview and record review, facility staff failed to meet professional standards of practice for identifying and monitoring potential medication-to-medication interactions and potential negative outcomes. Failure to meet current standards of practice for monitoring [MEDICATION NAME], an anticoagulant, and [MEDICATION NAME], an antibiotic, for decreased blood clotting ability resulted in an unidentified, elevated International Normalized Ratio (INR). Resident 1 suffered harm from the elevated INR when he fell , hit his head and suffered a subdural bleed in his brain. Definitions The Center for Medicare and Medicaid Services State Operating Manual, dated January 2011, defines "professional standards of quality" as services provided according to accepted standards of clinical practice. Recommended practices to achieve desired resident outcomes may be found in clinical literature, current manuals or textbooks, or published by a professional organization. The table titled "Common Medication-medication interactions in Long Term Care" identified [MEDICATION NAME], also brand name [MEDICATION NAME], interacts with some antibiotics, including [MEDICATION NAME]. The interaction between the two medications is listed as increased effects of [MEDICATION NAME], with potential for bleeding. [MEDICATION NAME] has a narrow therapeutic range. Basic blood thinning range is 2.0 - 3.0. Monitoring of the anticoagulation range is commonly done using the blood test, INR. Findings include: Resident 1 was admitted in February 2012 with [DIAGNOSES REDACTED]. He received [MEDICATION NAME] for his cardiac arrhythmia of [MEDICAL CONDITION] and history of stroke. On Saturday evening of 05/27/12, Licensed Nurse (LN) 2 took a new order from the on-call physician for [MEDICATION NAME], an antibiotic, for urinary tract infection and faxed a copy of the order to the pharmacy, which was closed for the weekend. LN 3 removed the first dose of the antibiotic from the emergency kit (e-kit) within the facility and administered it to Resident 1. Because the pharmacy was closed on Sunday (per usual) and Monday (holiday), LNs 4 and 5 also removed doses of the [MEDICATION NAME] from the e-kit and documented administration of the [MEDICATION NAME] to Resident 1 as ordered and scheduled on those days. On 05/29/12, Pharmacist (Ph 3) contacted LN 5 and informed her of the interaction between [MEDICATION NAME] and [MEDICATION NAME]. Per Ph 3's written statement, the order for the antibiotic was processed in the pharmacy on 05/29/12 and the computer flagged the medications for interaction. Ph 3 telephoned the physician of record twice, but did not reach him. Ph 3 phoned the facility that evening and told staff of the medication interactions. By that time, Resident 1 had received 4 of 6 ordered doses of [MEDICATION NAME]. LN 2 telephoned the on call physician and told him of the medication interactions. He stated he knew and not concerned at that time. On the morning of 05/30/12, Resident 1 completed the [MEDICATION NAME] medication. That morning, a previously scheduled INR check was performed. Resident 1's INR was greater than 8, a supratherapeutic level. Nursing notified the physician of the critical value INR. He ordered the [MEDICATION NAME] held and to recheck the INR level on 06/01/12. About 1:15 p.m. on 05/30/12, Resident 1 fell and hit his head on the metal frame of the bed in his room. LN 6, who cared for Resident 1 that day, reported she assessed Resident 1 and observed a "large reddened area" on the right back of his head. There was no open wound. She phoned the physician, who responded in 30-45 minutes, and ordered Resident 1 sent to the hospital for future evaluation. When transport arrived, Resident 1's speech was beginning to slur, and he was becoming more lethargic. Hospital records, dated 05/30/12, revealed Resident 1 had an INR above 11. A brain scan identified a new small subdural hematoma on the right. On 08/21/12 at 9:56 a.m., the Director of Nursing Services (DNS) reported the nursing standard in the facility was for nurses to not give any medication without knowing what was, what it was for, and what side effects to monitor. The DNS did not expect the nurses to know all medications and possible interactions. They should access references for medications. Among the written medications references the facility used was The Lippencott Nursing Drug Handbook. The handbook, dated 2013, identified [MEDICATION NAME] as a safety alert medication. [MEDICATION NAME] was listed under the incompatibilities section. Drug-drug interactions category identified all fluoroquinolones ([MEDICATION NAME] is within this group) in bold type as may increase anticoagulant effect. Monitor the patient carefully for bleeding and reduce the anticoagulant dosage as directed. Additionally, [MEDICATION NAME] was identified as a "black box warning" medication and described as able to cause major or fatal bleeding. On-line access to Medline revealed under the "important warning" section to notify the doctor if a person falls often and bleeding is more likely during [MEDICATION NAME] treatment for [REDACTED]. Under "special precautions" medication interaction of [MEDICATION NAME] and "especially antibiotics" was identified. Manufacturer on-line information, dated 11/08/11, noted [MEDICATION NAME] and [MEDICATION NAME] can affect each other causing side effects. On 08/22/12 at 2:23 p.m., LN 2 reported she obtained the order for the [MEDICATION NAME] from the on-call physician on 05/27/12. She did not alert the physician that Resident 1 was taking [MEDICATION NAME]. She did not recall whether she knew about the interaction between [MEDICATION NAME] and [MEDICATION NAME] at that time. She usually phoned the pharmacist for new MEDICATION ORDERS FOR [REDACTED]. She focused on Resident 1's fever and his behaviors, which she described as "delirious and restless". He needed more assistance during this time. She did not think about monitoring for medication interactions. LN 2 asked LN 3 to get the first dose from the e-kit. On 08/22/12 at 1:04 p.m., LN 3 reported she obtained the first dose of [MEDICATION NAME] from the e-kit and sent a fax to the pharmacy requesting a replacement dose for the one pulled from the e-kit. She knew Resident 1 was taking [MEDICATION NAME], but she was unaware of the medication-to-medication interaction between [MEDICATION NAME] and [MEDICATION NAME]. She did not check for any medication interactions prior to obtaining the [MEDICATION NAME]. She had access to written medication reference materials at the medication cart and Medline on-line via computer.

Based on interview and record review, the facility failed to recognize and monitor for potential clinically significant adverse medication-to-medication interaction. Failure to monitor medication-to-medication interactions of [MEDICATION NAME], an anticoagulant, and [MEDICATION NAME], an antibiotic, resulted in harm of a supratherapeutic level of [MEDICATION NAME] for Resident 1 International Normalized Ratio (INR) that contributed to a subdural bleed for which the resident required hospitalization for treatment when he fell and hit his head in the facility. The Center for Medicare and Medicaid Services State Operations Manual Appendix PP, dated January 2011, describes lack of adequate monitoring for [MEDICATION NAME] occurs when facilities fail to monitor for potential clinically significant adverse consequences when a resident receives other medications that are known to increase the risk of bleeding or to interact with [MEDICATION NAME] and increase INR. Findings include: Resident 1 was admitted in February 2012 with [DIAGNOSES REDACTED]. His physician ordered [MEDICATION NAME], an anticoagulant medication that slows blood clotting. [MEDICATION NAME] is known to interact with certain antibiotics, such as [MEDICATION NAME]. These interactions can increase the INR level, which increases the potential for bleeding when injury occurs. Review of the clinical record revealed on 05/27/12 evening shift, the physician ordered [MEDICATION NAME] started for treatment of [REDACTED]. LN 2 did not assess whether a current INR was present in the record. LN 2 did not contact pharmacy to identify any possible medication-to-medication interactions that should be monitored prior to initiating the order as described in the pharmacy policy. On 05/28/12 and 05/29/12 LNs 4 and 5 also removed the doses of [MEDICATION NAME] from the e-kit and administered them to Resident 1. Nursing administered 4 of 6 ordered doses of the [MEDICATION NAME] before the pharmacy re-opened for normal business hours on 05/29/12. Pharmacist (Ph) 3 attempted twice unsuccessfully to reach the physician of record during the day of 05/29/12. Ph 3 notified the facility of the medication-to-medication interaction during the evening shift of 05/29/12. There was no evidence of documentation of recommendation of INR monitoring during the administration of the antibiotic. On 05/30/12 Resident 1's INR level was above 8. The American College of Cardiology (2001:38:1231) noted the odds of [MEDICAL CONDITION] increase dramatically when a person has an INR above 7. Resident 1 had a history of [REDACTED]. He had poor balance and walked with an unusually high step. Nursing documentation, between 05/26/12 and 05/30/12, noted he was "really restless". He did not wait for help as he usually did. He fell on the morning of 05/27/12, but did not injure himself. New England Journal of Medicine (2011; 365:2002) reported [MEDICATION NAME] as the most likely medication for emergency hospitalization of adverse drug events in older adults of the United States (2007-2009). On the afternoon of 05/30/12, Resident 1 fell and hit his head on the metal frame of the bed. He was sent to and admitted into the hospital, where his INR was documented as above 11. Diagnostic testing revealed a subdural bleed in his brain. On 08/21/12 at 9:56 a.m., the Director of Nursing reported the facility had the capability to perform INR testing within the facility at any time. She noted nursing should follow pharmacy policy for medication administration, including contacting the pharmacist if they were not familiar with the adverse complications of medication interactions. Additionally, all nurses had access to current editions of medication reference materials at the medication carts. On 08/22 12 at 3 p.m., the DNS reported the INR test on 05/30/12 was scheduled as a monthly INR check. It was not performed as monitoring for the interaction of the [MEDICATION NAME] and [MEDICATION NAME] and any possible negative effects. On 08/22/12 at 08:20 a.m., Pharmacist (Ph) 1 reported the process for new medications ordered after hours was for nursing to telephone the after-hours phone number listed in the pharmacy contract section 1.3. If nursing removed a medication from the e-kit, nursing should contact the pharmacy, nursing was "obligated" to contact the pharmacy. In this instance, the pharmacy did receive notification until Tuesday, 05/29/12, when the pharmacy opened after the Monday holiday. Ph 1 stated the on-call pharmacist had remote computer access to resident records, including current medication orders, allergies [REDACTED]. He did not recall anyone from the facility calling him to request information or notify him of the new antibiotic medication order for Resident 1. Review of the pharmacy policy, dated 02/01/06, revealed pharmacy provided routine services 6 days per week and emergency pharmacy services 24 hours per day, 7 days per week. Pharmacy would screen each new medication order for drug interactions with other current medications ordered for the resident. The pharmacy contract, dated 01/03/12, section 1.3 identified the telephone number to initiate emergency pharmacy services. Section 1.2 read pharmacy services included provision of drug information and consultation to the facility's licensed professional staff regarding products ordered. See F281 - professional standards for additional details