Every finding on record at Regency Wenatchee Rehabiliation & Nursing Center

Based on observation, interview and record review, the facility failed to ensure residents health information remained private for 4 of 5 residents (Residents 5, 3, 23, and 41) reviewed for the resident's right to privacy. Additionally, the facility staff referred to Resident 5 by a pet name which did not respect their right to be addressed by their own name when interacting with staff. This failure placed residents at risk for embarrassment and a poor quality of life. Findings included . Review of the facility's policy titled, Resident Rights revised date, 11/2025, showed the facility will honor resident rights as follows: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including state agencies and the resident's representative. The resident has the right to receive treatment and care with respect and dignity in a manner and in a safe, clean, and homelike environment that promotes maintenance or enhancement of his or her quality of life. Resident 5 Review of the resident's medical record showed they were admitted to the facility with diagnoses which included dementia, Parkinson's disease (an ongoing disease that destroys nerve cells and effects muscle movement) and dysphagia (difficulty in swallowing).The comprehensive assessment dated [DATE] showed the resident had severe cognitive impairment and required total assistance from staff for activities such as dressing grooming toileting, mobility and bathing. The assessment also showed the resident had swallowing difficulty which required a specialized texture diet. During an observation on 03/09/2026 at 9:30 AM, Staff U, Nursing Assistant (NA) was standing by Resident 5's bed getting ready to assist them with their meal. Above the bed taped to the wall was an undated handwritten paper sign which had specific swallowing guidelines for Resident 5. The sign with health care information was clearly visible to anyone who entered the resident's room. The sign was titled, Swallow Strategies Sit upright Suspension/Support Encourage resident to fully chew and swallow Single drinks no changing Alternate bites and sips Make sure mouth is clear after meal Continued observation of Staff U conversing with Resident 5 while assisting them to eat, showed Staff U say to Resident 5 here baby take one more bite as they coaxed the resident to eat. Staff U continued to refer to the resident as baby several more times during the interaction. During additional follow up observations on 03/10/2026 at 9:30 AM, 03/10/2026 at 12:09 PM, and 03/11/2026, at 9:01 AM, showed the sign titled Swallow Strategies remained above Resident 5's bed with the specific health information visible to anyone who entered the room. During a concurrent observation and interview on 03/11/2026 at 9:10 AM, Staff C, Interim Director of Nursing Services was shown the sign above Resident 5's bed and agreed it had health care information and stated they (Resident 5) were unable to give consent to post the sign above their bed and removed it. Staff C stated they were not sure where the sign originated or why it was above the resident's bed. Additionally, Staff C stated it was not appropriate for staff to refer to Resident 5 as baby when conversing or interacting with them. Resident 3 Review of the medical record showed that Resident 3 was admitted to the facility on [DATE] with diagnoses that included stroke (when blood flow is blocked from the brain), cognitive communication deficit (trouble participating in conversations), dysphagia (difficulty swallowing), and the need for assistance with personal care. The comprehensive assessment dated [DATE] showed the resident's cognition was moderately impaired and required assistance of one staff member with eating. During an interview and concurrent observation on 03/09/2026 at 3:32 PM, Resident 3 stated they liked to be up for dinner to have their tuna salad. A yellow paper was observed hanging from the light fixture above the resident's bed dated 02/17/2026 that had Resident 3's diet and their diagnoses. During an observation on 03/10/2026 at 2:16 PM, Resident 3 was lying in bed resting. The same yellow sign was observed above the resident's bed taped to the light fixture. The yellow sign contained the resident's diet and diagnoses with a date of 02/17/2026. Resident 23 Review of the medical record showed Resident 23 was admitted to the facility on [DATE] with diagnoses to include heart failure, dysphagia, and diabetes (a disease in which the body does not control glucose [a type of sugar] in the blood). The comprehensive assessment dated [DATE], showed Resident 23 was independent with eating, required assistance of one staff member for transfers and their cognition was moderately impaired. During an interview and concurrent observation on 03/10/2026 at 11:44 AM, Resident 23 stated the food was hard to swallow because they did not like the stuff called puree (food that is blended to a silky-smooth texture). Resident 23 had a yellow paper above the bed taped to the light fixture; the paper had showed a puree diet and diagnoses of dysphagia for Resident 23. In an interview on 03/11/2026 at 12:38 PM, Staff M, Nursing Assistant (NA), stated the sign above the bed had been there since the resident admitted . Staff M stated they were unclear why the sign had been posted above the resident's bed. Staff M stated that there were a few residents in the facility with those types of signs up by the head of their beds. During an observation on 03/11/2026 at 12:41 PM, showed Resident 23 had a yellow paper taped to the light fixture above the bed with a puree diet and diagnoses of dysphagia. Resident 41 Review of the medical record showed Resident 41 was admitted to the facility on [DATE] with diagnoses to include Parkinson's disease (a progressive brain disorder that causes movement problems like tremors, stiffness and slowness), dysphagia, and dysphonia (an abnormal voice). The comprehensive assessment showed Resident 41 required setup assistance of one staff member for meals, and their cognition was moderately impaired. During an observation and concurrent interview on 03/09/2026 at 12:20 PM, Resident 41 was lying in bed resting, they had a sign above their bed for thickened liquids. The resident was being assisted by an unidentified staff member with their meal. The unidentified staff member stated they were unsure who placed the signs above the beds but stated a lot of the residents had the signs posted in their rooms. During an observation on 03/11/2026 at 10:53 AM, Resident 41 was asleep in bed covered with a sheet. There was a sign above their bed that stated the resident was to have thickened liquids. In an interview on 03/13/2026 at 10:04 AM, Staff C Interim Director of Nursing Services acknowledged the signs above the residents' beds and stated they had removed the signs that were above the beds. Reference: WAC 388-97-0180 (1-4)

Based on interview and record review, the facility failed to ensure notification of the notice of transfers to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a person that advocates for residents in nursing homes) occurred for 2 of 5 residents (Residents 52 and 61) reviewed for discharge. This failure placed the residents at risk for diminished protection, lack of access to an advocate that could inform them of their options and rights, and to ensure the resident advocacy agency was aware of the facility practices and activities related to discharge. Findings included . Resident 52 Review of the resident's medical records showed they admitted to the facility on [DATE] with a diagnosis of sepsis (A life threatening medical emergency caused by the body's extreme dysfunctional response to an infection). Review of the 02/18/2026 discharge assessment showed Resident 52's cognition was intact. Review of Resident 52's medical record showed Resident 52 was discharged home on [DATE]. Review of the Ombudsman notification list (a formal internal record or log used by a nursing facility to track and verify that they have informed the ombudsman of every resident transfer or discharge) for February and March 2026 showed no notification of discharge to the Ombudsman for Resident 52. Resident 61 Review of the resident's medical records showed they admitted to the facility on [DATE] with a diagnosis of influenza A (A highly contagious respiratory illness). Review of the 02/11/2026 discharge assessment showed Resident 61 had moderately impaired cognition. Review of Resident 61's medical record showed Resident 61 was discharged home on [DATE]. Review of the Ombudsman notification list (a formal internal record or log used by a nursing facility to track and verify that they have informed the ombudsman of every resident transfer or discharge) for February and March 2026 showed no notification of discharge to the Ombudsman for Resident 61. During an interview on 03/11/2026 at 10:49 AM, Staff P, Admissions Manager, stated they were responsible for notifying the Ombudsman of discharges. Staff P stated they only notified the Ombudsman if a resident was transferred to the hospital. Staff P further stated they were not aware of the requirement to notify the Ombudsman of all facility discharges. During an interview on 03/12/2026 at 12:11 PM, Staff B, Administer in Training, stated the correct process was for the Ombudsman to be notified of every resident discharge. Staff B further stated Staff P did not follow the correct process. Reference WAC 388-97-0120 (5)

Based on observation, interview, and record review, the facility failed to identify the risks and initiate interventions to prevent further accidents for 2 of 3 residents (Residents 35 and 11) reviewed for accidents. Resident 35 experienced harm when hot soup was served on the overbed table and when the resident went to pull the tray closer to them to be within reach, the soup spilt onto their lap causing a third-degree burn to the left thigh. In addition, the facility failed to provide consistent supervision, thoroughly investigate the cause of falls, and ensure interventions were put into place to prevent further falls for Resident 11. These failures placed the residents at risk for injury and/or medical complications and a decreased quality of life. Findings included . Review of an article written by the American Burn Association titled Scald Injury Prevention dated 04/25/2017, showed the time and temperatures it would take for a hot liquid to cause a third-degree burn as, 155 degrees Fahrenheit (F), one second, 148 degrees F, two seconds, 140 degrees F, five seconds, 133 degrees F, 15 seconds, 127 degrees F, one minute, 124 degrees F, three minutes, 120 degrees F, five minutes and 100 degrees F as a safe temperature. <Resident 35> Review of the medical record showed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a fractured pelvis, heart disease, and chronic pain. Resident 35 ' s most recent comprehensive assessment dated [DATE] showed they were cognitively intact and required moderate to maximum assistance of one to two caregivers for activities of daily living (ADLs). During an interview on 04/29/2025 at 10:07 AM with Resident 35 ' s Representative, they stated the resident received a third-degree burn on the top of their left thigh on 03/27/2025 from hot soup spilling on their lap. The Representative stated they had concerns that the soup was so hot that it caused such a serious burn and that it was taking so long to heal. They stated they felt Resident 35 ' s health status had declined in both their ability to care for themselves and cognitively since they returned from the hospital on 03/22/2025 after falling and fracturing their pelvis and had shared this concern with the facility ' s administrative staff. During an interview on 04/30/2025 at 9:32 AM, Resident 35 stated they remembered well what had happened the day the soup spilled on their lap but could not recall the date. They stated they were eating in their room because the dining room was closed that day, and their dinner was brought to them and set on the overbed table. Resident 35 stated they went to pull the tray closer to them and the tray with the soup bowl fell off onto their lap and they felt it burn through their pants right away. Resident 35 stated they called for help and a nurse came in and helped them clean up and later told them the area was starting to blister and would call their physician. During the same interview Resident 35 stated their physician examined the burn about a week ago (prior the interview) and said it was a stage three burn and looked infected, which caused them a lot of concern. They stated they had been taking antibiotics for the burn which was still painful and itched constantly. Review of a provider note dated 04/17/2025 stated, left thigh 2/3- (second to third) degree burn observed and noted green eschar (a thick, dry, crusty layer of dead tissue that forms on the surface of a wound or burn) in the center of the wound and would be starting the resident on antibiotics. Review of the facility ' s incident report regarding the burn dated 04/01/2025 showed the resident received a burn to the top of the left thigh on 03/27/2025 from hot soup spilling in their lap. The resident ' s skin was checked at the time and a light pink area measuring 8.0 centimeters (cm) (a unit of measure) in width by 4.0 cm in length was noted to the left medial (middle) thigh. The skin was checked later that evening and the skin on the thigh was loose and a blister had formed measuring 6.5 cm in width by 2.0 cm in length. The area was cleansed and covered with a dressing and the resident ' s physician was notified. The incident report further showed that the soup was being held at a temperature of 187 degrees Fahrenheit (F) on the tray line in the kitchen, an appropriate temperature to allow for cooling during service. Per the Registered Dietician statement, the soup likely would have cooled as much as 20 degrees F or more at the time of delivery to the resident. Review of Resident 35 ' s care plan last revised on 11/29/2024 showed they were independent with eating and set up. An updated intervention on the care plan dated 04/04/2025 showed when the resident ate in their room, staff would provide frequent checks to ensure the resident did not require any assistance during the meal and all items were within reach and easily accessible before leaving the room. Review of the facility ' s kitchen temperature logbook showed staff were to take the temperature of the food prior to the tray line service and again halfway through the tray line service. Review of the temperatures of the food for dinner on 03/27/2025 showed the holding temperature for soup was 187 degrees F both prior to serve out and mid serve out. Review of soup temperatures from 03/27/2025 through 04/17/2025 for dinner showed the lowest holding temperature as 175 degrees F and the highest holding temperature as 196 degrees F with varying degrees in between the high and low temperatures noted. During an interview with the Staff L, Dietician, on 04/30/2025 at 12:35 PM, they stated the facility kitchen staff followed the regulations that required certain foods to be cooked to a specific degree for food safety and all hot foods needed to be held at a temperature of 135 degrees F or higher to prevent food borne illness and then to a temperature that was palatable (pleasant to taste) for the residents. Staff L stated the facility did not hold food or drink to the degrees to prevent possible burns if spilled on a resident as different foods and drinks have different palatable tastes, but if there is a concern that a resident was not physically or cognitively able to safely handle hot liquids, then an individual assessment of the resident ' s competence to do so should be completed. During an interview with Staff M, Dietary Manager (DM) on 05/01/2025 at 12:44 PM, they stated they kept soup in the holding cabinet warmer in soup bowls prior to serve out or the kitchen staff microwaved the soup and sent it out if the soup was cold. Staff M stated when residents asked for soup and had not preordered it for the meal, the staff would microwave the soup for them. The DM stated they did not take the temperature of the soup after it came out of the microwave and had no process or direction in place on how long to microwave the soup or any food, but usually did it for two or three minutes, or until it seemed hot. In addition, Staff M did not know how long it took for staff to deliver the food to the residents after it was microwaved or if Resident 35 ' s soup was kept in the holding cabinet or microwaved prior to serving them on 03/27/2025. Observation of the wound on 05/02/2025 at 9:47AM, while being toileted by a nursing assistant, showed a 4.0 cm width by 2.0 cm length wound to the left medial thigh with black eschar in the center of the wound with surrounding redness. The resident stated the wound hurt all the time but hurt the worst when the dressings were changed on it. During an interview with Staff A, Administrator, on 05/01/2025 at 4:17 PM, they stated the facility did not do any follow up assessments on Resident 35 to see if they were capable of handling hot liquids at a high temperature after they obtained the burn on 03/27/2025 to possibly prevent burns in the future. During an interview with Staff B, Director of Nursing and Staff C, Regional Clinical Director on 05/06/2025 at 12:25 PM, they stated no further follow up was completed for Resident 35 after the burn happened to see if they could competently handle hot liquids while eating or drinking to mitigate the risk for repeated burns from occurring. <Resident 11> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including dementia and degenerative joint disease (a type of arthritis characterized by the breakdown of [NAME] in the joints causing pain, stiffness and decreased movement) in both knees. Resident 11's most recent comprehensive assessment dated [DATE] showed they had moderately impaired cognition and required minimum to moderate assistance of one to two caregivers for activities of daily living (ADL's) and could not ambulate. During an observation and interview with Resident 11 on 05/02/2025 at 11:13 AM, showed them sitting in their wheelchair in their room looking out the window. Resident 11 stated they had never had a fall in their room or bathroom and could walk independently without any assistance. Review of the facility reporting logbook showed Resident 11 had nine falls in the facility within the past five months. November 2024 through March 2025. Review of the facility incident reports for Resident 11 showed they had two observed falls on 11/14/2024 and 12/23/2024 and seven unobserved falls on 11/04/2024, 12/26/2024, 01/13/2025, 02/19/2025, 03/01/2025, 03/13/2025 and 03/31/2025. None of the unobserved falls had witness statements attached showing a thorough investigation was completed into the possible causes of the falls or that abuse, and neglect had thoroughly been ruled out as a cause of the falls. Review of Resident 11's care plan initiated on 03/03/2021 and last revised on 04/07/2025, showed the resident was at risk for falls r/t pain, weakness, deconditioning, degenerative joint disease in both knees, vertigo (dizziness), history of falls, cognitive impairment, profound hearing loss, epilepsy (a seizure disorder), impulsiveness, impaired vision, poor decision making, and overestimating abilities. Further review of the care plan showed the problem of being at a high risk for falls and goals to be free of falls were updated on 01/13/2025, 03/18/2025 and 04/07/2025, additional interventions to decrease the risk for falls were only initiated for the two of the nine falls dated 01/13/2025 and 02/19/2025. During an interview with Staff B, DON and Staff C, RCD on 05/07/2025 at 12:48 PM, they both acknowledged that thorough investigations into the causes of the falls and to ensure abuse or neglect was not the cause of the falls was not completed. In addition, they both acknowledged that limited interventions were put into place after the falls to prevent future falls and keep Resident 11 as safe as possible. Reference: WAC 388-97-1060(3)(g)

Based on interviews and record reviews, the facility failed to follow up on written notices of bed holds (holding or reserving a resident's bed while the resident was absent from the facility) given at the time of hospital transfers, and/or failed to send a copy of the notice of transfers to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a person that advocates for residents in nursing homes) for four of four residents (Residents 35, 14, 51 and 49) reviewed for discharge process. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed hold while in the hospital and disallowed the resident and/or their representative an opportunity to fully understand the rationale/resident rights associated with the discharge. This failure also placed the residents at risk for diminished protection, lack of access to an advocate that could inform them of their options and rights, and to ensure the resident advocacy agency was aware of the facility practices and activities related to transfer or discharge. Finding included . Review of a facility policy titled Bed Hold/Notice of Transfer/Discharge last revised on 02/2025 and located in the transfer and discharge packets sent with residents on transfer or discharge from the facility, shows Statement #5 of the policy reading as If a resident is Medicaid, the resident may elect to privately pay for the bed hold at 90% of the current rate per day. <Resident 35> Review of the medical record showed Resident 35 was readmitted to the facility on [DATE] with diagnoses including a fractured pelvis and chronic pain. The resident's comprehensive assessment dated [DATE] showed they required moderate assistance of one staff member for activities of daily living (ADLs) and was cognitively intact. Further review of Resident 35's medical record showed the resident was transferred to the hospital on 03/19/2025 following a ground level fall in their bathroom. The resident was admitted to the hospital for a fractured pelvis and returned to the facility on [DATE]. The record showed no notice of a bed hold was given to either Resident 35 or their representative. During an interview on 04/29/2025 at 10:07 AM with Resident 35's representative, they stated they had not seen a notification of a bed hold policy sent to the hospital with Resident 35 on 03/19/2025 and no one from the facility had contacted them at anytime during the resident's hospital stay asking if they would like to hold the resident's bed. <Resident 14> Review of the medical record showed Resident 35 was readmitted to the facility on [DATE] with diagnoses including end stage renal disease with dialysis, and paralysis of the lower extremities. The resident's comprehensive assessment dated [DATE] showed they required maximum total assistance of one to two caregivers for ADLs and was cognitively intact. Further review of Resident 14's medical record showed they were transferred to the hospital on 01/23/2025 for abdominal pain and was admitted . The resident returned to the facility on [DATE] with diagnoses of a urinary tract infection and a fecal impaction. There was no record showing whether the resident or their representative were given a bed hold notification. During an interview on 04/29/2025 at 11:10 AM with Resident 14, they stated they did not recall ever being asked if they wanted to hold their bed when they were transferred out to the hospital and did not know it was a possibility, they might not have a bed to return to. 43280 <Resident 51> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including surgical aftercare of a left ankle infection/debridement (removal of dead, damaged or infected skin) with intravenous (medication through a vein in the body) antibiotic therapy. The 01/25/2025 comprehensive assessment showed Resident 41 was cognitively intact and was able to make their needs known. Resident 51 was discharged on [DATE]. An additional review of Resident 51's medical showed no documentation that the LTC Ombudsman was notified of the resident's discharge. <Resident 49> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including multiple heart/lung complications, depression and anxiety. The 02/10/2025 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Review of Resident 49's hospital transfer evaluation showed the resident was transferred to the hospital on 02/22/2025 when they became confused and unable to stay awake. Resident 49 was discharged on [DATE]. An additional review of Resident 49's medical record showed no documentation that the LTC Ombudsman was notified of the resident's discharge. During an interview on 05/01/2025 at 4:17 PM with Staff A, Administrator, about the facility's processes for bed holds, and Ombudsman notifications of transfers and discharges, they stated bed holds go out with the resident's in a packet on transfer and are followed up if necessary after admission to the hospital with the resident and/or their representative by the facility's Business Office Manager (BOM). Staff A stated during the same interview they recently discovered the facility was not sending out notifications of transfers and discharges to the Ombudsman office as required. Staff A stated the medical records department previously sent out the Ombudsman notifications and would have more information on the facility's current process. During an interview on 05/05/2025 at 11:08 AM, Staff S, Medical Records, stated they had started their position in the facility in July of 2024 and had not sent any notifications of residents transferred and discharged out of the facility to the Ombudsman office since that time. Staff S stated that no one had informed them when they took the position that it was a requirement to do so. During an interview on 05/05/2025 at 11:16 AM, with Staff T, BOM, they stated they did not follow up on bed holds for residents if their payor source was Medicaid because Medicaid paid for 20 days of hospitalization automatically. Staff T stated the facility always held these residents beds for them and took them back regardless of how many days they had been gone as this was their home. The BOM stated during the same interview that all residents transferred to the hospital get a packet sent with them that had a bed hold policy in it regardless of pay source, so they thought the requirement was met by providing the information on all transfers and/or discharges. Reference: WAC 388-97-0120(3)(c)(5)(a)(b)

Based on interview and record review, the facility failed to develop a baseline care plan [(BCP) a document outlining initial care goals and necessary healthcare information for a resident], within 48 hours of admission, that included the minimum requirements of resident specific goals, physician orders, dietary orders, treatment plans, and social service needs for 6 of 10 residents (Residents 39, 13, 202, 33, 41, and 32) reviewed for new admissions (residents admitted to the facility in the last 30 days). Failure to develop a BCP placed the residents at risk of not receiving continuity of care and resident centered care needs. Findings included . Review of a policy titled, Baseline Care Plan, revised 11/08/2021, showed a BCP would be developed within 48 hours of admission that included the minimum healthcare information necessary to care for the resident, that also met regulatory requirements. <Resident 39> Review of the medical record showed Resident 39 was admitted to the facility on [DATE] with diagnoses including palliative care (specialized medical care for individuals with serious illnesses, focusing on relieving symptoms, managing stress, and improving quality of life), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), severe malnutrition (significant low body weight for height), and adult failure to thrive (a progressive loss of physical and functional abilities, often accompanied by weight loss, poor appetite, and reduced activity levels. The 04/25/2025 comprehensive assessment showed Resident 39 required substantial/maximum assistance of one staff member for activities of daily living (ADLs) and had a severely impaired cognition. The assessment also showed Resident 39 was receiving hospice services. Record review of Resident 39's BCP, dated 04/21/2025, showed no resident specific goals or interventions for Resident 39's dietary orders, social services, or hospice services. <Resident 13> Review of the medical record showed Resident 13 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening condition that arises when the body's response to an infection that damages its own tissues and organs), bacteremia (the presence of bacteria in the blood), and inflammation of the brain and spinal cord. The 03/29/2025 comprehensive assessment showed Resident 13 was dependent on one to two staff for ADLs and was cognitively intact. The assessment also showed Resident 13 was receiving antibiotics (medications that fight bacterial infections) through a peripherally inserted central catheter [PICC) a long, thin tube inserted into a vein in the upper arm and threaded to a larger vein in the chest, near the heart). Record review of Resident 13's BCP, dated 03/25/2025, showed no resident specific goals or interventions for Resident 13's dietary orders, physicians orders, social services, or care and treatment of their PICC line. <Resident 202> Review of the medical record showed Resident 202 was admitted to the facility on [DATE] with diagnoses including a stroke (damage to the brain from interruption of its blood supply), pain, and difficulty swallowing. The 04/28/2025 comprehensive assessment showed Resident 202 required supervision for eating, and set-up assistance for personal cares. The assessment showed Resident 202 had an intact cognition. Record review of Resident 202's BCP, dated 04/24/2025, showed no specific goals or interventions for Resident 202's dietary orders and social service's needs. 43280 <Resident 33> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including left ankle surgical aftercare, with a long-term history of spin/back complications. The 03/29/2025 comprehensive assessment showed Resident 33 had functional impairments (weakened or damaged) to their range of motion on both upper and lower legs/arms. The resident had moderately impaired cognition but was able to make their needs known. Record review of Resident 33's medical record showed no documentation of a BCP had been completed. <Resident 41> Review of the medical record showed the resident was admitted to the facility on [DATE] and readmitted from the hospital on 04/22/2025 with diagnoses including right below the knee amputation (BKA, removal of a body part) surgical aftercare, anxiety, long term pain, and peripheral vascular disease (PVD, a narrowing or blockage of blood vessels, leading to reduced blood flow, primarily to the legs and feet, with common symptoms including leg pain and non-healing wounds) with a history of PVD angioplasty (a procedure to open the blocked or narrowed arteries in the legs). The 04/26/2025 comprehensive assessment showed Resident 41 had moderately impaired cognition but was able to make their needs known. Record review of Resident 41's medical record showed no documentation of a BCP had been completed. <Resident 32> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including bone infection and right-hand surgical aftercare. The 04/06/2025 comprehensive assessment showed the resident had a PICC line for antibiotic therapy, was cognitively intact and able to make their needs known. Record review of Resident 32's medical record showed no documentation of a BCP had been completed. During an interview on 05/05/2025 at 3:22 PM, Staff D, Registered Nurse/Resident Case Manager, stated the facility's process would be to go over the residents BCP within 24 hours after their admission and it would include a summary of a resident's initial care goals and necessary healthcare information. Staff D stated that Resident 33, 41 and 32's BCP were not completed, just slipped by. Staff D stated they were working on a new process to make sure BCP were completed for the facility's residents. During an interview on 05/05/2025 at 2:11 PM, Staff C, Regional Clinical Nurse, stated there were recent changes in staffing that led to gaps in the completion of baseline care plans. During a follow up interview on 05/05/2025 at 4:34 PM, Staff C stated the facility was not following the correct procedure for BCP and they were no longer utilizing that process. Staff C stated they would make a new process that included the requirements and was according to the BCP regulation. Reference: WAC 388-97-1020(3)

Based on interview and record review, the facility failed to identify a designated interdisciplinary [(IDT) a group of healthcare professionals from different disciplines to help people receive the care they need] team member, appointed as the responsible party for coordinating care and communication with hospice, and implement the written agreement that ensured effective communication, collaboration, and coordination of care between the facility and the hospice (a specialized type of care focused on providing comfort and support to individuals nearing the end of life) provider for 2 of 2 residents (Resident 39 and 45) reviewed for hospice services. This failure placed the residents at risk of not receiving necessary care and services at end-of-life. Findings included . Review of a policy titled, Palliative/End of Life Care, revised 11/2015, showed the facility and hospice would identify specific services that would be provided by each entity, and that information would be communicated in the care plan. Record review of a document titled, Hospice Services Agreement, dated 09/10/2020, showed the facility would coordinate with hospice in developing a plan of care for the resident. The facility would designate a member of the IDT that was responsible for working with hospice representatives to coordinate care of the resident. The facility was responsible for obtaining the hospice care plan, medications, orders, hospice election form, and physician certification of illness from hospice. <Resident 39> Review of the medical record showed Resident 39 was admitted to the facility with diagnoses including Alzheimer ' s disease (a progressive disease that destroys memory and other important mental functions), severe malnutrition (significantly low body weight for height), and weakness. The 04/25/2025 comprehensive assessment showed Resident 39 required substantial/maximum assistance of one staff member for activities of daily living (ADLs) and had a severely impaired cognition. The assessment also showed Resident 39 was receiving hospice services. Record review of Resident 39's medical record showed there was no documentation of a designated facility employee responsible for coordinating the resident ' s care. There was no hospice election form (a document that a patient or their authorized representative signs to formally choose to receive hospice care under Medicare), physician certification of Resident 39's terminal illness, or their most recent hospice care plan/coordinated care plan. Record review of Resident 39's facility care plan dated 04/24/2025 showed interventions related to palliative as hospice to provide the following services with no documentation of what those services were and refer to hospice care plan for coordination of services with no documentation of a hospice care plan. <Resident 45> Review of the medical record showed Resident 45 was admitted to the facility with diagnoses including palliative care (specialized medical care for individuals with serious illnesses that focuses on relieving symptoms, managing stress, and improving the resident's quality of life), cancer of the digestive system, and severe malnutrition. The 04/11/2025 comprehensive assessment showed Resident 45 was independent/required set-up assistance with ADLs. The assessment also showed Resident 45 was cognitively intact and was receiving hospice services. Record review of Resident 45's medical record showed no documentation of a designated facility employee responsible for coordinating the resident's care, no hospice election form, or physician certification of Resident 45's terminal illness. During an interview on 05/02/2025 at 9:37 AM, Staff D, Resident Care Manager, stated the process for enrolling a resident into hospice services included receiving the hospice care plan and coordinating it with the resident's current facility care plan. There should be a terminal illness (a medical prognosis that includes life expectancy of six months or less if the illness ran its normal course). that would come from the hospice physician. Staff D, Resident Care Manager (RCM), stated they were not aware of a hospice care plan for Resident 39. They stated they did not receive a physician order for a terminal illness, a hospice care plan, or daily communication. Staff D stated the hospice process was a broken system. During an interview on 05/02/2025 at 11:24 AM, Collateral Contact 1 (CC1), hospice Registered Nurse, stated the process for admitting a resident to hospice services included the resident's primary care provider putting in an order for hospice services. Hospice would complete an on-site evaluation of the resident and create an individualized care plan. That care plan was sent to the facility for collaboration of care. Hospice communication occurred through both verbal and written communication that was sent to the facility by fax after each visit. The CC1 stated they updated the resident's care plan as needed in the hospice charting system but was unsure if the facility received any copies of that updated care plan. During an interview on 05/05/2025 at 2:35 PM, Staff C, Regional Clinical Director, stated the facility did not follow the process for new admissions. They stated the facility did not have a designated member of the IDT to coordinate the hospice program that would have ensured the process was followed. During an interview on 05/06/2025 at 11:24 AM, Staff A, Administrator, stated the facility did not have a designated employee appointed for coordinating and collaborating care with hospice services. They stated the RCMs were primarily the contact and that was split over three hallways, so it could be anyone. Staff A stated they were not aware of the regulatory requirement of designating (in writing) an appointed staff member for the coordination of services. Staff A stated they expected staff to follow the facility's policy for hospice care and services. Reference: WAC 388-97-0020

Based on observation, interview, and record review, the facility failed to follow the Centers for Disease Control [(CDC) a public agency that protects the public's health and well-being] guidance for temperature monitoring of vaccines in 1 of 1 medication storage refrigerators (Refrigerator 1) reviewed for medication storage. This failure placed the residents at risk of receiving compromised or ineffective vaccines and negative outcomes. Findings included . Review of the CDC guidance titled, Vaccine Storage and Handling, dated 04/03/2024, showed to ensure safety of vaccines, the refrigerator must have a reliable temperature monitoring device with the recommended use of a recording device called a digital date logger (DDL-a device that records temperatures at least every 30 minutes). The guidance further showed when a DDL was not used, the facility should monitor and record the vaccine refrigerator temperature at a minimum of twice daily. Review of a policy titled Storage and Expiration Dating of Medications and Biologicals, revised 08/01/2024, showed the facility would ensure medication and biologicals were stored at their appropriate temperatures according to the guidelines for temperature ranges and manufacturer guidance. Facility staff should monitor cold storage containing vaccines two times daily per CDC guidelines. An observation on 05/06/2025 at 8:39 AM, accompanied by Staff C, Regional Clinical Director, showed a temperature log posted to the front of Refrigerator 1. The temperature log showed once a day temperature monitoring for the months of March 2025, April 2025, and May 2025. Refrigerator 1 contained influenza (a contagious respiratory virus caused by the influenza virus) and pneumococcal (an invasive bacterial infection) vaccines. During an interview on 05/06/2025 at 9:34 AM, Staff C stated the vaccines stored in Refrigerator 1 required twice daily monitoring. Staff C stated the facility had posted the wrong temperature log for staff to complete. Reference: WAC 388-97-1300(2)

Based on interview and record review, the facility failed to ensure residents were offered the pneumococcal immunizations (a vaccine that protects against pneumococcal infections that can lead to serious lung infections) nor documentation of the resident refusal or acceptance of the vaccine along with education on the risk/benefits of the vaccine for 1 of 5 residents (Resident 29) residents reviewed for pneumococcal immunizations. This failure placed the resident at an increased risk for a contagious disease without the opportunity to make an informed decision in the refusal or acceptance of the pneumococcal vaccine. Findings included . Review of the facility policy titled, Resident Immunizations, revised 2022, showed the facility would offer the pneumococcal vaccine to residents with the facility, and have a consent completed, education and the pneumococcal vaccine administered unless medically contraindicated (something that is not advised as the course of treatment). Additionally, the policy showed that PneumoRecs VaxAdvisor (a tool used to help determine which pneumococcal vaccine a resident might need), would be used to easily determine which pneumococcal vaccine was required. <Resident 29> Review of the resident's medical record showed they were admitted to the facility on [DATE], with diagnosis including heart failure, bladder infection and pneumonia (an infection in the lungs, that can cause a build-up of fluid, making it difficult to breathe). Review of the 03/03/2025 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Review of Resident 29's immunization records showed the facility completed an assessment on 03/11/2025 and is up to date on all pneumococcal vaccines, was not offered a pneumococcal vaccine and no consent was obtained. Additionally, the records showed the resident had a history of receiving one of the pneumococcal vaccines on 05/03/2023. Review of Resident 29's PneumoRecs VaxAdvisor showed that for the resident to be up-to-date regarding the pneumococcal vaccine they would require another pneumococcal vaccine one year after their last dose in 05/03/2023 (so the resident was not up-to-date and needed to be offered a pneumococcal vaccine). During an interview on 05/02/2025 at 10:52 AM, Resident 29 stated they had not been offered or educated on the pneumococcal vaccine and was not aware of the risk/versus benefits. During an interview on 05/02/2025 at 11:04 AM, Staff B, Director of Nursing Services, stated that Resident 29 had not been offered the pneumococcal vaccine. After reviewing Resident 29's immunization records, Staff B stated the resident needed an additional dose of the pneumococcal vaccine and the correct process was not followed for offering the pneumococcal vaccine to the resident. During an interview on 05/05/2025 at 4:47 PM, Staff C, Regional Clinical Director, stated the correct process was not followed for offering or educating Resident 29 on the risk/benefits of the pneumococcal vaccine. Reference: WAC 388-97-1340(2)

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice regarding, A) a residents Central Vascular Access Device (CVAD, also known as a central line, is a thin, soft tube that is inserted into a main vein in the arm, leg, or neck for long-term administration of antibiotics, medication, nutrition, and/or blood draws) dressing change and medication administration after nursing staff noted the central line migration (movement of the tubing from its original position) for 1 of 4 residents (Residents 32) reviewed for central lines, B) nursing staff failing to process, initiate, and follow physician orders with residents wound care for 1 of 4 residents (Resident 41) reviewed for wound care orders. This failed practice placed residents at risk for improper medication delivery, a delay in treatment, and adverse outcomes. Findings included . Review of the facility's guidance titled, Central Vascular Access Device Dressing Change, revised 01/15/2004, showed a Peripherally Inserted Central Catheter (PICC) was a specific type of central line, the dressing on all CVAD's should be dated, so a dressing change schedule could be started for every seven days and .upper arm circumference (a measurement around a residents arm, used as a baseline to detect possible swelling or blood clots) with PICC, and external catheter length measurement must still be completed as part of the initial assessment . The facility's guidance showed that the external catheter measurement was to be obtained upon admission, during dressing changes and that a securement/stabilization device (a small attachment that helps anchor the PICC line in place, to the skin, and prevent migration of the line) should be used and to not removed during a PICC line dressing change. Additionally, the facility's guidance showed that when changing the PICC line dressing, staff should not .disturb (to move or change something from its usual position) catheter . or remove the securement device. Review of Lippincott's nursing procedures manual, 8th edition, Peripherally Inserted Central Catheter Use, dated 2019, showed that a stabilization device should be used to decrease the risk of unintentional movement of the catheter or dislodgement which could lead to complications. Additionally, movement of the catheter should be avoided but if noted during a dressing change that the catheter has migrated more than two centimeters (cm, a unit of measure) a provider should be notified due to the need to confirm if the PICC is still in the correct position. <Resident 32> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including bone infection and right-hand surgical aftercare. The 04/06/2025 comprehensive assessment showed the resident had a PICC line for antibiotic therapy, was cognitively intact and able to make their needs known. Review of the resident admission assessment dated [DATE] showed the resident was receiving intravenous (IV, the administration of medications or fluids directly into a person's vein) therapy with antibiotics for their bone infection with an IV insertion date of 04/04/2025. The assessment did not show the external catheter length measurement or the upper arm circumference measurement. During an observation on 04/29/2025 at 9:10 AM, showed Resident 32 in their room. The resident's PICC line had a change date of 04/23/2025 handwritten on the top of the dressing and a small two inch (in, a unit of measure) long by 1/4 in wide amount of blood was noted under the PICC line dressing. The external catheter length and time of the last dressing change were not noted on the dressing. During an interview on 05/01/2025 at 12:54 PM, while in Resident 32's room observing the PICC line dressing, Staff O, Registered Nurse (RN), stated they did not know the external catheter length and the blood noted under the dressing was recent since the last dressing change. During a concurrent observation and interview on 05/01/2025 at 1:28 PM, Staff O was in Resident 32's room performing a PICC line dressing change. Staff O stated they remembered the external catheter length was six cm but was unsure if it was documented. Observations showed after removing the old dressing, Staff O picked up and moved the placement of the PICC line from a downward position, where the PICC line access ports were pointing toward the residents elbow, to an upward position, where the PICC line access ports were pointing toward the resident's armpit and then continued to flip/rotate the PICC line two more times (no securement device was in place). Staff O measured the external catheter length and noted that it had been pulled out from six cm to nine cm. Staff O did not measure Resident 32's upper arm circumference. During an interview on 05/01/2025 at 2:07 PM, Staff D, RN/Resident Case Manager (RCM), stated the process for admission/assessments of residents with PICC lines would include documenting the external catheter length. Staff D was unable to find documentation showing Resident 32's external PICC length or upper arm circumference. Staff D stated the external length of the PICC line was needed to assess if migration of the line took place. Staff D stated that when migration of the PICC line was noted, the line would no longer be used for infusion of medications and the provider would be notified. During an interview on 05/01/2025 at 2:19 PM, Staff B, Director of Nursing Services, and Staff C, Regional Clinical Director, stated that when a resident was admitted with a PICC line a group of orders were to bed and included the external catheter length. Staff B stated the process for central lines included assessing the PICC lines external catheter length and the upper arm circumference, so that migration of the catheter line or complications with swelling could be noted/acted upon. Staff B stated they were unable to find Resident 32's external catheter length or upper arm circumference and the correct process was not followed. Staff B and Staff C stated they were informed that Resident 32's PICC line catheter had migrated from six cm to nine cm, so Resident 32's IV medication infusions should be stopped and a notification to the provider would be completed before utilizing the residents PICC line. During a concurrent observation, upon the surveyor and Staff B entering Resident 32's room, and interview on 05/01/2025 at 2:45 PM showed IV medication infusing through the residents PICC line. Staff B stated the IV medication should not be infused through the PICC line since the line had migrated and Staff O did not follow the correct process. Staff B stated they were going to stop the infusion immediately. During an interview on 05/01/2025 at 3:21 PM, Staff B stated that during a CVAD/PICC dressing change the catheter should not be moved from its usual position and Staff O's moving the catheter placement and flipping/rotating catheter during a central line dressing change was not the correct process. <Resident 41> Review of the medical record showed the resident was admitted to the facility on [DATE] and readmitted from the hospital on 04/22/2025 with diagnoses including right below the knee amputation (BKA, removal of a body part) surgical aftercare, anxiety, long term pain, and peripheral vascular disease (PVD, a narrowing or blockage of blood vessels, leading to reduced blood flow, primarily to the legs and feet, with common symptoms including leg pain and non-healing wounds) with a history of PVD angioplasty (a procedure to open the blocked or narrowed arteries in the legs). The 04/26/2025 comprehensive assessment showed Resident 41 had moderate cognitive impairment but was able to make their needs known. Review of the hospital physician's transfer orders dated 04/22/2025, showed Resident 41 right BKA was to have a dressing change every other day/as needed and to apply betadine (a solution that is used to disinfect skin and prevents further infections) over the incision site. The transfer orders stated the left fourth toe was necrotic (a term used to describe the death of living tissue due to a lack of blood supply) and .gauze to keep in between 4th/5th toe . Review of the admission assessment dated [DATE] at 11:36 AM, showed Staff P, RN/RCM, stated that Resident 41's fourth toe on their left foot was necrotic and was to be painted with betadine every other day. Review of Resident 41's provider orders dated 04/25/2025, showed that nursing staff input orders for necrotic 4th digit left toe: monitor daily. Notify MD (facility provider) of any change or if it falls off. every shift. No orders for a dressing change or gauze placement for the resident's necrotic toe were noted. During a concurrent observation and interview on 04/29/2025 at 11:36 AM, Resident 41 was noted lying in bed with their left foot open to the air. The resident's fourth toe on the left foot was necrotic and no dressing was in place. Resident 41 was unsure if a dressing was in place between their toes on their left foot, but did not have their pressure relieving boot in place under their left foot so they could let it air out. During a concurrent observation and interview on 05/01/2025 at 11:52 AM, Resident 41 was noted in their room with Staff Q, RN and Staff R, Medical Provider, performing a dressing change on the resident's right BKA. No dressing or gauze noted in between the resident's left [NAME] necrotic 4th toe. After the resident's right BKA dressing was completed Staff R inquired about the resident left fourth necrotic toe and Staff Q stated that they were not performing a dressing change for the residents necrotic fourth toe and were to be monitoring the toe daily. During an interview on 05/01/2025 at 12:38 PM, Staff Q stated that no dressing had been in place for Resident 41's left foot necrotic toe since the resident's readmission on 04/22/2025. Staff Q stated they looked at the orders in a resident chart and it was not their process to look at the wound care transfer orders from the hospital. During an interview on 05/01/2025 at 12:51 PM, after reviewing Resident 41's wound care transfer orders, Staff R stated that nursing staff should have been completing a dressing change for the resident's necrotic 4th toe. Staff R stated the necrotic toe's dead tissue should have been separated from the living tissue of the resident's other toes. During an interview on 05/05/2025 at 3:30 PM, Staff P stated they completed the admission assessment for Resident 41. Staff P stated they had missed the orders to have the gauze in-between the resident necrotic fourth/fifth toe, and they did not read through the whole order. During an interview on 05/05/2025 at 4:34 PM, Staff C, Regional Clinical Director, stated that Resident 41's physician's orders transfer orders from the hospital were not processed or initiated correctly and nursing staff were not following the orders regarding the resident's wound care. Reference: WAC 388-97-1620(2)(b)(ii)

Based on observation, interview, and record review, the facility failed to ensure a Preadmission Screening and Resident Review [(PASARR) a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment] accurately reflected residents' mental health conditions for 1 of 5 residents (Resident 39) reviewed for PASARR accuracy. This failure placed the residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings including . Review of a policy titled, Pre-Admission Screening and Resident Review, revised 06/2024, showed prior to admitting a resident, the admission coordinator or designee would request a PASARR Level I screening. The Level I screening must be completed prior to admission to identify individuals who have or may have a serious mental illness or related condition. A negative screen would permit admission and end the pre-screening process. Those individuals identified with any qualifying criteria, or a positive screen would require a PASARR Level II referral for evaluation and determination prior to admission to the facility. Social Services was responsible to review the PASARR to verify accuracy. <Resident 39> Review of the medical record showed Resident 39 was admitted to the facility with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions), delirium (a sudden change in mental state characterized by confusion, disorientation), hallucinations (sensory perceptions that occur in the absence of a real external stimulus), anxiety, and depressive disorder. The 04/25/2025 comprehensive assessment showed Resident 39 required substantial/maximum assistance of one staff member for activities of daily living (ADLs) and had a severely impaired cognition. The assessment also showed Resident 39 was receiving hospice services. Record review of Resident 39's medical record showed a PASARR Level I form, dated 04/14/2025, showed Resident 39 had no serious mental illness indicators, no evidence of serious functional limitation during the past six month related to a serious mental illness, and had not had psychiatric treatment greater than outpatient care or experienced a significant disruption to the normal living situation. The PASARR Level I form showed no Level II evaluation was indicated for Resident 39, despite their mental health diagnoses of dementia, delirium, hallucinations, anxiety, and depressive disorder. During a concurrent observation and interview on 05/02/2025 at 11:41 AM, Staff K, Social Services Director, review Resident 39's PASARR Level I form. Staff K stated they were responsible to ensure the facility received the PASARR Level I form prior to admission and to review it for accuracy. Staff K stated Resident 39's PASARR form was filled out incorrectly and it should have been sent for a PASARR Level II evaluation prior to admission. Staff K stated they were unsure why they had not caught the error. They stated if they had realized the form was incorrect, they would have sent it to the admissions coordinator to reach out to the hospital case manager for accuracy. During an interview on 05/02/2025 at 11:52 AM, Staff A, Administrator, stated the admissions coordinator was responsible for the initial review of the PASARR Level I form to ensure it was accurate before admitting the resident. They stated a second check was completed by the Social Services Director. Staff A stated they were not sure how Resident 39's incorrect PASARR got by us. Reference: WAC 388-97-1915(1)(2)(a-c)

Based on interview and record review, the facility failed to immediately implement effective measures in the protection of a resident from further abuse/neglect, nor conduct a thorough investigation into an allegation of abuse for 2 of 3 residents (Residents 41 and 11), reviewed for abuse and neglect. This failure placed the residents at risk for unidentified abuse, unmet care needs, and the potential for continued exposure to abuse and/or neglect. Findings included . Review of the facility's policy titled, Abuse/Neglect/Misappropriation/Exploitation, revised October 2022, showed that it was the facility's policy to protect residents from abuse and .All alleged incidents of abuse, neglect, misappropriation of resident property and injuries of unknown source must be thoroughly investigated . The policy showed the investigator would collect as much data as needed to be able to reach a reasonable conclusion and that data collection could involve .Interview assigned caregiver, caregivers in the immediate area, caregivers from the shift prior to the incident's discovery, visitors, family, roommates and the alleged perpetrator .' Additionally, the policy showed .Protecting the resident from further harm means keeping the resident safe by .immediately suspend the alleged perpetrator .having a trusted person stay with the resident . <Resident 41> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including right below the knee amputation (BKA, removal of a body part) surgical aftercare, anxiety, long term pain, and peripheral vascular disease (PVD, a narrowing or blockage of blood vessels, leading to reduced blood flow, primarily to the legs and feet, with common symptoms including leg pain and non-healing wounds). The 04/26/2025 comprehensive assessment showed Resident 41 had moderate cognitive impairment but was able to make their needs known. Review of the alleged abuse investigation, dated 04/24/2025 at 9:00 AM, showed that Staff H, Nursing Assistant (NA), reported to the Administrator and Director of Nursing Services (DNS), that they had witnessed Staff I, Registered Nurse (RN), physically and verbally abuse Resident 41 when administering medications and providing care to the resident. Staff H stated that Resident 41 had requested a suppository medication (a type of drug, inserted through the rectum) to help them have a bowel movement. Staff H stated that Staff I's inserted the suppository medication incorrectly, and Resident 41 yelled at Staff I you're hurting me. Staff H stated that both Staff H and Staff I left the resident's room to gather supplies and upon Staff H's reentry to Resident 41's room they overheard the resident telling Staff I you're hurting me you b***h, and witnessed Resident 41 swinging her left arm at Staff I and Staff I grabbing the resident's left arm and proceeded to shove while cursing at the resident, telling the resident to Stop (Resident 41) f*****g s**t. The investigation showed Resident 41 stated that when the suppository was inserted incorrect the resident threw their arm up at Staff I to get the staff members attention and Staff I grabbed the resident's arm and pushed them, The nurse is rude and was rough with me. Resident 41 requested their emergency contact to be informed about the incident. Additionally, no interview with Resident 41's representative (RR) was documented. Further review of the 04/24/2025 alleged abuse investigation showed Staff H conveyed the witnessed abuse to the Director of Nursing Services (DNS) on 04/24/2025 at 9:00 AM and then Staff I, who had already completed their night shift, was suspended pending the investigation and safety of Resident 41 was ensured. The investigation showed that Staff H feared the nurse and so did not report the witnessed event until after their shift had ended. During an interview on 04/29/2025 at 10:25 AM, Resident 41 was unable to remember specifics about the incident at certain times, was not interested in talking more about the incident and did not remember the suppository medication that was administered by Staff I. Resident 41 then stated that during the incident Staff I was really mean and aggressive when providing cares, because the resident was not turning to their side fast enough and they did not feel safe with Staff I. During a follow-up interview on 04/30/2025 at 2:36 PM Resident 41 was forgetful/confused on specifics related to the incident but then stated feeling uncomfortable and helpless with the way Staff I provided care to them. During an interview on 05/01/2025 at 5:01 PM, Staff H stated that after witnessing the incident of abuse in Resident 41's room. Staff H stated they did not report the witnessed abuse to any other staff until around 7:30 AM to 8:00 AM, when they notified the Administrator. Staff H stated they did not report to the State Agency hotline number. Staff H stated they did not protect the resident from further harm and was afraid of the nurse, so after the incident went back to their regular duties. When asked if Staff I had gone back into Resident 41's room, Staff H stated that it was possible. During an interview on 05/02/2025 at 7:13 AM, Staff A, Administrator, stated that interviews with other staff, Resident 41's roommate and other residents were completed during the investigation and did not correlate with Staff H's witnessed statements of verbal/physical abuse by Staff I on Resident 41. Staff A stated that none of the interviews conducted corroborated (to support with evidence or make something more certain) with the allegations brought forth by Staff H. Staff A stated the investigation had been completed and education was performed on Staff I regarding the incorrect insertion of the suppository medications. During an interview on 05/02/2025 at 9:20 AM, Resident 41's Representative (RR), stated they had known the resident for [AGE] years now and were notified by the Administrator about the incident. The RR stated they came to talk with Resident 41 after they got off work. The RR stated Resident 41 stated that Staff I was hurting them, pushing them and the resident felt helpless in the situation. RR stated, (Resident 41) did feel abused and did not feel safe with Staff I and did not want that nurse working with them anymore. (Resident 41) was frightened. During an interview on 05/02/2025 at 11:29 AM, Staff B, DNS, stated they had interviewed Resident 41, other residents, staff and the RR. When inquiring about the RR, Staff B stated that Resident 41 did not have family, and the resident had requested to talk with their RR after the incident/allegation of abuse took place. Staff B stated the RR came in to talk with Resident 41 on the 24th or 25th of April 2025 but was unsure of the exact date/time. Staff B stated that per Resident 41, Staff I was rude, rough and fast when providing care, but felt safe with the staff member. Staff B stated the resident's recollection of the events was not good and that it would change. Staff B stated that staff/resident interviews conducted could not corroborate the allegations brought forth by Staff H and the investigation was completed. When informed of RR interview, Staff B stated they were unaware of information conveyed to the RR by Resident 41 and thought Staff A had interviewed the RR and that the RR did not have any concerns. Staff B stated the correct process was not followed and the investigation was not thorough. Staff B stated the investigation would have to be reopened and follow-up with the RR. During an interview on 05/05/2025 at 5:11 PM, Staff C, Regional Clinical Director (RCD), stated that Staff H should have protected Resident 41 after witnessing the alleged abuse by Staff I. Staff C stated the protection of the resident from further harm was not implemented, Staff I still had access to Resident 41 after the witnessed abuse and the correct process was not followed. <Resident 11> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including dementia and degenerative joint disease (a type of arthritis characterized by the breakdown of [NAME] in the joints causing pain, stiffness and decreased movement) in both knees. Resident 11 ' s most recent comprehensive assessment dated [DATE] showed they had moderately impaired cognition and required minimum to moderate assistance of one to two caregivers for activities of daily living (ADL ' s) and could not ambulate. During an observation and interview with Resident 11 on 05/02/2025 at 11:13 AM, showed them sitting in their wheelchair in their room looking out the window. Resident 11 stated they had never had a fall in their room or bathroom and could walk independently without any assistance. Review of the facility reporting logbook showed Resident 11 had nine falls in the facility within the past five months. November 2024 through March 2025. Review of the facility incident reports for Resident 11 showed they had two observed falls on 11/14/2024 and 12/23/2024 and seven unobserved falls on 11/04/2024, 12/26/2024, 01/13/2025, 02/19/2025, 03/01/2025, 03/13/2025 and 03/31/2025. None of the unobserved falls had witness statements attached showing a thorough investigation was completed into the possible causes of the falls or that abuse, and neglect had thoroughly been ruled out as a cause of the falls. Review of Resident 11 ' s care plan initiated on 03/03/2021 and last revised on 04/07/2025, showed the resident was at risk for falls related to pain, weakness, deconditioning, degenerative joint disease in both knees, vertigo (dizziness), history of falls, cognitive impairment, profound hearing loss, epilepsy (a seizure disorder), impulsiveness, impaired vision, poor decision making, and overestimating abilities. Further review of the care plan showed the problem of being at a high risk for falls and goals to be free of falls were updated on 01/13/2025, 03/18/2025 and 04/07/2025. Additional interventions to decrease the risk for falls were only initiated for the two of the nine falls dated 01/13/2025 and 02/19/2025. During an interview with Staff B, DON and Staff C, RCD, on 05/07/2025 at 12:48 PM, they both acknowledged that thorough investigations into the causes of the falls and to ensure abuse or neglect was not the cause of the falls was not completed. In addition, they both acknowledged that limited interventions were put into place after the falls to prevent future falls and keep Resident 11 as safe as possible. Reference: WAC 388-97-0640 (2)(a)(6)(a)

Based on interview and record review, the facility failed to ensure nursing staff reported, witnessed verbal and physical abuse, to the State Agency, immediately, but no later than two hours after the abuse took place, for 1 of 3 residents (Residents 41), reviewed for abuse/neglect. This failure placed the residents at risk for unidentified abuse/neglect, and the potential continued exposure to abuse and/or neglect. Findings included . Review of the facility's policy titled, Abuse/Neglect/Misappropriation/Exploitation, revised October 2022, showed that all facility employees were mandated reporters that must immediately report when there was a reasonable cause to believe an incident of abuse occurred. The facility policy stated all alleged violations involving abuse were to be reported immediately, but not later than two hours after the event had taken place. <Resident 41> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including right below the knee amputation (BKA, removal of a body part) surgical aftercare, anxiety, long term pain, and peripheral vascular disease (PVD, a narrowing or blockage of blood vessels, leading to reduced blood flow, primarily to the legs and feet, with common symptoms including leg pain and non-healing wounds). The 04/26/2025 comprehensive assessment showed Resident 41 had moderate cognitive impairment but was able to make their needs known. Review of Resident 41's incident investigation, dated 04/24/2025 at 9:00 AM, showed that on 04/24/2025 at 3:40 AM Staff H, Nursing Assistant (NA), witnessed Staff I, Registered Nurse (RN), when providing care , grabbed Resident 41's left arm and shoved the resident while cursing at the resident, telling the resident to Stop (Resident 41's), f*****g s**t. During an interview on 04/29/2025 at 10:25 AM, Resident 41 stated they could not remember the exact date of the incident, but the incident happened in the early morning when the nurse and nursing assistants (NA) had come into the room to change the resident brief. Resident 41 stated Staff I got hostile (showing strong dislike and unfriendly) because the resident was not turning to their side fast enough during incontinent care. During an interview on 05/01/2025 at 5:01 PM, Staff H stated they had gone in/out of Resident 41's room early on the morning of 04/24/2025, and upon entering back into the resident room, after grabbing supplies, Staff H witnessed Staff I grabbing Resident's 41 arm, as the resident swung at Staff I, and Staff I proceeded to pushed the residents arm down while cussing at the resident to stop. Staff H stated they did not report the witnessed verbal and physical abuse to any other staff or State Agency until around 7:30 AM to 8:00 AM, when they texted Staff A, Administrator. During an interview on 05/02/2025 at 11:29 AM, Staff B, Director of Nursing Services, stated they were informed of the allegation of verbal and physical abuse towards Resident at 9:00 AM on 04/24/2025 by Staff H. Staff B stated that the report to the State Agency was made after Staff B became aware of the allegations. Staff B stated a report to the State Agency should have been made immediately after being witnessed by Staff H or within two hours. Staff B stated the correct process for reporting abuse allegations was not followed. Reference: WAC 388-97-0640(5)(a)

Based on interview and record review, the facility failed to ensure grievances (resident and/or resident representative concerns that can be voiced or written) conveyed to staff underwent prompt resolution and appropriately updated residents on the grievance progress/conclusion for 1 of 2 residents (Resident 46) reviewed for grievances. This failure placed residents at risk for unresolved concerns and unmet care needs. Findings included . Review of the facility policy titled, Grievances Procedure, revised August 2023, showed the facility would ensure each residents' right to .voice grievances (such as those about treatment, care, management of funds, lost clothing, or violation of rights) . and that facility staff were responsible for making prompt efforts to resolve a grievance and to keep the resident appropriately apprised (updated on information) of progress towards the residents grievance resolution. The policy showed the facility would .have a process in place for identification, investigation and follow-up of resident/resident representative grievances in a timely manner, and that residents had a right to obtain a written decision regarding their grievance. Additionally, the policy showed the facility would ensure that grievance decisions included the date the grievance was received, a summary of the resident's grievance, the steps taken to investigate the grievance, and the finding or conclusions of the grievance and the date the written decision was issued. <Resident 46> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including pneumonia (an infection in the lungs, that can cause a build-up of fluid, making it difficult to breathe), insomnia (difficulty falling and/or staying asleep), sepsis with septic shock (a potentially life-threatening condition that comes when the body's response to an overwhelming infection causes injury to its own tissues and organs) and delirium (a serious change in metal ability that causes confused thinking and lack of awareness of surroundings and can be caused by infections). The 04/14/2025 comprehensive assessment showed that Resident 46 had a moderately impaired cognition with evidence of delirium but was able to make their needs known. During an interview on 04/28/2025 at 2:09 PM, when asked if they were missing any personal items, Resident 46 stated that right after their admission to the facility, 193 dollars in cash went missing, but the facility staff found 93 dollars of it. Resident 46 stated they had a conversation with Staff A, Administrator, about the missing money after the facility had found the 93 dollars, but they had not received any money back nor an update since Staff A had informed them that an investigation would be conducted into the missing money. During an interview on 04/30/2025 at 9:26 AM, Staff N, Laundry/Housekeeping Supervisor, stated the process when money was found in the laundry room was to fill out a grievance form and then give the money over to the Administrator to continue the grievance process. Staff N stated that a weekend laundry aid contacted Staff A and informed them that they had found 93 dollars in cash, which belonged to Resident 46. Staff A stated the money was found the day after the resident had been admitted to the facility and the weekend laundry aid put the money under the Administrator's locked door. During a follow-up interview on the same day at 10:43 AM, Staff N stated they were unaware of the additional 100 dollar amount of cash that Resident 46 stated was in their clothes and would have investigated further by interviewing the laundry aid/looking into where the money might have gone. Review of the facility's grievance log for April 2025, showed no documentation of grievance regarding missing money. During an interview on 04/30/2025 at 10:01 AM Staff A stated that if a resident was missing cash monies in the facility the grievance process would be started, and the facility would try to get them a locked drawer for the money. When asked about Resident 46's missing money, Staff A stated they intended to go through the grievance process, I probably missed that one, since a grievance form was not filled out and the resident informed Staff A that there was 100 more dollars that was in the resident's pants pocket, in addition to the 93 dollars found in the laundry. Staff A stated they did not have documentation of the steps taken to investigate and/or the resolution/conclusion of Resident 46's grievance. Reference: WAC 388-97-0460(2)

Based on observation and interview the facility failed to ensure the resident environment was free from accident hazards, due to the placement of a 1500-[NAME] oil filled indoor electric space heater in 1 of 1 resident room (room [ROOM NUMBER]), reviewed for accident hazards. This failure placed the residents at risk for avoidable accidents and/or injury. Findings included . An observation on 12/10/2024 at 3:50 PM, in room [ROOM NUMBER], showed an oil filled indoor electric space heater was on the right side of the sink, turned on medium heat, was hot to touch. When the Department Investigator placed their hand near the electric space heater, they had to quickly remove their hand (after less than two seconds) due to the hot temperature felt on palm of their hand. During an interview on 12/10/2024 at 5:10 PM, Staff B, Maintenance Director, stated they had placed the space heater in room [ROOM NUMBER] when the thermostat in the room stopped working on 12/03/2024. Staff B stated they were not aware if there was a process/policy for space heaters and they had not notified the Administrator prior to placing the oil filled electric space heater in the room. During an interview on 12/10/2024 at 5:15 PM, Staff A, Administrator, stated they were not aware Staff B had placed the space heater in room [ROOM NUMBER]. Staff A stated when a thermostat or any heating problem occurred in a resident room, staff were required to notify them. Staff A explained the process was to move the resident to a different room until the problem was fixed. Staff A further stated Staff B did not follow the correct process when the thermostat stopped working for room [ROOM NUMBER]. Reference WAC: 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Eight medication errors were identified for 3 of 11 residents (Residents 9, 5 and 13) observed during 28 medication administration opportunities, that resulted in an error rate of 28.57%. Errors in medication administration placed the residents at risk for side effects and/or reduced or increased medication effectiveness due to improper administration. Findings included . Review of the Instructions for use of an insulin pen, by the U.S. Food and Drug Administration, (USFDA), dated 10/2022, showed the instructions for use stated to prime (to remove air from the needle and cartridge that may collect during administration) the insulin pen before each injection. This step was important to ensure the insulin pen worked correctly and the proper dose of medication was administered. Review of a document titled, Medication Administration Schedule, showed the following: AM- Meds to be administered between 6AM and 10AM; Midday-Meds to be administered between 10AM and 2PM; PM-Meds to be administered between 4PM and 8PM; HS (bedtime)-Meds to be administered between 8PM and 10PM. <Resident 9> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnosis of diabetes [your body can not make enough insulin (a hormone that lowers the level of sugar in the blood) or can't use it as well as it should]. The 02/04/2024 comprehensive assessment showed the resident had an intact cognition and required extensive assistance of one staff member for activities of daily living (ADLs). Review of Resident 9's physician orders, dated 03/04/2024, showed an insulin sliding scale (used as reference for insulin to be administered) to be given before meals based on the resident's blood sugar test results. During an observation and concurrent interview on 03/07/2024 at 11:29 AM, Staff N, Licensed Practical Nurse (LPN), stated Resident 9's blood sugar level was 221 milligrams/deciliter(a unit of measure) and they would need to administer three units of insulin based on the sliding scale. Staff N prepared the insulin pen (a pre-filled disposable device containing insulin) by cleaning the pen tip with an alcohol swab and attached a needle to the pen. Staff N administered the insulin to Resident 9 with the insulin pen into the resident's left arm, pressed the button to dispense the medication, and removed the needle from their skin. Staff N did not prime the needle of the insulin pen prior to administration. Staff N stated that they did not prime the needle of the insulin pen this time, but they usually do. <Resident 5> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnosis of diabetes. The 01/07/2024 comprehensive assessment showed the resident had an intact cognition and required extensive assistance of one staff member for ADLs. Review of Resident 5's physician orders, dated 02/01/2024, showed the resident was to have 10 units of insulin administered subcutaneously (under the skin), with meals. Further review showed a sliding scale was to be administered in addition to the 10 units based on the resident's blood sugar test. During an observation and concurrent interview on 03/27/2024 at 12:14 PM, Staff O, LPN, stated Resident 5's blood sugar level was 169 milligrams/deciliter and they needed to administer 13 units of insulin based on the physician orders and sliding scale. Staff O prepared the insulin pen by attaching a needle. Staff O administered the insulin to the resident with the insulin pen into the resident's left arm, pressed the button to dispense the medication, and removed the needle from their skin. Staff O did not prime the needle of the insulin pen prior to administration. Staff O stated they were unaware that they needed to prime the needle of the insulin pen; it is not my normal process. <Resident 13> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include a right femur (thigh bone) fracture and hypertension (high blood pressure). The 02/04/2024 comprehensive assessment showed the resident had an intact cognition and required extensive assistance of one staff member for ADLs. During an observation and concurrent interview on 03/28/2024 at 1:00 PM, showed Staff I, Resident Care Manager, administered the following medications: Amlodipine (treatment of high blood pressure), Vitamin D, Vitamin B12, Miralax (used to relieve constipation), Mybetriq (treatment for overactive bladder), and Tums (stomach acid reducer). The physician's orders showed the above medications were to be administered in the morning (between 6:00 AM and 10:00 AM). Staff I stated they knew they were late giving the morning medications (three hours past the scheduled time), it is just so busy. During an interview on 03/29/2024 at 10:40 AM, Staff B, Regional Director of Nursing Services, stated they expected the nurses to know how to administer insulin correctly. Staff B further stated they would expect the nurses to follow the med pass times and physician orders and they would be giving education to all nurses on following the correct processes. Reference: WAC 388-97-1060(3)(k)(ii)(iii)

Based on observation, interview, and record review, the facility failed to ensure appropriate administration and documentation of enteral feedings (delivery of nutrition directly to your stomach or small intestine through a tube) and fluid intake via gastrostomy tube [(g-tube) a device inserted into the stomach through the abdomen that provides nutrition when you are unable to eat on your own] feedings for 1 of 2 residents (Resident 16) reviewed for enteral feeding. This failed practice put Resident 16 at risk for dehydration, fluid overload, and weight loss/gain. Findings included . <Resident 16> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include difficulty swallowing which resulted in nutritional support provided via a g-tube, malnutrition (lack of sufficient nutrients in the body) and absent of speech. The comprehensive assessment, dated 12/31/2023, showed Resident 16's cognition was moderately impaired and received greater than 51 percent of their nutritional needs via the g-tube and received 501 milliliters [(ml) a measurement of volume] or more of fluids per day. The assessment further showed the resident required one staff assistance with eating. A concurrent observation and interview on 03/27/2024 at 8:27 AM, showed Staff N, Licensed Practical Nurse (LPN), administered fluids and medication to Resident 16 via their g-tube. Staff N stated Resident 16 received 210 ml of free water per their shift. Staff N then flushed the resident's g-tube with 120 ml of water prior to administering medications and 90 ml of water after medications were administered to equal the 210 ml prescribed. Staff N stated the resident received bolus (a given dose delivered within a specific time frame) feedings with formula that were started on the night shift and completed on the day shift. Staff N further stated the LNs worked 12 hour shifts, resulting in two shifts for a 24-hour period. Staff N did not check residuals (the amount of liquid that remains in the stomach after administering through a g-tube) prior to flushing or ask the resident if they experienced any symptoms. Review of the March 2024 physician orders, showed the following: 09/26/2023 Document the amount of (nutritional) formula administered in ml each shift. Clear the volume administered on the pump each shift. 09/26/2023 free water flush: 210 ml each shift, document total ml administered each shift, including water administered with medications. 09/27/2023 Jevity (a brand of nutritional formula) 1000 ml to be administered over 13 hours at 77 ml per hour (flow) once daily. Start at 8:00 PM and remove at 9:00 AM. 09/26/2023 Check residual as ordered. Hold if residual is greater than half the rate of the flow or half the amount of the bolus. 09/26/2023 Administer 30 ml of water before and after medication administration every shift. 09/26/2023 If the resident is alert and oriented and able to report symptoms, gastric aspiration (checking residual) is not indicated. Review of a Registered Dietician (RD) Nutrition assessment dated [DATE], showed Resident 16's daily fluid needs were 1310 ml to 1510 ml per day. The resident received 807 ml of fluid from the Jevity, 210 ml every shift for a total of 630 ml per day, of free water (note that there are only two 12-hour shifts a day, this total would be for three shifts), 30 ml of flushes before and after medication administration and 5 ml between each medication for a total of 280 ml per day from the med pass. Total fluid calculated per day was 1717 ml. The assessment further showed the resident received two to four medications per day but listed eight medications, with one to be given twice daily, for a total of 9 medications. Review of Resident 16's March 2024 MAR, showed the following: document actual amount of formula administered in ml each shift (total of both shifts should equal 1000 to 1001 ml). The MAR showed out of 31 days, 27 days showed Resident 16 received greater than one and a half times the amount of formula ordered. document total free water administered every shift, including water administered with medications, plus 30 ml before and after medication administration (total should equal 910 ml for both shifts). The MAR showed 31 out of 31 days showed a total of 540 ml of free fluid had been given, which was 370 ml less than what the resident's fluid needs were. During an interview on 04/01/2024 at 11:42 AM, Staff N stated per the physician orders, if the resident was able to self-report their symptoms, residuals would not need to be checked. Staff N stated their normal process would be to ask Resident 16 if they had symptoms but must have forgotten on 03/27/2024. Staff N was unaware they were to clear the pump after each shift documented the amount of formula administered. During an interview on 04/01/2024 at 12:55 PM, Staff C, RD, stated when a resident admitted to the facility with a g-tube, the Resident Care Managers or the Admission's nurse would enter the orders into the medical record and Staff C would review them for appropriateness. Staff C stated if the resident admitted from home, then they would communicate with the home infusion RD, calculate any fluids that they received to make sure they met their fluid needs and adjust as needed. During an interview on 04/02/2024 at 10:49 AM, Staff B, Regional Director of Nursing Services, stated they would expect the orders to be entered as they received them on admission and would expect documentation to be accurate and the orders to be followed as written. Staff B stated they were not aware of the inaccuracy of the g-tube orders and documentation. Reference: WAC 388-97-1060(3)(f)

Based on observation, interview, and record review, the facility failed to ensure restorative therapy services including the consistent use of braces/splints were implemented for 4 of 4 residents (Resident 6, 16, 17, and 23), reviewed for restorative therapy and limited range of motion [(ROM) the extent the joint can move within the expected (normal) range of values]. This failure placed the residents at risk for loss of ROM, deconditioning, and contractures (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen). Findings included . Review of a document titled, Restorative Program, dated 04/2018, showed: The goal of the Restorative Program was to promote and maintain functioning. Identify residents need for a restorative program at the time of admission/readmission/identified concerns. Restorative program to include but not limited to ROM, applying, and removing splint or braces, and walking with/without assisted devices. Daily documentation <Resident 6> Review of the resident's medical record showed Resident 6 admitted on [DATE] with diagnoses to include Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement) and contractures to their right hand, arm, and shoulder. The comprehensive assessment dated [DATE] showed the resident's cognition was intact and had impairment to one side of their upper and lower extremities. Resident 6 was assessed to require partial/moderate assistance with their oral hygiene and dependent on staff assistance for toileting hygiene, upper/lower body dressing, bed mobility, and wheelchair (w/c) use. Additionally, the 01/02/2024 comprehensive assessment showed a decline in all areas when compared to the 04/01/2023 comprehensive assessment (nine months prior). A concurrent observation and interview on 03/25/2024 at 1:07 PM, showed Resident 6 sitting in their recliner reading, with a bedside table in front of them. Their legs were over the top of the leg of the bedside table, the right foot was dangling with no support, and the left foot was turned inward and resting on the leg of the bedside table. Resident 6 stated they used to have exercises to their upper right side with the previous Restorative Aide (RA), but the new one only does them every now and then. Resident 6 stated they had never received exercises to their upper left side or their legs and could not recall the last time they had exercises. During an interview on 03/25/2024 at 3:27 PM, the Resident's Representative (RR) stated Resident 6 did not consistently receive exercises that they were aware of. The RR further stated Resident 6 wanted to be able to self-propel their w/c so they could go out of their room whenever they wanted to and not have to depend on staff. The RR stated the w/c was not the correct one for the resident due to their right-side contractures. Resident 6 was assessed and ordered a new w/c, one they could propel with their feet. The w/c arrived 2-3 months ago and required adjustments and no one has ever come back. During a concurrent observation and interview on 03/28/2024 at 8:34 AM, Resident 6 was sitting in their recliner, bedside table placed to the front of them, eating their breakfast. Their left knee was turned in towards the right knee, and left heel resting on the leg of the bedside table with their toes pointed to the floor. Resident 6 could lift their leg no more than an inch above the leg of the table. Resident 6 stated they could not lift their right leg or foot. Resident 6's right arm remained close to the right side of their body and their left arm and hand were used to eat with. Their left hand was shaky when taking bites of food. Resident 6 complained of discomfort to both of their knees. A concurrent observation and interview on 03/28/2024 at 4:17 PM, showed Resident 6 being assisted back to their room from an activity. The resident's feet, without footrests attached, dangled greater than 4 inches from the floor. Resident 6 stated the w/c was comfortable to sit in, but they could not move the w/c without staff assistance, I am absolutely immobile, and I have claustrophobia (fear of confined spaces) and wanted to get out of their room more often. Review of a document titled, Restorative Evaluation and Summary (a quarterly program review), dated 03/05/2024, showed Resident 6 received a ROM restorative program to both upper extremities. The evaluation showed if the resident did not participate, they would have decreased upper extremity ROM, independence, and a decreased quality of life. The evaluation further showed the program had been modified to reflect the resident's current status. The evaluation did not show a program for lower extremities. This was the only restorative evaluation completed after the initial program was initiated by Occupational Therapy [(OT) teaches a patient the skills they need to live independently or perform everyday tasks more easily and free of pain] in 05/2022 and the exercises had not been modified. During an interview on 03/29/2024 at 10:57 AM, Staff CC, RA, stated residents were referred to a restorative program when OT or Physical Therapy [(PT) treatment of disease, injury, or deformity by methods such as massage, heat, and exercise] assessed them to need more help. Staff CC stated they completed programs at least four days a week because they worked four days on and two days off and they were the only RA. Staff CC stated they completed stretching and stretching band exercises to Resident 6's right upper extremity. Staff CC stated the resident did not have a program for their left upper extremity or their legs. Review of Nursing Assistant (NA) task documentation, showed Resident 6 had a ROM program for their left upper extremity using a stretching band up to five times a week and to their right upper extremity with prolonged stretches up to five times a week and had been completed as follows: December 2023 had 10 of 31 days of exercises and two days showed not applicable. January 2024 had seven of 31 days of exercises. February 2024 had three of 29 days of exercises. During an interview on 03/29/2024 at 11:34 AM, Staff I, Resident Care Manager (RCM), stated on admission, residents would be assessed by PT and OT and a restorative program would be started if they were assessed to need one. Staff I stated they were made aware of a decline in a resident by staff, family, or during quarterly assessments. Staff I stated Resident 6 had a program for both of their upper extremities and had been assessed by PT in September 2022, and was not sure what the outcome of that assessment was. Staff I further stated they were not aware Resident 6's w/c had been delivered and was not sure what had been done with it since it arrived. Review of a PT note dated 10/26/2022, showed Resident 6 had completed PT and a restorative program had been established for their bilateral lower extremities. Review of the record showed no program had ever been started. Further review of a PT note dated 09/15/2023, showed the resident had been referred to PT due to a decline in functional mobility that limited Resident 6's independence and participation in their ADL's. Further review of a PT discharge note dated 11/28/2023, showed Resident 6 had been fitted for a new w/c that would allow the resident to self-propel the w/c using their left upper and lower extremity and was awaiting delivery. The note further showed the resident would be reevaluated for w/c training when the new w/c arrived, and no restorative/functional maintenance program had been indicated. During an interview on 03/29/2024 at 12:26 PM, Staff F, Therapy Director, (TD), stated Resident 6 had a PT assessment in September 2023 related to their increased weakness and their inability to perform ADLs independently. Staff F stated they fitted and ordered a new w/c for the resident and were pending the delivery of the w/c. Staff F further stated Resident 6 should have been referred to a restorative program to maintain what they had gained while working with PT until their new w/c arrived and did not know why that had not been done. Staff F further stated, anyone that is long term should be set up on a restorative program. Staff F was unaware Resident 6 had the new w/c delivered and upon checking to see when it had been delivered, Staff F discovered the w/c had been delivered on 12/15/2023. Staff F stated the w/c would have been delivered to the resident by one of the therapy staff and did not know why the resident had not been put back on the therapy schedule. Staff F was unaware who delivered the w/c to the resident's room or assessed Resident 6 for use of the w/c. Staff F could not find any notes on an assessment and stated if there were not any notes, then it had not been done. <Resident 16> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include a stroke that resulted in weakness to the right side of the body, a contracture to their right hand, and absence of speech. Review of the comprehensive assessment, dated 12/31/2023, showed the resident's cognition was moderately impaired, used a cane and w/c for mobility, and required substantial/maximal staff assistance with rolling side to side in bed, w/c mobility at 50 and 100 feet ([ft) a type of measurement], dependent on staff assistance for toileting hygiene, and not applicable for walking 50 and 150 ft. Additionally, the 12/31/2023 comprehensive assessment showed a decline in all areas in comparison to the comprehensive assessment dated [DATE], three months prior. Review of Resident 16's care plan dated 01/01/2024, showed no restorative program for the right upper extremity contracture or decline in the assessment areas identified on the 12/31/2023 assessment. Furthermore, the care plan showed no documentation that the resident used a hand brace/splint. Review of March 2024 physician orders showed no orders or a wearing schedule for Resident 16's hand brace/splint. A concurrent observation and interview on 03/25/2024 at 10:06 AM, showed Resident 16 sitting in their recliner and could only use hand gestures and yes/no head nodding for communication. On the nightstand, across the room from the resident to the left side of the sink, showed a blue/black hand brace/splint sitting on the top. The resident pointed to their right hand that was folded into a fist and sitting in their lap, when asked if the brace belonged to them. Resident 16 shrugged their shoulders and scrunched their forehead when asked if they wore the brace, as if they didn't understand what the Surveyor had asked. Observations on 03/26/2024 at 10:10 AM, 03/26/2024 at 3:30 PM, 03/27/2024 at 8:27 AM, and 04/01/2024 at 11:47 AM, showed the hand brace/splint was sitting on the nightstand next to the sink as previously observed on 03/25/2024. An observation on 03/29/2024 at 1:40 PM, Resident 16 was sitting in their recliner supporting their right arm and closed hand with their left hand. The hand brace/splint was sitting at the head of the bed, beside the resident. During an interview on 03/27/2024 at 8:27 AM, Staff N, Licensed Practical Nurse (LPN), stated they thought the hand brace/splint was worn at night and removed in the morning because it was not a task that was scheduled on their shift. During an interview on 03/28/2024 at 4:08 PM, Staff GG, NA, stated Resident 16 wore the hand brace/splint on their right hand because if not, their hand would be scrunched up like a fist. Staff GG was not sure what the wearing schedule was because it was not something they placed on the resident during their shift. During an interview on 03/29/2024 at 10:57 AM, Staff CC stated they were responsible for applying hand brace/splints and there was one resident that required one and that was not Resident 16. Staff CC stated they did not have a program for a hand splint/brace to be applied and removed for Resident 16. During an interview on 03/29/2024 at 1:03 PM, Staff K, Minimum Data Set Coordinator [(MDS) a standardized comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status], stated once a comprehensive assessment was completed, the facility had a program that alerted them if a resident had a decline in their functional abilities. Staff K further stated the reports were from one comprehensive assessment to the next (which were quarterly) and would not produce an alert if there was a decline over a period greater than quarterly. There had been no decline alert for Resident 16. Staff K further stated the RCMs were responsible for the MDS assessments as of 10/2023, but if the RCMs did not complete the assessments timely, Staff K was not able to use the information because they were completed outside of the timeline. Additionally, Staff K stated if there was a not applicable documented on the comprehensive assessment, it was because the resident was no longer able to do that task, or they did not have documentation that the task was completed. 48368 <Resident 23> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent it interferes with a person's daily life and activities) and muscle weakness. The 01/30/2024 comprehensive assessment showed the resident had a moderately impaired cognition and required extensive assistance of one staff member for ADLs. Record review of Resident 23's medical record, showed no assessment had been completed by therapy and no restorative programs had been implemented since their admitted [DATE]. During an interview on 03/25/2024 at 2:55 PM, the RR stated Resident 23 had not had any therapy or exercise programs since they were admitted to the facility. The RR further stated they had requested therapy services about four to five months ago so Resident 23 could get stronger and out of their wheelchair more often The RR stated they did not hear back from the facility. During an interview on 03/29/2024 at 9:17 AM, Resident 23 stated they did not receive any exercises at the facility, and they were interested in it. During an interview on 03/29/2024 at 12:39 PM, Staff F stated long term care residents should be on a restorative program. Staff F stated they were new to the position, and they did not have an answer as to why Resident 23 was not on a restorative program or had an assessment completed. <Resident 17> Review of the medical record showed the resident was admitted to the facility on [DATE] with a diagnoses of acute kidney injury (when your kidneys suddenly stop working properly), history of a stroke (a loss of blood flow to part of the brain, which damages brain tissue), and congestive heart failure (when the heart does not pump blood as efficiently as it should). The 01/19/2024 comprehensive assessment showed the resident had an intact cognition and had impairment to both lower extremities requiring extensive assistance of one staff member for ADL's. Review of physician's orders dated 11/22/2023, showed Resident 17 was to have their ankle-foot brace to their left foot daily; do not wear to dialysis. During observations on 03/26/2024 at 10:00 AM, 03/28/2024 at 1:15 PM, 03/29/2024 at 9:02 AM, and 04/02/2024 at 9:15 AM, Resident 17's ankle-foot brace was located on the floor under their chair next to the television. During an interview on 03/26/2024 at 11:53 AM, Resident 17 stated the staff forget to put their ankle-foot brace on, I forget, they forget, so it never gets put on, I should remind staff. During an interview on 04/02/2024 at 11:07 AM, Staff L, Physical Therapy Assistant, stated Resident 17 should have had their left ankle-foot brace on when they were not at dialysis and the physician's order should be followed. Staff L further stated the correct process was not being followed for Resident 17. During an interview on 04/02/2024 at 10:27 AM, Staff B, Regional Director of Nursing Services, stated they would have expected restorative programs had been started for any resident who had contractures. Staff B stated they were unaware that Resident 6 had a new w/c and would have expected them to continue a ROM program until their w/c was delivered to maintain what they had already gained. Staff B stated they would expect residents who used braces/splints have an order, a wearing schedule, and be monitored by the Licensed Nurses. Staff B stated they would expect all residents to be evaluated by therapy for a Restorative program and did not know where the disconnect was. Reference: WAC 388-97-1060(1)(2(a)(i-ii)(b)(3)(d)

Based on interview and record review, the facility failed to ensure interdisciplinary team [(IDT) a group of healthcare providers from different fields who work together for the best outcome for residents] care conferences were completed for 2 of 2 residents (Residents 18 and 6) reviewed for comprehensive care planning. Additionally, the facility failed to ensure the IDT care conference meetings included the required team members for 2 of 2 residents (Residents 14 and 25) reviewed for comprehensive care planning. These failures disallowed the resident and/or their representative the involvement in planning resident care and placed the residents at risk for unmet care needs. Findings included . <Care Conferences> <Resident 18> Review of the medical record showed Resident 18 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), kidney disease, and depression. The 02/03/2024 comprehensive assessment showed Resident 18 required substantial to dependent assistance of one to two staff members for activities of daily living (ADLs). The assessment also showed Resident 18 had a severely impaired cognition. During an interview on 03/25/2024 at 1:04 PM, Resident 18's Representative, stated that when Resident 18 was initially admitted to the facility for short term care, they had frequent care conferences, and they would attend those conferences virtually (using computer technology to attend from another location). Resident 18's Representative stated that they had not been invited to or had a formal meeting with the facility for at least the last year. Review of the medical record showed the last IDT care conference was held on 03/29/2022 and the RR was present. There was no additional documentation of care conferences in the record. <Resident 6> Review of the medical record showed Resident 6 was admitted to the facility 03/25/2022 with diagnoses including Parkinson's disease, heart failure, and contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right side. The 01/02/2024 comprehensive assessment showed Resident 6 was dependent on one to two staff members for ADLs. The comprehensive assessment showed the resident had an intact cognition. During an interview on 03/25/2024 at 1:25 PM, Resident 6's Representative stated they had not been invited to a care conference in a long time. Resident 6's Representative further stated, it would be nice to have one (care conference) so we could discuss issues at that time rather than every time I have an issue. Review of Resident 6's medical record showed the last IDT care conference was held on 04/14/2022. The record showed the RR attended. During an interview on 03/27/2024 at 10:34 AM, Staff E, Social Services Director (SSD), stated they completed IDT care conferences on admission to the facility, one week prior to discharge from the facility, quarterly, and annually. During an interview on 03/28/2024 at 11:34 AM, Staff A, Administrator, stated care conferences should be completed within the first two to three weeks of admission, quarterly, and as needed. <IDT Attendance> <Resident 14> Review of the medical record showed Resident 14 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia (a group of thinking and social symptoms that interferes with daily functioning). The 03/19/2024 comprehensive assessment showed Resident 14 was dependent on one to two staff members for ADLs. The assessment also showed the resident had a moderately impaired cognition. Review of Resident 14's medical record showed a quarterly IDT care conference had been completed on 03/15/2024, attended by Resident 14 and Staff E. There were no other IDT members represented at the IDT care conference. <Resident 25> Review of the medical record showed Resident 25 was admitted to the facility on [DATE] with diagnoses including a right hip fracture (a complete or partial break in a bone), right clavicle (collar bone) fracture, and atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow). The 03/10/2024 comprehensive assessment showed Resident 25 was dependent on one to two staff members for ADLs. The assessment also showed Resident 25 had an intact cognition. Review of Resident 25's medical record showed an IDT care conference was held on 03/15/2024 in the resident's room, with the resident, their representative, and Staff E present. There was no documentation that other required IDT members were present at the IDT care conference. During an interview on 04/01/2024 at 11:26 AM, Staff E stated their process for notification of upcoming IDT care conferences was to notify the family of the date and time of the IDT care conference by phone. They stated they gathered information from nursing, therapy, and social services and documented that information on the IDT care conference form. Staff E stated they were the only staff member that attended the IDT care conference meeting. Staff E understood that it was okay to document the information from each department and they did not need to attend the meetings. During an interview on 04/01/2024 at 12:53 PM, Staff A stated IDT care conferences were held for new admissions and quarterly. They stated Staff E called the family if the resident declined or were not able to attend the IDT care conference. Staff A stated that not all IDT members attended the IDT care conferences; they have focused on therapy, nursing, and social services. During an interview on 04/02/2024 at 11:59 AM, Staff B, Regional Director of Nursing Services, stated the process was to reach out to the resident families to allow them to accept or decline attendance at the IDT care conferences. Staff B stated all required IDT staff members should be attending the IDT care conferences. Reference: WAC 388-97-1020(c)(i)(ii)(e)(f)(5)(b) 45117

Based on interview and record review, the facility failed to implement two components of their abuse policy when they did not verify licensure for 1 of 2 staff (Staff AA) for screening and did not provide abuse training for 5 of 8 staff (Staff O, T, U, V, and R) reviewed for abuse and neglect. This failure placed the residents at risk for unrecognized abuse, and unmet care needs. Findings included . Review of the policy titled, Abuse/Neglect/Misappropriation/Exploitation, dated ,d+[DATE], showed the facility would; screen employees by verifying their licensure, and train employees at orientation, annually, and as needed. <Licensure> Review of employee files showed Staff AA, Nursing Assistant Registered (NAR), was hired on [DATE] as a student in a Nursing Assistant (NA) training class at a nearby training center. Staff AA graduated the training class and worked as a NAR for the facility starting on ,d+[DATE]. Staff AA obtained NAR licensure on [DATE], which expired on [DATE] (on their annual birthdate) and failed to renew their license. Staff AA continued to work with an expired licensed, unsupervised, providing care to vulnerable adults on [DATE], [DATE], [DATE], and [DATE]. Staff AA was then removed from the schedule when their expired license was brought to the facility's attention. During an interview on [DATE] at 12:08 PM, Staff A, Administrator, stated they were not aware Staff AA had been working with an expired license. Staff A stated Staff M, Housekeeping Supervisor/Scheduler, was responsible for ensuring Staff AA had an active license . During an interview on [DATE] at 11:00 AM, Staff M stated they were not aware Staff AA's NAR license had expired. Staff M stated Staff AA had taken their Nursing Assistant Certification (NAC) test prior to their NAR license expiring but did not pass the NAC test and did not communicate that to the facility. Staff M stated they should have had better communication and did not have a process for following up or ensuring licenses were up to date and/or renewed. <Annual Training> Review of staff personnel files showed the following staff had no documented annual training for abuse and neglect: Staff O, Licensed Practical Nurse, was hired on [DATE]. Staff T, Registered Nurse, was hired on [DATE]. Staff U, Nursing Assistant (NA), was hired on [DATE]. Staff R, Registered Nurse, was hired on [DATE]. Additionally, Staff V, NA, was hired on [DATE]. The facility could not provide documentation that Staff V had received initial training on abuse and neglect. During an interview on [DATE] at 11:15 AM, Staff H, Infection Preventionist/Staff Development, stated they offered the required annual abuse and neglect training and had not reviewed which staff had received the training and which did not. Staff H stated when they had staff that worked on an as-needed (part-time) basis, they would put the education in their assigned mailbox so they could complete it. Staff H stated they did not have a process for following up to ensure the as-needed staff completed the trainings. Staff H could not verify which as-needed staff had abuse and neglect training. Review of a document provided by Staff A on [DATE], showed a list of employees who had and had not received the required annual abuse and neglect training. The list showed Staff O, T, U, R, and V had not received their annual abuse and neglect training. During an interview on [DATE] at 11:03 AM, Staff B, Regional Director of Nursing Services, stated they were unaware the abuse and neglect training had not been tracked more efficiently and needed a better process. Reference WAC: [DATE](2)

Based on interview and record review, the facility failed to address required documentation for Advanced Directives [(ADs) a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity] including incorporating ADs into the care planning process for 3 of 5 residents (Residents 6, 15, and 16) reviewed for ADs. These failures placed the residents at risk of losing their right to have their preferences and/or decisions followed regarding their end-of-life care. Findings included . Review of the policy titled, Advanced Directives/POLST (a portable physician order form that describes the residents care direction regarding end of life treatment), revised date 05/2019, showed the Social Services Director (SSD), would offer assistance in developing an AD if the resident wanted to formulate one and the ADs would be reviewed periodically. <Resident 6> Review of the resident's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include heart failure and Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement). The comprehensive assessment dated [DATE], showed the resident had an intact cognition and impairment to their right arm and leg. Review of Resident 6's medical record showed a document titled, Durable Power of Attorney for Healthcare (DPOA), dated 01/24/2011, showed no preferences for end-of-life care. Review of Resident 6's care plan dated 01/03/2024, showed no focus area care planned for ADs. Review of an admission assessment titled Psychosocial History and Discharge, dated 03/30/2022, showed Resident 6 was asked if they had an AD and the yes box was checked, with comments that showed the resident had a DPOA and a Physician Orders Life Sustaining Treatment. <Resident 15> Review of the resident's medical record showed they admitted to the facility on [DATE] with diagnoses to include dementia (a group of symptoms that affects memory, thinking and interferes with daily life). The comprehensive assessment, dated 02/27/2024, showed Resident 15's cognition was severely impaired and required one to two staff assistance for all activities of daily living (ADLs). Further review of the record showed the resident did not have an AD in place. Review of the care plan, with a revision date of 03/12/2024, showed a focus for comfort care (a specialized medical care aimed at easing suffering and improving the quality of life of people with severe medical conditions) for Resident 15 due to their disease process. The care plan showed an intervention to review the resident's AD and ensure it was followed. During an interview on 03/25/2024 at 2:30 PM, the Resident's Representative (RR) stated the facility had not talked to them about formulating an AD or about any end-of-life preferences for Resident 15. <Resident 16> Review of the resident's medical record showed they admitted to the facility on [DATE] with diagnoses to include a stroke (when blood flow to the brain is interrupted) that caused deficits to the right side of the body and absence of speech. The comprehensive assessment dated [DATE], showed the resident's cognition was moderately impaired and required one to two staff assistance for bed mobility and transfers. Review of a document titled, Psychosocial History and Discharge Plan, dated 10/11/2023, showed Resident 16 did not have an AD. Review of an admission packet document titled Advanced Directive, dated 2013, showed no information about the facility offering assistance to formulate an AD or how to formulate an AD. Review of the care plan dated 01/01/2024, showed no care plan regarding Resident 16's wishes for end-of-life care or their refusal to formulate an AD. During an interview on 03/27/2024 at 10:34 AM, Staff E, SSD, stated it was the responsibility of the SSD to address ADs on admission. Staff E stated their process was to ask the resident or RR if there was an AD. If they did not have one and wanted one, they would assist the resident or the RR in obtaining/formulating one. Staff E stated they did not have a process for following up with the resident and/or RR, if an AD was refused on admission. Staff E further stated they did not know what transpired with Residents 6, 15, and 16's ADs because they were not employed at the time they were completed. During an interview on 03/28/2024 at 11:34 AM, Staff A, Administrator, stated they would expect for ADs to be asked about on admission and then followed up during quarterly care conferences. Staff A stated they expected the former and current SSD to have completed ADs in the same manner and the ADs should have been documented and care planned. Reference: WAC 388-97-0280 (3)(c)(i-ii), -0300(1)(b)(3)(a-b)

Based on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADL's) related to nail care for one of six residents (#1) reviewed for ADL care. Failure to provide the resident who was dependent on staff for toenail and fingernail care caused harm by allowing the nails to grow so long they dug into the resident's skin causing skin breakdown and pain. Findings included . Resident #1. Per review of the medical record, the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's most recent comprehensive assessment, dated 03/15/2021, showed she was alert and oriented and required total assistance of one to two care givers for bed mobility, transfers, dressing, toileting, bathing and personal hygiene. Observation and interview with Resident #1 on 05/17/2021 at 1:20 PM showed the resident lying on her back in bed, covered by a sheet, with the head of bed slightly raised. Resident #1 was alert and pleasant in conversation. Observation of the toenails on both feet were very long. The left big toenail was one half of an inch over the top of the toe and was jagged with crusted blood surrounding the outside of the nail. The rest of the toes on the left foot were long as they were bent over touching the back of the toes and imbedded into the skin in several areas. Observation of the right toenails showed the right big toenail was not as long and jagged as the left, though three of the other nails on the right, were also bent back touching and imbedded into the skin in several places on the back of the toes. Observation of Resident #1's left hand showed it was contracted (a permanent tightening of the muscles, tendons, skin and tissues that cause the joints to shorten and become very stiff preventing normal movement) and closed in a fist. She stated the fingernails on that hand were also very long and the thumb nail in particular was cutting into her skin. Resident #1 slowly opened her fingers on her left hand with her right hand and showed all of the nails to be very long and soiled with a dark substance underneath the nails, with the thumb nail pointed and jagged puncturing the inside of her palm. Observation of the right fingernails were also long and dirty underneath the nails. Resident #1 stated she did not remember when the last time her nails were cut but didn't like people messing with my feet and toes in particular because they hurt all the time. In addition, she stated that the fingernails pressing into her skin on the left hand were painful and if anyone was going to do any cutting of the nails she needed notice and to be medicated for pain prior to anyone touching her feet or hands. Review of Resident #1's physician orders, with a start date of 06/10/2018, showed to check skin once a week, and indicate with a (+) if a new skin condition was present and (-) if no new skin condition was present. If a new skin condition was present, the Licensed staff were to document a progress note and initiate a skin documentation form. Review of Resident #1's treatment administration records (TAR) from 01/01/2021 through 05/17/2021 showed Licensed Nurses (LNs) were checking for skin breakdown every Sunday in the morning with no new skin conditions documented. Review of Resident #1's nursing progress notes and physician visit reports from 01/01/2021 through 05/17/2021 showed only one entry related to nail care which was dated on 03/17/2021 at 1:47 PM, when a facility Licensed Practical Nurse (LPN) wrote, resident declined podiatry appointment, stated 'no one is looking at my feet,' resident declined having her toenail trimmed by staff at present. Will continue to monitor toenail with biweekly baths. Review of Resident #1's care plan, last revised on 11/20/2020, showed the resident had an ADL self-care deficit and limited physical mobility problem. Interventions regarding bathing and showering showed the Certified Nursing Assistant (CNA) was responsible for total care of the resident, and to check nail length and trim and clean them on bath day as necessary and report any changes to the nurse. Review of the NAC tasks from 01/01/2021 through 05/17/2021 showed Resident #1 received a bath or shower one to two times per week with total care checked as completed on those days. During an interview with the Director of Nursing (DON) on 05/17/2021 at 1:35 PM, she stated I can't disagree after looking at those nails that it's been a while since any care was provided to them and I'll make sure it gets taken care of today. Reference (WAC) 388-97-1060(2)(c)

Based on observation, interview, review of the facility policy, and review of the Centers for Disease Control and Prevention (CDC) Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens for COVID-19, the facility failed to conduct specimen collecting and testing in manner that was consistent with CDC guidance and the manufactures instructions. The facility was obtaining nasal specimens from one nare on residents and staff, instead of collecting specimens from both nares. The facility's failure of improper testing technique was likely to produce erroneous results and result in the failure to identify COVID positive residents and staff. This failure had the potential to affect all 26 residents who resided at the facility. On 11/24/20 at 1:43 PM, the facility's Administrator was notified that an Immediate Jeopardy at F886 was identified and issued for the improper collection of specimens for resident and staff COVID-19 testing. The Immediate Jeopardy was determined to exist from 11/03/20, when the facility began using the BinaxNow COVID-19 Ag Card which required specimen collection from both nares, through 11/24/20 when a removal plan was accepted and validated. The removal plan for the Immediate Jeopardy at F886 was validated on 11/24/20 through observations, interviews, and documentation reviews. The facility was notified that the Immediate Jeopardy was removed on 11/24/20 at 5:45 PM. Findings include: Review of the facility's policy titled, SNF COVID-19 Testing Requirements, dated 09/01/20, revealed, Purpose: To provide (name of facility's corporation) affiliated facilities guidance to enhance efforts to keep COVID-19 from entering and spreading through the facility .Facilities are required to test residents and staff based on parameters and frequency set forth by the HHS (Health and Human Services) Secretary . Review of the CDC Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19) (https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html) revealed for both the nasal mid-turbinate specimen and the anterior nasal (nares) specimen, both nostrils are to be sampled with the same swab. Review of BinaxNOW COVID-19 Ag Card(Abbott), instructions revealed, .Specimen Collection and handling .Inadequate specimen collection or improper sample handling/storage/transport may yield erroneous results. Refer to CDC interim guidelines for collecting .Nasal Swab .To collect a nasal swab sample, carefully insert the swab into the nostril exhibiting the most visible drainage, or the nostril that is most congested if drainage is not visible .Rotate the swab 5 times or more against the nasal wall then slowly remove from the nostril. Using the same swab, repeat sample collection in the other nostril . Review of the facility's undated, laboratory document titled, How to obtain nasal/nasopharyngeal swab specimen, revealed the process did not reflect the CDC's guidance for specimen collection from both nares. Observation on 11/23/20 at 1:45 PM revealed Registered Nurse (RN) 3 collecting a specimen for COVID-19 testing from Certified Nurse Aide (CNA) 5. RN3 placed the swab halfway up the CNA's right nostril, swabbed for approximately five seconds and placed the specimen in a collection tube. RN3 failed to obtain a specimen from the CNA's left nostril. Observation on 11/23/20 at 1:50 PM revealed RN3 collected a specimen for COVID-19 testing from CNA6. RN3 placed the swab approximately halfway up the CNA's right nostril and swabbed for approximately five seconds and then placed the specimen in a collection tube. RN3 failed to obtain a specimen from the CNA's left nostril. Interview on 11/23/20 at 1:47 PM with RN3 revealed she had been completing staff testing for approximately six weeks. When asked about training she received related to specimen collection and testing, she stated her training had been through word of mouth. Interview on 11/23/20 at 1:54 PM with Resident Care Manager (RCM)1 revealed she was one of the staff who assists with testing residents and staff for COVID-19. When asked about training related to performing tests, she stated she watched a video from corporate around May 2020. RCM1 stated all resident tests are rapid tests, while all staff tests are sent to a lab. Interview on 11/23/20 at 5:52 PM with RN7 revealed she completes COVID-19 testing of night shift employees. RN7 stated she was shown by another nurse how to complete the specimen collection. The RN stated she puts the swab mid nose, and swirls around the entire nasal cavity of one nostril. RN7 confirmed that she did not swab both nares when obtaining specimens for COVID testing. An additional interview on 11/24/20 at 7:52 AM with RCM1 revealed she was the only staff who completed resident COVID-19 testing. The RCM stated the residents were tested using a rapid [MEDICATION NAME] test. The RCM also stated the specimen collections are the same for residents and staff; she swabs one nasal area, mid-turbinate, rotates the swab 5 times, and then places the swab in a tube. When asked if she had seen any instructions for either test as to how to collect the specimen, the RCM stated no. The RCM then opened the rapid test box and read the instructions for performing the BiNax NOW COVID-19 test. After review of the instructions, the RCM confirmed she had not been completing the specimen collections per the instructions because she only swabbed one nostril and the instructions stated to swab both. Interview on 11/24/20 at 8:42 AM with the Director of Nursing Services/Infection Preventionist (DNS/IP) revealed the facility nurses had watched a video on YouTube in June 2020 related to COVID-19 testing. The DNS/IP stated she had not completed any resident or employee testing but did assist with processing the paperwork. The DNS stated it was her understanding RN3 and the RCMs were only completing nasal swabs in one nare. The DNS further stated the facility had not received any instructions related to specimen collection from the laboratory they use. Continued interview with the DNS revealed specimen collections should have been completed per manufacturers recommendations to ensure the facility received accurate test results. Interview on 11/24/20 at 12:20 PM with the facility's Contract Laboratory Representative revealed when she personally collected specimens for COVID-19 testing, she always obtained specimens from both nares; however, their laboratory printout did not specify one or two nares. An additional interview on 11/24/20 at 1:54 PM with the DNS/IP revealed the facility began using the Abbott BinaxNOW COVID-29 Ag Card, rapid COVID-19 specimen collection, whose instructions called for collecting specimens from both nares, on 11/03/20. Interview on 11/24/20 at 3:45 PM with the Medical Director revealed it was her expectation that specimens would have been collected from both nares. The Medical Director stated not obtaining specimens from both nares could result in false negatives. Interview with the Administrator on 11/23/20 at 12:50 PM during the entrance conference revealed that, as of the date of the survey, the facility had identified a total of three residents and five staff as positive for COVID-19 since the beginning of the pandemic in March, 2020. Additional interview on 11/24/20 at 5:38 PM with the Administrator revealed it was his expectation the facility nursing staff who conducted COVID-19 testing would have been trained on the CDC's guidelines and the manufacturers guidelines related to testing. The Administrator stated it was important staff were trained to ensure the facility received accurate test results.

Based on observation, record review, and interview, the facility failed to implement abuse prohibition policies and procedures to protect 7 of 7 sampled residents (#6, #7, #8, #9, #10, #11, & #12) from Resident #5's abusive and intimidating behaviors. The facility failed to ensure staff fully recognized that Resident #5's physical intimidation, intrusiveness, taking others' personal items, offering inappropriate food to a resident with swallowing problems, and slapping confused, dependent residents constituted abuse. Despite staff knowledge of Resident #5's behaviors, facility residents were not adequately protected to prevent ongoing abusive behaviors. The facility's failure to recognize abuse and protect residents demonstrated that the facility's abuse prevention policies and procedures were not being implemented. Dependent Resident #8 was kissed and touched against his will. He was physically unable to defend himself against Resident #8's repeated unwelcome entries into his room. Other alert residents experienced intimidation and some attempted to protect themselves by maintaining a distance from Resident #5. Findings include but were not limited to: According to the facility's Abuse Prevention Program, Abuse Identification on page 12, "It is the policy of this facility to evaluate residents for potential/actual abuse and educate staff, residents and responsible parties on identifying abuse." On page 16, Abuse and Neglect Investigation, the purpose included: "To provide a safe environment for residents, staff and visitors. To identify the cause of the occurrence. To develop interventions to prevent re-occurrence." Resident #5: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. According to a 3/28/12 assessment document, the resident had past behaviors that included intimidating/threatening others and some aggressive behaviors in the community prior to hospitalization . Initial nursing entries noted the resident demonstrated some pacing, exit seeking, and refusal of care. An 8/18/12 nursing entry documented, "Resident continues to wander into other residents (sic) rooms, she takes food (sic) doesn't belong to her. She redirects easily @ times/other times she doesn't." The entry also noted Resident #5 would get too close to male visitors when they came to the facility. The nursing entry for 8/19/12 documented the resident was entering a specified resident's room and was "rummaging thru that resident's snack items." Resident #5 removed a snack item. Upon redirection, Resident #5 became angry and would not return the snack item. In addition, Resident #5 entered Resident #2's room and placed a "chocolate peanut butter wafer cookie" into the mouth of (Resident #2)." Resident #2's medical record noted he had diabetes and swallowing problems and was on a special diet. No negative outcome was documented in Resident #2's medical record. On 9/06/12 at approximately 2:55 p.m., the Social Service Director was interviewed and stated she heard that staff had intervened successfully for Resident #2 prior to him ingesting the wafer. According to nursing entries in Resident #5's record, on 8/24/12, 8/25/12, 8/30/12, and 8/31/12 Resident #5 continued to enter other residents' rooms. At times the resident would say "no" during staff redirection attempts. A 9/01/12 nursing entry documented a staff member observed Resident #5 entering another resident's room and taking food and bottled water out of the other resident's refrigerator. On 9/03/12 an evening shift nursing entry documented Resident #5 had opened a door into another resident's room "upsetting" that resident. When the Licensed Nurse (LN) attempted to remind the resident that she was not to enter other residents' rooms, Resident #5 "glared @ (at) this LN" and stated in a firm tone "no." A 9/04/12 nursing entry documented the LN was charting and "heard loud slapping noise" and Resident #11 started crying. Resident #11's left hand had a reddened area noted. Resident #5 also stated she had slapped Resident #11 because she was touched by her. Resident #5 was then placed on every 15 minute staff checks to monitor her whereabouts/activities. Further review of Resident # 5's medical record revealed that on 9/05/12 she was standing near the nurses' station when another resident (#10) reached out her hand to touch her. Resident #5 "slapped the other resident's hand away." On 9/06/12 at approximately 10:50 a.m. Staff Member A, a LN, was asked about the specialty doorknob observed on Resident #8's door. Staff Member A stated the doorknob had been placed to deter Resident #5 from getting into Resident #8's room but it didn't stop her from getting in. Resident #5 just waited for the right opportunity. According to Staff member A, Resident #8 was paralyzed from the waist down and received frequent pain medication due to his end of life condition. Resident #8 often had to ask Resident #5 to leave his room after her entry into his room. Resident #8: The resident was identified by facility staff as cognitively alert, and was interviewed on 9/06/12 at approximately 10:52 a.m. Resident #8 stated he had a terminal illness and was receiving pain medication. Shortly after he first arrived he awoke to find Resident #5 standing at his bedside holding his hand. Then she bent down and kissed him on the mouth. He stated he "didn't know who she was or what she had." Resident #8 stated, staff "can't stop her." She "needs supervision." Resident #8 also stated Resident #5 picked up his things and he had to tell her to stop. When asked how often Resident #5 entered his room, he stated 20-30 times a week plus the times staff caught her. Resident #5 reportedly came in day and night. Despite the staff supervision plan of every 15 minute checks, Resident #5 had entered his room that morning the resident stated. Resident #8 also said he wasn't sure if she was dangerous but she was "intimidating." He demonstrated the posed smile he had to put on when talking to her. He stated he tried not to "upset her" as he had seen her upset and acting out on an occasion when a LN tried to remove her from his room against her will. She kept saying, "no, no." "She (Resident #5) doesn't belong here." Refer to F323 for details related to Resident #5's behavior in relation to Residents #6, #7, #9, and #12. Resident #5 entered residents' rooms without permission and caused uneasiness/intimidation, took items belonging to Resident #7, and caused Resident #12 to have concern about his personal safety while walking in close proximity to Resident #5. Residents observed scavenging behaviors, overheard others' experiences, and some residents developed personal strategies to try to prevent further negative interactions with Resident #5. Staff attempted to provide care for facility residents and watch Resident #5 but acknowledged that Resident #5 went in and out of others' rooms and took other residents' items. On 9/19/12 at approximately 4:00 p.m. a Department Staff Member contacted the facility to inform them that the actions of Resident #5 constituted abuse.

Based on observation, record review, and interview, the facility failed to provide sufficient staff supervision to prevent cognitively impaired Resident #5 from: slapping other confused residents who randomly reached out to her, entering other residents' rooms without their permission, kissing/touching a resident without permission, taking residents' possessions, and staring/intimidating other residents. Seven of seven sampled residents (#6, #7, #8, #9, #10, #11, & #12) were impacted by Resident #5's behavior. Dependent, terminally ill Resident #8 experienced harm as a result of having been unexpectedly touched and kissed by Resident #5 and frequently disturbed by her unauthorized entry and unpredictable behaviors. Dependent Resident #8 also had to try to persuade Resident #5 to leave his room without evoking her agitation. Findings include but were not limited to: Resident #5: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. According to a 3/28/12 assessment document, the resident had past behaviors that included intimidating/threatening others and some aggressive behaviors in the community prior to hospitalization . Initial nursing entries noted the resident demonstrated some pacing, exit seeking, and refusal of care. An 8/18/12 nursing entry documented, "Resident continues to wander into other residents (sic) rooms, she takes food (sic) doesn't belong to her. She redirects easily @ times/other times she doesn't." The entry also noted Resident #5 would get too close to male visitors when they came to the facility. The nursing entry for 8/19/12 documented the resident was entering a specified resident's room and was "rummaging thru that resident's snack items." Resident #5 removed a snack item. Upon redirection, Resident #5 became angry and would not return the snack item. In addition, Resident #5 entered Resident #2's room and placed a "chocolate peanut butter wafer" into the mouth of (Resident #2). Resident #2's medical record noted he had diabetes and swallowing problems and was on a special diet. No negative outcome was documented in Resident #2's medical record. On 9/06/12 at approximately 2:55 p.m., the Social Service Director was interviewed and stated she heard that staff had intervened successfully for Resident #2 prior to him ingesting the wafer. According to nursing entries in Resident #5's record, on 8/24/12, 8/25/12, 8/30/12, and 8/31/12 Resident #5 continued to enter other residents' rooms. At times the resident would say "no" during staff redirection attempts. A 9/01/12 nursing entry documented a staff member observed Resident #5 entering another resident's room and taking food and bottled water out of the other resident's refrigerator. On 9/03/12 an evening shift nursing entry documented Resident #5 had opened a door into another resident's room "upsetting" that resident. When the Licensed Nurse (LN) attempted to remind the resident that she was not to enter other residents' rooms, Resident #5 "glared @ (at) this LN" and stated in a firm tone "no." A 9/04/12 nursing entry documented the LN was charting and "heard loud slapping noise" and Resident #11 started crying. Resident #11's left hand had a reddened area noted. Resident #5 also stated she had slapped Resident #11 because she was touched by her. Resident #5 was then placed on every 15 minute staff checks to monitor her whereabouts/activities. Resident #11: review of the resident's medical record revealed [REDACTED]. The resident's Physician examined her on 8/30/12 and noted the resident was frail and unable to communicate at that time noting she had severe end stage dementia. Further review of Resident # 5's medical record revealed that on 9/05/12 she was standing near the nurses' station when another resident (#10) reached out her hand to touch her. Resident #5 "slapped the other resident's hand away." Resident #10: According to the medical record, the resident had [DIAGNOSES REDACTED]. The resident's plan of care identified she was dependent on staff for activities of daily living and was unable to move herself in her tilting wheelchair. An 8/14/12 comprehensive assessment documented the resident had some hearing difficulty and only understood others "sometimes." She scored a 0 out of 15 on a cognitive assessment, noting she was highly cognitively impaired. On 9/06/12 at approximately 10:50 a.m. Staff Member A, a LN, was asked about the specialty doorknob observed on Resident #8's door. Staff Member A stated the doorknob had been placed to deter Resident #5 from getting into Resident #8's room but it didn't stop her from getting in. Resident #5 just waited for the right opportunity. According to Staff member A, Resident #8 was paralyzed from the waist down and received frequent pain medication due to his end of life condition. Resident #8 often had to ask Resident #5 to leave his room after her entry into his room. Resident #8: The resident was identified by facility staff as cognitively alert, and was interviewed on 9/06/12 at approximately 10:52 a.m. Resident #8 stated he had a terminal illness and was receiving pain medication. Shortly after he first arrived he awoke to find Resident #5 standing at his bedside holding his hand. Then she bent down and kissed him on the mouth. He stated he "didn't know who she was or what she had." Resident #8 stated, staff "can't stop her." She "needs supervision." Resident #8 also stated Resident #5 picked up his things and he had to tell her to stop. When asked how often Resident #5 entered his room, he stated 20-30 times a week plus the times staff caught her. Resident #5 reportedly came in day and night. Despite the staff supervision plan of every 15 minute checks, Resident #5 had entered his room that morning the resident stated. Resident #8 also said he wasn't sure if she was dangerous but she was "intimidating." He demonstrated the posed smile he had to put on when talking to her. He stated he tried not to "upset her" as he had seen her upset and acting out on an occasion when a LN tried to remove her from his room against her will. She kept saying, "no, no." "She (Resident #5) doesn't belong here." Resident #9: On 9/06/12 at approximately 11:00 a.m. the resident's room was observed to have a mesh type barrier strip with a velcro closure across the doorway to her room. The resident stated that a few nights earlier Resident #5 had opened her closed door and entered without permission. It "surprised and startled" her. "It was scary. I panicked and shouted, get out of here" and she left. Resident #5 was looking around in her room. Resident #9 stated she had seen her looking in cupboards in a dining room and trying to get into the refrigerator in the main dining room but it was locked. She had heard from other residents Resident #5 was in their rooms. Resident #9 further stated she tried to make sure Resident #5 was not close to her when she was out and about in the facility. Review of Resident #9's medical record revealed she had a [DIAGNOSES REDACTED]. Resident #7: When interviewed on 9/06/12 at approximately 10:00 a.m., the resident stated that a woman was coming into his room "pilfering in my refrigerator." The resident noted the female resident had taken candy and some special bottled water from him. The resident made a statement about what he planned to do to her if she came in again but then stated he wouldn't really hurt her. Resident #6: Review of the medical record revealed the resident had been admitted to the facility on [DATE] for rehabilitation. When interviewed on 9/06/12 at approximately 9:45 a.m., the resident stated it was almost dark one evening and a female resident entered his room without permission. She "startled" him. He had to put on his call light and get assistance from staff to remove her from his room. On 9/06/12 Resident #12, a resident identified by staff as interviewable, approached the Investigator twice, at approximately 8:50 a.m. and 10:30 a.m., to report his personal concerns about Resident#5's behavior. Resident #12 stated he thought Resident #5 was trying to bump into him (while he was walking). No contact had occurred yet but it "probably will sometime." Multiple observations were conducted of Resident #5 on 9/05/12 and 9/06/12. On 9/06/12 at approximately 6:00 p.m. the resident exited briskly from the day room to observe the Investigator exit the building. There were observations of the resident at the nurses' station rocking against the handrail or staring blankly. Facility observations on 9/06/12 at approximately 4:45 p.m. noted that although there were barrier gates installed in doorways of Residents #6, #7, & #8's rooms, all of them were hanging down unattached. This would allow free entry into the room, rendering these interventions ineffective. When interviewed on 9/06/12 at approximately 4:55 p.m., Staff Member B, a Nursing Assistant, stated that during the evening the resident went in and out of residents' room taking items, especially food, from other residents. Specific residents were named. Staff tried to stay on top of supervising her the best they could. Twice in the last couple days Resident #5 had struck out at other residents, two of their "most vulnerable" residents. The facility failed to provide a necessary level of supervision to prevent inappropriate conduct by Resident #5 and the impact it had on facility residents.

Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (#1) remained free of physical and verbal abuse. Resident #1 experienced harm related to facial bruising and psychological distress. Findings include: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The plan of care noted staff were to greet the resident by name, smile and touch her arm to get her attention, have a slow unhurried approach, and offer simple explanations about care while allowing her time to understand. Staff were also to assess her for comfort level, pain, thirst, toileting needs, and tiredness and to intervene as needed. The resident had physician orders [REDACTED]. Review of the May 2012 [MEDICAL CONDITION] Medication Sheet noted on 5/05/12 at 7:00 a.m. the resident was nervous, anxious, and fearful. Staff Member A, a Licensed Nurse (LN), attempted to administer as needed anti-anxiety medication but the resident spit it out. When interviewed on 5/22/12 at approximately 11:00 a.m., Staff Member B recalled she was in Resident #1's room providing care the morning of 5/05/12 when Staff Member A entered to administer medication. The resident "didn't want to open her mouth, she needed reassurance." The resident was "100% trying to refuse" the medication and "told him 20 times, no, no." Staff Member B stated the LN kept trying to give the medication and at one point was holding the resident "by the chin." Despite placement of the spoon/medication in her mouth, she spit out the medication all over. The LN was frustrated with the resident, stating "Why the f--- are you so difficult?" and then exited the room. According to Staff Member B, the resident already had anxiety issues before but after the occurrence with the LN "she was scared" and had to be cleaned up and reassured. Staff B further stated she observed a bruise on the resident's face (left chin area) the next day. A 5/06/12 nursing entry revealed the resident was found with a "2 by 1 (centimeter)" bruise on the left side of her chin. Facility investigative documents contained a 5/07/12 statement from Staff Member A. (On 5/05/12) the LN attempted to administer anti-anxiety medication to the resident. When he put the spoon of medication in her mouth she began spitting and the medication went "all over, mostly on her face." The LN further noted he used his left hand to straighten the skin near her mouth so he could spoon it into her mouth. An additional investigative statement from Staff Member D, the second LN who arrived late morning on 5/05/12, recalled that Staff Member A had reported to him that Resident #1 was very anxious that morning and that Staff Member A stated, "I had a hell of a time trying to get (her) to take her meds." Per the eye witness account, the resident was force-fed medication despite her verbal and physical protests and that constituted abuse. See F155 for further details of the occurrence.

Based on observation, record review, and interview, the facility failed to recognize the rights of 2 of 3 residents (#1 & #4) in the sample to refuse care/services. Resident #1 experienced harm related to facial bruising and psychological distress. Resident #4 experienced harm related to ongoing psychological harm. Findings include but were not limited to: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The plan of care noted staff were to greet the resident by name, smile and touch her arm to get her attention, have a slow unhurried approach, and offer simple explanations about care while allowing her time to understand. Staff were also to assess her for comfort level, pain, thirst, toileting needs, and tiredness and to intervene as needed. The resident had physician orders [REDACTED]. Review of the May 2012 [MEDICAL CONDITION] Medication Sheet noted on 5/05/12 at 7:00 a.m. the resident was nervous, anxious, and fearful. Staff Member A, a Licensed Nurse (LN), attempted to administer as needed anti-anxiety medication but the resident spit it out. A 5/06/12 nursing entry revealed the resident was found with a "2 by 1 (centimeter)" bruise on the left side of her chin. Facility investigative documents contained a 5/07/12 statement from Staff Member A. (On 5/05/12) the LN attempted to administer anti-anxiety medication to the resident. When he put the spoon of medication in her mouth she began spitting and the medication went "all over, mostly on her face." The LN further noted he used his left hand to straighten the skin near her mouth so he could spoon it into her mouth but "she effectively spit it out. According to the facility investigation, Staff Member B, a Nursing Assistant, was present with the resident when Staff Member A attempted to administer the anti-anxiety medication on 5/05/12. When interviewed on 5/22/12 at approximately, 11:00 a.m., Staff Member B recalled she was in Resident #1's room providing care the morning of 5/05/12 when Staff Member A entered to administer medications. The resident "didn't want to open her mouth, she needed reassurance." The resident was "100% trying to refuse" the medications and "told him 20 times "no, no." Staff Member B stated the LN kept trying to give the medication and at one point was holding the resident "by the chin" and appeared frustrated with the resident. The resident spit out the medication and had to be cleaned up and reassured after Staff Member A exited the room. Staff Member B reported the incident the next day when she saw the bruise on the resident's chin. Resident #4: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A 5/11/12 hospice nurse entry documented a meeting and a decision by the family to attempt rehabilitation services prior to opting for hospice services. Physician orders, dated 5/11/12, were obtained for physical and occupational therapy services. Review of a 5/14/12 form entitled, Pain Assessment in Advanced Dementia Scale, noted the Physical Therapist had rated the resident's pain level at 8 of 10 with symptoms such as occasional labored breathing, repeated troubled calling out, loud moaning/groaning/crying behaviors, and other physical manifestations such as rigidity, fists clenched, knees pulled up, pulling/pushing away or striking out. According to an anonymous investigative witness statement, on 5/16/12 in the morning, Resident #4 was observed in the therapy room receiving physical therapy. Multiple witnesses were present. The resident was reportedly screaming and yelling, "Please, please no!" but staff was "forcing her" to have physical therapy. Observations on 5/22/12 at approximately 9:15 a.m. revealed Resident #4 was in the therapy gym and Physical Therapist (PT) A was providing therapy for the resident. The resident was in a wheelchair facing the PT. Resident #4 was stating, "I can't. I did that enough, please!" The PT asked the resident, "What do you want me to do?" and Resident #4 stated, "Nothing." The PT stated, "We need to go a little longer" and he began to move her right leg. Resident #4 stated, "No, please, please." The PT then said, "You've got to do this, (the Resident's name), to get your legs stronger." The PT then moved the resident's right arm and she once again said, "Please, no, no." The PT grasped both of the resident's hands stating, "Let me move your hand". Once again the resident said, "Please, no." The PT stated, the resident says, "Ou" but she was not in pain. During the final phase of the PT session the resident was observed frowning, pulling her head away, diverting her gaze, and stating, "Please don't make me." The resident then called out for "Barney" even though there were no other individuals present in the rehab gym. The PT discontinued the session at approximately 9:20 a.m. (reportedly after 30 minutes). The PT stated the reaction the investigator observed was the resident's typical response throughout the therapy session(s). The PT then stated he planned to try to provide therapy to Resident #4 that afternoon as well. Staff Member A and the contracted PT failed to allow the residents to refuse care and services despite verbal and physical protests by the residents.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services for 1 of 3 residents reviewed for change in condition (#55); 1 of 5 residents reviewed for skin conditions (#1); 1 of 4 residents reviewed for pain (#61); 1 of 3 residents reviewed for positioning (#6); 1 of 1 resident reviewed for bowel program (#3) in a sample of 35. The failure of multiple licensed nurses to take appropriate action when Resident #55 developed signs of glandular infection in the mouth and dehydration resulted in the resident not being medically evaluated until the symptoms worsened and the legal representative insisted the resident be sent to the emergency room . The medical evaluation determined the resident had dehydration,[MEDICAL CONDITION] (severe illness in which the bloodstream is overwhelmed by bacteria), and resulting kidney failure. The resident was treated with intravenous antibiotics but did not improve. The failure of multiple licensed nurses over several shifts to recognize symptoms of infection and dehydration and take responsibility for promptly and verbally notifying the resident's physician about the resident's signs and symptoms and ensuring the resident received prompt medical evaluation placed all residents in immediate jeopardy of treatment delays when their conditions decline. Resident #1 experienced harm when the facility failed to evaluate the effectiveness of treatment for [REDACTED]. Resident #61 was placed at risk for ongoing untreated pain due to a delay in responding to her complaints of pain. Resident #6 was placed at risk for harm due to being improperly positioned at meals, potentially impeding his ability to feed himself. Resident #3 was placed at risk for complications related to untreated constipation. Findings include: 1. Resident #55 had [DIAGNOSES REDACTED]. The resident was admitted to the facility [DATE] following a stay in the local hospital for treatment of [REDACTED]. Review of the facility assessment dated [DATE] revealed the resident had memory problems, anxiety, and behavior problems including repeatedly calling out and refusing care. The resident required total assistance with all activities of daily living, including eating. The resident had a urinary catheter and was being treated with oral antibiotics for the UTI. Physical therapy was ordered for strengthening. Per record review, the resident had a family member who was also the legal representative. The legal representative was supportive and visited frequently. The resident ' s care plan noted the resident was at risk for dehydration. Interventions directed staff to evaluate for symptoms of dehydration including dry lips, dry mucous membranes, sunken look, decreased urine output, change in mentation, and to notify the physician if symptoms were present. Per record review, the resident's urinary catheter was removed [DATE] and staff was to check and change the resident's briefs. Review of nursing notes between [DATE] and [DATE] noted the resident was urinating without problems. After [DATE], there was no information in the nursing notes about the resident ' s urinary status. A day shift nursing note dated [DATE] noted the resident had been refusing to eat, refusing to help herself in any way with activities of daily living, and calling out constantly. The note stated " Spoke to (physician) today and he will be writing an order with (diagnosis) of failure to thrive. " According to the note, the physician stated he would call a psychiatrist and talk to him in regards to the resident's behaviors and preferred to wait on any medication for appetite stimulation until he spoke to the psychiatrist. The note indicated nursing would continue to monitor and assess. There was no documentation by the licensed nurse in the resident's nursing notes between [DATE] and [DATE]. There was no documented communication to or from the physician regarding a psychiatric consultation and/or medication for appetite stimulation after [DATE]. A day shift nursing note by Staff #A dated [DATE] noted the resident had a 3 by 2 centimeter (cm) swollen area under the right jaw that was very tender to touch. The Fax Sheet to Physicians dated [DATE] noted the resident had the large swollen area under the jaw, had thick blood-tinged sputum, and did not have a fever. There was no documentation by the licensed nurses in the resident's nursing notes between [DATE] and [DATE] including evaluation of the swollen face, blood-tinged sputum, and vital signs. There was no evaluation of the resident's mouth for possible signs of infection, pain level, whether oral care was offered and the resident's tolerance, the resident's fluid intake and ability to drink fluids, or respiratory status. Per record review, on [DATE] there was no communication from the facility to the physician to follow up on the Fax sent [DATE]. There was no evaluation of the resident's status in the nursing notes on the day and evening shift. Per record review, the resident was calling out during the evening shifts on [DATE] and [DATE] and was not evaluated for increased pain and/or anxiety. A day shift nursing note dated [DATE] at 0840 a.m. noted the resident's legal representative called the facility at 1:30 a.m. with a request for the resident to be sent to the local hospital emergency room for evaluation by the physician for the swollen facial gland, a possible UTI, and concerns about the resident's [MEDICAL CONDITION] and sodium level based on the resident's history. Per facility record review, Staff #G worked the night shift on [DATE] and would have received the phone call from the legal representative at 1:30 a.m. Despite the serious concerns expressed by the legal representative, there was no evaluation of the resident's swollen face, hydration, respiratory, urinary status, or vital signs during the night shift on [DATE]. The resident was transported to the hospital at 8:30 a.m. The note was signed by Staff #F who worked the day shift on [DATE]. There was no documented evaluation of the resident' s swollen face, hydration, respiratory status, urinary status, vital signs, and pain prior to transfer on the day shift on [DATE]. Review of the hospital admission History and Physical noted on arrival the resident was responsive but confused and painful and was immediately given a dose of narcotic pain medication. There was an approximately 5 cm reddened, raised mass in front of her right ear that was warm to touch and painful. The resident's mouth had markedly dry mucous membranes (symptom of dehydration). The resident's heart rate was 114 (rapid) and she had no fever. The hospital staff could not obtain a peripheral intravenous (IV) site and had to use an IV site in the leg (venous infusion in the leg is used emergent situations). The physician evaluation determined the resident was dehydrated, [MEDICAL CONDITION], a probable UTI, kidney failure, and was in serious medical condition. Per review of the resident's hospital record, the resident was treated with intravenous antibiotics and did not improve. The resident subsequently declined and died on [DATE]. In an interview on [DATE] at 10:30 a.m., Staff #B stated the resident was not eating, refused to get out of bed, and refused to participate in therapies. The resident ' s status was reviewed with the physician and the physician wrote the resident had "failure to thrive." Staff #B stated the care plan interventions to monitor the resident were still in place and the resident did not present with any new symptoms that required nursing monitoring. On [DATE] at 1:50 p.m., Staff #K and #L were interviewed. Staff #K stated the legal representative visited a lot in the evening. The resident refused to eat but staff could encourage her to drink some. On a good day she drank ,[DATE] small glasses of fluids, on a bad day ,[DATE] glasses. The resident was often withdrawn or calling out frequently. The resident had pain in her fingers and leg. On a bad day, the resident tried to move as little as possible. Staff #K stated she could not remember if she reported symptoms to the licensed nurses. She stated if she found anything she would have reported it. Staff #L stated the resident called out and seemed more confused the last month or so. When the resident used the bedside commode she would complain of pain in her back. The resident very seldom ate or drank anything. In an interview on [DATE] at 4:30 p.m., Staff #F stated he did not recall that the resident had any symptoms of infection and he didn't think he worked when the resident became ill and went to the hospital. Per resident record review, Staff #F administered medications to the resident on the day shift on [DATE]. During interviews on [DATE] at 10:40 a.m. and [DATE] at 1:00 p.m., the legal representative stated she was the resident's care giver prior to her admission to the nursing home. She stated about the last 2 ,[DATE] weeks before the resident was transferred to the hospital, she noticed the resident developed a cough. The resident was eating less and less and not drinking fluids very well. The resident's brief was often dry and she thought the resident had less urine output. She noticed the resident was having mental status changes and stated these changes could be a symptom the resident was having a UTI. She stated she asked the licensed nurses to contact the physician about obtaining a urine sample. The legal representative stated she didn't see the resident from [DATE] to [DATE]. She did visit the facility on [DATE] and the resident was asleep so she did not wake her up. She stated she received no communication from the facility that the resident's condition had changed or that the physician had written any new orders. The legal representative stated she visited the resident after 4:30 p.m. on [DATE]. The resident's mouth was as " dry as a bone", her mouth was full of phlegm, she had what looked like a swollen gland on the right side of her face. Her eyes looked sunken and she was mouth breathing. The right side of the face was completely swollen. The swollen gland was firm and felt hard and the resident said "ow-ow" when the legal representative palpated it. The resident aroused but went back to sleep easily and appeared overall sleepy. The legal representative stated she found Staff #A and asked her about the resident's swollen gland. Staff #A looked at the resident with the family member and faxed the physician immediately ([DATE]). The legal representative stated she was not contacted by the facility on [DATE]. On [DATE] she left a message for the resident' s physician and did not receive a call back. She called the facility after midnight on [DATE] and requested that the resident be transferred to the local hospital emergency room when there would be day shift staff available to evaluate the resident. The resident was transferred at 8:30 a.m. on [DATE]. The legal representative stated she was the resident's caregiver and knew the resident well. She stated the facility did not listen to her concerns and report them to the physician so the resident could receive timely treatment for [REDACTED]. In an interview on [DATE] at 1:50 p.m., the physician stated he saw the resident on [DATE]. The resident seemed fairly lucid about what she wanted to do. She didn't want to eat or participate in therapies. He stated her responses were consistent with her responses on office visits prior her admission to the facility. He stated he considered following up with a mental health consult but did not do so because she was making decisions not to participate in her care or eat. The physician stated he advised the facility and the resident's family member that the resident was at high risk for pneumonia or other infections and was at risk to become ill quickly. He stated he would have expected the facility to notify him of any symptoms of infections. He stated he did not have information that he was notified of any symptoms. He was not on duty the weekend the resident became ill and didn't see the resident in the hospital. In an interview on [DATE] at 8:15 p.m., Staff #A stated she was no longer employed at the facility. She stated on [DATE] she was not assigned to care for the resident. The resident's family member approached her in the hall and asked her to observe the resident. She observed the resident had about a quarter-sized lump on the right side of her face that did not appear red or painful. The resident did not appear to be in distress. She stated she faxed the physician rather than call because the resident was in no distress. If the physician was not working the next day, she assumed the physician on call would pick up the Fax. She notified the licensed staff coming on for the next shift of her observations and of the Fax to the physician. In an interview on [DATE] at 10:00 a.m., Staff #E stated the facility received a monthly calendar for physician coverage for the main physician clinic that served residents at the facility. She stated the resident's physician did not submit a schedule. If staff wanted to contact the physician, they should send a Fax or call the physician directly and find out which physician was covering for him. In an interview on [DATE] at 6:45 p.m., Staff #G stated she worked the 6 p.m. to 6 a.m. shift as the only licensed nurse in the facility. She stated she did not remember clearly but by reviewing the resident's record she probably did care for her on [DATE] or [DATE]. Regarding the resident's swollen face, she stated she probably cared for the resident at the time the resident had the facial infection in her gland but it wasn't passed on to her in report and the resident was not on alert charting so she didn't know to evaluate it. She said it was usually dark on her shift and she didn't see anything. Regarding whether or not the resident had a cough, she stated the resident had a cough but not anything with blood. Skin Conditions 2. Resident #1 had [DIAGNOSES REDACTED]. Per record review, the resident had severe memory and decision-making problems, inability to speak, no voluntary movement in her arm and legs, and was totally dependent on staff for all activities of daily living. The resident's care plan for incontinence noted the resident was incontinent and directed staff to check and change the resident every 2 hours. Per record review, the resident had a new physician order [REDACTED]. Review of the resident's [DATE] treatment record noted beginning [DATE] the resident was to receive " diaper rash cream (twice daily)." Between [DATE]-,[DATE], there were 9 entries on the day shift that were left blank, indicating staff did not document the completion of the treatment or the resident did not receive the treatment. There was no evaluation by the licensed nurses on the resident's treatment record or in the nursing notes on [DATE] when the physician ordered the diaper rash cream for excoriated buttocks. A day shift nursing noted dated [DATE] noted the resident's "butt" was sore with an open area and no pain. During observation of care with Staff #M on [DATE] at 11:00 a.m., the resident, who was in bed, was turned to the left side. She had contractures of knees, ankles, elbows, wrists, and fingers. Both buttocks had red excoriated skin with open areas visible through the cream. Staff #M confirmed there were open skin areas. He stated the resident had the open areas for at least 3 weeks and was probably "a little worse" than when he last saw the resident. Staff #M stated the resident's skin folded together creating a moist environment that was difficult to keep dry. He stated staff provided perineal care and turned the resident side to side every 2 hours and the resident was in bed except for meals. There was no evaluation by the licensed nurses in the nursing notes after [DATE] including treatment effectiveness, contributing factors to the lack of healing, and new interventions tried. Staff #M did not document the evaluation of the resident's skin on [DATE]. During observation of care with Staff #K and #T on [DATE] at 10:25 a.m., the skin excoriation on both buttocks was less reddened. The skin areas on the left buttocks were intact. The open areas on the right buttock remained. In an interview on [DATE] at 3:30 p.m., Staff #D stated the licensed nurses were responsible for documenting and evaluating treatment of [REDACTED]. The facility's failure to monitor and evaluate the effectiveness of treatment and determine the need to implement new interventions to promote healing for a preventable skin condition that lasted at least 33 days, and that worsened before improvement resulted in harm to the resident. Pain Management 3. Resident #61 had [DIAGNOSES REDACTED]. Per record review, the resident was alert and could make her needs known, had no short-term memory, mood, or behavior problems, and required limited assistance of one staff for most activities of daily living. The resident had moderate pain rarely which was relieved with as needed doses of oral narcotic medication. In an interview on [DATE] at 12:00 p.m., the resident stated she was not having pain at the time of the interview but did have pain in her hip which was improving. She stated she asked for pain medication about every 4 hours and rated her pain level as about a 6 (moderate pain) when she asked for the pain medication. She stated she asked for her pain medication before going to therapy but did not know what her schedule was each day. In an interview on [DATE] at 7:50 a.m., the resident was seated in her wheelchair in her room eating breakfast. She stated her pain level was about a 4. She stated the night shift nurse gave her a muscle relaxant on night shift. She had not seen the day shift nurse yet but had been waiting for a pain pill for about an hour. During the interview, the resident pressed her call light button to request a pain pill. At 7:55 a.m., medication pass was observed with Staff #C. A staff member informed her that the resident was requesting pain medication. Staff #C stated she had 2 more residents for medication pass, Resident #61 and Resident #63 who was in the hall. Staff #C stated she would administer medications to Resident #63 first because the resident was waiting in the hall and only had one medication. When asked by the surveyor, Staff #C stated she knew Resident #61 had requested a pain pill and had not yet evaluated the resident's pain level. Per observation, Staff #C visited the resident in her room at 8:10 a.m. The resident reported her pain level as a 6. Staff #C prepared and administered and administered the pain medication at 8:15 a.m. After observation of medication pass, the surveyor informed Staff #D regarding the delay of more than one hour in responding to the resident's report of pain, evaluating her pain level, and administering as needed pain medication. Positioning 4. Resident #5 had [DIAGNOSES REDACTED]. The resident used a recliner and tilt wheelchair to maintain body alignment and proper positioning. The wheelchair had a padded seat, back, and head rest and a one piece foot plate instead of foot pedals. The resident was dependent on staff for proper positioning in the wheelchair. ON [DATE] at 3:30 p.m., the resident was in the wheelchair in the hall. He was slumped down and leaning to the left. During a brief interview the resident stated he wanted to go to bed. During periodic observation from 3:30 p.m. to 6:30 p.m., the resident remained in the same position until he was repositioned for dinner at 5:50 p.m. During observation of breakfast on [DATE] in the East Hall dining room, the resident was reclined in the wheelchair. His legs did not fit under the horseshoe table so Staff #T positioned him beside the table. He had to turn his head to the left to see his food and he could reach items on his tray. After the meal, the surveyor asked Staff #T if the resident could fit under the table if the foot plate was lowered. Staff #T stated the foot plate could not be lowered. In an interview on [DATE] at 4:30 p.m., Staff #W stated the resident's leg rests adjusted when the wheelchair was in the upright position and that the wheelchair was the proper fit for the resident. The facility's failure to offer position changes and position the resident properly during dining placed him at risk for discomfort and potentially impeded his ability to participate in feeding himself. Bowel Management 5. Per record review, the facility bowel management protocol was as follows: Bowel Program #1: if no bowel movement times 3 days, give Senna 8.6 milligrams by mouth as needed, not to exceed 8 tablets in 24 hours. Bowel Program #2: If no bowel movement by the evening shift give Milk of Magnesia 30 milliliters, by mouth as needed. Bowel Program #3: If no bowel movement by the next morning, night shift to give [MEDICATION NAME], give oral or rectal as needed. Bowel Program #4: Fleet Enema, insert 1 rectally if goes longer than 4 days without bowel movement. If no results with your shift, call physician. Per review of Resident #3's record, she had [DIAGNOSES REDACTED]. She required extensive assistance with toileting and peri-care. Resident #3 was observed in her room sitting in her recliner chair on [DATE] (6 days after her last recorded bowel movement). She was calling out repeatedly "help me, help me" and was observed pushing on the recliner armrests in an attempt to reposition herself. She was unable to verbalize her discomfort. Staff #J made an observation of Resident #3's actions and stated Resident #3 often repeated phrases and had no awareness of what she was saying or doing. Per review of the Nurse Aide flow sheets for [DATE], Resident #3 had bowel movements recorded on [DATE] and [DATE], which was a 7 day period. Per review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility failed to implement the bowel protocol.

Based on observation, interview, and record review, it was determined the facility failed to have sufficient qualified nursing staff to safely provide nursing services to attain or maintain the highest physical and psychosocial well-being for 10 of 35 sample residents (#1, 2, 3, 10, 30, 37, 40, 41, 55, 60) related to effective management of changes in condition, non-pressure skin conditions, pressure ulcers, appropriate treatment and services to address mental/psychosocial adjustment issues, and supervision to prevent accidents and ensure the resident environment was as free of accident hazards as possible. Failure to provide timely medical evaluation and treatment, prevent worsening of non-pressure skin conditions and pressure ulcers, and provide timely interventions for repeated episodes of emotional distress resulted in harm for Resident #1, #3, #55, and #60 and placed all other residents at risk for harm. Findings include: 1. Nursing services failed to ensure licensed nursing staff recognized the need for prompt medical attention and treatment for [REDACTED]. Refer to 42CFR 483.25, F309, Quality of Care. 2. Nursing services failed to ensure licensed nursing staff provided residents with adequate treatment and monitoring to prevent the worsening of avoidable non-pressure skin conditions and pressure ulcers. This resulted in harm for Resident #1 and #60. Refer to 42CFR 483.25 F309, Quality of Care. Refer to 42CFR 483.25(c), F314, Treatment/Services to Prevent/heal Pressure Sores. 3. Nursing services failed to ensure there was sufficient qualified staff to safely provide appropriate treatment and services to address mental/psychosocial adjustment difficulty. This resulted in harm for Resident #3. Refer to 42CFR 483.25(f)(1), F319 Treatment/Services for Mental/Psychosocial Difficulties. 4. Nursing services failed to ensure there was sufficient qualified staff to safely provide adequate supervision to prevent accidents and ensure the resident environment was as free of accident hazards as possible. This placed Resident #2, #10, #30, #37, #40, #41 and potentially all residents who resided on the West Hall at risk for harm. Refer to 42CFR 483.25(h), F323, Free of Accident Hazards/Supervision/Devices.

Based on observation, interview and record review, the facility failed to develop and implement interventions when pressure ulcers developed and worsened, failed to monitor and develop new interventions to prevent the pressure ulcers from worsening for 2 of 5 residents (#60, #3) reviewed for skin issues in a sample of 35. This resulted in harm for Resident #60 who developed avoidable pressure sores. Findings include: Federal guidelines define a pressure ulcer as any lesion caused by unrelieved pressure that results in damage to underlying tissue(s). Friction and shear are important contributing factors to the development of pressure ulcers. A "Stage II" pressure ulcer involves partial thickness loss involving the top layer of skin (epidermis), underlying skin (dermis), or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. 1. Resident #60 was admitted to the facility on [DATE] from an acute care setting. Per record review, she had [DIAGNOSES REDACTED]. Resident #60 had no identified pressure ulcers upon admission. An Admission Care Plan dated 12/10/11 identified Resident #60 as at risk for skin breakdown related to decreased mobility which included intervention to monitor skin daily during care. An "In Room Care Plan" dated 12/10/11 was located inside Resident #60's closet. It contained a category entitled: skin condition: Skin care and Pressure Ulcer Prevention: which was blank with no directives for staff to follow to monitor and/or prevent skin breakdown. On 12/14/11 at 11:15 a.m., during observation of care for Resident #60, Staff #K discovered a new small red flat area, blister-like in the center, on Resident #60's right buttock. Staff #K reported to Staff #J, a licensed nurse, who looked at the area and indicated a barrier cream ([MEDICATION NAME]) would provide protection to the skin. Staff #K stated that occasionally Resident #60 was assisted to turn side to side during bathing and so was off her back at those times. Per record review, there was no evaluation of the presence of a new pressure area by Staff #J on 12/14/11. On 12/15/11, during hourly observations between 9:00 a.m. and 3:00 p.m., Resident #60 was observed on her back in an inclined position. In an interview on 12/15/11 at 4:30 p.m., with Resident #60, she stated she did not think anyone came in to look at her buttock that day. On 12/16/11 at 11:25 a.m., another observation was made of Resident #60's buttocks. Staff #J was again called in to look at the resident's skin. She stated that the pressure ulcer on the right buttock noted on 12/14/11 seemed to have improved, in addition, Staff #J stated there were two new fluid-filled vesicles in Resident #60's coccyx area. Before she left the room, she gave no new directives to the caregivers regarding skin care. Per record review, there was no nursing evaluation of the pressure ulcers that developed on 12/14/11 on the buttocks and 12/16/11 on the coccyx, and there were no new interventions developed or implemented for either positioning or treatment of [REDACTED]. On 12/19/11 at 2:10 p.m., observation was made of Resident #60's skin with Staff #M, a licensed nurse. Staff #M stated that the right buttocks pressure ulcer had worsened to a Stage II ulcer and was caused by shearing. The measurement was 4 X 2 centimeters. After observing the resident's skin, Staff #M didn't document the evaluation of the buttocks ulcer or the coccyx, and didn't notify the physician or the family that the pressure areas worsened. In an interview on 12/19/11 at 2:30 p.m., when notified by the surveyor that Resident #60 had pressure ulcers, Staff #B, the Director of Nursing Services, stated she was not aware of the pressure ulcers and had not been notified by her staff. She described the treatment protocol followed upon discovery of a pressure ulcer. She stated if a resident developed a pressure ulcer, staff should fill out a report, initiate treatment orders, and notify all parties involved. On 12/20/11 at 9:30 a.m., per review of the treatment administration record, there were no new treatments listed for monitoring/treating Resident #60's observed and identified pressure ulcers. On 12/21/11 at 10:00 a.m., with Staff #F, a licensed nurse, an observation was made of Resident #60's skin. Staff #F stated the right buttock was still a Stage II pressure ulcer and the coccyx still had blisters. Staff #F stated there was a new Stage II pressure ulcer on the left buttock that measured 1 centimeter in diameter. Staff #F cleansed the area with gauze pad and normal saline. Staff #F grasped the skin of the blister on the left buttock with the gauze pad and removed it by pulling the skin abruptly. The area exposed by the removal of the skin began bleeding and Resident #60 stated loudly, "That hurt". Staff #F placed a new gauze 2X2 on the area to stop the bleeding. In an interview on 12/21/11 with Staff #F at 11:00 a.m., he was asked if it was a normal procedure to remove skin from a pressure ulcer. Staff #F stated no, but he thought the skin would cause more damage if left in place as the blister had popped and the skin was crinkled. Staff #F stated he placed a foam dressing on the area as there was moderate drainage per the directives stated in the Regency Pacific Skin and Wound Care guide. He stated the plan was to notify the Physician, get the treatment order and fill out the Weekly Ulcer Measurement Tool per the facility policy. Despite multiple observations and verification of pressure ulcers by multiple staff over the course of time from 12/14-12/21/11, an 8 day period, facility staff failed to take action as directed by facility protocols and guidelines to prevent pressure ulcers and worsening of pressure ulcers for Resident #60. 2. Resident #3 had [DIAGNOSES REDACTED]. Her plan of care identified her at risk for skin impairment related to her medical condition and included interventions for staff to reposition her every 2 hours, and daily skin checks by the nursing assistants. On 12/13/11 at 7:45 a.m., Resident #3 was observed in her recliner; she appeared asleep. Observations were made at 9:30 a.m., 10:20 a.m., 11:30 a.m., and 1:00 p.m. At each observation, the resident remained in her recliner in the same position with eyes closed. Staff #J was interviewed on 12/14/11, and verified that Resident #3 had cycles of time where she was awake for extended periods, even days at a time, followed by times where she slept the entire day. Staff #J stated due to Resident #3's cycling with behaviors when awake, when she was asleep, staff checked on her and just let her sleep. Resident #3 was not repositioned every two hours per the Plan of Care directives and per the facility protocol. Per record review, the weekly skin check on the treatment administration record (TAR) on 12/4/11 indicated the resident had no pressure ulcers. Per observation of Resident #3 on 12/14/11 at 1:50 p.m., the resident had a Stage I reddened area on her right buttock. At the time, Staff #J directed the nursing assistant to apply [MEDICATION NAME], a house barrier ointment. Staff #J stated the area was not new. Resident #3's right buttock was observed on 12/16/11 at 11:30 a.m. Staff #J noted the right buttock pressure ulcer had increased from a Stage I to a Stage II open area and was about the size of a dime. Staff #L applied the house barrier ointment, dressed Resident #3 and placed her in her recliner without any wound dressing to the pressure area. Per review of the December 2011 TAR, a skin check on 12/16/11 indicated Resident #3's skin was intact. Per record review, there was no documented nursing evaluation when the Stage I pressure ulcer was observed on 12/14/11. On 12/16/11 when it worsened to a Stage II open pressure area, there was no documented evaluation. The facility did not act to ensure further evaluation or new treatment after the barrier cream proved ineffective. The resident's physician and family were not notified. In an interview with the Staff #B, she stated she knew of the presence of a Stage I area on Resident #3's coccyx, but had not been notified that the area had worsened.

Based on observations, interview, and record review, the facility failed to ensure 1 of 2 residents (#3) with behavior and mood problems in a sample of 35 received appropriate treatment and services to address mental/psychosocial adjustment issues. The lack of staff attempting to address the multiple episodes of distress exhibited by the resident resulted in harm. Findings include: Resident #3 had [DIAGNOSES REDACTED]. The resident had memory problems and required assistance with decision-making. Per social service notes dated 9/2/11, the resident was focused on returning to her home in the community where she lived with family prior to admission to the facility on [DATE]. The resident was noted to have few interests and had periods of anxiety and restlessness since admission. At this time she was not on any anti-anxiety medication. Per social service notes dated 9/12/11, the resident was noted to have anxiety and continued to perseverate about returning home. Per the record, the resident said she tried to do puzzles and word searches to help with her restlessness. Per social service noted dated 10/4/11, the resident was started on an anti-anxiety medication secondary to an increase in restlessness and calling out. The resident was also noted to have gone from moderately impaired to severely impaired for decision-making. Per nursing notes dated 10/11/11, the physician was contacted secondary to agitation and her anti-anxiety medication was increased. Per record review, the resident went home from 11/6/11 to 11/9/11 and it was too difficult for her caregivers to take care of her and she returned to the facility. Per record review there was no assessment of the resident's ability to cope and adjust to the new discharge plan. Per nursing notes dated 11/10/11, the resident called out through most of the night and told staff to take her home. Progress notes documented the resident was not re-directable. Per nursing notes dated 11/14/11, the resident had an increase in agitation, continuous calling out, which was noted as "unreasonable." The physician was informed and on 11/16/11 the resident was started on a medication for dementia. The most recent assessment dated [DATE] noted the resident had daily disruptive behavior/calling out and directed staff to provide assistance with adjustment to placement in the facility, to encourage the resident to verbalize feelings, and provide redirection to reduce confusion and/or distress. On 12/14/11 at 1:30 p.m., the resident was overheard calling out in her room, "help me, help me." There were no staff members in the hall way. The resident was squirming in her recliner, crying out. At 1:45 p.m., the resident continued to call out and cry "help me, help me." The surveyor did not see staff in the area and no one responded to the resident's calls for help. At 1:50 p.m. the surveyor informed Staff #J that the resident was calling out and the resident said she was in pain. Staff #J said the behavior was normal for the resident and said the resident cycled with these behaviors, and wore herself out until she fell asleep. The resident continued to call out for help and for her children throughout the evening on 12/14/11. On 12/20/11 at 4:30 p.m. the resident was observed sitting in her wheelchair in the hall way next to the medication nurse. The resident yelled out "help me, help me" on and off while Staff #M passed medications. The resident continued to call out over and over again when Staff #M said, "Why are you yelling that's not okay your family was just here, it's not okay... people are trying to sleep." The resident stopped calling out for a moment and Staff #M said, " That's my girl." At 4:40 p.m., the resident started calling out again and whimpering. Staff #M said, "No hollering okay, do you want to sit in your recliner?" The resident said, "I don' t care," while she continued to whimper. At 5:00 p.m., the resident was observed in her recliner while she called out for help over and over again. At 5:15 p.m., the resident was still calling out for help. The resident was observed to be very restless, whimpering and moaning. There were no staff observed to respond to the resident. On 12/21/11 at 5:45 p.m., the resident was observed in the hall at the nurses' station in her wheelchair calling out and moaning, "Help me, help me," over and over again. There were no staff observed around the resident and no staff observed to provide assistance to the resident. Per interview on 12/21/11, Staff #F said "nothing" works with the resident. Staff #F said sometimes you can talk to her and she will calm down and when she is around people she feels like a real person. The resident was observed in distress on numerous occasions during the survey process. Per record review, the resident 's discharge plan changed from returning to the community to staying in the facility long-term care. The resident's difficulty dealing with her loss of her independence and ability to return to the community were not addressed by the facility. The facility did not attempt to determine whether there was an underlying cause of the behavior. The interventions of encouraging the resident to verbalize and provide redirection were neither consistently practiced nor effective. There was no evaluation of the interventions to determine whether there was another way to provide the support needed by the resident for her mental distress. The resident exhibited sadness and anxiety daily and the facility did not have a plan in place to address this to improve the resident's quality of life.

Based on observation, record reivew, and interview, the facility failed to provide treatment and services for 1 of 25 sample residents (#22) related to pain management. This resident had on going unrelieved pain which limited his ability to participate in therapy. The lack of interventions for pain management resulted in harm to resident # 22. Findings include: Resident #22 per record review, had [DIAGNOSES REDACTED]. The resident had short term memory problems and was moderately impaired in daily decision-making. The resident required extensive assistance for most activities of daily living. Per the pain assessment completed in June 2010, the resident had pain in both of his thighs down to his knees. It was documented that the resident was not satisfied with the current treatment and said he just wanted to be free of pain. The intervention initiated after this assessment was a referral for physical therapy to evaluate and treat. There was no record of request for medication changes or initiation of non-med interventions. There was no care plan in the resident's record to reflect interventions being used for pain management. Per the physical therapy notes dated 6/17, 6/18, 6/22, 6/24, and 6/26/10, the resident rated his pain a 10 out of 10. Per the therapy note dated 6/24/10, the resident became agressive and violent when pain was felt during stretching. Per the physical therapy notes dated 7/1, 7/3, 7/6, 7/7/10, the resident refused therapy. Per a physician's progress note dated 8/15/10, it was noted that the resident "still has leg pain" and had complained recently that physical therapy abused him. There were no recommendations or new orders for management of pain. Per the physical therapy note dated 8/24/10, the resident rated his pain 10 out of 10 and on 8/26/10 rated it 7 out of 10. The pain assessment done in September 2010, documented the resident as having no pain. However, per physical therapy notes dated 9/16/10, the resident refused to do the sit-to-stand activity and rated his pain 10 out of 10. Per therapy notes dated 9/17/10, 9/24 and 9/25/10, the resident rated his pain 10 out of 10. On 9/29/10, therapy notes documented the resident refused to continue physical therapy due to pain. The therapist asked the nurse if the resident could be medicated prior to therapy. The nurse said the resident was already getting pain medications and continued to "constantly" experience it. Per the MAR (medication administration record) for September 2010, the resident received 1 prn dose of pain medication on 9/29/10 and it was documented that the resident still complained of pain after he received it. There was no documentation evaluating the routine pain medication for effectiveness either on the MAR indicated [REDACTED]. Per the MAR for October 2010, the resident did not receive any prn pain medication. There was no documentation evaluating the routine pain medication for effectiveness either on the MAR indicated [REDACTED]. Per resident interview on 11/4/10 at 1:00p.m., the resident stated he had pain in his left hip and knee and down to his ankle. He stated he had pain for quite sometime and staff was aware. He stated he was frustrated because he was unable to stand or walk due to the pain and often was not able to participate in Physical Therapy. When asked if he took his pain medication that was ordered "as needed" he stated "I didn't know I had any." On 11/4/10 at 1:45p.m., Staff G stated she was aware of the resident's pain. She stated he had [MEDICAL CONDITION] pain that had progressively gotten worse. The facility failed to adequately assess, treat, and monitor the resident for pain which resulted in ongoing unresolved pain which impacted his quality of life.