Every finding on record at Renton Health & Rehabilitation

Based on observation, interview, and record review the facility failed to maintain a homelike environment for 3 of 4 units (Unit B, Unit, C, & Unit D) reviewed for environment. The failure to ensure walls, flooring, and windows were in good repair left residents at risk of an unsafe environment, and a less than homelike environment.Findings included.<Policy>According to the facility policy titled, Safe and Homelike Environment, dated 12/2025, the facility would maintain a safe, sanitary, orderly, and comfortable homelike environment.<Unit B> Observation on 01/06/2026 at 10:09 AM showed gouges on the wall at the head of bed 1 in room [ROOM NUMBER]. Observation on 01/06/2026 at 9:02 AM showed the entrance tiles were broken and the baseboards were dirty and broken in room [ROOM NUMBER]. <Unit C> Observation on 01/06/2026 at 10:21 AM showed white paint patches on the wall behind the head of bed 2 in Room . Observation on 01/06/2026 at 11:00 AM showed some of the window blind slats were bent and missing in room [ROOM NUMBER]. Observation on 01/06/2026 at 11:17 AM showed the privacy curtain was missing for bed 2 in room [ROOM NUMBER]. The observation showed the resident in bed 2 used supplemental oxygen and their oxygen concentrator was dirty with dust and stains. <Unit D> Observation on 01/06/2026 at 9:00 AM showed large, black gouges in the hallway flooring outside of room [ROOM NUMBER]. Observation on 01/06/2026 at 1:43 PM showed scrapes along the wall behind the head of bed 1 in room [ROOM NUMBER]. Observation on 01/07/2026 at 11:06 AM showed some of the blind slats in room [ROOM NUMBER] were bent and missing. The resident in bed 2 stated the blinds were broken for a while. Observations on 01/06/2026 at 12:32 PM and on 01/12/2026 at 9:00 AM showed a plastic bag was tied to a string to turn the light on in room [ROOM NUMBER] at the resident in bed 2's bedside. In an interview on 01/13/2026 at 9:00 AM, Staff C (Maintenance supervisor) confirmed these findings in the facility walkthrough and stated residents should have a homelike environment. In an interview on 01/13/2026 at 9:23 AM, Staff B (Director of Nursing) stated their expectation was for residents to have a homelike environment. Staff B stated the damaged walls, blinds, and flooring should be fixed. REFERENCE: WAC 388-97-0880, -2040.

Based on observations, interview, and record review the facility failed to ensure food was stored in accordance with professional standards of safety. The failure to ensure foods stored in the facility's main kitchen and [NAME] Unit fridges were labeled, covered, dated, and/or disposed of upon expiration placed residents at risk of ingesting expired and/or contaminated foods and the development of food-borne illness.Findings included.<Facility Policy>According to the facility's Food Safety Requirements policy, revised 12/2025, food requiring refrigeration would be labeled, dated, and monitored to ensure the food was used by the use by date or frozen/discarded when applicable. The policy showed refrigerated food would be covered or in tight containers.<Main Kitchen Refrigerator>Observation on 01/06/2025 at 8:36 AM showed the walk-in refrigerator in the main kitchen contained a tray with 11 house made Jello cups. The Jello cups were uncovered and undated. In an interview on 01/06/2026 at 8:51 AM, Staff H (Dietary Supervisor) confirmed the Jello should be covered.<West Nursing Unit Refrigerator>Observation on 1/06/2026 at 9:25 AM showed the refrigerator in the [NAME] Nursing Unit contained the following food items: A carton of thickened liquid dated 12/22/2025, use by 12/29/2025 Two packages of sliced bread dated 12/09/2025 One bag of carrots dated 12/14/2025 Three avocadoes, undated Two packages containing sliced meat and cheese, undatedIn an interview on 01/06/2026 at 9:25 AM, Staff D (Registered Nurse Manager), stated staff wrote the date on food when they put it in the refrigerator. If food items were not used within a week, staff discarded the food. Staff D confirmed the thickened liquid, bread, and carrots were expired and should be discarded. Staff D stated staff should write a date on the avocadoes, meat, and cheese trays so they knew when to discard the items.REFERENCE: WAC 388-97-1100 (3), -2980.

Based on observation, interview, and record review the facility failed to: ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 1 of 6 residents (Resident 5) reviewed for Infection Control; and ensure visitors used gloves while pouring ice from a communal ice bucket to avoid cross contamination. These failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases.Findings included . <Facility Policy>Review of the facility's Infection Prevention and Control Program policy, revised 04/23/2025, showed the facility established and maintained an infection control program to provide a safe, sanitary, and comfortable environment to all residents and staff to prevent the development and transmission of communicable diseases. The policy showed the facility would ensure healthcare personnel were educated and trained regarding the appropriate use of PPE prior to caring for a resident on isolation precautions including EBP. Staff would follow the signs posted outside resident's rooms for precaution. The policy showed the central supply staff would clean/decontaminate the equipment prior to storing for reuse. <Resident 5> According to the 10/15/2025 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 5 had multiple medically complex conditions including a stroke (a medical condition that occurred when blood flow to part of the brain was interrupted) with left sided weakness. The assessment showed Resident 5 had an indwelling catheter (a flexible tube inserted into the bladder to drain urine) and was assessed to require maximal assistance from staff for their toileting hygiene. Observations on 01/06/2026 at 8:52 AM, on 01/07/2026 at 11:43 AM, on 01/08/2026 at 1:42 PM, and on 01/09/2026 at 8:20 AM showed an EBP sign was posted outside Resident 5's room that instructed staff to perform hand hygiene and to wear PPE while providing direct care to Resident 5. These observations showed an isolation cart filled with PPE inside Resident 5's room. In an interview on 01/06/2026 at 10:02 AM, Staff P (Licensed Practical Nurse) stated Resident 5 was on EBP precautions because Resident 5 had an indwelling catheter and staff had to wear PPE while providing care to Resident 5. Observation on 01/09/2026 at 9:23 AM showed Resident 5 lying in their bed and Staff N (Certified Nursing Assistant) providing incontinence care to Resident 5. Observation showed Staff N did not wear a gown while providing incontinence care. In an interview on 01/09/2026 at 9:30 AM, Staff N stated they should wear PPE including gloves and gown while providing care to Resident 5 but they forgot to wear the gown as instructed on the sign posted outside Resident 5's room. Observation on 01/09/2026 at 9:35 AM showed Staff O (Registered Nurse) providing wound care to Resident 5 in their room without wearing a gown. In an interview on 01/09/2026 at 9:40 AM, Staff O stated they should follow the instructions on the sign posted outside Resident 5's room and wear PPE while providing care to Resident 5, but they did not. Staff O stated it was important to wear PPE as instructed to prevent spreading infection to other residents and staff. In an interview on 01/09/2026 at 1:23 PM, Staff B (Director of Nursing) stated all staff should follow the directions on the sign posted outside residents' rooms to prevent spreading of infections. <Ice Bucket> Observation on 01/08/2026 at 9:39 AM showed a visitor walking in the [NAME] hallway, touching their hair and corridor side rails. The visitor approached a cooler filled with ice, picked up the ice scoop with their bare hands and poured ice from the scoop into their personal water bottle. The visitor did not use gloves or perform hand hygiene before or after using the ice scoop. In an interview on 01/08/2026 at 10:13 AM, Staff P stated the visitor should ask staff for ice. Staff P stated staff should not leave the ice bucket in the hallway as it caused infection control concerns. REFERENCE: WAC 388-97-1320 (1)(a), (2)(b).

Based on observation, interview, and record review the facility failed to ensure confidentiality of resident records was maintained for 1 of 4 units (Unit A) and services provided were appropriately documented in resident records for 1 of 18 residents (Resident 17) reviewed. This failure placed residents at risk for a violation of their rights to privacy and their right to receive care and services as ordered.Findings included.<Policy>According to the facility policy titled, Confidentiality of Personal and Medical records, dated 12/2025, the facility would ensure all resident information was secured and confidentiality was maintained. The policy showed papers with resident information would not be left unattended.<Unit A> Observation on 01/06/2026 at 12:30 PM showed the Unit A medication cart with a paper that had resident health information on it unsecured and in view for all. In an interview on 01/06/2026 at 12:31 PM Staff E (Registered Nurse) stated they were expected to cover and secure the resident information prior to leaving it but forgot. Staff E stated it was important to secure resident information to protect residents' health information from others. In an interview on 01/13/2026 at 8:30 AM Staff B (Director of Nursing) stated they expected staff to secure resident information prior to leaving it unattended. Staff B stated it was important to prevent HIPAA (Health Insurance Portability and Accountability) violations. <Resident 17> According to the 12/18/2025 admission Minimum Data Set (MDS – an assessment tool) Resident 17 was dependent on staff for bathing/showers. The MDS showed Resident 17 had no memory impairment. Review of Resident 17's medical records showed a 12/30/2025 ADL (Activities of Daily Living) Care Plan (CP) with showers scheduled twice weekly every Monday and Thursday on evening shift and as needed. Resident 17's medical records documented shower transfers on 12/12/2025, 12/15/2025, 12/16/2025, 12/17/2025, 12/18/2025, 12/20/2025, 12/21/2025, 12/22/2025, 12/23/2025, 12/25/2025, 12/28/2025, 12/29/2025, 12/30/2025, 12/31/2025, 01/01/2026, 01/02/2026, 01/03/2026, 01/05/2026, 01/06/2026, 01/08/2026, and 01/09/2026. Resident 17's medical record showed two-person assistance was provided for preferred showers on Wednesdays and Saturdays, 12/17/2025, 12/20/2025, 12/24/2025, 12/27/2025, 12/31/2025, 01/03/2026, and 01/07/2026. In an interview on 01/06/2026 at 10:30 AM Resident 17 stated it was difficult to get showers at the facility. Resident 17 stated they were scheduled to receive showers twice a week but had not received or been offered them as scheduled. Resident 17 stated they only received one shower since admission to the facility on [DATE]. In an interview on 01/12/2026 at 12:38 PM Staff F (Certified Nursing Assistant) stated they did not provide Resident 17 bathing since admission. Staff F stated they documented showers provided by Occupational Therapy for Resident 17 on 12/17/2025 and 01/03/2026. In an interview on 01/12/2026 at 12:42 PM Staff B stated staff should not be documenting for other staff. Staff B stated it was important for staff to only document services they provided to ensure no missed services. In an interview on 01/12/2026 at 12:54 PM Staff F stated they were instructed by Staff B to never document services they themselves did not provide. In an interview and record review on 01/13/2026 at 10:54 AM Staff U (Certified Occupational Therapy Assistant - COTA) stated they assisted Resident 17 with one shower since admission. Review of the therapy notes showed only one shower provided by therapy since admission on [DATE]. Bathing/shower services were not provided by therapy to Resident 17 on 12/17/2025 or 01/03/2026. Reference: WAC 388-97-1720 (1)(a)(i-iv)(b)(c)(2)(a-m), -0360(1-3).

Based on observation, interview, and record review the facility failed to provide care in a manner that promoted dignity for 2 (Residents 11 & 2) of 18 sample residents. The failure to provide privacy during assessment and treatment placed residents at risk for feelings of diminished self-worth and embarrassment. Findings included . <Facility Policy>Review of the facility's revised 12/2025 Promoting/Maintaining Resident Dignity policy showed the facility would treat each resident with respect and dignity. The policy showed all staff members would speak respectfully to residents and avoid discussions about residents that could be overheard by others. Staff involved in providing care would provide do so in a manner that promoted and maintained resident privacy and dignity.<Treatment in a Dignified Manner> <Resident 11> According to the 10/29/2025 5-Day Minimum Data Set (MDS - an assessment tool), Resident 11 had multiple medical conditions including stroke (a medical condition occurring when blood flow to the part of the brain was interrupted) with left side weakness, pain, and depression. This MDS showed Resident 11 had intact memory and made their own decisions Observation on 01/06/2026 at 11:52 AM showed Resident 11 was sitting in the dining room with three other residents at the same table, waiting for their lunch. Staff I (Nurse Practitioner) came to Resident 11 in the dining room and started talking about Resident 11's pain. Staff I started giving Resident 11 an injection in the dining room before another staff member stopped Staff I from administering the injection in the dining room. <Resident 2> According to the 11/13/2025 5 Day MDS, Resident 2 had multiple medical conditions including a hip fracture and pain. This MDS showed Resident 2 had intact memory and made their own decisions. Observation on 01/06/2026 at 12:06 PM showed Resident 2 was in the dining room with other residents during lunch time. Staff I started assessing Resident 2 in the dining room, talking about their pain and treatment in front of other residents and staff members. In an interview on 01/06/2026 at 12:29 PM, Staff I stated they should not assess and/or treat residents in public places. Staff I stated they should provide privacy to residents during assessment and treatment. In an interview on 01/09/2026 at 11:49 AM, Staff B (Director of Nursing) stated all residents should be treated in a dignified manner. Staff B stated the facility staff should not assess, treat, or provide care in the dining room. Staff should provide privacy to residents, but they did not. REFERENCE: WAC 388-97-0180(1-4).

Based on observation, interview, and record review the facility failed to ensure person-centered Care Plans (CPs) were revised as needed to address all aspects of resident care for 4 of 18 residents (Residents 4, 5, 6, & 7) reviewed for comprehensive CPs. These failures placed residents at risk for inconsistent and/or inadequate care and treatment and a diminished quality of care.Findings included.<Policy>According to the facility policy titled, Comprehensive Care Plans, dated 12/20/2025, the facility would ensure care and treatments provided to residents would be included in the CP.<Resident 4> According to the 11/24/2025 Annual Minimum Data Set (MDS - an assessment tool) Resident 4 had clear speech and was able to make themselves understood. Resident 4 had multiple medically complex conditions including heart problems and high blood sugar. The MDS showed Resident 4 received blood thinner medications during the assessment period. Observations on 01/06/2026 at 1:41 PM, on 01/07/2026 at 10:46 AM, 01/08/2026 at 9:22 AM, and on 01/12/2026 at 8:11 AM showed Resident 4 had multiple, scattered purple-colored bruises to their left arm. Review of the revised 12/01/2025 Anticoagulation therapy CP showed Resident 4 received blood thinner medication and instructed staff to monitor Resident 4 for bruising and bleeding and notify the provider for new bruises or bleeding. Review of Resident 4's comprehensive record on 01/10/2026 showed no documentation Resident 4 had multiple bruises on left arm. In an interview on 01/12/2026 at 8:20 AM, Resident 4 stated they did not know how they got the bruises on their arms. In an interview on 01/12/2026 at 9:16 AM, Staff D (Registered Nurse (RN) Manager) observed Resident 4's arms and stated staff should assess Resident 4's skin, notify the provider, document in Resident 4's record to monitor the bruises for worsening, and follow the CP. Staff D Reviewed Resident 4's record and stated staff should update Resident 4's CP to include the new bruising, but they did not. Staff D stated it was important to update the CPs to provide directions to staff for managing the resident's current health issues as required. <Resident 5> According to the 10/15/2025 Quarterly MDS, Resident 5 had multiple medically complex conditions including a stroke (a medical condition occurring when blood flow to the brain was interrupted) with the left-sided weakness and a left hand contracture (tightening of muscles or other tissues causing joints to become very stiff). Review of the 08/05/2025 Stroke CP showed interventions directing staff to monitor Resident 5's abilities for daily activities and provide assistance as needed. The CP did not have directions or interventions showing how to manage the left-hand contracture. Observations on 01/06/2026 at 11:02 AM, on 01/07/2026 at 9:01 AM, on 01/08/2026 at 10:02 AM, and on 01/09/2026 at 11:14 AM showed Resident 5 lying in their bed with their left hand contracted. Resident 5 stated they had a stroke in 2022 resulting in weakness to the left side of their body and a contracture to their left hand. In an interview on 01/09/2026 at 12:32 PM, Staff M (RN Manager) stated Resident 5 had left side weakness and a left-hand contracture. Staff M Reviewed Resident 5's record and stated they did not update Resident 5's CP to reflect the left-hand contracture. In an interview on 01/12/2025 at 11:00 AM, Staff B (Director of Nursing) stated staff should have assessed Resident 5's left hand contracture and updated the CP with interventions to prevent further damage, but did not. <Resident 6> According to the 12/15/2025 Quarterly MDS, Resident 6 had diagnoses including a traumatic brain injury and difficulty swallowing. The MDS showed Resident 6 was dependent on staff for eating. Review of Resident 6's comprehensive CP showed a 09/23/2025 revised .resident requires tube feeding [nutrition provided via a tube surgically placed in the stomach] related to [difficulty swallowing]. The CP directed staff to elevate Resident 6's head for 60 minutes before and after tube feeding was provided, check for feeding tube placement, and hold tube feeding as ordered, and showed Resident 6 was dependent on the tube feeding for their nutrition. Review of Resident 6's 01/08/2026 physician orders showed no current orders directing staff to provide the resident with nutrition via their feeding tube. The physician orders showed a 01/06/2026 order directing staff to provide Resident 6 with a soft-textured, regular diet. Observation on 01/08/2026 at 12:19 PM showed Staff S (Certified Nursing Assistant) feeding Resident 6 lunch in their room. Resident 6's meal ticket showed their diet order of soft foods and pureed vegetables. In an interview on 01/13/2026 at 8:22 AM, Staff T (Licensed Practical Nurse) stated Resident 6 still had their feeding tube but did not receive nutrition via the tube anymore. In an interview on 01/13/2026 at 8:51 AM, Staff D reviewed Resident 6's CP and confirmed the CP needed to be revised since the resident was no longer dependent a the feeding tube for nutrition . <Resident 7> According to the 11/20/2025 Quarterly MDS, Resident 7 was cognitively impaired and sustained a fall since the last MDS assessment. Review of a 01/02/2026 fall investigation showed Resident 7 sustained an unwitnessed fall when attempting to retrieve an item from a side table drawer in their room. The investigation showed Resident 7 did not have their wheelchair breaks locked, and their call light was not in use. The investigation showed staff identified new safety interventions of adding a visual reminder for the resident to lock their wheelchair breaks and for staff to provide a grabber device to Resident 7 to help prevent future falls. Review of Resident 7's comprehensive CP showed a revised 01/03/2024 .resident is at high risk for falls. CP and a revised 11/17/2025 .resident has had an actual fall. CP. Review of these CPs showed staff did not revise the CPs to include the newly identified interventions of the visual reminder or the grabber to help prevent further falls. In an interview on 01/13/2026 at 8:34 AM, Staff D reviewed Resident 7's CP and confirmed staff should have revised the CP to include the new interventions but did not. Staff D stated it was important to revise the CP because the CP fed the Kardex (care giver instructions) which instructed direct care staff on what type of care the resident required. REFERENCE: WAC 388-97-1020(2)(c)(d).

Based on observation, interview, and record review the facility failed to ensure resident's skin was assessed, monitored, and treated as required for 1 (Resident 4) of 1 residents reviewed for non-pressure skin and 1 (Resident 6) supplemental resident. These failures placed residents at risk for new or worsening skin impairment, infection, and other negative health outcomes.Findings included.<Resident 4> According to the 11/24/2025 Annual Minimum Data Set (MDS - an assessment tool), Resident 4 did not have cognitive impairment and was understood and able to understand others in conversation. The MDS showed Resident 4 received blood thinner medications during the assessment period and did not have any skin problems. Observations on 01/06/2026 at 1:41 PM, on 01/07/2026 at 10:46 AM, on 01/08/2026 at 9:22 AM, and on 01/12/2026 at 8:11 AM showed Resident 4 had multiple scattered purple-colored bruises on their left arm. Review of Resident 4's January 2026 physician orders showed there were no orders directing staff to monitor the bruises on the resident's left arm. The orders included a 11/25/2024 order for a blood thinner medication. Review of the 01/03/2026 and 01/10/2026 weekly skin checks showed staff performed head-to-toe skin assessments on Resident 4 and did not identify any skin issues on Resident 4's arms. In an interview on 01/12/2026 at 9:16 AM, Staff D (Registered Nurse (RN) Manager) stated Resident 4 received blood thinner medications and was at risk for new bruising and bleeding. Staff D reviewed Resident 4's record and confirmed there was no order directing staff to monitor the resident's bruises for changes or worsening of the bruising. Staff D reviewed Resident 4's weekly skin checks completed on 01/10/2026 and stated staff should assess the resident's skin and document accurately in the record. In an interview on 01/12/2026 at 9:39 AM, Staff B (Director of Nursing) stated it was their expectation staff notified the RN Managers of any new skin issues, evaluate and document the newly identified skin issue, and notify the provider to obtain orders to manage the skin issues. <Resident 6> According to the 12/15/2025 Quarterly MDS, Resident 6 had severe cognitive impairment. The MDS showed Resident 6 had diagnoses including a traumatic brain injury, fractures, and a stroke and required assistance for personal care. In an interview on 01/07/2025 at 1:39 PM, Resident 6's spouse stated they were concerned the resident had a scab on their left great toe because the toenail was improperly trimmed. Observation on 01/12/2026 at 10:08 AM with Staff Q (RN) showed Resident 6's left great toe had a thick, black scab along the inside edge of the toenail. In an interview at that time, Staff Q stated there should be a physician order to treat the toe. Review of a 12/25/2025 nurse progress note showed staff documented Resident 6's ingrown toenail on their left great toe was resolved and the skin surrounding the toenail healing. Review of Resident 6's physician orders showed a 12/18/2025 order directing staff to perform weekly skin checks every Thursday for Resident 6. The order directed staff to identify any new skin issues on the skin check. Review of the 01/08/physician orders showed no orders in place directing staff to treat or monitor Resident 6's scab on their left toe. Review of a skin check completed by staff on 01/08/2026 showed staff documented Resident 6 did not have new skin issues. In an interview on 01/13/2026 at 8:41 AM, Staff D stated they assessed Resident 6's left toenail and confirmed the scabbed area should be monitored and treated by staff. Staff D stated Resident 6's left toenail was healed previously but was now worse. REFERENCE: WAC 388-97-1060.

Based on observation, interview and record review, the facility failed to provide ongoing assessment, documentation, and prevention interventions consistent with professional standards of practice for 2 of 4 residents (Residents 5 & 2) reviewed for Pressure Ulcers (PU). Failure to assess and monitor PUs and implement preventative measures including repositioning placed residents at risk for deterioration in their skin condition.Findings included.<Facility Policy>Review of the facility policy titled, Pressure Injury Prevention and Management, dated 12/2025, showed the facility was committed to the prevention of avoidable PU, unless clinically unavoidable and to provide treatment and services to heal the PU, and prevent infection and the development of additional PU's. The policy showed the facility established a systemic approach for PU prevention and management, including prompt assessment and treatment, stabilizing interventions, reducing underlying risk factors, monitoring the effectiveness of interventions, and modifying the interventions as appropriate.<Resident 5> According to the 10/15/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 5 had multiple medically complex conditions including stroke (a medical condition occurs when blood flow to the part of the brain is interrupted) with left-sided weakness. The assessment showed Resident 5 was assessed to require maximal assistance from staff for transferring and bed mobility. The assessment showed Resident 5 was at risk for PUs and had no PUs during the assessment period. Observation and interview on 01/06/2026 at 10:23 AM showed Resident 5 lying on their back in bed. Resident 5 stated they had a sore on their bottom which hurt when staff provided incontinence care. Review of the revised 09/18/2024 Skin Integrity Care Plan (CP) showed Resident 5 was at risk for skin issues related to bowel incontinence, limited mobility, fragile skin, and a history of PUs. The CP instructed staff to monitor Resident 5's skin, notify the provider of any skin breakdown, provide preventative skin care, provide a pressure reducing mattress, and use pillows to protect the resident's skin while in bed. Record review showed a 11/10/2025 Physician Orders directed staff to perform weekly skin assessments for Resident 5 and document any new skin issues. According to an 11/28/2025 physician order, staff should apply barrier cream to Resident 5's left buttock after each incontinence episode. Review of Resident 5's records showed staff completed weekly skin checks on 12/31/2025 and 01/07/2026 as ordered. Both skin checks documented no new wound/skin issues identified. Observation on 01/07/2026 at 9:30 AM showed Resident 5 lying on their back in bed with the head of the bed slightly elevated. Observation on 01/09/2026 at 9:20 AM showed Resident 5 had open areas of skin on both buttocks. Staff O (Registered Nurse - RN) measured the wounds at 2 centimeters (CM) X 1.4 CM X 0.1 CM on the right buttock and 2 CM X 1.0 CM X 0.1 CM on the left buttock open area with no drainage or odor. Observation showed Resident 5 had a bath blanket folded in four layers between their bottom and the mattress. In an interview on 01/09/2026 at 9:25 AM, Staff N (Certified Nursing Assistant) stated they came back to work today after few days off. Staff N did not know if the licensed nurse assigned to Resident 5 knew about the open skin areas on Resident 5's buttocks. In an interview on 01/09/2026 at 9:30 AM, Staff O stated they did not know about the open wounds on Resident 5's buttocks. In an interview on 01/09/2026 at 9:37 AM, Staff M (RN Manager) stated they did not know Resident 5 had open wounds on their buttocks. Staff M stated they expected staff to reposition Resident 5 in bed from side-to-side and that there should be a folded bath blanket underneath any resident when in bed. In an interview on 01/09/2025 at 9:45 AM, Staff B (Director of Nursing) stated staff should follow the CP and update as needed. , and follow physician orders to complete weekly skin checks and document if there were any new skin issues. Staff B stated they knew Resident 5 had the tendency to refuse care including repositioning in bed, but staff needed to document such refusals in Resident 5's record. Staff B stated they expected staff to implement the interventions the resident was assessed to require to prevent new skin issues, but they did not. <Resident 2> According to the 11/13/2025 Significant Change MDS, Resident 2 had multiple medical conditions including a hip fracture and pain. This MDS showed Resident 2 was assessed to be cognitively intact and was dependent on staff for transfers, and toileting, and needed two-person assistance for bed mobility. The MDS showed Resident 2 used a wheelchair for locomotion in their room and in hallways. The MDS showed Resident 2 was at risk for PUs and had no PU during the assessment period. According to the 11/13/2025 PU Care Area Assessment (CAA) staff assessed Resident 2 was at risk for skin breakdown related to a recent decline in functional mobility. This CAA directed staff to complete weekly skin assessments to monitor for skin breakdown. Review of the revised 11/15/2024 Skin Integrity CP showed Resident 2 was at risk for skin issues related to decreased functional ability, fragile skin, diabetes, and edema. The CP instructed staff to monitor Resident 2's skin weekly and notify the provider of any skin breakdown, provide preventative skin care, and provide a pressure reducing wheelchair cushion to protect the resident's skin when seated. Observation and interview on 01/07/2026 at 10:52 AM showed Resident 2 sitting up in their wheelchair in their room with foam heel protectors on both feet. Resident 2 stated they had blisters on both their heels. Resident 2 stated the blisters happened in the facility and were caused by their wheelchair footrests. Review of Resident 2's weekly skin assessments completed on 12/01/2025, 12/08/2025, 12/12/2025, 12/15/2025, and on 12/22/2025, showed no new skin issues identified. Review of Resident 2's December 2025 Treatment Record Administration showed a 12/03/2025 physician order for left heel PU treatment. According to a 12/28/2025 nursing progress note, Resident 2 had intact, pink, warm skin with good skin turgor. According to a 01/02/2026 nursing progress note , Resident 2 had a popped blister measuring 5 CM X 7 CM on their right heel and 3 CM X 2CM open wound on their right ankle. Review of Resident 2's record showed no CP developed and no physician order was initiated until 01/03/2026 about heel boots or to elevate heels in bed to avoid further damage to the pressure wounds on both feet. In an interview on 01/09/2026 at 9:44 AM, Staff M stated Resident 2 had a left heel wound and right heel wound that both developed in the facility due to their feet rubbing their wheelchair footrests. Staff M stated the resident had diabetes and did not have sensation in their feet. Staff M stated they initiated the treatment when they noticed the skin issues, but they should have obtained an order for heel protectors and should updated the CP, but they did not. In an interview on 01/09/2025 at 9:48 AM, Staff B stated staff should complete weekly skin checks appropriately and document in resident's records. Staff B stated Resident 2 stated their feet were rubbing with their wheelchair footrest and blistered. Staff B stated staff should assess and initiate orders for preventative measures for new pressure wounds, but they did not. REFERENCE: WAC 388-97-1060(3)(b).

Based on observation, interview, and record review the facility failed to ensure 2 (Residents 5 & 11) of 5 sample residents reviewed for Restorative Nursing Program (RNP) received the services as they were assessed to require. These failures placed residents at risk for further decline in Range of Motion (ROM), a reduction in mobility, increased dependence on staff, and decreased quality of life.Findings included .<Facility Policy>According to a facility policy titled, Restorative Nursing Programs, revised 12/2025, the facility would provide maintenance and restorative services to maintain and improve residents' abilities to the highest practicable level. The policy showed residents identified during the comprehensive assessment process would receive restorative services included ROM, splint/brace services, and walking from restorative aides. The policy showed residents would receive RNP services upon admission or upon discharge from therapy. The Restorative Nurse was responsible for ensuring all elements of each resident's program were implemented.<Resident 5>According to the 10/15/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 5 had multiple medically complex conditions including stroke (medical condition occurring when blood flow to the part of the brain is interrupted) with the left side of the body weakness. The assessment showed Resident 5 had impairment to their right arm and required maximal assistance from staff for personal hygiene and daily activities. The MDS showed Resident 5 did not have behaviors of refusing care during the assessment period.Observations on 01/06/2026 at 12:33 PM, on 01/07/2026 at 9:01 AM, on 01/08/2026 at 10:02 AM, and on 01/09/2026 at 11:14 AM showed Resident 5 lying in their bed and their left hand had a contracture. Observations at these times showed a hand brace sitting on Resident 9's nightstand in their room. Resident 5 stated they had a stroke three years ago and the left side of their body was weak since the stroke. Resident 5 stated therapy was working with them for their left hand contracture but staff did not provide therapy services for the last three months.Review of the 09/19/2025 Activity of Daily Living (ADL) Care Plan (CP) showed Resident 5 required assistance from staff for ADLs and bed mobility. There was no CP or directions to staff to follow to provide care for Resident 5's left hand contracture.Review of the January 2026 Physician Orders showed no documentation for a RNP for Resident 5's left hand contracture.Review of Resident 5's 10/13/2025 Occupational Therapy (OT) services record showed Resident 5 had a left hand contracture and Resident 5 received OT services from 10/13/2025 through 11/07/2025. Resident 5 was discharged from OT services to a RNP on 11/07/2025 with recommendations of a restorative splint and brace program.In an interview on 01/09/2026 at 11:17 AM, Staff R (Restorative Aide) reviewed list of residents in RNP and stated Resident 5 was not on any restorative programs. Staff R provided a Restorative Nursing Recommendations form showing Physical Therapy referred Resident 5 to a RNP on 11/07/2025 for Passive Range of Motion (PROM) for their lower body.Staff R Stated Staff B (Director of Nursing) was responsible for entering RNP recommendations on the computer for restorative aides, but they did not receive a program for Resident 5.In an interview on 01/09/2026 at 12:13 PM, Staff K (Rehab Director) stated they expected rehab staff to refer residents to RNP services when discharged from PT and OT services as indicated. Staff K reviewed Resident 5's record and stated therapy discharged Resident 5 from PT and OT services on 11/07/2025 with RNP recommendations. They usually gave recommendations to the RNP supervisor, and they did not know what happened this time.In an interview on 01/09/2026 at 12:35 PM, Staff B stated they were responsible to oversee the RNP. Staff B stated they did not receive RNP recommendations from PT and OT for Resident 5. Staff B stated they expected the rehab department to provide RNP recommendations to Staff B to initiate the programs, but they did not.<Resident 11>According to the 10/29/2025 admission MDS, Resident 11 was cognitively intact and had diagnoses including below the knee amputation to both legs and a stroke weakness to the left side of their body. The assessment showed Resident 11 had impairment to their left arm with functional limitation in ROM and required maximal assistance for bed mobility, rolling from their back to their left and right side, toileting, and taking showers. Resident 11 did not reject care during the assessment period.Observation on 01/08/2026 at 11:23 AM showed Resident 11 sitting in their wheelchair. Resident 11 stated both of their legs were amputated below their knees. Resident 11 stated they worked with therapy until 01/03/2026, and did not receive any exercise assistance since then. Observation at that time showed both prosthetic devices for their legs were sitting in a chair in the resident's room.Review of Resident 11's OT discharge summary showed Resident 11 was discharged from OT services on 01/03/2026 to a RNP for a ROM program to maintain ROM on their affected arm and to prevent contractures. In an interview on 01/09/2026 at 11:30 AM, Staff R stated Resident 11 did not have a RNP currently. In an interview on 01/09/2026 at 12:30 PM, Staff K stated Resident 11 received rehab services from 12/22/2025 through 01/03/2026 until insurance no longer covered the services. Staff K reviewed Resident 11's record and stated Resident 11 was discharged from OT services to a RNP for ROM to their left arm.In an interview on 01/09/2026 at 12:40 PM, Staff B stated they expected therapy staff to provide restorative recommendations to Staff B to initiate RNP in timely manner, but they did not.REFERENCE: WAC 388-97-1060 (3)(d).

Based on observation, interview, and record review the facility failed to ensure sharps and chemicals were stored safely for 1 of 1 Maintenance Offices and 1 of 2 Nurses station's (West Nurse's Station) reviewed. This failure to ensure sharps and chemicals were secured placed residents at risk of injury, an unsafe environment, and other negative health outcomes.Findings included.<Policy>According to the facility policy titled, Environmental Services Safety Procedures, dated 12/2025, the facility would ensure general safety procedures were followed. The policy showed staff would ensure chemicals and unsafe equipment would not be left unattended and would be stored in a locking cabinet or storage area for resident safety.<Maintenance Office> Observation on 01/06/2026 at 11:51 AM showed the maintenance door propped open without staff inside. Observation inside of the unlocked maintenance office showed chemicals, sharp tools, and objects. In an interview on 01/06/2026 at 11:54 AM, Staff C (Maintenance Supervisor) stated they expected staff to lock the door upon exited the maintenance office. Staff C stated there was a tremendous number of hazardous materials in the maintenance office and the door should remain locked when not in use for resident safety. In an interview on 01/06/2026 at 12:15 PM Staff A (Administrator) stated they expected staff to close and lock the maintenance office door for resident safety. <West Nurses Station> Observation on 01/06/2026 at 8:52 AM showed three bottles of a chemical used to safely dispose of old/unneeded medications and a container of sanitizing wipes unsecured/unlocked at the west nurse's station. In an interview on 01/06/2026 at 9:06 AM Staff D (Registered Nurse Manager) stated the three bottles of the chemical compound and container of sanitizing wipes should be stored behind locked doors or cabinets. Staff D stated it was important to store the chemical compound and sanitizer wipes behind locked doors for residents' safety. In an interview on 01/07/2026 at 12:22 PM Staff B (Director of Nursing) stated they expected staff to secure all chemicals behind locked doors for resident safety. Reference: WAC 388-97-1060 (3)(g).

Based on observation, interview, and record review the facility failed to ensure proper storage and labeling of medications in 2 of 4 medication carts (Medication Cart A & C) reviewed for medication storage. This failure placed residents at risk for receiving expired medications, ineffective treatment, accidental ingestion of medication, and a diminished quality of life.Findings included.<Policy>According to the facility policy titled, Medication Storage, dated 08/2024, the facility would ensure all medications would be stored in locked compartments or rooms. The policy showed that medications would be destroyed upon expiration.<Medication Cart A>Observation on 01/06/2026 at 12:30 PM showed Medication Cart A unlocked and unattended.In an interview on 01/06/2026 at 12:31 PM Staff E (Registered Nurse) stated they were expected to lock the medication cart before leaving it unattended but forgot to. Staff E stated they should lock the medication cart before walking away for resident safety.In an interview on 01/13/2026 at 8:30 AM Staff B (Director of Nursing) stated they expected staff to lock medication carts prior to leaving the cart unattended. Staff B stated it was important to properly secure and lock medications for residents' safety.<Medication Cart C>Observation of medication cart C on 01/06/2026 at 10:05 AM showed a bottle of over-the-counter pain medications expired on 09/2025, another bottle of pain medication expired on 12/2025, an injectable medication used to control blood sugar opened on 12/06/2025, and a bottle of eye lubricant for a resident that was discharged from the facility in December 2025.In an interview on 01/06/2026 at 10:05 AM Staff P (Licensed Practical Nurse) stated the expired pain medications should be discarded upon expiration. Staff P stated they were unsure of how long an injectable medication for lowering blood sugar was good for after opening. Staff P stated the eye lubricant for the discharged resident should be discarded upon discharge from the facility.In an interview on 01/07/2026 at 12:22 PM Staff B stated expired or discontinued medications should not be in the medication carts and staff should remove them upon expiration. Staff B stated the injectable medication used to lower blood sugar was only good for 28 days after opening. Staff B stated the injectable medication should be discarded and not be in the medication cart.Reference: WAC 388-97-1300 (2), -2340.

Based on observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in 1 of 1 facility kitchens and for one unit refrigerator reviewed for food services. The failure to clean the facility's kitchen ice machine, cover food during transport, perform hand hygiene between glove use, and maintain sanitary unit refrigerators placed the residents at risk for food borne illness (illness caused by ingesting contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . <Facility Policy> According to the facility's revised August 2024 Food Safety Requirements policy, the facility would store, prepare, distribute and serve resident meals in accordance with professional standards of food service safety. The policy showed to prevent foodborne illness, dietary staff should clean and sanitize the internal components of the ice machines according to manufacturer's guidelines. The facility's revised July 2024 Ice Machines and Ice Storage Chest policy, ice machines and ice storage/distribution containers would be used and maintained to ensure a safe and sanitary supply of ice. The policy showed the facility would establish procedures for cleaning and disinfecting ice machines and ice storage chests that adhered to the manufacturer's instructions. The infection preventionist (or designee) would maintain a copy of these procedures. <Dirty Equipment> <Ice Machine> In an observation and interview on 09/10/2024 at 9:06 AM, the top portion of the facility's ice machine was observed to have brownish-black mold-like debris on the cover and on the plastic dispenser that led into the bottom portion of the ice machine. The bottom portion where the ice was held, had a streak of pink mold-like debris on the interior frame of the ice maker. When Staff Z (Dietary Supervisor) wiped the pink material with their gloved hand, some pink was noted on their glove. When Staff Z wiped the brownish-black material with a napkin, the area sampled wiped clean, and the remnants were on the napkin. Review of the daily cleaning log showed cleaning was last completed on September 8th, two days previous. In an interview at this time, Staff Z stated the kitchen staff provided a daily wipe of the ice machine and the maintenance staff provided deep cleaning to the ice machine. Staff Z stated maintenance was responsible for cleaning the top part of the ice machine and indicated it was cleaned, last month. Staff Z stated they were unaware of the date when the maintenance staff provided a deep cleaning of the ice machine but would check. When asked if they expected the ice machine to be clean, Staff Z stated yes. In an interview on 09/16/2024 at 2:02 PM, Staff O (Maintenance Supervisor) stated they were unable to locate any maintenance logs for the cleaning of the ice machine since they were last here in October 2023. Staff O stated the ice machine should be cleaned monthly and receive a deep clean quarterly. When asked if they were able to determine when the ice machine was last cleaned, Staff O stated, no. <Wall Fans> Observations during initial kitchen rounds on 09/10/2024 at 9:18 AM showed two mounted upper wall fans facing over a food preparation area and the dishwashing area. Both fans were dirty with hanging debris from the front grill that moved with the flow of air into the kitchen during observations. Observations on 09/12/2024 at 9:49 AM showed the dirty fan was running while staff were brushing melted butter on breadsticks in the adjacent food preparation area. In an interview on 09/10/2024 at 9:06 AM, Staff Z confirmed the fans were dirty and needed to be cleaned. <Hand Hygiene/Cross Contamination> Observations during initial kitchen rounds on 09/10/2024 at 9:18 AM showed Staff DD (Dietary Aide) handling dirty food containers and dishes. Then, while wearing the same soiled gloves, Staff DD removed clean dishes out of the dishwasher. Observations during meal preparation rounds on 09/12/2024 at 9:49 AM showed Staff EE (Dietary Cook) take out a thermometer, touch the probe with their bare fingers, and put the now-soiled thermometer probe into a pan of ground sausage. Staff EE checked the temperature and then disinfected the probe. Observation on 09/12/2024 at 9:54 AM showed Staff EE cutting up partially thawed chicken on a cutting board while wearing gloves. Staff EE then reached under the counter to obtain a clean pan, while still wearing the soiled gloves, and touched the edges of several clean pans while trying to get a pan to use. Staff EE removed their gloves and without performing hand hygiene, removed a pan of ground chicken from the oven, sanitized a thermometer probe, checked the temperature of the ground chicken, and placed it back in the oven prior to performing hand hygiene. Staff EE put on new gloves and finished cutting up the chicken, removed gloves, did not perform hand hygiene, and took a clean pan from under the counter, then went to wash their hands. Observations on 09/12/2024 at 10:43 AM showed Staff DD pick up a stack of clean plates, press them against their body, and carried them over to the plate warmer holder. The top plate made contact with Staff DD's apron and name badge. Observations on 09/13/2024 at 11:50 AM, showed Staff FF (Dietary Cook) wearing gloves while assisting with tray line. Staff FF turned around to get some condiments from a nearby shelf, touched the counter, shelf surface, and condiment container. Staff FF then returned to tray line, and using the same soiled gloves, placed parsley garnish on the residents' plates. In an interview on 09/13/2024 at 1:45 PM, Staff Z (Dietary Supervisor) stated it was their expectation staff perform hand hygiene with each glove change, when moving from dirty to clean in the dishwashing area, and after touching contaminated items or surfaces. Staff Z stated items should be sanitized prior to touching food products. 42203 <Uncovered Desserts> Observation of the Garden Way unit on 09/10/2024 at 12:32 PM showed two nurse's aide distributing lunch trays from a cart placed mid-way down the hall. Each tray included a cookie in a placed in a plastic cup. The cookies were not covered. The nurse's aides delivered trays to each resident without moving the cart down the hall. The further the resident room was from the cart, the longer their cookie was exposed to the hall environment. In an interview on 09/13/2024 at 1:45 PM, Staff Z stated it was their expectation food be covered in the hallways if the tray is passing other rooms. Staff Z stated staff were supposed to be moving the tray cart to each room during delivery, so the uncovered food was brought directly to the resident. <Unit Refrigerator> Observation on 09/16/2024 at 7:52 AM showed the unit refrigerator located between the Collectable Court and Garden Way units was unclean. The lower shelf and vegetable crisper below were covered with considerable amount of a purple-red dried up fluid. In an interview at that time, Staff Z stated the refrigerator was dirty and needed to be cleaned. REFERENCE: WAC-388-97 -1100 (3). 43642

Based on observation, interview, and record review the facility failed to ensure the environment was free of accident hazards for 1 of 1 laundry room and failed to ensure resident rooms were free of fall hazards for 1 of 3 (Resident 11) residents reviewed for falls. These failures placed residents at risk for elopement, ingestion of chemicals, and falls. Findings included . <Laundry Room Door> Observation on 09/10/2024 at 1:43 PM showed the door to the facility's laundry room was unlocked. The key code to unlock the door did not function. The door opened freely and allowed access to the laundry room. Observation on 09/11/2024 at 8:30 AM showed the laundry room door remained unlocked, entered the laundry room and a middle door was open. Inside the laundry room was a cart containing laundry detergent and other chemicals. The exterior door opening to the rear of the building was propped open and a large fan was placed in the doorway. There was nothing preventing a wandering resident from passing through the laundry room to the outside. In an interview at that time, Staff CC (Laundry Aide) stated the laundry room lock was broken for two weeks. Staff CC stated they reported the broken lock to the facility's Head of Maintenance. Staff CC said laundry staff typically kept the exterior door open when they worked to allow ventilation. In an interview on 09/11/2024 at 11:10 AM, Staff A (Administrator) confirmed the door lock was broken and needed repair. Staff A stated the laundry door should be locked, and residents should not be allowed free access to the laundry room. 50511 <Resident Falls> <Facility Policy> According to the facility's Fall Prevention Program policy, revised 08/2024, the facility would reduce the risk of falls by assessing fall risk, residents would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Interventions would include a clear pathway to the bathroom and bedroom, implement routine rounding schedules, and encourage residents to wear shoes or slippers with non-slip soles when walking. <Resident 11> According to the 07/10/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 11 was admitted to the facility on [DATE]. The MDS showed Resident 11's medical conditions included arthritis, abnormal posture, lack of coordination, history of pain, altered mental status, and a history of falls with injury. The MDS showed Resident 11 required maximal assistance from staff with transfers from lying to sitting, chair to bed assistance, and required moderate assistance with upper and lower body dressing including putting on and taking off footwear. Review of the revised 07/15/2024 Functional Care Plan (CP) showed the resident was at risk for falls due to weakness, medications used, history of falls, poor safety awareness, unsteady balance, and clutter in the room and on the floor. The goal identified showed the resident would be free of minor injury through the review date. Interventions directed staff to encourage and assist the resident with keeping a clear pathway in their room to allow for safe mobility, encourage and assist with putting on non-skid socks, encourage resident to use call light, ensure the resident had appropriate footwear when transferring, help with transfers to the commode, follow current interventions for falls. The CP showed the resident required supervision to dress instead of maximum assistance as stated on the MDS. The CP did not provide instructions on how often clutter should be cleared, did not show how often staff were to assist with transfers to commode, and did not show how often staff were to check if resident had appropriate footwear on. Review of the safety Kardex (directions to care staff) on 09/12/2024 showed the staff were to ensure the resident was wearing appropriate footwear when transferring, ensure Resident 11's pathway was clear of clutter, and to notify the physician if interventions were unsuccessful. In an interview on 09/10/2024 at 12:43 PM, Resident 11 stated they sat around too much. Resident stated they had pain and used a toilet commode because they could not walk due to their physical balance being off. In an interview on 09/11/2024 at 8:56 AM, Resident 11 stated they have had several falls, and the staff tried to keep tabs on them. Observation on 09/13/2024 at 7:51 AM showed Resident 11 sitting on the edge of the bed. The bed was cluttered with blankets and many various items. Resident 11 had a gripper sock on their right foot and no sock on their left foot. There was a stack of four to five pieces of paper in the middle of the resident's bedroom floor. The room was cluttered with various items in bins on the floor and items were scattered on dresser and the bed including papers, blankets, clothing, and books. Observation on 09/16/2024 at 8:16 AM showed various items including books, papers, buckets with toiletries lying directly on the floor. The toilet commode was placed in between the bed and next to the wheelchair, only small area was clear for Resident 11 to walk around. Review of the 08/30/2024 fall investigation report showed the resident was found on the floor, the resident had a nonskid sock on their left foot and their right foot was bare. The resident did not call for staff assistance when transferring. In an interview on 09/16/2024 at 11:14 AM, Staff D (Social Services Director) stated Resident 11 had a lot of clutter in their room, the facility stored some of the resident's stuff. Staff D stated staff discussed action plans to reduce clutter in Resident 11's room but would need to check interventions to ensure the CP was more personable. In an interview on 09/16/2024 at 11:16 AM, Staff GG (Director of Rehabilitation) stated they were working on falls with Resident 11 and that the resident's cognition was not good. Staff GG stated Resident 11 did not follow staff instructions to pull the call light when needing assistance. In an interview on 09/16/2024 at 10:51 AM Staff B (Director of Nursing) confirmed Resident 11 had clutter on the floor and the facility provided storage for the resident's additional items. Staff B stated the facility's plan was to continue to offer to remove things from Resident 11's room. Staff B stated nursing staff were expected to offer and assist resident with their care needs. REFERENCE: WAC 388-97-1060(3)(g).

Based on observation and interview, the facility failed to ensure walls in resident rooms were maintained in a homelike condition for 9 of 18 rooms sampled (Rooms 22, 26, 32, 34, 50, 42, 47, 48, & 49). The failure to ensure rooms were free from gouges (Rooms 22, 32, 50, 48), resident televisions were mounted (room [ROOM NUMBER]), fans in resident rooms were clean (room [ROOM NUMBER]), and sinks, toilets, and bathroom fixtures in resident rooms were free from rust and maintained in clean, sanitary conditions (Rooms 22, 32, 34, 42, 47, & 49). These failures left residents at risk for a diminished quality of life and a less than homelike environment. Findings included . <room [ROOM NUMBER]> Observation of room [ROOM NUMBER] on 09/10/2024 at 10:46 AM showed wall behind the bed nearest the door was gouged where the bed rubbed against the wall, exposing drywall. The bathroom in room [ROOM NUMBER] had considerable dark yellow stains on the tile underneath and around the toilet. In an interview on 09/16/2024 at 9:18 AM Staff O (Maintenance Supervisor) stated the wall should be repaired. Staff O stated the bathroom tile was gross and should be cleaned. <room [ROOM NUMBER]> Observation in room [ROOM NUMBER] on 09/11/2024 at 10:58 AM showed the television was not mounted on the wall. Instead the television rested on top of a dresser at an angle that made viewing from the resident bed less manageable than necessary. In an interview on 09/16/2024 at 9:18 AM Staff O stated all televisions should be mounted on walls. 43642 <room [ROOM NUMBER]> Observations on 09/10/2024 at 9:47 AM showed room [ROOM NUMBER] bed 1 with deep gouges and exposed drywall on the wall next to the resident's bed. The toilet seat had brown dried smears across the toilet seat rim and down the front of the toilet. The white paint was also worn off the toilet seat rim in the front and the back. The roll of toilet paper was sitting on the floor near the toilet and the holder for the toilet paper was missing. On 09/11/2024 at 10:17 AM, over 24 hours later, observations showed the same dried brown smears on the toilet,worn off paint on the toilet rim, missing toilet paper holder, and the toilet paper sitting on the ground next to the toilet. In an interview on 09/16/2024 at 8:49 AM, Staff O stated the wall gouges needed to be patched and fixed, toilets and bathrooms should be cleaned every day and as needed, and the missing toilet paper holder and toilet seat rim needed to be replaced. <room [ROOM NUMBER]> Observations on 09/10/2024 at 9:59 AM showed room [ROOM NUMBER] bed 1 had a standing fan full of dust debris on the front grill. The debris was blowing and moving with the flow of air in the room during observations. In the bathroom, there was a roll of toilet paper on the floor and the holder for the toilet paper was missing. In an interview on 09/16/2024 at 8:49 AM, Staff O stated the fans in the facility needed to be cleaned and would be taken care of. Staff O stated a clean and homelike environment was important for residents to be able to feel comfortable, as the facility was their home. 46479 <room [ROOM NUMBER]> Observation on 09/10/2024 at 9:58 AM showed room [ROOM NUMBER] Bed 2 with multiple gouges and scrapes along the wall, behind the resident's headboard. In an interview on 09/16/2024 at 9:10 AM, Staff O confirmed the gouges on the wall behind the resident's headboard and stated the wall needs repaired. 50511 <room [ROOM NUMBER]> Observation on 09/10/2024 at 10:36 AM toilet seat cover in bathroom was lifted to expose the underside of the lid. Observed several cracked and chipped paint on toilet seat rim. Observed bathroom floor tiles next to toilet had brown dirt on the tiles. <room [ROOM NUMBER]> Observation on 09/10/2024 at 10:51 AM bathroom sink had brown rust stains around the drain hole,sink was cracked, chipped and dented on the lower left corner of the sink. Observed the cracks and dents were covered with white chalking material and white pain brushed over the dents. Floor around the bathroom was brown with dirt and debris. <room [ROOM NUMBER]> Observation on 09/10/2024 at 12:52 PM wall behind room [ROOM NUMBER] Bed 2 had several gouges with cracked paint, window blinds were dented and twisted. <room [ROOM NUMBER]> Observation on 09/10/2024 at 12:50 PM room sink had jagged, torn, pink foam partially falling off the sink covering the corners of the sink. Floor in bathroom had brown debris in corners of the bathroom. In an interview on 09/13/24 at 09:38 AM Staff P (Registered Nurse Manager) observed the pink foam falling off the sink, Staff P stated it should not be there as there was no purpose for the pink foam, that it should be removed. In an interview on 09/16/2024 at 8:49 AM, Staff O stated the wall gouges needed to be patched and fixed, toilets and bathrooms should be cleaned every day and as needed, and the missing toilet paper holder, toilet seat rim and sink needed to be replaced. REFERENCE: WAC 388-97-0880.

Based on interview and record review, the facility failed to notify 5 (Resident 1, 6, 25, 219, & 119) of 23 residents reviewed, who were Medicaid recipients, when their personal fund account balances reached $1800 (i.e. within $200 of the $2,000 resource limit beneficiaries could possess, without their Medicaid coverage being impacted). This failure placed residents at risk for personal financial liability for their care. The facility failed to ensure funds were reimbursed to the state Office of Financial Recovery (OFR), within 30 days of resident discharge or death, for 1 (Resident 219) of 3 discharged residents reviewed. This failure caused a delay in reconciling resident accounts within 30 days as required. Findings included . Review of a revised 08/2024 Resident Personal Funds policy, showed the facility must notify each resident who received Medicaid benefits: when the amount in the resident's account reached $200 less than the Supplemental Security Income (SSI) resource limit for one person; and if the amount in the account reached the SSI resource limit, the resident may lose eligibility for Medicaid or SSI. This policy showed, upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility would convey within 30 days the resident's funds to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State Law. <Notice of Medicaid Balances> Review of the facility's Trial Balance report showed the following resident balances over the resource limit, as of 09/10/2024: Resident 6 - $7213.83; Resident 25 - $5533.75; Resident 1- $6543.31; Resident 219 - $3286.02; Resident 119 - $3744.05. In an interview on 09/13/2024 at 9:27 AM, Staff N (Business Office Manager - BOM) stated the facility did not have a BOM for a few months and they were helping in the business office. Staff N stated they were aware of the broken system in the business office. Staff N confirmed Residents 1, 6, 25, and 219 were all over the $2000 limit and stated, the system was broken. No further documentation was provided from the facility. <OFR Fund Disbursement> <Resident 219> Record review showed Resident 219 was discharged from the facility on 05/30/2024. Review of trust records showed the resident had a balance of $3286.02, which was not transferred to the resident or to OFR until 09/13/2024, more than three months after discharge. In an interview on 09/13/2024 at 9:30 AM, Staff N stated, upon a resident's discharge, accounts should be closed, and any remaining funds sent to OFR before 30 days at the very most. Staff N confirmed Resident 219's account was not closed. Staff N stated Resident 219 was transferred to another facility and their personal fund was not sent with the resident. REFERENCE: WAC 388-97-0340(4)(5).

Based on observation, interview, and record review the facility failed to ensure medications were stored, labeled, dated when opened, and discarded when expired for 1 of 2 medication carts (Garden Wing Cart), 1 of 1 medication rooms (West Hall Medication Room Refrigerator), and for 1 of 19 residents (Resident 60) observed. The facility failed to ensure 2 of 4 medication carts were locked when left unsupervised by staff. The failure to ensure medication refrigerators were double locked, medications were discarded when expired, eye drop medications were dated upon opening, medication carts were locked, and medications were not left at bedside, placed residents at risk for ineffective treatment, expired medications, and contaminated medications. Findings included . <Facility Policy> According to a facility policy titled, Medication Storage, revised 08/2024, the facility would secure narcotics and controlled substances under double lock and key. The policy showed medication rooms and carts would be inspected routinely for discontinued and outdated medications. The policy showed the facility would destroy the discontinued and outdated medications upon finding. This policy showed all drugs would be stored in locked compartments such as medication carts and only authorized personnel would have access to the keys to locked compartments. <West Hall Medication Room Refrigerator> Observation and interview on 09/10/2024 at 9:15 AM showed a narcotic medication in the west hall medication room refrigerator. The west hall medication room door was locked but the refrigerator inside of the medication room was unlocked with the narcotic medication stored inside of the refrigerator. At this time, Staff M (Licensed Practical Nurse -LPN Supervisor) stated the narcotic medication should be under double locks. Staff M stated the refrigerator should be kept locked. <Garden Wing Cart> Observation and interview on 09/10/2024 at 9:22 AM showed a bottle of medication expired on 08/2024, a liquid solution expired on 03/2024, and two bottles of eye drop medications without an open date written on them. At this time, Staff Q (Registered Nurse - RN) stated the expired medications should be removed from the medication cart and destroyed. Staff Q stated the eye drops should be dated upon opening so staff knew when to discard them, but they were not. <Resident 60> Observation and interview on 09/13/2024 at 9:41 AM showed a tube of medicated cream on Resident 60's over the bed table. Resident 60 stated staff left it there sometimes, which they didn't mind because it reminded them to ask the staff to apply it for them. At this time, Staff E (LPN) stated medications at bedside were required to be locked up in resident rooms. Staff E stated staff were expected to complete a self-medication assessment on the resident for safety and obtain a physician order before leaving medications with the resident. Staff E stated Resident 60 was not assessed and did not have a physician order to keep medications at their bedside. In an interview on 09/16/2024 at 12:32 PM Staff B (Director of Nursing) stated they expected staff to remove all expired medications from the carts and medication rooms, not administer expired medications to the residents, and to destroy the medications. Staff B stated they expected the staff to date eye drops upon opening and dispose of the drops after 28 days. Staff B stated residents with medications in their rooms should have an assessment for a self-medication program, ensure the resident knew how to store the medication properly, lock the medication in their room, and know the reason they were taking the medication. Staff B stated it was not facility policy to have medications unsecured at bedside without a resident assessment done for safety of self-administering. 43642 <Unlocked Medication Carts> <Unit Catsablanca> Observations on 09/11/2024 at 12:56 PM showed the medication cart on the Catsablanca unit was unlocked with no staff in the area. Staff Y (RN) was sitting at the nurse's station without the ability to view their unlocked medication cart. It was not until 1:19 PM, 23 minutes later, when Staff Y passed the medication cart, went back, and locked the cart. In an interview on 09/11/2024 at 1:19 PM, Staff Y stated the medication cart should be locked since there were medications inside. Staff Y stated having unsecured medications was a safety risk. In an interview on 09/16/2024 at 1:16 PM, Staff B stated their expectation was for nursing staff to lock the medication carts when they were away from the cart. Staff B indicated the carts had medications in them and anyone, including confused residents could access them. Staff B stated that would be dangerous. 50511 <Unit Wild West> Observation on 09/11/2024 at 12:58 PM showed the medication cart on the Wild [NAME] unit was unlocked. Staff S (LPN) was assigned to the unit was not in the hallway at the time of observation. This surveyor was able to open top and bottom drawers of medication cart and observed medications in the cart. In an interview on 09/11/2024 at 1:28 PM Staff S stated the medication cart should be locked for patient safety. REFERENCE: WAC 388-97-1300(1)(b)(ii). 45941

Based on interview and record review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the residents' mental health conditions for 1 of 5 (Resident 51) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs. Findings included . <Facility Policy> According to the facility policy titled, Admissions Criteria, revised July 2024, all new admission and readmissions must go through a PASRR screening prior to admission. The policy showed the facility's social worker was responsible for making referrals for Level II PASRR services. <Resident 51> According to a 06/26/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 51 had multiple medically complex diagnoses including dementia, anxiety, and schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors). Review of Resident 51's physician orders showed the resident had been receiving an antipsychotic medication from 09/06/2023 until 04/17/2024 for acute psychosis. On 07/23/2024 the same antipsychotic medication was restarted for Resident 51 with an indicated diagnosis of psychosis and schizophrenia. Review of a 01/18/2023 Level 1 PASRR showed staff identified Resident 51's only serious mental illness indicator was anxiety and the resident's primary language was English. Staff did not identify Resident 51's primary language was Vietnamese, as identified by staff on the resident's 01/13/2024 admission assessment. No updated PASRR Level 1 was found addressing Resident 51's psychosis. In an interview on 09/16/2024 at 12:33 PM, Staff D (Social Service Director) stated PASRR's were important to identify if residents required Level 2 evaluations and to assist residents with being successful in the facility. Staff D stated their expectation was for Level 1 PASRR's to be accurate and should be updated with changes. Staff D reviewed Resident 51's records and stated the primary language was identified inaccurately and stated the Level 1 should have been updated to include the diagnoses identified for the antipsychotic medications for Resident 51. REFERENCE: WAC 388-97-1975(1)(9).

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS -an assessment tool) accurately reflected the status for 3 (Resident 37, 51, & 61) of 19 residents reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident 37> Review of a 07/24/2024 Annual Minimum Data Set (MDS - an assessment tool) showed Resident 37 had clear speech, understands, and was understood by others. This MDS showed staff assessed Resident 37 with broken or loosely fitting full or partial denture, no natural teeth or tooth fragments, (obvious or likely cavity or broken natural teeth, and mouth or facial pain, discomfort or difficulty with chewing. Observations on 09/10/2024 at 10:38 AM showed Resident 37 with multiple lower teeth and no upper denture in their mouth. In an interview at this time, Resident 37 stated they were waiting to have their dentures fixed. In an interview on 09/16/2024 at 1:35 PM, Staff BB (MDS Coordinator, Registered Nurse) reviewed Resident 37's 07/24/2024 Annual MDS, stated staff incorrectly marked the section indicating the resident had no natural teeth, and needed to be corrected. <Resident 51> Review of a 06/26/2024 Quarterly MDS showed Resident 51 had multiple medically complex diagnoses including stroke and had a functional limitation in range of motion to one side of their lower extremity. This MDS showed in the last seven days of the assessment period, Resident 51's normal mobility device was a walker. Observations on 09/12/2024 at 11:05 AM and 09/13/2024 at 2:12 PM, showed Resident 51 reclined in a wheelchair in the hallway positioned next to staff. In an interview on 09/16/2024 at 1:35 PM, Staff BB reviewed Resident 51's 06/26/2024 Quarterly MDS and stated, that was an error, [they] do not use a walker. Staff BB stated the MDS needed to be corrected. 42203 <Resident 61> According to the 08/13/2024 Quarterly MDS, Resident 61 had intact memory and had a preferred language that was not English. This MDS showed Resident 61 had clear speech and was understood and able to understand others in conversation. Section F (Preferences for Customary Routine and Activities) of this MDS had two sections, a resident interview section, and a staff assessment section. The MDS directed the staff completing the assessment to skip the resident interview only if the resident was rarely or never understood and a family member or significant other was not available. The resident assessment section was marked with zero, indicating Resident 61 was rarely/never understood, contradicting earlier in the assessment where Resident 61 was assessed to always be understood. Instead of a resident interview a staff assessment of Resident 61's daily and activity preferences was completed. This assessment provided less specific information and lacked Resident 61's perspective on their choices and preferences. In an interview on 09/13/2024 at 12:29 PM Staff BB stated facility activities staff were responsible for completing Section F for residents. Staff BB reviewed Resident 61's records and stated staff should have, but did not, interview Resident 61, using translation services, if necessary, to ensure the resident's preferences were included in the assessment. REFERENCE: WAC 388-97-1000 (1)(b).

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Notice of Medicare Non-coverage (SNF-NOMNC - a required form notifying the resident that their skilled services coverage was ending and would no longer be covered by their Medicare A benefits) as required for 2 of 4 residents (Resident 219 and 119) reviewed for beneficiary notification. This failure placed Residents 219, 119, and other residents at risk for not being fully informed and losing their right to an appeals process. Findings included . <Facility Policy> According to the facility policy titled, SNF Beneficiary Notices Under Medicare Part A, revised 06/2023, the facility would inform Medicare A beneficiaries when they no longer met the skilled coverage criteria. The policy showed a NOMNC was given by the facility to all Medicare beneficiaries at least two days before the end of their Medicare covered Part A stay because the notice contained information regarding the beneficiary's right to an expedited appeals process review by a Quality Improvement Organization. The policy showed the facility would maintain a log of notices that had been provided to residents/representatives. <Resident 219> According to the 05/15/2024 Discharge Return not anticipated Minimum Data Set (MDS - an assessment tool), Resident 219 was admitted to the facility on [DATE] and was discharged to the community on 05/15/2024. Review of Resident 219's record showed a 05/14/2024 Physician Order for the resident to discharge home. Review of Resident 219's record did not show a NOMNC was provided to the resident to explain their Medicare A benefits. <Resident 119> According to the 05/22/2024 Discharge Return not anticipated MDS, Resident 119 was admitted to the facility on [DATE] and was discharged to the community on 05/22/2024. Review of the 05/22/2024 Nursing progress note showed Resident 119 was discharged home. Review of Resident 119's record did not show a NOMNC was provided to the resident to explain their Medicare A benefits. In an interview on 09/12/2024 at 9:45 AM, Staff D (Social Services Director) stated it was important to provide beneficiary notices to residents whose skilled services were ending so residents could prepare themselves for a safe discharge or they could exercise their right to an appeals process if/when residents felt they needed more services. Staff D stated they should have but did not provide Resident 219 or 119 a NOMNC as required. REFERENCE: WAC 388-97-0300(1)(e), (5), (6).

Based on observation, interview, and record review the facility failed to ensure informed consent (a process explaining the risks and benefits of a treatment prior to use) was obtained prior to administration of psychotropic (affecting mental state) medications for 2 of 5 (Residents 20 & 34) reviewed for unnecessary medications and for bed rails for 1 of 2 residents (Resident 60) reviewed for accident hazards. This placed residents at risk for unwanted treatment. <Findings included> <Facility Policy> According to the facility policy titled, Use of Psychotropic Medication, revised 08/2024, residents needing psychotropic medications would be educated on the risks and benefits. <Facility Policy> According to a facility policy titled, Proper Use of Bed Rails, revised 03/2024, showed the facility would obtain informed consent from the resident or resident representative prior to installation and use of the bed rails. The policy showed risks and benefits of bed rail use for the resident would be provided to the resident or resident representative as part of the informed consent. <Resident 34> According to the 07/24/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 34 had diagnoses including anxiety and depression. The MDS showed Resident 34 took antianxiety and antidepressant medications. Review of the physician's orders showed Resident 34 had two antidepressant orders, both with start dates of 05/31/2024. Resident 34 had one order for an antianxiety medication with start date of 05/30/2024. Record review showed three informed consent documents explaining the risks and benefits of the two antidepressants and the antianxiety medication. Each form was dated 08/15/2024. Each form was signed by Resident 34 on 09/06/2024. In an interview on 09/16/2024 at 1:02 PM Staff P (Registered Nurse - RN, RN Manager) stated informed consent should be obtained from a resident prior to administration of a psychotropic medication. Staff P stated the facility should have but did not provide Resident 34 informed consent prior to administering the three psychotropic medications. <Resident 20> According to the 06/10/2024 Quarterly MDS Resident 20 had no memory impairment, and diagnoses including depression. The MDS showed Resident 20 took antidepressant medications. Record review showed a 05/16/2024 order for an antidepressant medication. Record review showed an informed consent form for the antidepressant with an effective date of 05/16/2024. The form was not signed by Resident 20 but showed verbal consent was given on 05/16/2024 The form was signed electronically by Staff C (RN Manager) on 09/06/2024, over three months later. A copy of this form with undated handwritten signatures by Staff P and Staff C, and a digital signature date for Staff C of 09/06/2024. The form was scanned in to Resident 20's record by Staff R (Medical Records Supervisor) on 09/13/2024. In an interview on 09/13/2024 at 12:29 PM Staff C stated their signature date of 09/06/2024 was the date the form was finalized in the electronic record. When asked if they could demonstrate consent was obtained prior to 09/06/2024 Staff C showed the hand signed form including only the 09/06/2024 electronic signature date. In an interview on 09/13/2024 at 12:37 PM Staff R stated they were given the form to scan into the record that day by Staff P. 47836 <Resident 60> According to the 07/15/2024 Admission MDS Resident 60 was admitted on [DATE] with a diagnosis that resulted in paralysis to the left side of their body. The assessment showed Resident 60 had no memory impairment. Record review showed a 07/24/2024 physician order for bilateral quarter bed rails to Resident 60's bed. Review of Resident 60's records showed no consent documentation for the use of the bed rails. On 09/10/2024 at 10:02 AM, Resident 60 was observed to have bed rails attached to both sides of their bed. Resident 60 stated staff did not discuss the risks and benefits of the bed rails with them or obtain their consent for the side rails. In an interview on 09/15/2024 at 10:26 AM Staff C stated prior to placing bed rails on a resident's bed, they were expected to complete a safety device assessment on the resident, explain risks and benefits of the bed rails, obtain the residents consent, and care plan the bed rails to ensure all staff were aware of the reason for the bed rails. Staff C stated they had not obtained consent for Resident 60's bilateral bed rails but should have. Staff C stated it was important to obtain resident consent to ensure the resident was included in their plan of care and aware of all treatments. Refer to F656 - Develop/Implement Comprehensive Care Plan REFERENCE: WAC 388-97-0260.

Based on observation, interview, and record review, the facility failed to have a system in place that ensured basic life support was initiated immediately, as directed in the facility policy, including Cardio-Pulmonary Resuscitation (CPR - an emergency procedure consisting of chest compressions combined with giving breaths of air) when 2 of 3 residents (Residents 1 & 2) were reviewed for unexpected death in the facility. This failed practice placed 35 additional residents (Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, & 39), who had current physician orders to receive CPR, at serious risk for adverse outcome including death and constituted an Immediate Jeopardy (IJ). On [DATE] at 3:58 PM, the facility was notified of an IJ in F678. The facility removed the immediacy on [DATE] after they audited the records of all residents, audited the Physician Order for Life Sustaining Treatment (POLST - a form indicating the resident's wishes to have or not have CPR) binders, educated staff on the facility's Medical Emergency Response Policy and Code Blue Emergency Recorder process during CPR, performed CPR drills, and implemented a plan of correction to sustain ongoing compliance. Findings included . <Facility Policy> Review of the facility policy, Medical Emergency Response, revised ,d+[DATE], showed the employee who first witnessed or was first on the site of a medical emergency, that were trained, would initiate immediate action, including CPR as appropriate, .and summon for assistance. CPR would continue unless there was a DNR (Do Not Resuscitate) order in place .The RN (Registered Nurse) supervisor or Charge Nurse of the unit would take the Emergency Cart to the code site, and ensure accurate documentation of the event. Review of the 2020 American Heart Association Advanced Cardiovascular Life Support Provider Manual showed the passage of time drove all aspects of emergency cardiovascular care. The final outcomes were determined by the intervals between collapse or onset of the emergency and the delivery of basic and advanced interventions. The manual showed the probability of survival declined sharply with each passing minute of cardiopulmonary compromise. Some interventions, like basic CPR, slow the rate at which this decline in probability occured. CPR made this contribution by supplying some blood flow to the heart and brain. Some single interventions, such as tracheal intubation (insertion of a tube through the mouth or nose and into the airway/windpipe), clearing an obstructed airway, or defibrillating a heart (administering a controlled electric shock to restore the heart's normal rhythm), were sufficient alone to restore a beating heart. For all of these interventions, independently sufficient or simply contributory, the longer it took to administer these therapies, the lower the chances of survival. <Resident 1> Review of Resident 1's POLST showed it was signed by the Resident or Legal Surrogate on [DATE] and signed by the Nurse Practitioner on [DATE]. The form showed Resident 1 wanted CPR if they were not breathing and had no pulse. The form showed Resident 1 wanted full treatment to prolong life by all medically effective means including transfer to the hospital and intensive care (Full Code). Review of Resident 1's medical records showed Resident 1 was designated as a Full Code. Review of the Advanced Directives Care Plan (CP), revised [DATE], showed Resident 1's POLST indicated the resident was a Full Code. Review of the Minimum Data Set (MDS - an assessment tool) showed a [DATE] Death in Facility MDS was completed for Resident 1. Review of a nursing note documented by Staff F (Registered Nurse) showed on [DATE], Resident 1's family member (CC1) came out of the resident's room and went to Collectible Court hallway (A-Hall) to tell Staff F that Resident 1 was cold. Staff F notified the nurse assigned-Staff E (Licensed Practical Nurse - LPN) at Garden Way hallway (B-Hall), who was at the time in another resident room, that attention was needed in Resident 1's room. A Certified Nursing Assistant (CNA) then came out with CC1 needing help. Staff F went to Resident 1's room, noticed that Resident 1 was unresponsive and not breathing, and warmth still present in their arms and chest. Staff F told a CNA to notify another nurse of the situation and to call 911. The CNA and Staff F moved Resident 1 from the bed to the ground, and started doing chest compressions until the air bag was available to do CPR. CPR continued until EMS (Emergency Medical Services) arrived. Review of a nursing note, documented by Staff E on [DATE], showed while they were in the different room administering medications, a nurse called them to attend to Resident 1's room. Staff E found Resident 1 unresponsive. Resident 1 was cold around the neck but warm on the chest and legs. Staff E yelled out to get more people to lower resident down and start CPR. 911 was called and CPR continued until help arrived. Review of a statement in the facility investigation written by Staff E, dated [DATE], showed Staff E and a CNA responded to Resident 1 and stated, we were unable to lower resident down by ourselves to start CPR, therefore I asked a CNA to call everyone while I called 911. Review of an undated statement in the facility investigation written by Staff G (CNA) showed they saw Resident 1's family member (CC2) worried and calling out for help so they went to find the nurse, Staff E, who was in another room. Staff E and Staff G went in to Resident 1's room, and the resident was unresponsive. During an interview on [DATE] at 5:45 PM, Staff G, stated , we went in, we couldn't do CPR. Staff G stated they went out to get Staff F to pull the resident from the bed. Staff G stated they put Resident 1 on the floor, Staff F started CPR, and Staff E called 911. Review of the facility investigation, dated [DATE], showed it was noted in the visitor log that CC2 arrived to the facility at around 7:07 PM finding the resident unresponsive. Per Staff F, the incident occurred between 7:00 PM to 7:12 PM, when they were called and performed CPR, while Staff E called 911, which was at 7:14 PM. 911 arrived at 7:18 PM and took over CPR until around 7:56 PM. Attempts to resuscitate Resident 1 were unsuccessful. Resident 1 passed away between 7:45 PM - 8:00 PM. During an interview on [DATE] at 3:02 PM, Staff C (Director of Nursing - Interim) stated the staff involved could not recall specific times. Staff C confirmed CC2 signed in at 7:07 PM, 911 was called at 7:13 PM, and CPR was in process when the medics arrived. Review of the facility investigation dated [DATE] showed there was no timeline or actual documentation of the sequence of events. On [DATE] 3:15 PM, the back hall crash cart was observed with a clipboard and a Code Blue Emergency Recorder (Time Line) form was on the clipboard. The front hall crash cart was observed with a clipboard, but there was no Code Blue Emergency Recorder form on the clipboard or the cart. During an interview at that time, when asked if the Emergency Recorder form was completed for Resident 1's code, Staff C stated no, they did not have one in the investigation. Staff C looked at the nurse's station and other places within the facility and was unable to locate a form documenting the sequence of events. On [DATE] at 2:27 PM, an Automated External Defibrillator (AED - a lightweight, portable device that delivers an electric shock through the chest to the heart when it detects an abnormal rhythm and changes the rhythm back to normal) was observed in the facility, mounted on the wall. During an interview on [DATE] at 4:48 PM, Staff B (Director of Nursing) stated it was not a requirement to use the AED during CPR. During an interview on [DATE] at 5:10 PM, Staff A (Administrator) was unable to provide staff training in the use of an AED and stated the facility did not have a policy or procedure regarding the use of the AED. During an interview on [DATE] at 3:02 PM regarding the investigative findings, Staff D (Resource Nurse) stated CC2 came out, Staff F went to the room, and initiated CPR. Both Staff C and Staff D thought Staff F was the first on the scene to identify the resident had no pulse and no respiration. During an interview on [DATE] at 11:19 AM, CC2 stated, after exiting Resident 1's room, they ran down the hallway, saw a nurse and yelled It's an emergency, hey we need help, [Resident 1] is in trouble! CC2 stated they told a nurse who went and told another nurse. During an interview on [DATE] at 11:38 AM, CC1 stated they stayed in the room while CC2 went to find staff, trying to find staff took a while. They said they were looking for [Resident 1's] nurse. CC1 stated ,I started screaming, then they [staff] came in. During an interview on [DATE] at 10:03 AM, Staff H (Corporate Consultant) stated they re-interviewed the staff involved and determined that Staff G was the first in the room, summoned Staff E, who told Staff G to get Staff F. When asked why Staff G did not initiate CPR, Staff H stated that a licensed nurse needed to verify the code status, the POLST, and then make the decision to do CPR or not. <Resident 2> Review of Resident 2's POLST showed it was signed by the resident (undated) and signed by the physician on [DATE]. The form showed Resident 2 wanted CPR if they were not breathing and had no pulse. The form showed Resident 2 wanted full treatment to prolong life by all medically effective means including transfer to the hospital and intensive care. Review of Resident 2's electronic medical record showed Resident 2 was designated as a Full Code. Review of the Advance Directives CP, revised [DATE], showed Resident 2's POLST indicated the resident was a Full Code. Review of the MDS showed a [DATE] Death in Facility assessment was completed for Resident 2. Review of a [DATE] nursing progress note time stamped at 12:22 AM showed on [DATE], Resident 2 complained of stomach upset and the physician came, assessed Resident 2's discomfort, and ordered medications for the resident. The note showed, at 8:30 PM, Staff F saw Resident 2 watching television in bed while holding a bucket (in case of vomiting). At 9:10 PM, Staff F found Resident 2 unresponsive and their breathing and pulse were present but weak. The note showed Staff F notified a nursing aide to obtain Resident 2's vital signs, went and told another nurse of Resident 2's condition, and called 911. Review of the [DATE] facility investigation showed no emergency response timeline or documentation of the sequence of events was included in the report to support the facility initiated CPR timely as required. A [DATE] investigation note showed, on Staff F's way to call 911, Staff F alerted Staff I (LPN) about what was going on with Resident 2, and by the time Staff I got to the room, Resident 2 had stopped breathing. A [DATE] testimony (staff interview/statement) by Staff I showed, when Staff F told them of Resident 2's condition, they went to the resident's room and assessed the resident while Staff F called 911. The testimony showed it was not until Staff F came back (after making the 911 call) and multiple staff were present in the room when Resident 2 was pulled on the floor to initiate CPR. The testimony showed Staff I called a Code Blue at 9:20 PM. Review of an undated statement in the facility investigation by Staff J (CNA) showed they participated in bringing Resident 2 down on the floor to do CPR at 9:15 PM. In an interview on [DATE] at 1:51 PM, Staff H confirmed there was no timeline completed for Resident 2's emergency response. Staff H stated the staff should have initiated the Code Blue Emergency Recorder form as part of the facility's process, but did not. Review of the facility provided Timeline of [Resident 2] CPR event document on [DATE] (created after the incident) showed when Staff F called 911, Resident 2 was unresponsive but was still alive, breathing and with a pulse. The document showed Staff F told Staff I that Resident 2 was unresponsive as they were running to a phone to call 911 and at 9:13 PM, the 911 dispatcher was updated by Staff F (while they were still on the phone) that Resident 2 had coded (stopped breathing and without a pulse). The document showed Staff F initiated the CPR after completing the 911 call and moving Resident 2 down on the floor with Staff J until the EMS (Emergency Response Services) arrived at 9:16 PM and took over the resuscitation efforts. The document showed Staff I told the investigative staff the time (9:20 PM) they provided in their testimony was a guesstimate. The document did not show if/when Staff I performed CPR on Resident 2 after they assessed the resident was unresponsive and called the Code Blue. In an interview on [DATE] at 11:12 AM, when Staff H was asked who was in Resident 2's room when the resident coded at 9:13 PM, Staff H stated Staff I was, and that Staff I did not move Resident 2 down on the floor to initiate CPR because the staff had a back injury. Staff H stated it was Staff F who initiated the CPR (and not Staff I) and confirmed it was a similar situation (where the first CPR-trained staff member who was on scene did not initiate CPR) as with the case of Resident 1. A review of the electronic medical records on [DATE] showed 35 residents (Residents 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, & 39) had current physician orders to receive CPR according to the facility policy. These 35 residents all resided in the facility on [DATE]. REFERENCE: WAC [DATE](1). 46471

Based on observation, interview, and record review, the facility failed to identify allegations of abuse, ensure alleged abuse, neglect and/or unexpected deaths were reported, and thoroughly investigated for 8 of 9 residents (Residents 2, 3, 4, 5, 6, 7, 8 & 1) reviewed for abuse. Residents expresed fear of staff, not feeling safe, crying, nervous from the fear and not calling for assistance due to fear of being yelled at or pushed and pulled by staff. Although the facility was aware of these concerns, they were not identified, reported, or investigated as potential allegations of abuse, but were considered grievances. In addition, residents were not proteted when the facility allowed the alleged perpetrator(s) to have continued access to residents prior to determining if abuse or neglect occurred. This failure placed residents at serious risk for unidentified abuse and/or neglect and a diminished quality of life. On 08/31/2023 at 3:00 PM, the facility was notified of an Immediate Jeopardy at CFR 483.12(c)(2)-(4) F610, Alleged Violations-Investigate/Prevent/Correct, related to the facility's failure to identify allegations of abuse, ensure alleged abuse, neglect and/or unexpected deaths were reported, thoroughly investigated and protect residents during the investigation. The facility removed the immediacy on 09/05/2023 with an onsite verification from investigators by, conducting resident interviews, reporting and investigating all allegations of abuse or neglect, and placing residents on psychological monitoring. And re-educating all staff (prior to working their next scheduled shift) regarding abuse policies/procedures, which ensured an effective system was in place to safeguard, protect and prevent residents that were at risk for abuse. Findings included . Review of the facility policy titled, Abuse, Neglect and Exploitation, revised April 2023, showed the facility would develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, establish policies and procedures to investigate any such allegations and provide ongoing oversight and supervision of staff in order to assure that policies were implemented as written. According to the policy, the facility would identify, correct, and intervene in situations in which abuse, neglect .was more likely to occur with the deployment of staff on each shift in sufficient numbers to meet the needs of the residents. Investigation of Alleged Abuse, Neglect and Exploitation included identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation, focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment occurred, the extent, and cause, and providing complete and thorough documentation of the investigation. In addition, the facility would report all alleged violations to the state agency within required time frames. Review of the facility policy titled, Incidents and Accidents, revised March 2023, showed that an incident was defined as an occurrence or situation that was not consistent with the routine care of a resident or with the routine operation of the organization. This can involve a visitor, vendor, or staff member. The policy listed incidents that required an incident report which included allegations of abuse, neglect, mistreatment, combative behavior, falls, pressure injuries/ulcers, resident to resident altercations, and unexpected deaths. In the event of an unwitnessed fall, the nurse initiated neurological checks per protocol and documented on the neurological flow sheet. Abnormal findings were reported to the practitioner. If an incident was witnessed by other persons, the supervisor or designee obtained written documentation of the event by those that witnessed the incident. The facility would report to appropriate state and federal agencies according to regulatory requirements. <Resident 2> Review of a 07/26/2023 Admission MDS showed Resident 2 admitted to the facility on [DATE] with diagnoses including arthritis, vascular disease, diabetes, and muscle weakness. Resident 2 was assessed as able to make their own decisions, with adequate hearing, clear speech, and required two person extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of a Concern and Comment form, dated and signed 08/10/2023 by Resident 2 showed their concern was that a number of CNAs were very difficult to deal with, which caused Resident 2 to be reluctant to push their call button for help. The form showed a letter of explanation was included but was not attached to the concern and comment form when first requested from facility staff. Review of the requested letter of explanation showed Resident 2 documented Second shift had become difficult and makes me feel like a burden or nuisance, Third shift is very difficult, we get yelled at, moved around harshly, and are told no when we ask for help or for something we need, I don't push my button unless I am very wet, otherwise I am hiding in my bed, not all CNA's make me sad but a few do, I would like to feel safe and secure and it is hard to feel good when you get ridiculed and shoved around when my brief is being changed. Review of a 08/11/2023 statement written by Staff G, showed Staff G interviewed Resident 2 on 08/11/2023, who stated concerns about Staff I, CNA and at times with Staff J, CNA. Resident 2 stated they [NAME] and puff when you need to be changed and tell me they don't have time or say they will come back and don't, and they yell in high pitch voices, throw things on the ground when they are mad, and Staff N, Registered Nurse (RN) yells at us, Staff I throws me around and had hurt my legs a few times, they act like they don't like me, and Staff I wants me to go to sleep at 8:00 PM but I prefer to stay up until at least 10:00 PM. Review of the August 2023 facility Abuse Log showed the facility did not log or make mandatory reports as required for Resident 2's allegations of neglect, verbal, and physical abuse. During an interview on 08/23/2023 at 12:25 PM, Staff G stated grievances or concern/comment forms were reviewed for potential allegations of abuse, when an allegation was suspected, the form was forwarded to the Director of Nursing (DNS) or in their absence the Administrator, the Administrator in training (AIT) or the Chief Nursing Officer (CNO). Staff G stated the concern/comment form for Resident 2 was forwarded to Staff C, AIT because the form showed an allegation of abuse and neglect and needed to be investigated. Review of a 08/14/2023 Summary of Resident 2's grievance/concerns completed by Staff B showed Resident 2 complained that aides make them feel uncomfortable because they talk loud and at times in a different language, which makes Resident 2 feel like the aides are taking about them and Resident 2 is reluctant to use their call button for help. The summary showed Staff I was removed from work on 08/11/2023 and 08/12/2023, and returned to work on 08/13/2023 on a different hallway from Resident 2. During an interview on 08/14/2023 at 11:55 AM, Resident 2 stated both Staff I and Staff J had been harsh and rough towards them and their previous roommate (Resident 3). Resident 2 stated they were shocked when Staff I showed up in their room during the night shift last night to help another Staff O, CNA, change the resident and their bed sheets. Resident 2 was informed that Staff I was suspended and thought they should not have been in the their room. Resident 2 stated that Staff J came into their room on a different occasion asking what they did to the resident, and informed them they were not allowed in their rooms anymore. Review of facility staffing sheets, dated 08/11/2023, showed Staff J worked with Resident 2 that evening shift. A 08/12/2023 staffing sheet showed Staff I worked on the same hallway as Resident 2. The 08/13/2023 staffing sheet showed Staff I worked evening and night shift on a different hallway. In an interview on 08/23/2023 at 1:01 PM Staff C stated Staff I was suspended Friday and Saturday and was brought back to work on Sunday (08/13/2023), after they received customer service training, they had to work in a different area of the building and was directed not to walk down the hall where both residents (Resident 2 and Resident 3) were or have contact with the residents. When asked if Resident 2's concerns were an allegation of abuse or neglect, how was abuse or neglect ruled out before allowing Staff I to have access to residents, Staff C replied that at the time they did not consider the concerns an allegation of abuse or neglect. Staff C was not sure and could not confirm what staff member educated Staff I on customer service or if the education was completed before Staff I returned to work with residents. When asked what was done with Staff J, Staff C stated that Staff I was the main focus of concern and they did not recall interviewing or re-educating, Staff J. Staff C stated that residents on the same hall as Resident 2 were interviewed for concerns, although the interviews were not dated and did not indicate when the interviews occurred. Review of a 08/14/2023 Education Record showed customer service training was provided on Monday 08/14/2023 to Staff I and Staff J, this was after Staff I had already worked the floor and had access to residents. During an interview on 08/23/2023 at 1:31 PM, Staff B stated when abuse or neglect were suspected they would expect staff to report the allegation immediately to required entities; abuse hotline, resident representatives, physician, and the administrator. Staff B would expect staff to log the allegation of abuse or neglect on the facility abuse log, and suspend staff involved until a investigation was completed to rule out abuse and neglect. Staff B acknowledged Resident 2's allegations of abuse or neglect were not logged, reported, or investigated as they would expect. Staff B stated Staff I was brought back to work before the investigation was completed and before abuse and neglect was ruled out and Staff J should have but was not suspended during the investigation as Staff B would expect, giving both staff members access to residents. <Resident 3> Review of a 08/03/2023 Admission MDS, showed Resident 3 admitted to the facility on [DATE] with diagnoses including a leg fracture, heart failure, arthritis, and hip fracture. Resident 3 was assessed as able to make their own decisions, with minimal difficulty hearing, clear speech, and required two person extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Review of a Concern and Comment form dated and signed by Resident 3 on 08/10/2023, showed Resident 3 had concerns about the treatment of resident's by the CNAs. Resident 3 documented details to include; lack of respect, make me feel uncomfortable, and don't give messages to the nurse when I need something. Review of a four page handwritten letter by Resident 3 showed they had problems with Staff I and Staff J, when someone is constantly yelling at me, not changing my briefs, hurting me, and being very rough both physically and verbally it scares me, I cry, get nervous, and hyperventilate, then they yell at me again for crying. There was a time a CNA told me to stop laughing, and yelled, yes you are! I laid my head down and never talked again. I wasn't laughing, I was crying because they dropped my legs and it hurt really bad. I have asked to be changed and was told, no. I have had many times where my ice bag fell on the floor or leaked, the CNA yelled at me and threw my ice bag on my dresser, drenching my clothes. Review of a 08/11/2023 statement written by Staff G, showed Staff G interviewed Resident 3 on 08/11/2023 about their concerns. Resident 3 told Staff G that Staff I wipes me roughly and drops my legs all the time, I am scared of Staff I and Staff J is mean sometimes. Review of the August 2023 facility Abuse Log showed the facility did not log or make mandatory reports as required for Resident 3's allegations of neglect, verbal and physical abuse. Review of a 08/11/2023 facility staffing sheet showed Staff J worked with Resident 3 on evening shift. Review of 08/12/2023 staffing sheet showed Staff J worked day and evening shift on a separate hall from resident 3, but still had access to residents. Review of a 08/13/2023 staffing sheet showed Staff J worked day and evening shift on a separate hall from Resident 3 and Staff I worked a evening shift on the same hall as Resident 3 and worked a night shift on a separate hall from Resident 3. Review of a 08/14/2023 Summary of Resident 3's grievance/concerns completed by Staff B showed Resident 3 had concerns that Staff I pulled a pillow out from under their legs and did not set their feet lightly on the bed, felt rushed by Staff I and had concerns about the aide's heavy accent. Staff I was provided education on customer service, informed to limit their time in the hallway where Resident 2 and 3 resided, not to interact with Resident 2 and 3, and to not discuss grievances with resident or other staff. The summary did not include Resident 3's concerns about Staff J or address Resident 3's allegations of neglect, verbal and physical abuse. During an interview on 08/14/2023 at 12:15 PM, Resident 3 stated they had a rough night and woke up to a nurse yelling at them because the ice bag fell on the floor and leaked, how was I supposed to know, I was sleeping, then [Staff I] came to the door with another aide and just stared at me, I don't want them [Staff I] to come in my room I am not sure why they are back. I don't want [Staff I] or [Staff J] to provide care to me because they are rough and hurt my feet. In an interview on 08/23/2023 at 12:25 PM, Staff G stated Resident 3's grievance/concerns were reviewed for abuse allegations, once reviewed Staff G determined Resident 3's concerns were allegations of neglect and abuse. Staff G stated the concern/comment form for Resident 3 was forwarded to Staff C because the form showed an allegation of abuse and neglect and needed to be investigated. In an interview on 08/23/2023 at 1:01 PM, when asked if rough wiping, being mean, yelled at, and residents being scared of staff was an allegation of abuse or neglect, Staff C stated at the time they did not consider the concerns to be an allegation of abuse or neglect. When asked what was done with Staff J, Staff C stated that Staff I was the main focus of concern and they did not recall interviewing or suspending Staff J. Staff C stated they were not sure and could not confirm what staff member educated Staff J on customer service or if the education was completed. During an interview on 08/23/2023 at 1:31 PM Staff B stated when abuse or neglect are suspected they would expect staff to report the allegation immediately to required entities, abuse hotline, resident representatives, physician, and the administrator. Staff B would expect staff to log the allegation of abuse or neglect on the facility abuse log, and suspend staff involved until an investigation is completed to rule out abuse and neglect. Staff B acknowledged Resident 3's allegations of abuse or neglect were not logged, reported, or investigated as they would expect. Staff B stated Staff I was brought back to work before the investigation was completed and before abuse and neglect was ruled out and Staff J should have but was not suspended during the investigation as Staff B would expect, giving both staff members access to residents. <Resident 4> Review of the 08/07/2023 Admission MDS Resident 4 admitted to the facility 08/01/2023. The resident had no falls prior to admission or since admission. The resident exhibited verbal behaviors towards others, and rejected care, on one to three days of the look back period. The resident was assessed as a two-person physical extensive assist with bed mobility, transfers, dressing, toileting. Review of an 08/08/2023 11:30 AM Nurse's Note showed, Resident and roommate did not get along; screaming at each other, accusing each other's TV was too loud. The Roommate told the nurse they could not stand the other resident's attitude; the other resident heard, and shot back, Me either. Staff received a physician's order to transfer resident to another room. During an interview on 08/23/2023 at 1:31 PM, Staff B stated that if abuse occurred or was suspected staff were to protect the resident, report the incident up the chain of command, initiate an incident report, and report to the State Agency. During an Interview on 08/23/2023 at 2:07 PM Staff K, RN, stated that the residents were verbally abusing each other. Staff K stated she witnessed it she pulled Resident 4 out of the room. Staff K stated that she reported the incident to Staff L RN/Staff Development Coordinator, and she told Staff H, Social Services Assistant. Staff K stated she should have but did not complete an incident report or report the event to the Hotline (State Agency abuse reporting line) as required. During an interview on 08/23/2023 at 2:11 PM, Staff L stated that she received no reports from Staff K. During an interview on 08/23/2023 at 2:15 PM, Staff G stated she received a request for a room move, but she was not told it was a resident-to-resident altercation. At 2:20 PM, Staff G stated that Staff H was not on duty on 08/08/2023. During an interview on 08/23/2023 at 2:21 PM, Staff D, CNO, stated the resident-to-resident altercation with screaming and cursing should have been reported to the Hotline. During an interview on 08/23/2023 at 2:40 PM Staff B reviewed the 08/08/2023 progress note and stated, I'd expect them to report that. Review of the August 2023 Incident Reporting Log showed the resident-to-resident altercation was not reported nor investigated for abuse. Review of the August 2023 Incident Reporting Log showed Resident 4 sustained a non-injury fall on 08/14/2023 at 9:00 PM in their room. Actions taken to prevent recurrence included a care plan revision. The Hotline was not notified. On 08/23/2023 at 2:01 PM the facility investigation was requested and Staff B stated they did not have it completed. Staff B acknowledged the investigation was not completed within five days as required. Review of the Nurse's Notes showed an 08/14/2023 9:21 PM entry that Resident 4 was assessed with a bruise to their left face. A 08/15/2023 1:14 PM Nurse's Note showed Resident 4 had bruising to their left face, under the chin and neck area. Review of the Post Fall Observation dated 08/18/2023 showed there were reports of swelling, bruising, or other signs/symptoms of injury since the event. Review of the investigation summary dated 08/23/2023 at 2:21 PM showed the resident sustained an unwitnessed fall with no injury. During an interview on 08/23/2023 at 1:31 PM, Staff B stated that after a fall, Residents were placed on alert (documented monitoring) for latent injuries. If a Resident was noted with a bruise the nurse was expected to conduct a skin assessment weekly until resolved. During an interview on 08/23/2023 at 2:12 PM, Staff H, Registered Nurse (RN), Resident Care Manager (RCM) stated that Resident 4 sustained bruising and an injury to their head in the neck and chin area. Staff H stated when the bruising was noted the nurse should have but did not do a skin assessment. During an interview on 08/23/2023 at 2:40 PM Staff B stated that no one reported the bruising to her, it was not on the 24 hour report and should be reported on the log as a substantial injury. <Resident 5> Review of a 07/05/2023 Admission MDS showed Resident 5 admitted to the facility on [DATE] and had diagnoses including a brain bleed, cancer, and weakness. The MDS assessed Resident 5 with moderate cognitive impairment, moderate difficulty hearing, clear speech, had no skin impairments, and required extensive assistance from two staff members for bed mobility, transfers, dressing, and toileting. Review of three grievances/concern forms, dated 08/15/2023, showed Resident 5's collateral contact (CC1) had concerns that Resident 5 was not being turned every four hours and now has two bedsores. The resident had a swollen hand, and when CC1 requested an x-ray, was told that x-rays were not done at the facility, no one followed up, and the resident did not receive an x-ray. The resident was only receiving one bath a week and was told by facility staff that was because they were a fall risk. All three concern forms showed staff left the question blank regarding the concerned party's response to the action plan or outcome. During an observation and interview on 08/23/2023 at 3:05 PM, Resident 5 was observed lying in bed on their back with their left hand elevated on a pillow and stated staff only repositioned them when they called and asked the staff to turn them, at times staff said they will go get another aide to help and never return to reposition them, and that it happened often. Resident 5 stated they were told by facility staff they had blood clots in their hand. Resident 5 could not recall if an x-ray was done. In an interview on 08/23/2023 at 3:15 PM, Staff B stated they did not follow up with CC1 regarding their concerns of neglect and acknowledged the concerns should have but were not identified as neglect, or logged, reported, and investigated as required. <Resident 6> Review of a Concern and Comment form dated 08/20/2023 showed Resident 6 provided a handwritten letter to Staff G. Review of the letter showed Resident 6 reported that three staff, who identified as either Physical or Occupational Therapists, began to pull and push on me I became frightened because of my pain! They hollered at me! They were not professional people! . Further review of the concern form showed the facility identified the resident's concern as Stating therapy was unprofessional. Review of the August 2023 Concern Log and the August 2023 Incident Reporting Log on August 23, 2023, showed that Resident 6's allegations of abuse were not logged. During an interview on 08/23/2023 at 12:44 PM, Staff D stated that the allegation should have been investigated. <Resident 7> Review of a 08/12/2023 Admission MDS, Resident 7 admitted to the facility on [DATE] with diagnoses including cancer, depression, and post spinal surgery. Resident 7 was assessed to be able to make their own decisions, with adequate hearing, clear speech, and required extensive assistance of two staff members for bed mobility, transfers and toilet use. Review of a 08/11/2023 grievance/concern form showed Resident 7 had concerns of being left in a wheelchair for two hours after working with therapy. Review of a 08/11/2023 statement from Staff G showed Resident 7 was interviewed by Staff G, and stated on 08/11/2023 at lunch time a therapist brought them into their room and Resident 7 agreed to eat lunch in their wheelchair. Resident 7 put their call light on, was left in the wheelchair during that time which caused Resident 7 pain, and no one answered the call light for two hours. A 08/16/2023 statement by Staff B showed that Resident 7 complained of being in their wheelchair and the therapist asked the resident to remain in the wheelchair for lunch. Per Staff B's statement staff returned resident to bed after one hour and the resident's perception was longer than the actual time they waited. Review of the August 2023 facility Abuse Log showed the facility did not log or make mandatory reports as required for Resident 7's allegations of neglect. The facility did not identify the concern as an allegation of neglect, therefore did not log, report, or investigate Resident 7's allegation of neglect as required. <Resident 8> Review of the 08/01/2023 Annual MDS, Resident 8 was alert and oriented, did not exhibit behaviors which interfered with care, was always incontinent of bowel and bladder, had Moisture Associated Skin Damage, and was dependent on two persons for mobility, transfers, dressing, and toileting. According to a facility reported incident, on 08/24/2023 during morning rounds, Resident 8 told Staff L that they requested to be changed on 08/23/2023 at 9:55 PM and was told by the evening shift aid, Staff U, CNA, that Resident 8 had to wait for the night shift staff as the resident required two person assist. During an interview on 09/01/2023 at 10:30 AM, when asked how the incident made them feel, Resident 8 responded, Like I am not worth it. Review of the 08/25/2023 facility investigation showed that it took two aids to change this resident as they were care in pairs. During an interview on 09/01/2023 at 1:23 PM, Staff B stated Resident was a two person assist with mobility as the resident could not assist. When questioned regarding the investigation stating the resident was care in pairs, Staff B noted that Resident 8 was both, care in pairs and two person assist with mobility. Review of the 08/25/2023 facility investigation showed no statement by, or interview with the Licensed Nursing Staff working on 08/23/2023 to determine if Staff U requested assistance from the nurse or notified the nurse. Review of the statement written by Staff U Staff U told the resident that as it took two CNAs to change them, and Staff U's co-worker went home, night shift CNA would be in at 10:00 PM and Staff U would let them know Resident 9 needed to be changed. Review of the 08/24/2023 facility investigation showed it did not identify the nursing assistant that left work before the end of shift, did not include statements to determine if the absence was known, approved, or covered by the nurse on duty. During an interview on 09/01/2023 at 1:23 PM, Staff B stated that staff were not allowed to leave early. Review of the 08/25/2023 facility investigation showed that Staff U was working at the time of the resident's complaint Thursday morning. Staff U was removed from their assignment pending investigation. The investigation did not identify what time Resident 8 notified Staff L, or what time Staff U was removed from the floor. During an interview on 09/01/2023 at 1:23 PM, Staff B stated that they did not know when Staff L was aware of the allegation, but Staff L was delayed in reporting the allegation to Staff B. Review of the 08/25/2023 facility investigation showed residents on D Hall were interviewed and the resident's felt safe and their needs were met. Review of the Resident Abuse/Allegation Questionnaires dated 08/24/2023 showed they asked the residents the following questions: Has any staff been physically or verbally abusive towards you? Have you seen any of the staff being physically or verbally abusive towards any other residents? Do you feel safe in the facility? Do you feel the staff transfer you correctly? None of the questions asked pertained to the allegation being investigated - neglect, refusal to provide care requested, delay in care due to requiring two staff, and/or care provided by Staff U specifically. <Resident 1> Review of the 05/24/2023 Significant Change in Status Minimum Data Set (MDS - an assessment tool), showed Resident 1 admitted to the facility 09/06/2022, with multiple medical diagnoses. During an interview on 07/18/2023 at 11:50 AM, Resident 1's family member, CC2 stated staff at the facility were keeping them away from the facility. CC2 recalled that he had been at the facility on 06/19/2023 with his family, had an altercation with the Social Worker and they called the cops on us. CC2 denied having been served with any written notice, letter or court order and stated since then they hadn't called with any changes or updates and if he called to speak to Resident 1 staff said the phone was broken. CC2 stated, I want to be able to see my dad, and I'd like to pick him up and go take him out to eat. Review of a Social Services Note dated 06/19/2023 at 1:50 PM showed an intense argument/verbal abuse that occured between facility staff and CC2 in front of residents. Staff A, Administrator (Executive Director - ED), called the police. According to the note, they were told they could not return as they were volatile and it's no longer safe for them to come to the building. During an interview on 08/01/2023 at 2:58 PM, Staff B stated CC2 threatened Staff G and Staff A, Administrator. They had to call police and he left before they came. Staff B stated, He was asked to not come back because he was threatening staff. The faciltiy failed to provide support or assist Resident 1 to cope with the cope with the potential emotional stress as a result of witnessing verbal abuse and having their family members banned from the facility. During an interview on 08/23/2023 at 3:34 PM, Staff A stated that CC2 stated mouthing off, using vulgar words and yelling at Staff G. Staff A stated that he told CC2 that he was being disruptive and inappropriate and they would call police. When Staff A started to call the police, Resident 1's family left the facility. Staff A stated, I didn't tell him he couldn't come back. Staff G put Resident 1's roommate on alert for potential psychosocial harm. Review of a 07/20/2023 8:06 AM Nurse's Note showed Staff F received a phone call from CC2, who was yelling at Staff F saying, you guys killed Resident 1, he has 24 hours someone to watch him, how can he be dead? The nurse documented in the resident's record that CC2 stated the facility kicked him out, and wouldn't let him come to see his dad. Review of the June 2023 Incident Reporting Log showed no entry for a 06/19/2023 incident. Review of the July 2023 Incident Reporting Log showed no entry for the 07/20/2023 allegation of abuse by the son against facility. REFERENCE WAC: 388-97-0640(5)(a)(6)(a)(b)(c)(7)(a). 44295

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent the development of avoidable pressure ulcers (PUs) for 1 (Resident 1) of 3 residents reviewed. The facility's failure to timely and accurately assess Resident 1's clinical condition and UP risk factors, precluded staff from identifying, developing and implementing resident specific interventions to prevent the development of PUs. Additionally, the facility failed to notify the Physician of the continued deterioration of Resident 1's UP. These failures placed the resident at risk for unidentified wound deterioration, a delay in treatment, and resulted in harm to Resident 1 who developed an avoidable full thickness UP to the sacrum (tail bone), which required medical intervention. Findings included . According to the facility's undated Pressure Ulcer/Injury Risk Assessment policy, the purpose of a structured risk assessment is to identify risk factors and then determine which ones can be immediately addressed to decrease the risk of UP development and which risk factors will take time to modify. Risk factors include under nutrition, impaired/decreased mobility, exposure of skin to urinary or fecal incontinence, co-morbid conditions such as diabetes, cognitive impairment and refusal of some aspects of care or treatment. Staff were instructed to use only a facility-approved risk assessment tool to obtain risk assessment data, and were directed to: conduct the assessment as soon as possible after admission, but no later than eight hours after admission; Repeat the assessment weekly for the first four weeks; and repeat the assessment with a significant change in condition, or as often as is required based on the resident's condition. After the risk factors are identified a resident-centered care plan can be created to address the modifiable risks for pressure ulcers. According to the facility's undated Pressure Ulcers/Injuries Overview policy, Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed: Evaluation of the resident's clinical condition and risk factors; Definition and implementation of interventions consistent with the resident's needs, goals, and professional standards of practice; monitoring or evaluation of the impact of the interventions; or revision of the interventions as appropriate. Resident 1 admitted to the facility on [DATE]. According to the 08/01/2021 Admission Minimum Data Set (MDS, an assessment tool), the resident was cognitively impaired, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 08/17/2021 at 12:03 PM Staff B, Director of Nursing, explained the facility utilized the Braden (Formal assessment instrument/tool) to help determine a resident's UP risk, then staff used the assessment to develop a resident centered plan of care and resident specific interventions. After completing a Braden assessment a scoring system helps to determine a resident's risk for UP development, as follows; scores of: less than 9 = very high risk; 10-12 = High Risk; 13-14 = Moderate risk.; and 15-18 = Mild Risk Review of the 07/26/2021 Nursing Admission Evaluation showed Resident 1 admitted to the facility without any wounds or skin conditions. The 07/26/2021 Braden risk assessment, determined Resident 1 was at moderate risk for UP development. Under the Care Plan [CP] heading at the end of the Braden assessment,the following interventions were recommended:: good nutrition and hydration to promote healthier skin; elevate heels; and to identify and document potential causative risk factors and eliminate/resolve them where possible. Review of the 07/28/2021 Baseline Care Plan [BCP] showed it was incomplete. Facility staff failed to assess/evaluate the following risk factors: Bowel and bladder continence; cognitive status; presence of pain; active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .g. diabetes); and Resident 1's current medications that can impact skin integrity, such as daily subcutaneous [MEDICATION(S)] (an anticoagulant medication) injections. Each of these sections on the BCP were left blank. The BCP also failed to direct staff to elevate the resident's heels, or attempt to identify and document other potential risk factors, as recommended in the 07/26/2021 Braden assessment. The BCP did identify Resident 1 required extensive assistance with bed mobility and should be turned side to side every two to three hours but no other resident specific risk factors or interventions related to UP prevention were identified. In an interview on 09/02/2021 at 12:15 PM, Staff B stated it was the expectation that all sections of the BCP be assessed and completed to ensure risk factors are identified, and an immediate plan of care can be initiated to meet the resident's specific needs. Staff B then acknowledged for this resident, that did not occur. A 08/10/2021 3:00 PM nurses note, assessed that Resident 1 had a purple non-blanchable area to the coccyx with surrounding non-blanchable redness, measuring 9.5 centimeters (cm) by 7 cm. The area was determined to be a deep tissue injury (DTI, a type of UP characterized by persistent non-blanchable deep red, purple or maroon areas of intact skin, caused by damage to the underlying soft tissues). The note stated the practitioner was notified of the new skin issue and would assess the resident on 08/11/2021. Review of the August 2021 Treatment Administration Record (TAR) showed a 08/10/2021 order to monitor the DTI to the coccyx every shift for skin integrity, and notify the provider if it worsens. Record review showed from 07/26/2021 (when the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Braden assessments should have been, but were not, conducted on 08/02/2021 and 08/09/2021. On 08/10/2021 a Braden assessment was performed, after Resident 1 was identified with a DTI to the coccyx/sacrum. Review of this assessment showed staff assessed the resident had adequate nutrition, and again was determined to be at moderate risk for PUs. Review of Resident 1's July and August 2021 weight flowsheets showed the following weight trend:: 07/26/2021- 166.8 pounds (lbs); 08/01/2021 -159.3 lbs (- 4.5%); 08/13/2021- 159 lbs (- 4.68 %); and 08/20/20- 156.6 lbs (- 6 % in less than 30 days. A 08/03/2021 Nutritional Evaluation assessed that Resident 1 had inadequate intake to meet nutritional needs, and identified the resident was at risk for unavoidable weight loss due to decreased appetitive, impaired cognition and [CONDITION(S)]. The Registered Dietician (RD) recommended 2 cal (a Nutritional supplement) 60 milliliters twice daily, and changing the resident's diet to nutritionally enhanced meals (increased fat/ calorie content) to cease the weight loss trend and meet the resident's nutritional needs. Similar findings were noted on the 08/17/2021 Braden assessment, which determined the resident had adequate nutrition, despite trending weight loss and the RD's assessment to the contrary. Again, Resident 1 was found to be at moderate risk for UP development, despite the presence of a facility acquired UP. During an interview on 09/02/2021 at 12:15 PM, when asked if the 08/10/2021 and 08/17/2021 Braden assessments accurately depicted the resident's condition Staff B indicated it did not appear so, but wanted to look into it further. No further information was provided. A 08/11/2021 provider note assessed Resident 1 had a non-blanchable area to the buttock that appears to be a deep bruise. The provider ordered the coccyx area be cleansed with normal saline (NS), and covered with a dry dressing daily, referred Resident one to the Wound Care Clinic for evaluation and treatment, and ordered implementation of an alternating low air loss (LAL) mattress for pressure redistribution. Review of Resident 1's .Skilled Progress Notes showed nursing documented the following: 08/10/2021 at 6:27 PM, Resident resting in bed comfortably, re-position for comfort and skin care. Skin discoloration on bottom remains intact.; 08/13/2021 at 9:50 PM nursing documented, Skin discoloration coccyx sacral area 9.0[cm] X 6.0 cm grayish black in color with skin redness around. Skin remains intact; and on 08/15/2021 6:53 PM nursing again assessed the wound as, Skin discoloration coccyx sacral area grayish black in color with skin redness around continue apply protect cream and turn Q 2 hours. Despite facility staffs awareness of the change in wound/skin characteristics, from purple/red, non -blanchable, to grayish/ black, indicating the skin was devitalized, and demonstrating a clear decline in the wound, record review showed no indication the provider was notified of the decline as ordered. During an interview on 09/02/2021 at 12:15 PM, Staff B acknowledged Resident 1's wound had declined from 08/10/2021 when it was assessed as purple to 08/13/2021 when it was assessed as grayish black. When asked if there was any documentation to support the practitioner was notified of the wound decline Staff B stated, No. On 08/16/2021 Resident 1 was seen by the wound practitioner, who assessed Resident 1 had an unstageable UP to the sacrum with peri-wound (surrounding) [CONDITION(S)] (redness). According to the evaluation, the wound bed was 100% slough (dead, devitalized tissue), with a moderate amount of serous (clear straw colored fluid) drainage, and had no odor. The practitioner performed Sharp debridement [use of scalpels, curettes, or scissor] to remove devitalized tissue, and Discussed the importance of offloading (weight distribution) and pressure relief to promote wound healing. An order was written to change the UP treatment to Apply quarter strength Dakins [a mixture of water,baking soda and bleach] soaked gauze [to the wound bed] and cover with foam or ABD [abdominal pad] daily. Observations on: 08/17/2021 at 12:23 PM; 08/20/2021 at 5:58 AM and 6:47 AM; and 08/26/2021 at 12:20 PM, showed Resident 1 lying in bed on a Proactive Air (model Protext air 4000DX) Alternating LAL mattress. On each occasion Resident 1's heels were not floated/elevated, as directed on the 08/06/2021 comprehensive CP. On each day it was also observed that Resident 1's weight was programmed in the LAL mattress pump as 210 lbs. However, review of the August 2021 weight flow sheet showed on 08/13/2021 Resident 1 weighed 159 lbs, and on 08/20/2021 weighed 156 lbs, greater than 50 lbs less than what the LAL mattress was programmed for. Review of the August 2021 TAR showed a 08/12/2021 order directing nursing to Monitor Alternating Air Pressure Mattress for proper functioning and inflation every shift. Further review showed facility nurses, from 08/13/2021 through 08/25/2021, signed the task off as completed three times daily. The order did not indicate what the pump settings should be, which likely contributed to the failure by facility nurses' to identify the LAL pump, was inaccurately set for Resident 1. During an interview on 09/01/2021 at 12:43 PM, Staff B explained that the weight programmed into the LAL mattress's pump affected the air pressure (firmness) of the mattress. When asked if having the incorrect weight programmed could affect the efficacy of the mattress, Staff B stated, Yes. When queried what the facility nurses were signing as completed ., if they were not checking the pump settings (such as weight) to ensure appropriate function and inflation, Staff B indicated she did not know and stated that the resident's specific pump settings should have been in the body of the order, and that the nurses should have identified they were not and clarified the order. Review of 08/25/2021 provider note showed, on 08/24/2021 Resident 1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound culture was ordered and antibiotic therapy initiated. A 08/26/2021 provider note indicated Resident 1 had a decline in mental status, potentially related to the wound infection, and required transport to the hospital for further evaluation. Reference: WAC 388-97-1060(3)(b).

Based on interview and record review, the facility failed to timely and thoroughly investigate allegations of verbal abuse and resident to resident altercations for three (#1, #2, #3) of five residents reviewed for abuse. Failure to thoroughly investigate allegations, precluded the facility from identifying ongoing and trendable verbal abuse and intrusive behaviors by Resident #4 toward other residents, and resulted in harm to Resident #1. Findings included . RESIDENT #2 According to the 10/09/19 Quarterly Minimum Data Set (MDS, an assessment tool), Resident #2 was cognitively intact, had a life expectancy of less than three months and received hospice services for End Of Life care. According to the 11/15/19 discharge MDS, the resident passed away in the facility on 11/15/19. Review of the facility Resident Incident Log (RIL) showed an 11/04/19 entry for a resident to resident incident between Resident #2 and Resident #4. According to the RIL, on 11/01/19 Resident #2 reported to Staff E, Licensed Practical Nurse, that Resident #4 (roommate) was cursing at her. According to Staff E's written statement, (Resident #2) reported to me that (Resident #4) called her a f*cking B*tch, (Resident #2) also stated that (Resident #4) called her the same name at 2:30 AM. According to the investigative documents, (Resident #4) began cursing in her room that she shares with her roommate (Resident #2). She began cursing because she thought the empty breakfast tray sitting in her room was her tray and was cursing because she thought her roommate ate the food. Staff intervened and reminded (Resident #4) that she eats in the dining room and that the empty tray is her roommate's. (Resident #4) began cursing at the staff member but was easily redirected . The investigation stated that the residents were offered room changes and Neither one wished to move .both denied having an issue or concern with the other. Review of the investigation showed, the facility did not interview other residents to determine if other residents were affected by Resident #4's verbal outbursts. No staff interviews were conducted to determine if Resident #4 had a history of [REDACTED]. Additionally, the allegation of Resident #4 calling Resident #2 a f*cking B*tch at 2:30 AM was not addressed. The facility investigation did not conclude whether abuse occurred, however, the investigation suggested that the incident was a misunderstanding over a breakfast tray. Review of Resident #4's progress notes between 10/11/19 and 10/22/19 revealed multiple progress notes detailing Resident #4's profanity/verbal outbursts towards staff and other residents. During an interview on 11/27/19 at 9:40 AM, when asked if staff should have been interviewed about their awareness of Resident #4's behaviors, Staff B, Director of Nursing, stated Yes. When asked if that occurred, Staff B stated no. When asked if during the investigative process someone should have identified Resident #4's progress notes that indicated she was having frequent resident to resident incidents with other unidentified residents, Staff B stated Yes, it should have been identified. When asked if it was identified Staff B stated, No . When asked if the failure to thoroughly investigate the alleged verbal abuse contributed to staff not recognizing Resident #4's trendable behaviors, Staff B stated, possibly. RESIDENT #1 Resident #1 admitted to the facility on [DATE] for rehabilitation after abdominal surgery related [MEDICAL CONDITION]. According to the 11/20/19 admission note, the resident was .a/o (alert and oriented) X 4 (to person, place, time, and situation), Res(ident) states 'Has a little bit of memory loss since surgery/anesthesia.' There was no notice of this during conversation with res. Res is aware of surgeries past and present. She understands her limits and knows precautions to take to protect incision .Res was in good spirits when she arrived, laughing with staff and making jokes . Review of an incident report dated 11/21/19, showed that Resident #1 reported Resident #4 (roommate) made threatening comments and that Resident #1 did not feel safe around her roommate (Resident #4). According to the incident report, Staff F, Licensed Practical Nurse (and the nurse assigned to Resident #1 on 11/20/19) stated (Resident #1' said that (her) roommate was cursing and mumbling while in bed using the phrase You c*nt'. (Resident #1) stated she did not know if it was just part of her mumbling or directed toward her. The incident report did not include any follow up to Staff F's statement or give any indication what was done to resolve the situation when Resident #1 reported to Staff F on 11/20/19. The conclusion of the facility investigation stated Through the investigative process verbal abuse was unsubstantiated. The incident investigation did not: address Resident #1's recent history of similar resident to resident altercations with roommates (Resident #2); identify that it occurred at a similar time as the previous allegation (around 3:00 AM); address or explain how Resident #1 knew a resident had just passed away in her bed, if she was not informed by Resident #4, as she reported; or identify that the verbiage alleged such as you c*nt was the same phrase Staff F stated Resident #4 called her on the night of the incident. The incident investigation also failed to interview staff about their knowledge of Resident #4's behaviors. The incident report also indicated that Resident #1 had no psychological harm. During an interview on 12/03/19 at 11:05 AM, when asked how the facility, with the available information, determined that the allegation of verbal abuse was unsubstantiated, Staff A stated, We shouldn't have. When asked if he felt the investigation was thorough and accurate, Staff A stated No. RESIDENT #3 Review of the incident log revealed Resident #3 made allegations against Resident #4 cussing at him and his roommate had not been investigated. In an interview on 11/27/19 at 9:40 AM, when asked why Resident #3's allegations were not investigated, Staff B stated I don't know. When asked if they should have been investigated, Staff B stated, Yes. Staff B stated that the facility would investigate the allegations at this time. According to the 11/27/19 incident report, reviewed on 12/03/19 (initiated after conversation with surveyor) On Wednesday 11/27/19 (Resident #3) told a state surveyor that a female resident (Resident #4) calls him ?pervert?(sic) and cusses at him, and on Monday 11/25/19 he had been sitting in the dining room eating popcorn when she entered the dining room with arm raised and (Resident #3) thought she was going to hit him. (Resident #3) did not report this to anyone and then had forgotten about the incident until speaking to surveyor. The investigation stated spoke with (Resident #3 again today he states that there have (sic) been no further name calling or cursing at him. Abuse and neglect was ruled out. The investigation did not include any staff or resident interviews to determine if others were affected, or had knowledge of Resident #4's behaviors. During an interview on 12/03/19 at 11:05 AM, Staff A acknowledged that staff and resident interviews should have been conducted and were not. When asked if the allegation was thoroughly investigated, Staff A stated no. The facility's failure to thoroughly investigate allegations of verbal abuse, identify Resident #4's trenable and repeated verbal outbursts towards other residents, and implement interventions to prevent reoccurrence, resulted in further residents being subjected to verbal abuse and psychological harm to Resident #1. REFERENCE WAC 388-97-0640(6)(a)(b)

Based on observation, interview and record review, the facility failed to ensure three (#1, 2, 3) of five residents, and multiple unidentified residents, were free from verbal abuse. The facility failed to identify trendable behaviors and provide interventions to assure the safety of residents, and prevent resident to resident abuse. Staff's failure to adequately monitor Resident #4's verbally aggressive behavior and put interventions in place to protect other residents, resulted ongoing verbal abuse and psychological harm to Resident #1. Findings included . Refer to CFR: 483.12(c)(,[DATE]), F-610, Investigate/Prevent/Correct Alleged Violations RESIDENT #2 According to the [DATE] Quarterly Minimum Data Set (MDS, an assessment tool), Resident #2 was cognitively intact, had a life expectancy of less than three months and received hospice services for End Of Life care. According to the [DATE] discharge MDS, the resident passed away in the facility on [DATE]. Review of the facility Resident Incident Log (RIL) showed an [DATE] entry for a resident to resident incident between Resident #2 and Resident #4. According to the RIL, on [DATE] Resident #2 reported to Staff E, Licensed Practical Nurse, that Resident #4 (roommate) was cursing at her. According to Staff E's written statement, (Resident #2) reported to me that (Resident #4) called her a f*cking B*tch, (Resident #2) also stated that (Resident #4) called her the same name at 2:30 AM. Review of the investigation showed, the facility did not interview other residents to determine if other residents were affected by Resident #4's verbal outbursts. No staff interviews were conducted to determine if Resident #4 had a history of [REDACTED]. Additionally, the allegation of Resident #4 calling Resident #2 a f*cking B*tch at 2:30 AM was not addressed. The facility investigation did not conclude whether abuse occurred, however, the investigation suggested that the incident was a misunderstanding over a breakfast tray. Review of Resident #4's (alleged prerpetrator) record revealed the following: According to a [DATE] Significant Change in Condition Minimum Data Set (MDS, an assessment tool), Resident #4 had severe cognitive impairment, and demonstrated Verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) one to three days during the assessment period. According to the [DATE] Psychosocial Well-Being Care Area Assessment (CAA), Resident #4 .exhibited some periods of increased agitation with socially inappropriate behavior swearing and name calling. The plan was Staff will continue to monitor providing cues, redirection and opportunities for (Resident #4) to vent as needed. Record review on [DATE] showed the following progress notes: [DATE] 4:48 PM, Staff has reported some periods of increased agitation aeb (as evidenced by) swearing with difficulty redirecting resident. (Resident #4) does not recall periods of agitation; [DATE] 10:13 PM, Occasionally yells at staff ., [DATE] 10:13 PM, Resident on alert for increased behaviors/yelling at staff .; [DATE] 10:54 AM, Has behaviors at times swearing at staff .; [DATE] 11:03 AM, Met with (Resident #4) yesterday and today regarding reports of continued inappropriate statements .; [DATE] 1:37 PM, Has some behaviors with calling staff names and attempting to go into male rooms .; [DATE] 1:33 PM, Has some behaviors with calling staff names and attempting to go in male rooms; [DATE] 10:10 PM, Has occasional unpleasant words thrown at staff and co-residents .; and [DATE], Has some behaviors calling staff names and attempting to go in male rooms . On [DATE], facility staff were interviewed related to their knowledge of Resident #4's behavior/ verbal outbursts and cussing at others, with the following responses: On [DATE] at 4:38 AM, Staff G, Certified Nursing Assistant (CNA) stated, Ya a lot .a lot of f-words to us when we are giving care .I work nights so I don't see her (cuss at other residents) do that. On [DATE] at 4:44 AM, Staff H, CNA, Oh ya, she does it in the dining room it's disgusting .f-word, cursing . When asked who Resident #4 was directing it at Staff H stated, I don't know really. Staff H then stated that last week she came around the corner (in front of the nurses station) and said shut the f-up to a resident speaking with the maintenance director. On [DATE] at 5:53 AM, Staff J, Maintenance Director, denied recalling the above stated incident. When asked if he was aware of a history of Resident #4 cussing or swearing at staff or other residents Staff J stated, Oh ya. When asked if it was at staff or residents Staff J stated, Everybody. On [DATE] at 7:09 AM, Staff I, Restorative Aide, stated, (Resident #4) has an attitude and a mouth .she will say F-something or something negative .it could be (to) anybody. When asked if she does it to other residents Staff I stated, Yes. When asked how frequently this occurred Staff I stated, My observation is twice daily .we usually report the behavior .everybody knows it she (Resident #4) doesn't hide it. On [DATE] at 7:27 AM, Staff K, Licensed Practical Nurse, stated, (Resident #4) started talking and now she can say anything when it comes to her head, she just yells it out, when other residents are talking (in the hallway by the nurses station) she will (insert) herself in the conversation, she cusses at them sometimes or says I don't like you go away .its loud. When asked to clarify if Resident #4 cusses at staff or other residents Staff K stated, Both. When asked how often this occurred Staff K stated, I'm on the other side (works on the other end of the hall) she will come down here by the nurses station and I will hear her cussing, so three times a day in eight hours .it may be more but I work on the other side and that is what I hear. Staff K went on to state when these events occur I go approach (Resident #4) and ask her if she wants coffee and take her away from other residents so they (other residents) don't get agitated and argue because they will call names back .if she says F-this they might say it back. On [DATE] at 7:48 AM, Staff E, Licensed Practical Nurse (and the nurse who reported the alleged incident), stated, Oh Ya always, she has called me a F-ing B*tch many, many times, she is always swearing at everyone. When asked how often this occurred Staff [NAME] stated, Everyday, many times a day . When asked if she only cussed at staff, Staff [NAME] stated, No the residents too, most residents just walk away or we (staff) try to mover her to get it deescalated . Staff [NAME] then stated, Her (former) roommate (Resident #2) was dying and she called her a [***] everyday, I reported it to hospice and to social work (Staff D) at least three times in one week .) Staff [NAME] indicated Resident #2 was offered a room change but (Resident #2) stated 'I will just put up with it.'. Despite multiple facility staff members awareness of Resident #4's agitation and trendable verbal abuse/profanity toward staff and other residents, the facility failed to identify or address this in the investigation. Additionally, the co-residents who had occasional unpleasant words thrown at them, were never identified or interviewed as to what Resident #4 said to them, or what effect, if any, it had on them. RESIDENT #1 A [DATE] 12:23 PM nurses note stated, The resident reported this AM that her roommate was saying disturbing things during the noc (night). When asked what kind of things were said & (sic) she (Resident #1) stated that her roommate told her that the person in that bed (Resident #4) had died and she (Resident #1) didn't deserve to live, (Resident #4) told her that she was going to kill her, & she (Resident #4) was going to come over to ther and put a pillow over her head . Review of the [DATE] incident report showed an attached [DATE] interview with Resident #1. According to this document, Resident #1 reported when she and her roommate were in bed, Resident #4 (roommate) began mumbling and occasionally she was able to understand a few words and most of them were profanity. Resident #1 said that at first she was not concerned, but as the evening went on, she began to feel the comments were aimed at her. When asked if she felt safe in the facility, Resident #1 stated that if she had to stay in the same room with her current roommate, then the answer was no, but otherwise, yes, she felt safe. Resident #4 was then offered and accepted a room change. In an interview on [DATE] at 4:26 AM, when asked if Resident #4 had a history of [REDACTED]. me you b*tch; later when I was trying to give her meds (medications) she called me a c*nt.' During an interview on [DATE] at 2:07 PM, Resident #1 stated, (Resident #4) was cussing and mumbling and at first I was not sure if it was directed at me, but during the night she started saying the person in my bed had died and that I didn't deserve to live and that she (Resident #4) was going to put a pillow over my head and kill me .when I got here I couldn't walk or defend myself, everyone had to hear her but no one came, at 3:30 AM. I am exhausted and I am getting scared, I started to nod off and she was still saying 'You just wait b*tch,' I have never felt so threatened and helpless. I waited until morning and told (Staff F) I think. Ten minutes ago, (Resident #4) came to my room and kicked over that sign (motion to the door). A wet floor sign was observed at the threshold of Resident #1's door. She (Resident #4) was never supposed to approach me again, she was supposed to be watched .those 12 hours (as Resident #4's roommate) I have never felt so violated, I was scared .how many times does she get to threaten people .I trusted them (staff) but she is still coming in, so I am living it all over again .I want to go home even though I need help (therapy to get stronger) for my safety. She (Resident #4) told me I need to be out of my misery and I believe her .I can't believe this is the first time (Resident #4 had threatened people) .they can't tell me that . According to a [DATE] incident report, Resident #4 did knock over the wet floor sign in Resident #1's doorway as alleged. During an interview on [DATE] at 4:26 AM, Staff F stated that she stopped by to see Resident #1 on [DATE] after she heard what happened. When asked if Resident #1 was scared, Staff F stated, Ya, well very anxious. During an interview on [DATE] at 7:48 AM, Staff [NAME] stated, I took care of (Resident #1) .that lady was really scared and frightened, every time I opened the door, she was jumpy, I took care of her the day after (the incident). Record review on [DATE] showed that Resident #1 left the faciity on [DATE] as she did not feel safe and felt the facility did not appropriately address the abuse. The [DATE] incident report tated, Social services conducted resident interviews with residents throughout the facillity & all were without findings. Review of the resident interviews revealed an [DATE] interview with Resident #3 when the resident was asked Have you had another resident curse at you? Resident #3 responded she is always telling people to f*ck off. The lady in room [ROOM NUMBER] (Resident #4). Review of the incident report showed that the allegation was not followed up on. RESIDENT #3 During an interview on [DATE] at 7:27 AM, when asked about his interactions with Resident #4, Resident #3 stated, she is constantly cussing at me (saying) you're a f*cking pervert .me and my roommate are like brothers we have a strong bond .so we are together a lot and she calls us perverts . Resident #3 went on to say the night before last we were in the dining room by the popcorn machine, the lady (Resident #4) came at me with her hand up, like she was gonna hit me .she can't go fast so I had time to get out of the way, let's see today is Wednesday, so that was Monday. When asked if he reported the incident, Resident #3 stated, No. When asked if Resident #4 cussing at him bothered him Resident #3 stated, Yes, why would you want to be called a pervert everyday .it's about time this got out in the open, the lady is not a nice lady. In a follow up interview with Resident #3 on [DATE] at 8:20 AM, Resident #3 reported, last night she (Resident #4) called me a f*cking pervert again .the one to one was with her (reference to staff closely supervising Resident #4) .it was before dinner about 5ish. REFERENCE WAC: [DATE] (1)

Based on interview and record review, the facility failed to ensure that staff recognized vital sign changes were significant, and failed to ensure the resident received timely action for worsening changes in respiratory status, for one (Resident #1) of four sampled residents reviewed for care and services. These failures resulted in a delay in receiving further evaluation and treatment in a time consistent with the resident's needs, and subsequent hospitalization . Findings included . Review of the facility 2014 Fall Care Path showed staff were to notify the Medical Doctor (MD) if a resident's respiratory rate is more than 28/min. During an interview on 11/18/19 at 1:18 PM, Staff D, Licensed Nurse Unit Manager stated that Neuro checks were done to assess if there was a possible head injury to the portion of the brain that regulates Blood Pressure (BP), Heart Rate (HR), Respiratory Rate (RR). Staff D stated that the MD should be notified if the vital signs were outside of the resident's baseline. During an interiew on 11/18/19 at 12:40 PM, Staff E, Licensed Practical Nurse (LPN) stated that she would notify the MD immediately when a resident's vital signs were out of range, for example, BP going up or down, RR greater than 22 respirations per minute (rpm) and breathing hard. During an interiew on 11/18/19 at 2:45 PM, Staff F, Registered Nurse (RN) stated that she would be concerned of any RR greater than 21 and notify the MD if it became too fast or too slow, mid 20s or 30s rpm. RESIDENT #1 Resident #1 was a long term resident in the facility. According to the Annual Minimum Data Set (MDS - an assessment tool) dated 08/30/19, Resident #1 was assessed with [REDACTED]. Resident #1 was dependent on staff for care and received nutrition through a feeding tube. Review of Resident #1's Care Plan (CP) dated 05/31/19 showed, the resident had a Health Care Agent/Guardian who assisted with decision making. Review of the Physician order [REDACTED]. Further review of the CP showed the resident required tube feeding related to dysphasia/swallowing problem, and listed interventions of listening to lung sounds, Monitor/Document/Report PRN (as needed) any signs or symptoms of Aspiration including fever, shortness of breath, abnormal breath/lung sounds, and nausea/vomiting. Review of progress notes showed on 09/16/19 around 2:40 PM, Resident #1 was found on the floor, on the fall mat next to the bed. The resident was assessed with [REDACTED]. Neurological Assessments were initiated according to facility protocol. Resident #1's vital signs recorded at 3:00 PM, were: blood pressure (BP) of 118/72; Pulse 78 beats per minute (bpm); Respirations of 24 respirations per minute (rpm); and temperature (T) of 97.8 degrees Fahrenheit (dF). Review of the Neurological Assessment (Neuro checks) Flow Sheet dated 09/16/19 showed that the resident's respirations continued above 24 rpm, at 3:30 PM, were 29 rpm, at 4:00 PM, were 32 rpm, at at 6:00 PM, were 36 rpm. In addition, at 5:00 PM, Resident #1's BP had risen to 143/83. By 6:00 PM, the resident was assessed with [REDACTED]. At 7:00 PM, the resident's temperature was 100 dF, pulse 97 bpm and respirations remained high at 29 rpm. Record review showed at 8:00 p.m. Staff C, RN, administered Resident #1 a bolus tube feeding. Resident #1 vomited at 8:30 PM. The Resident's vital signs at the time of vomiting were BP 188/110, P 103, R 36. Ten minutes after vomiting the resident's BP was 138/82, P 98, RR 38. Staff C administered an antiemetic at 8:39 PM, and then called the MD. During an interview on 09/24/19 at 2:35 PM, Staff C stated that he called the on call service, gave the operator the resident's vital signs to relay to the practitioner and was waiting for a call back. During an interview on 11/14/19 at 10:29 AM, Resident #1's Guardian stated that she was at the facility on 09/16/19 at 4:00 PM, and Resident #1 was breathing heavy. Resident #1's Guardian stated that she had asked the staff for two hours to call 911 and the nurse refused. At 8:00 PM, Resident #1 was breathing like a small dog, was sweating, I told the nurse please call 911. The nurse said I could call 911, but he wouldn't call until he heard from the manager. Despite the resident being assessed as at risk for aspiration, at no point did nursing staff perform a lung assessment to ascertain abnormal lung sounds. Review of the 09/16/19 9:31 PM Progress Note written by Staff C, showed that while awaiting a callback with further instructions, the resident's wife was worried about when it was appropriate to send the resident to the hospital, and wanted to call 911, so I told her she was welcome to call 911 while I was awaiting further instructions callback from the oncall provider. The on call provider called back with recommendations to send the resident to the ER if respirations were still above 23. During an interview on 09/24/19 at 2:35 PM, Staff C stated that the provider called back when the medics were in the facility. At the hospital, Resident #1 was diagnosed with [REDACTED]. Review of Valley Com 911 dispatch dated 09/16/19 showed that Resident #1's Guardian called 911 at 8:59 PM, and the ambulance was on the scene at 9:06 PM. During an interview on 11/18/19 at 3:11 PM, Staff B, Director of Nursing stated that if a resident, and/or resident representative requests to go to the hospital, the nurse on duty should send them out. Staff B reviewed the 09/16/19 Neurological Assessment Flow Sheet, noted the high respiratory rate and stated that Staff C should have called the practitioner earlier. Refer to WAC 388-97-1060(1)

Based on observation, interview, and record review it was determined the facility failed to ensure residents were safe when smoking. Failure to perform accurate, thorough assessments, and/or initiate care plans, and/or implement interventions including safety devices, and/or provide adequate supervision when residents smoked, placed nine of nine residents identified by the facility as smokers (#s 125, 72, 44, 111, 28, 64, 43, 124 & 101) at risk for harm related to smoking related injury and/or incidents. An immediate jeopardy was called related to Resident #s 125 and 72 on 09/15/16 and removed on 09/19/16. Additionally, facility staff failed to thoroughly analyze, identify, and ameliorate contributing factors for falls for four (#s 125, 64, 31 & 28) of five residents reviewed for falls. Findings include: The Facility Supervised Smoking Policy, dated 10/15, indicated, Residents will not be allowed to borrow cigarettes or other smoking materials from other residents. ALL smoking materials, including cigarettes, electronic cigarettes and lighters will be kept in a locked drawer in the resident's room. This policy further indicated, Cigarettes and other smoking materials will be disposed of in these (non combustible) containers and not discarded elsewhere on grounds. This policy also indicated residents will be reassessed on at least a quarterly basis or more frequently as dictated by any significant changes in condition . RESIDENT #125 Resident #125 admitted to the facility on [DATE]. According to the 08/26/16 Minimum Data Set (MDS), the resident had [DIAGNOSES REDACTED]. This MDS also assessed the resident to have impaired vision and required one person extensive physical assistance for locomotion off the unit. Review of physician's orders [REDACTED]. According to a smoking evaluation dated 08/21/16, staff determined the resident had independent cognitive skills and adequate memory recall, knew how smoking materials were to be stored, could exhibit proper storage of smoking materials, could safely light, hold and extinguish smoking materials, and had personal belongings that were free from burn holes. While staff did identify on the assessment the resident had a history of [REDACTED]. The resident was determined to have physical limitations, decreased sensation, and neurological deficits that prohibited safe smoking and determined the resident required supervision with smoking because the resident required assistance with oxygen immediately after smoking related to significant respiratory disease. Staff documented the resident, needs to have supervision so that oxygen can be applied right away after smoking, resident easy to SOB (Shortness of breath) after smoking. There was no indication facility staff considered the resident's medication regime and how the sedating effects of these medications impacted the resident's ability to smoke safely. According to the resident's Supervised smoking Care Plan (CP) dated 08/28/16, there was a stated goal of will have no complications related to smoking through next review date. Interventions included, CNA (Certified Nursing Assistant) to observe resident during smoking, timer provided to resident to monitor time during smoking, CNA to assist resident to the smoking area & observe res(ident) while smoking. Resident to turn off the oxygen while at the door to the smoking area. CNA to place oxygen in the portable carrier. Resident is to leave the oxygen in the facility at the door. Resident to smoke for no longer than 5 minutes, 20 feet away from the door. Resident to turn on the oxygen . All smoking materials are locked in the nurses cart. physician's orders [REDACTED]. LNs (Licensed Nurses) to transfer 02 (oxygen) cylinder . There was no indication facility staff identified or clarified the disparity between the CP and POs regarding who was responsible for transferring the oxygen cylinder. Progress notes dated 08/19/16 reflected, valium . given around (6:00 p.m.) but night time dose held because sedation noted. On 08/22/16 staff wrote, Resident was not able to shut down her oxygen by herself or turn it back on. resident continues on valium . (four times a day). On 08/23/16 staff documented, Valium . given around (6:00 p.m.) but night time dose held because sedation noted. A progress note on 08/31/16 indicated, hold valium because resident was sleeping most of the shift . Despite staff awareness, there was no indication staff considered sedation's potential impact on the resident's ability to safely smoke. According to notes dated 08/23/16, the resident's physician documented, She wants to smoke cigarettes just twice a day. Staff states she is keeping tobacco with her prednisone bottle. Despite awareness the resident kept tobacco with her, there was no indication facility staff assessed what type of tobacco (cigarette, loose tobacco, smoked cigarette) the resident kept or considered the significance of keeping smoking paraphernalia when the facility had assessed it was to be stored in the nurse's cart. A progress note dated 09/06/16 revealed, resident alert with base line confusion, up and down from w/c (wheelchair), taking oxygen off repeatedly . resident was offered her PRN (as needed) Roxinol (narcotic) with good effect, resident out to smoke x once this shift, resident noted trying to light a lighter in the building while still wearing oxygen. Lighter was dead and could not spark. Resident warned that lighting the lighter in the building and or with the oxygen on could terminate her smoking privileges. Smoking material secured in med cart. continue with plan of care. There was no indication staff attempted to determine why the resident had a lighter in her possession when, according to the CP, the resident's smoking materials were to be stored in the nurse's cart. On 09/06/16 staff documented, Room smelled of cigarettes smoke. Resident denies smoking in her room. Resident's lighter in nursing cart for safekeeping and resident had agreed to this. There was no indication staff verified there were no smoking materials in the resident's room prior to this, despite assessments and care plans that indicated they were to be stored in the nurse's cart all along. In an interview on 09/20/16 at 9:03 a.m. Staff B (Director of Nursing) indicated that the 09/06/16 progress notes regarding the resident's lighter use and the smell of smoke in the resident's room warranted further investigation, to include determining why the resident had a lighter, and to ensure the resident did not have smoking materials in the room. No such investigation took place. According to the resident's In Room Care Plan (IRCP) dated 09/06/16, staff were directed to, Remind resident to ask for assistance when going for smoking and CNA to take resident to smoking area and observe resident while smoking. Resident provided with timer to monitor time during smoking. While CNAs were directed to observe the resident smoking, there were no details provided, such as who was to light the resident's cigarettes or how to ensure safe disposal of smoking material. Observation on 09/13/16 at 9:10 a.m. revealed Resident #125 sitting at the edge of her bed eating breakfast. An unsmoked cigarette was noted on the resident's bedside stand. In an interview on 09/13/16 at 11:29 a.m., Staff D (Resident Care Manager-RCM) reported Resident #125 had multiple falls in the last 30 days and that one resulted in a fractured arm. On 09/14/16 at 1:48 p.m. Staff Y brought Resident #125 out to the smoking area. Staff Y said she needed a light and retrieved a lighter from Resident #43. After Resident #125's cigarette was lit, Staff Y gave Resident #43 the lighter back. In an interview on 09/14/16 at 1:51 p.m. Staff Y said he was providing supervised smoking for Resident #125. When asked if there were designated smoking times, Staff Y said I think like 7:00 a.m., 9:00 a.m., 1:30 p.m. 5:00 p.m. and 9:00 p.m. Staff Y said the doctor only wanted Resident #125 out here twice a day and she's agreed to that. Staff Y said Resident #125 was on supervised smoking related to poor safety awareness and oxygen use. We have a roller rack we keep inside the door. The oxygen is stored on the rack just inside the building so we can get her back on it. At 1:57 p.m. Staff Y propelled Resident #125 back inside and reapplied her oxygen. Observation on 09/15/16 at 11:22 a.m. revealed Staff H (CNA) brought Resident #125, in a wheelchair, out to the smoking area. Staff H was noted to push Resident #125 up to Resident #101 and request that he light Resident #125's cigarette, which he did. Staff H then pushed Resident #125 under the tent area and provided the resident with a safety ashtray. At 11:25 a.m. Resident #125 was noted to smoke half the cigarette, tap the cigarette on the side of the ashtray, then place the partially smoked cigarette into her pocket. While Staff H informed the resident the cigarette should be disposed of in the ashtray, the resident replied, I can use it later. Staff H said, Oh, so you gonna use it later? and took the resident back into the building and proceeded to reconnect the resident's oxygen. At no time did the staff member insist on safely disposing of the cigarette, nor did staff attempt to establish the cigarette was completely extinguished prior to or after the resident placed the cigarette in her pocket. Observation on 09/15/16 at 1:31 p.m. revealed the resident's purse had two burn holes in it (approx .5 to 1 centimeter). In the resident's purse was a pill bottle labeled for prednisone but that contained a partially smoked cigarette. Observation on 09/15/16 at 3:35 p.m. revealed Staff D had removed a glass pipe, partially smoked cigarettes and a cigarette roller from the resident's room. STAFF INTERVIEWS Review of the 09/15/16 smoking schedule revealed CNAs were assigned to provide supervised smoking: Staff T at 5:00 p.m. and Staff Q at 9:00 p.m. In an interview on 09/15/16 at 2:13 p.m. when asked what training was provided regarding smoking supervision, Staff T replied, Some residents with oxygen, put oxygen inside. The oxygen and fire 20 feet away. When asked if she had to supervise any residents, Staff T replied, No. My second day working by myself. On 09/15/16 at 2:16 p.m. when asked about training received, Staff Q said I had training six month ago. When we go there, have to stand there, put apron on residents, gloves for us to handle, sanitizer to clean the kit and cart. If they have oxygen we take if off, not supposed to bring them and smoke at the same time, fire hazard. Staff Q said the lighters were kept at the nurse's station. On 09/15/16 at 2:05 p.m. when asked about smoking, Staff R said the staff were to leave 02 (oxygen) tank here, push (resident) to smoking area . If not independent we have to light their cigarette, keep lighter with us, stay there and give lighter to the nurse. On 09/15/16 at 2:07 p.m. Staff S said put 02 over there (pointing inside by door), take (resident) outside, stay and bring back. Regarding Resident #125, Staff S said I don't light her cigarette, the resident lights it. The resident has the lighter. I stay 20 feet away. On 09/15/16 at 2:20 p.m. Staff O was observed going around talking to staff. When questioned, Staff O said she was training staff on supervised smoking. When asked what the training consisted of, Staff O said not allowed to share smoking materials, supervised smokers have to have supplies locked up in med cart, no oxygen in the smoking area. so far that's it. In an interview on 09/15/16 at 2:03 p.m., Staff J (CNA) stated she had worked at the facility for one and a half years, had never supervised smoking but, tomorrow I will. When asked what training she had received regarding how to safely supervise smoking, Staff J stated, Training, we need to watch if they have oxygen and if they have a hole (in the clothes) we need to report . When asked who lit the cigarettes, Staff J replied, I don't know, the lady in (a specific room) always wants to go out to smoke, we have a schedule. When asked where resident's smoking supplies were kept, Staff J stated, I need to ask the nurse. In an interview on 09/15/16 at 2:06 p.m., Staff I (CNA) stated he had worked at the facility three months and had supervised smoking only once. Staff I stated, I only push the resident if they need to (have) assist. I am usually too busy to wait on them cuz there are call lights (that need to be answered). Staff I indicated he had received training to, Make sure if there is oxygen to turn it off because that is hazardous . that's pretty much it. When asked Who lights Resident #125's cigarette, Staff I stated, She (the resident) does. Additionally, observation on 09/21/16 at 9:32 revealed Staff G (CNA) removed Resident #125's oxygen and proceed to assist the resident with lighting a cigarette at 9:33 a.m., less than the required five minutes after removal of oxygen. At 9:39 a.m., Staff G assisted the resident back into the building and reapplied the resident's oxygen tubing and turned on the oxygen. The facility failed to have a system by which staff were knowledgeable about what constituted supervised smoking and failed to ensure staff implemented facility policies regarding supervised smoking, including the extinguishing and disposal of cigarettes. RESIDENT #72 Resident #72 admitted to the facility on [DATE]. According to the 07/22/16 MDS, the resident had multiple complex medical conditions and was assessed to use tobacco. According to a 06/01/16 CP, the resident has been assessed to be able to smoke independently and propel wheel chair to and from the smoking area. On 06/21/16 staff documented, This RCM went to do smoking assessment and teaching about leaving oxygen in the facility during smoking. Resident stated, 'I quit long time ago and I do not carry oxygen tank on wheelchair.' A progress note dated 06/23/16 indicated resident is educated about the risks of carrying oxygen while smoking. Resident signed the risk and benefits form regarding above mention statement. According to the resident's current POs, the resident received the following medications with listed side effects: Celexa (somnolence, dizziness, impaired concentration, insomnia), Doxepin (drowsiness, dizziness, confusion), as needed Ultram (dizziness, vertigo, somnolence, confusion) and as needed oxycodone (sedation, somnolence, clouded sensorium, dizziness) which the resident received up to four times a day. Additionally, the resident received melatonin, a medication to enhance sleep. A smoking evaluation dated 07/20/16 indicated the resident had no neurological deficits that would prohibit smoking and determined the resident could smoke independently without supervision. Staff did not consider the resident's medication regime as having any potential impact on the resident's ability to safely smoke. A 07/25/16 note reflected, This writer explained to the resident the risk of using electric wheelchair while taking opiods . Resident also asked not to sleep in electric wheelchair. Resident encouraged to take nap in recliner during day . A progress note of 08/10/16 revealed, Patient falling asleep during the day and falling . Currently, patient sitting in a chair nodding off to sleep in the hallway. Similar instances of the resident sleeping during the day in his wheelchair were identified in an 08/24/16 progress note. On 09/14/16 at 1:40 p.m. Resident #72 was observed smoking a cigar independently in the facility designated smoking area, without staff present. Resident #72 was observed to intermittently doze off while smoking. When asleep, the resident's mouth would open slightly, but the cigar stayed in place. At 1:42 p.m. Resident #72 twitched, woke up, took a drag and, noting the cigar had gone out, re-lit the cigar. At 1:45 p.m. Resident #72 again fell asleep while smoking and woke up coughing. At 1:57 p.m. Resident #72 was observed with ashes on the foot rests of his wheelchair. In an interview on 09/14/16 at 2:07 p.m. Resident #72 indicated he did not sleep well at night. He acknowledged that he falls asleep while smoking and said he occasionally dropped his cigar on the ground. Observation on 09/15/16 at 11:54 a.m. revealed Resident #72 had a moderate amount of ash debris on the seat cushion of his wheelchair and copious amounts of loose tobacco noted on the foot rest. The resident again confirmed that he falls asleep sometimes during the day stating, I'll be doing a puzzle and fall asleep for maybe five or 10 minutes, not for long. A subsequent smoking assessment performed on 09/15/16 identified a sleeping disorder and alcohol abuse as potential [DIAGNOSES REDACTED]. Staff also identified the resident could not safely light, hold and extinguish smoking materials and identified the resident required supervision. A 09/16/16 Resident Smoking Inservice directed staff to see smoking list and/or CP for individual specifics. The attached smoking list indicated Resident #72 was deemed a supervised smoker and must be offered an apron, can keep smoking supplies locked up. The attached IRCP dated 09/15/16 did not indicate whether or not the resident was a smoker, but did instruct staff that Resident need supervision when out in smoking area and smoking material locked with nurses. Under special instructions was Resident must be offered apron and keep smoking supplies locked. On 09/19/16 at 1:01 p.m. Resident #72 was observed in the designated smoking area asleep in his electric wheelchair. The resident was not smoking. No smoking apron was observed on the resident or in the designated smoking area. On 09/19/16 at 1:01 p.m. Staff N was observed seated outside across from the designated smoking area. Staff N said he was scheduled to sit there and observe smoking from 6:45 a.m. to 1:30 p.m. Staff N said the nurse was to bring the resident's cigarettes at the designated smoking time of 1:30 p.m. Staff U arrived and said she was hired to sit outside and observe the smoking area from 1:30 p.m. to 9:00 p.m. On 09/19/16 at 1:35 p.m. Resident #72 was observed outside without any smoking supplies. According to Resident #64, also in the designated smoking area, the nurse had not yet been out. In an interview at that time, Staff U said she had been hired that day to watch them, and was on orientation. Staff U said she had been instructed to watch that they don't share cigarettes, that they use the ashtray, that they don't take oxygen outside. If they are sleeping, I have to wake them. I have to help them to open the door for them. In an interview on 09/21/16 at 12:31 p.m. Staff B was asked about a smoking apron for Resident #72 and said He doesn't smoke. When questioned, Staff B replied I'll get back to you. In an interview on 09/21/16 at 1:20 p.m., Staff B was asked if, based on the In Room Care Plan, the resident was assessed to require the smoking apron, or if it was to be used at the resident's discretion. Staff B indicated she would clarify this issue. Staff B was asked to provide evidence the facility had smoking aprons. No smoking aprons were provided. RESIDENT #44 Resident #44 was a long term care resident, admitted in 2014. According to the 10/15 Supervised Smoking Policy, Independent Smoking times are from 5:30 a.m. until 10 p.m. For the safety of all residents and staff the smoking area is closed at 10 p.m.; non compliance with this is considered unsafe behavior and and will result in loss of smoking privileges. According to the 05/20/16 MDS, the resident had moderately impaired vision. A mental status interview could not be conducted as the resident was rarely understood. According to the 08/10/16 MDS, the resident was interviewed and assessed with [REDACTED]. According to the 05/12/15 Tobacco Dependence CP, the resident expressed a desire to smoke. Verbally states that he understands the policy. Unable to sign due to poor vision. Agreement placed in chart. The listed goal was Resident will comply with facility smoking policy through next review with a goal date of 11/16/16. Approaches included may smoke independently, resident educated on usage and location of safety equipment in the designated smoking area, provide smoking policy to resident, Staff to continue to reinforce smoking policy as well as safety of resident, Staff will continue to monitor for compliance of smoking policy throughout resident stay and Update smoking evaluation as needed to reflect resident's smoking ability. Review of the resident's record revealed a 05/29/15 progress note that on 05/27/15 it was reported there was a burn hole in Resident #44's clothing. He was unwilling to allow us to inspect his clothing due to the fact that he was holding marijuana and alcohol, which is against facility policy. He was then placed on supervised smoking for safety. LN was able to inspect clothing last noc (night) for burn holes and none were found. He has been observed smoking safely since then . (Resident #44) may now smoke independently according to his assessment. However, he has been spoken to regarding drinking alcohol and using marijuana on the premises without the proper documentation. On 06/08/15 a progress note revealed resident smokes, non compliant to facility policy and procedure. Continue to monitor. Resident appeared to smell of pot, and affected appear to reflect that of being stoned. MS Contin held. MD notified . will continue to monitor . On 03/22/16 a progress note revealed the resident refused to sign the facility smoking agreement; stating that he is unable to see to sign anything. A 06/22/16 progress note indicated This SSC went to this resident's room to speak with him in regards to the smoking policy. This SSC went over the smoking policy with this resident and he stated I'm not signing a damn thing, I will smoke when the hell I want to. This SSC informed the resident that if he violates the smoking policy his privileges will be taken away. This resident stated I will still smoke now get the hell out of my room. On 07/02/16 a progress note indicated 0430 observed resident in a hallway heading out to smoke, this writer reminded resident that the doors are still locked down and will be opened at 0530 for security purposes for the building and everyone in the building per policy, resident yelling and cursing replied, I don't give a[***] I am going to smoke anyway. Explained consequences that resident breaking the policy will lose smoking privileges, resident shouted, I don't give a damn. He propelled himself in a wheelchair and went out. Checked on resident with a NOC CNA outside for his safety and reapproached 15 minutes after, resident refused to come back inside the building stating I'm fine. Review of the Annual, and most recent Smoking Evaluation dated 05/23/16 revealed Resident #44 was assessed with [REDACTED]. The resident was assessed as able to smoke independently without supervision and/or adaptive devices. The assessment failed to identify the resident's cognitive impairments, visual impairments and prior history of smoking related incidents. Throughout the survey, outside in the designated smoking area a sign was posted notifying all that Cigarette butts MUST be disposed of in the smoking trees or the white trash can only. A white trash can was observed with a step lid closer. On 09/14/16 at 1:36 p.m. Resident #44 was observed smoking without staff supervision in the facility designated smoking area. Resident #44 was observed to have his cigarettes and lighter on his person. When finished smoking, Resident #44 was observed to hand the lit cigarette to Resident #64 who disposed of the butt in an ashtray. On 09/15/16 at 2:10 p.m. Resident #44 was observed outside in smoking area without staff supervision. On 09/15/16 at 5:00 p.m. the facility provided a 09/15/16 Smoking Evaluation for Resident #44. Although the evaluation listed Vision patterns - adequately or slightly impaired? the facility staff failed to answer that portion of the form. The facility staff also failed to conduct a medication review for medications that may induce drowsiness or impaired judgement. The evaluation indicated the resident was able to safely extinguish smoking materials, had a history free of smoking related incidents and indicated the resident observed state and facility smoking regulations/policies regarding smoking. The facility staff assessed the resident as safe to smoke independently, without supervision and maintain smoking materials in a locked drawer. In an interview on 09/15/16 at 5:26 p.m. when asked how it was determined the resident could safely extinguish, Staff B said I have watched him smoke a couple of times and he is safe to smoke independently. A 09/16/16 Resident Smoking Inservice document instructed staff to Please see smoking list and/or care plan for individual specifics. The attached smoking list indicated Resident #44 was a supervised smoker and must be offered an apron, can keep smoking supplies locked up. An IRCP for Resident #44 dated 09/16/16 indicated the resident was an independent smoker, and instructed staff Resident must be offered apron during smoking. On 09/20/16 at 9:53 a.m. Staff N was observed seated outside in the smoking area. Resident #44 was observed seated by the tall safety ashtray without a smoking apron. The resident was observed to smoke holding the cigarette over his lap/chest, occasionally flicking the ash off to the side onto the cement. When finished, ashes were observed to fall on his lap as Resident #44 moved the cigarette butt from his right to his left hand to dispose of it in the ashtray. At 10:02 a.m. Staff O and P entered the smoking area to smoke. Staff P brushed ashes off Resident #44's coat and said You need a wet cloth to wipe it down. Staff O was observed to brush off the ashes that had fallen onto the Resident #44's wheelchair pad between his legs. In an interview on 09/21/16 at 12:31 p.m. Staff B said We did offer an apron. We did a risk and benefit because he refused. When asked if the resident had been assessed to require the smoking apron, Staff B said I'd have to go back to the documentation. When asked where the smoking aprons were located, Staff B did not know and said I'll come back to you with the answer. RESIDENT #111 Resident #111 admitted [DATE]. According to the 05/13/16 and 08/04/16 MDS assessments, the resident was cognitively intact, had [DIAGNOSES REDACTED]. According to the 08/04/16 MDS, the resident received anti-depressant medications daily during the observation period. Record review revealed on 05/06/16 the new admit smoking assessment included [DIAGNOSES REDACTED]. Under the question Neurological deficits prohibit safe smoking? staff replied, no. and indicated the resident was assessed to smoke independently without supervision. According to the 06/06/16 CP, the Resident currently uses tobacco. Able to ambulate independently or with walker to and from smoking area without assistance. The listed goal was Resident will safely smoke, use chewing tobacco. The approach listed was Explain to resident where designated smoking areas are located. Remind as needed. According to the 08/16/16 CP, the resident received the anti-depressant Trazodone to treat sleeplessness. The 05/19/16 Psychotropic Drug Use CP directed staff to observe for and report common adverse side effects including but not limited to sedation, drowsiness, blurred vision, muscle tremor. The 05/19/16 Alteration in Health Maintenance CP directed staff to Observe for seizure activity and protect resident from injury during seizure activity, do not move if unavoidable, remove items around that can injure resident. A 05/11/16 alteration in mobility/safety/fall risk CP identified issues related to weakness, balance deficits, impaired vision, ataxia, pain issues, progression of [DIAGNOSES REDACTED], psych med use and currently smokes cigarettes. Resident with falls in facility related to seizure disorder. One listed goal was Resident will safely smoke cigarettes as evidenced by no injuries related to smoking through next review. Approaches listed included Resident is Independent smoker: remind of smoking times and to keep material secured on person or in locked drawer when not in use. According to progress notes, on 05/22/16 the resident was ambulating with walker, paused to read the lunch menu in the hall and was noted falling over to his left landing on his shoulder. Resident started seizing once on the ground. The seizure was noted to last three minutes. Assisted into wheelchair and taken to room to lay down. Resident started to seize again while being transferred. Elapsed time of eight minutes between seizures. second episode lasted five minutes. The resident was not following commends, thrashing when attempts were made to take blood pressure. Resident shoving staff away so he could stand once standing he would lose his balance and start to fall, staff guided resident back onto bed. Received orders to send out to emergency room for evaluation and treat related to no as needed medications available for acute seizure situations. According to a 06/16/16 progress note, around 5:00 p.m. a resident came into the nurse's station and told the nurse that Resident #111 had a seizure outside. The nurse and one CNA went outside, found the resident lying on the pavement. This LN stayed with resident while CNA called for help. Once enough staff were assembled, assisted resident into a wheelchair and took resident back to his room. Resident had a skin tear on right knuckles and abrasions on forehead. Around 9:00 p.m. the resident had a second seizure. CNA passing by and saw resident starting to have seizure and yelled out for help. The LN and other LN went into the room and found resident was on the floor. Assisted resident back to bed. According to a 06/24/16 progress note, around 5:30 p.m. CNA reported to the LN that resident was having seizure for less than a minute in the dining room while sitting on his chair. According to a 07/04/16 progress note, around 6:30 p.m. a resident informed the nurse that Resident #111 had a seizure outside in the smoking area. When the nurses arrived the resident was sitting on the chair and breathing deeply. Other residents who spotted seizure said the resident had jerking movements about a minute sitting on the chair. After two minutes recovering and resting, resident finally can answer questions. Resident stated he was fine and sustained no injury. According to a 08/13/16 evening shift progress note, twice the resident had seizure activity lasting less than one minute during the shift. The nurse administered the psychoactive medication, Ativan as ordered for seizure activity. The most current Smoking Evaluation, dated 05/19/16, did not incl

Based on observation, interview, and record review the facility failed, for three of four residents, (#1, #2 & #3), assessed for falls, to ensure residents were assessed for risk of falls and or devices, ensure the resident's environment was safe and staff were provided with adequate supervision to ensure fall prevention interventions were implemented to prevent accidents and/or injury. These failed practices resulted in harm to Resident #1 who sustained a head injury during an avoidable fall and placed other residents at risk for falls and injury. Findings included: RESIDENT #1 According to the 5/18/13 Minimum Data Set (MDS), Resident #1 had [DIAGNOSES REDACTED]. Resident #1 scored fifteen out of fifteen on the Brief Interview for Mental Status portion of the MDS indicating the resident was able to make their own decisions. Resident #1 said in an interview on 05/24/13 at 11:05 a.m., "I fell . I tried to get out of bed and slid out." The Resident identified a six to eight inch semi-circular laceration on the top front of the resident's head, held together with staples. Resident #1 continued, "My (roommate) said stop but I couldn't get my feet back on the bed." The Low Air Loss Mattress upon which the resident was lying was 41 inches from the floor and did not included bolsters. According to manufacturer's definitions, the Low Air Loss Mattress is used to assist in prevention and treatment of [REDACTED]. The material used in construction of the mattress is reinforced nylon and can be slippery. According to 03/27/13 Care Area Assessment (CAA), Resident #1 was unable to self transfer, required multiple staff to provide care, was dependent upon staff for mobility and returned from a hospital stay with a skin breakdown. The 05/18/13 Minimum Data Set indicated the resident had experienced falls since the 03/27/13 CAA's was dependent upon staff for care and activities of daily living. The most recent fall assessment was dated 10/2/12. Staff assessed the resident at a score of 15 which indicated the resident was "at risk" for falls and instructed staff to "consider environmental risk factors in the resident's interventions." The back of this assessment indicated staff should "Document interventions below...," but the page was blank. Staff C, D and E indicated Low Air Loss Mattresses were not assessed for safe use before implementation during interviews, on 05/24/13 at 12:05 p.m. and 1:00 p.m. respectively. Review of the 07/12/12 aide directive care plan revealed the resident was non-compliant with pressure ulcer prevention interventions and instructed staff to keep the bed low and the call light within reach to prevent falls. The updated 03/22/13 nursing care plan for skin included a 3/29/13 handwritten entry, "Bariatric air mattress." The 03/4/13 care plan for fall prevention included interventions; bed low, call light in reach, monitor for adverse side effects with medications, fall assessment ...quarterly and with incident of falls..." Staff D said, in an interview on 05/24/13 at 12:05 p.m., "(Resident) is known to put (her) leg over the bed. It is not surprising the resident fell ." Staff C, interviewed on 5/24/13 at 12:05 p.m. indicated this information was familiar to staff. Review of the facility's incident log revealed the resident had an injury fall out of bed on 4/15/13. According to 04/15 and 15/2013 progress notes and the facility's evidence of investigation the fail was the result of the resident "trying to sit on the edge of the bed." Review of the 5/18/13 evidence of investigation revealed an incomplete document without cumulative summary of variables related to the 05/18/13 fall. There were no additional fall prevention interventions listed for either fall. On 05/24/13 at 1:15 p.m. the acting Director of Nursing, Staff B, was asked for an updated fall assessment, completed 05/18/13 investigation and an assessment indicating the Air Loss Mattress was safe for the resident to use. None of this information was provided. The facility did not assess Resident #1 for falls for six months. The facility did not reassess Resident #1 after Resident #1 experienced an injury fall out of bed and did not implement other interventions to prevent further falls. The facility did not assess the Low Air Loss Mattress for safe use. RESIDENT #3 Resident #3 was observed lying in a low bed without a concave mattress or bilateral fall mats on 5/24/13 at 10:58 a.m. The resident was not able to be interviewed. According to the 11/22/12 CAA's Resident #3 required total assistance for all activities of daily living, was cognitively impaired, restless, combative and had a long history of falls. The CAA indicated Resident #3 was not able to use the call light so staff would be required to anticipate needs. Staff indicated the resident did not purposefully attempt to get out of bed but was so restless the resident might fall out of bed. This document indicated staff were to place bilateral falls mats on either side of the resident's bed. Staff last assessed Resident #3 on 4/16/13 as at risk for falls. The 2/13/13 care plan last updated 4/22/13 included fall prevention interventions; bed low, call light in reach, assessment quarterly, monitor for potential adverse side effects with medications..." The resident experienced a fall on 5/15/13 according to the incident log, but there was no subsequent reassessment of the resident before staff indicated other fall prevention interventions. A 5/10/13 handwritten note indicated "fall mats bilateral... " A 5/15/13 handwritten note on this care plan indicated "Scoop (concave) mattress to define bed position." Not only did staff not implement fall mats staff assessed to be required in 2012 but did not reassess the resident for other applicable fall preventions interventions after the most recent fall. Yet staff updated the care plan to include a "scoop" mattress that was never implemented. RESIDENT #2 Resident #2 was reviewed as a closed record and not available for interview. According to the 11/30/12 CAA's Resident #2 was at risk for falls due to poor safety awareness. A 5/10/13 Fall Risk Evaluation indicated the resident was at high risk for falls with a score of 20. (A score of 10 or higher is at risk) A 5/18/13 reassessment after the resident fell , indicated the resident was at further risk for falls with a score of 22. Staff determined the resident's bed should be in the low position and this is what the 5/10/13 direct-care directives indicated. The directives also included an intervention for prevention and treatment of [REDACTED]." Staff were asked for the assessment indicating the resident was able to use the mattress safely but no assessment was provided. Resident #2 had a injury fall out of bed on 5/18/13.

Based on record review the facility failed to ensure one of one (Resident #34) residents reviewed for catheter use remained free from urinary tract infections. The facility failed to identify symptoms associated with urinary tract infections and persue treatment for [REDACTED]. This failure resulted in the resident's hospitalization due to acute [MEDICAL CONDITION] and a systemic infection which constituted actual harm. Findings include: RESIDENT #34 According to the 9/19/11 MDS, Resident #34 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #34 was reviewed as a closed record and was not available for observation or interview. A 9/15/11 Social Service note revealed the resident "...has recurrent UTIs, chronic indwelling Foley." Review of the resident's CPs and progress notes revealed throughout her stay at the facility she frequently refused care and medications and exhibited [MEDICAL CONDITION] about being poisoned or contaminated. A Mental Health progress note, dated 11/09/11, revealed the resident exhibited new and worsening behaviors as she "appeared in manic phase, with grandiose [MEDICAL CONDITIONS], screaming out." [MEDICATION NAME], an antipsychotic medication, was recommended and started on 11/11/11. A Social Service note, dated 11/09/11, revealed the resident was spoken to regarding "...concerns of not sleeping well and yelling out at night multiple times." On the same date, POs were received for a sleep medication and a narcotic pain patch. There was no documentation to support the resident was assessed for a medical cause of the change in behaviors, including a UTI (given her history of recurrent infections and a catheter which increased the risk of infection.) Despite the addition of the antipsychotic and hypnotic medications and the narcotic patch, there was no indication staff considered the cause of the resident's decline. Additional progress notes revealed the resident was discharged to the hospital on [DATE] where she was found to have a severe urinary tract infection that had developed [MEDICAL CONDITION] (a systemic infection). The [MEDICAL CONDITION] Critical Care Consult, dated 11/16/11, revealed while in the emergency room , the resident's "Foley catheter was obstructed requiring manipulation and subsequently did drain very purulent material." The "Problem List" included "Sepsis...AMS (altered mental status)...Acute [MEDICAL CONDITION] functioning Foley...". The Emergency Department Report, dated 11/15/11, revealed the facility reported the resident "...had slowly progressive decreased level of consciousness over the past 2 days...". Her [DIAGNOSES REDACTED]. Failure to thoroughly assess a change in the resident's condition based on her past medical history caused a delay in treatment for [REDACTED].

Based on observation, interview and record review the facility failed to recognize, assess and treat one (#88) of three residents reviewed for pain. This failure caused Resident #88 to experience untreated pain which constituted actual harm. Additionally, facility staff failed to identify, assess or monitor [MEDICAL CONDITION] and/or skin conditions for two (#s 38 & 88) of two residents who required these services. This failure placed residents at risk for untreated [MEDICAL CONDITION] and delayed wound healing. Findings include: RESIDENT #88 According to the 12/20/11 Minimum Data Set (MDS), Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of admission Physician order [REDACTED]. Observation on 2/28/12 at 2:15 p.m. revealed the resident sitting in a wheelchair. His right foot was swollen and a scab was noted on the tip of the right great toe and what appeared to be a blood blister on the fourth toe. The resident stated, "Yeah, my foot hurts... it hurts more when it's down, it's better when it's up." Care Plan (CP) documents for Activities of Daily Living, dated 12/14/11, reflected the resident had, "burns to head and neck" and a "painful right great toe". Staff interventions included, "Manage pain adequately and effectively." The Pain Management CP, dated 12/13/11, indicated the resident experienced pain related to: "6% total body surface [MEDICAL CONDITION] head (and) left shoulder, right great toe, arthritis, spinal stenosis." Goals included: "resident's pain is relieved within one hours of intervention"; "resident able to participate with skilled therapy program due to the absence of, or controlled, pain"; and "pain management program is meeting resident's needs of comfort." Interventions included: "report to licensed nurse when resident complains of pain" and "complete on-going assessment of effectiveness of current medications. If not effective consult with physician." According to the 12/20/11 MDS, the resident experienced frequent pain described as a "9" on a scale of 0-10, which made it hard to sleep at night and limited day to day activities. Staff identified at this time the resident was not on a scheduled pain medication regimen and did not receive as needed pain medication or non-medication interventions for pain in the past five days. Review of 12/11 Medication Administration Records (MARs) confirmed the resident did not receive any as needed pain medications for the month. According to the Care Area Assessments (CAAs) the resident experienced pain, redness and swelling in the right great toe. Additionally according to the CAA, the resident "is stubborn and refuses to participate in certain activities or interviews as "he is in pain"." Staff assessed the resident to have some repetitive speech, "i.e.: yes, yes, yes", or "pain, pain, pain". In an interview on 2/29/12 at 7:45 a.m., Staff B was unable to explain why the resident received no as needed pain medication despite the MDS assessment which indicated the resident experienced significant pain. Telephone orders dated 12/14/11 indicated, "Refer to podiatrist r/t Right big toe pain." Review of Pain Monitor Flowsheets (PMFs) from 12/15 through 12/31/11 revealed facility staff consistently documented the resident experienced no pain. In an interview on 2/29/12 at 8:15 a.m., Staff B was unable to explain the discrepancy between the MDS assessment and the PMFs. In an interview in the morning of 2/29/12, Staff E said the resident was currently taking medication for gout (a disorder characterized by severe recurrent acute arthritis of sudden onset resulting from deposition of crystals in connective tissues) which was ordered in December. Staff E stated, "He didn't complain of pain except for the gout." Record review revealed a Telephone Order (TO) dated 12/21/11 for "[MEDICATION NAME] (a nonsteroidal anti-[MEDICAL CONDITION] drug)... three times a day for seven days". Staff E indicated she was mistaken and believed the resident was still receiving the gout medication. There was no documentation in the record to support staff assessed effectiveness of or continued need for pain medication after this medication was stopped on 12/28/11. Multiple Interdisciplinary Team Weekly Review (ITWR) notes reflected issues with pain: 12/21/11 listed nursing concerns as, "wound care to full thickness burns...pain..."; 12/27/11 indicated nursing concerns were "wound care, pain"; 1/04/12 indicated the resident was unable to ambulate, "(secondary to) right heel pain" and 1/11/12 indicated ambulation, "varies (secondary to) right toe pain." According to the 1/10/12 MDS, the resident was not on a scheduled pain medication regimen, didn't receive as needed pain mediation and had no non-medication interventions for pain. According to this assessment the resident experienced "severe" pain or hurting in the last five days occasionally which limited his day to day activities. According to therapy notes, the resident continued to have issues with pain that impacted his therapy: 1/10/11, "therapy limited secondary to pn (pain) right toe, limiting pts progress in therapy; 1/11/12 "...after ambulation c/o (complained of) right le (lower extremity) toe (pain) declined to amb(ulate) any further."; 1/12/12,"(pain) in right le is biggest barrier"; 1/13/12 "pt decreased distance secondary to right le (pain)". Review of 12/11 and 1/12 MARs revealed the resident received only one as needed pain medication on 2/20/12 when staff documented the resident reported, "a lot" of pain. There was no documentation to support the resident was consistently assessed for, offered, or administered pain medication as it related to wounds, arthritis, gout or position changes. Record review revealed the resident was identified with an infected ingrown toe nail on 2/12/12 which required the use of antibiotics. There was no documentation to support staff considered pain associated with this acute infection. In an interview at 10:30 a.m. on 2/29/12, Staff F (Rehabilitation Director) indicated that if a resident experienced pain during therapy, "we'll stop... and get pain medication...". Staff F indicated the resident's pain was discussed by the interdisciplinary team but could not show the resident was offered or received pain medication despite acknowledgement and documentation the resident experienced pain with ambulation/therapy. On 3/01/12 at 9:25 a.m. Staff B indicated that she would expect staff to provide pain medication if the resident experienced pain. Staff B stated nursing staff was not aware the resident was experiencing pain with therapy as, "there was a lack of communication with therapy." The facility failed to administer [MEDICATION NAME] or Tylenol for pain when it was assessed to be required, did not consistently provide pain medication of any kind when the resident expressed pain, and did not consider premedication in instances (therapy) when pain with movement could be reasonably anticipated, which contributed to the resident's continued experience of pain. RESIDENT #38 According to the 1/25/12 MDS, Resident #38 had [DIAGNOSES REDACTED]. Review of wound ulcer report tracking documents revealed staff were monitoring a wound to the resident's mid back since 9/11. The 2/20/12 CPs indicated the resident had an "open area to low back" which had a goal of "will gradually resolve ...over next 30 days." Observations on 2/26/12 at 8:25 a.m., 10:15 a.m., 11:05 a.m. and 1:09 p.m. revealed the resident sitting in her wheelchair (w/c), her lower back directly against the back sling of the w/c. The resident's feet appeared [MEDICAL CONDITION] and she wore short socks that were embedded into her ankle. Similar observations were made on 2/27/12 at 8:01 a.m. and 9:50 a.m. Observations on 2/28/12 at 8:30 a.m. and 9:05 a.m. the resident was observed asleep in the w/c in the same position, her back against the back rest. Similar observations of positioning and lower extremity [MEDICAL CONDITION] were made at 9:55 a.m., 10:30 a.m., 11:01 a.m., and 11:24 a.m. The resident was observed to be toileted via a sit to stand lift at 12:45 p.m. and placed back in the wheelchair. A bandage was noted on the resident's back. A small amount of dark drainage was on the 4x4 dressing. The location of the dressing was directly where the resident's back pressed up against the wheelchair. The resident was observed in the wheelchair at 1:30 p.m. and 2:15 p.m.. Similar observations of the resident sitting in the w/c, her back against the back sling of the w/c, were made throughout the day on 2/29/12. Observation of a dressing change to the back wound on 2/29/12 at 10:35 a.m. took place with the resident seated in the wheelchair. Record review revealed no evidence staff considered the resident's positioning as impacting the resident's back wound. In an interview on 2/29/12 at 1:43 p.m., Staff B indicated staff should at a minimum change the resident's position every two hours and that staff should have considered the resident's positioning as it related to the wound. Failure to relieve the pressure of the w/c had the potential to detract from wound healing. Record review revealed no evidence staff were aware of or provided interventions for the resident's lower extremity [MEDICAL CONDITION] despite being observed throughout the survey. Staff B, on 2/29/12 at 1:41 p.m., stated she assessed the resident with "Three to four plus pitting (a means of measuring the severity of [MEDICAL CONDITIONS] on the left" with the right lower extremity having [MEDICAL CONDITION] which was, "trace to one plus". Staff B stated, "staff aren't identifying issues with the skin assessments" and confirmed the resident's positioning contributed to the lower extremity [MEDICAL CONDITION]. Similar findings were identified for Resident #88 who was observed with lower extremity [MEDICAL CONDITION] and a foot wound throughout the survey which were not previously identified by staff. This despite documentation from a 12/14/11 consult which identified the resident experienced " (+) 2 lower extremity [MEDICAL CONDITION] (bilaterally)... " and a 1/09/12 report which documented "necrotic right great toe." In an interview on 2/29/12 at 7:45 a.m. Staff B confirmed the lack of assessment and wound measurements for Resident #88 stating, "the non pressure ulcer documentation is non- existent." Staff B also confirmed the resident had [MEDICAL CONDITION] which the staff did not identify, monitor or provide interventions for. Failure to identify and provide interventions for [MEDICAL CONDITION] and skin issues placed the resident at risk for pain and untreated wounds. .

Based on interviews and record reviews the facility failed to monitor a resident's input and output, and failed to determine if the resident received sufficient hydration, for one of one resident (#1) with dehydration. These failures resulted in the resident's hospital admission for care and treatment of [REDACTED]. Review of hospital records dated 8/29/11 revealed during Resident #1's three week follow up visit after surgery, the resident was ill, with a systolic blood pressure (SBP) of 50 palpable while sitting, and lying down went up to 90's. The physician ordered a liter of fluids and the resident was sent to the emergency department (ED). According to the ED notes, Resident #1 appeared ill, with a heart rate (HR) of 150s, and an SBP in the 80's. The resident received 4 liters of fluids in the ED with improvement in the HR and BP. Resident #1 was hospitalized , with a final [DIAGNOSES REDACTED]. On 9/22/11 at approximately 9:20a.m. Others Not Associated with the Facility (ONAF) reported that Resident #1 was admitted to the facility for rehabilitation following an orthopedic related surgery. According to ONAF, three weeks after Resident #1's admission to the faciilty, during an outpatient visit for a post surgical follow up evaluation, the resident was transported to the emergency department and hospitalized for [REDACTED]. Review of Resident #1's 8/29/11 discharge minimum data set (MDS) assessment, revealed that the resident was admitted to the facility on [DATE] for physical therapy (PT) and occupational therapy (OT). The 8/29/11 OT discharge summary indicated Resident #1 was "doing well with therapy," however, the resident was unable to progress with therapy when he became ill and weak. The 8/26/11 PT note stated Resident #1 was "making progress toward goals," and that the resident's illness "was a barrier toward progress." On 8/24/11 Resident #1 was unable to participate in PT as the resident was ill with nausea and diarrhea, according to the PT note. The 8/25/11 PT note indicated Resident #1 was ill with nausea and diarrhea and again was unable to participate in PT. On 8/26/11 the PT note revealed "..treatment focus on ambulation with FWW (front wheel walker), not cane, secondary to weakness from being ill/diarrhea." According to the 8/27/11 PT note, Resident #1 "complained of fatigue...clearly not himself today. Low energy, decreased conversation, poor posture, unable to correct ...Leaned on FWW heavily..." According to the 8/25/11 OT note, Resident #1 "reported having "diarrhea" all day and not feeling well." The 8/26/11 OT note indicated Resident #1 felt nauseated. In interview on 9/23/11 at approximately 3:00p.m., Staff A explained that Resident #1 had diarrhea, and was unable to participate in PT. According to Staff A, for two days, Resident #1 was unable to get out of bed, and had a poor appetite, explaining the licensed nursing (LN) staff were aware. Review of 8/24/11 evening nursing progress note revealed Resident #1 had two loose stools on the evening shift. The 8/25/11 day shift nursing progress note indicated Resident #1 was "not feeling well, sick to his stomach, appetite poor..." The 8/25/11 nursing progress note revealed the resident had a poor appetite. In interview on 10/6/11 at approximately 2:00 p.m. Staff B said Resident #1 had two loose stools on the 8/24/11 evening shift. According to Staff B, residents were evaluated after three loose stools, by sending a specimen to the lab, so Staff B said she was not concerned. Staff B said the resident's medication contributed to the loose stools. Staff B did not recall reporting the resident's two loose stools on 8/24/11. On 8/26/11, Resident #1 was placed on alert charting for loose stools and fluid restriction. Review of Resident #1's 8/8/11 physician orders [REDACTED]. On 8/17/11 a new PO was written for a stronger diuretic (to cause larger amounts of fluid loss through urination of large amounts). On 8/26/11 there was a PO to restrict Resident #1's fluid intake to 1000ml (milliliters-approximately one quart) per day, 360 mls from the kitchen, 640 mls from nursing-250 mls day, 250 mls evening, 140 mls night shift. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the document titled Care Plan Flow Sheet, directed staff to record BM (bowel movement) every shift. Resident #1's stools were recorded as small, medium, large. The BM record did not show the resident was having loose stools. On 8/26/11 the dayshift nursing progress note indicated Resident #1 had medication for loose stools at the resident's request. The 8/27/11 evening nursing progress note revealed Resident #1 "spent all evening in bed...with poor appetite." On 8/28/11, the facility sent a stool specimen to the lab to evaluate Resident #1's loose stools. Review of Resident #1's 8/16/11 care plan (CP) for hydration, revealed it was inconsistent with the resident's needs. The CP did not reflect the resident's fluid restriction goals, as the plan included "encourage fluid intake..." Although the CP included monitoring the resident's input and output (I/O), and monitoring for signs and symptoms of dehydration, it did not emphasize Resident #1's risks for dehydration with fluid restriction and the resident's reports of loose stools. In interview on 9/28/11 at approximately 2:30 p.m., the Director of Nursing Services (DNS) stated Resident #1's CP should have been updated for fluid restriction and diarrhea. The DNS explained that sometimes before the CP was updated, the resident was placed on alert charting for "monitoring." In interview on 10/9/11 at approximately 3:00 p.m., Staff C said he provided care for Resident #1 on 8/27/11 and 8/28/11. Staff C explained that he did not know how long Resident #1 had loose stools, as it was not clear from the BM record. Review of Resident #1's I/O monitor flow sheets revealed the I/O did not reflect the meal monitors, and the resident's I/O status was not accurately represented. There was a third document titled Antibiotic (ABO) Flow Sheet, and it was unclear how it calculated in with the total I/O. The ABO flow sheet found that on 8/27/11 the amounts listed were 250mls day, 200 mls evening, and on 8/28/11, there was no documentation. On 8/26/11 the I/O monitor revealed a 24 hour input total of 570 mls and on 8/28/11 the 24 hour input total was 450mls. The output for 8/27/11 was documented as "1" for the night (noc) shift, "2" for the day shift, and "2" for the evening shift, with a 24 hour output total of "5." On 8/28/11, the 24 hour output listed was "5." The output volume was not measured, so the actual outputs were unknowns. The meal monitor for 8/27/11 revealed Resident #1 received 240 mls at breakfast, 360 mls at lunch, and 240 mls at dinner. On 8/28/11, the meal monitor did not indicate that the resident received any fluids for breakfast or lunch, however, the dinner amount was documented as 360 mls. On 10/9/11, Staff C said Resident #1's output was monitored by documenting frequencies of urination (voiding), not by amount. According to Staff C, although Resident #1 had a urinal, the volumes voided, were not documented. On 10/6/11, Staff B explained the I/O was documented by the nursing staff on the I/O monitor sheet and on the ABO flow sheet, and that the meal monitor was documented separately by the nursing assistants. On 9/28/11 at approximately 3:00 p.m. Staff D said her understanding of the I/O monitor included the meal monitor, so it included fluids given by nurses during medication pass as well as the fluids received during meals. On 9/28/11 the DNS said the I/O system was not followed and the totals were to include the meal monitor and I/O monitor totals together. According to the DNS, the reviewer of the documentation was unable to discern the totals for I/O. On 10/4/11 at approximately 6:00 p.m. the medical doctor (MD) said Resident #1's loose stools were not reported to him until 8/26/11. According to the MD, if a resident had two or more stools within a 24 hour period, then he would have ordered the stool to be sent to the lab for evaluation. The MD explained that in reviewing Resident #1's chart, he found the resident had several loose stools, however, the staff reporting and monitoring did not clarify the extent of the resident's diarrhea. The MD stated that if Resident #1 was not eating, there needed to be better reporting of how much loss the resident had. According to the MD, if Resident #1 was having diarrhea, and loss of appetite, the resident should have been assessed for dehydration to indicate status of the skin turgor, mucus membranes, etc. The MD also said his expectations included evaluating the resident's orthostatic (changes in blood pressure from sitting or standing to lying position) blood pressure frequently. In interview on 10/6/11 at approximately 10:30 a.m., the Administrator said she agreed it was unclear when Resident #1's loose stools began, and how much fluid loss (output) there actually was, as the I/Oand BM monitoring provided unclear information. .