Every finding on record at Richmond Beach Rehab

Based on interview and record review, the facility failed to report an allegation of sexual abuse for 1 of 5 residents (Resident 1), reviewed for abuse reporting. The failure to report an allegation of sexual abuse to the State Agency placed the residents at risk for repeated incidents and unidentified abuse.Findings included.Review of the facility's policy titled, [Facility] Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated September 2022, showed, It is the policy of this facility that all suspected, alleged, or actual cases of resident abuse.shall be thoroughly and completely investigated and reported according to Federal and/or State regulations. It showed that Sexual abuse means non-consensual sexual contact of any type with a resident. It further showed that Mandated reporters are to immediately report all alleged violations to the Administrator, state agency and all other required agencies.when they have reasonable suspicion of abuse.has occurred.Resident 1 discharged to the hospital on [DATE] and did not return to the facility.Review of the quarterly Minimum Data Set (MDS-an assessment tool), dated 02/06/2026, showed that Resident 1 was cognitively intact.Review of the February 2026 grievance log showed a grievance made by Resident 1 on 02/04/2026.Review of the Grievance Communication Form, dated 02/04/2026, showed that Resident 1 reported an interaction with another resident that 'surprised' her.In an interview on 04/15/2026 at 11:30 AM, Resident 1 stated that in January [2026], I was going down the hallway, he [Resident 2] called me over to outside his room, put his hands on my face, said you're [you are] pretty, and gave me a kiss. Resident 1 stated it was not a wanted kiss and not consensual. Resident 1 stated the Director of Nursing and the Administrator talked to me and everyone knew it happened. Resident 1 stated, After it happened I wouldn't [would not] go to the activities room because he [Resident 2] was there. Resident 1 further stated, it tore me up inside. I was scared all the time and did not want to return to the facility after going to hospital unless they got rid of him [Resident 2].Review of the incident log for January 2026, February 2026 and March 2026, showed no documentation that the allegation of sexual abuse was reported to the state agency.Review of the activity note dated 02/03/2026, showed Staff B, Activities Director, documented that Resident 2 continues to be blunt and make inappropriate comments and behaviors at times.In an interview on 04/14/2026 at 12:31 PM, Resident 2 stated that they did not remember any interaction with Resident 1.In an interview on 04/12/2026 at 11:29 AM, Staff B stated that Resident 2 would sometimes say inappropriate things, he might say to residents, 'oh, you're pretty, your outfit is nice. Staff B stated that I'm [I am] sure I could hear him say 'you're pretty' to Resident 1. Staff B stated that their assistant as part of an internal action plan called caring partners asked Resident 1 if they felt safe in the facility and Resident 1 told them about the incident with Resident 2. Staff B stated, when it came to light, the Administrator [Staff A] and Director of Nursing, investigated it. Staff B further stated that Resident 1 stopped coming to activities after whatever happened triggered her anxiety and she already did not come a lot [to activities].In an interview on 04/21/2026 at 11:45 AM, Staff C, Social Services Coordinator, stated that Resident 1 had told them that Resident 2 had said you're pretty, he said 'he come here', and he kissed her. Staff C stated that they found out six weeks after the incident happened and no one knew until she told me. Staff C stated that they reported the incident to the Administrator and the Director of Nursing. Staff C stated that Resident 1 stopped going to activities and their anxiety went up about talking about the incident. Staff C stated, I don't think she made it up, she wouldn't [would not] just say that I believe her. In a follow-up interview at 1:42 PM, Staff C stated that I don't [do not] think it [the kiss] was mutual. She was shocked when it happened and it was not agreed upon.In an interview on 04/21/2026 at 2:10 PM, Staff A stated that they reported to the state agency any allegations of abuse, neglect, resident to resident incidents. Staff A stated that sexual abuse has to do with two people, involves something intimate, unwanted sexual advance, touch. Staff A stated that a non-consensual kiss reported by a resident was an allegation of sexual abuse and that they would report it to the state agency. When asked if Staff A reported the incident between Resident 1 and Resident 2, when they first heard about it, Staff A stated that when they had heard that Resident 1 stated that another resident kissed her, we went to talk to her and she stated that she didn't want this to go any further and she said she didn't want other staff to know about it. Staff A stated that that they did write a vague grievance report and did an investigation and that she was having more anxiety about having the incident documented or reported. In a follow-up interview at 3:37 PM, Staff A stated, we didn't report it and we were going to but she [Resident 1] was having more trauma about reporting it. Staff A stated that we wanted to honor her wishes. Staff A further stated that they usually reported resident to resident incidents and in this case they did not.Reference: (WAC) 388-97-0640 (5)(a).

Based on observation, interview, and record review, the facility failed to ensure chlorine test strips (used to measure the concentration of free available chlorine in sanitizing solutions) were not expired in accordance with professional standards for 1 of 1 kitchen, reviewed for dinnerware sanitization and storage. This failure placed the residents at risk for unsanitary dining conditions and a diminished quality of life.Findings included .Review of the facility's policy titled Dishwashing Machine Use, revised in March 2010, showed, Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation.During a joint observation and interview on 02/23/2026 at 8:33 AM, Staff R, Culinary Aide, checked the dishwasher temperature and the chemical sanitation Parts Per Million (ppm - unit of measure for concentration) range. Staff R used [Brand name] Chlorine Test Paper. Staff R stated that the test strip results should be between 50 ppm to 100 ppm. A joint observation of the Chlorine Test Paper showed that the strip Staff R had used was expired on 01/01/2026. Staff R stated they had expired and someone had forgotten to throw them away and get a new one.On 02/23/2026 at 8:33 AM, Staff S, Registered Dietitian, stated that the facility used a low-temperature dishwasher with chemical sanitization.On 02/23/2026 at 10:05 AM, Staff U, Culinary Services Manager, stated staff should check the expiration date of the chlorine test strips before use and had missed that.In a follow-up interview on 02/24/2026 at 2:29 PM, Staff S stated that they would expect kitchen staff to test the dishwasher chemical sanitization before meals and would expect staff to check the expiration date of the chlorine test strips before use. Staff S further stated that it would be important because if the chlorine test strips were expired, they could give a false reading and could be inaccurate.On 02/25/2026 at 10:30 AM, Staff A, Administrator, stated they would expect the chlorine test strips in the kitchen to not be used if expired.Reference: (WAC) 388-97- 1100(3), 2980 (6).

Based on observation, interview and record review, the facility failed to develop a system that ensured the right to file grievances anonymously for 5 of 8 residents (Resident 26, 37, 10, 100 & 104), reviewed for grievances. This failure placed the residents at risk for unresolved concerns, unmet care needs and a diminished quality of life.Findings included. Review of the facility's policy titled, Grievance Policy, revised in January 2017, showed, Grievance may be filed orally or in writing and with the right to file anonymously. Review of the facility's undated document titled, Resident Grievance/Complaint Procedures, did not show documentation of a system to file grievances anonymously. Review of the facility's undated form titled, Grievance Communication Form, did not show documentation of a system to file grievances anonymously. Observation and record review on 02/19/2026 at 10:24 AM, showed an undated document titled, Grievance/Complaint Procedures, in an enclosed glass bulletin board outside the administrator's office. Review of the undated document showed, [Grievance] Forms can be obtained from the wall mounted outside the administrator's office. Further observation did not show a rack for grievance forms or a locked box to file a grievance form anonymously. During a meeting on 02/20/2026 at 10:00 AM with the Resident Council (a group of residents meeting regularly to discuss about their care and daily living in the facility), Residents 26, 37, 10 & 100, stated, No when asked if they were able to file their grievances anonymously. RESIDENT 26On 02/20/2026 at 10:00 AM, when asked about the process of filing their written grievance form, Resident 26 stated that they had to write their name on the grievance form and would give it directly to a staff or they would slide it under the administrator's office door. Resident 26 stated that there was a rack outside the administrator's office where they could put the grievance form and that the rack was no longer available. Resident 26 further stated, No, when asked if they were able to file their grievance anonymously. RESIDENT 37On 02/20/2026 at 10:00 AM, Resident 37 stated that they had to write their room number in the grievance form and would give it to a staff. Resident 37 stated, No, when asked if they were able to file their grievance anonymously. RESIDENT 10On 02/20/2026 at 10:00 AM, Resident 10 stated, No, when asked if they were able to file their grievance anonymously. RESIDENT 100On 02/20/2026 at 10:00 AM, Resident 100 stated, No, when asked if they were able to file their grievance anonymously. RESIDENT 104In an interview on 02/23/2026 at 11:29 AM, Resident 104 stated that they were not sure about filing grievances anonymously. In an interview on 02/23/2026 at 2:25 PM, Staff H, Social Services Assistant, stated that residents would hand in their written grievances to us or slide it under the [office] door. Staff H further stated, No, when asked if there was a locked box for residents to file/put in their grievances anonymously. In an interview on 02/23/2026 at 2:54 PM, Staff A, Administrator, stated that grievance forms were handed directly to them or slid under their door. Staff A stated that they had a rack outside their office where grievance forms where placed. Staff A stated that they had decided to remove the rack about a week or a week and a half ago due to some residents taking the completed grievance forms from the [opened] rack. Staff A stated that they did not have a closed or a locked box to put in the completed grievance forms. Staff A further stated that they expected residents to be able to file their written grievances anonymously. Reference: (WAC) 388-97-0460 (1).

Based on observation, interview, and record review, the facility failed to properly store the Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) mask when not in use, administer CPAP as ordered, and monitor oxygen (O2) saturation (the amount of oxygen in the blood) for 3 of 6 residents (Resident 52, 2 &104), reviewed for respiratory care. These failures placed the residents at risk for unmet care needs, respiratory infections, and related complications.Findings included . Review of the facility's policy titled, CPAP/BiPAP [Bilevel Positive Airway Support-used to assist breathing by delivering air through a mask that covers the nose, mouth, or both] Support, dated July 2025, showed the purpose of CPAP/BiPAP was to improve O2 levels present in the blood in residents with OSA [Obstructive Sleep Apnea - a sleep disorder that is marked by pauses in breathing of ten seconds or more during sleep and causes unrestful sleep] . The policy further showed, Review the resident's medical record to determine his/her baseline O2 saturation [using a pulse oximeter-a non-invasive device] . RESIDENT 52Review of the admission record printed on 02/22/2026, showed Resident 52 was admitted to the facility on [DATE] with diagnosis that included OSA. Review of the February 2026 Treatment Administration Record (TAR) showed that Resident 52 had an order for, CPAP: Clean face mask with soap and water, air dry, and store in plastic bag every day shift with a start date of 12/01/2025. Observations on 02/17/2026 at 1:54 PM and on 02/18/2026 at 10:03 AM, showed Resident 52's CPAP machine was sitting on their nightstand, and the CPAP nasal mask was not covered and sitting on the CPAP machine. Further observation showed there were two urine-filled urinals hanging on the nightstand drawer. Observation on 02/19/2026 at 9:44 AM, showed Resident 52's CPAP machine was sitting on the resident's nightstand, and the CPAP nasal mask was not covered and sat on the CPAP machine. Observation on 02/20/2026 at 8:25 AM, Resident 52's CPAP tubing and the nasal mask were hanging below the resident's bed and touching the ground. In an interview and joint record review on 02/24/2026 at 10:00 AM, Staff N, Registered Nurse (RN), stated that CPAP nasal mask would be stored in a bag when not in use. A joint record review of the February 2026 TAR showed that Resident 52 had an order to clean face mask and store it in plastic bag every day shift. Staff N stated that the CPAP mask should be stored in the bag when not in use. In an interview on 02/24/2026 at 11:08 AM, Staff F, Resident Care Manager (RCM), stated that CPAP masks would be stored in a plastic bag when not in use. In an interview on 02/24/2026 at 2:37 PM, Staff B, Director of Nursing Services, stated it was their expectation that CPAP nasal masks would be stored in a plastic bag when they were not in use. RESIDENT 2 Review of the admission record printed on 02/18/2026 showed Resident 2 had a diagnosis of OSA. Review of the Order Summary Report printed on 02/18/2026 showed Resident 2 had an active order for a CPAP pressure settings of 12-20 cm H2O (centimeter of water-a unit of measurement for airway pressure) via a full humidified (with added moisture) mask. Review of the Respiratory Therapy (Nursing) care plan printed on 02/23/2026 showed Resident 2 had impaired respiratory function requiring CPAP treatment related to OSA. Review of Resident 2's physician progress note dated 02/12/2026 showed to use CPAP for all sleep. In an interview on 02/18/2026 at 11:13 AM Resident 2 stated that they had not used their CPAP and that They [staff] need to change the filter [CPAP machine]. Observation on 02/19/2026 at 7:17 AM showed Resident 2 was asleep with slight snoring sound and was not using their CPAP machine. Another observations on 02/20/2026 at 7:28 AM and at 11:23 PM showed Resident 2 was asleep and was not using their CPAP machine. In an interview and joint observation on 02/21/2026 at 12:15 AM, Staff T, RN, stated that CPAP was to be administered when they [residents] are about to sleep. Staff T stated that Resident 2 had an order for CPAP due to OSA. A joint observation showed Resident 2 was sleeping and was not using their CPAP. Staff T stated that they were expected to administer CPAP to Resident 2. In an interview and joint record review on 02/24/2026 at 9:17 AM, Staff F stated that the use of CPAP was important for residents with OSA to prevent them from desatting [desaturation-drop in the amount of O2 in the blood] or O2 level will drop. A joint record review of the physician order showed Resident 2 had an order for CPAP. When informed about the times Resident 2 was observed without their CPAP mask, Staff F stated that they expected staff to administer Resident 2 their CPAP. RESIDENT 104 Review of the admission record printed on 02/17/2026, showed Resident 104 was re-admitted on [DATE] and had diagnoses that included respiratory failure with hypoxia (oxygen deficiency) and OSA. Review of the Order Summary Report printed on 02/23/2026 showed Resident 104 had a physician order for O2 at two liters per minute (LPM) to maintain sats (saturation) equal to (or) greater than 92 percent for shortness of breath. The order summary report further showed O2 at two liters per minute via nasal cannula [a plastic tubing that delivers O2 through the nostrils] at bedtime for severe nocturnal [night] desaturation as needed. Review of Resident 104's O2 therapy care plan dated 02/02/2026 showed, Monitor O2 saturation while providing daily cares. Review of Resident 104's cardiology [doctors/healthcare providers specializes in heart] consultation note dated 02/09/2026 showed, Monitor oxygen sats [saturation]. Review of the electronic health record under vital signs did not show Resident 104's oxygen saturation was monitored on the following dates: 02/04/2026, 02/05/2026, 02/08/2026, 02/10/2026, 02/11/2026, 02/14/2026, 02/16/2026, 02/17/2026, 02/20/2026, and 02/22/2026. In an interview on 02/17/2026 at 11:28 AM, Resident 104 stated, The oxygen is not being provided to me and that they were supposed to use oxygen. In an interview and joint record review on 02/24/2026 at 9:37 AM, Staff F stated that staff monitored residents' respiratory status. Staff F stated that they use a pulse oximeter to measure a resident O2 saturation level. When asked, Staff F stated, It is important [to measure O2 saturation] because it will indicate desaturation and will tell you if they [residents] are going into respiratory distress. A joint record review of Resident 104's physician order showed they had orders for oxygen at two LPM to maintain (O2) saturation equal to or greater than 92 percent for shortness of breath and severe nocturnal desaturation. A joint record review of the vital signs records did not show Resident 104's O2 saturation was monitored on the following dates: 02/04/2026, 02/05/2026, 02/08/2026, 02/10/2026, 02/11/2026, 02/14/2026, 02/16/2026, 02/17/2026, 02/20/2026 and 02/22/2026. Staff F stated that they expected Resident 104's O2 saturation to have been monitored to know if they were having desaturation. In an interview on 02/24/2026 at 10:51 AM, Staff B stated that they expected staff to have administered Resident 2 their CPAP and monitored Resident 104's O2 saturation to assess their respiratory status. Reference: (WAC) 388-97-1060 (3)(j)(vi) .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed by 4 of 12 staff (Staff W, K, O & P) and for 2 of 2 residents (Residents 29 & 44), reviewed for infection control. The failure to properly transport clean clothes, use Personal Protective Equipment (PPE-face shield/goggles, gowns) before entering a droplet precaution (measure taken to prevent spread of germs transmitted when a person coughs, sneezes, talks or breaths) room and during wound care, disinfect a glucometer (a device used to measure blood sugar level) and pen injector (device used to inject Liraglutide [medication that helps regulate blood sugar levels]), and ensure a urine-filled urinal was not placed next to a resident's meal tray, placed the residents, visitors, and staff at risk for infection and related complications.Findings included. Review of the facility's policy titled, Infection Prevention and Control Program, dated October 2025, showed, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy showed that prevention of infection included implementation of appropriate Enhanced Barrier Precautions (EBPs-precaution to protect residents from multidrug-resistant organism [MDRO -a germ that is resistant to medications that treat infections]) and Transmission Based Precaution (a specialized infection control measure used to prevent the spread of specific infections) and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC-a public health agency). The policy further showed, Those with potential direct exposure.are trained in and required to use appropriate precautions and personal protective equipment. According to Centers for Disease Control and Prevention online publication titled, Appendix D-Linen and laundry management, dated 03/19/2024, showed, Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. Review of the facility's policy titled, Enhanced Barrier Precautions, revised in April 2025, showed the use of gown for high-contact resident care activities that included wound care (any skin opening requiring a dressing). TRANSPORTING CLEAN CLOTHES STAFF W Observation on 02/19/2026 at 2:03 PM showed Staff W, Laundry Aide, was transporting clean clothes and delivering them to the residents' room. Further observation showed the clean clothes on the rolling clothing rack were not fully covered while being transported by Staff W. Observation on 02/19/2026 at 2:17 PM, showed Staff W was transporting the rolling clothing rack when the white linen covering the cart fell to the floor. Staff W picked up the white linen and placed it back on top of the rolling clothing cart containing clean clothes. In an interview on 02/19/2026 at 2:20 PM, Staff W stated that they were expected to fully cover clean clothes with a clean linen when transporting them to the units. When asked about their recent transport, Staff W stated that the clean clothes were not fully covered and that the white linen covering should not have been placed back on the clothing rack. In an interview on 02/25/2026 at 10:53 AM, Staff X, Laundry Manager, stated that their process was to transport clean linens/clothes on a covered cart. Staff X stated, I expect the clothes are fully covered. When asked about the linen that fell on the floor, Staff X further stated, I want them [the staff] to put it in the dirty laundry and not put it back on the rack. In an interview on 02/25/2026 at 11:25 AM, Staff C, Infection Preventionist, stated that they expected staff to fully cover linens/clothes when transporting them to the unit. Staff C further stated, Once it [the linen] is on the floor, it is considered soiled. I expect them [the staff] to have it placed in the dirty laundry. USE OF PPE-DROPLET PRECAUTION STAFF K Observation on 02/19/2026 at 9:25 AM, showed Staff K, Licensed Practical Nurse, was putting on a gown, gloves, and entered room [ROOM NUMBER] (a droplet precaution room). Staff K was wearing a dark-rimmed eyeglasses and was not using eye protection (face shield or goggles) when they entered room [ROOM NUMBER]. In an interview and joint record review on 02/19/2026 at 10:05 AM, Staff K stated that they were expected to wear PPE when providing care for residents on droplet precautions. A joint record review of the signage posted outside room [ROOM NUMBER] showed staff must wear eye protection. When asked, Staff K stated that they were wearing their prescription eyeglasses and was not sure whether it [eyeglasses] is counted [as PPE] or not. In an interview on 02/25/2026 at 10:02 AM, Staff C stated that they expected staff to wear proper PPE for residents on droplet precautions. Staff C stated that prescription eyeglasses were not considered PPE and that Staff K was expected to wear a face shield or goggles upon entering room [ROOM NUMBER]. In an interview on 02/25/2026 at 11:32 AM, Staff B, Director of Nursing Services, stated that they expected staff to follow droplet precautions which included use of face shield or goggles. Staff B further stated that they expected staff to fully cover clean linens/clothes during transportation to the unit and that the linen on the floor is considered soiled and it should have been placed to [the dirty] laundry. WOUND CARE-EBPSTAFF O AND STAFF PRecord review of the wound evaluation dated 02/12/2026 showed Resident 20 had a bed sore on their sacrum (between the lower back and the tailbone) that required a dressing change three times a week. Observation on 02/19/2026 at 8:29 AM, showed Staff O, Nurse Practitioner, and Staff P, Registered Nurse, were providing wound care for Resident 20. Staff O and Staff P provided wound care to Resident 20 wearing gloves and were not wearing gown. In an interview on 02/19/2026 at 8:51 AM, Staff O and Staff P were asked regarding PPE requirements for wound care, they stated that residents on precautions were identified by signage and a PPE cart outside their room and that there was no signage or PPE cart outside Resident 20's room. Staff O and Staff P stated that they were aware that wound care required EBP, and a gown should have been worn during Resident 20's wound treatment. In an interview on 02/23/2026 at 8:52 AM, Staff C stated that wound care should be on EBP and gloves and gown should be worn during wound treatment. Staff C further stated that Staff O and Staff P should have worn gowns during wound treatment. In an interview on 02/24/2026 at 2:28 PM, Staff B stated that their expectation was for staff to wear gloves and gown during wound care treatment. GLUCOMETER DISINFECTIONRESIDENT 29Review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, revised in October 2011, showed, Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses .clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. Review of the February 2026 physician orders showed Resident 29 had an order to check their blood sugar levels before meals and at bedtime prior to administration of insulin (a medication that helps regulate blood sugar level). During an observation and interview on 02/23/2026 at 8:44 AM, Staff K was using a glucometer to check Resident 29's blood sugar level. Staff K then used an alcohol wipe to clean the glucometer. Staff K stated it was their practice to clean glucometers with alcohol wipes after every use. Staff K stated they had two glucometers in their medication cart that they used interchangeably to check the blood sugar level of eight residents. Staff K further stated that they were told not to use the Sani-cloth [brand name- sanitizing wipes] because it was too harsh on the glucometers. In an interview on 02/25/2026 at 1:01 PM, Staff C stated they expected glucometers to be disinfected with Sani-cloth wipes or bleach-based wipes after every use. Staff C stated that Staff K should have cleaned the glucometer with a Sani-cloth wipe after it was used for Resident 29. In an interview on 02/25/2026 at 2:44 PM, Staff B stated that Staff K should have used Sani-cloth wipes to clean the glucometer after it was used to check Resident 29's blood sugar level. CLEANING OF LIRAGLUTIDE PEN INJECTORReview of the facility's policy titled, Medication Administration, revised in April 2019, showed, Staff follows established facility infection control procedures ( . antiseptic technique [procedure to prevent spread of germs] .) for the administration of medications. Review of the manufacturer's recommendations titled, Liraglutide Injection, revised in February 2025, showed, .Pull off pen cap.Wipe the rubber stopper with an alcohol swab. Remove protective tab from outer needed cap. Push outer needle cap containing the needle straight onto the pen, then screw needle on until secure. Observation on 02/23/2026 at 8:46 AM, showed Staff K was preparing Resident 29's Liraglutide dose. Staff K removed the cap from Resident 29's Liraglutide pen, placed a new pen needle in and administered it to Resident 29. Staff K did not clean the Liraglutide pen rubber seal [with alcohol wipes] before placing the new needle onto the pen. Staff K stated they should have cleaned the Liraglutide rubber seal with an alcohol wipe prior to connecting the pen needle. In an interview on 02/25/2026 at 1:10 PM, Staff C, stated they expected nurses to clean the pen injector rubber seal with alcohol wipes prior to connecting pen needles. Staff C further stated that Staff K should have cleaned Resident 29's Liraglutide rubber seal with an alcohol wipe before connecting the pen needle. In an interview on 02/25/2026 at 2:47 PM, Staff B stated that Staff K should have cleaned Resident 29's Liraglutide pen rubber seal with alcohol wipe prior to connecting the pen needle. URINAL NEXT TO MEAL TRAYRESIDENT 44Observation on 02/19/2026 at 2:45 PM, showed a urine-filled urinal on Resident 44's side table next to their meal tray. A joint observation and interview on 02/19/2026 at 2:54 PM with Staff L, Certified Nursing Assistant, showed Resident 44's urinal filled with urine was on their bedside table next to their meal tray. Staff L stated that Resident 44's urinal should not have been on the table next to their meal tray and that it should have been emptied. In an interview on 02/25/2026 at 1:02 PM, Staff C stated they did not expect urinal filled with urine to be placed next to their meal tray. Staff C further stated that Resident 44's urinal should have been emptied and placed away from their bedside table. In an interview on 02/25/2026 at 2:40 PM, Staff B stated they did not expect Resident 44's urinal to be on their bedside table next to their meal tray. Reference: (WAC) 388-97- 1320 (1)(a)(3)(5)(c).

Based on observation, interview and record review, the facility failed to document medication administration in accordance with professional standards for 4 of 6 residents (Residents 46, 90, 29 & 93), reviewed for medication administration. This failure placed the residents at risk for medication errors, negative outcomes, and a diminished quality of life.Findings included.Review of the facility's policy titled, Medication Administration, revised in April 2019, showed, the individual administering the medication initials the resident's MAR [Medication Administration Record] on the appropriate line after giving each medication and before administering the next ones.RESIDENT 46Review of Resident 46's February 2026 MAR showed they had orders for the following medications:- Cranberry (supplement), 1 (one) tablet- Senna (stool softener), 2 (two) tablets- Lactulose (stool softener) oral solution, 15 milliliters (a unit of measurement)- Excedrin (pain reliever), 2 tablets- Aripiprazole (mood stabilizer), 1 tablet- Lamotrigine (mood stabilizer), 1 tablet- Oxycodone (pain reliever), 1 tabletObservation on 02/23/2026 at 8:33 AM, showed Staff K, Licensed Practical Nurse, was preparing Resident 46's morning medications. Staff K poured 1 cranberry tablet, 2 senna tablets, 2 Excedrin tablets, 1 aripiprazole tablet, 1 lamotrigine tablet, and 1 oxycodone tablet in a medication cup; and 15 ml of lactulose in another medication cup. Staff K documented, Yes [medication administered] and saved/signed it in Resident 46's EMAR (Electronic MAR) before taking the medications to Resident 46. Staff K then entered Resident 46's room and administered their medications.RESIDENT 90Review of the February 2026 MAR showed Resident 90 had orders for the following medications:- Acetaminophen (pain reliever), 2 tablets- Fish oil (supplement), 1 capsule- Folic acid (supplement), 3 (three) tablets- Ropinirole (helps control movement disorders), 2 tablets- Prednisone (treats inflammation), 1 tabletObservation on 02/23/2026 at 8:37 AM, showed Staff K was preparing Resident 90's medications. Staff K poured 2 acetaminophen tablets, 1 fish oil capsule, 1 folic acid tablet, 2 ropinirole tablets, and 1 prednisone tablet in a medication cup. Staff K documented, Yes and saved/signed it in Resident 90's EMAR taking the medications to Resident 90. Staff K then entered Resident 90's room and administered their medications.RESIDENT 29Review of the February 2026 MAR showed Resident 29 had orders for the following morning medications:- Linzess (stool softener), 1 capsule- Fluticasone (treats nasal congestion), [with instructions to administer] 1 spray on both nostrils- Metoprolol (treats high blood pressure), 1 tablet- Senna, 2 tablets- PreserVision (supplement), 1 tablet- Multivitamin (supplement), 1 tablet- Apixaban (blood thinner), 1 tablet- Torsemide (water pill), 1 tablet- Morphine (pain reliever), 1/2 (half a) tablet- Allopurinol (for gout - joint pain), 1 tabletObservation on 02/23/2026 at 8:43 AM, showed Staff K was preparing Resident 29's medications. Staff K took a fluticasone nasal spray out of the medication cart; poured 1 linzess capsule, 1 multivitamin tablet, 2 senna tablets, 1 PreserVision tablet, 1 apixaban tablet, 1 allopurinol tablet, 1 metoprolol tablet, 1 torsemide tablet, and one-half morphine tablet in a medication cup. Staff K documented, Yes and saved/signed it in Resident 29's EMAR before taking the medications to Resident 29. Staff K then entered Resident 29's room and administered their medications.RESIDENT 93Review of the February 2026 MAR showed Resident 93 had orders for the following morning medications:- Aspirin (pain reliever/prevent blood clot), 1 tablet- Bupropion (for mood disorder), 1 tablet- Fluoxetine (for mood disorder), 1 tablet- Probiotic (supplement), 1 capsule- Acetaminophen, 2 tabletsObservation on 02/23/2026 at 9:07 AM, showed Staff K was preparing Resident 93's medications. Staff K poured 2 acetaminophen tablets, 1 aspirin tablet, 1 probiotic capsule, 1 fluoxetine tablet, and 1 bupropion tablet in a medication cup. Staff K documented, Yes and saved/signed it in Resident 93's EMAR before taking the medications to Resident 93. Staff K then entered Resident 29's room and administered their medications.In an interview on 02/23/2026 at 2:38 PM, Staff K stated that they signed the MARs as given before they administered Residents 46, 90, 29 and 93's morning medications.In an interview on 02/25/2026 at 1:47 PM, Staff I, Resident Care Manager, stated they expected nurses signed the residents' MAR after medication was taken and swallowed by the resident. The nurses are not supposed to pre-sign it [the MAR]. Staff I further stated that the nurse [Staff K] should have signed Residents 46, 90, 29 and 93's MARs after the residents took their medications.In an interview on 02/25/2026 at 2:29 PM, Staff B, Director of Nursing Services, stated they expected nurses to sign residents' MARs after the residents took their medications.Reference: (WAC) 388-97-1300(3)(a).

Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed timely for 1 of 6 residents (Resident 107), reviewed for significant change in condition. The failure to complete an SCSA timely placed the resident at risk for unmet care needs and a diminished quality of life.Findings included .Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed that a SCSA is required to be performed when a terminally ill resident enrolls in a hospice (compassionate care provided to individuals who are in the final stages of a terminal illness) program or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD - observation period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the ARD) must be within 14 days from the effective date of hospice election. The RAI manual further showed that the assessment should be completed no later than 14 days after the determination was made (determination date [or effective date of hospice election] plus 14 calendar days).Review of a document titled, Certificate of Terminal Illness, dated 12/15/2025, showed Resident 107 started hospice services on 12/14/2025.Review of Resident 107's SCSA MDS dated [DATE] showed it was completed on 01/02/2026, 19 days after hospice election (five days late).During a phone interview and joint record review on 02/25/2026 at 12:22 PM with Staff E, MDS Coordinator, stated they followed the RAI manual to complete MDS. A joint record review of Resident 107's SCSA MDS dated [DATE] showed it was completed on 01/02/2026. A joint record review of the certificate of terminal illness document showed Resident 107 was admitted to hospice on 12/14/2025. Staff E stated that the hospice admission date of 12/14/2025 was equivalent to the determination date. A joint record review of the RAI manual MDS assessment summary showed that SCSA MDS should be completed no later than 14 days after determination that significant change in resident's status occurred. Staff E stated they would consult with their supervisor to check for completion timeframe.In an interview on 02/25/2026 at 12:40 PM, Staff D, Case Manager, stated that Resident 107's assessment was five days late and that it should have been completed timely.In an interview on 02/25/2026 at 2:25 PM, Staff B, Director of Nursing Services, stated they expected MDS assessments to be completed timely and accurately. Staff B stated Resident 107's assessment should have been completed timely.Reference: (WAC) 388-97-1000 (3)(b).

Based on observation, interview, and record review, the facility failed to ensure residents were evaluated and assessed, and/or a physician order was obtained for safe administration of medication for 2 of 3 residents (Residents 92 & 64), reviewed for self-administration of medication. This failure placed the residents at risk for inaccurate and unsafe medication administration, adverse side effects, medical complications, and a diminished quality of life.Findings included.Review of the facility's policy titled, Medication Administration, revised in April 2019, showed, Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do safely.RESIDENT 92Review of Resident 92's Electronic Health Records (EHR) under evaluations tab from 01/24/2025 to 02/19/2026 showed no documentation to indicate that Resident 92 had a self-administration of medication evaluation.Review of a physician orders printed on 02/18/2026 showed no documentation to indicate that Resident 92 had an order for self-administration of medication.Review of the February 2026 Medication Administration Record (MAR) showed Resident 92 were given the following medications in the morning of 02/17/2026:- Amlodipine for high blood pressure), 1 (one) tablet- Aspirin (used to lower the risk of heart attack, stroke [blockage of blood supply to the brain], or blood clot [a mass that forms when blood hardens from a liquid to a solid]), 1 tablet- Atenolol (for high blood pressure), 1.5 (one and one-half) tablet- Lisinopril (for high blood pressure), 1 tablet- Spironolactone (for high blood pressure), 1 tablet- Acetaminophen (for pain), 2 (two) tablets- Calcium Carbonate (for heartburn, supplement), 2 tablets- Carbamazepine (for epilepsy [a medical condition that causes people to have repeated seizures - bursts of electrical activity in the brain that can cause changes in awareness, behavior, movements or feelings]), 1 tabletObservation on 02/17/2026 at 10:29 AM showed Resident 92 had eight and one-half tablets in a medication cup and another medication cup with two big tablets on their bedside table. Resident 92 stated, they [the nurse] just brought them in. When asked if they knew what medication they were taking, Resident 92 stated, I don't [do not] remember the names.In an interview and joint record review on 02/24/2026 at 10:43 AM, Staff M, Licensed Practical Nurse, stated they would leave medications at bedside for residents who had orders to leave them at bedside and for residents who were evaluated for self-administration of medications. A joint record review of Resident 92's February 2026 MAR showed Resident 92 was given 1 amlodipine tablet, 1.5 atenolol tablet, 1 aspirin tablet, 1 lisinopril tablet, 1 spironolactone tablet, 2 acetaminophen tablet, 1 carbamazepine tablet, and 2 calcium carbonate tablets. Staff M stated they provided Resident 92 with eight and one-half tablets in one medication cup and 2 tablets of calcium carbonate in another medication cup and left them in Resident 92's room. Staff M stated Resident 92 did not have orders for medications to be left at bedside or that they were on self-administration of medication program. Staff M further stated they should not have left the medications with Resident 92 and that they should have waited for Resident 92 to take all their medications.In an interview and joint record review on 02/25/2026 at 1:22 PM, Staff J, Resident Care Manager, stated they did not expect nurses to leave medications in residents' room. A joint record review showed Resident 92 did not have a physician order to leave medications at bedside and/or a self-administration of medications evaluation in place. Staff J stated that Resident 92 did not have orders for self-administration of medications and that Staff M should have stayed with Resident 92 until they took their medications.RESIDENT 64Review of the physician orders printed on 02/18/2026 showed no documentation to indicate that Resident 64 had an order for self-administration of medications.Review of the evaluations tab from 03/19/2025 to 02/21/2026 showed no documentation to indicate that Resident 64 had a self-administration of medication evaluation.Review of the February 2026 MAR showed Resident 64 had the following oral medication scheduled between 7:00 AM to 10:00 AM:- Amlodipine, 1 tablet- Lamotrigine (for bipolar disorder [mental health condition that causes extreme mood swings]), 1 tablet- Acetaminophen, 1 tablet- Mirabegron (for overactive bladder [condition that causes sudden urges to urinate]), 50 milligram (unit of measurement) tabletOn 02/24/2026 at 9:41 AM, Resident 64 was observed taking her oral medications from a medication cup in their room. Resident 64 stated they were taking medications for blood pressure, for bladder, Tylenol [or acetaminophen], and a medication for bipolar disorder. When asked if a facility staff had evaluated them for self-administration of medications, Resident 64 stated, No.In a joint record review and interview on 02/24/2026 at 10:57 AM with Staff M, the February 2026 MAR showed Resident 64 was given the following morning medications: 1 amlodipine tablet, 1 lamotrigine tablet, 1 mirabegron tablet, and 1 acetaminophen tablet. Staff M stated they left Resident 64 with their medications and that they should have watched them take their medications before leaving their room.A joint record review and interview on 02/25/2026 at 1:30 PM with Staff J, did not show that Resident 64 had a physician order for self-administration of medications. Staff J stated, the nurse [Staff M] should not have left the medications at bedside, and should have waited next to the resident [Resident 64] until they took all their medications.In an interview on 02/25/2026 at 2:50 PM, Staff B, Director of Nursing Services, stated that they did not expect nurses to leave medications at residents' bedside if they [the residents] are not on self-med [self-administration of medication] program. Staff B further stated that the nurse [Staff M] should have stayed with Residents 92 and 64 until they took all their medications.Reference: (WAC) 388-97-0440,1060 (3)(I).

Based on interview and record review, the facility failed to ensure care plans were revised accurately to reflect changes related to discontinuation of medications for 2 of 22 residents (Residents 13 & 12), reviewed for care planning. This failure placed residents at risk for unidentified and unmet care needs, and a diminished quality of life.Findings included. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated July 2025, showed, Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. RESIDENT 13 Review of the Behavior Monitor care plan printed on 02/22/2026 showed Resident 13 takes Venlafaxine.and Mirtazapine [both medications used to treat depression (persistent feelings of sadness and loss of interest)]. Review of the Order Summary Report printed on 02/18/2026, did not show Resident 13 had orders for Venlafaxine and Mirtazapine. Review of Resident 13's December 2025 Medication Administration Record (MAR) showed Venlafaxine was discontinued on 12/07/2025 and Mirtazapine was discontinued on 12/08/2025. In an interview and joint record review on 02/24/2026 at 8:39 AM, Staff V, Resident Care Manager (RCM), stated, We do review and update [the] care plan as a team. Also, if there are changes to the medication.we update them. A joint record review of the Behavior Monitor care plan showed Resident 13 takes Venlafaxine.and Mirtazapine . When asked if Resident 13 was taking both medications, Staff V stated that both medications were discontinued in December 2025. Staff V further stated, It [behavior monitor care plan] does not look like it was updated. In an interview on 02/24/2026 at 10:33 AM, Staff B, Director of Nursing Services, stated that they reviewed resident's care plan with any change in condition. Staff B stated, Yes when asked if they expected Resident 13's behavior monitor care plan to have been revised and/or updated. Staff B further stated, The care plan should be reflecting [Resident 13's] status. RESIDENT 12Review of Resident 12's alteration in cognition and communication care plan, revised on 04/08/2025, showed Resident 12 takes Rivastigmine [medication used to treat mild to moderate dementia] for memory loss due to Lewy Body Dementia [a type of dementia]. An additional care plan revised on 12/31/2024 showed Resident 12 had alteration in vision related to vision loss and Medication: Prednisone [medication used to treat inflammation], carboxymethylcellulose [an artificial tear to relieve dry eyes]. Review of Resident 12's February 2026 MAR did not show an active order for rivastigmine, prednisone, or carboxymethylcellulose. On 02/24/2026 at 10:12 AM, Staff K, Licensed Practical Nurse, stated that they would expect a care plan to be updated or revised to reflect the medication the resident was currently on. On 02/24/2026 at 11:18 AM, Staff I, RCM, stated that the RCMs were responsible for revising the care plan, quarterly and as needed. A joint record review of Resident 12's care plan showed that the resident had medication for rivastigmine, prednisone, and carboxymethylcellulose. Staff I stated that Resident 12 had discontinued medications and did not currently take those and that the care plan should have been revised to reflect that. On 02/25/2026 at 10:27 AM, Staff B stated that they would expect resident care plans to be revised when medication was discontinued. Reference: (WAC) 388-97-1020 (5)(b) .

Based on interview and record review, the facility failed to ensure the pneumococcal vaccine (used to prevent pneumonia [a lung infection]) was up to date for 1 of 5 residents (Resident 3), reviewed for pneumococcal immunizations. This failure placed the resident at risk for acquiring, transmitting, and/or experiencing potential complications from pneumococcal disease.Findings included. Review of the facility's policy titled, Pneumococcal Vaccine, dated October 2025, showed that all residents would be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The policy further showed, Administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. According to CDC's official website publication titled, Adult Immunization Schedule Notes, dated 10/07/2025, showed an adult who had previously received both PCV [Pneumococcal Conjugate Vaccine-a type of vaccine]13 and PPSV [Pneumococcal Polysaccharide Vaccine- a type of vaccine]23 but NO PPSV23 was received at age [AGE] years or older will have one dose PCV20 or one dose PCV21 at least 5 [five] years after the last pneumococcal vaccine dose. Review of the admission record printed on 02/25/2026 showed Resident 3 was admitted to the facility on [DATE]. Review of the immunization record showed Resident 3 had received PPSV23 on 02/14/2001 and PCV13 on 11/12/2018. Review of the Vaccination History and Consent dated 03/10/2024 showed Resident 3 had agreed to Prevnar 20 (or PCV20) administration. Review of the Electronic Health Record (EHR) did not show Resident 3 had received Prevnar 20. In an interview and joint record review on 02/25/2026 at 8:30 AM, Staff C, Infection Preventionist, stated that they followed the CDC guidelines for pneumococcal vaccination schedule for residents. Staff C stated that Resident 3 had signed a consent dated 03/10/2024 to receive Prevnar 20. A joint record review of the EHR did not show Resident 3 was provided the Prevnar 20. Staff C stated, No, there is no documentation that it [Prevnar 20] was administered. Staff C further stated that they expected Resident 3 to have received Prevnar 20. In an interview on 02/25/2026 at 11:44 AM, Staff B, Director of Nursing Services, stated that they expected Resident 3 to have received their pneumococcal vaccination per CDC guidelines. Reference: (WAC) 388-97-1340(2).

Based on interview and record review, the facility failed to accurately assess 3 of 24 residents (Residents 68, 13 & 8), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure resident assessments were completed accurately on the MDS regarding dialysis (treatment that helps body remove extra fluid and waste products from blood when the kidneys cannot), medication, and smoking placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included. According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated in October 2025, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). RESIDENT 68Review of the admission record printed on 02/21/2026, showed Resident 68 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (last stage of kidney disease where kidneys no longer work) and dependence on renal dialysis. Review of a nursing progress note dated 01/16/2026 showed Resident 68 was on dialysis. Review of Resident 68's admission MDS dated [DATE], showed that dialysis was not marked under Section O (special Treatments, Procedures, Programs). In a phone interview and joint record review on 02/23/2026 at 1:33 PM, Staff E, MDS Coordinator, stated that they would follow the RAI manual and review the resident's medical records to complete MDS assessments. A joint record review of Resident 68's Electronic Health Record showed the resident was on dialysis during the assessment period. A joint record review of Resident 68's admission MDS dated [DATE] showed dialysis was not marked on the MDS. Staff E stated that Resident 68's dialysis was not marked on the MDS, it was a coding error, and that MDS correction would be completed. In an interview on 02/24/2026 at 2:30 PM, Staff B, Director of Nursing Services, stated that the facility would use the RAI manual as guidance for MDS completion, and that they would expect staff to follow the manual when completing MDS assessments. RESIDENT 13 Review of the significant change MDS dated [DATE] showed Resident 13's MDS Section N0415 (High-Risk Drug Classes: Use of Indication) was not marked for antianxiety medication during the assessment period. Review of the January 2026 Medication Administration Record (MAR) printed on 02/22/2026 showed Resident 13 had received antianxiety medication during the assessment period. During a phone interview and joint record review on 02/24/2026 at 3:31 PM, Staff E stated that they followed the RAI manual in completing the MDS. A joint record review of Resident 13's significant change MDS dated [DATE] did not show antianxiety medication was marked. A joint record review of the January 2026 MAR showed Resident 13 had received Buspirone- an antianxiety medication during the 7-day look back period. Staff E stated that the MDS was not accurate and was miscoded. RESIDENT 8Review of Resident 8's progress note dated 09/08/2025 showed, . Continues to smoke 1 [one] cigarette daily. Current light daily smoker – 1 - [to] 2 [two] cigarettes daily. Review of a Smoking Safety Evaluation, dated 09/11/2025, showed Resident 8 required supervision with smoking. Review of Resident 8's annual MDS dated [DATE] showed J1300 (Current Tobacco Use) in Section J (Health Conditions) was marked No, indicating that Resident 8 did not use or smoked tobacco during the look-back period (09/05/2025 to 09/11/2025). During a phone interview and joint record review on 02/25/2026 at 12:22 PM, Staff E stated they followed the RAI manual to complete MDS. Staff E stated that they would mark Yes in section J1300 if they would find documentation showing that residents used or smoked tobacco during the look-back period. A joint record review showed Resident 8's annual MDS dated [DATE] was marked No for tobacco use. A joint record review of a progress note dated 09/08/2025 and a smoking safety evaluation dated 09/11/2025 showed Resident 8 used and/or smoked tobacco during the look-back period. Staff E stated Resident 8 smoked during the look-back period and that their MDS was inaccurate for tobacco use. In an interview on 02/25/2026 at 2:25 PM, Staff B stated they expected MDS to be completed accurately. Reference: (WAC) 388-97-1000(1)(b).

Based on interview and record review, the facility failed to ensure an informed consent explaining the risks/benefits for psychotropic medication (alters mood, perception, and behavior) was completed prior to medication administration for 1 of 5 residents (Resident 12), reviewed for unnecessary medications. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about medications prior to administration.Findings included .Review of the facility's policy titled, Psychotropic Medication Use, revised in July 2022, showed, Residents (and/or representatives) have the right to decline treatment with psychotropic medications. The policy further showed, The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives.Review of Resident 12's February 2025 Medication Administration Record (MAR) showed an as needed (PRN) order for lorazepam (an antianxiety) medication was administered.Review of Resident 12's January 2025 through February 14, 2025, progress notes did not show whether Resident 12 or their representative received informed consent regarding lorazepam and whether they agreed to start the medication.Review of Resident 12's Consent for use of Psychotropic Medication Therapy - V 3, dated 01/09/2025, showed lorazepam was prescribed for Generalized Anxiety Disorder. The consent showed under section, D. Informed Consent, the Patient [resident] does not give consent to the use of the prescribed medication and understands the risk/s associated with not accepting the prescribed medication. The consent further showed under section D 3. The responsible party that was informed.Further review of Resident 12's electronic health record evaluations showed no other informed consent was given to Resident 12 or their representative prior to receiving lorazepam in February 2025.Review of Resident 12's Anti-Anxiety Psychotropic Medication Disclosure and Consent, dated 04/01/2025, showed a consent for lorazepam that did not show whether the resident and/or representative accepted or declined the medication.On 02/24/2026 at 10:53 AM, Staff I, Resident Care Manager, stated that when a resident began a psychotropic medication they would obtain consent from the resident or representative. Staff I stated the consent would inform the resident and/or representative what the medication was and the risks and benefits of the medication. Staff I further stated if the resident or representative disagreed with taking the medication they would not start it and document it in the progress notes.In a joint record review and interview on 02/24/2026 at 10:58 AM with Staff I showed an incomplete consent for lorazepam dated 04/01/2025. Staff I stated that the form was not complete and that they should have checked the box to indicate whether they accepted or declined the medication. Staff I further stated that lorazepam was an order from hospice (end of life care) and that they would have expected to obtain informed consent and make a progress note. A joint record review of Resident 12's progress notes showed no documentation that the informed consent was reviewed with the resident and or their representative and whether they had agreed to begin the medication. Staff I stated they should have made a progress note.On 02/25/2026 at 10:22 AM, Staff B, Director of Nursing Services, stated they would expect staff to obtain consent from the resident and/or representative prior to starting a psychotropic medication. Staff B further stated the consent would be important because it would inform the resident and/or representative about the medication, risks and benefits, and when consent was given.Reference: (WAC) 388-97-0260.

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR or PASRR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), Intellectual Disabilities (ID); or related conditions are not inappropriately placed in nursing homes for long term care) form was followed up on or sent out for a Level II PASARR referral for 2 of 6 residents (Residents 15 & 12), reviewed for PASARR Screening. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.Findings included.On 02/24/2026 at 9:40 AM, Staff H, Social Service Assistant, stated they would send in a referral for a Level II PASARR for anyone who had a diagnosis of a mental illness. Staff H stated they would send medical records including a face sheet, diagnoses, medication, and progress notes. Staff H stated that they would email this information and expect to follow up within a month. Staff H further stated it would be important for a resident to be evaluated for a Level II PASARR to see if there was anything the resident could get extra help with or was available to them.RESIDENT 15Resident 15 admitted to the facility on [DATE] with diagnoses that included Post-Traumatic Stress Disorder (PTSD- mental health condition triggered by experiencing or witnessing terrifying, life-threatening events like combat, abuse, or disasters), Anxiety Disorder (persistent, excessive fear or worry that interferes with daily life), Major Depressive disorder (MDD- persistent, intense sadness or a loss of interest in activities), Schizophrenia (a severe, chronic mental disorder that causes a disconnection from reality, characterized by hallucinations [vivid, involuntary sensory perceptions], delusions (false beliefs), and disorganized thinking), paranoid personality disorder (long-term, pervasive pattern of unwarranted distrust and suspicion of others), visual hallucinations, adjustment disorder with mixed anxiety and depressed mood, and auditory (hearing) hallucinations.On 02/24/2026 at 9:43 AM, Staff H stated that Resident 15 had diagnoses that included anxiety, PTSD, unspecified schizophrenia, visual hallucinations, paranoia, and adjustment disorder. Staff H stated that they emailed for a Level II PASARR referral on 11/05/2025 and did not see an evaluation yet. Staff H further stated that they had not followed up since 11/05/2025 and that they should have.RESIDENT 12Resident 12 admitted to the facility on [DATE] with diagnoses that included anxiety disorder, auditory hallucinations, visual hallucinations, delusional disorders, and MDD.Review of Resident 12's PASARR form dated 12/11/2024, showed they had SMI and a Level II PASARR referral was needed.Review of an email dated 12/10/2024 showed Staff H, had reached out to a PASARR evaluator stating, Please review for level II for [Resident 12]. The email further showed a response of, This has been received. Can you please send the completed PASRR Level I? The email showed no further documentation that the facility staff provided the requested information.Review of Resident 12's Level II PASRR Invalidation Assessment, dated 11/22/2025 showed a date of referral of 12/11/2024. The Invalidation Assessment further showed, 6. Other: Medical records not received, and that Admin closing case due to records not received.On 02/24/2026 at 9:53 AM, Staff H stated that they had just realized that the PASARR coordinator had not received Resident 12's medical records and would resend them. Staff H stated that they would have expected to send the medical records prior.On 02/25/2026 at 9:23 AM, Staff G, Social Services Director, stated that they expected to review PASARRs on admission and send them out for a Level II referral if required. Staff G stated that they expected staff to follow up every month.In a follow up interview on 02/25/2026 at 12:53 PM, Staff G stated that this was the best we could come up with [email from 12/10/2024], and that the email with the initial records had been deleted and could not provide other supporting documentation.On 02/25/2026 at 10:28 AM, Staff A, Administrator, stated that they expected staff to routinely (monthly) talk to the PASARR assessor to continue checking in to have either a Level II PASARR evaluation or invalidation. Staff A further stated that they would expect there to be documentation to show that they were following up with a resident's PASARR.Reference: (WAC) 388-97-1915 (4).

Based on observation, interview, and record review, the facility failed to ensure dignity was provided during dining observations for 2 of 10 residents (Residents 89 & 47), reviewed for dining. The failure to ensure licensed nurses refrained from administration of medications during resident meals placed the residents at risk for a diminished quality of life.Findings included.Review of the facility's policy titled, Dignity, revised in October 2025, showed, Residents are treated with dignity and respect at all times.RESIDENT 89Observation on 02/17/2026 at 12:54 PM, showed multiple residents were eating their meals in the dining room. Staff K, Licensed Practical Nurse, entered the dining room and mixed Resident 89's medication with yogurt. Resident 89 took their medication in the dining room.An additional observation on 02/19/2026 at 1:03 PM, showed multiple residents were eating their meals in the dining room. Staff K administered Resident 89 their medication in the dining room.RESIDENT 47Observation on 02/17/2026 at 1:04 PM showed Staff K administered Resident 47 their medication in the dining room while multiple residents were present eating their meals.In an interview and joint record review on 02/19/2026 at 1:12 PM, Staff K stated medication could be administered in the dining room if it was necessary for the routine of the resident. Staff K stated that administering medication to Resident 89 and Resident 47 was a part of the residents' routine. Staff K stated that this should be reflected in the residents' care plan. A joint record review of Resident 89's care plan did not show that they preferred medication in the dining room as part of their routine. A joint record review of Resident 47's care plan did not show that they preferred medication in the dining room as part of their routine. Staff K stated that the care plans did not reflect their routine and that they should have.On 02/24/2026 at 11:28 AM, Staff I, Resident Care Manager, stated that medication should not be administered during mealtimes in the dining room because residents were eating their meal and for privacy. Staff I stated that if a resident wanted their medication in the dining room, they would expect their care plan to reflect that. Staff I further stated that Resident 89 and Resident 47's care plan did not reflect that.On 02/25/2026 at 10:24 AM, Staff B, Director of Nursing Services, stated that the facility staff knew the residents and their routine and did not really expect to care plan if a resident took their medication in the dining room as part of their routine.Reference: (WAC) 388-97-0860 (1).

Based on interview and record review, the facility failed to ensure the necessary treatment and services for pressure ulcer/pressure injury (PU/PI - an injury to skin and underlying tissue resulting from prolonged pressure on the skin) was provided consistent with professional standards of practice for 1 of 1 resident (Resident 1), reviewed for pressure ulcer care. This failure placed the resident at risk for deterioration of their pressure ulcer and a diminished quality of life. Findings included . Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised in March 2014, showed, The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement [the process of removing adherent dead or foreign material from wounds to minimize the risk of infection and promote healing] approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration. Review of Resident 1's admission Minimum Data Set (an assessment tool) dated 11/01/2024, showed Resident 1 had an intact cognition. The MDS further showed Resident 1 had one unstageable PU/PI related deep tissue injury (a purple or maroon area of discolored intact skin due to damage to the underlying soft tissue). In an interview on 12/26/2024 at 11:01 AM, Resident 1 stated that they had pressure ulcer to their buttock. When asked if they were receiving wound care, Resident 1 stated that they were not getting wound treatment according to their physician's order stating, My wound cleaning solution is missing. Review of the nursing progress note dated 12/03/2024, showed Resident 1 had an order to, Apply moistened gauze with Dakin's [a solution used to prevent and treat skin and tissue infections] solution 25 percent into wound bed. Review of a wound consultant note dated 12/12/2024, showed Resident 1 had a Stage 4 (a PU/PI with full thickness tissue loss with exposed bone, tendon or muscle) with a treatment recommendation to, Apply 1/4 [quarter] strength Dakin's soaked gauze. The nursing progress note dated 12/23/2024 showed that Resident 1 refused their wound treatment due to, Dakins solution not being available and being in a significant amount of pain. The nursing progress notes dated 12/26/2024, 12/28/2024, 12/29/2024, 12/31/2024, 01/02/2025, and 01/03/2025, showed that Dakin's solution was not available for Resident 1's wound treatment. Further review of the progress notes did not show that Resident 1's physician or their wound consultant were notified about the unavailability of the Dakin's solution. In an interview on 01/10/2025 at 10:33 AM, Staff D, Licensed Practical Nurse, stated that Resident 1's Dakin's wound treatment solution was not available in the past and, they were treating Resident 1's wound with wet-to-dry (a wet or moist gauze dressing applied on wound and allowed to dry) dressing. When asked if Resident 1's physician was notified or a new wound care order was received, Staff D stated that Resident 1's wound doctor was aware, but their physician was not notified, or a new wound treatment order was received. In an interview and joint record review on 01/10/2025 at 12:40 PM, Staff C, Resident Care Manager, stated that when a prescribed wound treatment solution was not available, the pharmacy and the resident's physician would be notified. Staff C stated that they were aware of Resident 1's Dakin's solution was not available on 12/23/2024 and they notified the Director of Nursing (DON), and the solution was ordered. Joint record review of Resident 1's progress notes from 12/23/2024 to 01/03/2025 showed no record to show that Resident 1's physician was notified. Staff C stated that licensed nurses should have notified Resident 1's physician when the solution was not available. On 01/10/2025 at 1:18 PM, Staff B, DON, stated that Resident 1's physician should have been notified and an alternative wound treatment order should have been obtained when Dakin's solution was not available. Reference: (WAC) 388-97-1060 (1)(3)(b)

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), Intellectual Disabilities (ID); or related conditions are not inappropriately placed in nursing homes for long term care) form was accurate and sent out for a Level II PASARR referral for 5 of 6 residents (Residents 41, 67, 36, 46 & 20), reviewed for PASARR Screening. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the facility's policy titled, PASRR, revised on 03/22/2024, showed that the social services department would review residents for any indicators that would need a level II screening, such as SMI or ID, and contact the community mental health program to request a Level II screening. Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarification to the Pre-Admission Screening and Resident Review (PASARR or PASRR) Level I Screening Process, dated 07/06/2024 and amended on 08/23/2024, showed a positive Level I PASARR screen (that would then require a referral for a Level II PASARR) was if Any of the questions in Section IA (1, 2, and/or 3) are marked Yes. RESIDENT 41 Review of the face sheet printed on 11/27/2024 showed Resident 41 admitted to the facility on [DATE] with medical diagnoses that included major depressive disorder (mood disorder that causes a persistent feeling of sadness) and anxiety disorder (a condition that causes excessive feelings of fear or worry that can interfere with daily life). Review of Resident 41's current Level I PASARR completed by Staff I, Social Services Assistant, dated 09/05/2024 showed Section I was marked for a SMI indicator for Mood Disorders (Depression), but not for Resident 41's anxiety disorder. Joint record review and interview on 11/29/2024 at 8:28 AM with Staff I, showed Resident 41's Level I PASARR, revealed an evaluation referral for a Level II PASARR was not completed. Staff I stated that anyone who had anything marked for Section IA would require a Level II referral. Staff I stated that there was no referral sent for Resident 41 and that there should have been one. Staff I further stated that Resident 41's anxiety disorder should have also been marked as a SMI indicator. On 11/29/2024 at 8:53 AM, Staff G, Social Services Director, stated that if the PASARR form was incorrect, they would expect it to be corrected. Staff G stated that they were aware of the regulation requiring a Level II PASARR referral for any SMI indicators per Section IA. Staff G further stated, did not understand it, until now. On 11/29/2024 at 10:10 AM, Staff A, Administrator, stated it was their expectation to review PASARR forms to ensure accuracy in accordance with residents' diagnoses. Staff A further stated that if any SMI were marked for Section IA, they would expect a referral for a Level II assessment. 45146 RESIDENT 67 Resident 67 admitted to the facility on [DATE] with diagnoses that included anxiety and major depressive disorder. Review of the admission Minimum Data Set (an assessment tool) dated 10/16/2024, showed Resident 67 had an active diagnoses of anxiety disorder and depression. Review of Resident 67's Level I PASARR dated 10/11/2024, showed under Section IA was marked Yes to include the diagnosis of anxiety disorder. Further review of the PASARR showed mood disorder - depressive was not marked on the PASARR and Section IV showed, No Level II evaluation indicated. Review of the physician's progress note dated 10/15/2024 showed Resident 67 had an active diagnosis of anxiety and depressive disorder. Review of the Electronic Health Record (EHR) showed no documentation that Resident 67's PASARR Level I was corrected or a Level II PASARR referral was sent for review. In an interview and joint record review on 11/28/2024 at 10:03 AM, Staff G stated that when residents were admitted from the hospital, they would review their PASARR and check for accuracy. A joint record review of Resident 67's Level I PASARR dated 10/11/2024, showed Section IA was marked yes for diagnosis of anxiety disorder but not for depressive disorder. Staff G stated that Resident 67's PASARR Level I should have been corrected and referral for Level II should have been sent. On 11/29/2024 at 11:09 AM, Staff A stated that they expected that PASARR should be reviewed on admission for accuracy and Level II referral sent for any indicators of SMI. 48899 RESIDENT 36 Review of the face sheet showed that Resident 36 initially admitted to the facility on [DATE] with multiple diagnoses that included bipolar disorder (a mental health condition characterized by extreme mood swings, which include emotional highs), anxiety disorder, and delusional disorder (a mental health condition that makes it hard for a person to distinguish reality from fantasy). Review of Resident 36's Level I PASARR form dated 02/21/2024, showed that mood and anxiety disorders were marked in section IA for SMI. Further review of the document showed that the SMI Indicators section was marked yes [has SMI]. Joint record review of the face sheet and interview on 11/29/2024 at 8:14 AM with Staff I, showed Resident 36 had diagnosis that included mood, anxiety and delusional disorders. Joint record review of Resident 36's Level I PASARR showed that mood and anxiety disorders were marked. The review of Resident 36's Level I PASARR also showed that delusional disorder was not marked. Further review of the record showed that SMI Indicators section was marked yes. Staff I stated that Resident 36's Level I PASARR should have been consistent with their medical diagnosis. After reviewing the new regulation, Staff I stated that they should have sent a Level II PASARR referral to evaluator for Resident 36. In an interview on 11/29/2024 at 10:06 AM, Staff G stated that they expected Resident 36's Level I PASARR should have been consistent with their medical diagnosis. In an interview on 11/29/2024 at 10:41 AM, Staff A stated that they expected Resident 36's medical diagnosis to align with their Level I PASARR evaluation. Staff A stated Level II PASARR referral should be sent for any indicators of SMI. 51090 RESIDENT 46 Resident 46 admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder (PTSD - a mental health condition that can develop after a person experiences a traumatic event), anxiety, and major depressive disorder. Review of Resident 46's physician's order, dated 07/31/2024, showed Resident 46 received an antidepressant medication for diagnosis of major depressive disorder. Review of Resident 46's Level I PASARR completed on 02/29/2024, showed IA was marked Yes to include the diagnosis of PTSD and anxiety disorder. Further review of the PASARR showed major depressive disorder was not marked in section IA and Section IV showed No level II evaluation indicated. Review of Resident 46's EHR showed no documentation that a Level II PASARR referral was completed. In a joint record review and interview on 11/29/2024 at 8:43 AM with Staff I, showed Resident 46's Level I PASARR dated 02/29/2024 did not show the diagnosis of major depressive disorder was marked in Section IA and that Section IV was marked no level II evaluation indicated. Staff I stated, Depression should be checked, and it wasn't captured, so I missed that. Staff I further stated that they were aware of the new law and that I don't think I put in a level II [PASARR evaluation] for [them]. RESIDENT 20 Resident admitted to the facility on [DATE] with diagnoses that included delusional disorders and major depressive disorder. Review of Resident 20's Level I PASARR completed on 08/20/2021, did now show the diagnosis for major depressive disorder was marked in Section IA and that Section IV was marked No level II evaluation indicated. Review of Resident 20's EHR showed no documentation that a Level II PASARR referral was completed. Joint record review and interview on 11/29/2024 at 8:43 AM with Staff I, showed Resident 20's Level I PASARR dated 08/20/2021 revealed the diagnosis of major depressive disorder was not marked in Section IA and that Section IV was marked No level II evaluation indicated. Staff I stated, It came from the hospital this way and I can't believe I didn't correct it. Staff I further stated Resident 20 should have had a level II PASARR referral completed. In an interview on 11/29/2024 at 8:53 AM, Staff G stated social services were responsible for reviewing PASARR documents received from the hospitals and that they expected them to be accurate. Staff G stated that they expected PASARR Level I form to have been accurate and that Level II PASARR evaluation referrals should have been completed for Resident 46 and Resident 20. In an interview on 11/29/2024 at 12:09 PM, Staff A stated they were aware of the clarification on the PASARR Level I since July 2024. Staff A further stated that they expected PASARR forms to be accurate and that Level II referrals would be completed as needed. Reference: (WAC) 388-97-1915 (2)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked for each shift for 6 of 7 days (11/23/2024, 11/24/2024, 11/25/2024,11/26/2024,11/27/2024 & 11/28/2024), reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels. Findings included . Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised in August 2022, showed that shift staffing information must be recorded on a form for each shift. The policy further showed the form should include the actual hours worked during that shift for each category and type of nursing staff [Registered Nurse, Certified Nursing Assistant and Licensed Practical Nurse]. Observations on 11/23/2024 at 1:36 PM, on 11/24/2024 at 2:26 PM, on 11/25/2024 at 2:21 PM, on 11/26/2024 at 1:23 PM, on 11/27/2024 at 1:43 PM and on 11/28/2024 at 2:03 PM, showed that the facility's daily nursing staffing form posted did not show the actual hours worked for each shift for all nursing staff. In an interview on 11/29/2024 at 8:38 AM, Staff B, Director of Nursing Services stated that they were responsible for completing the nurse staffing postings. Staff B stated that they had not been filling out the actual total hours because that was how their previous staffing coordinator trained them. In an interview on 01/20/2024 at 10:05 AM, Staff A, Administrator, stated, Daily nurse staff postings need to be visible and available, with the actual hours filled out. No associated WAC

Based on observation, interview, and record review, the facility failed to ensure drugs and/or biologicals were properly labeled, stored, and/or expired supplies were removed/discarded in accordance with current accepted professional standards for 2 of 4 medication carts (Cascade and Olympic Medication Cart) and for 2 of 2 medication room refrigerators (Cascade and [NAME] Medication Room Refrigerators), reviewed for medication storage and labeling. These failures placed the residents at risk for receiving compromised and ineffective medications and medical supplies. Findings included . Review of the undated facility's dispensing pharmacy reference guide titled, Did you know? showed that Unless otherwise stated by manufacturer or stricter facility policy, open meds generally expire on the printed expiration date or one year since open date (whichever is sooner) .record an 'open date' on all opened meds (liquids, topicals, insulin [hormone that lowers blood sugar level] vials, insulin pens, eye drops, etc.) .Expiration dates: Insulins should be dated once opened and stored in [medication] cart .Storage: no unlabeled meds (e.g., from e-kit [emergency medication supply]). Review of the facility's undated policy titled Medication Labeling and Storage, showed that Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices .The medication label includes, at a minimum: medication name, prescribed dose; strength; expiration date, when applicable; resident's name; route of administration; and appropriate instructions and precautions .If medication containers have missing, incomplete or incorrect labels, [facility staff] contact the dispensing pharmacy for instructions regarding returning or destroying these items .only the dispensing pharmacy may label or alter the label on a medication container or package. CASCADE MEDICATION CART Joint observation and interview on [DATE] at 8:57 AM, showed Staff P, Licensed Practical Nurse (LPN), primed (removing air from the insulin pen to ensure the correct dose of insulin was delivered) two newly opened insulin pens. Further observation showed Staff P did not date the two insulin pens before storing the insulin pens in the medication cart. When asked if insulin pens should be dated with an open date, Staff P stated they should have dated the insulin pens with the open date. OLYMPIC MEDICATION CART Joint observation and interview on [DATE] at 10:03 AM with Staff K, LPN, showed a prescription bronchodilator (used to prevent and treat difficulty breathing) inhaler (medical device that delivers medication directly to the lungs through a mist or spray that the user breaths in) that had a pink label sticker. Written on the sticker was Resident 301's last name and an incomplete date, ,d+[DATE]. Further observation showed Resident 301's inhaler did not have a prescription or pharmacy label. Staff K stated, The label should come from the pharmacy; this is not the right label. Staff K further stated the pink label attached to Resident 301's inhaler did not contain a complete name or date. Joint record review and interview on [DATE] at 11:55 AM with Staff B, Director of Nursing Services, showed the facility's pharmacy reference guide was the guidance followed and implemented by the facility. Staff B stated they expected OTC medications and prescribed inhalers to be properly labeled with the resident and prescription information when they were stored in the medication cart. 45146 CASCADE MEDICATION ROOM REFRIGERATOR According to the Centers for Disease Control and Prevention (CDC) website titled, Vaccine Storage and Handling, dated [DATE], showed, To ensure the safety of vaccines, the storage unit minimum and maximum temperatures should be checked and recorded at the start of each workday. If using a TMD [Temperature Monitoring Devices] that does not display minimum and maximum temperatures, then the current temperature should be checked and recorded a minimum of two times (at the start and end of the workday). Review of the Cascade medication room refrigerator temperature log for [DATE], [DATE] and [DATE] showed that the refrigerator's temperature was checked once a day during night shift. Further review of the log showed a written direction that stated, CDC recommends twice daily temps if vaccines present. In a joint observation and interview on [DATE] at 8:29 AM with Staff E, Resident Care Manager (RCM), showed there was a vaccine for Respiratory Syncytial Virus (RSV - a common respiratory virus usually causes mild, cold-like symptoms, serious lung infections) stored in the Cascade medication room refrigerator. Staff E stated that the vaccine stored in the refrigerator was for RSV. In an interview and joint record review on [DATE] at 10:55 AM, Staff E stated that the facility followed CDC's guideline for vaccines storage. Joint record review of the Cascade medication room temperature log for [DATE], [DATE] and [DATE] showed that the refrigerator's temperature was checked once a day. Staff E stated the refrigerator temperature should have been checked twice a day. BAKER MEDICATION ROOM REFRIGERATOR During a joint observation and an interview on [DATE] at 11:10 AM with Staff D, RCM, showed there was a box containing intravenous starter needle (IV - a small plastic tube, inserted into a vein to administer medications or fluid) with an expiration date of [DATE]. Staff D stated the IV needles were expired and should have been discarded. During a joint record review and an interview on [DATE] at 11:22 AM with Staff D, showed the [NAME] medication room refrigerator temperature log revealed no records of temperature on [DATE], [DATE] and [DATE]. Further review of the temperature log showed the temperature were checked once a day on [DATE], [DATE], [DATE], [DATE] and [DATE]. Staff D stated the refrigerator's temperature should have been consistently checked twice daily. In a joint observation and an interview on [DATE] at 8:42 AM with Staff D, showed there was an RSV vaccine stored in the medication room's refrigerator. Staff D stated that the vaccine stored in the refrigerator was for RSV and the refrigerator's temperature should have been checked twice daily. On [DATE] at 10:59 AM Staff C, Infection Preventionist, stated the medication rooms refrigerators' temperature should have been checked twice daily. On [DATE] at 8:22 AM, Staff B stated that the facility followed CDC's guideline for storage of vaccines and the medication rooms refrigerators temperature should have been checked twice daily. Staff B further stated expired IV starter needles should have been discarded. Reference: (WAC) [DATE] (2)

Based on observation, interview, and record review, the facility failed to ensure insulin (hormone that lowers blood sugar level) pens were properly disinfected and hand hygiene practices were followed during medication administration for Resident 155, and failed to properly store personal care items for room [ROOM NUMBER] and Personal Protective Equipment (PPE) for 5 of 7 isolation carts in (Rooms 200, 215, 205, 118 & 325), reviewed for infection control. In addition, the facility failed to provide hand hygiene supplies for 2 of 2 medication rooms (Cascade & Baker), and failed to ensure disinfection of shared transfer lift equipment was conducted between resident use for 2 of 2 residents (Residents 82 & 301). These failures placed the residents and staff at an increased risk for infection and related complications. Findings included . Review of the facility's policy titled, Infection Prevention and Control Program, revised in October 2018, showed, The program is based on accepted national infection prevention and control standards .The infection prevention and control program . a facility-wide effort involving all disciplines and individuals .Policies and procedures reflect the current infection prevention and control standards of practice. Review of the website titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated April 12, 2024, showed that the following core practice categories were listed: 5c. Injection and Medication Safety 1. Prepare medications in a designated clean medication preparation area that is separated from potential sources of contamination, including sinks or other water sources. 5f. Reprocessing of reusable medical equipment 1. Clean and reprocess (disinfect or sterilize) reusable medical equipment .prior to use on another patient or when soiled . 2. Maintain separation between clean and soiled equipment to prevent cross contamination. RESIDENT 155 INSULIN PEN DISINFECTION & HAND HYGIENE Review of the facility's policy titled, Handwashing/Hand Hygiene, revised in August 2019, showed that hand hygiene is the final step after removing and disposing of PPE, including after removing gloves. Observation and interview on 11/26/2024 at 8:57 AM, showed Staff P, Licensed Practical Nurse (LPN), donned a gown and gloves prior to administering two separate insulin doses for Resident 155. After administering the first dose of insulin to Resident 155, Staff P needed a second alcohol wipe (used to clean the skin prior to insulin administration). Staff P then placed Resident 155's two insulin pens and one new insulin pen needle directly on the sink counter in Resident 155's room and doffed their gloves. Staff P did not perform hand hygiene after doffing gloves. While wearing a gown, Staff P found an alcohol wipe in their uniform pocket. Staff P did not perform hand hygiene after touching their uniform and gown before donning a new pair of gloves to administer Resident 155's second insulin dose. Further observation showed Staff P stored the two insulin pens in the medication cart without cleaning them. Staff P stated, After using them [Resident 155's insulin pens], yes, we should be wiping [cleaned/disinfected] them, I did not. Staff P further stated they did not perform hand hygiene before and after glove use when they administered Resident 155's insulin doses and that they should have performed hand hygiene. room [ROOM NUMBER] STORAGE OF PERSONAL CARE ITEMS Observation on 11/23/2024 at 8:18 AM, showed unbagged personal care items that included a portable toilet seat extender (a device that attaches to a toilet seat to increase its height), a female bed pan (portable container used for toileting) and two plastic basins stacked and placed directly on the bathroom floor in room [ROOM NUMBER]'s bathroom. Joint observation and interview on 11/24/2024 at 9:57 AM with Staff D, Resident Care Manager, showed unbagged items that included a portable toilet seat extender, a female bed pan, and two plastic basins stacked and placed directly on the bathroom floor in room [ROOM NUMBER]. Staff D stated that the personal items stacked on the floor were used and that It should be removed. Staff D stated personal hygiene items should be bagged whenever they were clean and stored in the resident's bathroom and that once they are used, they need to be taken to the dirty utility [room] to be washed. PPE AND ISOLATION CARTS Review of the CDC website tiled, Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs-germ that is resistant to medications that treat infections), dated April 2, 2024, showed, Make PPE, including gowns and gloves, available immediately outside of the resident room. room [ROOM NUMBER] Observation on 11/24/2024 at 9:01 AM, showed the isolation PPE cart for Enhanced Barrier Precautions (EBP- gown and glove use to protect residents from MDRO in front of room [ROOM NUMBER] had one bag of Lays (a brand) chips stored in the first drawer, two plastic drink cups stored with a box of gloves in the second drawer, and an empty third drawer. Further observation did not show gowns were stored in the isolation cart. Joint observation and interview on 11/24/2024 at 9:05 AM, showed Staff H, Case Manager, took out the two plastic cups and the bag of chips from room [ROOM NUMBER]'s isolation cart. Staff H stated the two cups and bag of chips should not have been stored with PPE and that face shields, gowns and gloves should be stored in the isolation cart for EBP. Staff H further stated that room [ROOM NUMBER]'s isolation cart did not have gowns stored. In an interview on 11/24/2024 at 9:21 AM, Staff C, Infection Preventionist, stated the bag of chips and two cups should not have been stored in the isolation cart for room [ROOM NUMBER]. room [ROOM NUMBER] Observation on 11/24/2024 at 9:09 AM, showed the isolation cart for EBP in front of room [ROOM NUMBER] had linen stored in the third drawer. Further observation did not show gowns were stored in the isolation cart. In an interview and joint observation on 11/24/2024 at 9:11 AM, Staff Q, LPN, stated they did not know what PPE should be stored in the isolation cart for EBP. Joint observation showed that room [ROOM NUMBER]'s EBP signage directed staff to wear gloves and a gown for high contact resident care activities. Further joint observation showed that room [ROOM NUMBER]'s isolation cart did not have gowns stored. Staff Q stated there should not have been a bedsheet stored in the third drawer and that gowns should be stored in the isolation cart. In a joint observation and interview on 11/24/2024 at 9:18 AM with Staff C, showed room [ROOM NUMBER]'s isolation cart had a draw sheet in the third drawer. Staff C took out the draw sheet and stated it should not have been stored with the PPE. Staff C further stated that room [ROOM NUMBER]'s isolation cart should have had gowns readily available for staff. room [ROOM NUMBER] Observation on 11/24/2024 at 9:08 AM, showed the isolation cart for EBP in front of room [ROOM NUMBER] had incontinent briefs stored in the first drawer with a box of gloves. In an interview and joint observation on 11/24/2024 at 9:13 AM, Staff Q stated, I have no idea why [room [ROOM NUMBER]] would be on precautions. Joint observation showed room [ROOM NUMBER] had an EBP signage posted at their door and that incontinent briefs were stored in the first drawer of the isolation cart. Staff Q stated they did not think incontinent briefs should be stored with PPE. When Staff Q was asked what PPE should be stored in the isolation cart, Staff Q stated, I think you should ask management. Joint observation and interview on 11/24/2024 at 9:17 AM with Staff C, showed room [ROOM NUMBER]'s isolation cart had incontinent briefs stored with PPE. Staff C stated the incontinent briefs should not have been stored with PPE. Staff C further stated that they expected staff know the facility's process for EBP. room [ROOM NUMBER] Joint observation and interview on 11/24/2024 at 9:24 AM with Staff H, did not show the isolation cart in front of room [ROOM NUMBER] had gowns stored. Staff H stated No, it's not properly stocked; we are getting those supplies now. room [ROOM NUMBER] Observation on 11/24/2024 at 9:37 AM, showed the isolation cart for EBP in front of room [ROOM NUMBER] had oxygen tubing and normal saline stored with PPE. Joint observation and interview on 11/24/2024 at 9:40 AM with Staff B, Director of Nursing, showed the oxygen tubing and normal saline were stored in room [ROOM NUMBER]'s isolation cart. Staff B stated medical supplies should be stored in the medication room and should not have been stored in the isolation cart. In an interview on 11/29/2024 at 10:57 AM, Staff C stated the facility followed CDC's guidelines for infection prevention and control. Staff C stated that they expected PPE would be available at the point of use, stored in isolation carts. Staff C stated that they expected staff would perform hand hygiene before and after glove use. Staff C further stated that infection prevention practices would be followed when handling insulin pens to include disinfection after each use and before they were stored in the medication cart. In an interview on 11/29/2024 at 11:42 AM, Staff B stated they expected PPE supplies to be readily available in isolation carts and that they expected staff to know what PPE should be stored in the isolation carts and the indications for EBP. Staff B stated, that If [staff] forget, they can always read the [EBP] sign. Staff B stated the facility followed the process of cleaning insulin pens before and after each use and that insulin pens should not be placed on a surface near a sink. Staff B stated they expected staff to perform hand hygiene with glove use and always before and after having contact with the resident or their environment. Staff B further stated they expected personal hygiene supplies stored in residents' bathrooms to be bagged and should not have been placed directly on the floor. 45146 HAND HYGIENE SUPPLIES-CASCADE AND BAKER MEDICATION ROOMS Review of the facility's policy titled, Handwashing/Hand Hygiene, revised in August 2019, showed, Hand hygiene products and supplies (sink, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Observation of the Cascade medication room on 11/26/2024 at 10:43 AM, showed that the medication room had a hand washing station but there was no paper towel or trashcan available in the room. Further observation showed the medication room's hand sanitizer dispenser was empty. During a joint observation and an interview on 11/26/2024 at 11:03 AM with Staff D, showed the [NAME] medication room did not have a working hand washing station or hand sanitizer available in the room for use. Further joint observation of the room's sink showed a notice, Do not use, faucet pipe under construction. Staff D stated, We should have hand sanitizer in here. In an interview and joint observation on 11/26/2024 at 12:57 PM, Staff C stated, Hand washing supplies and hand sanitizer should be available in the medication rooms. Joint observation showed there was no trashcan available for use in the Baker's medication room. Joint observation of the Cascade medication room at 12:59 PM showed there was no hand sanitizer, paper towel or trashcan available for use in the medication room. Staff D stated hand hygiene supplies should have been available for use in the medication rooms. On 11/29/2024 at 8:22 AM, Staff B stated that hand hygiene supplies should have been available in the medication rooms. 48899 TRANSFER LIFT EQUIPMENT Review of facility's policy titled, Cleaning and Disinfection of Resident Care Items and Equipment, revised in September 2022, showed Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard [a regulation designed to protect workers from the health hazards of exposure to bloodborne pathogens]. According to the OSHA Bloodborne Pathogens Standard website, standard number 1910.1030, titled Bloodborne pathogens, section 1910.1030(d)(4)(ii) showed All equipment and environmental and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials. Observation on 11/23/2024 at 11:51 AM, showed that Staff L, Certified Nursing Assistant (CNA) and Staff M, CNA, transferred Resident 82 from their bed to a wheelchair using a Hoyer lift (or transfer lift-a mechanical device designed to assist with transferring residents who have limited mobility). After completing the transfer, Staff L did not disinfect the Hoyer lift before leaving it in the hallway. Further observation showed an EBP was indicated for Resident 82. Observation on 11/23/2024 at 12:16 PM, showed Staff K, LPN, and Staff M transferred Resident 301 from a wheelchair to their bed using the same Hoyer lift that had been previously used for Resident 82. In an interview on 11/23/2024 at 12:38 PM, Staff K stated that they, along with Staff M, transferred Resident 301 from a wheelchair to a bed using Hoyer lift. Staff K stated that they did not disinfect the Hoyer lift because the resident did not touch it. Staff K stated, they would clean Hoyer lift if the resident had an active infection. In an interview on 11/23/2024 at 12:45 PM, Staff L stated that they assisted Staff M in transferring Resident 82 from their bed to a wheelchair using a Hoyer lift. Staff L stated after the transfer, they left the Hoyer lift in the hallway without disinfecting. Staff L stated, I was supposed to sanitize it but forgot. In an interview on 11/23/2024 at 12:52 PM, Staff M stated that they transferred both Resident 82 and Resident 301 using the same Hoyer lift. Staff M stated that they did not clean or sanitize the Hoyer lift before and after transferring Residents 82 or 301. In an interview on 11/27/2024 at 1:30 PM, Staff C stated that their expectation was for the Hoyer lift to be cleaned after each use. Staff C stated that Staff K, Staff L, and Staff M should have cleaned the Hoyer lift after each use. In an interview on 11/29/2024 at 10:09 AM, Staff B stated that they expected staff to clean the Hoyer lift after each use. Staff B stated that Staff K, Staff L, and Staff M should have cleaned the Hoyer lift after using it. Reference: (WAC) 388-97-1320 (1)(a)(c)(5)(a)(c)

Based on interview and record review, the facility failed to properly notify the Office of the State Long Term Care (LTC) Ombudsman (an advocacy group for residents) in writing, describing the reason for transfer for 1 of 1 resident (Resident 36), reviewed for hospitalization . This failure placed the resident at risk for not having the access to an advocate who informed residents about options and resident rights. Findings included . Review of the facility's policy titled, Transfer or Discharge Notice, revised in March 2021, showed, A copy of the notice is sent to the Office of the State LTC Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Review of the progress note dated 09/30/2024, showed Resident 36 was transferred to the hospital for further evaluation. Review of Resident 36's nursing progress note date 09/30/2024 to 11/25/2024 showed no documentation to show that the notice of transfer was sent to the State LTC Ombudsman office. In an interview on 11/27/2024 at 2:32 PM, Staff I, Social Services Assistant, stated that their responsibility included completing the transfer notice form and faxing it to the State LTC Ombudsman office. Staff I stated that there was no documentation confirming the completed transfer notice had been sent to the State LTC Ombudsman office or a fax receipt that showed the transfer notice was sent. Staff I stated that they did not document their communication with the State LTC Ombudsman office about Resident 36's hospital transfer. In an interview on 11/29/2024 at 10:41 AM, Staff A, Administrator stated that they expected the State LTC Ombudsman office to be notified in writing that Resident 36 was sent to the hospital. Staff A further stated that the communications between Staff I and the State LTC Ombudsman office should have been documented. Reference: (WAC) 388-97-0120 (5)(b)(i)

Based on observation, interview, and record review, the facility failed to ensure safe transportation was provided for 1 of 3 residents (Resident 45), reviewed for transportation to an appointment in the facility van. This failure caused harm when the wheelchair tipped over causing ongoing pain in Resident 45's left shoulder, arm, and hand. The failure to ensure the straps attached to the floor of the van were securely attached to the wheelchair before/after appointment transportation placed other residents at risk for injury and harm. Findings included . Review of Resident 45's quarterly Minimum Data Set assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating Resident 45 was cognitively intact. Resident 45 was identified as requiring extensive assist of two person for bed mobility, transfers, and toileting, and required a wheelchair for mobility. Review of Resident 45's medical diagnoses included low back pain and chronic pain. The diagnosis of left shoulder osteoarthritis (inflammation of one or more joints) and left shoulder rotator cuff tear/rupture (condition of muscles and tendons of the shoulder causing pain), and adhesive capsulitis (frozen shoulder-loss of range of motion) of left shoulder were added to the diagnosis list by the physician on 07/10/2023. Review of a progress note dated 05/04/2023 at 3:30 PM, showed Resident 45 came back from an appointment and reported Resident 45 fell in the van while sitting in their electric wheelchair when the van was making a turn. According to the note, Resident 45 was alert and oriented and did not complain of pain and no bruising or injuries were observed. The note stated the resident was seen and evaluated by the nurse practitioner and was sent to the hospital for evaluation. A progress note, dated 05/04/2023 at 9:41 PM, stated Resident 45 returned from the emergency room and was alert and responsive, denied pain, headache, or dizziness. Review of a progress note written by the nurse practitioner, dated 06/13/2023 at 4:11 PM, revealed Resident 45 had been complaining of left shoulder pain for the past month. The note stated Resident 45 injured their shoulder when they were being transported to an appointment [referring to the 05/04/2023 fall incident in the facility van]. Resident 45 was prescribed diclofenac (anti-inflammatory medication) gel and Tylenol as needed for the pain. Review of a pain management consultant note, dated 06/14/2023 at 4:51 PM, stated Resident 45 was seen for complaint of left shoulder pain. The note stated that Resident 45 had left shoulder pain of around one month duration starting after a partial fall [referring to the 05/04/2023 fall incident in the facility van] when their wheelchair tipped over impacting the shoulder. The note stated the pain score was 3-5/10 and was described as aching when at rest and motion. Review of the Internal Medicine [physician who specializes in preventing, diagnosing and treating a wide variety of diseases and other health issues] Discharge Summary, dated 07/10/2023, revealed the physician stated, recent ground level fall from wheelchair into left side on 05/04/2023, and added diagnosis of rotator cuff arthropathy (joint disease causing pain, stiffness, and disability) and frozen shoulder. On 08/20/2023 at 9:42 AM, Resident 45 stated that a few months ago [referring to the fall incident on 05/04/2023] the facility staff picked them up from a doctor's appointment in the facility van and the van driver (Staff G, Maintenance Assistant) did not tie the wheelchair down to the van. When the driver made a left-hand turn to get on the interstate, the wheelchair tipped over and Resident 45's head, left shoulder, arm, and hand hit the side of the van's door. Resident 45 stated they had pain in their left shoulder, arm, and hand ever since this incident occurred. On 08/22/2023 at 1:04 PM, further interview regarding the 05/04/2023 fall incident showed, Staff H, Certified Nursing Assistant, accompanied Resident 45 to the doctor's appointment. When the appointment was over, the van driver picked them up, and pushed Resident 45's wheelchair into the van. Resident 45 told the driver to tie the wheelchair down to the van with the four straps on the floor, but the driver acted like they did not hear what they said. Resident 45 stated as the driver turned left to get on the highway, their wheelchair tipped over and they screamed. Resident 45 stated they hit their head on the driver's side sliding door of the van and landed on their left arm and shoulder. Resident 45 stated the driver pulled the van over, then Staff H lifted their legs to get the wheelchair upright, and the driver just kept saying they were sorry. Resident 45 stated that prior to the incident they did not have left shoulder or arm pain, but ever since it happened, they were having pain. On 08/22/2023 at 10:13 AM, Staff G was interviewed and stated they arrived at the clinic in the facility van to pick up Resident 45 and Staff H from their medical appointment. Staff G stated that Staff H got into the front passenger seat of the van, and they pushed the resident up the van ramp and into the van. Staff G stated they did not strap the wheelchair down because they did not think it would tip over because it was an electric wheelchair, and it was big. Staff G demonstrated that after the side sliding door on the passenger side of the vehicle was opened a ramp was manually pulled out from under the van and the wheelchair was pushed up into the van and maneuvered so it was facing to the front of the van. Observation of the van revealed it had four tiedown straps attached to the floor of the van. Staff G stated they were supposed to strap each corner of the wheelchair down using the straps, which had hooks on the end of the straps. Staff G stated it was possible to strap Resident 45's electric wheelchair down, but they did not strap it down because it was a big electric wheelchair and did not think it would tip over during the ride. Staff G stated as they were making a left-hand turn onto the freeway Resident 45's wheelchair tipped over, and Resident 45 screamed, the wheelchair, and Resident 45 hit the left side of the van door. Staff G stated it was loud when the wheelchair tipped over and hit the inside of the door. Staff G pulled the van over, opened the back passenger side sliding door, and Staff H opened the back driver side sliding door and pulled the wheelchair while Staff H pushed the wheelchair to get it back in the upright position. Staff G then strapped the resident's wheelchair down and drove back to the facility. On 08/22/2023 at 2:10 PM, Staff H stated that Staff G arrived at the medical center to pick them up in the facility van. Staff H stated that Staff G opened the passenger side back sliding door, pulled the ramp out, and pushed the resident in their electric wheelchair up into the van and positioned it, so they were faced forward. Staff H stated Resident 45 told Staff G to tie the wheelchair down, but Staff G stated they did not need to strap it down. Staff H sat in the front passenger seat because the wheelchair was big, and they would not fit in the back seat. Staff H stated as Staff G turned left to get on the freeway Resident 45's wheelchair tipped over to the left and hit their head, left arm, and shoulder on the left side of the van. Staff H stated that Staff G immediately pulled over and stopped and they got the wheelchair back in the right up position. Staff H stated the resident complained of left arm pain immediately after it happened. Staff G then put the four tiedowns on the loop brackets on each corner of the bottom of the wheelchair and drove them back to the facility. Staff H stated they did not call anyone but told the nurse about the incident after they arrived and brought Resident 45 into the facility. On 08/23/2023 at 8:08 AM, Staff B, Director of Nursing Services, was asked if the resident had complained of left shoulder pain prior to the 05/04/2023 incident. On 08/23/2023 at 9:30 AM, Staff B stated they reviewed Resident 45's record, and the only documentation of left shoulder pain was on 09/25/2022. Staff B provided a nursing progress note dated 09/25/2022 and timed 9:41 PM, stating the resident complained of left arm/shoulder pain and chest pain. 911 was called and the resident was sent to the emergency room . Review of the Electronic Medical Record, and interview with Staff B revealed the medical record did not show documentation of left arm or shoulder pain between 09/25/2022 and 05/04/2023. On 08/22/2023 at 3:04 PM, Staff A, Administrator, stated they did not have any policy specific to securing wheelchairs in the facility vans. Staff A stated they follow the instructions in the training material. The training materials were reviewed, the section titled, Ride Safely in the Van Safety Training Program 2012 training packet stated the four tiedown straps attached to the floor of the van must be attached to the securement points provided on the wheelchair and the straps must be tightened to remove all slack. On 08/02/2023 at 3:51 PM, the wheelchair was examined for the securement points/tiedown spots, and the wheelchair was manufactured with the securement points as illustrated in the training packet. Staff A was present during the observation and verified the observation. Staff A stated the wheelchair should have been secured to the van with tiedown straps prior to driving Resident 45 back to the facility. Reference: (WAC) 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to follow and implement written policies and procedures, assessments, physician orders, plan of care, and evaluation related to smoking, and did not ensure smoking materials were securely maintained for 4 of 4 residents (Residents 38, 85, 49 & 76) for whom the facility had identified as smokers. The failure to ensure smoking materials were securely maintained for Resident 38 whose roommate was using oxygen in their room placed the residents at increased risk of serious harm and injury from potential fire hazards and risks of potential [CONDITION(S)]. The failed practice resulted in an Immediate Jeopardy (IJ) on 05/10/2022 at 3:40 PM when the facility failed to ensure the residents and the residents' environment was safe as practicable from potential fire related accidents related to smoking. The facility was notified of the IJ related to CFR 483.25 - F689 Free of Accident Hazards/Supervision/Devices on 05/10/2022 at 3:55 PM. An acceptable removal plan was received from the facility on 05/13/2022, and the immediacy was removed on 05/17/2022. In addition, the facility also failed to implement interventions for 2 of 8 residents (Residents 82 and 67) reviewed for accident hazards. This failure placed the residents at risk for sustaining another injury. Findings included . SMOKING Review of the facility's smoking policy, dated 09/20/2021, documented that, All smoking materials will be secured when the resident is not smoking. Residents are not allowed to have smoking materials on their person in the facility. All staff are expected to enforce this rule. RESIDENT 38 Resident 38 admitted to the facility on [DATE] for multiple care needs. According to the resident's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident 38 had diagnoses that included non-traumatic [CONDITION(S)], cerebral vascular accident (stroke) and [CONDITION(S)] ([CONDITION(S)]). Review of Resident 38's electronic record showed that he was assessed to be an independent smoker. On 05/10/2022 at 11:34 AM, Staff B, the Director of Nursing Services (DNS) was asked if residents were able to maintain their smoking materials with them. Staff B stated that Resident 38 was grandfathered in and was able to maintain his smoking materials. Observation of Resident 38's room on 05/10/2022 at 11:40 AM, showed his roommate was using oxygen in their shared room. Resident 85 Resident 85 was admitted to the facility 12/11/2021 with a diagnosis of a stroke that affected the left side of his body and facial weakness. A smoking assessment for the resident was not performed until 02/22/2022 and the smoking assessment was found to be incomplete. Review of the Care Plan initiated on 02/22/2022 showed the resident was modified independent with smoking, and at risk for injury with a history of burn holes in his clothing. The Medication Administration Record (MAR) for April 2022 and May 2022 showed that LNs signed off every 4-hour room rounds to secure smoking materials from Resident 85. The MAR also show the resident's smoking materials were to be locked at the nurse's station, and if smoking materials were found on the resident to notify Staff A, the Administrator, or the DNS. On 5/13/2022 at 12:03 PM, Resident 85 stated he was a smoker and stated he did not need assistance with smoking and that a smoking assessment had been performed and that he signed a form saying it was okay for him to smoke. Resident 85 also stated that the staff did not perform a visual confirmation to assess if he was safe to smoke without assistance. The resident was asked where he stored his cigarettes. The resident stated he stored his cigarettes in his coat pocket. At this time, the resident picked up his coat, reached into the pocket and pulled out his lighter and package of cigarettes. The resident was asked if he was aware of the facility smoking policy, to which he stated no. RESIDENT 49 Resident 49 was admitted to the facility on [DATE] with multiple diagnoses that included stroke with right side weakness. Review of the resident's annual MDS assessment dated [DATE] showed the resident had moderately impaired cognition and needed extensive assistance with activities of daily living. The assessment also showed that Resident 49 was a current smoker. The facility's smoking safety evaluation dated 04/14/2022 showed that Resident 49 was dropping ashes and was not able to use an ashtray. The resident was putting cigarette butts in the pack and was unable to retrieve a dropped cigarette. The evaluation also showed Resident 49 was unable to smoke safely independently. Review of Resident 49's smoking care plan initiated on 01/16/2020 and revised on 04/04/2022, showed that Resident 49 was no longer safe to smoke independently. Resident 49's April 2022 and May 2022 TAR showed the following orders, which were signed by the LNs: 1) Resident is not safe to smoke independently. If found smoking, assure safety, and lock up smoking materials and notify Admin [Administrator] and DNS. 2) Room rounds Q4 (every four) hours to ensure all smoking materials are secure. May have smoking materials locked at nurse's station. Smoking materials include cigarettes, lighter, pipe, loose tobacco, wrapped tobacco, vapes/E [electronic]-cigarettes, matches, etc. If smoking materials found unsecure, secure smoking items, report to Administrator and DNS. On 05/10/2022 at 11:43 AM, observed Resident 49 lying in bed. The resident stated that he was a current smoker and that he had his smoking materials with him in his room. The resident then pointed to one of the room drawers. Observation of the resident's open drawer showed a key on it and there was a pack of CROWNS cigarette with multiple cigarettes in it. The resident also stated that he had his lighter with him in his room. RESIDENT 76 Resident 76 admitted to the facility on [DATE] for multiple care needs. According to the resident's most recent annual MDS dated [DATE] showed the resident had diagnoses that included cancer, diabetes, and arthritis. Review of Resident 76's electronic record showed that she was assessed to be an independent smoker. Review of the Resident's Treatment Administration Record (TAR) for May 2022 showed an order that started on 04/12/2022, Safe smoker with Independent smoking privledges [privileges]. Assess as needed for safety. Cigarettes and smoking materials are to be kept locked at nursing station. This order was signed off by the Licensed Nurses (LNs) every shift as completed. Further review of the May 2022 TAR showed another order started 04/12/2022 for LNs to do Room rounds Q [every] 4 hours to ensure all smoking materials are secure. May have smoking materials locked at nurses' station. Smoking materials include cigarettes, lighter, [NAME], loose tobacco, wrapped tobacco, vapes/E-cigarettes, matches, etc. If smoking materials found unsecure, secure smoking items and report to Administrator and DNS. This order was signed as completed every 4 hours by the LNs. On 05/10/2022 at 11:43 AM, Resident 76 was asked if she was a smoker, then resident replied yes. The resident then was asked if she had her smoking materials on her, she also replied yes. Resident 76 was observed to have a lighter and two packs of cigarettes in her room. On 05/10/2022 at 3:55 PM, during an interview with Staff A and Staff B, and Staff Q, Corporate Nurse, the above concerns, observations, interviews were discussed. They stated the understanding of the IJ that the facility placed the residents and other residents at risk by allowing residents to maintain their smoking materials, especially when sharing a room with a resident who was using oxygen, and that even though the facility had physician orders in place to ensure residents did not have their smoking materials, but residents were keeping smoking materials in their rooms putting them and other residents at risk. ACCIDENTS RESIDENT 82 Resident 82 admitted to the facility on [DATE] for multiple care needs. Review of the resident's most recent quarterly MDS assessment dated [DATE] showed the resident required extensive assistance of one staff member for bed mobility and was independent with eating. Review of the incident report dated 05/05/2022 showed the resident sustained a burn on his lip, chin, and chest from hot soup served to him at lunch. Review of the resident's care plan revised 05/10/2022, showed an intervention, that [the resident] is to be up in a chair with a high back or in a WC [wheelchair] for all meals . Resident is not to be in a reclining position when eating or drinking hot food or beverage. Observation of Resident 82 on 05/11/2022 at 11:58 AM, showed Resident 82 eating lunch in bed. The head of bed was raised but resident was not sitting up right. The resident was eating his pie and had his entrée of mashed potatoes, meatloaf, and peas and carrots resting on his left thigh. When asked if staff had asked him if he wanted to sit in a chair for lunch, replied they may have mentioned that, but I am happy how I am. A second observation of the resident on 05/12/2022 at 8:07 AM, showed the resident lying down in bed eating breakfast. The head of the bed was elevated but the resident was not sitting upright in bed, nor was he in a chair as the care plan had stated he should have been for meals. On 05/12/2022 at 9:14 AM, during an interview with Staff R, Nursing Assistant Registered, when asked what he does for meal set up for Resident 82, Staff R stated the resident usually just wants them to leave his tray on his over bed table, if residents were asleep, they would go in and wake them up and try to reposition them. On 05/12/2022 at 1:58 PM, during an interview with Staff K, Certified Nursing Assistant, when asked what she does for meal set up for Resident 82, Staff K stated that even if they ask him if he wants to sit up, he gets mad at them, so we just set up his tray. On 05/16/2022 at 1:44 PM with Staff B, when asked if staff should be documenting and reevaluating a post incident intervention due to a resident refusing, stated that staff should be documenting refusals so the facility can readdress the intervention to prevent further incidents. RESIDENT 67 Resident 67 admitted to the facility on [DATE] for multiple care needs. Review of the resident's record showed she had sustained falls on 02/07/2022, 04/07/2022 and 04/13/2022. Review of the resident's care plan initiated on 02/09/2022, showed a post fall interventions of Auto lock brakes to wheelchair. Review of the resident's record did not include an order for the auto lock brakes. Observation of the resident's wheelchair on 05/17/2022 at 11:19 PM did not show the auto lock brakes to the back of the wheelchair. On 05/17/2022 at 1:19 PM, in a joint observation with Staff T, Rehab Director, the auto lock brakes were not observed on the back of either of the two wheelchairs in the resident room. Staff T stated that the wheelchair had no lock brakes, and that the resident should also have an order for the use of the auto lock brakes. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident 87) reviewed for unnecessary medications was free of unnecessary drugs. Failure to ensure the facility monitored behaviors the medications were intended to treat and ensure monitoring for Adverse Side Effects (ASEs) and consider pharmacy recommendations for Gradual Dose Reductions (GDRs), resulted in Resident 87 experiencing harm related to ASEs of medications prescribed. The facility's failure resulted Resident 87 being hospitalized for a diagnosis of Serotonin (a neurotransmitter affecting mood and depression) Syndrome (SS - also known as serotonin toxicity, is a potentially life-threatening condition caused by therapeutic medications, drug interactions or an overdose.) In addition, the Resident was recently diagnosed with an abnormal movement disorder, which was commonly related to the use of [CONDITION(S)] (Antipsychotic [AP], Anti-Depressants [AD], Anti-Anxiety [AA]) medications. Findings included . The policy titled Psychoactive Medication Management Guideline dated 08/25/2020, indicated each medication would have an appropriate diagnosis and target behaviors identified, resident would be monitored for side effects and effectiveness, and would be reviewed by the IDT (Inter Disciplinary Team), the Pharmacists, and [CONDITION(S)] Drug Committee. And documented GDRs would be completed as indicated, to ensure the lowest effective dose was ordered and administered. Resident 87 was admitted to the facility on [DATE]. The most recent annual Minimum Data Set (MDS) assessment dated [DATE], documented the resident was alert and oriented, and indicated the resident was on three different classifications of medications including multiple AD, an AA, and an AP medications. The admission orders dated 08/17/2020, included multiple [CONDITION(S)] medications, [MEDICATION(S)] (an AD) 60 Milligrams (mg), [MEDICATION(S)] (an AD) 75 mg a day, [MEDICATION(S)] (a mood stabilizer) 450 mg once a day, [MEDICATION(S)] (an AP) 1.5 mg a day were ordered to treat bi-polar depression. [MEDICATION(S)] (an AA) 10 mg a day, was ordered to treat anxiety. All these medications could affect or modulate serotonin levels. On 05/05/2022 at 3:43 PM, Resident 87 reported she was hospitalized last November 2021, with serotonin syndrome. Resident 87 said prior to going to the hospital they were administering a ton of psych [[CONDITION(S)]] meds [medications] and was hospitalized for 9 days between 11/04/2021 and 11/12/2021. The resident reported the [CONDITION(S)] medications were all the medications discontinued in the hospital except one [MEDICATION(S)] (or [MEDICATION(S)], an AD). On 05/09/2022 at 3:00 PM, a follow-up interview was conducted for Resident 87, the resident displayed pill rolling (rubbing the finger and thumb on the surface of a blanket on her lap), abnormal tongue and foot movements, which related to the use of [CONDITION(S)] medications. Resident 87 said the physician recently discontinued the [MEDICATION(S)] and was going to start a different AD and start another medication to treat the abnormal tongue movement (a movement disorder). The Behavior Monitors (BMs) dated for 10/2021 and 11/2021, found the medication had a specific behavior the medication was intended to treat, but did not document any behaviors had occurred. In addition, there was no evidence the ASE's associated with the medications were monitored. The Medication and Treatment Administration Records (MAR/TAR) for 10/2021 and 11/2021, were reviewed and there was no monitoring in place for ASE's. The care plan implemented on 08/19/2020, identified potential ASEs related to the AP medication included the following: Tardive Dyskinesia (a movement disorder, EPS (shuffling gait, rigid muscles, shaking), refusal to eat, depression, diarrhea, fatigue, [CONDITION(S)], loss of appetite, nausea, vomiting. The care plan implemented 12/06/2021 (after readmission) noted was on an AD medication, and did identify ASE's which included the following, confusion, hallucinations/delusions, cognitive function, movement problems, tremors, diarrhea, [CONDITION(S)], nausea/vomiting. The progress notes documented on 10/25/2021, staff documented Resident 87 started displaying jerky movements of the left arm, abnormal hand movements on 10/25/2021. The progress noted documented the resident was still not feeling well but did not think it was a Urinary Tract infection ([CONDITION(S)]- bladder infection), a course of antibiotics was prescribed on 10/18/2022 for a [CONDITION(S)] but felt shaky. The progress notes between 10/25/2021 and 11/04/2021 documented Resident 87 continued to display hand tremors or jerky movements, excess sweating, vomiting, poor appetite, diarrhea, and episodes of [CONDITION(S)] (low blood sugar) [related to not eating] were documented by staff sporadically in the progress notes. There was no evidence staff documented the resident was experiencing hallucinations (false perceptions of objects or events involving the senses). A progress note dated 11/04/2021 documented by Staff E, the Resident Care Manager (RCM), showed Resident 87's condition had deteriorated further. The entry noted a change in cognition or mentation and Staff E requested Resident 87 be sent to the emergency room . On 11/04/2021, the resident was transferred and admitted to the hospital. The hospital physician's summary documented Resident 87 was having trouble with hand dexterity, jerking movements in the upper and lower extremities, frequent urination, no appetite, vomiting for the past 7 days, noting multiple episodes a day and noted the resident experienced a hallucination while the physician was present. The hospital discharge summary dated 11/12/2022, indicated the resident was diagnosed with SS and treated for a [CONDITION(S)]. The discharge instructions identified a list of medications the resident should stop taking including the [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], in addition to other routine medications ([MEDICATION(S)] [narcotic pain medication], [MEDICATION(S)] [medication to prevent/control [CONDITION(S)] and/or to relieve nerve pain], and [MEDICATION(S)] [a water-pill]). Review of the Abnormal Involuntary Movement Scale (AIMS- test is a commonly used assessment tool to monitor for symptoms of abnormal movements) dated 11/28/2021, showed the score was 0, on 01/17/2022, an AIMS test score of 4 was obtained, and on 04/24/2022 a third AIMS test showed a score of 6. On 05/17/2022 at 11:00 AM, during an interview with Staff E, the Resident Care Manager (RCM), reported the resident had recently been diagnosed with an abnormal movement disorder (Tardive Dyskinesia). When asked why the behavior monitor showed no behaviors occurred, Staff E, commented some staff may have viewed the behaviors displayed as a normal baseline for the resident. She acknowledged the BM documented no behaviors were displayed. The RCM was not able to locate any information to verify what symptoms staff should be monitoring for any on-going documentation related to the medications ASEs. On 05/17/2022 at 11:40 AM, Staff B, the Director of Nursing Services, was asked if she could locate any documentation to show the physician had responded to the pharmacy recommendations to do GDR for all [CONDITION(S)] medications. Staff B stated they had reviewed the physician entries and were not able to find any documentation to verify the physician responded to the recommendations. Staff B was also asked about the policy for management of [CONDITION(S)] medications. The DNS stated the facility expectation of staff was to monitor behaviors and ASEs associated with [CONDITION(S)] medication. Staff B stated the monitoring could be on the MAR and/or TAR or on BMs. When asked if the monitoring for Resident 87 was in place, she commented it was plausible it was not. Staff B explained Resident 87 was screened for ASE's using the AIMS test and indicated monitored the [MEDICATION(S)] levels (in the blood) to check for toxicity. On 05/17/2022 at 1:50 PM, Staff D, the Advanced Registered Nurse Practitioner (ARNP), was interviewed. Staff D explained the all the [CONDITION(S)] medications were discontinued while in the hospital and the abnormal movement movements had worsened over time since the readmission. The clinical records found two pharmacy consults dated 01/17/2021 and 07/09/2021, recommending a Gradual Dose Reduction (GDR), for the medications present on admission, including the AP, AD, and AA, they remained in place until the Resident 87 transferred to the on 11/04/2021. Not ensuring the facility policy to monitor behaviors, and ASEs associated with the medications left the facility without justification for the use of the [CONDITION(S)] medications prescribed. In addition, they failed to ensure Gradual Dose Reductions (GDRs) were completed when recommended by the pharmacists. (See citation under F 756 for failure to respond to the pharmacy consults). The failure to meet these requirements resulted in the resident being hospitalized and treated for Serotonin Syndrome a life-threatening condition and being diagnosed with a movement disorder (commonly referred to as Tardive Dyskinesia) an ASE related to the use of [CONDITION(S)] medications, which was an actual harm. Reference: (WAC) 388-97-1060(3)(k)(i)

Based on observation, interview, and record review, the facility failed to ensure a resident received adequate supervision during a meal for 1 of 3 residents (Resident 1) reviewed for supervision during mealtime. Failure to provide consistent and sufficient supervision during a meal for Resident 1 resulted in Resident 1's having respiratory failure (serious condition where lungs cannot get enough oxygen) related to aspiration (breathing in) of food into the airway, and subsequently died . A past noncompliance Immediate Jeopardy (IJ) was identified on [DATE] related to F689 Free of Accident Hazards/Supervision/Devices for failure to supervise a resident during mealtime. The immediacy was corrected on [DATE]. The facility implemented the following interventions on [DATE], which corrected the deficiencies: · completed IJ Protocol Response form. · completed an audit of the residents that required supervision during meals. · completed an audit of the level of supervision required by residents. · completed an audit to ensure the residents had the correct diet consistencies. · provided staff education on the levels of supervision during mealtime, precautions to take during mealtime to avoid food going into residents airway, how to report any changes in residents current level of assistance and where to find information on residents needs. · staff was given list of residents that required assistance and supervision during mealtimes. Findings included . Resident 1 admitted to the facility on [DATE] with a diagnosis list that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dysphagia (difficulty or discomfort swallowing food or fluids). Review of the most recent comprehensive quarterly Minimum Data Set (MDS) assessment tool, dated [DATE], showed Resident 1 had a Brief Interview for Mental Status (BIMS) score which indicated severe mental impairment. The MDS assessment also showed Resident 1 required extensive assistance of one person for eating and was on a mechanically altered diet. Record review of the care plan dated [DATE], showed, Impaired swallow, aspiration (a condition in which food or liquids is breathed into the airways) precautions, distant supervision in line of sight. Record review of the of the physician's orders, dated [DATE], showed the resident was to have a regular diet with bite sized, soft texture. Record review of the Speech-Language Pathologist (SLP - a specialist who evaluates and treats swallowing disorders) discharge summary, dated [DATE], showed the resident swallowing abilities required, distant [staff] supervision. Review of an undated SLP recommendations form showed the supervision level of distant supervision as within the line of sight of a nursing station, in hallways or large dining venues. Record review of a nursing progress note dated [DATE], documented, Resident 1 was sitting in w/c [wheelchair] for lunch. Resident 1 was sitting in w/c and eating lunch by herself [in her room]. Resident 1 was not breathing and had no pulse. The facility staff initiated CPR [cardiopulmonary resuscitation] and called 911, paramedics arrived to the facility, continued CPR, inserted a breathing tube and transferred Resident 1 to the hospital. Review of the hospital assessment report dated [DATE], showed Resident 1 had respiratory failure due to aspiration of food into the airway. Observation on [DATE] at 1:52 PM showed Resident 1's room was not within the line of sight from the nurses' station [Unit 200 nursing station] and was more than halfway down the hallway away from the nurses station. The resident's bed was positioned by the window, farthest bed from the room's doorway. On [DATE] at 11:27 AM, Staff H, Certified Nursing Assistant (CNA), Restorative Aide (RA), stated residents that required staff assistance to eat should go to the dining room (DR). If a resident who required assistance did not go to the DR, staff helped the resident eat in their rooms. Staff H then said Resident 1 required some physical assist, and sometimes needed verbal cues to eat. Staff H stated that Resident 1 did not go to the DR on the day she went to the hospital ([DATE]). Staff H stated Resident 1 ate lunch in her room by herself while she sat in her wheelchair by her bed on the day she went to the hospital. On [DATE] at 11:32 AM, Staff F, Charge Nurse (CN), Licensed Practical Nurse (LPN), stated residents that required staff assistance to eat either went to the DR or ate in their rooms with staff assistance. Staff F also stated residents that were required to be in the line of sight went to the DR or sat in the hallway, outside of their rooms to eat. Staff F further stated when the DR was closed and residents needed assistance to eat or was required to be in the line of sight to eat meals, the residents ate in their rooms with staff assistance or was placed at the doorway of their rooms to eat in the line of staff sight. On [DATE] at 12:48 PM, Staff G, CNA, stated Resident 1 did not go to the DR on the day she was transferred to the hospital. Staff G also said Resident 1 ate in her room without staff presence or assistance on the day she was transferred to the hospital. Staff G then stated Resident 1 required some verbal cues and physical assist to eat. On [DATE] at 12:03 PM, Staff C, CNA, stated residents that required staff assistance to eat went to the DR, but if they did not go to the DR to eat, staff would help the residents eat meals in their rooms. On [DATE] at 2:07 PM, Staff D, Nursing Assistant (NA), stated residents that required staff assistance to eat went to the DR for meals. Staff D also stated residents that required line of sight to eat meals should go to the DR or eat with staff present to help the resident eat the meal. On [DATE] at 2:14 PM, Staff E, CN, LPN stated residents that required staff assistance to eat went to the DR so staff could help them. Staff E also stated if the resident did not go to the DR for the meal, staff would help the resident eat in their rooms. Staff E then stated the residents that required line of sight to eat and had problems swallowing should not eat alone in their rooms because they could not be seen by staff while they ate and could aspirate their food or drinks. On [DATE] at 2:40 PM, Staff B, Director of Nursing Services stated that residents that required line of sight for eating meals should go to the DR for staff assistance or eat in the hallway in the vision of staff if they did not go to the DR to eat. Staff B also stated residents could be placed at the room doorway to be in the line of sight, if they could not be placed in the hallway to be in the line of sight. Staff B acknowledged Resident 1's bed was not within the sight of Unit 200's nursing station. On [DATE] at 3:13 PM, Staff A, Administrator, acknowledged that Resident 1 ate lunch meal in her room next to her bed out of the line of site without staff presence or physical assist which led to the resident's emergent transport to the hospital. Review of the hospital records dated [DATE], showed that Residenr 1 passed away on [DATE] with diagnoses of respiratory failure and aspiration pneumonia (lung infection). In summary, Resident 1 had severely impaired cognition and required verbal cues, extensive physical assist of staff and was to remain in the line of sight of staff to eat meals. On [DATE], Resident 1 ate lunch in her room by herself, and then was found unresponsive without respirations or a pulse. The facility staff initiated CPR and called 911. Paramedics arrived at the facility, continued CPR, placed a breathing tube in Resident 1's airway, and transferred Resident 1 to the hospital. A hospital report dated [DATE], showed Resident 1 had respiratory failure due to aspiration of food into the airway. Reference: (WAC) [DATE](3)(g)

Based on observation, interview and record review, the facility failed to consistently provide an environment which supported and enhanced each resident's quality of life which was person-centered, supported each resident's preferences and personal control over choices, and promoted each resident's sense of well-being. This failure resulted in the cumulative effect of psychological harm for four of seven residents (#1, #2, #3 & #7) reviewed for room changes who subsequently felt unsafe and distressed regarding roommate changes, and resulted in physical harm for Resident #1 who sustained a head injury. Findings included . (Also refer to F 560- Right to Refuse Certain Transfers) Resident #1 was readmitted to the facility on [DATE] to her room in the Cascade Unit for rehabilitation following hip surgery. A significant Minimum Data Set (MDS) Assessment, dated 08/19/19, showed the resident had no behaviors of yelling out. Review of the facility's clinical census log showed that Resident #1 had lived on the Cascade Unit until 09/17/19 when she was moved into a semi-private room on the Baker Unit and shared a room with Resident #7 until 09/19/19. On 09/19/2019, Resident #1 was moved to another semi-private room on the Olympic Unit and shared a room with Resident #3 until 09/23/2019 when Resident #3 informed the facility that Resident #1 was yelling and making comments about her that made her feel uncomfortable. Resident #1 was then moved to another semi-private room on the Rainer Unit with Resident #2. On 09/24/2019, Resident #1 was moved to a semi-private room by herself after an altercation with Resident #2. On 10/31/19, the Director of Nursing provided a written summary of Resident 1's room moves. The 09/19/2019 room move was due to Resident #1's yelling out and the room move was requested by Resident #7. Resident #7 had complex medical [DIAGNOSES REDACTED]. Resident #7's care plan showed that she preferred to spend most time in her room. During an interview on 10/31/2019 at 12:45 p.m., Resident #7 stated that when Resident #1 was her roommate, it was stressful and aggravating and I was not informed of getting this new roommate. Resident #7 stated that Resident 1 was intrusive and it made me crazy. A nursing progress notes for Resident 1, dated 09/19/19, showed that a room move was done due to an incompatibility with Resident #7. Resident 1 was moved to another semi-private room with Resident #3. Resident #3 had [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 08/08/19, showed that Resident #3 had exhibited verbal behaviors toward others which disrupted care and that she required extensive assistance with bed mobility and toileting and remained in her bed most of the time. Resident #3's care plan regarding mood and behavior related to medical [DIAGNOSES REDACTED]. Interventions for Resident #3's behavior of calling out included approaching her in a calm manner and reassure her, as she calls out nearly constantly. The facility's Grievance Log for (MONTH) 2019 showed that three residents (Resident #4, #5, #6) had voiced grievances due to Resident #3's constant yelling. The Grievance Communication forms, dated 08/03/19, which was submitted by Resident #4 had informed the facility that he was unable to sleep due to Resident #3 demanding attention and that Resident #3 was rude and we don't deserve constant harassment 24 hours a day 7 days a week! Two other Grievance Communication forms, dated 08/02/19, were completed by Resident #5 and Resident #6 who lived on the same unit as Resident #3. Resident #5 had informed the facility in writing that Resident #3 yells at the top of her lungs every few minutes all day & all night, she screams can I get some help here! Resident #6 informed the facility that Resident #3 makes an extreme amount of noise, shouts morning and night and this is ridiculous. The facility's response to the grievances, dated 08/06/19, regarding Resident #3's yelling was to inform her to use her call light as she was disturbing others while sleeping. The grievance forms showed that Resident #5 and #6 were visited by the administrator regarding their grievances regarding Resident 3's yelling. During an interview with Resident #4 on 10/31/2019 at 10:30 a.m., he stated that Resident #3 yells and screams that she needed help and it seemed that nothing had been done. During an interview with Resident #5 on 10/31/2019 at 11:05 a.m., she stated that Resident #3 shouts out help, help all day and night. Resident #5 stated that it's emotionally distressing. Resident #5 stated that she was not able to get any sleep especially at night due to Resident #3's yelling, so she will sleep during the day. During an interview with Resident #6 on 10/31/2019 at 11:10 a.m., she stated that Resident #3 yells out, will someone help me and that she attempted to talk to Resident #3 but the yelling continues and Resident #6 stated that now people just ignore her. Even though the facility was aware of Resident #3's behavior of constantly calling out, the facility then transferred Resident #1 into Resident #3's room on 09/19/19. During an interview on 10/31/19 at 10:58 a.m., with Resident #3, she stated that Resident #1 had insulted her, and yelled and swore at her. Resident #3 stated that when Resident #1 yelled at me, it made me mad and I did not appreciate it. Resident #3 stated when she informed the Resident Care Manager (RCM A) about Resident #1's behaviors towards her, Resident #1 was moved to another room. A facility investigative report, dated 09/23/19, showed that Resident #3 had informed the facility that Resident #1 was very loud over the weekend, made inappropriate comments and was throwing items on the floor. Resident #3 told staff that Resident #1 had made comments about her weight and that she was not comfortable with Resident #1 being her room-mate. The report showed that Resident #1 was alert, but often confused, forgetful and had a recent history of verbal abuse to staff, and yells and calls out. The report concluded that verbal aggression noted and substantiated and Resident #1 was moved into a semi-private room with Resident #2. Resident #2 had chronic medical [DIAGNOSES REDACTED]. Resident #2's plan of care for verbal altercations, dated 04/08/19, showed that Resident #2 was counseled to not touch other residents and to avoid contact with other female residents. The care plan for chronic pain, dated (YEAR), showed that if Resident #2 was experiencing a headache, staff were to darken her room, and close room door to make the room quiet. During an interview on 10/23/19 at 11:45 AM., Resident #2 was asked regarding the altercation on 09/24/19 with Resident #1. Resident #2 stated that Resident #1 had been her roommate and that she was horrible, horrible. Resident #2 stated that Resident #1 had been very demanding and wanted her to assist her to get up in her wheelchair and that Resident #1 had rules which she (Resident #2) needed to know. Additionally, Resident #2 stated that every time she tried to sleep, Resident #1 would take her cane and pull the curtain back (curtain between the two beds) and would not let her sleep. Resident #2 stated that Resident #1 yelled at her and then threw a bowl of pineapple at her that hit her. Resident #2 stated she was shocked and it was unbelievable, and that Resident #1's last roommate (Resident #3) had the same behavior of yelling out. Resident #2 stated that Resident #1 should have been in a room by herself, and only now does she feel safe since Resident #1 was no longer her roommate. A facility investigative report, dated 09/24/19, showed that nursing staff responded to sounds of an altercation between Resident #1 and Resident #2. Resident #1 had reported that she had been calling out for help a couple of times during the night, and this made Resident #2, her current roommate, mad because it woke her. The facility's investigative report showed that Resident #1 had stated that when she was in bed, Resident #2 had come over to her bed and hit her on the head with a cane. The report showed that Resident #1 had stated that Resident #2 attacked her and hit her in the head. The report showed that Resident #1 was assessed and swelling was noted on the top of Resident #1's head which measured 5 centimeter (cm) by 3 cm in size with a 2 mm (millimeter) area of red discoloration and hurt. The report showed that Resident #1 had thrown a fruit cup at Resident #2. The facility's investigative report showed that Resident #2 came out to the nursing station at 3:45 a.m. and informed the Licensed Nurse (LN) that Resident #1 had woke her up due to her yelling. She denied that she hit Resident #1 but verbalized that she would. Resident #1 was sent to the hospital for evaluation and when she returned to the facility she was put in another room. The hospital report, dated 09/24/19, showed that Resident #1 told the hospital that she had been hit on the top of her head with a cane. The hospital report showed that Resident #1 had sustained a contusion and abrasion on her head. The following nursing progress notes, from 09/16/19 to 09/23/19, for Resident #1 showed that she had a history of [REDACTED].#7, #3, and #2. There was no documented evidence that the facility considered a private room until Resident #1 sustained physicial harm. The nursing progress notes, dated 09/16/19, showed Resident #1 had acceptable behavior for first part of morning .call NAC/LN from previous shift. Resident gets aggressive, slapping and scratching staff and disruptive in activities. Another 09/16/19 nursing progress note showed the Resident #1 was hollering this afternoon when she was ready to go back in bed. The licensed nurse (LN) had informed Resident #1 that her behavior was not acceptable and reminded the resident to use the call light to get assistance. A physician note, dated 09/19/19, showed due to ongoing anxiety and agitation, Resident #1's anti-anxiety medication was changed ([MEDICATION NAME] to [MEDICATION NAME]) which resulted in increased confusion and agitation, and the plan was to discontinue the [MEDICATION NAME]. Resident #1 continued to have frequent episodes of confusion and agitation, including aggressive behavior towards nursing and continued to scream, hit and call 911. Resident #1 had reported that she was not agitated, but reported increase in depression since the [MEDICATION NAME] had been discontinued and reported suicidal thoughts. Nursing stated that Resident #1 was up most of night and naps only a few hours. The physician note showed Resident #1's depression and [MEDICAL CONDITION] (sleep) had worsened, experiences anhedonia (in their own world, lack of humor) and ordered an antipsychotic medication .Resident #1 attempted to call 911, but has been using her remote control to do so, she has been noted to respond to internal stimuli. Reports that she has not been as agitated as nursing say she was .reports increase of depression since discontinuation of [MEDICATION NAME], anxiety due to increased pain, continues to experience anhedonia and reports some suicidal thoughts. Resident #1 was moved (09/19/19) from the Baker Unit to the Olympic Unit due to roommate incompatability. Review of a nursing progress note for 09/20/19 showed that Resident #1 was adjusting to new room and new roommate (Resident #3), but was having difficulties to understand that staff need to provide care to all residents which included her roommate (Resident #3). The nursing note showed that Resident #1 had asked Resident #3 (roommate) to call the police as staff were not coming to help them. The notes showed that Resident #1 was being checked frequently to accommodate her needs, but was forgetful and requested assistance for the same need as before. A nursing note entry for 09/21/19 showed that Resident #1 exhibited anxiety and verbalized threats to staff, threw her food tray and stated she was in pain without the ability to specify the type of pain. Resident #1 was difficult to redirect, and appeared upset. Nursing interventions included therapeutic communication, and administration of a narcotic pain medication A nursing note entry for 09/21/19 showed that Resident #1 needs a different room or a single room where she does not have a roommate as she is confused and visibly has anger management issue and is very hard to re-direct. Resident #1 is throwing items on the floor and talking loud and stating that no one has helped her for years even though the staff had assisted her 1 to 2 hours ago. Resident #1 would deny receiving pain medication. The nursing interventions was to check on the resident several times and to anticipate anything that would trigger her anger or secure the roommate safety. Staff were to continue to monitor Resident #1. A progress note on 09/22/19 showed Resident #1 woke up at 4:00 AM was confused and started to shout, asking for help, and kept her call light on. Resident #1 denied that staff were assisting her and when her roommate (Resident #3) requested medications, she would also request medications. The plan was to continue to check on Resident #1 and to anticipate her needs. A nursing progress note for 9/23/19 showed that Resident #3, Resident#1's current roommate, reported that Resident #1 was yelling out and was verbally inappropriate. Resident #1 was then moved to another unit (Rainer). The note showed that there was an incompatibility between Resident #1 and Resident #3. Resident #1 was moved to another semi-private room with a roommate (Resident #2). During an interview on 10/31/2019 at 1:00 p.m., RCM A, a registered nurse, was asked about Resident #1's room moves prior to placement in a room by herself on 09/23/19. RCM A stated that Resident #7 had complained about Resident #1 being her room-mate as she did not like to have roommates and always complains when she gets a roommate. When asked about the move of Resident #1 with Resident #3, RCM A stated that Resident #3's behaviors of yelling to get people into her room and she yells out to seek attention as she was bored. RCM A also stated that Resident #3 had not had a roommate for over one year and that yelling can be verbal abuse. RCM A stated that the facility was aware that both Resident #1 and #3 were not quiet and there was no other ideal room so we have to try. The RCM stated that when she spoke with Resident #3 and she informed her about the comments Resident #1 had made about her, Resident #1 was moved and then shared a room with Resident #2. The RCM stated that the facility had decided to move Resident #1 with Resident #2 as Resident #2 was usually out of her room and only wakes up for pain medication. During an interview with the Director of Nursing (DNS) on 10/31/2019 at 3:35 p.m., she stated that there was no documented evidence regarding assessment of roommate compatability for Resident #7, #3 or Resident #2. The DNS stated that corporate had identified this as an opportunity to ensure evaluation of residents were done prior to room moves. WAC Reference 388-97-0860(2)

Based on observation, interview and record review, the facility failed to comprehensively assess the increased risk for skin breakdown, and implement timely and individualized interventions necessary to prevent the develpment of facility-acquired pressure ulcers/injury (PU/PI) for one of three residents (#5) who was dependent on staff for care and had a history of [REDACTED]. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Maceration of the skin around wounds is a common wound care problem. Maceration is defined as the softening and breaking down of skin resulting from prolonged exposure to moisture. Maceration is caused by excessive amounts of fluid remaining in contact with the skin or the surface of a wound for extended periods. [MEDICAL CONDITION] is paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs and torso. The loss is usually sensory and motor which means that both sensation and control are lost. RESIDENT 5: Resident 5 was admitted to the facility on [DATE] following hospitalization for a spinal injury (SCI). The SCI resulted in loss of use of all four extremities. Other [DIAGNOSES REDACTED]. The facility physician's history and physical examination [REDACTED]. The physician's note also showed that Resident 5 had an indwelling urinary catheter in place. The physician's plan for wound care for Resident 5's Left Buttock/Sacrum included: --cleanse with soap and water or normal saline --No sting barrier spray to periwound skin, allow 30 plus seconds to dry --cover with a sacral [MEDICATION NAME] border and change every 3 days and as needed. --Keep pressure off. Continue to turn patient every 2 hours while in bed and perform every 15 minute tilt backs while up in the wheelchair --Continue use of the high specification gel foam mattress and closely monitor the skin. The nursing admission data base assessment, dated 01/28/2019, showed that Resident 5 was alert, had an indwelling urinary catheter in place, had a history of [REDACTED]. The Care Plan, dated 01/29/2019, for potential for PU development related to his history of flap surgery to repair a Stage 4 PU, immobility due to [MEDICAL CONDITION], catheter tubing and potential for friction, and shearing including the following interventions included: -application of protective creams and moisturizers -assess/record/monitor wound healing -turn and reposition every 1 hour and prn (as needed) and ensure catheter tubing is not causing pressure -check skin for breakdown during routine care, bowel care and when repositioning. The Care Plan, dated 01/28/2019, for Activities of Daily Living (ADLs) deficit and limited mobility related to SCI with [MEDICAL CONDITION] directed staff to reposition and turn the resident in bed every 2 hours and check skin with repositioning, and apply lotion to both lower extremities due to dry flaky skin. The Mimimum Data Set (MDS) assessment, dated 02/04/2019, showed that Resident 5 required maximum assistance of two staff for repositioning, had an indwelling urinary catheter, and had no PU/PI. The Treatment Administration Record (TAR) from (MONTH) to (MONTH) 2019 showed that Resident 5 was being turned and repositioned every 2 hours. During an interview on 04/24/2019 at 10:25 AM, Resident 5 stated that the staff were not turning him every hour, and that the staff are not putting on his special boot(s) for pressure relief. During this interview, the pressure relief boots were observed behind his TV. On 04/24/2019 at 10:40 AM, Resident 5's skin was assessed with [REDACTED]. Resident 5's lower legs were [MEDICAL CONDITION] (swollen) and both (calves) were observed resting on a green foam pad. The bottom of his right foot rested against the support hook of the bed device. When LN D lifted Resident 5's right foot, there was aN indentation of the hook on the bottom area of his right foot and there was an indentation of the dressing which was on Resident 5's left calf. Both heels of his feet had a dime-size dry scab formation with dry scaly skin around these areas. During this observation, two nursing assistants (NACs) turned Resident 5 onto his right side. The dressing on his sacral area was not secured and was soiled with brown matter. The LN removed the sacral dressing and cleansed the sacral and buttocks with saline. The sacral area where the flap surgery (repair of old PU) was intact, but had a red discoloration to the surgical repair site and at the inferior portion of the old surgical repair site had an open wound. The wound base was clean and measured 0.5 cm by 0.5 cm in size. This pressure ulcer was identified on 02/28/2019. Both buttocks had unstageable pressure ulcers. The wound base of these PUs contained 100% slough (dead tissue). LN D measured the PUs on the buttock areas. The right buttock PU measured 2 cm by 4 cm in size and the PU on the left buttock measured 2 cm by 1.5 cm in size. The periwound area (tissue surrounding the PUs) were red and macerated (moisture). During an interview on 04/24/2019 at approximately 10:56 AM, NAC D stated that Resident 5's lower extremities and feet were usually swollen and his skin was dry. When asked about what interventions were being done to avoid pressure on his lower extremities and heels, NAC D stated it depended on who worked with him. During an interview on 04/24/2019 at 10:05 AM, NAC C was assigned to provide Resident 5's care. When NAC C was asked about Resident's 5's turning schedule, NAC C stated that we reposition him only when he asks, if he doesn't ask, I don't (reposition him). During an interview on 04/24/2019 at approximately 10:15 AM, LN D was asked about Resident 5's plan for pressure relief measures. LN D stated that staff offer turning side to side, every 1 or 2 hours, however Resident 5 will tell us what he wants. LN D also stated that Resident 5 was to have boots on his legs to relieve pressure on his heels. During an interview on 04/24/2019 at 3:10 PM, RCM A, a registered nurse, stated that Resident 5 sat up in his wheelchair (WC) most of the day, and goes to bed between 8 PM or 10 PM. RCM A stated that Resident 5 refused to be repositioned. RCM A stated that the PU/PIs on Resident 5's buttocks and sacrum area were due to sitting in chair for a long time. RCM A stated Resident 5 had acquired in-house pressure sores since admission. The pressure sores included Stage 2 PU on both heels and a blister formation on his left calf area. Review of nursing notes on 04/24/2019 showed the following entry: On 2/13/2019, the LN found open area on both of Resident 5's heels. The note showed that Resident 5 informed the LN that he had a history of [REDACTED]. The LN applied foam dressings to the heels. There was no documented evidence regarding what pressure relieving measures were initiated to avoid further decline. Resident 5 was referred to the wound consultant on 02/13/2019. The Wound Care Consultant (WCC) saw Resident 5 on 02/14/2019 and documented bilateral heel PU/PI. The WCC note for 02/14/2019 showed that Resident 5 had developed unstageable PU/PI of both heels. The PU on the left heel measured 2.2 centimeters (cm) by 2.2 cm in size, and the right heel PU measured 2.4 cm by 2.4 cm in size. Both PU/PIs had light amount of sero-sangious (blood tinged) drainage, the wound bases were covered in slough (dead tissue), and the tissue around the pressure ulcers were macerated (moisture). The WCC documented that due to Resident 5's medical condition, Resident 5 was unable to detect any pain on his heels (insensate). A care plan was initiated with interventions dated 02/15/2019 for unstageable PU/PIs on bilateral (both) heels and included: --off loading with bilateral foam boots when in bed at all time, notify LN (licensed Nurses) with refusal, --inspect the feet daily and to report changes to the nurse (LNs). Resident 5 was admitted to the hospital on [DATE] until 02/20/2019 due to a temperature, and increased heart rate with sweating. The hospital's history and physical, dated 02/20/2919, showed that Resident 5 was septic(widespread infection), source unknown. The hospital note showed that his sacral (s/p flap area) was well healed, and that he had pressure ulcers on both heels. Upon return to the facility on [DATE], the nursing assessment showed that both heels had a PU/PI. The nursing assessment documented that the PU on both heels were now Stage 2, even though the WCC had previously staged (classified) the PU on both heels as being unstageable due to slough (dead tissue) in the wound beds. The WCC saw Resident 5 on 02/21/2019. The WCC note documented that the PUs had improved and decreased in size and depth. The base of the right heel was free of slough, and the left heel had a small amount of slough in the wound bed. The WCC classified the heel pressure sores as Stage 3 PU. The physician visit on 02/21/2019 showed that Resident 5 had pressure wounds on both heels and had bilateral lower extremity wraps around both legs. A nursing note entry dated 02/23/19 showed that there was a blanchable redness overlaying his sacrum and one significant area which appears a dark blue color. Another note for 02/23/19 showed that Resident 5 stayed up in his wheelchair (WC) the whole shift and did not want to go back to bed. There was no documented evidence that pressure relief was being provided while seated in chair the entire shift. A nursing note entry dated 02/27/19 showed that during a skin check, skin abrasions were noted on his buttocks. The nursing notes from 03/01/19 to 03/07/19 showed that Resident 5 was up in his WC after lunch time, had showers and cream was being applied to his buttocks. A nursing note entry dated 03/07/19 documented that Resident 5 had an additional PU/PI. The wound was on his sacral area and measured 6 cm by 10.5 cm in size, had drainage, and the wound base contained slough and dark brown eschar (dead tissue) which the WCC debrided. The WCC note dated 03/07/19 documented that the sacral pressure ulcer developed in the facility on 02/28/19. The 03/07/19 note by the WCC showed that the sacral pressure ulcer/wound was unstageable, the wound base was covered with dead tissue (slough and eschar) and there was drainage. The nursing notes from 03/08/19 to 03/20/19 documented that staff were applying barrier cream to Resident 5's buttocks, showers were provided, and that he was up in his WC. An Occupational note dated 03/20/19 showed that OT placed lambswool in the heel cup of the WC to provide cushioning when the WC was in the tilted position, and staff will need to replace soon. Another entry by OT showed that the WC cushion (ROHO) was assessed to ensure inflation of the ROHO cushion was sufficient for pressure relief. A nursing note dated 03/20/19 showed that Resident 5 had red spots on both sides of his buttocks, and was placed on his side for pressure relief. The WCC note dated 03/21/19 showed that the surrounding tissue of the pressure wounds on both heels and sacral area had maceration around the wounds. During this visit, the WCC documented and staged the PU/PI as: -Left Heel- Stage 3 Pressure Injury-not healed, -Right Heel- Stage 3 -Sacral PI as 'acute' and an unstageable PU/PI. The sacral wound measured 3 cm by 6 cm in size and had drainage. Review of the clinical record showed that there was no skin assessment completed on 3/28/19 by facility staff. A WCC note dated 4/4/19 documented that the sacral wound had divided into 3 open areas. The treatment was to apply 3 separate dressings to these open wounds. The WCC note for 04/11/19 showed that Resident 5 had 5 PU/PIs; 1) left heel, 2) right heel, 3) right buttock, 4) Left buttock, and 5) coccyx. The TAR for (MONTH) 2019 showed that the LNs did not revise the plan of care to reposition Resident 5 every hour until after 04/11/19. A 04/11/19 Care Conference showed that the care plan was changed to turn every hour, and that the Occupational Therapy (OT) was to assess the WC cushion and actual wc for pressure and adjustments. There was no documented evidence that OT had assessed the WC cushion after the Care Conference. On 04/11/19, a new PU/PI was identified on Resident 5's left posterior calf (back of lower leg). The WCC note for 04/11/2019 showed that the deep tissue injury DTI (PU) measured 5.8 cm by 1.4 cm by 0.1 cm in size. The WCC note showed that staff were using a wedge cushion under his legs which could be the reason for the development of the PU or the ace (elastic bandages). The WCC recommendations included: -turn and position every 1 hour in bed and in chair, -do not use wedge to offload his legs, but use offloading boots, -check bilateral lower calfs (posterior/back) for new PU every one hour. Review of the clinical record showed that there was no care plan intervention regarding how nursing was to assess and monitor the WC or what pressure relief devices were to be used when Resident 5 was in his WC. During an interview with the acting Director of Nursing (DNS) on 04/24/19 at 9:30 AM, she stated that LNs were not staging the PS/PIs correctly when performing weekly skin assessments. Additionally, the DNS stated that the care plan should have individualized interventions, and that whenever NACs performed resident care, if a skin issue was noted, the NACs were to inform the LN. During an interview with the acting DNS on 05/24/2019 at 1:45 PM, she stated that OT had not assessed Resident 5's WC after the 04/11/19 conference and the care plan did not define the approaches to address Resident 5's individualized care needs for skin prevention in relationship to his medical condition and history of PU/PI. WAC reference 388-97-1060(3)(b)

Based on observation, interview, and record review, the facility failed to provide the necessary supervision for one of three (#1) when repositioning in bed and providing personnel care. Failure to provide the necessary assistance resulted in a fall with harm with transfer to the hospital. Resident #1 sustained fractures. Findings included . RESIDENT 1 The annual Minimum Data Set (MDS) assessment dated [DATE] showed that Resident 1 required 2-person assistance with bed mobility and transfers, had impairment of her upper and lower right side of her body ([MEDICAL CONDITION]), and weighed 286 pounds. The CCA (Comprehensive Assessment) worksheet summary for Activities of Daily Living (ADLs) showed that Resident 1 required assistance with all ADLs and with mobility. The CCA identified that she had a stroke with right sided [MEDICAL CONDITION] of her body, and had limitation in communication due to [MEDICAL CONDITION]. The care plan, dated 03/31/2017, for Activities of Daily Living (ADL) Self Care Performance Deficit due to limited mobility related to right side [MEDICAL CONDITION] showed that Resident 1 required extensive assistance for repositioning and turning in bed, and two person total assistance to pull up in bed. The Care Plan, revised on 01/22/2019, for high risk for falls related to right [MEDICAL CONDITION] and deconditioning showed that fall mats were to be on each side of the bed. The Kardex(daily care guide) used by nursing assistants (NACs) showed that for safety, fall mats were to be at each side of the bed, and that 1 to 2 person extensive assistance for repositioning and turning in bed. The nursing assistants' ADL (Activitity Flow Sheets) for (MONTH) 2019 showed that Resident 1 was total dependence for bed mobility. Observation on 04/03/19 at 11:40 AM showed Resident 1 was in bed. No fall mats were observed on the floor on either side of the bed. Resident 1's voice was soft. She pointed to the floor when asked about her recent fall out of bed. When asked if she was at the edge of her bed positioned on her left (unaffected) side prior to the fall, she nodded 'yes.' Resident 1 also nodded 'yes' that she was having pain since the fall. The facility investigation report, dated 04/03/2019, regarding the fall showed that one staff (NAC) had raised the bed, and rolled Resident 1 onto her left side on the bed (unaffected side) at the edge of the bed. The NAC was behind the resident (resident was facing away from NAC) providing personnel care when Resident 1 rolled off the bed onto the floor. The Licensed Nurse indicated that Resident #1 was found lying on her right side, crying incoherently, especially when staff touched her, and the resident's head rested on the rectangular-shaped waste paper basket. The investigative report did not indicate whether the fall mat(s) were in place when Resident 1 fell out of bed. The investigative report dated 04/03/2019 showed that the facility needed to be precise about the number of staff necessary to complete the bed mobility task. During an interview on 04/03/2019 at 3:00 PM, the acting Director of Nursing stated that two staff should have been assisting Resident 1 with repositioning in bed during personal care. During an interview on 04/03/2019 at 11:45 AM, the Licensed Nurse (LN A ), a licensed practical nurse (LPN), stated that Resident 1 was not able to tun herself in bed, had no function of her right side, and no functions of her legs. LN A stated that Resident 1 usually stayed in bed. During an interview on 04/03/2019 at 11:50 AM, the nursing assistant (NAC) NAC B stated that Resident 1 could not turn herself, and that she required two person assistance with turning and positioning in bed and when doing personnel care. During an interview on 04/03/2019 at 3:00 PM, LN A stated that Resident 1 required total assistance of two staff for turning and positioning in bed. During an interview on 04/08/2019 at 8:25 AM with the facility's acting administrator, a registered nurse, she stated that Resident 1 had a fall when she rolled out of bed when only one nursing assistant (NAC) was providing care. The acting administrator stated that Resident 1 was unable to stop the fall due to her medical status ([MEDICAL CONDITION]) as Resident 1 did not have the ability to protect herself from falling out of bed. She stated that when Resident 1 was positioned on her left side in the bed while the NAC was behind her along with Resident 1's inability to grab onto the left side of bed and lack of control, the resident fell from bed. Observation on 04/17/2018 at 11:18 AM showed Resident 1 lying in a bariatric (wide) bed with her right arm positioned on a pillow. Resident 1 pointed to the floor when asked about the fall (04/03/2019) and nodded her head, and pointed to her arm, leg, and hip when asked if she was experiencing pain after the fall. During an interview on 04/18/2019 at 2:00 PM, the acting Director of Nursing (DNS) stated that Resident 1 required two person assistance with turning and personnel care. The DNS stated that the fall could have been prevented if another staff had been supporting the resident during the provision of care, as the resident's medical condition prevented her from assisting staff with turning and positioning. The DNS stated that the force of gravity and Resident 1's inability to assist with safe positioning during care on 04/03/2019 resulted in the fall with fractures. During an interview on 04/17/2019 at 12:25 PM, the Assistant Director of Nursing (ADNS) stated that even though Resident 1's care plan intervention stated one to two persons with mobility, the care plan should have read two person assistance with positioning and turning with personnel care. WAC Reference 388-97-1060(1)(3)(g)

Based on observation, interview, and record review, the facility failed to consistently provide adequate care and monitor catheter care for two of six sampled residents (#2, #3) reviewed for urinary catheter use. This failure resulted in harm for both Resident #2 and #3 who developed skin breakdown. Resident #2 required transfer to the hospital due to an erosion from the urinary catheter. Findings included . Review of the facility's Catheter Care Policy and Procedure (revised 2010) showed for catheter care, the staff were to cleanse the glans(end of penis) using circular [MEDICAL CONDITION] from the meatus(opening) outward, check drainage tubing and bag to insure that the catheter was draining properly, and to document if any problems, such as drainage, redness, irritation, crusting or pain were noted at the catheter-urethral junction during perineal care. A facility inservice(training) dated 03/29/2019 read as follows: Penile Erosion- tearing of the urethra, primarily the urinary meatus, occurs in individuals who have had indwelling catheter for a long period of time. This erosion is usually secondary to catheter tension on the distal urethra at the meatus. The manner in which a catheter is secured should be alternated to prevent prolonged tension or pressure at an individual site. To prevent penile erosion is important that a stat lock be placed on the res (resident) thigh area and that the Foley catheter is secured on the stat lock correctly hence preventing an pulling or tugging. A [MEDICATION NAME] is a Foley Catheter (urinary) Stabilization Device which is a disposable catheter holder for Foley catheters and the swiveling retainer allows complete freedom to move without pulling the Foley catheter. The Nursing Assistant (NAC) skill competency for catheter care directed NACs to use soap and water to carefully wash around the drainage tube and use a clean portion of the wash cloth for each stroke. Hold the catheter near the urethra (opening) to prevent tugging on catheter. RESIDENT 2 Resident 2 was a long term care resident who had a foley (urinary) catheter due to bladder dysfunction. Resident 2 was seen by a urologist in (MONTH) (YEAR) for [MEDICAL CONDITION] and was to follow up with urology the following month. A Care Plan, dated 11/15/15 and revised 09/14/18, showed Resident #2 had an indwelling catheter (foley) placed in (YEAR) related to [MEDICAL CONDITION] (inability to urinate) secondary to [MEDICAL CONDITION] bladder. The goals identified, Will be dry and comfortable and no s/sx (signs or symptoms) of UTI (urinary infection). Another care plan, dated 06/06/18, showed that Resident 2's goal was to have no complications from chronic use of the indwelling urinary catheter. Nursing interventions included catheter care every shift and to ensure catheter tubing was secured. The Treatment Administration Record (TAR) for (MONTH) 2019 showed the weekly skin assessments for 03/04/19, 03/11/19, and 03/18/19 showed no new skin issues. The TAR for (MONTH) 2019 also showed that catheter care was provided every shift and that the Licensed Nurse checked placement of the catheter strap every shift. Review of the shower sheets for (MONTH) 2019 showed that Resident 2 had a shower on 03/03/19, 03/07/19 and 03/11/19. There was no documented evidence that any skin issues were noted. The physician's note dated 03/14/19 showed that Resident 2 had a rash to the groin area. A nursing progress note entry dated 03/14/19 showed that Resident 2's urinary catheter was changed. The Licensed Nurse (LN B), a registered nurse, documented that there was a preexisting penis erosion noted at the foley catheter insertion. A nursing note dated 03/22/19 showed that Resident 2 reported that he felt that his foley catheter was leaking. LN C documented Res (resident) Foley noted laceration pens (penis) 4 cm (centimeters) and 0.3 depth and FC (foley catheter ) placed incorrectly on [MEDICATION NAME] but corrected immediately Resident 2 was transferred to the hospital for evaluation. The hospital note dated 03/22/19 showed that Resident 2 had a large full thickness laceration down to the urethra approx (approximately) 50% of the length of the penile shaft. The hospital notified the urology physician who reported there is no real treatment for [REDACTED].recommended good wound care. The facility's investigative report dated 03/22/19 showed that Resident 2's foley catheter was changed on 03/01/19 by the Resident Care Manager (RCM B). RCM B's written statement showed that penis of head has old erosion on head of penis not foreskin. RCM B's statement showed that she had directed another Licensed Nurse (LN) to do an assessment, initiate a incident report, notify the physician, and place Resident 2 on alert. During an interview with the RCM B on 04/03/19 at 2:15 PM, she stated that catheter care was performed by nursing assistants (NACs) every shift, and LNs document that the task of catheter care had been completed. RCM A stated that the LNs were responsible to assess foley (catheter) placement and positioning. RCM B stated that Resident 2 required incontinent bowel care by staff and used an incontinent brief. During an interview with RCM B on 04/17/19 from 1:08 PM to 1:34 PM, she stated that there was no further skin assessment after the 3/14/19 nursing note or further followup. RCM B stated that Resident 2 was not placed on alert charting, and the physician was not notified. RCM B stated that when the leak was discovered, the catheter strap was not secured to prevent pulling. During an interview with LN C on 04/17/19 at 2:05 PM, he stated that when Resident 2's catheter was leaking and there was a laceration at the base of the penis, the catheter was not secured with a [MEDICATION NAME] device to prevent pulling on the penis. During an interview on 4/3/19 at 3:00 PM, the Administrator, a Registered Nurse, stated that there was no documented evidence as to when Resident 2's erosion was first identified. She also stated that when the LN documented on 3/14/19 regarding the preexisting erosion of the penis, there was no documented skin assessment or MD notification. In addition, RCM B did not document any assessment regarding the erosion and/or follow up regarding a skin issue. RESIDENT 3 Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had an indwelling catheter (urinary) due to neuromuscular dysfunction. The initial Care Plan, dated 03/06/19, for Activities of Daily Living (ADLs) due to self care performance deficit directed staff to perform complete catheter care every shift. The Minimum Data Set(MDS) assessment dated [DATE] showed that Resident 3 was alert, required 2 person assistance with toileting (catheter), was incontinent of bowel and had a urinary catheter due to a [MEDICAL CONDITION] bladder. The MDS showed that he had impairment of his lower extremities ([MEDICAL CONDITION]). The Treatment Administration Record (TAR) for (MONTH) 2019 showed that weekly skin assessments were performed by Licensed Nurses (LNs) on 03/08/19, 03/15/19, and 03/22/19. No new skin issues were identified. Review of Resident 3's NAC flow sheet for (MONTH) 2019 showed that catheter care was provided every shift. Additionally, the bath/shower record for (MONTH) 2019 showed that Resident 3 had received either a shower or bath on 3/8/19, 03/13/19 and 03/19/2019. A facility investigation was initiated on 03/22/19 due to discovery of penile erosion for another resident (Resident 2). During this investigation, Resident 3 was assessed for any complications, skin issues or penile erosion related to his foley urinary catheter. The report showed that an open area was discovered on the head of his penis. Resident 3's care plan was updated to ensure the right incontinent brief size and placement to avoid irritation against his penis. During an interview on 04/03/19 at 2:25 PM, the acting Director of Nursing (DNS) stated that during their investigation, Resident 3's open area was the result of his brief (incontinent) being too tight against his penis. A nursing progress note, dated 03/24/19, showed that Resident 3 reported that for the last 4 to 5 days his penis has been bleeding at the tip. The LN assessment noted an open area on tip and side of penis with serosanguinous drainage and catheter insertion site showed some erosion that appears to be well healed. Another nursing progress dated 03/24/19 showed that Resident 3 had an open area on left side of F/C (foley catheter) and measured 2.5 cm by 2.5 cm H shape discoloration with serosanguinous drainage. The physician's note 03/24/19 showed Resident 3 was being seen due to injury to his penis The note showed the resident had a chronic indwelling foley (urinary) catheter and had a lesion on the tip of his penis near the meatus that appeared to be from possible pressure (pressure sore) from his incontinent brief that caused compression of the catheter against Resident 3's penis. Resident 3 was referred to a wound care specialist (WCS). The WCS assessment, dated 03/28/19, showed that Resident 3's had an abrasion to the meatus of his penis. Another WCS note, dated 04/04/19, showed that the open area on the penis was not healed with partial thickness and recommended application of an ointment. During an interview on 04/08/19 at 8:40 AM, Resident 3 stated that he used to wear incontinent briefs which the staff put on, but now he is very concerned about the sore on tip of penis, and stated that he currently does not have his incontinent brief secured to avoid pressure or irritations from the brief against his penis. Observation on 04/08/19 at 9:30 AM of catheter (urinary) care showed Resident 3's legs were positioned in a frog-leg position. Resident 3's urinary catheter tubing was secured on the top of his left thigh area with a [MEDICATION NAME] (catheter strap) and his incontinent brief was not secured (to avoid pressure on penis). The Nursing Assistant (NAC B) was observed to provide catheter care. NAC B wiped the urinary catheter with wipes and then used alcohol wipes. NAC B stated that catheter care included the use of the alcohol wipe. NAC B stated when catheter care was completed, the task was checked off in Resident 3's electronic record. If a skin issue was identified, the Licensed Nurse (LN ) would be notified and an alert would be activated in the electronic record (skin red). During an interview on 04/17/19 at 0930 AM, the Director of Nursing (DNS) stated that NAC B (who had performed catheter care on 04/08/19 for Resident 3) had not followed the facility procedure of using soap and water for catheter care. During an interview on 04/17/19 at 1:11 PM, the Resident Care Manager (RCM B) stated that the Licensed Nurse who discovered the erosion on the penis did not complete a skin assessment form or notify the physician. During an interview on 04/08/2019 at 8:33 AM, RCM C stated that Resident 3's skin breakdown was from penis rubbing against his brief (incontinent brief). WAC Reference 388-97-1060(3)(c)

Based on observation, interview, and record review, the facility failed to follow the plan of care for 1 of 2 residents (1). Failure to use a mechanical lift (hoyer) during a transfer as assessed and care planned for resulted in harm for Resident 1 who experienced pain and sustained a fracture. Findings included: RESIDENT 1 Resident 1 had resided in the facility since (YEAR) and had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that Resident 1 had no cognitive impairment and was totally dependent on staff for transfers using 2 or more staff. The Plan of Care (P[NAME]) and Kardex showed that Resident 1 required total assistance with two person and hoyer (mechanical) lift with all transfers. On 12/5/2018 at 10:33 A.M., the Assistant Director of Nursing ( ADNS) stated that 2 staff were always required to be present when a transfer is done using a mechanical lift (hoyer). The facility's investigative reported dated 11/28/18 showed that 2 nursing assistants (NACs) had transferred Resident 1 out of bed without using the hoyer lift. During the transfer, one of the NACs lost their balance and both Resident 1 and the NAC landed on the floor. At the time of the fall, the resident twisted her left knee. The facility's investigative report showed that Resident 1's P[NAME] was not followed. The physician's (MD) note dated 11/29/18 showed that Resident 1 was experiencing increased pain from the trauma (fall to the ground), so her pain medication was increased temporarily. The MD's note showed that the resident had experienced foot pain and swelling. An x-ray of the foot dated 11/28/10 showed a fracture. During an observation and interview on 12/5/2018 at 1:20 P.M. with Resident 1, she stated that two nursing assistants ( NACs) had transferred her without using the mechanical lift. She stated she landed on the floor, felt pain in her knee, and fractured her foot. During an interview on 12/5/18 at 1:20 P.M. with the ADNS, she stated that Resident 1's plan of care was not followed and that 2 NACs had transferred the resident without the use of a mechanical lift during the transfer. The ADNS also stated Resident 1 sustained a foot fracture, and after the fall experienced pain which required an increase in the frequency of her pain medication. Reference: WAC 388-97-1060 (3) (g)

Based on observation, interview and record review, the facility failed to provide and implement resident-directed care consistent with the resident's comprehensive assessment and choices, goals and professional standards of practice for 8 of 8 residents (26, 74, 97, 94, 43, 155, 91, and 38), reviewed for choices and shower preferences. This failure caused harm to Resident 74, 97, 94, 43 and 155 in the form of self-humiliation, embarrassment, self-isolation and diminished quality of life. Additionally, the facility failed to ensure the resident received physician ordered blood tests and timely follow-up on blood test results for 1 of 1 residents (75) and failed to implement consistent interventions to prevent aspiration pneumonia for 1 of 1 residents (9). These failures placed the resident at risk for re-hospitalization , diminished quality of life and unmet care needs. Findings included: A review of the facility policy and procedure titled Shower/Tub dated (MONTH) 2010, stated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The policy directed facility staff to: A. If the resident refused the shower/tub bath, document the reason(s) why and the intervention taken. B. Notify the supervisor if the resident refuses the shower/tub bath. C. Report other information in accordance with facility policy and professional standards of practice. RESIDENT 74 Resident 74 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had intact cognition and needed one person assist with daily personal hygiene and bathing. Review of the resident's Activities of Daily Living (ADL) care plan dated 01/09/18, documented, the resident has an ADL self-care performance deficit due to limited mobility, impaired balance, pain, and generalized weakness. During an observation and interview on 10/10/18 at 9:20 AM, a strong body odor was present in the resident's room. The odor was strong enough that it could be smelled in the hallway and at the unit 200 nursing station. The resident stated, he had not taken a shower or bath for weeks. The resident stated, he was embarrassed and didn't know what to do about the situation. I would like to have a regular shower or bath. I never refuse to shower. The resident added, Who would like to smell this bad? This is embarrassing and humiliating. A normal person would like to take a bath at least once a week. The resident further stated, You feel like less human in here. Nobody wants to see you. The resident was observed with white dried matter on his eyes and face. The resident hair was greasy, with dirty and long finger nails (observed with brown/black matter underneath). The resident clothing was observed with dried flaky white matter. The resident's bed had a strong urine odor and the room floor was sticky and had signs of dried/liquid spills. Similar findings were observed on the same day, at 10:30 AM, 11:14 AM and 1:30 PM. The strong body odor and urine odor were present. A review of the resident's shower and bath documentation from 09/11/18 to 10/11/18, showed the resident only received 2 showers/bath in the past 30 days. Review of the resident's clinical record showed no evidence or documentation that a shower was offered and if the resident had refused a shower from any facility staff member. RESIDENT 97 Resident 97 was admitted to the facility on [DATE] for rehabilitation therapy. The [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE], showed the resident had an intact cognition and needed one person daily assist with personal hygiene and bathing. Review of the resident's ADL care plan dated 04/12/18, documented, the resident has an ADL self-care performance deficit due to limited mobility, pain, and generalized weakness. During an observation and interview on 10/10/18 at 9:20 AM, a strong body odor was present in the resident's room. The odor was strong enough that it could be smelled in the hallway and at the unit 200 nursing station. A strong cigarette odor was also smelled. The resident stated, he had not taken a shower or bath for weeks. The resident stated, the odor situation and not getting the care you need is not acceptable. The resident added, the staff barely checked on them and the facility is always short-handed. The resident further stated, It is embarrassing to stink. Similar findings were observed on the same day at 10:30 AM, 11:14, AM and 1:30 PM. The strong body odor and urine odor were present. In an interview on 10/11/18 at 9:20 AM, Staff E, NAC, stated, he was not sure when the last time Resident's 74 or 97 received showers. Staff E further stated, he does not check both residents because they are independent. Review of the resident's clinical record showed no evidence or documentation that a shower was offered and if the resident had refused a shower from any facility staff member. RESIDENT 94 Resident 94 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE], showed the resident had intact cognition and needed one person assist with daily personal hygiene and bathing. Review of the resident's ADL, care plan dated 01/26/18, documented, the resident has an ADL self-care performance deficit due to immobility, limited range of motion, [MEDICAL CONDITIONS] and pain. During an observation and interview on 10/10/18 at 3:50 PM, the resident stated, she had not had a bath or shower for at least 13 days now. A strong body odor and urine odor were present during the interview. The resident was wearing a soiled gown and the resident's hair was greasy. The resident stated, the staff would just clean her in bed and not give her a shower. I like shower. The resident added, They are no good. They let me wait and wait. 2 weeks at least. The resident further stated, she would itched a lot, developed on and off rashes and she felt bad for herself and dirty. A review of the resident's shower and bath documentation from 09/11/18 to 10/11/18, showed the resident only received 2 showers/bath in the past 30 days. Review of the resident's clinical record showed no evidence or documentation that a shower was offered and / or if the resident had refused a shower from any facility staff member. RESIDENT 43 Resident 43 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE], showed the resident had intact cognition and needed 1 person assist with showers and personal hygiene. Review of the resident's ADL care plan initiated on 12/30/16 and revised on 05/08/18 documented, the resident has an ADL self-care performance deficit due to limited range of motion, pain and shortness of breath. During an observation and interview on 10/11/18 at 2:55 PM, the resident stated, she was not getting her shower/bed bath as scheduled. The resident added, I don't get the bath. I get used to it now. The resident was apologetic for her physical look and stated, I apologize for the odor. I haven't had a bath for a while. The resident further stated, I felt bad and embarrassed. The resident was observed wearing a soiled gown and the resident's hair was greasy. A strong body odor and urine odor were present. RESIDENT 26 Resident 26 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had an intact cognition and needed one person assist with transfers and bathing. Review of the resident's care plan dated 12/12/17, showed the resident had self-care deficits related to limited mobility and bilateral (both lower extremities) [MEDICAL CONDITION]. The care plan also indicated the resident required 1 person extensive assist with bathing. In an interview on 10/05/18 at 10:30 AM, Resident 26 stated during a resident council meeting, I have missing showers. They want to give me a shower at a different time than my scheduled time, which is Wednesday and Sunday. I have missed 3 showers in the past month. A review of shower documention from 9/1/18 to 10/15/18 showed the resident received four showers over the six week period, not the two per week as the resident prefered. RESIDENT 155 Resident 155 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the comprehensive MDS assessment dated [DATE], showed the resident had intact cognition and needed one person assistance with showers and personal hygiene. Review of the resident's ADL care plan initiated on 01/18/16 and revised on 10/06/18, documented, the resident had an ADL self-care deficit and limited mobility status [REDACTED]. During an observation and interview on 10/11/18 at 2:51 PM, the resident stated, she's not receiving the care, especially showers as she wanted. The resident added, She had to ask staff to give her one. The resident further stated, It is not ok. You don't feel good and you smell, It is embarrassing. The resident was observed wearing normal clothing with greasy hair. A body odor and urine odor were present during the interview. RESIDENT 91 Resident 91 was admitted to the facility on [DATE] and was a long term care resident. Her Quarterly MDS assessment dated [DATE] indicated that she was a 13 on her BIMs. Her care plan indicated that she preferred bed bath over shower and liked it done once a week at 3 pm and was a one person total assistance. Review of the shower records from 9/11/18 to 10/11/18 did not show that she had received any bathing. RESIDENT 38 Resident 38 was admitted to the facility on [DATE] and was a long term care resident. His MDS Quarterly 8/15/18 indicated that he was a 6 and needed extensive physical assistance of one person for bathing. His care plan did not indicate how often his bathing should be done, but did say the resident had a ADL self Care Performance Deficit due to a let foot amputation and years of neglect to person hygiene. Review of the shower records from 9/11/18 to 10/11/18 showed that he had only one shower in the months time. In interview on 10/11/18 at 9:25 AM Staff U, NAC, stated, There are not enough aides. I have one resident, I give a shower to, and never have enough time. Staff U stated the shower aides always get pulled to help on the floor and showers don't get done. In interview on 10/11/18 at 9:51 AM Staff W, NAC, stated NAC's shower one resident a shift. Staff W said, Showers do get missed. In an interview on 10/11/18 at 2:40 PM, Staff C, Assistant Director of Nursing and Staff L, Resident Care Manager, both staff members stated that showers and baths were not given to the residents, as needed, and per each resident's plan of care. Both staff members stated, the facility had a system problem with showers they would immediately audit, to ensure residents received showers as needed. In an interview and record review on 10/11/18 at 2:58 PM, Staff X, staffing coordinator, stated, she tracked showers and missed shower schedules. Staff X stated, the current system the facility had for showers was not working because the residents were not getting showers as scheduled and as needed. In an interview on the same day at 3:26 PM, the Administrator and Director of Nursing stated, they were aware of the shower problems affecting the entire facility and they would immediately audit and get additional help to meet the residents' needs. A review of Resident's 74, 97, 94, 43 and 155 showers and bath documentations from 09/11/18 to 10/11/18, showed the resident only received 1-2 showers/bath in the past 30 days. Further record review did not show evidence of person centered care planning for residents, scheduling for showers, or evidence that showered were tracked or monitored. Review of the resident's clinical records showed no evidence, or documentation, that a shower was offered and / or if the residents had refused a showers from any facility staff member. In summary, the facility's lack of care, monitoring and a system for giving showers or baths caused psychosocial harm to Resident's 74, 97, 94, 43 and 155. A reasonable person would experience anxiety, low self-esteem, decrease self-confidence and sense of well-being related to poor hygiene and bad body odor. Refer to F561 - Self-determination for more information and F 725 - Sufficient Nursing Staff for additional information RESIDENT 75 Resident 75 was readmitted to the facility from the hospital on [DATE] with a recent history of [MEDICAL CONDITION] (critically high salt levels in the blood), dehydration (lack of needed fluid in the body) and severe malnutrition. Record review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident required assist with all care needs. Record review of the hospital discharge summary form dated 06/04/18 showed the resident was admitted to the hospital on [DATE] with the principal [DIAGNOSES REDACTED]. He was discharged to the facility on [DATE] and readmitted to the hospital on [DATE]. Record review of the hospital discharge summary form dated 06/11/18 showed the resident was readmitted to the hospital for [MEDICAL CONDITION] and had similar presentation to the previous, most recent hospitalization of 05/30/18. Review of the clinical record showed the resident had physician's orders dated 07/19/18 for monthly blood tests for: complete metabolic panel (CMP) (a blood test that measured salt levels and other critical elements in the blood). Further review of the clinical record showed the last completed monthly CMP was dated 07/19/18. Record review of the blood test results form dated 07/19/18 for [MEDICATION NAME] (can be an indicator of poor nutrition) showed: [MEDICATION NAME] 2.8 (normal reference range 3.5-5.0). Further record review of the physician's order dated 09/06/18 revealed an order for [REDACTED]. In interview on 10/10/18 at 2:05 PM Staff R, Licensed Practical Nurse: when we get the order, we fill out a lab slip with the resident's name and what to test for, and put it in the lab book. The person drawing the lab will come to the facility, look in the book and then go to the resident and draw the blood. In interview on 10/10/18 at 2:50 PM Staff L, Registered Nurse (RN), Resident Care Manager (RCM): the person comes in every evening to draw blood for the tests. And then they leave a slip after the blood is drawn. I come in the next morning and look to see whose blood they drew. If someone refused, they are supposed to go get someone that the resident is familiar with, because maybe the familiar face may help them to agree to the test. No the blood tests were missed, they did not get done, I don't know why. In interview on 10/11/18 at 2:19 PM Staff AA Dietician, I don't recall getting a consult for that. The lab was from two months before, they wrote the consult in September. I think they just saw the low blood level and wrote the consult for it. RESIDENT 9 Resident 9 re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident then discharged back to the hospital on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's most recent 10/9/18 Minimum Data Set (MDS) showed the resident was cognitively intact and was able to make his needs known. Review of the resident's care plan revised on 12/10/16 identified the resident with Dysphagia(difficulty swallowing). Goals included the resident would not aspirate related to swallowing or chewing. Interventions included head of bed (HOB) up 30 degrees and for the resident to be upright for meals and 30 minutes after. In an interview on 10/08/18 at 2:05 PM, Staff I Registered Nurse (RN), stated the resident was able to swallow with no issues as evidenced by being able to take multiple pills at once without coughing or choking. When asked why he had aspiration PNA, she stated the resident had been instructed many times to have the HOB up while he was eating but was non-compliant. She did not know if the resident needed supervision during meal times but stated He eats well, the problem is after he eats he lays back down flat. She also stated the resident refused to get up in his wheelchair for anything. At 2:25 PM, the resident confirmed that he did tend to lay flat after eating. He stated the staff have told him not to but he would sometimes forget. When asked why he does not get up in the wheelchair, he stated It hurts my tailbone and I can't stand it. He stated he injured his tailbone twice and he would rather stay in bed than get up in his wheelchair. He stated in the past they had kept him in the chair for long periods when asked what would help with the discomfort he stated I don't know. When he was asked if a cushion or specialized cushion would help he stated Well I have never tried it, maybe it would. he stated it would be nice to get up once in a while. At 2:36 PM, Staff I was explained why the resident did not want to get up and she stated We give him [MEDICATION NAME] which should help him. She was then told about a cushion that could help and stated Oh I guess we have never tried anything like that She stated she would speak with Physical therapy (PT) and and the Interdisciplinary team (IDT) to get ideas on what could help the resident get up more comfortably, pain free, thus preventing aspiration PNA. Reference (WAC) 388-97 -1060 (1)

Based on observation, interview and record review, the facility failed to provide adequate supervision and/or failed to follow the resident's care plan to minimize the risk of injuries and prevent avoidable accidents for 3 of 4 residents (26, 46, and 100) reviewed for injuries and accident hazards. These failures caused harm to Resident 26, Resident 46 and Resident 100, who suffered injuries during staff handling and falls. Additionally, the facility failed to ensure 1 of 5 medication carts were kept locked when unattended and that medication was not left at a resident's bedside (81). This failure placed residents at risk for harm related to smoking hazards and ingestion of potentially harmful substances. Findings included: AVOIDABLE ACCIDENTS, FALLS and SUPERVISION RESIDENT 26 Resident 26 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had an intact cognition and needed one person assist with transfers and bathing, and supervision with wheelchair locomotion. Review of the resident's care plan dated 12/12/17 showed the resident was at high risk for fall and had self-care deficit related to limited mobility and bilateral (both lower extremities) [MEDICAL CONDITION]. The care plan also indicated the resident required 1 person extensive assist with bathing, and used an electric wheelchair for mobility. Review of the State Hotline report dated 10/01/18 showed the resident had a fall on 09/30/18 during a staff-assisted shower chair transport that resulted in a [MEDICAL CONDITION]'s left (L) arm. During an interview and observation on 10/10/18 at 10:44 AM, the resident stated the incident happened on 09/30/18 at approximately 7:20 AM. The resident stated he had just finished his shower and was on his way back to his room. Staff O, Nursing Assistant Certified, (NAC), was pushing me using a shower chair. The resident added, The shower chair hit (the rubber transitional threshold between the hallway and the resident room) causing the shower chair to suddenly stop and tip over(forward). I immediately experienced pain and I knew I fractured my arm. The resident added, He (NAC) should have pulled me over (the rubber threshold) instead. He is the only NAC that pushed me when wheeling me back to my room. The resident was observed with a soft non-removable cast on his left arm. The resident stated, I only slept 20 minutes last night because of the pain. The pain medication was not helping. It doesn't stop the pain. The resident further stated that the accident and the fracture had affected his ability to perform his activities of daily living, such as dressing and simple grooming, and his day to day activities, such as bingo, running the resident council meetings, activities, and other committees. In an interview on 10/10/18 at 10:53 AM, Staff O, NAC, stated he knew he should have pulled the resident's shower chair (backed it up) over the threshold, but I didn't think of it at that time. I am sorry. Staff O further stated he should have followed his training and the accident could have been prevented. Review of the hospital record dated 09/30/18, showed the resident suffered a Left Distal Humerus elbow fracture (lower part of the upper arm bone near the elbow) from the fall. In an interview on 10/10/18 at 2:30 PM, The Administrator and the Director of Nursing, (DNS), stated the accident and the injury of Resident 26 was avoidable if the NAC had followed his training and the resident's plan of care. RESIDENT 46 Resident 46 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE], showed the resident had impaired cognition and needed 2 person staff assistance with bed mobility, transfers, dressing and toilet use. Review of the resident's care plan dated 10/06/16 and revised on 08/28/18, showed the resident required 2 staff person for repositioning and turning in bed. The resident was also identified to be at high risk for falls related to impaired cognition, impaired mobility and poor safety awareness. Review of the State Hotline report dated 10/02/18, showed the resident had a fall on 10/01/18 during care that resulted in a head injury. Review of the facility investigation report dated 10/01/18, documented, on 10/01/18 at 8:20 PM, Staff Q, NAC, yelled we have a fall, please come to the room. This RN (Registered Nurse) went in and saw the resident laying on the ground with her head beside the wall. Bruise on the left eye was noted. The resident's left eye and nose were bleeding . The resident was alert and groaning. Review of the physician progress notes [REDACTED]. Review of the hospital report dated 10/01/18, showed the resident suffered a head injury (contusion) with hematoma and swelling of the head, face and left eye from the fall. During an observation on 10/03/18 at 12:25 PM, the resident was observed with a dark purple bruise covering most of her face and neck area. In an interview on 10/10/18 at 2:30 PM, the Administrator and the DNS stated, the facility had substantiated neglect against Staff Q, NAC, for not following the resident's plan of care when repositioning, which resulted to a substantial injury. Staff Q attempted to reposition with 1-person care instead of 2-person, and the resident rolled out of bed. Both the Administrator and DNS stated the accident and the injury of Resident 46 would have been avoidable if the NAC had followed her training and the resident's plan of care. RESIDENT 100 Resident 100 was admitted to the facility on [DATE] for rehabilitation therapy. The resident [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE], showed the resident had impaired cognition and needed 2 person staff assistance with bed mobility, transfers and toileting. Review of the resident's fall care plan dated 02/25/18, showed the resident was at high risk for falls related to cognitive problems and history of falls in the past. The fall interventions directed staff to: A. Keep call light within reach and encourage the resident to use call light for help. B. Frequent visual checks. C. Ensure the resident wears non-skid footwear at all times. Review of the State Hotline report dated 09/13/18, showed the resident had a fall on 09/12/18 that resulted on a [MEDICAL CONDITION]. Review of the facility investigation report dated 09/12/18, showed the resident was left unattended and unsupervised in the room while a family member was visiting. The incident report also documented, root cause was determined to be sliding on the floor in sock feet. Review of the X-ray report taken on 09/12/18, showed the resident suffered a left [MEDICAL CONDITION] from the fall. The resident was later sent to the hospital for further evaluation and treatment. The resident was admitted to the hospital for treatment and returned to the facility on [DATE]. During an observation on 10/10/18 at 11:05 AM, the resident was observed in her room sitting alone on her wheelchair. The resident call light was clipped on her bed away from her reach. There was no staff member around to supervise the resident. In an interview at the time of the observation, the resident stated, she fell and she was not feeling good at this time. The resident added, I haven't had a decent sleep and was irritated and frustrated. The resident further stated, the accident had caused delay for her move to another facility/home. Review of the nursing progress notes and Medication Administration Record [REDACTED]. During interviews on 10/10/18 at 11:14 AM with Staff S, NAC, at 1:13 PM with Staff T, RN, and at 1:30 PM with Staff L, Resident Care Manager, (RCM), each staff member stated the interventions for Resident 100 needed to be more specific to effectively follow the plan of care. Each staff member had different answer on what frequent visual checks meant. During multiple observations on 10/10/18, the resident was left alone in the room with no staff supervision. During a record review and interview on 10/10/18 at approximately 1:31 PM, Staff L. RCM, stated the resident plan of care was not followed on the day of the accident because the resident was wearing a regular/non-skid socks. Staff L further stated, Resident 100 was recently started on [MEDICATION NAME] (a narcotic pain medication) due to uncontrolled pain related to the fracture. In an interview on 10/10/18 at 2:30 PM, the Administrator and DNS stated the accident and the injury of Resident 100 was avoidable if the resident's plan of care was followed. MEDICATION CART On 10/11/18 at 1:51 PM, the Baker medication cart 2 was observed to be unlocked and unattended in the hallway between resident rooms [ROOM NUMBERS]. The drawers were able to be opened. There were no residents nearby. At 1:52 PM, Staff Z, Registered Nurse, opened a door from across the hall from the unattended medication cart and walked to the cart. Staff Z then locked the cart promptly, stating it was supposed to be locked. During an interview at 2:19 PM, Staff L, Resident Care Manager (RCM), said the medication carts should be kept locked when the nurse is not present. MEDICATION AT BEDSIDE On 10/03/18 at 9:34 AM, Resident 81 was observed lying in bed. On the over bed table was observed a red oblong gel capsule in a clear plastic medication cup. Resident 81 said a nurse brought it in last night for her to take. The resident went on to say it was not her medication, so she did not take it. Staff T, Registered Nurse was notified and reviewed Resident 81's Medication Administration Record. There was no physician order for [REDACTED]. In an interview on 10/10/18 at 2:51 PM, Staff L, RCM, said there was no physician order for [REDACTED]. Reference (WAC) 388-97-1060 (3)(g), 388-97-1300 (1)(b)(ii)

Based on observation, interview and record review, the facility failed to have safe systems in place for hot temperatures in the kitchen that led to harm, a substantial injury, of a second degree burn for 1 of 6 residents sampled for injuries (Resident #12). This failure placed also placed all facility residents who could potentially eat in their rooms at risk [MEDICAL CONDITION] to lack of procedures and monitoring for safety. An immediate jeopardy was called on 01/11/18 at 2:45 p.m. A removal was submitted by the facility. The jeopardy was removed after a removal was presented on 01/11/18 at 5:00 p.m. Findings include: Review of facility medical records revealed, Resident #12 resided in the facility for long term care since 2014. According to the facility Minimum Data Set (MDS) assessment dated [DATE], Resident #12 had a BIMS score of 15 (mentally intact) and ate with setup and supervision from staff. The Care Plan for Resident #12 noted: Resident #12 eats independently after staff set up. Review of the facility incident investigation dated 12/11/17 revealed, Resident #12 stated she sustained a burn on her left hand when the Salisbury Steak fell on top of her hand during a meal in her room. The facility investigation noted Resident #12's left hand had a fluid filled blister that measured 1 centimeter by 0.5 centimeters. Review of progress notes revealed: On 12/13/17, there was a blister on her hand hand On 12/14/17, the hand had a blister and was pink On 12/14/17, 3 days after the reported burn, it was noted the hand blister was the same size and pink and Resident #12 was irritable. According to the Centers for Disease Control and Prevention, Emergency Preparedness and Response, Mass casualties: Burns. March 25, 2014: A second degree burn involves the first two layers of the skin and may present as reddening of the skin, and blisters. In an interview on 01/11/18 at 12:15 p.m. and 01/16/18 at 9:45 a.m., the facility Administrator stated Res #12 reported to him on the morning of 12/11/17 that she had a burn on her hand. The Administrator stated he saw a red spot on her left hand. There was no evidence the Administrator took any action. In an interview on 01/10/18 at 2:00 p.m., Staff J, a licensed nurse and manager, stated she heard about the burn on the morning of 12/11/17 and she saw a blister on the left hand that was 1 cm fluid filled. Staff J stated Resident #12 always ate in bed in her room. In an interview on 01/11/18 at 1:12 p.m., Staff B, a nurse aide, stated he saw the burn on Resident #12's hand, and the resident told him it was burned. Staff B said the burn was dark red. Staff B also stated Resident #12 always wants the metal plate warmer under her plate on her over bed table for meals and always eats in bed in her room. In an interview on 01/11/18 at 2:20 p.m., Staff G, a licensed nurse stated she saw the burn a few days later and it was pink. Staff G stated Resident #12 told her she thought it was a burn from the Salisbury Steak. Review of facility weekly menu for 12/10/17 revealed, the lunch entree was Salisbury steak. Review of the facility meal intake charting for Resident #12 revealed she ate 50 to 100 percent that day 12/10/17 at lunch. According to the facility recipe for Salisbury Steak, the entree included 2 ounces of hot gravy. Review of facility food temperature logs for 12/10/17 revealed, the lunch gravy temperature was 175 degrees. According to Studies of Thermal Injury, American Journal of Pathology, 23, 695-720 cited in the regulations, a third degree burn can occur with a water temperature of 155 (F) in one second, 148 (F) in 2 seconds, 140 (F) in 5 seconds, and 133 (F) in 15 seconds. Review of the facility treatment record for December 2017 revealed, the facility monitored Resident #12's burn for 20 days, from 12/11/17 through 12/30/17 when the resident had a change of condition and went to the hospital. Observation and interview on 01/16/18 at 10:45 a.m., over a month after the burn, revealed a pink healing area on the left hand about half inch in diameter with peeling skin around the perimeter. Resident #12 stated it was the burn from Salisbury Steak falling on her hand. Resident #12 stated she eats with her left hand. ROOM TRAY SAFETY On 01/11/18, the facility Assistant Director of Nursing (ADON) stated the facility had residents who ate meals in their room and the ADON marked on the facility roster 70 resident names who ate meals in their rooms on a regular basis. In a subsequent interview on 01/11/17 at 1:20 p.m., the ADON stated some residents want to keep the metal plate warmer under their plates in their rooms when they are eating and the facility had not considered it to be a safety issue. The ADON was not aware of any facility policy about the plate warmers. The ADON stated leaving the metal pellet warmer under the plates in front of the residents eating in their rooms was according to resident preference. In an interview on 01/11/18 at 1:10 p.m., Staff A, a licensed nurse, stated the staff take the meal tray into the resident rooms, remove the lid from the dinner plate, and leave the plate along with the metal pellet warmer in front of the resident. In an interview on 01/11/18 at 1:12 p.m., Staff B, a nurse aide, stated some residents wanted the metal pellet warmer under the dinner plate, so they left it there, in front of the resident, while they were eating. Staff B also stated they have not received any training about when it is safe or not to leave the metal plate warmer in the room in front of the resident, the staff decides. In an interview on 01/11/18 at 1:20 p.m., Staff C, a nurse aide, stated the metal warmer under the dinner plates is hot, and they sometimes leave it in the resident's room if the resident wants it under their plate. During observations of residents eating lunch in their rooms on 01/11/18 revealed: At 1:00 p.m., Resident #21 was seated in her room with a plate of food in front of her, on a metal warming pellet, that was warm to touch and the metal rim was exposed around the dinner plate. The resident was not interviewable. At 1:05 p.m., Resident #22 was eating lunch in bed with the plate of food on the metal warmer from the kitchen, that was warm to touch and the metal rim was exposed around the dinner plate. Resident #22 stated the metal warmer was always on her table under her plate of food at meals. At 1:15 p.m., Resident #23 was seated in her room with a plate of food in front of her on a metal warmer, that was warm to touch and the metal rim was exposed around the dinner plate. The resident was not interviewable. Record review revealed no assessment or care plan to determine the safety of a heated metal plate warmer for Residents #12, 21, 22 & 23. In an interview on 01/11/18 at 2:00 p.m., the facility dietary manager (DM) stated the facility had a goal of at least 135 degrees Fahrenheit (F) for food temperatures in the kitchen holding area, and she preferred 150 degrees F so the food tastes hot when it gets to the resident rooms. The DM stated the kitchen staff heat the plates, she thought was close to 100 degrees (F), placed the plates on a heated metal pellet and then set it in a plastic bottom before sending it out to the residents in the tray cart. The DM also stated the facility had no written procedure for the heating of the dinner plates or the heating of the metal pellets that go under the plates or a procedure for the kitchen staff for how long to heat the the plates or the pellets or to what temperature. The dietary manager (DM) stated she only checked plate temperatures and the metal pellet plate warmer temperatures one time after the burn and there was no evidence of that any changes were put into place. According to the DM, the facility also did not check temperatures of the plates or pellets before sending them out of the kitchen to the residents. Observation of the facility metal pellet heating machine showed it had no temperature gauge. The DM stated she did not know whether the metal pellets were placed in resident rooms under the dinner plate when the residents ate their meals. The DM demonstrated the following during observation in the kitchen on 01/11/18 at 12:45 p.m. when lunch was being prepared and served: The heated metal pellet with a diameter slightly larger than the dinner plate, was placed under the dinner plate into a plastic dish, then a plastic lid placed on top. The hot metal rim of the pellet was exposed all the way around the dinner plate. The facility policy/procedure for serving resident meals received from the Director of Nursing (DON) on 01/11/18 at 1:00 p.m., did not include any instructions for how to handle the heated metal plate warmers in resident rooms. The DON stated there was no policy or procedure for the metal plate warmers in resident rooms at meals. KITCHEN SAFETY In an interview on 01/11/18 at 2:30 p.m., Staff D, a facility cook, stated the metal pellet heating machine should be turned off at intervals during the day because the metal pellets that get placed under the dinner plates will get as hot as branding irons if the pellet warmer is left on all day. Staff D stated he has come in to prepare dinner on several occasions, and the metal pellet warmer was left on all day, leaving the pellets extremely hot but they have to use them to get the trays out on time. Staff D said the food will just keep on cooking on hot metal pellets as it goes onto the meal cart. Staff D also stated sometimes the plate warmer is set at 200 degrees when he comes in to work the lunch and dinner meals. In an interview on 01/11/17 at 1:30 p.m., Staff F, a facility cook, stated the facility did not have a procedure for the metal pellet heating machine. He usually sets the plate warmer to 146 degrees however there was no procedure for that either. In an interview on 01/11/17 at 2:35 p.m., Staff E, a dietary staff working on the tray line, stated the metal pellet heating machine gets very hot, and the pellets are placed under the plates quickly, in less than 30 seconds for three plates, and placed in the heated cart that goes out to the resident rooms. Staff E stated there was no checking of temperatures of the metal pellets, and no thermostat on the machine. Observation of the metal pellet heater machine on 01/11/18 at 1:30 p.m., revealed a very hot machine on the inside as well as on the outside. It was too hot to leave a hand on the outside of the machine for more than a second. The metal pellet heating machine had no temperature gauge. Observation of the plate warming machine revealed, it was set at 155 degrees (F). Observation on 01/11/17 at 2:30 p.m., revealed a dinner plate temperature was 99.3 F and the metal plate warmer pellet was 145 degrees F. Reference (WAC) 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure a resident received adequate supervision during repositioning to prevent accidents for 1 of 1 residents (1). Failure to have 2 staff present while turning a resident in bed as per the resident's care plan resulted in the resident rolling out of bed and sustaining a hip fracture. Findings include: During an interview on 5/10/17 at 1:15 pm with Resident 1, the resident was asked if she recalled an incident of falling out of bed. The resident said she did remember and then went on to describe the incident. She said she was being cleaned up while lying in bed, and then the aide asked her to turn on her side. The resident said as she turned, the aide tried to help her turn by pushing and then she just rolled out of bed on the opposite side from where the aide was standing, I don't think the aide deliberately pushed too hard, but I couldn't stop. It ended up that I broke my hip. Sometimes it still aches badly, like now. Review of the resident's care plan for incontinence dated 3/28/17 and the 4/4/17 Minimum Data Set Assessment revealed the resident required a 2 person extensive assist for bed mobility to turn & reposition. Review of facility documentation regarding the incident of 4/26/17 indicated that a nursing assistant (NA) was cleaning & changing the resident in bed. The NA rolled the resident away from her to get the dirty linen out & get the clean linen under the resident. As the NA pushed on the resident to help turn her onto her side, Resident 1 kept turning & rolled out of bed. The NA was unable to stop the resident & Resident 1 fell to the floor. The facility documentation concluded the NA did not follow the resident's plan of care that had clearly indicated there should be 2 staff when turning & repositioning Resident 1. During an interview on 5/17/17 at 4 pm with Director of Nursing Service (DNS), the DNS said the staff NA did not follow the plan of care and there should been have been 2 staff during care. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview and record review the facility failed to consistently provide sufficient supervision to prevent an accident for 1 of 1 residents. (1). Failure of the facility to recognize that a resident who had recent changes in status may require consistent increased supervision with hot beverages & food likely resulted in Resident 1 sustaining a second degree burn for and placed other residents at risk for injury. Findings include: Resident 1 was admitted to the facility in December 2016 with a recent history of falls without fracture, and Parkinsons disease. Her Minimum Data Set assessment dated [DATE] revealed she had moderate cognitive impairment, required extensive assistance of 1 person for most activities of daily living (ADL) except for eating, had no impairment in range of motion in her upper extremities, and did not have any skin problems. Review of the progress notes from 1/29/17 - 2/11/17 regarding the resident's ADL needs revealed the resident required 1 person for transfer & toilet with maximal cuing due to poor safety awareness & spacial awareness, and able to feed herself after setup assist for meals. In an observation and interview on 4/6/17 at 11:20 am. Resident 1 was observed wearing a sling on her left elbow and displayed constant bilateral hand tremors throughout the interview. On 4/7/17 at 9:50 am, the skin areas were identified by staff as burn wounds on Resident 1's inner thighs and were observed in the presence of 2 facility licensed nurses. Documentation indicated that both inner thighs had several linear-shaped dark red skin areas radiating from almost the groin area, varying in length & width, and with one small open area approximately 0.5 cm on her left (L) inner thigh. The licensed staff indicated the skin areas/wounds have much improved 'almost healed' from when first discovered. Nursing notes from 2/18/17 through 2/29/17 indicated staff were monitoring of the resident's adjustment to a new room, but did not note the resident's physical status or ADL capabilities. On 3/1/17 the resident had an unwitnessed fall that resulted in injury to her L arm which required wearing an arm sling at all times. There was no indication that staff identified whether this could affect her ADL abilities, such as eating & drinking, assessed to see if the resident required increased assistance and supervision or whether Resident 1 was still a candidate for the independent dining room as per the current plan of care. On 3/3/17, it was noted the resident was alert & forgetful, had the sling on L arm, and tremors related to Parkinsons noted upon having meals. The note did not mention whether the resident required or received increased assistance and supervision during meals/drinks. Later that day, the resident sustained [REDACTED]. On 3/4/17 at 12:29 pm, the resident was noted to have the sling was in place, hand tremors, a right eyebrow bump with bruise, and that she was supervised with activity, ambulating around room, and was extensive assist with dressing. The note did not mention whether the resident required or received increased assistance and supervision during meals/drinks. Later that day, it was noted that Resident 1 had increased hand tremors & gait shuffles. Her left arm sling was monitored since the resident takes it off at times. Assured the resident was supervised with meals due to tremors. The resident will now require 1 person extensive assist w/ dressing & toileting. On 3/5/17 at 2:00 pm, the resident was noted to have a spread out uneven redness on bilateral inner thighs. Resident calmer with less tremors. A physician order [REDACTED]. There were no further nursing notes regarding the appearance of the reddened areas until 3/8/17. There was no mention noted in the progress notes on 3/5/17, 3/6/17, or 3/7/17 regarding staff supervision or assistance for the resident while consuming beverages/meals. On 3/8/17, Resident 1 was noted to have a blistered area on her L inner thigh 13 x 4 centimeters (cm) and blister area on R inner thigh 4 x 2 cm. The physician was notified, resulting in a new order for a topical skin antibiotic used to treat or prevent infections on areas of burned skin. A neurology consult of 3/8/17 increased the daily dose of Resident 1's Parkinsons medication. On 3/10/17, it was noted the blisters had broken. A Wound Rounds Summary Assessment history dated 3/10/17 documented the L middle posterior thigh wound was a facility-acquired second degree thermal heat burn with an open, partial thickness wound with 100% slough (dead tissue) measuring 18.30 cm by 7.50 cm; & the R middle posterior thigh wound was a facility-acquired second degree thermal heat burn with a partial thickness wound with 100% slough measuring 14.00 cm by 13.00 cm Resident 1's written plan of care (POC) for nutrition was reviewed on 3/17/17. The POC indicated the resident was set-up assist & dined in the NW Bistro, used by the more independent residents. The daily care instructions (Karedex) was also reviewed on 3/17/17. The Karedex listed instructions for increased visual checks for safety and the resident dined with set/up cues in the supervised dining room. The POC for ADL interventions was revised on 3/12/17 to include assistance with eating, place in an area of supervision when in wheelchair, and noted Resident 1 was at increased risk for burns secondary to hand tremors & L arm sling, and that staff were to ensure all hot beverages have a lid on before serving. An initial self-feeding assessment by occupational therapy on 3/14/17 indicated the resident required 50% hands on moderate assist for drinking & was very inconsistent throughout the session. It also noted the resident needed minimal assist with utensils during the meal, but the resident demonstrated difficulty keeping food on plate during scooping. During an interview with licensed nurse Staff A on 4/7/17 at 10:15 am regarding Resident 1, Staff A said the resident was newer to the long-term care area on the weekend when she first noted Resident1's inner thigh redness. She said the resident did have hand tremors and a sling at the time. She said she didn't see the resident spill food or drink during her shifts. In interviews with Director of Nursing (DNS) on 4/6/17 & 4/7/17, the DNS said they tried to determine when & how Resident 1 sustained the skin burns to her inner thighs, but could not narrow it down to a specific spill event. She said that after Resident 1's inner thigh areas blistered and appeared to be a burn injury, they put additional safety interventions into place for Resident 1. The DNS also stated they also reviewed the facility hot beverage policy with staff, ensured all hot beverages were served with a lidded mug, and did burn risk assessments on all residents. Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure a resident with a pressure sore consistently received the necessary treatment and services to prevent new sores from developing for 1 of 4 sample residents (2). Failure to consistently ensure effective repositioning for pressure relief to and treatment to the appropriate buttocks area resulted in harm for Resident 2 who developed 2 additional necrotic (dead cells or tissue from severe injury or disease) pressure sores (PS) acquired after admission to the facility. Findings include: Resident 2 admitted to the facility on [DATE] with multiple diagnoses, including lower body paralysis, and had a Stage 4 pressure sore on his Left (L) buttock (A Stage 4 PS has full thickness skin tissue loss with exposed bone, tendon or muscle, often with dead skin tissue on some parts of the wound.) His admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had no cognitive impairment, required extensive assistance of 2 staff for bed mobility, rarely transferred out of bed, had a feeding tube & a urine catheter, was incontinent of bowel, and had one Stage 4 PS (on L buttock). Approximately 1 month after admission, a 6/22/16 MDS assessment revealed Resident 2 had developed 2 unstageable necrotic PS, in addition to his admission Stage 4 PS. During an observation on 8/11/16 at 1:15 pm, Resident 2's current pressure sores were viewed with a facility nurse. The resident had 1 PS on his L (Left) buttock measuring 1.5 centimeters (Length) x 1.2 cm (Width) x 0.5 cm (Depth); A second PS on his R (right) buttock measuring 4.5 cm x 6.2 cm x 1.6 cm. During the observation, the resident was able to help with turning in bed by pulling on a mobility bedrail while the staff pulled on an under pad to fully turn him onto his side. In an interview on 8/9/16 at approximately 10 am with the Director of Nursing (DNS), the DNS said Resident 2 had developed pressure sores on his R buttock and coccyx (tailbone area) while residing at the facility. The DNS said the coccyx wound had since healed, but the resident still was receiving treatment for [REDACTED]. She stated the resident had been paraplegic for years with a long history of PS development. During an interview on 8/11/16 at approximately 11:15 am, staff nurse (LN 1) said she was usually responsible for doing a weekly skin assessment & measurements of any identified skin issues (new or ongoing) while the unit staff LNs did any ongoing wound treatments & dressing changes. LN 1 initially stated the resident was admitted with 1 pressure sore on the R buttock but then said, At first, we got the R versus L buttock site mixed up on the wound documentation & wrote down the wrong buttock, but then we fixed it on the forms to indicate the admission PS was the L buttock. LN 1 said Resident 2 developed some R buttock excoriation (abraded skin) in June 2016, ' We started putting cream on the area, however he later ended up with a R buttock PS and one on his coccyx as well.' In regards to other pressure relief interventions, LN 1 said the resident wore special boots for his heels and had an air mattress on the resident's bed upon admission which was then switched at some point to an alternating air mattress. Review of Resident 2's record revealed: A progress note dated 6/6/16 regarding the discovery of a new skin issue: ' .R Buttocks open area .L buttock Stage 4 dressing changed. New R buttocks open area cleaned & dressing applied. Resident educated to reposition self.' Between 6/7/16 - 6/17/16, nursing progress notes varied in naming the wound sites that had been treated & dressed (coccyx, R buttock, L buttock). Also between 6/7/16 - 6/17/16, there were no progress notes indicating consistent repositioning assistance was provided by staff nor indication of frequent monitoring by the unit nurse(s) to ensure Resident 2 had effective pressure-relief to all compromised skin areas. The June 2016 Treatment Administration Record (TAR) revealed a new order on 6/10/16 to apply cream after each incontinent episode for excoriation to L buttock. The order did not direct staff to apply the cream to the newly excoriated R buttock. The order was then changed on 6/16/16 indicating application of cream to the buttocks & coccyx. There was an ongoing TAR order directing nurses to monitor the stage 4 PS on L buttock every day and note any changes. However, there was no TAR order for nurses to consistently monitor and observe the newly opened/excoriated area on the R buttock or coccyx area. Review of weekly wound summaries revealed the following information: On admission, Resident 2 had an L Buttock (Stage 4 PS) that measured 1.9 x 1.7 x 2.0 cm; by 6/20/16, the L buttock PS was larger and measured 2.8 x 2.5 x 1.9 cm with 90% layer of dead skin tissue in the wound. On 6/9/16, Resident 2 was found to have an open excoriated area on the R Buttock that measured 7 cm x 4 cm x 0 cm; By 6/20/16, the R buttock excoriated area had deteriorated to a PS that measured 9 cm x 5 cm x an unknown depth due to the wound having a 60% layer of necrotic skin tissue. On 6/20/16, Resident 2 had a coccyx PS was that measured 5.5 cm x 3.7 cm x with unknown depth due to 50% layer of necrotic skin tissue in the wound. During an interview with a direct caregiver NA 1 on 8/25/16 at 8:45 am regarding repositioning needs for Resident 2, The resident is actually really good about consistently calling for help with repositioning. He puts on his call-lite and we help him move on his side, back or other side. The resident is much better and regularly gets up in wheelchair now. When NA 1 was asked about repositioning during Resident 2's first month at the facility, NA 1 said, Well at that time he (the resident) wasn't as good about calling for help with turning. He had an abdominal wound & tube(s) in stomach and many more things going on, so the resident wasn't so good about calling for assist with repositioning. On 8/11/16 approximately 11:15am, LN 1 & LN 2 were asked about individualized turning and repositioning needs of Resident 2. They said the resident was able to help with turning and repositioning by using mobility bars on his bed. When asked about the frequency of repositioning and a specific individualized pressure-reduction/relief plan for Resident 2's buttocks/coccyx areas, the LNs stated that regular turning & repositioning was a standard of care, so in most instances, information regarding turning/repositioning would not be specified and/or documented in the plan of care and Karedex (a list of a resident's daily care needs information used by the direct caregivers). Review of Resident 2's written POC indicated the resident required 2 person assist with resident using bilateral bed bars with a transfer sheet to pull the resident up in bed & to assist with side mobility. Other interventions included registered nurses to assess and measure wound status & healing, labs, notify MD of new areas & obtain orders, place incontinent products under resident to assist with skin protection (6/10/16), and treatments per order. The POC & Karedex did not list any individualized information regarding specific turning/repositioning approaches or frequency of repositioning. Individualized care information could have increased the likelihood of staff providing consistent & effective pressure reduction/relief for Resident 2. There was no documented evidence for at least 10 days (6/9/16 - 6/17/16) to indicate Resident 2 was being consistently monitored to ensure frequent repositioning with effective pressure relief off his R buttock and coccyx areas was occurring. In addition, a 6/10/16 - 6/16/16 initial treatment incorrectly directed staff to only apply cream to the L buttock, rather than the newly identified excoriated R buttock. Lastly, there was no documented evidence of ongoing nurse monitoring/observation of the newly affected areas (other than weekly). During this period of time, Resident 2's R buttock & coccyx skin condition deteriorated from being excoriated to having 2 necrotic additional pressure sores.

Based on observation, interview and record review, the facility failed to secure a air matress to a bed frame which caused an avoidable fall for 1 of 4 (75) sampled residents reviewed for falls. In addition they failed to safely secure hazardous cleansing wipes on 3 of 6 medication carts. These failures resulted in harm to one resident (75), as evidenced by: a 4 centimeter (cm) skin tear under his left eye, a bruise on the left eye lid and a 3 cm by 3 cm abrasion to his left knee. And placed other facility resident's at risk of harm related to ingestion, inhalation, and contact with skin or eyes of hazardous chemicals. AVOIDABLE FALL Resident 75 was admitted to the facility August, 2011 with a [DIAGNOSES REDACTED]. According to the most recent comprehensive Minimum Data Set (MDS) assessment, dated December 26, 2015, he required extensive to total assist of 1 to 2 staff members for all activities of daily living. In an interview with Resident 75 on 4/11/16, it was determined that he was uninterviewable. He was observed in his bed with the air mattress attached to the bed frame. During record review of Resident 75 on March 28, 2016, Staff DD, a Licensed Nurse, went to check on the resident after hearing moaning. Resident 75 was found laying on the floor face down next to his bed. His bed mattress was on top of him. Further record review revealed the resident's room was cleaned by housekeeping the morning of March 28, 2016. The mattress was taken off the bed and put back on the bed, staff did not secure the bed mattress to the bed frame, causing Resident 75 to fall and sustain a 4 centimeter (cm) skin tear under his left eye, a bruise on the left eye lid and a 3 cm by 3 cm abrasion to his left knee. Review of witness statement to fall dated 03/28/16, when Staff EE, a housekeeper, was asked to tell what he found or what happened, he wrote: I did not tie down the bed. Another witness statement to the fall dated 03/28/16, Staff FF, a housekeeping supervisor, wrote: we did a deep clean in the room today and forgot to tie down the air mattress which caused the resident to fall when he moved. During an interview with Director of Nursing Services on 04/22/16 at 12:08 PM, she stated: the fall happened because the housekeeper did not re-attach the bed mattress to the frame and all staff had been inserviced since the incident happened. HAZARDS AND CLEANSING WIPES On 04/13/16 at 6:55 PM observation revealed a tub of Super Sani Cloth wipes on the Olympic Hall medication cart. The label read Danger keep out of reach of children. During interview, Staff R stated the Super Sani Cloth wipes are used for cleaning the glucometers after each use. He stated, They told us not to keep them in the cart, I don't know why. On 04/13/2016 at 6:59 PM observed a tub of Micro Kill wipes on the Baker Hall medication cart. The label read Danger keep out of reach of children. During interview, Staff Q stated they keep them on the cart to clean glucometers between residents. She left the wipes on the cart. On 04/13/2016 at 7:09 PM observed a tub of Micro Kills wipes on the Ranier Medication cart. The label read Danger keep out of reach of children. During interview, Staff H stated they keep the wipes on the cart to clean the glucometers between residents. He left the wipes on the cart. Access to these toxic chemicals placed residents at risk of harm related to ingestion, inhalation and contact with skin or eyes.

Based on interview and record review, the facility failed to provide medically related social services to advocate for 1 of 1 sampled resident (1) with cognitive and physical impairments to ensure his safety while attending a medical appointment unescorted. Resident 1 went missing while attending a medical appointment and has not yet been located, remaining unsupervised, and without care or prescribed medications. This was placed Resident 1 at imminent risk for harm. This situation was determined on 12/17/12 to be immediate jeopardy. Findings included: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His Minimum Data Set (MDS) assessment 11/12/15 indicated the resident was severely impaired in his cognition, had communication deficits, balance instability, and needed staff assistance with most of his activities of daily living, except eating. On 12/11/15, the resident was taken to a medical appointment at approximately 12:00 noon by a transportation service and was dropped off at a large medical clinic. The clinic was to call the transport service upon completion of the appointment, and the transportation agency was to pick the resident back up and return the resident to the facility. Around 2 pm, the facility received a call from the clinic physician asking if the resident had been picked up by the transport service. The clinic told the facility Resident 1 had been seen by the physician, but had then disappeared when the physician left the resident alone in an exam room for a short time. The clinic was unable to locate the resident on the clinic premises. During a record review on 12/15/15, there was no documentation the facility attempted to thoroughly assess Resident 1 for supervision needs/safety while out of the facility or create a safe plan that included an escort for the resident, instead of sending the resident alone to his medical appointment. In an interview on 12/14/15, Staff A, B, and C stated they had discussed what type of transportation would be arranged prior to the appointment, facility van versus transport service, but they thought the door to door transport service would be adequate for getting Resident 1 to and from his appointment. The facility did not attempt to have a staff or volunteer accompany the resident to his appointment. The care plan did not show any safety interventions for sending the resident unescorted to medical appointments. Refer to 42 CFR 483.25(h)(1)-Free of accident hazards/supervision

Based on observation, interview and record review the facility failed to ensure the safety of 1 of 1 sampled residents (1), who was sent unaccompanied to a physician's appointment. The facility's failure to assess and identify the potential risks associated with sending the cognitively and physically impaired resident to a medical appointment without supervision, placed Resident 1 in imminent risk of harm from exposure to the elements or accident hazards in an environment that was potentially unfamiliar to the resident. On 12/17/15, this was determined to constitute an immediate jeopardy situation. Findings Include: Resident 1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He received an antipsychotic medication for this disorder. His Minimum Data Set (MDS) assessment dated [DATE] had a brief interview screen of mental status that indicated Resident 1 had severe cognitive impairments, unclear speech, usually understood others, and was sometimes able to express his needs/wants to others. Resident 1 needed 1 person assistance with most activities of daily living, and was not steady in balance. A facility physician note dated 12/2/15 regarding Resident 1 documented the following: .(brain disorder) has progressed these past 3 months. He no longer seems to be cognitively aware .great difficulty in movement .have filled out an incompetence form for DPOA (durable power of attorney) for this facility to be able to continue care on a financial basis since he cannot make any decisions. A nursing progress note dated 12/11/15 documented Resident 1 had left the facility for an appointment at noon. Received a phone call at 2:30 pm from (appointment) MD that the resident was not at the VA (Veterans Administration) facility .Called (transportation service) to confirm that the resident was .not picked up yet. Interviews with facility staff: During an interview with Staff A & B on 12/14/15 at 11:45 am, they said Resident 1 had been picked up from the nursing home by a transportation service on 12/11/15 and taken to a physician appointment at a medical facility in the city. The facility was told by medical facility staff that the resident had checked in for his appointment. He was seen by the physician, who left the resident alone in a room to get another physician. When the physician returned to the room, the resident was gone. Staff A & B were told the resident had not been found during immediate searches of the area/facility by medical staff or police. Resident 1 had not yet been located as of 12/14/15. Staff A & B also said they had discussed what the best mode of transportation should be for the resident's 12/11/15 appointment during an interdisciplinary meeting on 12/10/15. The facility decided that the transport service was the best option. The transport service would take and pickup the resident door to door, ie. to/from a specific appointment area. Per Staff A & B, Resident 1 had not displayed any wandering and/or exiting behaviors. He had not given any previous indication of wanting to leave/discharge from the nursing home. Therefore, the facility did not think the resident needed a person to escort him and remain with him throughout his appointment excursion. In an interview on 12/14/15 at 12:50 pm, Staff C stated they had knowledge of the resident because he had been at the facility for several months. The resident had been in rehab and used a wheelchair (wc), but since his rehab he usually walked. The resident's communication was difficult, but you could usually get him to understand, and get a response. Staff C stated they recently did the (advanced directive) with him .it took 45 minutes, but I did get him to understand & indicate his preferences. He had very 'garbled' speech, and was hard to understand. The resident had his routine of staying in room, going to dining room across the hall, then back to his room. He didn't really go much further around the facility and didn't participate much in activities. The resident had a very wobbly walk, arms and body kind of wheeling about . I felt more comfortable when he walked with gait belt .He didn't seem to use a wc much, although was sent via wc to his appointment. Staff D on 12/14/15 at 1:05 pm: He's been in our unit for a few months, was in rehab prior, He was initially confused when moved to our unit, seemed not sure where he was, went back to his other room. but then seemed to get used to us, and had settled into routine. He liked to ambulate/walk, often left his walker behind, would get himself to bathroom and then used the call light. He didn't go much beyond his room/dining room. He never showed any wandering/elopement tendency, so did not have a wandergard(alarm bracelet). Communication by short sentences to him with usually single word responses. Would often say 'No' when asked to do something, but then would get up and go do whatever ever asked. Had to take time in communicating with him .He seemed to understand. Just really surprised by this (leaving from appointment). Staff D was not aware of Resident 1 going out to any appointments prior 12/11/15. Staff D also said she was not aware of any family members living in-state or friends that visited him at the facility. Staff E on 12/15/15 at 1:30 pm: Resident 1-had to take time with him. He didn't necessarily answer the (mental status screen) questions .sometimes it seemed the more specific the questions, the more his involuntary movements happened. But if I took time with him and told him to take his time, he could answer and seemed to understand. He used short-word answers. Never had any hint of him wanting to leave/go elsewhere, he never wandered around. MDS Care Area Assessment Summary worksheets 8/25/15: Cognitive Loss: Triggering conditions: cognitive loss r/t diagnosis. resident has potential to make unsafe decisions. Observable conditions: Decreased ability to make self understood r/t diagnosis. Can answer some simple yes/no by nodding. Not always appropriate answers. Other considerations: resident benefits from reminders & cues. Hearing/vision loss potential to impair cognition & safety issues .Family says resident has always been prideful, independent & continue to do things his way. Communication: Triggered related to resident sometimes understood. Usually understands.(brain disorder), dysarthria (difficulty in speech articulation), speech soft. Confounding problems: Clarity fluctuates, do not anticipate improvement secondary to progression nature of disorder.Care Plan Considerations: resident can say yes/no, & tries to nod head Yes/No although can be difficult to determine due to involuntary physical movements. Resident appears to understand what is said. He is not able to make concrete requests for needs consistently. Activities of Daily Living: Resident wants to maintain as much independence as possible and may act somewhat impulsive & forgetful of directions/precautions .staff must anticipate needs & ask Yes/No questions. Review of the written Plan of Care for Resident 1 did not have specific plan in place related to his impaired cognition. There was a care plan related to his communication problem, ADLs self care deficit, and high risk for falls related to uncontrolled muscle movement. The facility had knowlege of the resident's impaired cognition and physical deficits. There was no documented assessment or plan regarding whether the resident was safe to leave the facility unsupervised and that he would remain safe due to his impaired condition and physical deficits.

Based on interview and record review, the facility's administration failed to effectively and/or efficiently use its resources to maintain the highest practicable well-being for 1 of 1 sampled resident(1). Failure of the Administrator to ensure medically related social services to advocate for and to ensure supervision for the cognitively and physically impaired resident while attending a medical appointment affected the quality of care and safety of Resident 1. Findings include: 1.The Administration failed to ensure medically related social services to advocate for Resident 1's safety while attending a medical appointment. Refer to CFR 483.15(g)(1), F-250- Provision of Medically related Social Services 2. The Administration failed to ensure thorough assessment and identification by facility staff of the potential risks associated with sending the cognitively and physically impaired resident to a medical appointment without supervision. Refer to CFR 483.25(h), F-323 - Free of Accident Hazards/Supervision.

Based on observation, interview and record review, the facility failed to prevent an accident hazard for 1 of 6 residents sampled (Resident #1), when facility staff re-heated a hot liquid for Resident #1 without the use of a safety procedure for hot liquid temperatures. This failure contributed to a substantial injury for Resident #1, who aquired a second degree burn with pain from hot coffee, after it was reheated by facility staff in a microwave in the facility utility room. Findings include: According to record review of facility medical record on 06/13/2014, Resident #1 was admitted to the facility for rehabilitation in May 2014. Review of the facility Minimum Data Set (MDS) assessment dated [DATE] revealed, Resident #1 was alert and oriented, needed extensive assistance for bed mobility and needed supervision for eating. Review of the facility Care Plan dated 05/02/2014 revealed, Resident #1 was able to to hold a cup and feed self, and preferred to eat meals in her room. According to the facility Incident Investigation dated 05/11/2014, Resident #1 asked a facility staff member to re-heat a cup of coffee after lunch and bring it back to her in her room, where she sat in bed with her lunch. Further review of the facility investigation revealed, Resident #1 was sleepy after noon pain medication, reported that she spilled some of the re-heated coffee on herself, which was unwitnessed, and sustained a coffee burn on her lower abdomen. In an interview on 06/24/2014 at 10:25 a.m., Staff B stated she warmed the coffee up in the microwave in the facility utility room for Resident #1 at the resident's request, and gave the re-heated cup of coffee to Resident #1 in her room, on the overbed table over the bed where the resident was sitting at lunch time. Staff B also stated she did not use any safety procedure, thermometer or temperature check of any kind when she re-heated the hot coffee for Resident #1. Staff B also stated she had no training in the facility about re-heating hot liquids, or the use of thermometers or any procedures for safe hot liquid re-heating while she has worked in the facility since 2013. In addition, Staff B stated Resident #1 was sleepy with "droopy eyelids" when she gave Resident #1 the hot re-heated coffee in bed. In an interview on 06/24/2014 at 9:45 a.m., Staff C, the nurse on duty when Resident #1 was burned with hot coffee, stated she gave Resident #1 pain medication (narcotic) at 11:55 a.m. on 05/11/2014, then after lunch around an hour or so later, Staff C heard Resident #1 scream "I burned!" Staff C entered Resident #1's room where the resident stated she asked Staff B to re-heat her coffee from lunch, spilled it on herself when she was sleepy, and sustained a pink burned area on the lower abdomen about 5 centimeters by 10 centimeters in size. Staff C also stated she immediately administered an ice pack to the burn area on the abdomen of Resident #1, and gave her Tylenol for pain. In addition, Staff C stated Resident #1 was "droopy" at the time of the burn incident, and had been getting more forgetful and sleepy since her pain medication had been increased before the burn. Staff C also stated there was a procedure on the utility room microwave about re-heating but she did not recall what it said. In an interview on 06/24/2014 at 11:30 a.m., Staff A, a nurse supervisor, stated on 05/12/2014, the day after the initial burn on Resident #1, Staff A received an order from the practitioner for a treatment for [REDACTED].#1. Staff A also stated the second degree burn had blisters that covered at least half of the burned area, as well as small red open areas, and the burn wound was 23 centimeters long by 7 centimeters wide on the abdomen of Resident #1. Staff A also stated Resident #1 stated the burn wound was painful when he assessed it on 05/12/2014, the day after the initial burn. Review of the facility Occupational Therapy Treatment Notes dated 05/11/2014, the day of the burn for Resident #1 revealed, the therapist noted Resident #1 reported feeling drunk after pain medication, was very fatigued and sleepy, and had pain on the abdomen due to hot coffee spill. Further review of the facility Weekly Wound Progress Note dated 05/12/2014, the day after the burn, for Resident #1 revealed, the resident had a burn on the abdomen size 23 centimeters by 7 centimeters with blisters. Review of the facility Progress Note dated 05/13/2014 revealed, Staff A, a nurse supervisor, noted Staff B heated coffee in the microwave for Resident #1 on 05/11/2014, and further noted the facility staff were inserviced on re-heating in microwaves for residents and how to appropriately measure after the burn incident. Staff A also noted all microwaves were removed from clean utility rooms in the facility after the burn. In an interview on 06/13/2014 at 9:00 a.m., Staff D, an administrative employee, stated that in employee orientation, the facility did talk about the utility microwaves, re-heating food/liquids, and thermometers and how to check for correct temperatures prior to the 05/11/2014 burn, but could not provide any written documentation of any staff training in the facility. Staff D also could not provide any documentation of a procedure for re-heating hot liquids for residents, since the procedure had been posted on the microwaves in the utility rooms,and they were removed from the facility after the coffee burn for Resident #1. Staff D could not recall what the written procedure for re-heating said that was posted on the microwaves prior to the burn. In an interview on 06/13/2014 at 9:00 a.m., Staff E, an administrative employee, stated that prior to the burn injury for Resident #1 on 05/11/2014, the facility procedure for re-heating hot liquids was vague. In an interview on 06/13/2014 at 8:15 a.m., Staff F, a facility caregiver since March 2014, stated she had not received any training in the facility about safe re-heating of hot liquids in the utility room microwaves for residents. In an interview on 06/13/2014 at 9:40 a.m., Staff G, a facility caregiver, stated she did not receive any training in the facility about re-heating hot liquids safely for residents prior to the burn incident on 05/11/2014. In an interview on 06/13/2014 at 9:45 a.m., Staff H, a facility caregiver for the past 4 years, stated he had no training in the facility regarding safe re-heating of hot liquids for residents prior to the burn on 05/11/2014. In an interview on 06/13/2014 at 9:50 a.m., Staff I, a facility caregiver for the past one and a half years, stated he did not receive any facility training for safe re-heating of hot liquids for residents.