Every finding on record at Rock Hill Health & Rehabilitation

Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from physical abuse by an alleged unidentified male staff member for 1 of 3 sampled residents (Resident 1) reviewed for abuse. Resident 1alledged an unidentified male staff member twisted their hand and caused bruising, swelling and pain to their left pinky. The failure to protect the resident from an unidentified staff member placed the resident at risk for potential ongoing abuse and a diminished quality of life. Findings included . Review of the facility policy titled, Abuse, revised on 10/20/2022, documented the organization recognizes and respects that each resident has the right to be free from abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Resident 1 admitted to the facility with a diagnosis to include a fracture on both sides of their sacrum (a large bone at the base of the spine and sits between the hip bones and above the tailbone). Review of Resident 1's admission Minimum Data Set (an assessment tool) assessment, dated 07/06/2026, documented the resident had moderate cognitive impairment. Review of Resident 1's progress note, dated 07/05/2026 at 1:24 PM, Staff D, Registered Nurse (RN), documented Staff C, RN, reported to them around noon that a guy had come into the resident's room last night and twisted their left hand. Staff D documented Resident 1 had a 6 centimeter (cm) long bruise to the left pinky finger, an 11 cm bruise to the side of the left hand, and a 3.5 cm width by 5 cm length by approximately 1.25 cm diameter bruise on the back of the left hand that included below the left thumb. Review of a facility incident investigation, dated 07/05/2026, documented Resident 1 made an allegation of physical abuse from an unidentified male that resulted in Resident 1's left pinky finger and outer hand being bruised, swollen, and caused discomfort. Review of an x-ray result, dated 07/06/2026, documented Resident 1 had osteoarthritis (a joint disease) in their left hand and there was no fracture. Review of Resident 1's psychosocial well-being care plan, dated 07/08/2026, the resident was at risk for an alteration in their well-being due to an allegation of abuse. An intervention included to give the resident the opportunity to discuss their positive and negative feelings regarding nursing facility placement, dated 07/08/206. In an interview on 07/14/2026 at 10:42 AM, Staff D stated they worked on 07/05/2026 when Resident 1 made an allegation of physical abuse. Staff D stated Staff C reported on 07/05/2026 around noon that Resident 1 made an allegation of physical abuse. Staff D assessed the resident's left hand and observed a bruise on their left pinky finger and on the outer part of the left hand. The resident complained of pain in this area. Staff D administered oxycodone (a narcotic pain medication) to the resident, called the on-call physician, and obtained an order to x-ray the resident's left hand. In an interview on 07/14/2026 at 11:02 AM, Staff C stated on 07/05/2026 around noon Resident 1's family member asked what happened to the resident's left hand. Staff C observed a faint bruise and swelling to Resident 1's left pinky finger and outer left hand. When Staff C asked Resident 1 what had occurred, the resident stated an unidentified male came into their room the prior night and twisted their left hand when the male attempted to take the resident's dog away from them. Staff C immediately reported the allegation to the resident's primary nurse, Staff D. In an interview and observation on 07/14/2026 at 12:58 PM, Resident 1 was observed sitting in a recliner visiting with a family member. The resident's left pinky finger was observed to have a faint bruise along the side and top of the finger, and the finger was slightly swollen. When asked what happened, the resident stated that a guy came into her room one night and attempted to remove their dog from the room. The unidentified person grabbed their left hand (the resident then took their right hand and grabbed the middle, ring, and pinky fingers and made a twisting motion) and twisted their hand. Resident 1 stated they threw a glass of water on the guy and they left the room. In an interview on 07/15/2026 at 3:37 PM, Staff A, Administrator, was asked regarding Resident 1's abuse allegation and identifying how the injury of unknown origin occurred. Staff A stated they would ask Staff B, RN/Director of Nursing Services, in the morning. A follow up phone call was held on 07/16/2026 at 11:35 AM with Staff A, Staff C, and Staff E, Licensed Practical Nurse (LPN)/Resident Care Manager. Staff A stated Staff B was not available to be interviewed. When asked how Resident 1's physical abuse allegation was ruled out, Staff A, Staff C and Staff E could not state how abuse was ruled out. Cross Reference with CFR 483.12(c)(2)(3) - F610 - Investigate/Prevent/Correct Alleged Violation Refer to WAC 388-97-0640(1)

Based on observation, interview and record review, the facility failed to thoroughly investigate allegations of abuse including an injury of unknown origin and of an injury to an area not vulnerable to trauma for 1 of 3 sampled residents (Resident 1) reviewed for allegations of abuse. The failure not to conduct a thorough investigation, and correct actual or potential alleged violations left residents at risk for unidentified and/or repeated incidents, and a decreased quality of life. Findings included.Review of the facility policy titled, Abuse, revised on 10/20/2022, documented the facility is committed to developing and operationalizing policies and procedures that included protection of residents and for the preventions, identification, and investigation of abuse and neglect. The facility will review and investigate all allegations or observations of abuse. Review of a facility incident investigation dated 07/05/2026 at 1:05 PM, Staff D, Registered Nurse (RN), documented Resident 1 reported to Staff C, RN, the resident made an allegation of physical abuse. When Staff D interviewed the resident, they stated some guy came last night and twisted their left hand. The resident's left hand was assessed, and a bruise was present on the left little finger, left side of the hand, back of left hand, and below the left thumb. The resident complained of pain and tenderness when their left hand was touched. Staff D documented in the morning of 07/05/2026, when they took Resident 1's blood pressure on the left arm the resident did not complain of any pain nor was there any bruising observed on their left pinky finger and/or hand. Review of Resident 1's incident investigation, dated 07/05/2026, documented the resident had hallucinated about their dog, was confused who staff were and why they would not bring them their dog. The resident made an allegation of physical abuse from an unidentified male who came into their room last night, attempted to remove the resident's dog from their lap, and in the process twisted Resident 1's left hand causing an injury. The resident's left hand was assessed and noted to have bruising on the left pinky finger and outer part of their hand, swelling and discomfort. The facility summary documented abuse and neglect were ruled out, and it was reasonable to conclude the resident was having hallucinations as charted, and the resident revealed no care issues or physical abuse. Review of Staff C's witness statement, dated 07/05/2026, documented Resident 1 made an allegation of abuse on 07/05/2026 around noon that an unidentified man came into their room last night and attempted to take the resident dog from them. The unidentified male grabbed and twisted Resident 1's left hand when they did not relinquish their dog to the unidentified male. The resident could not give a description of the man except for their clothing. Staff C reported the allegation to Resident 1's primary nurse, Staff D. Review of Staff H, Nursing Assistant Certified (NAC), witness statement, dated 07/05/2026 at 2:45 PM, documented they had worked the evening and night shift on 07/04/2026 and had not entered Resident 1's room or heard of any concerns. Review of Staff G, NAC, witness statement, dated 07/07/2026, documented they were assigned to Resident 1 on 07/04/2026. Staff G documented every time they went into the room another staff member was with them. There was no documentation about whether the resident had bruise, pain or swellings on their left hand. Review of Staff F, NAC, witness statement, dated 07/09/2026, documented they did not work with Resident 1 on the night of 07/04/2026. There were no other witness statements to review. In an interview on 07/14/2026 at 10:42 AM, Staff D stated they were Resident 1's primary nurse on 07/05/2026, day shift. Staff C was in the resident's room earlier on 07/05/2026 to take their blood pressure (B/P). They assisted Resident 1 to sit at the edge of the bed and placed a B/P cuff on their left arm. Staff C stated they did not notice any bruising to their left hand, the resident did not complain of any pain to their left hand, nor did they bring up any allegation of an unidentified male being in their room last night. In an interview on 07/14/2026 at 11:02 AM, Staff C stated they were working as a NAC and were assigned to Resident 1 on the day shift on 07/05/2026. Staff C stated around 10:30 AM they provided care to Resident 1 and they had no concerns, no complaints of pain, and there was no bruise observed on their left hand. Staff C stated when they returned to care for Resident 1 around noon, was when the resident's family inquired what happened to the resident left hand. Resident 1 proceeded to state that an unidentified male had entered their room last night and twisted their left hand when the resident would not give the unidentified male the resident's dog. In an interview and observation on 07/14/2026 at 12:58 PM, Resident 1 was observed sitting in a recliner visiting with a family member. The resident's left pinky finger was observed to have a faint bruise along the side and top of the finger, and the finger was slightly swollen. When asked what happened, the resident stated that a guy came into her room one night and attempted to remove their dog from them. The resident stated when they would not hand over their dog, the unidentified male grabbed their left hand and twisted it. When asked if they could describe the male, Resident 1 stated they were white and were in their late 40's - 50's. Resident 1 stated they had not seen the male since the incident. On 07/14/2026 at 1:13 PM, Staff B, RN/Director of Nursing Services, was updated Resident 1 identified the unidentified as being a white male in their late 40's to 50. In an interview on 07/14/2026 at 2:31 PM, Staff G stated they worked with Resident 1 on 07/04/2026 and 07/05/2026. Staff G stated at no time did the resident complain of any pain in their left hand, they did not observe any bruising, and the resident had not reported any allegation of physical abuse to them. In an interview on 07/15/2026 at 3:37 PM, Staff A, Administrator, was asked regarding Resident 1's abuse allegation and the lack of the facility investigator identifying how the injury of unknown origin occurred on Resident 1 left hand. Staff A stated they had informed Staff B regarding how the information that was reported to them, on the sequence of events when the resident was provided care that morning there was no mention of the allegation and their left hand was not injured. Resident 1 made the allegation of physical abuse around noon on 07/05/2026. Staff A stated they would ask Staff B, RN/Director of Nursing Services, in the morning and follow up with the compliant investigator. A follow up phone meeting was held on 07/16/206 at 11:35 AM with Staff A, Staff C, and Staff E, Licensed Practical Nurse (LPN)/Resident Care Manager. Staff A stated Staff B was not available to be interviewed. Resident 1's abuse allegation investigation, dated 07/05/226, was reviewed with Staff A, Staff C, and Staff E. The staff were asked, based on the summary of the investigation, how the resident hallucinating a factor contributing to their left-hand injury and no other factors were investigated. Staff A stated they were aware through talking with Staff C and Staff D, Resident 1 did not have any concerns the morning of 07/05/2026. Staff A, Staff C, and Staff E acknowledge Resident 1's allegation of abuse was not thorough. Refer to WAC 388-97-0640(6)(a)(b)

Based on interview and record review the facility failed to ensure the designated Infection Preventionist (IP) responsible for the facility's Infection Control Program met the education qualifications for certification prior to accepting the role as the IP in a long-term care facility. This failure placed residents at risk for not having an adequate oversight of infection control issues specific to long-term care. Findings included . Review of the undated facility policy titled, Infection Preventionist documented the IP had obtained specialized infection prevention control training beyond initial professional training or education prior to assume the role. In an interview on 05/28/2026 at 10:58 AM, Staff B, Director of Nursing Services, stated they were in charge of IP until they hired someone for that role. Staff B stated they did not have a copy of their IP certification but had completed it in 2022. Staff B stated no one else in the building had an IP certification. Staff B stated they sent an email to get a copy of their IP certification but had not heard back. No confirmation of IP certification was provided. Reference WAC: 388-97-1320(1)(a)

Based on interview and record review, the facility failed to ensure a system was in place in which residents' records were complete, accurate, accessible, and systematically organized for 6 of 6 residents (Resident's 4, 17, 23, 30, 44, and 50) reviewed for accurate and complete medical records. The facility failed to ensure the medical records reflected weight and sleep monitoring and alert charting after an allegation for Resident 50 and a discharge note for Resident 4. Further, Residents 4 and 23 had other resident records in their medical record. The failure to maintain complete and accurate medical records placed residents at risk for medical complications, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Release of Medical Records, revised 08/05/2022 showed Medical Records are a collection of documents prepared and maintained during a resident's stay in the facility that records the clinical/medical care of the resident. These documents can be written or electronic information and include progress notes, physician orders, nursing notes, consultations, laboratory, diagnostic reports, and plans of care. <RESIDENT 50> In an observation and interview on 05/26/2026 at 12:27 PM Resident 50 was in bed with only a top sheet on them. The resident's blanket was noted to be on the floor. The resident was asked if staff treated them with dignity and respect. The resident stated that everybody was nice, but this one b**ch, she was just nasty, she works in the evenings. You do it her way or no way. I have told them (staff) about her. The resident said they had to holler for staff when they were cold and their blanket was on the floor. They also stated they had waited 3 to 4 hours for their call light to be answered. Review of a progress note on 05/27/2026 at 4:16 PM showed one entry from Staff A, Administrator that showed Resident 50 had made a statement to Surveyor that they had to wait 2 hours for their call light to be answered. The progress note did not include information about the concern with a staff member. Review of Resident 50's progress notes showed the resident was not placed on alert for monitoring every shift for 3 days to assess for any psychosocial distress after their allegation on 05/26/2026. There were no other progress notes about the allegation. Review of Resident 50's May Medication Administration Record (MAR) showed missing documentation of daily weights on 05/18/2026 and 05/23/2026. The sleep monitor was set up for a check mark as task completed rather than the number of hours. This resulted in no monitoring of sleep for nursing to evaluate the sleep pattern. <RESIDENT 44> Review of Resident 44's electronic health record (EHR) documented they discharged with their family to a facility in Michigan on 04/03/2026. Review of Resident 44's progress from 04/01/2026 through 4/03/2026 provided no information regarding their discharge. In an interview on 05/27/2026 at 10:38 AM Staff D, Registered Nurse/Resident Care Manager (RCM), stated the RCM's had taken over the discharge process to include completing assessments and faxing to the pharmacy. When asked if a progress note is completed when a resident was discharged , Staff D stated there should be a note. Staff D stated they must have forgotten to complete a discharge note for Resident 44. <RESIDENT 4> Review of Resident 4's EHR under miscellaneous records, contained a hospice note which belonged to Resident 17. In an interview on 05/29/2026 at 1:02 PM Staff D, stated medical records were responsible for uploading documents into the medical records of residents. <RESIDENT 23> Review of Resident 23's EHR, under miscellaneous records, contained a pharmacy recommendation which belonged to Resident 30. In an interview on 06/01/2026 at 12:25 PM, Staff A, Administrator stated they were going to add a performance improvement plan (PIP) on charting. Staff A was asked about lack of discharge note for Resident 4 and missed daily weights, hours of sleep and alert charting for Resident 50. They were unaware that Resident 4 and Resident 23 had other resident records scanned into their record. Staff A stated they were not sure why the staff were not charting. Staff A stated they were going to review charting while they were at home before bed and follow up with staff accordingly. Staff A stated the resident care managers and Director of Nursing Services (DNS) were to audit daily. Staff A stated they would no longer give verbal warnings; there would be a written warning for failure to document. They stated they would discuss the issues with medical records and have them do an audit of charts. They stated Staff B, DNS just started using the missed documentation audit in the EHR and they should be doing standard audits. No additional information was provided. This is a repeat deficiency from SOD dated 05/01/2025 Refer to WAC 388-97- 1720 (1)(a)(i-iv)(b)

Based on observation, interview and record review, the facility failed to ensure dishwashing temperatures met the requirements in the facility kitchen. Failing to ensure proper dish sanitation placed residents at risk for food borne illness. Findings included . Review of the Washington State Retail Food code (dated March 1, 2022) stated high temperature dishwashers required wash cycle temperatures of 150 degrees Fahrenheit (f) and rinse cycle temperatures of 180 degrees f. In an observation and interview on 05/28/2026 at 11:51 AM, Staff K, Dietary Manager, stated the facility utilized a high temperature dishwasher which was being leased. A High Temperature Dish Machine Log, dated May 2026, specified a wash cycle of 150-165 degrees f and a rinse cycle greater than or equal to 180 degrees f. There were columns for temperature entries three times per day. There were observed to be 18 entries logged where the dishwasher had not met the minimum wash cycle temperature of 150 degrees f and three instances it had not met the minimum rinse cycle temperature of 180 degrees f. Staff K stated the company they leased the dishwasher from, reported the machine was functioning properly and was getting up to temperature. Staff K stated they were told their dial was reading about 5 degrees off and they had instructed the dietary staff to continue to write down exactly what the dial read. Staff K stated they had been told by the company the machine was functioning, so they were not concerned. Staff K stated they would provide the most recent maintenance notes from the company. Record review of the provided dishwasher service note on 05/28/2026 revealed the date of the most recent service was March 2026 and did not include notes regarding low temperature readings at the facility or inaccurate dial readings at the time of the service visit. In an interview on 05/29/2026 at 10:47 AM, Staff A, Administrator, stated they were not aware of the low dishwasher temperatures. They stated it was a leased machine and if the dishwasher dial was not reading correctly and if the temperatures were not reaching the minimum temperatures, the company needed to be contacted for repairs and come repair it. Refer to WAC 388-97-1100 (3)

Based on interview and record review, the facility failed to ensure there was not greater than 14 hours between the evening meal and breakfast in the main resident dining room without the approval of the resident group and with the provision of a substantial evening snack. This had the potential to affect all residents who received their meals in the main dining room and impact resident quality of life. Findings included . Review of the facility's mealtime schedule documented the main dining room was served dinner at 5:30 PM and served breakfast at 8:00 AM, which was greater than 14 hours. In an interview on 05/28/2026 at 12:54 PM, Staff K, Dietary Manager, stated they had adjusted times and thought they were within the 14 hours. Staff K stated nursing assistants offered snacks in the evening as residents requested, but there was not a specific routine snack provided in the evening. Staff K stated the facility had started a food committee and they attended resident council but confirmed that the time frames for meal service had not been discussed as they were not aware there was an issue. In an interview on 05/29/2026 at 10:45 AM, Staff A, Administrator, confirmed the posted dining room times were accurate and stated they had not recognized the mealtimes for the main dining room exceeded 14 hours. Staff A confirmed there had been no approval by the resident group or a substantial evening snack provided. In a resident group interview on 05/29/2026 at 2:00 PM, the resident council confirmed there had been no approval by the group for meal service between dinner and breakfast to exceed 14 hours. Refer to WAC 388-97-1120 (1)(3)(a)(b)

Based on observation, interview, and record review the facility failed to dispose of expired medications in 2 of 2 medication rooms (Forest and Artist Medication Rooms), failed to properly label and discard open vials of Tuberculosis solution (TB solution - used to test for persons with possible Tuberculosis - an infectious respiratory disease), and failed to correctly monitor temperatures of vaccines in 1 of 2 medication refrigerators (Forest Medication Room). These failures placed residents at risk of receiving compromised or ineffective medications. Findings included . Review of the undated facility policy titled, Medication Storage, documented that the facility shall not use outdated drugs or biologicals. Review of the Center for Disease Control (CDC) guidelines titled, Vaccine Storage and Handling, dated 03/29/2024, documented to check and record temperatures with the minimum and maximum temperatures at the start of each workday. If the temperature monitoring device does not read minimum/maximum temperatures, then you are to check and record the current temperature a minimum of two times per workday. <ARTIST MEDICATION ROOM> In an observation on 05/27/2026, at 1:52 PM, with Staff O, Licensed Practical Nurse (LPN), the Artist Medication room contained probiotics that were in the medication refrigerator with an expiration date of 04/2026 and multiple individual packets of white petroleum in the cupboard with an expiration date of 11/2025. The medication refrigerator had no vaccines observed. In an interview on 05/27/2026 at 1:56 PM, Staff O confirmed the expiration dates on the probiotics and white petroleum. Staff O took the medications from the medication room and stated they would dispose of them. Staff O stated they only keep vaccines in the Forest Medication Room. <FOREST MEDICATION ROOM> In an observation on 05/27/2026, at 2:21 PM, with Staff D, Registered Nurse/Resident Care Manager, the Forest Medication room contained probiotics that were in the medication refrigerator with an expiration date of 04/2026 and another bottle of probiotics in the cupboard with an expiration date of 04/2026. The medication refrigerator had two bottles of TB solution with a label that documented good for 30 days after open. No open date was observed. The medication refrigerator did contain influenza vaccines. Review of the medication refrigerator temperature logs on 05/27/2026, at 2:30 PM, documented checking both refrigerator temperatures only daily. The temperature log had four missing temperatures in January 2026 for both medication refrigerators, one missing temperature for both medication refrigerators in February 2026, one missing temperature for both medication refrigerators in March 2026, four missing temperatures for both medication refrigerators in April 2026, and one missing temperature for medication refrigerators in May 2026 as of 05/27/2026. In an interview on 05/27/2026, at 2:34 PM, Staff D stated the probiotics did not need to be in the refrigerator and confirmed the expiration dates. Staff D took the medications from the medication room and stated they would dispose of them. Staff D confirmed there was no open date on the TB solution and stated they should be dated when opened. Staff D stated night shift checked both medication room refrigerators temperature once a day. Staff D stated they were unaware of the CDC guidelines to check the temperatures twice daily for vaccines. In an interview on 05/28/2026, at 10:58 AM, Staff B, Director of Nursing Services/Infection Preventionist, stated they were unaware of the vaccine temperature guidelines for checking temperatures twice daily. Staff B stated their expectation for the medication rooms was that expired mediations were to be discarded and TB solution be dated when opened. Reference WAC: 388-97-1300(2)

Based on interview and record review, the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 6 of 7 sampled staff (Staff B, G, H, T, U and W) reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life.Findings included . Review of the facility staff list documented: Staff B, Director of Nursing Services, was hired 04/25/2025, Staff G, Certified Nursing Assistant (CNA) was hired 05/02/2025, Staff H, CNA, were hired 06/19/2024, Staff T, CNA, were hired 10/15/2018, Staff U, CNA were hired 04/02/2024, and Staff W, Physical Therapist Assistant, was hired 03/03/2016. The most recent performance evaluations for Staff B, G, H, T, U, and W were requested on 05/27/2026 and none were provided. In an interview on 05/28/2026 at 10:37 AM Staff E, Business Office Manager/Human Resources, stated they were unable to provide proof of performance evaluations for Staff B, G, H, T, U and W, as the facility recently went through a change of ownership and the proof of performance evaluations were in electronic files that could no longer be accessed. This is a repeat deficiency from SOD dated 05/01/2025. Reference: WAC 388-97-1680(1), (2)(a-c)

Based on interview and record review, the facility failed to implement a system to evaluate staff competencies in skills and techniques to ensure staff provided necessary care and responded to each resident's individualized needs for 3 of 5 certified nursing assistants (CNA) (Staff G, U and V) reviewed for nursing services. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, unmet care needs, and diminished quality of life.Findings included . Review of the facility assessment dated [DATE] documented Certified Nursing Assistants participated in annual skills assessments and were assessed annually for care competencies by qualified nurses in addition to training during all staff in-services. Review of the facility staff roster documented Staff V, CNA, was an agency aide that was used by the facility and was hired on 10/01/2025. Staff V's competencies checks, training and education were requested on 05/27/2026. There were no competencies, training, or education for Staff V provided by the facility. Review of the facility staff roster documented Staff U, CNA, was hired on 04/02/2024. Review of the competencies provided by the facility documented their last competency evaluation was completed on 04/30/2025. Review of the facility staff roster documented Staff G, CNA, was hired on 05/02/2024. Review of the competencies provided by the facility documented their last competency evaluation was completed on 05/06/2025. In an interview on 05/28/2026 at 10:37 AM Staff E, Business Office Manager/Human Resources, stated they were unable to provide proof of education and training for Staff G, U, and V as the facility recently went through a change of ownership and the proof of education and training were in electronic files that could no longer be accessed. Staff E stated the prior staff development coordinator had completed competencies for staff prior to them leaving. In an interview on 06/01/2026 at 10:20 AM Staff B, Director of Nursing Services, was unaware competencies were not completed and electronic access to staff education had been removed. Reference: WAC 388-97-1080(1), 1090(1)

Based on observation, interview and record review, the facility failed to provide assistance with bathing for 4 of 5 residents (Residents 3, 5, 7 and 50) reviewed who were unable to carry out their ADL's (activities of daily living) independently. Failure to provide bathing assistance according to the resident's needs and preferences placed the residents and others at risk for poor hygiene, diminished dignity and diminished quality of life. Findings included .Review of the undated facility's policy titled, Shower/Tub Bath, showed the purpose of the procedure was to promote cleanliness, promote comfort and to observe the condition of the resident's skin. The procedure directed qualified nursing staff to provide a bed bath to the residents as needed. At a minimum of at least two full baths or showers a week. The documentation was to include the date and time the shower or tub bath was performed and if the resident had refused, include the reason. The licensed nurse was to be notified of refusals. <RESIDENT 3> Resident 3 admitted on [DATE] following a stroke which resulted in paralysis of the right side of the body and speech deficits. Review of the admission Minimum Data Set (MDS) (a required assessment tool) dated 02/09/2026 documented Resident 3 required extensive assistance for bathing. Review of Resident 3's care plan related to bathing documented substantial/maximum assistance was required and did not include resident bathing preferences. In an interview on 05/26/2026 at 12:08 PM, Resident 3 stated they were not receiving showers as scheduled. Resident 3 stated they were supposed to have showers on Mondays and Thursdays which was not happening. In a follow-up interview on 05/28/2026 at 11:29 AM, Resident 3 stated they had not been asked regarding their preferences for bathing. Resident 3 stated they were told the schedule was twice a week, but they were not getting showers at all for a while and now they only got one a week. Resident 3 stated the wash up was not a real bath but the staff tried to say it was. Resident 3 stated they were supposed to have a shower today (Thursday) but nobody had come yet and they would have come by now if they were going to. Review of Resident 3's bathing documentation showed Resident 3 was scheduled for eight showers on Mondays and Thursdays in the Month of May 2026 and was documented as receiving four showers and two bed baths. There were no refusals documented. Review of prior months of bathing documentation revealed Resident 3 was scheduled for eight showers in the month of April 2026 and received only one. The April 2026 documentation contained several documentations of N/A (not applicable) with no further explanations. Resident 3 was not charted as having any refusals of bathing. Review of documentation for March 2026 and February 2026 revealed no documentation. The requested reports pulled up showed no data available. In an interview on 06/01/2026 at 8:45 AM, Staff H, Nursing Assistant, Shower Aide, stated Resident 3 was supposed to get two showers per week and there should not be any documentation that says N/A, That is wrong. Staff H stated they were sometimes pulled from shower duties to work on the floor and the floor staff should attempt showers and should be documenting yes, no, or refused, and then offer again later that shift, or try the next day. Staff H stated Resident 3 sometimes only wanted a sponge bath or could refuse which was their right. Staff H stated this should be reflected in the documentation, though, showing attempts and refusals if they had occurred. <RESIDENT 5> Resident 5 readmitted to the facility on [DATE] with diagnoses to include cerebral infarction with hemiplegia (paralysis on one side of body) and hemiparesis (weakness on one side of body), dementia and multiple sclerosis ( a disorder where the immune system is impaired and signals are misinterpreted between the brain, spinal cord and rest of the body). Review of the quarterly MDS dated [DATE] showed the resident had cognitive impairment, upper and lower extremity impairment on one side and required extensive assistance for bathing. Review of the Kardex (guide to show nurses aides how to care for resident) did not include how the staff were to provide grooming assistance or bathing. Resident 5's bathing preference was not included. Review of Resident 5's April bathing documentation on the documentation survey report showed Resident 5 wanted two showers a week on Tuesdays and Saturdays. Resident 5 received showers on six rather than eight days (04/07/2026, 04/09/2026, 04/14/2026, 04/18/2026 04/21/2026 and 04/29/2026). <RESIDENT 7> Resident 7 admitted to the facility on [DATE] with diagnoses to include depression, low back pain, muscle wasting, atrophy and muscle weakness. Review of the quarterly MDS dated [DATE] showed Resident 7 had no cognitive impairment, required moderate assistance for bathing and did not refuse care. Review of the Kardex directed staff to provide moderate assistance with bathing. Resident 7's bathing preference was not included. The Kardex did not include that Resident 7 experienced nightmares related to being stuck in a bathtub for multiple days prior to admit which resulted in PTSD. Review of Resident 7's April bathing documentation on the documentation survey report showed Resident 7 wanted three showers a week on Mondays, Wednesday and Fridays. Resident 7 received showers on six rather than eleven days (04/09/2026, 04/13/2026, 04/16/2026, 04/23/2026, 04/27/2026 and 04/30/2026). Review of Resident 7's May bathing documentation on the documentation survey report showed they received showers on eight rather than thirteen days (05/04/2026, 05/07/2026, 05/14/2026, 05/18/2026, 05/20/2026, 05/21/2026, 05/25/2026 and 05/28/2026). In an interview and observation on 06/01/2026 at 10:00 AM, Resident 7 was sitting on the edge of their bed with greasy and uncombed hair and body odor noted. They stated they were not getting showers as often as they liked. <RESIDENT 50> Resident 50 admitted to the facility on [DATE] with diagnoses to include depression, heart failure and muscle weakness. Review of the admission MDS dated [DATE] showed Resident 50 had cognitive impairment, required moderate assistance for bathing and did not refuse care. Review of the Kardex directed staff to provide moderate assistance with bathing. Resident 50's bathing preference was not included. Review of Resident 7's May bathing documentation on the documentation survey report showed they received one shower 13 days after admit on 05/25/2026. In an interview on 05/29/2026 at 1:24 PM, Staff L, NAC stated the shower aide had been pulled to work the floor rather than bathing duties quite a bit since the new company took over. Staff L stated they had heard residents complain about not getting their showers. In an interview on 05/29/2026 at 2:32 PM, Staff D, Registered Nurse/ Resident Care Manager reviewed shower documentation of Resident's 5, 7 and 50. Staff D stated Resident 50 refused some showers and they would document that in their progress notes. Staff D stated Resident 50 had not and would not refuse their showers. Staff D stated the expectation is the resident would be offered a shower the next day after refusals. They stated the NAC's and nurses needed to document refusals. In an interview on 06/01/2026 at 8:41 AM, Staff H, shower aide stated they are pulled from their duties to work the floor once a week. Staff H confirmed Resident 50 had one shower in May. They stated Resident 5 accepted showers. They stated when they are pulled from their duties the PM shift aides were supposed to complete one shower. Staff H stated Staff D gave them a missed shower list when they work Monday through Thursday. They stated refusals were to be reattempted three times and documented when they occur. In an interview on 06/01/2026 at 12:25 PM, Staff B, Director of Nursing was asked about missed showers for Resident's 3, 5, 7, and 50. Staff B stated the nurses were to document refusals. They stated they would be adding reviews of missed showers to their clinical meeting. Staff A, Administrator stated they would be adding a performance improvement plan for those who missed documentation. No additional information given Reference: (WAC) 388-97-1060 (2) (c)

Based on interview and record review the facility failed to have a system in place to ensure information was readily available and posted in prominent places for residents on how to file grievances or complaints for 1 of 1 resident groups and grievances were addressed and resolved in response to residents' concerns for 2 of 2 residents (Residents 7 and 47) who voiced grievances. These failures placed residents at risk of feeling frustrated, unimportant, with diminished self-worth and decreased quality of life.Findings Included . Review of the facility policy titled Grievances/Complaints Policy, revised 07/27/2022, documented residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. <RESIDENT 47> Resident 47 admitted on [DATE]. In an observation on 05/28/2026 at 2:09 PM, at the nurse's station, Staff G, Nurse's Aide Certified (NAC) was talking to Staff L, NAC and stated a resident (no name provided) was complaining about their food being cold. Staff G said Sorry [NAME], I just took it off the cart and that is just how it is. If you want your food hot, then you need to go to the dining room. Staff C, Social Worker, quickly turned to Staff G, NAC and asked when that happened. Staff G stated it was the night the resident had admitted . Staff G said, I told (resident) we can't just keep putting your food in the microwave. Staff G was asked who the resident was and Staff L responded it was the resident in room [ROOM NUMBER], (Resident 47). Staff C stated they were in the process of completing a grievance form for this. In an interview on 06/01/2026 at 12:29 PM, Staff A, Administrator, stated the process for grievances included attempting to resolve the concern immediately and completing the grievance form. Staff A stated they would reeducate the staff on the grievance process. They stated they were unaware residents and staff did not know the grievance process. Staff A stated a grievance should have been initiated for Resident 47 at the time they complained. <RESIDENT 7> Review of the grievance log dated December 2025 documented a grievance for Resident 7 dated 12/09/2025, they had never received valium (an anti-anxiety medication) prior to their dental appointment. The grievance was reported by an employee and assigned to social services for resolution. The grievance was documented to have been resolved on 12/11/2025. In an interview on 05/28/2026 at 9:30 AM Staff C, Social Services, stated they were unable to locate the grievance form with the resolution as described in the log. In an interview on 05/29/2026 at 9:34 AM, Resident 7 stated they had spoken to the prior social worker about the grievance. They said they were never provided the medication and were told the facility never received the prescription from the dentist's office. The resident stated their dentist was unhappy they did not receive the medication at the facility as they required additional numbing medication at the appointment. <RESIDENT COUNCIL> During Resident Council on 05/29/2026 at 2 PM, Residents 12, 19, 23, 30, and 33 (five of the six residents who attended) stated they were unaware of who the grievance official was or where they could locate a grievance form. Resident 12 stated when they have asked for a grievance form, they are told I'll fill it out for you. Resident 23 stated they believed the grievance official was the activities director. On 06/01/2026 at 12:28 PM, grievance forms were located at the time clock area, attached to the employee board. The facility cat litter box was located below the board, making the forms out of reach of residents. In continued observation of the facility a large, framed noticeboard was in the hallway near the nurses' station, partially concealed by a wall. The notice board contained large black and white print with contacts for the state agency and ombudsman. In additional observation a wooden grievance box was in the reception area, above wheelchair height and table was below it, obstructing access. The grievance box was locked and there was one blank grievance form folded into a square in the front pocket of the box. In an interview on 06/01/2026 at 12:56 PM Staff C, stated they were the grievance official. Staff C stated when grievances were initiated, the completed form would be sent to them, and they would attempt to resolve the grievance immediately or if they were more complex, they would be forwarded to department heads to resolve. Staff C stated residents were informed of the grievance process at admission and they also let them know. Staff C stated if a resident had a complaint the staff would provide the form to the residents to fill out or assist if needed. Staff C stated they did not have the key to the grievance box located in the receptionist area and were not sure when it was last checked. Staff C stated the only other place a resident could locate a grievance form was at the time clock area. Reference: (WAC) 388-97-0460

Based on observation and interview, the facility failed to ensure the facility environment was clean, sanitary and orderly for 3 of 3 halls and rooms [ROOM NUMBER]. The facility failed to identify and provide the necessary maintenance and housekeeping in resident rooms and common areas. These failures placed residents at risk for decreased quality of life and potential infection control issues.Findings included.On 05/26/2026 at 9:44 AM, a privacy curtain was observed in room [ROOM NUMBER], located between the two beds, to contain yellowish and white matter on the middle of the curtain, consistent with the height of the bed. Red debris was noted on the flooring near the window which was sticky when stepped on. In an interview on 05/26/2026 at 9:44 AM, Resident 14 stated they did not have housekeeping services everyday. On 05/27/2026 at 8:48 AM, 05/28/2026 at 11:08 AM and 05/29/2026 at 3:30 PM, the shared bathroom between 136 and 135 were observed to have a dime sized piece of fecal matter on the rim of the toilet and smelled of urine/feces. On 05/28/2026 at 2:27 PM, the flooring throughout the hallways of the facility was observed to have various cracks, dried brown liquid and visible dirt between the door and frames, round brownish marks consistent with spills, and debris stuck to the flooring (easily removed with pressure and pushing with a shoe). On 05/28/2026 at 2:27 PM, an overbed table in room [ROOM NUMBER], the bottom portion/frame of the overbed table was observed to have debris and dried brown liquid on it. On 05/28/2026 at 2:50 PM, there were three long rectangular light fixtures observed in the main nurse's station ([NAME] Lane), to contain multiple debris in the light cover to include the outline of dead bugs. The hand sanitizer dispenser tray next to the nurse's station contained a dead bug and dust in a pool of hand sanitizer. On 05/29/2026 at 12:02 PM, the visitor's bathroom, located in the dining room, had cracked linoleum with large black spots under the flooring, and knicks and gouges in the flooring, tears and rips in the drywall around the door frame, and brown matter on the wall below the light switch. In an interview on 05/29/2026 at 11:18 AM Staff I, Housekeeper stated the housekeeper schedule was typically 6am to 2pm with one housekeeper that worked in the evenings, one to two times a week. Staff I stated there were two housekeepers working together unless there was a call out. Staff I stated they split the hallways and rooms up with the other housekeeper and duties included disinfecting high touch areas, sweeping and mopping floors, disinfecting toilets and taking out the trash. Staff I, when asked about cleaning overbed tables, stated they were to be wiped down completely to include the bottom frame. Staff I stated there was a daily cleaning checklist they used. Staff I stated deep cleaning for resident rooms only occurred when a resident moved or discharged . Review of the daily cleaning checklist documented housekeepers were to check and fill soap and sanitizer dispensers, sweep and mop the bathrooms and clean the toilets, and empty garbage. There was no mention of how and when to clean the overbed tables. In an interview on 05/29/2026 at 11:35 AM Staff P, Maintenance Director, stated they had just taken over the housekeeping department, had not supervised housekeeping prior and had previously only been a maintenance director. Staff P stated they expected the housekeepers to clean, stock, move and clean under beds, wipe windowsills, toilets, and everything. Staff P stated the hand sanitizer dispensers were in the process of getting replaced, when they were shown the tray with the dead bug. When asked about scheduled deep cleaning rooms and privacy curtains, Staff P stated privacy curtains were cleaned when they were visibly soiled and deep cleaning was done daily on a rotation. Reference WAC 388-97-0880(1)

Based on interview and record review the facility failed to ensure 5 of 5 nurse aides (Staff G, H, T, U, and V) had their required 12 hours of in-service training. The failure to ensure Nursing Assistants Certified (NACs) received 12 hours per year in-service training placed residents at risk of less than competent care and services from staff.Findings included .Review of the facility staff roster documented:Staff G, CNA, was hired 05/02/2025,Staff H, CNA, were hired 06/19/2024,Staff T, CNA, were hired 10/15/2018,Staff U, CNA, was hired on 04/02/2024, andStaff V, CNA, was an agency aide that was used by the facility and was hired on 10/01/2025.Staff G, H, T, U, and V's, required 12 hours of in-service training were requested on 05/27/2026, none were provided by the facility or staff.In an interview on 05/28/2026 at 10:37 AM Staff E, Business Office Manager/Human Resources, stated they were unable to provide proof of education and training for the Staff G, H, T, U, and V, as the facility recently went through a change of ownership and the proof of education and training were in electronic files that could no longer be accessed. Staff E stated the prior staff development coordinator had completed competencies for staff prior to them leaving.In an interview on 06/01/2026 at 10:20 AM Staff B, Director of Nursing Services, was unaware required education were not completed and electronic access to staff education had been removed. Reference WAC 388-97-1680(2)(a-c)

Based on record review and interview, the facility failed to provide 2 of 3 residents (Residents 38 and 51) required notices regarding anticipated Medicare non-coverage. The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) for Resident 51. Additionally, the facility failed to provide Resident 38 a Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN), which informs the beneficiary about potential non-coverage and the option to continue services by accepting the cost of continuing the services. These failures had the potential to impact residents and their representative's ability to decide if they wish to continue receiving the skilled services that may not be paid for by Medicare, assume financial responsibility or exercise their right to an appeal. Findings Included .Review of SNF (Skilled Nursing Facility) Beneficiary Review form provided by the facility documented Resident 51 started to receive Medicare skilled services on 11/29/2025 which ended on 12/04/2025. The form documented both a NOMNC nor SNFABN were provided to Resident 51. Review of the SNF (Skilled Nursing Facility) Beneficiary Review form provided by the facility documented Resident 38 started to receive Medicare skilled services on 09/03/2025 which ended on 09/18/2025. The form documented a SNFABN form was not provided to Resident 38. In an interview on 05/26/2026 at 1:47 PM Staff C, Social Services Director, stated Resident 51 and 38 should have received an SNFABN to explain potential costs of their care. Staff C stated they were unable to locate a NOMNC for Resident 51 or documentation that one was provided to them. Reference WAC 388-97-0300(1)(e),(5),(6)

Based on interview and record review, the facility failed to ensure 2 of 5 sampled residents (Residents 8 and 23) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to obtain consent, monitor and document behaviors and symptoms, failed to attempt and document non-pharmacological interventions prior to administration and demonstrate adequate indication of use of medications. These failures placed the residents at risk for medication-related complications such as drowsiness, withdrawal from activities and socialization, movement disorders, falls with injury, stroke, and increased risk of death, for receiving unnecessary psychotropic medication. Findings included . As referenced in the Food and Drug Administration (FDA) Safety Information, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the cause, there was little chance that they would be effective. They commonly cause complications such as movement disorders, falls with injury, stroke, and increased risk of death. The FDA Black Boxed Warning, which accompanied, second-generation anti-psychotics stated, Elderly patients with dementia-related psychosis treated with atypical anti-psychotic drugs are at an increased risk of death. Review of the undated facility policy titled, Antipsychotic Medication Use, documented that antipsychotic medications are only to be used when necessary to treat specific conditions for which they are indicated. The policy documented that antipsychotic medications will not be used unless behavioral symptoms are not sufficiently relieved by non-pharmacological interventions or not due to psychological stressors (such as loneliness). <RESIDENT 8> Resident 8 admitted to the facility on [DATE] on Hospice (specialized care for people with terminal illnesses) with diagnoses to include cerebrovascular disease (any condition that affects the blood vessels and blood flow in the brain), dementia (loss of memory, language, problem-solving, and other thinking abilities) and chronic kidney disease. Review of Resident 8's quarterly Minimum Data Set (MDS) assessment dated [DATE], documented the resident had no hallucinations or delusions. Resident 8 had physical symptoms (i.e. hitting, kicking, pushing, etc.) directed towards others occurred one to three days in the seven-day lookback period. The MDS documented conflicting information about the impact and risks to the resident and others. Review of Resident 8's physician orders, dated 02/13/2026, documented Hospice ordered an as needed antipsychotic gel (CMPD ABHR (a compounded topical medication prescribed to manage severe nausea, vomiting, and sometimes anxiety or agitation) topical compounded gel, which included 1 milligram (mg) of Lorazepam (a fast acting anti-anxiety medication that slows down your nervous system), 25mg Benadryl (an antihistamine with known sedative effects and contraindicated in the elderly) and 1 mg Haldol (a first generation antipsychotic medication with increased side effects vs second generation, used for schizophrenia and delirium) to start if resident was refusing oral medications and to apply topically as needed for anxiety, restlessness, or agitation. Applying a topical antipsychotic when the resident refused their oral medications removed the residents right to refuse. Review of Resident 8's electronic health record (EHR) documented consent was not obtained for the antipsychotic gel until 03/02/2026 by Resident 8's power of attorney (POA - a legal document that gives someone the authority to make decisions for you when needed). The POA documentation was not found in Resident 8's EHR. Review of Resident 8's February 2026 MAR documented that the as needed antipsychotic gel was administered on 02/27/2026 and 02/28/2026. Non-pharmacological interventions in the February 2026 MAR documented to offer coffee, sit and talk, or take for a walk as needed. Nursing staff were to document interventions prior to administration and document the effectiveness. No non-pharmacological interventions were attempted as documented in February 2026. Review of Resident 8's March and April 2026 MAR documented the as needed antipsychotic gel was administered nine times in March and four times in April. Non-pharmacological interventions in the March and April 2026 MAR documented to offer coffee, sit and talk, or take for a walk as needed. Nursing staff were to document interventions prior to administration and document the effectiveness. No non-pharmacological interventions were attempted as documented in March and April 2026. Review of Resident 8's care plan, dated 04/18/2026, documented antipsychotic use for Quetiapine (an antipsychotic medication) and an antipsychotic gel. The care plan directed use of non-pharmacological interventions before administering anti-psychotic medications and to document for behaviors related to anxiety, restlessness, and agitation. Review of Resident 8's quarterly MDS dated [DATE], documented that the resident had no hallucinations or delusions. Resident 8 had physical symptoms directed towards others that occurred one to three days in the lookback period and had no impact on the resident or on others. The MDS documented no behaviors associated with rejecting care or wandering. They had a change in behavior and their symptoms had worsened. Review of Resident 8's May 2026 MAR documented the as needed antipsychotic gel was administered 11 times. Non-pharmacological interventions directed nursing staff to reposition, massage, involve in an activity, provide a quiet setting, relaxation techniques, music, remove from area, distraction, toilet, ambulate, provide food/drink, education, one on one, or other (other was not defined) as needed before administration of the as needed medication. Nursing staff were to document interventions prior to administration and to document the effectiveness. No non-pharmacological interventions were documented in May 2026. Beginning 05/01/2026, a behavior monitor was implemented specifically for the use of the antipsychotics. The monitor directed nursing staff to document times the behavior (hallucinations, delusions and verbal aggression) occurred per shift however the behavior monitor was set up to document a check mark, and nursing staff initials rather than a number. Review of a progress note on 05/03/2026 at 11:02 AM showed Resident 8 was on 15-minute checks, and while checked on in the dining room at 10:45 AM, they were found leaning to the right with both arms hanging down. The resident was hard to arouse, and required a sternal rub (applying firm, grinding pressure to see if unconscious person is responsive, commonly used in drug overdoses). The resident became alert when the blood pressure cuff was being inflated. Review of a progress note on 05/04/2026 at 3:20 PM, Staff C, Social Services documented Resident 8 had severe cognitive impairment, was currently taking 6 psychoactive medications and had an increase of wandering and grabbing staff and peers. Review of a progress note on 05/21/2026 at 3:57 PM documented Resident 8 was very drowsy and had a hard time opening their eyes when calling their name. The nurse held their 2:00 PM medications as they were not safe to administer in their drowsy condition. In observation on 05/26/2026 at 2:11 PM, Resident 8 was sitting with nurse at the medication cart. In observations on 05/28/2026 at 10:31 AM Resident 8 was opening the door and attempting to enter the beauty shop. At 11:06 AM, Resident 8 was going into another resident's room (113). Staff Y, Activity Director went to get the resident and redirect them. At 11:09 AM, they were sitting and grabbing at the nurse. In an interview on 05/28/2026 at 1:14 PM, Staff Z, Registered Nurse stated Resident 8 took all their medications yesterday and this morning, and they were feisty. Staff Z stated the provider just adjusted some of their headache medications and also increased their anti-psychotic medication Quetiapine. They stated that on Sunday, it was very hard to give Resident 8 their medication and today they accepted no medications. Staff Z stated it was hard to get them to take the Carbamazepine (seizure medication) since it was increased to 300 mg and it was a large amount. Staff Z stated they applied the ABH gel today and would reapproach giving the pills after lunch. In observations on 05/28/2026 at 3:24 PM, Resident 8 was trying to get into the therapy office and another resident was helping to redirect them back to the hallway then they started to propel themself down the hallway back to Artist lane. At 3:28 PM, Resident 8 was self-propelling and opened the door to the outside courtyard with no staff present. Minutes later Staff E was walking by and told them they could not go out there. In observations on 05/29/2026 at 9:56 AM, Resident 8 was still in bed asleep. They woke briefly at 10:17 AM then were back asleep at 10:27 AM. At 2:00 PM, they were trying to get into the utility room. In an observation on 05/29/2026 at 3:59 PM, Resident 8 self-propelled their wheelchair into a new admit in their wheelchair who had just arrived and then ran into this surveyor then used the medication cart drawer handle to propel themself down the hall. Staff J, Staffing Coordinator tried intervening but did not prevent the unwanted touching. Review of a revised Pre-admission Screening and Resident Review (PASRR- assessment/federal requirement for Medicaid-certified nursing facilities to ensure individuals, especially those with mental illness, seeking admission are appropriately placed and receive necessary services) for Resident 8 on 05/29/2026 showed the resident experienced mood disorder including depression and anxiety with no psychosis (delusions or hallucinations). Staff C, Social Services documented the resident was currently taking psychotropic medications Citalopram (antidepressant), ABH (Ativan (antianxiety), Benadryl and Haldol (anti-psychotic) gel, Lorazepam (anti-anxiety), Clonazepam (anti-anxiety) and Quetiapine (anti-psychotic). In an interview on 06/01/2026 at 10:10 AM, Staff B, Director of Nursing Services (DNS) stated consent for the use of psychotropic medications should be obtained before administering the medication. Staff B stated that non-pharmacological interventions should be followed before administration of an as needed antipsychotic medication and documented. In observations on 06/01/2026 at 10:40 AM Resident 8 was asleep in the hallway. At 12:47 PM they were in bed asleep and did not eat lunch. <RESIDENT 23> Resident 23 was admitted to the facility on [DATE] with diagnoses to include anxiety disorder, unspecified depression, and pseudobulbar affect (PSA-neurological condition characterized by involuntary, sudden, and frequent episodes of laughing or crying that do not match a person's actual mood or the situation). In a review of Resident 23's Annual Care Area Assessment (CAA-tool used to develop individualized care plans) dated 09/23/2025 documented they were prescribed Abilify for depression, their behaviors were such that a gradual dose reduction was not warranted, with the goal for their behaviors to improve and to have no side effects. In a review of Resident 23's medication order summary as of 05/26/2026 documented they were prescribed Abilify (an antipsychotic medication) 5 milligrams by mouth twice daily on 01/27/2026 for treatment of unspecified depression. In a review of Resident 23's care plan dated 05/27/2026 documented their target behaviors for use of the Abilify was for depression and PSA to include excessive crying, verbal aggression toward staff and refusing care and meals. In a review of Resident 23's MAR for May 2026 showed a behavior monitor, implemented as of 03/26/2026, to document excessive crying, verbal aggression toward staff and refusing care and meals. There was one instance of excessive crying documented for May 2026. There were no documented non-pharmacological interventions used in May 2026 per the MAR. Review of a progress note dated 05/29/2026 documented the provider was contacted to provide an appropriate diagnosis for Resident 23's use of Abilify. In an interview on 05/29/2026 at 1:02 PM Staff D, Registered Nurse/Resident Care Manager, stated when a resident admitted to the facility on a psychotropic medication, the order and monitor for side effects were put into the MAR by nursing and social services put in the behavior monitors. Staff D stated the nurse who completed the MDS- inputted the 0diagnoses for the resident and then assigned the diagnosis for the use of psychotropic medication. Staff D stated they attended gradual dose reduction meetings monthly and could contact the provider to obtain the proper diagnosis for the use of Abilify for Resident 23. Staff D stated the unspecified depression was not an appropriate diagnosis for the use of Abilify. In an interview on 05/29/2026 at 2:03 PM Staff B, DNS, stated if a resident admitted with use of psychotropic medication, they would implement monitoring for behavior and side effects. Staff B stated social services were responsible for ensuring the care plan was completed related to psychotropic drug use and there were monthly meetings to review residents on those medications. Staff B stated Resident 23's diagnosis of unspecified depression was not an appropriate diagnosis for use of Abilify. Reference: (WAC) 388-97-0620 (1)

Based on interview and record review, the facility failed to provide a written notice of bed hold at the time of transfer to the hospital for 3 of 3 residents (Residents 1, 4, and 42) reviewed for hospitalization and failed to ensure notification to the Office of the State Long-Term Care Ombudsman (LTCO - resident advocates) occurred for 1 of 3 residents reviewed for hospitalization. Failure to offer bed holds placed residents and/or representatives at risk of not having the necessary information to make an informed decision regarding their ability to return to the facility. Failure to notify the LTCO and ensure written notification was provided to the resident and/or representative placed residents at risk for not having an opportunity to make informed decisions about their transfer/discharge rights. Findings included . Review of the facility policy titled, Bed Hold Notice, dated 10/01/2021, documented that prior to transfers, residents or resident representatives will be informed in writing of the bed-hold and return policy. <RESIDENT 42> Resident 42 was discharged to the hospital on [DATE] while out at a medical appointment. Review of Resident 42's electronic medical record (EMR) showed no uploaded document to show a bed hold was offered to them or their representative. The EMR showed a progress note dated 04/20/2026 documented the Resident 42's representative was offered a bed hold and a notice was signed. In an interview on 05/27/2026 at 2:20 PM Staff F, Medical Records provided a copy of the signed bed hold document. Staff F stated they had not uploaded the record into the EMR and found the record in the administration documents. Staff F stated Staff E, Business Office Manager, uploaded the document into financial documents not in the EMR. Review of the bed hold notice signed 04/20/2026 documented Resident 42's representative wanted to hold their bed. The form was incomplete and lacked signature where the bed hold policy was provided to the resident or their representative. In an interview on 05/27/2026 at 2:36 PM Staff E stated they received the signed bed holds in their box when completed and they reviewed them for signatures. Staff E stated they only reviewed the form for billing purposes. In an interview on 05/28/2026 at 2:12 PM Staff O, Licensed Practical Nurse (LPN), stated they had not completed a bed hold in a while. Staff O stated the facility process was that nursing would ask the resident or resident representative if they wanted a bed hold at the time of transfer. Staff O stated they would fill out the bed hold paperwork and forward it to social services for review. When asked if they had provided the bed hold policy at the time a bed hold was offered, Staff O stated they had not and only had them fill out a bed hold form. In an interview on 05/28/2026 at 2:15 PM Staff C, Social Services, stated the facility process for bed hold was for nursing to complete them with the resident and or representative at the time of transfer. Staff C stated if nursing were unable to get a signature or review the form with the resident and or representative then they would attempt to contact the family to explain the bed hold and attempt to get a signature. Staff C stated when a resident was transferred to the hospital, they would look in their clinical record to ensure a bed hold was offered and if it wasn't they would know to follow up with the resident and or representative. Staff C stated they did not review completed bed holds completed by nursing, but when they completed them, they ensure they were complete and then they uploaded them into the EMR. <RESIDENT 1> Resident 1 initially admitted to the facility on [DATE]. Resident 1 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of Resident 1's progress notes on 02/05/2026 at 3:33 AM, Staff S, LPN, documented Resident 1 was sent to the hospital for their well-being. Review of Resident 1's EMR showed no documentation of written bed hold information being provided to the resident or responsible party at the time of discharge to the hospital. In an interview on 05/29/2026, at 1:00 PM, Staff D, Registered Nurse (RN)/Resident Care Manager (RCM), stated that when residents are transferred to the hospital that a bed hold should be provided at the time of transfer either to the resident if possible or the resident's responsible party. Staff D stated the bed hold should be in a progress note or uploaded to the EMR. Reference: WAC 388-97-0080

Based on interview and record review the facility failed to thoroughly investigate and report timely an allegation of verbal/mental abuse for 3 of 4 residents (Residents 1, 7, and 38) reviewed for abuse. The lack of thorough investigation prevented the facility from ruling out abuse and failure to report immediately caused a delay in further investigation and protection of the residents. These failures placed residents at risk for harm related to potential unrecognized abuse.Findings Included.Review of the facility policy titled, Abuse dated 10/01/2021 documented each resident had the right to be free from abuse.staff would immediately review and investigate all allegations or observations of abuse.protect the resident .and ensure each mandated reporter reported immediately. Review of an incident report dated 02/20/2026 documented Resident 1 reported to Staff D, Registered Nurse/Resident Care Manager on 02/15/2026 that the social services director (currently no longer with the facility), had called Resident 7 a derogatory name using profanity in conversation with Resident 38 on 02/14/2026. Review of the timeline of events as outlined in the incident report documented Resident 1 reported that Resident 7 was upsetting Resident 38 in conversation and this was reported to the social services director on 02/14/2026. There was no specific description of what Resident 7 had said to Resident 38 to upset them. There was no documentation, interviews, or witness statements to determine what was said by Resident 7 to Resident 38. An investigation was initiated on 02/20/2026 and a report was made to the state hotline, five days after knowledge of the alleged verbal/mental abuse. The incident report contained staff education for As a mandated reporter, when a resident makes an allegation against a staff member it is an immediate call to the DNS or ED for guidance. This is abuse/neglect prevention, and there are steps that need to be followed timely. Review of the incident reporting log dated February 2026 showed no other incident reports related to Resident 1, 7, or 38. In an interview on 05/28/2026 at 2:00 PM Staff D stated they were notified by a staff member they could not recall, of the social services director calling Resident 7 a derogatory name using profanity in conversation with Resident 38. Staff D stated they could not recall the date of when they were informed. They had spoken to Resident 1 and they reiterated what the staff member had reported. Staff D stated they reported the allegation to Staff B, Director of Nursing, either that day or the following day and did not make a report to the state hotline but should have. Staff D stated they spoke with Resident 38 and they could not recall any details of their conversation with the social services director. In an interview on 05/29/2026 at 12:44 PM Resident 1 stated they did not report the allegation of the social services director calling Resident 7 a derogatory name. Resident 1 stated they were not surprised to hear of the allegation as the social services director often used derogatory language and profanity as they were one to speak their mind. Resident 1 stated they had heard the social services call Resident 7 derogatory names with use of profanity in the past. Resident 1 stated Resident 7 often visited their room they share with Resident 38, and they had been roommates with Resident 7 in the past. Resident 1 stated Resident 7 had told Resident 38 sexually inappropriate, demeaning, and critical comments and they had to ask Resident 7 to leave the room. Resident 1 stated they had been looking out for Resident 38. In an interview on 05/29/2026 at 12:53 Staff C, Social Services Director, stated they had no knowledge of the allegation and had not reviewed the incident report related to the prior social services director. Staff C stated they had started with the facility in March 2026. Staff C stated Resident 7 had been roommates with both Resident 1 and Resident 38 in the past and it had not worked. Resident 7 resided in a room by themselves and were next door neighbors with Resident 1 and 38. Staff C stated they had received reports from staff about Resident 7 eavesdropping from the shared bathroom when staff were in the room with Resident 1 and 38. Staff C stated they were unaware of Resident 7 making sexually related comments to Resident 38. In an interview on 06/01/2026 at 10:20 AM, Staff B stated they were familiar with the allegation involving Resident 7, 38 and 1 and stated the social services director at the time was attempting to reassure Resident 38 in conversation about Resident 7 and Resident 38's comfort around using the toilet. Staff B stated a mandated reporter was anyone who worked with a vulnerable adult and were mandated to make a report to the state agency if there were allegations of abuse or neglect of a vulnerable person. Staff B stated the allegation was reported on 02/19/2026 and the facility called it into the hotline on 02/20/2026. Reference WAC 388-97-0640(2)(b)(5)(a)

Based on interview and record review, the facility failed to ensure the level one Pre-admission Screening and Resident Review (PASRR- assessment/federal requirement for Medicaid-certified nursing facilities to ensure individuals, especially those with mental illness, seeking admission are appropriately placed and receive necessary services) were referred and followed up on for 3 of 5 residents (Residents 1, 4 and 8) reviewed for PASRR. This failure placed residents at risk of unmet mental health services and a diminished quality of life. Findings included . Review of the undated facility policy titled, Long-Term Services and Supports Screening, PASRR Policy documented that when a resident has a positive level one screening, the facility will initiate the level two screening request by contacting the PASRR coordinator. <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include heart failure, depression, and anxiety. Review of Resident 1's level one PASRR dated 05/20/2024 documented that a level two evaluation referral was required for serious mental illness (SMI). The comments stated that Resident 1 had a history of depression and anxiety and was taking an antidepressant medication. No other updated PASRR was in Resident 1's EMR and the progress notes showed no documentation about a level two evaluation. Review of Resident 1's progress notes on 05/14/2026, at 1:04 PM, Staff C, Social Services Director (SSD), documented that they had requested an invalidation or a level two PASRR from the PASRR coordinator and were awaiting response. In an interview on 05/28/2026 at 12:22 PM, Staff C stated they had just done a PASRR audit for all residents. Staff C stated a new PASRR had not been completed for Resident 8 on his admission. They stated this was due to the hospital not completing a new one since it had not been more than 30 days. Staff C stated social services should have completed a new PASRR. <RESIDENT 8> Resident 8 admitted to the facility on [DATE] on Hospice (specialized care for people with terminal illnesses) with diagnoses to include cerebrovascular disease (any condition that affects the blood vessels and blood flow in the brain), dementia (loss of memory, language, problem-solving, and other thinking abilities) and chronic kidney disease. Review of Resident 8's level one PASRR dated 11/06/2025 documented the resident was positive for a SMI with indicators marked for mood disorders (depression) and anxiety. Section C also marked no for the individual having a diagnosis of dementia. The service needs section documented that no level two evaluation was indicated as person did not show indicators of SMI. The comment section documented that the resident was on Hospice, nearing end-of-life within final weeks to months of life and that their anxiety and depression were stable with current medications. PASRR level one was completed by a Hospice social worker. In an interview on 05/28/2026, at 12:27 PM, Staff C, SSD, stated that they had been auditing the PASRR's and saw that Resident 8's PASRR was incorrect and they sent in a new PASRR on 05/26/2026 to the PASRR coordinator. Review of Resident 8's updated PASRR dated 05/26/2026, completed by Staff C, stated a level two evaluation referral was required for SMI. The comments documented that the previous PASRR was positive but no level two evaluation needed was checked. Comment section also documented that Resident 8 was still on Hospice, had a diagnosis of dementia and was on antipsychotic, antianxiety, and antidepressant medications. <RESIDENT 4> Resident 4 admitted to the facility on [DATE] with diagnoses to include anxiety disorder, depression, and post-traumatic stress disorder. Review of Resident 4's PASRR dated 11/24/2025 documented they had known indicators of serious mental illness and were exempted from receiving a Level II evaluation as they were anticipated to be in the nursing facility for less than 30 days. Review of Resident 4's progress notes documented two progress notes, one dated 01/11/2026 when the Level II evaluator was notified, they remained in the facility past 30 days and another on 04/13/2026 indicating the evaluator was planning on completing the Level II evaluation. In an interview on 05/28/2026 at 11:10 AM Staff C, Social Services, stated admissions reviews the PASRR and then they review. Staff C stated if a resident has an exemption they would send electronic communication to the evaluator on day 25 and provide admission date, behaviors, medications and the discharge plan for the resident. Staff C stated Resident 4 had a hospital exemption of a Level II evaluation at admission, there was a progress note on 01/11/2026 and a follow up note on 04/30/2026. Staff C stated there was currently a backlog of Level II evaluations to be completed by the evaluator and they follow up with them from every 30 days to six weeks. Reference: WAC 388-97-1915(1)(2)(a-c)

Based on observation, interview, and record review the facility failed to ensure care plans were revised as need for 4 of 5 residents (Residents 7, 8, 38, and 44) reviewed for care planning. The failure to review and revise care plans by the interdisciplinary team placed residents at risk for unmet care needs, anxiety, fear, decreased quality of care related to outdated or inaccurate care plans, and a diminished quality of life. Findings included .<RESIDENT 8> Resident 8 admitted to the facility on [DATE] on Hospice (specialized care for people with terminal illnesses) with diagnoses to include cerebrovascular disease (any condition that affects the blood vessels and blood flow in the brain), dementia (loss of memory, language, problem-solving, and other thinking abilities) and chronic kidney disease. Review of Resident 8's physician orders, dated 02/13/2026, documented Hospice ordered an as needed antipsychotic gel (CMPD ABHR (a compounded topical medication prescribed primarily in palliative and hospice care to manage severe nausea, vomiting, and sometimes anxiety or agitation) topical gel, which included 1 milligram (mg) Lorazepam (a fast acting anti-anxiety medication that slows down your nervous system), 25mg Benadryl and 1 mg Haldol (a first generation antipsychotic medication) to start if resident was refusing oral medications and to apply topically as needed for anxiety, restlessness, or agitation. The order was active on the medication administration record (MAR) as of 02/16/2026. Review of Resident 8's care plan, dated 04/18/2026, did not include the antipsychotic gel until 04/18/2026. In an interview at 06/01/2026, at 10:10 AM, Staff B, Director of Nursing (DNS) confirmed the antipsychotic gel was ordered in February 2026 and was not updated on the care plan until April 2026. Staff B stated that their expectation of the care plan should have been updated timelier. <RESIDENT 38> Resident 38 was admitted to the facility on [DATE] with diagnoses to include dementia (loss of memory, language, problem-solving, and other thinking abilities), schizoaffective disorder (mental health condition that includes symptoms of both schizophrenia and mood disorders), post-traumatic stress disorder and homelessness. Review of Resident 38's progress notes documented an elopement from the facility on 10/02/2025 and 10/13/2025. Review of Resident 38's care plan, dated 02/26/2026, documented that Resident 38 an elopement risk with an initiation date of 10/03/2025. The care plan documented interventions to include an air-tag on Resident 38. Review of Resident 38's elopement risk assessment, dated 05/26/2026, Staff B, DNS documented that the resident was no Review of Resident 38's progress notes dated 05/26/2026 at 11:31 AM, Staff B, DNS documented that Resident 38 is not at risk for elopement at this time. The electronic health record did not contain any information that the interdisciplinary team reviewed or revised the comprehensive care plan after the elopement risk assessment. In an interview on 05/29/2026 at 2:23 PM, Staff B, DNS stated that care plans should be updated for residents when assessments are updated. <RESIDENT 44> Review of Resident 44's electronic medical record (EMR) documented they discharged with their family to a facility out of state on 04/03/2026. Review of Resident 44's care plan documented an area of focus, discharge, resolved as of 06/13/2025 that they had no discharge plan. There was no discharge care plan since 06/13/2025. Review of Resident 44's care conference record dated 09/10/2025 documented there was a discussion of them moving to another state with a family member. Review of a progress note dated 03/27/2026 documented by Staff C, Social Services, showed there was a plan for Resident 44 to discharge with family to another state. Review of a hospice note dated 03/31/2026 documented there was a discharge plan for Resident 44 to discharge to another state with their family member. In an interview on 05/27/2026 at 10:50 AM Staff C, stated there was not an active discharge care plan for Resident 44, and confirmed the prior one had been resolved in June 2025, and was unaware of the reason why it was resolved, and there should have had current one. <RESIDENT 7> Resident 7 admitted on [DATE] with diagnoses to include schizoaffective disorder (mental health condition with hallucinations, delusions, mania and depression), PTSD, depression and anxiety. Review of Resident 7's psychosocial well-being care plan initiated on 04/09/2026 showed Resident 7 had a diagnosis of PTSD and had difficulty falling asleep and nightmares related to being stuck in the bathtub for multiple days when living in the community. The care plan lacked a personalized care plan that outlined the resident's physical symptoms, triggers, recovery goals and actionable coping strategies to decrease anxiety and fear. The care plan had no interventions related to bathing to mitigate this known trigger. In an interview on 06/01/2026 at 8:41 AM, Staff H stated they were unaware of any specific bathing approaches for Resident 7. This is a repeat deficiency from SOD dated 05/01/2025. Reference: WAC 388-97-1020(5)(b)

Based on interview and record review, the facility failed to address the required documentation for advance directives (AD) for 3 of 6 residents (Residents 4, 7 and 8) reviewed for advance directives. This failure placed residents at risk for not having their preferences and decisions honored for end-of-life care. Findings included . The undated facility Advance Directives policy defined an Advance Directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under state law, relating to provision of health care when the individual is incapacitated. The policy directs staff upon admission to provide with written instruction information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. The policy documented that prior to admission or upon admission of a resident, the Social Services Director or designee will inquire about the resident or his/her family member and/or his or her legal representative, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. If the resident indicated that he or she has not established an AD, the facility staff will offer assistance in establishing one. Nursing staff will document in the medical records the offer to assist and the resident's decision to accept or decline assistance. <RESIDENT 7> Resident 7 was admitted to the facility on [DATE]. Review of the facility advance directives tab showed Resident 7 had a Physician Orders for Life-Sustaining Treatment (POLST,) a medical order from a physician, nurse practitioner or physician's assistant or other health professional with instructions that complement an advanced directive developed on 08/13/2025 in place but no AD. The residents POLST showed they did not want resuscitation attempted and chose comfort-focused treatment. The POLST does not take the place of an Advance Directive or replace the need for or the importance of a durable power of attorney for healthcare. Review of the progress notes since admission showed no discussion of AD with Resident 7 however provider progress notes on 03/21/2026 at 10:24 AM and 04/16/2026 at 4:21 PM showed the resident did not have an advanced directive and directed the facility to provide discussion and counseling on advanced directives. In an interview on 05/26/2026 at 1:03 PM, Resident 7 stated that they did not have an advanced directive and had not been offered assistance to formulate one. <RESIDENT 8> Resident 8 admitted to the facility on [DATE] on Hospice (specialized care for people with terminal illnesses) with diagnoses to include cerebrovascular disease (any condition that affects the blood vessels and blood flow in the brain), dementia (loss of memory, language, problem-solving, and other thinking abilities) and chronic kidney disease. Review of Resident 8's admission MDS dated [DATE], documented that the resident had severe cognitive impairment. Review of Resident 8's quarterly Minimum Data Set assessment, dated 05/05/2026, documented that the resident is rarely/never understood and is severely impaired for cognitive skills for daily decision making. Review of Resident 8's electronic health record (EMR) documented a power of attorney (POA - a legal document that names someone to make decisions on your behalf when you are unable to) who had been making decisions for Resident 8 since their admission to the facility. Resident 8's EMR did not have a copy of the legal POA paperwork. In an interview on 06/01/2026, at 8:51 AM, Staff C, Social Services Director, stated they were unable to find Resident 8's POA paperwork in the EMR. At 11:36 AM Staff C stated the paperwork may have been lost during the transition of the new company and that they did not have Resident 8's POA paperwork on file. <RESIDENT 4> Resident 4 admitted to the facility on [DATE] with diagnoses to include left leg fracture and post-traumatic stress disorder. Review of Resident 4's EMR dated 12/05/2025 though 05/26/2026 showed no documented instances where they were notified verbally or in writing of their right to formulate an AD, types of AD's available to them, or how to formulate one. In a review of Resident 4's admission agreement signed 11/28/2025 showed no documentation that AD's were discussed or reviewed with them. In an interview on 05/28/2026 at 10:15 AM Staff R, Admissions, stated they were recently hired in March 2026, and they stated there was a process in place to provide and review AD information to residents in writing and verbally. Staff R stated when AD's options were reviewed and discussed with the residents they would place the information in their electronic health record. In an interview on 06/01/2025 at 12:25 PM, Staff A, Administrator, stated they had not located the advanced directives for resident's 2, 4, 7, or 8. Staff A stated the expectation was advanced directives would be offered to each resident and if they did not have one and that there should be documentation on this. Reference: (WAC) 388-97-0300 (3)(b-c)

Based on interview, and record review, the facility Administration failed to ensure the facility's finances were maintained effectively for continuity of resident care and services. The Administration was aware the facility was behind on vendor payments and receiving notices for discontinuation of services. The Administration's failure to ensure the facility met their financial obligations to vendors resulted in the facility laboratory services provider discontinuing services to the facility resulted in four residents (Residents 10, 34, 95, and 7) not receiving timely laboratory services, and placed all 41 residents at risk of not receiving necessary care and services and constituted an Immediate Jeopardy (IJ). On 04/25/2025 at 5:19 PM, the facility was notified of an IJ in F835. The facility removed the immediacy on 04/26/2025 as confirmed by an onsite verification by a surveyor after the facility ensured past due resident lab testing had been completed and an active laboratory services vendor was in place. The facility provided evidence of vendor contract payments to ensure continuity of essential services, audited all resident laboratory orders, and obtained ordered laboratory testing for affected residents. The immediate jeopardy was determined to begin on 04/23/2025 when laboratory services were not provided timely. Findings included . Review of the undated facility policy titled Administrative Management, stated the Facility Administrator appointed was accountable to facility management and operations, which would be reported to a governing board. Based on record review the following vendors sent demand bill notices to the facility: - Trident Lab corporation, past due $9,536.92 with a hold for non-payment with invoices beginning 11/30/2024. - City of [NAME] water, a shut off notice was sent on 04/07/2025 with shut off date of 05/07/2025 with a past due amount of $2,487.91. - Kavala staffing agency statement #3545 dated 03/26/2025 total amount owed $191,210.01 for invoices from 11/25/2024 through 03/21/2025. - Clipboard staffing agency owing $2,563.89, with a notice they will cease to send staff after 05/05/2025. - KCI (a medical supply company) invoice owing $12,550 with a notice on 04/21/2025 demand bill to pay by 04/21/2025 with invoices beginning 10/21/2024. -Cascade Natural Gas invoice with urgent past due notice dated 04/14/2025 requested payment of $1877.85 be received by 5:00 PM on April 22, 2025, or service may be disconnected. -According to the Office of Rates Management, as of 04/07/2025, the Safety Net Assessment (SNA) account for Shuksan HealthCare was 60 days past due in the amount of $119,996.01, which included a new outstanding balance for December 2024 days of $29,377.00, due to be paid 01/20/2025. In an interview with the facility lab services provider on 04/25/2025 at 1:42 PM, CC5, the lab services provider confirmed that the facilities lab services were placed on a non-payment hold on 04/23/2025 which had not been corrected in their system. This lack of lab services impacted four residents (Residents 10, 34, 95, and 7) and potentially additional residents if new orders were received or delayed due to the lab vendor not coming out due to the nonpayment) Resident 10's Depakote level (critical lab to determine therapeutic drug level in the body and prevent toxicity for seizure medication) was not obtained. Resident 34's Depakote level (critical lab to determine therapeutic drug level in the body and prevent toxicity for seizure medication) was not obtained. Resident 95's Comprehensive Metabolic Panel (test to determine overview of the body's chemical and metabolic status) and Complete Blood Count (test to determine number and types of blood cells) were not obtained. Resident 7's Hemoglobin A1C (test to determine average blood sugar levels) was not obtained. In a joint interview and record review on 04/25/2025 at 12:32 PM, Staff F, Resident Care Manager, stated the lab was scheduled to come on Sundays, Mondays, Tuesdays and Thursdays. The labs due were kept in a binder at the nurse's station and should be audited for completion and then results usually come in a day or two depending on the type of test. Staff F was asked to review some missing laboratory results, and they stated that Residents 7, 10, 34 and 95 had labs ordered to be drawn on 04/23/2025 which had not been completed as of this interview. Staff F stated they could not see documentation about why those labs had not been ordered but stated the lab may not have come, I heard something about a bill not being paid. Staff F was asked if there was an alternative option or an alternate laboratory available and they stated there was a different lab they used only for urinalysis (lab test to analyze urine samples). Staff F was asked if the providers for those residents had been notified that those labs had not been obtained, and they stated they did not know. In an interview on 04/25/2025 at 1:08 PM, Anonymous facility staff stated the facility had delayed payroll on one recent occasion at which time staff lost benefits for a period of time and staff had to pay out of pocket for medical appointments and prescriptions. In an interview on 04/25/2025 at 1:08 PM, Staff L, Business office Manager, stated invoices, came to them and Staff A, Administrator, and they were processed and sent to the corporate office for payment. The corporate office cuts the checks and pays the vendors unless we were instructed by them to pay for something by credit card. Staff L stated in regard to the laboratory bill, there was a payment that was not received, and a check that was supposed to have been sent overnight and that prevented the non-payment hold. Staff L stated they get calls daily from vendors regarding overdue balances and all they could do was forward that information to corporate. In an interview on 04/25/2025 at 1:55 PM, Staff A stated they receive the invoices for all the bills, and they are all forwarded to the corporate office for payment. Staff A stated they were aware of the lab services hold but thought it had been taken care of. Staff A was aware of a recent demand bill from the natural gas company and that the facility was paying bills late or had payment plans in place with some vendors. Staff A stated the facility had used a company credit card to obtain some resident supplies. In an interview on 04/25/2025 at 4:47 PM, Staff D, Chief Operating Officer, stated the corporation managed vendor contracts and payment plans according to the individual arrangements. Staff D stated they receive invoices every week and they are processed. The laboratory payment was stated to have been sent. The facility was managing cash flow. Refer to F770- Labratory Services Reference WAC 388-97-1620 (1)

Based on interviews and record review, the facility failed to ensure timely laboratory services were provided for 5 of 5 residents (Residents 7, 10, 15, 34 and 95) reviewed for laboratory services. Resident 15 did not have a urinalysis sample collected for laboratory study per physician order, Resident 7 did not have a Hemoglobin A1C (lab measures blood sugars in the body over a period) test completed as ordered and Resident 95 did not have a metabolic panel and blood count completed timely. Resident 10 and 34's Depakote levels (critical lab test to determine therapeutic drug level in the body and prevent toxicity for seizure medications, reference range 50-100) were not completed timely as ordered and constituted an Immediate Jeopardy (IJ). These failures placed residents at risk of delay in treatment, drug toxicity, decline in medical conditions, hospitalization and a diminished quality of life. On 05/01/2025, the facility was notified of an IJ for F770. The immediate jeopardy was determined to begin on 04/23/2025 when laboratory services were not able to be provided timely due to vendor non-payment. The immediate jeopardy was removed on 04/26/2025 as confirmed by an onsite verification by a surveyor after the facility obtained an alternate vendor to obtain missing labs, all other residents were audited to ensure labs were completed as ordered and overnight payments were sent out to the lab to cover the demand bills. Findings included . Review of facility lab contract titled Trident Care, Letter of Agreement, signed 07/29/2020, showed the facility would pay the Provider (lab) in accordance with the pricing terms of the agreement. The contract directed the facility to pay the provider within thirty (30) days of the date of the invoice, unless required by law to pay sooner, in which case the earlier date required by law shall apply. If payment due to the provider by facility is more than ten (10) days past due, the provider shall have the right to refuse to provide services to the facility without further notice. <RESIDENT 10> Resident 10 was admitted to the facility on [DATE] with diagnoses to include dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) with psychotic disturbance, anxiety (a mental health condition that involves excessive worry and feelings of fear, dread, and uneasiness) and depression. Review of the physician's orders showed Resident 10 was receiving Depakote 250 mg (milligrams) every day and evening for gradual dose reduction of Quetiapine (anti-psychotic) and behavior management related to Major Depressive Disorder, severe with psychotic features since 01/29/2025. Review of a social service progress note on 04/22/2025 at 4:42 PM showed a psychotropic meeting recommendation that the psychiatric physician was increasing Depakote to 375 MG twice a day and ordering a Depakote level in hopes to relieve Resident 10's distress due to increased aggressive and distressing behaviors. Review of a progress note on 04/24/2024 at 10:52 AM, showed the new order was processed to increase Depakote dose and draw a Depakote level on the next lab day. Review of the physician's orders dated 04/23/2025 at 10:00 PM directed the facility to draw a Depakote level every night shift until 04/24/2025. There was an additional order to draw a complete metabolic panel (CMP - a lab that provides an overview of the body's chemical balance and metabolism) on 04/28/2025 at 10:00 PM. Review of the April Medication Administration Record (MAR) showed the Depakote level was not signed as completed on 04/24/2025. The CMP was signed as not completed with a code of 9 indicating to see the progress notes. Review of the Depakote lab requisition showed the Depakote level was obtained from an alternate lab on 04/26/2025 (two days after it was ordered to be drawn) and results were reported to the facility on [DATE] (two days after the lab was obtained). The results were low at 19 ug/ml with a normal reference range at 50-100 ug/ml. Review of the progress note on 04/29/2025 at 12:22 PM, documented the 04/26/2025 Depakote results were reviewed by the physician. Review of the progress notes and MAR did not show if the CMP had been drawn as ordered on 04/28/2025. <RESIDENT 34> Review of the physician's orders showed Resident 34 was receiving Depakote every day related to mood disorder. Review of the physician's orders dated 04/23/2025 at 10:00 PM directed the facility to draw a Depakote level every night shift until 04/24/2025. Review of Resident 34's medical record on 04/25/2025 showed the Depakote level was not drawn. <RESIDENT 7> Resident 7 admitted on [DATE] with diagnoses which included diabetes (disease that results in abnormal processing of sugar in the body). Review of Resident 7's medical record showed an order for a Hemoglobin A1C (test to determine average blood sugar levels) to be completed on 04/23/2025. Review of Resident 7's April 2025 Treatment Administration record showed a blank for the A1C on 04/23/2025. Review of Resident 7's medical record on 04/25/2025 showed no documentation that the lab had been drawn or any result of the lab, or any documentation regarding the lab. <RESIDENT 95> Resident 95 admitted on [DATE] with diagnoses to include a left hip fracture, recent toe amputation after an infection, dementia and depression. Review of the physician visit note on 04/22/2025 showed the physician assessed the second toe tip and noted it to be gangrenous and would need close follow-up on this with frequent exams and a repeat a CBC (complete blood count) lab in three days. The assessment and plan for the congestive heart failure was to repeat a CMP next week. Review of an ARNP (Advanced Registered Nurse Practitioner) visit note dated 04/23/2025 showed the assessment plan related to Resident 95's chronic congestive heart failure was to monitor and consider increasing their diuretic with a repeat CMP next week. Review of a laboratory progress note on 04/23/2025 at 12:49 PM showed CBC and CMP labs were to be drawn on 04/25/2025. Review of the clinical record on 04/25/2025 showed the CMP and CBC had not been drawn. Review of the lab requisition in the lab book showed the labs had not been drawn yet. Review of the lab faxed to the facility on [DATE] at 10:06 AM showed the results of a BMP (Basic Metabolic Panel) panel rather than the ordered CMP. The BMP had been drawn on 04/29/2025 at 10:37 PM (four days after it was ordered to be collected). <RESIDENT 15> Resident 15 admitted on [DATE] with a diagnosis of calculus of ureter (presence of stones within the tube that carries urine from the kidneys to the bladder). Review of a progress note on 01/31/2025 at 5:10 PM, showed Resident 10's family member was in the facility and stated that when their family member was delusional (holding a belief of altered reality that is believed) they were septic (a life-threatening bloodstream infection from an overwhelming infection) with a urinary tract infection (UTI). Physician orders were to be obtained to rule out UTI as the cause of the increased confusion and delusions. Review of a progress note on 02/04/2025 at 3:33 PM showed a urinalysis (UA) order was received due to recent delusions and hallucinations (perception of having seen, heard, touched, tasted or smelled something that was not actually there) to rule out a UTI. Review of the February MAR showed the UA with culture and sensitivity was ordered to be completed on 02/05/2025. The order was signed as 9 indicating to see the progress notes. The lab was not set up in the MAR for another shift to collect and follow up on the missed UA. Review of a progress note on 02/05/2025 at 1:34 PM showed the nurse was not able to collect a UA due to the resident not cooperating. Review of the clinical record after the 02/05/2025 progress notes and lab results contained no further information about the urinalysis or if the physician had been informed the lab was not completed as ordered. In an interview on 04/25/2025 at 12:32 PM, Staff F, Registered Nurse (RN)/ Resident Care Manager (RCM) stated the lab was supposed to come on Sundays, Mondays, Tuesdays and Thursdays. The labs due are kept in a binder at the nurse's station and should be audited for completion and then results usually come in a day or two depending on the type of test. Staff F confirmed that Residents 7,10, 34 and 95 had labs ordered to be drawn on 04/23/2025 (which is the night shift that begins on 04/23/2025 but then becomes 04/24/2025), which were not done. Staff F stated they could not see documentation about why those labs had not been ordered but stated the lab may not have come, I heard something about a bill not being paid. Staff F was asked if there was an alternative option or an alternative laboratory available and they stated there was a different lab they used only for urinalysis. Staff F was asked if the providers for those residents had been notified that those labs had not been obtained and Staff F stated they did not know. In an interview on 05/01/2025 at 9:25 AM, Staff I, RN stated the facility had a new lab provider due to a payment issue and they were not sure who the new lab provider was. Staff I said the facility had a lab binder and the night shift nurse followed up on labs. Staff I stated they would be told in report if the lab had not been obtained. Staff I said sometimes the lab orders would be placed on the Medication Administration Record (MAR) which was helpful to know who had labs due. They stated they could look at the lab book or ask night shift to know if a lab sample had been obtained. In an interview on 05/01/2025 at 9:49 AM, Staff H, Licensed Practical Nurse (LPN) stated the facility had just changed lab companies. Staff H stated the phlebotomist would come in, grab the lab book and complete the lab draws, then have them sign off that the sample was obtained. Staff H stated night shift was responsible for putting the upcoming labs into the MAR so nurses would know who was due. Staff H stated they would check the lab binder or MAR to see if the lab had been obtained. In an interview on 05/01/2025 at 11:37 AM, Staff B, Interim Director of Nursing (DNS), stated the UA was not collected or followed up on. Staff B stated their expectation was labs were to be completed as ordered and followed up on. Reference WAC 388-97-1620 (2)(b)(i)

Based on observation, interview, and record review, the facility failed to ensure a pressure offloading mattress was ordered and implemented timely to prevent pressure ulcer (PU)/pressure injury (PI) development for 1 of 2 residents (Resident 7) reviewed for facility acquired PU. Resident 7 experienced harm when they developed a preventable Stage 3 PU to their coccyx (tailbone), requiring wound vacuum treatment which impacted the resident's rehabilitation and discharge potential. This failure placed residents at risk for adverse outcomes and a decreased quality of life. Findings included . PRESSURE ULCER DEFINITION AND STAGES The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, defined Pressure Ulcer (PU) Definition and Stages as: -A PU is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present itself 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 (a combination of downward pressure and friction). -Stage 2 PU: 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. -Stage 3 PU: 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 PI. -Unstageable PU: 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. RESIDENT 7 Resident 7 admitted to the facility on [DATE] with diagnoses which included diabetes (abnormal processing of sugar), existing stage 2 PUs on the right and left buttocks areas and an unstageable PU to the left foot. The resident's discharge plan included the resident's intention to return home when wounds were manageable with home health assistance. Review of Resident 7's admission nursing assessment dated [DATE] documented the healing stage 2 PU on the right and left buttocks, and an unstageable PU to the left foot. The assessment showed no skin breakdown on the coccyx area on admission. Review of the Braden Scale (an assessment tool that measures risk for pressure injury) dated 10/17/2024, scored the resident as 12 which was moderate risk for PU development. Review of the resident's care plan dated 10/17/2024 showed Resident 7 required total assistance of two staff for bed mobility and was able to use a bed enabler bar to assist with turning and positioning. Further review of the care plan on the date of admission showed no care plan problem related to existing pressure ulcers, pressure ulcer prevention or interventions put in place upon admission. Review of Resident 7's care plan showed a focus area initiated on 10/24/2024 instructing staff to offer and assist with turning and repositioning every two-three hours, off load pressure with positioning side to side when in bed, limit time on back to meals. The care plan included a low air loss mattress (a higher-level surface which is rated for prevention and treatment of pressure ulcers) on the bed for pressure relief and a pressure reduction cushion in the wheelchair. Review of Resident 7's nursing progress note dated 10/31/2024 at 3:24 PM, documented the resident with a new stage 3 PU to the coccyx that started as slit open area a week ago and now the wound bed was covered with 100% slough. The progress note stated the provider and resident were notified and that the resident had pain that limited their mobility to turn and reposition frequently. The note stated the Resident Care Manager (RCM) was notified to see if a Low air loss (LAL) mattress could be provided in addition to turning and repositioning, as the resident was not tolerating side to side positioning due to low back and lower leg pain. Review of Resident 7's progress notes and care plan updated on 11/24/2024, documented that the resident was not placed on the LAL mattress until 11/24/2025 (30 days after the RCM was notified to order the LAL). Review of Resident 7's medical record showed they were being seen by an outside wound clinic related to existing wounds and the wound clinic began following the coccyx wound in December of 2024. Review of the wound clinic notes documented the wound as unstageable and treatment plan included placement of a wound vacuum, which was changed three times per week and was in place until 04/08/2025. Review of the facility wound assessment notes showed inconsistent documentation of the coccyx wound characteristics and size, obtaining wound clinic assessment notes and interchanges the location of the wound to be coccyx or sacrum. The documentation was as follows: - 10/24/2024 coccyx documented as a slit with no measurement. - 10/31/2024 coccyx ulcer stage 3 with no measurement included in the note. - 11/26/2024 50% wound bed noted with covered with slough, with tunneling measuring 5.5 centimeters (cm) at 12 o'clock, 4 cm at 3 o'clock, 2 cm at 6 'o'clock, 1.5 cm at 9 o' clock. There were no would bed dimensions documented. - 12/07/2024 Length (L) 5.6cm x Width (W) 5.5cm wound vacuum to coccyx wound, changed three times per week. - 01/25/2025 wound on coccyx L 2.2cm x W 1.8 cm, Depth (D) of 2 cm - 02/01/2025 wound on coccyx L 2.0cm x W 1.8 cm x D 2.0 cm - 02/12/2025 wound on sacrum L 1.5cm, W1.5cm, D 1.0 cm - 02/12/2025-04/08/2025 - continued slow healing - 04/08/2025 wound vac discontinued - 04/22/2025 L 0.5cm, W 0.4cm, D 0.4cm (most current measurements) continues to be followed by wound clinic visits every other week. In an interview and observation on 04/23/2025 at 3:00 PM, Resident 7 was sitting up in their wheelchair with foam boots noted on bilateral feet. Resident 7 stated when they admitted they were on a flat mattress that felt like an army cot. The current mattress was observed to be an air mattress. Resident 7 stated they were supposed to have been on a specialty bed from day one, but I did not get one for over a month. Resident 7 stated they already had wounds when they admitted and then developed the one on their tailbone. Resident 7 stated (the tailbone) is the one that has given me the most trouble. Resident 7 stated they were frustrated that due to the wound vacuum and positioning restrictions, they had not been able to effectively participate in therapy until recently, so they lost strength and needed to be able to walk in order to go home, which they stated was still very much their goal. In an interview on 04/30/2025 at 12:57 PM, Staff F, RCM, stated there were standard batch orders for basic skin interventions that auto populate when a resident admitted and from there, individualized interventions would be entered, but stated there was no standard protocol to follow. Staff F stated air mattresses, overlays or special beds are indicated for anyone with skin issues, obesity, or bony prominences. Staff F reviewed Resident 7's medical record and verified that there were no PU prevention interventions in the record until 10/25/2024, when the coccyx wound was first identified as a slit. Staff F stated they did not know why Resident 7 did not have a higher-level mattress placed on admission. Staff F stated they were not very knowledgeable about the types of mattresses but stated Staff A, Administrator, would know because they were the ones who ordered the mattresses. In an interview on 04/30/2025 at 1:40 PM, Staff B, Interim Director of Nursing, stated Resident 7 admitted with several existing wounds, and stated upon admission, residents were assessed for risk and interventions were put in place. Staff B stated if a wound developed or worsened, it was ours, and stated interventions would include turning and positioning, pressure prevention mattresses and cushions, nursing assessments, wound specialists, dietician, and ensuring the practitioner assessed. Staff B stated that for a stage 3 or higher it was common sense to have an air mattress, the mattresses that are standard are pressure relieving, but they were not enough for stage 3 or higher. Staff B acknowledged that Resident 7 admitted with a stage 3 or higher already present and stated they do not know why a higher-level mattress was not placed until 11/24/2024. In an interview on 04/30/2025 at 2:00 PM, Staff A, Administrator, stated Resident 7 did not have an LAL mattress on admission. Staff A stated they remembered ordering the mattress for Resident 7 and assisting with putting it on their bed when it arrived, Staff A stated they double checked the dates and the documentation showing it was not placed until 11/24/2024 was correct and that they dropped the ball in preventing the development of a preventable stage 3 PU for Resident 7. Refer to F835- Administration Reference WAC 388-97-1060 (3)(b)

Based on interview, and record review, the facility failed to ensure a resident was free from neglect for 1 of 1 resident (Resident 1) when the facility failed to provide Resident 1 with the routine physician ordered Circulation Motor Sensory (CMS - a medical exam/check of the resident's neurological and vascular health) to their left leg. Resident 1 experienced harm when they were found with a Stage 4 (a full thickness tissue loss with exposed bone, tendon, or muscle. Nonviable tissue, dead or devitalized tissue may be present on some parts of the wound bed. Often includes undermining, which was destruction of tissue or ulceration extending under the skin edges, and tunneling, which was a passageway of tissue destruction under the skin surface) which pressure injury they had developed unbeknownst to the facility. Findings included . Review of the facility's undated policy titled, Abuse Prevention Program (screening, training and prevention), showed the definition for neglect is found in the Nursing Home Guidelines, The Purple Book, and signs of actual physical neglect included inadequate provisions of care. Review of the Nursing Home Guidelines, The Purple Book, dated October 2015, showed neglect may result from an inaction by an individual or entity with a duty of care for nursing home residents. The failure to provide goods and services necessary to avoid physical harm. Resident 1 was admitted to the facility with diagnoses to include a fractured kneecap and anxiety. Review of a nursing progress note, dated 12/27/2023, showed a cast was removed from Resident's 1's left leg, and a knee brace was implemented. Review of a physician order, dated 12/29/2023, directed the licensed staff to access Resident 1's left lower leg for CMS and check the skin under the left brace day and evening shift. The ordered specified to check the resident's skin under the brace, document, and report to the Medical Doctor any problems noted with either the CMS checks or if there were signs of skin breakdown. Review of Resident 1's 12/29/2023 through 02/13/2024 Treatment Administration Record, showed the licensed nurse documented CMS to the resident's left lower leg had not been completed on six-day shifts (on 12/31/2023, 01/22/2024, 01/25/2024, 01/26/2024, 01/27/2024, and 01/29/2024). Review of a nursing progress note, dated 02/13/2024, showed Resident 1 had an order in place for the nurses to check for skin break down under the brace twice daily (once on day shift and once on evening shift). The Nursing Assistants Certified (NAC) was to remove the brace when the resident received a shower or bed bath, to monitor the resident's skin and clean under the brace area. The nurses performed weekly head to toe skin assessments and assessed for any new skin issues. Resident 1 had a wound to their inner left knee area. The wound was documented as an unstageable wound due to equipment usage. The equipment used was a hinge brace was first applied on 12/27/2023. Review of the contracted wound clinic note, dated 02/15/2024, showed Resident 1 had a Stage 4 pressure injury (a full thickness tissue loss with exposed bone, tendon, or muscle. Nonviable, dead, or devitalized tissue may be present on some parts of the wound bed. Often includes undermining and tunneling). to their left medial knee. In an interview on 03/14/2024 at 2:11 PM, Staff F, NAC, stated they had received training on abuse and neglect. Staff F stated neglect would be obviously, like an example of letting more than a week go by without making sure a resident had a proper shower or going over two hours not providing incontinent care. Staff F stated neglect could be lots of things, and not fulfilling the needs, rights, and responsibilities to a resident would be neglect. In an interview on 03/14/2024 at 3:06 PM, Staff B, Licensed Practical Nurse/ Resident Care Manager, stated neglect would be purposefully or not on purpose not providing the care that a resident needed. In an interview on 03/14/2024 at 3:15 PM, Staff E, NAC, stated neglect was when you do not do the proper care, or you do not do what you were supposed to do. In an interview on 03/14/2024 at 3:30 PM, Staff H, Registered Nurse (RN), stated neglect was when care was not being rendered. In an interview on 03/14/2024 at 3:38 PM, Staff G, RN/Director of Nursing Services, stated neglect was willful when you purposefully did not do something you know should be done for the betterment of the resident. Staff G stated at the time Resident 1's wound was identified; they did not feel that the staff was being neglectful. Staff G felt they were confused and did not seek clarification. In an interview on 03/14/2024, 4:17 PM Staff I, Administrator, stated neglect was not providing the care that should be standard. Staff I stated that Resident 1's situation of not receiving the physician order skin checks and the development of a Stage 4 pressure injury to their left inner knee would fall to neglect. Cross Reference to CFR 483.25 (b)(1)(i), F-686 Treatment/svcs To Prevent/heal Pressure Ulcer Refer to WAC 388-97-0640(1)

Based on interview, and record review the facility failed to ensure nursing staff consistently provided the skin integrity and Circulation Motor Sensory (CMS - a medical exam/check of the resident's neurological and vascular health) assessment and monitoring as ordered, for 1 of 1 resident (Resident 1) reviewed for pressure ulcer/pressure injury (PU/PI). Resident 1 experienced harm when they developed an avoidable Stage 4 (a full thickness tissue loss of tissue with exposed bone, tendon, or muscle. There may be nonviable tissue, dead or devitalized tissue present on some parts of the wound bed) PU/PI under the resident's knee brace (also known as an immobilizer - a medical device that stabilizes your knee joint and holds it in place). This failed practice placed residents at risk for developing PU/PIs under a brace and/or immobilizers. Findings included . Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, defined: - A PU is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. Resident 1 was admitted to the facility on [DATE] with diagnoses to include facture of the left patella (kneecap) and anxiety. Review of the Admission Nursing Assessment, dated 11/20/2023, showed Resident 1 had a cast to their left leg. Review of a nursing progress note, dated 12/27/2023, showed Resident 1's left leg cast was removed after a doctor's appointment, and the resident was released to bear weight as tolerated with the use of a leg brace. The skin on the resident's inner knee was noted to be red from the leg brace when checked, and a thin pillowcase was applied. Review of Resident 1's physician orders, dated 12/29/2023, showed an order to monitor the resident's left leg for CMS. The order directed staff to check the resident's skin under the left brace, document, and report to the medical doctor any problems noted with the CMS checks or signs of skin breakdown. The skin check was ordered to be completed twice daily, every day and evening shift. Review of Resident 1's 12/29/2023 to 12/31/2023 Treatment Administration Record (TAR), showed the CMS checks were checked off as completed for the day and evening shifts of 12/29/2023 through 12/30/2023 and the evening shift of 12/31/2023. Review of Resident 1's January 2024 TAR, showed the CMS checks were documented as completed for all day and evening shifts except for day shift on 01/22/2024, 01/25/2024, 01/26/2024, 01/27/2024 and 01/29/2024. Review of Resident 1's 02/01/2024 through 02/13/2024 TAR, TAR showed the CMS checks were documented as completed for all day and evening shifts. Review of a nursing progress note, dated 02/13/2024, showed at approximately 7:30 AM, the nurse was alerted by staff that Resident 1 had a wound to their inner left knee area. The wound was noted to be unstageable due to equipment usage. The equipment was a hinge brace which was first applied on 12/27/2023, which had an order for the nurses to check the resident's skin twice daily for any skin breakdown. The Nursing Assistants Certified (NAC) were to remove the brace to give Resident 1 a shower or a bed bath, to clean under the brace area, and to monitor the resident's skin. Resident 1 was to have a weekly a head-to-toe skin assessment performed by the license nurse that included to assess for any new skin issues. Review of a contracted wound consultant note, dated 02/15/2024, showed a Stage 4 pressure injury to Resident 1's left medial (inner side) knee measured 3 centimeters (cm) by 1.5 cm. In an interview on 03/13/2024 at 3:48 PM, Staff A, Licensed Practical Nurse (LPN), stated they had worked with Resident 1 for a few weeks when they had the brace on their left knee. Staff A stated they had not removed the brace to completely look at Resident 1's knee. Staff A stated now they know they were to completely remove the brace and assess the resident's skin. Staff A stated they thought they were not allowed to fully remove Resident 1's brace. In an interview on 03/13/2024 at 3:55 PM, Staff G, Registered Nurse (RN), Director of Nursing Services, stated there was an order for CMS checks under the brace of Resident 1's left leg. Staff G stated the order was not being followed but the ordered had been clicked off on the TAR as if it had been. In an interview on 03/14/2024 at 1:31 PM, Staff D, Physical Therapist Assistant, stated Resident 1 had a shower the day the resident's wound to their knee was discovered (on 02/13/2024). Staff D stated the shower aide had discovered Resident 1's wound. Staff D stated when Resident 1 received therapy services, they would take the resident's knee brace off to adjust the brace. Staff D stated when Resident 1 was working with skilled therapy services they would check the brace was in the right place and would check the brace for rubbing on the resident's skin. Staff D stated Resident 1 had received therapy about a month prior to identification the wound to their inner knee. In an interview on 03/14/2024 at 1:42 PM, Staff C, LPN, stated they checked Resident 1's toes, removed the straps to the brace, opened the brace and checked the resident's skin for the CMS checks. Staff C stated they had completed the CMS checks, but they had not removed the brace and looked at the resident's skin under where the hinge of the brace was located. Staff C stated they had placed a pillow between Resident 1's legs but did not focus on where the hinge of the brace contacted Resident 1's skin. Staff C stated they thought the nursing bathing staff was under the impression Resident 1's brace could not come off and the nurses did not clue in that the brace was not removed. Staff C stated an agency NAC had removed Resident 1's brace when they gave the resident a shower and that was who found the resident's pressure injury. Staff C stated that the facility's NAC staff thought they were not to take Resident 1's brace off. In an interview on 03/14/2024 at 3:15 PM, Staff E, NAC, stated they were not supposed to touch Resident 1's brace, therapy dealt with it. Staff E stated they were to cover the brace with plastic when giving the resident a bed bath or shower so the brace would not get wet. In an interview on 03/14/2024 at 3:30 PM, Staff H, RN, stated they worked with Resident 1 for one shift. Staff H stated they opened the resident's brace and checked on their skin. Staff H stated they had to take the brace off the resident's leg as it was part of completing the resident's skin assessment. In an interview on 03/14/2024 at 3:48 PM, Staff G stated they had identified the nursing staff had not completed the CMS checks for Resident 1 and they just clicked off in the medical record that they were doing the skin checks. Staff G stated when they talked with the nursing staff, the nursing staff had heard they were not to mess with Resident 1's brace. Cross Reference to CFR 483.12(a)(1), F-600 Free From Abuse And Neglect Refer to WAC 388-97-1060(3)(b)

Based on observation, interview and record review the facility failed to implement interventions following the Registered Dietician (RD) recommendations for three of four residents (#1, #2, and #3) reviewed for weight loss. This failed practice placed the residents at risk for significant decline in nutritional status and caused harm to Resident #1, who had severe weight loss and placed the resident at risk for adverse health, safety and diminished quality of life. Findings include . According to the State Operations Manual (SOM), with an implementation date of 11/22/17, the Centers for Medicare and Medicaid Services defined the parameters for significance of unplanned and undesired weight loss as being severe if there was a greater than 5% weight loss in one month and greater than 7.5% in three months. RESIDENT #1 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident required supervision, oversight, and encouragement or cueing with set up only. Additionally, the resident was assessed to have severe cognitive impairment. Review of the Activity of Daily Living Care Plan (ADL), initiated on 07/26/2020, indicated the resident required set up and clean up with meals, a CCHO (consistent or controlled carbohydrate diet) mechanical soft diet with extra sauces or gravy and thin liquids. Review of the RD Nutritional assessment dated [DATE], showed a goal to promote weight gain. The RD recommended to fortify and liberalize the resident's diet and to add Glucerna (a liquid supplement) three times during the medication pass. Review of the Nutrition Care plan, initiated on 08/04/2020, showed the resident was at risk due to a [DIAGNOSES REDACTED]. The Care Planned Interventions included: - RD to evaluate and make diet change recommendations as needed; - General, mechanical soft diet with thin liquids, straws were ok and offer sugar free condiments. Additionally, offer fortified meal options, whole milk, fortified cereal at breakfast, ice cream, extra sauces/gravy; and - Monitor, record, and report to physician as needed signs and symptoms of malnutrition: Emaciation, muscle wasting, significant weight loss: 3 Lbs in 1 week, more than 5% in 1 month, more than 7.5% in 3 months, and more than 10% in 6 months. Review of the Care Conference Summary dated 08/13/2020, showed the resident had a MOCA (Montreal Cognitive Assessment which was a type of cognitive assessment) score of 13 out of 30 with noted moderate cognitive impairment. A reassessment showed a result of 11 out of 30 with a noted decline and consistent confusion. The resident was noted to need a lot of cueing and step by step direction related to the resident's lack of retention. The Dietary section noted the resident's weight had declined. Review of the August 2020, Medication Administration Record [REDACTED]. Review of the resident's weight record over a three months period showed the following: - On 07/27/2020 = 98.5 pounds (Lbs). The resident was weighed using a mechanical lift; - On 07/29/2020 = 95.0 Lbs, indicating a 3.5 Lb weight loss in two days. The resident was weighed using a mechanical lift; - On 08/30/2020 = a standing weight of 86.9 Lbs, indicating an 11.7% weight loss in one month; - On 09/27/2020 = a standing weight of 82.8 Lbs, indicating a 15.9% weight loss in two months; and - On 11/01/2020 = a standing weight of 79.4 Lbs, which was a 19.3% weight loss in 14 weeks. Review of the August 2020 Certified Nursing Assistant (CNA) Survey report showed the resident had no documentation of assistance with meals four times and only received setup with no oversight or cueing with her meals 28 times. Review of the resident's meal intake showed the resident ate less than 25% of her meals 21 times, ate less than 50% of her meals 43 times and had no documentation of meal intake for nine times. Review of the RD Nutritional Referral note dated 09/15/2020, showed the resident had a 5% weight loss in one month and a 16% weight loss since admission. The plan was noted to continue to offer fortified meal options to maximize the resident's intake, add cottage cheese with fruit to lunch and dinner, whole milk to all meals, offer assistance and encourage with meals as needed. Review of the September 2020 CNA Documentation Survey Report, showed the resident had no documentation of assistance with meals ten times during and 41 times the resident only received setup with no oversight or cueing with her meals. Review of the resident's meal intake showed the resident ate less than 25% for six of her meals, ate less than 50% for 33 meals and had no documentation of meal intake for 16 meals. Review of the October 2020 CNA Documentation Survey Report, showed the resident had no documented assistance with meals 11 times and 39 times the resident only received setup with no oversight or cueing with her meals. Review of the resident's meal intake showed the resident ate less than 25% of her meals for nine meals, ate less than 50% for 18 meals and had no documentation of meal intake for 18 meals. In a phone interview on 11/04/2020 at 10:05 AM, a resident representative expressed concern for the resident's nutritional condition. In an observation on 11/12/2020 at 3:30 PM, Resident #1 was sitting by herself, in her room, eating ice cream independently. In an interview on 11/12/2020 at 3:34 PM, Staff B, CNA, stated that she knows the level of care needs for the resident from the Kardex (a guide for the direct care staff) and therapy would let us know of any changes. Staff B stated that if a resident refused care, she would step back, ask another CNA to assist the resident and if the resident continued to refuse staff would document the refusal of care. Staff B stated that if a resident was not eating a meal, staff would take the tray away and offer a sandwich or a snack and chart the amount the resident had eaten. Staff B stated that Resident #1 picked at her food, was picky, but was able to feed herself. Staff B stated that the resident ate in her room and loved butter and jelly sandwiches, coffee and junk food. Staff B stated that they always offered the resident a snack or a mighty shake (a liquid nutritional supplement) and would let the nurse know if the resident refused a meal. In an interview on 11/12/2020 at 3:52 PM, Staff C, Nurse Aide Register, stated that Resident #1 had never refused a meal, if she ate less than 50% she would offer her a snack. Staff C stated the resident liked egg salad sandwiches, Pringles and other snacks she had in her room. In an interview on 11/12/2020 at 4:15 PM, Staff D, Dietary Manager (DM), stated that he had a weekly call with the RD. Staff D confirmed the last Diet Order and Communication sheet he received for Resident #1 was on 08/05/2020. In an interview on 11/12/2020 at 4:30 PM, Staff A, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), stated Resident #1 would be happy to eat but then would lose interest. Staff A confirmed the resident's electronic medical record had weight loss alerts, and that the resident triggered weight loss daily, so the facility decreased the weight loss notification alerts. Staff A stated that the staff cued or encouraged the resident but if she did not like the item, cueing and encouragement was ineffective. Staff A stated the resident had not had any issues with [MEDICAL CONDITION] or swelling that may have impacted her weight loss. Staff A reviewed the RD recommendations and confirmed the 09/15/2020 RD recommendations had not been implemented. In an observation on 11/12/2020 at 5:27 PM, the resident was lying in bed with the lights out, the dinner meal had yet to be served. In an interview and record review on 11/12/2020 at 5:33 PM, Staff E, CNA, confirmed the resident's meal tray card showed the resident was on a mechanical soft CCHO diet, with extra sauces and gravies, breakfast included cream of wheat x 2 only, lunch and dinner noted to have half of an egg salad sandwich. The facility failed to implement the RD recommendations from 09/15/2020, to add cottage cheese with fruit to lunch and dinner and to offer assistance and encourage with meals as needed. RESIDENT #2 Resident #2 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Weight Summary Report showed the following: - On 10/12/2020, twelve days after admission, an admission standing weight of 173 Lbs; - On 10/12/2020, a standing weight of 169 Lbs; and - On 11/11/2020, a weight of 163.4 Lbs, which was done in a wheelchair, indicating a 5.5% weight loss in less than a month and a half. Review of the RD Nutritional assessment dated [DATE] showed, the RD documented the resident had a decrease in intake since his wife was hospitalized and required increased assistance and cueing with meals. The RD recommended to 1) continue diet texture per Speech therapy; 2) fortify meals with whole milk, fortified cereal at breakfast, extra butter/gravy, ice cream with lunch and dinner; 3) offer 120 cc (cubic centimeter) mighty shake twice daily with med pass; and 4) recommend meals be taken in the assisted dining unless resident's wife was present. Review of the Focus Nutritional Care Plan, initiated on 10/12/2020, identified the resident was a nutritional risk related to poor variable intake. The 10/14/2020 RD recommendations were not care planned until 11/13/2020. Review of the resident's dietary slips showed the 10/14/2020 RD dietary recommendations were not implemented until 11/13/2020, a month later. RESIDENT #3 Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Weight Summary Report showed the following: - On admission the resident weighed 167.6 Lbs; and - On 10/27/2020, the resident weighed 157.8 Lbs, which was a 9.8 Lb or 5.8% weight loss in a month. Review of the RD Nutritional assessment dated [DATE], showed the resident was at risk for malnutrition due to inadequate oral intake as evidenced by intake less than 75%. The plan included: 1) continue diabetic diet modifications; diet textures per speech therapy recommendations; 2) change nutritional supplement to Glucerna twice daily with med pass (may tolerate better if cold); 3) increase anti-nausea medication as appropriate; given before meals; 4) offer cold foods and beverages while nauseated (may tolerate better than hot foods); and 5) Offer comfort foods i.e. soup, broth, pudding, yogurt, cottage cheese, crackers while nauseated. Review of the Focus Nutritional Care Plan, showed the resident was at risk due to a very poor appetite related to nausea. The 09/29/2020 RD recommendations were not updated to the Care Plan until 10/06/2020. Review of the resident's dietary slips showed the 09/29/2020 RD dietary recommendations were not updated until 11/13/2020, over a month later. In a phone interview on 11/13/2020 at 3:03 PM, Staff D, DM, stated that Staff A, LPN/RCM had brought in updated dietary slips for Resident #2 and Resident #3 earlier in the day. In a phone interview on 11/13/2020 at 3:43 PM, the RD stated that they had to modify their communication with the current COVID - 19 pandemic. She stated that she reviewed the facility's admissions and weight summary report weekly and determined who she was going to see. She stated that she would make a phone call to the facility and speak with the Director of Nursing Services (DNS), RCM or Assistant Director of Nursing Services (ADNS) who would give her firsthand knowledge of the resident and they would work through the residents weight loss or whatever issues nursing staff was seeing. The RD stated that she would call the Kitchen Staff and communicate the recommended plan on the phone and by email which was sent to the nursing administration team and the DM. The RD stated that the nursing staff would enter any recommended orders and the DM would take the dietary recommendations and add to the dietary meal card. Reference: (WAC) 388-97-1060 (3)(h)

Based on observation, interview and record review the facility failed to maintain resident dignity for one of one residents (#13) by not answering the residents call light in a timely manner, the resident had to urinate in an inappropriate place and then a staff member chastised the resident. This failure caused harm by making the resident have feelings of frustration, humiliation, diminished self-worth and psychosocial harm. Findings included . Resident #13 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated [DATE], showed the resident had no cognitive impairment, was continent of her bladder, and required supervision with set up assistance from staff for transfers, walking in her room, toileting and personal hygiene. The resident used a Front Wheeled Walker (FWW) and a wheelchair for her mobility needs. Review of the Activities of Daily Living care plan, revised on 09/16/19, showed the resident required limited stand by assistance with the use of a FWW and one staff to use the bathroom. Review of a progress note dated 06/20/19 at 6:44 AM, showed Staff F, Registered Nurse, received a communication form from a staff member (not identified) that the resident was very upset because the resident did not have her wheelchair (w/c) readily available, had to go to the bathroom and had to urinate in a trash can. Review of a progress noted dated 06/20/19 at 7:20 AM, showed Staff G, Social Service, documented that the Director of Nursing Services (DNS) and Staff G met with Resident #13 to discuss the use of using the trash can for toileting. The resident stated that her w/c was not readily available and the FWW was across the room. The resident stated she did not want to urinate in her bed, so she used the trash can. Both staff members told the resident that using the trash can was her best option. The plan was to ensure her FWW was next to her if the w/c was absent. Review of the Kardex (a care guide for the Nursing Assistants), with a print date of 10/25/19, showed no evidence the facility had updated the Kardex to direct staff to ensure her FWW was next to her if her w/c was unavailable. During an interview on 10/25/19 at 12:10 PM, Resident #13 was observed sitting in her w/c in her room. The resident stated she was treated with respect and dignity most of the time. When asked what that meant, she was very hesitant to answer and stated she didn't want to get anyone in trouble. The resident stated one night it was dark in her room, she could not see the clock and needed to go to the bathroom. Her w/c was usually kept next to her bed, but when she woke up it was not there. The resident pointed across the room where her FWW was stored next to the armoire, and out of reach. The resident stated her call light was on for approximately 40 minutes. Resident #13 stated she did not want to pee in her bed, so she decided to use that trash can (and pointed to a small white trash can next to her nightstand) to urinate. The resident again stated she did not want to get anyone in trouble. The resident stated that when Staff H, Nursing Assistant, came back to her room, Staff H scolded her for urinating in the trash can. Resident #13 stated the DNS did speak with her about the incident and the DNS stated that Staff H would be moved to work on another unit, but now Staff H was back working on this unit. Resident #13 stated she did not want to work with Staff H, and she was fearful of retaliation from her. Resident #13 stated she felt humiliated by this incident. Review of the grievance log from (MONTH) to October, showed no evidence the incident was investigated. During an interview on 10/25/19 at 1:04 PM, the DNS stated that she received the incident on a communication form and spoke to Resident #13 regarding incident with Staff G. The resident stated what occurred and that Resident #13 did not feel comfortable working with Staff H. The DNS confirmed that Staff H was moved to a different unit for a short time. On 10/25/19 at 1:20 PM, the facility Administrator and Staff H were interviewed. Staff H stated she had worked the night shift on the night of the incident. Staff H stated part of the night shift duties was to clean resident's w/cs. Staff H stated when she returned Resident #13s w/c, she was upset and told Staff H she had urinated in the trash can. Staff H told the resident she should have called her for help and did not have to pee there. Staff H stated Resident #13 had her call light on, but was not sure how long it had been on for. Staff H stated she then filled out a communication form and turned it into the nurse. During an interview on 10/31/19 at 1:38 PM, the facility Administrator was informed that former facility Administrator was aware of the incident and no further action had been taken regarding how Staff H spoke to Resident #13. The Administrator stated she would look into the incident. During an interview on 10/31/19 at 11:31 AM, Staff G stated her and the DNS went to talk to Resident #13 about the incident. Staff G stated Resident #13 did not want to talk about the incident and did not want anything further done about it. When asked why this was not done as a grievance, Staff G stated because the resident did not want anything further done about it. Refer to CFR 483.12(c )(2)-(4) - F 610 - Investigate/prevent/correct Alleged Violations Reference: (WAC) 388-97-0180 (1-4)

Based on observation, interview and record review the facility failed to evaluate the root cause, provide adequate supervision and follow care plan interventions specific to resident needs for one of two residents (#1) reviewed for accidents. This failed practice caused harm to Resident #1 when she sustained a fracture to her left leg after falling from her bed, had an increase in discomfort and a potential diminished quality of life. Findings included . Review of the facility policy titled, Fall Procedure, with a review date of 02/2012, showed all falls would be investigated, interventions initiated to prevent further falls, and staff would call for assistance and not leave the resident who fell alone. Resident #1 was a long term care resident with [DIAGNOSES REDACTED]. According to the Significant Change in status Minimum Data Set assessment dated [DATE], showed Resident #1 was severely cognitively impaired, required total assistance with two persons for transfers and extensive assistance with two persons for bed mobility. Resident #1 had demonstrated physical and verbal behaviors, but did not refuse care. Review of high risk for falls care plan, revised on 09/16/19, showed the goal was to reduce the risk of injury from falls through the next review date. Interventions included: - To anticipate and meet the resident's needs; - Ensure her call light was within reach and encourage her to use it for assistance as needed; - Provide prompt response to all requests for assistance, she was forgetful and may not ask for help; - Bed against the wall secondary to flow of room; - Do not place mats next to bed; - Bed always in low position; and - The resident was checked every two hours and offered toileting every three hours. Review of the fall assessment dated [DATE] and 09/15/19, showed Resident #1 was at high risk for falls. Review of the state reporting log showed Resident #1 had a fall 09/14/19 at 5:45 PM with no injury, further review of the state reporting log identified a fracture on 09/18/19. Review of the analysis of the undated and unsigned incident report, showed Resident #1 had a witnessed (even though it was unwitnessed) fall in the evening of 09/14/19. Staff A, Nursing Assistant (NA), saw the resident sitting on the floor with her back leaning against the bed. Staff A left the room and notified the Licensed Nurse (LN) and another N[NAME] When Staff A entered Resident #1s room, she was now lying on her back on the floor. Following the fall the resident did not complain of pain. Due to Resident #1s cognitive status she was not able to make a statement. The investigation stated that on 09/16/19 at 7:45 AM, the Director of Nursing Services (DNS) and the Resident Care Manager (RCM) went to assess the resident and follow up on the fall (from two days prior). The resident complained of pain in her legs when range of motion was performed. On 09/16/19, the facility had obtained the lumbar spine and left hip X-ray, which were both negative for a fracture, but was unable to obtain an x-ray to the left knee because the resident was combative. On 09/18/19 the ARNP (Advanced Registered Nurse Practitioner) reordered a left knee x-ray. The results of this x-ray showed a closed [MEDICAL CONDITION] distal femur. The resident was sent to the emergency room . The analysis of the investigation did not rule out abuse and neglect or put interventions into place to prevent another fall for Resident #1. Review of the nursing progress notes showed no documentation of the fall or that the physician/responsible party were notified. Review of the nursing progress notes showed on 09/15/19 at 7:03 AM, the following morning, the LN documented Resident # 1 had a non-injury fall on evening shift. Review of the nursing progress note dated 09/15/19 at 10:59 AM, showed Staff F, Registered Nurse (RN), documented the resident did not appear to have an injury at the time of the fall, but had recently begun to complain of leg pain. Staff F documented an order for [REDACTED]. Review of the Physicians orders showed a verbal order to X-ray to left hip, low back, and 2 views of the left knee. Review of a communication book to providers showed an SBAR (an assessment tool for medical providers), dated 09/14/19 that Resident #1 had fallen on 09/14/19. The SBAR described the incident and stated initially the resident did not complain of pain, but did complain of leg and knee pain the following day. The SBAR was signed by the Physician assistant-Certified (PA-C) on 09/16/19 with directions that stated, X-rays already ordered. Review of the nursing progress note dated 09/16/19 at 2:48 PM, showed the resident had no injuries or bruising noted from the fall. The Resident continues to be guarded at left hip, complains of low back and bilateral knee pain. X-ray was done today showing no fractures or displacement of left hip and lumbar spine. Resident was seen today by PA-C with orders to monitor pain, use routine and as needed Tylenol for pain management, call medical provider if complains of new pain worsen or change to obtain order for X-ray. There was no documentation indicating that the resident had refused the left knee x-ray or the facility had notified the physician of the refusal. Review of the nursing progress note dated 09/17/19 at 10:39 AM, documented the resident had complained of intense left knee and thigh pain at rest and with an emphasis during any movement. The nurse called the PA-C and reported the resident's pain. The PA-C, reordered a left knee x-ray and prescribed [MEDICATION NAME]. Review of the progress notes showed no documentation of when the left knee x-ray was obtained. Review of the Radiology report, documented date of service was 09/17/19, showed [MEDICAL CONDITION] femur (thigh bone). Further review showed the results of the x-rays were faxed to the facility in the afternoon of 09/17/19. Review of an incident description dated 09/18/19 at 10:31 AM, documented x-ray results from 09/17/19 were given to the PA-C this morning showing [MEDICAL CONDITION] femur. PA-C gave orders to transport to ED (emergency room ) for evaluation and management Review of the nursing progress note dated 09/18/19 at 10:35 AM, the following morning after the x-ray results were faxed to the facility, documented per results of x-ray from 09/16/19 (this x-ray was negative for fracture but the x-ray taken on 09/17/19 was positive for a fracture) the resident would be transferred to the emergency room (ER) for further evaluation and treatment. In an observation on 10/02/19 at 9:24 AM, Resident #1 was eating breakfast in bed. Her bed was positioned at a standard position (hip level), a tray table was over the bed with her breakfast. Resident #1 stated hi but was unable to answer any further questions. In an observation on 10/02/19 at 10:59 AM, Resident #1 was in bed lying on her back, dressed, and the call light was within reach. The resident's bed was in the lowest position (close to the ground). In an interview on 10/02/19 at 11:04 AM, Staff, B, NA, stated that Resident #1 was unable to use her call light but she could pull it out of the wall. Staff B stated the resident's bed was supposed to be in the lowest position possible, which meant the bed was supposed to be as low to the ground as it could get because the resident was a fall risk. Staff B stated if the care plan and Kardex (a care guide for the NAs) did not specify the bed was to be in the lowest position, then that indicated beds were in the standard position. Staff B stated that during meals the bed side table does not fit under the bed when it was closest to the ground so the staff had to keep on checking on Resident #1 every 20 minutes because she would fall asleep during meals and her bed was in the standard position. Staff B stated if a resident was found on the floor that the staff should yell for help, but never leave the resident alone. In an interview on 10/02/19 at 11:16 AM, Staff C, Registered Nurse (RN), stated that if a resident was found on the floor, the nurse was required to do a full assessment including vital signs, range of motion, and a pain assessment. Staff C stated they were supposed to put an intervention in place after the fall to prevent the resident from falling again. Staff C stated the resident should never be left alone after they were found on the floor. Staff C stated she had not worked with Resident #1 since she had fallen on 09/14/19. In an interview on 10/02/19 at 12:28 PM, Staff D, RN/RCM, stated the floor nurses completed the incident reports in the medical record. Staff D stated the physician and the family should be notified, the resident should be assessed including a neurological assessment if the resident hit their head, a new fall assessment should be completed and if the resident was identified as a high fall risk, then interventions should be put into place to try and prevent another fall and protect the resident from injury. In an interview at 10/02/19 at 12:46 PM, the stated that Resident #1s fall was an unwitnessed fall and not a witnessed fall like the investigation showed. The DNS stated that all parties (the physician and responsible party) should be notified of the fall and witness statements should be obtained including pertinent events regarding the fall. The DNS stated she had assessed Resident #1 on her next scheduled work day. In an interview on 10/02/19 at 1:46 PM, Staff A stated he was Resident #1's NA on the day she fell . Staff A stated he had worked a double that day. He stated he did not remember what time she had fallen but he thought it was before dinner. Staff A was unable to recall any other events surrounding the fall except that when he found her, her back was leaning against the bed and her legs straight out in front of her. Staff A stated he left the resident and got the nurse. When he returned, she was in a different position. Staff A stated it was like she had just tilted over to her left side with her legs parallel to the bed, instead of her back against the bed and her legs straight out in front of her. He stated after the nurse assessed her he wanted to get her up in the chair because he remembered her jumping around in bed. When asked what that meant, Staff A stated she was fidgety. Staff A stated, I'll cop to it, her bed was probably higher than it should be, it should be as low as it can go. In an interview on 10/03/19 at 10:40 AM, Staff E, NA, stated if the care plan stated, bed is lowest position that meant the bed has to go as close to the floor as possible. Staff [NAME] stated this was for residents who were at high risk for falls. Staff [NAME] stated she would normally never leave a resident that was on the floor, but if the room was at the end of the hall where there was not a lot of staff traffic, she felt she would have to leave the resident to get the nurses attention. Staff [NAME] continued to state that she knew the needs of each resident by the care plan, the Kardex and by shift to shift report. In an interview on 10/03/19 at 2:05 PM, Staff F, RN, stated she was very busy that evening with three other falls but she remembers walking into Resident #1s room with Staff A and she was parallel to the bed on her back. Staff F performed an assessment and Resident #1 was placed back in her bed because she required incontinent care. Staff F stated they performed incontinent care and performed range of motion and the resident didn't act like she was in pain. Staff F stated that she gave Staff A a witness statement to complete but does not remember if she (Staff F)reviewed it. Staff F stated witness statements should include all pertinent information regarding the fall. Reference (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the Licensee/Owner of the facility failed to administer the facility effectively and efficiently to ensure the facility's finances were maintained effectively. The Licensee/Owner was aware the facility had not been paying their vendors, leases, Internal Revenue Services and employee benefits timely with the threat of services not being supplied or discontinued. The Licensee/Owner failed to pay all of the vendors in a manner that ensured staff had the necessary resources that were timely and were available to care for the residents. This placed all of the residents at risk of not receiving necessary care and services or causing a risk of a facility closure. This resulted in an Immediate Jeopardy (IJ) on 08/29/19. On 09/04/19, the IJ was removed when verification of a new Management and Operations Transfer Agreement was established, and when the facility verified that current vendors would not stop services to ensure residents services were not disrupted. Findings included . In a phone conference and record review on 08/22/19, the building owners stated the Licensee was the owner of a company, WAATU, Inc., that managed the Nursing Home. The facility had been without a permanent administrator since 07/22/19, when the Licensee terminated the permanent Administrator. Most all of the major vendors of the facility also served as vendors for another nursing home that the Licensee/Owner was the Acting Administrator. The Licensee leased both of the buildings from a company, Aventurer Senior Living, Inc. (ASL), the building owners. In the phone conference the building owners, stated that the Licensee was past due on his leases in the approximate amount of $800,000.00 dollars. The owners of ASL also reported the the Licensee owned $80,000.00 in past due employee health insurances. In an interview on 08/22/19 at 2:58 PM, the part owner of the pharmacy stated that WAATU, Inc. owed the pharmacy approximately $329,000, which included (MONTH) - July. He stated the pharmacy used to get a check every month. He stated the pharmacy supplied both of the company's nursing homes. He stated that if they did not get a check by tomorrow, 08/23/19, the pharmacy was going to make a decision to stop supplying WAATU's nursing facilities. The pharmacy had discussed putting a lien against WAATU, Inc. The pharmacy called the owner today and was going to give him a date of when the pharmacy was going to cut off their services to WAATU. After the call, the owner authorized a $53,000.00 payment for the next day, but the pharmacy partners would continue to review this. In an interview on 08/23/19 at 9:56 AM, the Chief Financial Officer (CFO) confirmed bills were behind. He stated the owner owed the Internal Revenue Services approximately $618,000.00. The CFO stated they were working on a plan. The CFO stated the owing money was because in (MONTH) of (YEAR) and (MONTH) of (YEAR) the owner missed paying the payroll taxes and this was the result. He stated that he paid $116,000.00 in payroll taxes and $372,000.00 in payroll equaling $488,000.00. At 10:03 AM, he stated that he had thought of walking away, but he said there were about 200 residents and 300 employees that he was committed to. That day he was paying: Relias, the training company $13,000 to resume services, $53,000 to pharmacy, so they would continue to supply medications, to an Insurance broker so they could find insurance for their employees, to Dietary services, and the Storage fee of $800.00. In an interview on 08/22/19 at 3:19 PM, the CFO the employee health provider had told him they were done and would not go forward with providing health care to the employees if they do not pay by 09/10/19. If not paid, the employee health insurance would be cut off as of (MONTH) 31, 2019. In an email on 08/23/19 on 11:51 AM, from Pay Northwest, a payroll agency, showed the facility owed this company approximately $45,000.00 dollars. In a joint telephone conference call on 8/23/19 at 1:00 PM, with the Department and the facility attorney, it was mentioned that the owner owed health insurance in total of $145,000.00 that is due by 09/05/19. Reference WAC 388-97-1620(1),(2)(ii)

Based on interview and record review, the facility failed to have a functioning governing body to oversee the Licensee/Owner. The lack of a functional governing body failed to act to protect the well-being of the residents of the facility due to a known financial crisis. By not having a responsible, effective, active, and engaged governing body placed all of the residents at risk when staff became aware of a financial crisis. This impacted all 41 residents in the facility. The Licensee/owner did not create a functioning system to oversee the Licensee/owner, hold the Licensee/owner accountable to ensure bills and staff benefits were paid. This placed residents at risk of not having necessary supplies, receiving care, if staff decided to leave due to lack of benefits, and caused the potential of psychological harm for residents by becoming homeless if the bills were not paid and the facility was forced to close. This created an Immediate Jeopardy (IJ) on 08/29/19. On 09/04/19, the IJ was removed when verification of a new Management and Operations Transfer Agreement (MOTA) was established and implemented, when the facility verified that current vendors would not stop services to ensure residents services were not disrupted and when the facility verified a meeting occurred with the new Governing Body. Findings Included . See also F 835, CFR 483.70 - Administration for additional information A review of a Operating Policy titled Governing Body, dated (MONTH) 2019 documented under the SECTION: Shuksan Health Care Center TITLE: Governing Body The facility will have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. Policy Explanation and Compliance Guidelines: 1. The governing body will appoint an administrator who is: a. Licensed by the state where required. b. Responsible for management of the facility. c. Reports to and is accountable to the governing body. 2. The governing body is responsible and accountable for the QAPI program. 3. The Governing body refers to individuals such as facility owner(s), and Chief Executive Officer(s) who are legally responsible to establish and implement policies regarding the management and operations of the facility. 4. The governing body will have a process in place by which the administrator: a. Reports to the governing body. b. Method of communication between administrator and governing body. c. How the governing body responds back to the administrator. d. What specific types of problems and information (i.e., survey results, allegations of abuse or neglect, complaints, etc.) are reported or not reported. e. How the administrator is held accountable and reports information about the facility's management and operation (i.e., audits, budgets, staffing supplies, etc.) f. How the administrator and the governing body are involved with the facility wide assessment. In an interview on 08/22/19 at 3:19 PM, the Chief Financial Officer (CFO) stated the governing body consisted of the WAATU, Inc., owner and the CFO. They were both aware of the financial trouble that was occurring. The facility had been without a permanent Administrator for approximately 4 weeks, since 07/22/19. It was unclear if there was search being done to find a permanent administrator. In an interview on 08/27/19 at 2:27 PM, the Licensee/owner of WAATU, Inc., stated himself and the CFO, an employee, were the governing body. There was no appointed governing body or system in place to develop policies or hold the Licensee/owner accountable, since the Licensee was the owner and decision maker of the building and the company. In interviews and record reviews on 08/22/19 and 08/29/19 with facility staff, the corporate CFO, building owners, facility attorney, and the Licensee/owner of the company showed the Licensee was also the governing body. There was no system in place to provide active, engaged oversight of the Licensee/owner to ensure bills were paid timely when a financial crisis began. In review and interviews on 08/22/19, 08/23/19, 08/24/19, 08/25/19, 08/26/19, 08/27/19 and 08/28/19, the facility had multiple bills for vendors that were either unpaid and or were consistently paid late. Staff were paid but employee benefits were not being submitted timely, leaving employees potentially with no health benefits. This placed the residents at risk of not having needed supplies, staff/care givers (if they were not paid). Reference: WAC 388-97-1620 (2)(c)

Based on observation, interview and record review, the facility failed to ensure that one of one resident (#22) reviewed for pressure ulcers did not develop a pressure ulcer unless the resident's clinical condition demonstrated that they were unavoidable. This failure caused harm to Resident #22 who developed a Stage III pressure ulcer (PU). Findings included . According to the National Pressure Ulcer Advisory Panel (NPUAP, experts in pressure injury), recommends protecting the skin from exposure to excessive moisture with a barrier product in order to reduce the risk of pressure damage and to consider the need for moisture and temperature control when selecting a support surface cover. The NPUAP defines a Stage 3 Pressure Injury as: 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 (both non viable tissue) 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. The Resident Assessment Instrument (RAI) Manual defined the stage of a PU as follows: - A Stage III Pressure Injury (ulcer) was described as full thickness loss of the skin (wound extends through second layer of skin into fatty subcutaneous (below the skin) tissue). Review of a facility policy titled, Skin at Risk, dated 11/2018, showed that: - All residents were considered at risk for skin breakdown and an individualized care plan would be addressed; - All mattresses were pressure reducing. If the resident was assessed for requiring a specialty mattress, one would be provided; - All wheelchairs would have a pressure reducing cushion placed in them unless otherwise specified and care planned; - All residents received a weekly skin check. Weekly skin checks would be completed by the Licensed Nurse (LN) as scheduled .utilizing a progress note in the electronic medical record; - Any necessary follow up to newly identified skin issues would be completed by the nurse and may include but was not limited to notification of physician and responsible party, implementation of new treatment order(s), documentation and nurse-to-nurse communication; -Skin impairments would be monitored until resolved; -Skin impairments would be care planned and updated as needed; and - Areas of pressure injury may be assessed weekly by the wound team and measurements documented weekly. Resident #22 re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes showed there was no documentation identifying the LN assessed the resident's skin upon admission. The Initial Admission Assessment skin integrity section was partially completed. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had no cognitive impairment, required two person extensive assistance for activities of daily living such as bed mobility and transfers, was considered high risk for PU development and did not admit with a PU. The assessment revealed he currently had two venous or arterial wounds (non-pressure wounds developed from blood flow issues). A review of Resident #22's care plan and care directive (a guide for the direct care staff) revised 06/04/19, showed the care plan identified the resident required distant supervision to turn and reposition in bed as necessary. There were no skin related instructions on the care directives or care plan. Review of the behavior documentation showed no refusals of care since admission. Review of a progress note dated 06/17/19 at 1:57 PM, showed the resident was placed on alert charting for skin concerns. The LN documented the resident had no changes in his skin color but did have a quarter size skin tear to the left buttock and cream was applied. Review of the care plan, initiated on 06/21/19, showed the resident had a potential for pressure injury development/impaired skin integrity. The care plan did not include the actual new left buttock open area discovered on 06/17/19. Review of the progress note dated 06/18/19,showed Staff D, Physician's Assistant (who worked at Wound Consultant Company), documented he was Unable to see a new open area on his L (left) buttock, however nursing staff had a photo in CarePICS (remote clinical Imagery System) for me to review. This area started several days ago when he was found to be sitting on a pillow and he was very sweaty. His skin was macerated (softening and breaking down of skin from prolonged exposure to moisture) and during a transfer, he sustained a superficial abrasion . Wound # 8 Left Distal buttock is an acute Partial Thickness Abrasion and has received a status of Not Healed. Measurements are 2 cm (centimeters) length X (by) 2.5 cm width X (by) 0.1 cm depth, with an area of 5 sq. (square) cm and a volume of 0.5 cm .Wound bed is 76-100 % [MEDICATION NAME] (regeneration of new skin) . Staff were directed to avoid pillows or other surfaces that could increase moisture and maceration. In an observation and interview on 06/21/19 at 8:17 AM, Resident #22 was lying on his back in bed. He stated he had a new sore on his bottom and he was to limit his time up in the wheelchair for pressure relief. His wheelchair was a large size standard sling chair, which had an approximate one-inch blue fabric cushion. He said he had purchased the cushion at a local store. He continued to state he did not have a foam or pressure relieving cushion because they cost three hundred dollars. He said the facility had not offered to provide him with one. The resident was observed on a standard mattress and not a low air loss mattress (mattress designed to prevent and treat pressure wounds). In an interview on 06/26/19 at 9:11 AM, Staff E, Licensed Practical Nurse (LPN), Resident Care Manager (RCM)confirmed the resident could benefit from pressure reducing surfaces. Review of the progress notes from admission through 06/27/19 did not include any detailed progress note which identified any PU measurements, wound color, drainage or indication of signs of infection after the LN was made aware of the skin impairment. There was no documentation or care plan interventions to prevent wound deterioration. In a joint interview on 06/27/19 at 9:48 AM, the Director of Nursing Services (DNS) and Staff F, Vice President of Clinical Operations, were informed Resident #22 was not observed off of his back on any observations in bed on all days of survey. Staff F said Resident #22 would benefit from a pressure relieving mattress. Staff F stated the facility would provide the resident with a Roho (type of pressure relieving cushion) or better cushion for his wheelchair. Staff F stated she thought Staff D had stated the resident's left buttock wound was considered to be Moisture Associated Skin Damage (MASD). Staff F was not aware Staff D documented the wound to be an abrasion. On 06/27/19 at 11:05 AM, Staff E, LPN/RCM, and Staff B, Registered Nurse (RN), were observed performing wound care to Resident #22. The left distal buttock was observed to have an approximately quarter sized wound bed which had 90% yellow slough with a depth of approximately 0.3 cm with clearly defined circular edges. In an interview on 06/27/19 at 12:20 PM, Staff F was informed by this surveyor the left buttock wound was consistent with a Stage III PU, which had clearly defined wound edges, the wound was covered with 90% slough, and was located in an area of pressure. The wound progression from 06/18/19 went from 76-100% epithelization and now it had 90% yellow slough. The resident continued to be on the same mattress with no new pressure-relieving mattress or wheelchair cushion in place. The care plan lacked interventions since admission to prevent further skin issues for this high-risk resident. Staff F was not able to provide any further information. Record review on 06/27/19 at 1:15 PM, showed Staff D's recommendations from 06/18/19had not been implemented. In a follow up interview on 06/27/19 at 1:15 PM, Staff [NAME] confirmed the wound had changed since the last time he saw it. He said he was unaware of the recommendations from Staff D on 06/18/19, which stated, Avoid pillows or support surfaces that could increase moisture and maceration. Staff [NAME] confirmed the care plan had not been revised. In a telephone interview on 06/27/19 at 3:03 PM, Staff D stated that, My first encounter with (Resident # 22) was (MONTH) 2019. I see him every one to two weeks and we do virtual visits. I saw him (MONTH) 18th. I learned he had an open area on his left buttock and we were unable to get him into bed at that time and so nursing staff showed me images of his back side and the history I heard was (Resident #22) used a typical nursing home pillow causing a maceration and he got a skin tear or abrasion when he was being stood up. The picture I saw showed no slough just broke down [MEDICATION NAME] not full thickness tissue. The 06/25/19 picture shows the wound to be 1/2 the size (0.7) with scar tissue .It looks fibrous to me not slough that has a partial thickness look. If it is slough, it should be considered full thickness .maybe it did not happen because of friction or shear. Shear can be pressure. Staff D confirmed he did not actually visualize the left gluteal wound but looked at the picture taken from the facility. Staff D stated, He certainly should be and most residents should be on a low air loss mattress . He needs to have a better cushion. Slough would be a deeper injury. In an interview on 06/27/19 at 3:24 PM, Staff [NAME] had a picture he took on 06/25/19 at 8:20 AM, of Resident #22's left buttock wound. The picture showed white [MEDICATION NAME] in the wound bed and an area of healed scar tissue around the wound. Staff [NAME] said the left buttock wound had developed in the past week. The DNS stated, He drives his own care and is non-compliant. The DNS acknowledged that there had not been interventions specific to the resident's offloading and that there had been inconsistent assessment data completed related to the resident's existing ulcers and rejections of care, as the resident was not always compliant with interventions. Staff [NAME] was asked if Resident #22 ever had a pressure ulcer on the left buttock area before and he said, No he did not. The facility failed to address concerns with pressure ulcer prevention including lack of appropriate pressure reducing surfaces in bed and wheelchair, and inadequate care planning. This is a repeat deficiency from 03/30/18 and 10/15/18. Reference (WAC) 388-97-1060 (3) (b)

Based on interview and record review, the facility failed to ensure 4 of 4 residents (1, 2, 3 and 4) received care and treatment in accordance with professional standards of practice. The facility failed to follow physician orders [REDACTED]. This failed practice resulted in harm for Resident 1 who was hospitalized and placed other residents with similar health conditions at an increased risk of unmet health care. Findings include: Review of the facility's policy titled, Weight Policy, updated on 07/11/18, showed the following: - Residents with [MEDICAL CONDITIONS] would have daily weights unless the provider (physician) ordered otherwise; - As a standard of practice, a weight gain of 3 pounds (lbs) in one day met the criteria to notify the physician or Advanced Registered Nurse Practitioner (ARNP); and - Any weight with a 3 lbs weight minimum variance needed to be re-weighed that day. Weight changes would be reported to the physician, ARNP, the resident and the Registered Dietitian (RD) would follow up. RESIDENT 1 Resident 1 was admitted to the facility on [DATE] with an order to be weighed daily for [MEDICAL CONDITION] and to notify the physician if the resident had a weight gain of three pounds in one day. Review of the (MONTH) (YEAR) Medication Administration Record (MAR) showed two orders for weights. One order dated 11/03/18, with no stop date, was to weigh the resident upon admit and for two days. The resident's admit weight was 178 pounds. There was no other weights documented on this entry. The second order directed the Licensed Nurse (LN) to weigh the resident every day starting on 11/03/18. Review of the medical record showed no evidence the LN clarified the two conflicting entries. Further review of resident's weights from the MAR and the Weight and Vital Summary sheet showed the following weights: - On 11/05/18, the weight was 178.8 lbs and on 11/06/18 the weight was 184.8 lbs, a 6 lb weight gain in one day; - On 11/19/18, the weight was 186.4 lbs, there was no weight on 11/20/18 and on 11/21/18, and the weight was 250.8 lbs, a 64.4 lb weight gain in two days; - On 12/02/18, the weight was 198.6 lbs and on 12/03/18 the weight was 206.2 lbs, a 7.6 lb weight gain in one day; and - On 12/07/18, the weight was 211.6 lbs and on 12/08/18 the weight was 214.4 lbs. Additional review of the resident's heart rate from the MAR showed the resident had an abnormally rapid heart rate on the following dates: - On 11/15/18, the heart rate was 116; - On 11/16/18, the heart rate was 114; - On 11/18/18, the heart rate was 108; - On 11/19/18, the heart rate was 108; - On 11/20/18, the heart rate was 112; - On 11/21/18, the heart rate was 105; - On 11/24/18, the heart rate was 102; - On 12/04/18, the heart rate was 113; - On 12/06/18, the heart rate was 105; - On 12/07/18, the heart rate was 107. Review of the medical record, including the paper chart and the electronic medical record, showed no documented evidence the physician or ARNP was notified of the resident's weight gain or the resident's rapid heart rate. Review of a progress note dated 12/08/18 at 4:46 PM, showed the resident's son, with a medical background, arrived about 1:45 PM and felt the resident's overall health and condition had declined over the past two weeks. The son requested a stethoscope to assess the resident's heart and lung sounds. The son reported, to the facility, the resident had an irregular heart rate of 125 beats per minute which was confirmed by the facility's Registered Nurse (RN). The son further reported concerns regarding the resident's decline, overall appearance, worsening labored breathing, lower extremity swelling, increase weakness and fatigue. The son called 911 and initiated the resident to be transferred to the emergency department (ED). The facility notified the on call physician and no orders were given due to the ED transfer. Review of the Hospital's History and Physical dated 12/08/18, showed the resident had a history of [REDACTED]. The resident was scheduled to discharge home from the facility in about two days however his shortness of breath brought the resident into the ED. The resident was diagnosed to have [MEDICAL CONDITION] with a rapid ventricular response, a heart rate of 120 beats per minute, a swollen scrotum, and 3 + [MEDICAL CONDITION] (swelling) of both lower extremities. The resident was noted to be losing muscle mass secondary to poor nutrition and a 20 pounds of water weight overload. During an interview on 12/18/18 at 1:51 PM, Staff A, RN, stated a resident would be assessed when noted to have a decline in their health and any [MEDICAL CONDITION] would be reported to the physician. Staff A stated Of course this would be documented in the progress notes and the resident would be placed on alert charting. At 2:13 PM, Staff B, RN, stated when a resident concern was identified the resident would be assessed, the care plan updated, a progress note would be made and the physician orders [REDACTED]. At 3:45 PM, Staff E, RN, stated the physician would be notified by phone if a resident had a three pound weight gain. Staff E stated if the resident's weight was very high they would obtain a re-weigh. At 3:50 PM, Staff F, Physical Therapist, stated the resident had started to decline toward the end of his therapy. Staff F stated the resident was planned to go home but it became more challenging for him to breath and the nursing was notified. Staff F stated she had told the resident's spouse to talk with nursing if they felt he (the resident) needed to stay longer and encouraged her to talk to nursing to find out medically to see if they could get more care. Staff F stated she had spoken with nursing and nursing suggested revisiting the resident's POLST (Physician order [REDACTED]. Staff F continued to state, I am realizing he had [MEDICAL CONDITION] and went to the hospital. At 4:11 PM, the Interim Director of Nursing Services (IDNS) stated that her expectations would be for the physician orders [REDACTED]. In an interview on 12/19/18 at 12:44 PM, Resident 1 stated, I started getting weaker, I told them and they could see that. I was worse and worse. I saw two doctors but did not see a doctor about why I was getting weaker. I complained to the therapist and they would tell the nurse. I was getting worse and worse and no one was addressing the issue that was developing on their watch. My son realized something was not right and he drove up from Seattle. Then I found out I was in heart failure. They weighed me any old time, sometimes it was in the wheelchair or in the shower chair. They did it any old way and at any time of the day. I mentioned that I was gaining weight. I only say the raw number and I knew to subtract the 40 LBS (for the weight of the wheelchair). I mentioned it to them that I was gaining weight. What good is it to chart if you do not look at the curve it was like they were not looking at the whole picture and did not do anything with it. No one felt my legs or told me they were puffing up. I did not know what all the signs meant but the nurses and the doctors should have known. The one thing that I was focused on was that I could not eat anything. I attributed my weakness to not eating and not getting enough nutrition. It seemed contrary that I was gaining weight but not eating very well. If I realized there was something I needed to speak up but I did not recognize the associated symptoms. What happens when someone is in there and they do not have a son who is an RN? At 3:30 PM, the ARNP stated that her expectations were to be notified if a resident gained three pounds in a day. The ARNP stated she would assess for signs to prevent [MEDICAL CONDITION] and a resident's condition could change at any time. The ARNP stated the weight is a basic thing we can catch. It is a little guidance to know, you can tell the difference in the weight. The ARNP stated she did not recall being notified about Resident 1's weight gain. At 3:48 PM, Staff D, Licensed Practical Nurse (LPN), stated daily weights should be done in the morning using the same scale. At 4:06 PM, Staff A stated the resident's weight should be taken in the morning before breakfast. If there was a big difference in the weight, then they would have to weigh the resident again. Staff A stated the resident should be assessed, call the doctor, document the information in progress notes and place the resident on alert. At 4:15 PM, Staff C, LPN/Nurse Manager, stated she reviewed each resident before the physician or ARNP would see the resident. Staff C stated she would talk with the nurses about the residents as well. I don't remember his weight change. I do remember one weight that was different. Staff C stated the physician noted the resident's weakness on a visit and passed it on to therapy. I told therapy about it, I do not think I talked with the nurses. Therapy said they would look at him. I do not recall if they got back with me. We had moved his discharge back. Staff C stated she did not recall documenting to the resident's decline. At 4:37 PM, the IDNS stated she was not able to locate an SBAR or documentation the physician had been notified of Resident 1's weight gain. RESIDENT 2 Resident 2 was a long term resident of the facility who had daily weights for [MEDICAL CONDITION]. Review of the resident's weight summary showed the following weight variances: - On 12/04/18, the weight was 192 lbs and on 12/05/18 the weight was 197 lbs, a five lbs weight gain in one day and no evidence of a re-weigh; - On 12/07/18, the weight was 193 lbs and on 12/08/18 the weight was 197, a gain of four pounds in one day and no evidence of a re-weigh; - On 12/10/18, the weight was 194 lbs and on 12/11/18 the weight was 198, a gain of four pounds in one day and no evidence of a re-weigh; - On 12/17/18, the weight was 198 lbs and on 12/18/18 the weight was 201.5 lbs, a gain of 3 1/2 pounds in one day and no evidence of a re-weigh. Review of the medical record show no documentation the physician or ARNP was notified of the resident's weight gain. In an interview on 12/18/18 at 4:00 PM, the resident stated, I am weighed on the same scale but not at the same time of day. Last month before my last stay in the hospital I had A Fib. I gained 13 pounds in one week. I kept telling them my body was filling up with water. They just said we will keep checking you, when it got to 10 pounds I said come on guys . When I fill up with water, I feel it when I eat and I am not able to eat. I fill up in my abdomen and my left foot. RESIDENT 3 Resident 3 admitted to the facility on [DATE] with an order for [REDACTED]. Review of the resident's MAR for the month of October, (MONTH) and (MONTH) showed the following days with a three pound weight gain: - On 10/10/18, the weight was 142.2 lbs and on 10/11/18 the weight was 162.2 lbs, a weight gain of 20 lbs; - On 11/17/18, the weight was 147.6 lbs, no weight on 11/18/18 and on 11/19/18 the weight was 156.8 lbs, a weight gain of 9.2 pounds in two days; - On 11/25/18, the weight was 147.2 and on 11/26/18 the weight was 151.0, a weight gain of 3.8 lbs; and - On 12/13/18, the weight was 141 lbs, no weight on 12/14/18 and 12/15/18, and on 12/16/18 the weight was 146.4 lbs. A weight gain of 5.4 pounds in three days. Review of the medical record show no documentation the physician or ARNP were notified of the resident's weight gain or evidence the resident was re-weighed. RESIDENT 4 Resident 4 was admitted to the facility on [DATE]. The resident had an order for [REDACTED]. Review of the resident's October, (MONTH) and (MONTH) weight Summary showed the following days with a three pound weight gain: - On 10/08/18, the weight was 266.2 lbs and on 10/09/18 the weight was 273.0 lbs, a weight gain of 6.8 lbs; - On 11/16/18, the weight was 230.6 lbs and on 11/17/18 the weight was 251.0 lbs, a weight gain of 20.4 lbs; and - On 11/20/18, the weight was 257.4 lbs, no weight on 11/21/18 and on 11/22/18 the weight was 281.4 lbs, a weight gain of 24 lbs in two days. Review of the medical record show no documentation the physician or ARNP was notified of the resident's weight gain. The facility failed to recognize and notify the physician or ARNP of Resident 1's shortness of breath, swelling, weight gain, weakness, and overall decline causing Resident 1 harm resulting in a hospitalization and delay in his discharge home. Additionally, the facility failed to notify the physician or ARNP of Resident 2, 3 and 4's weight gain placing them at risk of unmet health care needs. Reference WAC: 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to ensure that residents did not develop pressure ulcers unless the resident's clinical condition demonstrated that they were unavoidable for two of three residents (1 and 2) reviewed for facility acquired pressure ulcers (PUs). This failure caused harm to Resident 1 who developed two stage III pressure ulcers on the sacrum and Resident 2 who developed an unstageable pressure ulcer to the heel. Findings include: The Resident Assessment Instrument (RAI) Manual defined the stage of a pressure ulcer (PU) as followed: · A stage III pressure injury (ulcer) was described a full thickness loss of the skin; and · An unstageable pressure injury (ulcer) was full thickness skin and tissue loss was obscured by slough (non-viable tissue) or eschar (dead or devitalized tissue that was hard or soft in texture). Record Review of a facility policy titled: Skin at Risk dated 3/18 showed that: · All residents received weekly skin assessments and any abnormalities would be addressed with the physician (MD)/nurse practitioner (NP) for orders/treatments; · skin sheets would be placed in the paper medical record upon completion; · Areas of skin breakdown would be documented in PCC (the facility electronic medical record) on the skin assessment tool; · All skin impairments would be monitored until resolved and measured weekly; · All skin impairments would be care planned and updated as needed; · MD/NP notified for treatment orders; and · The contracted facility wound consultants would be sent a referral form for assessment on the next visit. RESIDENT 1 Resident 1 re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had cognitive impairment, required two person extensive assistance for activities of daily living such as bed mobility and transfers, was considered high risk for PU development and did not admit with PUs. A review of Resident 1's care plan and care directive showed the care plan identified the resident required two person assist for bed mobility and repositioning and directed nursing assistants to report skin breakdown. The care plan did not include specific resident centered skin prevention interventions. A review of the weekly skin check slip documentation showed that on 09/20/18, the resident's skin was assessed by Staff F, Licensed Practical Nurse, and was found to be intact with no areas of breakdown. On 09/27/18 a skin check slip was in the resident's chart which was signed only by a Nursing Assistant (NA) and stated the resident had a red area and area around the catheter is red also. The skin check slip included pictures of a generic body front facing and rear facing which allowed staff to draw or indicate where skin problems were. The rear facing picture included a circle drawn in pen around the residents bottom and the front facing picture showed circles drawn in pen in each groin fold. The space for a licensed nurse's signature was blank. Review of the progress notes showed there was no corresponding documentation in the medical record identifying the Licensed Nurse (LN) assessed the resident's skin after the skin check slip was turned into the LN. There was no documentation the resident had any new skin issues. On 10/03/18 a skin check slip was in the medical record singed only by a NA (Staff G) and stated old sores on resident's bottom. The space for a LNs signature was left blank. The rear facing picture showed there was an S-shaped mark made in pen over the resident's buttocks area. Review of the progress notes did not include any corresponding progress note or an assessment completed of the resident's skin after the LN was made aware of the skin impairment. The resident transferred emergently out to the hospital on [DATE] where he was assessed to have admitted with two stage 3 pressure ulcers. One pressure ulcer was located on the middle sacrum measuring 1.1 centimeters (cm) x 0.5 cm x 0.3 cm and one on the right sacrum measuring 0.5 cm x 0.7 cm x 0.3 cm. The hospital also noted the known groin redness and catheter irritation. The resident was re-admitted to the facility on [DATE]. A review of the record showed the resident had not had an updated pain assessment done since returning from the hospital and and the care plan had not been updated to include the pressure ulcers. During an interview on 10/11/18 at 10:00 AM, Resident 1 stated he had sores on his bottom and when asked how long he had them he stated forever. Resident 1 was observed to be sitting forward in his chair, pushing up on the armrests moving back and forth in a squirming motion. He was asked if he was uncomfortable and he stated he had some discomfort related to both his catheter and his butt. He stated he did not recall what was being done as far as care but he said they were looking at it often and he believed there was a bandage on it. At 11:40 AM, Staff B, NA, stated she often cared for Resident 1. Staff B stated he needed a lot of help one or two people and was always cooperative with care. Staff B stated he had wounds on his bottom but did not know how long they had been there. At 1:00 PM, the Director of Nursing Services (DNS) stated she had not been made aware of any pressure ulcers for Resident 1 until he was at the hospital and read the hospital notes. The DNS stated a nurse had not signed off on Resident 1's skin assessments and that there was no follow up assessment of the areas identified on the skin sheets. I can't answer that, no assessment was done. During an interview on 10/15/18 at 9:15 AM, Staff E, Registered Nurse (RN), stated the NA filled out the skin check slips and put them on the desk. Staff E stated the nurse's were supposed to review them and then do an assessment of the resident's weight, check for dehydration, [MEDICAL CONDITION] and pedal pulses and then the LN would sign off on the skin check slip and put the slip in the resident's chart. Staff E stated she did not know how Resident 1's slip would end up in the chart with no signature and no progress note. Staff E stated that she could not recall how long Resident 1 had pressure ulcers on his bottom but she thought he had them when he moved over to his current room, which was on 09/18/18. At 9:30 AM, Staff G, stated the process was for the shower aides to fill out the skin check slip during the resident's shower. Staff G stated the NAs only filled out the top part of the form and then gave the slip to the LN. Staff G stated she either put the slip on the nurse's cart or handed it to the LN. Staff G confirmed she had filled out the skin slip for Resident 1 on 10/03/18 and there were red sores on the resident's bottom. Staff G stated she gave the skin slip to the LN on duty. At 11:15 AM, Staff F, Licensed Practical Nurse (LPN), confirmed the 09/20/18 skin check was done by her and that the resident had no skin breakdown at that time. Staff F stated she did recall the resident having some rash in the groin area, and had a skin irritation related to his catheter, but did not recall the exact time frame as he had moved rooms. Staff F did not recall him having any breakdown in his sacral or coccyx area. Staff F stated the nurse's had to sign off on the skin check slips and a nursing assistant would not file those in the chart themselves, that had to be a nurse. On 10/15/18 at 11:30 AM, Staff E, RN, was observed performing wound care to Resident 1. There were two wounds, one was mid-sacrum and was round approximately the size of a pea with an unobservable wound bed due to depth. The other was on the right sacrum and was moon shaped and approximately twice the size of the first with a small amount of slough (non-viable tissue). Staff E did not obtain measurements and stated the wound consultant team would be in the facility to see the resident tomorrow and would do an assessment. The facility failed to follow their established process for skin assessment and to provide a nursing assessment in accordance with accepted standards and practice, which resulted in a lack of identification of developing pressure ulcers for a period of up to two weeks for Resident 1. The identified skin issues were therefore not reported to a physician or NP, and no additional interventions put in place in response to what may have been preventable progression to full thickness stage III PUs. RESIDENT 2 Resident 2 admitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], showed the resident was alert and oriented and required extensive assistance of two staff for activities of daily living such as bed mobility and transfers. A review of a podiatrist note dated 09/25/18 showed pre-ulcer, pressure spot posterior left heel, the recommendations stated to apply an offloading boot to the left foot/left leg daily, both at night and during the day. Staff were to monitor the area daily for changes to the skin until healed. Record review showed the podiatry recommendations were not implemented. Record review showed the resident was emergently transferred to the hospital on [DATE] and upon admission was assessed to have on the left heel, an intact area of eschar (non-viable tissue obstructing the wound bed). The area was brownish and firm and measured 2 centimeters (cm) x 4.5 cm. The area was on the posterior surface of the heel and was consistent with an unstageable PU. The resident readmitted to the facility on [DATE]. During an interview on 10/11/18 at 1:00 PM, the Director of Nursing Services (DNS) stated that she had not been made aware of any pressure ulcers for Resident 2 until he was at the hospital and read the hospital notes. The DNS stated that a nurse had not completed further assessment of the heel ulcer I can't answer that, no assessment was done. Review of the wound consultants notes dated 07/31/18 and 08/14/18, directed staff to encourage the resident to repositioning every 2-3 hours, and to encourage offloading of the resident's heels and bony prominence. A review of the care plan and Treatment Administration Record (TAR) revealed an intervention in place to encourage the resident to turn side to side in bed and to document non- compliance. There were no interventions implemented in the care plan, care directive, or the TAR regarding recommendations to provide offloading for the resident's heels. During an interview on 10/11/18 at 11:40 AM Staff D, NA, stated the NAs referred to the care directive for how to care for residents. Staff D stated the care directive was in the computer and a paper copy was in every residents closet. At 12:00 PM, Resident 2 was up in her wheelchair and observed to have foam boots on her both of her lower legs. The resident stated that she had sores on her bottom that were getting better but that now she had an ulcer on her heel. The resident stated I had a stroke back in June, and that I used to be able to move my leg myself and now it just lays there and I don't feel it. The resident stated the staff helped her move in bed, to get comfortable and that staff used to put pillows under her legs but said they only did it at night and I guess we didn't realize we should be doing it in the day. The resident stated we didn't even know there was anything wrong with my heel until the podiatrist found it. At 1:00 PM, the DNS acknowledged that there had not been interventions specific to the resident's heel offloading and that there had been inaccurate assessment data completed related to the residents existing ulcers and rejections of care as the resident was not always compliant with interventions. The facility failed to implement interventions to ensure that Residents 1 and 2 did not develop PUs unless the resident's clinical conditions demonstrated that pressure ulcers were unavoidable. Reference (WAC) 388-97-1060 (3)(b)

Based on observation, interview, and record review the facility failed to identify, assess and implement interventions to prevent Resident 74 from having 3 separate acute, life threatening emergencies when staff provided food containing allergens that resulted in [MEDICATION NAME] on two occasions. Additionally, the resident experienced a choking event requiring emergency intervention. These failures placed residents at risk for adverse complications and death. It was also determined the facility failed to provide effective pain management for 1 of 1 (117) residents who experienced pain resulting in complaints of unrelieved pain and an emergent transfer to the hospital for effective pain relief. Findings include: [MEDICATION NAME] Resident 74 Resident 74 re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's medical record initiated on 04/20/16 indicated the resident was allergic to peanuts and tree nuts. The resident's allergy was noted on the physician's orders [REDACTED]. On 04/27/16 the tree nut allergy severity was coded as being severe. In review of a progress note dated 10/30/16 at 3:47 PM, Resident 74 went on an outing with activities in the morning and ate an ice cream treat with peanuts. The note went on to say the resident had a peanut allergy. The activity staff member was not aware of the resident's peanut allergy when she offered the resident the treat. On the same day at 2:15 PM, a nursing assistant (NAC) reported to the nurse that the resident was not feeling well. The resident reported she felt she was having an allergic reaction to peanuts. The resident appeared distressed and flushed, had labored breathing, so she was medicated with an as need dose of [MEDICATION NAME]. The physician ordered to send the resident to the emergency room for eval and treatment. The hospital emergency room record for 10/30/16 indicated the resident had an allergic reaction. The MD stated the patient's symptoms were completely resolved after receiving 3 intravenous medications to resolve the allergic reaction ([MEDICATION NAME], and [MEDICATION NAME]). [MEDICATION NAME] ([MEDICATION NAME] auto-injector) had been ordered for the resident for immediate administration as emergency supportive therapy on admission. The [MEDICATION NAME] auto-injector manufacturer information stated the [MEDICATION NAME] should be administered with caution to patients with hypertension , elderly individuals. Elderly patients may be at greater risk of developing adverse reactions. Patients with [MEDICAL CONDITION] may notice a temporary worsening of symptoms. The manufacturer warns that in conjunction with its use; seek immediate medical or hospital care. On 02/15/17 at 10:33 AM, the incident report was requested for the 10/30/16 [MEDICATION NAME] incident. The DNS stated she did not have an incident report for this incident and was unsure if she had even been notified of it. No additional information was provided. The record did not reflect that any plan or interventions had been put into place to prevent a reoccurance of peanut ingestion. Six weeks after the [MEDICATION NAME] incident a progress note dated 12/13/16 at 2:00 PM, was written by Staff J, Licensed Nurse (LN). She documented a that CNA reported that the resident had ingested a small amount of food containing peanuts. The resident had some facial redness so [MEDICATION NAME] had to be administered. Review of the incident report dated 12/13/16 stated upon investigation the cook had not used the tray card when preparing the tray. Staff A, Dietary Manager (DM) educated her staff to never prepare a tray without a card. She implemented a policy to that effect. There was no documentation the nursing staff who delivered the tray was educated on verifying diet orders and allergies [REDACTED].>In an interview on 02/13/17 at 1:31 PM, Staff A, DM, stated the diet card was missing and the cook served a tray without verifying the diet texture or allergies [REDACTED]. In an interview on 02/15/17 at 2:43 PM, the DNS stated that the admit nurse documents allergies [REDACTED]. allergies [REDACTED]. When asked how activity staff knows about allergies [REDACTED]. The DNS stated she would not expect nurses to develop a care plan for allergies [REDACTED]. The record showed that there had been no plan created or interventions put into place to prevent another [MEDICATION NAME] episode. During an interview and activity record review on 02/15/17 at 10:35 AM, the activity staff presented a list that they work from to identify residents with allergies [REDACTED]. The activity list included Resident 74 as having a peanut allergy. The activity staff could not provide a procedure on how they identify allergies [REDACTED]. The kitchen allergy report included 6 residents with food allergies [REDACTED]. In a joint interview on 02/16/17 at 8:21 AM, with Staff N and V, both NA's, they stated special instructions for swallow techniques and allergies [REDACTED]. In review of the facility's allergy identification there was no clear process in place to prevent the introduction of allergens to the residents. Choking Event Review of Resident 74's progress note dated 08/29/16 at 4:39 PM revealed At 1330, a nurse reported that they had to give pt. abd (abdominal) upward thrust during lunch, in the assisted dining room due to a choking episode, the nurse reported I heard a loud popping sound when giving her the [MEDICATION NAME]. Review of the incident report included a witness statement from Staff U while feeding the resident in the dining room, the resident was struggling to breathe and was attempting to cough to no avail. Once I noticed resident was not breathing I called Staff W, LN close by and she proceeded to administer the [MEDICATION NAME] maneuver. Staff W, LN documented on a witness statement, she was called into the dining room by Staff U, NA and observed resident 74 turning purple and blue and was not breathing. Staff W,LN stated she had performed the [MEDICATION NAME] maneuver which was successful. The resident continued to receive a regular textured diet. The resident's diet was not modified after the incident as a means to prevent further choking episodes and/or aspiration pneumonia prior to the speech therapist assessment. The resident was not assessed by the speech therapist until 4 days after the incident on 09/02/16. Review of the speech therapy evaluation dated 09/02/16, stated a CNA reported it (choking episode) was with rice dish and likely was precipitated by patient being too sleepy. The speech therapist completed an aspiration precaution sheet that directed staff to ensure the resident was sitting up, preferably in chair for all intake. Small bites and sips (1/2 teaspoon and go slowly), check for pocketing after meals, alternate liquids/solids, maintain alertness with eating or stop feeding. The care plan had not been updated to guide the staff on safe meal assistance techniques for this resident. The aspiration sheet was located at the bottom of the resident's closet and the resident dines out of her room. Pain Review of the facility pain policy, dated April 2016, revealed Shuksan Healthcare is committed to providing our elders with interventions designed to reduce pain, whether acute or chronic, to a non-sedating level that allows for comfortable participation in Activities of Daily Living. 1. All elders will be assessed for pain upon admission, quarterly, and as needed. Elders will be encouraged to give a pain history and communicate their personal goals for pain management. 2. Pain will be further defined as either acute or chronic, and Plan of Care developed. 3. Evaluation of interventions will be accomplished by the direct care LN (Licensed Nurse) and further interventions put in place as needed. 4. The DNS will review all Physicians' orders relating to pain management and forward those to the individual Care Managers for follow up as needed. 5. SHCC will recognize medications as well as other modalities will be considered during the course of working toward the elder's goals. Resident 117 Resident 117 was admitted to the facility in December 2016 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 02/01/17, revealed she had no cognitive impairment. Review of the admission MDS assessment, pain was coded as almost constantly on the 12/11/16 & 12/18/16 MDS, with a pain intensity of 7. Review of the resident's pain care plan developed on 12/05/16 with one revision occurring on 12/30/16. There was no documented change to the plan of care to guide staff on non-pharmacological interventions or when to give which pain reliever. Additionally, there was no direction to the staff on what relieved her pain or made it worse. Pain was not identified as acute or chronic. The pain assessment tool dated 12/05/16 listed the pain site abdomen- chronic almost constant throbbing pain, pain rated at an 8. What makes pain better? medication, rest, movement makes it worse. Worst possible pain was a 10. Pain affects her residents sleep, appetite, and mood. In review of the pain care area assessment dated [DATE], stated the resident reports almost constant level 6-7 pain . The resident reports none of her medications are particularly effective for relieving her pain. Cancer pain is just awful. I have tried everything and there isn't much that can be done for it. Diseases and conditions that may cause pain: cancer, other ulcers, musculoskeletal arthritis. Pain adversely affects mood, limits day to day activities . The above assessment was never transferred to the care plan so staff caring for the resident would be unaware of this assessment. In review of a progress note dated 12/12/16 at 9:18 AM, stated call out to doctor to discuss resident persistent nausea and unrelieved pain. Resident reports that abdominal pain is escalating and has a different quality than the pain she has been experiencing .Resident requests to be transferred to hospital for intravenous (IV) pain control. In review of the progress note dated 12/12/16 at 7:36 PM, stated nurse contacted residents daughter .the daughter advocated for her mother, reasserting the importance of round the clock pain management and would like her mother to be woken for pain assessment and medication. Resident has communicated this as well. This nurse added nursing order to assess pain every 4 hours and offer as needed [MEDICATION NAME] when indicated was implemented. Review of the physician's orders [REDACTED]. In an interview regarding pain on 02/02/17 at 10:47 AM, the resident stated I am not in very much pain right now. I am way better now but I was in severe pain when I came in. I have back pain occasionally as I broke my back twice . I have chronic pain. There was one night they didn't wake me up and I was in uncontrollable pain. I had to go to the hospital for help. My daughter and I were adamant about me being woke up and checked for pain when I admitted here. In an interview on 02/15/17 at 8:44 AM, the DNS indicated the nurses were directed to assess her for pain every four hours after she returned from the hospital on [DATE]. No additional information was provided. Failure to develop and implement a pain management care plan resulted in harm to the resident when she experienced almost constant pain which limited her activities, sleep and appetite. Resident 10 Resident 10 was admitted to the facility in November 2016 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED].>Daily weights related to [MEDICAL CONDITION] and to notify the physician if there was a weight gain of more than 3 pounds (lbs) in 1 day or more than 5 lbs in 1 week. Detailed lung assessment every day shift monitoring for signs and symptoms of [MEDICAL CONDITION] exacerbation and pneumonia. Contact provider with adventitious sounds every day shift for lung integrity. Review of the resident's documented weights from 12/21/16 through 01/12/17 revealed the resident had a 3 lb weight gain from 12/24/16 to 12/26/16 with no weight documented on 12/25/16. On 01/03/17 to 01/04/17 there was a 3 lb weight gain with no documentation the physician was informed. Review of the resident's documented detailed lung assessment revealed an order on the Medication Administration Record [REDACTED]. Review of the resident's progress notes from 12/21/16 through 01/12/17 revealed no detailed lung assessment documentation for 5 of 18 days prior to the resident being discharged to the hospital. The licensed practical nurse documented the lung assessments on 3 of the days. In an interview on 02/14/17 at 1:31 PM, Staff X, LN stated, If a resident's weight was outside the physician order [REDACTED]. Would assess the resident's lungs and document in the resident's progress notes. In an interview on 02/14/17 at 1:59 PM, the DNS stated she would expect the nursing staff to call the physician and document in the resident's progress notes any weight outside the ordered parameter and would expect the resident's lung assessment documented daily. At 2:35 PM, the DNS indicated she could not provide any documentation.

Based on the observations, interviews, record reviews and the noncompliance findings throughout the standard and extended survey on 02/07/17, 02/08/17, 02/09/17, 02/10/17, 02/13/17, 02/14/17, 02/15/17, 02/16/17, 02/17/17 and 02/21/17. The Governing Body of the facility failed to provide monitoring of the appointed administrator to ensure facility policies were established and implemented to meet minimum standards for the delivery of medical services in skilled nursing facilities as outlined by statute and regulation. These failures created and included actual harm to Resident 117 and an immediate jeopardy conditions for Resident 74. Finally, review of the facility's compliance history reveals a pattern of failing to establish and maintain regulatory compliance across time. Findings include: Throughout the survey, the following deficiencies were identified which included repeat deficiencies. Refer to: 1. F 156, CFR 483.10(g) (1), residents of resident rights This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. 2. F 167, CFR 483.10(g) (11) (i) (ii), survey reports readily accessible for the preceding 3 years. 3. F 241, CFR 483.10 (a)(1), dignity. This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. 4. F 242, CFR 483.10(f) (2)(3), treating residents with respect and dignity. 5. F 253, CFR 485.10(i) (2), maintenance and housekeeping. This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. 6. F 272, CFR 483.20(b) (1) (xv), resident assessments. This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. 7. The QA&A committee failed to identify deficiencies in regards to comprehensive care plans. Refer to F 279, CFR 483.21 (b)(1)(i) 8. F 282, CFR 483.20 (b)(3)(ii), qualified persons This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. 9. F 309, CFR 483.24 and 483.25 (k), necessary care and services to attain or maintain their highest practicable level of physical, mental and psychosocial well-being. This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. Immediate Jeopardy 10. F 315, CFR 483.25(e)(1), urinary function. 11. F 318, CFR 483.25(c) (2), range of motion function. 12. F-323 CFR 483.25 (d) (1), safe security hazardous liquids. This a repeat deficiency from the annual QIS survey conducted on 04/04/16. 13. F-329 CFR 483.45 (d) (6), [MEDICAL CONDITION] medications. This a repeat deficiency from the annual QIS survey conducted on 02/02/15 and 04/04/16. 14. F-332 CFR 483.45 (f) (1), physician and per manufacturer recommendations. This a repeat deficiency from the annual QIS survey conducted on 04/04/16. 15. F-334 CFR 483.80 (d) (1) (i) (iv) (A) (2) (i) (iv), educate and document the risk and benefits of the influenza the pneumococcal vaccines for the residents. 16. F-356 CFR 483.35 (g)(iii)(A)(B)(C), posted staffing. This a repeat deficiency from the annual QIS survey conducted on 04/04/16. 17. F-371 CFR 483.60(i) (2), storing, preparing, distributing and serving food under safe and sanitary conditions This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. 18. F-425 CFR 483.45(a), following physician orders, and ensuring routine medication was available and/or administered as ordered. 19. F-441 CFR 483.80 (2) (iv)(e), infection control practices for isolation precautions. This a repeat deficiency from the annual QIS survey conducted on 04/04/16. 20. F-490 CFR 483.70, administration ensuring a system is in place to safeguard residents who had food allergies [REDACTED].>19. F-497 CFR 483.35(d) (7), completion of the required performance reviews for nursing assistants (NA) at least once every 12 months from the NA's date of hire 20. F-498 CFR 483.35(c), required 12 hours of in-service and/or the inclusion of mandatory abuse and dementia training for the facility's nursing assistants. 21. F-514 CFR 483.70(i) (1) (i), resident records were complete and accurate. This a repeat deficiency from the annual QIS survey conducted on 04/04/16.

Based on interview and record review, the facility failed to identify deficiencies, and implement appropriate preventive corrective actions in the Quality Assessment and Assurance Program (QA&A). The facility failed to recognize care and services that resulted in the severity of immediate jeopardy, resident harm, and substandard care, with a patterned scope. Findings include: Throughout the survey, the following deficiencies were identified: 1. The QA&A committee failed to identify deficiencies in regards to informing residents of resident rights. Refer to F 156, CFR 483.10(g) (1) This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. 2. The QA&A committee failed to identify deficiencies in regards to the residents rights to survey reports readily accessible for the preceding 3 years. Refer to F 167, CFR 483.10(g) (11) (i) (ii) 3. The QA&A committee failed to identify deficiencies in regards to dignity. Refer to F 241, CFR 483.10 (a)(1) This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. 4. The QA&A committee failed to identify deficiencies in regards to treating residents with respect and dignity. Refer to F 242, CFR 483.10(f) (2)(3) 5. The QA&A committee failed to identify deficiencies in regards to maintenance and housekeeping. Refer to F 253, CFR 485.10(i) (2) This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. 6. The QA&A committee failed to identify deficiencies in regards to resident assessments. Refer to F 272, CFR 483.20(b) (1) (xv) This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. 7. The QA&A committee failed to identify deficiencies in regards to comprehensive care plans. Refer to F 279, CFR 483.21 (b)(1)(i) 8. The QA&A committee failed to identify deficiencies related to qualified persons Refer to F 282, CFR 483.20 (b)(3)(ii) This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. 9. The QA&A committee failed to identify deficiencies in regards to residents receiving the necessary care and services to attain or maintain their highest practicable level of physical, mental and psychosocial well-being. Refer to F 309, CFR 483.24 and 483.25 (k) This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. 10. The QA&A committee failed to identify deficiencies in regards to residents decline in urinary function. Refer to F 315, CFR 483.25(e)(1) 11. The QA&A committee failed to identify deficiencies in regards to receiving necessary care and services to assist in maintaining the residents' current level of range of motion function. Refer to F 318, CFR 483.25(c) (2) 12. The QA&A committee failed to identify deficiencies in regards to safe security hazardous liquids. Refer to F-323 CFR 483.25 (d) (1) This a repeat deficiency from the annual QIS survey conducted on 04/04/16. 13. The QA&A committee failed to identify deficiencies in regards to consistently assessing, monitoring and/or evaluating the use of [MEDICAL CONDITION] medications. Refer to F-329 CFR 483.45 (d) (6) This a repeat deficiency from the annual QIS survey conducted on 02/02/15 and 04/04/16. 14. The QA&A committee failed to identify deficiencies in regards to ensure residents received medications as ordered by the physician and per manufacturer recommendations. Refer to F-332 CFR 483.45 (f) (1) This a repeat deficiency from the annual QIS survey conducted on 04/04/16. 15. The QA&A committee failed to identify deficiencies in regards to educate and document the risk and benefits of the influenza the pneumococcal vaccines for the residents. Refer to F-334 CFR 483.80 (d) (1) (i) (iv) (A) (2) (i) (iv) 16. The QA&A committee failed to identify deficiencies in regards to provide accurate daily posted staffing to ensure information was available to residents and the public. Refer to F-356 CFR 483.35 (g)(iii)(A)(B)(C) This a repeat deficiency from the annual QIS survey conducted on 04/04/16. 17. The QA&A committee failed to identify deficiencies in regards to storing, preparing, distributing and serving food under safe and sanitary conditions in the facility kitchen and the unit nourishment refrigerator/freezer units. Refer to F-371 CFR 483.60(i) (2) This is a repeat deficiency from the annual QIS survey conducted on 04/04/16. 18. The QA&A committee failed to identify deficiencies in regards to following physician orders, and ensuring routine medication was available and/or administered as ordered. Refer to F-425 CFR 483.45(a) 19. The QA&A committee failed to identify deficiencies in regards to ensure accepted standards of infection control practices for isolation precautions. Additionally, failed to adequately ensure the proper hand hygiene and glove use when handling soiled linens. Refer to F-441 CFR 483.80 (2) (iv)(e) This a repeat deficiency from the annual QIS survey conducted on 04/04/16. 20. The QA&A committee failed to identify deficiencies in regards to administration ensuring a system is in place to safeguard residents who had food allergies [REDACTED].>Refer to F-490 CFR 483.70 19. The QA&A committee failed to identify deficiencies in regards to ensuring the completion of the required performance reviews for nursing assistants (NA) at least once every 12 months from the NA's date of hire including in-service education for areas of weakness identified in performance reviews, special resident needs and needs of residents with cognitive impairments. Refer to F-497 CFR 483.35(d) (7) 20. The QA&A committee failed to identify deficiencies in regards to ensure the completion of the required 12 hours of in-service and/or the inclusion of mandatory abuse and dementia training for the facility's nursing assistants. Refer to F-498 CFR 483.35(c) 21. The QA&A committee failed to identify deficiencies in regards to ensure resident records were complete and accurate. Refer to F-514 CFR 483.70(i) (1) (i) This a repeat deficiency from the annual QIS survey conducted on 04/04/16. In an interview on 02/16/17 at 8:35 AM, the Administrator stated the QA&A committee meets on a monthly basis and the committee determined issues to address through resident council concerns, quality measures, resident concerns, new regulations and existing regulations. The Administrator was unable to verbalize why repeat deficiences were reoccuring.

Based on interview and record review, the facility failed to follow physician orders, and ensure a routine medication was available and/or administered as ordered, for 1 of 1 residents (117), reviewed for medication administration. This failure resulted in delayed chemotherapy treatment, infection with hospitalization and resulted in psychosocial harm for resident 117. Findings include: Neupogen is a medication to stimulate [DIAGNOSES REDACTED]s. [DIAGNOSES REDACTED]s are key components in the system of defense against infection. [DIAGNOSES REDACTED] (abnormally low levels of [DIAGNOSES REDACTED]s) is the most serious potential side effect of chemotherapy. Once [DIAGNOSES REDACTED] occurs, chemotherapy is often delayed and or a reduction in the regular dose of chemotherapy is given to avoid adverse health effects. This prevents full cancer treatment as scheduled. Resident 117 was admitted [DATE] with a [DIAGNOSES REDACTED]. Neupogen /Granix was ordered by a physician to be administered to the resident weekly on 12/22/16. In an interview on 02/09/17 at 1:28 PM, the pharmacy manager stated he first received the Neupogen order on 12/23/16 from physician's office. In an interview on 02/10/17 at 11:23 AM, the Director of Nursing (DNS) stated they did not receive the Neupogen prescription until 12/28/16 but the prescription was dated 12/22/16. In review of a progress note dated 12/28/16 at 3:50 PM, Staff I, LN clarified the Neupogen order with the cancer care center. The only restriction was not to administer Neupogen on chemotherapy days. The facility first administered the Neupogen on 12/29/16, 7 days after it was ordered. Neupogen was again scheduled to be given on 01/05/17 but the facility did not administer it. The nurse noted the medication was not received from the pharmacy. This day the resident had an achiness, elevated fever, chills and felt like she caught a cold and had a temperature of 100.9 There was no documentation the physician or pharmacy was notified of the missed Neupogen until 01/06/17. On the same day Thursday, 1/5/17, there was a note that indicated the resident was to receive the Neupogen every Thurday but not on Chemo day and Medication not available. In a progress note on 01/06/17 at 9:22 AM, Staff T, LN called the cancer center and was notified them that the resident was not receiving chemotherapy this week, but the resident still needed to be given Neupogen. Staff T documented she called the pharmacy to order it. Additionally, the resident was diagnosed with [REDACTED]. On 01/07/17 at 1:53 PM, the resident was sent to the Emergency Department (ED). The resident reported that she had a fever for the past 3 days and now had a fever of 101.8 and diagnosed with [REDACTED]. Her absolute [DIAGNOSES REDACTED] count (ANC) was critical at 0.0. The normal range for the ANC is 1.5 to 8.0. The resident was evaluated and treated and returned to the facility and instructed to continue with antibiotics. On 01/09/17 Resident 117 returned to the hospital and was admitted for ongoing fever and blood culture positive for gram negative bacilli. The history and physical indicated She was evaluated one day ago here in the ED She is still having fevers and feels worse today she returned to the ED ongoing fever and blood culture is positive .She is immunocompromised and is now admitted for inpatient management. Her [DIAGNOSES REDACTED] count (ANC) was very low at 0.5. The resident was discharged from the hospital and returned to the facility on [DATE]. In review of a progress note dated Tuesday, 01/24/17 at 7:10 PM, stated Neupogen held per resident request related to chemo is scheduled for Friday 01/27/17. The resident denied that she said this, this and there was no documentation as to why the medication was not offered at a different time since the only restriction was not to give on Chemo days. There was also not documentation of Patient education to this. There was no documentation that the physician or Cancer Care Center was not notified of this. In an Cancer Care Center progress note dated 01/27/17 stated ANC 0.3 chemo held. In an cancer center note dated 01/30/17 stated physician wanted to know if patient was on Granix injection as chemo was held Friday due to ANC 0.3. Called patient and daughter as patient is at Shuksan nursing home and she is not receiving Granix . On 01/30/17, the physician faxed the facility Please start Granix 300 microgram (mcg) subcutaneous injection once a week to keep white blood count (WBC) up for weekly chemotherapy. Facility Staff I, LN noted the order. Review of the resident's Medication Administration Record [REDACTED]. There was no documentation the physician or pharmacy was notified of this. In review of a Cancer Care Center progress note on 02/02/17 stated patient here for Carbotaxol (chemotherapy). Patient states still not getting injections at Shuksan. The resident's last dose of Neupogen was administered on 01/16/17 at 4:38 PM at the facility. ANC 0.2 (critical lab) and chemo held - due back for another injection on Tuesday 02/07/17 and chemo on 02/10/17. In review of a Cancer Care Center note dated 02/03/17 at 1:51 PM, revealed resident needs to get injections here, extended care facility (ECF) cannot provide documentation of consistent Granix administration, hence [DIAGNOSES REDACTED]. In an interview on 02/09/17 at 9:11 AM, Resident 117 stated I just sit here and worry. Is my cancer spreading? My hair is already growing back because I have missed chemo. Is my tumor growing too? I'm worried She adamantly denied refusing the Neupogen. She stated I never once refused it. I would never refuse it except on chemo day and the 24th was a Tuesday and my chemo was Friday. In a phone interview on 02/09/17 at 12:34 PM, the Cancer Care Center nurse stated She missed treatments (chemo) because of her [DIAGNOSES REDACTED]. Her counts were so low she couldn't get her treatment as planned. I know we were suspicious she was not receiving her Neupogen so we called the ECF (Shuksan) and they were unable to provide documentation otherwise. Her blood counts reflected she did not get the injections. The Cancer Care Center has arranged to administer the medication there to avoid further missed doses. In an interview on 02/10/17 at 8:44 AM, the Resident's daughter stated My mom was supposed to get a shot weekly and my aunt personally handed the prescription to the nurse at Shuksan on December 22nd. Mom missed chemo because she didn't get her shots. The facility had various stories about this. I heard it was because they cost a lot of money. In an interview on 02/10/17 at 11:25 AM, the DNS provided a timeline of the missed Neupogen. She stated she was unable to provide additional documentation as to why the resident had missed the doses of the medication. She stated she had no formal policy for pharmacy and stated it was standard of practice. The facility did not follow the physician's orders [REDACTED]. Without the medication, the resident had complications of low WBCs and infections which caused the resident to become anxious and worried that her health would decline.

Based on interview, and record review, the facility's administration failed to ensure a system to safeguard residents who had food allergies [REDACTED]. These failed practices resulted in harm for Resident 74 as referenced in F 309. Findings include: Refer to 42CFR 483.25 - F309 Quality of Care The administration failed to ensure the facility staff provided resident care in an acceptable and safe manner for 1 of 8 residents (74) reviewed for allergies [REDACTED]. Refer to 42CFR 483.45 (a)(b)(1) Pharmaceutical Services The administration failed to ensure that medications were being delivered and administered per physician orders. The failed practice resulted in actual physical and psychological harm for Resident 117. Refer to 42CFR 483.75 (g)(l)(i) - (iii)(2)(i)(ii)(h)(i) - F 520 QAA committee The administration failed to ensure that the QAA committee maintained a quality assurance committee that corrected past non-compliance and prevent further episodes on non-compliance.

Based on observation, interview and record review, the facility failed to ensure a resident driven acceptable pain management plan for 2 of 6 sample residents (71,131) reviewed for pain management. The failure to develop and implement a pain care plan and to consult with the resident's physician when her pain severity levels increased resulted in harm to Resident 71 as evidenced by her complaints of unrelieved pain, decreased functional status, and diminished quality of life. Findings include: Review of the facility pain management protocol, dated March 2012, revealed Shuksan Healthcare (SHCC) is committed to providing our elders with interventions designed to reduce pain, whether acute or chronic, to a non-sedating level that allows for comfortable participation in Activities of Daily Living. 2. Pain will be further defined as either acute or chronic, and Plan of Care developed. 3. Evaluation of interventions will be accomplished by the direct care LN (Licensed Nurse) and further interventions put in place as needed. 4. Shuksan Healthcare Center will recognize medications as well as other modalities will be considered during the course of working toward the elder's goals. RESIDENT 71 Resident 71 was admitted to the facility in September 2015 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 12/09/15, revealed she had no cognitive impairment. Review of the admission MDS assessment 09/08/15 indicated no pain was present. Pain was coded as occurring occasionally on the 12/09/15 MDS, with a pain intensity of 3. Pain was coded as occurring frequently on the 03/10/16 MDS, with a pain intensity of 7. There were declines in the Activities of Daily Living (ADLs) functional status areas of bed mobility, transfers and toileting from the 12/09/15 MDS to the 3/10/16 MDS when the resident changed from requiring only limited assistance to requiring extensive assistance. During record review and interview on 03/31/16 at 3:12 PM, with the Director of Nursing. Resident 71 ' s record showed no evidence that the physician was notified of Resident 71 ' s increase in pain or the decline in her ADL functional abilities due to the pain. There was no documented change to the plan of care to guide staff on the increased pain or decline in ADLs. Review of Resident 71's clinical record revealed no pain care plan had been developed as of 04/01/16. In observations on 03/29/16 at 8:32 AM, 9:15 AM, 10:00 AM, 11:23 AM and 12:30 PM, Resident 71 was observed sitting in her recliner with her eyes closed and moaning. On 3/29/16 the narcotic ledger revealed on that day, the resident received [MEDICATION NAME] (narcotic pain medication) at 5:30 AM. At 6:15 AM she fell in her room with complaints of pain all over. Resident 71 did not receive additional [MEDICATION NAME] until 1:00 PM this day. [MEDICATION NAME] orders directed the licensed nurses to give [MEDICATION NAME] 5 MG (milligrams) to 10 MG every 4 hours as needed for pain. In an interview at 1:11 PM, Resident 71 stated I have had chronic arthritis for years and years. The pain never goes away. In an interview on 03/30/16 at 8:50 AM, Staff R, a Licensed Nurse (LN), stated She moaned and groaned her way through therapy (restorative) this morning. He (the Restorative Aide) even checked back to see how she was doing now. Record review showed that she that Resident 71 was given 10 mg of [MEDICATION NAME] for a pain level of 7/10 prior to Restorative therapy. The follow up assessment (time unknown) indicated, the medication was effective but does not indicate what effective meant to the resident or if it was acceptable. In an interview at 1:34 PM, the resident stated I have pain in my left shoulder always; it aches and aches and aches. In an observation on 03/30/16 at 1:44 PM, Staff D, a Nurse Aide - Certified, assisted the resident from her recliner to the bedside commode and back to the recliner. The resident's jaw was clenched and she moaned during ambulation, transferring and while sitting and standing. In an interview on 04/01/16 at 8:17 AM, the resident was asked about her pain, she stated I ache here (pointing to left shoulder/neck region), Can you go any higher than 10? The surveyor alerted facility Staff F, Licensed Nurse, about the resident's complaint of 10/10 pain. Staff F administered [MEDICATION NAME] 10 MG at 8:30 AM. At 10:18 AM she stated My pain is much better, it wasn't this morning. Review of the Admission History and Physical, dated 08/31/15, revealed the resident had low back pain, arthralgia's (joint pain), back pain, joint stiffness, right leg pain and myalgia's (muscle pain), chronic pain, trigger finger, seems to be in moderate pain, tired-appearing, and pain in neck, shoulders, hips, and back. Review of a left shoulder x-ray report, dated 11/28/15, revealed severe [MEDICAL CONDITION] joint disease and was suggestive of a rotator cuff tear. Review of the Pain Assessment Flow Sheets from 12/21/15 - March 2016 revealed that Resident 71 had 70 resident reports of severe pain (8-10 on a scale of 0 (no pain) - 10 (worst pain you can imagine). Failure to thoroughly assess, develop, and implement a pain management care plan and the failure to notify the physician of the resident's increased pain severity on/around December 2015 resulted in harm to the resident when her ADL functional abilities declined and she experienced almost daily chronic pain. RESIDENT 131 Resident 131 was admitted to the facility in March 2016 with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. In an observation and interview on 03/29/16 at 10:32 AM, Resident 131 had facial grimacing, frowning, and was restless. She stated they should have given me my Tylenol, otherwise I am in so much pain. At 10:34 AM, Staff H, NAC, was observed to respond to the resident's call light and stated she would let the nurse know that the resident was requesting her Tylenol. Staff H instructed the resident to call again if the nurse does not come in the next 5 minutes. At 10:36 AM, Staff H returned to the resident's room and stated the nurse was in the middle of something but when she was available she would let her know of the pain. In an observation and interview on 03/30/16 at 1:54 PM, Resident 131's husband was with her. He stated he had asked 2 different staff members for help for his wife about 10 minutes ago. He stepped outside the room in an attempt to get help for his wife. The resident began calling out please, please as staff walked by her room. At 2:00 PM, the resident's husband stated he had asked for a hot pad for his wife 15 minutes ago and added he did not know what to do to get help. At 2:06 PM, he stated loudly, we have been waiting 24 minutes now. I have talked to 3 different people. He said to his wife I am sorry. I am doing the best I can to help. On 03/31/16 at 8:02 AM, Resident 131 stated she was in pain, and had suffered something terrible last night. The therapists prepare the hot pad now and they are not here at night. She said she had requested something for pain from the little girl that helped me get dressed earlier but I'm still waiting. At 8:09 AM Staff J, NAC came into the resident's room and turned off the call light. The resident asked Staff J, NAC to let the nurse know she needed her Tylenol. At 8:32 AM the resident frowned and put her head in her hands. At 8:33 AM Staff K, Licensed Nurse (LN) entered and asked the resident if she wanted Tylenol. In an interview on 03/31/16 at 3:10 PM, Staff S, LN stated the following: that the goal is to keep the residents' comfortable with overall quality of life. If the pain management regimen was ineffective the resident's family would be contacted to see if they might be aware of what works best for the resident. It was important to try non-pharmacological interventions and keep the physician informed of the resident's pain. It was important to determine if an intervention for pain was effective within 1 hour. Review of the March Medication Administration Record [REDACTED]. There was no documentation of the physician or family contact regarding the ongoing unrelieved pain issues for Resident 131. Refer to CFR 483.25(h), F-323 for failure to ensure safe use of a hot pad.

Based on observation, interview and record review, the facility failed to prevent an avoidable injury during care sustained by 1 of 4 sampled residents, Resident 4. The resident sustained [REDACTED]. She required a new order for narcotic pain medication to manage pain caused by the injury. Findings include: Resident 4 had multiple health conditions including arthritis and depression. According to the MDS (Minimum Data Set) assessment dated [DATE], the resident required the help of 2+ staff persons for mobility in bed, had impairment of both legs, had no pain and did not use pain medication. On 10/22/14 at 11:20 a.m., the resident was observed lying in bed. The left foot was bare, swollen and bruised, a pillow under it. Staff C, a nursing assistant, was observed changing the resident's incontinence brief alone. He turned the resident from side to side in the bed. Staff C stated the resident was "maximum assist" with turns, according to the care guide, and that this meant one staff person, unless the care guide said "2 persons." He stated he would obtain another staff person to assist him in moving the resident up in the bed after he was finished turning her. A facility incident report described on 10/12/14 the resident was being turned in bed by Staff D, and went over the opposite bed railing, her lower body falling out of bed. The resident sustained [REDACTED]. The care plan in place at the time included the use of the bed rails "per (resident's) preference for safety during care provision." Review of the medication administration record from October 1 to October 15, 2014 revealed the resident had no documented pain between October 1 and October 11. On October 12, 13, 14, and 15, the resident had left foot pain. A new order for narcotic pain medication for "severe pain" was implemented October 12, which the resident required at least once each day subsequently during the period reviewed. During an interview on 10/22/14 beginning at 12:15 p.m., Staff A said that the foot injury occurred when the resident's legs went down on the floor and the "foot bent under" when it made contact with the floor. When asked about the resident's bed mobility, Staff A said the resident needed two staff because she could be "overzealous" and pull herself over the edge of the bed. Staff A also stated the nursing assistant care directives since the injury included physical therapy instructions that staff were to stabilize the leg during turns in bed, necessitating at least two staff. The medical record included an order dated 10/16/14 for an ice pack to be applied to the resident's left foot as needed to treat the swelling. Review of the nursing treatment record (TAR) with Staffs A and B revealed no order for an ice pack. Staff A said the facility was in the process of getting orders computerized, and this order had not made it onto the TAR.

Based on observation, interview and record review it was determined that the facility failed to recognize the signs of burn-out and failed to act on the verbalization of "burn-out" by the family member of 1 of 6 sample residents (1) who the facility was using as an intervention for the resident's problem behaviors. This failure resulted in the physical abuse of Resident 1 by the family member. Findings include: Resident 1 was admitted to the facility 12/3/13 with [DIAGNOSES REDACTED]. His Minimum Data Set (MDS) assessment, dated 6/6/13, indicated the resident was able to ambulate without assistance. The assessment also indicated he had behaviors that were directed towards others. The resident's behaviors significantly interfered with the resident's care; the resident intruded on the privacy of others, significantly disrupted the living environment and his behaviors had worsened since his last assessment. Resident 1's current care plan for Psychosocial Well-Being was developed initially on 1/2/13 with a revision in 6/11/13 and goal dates set for 9/13/13. An exit seeking care plan was developed on 7/8/13 when the resident began wandering in the facility and exit seeking. There were 4 interventions listed on the 7/8/13 plan: Bring the resident back in the building, 1:1 supervision, redirect the resident with food/activity and call the resident's family member. On 7/17/13, the family member took Resident 1 to a medical appointment. Following the appointment the resident refused to get into the car to return to the facility. The mental health professional (MHP) stated a colleague informed him there was a patient in the parking lot that was involved in an altercation. The MHP went to the parking lot to see if he could help. The MHP stated that the family member was "in hysterics." He wanted to defuse the situation so he called the facility, told them the resident was having a problem and asked if they could intervene by sending a van to pick up the resident. He was told "No" by the Social Worker. The MHP stated the facility Social Worker did not ask any further questions about the situation and he did not offer details.The resident became increasingly agitated and the police were called for assistance. The police got the resident into the family member's car and he was returned to the facility. When the family member returned with the resident she told the Social Worker that she no longer wanted to be the Power of Attorney (POA). The SW stated the family member stated she was "burned- out." The SW indicated the family member had a bad day with the resident. The SW gave the family member papers to fill out relinquishing her POA. The SW did not assess the situation and did not inform nursing staff of the family member's statement. LN 1 documented that from the beginning of the shift the resident had been exit seeking. Documentation went on to say the LN called the family member and the family member stated "that she can't come in, she's too burned out." The resident continued to be agitated and the LN called the family member again and informed the family member that "we can't keep watching him and she needed to come in." Resident 1's family member had now told 2 facility staff that she was "burned-out" they continued to use her presence as a behavioral intervention for Resident 1. The family member came to the facility at LN 1's request. A Nursing Assistant (NA) documented that she walked past the resident's room and found the resident with blood on arm, the family member was crying and saying "He hit me and I hit him back. " The NA documented that she "left the room, shutting the door behind me and alerted" the LN. LN 1 documented that she was called into the resident's room by the NA because there was an altercation. When she entered the resident's room, the resident was "extremely agitated," appeared to be "still violent" and he was bleeding from his nose and left forearm. The family member was crying, was very upset and was bleeding from her eyebrow. The LN documented that she left the room to call local law enforcement. LN 2 documented that the NA told her that LN 1 needed her. When she arrived at the room the door was closed, when she entered the room the resident was clinging to the curtains. The family member was standing behind the resident when the resident began to sit on the bed the family member grabbed his arm and told him no. The resident began swinging his elbows to get her hands off him. The family member balled up her fist and began to swing at the resident. The LN blocked the family member's swing with her arm. The family member wrote a statement for the facility incident investigation. She stated that after the resident had become physically assaultive she grabbed him by his belt and physically restrained him from leaving the room. The family member also documented that she told LN1 that she needed to leave the area or the resident was going to "kill me or I was going to kill him." Both the NA and LN 1 failed to protect Resident 1 from further physical abuse when they left the family member alone in the room with the resident, knowing that she had hit him. Review of Resident 1's medical record revealed the resident's family member had exhibited signs of burn-out prior to 7/17/13 including: - Returning on multiple occasions from appointments and/or outings with the resident and immediately requesting that staff give him "as needed" [MEDICATION NAME] (an antianxiety/sedative medication). - Documentation that the resident either became agitiated upon seeing or talking to the family member. - Documentation that the family member was called 3 times in one shift to assist the facility with the resident and the family member "hung up phone in apparent frustation one time." - Documentation that the resident and family were noted to have raised voices in the resident's room. The resident left the room and went to the courtyard and "appeared agitated." The family member reported to staff "that she may not be helping." There was no evidence staff recognized these situations as precursers to abuse, attempted to determine what had occurred and if any other interventions would have been appropriate. The facility continued to rely on Resident 1's family member to intervene when the resident displayed problem behaviors culminating in the physical abuse on 7/17/13.

Based on observation, interview and record review, the facility failed to provide medically related social services to attain the highest level of physical, mental and psycho-social well-being for 2 of 4 residents (#1 & 2) investigated for social service support. The failure to aggressively identify the need for medically-related social services related to behaviors, and pursue the provision of these services placed the residents at risk for worsening behaviors and increased the likelihood they would display behaviors that could cause injury. Failure to address the reasons for Resident 1's behaviors led to escalating assaultive behaviors and Resident 2 leaving the building and obtaining injuries. These patterned failures resulted in harm for Resident 1 & 2 and caused residents to be at risk for the high likelihood of behaviors needs not being addressed. Findings Include Resident 1 was admitted to the facility 12/3/13 with [DIAGNOSES REDACTED]. His Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was able to ambulate without assistance. The assessment also indicated he had behaviors that were directed towards others. The resident's behaviors significantly interfered with the resident's care; the resident intruded on the privacy of others, significantly disrupted the living environment and his behaviors had worsened since his last assessment. Staff documentation revealed that Resident 1 had escalating behaviors between the months of April 2013 to July of 2013. Examples included: The resident was wandering, cussing at staff, becoming "extremely agitated", having angry violent outbursts including trying to put fist through a wall, displaying finger gestures, throwing things at staff, banging on walls, using profanities and increased exit seeking. A care plan was developed on 1/2/13 that was not specific to each behavior. The interventions were bring animals into his room, call the daughter, encourage the resident to attend an activity of interest. (According to the DNS, daughter and the Administrator the resident was not interested in the facility's activity program), offer the resident to take a walk and use medications as ordered. Interventions on the MAR included interaction with the facility dog or distraction with activities. If those interventions failed then call the daughter. One LN documented that they called the daughter to see if "she could talk some sense into the resident", another time, the "daughter showed up and took over the situation" and the "daughter was called to sit with him" On multiple occasions the daughter instructed staff to give the resident "as needed" medications including Ativan (an Anti-anxiety medication) In an interview with the daughter on 09/05/13, she stated that she had noticed a gradual change in the resident's mood and behaviors in about April of 2013. He became more physical where he was never physical prior. On 7/17/13 the daughter took the resident to an appointment. The resident became agitated at the appointment and took a swing at her. A Mental Health Worker from the clinic came out to the parking lot and attempted to get the facility to come and help the daughter. The facility declined to do so the local law enforcement was called. They got the resident into the car and she got him back to the facility. Upon entering the facility she spoke with the Social Worker (SW) who told her that she heard that the resident was having a problem at his appointment. She informed the SW that she did not want to be the Power of Attorney (POA) anymore, was burnt out and did not want to come back to the facility. Facility staff called her regardless of her statements, without attempting any interventions including medications, and when the daughter came to the facility there was an altercation. There was no documentation that the facility assessed the behaviors, revised the care plan, and was actively involved in assisting staff in understanding and dealing with the resident's behaviors. There was no evidence that the SW provided the staff with any type of support. There was only documentation on admission, during the MDS review and during a care conference dated 6/19/13 where the resident's behaviors were discussed. There was no change in the care plan at that time. 2. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/18/13, documentation in the progress notes showed that the resident was self-ambulating in his wheel chair and was looking for his mother. On 08/19/13, there was documentation that the resident was moved closer to the nurses' station due to safety concerns. The resident was looking for his wife and "wanted to go home". Staff attempted multiple times to redirect the resident but was unsuccessful. The resident circled the facility in his wheel chair multiple times. On 8/20/13 an assessment was done by a Licensed nurse (LN) for Mood and behaviors. The LN determined that he had a new chronic: wandering behavior. On 8/20/13 a LN contacted the physician because the resident seemed restless and agitated. The physician documented that the LN informed the physician that on 8/19/13 the resident " had to be redirected a number of times as he tried to leave the building" There was no evidence of a care plan being developed for behaviors to prevent the resident from leaving the building. On 8/21/13, documentation showed that at 3:00 am the resident was ambulating about the building and staff was providing 1:1 supervision during the night shift. There was no care plan developed even though night shift was providing 1:1 supervision. At approximately 6:30 pm. the facility discovered the resident was missing. Staff searched the neighborhood and found the resident about 11/2 to 2 blocks away lying on the ground. By the time the facility staff arrived the paramedics were already on scene assessing and tending to the resident. There was no documentation that the SW aggressively assessed the behaviors, revised the care plan, or was actively involved in assisting staff in understanding and dealing with the resident's behaviors. There was no evidence that the SW provided the staff with any type of support. A care plan for elopement was not created until 8/22/13 after the resident eloped and had fallen.

Based on interviews and record reviews the facility's administration failed to effectively and/or efficiently use its resources to attain or maintain the highest practicable well-being of each resident. Failure of the Administrator to ensure a thorough and effective abuse prevention program was implemented or to recognize resident behaviors that constituted abuse resulted in harm for 3 of 4 residents (#1, 2 & 3) and placed all other residents at risk for experiencing unrecognized abuse. Failure to provide supervision for residents 2 & 3 who had dementia lead to both residents eloping from the facility and Resident 3 sustaining substantial injuries. Findings include: The Administration failed to assess and recognize that using a family member as a behavioral intervention for a resident's behaviors created family burn out. The facility insisted the family member take care of Resident 1 who was agitated and resulted in actual harm due to an altercation between Resident 1 and the family member. Refer to F 223, CFR 483.13(b) Abuse The Administration failed to thoroughly investigate allegations of abuse. The Administration took no actions to protect residents from further potential abuse by not providing supervision to prevent exit seeking behaviors in two residents (2 & 3) which resulted in actual harm for Resident 3. Refer to F 225 CFR 483.13(c)(3) Investigate/Report Allegations/Individuals The Administration failed to provide medically related social services to attain the highest level of physical, mental and psycho-social well-being for 2 of 4 residents who exhibited behaviors (#1 & 2) investigated for social service support. Refer to F 250 CFR 483.15(g)(1) Social Services The Administration failed to provide safe and secured environment, and ensure adequate monitoring and supervision of cognitively impaired resident's. This potentially placed all other cognitively impaired residents with eloping and exit seeking behaviors residing at the facility at risk for potential harm. Refer to F 323 CFR 483.25(h) (2) Prevention of accidents.

Based on observation, record review, and interview, the facility failed to identify and provide sufficient supervision for 2 of 4 residents with dementia to prevent the residents from exiting the building and falling. (#2 & 3) reviewed. Residents 2 & 3 experienced actual substantial harm as a result of a fall down the cement steps outside of the building. Findings include: 1. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/24/13, documentation on a Resident Incident Report indicated a pedestrian reported Resident 3 was lying at the bottom of the cement stairs in front of the building. A Licensed Nurse (LN) documented that the resident had last been seen in the front of the building where there was lots of activity, visitors and residents. A staff person documented that he was sitting in his car in the front of the building and saw two people walk outside the building "followed shortly" by the resident. The staff member assumed they were together so he took a nap. The staff member did not question the people even though the resident was following them instead of the people pushing him in is wheel chair. The resident fell down the stairs and received abrasions to knees and forehead, subdural hematoma and a left femur fracture. The resident passed away 2 days later. The medical record revealed multiple entries that the resident had confusion, agitation and mild anxiety related to new environment. There was no wander or risk assessments completed to determine if the resident had the potential to exit the building even though the resident had dementia. The care plan indicated the resident had impaired cognition, needed assistance with all of his activities of daily living and the goal was for the resident to remain oriented to person. The care plan did not address increased supervision to ensure the resident was safe. 2. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/21/13, an LN documented that the resident returned to the facility after a medical appointment. The resident was agitated and not easily redirected. At approximately 6:30 pm. staff were unable to locate the resident. Staff searched the neighborhood and found the resident about 1 1/2 to 2 blocks away lying on the ground with paramedics on the scene assessing and tending to the resident. The resident received 2 abrasions from the fall. On 8/18/13, documentation in the progress notes showed that the resident was self-ambulating in his wheel chair and was looking for his mother. On 08/19/13, there was documentation that the resident was moved closer to the nursing station due to safety concerns. The resident was looking for his wife and "wanted to go home". Staff attempted multiple times to redirect the resident but was unsuccessful. The resident circled the facility in his wheel chair multiple times. On 8/20/13 an assessment was done and for Mood and behaviors it was determined that he had a new chronic wandering behavior On 8/20/13 a Licensed nurse (LN) contacted the physician because the resident seemed restless and agitated. The MD documented that the LN informed the MD that on 8/19/13 the resident "had to be redirected a number of times as he tried to leave the building" There was no evidence of a care plan being developed to prevent the resident from leaving the building. On 8/21/13, documentation showed that at 3:00 am the resident was ambulating about the building and staff was providing 1:1 supervision during the night shift. There was no care plan developed even though night shift had been providing 1:1 supervision. A care plan for elopement was not created until 8/22/13 after the resident eloped and had fallen.

Based on observation, interview and record review, the facility failed to provide assistance and supervision for one of two sampled residents (# 2) who were reviewed for accidents. Failure to provide care as assessed and needed when positioning Resident 2 allowed Resident 2 to fall off of the bed suffering an arm fracture and lacerations and bruises to her face. Findings include: Resident 2 was admitted in July 2009 with multiple diagnoses, including neuromuscular disease. Her most recent Minimum Data Set assessment, dated 04/27/13, identified she needed two person assist for positioning in bed and a mechanical lift with two persons for transfer to and from her bed. On 06/23/13 at about 5 p.m., one staff, Staff 1, entered Resident 2's room to assist her with toileting on the bedpan prior to assisting the resident out of bed. Staff 1 positioned the mechanical lift next to the left side of the resident's bed. Staff 1 moved to Resident 2's right side of the bed and placed the bedpan on the bed next to the resident. Staff 1 turned Resident 2 onto her left side, away from her. Resident 2 rolled out of the bed and fell on to the mechanical lift and floor. Resident 2 was face down on the floor with her body straddling the mechanical lift. Staff 1 exited the room to get help. Three staff assisted Resident 2 from the floor. Staff 2 assessed Resident 2. Staff 2 noted a "large lump to the right side of center of her forehead and a small laceration on the top bridge " of Resident 2's nose. Resident 2 was unable to move her right arm. Swelling was present on the resident ' s right shoulder and arm. The physician ordered Resident 2 sent to the hospital for evaluation and treatment. Hospital x-rays identified a fracture of the right arm humerus, the large bone of the upper arm, and no fractures of her facial bones. On 06/25/13 at 11:50 a.m., observation of Resident 2 found black-purple bruises around both eyes. Purple bruising across the right cheek and swelling across the bridge of her nose was also present. Resident 2 wore a sling that immobilized and supported her right arm against her right ribs. Resident 2 reported her right arm was broken. The fracture happened a couple of days ago when Staff 1 was going to place the bedpan for her. Staff 1 placed the bedpan next to Resident 2's right hip area. Staff 1 rolled Resident 2 onto her left side. Resident 2 reported she rolled out of the bed and hit the mechanical lift, then landed on the floor. She stated it "hurt a lot." Only Staff 1 was present when the incident occurred. The most recent Minimum Data Set assessment, dated 04/27/13, identified Resident 2 needed two person assist for positioning in bed and a mechanical lift with two persons for transfer to and from her bed. The facility failed to supervise the care of this resident to provide appropriate assessed assistance to prevent injury.

Based on observation, interview and record review, the facility failed to provide medically related social services to maintain the highest practicable mental and psychosocial well-being for Resident 47. The failure to respond to the increasing evidence of depression and anxiety, or to place appropriate interventions when Resident 47 expressed suicidal ideations, resulted in psychological harm and a diminished quality of life. Findings include: Resident 47 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated [DATE], indicated Resident 47 required extensive assistance with all of her daily care needs and was totally dependent on staff for transfers and mobility. Resident 47 had a history of [REDACTED]. A Progress Note in Resident 47's clinical record, dated [DATE], read "Resident was tearful and crying, stating "My daddy and son died . They're all dead...medicated." A request to Resident 47's physician, dated [DATE], in the resident's clinical record, read "Patient has become increasingly tearful with increased depression and statements including verbalizations of fear. May we have orders to increase her antidepressant...and pain medication? Patient has had no increased in lethargy since we increased her pain medication last. Also, family and staff has noticed an increase in anxiety...may we increase the frequency of her antianxiety medication? Resident is also now frequently trying to get out of bed, increased alertness." The facility continued to monitor the resident but did not contact the resident's physician to follow-up on the [DATE] request. The physician response, dated [DATE], read "Mental Health will see patient and evaluate." No documentation was present in Resident 47's clinical record to indicate the Mental Health Professional had been requested to assess Resident 47 other than the entry made in the facilities "Mental Health Referral" book on [DATE]. The request made in the referral book ensured Resident 47 would be assessed on the next scheduled routine visit to the facility, scheduled for [DATE]. A PN, dated [DATE] for days, read "Resident crying inconsolably throughout the day..kept crying and stating "I just want to go home"..medicated." A PN, dated [DATE] for evenings, written by Licensed Nurse (LN) 3, read: "Patient has become increasingly tearful with many more depressive statements and trying repeatedly to crawl out of bed. Patient stated when asked why she wanted to get out of bed "I'm trying to fall out to kill myself." Patient always trying to give reasons to die. Very tearful, ongoing for hours, even after food, change in position and fluids have been offered. 1:1 effective for short periods. Patient wants someone with her at all times...medicated...Patient requests to see her relatives who have passed on all the time. Patient is not talking about anything positive at all." A PN, dated [DATE], for early morning shift, read "Resident tearful and complaining of pain this shift...medicated..but still tearful...Resident praying "please Dear Lord just take me"..."I wish I could just die." A PN, dated [DATE] for day shift, read "Resident very alert and talkative and trying to climb out of bed. Appeared very anxious at beginning of shift..medicated." A PN, dated [DATE] for night shift, read "Resident continues to call out "Help me" with depressive statements. Requesting to die. Patient with increasing anxiety and restlessness...medicated...Resident is trying to get out of bed and is sleeping less. Very tearful. 1:1 helpful for short periods." A PN, dated [DATE] for day shift, read "Resident continues crying with statements of dying and wanting to go home." A PN, dated [DATE] for evening shift, read "Patient continues with increased anxiety and anxious statements along with inconsolable crying...medicated.." A PN, dated [DATE] for night shift, read "Resident had a restful night." There was no documentation present in Resident 47's clinical record to indicate Resident 47's Physician or family had been notified of the excalating psychological distress Resident 47 had been experiencing between [DATE] and [DATE]. On [DATE] and on [DATE], Resident 47 was observed to be sitting in her wheelchair in the hallway and was crying. Facility staff was observed, both days, to stop and ask Resident 47 what was wrong and to offer assistance. On [DATE] at 12:53 a.m., LN 3 reported Resident 47 was "watched closely" that night ([DATE])because she cried a lot and reported she wanted to die. LN 3 reported she put a request in the facilities "Mental Health" referral book for Resident 47 to be seen by the Mental Health Professional on their next visit to the facility, scheduled for [DATE]. LN 3 wrote the request for Resident 47 to be seen because of her recent behaviors of crying and making depressive statements, not specifically her statement about harming herself. LN 3 reported she had not implemented any suicide precautions for Resident 47 and had never seen the facility "Suicide Protocol." Resident 47 was seen by the Mental Health Professional on [DATE] during the scheduled visit to the facility. On [DATE] at 1:45 p.m., the Social Service Director (SSD) reported he had not been informed of the statement made by Resident 47 until the surveyor asked about it earlier on [DATE]. The SSD reported he was "shocked" to find out Resident 47 was not placed on suicide precautions. On [DATE] at 10:10 a.m., the Director of Nursing services (DNS) reported the facility did have a "Suicide Protocol", which included every 15 minute checks, but she could not find it. The facility failed to ensure a holistic approach to the resident's emotional distress that included spiritual support for Resident 47 or to recognize suicidal ideations and implement interventions to keep Resident 47 as safe as possible.