Every finding on record at Soundview Rehabilitation and Health Care Inc

Based on interview and record review the facility failed to prevent the loss of controlled (narcotic) medications for 1 of 1 sampled resident (Resident 3) reviewed. This failure resulted in Resident 3's narcotic pain medication being diverted within the facility, and Resident 3's controlled medication for use other than their pain management program. Findings included . Review of the facility's policy titled Controlled Substances, dated 02/26, documented controlled medications as substances that have an accepted medical use and have a potential for abuse. These medications are subject to special handling, storage, disposal, and record keeping at the center, in accordance with federal and state laws and regulations. Resident 3 was admitted to the facility with a diagnoses to include chronic pain, a broken right rib bone, and arthritis. Review of Resident 3's physician order, dated 03/11/2026, documented an order for oxycodone (a narcotic pain medication) 5 milligrams (mg) every four hours as needed for moderate pain. Review of a facility investigation report, dated 04/11/2026, documented during a controlled substance medication count with Staff F, Registered Nurse (RN)/off going nurse and Staff G, Licensed Practical Nurse/oncoming nurse, Resident 3's card of oxycodone 5 mg tablets was missing. There were 23 missing tablets documented. The facility conducted a search of the facility and could not locate the missing card of oxycodone. The facility concluded that the medication was not deliberately taken and it was discarded into the garbage. Local law enforcement (LE) was not notified. Review of Resident 3's pharmacy bill, invoice date 04/30/2026, documented the facility reordered the oxycodone on 04/11/2026 and Medicare part A was charged for the missing medications. The facility did not reimburse the resident for the missing medications. A joint interview was conducted on 06/04/2026 at 2:32 PM with Staff A, Chief Executive Officer and Staff B, RN/Chief Nursing Officer. When asked if the facility paid for the misappropriation of Resident 3's medication, both stated no. Staff A and Staff B stated the local LE was notified of the potential theft/missing oxycodone. Refer to WAC 388-97-0640(2)(a), (3)(d)

Based on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 2) was adequately monitored and supervised while walking to the emergency room (ER). This failure placed residents at risk for fall and injury. Findings included.Review of the policy titled Discharge or Transfer with a revised date of 08/30/2025 documented, the facility should take appropriate steps to inform the resident where he or she is going and to ensure safe transportation. Additionally, if a resident is being transferred and return is expected, the following information should be conveyed to the receiving provider:Contact information of the provider responsible for care of the resident.Resident representative information.Advance Directive informationResident's care planOther information necessary to meet the resident's needs such as resident status, current mental, behavioral and functional status, reason for transfer and recent vital signs, diagnoses, allergies, medications including last received. Resident 2 admitted to the facility on [DATE] with diagnoses to include right cranioplasty (a neurosurgical procedure to repair a structural defect on the skull). The resident had a fall in January of 2026 which resulted in an acute subdural hematoma (a life-threatening medical emergency where blood pools between the brain and the skull's outer lining) that required a craniectomy (major neurosurgical procedure to permanently remove a section of the skull).Record review of Resident 2's progress note documented on 05/25/2026, the resident complained of shortness of breath, chest pain and left arm pain. The note indicated that the Licensed Nurse offered to call 911 and the resident refused and preferred to just walk over to the ER. The note did not indicate if a staff member walked with the resident or if they called the ER ahead of time to inform them that the resident was on their way.Record review of Resident 2's progress note documented on 05/28/2026, the resident informed the Licensed Nurse they were anxious and needs medication and wanted to go to the ER. The note indicated the resident walked to the ER. The note did not indicate if someone walked with the resident or if they called the ER ahead of time to inform them that the resident was on their way.Record review of Resident 2's progress notes documented on 05/30/2026, the resident complained about something wrong with their head and wanted to go to the ER. The Licensed Nurse documented Resident 2 walked to the ER. The note did not indicate if a staff member walked with the resident or if they called the ER to inform them that the resident was on their way.Review of Resident 2's activities of daily living care plan, with a print date of 06/03/2026 documented an intervention that the resident was able to walk in their room and the halls with distant supervision using a front-wheeled walker (FWW). This was dated 01/16/2026. There was no care plan of resident's ability to walk outside of the facility. Review of Resident 2's Kardex (reference tool on resident's medical status and daily routine) with a print date of 06/03/2026 documented that the resident was able to walk in room and halls with distant supervision using FWW. There were not mention about the resident's ability to walk outside of the facility. In an interview on 06/03/2026 at 1:50 PM, Resident 2 stated every time they had told staff they wanted to go to the ER they get scolded by the nurses, so they just walked to the ER on their own. In an interview on 06/03/2026 at 2:31 PM, Staff D, Licensed Practical Nurse (LPN) stated that when a resident requested to go to the ER, they usually asked why, assessed the resident then call 911 for transportation. Staff D stated they would not allow a resident to walk to the ER. They would call an ambulance to transfer them to the ER, send transfer forms, their face sheet, medication list and their Portable Orders for Life-Sustaining Treatment (POLST - a from designated a resident's code status and other treatment options) form with them.In an interview on 06/04/2026 at 9:49 AM, Staff E, LPN, stated they would not allow a resident to walk to the ER because of safety reasons.In an interview on 06/04/2026 at 11:05 AM, Staff C, LPN/Resident Care Manager stated when a resident insisted on walking to the ER, they would educate the resident about safety, called the ER to inform the resident was on their way, followed up to make sure the resident arrived to the ER safely, and then documented the information in the resident's progress note. Staff C added they would not allow a resident with chest pain to walk to the ER.In a joint interview with Staff A, Chief Executive Officer and Staff B, Registered Nurse/Chief Nursing Officer, on 06/04/2026 at 2:06 PM, Staff B, stated that a resident should not be walking on their own to the ER. Refer to WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure pharmaceutical services which assured the accurate acquiring, dispensing, and administration of all drugs to meet the needs of each resident for 2 of 3 sampled residents (Residents 7 and 8) reviewed for medications. Failure to accurately transcribe physician's orders placed residents at risk for medication errors, medical complications, and unmet needs. Findings included. <RESIDENT 7>Resident 7 was admitted to the facility on [DATE] with a diagnosis to include Chronic Obstructive Pulmonary Disease (COPD - group of diseases that cause airflow blockage and breathing problems). Review of Resident 7's hospital discharge orders, dated 05/09/2026, documented an order for prednisone (a steroid that reduced inflammation, swelling, redness and allergic reactions) 20 milligram (mg) tablet. The order directed the nurse to administer 40 mgs by mouth [NAME]. Review of Resident 7's facility order summary report, dated 05/09/2026, documented an order for prednisone 20 mg tablet. The order directed the nurse to administer 20 mg by mouth daily. Review of a facility investigation, dated 05/13/2026, documented the prednisone order was transcribed incorrectly. Resident 7 received prednisone 20 mg for four days before the error was recognized. <RESIDENT 8>Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's hospital discharge orders, dated 05/10/2026, documented an order for prednisolone acetate (a steroid that alleviated swelling, redness, and irritation in affected tissues) 1% eye drops place one drop in each eye four times a day. The resident was to receive atorvastatin (a medication to help lower cholesterol) 40 mg daily. Review of Resident 8's May 2026 Medication Administration Record (MAR), documented the atorvastatin and eye drops were not transcribed to the MAR. Review of a Facility investigation, dated 05/14/2026, documented Resident 8's atorvastatin and eye drops were not transcribed correctly to the MAR. The resident missed four days of receiving these medications. During an interview on 06/04/2026 at 2:21 PM, Staff B, Registered Nurse (RN)/Chief Nursing Officer, stated the expectation was two Licensed Nurses (LN) were to double check the hospital discharge orders and the facility admission orders to ensure medications were transcribed correctly. Staff B was aware this was not the first time in recent months the admission orders were not transcribed correctly to the facility admission orders and/or the MAR which resulted in medication errors. Refer to WAC 388-97-1300(1)(b)(i)(ii)

Based on interview, and record review, the facility failed to review and revise care plans for 5 of 10 sampled residents (Resident's 4, 7, 8, 33 and 35) reviewed for care planning. These failures placed residents at risk for lack of consistent interventions, unmet care needs, adverse health effects, and a diminished quality of life.Findings included .<RESIDENT 4> Resident 4 was admitted on [DATE] with diagnoses to include routine healing of lumbar fracture, high blood pressure, and osteoporosis (disease that makes bones weak). Review of Resident 4's MORSE fall assessment, dated 03/05/2026, documented that they were a low fall risk upon admission. In a review of Resident 4's progress notes, on 03/14/2026 at 7:57 AM, Staff R, Registered Nurse (RN), documented that Resident 4 had a fall in the bathroom and 911 was called due to left hip pain. In a review of the incident report related to Resident 4's fall dated 03/14/2026 at 12:00 AM, Staff B, Director of Nursing (DNS)/RN, documented that Resident 4 was admitted to the hospital after the fall due to a left hip fracture requiring surgery. Resident 4 was planning to return to the facility after discharging from the hospital. Resident 4 readmitted to the facility on [DATE] with an updated MORSE fall assessment, dated 03/19/2026, documented that they were a high risk for falling. In a review of Resident 4's care plan dated, 03/12/2026, did not have documentation of the fall, after surgical interventions, or the updated high fall risk. In an interview on 03/26/2026, at 2:22 PM, Staff B, DNS/RN, confirmed that Resident 4's care plan was not updated with their high fall risk or surgical after care. Staff B stated the admission nurse who readmitted Resident 4 should have updated the care plan. <RESIDENT 7> Resident 7 admitted on [DATE] with diagnoses which included major depressive disorder, generalized anxiety disorder, bipolar disorder and post-traumatic stress disorder. Review of the trauma screening questionnaire completed on 02/23/2026 showed the resident experienced an extraordinarily stressful or event. Review of Resident 7's care plan, initiated on 02/24/2026, showed the resident was at risk for feelings of trauma or re-traumatization due to past trauma the resident experienced that includes diagnosis of PTSD. The care plan did not include individualized interventions to mitigate triggers. Review of a psychiatric consult on 03/09/2026 documented Resident 7 was hospitalized 30 years ago for a mental breakdown secondary to spousal abuse. In an interview and observation on 03/27/2026 at 9:20 AM Resident 7 stated they had been on psychotropic medications for a long time and they had PTSD. Resident 7 stated confrontations or loud voices trigger their PTSD. <RESIDENT 8> Resident 8 admitted on [DATE] with diagnoses to include brain, skin and liver cancer and drug induced constipation. Review of the significant change Minimum Data Set assessment on 02/13/2026 showed Resident 8 was on hospice with a life expectancy of less than six months and experienced constipation. Review of the care plan revised on 02/17/2026 failed to include the hospice provider, contact information and delineation of responsibilities between the facility and hospice provider. The care plan did not include constipation goals and interventions. The care plan only addressed monitoring for it in the pain care plan problem. In an interview and observation on 03/23/2026 at 9:50 AM, Resident 8 stated they were experiencing constipation and were miserable and thus was the first time dealing with terrible pain with constipation. Resident 8 said they had brain cancer and were on hospice. In an interview on 03/30/2026 at 12:10 PM, Staff B, Director of Nursing Services (DNS) stated they were unaware Resident 7 had PTSD and acknowledged triggers and interventions should be on the care plan. Staff B was unaware Resident 8 did not have a care plan addressing their constipation and hospice provider contact information and facility/ hospice provider responsibilities. Staff B commented care plans could be better managed. <RESIDENT 33> Resident 33 admitted to the facility on [DATE] with diagnoses to include acute posthemorrhagic anemia (a condition where a rapid, large volume of blood is lost), H. pylori infection (bacteria that infects the stomach lining), and an enlarged prostate. Resident 33's care plan, dated 02/14/2026, documented that they were a moderate fall risk, able to ambulate with one person assistance, requires one person assistance for dressing, bed mobility, eating, and toileting. In a review of Resident 33's progress notes, dated 03/14/2026 at 6:45 PM, Staff Q, Licensed Practical Nurse (LPN), documented that Resident 33 was found on the floor of the bathroom and was not transported to the hospital per evaluation from emergency medical services. In an observation on 03/23/2026, at 12:52 AM, Resident 33 was restless in bed, unable to answer coherently and unable to follow direction to push the call light for help. In an interview on 03/23/2026, at 12:58 AM, Staff N, Certified Nursing Assistant(CNA)/Staffing Coordinator, went in to assist Resident 33. Staff N stated Resident 33 had been declining for approximately 10 days and is now requiring dependent care. In an interview on 03/30/2026, at 10:00 AM, Staff F, CNA, stated that Resident 33 was alert and orientated upon admission to the facility. Staff F stated that after the fall Resident 33 was having hallucinations and that is when they started to decline and needing more dependent care. In an interview on 03/26/2026, at 12:35 PM, Staff D LPN/Resident Care Manager, stated that they knew Resident 33 had declined quickly. Staff D confirmed the care plan was not updated to reflect Resident 33's change in care needs. In an interview on 03/26/2026, at 4:11 PM, Staff B, DNS/RN, stated that Resident 33's care plan was not updated timely. Staff B stated that that physical therapy department should be updating resident's needs in activities of daily living such as transferring, positioning, etc. and that nursing should be updating resident care needs. <RESIDENT 35> Resident 35 admitted to the facility on [DATE]. Review of Resident 35's admission Care Area Assessment (CAA-a tool used to create care plans), dated 12/08/2026, documented they had no teeth and had only dentures. In a review of Resident 35's care plan dated 12/08/2025 documented they had dentures, required assistance with denture care and directed staff to remove dentures at night to soak. Review of Resident 35's dental hygienist note, dated 01/07/2026, documented they had implants and the tissue around the implants were reddened and edema was present. Resident 35 was documented to decline cleaning. The dental hygienist recommended to remind Resident 35 to brush her implants. In an interview on 03/30/2026 at 9:41 AM Staff F, Nursing Assistant Certified, stated they were familiar with Resident 35. Staff F stated Resident 35 had dentures and was offered to have them removed and cleaned. Staff F stated sometimes Resident 35 declines. Staff F stated they know how to care for Resident 35 by reviewing their care plan and through report given by other staff. Staff F stated they were unaware Resident 35 had dental implants. Reference WAC 388-97-1020(5)(b)

Based on interview, and record review, the facility failed to provide sufficient qualified staff to provide care and services for 7 of 12 sampled residents (Residents 7,8,18,24,33,44 and 52), that had concerns related to staffing on 2 of 2 halls (Portage and Ship Harbor). The facility had insufficient staff to ensure residents received prompt call light response, medications delivered timely, assistance with activities of daily living including nail care, restorative care, and meal assistance and to ensure care was completed in accordance with established clinical standards, the facility assessment, and resident's needs and preferences. These failures placed residents at risk of experiencing feelings of frustration, vulnerability, diminished quality of life, and unmet care needs.Findings included . <FACILITY ASSESSMENT>Review of the facility's assessment, reviewed 03/24/2026, showed the average daily census was 35.53 and the facility averaged one to three admits and one to two discharges daily. The assessment showed the Director of Nursing Services determined the staff to resident ratios based on acuity of the residents in each hall and skills and training of nursing staff. The DNS was responsible for adjusting staffing schedules as needed in care of call off for illness. The staff plan showed there were 2 nurses on days, 2 nurses in the evenings and one nurse on the night shift to care for an average of 35 residents. <MATRIX>Review of the facility's matrix, dated 03/23/2026, showed the facility admitted 19 residents in the past 30 days. <STAFFING PATTERN>Review of the facility provided staffing pattern for the last 31 days, dated 02/22/2026 through 03/23/2026, showed that 4 of the 31 days did not have the required 16 hours of RN coverage and 12 of the 31 days did not have 24-hour Registered Nurse (RN) coverage in the facility. <RESIDENT INTERVIEWS><RESIDENT 52>In an interview on 03/23/2026 at 9:28 AM, Resident 18 said the facility did not have enough staff. They stated they call for help and wait. The residents stated they wish they had more staff on the floor.<RESIDENT 7>In an interview on 03/23/2026 at 11:54 AM, Resident 7 stated the facility needed staffing help. The resident stated they had waited 45 minutes to get help to go to the bathroom. The resident stated when they complained to staff, the staff told them that it wasn't too long. The resident said they knew it was 45 minutes because they were watching the clock across from their bed. They stated they had to go to the bathroom so bad. The resident stated there were a few other times they waited almost 45 minutes. Resident 7 also stated they had only received warm meals on two days; other meals are delivered cold. <RESIDENT 33>In an interview on 03/23/2026 at 2:17 PM, Resident 33 stated call light wait times were grim here. The resident stated the facility was short staffed and staff were exhausted. The resident stated their care was not personalized. <RESIDENT 24>In an interview on 03/23/2026 at 3:15 PM, Resident 24 stated the facility seemed to be short staffed. The resident stated they were told three staff members called in sick over the weekend. <RESIDENT 44>In an interview on 03/23/2026 at 3:16 PM, Resident 44 stated the facility was short staffed. The resident said they waited up to an hour for staff to answer their call light. <RESTORATIVE CARE><RESIDENT 8>Review of Resident 8's physician order directed staff to complete the resident's restorative walking program 6 days a week.Review of restorative care documentation for Resident 8 showed they received their restorative program 5 of 31 days in January and 5 of 17 days in February. <RESIDENT COUNCIL MINUTES>-Review of the resident council minutes, dated 11/25/2025, residents voiced they wanted faster call light response times and for the aides to be more patient with them.-Review of the resident council minutes, dated 12/30/2025, residents voiced that staff never seem to have time when they need them and tell them they are too busy.- Review of the resident council minutes, dated 01/27/2026, residents were asked what staff can do to be more helpful with their stay. Residents responded they would like quicker call light response time.-Review of the resident council minutes, dated 02/24/2026, showed the residents voiced the staff needed to make sure call lights were in reach at all times. <RESIDENT COUNCIL MEETING>During a resident council meeting with the surveyor on 03/25/2026 at 10:23 AM, Resident 18 stated call lights were being answered timely since state has been here. The resident stated they have waited hours and hours to get help and staff just let the call light go off. <STAFF INTERVIEWS>In an interview on 03/23/2026 at 11:36 AM, Staff N, Staffing Coordinator, said nursing assistants often worked double shifts. Staff N stated the facility needed two full time AM and two full time PM shift NAC's and another nurse.In an interview on 03/26/2026 at 2:52 PM, Staff I, Licensed Practical Nurse, said there were only two nurses on AM and PM shift then one on night shift. Staff I stated at least one day a week they are floundering. Staff I stated they were responsible for passing medications to an average of 20 residents, and last week they had 23 residents to pass medications to. Staff I stated residents have complained about cold meals for the past year. Staff I stated d last week breakfast trays were delivered at 7:45 AM and they were still giving care, so trays were not passed. Sometimes breakfast trays are delivered at 9 am and lunch can be anytime between 12 and 1 PM She said this is an ongoing frustrating issue that there is no consistency with mealtimes. They stated the wide range of meal deliveries makes it hard to give meds before meals, during or after per resident preference when they do not know what time the meals are coming.In an interview on 03/30/2026 at 12:10 PM, Staff B, Director of Nursing Services stated they currently needed to hire two AM shift aides and one PM shift aide and they may need another nurse next month. Staff B stated they were concerned that the new company told them to cut staffing and for the Per Patient Day (PPD) to go from their current 4.2 down to 3.38. Staff B stated the facility was very busy with 30-35 admits and discharges a month. They stated they have a very high acuity and cannot lower their staffing from what it is. Staff B stated the nursing staff were spread thin. They had hoped staffing would increase with the new company. Staff B stated they were aware of identified complaints that meals trays were delivered late, nail care was not provided, meds were administered late and two person transfers were being completed with only one staff present. Staff B stated restorative gets pulled to the floor often because they cannot find agency to cover shifts. Staff B stated they were aware they needed more oversight in the facility.In an interview on 03/30/2026 at 1:53 PM, Staff A, Administrator stated maybe the staff needed more training. Staff A stated the staff can grab them of Staff N for two person transfers. Staff A stated they had talked to the staff on how to plan their day. Staff A stated the facility had enough staff and they just needed them to do what they were supposed to do. They stated maybe the staff were not effective enough and they needed to do more training and have more accountability. Staff A stated the floor staff and shower aide should help with meals. Refer to WAC 388-97-1080 (1) .

Based on interview and record review, the facility failed to ensure the Dietary Manager, (Staff P), had proper qualifications. This failure placed residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.Findings included .Review of the facility provided position description for Dietary Manager (DM), undated, showed staff were to have one or more of the following required:Must have successful completion of a Dietary Manager's course from a vocational or community collegeMust have and maintain a Certified Dietary Manager's license, with associated continuing educationIn an interview on 03/23/2026 at 09:15 AM, Staff P stated they had been the Dietary Manager since December 2025. Staff P stated they were enrolled in the Dietary Manager course in February 2026 and have not completed it.In an interview on 03/30/2026 at 11:34 AM, Staff A, Administrator confirmed they were aware Staff P had not completed the Dietary Manager course.Reference WAC: 388-97-1160(2)(3)

Based on observation, interview and record review the facility failed to ensure preplanned menus were followed. Failure to follow the preplanned menus altered the nutritional content of the diet and placed residents at risk for malnutrition and weight loss.Findings included .On 03/23/2026 Staff P, Dietary Manager (DM), provided 2 weeks of menus that were requested.Review of the weekly menu documented on 03/26/2026 the lunch meal would consist of cream of tomato soup, pepper steak, delicious rice, steamed vegetables, baked roll and peach marshmallow jello salad.In an interview on 03/26/2026 at 11:46 AM, Staff P, DM, stated they have been pretty good about sticking to the menu. Staff P stated if there was a change to the menu, they do not inform facility staff, they would update the menu outside of the dining room.In an observation on 03/26/2026 at 12:06 PM, Staff T, Cook, stated the prepared peach marshmallow jello salad was outside of the safe zone. Desserts were then placed in an ice bath (ice and water) to adjust the temperature.In an observation on 03/26/2026 at 12:21 PM, Staff T, Cook, rechecked the temperature of the peach marshmallow jello salad and it was not in the safe zone.In an observation on 03/26/2026 at 12:23, Staff T, Cook, stated they would not be able to serve the peach marshmallow jello salad to residents, and it was decided they would serve yogurt in place of the scheduled dessert.In an observation on 03/26/2026 at 12:54 PM, Staff N, NAC, stated a resident had asked about a roll that was on the menu for today's lunch meal. Staff T, cook stated they did not know if there was a change to the menu.In an observation on 03/26/2026 at 1:00 PM, the daily menu outside of the dining room showed the daily menu. There was no baked roll included in the daily menu. Staff N came back and stated they reviewed the resident's menu and there had been a baked roll for the lunch meal. No alternative for the baked roll was offered to the residents.Reference WAC: 388-97-1160(1)(a)(b)

Based on observation, interview and record review, the facility failed to provide appetizing, palatable, and warm food for 7 of 7 residents (2, 7, 9, 18, 24, 26, and 27) reviewed for dining. This failure placed the residents at risk of a diminished dining experience and less than adequate nutritional intake, potentially leading to weight loss, dissatisfaction with meals and a decreased quality of life.Findings included .<RESIDENT COUNCIL MINUTES> Review of the 09/23/2025 resident council minutes showed residents stated sauces need more flavor, mac and cheese sauce were no longer good. They wanted more fresh fruit and vegetables. Residents said when they complete menu forms, their selections were not fulfilled or followed. Review of the 10/25/2025 resident council minutes showed the residents were asked about the menu. Residents stated it was easier to give up at this point. They stated they would like hot food and more vegetables. Review of the 11/25/2025 resident council minutes showed the residents stated they were served too much chicken and the desserts need work. Review of the 12/30/2025 resident council minutes showed the residents would like more green salads, diabetic friendly desserts and more of a variety of desserts. Review of the 01/27/2026 resident council minutes showed the residents again stated they were served too much chicken and they would like more variety of desserts. Review of the 02/24/2026 resident council minutes showed the residents again stated they were served too much chicken. <RESIDENT COUNCIL MEETING> In a Resident Council group interview on 03/25/2026 at 10:15 AM: - Resident 26 stated Don't ask me about the food. By the time it gets to me I do not expect it to be hot. - Resident 24 stated they were the last one at the end of the hall to get food and the food basically comes very cold. The resident stated they complained so much about the cold food, the staff now microwave theirs. -Resident 2 stated their chicken was cold yesterday. -Resident 18 stated their food is never delivered hot and staff do not offer to reheat their food. The resident stated if they had asked for their meal to be reheated, they are told the aides cannot run back and forth. In an interview on 03/26/2026 at 2:52 PM, Staff I, Licensed Practical Nurse stated residents complained of cold meals. Staff I stated this had been an issue for the past year. They stated last week breakfast trays were delivered at 7:45 AM and the staff were still giving care, so trays were not passed. Staff I stated sometimes breakfast trays were delivered at 9 am and lunch can be anytime between 12 and 1 PM. Staff I said this was an ongoing frustrating issue that there was no consistency with meal times. In a phone interview on 03/27/2026 at 1:50 PM, Collateral Contact 1 (CC 1) Registered Dietician stated cold food had been the biggest complaint from the residents. CC 1 stated then they arrive at the facility at 9 AM the residents complain about the cold food. The residents say there is room for improvement in the food quality, temperature being cold and food being overcooked. In an interview on 03/30/2026 at 9:46 AM, Staff F, NAC stated residents complained of cold food. Staff F stated if they knew the resident is picky, they would try to hand deliver those trays first. They stated that sometimes trays are delivered at 7:30 AM and they are still getting residents up. They stated some kitchen staff are slow, and they get the trays at 8:30 AM. In an interview on 03/30/2026 at 11:21 AM, Staff E, Infection Preventionist stated the residents complained about cold food. Staff E stated they did not know what the root cause of the cold food was. In an interview on 03/30/2026 at 12:08 PM, Staff B, DNS stated the cold food issue should resolve when the elevator gets fixed and they can use the hot plates from downstairs to keep meals warm. <RESIDENT INTERVIEWS> <RESIDENT 4> In an interview on 03/23/2026, at 11:40 AM, Resident 4 stated that food that is supposed to be hot is served cold. In an interview on 03/26/2026, at 9:36 AM, Resident 4 stated that breakfast was served cold, which included cold scrambled eggs that they did not eat. In an interview on 03/27/2026, at 9:16 AM, Resident 4 stated that breakfast was served cold again, eggs are always cold and that the waffles were not good. <RESIDENT 7> In an interview on 03/23/2026 at 11:54 AM, Resident 7 stated the food sucks, I got warm meals delivered for 2 days otherwise all my food has been delivered cold. My old roommate's husband was bringing us meals three times a day since our food was cold. We do not get a lot of fresh fruit and vegetables. In an interview and observation on 03/24/2026 at 2:16 PM, Resident 7 was on the phone ordering a pizza.They stated lunch was too spicy and too dry, so they had to order a pizza. In an interview on 03/25/2026 at 11:29 AM, Resident 7 stated they did not eat their eggs this morning, only their bagel and fruit. The resident stated they did not eat the eggs because they were not solid. The resident stated the food had been delivered warmer since state was here, but it will go back to cold when we leave. In an interview on 03/26/2026 at 9:00 AM, Resident 7 stated they were served room [ROOM NUMBER]-1's tray and they ate some of their food before reading the meal slip. Resident 7 stated their eggs were lukewarm, they served toast but no butter. In an interview on 03/27/2026 at 9:20 AM, Resident 7 stated their breakfast was cold. They stated they were served cold waffles and would never eat the eggs because they were unrecognizable. The resident looked at the menu for lunch and said they would not eat that. Resident 7 stated they needed the alternate list so they could order what they wanted for lunch. <RESIDENT 9> In an interview and observation on 03/24/2026 at 09:31 AM Resident 9 stated they received cold cereal and scrambled eggs for breakfast. Resident 9 stated they do not like cold cereal and would prefer to have eggs, sausage or bacon and toast. Resident 9 stated they did not think there was an option to request their preferences for meals. In an observation and interview on 03/26/2026 at 08:51 AM, Resident 9 stated that their tray had toast that was cut into pieces and they did not like their toast cut into pieces. Resident breakfast tray was in front of them, and toast was observed to be cut into small square pieces and uneaten. In an interview on 03/27/2026 at 10:01 AM, Resident 9 stated they had a waffle and eggs that were cold. <RESIDENT 24> In an interview on 03/23/2026 at 3:15 PM, Resident 24 stated the food was always cold and feels they are the last residents to get their meals. <RESIDENT 27> In an observation on 03/25/2026 at 9:12 AM, Resident 27 was observed to request a banana and peanut butter, and they stated they had a terrible breakfast. Resident 27 admitted to the facility on [DATE] with diagnosis to include pressure ulcers. In an interview on 03/23/2026 at 2:41 PM Resident 27 stated the food at the facility was poor. Resident 27 stated they wrote down what had been served to them since admission and the food is awful. Resident 27 stated they continue to provide rice and green beans despite their preference for something different. In an interview and observation on 03/24/2026 at 1:02 PM Resident 27 was sitting on the edge of their bed, their overbed table in front of them, their lunch meal on a tray on the overbed table. Resident 27 stated the lunch served was not good. Observed Resident 27's platet which contained uneaten rice and salsa. Resident 27 stated the meal was not warm, the apple dessert wasn't good and the rest would be going back. Review of Resident 27's food preferences dated 03/06/2026, completed by the dietary manager, documented resident disliked green beans and apples. Reference: (WAC) 388-97-1100 (1), (2)

Based on observation and interview, the facility failed to consistently serve meals within the posted timeframe's and had longer than a 14 hour wait between when dinner and breakfast were served for 2 of 2 hallways. Failure to serve nourishing snacks to 5 of 7 residents (2, 12, 18, 24 and 26) and meals in a timely manner placed residents at risk of nutritional concerns, food temperatures served outside the desired temperature range, and a decreased quality of life.Findings included .<RESIDENT COUNCIL> In resident council group meeting on 03/25/2026 at 10:24 AM, Residents were asked if they received snacks at night. Residents 2, 12, 18, 24 and 26 stated they were not aware of possible snacks at night, and staff did not offer them. In an interview on 03/30/2026 at 12:08 PM, Staff B, DNS was informed resident council stated they were unaware about HS snack availability and that Ship Harbor got their trays at 8:53 AM when tray line was at 7:15 AM. Staff B was unaware of these concerns. No additional information was provided. On 03/23/2026 at 09:22 AM, Staff A stated mealtimes were 7:30 AM-8:00 AM for breakfast, 12:00 PM to 1:00 PM for lunch and dinner was scheduled for 5:00 PM to 6:00 PM. In an interview on 03/23/2026 at 09:15 AM, Staff P, Dietary Manager (DM) stated the mealtimes expectations were to serve breakfast from 7:15 AM to 8:15 AM, lunch from 12:00 PM to 1:00 PM and dinner from 5:00 PM to 6:00 PM. In an interview on 03/26/2026 at 11:23 AM, Staff P, DM, stated they were unaware breakfast trays were not delivered to some residents until 8:45 AM or later. Staff P stated kitchen staffing was stretched thin, and they tried to schedule increased staff in the mornings. In an observation and interview on 03/24/2026 at 08:44 AM, observed breakfast meal cart for room trays still parked on the Portage hallway. Staff I, Licensed Practical Nurse, (LPN), verified the meal cart with breakfast trays had not made it to the Ships Harbor hallway yet and stated it could take until 09:00 AM. In an observation on 03/26/2026 at 08:20 AM, the breakfast meal cart with hall trays was observed to be on the Portage hallway with trays still being served. In an interview on 03/26/2026 at 08:26 AM, Staff F, Nursing Aide Certified (NAC), confirmed the breakfast meal cart had not been delivered to Ships Harbor hallway. In an observation on 03/26/2026 at 08:45 AM, the breakfast meal cart was observed on the Ships Harbor hallway and trays were being delivered to resident rooms. Reference WAC: 388-97-1160(1)(a)(b)

Based on observation and interviews, the facility failed to ensure resident meals were prepared and stored in accordance with professional standards of food safety 1 of 1nourishment refrigerators. The failure to ensure the nourishment refrigerator were free from potential contaminants, maintenance to ensure the nourishment refrigerator and freezer were properly maintained left residents at risk for food contamination, food borne illnesses, and spoiled food. Findings Included .In an observation on 03/23/2026 at 12:19 PM the nourishment refrigerator and freezer had multiple items in it opened, undated and expired food items. Observed a sign on the refrigerator that read the refrigerator/freezer were used for patient snacks and supplements and any non-labeled items would be discarded, signed by the dietary manager. The following items were located within the refrigerator:- A sandwich covered with foil with the room [ROOM NUMBER]-2 on it, not dated. -A peach cobbler dated 3/20 with room [ROOM NUMBER]-2 -A hardboiled egg, undated, in a plastic cup with a cover. -Peanut Butter and Jelly dated 3/17-A cheese and meat sandwich dated 3/20 use by 3/17-Fried chicken labeled for staff packed on 3/18 with a sell by date of 3/19-Noodle soup in container inside a plastic bag with room [ROOM NUMBER]-1, undated.-Cheeseburgers sliders and half eaten salad labeled room [ROOM NUMBER]-1, undated. -A paper bag with two mushy eggs dated 3/19-Quarter gallon of milk with expiration date of 03/18/2026-Half and half with expiration 2/8/2026 labeled room [ROOM NUMBER]-2 -Moldy cheese in plastic container, undated, labeled room [ROOM NUMBER]-16 -Allen's cheese 16-1 2/23/2026 trash in it -Fast food bag with food in it, undated, labeled room [ROOM NUMBER]-2-Brown paper bag labeled with Staff L, Nursing Assistant Certified, name, contained half eaten burrito, undated. -Opened half empty 20-ounce sprite, undated-grapes, undated-Opened melon and pineapple tray, dated it was packaged on 3/17/2026 with a sell through date of 3/20/2026.-Container of carrots and rice/chicken, undated-Plastic cup with light golden-brown color food item with liquid on the top and solids on the bottom, undated dated. -Bag full of sodas and glass jars filled with pickled herring rolled in disposable chuck pads with undated and unnamed. -Asian spice sauce in jar in fridge door, no date. -Wild sockeye salmon, 16-2 undatedThe refrigerator bottom drawer was empty, dirty with debris and yellow spill marks. The following items were located in the freezer:-grocery store plastic bag frozen to door storage, undated and no name. Unable to see the contents.-banana frozen in bag no date, unlabeled -undated chimichangas On 03/23/2026 at 12:30 PM located the temperature log for the nourishment refrigerator, in a drawer next to the refrigerator, dated July 2025, with multiple missing entries. No other temperature logs were located or provided. In an interview on 03/23/2026 3:30 PM Staff L, NAC, stated they were leaving with their paper bag and burrito from yesterday's lunch from the nourishment refrigerator. When asked where their lunch should be kept, Staff L stated they did not know and they had only worked at the facility for three weeks and was still learning. In an interview on 03/26/2026 at 11:20 AM, Staff P, Dietary Manager stated they and the dietary staff were not responsible for checking the temperature in the nourishment refrigerator. Staff P stated nursing staff were responsible for the maintenance and logging of temperatures of the nourishment refrigerator. In an interview on 03/30/2026 11:16 AM Staff E Infection Control/Registered Nurse stated the nourishment refrigerator temperatures and oversight were completed by the nurses on overnight shift. Reference WAC 388-97-1100(3)

Based on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and and Control Guidelines and standards of practice for 2 of 2 hallways (Portage Hall and Ship Harbor Hall) reviewed for Contact Precautions (infection control measures used to prevent the spread of germs through direct or indirect contact by wearing a gown and gloves before entering the resident room) for residents (Resident 20, 33, and 49) and ensure appropriate disinfection of blood glucose meters (device used to measure blood glucose levels) between each resident use. The facility failed to ensure staff were compliant with appropriate hand hygiene practices during wound care for 1 of 1 residents (Resident 28). These failures placed all residents and staff at risk of potential infection. Findings included .According to the Centers for Disease Control (CDC) titled, Transmission-Based Precautions, dated 04/03/2024, Contact Precautions are used for patients with known or suspected infections that represent an increased risk for contact transmission. Contact Precaution patients should be placed in a single patient room or make room placement decisions balancing risks to other patients. Contact Precautions require using personal protective equipment (PPE) appropriately, which included putting on gown and gloves upon room entry. According to the CDC titled, Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, Enhanced Barrier Precautions (EBP) may be indicated when Contact Precautions do not otherwise apply for residents with the following: indwelling medical devices (such as a catheter, a tube that goes into the bladder to drain urine), regardless of MDRO colonization or infection or colonization with an MDRO. EBP require staff to wear a gown and gloves only during high contact resident care activities. <CONTACT PRECAUTIONS> <RESIDENT 20> Resident 20 was admitted to the facility on [DATE] with diagnoses to include an indwelling catheter related to obstructive uropathy and an enlarged prostate (a blockage in the urinary tract that prevents normal urine flow) and a urinary tract infection (UTI) with Methicillin-resistant Staphylococcus aureus (MRSA) a type of MDRO. During an observation on 03/23/2026, at 9:30 AM, Resident 20 had a Contact Precautions sign posted outside of their door with a note on it that said Bed #1. Resident 20 had a roommate who was not on Contact Precautions. The Contact Precautions sign stated to wear gown and gloves when entering the room. Review of resident 20's care plan, dated 02/23/2026, documented that Resident 20 had a UTI with MRSA and was on Contact Precautions. The care plan also documented that staff would follow the Contact Precautions on the sign posted outside the room. In an interview on 03/23/2026, at 9:31 AM, Staff G, Certified Nursing Assistant (CNA), stated that Resident 20 was on Contact Precautions because they have a catheter. In an observation on 03/23/2026, at 10:11 AM, Staff F, CNA, went into Resident 20's room without gown or gloves on and Contact Precautions sign posted outside of the door. In an observation on 03/23/2026, at 10:12 AM, Staff G, CNA, went into Resident 20's room without gown or gloves on and Contact Precautions sign posted outside of the door. In a joint observation and interview on 03/24/2026, Staff U, CNA, went into Resident 20's room without gown or gloves on and Contact Precautions sign posted outside of the door. When Staff U exited the room, they stated that they should have worn gown and gloves when assisting bed one. <BLOOD GLUCOSE METERS> In a joint observation and interview of Portage Hall Medication cart on 03/26/2026, at 10:13 AM, blood glucose monitors were observed to be in individual pouches for each resident that required one with diabetic strips, lancets, and alcohol prep pads. Staff K, Licensed Practical Nurse (LPN), stated that diabetic supplies are individual for each resident, they are to be cleaned after each use with an alcohol prep pad. In review of the Assure Prism User Instruction Manual, documented that the blood glucose meters should be cleaned and disinfected after use on each patient. The user manual stated that they have validated Clorox Healthcare Bleach Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, CaviWipes1, and PDI Super Sani-Cloth Germicidal Disposable Wipe for disinfecting the Assure Prism multi meter. In an interview on 03/26/2026, at 11:37 AM, Staff E, IP/RN, stated that each reach resident has their own blood glucose monitor but it should be disinfected between each use with the purple top wipes (Super Sani-Cloth Germicidal Disposable Wipe). In an interview on 03/26/2026, at 3:55 PM, Staff B, Director of Nursing (DNS)/RN, stated that their expectation of disinfection for the blood glucose glucometers would be to clean after every use with the purple top wipes (Super Sani-Cloth Germicidal Disposable Wipe). <RESIDENT 33> Resident 33 admitted to the facility on [DATE] with diagnoses to included indwelling catheter. Resident 33 was diagnosed with a urinary tract infection (UTI), 03/09/2026, with Extended-Spectrum Beta-Lactamases (ESBL - a type of MDRO). During an observation on 03/23/2026, at 9:30 AM, Resident 33 had a Contact Precautions sign posted outside of their door with a note on it that said Bed #1. Resident 33 had a roommate who was not on Contact Precautions but was on Enhanced Barrier Precautions. Review of Resident 33's care plan, dated 02/14/2026, documented that Resident 33 is on Contact Precautions due to the ESBL UTI. The care plan documented that staff will wear appropriate PPE when caring for resident. In an observation on 03/23/2026, at 12:30 PM, Staff N, CNA/Staff Coordinator, went into Resident 33's room without gown or gloves on and Contact Precautions posted outside of the door. The Contact Precautions sign stated to wear gown and gloves when entering the room. In an interview on 03/25/2026, at 3:15 PM, Staff E, Infection Preventionist (IP)/Registered Nurse (RN), stated that if a resident on Contact Precautions is sharing a room then the staff only need to gown and glove for the resident with the precautions. Staff E also stated residents on Contact Precautions should be isolated to their rooms as much as possible. Staff E stated that residents on Contact Precautions would be in private rooms in available or would try to room them with other Contact Precaution residents with similar infections if possible. In an interview on 03/27/2026, at 2:33 PM, Staff B, DNS/RN, stated that they decide as a team which precautions resident's should be. Requested any documentation that would justify that the resident's needed to be on Contact Precautions versus Enhanced Barrier Precautions. No further information was provided. <RESIDENT 49> In an observation and interview on 03/23/2026 at 2:26 PM, Staff O, Licensed Practical Nurse (LPN), was observed to be in Resident 49's room with no PPE. Observed signage outside of Resident 49's room indicated transmission-based precautions (TBP) and what specific PPE to be worn. Staff O, LPN, was observed to come out of Resident 49's room, when asked about the TBP signage, they stated they did not require any PPE since they did not provide care to the resident. In an observation and interview on 03/25/2026 at 08:46 AM, Staff W, Nursing Assistant Certified (NAC) was observed to enter Resident 49's room without putting on PPE or hand hygiene. Staff W, NAC, was observed to remove Resident 49's breakfast tray and put it in the meal cart. Staff W stated they should have performed hand hygiene before entering the room. Staff W, NAC, confirmed the TBP signage instructed staff to wear gloves and a gown to enter the room. Staff W, NAC, stated they were unsure if they required PPE if they did not provide care to the resident. In an interview on 03/24/2026 at 09:45, Staff E, Infection Preventionist/Registered Nurse (IP/RN), stated their expectation was for staff to follow TBP signage. Staff E, IP/RN, stated staff should have worn gloves and a gown to enter Resident 49's room. In an observation on 03/30/2026 at 11:33 AM, Resident 28 was positioned on their back then positioned on their right side. Staff C, Registered Nurse (RN) removed a dressing that had feces on it. Staff C proceeded to apply cream with a cotton swab and place a clean foam dressing without removing gloves or performing hand hygiene. In an interview on 03/30/2026 at 11:59 AM, Staff B Director of Nursing Services stated Staff C, RN should have completed hand hygiene and put new gloves on in between soiled dressing removal and application of the clean dressing. Reference WAC: 388-97-1320 (1)(C)(2)(C)(5)(C)

Based on observation and interview the facility failed to maintain a resident call light system that was functionable and audible, as required in 2 of 2 halls (Portage Hall and Ships Harbor Hall). This failure placed all facility residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included .<SHIPS HARBOR HALL> In an observation on 03/23/2026 at 12:49 PM room [ROOM NUMBER] call light was on, visible, not audible. In an observation on 03/24/2026 at 12:48 PM room [ROOM NUMBER]'s call light was on, visible, not audible. In an observation on 03/25/2026 at 9:27 AM room [ROOM NUMBER]'s call light was on, visible, not audible. In an observation on 03/23/2026 at 10:28 AM, the call light was on for room [ROOM NUMBER]-1 but it was not audible. In an observation on 03/23/2026 at 11:50 AM, the call light was on for room [ROOM NUMBER] but it was not audible. In an observation on 03/23/2026 at 2:59 PM, the call lights were on for room's 1 and 3 but they were not audible. In an observation on 03/25/2026 at 1:16 PM the call light for room [ROOM NUMBER] light was on but not audible. In an observation and interview on 03/26/2026 at 9:23 AM, the call light for room [ROOM NUMBER] was on but not audible. Staff F, Nurse's Aide Certified (NAC) stated the volume must have been turned down but if you listen closely and it is quiet, you can hear it. In an interview on 03/26/2026 at 10:16 AM, Staff N, Staffing Coordinator stated the call light sound has been very light but if they listen closely, they can hear them. Staff N could not say how long the call lights were turned down. In an observation on 03/27/2026 at 12:18 PM, the call light was on for room [ROOM NUMBER] and faintly audible at nurses' station at the computer but not audible in the halls. In an observation on 03/27/2026 at 3:11 PM, the call light for room [ROOM NUMBER] was light on. Staff _maintenance was moving wires by the call light monitor computer screen. The sound was audible only when at the monitor. In a follow up interview on 03/30/2026 9:46 AM, Staff F, NAC stated call light volumes were turned down on night shifts. Staff E stated the night shift tells them they turn the volume down because the residents could hear it. Staff F stated when they come in at 6 AM, the call lights were turned down. Staff F stated they hid the mouse from night shift and one of the Director of Nursing Services even locked the mouse up so night shift could not turn the volume down. Staff F stated this was an ongoing issue. In an interview on 03/30/2026 at 11:18 AM Staff E, Infection Preventionist stated the call light volume is supposed to be up and audible, but the staff had access to change it. In an interview on 03/30/2026 at 12:47 PM, Staff A, Administrator stated they were aware the call light volume was being turned down and the expectation was that the call lights must be audible at all times. In an observation on 03/30/2026 at 4:02 PM, the call light volume was observed turned down on the call light monitor screen. <PORTAGE HALL> In an observation on 03/23/2026, at 10:33 AM, room eight had a red call light, indicating an emergency, lit above their door but not audible in the hallway. In an observation on 03/23/2026, at 12:14 PM, room six had their call light lit above their door but not audible in the hallway. In an observation on 03/24/2026, at 9:14 AM, room seven had their call light lit above their door but not audible in the hallway. In an observation on 03/25/2026, at 9:19 AM, room one had their call light lit above their door but not audible in the hallway. In an observation on 03/26/2026, at 11:37 AM, room five had a red call light lit above their door but not audible in the hallway. This is a repeat deficiency from 05/14/2025. Reference WAC 388-97-2280 (1)(a)(b)(c)(2)

Based on interview and record review the facility failed to ensure that each resident was treated with respect, dignity and failed to promote and protect the rights of each resident for three of three residents (27, 31, and 28) reviewed for dignity. This failure had the potential to result in embarrassment and psychological harm to Resident's when staff members failed to provide privacy during care.Findings included . Review of the undated facility policy Resident Rights showed employees shall treat resident's with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of the facility and include the right to a dignified existence, be free from abuse, participate in care planning and treatment, and be supported by the facility to exercise their rights. Review of the admission packet included an undated copy of Your Rights as a Resident showed residents have the right to choose their activities, schedules and health care they want. Residents have the right to plan aspects of their life in the facility taking into consideration those things that are significant and important to them. <RESIDENT 28> Resident 28 admitted to the facility on [DATE] with diagnoses to include cardiac disease and anxiety. Review of the annual Minimum Data Set (MDS), an assessment tool dated 01/13/2026 showed the resident had depression, anxiety and cognitive impairment. In an observation on 03/30/2026 at 11:33 AM until 11:42 AM, Staff C, Registered Nurse performed wound care to Resident 28. Resident 28 was positioned on their back. The privacy curtain was not pulled around the resident during the peri care or wound care. The curtain remained pulled halfway to the residents waist on both sides. The resident was exposed from their waist down. Resident 28's roommate was present in the room. In an interview on 03/30/2026 at 11:59 AM, Staff B, Director of Nursing was informed of the lack of privacy curtain for Resident 28 during observation of peri and wound care. Staff B stated the privacy curtain should be pulled around the resident during care. <RESIDENT 27> Resident 27 admitted to the facility on [DATE], with diagnoses to include pressure-induced deep tissue injury, surgical aftercare, anxiety and depression. In an observation on 03/25/2026 at 09:23 AM, Staff K, Licensed Practical Nurse, was observed to check Resident 27's wound dressing. Staff K closed the door to Resident 27's room and requested the resident to pull down his pants so that the wound dressing could be observed on his back side. Staff K did not pull the privacy curtain around to protect Resident 27's privacy. The full window blinds were open, and the view is of the facility parking lot. Resident 27 pulled pants down, Staff K assessed the wound dressing and left the room. In an interview on 03/25/2026 at 09:30 AM, Staff K stated they should have closed the blinds to maintain Resident 27's privacy. <RESIDENT 31> Resident 31 was admitted to the facility on [DATE] with diagnoses to include chronic venous insufficiency (condition that damages leg veins and causes blood to pool in the legs), weakness, chronic pain and depression. In an observation on 03/23/2026 at 10:32 AM, Staff L, Nursing Assistant Certified (NAC), was observed to provide incontinence care for Resident 31. Staff L provided incontinence care with Resident 27's window blinds open and did not protect Resident 27's privacy. In an interview on 03/30/2026 at 11:34 AM, Staff B, Director of Nursing Services (DNS) stated their expectation was to provide privacy for resident's during care. Reference (WAC) 388-97-0180 (1-4)

Based on observations and interviews, the facility failed to ensure a clean, safe, comfortable and homelike environment for 2 of 2 halls (Portage Hall and Ship Harbor Hall), 1 of 1 shower rooms and 1 of 1 resident rooms (room [ROOM NUMBER]) reviewed for restraints and securement of a cable box device, and 1 of 1 resident rooms (room [ROOM NUMBER]) reviewed for floorboards. Failure to maintain carpets, floorboards, shower rooms and bed rails and floorboards in good repair and safely functioning, and carpets and shower room in sanitary condition placed residents at risk for diminished quality of life and compromised dignity. Findings included .<SHOWER ROOM> On 03/25/2026 at 8:56 AM observed the shower room to have a bathroom to the left upon enter with a sign noting for staff use, a room which was tiled and had missing shower head and handle with various items stored and another room which contained the shower room. The storage room contained various items in the corner, piled high, hair washing blow up sink, bagged items, and shoes. In an interview on 03/30/2026 at 11:48 AM Staff B, Director of Nurses services, stated the items found in the shower room storage area were items stored by social services and needed to be removed. <BED RAILS> On 03/23/2026 at 12:06 PM observed room [ROOM NUMBER] window bed with bilateral half bed rails attached to their bed. When touched the left side bed rail was wobbly and not secured tightly. On 03/25/2026 9:09 AM observed bed rails in resident room. When touched the left side was not attached securely with movement back and forth. In an interview and observation on 03/30/2026 at 11:54 AM Staff M, Regional Maintenance Director, checked room [ROOM NUMBER] windows bed half bed rails. Observed the right side of the bed to have a securely attached bed rail and the left side not securely attached. Staff K stated the bed rail on the left side needed to be tightened and was unaware of how it became loose as it was just checked as part of an audit. <CABLE BOX> On 03/23/2026 at 12:06 PM observed room [ROOM NUMBER]'s, bed closest to the door, had a television mounted to the wall with a cable box hanging from the television by cords. In subsequent observations on 03/24/2026 12:31 PM and 03/25/2026 9:12 AM the cable box was hanging from the television by cords. In an interview on 03/30/2026 at 9:41 AM Staff O, NAC stated there were several rooms with cable boxes hanging by cords from televisions mounted on the wall. Staff NAC stated it looked tacky and they had not fallen yet. In an interview on 03/30/2026 at 12:42 PM Staff A, Administrator stated they had switched cable providers last year and had been working on securing the cable boxes. <room [ROOM NUMBER]> On 03/24/2026 at 9:41 AM observed the floorboard molding, behind bed, peeling from the wall in room [ROOM NUMBER]. In an interview on 03/30/2026 at 12:42 PM Staff A, Administrator stated they were unaware of the floorboard molding pulling from the wall in room [ROOM NUMBER]. <SHIP HARBOR HALL> On 03/23/2026 at 12:58 PM observed several large red stains/markings on the hallway carpet. On 03/24/2026 at 8:50 AM observed large stains/markings on carpet outside of room [ROOM NUMBER] and across from room [ROOM NUMBER]. In a joint interview on 03/30/2026 at 12:42 PM Staff A, Administrator, and Staff B Director of Nursing Services stated they were in the process of replacing the carpet and measurements had already been taken. <PORTAGE HALLWAY> In an observation on 03/23/2026, at 12:15 PM, a red stain was on the carpet in front of room seven measuring approximately 12 inches long and six inches wide. In an observation on 03/23/2026, at 12:16 PM, a red stain was on the carpet in front of room one measuring approximately eight inches long and 12 inches wide. In an observation on 03/23/2026, at 12:17 PM, a dark brown/yellow stain was on the carpet in front of room [ROOM NUMBER] measuring approximately 12 inches long by four inches wide. In an observation on 03/24/2026, at 9:36 AM, a blue two-seater couch at the nurse's station looked worn with torn fabric. A gray one-seater chair also looked worn with torn fabric. WAC Reference 388-97-0880(1)(2)

Based on observation, interview, and record review, the facility failed to ensure the identification of verbal and mental abuse, and the protection of residents from their Alleged Perpetrator/Alleged Perpetrators (AP/APs), after allegations of abuse were reported to the facility for 1 of 1 residents (Resident 14) reviewed for abuse/neglect. This failure placed all residents at risk for further abuse, fear, and unmet care and services. Findings included .Review of the facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated as version 09/21/2022 documented the facility residents have the right to be free from abuse, neglect, and misappropriation of resident property, and exploitation to include verbal and mental abuse. The facility would not condone any form of resident abuse or neglect, protect residents from harm during investigations and screening and training employees.Resident 14 admitted to the facility on [DATE] with diagnoses to include fracture and urinary tract infection.Review of Resident 14's admission Minimum Data Set (an assessment tool) dated 03/17/2026 showed they were cognitively intact with a score of 13 out of 15 on their Brief Interview for Mental Status (BIMS).In an interview on 03/24/2026 at 9:48 AM Resident 14 stated the facility had to move them to a different room after their room mate was insulting them and their visitors, calling them stupid.Review of Resident 14's progress note dated 03/15/2026 documented they had a concern their roommate, Resident 35, was verbally abusive to their friends while visiting.Review of Resident 35's progress note dated 12/31/2025 documented their roommate stated they were verbally aggressive and rude to them; however the staff had not seen or heard the verbal aggression.Review of Resident 14's progress note dated 03/17/2026 documented they were unhappy with their roommate and was being moved to a different room, two days after their initial concern was reported to the nurse.In an interview on 03/25/2026 at 2:43 PM Staff K, Licensed Practical Nurse (LPN), stated they were familiar with Resident 35, they were aware of their behaviors which included yelling and cussing at people and thought they were told about an incident in which it was directed at their roommate from December 2025. Staff K stated Resident 35 could be verbally nasty, which was a form of verbal abuse. Staff K stated they could not recall all the details but would report the concerns to the Director of Nurses (DNS) and social services.In an interview on 03/25/2026 at 2:59 PM Staff A, Administrator stated Resident 14 had made a comment to the nurse that their roommate, Resident 35, was mean to their visitors. Staff A stated they did not know whether Resident 14 was interviewed or not about the incident.In an interview on 03/25/2026 at 4:44 PM Staff J Social Services Manager, stated they were made aware Resident 14 wanted to move rooms due to concerns with their roommate, Resident 35. Staff J stated they met with Resident 14 and asked them if they still wanted a room move and they confirmed they did and they were moved. Staff J stated they did not speak with Resident 14 about the issues surrounding the reason for wanting to move or any interactions between Resident 14 and Resident 35. Staff stated Resident 35 was confused, had cognitive impairment and often yelled out which caused difficulty for their roommates.In an interview on 03/30/2026 at 9:41 AM Staff F, NAC, stated they were a mandated reporter, and they were required to make a report to the state hotline, their nurse, and DNS. Staff F described Resident 35 as being more vocal at night per report from night shift. Staff F stated Resident 35 could become angry and verbally unfriendly to staff. Staff F stated they had not witnessed but was informed Resident 35 was not nice to a prior roommate, could not recall their name and was a couple months ago. Staff F described Resident 35 as being more lucid and nicer during the day and more confused at night.In an interview on 03/30/2026 at 10:17 AM Staff I, LPN, stated they were familiar with Resident 35 and had been informed, by other staff in report, they had been rude to a couple of roommates and families. When asked what was reported, Staff I stated Resident 35 had been belittling and degrading toward their roommates. Staff I stated belittling and degrading was a form of mental/verbal abuse. Staff I stated the facility moved Resident 35's roommate to another room. Staff I stated they did not witness the interaction between Resident 35 and Resident 14 as it occurred when they were not there.Review of the incident report dated 03/25/2026, received on 03/31/2026, documented Resident 35 had a history of being verbally aggressive toward their roommate as of 12/31/2025, had an interaction with Resident 14 and their visitors on 03/15/2026, and a room move was complete on 3/17/2026. Resident 14 was interviewed on 03/25/2026 at which time they confirmed their roommate, Resident 35 was belligerent toward them and their visitors. There was no noted interviews with Resident 14 at the time of the incident or at the time of the room move.WAC Reference 388-97-0640(1)

Based on interview and record review the facility failed to ensure a resident was not administered an antipsychotic (medication that affected the brain, emotions, or behaviors) unless the medication was necessary to treat a specific condition documented in the clinical record for 1 of 5 sampled residents (Resident 35), reviewed for unnecessary medications. This failure placed residents at risk of side-effects from the medications, unnecessary chemical restraints, and a diminished quality of life.Findings included .As referenced in the Food and Drugs/Drug (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, and they commonly cause complications such as movement disorders, falls with injury, stroke, and increased risk of death. The FDA 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 facility policy titled, Medications, Psychotropics, undated documented the facility would gather behavioral information and history of a resident when they admitted with psychotropic medications. During their stay, the residents would be monitored, assessed for environmental triggers, pain, depression, infection or other illness as possible factors that impacted the resident's behavior/mood. Nonpharmacological methods for resident challenging behaviors would be utilized prior to the use of a psychotropic medication.Resident 35 admitted to the facility on [DATE] with diagnoses to include dementia with behaviors and major depressive disorder.Review of Resident 35's admission Minimum Data Set (MDS-an assessment tool) dated 12/08/2025 showed they were severely cognitively impaired with a score of 4 out of 15 on their Brief Interview for Mental Status (BIMS-cognitive assessment tool).Review of Resident 35's Care Area Assessment (CAA-tool to create a care plan) dated 12/10/2025 documented they prescribed Seroquel (an antipsychotic medication) to treat dementia with behaviors. Resident 35 was described as having confusion and forgetfulness in addition to treatment for a urinary tract infection.Review of Resident 35's care plan dated 12/02/2025 documented they used Seroquel to treat dementia with behaviors with the goal to be free of complications related to use. Interventions included monitoring target behaviors for the use of Seroquel; yelling/screaming at staff, hitting/grabbing staff, and increased confusion. There were no monitors personalized to Resident 35's to capture psychosis (thought and emotions that are so impaired that contact is lost with external reality).Review of Resident 35's pharmacy review dated 12/31/2025 documented a recommendation for the provider to review Seroquel use as they had been taking an as needed dose prior to admission to the facility.Review of behavior monitors for December 2025 documented Resident 35 had 6 instances of yelling/screaming at staff during day shift, 13 instances during evening shift, and 3 instances during night shift.Review of Resident 35's behavioral progress note dated 01/06/2026 documented they were pleasantly confused with a bright affect and fully engaged in conversation.Review of Resident 35's electronic health record documented no information regarding their behaviors prior to their admission to the facility.In an interview on 03/25/2026 at 4:44 PM Staff J, Social Services Manager, stated Resident 35 admitted to the facility from an assisted living facility. Staff J stated Resident 35 often believed they worked at the facility and yelled out.In an interview on 03/26/2026 at 3:25 PM Staff D stated when a resident was placed on psychotropic medication there were assessments completed by social services. Staff D stated antipsychotic medications were used to treat behaviors like hallucinations and dementia with behaviors.In an interview on 03/27/2026 at 10:25 AM Staff B, Director of Nursing Services, stated Resident 35 admitted with confusion and difficult behaviors, was sent to the emergency room, and found to have a urinary tract infection.Reference WAC 388-97-0620 (1)(a)(4)(a)

Based on interview and record review, the facility failed to ensure reporting of alleged verbal and mental abuse, resident to resident altercations, to the State Agency for 2 of 2 residents (Resident 14 and unidentified resident), reviewed for abuse/neglect reporting. This failure placed residents at risk for potential unidentified and ongoing abuse and lack of protection from abuse.Findings included .Review of the facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated as version 09/21/2022 documented the facility would report per the Nursing Home Guidelines, The Purple Book, facility staff were mandated reporters and thy would report to state agency if they had a reasonable cause to believe or suspect abuse occurred to a vulnerable adult.Review of the Nursing Home Guidelines, also known as the Purple Book, dated October 2015 showed the facility was to report to the state agency and one method of reporting was by the state reporting log. The incident was to be reported via the reporting log within 5 days of discovery.Review of Resident 14's progress note dated 03/15/2026 documented they had a concern their roommate, Resident 35, was verbally abusive to their friends while visiting.In an interview on 03/24/2026 at 9:48 AM Resident 14 stated the facility had to move them to a different room after their room mate was insulting them and their visitors, calling them stupid.Review of Resident 35's progress note dated 12/31/2025 documented their roommate (unidentified resident) documented they were verbally aggressive and rude to them; however, they had not seen or heard the verbal aggression.Review of the state reporting log from December 2025 through March 23, 2026 documented no instances of a resident-to-resident verbal altercations.In an interview on 03/30/2026 at 9:41 AM Staff F, Nursing Assistant Certified, stated they were a mandated reporter, and they were required to make a report to the state hotline, their nurse, and DNS. Staff F described Resident 35 as being more vocal at night per report from night shift. Staff F stated Resident 35 could become angry and verbally unfriendly to staff. Staff F stated they had not witnessed but was informed Resident 35 was not nice to a prior roommate, could not recall their name and occurred a couple months ago.In an interview on 03/30/2026 at 10:17 AM Staff I, Licensed Practical Nurse, stated they were familiar with Resident 35 and had been informed, by other staff in report, they had been rude to a couple of roommates and families. When asked what was reported, Staff I stated Resident 35 had been belittling and degrading toward their roommates. Staff I stated belittling and degrading was a form of mental/verbal abuse. Staff I stated the facility moved Resident 35's roommate to another room. Staff I stated they did not witness the interaction between Resident 35 and Resident 14 as it occurred when they were not there.Review of the incident report dated 03/25/2026, received on 03/31/2026, documented Resident 35 had a history of being verbally aggressive toward their roommate as of 12/31/2025, had an interaction with Resident 14 and their visitors on 03/15/2026, and a room move was complete on 3/17/2026. Resident 14 was interviewed on 03/25/2026 at which time they confirmed their roommate, Resident 35 was belligerent toward them and their visitors. There was no noted interviews with Resident 14 at the time of the incident or at the time of the room move. Reference WAC 388-97- 0640 (2)(b).

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of five (Resident 31) residents reviewed for care planning. The failure to ensure the comprehensive care plan was implemented to maintain or attain the residents highest practicable well-being placed the residents at risk of not receiving services that would meet their needs, and a decreased quality of life.Findings included .Resident 31 was admitted to the facility on [DATE] with diagnoses to include chronic venous insufficiency (condition that damages leg veins and causes blood to pool in the legs), weakness, chronic pain and depression.Review of Resident 31's Activities of Daily Living (ADL) care plan documented they required extensive assist of 2 staff to turn and reposition in bed and also for personal care to be completed to help prevent them from rolling too close to the edge of the bed.Review of Resident 31's Kardex (resident care directive for Nursing Assistant Certified to provide care), dated 03/23/2026, documented they require extensive assist of 2 staff to turn and reposition in bed and for personal care to be completed to help prevent them from rolling to the edge of the bed with potential to fall.In a continuous observation on 03/23/2026 from 10:32 AM until 11:13 AM, Staff L, Nursing Assistant Certified (NAC), was observed to provide personal care, and incontinent care that required extensive bed mobility to Resident 31. Staff L, NAC, was observed to provide care independently and without another staff member. At 10:47 AM, Staff L stated to Resident 31 they had asked another NAC for assistance before they initiated the current care. Staff 31 encouraged Staff L to go get someone to help, Staff L stated they did not feel comfortable leaving them alone. At 10:51 AM, Staff S, NAC, knocked on the door, entered the room and asked if Staff L needed assistance with Resident 31's care.In an interview on 03/23/2026 at 11:51, Staff L stated they needed another staff member to complete care for Resident 31.In an interview on 03/30/2026 at 11:34, Staff B, Director of Nursing Services (DNS) stated their expectation was staff review the residents care plan, and Kardex to know what care a resident requires. Staff B stated their expectation was Resident 31 required 2 person assist for incontinent care, and bed mobility and that meant 2 staff were to provide care. WAC reference: 388-97-1020(1)(2)(a)(b)

Based on observation, interview and record review, the facility failed to provide assistance with grooming, including nail care for 3 of 4 residents (9, 31 and 37) reviewed who were unable to carry out their ADL's (activities of daily living) independently. Facility failure to provide the resident, who was dependent on staff for assistance with grooming, placed the residents and others at risk for poor hygiene, injury, unmet care needs and a diminished quality of life.Findings included .Review of the facility's policy, titled, ADL's revised July 2015, documented Nursing assistants will provide assistance with ADL's based on the resident's individualized plan of care. These interventions will be on the Kardex (tool that shows how to care for the resident), which is accessed in Point of Care (POC). Any changes noted in the resident's performance or abilities will be reported to the licensed nurse. <RESIDENT 7> Resident 7 admitted to the facility on [DATE] with diagnoses to include hemiplegia left hip fracture and osteoarthritis. In an interview and observation on 03/23/2026 at 11:54 AM, Resident 7 stated they had not had their toenails trimmed since admission. Their toenails were long extending over the toe. The resident asked who should be helping them with this. They stated they finally trimmed their fingernails because they were scratching them. In an interview on 03/25/2026 at 11:29 AM, Resident 7 stated they finally got their toenails trimmed when they asked Staff H, shower aide to clip them. Resident 7 stated Staff H told them that their nurse's aide could trim them as well. Review of the care plan dated 02/24/2026 showed the resident required the assistance of one person for grooming. <RESIDENT 9> Resident 9 admitted to the facility on [DATE] with diagnoses to include Diabetes Mellitus with neuropathy (nerve damage that occurs in people with diabetes), heart failure (chronic condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and muscle weakness. Review of Resident 9' care plan documented no interventions related to fingernail care. Review of Resident 9's provider (Physician, Medical Doctor, Physician's Assistant or Advanced Registered Nurse Practitioner) orders documented they were to have nails checked by a Licensed Nurse every week. Review of Resident 9's Treatment Administration Record (TAR) dated March 2026 documented their nails had been checked on 03/7/2026, 03/14/2026, and 03/21/2026. In an observation on 03/23/2026 at 09:40 AM, Resident 9 was observed to have long fingernails with yellow and brown matter underneath. In an interview on 03/23/2026 at 10:33 AM, Resident 9 stated that the nurse was supposed to cut his fingernails and acknowledged their fingernails were long with brown matter underneath. In an observation on 03/24/2026 at 09:31 AM, Resident 9 was observed to have long fingernails with yellow and brown matter underneath. In an observation on 03/25/2026 at 11:21 AM, Resident 9 was observed to have long fingernails with brown and yellow matter underneath. In an observation on 03/27/2026 at 10:01 AM, Resident 9 was observed to have long fingernails with brown matter underneath. In an interview on 03/30/2026 at 10:17 AM Staff I, Licensed Practical Nurse (LPN) stated they had been told they were not supposed to cut diabetic resident's fingernails and podiatry was responsible to cut their fingernails. In an interview on 03/30/2026 at 11:34 AM, Staff B, Director of Nursing Services (DNS) stated the Licensed Nurses were responsible to cut Resident 9's fingernails since they were diabetic. <RESIDENT 31> Resident 31 was admitted to the facility on [DATE] with diagnoses to include chronic venous insufficiency (condition that damages leg veins and causes blood to pool in the legs), weakness, chronic pain and depression. Review of Resident 31's skin integrity care plan documented an intervention to keep their fingernails short, intervention initiated on 10/06/2022. In an observation and interview on 03/24/2026 at 10:35 AM, Resident 31 was observed to have long fingernails with matter underneath and stated staff cut their fingernails. In an observation on 03/25/2026 at 09:23 AM, Resident 31 was observed to have long fingernails with brown matter underneath. In an observation on 03/26/2026 at 08:49 AM, Resident 31 was observed to have long fingernails with discolored matter underneath. In an observation and interview on 03/27/2026 at 10:04 AM, Resident 31 stated their fingernails were still long, observed fingernails to be long with brown/yellow matter underneath. In an interview on 03/30/2026 at 09:29 AM, Staff F, Nursing Aide Certified (NAC), stated they review a resident Kardex (resident care directive for NAC's to provide care) to know what care the resident requires. Staff F stated nail care can be done by NAC's unless the resident was diabetic. Staff F stated if they saw a resident who had long nails or matter underneath the nails, they would offer to clean out the matter from under the nails and offer to trim the nails. Review of Resident 31's Kardex dated 03/23/2026 documented to keep fingernails short in the resident care section. In an interview on 03/30/2026 at 10:17 AM, Staff I, LPN, stated they had not looked at Resident 31's nails. In an interview on 03/30/2026 at 11:34 AM, Staff B stated their expectation is that staff review residents care plans and Kardex's to know what care a resident requires. <RESIDENT 37> Resident 37 admitted to the facility on [DATE] with diagnosis to include cerebellar Review of Resident 37's care plan, dated 07/18/2024, showed Resident 37 had an ADL self-care performance deficit related to stroke, left side weakness and cerebellar ataxia. The care plan showed the residents required one person extensive assistance for all grooming. Review of a progress note dated 07/17/2025 at 4:32 PM showed Resident 37 had self-inflicted scratches to both cheeks. Review of a progress note on 01/07/2026 at 5:56 PM, showed Resident 37 had scratches on their face and bloody fingernails. Resident replied yes to facial itching and nails were trimmed. In an observation on 03/24/2026 at 8:46 AM Resident 37 was in the activity room watching TV. Their fingernails were long and jagged. In an observation on 03/26/2026 at 9:00 AM Resident 37 was up in their wheelchair across from the nurse's station. The resident had a large band aid on the left side of face. Review of a progress note on 03/26/2026 at 7:14 AM, showed self-inflicted scratches found below the residents' left ear and their cheek. Fingernails were documented as sharp. Review of a provider visit note dated 03/28/2026 at 8:22 AM, documented that on 03/26/2026, two self-inflicted scratches were noted on the face, one below the left ear with minor bleeding and one on the right cheek without bleeding, both cleaned and dressed with antibiotic ointment and elastic bandages. The note showed that on 03/27/2026, skin assessment documented two new scratches, 4 centimeter (cm) on the right and 2 cm below the left ear. In subsequent observations on 03/27/2026 at 9:13 AM and 3:09 PM Resident 37's nails remained long and jagged. In observations on 03/30/2026 at 9:15 AM and 3:44 PM, Resident 37 were asleep in their recliner and nails remain untrimmed and long. In an interview on 03/30/2026 at 9:46 AM, Staff F, NAC stated the NACs were expected to clip nondiabetic residents' fingers and toenails. Staff F stated nurses did nail care for diabetic residents. They stated Staff H usually clipped nails during showers and some NAC's expected Staff H to clip them. In an interview on 03/30/2026 at 10:24 AM, Staff I, LPN stated they were unsure if the Podiatrist or nurses were expected to trim toenails. Staff I stated Podiatry did not come in every month but visited every 3 months. Staff I stated they had asked several Director of Nurses (DNS) who was responsible to do diabetic nail care and they never get an answer. Staff I stated the NACs are to clip finger and toenails for residents that are not diabetic. In an interview on 03/30/2026 at 12:19 PM, Staff B, DNS stated preferably the shower aide, or aide should cut nails unless the resident is diabetic. Staff B was unaware Resident 7 asked to have their toenails trimmed for a month and Resident 8 still had long jagged nails after self-inflicted facial scratches last week. Staff B stated podiatry came to the facility every 3 months. Reference: (WAC) 388-97-1060 (2) (c)

Based on observation, interview, and record review, the facility failed to ensure 2 of 3 residents (Resident 14 and 27) reviewed received the necessary care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The failure to secure a wound vacuum (wound vac-medical device that uses controlled suction to speed healing of chronic or deep wounds) when ordered, provide pressure relieving devices and supplements as ordered for Resident 27 placed them at risk for delay in healing and poor quality of life. The failure to coordinate timely a timely orthopedic appointment per resident's orders and preferences placed them at risk for delay in healing for Resident 14. These failures placed all residents at risk for delay in care and treatment, confusion, and potentially poor quality of life. Findings included .<RESIDENT 14>Resident 14 admitted to the facility on [DATE] with diagnoses to include fracture and urinary tract infection.In an interview on 03/24/2026 at 8:55 AM Resident 14 stated they were concerned about a follow up appointment with an orthopedic surgeon. Resident 14 stated they had been at the facility for 11 days and had been asking for an appointment with their orthopedic surgeon. Resident 14 stated they asked the nurse and several nursing assistants but had not heard anything.Review of Resident 14's hospital Discharge summary dated [DATE] documented orders for them to follow up with their primary care physician and orthopedic physician.Review of Resident 14's provider note dated 03/12/2026 documented order for them to see an orthopedic provider for a consultation. Review of Resident 14's care plan dated 03/19/2026 documented they were to follow up with an orthopedic provider.In an interview on 03/26/2026 at 9:53 AM Staff U, Health Information Management HIM), stated they were responsible for scheduling appointments and worked alongside Staff D, Licensed Practical Nurse (LPN), to schedule and coordinate appointments. Staff U stated a fax was sent to the orthopedic clinic on 3/12/2026 to coordinate an appointment. Staff U stated an appointment was scheduled on 03/25/2026 after contact with the orthopedic clinic on 03/20/2026 revealed they had not received the initial fax sent on 03/12/2026. Staff U stated referrals or appointments needed for residents are completed at admission. In an interview on 03/26/2026 at 10:21AM Staff D, LPN, stated ordered referrals and follow up appointments were noted, put into the clinical record and communicated to Staff U, HIM to schedule. Staff D stated they spoke to residents about their appointments to ensure they were on the same page. Staff D stated they had not spoken to Resident 14 about their orthopedic appointment and were not aware they had concerns about the scheduling of an appointment. Review of Resident 14's progress notes from 3/11/2026 through 3/23/2026 documented no information related to scheduling an orthopedic appointment. Review of fax cover sheet dated 03/12/2026, from Staff D, LPN, to the orthopedic clinic documented Referral to set up ortho [orthopedic], New patient. Call to set up appt with [Staff U]. There was no confirmation that the fax had gone through. In a follow up interview on 03/27/2026 at 3:09 PM Resident 14 stated they were told about the orthopedic appointment scheduled on 03/25/2026 until about a half an hour prior to it occurring. Resident 14 stated the nursing assistant came in and said they had an appointment with the orthopedic doctor. Resident 14 stated no notice was given to them in writing.<RESIDENT 27>Resident 27 admitted to the facility on [DATE] with diagnoses to include pressure ulcer of the left buttock.Review of Resident 27's Minimum Data Set (MDS-an assessment tool), dated 03/12/2026, documented they had skin care related to pressure ulcers.Review of Resident 27's Care Area Assessment (CAA-tool used to create care plans) dated 3/16/2026 documented Resident 27 had multiople skin related conditions to include a pressure ulcer to their left buttock and wound care provided as per wound clinic orders. Resident 27 was followed by the hospital wound clinic and orders were to be followed per their recommendations and orders.Review of Resident 27's care plan dated 03/17/2026 documented that they had a pressure ulcer to their left buttock and were at risk for development of additional pressure ulcers due to decreased mobility with the goal of the pressure ulcer would show signs of healing within infection. Interventions included administering treatments as ordered and monitor for effectiveness, continued wound clinic appointments as scheduled, provide supplements as ordered (Vitamin C and Zinc) and wound care per order from the wound care clinic.Review of Resident 27's wound care note dated 03/12/2026 and 03/19/2026 documented orders for the following:-Specialty Bed/Mattress for pressure reduction. Patients need low air loss mattress overlay, group 2 specialty mattress (designed for hospital beds and features alternating pressure, low pressure, lateral rotation to reduce pressure ulcers).-Take Vitamin C 1000 milligrams (mg) daily by mouth-Take Zinc 25 mg by mouth daily-Return appointment in one week-please initiate wound vac (specialty medical device used for wound healing), order and send to next appointment.Review of Resident 27's order summary as of 03/23/2026 documented they had orders for the following:-Obtain alternating pressure mattress related to pressure wounds to left buttocks and bilateral thighs dated 03/06/2026- Vitamin C Oral) Give 500 mg by mouth one time a day for wound healing dated 03/09/2026-Zinc Sulfate Tablet 50 mg by mouth one time a day for wound healing dated 03/09/2026-Wound Care for left buttocks and use of wound vac dated 03/20/2026On 03/23/2026 at 2:51 PM, 03/24/2026 at 9:13 AM and 3/26/2026 at 10:56 AM observed Resident 27's bed and mattress. Resident 27's bed was observed not to have an alternating pressure mattress.In a review of Resident 27's progress notes dated 03/20/2026 documented the wound vac was placed per wound clinic orders, 8 days after receipt of the wound clinic order.In an interview on 03/26/2026 at 12:13 PM Staff I, Licensed Practical Nurse, stated Resident 27 had their wound vac placed on 03/20/2026.In an interview on 03/27/2026 at 10:11 AM Staff D, LPN, stated they attempted to obtain a wound vac for Resident 27 through a medical supply company, however, was notified the facility did not have a contract and had to find a different company. Staff D stated they informed the wound clinic about the delay for Resident 27's wound vac and stayed in contact with them. When asked about orders for the alternating pressure mattress and supplements (Vitamin C and Zinc) Staff D stated they were standing orders given by the wound clinic for their patients and due to Resident 27's mobility, independent with walking, an alternating pressure mattress was not indicated. Staff D stated Resident 27 did not have an alternating pressure mattress on their bed. Staff D stated they had not documented their conversations with providers with regard to the wound vac in Resident 27's medical record.Reference WAC 388-97-1060(1)(3)(b)

Based on interview, and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse for 1 of 3 sample residents (Resident 2) reviewed for abuse. Resident 2 experienced harm when they had increased discomfort when a caregiver was physically forceful in providing care, and psychological harm when the resident expressed there was a delay in seeking continence care and remained in soiled briefs until the next shift due to fear and humiliation. This failure placed all other residents at potential risk for abuse, discomfort, risk of injury, psychosocial harm, and diminished quality of life. Findings included . Review of the facility policy, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, dated 09/21/2022, showed it is the facility policy that residents had the right to be free from abuse, neglect, misappropriation, and exploitation, and included freedom from verbal, mental, or physical abuse. All staff are expected to report any signs/symptoms of abuse to the Administrator or Director of Nursing Services (DNS) immediately. Resident 2 admitted to the facility on [DATE] with diagnoses to include an inoperable fracture around the prosthetic (artificial joint) in their right hip, anxiety, depression, and chronic pain. Review of the Admission Minimum Data Set (MDS - an assessment tool) assessment, dated 04/01/2024, showed Resident 2 was cognitively intact. Resident 2 required maximum assist for bed mobility. Review of Care Area Assessments (CAA - a systematic process to interpret the triggered information from the MDS assessment to assess the potential problem and determine if the area should be care planned), dated 04/01/2024, showed Resident 2 was noted to have a significant decline from their baseline activity of daily living functions due to decreased strength, acute right hip pain, impaired mobility, decreased activity tolerance and required moderate to total assistance with mobility. Review of a nursing progress note, dated 03/26/2024, showed Resident 2 was alert and oriented and able to make their needs known. In addition to the peri-prosthetic right hip fracture, Resident 2 had a left wrist sprain. Review of a facility investigation, dated 04/02/2024, showed Resident 2 reported concerns with cares provided by Staff B, Certified Nursing Assistant (CNA), starting on their date of admission, 03/26/2024. Resident 2 reported on their first day at the facility, while providing care, Staff B told the resident You got to do better than that, and told the resident's family to leave the room. Resident 2 reported Staff B pulled on their broken hip during their brief change and told the resident If you want it done you have to roll over. The resident stated Staff B showed disrespect and manhandled them, told them to do what you are told, it's my job I know how. Resident 2 stated they had grabbed Staff H, CNA, who helped Staff B provide incontinent care, shirt to steady themselves and Staff B told them to not touch the CNA, and if you hurt him, you hurt me. Resident 2 stated Staff B yanked their pants down roughly and was nasty, curt, and rude. The resident stated they stopped talking. Resident 2 stated when they put their call light on, Staff B would turn the light off, not offer help, and not return. The resident stated they laid in bed wet until the next shift came because they were afraid and humiliated. Review of the facility's interview with Collateral Contact 1 (CC1), Resident 2's family member, dated 04/02/2024 at 1:30 PM, showed on the day of admit (03/26/2024) when Staff B and another CNA were providing care, CC1 had to support the resident's leg when staff turned Resident 2 because Staff B was pulling on the resident without supporting their injured leg. CC1 stated Staff B had not shown any kindness. They stated had Resident B been unable to verbalize their needs, they didn't know what may have happened. CC1 stated this type of treatment occurred not just on admission but also the following days, and stated the resident was worried about whether Staff B would return to work. In an interview on 04/11/2024 at 12:30 PM, Resident 2 stated the day they arrived at the facility they were useless to do anything on my own and having horrific pain. Resident 2 stated they had just arrived at the facility and did not yet have quarter length side rails on their bed to assist with mobility, so were unable to do anything to help with rolling back and forth in bed. The resident stated Staff B and Staff H assisted with changing their brief, and Staff B ordered them, in a sharp tone, to turn over. Resident 2 stated when they informed Staff B they couldn't roll over, Staff B said they had to and started pushing them over. Resident 2 informed Staff B they were hurting them, and Staff B said It's going to hurt worse if you don't move and kept pushing until they were on their side against Staff H on the other side of the bed. Resident 2 stated they were scared, and spontaneously grabbed Staff H's shirt. Resident 2 stated when they were rolling back, Staff B yelled at them you are pushing against me, I don't want you to hurt my back. Resident 2 stated they asked Staff B if they knew why they were at the facility, and Staff B said, I know my job, and left the room. Resident 2 stated Staff B had a sergeant-like attitude; each time they entered their room they gave orders, had a very forceful attitude and were very forceful with their movements and not at all gentle. Resident 2 said Staff B would make them roll totally against the rail, and said their treatment and attitude was awful. Resident 2 stated Staff B flipped them over, pulled on them, and grabbed their injured leg. When they told Staff B they were hurting them, Staff B said they had to do it if they wanted to be changed. Resident 2 stated they did not understand why Staff B treated them so rough and would not listen to them. The resident said, I couldn't do what Staff B wanted; they continued with the commands, and I needed help. Resident 2 stated when they put their call light on, often Staff B came in and turned it off without saying a word or asking what was needed, so they just laid in bed with a wet brief until the next shift came because they were humiliated and afraid to persist with trying to get care. Resident 2 stated Staff B was nasty, curt, and very rude, so they just quit talking. Resident 2 stated they had tried to give Staff B a chance, but by the third day of their rough and rude treatment they had to report it. Resident 2 stated they could not handle how demeaning and disrespectful Staff B was and had manhandled and ordered me around. Resident 2 stated it was very distressing those first three days when Staff B was their CNA, but they have tried not to dwell on it and currently felt safe at the facility. In an interview on 04/15/2024, Staff A, Registered Nurse/DNS, stated Staff B just doesn't get it, sees everything in black and white, and there was no softness about them. Staff A stated they worried about those residents who were unable to speak up and report if Staff B was abusive. Staff A stated Staff B did not seem to understand they could not talk/act that way to residents. In an interview on 04/17/2024 at 1:35 PM, Staff I, CNA, said some residents had complained to them about Staff B being rough and rude with cares on night shift. Staff I stated most had already been discharged . In an interview on 04/23/2024 at 1:32 PM, Staff D stated they had worked with Staff B a few years ago and had observed them being physically rough with residents. Staff D stated since Staff B was re-hired, they had not worked with them, but had worked day shifts, following many night shifts when Staff B had worked. Staff D recalled several residents had informed them they were relieved when Staff B's shift was over. Staff D stated an unidentified former resident told them almost the identical complaints about Staff B as Resident 2 had; Staff B handled them rough and was rude and spoke down to them. Staff D stated Resident 2 informed them numerous times that Staff B had been rough and rude to them. Staff D stated the resident had declined to file a grievance due to Resident 2 wanted to win [Staff B] over. Resident 2 finally agreed to have Staff D report Staff B's abusive behavior to the facility's management. Staff D realized they should have reported the allegations when first told. On 04/25/2024 at 2:10 PM, Staff A stated when making the decision on whether abuse was substantiated, they reviewed the investigation, consulted with the company's nurse consultant and the owner of the company who was acting as interim Administrator. Staff A stated they used nursing judgment to determine if abuse occurred; if a resident was not alert, oriented, and able to report, and the same events happened, would the resident have been harmed and facility not been aware. Staff A stated they discovered Staff B's history of similar behaviors and treatment of residents and made the decision to terminate their employment. Refer to CFR 483.10(e), F-557 - Respect, Dignity/right to have Personal Property. Refer to CFR 483.12(b), F607 - Develop/implement abuse/neglect policies. Refer to CFR 483.12 (c), F-610 - Investigate/prevent/correct alleged violation. Refer to WAC 388-97-0640(1)

Based on interview and record review, the facility failed to provide adequate supervision for one of three residents (1) reviewed for falls. This failure caused harm to Resident 1 who sustained physical injury and placed other residents at risk for potential harm and injury. Findings included . Review of facility policy titled, Safety and Supervision of Residents, undated, showed Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy interpretation and implementation included, The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Resident 1 admitted to the facility on [DATE] with diagnoses to include [CONDITION(S)] (progressive disease of nervous system marked by tremor, muscular rigidity and slow, imprecise movement), dementia, increased weakness and falls at home. Review of Resident 1's five day Minimum Data Set assessment dated [DATE], revealed they had short and long-term memory impairment, frequent incontinence of bowel and bladder, had falls in the past month and past 6 months, and required extensive assistance for mobility. Review of the facility incident log showed Resident 1 had falls from their wheelchair on 05/13/2022, 05/15/2022, and 05/17/2022. The falls on 05/13/2022 and 05/17/2022 occurred in dining room area. Review of facility incident report dated 05/17/2022, showed Resident 1 had been alone in Progressive Self Feeding Program (PSFP) dining room and was attempting to leave the room and had an unwitnessed fall. The incident report indicated the resident had a history of falls and cognitive impairment. The incident report did not indicate when the resident was last toileted or changed, re-positioned in the wheelchair (w/c), checked for safety, or when they were brought to the dining room and finished breakfast. Review of a progress note dated 05/17/2022, revealed the nurse heard a loud thud from the dining room at 10:30 AM and Resident 1 was found face down on the floor in front of the w/c. The resident was noted to be incontinent of stool when found on the floor. Review of handwritten incident review dated 05/18/2022 and signed by the Administrator and co-signed by interdisciplinary team, showed under 5 Why's, history of falls, cognition, he was alone in dining room (PSFP) after eating . Review of the resident's care plan showed they were at high risk for falls related to deconditioning, gait/balance problems, and [CONDITION(S)]. Interventions included anti-rollback w/c (a device put on the w/c so when the resident would go backwards it would stop the w/c from doing to) and not to be out of vision of staff when in their w/c. Additionally, the care plan showed the resident had limited physical mobility and was totally dependent on staff for locomotion. Review of hospital emergency department and history and physical report dated 05/17/2022, revealed the resident sustained a right orbital fracture and laceration to right forehead. On 06/13/2022 at 3:20 PM, Staff B Licensed Practical Nurse (LPN), stated Resident 1's spouse stated the resident had so many falls at home that the dry wall was dented. Staff B stated the resident was a very tall man and moved very quickly. They stated they had intercepted a potential fall at the nurse's station when the resident attempted to stand up from the w/c. Staff B stated the facility had not had sufficient staff to provide one on one care for a resident if needed. In an interview on 07/01/2022 at 12:38 PM, Staff C, LPN, stated at the time Resident 1 had a serious injury fall in May, they also had another high fall risk resident and they tried to keep the residents by the nurse's station when they were out of bed because they were constantly up and down from bed or their chair. In an interview on 07/01/2022 at 1:10 PM, Staff D, Nursing Assistant (NA), stated Resident 1 was supposed to have been taken out of the dining room right after meals. In an interview on 07/01/2022 at 3:30 PM, Staff E, LPN, stated Resident 1 had been very impulsive and in constant need of supervision. Staff E stated they would check on the resident, walk back to the medication cart, and they were already self-transferring. Staff E stated this resident and another high fall risk resident at the time needed to be in a dementia facility or provided one to one care. In a telephone interview on 07/06/2022 at 1:10 PM, Staff A, Registered Nurse (RN), stated they were Resident 1's nurse at the time of their fall on 05/17/2022. Staff A stated the resident was provided morning care, received medications and was taken to the dining room approximately 8:00 AM to 8:30 AM. Staff A stated the resident's fall occurred at approximately 10:15-10:30 AM, over two hours after being taken to the dining room, and the resident was incontinent of stool at the time. Staff A stated the resident was very confused at baseline and attempted for some reason to stand up from the w/c. Staff heard a thud and found the resident on the floor; unresponsive and bleeding from their nose. In a telephone interview on 07/06/2022 at 3:10 PM, Staff H, NA, stated staff were not to leave residents unattended in the dining room area, especially confused residents. On 07/07/2022, the Director of Nursing Services (DNS) stated residents who had confusion, dementia, and/or needed assist with mobility should have been assisted out of the dining room right after meals and brought back to their room for cares or if going to bed or kept in a supervised area. The DNS stated they should not have been left unsupervised in the dining room area and stated the expectation was that staff would use common sense about not leaving confused residents in the dining room after they finished eating. (WAC) Reference 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility Administration failed to administer the facility effectively and efficiently to ensure the facility's finances were maintained effectively. The Administration 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 facility Administrator 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 the facility appointed a new Administrator, 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 at 2:18 PM, the building owners indicated, the Acting Administrator (AA) was also the owner of the company, WAATU, Inc. that managed the facility. Record review showed the AA was the Licensee of the facility and became the Administrator of the facility on 02/25/19 when the permanent Administrator left the position. Interview revealed that most all of the major vendors for the facility were also vendors for another nursing home that the AA managed. The AA leased the building from a company, Adventurer Senior Living, Inc. (ASL), the building owners. The building owners stated that the AA was past due on his leases in the approximate amount of $800,000.00 dollars. The owners of ASL also reported the AA owned approximately $80,000.00 in past due employee health insurances. In an interview on 08/22/19 at 2:58 PM, the co-owner of the pharmacy stated that WAATU, Inc. owed the approximately pharmacy $329,000, which included (MONTH) - (MONTH) billing. He stated the pharmacy used to get a check every month. He said the pharmacy supplied both of the company's nursing homes. He said that if they did not get a check by tomorrow, 8/23/19, 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 payment for the next day, but the pharmacy partners would continue to review this. In an interview on 8/22/19 at 4:46 PM, Staff A, the head of the therapy department and former Administrator of the building, stated he received a call from Money Saver Mini-storage and was told, the facility had been behind in paying their bill since (MONTH) 19, 2019, and the facility now owed $855.00 dollars. Staff A was told by the storage company, that if the facility did not pay by [DATE], the storage company would take over the locker. Staff A went on to say the facility had confidential employee files and some resident equipment in the locker. Staff A stated he received calls at least once a week regarding the facility being behind in their bills. When the residents required prosthetics/orthotics/braces he called the local orthotic company to order them. When this occurred, they told him the facility owe money, and they cannot help him unless the facility paid their bill or purchased the equipment cash on delivery. Staff A said they have always received the equipment but now he has to deal with being told the facility owed the company money. Staff A said he posted help wanted advertisements on a Social Media web site for nursing staff. Staff A received a message from the site saying that the facility owed money and the advertisement had been removed. Staff A said he had a company credit card, and when the facility needed office supplies he would go to the local office supply company and found out the facility owed the company money, and when he tired to charge the supplies using the company credit card it was denied. Staff A stated that this also occurred at times when he went out to obtain nursing supplies. Staff A said that he had ordered wheelchair (w/c) cushions, w/c's , walkers, or exercise bands from a local company. Staff A was told that the company would not ship until they (the facility ) had paid the last two months of bills. In a joint interview on 08/22/19 at 5:25 PM with the Director of Nursing (DNS) and Staff B, Registered Nurse, the DNS stated the Registered Dietician (RD), had not been to the facility, because the facility had not paid the RD's company. Staff B stated that she tried to get transportation for a resident to Seattle and the transportation company stated the facility would have to pay up front because the facility owed money. The DNS stated the facility owed the transportation company approximately $5,000 from (MONTH) of 2019. 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 $618,000. 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 in payroll taxes and $372,000 in payroll equaling $488,000. 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 (on 08/23/19) he was paying: Relias, the training company $13,000 to resume services, $53,000 to pharmacy, so they would continue to supply medications, an Insurance broker so they can find insurance for their employees, Dietary services, and the Storage fee of $ 800. In a phone call on 08/23/19 at 11:35 AM, Staff A stated that an employee had went to the dentist. The dentist office told the employee they were not part of a plan, and that the facility would have to pay up. The dentist told the employee they have the option of either paying out of pocket or rescheduling their appointments once their plan is back on line. In an email on 08/23/19 on 11:51 AM from Pay Northwest, a payroll agency. A review of the statement showed the facility owed this company approximately $45,000.00 dollars. In a joint telephone conference call on 08/23/19 at 1:00 PM with the Department and the facility Attorney it was mentioned that the owner owes health insurance in total he owed $145,000.00 that is due by 09/10/19. The AA had not been paying all bills timely to ensure staff had access to resources to care for the residents or that the employee's payroll contributions were paid timely to allow employees their health benefits. 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 Administrator/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 38 residents in the facility. The Company owner/Administrator did not create a functioning system to oversee the owner/administrator, hold the owner/administrator 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: Fidalgo 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. In an interview on 08/27/19 at 2:27 PM, the 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 owner/Acting Administrator accountable, since the Administrator 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 owner/Administrator of the company showed the acting Administrator was also the governing body. There was no system in place to provide active, engaged oversight of the owner/administrator to ensure bills were paid timely when a financial crisis began. In review and interviews with staff on 08/22/19, 08/24/19, 08/25/19, 08/26/19 and 08/28/29 the facility had multiple outstanding bills for vendors that were either unpaid and or were consistently paid late. Staff were paid but employee benefits were not being submitted timely, potentially leaving employees with no health benefits. This placed the residents at risk of not having needed supplies, staff/care givers if they were to quite due to lack of promised benefits not being paid. On 09/03/17 at 10:17 AM, a request was made to review the background check for the Acting Administrator (AA). The last background check was from (MONTH) of (YEAR), even though the AA had unsupervised assess to residents. The lack of a governing body to oversee the AA showed there was no accountability of the AA to ensure bills were paid, the AA was held accountable, or that background checks were completed per regulation. Reference: WAC 388-97-1620 (2)(c)

Based on observation, interview and record review the facility neglected to follow documented orders and provide wound care for 1 of 4 residents (29) reviewed. These failures resulted in harm to Resident 29 in the form of a decline in the resident's health which required re-hospitalization , a second surgery, a [DEVICE] (negative-pressure wound therapy) attached to the resident's chest and six weeks of antibiotic therapy in the hospital. Findings included: The facility skin protocol stated the goal was to reduce the risk of skin breakdown, identify skin issues in a timely manner, and to resolve any skin issues as quickly as possible. The admitting Licensed Nurse (LN) would do a thorough head to toe assessment to identify any skin issues upon admission and would initiate preventative/breakdown risk reduction interventions from the time of admission. The policy stated skin will be observed with provision of care and all caregivers were instructed to report any findings to the LN on duty. The physicians would be notified of new and worsening skin issues and treatment orders obtained. Resident 29 admitted on [DATE] following a complicated cardiac surgery on 05/21/18. The resident had coexisting conditions including diabetes which placed her at higher risk for postoperative complications such as infection and poor healing. The resident's hospitalization included complications related to increased fluid which required medications to remove the excess fluid (diuretics). A review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact with no rejections of care and required extensive assistance with activities of daily living such as dressing, bathing and mobility. The MDS further stated the resident had a surgical wound present with no surgical wound care needed. Record review of the admitting physician's orders [REDACTED]. please notify the medical doctor (MD) if signs of infection develop. The resident's surgeon was listed as the MD to notify. The physician's orders [REDACTED]. doctor for possible increase in diuretic medication. Record review of the care plan dated 06/14/18, showed the resident had sternal precautions (restrictions on lifting and use of the arms related to the healing of the chest) following the cardiac surgery for [REDACTED]. An intervention for activities of daily living dated 06/15/18, showed provide assist at back of pants and for bra in order to follow sternal precautions. The only intervention related to the resident's mid chest surgical sternal wound stated, sternal incision open to air, may shower. A review of the resident's Treatment Administration Record (TAR) showed no monitoring was in place to observe or provide surgical wound care to the resident's sternal wound. The TAR showed the resident had an increase in weight of 5 lbs in one day from 06/20/18 to 06/21/18 and a further increase of 2 lbs from 06/21/18 to 06/24/18 (7 lbs in 5 days.) A review of progress notes and physician notes showed no evidence that the sternal wound was being assessed or that surgical wound cleansing was being completed by the facility nursing staff. There was no documentation that the MD had been notified of the increase in weight. There was a progress note on 06/24/18 at 2:34 PM, stating the physician had been faxed rather than phoned regarding a high blood sugar and to reassess the resident's swelling. A review of an admission note from the Advanced Registered Nurse Practitioner dated 06/15/18 at 3:25 PM, showed the resident's sternal wound was glued and intact. There were no other entries found in the resident's medical record that described or assessed the resident's sternal wound until 06/24/18. A skin observation tool dated 06/24/18 at 1:34 PM, but not signed until 06/25/18 at 7:10 PM, showed that a facility nurse (Staff G) had documented the resident's sternal wound was well approximated and stitches intact with no s/sx (signs and symptoms) of irritation or redness. Staff G made a progress note on 06/25/18 at 2:20 PM stating that the resident had been sent to the hospital related to 1/3 of the sternal wound open where the resident's bra was rubbing. In an interview on 06/28/18 at 3:40 PM the Director of Nursing Services (DNS) stated she had been aware that the resident's sternal wound was angry three or four days before. The DNS stated she had observed the wound the previous Thursday (06/21/18) and it looked like it was still healing but not as well. The DNS stated she thought she had reminded the resident not to wear her bra .she basically wanted to wear a bra. The DNS further stated that the resident did not want to take showers and that the resident was doing her own soap and water washes. The DNS denied she did any documentation nor did she inform the doctor regarding the condition of the wound. When the DNS was made aware that there was no evidence that the resident's wound was being assessed or cleansed for the 10 days she was in the building, the DNS did not have further information. The DNS explained that there would only been one skin assessment per week. Assessing skin was done by exception. When asked regarding the inconsistent skin observation tool completed by Staff G, the DNS stated that she did not believe the skin observation tool was accurate based on her own observation of the wound on 06/21/18 and stating, I know she didn't see it with me that day, and she didn't have stitches, her wound was closed with glue. The DNS stated she would need to get more information about that assessment from Staff G. There was no documentation that the surgeon had been notified of any change in the resident's sternal wound on 06/21/18. There was also no documented evidence that there had been a contraindication to the resident wearing a bra or that any clarification had been obtained from the surgeon regarding recommendations or restrictions on clothing for the resident. A review of a primary physician visit note dated 06/25/18, stated sternum incision looked stable to top half .unfortunately, the lower half was open with quite a bit of tissue and drainage .there was surrounding [DIAGNOSES REDACTED] (redness). The note indicated the resident was noted to have been gaining weight and the swelling in her foot was getting worse. The physician documented the resident had a large open area on the bottom half of her sternal incision which looked like it could be infected as well. The physician reviewed the information with the resident's surgeon and a decision was made to admit her to the hospital. A review of the hospital readmission note dated 06/26/18, showed the resident was admitted with sternal wound dehiscence (separation of the incision) and liquefactive necrosis described as irreversible injury to cells causing cell death .can be caused by infectious agents with onset date listed as unknown. The wound assessment stated the sternal incision was un-approximated, distal, 3 inch by 3 inch, with horizontal and vertical tunneling, sternal wire exposed. Apparently the patient's wound was not examined for a number of days and when it was, noted to have fairly extensive dehiscence directly between both breasts. The dictation stated the resident reported she was doing daily cloth baths but that her sternal incision had not been cleansed since her last physician assessment, when she was in the hospital before admission to the facility. On 06/27/18 at 11:05 AM, in an interview with the RN Cardiac Transition Coordinator at the hospital who stated she had called the facility on 06/23/18 at 1:28 PM, and spoke with Staff G, LPN, who reported the resident was doing well. The resident was admitted to the hospital on [DATE]. The resident had surgery on 06/26/18 which required a debridement of the wound and a [DEVICE] applied to the residents chest. She stated we did not feel the wound was cleansed daily and they did not follow the surgeons orders. The protocol for these types of chest wounds is daily showers with soap and water when unable to shower the wound needed to use wound cleanse since this was not done, the wound dehisced. Photos of the wound were also obtained as part of the documentation at the hospital. A review of the lab cultures dated 06/27/18, showed moderate growth of gram positive rods with Staphylococcus. On 07/02/18 at 5:00 PM, in an interview with the resident's surgeon at the hospital, who stated he considered his patient to be medically frail and had multiple risk factors for a non-healing wound. The surgeon stated we sent her to a facility to have surveillance. In the case of no news is good news, that's not how this went for the patient. When she was here we worked out a glucose control program for her which was working and I forwarded to the facility. The patient told me that her blood sugars were all over the place and they had no consistency in their system. They didn't follow my plan. The surgeon also stated his orders for the three week old chest wound were to wash daily and if can't shower needed to have wound cleanse applied. The surgeon was informed that the resident was left to cleanse her own wound, there was no supervision of the wound. The surgeon replied the patient was unable to even look at the wound when she was here in the hospital, I can only imagine how much time she spent cleaning it. The surgeon stated he was shocked when the facility physician called him and stated it was the first time she had visualized the wound. The surgeon stated I found this disturbing. When I saw the photos I was shocked, not only did no one call me, but the wound had already fallen apart. It didn't just one day fall apart, that took time. When the patient arrived she also told me that no physician had looked at her wound while she was in the facility. I felt no physician was there to look at the wound until it fell apart. I found this to be neglectful on the physicians part. The surgeon stated the wound was debrided down to her sternum and now she was at risk for a sternal infection and will have weeks of intravenous antibiotics. There was also a [DEVICE] applied to the chest wound. When asked if wearing a bra caused this to happen to her sternal incision, the surgeon said unless her prosthetic bra was on her midline, which it was not, it was not an issue. The surgeon was also informed about the weight gain that was not reported to him. He verified that he received no calls from the facility. The surgeon stated, The wound literally fell apart, I felt this was unusually neglectful for no one to check this wound. On 07/05/18 at 10:10 AM, the resident was interviewed in the hospital. The resident was neatly dressed and sitting up in a chair, both feet were elevated and the resident had a [DEVICE] machine next to her on the bedside table. The resident was receiving an intravenous antibiotic. When asked about her care at the facility she stated, no one looked at her wound the entire time she was in the facility. The resident recalled asking when she would see a doctor and the staff wound tell her the doctor had already left. The day the doctor finally saw me, she was the only one who removed my shirt to look at my chest wound and then she got on the phone to my surgeon. I did not clean my wound, I did a sponge bath but I never was told I had to clean it. I never had a shower there. I didn't even want to look at it. My surgeon showed me the orders he wanted it cleansed and I told him that did not happen. Now I have this [DEVICE] attached to my chest. It doesn't hurt but sometimes I get a twinge, like a nerve pain. The resident lower her shirt to show the [DEVICE] attached to her sternum and a large [MEDICATION NAME] dressing covering most of her chest. The black [DEVICE] sponge was on the sternum and was approximately 5 inches in length with a large [MEDICATION NAME] dressing on top of the entire chest up to her neck and close to her shoulders. The resident stated my surgeon tells me it is very dangerous to have this area open, but I try not to get upset about how bad this is and I focus on doing what I have to do to get better. The nurses change the canister three times a week and tell me how it is doing. The resident continued to stated The care I am receiving here is better, the staff seem more invested in me getting better. They are definitely more thorough than they were at the facility. I think the physical and occupational therapists are more thorough than at the facility. I feel like I am getting good care here. I am completely frustrated that I am going through all this because a doctor or someone didn't read the orders my doctor gave them. I have been in a hospital since (MONTH) 21st. Now I have 5 more weeks of antibiotics and I have to stay here to get them. I have financial concerns about what my insurance will pay and what I will have to pay, this might wipe out my retirement. Yep, frustrated is a good word to explain how I feel. During an interview on 07/11/18 at 10:10 AM, with Staff D, the facility's Medical Director, stated when she saw the wound for the first time on 06/25/18 it was open had drainage and redness it was obvious the resident needed to see the surgeon. Staff D was surprised how quickly this (the wound) went bad. The resident has zero complaints and was at risk for complications during healing. Staff D recalled the resident had severe swelling in both her feet with wounds. Staff D stated We have never had a chest wound here before and if we are going to accept these complicated patients we need to be aware of their care needs. When Staff D was made aware of the lack of observation, care, and documentation for the sternal chest wound she asked, where were the nurses on this? Staff D went on to say this never should have happened to this woman. The facility neglected to follow accepted standards of practice related to the assessment, monitoring, and postoperative wound care. This resulted in harm for the resident who developed a significant post operative wound infection with dehiscence of the wound, required re-admission to the hospital, surgical debridement of her sternal chest wound, placement of a [DEVICE] to the chest and an additional six weeks in the hospital to receive IV antibiotics. This was a preventable occurrence if the Licensed Nurses, the Director of Nursing Services, and the physician had checked the wound and followed the surgeon's orders. They neglected to provide the necessary care and services for Resident 29. Reference WAC 388-97-0640 (1)

Based on interview and record review the facility failed to implement written policy and procedure components of thorough investigation, including prevention from abuse, identification of abuse, protection and reporting of allegations of abuse for thirteen (128, 9, 213, 92, 212, 214, 215, 216, 40, 72, 211, 21 and 63) of seventeen residents reviewed for abuse and failed to complete a Washington State Criminal Background Check for 2 of 2 volunteers (1 and 2) reviewed for pre-employment screening. These failed practices resulted in residents risk for potential abuse and continued exposure to alleged abusive caregivers or residents; thereby constituting a situation of immediate jeopardy. Findings included: Upon survey entrance on 11/13/17 the contact person for abuse prohibition policies were the Director of Nursing Services (DNS). The Social Services Director (SSD) was the contact person for complaints and grievances information A Review of the facility's Abuse Policy and Procedure: It is the policy of the facility to maintain an environment free from abuse (verbal, sexual, mental and physical), neglect .Residents will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, volunteers, family members, resident representatives, friends and visitors. All staff and volunteers are mandatory reporters and must report all suspected, alleged and /or witnessed abuse, neglect . Protection: Residents are to be protected during and after alleged, suspected and or witnessed abuse, neglect .If the alleged perpetrator is facility staff, he/she will be suspended immediately and will leave the property. Prevention: All employees and volunteers will be screened for a history of abuse, neglect and exploitation on hire, prior to having unsupervised access to residents and as required by regulation thereafter. This includes criminal background check, OBRA registry check, professional license and certification check and reference checks. Staff will receive ongoing in-service education on abuse recognition, prevention and reporting. Reporting: All facility staff are mandatory reporters and as such will report alleged, suspected and or witnessed abuse, neglect and exploitation to the DSHS hotline. In addition .staff will report to the Administrator and Director of Nursing Services. Investigation: All incidents of alleged, suspected and or witnessed abuse, neglect .will be investigated immediately . will be reported to the DSHS hotline, DSHS log, local law enforcement or 911 .per Appendix D Reporting Guidelines for Nursing Homes .Investigation specifics may be found in: Nursing Home Guidelines AKA The Purple Book 5th edition [DATE] (current guidelines are October 2015). Incident Investigation forms will be completed .within the mandated timelines. The facility's abuse policy included the outdated nursing home guidelines. The Nursing Home Guidelines a.k.a., The Purple Book, sixth edition, dated October 2015, indicated facilities were to conduct phase 1 investigations within 24 hours, follow up with a phase II investigation if the cause or reasonable cause was undetermined, to document factors on the incident, and to document responsive steps taken by the facility, as well as resident outcomes. The facility was to report to the Department (the State hotline), the Police or 911, and log within 5 days. In an interview on 11/17/17 at 10:35 AM, Staff O, Social Services was asked about the process for grievances. Staff O, stated I give it (concern) to the department involved .on the weekends they go in my box and I address them Monday morning. Concerns with abuse and neglect get routed to the DNS. Staff O, confirmed the concerns were just placed in her box at all times. If the concern is night shift I get it at 6 am the next day during the week. ALLEGATIONS OF NEGLECT RESIDENT 128 Resident 128 admitted August of 2017. According to the 09/21/17 Minimum Data Set (MDS) assessment, the resident was understood, had clear comprehension and was cognitively intact. Review of a comment & concern form for Resident 128 dated 07/20/17 documented was laying in urine he believes since 12:00 . last night and was in bed until 1:15 PM today in gown; soaked. He would like to be up at 8:30 AM - 9:00 AM. In an interview on 11/17/17 at 9:46 AM, the DNS was asked if she received a concern about a resident being wet for hours would she consider this neglect. The DNS responded Yes .if it was substantiated we would call the hotline. We would call within 2 hours. In the past we have interviewed other residents and staff. We start with 5 patients and go on. If a resident complains of a neglect type issue on noc (night) shift, they should call me. The older staff I have not educated that far yet but have with new staff. Nurse should call me and I would come in and investigate that. I do pull them (involved staff) off the floor pending investigation. The DNS was asked about Resident 128's concerns on 07/20/17. She repeatedly stated I know for a fact he didn't stay in bed that long. I will have to investigate it. She confirmed there was no investigation for the alleged neglect nor a statement from the staff involved. When the DNS was asked why further investigation was not completed for Resident 128's concern of laying in urine for over 13 hours, she had no response. This allegation was not identified as neglect. The allegation was not thoroughly investigated, called into the hotline or documented on the state reporting log. There was no evidence the residents skin was assessed. The facility did not monitor for psychological harm. There was no record of this incident in Resident 128's medical record. The facility's failure to interview involved staff and to determine whether physical or psychosocial harm occurred precluded the facility from determining that the allegation of abuse was unsubstantiated. The facility also failed to interview other residents and staff to determine if any others had been affected or had negative interactions. Additionally; the staff involved continued to provide care for vulnerable residents unsupervised placing all residents at risk for potential abuse. RESIDENT 9 Resident 9 admitted [DATE]. According to the MDS dated [DATE], she was alert and oriented and able to make needs known. Review of the 06/13/17 comment/concern log revealed Resident 9 had care concerns. Review of the comment and concern form dated 06/13/17 was completed by Staff P, Physical Therapist Assistant (PTA), Pt (patient) feels she has to wait too long for assistance and once she has pressed call light. Pt states she has to scream for assistance. Pt stated that night shift personnel do not treat her with [MEDICATION NAME]. Attached to the concern form was a customer service in-service. There was no thorough investigation to include interviews of other residents and staff. The incident was not located on the incident report log or called to the state hotline. There were no statements from the night shift staff. One call light audit was completed on day shift although the concern was on night shift. The DNS on 06/14/17 and the prior Administrator signed off the comment and concern form on 06/19/17. RESIDENT 213 Resident 213 admitted [DATE]. According to the 05/08/17 MDS, he was alert & oriented and able to make his needs known. According to the comment/concern log entry dated 05/04/17, documented CNA answered in a flippant tone per resident The comment and concern form completed by Staff O, Social Services, stated During care conference on 05/04/17, Resident reported that on 05/03/17 at 3:00 AM, he turned his call light on and a CNA (Certified Nursing Assistant) came in, he was trying to get comfortable in his bed, CNA tried to help him but, he still couldn't get comfortable. CNA left the room and said When you figure it out let us know. Per Resident 213 this was said in a flippant tone of voice. The alleged staff member was not identified precluding the facility from protecting this resident and other residents. This incident was not thoroughly investigated, called to the state hotline or logged on the incident reporting log. The resident was not placed on alert status to monitor for psychosocial harm. This concern was not in the medical record and there was no evidence the physician was notified. RESIDENT 92 Resident 92 admitted [DATE]. According to the 05/25/17 MDS, she was alert & oriented and able to make needs known. Review of the comment/concern log on 05/31/17 Resident 92 had a concern documented Rude caregiver-needs weren't met The comment and concern form written by Resident 92 stated Caregiver rude when speaking to patient. Didn't help patient to commode and back to bed-needs weren't met for the safety of patient. She stood waiting for me to transfer myself. Staff R, prior Administrator, completed the facility's action section of the comment and concern form. Staff R wrote: This investigation could not substantiate lack of care. Employee will be on 60 day plan and will not receive any complaints regarding care and services; you will be required to complete lessons on health care academy: 1), Vulnerable Adult Protection 2). Right on Target-Respecting Patients' rights 3). Customer service Strategies. August 1st all lessons will be complete and should any allegation of verbal abuse or lack of care, or rudeness occurs you may be at risk for further disciplinary action or termination? Should any allegation be substantiated at any time, you will be immediately terminated for direct violation of facility policy on resident rights. The facility was aware of the possible verbal abuse. This incident was not thoroughly investigated, called to the state hotline or logged on the incident reporting log. The resident was not placed on alert status to monitor for psychosocial harm. This concern was not in the medical record and there was no evidence the physician was notified. There was an unsigned and undated caregiver statement attached to the concern form. The facility interviewed 3 other residents but no staff about possible concerns with the unnamed caregiver. There was no evidence the caregiver's personnel file was reviewed. ALLEGATION OF SEXUAL ABUSE RESIDENT 212 Resident 212 admitted [DATE]. According to the MDS dated [DATE], the resident was alert and oriented, able to make needs known and cognitively intact. According to the comment/concern log entry dated 02/09/17, the resident had a staff accusation. The comment and concern form submitted by the DNS dated 02/09/17 at 5:00 AM, revealed During Noc (night) shift, NAC went in to check and change residents and she stated loudly You are molesting me. A witness statement from Staff K, NAC stated, I was at the nurse's station when I hear a resident yelling. I walked down the hall to find out where it was coming from and realized it was a resident in 19-2. I walked into the room as the resident said to caregiver You are molesting me. Caregiver (Staff D) immediately took his gloves off and walked out as I told him (Staff D) that I would reapproach resident in a few minutes. I reapproached resident 20 minutes later, she refused care for me and told me to leave her alone right now. The DNS interviewed other residents and included a summary with the concern and comment form. The DNS findings included She stated that some man came into her room and wanted to take her pants down. I asked resident if she knew who it was and she stated No .Male NAC was suspended during investigation. Investigation is unsubstantial. Review of a statement written by the DNS, Called Staff D at 1000 suspended until investigation completed. Resident 212 was not immediately protected or assessed for possible sexual abuse. Staff D was not suspended until 5 hours after the allegation. This allegation was not included in the resident's progress notes. The resident was not placed on alert status to monitor for potential physical, sexual or psychosocial harm. This allegation was not called to the hotline or logged on the state log. There was no evidence the physician was notified of the allegation. The protocol for alleged sexual assault was not followed. ALLEGATIONS OF VERBAL ABUSE RESIDENT 214 Resident 214 admitted [DATE]. According to the MDS dated [DATE], he was alert and oriented and able to make needs known. Review of the comment/concern log entry dated 01/15/17 revealed Resident 214's concern of Rude therapist. The comment and concern form dated 01/15/17 stated OT (Occupational Therapist) informed him he needed to start doing things on his own, because she didn't want her girls to break their backs. This provoked resident to perform a self-transfer without calling for help. The resident voiced his concerns to three staff members. This incident was neither thoroughly investigated, nor logged on the incident reporting log. The resident was not placed on alert status to monitor for potential psychosocial harm. This concern was not in the medical record and there was no evidence the physician was notified. RESIDENT 215 Resident 215 admitted [DATE]. According to the MDS dated [DATE] she was alert and oriented, able to make her needs known and cognitively intact. Review of the comment/concern log entry dated 01/15/17 included Resident 215 and stated Rude therapist. The comment and concern form dated 01/16/17 by Staff T,stated Rude and not [MEDICATION NAME]. Should not be working with people. Not kind at all. Did not help her at all. Threw clothes on the floor, that I myself did clean up. Resident is just extremely upset on how she was treated. Did not care at all. I do not want her near me. General tone overall not sitting well with resident. This incident was not thoroughly investigated nor called to the state hotline or logged on the incident reporting log. The resident was not placed on alert status to monitor for psychosocial harm. This incident was not in the medical record and there was no evidence the physician was notified. There was no evidence this resident or other residents were protected from this employee. RESIDENT 216 Resident 216 admitted [DATE]. According to the MDS dated [DATE], he was alert and oriented, able to make his needs known and cognitively intact. Review of the comment/concern log entry dated 01/15/17 included Resident 216 and stated Rude therapist. Review of the concern and comment form dated 01/15/17, Staff V wrote Her tone (OT, Occupational Therapist) was very matter of fact instead of explaining procedures in new facility .Therapist responded I am the therapist, I ask the questions. The resident reported his concern to Staff T who completed a statement (undated) OT basically told him to shut up and be quiet and that upset him very much. This incident was not thoroughly investigated nor called to the state hotline or logged on the incident reporting log. The resident was not placed on alert status to monitor for psychological harm. This concern was not in the medical record and there was no evidence the physician was notified. Staff U, OT was placed on a performance improvement plan / 1st written notice on 01/16/17 for negative interactions involving 3 residents. The Administrator signed the plan on 01/23/17 and Staff U did not sign it until 01/24/17. The Staff member was not suspended pending investigations. These incidents were not reported to the Department of Health. RESIDENT 40 Resident 40 admitted in July of 2017. According to the 08/22/17 MDS, the resident was alert and oriented, able to make her needs known and cognitively intact. Review of an undated comment & concern form submitted by the prior Administrator stated, 3 or 4 days ago on night shift a tall, black aide yelled at her to turn her call light off. The findings portion at the bottom of the comment and concern form completed by the Administrator on 07/28/17 documented We have one CNA (nurse's assistant) that resembles that description and she has been counseled. Review of Staff W's employee file revealed a prior incident of rudeness to a resident in 2016. Staff W was placed on a performance improvement plan at that time. On 07/31/17 Staff W was moved from a nurse's aide position to a housekeeping position with a plan to re-evaluate in 2 weeks. Staff W was terminated on 08/07/17. The Administrator marked the personnel change notice as recommended for re-employment. 6 months and then may reapply. The facility's failure to interview Staff W to determine whether psychosocial harm occurred precluded staff from determining that the allegation of abuse was unsubstantiated. The facility also failed to interview other residents and staff to determine if any others had been affected or had negative interactions with Staff W. Additionally; Staff W was moved from her nurse's aide position to housekeeping where she continued to have unsupervised access to vulnerable residents placing all residents at risk for potential abuse. In an interview with the DNS on 11/17/17 at 10:36 AM, she stated I would consider yelling at a resident abuse. She confirmed there was no investigation, log or reporting for this alleged verbal abuse. WANDERING TO UNSAFE PLACE/POSSIBLE NEGLECT RESIDENT 72 Resident 72 admitted [DATE] with a [DIAGNOSES REDACTED]. She was assessed as a high risk to wander on readmission on 10/29/17. According to Resident 72's progress note dated 10/07/17 at 4:36 PM, resident found out of building X 3 near kitchen or therapy and when asked where she was going she stated up the hill call out to significant other unsuccessful. A progress note the following day on 10/08/17 at 1:30 PM, read left building independent of staff (walking with FWW (walker)) . A progress note the next day dated 10/09/17 at 5:21 PM, Res wandered X 1 this shift. She was sitting out under the awning between buildings. No further action was taken. In an interview on 11/17/17 at 9:42 AM, the DNS stated I was not aware of these. The DNS confirmed there was no assessment of the resident for injury. These incidents were not investigated until brought to the DNS' attention on 11/17/17. Additionally, they were not called to the state hotline or logged on the incident report log. There was no evidence the physician or responsible party were notified of Resident 72 wandering outside on 5 occasions. RESIDENT 211 Resident 211 admitted in October of 2017 with multiple fractures. According to the 11/13/17 MDS, he was assessed as alert and oriented and able to make his needs known and cognitively intact. Review of a comment and concern form dated 11/02/17 submitted by Resident 211's spouse and roommate Resident 202, Male night asst. was very rude to (Resident 211) per Resident 202 about the choice of underwear, and he was cold-put his jacket on him-no blankets here? He was moaning in pain all night and when I got here (9 AM). Please don't let him treat (my husband) like this-I will take him home! Review of the actions portion of the comment and concern form, the Administrator investigated the staff treatment concern on 11/03/17. The staff member was identified by Resident 202 by name as Staff D, Nurses Assistant (NAC). Staff D was not suspended pending investigation. Staff D's statement was taken on 11/06/17, four days after the allegation. There was a statement attached from Staff F, NAC dated 10/30/17 prior to the allegation (Resident 211 was not yet admitted to the facility). The resident was not protected. The incident was not thoroughly investigated, logged or reported to the state hotline. Resident 211 was not placed on alert status and there was no evidence of monitoring for physical or psychological signs. Abuse could not be ruled out. In an interview on 11/20/17 at 10:09 AM, Resident 202 (roommate of Resident 211) stated Staff D tried to bully and intimidate (Resident 211), he was forceful and demanding. It was late at night. It was around 11:00 PM. He (my roommate) is a little more passive .He (Staff D) woke me up, aggravated me, but his forceful I'm the boss attitude . After I was not going to be pushed the aide was more cautious and appropriate. Resident 202 stated facility staff had interviewed him about the situation. The facility's failure to immediately interview Staff D and protect the resident precluded the facility from determining that the allegation of abuse was unsubstantiated. The facility did not determine whether physical and or psychological harm occurred. Staff also failed to interview other residents to determine if any others had been affected or had negative interactions with Staff D. Additionally; Staff D continued to provide care for vulnerable residents unsupervised placing all residents at risk for potential abuse. MENTAL ABUSE RESIDENT 21 Resident 21 admitted [DATE]. According to the 07/01/17 MDS assessment, she was alert and oriented and able to make her needs known. In an interview on 11/17/17 at 9:45 AM, the DNS stated Everything I have ever investigated as a concern and comment form. I do not have another log except for med errors. I did not report the one staff I fired or call the hotline. We walked her off the property. She was extremely, really rude to a resident. I did not log that. I was not aware I had to log that. The DNS asked the surveyor team So I should as of today call these things into the hotline and log them? I was never trained to log things or call the hotline. This incident report for this allegation was then requested. Review of the state reporting log and concern/comment log did not include Resident 21. In review of a written statement by Staff N, Licensed Practical Nurse (LPN) dated 07/26/17,stated There was a student nurse giving medications to Resident 21, when Staff S, NAC came into the room, she proceeded to push the medications off to the side of the table with her bare hands, slammed the patients lunch tray down and left the room without speaking to the patient .I spoke with the patient and she confirmed what happened .I notified the DNS .she went down to the caregiver, pulled her off the floor and walked her out of the building. This allegation was not documented on the incident reporting log, grievance report nor reported to the state hotline or Department of Health. There was no thorough investigation nor interviews of other residents and staff. The resident was not placed on alert status to monitor for psychological harm. There was no mention of the incident in her medical record. RESIDENT 63 Resident 63 admitted [DATE]. According to her MDS dated [DATE], she was alert and oriented, able to make her needs known and cognitively intact. On 11/15/17 at 10:40 AM, Staff C, completed a comment/concern form on Resident 63, Nurse (Staff Q, Registered Nurse) makes her feel insecure about her weight .Resident 63 feels embarrassed by Staff Q's .comments about her weight fluctuating and Staff Q .is the reason she stays in her room more. On 11/16/17 the following day, the DNS interviewed Resident 63. The incident summary stated Upon learning of the concern and determining that this is a potential abuse situation. The DNS called the DSHS hotline and logged the incident. The hotline was not called until 11/18/17 at 2:56 PM over 72 hours after the DNS was aware of the potential abuse situation. The investigation did not include interviews from other residents or staff. Staff Q was not suspended pending investigation. Progress notes and the care plan were not included with the incident report. It was unclear if the resident was assessed for psychological harm or the care plan was revised. No additional action was taken. FACILITY VOLUNTEERS: In an observation on 11/16/17 around 10:00 AM there were several residents in a circle in the Baker room with towels over their shoulders. In an observation of the posted activity board on 11/16/17 at 11:23 AM, Massage with (Volunteer 1) was posted for the 10:00 AM activity in the Baker Room. In an interview on 11/16/17 at around 12:00 PM, the DNS was asked if Volunteer 1 was licensed, if there were physician orders, care plan and consents for the massages. The DNS repeatedly stated I don't know ask Staff C , Activity Director, I don't know you will have to ask Staff C. This is an activity. In an interview on 11/16/17 at 1:43 PM with Staff C, Activity Director, She stated She is a massage therapist (Licensed Massage Therapist /LMP) and comes every other week. Not sure about her license she has been here for years. You would have to ask HR (human resources)? In an interview with Staff A, HR on 11/16/17 at 2:50 PM, she was asked if Volunteer 1's license and background check were verified. Staff A stated No, she is paid by us, but kind of a volunteer. She confirmed volunteers did not receive abuse and neglect training prior to interacting with vulnerable residents. Staff A was unable to provide any facility in-servicing records for Volunteer 1. In a phone interview on 11/17/17 at 9:00 AM, Volunteer 1, LMP stated I have been coming here to give massages about 2 1/2 years every other Thursday. I do healing touch therapy . necks, heads, shoulders, backs and on front of shoulders. She was asked if she received any facility training, a background check or [MEDICAL CONDITION] testing. She responded No I thought it was really strange they didn't ask me for anything .it was weird they didn't even ask me about my credentials .Volunteer 1 was asked if she reviewed the resident's medical records and obtained consent prior to massaging residents. Volunteer 1 responded No, the activity person should not bring them (residents) to me if they can't be massaged. She stated the only reasons she would not massage would be Only if they had a cold or were sick or like bad circulation. When Volunteer 1 was asked what mandatory reporting was, she responded I don't know. In an observation on 11/21/17 at 11:34 AM, Volunteer 2, facility pastor was at the reception desk stating I heard I need to have background check now. I didn't need it for the past [AGE] years. The facility abuse policy and procedure stated visitors and volunteers will get background checks. Review of employee files for pre-employment criminal background checks revealed Volunteer 1 and Volunteer 2 did not have a completed Washington State (WA) criminal background check done. On 11/17/17 at 10:00 AM, the DNS confirmed there were no outstanding investigations or grievances that had not yet been investigated or logged. The facility demonstrated a consistent failure to follow policies and procedures to protect the residents from alleged abusive staff. The facility staff failed to recognize abuse and neglect, monitor involved residents for potential physical or psychosocial harm and document the assessments after allegations. The facility failure to thoroughly investigate and report incidents and allegations which placed all residents at risk of potential abuse and neglect. Reference: (WAC) 388-97-0640 (1), (2)(a)(b), (3)(a), (5)(a)(b), (6)(a-c), (7)(a), 8(a)

Based on observation, interview and record review, it was determined the facility was not administered in a manner to effectively use its resources to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility complied with regulatory requirements, which affected or potentially affected all residents in the facility. Failure to ensure compliance represented Immediate Jeopardy for Residents (9, 21, 40, 63, 72, 92, 128, 211, 212, 213, 214, 215, and 216) referenced in F 226. The facility's failure to thoroughly use its resources to ensure complete and thorough investigations of potential abuse and neglect placed all residents at risk of abuse and neglect. Findings included: The Administration failed to implement their policies and procedures to protect 13 of 17 residents (9, 21, 40, 63, 72, 92, 128, 211, 212, 213, 214, 215, and 216) reviewed for potential neglect and abuse. Additionally, the facility failed to utilize its resources to take immediate measures to protect residents in potential neglect and abuse situations. The administration failed to ensure the facility operated within its policies and procedures to protect, prevent, identify or investigation potential concerns of abuse, neglect and/or mistreatment of [REDACTED]. This resulted in Immediate Jeopardy and placed all residents at risk of similar failed practice. Refer to F 226 CFR 483.12(b)(1)(2) The Administration failed to ensure residents were treated with respect and dignity. Refer to F 241 CFR 483.10 (a)(1) The Administration failed to ensure a resident was able to exercise their rights for self-determination. Refer to F 242 CFR 483.15(b) The Administration failed to ensure all residents had activities. Refer to F 248 CFR 483.24 (c) The Administration failed to ensure the activity program was directed by a qualified professional. F 249 CFR 483.24 (c) (2) The Administration failed to ensure revision of the comprehensive care plan reflected person-centered objectives and time frames to meet a resident's medical, nursing and mental health needs. Refer to F 279 CFR 483.21 (b) The Administration failed to ensure resident's had the right to participate in care plan development and implementation. Refer to F 280 CFR 483.10 (c) (2) The Administration failed to ensure quality of care for residents recieving massages. Refer to F 309 CFR 483.25 The Administration failed to protect residents from accidents and provide adequate supervision. Refer to F 323 CFR 483.25 (d)(1)(2) The Administration failed to ensure residents were free of unnecessary medication. Refer to F 329 CFR 483.45 (d) The Administration failed to ensure proper use of sanitizer in the kitchen. Refer to F 371 CFR 483.60 (i) The Administration failed to ensure medications were labeled according to current accepted professional principles. Refer to F 431 CFR 483.45 (g) The Administration failed to ensure an infection control prevention program to monitor proper injection practices and glove usage. Refer to F 441 CFR 483.80 The Administration failed to ensure nurse aides received a performance review every year and provide regular in-service education based on the outcome of the reviews. Refer to F 497 CFR 483.35 (d)(7) The Administration failed to ensure nurse aides received the required 12 hours of continued education, including dementia management training and abuse. Refer to F 498 CFR 483.95 (g)(1)(2) The Administration failed to ensure records were complete and accurate. Refer to F 514 CFR 483.75 (l)(1) The Administration failed to ensure all staff were trained in emergency procedures. Refer to F 518 CFR 483.75 (m)(2) Reference: (WAC) 388-97-1620

Based on observation, interview, and record review the facility failed to ensure nursing staff followed accepted professional standards of practice by 11 identified nurses and over all shifts by assessing and treating pain for 1 of 11 residents (141) reviewed for pain management, follow physician orders [REDACTED]. This failure caused harm to Resident 1 who experience unrelieved pain due to pressure injury and repositioning. Findings include: According to the Lippincott Manual of Nursing Practice, 10th edition, the nursing process is a deliberate, problem-solving approach to meeting the health care and nursing needs of patients. The process involves assessment (data collection), nursing diagnosis, planning, implementation, and evaluation, with subsequent modifications used as feedback mechanisms to promote the resolution of the nursing diagnoses. The process as a whole is cyclical, with the steps being interrelated, interdependent, and recurrent. Implementation includes coordinating care with other health team members. Refer to 42 CFR 483.29 F309, Failure to adequately assess pain management effectiveness lead to harm for 1 of 11 residents (141) and had the potential for residents (4, 8, 27, 48, 69, 116, 117, 118, 147, and 148) to have ineffective pain control. Refer to 42 CFR 483.25 (c)(1)(2) F 314, Failure to prevent and/or treat pressure injuries for 1 of 2 residents (141) reviewed for pressure injuries. Failure to implement the correct physician ordered wound treatment, individualized interventions, reduce or remove underlying risk factors such as pain with movement, or timely modify interventions for an existing pressure injury and a developing pressure injury resulted in harm to Resident 141, who had significant pain to the left foot and sacrum (tailbone) area due to pressure and repositioning. ,

Based on observation, interview and record review, the facility failed to provide effective pain management for 1 of 11 sample residents (141), and failed to adequately assess acceptable pain management effectiveness for 11 of 11 sampled residents (4, 8, 27, 48, 69, 116, 117, 118, 141, 147, and 148). This failure placed residents at risk of not reaching or maintaining their highest level of function. In addition, by not adequately assessing the resident's pain management, notifying the physician and implementing effective interventions, Resident 141 suffered harm due to inadequate pain relief as evidenced by the resident's verbal and non-verbal complaints of pain. Findings include: RESIDENT 141 Resident 141 was admitted to the facility in August 2016 after a hospitalization for a ground level fall with acute injuries. The resident's brief mental assessment on 09/01/16, 09/08/16 and 09/24/16 revealed the resident was cognitively intact. In an interview and observation on 09/26/16 at 2:50 PM, the resident was noted with facial grimacing and stated, They just changed my dressing and it hurts, it always hurts, every time they change my dressing. In an interview on 09/28/16 at 1:15 PM, the resident stated, My foot hurts terribly and I am nauseated. In an interview on 09/28/16 at 2:48 PM, the resident stated, my tailbone is very sore, and my left foot hurts. The resident stated my pain is a 20 on a 1 to 10 pain scale. (zero being no pain and 10 being the worst pain.) In an interview on 09/29/16 at 8:51 AM, the resident stated has had a sharp constant pain to my left foot. On 09/29/16 at 9:18 AM, in an interview the resident stated, My tailbone hurts real bad. In an observation on 09/29/16, the resident was observed to be up in a wheelchair at 12:43 PM. During an observation on 9/29/16 at 1:53 PM, three nursing staff members sitting behind the nurses desk and not responding to the resident's call light. Another nurse was standing in the hallway in front of a medication cart and a therapy staff member walked past the resident's room and did not respond to the resident's call light. Upon entering the resident's room, she was observed sitting in a wheelchair crying out in severe pain and stated Help, help, no one will help me. My feet hurt, they should be elevated. In an observation on 09/29/16 at 1:57 PM, the resident's roommate (118) was sitting in the hallway across from the resident's room. Resident 118 stated, I do not know what is going on, I am in distress for my roommate, I thought the staff were going to provide care for my roommate. In an observation on 09/29/16 at 2:03 PM, resident 141 continued to cry out Help, Help. In an interview on 09/30/16 at 11:53 AM, Staff X, a nursing assistant stated the resident calls every 5-10 minutes throughout the day complaining about pain to her feet and butt. Staff X reported the resident's complaints to the nurse. Staff X stated we have to drape the resident's blankets over the footboard so they do not touch the resident's feet. Staff X stated the resident is resistant to care for a lot of things and the resident refuses hot and cold packs, therapy has been working with the resident to reposition. In an interview on 09/30/16 at 2:36 PM, the resident stated she had pain at a 10 out of 10, my tail bone hurts all the time, the staff do not care, and I hurt all the time. In an interview on 09/30/16 at 2:42, Staff J, licensed nurse stated if a resident was experiencing pain; a pain assessment would be completed on admission and one-week post admission. Staff J stated the resident's pain would be documented using a 0-10 pain scale along with the type and location of the pain. Staff J stated if the resident's pain was not relieved, the doctor would be notified. In an interview on 09/30/16 at 1:57 PM, the Director of Nursing Services stated, nursing should be discussing with the physician regarding the resident's response to the ordered pain management. The nursing staff should document the response to the pain management for example effective at 2 out of 10. Review of Resident 141's Medication Administration Record [REDACTED]. Of the 100 doses, 45 times the resident reported her pain at a level 10 (the worst pain). There were only 3 times Resident 141 reported her pain below a 6. The LNs would document an E for effective, I for ineffective, but did not document a pain scale number to correspond to determine what E meant and there was no documented thorough assessments done. The MAR indicated [REDACTED]. Review of Resident 141's medical recorded revealed no reporting to the resident's physician of the resident's uncontrolled severe pain. Review of a MD progress note dated 09/18/16 revealed the resident reported pain can be very bad most of the time to the left foot. Review of the facility's pain management protocol revealed: -The facility is committed to providing our elders with interventions designed to reduce pain . -Pain management will be accomplished through assessment and identification of the nature of pain. -Pain is subjective. It is any experience that the elder states as pain or is observed to be an alteration in comfort. -The elder will be on Alert Charting (Resident 141 was not on alert charting to monitor pain). PAIN REASSESSMENT Review of residents 4, 8, 27, 48, 69, 116, 117, 118, 141, 147, and 148 revealed residents were being treated for [REDACTED]. Review of the above resident's medical records revealed lack of adequate assessment of the effectiveness of the residents as needed pain medication. PARAMETERS FOR PAIN MEDICATIONS Review of residents 4, 8, 27, 48, 69, 116, 117, 118, 141, 147, and 148 revealed the residents were receiving one or more as needed pain medication without parameters for individual pain medication usage. PAIN MANAGEMENT CARE PLANNING Review of residents 4 and 116 revealed the residents were being treated for [REDACTED]. Review of residents 4 and 116 medical records revealed lack care planning for the residents' pain management. See F 314 and F 281 for additional information.

Based on observation, interview and record review, it was determined that the facility failed to identify, prevent and/or treat pressure injuries for 1 of 2 residents (141) reviewed for pressure injuries. Failure to implement the correct physician ordered wound treatment, individualized interventions, reduce or remove underlying risk factors such as pain with movement, or timely modify interventions for an existing pressure injury and a developing pressure injury resulted in harm to Resident 141, who had significant pain to the left foot and sacrum (tailbone) area. Findings include: Resident 141 was admitted to the facility in August 2016. The resident was admitted with an unstageable pressure injury to the left foot and was identified, through an assessment, to be at risk for additional pressure injuries. In an interview and observation on 09/26/16 at 2:50 PM, the resident was lying in bed on a standard mattress. On 09/29/16 at 9:18 AM, in an interview the resident stated, My tailbone hurts real bad. In an observation of personal care, the resident now had a red area to the sacrum (tailbone). In an observation of Resident 141's wound care to the left foot on 09/28/16 at 9:30 AM, Staff V, Licensed Nurse (LN) removed a xeroform dressing from the resident's left foot. Staff V stated, The xeroform was probably used because the facility had been out of the physician ordered oil [MEDICATION NAME] gauze dressing. The resident stated, My foot is throbbing. On 09/29/16 at 9:42 AM, Staff V removed the sock from the resident's right foot. The resident asked, What are you doing? Staff V stated, A dressing is ordered for your right foot. In an observation, there was no dressing on the right foot. The resident stated there had not been a dressing to my right foot for over a week. Staff V applied [MEDICATION NAME] ointment to the resident's right great toe, covered the area with gauze and secured it with tape. In a review of the resident's physician orders, the wound care orders revealed, the current orders: 1) Apply [MEDICATION NAME] cream to the left foot wound, with an oil [MEDICATION NAME] dressing, covered with an abdominal pad, followed with a conform gauze wrap and secured with an ACE wrap. 2) Apply [MEDICATION NAME] to the right great toe, cover with gauze and secure with tape. The physican's order for wound care for xeroform dressing to the left foot wound had been discontinued on 09/03/16. In an interview on 10/05/16 at 9:42 AM, Staff T, LN stated, Cream is applied to the resident's sacrum. Staff T stated the resident refused to be reposition or to use the commode. Staff T stated, a weekly Braden assessment evaluation would be completed for residents at risk of a pressure injury and a pressure relieving mattress would be utilized for residents that are bed ridden or at moderate to severe risk of skin impairment. Review of the resident's facility medical record revealed no order for cream to be applied to the resident's sacrum. During all observations of the resident while lying in bed during the survey from 09/26/16 through 09/30/16, and 10/03/16 through 10/05/16, the resident was at a 45-degree angle on a standard mattress. The resident had the bedding linens draped over the footboard with no linen cradle in use to prevent the linens from creating pressure or discomfort to the resident's feet. Review of the facility's Skin Protocol revealed: · Skin breakdown intervention to include nutritional supplements along with specialty mattresses. Review of the resident's record revealed the recommendations from the nutritional assessment for added calories for wound healing had not been care planned and he resident's pain management regime had not been adjustment since the first week the resident was admitted . The facility did not follow physician's orders [REDACTED]. See also F 309 for additional information on pain.

Based on interview and record review the facility failed to use good nursing standards of practice by not assessing, documenting assessments, or care planning to provide care for 1 of 2 residents (1) when he was having a change of condition. The failure caused harm to the resident by not being thoroughly assessed, but instead being administered medications which caused restlessness, wandering and a fall with injuries resulting in an unnecessary hospitalization . Findings include: According to Lippinocott Manual of Nursing Practice, the 10th addition, pgs 7 & 8. The Nursing process consists of Assessment, Nursing diagnosis, Planning, Implementation, Evaluation and Continuation of the nursing process. Assessment consists of a systematic collection of data to determine the patient's health status and to identify any actual or potential health problems. Facility documentation showed that on 06/09/16, Staff A, a Licensed Nurse (LN) placed Resident 1 on 15 minute checks at 10:00 P.M., but there was no documentation to verify an assessment or why the monitoring was needed. Documentation on a nursing progress note for 2:57 A.M., stated the resident was restless, getting out of bed, talking off oxygen and talking about needing to do some construction. Per facility incident investigation dated 06/10/16 at 1:45 A.M., the exit door alarm sounded alerting staff a resident had left the facility. Resident 1 was found on the lawn, next to a sidewalk on his knees and was wet from lawn sprinklers. The Resident who was confused, according to documentation reported that he did not hit his head. Staff A, noted in the investigation that another resident, who was in his room, witnessed the fall and reported Resident 1 did not hit his head. Staff A, did not do her own assessment, but instead relied on the statement from a resident and Resident 1 who had a mental status change and a fall. The LN also did follow facility policy for unwitnessed (staff) fall by starting neurological monitoring. Although the LN noted a significant change in Resident 1's behavior the Physician and family were not notified of the change in condition. A Progress note dated 06/10/16 at 12:20 P.M., reported the Resident was transferred to the ER at 11:00 A.M., related to his mental status change from admit. At 12:50 P.M., a physician progress notes [REDACTED]. Fall was unwitnessed. During the exam the resident was displaying random flailing/jerking/tremor movements of his upper extremities during the entire exam. Somnolent, arousal to verbal command. Speech is halted and difficult to understand. Continuous random, flailing movements of bilateral upper extremities and head, which staff report were present prior to fall, as well as resident having hallucinations witnessed by staff. The LN did not document or assess hallucinations, tremors, or flailing movements. The LN only documented restlessness, which was clinically different from the behaviors the Physician was seeing upon examination. In a Hospital Physicians note dated 06/10/16, indicated the resident was diagnosed with [REDACTED]. In an interview on 07/12/16 at 10:25 A.M., a family member stated the Resident should have been evaluated related to the confusion, grasping at air, restlessness, and hallucinations. This information about the behaviors of the Resident was obtained from the facility the day after the incident in a meeting with the family. The family member stated, The goal is to make sure this does not happen to anyone else. In an interview on 07/13/16 at 9:05 A.M., Staff A, LN, verified he was getting out of bed and wandering around his bed, he was on 15 minute checks because of his behaviors. She reported after the medications were given things got worse. After the fall, the LN assessed an abrasion on the Resident's shin after the fall, no other injuries noted. Another resident and Resident 1 both said he did not hit his head, so I did not start neuros. The Resident was able to rest in the recliner but he remained restless when awake. The LN stated the temple bruise did not appear until the AM shift. The LN acknowledged, she should have notified the physician and started neurological monitoring for the unwitnessed fall. The medications [MEDICATION NAME] discontinued after the incident. In an interview on 7/15/16 at 4:15 P.M., the DNS stated that the physician confirmed that the combination of the [MEDICATION NAME] the resident's change in mental status.

Based on interview and record review the facility failed to assess and recognize the potential hazards of administering a combination of mind altering medications for 1 of 2 residents (1). Failure to assess if medications were necessary or justified caused harm to the resident experienced unrecognized adverse side effects, which presented as restlessness, wandering, a fall with injury and receiving unnecessary or ineffective medications. Findings Include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record showed that on admit the resident was alert and oriented and able to make his needs known. He was able to verbalize his medical history in detail and discuss prior surgeries and his medication regime. Review of the clinical record showed that on 06/09/16 the resident received: [MEDICATION NAME] (an antidepressant) between 8:00 PM and 12:00 PM. [MEDICATION NAME] 200 milligrams (mg) (a narcotic pain medication) at 8:00 PM. By 10:00 PM, Staff A, an RN documented, Resident 1 was beginning to have a mental status change exhibited by restlessness, removing his oxygen, and getting up out of bed. Staff A placed the resident on 15 minute checks at 10:00 PM with no thorough documentation to verify the need for 15 minute checks. There was no documentation of a thorough assessment of what caused the resident to have a change in condition, so Staff A continued to administer medications which could continue to alter the resident ' s mental status. The LN gave the resident: Ambien 10 mg (a sleep medication) at 11:00 PM. Diluadid 4 mg (a narcotic pain medication) at 1:30 AM. In an interview on 7/15/16 at 4:10 PM, the Director of Nursing verified that Staff A should not have administered all of the medications without doing an assessment. The DNS also stated that Staff A was also given a reprimand for her actions. The physician verified that the combination of medications was the cause of the resident having a change of condition.

Based on interview and record review, the facility staff failed to maintain verbal respect for Resident 2. Failure to acknowledge Resident 2's limited English and communicate politely during a conversation resulted in Resident 2's feeling "despised" and "looked down on" for not understanding what was said to her in English. Findings include: Resident 2 was admitted in May 2011 with [DIAGNOSES REDACTED]. Her native language was Korean. Her most recent minimum Data Set (MDS) assessment, dated 10/17/12, identified some memory impairment by staff. On 12/03/12 Resident 2 told NA 5 of an incident with NA 6 on the evening of 12/02/12. The resident reported NA 6 "told her several times to 'speak English' and told her to "wait 30 minutes" to use the bathroom when the resident requested toileting assistance. Resident 2 told NA 5 this behavior "hurt her heart". On 12/04/12 Resident 2 told NA 7 of the same incident with NA 6. She repeated her statement of feeling "it hurts my heart." NA 7 wrote she knew Resident 2 was "sincerely upset". Resident 2 told NA 7 she never wanted to see NA 6 again. On 12/19/12 at 2:14 p.m., Resident 2 reported she did not speak much English. She reiterated she did not speak English, she spoke Korean. On 01/09/13 at 9:16 a.m., Resident 2 was interviewed with a Korean speaking interpreter. She reported NA 6 and another NA entered her room and she could not understand what they said to her. NA 6 said "speak English". Her tone of voice was "despising" and "looking down on" Resident 2. Resident 2 did not feel good. She felt NA 6 was ordering and commanding her. She stated NA 6 told other staff, and they were laughing at her. She did not want NA 6 to provide care services to her any more. See F225 for additional details.

Based on interview and record review, the facility staff failed to provide care services with adequate personnel and consistent with Resident 1 ' s care plan for a safe transfer. Failure to use a two-person assist technique for transfer contributed to harm of a fractured rib for Resident 1. Findings include: Resident 1 was admitted in January 2011 with multiple [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) assessment, dated 10/17/12, identified her memory and recall as intact (15/15/ points on the memory assessment tool). On 12/19/12 at 9:38 a.m., Resident 1 reported she recalled one nursing assistant (NA) who "grabbed" her one night. The NA had "hands like steel"; she "hurt me". Later, Resident 1 told other staff about the incident. Review of the facility investigation revealed during the night of 11/06/12 Resident 1 complained of right sided chest pain to NA 1. The resident told NA 1 that during a transfer by NA 2 a couple of nights previously she heard a "pop" in her right chest. She had pain off and on since then. Written statement from NA 2 read on 11/03/12 she transferred Resident 1 alone using a transfer technique she had "seen other co-workers do". As she lifted Resident 1, she heard a "pop". NA 2 lowered Resident 1 back to a sitting position on the edge of the bed. She did not notify the licensed nurse (LN) of the incident at that time. Instead she obtained a gait belt and placed it on Resident 1. A second staff, NA 3, was present when the incident occurred. In her written statement, she wrote NA 2 asked her to help with the transfer of Resident 1. When she entered to assist NA 2, she was told by NA 2 she would move Resident 1 alone. NA 2 asked NA 3 to hold the wheelchair rather than participate in a two-person assist transfer. After the incident, NA 2 and NA 3 used a two-person assist technique to move Resident 1. Neither NA 2 nor NA 3 notified the LN of the incident that shift. On 11/04/12 Resident 1 told NA 4 how NA 2 gave her "a hug to transfer" and it caused pain to her right rib. NA 4 asked NA 2 about the transfer incident and told NA 2 to follow the "IP" for Resident 1, which instructed staff to use 2 assist for bed mobility and transfer. NA 4 told LN 1 of the incident. The facility notified the resident ' s physician who ordered a chest x-ray. The chest x-ray revealed a fractured rib on the right side. The facility substantiated abuse by NA 2 for failure to follow the "IP" and use a two-person transfer technique and terminated her employment. On 12/19/12 at 11:50 a.m., the Director of Nursing Services reported Resident 1 was a two-person assist for transfer at the time NA 2 chose to assist Resident 1 by herself. The DNS stated NA 2 had no explanation for not following the care plan. See F225 for additional details.