Every finding on record at Spokane Valley Health and Rehabilitation of Cascad

Based on interview and record review, the facility failed to ensure that direct care staffing information, including information for agency and contract staff, was electronically submitted correctly to the Centers for Medicare and Medicaid Services (CMS), for Quarter 2 of 2025, reviewed for Payroll Based Journal (PBJ - mandatory reporting of staffing information based on payroll data) submission. This failure resulted in CMS receiving inaccurate data related to nursing home staffing levels and had the potential to impact resident care and services.Findings included. Review of the Certification and Survey Provider Enhanced Reports (CASPER) Payroll-Based Journal Staffing Data Report showed the facility reported data for the period of April 1, 2025, through June 30, 2025, at a level lower than the required by mandated staffing levels. In an interview with Staff A, Administrator, and Staff B, Director of Nursing, on 05/22/2026 at 10:09 AM, Staff A confirmed the PBJ data that had been submitted for Quarter 2 was incorrect and collaboration with CMS personnel occurred to correct and resubmit the data. Staff A further stated the inaccuracies were attributed to a change in the facility's Human Resource staffing and in the process for entering the agency staff hours. The hours for agency staff were being entered at the end of the month, which made it difficult to determine if there were any discrepancies. Starting in July 2025, the facility began entering the hours for agency staff within one to two business days, to ensure accuracy. Reference: WAC 388-97-1090(1)(2)(3)

Based on observation, interview and record review, the facility failed to ensure the consistent and required provision of Restorative Nursing Programs (RNP, a formal, planned and organized program of care which is intended to restore a lost ability or maintain a potentially deteriorating function for a particular resident), including periodic reviews of the RNP, for 4 of 4 sampled residents (Residents 49, 68, 82, and 88) reviewed for limited range of motion and mobility. These failures placed the residents at risk of development or worsening of contractures (a medical condition where muscle, tendon, or other soft tissue becomes abnormally tight and shortened, limiting the range of motion at a joint) and a diminished quality of life.Findings included.Review of a revised 08/30/2025 facility policy titled Range of Motion showed, the facility would provide range of motion (ROM, the full movement potential of a joint or series of joints) exercises to assist the resident to prevent avoidable decline including avoidable contracture development. The policy showed the facility identified residents through the comprehensive assessment as having limited ROM or at risk for decline and assessed appropriateness of formal interventions that included a referral to skilled therapy programs or a RNP. A decline in ROM and muscle atrophy (the loss or wasting of muscle tissue, resulting in decreased muscle mass and strength) was considered unavoidable if the facility adequately assessed the resident, appropriate care planning was evident, and a limb or digit was immobilized due to injury or from a surgical procedure.<Resident 49> Review of an 11/14/2025 quarterly assessment showed Resident 49 admitted to the facility on [DATE] with traumatic brain injury, dementia, and paralysis or weakness to one entire side of the body, and aphasia (a language disorder caused by damage to the brain that impairs a person's ability to communicate). The staff assessed Resident 49 had severe cognitive impairment. The assessment showed the resident had impaired Functional Limitation in Range of Motion [FLROM, limitation that interfered with daily functions or placed resident at risk of injury] to both upper and lower extremities to one side of the body and received a passive (staff perform to the resident) ROM RNP three of the seven days of the assessment reference period. An observation and interview on 11/20/25 at 11:06 AM showed Resident 49 in bed, dressed in a hospital gown. Resident 49's left hand fingers were curled inwards; no splint or brace were observed to the left hand. Their left arm was bent at the elbow, and Resident 49 used their right arm to extend open their left arm, slowly and unsuccessfully. When asked if the staff placed a splint to the left hand and how often, Resident 49 said, Not really and Not very [often]. Resident 49 said about the left-hand splint, I don't want it, I don't care.Review of Resident 49's comprehensive care plan showed an intervention that read, No splints to left hand contracture per resident preference, initiated 09/05/2025. A restorative care plan showed Resident 49 required a RNP secondary to limited physical mobility, communication problem and had contractures (date initiated 12/04/2018). Interventions dated 12/04/2018 showed a passive ROM RNP to both upper extremities, 15 minutes a day up to six days a week. Another 12/04/2018 and revised 01/03/2025 intervention showed, Assistance with splint or brace. Remove palm protector daily to monitor skin on L [left] hand and perform hand hygiene. Monitor both hands for signs of redness at pressure points and notify nurse in the morning and at bedtime, 15 minutes a day up to six days a week. The intervention instructed the staff to notify therapy services, if further issues arise. Review of paper RNP flow sheets showed that for the month of August 2025, Resident 49 received no RNP from 08/01/2025 to 08/10/2025. The second and third weeks of September 2025, the resident received RNP only twice each week, and only once from 09/22/2025 to 09/30/2025, a span of 9 days. In October 2025, the staff provided RNP twice on the second and third weeks of the month, and no RNP the week of 10/22/2025 to 10/28/2025. In November 2025, the staff provided RNP only twice the first week of the month, and once from 11/15/2025 to 11/20/2025. Review of the electronic medical record (EMR) showed an RNP for the palm protector. The flow sheet showed that between 10/22/2025 and 11/19/2025, Resident 40 refused the RNP 14 days (10/22/2025, 10/27/2025, 10/28/2025, 10/30/2025, 11/02/2025, 11/04/2025, 11/06/2025, 11/09/2025, 11/12/2025, 11/13/2025, 11/14/2025, 11/17/2025, 11/18/2025, and 11/19/2025).Record review showed no documentation on how the facility addressed the refusal of the RNP. Review of the medical record showed no documentation the facility periodically reviewed the effectiveness of and tolerance to the RNP. <Resident 68> Review of a 10/03/2025 quarterly assessment showed Resident 68 admitted to the facility on [DATE] with weakness, heart and lung conditions and was cognitively intact. The assessment showed Resident 68 had no FLROM and received no RNP during the assessment reference period. Review of a 03/27/2025 admission evaluation showed the staff identified Resident 68, has a contracture to the right hand that [the resident] also states does cause [them] some discomfort when touched.An observation and interview on 09/25/2025 at 1:50 PM showed Resident 68 sitting on the edge of the bed. A visible contracture was noted to the right hand, and the resident was unable to open or extend their fingers. Resident 68 said they were told, Nothing can be done for it, and received no RNP for its management. Review of a Physical Therapy Discharge summary dated [DATE] showed the therapist established and trained the staff on a Restorative Ambulation [walking] Program. Additionally, the program included, Nustep [a cross-trainer machine that provides a low-impact, total-body workout] as tolerated to improve general conditioning. Review of Resident 68's care plan and the remaining EMR showed no documentation the facility developed and implemented an RNP for the management of contractures including their worsening. The care plan showed no inclusion of the required RNP (ambulation and Nustep) developed by the therapist. Review of paper RNP flow sheets showed that for the month of August 2025, Resident 68 received no RNP from 08/01/2025 to 08/13/2025, and refused on 08/14/2025, 08/15/2025, 08/25/2025, 08/26/2025, 08/28/2025 and 08/29/2025. The resident participated in the RNP two days out of the entire month of August 2025. This flow sheet did not show which RNP were offered or refused. Review of paper RNP flow sheets showed that for the month of September 2025, Resident 68 resident received their RNP once on 09/01/2025 and refused on 09/03/2025 and 09/05/2025. There was no documentation on the flow sheet from 09/06/2025 to 09/30/2025 to show provision of the required RNP. This flow sheet did not show which RNP were offered or refused.Review of paper RNP flow sheets showed that for the month of October 2025, Resident 68 refused their RNP on 10/06/2025, 10/07/2025, 10/09/2025 and 10/16/2025. The flow sheets showed no documentation the staff provided the resident the RNP as required from 10/01/2025 to 10/05/2025, 10/10/2025 to 10/15/2025, and 10/17/2025 to 10/31/2025. This flow sheet did not show which RNP were offered or refused.Review of November 2025 paper RNP flow sheets showed no documentation the staff provided Resident 68 the RNP programs as required. Review of the medical record showed no documentation the facility periodically reviewed the effectiveness and resident tolerance to the required RNPs or how they addressed the Resident 68's refusals. <Resident 82> Review of a 09/03/2025 quarterly assessment showed Resident 82 admitted to the facility on [DATE] with the diagnosis of a stroke, one sided paralysis or weakness, and assessed to be cognitively intact. The assessment showed the resident had no FLROM and received no RNP during the assessment reference period. An observation on 11/20/2025 at 11:02 AM showed Resident 82 participating in a group activity sitting in their wheelchair. A splint was observed to their right hand. Review of Resident 82's care plan showed a 09/04/2025 intervention that instructed the staff to, Provide supportive devices as recommended - [Resident] is to wear splint to [their] right hand following restorative ROM program; resident should wear for at least 3-4 hours until tolerance increases. The care plan showed the resident had a contracture of right hand. The care plan showed no mention or details of the ROM program. Review of the November 2025 Treatment Administration Record (TAR) from 11/01/2025 to 11/19/2025 showed an order for Splint to right hand r/t [related to] contracture - Restorative will don following Restorative ROM program. Leave on for at least 3- [to]4 hrs [hours] (as tolerated by resident), then remove and check skin to hand every shift for right hand contracture. The TAR showed no documentation of how long Resident 82 tolerated the splint for. Review of a Restorative Nursing Referral dated 09/04/2025 showed instructions for a passive ROM and splint RNP. The referral showed that if Resident 82 refused three times in a row, they would be taken off the RNP. The referral showed ROM should be provided to the arm, elbow and wrist, as well as their hand and fingers. The referral showed no instruction on how often the RNPs should be provided to the resident. There was no acknowledgment to the referral by either a Restorative Nurse or aide. Review of the electronic medical record showed no documentation the facility provided the ROM RNP to Resident 82 as required or the periodic evaluation of the ROM and splint program to assess their effectiveness and tolerance by the resident. Review of paper RNP flow sheets showed that for the month of September 2025, Resident 82 received their RNP twice between 09/01/2025 to 09/07/2025, three times between 09/08/2025 to 09/14/2025, and once between 09/15/2025 and 09/21/2025. The flow sheet showed no documentation the staff provided the required RNP to Resident 82 between 09/20/2025 and 09/30/2025. This flow sheet did not show which RNP were offered. Review of paper RNP flow sheets showed that for the month of October 2025, Resident 82 received their RNP twice between 10/01/2025 to 10/07/2025, once from 10/08/2025 to 10/14/2025 (refused on 10/09/2025), and twice from 10/15/2025 to 10/21/2025. The flowsheet showed no documentation the staff provide the RNP to Resident 82 between 10/22/2025 to 10/29/2025. This flow sheet did not show which RNP were offered or refused.Review of November 2025 paper RNP flow sheets showed Resident 82 received their RNP once from 11/01/2025 to 11/07/2025 (refused on 11/06/2025), three times from 11/08/2025 to 11/14/2025, and once from 11/15/2025 to 11/20/2025. Review of the medical record showed no documentation the facility periodically reviewed the effectiveness and resident tolerance to the required RNPs or how they addressed the Resident 82's refusals.<Resident 88>Review of a 09/23/2025 quarterly assessment showed Resident 88 admitted to the facility on [DATE] with a stroke, had impaired FLROM to one side of their body that affected both upper and lower extremities, and was cognitively intact. The assessment showed Resident 88 received no RNP. In an interview on 09/25/2025 at 3:19 PM, Resident 88 stated they were supposed to get rehab [rehabilitation] five days a week, but there are never enough staff here to do rehab. The resident said they came to the facility to get stronger after their stroke and then hoped to discharge to an assisted living facility if possible. Review of a Restorative Nursing Referral dated 07/17/2025 showed a ROM exercise program to the upper and lower body, for conditioning and preventing contractures. The staff was to provide the RNP three to five times a week. There was no acknowledgment to the referral by either a Restorative Nurse or aide.Review of paper RNP flow sheets showed that for the month of August 2025, Resident 88 received no RNP from 08/01/2025 to 08/10/2025 and from 08/16 to 08/25/2025. The flow sheet showed the resident refused on 08/27/2025. The staff provided RNP four times out of the required minimum of 12 times in a four-week period (08/11/2025, 08/12/2025, 08/15/2025 and 08/26/2025). The staff documented Resident 88 refused their RNP on 08/27/2025. Review of paper RNP flow sheets showed that for the month of September 2025, Resident 88 resident received their RNP eight times, not meeting the minimum requirement of three times per week. There were no documented refusals. Review of paper RNP flow sheets showed that for the month of October 2025, Resident 88 received their RNP twice a week from 10/08/2025 to 10/31/2025, not meeting the minimum requirement of three times a week. There were no documented refusals.Review of November 2025 paper RNP flow sheets showed the staff provided Resident 88 their RNP once from 11/01/2025 to 11/08/2025, twice from 11/08/2025 to 11/14/2025 and none from 11/15/2025 to 11/20/2025, not meeting the minimum requirement of three times a week. There were no documented refusals.Review of the medical record showed no documentation the facility periodically reviewed the effectiveness and resident tolerance to the required RNPs or how they addressed Resident 88's refusals.In an interview on 11/19/2025 at 12:13 PM, Staff Y, Restorative Nursing Assistant, said they were not involved in the periodic review of the residents who received RNP. Staff Y said they did not know who the Restorative Nurse was who oversaw the facility RNP adding, We haven't done that for a while [RNP reviews]. Staff Y said they were unable to complete or provide assigned RNP for the residents in the facility because the facility would pull them away from the RNP and have them escort residents to appointments or work the floor as a nursing assistant. Staff Y said when they were re-assigned from the restorative aide duties that the other nursing assistants completed the programs for their assigned residents. Staff Y said they made the facility aware a resident refused their program by documenting it in the restorative EMR or paper flow sheets. In an interview on 11/20/2025 at 11:16 AM, Staff X, acting Therapy Director/Physical Therapist, stated that they were not aware of any residents refusing their RNP.In an interview on 11/20/2025 at 10:45 AM, Staff Z, Nursing Assistant said Staff Y completed the RNP in the facility and not the Nursing Assistants. In an interview on 11/20/2025 at 11:51 AM, Staff AA, Assessment Coordinator, said they were not the Restorative Nurse and, Honestly, we do not have one. If they [facility] did it was prior to me coming here and I've been here about a year and half. Staff AA confirmed Staff Y provided the RNP to the residents in the facility. The above findings were shared in a joint interview with Staff A, Administrator, and Staff B, Director of Nursing, on 11/20/2025 at 11:55 AM. Staff B said residents on RNP were reviewed through clinical meetings and at the time of the quarterly and annual assessments, but do not have the RNP periodic reviews documented. Staff B said they expected the residents care plan to show the RNP, including the goal, frequency and duration and document it was provided in the EMR. Staff B said that if a resident refused their RNP, the staff should reapproach them and if still unsuccessful to report the refusal to the Nurse Manager. Staff B said they were only aware Resident 49 refused their RNP. Reference WAC [PHONE NUMBER] (3)(d), (j)(ix)Refer to F725 - Sufficient Nursing Staff

Based on observation, interview, and record review, the facility failed to ensure sufficient staff were available to meet the care needs for 3 of 6 sampled residents (Residents 4, 68, 88) reviewed for activities of daily living for dependent residents, and 4 of 4 sampled residents (Residents 49, 68, 82, and 88) reviewed for restorative nursing (interventions that promote a resident's ability to adapt and adjust to living as independently and safely as possible). Failure to ensure there was adequate nursing staff available to provide bathing and restorative services placed the residents at risk for unmet care needs, a diminished quality of life. Findings included . <Resident Council>During a Resident Council meeting on 09/30/2025 at 1:28 PM, attendees were asked if care and assistance was provided timely, without having to wait a long time. All residents in attendance (Residents 18, 20, 24, 5, 35, 41, 11, 6, 47, 75, and 91) stated they often had to wait for assistance because there wasn't enough staff. Resident 24 stated they had even used their cell phone to call the facility in an attempt to get care because their call light was not being answered, and even after the call was made, they waited another 10 to 15 minutes longer before assistance was provided. Resident 24 then stated that last weekend they were not bathed because there wasn't enough staff. All residents agreed with Resident 24 that showers were not being provided, sometimes you had to wait days to get bathed, and one resident had not been bathed in two weeks. <Resident Observations and Interviews>On 09/25/2025 at 10:32 AM Resident 32 stated there are many days were the facility was short staffed, and they have had to wait an hour for a bedpan and then 55 minutes to be assisted off of it. Resident 32 stated concern had been expressed to administration, and the response was that the facility was not understaffed, but if they are not understaffed, then they are understaffed for the care we need. On 09/25/2025 at 12:54 PM, Resident 4 stated sometimes they had to wait as long as 45 minutes to get assistance at night to the bathroom. On 09/25/2025 at 1:03 PM, Resident 99 stated it was difficult sometimes at night to be assisted to the bathroom, and they soiled the bed one night because of it. On 09/25/2025 at 1:50 PM, Resident 68 was observed sitting at the edge of their bed, their right hand was visibly contracted, with the resident being unable to open or extend their fingers. When asked if the facility a provided restorative program for their hand, Resident 68 stated no. On 09/25/2025 at 3:21 PM Resident 88 stated they wait a long time for their call light to be answered and they aren't being bathed.<Interviews>In an interview on 11/21/2025 at 11:39 AM, Staff EE, Human Resource Director, stated there were two nursing assistants assigned to both Berryway and Morningside units and the nursing assistants on those units were responsible to provide the bathing for their residents. Staff EE stated when the concern about residents not being bathed was expressed, the decision was made to pull one of the nursing assistants to do the bathing for the residents for both units, and the three remaining nursing assistants would then provide the resident care. This was implemented on 11/05/2025 and the next day it was determined that it was not effective, and each nursing assistant was again responsible for providing the bathing for their assigned residents. Staff EE stated staff were now being written up for not completing showers, and some staff have put in their notice of resignation because of it. Staff EE stated the issue was more a lack of not enough staff to complete the bathing, rather than staff just choosing not to do the care. In an interview on 11/21/2025 at 7:00 AM, Staff P, Licensed Practical Nurse, stated there was not enough nursing assistants to complete showers consistently. In an interview on 11/24/2025 at 11:18 AM, Staff FF, Staffing Coordinator, stated staffing was based on resident census and currently for day and evening shifts, eight nursing assistants were scheduled for each unit, and five nursing assistants were scheduled for the entire building at night. Staff FF stated each resident care manager had a radio and staff were able to call for assistance if needed. At 11:52 AM during the continued interview related to staffing, Staff FF stated Staff Y, restorative aide, would also be pulled to work the floor if needed. When informed there were concerns also with restorative services not being provided, Staff FF stated they were not aware. In an interview on 11/24/2025 from 12:07 PM to 12:25 PM with Staff A, Administrator and Staff B, Director of Nursing, concerns were expressed with the facility not having adequate staff to complete bathing and restorative services. Staff A stated staffing needs were based on resident census and the facility always referred to the State minimum requirements. Both Staff A and Staff B acknowledged there had been issues with residents not being bathed, but believed that there was adequate nursing staff to complete and it was a matter of disciplinary action. When informed that restorative services were not being completed due to the restorative aide being pulled to work the floor, neither Staff A nor Staff B stated they were aware. Please see F677 ADL care for Dependent Residents and F688 Increase/Prevent Decrease in ROM/Mobility for additional information.Reference (WAC): 388-97-1080(1)

Based on observation, interview, and record review the facility failed to assess a resident's smoking abilities, appropriately care plan, and implement safety interventions as needed for 1 of 5 sampled residents (Resident 81), reviewed for accidents. This failure placed residents at risk of potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included.According to the 09/15/2025 admission assessment, Resident 81 had diagnoses of metastatic cancer (cancer that had spread to other parts of the body). Resident 81 was alert and oriented, made their needs known and used a wheelchair for mobility.During observation and interview on 09/25/2025 at 3:38 PM, Resident 81 was in their room with a red lighter in their hand. Resident 81 stated they smoked, but only 4 cigarettes a day and went out to the other side of the road to smoke. When asked what they were informed about smoking at this facility, Resident 81 replied there were no rules about cigarettes.Review of Resident 81's admission documents showed a Smoke Free Campus Acknowledgement. The document included that the facility prohibited the use of any tobacco or tobacco products by residents while on company premises. The document also included the statement I am requesting to proceed with the admission, understanding that I will not be able to smoke at the facility or on the premises. The form was initialed by the resident on 09/11/2025 and signed by facility staff as witnessed.Review of September 2025 nursing progress notes showed the following: -09/10/2025 at 11:13 PM an admission summary documented that when Resident 81 arrived, they immediately wanted to go out to smoke and were very upset the facility was a non-smoking facility.-09/12/2025 at 5:42 PM Resident 81 had a pack of cigarettes and was observed smoking them in the parking lot the day before. A facility staff member re-educated the resident on the no-smoking policy. No documentation was found to show Resident 81 was assessed and determined to be able to safely smoke a cigarette independently. Review of the 09/12/2025 smoking care plan showed Resident 81 wished to smoke cigarettes and had been determined to be [Specify: Independent, Dependent] with the process. An intervention instructed staff to complete the smoking/nicotine use evaluation on admission, quarterly and with changes of functional ability that may affect the ability to manage smoking materials. Additional review of Resident 81's record showed no documentation a smoking/safety evaluation was completed.During an interview on 11/20/2025 at 11:53 AM, Staff G, Assistant Director of Nursing, stated if a resident admitted , who was a current smoker, they were educated the facility was non-smoking and offered smoking cessation aids, such as the patch or gum. If a resident insisted on smoking, they were asked not to smoke on facility grounds. When asked how they ensured resident safety with smoking, Staff G replied, that was a good question. Staff G further stated since the facility was non-smoking, they did not have a good smoking evaluation to complete. Staff G reviewed Resident 81's medical record. Staff G stated they initiated the smoking care plan, and meant to ask Staff B, Director of Nursing, about the smoking evaluation referenced, but did not follow up on it. Staff G acknowledged they should have assessed and evaluated Resident 81's ability to safely smoke independently. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure consistent, ongoing communication and collaboration with the dialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) center regarding dialysis care and services for 1 of 1 sampled resident (Resident 24) reviewed for dialysis. Failure to ensure accurate and complete communication to and from the dialysis center, address dietitian communication, and ensure administration and disposition of medications on dialysis days, placed the resident at risk for unmet care needs and dialysis complications.Findings included.Review of an 08/03/2025 quarterly assessment showed Resident 24 re-admitted to the facility on [DATE] with medically complex conditions, including diabetes. The assessment showed Resident 24 was cognitively intact, staff administered insulin, and they received dialysis services.<Communication Before and After Dialysis>Review of an 11/07/2024 care plan in Resident 24's medical record showed the resident had an AV fistula (a surgical procedure that creates a direct connection between an artery and a vein, allowing blood to flow directly from one to the other. This is done to provide adequate blood flow for dialysis) to the left upper arm. Blood flow through the fistula was checked by feeling for a thrill (vibration) and listening for a bruit (whooshing sound). Checking the blood flow was crucial for effective dialysis. The care plan also showed the staff was to, Collaborate with dialysis center regarding medications, diet, nutritional counseling, weight, and lab results and to Communicate and send Dialysis Communication record to every dialysis appointment. Validate report is returned with the resident. Process any changes in progress note.Review of a Dialysis Communication Record showed required written communication between the facility and the Dialysis Center (DC). The form showed the facility would list the medications given within the last six hours prior to sending the resident for the dialysis treatment, the type of access site with choices of an AV fistula, an AV graft (a synthetic tube is implanted between an artery and a vein, creating an artificial channel for blood flow), and a Central Venous Catheter (CVC, a thin, flexible tube inserted into a large vein in the chest or neck for the purpose of administering hemodialysis), if there were signs of infection, if the dressing was dry and intact, if no bleeding was present after last dialysis treatment, the time of the resident's last meal, the resident's most recent weight, and if there were any changes or information to the resident's condition, to include compliance with fluid and diet restrictions. The DC was responsible for communicating to the facility what medications were given during and after the dialysis treatment, the residents before and after treatment weight and vital signs, what foods and how much the individual ate or drank, and any special instructions, comments or changes in the resident's condition during the dialysis treatment, including lab results drawn and the resident's tolerance to the dialysis procedure.Review of Resident 24's Dialysis Binder showed instructions for the nurses titled LN [Licensed Nurse] tasks to complete Pre [before] and Post [after] dialysis. Before dialysis the nurse was instructed to open and fill out the dialysis communication evaluation form in PCC [electronic medical record], print out and place in the dialysis binder. Send binder with the resident to dialysis. Ensure resident has sack lunch or snack to take with them to dialysis. Administer any medications per MAR [Medication Administration Record] and note on the communication evaluation. The instructions showed that after dialysis, the nurse was to receive the dialysis binder back from the resident, Review dialysis communication form received back from dialysis. Enter pertinent information from the form into the evaluation in PCC, then sign and lock the evaluation in PCC. Chart the post-dialysis weight only in weights [section] in PCC. Review evaluation for any medications administered by dialysis then proceed with medications due here at facility assuming there's no overlap or contradictions.Review of Dialysis Communication Records from 08/01/2025 to 10/06/2025 showed incomplete or inaccurate information or missing records:- 08/4/2025 showed no indication of who the facility staff was that assessed the resident before going to dialysis.- 08/6/2025 showed no indication of time of last meal or assessment of bleeding after last dialysis treatment- 08/13/2025 showed no indication of the access site assessment, time of last meal, or what the resident's weight was after dialysis.- 08/15/2025 showed no indication of the access site assessment or time of last meal. Additionally, the dialysis center wrote the name of two medications in the weight section. - 08/18/2025 showed the staff assessed Resident 24 had a CVC for their access site.- 08/20/2025 showed no assessment of the access site or time of last meal. - 08/22/2025 showed the record was electronically dated as 08/22/2025, but on the top of the page it was handwritten 08/29/2025. The record showed no assessment of the access site or time of last meal. Dialysis staff also hand-dated the form with their signature 8/29/2025.- 08/29/2025 showed the staff did not assess the resident status prior to going to dialysis, dialysis staff also did not assess the resident status during dialysis, and no post dialysis weight or vital signs were documented. - 09/01/2025 showed no documentation of access site assessment or time of last meal; only one of the two pages were scanned into the EMR which did not include post-dialysis communication. Additionally, the dialysis staff documented the medications they gave during the dialysis treatment in the section that asked the facility staff to list the medications given within the last six hours prior to sending the resident to dialysis. - 09/03/2025 showed no documentation of access site assessment and time of last meal.- 09/05/2025 showed no documentation when the nurse obtained the vital signs and did not include a temperature. - 09/08/2025 showed no indication of the access site assessment or time of last meal. - 09/10/2025 showed no documentation of the access site assessment or time of last meal.- 10/01/2025 showed no documentation of a pre-dialysis weight.- 10/03/2025 showed no assessment of the access site or time of last meal and undated by the dialysis staff. Additionally, review of the medical record showed no Dialysis Communication Records for 08/01/2025, 08/08/2025, 08/25/2025, 09/12/2025, 09/15/2025. 09/17/2025, 09/19/2025, 09/22/2025, 09/24/2025, 09/26/2025, and 09/29/2025.The above findings were shared in a joint interview on 10/09/2025 at 10:46 AM with Staff B, Director of Nursing, and Staff N, Resident Care Manager (RCM). Both Staff B and N acknowledged and confirmed the staff did not ensure consistent, complete and accurate communication with the DC.<Failure to Address Dietitian Communication>Review of Resident 24's medical record showed an order summary for a Renal diet [designed for individuals with kidney disease], regular texture, thin liquid consistency, Phosphorus < (less than) 1200, K+ [potassium] 3 gram, dated 07/30/2025. The summary included a 07/31/2025 order for Boost [liquid nutrition supplement] once a day.Review of an Order Summary Report showed orders for Sevelamer 800 MG (milligrams) Give 3 tablet by mouth three times a day and To be taken with meals; Ok [okay] for resident to keep this medication at bedside in lockbox and self-administer since 08/05/2025 and Velphoro Oral Tablet Chewable 500 MG, Give 1 tablet by mouth three times a day with meals. Sevelamer and Velphoro are phosphate binders, prescribed to people on dialysis to help remove excess phosphate from the body, preventing progression of chronic kidney disease and fractures.Review of a 09/12/2025 Monthly Nutrition Communication Form sent from the dialysis Registered Dietitian [RD] showed the RD informed the facility that Resident 24's potassium and phosphorus levels were elevated. The dialysis RD asked the facility to encourage the resident to increase protein intake, continue/recommend adding protein powder to appropriate foods, continue/recommend adding a protein bar for additional protein and calories, decrease potassium and phosphorus rich foods, and ensure phosphate binder was given with meals and snacks. This communication was noted by the facility staff on 09/12/2025 and FAXED to [facility] RD.Review of a 09/12/2025 progress note showed the facility provided education to Resident 24 regarding phosphorous and potassium levels and eating a diet of low phosphorus and potassium foods, Resident verbalized understanding. Education material provided. Review of the medical record showed no documentation the facility RD responded to the FAX or of what efforts the facility made to follow-up with their RD after the FAX was sent and address the low phosphorus, potassium and protein levels. The diet orders remained unchanged.The above findings were shared in a joint interview with Staff B and Staff N on 10/09/2025 at 10:12 AM. Staff B said they expected the facility RD to respond to the FAX by the next Nutrition Meeting, on or around 09/17/2025. Staff B said there were no changes made to Resident 24's diet and acknowledged the dialysis RD recommendations remained unaddressed. <Medication Administration on Dialysis Days>Review of a 06/27/2025 Secure Conversations Messages showed the facility sought clarification about medications on dialysis days and asked the provider, Can we send resident with am [morning] medications on dialysis days or administer prior to leaving facility for dialysis around 0600 [6:00 AM]? Or are meds [medications] just supposed to be held/not administered on those AM's [mornings]? The provider answered, Any AM meds can be given before dialysis. It looks like most are administered [at] noon or hs [bedtime].Review of a 07/18/2025 Secure Conversations Messages showed Resident 24 desired to keep the medication Sevelamer at bedside in lockbox for self-administration. The provider agreed to the request. Review of the August 2025 MAR showed the staff did not administer Resident 24 the following medications on dialysis days even though the provider instructed them that, Any AM meds can be given before dialysis:- - Carvedilol (used treat several heart and blood vessel conditions), Amlodipine (used to treat high blood pressure and certain types of chest pain), and Isosorbide (to prevent and manage chest pain (angina) in people with coronary artery disease), Eliquis (a blood thinner), furosemide (a water pill), escitalopram (an antidepressant), Renavite (used to treat nutritional deficiencies in patients with kidney disease or those on dialysis) and rosuvastatin (for cholesterol) scheduled at AM or unspecified morning time - 08/01/2025, 08/04/2025, 08/06/2025, 08/11/2025, 08/13/2025, 08/27/2025, and 08/29/2025.- - Loperamide (for loose stools) at AM or unspecified time in the morning - 08/01/2025, 08/04/2025, 08/06/2025, 08/13/2025, 08/27/2025, and 08/29/2025.- - Aspart (an insulin) scheduled at 8:00 AM - 08/06/2025, 08/11/2025, 08/13/2025, 08/15/2025, 08/18/2025, 08/20/2025, 08/22/2025, 08/27/2025, and 08/29/2025.- - Sevelamer and Velphoro - 08/01/2025, 08/04/2025, 08/06/2025, 08/13/2025, 08/15/2025, 08/20/2025, 08/22/2025. Record review showed no documentation of what efforts the facility made to ensure Resident 24 received the Sevelamer, Velphoro, and insulin with a meal prior to dialysis. Record review showed no documentation the facility communicated to the provider and dialysis center staff, including the dialysis Registered Dietitian (RD), the resident was not administered their insulin, the phosphate binders and other medications on dialysis days.Review of an Order Summary Report showed a 09/11/2025 instruction to the nurses that it was, OK [Okay] to give am [morning] meds [medications] after dialysis every Monday, Wednesday and Friday. Review of the September 2025 MAR showed Resident 24 missed the following medications on dialysis days: - - Amlodipine, Furosemide, Carvedilol, Aspirin, Escitalopram, Isosorbide, Loperamide, Renavite, Rosuvastatin and Eliquis at AM or unspecified time in the morning - 09/17/2025.- - Aspart insulin with meals at 8:00 AM - 09/01/2025, 09/03/2025, 09/05/2025, 09/08/2025, 09/10/2025, 09/12/2025, 09/15/2025, 09/17/2025, 09/19/2025, 09/22/2025, 09/24/2025, 09/26/2025, and 09/29/2025.- - Sevelamer scheduled at 8:00 AM and Velphoro scheduled at 7:30 AM with meals- 09/01/2025, 09/03/2025, 09/05/2025, 09/08/2025, 09/10/2025, 09/12/2025, 09/15/2025, 09/17/2025, 09/19/2025, 09/22/2025, 09/24/2025, 09/26/2025, and 09/29/2025.Record review showed no documentation of what efforts the facility made to ensure Resident 24 received the phosphate binders, Sevelamer and Velphoro, and insulin with a meal prior to dialysis. Record review showed no documentation the facility communicated to the provider and dialysis center staff, including the dialysis RD, the resident was not administered their insulin and phosphate binders on dialysis days.Review of the October 2025 MAR showed Resident 24 missed the following medications on dialysis days:- - Aspart insulin with meals scheduled at 8:00 AM on 10/01/2025, 10/03/2025, 10/06/2025 and 10/08/2025.- - Sevelamer scheduled at 8:00 AM and Velphoro scheduled at 7:30 AM with meals - 10/03/2025, 10/06/2025 and 10/08/2025.On 10/02/2025 at 12:52 PM (a Thursday, the day after Resident 24's dialysis treatment), the Surveyor opened Resident 24's dialysis binder in the presence of Staff O, RCM. A small transparent envelope was observed inside the inner pocket of the front cover of the binder. The envelope had three white tablets marked S6 and a round brown tablet marked PA 500. Staff O identified these as Sevelamer (white tablets) and Velphoro (brown tablet). In the binder was a Dialysis Communication/Referral form that showed communication between the facility and the DC for the 10/01/2025 treatment. The form showed no documentation the facility communicated to the DC that the phosphate binders were sent with Resident 24 or that the resident took them while at the DC. Staff O stated that if a resident was sent with medications to dialysis, they would ensure the disposition of the medication by asking the resident if they took the medication and documented it in the MAR if the resident took the medication or not.On 10/02/2025 at 12:57 PM, Staff P, Licensed Practical Nurse, and Resident 4's primary nurse on day shift identified the medications in the dialysis binder as Sevelamer and Velphoro and stated, Oh my God, that's [the] meds [the resident] takes before dialysis. I will get rid of them right now.On 10/09/2025 at 9:08 AM, Resident 24 was observed sitting in their wheelchair in their room. Resident 24 said that on dialysis days, I go without it [the insulin]. I always thought it was weird that I don't get the insulin before I go there. They have not offered me an early breakfast, and I leave at 5:30 [AM]. Resident 24 stated that they asked the staff to give them the Sevelamer and Velphoro to take with them to dialysis where, I take them with the food I am sent with on that day.Review of Dialysis Communication Records from 08/01/2025 to 10/06/2025 showed no documentation the staff administered Velphoro, Sevelamer, or insulin to Resident 24 with a meal prior to going to dialysis or that any medication was sent with the resident to the DC with instructions to take with a meal. On 10/08/2025 at 1:51 PM, a DC Collateral Contact (CC) stated the residents needed to take their medications at the nursing home prior to arriving at the dialysis center because they gave no assistance to the resident except maybe a glass of water. When another DC CC was asked whose responsibility was it to ensure insulin was given if scheduled during dialysis hours they stated, They [the nursing home staff] have to give it before [dialysis].The above findings were shared in a joint interview with Staff B and N on 10/09/2025 at 10:46 AM. Staff N said the staff either send the phosphate binders along with the resident to dialysis or the resident, can pack it up and take with [them] as well. Staff N said the staff should document they sent the medication with the resident on the Dialysis Communication Record form sent with the resident on dialysis days and, we would be able to take [the resident's] word that [they] took the medications unless dialysis wrote it down [in the form]. Staff B acknowledged the staff did not ensure Resident 24 received their phosphate binders and insulin on dialysis days. No further information was provided to show what efforts the facility made to coordinate with the dialysis center and the provider the effective and consistent administration of the phosphate binders and insulin on dialysis days.Reference WAC 388-97-1900 (1), (6)(a-c).

Based on observation, interview, and record review, the facility failed to ensure expired medications were disposed of timely, in accordance with currently accepted professional standards, in 2 of 4 medication storage rooms and 2 of 4 medication carts were not maintained in a sanitary manner. This failure placed residents at risk for receiving compromised or ineffective medication. Findings included .During an observation of the Berry Way medication room on 09/26/2025 at 10:15 AM, with Staff B, Director of Nursing, there were three bags of Zosyn, an intravenous (IV) antibiotic medication for Resident 78 that had expired on 08/27/2025, Gabapentin liquid, a medication used to treat seizures or pain, for Resident 57 that had expired on 08/28/2025. In an interview on 09/26/2025 at 10:35 AM, Staff B stated the nurse managers and themselves checked the medications monthly to ensure they were not expired. Staff B stated it was important to discard the expired medications to ensure the residents did not receive medication that might not be effective. In an observation on 09/26/2025 at 10:44 AM of the Mountain View medication room, there were 10 packs of Juven (a nutritional powder) that had expired on 09/01/2025. In an observation on 09/26/2025 at 10:56 AM of the refrigerator in Staff B's office that contained the vaccines, there was a bottle of Tubersol (medication used to check for tuberculosis) that had been opened and dated 08/20/2025. Tubersol needed to be discarded 30 days after it was opened. In an interview on 09/26/2025 at 11:04 AM, Staff B stated they checked the vaccines monthly to ensure they were not expired, and it was important to discard the Tubersol after 30 days because the results of the test might be inaccurate. In an observation on 09/26/2025 at 1:39 PM of the Mountain View medication cart with Staff W, Licensed Practical Nurse, there was an Aspart insulin pen (medication used to treat diabetes) that had been used without a date of when it had been opened. Staff W stated the insulin was good for 30 days and it was important to date the insulin pens because if it was used past the date, it might change the efficacy of the medication. The medication cart was unclean with remnants of pills and small pieces of torn paper. Staff W stated they had bought a miniature vacuum to clean it out because they did not like the way it looked. In an observation on 09/26/2025 at 2:44 PM of the Morning Side medication cart with Staff L, Licensed Practical Nurse, the cart was unclean with spilled pills, dust from the pills and pieces of torn paper. There were insulin pens for Resident 78 and 47 that had been used with no open dates. In an interview on 09/26/2025 at 3:03 PM, Staff L stated the insulin needed to be dated so you knew when to discard it so it did not go bad, and it was important to keep the medication carts clean for infection control. Reference: WAC 388-97-1300 (2)

Based on interview and record review, the facility failed to ensure resident records were complete and accurate for 2 of 3 sampled residents (Resident 6 and 17) reviewed for advance directives (a legal document that outlined a resident's wishes for medical treatment if they could not make decisions for themselves) and 2 of 6 sampled residents (Resident 2 and 3) reviewed for admission. This failure placed the residents at risk of delay in care, inaccurate medical records, and decreased quality of life. Findings included. Review of facility policy titled, Resident Medical Record revised October 2022, showed each resident medical record was to be maintained complete, accurately documented, readily accessible, and systematically organized.<Resident 6> Review of a 08/20/2025 Care Conference Review showed Resident 6 had an advanced directive and a copy of the healthcare Power of Attorney (POA, a document that appointed a person to make medical decisions on the resident's behalf) was on file. Review of the medical record showed no presence of the POA paperwork. The above findings were shared with Staff Q, Social Services Director (SSD), on 11/19/2025 at 11:54 AM. Staff Q said the reference to the POA paperwork documented in the 08/20/2025 Care Conference Review, might have been a typo [mistake made while typing or printing]. Staff Q said that sometimes resident representatives dropped off advance directives paperwork at the front desk with the receptionist and, I won't see it. No further information was provided. <Resident 17> According to the 10/13/2025 quarterly assessment, Resident 17 admitted to the facility on [DATE]. Resident 17 was cognitively intact. Review of the 01/08/2025 care conference summary showed Resident 17 had a POA. A summary showed POA paperwork was provided during the care conference. Additional record review showed no documentation of Resident 17's POA paperwork on file. In an interview on 11/18/2025 at 1:05 PM, Staff Q, SSD, stated they asked residents if they had advanced directives during the initial care conference, obtained paperwork, and gave it to medical records to upload into the record or uploaded it themselves. POA paperwork for Resident 17 was requested from Staff Q on 11/18/2025 at 1:13 PM and on 11/19/2025 at 2:38 PM. No documentation was provided. <Resident 2> According to the 11/03/2025 quarterly assessment, Resident 2 admitted to the facility on [DATE] with diagnoses including non-traumatic brain dysfunction (brain impairment not caused by physical trauma), dementia, and encephalopathy (brain disorder that caused confusion, memory loss, and trouble thinking). Resident 2 had severe cognitive impairment with inattention. Additional review of the medical record showed no documentation of admission paperwork on file. Review of the 05/03/2023 durable power of attorney (POA, legal document that allows an individual to appoint a representative to make medical decisions when a person was unable to do so) showed Resident 2 had a designated POA. The agreement further showed Resident 2's representative had no power to agree to pre-dispute binding arbitration. Review of the voluntary agreement for arbitration showed it was electronically signed by the severely cognitively impaired Resident 2, on 12/26/2024. Review of the 05/05/2025 care plan showed Resident 2 had impaired communication related to cognitive decline and instructed staff to ask simple and direct questions. In an interview on 11/19/2025 at 1:01 PM, Resident 2 was asked to explain binding arbitration. Resident 2 replied, well, oh boy, lets see, I can't think, no one explained things, I just can't think. In an interview on 11/19/2025 at 3:19 PM, Resident 2's POA stated staff reviewed paperwork with them upon Resident 2's admission but binding arbitration was not ringing a bell and did not recall staff reviewing that with them. The POA further stated Resident 2 would not know what an arbitration agreement is. In an interview on 11/19/2025 at 1:31 PM, Staff J, Admissions Coordinator, stated they reviewed the binding arbitration agreements with new admissions. Staff J explained they printed out the agreement, offered to read it out loud and answered any questions. Staff J further stated they were not sure if a resident who has cognitive impairment should sign, it's not up to me to decide if someone is too cognitively impaired to sign the paperwork. In an interview on 11/19/2025 at 2:22 PM, Staff A, Administrator, stated binding arbitration agreements were reviewed upon admission. Staff A acknowledged if a resident had severe cognitive impairment or a POA, the arbitration agreement should be reviewed with the appointed resident representative. <Resident 3> According to the 10/27/2025 quarterly assessment, Resident 3 admitted to the facility on [DATE] with diagnoses including dementia without behaviors. Resident 3 had severe cognitive impairment with disorganized thinking. Additional review of the medical record showed no documentation of admission paperwork on file. In an interview on 11/20/2025 at 2:58 PM, Staff A, Administrator, stated they expected resident records to be complete and accurate. Reference WAC 388-97-1720 (1)(a)(i-iv)(b)

Based on observation and interview, the facility failed to perform hand hygiene when indicated during 2 of 3 medication administration observations. This failure placed residents at risk for potential unintended health consequences and diminished quality of life.Findings included .In an observation on 09/29/2025 at 7:26 AM, Staff P, Licensed Practical Nurse, sanitized their hands and put on gloves. At 7:27 AM, Staff P walked down the hall wearing their gloves, opened a resident's door, and moved their curtains. Wearing the same gloves, Staff P lifted Resident 38's gown, wiped their abdomen with an alcohol swab, and gave them their insulin injection. In an interview on 09/29/2025 at 11:33 AM, Staff P stated they should have removed their gloves and performed hand hygiene after they touched those things, prior to administering the medications, and it was important to do so for infection control. In an observation on 09/29/2025 at 8:53 AM, Staff D, Licensed Practical Nurse, was wearing gloves and opened the door to Resident 22's room. Wearing the same gloves, Staff D, moved the resident's tray table and administered their medications though a gastrostomy tube (a feeding tube inserted through a small opening in the abdomen directly into the stomach used to deliver nutrition, fluids and medications) without hand hygiene being performed or gloves changed.In an interview on 09/29/2025 at 9:00 AM, Staff D stated they should have removed their gloves and performed hand hygiene after they opened the door and moved the tray table, prior to administering Resident 22's medication to prevent cross contamination. In an interview on 09/29/2025 AT 3:53 PM, Staff G, Infection Preventionist, stated hand hygiene and glove changes needed to be performed after touching items, prior to administering medications. Staff G stated it was important to prevent the spread of bacteria. Reference: WAC 388-97-1320

Based on observation, interview, and record review, the facility failed to consistently provide bathing/showers for 3 of 6 sampled residents (4, 68, 88) reviewed for activities of daily living (ADLS). This failure placed the residents at risk for a diminished quality of life and unmet care needs. Findings included .<Resident 4>The 09/19/2025 quarterly assessment documented Resident 4 was cognitively intact to make decisions regarding their care and required assistance from nursing staff to complete activities of daily living (ADLS) such as bathing. On 09/29/2025 at 8:48 AM, Resident 4 was observed in their room. During conversation with the resident, they stated it had been a couple of weeks since they were last bathed, and they did not know why they were not getting bathed. Review of the ADL care plan documented Resident 4 needed assistance to bathe from one nursing staff. Interventions implemented on 03/19/2024 instructed nursing staff to bathe the resident twice a week and as needed, and to provide a bed bath when the resident refused or was unable to tolerate being bathed. Review of the Documentation Summary Reports from 09/01/2025 through 11/18/2025 documented the following: - Resident 4 was bathed on 09/03/2025, and was not bathed until a week later on 09/10/2025. Bathing occurred again on 09/13/2025 and 09/17/2025, but the next bath was not provided until 10 days later on 09/27/2025. - Resident 4 was next bathed 28 days later on 10/25/2025. The only other documented bath occurred on 10/29/2025. Documentation showed the resident had been bathed twice for the month of October.- Resident 4 was bathed 11/05/2025, a period of seven days from their last bath on 10/29/2025. Review of the progress notes from the same time period found no documentation that Resident 4 had refused to bathe, nor was there documentation that stated the resident was not being bathed or reasons provided for the lack of bathing. <Resident 68>The 10/03/2025 quarterly assessment documented Resident 68 was cognitively intact to make decisions regarding their care and required assistance from nursing staff to complete activities of daily living (ADLS) such as bathing. In addition, the assessment documented Resident 68 was not bathed during the seven-day time frame of the assessment. On 09/25/2025 at 1:30 PM, Resident 68 was observed sitting at the edge of their bed. When asked if they had any concerns about their care, Resident 68 stated they were supposed to be bathed twice a week, and it wasn't happening because there wasn't enough staff. A review on 11/18/2025 of the ADL care plan documented interventions were implemented on 03/27/2025 which informed nursing staff Resident 68 needed assistance from one nursing staff to bathe, was to be bathed on Wednesdays and Saturdays, and when the resident refused or was unable to tolerate being bathed, a bed bath was to be provided. A review of the Documentation Summary Reports from 09/01/2025 through 11/18/2025 documented the following: - Resident 68 was bathed on 09/08/2025 and 09/11/2025, and was not bathed again until 09/25/2025, a period of 14 days. For the month of September 2025, Resident 68 was bathed a total of four times. - Resident 68 was bathed on 10/25/2025, a period of 30 days from the last documented shower on 09/25/2025 and had refused to be bathed on 10/29/2025. No other documentation was found that showed Resident 68 had been offered a bed bath after refusing to be bathed as instructed in the care plan. - Resident 68 was bathed on 11/05/2025, 10 days from the last shower on 10/25/2025. Documentation showed the resident refused to be bathed on 11/08/2025, however, no documentation was found that showed Resident 68 had been offered a bed bath. <Resident 88>The 09/23/2025 quarterly assessment documented Resident 88 was cognitively intact to make decisions regarding their care, and needed assistance from one nursing staff for bathing. In addition, the assessment documented the resident had not been bathed during the seven days of the assessment period. During a resident interview on 09/25/2025 at 3:17 PM, Resident 88 stated he wanted to stay clean, was scheduled to be bathed on Tuesdays and Fridays, but was not getting showered regularly. Resident 88 further stated they were bathed Friday (09/19/2025), and the last shower prior to that had been three weeks ago. Review of the ADL care plan documented interventions related to bathing were implemented on 03/17/2025 and informed nursing staff that Resident 88 preferred to be bathed twice a week, needed assistance from one nursing staff, and a bed bath was to be provided if bathing was refused or Resident 88 was unable to tolerate being bathed.Review of the Documentation Summary Report from 09/01/2025 through 11/18/2025 documented the following:- Resident 88 was bathed on 09/02/2025, and was not bathed again until 09/16/2025, 14 days later. Bathing occurred on 09/19/2025 and 09/23/2025, but the next bath did not occur until a week later on 09/30/2025.- No documentation was found that showed Resident 88 had been bathed in October 2025.- Resident 88 was bathed 11/04/2025, a period of 34 days after last being bathed, and at the time of the review, the last documented bath occurred on 11/11/2025, seven days ago. <Interviews>In an interview on 09/30/2025 at 9:57 AM, Staff P, Licensed Practical Nurse, stated all documentation for bathing/showers was done in the resident's electronic records, there was not a shower log or paper documentation. In a follow-up interview on 11/21/2025 at 7:00 AM, After discussion of bathing documentation, Staff P confirmed residents were not being bathed consistently. See F725 - Sufficient staffing for additional information

Based on interview and record review, the facility failed to fully assess and implement orders and interventions, monitored a change in condition for 4 of 9 sampled residents (Residents 7, 24, 6 and 51) whose records were reviewed for quality of care. This failure placed residents at risk of medical complications, discomfort and a decreased quality of life. Findings included . <Resident 51> Review of Resident 51's medical record showed the resident had a bowel movement (BM) on [DATE], and not again until [DATE], a span of six days with no BM. Review of Resident 51's medical record showed the resident had a BM on [DATE] and not again until [DATE], a span of five days with no BM. Review of Resident 51's medical record showed the resident had a BM on [DATE] and not again until [DATE], a span of six days with no BM. Review of a [DATE] progress note showed Resident 51, is complaining of constipation, looked over B&B (bowel and bladder record) and [they have] not had a BM documented since 9-9 2025 [a span of 11 days]. The note showed the nurse asked the aide to take the resident to their room to administer an enema. Review of the [DATE] Medication Administration Record showed no documentation the staff administered the enema on [DATE]. Review of a [DATE] progress note showed Resident 51 experienced a fall on their way to the bathroom. The note showed Resident 51 was found sitting in front of their bathroom and Resident was concern [sic] of being constipated. The note showed the nurse gave the resident MOM (Milk of Magnesia, a laxative) and encouraged fluids. Review of the [DATE] MAR showed the MOM administration was ineffective. Review of a [DATE] Secure Conversations progress note showed the doctor gave an order for the staff to administer, dulcolax [ a stool softener] rectally daily as needed for constipation. The progress note showed the staff addressed the provider's order on [DATE], two days later, and informed the provider that Resident 51 was transferred to the hospital on [DATE] (after two falls) and Does not appear these orders were processed prior to resident going OOF [out of facility]. Review of the [DATE] MAR showed no documentation the provider's [DATE] order to administer the Dulcolax suppository was implemented. Review of the [DATE] MAR showed various medications available for administration to relieve constipation or facilitate a BM: - Polyethylene Glycol by mouth if no BM in 24 hours: The MAR showed it was only administered as given on [DATE] and was ineffective. - Milk of Magnesia Suspension orally as needed for no BM for two days. If no results within 24 hours, see Dulcolax Suppository order: The MAR showed no documentation it was administered for the month of [DATE] until [DATE] and it was ineffective. - Dulcolax Suppository rectally as needed if no results from MOM. If no results in 24 hours, see Fleets Enema order: The MAR showed no documentation it was administered for the review period of [DATE] to [DATE]. - Fleet Enema as needed if no results from MOM and subsequent Dulcolax suppository. Complete bowel assessment and notify the doctor if no results: The MAR showed no documentation it was administered for the review period of [DATE] to [DATE]. The above findings were shared with Staff B, Director of Nursing, on [DATE] at 9:22 AM. Staff B acknowledged the staff did not but should have documented the administration of the enema on [DATE] and implemented available as needed orders to address bouts of no documented BM as required. Staff B acknowledged the staff did not implement the provider order to administer the Dulcolax suppository when ordered on [DATE]. When asked why the facility took two days to recognize the [DATE] provider order, Staff B stated, Normally, the nurse managers process the orders. They're not here on the weekends. According to the American Red Cross (a nonprofit humanitarian organization that offers services like domestic disaster relief, blood services, and health/safety training like CPR [Cardiopulmonary Resuscitation, an emergency lifesaving procedure performed when the heart stops beating] and First Aid), a level of less than 85 percent (%) oxygen saturation is considered severe hypoxia. Severe hypoxia is a condition where the body's tissues do not receive enough oxygen and can lead to organ damage and confusion. It is a life-threatening medical emergency that requires immediate attention. Review of a [DATE] at 12:41 PM progress note showed Resident 51 vomited in the dining room at lunch time. The staff obtained vital signs and assessed an oxygen saturation level of 80%. A subsequent note at 2:18 PM showed the nurse called the provider who instructed the nurse to put oxygen on resident to bring up oxygen stats [sic]. Another note showed the resident fell at 2:35 PM and the nurse obtained an oxygen saturation level of 96%. The resident was transferred to the hospital after a second fall on [DATE] at 12:53 AM. Review of an Oxygen Saturation Summary and the remaining medical record showed no documentation the nurse obtained, documented, or monitored Resident 51's oxygen saturation level or their respiratory rate and heart rate on [DATE] from 12:41 PM until 2:35 PM (when the resident fell). Review of the [DATE] MAR showed no orders for the delivery of oxygen as documented in the [DATE] note to put oxygen on resident. Review of the remaining medical record showed no documentation the nurse administered oxygen to Resident 51, how much oxygen was given, and method of delivery. The above findings were shared with Staff B on [DATE] at 9:22 AM. Staff B acknowledged the medical record did not show the nurse frequently monitored Resident 51's oxygen saturation level after identifying it was at a dangerously low level. Staff B stated, Our standing [doctor's] order is to place oxygen with a saturation level below 88%. Staff B acknowledged the medical record showed no documentation the nurse implemented the provider's order to administer oxygen when directed. <Resident 7> According to a comprehensive assessment dated [DATE], Resident 7 had diagnoses of lung disease, pneumonia, and respiratory failure. They were alert and able to make their needs known. Resident 7 was totally dependent on staff for repositioning, toileting, and was always incontinent of their bowels. Review of the bowel task record from [DATE] through [DATE], showed that the resident had a bowel movement (BM) on [DATE]. There were no BM's documented until [DATE], 12 days later. Review of the [DATE] MAR showed the resident had three medications scheduled daily for their bowels. Additionally, the resident had the following medications that could be given PRN (as needed) for constipation: 1) An [DATE] order for Milk of Magnesia (MOM, a liquid laxative), give 1 dose by mouth as needed for No BM for 72 hours. If no results within 24 hours, see Dulcolax suppository order. 2) An [DATE] order for Dulcolax Suppository (a laxative given rectally), insert 1 suppository rectally as needed for bowel care, if no results from MOM. If no results in 24 hours, see Fleets Enema order. 3) An [DATE] order for Fleets Enema (a liquid laxative given rectally) insert 1 unit rectally as needed for bowel care if no results from MOM and subsequent Dulcolax suppository after 24 hours. Complete bowel assessment and notify MD if no results. Per the [DATE] MAR, a dose of MOM was given on [DATE] at 6:42 PM. The follow-up code documented results as unknown. No other doses of any PRN medications were given. Review of progress notes from [DATE] through [DATE] showed no documentation related to Resident 7 lack of BM's, nor any offers or refusals of prn bowel medications. In an interview on [DATE] at 10:14 AM, Staff C, Nursing Assistant (NA) stated that the NA's documented in the computer which residents had BM's. The nurse had a list of residents who did not have a BM to track. In an interview on [DATE] at 10:24 AM, Staff D, Licensed Practical Nurse, stated that the nurse managers run a report every morning that showed who was due for a BM, and gave that list to the floor nurse. In interviews with Staff E, NA on [DATE] at 9:10 AM and Staff F, NA on [DATE] at 9:19 AM, both stated that Resident 7 did not verbalize or indicate any signs of abdominal discomfort when they took care of them recently. In an interview on [DATE] at 12:29 PM, Staff B, Director of Nursing was informed of the documentation of no BM's from [DATE] until [DATE], PRN medications not given and lack of documentation about it. They stated that it was a long span of time and that should have been caught and followed up on. <Failure to Follow a Doctor's Order> <Resident 24> Review of a [DATE] quarterly assessment showed Resident 24 re-admitted to the facility on [DATE] with medically complex conditions, including diabetes. The assessment showed Resident 24 was cognitively intact and received insulin and an anticoagulant (blood thinner). Review of a [DATE] Medication Administration Record (MAR) showed an [DATE] physician order that instructed the nurses to check Resident 24's blood sugars at mealtimes and administer insulin based on the blood sugar reading. The orders showed that if the blood sugar reading was between 350 and 399, the nurses must give five units of Novolog (a type of insulin) and call the provider. Review of the MAR showed blood sugar measurements of 394 on [DATE] at 8:00 AM and 355 on [DATE] at 12:00 PM. Review of the medical record showed no documentation the nurse notified the provider of the elevated blood sugars as ordered. Review of a [DATE] MAR showed an [DATE] physician order that instructed the nurses to check Resident 24's blood sugars at mealtimes and administer insulin based on blood sugar reading. The provider orders showed that if the blood sugar reading was between 350 and 399, the nurses must give five units of Novolog and call the provider. Review of the MAR showed blood sugar measurements of 388 on [DATE] at 5:00 PM. Review of the medical record showed no documentation the nurse notified the provider of the elevated blood sugar as ordered. The above findings were shared with Staff B, Director of Nursing, on [DATE] at 10:25 AM. Staff B acknowledged the medical record showed no documentation the nurses notified the provider of Resident 24's elevated blood sugars as ordered. <Resident 6> Review of a [DATE] quarterly assessment showed Resident 6 admitted to the facility on [DATE] with medically complex conditions, including high blood pressure and diabetes. The assessment showed Resident 6 was cognitively intact and received insulin. Review of a [DATE] MAR showed an order that instructed the staff to check Resident 6's blood sugar before meals and at bedtime since [DATE]. The MAR showed the staff obtained the blood sugars at bedtime only. The above findings were shared with Staff O, Resident Care Manager, on [DATE] at 12:32 PM. Staff O acknowledged the staff should have but did not obtain Resident 6's blood sugars as ordered by the provider. Review of a [DATE] MAR showed an order that instructed the nurses to give Resident 6 Lisinopril (a medication for high blood pressure) 2.5 milligrams (a measurement) in the morning. The MAR showed the nurse did not give the Lisinopril on [DATE] due to Vitals out of parameter and documented a blood pressure of 98/58. Review of the medical record showed no provider orders that directed the nurse when to hold the Lisinopril or that the nurse notified the provider of their action and obtained an order to hold the medication. The above findings were shared with Staff O on [DATE] at 12:29 PM. Staff O stated the nurse should have notified the provider of the low blood pressure and obtained an order to hold the Lisinopril or clarify the order to show hold parameters. <Resident 24> Review of the [DATE] American Diabetes Association (ADA, an organization that funds research, advocates policy changes and access to care, and provides education and resources for patients, families, and healthcare professionals) article The Injection Technique Factor: What You Don't Know or Teach Can Make a Difference showed, insulin injections should be rotated to avoid repeat tissue trauma and prevent lipohypertrophy (a condition where fatty tissue develops hard lumps or pits, which impairs insulin absorption and leads to unpredictable blood sugar levels). Rotating sites allowed the fatty tissue to recover, ensured consistent insulin uptake and action, helped maintain stable glucose (sugar) control, and prevented injection site complications like scarring and pain. Review of a [DATE] progress note showed the provider saw Resident 24 for a routinely scheduled visit. The notes showed the provider documented the resident, has been having some bruising to [their] abdomen that is nonpainful, the resident was somewhat concerned about it, and was happening where the resident primarily receives [their] insulin injections. The notes showed the provider Discussed with nursing staff about using an alternative site and they state that they can use [the resident's] arm. Review of the [DATE] MAR showed scheduled insulin orders four times a day at 8:00 AM, 12:00 PM, 5:00 PM and bedtime. The MAR showed the nurses documented they administered the insulin injections to Resident 24's abdomen from [DATE] to [DATE]. Review of the medical record showed no documentation Resident 24 refused to have the insulin administered to other alternative sites. Review of the [DATE] MAR from [DATE] to [DATE] showed scheduled insulin orders four times a day at 8:00 AM, 12:00 PM, 5:00 PM and bedtime. The MAR showed the nurses documented they administered the insulin injections to the Resident 24's abdomen except once (on [DATE] to the right arm). Review of the medical record showed no documentation Resident 24 refused to have the insulin administered to other alternative sites. The above findings were shared with Staff B on [DATE] at 10:39 AM. Staff B acknowledged the medical record showed the nurses continued to use the abdomen as the site for insulin injections despite previous discussion with the provider to rotate or use alternative injection sites to prevent trauma to the abdomen. <Resident 24> Review of a [DATE] progress note showed the nurse trimmed Resident 24's right foot toenails. Review of the physician orders showed an order dated [DATE] that instructed the staff to provide nail and foot care every Saturday. Review of a [DATE] Skin Inspection Note showed, skin assessment head to toe completed upon admission. No skin issues noted. Review of a [DATE], [DATE], and [DATE] Skin Inspection notes showed, no new skin issues. Review of a [DATE] progress note showed Resident 24, has been complaining about rt [right] big toenail . for 6 weeks. It's in the drs [doctor's] book x3 [three times]. The note showed the nurse assessed, redness is going up from the toenail approx 14 cm [centimeters, a measurement] and blister has developed on front of toe. The note showed the nurse then called the provider who prescribed a topical antibiotic for the diagnosis of paronychia, a nail inflammation that may result from trauma, irritation or infection. Review of the medical record showed no documentation the staff monitored Resident 24's right big toenail, including an initial assessment, preceding the [DATE] progress note. The medical record showed no documentation the staff escalated the persistent concern of the right big toenail when it was not addressed the first time in the provider communication book. The above findings were shared with Staff B on [DATE] at 10:45 AM. Staff B stated, I will find information, when asked if the medical record showed the staff monitored and promptly addressed Resident 24's change in condition preceding [DATE]. No further information was provided. <Failure To Clarify a Physician's Order> A [DATE] facility policy titled Intravenous (IV, by vein) Therapy showed, any IV order was accurately transcribed to the appropriate forms and documented in the resident's medical record. According to a quarterly assessment dated [DATE], Resident 7 had diagnoses of lung disease, diabetes, and hypotension (low blood pressure). They were alert and able to make their needs known. In an interview on [DATE] at 11:34 AM, Resident 7 was observed in their room. They had an IV saline lock (A tube inserted into a vein that does not have fluid running through it. Nurses periodically flushed with saline solution to prevent blockage) in their right wrist. Resident 7 stated that it was placed about a week ago to get IV fluids because they were dehydrated. They further clarified that they only needed fluids one time, and it had not been used since. A review of Resident 7's orders included a [DATE] order to insert an IV catheter to administer fluids, for one time only. This order was signed as completed at [DATE] at 11:03 PM on the [DATE] Treatment Administration Record (TAR). Another [DATE] order instructed the nurses to follow facility IV policy for flushing and site maintenance. This order was not found on the September TAR or MAR. During an interview on [DATE] at 10:24 AM, Staff D, Licensed Practical Nurse, stated that routine care of an IV catheter included flushing it every shift to make sure it did not get clogged. The saline flushes were documented on the MAR. During an interview on [DATE] at 11:31 AM, Staff G, Assistant Director of Nursing, stated that an IV should be flushed every shift if not in use, or the IV line could clog and not be usable. When Staff G reviewed Resident 7's September MAR, they acknowledged there was no order that instructed the staff to document saline flushes every shift and there should have been, and the facility did not follow their policy and the provider order for flushing the IV catheter. Reference WAC 388-97-1060(1)

Based on interview and record review, the facility failed to ensure a complete and thorough investigation of an allegation of abuse for 1 of 3 sampled residents (Resident 3) whose records were reviewed for accident hazards. This failure placed the residents at risk for continued abuse or neglect.Findings included.Review of the October 2015 Nursing Home GUIDELINES or the Purple Book showed that the thoroughness of the investigation was a critical component of any investigation. The guidelines showed that for the facility to provide evidence of the thoroughness of the investigation, the information must be recorded. Each phase of a thorough investigation included two steps, data collection (which answered Who? What? and When? of the event) and data analysis (which summarized and analyzed the facts gathered to either establish reasonable cause for the incident or establish the need for further investigation). Within the first 24 hours of the allegation, part of the initial investigation included interviewing caregivers in the immediate area. Evidence collected during the facility's investigative activities included written, signed and dated witness statements by the individual providing the statement on a one-to-one basis, and as soon as possible after an incident/event, to avoid the witness becoming confused by hearing other accounts of what occurred. The statements described as much detail as possible of what the witness observed. The facility staff who received the statements signed and dated the document. Blank areas on the paper of such statements were crossed out and initialed.Review of a 09/22/2025 admission assessment showed Resident 3 admitted to the facility on [DATE] with medically complex conditions, including muscle weakness, difficulty walking and right foot drop (a condition where the muscles that lift the front part of the foot are weakened or paralyzed resulting in an inability to raise the foot, causing the toes to drag or slap on the ground while walking). The assessment showed the resident had intact cognition and was dependent on the staff for bed mobility and transfers. Review of Resident 3's care plan showed an instruction to the staff to provide substantial/maximal assistance of two persons, with the use of a sit-to-stand (a mechanical lift) for transfers between surfaces and for turning, repositioning, and bed mobility tasks (Date Initiated - 09/16/2025).In an interview and observation on 10/30/2025 at 12:41 PM, Resident 3 stated that when they first arrived at the facility, two staff assisted with transfers and bed mobility. Resident 3 stated that in the process of being assisted back to bed by Staff H, Nursing Assistant (NA), on 10/27/2025, they experienced pain. Resident 3 said Staff H grabbed their legs and, had them up in the air, pushing and trying to turn me with my legs up and pushing towards the windows. It was wrenching on my back and pelvic area. I yelled out. Resident 3 continued, [Staff H] was yelling at me telling me I was supposed to turn towards the window, but I can't turn the other way. I said, 'No.' [Staff H] just kept hollering, 'No, you keep going against me,' and kept yelling at me. Resident 3's family member was present during the interview, and both stated the family member was in the room and witnessed the 10/27/2025 incident with Staff H. Resident 3 said the 10/27/2025 incident with Staff H left them feeling with a combination of angry and hurting, physically hurting [residual right sided groin pain].In an interview on 11/03/2025 at 10:05AM, a Collateral Contact (CC) stated they heard Resident 3 issue a blood curdling scream as they approached their room on 10/27/2025. When the CC entered Resident 3's room they found Staff H in the room along with Resident 3 and another family member. The CC stated they visited Resident 3 daily, multiple times throughout the day. When asked how many staff they observed transfer and assist the resident with bed mobility, the CC stated, It's bad. I have never seen two people in there with [the resident] and I come down there quite often.In an interview on 10/31/2025 at 3:40 PM, Staff H stated they did not ask other staff to assist them with the lift transfer or position Resident 3 in bed and that they usually transferred or completed bed mobility for Resident 3 by themself, Always one person since taking care of [the resident].Review of a 10/27/2025 schedule showed Staff H and Staff N, Licensed Practical Nurse (LPN), were assigned to Mountain View Unit, where Resident 3 resided. Review of an undated facility investigation showed the facility interviewed Resident 3, the CC, Staff H, other residents and other staff. The investigation showed the facility reviewed Resident 3's care plan and would provide staff education on bed mobility. The investigation concluded that the pain Resident 3 experienced was from bed mobility and/or positioning and that the way Staff H adjusted their legs resulted in pain. Staff H did not respond with professionalism and will be educated.Review of staff interviews showed no documentation the facility obtained a statement from Staff N. The facility interviewed 10 staff; all of the interviews were unsigned and undated and only one interview showed the title of the staff member. The interviews asked the staff three questions, What would you immediately do if a resident reported something that could be abuse or neglect to you? Who is the abuse coordinator of the facility? And do you need more training on abuse or neglect situations? Only one of the 10 staff answered, Protect resident. The investigation showed no documentation the facility interviewed the family member who was with Resident 3 and witnessed the staff -to-resident event on 10/27/2025. The investigation showed no documentation the facility investigated why Staff H did not follow Resident 3's care plan instruction to transfer and assist with bed mobility with two people and if the practice extended to the other staff and shifts. The investigation showed no documentation the facility asked other staff how Staff H treated other residents, including observations of yelling. The above findings were shared with Staff A on 11/04/2025 at 1:43 PM. No further information was provided.Reference: WAC 388-97- 0640 (6)(a)

Based on interview and record review, the facility failed to ensure adequate staffing was maintained to provide consistent and required assistance during bed mobility and use of a mechanical lift (a device that uses mechanical means, like gears, chains, or cables driven by a motor, to raise and lower persons and moving individuals with limited mobility safely) for 1 of 3 sampled residents (Resident 3) reviewed for accident. In addition, the facility failed to ensure the Director of Nursing maintained a license that authorized them to work as a Registered Nurse (RN) in the State of [NAME]. These failures placed the resident at risk for unmet care needs.Findings included.<Insufficient Staffing> Review of a [DATE] admission assessment showed Resident 3 admitted to the facility on [DATE] with medically complex conditions, including muscle weakness, difficulty walking and right foot drop (a condition where the muscles that lift the front part of the foot are weakened or paralyzed resulting in an inability to raise the foot, causing the toes to drag or slap on the ground while walking). The assessment showed the resident had intact cognition and was dependent on the staff for bed mobility and transfers. Resident 3's care plan instructed the staff the resident required substantial/maximal assistance of two persons, with the use of a sit-to-stand (a mechanical lift) for transfers between surfaces and for turning, repositioning, and bed mobility tasks (Date Initiated - [DATE]). In an interview and observation on [DATE] at 12:41 PM, Resident 3 stated that in the process of being assisted back to bed by Staff H, NA, on [DATE], they experienced pain. The resident stated Staff H transferred them from the wheelchair to the bed with the use of a EZ lift (a sit-to-stand mechanical lift that helped the person from a sitting to a standing position). Additionally, Staff H helped the resident from the seated position at the edge of the bed and into bed by themself. Resident 3 stated, I can't help with my upper body, and I flop to my left side, and I can't move my shoulder. Resident 3 said Staff H grabbed their legs and, had them up in the air, pushing and trying to turn me with my legs up and pushing towards the windows. It was wrenching on my back and pelvic area. I yelled out. In an interview on [DATE] at 10:05AM, a Collateral Contact (CC) stated they heard Resident 3 issue a blood curdling scream as they approached their room on [DATE] and found only Staff H in the room assisting the resident with positioning in bed. The CC stated they visited Resident 3 daily, multiple times throughout the day. When asked how many staff they observed transfer and assist the resident with bed mobility, the CC stated, It's bad. I have never seen two people in there with [the resident] and I come down there quite often. Review of an [DATE] census form showed Resident 3 resided in the Mountain View Unit. The census showed 14 residents living in the unit. Review of Staff Schedule sheets from [DATE] to [DATE] showed one nurse and one NA were assigned to the Mountain View Unit on all three eight-hour shifts. In an interview on [DATE] at 3:40 PM, Staff H stated two people were required when mechanical lifts were used, but with a sit-to-stand not always. It just happens that way. Staff H said she did not ask other staff to assist them with the lift transfer or help Resident 3 position in bed and that they usually transferred Resident 3 by themself. Staff H stated they cared for 15 to 18 residents in the Morning View Unit, including providing their assigned two or three showers. Staff H said they did not have enough staff to care for the residents in the Mountain View Unit, because the nurse was busy with meds [medications] and they're pretty busy doing what they're doing. Staff H said that on [DATE], when Resident 3 required transfers and bed mobility assistance, they didn't ask the nurse for help because the nurse, was nowhere to be found. I find myself doing two- person transfers alone. Staff H said, You know, I thought the mechanical lifts was supposed to be two persons [assistance] but there's times where it's not. In an interview on [DATE] at 3:16 PM, Staff J, who wished to remain anonymous, said that when they could not find anyone to help them transfer a resident, they would physically pick them up and put them in bed but only if they were semi-mobile. Staff J said that every once in a while they would transfer a resident in a sit-to-stand by themself and, It all depends on if the nurse is available or the nurse is nice. Usually, we have to go to one of the other halls then ask the other aides for help and if they're not too busy, to come help. Staff J said they were assigned to 14 residents in the Mountain View Unit, provided showers and assisted residents to eat. Staff J said when they could not find a nurse or aide to help them with mechanical lift transfers, they would ask Staff M, Human Resources, for assistance. In an interview on [DATE] at 3:26 PM, Staff K, Registered Nurse (RN), stated they were assigned to 14 residents. Staff K stated there was not enough staff to care for the residents in the Mountain View Unit because they were assigned only one aide and Staff K had, 13 blood sugars to do and 5 major dressing changes. Staff K said they also had to help pass dinner trays and assist the residents to bed and to the bathroom or with their toileting needs. Staff K said, I have to help the aide out. It's too much for one person. I don't sit down until after report for night shift and don't get out of here until midnight or 1:00 AM and then I get in trouble because I cannot not be late. In an interview on [DATE] at 3:10 PM, Staff L, NA, said they assisted Resident 3 with no help for bed mobility. When asked if the facility had enough staff to care for the residents, Staff L said, Truthfully no. It's hard to complete the mechanical lift transfers. I try my best to go get a helper because you never know what can happen. Staff L said they took care of 14 residents, to include giving them showers and it was hard to get breaks. The above findings were shared with Staff A, Director of Nursing (DON), on [DATE] at 1:43 PM. Staff A said Resident 3 required two-person assistance for bed mobility and transfers because of weakness to the legs and decreased mobility. When asked if the staff brought concerns about staffing needs on Mountain View Unit, Staff A said, They have recently because the acuity [the severity of a resident's condition and the resources necessary to provide appropriate care] is getting pretty high. Staff A said they had no knowledge the staff needed additional staff and would provide a solution had they known. Staff A said that two months ago they provided the staff in the facility walkie-talkies so they could access and assist each other more readily and that ancillary staff like Staff M assisted the staff with cares. Staff A stated Staff M was a NA. Review of the State of [NAME] (WA) Department of Health provider credential search on [DATE] at 2:36 PM showed Staff M had a credential for a NA (Registration) that expired on [DATE]. <Registered Nurse as Director of Nursing> Review of the Idaho Department of Professional Licensing (DOPL) Online Services on [DATE] at 7:14 AM showed that Staff A's multistate registered nurse (RN) license (an agreement between states that allowed a professional to practice in all participating states with a single license from their home state) had expired on [DATE]. A Registered Nurse Temporary License was issued on [DATE], 10 days later, and was current. Review of a NURSYS (the national database for nurse licensure verification and discipline, maintained by the National Council of State Boards of Nursing, provided primary-source data from United States boards of nursing for license verifications for nurses and institutions) showed Staff A had a multi-state RN license that expired on [DATE]. In a telephone interview on [DATE] at 2:44 PM, a staff member from the Idaho Department of Professional Licensing stated that an RN temporary license only granted authority to practice in the State of Idaho, not Washington State. The staff member confirmed Staff A's license was a temporary license issued by the state of Idaho. In a telephone interview on [DATE] at 4:15 PM, a staff member from the WA Board of Nursing stated that in order for an out-of-state RN to be able to work in Washington State they must have a permanent out-of-state license and apply through the endorsement process (a request for the local state nursing board to verify the nursing credentials) or a permanent multi-state (compact) license from another state; having a temporary Idaho license did not allow an individual to practice working as an RN in Washington State. They further added that multi-state licensure was granted based on the state of residence and that a person's driver's license state of residence must match the RN license state of residence. During an interview on [DATE] at 10:54 AM, Staff A stated that when they had obtained their temporary nursing license, they were told it was a multi-state license, just as their previous license (with the same license number). When informed that temporary nursing licenses were only valid in the state they were issued by, Staff A stated they must have been misinformed. During an interview on [DATE] at 12:50 AM, Staff O, Administrator was informed that Staff A's credentials were not valid in the state of [NAME]. Staff O confirmed another staff RN to act as the Director of Nursing and provided their current credentials. During an interview on [DATE] at 10:12 AM, Staff A and Staff O acknowledged that Staff A needed either a current [NAME] or multi-state license to practice as an RN in the facility. Staff A provided a copy of their newly issued [NAME] RN license, issued on [DATE]. WAC 388-97-1080 (1)

Based on observation, interview, and record review, the facility failed to develop and implement interventions to prevent falls and associated injuries and injury during transfers or bed mobility for 3 of 3 sampled residents (Residents 1, 2 and 3) whose records were reviewed for accident hazards. This failure placed the residents at risk for falls, physical injury, and pain. Findings included.<Resident 1>Review of a 10/03/2025 annual assessment showed Resident 1 admitted to the facility on [DATE] with medically complex conditions including dementia with anxiety, a stroke, and pain in the right knee. The assessment showed the staff assessed the resident to be cognitively intact, did not reject care, used a wheelchair, and was dependent on the staff for toileting hygiene, bed mobility, transfers and dressing. The assessment showed the staff identified the resident was frequently incontinent of both bowel and bladder and not on a toileting program and had one fall since the prior assessment.In an interview on 10/24/2025 at 2:58 PM, Resident 1's representative (RR) stated the resident fell and hit the back of their head while participating in an activity class in the facility. The RR stated they were informed by the facility staff that the Resident 1 attempted to stand up on their own with nobody around and fell. The RR stated that this was the resident's third fall within a month. In an observation and interview on 10/27/2025 at 10:31 AM, Resident 1 sat in their wheelchair in their room. A grab bar (a sturdy mounted bar that provides support and stability for people who have difficulty with balance or limited mobility) was attached to the upper right side of the bed frame. Resident 1 stated, I hurt my back yesterday (10/26/2025) and explained they, tried going from one chair to the other and I missed, and I don't know how come I missed but I just did. It was in the dining room. Resident 1 said they fell before lunch. Observed was a one centimeter (unit of measurement) raised area about two inches above the left eye surrounded by a faint bruise. When asked if they had any prior falls, the resident stated, Once before. I pulled a wooden toy cat down on top of myself. I had a great amount of blood. I don't know if I lost my balance, I just reached for it, and it fell off and hit me in the head. The resident then said they did not fall at that time. When asked what the facility did to help prevent them from falling, Resident 1 stated They don't let me sit from one chair to the other. Resident 1 was observed wearing loose-fitting slippers and stated they did not fit well, They're bigger than they should be. Once in a while they slip off my feet.In an interview on 10/27/2025 at 10:55 AM, Staff B, Nursing Assistant (NA), stated they became aware of what interventions or assistance residents required for care by reviewing the Kardex (an abbreviated form of the comprehensive care plan with pertinent instructions and information for the NA), day to day interactions with the resident, or asking the nurse. Staff B said they were aware Resident 1 fell two or three weeks ago, and their memory was, Slipping a little, more forgetful and delusional [fixed, false beliefs that are maintained even when presented with evidence to the contrary]. Staff B stated Resident 1 would sometimes call for assistance for completion of Activities of Daily Living. In an interview on 10/27/2025 at 10:59 AM, Staff C, NA, stated they reviewed a resident's Kardex and received information from the nurse to stay updated of care plan changes. Staff C said the Nurse Managers made the staff aware when care plan changes occurred. Staff C said Resident 1 had, fallen a couple times. One [fall] from bed and one in their wheelchair reaching for something in their room. Staff C said the falls did not happen on their shift and was aware that the care plan recently changed with the instructions to the night shift aides to get the resident up at 5:00 AM if the resident chose to.In an interview on 10/27/2025 at 12:00 PM, Staff D, Licensed Practical Nurse (LPN), stated they determined a resident's risk for falls by asking the NA or observing the resident. Staff D said they witnessed Resident 1 fall once, maybe last month or this month when the resident slipped in the room. Staff D said they did not know what changed with Resident 1's care plan after the fall they witnessed, because I float throughout the facility. When asked how they became aware a resident's care plan changed, Staff D said, I really don't know and that they only worked as needed. Staff D said none of the residents in the specific unit Resident 1 resided were consistent with using the call light to ask for assistance.In an interview on 10/31/2025 at 9:15 AM, Staff E, LPN, stated that Resident 1 needed extensive assistance from the staff for transfers in and out of their bed or wheelchair, but recently I was told [the resident] got up on [their] own volition [will] out of bed. Staff E said the Night Shift staff awakened Resident 1 twice at night around midnight and 4:00 AM because the resident did not call the staff and was unaware of their need to go to the bathroom or of their incontinence. Staff E said Resident 1 seemed to more actively try to get out of bed or their wheelchair without assistance, which was new for the resident, and normally did not walk on their own. Staff E said they observed the resident move their legs off and over the edge of the bed.Review of a 07/28/2025 MAHC-10 Assessment Tool (Missouri Alliance for Home Care, a fall risk assessment tool based on the presence of a fall risk factor, with a total range of zero to 10; a total score of four or higher indicated an increased risk of falling) showed the staff assessed Resident 1's fall risk score was a 6 out of 10.Review of Resident 1's care plan showed they required substantial/maximum assistance of two staff for chair to bed and toileting transfers (06/02/2025) and one person partial/moderate assist for bed mobility. A revised 12/20/2024 intervention instructed the staff to assist the resident with toileting before and after all meals, HS [bedtime] and PRN [as needed] and a 10/08/2025 intervention to, Encourage fluids during the day to promote prompted voiding responses (a behavioral therapy used to manage urinary incontinence by combining scheduled toileting with caregiver prompts and positive reinforcement). The care plan showed Resident 1, needs supervision and assistance with decision-making intermittently for safety [revised 03/03/2025].Review of progress notes from 06/01/2025 to 09/17/2025 showed the staff documented Resident 1 showed: - poor safety awareness and/or confusion, including inconsistent or no use of the call light to ask staff for assistance with bed mobility or transfers or found sitting at the edge of the bed - 06/02/2025, 06/06/2025, 06/08/2025, 06/08/2025, 06/15/2025, 07/18/2025, 07/22/2025, 08/02/2025, - interrupted sleep pattern at night or staff waking the resident up at night for routine cares 06/08/2025, 07/17/2025, 07/19/2025, 09/13/2025, 09/17/2025, - physical and mental decline - 07/19/2025.Review of 09/17/2025 progress notes showed the staff found Resident 1 on the floor in their room at 6:15 PM. The note showed the staff assessed Resident 1 sustained a small laceration [cut] on forehead. The staff told the resident they tried to get their pajamas from the dresser. The resident's MAHC score rose to 8.A 09/23/2025 facility investigative document associated with the 09/17/2025 fall concluded the cause of the fall was Resident 1 lost their balance when they attempted to stand up. The investigation showed the resident told the staff, My right knee is weak, when asked what was different this time when they fell. The intervention to prevent falls was for the staff to ask the resident if they would like to get dressed and ready for bed after dinner as the resident preferred going to bed early. Review of the care plan showed no documentation the facility developed or revised interventions to compensate for Resident 1's cognitive deficits and decline at other times throughout the day, including interrupted sleep pattern either from progressing dementia or staff waking up the resident at night for routine cares or how to anticipate or mitigate the resident's impulsiveness to get out of bed or self-transfer. Review of the care plan showed no documentation the facility developed or modified the care plan to address the level of supervision during times the staff identified the resident transferred without assistance or the resident's right knee weakness.Review of a 09/26/2025 provider note showed the staff notified the provider Resident 1 seemed more confused than usual. Resident is talking about 'numbers on the screen'. A 10/01/2025 provider note showed expect progressive decline of dementia.Review of progress notes from 09/28/2025 to 10/07/2025 showed the staff documented Resident 1 showed: - poor safety awareness and/or confusion, including inconsistent or no use of the call light to ask staff for assistance with bed mobility or transfers or found sitting at the edge of the bed - 09/29/2025, 09/30/2025, 10/07/2025, - interrupted sleep pattern at night or staff waking the resident up at night for routine cares - 09/28/2025, 09/30/2025, 10/07/2025.Review of a 10/08/2025 at 5:00 AM progress note showed the staff walked into Resident 1's room for scheduled rounds and found the resident on the floor, lying on their back near the bed. The resident told the staff, I was trying to get some [sic] out of my dresser drawer and I fell. The staff assessed Resident 1 sustained a small knot on their forehead and that the resident told them they hit their head.Review of a 10/13/2025 facility investigate document associated with the fall showed Resident 1 preferred to, Spends a lot of time in [their] room doing activities there and the intervention was to get the resident, First up in the morning. The medical record showed the instruction to the staff to Offer to get up at 5 am [morning]. Review of the investigative document showed no documentation the facility reviewed and revised the resident's care plan to include the level of supervision for intercepting and providing the required assistance for the ongoing staff observations of self-transfers or change in bed mobility. Review of the care plan showed no documentation the facility revised interventions to compensate for Resident 1's cognitive deficits and decline, including interrupted sleep pattern either from progressing dementia or staff waking up the resident at night for routine cares or how to anticipate or mitigate the resident's impulsiveness to get out of bed or self-transfer.Review of a 10/13/2025 at 4:33 PM progress note showed the staff heard gasping from another resident in the dining room and found Resident 1 lying on their back. The staff assessed a bump to the back of the resident's head, the size of a small egg. The progress notes showed the resident fell when they tried to walk to another chair in the dining room. The notes showed, Analysis: Res [Resident] is confuse [sic], mentally declining. Per staff reported to this LN [Licensed Nurse] res is walking inside [their] room without the assist from staff. Res is high risk for fall.Review of a 10/14/2025 provider note showed Resident 1 displayed apparent self ambulation [walking] attempts in room. The provider documented the resident had, memory loss, doesn't call for transfer assistance, directly leading to falls, expect progressive decline. The provider stated the resident walked impulsively and that dementia negates remembering to call for assistance.Review of a 10/14/2025 facility investigative report associated with the fall showed the root cause of the fall was a lack of education of activity assistant regarding resident's fall risk and care plan interventions and to provide education to the activities department to maintain resident safety. The investigation and the care plan showed no documentation the facility revised the care plan to address Resident 1 mentally declining or their impulsivity, including the supervision required to mitigate the progressing dementia or fall prevention strategies to compensate for the resident's cognitive deficits.In an interview on 10/30/2025 at 11:08 AM, Staff F, Activities Director, stated they did not know what Resident 1's level of cognitive impairment was and was unaware their cognition or physical abilities had changed. Additionally, they did not know Resident 1 fell during an activities session with an activities staff present. The above findings were shared with Staff A, Director of Nursing, on 11/04/2025 at 1:43 PM. Staff A said, The interventions in the care plan are based on the fall [that happened]. <Resident 2>Review of a 10/11/2025 quarterly assessment showed Resident 2 admitted to the facility on [DATE] with the diagnosis of dementia, a history of falling, and muscle weakness. The assessment showed the resident's cognition was severely impaired and had one fall since the prior assessment. The assessment showed Resident 2 was dependent on or required physical assistance from the staff for toileting hygiene, putting on footwear, and transfers. Resident 2 was frequently incontinent of both bowel and bladder and on no toileting program.Review of Resident 2's comprehensive care plan showed a risk for falls care plan with 04/04/2025 and 04/15/2025 instructions to the staff to, Provide direct supervision while resident is toileting, Reinforce safety awareness: use call light, lock brakes on chair before transferring, utilize device. When rising from a lying position, sit/rest at edge of the bed at least 10 seconds before transferring, Respond to resident requests timely. Anticipate needs, and Encourage resident to be in areas of increased traffic area to promote frequent observations. The most recent intervention was dated 08/13/2025 to ask the resident if they want to eat in a less stimulating environment. Resident 2's comprehensive care plan also showed a 06/12/2025 impaired cognition care plan that informed the staff the resident was able to remember one or two instructions, find their room, and sit for an hour. A 09/28/2025 urinary incontinence care plan and interventions instructed the staff to check the resident every two to three hours for incontinent episodes. A 04/09/2025 care plan and interventions informed the staff the resident required one person assist with the use of a walker for walking inside their room only, and that therapy walked with the resident for longer distances. This care plan showed the resident required the use of a walker for toileting transfers and one-person minimal assist with turning, repositioning, and bed mobility tasks. Review of 07/08/2025 progress notes showed the staff observed Resident 2 walking up [the] hallway and suddenly fell to the ground, did not hit their head and landed more on [their] left side. The staff documented There was no trip or stumble but possibly the rubber on [their] shoes caught the floor. The note showed the resident was walking without staff assistance or supervision and had a bit of anxiety about not being able to find their family member. The nursing interventions implemented immediately after the fall were to ensure safe wandering and every 2 hours of toileting (an intervention already in place in Resident 2's care plan). A subsequent note on 07/09/2025 showed Resident 2 was wearing their sandals at the time of the fall. Review of the 07/08/2025 provider note showed, wearing sandals today, suspect tripped and discussed not wearing sandals with staff.Review of a 07/09/2025 Fall Risk -MAHC-10 Assessment Tool showed a score of five out of 10.Review of a facility investigative report associated with the 07/08/2025 fall showed the fall was also witnessed by the provider and concluded the resident did not trip or stumble, but just lost [their] balance contrary to the 07/08/2025 provider's documentation, and the resident's show [sic] got caught on the material of the floor. The investigation stated therapy would screen for therapy services and assess footwear to ensure the resident was safe with current footwear. Review of Resident 2's care plan or the rest of the medical record showed no instruction to staff Resident 2 was assessed safe to wear sandals.Review of a 08/09/2025 at 5:30 PM progress note showed a nurse observed Resident 2 sitting at the dining room table then stood up and started walking and tripped over [their] foot and fell to the floor. The resident was crying and asking about their family member. Review of an 08/11/2025 facility investigative report associated with the 08/09/2025 fall showed Resident 2 abruptly stood up, tripped over their own foot and fell to the ground. Associated documents also showed the Resident stood up [and] tripped over shoe. The care plan intervention for the fall was to ask the resident if they preferred to eat in a less stimulating environment to help keep their anxiety low.Review of 08/11/2025 progress notes showed the nurse heard Resident 2 calling out for help and found the resident on the floor by their bed. The resident told the nurse they did not know what happened, that they just went down, just like that. The resident told the nurse they were returning to bed from the bathroom and did not call for assistance. The nurse observed Resident 2 wore non-slip socks and sandals. The nurse documented, Due to cognitive impairment, [the resident] doesn't remember to call for help with OOB [out of bed] activity.Review of a 08/11/2025 Fall Risk -MAHC-10 Assessment Tool showed an increased score of 8 out of 10.Review of an 08/11/2025 investigative report associated with the 08/11/2025 fall showed Resident 2 walked independently in the unit, contrary to the 04/09/2025 care plan intervention of one person assistance with the use of a walker for walking inside their room only and that therapy walked with the resident for longer distances. The investigative report showed the resident had a wheelchair that was self-locking, but the care plan did not include this intervention. The report showed Resident 2 sustained bruising discoloration and wore nonskid socks and open-toed sandals, deemed appropriate footwear at the time of the fall. A therapy screen was recommended. Review of the resident's care plan showed no interventions that addressed the provider's discussion with the staff of, not wearing sandals or strategies to compensate for Resident 2's severely impaired cognition to better anticipate needs or mitigate self-transfers. In an interview on 11/04/2025 at 11:54 AM, Staff G, Physical Therapist, stated appropriate footwear for fall prevention included non-skid socks or shoes that are supportive and have nonskid surfaces. The shoes should not be coming off the foot but should fit securely. Staff G was asked if open-toed sandals were safe to wear for fall prevention and they stated, No, it would not be considered safe footwear. Therapy evaluation or screening results for Resident 2's footwear were requested.An observation on 10/27/2025 at 11:20 AM showed Resident 2 sitting in a wheelchair and propelling themselves out of the dining room and into the hallway. Resident 2 softly stated, I gotta' get outta' here. Resident 2 was observed wearing open-toed rubber sandals with nonskid socks. The nonskid sock to the left foot extended out and in front of the open-toed sandal about three to four inches from the toes.The above findings were shared with Staff A on 11/04/2025 at 1:27 PM. Staff A stated that, Sandals are not appropriate footwear. I can't force [the resident] not to wear sandals. Staff A was asked what efforts were made to collaborate with Resident 2's representative to replace the open-toed sandals and stated, It wouldn't be in the medical record and It should be documented.On 11/07/2025 at 1:17 PM, the facility sent an electronic mail to the surveyor which stated, The therapy notes we have for [Resident 2] are not around that timeframe [July and August 2025], we do not have any additional therapy notes to give you.<Failure to Follow the Care Plan><Resident 3> Review of a 09/22/2025 admission assessment showed Resident 3 admitted to the facility on [DATE] with medically complex conditions, including muscle weakness, difficulty walking and right foot drop (a condition where the muscles that lift the front part of the foot are weakened or paralyzed resulting in an inability to raise the foot, causing the toes to drag or slap on the ground while walking). The assessment showed the resident had intact cognition and was dependent on the staff for bed mobility and transfers. Resident 3's care plan instructed the staff Resident 3 required substantial/maximal assistance of two persons, with the use of a sit-to-stand (a mechanical lift) for transfers between surfaces and for turning, repositioning, and bed mobility tasks (Date Initiated - 09/16/2025).In an interview and observation on 10/30/2025 at 12:41 PM, Resident 3 stated that in the process of being assisted back to bed by Staff H, NA, on 10/27/2025, they experienced pain. The resident stated Staff H transferred them from the wheelchair to the bed with the use of a EZ lift (a sit-to-stand lift that helped the person from a sitting to a standing position). Additionally, Staff H helped the resident from the seated position at the edge of the bed and into bed by themself. Resident 3 stated when they first arrived to the facility, two staff assisted with transfers and bed mobility. Resident 3 stated that nothing changed in the way the staff transferred or positioned them in bed after the 10/27/2025 incident. In an interview on 11/03/2025 at 10:05AM, a Collateral Contact (CC) stated they visited Resident 3 daily, multiple times throughout the day. When asked how many staff they observed transfer and assist the resident with bed mobility, the CC stated, It's bad. I have never seen two people in there with [the resident] and I come down there quite often. The CC explained that on some occasions when the staff assisted getting Resident 3 out of bed, they saw the resident almost hit their head on the headboard and, I just cringed. I've seen where [the resident is] sitting on the bed and [the staff] just lift [their] legs from under the bed and [the resident] falls over onto [their] right side. The CC added, I've not seen two people and I said that to [Resident 3] who goes, 'Well, sometimes they have two people in here and I told [the resident], 'sometimes' isn't enough.In an interview on 10/31/2025 at 3:40 PM, Staff H stated they knew how to care for the residents by obtaining report from their nurse or the aide from the previous shift. When asked how many people were required when mechanical lifts were used, Staff H stated two people, but with a sit-to-stand not always. It just happens that way. Staff H said she did not ask other staff to assist them with the lift transfer or help position Resident 3 in bed and that they usually transferred Resident 3 by themself, Always one person since taking care of [the resident].In an interview on 10/30/2025 at 12:35 PM, Staff I, who wished to remain anonymous, stated that some of the staff did not use the mechanical lifts because they were physically big enough to lift and transfer the residents on their own.In an interview on 10/31/2025 at 3:16 PM, Staff J, who wished to remain anonymous, said they became aware of changes to the care plan or resident needs by checking the Kardex or the aide who worked the previous shift. Staff J said Resident 3 had become more dependent on the staff and required more physical assistance. Staff J said that when they could not find anyone to help them transfer a resident, they would physically pick them up and put them in bed but only if they were semi-mobile. Staff J said that every once in a while they would transfer a resident in a sit-to-stand by themself.In an interview on 10/31/2025 at 3:26 PM, Staff K, Registered Nurse (RN), stated that at first the staff transferred Resident 3 with a Hoyer lift (a mechanical lift) and then transitioned to a sit-to- stand lift and had been using a sit-to-stand for a couple of months. Staff K said they assisted Resident 3 with bed mobility, By myself numerous times. Turning [the resident] in bed you can do with one person. You have to go slow and easy and [the resident's] legs are heavy, so you have to be a strong person. I've done it. In an interview on 10/31/2025 at 3:10 PM, Staff L, NA, said they assisted Resident 3 with no assistance for bed mobility. The above findings were shared with Staff A on 11/04/2025 at 1:43 PM. Staff A said Resident 3 required two-person assistance for bed mobility and transfers because of weakness to the legs and decreased mobility. When asked if Staff H implemented the care plan instruction to provide two people for transfers and bed mobility, Staff A said, No. Reference: WAC 388-97-1020(1), (2)(a)(b).

Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 6), reviewed for medication administration, received medication as ordered by the physician. This failure resulted in a pattern of significant medication errors which placed the resident at risk for medical complications, unintended health consequences and diminished quality of life. Findings included . Review of the hospital discharge summary and orders dated 10/10/2024 showed Resident 6 was to receive fluconazole (oral antifungal medication) 600mg (milligrams; a unit of measurement) daily until 10/28/2024. The resident was to be closely monitored by nephrology (medical specialty that focuses on the kidneys) due to their advanced kidney disease. Per the October 2024 Medication Administration Record, Resident 6 received fluconazole 600mg twice daily on 10/11/2024, 10/12/2024, 10/13/2024, 10/14/2024, and 10/15/2024 (double the amount ordered). The resident's record showed they discharged from the facility on 10/15/2024. Review of the October 2024 progress notes showed no entries addressing the increase in Resident 6's fluconazole. In an interview on 03/18/2025 at 4:03 PM Staff F, Registered Nurse, stated when a resident discharged to the facility from the hospital their medication orders were processed by the Resident Care Manager. Staff F was unable to provide any information related to Resident 6's fluconazole. In an interview on 03/18/2025 at 4:15 PM Staff A, Director of Nursing, stated they started working at the facility in November and had identified concerns with the admission medication process shortly afterward. Staff A stated they now required two staff to review and verify the hospital discharge medication list was accurately entered into the facility's electronic system. Staff A reviewed Resident 6's record and confirmed the fluconazole administered to the resident did not match their hospital discharge orders, which constituted a medication error. Reference: (WAC) 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to notify the resident representative of an incident requiring transfer to the hospital experienced by 1 of 4 sampled residents (Resident 1), reviewed for accident hazards. This failure placed the resident at risk for delayed decisions for treatment by the legal representative. Findings included . Review of the 11/20/2024 annual assessment showed Resident 1 had significant cognitive impairments and was dependent upon staff for assistance with activities of daily living (ADLs). Per the 11/21/2024 care plan, Resident 1 had a surrogate decision-maker who was to be involved in all medical and financial decision making. Review of the December 2024 progress notes for Resident 1 showed on 12/05/2024 Staff B, Registered Nurse was notified by staff at the front desk that Resident 1 had a fall during an external appointment that day which resulted in low back pain and required a transfer to the hospital for evaluation. The note showed the resident was transferred back to the facility with no new physician orders. There was no documentation showing the resident's representative was notified of the incident. In an interview on 01/15/2025 at 11:57 AM, Resident Representative 1 (RR1) stated they were not aware Resident 1 had a fall on 12/05/2024 while at an appointment. RR1 further stated they were not aware the resident was even at an appointment and would not have agreed to the appointment due to the resident's confusion and history of refusal with the type of provider the appointment was scheduled with. In an interview on 01/15/2025 at 4:22 PM Staff A, Director of Nursing, stated a fall that occurred outside of the facility still needed to be reported to all responsible parties. Staff A reviewed Resident 1's medical record then confirmed that a fall requiring hospital transfer occurred at an external provider appointment on 12/05/2025. Per Staff A, the incident had not been reported to them and an investigation of the incident (which occurred more than a month prior to the interview) was still underway. Staff A was unable to provide additional information regarding notification to the resident's representative. Reference WAC 388-97-0320.

Based on observation, interview and record review, the facility failed to ensure 1 of 4 sampled residents (Resident 1), reviewed for accident hazards, received adequate supervision while at an appointment with an external provider. This failure placed the resident at risk of injury and unmet needs. Findings included . Review of the 11/20/2024 annual assessment showed Resident 1 had significant cognitive impairments and was dependent upon staff for assistance with activities of daily living (ADLs). Per the 11/21/2024 care plan, Resident 1 was at a high risk to fall, had a history of seizures (sudden uncontrolled electrical disturbance in the brain) and involuntary movements, and was confused. The care plan showed staff were to provide close monitoring of the resident, a specialty wheelchair that tilted back (to prevent falls from leaning forward), and required the assistance of two staff and a mechanical lift for transfers. Review of the December 2024 progress notes for Resident 1 showed on 12/05/2024 Resident 1 had an external appointment that day. Further review of the progress notes showed no documentation whether the resident was accompanied by either staff or family. Additionally, there was no documentation prior to the appointment showing an assessment was done to determine if the resident would be safe in their wheelchair, unaccompanied, out of the facility, for the duration of their appointment. In an interview on 01/14/2025 at 1:05 PM Collateral Contact 1 (CC1) stated Resident 1 arrived at their appointment on 12/05/2024 alone and confused. Per CC1, Resident 1 did not know their medical history or where they lived. Observation at 01/15/2025 at 10:29 AM showed Resident 1 was in their room on the locked memory unit. The resident was able to state their name but did not know how long they lived in the facility and was unable to recall what they ate for breakfast that day. In an interview on 01/15/2025 at 11:57 AM, Resident Representative 1 (RR1) stated they were not asked if they could accompany Resident 1 to an external appointment on 12/05/2024. RR1 further stated they were not aware the resident had an appointment scheduled that day and would not have agreed to the appointment due to the resident's confusion and history of refusal with the type of provider the appointment was scheduled with. RR1 stated they did not feel it was safe to send the resident to an external appointment alone. In an interview on 01/15/2025 at 12:10 PM Staff C, Nursing Assistant, stated Resident 1 was at high risk to fall and needed staff assistance to move in their wheelchair. Staff C stated staff could accompany residents to their appointments if they were notified in advance, but did not recall that any staff accompanied the resident on 12/05/2025. In an interview at 2:45 PM the same day, Staff E, Resident Care Manager, stated when the facility received notification of a resident appointment a transportation request sheet would be filled out and given to Staff D, Receptionist, for confirmation and scheduling of transportation. Staff E stated the interdisciplinary team (IDT: group of professionals from various health care disciplines) discussed upcoming appointments and if a resident was cognitively impaired, they would schedule a staff member or ask the resident's family to accompany the resident. Staff E stated they were out of the facility for a few weeks around the beginning of December, and they did not have additional information regarding Resident 1's 12/05/2025 appointment, including whether they were assessed to need supervision while out of the facility. Staff E stated Resident 1 was a high fall risk and had a fall the day prior to their appointment. At 3:13 PM the same day, Staff D confirmed they were responsible for scheduling appointments and transportation. Staff D stated they were not aware of each resident's mobility and cognitive status and relied on staff to notify them when a resident needed someone to accompany them to an appointment, which did not always occur. Per Staff D, Resident 1's 12/05/2025 appointment and transportation were scheduled by Staff E before Staff D started working at the facility. Staff D stated they were surprised the nursing staff let the resident go to the appointment when the transportation company arrived, and no one was scheduled to accompany the resident. In an interview on 01/15/2025 at 4:22 PM, Staff A, Director of Nursing, stated the facility would provide staff to accompany a resident to an appointment if it was needed, and that such information should be communicated to Staff D on the appointment/transportation form. Staff A stated they were not sure if Resident 1 needed staff to accompany them to their appointments and would defer to Staff E on the decision. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure 1 of 8 sample residents (Resident 1) reviewed for abuse, was free from sexual abuse from another resident (Resident 2). This failure placed Resident 1 and other residents at risk for psychosocial harm and a diminished quality of life. Findings included . Review of the 09/09/2024 annual assessment showed Resident 2 was severely cognitively impaired, wandered one to three days of the assessment period, had delusions (false belief about external reality despite evidence to the contrary) and was able to walk with supervision. Review of the care plan initiated 09/06/2023 showed Resident 2 had poor physical boundaries with others and required staff to monitor their behavior. Per the 09/04/2024 quarterly assessment Resident 1 was severely cognitively impaired and independent with walking. Review of a 09/17/2024 facility investigation showed Staff D, Nursing Assistant, was walking down the hallway at approximately 2:45 PM that day and found Resident 2 in Resident 1's room. Per the report, Resident 1 was lying on their bed under the blankets and Resident 2 was next to the bed with one hand on Resident 1's (clothed) breast and the other hand under the blankets. Staff D told Resident 2 to stop and to leave; the resident responded with aggression towards Staff D and required two additional staff to assist in separating the residents. The investigation report showed Resident 1 stated they did not invite Resident 2 into their room. Observation on 09/30/2024 at 3:52 PM showed Resident 2's room was at the end of the hallway, furthest from the nurse's station. Resident 1's room was on the same side of the hallway, directly next to Resident 2's room. Resident 2 was in their room seated in their recliner with the door closed. When interviewed, the resident gave clear but incorrect answers to simple questions such as how long they had been residing in the facility. Resident 2 denied ever going into any other resident rooms and denied any inappropriate interactions with other residents. At 3:57 PM the same day Resident 1 was observed seated in the dining room conversing with other (unidentified) residents. Resident 1 was interviewed and stated they did not feel safe around too many people as they were used to living in the country with less crowding, however they did not have any concerns with the other residents at the facility. Resident 1 was pleasantly confused and did not recall the incident with Resident 2. In an interview on 09/30/2024 at 4:04 PM Staff C, Registered Nurse, stated Resident 2 had a history of wandering into other resident rooms and could be aggressive. Staff C stated they assisted to remove Resident 2 from Resident 1's room on 09/17/2024 due to the resident's aggression with Staff D. Staff C stated neither resident remembered the incident and Resident 1 had not had any changes in behavior afterwards. In an interview on 10/16/2024 at 10:25 AM Staff D stated on 09/17/2024 they began their shift on the unit Resident 1 and 2 resided on at 2:00 PM and were doing their initial checks on the residents when they found Resident 2 in Resident 1's room at 2:45 PM. Staff D stated Resident 1 was lying in their bed awake and unmoving while Resident 2 was seated in a chair next to the bed with their right hand on Resident 1's breast and their left hand under the covers in the area of Resident 1's genitalia. Staff D stated after they told Resident 2 to leave the resident responded that they were talking to Resident 1 and Staff D should mind their own business. Staff D stated Resident 1 did not have any changes in their behavior the night of the incident and had no negative responses to questioning about the incident. Per Staff D, Resident 2 had a prior history of wandering into female residents' rooms and staff were responsible to monitor the resident. Reference: (WAC) 388-97-0640 (1)

Based on interview and record review, the facility failed to ensure that direct care staffing information was accurate upon submission to the Centers for Medicare and Medicaid Services (CMS) for Quarter 1 of 2024 (January 1, 2024 through March 31, 2024) reviewed for Payroll Based Journal (PBJ - mandatory reporting of staffing information based on payroll data) submission. This failure caused CMS to have inaccurate data related to facility staffing levels and had the potential to impact resident care and services. Findings included . Review of the Certification and Survey Provider Enhanced Reports (CASPER) PBJ Staffing Data Report showed the facility reported data for Quarter 1, 2024 at a level lower than required by mandated staffing levels. In an interview on 10/16/2024 at 3:15 PM Staff B, Director of Nursing, stated the facility was having a lot of change during Quarter 1, 2024 and they did not think hours were being reported correctly. On 11/14/2024 at 8:10 PM Staff A, Operations Director, documented the facility had additional staffing data from Quarter 1, 2024 that was not reported. Per Staff A the missing staffing data related to staff who worked for external staffing agencies and provided invoices from the pertinent agencies.

Based on observation, interview, and record review, the facility failed to provide appetizing and palatable food for 6 of 7 sampled residents (48, 59, 8, 41, 1, 43) reviewed for food. This failure placed the residents at risk for decreased nutritional intake, and a diminished quality of life. Findings included . According to [NAME] Administrative Code [PHONE NUMBER]0, Time/temperature control for safety food, hot and cold holding (FDA Food Code 3-501.16). Food must be maintained: At 135 F (57 C) or above, or at 41 F (5 C) or less. Resident Observations and Interviews <Resident 48> On 08/01/2024 at 2:41 PM, Resident 48 was observed sitting in a wheelchair in their room using their computer. When asked about the food, the resident stated the food was horrible, did not have much taste, and was not something they would eat if they had a choice. On 08/06/2024 at 8:29 AM, Resident 48 stated breakfast was good, had eggs, toast, oatmeal, and coffee, but there was no meat. Resident 48 further stated the meals often seemed incomplete, like the other night, they served mashed potatoes with gravy, and some meat, but there were no vegetables. <Resident 59> During an interview on 08/01/2024 at 12:18 PM, Resident 59 stated the food was horrible, the meat was mushy, ground garbage, and a week ago Sunday, one could not tell what it even was. In a follow-up interview on 08/06/24 between 8:45 and 9:11 AM, Resident 59 stated one of the worst foods the kitchen served was the steak teriyaki, the meat tasted and looked like little strips of cardboard. Resident 59 then stated the lasagna and pizza were made with just the sauce, there was no cheese or meat, and the stroganoff one night looked like dogfood. <Resident 8> On 08/02/2024 at 11:05 AM, Resident 8 was observed resting in bed in their room. When asked if they had any concerns, the resident stated the food was horrible, had no taste, and sometimes they didn't know what it was. <Resident 41> During an interview on 08/02/2024 at 11:47 AM, when asked about the food, Resident 41 stated the food did not taste good and was often cold. <Resident 1> On 08/01/2024 at 10:15 AM, Resident 1 was observed lying in their bed in their room talking with their representative. When asked if the food tasted good, Resident 1 gave a thumbs down gesture with their left hand. The representative stated the food was disgusting, did not taste good, and sometimes resembled glue. In response to the comment, Resident 1 then made a thumbs up gesture and shook his head up and down. <Resident 43> In an interview on 08/06/2024 at 3:17 PM, Resident 43 stated the food was terrible, and did not taste good at all. The resident further stated that they had been excited to get fried chicken at lunch, but the meat was so fused to the bones on the piece of the back that they were served that they couldn't eat it. Interviews In an interview on 08/12/2024 at 12:32 PM, when informed of the food concerns expressed by the above residents, Staff II, Dietary Manager, stated they were not aware of any food complaints. With regards to the food not having much taste/flavor, Staff II stated there was a new cook and they may be afraid of using the spices and seasonings that were available. 47728 <Test tray> During an observation and sampling of the lunch meal on 08/09/2024 at 12:15 PM the food was not colorful and did not appear appetizing. The meal consisted of brown meatloaf with a dark red sauce, white mashed potatoes, white cauliflower, off-white banana cream pie and a dark purple fruit flavored drink. The temperatures of the food items were outside of the acceptable parameters and were as follows: Meatloaf 115 F, Mashed Potatoes 110 F, Cauliflower 80 F, Banana cream pie 60 F, and Grape flavored drink 58 F. The flavor of the food was bland with the meatloaf having only a slight taste of onion, the mashed potatoes tasted only of salt, the banana cream pie tasted only of sugar, and the drink tasted like a grape drink mix for children. In an interview on 08/09/2024 at 2:23 PM, when asked what seasonings are used when preparing the food for the residents, Staff II stated onion, garlic, sage, all sorts of seasonings, and stated they tasted the food as it was prepared. Reference: WAC 483.60(d)(1)(2)-1100 (1), (2)

Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions (EBP, an infection control intervention to reduce transmission of multi-drug resistant organisms) were implemented when indicated for 4 of 4 sampled residents (69, 7, 73, 1) reviewed, and that hand hygiene was completed when indicated during 1 medication pass observed and 2 wound treatments observed. Additionally, the water management plan was not developed and implemented as required, Infection Prevention Program policies and procedures were not reviewed annually, and appropriate follow-up measures were not completed timely when one resident screened for Tuberculosis exposure (TB, a bacterical infection that mainly affected the lungs) had a positive skin test. These failures placed residents at risk for cross contamination of infectious material, and possible exposure or illness from debilitating bacterial and viral illnesses. The article, Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to present the spread of multi-drug resistant organisms (MDROs), published by the Center of Disease Control (CDC) on 07/12/2022 stated because nursing home residents with wounds and indwelling medical devices were at especially high risk of acquisition and/or colonization of an MDRO, the use of enhanced-barrier precautions which included the use of a gown and gloves during high contact resident care activities such as: dressing, bathing, transferring, providing hygiene, changing linens, providing assistance with toileting or incontinence care, wound care, and device care was indicated. Findings included . 46033 <Enhanced Barrier Precautions> <Resident 69> A quarterly assessment dated [DATE] documented Resident 69 had diagnoses including state 4 pressure ulcer, and a history of multi-drug resistant organisms (MDROs) in a leg wound. Resident 69 was moderately cognitively impaired, required moderate staff assistance with most Activities of daily living (ADLs), and required use of an indwelling urinary catheter (a catheter inserted in the bladder that allowed urine to drain into a collection bag.) The 05/07/2024 care plan documented Resident 69 required enhanced barrier precautions (EBP) related to their wound treatments and their indwelling catheter. Staff were instructed to use a gown and gloves for high contact resident care including dressing, bathing, transferring, toileting care, changing linens, or device or wound care. Staff were to monitor and report any signs or symptoms of infection to the provider. The resident was able to leave their room. On 08/02/2024 at 2:37 PM, the door to Resident 69's room had signage on the door indicating contact precautions were to be in use when the resident's room was entered. A cart containing personal protective equipment (PPE, disposable gowns and gloves used to prevent contact with harmful bacteria and body fluids) was located next to the door at the entrance. On 08/06/2024 at 9:15 AM, the door to Resident 69's room was open, and the resident was observed from the hall. There was no longer a PPE cart at the entrance or contact precautions signage on the door. At 9:19 AM, a student Nursing Assistant (NAC) was observed wearing gloves and no gown and pushing a mechanical lift out of the room. The student parked the lift in the hall next to the door, re-entered the room, disposed of their gloves and washed their hands. The lift was not cleaned after it's use. A staff member later identified as Staff HH, NAC, was observed straightening the linens on Resident 69's bed. They were not wearing a gown or gloves. Resident 69 was now seated in their wheelchair in the room. During an interview on 08/06/2024 at 9:27 AM, Staff HH stated Resident 69 was not on any type of care precautions; the roommate had been on antibiotics, so gloves were required when providing care to Resident 69's roommate. Staff HH stated they had been educated on EBP and the Infection Control Nurse told the staff who required precautions. Staff HH stated residents with urinary catheters did not require enhanced barrier precautions. On 08/07/2024 at 9:58 AM, Resident 69 was out of their room. There was no signage on the door indicating EBP was required. There was a PPE cart at the entrance again. On 08/08/2024 at 10:00 AM, Staff HH and an unidentified male staff entered Resident 69's room pushing a mechanical lift into the room. Neither staff wore a gown or gloves into the room. There was no signage on the door indicating EBP was in use. During an interview on 08/13/2024 at 2:10 PM, Staff C, Infection Control Registered Nurse, stated EBP was an ongoing battle. Staff C stated they placed a red stop sign on a resident's door and an additional sign underneath that notified staff of the reason the resident required EBP. Staff C stated they made rounds on the units to ensure signage was in place when indicated. Staff C stated they expected staff to put on the appropriate PPE when residents were on EBP. They stated it protected residents from cross contamination and decreased the change that infections were spread to other residents. <Resident 1> The 07/08/2024 annual assessment documented Resident 1 had diagnoses which included neurogenic bladder, a condition caused from injury to the spinal cord, brain or nerves that resulted in the loss of bladder control, was dependent on nursing staff to complete ADLS and utilized a urinary catheter. The 11/16/2023 care plan documented enhanced barrier precautions were implemented for Resident 1 due to the use of an indwelling catheter, and nursing staff were instructed that gown and gloves were required when performing high-contact resident care (dressing, bathing, transferring, incontinence or toileting care, dressing, changing linens, or device/wound care). On 08/01/2024 at 9:34 AM, Resident 1 was observed lying in their bed talking with their representative. A sign on the door informed visitors and staff that enhanced barrier precautions were in place due to device care/use and asked them to speak to the nurse before entering the room. The sign included information on what PPE were to be used and a cart containing PPE supplies was in the hall next to the entrance to the resident's room. On 08/01/2024 from 9:57 AM, Staff S, Nursing Assistant, was observed doing ADL care for Resident 1. Staff S performed hand hygiene and donned gloves, but no gown, then used cleansing wipes to clean the resident's groin area and buttocks. After placing an incontinence brief on Resident 1, Staff S then doffed the gloves, performed hand hygiene and donned new gloves, but no gown, and began to assist the resident to put on a shirt. When Staff S was asked what type of PPE should be used for Resident 1 when doing cares, Staff S stated they were told only gloves were needed. After getting the shirt on Resident 1, Staff S doffed the gloves, performed hand hygiene, donned new gloves and then emptied the urinary catheter bag before putting pants on the resident. Once the resident was dressed, Staff S doffed the gloves, did hand hygiene and left the room. On 08/01/2024 at 10:11 AM, Staff S returned to the room with a Hoyer lift, a mechanical lift used to transfer residents, and Staff OO, Licensed Practical Nurse, to get Resident 1 up in their wheelchair. Both Staff S and Staff OO performed hand hygiene, donned gloves, but no gown, and then used the Hoyer to transfer Resident 1 into their wheelchair. In an interview on 08/13/24 02:02 PM, Staff B, Director of Nursing, was informed of the above observations of enhanced barrier precautions/PPE not being implemented. Staff B stated it was the expectation that staff would implement EBP as instructed. <Resident 7> According to the 06/25/2024 Assessment, Resident 7 was severely cognitively impaired, unable to direct their own care, required assistance for Activities of Daily Living (ADLs) such as positioning in bed, and personal hygiene. Resident 7 had a feeding tube (a flexible plastic tube placed into the stomach or bowel to supply nutrients and fluids), and had diagnoses which included malnutrition and catatonic disorder (a brain disorder which often results in a lack of movement and communication). A sign by the door outside of the resident's room indicated Enhanced Barrier Precautions (EBP) were to be implemented for this resident and instructed staff to wear gloves and a protective gown when performing personal care for the resident as well as transferring, and device care and use including a feeding tube. During an observation on 08/26/2024 at 9:44 AM, Staff LL, Registered Nurse (RN) provided medication and fluid administration to Resident 7 through the feeding tube. Upon entering Resident 7's room, Staff LL did not put on gloves or a gown. Staff LL with the assistance of Staff MM, Resident Care Manager, who was wearing gloves but no gown, positioned the resident in bed, adjusted the over bed table, used the bed controls to adjust the bed height, and removed a surgical mask from the resident's face. Staff LL then performed hand hygiene and put on gloves but still no gown and proceeded to use a syringe to administer water and medications through Resident 7's feeding tube, then used a gloved hand and cleaned out the resident's mouth with a moistened foam swab, and applied lip balm to Resident 7's lips. In an interview on 08/06/2024 at 10:07 AM when asked what EBP meant, Staff LL stated they were not doing that and that they wore gloves when doing device care. In an interview on 08/06/2024 at 10:23 AM, Staff C, Infection Preventionist stated EBP included gloves and gown being worn when providing any personal care to a resident, including transfers, rolling, and positioning in bed. <Resident 73> According to a provider note date 07/29/2024, Resident 73 was cognitively intact, able to direct their own care and had diagnoses including fracture of the right lower leg with a subsequent infection. They had a Peripherally Inserted Central Catheter (PICC- a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) through which they received an antibiotic (a medication that can kill or stop the growth of bacteria). A sign by the door outside of the resident's room indicated Enhanced Barrier Precautions (EBP) were to be implemented for this resident and instructed staff to wear gloves and a protective gown when performing personal care for the resident, as well as when performing device care and use of a central line (a long flexible tube inserted into a large vein that leads to the heart). During an observation on 08/12/2024 at 8:48 AM, Staff E, Licensed Practical Nurse (LPN) entered the resident's room and put on gloves but did not put on a gown. Staff E then proceeded to administer medication through the PICC line. In an interview on 08/12/2024 at 9:01 AM when asked why the resident was on EBP, Staff E stated the resident was no longer on those precautions. When Staff E was shown the EBP sign on resident's door and the central line instruction were pointed out, Staff E stated the resident didn't have a central line. When Staff E was informed that a PICC line is a central line they stated they should have gowned and gloved when performing PICC line care and medication administration because it was important to prevent the spread of infection. <Infection Prevention Policies> A review of the Infection Prevention Program policies and procedures showed the following: -The facility Infection Prevention and Control Program policy was released 10/31/2017 and revised 10/15/2022. -The facility Influenza Program policy was released 10/31/2017 and revised 08/01/2023. -The facility Infection Control Sub-Committee policy was released 11/28/2017 and revised 09/10/2020. -The facility Pneumococcal Program policy was released 10/31/2017 and revised 05/31/2023. -The facility Infection Engineering Controls policy was released 10/01/2017. -The facility Infection Exposure Control Plan policy was released 10/31/2017. -The facility Antibiotic Stewardship policy was released 10/01/2017 and revised 10/15/2022. None of the listed policies had dates listed on them that indicated the policies had been reviewed (or revised when indicated) within the previous year. During an interview on 08/13/2024 at 2:10 PM, Staff C stated they were not aware the infection prevention policies were required to be reviewed annually. Staff C stated they were not sure who was responsible for reviewing the policies, if it was them, or if this was done at the corporate level. <Water Management Plan> On 08/12/2024 at 7:28 AM, documents detailing the facility water management plan were requested and provided by Staff KK, Maintenance Director. At that time, two binders and a water test kit were provided. The Water Test Kit was observed and listed 17 elements the kit identified if present in a water sample. The 17 elements the kit tested for did not include Legionella (a water-born bacteria that if inhaled caused pneumonia.) The Water Test results were logged in one of the binders under the heading titled Monthly Legionella Testing. Results were documented as negative. A further review of the water management binders included a title page that documented the plan had been reviewed in 04/2024 and showed policies and procedures as references that were from the facility's previous owner's group. Water system descriptions, ways of monitoring facility water sources, and interventions were specific to a facility located at a different site. During an interview on 08/13/2024 at 8:10 AM, Staff KK stated they had quickly reviewed the Water Management binders with their corporate resource staff member. At that time, they had done the risk assessment, but Staff KK stated they had not read through all of the documents in the plan thoroughly and did not realize they referred to a different facility. Staff KK stated a previous version of the water test kits they had used tested for Legionella and when new ones arrived, they had not noticed that the new kits no longer included Legionella. Staff KK stated they would review the plan more closely and make it specific to their facility. 46115 <Hand Hygiene> <Resident 75> According to the 07/01/2024 admission assessment, Resident 75 had a wound to their buttock and was cognitively intact. On 08/07/2024 at 10:46 AM, an observation was made of the wound care and dressing change to Resident 75's left buttock with Staff E, Licensed Practical Nurse. Staff E donned gloves and removed the dressing from the resident's left buttock, removed their gloves, and without performing hand hygiene, placed a new pair of gloves on and applied the treatment and dressing. Staff E did not perform hand hygiene during glove changes when indicated. <Resident 283> According to the 07/15/2024 admission assessment, Resident 283 had vascular wounds to their left lower extremity and was cognitively intact. On 08/07/2024 at 1:10 PM, an observation was made of the wound care and dressing change to Resident 283's left heel and lateral side of ankle with Staff E. Staff E donned gloves, removed the bandages, cleaned the wounds and removed their gloves, and without performing hand hygiene, placed a new pair of gloves on and applied the treatment and dressing. Staff E did not perform hand hygiene during glove changes when indicated. During an interview on 08/07/2024 at 1:34 PM, Staff E stated hand hygiene needed to be completed before and after the dressing change and was unsure if it needed to be completed after their gloves were removed. In an interview on 08/13/2024 at 10:03 AM, Staff C, Infection Prevention Registered Nurse, stated gloves needed to be changed when going from a clean area to a dirty area and hand hygiene was not needed after gloves were removed unless you touched something unclean. During an interview on 08/13/2024 at 10:12 AM, Staff B, Director of Nursing, stated hand hygiene needed to be completed after gloves were removed during dressing changes and this was important to prevent the spread of bacteria. During an observation on 08/26/2024 at 9:44 AM, Staff LL, Registered Nurse (RN) provided medication and fluid administration to Resident 7 through a feeding tube. Upon entering the resident's room, Staff LL washed their hands at the sink in the room and put on gloves. After they used a syringe to administer fluids and medications through the feeding tube, Staff LL rinsed the syringe at the sink in the resident's room and turned off the water using their gloved hand, then without performing hand hygiene or changing gloves, placed the syringe in a plastic bag, cleaned the resident's mouth, and applied lip balm to the resident's lips. Staff LL then removed their gloves and rinsed their hands with water at the sink, they did not wash with soap or use alcohol-based hand sanitizer to clean their hands. Staff LL then proceeded to prepare medications and administer them to another resident. In an interview on 08/06/2024 at 10:07 AM, when asked why they only rinsed with water after removing their gloves, Staff LL stated they never washed with soap after removing gloves. They said they only washed their hands with soap and water before putting on gloves. During an observation on 08/12/2024 at 8:48 AM Staff E, Licensed Practical Nurse prepared and administered medication to Resident 3 through the resident's PICC line. Upon entering the resident's room, Staff E washed their hands with soap and water, scrubbing their hands with the soap for five seconds, turned off the water faucet with their bare hand, and proceeded to put on gloves and administer the medication. After removing their gloves, Staff E washed their hands with soap and water, scrubbing their hands with the soap for three seconds, then turned off the water faucet with their bare hand. In an interview on 08/12/2024 at 09:01 AM, when asked how handwashing should be performed, Staff E stated, turn on the water, apply soap to hands, scrub hands with soap for 10-15 seconds, use a paper towel to dry hands, then use another paper towel and turn off the water. Staff E stated this was important to prevent the spread of infection. In an interview on 08/06/2024 at 10:23 AM Staff C, Infection Preventionist stated nursing staff were expected to wash their hands when entering or exiting a resident room, before putting on gloves, and after removing gloves. 47728 <Tuberculosis Surveillance> In a review of Resident 48's record there was documentation of a positive reaction to a tuberculosis (TB) skin test. (TB- a contagious bacterial infection that affects the lungs and can spread through the air), (TB skin test- a simple and low-cost method to detect TB infection by injecting a solution under the skin). Staff NN, Licensed Practical Nurse documented on 5/18/2024 that resident 48's TB skin test resulted in a one centimeter touchable, raised, hardened area, at the TB test site. No further documentation of testing related to the TB skin test result was found in Resident 48's record. In an interview on 08/13/2024 at 11:19 AM, Staff C, Infection Preventionist stated they monitored the residents records to ensure documentation on TB testing was completed. Staff C stated a positive TB skin test result consisted of any induration, a raised, hard, reddened area, present at the test site. When asked what would happen if a resident had a positive TB skin test result, Staff C stated, they would investigate further by having the resident get a chest X-ray and/or a more conclusive TB test, and the results would have been documented in the resident record. Staff C stated they were unaware of Resident 48's positive TB skin test and no further action had been taken. An interview with Staff NN was unable to be conducted because they were no longer employed by the facility and did not return a phone call requesting an interview. Reference: WAC 388-97-1320(1)(c)(2)(a)(b)

Based on interview and record review, the facility failed to take action or evaluate the need for action for 2 of 3 sampled residents (Resident 1 and 2), who experienced significant changes in clinical status. There was a lack of timely interventions, physician notification and adherence to the bowel management program, Resident 1 experienced harm when complaints of stomach pain were not reported or managed, Resident 2 experienced harm when pain and significant weeping edema was not addressed. Findings included: Review of the facility's policy for change of condition, dated [DATE], stated that upon recognition of a potentially life-threatening condition or significant change in status, the nurse should communicate with other health care providers to meet the needs of the resident. Review of a provider notification binder, found at all the nurses' stations within the facility, titled Alert to change in condition, dated 2020, stated early intervention is key! It further stated to call the provider if the resident was not themselves today and included decreased participation in activities, decreased food intake or appetite, increased complaints of pain, increased weakness, decreased ability to participate in ADL's, resident looks puffy. <Resident 1> Review of Resident 1's quarterly assessment dated [DATE] showed they were severely cognitively impaired and had diagnosis of Alzheimer's. Resident 1 was documented to require supervision by staff for walking and using the bathroom but walked independently, using a walker, around the unit they lived on. Review of Resident 1's medical record showed that nursing staff documented their food intake up to three times per day from [DATE] until [DATE]. Beginning [DATE] there was a decline in their usual food intake (of 76 meals recorded, during the time period, the resident consumed ,d+[DATE]% of the meal 52 times, and ,d+[DATE]% 15 times), with the resident refusing the lunch meal on [DATE] and their dinner meal intake recorded as ,d+[DATE]% consumed. On [DATE] the breakfast meal was not recorded, and lunch was marked as refused. On [DATE] breakfast was marked as refused and dinner was marked as ,d+[DATE]% eaten. On [DATE] the dinner meal was documented as ,d+[DATE]% eaten. On [DATE] the lunch meal was documented as ,d+[DATE]% consumed and dinner meal was marked as ,d+[DATE]% consumed. Further review of Resident 1's medical record showed that their care plan had a focus for constipation with a goal to have a bowel movement (BM) at least every two days. Review of the resident's Medication Administration Record (MAR) showed they had an as needed order for Senna-S tablet (an oral medication used to treat constipation) to be given up to two times daily for constipation, with direction to notify the provider/practitioner if there were three days without a significant BM. Review of Resident 1's BM record from [DATE] until [DATE] showed no BM recorded from [DATE] until [DATE] at 1:59 PM (more than three days). No BM was recoded from [DATE] until [DATE] at 10:06 AM (more than four days). Review of Resident 1's progress notes showed that on [DATE] Staff H, Licensed Practical Nurse (LPN), wrote the resident appeared anxious and was complaining of epigastric pain (area around and above stomach). On [DATE] at 5:13 AM Staff E, Registered Nurse (RN), noted they gave the resident as needed (to be given if needed for pain or fever) Tylenol (over the counter pain medication). At 7:00 AM Staff I, recorded the Tylenol as having been effective at relieving pain. At 7:30 AM Staff I, RN, wrote that they had received report from the night shift nurse, Staff E, that all residents were stable. They then wrote that upon entering Resident 1's room at 7:30 AM they found them on the floor on their left side covered in coffee ground emesis,(vomit that looks like coffee grounds and occurs due to old and coagulated blood in the gastrointestinal tract. It is a sign of internal bleeding). The resident was assessed and found to be deceased . During an interview on [DATE] at 1:35 PM, Staff F, RN, stated that they had worked with Resident 1 several times per week for the last several months. They stated that Resident 1 would tell the nurse if they were in pain and had said their stomach hurt several times. Staff F stated that they had worked with Resident 1 on [DATE] and that they had not said their stomach hurt that day, but they had seemed sleepier than usual and weak, and they had helped the resident to get ready and get into bed which was not at all typical. They did not report the previous reports of stomach pain or increased weakness to the medical provider or oncoming nurse. During an interview on [DATE] at 1:01 PM, Staff D, Resident Care Manger (RCM), stated that Resident 1 was active and largely independent but required staff supervision as they would pack their belongings daily and say that they were returning home to their family. They stated that Resident 1 went to the toilet independently and would tell the nursing staff if they had a BM. They stated that if a resident had not had a BM in two to three days the nursing staff would give bowel medications and tell the medical provider. They were not sure if this had happened with Resident 1. They further stated that sometimes Resident 1 would say their stomach hurt. They stated that an agency nurse had told them that on [DATE] that Resident 1 was less active and quieter than usual and did not join the rest of the residents for snacks and coffee as was typical for them, but stayed in their recliner, otherwise they were not aware of the resident's decreased food intake. Staff D stated that nurses did walking rounds at shift change (the off going and oncoming nurse walk room to room to check on each resident and talk about what happened during the shift), but this did not happen on the morning of [DATE]. Staff D stated that they did not notify the medical provider of Resident 1's reports of stomach pain, the decreased food intake, the decreased frequency of BM's or the staff report or unusual behavior. During an interview on [DATE] at 10:51 AM, Staff E, RN, stated that they had worked with Resident 1 for about a year and that they would complain every couple months that their stomach hurt. On the early morning of [DATE], about 5:00 AM, they had gone into the resident's room and found them in the bathroom with their arm across their mid abdomen and said their stomach hurt. Staff E stated that they gave the resident Tylenol for pain and then had to help Resident 1 back to bed, which was unusual and had not happened before. Staff E stated that they told the next nurse, Staff I, that they had given Resident 1 Tylenol but could not remember if they told Staff I what it was for and did not tell the day shift nurse that Resident 1 had complained of stomach pain or that they had to help them back to bed. They further stated that they did not notify the medical provider of resident 1's report of stomach pain or their increased weakness. During an interview on [DATE] at 10:28 AM Staff G, Nursing Assistant (NA), stated that they had received report from the off going NA about 6:00 AM and was told Resident 1 often woke up and would get dressed on their own and they then started their day working with other residents. They further stated that about 7:30 AM on [DATE] Staff I, RN, came out of Resident 1's room and said they needed help now. Staff G then stated that they entered Resident 1's room, the overhead light was on, and the resident was laying on their stomach on the floor next to their bed with their head turned to the left and a pool of black blood about the size of the resident's head on the floor. They then helped the RN move the resident from the floor onto their bed and left the room. They further stated that was their first day working at the facility and they had not worked with that resident previously. <Resident 2> Review of Resident 2's admit assessment dated [DATE] showed they were moderately cognitively impaired, had a urinary catheter (tubing placed to drain urine from the bladder) with a urinary tract infection in the last 30 days, wounds on both legs and heart failure. The assessment also showed Resident 2 required extensive assistance from staff to complete their activities of daily living and was receiving therapy services with the resident participating in therapy services daily. Review of Resident 2's medical record showed that on [DATE] at midnight, labs taken on [DATE] showed the resident had a significantly high white blood count (indicates infection). Staff J, Physicians Assistant saw the resident on [DATE] and noted they had abdominal distention (swelling of the abdomen) and a high white blood count. They examined the resident's abdomen and noted it was distended and firm and that both resident's legs were swollen (2+) and weeping (when swollen parts of the body produce liquid that leaks out of the skin). Staff J ordered antibiotics to treat the unknown source of infection while they waited for further labs to result. Review of the residents MAR showed the antibiotics were ordered at 3:00 PM [DATE] to start that evening, were marked as not available the evening of [DATE] and were not given until the morning of [DATE]. Further record review showed Resident 2 was taking scheduled narcotic pain medication for pain but did not have a focus for pain management in their care plan. Standard of practice indicates that narcotic pain medication cause constipation. Resident 2's BM record showed no BM's from [DATE] to [DATE] at 1:59 PM (more than four days) and from [DATE] to [DATE] at 1:59 PM (more than three days). Resident 2's MAR showed they had an order for a bowel medication to be given every 24 hours as needed for constipation. The [DATE] MAR showed the medication was not given. Review of nursing progress note written by Staff D, RCM, dated [DATE] at 3:58 PM stated that Resident 2 was up all morning shift moaning with agony .holding left lower extremity. The note indicated they gave the scheduled narcotic medication, and that the residents right leg was very swollen (3+++) and leaking fluid. At 10:43 PM on [DATE] Staff K, RN, wrote that Resident 2 was found at 8:30 PM unresponsive in their wheelchair in the hallway and was found to be deceased . During an interview on [DATE] at 1:01 PM, Staff D, RCM stated that Resident 1 was in a lot of pain and that their death was expected. When Staff D reviewed the resident's orders for treatment, they stated that the resident was not on comfort care and wanted treatment for infections. They further stated that sometimes orders placed for medications late in the day did not come until the next day from the pharmacy and it looked like that was what happened with Resident 2's antibiotic. They stated that they did not notify the provider of the increased leg swelling or increased resident complaints of pain. During an interview on [DATE] at 2:05 PM, Staff C, Nurse Practitioner, stated that they had worked in the facility since July of 2023. They stated that Resident 1 was pleasantly cognitively impaired and would always tell them not to worry about them because they were going home that day and never had any complaints. They further stated that they had not been notified of any complaints related to Resident 1. They stated that they had not been notified of stomach or epigastric pain, decreased food intake, no BM for three or more days, and increased weakness and need for assistance with activities of daily living by the nursing staff. They stated that those were all things that were indicative of a change in condition, and they should have been notified. They stated that they had not worked with Resident 2 and the medical provider that had was no longer working in the building because the medical director had changed. They stated that there was not a set bowel regimen in the facility to manage residents who had constipation related to the medical director having changed several times in the last several months. They stated that all the medical providers in the building had followed the document titled alert to change in condition, and expected to be notified of anything listed on that document. During an interview on [DATE] at 1:20 PM with Staff A, Administrator and Staff B, Director of Nursing. Staff B stated that they had started at the facility on [DATE]. The further stated that they were aware there was no bowel regimen in place to deal with residents' constipation and that was something they were actively working on with the new medical group which had started on [DATE]. They stated that all the medical groups that had been in the building in the last several months had followed the document titled alert to change of condition, and that the signs and symptoms on that document should be reported to medical providers. Staff A confirmed this. Staff B further stated that residents should receive antibiotics when they are ordered and if the facility does not have them when they are ordered to be given the nurse needs to notify the medical provider and/or the director of nursing. They further stated that since [DATE] they had started monitoring residents for no BM in two days, decreased food intake and new orders for antibiotics so that any concerns could be followed up on promptly. Reference: (WAC) [DATE] - 2 [A] (ii)(iii) - 2 [B]

Based on observation, interview, and record review, the facility failed to prevent abuse for 1 of 4 sampled residents (Resident 1), reviewed for abuse and neglect. This failure caused harm to Resident 1 who sustained physical injury, including bruising and psychosocial harm in the form of crying. Findings included . The Code of Federal Regulations (CFR) define abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Additionally, willful as defined in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated October 2015, Abuse is the willful action or inaction that inflicts injury, unreasonable confinement, intimidation, or punishment on a vulnerable adult. Review of the annual assessment dated [DATE] showed Resident 1 had diagnoses of dementia, anxiety, and depression, and was severely cognitively impaired. The resident required extensive assistance of one staff for activities of daily living and had verbal behaviors one to three days of the seven-day review period. Per the assessment the resident had no physical behaviors and/or rejection of care during the review period. Per the care plan initiated on 03/09/2018, Resident 1 had impaired cognitive function, agitation, and refusal of cares. Staff interventions included providing the resident with necessary cues, provide assistance of two staff when observed with aggressive behavior, approaching the resident positively, and to stop (care) and return if agitated. Review of a facility investigation, dated 04/08/2023, showed Staff E and F, Nursing Assistants, were providing care to Resident 1 in their room that morning, when the resident became combative with staff. The investigation showed staff continued to provide care to the resident, rather than stopping and returning later (as identified in the care plan), and the resident continued to be combative despite verbal redirection from Staff E. Per the investigation, Staff E reported to the manager on duty, Staff C, Clinical Care Leader, that they (Staff E) slapped Resident 1 in the face after the resident became combative. The report showed Staff F also reported seeing Staff E hit the resident in the face to Staff C, which caused the resident to become visibly upset. Review of the April 2023 nursing progress notes showed a skin assessment conducted on 04/08/2023 documented no redness or bruising, and Resident 1 was unable to answer questions about the incident. Further notes showed a fading bruise to the resident's lower jaw was later noted by multiple nurses, which resolved on 04/23/2023. Observation on 04/24/2023 at 3:12 PM showed Resident 1 was in their room on the dementia unit, seated in a wheelchair with their eyes closed. The resident did not open their eyes when spoken to, and mumbled in response to questions; the resident was unable to answer questions about the incident. In an interview on 05/01/2023 at 2:36 PM, Staff F stated they worked for an agency and had only worked at the facility twice. Staff F stated they and Staff E were the only staff members present in Resident 1's room on the morning of 04/08/2023. Per Staff F, the resident was combative during care, and Staff E (who was standing on the resident's left side) reacted to the resident by hitting them in the face with an open hand. Staff F stated Staff E left the room after the incident and the resident began to cry. Staff F also stated that they left the facility shortly afterwards and did not return, but called Staff C to report concerns for resident abuse. At 8:36 AM on 05/11/2023, Staff E was asked about the incident where they slapped Resident 1. Staff E stated they barely brushed [their] mouth, like with a toddler . felt bad immediately after. Per Staff E, they had worked at the facility for four months, mostly on the dementia unit, and had received training on how to work with residents with dementia. Staff E confirmed being aware hitting a resident constituted abuse. In an interview on 05/04/2023 at 2:30 PM, Staff D, Registered Nurse, stated Resident 1 had verbal behaviors of yelling and crying, and would occasionally refuse care, especially when working with new staff. Staff D stated they were unable to determine if Resident 1 had increased verbal behaviors after the incident, due to the resident's dementia and baseline behavior of yelling but did observe a small bruise in the shape of a fingerprint to the resident's left lower jaw. Per Staff D, the bruising matched the description of the incident of a staff person putting their hand on the resident's mouth. On 05/11/2023 at 10:50AM, Staff A, Administrator, and Staff B, Director of Nursing, stated the facility's investigation substantiated abuse of Resident 1 by Staff E, and a police report was filed. Both staff confirmed they were aware of the bruising later noted to the resident's face, which they notified the resident's representatives of. Staff A stated the representatives were notified of the open police report and how to press charges. Per Staff A, Staff E was not allowed to return to the facility. Reference: (WAC) 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to ensure sufficient staff were available to meet the care needs for five of eight sample residents (1, 5, 7, 10, 11), reviewed for activities of daily living for dependent residents, and restorative nursing (interventions that promote a resident's ability to adapt and adjust to living as independently and safely as possible). These failures placed the residents at risk for unmet care needs, a diminished quality of life, and caused psychosocial harm to Resident 1, who was oxygen dependent, and experienced emotional distress, related to not being assisted timely on several occasions. Findings included . RESIDENT INTERVIEWS Per the 02/21/2021 annual assessment, Resident 1 was able to make decisions regarding care, and needed extensive assistance from staff to complete activities of daily living such as getting out of bed and dressing. On 04/07/2021 at 1:00 PM, Resident 1 was observed wearing oxygen, sitting in a wheelchair watching television. When asked if there was enough staff available to provide assistance, the resident became tearful and stated, Absolutely not enough staff at all! The resident stated often times there was only one nursing assistant (NA) to provide care on the unit, and that weekends were particularly bad. Per the resident, on 03/21/2021, she put the call light on at her usual get up time (a little before 8:00 AM), and nobody came until almost 10:30 AM. When the resident was asked if she had received breakfast that morning, the resident stated, No, I got breakfast at lunch time. During the interview, the resident remained tearful. Toward the end of the conversation, Resident 1 stated, I put my light on to get out of bed. I depend on oxygen. What if something was wrong with the oxygen machine and I needed help? I wouldn't be here now, if that was the issue. During subsequent interactions and interviews, Resident 1 continued to express concerns with not enough staff to provide care, and would become tearful. On 04/11/2021 at 8:00 PM, the resident stated she often wondered what would happen if she needed help with the oxygen and nobody came. Review of the staffing schedules from 03/07/2021 through 03/15/2021 showed there were two NA positions and one licensed nurse for each of the units for day and evening shifts (Berry Way, Morningside, and Day Spring). On 03/16/2021, Berry Way was changed from two NA positions to one, and the Mountain View unit (which had been closed) was reopened, and staffed with one NA and one licensed nurse. On 04/11/2021 at 7:45 PM, Resident 5 stated they had to wait up to an hour to get assistance to the bathroom stating, I don't want to soil myself, and I was going to transfer myself to the bathroom, but I am afraid I would fall. On 04/13/2021 at 10:45 AM, Resident 7 stated they had to wait for over an hour to get assistance to the bathroom, stating one time she was left on the toilet for over an hour. The resident also stated the last time she received restorative therapy for ambulation was 03/31/2021. On 04/13/2021 at 1:15 PM, Resident 10 stated there was not enough staff, and she had to wait over an hour to get bathroom assistance. Resident 10 then stated, What if there was a fire? There is not enough staff to get the residents out. On 04/14/2021 at 6:30 PM, Resident 11 stated it had taken up to an hour to get assistance, and the restorative aides were being pulled to work the floor, so she was not getting restorative therapy. STAFFING OBSERVATIONS AND INTERVIEWS At 11:11 AM on 04/06/2021, Anonymous Staff H expressed concerns about resident safety, stating there was not enough staff to provide care and assist the residents timely, and the nurses were working the floor in addition to trying to do medication passes and resident treatments. On 04/07/2021 at 11:20 AM, the following staffing observations were made throughout the facility: the Mountain View unit did not have any nursing assistants, and the nurse was providing resident care in addition to completing medication passes and treatments for seven residents (Mountain View was the quarantine unit for new admissions, and staff were required to don and doff personal protective equipment before entering each resident room). The Berry Way unit had one licensed nurse and one NA providing care for 18 residents, the Morningside unit had one licensed nurse and two nursing assistants for 19 residents, and the Day Spring (memory care) unit had one nurse and two nursing assistants for 21 residents. At 11:30 AM on 04/07/2021, Anonymous Staff F stated in the past few weeks there was not enough staff, and it was hard to provide care timely as some residents required two people to provide care, and some residents had complex medical treatments that could be time consuming. At 12:15 PM, Anonymous Staff G expressed concern about resident safety and the increased risks for falls, when there was only one nursing assistant on a unit. Staff G also stated if a resident required two staff for cares, you had to wait until another staff member was available, which also delayed being able to provide care timely. At 6:00 PM on 04/11/2021, staffing observations were as followed: the Mountain View unit had been closed, and the seven residents had been moved to Berry Way and Morningside. Berry Way had a licensed nurse and a nursing assistant for 20 residents; Morningside had a licensed nurse - and due to staff calling in for their shift - a licensed nurse was working overtime to help provide care for the 23 residents; and the Day Spring unit had one licensed nurse and one NA to provide care for 24 residents. At 6:30 PM, Staff B, Director of Nursing, arrived to help provide resident care. In an interview at 6:30 PM on 04/11/2021, Staff A, Administrator, stated the decision to close the Mountain View unit was made on Friday (04/09/2021), in an attempt to better utilize staff to be able to provide resident care. INTERVIEWS On 04/07/2021 at 12:40 PM, Anonymous Staff C stated until recently, staffing was good, but for the past few weeks the restorative aides were being pulled to work the floor, and they were unable to do both restorative therapy and work the floor, so the therapy was not getting done. On 04/07/2021 at 1:00 PM, Anonymous Staff I expressed concerns that the staffing levels made it hard to get resident cares and tasks done. In addition, Staff I felt the staffing levels were not adequate to provide for resident safety. On 04/07/2021 at 2:15 PM, Anonymous Staff J stated the staffing levels placed the residents at risk for safety and health risks, and staff were tired of working extra shifts. Anonymous Staff J stated the staff were afraid that when they come to work, they would end up being forced to stay over, as nobody was willing to come in to replace them. On 04/08/2021 at 11:11 AM, Anonymous Staff K stated the facility did not have the resources to fill all the vacant openings stating, Staff are tired, they are working overtime to try and provide resident care, and sometimes are forced to stay to cover the next shift when nobody comes to relieve them. There were 37 open positions for April, just for nurses and in May, there are 83 open shifts that will need filled. In an interview on 04/20/2021 at 3:00 PM, with both Staff A and B, they confirmed the facility was having issues covering all the open positions. Per Staff A, the staffing schedule was reviewed daily to ensure there was adequate staff, but as staff called off or didn't show up for their shift, it becomes difficult to find replacement staff, and as a result the restorative aides were sometimes pulled to work the floor. In the same interview, the incident and concerns involving Resident 1 were discussed, and Staff B stated the resident was assessed for psychosocial harm at the time, but acknowledged that psychosocial harm could have occurred. (Refer to F 688 for additional information). Reference: (WAC): 388-97-1080(1)

Based on observation, interview, and record review, the facility failed to implement a consistent restorative program (a program that helps residents maintain and/or improve in their ability to participate in activities of daily living), for three of four sample residents (#4, 5, 6), reviewed for positioning and mobility. This failure caused actual harm to Resident #4, who experienced a decrease in her ability to ambulate, and to Resident #5, who had a decrease in joint mobility. This failure also placed residents at risk for debility, weakness, and a diminished quality of life. Findings included 1. According to the 12/18/19 annual assessment, Resident #4 was able to make her needs known, had impaired range of motion to both upper and lower extremities, needed limited assistance from one staff to ambulate, used a wheelchair and four wheeled walker for mobility, and was independent with activities of daily living. The 06/05/2020 quarterly assessment showed the resident now required assistance with activities of daily living, and was no longer utilizing a 4-wheeled walker for mobility. Ambulation had not been assessed. Review of the restorative care plan (revised 07/03/2019), instructed the restorative aides to provide active range of motion to the resident's left upper extremity, the NuStep program (a type of exercise program), gait balance training, and to ambulate the resident using a gait belt and 4-wheeled walker (with a wheelchair following behind it). The restorative therapy documentation from 06/01/2020 through 08/19/2020 showed the resident had received range of motion and gait balance training one time, had been ambulated with staff three times in June 2020, 11 times in July 2020, and one time in August 2020. The resident had walked a total of 14 times in three months. In an interview on 08/12/2020 at 1:45 PM, Anonymous Staff E stated that she was pulled to the floor almost every day, and that currently the restorative program might get done one time per week. When asked if residents had experienced any declines, she stated yes, and told the surveyor to ask Resident #4, stating she doesn't get to walk. In an interview on 08/12/2020 at 1:50 PM, Resident #4 stated she was losing the use of her legs. She stated there wasn't enough staff at the facility, and the restorative aides were pulled to the floor every day, so she only received therapy about once a month. The resident stated she was very independent, still able to get around in her room, make her bed, and transfer herself to the toilet. Resident #4 stated she wanted to maintain her independence, but was afraid if she didn't get consistent therapy soon, she would lose her ability to walk. She further stated that she used to be able to walk the entire hallway without resting, but as of a couple of weeks ago, when she walked, she was only able to go halfway (and had to sit and rest multiple times). In addition, she stated she used to be able to walk 500 feet which was her physical therapy goal, but she could not do that anymore. In an interview on 08/19/2020 at 7:44 AM, Anonymous Staff F stated Resident #4 used to be able to walk from her room all the way down the hall without stopping, but now she could only make it to the common area before she tired out. Staff F further stated that today was the first time she had worked as a restorative aide for two months, and also stated the restorative nurse resigned one to two months ago. In a follow-up interview the same day at 7:55 AM, Staff F stated the restorative nurse was supposed to assess residents every 3 months, but assessments had not been done since the nurse had resigned. On 08/19/2020 at 11:31 AM, Staff E was observed ambulating Resident #4 in the hallway. When asked about the resident's progress, Staff E stated the quality of her gait had changed, from good quality steps to a shuffling gait, and the resident now required frequent breaks and more cuing to keep her head up, and in order to take good quality steps. 2. According to the 08/13/2020 quarterly assessment, Resident #5 was alert and oriented, able to make her needs known, and had [DIAGNOSES REDACTED]. The assessment further showed the resident had impaired range of motion to both upper and lower extremities, was dependent on staff to complete activities of daily living, and had not received restorative services during the assessment period. The restorative care plan (initiated on 12/14/17), instructed the restorative aides to provide passive range of motion exercises for both upper and lower extremities (passive range of motion are exercises to help keep a person's joints flexible). Review of the restorative therapy documentation for 06/01/2020 through 08/19/2020 showed the resident had received restorative therapy seven times in June 2020, nine times in July 2020, and had not received any restorative therapy so far in August 2020. A 06/02/2020 care conference note documented the resident had a physical decline related to her advanced stage of MS, and therapy had been working with her more frequently to prevent loss of function, which had been successful. According to the above documentation, that did not appear to be the case. An additional care conference note on 08/11/2020, showed the resident had experienced a functional decline, as evidenced by increased weakness, fatigue, and an increased need for help with activities of daily living. A nursing progress note on 08/11/2020 at 8:00 PM documented Resident #5 can only use her R arm as L arm is frozen. On 08/12/2020 at 8:50 PM, a nursing progress note showed the resident had expressed frustration about not getting therapy, and felt that the lack of therapy was the reason for the increased weakness, and it was not a progression of the MS. In an interview on 08/13/2020 at 10:40 AM, Resident #5 stated she was supposed to receive restorative therapy six times per week, but that wasn't happening because the restorative aides were always pulled to work the floor, and as a result, she felt over the past few months she had declined because she felt weaker and had more pain. In an interview on 08/16/2020 at 11:18 AM, when asked how often restorative services were done, Staff F stated when restorative was ordered it was supposed to be done six times a week unless ordered as needed. 3. According to the 08/10/2020 quarterly assessment, Resident #6 has impaired range of motion to both the upper and lower extremities, needed extensive assistance from staff to complete activities of daily living, and had received restorative services three days during the assessment period. The restorative care plan (initiated on 09/20/13), included the following instructions: tan palm protectors (a type of hand splint) to be placed first thing in the morning by restorative nursing aides. It also showed if the resident was unable to tolerate the palm protectors, a rolled up washcloth was to be placed in the palm of each hand. On 08/12/2020 at 12:20 PM, Resident #6 was observed to have contractures (shortening of a muscle, causing the muscle to be resistant to stretching) of both her hands, which caused them to be clenched in a fist. No palm protectors or rolled up washcloths were in place. Similar observations were made at 2:00 PM the same day, and on 08/13/2020 at 10:30 AM and 1:00 PM, of the resident not wearing palm protectors or having a rolled up washcloth in place, as directed on the restorative care plan, related to the hand contractures. Review of the restorative documentation from 06/01/2020 through 08/19/2020 showed the palm protectors were put on the resident 13 out of 30 days in June 2020, 20 out of 31 days in July 2020, and nine of 19 days so far in August 2020. In an interview on 08/19/2020 at 7:44 AM, Anonymous Staff F confirmed Resident #6 was supposed to wear bilateral hand splints, but often the restorative aides were pulled to work the floor when there was not enough staff. Staff F further stated when that happened, the splints did not get placed, and the residents do not receive their restorative programs. In an interview on 08/19/2020 at 2:21 PM, Staff B, Director of Nursing, stated she was unaware of any decline with Resident's #4 and #5. With regard to residents who wear splints, Staff B stated it was her understanding that any nursing assistant could perform range of motion exercises and apply splints, and she was unaware that it was not being done. Staff B confirmed the restorative nurse had resigned about two months ago. When asked who was overseeing the restorative program, she stated ultimately it was her responsibility, and confirmed the facility was experiencing staffing challenges, which resulted in the restorative aides being pulled to the floor almost daily. Reference: WAC 388-97-1060 (3)(d)

Based on interview and record review, the facility failed to ensure one of four sample residents (#10), reviewed for toileting, received appropriate care and services necessary to maintain and/or avoid loss of bowel and bladder function. This failed practice caused harm to Resident #10, who experienced a decline in bowel continence, which resulted in feelings of frustration, embarassment, humiliation, and a diminished quality of life. Findings included . The 06/01/2020 quarterly assessment showed Resident #10 was able to make her needs known, required extensive assistance of one person for toileting, and was always continent of bowel. In an interview on 08/12/2020 at 3:00 PM, Anonymous Staff G stated Resident #10 was continent of bowel, and even though she had a medical condition that caused diarrhea, was able to tell staff when she needed to use the bathroom. Staff G stated often there wasn't enough staff to get Resident #10 to the bathroom on time to prevent soiling herself and when that happened, Resident #10 cried and felt embarassed. Review of the bowel and bladder records for the past 30 days (07/21/2020 through 08/18/2020) showed the resident had not experienced any bowel incontinence from 07/21/2020 until 08/04/2020. From 08/04/2020 until 08/18/2020, the resident had 15 episodes of bowel incontinence. On 08/16/2020 at 6:00 PM, Resident #10 confirmed she had a medical condition that caused diarrhea, and it was difficult to get help to the bathroom because the facility was very short on staff, and it made her feel humiliated and degraded when she had accidents, because she had always been continent of bowel. Resident #10 further stated she believed staff avoided answering the call light because she would probably be a mess. The resident stated that it made her feel frustrated and embarassed. When asked how long it took someone to answer her call light, she stated it varied, but weekends were the worst, and most of the time she had to wait for an hour or more. On 08/19/2020 at 3:00 PM, Staff B, Director of Nursing, acknowledged she was aware of Resident #10's toileting issues and how it made her feel. Reference: WAC 388-97-1060 (3)(c)

Based on observation, interview, and record review, the facility failed to implement interventions and/or modify care plans to prevent falls, for two of five sample residents (#50, 22), reviewed for accidents. This failure placed Resident #50 at risk for injury, and caused actual harm to Resident #22, who sustained a [MEDICAL CONDITION], after a fall. Findings included: 1. The 04/24/18 facility assessment showed Resident #22 was admitted in (MONTH) (YEAR), with [DIAGNOSES REDACTED]. A review of the facility incident log showed the resident had a non-injury fall on 05/09/18, and a fall on 05/17/18, which resulted in a laceration above the left ear, requiring staples. The facility investigation, dated 05/09/18, showed at 1:00 a.m., staff found Resident #22 had slid out of bed onto the floor. No apparent injuries were found. The investigation determined factors contributing to the fall were: the resident grabbing the assist bar of the bed, and rocking herself back and forth. This placed the resident on the edge of the mattress, and caused her to slide out of bed. The investigation documented the care plan was revised after the fall, to instruct staff to ensure the resident was positioned between the sheets, and not on top of her bedspread, to prevent recurrence. The 05/17/18 facility investigation showed staff found Resident #22 on the floor beside her bed at 10:00 p.m., with a laceration above her left ear. When asked what happened, the resident stated she was listening to music, and tried to get up so she could dance. The resident was sent to the hospital for evaluation, and returned to the facility with staples to the laceration. The investigation documented contributing factors to the fall included the bed not being in the low position, and the resident lying on top of the bedspread. Per the investigation, the care plan was revised to include: checking on the resident frequently, and placing the bed in the low position. A progress note dated 05/18/18 documented communication with the family regarding the fall on 05/17/18. The resident's daughter reported when she met the resident at the hospital, the resident was still wearing her clothes from earlier that day, and still had her dentures in place (i.e., the resident had not been ready for bed at the time of the fall, at 10:00 p.m.). Per the note, during the discussion with family, it was reported the resident's other daughter had visited at 7:00 p.m. on the night of the fall, and observed the resident lying on top of all the blankets, with the bed in the high position, with the head of the bed elevated. The progress note further showed the daughter was unable to find the nurse, and did not see any staff before she left. A review of the care plan showed Resident #22 was identified as being at risk for falls on 11/15/17 (the date of admission), related to [DIAGNOSES REDACTED]. Further review of the care plan showed the fall prevention interventions that were documented in the facility investigations on 05/09/18 and 05/17/18, as being added to the care plan, were not added until 05/22/18, 13 days after the fall on 05/09/18, and five days after the fall on 05/17/18. In an interview on 07/23/18 at 2:36 p.m., Staff B, Director of Nursing, stated Resident #22's care plan should have been updated to prevent further falls, as planned in the facility investigations, and confirmed it had not been done until 05/22/18. When asked if the bed was in the high position at the time of the injury fall on 05/17/18, Staff B stated she was unable to confirm if it was, but from the documentation, it appeared it was (placing the resident at greater risk of injury, after a fall from a higher distance). 2. According to the 05/15/18 annual assessment, Resident #50 had short and long-term memory problems, impaired decision-making abilities, needed extensive assistance with most activities of daily living, and was unsteady on her feet. Review of the facility's incident log showed the resident fell on [DATE], and again on 06/20/18. According to the facility investigation for the 06/09/18 fall, the resident had been found on the floor in her room, after trying to self-transfer. Per the investigation, the fall resulted in a 0.5 centimeter (cm.) by 0.5 cm. skin tear, on the resident's right forearm. The investigation also documented all safety measures were in place at the time of the fall, and showed the care plan would be amended, with no additional details given. A facility investigation for the 06/20/18 fall documented the resident was found beside her bed on her knees, and appeared to be trying to transfer self. A 05/10/17 care plan, related to the resident's high risk for falls, was found in the record. Interventions included: ensuring the resident was wearing shoes when up in her wheelchair, ambulating, or in bed, keeping the bed in the lowest positon with a fall mat next to it, and toileting the resident every four hours, during the night. The care plan did not reflect any revisions, after the falls 06/09/18 and 06/20/18. The most recently added intervention was dated 08/09/17 (10 months earlier). On 07/18/18 at 2:59 p.m., Resident #50 was observed lying in bed sleeping, with her shoes on. The bed was in the low position, and a fall mat was in place, with a wheelchair next to the bed. In an interview on 07/20/18 at 1:35 p.m., Staff E, Unit Manager, stated she thought she had updated Resident #50's care plan after her falls, but that she was new to the facility, and it was possible she had not done it correctly. Staff E stated the new intervention that should have been added was to ensure both of the resident's legs were up on the bed, when she was in it. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure one of three sample residents, reviewed for medication administration (#1), received medication appropriately, in accordance with a valid physician's orders [REDACTED]. These failures resulted in a significant medication error, causing an Immediate Jeopardy situation for the resident, who received an overdose of narcotic pain medication, and other residents, related to a lack of timely preventative measures. The State Agency informed the facility on [DATE] at 4:30 p.m. of the Immediate Jeopardy situation. The facility provided education to nursing staff, and performed an audit of all residents receiving oral liquid narcotic medications. They ensured there were no additional medication errors. On [DATE] at approximately 3:00 p.m., the facility was notified of the removal of the Immediate Jeopardy. Findings included: According to the hospital record/facility progress notes dated [DATE], Resident #1 was admitted to the facility [DATE] at 5:45 p.m., with [DIAGNOSES REDACTED]. According to the Roxane Laboratories, Inc. Full Prescribing Information, Reference ID: 72, Black Box Warning, [MEDICATION NAME] Oral Solution was available in different concentrations. The Black Box Warning further indicated one must take care when prescribing and administering [MEDICATION NAME] Oral Solution, to avoid dosing errors, due to confusion between different concentrations and between milligrams (mg.) and milliliters (ml.), which could result in accidental overdose and death. Record review of a progress note dated [DATE] at 10:55 p.m., after admission, Resident #1 complained of severe neck pain. The Nurse Practitioner issued a new prescription for [MEDICATION NAME] Concentrate Solution, 5.0 (mg.) sublingual (under the tongue), every two hours as needed for pain/air hunger. Staff C, Registered Nurse, contacted the pharmacy for authorization to obtain the medication without delay, by accessing the on-site medication storage cabinet (which provided immediate access to medications needed in emergency, and/or time sensitive first-dose situations). Staff C administered the medication at 9:15 p.m. After medication administration was completed, Staff C realized she miscalculated the dose, and administered 100 mg. (5.0 ml.) instead of 5.0 mg. (0.25 ml.). Staff C notified the physician immediately, administered a medication to block the effects of [MEDICATION NAME], and arranged for the resident's transfer to a local hospital emergency room . According to the hospital emergency room report dated [DATE], the resident received an accidental [MEDICATION NAME] overdose at the facility. The resident was monitored, remained alert, and was transferred back to the facility for end-of-life care. Additional progress notes reviewed showed the resident died an expected death on [DATE], during the night. Record review of the Nurse Practitioner order dated [DATE] showed the [MEDICATION NAME] was ordered in a concentration of 20 milligrams per milliliter, with an ordered dosage of 5.0 mg. The written order did not include directions for the 5.0 mg. dosage volume in ml. (i.e., how much medication was contained in each liquid amount). Review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]., and did not include calculation of the dosage volume in ml. In an interview and observation on [DATE] at 1:40 p.m. with Staff D, Registered Nurse, the resident's [MEDICATION NAME] was examined for pharmacy labeling. The medication was dispensed in the manufacturer's container, with a manufacturer's label identifying the medication as [MEDICATION NAME] Oral Suspension, 100 mg. per 5.0 ml.; 20 mg. per ml. The bottle was in a clear plastic bag, with a pink label. The pink label was handwritten with the resident's name, physician name, and date opened ([DATE]). A typed note on the label directed staff to refer to the MAR for directions. Staff D stated that was how medication was labeled, when it was obtained from the medication storage cabinet. In an interview on [DATE] at 3:10 p.m. with Staff A, Director of Nursing Services, and Staff B, Unit Manager, Staff B stated the investigation was ongoing, and she did not have information from Staff C, Registered Nurse, related to the dose miscalculation. When asked, Staff B stated when prescriptions for [MEDICATION NAME] Oral Solution were filled and delivered from the pharmacy, the prescription label included the calculation of the dosage volume in ml. When prescriptions were filled from the the medication storage cabinet, for medications needed immediately, there was no pharmacy label prepared. Staff A stated licensed nurses were expected to correctly calculate the medication dosage volume in milliliters for different medication concentrations. When asked, Staff A confirmed a serious medication error occurred. Additionally, Staff A and B were asked if a resident was readmitted on the evening of [DATE], what additional preventative measures had been taken, to prevent a similar serious medication error from occurring. Staff B stated staff would need to be educated about calculating the volume in ml., and stated that had not been completed. Staff A stated she planned to call the corporate representative for assistance with the plan for facility practice, but had not done so yet. For Resident #1, who was at increased risk for difficulty with breathing, the significant medication error represented, immediate, serious risk. Other residents with similar high risk medications were also at risk for serious medication errors. Refer to F658 for additional findings. Reference: (WAC) [DATE] (3)(k)(iii)

Based on observation, interview, and record review, the facility failed to identify and implement interventions related to accidents, and provide adequate supervision for 3 of 6 residents (#92, 93, 111) reviewed for falls, wandering, and resident-to-resident altercations, in a sample of 47. This failure placed residents at risk for involvement in resident-to-resident altercations, and resulted in actual harm to Residents #92 and Resident #111, who had falls with fractures. Findings include: 1. Resident #111 had [DIAGNOSES REDACTED]. Per record review, the resident required extensive to total assistance with activities of daily living, including transfers and bed mobility. The resident had both short and long term memory deficits, and had poor safety awareness. Per the admission assessment dated [DATE], the resident was unsteady during ambulation and had a history of [REDACTED]. The resident was admitted to the facility on [DATE], and had his first fall on 12/03/15. Review of the facility investigation showed the resident was found on his knees, after he had tried to pick up a glass he had dropped on the floor. The resident was reminded to use his call light. Corrective actions taken to prevent reoccurrence included a referral to the fall committee, and employee/resident education related to falls. It was also documented the care plan was amended. On 12/04/15, the resident was found kneeling in front of his recliner, using his urinal. The facility investigation concluded the resident lowered himself to his knees, similarly to the incident on 12/03/15. It was noted the resident was reminded to use his call light, to ask for assistance as needed. Corrective actions after this fall were the same as those identified when the resident fell on [DATE]. On 12/05/15, the resident had a third fall. He was found on the floor between the wall and his bed, with his brief off; there was urine on the floor. The facility investigation concluded the resident was confused, had poor safety awareness, and forgot to use his call light (which was within reach). Corrective actions after this fall were the same as those noted after the falls on 12/03 and 12/04/15. On 12/19/15, the resident was found on the floor, lying beside his recliner, on his back. The resident was able to say he was trying to go to the bathroom. The resident sustained [REDACTED]. The result of the facility investigation documented the resident had short and long term memory loss, and did not recognize his own limitations. It was also noted the resident's call light was in place, but he forgot to use it to call for assistance. There were no new corrective actions/interventions put in place to prevent additional falls (to include an assessment of his toileting needs). On 01/08/16, the resident had a fifth fall. He was found on his knees on the floor. It was concluded the resident attempted to stand up from his recliner, with the foot rest in an elevated position. No injuries were identified, and there were no new corrective actions taken to prevent further falls. On 01/12/16, the resident was found sitting on the floor by his refrigerator. The investigation concluded the resident had been sitting in his wheelchair brushing his teeth, and then tried to get up and walk to breakfast. The resident was again noted as having poor safety awareness, secondary to short and long term memory impairment. The resident did not sustain any injury, and there were no new corrective actions/interventions put in place to prevent additional falls. On 01/16/16, the resident was found on the floor next to his bed. The facility investigation noted the resident was sitting in his wheelchair prior to the fall. It concluded the resident attempted to transfer himself to bed. As of result of this fall, the resident sustained [REDACTED]. A physician's progress note, dated 01/18/16, documented the resident's family declined treatment of [REDACTED]. During the visit, the physician identified the resident was uncomfortable, but was not able to say how much pain he was having. Review of the most recent plan of care revealed the resident was at continued risk for falls, and the date of each fall was documented. Interventions included education to the resident/family about safety reminders, encourage the resident to use his grabber or to ask for assistance, and ensure the resident wears appropriate footwear when ambulating or using a wheelchair. In an interview on 02/24/16 at 2:06 p.m., Staff N, Resident Care Manager, stated the resident did not recognize his own limitations, which contributed to his falls. Staff N also explained when it was noted on the facility investigations the care plan was amended after each fall, it meant the date of the fall was recorded on the care plan, rather than new interventions put in place. On 02/25/16 at 10:50 a.m., the surveyor requested any additional information related to other safety interventions put in place for the resident. Staff N confirmed there were no new interventions tried. In an interview on 02/26/16 at 11:43 a.m., Staff P, Restorative Nurse, said the resident was discussed in the fall committee briefly, but he wasn't sure if there was any documentation related to that review. Staff P said the resident's cognitive deficits, and the inability to educate him about safety, made it difficult to prevent accidents. As noted above in the facility investigations, the resident was often reminded to use his call light after falls, however he was not able to retain that information, in order to help prevent ongoing falls and injury. 2. Resident #92 admitted to the facility in June 2014, and according to his 01/19/16 quarterly assessment, he had [DIAGNOSES REDACTED]. Per the assessment, he required physical assistance for bed mobility, transferring, and toileting. Resident #92's Falls care plan, initiated on 06/17/14 (the time of admission), had the goal of Resident will be free of falls, and included the intervention Keep wheelchair at bedside with brakes locked when resident is in bed. There were no new interventions listed since 10/19/15. The Bladder incontinence care plan, dated 06/17/14, indicated Resident #92 preferred a urinal when in bed and at night. Review of the facility incident log and related reports revealed Resident #92 had several falls in the facility, including on 10/19/15, 11/30/15, 01/31/16, and a fall in which he sustained a fracture on 02/17/16. During the falls on 10/19/15 and 01/31/16, the resident was noted to be trying to self-transfer out of bed into his wheelchair. The investigation, which was completed after the 01/31/16 fall, documented: Resident has poor safety awareness (and) poor memory. Will renew attempts to be sure (wheelchair) is locked (and) at bedside, which is in care plan. In an interview on 02/25/16 at 2:28 p.m., Staff C, Nurse Manager, stated she found the resident was unlocking the wheelchair himself, and staff were trying to remind him not to do that when he transferred. When asked whether the resident was capable of retaining that information, Staff C stated he was not. Review of the investigation for the fall on 02/17/16 revealed the resident fell again, when he was trying to self-transfer from the bed to the wheelchair, and he stated he was trying to use the urinal. In an interview on 02/25/16 at 2:23 p.m., when asked about what interventions changed between the resident's falls, Staff C stated she couldn't find any way to avoid further falls. She stated they discussed the resident's urinary urgency during a fall meeting (as a possible causal factor), but a review of the care plan did not reveal any updates related to urinary complications since September 2015. In an interview on 02/25/16 at 2:47 p.m., when asked what supervision was in place for Resident #92, Staff C stated there was nothing specific in the care plan related to frequency of staff supervision, and added the resident kept his door open, so they looked in on him. Observations during the survey, including on 02/24/16 at 2:48 p.m. and 3:27 p.m.; 02/25/16 at 9:15 a.m., 10:18 a.m. and 2:04 p.m.; and 02/26/16 at 8:53 a.m. revealed Resident #92 was lying in bed, with his wheelchair and urinal out of reach. On 02/26/16 at 9:51 a.m. the room door was mostly closed, and the resident could not be visualized from the hallway. In an interview on 02/25/16 at 2:42 p.m., when asked whether Resident #92 should still have his wheelchair next to the bed, and his urinal within reach while he was in bed, Staff C said she was still trying to decide what was appropriate for his current status, and confirmed lack of an updated care plan might be confusing for the direct care staff. Failure to identify effective fall prevention interventions for Resident #92, and provide adequate supervision to the resident, resulted in actual harm, when he fell in a similar manner as he had previously, and sustained a fracture. 3. According to Resident #93's quarterly review assessment dated [DATE], his behavioral symptoms included occasional wandering, and physical or verbal behavioral symptoms directed toward others. He was assessed to require physical assistance of 1 person for walking, and extensive assistance with transferring. Resident-to-Resident Altercation In an interview on 02/24/16 at 3:15 p.m., Staff I, a nurse, stated there was a resident-to-resident altercation on 02/23/16, in which Resident #93 was found in Resident #13's room, and Resident #13 was on the floor. She stated Resident #93 exhibited wandering behavior. Review of a facility Incident Testimonial Statement revealed Staff K, a nursing assistant, found Resident #13 on the floor of her room, on 02/23/16 at 6:45 p.m., with Resident #93 sitting on her bed. The report indicated Resident #13 stated Resident #93 pushed her off of her bed. Observation in the Dayspring Special Care Unit on 02/23/16 until 6:33 p.m., just prior to this incident, revealed all 5 staff members (Staff D, H, I, J and K) were in the dining room assisting residents with eating, and some residents were in the common areas unsupervised, including Resident #93, who was attempting to exit at the far end of the unit, from 6:29 p.m. to 6:32 p.m., and then turned around at 6:33 p.m. In an interview on 02/24/16 at 4:00 p.m., Staff J, a nursing assistant, stated Resident #93 required supervision consistently, all the time, but indicated that was not always possible, particularly in the evening. Upon further interview, Staff J and Staff K, other staff working the evening of 02/23/16, reported they found Resident #13 on the floor, and said Resident #93 was sitting on Resident #13's bed, and appeared agitated when they entered the room. Staff J stated Resident #93 had many personalities; happy then combative. Resident #13 was not able to answer any questions about the incident during the survey due to memory deficits. In an interview on 02/25/16 at 3:49 p.m., Staff D stated the staff kept an eye on residents that were not in the dining room, on and off, as they were able. She stated it could have been an hour since the resident was last seen on the evening of the incident with Resident #13. When asked if having more staff available during that time would help with supervision, Staff D stated it would, and indicated they sometimes have volunteers available, but it was not consistent. Falls Additional review of the record revealed Resident #93 had frequent falls, including on: 01/03/16, 01/07/16, 2 falls on 01/26/16, 02/06/16, 2 falls on 02/18/16, 02/22/16 and 02/23/16. The falls on 01/03/16 and 02/22/16 both occurred in the dining room, during the evening meal. Corrective actions after each fall repeatedly listed referral to restorative nursing. Other interventions were visual checks with redirection, and a medication review. A fall risk care plan, initiated on 06/12/14 (upon admission) included interventions such as: Encouraging activities, monitor the resident every 60 minutes for needs and fall risk (initiated 03/13/15), monitor resident for need to wander or reposition, and offer to ambulate with the resident to provide stability. The Activities of Daily Living Care Plan indicated Resident #93 required supervision to limited assistance with walking, during times when he was unsteady. In an observation on 02/23/16 at 5:17 p.m., Staff J and K, nursing assistants, were helping Resident #93 to walk into the dining room, by supporting each arm. They assisted him to sit in a chair, and then he promptly stood back up. Resident #93 was grabbing at a tablemate's wheelchair, and staff moved the other resident to another table. Resident #93 continued to stand up and walk around the dining room, looking in the closet, and wandering around the room, while staff J and K provided clothing protectors to residents, and continued to bring residents into the dining room. Resident #93 appeared slightly stooped forward, and unsteady, as he walked around. No staff were within reach of the resident. Shortly thereafter, Resident #93 exited the dining room, and walked down the hallway. Staff K walked by the resident, but did not stop and assist with his ambulation, or re-direct him at that time. In an interview on 02/25/16 at 3:51 p.m., when asked what the causes of the falls were for Resident #93, Staff D, Nurse Manager, stated he might have been experiencing medication side effects, that he had dementia, and that he was sometimes steady, and other times not. When asked about strategies to prevent falls, Staff D stated there were no new interventions in place between the falls, as she felt they were not preventable. She stated the minute we turn our head, there he is on the floor. When asked about the care plan intervention to check the resident every 60 minutes, and how often Resident #93 would currently need to be supervised to prevent falls, Staff D did not have a specific answer, but indicated it was more often than 60 minutes. She indicated that all staff try to keep an eye on him, but they were not able to always get to him before he fell . She stated, I wish we could get him always. Failure to re-evaluate the effectiveness of the interventions between falls, and supervise the resident adequately to prevent accidents, placed resident #93 and others around him at risk for injury. See F353 for additional information.

Based on observation, interview, and record review, it was determined the facility failed to maintain a safe environment to prevent accident hazards for 1 resident (#1) in a sample of 3. This resulted in harm for this resident. Findings include: Resident #1 had a history of [REDACTED]. Per facility investigation, on 5/14/13 the resident went to the assisted living to play Bingo. It was reported she was escorted down to the assisted living activity room with staff assistance. After Bingo the resident was asked to wait for assistance to return to the nursing facility but left before receiving any. A construction worker heard noise and found the resident face down in a room that was under construction. Staff was notified and after assessing the resident called the ambulance to transport her to the hospital. During observations on 6/20/13, the hallway that was under construction connected the nursing facility to the assisted living. The hallway had orange cones and construction tape that divided the hallway and tape was across some of the rooms still under construction. On 6/20/13 at 2:55 p.m. during a collatoral interview, it was stated the cones had not always been up in the hall blocking off the rooms under construction. Per hospital notes dated 5/24/13, the resident was admitted to the hospital with [REDACTED]. The resident passed away at the hospital on [DATE]. On 6/20/13 at 4:00 p.m., Staff #A stated the hallway under construction was the main walk way that connected the assisted living facility with the nursing facility. She stated the resident left Bingo before staff could assist her and was found in a room under construction face down on the floor. Staff was notified and an ambulance was called to transport the resident to the hospital. Staff #A stated there was an uneven surface between the hallway flooring and room flooring that may have contributed to the fall. She confirmed there was no cones or tape blocking off the area under construction. The facility was aware of the safety hazards related to the new construction, however, they failed to ensure residents were consistently safe when passing thru this area which resulted in harm to Resident #1.

Based on interview and record review, the facility failed to ensure 1 of 4 sample residents with swallowing problems (#1), was provided a therapeutic diet as ordered by the physician. The failed practice resulted in harm to the resident who did not get her diet as ordered, and asprirated food and was sent to the hospital on [DATE]. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per record review, the resident was cognitively impaired and required set-up and supervision at meals. Per physician's orders [REDACTED]. It was also noted in the record that the resident was on a safe swallow program (a plan for the resident to have supervision with eating/drinking and staff were to encourage the resident to take small bites and sips ..etc). Per nursing notes dated 9/5/11, Staff #A documented that at 12:50 p.m. Staff #D witnessed the resident "aspirating" on watermelon while she was eating lunch. Staff #A was not in the dining room at the time but was notified of the incident while it happened by a volunteer and went back to the dining room. Staff #A noted that when he arrived in the dining room, the resident had already vomited up her lunch and was coughing and sputtering. The resident was immediately placed on 5 liters of oxygen and was started on a breathing treatment. The resident's oxygen levels were at 94% (acceptable range 90 or above) at that time. Staff #A notified the physician, got an order for [REDACTED]. Per nursing notes dated 9/5/11, Staff #A documented that at 1:15 p.m., the resident started to decline, her oxygen levels decreased to 71% and the resident was placed on 15 liters of oxygen. The resident was sent to the hospital at that time. In an interview on 9/29/11 at 10:30 a.m., Staff #B stated she saw a family bring in non-pureed foods (watermelon and oranges). Staff #B said she had never given the resident those foods but she knew the family did at times. In an interview on 9/29/11 at 11:00 a.m., Staff #C said she knew the family brought the watermelon in because the son told her he left it in the refrigerator. Staff #C said the family member thought the resident should be able to have it, but she would never give it to the resident because she knew the resident was on pureed (altered texture diet.) In an interview on 9/29/11 at 12:10 p.m., Staff #D reported the residents family member brought the watermelon in and left it in the refrigerator in the dining room for her. Staff #D said the resident requested to have some of the watermelon her family member brought. Staff #D said she got the watermelon, cut it up and mashed it with a fork and gave it to the resident. It was not part of the meal provided by the facility. The resident ate some of the watermelon and was fine for a few minutes then started coughing and threw up. Staff #D said she should have looked at the diet card that came with the resident's meal tray before she gave the resident the watermelon. Staff #D confirmed the watermelon did not meet the resident's altered texture diet. In an interview on 10/7/11 at 11:00 a.m., the family member stated whenever he brought foods in for the resident he would ask the nursing staff if it was okay to feed them to her. The family member was not able to be specific on who the staff members were, but he did say they were nurses. The family member said he was under the impression it was okay to give the resident "dime size" pieces of watermelon as long as the resident ate slowly and took time to swallow. In the above interview, the family member said multiple staff members knew he was bringing in non-pureed items. The family member said he was not approached by staff to discuss the risks of not following the pureed diet. The facility failed to ensure staff were aware of dietary restrictions and safe supervision was provided by staff. This caused harm to Resident #1.