Every finding on record at Spokane Veterans Home

Based on interview and record review, the facility failed to ensure narcotic medication was administered to the resident for which it had been prescribed, and not diverted from use, for 1 of 3 sample residents (Resident 1) reviewed for medication administration. This incident constituted a Past-Non-Compliance (the facility was not in compliance at the time the incident occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified). The facility immediately and thoroughly investigated, made appropriate notifications, took appropriate safety actions to ensure resident safety. Education of all nursing staff on the proper administration and documentation for narcotic medications was completed by 07/11/2025. The facility was notified of the past non-compliance on 02/20/2026.Findings included. Review of a facility investigation dated 06/29/2025 documented a clear pouch containing two pills was found on the floor at the second-floor nurse's station by Staff A, Administrator, on the morning of 06/26/2025 at 7:00 AM. The medication was identified as being Norco 10/325 milligram (mg) tablets, a narcotic medication used to treat pain. Review of all of the resident's medication orders showed Resident 1 was the only resident in the facility that had the medication prescribed. A review of the narcotic logbook showed Staff D, Registered Nurse, had signed out the narcotic medication the night of 06/28/2025 at 11:30 PM, and at 5:00 AM on the morning of 06/29/2025. Resident 1's Medication Administration Records (MARS) documented the 11:30 PM dose had been given, but there was no documentation that showed the 5:00 AM dose was administered to the resident. When interviewed, Staff D stated they had given the medication, and had no knowledge or explanation for the pouch that had been found. When Resident 1 was interviewed, they stated they did not recall receiving any pain medication and they had not been woken during the night for cares or medication. An order was obtained on 06/26/2025 to obtain a urine sample from Resident 1 for a drug screen to check for the presence of narcotic medication. On 07/01/2025 the facility was informed the results of the drug screen was negative. The facility consulted with the laboratory for clarification and was informed the Norco would be detectable in the urine within one to two days of administration. Additional consultation with Resident 1's provider was done and it was determined that narcotic diversion had occurred. During the course of the investigation, in addition to Staff D, the facility identified two other nurses, Staff E and Staff F, both Registered Nurses, who had signed out the Norco and documented it had been administered to Resident 1 from 06/24/2025 to 06/26/2025. The facility substantiated drug diversion, and all three identified nurses were terminated from employment. Audits of all resident's records, and interviews found no other discrepancies. In an interview on 02/19/2026 at 11:13 AM, Resident 1 stated they felt the care was good, they had no concerns and anytime they had concerns in the past, the facility took care of it. Resident 1 stated they had chronic back pain and felt the pain management was good. In an interview on 02/20/2026 at 11:41 AM, Staff C, Registered Nurse, stated narcotic medication was signed out and documented at the time of administration to the resident, and the narcotics were counted and reconciled by checking the narcotic medication card to the narcotic logbook at the end of each shift. Staff C further stated that any discrepancies needed to be reported immediately to the Director of Nursing and the Administrator, and there had been education and training on the process. In an interview on 02/20/2026 from 2:15 PM to 3:00 PM with Staff A, Administrator and Staff B, Director of Nursing, the incident as described in the facility investigation was discussed, and both confirmed the facility had substantiated diversion. Staff B stated ongoing audits and reviews of narcotic medication administration have continued and the results are discussed and shared with the facility's Medical Director, and during their Quality Assurance meetings. This was a Past Non-Compliance, and the facility is not required to submit a plan of correction.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Failure to ensure expired foods were discarded for 1 of 3 refrigerators, 1 of 1 dry storage areas, opened dates were placed on food items in the refrigerator and freezer, appropriate hair coverings were worn, and hand hygiene was performed when indicated. The facility further failed to ensure the kitchen was cleaned and dishwasher temperatures were maintained at the appropriate temperatures. These failures placed residents at risk for food-borne illnesses and food served from unsanitary conditions. Findings included . <Expired/undated food> During an initial tour of the kitchen on [DATE] at 08:41 AM, the dry storage area revealed 12 containers of grits that had expired on [DATE], an opened box of spice mix cake that had no open or expiration date, and five bottles of honey that had expired on [DATE]. The refrigerator in the main kitchen contained a stock of celery that was brown and wilted, and a box of mushrooms that had no received or use by date. Staff S, Food Supervisor threw the mushrooms away and stated they should have been dated. The freezer contained an opened bag of blueberries, two opened bags of cinnamon rolls, 10 loaves of bread, box of opened enchiladas, bag of opened fried chicken, bag of opened tater tots, bag of opened sweet potato fries and an opened box of French toast, that had no open or expiration dates. In an interview on [DATE] at 09:33 AM, Staff S stated all food items that were opened needed an open date so they would know how long the product was good for. Staff S added it was important to get rid of expired food to prevent illness. <Sanitary Practices> During an observation of tray line on [DATE] at 10:41 AM, Staff T took the plate of food from the cook, put butter on the meal trays and placed them in the cart. Staff T wiped their nose on their shirt and kept putting the plates onto the trays and hand hygiene was not performed. At 11:53 AM, Staff T wiped their nose on their bare skin of their forearm, kept putting plates on meal trays and had not performed hand hygiene. In an interview on [DATE] at 12:32 PM, Staff S stated Staff T should have washed their hands after they wiped their nose and should have worn a mask if they had a drippy nose, and this was important for sanitary reasons. <Dishwasher temperatures> During a second observation of the kitchen on [DATE] at 10:41 AM, Staff S stated the dishwasher was a high temperature dishwasher and the final rinse had to reach 180 degrees. The [DATE] through [DATE] dishwasher temperature logs documented the temperature was below the required temperature on 34 occasions. In an interview on [DATE] at 10:50 AM, Staff S stated it was important for the final rinse to reach the proper temperature to kill the germs. <Cleaning> On [DATE] the kitchen cleaning schedules were requested and Staff S presented sheets that had [DATE] written on them but had no days of the week listed. There were numerous days in which there was no documentation that stated the daily cleaning had occurred. In an interview on [DATE] at 1:31 PM, Staff S stated the kitchen needed to be cleaned daily for sanitization reasons. Staff S stated the sheets needed to have the dates included. <Hair Covering> In an observation on [DATE] at 11:43 AM, Staff T was assisting with putting food on trays. Staff T, Food Service Worker, was observed with short hair, a mustache and short beard. Staff T was not wearing hair coverings as required when working with food. In an interview on [DATE] at 12:32 PM, Staff S stated the policy was to wear hair coverings when working with food in the kitchen. At 12:36 PM, Staff S stated it was important to wear a hair net to ensure everything was sanitary. Reference: WAC [DATE] (3), 2980

Based on observation, interview and record review, the facility failed to ensure residents or their representatives were provided the opportunity to participate in care planning for 2 of 3 sampled residents (Resident 29 and 35) whose medical records were reviewed for care planning. This failure placed the residents at risk for unmet needs and a diminished quality of life. Findings included . A revised 04/2016 facility policy titled Resident/Family Participation - Assessment/Care Plans documented the facility invited each resident and their family members to participate in the development of the resident assessment and care planning conference. The policy instructed the Social Services Director (SSD) or designee to maintain records that showed their efforts to invite the resident and family to the care planning conference, including refusal of participation. The policy showed the facility scheduled care conferences shortly after admission, quarterly, and at discharge to ensure resident needs and preferences were met and documented the care conferences in the medical record. <Resident 29> On 03/17/2025 at 12:35 PM, Resident 29 was observed in their room sitting in a wheelchair. Resident 29 stated the staff would bring in a copy of the care plan, say they had a new one, then hang the document in the closet. Resident 29 stated they never done a team care plan meeting. Staff came one by one but not as a team and the resident stated they had No input. Resident 29's family member, who lived with the resident, showed the surveyor a Delivery Guide they brought from the closet and stated, No nursing diagnoses, no nursing goals. Review of a 01/06/2025 quarterly assessment showed Resident 29 was readmitted to the facility on [DATE] from the hospital with medically complex conditions that included heart failure and diabetes. The assessment showed Resident 29 was cognitively intact. Review of Resident 29's medical record showed the facility completed quarterly assessments on 07/15/2024, 10/13/2024, and 01/06/2025. Further review showed the last time a care conference was held with Resident 29's participation was on 01/26/2024, as documented in a Care Conference Summary. The above findings were shared with Staff C, Social Services Director, on 03/20/2025 at 11:36 AM. When asked what process the facility used to ensure residents or their representatives were able to participate in their care planning, Staff C stated they were in the process of getting care plan conferences caught up and this was something they had been working on. They had noticed when they began their employment at the facility that care plan conferences had been hit and miss, but they had tackled other projects at that time. Staff C stated the facility completed care planning conferences within one to two weeks of a resident's admission, then typically followed the MDS (Minimum Data Set, an assessment tool) schedule or when a significant change happened. Staff C stated the facility identified the lack of care planning conferences the week of 12/20/2024. <Resident 35> Review of a 01/27/2025 quarterly assessment showed Resident 35 readmitted to the facility from a hospital on 09/19/2022 with medically complex conditions that included stroke, seizures, and mood disorder. The assessment documented Resident 35 had severe cognitive impairment. Further review of the resident's medical record showed they had an appointed guardian. Review of a 03/05/2025 audit completed by Staff B, Director of Nursing Services, showed the facility identified a total of 84 out of 97 residents who had not participated in care planning conferences. The audit showed Resident 35's last care planning conference was on 08/22/2023. Review of MDS schedules provided by the facility showed a total of 78 annual and quarterly completed assessments between 12/16/2024 to 03/14/2025. Review of the medical records with Staff C on 03/24/2025 at 8:55 AM showed there was no documentation the facility offered 47 of the 78 residents or their representatives the opportunity to participate in the development, review, and revision of their care plan, to include Resident 29 and 35. Staff C stated that care planning conferences occurred, not regularly and expected them to occur relatively close after the MDS completion, within a week or so. Reference WAC 388-97-1020 (2)(f), (4)(b).

Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, safe and homelike environment for 3 of 4 sampled residents (Resident 92, 58 and 35), reviewed for environment. Specifically, Resident 92's wall in their room was in disrepair and had a screw that protruded out of the wall, and Resident 58 and 32's walls were in disrepair. These failures placed all residents at risk for avoidable injuries and a diminished quality of life. Findings included . <Resident 35> An observation on 03/18/2025 at 9:09 AM showed an approximately 2 feet by 2 feet section of peeled, scraped paint on the wall, right next to the Resident 35's bed. The curved paint scrapes appeared to be from the bed's upper rail scraping the wall, when it was swung up or down. Similar observations of the wall damage were made on 03/19/2025 at 2:06 PM, 03/20/2025 at 2:58 PM and 03/24/2025 at 9:45 AM. On these subsequent observations, a cloth band-aide was observed stuck to the wall, over one of the gouges. <Resident 58> An observation on 03/18/2025 at 9:43 AM showed gouges in the wall next to the Resident 58's bed. Some of the gouges were deep into the drywall, where the bed and upper rail scraped it and around the wall box for the call light. The wall had dark gray paint, and the chalky white drywall exposed by the gouges were quite noticeable. Similar observations of the wall damage were made on 03/19/2025 at 2:04 PM, 03/20/2025 at 8:50 AM, 03/24/2025 at 9:46 AM, and 03/25/2025 at 9:12 AM. Neither Resident 35 nor 58 were able to verbalize about how long ago the walls were damaged. During an interview on 03/24/2025 at 9:58 AM, Staff U, Nursing Assistant (NA), stated that if they saw any maintenance issues, they would tell the nurse or the desk person, who would put in a work order. Staff U further stated they did not know how long the walls in Resident 35 or 58 had been in disrepair and were not aware if a work order had been submitted or not. During an interview on 03/25/2025 at 10:33 AM, Staff AA, Maintenance Mechanic, stated that their department received work orders in the computer system, then they would review the orders and prioritize them. Staff AA confirmed that they did not have any work order requests for Resident 35 or 58's rooms. After looking at the rooms with the surveyor, Staff AA verified that they should be repaired, and they would do so. <Resident 92> During an observation and interview on 03/17/2025 at 12:37 PM, Resident 92 was sitting in their wheelchair in their room. Resident 92's room had multiple gouges in their drywall on the wall next to their bed and there was a screw that protruded out of the wall within the resident's reach. The resident stated they did not feel like it was a homelike environment. Subsequent observations of the wall in disrepair and the screw protruding out of the wall were made on 03/19/2025 at 9:01 AM and 03/20/2025 at 8:36 AM. On 03/21/2025 at 10:31 AM and 03/25/2025 at 8:56 AM, the screw had been pushed into the wall but was not flush and still within the resident's reach. In an interview on 03/25/2025 at 9:03 AM, Staff D, Maintenance Director, stated the staff notified them when repairs were needed. Staff D stated they were unaware the room needed repairs and removed the screw from the wall and stated it was a safety concern. When Staff D was asked if the above observations were homelike, they stated, No, and it was important for the resident to have a homelike environment because this was their home. Reference: WAC 388-97-0880. 46115

Based on observation, interview, and record review the facility failed to ensure infection control practices were followed during meal service to include performing hand hygiene (HH) when indicated. In addition, staff did not follow Enhanced Barrier Precautions (EBP) when indicated for 1 of 3 sampled residents (Resident 91), reviewed for infection control. These failures placed the residents at risk for the spread of infections, illnesses and unintended health consequences. Findings included . Review of the facility policy titled, Hand Washing/Hand Hygiene revised March 2024, showed hand hygiene was the primary means of preventing the spread of infections. The policy further showed staff should perform hand hygiene before and after direct contact with residents, after contact with a resident's intact skin, after contact with objects in the immediate vicinity of a resident, before and after assisting a resident with a meal. Review of the facility policy titled, Enhanced Barrier Precautions revised March 2024, defined EBP as the use of a gown and gloves during high-contact resident care activities for residents known to be colonized or infected with a multi-drug-resistant organism (MDRO) or at increased risk of acquiring an MDRO. The policy defined high-contact care activities as dressing, bathing, transferring, providing hygiene, changing linens, changing an incontinence brief or assisting with toileting, invasive device (medical device that entered a person's body) care, or performing wound care that required a dressing. The policy instructed staff to use EBP for the duration of the affected resident's stay in the facility or until the wound healed or the invasive medical device was removed. HAND HYGIENE During an observation on 03/17/2025 at 11:44 AM, Staff G, Nursing Assistant, sanitized their hands, grabbed a meal tray, poured drinks, and then leaned down and picked up cups that had fallen onto the floor. Staff G had not performed hand hygiene and passed the tray to a resident. During an observation on 03/17/2025 at 11:46, Staff J Nursing Assistant (NA), used alcohol based-hand rub (ABHR), placed a clothing protector on a resident in the dining room, obtained a new tray off the meal cart without hand hygiene performed, poured fluids into plastic cups, and delivered the tray to the assisted dining room. Staff J obtained another tray from the meal cart and hand hygiene was not performed. During an observation on 03/17/2025 at 11:49 AM, Staff J, obtained a tray off the meal cart, poured fluids, and delivered the tray to the assisted dining room. Staff J opened the large round trash with their hand, hand hygiene was not performed and they entered room [ROOM NUMBER]. During an observation on 03/17/2025 at 11:52 AM, Staff J, Nursing Assistant, passed a tray, then grabbed another tray and hand hygiene was not performed in between trays. During a continuous observation on 03/17/2025 at 11:51 AM until 11:59 AM, Staff K, NA, delivered a tray to room [ROOM NUMBER] and exited the room and no hand hygiene was performed. Staff K obtained a second tray off the meal cart, poured drinks into cups, delivered the tray to room [ROOM NUMBER], and again exited the room and no hand hygiene was performed. Staff K obtained a third tray off the meal cart, grabbed a clothing protector, delivered the tray to room [ROOM NUMBER], adjusted the bedside table and opened/set up the tray. Staff K again exited the room and no hand hygiene was performed. During an interview on 03/21/2025 at 9:26 AM, Staff J, NA, stated hand hygiene was keeping hands clean or sanitizing, wearing gloves, and not getting stuff on hands I guess. Staff J acknowledged staff should have performed hand hygiene after touching a resident's immediate environment and between passing different resident trays. During an interview on 03/21/2025 at 9:34 AM, Staff H, Registered Nurse, stated hand hygiene was washing hands with soap and water or using ABHR. Staff H further explained staff were expected to perform hand hygiene at various times including between passing different resident trays during meal service to prevent the spread of infection between residents and staff. During an interview on 03/21/2025 at 9:42 AM, Staff I, Infection Preventionist, stated staff should have performed hand hygiene between passing meal trays and after the lid on the trash can was touched to prevent the spread of germs During a follow-up interview on 03/24/2025 at 1:34 PM, Staff I, stated hand hygiene should have been performed after the cups were picked up off the floor. Staff I stated it was important to sanitize after touching things to prevent the spread of germs. 46115 ENHANCED BARRIER PRECAUTIONS According to the 01/05/2025 admission assessment, Resident 91 had diagnoses including repeated falls and neurogenic bladder (bladder control issues caused by nerve damage). The assessment further showed Resident 91 had an indwelling urinary catheter (flexible tube inserted into the bladder to drain urine). Review of the 12/23/2024 provider orders showed active orders for Resident 91 to follow enhanced barrier precautions (EBP, use of gloves and gowns) during high-contact resident care activities such as dressing, bathing, transferring, changing linens, providing hygiene, or assisting with toileting. Review of the 02/26/2025 suprapubic catheter (catheter inserted directly into the bladder through a cut in the abdomen) care plan documented Resident 91 was on EBP. Interventions instructed staff to follow signage posted on the resident's door for application and removal of PPE (personal protective equipment, gown and gloves) to include use when dressing, bathing, transferring, providing hygiene, changing linens, during invasive device care. In an interview on 03/18/2025 at 9:02 AM, Staff P, Nursing Assistant, stated when precautions were implemented it would be documented in the resident's care plan for staff to reference and follow. During an observation on 03/20/2025 at 12:08 PM, an EBP sign was observed posted outside of Resident 91's room. Staff L, Nursing Assistant, assisted Resident 91 into the bathroom and helped them stand at the bar. Staff L was not wearing a gown as required to assist with transferring Resident 91. In an interview on 03/20/2025 at 12:17 PM, Staff L stated Resident 91 was on EBP because they had a catheter. Staff L acknowledged they did not wear a gown when they assisted Resident 91 transfer and should have worn a gown to protect the resident and themselves from germs. Reference: WAC 388-97-1320 (1)(c)(2)(b),

Based on interview and record review, the facility failed to ensure that consents for psychotropic medications (drugs that affected behavior, mood, thoughts or perception) were completed accurately for 1 of 5 residents (Resident 43) reviewed for unnecessary medications. Specifically, some consents were not documented as late entries, and two consents were not completed before the medication was resumed. Failure to ensure clinical records were accurate placed residents at risk of not having their needs met. Findings included . A quarterly assessment, dated 01/20/2025, documented Resident 43 had diagnoses of Parkinsons Disease (an illness that affected the part of the brain that controlled movement), depression and anxiety. The assessment further showed that they were alert and made their needs known. Resident 43's Medication Administration Record for March 2025, showed they were taking the following psychotropic medications, that required documented consents: 1) Quetiapine (a medication that treated symptoms such as delusions, hallucinations or paranoia) daily in the evening 2) Prazosin (a medication used to treat nightmares) daily at bedtime 3) Trazodone (an antidepressant medication) twice daily 4) Lorazepam (an antianxiety medication) every 8 hours A review of the medical record showed consents for the medications. The consent form had an Effective Date with the date at the top, further down a box that showed Date followed by the name of the medication, then a box to fill in the name of the resident or representative who provided verbal consent. The last line of the form was for the electronic signature of the staff and the date the document was signed. 1) The Quetiapine consent showed the effective date as 10/03/2024, the date box showed 10/18/2024, and the final line showed the document was signed by Staff N, Registered Nurse/Resident Care Manager (RN/RCM) on 01/28/2025. 2) The Prazosin consent showed both the effective date and the date box as 01/09/2025 and the last line showed the document was signed by Staff N on 01/28/2025. 3) The Trazodone consent showed both the effective date and the date box as 11/15/2024 and the last line showed the document was signed by Staff N on 01/28/2025. A review of the provider orders showed that Trazodone was discontinued on 11/01/2024 and resumed 14 days later, on 11/15/2024. 4) The Lorazepam consent showed both the effective date and the date box as 11/15/2025 and the last line showed the document was signed by Staff N on 01/28/2025. A review of the provider orders showed that Lorazepam was discontinued on 11/01/2024 and resumed 3 days later, on 11/04/2024. During an interview on 03/24/2025 at 2:15 PM, Staff W, Licensed Practical Nurse, stated that consents for psychotropic medications needed to be done before the first dose was given. They further stated that if the medication was stopped, then reordered, the consent needed to be redone. During an interview on 03/25/2025 at 9:16 AM, Staff N verified that consent for psychotropic medications needed to be done when the medication was started and when the dose changed. When asked about the differing dates on the consents, they stated they had not realized that the new facility process was to redo the consent if the dose changed. Staff N further explained that on 01/28/2025, they looked back and actually did those consents as late entries and manually put in the first two dates on the consent, as when the order started. Staff N acknowledged that the documents were not labeled as late entries, that it was not clear that the consents were actually obtained on 01/28/2025, and that the consents for Trazodone and Lorazepam should have been done when the medications were resumed. Reference: WAC 388-97-1720(1)(a)(i-iv)(b)

Based on observation, interview and record review, the facility failed to ensure meals were served at palatable temperatures for 1 of 6 sampled residents (Resident 12) reviewed and 1 of 1 meal test trays sampled.This failure put residents at risk of decreased enjoyment of their meals, and possible reduced dietary intake. Findings inculded . According to the Washington State Food Handlers Guide Website, the Washington State Department of Health Safety and Licensing Division recommended that all potentially hazardous foods be held at a temperature of 41 F or below in commercial refrigerators and freezers. This included meats, fish, poultry, eggs, dairy products, cooked vegetables, cooked rice and pasta, cut melons, and other perishable items. All frozen foods were to be stored at 0 F or below. Hot food items were to be held at a temperature of 140 F or above. The 03/10/2025 quarterly assessment documented Resident 12 had diagnoses that included obesity, high blood pressure and diabetes. The assessment further documented the resident was cognitively intact and was able to make their needs known. In an observation and interview on 03/18/2025 at 8:38 AM, Resident 12 was sitting in their wheelchair in their room. Resident 12 stated residents had the choice to eat in their room or in the dining room. They stated when they ate in the dining room the food was hot. If they ate in their room the food was served cold at times. In an interview on 03/19/2025 at 8:42 AM, Resident 12 stated breakfast was good but could have been hotter. In additions to cold cereal, they had an English muffin, sausage patty, hard boiled egg, and hashbrowns. The kitchen food temperature logs for March 2025 were reviewed. Temperatures for hot foods had been documented on the logs but not the cold food. There was a line through the box that asked for the temperature of the cold items. During an observation and sampling of the lunch meal served on 03/24/2025, the temperatures of the food items were outside of the acceptable parameters and were as follows: buttered noodles 119 F, oriental style mixed vegetables 100 F, and cubed seasoned potatoes 125 F. In an interview on 03/24/2025 at 12:31 PM, Staff S, Food Supervisor, stated it was important to check hot and cold food temperatures.This ensured the food was safe for consumption. Reference: WAC 388-97-1100 (1)(2)

Based on interview and record review, the facility failed to ensure a resident received doses of Ozempic, a medication used to control blood sugar levels, as ordered, and failed to notify the provider timely after the omissions for 1 of 5 sampled residents (Resident 36), reviewed for unnecessary medications. This failure placed residents at risk of complications secondary to high blood sugar levels, unmet care needs, and diminished quality of life. Findings included . According to the 01/06/2025 quarterly assessment, Resident 36 had diagnoses that included diabetes and stroke. Resident 36 received hypoglycemic (blood sugar lowering) medication including insulin (medication that lowered blood sugar levels) injections. Resident 36 was cognitively intact and able to clearly verbalize their needs. The 08/16/2019 diabetes care plan instructed staff to administer diabetes medications per provider orders and monitor for signs and/or symptoms of high or low blood sugar levels. On 04/20/2024 a provider order was given for Resident 36 to be administered an Ozempic injection once weekly on Saturday mornings for diabetes. Review of the March 2025 Medication Administration Record (MAR) showed Resident 36 did not receive two doses of the Ozempic; a code 9 was documented for the 03/08/2025 dose and a code 7 was entered for the 03/15/2025 dose. The key at the bottom of the MAR indicated a code 9 meant other /see progress note and a code 7 meant not given; MD notified. Review of March 2025 nursing progress notes showed Resident 36's Ozempic was not administered on 03/08/2025 because the medication was unavailable, no documentation was found to show the provider was notified of the Ozempic omission at that time. On 03/15/2025 the Ozempic was again not administered because it was not available. The notes documented Resident 36's Ozempic was ordered on 03/01/2025, 03/08/2025, and again on 03/15/2025 and that the provider was notified on 03/15/2025. A Provider Communication Form dated 03/15/2025 documented Resident 36 did not receive their Ozempic injection on 03/08/2025 or on 03/15/2025 related to the medication being unavailable. No documentation was found to show the provider was notified of the 03/08/2025 missed Ozempic dose prior to 03/15/2025. Review of provider progress notes showed no provider progress notes for March 2025. In an interview on 03/20/2025 at 9:33 AM, Staff Y, Pharmacist, reviewed Resident 36's record. Staff Y stated Resident 36's Ozempic was filled on 02/19/2025 and was not due to be refilled when ordered by the facility on 03/01/2025, 03/08/2025, or on 03/15/2025 so the refill was rejected and placed into a que to be automatically filled at the next appropriate time frame. Staff Y stated Ozempic was a specialty medication that required approval from Staff A, Administrator, or Staff B, Director of Nursing, if the medication was to be refilled earlier than scheduled. Staff Y stated they emailed the facility an authorization form for approval of an early refill if needed. Staff Y reviewed email correspondences between the pharmacy and the facility, and stated they had no document authorizing an early refill of Ozempic for Resident 36. In an interview on 03/20/2025 at 9:51 AM, Staff Z, Medical Records, stated all provider communication forms for Resident 36 were scanned into their record. Staff Z reviewed Resident 36's medical record. Staff Z acknowledged the only provider communication form for Resident 36 for March 2025, was the 03/15/2028 form, no other provider communication forms were found. In an interview on 03/20/2025 at 10:28 AM, Staff F, Resident Care Manager (RCM), stated the facility reordered resident medications when there was a one week supply remaining. Staff F stated if the facility ran out of a medication, staff were to check the facility's emergency medication storage machine or order medications from two back up emergency pharmacies the facility utilized. Staff F reviewed Resident 36's medical record and acknowledged Resident 36's Ozempic was ordered on 03/01/2025, 03/08/2025, and again on 03/15/2025. In an interview on 03/24/2025 at 2:21 PM, Staff W, Licensed Practical Nurse, explained nursing staff were to order new insulin pens as soon as the fourth dose was administered when ordered for weekly administration and the pharmacy would fill it. Staff W further stated they would notify the RCM if/when there was a medication refill issue, so appropriate follow-up could be taken. In a follow-up interview on 03/25/2025 at 9:30 AM, Staff F, RCM, stated they expected the provider to be notified timely if/when a medication was not available for administration, as ordered. Reference WAC 388-97-(3)(k)(iii)

Based on observation, interview and record review, the facility failed to ensure a resident received appropriate treatments and services to restore bladder continence to the extent possible for 1 of 2 sampled residents (Resident 69) reviewed for bowel and bladder incontinence. Failure to comprehensively assess the causes of incontinence and provide treatments and services to restore bladder function, placed the resident at risk for continued decline in urinary function, skin issues, and embarrassment. Findings included . The 01/01/2024 facility policy titled Incontinent Care cumented the facility provided incontinence care to keep the residents clean, dry and free from skin irritations, and to reduce the risk of urinary tract infections. The policy documented the facility assessed all residents upon admission for voiding patterns and the residents potential to participate in a bladder retraining program (helped the resident to begin to hold more urine for longer periods of time overcome bladder problems that included urgency, frequency and incontinence). Once the staff identified incontinence, the resident's care plan included interventions to promote or manage incontinence. On 03/17/2025 at 2:45 PM, Resident 69 was observed in bed fully dressed. Resident 69 stated they experienced episodes of urinary incontinence, quite a bit. You can't expect staff to be lined up waiting to care for you. Resident 69 stated the staff did not come on their own to take them to the bathroom; the resident had to call the staff. Resident 69 stated that they wore an incontinence brief. The 02/01/2025 quarterly assessment documented Resident 69 had diagnoses that included stroke. The resident had moderate cognitive impairment and did not reject care. Resident 69 required physical assistance from the staff to complete transfers and toileting. The resident was frequently incontinent of urine but on no toileting program, such as scheduled toileting, prompted voiding, or bladder training. Prior assessments dated 08/15/2024 and 11/04/2024 also showed Resident 69 was frequently incontinent and on no toileting program. An 08/19/2024 care areas worksheet associated with the 08/14/2024 assessment documented the staff identified Resident 69 experienced mixed incontinence (stress incontinence with urgency). The worksheet documented the staff addressed the incontinence in the care plan with goals for improvement, avoid complications, and minimize risks and will continue to offer toileting assistance/incontinence cares on comfort rounds. The worksheet showed the staff determined no referral to other disciplines was warranted for the identified urinary incontinence and to continue working with therapy. Review of the Bladder Elimination flowsheets documented Resident 69 was incontinent of urine, on an average of two to three times a day, between 02/19/2025 to 3/20/2025. The 08/08/2024 care plan documented Resident 69 required limited to extensive assistance for cleansing, changing incontinence products, and adjusting clothing and extensive assistance to move to and from bed to wheelchair. An 08/09/2024 intervention showed Resident 69 required a mechanical lift to complete transfers. Because of falls, the facility added an intervention on 08/27/2024 to check in on the resident every 30 minutes and, if awake, offer toileting. On 02/26/2025, an intervention was added to the care plan that Resident 69 preferred to keep the urinal at bedside while in bed and on the bedside table.On 03/24/2025 at 10:50, the resident's urinal was observed inside their bathroom and not at the bedside. In an interview on 03/24/2025 at 11:25 AM, Staff U, Nursing Assistant (NA), stated that they were familiar with the cares of Resident 69. Staff U stated that Resident 69 did not use a urinal and considered the resident continent 90% of the time if we went there right away and the resident experienced incontinence because we don't make it on time. Staff U stated that Resident 69 required a one person assist for transfers to the bathroom, required no lift, and would attempt to transfer on their own to go to the rest room. Staff U considered Resident 69's severity of bladder incontinence unchanged from admission to the facility and tried to manage incontinence by offer toileting before and after meals. They stated the resident was usually pretty good about letting them know. In an interview on 03/25/2025 at 8:44 AM, Staff V, NA, stated that Resident 69 required extensive assist for transfers, pulled the call light when ready to use the bathroom, and was continent of urine 50% of the time. They stated sometimes the resident did not make it to the bathroom. Staff V also stated that sometimes Resident 69 felt the urge to urinate but then did not void after being helped to the bathroom and the resident constantly went to the bathroom. Staff V stated Resident 69 drank a lot of coffee, and coffee was a diuretic (medication that increased urine output). Staff V stated they checked on Resident 69 every hour. In an interview on 03/24/2025 at 11:33 AM, Staff N, Resident Care Manager stated Resident 69 had a recent stroke that negatively affected their continence and made it harder for them to go to the bathroom when they wanted to. Staff N stated the resident relied on staff for transfers. When asked how the facility assessed for risks, causes, types, patterns of incontinence, and potential treatments to address or reverse any resident's urinary incontinence, Staff N answered the staff completed a Bowel and Bladder Assessment on admission and quarterly. Staff N reviewed Resident 69's medical record but could not locate the assessment. Staff N stated the Bowel and Bladder Assessment alerted the staff of the need to revise interventions to address unimproved incontinence. Staff N was asked what types of interventions were attempted to improve Resident 69's bladder continence. Staff N stated they had not done that, and the resident had moisture associated skin damage (response to prolonged skin exposure to moisture) related to their incontinence. Staff N stated it would be good to get the resident on a toileting schedule. Staff N confirmed no referrals had been made to therapy or the provider for the mixed incontinence identified on 08/19/2024. No further information was provided. Reference WAC 388-98-1060 (3)(c).

Based on observation, interview and record review the facility failed to identify, evaluate and analyze risks, and implement safety interventions to reduce risks and hazards for 2 of 3 sampled residents (Resident 95 and 2), reviewed for substance use disorder (SUD). In addition, the facility failed to monitor for injury and add interventions to the care plan after a fall was sustained, and failed to ensure a position change alarm was in working order for 2 of 6 sampled residents (Residents 13 and 92), reviewed for falls. These failures placed residents at risk of leaving the facility without staff knowledge, potentially avoidable accidents, and diminished quality of life. Findings included . The facility policy titled, Fall Management dated 01/01/2025 documented residents were to be placed on alert charting for further monitoring after a fall occurred. The fall would be reviewed and interventions would be added to the care plan as indicated. <Resident 95> According to the 02/03/2025 admission assessment, Resident 95 admitted to the facility on [DATE] with diagnoses that included anemia and alcohol abuse. Resident 95 was cognitively intact and able to clearly verbalize their needs. Review of the 01/25/2025 hospital progress notes showed Resident 95 had a significant alcohol abuse history and their spouse had been weaning the resident off of it over the three weeks prior to their hospital admission. The resident had most recently been drinking only one beer daily and did not show signs or symptoms of alcohol withdrawals. The 01/28/2025 nursing admission assessment documented Resident 95 was confused, oriented to self only, and had a past history of alcohol use. No additional details of Resident 95's significant alcohol abuse history were documented. The 01/28/2025 baseline care plan contained no documentation that Resident 95 had a significant history of alcohol abuse and had no interventions implemented to address potential risks associated with the SUD. Review of the 01/28/2025 wandering risk assessment showed Resident 95 could move without assistance while in their wheelchair (WC), did not wander, and had no exit seeking behaviors documented in the record prior to admission. No documentation was found to show Resident 95 had a significant alcohol abuse history or their risk for leaving the facility without staff notification. The January 2025 nursing progress notes documented Resident 95 had a history of heavy alcohol use, progressive cognitive impairment, was alert to self only, confused, forgetful, was agitated, refused meals and began adamantly wanting to go home on 01/30/2025, two days after their admission. Review of the 02/20/2025 wandering risk assessment showed Resident 95 showed exit seeking behaviors, could move without assistance while in their wheelchair, had wandered aimlessly within the facility or off the grounds, and wanted to get outside to go home. The assessment identified Resident 95 as a high risk to wander. Review of the 02/20/2025 impaired safety awareness care plan showed Resident 95 was confused, wanted to go home, had a wanderguard (a device placed on an individual that alarmed when an exit door was approached) placed on their WC and instructed staff to verify proper function nightly. No documentation was found to show Resident 95 had a significant history of alcohol abuse or interventions implemented to address potential risks associated with the SUD. <Resident 2> According to the 01/24/2025 assessment, Resident 2 admitted to the facility on [DATE] with diagnoses that included weakness and depression. Review of the 12/30/2024 nursing admission assessment showed Resident 2 was cognitively intact, had clear speech and clearly understood others. The assessment documented Resident 2 had past use of alcohol and Marijuana (cannabis), no additional details were documented. The 12/31/2025 social service assessment documented Resident 2 had a history of alcohol or drug abuse and had [AGE] years of sobriety. No documentation or details of Resident 2's Marijuana use history was found. The January 2025 nursing progress notes documented on 01/10/2025 Resident 2's spouse brought in an edible marijuana product and Resident 2 had consumed it the prior evening. Resident 2 had an elevated heart rate (HR) of 129 beats per minute (average HR ranges from 60-100). A care conference was held with Resident 2 and their spouse. They were both educated that edibles contained cannabis and were not permitted on the facility grounds. Resident 2's spouse stated Resident 2 had requested they bring the cannabis edibles into the facility. Resident 2's spouse acknowledged they had placed more edibles in Resident 2's nightstand drawer. Staff requested the additional cannabis edibles be removed from the facility grounds. The 01/10/2025 care conference assessment documented Resident 2 had edibles brought in from home and the provider was notified. Resident 2 was monitored, and additional edibles were taken home. The 01/14/2025 behavior care plan documented Resident 2's family members brought medications that included edibles to the facility without notifying staff. Staff were instructed to educate family, resident and staff of the dangers of bringing in outside medications without consent and instructed staff to inquire after each family visit if any outside items such as medications were brought into the resident. No documentation was found to show Resident 2 had a history of alcohol abuse. In an interview on 03/21/2025 at 10:34 AM, Staff G, Nursing Assistant, stated a SUD was when an individual had issues with substances such as alcohol, drugs or controlled substances. Staff G explained they received SUD training during new employee orientation (NEO). Staff G further stated they would go the nurse to deal with potential emergencies related to substance use. In an interview on 03/21/2025 at 10:54 AM, Staff H, Registered Nurse, stated a SUD was when a person was addicted to narcotics, alcohol or any sort of drug. Staff H stated they were unsure of the facility process for dealing with potential emergencies related to substance use, which facility staff had been trained to recognize signs and/or symptoms of substance use, how residents were assessed for potential risks associated with substance use, or how resident safety was maintained. Staff H further stated staff should not be offering alcohol to residents with an alcohol abuse history and the SUD should be care planned with identified interventions. Staff H acknowledged Marijuana in any form was not allowed on the property. In an interview on 03/21/2025 at 11:06 AM, Staff F, RCM, stated a SUD was when someone abused a substance that caused an ill effect in a person's health, change in mood or behavior and became a danger to themselves or others. Staff F further stated all facility staff were trained on SUD during NEO. Staff F was asked how the facility assessed residents for potential risks associated with SUDs. Staff F stated illegal substances were not permitted in the facility and if a resident had a SUD, it would be care planned but nursing had no specific assessment to complete. Staff F stated they were unsure if they cared for any residents with a history of SUDs and acknowledged Marijuana edibles were not allowed in the facility. In an interview on 03/21/2025 at 11:21 AM, Staff E, Social Service Director, explained they used to be a certified SUD counselor but did not utilize those credentials in the facility. Staff E stated all staff were trained to recognize signs and/or symptoms of substance use. Staff E further stated social services did not assess for potential risks associated with SUDs but if a resident had a history of substance use it should be care planned with interventions implemented for direct care staff to follow. Staff E acknowledged Marijuana was not allowed in the facility and Resident 2's edibles were removed from the facility property, on 01/10/2025. 46115 <Resident 13> The 12/23/2024 quarterly assessment documented Resident 13 had diagnoses that included diabetes, high blood pressure and a stroke. Resident 13 had moderate cognitive impairments and was able to make their needs known and had sustained two or more falls. The 03/19/2025 fall risk evaluation documented Resident 13 had a history of falls and was at risk for additional falls. The 12/21/2022 risk for falls care plan documented Resident 13 was at risk for falls related to deconditioning and problems with balance. The care plan had multiple fall interventions in place. A 02/11/2025 progress note documented Resident 13 had slid out of bed onto their fall mat. The incident investigation documented Resident 13 would be gotten up at 6:00 AM to prevent them from getting out of bed on their own. This intervention was not found on the care plan. A 02/18/2025 progress note stated Resident 13 was found on the floor sitting on their fall mat next to the bed. There was no further documentation in the resident's record regarding the fall. In an interview on 03/24/2025 at 2:11 PM, Staff P, Nursing Assistant, stated they knew what care to provide the residents by looking at the care plan. During an interview on 03/24/2025 at 2:15 PM, Staff Q, Registered Nurse, stated after a fall the resident was placed on alert charting to monitor for latent injury. Staff Q stated interventions after a fall should have been placed on the care plan and said this was important for the safety of the resident. In an interview on 03/24/2025 at 3:14 PM, Staff F, Resident Care Manager, stated fall interventions should have been on the care plan and said this was important to ensure the safety of the resident and that interventions were followed. Staff F stated after a fall the residents were placed on alert charting to monitor for latent injuries and pain. <Resident 92> The 01/08/2025 admission assessment documented Resident 92 had diagnoses that included stroke, dementia and anxiety. Resident 92 had severe cognitive impairments, had fallen prior to and after admission, and had sustained a fracture in the past six months. The 01/02/2025 fall risk evaluation documented Resident 92 had a history of falls and was at risk for additional falls. The 01/03/2025 risk for falls care plan documented Resident 92 was at risk for falls related to confusion, deconditioning and problems with balance. The care plan had multiple fall interventions. An incident investigation for 03/01/2025 stated Resident 92 was found on the floor in the dining room and the safety alarm in use had not sounded. The safety alarm was not assessed for the reason it had not functioned properly. In an interview on 03/24/2025 at 1:53 PM, Staff L, Nursing Assistant, stated safety alarms were checked to ensure they were working properly when they checked on the residents during their shift. In an interview on 03/24/2025 at 1:58 PM, Staff R, Registered Nurse, stated the nurses checked each resident's safety alarms every shift. In an interview on 03/24/2025 at 3:21 PM, Staff F, stated the nurses were to check the alarms every shift to ensure they functioned properly. Staff F stated the safety alarm not sounding should have been a part of the fall investigation and it was important that safety alarms functioned properly for the safety of the residents. Reference: WAC 388-97-1060 (3)(g)

Based on observations, interview and record review, the facility failed to develop and implement care plan interventions for aspiration precautions (measures taken to prevent food, liquid, or other substances from entering the lungs instead of the stomach) for 1 of 2 sampled residents (Resident 81), reviewed for hospitalization . In addition, the facility failed to follow care planned interventions when providing cares for Resident 91. This failure placed residents at risk of aspiration, unmet care needs, and diminished quality of life. Findings included . <Resident 81> According to the 02/17/2025 quarterly assessment, Resident 81 had diagnoses that included gastro-esophageal reflux disease (GERD, condition where stomach acid and contents back up into the throat) and diabetes. The assessment documented Resident 81 required a mechanically altered therapeutic diet, was cognitively intact and was able to clearly verbalize their needs. Review of the 10/31/2024 hospital discharge summary showed Resident 81 was to receive antibiotics for aspiration pneumonia (lung infection that occurred when food, liquid, or vomit entered the lungs instead of the stomach) upon hospital discharge. Review of the 10/31/2024 hospital discharge orders showed Resident 81 was receive an easy to chew diet and follow aspiration precautions to include providing oral care before eating or drinking, clearing secretions from oral cavity, moistening the mouth, being in an upright position as close as possible to 90-degree angle for oral intake, and elevating the head of the bed to at least 30-degree angle after eating for at least an hour. These were implemented by the facility provider on 10/31/2024. The 01/24/2024 nutrition care plan documented Resident 81 received a therapeutic diet and had a history of aspiration pneumonia. Staff were instructed to provide adaptive equipment, provide nutritional supplements to promote weight gain, and monitor for signs and/or symptoms of swallowing difficulties. The care plan had no goals or interventions developed and no instructions for staff related to the resident's need for aspiration precautions. Review of January 2024 through March 2025 nursing progress notes showed no documentation Resident 81 was non-compliant with following aspiration precautions as ordered. During an observation on 03/17/2025 at 8:57 AM, Resident 81 laid in bed, nearly flat (30 degrees or less), with a large round can to their left side. Resident 81 ate peanuts out of the large can while they watched television. During continuous observation on 03/18/2024 from 9:03 AM until 9:17 AM, Resident 81 again laid in bed, nearly flat (30 degrees or less), with a bitten chocolate candy bar sitting on their stomach and snack size bag of plain potato chips to their right side. Resident 81 ate the chocolate candy bar and plain potato chips while they watched television. At 9:17 AM Staff G, Nursing Assistant, entered Resident 81's room to assist their roommate but did not address Resident 81 eating while laying in bed nearly flat. In an interview on 03/24/2025 at 2:25 PM, Staff W, Licensed Practical Nurse, stated Resident 81 was on aspiration precautions but was not compliant. In an interview on 03/25/2025 at 9:10 AM, Staff P, Nursing Assistant, stated they were not aware Resident 81 had difficulty swallowing or required aspiration precautions. In an interview on 03/25/2025 at 9:36 AM, Staff F, Resident Care Manager, reviewed Resident 81's medical record. Staff F acknowledged Resident 81 had orders for aspiration precautions in place, but the care plan did not include goals or interventions for the ordered aspiration precautions. 46115 Resident 91> The 01/25/2025 admission assessment documented Resident 91 had diagnoses that included Multiple Sclerosis (a disease that caused nerve damage and affected communication between the brain and the body), dementia, and anxiety. Resident 91 was cognitively intact and had no behaviors. The 01/06/2025 behavioral care plan documented Resident 91 had a behavior problem and made repeated accusations toward staff. The care plan documented the staff were to provide care in pairs to rule out accusations that were made. In an observation on 03/20/2025 at 9:51 AM, Staff L, Nursing Assistant (NA), entered Resident 91's room and assisted them to the restroom and there were no other staff members present. At 12:08 PM that same day, Staff L assisted the resident in the bathroom by themselves. In an interview on 03/21/2025 at 10:08 AM, Staff G, NA, stated Resident 91 was in the shower with Staff M, NA. In an interview on 03/21/2025 at 10:20 AM, Staff M stated Resident 91 required assistance of one staff for showers. On 03/21/2025 at 10:32 AM, Staff L was observed in the resident's room providing cares and there were no other staff members present. In an interview on 03/24/2025 at 1:45 PM, Staff L stated they looked at the resident's care plan to see what care they needed. Staff L stated Resident 91 needed cares in pairs if they were having behavioral issues. Staff L stated it was important to have two person cares as care planned to protect the resident and themselves from allegations. During an interview on 03/24/2025 at 3:08 PM, Staff F, Resident Care Manager, stated care should have been provided in pairs to protect Resident 91 and the staff from accusations. Reference: WAC 388-97-1020(1), (2)(a)(b)

Based on interview and record review, the facility failed to address required documentation for advance directives for 1 of 4 sampled residents (Resident 49) reviewed for Advance Directives. This failure placed the resident at risk of losing their right to have their preferences/decisions regarding end-of-life care followed. Findings included . Review of a 02/10/2025 assessment showed Resident 49 admitted to the facility on [DATE]. This assessment showed the staff identified Resident 49 had moderately impaired cognition and, along with the family and significant other, participated in the assessment and goal setting of care. Review of a 09/28/2023 facility admission agreement showed it was signed by Resident 49 and a staff. Under the subject of Power of Attorney, Yes and No questions were asked to help the facility identify if the resident had a healthcare Power of Attorney (POA), advance directives, if copy of the advance directives were provided to the facility, and if they desired information and required assistance in obtaining documents to formulate advance directives. None of the questions were answered and handwritten next to them were the words, [Resident] doesn't know. Similar findings were identified in a 03/05/2024 facility admission agreement, also signed by Resident 49 and a staff, where none of the questions were answered and handwritten next to the questions were the words, [Resident] doesn't remember. Will forward to Social Services. Review of the progress notes and care plan showed no documentation the facility ascertained the status of Resident 49's Advance Directives wishes. The above findings were shared with Staff C, Social Services Director, on 03/19/25 at 10:37 AM. Staff C acknowledged the lack of closure to Resident 49's advance directives status. In a follow-up interview at 12:36 PM, Staff C stated they had not found anywhere where the advance directives status for Resident 49 had followed up on. Staff C stated they never had POA paperwork, but had offered the information to Resident 49's spouse that day, 03/19/2025, and had documented it. Staff C acknowledged the facility should have but did not ensure follow-up of advance directives status at either instance. Reference WAC 388-97-0280 (3)(c)(i-ii), -0300 (1)(b), (3)(a-c).

Based on interview and record review, the facility failed to promote and facilitate resident self-determination by honoring resident choices and/or refusals for 1 of 3 sampled residents (Resident 94), reviewed for choices. This failure placed residents at risk of being unable to exercise their rights, not having their choices honored, and a diminished quality of life. Findings included . According to the 02/02/2025 admission assessment, Resident 94 was cognitively intact and able to clearly verbalize their needs. Review of provider orders showed an active 01/27/2025 order for Resident 94 to utilize a wheelchair (WC) and bed position change alarms to alert staff for the need of assistance. The order instructed staff to remove the alarm if signs of distress were observed and report to the Resident Care Manager (RCM) so the position change alarm could be removed from the care plan as needed. Review of the 01/27/2025 risk for fall care plan showed Resident 94 utilized a fall mat on the right side of the bed, automatic locking WC brakes, a scoop mattress (mattress with defined lip or raised edges), the bed in the lowest position, and bed/WC position change alarms to alert staff when Resident 94 attempted to self-transfer. Review of the 01/27/2025 informed consent for safety/assistive devices showed the position change alarm consent was signed by Resident 94's representative. Review of the 01/28/2025 consent for device form showed Resident 94 utilized a bed alarm for notification of position changes to alert staff to provide assistance. Device use was discussed with Resident 94 and their representative. Review of January 2025 through February 2025 nursing progress notes showed on 02/13/2025, Resident 94 removed the position change alarm from their bed, tore the wire in half and stated, I don't want this on my bed. On 02/21/2025, Resident 94 was awake throughout the night, sat up on the edge of the bed, broke the bed alarm pad when beeping, and staff replaced the alarm pad. The notes further showed staff continued to utilize the bed position change alarm after Resident 94's documented refusals. An observation on 03/17/2025 at 8:51 AM showed Resident 94 had a white position change alarm pad on their bed. Similar observations were made at 10:32 AM and on 03/18/2025 at 2:12 PM. In an interview on 03/25/2025 at 9:06 AM, Staff P, Nursing Assistant, stated a resident's care plan would inform staff what care needs a resident required. Staff P acknowledged Resident 94 utilized position change alarms in their bed and WC. Staff P further stated if they were aware a resident refused to use a position change alarm, they would notify the RCM. In an interview on 03/24/2025 at 2:19 PM, Staff W, Licensed Practical Nurse, stated they were unsure what the facility process was if or when a resident with dementia refused a position change alarm and would need to refer to the RCM for guidance. In an interview on 03/25/2025 at 9:21 AM, Staff F, RCM, stated they would assess a resident if a bed/WC alarm was causing distress to determine what choices could be implemented and to remove the alarm per resident wishes. Staff F explained resident progress notes were reviewed by nurse managers and discussed in the morning meeting. Staff F reviewed Resident 94's medical record. Staff F acknowledged Resident 94 refused the bed position bed alarm on 02/13/2024 and 02/21/2025. Reference WAC 388-97-0900 (1)-(4)

Based on observation, interview, and record review, the facility failed to implement standards of care to prevent elopement (leaving a facility without notice or supervision) for 1 of 3 sampled residents (Resident 2), reviewed for accidents/supervision. This failure placed the resident at risk of injury, becoming lost, and/or exposure to the elements. Findings included . Review of the facility policy titled, WanderGuards, effective 02/06/2019, showed WanderGuards would be placed on residents identified to have a history of wandering and exit seeking. WanderGuards would be tested routinely to ensure they were working and all doors with WanderGuard monitors were to be checked monthly by maintenance to ensure they were working properly. The policy did not list any direction to staff on how to respond when a WanderGuard alarm sounded, and/or additional actions to take when an alarm sounded but no residents were found at the door/area of alarm. Review of the 08/26/2024 quarterly assessment showed Resident 2 had a diagnosis of dementia, was severely cognitively impaired, and required supervision with walking. During the assessment period the resident wandered 4 to 6 days of the week. Per Resident 2's care plan, initiated 08/09/2023, they walked independently with a walker, and used a WanderGuard (a device that alarms when near a sensor placed on exit doors). Review of a 10/20/2024 facility investigation showed Resident 2 left the facility unattended that evening. Per the investigation, local law enforcement called the facility to report finding Resident 2 at a nearby intersection, confused and uninjured. The resident returned to the facility and their WanderGuard was functioning. The facility's investigation showed the resident exited the front door and a nursing assistant responded to the door alarm, but the resident was walking outside and no longer in view, so the staff member did not investigate further. The following day the facility's front door magnetic lock was found to be malfunctioning and was repaired. On 10/22/2024 at 11:46 AM Resident 2 was observed in their room with a WanderGuard attached to their walker. The resident was confused and unable to answer questions related to the incident. In an interview at 12:38 PM the same day, Staff B, Director of Nursing, stated staff responded to the front door alarm one minute after Resident 2 had exited the building, and Resident 2 was already outside walking on the sidewalk. Per Staff B, the staff who responded turned off the alarm because no resident was in the area and the door was supposed to lock closed when the WanderGuard alarm sounded (preventing the resident from leaving). Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to provide timely follow-up for resident representative reported concerns (grievances) for 1 of 3 sampled residents (Resident 1), reviewed for grievances. This failure placed the resident at risk of having unresolved grievances and a diminished quality of life. Findings included . Review of the policy titled, Washington State Veterans Home Grievances, effective 08/01/2024, showed that residents had a right to make formal or informal concerns or grievances orally or in writing, and the facility would make efforts to provide a reasonable timeframe the resident or representative could expect a completed review of the grievance. Once the investigation was completed the facility would respond back to the resident or representative with any findings and steps the facility would take to resolve the concern, and the resident or representative's response to the investigation would be recorded on the grievance form. In an interview on 10/22/2024 at 1:11 PM a representative for Resident 1 stated they had several concerns with the resident's care during their stay at the facility which they had brought up orally to staff including licensed nurses, nurse managers, and social services. The resident's representative stated they did not hear back from the facility on the outcome of any investigations related to their reports and did not think their concerns had been registered as official concerns. Review of the September and October 2024 Grievance Logs showed no entries for Resident 1 during their stay at the facility. One entry for Resident 1 was marked as received after the resident no longer resided in the facility. In an interview on 10/22/2024 at 2:14 PM, Staff C, Resident Care Manager, stated Resident 1 and their representative reported concerns regarding their respiratory equipment and staff management of respiratory equipment during their stay at the facility. Staff C stated the facility investigated and determined additional staff training related to the resident's equipment was required, and the training had been implemented prior to the resident's discharge. In an interview at 4:46 PM the same day, Staff D, Social Services, stated Resident 1's representative had informed them of concerns related to the resident's care, which was referred to Staff C for nursing follow-up. Staff D stated they believed Staff C resolved the resident/representative's concern at the time it was brought up, and the resident/representative did not ask for a formal grievance process, so it was not documented and followed-up as a grievance. In an interview on 10/22/2024 at 5:10 PM, Staff A, Administrator, and Staff B, Director of Nursing, stated grievance forms were available throughout the facility for staff, residents, and visitors to fill out. Staff A and B stated families reported concerns all the time and if something just needed a quick fix then it would not be written up as a grievance and only something that needed a permanent fix would be a grievance. Staff B stated additional training related to Resident 1's respiratory equipment was provided after the resident's representative brought forth their concerns and stated it probably should have been viewed as a grievance. Reference WAC 388-97-0460

Based on interview and record review, the facility failed to notify the resident's representative of a significant change in condition for 1 of 3 sampled residents (Resident 4), reviewed for quality of care. This failure placed the resident at risk of receipt of inadequate care and diminished quality of life. Findings included . Review of the June 2024 progress notes showed on the evening of 06/20/2024, Resident 4 was transferred to the hospital due to a fracture to their foot. There was no documentation showing Resident 4's representative was notified of the transfer. Additional review showed the resident returned to their former residence (instead of the facility) after their hospitalization on [DATE], where the resident was found by their representative with injuries from falls that occurred while the resident was alone. In an interview on 06/27/2024 at 4:48 PM a representative for Resident 4 stated they were not notified of the resident's transfer to the hospital and were surprised to find the resident at their former residence on 06/21/2024. The representative stated they had medical power of attorney (POA; legal document giving a person legal authority to act on another's behalf) and expected to be notified of changes in the resident's status. In an interview on 07/24/2024 at 12:59 PM, Staff C, Licensed Practical Nurse, stated Resident 4 was somewhat confused prior to going to the hospital on 06/20/2024 and gave examples of the resident running over their own foot and blaming someone else, as well as hallucinating stuffed animals were real and playing with other animals. Staff C stated Resident 4 had a representative that facility staff were to report any concerns with the resident to. In an interview at 1:09 PM the same day, Staff B, Staff Development Coordinator, stated they worked with Resident 4 on the evening of 06/20/204 and received the physician order to transfer the resident to the hospital late in the evening. Staff B stated they left a message for staff to notify the resident's representative the next morning. Per Staff B, whether staff called resident representatives at night for changes depended on the situation. In an interview on 07/24/2024 at 1:46 PM Staff A, Director of Nursing, stated information was posted at the nurse's stations to guide staff on what to do when sending residents to the hospital, which included notifying their representatives. Staff A reviewed Resident 4's electronic medical record and verified the facility had documentation of Resident 4's POA at the time of their hospital transfer. Staff A stated Staff B should have notified the resident's representative of the transfer. Reference: (WAC) 388-97-0320 (1)(b)(d)

Based on interview and record review, the facility failed to follow up with a physician's order to advance a catheter, and obtain an order to increase the oxygen rate, for 1 of 3 sampled residents (1) reviewed for neglect. This failure placed the resident at risk for potential deterioration in their medical condition and unmet care needs. Findings included . According to the 03/16/2022 admission assessment, Resident 1 had diagnoses which included benign prostatic hyperplasia (prostate gland enlargement that can cause difficulty with urination), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and was able to make their needs known. The assessment also documented the resident required supplemental oxygen. A progress note dated 08/01/2022, by the urology clinic, documented Resident 1's urinary catheter was positioned in their prostate and was not placed fully into the bladder. The clinic called the facility and instructed Staff B, Registered Nurse, to advance the catheter into the bladder. A progress note dated 08/01/2022 at 5:25 PM, documented Staff B received a call from the urology clinic to inform the urinary catheter needed to be advanced an inch. Staff D, Resident Care Manager, instructed the nurse to notify the facility provider. Staff B left the provider a message to obtain the order. Review of Resident 1's record documented there was no further documentation found the facility had received a call back from the provider or that additional follow up communication occurred with the provider. Review of the 03/10/2022 provider orders, documented supplemental oxygen (oxygen delivered into the nostrils through soft tubing, typically at a rate between 1 and 10 liters per minute), was to be administered at 2 liters per minute (LPM) at rest, and 3 LPM with exercise. Review of the Medication Administration Records (MAR) for July and August 2022 documented the following times when oxygen was given above the ordered amount: Day Shift: 4 LPM on 07/13/2022, 07/14/2022, 07/24/2022, 07/30/2022, and 07/31/2022. Evening Shift: 4 LPM on 07/10/2022, 07/15/2022, 07/18/2022, 07/19/2022, and 08/05/2022. On 08/06/2022 the oxygen was administered at 5 LPM. In an interview on 4/30/2024, at 1:13 PM, Staff C, Registered Nurse, stated the resident care managers processed orders when they were available, if not, the nurses were responsible to do so. Staff C added, they would notify the oncoming nurse if no response was obtained back from a provider. In addition, Staff C stated the provider needed to be notified for an increase in oxygen rate. In an interview on 04/30/2024 at 1:25 PM, Staff D stated the facility provider was notified for all orders by outside providers and needed to approve the order prior to it being processed. Staff D stated the nurses were educated to call the provider more than once, and if no response was obtained, to notify the Director of Nursing. Staff D added the expectation was the nurses would notify the provider of the need for changing the oxygen rate. In an interview on 04/30/2024 at 1:33 PM, Staff A, Director of Nursing, stated the expectation was for nursing staff to continue to call the provider and if unable to make contact, they needed to be notified. With regards to the advancement of the catheter and obtaining an order, Staff A confirmed the provider had not returned the call, no further follow up was done, and the catheter had not been advanced. Staff A added the provider needed to be notified for changes to a resident's oxygen rate. Reference: WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to ensure that residents with fluid balance concerns were monitored for 1 of 3 sampled residents (89) reviewed for fluid restrictions. This failure placed residents at risk for adverse health events and decreased quality of life. Findings included The facility provided policy Encouraging and Restriciting Fluids revised in 10/2010 documented guidelines which included to record fluid intake in milliliters (mls) as instructed by the physician. When placed on restricted fluids, remove the water pitcher and cup from the resident's room. If the resident refuses to have the pitcher removed, notify the supervisor and provider to discuss the risk and benefits of continuing versus discontinuing the restriction to honor the resident's preference. A review of the record documented Resident 89 had diagnoses including cirrhosis of the liver (scarring caused by many years of damage to the liver from various sources), ascites (fluid in the abdomen caused by cirrhosis) and general edema (too much fluid trapped in the body's tissues.) The 01/08/2024 admission assessment documented Resident 89 was cognitively intact, required set-up assistance for their meals, and weighed 183 pounds (lbs). A review of the provider orders from 01/02/2024 and 01/03/2024 documented Resident 89 was to receive a regular diet and fluids were to be restricted to 2000mls daily. The resident was to receive 240mls with each meal, 240mls with each medication pass, and extra fluids received were to be documented each shift. Additionally, Resident 89 was to be weighed every day. A Spokane Veteran's Home Care Delivery Guide updated on 01/02/2024 (located in a binder at the nurse's station) documented Resident 89 was on a 2000mls fluid restriction and the resident was not to have a water pitcher. A 01/09/2024 Staff D, Registered Dietician, (RD), documented they spoke to Resident 89, the resident was aware of their fluid restriction, and the two discussed maintaining the fluid restriction to minimize fluid retention. On 02/22/2024, the Staff D progress note documented Resident 89 reported their belly felt larger and they had more edema in their feet. Resident 89 reported that they cheated on the fluid restriction and drank extra water because they got so thirsty. A review of Resident 89's weight showed the following trend: 01/03/2024 183.0 lbs. on admission, 02/03/2024 172.4 lbs., 03/03/2024 199.0 lbs., 03/11/2024 212.8 lbs. A review of Nursing Assistant (NAC) documentation of the Nutrition-Fluids task from 02/28/2024 to 03/12/2024 had no entries that documented Resident 89's fluid intake. A review of Resident 89's February and March 2024 medication administration records (MARs) included areas for nurses to document the resident's fluid intake each shift. An entry on 03/11/2024 nightshift had 180ml documented. All other shift entries for February and March had an X documented, no fluid amounts. On 03/08/2024 at 8:43 AM, Resident 89 was observed napping in their bed. A water pitcher was on the overbed table and was full of ice chips and had a spoon in it. An empty coffee mug was also on the table. At 2:56 PM, the water pitcher was still on the resident's table and the ice had melted. The pitcher was half full of water. Resident 89 was watching TV and stated they were not supposed to drink more than two 20-ounce bottles of water each day because they had a lot of fluid in their abdomen. While talking, an unidentified NAC brought in a fresh water pitcher full of ice and removed the pitcher that contained water. When asked who kept track of how much fluid the resident drank, Resident 89 stated I don't know .someone does. On 03/11/2024 at 8:54 AM, two plastic liners for the water pitcher were observed full of ice chips on Resident 89's overbed table. The water pitcher and an empty coffee mug were also on the table. At 11:52 AM, Resident 89 was eating their lunch, which included one mug of coffee, almost empty. On 03/12/2024 at 7:51 AM, Resident 89 was observed eating breakfast. There was a water pitcher full of ice chips on the overbed table. An empty coffee mug and a full coffee mug were on the resident's breakfast tray. During an interview on 03/12/2024 at 8:01 AM, Staff E, NAC, was asked where staff kept track of the amount of fluids Resident 89 was getting. Staff E stated they did not keep track of the resident's fluids unless the nurses did. Staff E stated Resident 89 got one drink on their meal trays because they were on a fluid restriction; Resident 89 was not supposed to have other fluids, so they gave Resident 89 ice chips instead. During an interview on 03/12/2024 at 11:01 AM, Staff F, Registered Nurse, stated staff did not document Resident 89's fluid intake. When asked how they would know if the resident maintained their fluid restriction, Staff F stated Resident 89 knew what they were supposed to do and kept track. During an interview on 03/13/2024 at 9:59 AM, Staff G, Resident Care Manager, stated staff were instructed to begin documenting Resident 89's fluid intake and the resident was not to have a water pitcher. Staff G stated initially, Resident 89 wanted to keep track of their own fluids, but the resident did not keep up with it so that had not worked. Staff G stated Resident 89 did not drink a lot of fluids but ate a lot of ice. Resident 89 had been told at the hospital that ice chips did not count as fluid and that is what the resident believed. Staff G stated it was important to monitor Resident 89's fluid intake so that the resident did not get overloaded with fluid related to their ascites. Reference: WAC 388-97-1060(1)

Based on interview and record review, the facility failed to complete a discharge summary that included a recapitulation/synopsis of the resident's stay as required, for 1 of 1 sampled residents (94), reviewed for community discharge. This failure placed the resident at risk for having an incomplete medical record. Findings included . Per the admission assessment dated [DATE], Resident 94 had diagnoses which included urinary retention and aspiration pneumonia (when food or liquid is breathed into the airways or lungs, instead of being swallowed), had moderate cognitive impairments, and needed moderate to substantial assistance to complete activities of daily living. A record review showed Resident 94 was admitted to the facility for physical and occupational therapy, following deconditioning related to the above diagnoses. The resident discharged to home on 01/26/2024. A review of the discharge packet showed the resident was discharged with a referral to a wound care provider and included the list of prescribed medications. A recapitulation, a summary that recounted the care and services the resident received at the facility, was not found documented in Resident 94's record. In an interview on 03/14/2024 at 3:15 PM, after review of Resident 94's record, Staff N, Resident Care Manager, stated a recapitulation discharge summary had not been completed. Reference: WAC 388-97-0080(7)(a)

Based on observation, interview and record review, the facility failed to ensure catheter care was provided in a dignified manner for 1 of 1 sampled residents (31), reviewed for use and care of a urinary catheter (a flexible tube that passes through the urethra and into the bladder to drain urine). This failure placed the resident at risk for diminished quality of life. Findings included . Per review of the 01/19/2024 annual assessment, Resident 31 had diagnoses which included neurogenic bladder, (a condition in which one lacked bladder control due to a brain, spinal cord, or nerve problem), and utilized a urinary catheter. On 03/06/2024 at 12:54 PM, Resident 31 was observed with the urine collection bag of their catheter attached to the bed, not covered by a privacy bag. Staff J, Nursing Assistant emptied the urine into a container and the procedure was visualized from the doorway of Resident 31's room. Additional observations of the collection bag without a privacy bag were observed on 03/06/2024 at 12:54 PM, 03/07/2024 at 9:22 AM, 03/08/2024 at 8:50 AM, 03/11/2024 at 9:00 and 03/14/2024 at 1:41 PM. In an interview on 03/14/2024 at 1:12 PM, Staff I, Licensed Practical Nurse, stated when a catheter was emptied, the curtain should have been pulled to ensure privacy. In an interview on 03/14/2024 at 1:32 PM, Staff B, Director of Nursing, stated the urine collection bag should have been placed in a privacy bag and it was a dignity issue if others could have seen staff empty the urine in the collection bag into a container. Reference: WAC 388-97-0180 (1-4)

Based on observation, interview, and record review, the facility failed to ensure 1 of 8 sampled residents (Resident 1) reviewed for medication administration received a provider ordered increased dose of their diuretic medication (rids the body of excess fluid). This resulted in harm as Resident 1's edema increased during the time they missed the ordered increase in medication and may have contributed to the need for emergency care due to complications from heart disease. Resident 1 developed increased lower leg edema (swelling), skin breakdown of their right calf, and increased shortness of breath, requiring further evaluation in the emergency department. This failure placed residents at risk for deterioration of their chronic health conditions, physical distress and discomfort, and a decreased quality of life. Findings included . Per the record which included the resident's current diagnoses list as of November 2022, Resident 1 had diagnoses including obesity, cardiomyopathy and heart failure (both diseases causing a weakened heart muscle that affects the heart's ability to pump blood throughout the body; symptoms included shortness of breath and swelling of the legs and ankles.) A 09/19/2022 assessment showed the resident was cognitively intact and had functional limitations of range of motion in both lower extremities (a restirction or lack of ability to move the legs in what would be considered a normal way). The 10/02/2022 care plan showed the resident had heart failure, was on diuretic therapy (as defined above), and was at risk for skin impairment. Interventions were to administer diuretic therapy medications as ordered, monitor for their effectiveness every shift, monitor and report increased edema of the legs and feet, increased shortness of breath, and weight gain not related to intake. The care plan also showed the resident was to have their skin checked for abnormalities weekly by the licensed nurse. In 08/2022, the resident had a provider order to take Bumex (a diuretic, which reduces extra fluid in the body) 2.0 milligrams (mg.) daily for heart failure. A review of the resident's weights showed the resident's weight fluctuated, and the resident had gained 7.5 pounds (lbs.), from 228.5 lbs. on 10/03/2022, to 336 lbs. on 11/17/2022. A skin assessment dated [DATE] showed Resident 1 had hyperpigmentation (skin that was darker than the surrounding skin) of both lower legs, a small water blister on the right inner shin, a scant amount of serous (clear) drainage, and 1+ edema (graded on a scale of 1 to 4, with 1 being 2 millimeters deep when the skin was pressed on, and 4 being 8 millimeters deep). On 11/24/2022, the skin assessment documented the resident had scabbed areas on the right lower shin, and 2+ edema (3-4 millimeters deep when the skin was pressed on). A progress note dated 11/10/2022 by Staff Q, Healthcare Unit Coordinator (HUC), showed the resident had an appointment at the primary care clinic scheduled for 11/18/2022, related to an evaluation of some leg issues and to receive a shingles vaccine. Per the note, the appointment was verified with the clinic staff. When reviewed on 12/02/2022, the resident's record did not contain a progress note or orders from the provider regarding their visit at the primary care clinic on 11/18/2022. During an interview on 11/28/2022 at 2:31 PM, Resident 1 stated they were concerned about one of their medications. They had been to an appointment at their primary care clinic on 11/18/2022. They brought an envelope back from their appointment that contained an order to increase their Bumex from 2.0 mg. daily to 2.5 mg daily. The resident had discussed this with Staff S, Licensed Practical Nurse, and an order had not been located. Resident 1 stated they had not received the increased dose, and their legs felt tight and big. On 12/01/2022 at 1:16 PM, the resident's lower legs were observed with the surveyor and Staff T, Nursing Assistant. Resident 1's calves were both brown/purple discolored. The left lower leg appeared edematous, and the skin was tight and shiny. The right lower leg was edematous. The mid-calf area to the right of the shin had an area similar in size to the palm of a hand that was flaky, and had several small dark scabbed-looking pockmarks (small, concave areas on a person's skin). The resident had just returned from the shower, so there was no drainage present. During a telephone interview on 12/02/2022 at 10:53 AM, the registered nurse (RN) at the primary care clinic stated the resident had been seen on 11/18/2022. The RN stated the nurse practitioner wrote in the progress note to increase the Bumex from 2.0 to 2.5 mg. daily for 14 days, because of resident complaints of increased edema and weight gain. The resident had a follow-up appointment that day, 12/02/2022. During an interview on 12/05/2022 at 9:36 AM, Staff R, HUC, stated they found documents from the resident's 11/18/2022 clinic visit on their desk, and did not know how they got there. Staff R stated if they did not receive documents from the resident's appointment, they sent an email requesting them. Sometimes they would receive the visit documents, and sometimes they got no response. During a follow-up interview on 12/05/22 at 9:41 AM, Resident 1 stated on 12/02/2022, they were sent to the wound clinic first, then went to the primary care clinic for a follow-up visit. Resident 1 stated the provider looked at their legs and decided to send them to the emergency room for further treatment. Resident 1 stated they were ordered to take 3.0 mg. of Bumex every day, and they were given the pills to bring back to the facility so they did not miss any doses. Review of the documents returned from the 12/02/2022 outpatient wound clinic appointment showed the reason for the visit per the resident was they changed my pee medication, now my leg is swollen and wet. The wound clinic note showed the right leg was edematous with a scab to the top right of the shin with intact eschar (dead tissue) and dark dry skin surrounding it. Edema was identified as a barrier to healing. A new treatment ordered was to cleanse with saline or wound cleanser daily and as needed for excessive drainage, and to cover the wound with an absorbent dressing such as foam gauze. Review of the documents returned from the 12/02/2022 emergency room visit showed the resident was seen for an exacerbation (worsening symptoms) of heart failure. Symptoms included breathing problems, tiredness, and swelling. Treatment orders were to increase Bumex to 3.0 mg daily for 10 days, then return the dose to 2.0 mg. During an interview on 12/05/2022 at 10:02 AM, Staff Q, RCM, stated when a resident went to an appointment, a packet that contained a blank order form, a blank progress note, a resident's allergy information, and the resident's facesheet went with them. When they returned, if Staff Q was working, the return documents were given to them. If not, they were given to the nurse working on the unit. They stated the expectation was for the nurse to transcribe any new orders, then place them in Staff Q's in-box for review. Staff Q stated there was no monitoring done to ensure documents from appointments were returned to the facility. Staff Q was not aware of orders to increase the diuretic from Resident 1's appointment on 11/18/2022 until they found the paperwork on the desk on 12/05/2022. The resident was already prescribed Bumex, but did not get the increased dose ordered 11/18/2022. They stated it was important for the resident to get the increased dose to prevent complications of increased edema, weeping skin conditions, and possible heart complications. During an interview on 12/7/22 at 9:09 AM, Staff S stated the resident told them about the increased Bumex dose on 11/20/2022. Staff S was unable to find the order for the increased medication dose. Staff S was unsure if anyone had called the clinic to verify if the dose was supposed to be increased and there should be a process in place to make sure paperwork from clinic appointments were returned to the facility with the residents. During a telephone interview on 12/08/22 at 9:12 AM, the RN from the primary care clinic confirmed they had sent the resident to the emergency department on 12/02/2022 as a result of missing the increased dose of Bumex. During the interview, the RN stated the resident had increased edema and difficult breathing. The emergency room had increased the dose even higher than what was originally intended. Resident 1 was to be seen again at the clinic on 12/16/2022. Reference: WAC 388-97-1060(3)(k)(iii)

Based on observation, interview, and record review, the facility failed to ensure that appropriate and timely services were provided to prevent a further decrease in range of motion (ROM) for 1 of 3 sample residents (2), reviewed for range of motion. This failure resulted in actual harm to Resident 2, who had a significant decline in range of motion to the lower extremities and a contracture to the right knee (a restriction of motion, in which the ability to extend, or straighten the knee all of the way is lost. The inability to extend the knee may result in many symptoms to include pain, swelling, and weakness). In addition, the facility failed to provide timely services in order to maintain the level of function the resident had upon admission. Findings included . Per the 03/30/2021 admission assessment, Resident 2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment also showed the resident had memory impairments, difficulty making needs known, required extensive to total assistance with activities of daily living (ADL's), and had impairment with range of motion of both lower legs. In addition, the assessment identified the resident used a wheelchair for mobility, and required limited assistance of one person when out in the hallway/outside of the room (i.e. the resident was highly involved in the activity, with staff providing guided maneuvering of the limbs or other non-weight-bearing assistance). On 06/16/2021 at 10:40 AM, Resident 2 was observed laying in bed, on an air mattress. The resident's right leg was bent up, and was under the left leg. The resident was able to nod to some questions asked by the surveyor, but was generally not interviewable. At 12:52 PM, Staff F, Restorative Aide, stated she had been doing ROM with Resident 2 for about a month. Staff F stated the resident could not stretch the right leg, and it was almost fixed in place. Staff F was asked about the resident getting up in a wheelchair, and stated it was not possible because of the contracted right leg, and was not aware of when the resident was no longer able to get up. During observation, Staff F attempted to straighten Resident 2's leg, which did not move when ROM was attempted. Resident 2's left leg was in a straight position. Staff F was able to slightly bend the resident's left knee, and stated that was really good for the resident. The resident moaned while his legs were being moved. Staff F verified working with the resident 5 days a week, and stated the contractures and decreased ROM in both legs were already present when she started working with the resident. The resident's care plan showed on 04/27/2021, a care plan was developed, related to contractures to the lower extremities (approximately a month after admission). The resident was placed on a Functional Maintenance Program (FMP) - to prevent declines in ROM, which included ROM and stretching to the lower extremities. Review of the resident's hospital discharge note, dated 03/24/2021, showed the resident's leg contracted intermittently, and the resident had been receiving [MEDICATION(S)] injections (a medication that helps the muscles relax). Per the note, the resident was to be encouraged to propel in a wheelchair at least 3 times a day, be reminded to do exercises with the hands/feet while seated in the chair, and be repositioned every 2 hours while in bed. The note showed the resident was able to self mobilize while in a wheelchair throughout the facility, but was dependent for other cares. Review of Resident 2's admission history and physical, dated 03/26/2021 by the facility physician, showed the resident was dependent for ADL's, and the plan was to continue a restorative nursing program to maintain the current level of function. On 04/07/2021, care conference notes showed the resident used a wheelchair daily, and moved independently. The resident's record was reviewed for restorative nursing notes. The resident was placed on a ROM program 04/28/2021. There was no documentation related to the program occurring from admission (03/24/2021), through 04/28/2021. During an interview on 06/16/2021 at 12:22 PM with Staff G, Occupational Therapy, and Staff H, Physical Therapy, residents were usually evaluated on admission for therapy needs. When a resident was discharged from therapy, a FMP would be started. When asked about Resident 2, Staff H stated initially Resident 2 did not have orders for therapy but that it had been ordered recently, and a maintenance program had been set up. Staff H stated Resident 2's left leg was relatively contracted, and his right leg was unable to be moved. On 06/16/2021 at 1:30 PM, Staff D, Restorative Nurse, stated Resident 2 had been moved to a different floor, wasn't sure of a date when that occurred, and stated at that time the resident was bed-bound and contracted. Staff D further stated Resident 2 was hard to move and reposition, was now on a FMP program, and was really contracted. Staff D was unable to provide information on when the resident went from propelling in a wheelchair to being bed-bound. On 06/16/2021 at 1:45 PM, Staff E, Registered Nurse, stated the resident used to be on a different floor. When the resident arrived to the current room, he was bed-bound and had contractures. Staff E went on to say the resident's right leg was contracted underneath the left leg, and when being moved, it caused pain. In an interview on 06/16/2021 at 2:37 PM, Staff B, acting Director of Nursing, stated if a resident was not on a FMP program then the provider would be notified to order one. The resident care managers would then follow up, to ensure a resident had been placed on a restorative/functional maintenance program. Staff B was asked for documentation as to when Resident 2 was placed on a FMP program, and at what point the resident was no longer able to be up in a wheelchair and became bed-bound. Documentation was received showing the start date of the FMP was 04/28/2021; no documentation was provided prior to that time. Staff B was unable to state when the ROM declines and contracture occurred. Reference: WAC 388-97-1060(3)(d)

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer/injury (areas of skin injury from prolonged pressure) for 1 of 3 sample residents (Resident 2), reviewed for pressure ulcers. This failure resulted in actual harm to Resident 2, who developed preventable pressure ulcers, due to not having preventative measures in place. Findings included . Per the 03/30/2021 admission assessment, Resident 2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment showed the resident had memory impairments, difficulty making needs known, required extensive assistance with bed mobility, was at risk for developing pressure ulcers, and had no pressure ulcers on admission. Review of a discharge note from the hospital, dated 03/24/2021, showed the resident had previous pressure ulcers to the lower legs. Per the note, the resident had worn leg sleeves while at the hospital, which had excellent results in preventing pressure ulcers. The admission assessment, dated 03/24/2021, showed the resident was admitted to the facility with dry skin on the buttocks, which was excoriated (red and damaged, with some skin loss), related to being incontinent. There were no further skin issues identified. On 06/16/2021 at 10:40 AM, Resident 2 was observed laying in bed with his eyes closed. The resident was on an air mattress with bolsters (long cushions) and had blue boots (a soft boot placed to protect the feet from pressure), on both feet. Resident 2's right leg was bent up underneath the left leg, with the right boot partially falling off. The resident was able to nod to a few of the questions asked by the surveyor, but was generally not interviewable. At 1:45 PM Staff E, Registered Nurse, assisted the surveyor with observing the resident's feet. The right foot had a dressing on the inner aspect of the ankle. The dressing was removed, and a large pink area of intact skin, with some dried appearing blood towards the outer wound, was seen. Staff E stated the wound was healing well. Staff E stated the resident received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff E stated the other wounds had healed. A 03/24/2021 care plan showed the resident was at risk for skin breakdown due to decreased mobility and medical conditions. Staff were to apply barrier cream and perform visual checks. On 05/24/2021, a revision was made to the care plan, which directed staff to place blue boots on both feet while in bed. On 05/27/2021, an additional revision showed actual impairment to the skin was present. Blue boots were to be on at all times, and an alternating air mattress was placed. Those revision were put in place after the resident had developed the pressure areas. Review of skin assessments showed the following: -05/13/2021, a right outer ankle scab was identified that measured 1.0 centimeter (cm.) x 1.0 cm. -05/20/2021 the skin assessment documented the resident's scab on the right outer ankle was now open, measuring 1.5 cm. x 1.0 cm. A new blister was identified on the top of the resident's right outer foot that was 1.0 cm. x 0.75 cm. -05/27/2021 the right outer ankle pressure area measured 2.0 cm. x 1.5 cm., with mild drainage. The blister on the top of the right outer foot remained intact, measuring 1.0 cm. x 5.0 cm., and the right foot (towards the heel) had another blister identified, measuring 8.0 cm. x 4.0 cm. with the largest area 8.0 cm. x 5.0 cm. Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The dressing was to be changed every 7 days and ordered to protect the ankle from pressure wounds. The next order for preventing pressure wounds was on 05/24/2021, with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/27/2021, an air mattress was ordered to provide pressure relief while in bed. A 05/27/2021 Interdisciplinary team (IDT) review was done, due to the resident developing a new skin issue on 05/24/2021. The document showed the resident was in bed the majority of the time, needed positioned frequently, and had a contracted leg (a permanent tightening of the muscles, tendons, skin, and nearby tissues, causing joint stiffness and immobility), so it was difficult to do. The resident had orders for blue boots and an air mattress at that time, after the skin issues had developed. Review of the nurse practitioner's note, dated 05/28/2021, showed the provider observed the resident's outer ankle wound. It was described as bleeding from the lower half of the open wound, some slough (yellow, tan or brown in color that may be loose and stringy) was in the wound bed, and a piece of eschar (dry, thick, tissue, black or brown in color) was running horizontally in the middle. A daily dressing change was ordered. During an interview on 06/16/2021 at 1:30 PM, Staff C, acting Resident Care Manager, stated when skin issues were found, the licensed nurse should evaluate the area, make notifications, measure the wound, and receive orders for treatment. Preventative measures should be put in place for a resident if they were bed bound or had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/16/2021 at 2:37 PM, Staff B, Director of Nursing, was asked for information related to skin preventative measures put in place before the pressure wounds developed. No additional information was received. Reference: (WAC) 388-97-1060(3)(b)

Based on interview and record review, the facility failed to implement and revise a functioning emotional behavioral support program for one of three sample residents (#1), reviewed for abuse/neglect. This failure resulted in actual psychosocial harm to Resident #1, who experienced severe anxiety and agitation. Findings included . Per the undated electronic profile for Resident #1, the resident admitted to the facility in 2017, and was diagnosed with [REDACTED]. Additionally, the resident was his own responsible party. Review of a workplace safety plan, dated 12/16/2019, showed Staff C, Social Services was to stay 15 feet away from Resident #1 at all times, would not make recommendations regarding the resident's care, would report all incidental contact with the resident, and a member of the management team would make a best attempt effort to notify Staff C when Resident #1 went between facility floors. Review of the emotional/behavioral care plan, initiated 12/17/19, showed the resident had anger towards a staff person he felt had wronged him (Staff C), and if the resident appeared agitated or angry at staff, other staff were to ask him what could be done to fix the issues, and provide good listening skills. Review of a facility incident report dated 06/03/2020 showed Resident #1 and Staff C had a physical altercation in the front lobby of the facility, following a verbal altercation outside of Staff C's office, on 05/01/2020. Per the report, Resident #1 went to the first floor to get his mail from the reception area, and water from the water cooler near Staff C's office; Staff C was not notified of the resident traveling between floors (as per the care plan intervention). Per the report, Staff C came to the doorway of his office and saw Resident #1 nearby, then returned to his office briefly before proceeding out into the hallway towards Resident #1, who had started showing signs of agitation when Staff C first appeared in the hallway. Staff C stopped to ask nearby Staff D, Resident Care Manager, what the resident was doing on the first floor in a tone audible to Resident #1, then continued to approach the resident in order to exit the building lobby, despite another exit in the opposite direction of the resident, and the staff member's nearby office. Staff D also approached the resident and told him to return to the second floor. The resident then followed Staff C into the lobby, rushed Staff C and shouted at him until Staff A, Administrator, intervened. In an interview on 11/13/2020 at 4:11 PM, Staff A stated after the resident was admitted in 2017 he was declared incompetent, though he was competent and responsible for his own affairs, due to a paperwork issue created by Staff C. Per Staff A, there was no process to repair the issue, and the resident was upset and intimidated by Staff C. Additionally, he stated it was a staff member's responsibility to not engage with a resident, even if a resident was verbally abusive to staff. On 11/18/2020 at 4:40 PM Staff B, Director of Nursing stated Staff C should not have approached Resident #1, and that he had other options including staying in his office with the door closed, or leaving via an exit that was both closer to Staff C's office and in the opposite direction of the resident. In an interview on 11/23/2020 at 12:20 PM, Staff H, Nurse Practitioner, stated Resident #1 left the facility shortly after the interaction with Staff C in May 2020, but prior to his discharge the resident showed signs of extreme fear and anger towards Staff C. On 11/23/2020 at 1:30 PM, Staff G, Human Resources, stated she was responsible for conducting the investigation of the incident between Resident #1 and Staff C on 05/01/2020 due to Staff A, Administrator's involvement. Per Staff G, the result of the investigation showed the workplace safety plan was not followed. Additionally, she stated there had been multiple previous encounters between the two. On 11/24/2020 at 2:30 PM, Staff C, Social Services, also stated there had been multiple previous encounters between himself and Resident #1, and that he thought the resident came in to his area to target him on 05/01/2020. When asked why he didn't call for assistance from his office telephone, Staff C stated he did not think of it. When asked why he approached the resident who was already showing signs of agitation, Staff C stated he thought he would be more than 15 feet away, and he did not agree with the safety plan. Staff C further stated the safety plan was not effective, as the resident was independently mobile between floors, and staff rarely called to report the resident's frequent travels between floors. In an interview on 11/24/2020 at 3:15 PM with Staff A, Administrator and Staff B, Director of Nursing, Staff A stated the issues between Resident #1 and Staff C existed prior to his and Staff B's arrival at the facility, and a safety plan was already in place. Both staff acknowledged that Resident #1 was mobile, and the intervention of staff notifying Staff C of the resident's movement throughout the facility was impossible. Staff A stated that Staff C had communicated concerns with the plan to human resources, and the safety plan was updated to the intervention of staff to make a best attempt effort to notify Staff C, which did not meet the resident's needs. When asked how Staff D and other staff throughout the building were educated on the care plan interventions identified to assist Resident #1 when he was upset with and close to Staff C, Staff A stated he was not aware that any staff education was done. In an interview on 11/25/2020 at 2:15 PM Resident #1 stated he moved out of the facility as soon as possible after the interaction on 05/01/2020, but still experienced [MEDICAL CONDITION] from the encounters with Staff C in the form of nightmares and continuous anxiety, for which he was seeking mental health services. Per the resident, Staff C had been told not to approach him by both Staff A and a previous administrator, but Staff C made a habit of approaching and intimidating him. The resident became noticably emotionally distressed during the interview. No Associated WAC

Based on observation, interview, and record review, the facility failed to provide medically-related social services for one of three sample residents (#3), reviewed for a resident-to-resident altercation. Failure to determine Resident #3's readiness for a roommate (after the passing of his previous roommate), and to inform Resident #3 that he was getting a new roommate, resulted in a witnessed verbal incident, and caused actual psychosocial harm to Resident #3, who experienced isolation, tearfulness, and fear. Findings included . Per the State Operations Manual, (MONTH) (YEAR) (Appendix P, Section IV, E, Psychosocial Outcome Severity Guide, Severity Level 3) shows noncompliance resulting in actual harm, can include but may not be limited to clinical compromise, decline, or the resident's inability to maintain and/or reach his/her highest practicable well-being. Examples of negative psychosocial outcomes, as a result of the facility's noncompliance, may include but are not limited to: tearfulness, persistent depressed mood, anxiety, thoughts of impending doom, and suicidal ideation (without an intent to act). 1. According to the quarterly assessment, dated 08/05/19, Resident #3 was cognitively intact, alert, cooperative with care, and able to make his needs known. A progress note, dated 09/03/19 at 1:10 AM, showed the resident exhibited some weepiness with the passing of his roommate. Progress notes reviewed 09/04/19 through 09/05/19 showed no documentation regarding planning for a new roommate for Resident #3, or notifying him it was going to happen imminently. A progess note on 09/06/19 at 9:06 AM showed the resident was introduced to a new roommate. On the same date at 9:36 AM, a progress note showed a verbal altercation between Resident #3 and the new roommate. On 09/06/19 at 11:12 AM, another state agency report showed the verbal altercation between Resident #3 and the new roommate did not fit the definition of abuse. In the report, Resident #3 stated he was unhappy to receive a new roommate, and was never informed by staff he would be receiving one. Resident #3 stated the new roommate had a reputation of being abusive, and he didn't want this type of roommate. Resident #3 stated that he attempted to voice his concerns to staff during the new roommate placement, but staff did not listen to his concerns. A progress note on 09/07/19 at 1:24 AM, showed Resident #3 talked to staff about the altercation that occurred the day prior (09/06/19), and stated that he would have liked notice about his new roommate. A progress note on 09/09/19 at 2:29 PM, showed Resident #3 stated that he felt like a victim, and further stated the incident (i.e., the resident-to-resident altercation), could have been prevented if the facility consulted with him about a new roommate. During an observation and interview on 09/24/19 at 11:15 AM, Resident #3's door was closed, and his curtain was pulled. Resident #3 stated that after the roommate incident, he felt fearful of the staff and kept the door and curtain closed, to alert him to anyone entering the room. Resident #3 stated that he was not included in the new roommate decision process. When he tried to talk to staff during the initial introduction with the new roommate, staff did not listen to his concerns or preferences, and forced him to have the new roommate. The resident stated that when his voice got loud, they (staff) called in administration reinforcement and the police department. The resident stated, They ganged up on me, and I didn't have any way of protecting myself. Resident #3 denied providing consent for the new roommate. During the interview, Resident #3 got emotional and teary as he explained the incident. In an interview on 10/04/19 at 4:05 PM, Staff A, Director of Nursing (DON), stated the resident care manager and social services department managed room/roommate change assignments. Per Staff A, those two departments, worked as a team, and notified residents and family members prior to room moves. In an interview on 10/04/19 at 4:25 PM, Staff B, Administrator, stated he spoke to Resident #3 following the roommate incident on 09/06/19, and was told by Resident #3 that he was not informed of a new roommate. In an interview on 10/04/19 at 5:00 PM, Staff A, DON, stated social services staff was unavailable at that time. No additional information was provided. (For additional information see F-559-Roommate Change Notices) Reference: WAC 388-97-0960 (1)

Based on observation, interview, and record review, the facility failed to ensure two of six sample residents (#69, 43), remained free from mental abuse and physical abuse, when staff intimidated Resident #69 by cornering him in a public hallway, and temporarily deprived the resident of his only means of mobility. This caused psychological harm to the resident, who continued to be tearful, and expressed feelings of being targeted/ambushed by the involved staff. Additionally, the facility failed to protect Resident #43 from resident-to-resident physical abuse, when another resident hit his wheelchair, yelled at, and struck him. This failure placed the resident at risk for harm from a peer. Findings included . 1. Per the facility assessment dated [DATE], Resident #69 had [DIAGNOSES REDACTED]. The assessment also showed the resident was cognitively intact, unable to walk, and required a wheelchair for mobility. A review of the resident's 02/13/19 care plan showed the resident had a recently diagnosed terminal condition. The care plan also showed the resident was reliant upon his electric powered wheelchair for all mobility inside and outside of the facility. According to the facility's quarterly Electric Scooter Use evaluations dated 05/22/18, 08/27/18, 12/12/18, and 03/07/19, the resident understood how to operate the electric wheelchair, and controlled the safety and speed of it. Per definition, mental abuse is any act including confinement, isolation, verbal assault, humiliation, intimidation, or any other treatment which may diminish the sense of identity, dignity, and self-worth. A facility incident investigation report dated 03/20/19 showed at 11:46 AM, Resident #69 was rolling down the hall in his electric wheelchair and accidentally ran over another resident's foot, causing injury to that resident. The investigation also showed the care planned intervention to prevent reoccurrence was wheelchair safety and speed training, and an evaluation by physical therapy/occupational therapy. A progress note dated 03/20/19 at 12:24 PM, showed Staff K, Registered Nurse/Restorative Supervisor, placed a call to a medical equipment company, and requested a technician come to the facility to mechanically lower the speed of the resident's wheelchair. The facility incident investigation noted above, showed no intervention to have the internal controls of the resident's wheelchair altered by a technician (in order to decrease the speed). In an interview on 03/28/19 at 2:00 PM, the resident was in his room sitting in an electric wheelchair. The resident stated that he liked to volunteer at the facility by transporting beverage carts, and hanging the calendars up in the common areas. The resident stated that it made him feel like he had a purpose, and he liked to help because if I do those things then the (nurse) aides can spend more time with the residents. I am lucky, my legs don't work, but my mind still does. Per interview at that time, Resident #69 stated that last week Staff A, Administrator, and Staff B, Resident Care Manager, had cornered him in the hallway, because he accidentally ran over another resident's foot. He stated that Staff A and Staff B had a guy go behind his wheelchair and turn it off. The resident stated that he was stuck in the hallway because of this, and he had wanted to get away from them, but couldn't move. The resident further stated that Staff A and Staff B told him the wheelchair had to be turned down, and he told them no. The resident stated he became angry and yelled at them, after they had someone go behind him and turn off his chair saying, I told them it was personal property and they better not touch it or I would sue them. And I got mad and shook my fist in the air. The resident became tearful and stated, I have never done anything to those two ladies. I would never hurt anyone on purpose; he (the resident whose foot was run over) was my friend. A progress note dated 03/20/19 at 4:47 PM, showed the resident approached Staff C, Resident Care Manager. The note showed the resident was calm, nearly in tears, and stated, I'm sorry but I don't trust those other ladies (referring to Staff A and B). They want to turn my chair down but that won't work for me because I like to go out of the facility; the other ladies don't trust that I will go slow. I don't trust them either. I will continue to do the calendar, but I will stop doing the other jobs. I'm sorry. During multiple observations of the resident during the survey period of 03/28/19 through 04/05/19, between the hours of 8:30 AM through 3:30 PM, the resident stopped the surveyor multiple times daily, stating he was the only one in the building who was forced to turn his wheelchair speed down. The resident stated that he was forced to agree to not go at speeds greater than two yellow bars while in the facility, or staff would have his chair speed permanently altered, or take it away, and make him use a manual wheelchair. The resident further stated that he was unable to propel himself in a manual wheelchair, so if that happened he would just have to stay in bed. On multiple occasions the resident was upset by the restriction, because he stated that the beverage carts were heavy, and he was unable to push them very easily with his chair, with it being at a reduced speed. A progress note dated 03/22/19 at 3:44 PM, showed two of the resident's family members came into the facility on [DATE] very upset and reported to Staff M, Social Services Director, that the resident felt attacked on 03/20/19. The note also showed family and the resident felt his rights were violated, as he was ambushed by the wheelchair technician, who snuck up behind him and disabled the wheelchair. The progress note showed Staff M was not present, so had not witnessed the incident. In a follow-up interview on 04/01/19 at 2:14 PM, Staff C stated that she was not present for the incident. She further stated the resident was sad and almost teary afterward. He had told Staff C if the wheelchair speed was turned down, he would lose his freedom, because he liked to go out of the facility. In an interview on 04/04/19 at 2:02 PM, with Staff A, and Staff E, Clinical Compliance Director, Staff A confirmed she had authorized the medical equipment technician to turn the power off to the resident's electric wheelchair. She stated that the resident's chair had been turned off for three to four minutes, during which time the resident was unable to leave the area. Staff A stated that she, Staff B, and the technician, were with the resident in the public hallway outside the main dining room on the first floor, when this occurred. Staff A stated other staff had already contacted the technician, when she was notified of the issue, and the technician was already in the hallway when she arrived to talk to the resident. Staff A further stated that the resident had refused to voluntarily let the technician alter the speed on his wheelchair. Staff A stated that the resident was very angry, and didn't agree to have his chair speed slowed down. Staff E stated that the resident was just told he was terminal, all his family had been coming to see him that week, so he had been kind of emotional. In an interview on 04/04/19 at 2:33 PM, Staff B acknowledged she had not had a discussion with the resident about the technician coming in, until the technician arrived to modify the speed of the wheelchair. She further stated the resident started to get upset the minute we told him he ran over someone's foot. Once the technician got here we literally had to chase him around the building; he kept racing away. Staff B stated she had called the resident's daughter to get her support, prior to contacting the technician. When asked if the resident was his own decision-maker, Staff B stated that he was, and acknowledged the daughter was not the resident's legal decision-maker. In an interview on 04/05/19 at 8:28 AM, Staff P, Director of Therapy, stated that the resident had always been safe in his wheelchair, but would sometimes go too fast. Staff P stated Resident #69 was very safe around the other residents, and had no previous incidents of running into other residents. She stated the resident had only a few minor incidents of running into objects, and was very remorseful about the accident involving the other resident. Staff P stated that they had called a care conference with the family, because the family was so angry about the way in which the resident's wheelchair settings were turned down. She further stated that the resident had agreed to maintain his speed at no greater than two yellow bars while in the facility, and that the resident had been maintaining that speed since the care conference. In a follow-up interview on 04/05/19 at 9:25 AM, Staff K stated that she talked to the resident, and notified him at the time she was contacting a technician to come and physically turn down his chair. She further stated the resident started yelling at staff you're not going to turn this down! Staff K acknowledged the resident had not given his consent to have his wheelchair turned off, or altered in any way. The facility failed to prevent mental abuse, when they caused Resident #69 to feel trapped and intimidated, anger and sadness, over an incident which occurred in a public area of the facility. 2. Review of the facility's incident reporting log, and related investigation for 03/26/19, showed Resident #43 and Resident #41 had a resident-to-resident altercation. RESIDENT #43 According to his 11/06/18 assessment, Resident #43 was cognitively impaired and required extensive assistance with activities of daily living including transferring, locomotion around the unit, and walking. In a continuous observation on 03/28/19 from 8:46 AM to 9:45 AM, Resident #43 was seated in his wheelchair in the hallway, going from the entryway of his room, to near the nurse's station. In observations on 03/28/19 at 10:46 AM and 11:34 AM, Resident #43 was again in the hallway in his wheelchair. At 11:39 AM, he told Staff V, Social Worker, that he was lost. She reassured him, and he continued sitting in the hallway. The resident was also seen propelling his wheelchair forward and backwards, without looking behind him. For example, this was observed on 03/29/19 at 10:16 AM. Observation on 04/02/19 at 12:36 PM revealed Resident #43 stood up from his wheelchair, and stood at the nurse's station, then walked behind his wheelchair, through the dining room. Additionally, daily during the survey, the second floor hallway near the nurse's station was congested with multiple residents in wheelchairs, particularly around meal times. For example, on 04/03/19 at 11:23 AM, Resident #43 and several unidentified residents were sitting in wheelchairs near the nurse's station, blocking passage through the hallway. RESIDENT #41 Per Resident #41's 01/28/19 assessment, he was cognitively intact, and was independent for locomotion around the unit, after setup assistance. Observation during the survey, including on 03/29/19 at 8:44 AM and 04/01/19 at 9:02 AM, showed Resident #41 spent time in the library on the second floor, which was on the opposite side of the nurse's station from his room. The most direct way to get there was through the hallway near the nurse's station, and past Resident #43's room. In an interview on 04/03/19 at 11:20 AM, Staff H, Registered Nurse, stated she was working the day of the incident between Resident #41 and Resident #43. She stated Resident #43 was confused that day, and standing up, holding on to Resident #88's wheelchair (a resident who witnessed the altercation), and talking to him. Staff H stated she did not directly see the incident, but was working nearby. She related her understanding of the incident was that Resident #41 hit Resident #43's wheelchair with his, Resident #43 said something to Resident #41, and Resident #41 turned around and slugged him in the arm. In an interview on 04/03/19 at 1:18 PM, Resident #88 confirmed there was a verbal exchange between Residents #43 and #41, when Resident #41 was trying to get by in the hallway. Resident #88 further confirmed that Resident #41 yelled at, and then hit, Resident #43. Resident #88 stated it was not a hard hit. In an interview on 04/03/19 at 1:49 PM, Staff F, Nursing Assistant, was asked about a resident-to-resident altercation between Resident #43 and Resident #41. She stated she did not witness it, but the hallway was crowded at times, and residents would get upset. She stated Resident #41 became impatient at times, with waiting to get through. Staff F stated that sometimes a bumped wheelchair was all it took to set off a resident. In an interview on 04/04/19 at 9:05 AM, Staff F added that they occasionally needed to provide one to one supervision to Resident #43, when he was agitated. When asked what Resident #43 did when he was agitated, Staff F stated he stood up from his wheelchair, and was confused, sometimes looking for his parents. In an interview on 04/05/19 at 8:09 AM, Staff C, Resident Care Manager, stated the facility's investigation concluded that Resident #41 struck out at, and hit, Resident #43, and that he intentionally rammed into Resident #43's wheelchair with his. When asked whether the facility considered that the congested hallway might trigger problems between residents, Staff C stated it could lead to problems, and staff tried to watch for that when they could. The facility failed to prevent an incident of physical abuse between residents. Reference: (WAC) 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to ensure one of three sample residents (#1), reviewed for incidents, was provided adequate supervision to prevent accident hazards. Failure to ensure care planned interventions to provide supervision were consistently provided for Resident #1, contributed to the resident exiting the building without staff knowledge, and experiencing a fall. This failure resulted in actual ham to Resident #1, who suffered abrasions to his hands and feet, and potential hypothermia. Finding included . Per the most recent facility assessment, dated 11/20/18, Resident #1 had [DIAGNOSES REDACTED]. The assessment also showed the resident required extensive assistance of one staff to reach distances on and off the unit, and he was only able to propel short distances independently. Per review of the Wandering Risk Scale dated 07/27/18, Resident #1 was a high risk to wander, due to a history of wandering, the inability to follow instructions, and the ability to move in a wheelchair independently. Resident #1 had a Wandergard (an alarm to alert staff when the resident exits the building) attached to his wheelchair, and his care plan, dated 11/13/18, had a goal stating the resident would not leave the facility unattended, and would be safe in the facility. According to the care plan dated 07/10/18, Resident #1 was at risk for falls because he was impulsive, confused, had balance problems, and was weak. A care plan intervention, dated 12/28/18, directed staff to keep the resident in line of site when he was up in a wheelchair. This intervention was revised on 12/31/18, to include when he was in the hallway, or to sit with him if he wanted to go to his room. Per review of a nursing progress note for 01/05/19, at 4:20 AM, another resident (Resident #2) alerted staff that Resident #1 was on the ground of the smoking area (which was a small patio/courtyard outside of the main dining room). Staff assessed the resident, assisted him back into his wheelchair, and then into bed. A skin assessment was completed and abrasions were found on the residents arms and feet. At 4:40 AM, the resident's temperature was 93.5 degrees Fahrenheit; warm blankets were applied. At 5:00 AM, his temperature was 94.8 degrees Fahrenheit. The resident was sent to the hospital for further evaluation. Per review of the Center for Disease Control and Prevention information on Hypothermia dated 12/20/16, hypothermia is a dangerous condition that can occur when a person is exposed to cold temperatures. Per the document, if a person had been exposed to cold temperatures and shows any sign of hypothermia, including a temperature below 95 degrees Fahrenheit, the situation is an emergency, and medical attention should be provided immediately. According to a review of the weather for 01/05/19 in Spokane, the low was 29 degrees Fahrenheit, and the high was 47 degrees Fahrenheit. Per review of the hospital records dated 01/05/19, Resident #1 arrived after an unwitnessed fall; he had multiple abrasions to his lower extremities and left arm. Per the record, the resident complained of pain all over. It was noted he was found outside, and reportedly did not walk without significant amounts of assistance. The wounds were treated with antibiotic ointment, and dressings were applied. The resident then returned to the facility. A full skin assessment was completed on 01/06/19 and documented the following: Abrasions to left lateral toe, left lateral foot, right great toe, and right 5th toe. Bruising to left elbow measuring 6.5 centimeters by 2.0 centimeters, right knee, and right hand. Review of the video recorded by the facility security cameras, dated 01/05/19, showed Resident #1 using the wall railing to propel his wheelchair to the patio door at 2:42 AM. The resident attempted to pull the door open, but was unable to hold it open, and the door closed. At 2:44 AM, the resident was seen again opening the door to the patio, exiting the building, and at 3:02 AM, he fell from his wheelchair onto the ground, near a metal picnic table. The resident attempted to pull a metal patio chair toward himself; he continued to lay, roll, and scoot on the ground near the patio table until 4:17 AM. (1 hour and 27 minutes). No staff was seen on the video until 4:20 AM. Multiple areas of blood, from the resident's injuries, were seen on the ground. Per observation of the nurse's station on 01/16/18, large video monitors were visible, showing live pictures of areas around the facility. These included the hallway leading to the patio, and the patio itself. Per interview on 01/14/19 at 1:10 PM, Resident #2 stated he went out to the patio (which was also the smoking area) in the early morning of 01/05/19 to have a cigarette, and saw Resident #1 on the ground. Resident #2 stated I saw blood all around him, and I knew it wasn't good. Resident #2 stated he immediately alerted staff. He also stated he didn't know why Resident #1 was outside, because the doors to that area locked at night, and to get back in you must have a key card. The resident produced a small rectangular badge with his name on it. The resident stated only staff and independent smokers had them. Resident #2 also thought the door had an alarm on it, but he wasn't sure. Per observation on 01/14/19 at 1:30 PM, the door to the patio had a Wandergard alarm. Per Staff A, Director of Nursing Services (DNS), in an interview on 01/16/19 at 2:50 PM, the alarm had been unplugged for a long time, because the patio is considered a secure area. On 01/14/19 at 2:50 PM, Staff A, DNS, stated she did not think the door to the smoking area locked requiring a key card, but stated the front door locked at night. She called Staff B, Maintenance Staff, who stated he thought the door to the smoking area did lock at 6:00 PM or 8:00 PM. On 01/18/19 at 1:57 PM, it was confirmed the doors to the smoking area patio locked at 8:00 PM, and reopened at 5:00 AM, per Staff C, Security Supervisor. Per an investigation dated 01/18/19, a Nursing Assistant, Staff D wrote the resident was .confused that night (i.e. the night of the incident) & kept trying to transfer independently, so I made sure I kept an extra eye on him because (he) started wandering around while up in his WC (wheelchair) & I did not want him to fall. The statement showed Staff D reported to the night shift nursing assistant and registered nurse the resident was very confused, attempting to self-transfer, and needed to be watched closely. WAC reference: 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to prevent an accident by not following the care plan, which directed staff to use a cup with a lid for hot liquids, for one of four sample residents (#1), reviewed for accidents. This failure resulted in harm to the resident who sustained significant burns, after he spilled soup on his right hand, abdomen, and thigh. Findings included: Per a facility assessment dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The record further showed the [MEDICAL CONDITION] affected the right/dominant side of the resident's body. The assessment also showed the resident required set-up assistance with eating, and total, physical assistance with transferring. A review of the resident's current care plan showed he had a self-care performance deficit, as the result of his medical diagnoses. Interventions for eating included the use a cup with a lid for hot liquids. Per record review, the intervention was initiated on 02/06/17, after the resident received a minor burn from spilling coffee. A 07/30/18 facility investigation was reviewed. Per the investigation, on 07/30/18, the resident was in the main dining room eating hot soup from a cup, when he spilled it on himself. Per the investigation, the spill resulted in second [MEDICAL CONDITION](which causes the skin to blister and become extremely red and sore) to the resident's entire right hand, and thumb. The investigation also showed the resident sustained [REDACTED]. The root cause (i.e., reason for the accident), was listed on the report as weakness secondary to MS. A review of the food temperature log from the facility kitchen for 07/30/18, showed the temperature of the soup was 167 degrees at the time it was served. In an interview on 08/09/18 at 1:59 p.m., a family member stated that she had requested a full investigation into the incident, because of the seriousness of the burn. She further stated that the resident had been burned previously (more than a year and a half ago) at the facility, when he spilled a cup of coffee on himself, but the injury he sustained at that time was not nearly as significant as his current injury. During an interview and observation with the resident on 08/09/18 at 2:40 p.m., he stated that the burn to his hand was still painful. His right hand was wrapped in a white gauze bandage. The skin protruding from underneath the bandage was very red, and the resident stated that part of the blister on his hand had gone down. The resident stated he wished to continue eating his meals in the main dining room, where he had friends. Upon questioning, the resident stated he did not remember exactly what happened when he spilled the soup on himself, just the pain when it burned his skin. In an interview on 08/09/18 at 2:50 p.m., Staff A, Registered Nurse, stated that the resident had been weaker prior to the accident, because he had to stay in bed a lot more, to try and heal a pressure ulcer on his bottom. Per record review, there was no re-assessment of the resident's ability to feed himself, to include managing hot liquids, after he spent a prolonged period of time on bedrest. During an interview on 08/09/18 at 2:57 p.m., Staff B, Physical Therapist, stated that the resident had been bed bound for weeks prior to the burn incident, related to a pressure ulcer. She stated that a request for new therapies, to assist with strength building, had not been submitted until after the resident was burned. During an interview on 08/10/18 at 9:17 a.m., Staff C, Registered Nurse, stated that the resident did not have a lid on the cup he was drinking soup from at the time of the spill, as soup had not been considered a liquid. Staff D, Director of Nursing, was interviewed on 08/10/18 at 3:05 p.m. She stated that the soup did not have a lid on it at the time of the spill. Reference (WAC): 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure four of four sample residents (#3, 4, 5, 6), reviewed for range of motion (ROM), received consistent treatment and services to prevent a decline in range of motion. This failure resulted in harm to Resident #6, who developed worsening contractures (a deformity which prevents the movement of a joint through its normal range) in both knees, and placed other residents at risk for further declines in ROM. Findings included: 1. According to the quarterly facility assessment dated [DATE], Resident #6 had ROM impairment in one upper extremity and both lower extremities. The resident received Occupational Therapy (OT) from 06/27/17 until 07/07/17, and Physical Therapy (PT) from 04/27/17 until 05/24/17. The resident received Restorative Nursing Assistance (RA) for passive range of motion, during 4 days of the quarterly assessment observation period. The resident's 07/17/17 care plan for restorative services, directed restorative staff to provide a Functional Maintenance Program (a specific program of resident-specific exercises) 3 to 6 times per week (or from 12 to 24 days). The program included directions for specific stretching exercises for both hamstrings (knees), both hips, the right shoulder and hand, and for warm moist packs to the right shoulder and both legs. Review of restorative flow sheets for (MONTH) (YEAR) showed the resident received treatment on 11 of 31 days. Review of restorative flow sheets for (MONTH) (YEAR) (the first through the 19th) showed the resident received treatment on three of 19 days. During interview on 09/20/17 at 9:45 a.m., Staff I, Restorative Aide, stated the resident was evaluated by therapy services on 09/19/17 and 09/20/17, and was determined to have declines in ROM. During an interview on 09/20/17 at 11:15 a.m., Staff L, Restorative Registered Nurse, was asked if the resident received ROM by the nursing assistants who provide direct resident care. Staff L stated the resident's ROM was being provided by restorative staff, due to the resident's specific needs. During interview on 09/20/17 at 3:20 p.m., Staff J, Nursing Assistant, stated she consistently provided care for the resident. Staff J was asked if the resident's care needs had changed. Staff J stated the resident's contractures were tighter, and stated the resident had previously been able to transfer with staff assistance using a sit-to-stand lift (designed to help residents rise to a standing position without the need for manual lifting). Staff J stated currently, Resident #6 required a manual mechanical lift, because she could no longer straighten her legs. During observation of care with Staff J on 09/20/17 at 3:40 p.m., the resident was lying in bed on her left side, with the right arm bent at the elbow. She did not move her right arm, and her hips and knees were bent. Staff J transferred the resident using a mechanical lift. During the transfer, the resident did not move her right shoulder or elbow, and her hips and knees remained in a fixed position. On 09/27/17 at 2:15 p.m. Staff L, Restorative Registered Nurse, stated since admission, the resident had been back and forth between the sit-to-stand and mechanical lift, and nursing did not see a decline in the resident's condition. Collateral Contact 1 (CC1), Physical Therapist, was interviewed by telephone on 09/28/17 at 7:25 a.m. CC1 stated when the resident's therapy ended in (MONTH) (YEAR), the knee contractures had improved, and she could transfer with the sit-to-stand lift. Per the therapist, the resident's knee ROM continued to improve with consistent restorative ROM exercises. CC1 stated when Resident #6 was evaluated on 09/20/17, she showed worsening contractures in the knees, and could not stand in the sit-to-stand lift. CC2, Occupational Therapist, was also interviewed by telephone on 09/28/17 at 7:25 a.m. CC2 stated during evaluation on 09/19/17, the resident's tolerance to right shoulder ROM had declined, due to a lack of consistent ROM. She stated the resident required consistent staff assistance to stretch the right shoulder, due to pain, and existing contractures. 2. According to the facility quarterly assessment dated [DATE], Resident #3 had range of motion (ROM) impairment in both lower extremities. The resident received Restorative Nursing Assistance (RA) for active ROM, on 4 days during the assessment period. The 07/16/17 care plan for restorative services directed restorative staff to provide a Functional Maintenance Program (FMP) 3-6 times per week. The program included directions for specific upper and lower extremity strengthening, and ROM. In addition, the RA program directed staff to ensure repetitions of sit to stand transfers and ambulation in the parallel bars were completed, 3-6 times per week, or 12 to 24 days per month. Review of (MONTH) (YEAR) restorative flow sheets showed the resident received treatment 14 of 31 days. Review of restorative flow sheets for (MONTH) (YEAR) (from the first to the 19th) showed the resident had treatment on four of 19 days. During observation in the restorative gym on 09/20/17 at 1:00 p.m., the resident walked across the gym several times. During interview, Staff H, Restorative Aide, stated ambulation was a very important goal for the resident. Staff H estimated the resident would walk a total of 110 feet during the session. Staff H stated the resident had lost some strength, when he did not consistently receive restorative services. During interview on 09/27/17 at 2:15 p.m., Staff L, Restorative Registered Nurse, reviewed the resident's August/September (YEAR) restorative program flow sheets, and had no additional information related to the lack of consistent restorative services provided. 3. According to the facility quarterly assessment dated [DATE], Resident #4 had range of motion impairment in both lower extremities. The resident received Restorative Nursing Assistance (RA) for active ROM 4 days, and walking for 5 days, during the assessment period. The resident's 08/18/17 care plan for restorative services directed restorative staff to assist with sit to stand transfers, ambulation in the parallel bars, and exercises for ROM and strengthening, 3-6 times per week, or 12 to 24 days per month. In addition, the resident was to walk 200 feet twice daily, with a Nursing Assistant (NA). Review of restorative flow sheets for (MONTH) (YEAR) showed the resident received treatment 18 of 31 days. Review of restorative flow sheets for (MONTH) (YEAR) (through the 19th of the month) showed the resident had treatment five of 19 days. On 09/20/17 at 9:30 a.m., the resident was observed walking in the hallway outside his room with Staff G, NA. The resident stood from the wheelchair and walked approximately 35 feet, with Staff G holding onto a gait belt, and bringing the wheelchair behind the resident. After about 35 feet, the resident stopped, could not propel his legs forward, and was assisted into the wheelchair. During interview after the observation, Staff G stated the resident used to be able to walk the length of both hallways, but his strength had declined. During observation in the restorative gym on 09/20/17 at 10:45 a.m., the resident was able to walk the length of the parallel bars with 2 restorative aides present. On the second repetition, the resident could only walk half the length of the parallel bars, then could not support his weight on his feet, and was assisted into the wheelchair. On 09/27/17 at 2:15 p.m. Staff L, Restorative Registered Nurse, reviewed the resident's August/September (YEAR) restorative flow sheets, and had no additional information related to the lack of consistent restorative services provided. When asked about the resident's variable ambulation ability, Staff L stated the resident's energy level was variable related to his chronic, progressive movement disorder. 4. According to the facility quarterly assessment dated [DATE], Resident #5 had range of motion impairment in both upper extremities. The resident received Restorative Nursing Assistance (RA) for active ROM four days, and walking assistance one day, during the assessment period. The 09/15/17 care plan for restorative services directed restorative staff to assist with specific exercises for ROM and strengthening 3-6 times per week, or 12-24 days. In addition, the resident was to walk 100 feet twice daily, with a Nursing Assistant. Review of restorative flow sheets for (MONTH) (YEAR) showed the resident received treatment 10 of 31 days. Review of restorative flow sheets for (MONTH) (YEAR) (through the 19th) showed the resident received treatment three of 19 days. During interview on 09/20/17 at 9:30 a.m. Staff G, Nursing Assistant, stated she walked with the resident earlier in the morning. Staff G stated the resident was supposed to walk 100 feet, but walked 25 feet, stated he was tired, and wanted to go to bed. On 09/20/17 at 12:45 p.m., the resident was observed in the restorative gym performing upper and lower extremity exercises for ROM and strengthening. On 09/27/17 at 2:15 p.m. Staff L, Restorative Registered Nurse, reviewed the resident's August/September (YEAR) RA flow sheets, and had no additional information, related to the lack of consistent restorative services provided. When asked about the resident's ambulation ability, Staff L stated the resident's energy level was variable. (Refer to F353 for additional findings). Reference: WAC 388-97-1060 (3)(d)

Based on observation, interview, and record review, the facility failed to ensure 2 of 4 sampled residents were free from unjustified verbal/mental abuse (#4) and physical contact/restraint (#3) by direct care staff. This failure resulted in actual harm to resident #3, who had a broken finger, and the potential for causing psychological harm to both residents. Findings include: 1. Resident #3 had [DIAGNOSES REDACTED]. According to a quarterly assessment, dated 10/03/16, Resident #3 was severely cognitively impaired. He had delusions (a belief that is not true) and hallucinations (the apparant perception of something not present). He also had physical behavioral symptoms directed towards others, 4-6 days out of 7, and verbal behavioral symptoms directed towards others, 1-3 days out of 7, during the assessment look-back period. The resident was on an antipsychotic medication on a daily basis. Multiple observations of Resident #3 were made during the survey. He was sitting in his wheelchair in front of the nurses's station, either with his eyes closed or open, and slowly self-propelled down the hallway. His left hand was observed to have bruising from the knuckles, down the 3rd and 4th fingers. The two fingers were taped together to form a splint. Resident #4 opened his eyes when his name was called. He was asked, by the surveyor, what happened to his hand. He stated, A girl bit me, I was trying to break them up because they were fighting. Review of the progress notes revealed on 11/03/16 at 4:30 a.m., an x-ray was ordered for Resident #4's left hand, related to complaints of pain in the 4th finger. The progress note further stated the resident was restless, agitated, and combative with staff. The licensed nurse intervened, and grabbed the resident's hands to protect him from hurting anyone else. In an interview on 11/10/16 at 6:20 a.m., Staff C, Certified Nursing Assistant, stated, He (Resident #3) doesn't sleep at night. On 11/03/16 the resident was extremely agitated. He kept saying, They are after my money, they are trying to kill me because of the money. Staff C said they tried to keep him safe and reassure him that he was ok, but he was fixated on the money. The resident started to swing at them - the resident grabbed the arm of another aide, and that is when Staff E, Registered Nurse, started to pry the resident's fingers away from the other aide's arm. Staff C said Staff E didn't realize her own strength, she heard a bone crack, and the resident yelled, You broke my fingers. She was asked if she felt this was intentional. She stated, No, it was an accident. In an interview on 11/10/16 at 6:33 a.m., Staff F, Night Supervisor, stated the resident was restless, agitated, and combative. Staff C was sitting behind the resident at his head. The resident grabbed at Staff E's arm, and when she went to break his hold, she pulled back on his fingers. The resident immediately yelled, You broke my hand. Staff F was asked if she felt his finger was broken on purpose. She stated, No, I think it was an accident. She further stated, Staff E is an old school nurse and can be rough and gruff towards the residents and staff however, I don't think it was intentional. In an interview on 11/10/16 at 7:17 a.m., Staff E stated on that night, she and Staff D had gotten Resident #3 up, toileted him, and then put him in his wheelchair at the nurse's station. She said the resident kept going on and on about his money, and people killing him. He kept trying to get out of his chair, so Staff D and myself got on each side of him, to pull him up in the chair in a sling manner (one arm behind the back and another arm under the legs). He started to grab Staff D's arm, who then said, He is hurting me. Staff E said she pulled away, and then grabbed his hand, to release his grip on Staff D. She placed his hands on his chest, and told him, You can't hit. The resident then reached back to hit Staff C, so Staff E grabbed his hands and said, Stop it. He then hit her in the leg. When she saw his fist coming to hit her, Staff E said she reached up to block it, and instead of blocking his fist, I caught the last 2 fingers. I heard them pop but didn't think they were broken. She was asked if this was willful on her part. She stated no. In an interview on 11/10/16 at 9:17 a.m., Staff D, Certified Nursing Assistant, stated she felt Staff E used physical force to stop a demented resident from lashing out, when he was having behaviors. She stated she saw Staff E grab his fingers, and snap them back towards his chest. She was asked if this was intentional or an accident. Staff D stated she did not believe it was intentional however, Staff E used more force than was necessary in her opinion. Staff D stated at the time, the resident was safe, and she and Staff C were trying to redirect him. He continued to try to get out of his wheelchair, and was continuing to lash out, as he was upset about some money. She stated, Staff E did not need to get involved with the situation. When Staff E became involved, it escalated the resident's behaviors. In an interview with the facility Superintendent, on 11/10/16, he stated Staff E was an old school nurse, and a little rough around the edges. The Superintendent said her tone can be miscontrued as rough. He was asked if the facility internal investigation substantiated the abuse allegation. He stated the investigation was concluded, and it was determined Staff E did not intentionally mean to hurt the resident. 2. Resident #4 had [DIAGNOSES REDACTED]. According to the admission assessment, dated 10/20/16, the resident was moderately impaired in cognition. He was able to express himself to others without difficulty, and usually understood others when asked questions. The admission assessment further documented he required extensive assistance of one staff member for his toileting needs. During multiple observations, Resident #4 was observed sitting in his wheelchair, either in his room, the dining room, or hallway, talking with staff and other residents. He was alert, talkative, and smiled easily. In an interview with Resident #4, he was asked if he had experienced verbal abuse by any staff member. He stated a nurse assistant was a little bit smart with me. I was trying to explain to her how I wanted to be cleaned up after using the toilet but she wouldn't listen. The resident said, I will not be talked to or abused like that. He was asked if the staff member was currently taking care of him. He stated, I have mostly let it go now, and wouldn't even know her if I saw her. When asked what was it Staff A said to him that caused him to be so upset, he said she called me a liar. According to facility documentation, Staff A, Registered Nurse, reported an incident of rudeness on 10/25/16. Staff B, Certified Nursing Assistant, was sent home, and the resident was placed on alert charting (every shift charting for a specific problem) for mental anguish. An alert charting progress note, dated 10/26/16 at 5:40 a.m., revealed that at 11:30 p.m., the resident was found to be holding a long 2 shoe horn in his left hand and a ''reacher in his right hand (in a defensive position). The resident was heard to have said, .I heard someone in the room .Something not right .I have a 6th sense about these things, that is how I got out of Vietnam alive .I am going to be ready .Nobody's going to get me . Staff reassured the resident that he was safe. The resident then referenced the incident with Staff B and stated, She was rude to me and wouldn't help me in the bathroom. I can't wipe myself and stand too because I have had a stroke. In a telephone interview with Staff B, on 11/08/16 at 9:30 a.m., she was asked what occurred between you and Resident #4 on the night of 10/25/16. She stated, He (the resident) was in an argumentative state that night. The bathroom was where it all started. He had toileted himself and then put the call light on. I came in and put my gloves on to help him. That is when he started in on me. He kept going on and on about how he doesn't want to be in a nursing home but had to be because of the stroke. Staff B further stated, He went out (of his room) and told the nurse and complained about me not cleaning him up. I told him (the resident) not to lie to the nurse, you don't need to lie. She was asked what happened after the incident. She stated, the nurse called my name and I realized I had over stepped by boundries and I left. In an interview with Staff A, on 11/08/16 at 2:45 p.m., he was asked what happened between Resident #4 and Staff B, on the evening of 10/25/16. He stated the resident was in his wheelchair, and approached him at the nurse's desk. Staff A said the resident was calm, and not agitated at all. The resident told Staff A the girl who came to help him, he did not like her at all. At the same time, Staff B interjected herself into the conversation, and started to argue with the resident about what she did. He stated she didn't need to do that. I said her name to get her stop and she started to leave, when she was 10-15 feet away, she turned back around and stated, He is a liar. The facility Superintendent, in an interview on 11/08/16, was asked if the facility investigated and substantiated the verbal abuse by Staff B, and he said yes.

Based on observation, interview, and record review, the facility failed to ensure a thorough medical assessment was completed, to determine the appropriateness of moving a resident who fell , to prevent further injury, for 1 of 4 sample residents (#1), reviewed for falls, in a sample of 15. This failed practice resulted in actual harm to the resident, who fell and sustained a fracture. Findings include: Resident #1 was admitted to the facility in May 2015. His most recent quarterly assessment of 08/01/16 documented [DIAGNOSES REDACTED]. Per the assessment, the resident was cognitively intact, was independent with some activities of daily living, required supervision with toileting, and limited assistance with ambulation. The assessment further documented he had sustained 1 non-injury fall, and 1 injury fall since the last assessment. The resident's care plan, dated 05/04/15, documented the resident was a fall risk, and was on fall precautions. The goal, related to falls, was .will decrease number of falls or injury. The interventions for fall prevention included: frequent checks when the resident was in bed (initiated 08/11/15), instruct the resident to call for assistance when getting out of bed, a chair, or when wanting to ambulate, and reinforce instructions as needed (initiated 08/11/15). An intervention for wearing non-skid socks was added to the care plan on 07/11/16. A nursing progress note, dated 10/02/16 at 10:00 a.m., documented, .Aide reports hearing a 'thump' in resident's room. She entered (and) found him lying on right side, just ahead of w/c (wheelchair), next to his dresser. His right shoulder (and) right hip hurt .Assisted by staff up to his recliner .Right hip 'smarts' he reports now, if he starts to stand up .Resident to be placed on alert charting for injury fall .He refuses pain meds now .MD (medical doctor) notified via log bk (book) and 24 hour report . A nursing progress note, dated 10/02/16 at 12:00 p.m documented, .Resident attempted four times to rise from recliner - severe pain prevents any transfer .MD has ordered resident to hospital for possible R. (right) hip fx (fracture) . A nursing progress note, dated 10/02/16 at 12:30 p.m., documented, .Resident given tylenol before departure . A Fall Scene Investigation Report, dated 10/02/16, documented the root cause of his fall was, Balance is poor. A hospital history and physical assessment and plan, dated 10/03/16 at 7:00 a.m., documented, .closed nondisplaced transverse fracture of right acetabulum (hip) .closed nondisplaced transverse fracture of left acetabulum (hip) .These fractures are minimally displaced and can be treated with wbat (weight bearing as tolerated) with assistive device. With this, possible displacement of the right side may occur .issue will be mostly pain managment .the left is minimally displaced, but will need to be watched as well . On 10/13/16 at 12:39 p.m., Staff R, a nursing assistant, was asked what occurred at the time the resident fell . She stated, I was in the room next door and heard a loud bang. I went into his room and noticed the curtains were closed. I opened the curtains and saw the resident on the floor next to his dresser. He had on his tennis shoes at the time and he told me he was going to stand up to urinate. I asked him if he was okay and he said, 'I'm in a lot of pain' in his leg. I grabbed another aide and yelled for the nurse. She further stated, The nurse asked him if he was in pain and he said, 'my leg.' hurt. We sat him up, applied the gait belt and lifted him physically into his recliner. I kept going back to check on him as he was in so much pain. On 10/1/16 at 1:00 p.m., the resident was observed lying in bed, eyes closed. He easily awakened to verbal stimulation. He was asked what happened the day he fell . He stated, I was standing up to use the urinal, then down I went, no warning. On 10/13/16 at 1:10 p.m., Staff S, a nurse, was asked what assessment and interventions were done, to ensure resident safety after the fall. She stated, I assessed him by checking his strength, grip on his arms, then gently turned him over to check to see if there was any bony protrusions. There was absolutely nothing to see. Several of us assisted him into his recliner which was very close. Once he was in the recliner I did not see any bumps, bruises, or gashes. He was not screaming in pain. I took vital signs which is our policy and shortly afterwards I gave him Tylenol. She further stated, It hurt some but, looked like it was a non-injury fall. I put it on the log book for the physician. She was asked how often do the physicians look at the log book. She stated, once a day. She was asked when did she notify the physician by phone. She stated, It was about 3 hours later. A review of the care plan, for updated interventions after the resident returned from the hospital, did not contain interventions after the fall to include transfer assistance, assistive devices, or interventions to prevent further falls. On 10/13/16 at 2:55 p.m., Staff K, interim Director of Nursing, was asked what the facility policy was regarding a resident who has fallen with potential injury. He stated, If a nurse aide or any staff observes a fall, they are to go and get the licensed nurse who will do an assessment. This would include neuro (neurological) checks, range of motion, skin checks then get the resident up. He was asked what was the policy if a resident told the licensed nurse they were in pain while on the ground. Staff L, the Administrator stated, Stabilize the injury and call EMS (ambulance). The Administrator and interim Director of Nursing reviewed the facility policy on fall management. They confirmed this direction was not in their policy. On 10/14/16 at 10:54 a.m., Staff H, Resident Care Manager, was asked if there was a policy regarding what was to be done after a resident sustained [REDACTED]. She stated, I don't think there is a policy, however, standard nursing practice would be if the resident was on the floor and complained of leg pain, you don't move them, call the ambulance, and transfer to the hospital. She further stated, He should have never been moved. She was asked what were the updated interventions on the care plan, since Resident #1's return from the hospital. She stated, He is more dependent now. He is not getting up on his own anymore. He transfers with one person. She was asked if the current care plan was still applicable. She stated, Yes, it was. He still needs to ask for assistance to get up.

Based on observation, interview, and record review, the facility failed to ensure the correct medications were administered to 1 of 9 sample residents (#2). The failed practiced resulted in a significant medication error and actual harm to the resident, who required hospitalization . Findings include: Resident #2 had [DIAGNOSES REDACTED]. According to the record, the resident had some cognitive impairment and required assistance with activities of daily living and medications. Per record review, on 10/15/14, the resident became non-responsive after being given medications prescribed for another resident. The resident was transported to the hospital for further evaluation and treatment. According to the facility investigation of the incident, Licensed Nurse #A poured medications for Resident #2, then discovered she was in the shower. The medication cup containing Resident #2's medications was labeled and placed in the medication cart for later administration. Licensed Nurse #A then poured medications for Resident #1, who was also unavailable when she tried to administer them. Resident #1's medications were also labeled and placed in the cart with those belonging to Resident #2. When Resident #2's shower was completed, Licensed Nurse #A retrieved Resident #1's medications from the cart, and administered them to Resident #2 without checking the label. Licensed Nurse #A was not aware of the error until Resident #2 became non-responsive and Resident #1's medications were noted to be missing from the cart. A total of seven medications prescribed for Resident #1 were inadvertently administered to Resident #2. The medications included an antipsychotic, an antidepressant, and a medication to treat movement disorders. Two of the medications had side effects that included sedation and altered mental status - none of the medications administered were prescribed for Resident #2. According to hospital records, the resident was treated for [REDACTED]. The resident was ready for discharge on the fourth day, but remained hospitalized for [REDACTED]. On 10/21/14 at 2:00 p.m., the resident and her family were interviewed in her room. The resident had multiple bruises on both arms consistent with blood draws and intravenous fluid administration while in the hospital. The resident stated, "I got the wrong pills and ended up in the hospital." A family member visiting the resident stated, "We thought she was going to die." When interviewed on 10/21/14 at 2:45 p.m., an administrative nurse stated that by not matching the medications to the resident, Licensed Nurse #A violated both the facility's medication administration policy and professional nursing standards. The facility's failure to ensure medications were administered correctly resulted in harm to Resident #2, who was hospitalized due to complications associated with the medication error.