Every finding on record at Stafholt Health and Rehabilitation of Cascadia

Based on observation, interview, and record review, the facility failed to ensure care, services and documentation that addressed skin integrity issues were provided in accordance with professional standards of practice for 3 of 4 residents (Residents 1, 2, and 6), reviewed for quality of care. The failure to consistently conduct skin evaluations to include assessing monitoring and necessary treatment This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Non-Pressure Wound Treatment, reviewed on 10/08/2024. The policy documented that a wound assessment is completed at least weekly and as clinically indicated, based on wound status and resident condition. The facility may determine the specific documentation tools or formats used to record wound characteristics, progress, and treatment, provided they are consistent with professional standards of practice, support clinical decision-making, and meet Center for Medicaid and Medicare Services documentation requirements. The documentation should reflect, if applicable:a. Wound type and etiology,b. Location, size, depth, and tissue type,c. Drainage characteristics and signs of infection,d. Pain assessment and peri wound condition, ande. Resident response to treatment and any changes in care plan. <RESIDENT 1>Resident 1 admitted to the facility on [DATE] with a diagnosis to include pneumonia and weakness. Review of the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 04/29/2026, documented the resident was independent with wheelchair (w/c) mobility. Review of a Skin Assessment Evaluation, dated 03/25/2026, documented Resident 1 developed a 0.5 centimeter (cm) by 0.5 cm open area to their right outer ankle. Review of Resident 1's alteration in skin care plan documented under the focus that resident had an open area to the outer right ankle related to continued bumping on the wheel of the w/c dated 03/25/2026. An intervention included treatment to the right ankle as ordered by the provider and a weekly skin/nail assessment. Review of Resident 1's progress note, dated 03/26/2026, documented Resident 1 developed a right outer ankle wound related to the resident's fragile skin and repeated contact with their w/c wheel. Review of Resident 1's Medication Administration Record, from 03/26/2026 to 05/30/2026, documented a physician ordered treatment and dressing change to the resident's right outer ankle to be done three times a week. Review of a Skin Assessment Evaluation, dated 03/28/2026 and 04/07/2026, documented Resident 1's right outer ankle wound was open, had no drainage, and no change in the size of the wound. There were no documented measurements of the ankle wound. Review of a Skin Assessment Evaluation, dated 04/11/2026 and 04/18/2026, documented Resident 1 had a previously open area to their right outer ankle. There was no documentation of the size or description of the right ankle wound appearance to assess if there had been any improvement or deterioration of the wound. Review of a Skin Assessment Evaluation, dated 04/28/2026 (10 days after the last Skin Assessment Evaluation) and 05/02/2026, documented Resident 1 had intact skin and no open areas. Review of a Skin Assessment Evaluation, dated 05/08/2026, Resident 1's right ankle wound was not mentioned in the assessment. Review of a Skin Assessment Evaluation dated 05/12/2026, 05/19/2026 and 05/26/2026, documented Resident 1 had a previous wound to their right ankle. There was no documentation of the size or description of the right ankle wound appearance to assess if there had been any improvement or deterioration of the wound. In an interview on 08/27/2026 at 11:07 AM, Staff E, Registered Nurse, stated residents skin was monitored weekly and there was a weekly skin inspection form in the computer to document if the resident had an open wound, bruise, etc. If a wound deteriorates, the provider is notified. In an interview on 08/28/226 at 7:43 AM, Staff F, RN, stated residents bruises, surgical incisions, skin tears and wounds were measured with the weekly skin inspections. On 08/28/2026 at 1:46 PM, Staff B, Chief Nursing Officer, and Staff C Licensed Practical Nurse/Resident Care Manager, were interviewed. Staff B and Staff C were asked regarding the incomplete skin assessments of Resident 1's right outer ankle open area. The skin assessment did not address the size, characteristics of the wound appearance, and if there had been any improvement or deterioration of the right ankle wound. Staff B stated they had educated the LN's wound documentation in June 2026. No other information was provided regarding Resident 1's skin assessments. <RESIDENT 2>Resident 2 admitted to the facility with a broken right ankle (specifically where the inner and outer bony bumps of the ankle were broken). Review of admission physician orders, dated 05/21/2026, documented to keep Resident 2's right lower extremity splint in place until their follow up visit in two weeks. Review of Resident 2's skin care plan, dated 05/21/2026, documented the resident had a surgical incision to the right lower extremity with the goal the surgical incision will resolve without complications. Staff were directed to follow the physician orders for skin care and treatment. Review of Resident 2's orthopedic surgeon visit, dated 05/29/2026, documented the physician removed the resident's splint and there were fractured blisters (fluid filled bubbles that form on the skin directly over a broken bone) over the lateral (relating to the side) incision and on the medial malleolus (the bony bump on the inner side of the ankle). Review of Resident 2's physician order, dated 05/31/2026, documented the resident to always have a removable Control Motion Ankle boot (a walking boot to help immobilize, protect, and support the ankle during healing) on their right lower extremity on except for hygiene, bathing, and skin checks twice a day. Review of a skin inspection evaluation, dated 06/05/2026, documented Resident 2's right heel was macerated (the skin becomes soft, wrinkly and discolored), the right lower leg was weeping, and the right medial (inner side of foot) foot had raw skin with one black spot. There was no documentation describing why or what part of the right lower leg was weeping, the size or what part of the inner foot had a black spot or mention of the fractured blisters observed by the orthopedic surgeon. Review of Resident 2's skin care plan documented on 06/05/2026 the care plan was updated to reflect their right heel macerated with no open areas. The resident goals or interventions have not been updated to reflect the new skin impairment. Review of a note dated 06/09/2026, documented photographs were taken of Resident 2's fractured blisters which have ruptured and there was dry, flaky skin present. New treatment orders were obtained. Review of a skin inspection evaluation, dated 06/13/2026 and 06/18/2026, documented Resident 2's right heel was macerated, and the right medial foot has raw skin with one black spot. There was no other documentation describing the size or what part of the inner foot had a black spot. Review of a progress note, dated 06/19/2026 at 1:01 PM, Staff C documented Resident 2's right ankle surgical incision had dehisced (the splitting open, bursting, or splitting long the seam of the surgical incision) with slough (a layer of dead tissue present that delays healing) present in the wound bed. There was no documented size of the area of the wound that had dehisced. The resident had been discharged from the facility as planned at 2:15 PM. On 08/28/2026 at 12:08 PM, Staff B and Staff C were interviewed. Both staff were asked regarding the LN's assessment documented of the Resident 2's skin inspection evaluations. Asked regarding the skin assessment dated [DATE] describing the resident's right lower leg was weeping, and the medial aspect of the right foot was raw with one black spot. Staff B and Staff C could not state what part of the resident's leg was weeping, and where the location and measurement of the black spot was on the right medial aspect of their foot based on the completed assessment. Staff C was asked if there were any measurements of the dehisced right ankle incision documented. Staff C replied, no. <RESIDENT 6>Resident 6 was a long-term care resident who received end of life services. Review of the Quarterly MDS assessment, dated 05/13/2026, documented the resident required substantial assistance for bed mobility. Review of Resident 6's skin inspection, dated 07/31/2026 documented the resident had no new skin issues. Review of Resident 6's potential for skin integrity documented the resident had a ruptured blister to their left medial heel, dated 08/03/2026. Interventions included applying skin prep to their heels twice daily, and a weekly Licensed Nurse (LN) skin assessment. Review of a progress note, dated 08/04/2026, documented Resident 6 had a 2 cm (length) by 3.5 cm (width) skin issue on their left heel. Redness surrounded the skin issue and there was no drainage. The LN obtained a new treatment order and placed the resident on alert charting to monitor the new skin issue. Review of a skin inspection, dated 08/04/2026, documented Resident 6 had a ruptured blister to their left medial heel. Review of a skin inspection, dated 08/14/2026 (ten days after the last skin inspection), documented Resident 6 had a ruptured blister to the left medial heel with no open areas. There was no other documentation describing the size of the ruptured blister. Review of a skin inspection dated 08/21/2026, documented Resident 6's had a previous blister to their left heel which continued to improve. There was no other documentation describing the size of the ruptured blister. On 08/28/226 at 8:50 AM, Resident 6's left heel was observed with Staff E. Staff E raised Resident 6's left lower leg slightly off the bed and a oval shaped skin impairment was observed on their left inner heel. Resident E approximated the size of the skin impairment to be 3.5 to 4 cm in length and 1.5 cm wide. In an interview on 08/28/2026 at 9:05 AM, Staff C was asked if Resident 6 had any additional left heel skin impairment measurements besides the original measurements. Staff C stated they would look in Resident 6's medical record for additional information. Refer to WAC 388-97-1060(1), (3)(b)

Based on interview and record review, the facility failed to ensure that resident-identifiable information was not given or shared with the public for 1 of 1 sampled resident (Resident 3) reviewed for safeguarding a resident's personal health information. The facility failed to ensure Resident 3's medical information was emailed to someone not related to Resident 3 regarding their behavior. This failure placed residents at risk for their personal medical information being shared with an unauthorized person. Findings included. Review of the facility policy titled, Confidentiality & Information Security, revised on 10/15/2022, documented employees shall not disclose confidential medical or personal information pertaining to Facility's resident without the express written consent of the resident or appropriate legal representative. Review of a Complaint Resolution Report received on 07/21/2026 documented Resident 3's confidential information was emailed to Collateral Contact 1 (CC1), a member of the public. The email documented Resident 3's behavior monitors reflected they had no behaviors, the resident was receiving good sleep at night with daytime napping, and no documented nightmares. The email also identified that Resident 3's cognitive and behavioral assessments were performed by an identified provider. In an interview on 08/28/2026 at 11:20 AM, Staff 4, Social Service Manager, located the email sent to CC1 regarding Resident 3's confidential medical information. Staff 4 stated this email was meant for another person regarding Resident 3's behaviors. Refer to WAC 388-97-1720 (1)(a)(b)

Based on interview and record review the facility failed to provide 1 of 3 residents (Resident 1) timely services and treatment for symptoms of a urinary tract infection (UTI) which met the criteria of current standards of practice and the facility's policy. This failed practice caused Resident 1 to experience a delay in treatment of a UTI and placed the resident at risk for diminished quality of life.Findings included. Review of the facility's policy titled, Prevention and Treatment of Urinary Tract Infection (UTI), revised on 01/25/2026, included the following:- The physician would be notified and orders obtained for appropriate laboratory work,- Loeb Criteria (a standardized set of clinical signs and symptoms used in long-term care and nursing homes to guide the safe initiation of antibiotics) was used as the minimum criteria for initiating antibiotics for an indication of urinary tract infection for residents with no indwelling urinary catheters:One of the Following: Acute dysuria (pain or discomfort when urinating) OR Fever (Temp >37.9C/100 F or 1.5C/2.4 F above baseline) PLUS One or more of the following: Urinary urgency, Suprapubic pain, Urinary incontinence, Urinary frequency, Gross hematuria (blood in the urine), or Costovertebral angle tenderness (pain between the 12th rib and the spine),- Notify the resident (if appropriate) and family/responsible party and update the care plan. Resident 1 was admitted to the facility on [DATE] with diagnosis to include unspecified urinary incontinence. Review the Resident 1's Minimum Data Set (MDS- an assessment tool) assessment, reference date 02/03/2026, showed the resident had a UTI in the last 30 days, was frequently incontinent of urine and was dependent with toilet hygiene. Review of Resident 1's focused care plan problem of baseline mixed incontinence of urine dated 02/12/2026, showed the following interventions:- Monitor/record/report to provider signs and symptoms of a UTI: pain, burning, urine, cloudiness,- Routine Toileting: Toilet with AM & PM cares, before meals and as needed,- Personal Peri care after each incontinent episode and- Utilize incontinent products, check and change when soiled. Review of Resident's March 2026 Nursing Assistant documentation showed Resident 1 was incontinent of bladder on 50 occurrences from 03/01/2026 through 03/25/2026. Review of Resident 1's Health Status Note dated 03/24/2026 at 9:56 PM, showed Resident 1 complained of burning and frequent urge with urination. The resident was encouraged to increase water and cranberry intake as tolerated. Resident 1 was placed on alert to monitor for any additional signs and symptoms of a UTI. Review of Resident 1's Health Status Note dated 03/25/2026 at 6:36 AM, showed Resident 1 complained of frequent urge and burning sensation with urination. Review of the State Agency complaint dated 04/02/2026, Resident 1's Collateral Contact (CC) 1, reported Resident 1's absorbent briefs were not changed very often, and Resident 1 was discharged home from the facility with a UTI. In an interview on 04/29/2026 at 2:05 PM, Staff A, Registered Nurse (RN), stated if a resident had one symptom of a UTI they would monitor the resident, place them on alert charting and encourage hydration. Staff 1 stated if the resident had two symptoms of a UTI, they would need to do something, place the resident on alert, let the provider know and manage any pain. Staff 1 confirmed the staff's actions would be documented in the resident's progress notes. Staff 1 stated the facility's Infection Preventionist would be notified as well at the resident's Resident Care Manager (RCM). In an interview on 04/29/2026 at 2:11 PM, Staff B, Licensed Practical Nurse (LPN), stated if a resident had two symptoms of a UTI they would call the provider. Staff B stated they usually would make a note about it and place the resident on alert for UTI symptoms. Staff B stated the RCM and Director of Nursing Services would know as they can see the alert notes, the alerts will trigger the electronic medical record so they can see the resident's charting. In an interview on 04/29/2026 at 2:22 PM, Staff C, RN, stated they would place a resident with symptoms of a UTI on alert. Staff C stated if a resident had two to three symptoms they would notify the provider of a possible UTI. Staff C confirmed they would chart what was done in the residents' progress notes. In an interview on 04/29/2026 at 2:35 PM, Staff D, RN/Infection Preventionist, stated as the facility's IP, they check to see if the LOABs criteria were met for symptoms of UTIs. Staff D stated they check to see if evidence base use of antibiotics are followed. Staff D stated they try to match up the LOABs criteria, try to start early once a culture is obtained to make sure treatment was correct. Staff D stated they might have a resident with reoccurring UTIs which they discuss in QAPI, review causative factors and possible non-antibiotic options, like the use of estrogen cream. Staff D stated once a prescription treatment was ordered they would follow McGeer's criteria, they would complete a 48 hour follow up to check to see if symptoms are any better. Staff D stated on the facility's line listing HUTI is coded for facility acquired and UTI code is used when a resident had a UTI on admit. Staff D stated they review the 24-hour nursing report to see if anyone was on alert, review resident labs and review resident infection evaluations. Staff D stated in the facility's electronic medical record there was an antimicrobial follow up and an infection evaluation. In an interview on 04/29/2026 at 3:17 PM, Staff E, LPN, stated they would assess a resident with one symptom of a UTI and place the resident on alert, once the resident had two symptoms of a UTI they would call the provider, place the resident on alert, assess and monitor the resident's vital signs. Staffe E confirmed all the nursing interventions would be documented in the resident's progress notes. In an interview on 04/29/2026 at 3:23 PM, Staff F, LPN, RCM, stated if a resident had one symptom of a UTI, they would be placed on alert, and the provider would be notified to cover our bases. Staff F stated if a resident had two symptoms of a UTI, they would be placed on alert, and the provider would be notified. Staff F stated if the resident had three UTI symptoms they would ask the provider for a urine culture. Staff F confirmed they would document all interventions in the resident's progress notes. Staff F stated the nursing assistants should do peri care every two hours and as needed maybe before or after meals, upon wakening and going to bed. Staff F stated the facility had started using a new software program to communicate with the providers. Staff F stated there was no note to Resident 1's provider about their UTI symptoms. In an interview on 04/29/2026 at 4:15 PM Staff G, Nursing Assistant Certified (NAC), stated they remembered Resident 1 was continent and they always assisted them to the bathroom. Staff G stated Resident1 always used an incontinent pull-up brief in the daytime and would wear a regular incontinent brief at night. In an interview on 04/29/2026 at 4:25 PM, Staff H, NAC, stated they would look at the Kardex to know if the resident was on a toileting plan and so far, the facility had enough available briefs. Staff H stated that they always wash the resident's personal area from front to back with wipes, but not with a wash basin. Staff H stated they make sure to always change an incontinent brief even if it was just a little bit wet as it smells and it could cause the resident to get a UTI. In an interview on 04/29/2026 at 4:54 PM, Staff I, NAC, stated when they take a resident to the bathroom after wiping the resident with a wipe while they sit on the toilet, they then have the resident stand and assist the resident to wipe the resident front to back. Staff I stated they changed residents incontinent brief on dayshift in the morning, would ask in the afternoon if they needed a brief change or if the resident was alert and oriented, they would tell us if they wanted to be changed. In a phone interview on 04/30/2026 at 11:16, CC 2 stated Resident 1 got UTIs a couple of times before their stay at the facility, but Resident 1 got a UTI at the end of their stay at the facility and it lasted longer, it was a bacterial infection. In a phone interview on 04/30/2026 at 11:51 AM, CC 3, community home care agency staff member, stated the agency was not notified by the facility of the resident's symptoms of a UTI. CC 3 stated Resident 1 was admitted to their services on 03/31/2026, at which time the resident had symptoms of a UTI, and the agency followed up to initiate care for the resident with the resident's provider at that time. Reference WAC 388-97-1060 (1)(3)

Based on interview and record review the facility failed to ensure pharmaceutical services included processes for the provision, monitoring and/or use of medication related to devices involving 1 of 1 resident (Resident 2) reviewed for anticoagulant (blood thinning) medications. Failure to perform quality control testing on test meters had the potential to result in inaccurate measurement of therapeutic drug levels. Findings included . Review of the Coag-Sense Professional User Guide copyright 2023 documented directions for use for control testing of Protime/INR (measure to determine therapeutic levels of anticoagulant medication) meters stated there were 2 Low Control Strips, 2 High Control Strips and a Control Activation Solution shipped with each test strip kit. Controls should be tested immediately upon receipt of each new lot number. The user guide provided instruction on how to perform testing and interpretation of the results to determine if the meter was providing accurate results. Resident 2 was admitted [DATE] and returned to the hospital on [DATE]. The resident re-admitted on [DATE] and returned to the hospital on [DATE]. The resident had orders for Warfarin (anticoagulant medication to prevent blood clots) which is monitored by Protime/INR testing with a therapeutic target goal range. Resident 2 had an INR goal range of 2-3. Resident 2 INR results during their stay showed: 02/12/2026 INR High 3.2 with orders to hold anticoagulant medication. 02/13/2026 INR Low 1.5 with orders to resume anticoagulant medication. 02/18/2026 INR Low 1.7 orders to increase anticoagulant medication dose.03/12/2026 INR High at 3.2 Hold anticoagulant medication 03/13/2026 INR 3.0 Resume anticoagulant medication 03/20/2026 INR Critical High 5.3 Anticoagulant held. Resident 2 had symptoms of bleeding and was sent to the emergency department and admitted . In an interview and observation on 03/30/2026 at 12:50 PM, Staff C stated the facility checked INRs within 24 hours of admission. Staff C stated the facility did their own INR testing in the facility and tracked the results on a flowsheet for each resident. An observation of the flowsheet for Resident 2 showed it was incomplete, staff C acknowledged it was missing several of the INR tests done while the resident was in the facility. Staff C was present for an observation of the testing supplies in the facility medication room, where Staff C stated there was just one INR meter for the facility and it was in a zippered canvas case. The case included the coag-sense meter and test strips sealed in thick packaging which included lot numbers and expiration dates. Staff C was observed to remove a large box labeled coag-sense test strips from the cupboard which was opened and not full. The box confirmed the supply counts as stated in the professional users manual stating there were 2 High and 2 Low control strips sent in each box as well as control solution. The lot numbers on box were observed to match the lot numbers on the test strips inside the box and the strips that were inside the canvas meter case. Staff C stated the meters were control tested each time a new box was opened. Staff C stated there was no process for documenting control testing suggesting that staff might sign the box. There was no such signature observed on the box. It was observed that there were 2 High and 2 Low control strip packages unopened still remaining in the box which matched the lot numbers on the side of the box. Staff C was asked if this would indicate that the control testing for this box of strips had not been done, and Staff C stated that is what that would mean. Staff C was asked how the facility would know if results obtained were accurate if the control checks had not been done and Staff C stated they did not know. Staff C stated there were currently no residents in the facility receiving warfarin, and Resident 2 had been the only recent resident with warfarin ordered. Staff C confirmed these strips had been in use during the time Resident 2 was in the facility receiving INR checks. In an interview on 04/01/2026 at 4:00 PM, Staff B, Director of Nursing stated there had not been a system to document the quality control checks on the INR meter and stated they were implementing a tracking system. Staff B stated the expectation was the quality control tests were conducted when a new box of strips was opened and documented. Refer to WAC 388-97-1300(1)(b)(ii)

Based on observation, interview and record review the facility failed to ensure adequate pain management was provided for 1 of 3 residents (Resident 1) reviewed for dental care. This failure had the potential to result in a decreased quality of life for Resident 1, who was experiencing dental pain. Findings included .Resident 1 admitted [DATE] and was a long-term care resident at the facility. In an observation and interview on 03/30/2026 at 10:40 AM, Resident 1 was in bed and stated they still had a sore tooth. Resident 1 opened their mouth to point out the left lower molar area. Resident 1 was observed to have many missing, broken teeth with silver colored prior dental work visible on many teeth. Resident 1 was observed to place her hand across their left lower jaw while speaking and hold it there. Resident 1 stated they had been to the dentist and was told they needed to see a doctor first before they could pull out their teeth. Resident 1 stated there was more than one bad tooth but one in particular that was hurting and was painful all the time. Resident 1 thinks all they got for tooth pain was Tylenol and stated it did not work very well. In an interview on 04/01/2026 at 2:11 PM, Staff D, Certified Nurse Aid, stated Resident 1 had to eat soft foods. Staff D stated Resident 1 said their tooth hurt all the time, had been for a while. Resident 1 could brush their own teeth and Resident 1 said the tooth hurt when it got touched. Record review on 04/01/2026 showed Resident 1 was experiencing tooth pain greater than 1 month. Record review of facility provider orders on 04/01/2026 showed orders for downgraded diet to softer textures on 03/08/2026 related to the resident's complaint of tooth pain and inability to chew foods. Resident 1 was seen by a dentist on 03/18/2026 related to tooth pain and orders included antibiotics for tooth infection (completed on 03/26/2026), with follow-up appointment pending for dental extractions (removals of affected teeth.)Review of the resident's most recent pain assessment showed it was completed in January of 2026 and did not include dental issues or pain. Review of the resident's care plan on 04/01/2026 showed a care plan problem related to arthritis pain, which had not been revised to include dental pain. Review of the resident's provider orders on 04/01/2026 showed orders for routine Tylenol (over the counter pain medication) three times per day routinely since November of 2025 related to difficulty walking. The provider orders also included Tylenol as needed every 6 hours for head and leg pain which was noted to have been administered 12 times in the month of March. Review of a provider's progress note and order dated 03/24/2026 documented the resident was complaining of continued tooth pain and an order was added for a topical medication to be applied to the gum area as needed for complaints of tooth pain. Review of the Resident's Medication Administration records on 04/01/2026 showed the topical medication had only been administered once since 03/24/2026. In an interview on 03/30/2026 at 3:13 PM, Staff C, Resident Care Manager, stated the resident's original dental appointment was in February but was delayed because they had gotten sick. The resident was not seen until March 18th and then needed a course of antibiotics. The medical clearance form had been completed, and the guardian was supposed to be setting up the next appointment. Staff C stated there was no date yet. Staff C stated the tooth was sore, which was the reason for the downgraded diet and stated there was a new order for topical medication. Staff C had not completed a new pain assessment for Resident 1 and was not aware that the new topical pain medication order had not been utilized. Reference WAC 388-97- 1060 (1)(2)

Based on interviews, observations and record review the facility failed to identify a fall hazard for 1 of 2 residents (Resident 3) reviewed for accidents and failed to secure the doors of the soiled utility room and janitor room on 1 of 2 halls (East Hall). These failures placed the residents at risk for accidents, access to hazardous items, and diminished quality of life.Findings included. <FALL HAZARD>Resident 3 admitted to the facility on [DATE] with diagnoses to include vision loss in both eyes, history of fall with fracture, and history of stroke. Resident 3 stated their vision loss was permanent and they were blind.In a review of Resident 3's care plan dated 03/19/2024 documented resident was at risk of falls related to history of falls and impaired mobility with a goal to remain free of falls. Interventions related to environment included placing personal items and assistive devices within reach.In an observation on 02/09/2026 at 12:03 PM and 02/10/2026 at 9:43 AM Resident 3's room had a recliner next to their bed. A power strip was positioned next to the right side of the recliner and plugged into the electrical socket located behind the recliner. A radio, which was sitting on Resident 3's over bed table was plugged into the power strip. The power cord to the radio ran across the front of the recliner, unsecured and posed a tripping hazard.In an interview on 02/12/2026 at 3:35 PM Staff N, Nursing Assistant Certified, stated Resident 3 was a fall risk and required standby assistance for care as they were blind. When asked about the power strip next to the recliner, Staff N stated they were not aware the cord was there and placed the cords behind Resident 3's recliner, eliminating the tripping hazard.In an interview on 2/13/2026 at 9:53 AM Staff O, Maintenance Director, stated that they were not aware Resident 3 had a power strip in their room and if they had known about the power strip, they would have attached it to the wall. Staff O stated they had removed the power strip from Resident 3's room.<JANITOR CLOSET/SOILED UTILITY ROOM>On 02/09/2026 at 9:56 AM observed the Janitor closet on the East Hall had a sign that read this door is to remain locked at all times, the door was observed to be unlocked. The closet, which had a keypad entry system, contained a bucket and mop with several bottles of chemicals on shelving to include bleach.On 02/09/2026 at 11:07 AM observed the soiled utility room on East Hall unlocked. The door had a keypad entry system.On 02/10/2026 at 9:28 AM the Janitor closet on the East Hall was unlocked and easily opened.In an interview on 02/10/2026 at 9:28 AM Staff D, Licensed Practical Nurse/Resident Care Manager stated the doors were secured by a keypad entry system which had been malfunctioning and maintenance was working to repair them. Reference WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure residents with personal funds/resident trust accounts had ready access to their accounts during weekends for 14 of 15 residents (Residents 3, 31, 34, 10, 39, 42, 43, 44, 48, 49, 50, 52, 61, 62) reviewed for trust fund accounts and failed to manage and account for the personal funds in an interest bearing account of 1 of 1 residents (Resident 3). These failures placed residents at risk of not having access to their accounts during non-banking hours, a decreased sense of autonomy and a diminished quality of life.<READY ACCESS TO FUNDS>Review of trust fund list provided by facility on 02/09/2026 at 11:22 AM, documented 15 residents had trust accounts and of those, 13 had funds available.In an interview on 02/12/2026 at 9:56 AM Staff C, Business Officer Manager, stated if a resident wanted to obtain funds on weekends there was 40 dollars kept in the nurse's cart. Staff C stated there was a locked box with the narcotics that contained 40 dollars in a plastic envelope and a resident statement to show available funds for each resident. Staff C stated they pulled the envelope and reconcile the cash box at the end of every month. When asked about Resident 3's trust account funds availability on weekends, Staff C stated they had funds and had handwritten in their available amount on the statement. Staff C stated they could not provide the statement because they were discarded. In an interview on 02/17/2026 at 9:01 AM, Staff F, Registered Nurse (RN), stated they had worked weekends. When asked about the process for residents to access their trust account funds during the weekend, Staff F stated they would contact a nurse manager, did not deal with any money, and was not aware of a locked box containing trust funds.In an interview on 02/17/2026 at 9:36 AM, Staff M, RN stated if a resident wanted funds from their trust account on the weekend, they would need to contact the on-call manager and let them know.In an interview on 02/17/2026 at 9:51 AM, Staff D, Licensed Practical Nurse/Resident Care Manager, stated they worked on-call on the weekends, had not had residents ask for funds on the weekends, and if requested would need to contact the administrator or director of nurses to gain access to funds. Staff D stated the nurses did not have access to a locked box containing trust funds.In an interview on 02/17/2026 at 12:20 PM Staff A, Administrator stated the expectation was for trust funds to be available to residents twenty-four hours a day, seven days a week.<MANAGEMENT OF FUNDS>Resident 3 admitted to the facility on [DATE] with diagnoses to include vision loss in both eyes, history of fall with fracture, and history of stroke. Resident 3 stated their vision loss was permanent, was blind, and was learning braille.Review of Resident 3's quarterly minimum data set (MDS-an assessment tool) dated 12/25/2025 documented their brief interview for mental status scored a 15 out of 15 indicating normal thinking and memory.In an interview on 02/12/2026 at 9:56 AM Staff C, Business Office Manager, stated the facility was the payee (a person appointed to manage personal funds) for Resident 3. Staff C stated they spoke with Resident 3 and explained to them the facility was going to be their payee and they would have personal needs allowance (PNA) every month. When asked how they provided information to Resident 3, Staff C stated they explained to them verbally and provided copies of their statements. Staff C stated they provided Resident 3 with their billing statements every month, around the 20th, and trust account statements quarterly. Staff C stated the facility received Resident 3's social security payments starting November 2025 as the payee. Staff C stated Resident 3 had not gotten any funds placed in their trust account and had their funds reserved in a different accounting system until they could get direct deposit of their social security.Review of the facility's trust fund ledger provided by the facility and dated 02/09/2026 showed Resident 3 had a zero balance in their trust fund.Review of Resident 3's billing statements from the facility documented a payment of $2832.00 was paid toward their bill on 11/03/2025 and 12/01/2025.Review of a transaction report dated 02/12/2026 documented Resident 3 paid $2726.22 on 11/01/2025 and 12/01/2025, contradictory to the billing statements.In an interview on 02/12/2026 at 10:42 AM Resident 3 stated they were unaware the facility had a trust account that held their PNA and did not recall any conversations with facility staff about it. In an interview on 02/12/2026 at 3:30 PM Staff A, Administrator stated Staff C handles the trust funds and billing. When asked about Resident 3's PNA and a zero balance in their trust account, Staff A stated they had just become aware of the issue and was being corrected that day.WAC Reference 388-97-0340.

Based on observations and interviews, the facility failed to ensure treatment carts and medication carts were locked for 2 of 3 medication carts (West and East medication carts) and 2 of 2 treatment carts (West and East treatment carts). These failures placed residents at risk for having access to treatment supplies and medication not prescribed to them, missing medication, and access to medication by unauthorized individuals. Findings included . Review of the facility's policy titled, Medication Storage and Labeling, dated 10/31/2025, stated that all medications must be stored in compliance with all regulations. Storage requirements included medications to be stored in locked compartments. <UNLOCKED WEST MEDICATION CART>In an observation on 02/09/2026 at 2:48 PM, the [NAME] medication cart was observed unlocked and unattended. Staff I, Infection Preventionist (IP)/Registered Nurse (RN), was observed at the [NAME] nursing station. Staff I returned to the [NAME] medication cart at 2:52 PM.<UNLOCKED EAST TREATMENT CART>In an observation on 02/10/2026 at 1:12 PM, the East treatment cart was observed unlocked and unattended. The treatment cart had prescribed Nystatin powders (antifungal medication), Jublia (antifungal medication), Diclofenac gel (topical pain medication), Clotrimazole/Betamethasone cream (antifungal medication), and wound supplies. Several facility staff walked by the East treatment cart while unlocked and unattended.In an interview on 02/10/2026 at 1:19 PM, Staff D, Resident Care Manager/Licensed Practical Nurse, stated that they did not know why the cart was unlocked and the expectation was to have treatment carts locked when unattended. Staff D locked the East treatment cart. <UNLOCKED EAST MEDICATION CART>In an observation on 02/11/2026 at 2:51 PM, the East medication cart was observed unlocked and unattended. Staff G, RN was observed in the East nurses' station office. Staff G returned to East medication cart and stated they left it unlocked when they went inside the nurses' station. Staff G locked the East medication cart. <UNLOCKED WEST TREATMENT CART>In an observation on 02/13/2026 at 12:39 PM, the [NAME] treatment cart was observed unlocked and unattended. Staff F, RN was observed on the [NAME] medication cart. Staff F acknowledged the [NAME] treatment cart was unlocked and then locked the cart. In an interview on 02/17/2026 at 12:00 PM, Staff B, Director of Nursing/RN, stated that the expectation is that medication and treatments carts are locked unless a nurse is present. Reference WAC 388-97-1300 (2)

Based on interview and record review, the facility failed to ensure the dietary/culinary manager (Staff J) had proper qualifications. This failure placed residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.Findings included . Review of the facility provided position description for dietary/culinary manager, dated 06/2018, showed staff were to have one or more of the following required: Certified Dietary Manager (CDM), Certified Food Protection Professional (CFPP) with the Dietary Manager's Association Dietetic Technician, Registered, with the Commission on Dietetic Registration of the American Dietetic Association; or, Certification with the American Culinary Federation In an interview on 02/09/2026 at 9:42 AM, Staff J, dietary/culinary manager, stated they had been hired in March of 2025. Staff J was requested to provide their dietary/culinary manager certificate. In a follow up interview on 02/11/2026 at 10:21 AM, Staff J stated they had not completed the training for their dietary/culinary manager certificate. In an interview on 02/17/2026 at 12:20 PM, Staff A, Administrator, stated they were aware Staff J had not completed the dietary course and the expectation was for Staff J to complete the program. Reference WAC: 388-97-1160(2)(3)

Based on interview and record review, the facility failed to ensure staff recognized and reported timely potential abuse allegations to the State Agency within 24 hours for 1 of 3 sampled residents (Resident 34) reviewed for abuse. This failure placed residents at risk for unidentified patterns of alleged violations and at risk for potential abuse. Findings included . According to the Nursing Home Guidelines, also known as the Purple Book, sixth edition, dated October 2015, documented, The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Review of the facility titled, Event Management & Reporting, dated 09/16/2025, documented that the nurse will notify the immediate supervisor, who will determine whether to escalate to the Director of Nursing (DNS) or Administrator. External notifications will include timely reporting to the appropriate authorities such as State Agency for incidents that meet reporting criteria. Review of the facility policy titled, Abuse, dated 09/04/2025, documented that all forms of abuse, including verbal, are strictly prohibited. Training for staff will include recognizing abuse and reviewing facility procedures and legal requirements for reporting suspected abuse. <RESIDENT 34> Resident 34 admitted to the facility on [DATE] with diagnoses to include vascular dementia and anxiety. In a record review of Resident 34's Minimum Data Set (an assessment tool), dated 01/14/2026, documented that verbal behavioral symptoms directed towards others occurred one to three days during the assessment period. In a record review of Resident 34's care plan, dated 02/08/2026, documented that Resident 34 had a potential mood problem related to their cognitive impairment and dementia. The care plan documented an unsuccessful medication reduction for Fluoxetine (antidepressant) and the medication was restarted on 10/25/2025. The care plan documented the Fluoxetine medication was restarted related to Resident 34 being verbally and physically aggressive, fixating on another resident and wandering. In a record review of Resident 34's progress notes, dated 02/05/2026 at 10:05 PM, Collateral Contact 2 (CC 2) documented that Resident 34 was seen due to undesirable behaviors impacting other residents. CC2 documented Resident 34 exhibited verbally aggressive and abusive behaviors toward the new resident in their room. CC 2 recommended starting Buspirone (anxiety medication) twice daily for anxiety to help calm Resident 34 down and to curb undesirable behaviors, poor boundaries, irritability and impulsivity. In a record review of Resident 34's progress notes, dated 02/04/2025 at 4:50 PM, Staff K, Social Services, documented that Resident 34 continued to be verbally aggressive towards others. In a record review of Resident 34's progress notes, dated 01/12/2026 at 8:54 PM, Staff L, Registered Nurse (RN), documented that Resident 34 was verbally aggressive towards other residents. In a record review of the incident reporting log from September 2025 through February 2026, no incident reports were documented on the log for Resident 34 pertaining to any abuse allegation. Previous 6 months of incident reports for Resident 34 was requested from Staff A, Administrator. On 02/13/2026, at 11:15 AM, an email was received from Staff A that stated they did not have any completed incident reports for Resident 34. In an interview on 02/10/2026 at 10:19 AM, CC 1, stated that Resident 34 has had issues with their roommate and especially other residents that had cognitive deficits. CC 1 stated that they moved Resident 34 to a private room as a result. In an interview on 02/10/2026, at 10:29 AM, Staff E, Resident Care Manager (RCM)/RN, stated that Resident 34 had sundowning behaviors (increased behaviors such as confusion, agitation, restlessness, that occur in people with dementia typically starting around dusk). Staff E stated that Resident 34 can have aggressive behaviors towards other residents and they were recently started on a new medication to help decrease behaviors. In an interview on 02/12/2026, at 2:19 PM, Staff E, RCM/RN, stated that there were no reports made for incidents involving Resident 34. In an interview on 02/13/2026, at 11:30 AM, Staff B, DNS/RN, stated that they would be investigating Resident 34's incidents and reporting to the state hotline. In a record review on 02/17/2026, at 10:00 AM, Staff B emailed a completed incident report for Resident 34 with a look back period of six months with an investigation and reported online to Residential Care Services. Reference: WAC 388-97-0640(5)(a)

Based on interview and record review, the facility failed to conduct a thorough investigation of potential abuse allegations for 1 of 3 residents (Resident 34) reviewed for abuse. This failure to initiate, conduct a thorough investigation, and correct actual or potential alleged violations left residents at risk for unidentified and/or repeated incidents of abuse and a decreased quality of life. Findings included . Review of the facility's policy titled, Abuse, dated 09/04/2025, stated that all forms of abuse, including verbal, are strictly prohibited. Review of the facility's policy titled, Event Management & Reporting, dated 09/16/2025, documented that a risk report will be completed per facility process of incident management. The policy documented that for incidents involving abuse to follow state-specific guidelines for reporting. According to the Nursing Home Guidelines, also known as the Purple Book, sixth edition, dated October 2015, documented that, All alleged incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. The Purple Book also documented, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment, personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences. The investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened, including the probable or reasonable cause. It should also allow the nursing home to determine if the allegations were true or not true. <RESIDENT 34>Resident 34 admitted to the facility on [DATE] with diagnoses to include vascular dementia and anxiety.In a record review of Resident 34's Minimum Data Set (an assessment tool), dated 01/14/2026, documented that verbal behavioral symptoms directed towards other occurred one to three days during the assessment period. In a record review of Resident 34's care plan, dated 02/08/2026, documented that Resident 34 had a potential mood problem related to their cognitive impairment and dementia. The care plan documented an unsuccessful medication reduction for Fluoxetine (antidepressant) and the medication was restarted on 10/25/2025. The care plan documented the Fluoxetine medication is related to Resident 34 being verbally and physically aggressive, fixating on another residents and wandering. In a record review of Resident 34's progress notes, dated 02/05/2026 at 10:05 PM, Collateral Contact 2 (CC 2) documented that Resident 34 was seen due to undesirable behaviors impacting other residents. CC2 documented Resident 34 exhibited verbally aggressive and abusive behaviors toward the new resident in his room. CC 2 recommended starting Buspirone (anxiety medication) twice daily for anxiety to help calm Resident 34 down and to curb undesirable behaviors, poor boundaries, irritability and impulsivity. In a record review of Resident 34's progress notes, on 02/04/2025 at 4:50 PM, Staff K, Social Services, documented that Resident 34 continued to be verbally aggressive towards others. In a record review of Resident 34's progress notes, on 01/12/2026 at 8:54 PM, Staff L, Registered Nurse (RN), documented that Resident 34 was verbally aggressive towards other residents. In a record review of the incident reporting log from September 2025 through February 2026, no incident reports were documented on the log for Resident 34 pertaining to any abuse allegations. Previous 6 months of incident reports for Resident 34 was requested from Staff A, Administrator. An email was received on 02/13/2026 at 11:15 AM, from Staff A that stated they did not have any completed incident reports for Resident 34. In an interview on 02/10/2026 at 10:19 AM, CC 1, stated that Resident 34 had issues with their roommate and especially other residents that have cognitive deficits. CC 1 stated that they moved Resident 34 to a private room as a result. In an interview on 02/10/2026 at 10:29 AM, Staff E, Resident Care Manager(RCM)/RN, stated that Resident 34 had sundowning behaviors (increased behaviors such as confusion, agitation, restlessness, that occur in people with dementia typically starting around dusk). Staff E stated that Resident 34 could have aggressive behaviors towards other residents and was recently started on a new medication to help decrease behaviors.In an interview on 02/12/2026 at 2:19 PM, Staff E, RCM/RN, stated that there were no incident reports for Resident 34. In an interview on 02/13/2026 at 11:30 AM, Staff B, Director of Nursing/RN, stated that they would be investigating Resident 34's incident's and reporting to the state hotline. Staff B stated that when the investigations were finished they would provided.In a record review on 02/17/2026 at 10:00 AM, Staff B emailed a completed incident report for Resident 34 including a look back period of six months with an investigation and reported online to Residential Care Services. According to the incident report there were four missed opportunities for investigations identified on 02/04/2026, 01/12/2026, 10/23/2025, and 07/07/2025.Reference WAC 388-97-0640(6)(a)(b)

Based on interview and record review the facility failed to ensure 2 of 3 residents (Residents 1 and 49) reviewed for quality of care received the necessary care and services in accordance with professional standards of practice to meet each resident's physical, mental and psychosocial needs. The facility failed to ensure that Resident 1 was appropriately assessed, monitored, and documented after returning from dialysis treatments and failed to set up and appropriately monitor Resident 49's side effects of an anticoagulant (blood thinner) medication. These failures placed the residents at risk for unrecognized or undetected medical complications and a decreased quality of life related to unmet care needs. Findings included .<RESIDENT 1>Resident 1 admitted to the facility on [DATE] with diagnoses to include dependence on renal dialysis (machine removes blood from the body, filters it through a dialyzer and returns the cleaned blood to the body), chronic kidney disease (long term condition in which kidneys gradually lose their ability to function properly), and congestive heart failure (long term condition in which the heart can't pump blood well enough to meet the body's needs).Review of Resident 1's provider orders showed they were to receive dialysis on Mondays, Wednesdays, Thursdays and Fridays at the kidney dialysis center. The facility was to collect the dialysis binder and complete the dialysis evaluation. Additionally, there was an order that showed staff were to check the shunt (a synthetic tube used to connect an artery to a vein) site for pain, redness, bleeding, swelling or non-functioning access site every hour for six hours.Review of Resident 1's Treatment Administration Record (TAR) dated February 2026 documented staff were to complete Part A of the dialysis communication record, print the document and send with the resident to the dialysis center. Additionally, staff were to verify that Part B of the dialysis communication record was returned with the resident and complete the dialysis evaluation upon their return. There was an order that documented staff were to check the shunt site for pain, redness, bleeding, swelling or non-functioning access site every hour for six hours, order initiated on 01/09/2026. There was only one box to document at 11:00 PM on Mondays, Wednesdays and Fridays that these checks had been completed, there was no documentation space available for Thursdays and no way to document the required six hourly assessments. Review of Resident 1's Medication Administration Records (MAR) dated February 2026 documented staff were to collect the dialysis binder and complete the dialysis evaluation every Monday, Wednesday, Thursday and Friday, which was initiated on 11/10/2025. Review of Resident 1's dialysis care plan documented staff were to check vital signs (blood pressure, heart rate, oxygen, respiration rate) after dialysis visits and validate the dialysis communication record returned to the facility with the resident. Additionally, there was an intervention to monitor the access site upon return from dialysis for bleeding, redness, swelling or non-functioning.Review of Resident 1's Dialysis communication binder that contained the dialysis evaluations from October 2025 until February 2026 showed Part A was completed by facility staff before the resident went to dialysis and Part B was completed by the dialysis staff prior to returning to the facility. There was no other place for facility staff to document an assessment or other information after the resident returned to the facility.In an interview on 02/17/2026 at 9:59 AM, Staff D, Resident Care Manager (RCM) stated after a resident returns from dialysis, their shunt site and vital signs should be monitored every hour for up to six hours. Staff D stated they input the orders in the TAR in a way that nurses would document vital signs, and site assessments every hour.In an interview on 02/17/2026 at 11:35 AM, Staff B, Director of Nurse Services (DNS), stated their expectation for dialysis monitoring after a resident returned to the facility would consist of vital signs, checking the dialysis site, and they were not sure if there was a specific time frame the resident should be monitored. Staff B stated they thought the facility nurses were filling out Part B on the dialysis communication record after the resident returned to the facility and stated there was no other dialysis communication form for additional documentation. Staff B verified that Resident 1's Part B of their dialysis communication records were completed by the dialysis staff. <RESIDENT 49>Resident 49 was admitted to the facility on [DATE] with diagnoses to include embolism (obstruction of an artery, typically by a clot of blood or air bubble) of left popliteal vein (knee joint) and acute embolism and thrombosis (formation of a blood clot in a blood vessel) of left femoral vein (thigh).Review of Resident 49's provider orders documented apixaban (blood thinner to treat and prevent blood clots) was ordered on 11/29/2023 to be administered twice daily related to their embolism and thrombosis.Review of Resident 49's MAR's, dated December 2025, January 2026 and February 2026, documented they had received apixaban since 11/29/2026 and there was no monitor in place to watch for and identify possible side effects of the medication.Review of Resident 49's TAR, dated December 2025, January 2026 and February 2026, showed there was no monitor in place to watch for and identify possible side effects of the medication.Review of Resident 49's anticoagulant care plan, initiated on 11/29/2023 by Staff D, RCM, documented they were at risk for abnormal bleeding due to anticoagulant use with an intervention to monitor/document/report to the provider any signs, or symptoms of bleeding such as bleeding gums, nose bleeds, or unusual bruising.In an interview on 2/17/2026 at 9:59 AM, Staff D, RCM, stated if a resident is on an anticoagulant medication, there should be a monitor set up in the TAR to monitor for the side effects of bruising, and bleeding and that it should be documented by the nurse every shift that they monitored for those side effects. Reference WAC: 388-97-1060(1)(4)

Based on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 1) received medically related social services assistance to understand their financial matters. This failed practice placed Resident 1 and other residents at risk of financial exploitation. Findings included .Resident 1 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder (a serious mental illness characterized by extreme mood swings) and cataracts with visual loss to both eyes. The Quarterly Minimum Data Set assessment dated [DATE] showed the resident was cognitively intact and had severely impaired vision, with no vision or sees only light, colors or shapes.Review of an online report sent to the Washington State Hotline dated 08/11/2025, documented a concern Resident 1 had not made a payment to the facility in over a year. The report noted Resident 1 had an individual, Collateral Contact (CC) 1, who assisted them with their finances. When the facility reached out to CC 1, they asked that they were not contacted about Resident 1's finances anymore. The report noted Resident 1 would become frustrated and emotional when their finances were brought up and would state the facility's payment was on its way.Review of Resident 1's administrative and clinical documentation from 04/29/2024 through 09/02/2025, found no documentation which showed the facility had assisted the resident to understand their facility charges or their financial matters.In an interview on 09/02/2025 at 3:07 PM, Staff A, Business Office Manager, stated they had asked CC 1 to provide Resident 1's last bank statements [SW1]. Staff A stated that CC 1 said they would fax Resident 1's bank statement but so far had not. Staff A stated Resident 1 wanted a full itemized bill for the past year. Staff A stated they told the resident it would be of interest for the resident to go to the bank with CC 1 and pay the resident's facility account balance. Staff A stated now the resident wanted an itemized statement sent to CC 1 along with a letter to CC 1 indicating the resident would need CC 1's assistance to go to the bank for the balance due on the resident's facility account. Staff A stated they had not worked with Social Services on Resident 1's financial matters. Staff A stated when CC 1 would not provide Resident 1's bank statements they were concerned there was no money in the resident's account.In an interview on 09/02/2025 at 4:17 PM, Staff B, Social Service Manager, stated they had not done much with Resident 1's financial matters. Staff B stated they had not assisted the resident with financial or legal matters as Resident 1 had not asked for assistance. Staff B stated they were aware of the resident's [JB2] [SW3] financial issues, but they were not in a place to understand the issues. Staff B stated they had not been involved in this situation as the BOM and Administrator were working on this. In an interview on 09/02/2025 at 4:31 PM, Resident 1 stated the problem was, I needed an itemized bill. The resident stated they knew their daily room rate was higher when they did not have a roommate, otherwise they did not recall the facility explaining an itemized room rate. Resident 1 stated they needed a copy of an itemized bill sent to CC 1, who helped them with their finances. Resident 1 stated they used to handle their finances in the past but did not handle them as well as they should have. Resident 1 stated they had hired someone to do their accounting but preferred not to reveal their name.In a follow-up interview on 09/04/2025 at 4:05 PM, Resident 1 stated they did not have an identification card. Resident 1 stated they called the Social Service's staff yesterday and they transferred them to the BOM. The resident stated the BOM tried to explain things to them, but the BOM was shouting, and they had to ask them to calm down. Resident 1 stated a facility staff member who no longer worked at the facility had told them they had Medicare A and B, and everything was okay. The resident stated, I do not recall who it exactly was, it was a long time ago, when they had first moved into the facility and they no longer worked at the facility. Resident 1 stated they had directed CC 1 to maintain $2000.00 in their bank account. The resident stated they had also directed CC 1 to pay for a field work loan they had, as well as to use some of their money for health issues for their pets and for food when CC 1 was not well. In discussion with Resident 1 of how the facility billed each resident a daily room rate which included the resident's meals, and services along with how long-term care Medicaid set an individual dollar amount which each individual with Medicaid paid the facility that was based on their income, referred to as a participation fee, Resident 1 stated, No one had explained the billing to them like that before. In an interview on 09/04/2025 at 5:00 PM, Staff C, Chief Nursing Officer, stated they had combed Resident 1's entire chart and did not find anything documented the facility had assisted the resident with understanding their financial matters. Reference WAC 388-97-0960 (1)

Based on observation, interview and record review, the facility failed to assess and implement resident centered pain intervention for one of four sampled residents (Resident 51) reviewed for pain. This failure placed residents at risk for unrelieved pain, lack of participation in therapy and a decreased quality of life. Findings included . Resident 51 admitted [DATE] with diagnoses which included strokes and history of falls, and a hospital acquired pressure ulcer of the sacrum. Review of Resident 51's Admission Minimum Data Set (MDS, a required assessment tool) showed the resident had cognitive impairment. The MDS showed the resident's pain was rated by resident interview and the resident response was that their pain was occasional, and the numeric rating was 9 on a scale of 0 through 10, with 10 being the highest. The MDS stated the resident had a non- stageable pressure ulcer. Review of Resident 51's most recent pain assessment dated [DATE] utilized the non-verbal pain scale and rated the resident's pain at a 5. The assessment documented the resident's pain goal was a 2, stated the resident had pain all the time, exhibited pain by moaning, grunting, wrinkled brow, rubbing body parts, frowning, grimacing, rocking and pounding. The pain assessment stated the cause of the pain was not able to determine. The assessment identified the pain locations as back and wound. Review of Resident 51's care plan for pain management dated 01/13/2025 documented Resident 51 had the potential for pain related to pneumococcal arthritis, hernia, history of pain the left knee and sacral wound. The goal was that Resident 51 would express an acceptable level of pain either verbally or non-verbally. The interventions included to administer medications as ordered by the provider and to monitor and document effectiveness and side effects. Review of Resident 51's physician's orders documented orders for Suboxone (a combination pain medication) twice per day routinely, and Tylenol three times per day routinely. Review of the current Medication Administration Record on 03/24/2025 showed Resident 51 had a pain monitor three times per day (each shift) and the resident's pain was frequently documented as 0. There were 11 instances the pain rating was higher than 2 (the resident's stated goal). In an interview on 03/18/25 at 1:52 PM, CC1, Family member of Resident 51 stated there was a problem with controlling the pain, stating it had been hell, and they come to visit and sometimes Resident 51 is in agony, and expressed frustration with some changes to medication. CC1 stated Resident 51 is able to tell them when they have pain. Review of Resident 51's physician's orders documented an as needed order for Morphine Sulfate (an opioid pain medication), able to be administered every four hours as needed for moderate to severe pain. The resident's orders did not include any as needed medication option for mild to moderate pain. In an observation of wound care on 03/20/2025 at 1:23 PM, Resident 51 was lying in bed, Staff E, RN, Resident Care Manager, raised the resident's bed up and lowered the head of the bed, and Resident 51 made a groaning sound. Staff E asked Resident 51 if they were in pain, and the resident did not provide a verbal response, but continued groaning and exhibited a furrowed brow as the head of the bed was lowered, and while being turned on their side in the bed the resident was visibly stiffened and verbally stating oh, oh, oh. A medicated ointment was applied to the resident's sacral wound and as it was being applied the resident stated ow, ow, ow. Staff E stated, I would say they have pain with the wound. The most recent noted administration of the resident's as needed medication was on 03/20/2025 at 2:00 AM. In an observation on 03/21/2025 at 11:13 AM, Staff F, Nursing Assistant Certified (NAC) and Staff E were transferring Resident 51 to bed using a mechanical lift. Staff F explained to the resident they are going to get up and the resident was trying to position their arms across their chest, and the resident kept reaching out to hold onto the lift straps. At 11:19 AM, the lift started to raise, and the resident's body position curved into the sling, and they began loudly humming and stiffened up, then made a ah, ah and a moaning sound as Staff F held onto their feet to raise up their legs to navigate their position toward the bed. When the moving stopped the resident would relax and Staff E commented that the resident relaxed quickly after the movement stopped. When asked if they were having pain, Staff E stated it might be, but that they relax quickly. When asked if this is an anticipated response to being moved, Staff F stated yes, (Resident 51) always does this when we move them. In an observation on 03/24/2025 at 10:58 AM, Staff G, Physical Therapy Assistant, was working with Resident 51 in the facility therapy gym. Resident 51 was seated in their wheelchair. The last documented as need pain medication was last given to Resident 51 on 03/20/2025 at 2:00 AM. Staff G was noting that Resident 51 was resisting movement to extend their legs and arms stating, when we attempt, (they) push back and was attributing the reaction to the prior strokes the resident suffered from. Resident 51 stated I hurt, and Staff G stated where? to which the resident pointed at the left side of their chin. Staff G asked if this was their chin or their tooth, and Resident 51 said the word tooth. At 11:19 AM, Staff G was attempting to cue Resident 51 to kick their legs at a ball and then said they were going to stretch. When Staff G manipulated Resident 51's left leg they stated ow. Staff G asked, where is your pain? and the resident reached out and touched their left knee. Staff G stated, now we know. In a joint interview on 03/24/25 at 1:55 PM, Staff E stated they are using the non-verbal pain assessment for Resident 51, and it references frowning, moaning, and rapid breathing. Staff E stated the resident had not been consistent with yes/no responses and that they quickly relax again if uncomfortable. Staff B, Director of Nursing Services, stated they had not identified that there was not an option for as needed medication until the resident's pain was assessed to be moderate to severe. Staff E and Staff B were made aware of observed concerns that Resident 51 was communicating pain which was already identified through prior assessments and pain interview with the resident, and anticipated points of the day such as transferring, therapy and wound care were observed to show the resident exhibiting both verbal and non-verbal pain. Staff B stated they should look at pre-medicating before known situations such as therapy or wound care. Reference WAC 388-97-1060(1)

Based on interview and record review, the facility failed to ensure that 1 of 5 residents (Resident 155) reviewed for informed consent had received the information of risks and benefits of their proposed care related to psychoactive medications (substances that affect a person's mental processes, behavior and mood). This failure placed the resident at risk for potentially unknown or unwanted side effects, and decreased quality of life. Findings included . Facility policy titled, 'Psychoactive Drug Use', revision date of 10/15/2022, showed psychoactive drug documentation guidelines were to document in the resident's medical record, by the appropriate discipline on designated forms assessment as indicated: Resident/resident advocate notification, education, and consent of psychoactive medication. Resident 155 admitted to the facility on [DATE] with diagnoses to include right femur fracture, major depressive disorder, anxiety disorder and chronic pain syndrome. Review of Resident 155's admission orders dated 3/14/2025 documented provider orders for aripiprazole 5 milligrams (mg) daily related to major depressive disorder, duloxetine 30mg twice daily related to depression, and buspirone 20mg twice daily related to anxiety disorder. Review of Resident 155's Medication Administration Record, dated March of 2025 documented the resident received buspirone and duloxetine on day of admission in the evening of 03/14/2025 and aripiprazole on the morning of 03/15/2025. Review of Resident 155's electronic medical record (EMR) showed no documentation or signed consents related to psychoactive medication use for the admitted d 03/14/2025. In an interview on 03/24/2025 at 12:23 PM, Staff C, Social Services Manager stated the Resident Care Manager (RCM) nurses obtain consents for psychoactive medications. In an interview on 03/24/2025 at 1:41 PM, Staff D, Licensed Practical Nurse (LPN), RCM, stated they obtain consents for psychoactive medications at time of admission. Staff D stated they thought the previous psychoactive consents from Resident 155's last admission could be used. Staff D stated they obtained new psychoactive medication consents for Resident 155 on 03/21/2025 for the admission on 03/14/2025. In an interview on 03/25/2025 at 9:02 AM, Staff B, Registered Nurse (RN), Director of Nursing Services (DNS) stated they believe there was an issue due to Resident 155 being a re-admit and unfortunately the consents had been checked off they were completed on the 03/14/2025 admit. Reference WAC: 388-97-0260 (2)(a)(c)(d)

Based on observation, interview and record review the facility failed to ensure resident care plans were reviewed and revised for 1 of 2 residents (Resident 51) reviewed for activities of daily living. This failure placed residents at risk for lack of appropriate care and services by the staff. Findings included . Resident 51 admitted to the facility on [DATE] with diagnoses which included history of strokes and was dependent on staff for activities of daily living such as grooming and hygiene. Review of Resident 51's care plan on 03/20/2025 documented the resident had their own teeth and was able to perform oral hygiene with supervision and cueing and preferred to use their electric toothbrush, initiated on 01/31/2025. In an interview on 03/18/2025 at 1:48 PM, CC1 stated Resident 51 had an electric toothbrush but they could tell it had not been used. CC1 stated they did not think the staff were brushing the resident's teeth. CC1 stated they had asked about it before, and they had checked recently and did not think the toothbrush was being used. In observations on 03/20/2025, 03/21/2025 and 03/24/2025, Resident 51's electric toothbrush was observed in the exact same position near the sink in the resident's room and was always observed to be dry. In an interview on 03/24/2025 at 10:47 AM, Staff F, Nursing Assistant Certified (NAC) stated Resident 51 was not able to assist with oral care, and they were not using the resident's electric toothbrush and only used foam toothettes (oral care swab) for oral care. Staff F stated they could not recall Resident 51 being able to participate in brushing their own teeth because they had too much shaking of their hands. Staff F stated Resident 51 had been on Hospice and they usually use the toothettes when people are on comfort care, but they were not sure what was in the resident's care plan regarding oral care. In a joint interview on 03/24/25 at 2:07 PM, Staff E, Registered Nurse, Resident Care Manager and Staff B, Director of Nursing Services, stated they updated the care plans and the care plans should be updated as changes occur such as a decrease in ability or change in orders. Staff E stated they were not aware that nursing assistants were only using toothettes for Resident 51's oral care. Resident 51 had been on Hospice services recently but had come back off and the care plan needed to be reviewed. Reference WAC 388-97-1020

Based on observation, interview and record review, the facility failed to provide services that ensured a resident's abilities in activities of daily living (ADLs) did not diminish for 1 of 2 sampled residents (Resident 206) reviewed for activities of daily living. This failure put residents at risk for physical decline and decreased quality of life. Findings Included . Resident 206 admitted to the facility on [DATE] with diagnoses to include chronic ulcer of the foot, high blood pressure and altered mental status. Review of Resident 206's Brief Interview for Mental Status (BIMS-an assessment tool used to screen for cognitive impairment) dated 03/12/2025 showed a score of 12 out of 15, indicating the resident had moderate impairment. <ORAL CARE> Review of the Admission Minimum Data set (MDS-an assessment tool) assessment dated [DATE] showed Resident 206 required set up assistance for oral hygiene. Review of Resident 206's care plan dated 03/06/2025 documented the resident had their own teeth, was missing their front upper teeth and could perform oral hygiene independently after setting up. In an interview on 03/19/2025 at 9:56 AM Resident 206 stated they had not brushed their teeth for the day. In an observation on 03/19/2025 at 9:56 AM, Resident 206's toothbrush was in a kidney basin in the bathroom. The toothbrush contained visible white matter consistent with toothpaste in the bristles. The toothbrush was visibly dry and there were no visible signs of moisture in or around the kidney basin. In additional observations on 03/20/2025 at 9:45 AM, 03/21/2025 at 2:10 PM and 03/24/2025 at 9:32 AM Resident 206's toothbrush was in their bathroom, in the same location, in the same position as the observation on 03/19/2025. In an interview on 03/24/2025 at 9:32 AM Resident 206 stated they had not had their teeth brushed for many days. Review of Documentation Survey Report (completed nursing assistant tasks) for March 2025 documented Resident 206 was to have had daily oral hygiene assistance. In an interview on 03/24/2025 at 11:14 AM Staff D, Resident Care Manager (RCM) stated a resident must be offered oral care at least twice a day, before/after breakfast and at bedtime or as the resident requests. <OFFLOADING BOOTS> Review of Resident 206's care plan dated 03/06/2025 showed they had required assistance with applying offloading boots when they were in bed. In an observation on 03/20/2025 at 2:50 PM Resident 206 was lying flat on their back in their bed. The offloading boots were observed on the resident's bedside table. In an interview on 03/24/2025 at 9:32 AM Resident 206 stated they wear the offloading boots sometimes and rely on staff to put them on. Resident 206 stated they did not refuse or decline to put the offloading boots on. Review of a progress note dated 03/20/2025 at 9:09 PM, showed Resident 206 was compliant with wearing offloading boots. In an interview on 03/24/2025 at 9:16 AM Staff K, Registered Nurse (RN), stated Resident 206 wore offloading boots as an intervention for treatment and prevention of a pressure ulcer. When asked how nursing ensures the offloading boots are placed on Resident 206, Staff K stated once a shift the nursing staff including the nursing assistants had prompts through their tasks on their computer and during their charting. In an interview on 03/24/2025 at 11:18 AM Staff D stated they had not known Resident 206 to refuse the use of the offloading boots. Staff D stated Resident 206 wore the offloading boots to provide added protection to their heels while in bed. Staff D was unaware of Resident 206 not wearing the offloading boots consistently when in bed. Reference WAC 388-97-1060(2)(a)(b)(3)(b)

Based on interview and record review the facility failed to prevent psychosocial and physical abuse of 1 of 3 residents (Resident 1) reviewed for abuse and neglect. Resident 1, who had a well-known history of sexual trauma, experienced psychosocial and physical harm when during an episode of constipation, a Nursing Assistant Certified (NAC) proceeded to break up and remove the resident's impacted feces without their consent and outside their scope of practice even after the resident told the NAC to stop. Findings included . Review of Lippincott Nursing Procedures, 8th Edition, showed the procedure for digital fecal impaction removal began with verifying the practitioner's order including the following: * Explain the procedure to the patient, expected outcomes, and potential complications, * Inform the patient that a chaperone may be present during the procedure, * Obtain baseline vital signs because anal stimulation may cause a vagal response (a series of unpleasant symptoms that occur when the vagus nerve is stimulated), * Perform a complete gastrointestinal assessment, * Inform the patient you are about to perform the procedure. Instruct the patient to breathe deeply to promote relaxation and * Record the time and date of the procedure, the patient's response. Note any complications, the interventions taken and the patient's response to those interventions. Resident 1 admitted to the facility on [DATE] with diagnoses to include traumatic brain injury, anxiety disorder, major depressive disorder, cognitive communication deficit, expressive language disorder, unspecified voice and resonance disorder, need for assistance with personal care, and difficulty walking . Review of Resident 1's Level II Pre-Admission Screening and Resident Review (PASRR) Initial Psychiatric Evaluation Summary dated 06/03/2022, showed the resident had a childhood history of sexual abuse by a male and the facility's staff should be aware, especially as those childhood experiences could sometimes come up. The staff training and approaches included to be thoughtful with male caregivers who provided personal care and to ensure the resident was comfortable with this including if their cognition worsened overtime which could sometimes take individuals back to situations from their childhood. Review of Resident 1's Quarterly Minimum Data Set (an assessment tool) assessment dated [DATE] showed the resident was cognitively intact, usually made themselves understood and usually understood others. Review of Resident 1's care plan showed the following focus problems with corresponding interventions: * PASRR Level II recommendations for plan of care initiated on 07/09/2024. There was a history of childhood sexual abuse by a male. Be thoughtful if males provided personal care. Ensure the resident was comfortable with this if the resident's cognition worsened over time which could sometimes take individuals back to things from childhood. * Understanding history of trauma to avoid re-traumatization. Resident had a history of childhood sexual abuse initiated on 07/19/2024. History of childhood sexual abuse by a male. Be thoughtful if males provided personal care to ensure the resident was comfortable with this and including if the resident's cognition worsened over time which could sometimes take individuals back to things from their childhood. * Resident had a communication problem related to hearing loss, difficulty finding words, anxiety and becoming overwhelmed initiated on 05/31/2022. When staff were communicating with the resident they were to face the resident, make eye contact and speak slowly and clearly. Clarify that information was understood as needed. * Monitor/document for physical/nonverbal indicators of discomfort or distress, and provide follow-up as needed. Review of Resident 1's current Kardex (guide for direct care providers) showed the resident had a history of childhood sexual abuse by a male. Be thoughtful if males provided personal care to ensure the resident was comfortable with this and included if the resident's cognition worsens overtime which could sometimes take individuals back to things from their childhood. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. Use consistent, simple, direct sentences. Provide Resident 1 with necessary cues- stop and return if agitated. Review of Resident 1's January 2025 Documentation Survey Report v2 (the direct care givers/ NAC documentation) showed on 01/08/2025 on the dayshift, Resident 1 was incontinent of an extra-large smooth, soft, stool which was like a sausage or snake. Resident 1 did not have a bowel movement on 01/09/2025 or on 01/10/2025. On 01/11/2025 on the evening shift the resident was continent of a large stool which was like a sausage but with cracks on the surface. Review of Resident 1's nursing progress notes dated 01/11/2025 showed the following entries related to the bowels: * 1:16 PM, two Senna - S (stimulant laxative medication) was given no bowel movement (BM) for two days, * 7:26 PM, the Senna - S was effective, * 8:20 PM, MiraLAX Powder (medication for constipation) was given, resident able to have a BM, but very hard, * 8:30 PM, Tylenol was given, pain to rectum from hard stool, * 9:30 PM, the Tylenol was effective, * 9:41 PM, The resident's groin and buttocks continued to be red as well as underneath the resident's right breast. The resident recently finished a seven-day course of an antifungal medication, and a note was left for the provider. (There was no documentation in the note to show the resident had a BM they were unable to pass or that a digital disimpaction was performed by staff, or how the resident tolerated the procedure.) Review of the incident report dated 01/24/2025, showed Resident 1 reported that two to three weeks ago they were feeling constipated. The resident stated they were in the bathroom with a NAC they had not seen before or since. The resident stated the NAC was helping them with toileting and communicated that they felt constipated and could not pass their stool. The resident reported the male NAC manually inserted their finger into the resident's rectum and removed the stool. The resident stated they had not given the male NAC consent to do that task and had asked them to stop. The resident reported the action by the NAC had reminded them of their childhood sexual abuse trauma. The resident's mental status was noted to be oriented to person, place, time and situation. The resident reported they had felt ashamed by the incident and had not reported it to anyone until that day. The root cause was noted to be the resident's past trauma of childhood sexual abuse, the resident was hard of hearing and the NAC was wearing a face mask and the resident was not able to read their lips. The NAC had a strong accent and that there was the potential of miscommunications between the NAC and the resident related to providing consent to touch the resident's rectum. Re-education was provided to the nursing staff to obtain consent from the residents prior to completing a task, effectively communicate task and inserting fingers into a resident's rectum for removal of stool was not in the NAC's scope of practice. Review and comparison of the in-service sign-in log to the facility staff roster showed 21 of 49 nursing staff were in-serviced on 01/25/2025 on clear, concise, respectful communication, active listening with attention to both verbal and non-verbal cues and to always explain what you are doing and why while allowing time for questions and consent. The in-service also noted a medical professional such as a nurse physician or physician assistant could digitally remove stool from a resident, but it was outside the NAC scope of practice. Review of Staff A, NAC's statement dated 01/24/2025, showed on 01/11/2025 , Resident 1 had called to be helped to the bathroom. Staff A noted they assisted the resident to the bathroom and gave them privacy by stepping out and waited for them to call when they were done. Staff A noted after waiting for 10 minutes they went back to check whether the resident was done. Staff A noted Resident 1 was still trying to push but the stool was not coming out. Staff A noted when Resident 1 stood up from the toilet they saw that the resident had bad constipation and the resident's stool was too hard for the resident to push but the stool was trying to come out. Staff A noted they told the resident lubricant could help and the resident had said OKAY. Staff A noted they told the nurse in charge who was passing medications in the opposite door, and the nurse had handed them the lubricant. Staff A noted they did not insert their fingers inside the resident's rectum but applied the lubricant and broke up the hard stool. Staff A noted they explained to the resident before touching them and they were okay and never asked them to stop at any point. Review of Staff B, Registered Nurse (RN), statement dated 01/24/2025 , documented Resident 1 had called for the nurse crying due to painful hard stool. Staff B noted they gave the resident as needed pain medication and MiraLAX to help with discomfort and constipation. Staff B noted Resident 1 did not mention anything about abuse. In an interview on 02/06/2025 at 1:42 PM, Resident 1, stated someone had entered their body without their permission. Resident 1 stated the person who entered my body caused me pain, it was very painful. Resident 1 stated I was disgusted and felt like they had been raped. Resident 1 stated that when they asked the staff member to stop, they did not. Resident 1 stated after they came out of the bathroom the medical nurse came into their room and saw the resident crying. Resident 1 stated they had asked the night nurse if they would talk to the administration about it after they came out of the bathroom as they were upset, and the nurse said they would tell the Director of Nursing Services. Resident 1 stated the medical nurse tried to comfort them and said they should have given them a laxative. Resident 1 stated they were so upset they had to wait to make a formal report of the incident and decided after a couple of weeks it was their obligation to report what happened so it would not happen to anyone else. Resident 1 stated it still bothered them, It bothers me in my dreams, it is like something traumatic and wished they would not remember it. Resident 1 stated they told, them to quit doing what they were doing but they kept doing what they were doing. Resident 1 stated, I did not want to tell anyone right then it was very disgusting. I could not think of what to do but to be as quiet as possible. Resident 1 stated they did not feel like screaming out even though it would have brought them help, I did not want anyone to know what was going on. In a phone interview on 02/10/2025 at 1:15 PM, Staff A, NAC, was asked about the evening the reported incident occurred on the evening shift of 01/24/2025 with Resident 1. Staff A stated they had worked the evening and night shift on that day. Staff A stated Resident 1 wanted to use the bathroom, and they assisted them to the bathroom. Staff A stated they went back and found the resident was complaining of pain to their bottom and had a hard constipated stool. Staff A stated they had gone to the nurse and explained the resident had a hard stool and the nurse had given them a packet of lubricant and did not say anything else. Staff A stated when the resident stood up to be cleaned, they broke the stool that was coming out of the resident's rectum. Staff A stated they were able to break the resident stool without placing their fingers in the resident's rectum and the resident did not tell them to stop. Staff A stated they told the nurse they had put the lubricant on the outside of the resident's rectum. In an interview on 02/10/2025 at 1:41 PM, Staff C, NAC, stated if they were providing care for a resident who was constipated, had visible hard stool in their rectum, and was unable to eliminate/pass the stool, they would let the resident have time and notify the nurse to see if there was anything that could be given to the resident. Staff C stated they would not try to remove the hard stool as it was out of their scope of practice. In an interview on 02/10/2025 at 1:50 PM, Staff D, NAC, stated if they were providing care for a resident who was constipated, had visible hard stool in their rectum, and were unable to eliminate/pass the stool, they would clean the resident up the best they could and let the nurse know the resident had a stool they could not pass. There was nothing they could do but tell the nurse. In an interview on 02/10/2025 at 2:01 PM, Staff E, NAC, stated if while they were providing care for a resident who was constipated, had visible hard stool in their rectum, and were unable to eliminate/pass the stool they would not go out of the scope of their practice. Staff E stated they would let the nurse know and would not remove or attempt to remove the stool. In an interview on 02/10/2024 at 2:07 PM, Staff F, NAC, stated if while they were providing care for a resident who was constipated, had visible hard stool in their rectum, and were unable to eliminate/pass the stool, stated they would just go asked the nurse to give the resident a stool softener. Staff F stated they would not try to remove the stool as they would be scared, they might hurt the resident. The following licensed nurses were asked what they would do if an NAC reported a resident was constipated and had visible hard stool in their rectum that they were unable to pass. In an interview on 02/10/2025 at 2:12 PM, Staff G, RN, stated if an NAC reported a resident was constipated and had visible hard stool in their rectum that they were unable to pass, they would place lubricant around the resident's rectum. Staff G stated they would not have the NAC apply lubricant as it was not in the NAC's job description. In an interview on 02/10/2025 at 2:21 PM, Staff H, RN stated if an NAC reported a resident was constipated and had visible hard stool in their rectum that they were unable to pass, they would notify the doctor and see what the precautions and the facility policy directed. Staff H stated they would see about a stool softener but ultimately, they would follow the facility's policy and procedures. Staff H stated they would not provide the NAC with lubricant to apply on the resident's rectum. In an interview on 02/10/2025 at 2:57 PM, Staff I, RN/DNS, stated it was their expectation for the nurse to assess the resident's situation. Staff I stated Staff B did not say why they did not assess the resident prior to giving the NAC the lubricant. In a phone interview on 02/11/2025 at 11:49 AM, Staff B, RN stated on the evening of the reported incident they were working on the medication cart. Staff B stated the NAC had come to them and reported Resident 1 had an impacted hard stool they could not pass. Staff B stated they did not assess the resident after the NAC reported the resident's issue. Staff B stated they were down by the resident's room but was in the middle of something. Staff B stated, It just happened I think I was in the middle of something, I guess. Staff B stated in the past they had experienced placing lubricant on the outside of the rectum so that was what they did in the same instance. Staff B stated they, themselves had not placed the lubricant on Resident 1's rectum. Staff B was asked if it was okay for a NAC to break up stool they could see in a resident's rectum. Staff B stated, No, it can cause injury, and it is just not very safe. Staff B stated they had been an NAC, and they knew as a NAC they were not allowed to do that. Staff B stated the resident ended up passing the stool. Staff B stated Resident 1 was crying and said their stool was hard and painful to pass. Staff B stated they were not for sure if they were in the in-service training on 01/25/2025 and was unable to recall what the in-service was about. Refer to WAC 388-97-0640 (1)

Based on interview and record review the facility failed to ensure 3 of 3 residents (Residents 1, 2 and 3) who had orders for daily weights were weighed daily. This failed practice placed residents at risk of diminished quality of life. Findings included . <RESIDENT 1> Resident 1 was admitted to the facility on [DATE] with a diagnosis to include congestive heart failure. Review of Resident 1's care plan showed a focus problem of chronic congestive heart failure with an initiated date of 06/10/2024. The care plan included interventions to monitor the resident's weight as ordered and to monitor for signs and symptoms of congestive heart failure which included weight gain unrelated to intake and swelling of the legs and feet dated 06/10/2024. Review of the August 2024 Medication Administration Record (MAR) showed an order for daily weights in the morning for weight monitoring with a start date of 08/02/2024. Resident 1 had no documented weights fored 16 of 29 days in August 2024. Review of the September 2024 MAR showed Resident 1 had no documented weights three of 12 days they were in the facility for the month. <Resident 2> Resident 2 was admitted to the facility on [DATE] with a diagnosis to include congestive heart failure. Review of Resident 2's August 2024 MAR showed an order for daily weights related to congestive heart failure and to notify the provider if consistent gain or loss of two to three pounds from dry weight over three days. Resident 2 was not weighed for seven days in the month of August 2024. Review of Resident 2's September 2024 MAR showed the facility did not weigh Resident 2 for eight of the 31 days in the month. <Resident 3> Resident 3 was admitted to the facility on [DATE] with diagnoses to include congestive heart failure. Review of Resident 3's care plan showed a focus problem of congestive heart failure. The interventions included to monitor and document weight gain . Review of Resident 3 's August 2024 MAR, showed an order for daily weights of which the facility failed to weigh the resident 13 out of 31 times for the month. Review of Resident 3's September 2024 MAR, showed Resident 3 was not weighed six out of 31 times for the month. In an interview on 10/01/2024 at 1:11 PM, Staff A, Registered Nurse (RN), stated they give the Nursing Assistant Certified (NAC) a daily communication sheet which would have listed the residents who needed to be weighed. Staff A stated the NAC's try to do most of the residents' weights but if they do not get to a weight, they pass the task onto the evening shift NACs to complete. Staff A stated the staff are to weigh the residents before breakfast. Staff A stated the resident weight would be documented in the Treatment Administrative Record (TAR) and some are set up to be documented in the MAR, so they were not missed. In an interview on 10/01/2024 at 1:29 PM, Staff B, Licensed Practical Nurse, stated NAC's know which residents need to be weighed as they were listed on the daily communication form. Staff B stated they ensure the residents who need to be weighed have a weight entered by clicking on a tab in the electronic medical records at the end of their shift. Staff B stated the nurses enter the resident's weight on the MAR or TAR and the NACs document the residents' weight in their section of the medical record. Staff B stated the section the NAC's document in does not auto populate into the MAR or TAR. In an interview on 10/01/2024 at 3:27 PM, Staff C, Director of Nursing Services stated the process for residents with daily weights are for the staff to obtain them. Staff C stated the electronic medical system would not flag on their dashboard if a daily weight was not obtained. Staff C stated they did not recall there was an issue with obtaining resident daily weights. Refer to WAC 388-97 1060 (3)

Based on interview and record review the facility failed to provide notification to the resident's representative of a change in treatment for 1 of 1 resident (Resident 4) reviewed for medication changes. This failed practice prevented the resident's representative from being informed and participating in care decisions. Findings included . Resident 4 was admitted to the facility on [DATE] with diagnoses to include chronic heart disease along with congestive heart failure, low blood pressure, and kidney failure. Review of a progress note dated 09/19/2024 at 11:53 PM, showed a new order for Lasix (medication used to treat fluid retention) 20 milligrams (mg) twice daily and a laboratory test ordered for to be completed 09/23/2024. Review of the September 2024, Medication Administration Record showed Resident 4 received a dose of Lasix 20 mg on the morning of 09/20/2024. In a phone interview on 10/02/2024 at 9:10 AM, Collateral Contact (CC)1, Resident 4's Representative stated they were not informed the resident had received a new order for Lasix. CC 1 stated while Resident 4 was at the hospital, the hospital staff told them Resident 4 should not receive Lasix due to Resident 4's kidneys function. In an interview on 10/02/2024 at 1:54 PM, Staff D, Licensed Practical Nurse/ Residential Care Manager, stated night shift had processed Resident 4's medication order for the Lasix and the resident's representative should have been notified of the new order. In an interview on 10/02/2024 at 5:00 PM, Staff C, Director of Nursing Services, stated the residents' representative should be notify of a change of treatment which would include medication changes. Refer to WAC 388-97-0320(1)(c)

Based on observation, interview, and record review the facility failed to offer assistance and supervision with meals, consistently offer an alternative meal when residents at less than 50% of their meal and evaluate the effectiveness of weight loss interventions to determine if additional interventions were needed for 2 of 3 residents (Resident 46 and 31) reviewed for nutritional needs. These failures caused harm to Resident 46 when they experienced a severe weight loss of 9.1% in less than three months and placed other residents at risk for additional weight loss and a decline in their nutritional status. Findings included . Review to the State Operations Manual (SOM) Appendix PP - Guidance to Surveyors for Long Term Care Facilities, dated 02/03/2023, the parameters for significance of unplanned and undesired weight loss as defined being severe if there is a greater than 5% weight loss in one month and greater than 7.5% in three months. Review of facility policy titled, Nutrition, revised 01/08/2023, showed the facility provides nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment. The facility recognizes, evaluates, and addresses the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and hydration; and provides a therapeutic diet that considers the resident's clinical condition, and preferences, when there is a nutritional indication. <RESIDENT 46 > Resident 46 admitted to the facility on [DATE] with diagnoses including dysphagia (swallowing difficulty), and Alzheimer's disease. The Admission Minimum Data Set (MDS - an assessment tool) assessment, dated 12/05/2023, showed the resident had significantly impaired cognition, difficulty focusing attention, and did not refuse care. Review of the facility documented titled, Mini Nutritional Assessment, dated 11/28/2023, showed Resident 46 was at risk for malnutrition and the plan was to monitor weights and food and fluid intake. Review of Resident 46's weight in the electronic medical record (EMR), dated 11/30/2023, showed the resident's admission weight was 183.2 pounds (lbs.), which the facility used as the resident's baseline weight. Review of the facility documented titled, Diet History & Food Preferences Assessment, dated 11/30/2023, showed Resident 46's daughter was interviewed and reported their loved one had a good appetite and no food allergies, intolerances or dislikes listed. Review of a physician note, dated 12/03/2023, showed nursing stated Resident 46 was cooperative with medications, cares, and meals. There was no reference to weight or nutrition. Review of the facility document titled, Nutrition Evaluation Comprehensive Assessment, dated 12/04/2023, showed no usual body weight in the past six months or year for Resident 46. The weight documented on the form was 184 lbs. on 12/04/2023. The assessment showed the resident was on a regular diet with easy to chew texture. The resident had a good appetite and was able to eat independently after setting up their meal. The assessment showed the resident's weight on discharge from the hospital was 191.6 lbs. and their admission weight was 183.2 lbs. The resident's intake was an average of 66%. The RD documented the resident would require 80% of their meal intake to meet their nutritional needs. Review of Resident 46's care plan showed a focus for at risk for nutritional decline related to dementia and change in environment and surroundings, dated 11/29/2023. The care plan interventions, updated 12/04/2023, included to notify the Registered Dietician (RD), family and physician of significant weight changes, assist the resident to the preferred dining environment and assist them with meals and intake as needed. The care plan directed staff to provide meals per the physician orders and record their intake. The RD was to review the resident as indicated. The care plan was revised on 02/04/2024 to include adding high calorie/fortified (nutrients added) food. Review of Resident 46's electronic medical record (EMR), showed on 12/07/2023 the resident weighed 188.8 lbs., a 5.6 lb. weight increase. On 12/21/2023, the resident weighed 191.2 lbs. Review of a physician note, dated 12/29/2023, showed nursing stated Resident 46 was cooperative with medications, cares, and meals. The physician's noted lower extremity swelling, was not on a diuretic (a medication used to reduce fluid buildup in the body), and their weight was trending down with a reference to 12/26/2023 weight of 192 lbs. and their weight of 187.8 lbs. on 12/28/2023. Review of Resident 46's electronic medical record (EMR), showed the following documented weights: - On 01/12/2024, 179.2 lbs., a 6.3% significant weight loss in 22 days. - On 01/23/2024, 174.0 lbs., a 9.4% severe weight loss in 31 days. Review of Resident 46's Activities of Daily Living (ADL) care plan, revised on 01/23/2024, directed the resident was to receive direct supervision with meals, lids on their drinks, built up utensils, and supervision to cue the resident for initiation of their meal, placing food onto their utensils as needed, and demonstrate feeding to promote independency. Review of Resident 46's ADL care plan, revised on 02/01/2024, directed staff the resident required one on one feeding assistance with meals. Review of Resident 46's nutrition/weight notes showed the following: - On 01/17/2024, the reason for the review was the resident's weight loss. The note showed the resident weighed 180 lbs., a 6.3% or 12.2 lbs. The note showed the resident might need more one on one assistance with feeding and a Speech Language Pathology (SLP) order was placed for an evaluation. - On 01/24/2024, the reason for the review was the resident's weight was down three percent from their last weight. The weight warning showed the resident had lost 9.4% or 18 lbs. The resident had been seen by SLP on 01/23/2024 and was having difficulty feeding themselves. Recommendations were to increase their diet texture, build up silverware, and the resident required one on one feeding. Interventions included adding high calorie/fortified food. - On 02/01/2024, the reason for the review was the resident had a 7.8% or 14.7 lb. weight loss. The note showed the resident was to receive high calorie fortified meals with direct supervision. No changes were recommended to their plan of care. - On 02/08/2024, the reason for the review was the resident had a weight loss of 12.0% or 22.7 lbs. in less than three months. The note showed the resident was now on one-on-one feedings with a high calorie fruit smoothie added twice a day with breakfast and lunch. Review of Resident 46's meal intake documentation, dated 11/28/2023 through 02/09/2024, showed 43 meals where the resident consumed 0-25% of their meals, and 32 meals where the resident ate less than 50%, supplements (facility's health shake) were not offered for 38 meals when the resident ate less than 50% of their meal. The meal monitors showed the: - December 2023, showed 11 meals with 0-25% intake, and four meals where the resident at less than 50%. Supplements were not offered for eight meals where the resident ate less than 50%. - January 2024, showed 26 meals with 0-25% intake, and 21 meals where the resident at less than 50%, Supplements were not offered for 22 meals where the resident ate less than 50%. - February 2024, showed six meals with 0-25% intake and seven meals where the resident at less than 50%. Supplements were not offered for eight meals where the resident ate less than 50%. Review of a physician assistant note, dated 01/21/2024, showed Resident 46 had lower extremity swelling. Review of a progress note, dated 02/01/2024 at 9:15 PM, showed Resident 46's family member requested the resident receive one on one feeding assistance because they were not feeding themselves well. SLP was notified of the family members request and agreed. The care plan was updated. In a continuous observation on 02/05/2024 starting at 12:56 PM, Staff J, Nursing Assistant Certified (NAC), placed Resident 46's tray up for lunch. The resident had built up utensils but did not initiate eating. The resident was observed to stare at their empty fork. Staff in the dining room did not assist the resident with eating. In an interview on 02/05/2024 at 2:26 PM, Collateral Contact 2 (CC2), a family member of another resident, stated they were concerned about dining. CC2 stated they visit their family member daily usually around mealtime. CC2 said they observed the staff did not assist residents when their ability to eat changed related to cognitive issues. CC2 said they do not help (Resident 46) who would put food on their utensil but not eat it. CC2 said Resident 46 was confused and needed assistance with meals. CC2 said they (staff) did not see the resident getting help and had asked the activity assistant to help them, but it did not change. CC2 said their family member had tried to help feed Resident 46. Review of Resident 46's weight in the EMR, dated 02/06/2024, showed the resident weighed 166.5 lbs., a 9.1% weight loss in 10 weeks. In a continuous observation on 02/06/2024 starting at 9:17 AM, Resident 46 was coughing at the dining room table. Staff R, NAC, got up from assisting another resident and asked Resident 46 if they were okay. The resident shook their head to indicate no, then continued with a frequent non-productive cough. At 9:40 AM, the resident was trying to pick up egg with their fork but could not get the egg onto the fork. The resident was observed to move their fingernail over the uneaten English muffin. Staff EE, housekeeper, asked if they were done eating and they responded no. Staff were not observed to not assist Resident 46 with their meal. At 9:54 AM, Staff R removed the tray. The resident had consumed bites of the English muffin and egg, and their cereal and drinks were untouched. In a continuous observation on 02/06/2024 starting at 1:00 PM, Resident 46 received occasional eating assistance from Staff L, Registered Nurse (RN). Staff L gave the resident a bite of food, got up, and went to their medication cart. At 1:10 PM, Staff L returned to give the resident a bite of food. At 1:36 PM, the resident was sitting in front of their meal that had only bites eaten. The resident was observed grabbing at their mechanical lift sling straps. In an observation on 02/07/2024 at 9:44 AM, Resident 46 was in the dining room with a mug of apple juice in front of them. Their meal had been removed. In a continuous observation on 02/07/2024 at 12:33 PM, Resident 46 was in the dining room with their meal in front of them and staff were observed to not assist them with their meal. In an interview on 02/08/2024 at 8:53 AM, Staff P, RD, said Resident 46 had been on their radar. Staff P said the resident was discussed in the nutrition at risk (NAR) meeting on 01/30/2024. Staff P stated Resident 46 had lost more weight and stated they would be looking at the resident again. Staff P said they discussed the resident on 01/24/2024 and added high calorie fortified foods. Staff P said on 02/01/2024 they thought the resident's weights were starting to stabilize so they did not add any interventions. Staff P said the NAR team consisted of a Resident Care Manager (RCM), the dietary manager and themself. They said they were unsure who was responsible to notify family and provider of weight loss. Staff P said they had not observed the resident in the dining room or consulted with the provider. They said on 02/01/2024 the SLP had documented the resident needed direct supervision at meals. Staff P said the documentation varied between meal supervision and assistance. Staff P said Resident 46's intake was variable and was about 26-75%. Staff P stated the reason they were losing weight was their intake was not enough. Staff P said they should have looked at adding supplements like magic cups or shakes. Review of Resident 46's physician's orders showed there were no supplements ordered until 02/08/2024 when high calorie fruit smoothies were added two times a day. In a continuous observation on 02/08/2024 at 9:05 AM, Resident 46 sat with their breakfast in front of them. They were looking down and playing with their hands but did not elicit eating. No meal assistance was provided. At 9:11 AM, the resident had not taken any bites of food or drinks, they just watched their three tablemates eat. There was one staff member, Staff Q, NAC, in the dining room assisting another resident. At 9:18 AM, Staff J briefly sat down with the resident and asked if they liked cream of wheat cereal. The resident responded yes, took a bite then looked at their empty spoon, and held their spoon down past their lap. The resident had an uneaten danish in their left hand for some time and did not elicit eating it. At 9:19 AM, Staff J got up, left the dining room, and went down the hall. At 9:22 AM, the resident was observed to put eggs on their spoon and tried to put it onto their danish. At 9:25 AM, the resident took their second bite of food since meal delivery. No fluids were consumed during the meal. At 9:34 AM, no further bites were taken, or any fluids consumed. The resident was still chewing their last bite. At 9:35 AM, Staff J sat down, said the resident should eat their eggs, and gave them their mug. In an interview on 02/08/2024 at 9:13 AM, Staff P came into dining room and reported it was the RCM's responsibility to notify providers and family or responsible parties of when a resident loses weight. In an observation and interview on 02/08/2024 at 11:03 AM, CC1, Resident 46's family member, stopped into visit and asked the resident if they ate good at breakfast. CC1 said Resident 46's cognition had good days and bad days. CC1 stated their family member would eat and other days they didn't even know what their fork was. CC1 stated they had requested the staff assist them with eating at meals. CC1 said they had not been informed of any weight loss. In an interview on 02/08/2024 at 11:50 AM, Staff J said Resident 46 was dependent on staff for all care and they were supposed to assist them with meals. Staff J said they were not surprised they had lost a lot of weight. They commented the foam padded utensils confused the resident more as it was like a [NAME] to the resident. Staff J said they were supposed to offer the resident replacements if they don't eat enough. Staff J said there were two NAC's that served the hall and dining room meal trays. Staff J said the nurses did not help in the dining room and they were not sure who the RCM was now. In an observation on 02/09/2024 at 9:17 AM, Resident 46 was sitting with their breakfast in front of them, and one bite of toast had been taken. There was no one on one assistance or verbal cues observed from staff. Staff T, NAC, offered to give the resident a tray under their plate so the plate would quit sliding on the glass tabletop. Resident 25, who sat across from the resident, told Resident 46 to eat and kept encouraging them. The resident was holding their built-up fork, staring at it with no initiation to eat. At 9:19 AM, Staff T added milk to their oatmeal and gave them a bite while standing over them. Staff T told the resident they did not have to eat it if they did not like the meal and offered them hot chocolate but no other food alternative. At 9:39 AM, Resident 15 leaned over and encouraged Resident 46 to eat. Resident 15 stated, This is your food, take a bite. Staff J was assisting Resident 5 with their meal while Staff T was assisting Resident 21 who was able to eat independently. Resident 46 then took a bite of food at 10:03 AM, the resident had eaten 5% of their meal and one on one meal assistance was observed to not be provided. In an interview on 02/09/2024 at 9:53 AM, Staff N, Licensed Practical Nurse (LPN), stated Resident 46 needed feeding assistance and to be monitored at meals. Staff N was unsure if the resident had lost weight. Staff N said the RCM would inform the provider of weight loss, and the Power of Attorney (POA) or family should be informed of the weight lost as with any changes in condition or medication. In an interview on 02/09/2024 at 10:49 AM, Staff K, RN/RCM, said Resident 46 needed extensive assistance with ADL's. Staff K stated the resident initially required supervision for feeding, but they changed them to one on one for feeding related to their cognition. Staff K said the resident's family had requested for staff to assist them as well. Staff K said they had referred the weight loss to the RD, and they had changed their diet to the high fortified diet two weeks ago on 01/24/2024. Staff K said the resident had been eating less than 50% of their meals. Staff K reviewed Resident 46's weight in the EMR that showed a 12% or 22.7 lb. weight loss since admission less than three months ago. Staff K stated there were no progress notes that the provider or responsible party/family had been informed of the significant weight loss. <RESIDENT 31> Resident 31 admitted to the facility on [DATE] with diagnoses to include acute respiratory failure (the air sacs of the lungs cannot release enough oxygen into the blood), pneumonia (infection of the air sacs in one or both the lungs), and abnormal weight loss. Review of the care plan, dated 01/16/2024, showed Resident 31 was at risk for nutritional decline related to oral sores and the need for mechanically altered diet and underweight status. The RD, family, and physician were to be notified of any significant weight changes. Review of Resident 31's weight record, dated 01/16/2024, showed the resident weighed 90.2 lbs. Review of the RD's evaluation in the EMR, dated 01/22/2024, showed Resident 31 had a good appetite, ate all three meals in their room, and required set up assistance for meals. Review of a nutritional progress note, dated 01/24/2024, showed Resident 31 had weight loss and deferred to RD evaluation completed on 01/22/2024. Review of provider progress notes, dated 01/29/2024 and 01/30/2024, showed no indication Resident 31 was reviewed for their weight loss. Review of a nutritional progress note, dated 02/01/2024, showed Resident 31's weight to have decreased, their current diet was a high calorie/fortified/minced and moist, with thin liquids. The resident's average intake was 77%. Resident 31 received a house supplement at breakfast. Resident 31's labs were reviewed and reviewed by the physician on 01/27/2024 with no new orders. A recommendation was made to increase the house supplement to breakfast and lunch. In an interview on 02/05/2024 at 11:29 AM, Resident 31 stated they had not eaten because the food was always the same. Resident 31 stated they would like to have some bacon and had not spoken to the dietary manager in a while. Resident 31 stated they had weighed 115 lbs. prior to becoming ill. Observation on 02/05/2024 at 11:29 AM, Resident 31 sitting on the edge of their bed, their breakfast was on a tray on top of their overbed table. The breakfast tray showed Resident 31 had consumed about 10% of their meal. Review of Resident 31's weight record, dated 02/06/2024, showed the resident weighed 84.2 lbs. which was a six pound or 6.65% weight loss in three weeks. Observation on 02/08/2024 at 10:46 AM, Resident 31 sitting on the edge of their bed, their breakfast was on a tray on top of their overbed table. When Resident 31 was asked about their breakfast, they stated they were not hungry. Resident 31 consumed less than 10% of their meal. Observation on 02/08/2024 at 12:37 PM, Staff S, NAC, carried Resident 31's breakfast meal tray from their room. The breakfast meal tray contained the same quantity of uneaten items observed at 10:46 AM. In an interview on 02/08/2023 at 9:30 AM, Staff P stated they reviewed Resident 31 on 01/22/2024, on 01/24/2024, and would be reviewing them again today in NAR interdisciplinary meeting. Staff P stated the RCM, dietary manager, and themselves attend the NAR meetings. When asked who had been notified of Resident 31's weight loss, Staff P stated the RCM notified the family and the provider. In an interview on 02/09/2024 at 9:39 AM Staff C, RCM, stated they had not had a conversation with Resident 31's provider regarding their weight loss. In a joint interview on 02/09/2023 at 2:00 PM, Staff A, Administrator, and Staff B, Director of Nursing Services, stated they were not aware Resident 46 had experienced severe weight loss since admission on 11/28/2023, and there was no documentation the provider or family had been notified of the resident's weight loss. Staff A and B were not aware of Resident 31's weight loss. Reference: (WAC) 388-97-1060(3)(h) 47047

Based on observation, interview, and record review, the facility had a systemic failure to provide accurate comprehensive assessments, monitors, treatments, and the development and implementation of timely interventions to minimize the risk, the development, or the deterioration of a pressure injury for one of three residents (1) reviewed for pressure injury/ulcers. These failures caused harm for Resident 1 who developed an in-house acquired Stage III pressure injury to their right ankle and placed other residents at risk for harm and unmet care needs. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: -A pressure injury (PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shearing; - A Stage III PI is a full-thickness skin loss/Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue are often present. Slough and/or eschar may be visible; and - An Unstageable PI is an obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (yellow/white material consisting of dead cells) or eschar (dead tissue). If slough or eschar is removed, a Stage III or Stage IV PI will be revealed. Resident 1 was a long-term resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's annual Minimum Data Set (MDS) assessment, dated 05/25/2021 and the quarterly MDS assessment dated [DATE], showed the resident was not at risk for developing PI's. (Not a comprehensive or accurate assessment). In an interview and record review on 04/14/2022 at 2:27 PM, the Director of Nursing Services (DNS) was asked for a list of residents who had PI's. The DNS presented a handwritten list which included Resident 1 had a right ankle wound which was measured as 0.4 centimeter (cm) by 0.4 cm and was scabbed over the wound. The treatment had been discontinued and was noted to be left open to air and continued to use a pressure relieving boot. The DNS confirmed the list was the facility's residents with current PI's. In an observation and interview on 04/14/2022 at 2:59 PM, Resident 1 was sitting up in a wheelchair (w/c) in the hallway with no sock, shoe, pressure relieving boot or treatment to their right foot or ankle. Resident 1 stated that their foot hurt. In an observation on 04/14/2022 at 3:15 PM, Resident 1 self-propelled in their w/c to the nurse's station and showed Staff A, Registered Nurse (RN), their foot. Resident 1 was heard to state to the nurse that their dressing was off. Resident 1 had their right foot crossed over their left leg showing the nurse and was observed to be without a sock, shoe, pressure relieving boot or treatment to their right foot or ankle. In an observation and interview on 04/14/2022 at 4:13 PM, Staff A was asked if they could look at the resident's right ankle. Staff A stated that the resident's wound happened a month ago. Resident 1 was observed to be without a dressing to their right ankle and no sock, shoe or pressure relieving boot on their right foot. A pressure relieving boot was observed lying on the resident's bed. Staff A confirmed the boot was for the resident and stated that it helped straighten the resident's foot. Resident 1 continued to be in their w/c and stated that their foot hurt as they lifted their right foot onto their bed. The resident's right foot was observed to rotate outward from their midline directly onto the outer ankle wound. Resident 1 directed Staff A to obtain an oversized lighted magnifying glass from the top drawer of their dresser. Staff A was asked to describe the resident's lateral/outer right ankle wound. Staff A stated that the wound appeared to be beefy red, had slough around and the center of the wound was good. Resident 1 stated that they had some pain, when not touched it was a 1 on a 0 to 10 scale and if touched the pain would be up to a 5 at times. Review of the resident's care plan printed on 04/14/2022, showed the resident did not have a care plan related to the resident's PI. Review of the resident's Kardex (guide for direct care givers) printed on 04/14/2022, showed under the Repositioning/Skin Care tab was to keep skin clean, dry and to use lotion on dry skin, not on site of injury. No other directions were noted related to the resident's PI. (Site of injury was not identified) Review of the resident's medical record showed the following inconsistent documentation related to the resident's skin impairments from 03/14/2022 through 04/11/2022: · Progress note dated 03/14/2022 at 3:27 AM, showed the resident had a small, scabbed area to their outer right ankle that appeared to have been bumped and opened. The area was cleansed and covered with a pressure dressing. · Progress note dated 03/14/2022 at 2:25 PM, showed the resident had a left ankle wound that appeared to be a boil. · Treatment Administration Record (TAR) dated 03/15/2022, showed a treatment was ordered for the left ankle boil which was to be cleansed with normal saline, apply silver alginate and cover with a foam dressing every other day which had been completed for three of the eight scheduled days for the month of March 2022. (Five schedule treatments were not completed) · Wound Data Collection assessment dated [DATE], showed the resident had a scabbed area measuring 2 cm by 3 cm with red colored surrounding tissue to their right outer ankle area. The area was described with increased redness and swelling with a noted pain level of an 8 on a 0-10 (10 being the highest level) pain scale. The treatment was noted to be calcium alginate fiber with a covered bordered dressing. · Skin Observation assessment dated [DATE], showed a skin check was completed and no skin conditions observed, or skin conditions had resolved. The Care Plan tab noted that the resident was at risk for minor skin injuries related to impaired mobility and use of aspirin. The goal was for the resident to be free from skin injury and the interventions were to keep the resident's skin clean and dry, use lotion on dry skin and do not apply on site of injury. (The site of injury was not identified). · Review of a hospital discharge summary dated 03/30/2022, showed the resident had presented to the hospital from the facility with a Stage III PI to their ankle (the documentation did not identify if the PI was on the right or left ankle, and was three days after the facility completed a skin observation that documented no skin conditions). · Physician communication dated 03/31/2022, showed a signed order which included to discontinue calcium silver alginate dressing, and to clean with normal saline and apply med honey, cover with foam dressing to the right ankle. (Silver alginate was ordered on 03/15/2022 to left ankle wound). · physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was noted to have intermittent pain to their ankle where the PI was and was to wear a pressure minimizing boot to protect the resident from further pressure to the area (The documentation did not identify which ankle, the right or the left). · TAR dated 04/01/2022, showed an order to cleanse the right ankle with normal saline apply med honey (a type of treatment) and cover with foam dressing every two days of which was not noted to have been completed and then was discontinued on 04/04/2022. · Progress note dated 04/04/2022, showed the boil to the right ankle had resolved, a scabbed area remained which measured 0.4 cm by 0.4 cm, the physician was notified, the treatment was discontinued and a pressure relieving boot was to remain in place. · Wound Registered Nurse (RN) assessment dated [DATE], showed the resident had a Stage II pressure injury. (The assessment did not identify where the pressure injury was located). · TAR dated 04/11/2022, showed an order on 04/11/2022 for [MEDICATION(S)], (a medication for dementia [the order was for [MEDICATION(S)] an antimicrobial medication]) gel and calcium alginate to wound bed, cover with foam dressing and change every two days as needed for only one time for the pressure ulcer Stage II. (The order did not identify where the pressure injury/ulcer was located). · Skin Observation dated 04/13/2022, showed right inner ankle had an intact dressing, the treatment section noted to be non-pharmacological treatment to monitor until resolved, the Care Plan section noted a focus risk of minor skin injuries related to impaired mobility with a goal to be free of skin injury and the intervention was to keep skin clean and dry, use lotion on dry skin, do not apply on site of injury. (Observation of the resident's wound on 04/14/2022 was to the right lateral malleolus [outer ankle] and review of the Care Plan showed no focused skin problem). In an interview on 04/14/2022 at 1:50 PM, Staff B, Nursing Assistant Registered, stated that if they had noted a new or worsening skin impairment, they would tell the nurse and complete a Stopwatch on the chart in the computer. Staff B stated that the specific care for the residents were directed from the care plan. Staff B stated that if a resident refused care, they would not provide the refused care but would notify the nurse. In an interview on 04/14/2022 at 2:23 PM, Staff C, Nursing Assistant Certified, stated that level of care the resident required was directed from the Kardex (a guide for direct care staff) and they would check the care plan book at the nurse's station. Staff C stated that if a resident had a new skin impairment, they would tell the nurse immediately so they could [MEDICATION(S)]. In an interview on 04/14/2022 at 2:40 PM, Staff A stated that if a resident had a new skin issue, they would assess the resident, obtain a measurement of the injury, would call the doctor, and place a skin assessment in the chart. Staff A stated that they would complete a risk management if the cause of the injury was unknown but would only complete that for injuries of unknown origin and not for pressure injuries. Staff A stated that if a resident's wound changed, they would inform the provider. Staff A stated that they had a wound nurse that came in the mornings, and they did daily wound assessments and the skin treatments were completed by the floor nurse. Staff A stated that the wound nurse was from outside the facility. Staff A stated that they measured the residents' wounds with the daily dressing changes and documented on the User Defined Assessment. In an observation and interview on 04/14/2022 at 4:28 PM, the DNS was asked to look at the resident's wound. The DNS stated that the wound to the outer right ankle looked like a Stage III PI injury and measured 1.0 cm by 0.5 cm by 0.2 cm deep. The DNS stated that initially the wound presented as a boil with red [CONDITION(S)] and did not look like a PI. The DNS stated that the Advanced Registered Nurse Practitioner had visualized the wound and had said that it was a boil. The DNS stated that right after the resident had gone to the hospital for a [CONDITION(S)], they had returned with new treatment orders for the resident's right ankle. The DNS stated that the wound was closed on 04/04/2022 and had a small scab. The DNS stated that the treatment orders were discontinued, and a new order indicated to keep the pressure relieving boot in place. The DNS stated that they had just visualized the wound now, since they had last seen the wound prior to going on vacation. In a follow up interview on 04/14/2022 at 4:47 PM, the DNS stated that their expectations were for the nurse to dress wounds after a resident's bath. The DNS stated that they expected the nursing staff to start an incident report on newly identified pressure injuries, complete the wound data collection assessment, an RN wound collection assessment, notify the resident's representatives and physician and complete the ordered wound treatment. The DNS stated that all the interventions would be documented. The DNS stated that they had just got back from vacation and needed to update the resident's information from her staff's email about the resident's PI. In conclusion the facility's documentation varied from a scabbed area to the right ankle to a boil on the left ankle, to no skin impairment at all which failed to ensure a complete and accurate representation of the resident's skin conditions. The facility failed to ensure treatments and interventions were consistently implemented to prevent the resident's PI from progressing to a Stage III PI. Reference: (WAC) 388-97-1060 (3)(b)

Based on interview, and record review, the facility failed to implement behavioral health interventions for one of one resident (1) reviewed for behavioral health. The failure to implement individualized approaches for Resident 1, resulted in harm to Resident 1 related to displacement from their home and placed other residents at risk of physical and psychological harm, and diminished emotional quality of life related to being displaced from their home. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan problem showed that the resident displayed inappropriate behaviors related to a previous TBI, recent stroke and impulse control impairment evidence by inappropriate hand gestures and attempted to touch females with an initiated date of 08/03/2020 and revision date of 04/22/2021. The goal was the resident would accept redirection if inappropriate behaviors were displayed. Review of the referral for Psychological Assessment and Treatment was noted to have been made on 08/04/2021. Review of the Psychological Treatment Plan dated 09/02/2021 showed the following interventions: 1. Journal/record all impulsive acts and bring to psychologist for weekly sessions on Thursdays; 2. Identify a uniform response to socially inappropriate sexual behavior; 3. Enact the uniform response to socially inappropriate behavior; 4. Refrain from smiling at inappropriate comments; and 5. Take the resident to their room as the resident indicated that they required time by themselves. Review of the resident's current care plan showed it had not been updated with the above Psychological Treatment Plan. Review of a blank undated Psychological Treatment Plan showed the following: - A detailed daily schedule for the resident from 8:00 AM to 7:30 PM; - 1:1 staff would perform every 15 minute checks, would document any inappropriate behaviors and would follow the procedure for responding to the inappropriate behavior; - Examples of inappropriate behaviors included grabbing, abusing others sexually, sexual comments, disruptive sounds, touching others and socially inappropriate comments such as comments about someone's dress or any body part. Procedures for responding to the inappropriate behavior was as follows: - If impulsive and/or made an inappropriate comment: i.e. take to room and then share why the action or comment was inappropriate; - Remove the resident from the situation first and take to a private place i.e. the resident's room-this had to be consistent and occur with all situations as they applied; - Refrain from smiling or laughing when the resident made inappropriate comments, i.e. about body parts, sexual acts or sexual intent; - Staff would provide options of activities that could be done independently such as watch television, use I-pad for a minimum of 15 minutes; - Staff could document very specifically in a hard copy log (of what had occurred); and - Health Information Management to follow up with medical records and scan into the resident records if needed. The plan stated the Psychologist would review the documentation every Thursday. The resident's care plan was not updated with the Psychological Treatment Plan. Review of the Behavior Monitoring Log had a every 15 minute time frame, which included an area to document behaviors, activities, interventions, and if the interventions were effective. Example of Behaviors showed the following: 1) Grabbing, 2) Hitting, 3) Abusing others sexually, 4) Cursing at others, 5) Sexual comments, 6) Public sexual acts, 7) Disrobing in public, 8) Disruptive sounds, 9) Obscene gestures, 10) Touching, 11) Negative statements, 12) Other- specify, enter N/A if no behaviors observed. The interventions included: 1) Distractive act, 2) Play bingo, games or structured act, 3) Help with privacy, 4) Validate feelings and needs, 5) Help call family, [NAME] or support group, 6) Give a stress ball to hold and 7) Take on wheelchair walks outside. Review of the one-to-one Behavior Monitoring Logs from time slots from 7:15 AM to 9:00 PM for 09/17/2021 through 10/07/2021 showed the following: - On 09/24/2021 - at noon the behavior was noted that the resident went to grab a staff member, the resident was placed in their room for 15 minutes and there was no indication that this intervention was effective or not, and all other times were not filled out (they were blank); - On 09/25/2021 - there was no documentation regarding the resident's behavior (it was left blank); - On 09/26/2021 - the 15-minute checks were completed on a 15-minute check sheet with a handwritten note, Sorry I couldn't find the other time sheet; - On 09/27/2021, 09/28/2021, 09/29/2021, 09/30/2021, 10/01/2021, 10/02/2021, 10/03/2021, 10/04/2021, and10/05/2021 - there was no documentation regarding the resident's behavior (the documentation was left blank); and -On 10/06/2021 and 10/07/2021there was no documentation provided.In an interview on 10/04/2021 at 1:49 PM, Staff E, Nursing Assistant Certified (NAC), stated that they knew the level of care a resident required by rereviewing the resident's care plan. In an interview on 10/06/2021 at 2:06 PM, Staff EE, NAC stated that they know the resident's care needs by checking the Kardex (a guide for direct care providers derived from the care plan). Review of the Progress Note dated 10/07/2021 showed Resident 2's hand was down the front of Resident 1's pants. Review of the Nursing Home Transfer or Discharge Notice dated 10/07/2021 showed the facility could not meet the resident's mental health needs and to keep other resident safe from Resident 1's sexual behaviors. (The resident did not have a change in behaviors from the time the resident had resided in the facility) In an interview on 10/21/2021 at 9:43 AM, Staff J, Registered Nurse (RN), stated that the resident's care plan would show the care needs of the resident. In an interview on 10/21/2021 at 9:54 AM, Staff B, Social Services stated that they could not answer why the resident was sent to the hospital with documentation that the facility would not accept the resident back to the facility. In an interview on 10/21/2021 at 11:12 AM, Staff H, NAC, stated that when doing the one-to-one for Resident 1 they were to fill out the 15 minute checks on the behavior monitoring log, initial every 15 minutes and write where and what the resident was doing at that time. In an interview on 10/21/2021 at 11:52 AM, Staff Y, RN, stated that prior to the current Interim Director of Nursing (DNS) that they had been the Interim DNS. Staff Y stated that they had worked with the Psychologist and came up with a specific behavioral health plan for Resident 1 that was kept in a book. Staff Y stated that they educated the nursing staff, so the plan worked, and everyone was to read and sign Resident 1's plan. Staff Y stated they thought the plan had been care planned but was unsure. The behavioral health book was not provided when requested to review, Staff Y indicated they were unsure where the book was as they were unable to locate it. In a follow up interview on 10/21/2021 at 3:07 PM, Staff Y stated the Psychologist was seeing Resident 1 and they reviewed Resident 1's plan with the one-to-one supervision and went over the resident's behaviors. Staff Y stated that the one-to-one documentation was missing, that they had a book with the documentation and now the book did not have all the items. In a co- interview on 10/21/2021 at 2:24 PM, the Administrator stated that they would not accept Resident 1 back into the facility. The Regional Vice President (RVP) stated that they were not aware prior to the resident's discharge to the hospital with documentation the facility would not accept the resident back was aware after the fact. The RVP stated that they supported the Administrator in the discharge and refusal to readmit Resident 1. In a phone interview on 11/01/2021 at 5:02 PM, Collateral Contact 5 (CC 5), Doctor of Psychology/Psychologist, stated that their understanding was that the facility was going to implement their plan but was not able to tell if the facility had followed through because they were not there to observe the implementation of the plan. CC 5 stated that they thought there was the piece of the TBI impulse ability and Resident 1 could learn to know what not to do and could curb their behavior. CC 5 stated that they felt Resident 1 would learn from the interventions if the plan was consistently implemented. CC 5 stated that they had a concern when the rsdient first was admitted to the facility as they were clearly focused on looking at the women, it was not suprising in and of itself. CC 5 stated that they were unsure if the facility was a good setting for the resident and had informed the facility when they first started therapy with the resident. CC 5 stated that when they had informed the facility of their concerns and the facility staff had stated that there were not concerns at that time. In conclusion the facility failed to implement identified behavioral health interventions that were to be implemented while the resident was on one-to-one supervised care. The facility did not provide the interventions which resulted in Resident 1 having non consensual sexual contact with Resident 2 and the discharge of Resident 1 from their home. The facility denied the readmission of Resident 1 which resulted in harm due to the displacement of Resident 1 from their home from 10/07/2021 to 11/12/2021. Refer to CFR 483.25 (d)(2) - F689 Free of Accident Hazards/Supervision/Devices Refer to CFR 483.12 - F 600 Free from Abuse and Neglect Refer to CFR 483.15 (c)(2) - F622 Transfer and Discharge Requirements Refer to CFR 483.15 (c) (3) - F623 Notice Requirements Before Transfer/Discharge Reference: WAC 388-97-1060(1).

Based on observation, interview and record review the facility failed to ensure two of two residents (1 and 2) received adequate supervision related to Resident 1's impulse control and a history of sexually acting out, and Resident 2's cognitive impairment. This failed practice resulted in harm to Resident 2 and placed other residents at a potential risk of harm, pertaining to Resident 1 having unsupervised access. Findings included . Review of the facility's policy for one-to-one supervision showed the facility did not have a policy to address the needs of facility residents who require one to one supervision. In an interview on 10/08/2021 at 10:45 PM, Staff F, Interim Director of Nursing Services (DNS)stated that a one to one caregiver meant a dedicated staff member to that one individual resident. RESIDENT 2 Resident 2 was admitted to the facility on [DATE] with diagnosis to include Alzheimer's disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident 2's Brief Interview or Mental Status (BIMS) impairment score was 3 out of 15, which indicated the resident had severe cognitive impairment. RESIDENT 1 Resident 1 was admitted to the facility on [DATE] with diagnoses to include [CONDITION(S)] (TBI) with left [CONDITION(S)] (muscle weakness or [CONDITION(S)] to one side of the body), from a motor vehicle accident in 1984, stroke, difficulty swallowing, wheelchair dependent and chronic pain. Review of the initial Minimum Data Set (MDS) assessment dated [DATE] showed the resident did have noted episodes of physical behavioral symptoms. Further review of the following quarterly MDS assessments dated 10/28/2020, 01/26/2021, and 04/13/2021 and the annual MDS assessment dated [DATE], showed the resident had no physical behavioral symptoms and had a BIMS of 13 out of 15, which indicated the resident was not cognitively impaired. Review of the care plan problem showed that the resident displayed inappropriate behaviors, with an initiation date of 08/03/2020 and revised date of 04/22/2021, related to previous TBI, recent stroke and impulse control impairment evidence by inappropriate hand gestures and attempt to touch females. The goal was the resident would accept redirection if inappropriate behaviors were displayed. The following interventions were noted: -Monitor resident for inappropriate behaviors including touching, displayed toward female residents. - Ensure resident remained well out of touching distance (at least six feet) with regard to female residents. - The resident was to be under one-to one direct supervision by staff when awake from 8:00 AM to 1:00 PM, and 4:00 PM to 7:30 PM; - Quiet time in the resident's room from 1:00 to 2:00 PM with 15-minute checks; - Door alarm in the entrance of the resident's room to alert the staff when the resident left the room; - Stop sign across the doorway to prevent confused residents from wandering into their room unsupervised; and - While providing one-to-one supervision, staff to offer and engage the resident in activities such as bingo, cared games, large print word puzzles and board games. Review of the documentation of the resident's one-to-one supervision from 09/19/2021 through 10/05/2021 showed the following times the resident was without one-to-one supervision: -09/19/2021 8:00 AM to 9:00 AM and 10:15 AM to 7:30 PM; - 09/20/2021 no documentation of one-to-one supervision; - 09/21/2021 no documentation of one-to-one supervision; - 09/22/2021 8:00 AM to 8:30 AM and 1:15 PM to 7:30 PM; - 09/23/2021 8:00 AM to 11:00 AM and 1:15 PM to 2:15 PM and 5:45 PM to 7:30 PM; - 09/24/2021 8:00 AM to 8:30 AM, 11:00 AM to 12:00 PM, 1:15 PM to 2:00 PM, 2:30 PM to 5:30 PM; - 09/25/2021 1:15 PM to 4:00 PM; - 09/26/2021 8:00 AM to 4:00 PM; - 09/27/2021 8:00 AM to 8:30 AM and 1:15 PM to 3:45 PM; - 09/28/2021 8:00 AM to 8:30 AM and 1:15 PM to 2:15 PM; - 09/29/2021 8:00 AM to 8:30 AM and 1:15 PM to 4:15 PM; - 09/30/2021 8:00 AM to 8:30 AM and 1:15 PM to 3:45 PM; - 10/01/2021 8:00 AM to 8:30 AM and 1:15 PM to 7:30 PM; - 10/02/2021 1:15 PM to 4:00 PM; - 10/04/2021 8:00 AM to 8:30 AM and 1:15 PM to 7:30 PM and - 10/05/2021 8:00 AM to 4:00 PM. In an observation and interview on 10/06/2021 at 12:45 PM, Resident 1 was in the dining room with no staff in the visible vicinity of the resident. The resident stated that they needed their teeth. The resident opened their mouth and noted to have their teeth in place. Review of the Progress Note dated 10/07/2021 at 2:38 PM, showed Resident 1 was witnessed sitting in the activity/dining room with a female resident. Staff A, Nursing Assistant Certified (NAC) noted Resident 1 was seen sitting next to Resident 2, a female resident with their hand down the front of Resident 1's pants. Review of the Progress Note dated 10/07/2021 at 6:48 PM showed that Staff C, Physician Assistant (PA) was in the facility and was in the office across from where Resident 1 had been when the incident had occurred. Staff C stated that they had been observing Resident 1 and their behavior during activities just prior to Resident 1 touching a female resident. Staff C stated that Resident 1 had been joking around a lot, not following the activities well and engaged in attention seeking behaviors. In an interview on 10/08/2021 at 9:37 AM, Staff D, NAC, stated that they had been on their lunch when the incident occurred with Resident 1 on 10/07/2021. Staff D stated that Resident 1 was one of their residents to care for on the day of the incident. Staff D stated that the resident had been good, joking and their usual self. Staff D stated that they had known the resident had been on one-to-one supervision recently but was not on one-to-one on the day of the incident. Staff D stated that they thought it was a staffing issue and they had difficulty getting someone to do the one-to-one full time. Staff D stated that the prior staff who was doing one-to-one had put in their notice, they had been supervising Resident 1 from 8:00 AM until lunch, then the resident would take a nap and would be supervised after the resident's nap until the resident went to bed. In an interview on 10/08/2021 at 10:22 AM, Staff E, NAC, stated that they had witnessed the end of the incident. Staff E stated that Staff A, NAC, alerted Staff E of the incident. In an interview on 10/08/2021 at 10:25 AM, Staff A, NAC, stated that they just started working at the facility and it was her second day. Staff A stated that her training partner left, and Staff A was at the nurses station. Staff A stated that they saw Resident 1 watching TV in the Dining/Activity room. Staff A stated that Resident 2 was in the Dining/Activity room as well. Staff A stated that Resident 1 was looking around like they needed something, and Staff A went into the Dining/Activity room and Resident 2 had their hand in the front of Resident's 1 pants. Staff A stated that Resident 1 did not have one-to-one supervision at the time. In an interview on 10/08/021 at 10:45 AM, Staff F, Interim Director of Nursing stated that Resident 1 had been alone in the Activity/Dining room. Staff F stated that Resident 2 had wheeled themselves up to Resident 1. Staff F stated that the facility did not have one-to-one dedicated staff supervision for Resident 1 due to critical staffing but had distance supervision. In an interview on 10/08/2021 at 11:18 AM, Staff G, Activities Supervisor stated that on 10/07/2021 they had been with Resident 1 from 10:30 AM to 11:30 AM in activities and at 11:30 AM, Resident 1 went to their room to use the bathroom. Staff G stated that Resident 2 was the only one left in the Activity/Dining room and they were watching TV. Staff G stated that the staff know that they were to watch Resident 1. Staff G stated that they were assigned to supervise the resident when the assigned staff was not in the facility. Staff G stated that they knew the activity staff would be pulled to supervise the resident. Staff G stated that they had reported in the facility's morning stand up meeting that they were with Resident 1 from 10:30 AM to 11:30 AM. Staff G stated that if they had been informed that Resident 1 did not have one-to-one supervision that they would flex there day and they were always available. In an interview on 10/21/2021 at 11:12 AM, Staff H, NAC, stated that if a resident was on one-to-one supervision the staff would fill out the 15-minute check log. Staff H stated that they would document the time, where and what the resident was doing, the resident's behavior and initial every 15 minutes. Staff H stated that they were aware the resident did not have one-to-one supervision on some days when there were not enough people to do the one-to-one assignment. Staff H stated that they would put Resident 1 right in front of the window in the Activity/Dining room across from the nursing station and everyone would keep an eye on Resident 1. In an interview on 10/21/2021 at 11:44 AM, Staff I, Licensed Practical Nurse (LPN) stated that originally the Administrator scheduled the one-to-one supervision for Resident 1 but then it was changed to nursing. Staff I stated that Resident 1 would be on 15-minute check if there was no one for one-to-one supervision or encourage them to stay in their room. Staff I stated that somedays the activity person did the one-to-one supervision and they had one-to-one documentation sheets. In an interview on 10/21/2021 at 9:43 AM, Staff J, Registered Nurse stated that the facility's leadership managed when a one-to-one staff was not present. Staff J stated that it was a team approach, and the DNS scheduled the one-to-one supervision, and it was discussed in the daily stand-up meetings. Staff J stated that everyone pulled together, and the one-to-one was documented on paper not on the electronic medical record. In an interview on 10/21/2021 at 9:55 AM, Staff K, Environmental Services Supervisor stated that they did not schedule one-to-one supervision for Resident 1 and was not sure who did. Staff K stated that one of their housekeepers was doing the one-to-one supervision for Resident 1 Monday through Friday, but that they were not the one to make sure there was someone scheduled. In an interview on 10/21/2021 at 10:09 AM, Staff L, NAC stated that there was a one-to-one schedule for Resident 1 in the staff room, they put it in there that way just in case there was a change. Staff L stated that it would give the staff of needed schedule range and they always tell the nurse about it. In a follow up interview on 10/21/2021 at 10:44 AM, Staff H, NAC stated that the licensed staff scheduled the one-to-one supervision for Resident 1. Staff H stated that there was a notebook to chart every 15-minute checks. In an interview on 10/21/2021 at 10:46 AM, Staff M, LPN stated that upper management schedules the one-to-one and we all are responsible to make sure the one-to-one was consistent with the resident. In conclusion the facility failed to coordinate the one-to-one supervision for Resident 1 which led to Resident 1 being unsupervised and engaged in non consensual sexual contact with Resident 2 who had severe cognitive impairment. Reference: (WAC) 388-97-1060 (1) (3) (g)

Based on observation, interview and record review, the facility failed to consistently provide an environment, which supported and enhanced each resident's quality of life, which was person-centered, supported each resident's preferences and personal control over choices, and promoted each resident's sense of well-being. This failure resulted in psychological harm for one of five residents (6) reviewed for abuse allegations who subsequently felt distressed regarding staff interaction, and lack of a dignified responsiveness to their needs and resulted in psychological harm for Resident 6 who experienced sadness, fear, disrespect, anxiety, restlessness and sleeping disturbance. Findings included . Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly Minimum Data Set assessment, dated 02/02/2021, showed the resident was cognitively intact and had no behaviors or rejection of care. Review of a handwritten statement from Resident 4, roommate of Resident 6, showed Staff E, Nursing Assistant Certified (NAC), told her roommate (Resident 6) that, This is a rehab (rehabilitation). I get sick and tired of you calling out every time you want something when you want it, no matter what anyone else is doing. You want, want, want and demand it be done when you want it. Resident 6 was in tears and told Staff E, Please do not talk to me like this. Staff E stated, You just sit in your doorway and holler about what you need. I will talk to you any damn way I want. I am tired of this. This is a rehab (swear word). Resident 6 was still in tears and stated, Please do not talk to me like this. Staff E stated the resident needed to go to the dining hall. If you don't like it, tell the Governor. You just watch TV all day. The resident again told Staff E Please don't talk to me like that. Staff E stated that I'm sick of people that lay around and never try to help themselves. Resident 6 remained in tears and responded, I can't use my hand and I need help. Resident 4 stated, Staff E then left Resident 6 in her bathroom and did not come back. A while later Staff X, Registered Nurse (RN), entered the room and the residents reported their concerns. Review of a progress note dated 02/28/2021 at 4:23 PM, showed at 8:00 AM, Staff X entered the resident's room and told her that the caregiver had treated them badly. The resident was noted to be somewhat subdued the rest of the morning. Review of a progress note dated 03/01/2021 at 12:38 PM, showed the resident was teary and stated I don't feel good how I was treated yesterday. It was bad. In an interview on 03/04/2021 at 3:25 PM, Resident 4, roommate of Resident 6 stated, they woke up to Staff E loudly calling her roommate (Resident 6) lazy, and telling her she needed to get up because this was a rehabilitation place. Staff E was swearing and her roommate was crying and saying, Please do not talk to me that way. Resident 4 stated that Resident 6 told Staff E three times to not talk to her that way. Resident 4 stated, Staff E was throwing her roommates things and saying you need to be busy with activities and quit staying in here. Staff E stated that You just sit in your doorway and holler about what you need. I will talk to you any damn way I want. I am tired of this. This is a rehab (rehabilitation) (swear word). Resident 6 was still in tears and stated, Please do not talk to me like this. Staff E stated the resident needed to go to the dining hall and that If you don't like it, tell the Governor. You just watch TV all day. The resident again told Staff E Please don't talk to me like that. Staff E stated, I'm sick of people that lay around and never try to help themselves. Resident 6 was in tears and responded, I can't use my hand and I need help. Resident 4 stated, Staff E then left Resident 6 in her bathroom and did not come back. A while later Staff X came in and both residents reported their concerns. In a phone interview on 03/04/2021 at 3:44 PM, Resident 6 stated Sunday morning Staff E's mood was up and down and she used nasty swear words at me. She hurt me to the core and there is no excuse for that. I am afraid they will bring her back. She told me to get up. She said I was lazy and this was a rehab place so I need to get out of bed and stop hollering from the doorway. It was terrible she made me feel very bad. I still feel that way. There was no reason for her to talk to me that way. She treated me like I was nothing. She swore at me. I do not like swearing. She looked like she was crazy .running back in the room, throwing my items and clothes down. It was as if she was not all there. She cannot work here, I cannot get over it. I am having bad dreams. I cannot settle myself down. The resident said she was worried other residents who could not speak up for themselves had been treated poorly. In a phone interview on 03/05/2021 at 12:20 PM, Staff E stated on the morning of 02/28/2021, Resident 6's call light was on. Staff E stated they went in to ask the resident about going to the dining room and it did not go well. Staff E said the resident will sit in their doorway and holler for their needs. Staff E said they yell their needs out and there are a lot of staff demands. Staff E stated the facility did not have the staff they need and they agreed with Resident 6 that residents have to wait longer than they should. Staff E commented turnover was high and they were short staffed. Staff E said staff are burned out and stretched thin. We can get to the point where we lose our ability to address ourselves at the time. You get stressed, you cannot stop yourself. We are all at risk of making mistakes. It is not a safe environment to work. Someone can be under enough pressure to be tired and aggressive with residents. I feel like a monster and I am not. I am labeled to be someone who is abusing and neglecting people. People have bad days, even me. Staff E said they told the (DNS) this morning, I cannot think of one good shift here in the past couple months. Not one. Review of the investigative summary for the allegation of verbal altercation between Staff E, NAC and Resident 6, showed the resident was offered on 02/28/2021 to go to the dining room for breakfast and became upset, as she had never gone to the dining room. Staff E provided rationale of complaining and being in her room all the time as an explanation. This upset the roommate (Resident 4) and resident, and they reported their concern to the nurse assigned .The caregiver lacked understanding of what implications might come into place for residents who have been in isolation for more than three months. The resident's preferences were also not care planned to appraise the caregiver .Residents became unhappy. Resident 6 felt pressured to leave her room and in a manner found to be unwelcomed and disrespectful. The manager evaluation dated 03/05/2021 showed Staff E had been spoken to about their behavior directed at residents on previous occasions. One instance was Staff E was educated to not lock a resident's w/cs who are unable to unlock them on their own. The evaluation showed Staff E was expected to treat residents, coworkers and all individuals they encountered with respect and professionalism. Staff E would be reeducated regarding resident rights and the expectation to be kind and provide dignified care to residents. During a joint telephone interview with the Director of Nursing (DNS) and Administrator on 03/17/21 at 12:33 PM, they were informed Resident 6 was emotionally upset by the 02/28/2021 incident with Staff E, during the incident as well as days later. The resident reported she experienced sadness, fear, was disrespected, difficulty coping and sleeping after the interaction with Staff E. No additional information was provided. WAC Reference 388-97-0860(1)(a)(2)

Based on observation, interview and record review, the facility failed to maintain resident dignity by not respecting privacy during care for 1 of 1 residents (# 1). This failure violated the residents' privacy resulting in harm to Resident #1 when she experienced feelings of humiliation, embarrassment, diminished self-worth, self-esteem and overall well-being. Findings included . The Cambridge English Dictionary defines Dignity as The quality of a person that makes him/her deserving of respect, sometimes shown in behavior or appearance. Review of the facility's routine practice policy dated 09/20/2020, directed staff to promote dignity by ensuring privacy. Resident #1 admitted on [DATE]. She was cognitively intact and able to make her needs known. In an interview and observation on 11/09/2020 at 12:40 PM, Resident #1 stated she had an upsetting experience with a nurse, Staff A, Registered Nurse (RN), who looked at her breasts with a young housekeeper present in the room. Resident #1 stated she pleaded with Staff A to come and look later in private but Staff A proceeded to lift her shirt and she (Resident #1) looked anyway. Resident #1 stated the nurse disregarded her privacy and her wishes. Resident #1 stated she was embarrassed and she apologized to the housekeeper for seeing her breasts. The resident began crying and stated, I told the nurse to stop and she didn't. I was so traumatized and mortified. I still am. In an interview on 11/09/2020 at 1:47 PM, Staff A stated she found out later Resident #1 was upset with her after she looked at her breasts. Staff A commented the resident was private and provided no additional information. In an interview on 11/12/2020 at 2:40 PM, Staff I, RN, stated Resident #1 was private and modest and comfortable with only a few staff. In an interview on 11/18/2020 at 10:28 AM, Staff J, facility contracted counselor, stated Staff A did not respect Resident #1's rights during an assessment. Resident #1 was upset, tearful and stated she felt embarrassed and humiliated. Resident #1 told Staff J that she was exposed (her breasts) and her rights were not honored. Staff J stated she reported the privacy breach to Staff C, Social Services. In an interview on 11/18/2020 at 10:50 AM, Resident #1's friend stated Staff A caused Resident #1 stress. She stated Staff A was checking her breasts with a cleaning lady present. Staff A disregarded her wish to have the nurse come back another time. Resident #1 stated she was humiliated, embarrassed and disregarded and did not want that nurse caring for her. The resident told her there had been a prior incident with this same nurse and she had been taken off Resident #1's care at one time, but Staff A was now back to taking care of her. In an interview on 11/18/2020 at 1:26 PM, Resident #1 stated the first incident with Staff A was she would come in and wake her up at six in the morning. Staff A commented to her,Oh I see you have a beard. I guess some ladies like that sort of thing. She (Staff A) was rude and crude. It was so upsetting. I am not at home so I couldn't take care of my stubble like I usually do. Nobody had even offered to help me with my hair on my face. I didn't even know I could have a washcloth or toothbrush. Resident #1 began to cry and stated she was used to taking care of all of her own needs. Resident #1 again commented that was humiliating when Staff A came in, lifted my top and I said please wait. The young housekeeper was there. She disregarded my wishes and looked at my boobs. I was pleading with her and now (Stafff A) is cold and indifferent to me. In a joint interview with the interim Administrator and Director of Nursing Services on 12/07/2020 at 10:18 AM, they were informed Resident #1 described embarrassment, humiliation, lack of value and that her wishes were not honored by Staff A. The interim Administrator stated the end goal would be for the resident's privacy to be honored and the nurse could have returned later or asked the housekeeper to step outside during the care. Reference: (WAC) 388-97-0860 (1)(a)

Based on observation, interview and record review, the facility failed to ensure two of two residents (#2 and #3), were free from sexual abuse from Resident #1. The facility failed to provide adequate supervision, ensure resident protection and interventions to prevent unwanted sexual touching in vulnerable female residents. These failures resulted in psychological harm for Resident #3 and caused Resident #2 signs of emotional distress and placed all residents at risk for abuse and placed them at risk for fear, mental anguish, intimidation and feelings of victimization. Findings included . Review of the facility's online abuse training provided to staff showed, Sexual abuse is non-consensual sexual contact .Sexual abuse includes unwanted touching .First, ensure the person's safety. If you actually witness abuse, you must intervene to stop it. Get help immediately, but do not leave the person alone with the abuser. You must also file an immediate report with your supervisor. It is your responsibility to protect vulnerable adults from abuse. In many cases, you are the first line of defense. This means you need to know what steps you can take to prevent abuse. Review of facility's policy titled, Abuse and Neglect Policy and Procedure, revised 10/18, showed residents have the right to be free from abuse. The location (facility) would: - Identify and remedy any abusive situations; - Prevent future injuries; - Have evidence that all alleged or suspected violations are thoroughly investigated and would prevent further potential abuse while the investigation was in progress; - The abuse/neglect policies and procedures could not and did not guarantee that abuse would never occur. To prevent such occurrences, all reasonable measures within our control would be taken; and - If it was an allegation of resident to resident abuse, the residents would be separated immediately and both ensured a safe environment. RESIDENT #1 Resident #1 admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 08/03/2020, showed over the past one to three days he had physical behavior symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). Resident #1 was identified to have cognitive impairment, but could make his needs known. He was able to self propel independently in his wheelchair. Review of the care plan, initiated on 08/03/2020, showed a history of inappropriate sexual behavior as evidenced by inappropriate touching of self in public and behaviors of inappropriate touching of female staff. The care plan directed to use two staff with all personal care and that the resident appeared to understand the phrase needing to act like a gentleman. Review of a nursing progress note written by Staff H, LPN (Licensed Practical Nurse) dated 09/09/2020 at 2:45 PM, showed that at approximately 12:15 PM, Staff E, Certified Nursing Assistant (CNA), witnessed Resident #1 inappropriately squeezing a female (Resident #2) resident's breast. Staff E, who was down the hall, asked Resident #1 to stop and Resident #1 removed his hand from Resident #2s breast. The nurse documented that when Resident #1 was asked about the incident, he was very apologetic, stating, I did something bad, I'm sorry and I won't do it again. Review of the Director of Nursing Services (DNS) communication to staff posted at the nurse's station, dated 09/09/2020 directed staff to: - Follow Resident #1s care plan to have two staff at all times for personal care .; - Resident #1 was to be kept at least six feet (or within reach) away from all female residents and was placed on fifteen minute status checks until further notice; and - Take advantage of opportunities to reinforce appropriate behavior be especially aware of his wheelchair mobility in relation to other potentially at-risk residents (ex. Resident #3). Report any further instances of inappropriate behaviors immediately to leadership and ensure safety of resident immediately. Review of a nursing progress note on 09/16/2020 at 2:40 PM, showed that Resident #1 was in the dining room in his wheelchair and Resident #3 (a female) was sitting on the couch when Resident #1 took his hand and touched Resident #3 on her knee and moved his hand up and touched her breast. Both residents were seen five minutes earlier in the dining room, by a staff member. Another unidentified CNA had been talking, 30 minutes prior to the incident, with Resident #1 who stated to the unidentified CNA that it was inappropriate to grope women. Resident #1 replied, I cannot touch a woman's breast without consent. Review of Resident #1s care plan, printed on 09/16/2020 with initiation of 09/09/2020, directed staff to monitor Resident #1 for inappropriate behaviors, including touching, displayed toward female residents. Staff were directed to ensure female residents remained out of touching distance (at least six feet). Resident #1 was to be under constant direct visual supervision whenever he was out of his room, in his wheelchair or within general proximity of other female residents. The care plan did not include the every fifteen minute checks until brought to facility staff's attention on 09/17/2020. Review of the Bedside Kardex (guide to direct CNAs on how to provide care) printed 09/17/2020 did not include any directive on supervision for Resident #1 or his history of inappropriate touching to two female residents. There was no directive to staff on every fifteen minute supervision. Review of a progress note dated 09/17/2020 at 12:00 PM, Staff A, Social Service (SS), showed that Resident #1 was an ongoing risk and thought he could verbalize his behavior was wrong, he had no ability to control himself, and per staff who Resident #1 had spoken too, he did not have the intellectual ability to connect what he was wrong with his actions. RESIDENT TO RESIDENT SEXUAL ABUSE ALLEGATION BETWEEN RESIDENT #1 AND RESIDENT #2 RESIDENT #2 Resident #2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Quarterly MDS assessment dated [DATE], showed she was cognitively impaired and unable to verbalize her needs. Resident #2 required extensive assistance for all care and was unable to move without staff assistance. Review of the witness report dated 09/09/2020 at 12:15 PM Staff E documented she saw Resident #1 five minutes before the incident when she witnessed Resident #1 trying to put a flower necklace on Resident #2. Resident #2 was observed to move her head away from Resident #1. Staff E told Resident #1 to stop because the look on Resident #2s face appeared she was upset with him. Staff E told Resident #1 to keep his hands to himself, and then proceeded to walk down the hall to help another CNA. Before Staff E entered another resident's room, she looked back and witnessed Resident #1 place his hand on Resident #2s right breast and began squeezing. Staff E stated she then yelled at Resident #1 to stop (which he did) and Staff E removed Resident #2 from the area. In a phone interview on 09/21/2020 at 4:04 PM, Staff E recalled the incident that occurred on 09/09/2020 between Resident #1 and Resident #2. Staff E stated, Resident #1 was sitting by Resident #2 and they were not six feet apart. Resident #1 had a paper necklace, and with his one good hand was trying to place this necklace on Resident #2. Staff E stated, Resident #2s hair was all messed up and she was distressed, her eyes were big and she looked like get that man away from me. Staff E told Resident #1 to stay six feet away from Resident #2 and thought she saw him backing up, in his wheelchair, as she then walked down the hall to help another CNA. Staff E stated, as she went into another resident's room, she looked back and saw Resident #1 squeezing Resident #2s right breast. Resident #2s mouth was wide open, looked distressed and shocked and she could not lift her hands up to protect herself. Resident #2's facial response was consistent with the reasonable person who did not wish to endure unwanted touching of their private body parts while in their environment. Staff E intervened and moved Resident #2 away from Resident #1 and reported the incident to the nurse (who had been on a break when this occurred). Staff E stated, she had spoken to Resident #1s mother who stated that he likes the ladies but did not go into much detail. Staff E stated, she did not remove Resident #1 when she reminded him to stay six feet away from Resident #2, but did see him back up his wheelchair and thought he would leave. Staff E stated that sometimes when you tell Resident #1 to not do something he will not do it again . at least not right away. Staff E said earlier that day Resident #1 had been observed wheeling up behind other female residents in the dining room. Staff E said Resident #1 told her he touched (Resident #5) on the head and she reported it to Staff H, LPN. In an observation/interview on 09/22/2020 at 1:30 PM, Resident #2 was observed in her bed, the resident was non verbal and moved her lips when spoken to but did not illicit a sound. She was deemed not-interviewable. In an interview on 09/22/2020 at 11:45 AM, Staff H, LPN stated, You have to keep your eyes on (Resident #1), he has the hormones and the brain of a [AGE] year old male. He likes to touch staff inappropriately, and has a few times. Staff H stated, she was aware of him kissing a staff member on her neck once and he touched another aide's bottom. Staff H stated, Resident #1 had reached out to touch her bottom once, but then before he touched her, Resident #1 stated, I shouldn't do that. Staff H stated he touched the breast of Resident #2 while she was on her lunch break. Staff H stated when she got back from lunch, the aide told her about it and she went to see Resident #2 ,who didn't appear to know anything happened as she (Resident #2) had a low cognitive function. When Staff H talked to Resident #1, he seemed really sad and kept saying he did something bad, so I really didn't think he would do it again. Staff H stated, a couple weeks earlier she had been at lunch and when she returned she had been told he tried to touch a different resident (Resident #6) but she was not sure what his intentions were. Staff H was asked if there were any other female resident interactions with Resident #1. She could not recall any prior interations. RESIDENT TO RESIDENT SEXUAL ABUSE ALLEGATION BETWEEN RESIDENT #1 AND RESIDENT #3 RESIDENT #3 Resident #3 admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], showed she had cognitive impairment but could make her needs known. She ambulated independently without any assistive devices. Review of an incident report statement by the DNS dated 09/16/2020, showed on 09/16/2020 at about 12:35-12:40 PM, Resident #3 was telling Staff M, CNA, something about being touched. Staff M reported that Resident #1 had touched Resident #3s leg while she was sitting near him on the couch watching TV. Resident #3 stated that said she had gone into the dining room and Resident #1 leaned over and touched her knee. Resident #3 stated Resident #1s hand went up her leg and she knocked his hand off. Resident #3 stated Resident #1 reached over again, touching her knee and his hand went up her leg onto her side, reached over underneath her breast and then touched her breast. The DNS revealed Resident #1 had demonstrated this action for him and stated the touching was on the top of her clothes. Resident #3 said she got up right away and came to the nurse's station to tell somebody. The DNS then went to speak with Resident #1 who was in the dining room and he volunteered, I did something bad. I'm not ever going to do it again. He repeated this statement two or three times. Review of the facility's incident investigation summary dated 09/16/2020 revealed Resident #3 was subjected to non-consensual sexual touching by another resident, who approached her while she was watching TV in a common area. Resident #1 displayed inappropriate sexual behavior/touching with female residents despite safeguards in place and attempts to educate resident on appropriate behaviors. The facility substantiated the incident as both parties affirmed inappropriate touching occurred. Review of the witness statement dated 09/16/2020, showed Staff M documented that five minutes before the accident happened Staff M saw Resident #3 sitting in front of the TV. Staff M had walked away for only five minutes when Resident #3 approached her and told her that Resident #1 began to touch her knee and was moving his hand upward. Review of the witness statement dated 09/16/2020 at 12:34 PM, Staff N, CNA, documented that it was lunch time and she was delivering Resident #1s meal tray, who was watching a movie seated at a table in the main dining room. As Staff N approached Resident #1 she noted Resident #1 had his hand in his pants. When Resident #1 saw Staff N approaching, he quickly took his hand out of his pants. Staff N then left the room and asked another CNA, to help her assist Resident #1 to his room. Review of the fifteen minute check documentation from 09/11/2020 to 09/16/2020, showed staff did not document they performed the fifteen minute checks on the following days: - On 09/10/2020 at 2:00 PM until 10:45 PM; - On 09/11/2020 at 11:00 PM until 6:00 AM; and - On 09/13/2020 at 6:15 AM until 2:00 PM and at 10:00 until 11:00 PM. Review of the nursing progress note dated 09/16/2020 at 12:40 PM, showed Resident #3 was sitting on the couch in the dining room in front of the TV and Resident #1 was sitting in his wheelchair by the TV. Resident #3 reported that a male resident touched her on her knee and went up and touched her on her breast. Resident #3 stated she immediately walked out of the room. Resident #3 was kept away from Resident #1 by a staff member and she verbalized she was upset. Review of the DNS communication to staff posted at the nurses station on 09/17/2020 at 2:40 PM, dated 09/16/2020, directed staff they must ensure the safety of all female residents. The DNS directed staff that the facility would continue ongoing interventions regarding Resident #1 (which included fifteen minute checks, two person assist with all care, setting clear boundaries and encouraging appropriate behavior) but in light of this new development (repeating these behaviors in an opportunistic manner) we must increase our safety measures as follows: Resident #1 was to be supervised directly whenever he was out of his room and especially if he was in his wheelchair. Resident #1 could not be unsupervised when awake and outside of his room; and Resident #1 could not be within close proximity to other female residents ever. In the general area was (assuming no inappropriate speech) but not close -6 feet at least. Review of Staff As statement dated 09/17/2020 at 4:00 PM (regarding the 09/16/2020 incident), showed that she had interviewed Resident #3 regarding the incident that occurred with Resident #1. Resident #3 revealed that she had a life long fear of men. In an observation and interview on 09/17/2020 beginning at 11:10 AM, Staff B, CNA, Resident #1 and Resident #4 (a female resident) were observed in the activity lounge. Resident #4 was sitting at a table, had her back to the surveyor and was working on a puzzle. Staff B was mixing cocoa and came over to this surveyor and stated, Be careful, he (identifying Resident #1) gropes and then left the room leaving Resident #1 unsupervised with a female resident in the vicinity. Resident #1 was able to identify who he was to this surveyor. Resident #1 stated, We do not grope other women. I might get kicked out. When asked who told him that, Resident #1 stated, The aides. Resident #1 then asked this surveyor three times for permission to touch (the surveyor). Resident #1 was told that he could not, then was observed to quickly self-propel himself away from the surveyor using his right arm and leg towards the other side of the room. From 11:10 AM until 11:24 AM, there was no other staff observed to be present or aware Resident #1 was unsupervised in the room with Resident #4. At 11:18 AM, Resident #1 was observed to propel his wheelchair approximately four feet away from Resident #4 whose back was to him. In an interview on at 09/17/2020 at 11:25 AM, Resident #3 was standing at the nurse's station. Resident #3 pointed to Resident #1, who had just came out of the activity room. Resident #3 was pacing and fidgeting with her hands. Resident #3 stated, He's (Resident #1) only been here a few days. He has a strong personality I don't plan on interacting with him. He scares me. I don't like anything to do with him and body parts. In an observation on 09/17/2020 at 11:32 AM, Resident #1 self- propelled out of his room to the hall in his wheelchair. There were no staff present. He reached out to touch this surveyor and commented that he never meant to hurt anyone. He said in the past he had been hurt. In an interview on 09/17/2020 at 11:36 AM, Staff B stated she had known about Resident #1s behaviors one week after he admitted to the facility when he grabbed her breast. Staff B stated they (the facility) were to keep him away from women, have two people to provide care and all work together on the fifteen minute checks. The current care plan for Resident #1 was reviewed with Staff B and she was asked what ' under direct visual supervision' meant when the Resident #1 was out of his room. Staff B stated that meant that Resident #1 needed eyes on him at all times when he was out of his room. Staff B stated that Resident #1 was not safe with females. Staff B was then asked why she left the activity lounge earlier, leaving Resident #1 and Resident #4 unsupervised. Staff B stated that, Well, there were no female residents there. Staff B was informed Resident #4 was in the room, and she replied, Oh, I did not see another resident there. In a follow up interview on 09/17/2020 at 12:25 PM, Resident #3 was the in activity room coloring and stated, That man touched me. I now know to back up, near him. He touched my breast. I did not like that. It was not yesterday but, not long ago. I am not sure when . Resident #3 had a furrowed brow and a worried expression. Resident #3 asked, Am I in trouble for reporting this? Please I do not want to be in trouble. Resident #3 reported a history of sexual abuse and a lifelong fear of men and thus she did not marry nor have children. In an interview on 09/17/2020 at 1:21 PM, Staff C, Registered Nurse (RN), stated Resident #1 was on fifteen minute checks. Staff C stated that now if she saw Resident #1 alone with other residents she would ensure he was not left alone. Staff C stated she would be scared because she felt Resident #1 would do something. When asked what she meant by do something. Staff C replied, Touch inappropriately. In an interview on 09/17/2020 at 1:37 PM, the Administrator was asked about the plan to keep residents safe from unwanted touching. The Administrator stated the facility was currently educating all staff (not just nursing staff) including housekeeping, dietary and maintenance personal which would help protect other female residents from Resident #1s potential sexual abuse. The Administrator stated this would help to have other staff besides nursing to protect him from approaching other female residents. The Administrator stated Resident #1 was on every fifteen minute checks and the facility had changed Resident #1s care plan around nine or ten this morning (which was over twenty hours after the second sexual abuse occurrence). In an interview on 09/17/2020 at 2:41 PM, Staff D, LPN, stated the staff attempted to watch Resident #1 closely, but the staff also had their work to do. Staff D was aware that at times Resident #1 would reach out and touch other residents. Staff D stated that, Yesterday, we were busy doing ADL's (examples of activity of daily living included dressing, grooming and toileting) and meals and he touched a resident, the most vulnerable resident, well, they are all vulnerable but she is fragile and has a history of sexual abuse. We just can't watch him enough and there are not activity people here 24/7. Yesterday, the aide had just spoke with him and then it happened, he grabbed another resident. He is so mobile and he has that strong arm. There is not enough staff to keep up with him. These residents are so frail. Not enough staff to watch him. Every fifteen minute checks are just not effective. In an interview on at 09/17/2020 at 2:50 PM, Staff F, RN, stated Resident #1 liked attention and to socialize. Staff F stated he self-propelled in his wheelchair quickly and quite easily. Staff F stated he had inappropriate behaviors and occasional attempts of inappropriate touching. Staff F expressed Resident #1 would apologize when he tried to reach out and touch other female residents. Staff F stated staff were to check on him every fifteen minutes when he was out of the room and monitor his proximity to female residents. In an interview on 09/17/2020 at 2:54 PM, Staff G, CNA, stated Resident #1 was to be supervised when out of his room at all times. Staff G stated they were directed to keep Resident #1 away from female residents. In an interview on 09/17/2020 at 4:03 PM, Staff A, Social Services stated she revised Resident #1s care plan to state he was under constant supervision when he was out of his room, in his wheelchair or within general proximity of other female residents. Resident A stated she did not have time to add other things, Resident #1s family had shared with her. Staff A stated Resident #1 had been on every fifteen minute checks and she was trying to make his care plan clear. Staff A stated she thought Resident #'s1 care plan had been changed. In a joint interview with the Administrator and Director of Nursing on 09/17/2020 at 3:10 PM, they were asked again how the facility was to protect vulnerable female residents from Resident #1. At that time, Resident #1 was placed on one on one supervision, which had not been implemented until over 25 hours after the second incident of sexual abuse. Review of a supervision plan for Resident #1 dated 09/18/2020, posted at the nurses station from the DNS, showed the following was implemented: - Resident #1 was under 1:1 direct supervision during daytime/evening hours; - Starting at bedtime, fifteen minute checks were to be started and extended throughout the overnight hours; - A long-term, formally structured schedule was being formalized by leadership. Review of a nursing progress note dated 09/19/2020 at 9:31 PM, Staff J, LPN, documented that around 7:30 PM, Staff J and Resident #3 observed Resident #1 sitting in his wheelchair in the dining room with an unidentified staff member. Resident #3 saw him wheeling over towards the unidentified staff member who was sitting on the couch. Resident #3 was convinced that Resident #1 had rubbed on the staff member's leg. Staff J reassured Resident #3 that Resident #1 had not touched anyone. Resident #3 said if Staff J asked him and he said no, that he was lying and to not believe him. Resident #3 stated, It was not ok for him to do that. Staff J documented Resident #3 appeared to be a little more anxious than usual. Review of a nursing progress note dated 09/21/2020 at 4:28 AM, Staff J documented Resident # 3 had been wandering around the unit most of the evening and had some periods of time where she seemed upset and worried. Resident #3 had asked a couple times if people were upset with her but didn't know why they would be upset. Staff J reassured resident that no one was upset with her. In an interview on 09/22/2020 at 11:42 AM, Staff L, CNA, stated Resident #1 told her it was inappropriate to touch others. Staff L stated she heard he touched two residents and had tried to touch Staff H. Staff L stated that Resident #1 was quick and she had to keep an eye on him. Staff L stated a lot can happen in fifteen minutes. The week before last on Tuesday or Thursday I saw him wheeling up to (Resident #4). I redirected him and distracted him. In an interview on 09/22/2020 at 12:22 PM, Staff J, LPN stated that the day after the 09/16/2020 incident happened, Resident #3 mentioned to her that she (Resident #3) thought she saw Resident #1 rub on a staff member's leg. Resident #3 mentioned Resident #1 should not do that and if he denied it, He was a liar. In an interview on 09/22/2020 at 12:30 PM, Staff M, NAC stated when the accident happened with (Resident #1 and Resident #3), I just saw him one minute before. Resident #3 came and approached Staff M and Resident #3 was shaking and crying and stated that Resident #1 had touched her. Staff M stated she was shocked because she had just seen Resident #1. Staff M reported this to the nurse right away . Staff M stated Resident #1 was now on 1:1 supervision. In an interview on 09/22/2020 at 12:39 PM, Staff N stated (Resident #3) was really shook up the day of the incident. Yesterday, and today she pointed to him (Resident #1) and said he liked to do things to people that is why she stayed away from him. She seemed scared of him. She remembered him .She is cautious of him and watches cautiously. Staff N stated she couldn't recall her last abuse in-servicing. In an interview on 09/22/2020 at 1:40 PM, Staff O, Resident Assistant, stated Resident #1 had tried to grab her breasts. Staff O stated that a couple weeks ago she observed Resident #1 sitting really close to Resident #7. Staff O stated that Resident #1 looked like he was going to touch Resident #7 so she called out his name while walking toward them. In an interview on 09/22/2020 at 2:28 PM Staff K, CNA, stated Resident #1 made inappropriate comments to her and at one point he groped another staff member. Staff K stated Resident #1 told her he was not supposed to grope. Staff K stated Resident #1 was currently on fifteen minute checks. Staff K stated that the prior Saturday (on 09/19/2020), Resident #3 said she was afraid that Resident #1 was touching a staff member. In a telephone interview on 09/29/2020 at 3:18 PM, Staff I, LPN, stated she was on shift the day Resident #1 touched Resident #3. Staff I stated staff had seen Resident #3 sitting on the couch right before Resident #1 touched Resident #3. Staff I stated that Resident #3 was shook up that day. Review of the Annual Spiritual Profile and Well-Being assessment dated [DATE] at 10:28 AM, showed Resident #3 stated, I think we are going to die, there are bad guys out there that want to get me, and they used to make fun of me. The assessment documented Resident #3 was fearful of many things but was okay with staff knowing about her fears. Resident #3 felt talking about her fears helped her to get through them and she needed reassurance that she was safe. Resident #3 felt praying helped her cope. In an interview on 10/01/2020 at 1:59 PM, the Administrator stated Resident #3 had a general fear of men and was able to recall events that occurred in back in January or February. The Administrator confirmed they had identified missing every fifteen minute checks on Resident #1. In an phone interview on 10/01/2020 at 3:01 PM, Staff O, Resident Assistant stated Resident #1 kissed her on neck. Staff O stated she was not sure how to react to it but told him it was not appropriate and Resident #1 apologized to her. Staff O stated she could not recall if she had reported this incident or not to the Administrator. Staff O stated that after that incident she was even more careful around Resident #1 and made sure he didn't touch other residents. The facility failed to ensure male Resident#1 who had displayed past sexually inappropriate behaviors towards vulnerable residents and female staff members was adequately monitored to prevent sexual abuse on two occasions and that all staff in the facility were aware of the preventive interventions. The facility failed to intervene and protect Resident #2 when she exhibited signs of distress when Resident #1 was trying to place a necklace on her. Resident #2 was completely dependent on staff for all movement. This failure led to Resident #1 touching her breast. The facility failed to separate Resident #3 from Resident #1 when they were observed sitting by each other. This failure led to Resident #1 touching her breast. The resident had a known history of behaviors toward two female residents and multiple staff members. The care plan included conflicting interventions to be under direct and indirect visual supervision when out of his room. The one on one supervision was not implemented until over 25 hours after the second incident of sexual abuse. He was observed to be unsupervised in touching distance at least six feet around a female resident after these known incidences. Reference: (WAC) 388-97-0640 (1)

Based on observation, interview and record review the facility failed to prevent and comprehensively assess and ensure the necessary care and services were provided to prevent the occurrence of an avoidable pressure ulcer for one of three residents (#36) reviewed for pressure ulcers (PU). These failed practices caused harm to Resident #36 who developed a Stage lll pressure ulcer to his sacrum. Findings Included . Record review of the facility's policy titled, Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements, dated (MONTH) 2012, showed: - A comprehensive assessment would be completed by the Registered Nurse (RN) evaluating the resident's risk factors, the resident's skin condition and the nature of the pressure to which the resident may be subjected; - Dietary was notified by an alert that occurred when the wound data collection UDA (user defined assessment) was signed and locked; and - If a pressure ulcer was identified, the RN should record the type of wound and the degree of tissue damage on the RN wound assessment UDA (for a PU, record the stage). The National Pressure Ulcer Advisory Panel Pressure Injury definition includes a pressure injury (also known as a pressure ulcer) was localized damage to the skin and/or underlying soft tissue usually over a bony prominence. The injury could present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shearing. The tolerance of soft tissue for pressure and shearing may also be affected by nutrition, perfusion and co-morbidities. The Resident Assessment Instrument (RAI) Manual described a stage III PU as full thickness loss of the skin. Resident #30 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident was alert and oriented, he required extensive assistance of two people for bed mobility and toileting and was always incontinent of urine. Further review of the MDS, showed that Resident #36 was at risk for the development of pressure ulcers, had moisture associated skin damage and he did not reject care. Review of the Care Area assessment dated [DATE], showed the Braden (an assessment for predicting pressure ulcers) Score was 14 (which indicated the resident was at moderate risk for PU development). Resident #30 was at risk for pressure injury related to impaired mobility and incontinence. The resident currently had no pressure injuries but does have an open area on his coccyx related to shearing. The required assistance to reposition regularly. Care plan considerations were to Add risk for pressure injuries to care plan and the goal was to minimize the risk for this overweight, mostly immobile resident. Review of the (MONTH) (YEAR) to 01/12/19 Medication Administration Records (MAR) showed a treatment order for butt paste (barrier cream) to reddened coccyx with a superficial opening every shift. On 01/13/19, the MAR indicated [REDACTED]. The nurse was to change the dressing every three days and as needed. Review of a care plan focus problem dated and revised 01/22/19, showed Resident #36 had potential for PU development related to impaired mobility. The care plan goal was the resident would have intact skin and would be free of pressure injury. Interventions included to turn and reposition the resident at least every two hours and provide an air mattress on the bed. Review of a care plan focus problem dated 01/22/19 and revised 04/24/19, showed Resident #36 had recurrent shearing of skin to his buttocks/sacrum area with the goal to be healed by 07/23/19. Interventions included use of total mechanical lift to be used to raise the resident higher on the bed and reposition regularly. Review of a Skin Observation sheet dated 01/24/19 showed a 6 cm (centimeter) by 7 cm superficial, macerated (softening and breaking down of the skin resulting from a prolonged exposure to moisture) skin to sacral (coccyx) area. Review of a Wound Data Collection (WDC) sheet dated 02/28/19, identified the sacral wound measured 1.6 cm by 1.8 cm and the depth was 0.3 cm. The assessment showed the periwound (the skin around the wound) was deep purple, blanchable, had excoriation with distinct wound edges and the bed of the wound was described as having beefy red tissue. The WDC sheet characterized the wound without slough (dead tissue or granulation (new tissue indicative of wound healing, with serosanguineous drainage and was a Stage lll pressure ulcer. Review of a WDC sheet dated 03/26/19, the facility had not assessed the wound for two weeks, showed a stage lll sacral wound to be 1.0 cm by 0.5 cm by 0.1 cm in depth. The PU was surrounded by 5.0 cm by 6.0 cm macerated area with 20% slough and minimum serosanguineous drainage with two tiny superficial open areas. Review of a WDC sheet dated 04/10/19 (again two missed weekly assessments), showed the a stage III PU which measured 1.5 cm by 2.0 cm by 0.1 cm in depth. The assessment showed the wound bed was red and the ulcer appeared to be bigger in size from the last evaluation. Review of a Braden assessment dated [DATE], showed Resident #36 had a score of 15 indicating that he was at a mild risk for the development of a PU. Review of a WDC sheet dated 04/23/19, showed the sacral wound measured 1.0 cm by 0.5 cm. ( again a missing assessment) Review of a Skin Observation sheet dated 05/05/19 (two missed weekly assessments), showed the coccyx open wound measured 0.1 cm by 0.5 cm with 5% slough and minimal serosanguineous drainage. The assessment showed the resident mostly stayed in bed, was turned and did not prefer to lie on his side for too long. Review of the medical record did not show evidence the Registered Dietician had assessed Resident #36 for the nutritional requirements related to the sacral ulcer. On 06/03/19 at 8:11 AM, Resident #36 was observed lying in bed on his back with his eyes closed. On 06/03/19 at 11:18 AM, Resident #36 was observed lying in bed on his back watching TV. On 06/04/19 at 2:45 PM, Resident #36 was observed lying in bed on his back with his TV on. On 06/05/19 at 10:08 AM, Resident #36 was observed leaving his room to have a shower, and on his bed there was a special air mattress. In an observation and interview on 06/05/19 at 12:29 PM, Resident #36 was laying on his back and he had a pillow under his left shoulder. Resident #36 stated he does have a sore on his bottom and he doesn't get out of bed because it was too much hassle. In an interview on 06/05/19 at 9:58 AM, Staff O, Nursing Assistant (NA), stated she knows how to take care of the residents by the care plan, walking rounds and shift to shift report. Staff O stated Resident #36 should get turned every two hours but he refused at times so pillows are placed under his shoulders. She continued to state he had a special mattress on his bed because he had something on his bottom but she had never seen it. In an interview on 06/06/19 at 9:41 AM, Staff B, Registered Nurse (RN), stated skin checks should be performed weekly on all residents and if an ulcer was found a wound assessment sheet would be completed, and the physician would be notified for a treatment order. In an observation on 06/06/19 at 10:43 AM, Staff N, RN, performed a dressing change to the sacral wound. The ulcer measured approximately 1.5 by 1.5 cm and 0.3 in depth. The ulcer had a very small amount of slough in with red beefy tissue surrounding it. The periwound was pink and blanchable. In an interview on 06/06/19 at 11:46 AM, Staff M, NA, stated she was aware Resident #36 had an ulcer to his bottom and it had gotten worse and then better and then worse. Staff M stated he refused personal hygiene and dressing and he didn't like to get up anymore. Staff M stated when he refused care the nurses would be notified. She stated he had a special air mattress on his bed to help with his pressure sore. Staff M stated, He prefers to be on his back but we don't turn him unless he wants. In an interview on 06/06/19 at 12:03 PM, Staff H, RN/Resident Care Manager, stated if a resident had a pressure ulcer, a weekly skin wound assessment would be completed including measurements, drainage, peri wound, and wound bed description. Staff H stated that he tried to stay away from staging the wound but rather using descriptive verbiage to identify the ulcer. Staff H stated he would defer to the MDS nurses to know if the wound should be on the care plan, but added that all nurses could revise the care plan. In an interview on 06/06/19 at 2:01 PM, the Director of Nursing Services (DNS) stated that prevention of pressure ulcers included doing a Braden scale assessment upon admission and quarterly to identify if they were at risk; and if a resident was identified at risk for pressure ulcers a turning schedule would be instituted and a barrier cream would be used for residents who were incontinent. She stated the nurses are responsible to perform weekly skin checks and if an ulcer was identified the physician would be notified for a treatment, an air mattress would be placed on the bed, weekly assessments of the wound would be completed including staging the ulcer and all interventions would be on the care plan. Reference: WAC 388-97-1060 (3)(b)

Based on observation, interview and record review the facility failed to prevent an accident for two of three residents (#2 and #1) reviewed for accidents and supervision. This failure resulted in harm when Resident #2 fell out of bed when a Nursing Assistant left the resident in an unsafe position that resulted in a [MEDICAL CONDITION]. In addition, Resident #1 received a second degree burn when the resident spilled coffee in the dining room. These failures placed all residents at risk of injury in the facility. Findings included . RESIDENT #2 Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE], assessed the resident as requiring 2 persons for bed mobility and transfers. The resident was assessed as being severely cognitively impaired. Resident 2 was not interviewable. Per the care plan the resident was an assist of 1-2 persons for bed mobility. Review of an incident investigation dated 04/28/19 at 8:10 PM, showed Resident #2 was receiving cares from Staff C, Nursing Assistant (NA). Staff C wrote in her statement she was about to change the residents brief, she had moved the bed up to hip height so she would not have to bend over to perform cares. Staff C documented Resident #2 had shifted a few inches closer to the edge of the bed. Staff C stated she was distracted for about 30 seconds because the roommate was trying to get her attention and ask a question. During this time, Resident #2 had moved her legs over the side of the bed and began to fall. Staff C stated she was about a foot away with her back to Resident #2 and attempted to catch Resident #2 but was unable to do so. Staff C stated I think her front half hit the floor first, including her head. I immediately yelled for help. A licensed nurse assessed the resident and called 911. The investigation noted the resident had a [MEDICAL CONDITION] and observed large amounts of blood all over her head. Review of a radiology note from the hospital dated 04/28/19, showed the impression was multifocal (more than one) hemorrhages and most significantly, a hematoma (an acute bleed between the brain and the inner surface of the skull) which was compressing the left side of the resident's brain. There were no skull or cervical fractures noted. Resident #2 returned to the facility and actions taken to prevent reoccurrences, were two persons for all ADL care and to ensure she does not swing her legs off the bed. The resident had a type of cervical collar for neck stabilization. On 05/03/19 at 12:15 PM, Resident #2 was observed sleeping in bed. The resident had intact staples on the left side of her head. In an interview on 05/03/19 at 1:00 PM, the DNS stated Staff C did a full body turn away from the resident, but did not step away from the resident. The DNS stated Staff C had turned away because the roommate was attempting to come thru the curtain while she was starting to give care to Resident #2 and she wanted to keep the roommate out of the area. The DNS stated Staff C would receive education. In an interview on 05/03/19 at 2:00 PM, Staff D, LPN, stated previously the resident was non-verbal but she would get frustrated and swing her legs around. Staff D stated Resident #2 had come back from the hospital on hospice services and appeared comfortable. In a telephone interview on 05/10/19 at 1:20 PM, Staff C stated she was getting ready to provide care to Resident #2 and realized she had left the towels on the sink. At that time Staff C stated she was going to grab the remote to lower the resident's bed and go get the towels, when the resident's roommate started to try to open the curtain. Staff C stated she stepped away to deal with the roommate and then heard Resident #2 start to fall and attempted to grab the resident but could not. Staff C stated she was arms length away from Resident #2. Staff C described Resident #2 as being frequently restless and was able to move her legs around at times. Staff C stated, I wish I had lowered the bed, before I dealt with the roommate. RESIDENT #1 Review of the facility policy dated 02/17, stated the serving temperatures for all hot beverages ranged from 155 degrees Fahrenheit to 175 degrees Fahrenheit. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], assessed the resident as being independent with meals. Review of the care plan noted the resident's goal was to continue to eat independently. Review of the facility investigation dated 05/01/19, stated the resident fell asleep at the dining room table while holding a coffee cup. The coffee spilled onto the resident's abdomen. The resident did not cry out, and another resident alerted staff of the spill. The Licensed Nurse (LN) assessed the burn and placed a cold wash cloth on her abdomen and and called the physician. The intervention for the incident was to put lids on all coffee cups that were in use. All coffee machines used by residents were decreased to 120 degrees immediately and residents' care plans were updated to include safety lids for all hot beverages. Review of the skin sheet dated 05/01/19, identified Resident #1 received a partial thickness burn (second degree burn) to her abdomen measuring 5 centimeters (cm) by 4 cm in size and the skin was described as pink in color. In an observation on 05/03/19 at 10:10 AM, the resident was observed with her chin on her chest sleeping at the dining table. No food or fluids were on the table. On 05/03/19 at 11:00 AM, Resident #1's abdomen was observed while Staff A, Licensed Practical Nurse (LPN), performed a dressing change. A red area, measuring approximately 5 cm by 4 cm, with a small piece of broken skin in the upper left corner, from a blister, which was no longer intact was observed on the resident's abdomen. The resident stated this occurred when she fell asleep and spilled her coffee on her stomach. In an interview on 05/03/19 at 10:35 AM, Staff B, Director of Food and Nutrition, stated she was notified of the incident and came into the facility on [DATE]. Staff B stated she checked the temperature of the coffee and it was 151 degrees at 7:15 PM. Staff B then lowered the temperature on the coffee machine and continued to check the coffee temperature. Staff B presented temperatures that were taken at different times. Staff B stated she added to the resident's care plan to use a lid for safety. Staff B, checked the temperature on the coffee during the interview and it was 127 degrees and stated she was getting complaints from the residents because the coffee is not hot enough. Staff B stated the facility policy was the coffee should temp at 155-175 degrees. I am still working on the temperature and working with the residents about the temperature. In an interview on 05/02/19 at 1:00 PM, the Director of Nursing Services (DNS) stated they were going to assess all residents for the use of lids and continue to check the temperatures of the coffee. Reference (WAC) 388-97-1060 (3)(g)

Based on observation, interview and record review the facility failed to identify hazards and risks in the environment for one of two residents (#1) reviewed for a fall with injuries and failed to ensure resident rooms on one of two halls (West hall) were free from potential environmental hazards. The failure of the facility to comprehensively assess Resident #1's environmental hazards and implement interventions to mitigate and contain the potential risk of heating unit surfaces resulted in Resident #1 suffering burn injuries from a baseboard heater following a fall and placed other residents at risk for potential burns. Findings included . A review of the facility policy titled, Fall Prevention and Management, with a revision date of (MONTH) (YEAR), showed the facility would identify risk factors and implement interventions before a fall occurs and prevent further injury. The policy stated that based on the resident assessment of risk factors, care planning would include appropriate interventions personalized to the specified areas. Resident #1 admitted [DATE] with [DIAGNOSES REDACTED]. Review of the significant Change Minimum Data Set (MDS) assessment dated [DATE], showed the resident was severely cognitively impaired and exhibited delusions, wandering and rejections of care. The MDS showed Resident #1 had impaired balance, required minimum to moderate assistance with activities of daily living but was able to ambulate and transfer at times independently, and had a history of [REDACTED]. A review of the care plan dated 10/05/18, showed the facility had identified the resident may attempt to transfer or walk without assistance due to lack of safety awareness. The only interventions on the resident care plan related to falls with a revision date of 12/26/18, showed the staff would supervise the resident when in the wheelchair due to poor safety awareness and for staff to monitor for significant changes in gait, mobility, balance and joint function. Review of the [MEDICAL CONDITION] disorder care plan dated 10/05/18, identified interventions for staff to observe during a witnessed [MEDICAL CONDITION] such as not leaving the resident alone, lowering the resident to the floor to prevent injury and protecting the resident from injury. The care plan did not identify interventions for prevention or mitigation of the risk for injury for unwitnessed [MEDICAL CONDITION]. The care plan did not identify environmental hazards in the resident environment such as the room's baseboard heater. Review of the resident record showed on 02/13/19 at 12:30 AM, Resident #1 was found on the floor of her room having had a presumed fall and suspected [MEDICAL CONDITION]. The resident was found in the corner of her room in a sitting position with the left side of her body leaning against the room's baseboard heater. The resident was observed to have a reddened area to her left side and her left elbow where contact was made with the baseboard heater. The resident was diagnosed to have a second degree burn which measured 1.5 centimeters (cm) by 2.7 cm inside a 9.0 cm x 6.0 cm reddened area to her left side and a first degree burn to the left elbow. On 02/22/19 at 10:30 AM, Staff B, Registered Nurse, performed wound care to Resident #1. There was an open blister observed on the resident's left side that measured approximately 2.5 cm by 1.5 cm and the skin around the open area was red. There was no injury to the left elbow. Staff B stated there had been no changes in the resident's room following the fall and that we assume she was standing at her closet or by her closet and had a [MEDICAL CONDITION] or just fell , she gets up and she can ambulate, Staff B stated the heaters get really hot and Resident #1 was on 15 minutes checks. Staff B stated the facility placed a recliner near the end of the resident's bed as a deterrent so the resident did not get near the baseboard heater. In an observation on 02/22/19 at 11:48 AM, the resident was up in a wheelchair outside of her room and was sleeping. Two staff assisted her to stand and transfer into a recliner chair in the hallway. The resident's spouse arrived and stated the resident had a fall and had a burn where she must have been against the baseboard heater. In an interview on 02/22/19 at 1:42 PM, the Director of Nursing Services (DNS) stated Resident #1's fall was unwitnessed but they were suspicious the resident had a [MEDICAL CONDITION]. The DNS stated the resident had recent medication changes and had a decline in her condition. The DNS was not able to provide any additional information regarding why the resident's care plan had not been updated to reflect her history of falls or [MEDICAL CONDITION]. The DNS stated there were several residents identified as having similar risk factors for [MEDICAL CONDITION] to the baseboard heaters and the facility had not implemented additional interventions for any other residents as they believed the incident was very specific to Resident #1. The DNS stated the baseboard heaters get really hot and we are brainstorming options to help protect the residents from potential burns. BASEBOARD HEATERS: An observation on 02/21/19 at 10:36 AM, showed all rooms on West Hall were heated using baseboard heaters. The heaters were all consistently located below the windows in each room and did not include protective frames/covers or grates making them accessible to residents. The resident closets were located respectively to the left of the baseboard for bed 1 and to the right of the baseboard for bed 2 in the corners of the room. Rooms 2, 3, 6, 7, 9, 10, 11 and 12 were observed to have their baseboard heaters on. Attempts to touch the heater in all stated rooms resulted in the baseboard heaters being too hot to touch. In an interview and observation on 02/22/19 at 12:18 PM, Staff A, Maintenance Director, stated the heaters were controlled at the wall for each room and although there was a setting on the wall for temperature control, the wall heater coils themselves were either on or off meaning that the heaters all turn on at the same high temperature until the temperature in the room reached the selected temperature. Staff A stated the facility was researching options for protective covers for the baseboard heaters but had not yet found a solution. Staff A stated the facility had not previously identified a hazard concern regarding the heaters stating the only time the temperatures were evaluated was if a resident had a concern with their room being too cold. Staff A stated for Resident #1 they were attempting to place the recliner chair in her room to prevent access to the heater. In an interview on 02/22/19 at 12:00 PM, the Administrator stated the facility was initiating frequent supervision for at risk residents who are able to independently access the baseboard heaters while the facility works on a permanent plan for a physical solution to contain the identified hazard and to protect residents from harm caused by the environmental hazard. The administrator acknowledged that the facility had not previously identified the heaters as a potential environmental hazard or assessed their risk to each resident. In an observation at 1:08 PM with Staff A, surface temperatures of the baseboard heaters were evaluated using a laser thermometer and read the following in sampled rooms on the West Hall: · room [ROOM NUMBER]- heater on, surface temperature was 186 degrees F; · room [ROOM NUMBER]- heater on, surface temperature was 210 degrees F; · room [ROOM NUMBER]- heater on, surface temperature was 195 degrees F; · room [ROOM NUMBER]- heater on, surface temperature was 160 degrees F; and · room [ROOM NUMBER]- heater on, surface temperature was 191 degrees F. Reference (WAC) 388-97-1060 (3)(g)

Based on observation, interview and record review the facility failed to provide enough supervision to prevent the resident from having a re-occurring fall for 1 of 3 Residents (1) reviewed for accidents. The facility also failed to provide appropriate supervision for a Resident (3) who wanders and has a potential for harm from altercations with other residents. These failures resulted in harm of multiple facial fractures and a subdural hematoma for Resident 1 and a physical altercation initiated by Resident 3. Findings Include: Resident 1 Resident 1 was admitted [DATE] with [DIAGNOSES REDACTED]. In a minimum data set (MDS) assessment dated [DATE] the resident was identified to be severely cognitively impaired. The Resident uses a walker for ambulation. The Care plan noted the resident uses a Front wheeled walker (FWW) for ambulating. Resident 1's care plan also noted a self-care performance deficit related to dementia, confusion, and falls with injury. A progress note dated 08/20/16 at 5:48 P.M., indicated the resident was found lying on the carpet on her right side. The resident was holding her glasses which were broken, she had a laceration to right cheek that was approximately 1.5cm and a laceration of right eyebrow of that was 0.5cm with a small hematoma noted on her right upper arm near elbow with bruising noted. The Resident was sent to the Emergency Department (ED) and received 5 sutures to eyebrow. Summary from the investigation dated 08/20/16 stated the Resident has a history of not using her walker. Her walker was found in upright position on the opposite side of the chair away from where she had fallen. She forgot to use it. There were bingo chips on the ground where she was lying. Was she trying to pick them up? Corrective action was Resident education and staff to retrieve Resident after activities. There was no evidence that the facility was going to increase supervision to prevent further falls with injury. The record showed that the resident had fall assessment and scored a 9, which determined the resident was a low risk for falls and was referred to therapies. As a result of the fall the resident was evaluated by Physical Therapy (PT). In a therapy note dated 08/26/16 it noted the current assistive device used was a front wheeled walker (FFW) which is too tall for resident and she needed to be fit with a shorter FWW which would also help to encourage anterior shift of gravity. The Gait analysis noted the resident had a spinal deformity. The resident had fall predictors noted with decreased balance and cognitive impairment. Therapy service notes provided from PT on 10/04/16 had services from 08/26/16 to 09/01/16, set up on a restorative program after 09/01/16. There was no documented information regarding the Resident's FWW being replaced or fitted appropriately by therapies. There was no indication who would follow up. The next Therapy service note was dated 09/21/16 and noted the resident had another fall. Progress notes dated 09/19/16 at 7:45 P.M., indicated the resident was found on the floor, in a pool of blood approximately 15 ml was on the floor where her face was. The blood seems to have come from a laceration beside her right eye. Another pool of blood approximately 15ml was seen near her chest, although no injury was noted there. The resident may have tried to move. Her right orbital was fully red, swollen and blue bruising. Her glasses were found next to a chair and were broken; her walker was at the end of her bed. The resident was assessed and sent to the ED. Per the hospital note, a head CT scan showed a subdural hematoma and multiple facial fractures on the right side of her face. Documentation on an incident investigation dated 09/19/16, noted it was again an unwitnessed fall, the resident was trying to transfer. The walker was not within reach or she had a history of [REDACTED]. She used heavy objects to hang on to, it looks as if she lost her balance and fell , hit right side of face on the bedside table. The corrective actions were to place a personal alarm on the resident, resident re-education, staff education (no indication what the staff education would be) and to modify the environment (no indication what the modification would be). Again, no increased supervision was implemented and it was unclear if there was a fall program or how it would be implemented. The result of the investigation was the resident attempted to self-transfer without using her adaptive equipment and lost her balance. The resident has had 2 closed head injuries in less than one month. The second fall resulted in harm of multiple facial fractures and a subdural hematoma. In observations on 10/04/16 at 10:00 A.M., the resident was seen in the dining room sitting in a chair, with her eyes closed, at a table with three other residents. The resident had a large bluish-green bruise noted on the right side of her face which from her forehead to her jaw. She had an area over her right eyebrow which appeared to have had recent stiches which had been removed. In observations at 10:20 A.M., the resident remained at the table while the other residents had been removed from the table. The resident's head was falling onto her right shoulder as if she was sleeping. At 10:45 A.M., the resident remained in the dining room alone at the table, moving around in the chair to adjust self but was unable to move much. At 11:00 A.M., the resident was awake and a conversation was attempted the resident but she was unable to be interviewed about the bruises on her face. The resident remained alone at the table in the dining room until 11:55 A.M., when staff using a gait belt, assisted her to walk her in the hallway. Resident 3 Resident 3 was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted the resident noted to be severely cognitively impaired. An investigation dated 09/08/16 noted an unwitnessed fall for the resident. The corrective action stated increase visual checks on resident. In observations on 10/04/16 from 9:50 A.M. until 12: 30 P.M., Resident 3 wandered around the west unit, walking into other resident's rooms continuously. During the observations the resident had very little contact with staff. The resident was non-verbal and walked with her head down while wringing her hands. She walks right up to others and did not speak. On 10/4/16 at 12:20 P.M., Resident 3 was seen standing in front of Resident 4 who was in a wheelchair. Resident 4 stated to Resident 3, I know you have my birthday card and I want it back. Resident 3 grabbed Resident 4's hand and began to pull her up the hallway. Resident 4 had grabbed hold of a drawstring on Resident 3's pants. Resident 4 was very verbal about the theft of the birthday card. The two Residents were in view of Staff A, NAC, who walked towards the two residents who were physically touching each other. Staff A, stopped to speak with other residents as the confrontation of Residents 3 and 4 continued to escalate. Staff A went to the residents and physically separated both residents. Resident 4 had grimaced and said ouch as hands were separated. Staff A stated to Resident 4 it was just a love pinch and told Resident 4 not to worry about it. In an interview on 10/4/16 at 12:28 P.M., with Staff A, she reported the reason Resident 4 had made a face was Resident 3 had a hold of her pinky finger and tightened her grip before letting go. That is why I told her it was just a love pinch. On 10/4/16 multiple other staff members were interviewed but were unable to provide any information surrounding the issues or systems to keep resident safe. On 10/4/16 at 12:30 Resident 3 was seen walking into Resident 4's room and laid down in her bed. Resident 4 was outside the door to her room and continued to state how Resident 3 should not be in her room, she was taking my things. The housekeeper noticed Resident 3 in the wrong bed and told staff the same time the Surveyor did. In an interview on 10/4/16 at 12:35 P.M., the incident and the lack of supervision of Resident 1 & 3 were discussed with the DNS and the Administrator. All parties were made of aware of the observations, the incident and the concern for residents who have the potential for injury were discussed at length with the DNS and Administrator. Resident 3 was allowed to wander continuously and invade other Resident's privacy and start a physical altercation with another Resident. The lack of moving Resident 1 out of the dining room when other Residents were moved. Resident 1 was an identified fall risk with injury, yet she was left alone. The DNS and Administrator were unable to provide any further information. See F 225 for additional information. .

Based on interview and record review the facility failed to provide a physician ordered medication for 2 of 5 sampled resident (Residents 1, 2) which resulted in harm of a hospitalization for Resident 1, a urinary tract infection [MEDICAL CONDITION] which progressed into urosepsis and ultimately death of the resident. Additionally, Resident 2 received two additional doses of an antibiotic without a physician's orders [REDACTED]. Findings Include: The Stafholt Good Samaritan Physican/Practioner Orders Policy states, Physician/practioner orders are a critical component to providing quality care to residents. Accurate processing of physician/practioner oreders is important. The nursing services and health information management (HIM) departments each have responsibilities for processing physician/practioner orders in a timely and accurate manner. Teamwork and communication between the two departments is essential. Transcribing/Processing orders Policy states, orders are processed and transcribed into PCC-Clinical-Orders immedicately upon receipt of an order. All orders must be noted by the licensed nurse who has processed the order. RESIDENT 1 Resident 1 was admitted August of 2010 with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment ((MDS) dated [DATE] stated the resident was severely cognitively impaired and was legally blind. The resident also had bilateral extremity impairments requiring a wheelchair for mobility. On [DATE] at 9:29 PM a progress note revealed the resident had cloudy, foul smelling urine, with blood noted on his brief. A [MEDICATION NAME] revealed the resident had a potential UTI and was positive for leukocytes, [MEDICATION NAME], protein, urobilogen and blood. Progress notes were reviewed: On [DATE] the resident continued to have abnormal findings which included dark colored urine. A urinalysis (UA) was collected, sent to lab, and contact was made with the physician. On [DATE] at 10:35 AM, the Licensed Nurse (LN) documented faxed final lab and suseptibilities r/t UA (urinalysis). On [DATE] at 2:41 P.M., the LN documented the resident's urine very oderous. Labs are possible for UTI. Staff were waiting for MD to send orders. On [DATE] at 10:15 P.M., the LN documented Temp 96.6 (a low temp is an indication of total body infection,[MEDICAL CONDITION]) urine was dark in color and had a strong odor. Resident was asking to go to bed very early. On [DATE] at 10:34 P.M., the LN documented there were no complaints of pain or discomfort during urination. Temp 96.3. On [DATE] at 6:38 A.M, no signs or symptoms of possible UTI, no mucous or blood noted, temp 95.4, d/c alert. The LN discontinued his monitoring with alert charting even though his temperature continued to drop. There were no further progress notes until [DATE] when the LN discovered the resident did not get his physician ordered antibiotic for a diagnosed UTI, which was ordered 7 days prior. On [DATE] at 6:34 A.M., the resident was sent to the hospital with lethargy, thick amber colored urine, and a blood pressure of ,[DATE]. The resident was diagnosed with [REDACTED]. Urosepsis can be life threatening if it is not treated immediately). The resident returned to the facility on [DATE] at 10:20 P.M., and was placed on comfort measures, because the family chose not to treat the infection. The Hospital discharge note dated [DATE] gives the final discharge [DIAGNOSES REDACTED]. The resident died on [DATE] at 6:10 A.M. in the facility. A review of the resident's record revealed a physician's orders [REDACTED].M. The fax included orders for [MEDICATION NAME] 250mg (an antibiotic) to be taken twice a day for five days. The fax was electronically signed by the physician. Resident 1 who had a diagnosed UTI per labwork and a physicians order for the antibiotic [MEDICATION NAME], did not receive his ordered antibiotic for his UTI. Nor was there documented evidence of any Licensed Staff following up on the orders for the resident from [DATE] until [DATE]. An incident investigation dated [DATE] stated the incident was discovered on [DATE] but occurred on [DATE]. Resident 1 did not receive his ordered antibiotic for the treatment of [REDACTED]. The LN was unaware of his UTI and investigated. The investigation summary documented the faxed forms went to the wrong nurse's station. The papers were delivered to the correct station but Staff E, LN said in her statement she did not see the order. All three of the papers, a UA culture with orders were altogether in Health Information Manager (HIM) box. The HIM picked up up the papers later in the day on [DATE]. All 3 forms were together in HIM box. There was a LN signature on the UA culture result (pg 2) only, which is not unusual. No other nurse saw these forms. The report went on to say that the medication error was considered not significant related to no signs or symptoms other than coudy urine. The action taken by the facility was: staff training and procedure revision Licensed Nurses will now initital every sheet on paperwork from outside the facility. On [DATE] at 12:30 P.M., in an interview with Staff B, Licensed Nurse (LN), the unit coordinator stated, I documented in the progress notes the resident did not receive the prescribed medication to treat the UTI. It was the question from the social worker about the resident's UTI which made me look into his record and then I found the medication ordered on [DATE]. Otherwise, I had no knowledge of the resident's UTI. I got vital signs and talked to the doctor and he didn't really seem to be having symptoms. I called the doctor and he said not to treat it but to get another urinalysis. The resident came back from the hopsital on comfort care, he and his grandson made the decision. He was not on comfort care prior to his hospitalization . Staff B LN, later clarified the conversation with the physician would be in the progress note she wrote. There was no documentation in the progress notes of what Staff B said the physician's statment was or as an order. The care plan did not have any evidence of comfort care for this resident. On [DATE] at 1:50 P.M., in an interview with the Director of Nursing Services (DNS) she reported she did not log the medication error and did not see it as a serious disregard of consequences as per the Appendix C Medication Error Decision Tree. The DNS also stated the resident was fine and she spoke to him after the error was discovered. When asked if there was an assessment performed she stated no, he was fine, denied pain and was in his wheelchair moving around the facility. The DNS further clarified the Licensed staff have a system of communication to alert other nurses which residents are awaiting orders etc. When asked why no licensed staff followed up on the orders for this resident for over a week she stated the nurse who was waiting for the orders went on vacation so she could not follow up. When asked again why no other licensed staff followed up for the care of the resident's UTI results and physician orders, the DNS again stated the nurse did not see the order and then she was on vacation, we never miss things like this. Per the DNS the infection control policy allows nurses to dip urine for two or more symptoms and then send a urinalysis and let the physician know if the urine is positive so the physician can make the decision to treat. The DNS stated it was the expectation the nurses would send the lab to the physician and then transcribe orders when received. The DNS was unable to explain the breakdown in communication for this resident's care of a UTI. The DNS reported the resident was fine and when the nurse who found the error phoned the physician he told her not to treat the resident. Temperatures recorded in the progress notes for ,[DATE] to ,[DATE] were at times below 96, when asked if it was standard practice to see a resident with low temperature and foul smelling urine and not follow up on his care. The DNS stated, we have people with low temps around 96 and cloudy, odorous urine all the time, it is the population we work with. In an interview on [DATE] at 3:25 P.M., Staff D, the Director of Health Information (HIM) stated I receive all paperwork in a basket at the nurses's station. The Licensed Nurses complete the orders, sign the first sheet, and then they place the paperwork in the basket. The paperwork for Resident 1 was all together, 3 pages, and signed by Staff E, Licensed Nurse (LN) when I picked it up. I then scanned it into the computer. Licensed staff failed to follow up and provide a prescribed medication to treat a diagnosed UTI. The final culture results from [DATE] and [DATE] contain the same results. Licensed Nurses did not write any progress notes on the resident from ,[DATE] to ,[DATE] therefore, the residents condition cannot be verified. Resident 1 had a systemic infection related to a significant medication error of the Licensed Staff to treat an infection. The lack of antibiotics led to a hospitalization and a [DIAGNOSES REDACTED]. RESIDENT 2 Resident 2 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. In a Minimum Data Set ((MDS) dated [DATE] noted the resident to be severly cognitively impaired. In September, the resident had a [DIAGNOSES REDACTED]. A review of the Medication Administration Record [REDACTED]. On [DATE], the same antibiotic was placed on the MAR indicated [REDACTED]. Review of the physician orders [REDACTED]. The investigaiton stated the Explaination/Description of what happened was, faxed order received for [MEDICATION NAME] DS on [DATE]- this order was processed on [DATE]. Medication was complete. Registered Nurse (RN) unaware med was complete- restarted the order. The RN's statement, I confirmed the order but did not look at the date at the top. Med was given x 2 administrations then stopped. In an interview on [DATE] at 2:00 PM, the Director of Nursing Services (DNS) stated the original order obtained on [DATE] was a telephone order. When the physician electronically signed and returned the order, the ward clerk entered the order into the computer system as a new order. The order was reviewed and confirmed by Staff A, the Licensed Nurse (LN) on duty. The DNS stated Resident 2 was given the antibiotic without a physician's orders [REDACTED]. Resident 2 received an additional two days of antibiotics without a physicians order. Refer to F281 CFR 483.20 (k)(3)(i)

Based on interview and record review the facility failed to ensure services provided met professional standards of quality for medication administration for 2 of 5 residents(Resident 1,2) when they failed to implement physician orders [REDACTED]. This failure resulted in harm for Resident 1 of hospitalization and Urosepsis. In addition, this failure also caused Resident 2 to receive an antibiotic without a physician's orders [REDACTED].>Findings include: The Stafholt Good Samaritan Physican/Practioner Orders Policy states; Physician/practioner orders are a critical component to providing quality care to residents. Accurate processing of physician/practioner orders is important. The nursing services and health information management (HIM) departments each have responsibilities for processing physician/practioner orders in a timely and accurate manner. Teamwork and communication between the two departments is essential. The Transcribing/Processing orders Policy states; orders are processed and transcribed into PCC-Clinical-Orders immedicately upon receipt of an order. All orders must be noted by the licensed nurse who has processed the order. According to the American Nurses Association, Scope and Standards of Practice, 2011, A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the client's response to that care. Nurses assume a liability risk if they fail to monitor a patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. RESIDENT 1 Resident 1 was admitted August of 2010 with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment ((MDS) dated [DATE] stated the resident was severely cognitively impaired and was legally blind. The resident also had bilateral extremity impairments requiring a wheelchair for mobility. Resident 1 had an order for [REDACTED]. The Licensed Nurses (LN) who worked with the resident for the next 7 days, 8 LN's over 20 shifts, did not follow up on the resident's lab results. The resident did not receive a prescribed antibiotic and required hospitalization due to Urosepsis (a severe illness that occurs when an infection starts in the urinary tract and spreads into the bloodstream). The Resident returned to the facility and died 2 days later. RESIDENT 2 Resident 2 received an antibiotic order on [DATE] for 5 days which was completed. On [DATE] another order was placed on the Medication Administration Record [REDACTED]. The orders were reviewed and signed by a Licensed Nurse. The lack of the Licensed Nurses to use Professional Standards of communication between Licensed Nurses every shift, to follow up on orders for labwork sent to the physician, and to document the resident's condition related to a diagnosed infection resulted in harm to a resident of hospitalization , severe infection, and death for Resident 1. The lack of Professional Standards resulted in Resident 2 receiving additional medication without an order. Refer to F-309 CFR 483.25 Refer to F-333 CFR 483.25(m)(2)

Based on interviews and record review the facility staff failed to implement and follow their own policies by immediately notifying the facility administrator of suspected abuse for 2 of 4 sampled residents (#1 & 2) when allegations were witnessed. The failure to protect and report led to a second incident of abusive behavior by the same staff member(Staff A) with Resident 2. In addition, the facility failed to accurately document on the state reporting log. Findings Include: The Stafholt Good Samaritan Abuse and Neglect Policy states Alleged or suspected violations involving any mistreatment, neglect or abuse including injuries of unknown origin will be reported immediately to the center administrator, the policy also stated will prevent further potential abuse while the investigation is in progress. A review of the facility's documentation revealed that on 01/04/15 at 4:00 a.m., Resident 1 was exhibiting signs of [MEDICAL CONDITION] on the night shift of 01/03/15. Staff A and B were observed, on either side of the resident's bed, holding down the resident's arms. Staff C witnessed Staff A and B laughing and antagonizing the resident while she was experiencing delusions and hallucinations. Staff C did not report to the administrator what she had witnessed. Six weeks later on 02/14/15, Staff A was observed putting her hand over Resident 2's mouth when he was yelling which muffled the sound. Staff F who observed the incident never reported until 4 days later when she was asked for a witness statement. On 2/15/15, Staff C reported both incidents, the witnessed abuse on 01/04/15 and the allegation of abuse on 02/14/15, to Staff D on 2/15/15. Staff D did not report both incidents to the DNS until 2/16/15 at 3:40 p.m. who in turn report to the Administrator. In an interview on 03/04/15 at 3:02 p.m. the DNS confirmed she was aware of the allegations, but continued to allow Staff A unsupervised access to the residents. The DNS was asked why Staff A continued to work when two allegations of abuse were being investigated. The DNS replied, Staff A was teaching a NAC class and was not providing direct resident care. The DNS was asked if Staff A was supervised the entire time she was in the building. The DNS could not guarantee Staff A did not have interactions with vulnerable adults. The DNS documented the allegation of abuse was substantiated and Staff A and Staff B were terminated. Staff did not follow their policy of reporting the abuse of a resident by staff in a timely manner in two separate incidents. The resident was not protected from Staff A during the investigation; the LN continued to be in the facility during the investigation. The incident log was incomplete and difficult to monitor what was occurring in the facility. These failures left residents vulnerable to potential abuse by staff members at the facility.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 sample residents (1). Failure to transfer Resident 1 using 2 people with a gait belt resulted in a fall with harm. Resident 1 sustained a fracture. Findings include: The facility Gait (Transfer) Belt procedure, dated September 2012, indicated Gait belts are to be used unless medically contraindicated for transfer. Resident 1 was admitted to the facility in May 2008 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 8/24/14, indicated Resident 1 required extensive assistance of 2 staff for bed mobility, transfers, and toileting. The plan of care (POC), initiated 10/15/13, indicated the resident required "ext (extensive) assist of 2 staff" for transfers. The POC also indicated Resident 1 had "weakness of lower extremities," was non-ambulatory, and dependent on staff for getting in & out of bed, and turning. The KARDEX (care directive for nursing assistants) read Transfer: she required ext assist of 2 staff and sara lift to transfer. On 9/25/14 at 11:00 a.m., Resident 1 was observed resting in bed. She had a splint on her leg. She stated she broke her leg during a fall in her bathroom. The facility's investigative report, dated 9/12/14, revealed that "Nursing assistant thought she could transfer her (resident) safely as another NAC (nursing assistant certified) had watched her assist her onto bedside commode in the bathroom". A X-Ray report dated 09/12/14 revealed a fracture to Resident 1's leg. Staff A, verified in her witness report that she had not used a gait belt when she transferred Resident 1 by herself. On 9/25/14 at 3:15 p.m., the Director of Nursing (DNS) confirmed Staff A did not follow Resident 1's POC and had transferred the resident by herself. The DNS verified Resident 1's POC directed staff that a two person assist is required for all transfers and also that a gait belt should have been used. On 9/25/14 at 4:45 p.m., during an interview with Staff B, she verified Staff A did not follow the POC for Resident 1 and had attempted a one person transfer without a gait belt from the commode. Staff B also stated the resident had a history of [REDACTED]. Staff B also stated that after the fall on 9/12/14, Resident 1 experienced increased pain and required narcotic pain medications to control her pain.

Based on observation, interview, and record review, the facility failed to ensure 1 of 4 sample residents (Resident 1) was free from unwanted or unjustified physical contact/restraint and/or mental abuse. Failure to immediately take action to protect a vulnerable, cognitively impaired resident from a staff's "assertive" attempt to feed and physically restrain the resident while the resident was actively refusing the food resulted in immediate anger, frustration, distress, and/or helplessness. Findings include: Resident 1 has resided at the facility for several years. According to the Minimum Data Set assessment of 1/13/14, the resident was cognitively impaired, sometimes understood simple direct communication, sometimes displayed verbal and physical behaviors towards others, and was totally dependent on staff for all activities of daily living, including eating. During several onsite facility visits, the resident was observed sitting in the dining room. At times during meals, she turned her head away from the food being offered to her by staff. Staff would then stop, and try again a few minutes later. According to facility documentation, staff reported a concern to facility management about a staff person's (Staff A) interaction with Resident 1 during breakfast on 2/17/14. The staff reported Staff A had appeared aggressive while trying to feed the resident and it had made the staff very uncomfortable. Their concern was that Staff A did not immediately stop trying to feed Resident 1 when the resident repeatedly said "No" and said she did not want the food. Resident 1 was also turning her head away from the offered food, and tried to hit Staff A during that time. Staff A then held Resident 1's hands down while continuing to hold food/fluid to Resident 1's mouth. On 4/30/14 from approximately 10 a.m. through 12 noon, interviews were conducted with staff who had been present in the West dining room during the 2/17/14 breakfast interaction between Resident 1 and Staff A: Staff A said her intent was never anger towards the resident or to get to get the resident upset, she "... just wanted to see if there was a way to work around the resident's behaviors towards food, as it changed from minute to minute. The resident would say no, strike out, then say yes and lay her head on staff's shoulders smiling, then say no again and turn her head away. The resident was displaying those behaviors that day (2/17/14) with other staff. I went to the resident and offered her food and drink, sometimes the resident said no, and sometimes said yes and took some (food/fluid). So finally the resident said, I don't want that' and I realized this wasn't working, the resident was doing the same mealtime behaviors for me as everyone else. So I stopped." Staff A also indicated she had just returned to work after being away for several weeks due to personal events, and indicated that perhaps that may have affected her thought-process/decision to assess the resident and work through the resident's behaviors during the meal on that day. Staff C said she heard the resident loudly saying no, turning her head away, and saw Staff A holding Resident 1's hands down ... "I don't think Staff A's intent was negative, but she crossed the line ...No means No and Staff A should have stopped instead of continuing to try to force her to eat." Staff D said, "I heard Resident 1 saying No loudly and it kept going. I turned to see (Staff A) holding (Resident 1) hands down on her chest and the resident saying no. But (Staff A) didn't stop trying to feed her (Resident 1) while the resident kept saying no. We all know when a resident says no, you stop." Staff E said, "It was shocking to us and we didn't know what to do at first...I was feeding another resident when I started hearing comments around me. I turned and saw Staff A holding the resident's hands on her chest while trying to feed her". Staff F said, "We were appalled and it seemed to go on forever, although it really was a few minutes. Staff A had made some comments to the resident prior to her attempting to feed the resident. The resident was loudly saying No, No, to Staff A, swatting at her, and trying to lean away from Staff A, and Staff A kept trying to get the resident to eat ... we couldn't figure out why Staff A kept trying to feed the resident". During the staff interviews, the staff indicated they first reported their concerns to management during break time (approximately an hour after the alleged incident). They also indicated the resident did not appear to display any further signs of distress or any changes in mood/behaviors after Staff A stopped trying to feed the resident. Facility documentation concluded the alleged incident had been "substantiated." It concluded Staff A had been too assertive with the resident by continuing to push the resident to eat while the resident was saying no, but the incident did not meet the criteria for abuse. During an interview with the Director of Nursing on 4/21/14 at approximately 11 a.m., she said she concluded the incident was not abuse, as Staff A would never intentionally harm any residents and had always previously been good and caring towards residents. The Washington State Nursing Home Guidelines: aka The Purple Book, Appendix A-Definition of Abuse defines abuse as, "There was impermissable or unwanted physical, verbal or non-verbal contact or intervention with the resident that cannot be properly justified."

Based on observation, interview and record review the facility failed to ensure professional standards of care were followed for 1 of 1 (13) residents reviewed. Failure to contact the physician, and complete a thorough assessment of the resident's skin placed the resident at risk of increased pain and discomfort. Also, the initiation of a skin treatment without a physicians order led to harm to the residents skin. Findings include: Resident 13 re-admitted to the facility on [DATE] with the hospital discharge paperwork noting a skin rash on the residents upper left side of the back. On 5/15/12 a nursing skin assessment noted Resident 13 to have a rash "on her upper left side of her chest all the way across to her back". The physician examined Resident 13 on 5/16/12, diagnosed the rash as "Shingles" (reactivation of chickenpox virus resulting in inflammation, pain and a rash of small skin blisters). The physician ordered her to receive an oral anti-[MEDICAL CONDITION] medication. On 5/23/12 at 9:00 a.m., a review of Resident 13's medical record was done. On 5/22/12 nursing documented there was a transparent dressing (OpSite) on the resident covering the rash on her back. The medical record stated the application of the OpSite over the rash was a "mistake". The decision was made to "very gently remove" the dressing. While removing the dressing, nursing documented "pulling tops of all blisters and some surrounding tissue off". On 5/23/12, at 10:30 a.m., during observation of nursing care, Resident 13's shingles to the upper left of her back was observed. The wound area was noted to be lightly covered with a 4 x 4 gauze, loosely taped on the corners. The guaze was slightly raised up to reveal an area of the left upper back - beefy red in color with the top layer of skin gone and pustules slightly raised. The dressing was noted to be stained with yellow drainage. On 5/24/12 at 9:30 a.m., Licensed Nurse (Staff G) stated she placed the OpSite on Resident 13's rash on 5/22/12. She stated the bath aid (Staff F) had come to her early morning on 5/22/12 and requested she come and look at the residents rash on her back. The Staff F had just completed giving the resident a bath and expressed concern about the rash she had observed on the residents back. Staff G stated she looked at the rash but did not observe any open blisters. She placed the OpSite over the rash. She went onto say she did not contact the physician to get an order nor did she document what she had done in the medical record. On 5/24/12, at 10:15 a.m., Staff F stated after giving Resident 13 a bath she requested Staff G to look at the residents rash. Staff F stated she observed the resident had 2 open blisters. She went onto say she documented the open skin on the facility Skin Observation Report. A review of the facility Skin Observation Report completed by Staff F, indicated the resident had "open" skin on the back. On 5/24/12 at 11:30 a.m., the Director of Nurses stated that Resident 13's rash should not have been covered with OpSite. She stated this was contraindicated for the type of rash the resident had. She stated that the goal would be to allow the open areas to dry out. She stated she was the one who assessed the resident and removed the OpSite the morning nursing found the cover over the rash. She documented in the medical record that now the area had "large islands of tissue missing". The discrepancy between the Staff F and Staff G who placed the Opsite regarding whether there were any open skin areas she stated she would look into. She stated there was an expectation that nursing assess, document and notify the physician prior to making decisions such as placing the OpSite over the rash without an order. None of this was done, leaving the resident much worse off then when originally assessed with [REDACTED].

Based on observation, interview and record review, the facility failed to provide appropriate services and treatment for 1 of 2 sample residents (13) related to the application of an inappropriate dressing placed on the resident's skin over an area infected with shingles. This failure resulted in harm for Resident 13, who experienced increased pain and the loss of the top layer of skin from the area where the dressing had been applied. Findings include: Resident 13 was admitted to the facility from the hospital on [DATE]. Hospital paperwork noted the resident had a "rash" on her back and was aphasic (language function is deficient or absent). Resident 13's comprehensive assessment ((MDS) dated [DATE], documented the resident sometimes was able to make her self understood and sometimes was able to understand others. The assessment also indicated during the previous 5 days the resident had frequent, "severe" pain. On 5/16/12, the resident's physician diagnosed the "rash" on her back as shingles ( a reactivation of the chickenpox virus resulting in skin inflammation, pain and multiple small fluid filled blisters). The treatment ordered by the physician was an oral anti-[MEDICAL CONDITION] medication and a narcotic [MEDICATION NAME] (for the severe pain). On 5/21/12, a nurse initiated an additional treatment for [REDACTED]. The next day, on 5/22/12, when the transparent dressing on the resident's back was discovered by another nurse, she removed the dressing. This resulted in "pulling the tops of all blisters and some surrounding tissue off ...with large islands of tissue missing" . On 5/23/12, at 10:30 am, the affected area on Resident 13's upper left back was observed. It had been lightly covered with a gauze 4 x 4, loosely taped at the corners. Once removed, the gauze had absorbed yellow drainage. The skin area was beefy red in color, with the top layer of skin missing. Slightly raised pustules were also noted. When the resident was asked by the surveyor if she had pain, with 10 being the highest level, she counted out the number 10 by opening and closing her hand 10 times. The process of initiating a treatment not ordered by the physician and creating an open of area skin with the removal of the dressing caused increased pain for the resident and increased the time needed for the area to heal. Refer to CFR 483.20(k)(3)(i), F 281 Services provided meet professional standards